NON PHARMACOLOGIC
THERAPY: LIFE STYLE
MODIFICATION

Mon Pharmacologic Therapy: Life Style Modification

Rational

1. This approach proved successful in lowering blood pressure.

2. It improves health profile and prevents cardiovascular disease.

3. Drugs have side effects and are expensive.

Components

1. Weight reduction.

2. Limit salt intake.

3. Increase physical activity.

4. Moderation in alcohol intake.

5. Stress management and relaxation therapy.

6. Control other cardiovascular risk factors: smoking, dyslipidemia.

7. Other dietary measures.

Weight Reduction

· Current data show a positive correlation between increased weight for height and hypertension in both adults and children.

· Weight reduction reduces blood pressure in a large proportion of hypertensive individuals who are more than 10% above ideal weight.

· It enhances blood pressure lowering effect of concurrent antihypertensive agents.

· It is achieved through caloric restriction and regular physical activty.

· Mon Pharmacologic Therapy: Life Style Modification

Mechanisms of Hypotensive Action of Weight Reduction:

1. Decreases intravascular volume which induces reduction in cardiac output.

2. Reduces plasma insulin levels secondary to enhanced insulin sensitivity. Insulin has a number of pressor effects that elevate blood pressure through stimulation or increased absorption of sodium in the renal tubule, increases adrenergic activity and alters Na-K distribution which increases peripheral resistance.

3. Reduces plasma norepinephrine level and diminish sympathetic nervous activity.

· General Guidelines to Reduce Calories:

1. Prepare all foods without addition of butter, margarine, fat, oil or sugar.

2. Limit servings to 3 meals a day and one small snack in the afternoon. Avoid continuous eating or snacking.

3. Limit portion sizes.

4. Avoid high caloric foods: Candy, cookies, pies, pasteries, carbonated beverages (e.g., coca cola), nuts, chips, french fries. In their place substitute fresh fruits and vegetables (specially raw), skim milk and fruit juices.

5. Avoid appetizers.

· Problems of Weight Reduction:

Limited compliance.

Effect is less dramatic than drug therapy.

Dietary Salt Reduction

· Individuals vary in their blood pressure response to changes in dietary sodium chloride, i.e., vary in their salt sensitivity (chapter 2).

· Moderate sodium restriction can reduce blood pressure in hypertensive individuals.

· A reduction in dietary salt to 5 gm/day can be achieved without making the diet unpalatable.

· Mon Pharmacologic Therapy: Life Style Modification

It is estimated that the average person consumes from 2 to 3 tea spoons of salt (NaCl) per day or about 9 to 15 gms*. Only a small amounts is needed to meet metabolic needs for cellular metabolism. By using a mildly controlled sodium or "No Added Salt" diet, it is possible to cut the intake of sodium at least in half.

· Guidelines

1. Omit the use of salt at the table.

2. Avoid processed or canned foods, meat tenderizers, ketchup.

3. Avoid obviously salty foods such as pickles, potato chips, salted nuts, any cheese, smoked fish, sardines.

· Sodium restriction potentiates the action of ACE inhibitors and possibly diuretics and beta- blockers.

Physical Activity

· Sedentary and unfit normotensive individuals have a 20 to 50% increased risk of developing hypertension during follow-up when compared with active individuals.

· Relatively intense phyical training, performed at least 30 minutes 3 times per week for one to eight months can reduce blood pressure.

· Regular physical activity can reduce systolic pressure in hypertensive patients by 10 mmHg.

· Moderate activity such as 30-45 minutes of brisk walking 3-5 times/week is beneficial.

· Exercise intensity can be set at a heart rate of 190 beats/min minus age.

· Training should be regular and progressive avoiding exhaustion and sudden bursts of energy.

· Mon Pharmacologic Therapy: Life Style Modification

Mechanisms of hypotensive action of physical activity include: Weight reduction, attenution of adrenergic activity and improved insulin sensitivity.

Stress Management And Relaxation

· Stress can raise blood pressure acutely and may contribute to the development of hypertension. The most likely causative mechanism is augmented sympathetic nervous system activity. Stress can result also in alteration in sodium and water excretion especially in subjects likely to develop hypertension.

· Relaxation training can range from instructions to "rest more" to highly structured formalized protocols which require months of training. The underlying features of relaxation training poptocols that require eyes to be closed, muscular relaxation and mental focusing. Instructions include the repetition of a word, sound, prayer or thought and the passive disregard of other thought.

· The basic elements for eliciting the relaxation response are found in islamic mysticism or sufism.

· Progressive muscle relaxation have beneficial influence in hypertensive patients. It is practiced in the supine position, in a quite room with a passive attitude. The subject is taught to recognize even slight muscle contractions so as to avoid them and achieve the deepest degree of relaxation.

· The value of stress management is controversal in the treatment of hypertension.

Control of Cardiovascular Risk Factors

Smoking Cessation

· Stroke and ischemic heart disease are more common among smokers.

· Malignant hypertension is almost a disease of smokers.

· Stopping smoking has the top priority in lifestyle modification.

Limit Cholesterol and Saturated Dietary Fat Intake

· Mon Pharmacologic Therapy: Life Style Modification

Excessive saturated fats increase the risks of both cerebrovascular thrombosis and coronary heart disease.

Other Dietary Measures

· Encourage high dietary potassium intake: fresh fruits and vegetables are rich in potassium.

· Potassium deficiency may increase blood pressure but potassium supplements do not lower blood pressure.

· There is an inverse relationship between dietary calcium and blood pressure.

· Calcium deficiency is associated with an increased prevalence of hypertension.

· An increased calcium intake may lower blood pressure in some patients with hypertension.

· Vegetarian diet has a blood pressure lowering effect.

· A diet rich in fruits, vegetables and low in dairy (milk) fat, and with reduce saturated and total fats, significantly lowers blood pressure.

*This is equivalent to 3 to 6 gm of sodium.