This document discusses non-pharmacologic management of hypertension. It recommends lifestyle modifications including weight loss, following the DASH diet which emphasizes fruits/vegetables, reducing sodium intake, regular exercise, limiting alcohol, and patient education. Other non-drug therapies mentioned are vitamin D and potassium supplementation, smoking cessation, and limiting NSAIDs and acetaminophen. The DASH diet was shown to lower blood pressure comparable to medication, especially when combined with low-fat dairy.

1. HYPERTENSION
Non Pharmacologic Management
Mohammad Ilyas, M.D.
Assistant Clinical Professor
University of Florida / Health Sciences Center
Jacksonville, Florida USA
6/24/2014
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2. Outline
1. Definition, Regulation and Pathophysiology
2. Measurement of Blood Pressure, Staging of Hypertension and Ambulatory
Blood Pressure Monitoring
3. Evaluation of Primary Versus Secondary
4. Sequel of Hypertension and Hypertension Emergencies
5. Management of Hypertension (Non-Pharmacology versus Drug Therapy)
6. The Relation Between Hypertension: Obesity, Drugs, Stress and Sleep
Disorders.
7. Hypertension in Renal diseases and Pregnancies
8. Pediatric, Neonatal and Genetic Hypertension
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3. 0
10
20
30
40
50
60
70
80
Hypertension Awareness, Treatment,
and Control: US 1976 to 2000*
NHANES III
(Phase 2)
1991-1994
NHANES III
(Phase 1)
1988-1991
51%
73% 68%
31%
55% 54%
10%
29% 27%
%Adults
NHANES II
1976-1980
NHANES
1999-2000
70%
59%
34%
Healthy People
2000/2010 Control
Target = 50%
Control
Awareness
Treated
Chobanian et al. JAMA. 2003;289:2560-2572.
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4. CV Mortality* Risk Doubles with
Each 20/10 mm Hg BP Increment*
Age 40-70 years
Ref: Lancet. 2002; 60:1903-1913.
JNC 7 Express. JAMA. 2003;289:2560-2572.
CV
mortality
risk
SBP/DBP (mm Hg)
0
1
2
3
4
5
6
7
8
115/75 135/85 155/95 175/105
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5. 0
1
2
3
4
5
6
7
8
9
120/80 140/90 160/100 180/110
HTN leads to an increased risk of death from stroke and heart disease
Systolic BP / Diastolic BP (mmHg)
8x
4x
2x
CV mortality risk doubles for every 20 mmHg increase in systolic blood pressure.1,2
CardiovascularMortalityRisk
Chobanian et al. Hypertension 2003;42:1206-1252; 2Lancet 2002;360:1903-1913
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6. Benefits of Treatment
 Reductions in Stroke about 35–40 %
 Reductions in MI, about 20–25 %
 Reductions in HF, about >50 %
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7. Goals of Treatment
Treating SBP and DBP to targets that are <140/90
mmHg
Patients with diabetes or renal disease, the BP
goal is <130/80 mmHg
The primary focus should be on attaining the SBP
goal.
To reduce cardiovascular and renal morbidity
and mortality
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8. Goal Blood Pressure
 Below 140/90 mmHg uncomplicated
 Below 150/90 mmHg in patients 60 years and older
 Individuals over age 65 years with isolated systolic
hypertension caution is needed not to reduce the
diastolic blood pressure to less 60 mmHg to attain a goal
systolic pressure less than 150 mmHg since such low
diastolic pressures have been associated with an
increased risk of myocardial infarction and stroke.
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9. JNC 7/8 Emphasizes Importance of Low BP
OPTIMAL
<120 and <80
HIGH NORMAL
130-139 or 85-89
STAGE 1
140-159 or 90-99
STAGE 2
160-179 or 100-109
STAGE 3
≥180 or ≥110
NORMAL
<130 and <85
NORMAL
<120 and <80
PREHYPERTENSION
120-139 OR 80-89
STAGE 2
≥160 or ≥100
STAGE 1
140-159 or 90-99
JNC 7 (2003) JNC 8 (2013)JNC VI (1997)
Hypertension
JNC VI. Arch Intern Med. 1997;157:2413-2446 JNC 7. JAMA. 2003;289(19):2560-2572. 6/24/2014
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10. 2014 Hypertension Guideline Management Algorithm SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI,
angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.aACEIs and ARBs should not
be used in combination.bIf blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the
current individual therapeutic plan.
JNC 8 (2014 Hypertension Guideline Management Algorithm)
JAMA. 2013;():. doi:10.1001/jama.2013.284427
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11. Adapted from the JNC 7 Slide Deck. Available at: http://www.nhlbi.nih.gov.
JNC 7: Guidelines for Hypertension
 Goal: To reduce cardiovascular and renal morbidity and
mortality through prevention and management of hypertension
Classification of Blood Pressure
DBP (mm Hg)SBP (mm Hg)Category
80
80-89
90-99
100
120
120-139
140-159
160
Normal
Prehypertension
Hypertension, Stage 1
Hypertension, Stage 2
and
or
or
or
JNC 7, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure; SBP, systolic blood pressure; DBP, diastolic blood pressure.
