Latin America must cut blood pressure to thrive

Therapeutic Advances in Cardiovascular Disease paper published today by SAGE

Los Angeles, London, New Delhi, Singapore and Washington DC , 27 june 2009– Combating high blood pressure is a global challenge. But while developed countries have enjoyed reductions in cardiovascular disease over recent decades, Latin America has been less fortunate. In fact new research published in the journal Therapeutic Advances in Cardiovascular Disease shows that high blood pressure is on the increase in many Latin American countries, a situation set to worsen unless immediate action is taken.

Adolfo Rubinstein from Hospital Italiano de Buenos Aires, Luis Alcocer from Universidad Nacional Autónoma de México and Hospital General de México, and Antonio Chagas from University of São Paulo Medical School Heart Institute have detailed the evidence in their article High blood pressure in Latin America: a call to action, and offer specific recommendations to remedy the situation.

Despite major healthcare problems in terms of equity and efficiency in the majority of Latin American countries, the overall health indicators of Latin America's population have been on an upward trend over the last 50 years, a trend that continues today.

Yet as life expectancy increases the most common health issues are shifting from dealing with acute disease to more expensive and complex chronic diseases. The chronic disease scenario is already common in developed countries, evidenced by the fact that cardiovascular disease makes up 11% of the global disease burden, leading to some 17.7 million deaths each year. Rapidly developing nations, like many in Latin America, still have a relatively high burden of infectious and communicable disease. The added increase in cardiovascular disease means these countries shoulder a 'double burden' of disease. In fact experts have noted that middle- and low-income regions have a five-fold greater disease burden, but have access to less than one tenth of global treatment resources.

Increasing rates of hypertension and chronic diseases, coupled with expected increases in population growth, then, present a mounting threat to Latin American economies.

"These dismal observations warrant a call to action for improved control of high BP and other cardiovascular risk factors across Latin America," says Alcocer. "Achieving these ambitious goals will require collaborative efforts by many groups, including policymakers, international organizations, healthcare providers, schools and society as a whole."

The report provides a comprehensive overview of the burden of high blood pressure across Latin America, but "it alone cannot bring about change," say the authors. Accepting and instituting core policy changes are key to galvanize action, and results.

In terms of core policy, regional policy makers must be alerted to the benefits of high blood pressure detection and control and make this a major public health priority. Leaders must provide resources to empower and train health professionals to detect, diagnose, treat and control high blood pressure, and these must include effective drugs and interventions. It is vital to launch high blood pressure detection and management campaigns. Education and awareness promotion is another critical step, and must include healthy lifestyle advice, and explain the links to risk factors such as smoking and obesity.

In treatment terms, policy makers must encourage therapeutic drug use based on clinical- and cost-effectiveness, acceptability, and affordability for Latin American countries. Healthcare professionals must manage high blood pressure in the context of other cardiovascular risk factors, and work to ensure treatment compliance and adherence.

Government officials and others bearing the cost must be sold the benefits of campaigns to prevent, identify and treat hypertension. The authors also recommend more research, specifically studies that include Latin American patients in large, long-term, clinical-outcome and epidemiological studies to improve clinical outcomes in specific regional context. This research needs support in the form of funding, including patient-oriented acceptance and compliance issues within the Latin American context.

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High blood pressure in Latin America: a call to action by Adolfo Rubinstein, Luis Alcocer and Antonio Chagas is published online today in Therapeutic Advances in Cardiovascular Disease, published by SAGE.

The article will be free to access online for a limited period from http://tak.sagepub.com/.

