I. Health Behaviour Management

Prevention and Treatment

Subgroup Members: Simon L. Bacon, PhD; Janusz Kaczorowski, PhD; Luc Trudeau, MD; Swapnil Hiremath, MD, MPH; Norman R.C. Campbell, C.M., MD; Gregory Moullec, PhD; Scott A. Lear, PhD; Debra Reid, PhD, RD
Central Review Committee: Stella S. Daskalopoulou, MD, PhD; Kaberi Dasgupta, MD, MSc; Kelly B. Zarnke, MD, MSc; Kara Nerenberg, MD, MSc; Alexander A. Leung, MD, MPH; Kevin C. Harris, MD, MHSc; Kerry McBrien, MD, MPH; Sonia Butalia, BSc, MD; Meranda Nakhla, MD, MSc
Chair: Doreen M. Rabi, MD, MSc

This information is based on the Hypertension Canada guidelines published in Leung, Alexander A. et al. Hypertension Canada’s 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults. Can J Cardiol 2017; 33(5): 557-576.

Guidelines

  1. Physical exercise
    1. For non-hypertensive individuals (to reduce the possibility of becoming hypertensive) or for hypertensive patients (to reduce their BP), prescribe the accumulation of 30-60 minutes of moderate intensity dynamic exercise (e.g., walking, jogging, cycling, or swimming) 4-7 days per week in addition to the routine activities of daily living (Grade D). Higher intensities of exercise are not more effective (Grade D). For non-hypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise (such as free weight lifting, fixed weight lifting, or handgrip exercise) does not adversely influence BP (Grade D).
  2. Weight reduction
    1. Height, weight, and waist circumference should be measured and body mass index calculated for all adults (Grade D).
    2. Maintenance of a healthy body weight (body mass index of 18.5 to 24.9 kg/m2, and waist circumference <102 cm for men and <88 cm for women) is recommended for non-hypertensive individuals to prevent hypertension (Grade C) and for hypertensive patients to reduce BP (Grade B). All overweight hypertensive individuals should be advised to lose weight (Grade B).
    3. Weight loss strategies should use a multidisciplinary approach that includes dietary education, increased physical activity, and behavioural intervention (Grade B).
  3. Alcohol consumption
    1. To prevent hypertension and reduce BP in adults, individuals should limit alcohol consumption to ≤2 drinks per day, and consumption should not exceed 14 standard drinks per week for men and 9 standard drinks per week for women (Grade B). (Note: One standard drink is considered to be equivalent of 13.6 g or 17.2 mL of ethanol or approximately 44 mL [1.5 oz] of 80 proof [40%] spirits, 355 mL [12 oz] of 5% beer, or 148 mL [5 oz] of 12% wine.)
  4. Diet
    1. It is recommended that hypertensive patients and normotensive individuals at increased risk of developing hypertension consume a diet that emphasizes fruits, vegetables, low-fat dairy products, whole grain foods rich in dietary fibre, and protein from plant sources that is reduced in saturated fat and cholesterol (Dietary Approaches to Stop Hypertension [DASH] diet (34-37); Supplemental Table S9) (Grade B).
  5. Sodium intake
    1. To prevent hypertension and reduce BP in hypertensive adults, consider reducing sodium intake toward 2000 mg (5 g of salt or 87 mmol of sodium) per day (Grade A).
  6. Calcium and magnesium intake
    1. Supplementation of calcium and magnesium is not recommended for the prevention or treatment of hypertension (Grade B).
  7. Potassium intake
    1. In patients not at risk of hyperkalemia (see Table 2), increase dietary potassium intake to reduce BP (Grade A).
  8. Stress management
    1. In hypertensive patients in whom stress might be a contributor to high BP, stress management should be considered as an intervention (Grade D). Individualized cognitive-behavioural interventions are more likely to be effective when relaxation techniques are used (Grade B).

Background

A. Physical Exercise

1. For non-hypertensive individuals (to reduce the possibility of becoming hypertensive) or for hypertensive patients (to reduce their BP), prescribe the accumulation of 30-60 minutes of moderate intensity dynamic exercise (e.g., walking, jogging, cycling, or swimming) 4-7 days per week in addition to the routine activities of daily living (Grade D). Higher intensities of exercise are not more effective (Grade D). For non-hypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise (such as free weight lifting, fixed weight lifting, or handgrip exercise) does not adversely influence BP (Grade D).

