Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials

Dietary starch intake of individuals and their blood pressure: the International Study of Macronutrients and Micronutrients and Blood Pressure

OBJECTIVE

Data from the Multiple Risk Factor Intervention Trial show an independent direct association between starch intake and blood pressure in American men at higher risk of coronary heart disease. Cross-sectional data from the International Study of Macronutrients and Micronutrients and Blood Pressure (INTERMAP) were used to assess relations of dietary starch intake to blood pressure in men and women from four countries.

METHODS

Data include 83 nutrients from four multipass 24-h dietary recalls and two timed 24-h urine collections; eight blood pressure readings; and questionnaire data, for 4680 participants aged 40-59 years from 17 population samples in Japan, People's Republic of China, United Kingdom, and United States of America.

RESULTS

In multiple linear regression analyses--adjusted for urinary sodium, urinary potassium, consumption of alcohol, cholesterol, saturated fatty acids, polyunsaturated fatty acids, calcium, and other variables--starch intake higher by two standard deviations (14.1% kJ) was associated with systolic/diastolic blood pressure differences of -1.0/-0.9 mmHg (P = 0.09, P < 0.05). Results were similar with additional control for fiber, magnesium, or phosphorus; reduced to -0.5/-0.7 mmHg (P = 0.47, P = 0.13) with separate adjustment for vegetable protein. Findings were similar for men analyzed separately, for American men, and for American men at higher coronary heart disease risk.

CONCLUSION

Our findings indicate that--if any--relations of starch intake to blood pressure are modestly inverse. Current dietary guidelines for hypertension prevention and control remain relevant.

A conceptual framework for studying alcohol intake and blood pressure on historically black college and university campuses

Drinking increases the risk of elevated blood pressure, a risk factor for chronic ailments such as hypertension and cardiovascular disease. The experience of elevated blood pressure in young adulthood may be critical for the development of these diseases later in life. College campuses are venues replete with young adults, and drinking is a popular activity in these settings. Because Historically Black Colleges and Universities (HBCU) produce a large proportion of black college graduates, understanding the social context of drinking among young blacks attending HBCUs is important in understanding the role and characteristics of drinking as a risk factor for the development of elevated blood pressure. This article reviews existing literature on alcohol and blood pressure and proposes a conceptual framework linking socioenvironmental factors, stress, and alcohol consumption at HBCUs in the context of elevated blood pressure among young blacks. Recommendations for future research are also proposed.

Influence of gender on the association of alcohol drinking with blood pressure

BACKGROUND

The purpose of this study was to determine whether gender influences the association of alcohol drinking with blood pressure.

METHODS

The subjects (43,810 healthy men and women at ages of 35-54 years) were divided into five groups by average daily ethanol intake (non-, very light (<10 g per day), light (> or =10 g and <20 g per day), moderate (> or =20 g and <30 g per day), and heavy (> or =30 g per day) drinkers). The means of each variable after adjustment for age, body weight, and history of smoking were compared among the groups.

RESULTS

Systolic blood pressure of men was significantly higher in moderate and heavy drinkers than in nondrinkers, and systolic blood pressure of women was significantly higher in heavy drinkers but not in moderate drinkers than in nondrinkers. Diastolic blood pressure of men and women was significantly higher in light, moderate and heavy drinkers than in nondrinkers. The differences in systolic and diastolic blood pressure between drinkers and nondrinkers were greater in men than in women. Both in men and women, serum HDL cholesterol was significantly higher in all four drinker groups than in the nondrinker group, and the difference between drinkers and nondrinkers was greater in women than in men. The above findings were not altered when age- and alcohol intake-matched groups of subjects were used.

CONCLUSIONS

The results suggest that blood pressure is more prone to be elevated by alcohol drinking in men than in women.

Alcohol consumption and the prevalence of metabolic syndrome: a meta-analysis of observational studies

BACKGROUND

In the past two decades, the metabolic syndrome has given rise to much clinical and research interest. The broad overlap of alcohol consumption with different components of metabolic syndrome makes alcohol-metabolic syndrome relationship a controversial topic.

OBJECTIVES

To support the evidence available about the relationship between alcohol consumption and metabolic syndrome as a comprehensive clinical entity, as well as to identify the gender-specific dose-response, by performing a meta-analysis based on information from published data.

METHODS

Manual and computer searches in different bibliographic databases were performed to identify the relevant scientific publications, on the relation between alcohol consumption and metabolic syndrome. Alcohol intake was converted into a same unit (g/day) and then categorized using standard classification in order to provide relevant comparisons. Fixed and random effects models were used to aggregate individual odds ratios and to derive pooled estimates and 95% confidence intervals.

RESULTS

Fourteen relevant publications were identified on the relation between alcohol consumption and the prevalence of metabolic syndrome. 7 studies were included in the meta-analysis. The results showed that alcohol consumption of less than 40 g/day in men and 20 g/day in women significantly reduced the prevalence of metabolic syndrome.

CONCLUSION

"Responsible alcohol intake" appears to be associated with a reduced prevalence of metabolic syndrome. Favorable metabolic effect seemed to be restricted to alcohol consumption of less than 20 g/day among women, and of less than 40 g/day among men. These findings support the actual recommendations regarding alcohol consumption among apparently healthy people.

Blood pressure reduction during treatment for alcohol dependence: results from the Combining Medications and Behavioral Interventions for Alcoholism (COMBINE) study

AIMS

Heavy drinking is associated with hypertension. This study evaluated blood pressure changes occurring during treatment for alcohol dependence.

PARTICIPANTS

Subjects included 1383 people participating in the Combining Medications and Behavioral Interventions for Alcoholism (COMBINE) study, a large multi-center treatment study for alcohol dependence.

MEASUREMENTS

Methods appropriate for repeated-measures data were used to assess the relationship of percentage of drinking days (PDD) to systolic and diastolic blood pressure over a 16-week treatment period. Modification of these associations by demographic and other variables was assessed.

