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Lifestyle Modifications for the Prevention and Management of Hypertension. ANDREAS PITTARAS MD. Blood Pressure and CVD. High BP is a strong, consistent and independent risk factor for CV events. The risk begins at BP 115/75 mm Hg and doubles with each incremental increase of 20/10 mm Hg.

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blood pressure and cvd
Blood Pressure and CVD
  • High BP is a strong, consistent and independent risk factor for CV events.
  • The risk begins at BP 115/75 mm Hg and doubles with each incremental increase of 20/10 mm Hg.
  • Vasan RS, et al. The Framingham Heart Study.JAMA 2002:287:1003-10
  • Lewington S. Lancet 2002;360:1903-1913
slide3
JNC Goal:

Not Only Treat HTN, But Prevent it.

Does Increased Physical Activity Prevent or Attenuate the Progression to HTN?

physical activity and bp
Physical Activity and BP
  • Moderate increases in PA can prevent or at least attenuate the development of HTN.
  • The RR for developing HTN is about 1.5 to 2.0 times higher in sedentary vs physically active individuals.

Staessen, et al., ’94; Sawada S, et al. ’93; Reaven et al., ‘91 Blair S, et al., ‘84 ; Paffenbarger et al., ‘83

slide5

Ambulatory SBP and Fitness in Men

Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58

mm Hg

N=407

Low-Fit

Mod-Fit

High-Fit

slide6

Ambulatory DBP and Fitness in Men

Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58

mm Hg

N=407

Low-Fit

Mod-Fit

High-Fit

slide7

Ambulatory SBP and Fitness in Women

Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58

mm Hg

N=243

Low-Fit

Mod-Fit

High-Fit

slide8

Ambulatory DBP and Fitness in Women

Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58

mm Hg

N=243

Low-Fit

Mod-Fit

High-Fit

lvmi and fitness in pre hypertensives
LVMI and Fitness in Pre-Hypertensives

Kokkinos, P, Pittaras A, Manolis T. Hypertension 2007; 49:1-7

g/m2.7

N=790

kokkinos p et al cardiology clinics 2001 19 3 507 516
Kokkinos P., et al.Cardiology Clinics 2001;19(3):507-516

Average Reduction in BP:

Active: 10.5/7.6 mm Hg

Controls: 3.8/1.3 mm Hg

exercise and bp
Exercise and BP
  • How Much Exercise for changes? (intensity, Duration, Frequency)
  • How Intense Should Exercise Be?
  • How Soon Do We See Results?
  • How Long Do the ChangesLast?
exercise intensity and bp reduction
Exercise Intensity and BP Reduction

Hagberg J., et al. Am J Cardiol 1989;64:348-53

mm Hg

SBP

DBP

SBP

DBP

High Intensity (73% VO2 max)

Low Intensity (53% VO2 max)

slide14

Exercise Intensity and BP Reduction

Matsusaki M, et al. Clin Exp Pharm & Physiol 1992;19:471-9

mm Hg

SBP

DBP

DBP

SBP

High Intensity (75% VO2 max)

Low Intensity (50% VO2 max)

bp changes with exercise in pts with severe hypertension stage 2 3
BP Changes with Exercise in pts with Severe Hypertension (Stage 2 & 3)

Kokkinos P, Pittaras A.et al. N Engl J Med 1995;333:1462-7

mm Hg

DBP

DBP

SBP

SBP

16 weeks

32 weeks

wall thickness at baseline 16 weeks
Wall Thickness at Baseline & 16 weeks

Kokkinos P, Pittaras A et al. N Engl J Med 1995;333:1462-7

mm

Baseline

*

16 Wks

Baseline

*

16 Wks

lvmi at baseline and 16 weeks
LVMI at Baseline and 16 Weeks

Kokkinos P, Pittaras A et al. N Engl J Med 1995;333:1462-7

g/m2

* p<0.05

*

Baseline

16 weeks

exercise intensity implications
Exercise Intensity Implications
  • Low-to-moderate exercise intensities carry a relatively lower risk.
  • Patients with more severe HTN and other risk factors can exercise safely.
  • Patients are more likely to participate and sustain Lo-intensity exercise programs.
exercise and bp reduction
Exercise and BP Reduction

How Soon Should We Expect

To Observe Changes in BP?

time course for exercise and bp reductions
Time Course for Exercise and BP Reductions
  • Acute changes occur immediately after cessation of activity. They last about 2-12 hours.
  • Chronic changes?
bp changes with exercise
BP Changes with Exercise

Kokkinos P., Pittaras A et al. N Engl J Med 1995;333:1462-7

mm Hg

2Weeks

2 Weeks

2 Weeks

16 Weeks

16 Weeks

DBP

SBP

exercise and bp reduction22
Exercise and BP Reduction

How Long Do

These Changes Last?

sbp response to training detraining
SBP Response to Training & Detraining

mm Hg

33% Reduction in Meds

Exercise Training

relative risk of all cause death and exercise capacity in hypertensive patients
Relative Risk of All-Cause Death and Exercise Capacity in Hypertensive Patients

Myers J. et al., N Engl J Med 1002;346:793-801

RR of Death

survival and fitness levels for htns
Survival and Fitness Levels for HTNs

N=4,368

>10 MET; n=968

>10 MET; n=1,000

7-10 MET; n=1558

7-10 MET; n=1563

5-7 MET; n=1310

5-7 MET; n=1286

<5 MET; n=578

Log Rank=222; p<0.001

<5 MET; n=524

exercise recommendations for bp control american college of sports medicine
Exercise Recommendations for BP Control American College of Sports Medicine