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12. 6/24/2014
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13. JAMA. 2013;():. doi:10.1001/jama.2013.284427
2014 Hypertension Guideline Management Algorithm SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI,
angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.aACEIs and ARBs should not
be used in combination.bIf blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the
current individual therapeutic plan.
JNC 8 (2014 Hypertension Guideline Management Algorithm)
2
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14. Non-pharmacologic therapy
(life style modification)
1. Weight loss
2. DASH Plan
3. Dietary salt restriction
4. Exercise
5. Limited alcohol intake
6. Patient education
7. Other non-pharmacologic therapies
Vitamin D supplementation, adequate potassium intake,
cessation of smoking, and limiting the use of non-steroidal anti-
inflammatory drugs and acetaminophen
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15. 6/24/2014
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16. Reducing Weight
Decrease time in sedentary behaviors such as
watching television, playing video games, or
spending time online.
Increase physical activity such as walking,
biking, aerobic exercise, tennis, soccer,
basketball, etc.
Decrease portion sizes for meals and snacks.
Reduce portion sizes or frequency of
consumption of calorie containing beverages.
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17. 6/24/2014
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18. Creeping Obesity
Physical activity
decreases and
leads to a decrease
In metabolic rate.
If energy expenditure
drops more than
energy intake, weight
gain will occur.
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19. What is The DASH Diet?
 The Dietary Approaches to Stop Hypertension
clinical trial (DASH)
 Diet rich in fruits, vegetables, and low fat dairy foods,
can substantially lower blood pressure in individuals with
hypertension and high normal blood pressure.
 As effective as one medication
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20. Dash Study
Control:
Ca, Mg, & K ~ 25% of US diet
Macronutrients and fiber ~ US average
Fruits and Vegetables
Fruits and vegetables increased to 8.5 servings
K and Mg to 75%
Combination:
Add 2-3 servings low-fat dairy to fruit & vegetable
diet.
Ca, K and Mg increased to 75%
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21. Dash Study Outcomes
Fruit and Vegetable Diet:
Decrease in systolic and diastolic blood pressure in
entire study group and in the hypertensive subgroup.
Combination Diet:
Significant decrease in both systolic and diastolic
blood pressure in both groups.
Greatest drop was in systolic BP in hypertensive group
(11.4 mmHg)
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22. Dash Diet Implications
Combination diet affects comparable to
pharmacological trails in mild hypertension.
Population wide reductions in blood pressure
similar to DASH results would reduce CHD by ~
15% and stroke by ~27%
Great potential in susceptible groups: African
Americans and elderly.
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23. The DASH Diet
The DASH Diet includes:
7-8 servings of grains and grain products
4-5 servings of vegetables
4-5 servings of fruits
2-3 servings of low fat dairy products
2 or less servings of meat, poultry and fish
2-3 servings of fats and oils
Nuts, seeds and dry beans 4-5 times /week
Limited ‘sweets’ low in fat. 6/24/2014
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24. 6/24/2014
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25. Effects of increasing Calcium-Rich Dairy
Food in Black Hypertensives
 Increases urinary sodium excretion
 Decreases volume
 Decreases peripheral vascular resistance
 Decrease blood pressure
 Reduces left ventricular mass and risk of left ventricular
hypertrophy
Effects sustained for one-year period of study
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26. Sodium in Foods
Conversion of milligrams to milliequivalents
(mEq):
mg/atomic weight x valence = mEq.
Atomic weight sodium = 23, valence = 1
The U.S. Food and Drug Administration
recommends 2,300 mgs of sodium per day
2300 mg/23 x 1 = 100 mEq sodium
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27. Reducing Sodium in the Diet
Use fresh poultry, fish and lean meat, rather than
canned or processed.
Buy fresh, plain frozen or canned with “no salt
added” vegetables.
Use herbs, spices and salt-free seasoning blends
in cooking and at the table; decrease or
eliminate use of table salt.
Choose ‘convenience’ foods that are lower in
sodium.
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28. Reducing Sodium in the Diet
When available, buy low- or reduced-sodium or
‘no-salt-added’ versions of foods like:
Canned soup, canned vegetables, vegetable juices
cheeses, lower in fat
condiments like soy sauce
crackers and snack foods like nuts
processed lean meats
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29. Food Labels
Claim Amount
Low Sodium >140 mg/serving
Very Low Sodium >35 mg/serving
Sodium Free >5 mg/serving
Reduced Sodium 25% less than original
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30. 6/24/2014
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31. Other non-pharmacologic therapies
1. Patient education
2. Vitamin D supplementation,
3. Adequate potassium intake,
4. Cessation of smoking, and
5. Limiting the use of non-steroidal anti-
inflammatory drugs and acetaminophen
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