Dark Chocolate a Comfort to Early Blood Pressure

COLOGNE, Germany, July 3 -- Dark chocolate may have a small blood-pressure-lowering benefit for early hypertension that is equivalent to other non-pharmaceutical interventions.So found investigators here who compared the purported blood pressure benefits of white and dark chocolate in a small study. White chocolate was a washout, but dark chocolate was not, with blood pressure apparently lowered by enhancing dilation of blood vessels.
One such intervention that dark chocolate matched is the DASH (Dietary Approaches to Stop Hypertension) diet plan, which has been proven to lower blood pressure, reduce cholesterol, and improve insulin sensitivity, reported Dirk Taubert, M.D, Ph.D., and colleagues, of University Hospital of Cologne, in the July 4 issue of the Journal of the American Medical Association
Among adults with pre-hypertension or stage 1 high blood pressure who consumed dark or white chocolate daily for 18 weeks, those who consumed the dark had significantly lower systolic and diastolic pressures.
They found that at 18 weeks, patients who ate the dark chocolate had a mean reduction in systolic blood pressure of −2.9 + 1.6 mm Hg (P<0.001) and a mean drop in diastolic of −1.9 + 1.0 mm Hg (P<0.001).
The 24 women and 20 men, ages 56 to 73, ate 6.3 g (30 kcal) per day of dark chocolate containing 30 mg of polyphenols, or matching polyphenol-free white chocolate (white chocolate is made from cocoa butter, the natural fat of the cacao bean, but unlike dark chocolate does not contain either chocolate liquor or cocoa solids).
The blood pressure drop was not accompanied by changes in either body weight, or in plasma levels of lipids, glucose, or 8-isoprostane.
Among the dark chocolate eaters, the prevalence of hypertension also declined from 86% to 68%.
Although the overall pressure reduction was modest, even small improvements may yield significant clinical benefits, the authors wrote. "On a population basis, it has been estimated that a 3-mm Hg reduction in systolic BP would reduce the relative risk of stroke mortality by 8%, of coronary artery disease mortality by 5%, and of all-cause mortality by 4%," they said.
Dark chocolate, the investigators said, appeared to work through flavonols in cocoa and their promotion of production of nitric oxide in the vascular endothelium, resulting in smooth muscle relaxation and vasodilation.
The effect is not unlike that of sildenafil (Viagra) or the other inhibitors of phosphodiesterase-5, which also cause relaxation of smooth muscle in the vascular endothelium.
The news is certainly good for chocolate lovers who worry about their blood pressure, but it doesn't warrant a change in clinical practice just yet, cautioned Alice H. Lichtenstein, D.Sc., a professor at Tuft University's Friedman School of Nutrition Science and Policy in Boston, who was not involved in the study.
"The differences themselves, on average, were quite modest," said Dr. Lichtenstein in an interview. "I think if somebody was treating somebody for hypertension, the degree of lowering that was achieved probably wouldn't be quite enough for adequate treatment. I think it's really more useful as far as demonstrating that there seems to be something there, and we have to figure out exactly what the compound is."
In short-term studies, high-dose cocoa consumption (more than 100 g/day), has been shown to improve endothelial function and reduce blood pressure from the effects of polyphenols -- specifically, flavonols, the authors noted.
But whether more modest, long-term consumption of cocoa, in the form of chocolate, would also have a beneficial effect on blood pressure was unclear, the authors said.
So they consigned to eat either dark chocolate or white chocolate for 18 weeks. The patients all had either prehypertension, defined as BP from 130/85 mm Hg to 139/89 mm Hg, or stage 1 hypertension, defined as a pressure from 140/90 mm Hg to 160/100 mm Hg
The main outcome measure was the change in BP after 18 weeks. Secondary endpoints included changes in plasma markers of vasodilative nitric oxide (S-nitrosoglutathione) and oxidative stress (8-isoprostane), and bioavailability of cocoa polyphenols.
Evidence for a beneficial effect on vascular endothelial function came from the fact that the drop in blood pressure was accompanied by a sustained increase of S-nitrosoglutathione by 0.23 + 0.12 nmol/L (P<0.001), and by the appearance of cocoa phenols in plasma after patients ate their daily dark chocolate ration.
In contrast, the patients who ate white chocolate bereft of polyphenols had no change in either blood pressure or in plasma biomarkers, the authors noted.
"The most intriguing finding of this study is that small amounts of commercial cocoa confectionary convey a similar blood presure-lowering potential compared with comprehensive dietary modifications that have proven efficacy to reduce cardiovascular event rate," they added.
"Whereas long-term adherence to complex behavioral changes is often low and requires continuous counseling," they continued, "adoption of small amounts of flavanol-rich cocoa into the habitual diet is a dietary modification that is easy to adhere to and therefore may be a promising behavioral approach to lower blood pressure in individuals with above-optimal blood pressure."
They acknowledged that the study was limited by its small sample size, homogenous population, lack of blinding to chocolate type, and the inability to isolate which cocoa phenols or metabolites may have accounted for the blood-pressure lowering effect.
The study was funded by the University Hospital of Cologne. The authors declared that they had no conflicting interests. Primary source: Journal of the American Medical AssociationSource reference: Taubert D et al. "Effects of Low Habitual Cocoa Intake on Blood Pressure and Bioactive Nitric Oxide: A Randomized Controlled Trial."
JAMA. 2007;298(1):49-60

