Scand J SOCMed, Vol. 19, No. 1
The effect of a weight reduction program on cardiovascular risk factors among overweight hypertensives in primary health care Laura Jalkanen Department of Clitiicnl Nutrition, University of Kiiopio, Kiropio, Finland
The effect of a weight redirctioti progrnm on cnrdiovasciilar risk foctors among overiceight hyperterzsir.es in primary health care (Department of Clinical Nutrition, University of Kuopio). Scarid J SOCMed 1991, 19 (66-71). The aim of the study was to test the effect of a nonpharmacological weight reduction program on cardiovascular risk factors among ovenveight hypertensives in a primary health care setting. Forty-nine ovenveight hypertensive patients completed the 12-month program. The patients were randomly allocated into either intervention or control groups. The examinations included interviews by a nutritionist, pertinent laboratory tests, and a medical examination. The intervention involved an individually planned energy-restricted diet of 1000-15M) kcal per day, weekly discussions, and various leaflets on diet modification and on increase of physical activity. The mean body weight was reduced by 5 kg in the intervention group, but remained unchanged in the control group. The intervention group reduced their fat intake by 14 @day while the control group increased it by 9 @day on the average. In the intervention group, the total serum cholesterol decreased, HDL-cholesterol increased and triglycerides decreased significantly. The systolic blood pressure fell by 8 mm Hg and 15 mm Hg in the intervention and control groups, respectively. The diastolic blood pressure fell on average by 11 mm Hg in both groups. The results demonstrate the comprehensive weight reduction program to be effective in the control of cardiovascular risk factors. Key words: hypertension, overweight, risk factors, weight reduction.
INTRODUCTION In many countries where cardiovascular diseases (CVD) are common, several studies have been conducted to find effective methods for their prevention and treatment. Of particular importance have been methods used to reduce elevated blood pressure and elevated serum cholesterol levels. The methods have comm.only been pharmacological, but non-pharmacological methods have also been introduced increasingly (1-3). In the prevention of CVD, non-pharmacological methods have routinely been accepted (3-6), and most efforts concern different dietary
modifications. Weight reduction has been shown to be beneficial for people with hypertension since it decreases the blood pressure significantly (7-12). Weight reduction has also lowered high serum cholesterol and triglycerides (4, 9, 13-16). The positive increase in HDL-cholesterol has been suggested to be a consequence of reduced weight among obese persons (15, 17, 18). Dietary modifications such as reduction of total fats or replacement of saturated fats with mono- and polyunsaturated fats have been documented in several studies to lo&er blood lipids and blood pressure (19-21). Many studies have been aimed at showing that reduced salt intake lowers blood pressure, which was found by Chapman & Gibbons-in late .193O's. In controlled studies, only few hypertensives have been shown to benefit from a moderate reduction of salt intake (7, 8, 20, 22, 23). In Finland, especially in the eastern part, in the province of North Karelia, the prevalence rates of hypertension and elevated serum lipids are high. According to the survey made in 1982, the mean level of systolic blood pressure was 145 mm Hg, the mean level of diastolic blood pressure 87 mm Hg, and the mean level of serum cholesterol 6.3 pmoUI
(25).
The purpose of this study was to test a comprehensive but practical intervention program aimed for general use in the non-pharmacological treatment of cardiovascular risk factors, especially. overweight, hypertension and high serum lipids, in a primary health care setting. MATERIALS AND METHODS Recriiitrnent Nurses in two hypertension clinics of the towns of Joensuu and Lieksa in the county of North Karelia selected, from their files, two groups of subjects who met the study criteria. The subjects were 35-59 years old, their diastolic blood pressure was 95 mm Hg or more, their body mass index 27-34 kp/m2. and they were motivated and volunteered. In the beginning of the study, there were 25 persons with
Scand J Soc hled 19
Downloaded from sjp.sagepub.com at GEORGE MASON UNIV on March 19, 2015
Weight reduction progmtn
67
Table I. The intervention program atid the progratti for the control groirp in the stirdy for the treattiietit of cardiovascirlar risk factors. Weeks
1.
2. 3.
4. 5.
6. 7. 8.
9.
10. 11. 12.
13.
14. 15.
16.
17. 1s. 19. 20. 21. 22. 23. 24. 35.
38.
41. 44. 47.
50. 52.