FINDINGS

Blood pressure reduction was evident only in people who were above the median blood pressure at baseline. In this group, systolic blood pressure decreased by an average of 12 mmHg and diastolic blood pressure decreased by an average of 8 mmHg. Blood pressure reduction occurred during the first month of treatment. This effect was similar regardless of age, sex, body mass index, reported history of hypertension and use of anti-hypertensive medications. An observed association between blood pressure and PDD in Caucasians was not evident in African Americans due largely to their lower pre-treatment blood pressure.

CONCLUSIONS

Reduction in alcohol consumption has a potent anti-hypertensive effect in alcoholics with higher blood pressure. For hypertensive, alcohol-dependent people, treatment for alcoholism should be considered a major component of anti-hypertensive therapy.

Modification of the association of alcohol drinking with blood pressure by cigarette smoking

The purpose of this study was to investigate whether the association of alcohol drinking with blood pressure was modified by cigarette smoking. The subjects were healthy male workers aged 40-59 years and were divided into three different groups by average daily consumption of alcohol (non-drinkers; light drinkers, less than 30 g ethanol per day; heavy drinkers, 30 g or more ethanol per day) and cigarettes (non-smokers; light smokers, less than 20 cigarettes per day; heavy smokers, 20 cigarettes or more per day). The mean levels of both systolic and diastolic blood pressures were significantly lower in the light and heavy smoker groups than in the non-smoker group. In the light and heavy smoker groups, systolic blood pressure was higher in the light drinker subgroup than in the non-drinker subgroup, while there was no significant difference between systolic blood pressures in the non- and light drinker subgroups of non-smokers. In the non-, light and heavy smoker groups, systolic and diastolic blood pressures were significantly higher in the heavy drinker subgroup than in the non-drinker subgroup, and these differences tended to be greater in light and heavy smokers than in non-smokers. The above differences in the relationships of alcohol drinking with blood pressure in non-, light and heavy smokers were also observed when age and body mass index were adjusted and when alcohol intake-matched groups were used. These results suggest that the association of alcohol drinking with blood pressure is stronger in smokers than in non-smokers, independently of age, body mass index and alcohol intake.

Racial/ethnic variation in hypertension-related lifestyle behaviours among US women with self-reported hypertension

Healthy lifestyles such as regular physical activity, frequent consumption of fruits and vegetables, weight control/weight loss and limited alcohol consumption are effective and recommended in hypertension control. Using data collected from a total of 131 788 female participants (aged > or = 18 years) of the 2003 Behavioral Risk Factor Surveillance System, we examined the racial/ethnic disparities in hypertension-related lifestyle behaviours in 36 770 US women with self-reported hypertension from five races/ethnicities (non-Hispanic white (29 237), non-Hispanic black (4288), Asian (445), American Indian/Alaska native (553) and Hispanic (2247)). The prevalence of hypertension varied by race/ethnicity, with the highest seen in non-Hispanic black population (36.9 versus 20.2-26.8% in other racial/ethnic groups). Of all hypertensive women, using non-Hispanic white women as the referent, we found that non-Hispanic black (adjusted odds ratio (AOR): 0.65; 95% confidence interval (CI): 0.55-0.77), American Indian/Alaska native (AOR: 0.72; 95% CI: 0.52-1.00) and Hispanic women (AOR: 0.70; 95% CI: 0.57-0.86) were significantly less likely to engage in physical activity at recommended levels; non-Hispanic black women were more likely to consume > or = 8 servings per day of fruits and vegetables (AOR: 1.70; 95% CI: 1.24-2.34), and less likely to report losing weight (AOR: 0.61; 95% CI: 0.53-0.71). In addition, Hispanic hypertensive women were significantly more likely than non-Hispanic white women to receive weight-loss advice (AOR: 1.97; 95% CI: 1.60-2.44). In contrast, non-Hispanic white women were significantly more likely than those from other races/ethnicities to consume alcoholic beverages or engage in binge drinking. Our results demonstrate that race/ethnicity is an independent predictor of lifestyle behaviours related to hypertension control among American women with hypertension.

Relation of iron and red meat intake to blood pressure: cross sectional epidemiological study

OBJECTIVE

To investigate associations of dietary iron (total, haem, and non-haem), supplemental iron, and red meat with blood pressure.

DESIGN

Cross sectional epidemiological study.

SETTING

17 population samples from Japan, China, the United Kingdom, and the United States participating in the international collaborative study on macro-/micronutrients and blood pressure (INTERMAP).

PARTICIPANTS

4680 adults aged 40-59.

MAIN OUTCOME MEASURE

Average of eight blood pressure readings.

RESULTS

In multiple linear regression analyses dietary total iron and non-haem iron were consistently inversely associated with blood pressure. With adjustment for potential non-dietary and dietary confounders, dietary total iron intake higher by 4.20 mg/4.2 MJ (2 SD) was associated with -1.39 mm Hg (P<0.01) lower systolic blood pressure. Dietary non-haem iron intake higher by 4.13 mg/4.2 MJ (2 SD) was associated with -1.45 mm Hg (P<0.001) lower systolic blood pressure. Differences were smaller for diastolic blood pressure. In most models haem iron intake from food was positively, non-significantly associated with blood pressure. Iron intake from combined diet and supplements yielded smaller associations than dietary iron alone. Red meat intake was directly associated with blood pressure; 102.6 g/24 h (2 SD) higher intake was associated with 1.25 mm Hg higher systolic blood pressure. Associations between red meat and blood pressure persisted after adjustment for multiple confounders.

CONCLUSION

Non-haem iron has a possible role in the prevention and control of adverse blood pressure levels. An unfavourable effect of red meat on blood pressure was observed. These results need confirmation including in prospective studies, clinical trials, and from experimental evidence on possible mechanisms.

Alcohol consumption and metabolic syndrome among Shanghai adults: A randomized multistage stratified cluster sampling investigation

AIM: To examine the relations of alcohol consumption to the prevalence of metabolic syndrome in Shanghai adults.

METHODS: We performed a cross-sectional analysis of data from the randomized multistage stratified cluster sampling of Shanghai adults, who were evaluated for alcohol consumption and each component of metabolic syndrome, using the adapted U.S. National Cholesterol Education Program criteria. Current alcohol consumption was defined as more than once of alcohol drinking per month.

