Lifestyle Interventions Are Effective Treatments of Hypertensive Patients

1. Lifestyle Interventions Are Effective Treatments of Hypertensive Patients William C. Cushman, MD Professor, Preventive Medicine and MedicineUniversity of TennesseeCollege of Medicine Chief, Preventive MedicineVA Medical Center, MemphisMemphis, Tennessee

2. Lifestyle Modifications: JNC 7

4. Trial of Nonpharmacologic Interventions in the Elderly (TONE)Reduction (%) in Incidence of Hypertensionor CV Event Whelton, et al. JAMA 1998;279:839-46

5. Trials of Hypertension Prevention (TOHP I)Sodium Excretion and BP Change @ 18 Months Age 30-54 yrs, DBP 80-89 mm Hg TOHP: Hypertension 1993;22:502-12

6. The DASH Dietary Pattern Food Group Servings Grains 7 to 8 Vegetables 4 to 5 Fruits 4 to 5 Low/non fat dairy 2 to 3 Meats, poultry, fish 2 or less Nuts, seeds, legumes 1

7. BP Effects of DASH Diets D Systolic D Diastolic -1.1 -2.8* -3.0* D BP (mmHg) -5.5* F/VDASH BP changes in CONTROL DIET group have been subtracted Mean +/- 97.5% C.I.; * sig diff from CONTROL DIET

8. Systolic BP Effects of DASH Diet by HTN Status - 3.5 D BP (mmHg) - 11.4 With hypertension No hypertension

9. A Standard Drink (U.S.) • Approximately 14 grams of ethanol • Contained in: • 12 oz glass/can of beer • 5 oz of table wine • 1.5 oz of distilled spirits (80 proof)

10. Effects of Alcohol and Caloric Restrictions on BP … in Overweight Men N=86 Baseline BP 137/85 mm Hg Alcohol : 3 drinks/d (BL 3.5 drinks/d) Weight : 7.5 kg (BL 92.5 kg) Puddey IB, et al. Hypertension 1992;20:533-41

11. Effects of AlcoholReduction Interventions in Randomized Controlled Trials • Meta-analysis of 15 randomized controlled trials. • The median duration of the trials was 8 weeks. • Subjects reduced their alcohol consumption by a median 76% from a baseline intake of 3-6 standard drinks/day. • This resulted in a pooled effect estimate of the effects of alcohol reduction on BP of 3.31/2.04 mm Hg. Xin X, He J, … Whelton PK. Hypertension 2001,38:1112-7

12. Average Net Change in BP (95%CI) with Alcohol Reduction Interventions in 15 Randomized Controlled Trials Xin X, He J, … Whelton PK. Hypertension 2001,38:1112-7

13. Controlled Trial of Exercise in Stage 1 HTN p=0.02 p=0.11 10 week; n=19 Martin, Dubbert, Cushman, et al. Circulation 1990;81

15. Weighted Net Change in BP with Endurance Training (Meta-analysis) Fagard. J Hypertens 1993;11(suppl 5):S47-S52

16. Intervention Exercise Weight reduction Alcohol intake reduction Sodium intake reduction DASH diet Blood Pressure Effect 5-10 mm Hg (>30 min >3x/wk) 1-2 mm Hg/Kg 1 mm Hg/drink/d 1-3 mm Hg/40 mmol/d 3-10 mm Hg  Lifestyle Interventions for Prevention or Treatment of Hypertension

17. Conclusions • In a newly diagnosed stage 1 hypertensive patient, I recommend what I believe to be the most important LSM(s) for that patient. • Then I negotiate whether to also begin AHT drug therapy immediately after the HTN is confirmed or, if the patient is enthusiastic about attempting LSM, follow the patient every 1-2 months and withhold drugs if the patient is making definite progress in LSM and normalizes BP within a few months. • If it is evident the patient is not adhering well to LSM or if the BP remains above goal for more than a few months, I will recommend initiating drug therapy in addition to LSM.

