ASH position paper: dietary approaches to lower blood pressure

Consumption of Berries and Flavonoids in Relation to Mortality in NHANES, 1999-2014

BACKGROUND

Berries are foods that are abundant in nutrients, especially flavonoids, that promote good health; however, the effects of total berries on mortality are not well characterized.

OBJECTIVES

We evaluated whether intakes of total berries and specific berry types including blueberries, strawberries, cranberries, flavonoids, and subclasses of flavonoids (anthocyanidins, flavonols, flavones, flavanones, flavan-3-ols, and isoflavones) in relation to mortality risk in United States adults.

METHODS

A nationally representative sample of the United States adult population was obtained using data from the 1994-2014 NHANES (n = 37,232). Intake of berries was estimated using 24-h food recalls (1999-2014), and flavonoids intake was calculated using the matched USDA's expanded flavonoid database. Mortality outcomes based on 8 y of follow-up were obtained using linked death certificates.

RESULTS

Compared with nonconsumers, the multivariable-adjusted hazard ratio for all-cause mortality was 0.79 [95% confidence intervals (CI): 0.7, 0.89] for any berry consumption, 0.86 (0.75, 0.99) for strawberry consumption 0.79 (0.66, 0.95) for blueberries, and 0.69 (0.51, 0.93) for cranberries. Compared with the lower median of intake, risk of all-cause mortality for greater intake was 0.85 (0.74, 0.97) for total flavonoids, 0.85 (0.76, 0.95) for anthocyanidins, 0.9 (0.82, 0.99) for flavan-3-ols, 0.89 (0.79, 0.9) for flavanols, and 0.89 (0.8, 0.99) for flavones. There was a dose-response relationship between intakes of total flavonoids, anthocyanidins, and flavones and lower all-cause mortality risks (Ptrend < 0.05). Risk for cardiometabolic mortality was 0.75 (0.58, 0.98) for berry consumers and 0.49 (0.25, 0.98) for cranberry consumers. For respiratory disease mortality, risk was 0.41 (0.2, 0.86), compared with blueberry nonconsumers.

CONCLUSION

Higher intakes of berries and flavonoids were associated with a lower overall mortality risk in adult Americans. Few adults regularly consume berries, indicating that increased intake of berries and flavonoid-rich foods may be beneficial to health.

Inverse Association between Fruit and Vegetable Intake and All-Cause Mortality: Japan Public Health Center-Based Prospective Study

BACKGROUND

A dose-response and nonlinear association between fruit and vegetable intake and mortality has been reported in Europe and the United States, but little is known about this association in Asia.

OBJECTIVES

This study aimed to evaluate the association of fruit and vegetable intake with all-cause, cancer, cardiovascular, and respiratory disease mortality in a Japanese cohort.

METHODS

In the Japan Public Health Center-based prospective study, we included 94,658 participants (mean age: 56.4; 46.0% male) without cancer and cardiovascular disease at baseline. Information on fruit and vegetable intake was collected using a validated FFQ. The Cox proportional hazard model was used to estimate HRs and 95% CIs of each quintile of fruit and vegetable intake, separately, in relation to all-cause and cause-specific mortality using the first quintile as a reference. Nonlinear associations were evaluated using a likelihood ratio test, comparing a linear model with a restricted cubic spline model.

RESULTS

During a median of 20.9 follow-up years (IQR: 19.6-23.8 y), 23,687 all-cause deaths were documented. After adjusting for age, sex, and potential confounding factors, fruit and vegetable intake was nonlinearly and significantly associated with lower all-cause mortality, with the fourth and fifth quintiles having comparable HRs (fruit: fourth quintile HR: 0.91; 95% CI: 0.87, 0.95 and fifth quintile HR: 0.92; 95% CI: 0.88, 0.96; P-nonlinearity < 0.001; vegetable: fourth quintile HR: 0.92; 95% CI: 0.88, 0.97 and fifth quintile HR: 0.93; 95% CI: 0.89, 0.98; P-nonlinearity = 0.002). Fruit intake was significantly associated with lower cardiovascular mortality (HR in the fifth quintile: 0.91; 95% CI: 0.83, 0.99; P-nonlinearity = 0.01).

CONCLUSIONS

In the Japanese population, higher intake of fruits and vegetables was nonlinearly associated with decreased all-cause mortality. These findings may contribute to the establishment of dietary recommendations for enhancing life expectancy in Asia.