F: Frequency: 3-6 times/wk

I: Intensity: Moderate (Brisk walk)

T: Time: 20-60 min/session. May split sessions (AM/PM)

T: Type: Type of Exercise: Aerobic

exercise intensity for health benefits

Exercise Intensity for Health Benefits

PMHR:60% - 70% >85%

METs: < 4 – 5 7 10 +

Fast walk Running

6 km/hr 10 km/hr

500 - 1000 3000 Kcal

body weight and bp
Body Weight and BP
  • A direct association between excess body wt and HTN regardless of age, gender & race.
  • 4.5 kg reduction in wt resulted in reduced BP.
  • 60% of pts remained normotensive without pharmacologic therapy (DISH Trial)
  • Better control of BP achieved when Wt reduction added to antihypertensive therapy.
  • Waist circumference <85 cm for women and <98 cm Men and BMI<27 are recommended.
exercise for htnsive obese patients
Exercise for HTNsive, Obese Patients
  • Likely to have multiple risk factors
  • ETT strongly recommended
  • Tailor exercise to patient needs/abilities.
  • Frequency: 3-6 days/week
  • Low intensity exercises (HR ~95-100 bpm)
  • Initial duration of 10 min/day
  • Two sessions (am/pm), 5 min/secs if needed)
  • Increase by 2 min/wk- Aim: 100-200 min/wk
salt reduction and blood pressure
Salt Reduction and Blood Pressure
  • Historically, the limitation of salt in food has been the primary dietary approach in the control of HTN.
  • Over 50 studies have been concluded. Recent Meta analysis revealed a reduction of 5/2.7 mm Hg in BP for a reduction of ~ 1.8 g/d in urinary sodium for HTN pts.

He FJ, et al. J Hum Hypertns. 2002;16:761-70

foods and blood pressure
Foods and Blood Pressure
  • Calcium and Magnesium:
    • Small reductions. Insufficient data to recommend supplementation.
  • Potassium:
    • Meta-analysis (33 trials): a modest reduction (3/2 mm Hg) in HTN pts receiving potassium supplements. Effects more AA and those with high sodium intake.
  • Fish Oil: Not routinely recommend
  • Fiber:Insufficient data.
  • High CHO Intake :
    • High sugar intake is shown to increase BP. More studies necessary
  • High Protein Intake:
    • Some evidence of lower BP, but may be due to lower CHO
comprehensive dietary approaches for bp control
Comprehensive Dietary Approaches for BP Control

It is becoming more evident that diets low in salt and fat and rich in other minerals are more effective in lowering BP than any one element alone. Such diets include the DASH Diet and the Mediterranean diet.

dash trial and blood pressure
DASH Trial and Blood Pressure

Appel L, et al. N Engl J Med 1997;336:1117-24

  • Control Diet:
    • Low in fruits, veggies and dairy products and typical fat content.
    • Potassium, magnesium, calcium at 25th percentile of US consumption.
  • Fruits & Vegetables Diet:
    • More fruits & Vegetables
    • Potassium, magnesium, calcium at 75% of US consumption.
    • Fat content similar to Control Diet.
dash trial and blood pressure39
DASH Trial and Blood Pressure

Appel L, et al. N Engl J Med 1997;336:1117-24

  • Combination Diet:
    • Rich in fruits, vegetables, fiber, protein, and low-fat dairy products
    • Reduced amounts of total fat, saturated fat and cholesterol.
  • Sodium content of each diet was similar- approximately 3 g per day.
weekly sbp in the dash trial
Weekly SBP in the DASH Trial

mm Hg

Appel L, et al. N Engl J Med 1997;336:1117-24

Control Group Diet

Fruits + Vegetables

X=5.5 mm Hg

Fruits + Vegetables + Low Fat

Intervention Week

weekly dbp in the dash trial
Weekly DBP in the DASH Trial

mm Hg

Appel L, et al. N Engl J Med 1997;336:1117-24

Control Group Diet

Fruits + Vegetables

X=3 mm Hg

Fruits + Vegetables + Low Fat

Intervention Week

sbp changes sodium in the dash trial
SBP Changes & Sodium in the DASH Trial

Sacks FM, et al. N Engl J Med 2001;344:3-10

mm Hg

Control Group Diet

-5.9

-5.0

-2.2

DASH Diet

dbp changes sodium in the dash trial
DBP Changes & Sodium in the DASH Trial

Sacks FM, et al. N Engl J Med 2001;344:3-10

mm Hg

Control Group Diet

DASH Diet

dash trial and blood pressure44
DASH Trial and Blood Pressure
  • Compelling evidence that adequate intake of minerals should be the focus of dietary recommendations in the control of BP.
  • The DASH Diet in combination with reduced salt intake optimizes BP control.
lifestyle interventions for bp control conclusions
Lifestyle Interventions for BP Control: Conclusions
  • High intake of fruits, vegetables, nuts and low-fat dairy products
  • Reduce total fat, saturated fats, TC,
  • Restrict salt intake, but increase calcium potassium and magnesium
  • Control body wt / Reduce body fat
  • Limit alcohol intake to <2 drinks/day
  • Brisk walk 3-6 times a week; 20-60 min per session (100-200 min/Wk).