This study followed 412 patients around the age of 48 years old through a controlled diet trial that included reducing sodium, followed a DASH diet that had increased fruits, vegetables, and low-fat dairy. Patient selected were either prehypertensive or in stage one and were not currently taking medications to assist with stabilization of blood pressure. Throughout there was a tracking of blood pressure readings to monitor for differences done solely through diet modifications. The result of this study showed that when following a DASH diet in combination with decreased sodium intake there was an improvement in blood pressure levels which allowed for patients to have lower blood pressure. This is important to note because it illustrates the impact of dietary modifications on disease progression. These patients were not making any other changes other than diet choice which allowed for decreased blood pressure, and improved classification within the hypertension groupings. The clinical implications of this would be counseling suggestions and evidence behind recommendations for anyone at risk for hypertension development, or throughout any stage of hypertension. 

Juraschek, Stephen P et al. “Effects of Sodium Reduction and the DASH Diet in Relation to Baseline Blood Pressure.” Journal of the American College of Cardiology vol. 70,23 (2017): 2841-2848. doi:10.1016/j.jacc.2017.10.011

 

This is a review of studies done on the effects of flavonoids on hypertension. Since hypertension is a prevalent and strong predicator of the development of CVD, but one with an unclear etiology at times, it is important to understand how we can lower BP through dietary supplementation. 

One key finding is that flavonoids apply their vasorelaxant effects by increasing NO levels through multiple mechanisms. For each of the 6 flavonoids reviewed in the study, they all had similar decreasing BP effects, with a large majority working to increase endothelium-derived nitric oxide (NO), which is critical in regulating BP. 

Different types of flavonoids are found in celery, garlic, chamomile tea, onions, broccoli, other teas, fruits, apples, pears, cocoa, and grape product. Supporting a nutrition plan that includes flavonoid-heavy foods could be beneficial if you are working with a hypertensive patient. The clinical implications are that, due to their anti-hypertensive and vasodilation properties, flavonoids could either be concentrated and given as a supplement or patients could increase dietary intake of these foods (although the efficacy of dietary intake is unclear). 

Worthy to note that although there seems to be potential for clinical use of flavonoids, they also have a very low bioavailability and most are not well absorbed in high does from diet, although repeated intake could have a cumulative effect. Even with this, some of them still have large biological effects which the article contributed to slower elimination or generation of metabolites that are more active. If it is to be concentrated and supplemented, it is also important to understand dosing and drug-drug interaction as high doses could have harmful effects, especially for elderly patients because some have the ability to affect metabolism of other drugs. So, even though they seem to have anti-hypertensive qualities in these studies, it might be more difficult to apply it to a broad based nutritional guideline for food intake or clinical use as a supplement.

For this week, the research paper selected is titled: “Association of Lipid, Inflammatory, and Metabolic Biomarkers with Age at Onset for Incident Coronary Heart Disease in Women” This January 20, 2021 article was published online in the JAMA Cardiology. 2021;6(4):437-447. The authors are Sagar B. Dugani, MD, PhD; M. Vinayaga Moorthy, PhD; Chunying Li, MPH; Olga V. Demler, PhD; Alawi A. Alsheikh-Ali, MD, MSc; Paul M Ridker, MD, MPH; Robert J. Glynn, PhD; Samia Mora, MD, MHS. Their affiliations are Center for Lipid Metabolomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts (Dugani, Moorthy, Li, Demler, Glynn, Mora); Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota (Dugani); Division of Preventive Medicine, Brigham and Women’s -Hospital, Harvard Medical School, Boston, Massachusetts (Moorthy, Li, Demler, Ridker, Glynn, Mora); College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates (Alsheikh-Ali); Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts (Ridker, Mora)

This study is a prospective cohort of US female health professionals participating in the Women’s Health Study. The study median follow-up was 21.4 years. Participants included 28,024 women aged 45 years or older without known cardiovascular disease. Baseline profiles were obtained from April 30, 1993, to January 24, 1996, and analyses were conducted from October 1, 2017, to October 1, 2020.The main outcomes and measures are as follows:  Four age groups were examined (<55, 55 to <65, 65 to <75, and75 years) for coronary heart disease (CHD) onset, and adjusted hazard ratios (aHRs) were calculated using stratified Cox proportional hazard regression models with age as the time scale and adjusting for clinical factors. Women contributed to different age groups over time.