Associations of Carbohydrate Intake With New-Onset Hypertension Subtypes: Results From the China Health and Nutrition Survey (2000-2011)

Background: The effects of carbohydrate intake on hypertension (HTN) subtypes are scarce. We examined the association of carbohydrate intake with new-onset HTN subtypes in Chinese adults. Methods: Chinese Health and Nutrition Survey (CHNS) 2000-2011, 22,418 individuals were recorded using a 24-h recall method over three consecutive days. We excluded those who were pregnant women, lactating mothers, age <18 years, baseline age, blood pressure, and energy intake deficiency, extreme energy intake (male > 6,000 kcal or < 800 kcal; female > 4,000 kcal or < 600 kcal), and pulse pressure difference (Systolic Blood Pressure [SBP] - Diastolic Blood Pressure [DBP]) <10 mm Hg, HTN at baseline and data from only one survey. The total number of subjects who participated in at least two surveys was 7,930. The main outcome was new-onset HTN subtypes over 6.9 person years of follow-up. Results: 2,521 participants were found to be HTN, which included 1,318 males (52.3%), 1,203 females (47.7%), 721 had systolic-diastolic hypertension (SDH, 28.6%), 655 had isolated systolic hypertension (ISH, 26.0%), and 993 had isolated diastolic hypertension (IDH, 39.4%). Compared with extreme quintiles of carbohydrate, multivariable-adjusted hazard ratios (HR) and 95% confidence intervals (CI) for new-onset HTN, SDH, ISH and IDH associated with carbohydrate intake were 1.12 (0.97-1.30), 1.54 (1.18-2.00), 0.89 (0.67-1.19) and 1.15 (0.91-1.45), respectively. The HR of SDH compared with extreme quintiles of carbohydrates was 1.56 (95% CI, 1.08-2.25; P trend = 0.04) in men and 1.52 (95% CI, 1.02-2.26; P trend = 0.02) in women. Conclusion: Carbohydrates were related to a higher risk of SDH, which were not observed with HTN, ISH, and IDH.

Dietary Salt-Related Determinants of Hypertension in Rural Northern Thailand

Hypertension and its connection to high salt consumption have been observed in the Thai population. This study mainly contributed to the literature to examine the dietary-salt-related determinants associated with the risk of hypertension in rural northern Thailand, which exhibited the highest prevalence of hypertension. A total of 376 adults residing in San Pa Tong District, Chiang Mai province, were face-to-face interviewed using a structured questionnaire assessing dietary-salt-related knowledge, attitudes, consumption, sources, and habits. The subject’s blood pressure (BP) was measured twice before and after the interview. Hypertension was defined as a systolic BP ≥ 130 mmHg or a diastolic BP ≥ 80 mmHg. The dietary-salt-related knowledge, attitude, and habits toward salt reduction were positively correlated; however, knowledge and attitudes were not significantly correlated with consumption. Multivariate logistic regression results indicated subjects who frequently bought ready-to-eat food, ate out, or used bouillon cube/monosodium glutamate (MSG) during food preparation were likely to have hypertension (OR = 2.24, 95% CI: 1.36–3.69, p = 0.002). MSG was heavily consumed and used as a flavor enhancer in northern Thai cuisine; however, a few subjects realized it contains sodium due to no salty taste. The deficiency of specific dietary-salt-related knowledge illustrated the need for tailored educational intervention strategies.

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.

Dietary Approaches to Stop Hypertension (DASH): potential mechanisms of action against risk factors of the metabolic syndrome

The metabolic syndrome is a cluster of disorders dominated by abdominal obesity, hypertriacylglycerolaemia, low HDL-cholesterol, high blood pressure and high fasting glucose. Diet modification is a safe and effective way to treat the metabolic syndrome. Dietary Approaches to Stop Hypertension (DASH) is a dietary pattern rich in fruits, vegetables and low-fat dairy products, and low in meats and sweets. DASH provides good amounts of fibre, K, Ca and Mg, and limited quantities of total fat, saturated fat, cholesterol and Na. Although DASH was initially designed for the prevention or control of hypertension, using a DASH diet has other metabolic benefits. In the present review, the effect of each dietary component of DASH on the risk factors of the metabolic syndrome is discussed. Due to limited fat and high fibre and Ca content, individuals on the DASH diet are less prone to overweight and obesity and possess lower concentrations of total and LDL-cholesterol although changes in TAG and HDL-cholesterol have been less significant and available evidence in this regard is still inconclusive. Moreover, high amounts of fruit and vegetables in DASH provide great quantities of K, Mg and fibre, all of which have been shown to reduce blood pressure. K, Mg, fibre and antioxidants have also been effective in correcting glucose and insulin abnormalities. Evidence is provided from cross-sectional investigations, cohort studies and randomised controlled trials, and, where available, from published meta-analyses. Mechanisms are described according to human studies and, in the case of a lack of evidence, from animal and cell culture investigations.

