s1fk-nutrition , diet , and hypertension

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Nutrition , Diet , andNutrition , Diet , and

HypertensionHypertension

Endang PurwaningsihEndang Purwaningsih



IntroductionIntroduction

19711971--19911991NHES: trend of blood pressureNHES: trend of blood pressurelevels & prevalence of hypertension in USA ?levels & prevalence of hypertension in USA ?

Adoption of healthier lifestyles may have Adoption of healthier lifestyles may havecontributed to this favorable trendcontributed to this favorable trend

19911991--20002000the prevalence of hypertension inthe prevalence of hypertension inUS increased by 3.7%US increased by 3.7%

--´́-- major risk factor for CVDmajor risk factor for CVD

~ 58 million people in the US have~ 58 million people in the US have BP systolic BP systolic> 140 mmHg; diastolic > 90 mmHg > 140 mmHg; diastolic > 90 mmHg taking taking antihypertension medicationsantihypertension medications



Blood pressureBlood pressure ²² associated risks ensue incrementally andassociated risks ensue incrementally andprogressively over a wide range of blood pressure levels andprogressively over a wide range of blood pressure levels anda critical value of a critical value of

blood pressure above which persons are classified asblood pressure above which persons are classified as

´hypertensiveµ is arbitrary ´hypertensiveµ is arbitrary

Among normotensive persons, blood pressure level is Among normotensive persons, blood pressure level is

predictive of morbidity and mortality from stroke, heartpredictive of morbidity and mortality from stroke, heart

disease, and renal impairmentdisease, and renal impairment

3030--40% of all blood pressure40% of all blood pressure--related cardiovascularrelated cardiovascular

disease events occur in persons with average blooddisease events occur in persons with average bloodpressure lower than currently defined definedpressure lower than currently defined defined

hypertensive levels but > 120/80 mmHg hypertensive levels but > 120/80 mmHg



A recent consensus report recommended that the A recent consensus report recommended that thegoal blood pressure levels at < 140/90 mmHggoal blood pressure levels at < 140/90 mmHg

HoweverHowever in patients with hypertension andin patients with hypertension and

diabetes or renal disease, the goal blood pressurediabetes or renal disease, the goal blood pressure

of 120 to 139 mmHg or for diastolic bloodof 120 to 139 mmHg or for diastolic bloodpressure of 80 to 89 mmHg should bepressure of 80 to 89 mmHg should be

considered ´preconsidered ´pre--hypertensiveµ and requirehypertensiveµ and require

healthhealth--promoting lifestyle modifications topromoting lifestyle modifications toprevent cardiovascular diseaseprevent cardiovascular disease



Specific nutrients and interactions among nutrientsSpecific nutrients and interactions among nutrientsinfluence blood pressureinfluence blood pressure

Fig 68.1 hal 1096Fig 68.1 hal 1096



Genetic influenceGenetic influence within a population, overall bloodwithin a population, overall bloodpressure responses to NaCl restriction may maskpressure responses to NaCl restriction may mask

individual variabilityindividual variability

Experimental models of hypertension and increasing Experimental models of hypertension and increasing information in the human provide convincing evidenceinformation in the human provide convincing evidencefor genetic susceptibility and genetic resistance to thefor genetic susceptibility and genetic resistance to theeffects of dietary NaCl on arterial blood pressureeffects of dietary NaCl on arterial blood pressure

In humanIn human a familial resemblance in the change of a familial resemblance in the change of blood pressure in response to salt restriction has beenblood pressure in response to salt restriction has been

described, and a phenotype of haptoglobin may be adescribed, and a phenotype of haptoglobin may be amarker of NaCl sensitivity marker of NaCl sensitivity



ObesityObesity indicated a direct linier correlation betweenindicated a direct linier correlation betweenbody weight or BMI and blood pressurebody weight or BMI and blood pressure

Insulin resistanceInsulin resistance

obesity is associated with resistance to insulinobesity is associated with resistance to insulin--

stimulated glucose uptake andstimulated glucose uptake andhyperinsulinaemia; and weight loss increaseshyperinsulinaemia; and weight loss increases

insulin sensitivity insulin sensitivity

population studies : approximately 25population studies : approximately 25--50% 50%

nonobese, nondiabetic hypertensive personsnonobese, nondiabetic hypertensive persons