This study is important because the diabetes and insulin resistance, in addition to hypertension, obesity, and smoking, appeared to be the strongest risk factors for premature onset of CHD. Most risk factors had attenuated relative rates at older ages. The lipoproteins and apoproteins except for lipoprotein insulin resistance (LP-IR) showed weaker associations with CHD onset. LP-IR is measured by nuclear magnetic resonance spectroscopy as a weighted score of VLDL, LDL and HDL particle sizes, and their subsets concentrations, and a biomarker for insulin resistance. 

The key findings from this study are of the clinical factors in the women, diabetes had the highest aHR for CHD onset at any age, ranging from 10.71 (95%CI, 5.57-20.60) at CHD onset in those younger than 55 years to 3.47 (95%CI, 2.47-4.87) at CHD onset in those 75 years or older. Risks that were also noted for CHD onset in participants younger than 55 years included metabolic syndrome (aHR, 6.09; 95%CI, 3.60-10.29), hypertension (aHR, 4.58; 95%CI, 2.76-7.60), obesity (aHR, 4.33; 95%CI, 2.31-8.11), and smoking (aHR, 3.92; 95%CI, 2.32-6.63). Myocardial infarction in a parent before age 60 years was associated with 1.5- to 2-fold risk of CHD in participants up to age 75 years. From approximately 50 biomarkers, lipoprotein insulin resistance had the highest standardized aHR: 6.40 (95%CI, 3.14-13.06) for CHD onset in women younger than 55 years, attenuating with age. In comparison, weaker but significant associations with CHD in women younger than 55 years were noted (per SD increment) for low-density lipoprotein cholesterol (aHR, 1.38; 95%CI, 1.10-1.74), non–high-density lipoprotein cholesterol (aHR, 1.67; 95%CI, 1.36-2.04), apolipoprotein B (aHR, 1.89; 95%CI, 1.52-2.35), triglycerides (aHR, 2.14; 95%CI, 1.72-2.67), and inflammatory biomarkers (1.2- to 1.8-fold)—all attenuating with age. (Mora et al., 2021) These findings relate to nutritional sciences because dietary lifestyles strongly correlated with diabetes, metabolic syndrome, hypertension, obesity, and insulin resistance. And these same diseases (metabolic biomarkers) showed the highest hazard ratios for CHD onset. 

Clinical implication of this study is our concern about fats as reflected by lipoproteins and apoproteins should be overshadow by the concern about carbohydrates as reflected by diabetes, insulin resistance, metabolic syndrome, hypertension, and obesity.

Mora, S., Dugani, S. B., Moorthy, M. V., Li, C., Demler, O. v., Alsheikh-Ali, A. A., Ridker, P. M., & Glynn, R. J. (2021). Association of Lipid, Inflammatory, and Metabolic Biomarkers with Age at Onset for Incident Coronary Heart Disease in Women. JAMA Cardiology, 6(4). https://doi.org/10.1001/jamacardio.2020.7073

Posted by Richard Proudfoot

Berge HM, Isern CB, Berge E. Blood pressure and hypertension in athletes: a systematic review. Br J Sports Med. 2015;49(11):716–23.

Niebauer J, Börjesson M, Carre F, et al. Recommendations for participation in competitive sports of athletes with arterial hypertension: a position statement from the sports cardiology section of the European Association of Preventive Cardiology (EAPC). Eur Heart J. 2018;39:3664–

 

The aim of this review of 30 randomized controlled trials (n = 5545 participants) was to assess the effect of the DASH diet compared to a control diet on blood pressure (BP) in adults with and without hypertension (HTN), independent of baseline BP. The participants were 45% male, mean age 51 years, mean BMI of 29.2 kg/m², mean baseline BP 134.3/84.9 mmHg, and mean follow-up period of 15.3 weeks. They tested different variables include age, BMI, controlled feeding, daily sodium intake, energy restriction diet, and duration of the follow-up period.

 

What they found is that the DASH diet was correlated with a significant reduction in BP in adults with and without HTN; however, BP reduction was most significant in participants less than 50 years old. What I found interesting is that greater BP reduction was seen in trials with sodium intake greater than 2400 mg compared to trials with sodium intake less than 2400 mg. This is counterintuitive in my opinion. The authors didn’t go into much detail as to why this would be, they speculated that higher amounts of sodium enhance the BP lowering effect of the DASH diet, as low amounts of sodium reduce the hypotensive effects of potassium. I haven’t heard about this concept before, I had always assumed that the greater the reduction in sodium intake, the more profound effect on BP. There is even a modified DASH diet with a much lower sodium intake goal of 1500 mg.