Study: Chocolate reduces blood pressure

By LINDSEY TANNER, AP Medical WriterTue Jul 3, 7:14 PM ET
Here's some good and bad news for chocoholics: Dark chocolate seems to lower blood pressure, but it requires an amount less than two Hershey's Kisses to do it, a small study suggests. The new research from Germany adds to mounting evidence linking dark chocolate with health benefits, but it's the first to suggest that just a tiny amount may suffice.
Volunteers for the study ate just over 6 grams of dark chocolate daily for almost five months — one square from a German chocolate bar called Ritter Sport, equal to about 1 1/2 Hershey's Kisses. People who ate that amount ended up with lower blood pressure readings than those who ate white chocolate.
University of Cologne researcher Dr. Dirk Taubert, the study's lead author, said the blood pressure reductions with dark chocolate were small but still substantial enough to potentially reduce cardiovascular disease risks, although study volunteers weren't followed long enough to measure that effect.
The research involved just 44 people aged 56 through 73, but the results echo other small studies of cocoa-containing foods. Cocoa contains flavanols, plant-based compounds that also are credited with giving red wine its heart-healthy benefits.
One problem is chocolate bars containing cocoa tend to have lots of calories, so Taubert and his colleagues tested small amounts containing just 30 calories each.
The study appears in Wednesday's Journal of the American Medical Association. It was funded by University Hospital in Cologne.
The results are interesting but need to be duplicated in larger, more ethnically diverse populations, said Dr. Laura Svetkey, director of Duke University's Hypertension Center.
She stressed that the study results should not be viewed as license to gorge on chocolate.
"I would be as happy as the next person if I got to eat more chocolate," she said, but cautioned that weight gain from eating large amounts of dark chocolate would counteract any benefits on blood pressure.
Study participants were otherwise healthy and mostly normal-weight German adults with mild high blood pressure or pre-hypertension, which includes readings between 120 over 80 and 139 over 89.
Average blood pressure at the start was about 147 over 86.
Every day for 18 weeks, the volunteers were instructed to eat one-square portions of a 16-square Ritter Sport bar, or a similar portion of white chocolate. White chocolate doesn't contain cocoa.
Systolic blood pressure, the top number, fell an average of nearly three points and diastolic dropped almost two points in the dark chocolate group, compared with no change in blood pressure readings in the white chocolate group.
Tests suggested that steady exposure to dark chocolate prompted chemical changes that helped dilate blood vessels and regulate blood pressure, the researchers said.
Participants were told not to eat other cocoa-containing products and to continue regular eating habits and activity levels. They also kept food diaries so researchers could see if other foods might have influenced the results.
But, said Taubert, "It is very unlikely that other factors may explain the blood pressure reduction."
Dr. Lawrence Appel of Johns Hopkins School of Medicine said the most proven non-drug methods for lowering blood pressure are losing weight and eating less salt. Eating dark chocolate might help if combined with those two, he said.
For most people, "the lower your blood pressure, the better you are. So if you can get it lower from different strategies that's good for the long term," Appel said,
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JAMA: http://jama.ama-assn.org

Soy Nuts Lower Blood Pressure in Postmenopausal Women

Soy nuts may help lower blood pressure in postmenopausal women, a new U.S. study finds.
Researchers at Beth Israel Deaconess Medical Center in Boston studied 60 healthy women -- 12 with high blood pressure (140/90 milligrams of mercury or higher) and 48 with normal blood pressure. All the women ate two kinds of diets for eight weeks each.
One was the Therapeutic Lifestyle Changes (TLC) diet, which consisted of 30 percent of calories from fat (with 7 percent or less from saturated fat), 15 percent from protein, and 55 percent from carbohydrates, 1,200 milligrams of calcium per day, two meals of fatty fish (such as salmon or tuna) per week, and less than 200 milligrams of cholesterol a day.
The other diet had the same calorie, fat and protein content, but the women replaced 25 grams of protein intake with one-half cup of unsalted soy nuts.
"Soy nut supplementation significantly reduced systolic (top number) and diastolic (bottom number) blood pressure in all 12 hypertensive women and in 40 of the 48 normotensive women," the study authors wrote.
"Compared with the TLC diet alone, the TLC diet plus soy nuts lowered systolic and diastolic blood pressure 9.9 percent and 6.8 percent, respectively, in hypertensive women, and 5.2 percent and 2.9 percent, respectively, in normotensive women."
In women with high blood pressure, the soy nuts also decreased levels of low-density lipoprotein ("bad") cholesterol by an average of 11 percent and levels of apoliprotein B (a particle that carries bad cholesterol) by an average of 8 percent.
The study was published in the May 28 issue of the journal Archives of Internal Medicine.
-- Robert Preidt
SOURCE: JAMA/Archives journals, news release, May 28, 2007

