Towards better blood pressure: Do non‐pharmacological strategies provide the right path?

Abstract

A scene like this plays out many times every day: A patient with newly diagnosed hypertension, confirmed with out-of-office readings, is seen in the clinic. What happens next depends on the patient, the doctor, and other less understood dynamics of that interaction. In most settings, the patient walks out with a plan to change their lifestyle, a prescription for a pill, or sometimes both. On one hand, most individuals demonstrate significant pill disutility, defined as the longevity gain desired by an individual to offset the inconvenience of taking a preventative tablet for life.1 This can vary considerably, ranging from >1 month for about twothirds of patients, to 12% demonstrating extreme pill disutility (bordering on pill hatred), 2 actually desiring ≥10 year increased life expectancy before taking any new medication. 1 On the other hand, undoubtedly, giving a prescription for a medication is a much faster and easier option for the physician. Data from a large health maintenance organization, which has achieved an enviable 85% hypertension control, demonstrate that the path to lower blood pressure does go through optimal pharmacotherapy. 3 Additionally, a successful non-pharmacological strategy should take into account the patient motivation for lifestyle changes and the pieces needed for actual execution, not just counselling for eating less salt. The paper by Liu et al tackle the latter aspect, using data from the National Health and Nutrition Examination Survey (NHANES) 1999-2004 survey of the 4000 hypertensive patients who reported that a recommendation from their doctor for any 1 (or more) of 4 non-pharmacologic strategies (less sodium, less alcohol, more physical activity, or weight loss). 4 As expected, reducing sodium intake was the most common (68%) and alcohol reduction the most uncommon (26%)recommendation. The self-reported adoption rates of these strategies were very high (ranging from 59% to 87%), but despite this, almost half the patients (47%) still had uncontrolled hypertension.

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“…In most trials of sodium reduction, including the Dietary Approach to Stop Hypertension-Sodium trial, the participants received packaged meals, thus representing feeding trials that are not feasible for routine practice. 6 , 7 , 8 Additionally, the source and amount of sodium intake consumed vary across the world. A systematic review reported that Americans consume 3,400 mg (147 mEq) per day, whereas the residents of Northern China consume >11,000 mg (480 mEq) per day.…”