RESULTS: The study population consisted of 3953 participants (1524 men) with a mean age of 54.3 ± 12.1 years. Among them, 448 subjects (11.3%) were current alcohol drinkers, including 405 males and 43 females. After adjustment for age and sex, the prevalence of current alcohol drinking and metabolic syndrome in the general population of Shanghai was 13.0% and 15.3%, respectively. Compared with non drinkers, the prevalence of hypertriglyceridemia and hypertension was higher while the prevalence of abdominal obesity, low serum high-density-lipoprotein cholesterol (HDL-C) and diabetes mellitus was lower in subjects who consumed alcohol twice or more per month, with a trend toward reducing the prevalence of metabolic syndrome. Among the current alcohol drinkers, systolic blood pressure, HDL-C, fasting plasma glucose, and prevalence of hypertriglyceridemia tended to increase with increased alcohol consumption. However, low-density-lipoprotein cholesterol concentration, prevalence of abdominal obesity, low serum HDL-C and metabolic syndrome showed the tendency to decrease. Moreover, these statistically significant differences were independent of gender and age.

CONCLUSION: Current alcohol consumption is associated with a lower prevalence of metabolic syndrome irrespe-ctive of alcohol intake (g/d), and has a favorable influence on HDL-C, waist circumference, and possible diabetes mellitus. However, alcohol intake increases the likelihood of hypertension, hypertriglyceridemia and hyperglycemia. The clinical significance of these findings needs further investigation.

Lifestyle modifications to lower or control high blood pressure: is advice associated with action? The behavioral risk factor surveillance survey

Routine lifestyle modification advice for managing high blood pressure (BP) is of questionable effectiveness. Using data from the 2005 Behavior Risk Factor Surveillance System, we examined whether receipt of advice is associated with reported adoption of lifestyle modifications. We determined proportions of hypertensive adults taking action to change eating habits, reduce salt intake, exercise, or decrease alcohol consumption to control high BP. We then determined associations between reports of advice given and corresponding actions being taken: 70.1% of respondents reported changing eating habits, 78.7% reported reducing salt intake, 67.1% reported exercising, and 57.9% of those who drank alcohol reported decreasing their consumption. Compared with those who did not recall being given advice, hypertensive adults who recalled being given advice were more likely to change their eating habits (prevalence ratio [PR], 1.62; 95% confidence interval [CI], 1.56-1.67), reduce salt (PR, 1.53; 95% CI, 1.48-1.58), exercise (PR, 1.41; 95% CI, 1.36-1.47), and reduce alcohol consumption (PR, 1.78; 95% CI, 1.70-1.87).

Urban—Rural Disparity of Overweight, Hypertension, Undiagnosed Hypertension, and Untreated Hypertension in China

The objective of this study was to examine the urban—rural variations in the prevalence of overweight, hypertension, undiagnosed hypertension, and untreated hypertension among adults. The China Health and Nutrition Survey was used to study adults 25 to 65 years old. Logistic regression was used to obtain the odds ratios (ORs) after adjusting for demographic, socioeconomic, and lifestyle variables. Urban adults have a higher probability of being overweight (OR = 1.18, P < .01) and having hypertension (OR = 1.19, P < .1). After further controlling for lifestyle variables, the difference is not significant. Urban hypertensive adults are less likely to be undiagnosed (OR = 0.54, P < .001) and untreated (OR = 0.53, P < .001), even after controlling for socioeconomic and lifestyle variables, suggesting that there are other reasons for the urban—rural disparity of undiagnosed and untreated hypertension. This finding suggests that modifying lifestyles is critical in preventing urban adults from being overweight. Interventions targeting rural adults should promote the awareness and treatment of hypertension.

Association of drinking pattern and alcohol beverage type with the prevalence of metabolic syndrome, diabetes, coronary heart disease, stroke, and peripheral arterial disease in a Mediterranean cohort

The purpose of this study was to investigate the relationship between alcohol consumption and the prevalence of the metabolic syndrome (MetS), type 2 diabetes mellitus (DM), coronary heart disease (CHD), stroke, peripheral arterial disease (PAD), and overall cardiovascular disease (CVD) in a Mediterranean cohort. It consisted of a cross-sectional analysis of a representative sample of Greek adults (n = 4,153) classified as never, occasional, mild, moderate, or heavy drinkers. Cases with overt CHD, stroke, or PAD were recorded. In our population, 17% were never, 23% occasional, 27% mild, 24% moderate, and 9% heavy drinkers. Moderate alcohol consumption was associated with a lower trend for the prevalence of the MetS (P = .0001), DM (P < .0001), CHD (P = .0002), PAD (P = .005), and overall CVD (P = .001) but not stroke compared with no alcohol use. Heavy drinking was associated with an increase in the prevalence of all of these disease states. Wine consumption was associated with a slightly better effect than beer or spirits consumption on the prevalence of total CVD, and beer consumption was associated with a better effect than spirits consumption. Alcohol intake was positively related with body weight, high-density lipoprotein cholesterol levels, and hypertension. Moderate alcohol consumption is associated with a lower prevalence of the MetS, DM, PAD, CHD, and overall CVD but not stroke compared with no alcohol use in a Mediterranean population. Heavy drinking was associated with an increase in the prevalence of all of these disease states. Advice on alcohol consumption should probably mainly aim at reducing heavy drinking.

Lifestyle modification advice for lowering or controlling high blood pressure: who's getting it?

Lifestyle modifications (LSMs) are important in hypertension management. Using data from a population-based sample of hypertensive adults (N=28,457), the authors examined variations in reports of receipt of LSM advice by patient characteristics. Most adults (90.3%) with known hypertension reported receiving some type of advice. Exercise advice was reported most frequently (74.6%), followed by advice to reduce salt intake (69.3%), change eating habits (61.9%), and reduce alcohol intake (43.5%). Compared with adults aged 60 years or older, persons aged 18 to 39 years were more likely to report receipt of advice (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.11-1.81). Overweight persons (OR, 1.64; 95% CI, 1.40-1.93) and obese persons (OR, 2.75; 95% CI, 2.28-3.31) were more likely to report receipt of advice. Persons receiving antihypertensive medication were also more likely to report receiving advice (OR, 2.35; 95% CI, 1.98-2.81). This study demonstrates that older persons, persons not taking antihypertensive medication, and individuals who are not overweight or obese are less likely to report receiving LSM advice.

