Effects of salt restriction counseling on primary hypertension patients already receiving pharmacotherapy; A Randomized controlled trial

Yıl 2019, Cilt: 13 Sayı: 4, 514 - 522, 20.12.2019

Ayşe Akay

https://doi.org/10.21763/tjfmpc.527288

Öz

Background and aim: Providing a healthy lifestyle is
the first stage of controlling hypertension, which is an important public health problem. However,
lifestyle modification targets can only be achieved among limited patients. As
a result, expected benefits from those modifications remain limited. In this
research, we aimed to verify the additional
gains from salt restriction counseling on blood pressure control among primary
hypertensive patients already receiving pharmacotherapy.Materials and
methods: Primary hypertension patients under a stable medical treatment
were randomly assigned to a salt restriction group and a control group. All
participants completed a questionnaire of demographic data, medical history,
and diet. Twenty-four-hours ambulatory blood pressure measurements were
recorded at the beginning and at the end of 3 months. Personalized education
and counseling were performed only to the salt restriction group. Patients were
followed up with phone calls. Effects of salt restriction were evaluated with
sodium excretion on 24-hour urine.Results: Total 172 patients enrolled
in the study; 86 patients were in salt restriction group and 86 patients were
in control group. The patients’ 71,5% (123) were women, 28,5% (49) were men.
The mean age of participants was 56,8±5,9 years. Urinary sodium excretion increased 1.8±5.2
g/day in the control group (Z=3,120; p=0,002) but decreased 1,0±4,9 g/day in the study group (Z=1,983; p=0,047). Ambulatory
systolic and diastolic blood pressures increased 3.2±9.3/2.3±6.9 mm Hg in the
control group (Z=3,165; p=0,002/Z=2,956; p=0,003), whereas they decreased
6.1±9.4/4.7±7.8 mm Hg in the salt restriction group (Z=5,137;
p<0,001/Z=4,993; p<0,001).Conclusion:
Our study indicates that salt restriction counseling significantly contributed
to blood pressure control also in primary hypertension patients already
receiving pharmacotherapy. Lifestyle modification proves to be an effective
treatment in patients who receive regular medical treatment.

Amaç: Önemli bir toplum sağlığı sorunu olan hipertansiyonun kontrolünde birinci
aşama, hastalarda sağlıklı yaşam tarzının sağlanmasıdır. Uygulamada tedavi
hedeflerine kısıtlı bir hasta grubunda ulaşılabilmekte, yaşam tarzı
değişiklikleri ve bunlardan beklenen yarar eksik kalmaktadır. Bu araştırmada
tıbbi tedavi altındaki primer hipertansiyon hastalarında mevcut tedavilerine
eklenecek tuz kısıtlaması danışmanlığı ile elde edilecek ek yararı belirlemek
amaçlanmıştır.Gereç-yöntem: Randomize, kontrollü desendeki çalışmaya
sabit tedavi altındaki primer hipertansiyon hastaları dâhil edildiler. Hastalar
tuz kısıtlaması ve kontrol gruplarına ayrıldılar. Tüm katılımcılara demografik
bilgileri, tıbbi öykü ayrıntıları, beslenme alışkanlıklarını sorgulayan bir
anket uygulandı. Çalışma başlangıcında ve 3 aylık çalışma süresi sonunda Holter
ile 24 saatlik ambulatuar kan basıncı ölçümü yapıldı. Tuz kısıtlaması konusunda
bireyselleştirilmiş danışmanlık görüşmesi yapıldı. Kontrol grubuna görüşme
planı verildi. Çalışma grubu hastalarının önerilere uyumu telefon görüşmeleri
ile izlendi. Tuz kısıtlaması danışmanlığının etkisi 24 saatlik idrarda
hesaplanan sodyum atılımı ile izlendi.Bulgular: Araştırmaya dahil olan toplam 172 katılımcının %71,5’i (123) kadın,
%28,5’i (49) erkek, yaş ortalamaları 56,8±5,9 yıl idi.Çalışma, tuz kısıtlaması grubunda 86 ve
kontrol grubunda 86 hipertansiyon hastası ile sonuçlandırıldı. Çalışmamızın
sonuçlarına göre üriner sodyum atılımı kontrol grubunda 1,8±5,2 gr/gün artarken
(Z=3,120; p=0,002), tuz kısıtlaması grubunda 1,0±4,9 gr/gün azaldı (Z=1,983;
p=0,047). Ambulatuar sistolik ve diyastolik kan basıncı ölçümleri kontrol
grubunda 3,2±9,3 mm Hg (Z=3,165; p=0,002) /2,3±6,9 mm Hg artarken (Z=2,956;
p=0,003), tuz kısıtlaması grubunda 6,1±9,4 mm Hg (Z=5,137; p<0,001) /4,7±7,8
mm Hg düştü (Z=4,993; p<0,001).Sonuçlar: Çalışma sonuçlarımız, halen
tedavi altında olan hipertansiyon hastalarında da tuz kısıtlaması danışmanlığı
verilmesinin daha iyi kan basıncı kontrolü sağlanmasına katkı yapmakta olduğunu
gösterdi. Yaşam tarzı değişiklikleri hipertansiyon hastalarının sabit ilaç
tedavi protokollerine geçildikten sonra da etkin tedavi özelliğini
sürdürmektedir.

