OST 524 Diet and Hypertension (www.msu.edu/course/hnf/470)I. NHLBI Joint National Commission VI

Treatment Guidelines (www.nhlbi.nih.gov)

II. Non-pharmacologic therapies in HTN trt

III. Dietary approaches to the trt of HTN

IV. DASH trial: results and implications

V. Implications of National Dietary Guidance

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Summary points

(Ramsay LE et al. BMJ 1999: 319: 630-635)

Use non-pharmacological measures in all hypertensive and borderline hypertensive people

Initiate antihypertensive drug treatment in people with sustained systolic blood pressure 160 mm Hg or sustained diastolic blood pressure 100 mm Hg

Decide on treatment in people with sustained systolic blood pressure according to the presence or absence of:

target organ damage, cardiovascular disease, diabetes, or a 10 year coronary heart disease risk of 15% according to the Joint British Societies coronary heart disease risk assessment programme or risk chart

Good evidence from trials shows that several lifestyle modifications lower blood pressure:

• weight reduction to achieve an ideal body weight via reduced fat and total calorie intake;

• regular physical exercise designed to improve fitness; this should be predominantly dynamic (brisk walking, for example) rather than isometric (weight training);

• limiting alcohol consumption to <21 units per week for men and <14 units per week for women;

• reduced use of salt when preparing food and elimination of excessively salty foods from the diet;

• increased consumption of fruit and vegetables.

Lifestyle modifications that further reduce cardiovascular disease risk are:

stopping smoking; reducing total intake of saturated fat,

replacing it with PUFA or MUFA fats;increased intake of oily fish;

regular physical exercise.

Non-pharmacological advice should be offered to all hypertensive people and those with a strong family history of hypertension.

Such measures may obviate the need for drug treatment or reduce the dose or number of drugsrequired to control blood pressure.

When drug treatment has to be introduced more quickly, non-pharmacological measures should be instituted in parallel with drug treatment.

A philosophical paradigm in which one attempts to explainA philosophical paradigm in which one attempts to explain complex phenomena using relatively simple principles.complex phenomena using relatively simple principles.

Dietary Patterns and Mortality Studies•• Assess effect of specific dietary patterns inAssess effect of specific dietary patterns in

longitudinal studies on subsequent mortality.longitudinal studies on subsequent mortality.

•• Patterns used include:Patterns used include:Mediterranean:Mediterranean: W.H.O.:W.H.O.:

High vs. LowHigh vs. Low

High MUFA: SFA ratioHigh MUFA: SFA ratio PUFA/SFA (g)PUFA/SFA (g)Moderate ethanol consumptionModerate ethanol consumption Fruit/vegetableFruit/vegetableHigh consump. legumes/cereals/High consump. legumes/cereals/ Pulses/nuts/seedsPulses/nuts/seedsLow consump. meat/dairy productsLow consump. meat/dairy products Dietary FiberDietary Fiber

ProteinProtein

ResultsMediterranean Dietary Pattern and Survival in the ElderlyMediterranean Dietary Pattern and Survival in the Elderly (Trichopoulou et al. (1995) BMJ 311: 1457-60)(Trichopoulou et al. (1995) BMJ 311: 1457-60)

•• In an elderly rural Greek cohort, total diet score was usedIn an elderly rural Greek cohort, total diet score was usedas a predictor of hazard of death.as a predictor of hazard of death.

•• No individual dietary component was independentlyNo individual dietary component was independentlyassociated with decreased risk of death . associated with decreased risk of death .

•• A one unit increase in diet score was associated withA one unit increase in diet score was associated witha significant 17% reduction in overall mortality (95% CIa significant 17% reduction in overall mortality (95% CI1-31%).1-31%).

ResultsW.H.O. Dietary Pattern and Mortality in Elderly MenW.H.O. Dietary Pattern and Mortality in Elderly Men (Huifbregts et al. (1997) BMJ 315: 13-17)(Huifbregts et al. (1997) BMJ 315: 13-17)

•• In 3 elderly cohorts (Finland, Netherlands, and Italy), In 3 elderly cohorts (Finland, Netherlands, and Italy), healthy diet indicator score was used as a predictor healthy diet indicator score was used as a predictor of hazard of death after 20 years of followup..of hazard of death after 20 years of followup..

