Blood pressure, stroke, and coronary heart disease: Part 1, prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias

The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (NIH Publication No. 98-4080)

The "metabolic syndrome" (MetS) is a clustering of components that reflect overnutrition, sedentary lifestyles, and resultant excess adiposity. The MetS includes the clustering of abdominal obesity, insulin resistance, dyslipidemia, and elevated blood pressure and is associated with other comorbidities including the prothrombotic state, proinflammatory state, nonalcoholic fatty liver disease, and reproductive disorders. Because the MetS is a cluster of different conditions, and not a single disease, the development of multiple concurrent definitions has resulted. The prevalence of the MetS is increasing to epidemic proportions not only in the United States and the remainder of the urbanized world but also in developing nations. Most studies show that the MetS is associated with an approximate doubling of cardiovascular disease risk and a 5-fold increased risk for incident type 2 diabetes mellitus. Although it is unclear whether there is a unifying pathophysiological mechanism resulting in the MetS, abdominal adiposity and insulin resistance appear to be central to the MetS and its individual components. Lifestyle modification and weight loss should, therefore, be at the core of treating or preventing the MetS and its components. In addition, there is a general consensus that other cardiac risk factors should be aggressively managed in individuals with the MetS. Finally, in 2008 the MetS is an evolving concept that continues to be data driven and evidence based with revisions forthcoming.

The Metabolic Syndrome

Abnormalities of glucose, insulin, and lipoprotein metabolism are common in patients with hypertension. These changes can also be discerned in normotensive first-degree relatives of hypertensive patients. They are not present in patients with secondary forms of hypertension, do not necessarily improve when blood pressure is lowered pharmacologically, and may even be made worse by some forms of antihypertensive treatment. These metabolic abnormalities may play a part in both the pathogenesis and the complications of hypertension in many patients. We hypothesize that the metabolic abnormalities are linked to the hypertension by a pathophysiologic process that involves the sympathoadrenal system and exerts . . .

Hypertension and Associated Metabolic Abnormalities — The Role of Insulin Resistance and the Sympathoadrenal System

Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention.

A four-year trial assessed whether less severe hypertensives could discontinue antihypertensive drug therapy, using nutritional means to control blood pressure. Randomization was to three groups: group 1—discontinue drug therapy and reduce overweight, excess salt, and alcohol; group 2—discontinue drug therapy, with no nutritional program; or group 3—continue drug therapy, with no nutritional program. In groups 1 and 2 patients resumed drug therapy if pressure rose to hypertensive levels. Loss of at least 4.5 kg (10+ lb) was maintained by 30% of group 1, with a group mean loss of 1.8 kg (4 lb); sodium intake fell 36% and modest alcohol intake reduction was reported. At four years, 39% in group 1 remained normotensive without drug therapy, compared with 5% in group 2. Study findings demonstrated that nutritional therapy may substitute for drugs in a sizable proportion of hypertensives or, if drugs are still needed, can lessen some unwanted biochemical effects of drug treatment. ( JAMA 1987;257:1484-1491)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=365075&pdfFileName=jama_257_11_027.pdf

Nutritional Therapy for High Blood Pressure: Final Report of a Four-Year Randomized Controlled Trial— The Hypertension Control Program

A 5-year trial involving 201 men and women with high-normal blood pressure at baseline demonstrated the ability to reduce the incidence of hypertension in participants randomized to nutritional-hygienic intervention compared with a control group. The incidence of hypertension was 8.8% among 102 intervention group participants vs 19.2% among 99 control group members. The odds ratio for the incidence of hypertension in the control group was 2.4. Mean trial blood pressure also was lower in the intervention compared with the control group ( -1.2 and -1.9 mm Hg, respectively, for diastolic blood pressure at work-site and office visits and -1.3 and - 2.0 mm Hg, respectively, for systolic blood pressure at the two sites). Net weight loss in the intervention group averaged 2.7 kg during the trial; sodium intake was reduced by 25% and reported alcohol intake decreased by 30%. The majority of intervention participants also reported an increase in physical activity. Effect on blood pressure was related particularly to degree of weight loss. Results indicate that even a moderate reduction in risk factors for hypertension among hypertension-prone individuals contributes to the primary prevention of the disease. ( JAMA . 1989;262:1801-1807)

https://jamanetwork.com/journals/JAMA/articlepdf/378849/jama_262_13_038.pdf

Primary Prevention of Hypertension by Nutritional-Hygienic Means: Final Report of a Randomized, Controlled Trial

Studies generally indicate that excretion of sodium, potassium, and water is greater during the day than during the night. To determine whether hypertensive patients exhibit this same pattern of excretion, diurnal variations in excretion of sodium, potassium, creatinine, and water were examined in 107 hypertensive men and women from a clinical trial on control of hypertension by nonpharmacological means--the Hypertension Control Program. Each participant provided two carefully timed 24-hour urine collections divided into daytime and overnight specimens. The median ratios of 24-hour to 8-hour overnight excretion were 2.84, 3.95, 2.99, and 2.77 for sodium, potassium, creatinine, and water, respectively. Thus, more than half of this hypertensive group exhibited a greater rate of sodium and water excretion during sleep than during daytime hours, a reversal of the usual pattern. When the group was subdivided based on age, sex, race, trial randomization group, use of diuretics, and hypertension severity, women had significantly lower ratios of 24-hour to overnight excretion for sodium and water than men and blacks had significantly lower 24-hour to overnight ratios for water and potassium than whites. When the 24-hour to overnight ratios for these hypertensive patients were compared with those for a group of 30 men and women with high-normal blood pressure, those with high-normal blood pressure had significantly larger ratios for sodium and water excretion than the hypertensive group. The results of this study suggest that hypertensive patients may have a different diurnal pattern of sodium and water excretion than normotensive subjects and that further research is needed to clarify this issue.

Do hypertensive patients have a different diurnal pattern of electrolyte excretion

Ability to safely withdraw medication from well-controlled mild hypertensives was tested in a 3-group randomized trial. Group I (Intervention): drugs were stopped 2 months after nutrition counseling began. Counselling continued throughout the remaining years of the trial to achieve: a minimum of 10 lb weight loss if overweight; reduction of sodium intake to 1800 mg/day or less; reduction of alcohol intake to not more than 2 drinks per day. Group II (control group 1): drugs were stopped to see if previous long-term blood pressure control had a carryover effect without diet change. Pressure was monitored frequently in both groups with return to treatment if diastolic blood pressure rose to 90 mmHg or above. Group III (control group 2) remained on drugs for comparison of blood pressure and biochemical variables. In Group I mean weight loss at 3 years was 7 lb (3.18 kg) with 39% losing 10 lb (4.55 kg) or more; sodium intake was reduced by 37%. Blood pressure control without drugs was achieved in 44% of Group I patients. This compares with only 15% in Group II. These findings suggest it may be possible after establishing good blood pressure control, to maintain control in a sizeable proportion with less or no medication, when reduction of weight, sodium, and alcohol is achieved.

Joan Fishman

Papers

Nutritional Therapy for High Blood Pressure: Final Report of a Four-Year Randomized Controlled Trial— The Hypertension Control Program

Primary Prevention of Hypertension by Nutritional-Hygienic Means: Final Report of a Randomized, Controlled Trial

Do hypertensive patients have a different diurnal pattern of electrolyte excretion

Trial on control of hypertension by nutritional means: three-year results.

Nonpharmacological control of hypertension