Theme of the meeting
Intervention group
Control group
Info, laboratory, doctor’s consultation, nutritionist’s interview, RR Lecture on cardiovascular risk factors (doctor) Lecture on nutritional risk factors in CVD (nutritionist) Lecture on physical activity in the treatment of CVD (physiotherapist), R R Lecture on the selection of foods (nutritionist) Break for winter holiday Lecture on behavior modification in the weight reduction (psychologist) Lecture on low fat cooking (nutritionist) Individual meeting with nutritionist Nurse’s consultation, RR Physical excercise with the physiotherapist, RR Lecture on eating in social events etc. (nutritionist) Break for Easter Lecture on food selection (nutritionist) Lecture on behavior modification in the tveight reduction (psychologist) Lccture on medical aspects in overweight (doctor) Laboratory, RR Physical excercise with the physiotherapist Lecture on low salt, low sugar cooking (nutritionist) Lccturc on eating in restaurants, cafeterias etc. (nutritionist) Lecture on behavior modification in weight reduction (psychologist) Lecture on different physical excercise for vacation (physiotherapist) Lecture on low fat bakery (nutritionist) Doctor’s advices for the summer vacation Physical excercise with the physiotherapist Nutritionist’s advices for the summer vacation Summer vacation Lecture on the medical aspects of weight controlling (doctor), RR Nurse’s consultation, RR Lecture on food selection in weight controlling (nutritionist) Lecture on physical excercise in the weight controlling (physiotherapist) Lecture on behavior modification in weight controlling (psychologist) Lecture on low fat, low sugar cooking in weight controlling (nutritionist) Lecture on food selection for Christmas (nutritionist) Laboratory, RR, Christmas party
RR = blood pressure measurements. anti-hypertensive drug treatment and 25 persons without any drug treatment. The subjects were randomised to the active intervention program and normal follow-up program as controls for the intervention group. In‘both programs, there were as many men as women. The number of drugtreated and non-drug treated persons was identical in both clinics. The drugs used in the treatment were diuretics and fi-blockers. The duration of the medication was less than 5 years at the beginning of the study. Sri bjects
Altogether 49 subjects of the average age of 49 years completed the 12-month weight reduction program. There were 9 subjects in both the intervention and the control groups with drug treatment for hypertension, and 13 subjects in the intervention and 11 subjects in the control groups without any medication, for whom all the laboratory analyses
could be made. For statistical analysis, the data of the two towns were pooled together. The final analysis refers to the situation at the beginning and end of the study and to subjects that completed the study procedures. Smdy program At the beginning of the study, before randomising the people to the intervention and control groups, the study population was invited to an information event where both programs were explained to them. Those who would be randomised to the control group were offered to participate in the intervention program after the study period. The intervention ’ program consisted of an individually planned energy-restricted diet of 1000-1500 kcal per day, weekly (after six months, every three weeks) sessions, where there were discussions and lessons on behavioral modification, choice of food, physical exercise, and medScand J Soc hfed 19
5‘
Downloaded from sjp.sagepub.com at GEORGE MASON UNIV on March 19, 2015
6%
L. Jalknnen
Table 11. The means of tlte body weiglit, and systolic and diastolic blood presstires at the beginning and at the end of a 12-niontlt intervention program. Intervention group Control group n = 25 R SD R SD
n = 24
Weight I kg I1 Systolic blood I Pressure II mm Hg Diastolic blood I Pressure I1 mm Ilg * p < 0.05. * * p < 0.01. I at the bcgining.
8 0 f 11 8 0 f 11
86 f 14 82 f 13** 152 f 17 143 f 20'
nurses. Both groups kept three times 2-3 days food records throughout the study. They got scales for weighing their food. The data of food consumption analysis included total energy, fats, carbohydrates and proteins processed using Finnish food composition tables. The significance of differences of means in the groups and between the groups was tested by Student's i-test. Pearsons's product-moment correlation coefficient was calculated for testing the strength of the relationship between the change of weight and systolic and diastolic blood pressure.
155 f 14 140 zk 16**
RESULTS Weight rediictiott
.
101 f 8 90 f 10"
102 f 1 91 f 1"
11 at the end.
R mean.
