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Diet, blood pressure and cardiovascular
diseases
Marianne Geleijnse, PhD
Voeding in de Praktijk
Rotterdam, 30 June 2015
Blood pressure (BP) rises with age
2
Age (years)
BP (
mm
Hg) Systolic BP
Diastolic BP
SBP 90 120 = +30 mmHg
SBP 120 130 = +10 mmHg
Total lifetime > 40 mmHg
Blood pressure (BP) rises with age
3
Age (years)
BP (
mm
Hg) Systolic BP
Diastolic BP
SBP 90 120 = +30 mmHg
SBP 120 130 = +10 mmHg
Total lifetime > 40 mmHg
Prevention starts here
BP and cardiovascular diseases (CVD)
4
About half of CVD events in people with “normal” BP (SBP <140)
Pooled data from over 1 million adults. Prospective Studies Collaboration. Lewington et al, Lancet 2002.
Ris
k o
f str
oke m
orta
lity
Systolic BP (mmHg)
“Hypertension”
Population-based approach for CVD
prevention
5 Whelton et al, JAMA 2002.
No obesity
Physically active
No alcohol
High intake
of plant foods
No salt
6 Mancilha-Carvalho et al, J Hum Hypertens 1989 Oliver et al, Circulation 1975
BP in Yanomami Indians (Brazil)
No BP rise
with age
Body weight
7 Neter et al, Hypertension 2003
Meta-analysis: pooling of 25 weight loss trials
Type of intervention:
diet and/or physical activity
Effect on systolic BP:
● All trials: -4.4 mmHg
● Weight loss ≤5 kg: -3 mmHg
● Weight loss >5 kg: -7 mmHg
8
Randomized controlled trial:
Half of the people randomly assigned to the intervention group
(less calories and/or more physical activity to achieve weight loss)
Half of the people assigned to the control group (e.g. regular diet)
(effect on BP)
9
Bariatric surgery versus non-surgical
treatment for obesity
Effect on weight loss (and BP)
10
Bariatric surgery versus non-surgical
treatment for obesity: meta-analysis
Gloy et al, BMJ 2013
Effect on body weight (kg)
Effect on systolic BP (mmHg)
Bariatric surgery Control Bariatric surgery Control
Dixon 2008 -20.3 -5.9 -6.0 -1.7
Dixon 2012 -27.8 -5.1 -7.3 -5.9
O’Brien 2010 -34.6 -3.0 -12.5 -20.3
Ikramuddin 2013 -28.5 -7.9 -12.0 -8.8
Mingrone 2012 -45.5 -7.0 -20.3 -21.6
Schauer 2012 -27.3 -5.4 -3.8 -3.9
Approx. reduction -30 kg -5 kg
-10 mmHg -10 mmHg
11
Bariatric surgery versus non-surgical
treatment for obesity: meta-analysis
Gloy et al, BMJ 2013
Effect on body weight (kg)
Effect on systolic BP (mmHg)
Bariatric surgery Control Bariatric surgery Control
Dixon 2008 -20.3 -5.9 -6.0 -1.7
Dixon 2012 -27.8 -5.1 -7.3 -5.9
O’Brien 2010 -34.6 -3.0 -12.5 -20.3
Ikramuddin 2013 -28.5 -7.9 -12.0 -8.8
Mingrone 2012 -45.5 -7.0 -20.3 -21.6
Schauer 2012 -27.3 -5.4 -3.8 -3.9
Approx. reduction -30 kg -5 kg
-10 mmHg -10 mmHg
Is it the body fat, or...?
Physical activity lowers BP by 3-5 mmHg
Baena et al, J Hypertens 2014
Cornelissen et al, Hypertension 2011
Healthy weight-loss diet: more whole grains, fruit &
vegetables, less alcohol, less sugared beverages...
