Long-term effects of weight-reducing diets in people with hypertension

Body mass index and sarcopenia and mortality risk among older hypertensive outpatients; the Nambu Cohort Study

Maintaining ideal body weight and muscle strength through lifestyle modification is essential for improving activities of daily living (ADL) and life expectancy in hypertensive patients. The effect of weight reduction in older patients with hypertension, however, is controversial. We evaluated the prognostic significance of body mass index (BMI) and handgrip strength (HG) in older patients with hypertension. Patients were stratified by the combination of BMI and HG. COX regression analysis was used to assess the mortality risk. A total of 563 patients (age 77 [71-84] years, 50% male, 40% frailty) were followed for a median duration of 41 (34-43) months. In total, 59 deaths occurred during the follow-up period. Validation of mortality by BMI level revealed that patients with BMI < 22 kg/m2 were likely to have higher mortality risk. Low HG, however, was associated with a 3.7-fold increased mortality risk. The risk of all-cause mortality using BMI combined with HG (adjusted hazard ratio [95% confidence interval]) was as follows: (1) Normal HG + 22 kg/m2 ≤ BMI, reference; (2) Normal HG + BMI < 22 kg/m2, 2.39 (0.12-16.46); (3) Low HG + 22 kg/m2 ≤ BMI, 4.01 (1.42-14.38); and (4) Low HG + BMI < 22 kg/m2, 4.55 (1.33-18.13). These findings demonstrate that weight reduction may deteriorate the mortality risk in older patients with hypertension, and new lifestyle modification strategies for improving ADL, quality of life, and prognosis are warranted for older patients with hypertension. We assessed the association between BMI, handgrip strength, and risk of all-cause mortality to evaluate the validity of weight reduction in older patients with hypertension.

Resistant hypertension: diagnosis, evaluation, and treatment a clinical consensus statement from the Thai hypertension society

Resistant hypertension (RH) includes hypertensive patients with uncontrolled blood pressure (BP) while receiving ≥3 BP-lowering medications or with controlled BP while receiving ≥4 BP-lowering medications. The exact prevalence of RH is challenging to quantify. However, a reasonable estimate of true RH is around 5% of the hypertensive population. Patients with RH have higher cardiovascular risk as compared with hypertensive patients in general. Standardized office BP measurement, confirmation of medical adherence, search for drug- or substance-induced BP elevation, and ambulatory or home BP monitoring are mandatory to exclude pseudoresistance. Appropriate further investigations, guided by clinical data, should be pursued to exclude possible secondary causes of hypertension. The management of RH includes the intensification of lifestyle interventions and the modification of antihypertensive drug regimens. The essential aspects of lifestyle modification include sodium restriction, body weight control, regular exercise, and healthy sleep. Step-by-step adjustment of the BP-lowering drugs based on the available evidence is proposed. The suitable choice of diuretics according to patients' renal function is presented. Sacubitril/valsartan can be carefully substituted for the prior renin-angiotensin system blockers, especially in those with heart failure with preserved ejection fraction. If BP remains uncontrolled, device therapy such as renal nerve denervation should be considered. Since device-based treatment is an invasive and costly procedure, it should be used only after careful and appropriate case selection. In real-world practice, the management of RH should be individualized depending on each patient's characteristics.

Diagnosis and management of resistant hypertension

Resistant hypertension is defined as blood pressure that remains above the therapeutic goal despite concurrent use of at least three antihypertensive agents of different classes, including a diuretic, with all agents administered at maximum or maximally tolerated doses. Resistant hypertension is also diagnosed if blood pressure control requires four or more antihypertensive drugs. Assessment requires the exclusion of apparent treatment resistant hypertension, which is most often the result of non-adherence to treatment. Resistant hypertension is associated with major cardiovascular events in the short and long term, including heart failure, ischemic heart disease, stroke, and renal failure. Guidelines from several professional organizations recommend lifestyle modification and antihypertensive drugs. Medications typically include an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, a calcium channel blocker, and a long acting thiazide-type/like diuretic; if a fourth drug is needed, evidence supports addition of a mineralocorticoid receptor antagonist. After a long pause since 2007 when the last antihypertensive class was approved, several novel agents are now under active development. Some of these may provide potent blood pressure lowering in broad groups of patients, such as aldosterone synthase inhibitors and dual endothelin receptor antagonists, whereas others may provide benefit by allowing treatment of resistant hypertension in special populations, such as non-steroidal mineralocorticoid receptor antagonists in patients with chronic kidney disease. Several device based approaches have been tested, with renal denervation being the best supported and only approved interventional device treatment for resistant hypertension.

Dietary protein and blood pressure: an umbrella review of systematic reviews and evaluation of the evidence

INTRODUCTION

This umbrella review aimed to investigate the evidence of an effect of dietary intake of total protein, animal and plant protein on blood pressure (BP), and hypertension (PROSPERO: CRD42018082395).

METHODS

PubMed, Embase and Cochrane Database were systematically searched for systematic reviews (SRs) of prospective studies with or without meta-analysis published between 05/2007 and 10/2022. The methodological quality and outcome-specific certainty of evidence were assessed by the AMSTAR 2 and NutriGrade tools, followed by an assessment of the overall certainty of evidence. SRs investigating specific protein sources are described in this review, but not included in the assessment of the overall certainty of evidence.

RESULTS

Sixteen SRs were considered eligible for the umbrella review. Ten of the SRs investigated total protein intake, six animal protein, six plant protein and four animal vs. plant protein. The majority of the SRs reported no associations or effects of total, animal and plant protein on BP (all "possible" evidence), whereby the uncertainty regarding the effects on BP was particularly high for plant protein. Two SRs addressing milk-derived protein showed a reduction in BP; in contrast, SRs investigating soy protein found no effect on BP. The outcome-specific certainty of evidence of the SRs was mostly rated as low.

DISCUSSION/CONCLUSION

This umbrella review showed uncertainties whether there are any effects on BP from the intake of total protein, or animal or plant proteins, specifically. Based on data from two SRs with milk protein, it cannot be excluded that certain types of protein could favourably influence BP.

Daily self-reported behavioural efficacy records on hypertension digital therapeutics as digital metrics associated with the reduction in morning home blood pressure: post-hoc analysis of HERB-DH1 trial

Digital therapeutics for hypertension, proven effective in the HERB-DH1 trial, enable patients to record and track their daily actions and achievements to improve their lifestyles using an app. However, the association between recording daily behaviours and blood pressure (BP) reduction has not yet been investigated. We conducted a post-hoc analysis to investigate the relationship between them in the HERB-DH1 trial. We defined the counts of daily records of antihypertensive behaviour taken by the patient into the app as daily self-reported behavioural efficacy records (SER). SER was categorised into quartiles, and the trend of changes from baseline to week 12 in morning home systolic blood pressure (SBP), salt intake checklist score, and body weight was assessed. A total of 156 patients with hypertension were included in the analysis. A higher total count of SER was associated with greater SBP reduction (P for trend: 0.049). Patients with a higher SER for salt intake and weight reduction showed reductions in SBP (P for trend: 0.034 and 0.027, respectively). Furthermore, patients with higher salt intake SER exhibited a decrease in the salt intake checklist scores, and patients with greater weight reduction SER experienced a reduction in body weight (P for trend: 0.001 and 0.007, respectively). SER during digital therapeutics is associated with a reduction in morning home SBP in patients with hypertension. Enhancing patients' intrinsic motivation and self-efficacy, as evaluated by the SER, can play an important role in reducing BP by promoting lifestyle improvement. Daily self-reported behavioural efficacy records (SER) defined as the number of patient's app inputs of recall of day-by-day activity of behaviours at the end of the day, is partially affected by self-efficacy and affinity of app, resulting in the effectiveness of digital therapeutics.