•• No individual dietary component was independentlyNo individual dietary component was independentlyassociated with decreased risk of death . associated with decreased risk of death .

•• Healthy diet indicator score was inversely associatedHealthy diet indicator score was inversely associatedwith mortality (p for trend <0.05). Relative risk inwith mortality (p for trend <0.05). Relative risk inhealthiest vs. least healthy score= 0.87 (95% CI:healthiest vs. least healthy score= 0.87 (95% CI:0.77-0.98)0.77-0.98)

Assessment of ObesityAssessment of Obesity

Weight Gain since age 18

Bjorntorp P. Obesity. Lancet 350: 423-426, 1997

Body Mass Index Waist Circumference

Weight (kg) / Height (m)2 Good Estimate of Central Adiposity

Weight (lbs) X 703 Height Squared (in 2) Men: 40”

Women: 35”

Underweight < 18Normal 18-24Overweight 25-29Obese > 30 Level of Fitness

Morbid Obesity > 40

The Obesity Epidemic• U.S.: 20% of men & 25% of women are obese.

• 97 million Americans are overweight or obese. (59.4% of men and 51% of women)

• >10% of 4-5 year old children are obese.– ~2-fold increase over preceding decade

These increases have occurred despite successes in reducingThese increases have occurred despite successes in reducingdietary fat as % of kcal.dietary fat as % of kcal.

Source: NCHS, National Health and Nutrition Examination Survey,1997

Trends in Age-Adjusted Prevalence of Overweight in U.S.

05

10152025303540

1960-62

1971-74

1976-80

1988-91

Years

MenWomenGoal

Kuczmarski et al. National Health and Nutrition Examination Surveys, MMWR; 43: 818-821,1994.

Consequences of Modest Weight Gain

10% increase in weight results in:

Fasting Blood Glucose of 2-3 mg/dL

Systolic Blood Pressure of 6-7 mm Hg

Conditions Associated With Obesity (Relative Risk)

Obesity

Diabetes Mellitus Gall Bladder Disease Sleep Apnea (Type II) (RR>>3) (RR>>3) (RR>>3)

Stroke Hypertension(RR= 2-3) (RR>>3)

Coronary Heart Disease Gout Osteoarthritis (RR= 2-3) (RR=2-3) (RR=2-3)

Upper Body Fat Distribution Increases Metabolic Complications

Central or Visceral Adiposity vs. Subcutaneous Adiposity

Excess central or abdominal fat Minimal risk associatedis an independent predictor of with lower body obesity.disease risk.

Visceral fat is more metabolically active.

Highly susceptible to Syndrome X.

Insulin Resistance

Hyperinsulinemia HDL Cholesterol

SYNDROME X

VLDL Hypertension Cholesterol GlucoseHypertriglyceridemia Intolerance

DEADLY QUARTET

Android Obesity

Zemel M. 1998. National Conference on Obesity and Co-morbidities,Ft. Myers, FL.

Lipoprotein Lipase Leptin IL-6

PAI-1 Adipsin (Complement D)

Lactate Serum Free Fatty Acids Angiotensinogen

Benefits of Modest Weight Loss

• Normalizes high blood pressure• Blood levels

• LDL cholesterol• Insulin• Glycated hemoglobin (HbA1C)• Blood glucose• Uric acid

• HDL Cholesterol• Improved Quality of Life

•• Since only 47% of Americans have optimal BP, theSince only 47% of Americans have optimal BP, thedemographics of aging and its effect of BP are of concern.demographics of aging and its effect of BP are of concern.

•• National guidelines suggest NaCl intakes, reduced alcoholNational guidelines suggest NaCl intakes, reduced alcoholconsumption, K consumption (?), and WEIGHT CONTROL.consumption, K consumption (?), and WEIGHT CONTROL.

