Non-drug therapy for hypertension: do effects on weight and sodium intake persist after discontinuation of intervention?

The long-term effects of lifestyle change on blood pressure: One-year follow-up of the ENCORE study

BACKGROUND

There is a paucity of data describing the sustained benefits of lifestyle interventions on health behaviors and blood pressure (BP).

METHODS

We examined the persistence of changes in health habits and BP in the ENCORE study, a trial in which 144 overweight individuals with above-normal BP were randomized to one of the following 16-week interventions: Dietary Approaches to Stop Hypertension (DASH) diet alone (DASH-A), DASH diet plus a behavioral weight management intervention (DASH-WM), or Usual Care. Follow-up assessments were conducted 8 months after the end of treatment.

RESULTS

At 16 weeks, systolic BP was reduced by 16.1 (95% confidence interval (CI) = 13.0-19.2) mm Hg in the DASH-WM group, 11.2 (95% CI = 8.1-14.3) mm Hg in the DASH-A group, and 3.4 (95% CI = 0.4-6.4) mm Hg in the Usual Care group. A decrease in BP persisted for 8 months, with systolic BP lower than baseline by 11.7 (95% CI = 8.1-15.3) mm Hg in the DASH-WM group, 9.5 (95% CI = 6.7-12.1) mm Hg in the DASH-A group, and 3.9 (95% CI = 0.5-7.3) mm Hg in the Usual Care group (P < 0.001 for active treatments vs. Usual Care). DASH-WM subjects lost 8.7 kg during the intervention and remained 6.3 kg lighter on follow-up examination. Changes in diet content were sustained in both DASH intervention groups. Among those who participated in DASH-WM, however, caloric intake was no longer lower, and only 21% reported still exercising regularly 8 months after completing the intervention.

CONCLUSIONS

Changes in dietary habits, weight, and BP persisted for 8 months after completion of the 16-week ENCORE program, with some attenuation of the benefits. Additional research is needed to identify effective methods to promote long-term maintenance of the benefits of lifestyle modification programs.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT00571844.

Barriers and facilitators of dietary sodium restriction amongst Bangladeshi chronic kidney disease patients

BACKGROUND

People of Bangladeshi origin have the highest mortality ratio from coronary heart disease of any minority ethnic group in UK and their rate of kidney disease is three- to five-fold higher than that of the European UK population. However, there is little information regarding their dietary customs or knowledge, beliefs and attitudes towards health and nutrition. This multi-method qualitative study aimed to identify: (i) barriers and facilitators to dietary sodium restriction; (ii) traditional and current diet in the UK; and (iii) beliefs and attitudes towards development of hypertension, and the role of sodium.

METHODS

Methods included focus group discussions, vignettes and food diaries. Twenty female chronic kidney disease patients attended four focus group discussions and maintained food diaries; ten responded to vignettes during telephone interviews. Triangulation of the results obtained from the three methods identified categories and themes from qualitative thematic analysis.

RESULTS

Identified barriers to sodium restriction were deeply-rooted dietary beliefs, attitudes and a culturally-established taste for salt. Facilitators of change included acceptable strategies for cooking with less salt without affecting palatability. Dietary practices were culturally determined but modified by participants' prosperity in the UK relative to their previous impoverished agrarian lifestyles in Bangladesh.

CONCLUSIONS

Cultural background and orientation were strong determinants of the group's dietary practices and influenced their reception and response to health communication messages. Efforts to understand their cultural mores, interpret and convey health-promotion messages in culturally-appropriate ways met with a positive response.

Sodium dietary restriction, knowledge, beliefs, and decision-making behavior of older females

PURPOSE

The purposes of this qualitative/descriptive study were to (a) explore experiences and decision-making behaviors associated with adoption of a sodium-restricted diet (SRD) among older women with hypertension or heart failure and (b) identify healthcare system and contextual factors that facilitate or impede adherence to SRD.

DATA SOURCES

Participants were 33 single older women, aged 65-98 years, residing in three congregate living facilities in the high-risk "coronary valley" area of the United States. A semistructured interview format was employed with three focus groups. The audio-taped transcribed data were content analyzed for themes by the researchers with the assistance of ATLAS.Ti computer software.

CONCLUSIONS

Predominant themes were lack of SRD education by healthcare providers, a desire for more information about sodium, including the use of alternative herbal seasonings, and large-print informational materials. Eating alone with no motivation to cook and share meals was a contextual barrier to healthy nutrition.

IMPLICATIONS FOR PRACTICE

To prevent costly hospitalizations and rehospitalization from nonadherence to SRD, clinicians need to provide more structured SRD education supplemented with printed brochures. Exploring the client's nutritional social setting may improve SRD adherence.

Persistence of normotension after discontinuation of lifestyle intervention in the trial of TONE. Trial of Nonpharmacologic Interventions in the Elderly

BACKGROUND

Weight loss and sodium reduction programs are effective in treating hypertension, but there is little information about the persistence of the benefit after discontinuation of the intervention.

METHODS

The Trial of Nonpharmacologic Interventions in the Elderly (TONE) was a four-center controlled clinical trial of weight loss, reduced sodium intake, or both in maintaining normotension after withdrawal of antihypertensive drug therapy in older men and women whose hypertension was controlled with a single antihypertensive medication. Information on maintenance of normotension without need for drug therapy was obtained on 222 of 223 participants at the Robert Wood Johnson Medical School clinical center on average of 48.4 months (range 45 to 54 months) after the end of TONE.

RESULTS

At the end of TONE follow-up, 43% of participants in the combined intervention group were off medication compared with 25% in the usual care group (P = .011). At 48 months after the end of TONE and discontinuation of contact of the participants with the clinical center, 23% of the combined intervention group v 7% in the usual care group were off medication (P = .012).

CONCLUSIONS

Some benefits of structured dietary intervention appears to persist long term in a significant number of patients after discontinuation of the intervention.

Lifestyle modifications in the prevention and treatment of hypertension

OBJECTIVE

To present an objective, evidence-based review of the current literature on the role of lifestyle factors in hypertension.

METHODS

We discuss the reported roles of obesity and overweight, nutritional factors, alcohol, physical activity, and smoking in the prevention and treatment of hypertension.

RESULTS

For all age-groups and in both sexes, cross-sectional and prospective studies have shown a direct strong relationship between weight and blood pressure. In general, overweight is associated with a twofold to sixfold increase in the risk of developing hypertension. Clinical trials have proved that weight loss is effective in the primary prevention of hypertension as well as in the reduction of both systolic and diastolic blood pressure in patients with normal or high blood pressure. A decreased intake of dietary sodium has been demonstrated to have a hypotensive effect, both alone and as an adjunctive measure to pharmacologic therapy. Although no consensus currently exists about the role of potassium intake in prevention or control of hypertension, some studies support the protective value of high intake of potassium. A consistent relationship has been noted between consumption of alcohol and increased blood pressure, and reduced intake of alcohol has been shown to decrease blood pressure significantly. An inverse relationship exists between blood pressure and physical activity, independent of overweight or obesity. Moreover, increased physical activity helps lower both systolic and diastolic blood pressure. In a study of the effect of smoking and use of smokeless tobacco in healthy middle-aged men, ambulatory diastolic blood pressures were increased in both smokers and smokeless tobacco users in comparison with nonusers.

CONCLUSION

Ample evidence supports the beneficial effects of healthful lifestyle modifications in the prevention and management of hypertension. Therefore, physicians should be motivated to provide guidance to the population relative to lifestyle practices that can help prevent and control hypertension.