Implementation of non-pharmacological interventions for the treatment of hypertension in primary care: a narrative review of effectiveness, cost-effectiveness, barriers, and facilitators

BACKGROUND

The current guidelines for the prevention, detection, evaluation, and management of hypertension recommend six types of non-pharmacological interventions: alcohol reduction, salt intake reduction, increased potassium intake, physical activity, weight loss, and heart-healthy diets. However, the non-pharmacological interventions are still not widely used in primary care. In this paper, we, therefore, reviewed and summarised the evidence on the effectiveness, cost-effectiveness, barriers, and facilitators of non-pharmacological interventions for the treatment of hypertension in primary care.

METHODS

A thorough literature search was conducted in Embase, Google Scholar, and PubMed databases, to identify the most recent reviews or, in their absence, primary studies on alcohol reduction, salt intake reduction, potassium supplementation, physical activity, weight reduction, heart-healthy diets, and other non-pharmacological interventions for the treatment of hypertension in primary care.

RESULTS

Alcohol reduction is a non-pharmacological intervention for the treatment of hypertension in primary care with proven effectiveness, feasibility, and acceptability. Interventions for sodium intake reduction, physical activity, and weight reduction are effective but there is insufficient evidence regarding their feasibility and acceptability in primary care settings. Evidence on the effectiveness of potassium intake and heart-healthy diets is limited and inconsistent. There is a lack of evidence on the cost-effectiveness of non-pharmacological interventions in the treatment of hypertension. The most common barriers to deliver such interventions related to healthcare providers include a lack of time, knowledge, self-confidence, resources, clear guidelines, and financial incentives. The most common barriers related to patients include a lack of motivation and educational resources. Less evidence is available on facilitators of implementing non-pharmacological interventions in primary care. Besides, facilitators differed by different types of interventions.

CONCLUSIONS

Available evidence suggests that more pragmatic, clinically feasible, and logistically simple interventions are required for sodium intake reduction, physical activity, and weight reduction in primary care settings. Future studies should provide further evidence on the effectiveness of weight control, potassium intake, and heart-healthy diets. More research is also needed on cost-effectiveness and facilitators of all types of effective non-pharmacological interventions for the treatment of hypertension in primary care.

Associations of genetic susceptibility and healthy lifestyle with incidence of coronary heart disease and stroke in individuals with hypertension

AIMS

This study explored the associations of genetic susceptibility and adherence to a healthy lifestyle with incident coronary heart disease (CHD) and stroke in individuals with hypertension.

METHODS AND RESULTS

This study included 258 531 European descendants with hypertension at baseline from UK Biobank. Genetic risk of CHD and stroke was estimated using polygenic risk scores derived from 300 and 87 single-nucleotide polymorphisms, respectively. Lifestyle scores were calculated based on 4 lifestyle components (no obesity, no current smoking, regular physical activity and healthy diet). Cox regression with age as the underlying timescale was fit for incident CHD (n = 7470) and stroke (n = 5015), separately. A favourable lifestyle (3-4 lifestyle components) was associated with 37% and 30% lower hazards of CHD (95% confidence intervals, 32-42%) and stroke (23-37%), compared with an unfavourable lifestyle (0-1 lifestyle component), at all levels of genetic risk. Evidence of interaction between genetic susceptibility and lifestyle adherence was found for stroke (P = 0.036): no evidence of interaction for CHD (P = 0.524). A favourable lifestyle at high genetic risk had lower 12-year absolute risk of CHD and stroke, compared with an unfavourable lifestyle at low-to-intermediate genetic (exception: an unfavourable lifestyle at low CHD genetic risk).

CONCLUSION

Adhering to a healthy lifestyle is associated with lower CHD and stroke risk regardless of genetic risk among individuals with hypertension. Risk of CHD and stroke for those at high genetic risk but adhering to a healthy lifestyle was generally lower than for those at low-to-intermediate genetic risk but adhering to an unhealthy lifestyle.

The Burden of Resistant Hypertension Across the World

PURPOSE OF REVIEW

Resistant hypertension (R-HTN) is related to worse cardiovascular, renal outcomes, and death compared to non R-HTN. We aimed to review the burden of R-HTN across the world, focusing on its prevalence, associated factors and outcomes, and the impact of treatment.

RECENT FINDINGS

R-HTN prevalence among hypertensive individuals varies around 10-20%, depending on the population and definition applied. R-HTN consistently relates to older age, chronic kidney disease, obesity, and obstructive sleep apnea - which are increasing in prevalence with global population aging. As such, R-HTN prevalence is also expected to rise. Infrequent use of ambulatory blood pressure monitoring to identify at higher risk individuals and poor adherence to treatment are still barriers in the approach of R-HTN. Available evidence suggests that 10-20% of patients with hypertension have R-HTN. However, the prevalence of true R-HTN using contemporaneous standardized definitions is still unknown. Novel strategies to address clinicians, patients and health system barriers to treatment inertia and adherence are fundamental to reduce the burden of R-HTN.

Hypertension Control and Guideline-Recommended Target Blood Pressure Goal Achievement at an Early Stage of Hypertension in the UAE

(1) Background: The present study aimed to assess the changes in blood pressure (BP) within the first 6 months of treatment initiation in a newly treated hypertensive cohort and to identify the factors that are associated with achieving the target BP recommended by the American (ACC/AHA, 2017), European (ESC/ESH, 2018), United Kingdom (NICE, 2019), and International Society of Hypertension (ISH, 2020) guidelines. (2) Methods: We analyzed 5308 incident hypertensive outpatients across Abu Dhabi, United Arab Emirates (UAE), in 2017; each patient was followed up for 6 months. Hypertension was defined as a BP of 130/80 mmHg according to the ACC/AHA guidelines and 140/90 mmHg according to the ESC/ESH, NICE, and ISH guidelines. Multiple logistic regression was used to identify factors associated with achieving the guideline-recommended BP targets. (3) Results: At baseline, the mean BP was 133.9 ± 72.9 mmHg and 132.7 ± 72.5 mmHg at 6 months. The guideline-recommended BP targets were 39.5%, 43%, 65.6%, and 40.8%, according to the ACC/AHA, ESC/ESH, NICE, and ISH guidelines, respectively. A BMI of <25 kg/m2 was associated with better BP control according to the ACC/AHA (odds ratio (OR) = 1.26; 95% confidence interval (CI) = 1.07-1.49), ESC/ESH (OR = 1.27; 95% CI = 1.08-1.50), and ISH guidelines (OR = 1.22; 95% CI = 1.03-1.44). Hypertension treated in secondary care settings was more likely to achieve the BP targets recommended by the ACC/AHA (1.31 times), ESC/ESH (1.32 times), NICE (1.41 times), and ISH (1.34 times) guidelines. (4) Conclusions: BP goal achievement was suboptimal. BP control efforts should prioritize improving cardiometabolic goals and lifestyle modifications.

Effects of Intermittent Compared With Continuous Energy Restriction on Blood Pressure Control in Overweight and Obese Patients With Hypertension

Background and Aims: Weight-loss diets reduce body weight and improve blood pressure control in hypertensive patients. Intermittent energy restriction (IER) is an alternative to continuous energy restriction (CER) for weight reduction. We aimed to compare the effects of IER with those of CER on blood pressure control and weight loss in overweight and obese patients with hypertension during a 6-month period.