Because of an acute increase in blood pressure (BP), and potential use of the Valsalva manoeuvre during weight training, there are concerns this form of exercise could adversely raise BP levels, leading to an increased risk of hemorrhagic stroke or subarachnoid hemorrhage. In a meta-analysis of 28 randomized controlled trials examining the effect of resistance training on BP, 33 study groups were pooled (1012 participants in total) (1). Most of these trials examined dynamic resistance training (30 study groups), largely with the use of weight or resistance machines (27 study groups). Twenty-two of the trials involved supervised exercise. For individuals with a baseline BP of 139/89 mm Hg, reductions in systolic BP (SBP) (mean change -3.9 mm Hg; 95%confidence interval [CI], -6.4 to -1.2) and in diastolic BP (DBP) (mean change -3.9 mm Hg; 95%CI, -5.6 to -2.2) were observed. In subjects with hypertension, statistically non-significant reductions in mean SBP and DBP occurred (-1.7 mm Hg systolic; 95%CI, -5.5 to +2.0, and -1.1 mm Hg diastolic; 95%CI, -3.1 to +0.91). Maximum baseline systolic and diastolic values were 154 mm Hg and 95 mm Hg, respectively, with no serious adverse events reported.

Overall, this meta-analysis might have been underpowered to detect statistically significant reductions in BP in hypertensive patients. However, absence of adverse effects provides reassurance regarding safety of resistance training in hypertensive individuals. Considering resistance training is associated with additional benefits on cardio-metabolic risk factor levels, the CHEP Guideline recommend that this type of exercise need not be avoided for fear of affecting adversely BP levels.

Meta-analyses of randomized trials confirm moderate intensity dynamic exercise (such as walking, jogging, cycling or swimming) reduces resting BP (up to 7.4/5.8 mm Hg in hypertensives, and 2.6/1.8 mm Hg in non-hypertensives) (6,7,10,11). Clinically important improvements in both SBP and DBP may be achieved from as little as 30 minutes to 60 minutes per week of moderate intensity aerobic exercise, particularly in adults (2-7). Greater frequencies of exercise (i.e., four to seven days per week) may produce greater reductions in BP (8-10) and may aid in weight loss.

B. Weight reduction

1. Height, weight, and waist circumference should be measured and body mass index calculated for all adults (Grade D).

Extensive epidemiologic data support a positive association between obesity and elevated blood pressure. Although BMI does not directly measure body fat, it is the metric most often used as an index of adiposity because is simple to calculate, is based on readily available clinical data, and predicts the development of obesity-related complications and death. The incidence of hypertension and associated cardiovascular risk factors increases substantially within the overweight and obese BMI categories (42,50,54). Prospective cohort studies also show a association between weight gain and increases in blood pressure (55,56,57). In the Framingham Study, for each 4.5 kg of weight gain, there was an associated increase in SBP of 4 mm Hg in both men and women (59). Furthermore, BP is reduced by 1.6 mmHg/1.1 mmHg for each 1 kg of weight loss (59).

High amounts of abdominal fat predicts development of hypertension to an even greater extent (43). Within each BMI category including normal weight (18.5 kg/m² to 24.9 kg/m²), overweight (25.0 to 29.9 kg/m²) and class I obesity (30.0 to 34.9 kg/m²), a high WC (greater than 102 cm in men and greater than 88 cm in women) is associated with a higher risk of hypertension (44-50). The standard method of measuring WC is by positioning the measuring tape horizontally, midway between the iliac crest and the bottom of the rib cage, in a standing patient at end-expiration (53).

2. Maintenance of a healthy body weight (body mass index of 18.5 to 24.9 kg/m2, and waist circumference <102 cm for men and <88 cm for women) is recommended for non-hypertensive individuals to prevent hypertension (Grade C) and for hypertensive patients to reduce BP (Grade B). All overweight hypertensive individuals should be advised to lose weight (Grade B).

The phase I study of The Trials of Hypertension Prevention showed that weight reduction was more effective than other lifestyle strategies in preventing hypertension (61). Data from randomized controlled weight reduction trials (including this trial), show that in this population, weight reduction is associated with a reduction in blood pressure (BP), which indicates the potential utility of weight reduction in preventing hypertension (60-62). Several randomized controlled trials of weight loss demonstrate that a reduction in weight is associated with a reduction in blood pressure in overweight hypertensive patients (52,63-70). For overweight patients, efficacy of weight loss in reducing BP is similar to that of single antihypertensive drug therapy (66,67).

3. Weight loss strategies should use a multidisciplinary approach that includes dietary education, increased physical activity, and behavioural intervention (Grade B).

Multidisciplinary approaches to weight loss appear to be more effective in reducing BP and promoting weight loss (54,74,75).

