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Coronary Heat-t Disease 0

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Chapter 3

High Blood Pressure

  Hence if too much salt is used in food.
       the pulse hardens.
Huang Ti (the Yellow Emperor, 2697-2597 B.C.)
   The Yellow Emperor's Classic of
        Internal Medicine

Introduction

Hypertension, the medical name for high blood pressure, is a common
chronid medical problem in the United States responsible for a major
portion of cardiovascular disease. In recent years. public health efforts
have increased public awareness and knowledge of the risks and appropri-
ate treatment of this condition. As a result, almost the entire adult U.S.
population has had at least one blood pressure measurement and 73 percent
of Americans have had their blood pressure checked within the previous 6
months. By 1985,77 percent of the public identified high blood pressure as
the factor that most increases a person's chances of having a stroke, and 91
percent indicated that high blood pressure increases a persons chances of
getting heart disease (Lenfant 1987). The proportion of hypertensive per-
sons who have their high blood pressure under control more than doubled
from the early 1970's to 1980 (Subcommittee 1985). The significant de-
crease in cardiovascular disease deaths and disability that has occurred
since the 1970's is believed by many experts to be due to the increased
detection and treatment of high blood pressure.

This success in the control of hypertension is generally credited to a
combination of improved detection and the use of antihypertensive medi-
cation. However, the implications of long-term drug therapy for millions of
Americans are unknown. There are documented side effects of the anti-
hypertensive drugs. Thiazide diuretics, for example, can induce short-term
increases in serum cholesterol, low density lipoproteins (LDL), and tri-
glyceride levels in some persons. Some studies suggest that these effects

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decrease or disappear with long-term therapy, although some clinical trials
have shown persistence of the adverse effects (JNC IV 1988). Beta-block-
ers tend to lower high density lipoprotein (HDL) levels. These and other
risks of drug therapy call attention to the potential benefits of nonphar-
maceutical treatment of high blood pressure (Kaplan 1985).

Currently, three nondrug methods-weight control, alcohol restriction,
and sodium restriction-are recommended as part of the treatment for
established hypertension (JNC IV 1988). These measures have also gained
support as likely to aid in the prevention of high blood pressure, particu-
larly for those at high risk.

Historical Perspective

The first successful dietary treatment of human hypertension has been
attributed to Kempner's rice-fruit diet that provided 20 g of protein, less
than 5 g of fat, 150 mg of sodium, 200 mg of chloride, and 3,000 mg of
potassium per day (Kempner 1944). Other studies confirmed that a very
low sodium intake, for example, 200 mg/day, was effective in lowering
blood pressure, although the effect on blood pressure of a moderate sodium
intake, for example, 2,000 mg/day, was inconsistent (Watkin et al. 1950).
Such studies laid the groundwork for subsequent investigations into the
role of sodium in the development of hypertension.

The positive association between body weight and blood pressure was
documented more than 60 years ago (Faber 1924). Clinical treatment of
hypertension with weight reduction was reported over 60 years ago by
Rose, who documented lower blood pressure and relief of edema in obese
patients who lost weight (Rose 1922). The historical evidence for dietary
associations with high blood pressure has been reviewed extensively
(McCarron and Kotchen 1983; McCarron, Filer, and Van Itallie 1982;
Horan et al. 1985).

A review of the development of U.S. public health policy on nutrition and
hypertension indicates that in a rather brief time period, the focus shifted
from acceptance of the association between sodium intake and blood
pressure-an emphasis of the 1969 White House Conference on Food,
Nutrition, and Health-to congressional attention on the topic of sodium
labeling and FDA action to promote sodium labeling to the 1980 issuance of
the DHHS/USDA recommendation in the Dietary Guidelines for Ameri-

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High Blood Pressure tl

~XVLV to avoid excessive sodium intake. The relatively fast pace of this
nutrition policy development can be appreciated by contrasting it with the
history of recommendations for dietary change for high blood cholesterol
levels (see chapter on coronary heart disease). A few milestones in the
development of nutrition-hypertension policy are noted here.

The role of dietary salt in hypertension was a major issue at the White
House Conference on Food, Nutrition, and Health and at the Senate Select
Committee hearings in I%9 (Mayer 1969). Subsequently, a committee of
the National Academy of Sciences recommended that no more than 0.25
percent salt be added to the commercial preparation of infant food (Sub-
committee 1970). In 1970, the infant food industry initiated restriction of
added salt.