Methods: Two hundred and five overweight or obese participants (BMI 28.7 kg/m²) with hypertension were randomized to IER (5:2 diet, a very-low-calorie diet for 2 days per week, 500 kcal/day for women and 600 kcal/day for men, along with 5 days of a habitual diet) compared to a moderate CER diet (1,000 kcal/day for women and 1,200 kcal/day for men) for 6 months. The primary outcomes of this study were changes in blood pressure and weight, and the secondary outcomes were changes in body composition, glycosylated hemoglobin A1c (HbA1c), and blood lipids.

Results: Of the 205 randomized participants (118 women and 87 men; mean [SD] age, 50.2 [8.9] years; mean [SD] body mass index, 28.7 [2.6]; mean [SD] systolic blood pressure, 143 [10] mmHg; and mean [SD] diastolic blood pressure, 91 [9] mmHg), 173 completed the study. The intention-to-treat analysis demonstrated that IER and CER are equally effective for weight loss and blood pressure control: the mean (SEM) weight change with IER was −7.0 [0.6] kg vs. −6.8 [0.6] kg with CER, the mean (SEM) systolic blood pressure with IER was −7 [0.7] mmHg vs. −7 [0.6] mmHg with CER, and the mean (SEM) diastolic blood pressure with IER was −6 [0.5] mmHg vs. −5 [0.5] mmHg with CER, (diet by time P = 0.62, 0.39, and 0.41, respectively). There were favorable improvements in body composition, HbA1c, and blood lipid levels, with no differences between groups. Effects did not differ according to completer analysis. No severe hypoglycemia occurred in either group during the trial.

Conclusions: Intermittent energy restriction is an effective alternative diet strategy for weight loss and blood pressure control and is comparable to CER in overweight and obese patients with hypertension.

Clinical Trial Registration:http://www.chictr.org.cn, identifier: ChiCTR2000040468.

Effectiveness of Body Roundness Index (BRI) and a Body Shape Index (ABSI) in Predicting Hypertension: A Systematic Review and Meta-Analysis of Observational Studies

INTRODUCTION

The body roundness index (BRI) and a body shape index (ABSI) are novel anthropometric indices established to determine both the amount visceral adipose tissue and body fat.

OBJECTIVE

to investigate whether BRI and ABSI are better predictors of hypertension than body mass index (BMI), waist circumference (WC) or waist-to-height ratio (WHtR). Methods: A systematic search was conducted in the Scopus, PubMed and Web of Science databases up until 31 December 2020.

RESULTS

The estimated pooled area under curve [AUC (95% CI)] for BRI [0.67 (0.65-0.70)] for the prediction of hypertension were superior to that of ABSI (0.58 (0.56-0.60)), similar to that of BMI [0.67 (0.64-0.69)], and lower than those WC [0.68 (0.66-0.70)] and WHtR [0.68 (0.66-0.71)]. Nevertheless, the difference of BRI compared to WC and WHtR in the context of predicting hypertension was non-significant. ABSI was significantly lower (p < 0.05) than BRI, BMI, WC and WHtR. Similar findings were observed with the summary receiver operating characteristic curve (AUC-SROC). There were no significant differences between subgroups according to type of population or diagnostic criteria of hypertension. The diagnostic odds ratio (dORs) proved that increased BRI and ABSI were related with an elevated hypertension risk.

CONCLUSIONS

BRI and ABSI have discriminatory power for hypertension in adult women and men from different populations. Although, WHtR and WC provided the best performance when assessing hypertension, no significant differences were found for BRI. Finally, BRI was significantly better predictor of hypertension than ABSI.

Altered dietary salt intake for people with chronic kidney disease

BACKGROUND

Evidence indicates that reducing dietary salt may reduce the incidence of heart disease and delay decline in kidney function in people with chronic kidney disease (CKD). This is an update of a review first published in 2015.

OBJECTIVES

To evaluate the benefits and harms of altering dietary salt for adults with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 6 October 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials comparing two or more levels of salt intake in adults with any stage of CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility, conducted risk of bias evaluation and evaluated confidence in the evidence using GRADE. Results were summarised using random effects models as risk ratios (RR) for dichotomous outcomes or mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI).

MAIN RESULTS

We included 21 studies (1197 randomised participants), 12 in the earlier stages of CKD (779 randomised participants), seven in dialysis (363 randomised participants) and two in post-transplant (55 randomised participants). Selection bias was low in seven studies, high in one and unclear in 13. Performance and detection biases were low in four studies, high in two, and unclear in 15. Attrition and reporting biases were low in 10 studies, high in three and unclear in eight. Because duration of the included studies was too short (1 to 36 weeks) to test the effect of salt restriction on endpoints such as death, cardiovascular events or CKD progression, changes in salt intake on blood pressure and other secondary risk factors were examined. Reducing salt by mean -73.51 mmol/day (95% CI -92.76 to -54.27), equivalent to 4.2 g or 1690 mg sodium/day, reduced systolic/diastolic blood pressure by -6.91/-3.91 mm Hg (95% CI -8.82 to -4.99/-4.80 to -3.02; 19 studies, 1405 participants; high certainty evidence). Albuminuria was reduced by 36% (95% CI 26 to 44) in six studies, five of which were carried out in people in the earlier stages of CKD (MD -0.44, 95% CI -0.58 to -0.30; 501 participants; high certainty evidence). The evidence is very uncertain about the effect of lower salt intake on weight, as the weight change observed (-1.32 kg, 95% CI -1.94 to -0.70; 12 studies, 759 participants) may have been due to fluid volume, lean tissue, or body fat. Lower salt intake may reduce extracellular fluid volume in the earlier stages of CKD (-0.87 L, 95% CI -1.17 to -0.58; 3 studies; 187 participants; low certainty evidence). The evidence is very uncertain about the effect of lower salt intake on reduction in antihypertensive dose (RR 2.45, 95% CI 0.98 to 6.08; 8 studies; 754 participants). Lower salt intake may lead to  symptomatic hypotension (RR 6.70, 95% CI 2.40 to 18.69; 6 studies; 678 participants; moderate certainty evidence). Data were sparse for other types of adverse events.

AUTHORS' CONCLUSIONS

We found high certainty evidence that salt reduction reduced blood pressure in people with CKD, and albuminuria in people with earlier stage CKD in the short-term. If such reductions could be maintained long-term, this effect may translate to clinically significant reductions in CKD progression and cardiovascular events. Research into the long-term effects of sodium-restricted diet for people with CKD is warranted.

Associations between PM2.5 exposure duration and physical activity intensity on the health of hypertension in urban residents of Beijing

Hypertension is reported to be associated with air pollution and physical activity (PA), and they have different or even conflicting effects on blood pressure (BP). The study evaluated the combined effects of PM2.5 exposure duration and physical activity intensity on systolic blood pressure (SBP) and diastolic blood pressure (DBP) of hypertension. A total of 2613 patients (≥18-year-olds) at baseline who attended surveys from the China Health and Nutrition Survey (2011-2015) in Beijing were selected, as well as the PM2.5 data collected in the same period. The mixed linear effects model and multivariate analysis of variance (MANOVA) were used to explore the multiple effects of PM2.5 exposure duration and PA intensity on SBP and DBP, respectively. The correlation results indicated PM2.5 exposure duration (>15 days) occurred more significant correlations with DBP and longer PM2.5 exposures duration (>60 day) with SBP. The mixed linear effects model showed the important random terms of gender, PA levels, and BMI classification for both SBP and DBP. It also indicated the significant fixed effect from age for both SBP and DBP, and the significant fixed effects from PM2.5 and weight, as well as the interaction in DBP. The random effects of PA levels put effects on different weight people for SBP and on different age people for DBP, while the person of SBP exposed to PM2.5 environments may tend to be affected by BMI classification. The model's main effects showed PA and the interaction with gender could put significant effects on BP. The gender effects and the PA level effects were also improved by the MANOVA results. We concluded that the more PM2.5 exposure duration may lead to more significant correlation with higher BP values. The PA levels could lead to the different effects on the health showing the variations in age, gender, and BMI classification. For SBP of people who are exposed to PM2.5 environments, it may tend to be affected by BMI classification, which also may influence the DBP through weight adjusting first and then cause hypertension. The gender difference of BP may be affected by PA showing the higher PA level and the more gender difference.