Higher insulin levels have been reported to beHigher insulin levels have been reported to beassociated with an increased risk of hypertension inassociated with an increased risk of hypertension in

African Americans and whites African Americans and whites PotassiumPotassium

Potassium loading prevents or amelioratesPotassium loading prevents or ameliorates

development of hypertension in several animaldevelopment of hypertension in several animalmodels of genetic and NaClmodels of genetic and NaCl ² ²inducedinducedhypertensionhypertension

Conversely, in Dahl_R and DahlConversely, in Dahl_R and Dahl--S rats on aS rats on a

highhigh--NaCl diet, low potassium intake results inNaCl diet, low potassium intake results inblood pressure elevation and renal vascularblood pressure elevation and renal vascularremodeling that indicating increased renalremodeling that indicating increased renal

vascular resistance vascular resistance



Dietary potassium may effect morbidity andDietary potassium may effect morbidity andmortality, independent of an effect on blood pressuremortality, independent of an effect on blood pressure

Unrelated to changes of blood pressure, a highUnrelated to changes of blood pressure, a high--

potassium diet was reported to decrease strokepotassium diet was reported to decrease stroke

mortality and to decrease renal damage inmortality and to decrease renal damage in

several rat models of hypertensionseveral rat models of hypertension

In prospective clinical study In prospective clinical study in the 12in the 12--year risk year risk

of stroke death was associated with potassiumof stroke death was associated with potassiumintake, independent of blood pressureintake, independent of blood pressure



In JapanIn Japan introducing a diet with a lowintroducing a diet with a lowsodiumsodium--to to--potassium ratio was associated withpotassium ratio was associated with

reduced 10 year stroke mortality ratereduced 10 year stroke mortality rate

CalciumCalcium

80 studies have reported that blood pressure is80 studies have reported that blood pressure islowered by increasing dietary calcium inlowered by increasing dietary calcium in

experimental models of hypertensionexperimental models of hypertension

This effect of calcium on blood pressure may be This effect of calcium on blood pressure may bemore pronounced in models of saltmore pronounced in models of salt--sensitivesensitive

hypertensionhypertension



Within and among populationWithin and among population ´ there is inverse´ there is inverseassociation between dietary calcium intake and bloodassociation between dietary calcium intake and bloodpressure, and low calcium intake is associated with anpressure, and low calcium intake is associated with anincreased prevalence of hypertensionµincreased prevalence of hypertensionµ

Epidemiologic reports and animal studiesEpidemiologic reports and animal studiessuggest a threshold for calcium intake below suggest a threshold for calcium intake below which arterial pressure increases, and low which arterial pressure increases, and low calcium intake may amplify the effects of a highcalcium intake may amplify the effects of a high--

NaCl diet on blood pressureNaCl diet on blood pressure In human, diets < 600 mg Calcium/day areIn human, diets < 600 mg Calcium/day are

most clearly associated with hypertensionmost clearly associated with hypertension



MagnesiumMagnesium relatively little informationrelatively little informationHigh Mg intake lowers blood pressure in rat modelsHigh Mg intake lowers blood pressure in rat models

of hypertension: and in rat, blood pressure increasesof hypertension: and in rat, blood pressure increasesin response to Mg deprivationin response to Mg deprivation

In human, as with calcium, evidence suggests anIn human, as with calcium, evidence suggests an

association between lower Mg in diet and higherassociation between lower Mg in diet and higherblood pressureblood pressure

Alcohol Alcohol

The contribution to the prevalence of hypertension The contribution to the prevalence of hypertensionattributed to consuming more than two drinks of attributed to consuming more than two drinks of

alcohol per day has been estimated to be 5 to 7 %alcohol per day has been estimated to be 5 to 7 %



T he contribution men > women; although inT he contribution men > women; although inwomen the risk of hypertension increasedwomen the risk of hypertension increasedprogressively with alcohol intake in excess of 20progressively with alcohol intake in excess of 20g/dayg/day