Dietary patterns associated with hypertension risk among adults in Thailand: 8-year findings from the Thai Cohort Study

Objective

Dietary intake is a leading risk factor for hypertension. We aimed to assess longitudinal associations between overall dietary patterns and incident hypertension among adults in Thailand.

Design

Prospective large Thai Cohort Study (TCS) conducted nationwide from 2005 to 2013. Dietary patterns were identified using factor analysis based on usual intake of fourteen food groups. Multivariable logistic regression assessed associations between dietary patterns and hypertension prevalence and incidence.

Setting

Emerging hypertension and changing diets in Thailand.

Subjects

TCS participants who were normotensive at baseline in 2005.

Results

Among 36293 participants without hypertension at baseline, 1831 reported incident hypertension (5·1 % incidence) at follow-up. Two dietary patterns were identified: ‘Modern’ and ‘Prudent’. The Modern dietary pattern (high intakes of roasted/smoked foods, instant foods, canned foods, fermented fruits/vegetables, fermented foods, soft drinks, deep-fried foods) was associated with increased incident hypertension (comparing extreme quartiles, OR for incident hypertension=1·51; 95 % CI 1·31, 1·75 in 2013). The Prudent dietary pattern (high intakes of soyabean products, milk, fruits, vegetables) was not associated with incident hypertension in a fully adjusted model. The association between the Modern dietary pattern and hypertension was attenuated by BMI.

Conclusions

Modern dietary pattern was positively associated with hypertension among Thai adults. BMI had a great impact on the relationship between the Modern dietary pattern and incidence of hypertension. Reduction of Modern diets would be expected to prevent and control hypertension. Such a strategy would be worth testing.

Ovo-vegetarian diet is associated with lower systemic blood pressure in Taiwanese women

OBJECTIVE

This study was designed to investigate blood pressure (BP) profiles among Taiwanese women with different dietary patterns.

STUDY DESIGN

Cross-sectional study.

METHODS

A total of 269 non-hypertensive Taiwanese women, 40 years of age or older, were surveyed using structured questionnaires, and measurements of BP and physiological parameters were made. To assess differences among vegans, ovo-vegetarians, and meat eaters in terms of BP, demographic, and health behavior data, the chi-squared and Fisher's exact tests were employed for categorical variables, and analysis of variance and independent t-tests were performed for continuous variables. Multiple regression analysis was used to examine the relationship between BP and dietary patterns while controlling for potential confounding factors.

RESULTS

A significant difference was found among the three test groups in terms of age, education, employment, stress, and waist-hip ratio. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) significantly differed among the three groups. After controlling for age, body weight, waist circumference, and hip circumference, the three groups were observed to be a significant risk factor of the SBP and DBP. The SBP and DBP of the ovo-vegetarian group were significantly lower than those of the meat-eater group. No significant differences were found between the vegan and meat-eater groups in terms of SBP and DBP.

CONCLUSION

Dietary pattern is a likely risk factor for SBP and DBP outcomes in Taiwanese women. In particular, the SBP and DBP of ovo-vegetarians are the lowest among the values observed for all dietary patterns. This finding suggests that an ovo-vegetarian diet is beneficial for long-term BP control and prevention of hypertension in females.

Diet-independent relevance of serum uric acid for blood pressure in a representative population sample

A direct relationship between serum uric acid and blood pressure (BP) has been reported, but the possible confounding impact of diet on this association is unclear. The authors performed a cross-sectional analysis in the representative German Health Interview and Examination Survey for Adults (n=6788, aged 18-79 years). In adjusted regression models considering dietary factors, each 1-mg/dL higher uric acid value was associated with a 1.10-mm Hg (P=.0002) and a 0.60-mm Hg (P=.04) higher systolic BP among participants younger than 50 years and participants 50 years and older, respectively. For diastolic BP, uric acid was a significant predictor (β=0.71 mm Hg, P=.0001) among participants younger than 50 years and for participants 50 years and older without antihypertensive treatment. Adjusted odds ratios of hypertension for participants with hyperuricemia were broadly similar in younger (odds ratio, 1.71; P=.02) and older (odds ratio, 1.81; P=.0003) participants. Uric acid is a significant predictor of systolic BP and hypertension prevalence in the general adult population in Germany independently of several known dietary BP influences.

