7th Brazilian Guideline of Arterial Hypertension: Chapter 6 - Non-pharmacological treatment



# Introduction
Non-pharmacological treatment (NPT) of AH involves body weight control, nutritional measures, practice of physical activities, smoking cessation and stress control. This chapter approaches the effects and recommendations of such measures.

## Body weight
The increase in body weight is directly related to BP increase in adults 1 and children. [bib_ref] Obesity-related hypertension: possible pathophysiological mechanisms, Vaneckova [/bib_ref] The relationship between overweight and BP changes can be observed from as early as 8 years of age. [bib_ref] Obesity-related hypertension: possible pathophysiological mechanisms, Vaneckova [/bib_ref] In addition, the increase in visceral fat is considered a risk factor for AH. [bib_ref] Obesity-related hypertension: possible pathophysiological mechanisms, Vaneckova [/bib_ref] [bib_ref] Mechanisms of chronic state of inflammation as mediators that link obese adipose..., Fuentes [/bib_ref] Reductions in body weight and AC correlate with BP reductions and metabolic improvement . [bib_ref] Blood pressure: effect of body mass index and of waist circumference on..., Guimaraes [/bib_ref] 

## (gr: i; le: a).

## Nutritional aspects

## Dietary pattern
The success of AH treatment with nutritional measures depends on the adoption of a healthy and sustainable dietary plan. [bib_ref] Adherence and success in long-term weight loss diets: the dietary intervention randomized..., Greenberg [/bib_ref] The use of radical diets results in treatment dropout. [bib_ref] Dietary adherence and weight loss success among overweight women: results from the..., Alhassan [/bib_ref] The focus on one single nutrient or food has given space to the total dietary pattern analysis, which allows assessing the synergism between nutrients/foods. [bib_ref] Dietary patterns, mediterranean diet, and cardiovascular disease, Martinez-Gonzalez [/bib_ref] The DASH (Dietary Approaches to Stop Hypertension) diet emphasizes the consumption of fruits, vegetables and lowfat dairy products, includes the ingestion of whole cereals, chicken, fish and nuts, and recommends a reduction in the ingestion of red meat, candies and sugary beverages. That diet is rich in potassium, calcium, magnesium and fibers, and contains reduced amounts of cholesterol and of total and saturated fat. Adopting that dietary pattern reduces BP. [bib_ref] A clinical trial of the effects of dietary patterns on blood pressure...., Appel [/bib_ref] [bib_ref] Effects on blood pressure of reduced dietary sodium and the Dietary Approaches..., Sacks [/bib_ref] (GR: I; LE: A).
The Mediterranean diet is rich in fruits, vegetables and whole cereals, but has large amounts of olive oil (source of monounsaturated fats) and includes the consumption of fish and nuts, in addition to the moderate ingestion of wine. [bib_ref] Dietary patterns, mediterranean diet, and cardiovascular disease, Martinez-Gonzalez [/bib_ref] Despite the limited number of studies, the adoption of the Mediterranean diet seems to low BP. 10 (GR: IIa; LE: B).
Vegetarian diets recommend the consumption of foods of plant origin, specially fruits, vegetables, grains and pulses. They exclude or rarely include meats, and some include dairy products, eggs and fish. They have been associated with lower BP levels. 11 (GR: IIa; LE: B).

## Reduction in sodium intake
The increase in sodium intake is related to BP elevation. [bib_ref] AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk A Report of..., Eckel [/bib_ref] However, the impact of sodium intake on CV health is controversial. Some studies have suggested that very low sodium intake increases the risk for CVD, while others argue that the decrease in sodium intake decreases the CV risk, [bib_ref] Compared with usual sodium intake, low-and excessive-sodium diets are associated with increased..., Graudal [/bib_ref] and that benefit is even higher with marked restriction of sodium intake. 14 Limiting daily sodium intake to 2.0 g is associated with BP reduction. [bib_ref] Urinary sodium and potassium excretion, mortality, and cardiovascular events, O&apos;donnell [/bib_ref] The Brazilian mean sodium intake is 11.4 g/ day.(GR: IIa; LE: B).