SD standard deviation.
ical aspects of overweight and weight reduction. Every session took about 1.5 hour; thus the total number of lectures was about 40 hrs. The subjects also received leaflets on the reduction of salt and fat consumption and on the increase of physical activity. The programs are detailed in Table I. The control group only had their normal visits every three months to the nurses, but no personal counceling or advice. Both the intervention and follow-up of the control group took 12 months. After the intervention period the study group moved to the normal hypertension follow-up program with visits to the nurses every three months. The nurses also recorded the changes in 'weight and tried to advise the patients on how to avoid relapse. The control group started the intervention program when the intervention group had completed it. The doctors of the subjects \yere asked to keep the dosage of antihypertensive drugs at the initial level. hfeasurernenrs The examinations included an interview by a nutritionist, pertinent laboratory tests, and a medical examination. The laboratory tests included blood samples taken three times from fasting subjects to be analysed for total serum cholesterol, UDL-cholesterol and triglycerides using an AutoAnalyzer I1 apparatus (Technican Instruments, Tarrytown. NY) in the laboratory of the National Public Health Institute, The blood pressure of each subject was measured at the local clinic by a trained nurse using an automated recorder (Infrasonde SR-2, Sphygmetrics, he.). Blood pressure readings were obtained on the right arm after the subject had been sitting quietly for five minutes. The mean of the two readings was used for further analysis. The subjects collected three 24-hour urine samples in order t o determine salt intake and sodium and potassium excretion, which were analysed by flame photometry in the laboratory of the National Public Health Institute. In the intervention group, the subjects were weighed during the meetings and in the control group during the visits to the
Table I1 presents weight changes in both groups. T h e mean weight reduction in the intervention group was 5 kg. Altogether 83% of the subjects in the intervention group responded to the weight reduction. T h e control group showed no significant change in weight. T h e difference of means in weight reduction was significant also between thc groups (p < 0.05).
Blood presslire T h e systolic blood pressure decreased significantly both in t h e intervention group (8 m m Hg), and in the control group (15 m m Hg). The diastolic blood pressure decreased significantly in both groups (11 mm Hg). T h e decrease in the diastolic blood pressure significantly correlated with t h e decrease in t h e weight in t h e intervention group (r = 0.5, p < 0.05). During the intervention there was no need for t h e changes in the medication. After t h e intervention 5 patients started gradually to reduce their antihypertensive medication (Table 11).
Table 111. The ritearts of total serittii cholesterol,
HDL-cholesterol arid triglycerides at the beginning
arid at tlte end of a 12-niotith intervention progrant. Intervention group Control group I t =.22 R SD ji SD
n = 22
*
Total cholestrol I mmoVl I1
6.0 f 1.0 5.8 f 1.0'
6.1 & 1.0 6.3 1.0'
HDL-cholesterol I mmoVl I1
1.3 & 0.4 1.4 f 0.3'
1.4 f 0.4 1.4 -I 0.4
Triglycerides I mmoVl I1
1.8 f 0.7 1.3 f 0.6"
1.8 f 0.8 1.8 f 0.8
* p < 0.05. ** p < 0.01.
I
at the begining.
Scand J Soc hled 19
Downloaded from sjp.sagepub.com at GEORGE MASON UNIV on March 19, 2015
11 at the end.
R mean.
SD standard deviation.
Weight rediictiori progratti Table IV. The ineatis of riritie potassiittn (K) arid sodiiirii (Na) excretion at the beginning arid at the end of n 12-montli intervention prograni. Intervention group Control group = 23 11 = 22 R SD R SD II
KI mmol/day I1
6 9 f 13 85 f 25**
75 I 2 0 78 f 26
Na I mmol/day I1
165 f 57 200 f 68**
142 f 51 171 f 99'
* p < 0.05. * * p < 0.01. I at the begining.
I1 at the end. R mean. SD standard deviation.
Blood lipids Total cholesterol decreased significantly in the intervention group (0.2 p o l / l ) and increased in the control group (0.2 pmoV1). The significant changes in both directions were among the subjects treated with antihypertensive drugs. HDL-cholesterol and triglycerides changed significantly in the intervention group. HDL-cholesterol increased by 0.1 pnoV1 and triglycerides decreased by 0.5 pmolll. The difference of means in the reduction of triglycerides was significant between the groups (p < 0.05) (Table 111). Potmsiritn arid sodirrtti excretions There were significant changes in the excretions of potassium and sodium in the intervention group. The increase in the excretion of potassium was 16 pmol/day and of sodium 35 pnoVday. In the control group a significant increase in the excretion of sodium was also found (Table IV). Dietary factors In the intervention group, there was a significant decrease (14 d d a y ) and, in the control group, there was a significant increase (9 dday) in the daily use of fats. The decrease was seen among both medicated and non-medicated subjects in the intervention group, but the increase in the control group was confined to the medicated subjects. The intake of proteins decreased significantly in the intervention group (by 6 @day) and increased in the control group (by 7 dday) (Table V).
