Lifestyle Modifications for the Prevention and Management of Hypertension

1. Lifestyle Modifications for the Prevention and Management of Hypertension ANDREAS PITTARAS MD

2. 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

3. JNC Goal: Not Only Treat HTN, But Prevent it. Does Increased Physical Activity Prevent or Attenuate the Progression to HTN?

4. 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

5. 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

6. 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

7. 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

8. 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

9. LVMI and Fitness in Pre-Hypertensives Kokkinos, P, Pittaras A, Manolis T. Hypertension 2007; 49:1-7 g/m2.7 N=790

10. The Role of Physical Activity in the Management of Hypertension

11. 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

12. 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?

13. 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)

14. 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)

15. 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

16. 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

17. 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

18. 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.

19. Exercise and BP Reduction How Soon Should We Expect To Observe Changes in BP?

20. Time Course for Exercise and BP Reductions • Acute changes occur immediately after cessation of activity. They last about 2-12 hours. • Chronic changes?

21. 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

22. Exercise and BP Reduction How Long Do These Changes Last?

23. SBP Response to Training & Detraining mm Hg 33% Reduction in Meds Exercise Training

24. Clinical Significance of Exercise-Induced BP Reduction

25. 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

26. Exercise Capacity and Mortality in HTN Pts (VAMC Data (n=4,397) RR of Death

27. Exercise Capacity and Mortality in HTN+DM: VAMC DATA RR of Death

28. Exercise Capacity and Mortality in HTN + Obesity: VAMC DATA RR of Death

29. 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

30. 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

31. 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

32. 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.

33. 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

34. Dietary Factors and Blood Pressure

35. 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

36. 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

37. 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.

38. 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.

39. 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.

40. 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

41. 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

42. 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

43. 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

44. 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.

45. Alcohol Consumption and BPPanagiotakos D. et al J Hypertens 2003;21:1-7

46. 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).