Red meat and chicken consumption and its association with high blood pressure and obesity in South Korean children and adolescents: a cross-sectional analysis of KSHES, 2011-2015

Background

The impact of meat consumption on high blood pressure (HBP) and obesity in children and adolescents is a subject of debate. The aim of this study was thus to evaluate the association between meat consumption and both HBP and obesity in this group.

Methods

We performed a cross-sectional analysis using nationally representative samples of children and adolescents aged 9, 12, and 15 years old (n = 136,739) who were included in the Korea School Health Examination Survey (KSHES) for the 2011–2015 period. Multiple linear and logistic regression analysis was used to determine the factors influencing systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index (BMI, kg/m²) levels, and to test the strength of these relationships.

Results

Adjusted for covariates, 6.3% of those subjects who consumed >5 servings of meat (including beef, pork, and chicken) per week were obese, compared with 9.1% of the subjects who consumed <1 serving of meat/wk (obesity adjusted odds ratio [OR]: 1.44; 95% confidence interval [CI]: 1.21–1.70; P ≤0.001). Those who consumed <1 serving of meat/wk had an HBP prevalence of 8.2%, compared with 7.2% for subjects who consumed >5 servings of meat/wk (systolic HBP adjusted OR: 1.30; 95% CI: 1.05–1.62; P ≤0.01, diastolic HBP adjusted OR: 1.25; 95% CI: 1.02–1.54; P <0.05). Obese subjects were estimated to have a higher SBP (β = 7.497, P < 0.001) and DBP (β = 4.123, P <0.001) than subjects who had no excess weight. Compared to subjects who consumed >5 servings of meat/wk, those who consumed <3 servings of meat/wk had a higher SBP (β = 0.574, P <0.001) and DBP (β = 0.376, P = 0.003) after adjusting for BMI. The intake of milk, fruit, and vegetables was not associated with either SBP or DBP (P >0.05). In contrast, BMI was significantly associated with milk, fruits, and vegetables (P <0.01).

Conclusions

Among children and adolescents, a higher level of meat consumption was associated with lower SBP, DBP, and BMI, and greater height, suggesting that consuming an appropriate amount of meat is important for healthy growth at a young age.

Adherence to recommended lifestyle modifications and factors associated for hypertensive patients attending chronic follow-up units of selected public hospitals in Addis Ababa, Ethiopia

INTRODUCTION

One of the most prevalent noncommunicable diseases is hypertension (HTN). The availability of effective antihypertensive medications does not result in the expected outcomes in terms of controlling blood pressure. The rationale for these and other findings of uncontrolled HTN points toward poor adherence. The most neglected causes of uncontrolled HTN are unhealthy lifestyles. Few studies have been conducted to show the gap and magnitude of self-management adherence.

OBJECTIVE

This study aimed to assess adherence to recommended lifestyle modifications of hypertensive patients undergoing follow-up at chronic follow-up units of public health hospitals in Addis Ababa, Ethiopia, 2016.

METHODS

Institutional-based cross-sectional study was conducted in four public health hospitals which were selected by drawing lots. Systematic random sampling was used to select study subjects. The results of the descriptive statistics were expressed as percentages and frequencies. Associations between lifestyle modification and independent variables were ana-lyzed using bivariate and multivariate logistic regression analysis. The study was conducted from February 15, 2016 to April 15, 2016.

RESULTS

The study included 404 respondents with a 97% response rate; 210 (52%) were male and the mean age was 54.00±10.77 years. The respondents' adherence to lifestyle modifications was 23%. The lifestyle adherence was found to be better in females, patients who had comorbidities, and had been knowledgeable about the disease and was poor among young adult respondents.

CONCLUSION

The rates of adherence to lifestyle changes were generally found to be low. Educational sessions that especially focus on lifestyle modifications and ongoing support for patients should be designed and studies which assess all the components of self-management should be conducted for comparison among different subgroups.