69
DISCUSSION The aim of this study was to test the effect of a practical non-pharmacological weight reduction program on cardiovascular risk factors among overweight hypertensives in a primary health care setting. Altogether 50 persons were gathered from two hypertension clinics in the county of North Karelia, Finland. The area is well-known for its high mortality and morbidity of cardiovascular diseases. The population has elevated serum cholesterol in general, and hypertension and overweight are common (25-28). The intervention program consisted of an energyrestricted diet, meetings with lessons on overweight, choice of food etc., leaflets of recommended foods and physical activity. The whole study took 12 months. The study population was randomly allocated to the intervention group and the control group, where there was an equal number of drug and non-drug treated hypertensive patients. The intervention group lost significantly its extra weight, which is known to be one of the most important risk factors in hypertension (10-12). The blood pressure dropped significantly, which is at least partly related to the decreased weight. The other risk factor of CVD, high serum lipids, also changed significantly. The total serum cholesterol decreased by 0.2 pnolll in the intervention group whereas there was an increase of 0.2 pnoVI in the control group. In the intervention group, HDL-cholesterol Table V. The trieati intake of carbohydrates, fats, proteins arid total energy at the begitinitig atid at the end of a 12-rnorith iriterveritioti program. Intervention group Control group n = 23 11 = 22 R SD R SD Carbohydrates I @day 11
232 f 98 242 f 91
246 f 82 284 f 97
Fats I dday 11
93 f 37 79 f 35**
85 f 30 91 f 40**
Proteins I g/day I1
85 f 40 79 f 24*
75 f 22 82 f 29'
Total energy I kcaVday I1
2115 f 852 1995 f 650
* p < 0.05. * * p < 0.01. I at the begining.
2145 f 600 2210 i 700
I1 at the end. mean. SD standard deviation.
x
Scand J Sac Aied 19
Downloaded from sjp.sagepub.com at GEORGE MASON UNIV on March 19, 2015
70
L. Jnlknnw
increased by 0.1 poV1 and triglycerides decreascd by 0.5 pmol/l. T h e main reasons for decreased \veight and changes in serum lipids in the intervention group were obviously the decreased consumption of fats. In the control group, the intake of fats increased. Another positive dietary change was the increased intake of potassium. T h e elevated intake of potassium might be caused by the increased consumption of fruit and bread, because also the carbohydrate intake increased (29). T h e increase of the excretion of sodium in both groups suggests that the restriction of salt may be difficult in every day living without using special food items. In the intervention group, the weight could also be reduced by increased physical activity, which was recom,mended by giving lectures on the subjects, but also by organising bicycle trips and distributing free tickets for local swimming baths. Increased physical activity may help in the control of weight (24). The decrcase of blood pressure in the control group was as large as in the intervention group. A closer analysis of the data showed that, in the control group, there were few persons whose weight as well as blood pressure decreased significantly. These persons were also under anti-hypertensive drug therapy which they had started less than five years ago, some of them in the previous year. During the study, the medication might have reached its maximal effect because of the regular use of the drug and its control by the nurses. The total change in the weight of the control group was still very small because, in this group, the general change was increasing body weight . As follows from the results, the intervention was feasible and the main objective, the reduction of cardiovascular risk factors, was achieved. This kind of an intervention program can apparently be organised as a part of the routine treatment and the follow-up of high risk subjects in primary health care: Also the costs are low because the whole program can easily be carried out by the general health care center personnel.
REFERENCES
Early intervention. Med Clin North Am 1984; 68:
477-90.
3. Keys A. Coronary heart diseases in seven' countries. Circulation 1970; Suppl 1: 41-2. 4. Keys A, Anderson JT, Grande F. Serum cholesterol respo&e to changes in the diet. Metabolism 1965; 14: 747-87.