Less calories → less salt
12
• Intake in most western countries: 7-12 g/day
- in the Netherlands: 9 g/day
Webster et al, J Hypertension 2011;29:1043-1050
• World Health Organization: max. of 5 g/day
WHO Forum on Reducing Salt Intake in Populations, Paris 2006
• The human body needs 0.5 g/day
Salt intake
What we eat: 3 kg pp per year
What we need: 9 tablespoons per year
Salt trial in chimpanzees
14 Denton et al, Nat Med 1995
• Intervention group: gradual increase in salt intake up to 15 g/day
during 20 weeks
• Control group: 0.5 g salt per day
• Systolic BP: +26 mmHg
KaNa trial
36 adults with untreated elevated BP
During 4-week periods:
● Salt pills (5 12 g/d)
● Potassium pills (2 5 g/d)
● Placebo pills
15
Fully controlled diet
Salt intake: 5 g/d (WHO guideline)
Gijsbers et al, J Hum Hypertens 2015, Feb 12
Effects on 24-hour systolic BP
105
110
115
120
125
130
135
140
145
150
22 24 2 4 6 8 10 12 14 16 18 20
SBP
, mm
Hg
Hour
Sodium Potassium Placebo
Gijsbers et al, J Hum Hypertens 2015, Feb 12
+7 mmHg
11 mmHg
-4 mmHg
Potassium in the diet
17
Intake in Dutch adults: 3.5 g/d Intake in Yanomami: ~8 g/d
Plant foods
Rich in:
● Potassium
● Fiber
● Vitamin C
● Folate
● Carotenoids
● Polyphenols
● Magnesium
● Nitrate
● ...
and relatively low in calories
18
May all lower BP
Fruit and vegetables
Randomized trial in 690 healthy adults (UK)
Advice to eat 5+ portions of fruit and vegetables
Daily consumption before the study: 3.4 portions
Increase during 6 months:
● Intervention group: +1.4 portion
● Control group: +0.1 portion
Effect on systolic BP: -4.0 mmHg
19 John et al, Oxford Fruit and Vegetable Study Group. Lancet 2002
Whole grains
Randomized trial in 197 healthy adults (UK)
16 weeks, 3 groups:
20
Tighe et al, Am J Clin Nutr 2001
Whole grains
Trial in UK men and women aged ~52 years
16 weeks, 3 groups:
21
Effect of whole grains on
systolic BP: -4.5 mmHg
Tighe et al, Am J Clin Nutr 2001
Pulses
Meta-analysis of 8 randomized trials
Lentils, chickpeas, peas, beans and/or lupin kernels vs.
isocaloric control
22
Effect on systolic BP: -2.3 [-4.2, -0.3]
Jayalath et al, Am J Hypertens 2014
Nuts
23
Meta-analysis of randomized trials
Mohammadifard et al, Am J Clin Nutr 2015
Effect on systolic BP
Cocoa
24
Rich in polyphenols, including
epicatechin, which may improve
the health of the blood vessels
Cocoa and BP (Zutphen Elderly Study)
Tertile of cocoa intake (g/d)
P for trend
<0.36 (n=165)
0.36-2.30 (n=149)
>2.30 (n=156)
Systolic BP (mmHg)
150.0
148.8
146.9
0.06
Diastolic BP (mmHg)
84.3
83.8
82.3
0.03
Buijsse et al, Arch Intern Med 2006
Meta-analysis of chocolate or cocoa trials
Ried et al. BMC Medicine 2010
Effect on systolic BP: -3.2 [-2.1, -1.2]
versus
27
FLAVO study
• Randomized trial in 35 healthy older adults
• Pills with epicatechin (cocoa flavonoid) or placebo, for 4 weeks
• Effect on 24-h systolic BP: -2.4 mmHg (NS)
• Effect on vascular health: flow-mediated
dilation improved by 1.1% (p=0.07)
• Improvement in insulin sensitivity (p=0.04)
Dower et al, Am J Clin Nutr 2015
Meat and fish
Insufficient number of randomized trials.
Observational evidence that processed meat
increases BP (because of salt?).
Fish oil
Meta-analysis of 36 randomized trials of fish oil
supplementation
High fish oil doses (~4 g/d)
Effect on systolic BP:
● All trials: -2.1 mmHg
● In hypertensives: -4.0 mmHg
● In normotensives: -1.0 mmHg
29 Geleijnse et al, J Hypertens 2002
Alcohol
Alcoholic beverages (all types) increase BP by ~1 mmHg
per 10 g/d alcohol
Puddey & Beilin, Clin Exp Pharmacol Physiol 2006
Meta-analysis of randomized trials of alcohol reduction:
Overall effect on systolic BP: -3.3 mmHg
Xin et al, Hypertension 2001
31
Milk
Lack of randomized trials of (non-fortified) milk and BP
Meta-analysis of dairy supplementation trials and
cardiometabolic risk factors
Benatar et al, PLoS One 2013
32
Effect on systolic BP
Low-fat dairy
beneficial for BP?