Alcohol consumption and risk for stroke among Chinese men

OBJECTIVE

Stroke is a leading cause of death and long-term disability in China. The objective of this study was to examine the relation between alcohol consumption and risk for stroke among Chinese men.

METHODS

We conducted a prospective cohort study among 64,338 Chinese men aged > or = 40 years who were free of stroke at baseline. Data on frequency and type of alcohol consumed were collected at the baseline examination in 1991 using a standard protocol. Follow-up evaluation was conducted in 1999 to 2000, which included determining vital status, interviewing participants or proxies, and obtaining hospital and medical records for incident and fatal strokes.

RESULTS

Over the course of 493,351 person-years of follow-up, we documented 3,434 incident strokes (1,848 stroke deaths). After adjustment for age, body mass index, physical activity, urbanization (urban vs rural), geographic variation (north vs south), cigarette smoking, history of diabetes, and education, compared with nondrinkers, relative risk (95% confidence interval) of incident stroke was 0.92 (0.80-1.06) for participants consuming 1 to 6 drinks/week, 1.02 (0.93-1.13) for those consuming 7 to 20 drinks/week, 1.22 (1.07-1.38) for those consuming 21 to 34 drinks/week, and 1.22 (1.08-1.37) for those consuming 35 or more drinks per week (p for linear trend < 0.0001). The corresponding relative risks for stroke mortality were 0.93 (0.76-1.14), 0.98 (0.85-1.13), 1.15 (0.95-1.38), and 1.30 (1.11-1.52), respectively (p for linear trend = 0.0004; p for quadratic trend = 0.03).

INTERPRETATION

These results suggest that heavy alcohol drinking may increase the risk for stroke in Chinese men and should be the target of strategies for prevention.

Antihypertensive effect and safety of dietary alpha-linolenic acid in subjects with high-normal blood pressure and mild hypertension

We investigated the antihypertensive effect and safety of alpha-linolenic acid (ALA) in human subjects. In Experiment 1, subjects with high-normal blood pressure and mild hypertension ingested bread containing 14 g of common blended oil (control oil) or ALA-enriched oil for 12 weeks. The test oil contained 2.6g/14 g of ALA. The subjects ingested strictly controlled meals during the study period. Systolic blood pressure was significantly lower in the ALA group than in the control group after ingestion of the test diet for 4, 8 and 12 weeks. Diastolic blood pressure was significantly lower in the ALA group than in the control group after ingestion of the test diet for 12 weeks. In Experiment 2, we evaluated the safety of high intake of ALA (7.8 g/d), particularly its effects on oxidation in the body and blood coagulation. Normotensive, high-normotensive and mildly hypertensive subjects ate bread that contained 42 g of the control oil or the test oil for 4 weeks. No significant difference was noted in the lipid peroxide level, high-sensitive C-reactive protein level, plasma prothrombin time or activated partial thromboplastin time between the two groups. No abnormal changes were noted after test diet ingestion on blood test or urinalysis, and no adverse event considered to have been induced by the test oil was observed in Experiment 1 and 2. These results suggest that ALA have an antihypertensive effect with no adverse effect in subjects with high-normal blood pressure and mild hypertension.

State of the Art Reviews: Relationship Between Diet/ Physical Activity and Health

Obesity and 4 of the leading causes of death—heart disease, cancer, stroke, and type 2 diabetes mellitus—are related to lifestyle. The combination of a healthy weight, prudent diet, and daily physical activity clearly plays a role in primary, secondary, and tertiary prevention of these and other chronic diseases. Because nearly 65% of the adult population is overweight or obese, weight loss and maintenance are central to this review article. Improved lipid profiles, blood pressure, insulin sensitivity, and euglycemia are associated with weight loss or a normal body weight; thus, maintaining a healthy weight is a universal recommendation for health. The methods for improving lifestyle described in the section on obesity include assessing nutritional status and stages of change of the client, setting realistic goals, eating a diet high in fruits and vegetables with low-fat sources of dairy and protein, and achieving appropriate physical activity levels. The importance of physicians discussing weight with clients and vice versa is stressed. The common features of lifestyle-related diseases make them amenable to similar lifestyle interventions.

Prehypertension

Prehypertension--blood pressure between 120-139/80-89 mmHg--is a major public health concern. The condition is very prevalent (especially in obese young people), is often associated with other cardiovascular risk factors and independently increases the risk of hypertension and subsequent cardiovascular events. In the general population, prehypertension can be lowered, but not often reliably, by lifestyle modifications. Drug therapy for prehypertension is not yet recommended, except for individuals with diabetes, chronic kidney disease, and perhaps known coronary artery disease, because of short-term cost considerations and unproven long-term benefits. Ongoing research will probably identify which individuals with blood pressures in the prehypertensive range, but with no serious comorbidities, would benefit from treatment. In this Review, we attempt to summarize the recently published data concerning the epidemiology, attendant risks and potential treatment options for this important and growing public-health problem.

Essential hypertension

Essential hypertension can be defined as a rise in blood pressure of unknown cause that increases risk for cerebral, cardiac, and renal events. In industrialised countries, the risk of becoming hypertensive (blood pressure >140/90 mm Hg) during a lifetime exceeds 90%. Essential hypertension usually clusters with other cardiovascular risk factors such as ageing, being overweight, insulin resistance, diabetes, and hyperlipidaemia. Subtle target-organ damage such as left-ventricular hypertrophy, microalbuminuria, and cognitive dysfunction takes place early in the course of hypertensive cardiovascular disease, although catastrophic events such as stroke, heart attack, renal failure, and dementia usually happen after long periods of uncontrolled hypertension only. All antihypertensive drugs lower blood pressure (by definition) and this decline is the best determinant of cardiovascular risk reduction. However, differences between drugs exist with respect to reduction of target-organ disease and prevention of major cardiovascular events. Most hypertensive patients need two or more drugs for blood-pressure control and concomitant statin treatment for risk factor reduction. Despite the availability of effective and safe antihypertensive drugs, hypertension and its concomitant risk factors remain uncontrolled in most patients.

