Chronic hypertension lifestyle modification

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2017 ACC/AHA Hypertension Guidelines

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Lakshmi Gopalakrishnan , M.D.; Arzu Kalayci, M.D. [2]

Overview

Lifestyle modification may prevent or delay the occurrence of hypertension, reduce the blood pressure, increase the efficacy of medications, decrease risk factors for hypertension and reduce the incidence of target organ damage. Lifestyle modification should be implemented in all hypertensive patients irrespective of the hypertensive stage. lifestyle changes alone can be considered as initial antihypertensive measure in patients with stage 1 hypertension, even in the presence of up to 1 or 2 risk factors (excluding diabetes or metabolic syndrome or established target organ damage). In these patients, pharmacologic therapy can wait for three to six months until lifestyle changes alone are provided a chance to control blood pressure.

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

Nonpharmacological Interventions

Class I
"1. Weight loss is recommended to reduce BP in adults with elevated BP or hypertension who are overweight or obese.(Level of Evidence: A) "
"2. A heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, that facilitates achieving a desirable weight is recommended for adults with elevated BP or hypertension.(Level of Evidence: A) "
"3. Sodium reduction is recommended for adults with elevated BP or hypertension.(Level of Evidence: A) "
"4. Potassium supplementation, preferably in dietary modification, is recommended for adults with elevated BP or hypertension, unless contraindicated by the presence of chronic kidney disease (CKD) or use of drugs that reduce potassium excretion.(Level of Evidence: A) "
"5. Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension.(Level of Evidence: A) "
"6. Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than 2 and 1 standard drinks* per day, respectively.(Level of Evidence: A) "
In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol)

Strategies to Promote Lifestyle Modification

Class I
"1. Effective behavioral and motivational strategies to achieve a healthy lifestyle (i.e., tobacco cessation, weight loss, moderation in alcohol intake, increased physical activity, reduced sodium intake, and consumption of a healthy diet) are recommended for adults with hypertension.(Level of Evidence: C-EO) "

Structured, Team-Based Care Interventions for Hypertension Control

Class I
"1. A team-based care approach is recommended for adults with hypertension.(Level of Evidence: A) "

Electronic Health Record (EHR) and Patient Registries

Class I
"1. Use of the EHR and patient registries is beneficial for identification of patients with undiagnosed or undertreated hypertension.(Level of Evidence: B-NR) "
"2. Use of the EHR and patient registries is beneficial for guiding quality improvement efforts designed to improve hypertension control .(Level of Evidence: B-NR) "

Telehealth Interventions to Improve Hypertension Control

Class IIa
"1. Telehealth strategies can be useful adjuncts to interventions shown to reduce BP for adults with hypertension.(Level of Evidence: A) "
"2. Use of performance measures in combination with other quality improvement strategies at patient-, provider-, and system-based levels is reasonable to facilitate optimal hypertension control.(Level of Evidence: B-NR) "

Quality Improvement Strategies

Class IIa
"1. Use of quality improvement strategies at the health system, provider, and patient levels to improve identification and control of hypertension can be effective.(Level of Evidence: B-R) "

Quality Improvement Strategies

Class IIa
"1. Financial incentives paid to providers can be useful in achieving improvements in treatment and management of patient populations with hypertension.(Level of Evidence: B-R) "
"1. Health system financing strategies (e.g., insurance coverage and copayment benefit design) can be useful in facilitating improved medication adherence and BP control in patients with hypertension.(Level of Evidence: B-NR) "

The Plan of Care for Hypertension

Class I
"1. Every adult with hypertension should have a clear, detailed, and current evidence-based plan of care that ensures the achievement of treatment and self-management goals, encourages effective management of comorbid conditions, prompts timely follow-up with the healthcare team, and adheres to CVD guideline-directed medical therapy (GDMT).(Level of Evidence: C-EO) "

2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk[1]

Recommendations for Lifestyle Management to Reduce Blood Pressure

Diet

Class I
"1. 1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats.

a. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes).
b. Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.(Level of Evidence: A)"