In controlled studiesIn controlled studies

reduction pf alcoholreduction pf alcoholconsumption has been associated with reductionconsumption has been associated with reduction

of 4of 4--8 mmHg in systolic blood pressure and8 mmHg in systolic blood pressure and

lesser reduction of diastolic pressurelesser reduction of diastolic pressure

The mechanism by which alcohol may affect The mechanism by which alcohol may affect

blood pressure has not been establishedblood pressure has not been established



LIPIDSLIPIDS

In animal and humanIn animal and human polyunsaturated npolyunsaturated n--3 and3 andnn--6 fatty acids play a role in blood pressure6 fatty acids play a role in blood pressure

regulationregulation

Experimental models of hypertensionExperimental models of hypertension linoleiclinoleicacid ( a long acid ( a long --chain nchain n--6 polyunsaturated fatty 6 polyunsaturated fatty

acid) and fish oil (rich in eicosapentanoic &acid) and fish oil (rich in eicosapentanoic &

docosahexaenoic acids both ndocosahexaenoic acids both n--3 fatty acids)3 fatty acids)

attennate the development of reninattennate the development of renin--dependentdependent

hypertensionhypertension



Epidemiologic evidenceEpidemiologic evidence a direct association between diets high ina direct association between diets high in

saturated fats & blood pressuresaturated fats & blood pressure population with low mean blood pressure levels population with low mean blood pressure levels

consume diets low in total fat and saturated fattyconsume diets low in total fat and saturated fatty

acidsacids

Diet high in nDiet high in n--3 fatty acids may be associated with lower3 fatty acids may be associated with lower

blood pressureblood pressure

Linoleic acidsLinoleic acids--enriched diets reduce blood pressure inenriched diets reduce blood pressure in

nornotensive & hypertensive personsnornotensive & hypertensive persons31 trial31 trial statistically significant reduction of bloodstatistically significant reduction of blood

pressureby fish oil ( pressureby fish oil ( 3.0/1.5 mmHg)3.0/1.5 mmHg)



In hypertensive patientsIn hypertensive patients dosedose--response hypotensiveresponse hypotensiveeffect of fish oileffect of fish oil

In healthy normotensive personsIn healthy normotensive persons little or nolittle or nohypotensive effects of fish oilhypotensive effects of fish oil

conclusionconclusion ::

*fish oil is unlikely to benefit healthy person for the*fish oil is unlikely to benefit healthy person for theprevention or treatment of hypertension, given theprevention or treatment of hypertension, given theuncertainty of response and large dose required to elicituncertainty of response and large dose required to elicitsmall changes in blood pressuresmall changes in blood pressure

*fish oil in doses that reduce blood pressure in*fish oil in doses that reduce blood pressure inhypertensive persons does not adversely affect insulinhypertensive persons does not adversely affect insulinsensitivity or glucose metabolismsensitivity or glucose metabolism



ProteinProtein Intersalt study: blood pressure level is inverselyIntersalt study: blood pressure level is inversely

associated with dietary protein and fiberassociated with dietary protein and fiberconsumptionconsumption

specific amino acids could effect neurotransmittersspecific amino acids could effect neurotransmitters

or humoral substances that control blood pressureor humoral substances that control blood pressure

e.g : tryptophan or tyrosinee.g : tryptophan or tyrosine CarbohydrateCarbohydrate

Simple carbohydrate feeding induces insulin resistanceSimple carbohydrate feeding induces insulin resistance

High dietary intake of glucose, sucrose, and fructoseHigh dietary intake of glucose, sucrose, and fructose

may increase arterial pressure in the normotensivemay increase arterial pressure in the normotensiveanimalanimal may augment NaCl sensitivity of bloodmay augment NaCl sensitivity of bloodpressurepressure potentiate development of hypertension inpotentiate development of hypertension inseveral experimental modelsseveral experimental models



**Prevention of obesity, beginning in childhood,Prevention of obesity, beginning in childhood,would seem important for the primary prevention of would seem important for the primary prevention of

hypertension and cardiovascular diseasehypertension and cardiovascular disease*several trial*several trial the efficacy of preventing hypertension the efficacy of preventing hypertensionin adults through altered dietary intakein adults through altered dietary intake

Reduce NaCl intake; control body weight;Reduce NaCl intake; control body weight;consume adequate amounts of potassium;consume adequate amounts of potassium;calcium and magnesium; and moderate alcoholiccalcium and magnesium; and moderate alcoholic

beverage intakebeverage intake

See leafletSee leaflet Diit rendah garam !!Diit rendah garam !!

s1fk-nutrition , diet , and hypertension

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