Nutraceuticals for blood pressure control

Significant effects on blood pressure (BP) have been reported from large nutritional interventions, particularly the Dietary Approaches to Stop Hypertension (DASH) and the Mediterranean diet. In more recent years, numerous studies have investigated the possible BP-lowering effect of different nutraceuticals; these range from specific foods to minerals, lipids, whole proteins, peptides, amino acids, probiotics, and vitamins. While a very large body of evidence supports the use of potassium, L-arginine, vitamins C and D, cocoa flavonoids, beetroot juice, some probiotics, coenzyme Q10, controlled-release melatonin, aged garlic extract, and coffee, the use of other nutraceuticals, such as green tea, flaxseed, and resveratrol, has not as yet been supported by adequate evidence. In some cases, e.g. proteins/peptides, the responsible component needs also to be fully uncovered. Finally, while for most of the products only short-term studies are available, with no specific end-points, an ongoing very large prospective study on chocolate flavanols will answer the question whether this may reduce cardiovascular risk. Thus, in addition to data on long-term safety, further clinical research is advisable in order to identify, among active nutraceuticals, those with the best cost-effectiveness and risk-benefit ratio for a wide use in the general population with a raised cardiovascular risk consequent to uncomplicated hypertension.

Dietary mineral intakes of rural midlife to older adult women with prehypertension in Midwestern United States

OBJECTIVES

Midlife to older rural women with prehypertension are at increased risk for hypertension and its impact on cardiovascular health with advancing age. Because modification of dietary factors could help alleviate risk, the objective of this study was to explore calcium, magnesium, potassium and sodium intakes of midlife to older rural women, with identification of their top food sources.

DESIGN

Survey of baseline dietary intake data of women and comparison to standard recommendations.

SETTING

Rural Midwestern United States.

PARTICIPANTS

289 rural women, age 40-69, with prehypertension who volunteered for lifestyle modification to reduce blood pressure.

MEASUREMENTS

Baseline nutrition data using the Block Health Habit and History Questionnaire were collected over a twelve-month rolling enrollment period from rural women with prehypertension. Mineral intakes were calculated and compared to recommended standards. Top ten foods contributing to each mineral were identified.

RESULTS

The percent of women who met the Recommended Dietary Allowance (RDA)/Adequate Intake (AI) recommendations for their age groups ranged from a high 42.9% for magnesium to a low of 4.2% for potassium. Mean intakes of calcium, magnesium and potassium were all below recommended levels and sodium intakes were above recommendation.

CONCLUSION

Midlife to older rural US women with prehypertension were eating some of the foods that would help them meet mineral recommendations. As a preventive approach to reducing hypertension risk, clinical practice could include advising on ways to increase both commonly and less commonly consumed nutrient-rich foods with awareness of what is typically available in the rural area.

Association of dietary pattern and body weight with blood pressure in Jiangsu Province, China

Background

To identify risk factors, associations between dietary patterns, body mass index (BMI), and hypertension in a Chinese population.

Methods

Dietary intake was assessed in 2518 adults by a 3-day 24 h recall and a food frequency questionnaire. Salt and oil intake was assessed by weighing records. Four dietary patterns were identified using principal component analysis. Overweight and obesity was determined according to the Chinese cut-offs for BMI. High blood pressure was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Prevalence ratios (PR) were calculated using Poisson regression.

Results

Of the subjects, 26.7% had high blood pressure. Subjects with overweight and obesity were more likely to have high blood pressure than those with normal weight (PR, 95% CI: 1.60, 1.40-1.87; 2.45, 2.11-2.85, respectively). Subjects with a ‘traditional’ dietary pattern were more likely to have high blood pressure (P _{for trend} = 0.001), whereas those with a ‘macho’ or ‘sweet tooth’ dietary pattern were less likely to have high blood pressure (P _{for trend} = 0.004 and <0.001, respectively). More than half of the population had salt intakes > 9 g/d, and blood pressure increased with salt intake (P _{for trend} <0.001). Subjects with a ‘traditional’ dietary pattern had the highest salt intake (12.3 g/d).

Conclusion

A traditional dietary pattern is associated with high blood pressure among the population of Jiangsu Province, which may be mainly due to high salt intake. Moreover, high BMI is an important determinant of high blood pressure. Both issues need to be addressed by lifestyle interventions.

Current therapeutic approaches to cardio-protection in hypertension

Targeting a specific blood pressure based upon patient risk has been the approach to reducing cardiovascular risk in patients with hypertension. Drug selection was based upon compelling indications with titration and the addition of other agents as needed until the blood pressure target was achieved. However, new information has emerged describing improved methods for measuring blood pressure, a re-evaluation of blood pressure targets and additional therapeutic approaches that together may further reduce cardiovascular risk in patients with hypertension.