4% lower risk of developing hypertension per glass of milk Same association for low-fat dairy No association for high-fat dairy
Milk
33
Meta-analysis of 7 prospective cohort studies of habitual milk
consumption and risk of hypertension
~48,000 individuals, of whom ~15,000 developed hypertension during
5-15 years of follow-up
Soedamah-Muthu et al, Hypertension 2012
Coffee
Three meta-analyses of randomized trials
34
Intervention Effect on systolic BP
Jee et al
Hypertension 1999
3-8 cups/d
vs. no coffee or decaf
+2.4 mmHg
Noordzij et al,
J Hypertens 2005
3-8 cups/d
vs. no coffee or decaf
+1.2 mmHg
Steffen et al,
J Hypertens 2005
2-6 cups/d (incl. decaf)
vs. no coffee
-0.6 mmHg
Coffee
Three meta-analyses of randomized trials
35
Intervention Effect on systolic BP
Jee et al
Hypertension 1999
3-8 cups/d
vs. no coffee or decaf
+2.4 mmHg
Noordzij et al,
J Hypertens 2005
3-8 cups/d
vs. no coffee or decaf
Caffeine pills (~410 mg/d*)
vs. placebo pils
+1.2 mmHg
+4.2 mmHg
Steffen et al,
J Hypertens 2005
2-6 cups/d (incl. decaf)
vs. no coffee
-0.6 mmHg
*Amount in ~5 cups of coffee
Why BP effect of coffee ≠ caffeine pills?
Not related to caffeine dose (similar in coffee and caffeine trials)
Coffee contains potassium and magnesium
● 5 cups of coffee per day: 26% of K intake and 12% of Mg intake in the NL
Coffee has a high antioxidant capacity and contains polyphenols,
e.g. chlorogenic acid may improve blood vessel health?
Pellegrini et al, J Nutr 2003
Geleijnse JM, (letter), JAMA 2006
Salt workshop – RIVM Bilthoven 7-8 Nov 2013
Coffee, cola and risk of hypertension in
the Nurses’ Health Study
Winkelmayer et al, JAMA 2006
Combined prospective cohort data of NHS I and NHS II
~156,000 US women of whom ~20,000 developed hypertension
during 12 years of follow-up
Risk of hypertension:
● 10% lower for 4 or more cups/day of coffee
● 30-40% higher for 4 or more glasses/day of sugared cola
Winkelmayer et al, JAMA 2005
Tea
Meta-analysis of 11 randomized trials Greyling et al, PLoS One 2014
Black tea consumption of 400-1800 mL/day vs. control drink (e.g. hot water)
Tea provided ~240-1500 mg/day of flavonoids
Effect on systolic BP: -1.8 mmHg
38
Meta-analysis by Liu et al, Br J Nutr 2014: • All tea: -1.8 mmHg • Green tea: -2.1 mmHg • Black tea: -1.4 mmHg
Vegetarian diet
39
Meta-analysis of 7 randomized trials of lacto-ovo
or vegan diets compared with omnivorous diets
Yokoyama et al, JAMA Intern Med 2014
Effect on
systolic BP
Salt workshop – RIVM Bilthoven 7-8 Nov 2013
DASH trial
Appel et al, N Engl J Med 1997
459 US adults with elevated BP
Salt workshop – RIVM Bilthoven 7-8 Nov 2013
Appel et al, N Engl J Med 1997;336:1117-1124.
DASH trial
-2.8 mmHg
-5.5 mmHg Appel et al, N Engl J Med 1997
Effect on systolic BP
Hypertensives (n=169)
Normotensives (n=243)
Salt restriction alone 8.3 mmHg 5.6 mmHg
Salt restriction + DASH diet 11.5 mmHg 7.1 mmHg
Comparable to medication
DASH-Sodium trial
Sacks et al, N Engl J Med 2001
DASH diet combined with less salt
Why go for a healthy diet?
43
• Reduces BP and risk of CVD, but also risk of
obesity, cancer, osteoporosis, dementia, etc.
• Far more cost-effective than medication
• No side effects
• Can start early in life
• No only for primary prevention,
but also for those on drug treatment
The impact of diet & lifestyle on BP
Weight loss
More physical activity
Less salt, more potassium
More fruit & vegetables
Whole grains in stead of refined grains
Less alcohol
Less sugar-sweetened beverages, less meat?
More low-fat dairy, nuts, seeds, pulses, cocoa, tea, fish?
44
10 mmHg?
20 mmHg?
30 mmHg?
Can we close the gap?
45
-40 mmHg
Systo
lic B
P (
mm
Hg)
Questions?
46