In 1974, the American Academy of Pediatrics Committee on Nutrition
recommended dietary modification of sodium intake for the pediatric
population at risk for hypertension. The committee also favored the devel-
opment of guidelines for reducing the use of salt by food processors and
recommended that information about the amount of salt added to pro-
cessed food be made available to consumers (AAP Committee on Nutrition
1974).

The Food and Drug Administration (FDA) sponsored a review of the health
implications of added salt as part of an evaluation of substances designated
"Generally Recognized As Safe" for use in foods. This evaluation, com-
pleted in 1979 by a committee of the Federation of American Societies for
Experimental Biology, concluded that consumption of sodium chloride in
the United States should be reduced, guidelines should be developed for
restricting salt in processed foods, and the sodium content of processed
foods should be labeled (Select Committee on GRAS Substances 1979).
Subsequently, the FDA proposed that more information on the sodium
content of foods be provided as part of nutrition labeling (U.S. Congress
1981; FDA 1982).

Sodium labeling is part of the FDA's five-point sodium program that
involves collaboration between the food industry and Government. The
effort intends to achieve changes in food labeling and to encourage the food
industry to reduce the amount of sodium added to processed foods and to
market a greater variety of foods with lowered sodium. The FDA will
encourage consumer education about the relationship between sodium and

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hypertension. It is intended to monitor changes in the marketplace to see
whether efforts to reduce sodium in the food supply and to increase sodium
labeling are successful. Legislation to mandate sodium labeling might be
considered if voluntary efforts fail (Forbes and Stephenson 1985).

Appropriate caloric intake to maintain desirable weight and avoidance of
excessive sodium intake are goals included in the Surgeon General's
Report on Health Promotion and Disease Prevention (DHEW 1979) and
the nutrition component of the 1990 Objectives for the Nation (DHHS
1980). These goals are also recommended by the Food and Nutrition Board
of the National Academy of Sciences (NRC 1980) and are consistent with
the Dietary Guidelines for Americans, published by the Departments of
Agriculture and Health and Human Services (USDA/DHHS 1980, 1985).

In recognition of the clear social need to reduce illness, disability, and
death from uncontrolled hypertension, the National High Blood Pressure
Education Program (NHBPEP) was initiated in 1972, led and coordinated
by the National Heart, Lung, and Blood Institute. This program includes
an extensive network of Federal agencies and major national health organi-
zations. During the time the NHBPEP has been in operation, age-adjusted
death rates for stroke and coronary heart disease have substantially de-
clined. The activities of the NHBPEP on improving hypertension control
are believed to have contributed to this decline (Lenfant and Roccella
1984).

Significance for Public Health

In the United States, hypertension is a public health problem of enormous
magnitude. Estimates of the prevalence of hypertension vary, however,
depending upon differences in interpretation and extrapolation of the data.
Current definitions of hypertension are listed in Table 3-l. A change in the
blood pressure threshold from 160/95 mm Hg (systolic/diastolic measure-
ments in millimeters of mercury) to 140/90 mm Hg was recommended in
1984 (JNC III 1984) and is maintained in the most recent report (JNC IV
1988). According to this definition, almost 58 million individuals have been
found to have elevated blood pressure or have reported taking antihyper-
tensive drugs prescribed by a physician (Table 3-2). About 39 million of
these people are under the age of 65; less than 3 percent are children.
Prevalence of hypertension increases with age in the U.S. population and is
higher for black Americans (38 percent) than for white Americans (29
percent) (Subcommittee 1985).

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High Blood Pressure O

               Table 3-l
Classification of Blood Pressure' in Adults 18 Years or Older

Range, mm Hg
Diastolic

-=c 85

85-89

90-104

105-l 14

> 115
Systolic, when diastolic blood
pressure is < 90

< 140

14&159

> 160

Categoryb


Normal blood pressure
High normal blood pressure
Mild hypertension
Moderate hypertension
Severe hypertension



Normal blood pressure
Borderline isolated systolic hypertension
Isolated systolic hypertension

aBased on the average of two or more readings on two or more occasions.
bA classification of borderline isolated systolic hypertension (SBP 140 to 159 mm Hg) or
isolated systolic hypertension (SBP > 180 mm Hg) takes precedence over high normal
blood pressure (diistolii blood pressure 85 to 89 mm Hg) when both occur in the same
person. High normal blood pressure (DBP 85 to 89 mm Hg) takes precedence over a
classification of normal blood pressure (SBP < 140 mm Hg) when both occur in the same
person.

Source: 1988 Joint National Committee.

