Lifestyle and Blood Pressure

Introduction

Lifestyle is the foundation of atherosclerotic cardiovascular disease (ASCVD) risk reduction efforts. As discussed in Cholesterol and Atherogenesis, atherosclerosis begins in childhood for most persons living in a developed country due to poor diet, physical inactivity and exposure to tobacco. As countries around the world become more prosperous, individuals in these countries are also taking up these unhealthy lifestyle habits.

Poor lifestyle habits accelerate a genetic propensity to atherosclerosis. The American Heart Association (AHA) has defined seven lifestyle habits and risk factors that largely predict the development of ASCVD through the lifespan. Excess caloric intake and poor dietary composition, along with physical inactivity, also act in a genetic background to promote overweight and obesity. Obesity promotes the development of diabetes, hypertension and dyslipidemia, which in turn contribute to atherosclerosis and increased ASCVD risk. Obesity also increases the risk of numerous non- cardiovascular (CV) morbidities, including osteoarthritis, sleep apnea, gall bladder disease and respiratory problems.

Clinical Highlight I

• Diet, physical activity, weight control, and avoidance of smoking are the foundation for ASCVD risk reduction efforts.
• Healthy lifestyle habits should be established in childhood, adolescence, and young adulthood and continued lifelong to prevent the development of atherosclerosis with advancing age.
• Use statins to substantially reduce ASCVD risk in middle age and older age and in those with familial hyperlipidemias.
• A healthy lifestyle is important for reducing morbidity from other causes.
• Control blood pressure and consider aspirin if the benefits outweigh the risks.

In 2008, the NHLBI convened a number of guideline panels and working groups as part of a CV risk reduction guideline effort. The Lifestyle Working Group and Obesity Guideline were transitioned to the ACC/AHA for implementation as the 2013 ACC/AHA Lifestyle Guideline and the 2013 ACC/AHA/TOS Obesity Guideline, respectively.

The 2020-25 US Dietary Guidelines for Americans is an excellent resource for information on good dietary practices, including maintaining a heart-healthy diet. Please refer to it specific recommendations for dietary composition.

Lifestyle Is the Foundation; Statins if Needed to Reduce ASCVD Risk

Lifestyle changes are the foundation of ASCVD risk reduction efforts, but initiation of drug therapy should not be delayed in high-risk patients (clinical ASCVD, low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dL, diabetes, and 10-year ASCVD risk ≥20%). In primary prevention in patients aged ≥50 years or with ≥10% 10-year ASCVD risk, it is unlikely that modest diet and physical activity improvements will be sufficient to reduce ASCVD risk to below 5%-7.5% 10-year ASCVD risk if re-estimated in 4 to 6 years. However, there are patients who after long-term maintenance (4 to 6 years) of substantial weight loss or large improvements in diet and physical activity may experience meaningful reductions in estimated 10-year ASCVD risk.

Ideal Cardiovascular Health

Ideal CV health is defined by the presence of both ideal health behaviors (nonsmoking, body mass index [BMI] <25 kg/m², physical activity at goal levels, and pursuit of a diet consistent with current guideline recommendations) and ideal health factors (untreated total cholesterol <200 mg/dL, untreated blood pressure (BP) <120/<80 mm Hg, and fasting blood glucose <100 mg/dL) (Table 9-1). Appropriate levels for children have also been identified. With the use of levels that span the entire range of the same metrics, CV health status for the whole population is defined as poor, intermediate, or ideal.

Individuals with all seven ideal CV health factors have a much lower risk of developing ASCVD and all-cause mortality (Figure 9-1). Efforts to achieve and maintain ideal CV health need to start in childhood and continue through adulthood. Public policy, community efforts and pharmacologic interventions are all needed to prevent the heavy burden of ASCVD, the leading cause of death and health expenditures in the United States. Many of these interventions are cost-effective and often cost-saving. A heart-healthy lifestyle can prevent not only ASCVD but also diabetes, cancer and many debilitating comorbidities.