 

Overall though, this review supports the already established clinical recommendations that lifestyle changes, including the DASH diet, are an integral part of the treatment plan for those aiming to reduce their BP. This reduction is even seen independently of medication. This is important to delay the onset of HTN and to increase the effectiveness of antihypertensive medications.

 

Filippou, C. D., et al. (2020). Dietary Approaches to Stop Hypertension (DASH) Diet and Blood Pressure Reduction in Adults with and without Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Advances in nutrition (Bethesda, Md.), 11(5), 1150–1160.

 

VASDEV, LONGERICH, L., & SINGAL, P. (2002). Nutrition and hypertension: Special Issue Preventive Nutrition. Nutrition Research (New York, N.Y.), 22(1-2), 111–123.

This review is important because it gives us a good insight into the link between the gut microbiome and hypertension. Having a healthy gut microbiota can be met by a healthy diet. However, as seen in this review, consuming an unhealthy high-salt diet can cause disturbance in the microbiome, consequently causing health problems like hypertension.


Naqvi, S., Asar, T. O., Kumar, V., Al-Abbasi, F. A., Alhayyani, S., Kamal, M. A., & Anwar, F. (2021). A cross-talk between gut microbiome, salt and hypertension. Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie, 134, 111156. https://doi.org/10.1016/j.biopha.2020.111156

The paper contends that resistant hypertension should be considered as three overlapping dimensions, resistant physician, resistant patient, and actual resistant hypertension. The authors state that their finding support that 1/3 of primary care practitioners do not provide treatment for high (>90-100) DBP and even more do not treat high (140-160) SBP. Even other studies showed that isolated systolic hypertension was left untreated by most physicians, and that true resistant hypertension could only be truly diagnosed when these other factors are unequivocally ruled out. Their findings outside of patient and physician resistance was hyperaldosteronism, problems with the sympathetic nervous system as it relates to diuretics and the kidneys, and kidney disease. 

At the time of this writing it seems that patient and physician resistance treatment are the biggest precursors to resistant hypertension. 

Doroszko A, Janus A, Szahidewicz-Krupska E, Mazur G, Derkacz A. Resistant Hypertension. Adv Clin Exp Med. 2016 Jan-Feb;25(1):173-83. doi: 10.17219/acem/58998. PMID: 26935512.

The purpose of the article is to examine the relationship of cognitive state in women and menopause and hypertension. This is important as over the past two decades, with advances in knowledge, cardiovascular disease has been observed to occur 10 years later in women in comparison to men and shows a significant increase in prevalence after menopause. This stage is very critical for women, as risk factors such has hypertension, dyslipidemia, obesity, diabetes, among others increase in prevalence after menopause. This is because menopause is associated with a reduction in estradiol and a decrease the estrogen to testosterone ratio. This results in endothelial dysfunction and increases in body weight or type II diabetes, which causes an increase in sympathetic activation, which all contributes to increase in renal vasoconstriction that will cause hypertension. However, an important result from the article was that cognitive impairment was higher in hypertensive menopausal women. This is important to nutritional sciences as nutritional awareness plays a major role in management of chronic diseases such as hypertension. The clinical implication of the article is to help in determining better implementation of programs to improve nutritional awareness, especially lifestyle strategies that would help after menopause, and thereby decrease the incidence of hypertension, which would help improve cognitive function.

Zilberman, J. M., Cerezo, G. H., Del Sueldo, M., Fernandez‐Pérez, C., Martell‐Claros, N., & Vicario, A. (2015). Association between hypertension, menopause, and cognition in women. The Journal of Clinical Hypertension, 17(12), 970-976.

“Beating Hypertension- the ‘Silent Killer.’” Tufts University health & nutrition letter 37.3 (2019): 4–5. Print.

This study tells us that maintaining health weight is a major factor in preventing hypertension.  Diet and exercise not only reduce weight but also contribute benefits to blood pressure for those not trying to lose weight.

 

This study has not yet published its data as it is still currently recruiting as of last summer. I chose this article because it shows a great example of active work being done in the field and how to think outside of the box. This study is important as it relates to nutritional sciences because curing CVD through diet and creating buy in will save many lives around the world. This study will present data for the first time on the combination use of both pre- and post-biotics to lower BP in humans.


Rhys-Jones, D., Climie, R. E., Gill, P. A., Jama, H. A., Head, G. A., Gibson, P. R., Kaye, D. M., Muir, J. G., & Marques, F. Z. (2021). Microbial Interventions to Control and Reduce Blood Pressure in Australia (MICRoBIA): rationale and design of a double-blinded randomised cross-over placebo controlled trial. Trials, 22(1), 496. https://doi.org/10.1186/s13063-021-05468-2