Nonpharmacological Treatment of Hypertension

Nonpharmacological Treatment of Hypertension

Hasan Abu-Aisha, FRCP

Healthy feeding habits◦ No extra table salt◦ No junk food◦ Extra vegetables and fruits

Get rid of the extra weight. Stop tobacco use. No alcohol Stop worrying! Regular exercises (aerobic, resistance,

flexibility).

Healthy Life Styles

The benefits of exercise: summary of the scientific evidence.

Types of exercise. The Sudan Safe Exercises for All (SEFA)

program.

Plan

Darren E.R. Warburton, Crystal Whitney Nicol, Shannon S.D. Bredin

CMAJ 2006;174(6):801-9

Review:Health benefits of physical activity: the evidence

13 Awesome Mental Health Benefits of Exercise: NIH, March 2013

Physical inactivity is a modifiable risk factor for

cardiovascular disease and a widening variety of other chronic diseases, including ◦ hypertension, ◦ diabetes mellitus, ◦ cancer (colon and breast),◦ obesity, ◦ bone and joint diseases (osteoporosis◦ and osteoarthritis), ◦ and depression.

Introduction

The prevalence of physical inactivity is higher than that of all other modifiable risk factors (51% of adults in Canada and 60% of USA adults, 86% of adults in Khartoum).

There is evidence that physical activity is profoundly helpful in the primary and secondary prevention of :◦ Premature death from any cause, ◦ cardiovascular disease, ◦ diabetes,◦ some cancers ◦ and osteoporosis.

The prevalence of physical inactivity is high.

Over the last 60 years or so, numerous long-term prospective follow-up studies (in men and women) have assessed the relative risk of death from any cause

and from specific diseases (e.g., CVD) associated with physical inactivity.

Primary prevention :All-cause and CV-related death

Both men and women who reported increased levels of physical activity and fitness were found to have

20-35% reductions in relative risk of death.

All-cause and CV-related death Primary prevention

being fit or active was associated with a greater than 50% reduction in risk.

Physically inactive middle-aged women (less than 1 hour of exercise per week) ◦ experienced a 52% increase in all-cause

mortality, ◦ a doubling of cardiovascular related mortality◦ and a 29% increase in cancer-related mortality

compared with physically active women.

All-cause and CV-related death Primary prevention in women

These relative risks from inactivity are similar to those for ◦ hypertension,◦ hypercholesterolemia ◦ and obesity,

and they approach those associated with moderate cigarette smoking.

All-cause and CV-related death Primary prevention

Fig. 1: Relative risks of death from any cause among participants with various risk factors (e.g., history of hypertension, chronic obstructive pulmonary disease [COPD], diabetes,

smoking, elevated body mass index [BMI ≥ 30] and high total cholesterol level...

Warburton D E et al. CMAJ 2006;174:801-809

©2006 by Canadian Medical Association

An increase in physical fitness will reduce the risk of premature death, and a decrease in physical fitness will increase the risk.

The effect appears to be graded, such that even small improvements in physical fitness are associated with a significant reduction in risk.

Physical fitness and the risk of premature death

Modest enhancements in physical fitness in previously sedentary people have been associated with large improvements in health status.

People who went from unfit to fit over a 5-year period had a reduction of 44% in the relative risk of death compared with people who remained unfit.

Does a slight effort in physical activity matter?

These protective effects were seen with as little as 1 hour of walking per week.

A dose–response relation appears to exist: people who have the highest levels of physical activity and fitness are at lowest risk of premature death.

How little is the minimum activity?Is high physical activity bad?

Fig. 2: Relation between changes in physical fitness and changes in mortality over time.

Warburton D E et al. CMAJ 2006;174:801-809

©2006 by Canadian Medical Association

The benefits of physical activity and fitness extend to patients with established CVD.

This is important because, for a long time, rest and physical inactivity had been recommended for patients with CVD.

Unlike studies of primary prevention, many studies of secondary prevention are RCTs.

Several systematic reviews have clearly shown the importance of engaging in regular exercise to attenuate or reverse the disease process in patients with CVD.

Secondary prevention of CV disease

Low-intensity exercise training (e.g., exercise at less than 45% of maximum aerobic power) has also been associated with an improvement in health status among patients with CVD.

Secondary Prevention for CV disase: Minimum Training Intensity Recommended For

Patients With Heart Disease

Both aerobic and resistance types of exercise have been shown to be associated with a decreased risk of type 2 diabetes.

DIABETES MELLITUS: primary prevention

Exercise interventions are also effective in the management of DM.

One prospective cohort study showed that walking at least 2 hrs /week was associated with a reduction in the incidence of premature death ◦ of 39%–54% from any cause, ◦ of 34%–53% from CVD.

DIABETES MELLITUS: Secondary prevention

Several seminal reviews published regarding the relation between cancer and routine physical activity.

In over 100 epidemiologic studies, routine physical activity is associated with

reductions in the incidence of specific cancers,

in particular colon and breast cancer.

CANCER: Primary prevention

Weight-bearing exercise, especially resistance exercise, appears to have the greatest effects on bone mineral density.

In one review,10 several cross-sectional reports revealed that people who did resistance training had increased bone mineral density compared with those who did not do such training.

Furthermore, athletes who engaged in high-impact sports tended to have increased bone mineral density compared with athletes who engaged in low-impact sports.