5. Posner BM, DeRusso PA, Norquist SL, Erich MA. Preventive nutrition intervention in coronary heart disease: Risk assessment and formulating dietary goals. J Am Diet Ass 1986; 10: 1395-1401. 6. Andrew G, hlachlahon S W , Austin A, Byrne DG. Hypertension: comparison of drug and non-drug treatments. Br hled J 1982; 284: 1523-26. 7. Kaplan Nhl. Non-drug treatment of hypertension. Ann Int hled 1985; 102: 359-73. 8. Gillum RF, Prineas RJ, Jeffery RW et al. Non-pharmacologic therapy of hypertension: the independent effects of weight reduction and sodium restriction in overweight borderline hypertensive patients. Am Heart J 1983; 105: 128-33. 9. Stamler R, Stamler J, Grimm R et al. Nutritional therapy for high blood pressure. .) Am hled Ass 1987; 11:
1484-91. 10. Cohen N, Flamenbaum W. Obesity and hypertension. Demonstration of a "Floor Effect:. J Am bled Ass 1986; 80: 177-81. 11. Anonymous. Weight reduction in hypertension (Editorial). Lancet 1985; i: 1251-2. 12. Sims EA, Berchtold P. Obesity and hypertension.
Mechanisms and implications for management. J Am Med Ass 1982; 241: 49-52. 13. Friedman CJ, Falks JM, Patel ST,Kim MII, Newman HA, Barrows H. Serum lipoprotein responses during active and stable weight reduction in reproductive obese females. J Clin Endocrinol Metab 1982; 55: 258-62. 14. Wolf RN, Grundy SM. Influence of weight reduction
on plasma lipoproteins in obese patients. Arteriosclerosis 1983; 3: 160-9. 15. Zimmerman J, Kaufmann NA, Fainaru M et al. Effect of weight loss in moderate obesity on plasma lipoprotein and apolipoprotein levels and on high density lipoprotein composition. Arteriosclerosis 1984; 4: 115-23. 16. Brownell K, Stunkard AJ. Differential changes in
17.
18.
1. MacMahon SW, Cutler JA, Furberg CD, Payne GH.
The effects of drug treatment for hypertension on morbidity and mortality from cardiovascular disease: a review of randomized controlled trials. Prog Cardiovasc Dis 1986'; 29: 3, Suppl 1: 99-118. 2. Grim RH jr. Should mild hypertension be treated.
19.
20.
plasma high-density lipoprotein cholesterol levels in obese men and women during weight reduction. Arch Intern Med 1981; 141: 1142-6. Streja DA, Boyko E, Rabkin SW. Changes in plasma high-density lipoprotein cholesterol concentration af-. ter weight reduction in grossly obese subjects. Br Med J 1980; 281: 770-2. Kuller LH. Hulley SB, LaParte RE, Neaten J, Dai WS. Environmental determinants of liver function, and h,igh density lipoprotein cholesterol levels. Am J Epidem 1983; 117: 406-18. Stamler J. Review of primary prevention trials of coronary heart disease. Acta Med Scand 1985; Suppl701: 100-28. Pietinen P, Dougherty R, Mutanen M et al. Dietary
Srand J SOCbled 19
Downloaded from sjp.sagepub.com at GEORGE MASON UNIV on March 19, 2015
Weight redirctioti program
21.
22. 23. 24.
25.
26.
intervention study among 30 free-living families in Finland. J Am Diet Ass 1984; 3: 313-8. Tuomilehto J, Salonen JT, Nissinen A. Factors associated with changes in serum cholesterol during a community-based hypertension programme. Acta Med Scand 1985; 217: 243-52. Chapman CB, Gibbons TB. The diet and hypertension: a review. hledicine 1949; 29: 29-35. Watt GChl, Foy CJW, Hart JT et al. Dietary sodium and arteral blood pressure. Evidence against genetic susceptibility. Br hled J 1985; 291: 1525-30. Kukkonen K, Rauramaa R, Voutilainen E, Llnsimies E. Physical training of middle-aged men with borderline hypertension. Ann Clin Res 1982; 14, Suppl. 34: 139-45. Nissinen A, Piha T, Tuomilehto J, Romo hl, Puska P. The comparison of the levels of cardiovascular risk factors between eastern and south-western Finland 1982. Acta bled Scand 1987; 222: 389-400. Puska P, Nissinen A, Salonen JT et al. The community-
71
based strategy to prevent coronary heart disease: conclusions from the ten years of the North Karelia project. Ann Rev Public Health 1985; 6: 147-93. 27. Puska P, Tuomilehto J, Salonen J et al. Community control of cardiovascular disease, the North Karelia project. WHO, Copenhagen 1981. 28. Tuomilehto J, Jalkanen L, Salonen JT, Nissinen A. Factors associated with changes in body weight during a five year follow-up of a population with high blood pressure. Scand J SOChled 1985; 13: 173-80. 29. Khan KT, Uarrett-Connor E. Dietary potassium and blood pressure in a population. Am J Clin Nutr 1984; 39: 963-8. Address for reprints: Laura Jalkanen Sandoz Nutrition Ltd hlonbijoustrassc 118 3001 Bern, Switzerland
Scand J SOCNed 19
Downloaded from sjp.sagepub.com at GEORGE MASON UNIV on March 19, 2015