           Table 3-2
Estimated Prevalence of Cardiovascular Disease
        in the United States

Hypertension (> 140/90 or on Rx)                   57,700,ooo
Rheumatic fever with or without heart disease             1,500,ooo
Coronary heart disease                         6,700,OW
Cardiac arrhythmias                           1.4WooO

Cerebrovascular disease                        2,700,OOO
Sources: Subcommittee on Definition and Prevalence of the 1984 Joint National
    Committee on Detection, Evaluation, and Treatment of High Blood Pressure
    1985; National Center for Health Statistics 1988.

Hypertension is a major risk factor both for heart disease, which is the
leading category of causes of death in the United States, and for stroke,

143


0 Nutrition and Health

which is the third most frequent cause of death. All of the cardiovascular
diseases are highly prevalent in this country (Table 3-2). A high proportion
of end-stage renal failure is due to hypertension. The magnitude of the high
blood pressure problem is demonstrated by the fact that in 1980 and 1981,
the estimated annual number of visits to physicians' o&es by patients
with cardiovascular disease was over 56 million. The largest subgroup was
for hypertension, a total of 29 million visits (Ezzati and McLemore 1980;
NCHS 1984).

Scientific Background

Regulation of Blood Pressure

Blood pressure is regulated by a complex process involving the interac-
tions of multiple factors that are not completely understood. Ultimately,
the regulation of blood pressure reflects the interaction of cardiac output
(the amount of blood the heart pumps per unit of time) and total peripheral
resistance (the resistance to flow that blood encounters in the arteries and
arterioles). Therefore, hypertension is an imbalance of the mechanisms
that affect either output or resistance, or both. Some of the many mecha-
nisms that affect these functions and, therefore, blood pressure are listed in
Table 3-3. These include alterations in hemodynamic factors (plasma vol-
ume, cardiac output, and arterial pressure); central nervous system mecha-
nisms that influence the hemodynamic mechanisms; interactions of the
renin-angiotensin and adrenergic system that elevate arterial pressure;
adrenal hormone secretion and maintenance of water, sodium, and other
electrolyte balance; and various other hormonal influences.

In over 95 percent of individuals with high blood pressure, the specific
cause cannot be determined, and the condition is referred to as primary or
essential hypertension. Primary hypertension may sometimes represent
nonspecific disturbances in blood pressure regulation, and the specific
mechanism is not always identifiable.

Methodological Issues

Each approach to investigating the effects of diet on blood pressure has
limitations. Animal experimentation provides optimal control over intake
of specific nutrients, and hypotheses generated from animal models have
been useful in the study of human primary hypertension. Different mecha-
nisms, however, may be important in humans. Epidemiologic studies that
compare customary diets and average blood pressure levels among popula-
tions or among smaller groups within populations can lead to inferences
about the relative importance of various nutritional factors, particularly if

144


High Blood Pressure O

Table 3-3

Control Mechanisms for Arterial Pressure

Mechanical (posture, etc.)
Hemodynamic
Autonomic nervous system
Central nervous system

Gastrointestinal system (absorption of fluids and electrolytes)
Renal parenchymal function
Maintenance of sodium and fluid balance
Regulation of excretion of other electrolytes
Renin-angiotensin-aldosterone system
Other hormonal factors

      Adrenal cortical hormones
     Vasopressin
       Growth hormone

       Parathormone
     Thyroid hormone
     Kallikrein-kinin system
     Prostaglandin system
     Histaminergic mechanisms
!%urcx: Adapted from Frohlii 1963.

data are collected longitudinally. Cross-sectional studies have two key
drawbacks: (1) only a few observations may be used to characterize factors
that often have large individual fluctuations (e.g., diet, blood pressure),
and (2) they do not consider whether the observed dietary intake is typical
of long-term habits, reflects an aberration in usual intake, or reflects a
dietary pattern that has been recently modified in response to health
concerns.

Observational studies cannot distinguish between the effects of highly
correlated dietary constituents. For example, in an observational study,
both a low intake of potassium and a high intake of sodium may be
associated with high blood pressure. A well-designed human intervention
study can yield information on the independence or interaction of the
nutrients. Such studies require reliable dietary assessment and use of
objective measures whenever feasible as well as standardized blinded
blood pressure measurements, adequate length of followup. and control of
potentially confounding variables such as other nutrients or weight change.

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O Nutrition and Health

Nutritional Correlates

Research on diet and hypertension is complicated by the need to assess the
relative importance of about 50 essential nutrients, dietary fiber, and
nutrition-related factors such as obesity in the face of serious meth-
odological problems inherent in studies of the role of diet in chronic disease
(Reed et al. 1985). Although certain individual nutrients are implicated in
hypertension, future nutrition research may need to focus more on the
interrelationships among dietary factors than to consider each separately
(Hegsted 1985).