Secondary hypertension due to drugs and toxins

This review summarizes the current state of knowledge about drugs, other chemical substances, and toxins on blood pressure. Many classes of drugs, such as steroids, sympathomimetic amines, immunosuppressive agents, nonsteroidal anti-inflammatory agents, antidepressants, erythropoietin, substances of abuse and other agents can induce transient or sustained hypertension, exacerbate well-controlled hypertension, antagonize the effects of antihypertensive therapy, or precipitate hypertensive emergencies. Heightened awareness on the part of the physician is important to avoid unnecessary tests in search for other etiologies, and to reduce antihypertensive medication prescriptions by eliminating contributing agents whenever possible. These agents represent an important modifiable cause of secondary or resistant hypertension.

Possible beneficial effects of health counseling, given less frequently than ordinary, on blood pressure

This study was initiated to investigate the effects of health counseling under Total Health Promotion Plan (THP). The study populations consisted of 1,655 working men who had an initial THP-based counseling and a follow-up 3 yr later (the THP group; the counseling was given on a once-three year basis), and 1,655 age- and body mass index (BMI)-matched controls (working men who had no health counseling; the control group). In the THP group, systolic blood pressure (SBP) and the prevalence of excessive alcohol drinking were decreased, and nutritional score was improved, although BMI was increased. In contrast, SBP, BMI and the ratio of excessive drinkers were all increased in the controls. Multiple regression analysis of the THP group showed that the reduction in SBP was positively associated with the increase in maximal oxygen consumption (VO(2max)) and physical activity scores, as well as the decrease in BMI. In sub-group analyses of the THP group, VO(2max) and physical activity scores were increased, and BMI did not change in the sub-group with marked BP decrease. In the sub-group with marked BP increase, however, BMI was increased, and VO(2max) was decreased. The ratio of excessive drinkers was reduced only in the sub-group with marked BP decrease. The obese-hypertensive subjects in the THP group showed decreases in BMI and BP, and increases in VO(2max). Thus, these results appeared to suggest that health counseling given even at a low frequency of once in three years prevented the age-associated increase in BP through improvement of physical endurance, decrease in alcohol intake and reduction in body weight.

Reducing the risks of cardiovascular disease in liver allograft recipients

Liver allograft recipients are at increased risk of death from cerebrovascular and cardiovascular disease. We propose the following strategy of risk-reduction, based on currently available literature. Lifestyle: standard advice should be given (avoidance of smoking, excess alcohol and obesity, adequate exercise, reduction of excess sodium intake). Hypertension: target blood pressure should be 140/90 mmHg or lower, but for those with diabetes or renal disease, 130/80 mmHg or lower. For patients without proteinuria, antihypertensive therapy should be initiated with a calcium channel blocker and for those with proteinuria, an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker. If monotherapy fails to achieve adequate response, calcium channel blockers and ACE-inhibitors or angiotensin II receptor blockers should be combined. If hypertension remains uncontrolled, an alpha-blocker may be added. Consideration should be given to changing immunosuppression and avoiding use of calcineurin inhibitors. Diabetes: recipients should be regularly screened for diabetes. For patients with new-onset diabetes after transplant, stepwise therapy should be guided by HbA1c concentrations, as with type II diabetes mellitus. Hyperlipidemia: annual screening of lipid profile should be undertaken, with treatment thresholds and targets based on those advocated for the high risk general population. Dietary intervention is appropriate for all patients. A statin should be considered as the first line treatment to achieve specified targets. In patients receiving a calcineurin inhibitor, Pravastatin should be commenced at a dose of 10 mg/day. In patients receiving other forms of immunosuppression, pravastatin may be commenced at a dose of 20 mg/day. Liver tests should be monitored and patients warned to report myalgia. If monotherapy is inadequate, ezetimibe or a fibrate may be added. Consideration may be given to change in immunosuppression if combination lipid-lowering therapy proves inadequate.

Systemic hypertension

Hypertension is a growing public health problem worldwide. Only 37% of American hypertensives currently have their blood pressures controlled. Hypertension is traditionally diagnosed in the medical office, but both home and ambulatory blood pressure monitoring can help. Lifestyle modifications are recommended for everyone who has higher than "normal" blood pressure (<120/80 mm Hg). Voluminous clinical trial data support beginning drug therapy with low-dose chlorthalidone, unless the patient has a specific indication for a different drug. Additional drugs (typically in the sequence, angiotensin converting-enzyme inhibitor or angiotensin receptor blocker, calcium antagonist, beta-blocker, alpha-blocker, aldosterone antagonist, direct vasodilator, and centrally acting alpha(2)-agonist) can be added to achieve the blood pressure goal (usually <140/90 mm Hg, but <130/80 mm Hg for diabetics and those with chronic kidney disease). Special circumstances exist for treatment of hypertension in pregnancy, in childhood, in the elderly, and in both extremes of blood pressure (pre-hypertension or hypertensive emergencies).

Nutritional strategies in the prevention and treatment of metabolic syndrome

The metabolic syndrome (MetS) is a clustering of metabolic abnormalities that increase the risk of developing atherosclerotic cardiovascular disease and type 2 diabetes. The exact etiology remains unclear, but it is known to be a complex interaction between genetic, metabolic, and environmental factors. Among environmental factors, dietary habits are of central importance in the prevention and treatment of this condition. However, there is currently no firm consensus on the most appropriate dietary recommendations. General recommendations include decreasing obesity, increasing physical activity, and consuming an anti-atherogenic diet, and have traditionally focused on low total fat intake. A major problem with the focus on low fat is that high-carbohydrate diets can contribute to increasing triglyceride and decreasing high-density lipoprotein (HDL) concentrations. Low-carbohydrate diets have been popular in recent years. However, such diets are typically higher in saturated fat and lower in fruits, vegetables, and whole grains than national dietary recommendations. More recently the quality of carbohydrate has been studied in relation to MetS, including a focus on dietary fiber and glycemic index. Similarly, there has been a move from limiting total fat to a focus on the quality of the fat, with evidence of beneficial effects of replacing some carbohydrate with monounsaturated fat. Other nutrients examined for possible importance include calcium, vitamin D, and magnesium. Together, the evidence suggests that the components of diet currently recommended as "healthy" are likely also protective against MetS, including low saturated and trans fat (rather than low total fat) and balanced carbohydrate intake rich in dietary fiber, as well as high fruit and vegetable intake (rather than low total carbohydrate); and the inclusion of low-fat dairy foods. Accelerating research on gene-diet interactions is likely to contribute interesting information that may lead to further individualized dietary guidance in the future.