Nutraceutical value of black cherry Prunus serotina Ehrh. fruits: antioxidant and antihypertensive properties

In Mexico black cherry (Prunus serotina Ehrh.) fruits are consumed fresh, dried or prepared in jam. Considering the evidence that has linked intake of fruits and vegetables rich in polyphenols to cardiovascular risk reduction, the aim of this study was to characterize the phenolic profile of black cherry fruits and to determine their antioxidant, vasorelaxant and antihypertensive effects. The proximate composition and mineral contents of these fruits were also assessed. Black cherry fruits possess a high content of phenolic compounds and display a significant antioxidant capacity. High-performance liquid chromatography/mass spectrometric analysis indicated that hyperoside, anthocyanins and chlorogenic acid were the main phenolic compounds found in these fruits. The black cherry aqueous extract elicited a concentration-dependent relaxation of aortic rings and induced a significant reduction on systolic blood pressure in L-NAME induced hypertensive rats after four weeks of treatment. Proximate analysis showed that black cherry fruits have high sugar, protein, and potassium contents. The results derived from this study indicate that black cherry fruits contain phenolic compounds which elicit significant antioxidant and antihypertensive effects. These findings suggest that these fruits might be considered as functional foods useful for the prevention and treatment of cardiovascular diseases.

Comprehensive Approach to Lower Blood Pressure (CALM-BP): a randomized controlled trial of a multifactorial lifestyle intervention

Complementary medicine advocates the use of a multifactorial approach to address the varied aspects of hypertension. The aim of this study was to compare the blood pressure (BP) effect and medication use of a novel Comprehensive Approach to Lowering Measured Blood Pressure (CALM-BP), based on complementary medicine principles, with the standard recommended Dietary Approach to Stop Hypertension (DASH). A total of 113 patients treated with antihypertensive drugs were randomly assigned to either CALM-BP treatment (consisting of rice diet, walks, yoga, relaxation and stress management) or to a DASH+exercise control group (consisting of DASH and walks). Ambulatory 24-h and home BP were monitored over a 16-week programme, followed by 6 months of maintenance period. Medications were reduced if systolic BP dropped below 110 mm Hg accompanied by symptoms. In addition to BP reduction, medications were reduced because of symptomatic hypotension in 70.7% of the CALM-BP group compared with 32.7% in the DASH group, P<0.0001. After 6 months, medication status was not altered in the majority of individuals. Significant reductions in body mass index, cholesterol and improved quality-of-life scores were observed only in the CALM-BP group. Lifestyle and diet modifications based on complementary medicine principles are highly effective with respect to BP control, medication use and cardiovascular risk factors.

Serum cotinine levels and prehypertension in never smokers

Background. Few studies have shown that self-reported secondhand smoke exposure in never smokers is associated with high blood pressure. However, there are no studies investigating the relationship between secondhand smoke exposure, measured objectively by serum cotinine levels, and high blood pressure in never smokers. Methods. We examined never smokers (n = 2027) from the National Health and Nutrition Examination Survey 2005–2008. Our exposure of interest was the secondhand smoke exposure estimated by serum cotinine level and our outcome was prehypertension (n = 734), defined as a systolic blood pressure of 120–139 mmHg or diastolic blood pressure of 80–89 mmHg. Results. We found that, in never smokers, serum cotinine levels were positively associated with prehypertension. Compared to those with cotinine levels in the lowest quartile (≤0.024 ng/mL), the multivariable odds ratio (95% confidence interval) of prehypertension among those with cotinine levels in the highest quartile (≥0.224 ng/mL) was 1.45(1.00, 2.11); P trend = 0.0451. In subsequent subgroup analyses, the positive association was found to be stronger among men, non-Whites, and non-obese subjects. Conclusion. Higher secondhand smoke exposure measured objectively by serum cotinine levels was found to be associated with prehypertension in certain subgroups of a representative sample of the US population.

Population-wide sodium reduction: the bumpy road from evidence to policy

Elevated blood pressure is a highly prevalent condition that is etiologically related to coronary heart disease and stroke, two of the leading causes of morbidity and mortality throughout the world. Excess salt (sodium chloride) intake is a major determinant of elevated blood pressure. In this article, we discuss the scientific rationale for population-wide salt reduction, the types and strength of available evidence, policy-making on dietary salt intake in the United States and other countries, and the role and impact of key stakeholders. We highlight a number of lessons learned, many of which are germane to policy development in other domains.

Effect of a physician uncertainty reduction intervention on blood pressure in uncontrolled hypertensives--a cluster randomized trial

BACKGROUND

Clinical inertia, provider failure to appropriately intensify treatment, is a major contributor to uncontrolled blood pressure (BP). Some clinical inertia may result from physician uncertainty over the patient's usual BP, adherence, or value of continuing efforts to control BP through lifestyle changes.