Investigation of Blood Pressure Control in Hypertensive Patients with and without Antithrombotic Therapy in a Real-World Setting

Background Although numerous studies have demonstrated a strong association between blood pressure (BP) and hemorrhagic complications of antithrombotic therapy, there is still a paucity of information regarding the status of BP control in hypertensive patients on antithrombotic therapy. Methods This cross-sectional, retrospective study was conducted at an outpatient clinic to examine BP control and its associated factors in hypertensive patients receiving or not receiving antithrombotic therapy. Results Of 26,803 outpatients who had scheduled visits in 2018, 7,800 hypertensive patients met the inclusion criteria, of whom 1,727 cases were on oral antithrombotic drugs. Then, target BP values were defined according to the Japanese Society of Hypertension Guidelines for the Management of Hypertension 2019. While BP values <140/90 mmHg were observed in 63.0% and 61.6% of patients with and without antithrombotic therapy, respectively, only 31.1% and 23.4% of them displayed BP values <130/80 mmHg. Multivariable logistic analysis indicated that comorbidity with obesity was a significant correlate of insufficient BP control (target BP <130/80 mmHg) in hypertensive patients, irrespective of antithrombotic therapy (patients with antithrombotic therapy, odds ratio (OR) = 1.690, 95% confidence interval (CI) = 1.351-2.113; patients without antithrombotic therapy, OR = 1.475, 95% CI = 1.290-1.687). Conclusion The majority of patients exhibited BP values <140/90 mmHg, whereas BP values <130/80 mmHg were achieved only in a small proportion of the patients. Furthermore, obesity appeared to be one of the factors contributing to insufficient BP control in a real-world setting.

Long-term effects of weight-reducing diets in people with hypertension

BACKGROUND

All major guidelines for antihypertensive therapy recommend weight loss. Dietary interventions that aim to reduce body weight might therefore be a useful intervention to reduce blood pressure and adverse cardiovascular events associated with hypertension.

OBJECTIVES

Primary objectives To assess the long-term effects of weight-reducing diets in people with hypertension on all-cause mortality, cardiovascular morbidity, and adverse events (including total serious adverse events, withdrawal due to adverse events, and total non-serious adverse events). Secondary objectives To assess the long-term effects of weight-reducing diets in people with hypertension on change from baseline in systolic blood pressure, change from baseline in diastolic blood pressure, and body weight reduction.

SEARCH METHODS

For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to April 2020: the Cochrane Hypertension Specialised Register, CENTRAL (2020, Issue 3), Ovid MEDLINE, Ovid Embase, and ClinicalTrials.gov. We also contacted authors of relevant papers about further published and unpublished work. The searches had no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of at least 24 weeks' duration that compared weight-reducing dietary interventions to no dietary intervention in adults with primary hypertension.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risks of bias and extracted data. Where appropriate and in the absence of significant heterogeneity between studies (P > 0.1), we pooled studies using a fixed-effect meta-analysis. In case of moderate or larger heterogeneity as measured by Higgins I2, we used a random-effects model.

MAIN RESULTS

This second review update did not reveal any new trials, so the number of included trials remains the same: eight RCTs involving a total of 2100 participants with high blood pressure and a mean age of 45 to 66 years. Mean treatment duration was 6 to 36 months. We judged the risks of bias as unclear or high for all but two trials. No study included mortality as a predefined outcome. One RCT evaluated the effects of dietary weight loss on a combined endpoint consisting of the necessity of reinstating antihypertensive therapy and severe cardiovascular complications. In this RCT, weight-reducing diet lowered the endpoint compared to no diet: hazard ratio 0.70 (95% confidence interval (CI) 0.57 to 0.87). None of the trials evaluated adverse events as designated in our protocol. The certainty of the evidence was low for a blood pressure reduction in participants assigned to weight-loss diets as compared to controls: systolic blood pressure: mean difference (MD) -4.5 mm Hg (95% CI -7.2 to -1.8 mm Hg) (3 studies, 731 participants), and diastolic blood pressure: MD -3.2 mm Hg (95% CI -4.8 to -1.5 mm Hg) (3 studies, 731 participants). We judged the certainty of the evidence to be high for weight reduction in dietary weight loss groups as compared to controls: MD -4.0 kg (95% CI -4.8 to -3.2) (5 trials, 880 participants). Two trials used withdrawal of antihypertensive medication as their primary outcome. Even though we did not consider this a relevant outcome for our review, the results of these RCTs strengthen the finding of a reduction of blood pressure by dietary weight-loss interventions.

AUTHORS' CONCLUSIONS

In this second update, the conclusions remain unchanged, as we found no new trials. In people with primary hypertension, weight-loss diets reduced body weight and blood pressure, but the magnitude of the effects are uncertain due to the small number of participants and studies included in the analyses. Whether weight loss reduces mortality and morbidity is unknown. No useful information on adverse effects was reported in the relevant trials.

Impacts of the urinary sodium-to-potassium ratio, sleep efficiency, and conventional risk factors on home hypertension in a general Japanese population

Recently, a high urinary sodium-to-potassium (Na/K) ratio and reduced sleep efficiency, in addition to conventional risk factors (obesity and excess alcohol intake), have been identified as risk factors for hypertension. We estimated the population attributable fraction (PAF) for home hypertension due to these risk factors in a general Japanese population. We conducted a cross-sectional study including 1384 participants (393 men and 991 women) to estimate the odds ratio (OR) and 95% confidence interval (CI) for the presence of any of the conventional risk factors using multivariable logistic regression analyses. The models were adjusted for sex, age, smoking status, and log-transformed average daily steps. We also estimated the OR and 95% CI for the presence of any of the overall risk factors. Furthermore, we calculated the PAF due to these risk factors. The results showed that the prevalence of home hypertension was 39.0% (540/1384). The presence of any of the conventional risk factors, as well as any of the overall risk factors, was significantly associated with an increased prevalence of hypertension (OR 2.80, 95% CI 2.15-3.65; OR 2.50, 95% CI 1.93-3.22, respectively). The PAF for hypertension due to the presence of any of the conventional risk factors and the PAF due to the presence of any of the overall risk factors were 30.2% and 39.0%, respectively. In conclusion, the impact of the overall risk factors, including the urinary Na/K ratio and sleep efficiency, on home hypertension was higher than that of conventional risk factors alone. The management of the urinary Na/K ratio and sleep efficiency as well as conventional risk factors might be important in the management of blood pressure.

Diabetes and cardiovascular disease: inter-relation of risk factors and treatment

Background

The diabetes mellitus prevalence is still advancing and increasingly becoming one of the globally most severe and expensive chronic illnesses. The strong correlation between diabetes as well as the most prominent reason for diabetes and death in diabetic patients is cardiovascular disorders. Health conditions like dyslipidemia, hypertension, obesity, and other factors of risk like the risk of cardiovascular are frequent in diabetic persons and raise the likelihood of heart attacks.

Main text

In particular, several researchers have found diabetes mellitus-related biochemical pathways that raise the likelihood of cardiovascular disorder in people with diabetes individually. This review describes diabetes-cardiovascular disorder relationships, explores potential therapeutic mechanisms, addresses existing treatment, care, and describes the directions for the future for study.

