NoN pharmacological maNagemeNt of...

NoN-pharmacological maNagemeNt of hyperteNsioN

RN Mondal (Ratin) FCPS (Medicine)

Fellow, Indian Society of Hypertension Associate Professor of Medicine

Rangpur Community Medical College

Prevalence of hypertension in Bangladesh 1999 11.3% 1

2002 14.9% 2

2010 17.9% (Nation wide survey)3

2015 24.4% (Bangladesh Demographic and Health Survey, 2011)

Bangladesh status of hypertension

1. MM Zaman and MA Rouf. Journal of Human Hypertension (1999) 13, 547–549 2. Sayeed MA. et al Bangladesh Med Res Counc Bull. 2002 Apr;28(1):7-18 3. NCD Risk Factor Survey. BSM 2010 4. Moniruzzaman, et al, Prevalence of hypertension among the Bangladeshi adult population: a

meta –analysis; J Epidemiol Community Health 2011;65:A405 doi:10.1136/jech.2011.142976n.89

Hypertension and Research Centre Rangpur

Creating awareness and treating hypertension and its consequences

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Bangladesh situation

• 12 million people suffers from hypertension in Bangladesh1.

• One in four adults (aged 35 years) had hypertension, and half

of them were unaware of their condition2.

Ref. 1. Sultana M H, BMRC Bull; 2009; 35:76-78 2. Md. Mizanur Rahman, Stuart Gilmour, Shamima Akter, Sarah K. Abe, Eiko Saito, and Kenji Shibuya; Prevalence and control of hypertension in Bangladesh: a multilevel analysis of a nationwide population-based survey; Journal of Hypertension 2014, 32:000–000



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Prevalence of hypertension Rangpur (northern part of Bangladesh)

• Prevalence of hypertension 33.3% and • Prevalence of pre-hypertension 29.9%.

Ref. Ratindra Nath Mondal, Md. Ashraful Haque, Shah Md. Sarwer Jahan, Abul Kalam Azad, Md. Mahfuzer Rahman, Moni Rani et al; Prevalence and Risk Factors of Hypertension in Rangpur, Bangladesh; World Heart Journal, Volume 5, Number 2; 91-100.

Study from Hypertension and Research Center Rangpur in 2013



Management of hypertension

To reach the goal blood pressure, there are 2 components

of management of hypertension

• Non-pharmacological management (DASH diet and life

style measures).

• Pharmacological treatment.

Hypertension and Research Centre, Rangpur, Bangladesh


Non-pharmacological management

Who should offer Non-pharmacological management?

• In all hypertensive patient and

• In pre-hypertensive patient.



Very important for primary prevention of hypertension.

Algorithm for treatment of hypertension

↓ Not at goal BP ↓ Start antihypertensive drug



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Non-pharmacological management (Life style modifications and DASH diet)

Who should offer only non-pharmacological treatment???

Stage 1 hypertensive patient with

a) No TOD and

b) Low risk of CVD (no DM, no dyslipidaemia, no past history of

CAD, PAD, stroke etc).



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Components of Non-pharmacological management

1. Lifestyle modifications and

2. DASH diet.



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Components of lifestyle modifications are…

Maintain normal body weight, keep body mass index

between 18.5 and 24.9 kg/m2.

Hypertension and Research Centre, Rangpur, Bangladesh Creating awareness and treating hypertension and its consequences

Reduces 5 to 20 mm of Hg of SBP

Physical inactivity should be avoided.

Components of lifestyle modifications are…



Exercise

• Aerobic exercise reduces blood pressure both in

hypertensive and non-hypertensive.

• Reduces

4 to 9 mm Hg SBP and

3 mm Hg DBP.

Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med. 2002;136:493–503



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Exercise (cond.)

• Moderate intensity dynamic activity like walking, jogging, cycling or

swimming.

• Frequency 30 to 60 minutes 4 to 7 days/week.

• This must be in addition to normal daily activities.

• Time to exercise

Best time early morning.

But it can be taken at any time of the day. (the best time is at your

convenient time).



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DASH diet



Fruits and vegetables (four or five servings each per day) Reduces 8 to 14 mm of Hg of SBP

Should take food that contains potassiumand calcium and magnesium

DASH diet (contd.)



DASH diet (contd.) • Increased potassium results in a reduction of

2.42 mm Hg in SBP and

1.57 mm Hg in DBP.1

• Current recommendations, however, are to obtain

adequate potassium intake through a healthy diet.2

1. Geleijnse JM, Kok FJ, Grobbee DE. Blood pressure response to changes in sodium and potassium intake: a metaregression analysis of randomized trials. J Hum Hypertens. 2003;17:471–80 2. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206–52

DASH diet (contd.)

