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Lifestyle and Dietary management of raised Blood Pressure

Lifestyle and Dietary management of raised Blood Pressure


Diagnosis and Epidemiology:


Hypertension is a common primary care diagnosis.It has a strong association with cardiovascular diseases (CVD) and has become one of the leading risk factors for premature death in the world. At least one quarter of adults (and more than half of those older than 60) have high blood pressure

Each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke

JNC-7 Classifies BP for adults aged 18 years or older as follows :

  • Normal: Systolic lower than 120 mm Hg, diastolic lower than 80 mm Hg

  • Prehypertension: Systolic 120-139 mm Hg, diastolic 80-89 mm Hg

  • Stage 1 Hypertension: Systolic 140-159 mm Hg, diastolic 90-99 mm Hg

  • Stage 2 Hypertension : Systolic 160 mm Hg or greater, diastolic 100 mm Hg or greater

Primary or essential hypertension accounts for 90-95% of adult cases, and secondary hypertension accounts for 2-10% of cases. Secondary hypertension can be caused by a variety of endocrine, renal, vascular causes etc which will not be discussed in this blog.

 

How to measure Blood Pressure:


White Coat Hypertension and Masked Hypertension are increasingly recognised and home blood pressure measurement is now the preferred method of diagnosing and monitoring blood pressure.  White Coat Hypertension is present in patients with high BP readings in clinic but normal BP otherwise. Masked hypertension is the opposite, normal clinic BP measurement but high BP readings at other times of the day.

Use a validated blood pressure monitor. List of approved machines can be found on 

https://hypertension.ca/hypertension-and-you/managing-hypertension/measuring-blood-pressure/devices2/ 

Omron upper arm BP monitors are both Gold Certified and reasonably priced. 

https://www.walmart.ca/en/ip/3-series-blood-pressure-monitor/6000200369703

https://www.costco.ca/omron-bp-745---blood-pressure-monitor-with-bluetooth-connectivity.product.100540709.html 

1. Ensure you are relaxed and have an empty urinary bladder at time of measurement. Ensure that you have not had tea of coffee for 30 minutes prior. Sit with your back supported, feet on ground and arm supported near level of heart ( armchair ) . 

2. Use an upper arm cuff and ensure that it is loose fitting. A looser cuff is preferable to a tight cuff as the latter can give a falsely raised diastolic ( lower ) reading. 

3. Take three readings one minute apart and note down the lowest one. Among the data collected, Systolic Blood Pressure reading is the most relevant when deciding which reading is lowest.

4. In order to identify a trend,  measure BP twice a day ( first thing in morning and again after 12 hours ) with alternate arms over five days. So measure twice a day using one arm on first day, other arm next day and so onwards. This will result in data set of ten blood pressure readings. 

5. Discard the two readings of first day and calculate average Systolic, Diastolic and Pulse of remaining eight readings which will be four from left arm and four from right arm. 

6. If you notice a consistent difference in readings between left and right arm of more than 10 mm Hg, provide readings separately and bring this to notice of monitoring physician. 


Target Blood Pressure on Treatment


National Institute of Clinic Excellence (UK) recommends target treated BP 

-below 140/90 in clinic and below 135/85 at home for patients below age 80

-below 150/90 in clinic and below 145/85 at home for age above 80 . 

-below 130/80 for high risk patients such as those with Diabetes and Kidney disease

 

American Heart Association recommends a target BP below 130/80 for all patients.  

This is influenced by the SPRINT trial which demonstrated reduction in morbidity and mortality when blood pressure was controlled more strictly, although more side effects were also reported.

 

Lifestyle and Diet modifications to reduce Blood Pressure:

 

  • Weight loss particularly focussed on reduction of waist circumference.

  • Limit alcohol intake to no more than 1 oz (30 mL) of ethanol per day for men or 0.5 oz (15 mL) of ethanol per day for women and people of lighter weight

  • Reduce sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride). The effect of sodium restriction is greater in black people, older people and in individuals with diabetes, metabolic syndrome or chronic kidney disease

  • Maintain adequate intake of dietary potassium, calcium and magnesium for general health

  • Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health

  • Engage in aerobic exercise at least 30 minutes daily for most days

The Americal Heart Association promotes the consumption of fruits, vegetables, and low-fat dairy products for reducing BP and lowering the risk of stroke. 

