Non-pharmacological prevention and
management of hypertension:
a global perspective
F.P.Cappuccio MD MSc FRCP MFPH
Cephalon Chair of Cardiovascular Medicine & Epidemiology
Warwick Medical School
Non-pharmacological prevention and
treatment of raised blood pressure
• Why ?
– Population effect
– High risk patient
• When ?
– Primary prevention
– Disease management
• What?
–
–
–
–
–
Weight reduction
Reduction in sodium (salt) intake
High potassium diet
Regular dynamic exercise
Moderate alcohol consumption
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Systolic blood pressure change in randomized controlled
trials of weight reduction in function of whether or not the
patients follow an antihypertensive treatment.
Untreated patients
Wing (1998)a
Blumenthal (2000)a
Fagerberg (1984)
MacMahon (1985)
Wing (1998)b
Fortmann (1988)a
Anderssen (1995)a
Croft (1986)
Blumenthal (2000)b
Gordon (1997)
Anderssen (1991)
Anonymous (1990)
Stevens (1993)
Anderssen (1995)b
Fortmann (1988)b
Anonymous (1997)
Masuo (2002)a
Langford (1991)
He (2000)
Oberman (1990)
Haynes (1984)
Stamler (1989)
Blumenthal (2000)c
Anderssen (1995)c
Masuo (2002)b
Wing (1998)c
Combined
-30
Neter et al. Hypertension.2003;42:878-84
-20
-10
0
Change in systolic blood pressure (mm Hg)
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4
Systolic blood pressure change in randomised controlled trials of
weight reduction in function of whether or not the patients follow
an antihypertensive treatment.
Treated patients
Singh (1990)
Reisin (1978)
Ard (2000)
Jalkanen (1991)
Lalonde (2002)a
Singh (1995)
Whelton (1998)
Lalonde (2002)b
Combined
-30
-20
-10
0
10
Change in systolic blood pressure (mm Hg)
5
Neter et al. Hypertension.2003;42:878-84
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Trial Of Non-pharmacological intervention
in the Elderly (TONE):
weight (-3.5kg) and sodium (-40mmol/d)
reductions in elderly patients (60-80 yrs)
►BP reduction (-30%)
Diet, Exercise and Weight loss Intervention
Trial (DEW-IT):
DASH-diet + fitness program ►-4.9kg and 12/-6mmHg
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Possible mechanisms
• Inhibition of an overactive R.A.A. system
in obese subjects
• Stimulation of the natriuretic peptides
system with natriuresis and vasodilation
• Reduction of the activity of the S.N.S.
• Reduction in insulin resistance and
hyperinsulinaemia
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‘Women sprinkling salt on their husbands
to stimulate their sexual performance’
Anonymous woodcut
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DOUBLE-BLIND STUDY OF THREE SODIUM INTAKES AND LONGTERM EFFECTS OF SODIUM RESTRICTION IN ESSENTIAL
HYPERTENSION
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Lancet 1989; ii:1244-7
Modest salt restriction in older people
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Lancet 1997;350:850-4
Dietary Sodium Reduction and Blood Pressure
-5.0 mmHg
-2.0 mmHg
17 trials in hypertensives (n=734)
11 trials in normotensives (n=2,220)
>4 wks duration
Reduction in sodium ~80 mmol/day
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J Hum Hypert 2002;16:761-70
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Estimated changes in systolic (left) and diastolic (right) blood pressures
for 100 mmol per day change in sodium intake by centiles of the blood
pressure distribution
16
8
Systolic BP (mmHg)
Diastolic BP (mmHg)
14
95th
7
12
80th
6
10
50th
8
95th
80th
5
50th
4
20th
6
20th
3
5th
5th
4
2
2
1
0
0
15-19
20-29
30-39
40-49
50-59
60-69
15-19
20-29
Age (years)
30-39
40-49
50-59
60-69
Age (years)
12
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How to reduce salt intake: a practical advice
Target daily salt intake should not exceed 5 grams per day
1. Never add salt to a meal
You shouldn’t
- Use rock salt or sea salt.
- Add sauces
2. Do not add salt to the cooking
You shouldn’t
- Use stock cubes, gravy browning, soy
sauce, or salted dry fish.
- Use curry powders and prepared
mustards
Instead
Use pepper, garlic, lemon, and herbs.