Effect of high-carbohydrate or high-cis-monounsaturated fat diets on blood pressure: a meta-analysis of intervention trials

BACKGROUND

The Dietary Approaches to Stop Hypertension (DASH) diet is recommended to manage blood pressure. The DASH diet is low in saturated fat, but it is not clear whether saturated fat should be preferentially replaced with carbohydrate or unsaturated fat, especially cis-monounsaturated fat.

OBJECTIVE

A meta-analysis of intervention studies comparing high-carbohydrate and high-cis-monounsaturated fat diets was conducted to increase understanding of the effect of carbohydrate and cis-monounsaturated fat on blood pressure.

DESIGN

For study diets to be included in the analysis, they had to be isoenergetic, and the subjects' body weight had to remain stable. Ten studies (6 randomized crossover, 1 randomized parallel, and 3 nonrandomized) met the inclusion criteria.

RESULTS

According to the random-effects model, which incorporates between-study variation to estimate the overall effect, diets rich in carbohydrate resulted in significantly higher systolic blood pressure [x(-) difference: 2.6 (95% CI: 0.4, 4.7) mm Hg; P=0.02] and diastolic blood pressure [1.8 (0.01, 3.6) mm Hg; P=0.05] than did diets rich in cis-monounsaturated fat. When the meta-analysis was limited to randomized crossover studies, both systolic [1.3 (-0.3, 2.9) mm Hg; P=0.11] and diastolic [0.9 (-0.2, 2.1) mm Hg; P=0.11] blood pressure were higher with a high-carbohydrate than with a high cis-monounsaturated fat diet, but the differences were not significant.

CONCLUSIONS

Diets rich in carbohydrate may be associated with slightly higher blood pressure than diets rich in cis-monounsaturated fat. However, the magnitude of the difference may not justify making recommendations to alter the carbohydrate and cis-monounsaturated fat content of the diet to manage blood pressure.

Clinical characteristics of resistant hypertension: the importance of compliance and the role of diagnostic evaluation in delineating pathogenesis

Resistant hypertension is defined as failure to achieve goal blood pressure despite adherence to 3 different antihypertensive medications, one of which must be a diuretic. True resistant hypertension must be distinguished by apparent resistant hypertension, of which an important cause is medication nonadherence, which can be recognized through a variety of monitoring strategies and may be improved through better patient education. A thorough history and examination should focus on evaluating for associated factors such as medication and illicit drug use, alcoholism, obesity, and obstructive sleep apnea. Further evaluation to differentiate apparent resistant hypertension from true resistant hypertension should include consideration of ambulatory blood pressure monitoring to rule out white coat hypertension. Routine laboratory work will reveal chronic kidney disease, which is the most common associated factor in resistant hypertension. Secondary or identifiable causes of resistant hypertension include primary aldosteronism, renovascular disease, and pheochromocytoma. Diagnostic evaluation for identifiable causes should be tailored for each patient and guided by signs and symptoms, as well as risks and benefits.

Effect of alcohol on risk of coronary heart disease and stroke: causality, bias, or a bit of both?

Epidemiological studies of middle-aged populations generally find the relationship between alcohol intake and the risk of coronary heart disease (CHD) and stroke to be either U- or J-shaped. This review describes the extent that these relationships are likely to be causal, and the extent that they may be due to specific methodological weaknesses in epidemiological studies. The consistency in the vascular benefit associated with moderate drinking (compared with non-drinking) observed across different studies, together with the existence of credible biological pathways, strongly suggests that at least some of this benefit is real. However, because of biases introduced by: choice of reference categories; reverse causality bias; variations in alcohol intake over time; and confounding, some of it is likely to be an artefact. For heavy drinking, different study biases have the potential to act in opposing directions, and as such, the true effects of heavy drinking on vascular risk are uncertain. However, because of the known harmful effects of heavy drinking on non-vascular mortality, the problem is an academic one. Studies of the effects of alcohol consumption on health outcomes should recognise the methodological biases they are likely to face, and design, analyse and interpret their studies accordingly. While regular moderate alcohol consumption during middle-age probably does reduce vascular risk, care should be taken when making general recommendations about safe levels of alcohol intake. In particular, it is likely that any promotion of alcohol for health reasons would do substantially more harm than good.

Hot flashes are associated with increased ambulatory systolic blood pressure

OBJECTIVE

To determine the association between ambulatory blood pressure (BP) and hot flash experience.

DESIGN

The participants in the study were 154 women (mean age=46 years, range=18-65 years), who were evaluated as part of a cross-sectional study on ethnicity, socioeconomic status, and diurnal BP patterns. Participants could be either normotensive or mildly hypertensive. Participants wore an ambulatory BP monitor for 24 hours and recorded their awake and sleep times. Hot flashes were assessed using an everyday complaint questionnaire that embeds symptoms associated with menopause into a list of everyday complaints.

RESULTS

Thirty-three percent of participants reported having had hot flashes during the 2 weeks before they completed the questionnaire. Compared with women who did not report hot flashes, mean awake and sleep systolic BP values were significantly higher (P<0.004 and P=0.007, respectively) in women who reported having had hot flashes. Hot flashes continued to independently predict average awake and sleep systolic BP (both P=0.03) after controlling for age, race/ethnicity, body mass index, and menopausal status. Hot flashes were not associated with diastolic BP or nocturnal dipping of BP.

CONCLUSIONS

Hot flashes are associated with increased awake and sleep systolic BP independent of menopausal status. Further investigation is warranted to elucidate the mechanisms by which hot flashes are associated with BP.