The effect of a weight reduction program on cardiovascular risk factors among overweight hypertensives in primary health care Laura Jalkanen Department of Clitiicnl Nutrition, University of Kiiopio, Kiropio, Finland
The effect of a weight redirctioti progrnm on cnrdiovasciilar risk foctors among overiceight hyperterzsir.es in primary health care (Department of Clinical Nutrition, University of Kuopio). Scarid J SOCMed 1991, 19 (66-71). The aim of the study was to test the effect of a nonpharmacological weight reduction program on cardiovascular risk factors among ovenveight hypertensives in a primary health care setting. Forty-nine ovenveight hypertensive patients completed the 12-month program. The patients were randomly allocated into either intervention or control groups. The examinations included interviews by a nutritionist, pertinent laboratory tests, and a medical examination. The intervention involved an individually planned energy-restricted diet of 1000-15M) kcal per day, weekly discussions, and various leaflets on diet modification and on increase of physical activity. The mean body weight was reduced by 5 kg in the intervention group, but remained unchanged in the control group. The intervention group reduced their fat intake by 14 @day while the control group increased it by 9 @day on the average. In the intervention group, the total serum cholesterol decreased, HDL-cholesterol increased and triglycerides decreased significantly. The systolic blood pressure fell by 8 mm Hg and 15 mm Hg in the intervention and control groups, respectively. The diastolic blood pressure fell on average by 11 mm Hg in both groups. The results demonstrate the comprehensive weight reduction program to be effective in the control of cardiovascular risk factors. Key words: hypertension, overweight, risk factors, weight reduction.
INTRODUCTION In many countries where cardiovascular diseases (CVD) are common, several studies have been conducted to find effective methods for their prevention and treatment. Of particular importance have been methods used to reduce elevated blood pressure and elevated serum cholesterol levels. The methods have comm.only been pharmacological, but non-pharmacological methods have also been introduced increasingly (1-3). In the prevention of CVD, non-pharmacological methods have routinely been accepted (3-6), and most efforts concern different dietary
modifications. Weight reduction has been shown to be beneficial for people with hypertension since it decreases the blood pressure significantly (7-12). Weight reduction has also lowered high serum cholesterol and triglycerides (4, 9, 13-16). The positive increase in HDL-cholesterol has been suggested to be a consequence of reduced weight among obese persons (15, 17, 18). Dietary modifications such as reduction of total fats or replacement of saturated fats with mono- and polyunsaturated fats have been documented in several studies to lo&er blood lipids and blood pressure (19-21). Many studies have been aimed at showing that reduced salt intake lowers blood pressure, which was found by Chapman & Gibbons-in late .193O's. In controlled studies, only few hypertensives have been shown to benefit from a moderate reduction of salt intake (7, 8, 20, 22, 23). In Finland, especially in the eastern part, in the province of North Karelia, the prevalence rates of hypertension and elevated serum lipids are high. According to the survey made in 1982, the mean level of systolic blood pressure was 145 mm Hg, the mean level of diastolic blood pressure 87 mm Hg, and the mean level of serum cholesterol 6.3 pmoUI
(25).
The purpose of this study was to test a comprehensive but practical intervention program aimed for general use in the non-pharmacological treatment of cardiovascular risk factors, especially. overweight, hypertension and high serum lipids, in a primary health care setting. MATERIALS AND METHODS Recriiitrnent Nurses in two hypertension clinics of the towns of Joensuu and Lieksa in the county of North Karelia selected, from their files, two groups of subjects who met the study criteria. The subjects were 35-59 years old, their diastolic blood pressure was 95 mm Hg or more, their body mass index 27-34 kp/m2. and they were motivated and volunteered. In the beginning of the study, there were 25 persons with
Scand J Soc hled 19
Downloaded from sjp.sagepub.com at GEORGE MASON UNIV on March 19, 2015
Weight reduction progmtn
67
Table I. The intervention program atid the progratti for the control groirp in the stirdy for the treattiietit of cardiovascirlar risk factors. Weeks
1.