Instead
Try other flavourings!
- Any herbs, spices.
- Lemon or lime. Vinegar
- Onions, garlic, ginger, and chillies.
3. Avoid manufactured or processed foods with added salt
Food labelling
Salt is sodium chloride. At the moment most food labels only report sodium as grams per 100
grams of food. To convert to salt multiply by 2.5.
1 gram of sodium per 100 grams of food is the equivalent to the saltiness of seawater!
Beware
Ideally
- Most breads, Many cereals
- Only chose food items with no more than
- All ready soups and meals, processed
0.3 grams of sodium per 100 grams of
meats, take-away pizzas, Chinese takefood
away.
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Difference in systolic blood pressure after potassium supplementation
as function of the hypertension status and urinary sodium (marker of salt intake)
Normotensive
Hypertensive
<140 mmol/d
140-164 mmol/d
>=165 mmol/d
-12
-10
-8
-6
-4
-2
0
Change in systolic blood pressure (mm Hg)
2
The blood pressure lowering effect of potassium appears to be higher in hypertensives than normotensives and
enhanced in patients with a high sodium intake. Potassium supplementation should be considered for the nonpharmacological treatment of hypertension, especially for those unable to reduce their salt intake.
Whelton P et al. JAMA 1997;277:1624-32
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Foods rich in potassium classified by descending content
Foods with 5 mmol or more of elemental potassium per 100g.
Fresh fruits
Pulses (legumes)
Vegetables
Banana
Bean (dry)
Mushroom
Apricot
Broad bean (dry)
Potatoes
Plum
Chickpeas (dry)
Spinach
Cherries
Lentils (dry)
Artichoke
Grapefruit
Broad bean (fresh)
Broccoli
Grapes
Cauliflower
Oranges
Chicory
Peaches
Asparagus
Cabbage
Fennel
Lettuce
Prickly lettuce
String beans
Raw tomatoes
Turnip
Other foods: 2 to 5 mmol of elemental potassium per 100g.
Fresh fruits
Pulses (legumes)
Vegetables
Orange juice
Canned beans
Carrots
Pear
Canned lentils
Green tomatoes
Apple
Peas (fresh)
Aubergine
Peas (frozen)
Radicchio
Green peppers
Peppers
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D.A.S.H. diet
132
Control
131
High fruit & vegetables
Low fat dairy products
Whole grains & Nuts
Poultry & Fish
Little red meat, sweets,
sugar-containing drinks
• Reduced total and
saturated fat
• Reduced cholesterol
130
129
SBP (mmHg)
•
•
•
•
•
Fruit & Veg
128
127
126
Combination
125
124
123
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weeks
N Engl J Med 1997;336:1117-24
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Systolic blood pressure reduction following the DASH diet and a
reduction of salt intake
3.5
-2.1
(-3.4 to –0.8)
Systolic blood pressure (mmHg)
134
3
-4.6
(-5.9 to –3.2)
132
2.5
130
2
128
1.5
126
-1.3
(-2.6 to 0.0)
-1.7
(-3.0 to –0.4)
124
1
122
0.5
120
0
High
Intermediate
Level of sodium consumption
Control Diet
g of sodium consumed per day
136
Low
DASH Diet
The reduction in salt consumption is a valuable non pharmacological measure to reduce blood pressure; its
combination with the DASH diet is additive.
Sacks et al. N Eng J Med. 2001;344:3-10.
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Mean net changes in SBP and DBP
Whelton SP et al. Ann Int Med 2002;136:493-503
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Effect of alcohol reduction on systolic and diastolic blood pressure
Lang et al, 1995
Cushman et al, 1998
Wallace et al, 1988
Maheswaran et al, 1992
Ueshima et al, 1987
Ueshima et al, 1993
Rakic et al, 1981
Rakic et al, 1982
Puddey et al, 1985
Kawano et al, 1998
Parker et al, 1990
Puddey et al, 1992
Cox et al, 1993
Puddey et al, 1986
Howes and Reid, 1986
Systolic blood pressure
76%
Combined
Lang et al, 1995
Cushman et al, 1998
Maheswaran et al, 1992
Ueshima et al, 1987
Ueshima et al, 1993
Rakic et al, 1981
Rakic et al, 1982
Puddey et al, 1985
Kawano et al, 1998
Parker et al, 1990
Puddey et al, 1992
Cox et al, 1993
Puddey et al, 1986
Howes and Reid, 1986
Diastolic blood pressure
76%
Combined
-15
-10
0
-5
Reduction in blood pressure (mm Hg)
5
10
Reduction in self-reported daily consumption of alcohol
There is a dose-response relation between the reduction in blood pressure following a reduction in alcohol
intake.