Conclusion

Thus, in individuals with diabetes, it is important to concentrate on cardiovascular threat variables to reduce the illness’s lasting cardiovascular complications. Further work to enhance knowledge of the disease state and its impact on cardiovascular function is required to boost medical treatment and cardiovascular disorders result in people with diabetes.

Lifestyle interventions for the prevention and treatment of hypertension

Hypertension affects approximately one third of the world's adult population and is a major cause of premature death despite considerable advances in pharmacological treatments. Growing evidence supports the use of lifestyle interventions for the prevention and adjuvant treatment of hypertension. In this Review, we provide a summary of the epidemiological research supporting the preventive and antihypertensive effects of major lifestyle interventions (regular physical exercise, body weight management and healthy dietary patterns), as well as other less traditional recommendations such as stress management and the promotion of adequate sleep patterns coupled with circadian entrainment. We also discuss the physiological mechanisms underlying the beneficial effects of these lifestyle interventions on hypertension, which include not only the prevention of traditional risk factors (such as obesity and insulin resistance) and improvements in vascular health through an improved redox and inflammatory status, but also reduced sympathetic overactivation and non-traditional mechanisms such as increased secretion of myokines.

Association of Isolated Diastolic Hypertension Based on the Cutoff Value in the 2017 American College of Cardiology/American Heart Association Blood Pressure Guidelines With Subsequent Cardiovascular Events in the General Population

Background The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines lowered the threshold of blood pressure (BP) for hypertension to 130/80 mm Hg. However, the clinical significance of isolated diastolic hypertension (IDH) according to the cutoff value of the 2017 ACC/AHA guidelines was uncertain. Methods and Results We analyzed the claims database of Japan Medical Data Center (a nationwide epidemiological database). We excluded individuals who were aged <20 years, had systolic hypertension, were taking antihypertensive medication, or had prevalent cardiovascular disease, and studied 1 746 493 individuals (mean age, 42.9±10.7 years; 961 097 men [55.0%]). The average observational period was 1107±855 days. Stage 1 IDH, defined as diastolic BP 80 to 89 mm Hg, and stage 2 IDH, defined as diastolic BP ≥90 mm Hg, were found in 230 513 (13.2%) and 16 159 (0.9%) individuals, respectively. Compared with individuals with normal diastolic BP, individuals with stage 1 and stage 2 IDH were older and more likely to be men. Prevalence of classic risk factors was higher in patients with IDH. Kaplan-Meier curves showed that stage 1 and stage 2 IDH were associated with a higher incidence of cardiovascular events, defined as myocardial infarction, angina pectoris, and stroke. Multivariable analysis showed that stage 1 (hazard ratio [HR], 1.17) and stage 2 (HR, 1.28) IDH were independently associated with a higher incidence of cardiovascular events. Subgroup analyses showed that the association of IDH with cardiovascular events was seen irrespective of age and sex. Conclusions The analysis of a nationwide epidemiological database showed that IDH based on the cutoff value in the 2017 ACC/AHA BP guidelines was associated with an elevated risk of subsequent cardiovascular events.

A multicenter clinical trial to assess the efficacy of the digital therapeutics for essential hypertension: Rationale and design of the HERB-DH1 trial

Digital therapeutics is a new approach to treat hypertension via using software programs such as smartphone apps and/or device algorithms. We develop a HERB system-new interactive smartphone app (HERB Mobile) with web-based patient management console (HERB Console)-to lower blood pressure (BP) based on an algorithm that helps users to promote lifestyle modifications in conjunction with medically validated non-pharmacological interventions. The app can assess the personalities, behavior characteristics, and hypertension determinants of each patient with hypertension to provide adequate guidance. To demonstrate the efficacy of the system, we designed a randomized, controlled, multicenter, open-label trial "HERB-DH1 (HERB digital hypertension 1)" to assess the efficacy of HERB system in patients with essential hypertension. The authors allocate patients to the intervention group (HERB system + standard lifestyle modification) or to the control group (standard lifestyle modification alone). In the intervention group, we provide the HERB Mobile for patients and the HERB Console for their primary physicians for 24 weeks. Both groups are instructed for standard lifestyle modifications based on the current recommendations in the Japanese Society of Hypertension 2019 guideline. The primary outcome is the mean change from baseline to 12 weeks in 24-hour systolic BP measured by ambulatory BP monitoring. We started this study in December of 2019, and the trial results will be expected in early 2021. We believe that this trial enables us to verify the efficacy of the HERB system in patients with essential hypertension.

Treatment of Obesity in Mitigating Metabolic Risk

Through diverse mechanisms, obesity contributes to worsened cardiometabolic health and increases rates of cardiovascular events. Effective treatment of obesity is necessary to reduce the associated burdens of diabetes mellitus, cardiovascular disease, and death. Despite increasing cardiovascular outcome data on obesity interventions, only a small fraction of the population with obesity are optimally treated. This is a primary impetus for this article in which we describe the typical weight loss, as well as the associated impact on both traditional and novel cardiovascular disease risk factors, provided by the 4 primary modalities for obtaining weight loss in obesity-dietary modification, increasing physical activity, pharmacotherapy, and surgery. We also attempt to highlight instances where changes in metabolic risk are relatively specific to particular interventions and appear at least somewhat independent of weight loss. Finally, we suggest important areas for further research to reduce and prevent adverse cardiovascular consequences due to obesity.

Dietary Factors and Risks of Cardiovascular Diseases: An Umbrella Review

Unhealthy diet is a significant risk factor for cardiovascular diseases (CVD). Therefore, this umbrella review aims to comprehensively review the effects of dietary factors, including dietary patterns, food groups, and nutrients on CVD risks. Medline and Scopus databases were searched through March 2020. Systematic reviews with meta-analyses (SRMA) of randomized controlled trials (RCTs) or observational studies measuring the effects of dietary factors on CVD risks were eligible. Fifty-four SRMAs, including 35 SRMAs of observational studies, 10 SRMAs of RCTs, and 9 SRMAs of combined RCT and observational studies, were included for review. Findings from the SRMAs of RCTs suggest the significant benefit of Mediterranean and high-quality diets for lowering CVD risk, with pooled risk ratios (RRs) ranging from 0.55 (95%CI: 0.39-0.76) to 0.64 (95%CI: 0.53-0.79) and 0.70 (95%CI: 0.57-0.87), respectively. For food nutrients, two SRMAs of RCTs found that high intake of n-3 polyunsaturated fatty acid (PUFA) significantly reduced CVD risks, with pooled RRs ranging from 0.89 (95%CI: 0.82, 0.98) to 0.90 (95%CI: 0.85-0.96), while evidence of efficacy of n-6 PUFA and combined n-3 and n-6 PUFA were inconsistent. Moreover, results from the SRMAs of RCTs did not find a significant benefit of a low-salt diet and low total fat intake for CVD prevention. For food groups, results from the SRMAs of cohort studies suggest that high intakes of legumes, nuts, and chocolate, as well as a vegetarian diet significantly reduced the risk of coronary heart disease, with pooled RRs of 0.90 (95%CI: 0.84-0.97), 0.68 (95%CI: 0.59-0.78), 0.90 (95%CI: 0.82-0.97), and 0.71 (95%CI: 0.57-0.87), respectively. Healthy dietary patterns had a significant benefit for CVD prevention. With the substitutional and synergistic interactions between different food groups and nutrients, dietary recommendations for CVD prevention should be focused more on healthy dietary patterns than single food groups or nutrients.