## Unsaturated fatty acids
Omega-3 fatty acids originating from fish oils (eicosapentaenoic and docosahexaenoic acids, EPA and DHA, respectively) are associated with a mild reduction in BP. Recent studies have indicated that the EPA+DHA ingestion  2 g/day reduces BP, and lower doses (1-2 g/day) reduce only SBP. 17 (GR: IIa; LE: B).
In addition, the consumption of monounsaturated fatty acids has been associated with BP reduction. 18 (GR: IIb; LE: B).

## Fibers
Soluble fibers are present in oat bran, pectin (fruits) and starch (oat, barley and pulses: beans, chickpeas, lentils and green peas), while insoluble fibers are present in cellulose (wheat), hemicellulose (whole grains) and lignin (vegetables). The ingestion of fibers, mainly beta-glucan originating from oat and barley, causes a mild decrease in BP. [bib_ref] Effects of dietary fibre type on blood pressure: a systematic review and..., Evans [/bib_ref] (GR: IIb; LE: B).

## Nuts
The consumption of nuts helps control several CVRF, but few studies have related that consumption to BP reduction. [bib_ref] Nuts in the prevention and treatment of metabolic syndrome, Salas-Salvado [/bib_ref] A meta-analysis has concluded that the ingestion of different types of nuts could reduce BP. 21 (GR: IIb; LE: B).

## Dairy products and vitamin d
There is evidence that the ingestion of dairy products, especially low-fat ones, reduces BP. [bib_ref] Dairy and blood pressure: a fresh look at the evidence, Park [/bib_ref] Milk contains several components, such as calcium, potassium and bioactive peptides, that can decrease BP. [bib_ref] The impact of milk proteins and peptides on blood pressure and vascular..., Fekete [/bib_ref] Some studies have shown that low serum levels of vitamin D are associated with a greater incidence of AH. [bib_ref] Vitamin D and risk of future hypertension: meta-analysis of 283,537 participants, Kunutsor [/bib_ref] However, studies on vitamin D supplementation have failed to show BP reduction. 25 (GR: III; LE: B).

## Garlic
Garlic has innumerous bioactive components, such as allicin (found in raw garlic) and s-allyl cysteine (found in processed garlic). Mild BP decrease has been reported with supplementation with several forms of garlic. [bib_ref] Potential of garlic (Allium sativum) in lowering high blood pressure: mechanisms of..., Ried [/bib_ref] [bib_ref] A systematic review and metaanalysis on the effects of garlic preparations on..., Rohner [/bib_ref] (GR: IIb; LE: B).

## Coffee and green tea
Coffee, although rich in caffeine, substance with an acute pressor effect, has polyphenols that can favor BP reduction. [bib_ref] Coffee consumption and cardiovascular health: getting to the heart of the matter, Rebello [/bib_ref] Recent studies have suggested that coffee intake at usual doses is associated with neither higher AH incidence nor BP elevation. [bib_ref] The effect of coffee on blood pressure and cardiovascular disease in hypertensive..., Mesas [/bib_ref] Coffee intake should not exceed low to moderate amounts. (GR: IIa; LE: B).
In addition to being rich in polyphenols, especially catechins, green tea has caffeine. There is no consensus, but some studies have suggested that green tea might reduce BP when consumed at low doses, because greater doses have a higher caffeine content and can increase BP. [bib_ref] Effect of green tea consumption on blood pressure: A meta-analysis of 13..., Peng [/bib_ref] Green tea consumption is recommended at low doses. (GR: IIb; LE: B).

## Bitter chocolate
Chocolate at least 70% cacao can cause mild BP reduction, because of its high polyphenol content. 31 (GR: IIb; LE: B).

## Alcohol
Usual alcohol consumption increases BP linearly, and its excessive consumption associates with an increase in the AH incidence. 32,33 A 10-g/day increment in alcohol ingestion is estimated to increase BP by 1 mm Hg, [bib_ref] Drinking pattern and blood pressure among non-hypertensive current drinkers: findings from 1999-2004..., Fan [/bib_ref] and a decrease in that consumption reduces BP. [bib_ref] Mechanisms of chronic state of inflammation as mediators that link obese adipose..., Fuentes [/bib_ref] Moderation in alcohol intake is recommended. (GR: I; LE: B).

## Physical activity/physical exercise
Physical activity refers to any body movement that increases energy expenditure, such as street walking, stair climbing, domestic chores, and recreational activities. The term 'physical exercise' refers to planned, structured, repetitive and purposeful physical activity. In addition, sedentary lifestyle, measured by the time spent sitting, has CV health implications [fig_ref] Table 2 -: Evidence of physical activity and physical exercise for BP reduction [/fig_ref].

