OST 524

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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
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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 lt21 units per week for
men and lt14 units per week for women
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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.
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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 drugs required to
control blood pressure. When drug treatment
has to be introduced more quickly,
non-pharmacological measures should be
instituted in parallel with drug treatment.
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Reductionism
A philosophical paradigm in which one attempts
to explain complex phenomena using relatively
simple principles.
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Dietary Patterns and Mortality Studies
Assess effect of specific dietary patterns
in longitudinal studies on subsequent
mortality. Patterns used include Mediterranea
n W.H.O. High vs. Low High MUFA SFA
ratio PUFA/SFA (g) Moderate ethanol
consumption Fruit/vegetable High consump.
legumes/cereals/ Pulses/nuts/seeds Low consump.
meat/dairy products Dietary Fiber Protein
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Results
Mediterranean Dietary Pattern and Survival in the
Elderly (Trichopoulou et al. (1995) BMJ
311 1457-60)
In an elderly rural Greek cohort, total diet
score was used as a predictor of hazard of
death. No individual dietary component was
independently associated with decreased risk of
death . A one unit increase in diet score
was associated with a significant 17 reduction
in overall mortality (95 CI 1-31).
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Results
W.H.O. Dietary Pattern and Mortality in Elderly
Men (Huifbregts et al. (1997) BMJ 315
13-17)
In 3 elderly cohorts (Finland, Netherlands, and
Italy), healthy diet indicator score was used
as a predictor of hazard of death after 20
years of followup.. No individual dietary
component was independently associated with
decreased risk of death . Healthy diet
indicator score was inversely associated with
mortality (p for trend lt0.05). Relative risk
in healthiest vs. least healthy score 0.87 (95
CI 0.77-0.98)
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Assessment of Obesity
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 lt
18 Normal 18-24 Overweight 25-29 Obese gt 30
Level of
Fitness Morbid Obesity gt 40
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Weight Gain since age 18
Bjorntorp P. Obesity. Lancet 350 423-426, 1997
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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)
• gt10 of 4-5 year old children are obese.
• 2-fold increase over preceding decade

These increases have occurred despite
successes in reducing dietary fat as of kcal.
Source NCHS, National Health and Nutrition
Examination Survey,1997
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Kuczmarski et al. National Health and Nutrition
Examination Surveys, MMWR 43 818-821,1994.
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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
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Conditions Associated With Obesity
(Relative Risk)
Diabetes Mellitus Gall Bladder Disease
Sleep Apnea (Type II)
(RRgtgt3) (RRgtgt3) (RRgtgt3) Stroke
Hypertension (RR 2-3)
(RRgtgt3) Coronary Heart Disease Gout
Osteoarthritis (RR 2-3)
(RR2-3) (RR2-3)
Obesity
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Upper Body Fat Distribution Increases Metabolic
Complications
Central or Visceral Adiposity vs.
Subcutaneous Adiposity Excess central or
abdominal fat Minimal risk associated is
an independent predictor of with lower
body obesity. disease risk. Visceral fat is
more metabolically active. Highly susceptible
to Syndrome X.
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Insulin Resistance
Hyperinsulinemia HDL
Cholesterol
SYNDROME X VLDL Hypertension
Cholesterol Glucose Hypertriglyceridemi
a Intolerance DEADLY
QUARTET Android Obesity
Zemel M. 1998. National Conference on Obesity and
Co-morbidities, Ft. Myers, FL.
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Adipose Tissue as an Endocrine Organ
Lipoprotein Lipase Leptin
IL-6 PAI-1 Adipsin
(Complement D) Lactate Serum Free
Fatty Acids Angiotensinogen
Increasing Fat Stores
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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

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Controlling Blood Pressure Approaches and
Hypotheses
Since only 47 of Americans have optimal BP,
the demographics of aging and its effect of BP
are of concern. National guidelines suggest
NaCl intakes, reduced alcohol consumption,
K consumption (?), and WEIGHT CONTROL. What
about non-pharmacologic approaches?
Hints-- Replacing animal products with
vegetable products BP High mineral content
(K, Mg), fiber and fat may contribute? Observ
ational studies indicate inverse associations of
BP with Mg, K, Ca, fiber, and protein in
foods
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Trial Participants 459 adults of which 133 had
stage I HTN (B.P. 140-159/90-99) 49
women 60 African-American Acclimation
Diet Low fruits (F), vegetables (V), dairy
products 40 fat for 3 weeks The
Diets 1. Control Diet average for fat, FV
consumption 2. 8-10 servings of FV, 35
fat 3. Low-fat (lt30 kcal), 8-10 servings of
FV, Rich in low-fat dairy foods. Duration 8
weeks
New Engl J Med (1997) 336 1117-1124
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DASH Target Nutrient Levels
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)
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Source http//dash.bwh.harvard.edu/
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DASH Comments B.P.
reductions occurred quickly (2 weeks) and
were maintained throughout the study. Investig
ators estimated that incidence of CHD and
strokes in U.S. could be reduced by 15 and
27, respectively, if DASH diet were followed.
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Dietary Guidelines 2000 (Proposed) Aim,
Build, Choose--for Good Health
Build a Healthy Base
Aim for Fitness
Choose Sensibly
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Dietary Guidelines 2000 (proposed) Aim 1. Aim
for a healthy weight. 2. Be physically active
each day. Build 3. Let the Pyramid guide your
choices. 4. Choose a variety of grains daily,
especially whole grains. 5. Choose a
variety of fruits and vegetables
daily. 6. Keep food safe to eat.
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Choose Sensibly 7. Choose a diet that is low
in saturated fat and cholesterol and
moderate in total fat. 8. Choose beverages
and foods that limit your intake of
sugars. 9. Choose and prepare foods with
less salt. 10. If you drink
alcoholic beverages, do so in moderation.