Should take fish and poultry Hypertension and Research Centre Rangpur


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DASH diet Reduced content of saturated and total fat



Stop smoking

DASH diet

Gul Tobacco leaf

Hypertension and Research Centre, Rangpur, Bangladesh Creating awareness and treating hypertension and its consequences

Tobacco and blood pressure (cond.)

Cigarette use causes a

• 4-mm Hg increase in SBP and

• 3-mm Hg increase in DBP compared with placebo.1

Ref. Benowitz NL, Hansson A, Jacob P III. Cardiovascular effects of nasal and transdermal nicotine and cigarette smoking. Hypertension. 2002;39:1107–12.



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Dietary sodium to less than 2.4 g per day (<6g NaCI day, 1 TSF)

reduce salt iNtake



Reduces 2 to 8 mm of Hg of SBP

salt iNtake iN BaNgladeshi people

• Bangladeshi people intake salt 17 g/day.

• In urban areas, people take 10.3 grams of salt a day.

• In Rangpur division we have found that 50% people took

added salt .

1. WHO SEARO, Expert Meeting on Population Sodium Reduction Strategies, 2012 2. NHF 3. Ratindra Nath Mondal, Md. Ashraful Haque, Shah Md. Sarwer Jahan, Abul Kalam Azad, Md. Mahfuzer Rahman,

Moni Rani et al; Prevalence and Risk Factors of Hypertension in Rangpur, Bangladesh; World Heart Journal, Volume 5, Number 2; 91-100.



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Bangladesh Scenario…

Bangladesh Scenario…contd.

• 1 time require 2 TSF • Average diet item (minimum) 2-4 • Salt require=3×2=6 TSF salt in one shift • Per day require=3×6=18 TSF for 4 adults • Per day/adult=18/4=4.5 TSF daily

Recommendation • Food should be taken with 2 or less items. • Salt items should be avoided.



Limit alcohol consumption to < 3 units/day for men and < 2 units/day for women)

DASH diet

Limit alcohol use. This means no more than two drinks a day for men or one for women.



http://www.winchesterhospital.org/health-library/article?id=14051

• Vitamin C

• Omega-3 fatty acids

• Coenzyme Q10 and

• Magnesium

Their use in management of hypertension is not

recommended because of the lack of data from well-designed

randomized controlled trials.

Hypertension and Research Centre Rangpur Creating awareness and treating hypertension and its consequences

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Dietary supplements

Non-pharmacological management of hypertension (cond.)

MEDITATION

• Meditation was shown to reduce blood pressure in one well-designed study. 1

• Meditation may have other benefits and does not appear to be harmful except to patients with psychosis.2

Ref. Schneider RH, Staggers F, Alexander CN, Sheppard W, Rainforth M, Kondwani K, et al. A randomised controlled trial of stress reduction for hypertension in older African Americans. Hypertension. 1995;26:820–7 Canter PH. The therapeutic effects of meditation. BMJ. 2003;326:1049–50



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Meat intake in hypertensive patients of our country before diagnosis of hypertension

Chicken

Frequency Percent Once in a week

52

51.0

Twice in a week 4 3.9 <1/week but >1/month 46 45.1

Beef

Frequency Percent Once in a week

44

43.1

Twice in a week 28 27.5 <1/week but >1/month 30 20.4

Practical Aspects

Ref.Mondal RN, Haque MA, Jahan SMS, Azad AK, Hossain MZ, Rahman MM et al. food intake in hypertensive patients (unpublished).

Practical aspects of non-pharmacological management Smoking status at the time of diagnosis

Frequency Percent Current smoker

29

13.9

Ex-smoker 35 16.7 Not smoker 145 69.4

Present smoking

Frequency Percent Continued

16

7.7

Quit 175 83.7 Occassional 4 1.9

Ref.Mondal RN, Haque MA, Jahan SMS, Azad AK, Hossain MZ, Rahman MM et al. frequency and causes of non-adherence to non-pharmacological management of hypertensive patients. (unpublished).