Trends in lifestyle factors affecting blood pressure in hypertensive and normotensive Finns during 1982–2002

OBJECTIVE

To assess the trends in blood pressure (BP) affecting lifestyle factors in hypertensive and normotensive Finns from 1982 to 2002.

DESIGN AND SETTING

Five independent cross-sectional population surveys conducted in 1982, 1987, 1992, 1997 and 2002 in the provinces of North Karelia and Kuopio in eastern Finland and the region of Turku-Loimaa in southwestern Finland.

PARTICIPANTS

Stratified random samples of men and women aged 25-64 years were drawn from the national population register. The participants (n = 28 235) were classified into four groups according to their BP level and treatment status: normotensive, unaware hypertensive, aware but untreated hypertensive, and treated hypertensive subjects.

MAIN OUTCOME MEASURES

Alcohol intake, body mass index (BMI), 24-h urinary sodium and potassium excretion (a subsample of 5849 subjects) and the proportion of subjects with leisure-time physical activity (LTPA) at least three times a week.

RESULTS

Mean BMI increased significantly in all groups except in untreated hypertensive women. Alcohol intake increased in all men but especially in hypertensive women (P < 0.001). The 24-h urinary sodium excretion decreased significantly in all BP groups. The proportion of subjects with a recommended level of LTPA increased significantly and similarly in all BP groups (P < 0.001).

CONCLUSIONS

The unfavourable trends observed in mean BMI and alcohol intake in the entire population should be reversed in order to decrease the frequency of hypertension in Finland. The health behaviours of hypertensive subjects should be carefully monitored and modified in a more systematic and efficient way than at present.

Dietetic guidelines on food and nutrition in the secondary prevention of cardiovascular disease ? evidence from systematic reviews of randomized controlled trials (second update, January 2006)

AIM

To update dietetic guidelines based on systematic review evidence on dietary advice to prevent further events in people with existing cardiovascular disease (CVD) (secondary prevention).

METHODS

The Cochrane Library, MEDLINE and EMBASE were comprehensively searched to January 2005 for systematic reviews on aspects of diet and heart health. Reviews were included if they searched systematically for randomized controlled trials relating to diet and secondary prevention of CVD. Each review was critically appraised by at least two members of the UK Heart Health and Thoracic Dietitians Group. The quality and results of each review were discussed and summarized at a group meeting.

RESULTS

Evidence-based strategies that reduce cardiovascular events in those with CVD include reduction in saturated fat and substitution with unsaturated fats. Individuals who have suffered a myocardial infarction may also benefit from adopting a Mediterranean type diet and increasing intake of omega 3 fats, but it is not clear whether they are beneficial for all patients with CVD. There is no systematic review evidence to support the use of antioxidant vitamins supplements, low glycaemic index diets, or homocysteine lowering therapies in this group.

CONCLUSION

There remains good evidence that reducing saturated fat reduces morbidity in patients with CVD. This advice is consistent for most manifestations of CVD, with the addition of Mediterranean dietary advice and increased omega 3 fats for those who have had a myocardial infarction.

Nonpharmacologic therapy for hypertension: Does it really work?

Nondrug therapy of hypertension really does work but requires strong motivation by both patient and physician. In addition to global health benefits, prescription of weight loss, exercise, moderation of salt and alcohol intake, Dietary Approach to Stop Hypertension (DASH) eating plan, and tobacco avoidance can decrease the risk for normotensive and prehypertensive patients of developing fixed hypertension. Initiating and maintaining a healthy lifestyle may be sufficient to avoid pharmacologic therapy for some patients and is a valuable adjunct to drug therapy for most. Blood pressure lowering can be achieved by weight reduction (5-20 mm Hg/10 kg), DASH eating plan (8-14 mm Hg), dietary sodium reduction (2-8 mm Hg), increased physical activity (4-9 mm Hg), and moderation of alcohol consumption (2-4 mm Hg). Combination of two or more modalities may have an additive benefit. Cessation of tobacco abuse not only has global health benefits, but may reduce blood pressure.

Sequelae of systemic hypertension in alcohol abstainers, light drinkers, and heavy drinkers

A link exists between alcohol intake and increased blood pressure (BP), with many studies showing increased hypertension prevalence in heavy drinkers. The harmful and beneficial effects of alcohol can confound the study of the long-term risks of alcohol-related hypertension. We therefore studied cardiovascular sequelae separately in heavy drinkers, light drinkers, and abstainers among 127,212 subjects with BP and alcohol intake ascertained at 1978 to 1985 health examinations. Subsequent cardiovascular end points included mortality risk, hospitalization risk, and outpatient diagnosis of hypertension. Analyses were performed for all subjects and stratified by 5 alcohol-drinking categories (from never drinkers to >or=3 drinks/day). With <120/80 mm Hg as the referent, Cox proportional hazards models were used to estimate relative risks and 95% confidence intervals for 3 higher BP categories (120 to 129/80 to 84, 130 to 139/85 to 89, and >or=140/90 mm Hg). The covariates were age, gender, race, body mass index, education, and smoking. The risk of all outcomes was progressively higher for increasing BP categories, with a similarly increased risk for abstainers, light drinkers, and heavy drinkers. The interaction tests for alcohol and BP were not statistically significant for the mortality and hospitalization outcomes. Interpretation was limited by an inability to separate subjects with increased BP from alcohol consumption from those with other etiologies. In conclusion, the data indicate that the risks of hypertension are similar regardless of the amount of alcohol consumption.

Update on the management of hypertension to prevent stroke

Hypertension is the leading modifiable risk factor for stroke, including first-ever and recurrent stroke. The association between blood pressure (BP) and stroke risk is continuous and may be documented as low as 115/75 mm Hg. Because of this continuum of risk, and because most strokes occur in individuals with mild hypertension or even normal BP values, we are now beginning to recognize "prehypertension" as a stage in which early recognition and intervention may confer benefit. In addition to increased risk for ischemic and hemorrhagic stroke, hypertension may be associated with increased risk of cognitive impairment. Reductions in BP are reliably associated with reduced stroke risk. Some evidence suggests that certain agents, including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, may have protective effects beyond BP lowering. Overall, the degree of BP lowering is key, and therefore most classes of BP-lowering agents may be recommended at this point. Many patients with hypertension will require more than one BP-lowering agent to control BP. Lifestyle modification is appropriate at all levels of intervention. Further studies are needed to ascertain the mechanisms of benefit of different classes of antihypertensive agents in the reduction of stroke and cardiovascular disease risk.