Anahtar Kelimeler

ambulatory blood pressure measurements, hypertension, primary care settings, life style change, salt restriction

Kaynakça

• 1. Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, et al. Global disparities of hypertension prevalence and control. A Systematic Analysis of Population-based Studies from 90 Countries. Circulation 2016; 134(6): 441–450.
• 2. Gu Q, Dillon CF, Burt VL, Gillum, RF. Association of hypertension treatment and control with all-cause and cardiovascular disease mortality among US adults with hypertension. American journal of hypertension 2010; 23(1): 38-45.
• 3. Cushman WC, Ford CE, Cutler JA, Margolis KL, Davis BR, Grimm RH, et al. Success and predictors of blood pressure control in diverse North American settings: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). J Clin Hypertens 2002; 4:393-404.
• 4. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289: 2560-2572.
• 5. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction. The American Heart Association’s Strategic Impact Goal through 2020 and beyond. Circulation 2010; 121: 586–613.
• 6. James PA, Oparil S, Carter LB, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311(5): 507-520.
• 7. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360: 1903-1913.
• 8. Karanja NM, Obarzanek E, Lin PH, McCullough ML, Phillips KM, Swain JF, et al. Descriptive characteristics of the dietary patterns used in the Dietary Approaches to Stop Hypertension Trial. DASH Collaborative Research Group. J Am Diet Assoc 1999; 99: 19-27.
• 9. Erdem Y, Arici M, Altun B, Turgan C, Sindel S, Erbay B, et al. The relationship between hypertension and salt intake in Turkish population: SALTURK study. Blood Press 2010; 19: 313-318.
• 10. Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, et al. Task Force for the Management of Arterial Hypertension of the European Society of Hypertension and the European Society of Cardiology. 2013 ESH/ESC Practice Guidelines for the Management of Arterial Hypertension. Blood Press 2013; 23: 3-16.
• 11. Subramanian H, Soudarssanane MB, Jayalakshmy R, Thiruselvakumar D, Navasakthi D, Sahai A, et al. Non-pharmacological interventions in hypertension: a community-based cross-over randomized controlled trial. Indian J Community Med 2011; 36(3): 191-196.
• 12. Naseem S, Ghazanfar H, Assad S, Ghazanfar A. Role of sodium-restricted dietary approaches to control blood pressure in Pakistani hypertensive population. J Pak Med Assoc 2016; 66(7): 837-842.
• 13. Strom BL, Yaktine AL, Oria M. Editors Committee on the Consequences of Sodium Reduction in Populations; Food and Nutrition Board; Board on Population Health and Public Health Practice; Institute of Medicine; Brief Report, 2013.
• 14. Whelton PK, Appel LJ, Sacco RL, Anderson CA, Antman EM, Campbell N, et al. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Circulation 2012; 11: 2880-2889.
• 15. Vollmer WM, Sacks FM, Ard J, Appel LJ, Bray GA, Simons-Morton DG, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001; 344: 3-10.
• 16. Trieu K, McMahon E, Santos JA, Bauman A, Jolly KA, Bolam B, et al. Review of behaviour change interventions to reduce population salt intake. International Journal of Behavioral Nutrition and Physical Activity 2017; 14(1): 17.
• 17. Friedberg JP, Rodriguez MA, Watsula ME, Lin I, Wylie-Rosett J, Allegrante JP, et al. Effectiveness of a tailored behavioral intervention to improve hypertension control novelty and significance: primary outcomes of a randomized controlled trial. Hypertension 2015; 65(2): 440-446.
• 18. Appel LJ, Champagne CM, Harsha DW, Cooper LS, Obarzanek E, Elmer PJ, et al. Effects of comprehensive life style modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003; 289(16): 2083-2093.
• 19. Ambrosius WT, Sink KM, Foy CG, Berlowitz DR, Cheung AK, Cushman WC, et al. The design and rationale of a multi-center clinical trial comparing two strategies for control of systolic blood pressure: The Systolic Blood Pressure Intervention Trial (SPRINT). Clinical Trials 2014; 11(5): 532–546.
• 20. Shima R, Farizah MH, Majid HA. A qualitative study on hypertensive care behaviour in primary health care settings in Malaysia. Patient Prefer Adherence 2014; 17: 1597-1609.
• 21. Ruzicka M, Ramsay T, Bugeja A, Edwards C, Fodor G, Kirby A, et al. Does pragmatically structured outpatient dietary counselling reduce sodium intake in hypertensive patients? Study protocol for a randomized controlled trial. Trials 2015; 16:273.