Poor health habits start in childhood and worsen during adolescence into adulthood. Before age 11, ideal BMI, total cholesterol and BP are common, although ideal diet is rare. In adolescence, about 20% of White boys and 60% of White girls have five or more ideal health components (Figure 9-2), with lower rates in African American adolescents.

Among adults, smoking, hypercholesterolemia and hypertension have declined between 1998 and 2008, but obesity and glucose intolerance/diabetes have increased. Physical activity and diet changed minimally.

Clinical Highlight II

• Counsel everyone on a healthy diet, regular physical activity, and avoiding obesity, tobacco and second-hand smoke.
• Control blood pressure.
• Place special emphasis on encouraging healthy lifestyle habits in children and adolescents and their parents.
• Middle-aged and older patients will usually need statin therapy in addition to healthy lifestyle changes to meaningfully retard atherosclerosis progression.

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Motivating Behavior Change

Clinicians can motivate patients to change behavior. Discussions of the individual patient’s 10-year and lifetime ASCVD risk can provide a context for the intensity of lifestyle changes needed and have been shown to motivate patients to initiate healthy lifestyle changes.

Helpful components of counseling include problem-solving guidance (to help patients develop a plan to change a behavior and overcome common barriers to behavior change) and the provision of social support as part of treatment. Complementary practices include motivational interviewing, assessing readiness to change, offering more intensive counseling or referrals and using mobile phone or internet-based programs.

Medium- or high-intensity interventions to promote a healthful diet and regular physical activity have been shown to be effective. These generally require referral to dedicated programs within the health care system or in the community.

Smoking cessation interventions are effective. All patients should be counseled to quit regardless of their interest in doing so.

Smoking Cessation

The US Preventive Services Task Force finds the net benefits of screening and tobacco cessation interventions in adults and pregnant women remain well established. Recommendations for clinicians are provided in Table 9-2.

Clinician advice to quit smoking is effective and should be followed by referral to a quit line, mobile phone or internet-based, or other community smoking cessation resources and provision of medications (Table 9-3). Adults should not smoke around children to minimize exposure to second-hand smoke.

All public and private health insurance plans should cover a comprehensive tobacco cessation benefit for plan members, including all medications and types of counseling recommended by the US Public Health Service.

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Clinical Recommendations for Smoking Cessation

Recognition of Behavior

The “5-A” behavioral counseling framework provides a useful strategy for engaging patients in smoking cessation discussions:

Ask about tobacco use

Advise to quit through clear personalized messages

Assess willingness to quit

Assist to quit

Arrange follow-up and support.

Counseling

In nonpregnant adults, the United States Preventive Services Task Force (USPSTF) found convincing evidence that smoking cessation interventions, including brief behavioral counseling sessions (<10 minutes) and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit and remain abstinent for 1 year. Although less effective than longer interventions, even minimal interventions (<3 minutes) have been found to increase quit rates.

Various primary care clinicians may deliver effective interventions. There is a dose-response relationship between quit rates and the intensity of counseling (that is, more or longer sessions improve quit rates). Quit rates seem to plateau after 90 minutes of total counseling contact time.

Helpful components of counseling include problem-solving guidance for smokers (to help them develop a plan to quit and overcome common barriers to quitting) and the provision of social support as part of treatment. Complementary practices that improve cessation rates include motivational interviewing, assessing readiness to change, offering more intensive counseling or referrals and using telephone “quit lines.”

Treatment

Combination therapy with counseling and medications is more effective at increasing cessation rates than either component alone. Pharmacotherapy approved by the FDA and identified as effective for treating tobacco dependence in nonpregnant adults includes several forms of nicotine replacement therapy (gum, lozenge, transdermal patch, inhaler and nasal spray), sustained-release bupropion and varenicline (Table 9-3).