Several symposia have reviewed the role of nutrition in blood pressure
regulation as well as the mechanisms by which dietary factors are known or
thought to influence blood pressure regulation (McCarron, Filer, and Van
Itallie 1982; Horan et al. 1985). The major dietary factors thought to
influence blood pressure and the mechanisms by which they may do so are
summarized in Table 3-4. The complexity of these interactions explains
why ". . . even where there is general agreement about the importance of a
specific nutrient's effect on blood pressure, there is not necessarily con-
sensus on the mechanisms involved" (McCarron, Filer, and Van Itallie
1982).

Key Scientific Issues

o Role of Obesity in Hypertension
o Role of Sodium in Hypertension
o Role of Alcohol in Hypertension
o Role of Other Minerals in Hypertension
o Role of Macronutrients in Hypertension
o Role of Caffeine in Hypertension
Of the many dietary factors listed in Table 3-4 that affect blood pressure.
three-obesity, sodium, and alcohol-have a role that is well supported by
scientific evidence (JNC IV 1988). At present, research on the effects of
other dietary factors is suggestive but not conclusive.

Role of Obesity in Hypertension

As was noted in a special supplement on nutrition and blood pressure
control (Dustan 1983; Havlik et al. 1983), early studies on the association
between body weight and blood pressure have been confirmed in epi-
demiologic studies of primitive as well as developed populations. In many

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High Blood Pressure 0

          Table 3-4
Major Nutrients and Possible Mechanisms
  for Influencing Blood Pressure

Calories and Macronutrients

rotal calories

Possible Mechanisms

Obesity
Energy generation

carbohydrates (and alcohol)

Energy metabolism
Membrane synthesis
insulin regulation-sodium excretion
Catecholamine regulation-vascular tone

Proteins

Lipids

Electrolytes and Minerals

ProteinIpeptide synthesis
Control of cellular function
Membrane transport systems

Energy source
Cell membrane components
Prostaglandin synthesis

Sodium

Potassium

Intravascular volume
Hormone regulation
Membrane potential

Vascular tone
Hormone regulation
Cation transport

Calcium

Receptor-ligand binding
Hormone synthesis/release
Vascular tone
Contractile protein interactions

Magnesium

Regulation of calcium channels
ATP production
Contractile protein interaction

Phosphorus

Membrane structure
ATP-energy metabolism
CAMP component

Trace elements           Copper-vascular integrity
                Manganese-energy metabolism
                 Chromium-lipid metabolism
                Vanadium-sodium/potassium ATPase
Source: Adepted from McCerron. Henry, and Morris 1982.

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0 Nutrition and Health

populations where body weight does not increase with age, neither does
blood pressure. Further connection between hypertension and obesity has
been demonstrated in the Hypertension Detection and Follow-Up Pro-
gram, which reported that 60 percent of the participants with hypertension
were more than 20 percent overweight (Hypertension Detection and Fol-
low-Up Program Cooperative Group 1977).

Evidence for the effect of weight reduction on blood pressure began to
accumulate in the early part of this century. This association has now been
investigated in many epidemiologic studies and several clinical trials (as
reviewed by MacMahon et al. 1987). Although a few studies have reported
that treatment of hypertension with weight loss did not result in lower
blood pressure, many investigators have reported significant reduction of
elevated blood pressure by weight loss (Table 3-5).

Complicating the relationship of obesity to blood pressure is the role of
sodium. An early hypothesis was that obese individuals with hypertension
are sensitive to the blood pressure-raising effects of a high sodium intake
associated with long-term calorie excess (Dahl, Silver, and Christie 1958).
However, other investigators have dissociated the two factors and demon-
strated that weight loss is effective in lowering blood pressure even in the
absence of sodium restriction (Reisen et al. 1981; Maxwell et al. 1984).

In conclusion, increased body weight is related to increased blood pres-
sure. Furthermore, a fall in blood pressure can be expected with weight
reduction. Further studies may help to define other factors such as the
distribution of body fat (Kalkhoff et al. 1983; Krotkiewski et al. 1983;
Berchtold 1985) or specific mechanisms by which obesity might be in-
volved in the development of hypertension,

Weight loss is recommended for all overweight persons, particularly for
those with hypertension. It has been suggested that control of obesit)
would eliminate hypertension in 48 percent of whites and 28 percent of
blacks (Tyroler, Heyden, and Hames 1975). Even when weight loss does
not reduce blood pressure to normal, health risks may be reduced, and
smaller doses of antihypertensive medication may be needed as a result.