## Physical inactivity/activity
Physical inactivity is "a major public health problem", [bib_ref] Physical inactivity: the biggest public health problem of the 21st century, Blair [/bib_ref] because it is the most prevalent RF and the second cause of death worldwide. [bib_ref] Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of..., Lee [/bib_ref] Survival is shorter among individuals who spend most of their time sitting than among those who do not. [bib_ref] Sitting time and mortality from all causes, cardiovascular disease, and cancer, Katzmarzyk [/bib_ref] There is a direct relationship between the time spent sitting or watching TV and BP. [bib_ref] Deleterious associations of sitting time and television viewing time with cardiometabolic risk..., Thorp [/bib_ref] To reduce the sitting time and to stand up for at least 5 minutes for every 30 minutes sited are recommended. (GR: IIb; LE: B).
Regular physical activity can benefit both AH prevention and treatment, and reduces CV morbidity and mortality. Active individuals have a 30% lower risk of developing AH as compared to those with a sedentary lifestyle. [bib_ref] Physical activity, physical fitness and the incidence of hypertension, Fagard [/bib_ref] The increase in daily physical activity reduces BP. [bib_ref] Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory..., Dunn [/bib_ref] Physical activity practice should be encouraged for the entire population, and no previous test is required. The individual should be instructed to seek a doctor if any discomfort occurs during the physical activity practice. (GR: I; LE: A).

## Physical exercise
The AH treatment can derive additional benefits from structured physical exercise practice, characterizing a customized training.

## Aerobic exercise
Aerobic training reduces casual BP of prehypertensive and hypertensive individuals. [bib_ref] Exercise training for blood pressure: a systematic review and meta-analysis, Cornelissen [/bib_ref] In addition, it reduces BP during wakefulness for hypertensives [bib_ref] Endurance exercise beneficially affects ambulatory blood pressure: a systematic review and meta-analysis, Cornelissen [/bib_ref] and lowers BP in situations of physical, mental and psychological stress. [bib_ref] Exercise therapy in hypertensive cardiovascular disease, Fagard [/bib_ref] Aerobic training is recommended as the preferential exercise type for AH prevention and treatment. (GR: I; LE: A).

## Dynamic and static resistance exercise
Dynamic or isotonic resistance training (contraction of localized body segments with joint movement) reduces BP of prehypertensive individuals, but has no effect in hypertensives. However, there are only four randomized, controlled studies on that exercise type for AH. [bib_ref] Exercise training for blood pressure: a systematic review and meta-analysis, Cornelissen [/bib_ref] Static or isometric resistance training (contraction of localized body segments without joint movement) reduces BP of hypertensives, but the studies have used small muscle masses, thus, further information is required prior to its recommendation. [bib_ref] Isometric exercise training for blood pressure management: a systematic review and metaanalysis, Carlson [/bib_ref] Dynamic resistance training is recommended to complement aerobic training for AH. (GR: IIa; LE: B).

## Caution
Hypertensives with higher BP levels or with more than three RF, DM, TOD or heart disease should undergo exercise testing before engaging in moderate-intensity physical exercises. In addition, every hypertensive engaging in competitive sports or high-performance exercise should undergo complete CV assessment. 45 (GR: IIa; LE: C).

## Table 1 -changes in body weight and in dietary ingestion and their effects on bp

## Measure approximate sbp/dbp reduction recommendation
Body weight control 20%-30% BP decrease for every 5% of weight loss 1
Maintain BMI < 25 kg/m 2 up to 65 years of age. Maintain BMI < 27 kg/m 2 after the age of 65 years. Maintain AC < 80 cm in women and < 94 cm in men