Useful Resources

• Quitting smoking resources for patients
  • http://www.cdc.gov/tobacco/campaign/tips/quit-smoking/
  • http://www.lung.org/quit-smoking/
• Detailed reviews and recommendations about clinical interventions for tobacco cessation are available in the US Public Health Service Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update available at https://www.ahrq.gov/prevention/guidelines/tobacco/clinicians/update/index.html. For information on research and treatment options developed since 2008, see Familial Hyperlipidemias of the Surgeon General’s 2020 Smoking Cessation report, available at https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf.
• Tobacco-related recommendations from the Centers for Disease Control and Prevention’s Guide to Community Preventive Services are available at https://www.thecommunityguide.org/topics/tobacco.html.

Clinical Highlight III

• Assess smoking status for every patient.
• Encourage all smokers to quit at every visit.
• Encourage participation in structured smoking cessation programs. Telephone quit lines are widely available.
• Offer smoking cessation medication.
• Follow-up until the patient has quit smoking.
• Regularly encourage ex-smokers to stay nonsmokers.

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2013 ACC/AHA Lifestyle Guideline

The National Heart, Lung, and Blood Institute (NHLBI) charged the Lifestyle Working Group with developing an evidence-based guideline for reducing LDL-C by diet or physical activity changes based on randomized trial data. These recommendations were transitioned to the 2013 ACC/AHA Guideline on Lifestyle Management to Reduce Cardiovascular Risk for implementation. These recommendations are listed in Table 9-4. Resources and information for dietary planning are provided in Table 9-5.

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Dietary Pattern

Most of the high-quality randomized trial data came from trials of the DASH (Dietary Approaches to Stop Hypertension) dietary pattern. An LDL-C lowering effect was demonstrated in White and African American men and women and in adults of all ages. The caloric content of the diet should be based on the need of the patient to lose, maintain, or gain weight. This dietary pattern can be adapted to personal and cultural preferences.

Dietary Fat Intake

Reducing saturated fat intake has the greatest impact on LDL-C. A diet rich in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, legumes and nuts, and vegetable oils and limited in sweets, sugar-sweetened beverages and red meats is more likely to have 5% to 6% of calories from saturated fats than the typical American diet (with about 11% of calories from saturated fat). Trans fats increase the risk of ASCVD, and their main source, partially hydrogenated vegetable oils, are being phased out of the US food supply. Reducing trans fats also lowers LDL-C. Avoiding red meat and dairy fat also will reduce intake of naturally occurring trans fats.

Physical Activity

To lower LDL-C and non–HDL-C the most effective “dose” of physical activity is 40 minutes of moderate to vigorous physical activity three or four times a week. Brisk walking is considered moderate physical activity. However, more frequent, moderate activity for 30 minutes a day has significant health benefits. Moderately vigorous activity 45 to 60 minutes 6 to 7 days a week can assist in weight maintenance.

Diet RCTs With ASCVD Outcomes

Few randomized trials have been of sufficient size and duration to evaluate ASCVD outcomes. Those that have been completed have been performed in middle-aged or older populations and the results have been underwhelming. Major trials are reviewed below.

Since modest dietary changes and modest increases in physical activity only modestly reduce LDL-C, the reductions in ASCVD observed in randomized trials has been modest at best. Moreover, it takes a great deal of effort by patients and providers to maintain healthy lifestyle behaviors, and study participants usually return to their previous lifestyle habits after the end of the intervention. Therefore, the emphasis should be on establishing healthy lifestyle habits early in life. Once atherosclerosis is well-established by middle age, the emphasis needs to turn to more aggressive LDL-C lowering with statin therapy to reduce ASCVD risk. Patients should still be encouraged to make healthy lifestyle changes for other reasons such as diabetes prevention, maintenance of mobility, depression avoidance and other potential health benefits.

Women’s Health Initiative (WHI)

The WHI was a large, randomized trial that evaluated the effect of decreasing dietary intake of fat and increasing dietary intake of vegetables, fruits and whole grains in healthy postmenopausal women aged 50 to 79 years. Although the intervention was intensive with frequent group and individual sessions, the trials did not achieve the desired reductions in total fat intake (20% of calories from fat) and increases in fruit and vegetable intake (to at least five servings) and grains (to at least six servings per day).