OBJECTIVE

To test the hypothesis that providing physicians with uncertainty reduction tools, including 24-h ambulatory BP monitoring, electronic bottle cap monitoring, and lifestyle assessment and counseling, will lead to improved BP control.

DESIGN

Cluster randomized trial with five intervention clinics (IC) and five usual care clinics (UCC).

SETTING

Six public and 4 private primary care clinics.

PARTICIPANTS

A total of 665 patients (63 percent African American) with uncontrolled hypertension (BP ≥140 mmHg/90 mmHg or ≥130/80 mmHg if diabetic).

INTERVENTIONS

An order form for uncertainty reduction tools was placed in the IC participants' charts before each visit and results fed back to the provider.

OUTCOME MEASURES

Percent with controlled BP at last visit. Secondary outcome was BP changes from baseline.

RESULTS

Median follow-up time was 24 months. IC physicians intensified treatment in 81% of IC patients compared to 67% in UCC (p < 0.001); 35.0% of IC patients and 31.9% of UCC patients achieved control at the last recorded visit (p > 0.05). Multi-level mixed effects longitudinal regression modeling of SBP and DBP indicated a significant, non-linear slope difference favoring IC (p (time × group interaction) = 0.048 for SBP and p = 0.001 for DBP). The model-predicted difference attributable to intervention was -2.8 mmHg for both SBP and DBP by month 24, and -6.5 mmHg for both SBP and DBP by month 36.

CONCLUSIONS

The uncertainty reduction intervention did not achieve the pre-specified dichotomous outcome, but led to lower measured BP in IC patients.

The importance of potassium in managing hypertension

Dietary potassium intake has been demonstrated to significantly lower blood pressure (BP) in a dose-responsive manner in both hypertensive and nonhypertensive patients in observational studies, clinical trials, and several meta-analyses. In hypertensive patients, the linear dose-response relationship is a 1.0 mm Hg reduction in systolic BP and a 0.52 mm Hg reduction in diastolic BP per 0.6 g per day increase in dietary potassium intake that is independent of baseline potassium deficiency. The average reduction in BP with 4.7 g (120 mmol) of dietary potassium per day is 8.0/4.1 mm Hg, depending race and on the relative intakes of other minerals such as sodium, magnesium, and calcium. If the dietary sodium chloride intake is high, there is a greater BP reduction with an increased intake of dietary potassium. Blacks have a greater decrease in BP than Caucasians with an equal potassium intake. Potassium-induced reduction in BP significantly lowers the incidence of stroke (cerebrovascular accident, CVA), coronary heart disease, myocardial infarction, and other cardiovascular events. However, potassium also reduces the risk of CVA independent of BP reductions. Increasing consumption of potassium to 4.7 g per day predicts lower event rates for future cardiovascular disease, with estimated decreases of 8% to 15% in CVA and 6% to 11% in myocardial infarction.

Health Implications of a Vegetarian Diet

There is now a significant amount of research that demonstrates the health benefits of vegetarian and plant-based diets, which have been associated with a reduced risk of obesity, diabetes, heart disease, and some types of cancer as well as increased longevity. Vegetarian diets are typically lower in fat, particularly saturated fat, and higher in dietary fiber. They are also likely to include more whole grains, legumes, nuts, and soy protein, and together with the absence of red meat, this type of eating plan may provide many benefits for the prevention and treatment of obesity and chronic health problems, including diabetes and cardiovascular disease. Although a well-planned vegetarian or vegan diet can meet all the nutritional needs of an individual, it may be necessary to pay particular attention to some nutrients to ensure an adequate intake, particularly if the person is on a vegan diet. This article will review the evidence for the health benefits of a vegetarian diet and also discuss strategies for meeting the nutritional needs of those following a vegetarian or plant-based eating pattern.

Effects of whey protein supplements on metabolism: evidence from human intervention studies

PURPOSE OF REVIEW

Epidemiological studies indicate that the consumption of milk and dairy products is inversely associated with a lower risk of metabolic disorders and cardiovascular diseases. In particular, whey protein seems to induce these effects because of bioactive compounds such as lactoferrin, immunoglobulins, glutamine and lactalbumin. In addition, it is an excellent source of branch chained amino acids. This review summarizes recent findings on the effects of whey protein on metabolic disorders and the musculoskeletal system.