"2. Lower sodium intake.(Level of Evidence: A)"
"3. Combine the DASH dietary pattern with lower sodium intake.(Level of Evidence: A)"
Class IIa
"1. a. Consume no more than 2,400 mg of sodium/d;

b. Further reduction of sodium intake to 1,500 mg/d can result in even greater reduction in BP; and
c. Even without achieving these goals, reducing sodium intake by at least 1,000 mg/d lowers BP. (Level of Evidence: B)"

Physical Activity

Class IIa
"1. In general, advise adults to engage in aerobic physical activity to lower BP: 3–4 sessions per wk, lasting on average 40 min per session, and involving moderate- to vigorous-intensity physical activity. (Level of Evidence: A)"

2013 ESH/ESC Guidelines For The Management of Arterial Hypertension[2]

Summary of Recommendations on Lifestyle Modification[2]

Class I
"1. Salt restriction to 5-6 g per day is recommended.(Level of Evidence: A)"
"2. Moderation of alcohol consumption to no more than 20-30 g of ethanol per day in men and to no more than 10-20 g of ethanol per day in women is recommended. (Level of Evidence: A)"
"3. Increased consumption of vegetables, fruits, and low-fat dairy products is recommended.(Level of Evidence: A)"
"4. Reduction of weight to BMI of 25 kg/m2 and of waist circumference to <102 cm in men and <88 cm in women is recommended, unless contraindicated.(Level of Evidence: A)"
"5. Regular exercise, i.e. at least 30 min of moderate dynamic exercise on 5 to 7 days per week is recommended.(Level of Evidence: A)"
"6. It is recommended to give all smokers advice to quit smoking and to offer assistance.(Level of Evidence: A)"

JNC 7 Lifestyle Modification Recommendations

According to JNC 7, lifestyle measures or interventions include the following, by order of effect on SBP reduction:[3]


Modification Recommendation Approximate SBP Reduction (Range)
Weight reduction Maintain normal body weight (body mass index 18.5–24.9 kg/m2) 5–20 mmHg / 10 kg weight loss [4][5]
Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat. 8–14 mmHg [6][7]
Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). 2–8 mmHg [6][7][8]
Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week). 4–9 mmHg [9][10]
Moderation of alcohol consumption Limit consumption to no more than consumption 2 drinks (1 oz or 30 mL ethanol; e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter weight persons. 2–4 mmHg [11]

References

  1. "Reprint: 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk". J Am Pharm Assoc (2003). 54 (1): e2. 2014. doi:10.1331/JAPhA.2014.14501. PMID 24898715.
  2. 2.0 2.1 Authors/Task Force Members. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A; et al. (2013). "2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)". Eur Heart J. 34 (28): 2159–219. doi:10.1093/eurheartj/eht151. PMID 23771844.
  3. Cuddy ML (2005). "Treatment of hypertension: guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1)". J Pract Nurs. 55 (4): 17–21, quiz 22-3. PMID 16512265.
  4. (1997) Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure. The Trials of Hypertension Prevention, phase II. The Trials of Hypertension Prevention Collaborative Research Group. Arch Intern Med 157 (6):657-67. PMID: 9080920
  5. He J, Whelton PK, Appel LJ, Charleston J, Klag MJ (2000) Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension 35 (2):544-9. PMID: 10679495
  6. 6.0 6.1 Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D et al. (2001) Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 344 (1):3-10. DOI:10.1056/NEJM200101043440101 PMID: 11136953
  7. 7.0 7.1 Vollmer WM, Sacks FM, Ard J, Appel LJ, Bray GA, Simons-Morton DG et al. (2001) Effects of diet and sodium intake on blood pressure: subgroup analysis of the DASH-sodium trial. Ann Intern Med 135 (12):1019-28. PMID: 11747380
  8. Chobanian AV, Hill M (2000) National Heart, Lung, and Blood Institute Workshop on Sodium and Blood Pressure : a critical review of current scientific evidence. Hypertension 35 (4):858-63. PMID: 10775551
  9. Kelley GA, Kelley KS (2000) Progressive resistance exercise and resting blood pressure : A meta-analysis of randomized controlled trials. Hypertension 35 (3):838-43. PMID: 10720604
  10. Whelton SP, Chin A, Xin X, He J (2002) Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 136 (7):493-503. PMID: 11926784
  11. Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK (2001) Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 38 (5):1112-7. PMID: 11711507

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