After 6 years, mean fat intake was reduced to 29% (vs 37% in controls), saturated fat to 9.5% (vs 12.4% in controls), fruits and vegetables to 4.9 servings (vs 3.8 in controls) and grains to 4.3 servings (vs 3.8 in controls). LDL-C was only modestly reduced by 4 mg/dL vs controls at year 6. Coronary artery disease (CAD) and stroke events were similar in both groups over the mean 8 years of follow-up, although there was a trend toward greater CAD reduction in women more adherent to the diet intervention.

Look AHEAD

Look AHEAD was a large, randomized trial to determine whether an intensive lifestyle weight loss program would reduce ASCVD events in overweight and obese individuals aged 45-75 years with diabetes. The trial was stopped at a mean 9.6 years due to futility. Weight loss (9% vs 1% of body weight at 1 year; 6% vs 3.5% at end of study), glycemic control, fitness and improvements in CV risk factors (other than LDL-C) were greater in the intensive lifestyle group. Nonetheless, there was no difference in the rate of ASCVD events (1.82% vs 1.92% per year; P = 0.51). Although statin use was reportedly higher in the control group, LDL-C levels were the same in both groups making this a less likely explanation for the lack of benefit. Look AHEAD did find significant non-CV benefits from the intensive lifestyle intervention. Intensive lifestyle induced the partial remission of diabetes in some participants, reduced the decline in mobility with aging, reduced depression and improved health-related quality of life and reduced healthcare costs.

PREDIMED

PREDIMED was a large, randomized trial to compare three diets in high-risk primary prevention Spanish adults with and without diabetes aged 55-80 years: a Mediterranean diet supplemented with extravirgin olive oil, a Mediterranean diet supplemented with nuts, or a control diet (advice to reduce dietary fat). At baseline, 57% were women, 83% had hypertension, 50% had diabetes and 40% were on statins. Adherence to the diets was good over the median 5 years of the trial. The Mediterranean diets reduced the primary composite endpoint (MI, stroke, CV death) by 28% to 30% compared to the control group. Most of the risk reduction occurred for stroke.

The Mediterranean diet recommendations included consumption of ≥4 tablespoons of olive oil per day, ≥3 servings of tree nuts per week, ≥3 servings of fruit per day, ≥2 servings of vegetables per day, ≥3 servings of fish per week, ≥3 servings of legumes per week, ≥2 servings of sofrito per week (tomato, onion and garlic sautéed in olive oil), white meat instead of red meat, and 1 or more glasses of wine with meals (habitual drinkers only). Soda drinks, commercial bakery goods, spread fats and red and processed meats were to be avoided. The olive oil–supplemented group was to consume an additional 4 tablespoons of olive oil per day, and the nut-supplemented group was to consume an additional serving of 30 g of nuts, composed of 15 g of walnuts, 7.5 g of almonds and 7.5 g of hazelnuts.

The Mediterranean diets also had beneficial effects on atrial fibrillation, depression in diabetic participants, cognitive function and preventing diabetes in nondiabetic participants.

Clinical Highlight IV

• Recommend patients consume a dietary pattern that:
• Emphasizes intake of vegetables, fruits and whole grains
• Includes low-fat dairy products, poultry, fish, legumes, extra-virgin olive oil and nuts
• Limits intake of sweets, sugar-sweetened beverages and red meats.
• Recommend patients be as active as possible through the day, aiming for a minimum of at least 30 minutes of moderate physical activity 5 days per week.

2013 ACC/AHA/TOS Obesity Guideline

The Obesity Guideline panel was convened in 2008 along with ATP IV and JNC 8. The recommendations of the obesity panel were transitioned to the 2013 ACC/AHA/TOS Guideline for the Management of Overweight and Obesity in Adults (Table 9-6). The Obesity Guideline focused on evidence-based treatment of excess body weight in individuals with overweight and obesity based on meta-analyses, systematic reviews and randomized trial data. Drug therapy for weight loss was not reviewed due to the availability of only one drug at the time of the panel’s review process.