C. Alcohol consumption

1. To prevent hypertension and reduce BP in adults, individuals should limit alcohol consumption to ≤2 drinks per day, and consumption should not exceed 14 standard drinks per week for men and 9 standard drinks per week for women (Grade B). (Note: One standard drink is considered to be equivalent of 13.6 g or 17.2 mL of ethanol or approximately 44 mL [1.5 oz] of 80 proof [40%] spirits, 355 mL [12 oz] of 5% beer, or 148 mL [5 oz] of 12% wine.)

Healthcare professionals should determine the alcohol consumption of all adult patients. One drink is considered 13.6 g or 17.2 mL of ethanol, or approximately 1.5 oz. of 80 proof (40%) spirits, 12 oz. of 5% beer or 5 oz. of 12% wine. Some randomized controlled trials have shown that that limiting alcohol consumption can blood pressure (SBP) (76-77); however, statistical significance in other trials (79–83), possibly because of low adherence to alcohol reduction interventions.  Overall, the data do not provide strong evidence, but are consistent with the conclusion that heavy alcohol consumption leads to increased BP.

D. Diet

1. It is recommended that hypertensive patients and normotensive individuals at increased risk of developing hypertension consume a diet that emphasizes fruits, vegetables, low-fat dairy products, whole grain foods rich in dietary fibre, and protein from plant sources that is reduced in saturated fat and cholesterol (Dietary Approaches to Stop Hypertension [DASH] diet (34-37); Supplemental Table S9) (Grade B).

Among non-hypertensive individuals, the Dietary Approaches to Stop Hypertension (DASH) diet (Table I) reduced BP by 3.5/2.1 mm Hg (SBP/DBP) respectively, while in hypertensive patients, the DASH diet reduced BP by 11.4/5.5 mm Hg (112–117).

E. Sodium Intake

1. To prevent hypertension and reduce BP in hypertensive adults, consider reducing sodium intake toward 2000 mg (5 g of salt or 87 mmol of sodium) per day (Grade A).

This recommendation is primarily based on clinical trial evidence from two systematic reviews published in 2013 (128,129). The evidence focuses on BP as a surrogate endpoint. The RTF noted the inconclusive nature of data examining morbidity and mortality endpoints, and awaits results of further studies examining these endpoints (130).

He and colleagues (128) examined 22 crossover- and parallel-arm randomized controlled trials that enrolled 999 hypertensive individuals and compared reduced salt intake with usual salt intake over a period of 4–52 weeks. Studies documenting a 40–120 mmol reduction in 24-hour urine sodium (equivalent to 920–2760 mg of sodium or 2.3–7 g of salt) were included. The median baseline BP was 148/93 mm Hg and the median baseline 24-hour urine sodium excretion was 162 mmol (range, 125–191 mmol). The pooled estimated reduction in sodium intake between usual intake and reduced intake was 75 mmol per 24 hours (95% confidence interval [CI], 52–112). Therefore, from baseline levels in the usual care arm, interventions reduced sodium intake toward a threshold of 87 mmol (i.e., 162–75 mmol) or 2000 mg per day. Reduced intake led to a 5.39 mm Hg reduction (95%CI, 4.15–6.62) in SBP and a 2.82 mm Hg reduction (95%CI, 2.11–3.54) in DBP (pooled mean effects).

The systematic review by Aburto and colleagues (129) was conducted on behalf of the World Health Organization (WHO) Nutrition Guidance Expert Advisory Group Subgroup on Diet and Health. In 36 randomized controlled trials that enrolled 5508 participants overall and 1478 subjects with hypertension, a reduction in sodium intake resulted in a mean 3.39 mm Hg reduction (95%CI, 2.46–4.31 mm Hg) in SBP in all subjects, and a 4.06 mm Hg SBP reduction (95%CI, 2.96–5.15) in the subgroup with hypertension. A subgroup analysis indicated that a reduction in sodium intake to less than 2000 mg/d led to a decrease in SBP of 3.47 mm Hg (95%CI, 0.76–6.18). Concurrent use of antihypertensive medication did not appear to diminish the effect of decreasing sodium intake. (Additional references: 131–155)

F. Calcium and magnesium intake

1. Supplementation of calcium and magnesium is not recommended for the prevention or treatment of hypertension (Grade B).

The BP-lowering benefits of the DASH diet have been repeatedly demonstrated in hypertensive patients and normotensive individuals at risk of developing hypertension who are consuming a diet deficient in potassium, calcium and magnesium, and high in total and saturated fat (118,156). An adequate intake of potassium, calcium and magnesium is an important component of the DASH diet. It mitigates salt sensitivity and appears to have a wide range of benefits beyond lowering BP including reducing insulin resistance and improving lipid metabolism (156–158).