Xin et al. Hypertension.2001;38:1112-7
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PREMIER Clinical Trial
•
•
•
•
•
•
•
4 centres RCT
810 adults
Women 62%
African-Americans 34%
BP 120-159 / 80-95 mmHg
Not on therapy
Treatment arms:
– Advice only (n=273)
– Established recommend. (n=268)
– Established plus DASH (n=269)
• Duration: 6 months
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JAMA 2003; 289: 2083-93
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Selected leading causes of death
worldwide in 1990
Ischaemic Heart Disease
Cerebrovascular Disease
Respiratory infections
Diarrhoea
COAD
TB
M easles
Road accidents
Respiratory Ca
M alaria
Cirrhosis
Stomach Ca
Diabetes
Violence
Tetanus
Drowning
War
Liver Ca
Bowel Ca
M alnutrition
Breast Ca
HIV
0
1
2
3
4
Number of deaths (million)
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6
7
Lancet 1997;349:1269-76
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Mortality due to leading
global risk factors
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Ezzati M et al. Lancet 2002;360:1347-60
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Stroke mortality in urban and rural Tanzania
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Lancet 2001;355:1684-7
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Stages in the epidemiological transition of C.V.D.
Cardiovascular Disease
Hypertensive
Atherosclerotic
Low smoking,
moderate fat
and salt intake
Moderate smoking,
moderate fat
but high salt intake
1
2
3
High smoking,
fat and salt
intake
4
5
6
Stage
Increasing levels of acculturation, urbanization and affluence
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Cappuccio FP. Int J Epidemiol 2004; 33:387-8
“More than a quarter of the
world’s adult population –
totalling nearly one billion (640
million in developing countries) –
had hypertension in 2,000, and …
this proportion will increase to
29% - 1.56 billion – by 2,025.”
Kearney PM et al. Lancet 2005;365:217-23
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Cappuccio FP; Unpublished
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Prevalence of detection, management and control
of hypertension in Ashanti
50
50
Women (n=628)
Men (n=385)
40
Rural (n=481)
Semi-urban (n=532)
40
P=0.007
P=0.06
%
30
%
30
P=0.05
20
20
10
10
0
0
Detected
Treated
Controlled
Detected
Treated
Controlled
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Cappuccio FP et al. Hypertension 2004; 43: 1017-22
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reduction in
Kumasi
Systolic BP (mmHg)
dietary salt
6.4 (0.5 to12.3)
135
130
125
90
Diastolic BP (mmHg)
Community
140
87.5
85
82.5
4.5 (-0.3 to 9.3)
80
Urinary Sodium (mmol/24h)
77.5
150
44 (22 to 66)
100
50
0
BASELINE
BASELINE
Cappuccio FP et al. Lancet 2000;356:677-8
20 farmers
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4 WEEKS
AFTER FOUR WEEKS
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Reduction in systolic blood pressure achieved by
two pilot trials of salt reduction in sub-Saharan Africa
Cappuccio FP et al. Lancet 2000;356:677-8
Adeyemo AA et al. Ethn Dis 2002;12: 207-11
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Risk of stroke attributable to high blood pressure
100%
Smoking
BP
AF
Others
80%
60%
~40%
~78%
40%
20%
0%
Developed
regions
Developing
countries
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Conclusions
• Lifestyle modifications are effective measures in
the prevention and management of hypertension
across the world
• The BHS IV Guidelines suggest:
– Maintain normal weight for adults (BMI 20-25 kg/m2)
– Reduce salt intake to <100 mmol/day (<6g NaCl or <2.4g
Na+/day)
– Limit alcohol consumption to <3 units/day for men and
<2 units/day for women
– Engage in regular aerobic physical exercise (brisk walking rather
than weightlifting) for >30 min per day
– Consume at least five portions/day of fresh fruit and vegetables
– Reduce the intake of total and saturated fat
• Necessary involvement of consumers,
industry and governments
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