ALCOHOL IS BAD FOR BLOOD PRESSURE

1. The regular consumption of alcohol elevates blood pressure, with global estimates that the attributable risk for hypertensive disease from alcohol is 16%. 2. The increase in blood pressure is approximately 1 mmHg for each 10 g alcohol consumed and is largely reversible within 2-4 weeks of abstinence or a substantial reduction in alcohol intake. 3. This increase in blood pressure occurs irrespective of the type of alcoholic beverage. In particular, the postulated effects of vasodilator flavonoid components of red wine to lessen or reverse alcohol-related hypertension have not been borne out in intervention studies. 4. Heavy drinking, especially a binge pattern of drinking, is linked to a higher incidence of cerebral thrombosis, cerebral haemorrhage and coronary artery disease deaths, although a role for alcohol-related hypertension in the causal pathway is not well defined. 5. In contrast, the light to moderate intake of alcohol has been consistently linked to a reduced risk of atherosclerotic vascular disease end-points. Such a protective effect may also extend to hypertensive subjects. 6. However, the magnitude of any protective effect appears to have been exaggerated because of unmeasured confounders, especially diet, lifestyle and patterns of drinking. Furthermore, a decrease in overall mortality with drinking appears confined to older subjects and to populations with a high background cardiovascular risk profile. 7. Any putative cardiovascular benefits from drinking need to be carefully considered against the effects of alcohol to elevate blood pressure, together with many other adverse health consequences from drinking. Maximum cardiovascular benefit occurs at relatively low levels of consumption (i.e. one to two standard drinks a day in men (10-20 g alcohol) and up to one a day in women (10 g alcohol)). In hypertensive subjects, consumption beyond these levels would be unwise.

Incidence of hypertension by alcohol consumption: is it modified by race?

OBJECTIVE

To investigate the influence of race, binge drinking and alcohol addiction on the association between consumption of alcoholic beverages and incidence of hypertension.

METHODS

In a population-based cohort study, 1089 adults were interviewed and had blood pressure and anthropometric measurements carried out at home. Their alcohol consumption was ascertained by an amount-frequency questionnaire. Binge drinking was defined as consumption of five or more drinks on one occasion for men or four drinks for women, and abuse of alcohol as consumption of 30 g/day or more in men or 15 g/day or more in women. Incident cases of hypertension were characterized by blood pressure > or = 140/90 mmHg or use of hypertension medication.

RESULTS

Among 589 normotensive individuals in the baseline visit, 127 incident cases of hypertension were identified, after a follow-up of 5.6 +/- 1.1 years. Binge drinking and alcohol dependency were not associated with the incidence of hypertension. Adjusted (age, education) risk ratios for the incidence of hypertension (95% confidence interval) were significant only for non-white abusers of ethanol: 11.8 (1.6-86.9). Systolic blood pressure of black abusers increased by 16.1 +/- 3.5 mmHg, in comparison with 4.9 +/- 1.5 mmHg among white abusers (P = 0.004).

CONCLUSION

Individuals with an African ancestry, who consumed larger amounts of ethanol, are at higher risk of developing hypertension. This risk is not explained by a binge drinking pattern or addiction to alcohol.

Role of diet in hypertension management

The prevalence of hypertension is high and increasing worldwide. Drug therapy is effective, but for both "prehypertensive" and treated hypertensive patients, lifestyle changes are also important. Dietary modification is a key part of these changes, although skepticism about the role of diet in determining blood pressure has slowed implementation of the available guidelines. However, there is now a large body of evidence supporting a role for dietary salt, potassium, alcohol, and body mass in determining blood pressure. Studies such as PREMIER have shown that salt restriction (<6 g/d), alcohol moderation (<2U/d in men and <1U/d in women), weight loss (if BMI>25), exercise, and a DASH (Dietary Approaches to Stop Hypertension) diet (supplying 20-30 mmol/d of potassium) can achieve decreases in systolic blood pressure of approximately 10 to 15 mm Hg when applied together. Of the dietary changes, salt intake remains the most amenable to change. But we must further reduce salt in processed food if it is to be part of a wider strategy to lower blood pressure in the general population. Nevertheless, the message to patients must be that dietary changes made within a concerted alteration in lifestyle can have a very significant impact on their blood pressure.

Alcohol and its relationship to blood pressure

Ethanol is a molecule of enduring research interest because its consumption has important social as well as medical implications. With excessive ethanol consumption, there is higher prevalence for hypertension, stroke, cardiomyopathy, and arrhythmias. A principal mechanism by which ethanol exerts these cardiovascular effects is through modulation of blood pressure. In this article, we focus on recent research that pursues information on the effects of alcohol on blood pressure in human subjects, regardless of whether they have hypertension or not. Known means by which alcohol exerts hemodynamic effects are briefly covered, and insights on novel biomediators, such as endothelin and gene-based mechanisms, are presented. Newer tools, such as the Alcohol Use Disorders Identification Test-Consumption Questions (AUDIT-C) survey and carbohydrate-deficient transferrin (CDT) serum test, are also covered. Reducing excessive alcohol intake can produce a reduction in blood pressure of up to 4 mm Hg, on average, which could substantially affect the rates of stroke and ischemic heart disease.

Les mesures nutritionnelles dans l’hypertension artérielle

Nutritional factors may explain 30-75% of cases of hypertension, depending on the population. Overweight alone can explain 11-25%. Nutritional measures are effective in reducing blood pressure or delaying the onset of hypertension. Globally, their impact is close to that of antihypertensive treatment with a single drug and they potentiate the drug's efficacy. The Dash diet, in particular, has been shown to be effective in lowering blood pressure. It is low in saturated fat and sodium, rich in fruit, vegetables and nonfat dairy products.