1. 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

2. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 2 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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4. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 4 Neter et al. Hypertension.2003;42:878-84

5. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 5 Neter et al. Hypertension.2003;42:878-84

6. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 6 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

7. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 7 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

8. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 8 ‘Women sprinkling salt on their husbands to stimulate their sexual performance’ Anonymous woodcut

9. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 9 DOUBLE-BLIND STUDY OF THREE SODIUM INTAKES AND LONG- TERM EFFECTS OF SODIUM RESTRICTION IN ESSENTIAL HYPERTENSION Lancet 1989; ii:1244-7

10. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 10 Modest salt restriction in older people Lancet 1997;350:850-4

11. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 11 J Hum Hypert 2002;16:761-70 17 trials in hypertensives (n=734) 11 trials in normotensives (n=2,220) >4 wks duration Reduction in sodium ~80 mmol/day Dietary Sodium Reduction and Blood Pressure -5.0 mmHg -2.0 mmHg

12. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 12 95 th 80 th 50 th 20 th 5 th 95 th 80 th 50 th 20 th 5 th Systolic BP (mmHg)Diastolic BP (mmHg) Age (years) 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

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15. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 15 Normotensive Hypertensive <140 mmol/d 140-164 mmol/d >=165 mmol/d 20-2-4-6-8-10-12 Change in systolic blood pressure (mm Hg) 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 non- pharmacological 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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17. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 17 D.A.S.H. diet 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 N Engl J Med 1997;336:1117-24 123 124 125 126 127 128 129 130 131 132 Baseline 12 3 4 5 6 7 & 8 weeks SBP (mmHg) Control Fruit & Veg Combination

18. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 18 120 122 124 126 128 130 132 134 136 HighIntermediateLow Systolic blood pressure (mmHg) 0 0.5 1 1.5 2 2.5 3 3.5 g of sodium consumed per day Level of sodium consumptionControl DietDASH Diet The reduction in salt consumption is a valuable non pharmacological measure to reduce blood pressure; its combination with the DASH diet is additive. Systolic blood pressure reduction following the DASH diet and a reduction of salt intake Sacks et al. N Eng J Med. 2001;344:3-10. -2.1 (-3.4 to –0.8) -1.3 (-2.6 to 0.0) -4.6 (-5.9 to –3.2) -1.7 (-3.0 to –0.4)

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20. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 20 Mean net changes in SBP and DBP Whelton SP et al. Ann Int Med 2002;136:493-503

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22. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 22 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

23. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 23 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 JAMA 2003; 289: 2083-93

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25. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 25 Selected leading causes of death worldwide in 1990 Number of deaths (million) Lancet 1997;349:1269-76 3M (~70%) in developing countries

26. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 26 Ezzati M et al. Lancet 2002;360:1347-60 Mortality due to leading global risk factors

27. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 27 Stroke mortality in urban and rural Tanzania Lancet 2001;355:1684-7

28. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 28 High smoking, fat and salt intake Low smoking, moderate fat and salt intake Moderate smoking, moderate fat but high salt intake Increasing levels of acculturation, urbanization and affluence Cappuccio FP. Int J Epidemiol 2004; 33:387-8 Stages in the epidemiological transition of C.V.D.

29. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 29 “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

30. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 30 Cappuccio FP; Unpublished

31. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 31 P=0.007 P=0.06 P=0.05 Prevalence of detection, management and control of hypertension in Ashanti Cappuccio FP et al. Hypertension 2004; 43: 1017-22

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33. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 33 Community dietary salt reduction in Kumasi Cappuccio FP et al. Lancet 2000;356:677-8 BASELINE 4 WEEKS 6.4 (0.5 to12.3) 4.5 (-0.3 to 9.3) 44 (22 to 66) 20 farmers

34. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 34 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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36. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 36 Risk of stroke attributable to high blood pressure ~40% ~78%

37. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 37 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/m 2 ) –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