Effect of Hemoglobin A1c Reduction or Weight Reduction on Blood Pressure in Glucagon-Like Peptide-1 Receptor Agonist and Sodium-Glucose Cotransporter-2 Inhibitor Treatment in Type 2 Diabetes Mellitus: A Meta-Analysis

Background Glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) have shown their beneficial effects on cardiovascular outcomes and multiple cardiovascular risk factors, including hypertension. However, the mechanism of blood pressure (BP)-lowering effects of these agents has not been elucidated. This study aims to evaluate the effect of hemoglobin A1c reduction or body weight reduction with GLP-1RA treatment and SGLT2i treatment on BP changes in patients with type 2 diabetes mellitus. Methods and Results Studies were identified by a search of MEDLINE, EMBASE, and the Cochrane Central Register until June 2019. Meta-regression analysis was performed to evaluate the association between hemoglobin A1c reduction or body weight reduction and changes of BP. A total of 184 trials were included. Both GLP-1RA and SGLT2i led to significant reductions in systolic BP (weighted mean difference, -2.856 and -4.331 mm Hg, respectively; P<0.001 for both) and diastolic BP (weighted mean difference, -0.898 and -2.279 mm Hg, respectively; P<0.001 for both). For both drug classes, hemoglobin A1c reduction was not independently associated with systolic BP reduction or diastolic BP reduction. In GLP-1RA treatment, weight reduction was positively associated with systolic BP reduction and diastolic BP reduction (β=0.821 and β=0.287, respectively; P<0.001 for both). In SGLT2i treatment, weight loss was significantly associated with systolic BP reduction (β=0.820; P=0.001) but was not associated with diastolic BP reduction. Conclusions Treatment with GLP-1RA and SGLT2i led to significant reductions in BP in patients with type 2 diabetes mellitus. Weight reduction was significantly and independently associated with BP reductions in GLP-1RA treatment and SGLT2i treatment.

Hypertension prevalence in patients attending tertiary pain management services, a registry-based Australian cohort study

Persistent pain and hypertension often co-occur, and share several biological and lifestyle risk factors. The present study aimed to provide insight into the prevalence of, and factors associated with, hypertension in the largest cohort of patients seeking treatment in 43 tertiary pain clinics in Australia. Adults aged > = 18 years registered to the electronic Persistent Pain Outcomes Collaboration registry between 2013 and 2018 were included if they had persistent non-cancer pain (N = 43,789). Risk Ratios (RRs) compared prevalence of self-reported hypertension with the general and primary care Australian populations, and logistic regression examined factors associated with hypertension. One in four (23.9%) patients had hypertension, which was higher than the Australian adult population (2014–15: RR = 5.86, 95%CI: 5.66, 6.06; 2017–18: RR = 9.40, 95%CI: 9.01, 9.80), and in primary care patients (2011–13: RR = 1.17, 95%CI: 1.15, 1.20). Adjusting for covariates, patients with higher odds of hypertension were older, lived in regions with higher socioeconomic disadvantage, had higher levels of BMI, were born outside the Oceania/Australasia region, and had comorbid arthritis, diabetes, or severe-extremely severe anxiety symptoms. Female patients and those with depression symptoms had lower adjusted odds. Unadjusted analyses showed an association between widespread pain, pain duration, pain severity and interference, and lower pain self-efficacy with hypertension; however, only pain severity remained significant in adjusted analyses. Hypertension was more prevalent in people with persistent pain than in the general community, was associated with more severe pain, and commonly co-occurred with pain-related impairments. Routine hypertension screening and treatment targeting shared mechanisms of hypertension and pain may improve treatment outcomes in the pain clinic setting.

Effect of Body Weight Change on Blood Pressure in a Japanese General Population with a Body Mass Index ≥ 22 kg/m2

The association between changes in body weight and blood pressure (BP) in overweight people in the general population still remains unclear. We sought to clarify the effect of body weight change on BP using a community-based cohort. We studied 1,170 overweight subjects with a body mass index (BMI) ≥ 22 kg/m² who underwent health check-ups. Among the study subjects, 175 (15%) were categorized in the weight loss group (weight loss ≥ 5%), 869 (74%) in the weight stable group, and 126 (11%) in the weight gain group (weight gain ≥ 5%). There were no significant differences in baseline BP between the 3 groups. In the weight loss group, systolic and diastolic BP, and the rates of stage 2 (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) and stage 1 hypertension (130 mmHg≤ systolic BP < 140 mmHg or 80 mmHg≤ diastolic BP < 90 mmHg) decreased. In contrast, in the weight gain group, systolic and diastolic BP and the rate of stage 2 hypertension increased. Subgroup analysis showed that the correlation between change in body weight and BP was seen in each subgroup according to age, sex, and BMI. The results of the present study suggest the significance of body weight control for BP control in subjects with BMI ≥ 22 kg/m².

Improving obesity and blood pressure

Obesity-associated hypertension is a serious public health concern. Sympathetic nervous system (SNS) overactivity, especially in the kidneys, is an important mechanism linking obesity to hypertension. Some adipokines play important roles in elevating blood pressure (BP). Hyperinsulinemia caused by insulin resistance stimulates sodium reabsorption, enhances sodium retention, and increases circulating plasma volume. Hyperinsulinemia also stimulates both the renin-angiotensin-aldosterone system (RAAS) and the SNS, resulting in the acceleration of atherosclerosis through the hypertrophy of vascular smooth muscle cells, which contributes to increased peripheral vascular resistance. Obesity is associated with increased RAAS activity despite volume overload, as the tissue RAASs are stimulated in obese hypertensive individuals. Mineralocorticoid receptor-associated hypertension must also be considered in obese patients with resistant hypertension. Obstructive sleep apnea syndrome (OSAS) is the most common cause of secondary hypertension. Some components of the gut microbiota contribute to BP control; therefore, gut dysbiosis caused by obesity might lead to increased BP. The ratio of visceral fat to subcutaneous fat is higher in Japanese patients than in Caucasian patients, which may explain why Japanese patients are more susceptible to metabolic disorders even though they are less obese than Caucasian individuals. Obesity-associated kidney dysfunction directly increases BP, leading to further deterioration of kidney function. A bodyweight reduction of more than 3% or 5 kg significantly lowers BP. Gastrointestinal bypass surgery is an effective treatment for morbid obesity and its related metabolic disorders, including hypertension. Because both obesity and hypertension are representative lifestyle-related disorders, lifestyle modification, especially to improve obesity, should be performed first as a treatment for hypertension.

Predictors for Blood Pressure Reduction in American Latinos: Secondary Analysis of the Adelgaza Program Data

Little is known about factors that predict blood pressure (BP) reduction in overweight American Latinos. The aim of this secondary analysis was to explore predictors of changes in mean systolic and diastolic BPs over an 8-week weight loss intervention period in a sample of 54 overweight American Latinos using data collected during the Adelgaza trial. Baseline BP, exercise energy use (in units of metabolic equivalent of task), weight change, average daily intake of calories from beverages, average daily intake of calories from fat, age, and gender were considered as potential predictors of reductions in BP, as measured at baseline, 3, and 8 weeks. Baseline characteristics were as follows: mean age 45.3 (SD = 10.8) years, 31.5% male, 61.1% born in the United States. Mean baseline systolic and diastolic BPs were 122.1 (SD = 14.4) mmHg and 76.6 (SD = 9.8) mmHg, respectively. Both baseline systolic and diastolic BPs predicted reductions in systolic BP after adjusting for other factors (p < .001). None of the nine variables predicted reductions in diastolic BP (p > .05). This finding suggests that overweight American Latinos with higher baseline systolic or diastolic BP should be identified and provided with early intervention education to achieve better hypertension management or prevention.

