Non-pharmacological treatment of Hypertension

(1)	Lifestyle Factors

1.	Stop smoking

2.	Avoid excess alcohol
(1) Journal of Hypertension, February 1996
(2) Alcohol and blood pressure – the Intersalt study, Marmot et al, BMJ 308(6939): May 14th 1994, 1263 - 1267
•	multicentre epidemiological study
•	questionnaires about alcohol consumption over previous week
•	>300mls (12 units) per week   BP
•	conclude alcohol positively associated with BP. 

(3) Alcohol and hypertension – kill or cure, Beilin et al, Journal of Human Hypertension 10 Suppl 2: S1 – S5, Feb 1996
•	Linear relationship, threshold effect 2-3 drinks/day
•	Effects additive to effects of obesity and high dose COCP
•	RCTs show that  alcohol reduces BP in treated and untreated hypertensives
•	Regular light/moderate drinking (1-4 drinks/day) appears to protect against coronary deaths and ischaemic CVA, while heavier drinking increases risk of haemorrhagic stroke

3.	Increased exercise
(1)	Lifestyle intervention: results of the Treatment of Mild Hypertension Study (TOHMS). Elmer et al, Preventive Medicine 24(4): 378 – 388, July 1995
•	weight loss
•	sodium restriction
•	reduced alcohol
•	increased physical activity
•	drug intervention
•	showed that patients could undertake and maintain these interventions.

4.	Avoid obesity
•	BP associated with overall BMI
•	Na+ restriction and weight loss in treatment of HTN
•	JAMA 279:839-46, 1998
•	Insulin resistance 2 to obesity  increased BP

5.	Optimise cholesterol and triglycerides
(1) Serum cholesterol, blood pressure, cigarette smoking, and death from CHD. Overall findings and differences by age for 316099 white men. Multiple Risk Factor Intervention Trial Research Group (MRFIT), Neaton et al, Archives of Internal Medicine 152(1): 56 – 64, Jan 1992
•	Randomised primary prevention trial
•	22 US medical centres from 1973 – 1982 to see whether  elevated cholesterol and DBP, and ceasing cigarette smoking would reduce CHD mortality.
•	Men 35-57 with  1 risk factor randomised to special intervention or usual care group and followed for 6-8 years
•	UC – info on risk factors, referred to usual sources of care, annual exam
•	SI – group and individual counselling on fat-modified diet, stepped-care drug treatment program for DBP and smoking cessation (if required). Risk factor assessments every 4/12 and annual exams
•	12 year follow-up
•	strong relationship between serum cholesterol >4.65, SBP >110mmHg, DBP>70mmHg and mortality from CHD
•	smokers with cholesterol and SBP in highest quintiles had death rates  20 times than non-smoking men with SBP and cholesterol in lowest quintile.
•	SBP greater predictor than DBP
•	MRFIT showed multiple dietary factors influence BP
•	Also showed small amts exercise (4.9 mins/day) reduced mortality from CHD

6.	Decrease salt intake 
•	Intake 9 – 12g/day (RDA 500mg/8-10mmol)
•	15% from cooking/meals
•	75% from salt added during food processing

(1) Intersalt revisited Elliot et al, BMJ 18/5/96, pp1249 – 1253)
•	Stronger relationship between high sodium intake and DBP
•	Used 4 different methods to reanalyse relationship between salt intake and effect on BP with age.
•	Original findings found to be robust
•	A higher sodium intake by 100mmol/day over 30 years will result in SBP rise 10mmHg, DBP by 6mmHg

(2) Salt – overwhelming evidence but still no action MacGregor et al, BMJ 312(7041): 1287 – 1289
•	Cash to set up direct links with food industry, with the aim to reach consensus about relationship between salt and BP, and how to reduce salt in food
•	Evidence in support of such a link
•	Epidemiological studies, e.g. Intersalt
•	Intervention studies – newborn babies, restricted salt for 6/12  lower BP than controls. Portuguese study showed than less salt in processed food  lower BP
•	Migration studies – Kenyans who migrated from rural to urban. BP higher in latter.
•	Animal studies.

(3) Geleijnse et al, BMJ 309(6952): 13th August 1994 436-440
•	RDBPCT
•	100 males, 100 females
•	half had common salt, half mineral salt (low sodium, high potassium, high magnesium)
•	mineral salt  lowering DBP 33mmHg, systolic 8mmHg

(4) Sodium restriction and weight loss in the treatment of hypertension of older patients, Whelton et al, JAMA 279: 839 – 846
•	585 obese patients - randomised to usual care, or sodium restriction, or weight loss, or both
•	390 non-obese randomised to usual care or salt restriction
•	SBP <145mmHg, DBP <85mmHg while treated with single antihypertensive
•	Aims – salt intake <80mmol/day, weight loss >4.5kg, withdraw antiHTN meds after 3/12, maintain BP < 150/90mmHg over 6/52 following withdrawal
•	Majority able to withdraw medication initially
•	At 30 months, 36/144 in sodium-restricted group remained off meds, 35/147 in weight loss group, 44/147 on both
•	Imply NNT for either sodium restricted or weight loss of 5, and for both, of 3, in obese patients

7.	?? Decreasing stress

8.	Optimise control of diabetes