30min. walking at the time of diagnosis

Frequency Percent Regular

14

6.7

Irregular 30 14.4 No 165 78.9

Exercise at present

Frequency Percent Regular

105

50.2

No exercise 63 30.1 Occasional 41 19.6


H/O taking added salt at the time of diagnossis

Frequency Percent Yes

102

48.8

No 107 51.2

Present added salt

Frequency Percent Continued

12

5.7

Quit 171 81.8 Occassional 20 9.6


Causes of non-adherence to non-pharmacological management Frequency Percent

Ignorance

50

29.32

Ignorance and poor counseling 53 25.35 Do not find time 8 3.82 Poor counseling 6 2.9 Others 4 1.9


Consequences of non-adherence to non-pharmacological management

• May result in uncontrolled hypertension. • May require more drugs to control hypertension.



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How adherence to non-pharmacological management can be improved

• Proper counselling the patients. • Assess adherence to pharmacological and non-

pharmacological therapy at every visit.

• Encourage greater patient responsibility.

• Educate patients and patients' families about their

disease/treatment regimens verbally and in writing.



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Non-pharmacological management of hypertension

• All recommendations are rated ‘C’ • Because, they only lower blood pressure • No direct evidence of mortality or morbidity benefit from

clinical trials.



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What’s still important?

• Measurement of more than one BP recordings will reduce wrong diagnosis of hypertension.

• Don’t diagnose and treat stage-I hypertension with no TOD with no DM at 1st visit.

• Prescription of single pill improve adherence.

• The most important step in prescription of antihypertensive therapy is achieving patient “buy-in”.

• The management target of hypertension is all about to prevent CVD, Stroke and CKD.

Hypertension and Research Centre Rangpur Creating awareness and treating hypertension and its consequences

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Hypertension matters….. • Hypertensive patient usually dies due to complications of

hypertension. Complications of hypertension

Data from Hypertension and Research Center Rangpur, Bangladesh (Ratindra et al)1

Hospital base study of china (Hua Cui et al )2

Stroke 33.3% 34.3%

CAD 20.3% 45.2%

CKD 17.8% 11.9%

1. Mondal RN, Haque MA, Jahan SMS, Azad AK, Hossain MZ, Rahman MM et al. Validity of Verbal Autopsy Questionnaire for Assessment of Causes of Death among Patients with Hypertension in Bangladesh, world heart journal, volume 6, issue 2, pages 107-116 2. Hua Cui, Yixin Hu, Changming Hong, Guoliang Hu, Li Fan; A 15 years study of the causes of death among elderly hypertensive patients in a hospital-based sample of China; Archives of Gerontology and Geriatrics; 2012,55 (3) , 709-712.



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http://www.aggjournal.com/issues?issue_key=S0167-4943(12)X0006-2

Indian Society of Hypertension BPCON-15

• From class room to community Working together for Alleviating hypertension.



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Hypertension and Research Center, Rangpur

Establishment -14th November, 2008



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• Total patient-

16866 (up to 5.3.16)

• Daily patient 50 (average)

New patient 10

Old patient 40

• Awareness generation programme 162.

• Free blood pressure check up camp 20

• Research work completed 08.

Publications from Hypertension and Research Center, Rangpur



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1.Mondal RN, Alam MS, Haque MA, Jahan SMS, Azad AK, Hossain MZ, Rahman MM et al; Validity of verbal autopsy for assessment of causes of death in Bangladesh; EUROPEAN ACADEMIC RESEARCH, Vol. III, Issue 8/ November 2015. 2.Mondal RN, Alam MS, Haque MA, Jahan SMS, Azad AK, Hossain MZ, Rahman MM et al; Prevalence of Diabetes Mellitus among Known Hypertensive Patients; World Heart Journal, Volume 7, Number 2, 2015; 97-106. 3.Mondal RN, Haque MA, Jahan SMS, Azad AK, Hossain MZ, Rahman MM et al; Prevalence and Risk Factors of Hypertension in Rangpur, Bangladesh; World Heart Journal, Volume 5, Number 2; 91-100. 4.Mondal RN, Haque MA, Jahan SMS, Azad AK, Hossain MZ, Rahman MM et al. Validity of Verbal Autopsy Questionnaire for Assessment of Causes of Death among Patients with Hypertension in Bangladesh, world heart journal, volume 6, issue 2, pages 107-116. 5.Mondal RN, Islam MJ, Jahan SMS, Alam ABMM, Hossain MZ, Hussain MM, Sarker MK et al. Association of left ventricular hypertrophy in patients with essential hypertension. WHJ, volume 6, number 3, 171-178. 6.Mondal RN, Haque MA, Jahan SMS, Azad AK, Hossain MZ, Rahman MM et al, Frequency of Causes of Dropout among Patients with Hypertension. World Heart Journal, Volume 4, Number 4; 293-300.

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