Resistant Hypertension Updated Guidelines

PURPOSE OF REVIEW

To discuss the current definition as well as recommendations for diagnosis and treatment of resistant hypertension (RH) based on the 2018 American Heart Association (AHA) guidelines and recent literature.

RECENT FINDINGS

RH is defined as uncontrolled blood pressure (BP) on ≥ 3 anti-hypertensives, one of which should be a diuretic, prescribed at maximally tolerated doses and appropriate dosing frequency. The diagnosis of RH requires exclusion of white coat effect and medication non-adherence, underscoring the importance of out-of-office BP measurements. Secondary causes of hypertension must be excluded in all patients with RH. A step-wise approach to treatment focusing on lifestyle modifications and medication optimization can be effective in > 50% of the patients with RH. Device-based interventional therapies for RH are currently investigational. Out-of-office BP measurements are central to the diagnosis of RH. Medication optimization is successful in most patients. Further studies are needed to define the role of device-based interventions.

Effect of Intentional Weight Loss on Mortality Biomarkers in Older Adults With Obesity

BACKGROUND

Observational research has identified several mortality biomarkers; however, their responsiveness to change is unknown. We tested whether the Healthy Aging Index (HAI) and other mortality biomarkers were responsive to intentional weight loss (WL), which is associated with lower mortality risk in recent meta-analyses.

METHODS

Older adults (70.3 ± 3.7 years) with obesity were randomized into a 6-month WL (n = 47) or weight stability (WS: ±5% baseline weight; n = 48) program. Baseline and 6-month HAI score (0-10) was calculated from component sum (each 0-2: systolic blood pressure, forced vital capacity [FVC], creatinine, fasting blood glucose [FBG], Montreal Cognitive Assessment), and gait speed, grip strength, Digit Symbol Substitution Test, FEV1, Interleukin-6, C-Reactive Protein, and Cystatin-C were assessed at baseline and 6 months.

RESULTS

Mean baseline HAI was 3.2 ± 1.6. By 6 months, WL participants lost 8.87 (95% CI: -10.40, -7.34) kg, whereas WS participants remained weight stable. WL group reduced HAI score (WL: -0.75 [95% CI: -1.11, -0.39] vs WS: -0.22 [95% CI: -0.60, 0.15]; p = .04), and components changing the most were FBG (WL: -3.89 [95% CI: -7.78, 0.00] mg/dL vs WS: 1.45 [95% CI: -2.61, 5.50] mg/dL; p = .047) and FVC (WL: 0.11 [95% CI: -0.01, 0.23] L vs WS: -0.05 [95% CI: -0.17, 0.08] L; p = .06). Among other biomarkers, only Cystatin-C significantly changed (WL: -2.53 [95% CI: -4.38, -0.68] ng/mL vs WS: 0.07 [95% CI: -1.85, 1.98] ng/mL; p = .04). Combining treatment groups, 1 kg WL was associated with a 0.07 (95% CI: 0.03, 0.12) HAI reduction (p < .01).

CONCLUSION

Intentional WL via caloric restriction reduced HAI score by 0.53 points, largely attributable to metabolic and pulmonary improvements.

Lifestyle modification strategies for controlling hypertension: How are these strategies recommended by physicians in Iran?

Background: This study aimed to evaluate lifestyle changes and their impact on hypertension control and why and how lifestyle modifications are recommended for patients with hypertension. Four non pharmacological strategies have been recommended by physicians for hypertension control for hypertensive patients in Iran: healthier diet, smoking cessation, physical activity, and weight loss.

Methods: Among participants of Iran STEPS Non-communicable Disease Risk Factors Survey (STEPs), 7879 hypertensive patients aged ≥25 years were selected. All statistical analyses were calculated using STATA software version 14. Means, proportions, and multiple binary logistic regression models were used. Two-tailed p values of <0.05 were considered statistically significant.

Results: The results of this study showed that about three quarters of people with high blood pressure had been recommended lifestyle strategies by their physician for blood pressure control. Of the participants, 41% reported that they had been recommended only lifestyle modification for their blood pressure (BP), while 35% reported that they were recommended both lifestyle changes and medications as part of their treatment. Healthier diet, 71.9% (70.8-72.9), and smoking cessation, 23.8% (21.4-25.6), were the most and least frequently recommended strategies, respectively. Also, the rates of recommendations on smoking cessation, weight loss, increased physical activity, and healthier diet were more among women, married, and illiterate individuals, respectively.

Conclusion: Because of the changes and transitions in the lifestyle and dietary habits in the modern world, policies and training programs should be developed to improve the recommendations on lifestyle modification. Also, educational programs should be developed to increase patient’s acceptance of lifestyle modifications and physical activity.

Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association

Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the "white-coat effect" (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.

Weight Loss Medications in the Treatment of Obesity and Hypertension

PURPOSE OF REVIEW

Weight loss is strongly associated with improvement in blood pressure; however, the mechanism of weight loss can impact the magnitude and sustainability of blood pressure reduction.

RECENT FINDINGS

Five drugs-orlistat, lorcaserin, liraglutide, phentermine/topiramate, and naltrexone/bupropion-are currently approved for weight loss therapy in the USA. Naltrexone/bupropion results in an increase in in-office and ambulatory blood pressure compared to placebo. Other therapies are associated with modest lowering of blood pressure, and are generally well-tolerated; nonetheless, evidence is limited regarding their effect on blood pressure, particularly longitudinally, in individuals with hypertension. Although weight loss medications can be an effective adjunct to lifestyle modifications in individuals with obesity, there is limited evidence regarding their benefit with regard to blood pressure. Future studies evaluating the effectiveness of weight loss medications should include careful assessment of their short- and long-term impact on blood pressure in individuals with hypertension.

Standardized ethanol-water extract of Ficus deltoidea Angustifolia reduces blood pressure in spontaneously hypertensive rats

Ficus deltoidea is used in Malay traditional medicine for the treatment of a number of disorders, including hypertension. There is, however, no scientific evidence on its anti-hypertensive effects. This study, therefore, investigated the effects of a standardized ethanolic-water extract of Ficus deltoidea Angustifolia (FD-A) on blood pressure (BP) in spontaneously hypertensive rats (SHR). Male SHR with systolic BP of >150 were divided into 4 groups (n = 8) and given either FD-A (800 or 1000 mg kg^-1 day^-1) or losartan (10 mg kg^-1 day^-1) or 0.5 ml of distilled water (control) daily for 28 days. BP, body weight, food and water intake, serum and urinary electrolytes, endothelin-1 (ET-1), total antioxidant capacity (TAC) and components of the renin-angiotensin-aldosterone system were measured. Data were analyzed using ANOVA with statistical significance set at p < 0.05. Following treatment, BP, heart rate, and heart weight in FD-A and losartan-treated rats were significantly lower than those in the controls. Serum TAC and urinary calcium excretion were significantly higher, whereas serum ET-1 concentration was significantly lower in FD-A treated rats when compared to those in controls. No significant differences were found in the components of the renin-angiotensin-aldosterone system between controls and FD-A treated rats. In conclusion, FD-A when given daily at doses of either 800 or 1000 mg kg^-1 day^-1 body weight reduces BP in SHR. This effect does not seem to involve the renin-angiotensin-aldosterone-system but might involve some other mechanisms. Abbreviations: FD-A: Ficus deltoidea Angustifolia; ACE: Angiotensin-converting enzyme; SHR: Spontaneously hypertensive rats; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; AUC: Area under curve; RAAS: Renin Angiotensin Aldosterone System.