ASH: Dual-drug Treatment Accomplishes Blood Pressure Control

CHICAGO -- Initiating treatment with a combination of anti-hypertensive drugs gets 75% of patients' blood pressures under control, researchers reported here.
They said that a strategy of startling anti-hypertensive treatment with a combination drug paid off with an "unprecedented" percentage of high risk patients achieving their therapy goal.
The preliminary unblinded analysis of the Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial revealed that among the 9,698 patients who have been followed for 18 months, the average systolic blood pressure was 131.8 mm Hg, down from a starting point of 145.4 mm Hg.
"These are unprecedented figures," emphasized Kenneth Jamerson, M.D., of the University of Michigan in Ann Arbor, at the American Society of Hypertension meeting. "Only about 37% of Americans who are taking high blood pressure medication are achieving their treatment goals.
"We find substantial evidence to broaden the use of combination therapy as an initial strategy for the treatment of hypertension," Dr. Jamerson said.
In the trial, Dr. Jamerson and colleagues enrolled more than 11,400 patients who were being treated for high blood pressure and had at least one cardiovascular risk factor that made the population high risk for events.
The patients were told to stop whatever medication they were on and to begin taking a combination dose of either amlodipine combined with benazepril or amlodipine combined with hydrochlorothiazide. Amlodipine is a calcium channel blocker; benazepril is an angiotensin converting enzyme- inhibitor, and hydrochlorothiazide is a diuretic.
"There was no washout period in this trial," Dr. Jamerson said.
The study was designed to determine whether there is a different in long-term outcomes depending on which drug combination is used, but Dr. Jamerson said the preliminary data he was discussing shows that it is feasible to get patients' blood pressure under control with aggressive dosing of the combinations.
The primary endpoint in the study was the time to first event of a composite of cardiovascular morbidity and mortality - including death due to any cardiovascular event and non-fatal events, hospitalization for angina, resuscitation from sudden cardiac death and the need for a coronary revascularization procedure.
At the start of the trial, 37.5% of these high-risk patients were at their treatment goal, and overall 76% attained treatment goal after 18 months of therapy. About 65% of the 3,333 patients from Nordic countries reached the treatment goals, while at baseline 21% were at goal.
Of the 8,067 U.S. participants, 44% were at their goal to start the program, but at 18 months after treatment 80.5% were at their high blood pressure goals. About 71.8% of African American patients reached their goals, although only 38.7% were at goal at the start of the therapy.
Dr. Jamerson said that the overall U/S. cohort was able to lower their systolic blood pressure to 129 mmHg "one of the lowest figures ever achieved in large scale clinical trials."
"The preliminary results of the ACCOMPLISH trial do indicate that combination therapy is what we need to get patients to treatment goals," commented Joseph Izzo Jr., of the State University of New York at Buffalo.
He said that when patients are treated with monotherapy drugs there can be considerable differences between individuals in how they will respond. "When you add a second drug, it basically obliterates that difference, Dr. Izzo said. "Not only is the treatment for effective that with one drug, the therapy outcome is more predictable."
He said there will always be a need to check how patients are doing individually but he suggested the fixed dose combinations will get more people to their goals and do it more easily.
He also said that taking fewer pills to achieve the goal also resonates with the patient. "We need to get the pills in the patient before they can do any good," he said.
Dr. Jamerson said the final results of ACCOMPLISH are not expected for another 12 to 13 months.

Blood Pressure Keeps Even Keel With Daily Chocolate

COLOGNE, Germany, April 11 -- Chocolate, the ultimate comfort food, has won another health vote of confidence. Tea -- black or green -- did not.Rationally applied, daily chocolate may contribute to normal blood pressure on a par with beta-blocker or ACE inhibitor monotherapy, according to a meta-analysis by Dirk Taubert, M.D., Ph.D., of University Hospital here, and colleagues.
Daily intake of chocolate improved systolic blood pressure 4.7 mm Hg and diastolic 2.8 mm Hg compared with controls, they reported in the April 9 issue of the Archives of Internal Medicine.
However, the meta-analysis of 10 short-term randomized trials looking at two antioxidant polyphenol flavonoid-rich foods-tea and cocoa products-revealed no significant blood pressure benefit from black or green tea, they reported in the April 9 issue of the Archives of Internal Medicine. All but one of the cocoa studies involved dark chocolate and one included milk chocolate.
Dark chocolate has been shown in previous studies to improve vascular function among hypertensive patients and many other populations.
At the population level, the improvements seen with chocolate "would be expected to substantially reduce the risk of stroke (by about 20%), coronary heart disease (by 10%), and all-cause mortality (by 8%)," Dr. Taubert and colleagues wrote.
http://www.medpagetoday.com/PrimaryCare/DietNutrition/tb1/5416