The weight of evidence from randomized controlled trials indicates that increasing intake of or supplementing diet with magnesium or calcium is not associated with prevention of hypertension, nor does it effectively reduce high BP. Therefore, the importance of ensuring adequate intake of calcium and magnesium cations by dietary means rather than by supplements should be emphasized in hypertensive patients.

G. Potassium intake

1. In patients not at risk of hyperkalemia (see Table 2), increase dietary potassium intake to reduce BP (Grade A).

A meta-analysis of 22 randomized controlled trials b reported that increased potassium intake reduced SBP by 3.49 mm Hg (95% CI, 1.82-5.15 mm Hg) and DBP by 1.96 mm Hg (95% CI, 0.86-3.06 mm Hg) (159). Notably, BP reduction was only seen in those with hypertension. There was no significant dose response according to the amount of potassium consumed. However, BP reduction appeared to be greatest in those who consumed the greatest amount of salt (reduction in SBP of 6.9 vs 2.0 mmHg in those with high [4 g/d] vs low [< 2 g/d] sodium intake). Although the magnitude of BP reduction is largest when the sodium intake is high, there still appears to be evidence of additive benefit when dietary interventions combine potassium increases with sodium reduction strategies (117).

The magnitude of expected BP reduction appears to be similar regardless of whether a potassium intervention is delivered through dietary changes or prescribed supplements (159). If possible, however, we recommend dietary modification as the preferred method of increasing potassium intake because of the additional nutritional benefits of whole foods over prescribed supplements. When appropriate, patients with hypertension should be encouraged to consume foods with higher potassium content (eg, fresh fruits, vegetables, and legumes). Overall, potassium interventions appear to be largely safe with no increase in reported adverse events (159). However, it should be acknowledged that the generalizability of existing studies is limited by stringent exclusion criteria (eg, excluding those with impaired urinary potassium excretion, renal failure or use of medications that predispose to hyperkalemia). As such, although the literature broadly supports increasing potassium intake to lower BP, caution should be exercised in those at higher risk of developing hyperkalemia including:

  1. Patients receiving renin-angiotensin-aldosterone inhibitors
  2. Patients receiving other drugs that can cause hyperkalemia (eg, trimethoprim and sulfamethoxazole, amiloride, or triamterene)
  3. Patients with chronic kidney disease (glomerular filtration rate < 60 mL/min/1.73 m2)
  4. Patients with baseline serum potassium > 4.5 mmol/L

H. Stress management

1. In hypertensive patients in whom stress might be a contributor to high BP, stress management should be considered as an intervention (Grade D). Individualized cognitive-behavioural interventions are more likely to be effective when relaxation techniques are used (Grade B).

Evidence emerging within the past several decades suggests that psychosocial factors from emotional states such as depression, behavioural dispositions such as hostility, and psychosocial stress can directly influence both physiological function and health outcomes (258,259). A systematic review (260) determined that stress related to depression, social isolation and lack of quality social support increased the risk of coronary artery disease similar to more conventional risk factors such as smoking, dyslipidemia and hypertension.

These findings suggest a link between psychosocial factors and atherosclerosis; however, the specific nature of the association is not known, and it still remains unclear exactly what the role of stress management on long-term outcomes related to hypertension morbidity may be (261–268). However, while there is no evidence that stress management prevents hypertension, there is some evidence that stress management can reduce blood pressure in hypertensive patients.

Although evidence indicated that single-component interventions such as transcendental meditation and relaxation therapy could be efficacious in some centres, meta-analyses showed only small effects or no reduction in blood pressure. In one meta-analysis (269) the change in BP with such interventions was –1.5 to +2.9/–0.8 to +1.2 mm Hg (SBP/DBP) respectively, whereas the change was –9/–6 mm Hg in a second meta-analysis (270). A third meta-analysis (271) showed a similar pattern, although differences between individualized cognitive stress management and other paired or single-component interventions were not as marked (Table 1) (269–271). There was some overlap (approximately two-thirds) in the studies that were included in the meta-analyses, as determined from an examination of the bibliographies of the original papers.

In contrast, multicomponent individualized cognitive behavioural interventions reduce BP to a greater degree and over a longer period of time. Linden and Chambers (270) performed a meta-analysis and found that BP was reduced by 9.7/7.2 mm Hg with multicomponent relaxation techniques. With individualized cognitive stress management, BP was reduced on average by 15.2/9.2 mm Hg. The key to this approach is tailoring the intervention to the patient’s needs.

Strategies used in individualized cognitive behavioural stress therapy include increasing awareness of stressors and stress responses, re-evaluating negative life events, communications skills training (e.g., marital communication and assertiveness training), development of problem- solving skills, management of negative emotions (e.g., anger and anxiety) and techniques for decreasing sympathetic arousal (e.g., relaxation exercises).

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