Role of Sodium in Hypertension

Definitions

In most human studies, sodium intake is estimated from reported dietary
intake of salt (sodium chloride) among the study participants. A more

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                     Table 3-5
Changes in Weight and Blood Pressure (Baseline to Followup) in Treatment (Rx)
     and Control Groups of Five Randomized Controlled Trials

   N     Followup  Weight Change (kg)  Systolic BP Change  Diastolic BP Change
Rx  Control (months) Rx     Control Rx     Control Rx      Control

  Diet trials
    Reisin et al.          57    26       4     - 14.9     - 1.2    - 37.4     -6.9   -23.3      -2.5
   Heyden et al.         63     64      12     -8.1     -1.9    - 18.0     - 12.0   - 13.0      -8.0
   Ramsay et al.         15     34      12      -5.1     -2.4    -11.9     -8.9    -6.9      -4.4
   Haynes et al.         30    30       6      -4.1     -0.8    +4.8     -0.2    + 1.4      -0.1
    MacMahon et al.       20     18       5      -7.4     +0.5   - 13.3      -7.4    -9.8      -3.1

  Pooled estimatesa
i
D  (Rx vs. control)
    Diet trials          185    172                -9.2           -6.3            -3.1
   (95% confidence limits)                   (-8.2, - 10.2)     (-3.3, -9.4)      (- 1.5, -4.7)
  Pooled estimatesa
  (Rx vs. control)
    All trials           336    254                -8.7           -5.3           -3.3
   (95% confidence limits)                  (-7.9, -9.5)     (-3.4, -7.31,      (- 1.8, -4.7)     s
  Gee MacMahon et al. 1987 for methods.                                          B

  Source: Adapted from MacMahon et al. 1987.                     B
                                         `Z
                                                                           3
                                                                           E
                                                                5


O Nutrition and Health

precise measure of sodium intake is 24-hour urinary sodium output, con-
sidered to be an accurate reflection of recent dietary sodium intake in
persons with normal kidney function. An average urinary sodium output
can be estimated to be about 150 mEq/24 hours. Dietary sodium intakes are
commonly reported in mEq, mM, or g. One mEq or one mM of sodium
equals 23 mg, and 1 g of sodium equals 44 mEq or mM and is equivalent to
2.5 g of sodium chloride (table salt). The average daily sodium intake of
adults is about 4 to 6 g (175 to 265 mEq).

Research Evidence

Epidemiology. A relationship of sodium to hypertension is supported by
several lines of evidence. In non-western populations with low salt con-
sumption, blood pressure does not rise with age. Populations with low
blood pressure generally do not consume much salt. These associations
have been reported among numerous populations such as the Bushmen of
Kalahari, Indian tribes in Brazil, and other groups in New Guinea, Malay-
sia, the Polynesian Islands, and Solomon Islands.

Salt intake is positively correlated with average systolic and diastolic blood
pressures in samples of men and women from 25 diverse populations,
regardless of methods of measurement (Gleibermann 1973; McCarron,
Henry, and Morris 1982); significant positive associations have not been
observed in other populations (see review, Subcommittee 1986). Associa-
tions among individuals within a population have been less consistent,
perhaps for methodological reasons (Liu et al. 1979).

Cfinical Studies. Many studies have examined the effect of moderate
restriction of sodium consumption on blood pressure in adults. One non-
randomized crossover study, for example, found that a diet considered to
be moderate in sodium restriction-that is, "avoiding all foods which had
sodium added during preparation"- reduced sodium excretion from 191 to
93 mEq and was accompanied by reductions in systolic and diastolic blood
pressure that averaged 7.7 and 4.4 mm Hg, respectively (Parijs et al. 1973).

A randomized study of 37 hypertensive patients with initial diastolic blood
pressures of 90 to 110 mm Hg reported that dietary restriction to 50 mEq of
sodium/day for 15 to 21 months produced reductions in systolic and di-
astolic blood pressure that were similar to those achieved by drug treat-
ment (Magnani et al. 1976). Long-term studies have shown that 39 percent
of hypertensive patients could control blood pressure with sodium intakes
below 50 mEq/day and close supervision by a dietitian and physician, and
about one-third of patients with mild hypertension could control blood
pressure with a sodium intake of 75 mEq/day or less (Hunt 1977).

150