OSTEOPOROSIS: Primary prevention

A study involving early postmenopausal osteopenic women revealed:

a 2-year intensive training program was effective in attenuating the rate of bone loss.

preliminary evidence indicates that regular physical activity is an effective secondary preventive strategy for the maintenance of bone health and the fight against osteoporosis.

OSTEOPOROSIS: Secondary prevention

There is increasing evidence that enhanced musculoskeletal fitness is associated with an improvement in overall health status and a reduction in the risk of chronic disease and disability.

This research has led to a shift in focus in research related to the health benefits of activities that tax the musculoskeletal system.

MUSCULO-SKELETAL FITNESS: a paradigm shift

Fig. 3: Theoretical relation between musculoskeletal fitness and independent living across a person's lifespan.

Warburton D E et al. CMAJ 2006;174:801-809

©2006 by Canadian Medical Association

Two recent systematic reviews have revealed that enhanced musculoskeletal fitness is positively associated with:◦ functional independence, ◦ mobility, ◦ glucose homeostasis, ◦ bone health, ◦ psychological well-being ◦ and overall quality of life

and is negatively associated with the risk of falls, illness and premature death.

Musculoskeletal fitness and functional independence

Currently, most health and fitness organizations and professionals advocate a minimum volume of exercise that expends 1000 kcal (4200 kJ) per week and acknowledge the added benefits of higher energy expenditures.

Recently, investigators have postulated that even lower levels of weekly energy expenditure may be associated with health benefits.

A volume of exercise that is about half of what is currently recommended may be sufficient, particularly for people who are extremely deconditioned or are frail and elderly.

How much physical activity is enough?

Chronic inflammation (indicated by CRP) has been shown to be strongly associated with most of the chronic diseases.

Recent RCTs have shown that exercise training may cause marked reductions in CRP levels.

This may explain directly or indirectly the reduced incidence of chronic disease and premature death among people who engage in routine physical activity.

How does physical activity and fitness lead to improved health outcomes?

Which type of exercise? Aerobic (e.g. walking) Resistance (muscle

building) Flexibility (joints and

tendons) Agility (dancing,

competitive games) High impact (athletes

involved in combat)

Which type of exercise? Aerobic (e.g. walking) Resistance (muscle

building): Flexibility (joints and

tendons): Agility (dancing,

competitive games): High impact (athletes

involved in combat)

Cardiopulmonary effects

musculoskeletal effects

musculoskeletal effects

all

all

Should be easily performable (at your own pace).

Should be safe (all ages). Should not require teams/out-door activity. No equipments (no special yards/pools). No cost. Not embarrassing!

What type would most acceptable to (most of) the public?

The Sudan Safe Exercises for All (SEFA) program

Which type of exercise used in SEFA Program?

TYPE Aerobic (e.g. moving

around): 30% Resistance (muscle

building): 30% Flexibility (joints and

tendons): 40%

BENEFITS

Cardiopulmonary health

Muscle and Bone Health

Healthy joints

Overall fitness including metabolic benefits

Principles :1. No special uniform needed.2. No special field/platform needed.3. No team needed.4. No equipment needed.5. You do not have to move to destinations.6. You can stop anytime and then resume.7. You do not compete with anybody else.8. Easy protocol that you can follow.

The Sudan Safe Exercises for All (SEFA) program

PhilosophyProper physical activity needs

three independent components that need to be fulfilled:

Potentiate your breathing capacity (capture more O2) and deliver the O2 to the cells.

There are over 300 joints that need to be mobilized, lest they will get stiff (ankylosis, calcification).

Resistance exercises to improve muscle power.

The Sudan Safe Exercise for all (SEFA) program: plan of action1. Build muscle power

by resistance (weight bearing).(30%)

2. Activate the cardiopulmonary system by aerobic efforts. (30%)

The Sudan Safe Exercise for all (SEFA) program: plan of action1. Flexibility of the

skeletal system: (40%)

a) Cervical spine, shoulders, thoracic cage and spine, lumbar spine and mid-section, hips and pelvis.

b) Stretch ligaments and tendons

Simple Resistance exercises Building neck muscle

power by simple resistance exercise.

Flexibility (joints and tendons)

Stretching the long posterior tendons (t60)

Forward bending (t30)

Flexibility (joints and tendons)

Open the pelvis (room for bowels, urinary bladder, prostate, uterus). Fights against constipation (Ca’ colon), urine problems.

Improves cerebral circulation (Gravity effect: anti-demenia !)

Weight- bearing on the cervical spine & improving cerebral circulation

The Friday morning group: 12th year of regular activity (2003-

2014)

Ending 2 hours of SEFA by complete relaxation for

3 minutes

Sudan Safe Exercises for all (SEFA): the young trainers

The Friday morning group: 11 years of regular activity (2003-

2014)

Several groups work regular activities every week:

The Green Yard, Khartoum 2/wk Manshia, Khartoum: 1/wk Police House, Khartoum 1/wk Mosques (5 in Khartoum) 1-2/wk each Kassala State North Kurdofan State North Darfur State Regular Television show (2/wk)

The Current State

The Sudan Safe Exercises for All (SEFA) academy is now officially registered as an academic sports body

Train the trainers Make a national program Include SEFA in PHC centers (Start with Khartoum

State): collaboration with National Health Insurance Fund

Include SEFA in universities (Start with Mughtaribeen and Kassala Universities)

Study the effects of SEFA on community health (research proposal under structure)

The future

Sudan SEFA Registered as a Sports Academy

SEFA for all Ages

Thank You