 DASH ( Dietary Approaches to Stop Hypertension ) Diet encourages greater intake of

      • fresh fruits and vegetables
      • fish - at least twice a week
      • dietary and soluble fibre
      • whole grains and protein from plant sources
      • reduced in saturated fat and cholesterol.

I would also recommend reduction in processed and refined carbohydrates ( particularly fructose ) and some degree of time restricted eating / intermittent fasting, particularly in patients with co-combitant  features of metabolic syndrome such as prediabetes, diabetes, obstructive sleep apnoea, obesity, fatty liver and raised triglycerides ( often with low HDL ) .

 

Obstructive Sleep Apnea:

 

Obstructive sleep apnea (OSA) is a common but frequently undiagnosed sleep-related breathing disorder defined as an average of at least 10 apneic and hypopenic episodes per sleep hour, which leads to excessive daytime sleepiness. Multiple studies have shown OSA to be an independent risk factor for the development of essential hypertension, even after adjusting for age, gender, and degree of obesity.

Approximately half of individuals with hypertension have OSA, and approximately half with OSA have hypertension. Apneic episodes are associated with increases in sympathetic nerve activity and elevations of BP. Individuals with sleep apnea have increased cardiovascular mortality, in part likely related to the high incidence of hypertension.

Although treatment of sleep apnea with continuous airway positive pressure (CPAP) would logically seem to improve CV outcomes and hypertension, studies evaluating this mode of therapy have been disappointing.  It is likely that patients with sleep apnea have other etiologies of hypertension, including obesity, hyperaldosteronism, increased sympathetic drive, and activation of the renin/angiotensin system that contribute to their hypertension. Although CPAP remains an effective therapy for other aspects of sleep apnea, it should not be expected to normalize BP in the majority of patients.

 

Salient features of Pharmacological Management :

 

 1. ACE-I and ARB's: eg Ramipril , Losartan

Pros: Protect kidneys, particularly in Diabetes and Chronic Kidney Disease

Cons: Less effective in older patients and Afro-Carribeans. ACE-I commonly cause dry cough while ARB generally don't.

2. Calcium Channel blockers: eg Amlodipine, Nifedipine 

Pros: Beneficial for angina / ischaemic heart disease 

Cons: Ankle swelling is common side effect

3. Diuretics : eg Indapamide , Chlorthalidone 

Pros: Beneficial when fluid accumulating eg heart failure or venous incompetence

Cons: Can exacerbate dehydration and gout 

4. Beta Blockers: eg Bisoprolol, Carvedilol

Pros: Beneficial for management of anxiety and stress related hypertension

Cons: Limit exercise tolerance by limiting heart rate and can exacerbate asthma in susceptible patients

5. Alpha Blocker eg Tamsulosin / Flomax 

Pros: Primarily used for males with urinary outflow obstruction related to enlarged prostate

Cons: Can cause sudden drop in BP causing light headedness ( orthostatic hypotension ) 


 

INFORMATION & DISCLAIMER: 

I obtained my primary medical education from India and post graduate MD in Family Medicine from the United Kingdom. After working in National Health Service, England for 15 years, I moved to  Canada five years ago.  As a Family Physician, I consider my speciality as engaging patients, interpreting medical information for them, guiding them through their health journey, promoting wise health choices and encouraging early detection and management of disease. 

The information on this blog is accurate as per time of publishing. Scientific information and evidence changes dynamically and my opinions would change accordingly. 

The recommendations on this blog are not prescriptions and any patients considering these should consult with a physician to check if these are applicable to their unique situation.
 
Physician websites I commonly use for reference include 

 
Patient reference websites I commonly recommend to patients include
 

 
 
https://patient.info/

Patient confidentiality must be upheld at all times and any patients wishing to discuss specific medical scenarios on social media are requested to do so anonymously in 'third party' sense. 

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Comments

  1. VMarch 30, 2021 at 7:29 AM

    Thanks for sharing this doctor. It's informative, especially on how to take bp readings.

    ReplyDelete
  2. UnknownJuly 16, 2021 at 10:12 AM

    Thanks Dr....It's very informative.
    What about ANALOG blood pressure measuring instruments? it gives more accurate readings

    ReplyDelete

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