•• What about non-pharmacologic approaches?What about non-pharmacologic approaches? Hints-- Hints--

*Replacing animal products with vegetable products BP*Replacing animal products with vegetable products BP*High mineral content (K, Mg), fiber and fat may contribute?*High mineral content (K, Mg), fiber and fat may contribute?*Observational studies indicate inverse associations of BP with:*Observational studies indicate inverse associations of BP with:

Mg, K, Ca, fiber, and protein Mg, K, Ca, fiber, and protein in foodsin foods

Controlling Blood Pressure: Approaches and HypothesesControlling Blood Pressure: Approaches and Hypotheses

Trial Participants:Trial Participants: 459 adults of which 133 had stage I HTN459 adults of which 133 had stage I HTN (B.P. 140-159/90-99)(B.P. 140-159/90-99)

49% women; 60% African-American49% women; 60% African-American

Acclimation Diet:Acclimation Diet: Low fruits (F), vegetables (V), dairy productsLow fruits (F), vegetables (V), dairy products~40% fat for 3 weeks~40% fat for 3 weeks

The Diets:The Diets: 1.1. Control Diet: average for fat, F&V consumptionControl Diet: average for fat, F&V consumption2.2. 8-10 servings of F&V, ~35+% fat8-10 servings of F&V, ~35+% fat3.3. Low-fat (<30% kcal), 8-10 servings of F&V,Low-fat (<30% kcal), 8-10 servings of F&V,

Rich in low-fat dairy foods.Rich in low-fat dairy foods.Duration:Duration: 8 weeks8 weeks

New Engl J Med (1997) 336: 1117-1124New Engl J Med (1997) 336: 1117-1124

Nutrient Control V & F Combo

K (mg) 1700 4700 4700

Mg (mg) 185 500 500

Ca (mg) 450 450 1240

Fiber (g) 9 31 31

Na (g) 3-3.5 3-3.5 3-3.5

Total Fat 36 36 26(% of kcal)

Source: http://dash.bwh.harvard.edu/

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DASH CommentsDASH Comments

B.P. reductions occurred quickly (2 B.P. reductions occurred quickly (2 weeks) and were maintained throughout the weeks) and were maintained throughout the study.study.

Investigators estimated that incidence of CHD Investigators estimated that incidence of CHD and strokes in U.S. could be reduced by and strokes in U.S. could be reduced by 15%15% and and 27%,27%, respectively, if DASH diet were respectively, if DASH diet were followed.followed.

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Dietary Guidelines 2000 (ProposedDietary Guidelines 2000 (Proposed))Aim, Build, Choose--for Good HealthAim, Build, Choose--for Good Health

BBuild a Healthy Baseuild a Healthy Base

CChoose Sensiblyhoose Sensibly

AAim for Fitnessim for Fitness

Dietary Guidelines 2000 (proposed)Dietary Guidelines 2000 (proposed)

AimAim 1.1. Aim for a healthy weight.Aim for a healthy weight.2.2. Be physically active each day.Be physically active each day.

BuildBuild 3.3. Let the Pyramid guide your choices.Let the Pyramid guide your choices.4.4. Choose a variety of grains daily, Choose a variety of grains daily,

especially whole grains.especially whole grains.5.5. Choose a variety of fruits and Choose a variety of fruits and

vegetables daily.vegetables daily.6.6. Keep food safe to eat.Keep food safe to eat.

Choose SensiblyChoose Sensibly

7.7. Choose a diet that is low in saturatedChoose a diet that is low in saturatedfat and cholesterol and moderatefat and cholesterol and moderatein total fat.in total fat.

8.8. Choose beverages and foods that limitChoose beverages and foods that limityour intake of sugars.your intake of sugars.

9.9. Choose and prepare foods with lessChoose and prepare foods with lesssalt.salt.

10.10. If you drink alcoholic beverages, doIf you drink alcoholic beverages, doso in moderation.so in moderation.