## Dietary pattern
Reduction of 6.7/3.5 mm Hg [bib_ref] Influence of Dietary Approaches to Stop Hypertension (DASH) diet on blood pressure:..., Saneei [/bib_ref] Adopt DASH diet Sodium intake restriction Reduction of 2-7 mm Hg in SBP and 1-3 mm Hg in DBP with progressive reduction of 2.4-1.5 g of sodium/day, respectively [bib_ref] AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk A Report of..., Eckel [/bib_ref] Limit daily sodium intake to 2.0 g (5 g of sodium chloride)
Moderation in alcohol intake Reduction of 3.31/2.04 mm Hg with the reduction from 3-6 to 1-2 doses/day [bib_ref] Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled..., Xin [/bib_ref] Limit daily alcohol intake to 1 dose for women and low-weight individuals, and 2 doses for men BMI: body mass index; AC: abdominal circumference; SBP: systolic blood pressure; DBP: diastolic blood pressure. *One dose contains 14g of ethanol, and is equivalent to 350 mL of beer, 150 mL of wine, and 45 mL of distilled beverage. [bib_ref] Alcohol and cardiovascular health: the dose makes the poison...or the remedy, O&apos;keefe [/bib_ref] 

## Smoking cessation
Smoking increases the risk for more than 25 diseases, including CVD. [bib_ref] Control of arterial pressure in patients undergoing anti-hypertensive treatment in Brazil: Controlar..., Nobre [/bib_ref] [bib_ref] Tobacco smoking strengthens the association of elevated blood pressure with arterial stiffness:..., Yun [/bib_ref] The smoking habit hinders AH control,knowledge about SAH 50 and adherence to antihypertensive medications. [bib_ref] Hypertension in the city of Sao Paulo: self-reported prevalence assessed by telephone..., Mion [/bib_ref] However, there is no evidence that smoking cessation reduces BP. (GR: III, LE: B).

## Slow breathing
Slow or guided breathing requires respiratory rate reduction to 6-10 breaths/minute for 15-20 minutes/day to promote casual BP reduction (SBP: -3.67; 95% confidence interval:

## Stress control
Studies on stress management techniques emphasize the importance of behavioral psychotherapies and meditation, [bib_ref] Investigating the effect of transcendental meditation on blood pressure: a systematic review..., Bai [/bib_ref] [bib_ref] Impact of Mindfulness-Based Stress Reduction (MBSR) on attention, rumination and resting blood..., Campbell [/bib_ref] [bib_ref] Mindfulness-based stress reduction as a stress management intervention for healthy individuals: a..., Sharma [/bib_ref] biofeedback and relaxation 56 practices in AH treatment. Despite methodological contradictions, clinical indications have revealed a strong trend towards BP reduction when those techniques are performed separately or combined. [bib_ref] Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific..., Brook [/bib_ref] (GR: IIa; LE: B).

## Multiprofessional team
The multiprofessional approach is mainly aimed at AH control, which is not satisfactory in our setting. Epidemiological studies have shown a 10% to 57.6% variation 57 in that control. The multiprofessional team promotes better AH control,which is directly related to adherence to pharmacological and nonpharmacological treatment. The multiprofessional team can consist of all professionals managing hypertensive patients: doctors, nurses, technicians and nurse aides, nutritionists, psychologists, social workers, physical therapists, physical education coaches, music therapists, chemists, educators, media professionals, administrative workers and community health agents. Moderate intensity defined as:
1) Higher intensity, but still being able to talk (without being breathless)
2) Feeling mildly to moderately tired 3) Maintain training HR calculated as follows: Training HR = (maximum HR -resting HR) x % + resting HR where: maximum HR: obtained either on a maximum exercise test, using the regular medications, or by calculating maximum HR estimated according to age (220 -age). The formula cannot be applied to hypertensives with heart disease or on beta-blockers or nondihydropyridine calcium channel blockers.
Resting HR: measured after 5-minute resting lying down. %: use 50% as lower threshold, and 70% as upper threshold.

## Resistance training
2 -3 times/week. 8 -10 exercises for the large muscle groups, prioritizing unilateral execution, when possible.

## -3 sets
10 -15 repetitions up to moderate fatigue (reduction in the velocity of movement and tendency towards apnea)
Long passive pauses -90 -120 s
[table] Table 2 -: Evidence of physical activity and physical exercise for BP reduction [/table]
[table] Table 3 -: Recommendations regarding physical activity and physical exercise For all hypertensives -Population recommendation -Physical activity practice Moderate, continuous (1 x 30 min) or cumulative (2 x 15 min or 3 x 10 min) physical activity: at least 30 min/day, 5 -7 days/week. greater benefits -Individual recommendation -Physical exercise Aerobic training complemented with resistance training Aerobic training Several modalities: walking, running, dancing, swimming. At least 3 times/week. Ideally: 5 times/week. Minimum of 30 min. Ideally: 40 -50 min. [/table]