RECENT FINDINGS

We identified 25 recently published intervention trials examining chronic and/or acute effects of whey protein supplementation on lipid and glucose metabolism, blood pressure, vascular function and on the musculoskeletal system. Whey protein appears to have a blood glucose and/or insulin lowering effect partly mediated by incretins. In addition, whey protein may increase muscle protein synthesis. In contrast there are no clear-cut effects shown on blood lipids and lipoproteins, blood pressure and vascular function. For bone metabolism the data are scarce.

SUMMARY

In summary, whey protein may affect glucose metabolism and muscle protein synthesis. However, the evidence for a clinical efficacy is not strong enough to make final recommendations with respect to a specific dose and the duration of supplementation.

Food sources and correlates of sodium and potassium intakes in Flemish pre-school children

Objective

The aim of the present study was to investigate dietary sources of Na and K intakes among Flemish pre-school children using multiple linear regression analyses.

Design

Three-day estimated diet records were used to assess dietary intakes. The contribution to Na and K intakes of fifty-seven food groups was computed by summing the amount provided by the food group for all individuals divided by the total intake for all individuals.

Setting

A random cluster sampling design at the level of schools, stratified by province and age, was used.

Subjects

A representative sample of 696 Flemish pre-school children aged 2·5–6·5 years was recruited.

Results

Mean Na intake was above and mean K intake was largely below the recommendation for children. Bread (22 %) and soup (13 %) were main contributors to Na intake followed by cold meat cuts and other meat products (12 % and 11 %, respectively). Sugared milk drinks, fried potatoes, milk and fruit juices were the main K sources (13 %, 12 %, 11 % and 11 %, respectively). Although Na and K intakes were positively correlated, several food categories showed Na:K intake ratio well above one (water, cheeses, soup, butter/margarine, fast foods and light beverages) whereas others presented a ratio well below one (oil & fat, fruits & juices, potatoes, vegetables and hot beverages).

Conclusions

Flemish pre-school children had too high Na and too low K intakes. The finding that main dietary sources of Na and K are clearly different indicates the feasibility of simultaneously decreasing Na and increasing K intake among children.

Primary hypertension and special aspects of hypertension in older children and adolescents

The prevalence of hypertension has increased at an accelerated rate in older children and adolescents. This has raised great concern about premature development of cardiovascular disease, which has major long-term health and financial implications. While obesity and sedentary habits largely explain this phenomenon, there are other social and cultural influences that may unmask genetic susceptibility to hypertension in the pediatric population. While it is essential to exclude numerous causes of secondary hypertension in every child, these disorders are not discussed in this review. Rather, the aim of this review is to familiarize pediatricians with casual and ambulatory blood pressure measurement, epidemiology, pathophysiology, and management of several common conditions that play a role in the development of hypertension in children and adolescents. Besides primary hypertension and obesity-related hypertension, emphasis is given to epidemiology, measurement of blood pressure, including ambulatory blood pressure monitoring, hypertension associated with drug use, teenage pregnancy, and video and computer games. Lastly, because pediatricians are increasingly confronted with special issues concerning the management of the hypertensive athlete, this topic is also addressed.

The Standard American Diet and its relationship to the health status of Americans

The Standard American Diet (SAD) has long been implicated in contributing to the health challenges experienced in the United States. Significant changes to the SAD have occurred since the 1950s, including a greater abundance and accessibility to calorie-dense and nutrient-poor food and beverage choices. The disparity of present consumption patterns to diet and nutrition recommendations from the Dietary Guidelines for Americans are addressed.

Chocolate: (un)healthy source of polyphenols?

There is recent epidemiological evidence that chocolate consumption may improve vascular health. Furthermore, several small-scale human intervention studies indicate that habitual chocolate intake enhances the production of vasodilative nitric oxide and may lower blood pressure. It is hypothesized that potential beneficial effects of chocolate on vascular health are at least partly mediated by cocoa polyphenols including procyanidins. Based on cell culture studies, molecular targets of chocolate polyphenols are endothelial nitric oxide synthetase as well as arginase. However, human bioavailability studies suggest that the plasma concentrations of cocoa polyphenols are manifold lower than those concentrations used in cultured cells in vitro. The experimental evidence for beneficial vascular effects of chocolate in human interventions studies is yet not fully convincing. Some human intervention studies on chocolate and its polyphenols lack a stringent study design. They are sometimes underpowered and not always placebo controlled. Dietary chocolate intake in many of these human studies was up to 100 g per day. Since chocolate is a rich source of sugar and saturated fat, it is questionable whether chocolate could be recommended as part of a nutrition strategy to promote vascular health.