18. I rest my case

19. Effects of Dietary Instruction and Na Excretion Feedback in Hypertensive Clinic PatientsReduction in Na Excretion (mmol/24 hr) N=122, 54% Black, BL UNa=197 mmol/24hr Dubbert, Cushman, Meydrech, et al. Behavior Therapy 1995;26:721-32

20. Effects of Dietary Instruction and Na Excretion Feedback in Hypertensive Clinic PatientsReduction in BP (mm Hg) and Weight (kg) N=122, BL BP = 142/86 mm Hg, BL Wt = 88 kg Dubbert, Cushman, Meydrech, et al. Behavior Therapy 1995;26:721-32

21. Trials of Hypertension Prevention (TOHP I)Systolic and Diastolic Change @ 6 Months * * * N=2182, age 30-54 yrs, DBP 80-89 mm Hg JAMA 1992;267:1213-20

22. -5.9 p<0.0001 -5.0 p=.0003 -2.2 p=.02 Effect of DASH Diet on Systolic Blood Pressure Sacks, et al. N Engl J Med 2001;344:3-10 Systolic Blood Pressure (mmHg) Control Diet DASH Diet Higher Intermed Lower Sodium Level

23. Background • Hemodynamic effects of alcohol have been reported at least since the middle of the nineteenth century. • The first population-based study of alcohol use and prevalence of HTN was reported in 1915 by a French surgeon, Lian: • He found a linear relationship between the amount of wine regularly ingested by French troops on the Western front and the prevalence of hypertension.

24. Epidemiology • Since Lian there has been a large number of cross sectional and prospective population studies which have consistently demonstrated a direct and positive relationship between ingestion of alcoholic beverages and an increase in both the level of BP and prevalence of HTN. • The relationship is most consistent above 2 drinks/day average intake.

25. Effects of Alcohol and Caloric Restrictions on BP … in Overweight Men -----, normal alcohol intake/normal caloric intake (n=20); - - - , normal alcohol intake/low caloric intake (n=22); -----, low alcohol intake/normal caloric intake (n=21); - - -, low alcohol intake/low caloric intake (n=23) Puddey IB, et al. Hypertension 1992,20:533-41

27. Walking to Work and Risk for HTN in Men: the Osaka Health Survey N=6,017 Japanese men age 35-60 yrs BP<140/90 @ BL Variable Multivariate RR 95% CI Walk to Work: 0-10 minutes 1.00 (reference) 11-20 minutes 0.91 0.77-1.08 >21 minutes 0.70 0.59-0.95 Walk to work continuous 0.88 0.78-0.98 variable (per 10 minutes) Hayashi, et al. Ann Intern Med 1999;130:21-26

28. Exercise Prescription to Develop and Maintain Cardiorespiratory Fitness(and Control BP) Mode of Activity Large muscle activity that is rhythmical and aerobic (e.g., walking, running, cycling) Frequency 3-5 days per week Duration 20-60 minutes Intensity 60-80% of maximum heart rate (50-85% of maximum oxygen uptake American College of Sports Medicine

29. Trials of Hypertension Prevention (TOHP I) • Weight reduction intervention produced weight loss of 3.9 kg (P <0.01). • Sodium reduction interventions lowered urinary sodium excretion by 44 mmol/24 h (P <0.01). • Despite good compliance, neither stress management nor nutritional supplements reduced diastolic blood pressure or systolic blood pressure significantly (P greater than .05). JAMA 1992;267:1213-20

30. Trials of Hypertension Prevention, Phase II (TOHP II) • Examined weight loss and reduction in sodium intake for the prevention of hypertension in 2400 overweight participants. • Age 30-54 years, high normal DBP. • Through 48 months, incidence of hypertension was significantly less with each active intervention, although effect lessened after 6 months. Arch Int Med 1997;157:657

31. Trials of Hypertension Prevention, Phase II (TOHP II) • TOHP II showed a 20% reduction in the incidence of hypertension with weight loss and reduction in sodium intake. • Incidence based on diastolic blood pressure threshold. Arch Int Med 1997;157:657

32. Long-term (7-Year) Cumulative Incidence of HTN after Weight Loss and Sodium Reduction Interventions in TOHP (Baltimore) p=0.19 p=0.02 He, et al. Hypertension 2000;35:544-54

33. Rare Genetic Defects and BP Every single gene defect discovered thus far that causes chronically elevated or low BP effects renal handling of sodium. Paraphrased from Richard Lifton, American Society of Hypertension Meeting, 2001

34. The DASH Dietary Pattern Food Group Servings Grains 7 to 8 Vegetables 4 to 5 Fruits 4 to 5 Low/non fat dairy 2 to 3 Meats, poultry, fish 2 or less Nuts, seeds, legumes 1

35. Lifestyle PackagesCausing >10 mm Hg BP Fall • Wt control + exercise Kingwell • Wt “ + salt mod Tone • Wt “ + alcohol mod Puddey • Wt “ + fish Bao • “Dash diet” Appel • Protein + fibre Burke • DASH Na? • PREMIER? • DEW-IT?