Nitrate-Rich Fruit and Vegetable Supplement Reduces Blood Pressure in Normotensive Healthy Young Males without Significantly Altering Flow-Mediated Vasodilation: A Randomized, Double-Blinded, Controlled Trial

Nitric oxide (NO) is a primary vasodilatory factor released from endothelial cells of the peripheral vasculature. NO production is stimulated through enzymatic-dependent mechanisms via NO synthase and from dietary intake of nitrate-containing foods or supplements. We evaluated the efficacy of a nitrate-rich fruit and vegetable liquid supplement (FVS, AMPED NOx, Isagenix International LLC) versus a juice low in nitrates (prune juice, PRU) on circulating nitrates/nitrites as well as cardiovascular parameters in 45 healthy normotensive men (18–40 y). Blood pressure, flow-mediated dilation (FMD), and plasma nitrates and nitrites were measured at baseline and after two weeks of supplementation (2 oz/d). Subjects also completed questionnaires on sleep quality and mood since these measures have been associated with endothelial function. In contrast to PRU, FVS significantly increased plasma nitrates and nitrites (+67%, p < 0.001) and decreased diastolic blood pressure (−9%, p=0.029) after two weeks. The change in FMD for FVS supplementation versus PRU supplementation was not significant (+2% vs. −9%, respectively, p=0.145). Changes in sleep quality or total mood state did not differ between groups after the 2-week study. Thus, the nitrate-rich FVS supplement increased plasma NO and reduced diastolic blood pressure in young normotensive men, but increased plasma NO was not associated with improvements in FMD, mood, or sleep. This trial is registered with ClinicalTrials.gov NCT03486145.

A defined, plant-based diet utilized in an outpatient cardiovascular clinic effectively treats hypercholesterolemia and hypertension and reduces medications

BACKGROUND

Cardiovascular disease (CVD) is a major economic burden in the United States. CVD risk factors, particularly hypertension and hypercholesterolemia, are typically treated with drug therapy. Five-year efficacy of such drugs to prevent CVD is estimated to be 5%. Plant-based diets have emerged as effective mitigators of these risk factors.

HYPOTHESIS

The implementation of a defined, plant-based diet for 4 weeks in an outpatient clinical setting may mitigate CVD risk factors and reduce patient drug burden.

METHODS

Participants consumed a plant-based diet consisting of foods prepared in a defined method in accordance with a food-classification system. Participants consumed raw fruits, vegetables, seeds, and avocado. All animal products were excluded from the diet. Participant anthropometric and hemodynamic data were obtained weekly for 4 weeks. Laboratory biomarkers were collected at baseline and at 4 weeks. Medication needs were assessed weekly. Data were analyzed using paired-samples t tests and 1-way repeated-measures ANOVA.

RESULTS

Significant reductions were observed for systolic (-16.6 mmHg) and diastolic (-9.1 mmHg) blood pressure (P < 0.0005), serum lipids (P ≤ 0.008), and total medication usage (P < 0.0005). Other CVD risk factors, including weight (P < 0.0005), waist circumference (P < 0.0005), heart rate (P = 0.018), insulin (P < 0.0005), glycated hemoglobin (P = 0.002), and high-sensitivity C-reactive protein (P = 0.001) were also reduced.

CONCLUSION

A defined, plant-based diet can be used as an effective therapeutic strategy in the clinical setting to mitigate cardiovascular risk factors and reduce patient drug burden.

Mechanisms of weight loss and improved metabolism following bariatric surgery

Bariatric surgery is increasingly recognized as one of the most effective interventions to help patients achieve significant and sustained weight loss, as well as improved metabolic and overall health. Unfortunately, the cellular and physiological mechanisms by which bariatric surgery achieves weight loss have not been fully elucidated, yet are critical to understanding the central role of the intestinal tract in whole-body metabolism and to developing novel strategies for the treatment of obesity. In this review, we provide an overview of potential mechanisms contributing to weight loss, including effects on regulation of energy balance and both central and peripheral nervous system regulation of appetite and metabolism. Moreover, we highlight the importance of the gastrointestinal tract, including alterations in bile acid physiology, secretion of intestinally derived hormones, and the microbiome, as a potent mediator of improved metabolism in postbariatric patients.

Recognition and Management of Resistant Hypertension

Despite improvements in hypertension awareness and treatment, 30%-60% of hypertensive patients do not achieve BP targets and subsequently remain at risk for target organ damage. This therapeutic gap is particularly important to nephrologists, who frequently encounter treatment-resistant hypertension in patients with CKD. Data are limited on how best to treat patients with CKD and resistant hypertension, because patients with CKD have historically been excluded from hypertension treatment trials. First, we propose a consistent definition of resistant hypertension as BP levels confirmed by both in-office and out-of-office measurements that exceed appropriate targets while the patient is receiving treatment with at least three antihypertensive medications, including a diuretic, at dosages optimized to provide maximum benefit in the absence of intolerable side effects. Second, we recommend that each patient undergo a standardized, stepwise evaluation to assess adherence to dietary and lifestyle modifications and antihypertensive medications to identify and reduce barriers and discontinue use of substances that may exacerbate hypertension. Patients in whom there is high clinical suspicion should be evaluated for potential secondary causes of hypertension. Evidence-based management of resistant hypertension is discussed with special considerations of the differences in approach to patients with and without CKD, including the specific roles of diuretics and mineralocorticoid receptor antagonists and the current place of emerging therapies, such as renal denervation and baroreceptor stimulation. We endorse use of such a systematic approach to improve recognition and care for this vulnerable patient group that is at high risk for future kidney and cardiovascular events.

The effect of a reduction in alcohol consumption on blood pressure: a systematic review and meta-analysis

BACKGROUND

Although it is well established that heavy alcohol consumption increases the risk of hypertension, little is known about the effect of a reduction of alcohol intake on blood pressure. We aimed to assess the effect of a reduction in alcohol consumption on change in blood pressure stratified by initial amount of alcohol consumption and sex in adults.

METHODS

In this systematic review and meta-analysis, we searched MedLine, Embase, CENTRAL, and ClinicalTrials.gov from database inception up to July 13, 2016, for trials investigating the effect of a change of alcohol consumption on blood pressure in adults using keywords and MeSH terms related to alcohol consumption, blood pressure, and clinical trials, with no language restrictions. We also searched reference lists of identified articles and published meta-analyses and reviews. We included full-text articles with original human trial data for the effect of a change of alcohol consumption on blood pressure in adults, which reported a quantifiable change in average alcohol consumption that lasted at least 7 days and a corresponding change in blood pressure. We extracted data from published reports. We did random-effects meta-analyses stratified by amount of alcohol intake at baseline. All meta-analyses were done with Stata (version 14.1). For the UK, we modelled the effect of a reduction of alcohol consumption for 50% of the population drinking more than two standard drinks per day (ie, 12 g pure alcohol per drink).

FINDINGS

36 trials with 2865 participants (2464 men and 401 women) were included. In people who drank two or fewer drinks per day, a reduction in alcohol was not associated with a significant reduction in blood pressure; however, in people who drank more than two drinks per day, a reduction in alcohol intake was associated with increased blood pressure reduction. Reduction in systolic blood pressure (mean difference -5·50 mm Hg, 95% CI -6·70 to -4·30) and diastolic blood pressure (-3·97, -4·70 to -3·25) was strongest in participants who drank six or more drinks per day if they reduced their intake by about 50%. For the UK, the results would translate into more than 7000 inpatient hospitalisations and 678 cardiovascular deaths prevented every year.

INTERPRETATION

Reducing alcohol intake lowers blood pressure in a dose-dependent manner with an apparent threshold effect. Implementation of effective alcohol interventions in people who drink more than two drinks per day would reduce the disease burden from both alcohol consumption and hypertension, and should be prioritised in countries with substantial alcohol-attributable risk.

FUNDING

National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health (NIH).