Clinical Highlight V

• Calculate BMI at every visit.
• Counsel patients with overweight (BMI 25-<30) and obesity (BMI ≥30) to lose weight through portion size control of a healthy diet and increasing regular physical activity.
• Participation in healthcare, community, commercial, or internet- or phone-based structured weight-loss programs is helpful.
• Once the patient achieves the desired weight loss, encourage participation in weight maintenance programs.
• Bariatric surgery can be considered for some adults with BMI ≥40 kg/m² and obesity-related comorbid conditions.

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Blood Pressure Treatment

Hypertension is the most common ASCVD risk factor. Elevated BP increases the risk of MI, stroke, renal failure, heart failure and death if not detected and treated.

Lifestyle Treatment of Hypertension

The 2013 ACC/AHA lifestyle guideline reviewed evidence from randomized trials of diet and lifestyle to make recommendations for the management of hypertension through dietary and physical activity changes (Table 9-7).

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Drug Treatment of Hypertension

The Systolic Blood Pressure Intervention Trial (SPRINT) was designed to test the ASCVD event and mortality reduction benefit of intensive BP reduction. SPRINT enrolled 9,361 people age 55 years or older with systolic BP ≥130 mm Hg with increased ASCVD risk (but no diabetes). Participants were randomized to titration to a systolic BP of <140 mm Hg (standard treatment) or <120 mm Hg (intensive treatment). The primary endpoint was a composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. The trial was stopped early (median follow-up of 3.26 years) when the benefits of intensive treatment became apparent: the incidence of the primary outcome was 1.65% per year in the intensive-treatment group, compared to 2.19% per year in the standard-treatment group (hazard ratio, 0.75; 95% confidence interval, 0.64-0.89; P <0.001).

2017 Multi-Society Hypertension Guidelines

In 2017, the ACC/AHA, together with 9 other societies, issued the Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. In line with the 2013 ACC/AHA lifestyle guideline, the 2017 multi-society hypertension guideline recommends Class of Recommendation (COR I) 6 nonpharmacologic interventions to reduce high BP, including weight loss, a heart-healthy diet, sodium reduction, potassium supplementation (except in patients with chronic kidney disease), increased physical activity and limiting alcohol consumption. Using data from SPRINT and other available systematic reviews and meta-analyses of pharmacologic BP control efficacy, the guideline also recommended (COR I) the use of BP-lowering medications in:

• Patients with clinical ASCVD (secondary prevention) and an average systolic BP of ≥130 mm Hg or an average diastolic BP of ≥80 mm Hg
• Patients with a 10-year ASCVD risk of ≥10% (primary prevention) and an average systolic BP of ≥130 mm Hg or an average diastolic BP of ≥80 mm Hg
• Patients with a 10-year ASCVD risk of <10% (primary prevention) and an average systolic BP of ≥130 mm Hg or an average diastolic BP of ≥80 mm Hg.

For patients in whom pharmacologic BP control is indicated, the guideline recommends (COR I) thiazide diuretics, calcium channel blockers (CCBs) and ACE inhibitors or ARBs, as first line agents. For treatment goals, the guideline recommends (COR I) a BP target of <130/80 mm Hg in patients with hypertension and either clinical ASCVD or those with a 10-year ASCVD risk of 10% or higher and considers this same target level reasonable in patients with hypertension but no elevated ASCVD risk (COR IIb). See Table 9-8 for recommendation details, and the guideline publication for other recommendations and discussion.

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Clinical Highlight VI

• Record BP at every visit.
• Counsel patients with elevated BP or hypertension to lose weight, adopt a heart-healthy diet, limit sodium intake, supplement potassium intake (unless contraindicated), increase physical activity and limit alcohol consumption.
• Use pharmacologic agents to control BP in patients with clinical ASCVD or a 10-year ASCVD risk of 10% or higher whose BP is 130/80 mm Hg or higher and in patients with a 10-year ASCVD risk below 10% or whose BP is 140/90 mm Hg or higher.