2. 3.
4. 5.
6. 7. 8.
9.
10. 11. 12.
13.
14. 15.
16.
17. 1s. 19. 20. 21. 22. 23. 24. 35.
38.
41. 44. 47.
50. 52.
Theme of the meeting
Intervention group
Control group
Info, laboratory, doctor’s consultation, nutritionist’s interview, RR Lecture on cardiovascular risk factors (doctor) Lecture on nutritional risk factors in CVD (nutritionist) Lecture on physical activity in the treatment of CVD (physiotherapist), R R Lecture on the selection of foods (nutritionist) Break for winter holiday Lecture on behavior modification in the weight reduction (psychologist) Lecture on low fat cooking (nutritionist) Individual meeting with nutritionist Nurse’s consultation, RR Physical excercise with the physiotherapist, RR Lecture on eating in social events etc. (nutritionist) Break for Easter Lecture on food selection (nutritionist) Lecture on behavior modification in the tveight reduction (psychologist) Lccture on medical aspects in overweight (doctor) Laboratory, RR Physical excercise with the physiotherapist Lecture on low salt, low sugar cooking (nutritionist) Lccturc on eating in restaurants, cafeterias etc. (nutritionist) Lecture on behavior modification in weight reduction (psychologist) Lecture on different physical excercise for vacation (physiotherapist) Lecture on low fat bakery (nutritionist) Doctor’s advices for the summer vacation Physical excercise with the physiotherapist Nutritionist’s advices for the summer vacation Summer vacation Lecture on the medical aspects of weight controlling (doctor), RR Nurse’s consultation, RR Lecture on food selection in weight controlling (nutritionist) Lecture on physical excercise in the weight controlling (physiotherapist) Lecture on behavior modification in weight controlling (psychologist) Lecture on low fat, low sugar cooking in weight controlling (nutritionist) Lecture on food selection for Christmas (nutritionist) Laboratory, RR, Christmas party
RR = blood pressure measurements. anti-hypertensive drug treatment and 25 persons without any drug treatment. The subjects were randomised to the active intervention program and normal follow-up program as controls for the intervention group. In‘both programs, there were as many men as women. The number of drugtreated and non-drug treated persons was identical in both clinics. The drugs used in the treatment were diuretics and fi-blockers. The duration of the medication was less than 5 years at the beginning of the study. Sri bjects
Altogether 49 subjects of the average age of 49 years completed the 12-month weight reduction program. There were 9 subjects in both the intervention and the control groups with drug treatment for hypertension, and 13 subjects in the intervention and 11 subjects in the control groups without any medication, for whom all the laboratory analyses
could be made. For statistical analysis, the data of the two towns were pooled together. The final analysis refers to the situation at the beginning and end of the study and to subjects that completed the study procedures. Smdy program At the beginning of the study, before randomising the people to the intervention and control groups, the study population was invited to an information event where both programs were explained to them. Those who would be randomised to the control group were offered to participate in the intervention program after the study period. The intervention ’ program consisted of an individually planned energy-restricted diet of 1000-1500 kcal per day, weekly (after six months, every three weeks) sessions, where there were discussions and lessons on behavioral modification, choice of food, physical exercise, and medScand J Soc hfed 19
5‘
Downloaded from sjp.sagepub.com at GEORGE MASON UNIV on March 19, 2015
6%
L. Jalknnen
Table 11. The means of tlte body weiglit, and systolic and diastolic blood presstires at the beginning and at the end of a 12-niontlt intervention program. Intervention group Control group n = 25 R SD R SD
n = 24
Weight I kg I1 Systolic blood I Pressure II mm Hg Diastolic blood I Pressure I1 mm Ilg * p < 0.05. * * p < 0.01. I at the bcgining.
8 0 f 11 8 0 f 11
86 f 14 82 f 13** 152 f 17 143 f 20'
nurses. Both groups kept three times 2-3 days food records throughout the study. They got scales for weighing their food. The data of food consumption analysis included total energy, fats, carbohydrates and proteins processed using Finnish food composition tables. The significance of differences of means in the groups and between the groups was tested by Student's i-test. Pearsons's product-moment correlation coefficient was calculated for testing the strength of the relationship between the change of weight and systolic and diastolic blood pressure.
155 f 14 140 zk 16**
RESULTS Weight rediictiott
.
101 f 8 90 f 10"
102 f 1 91 f 1"
11 at the end.
R mean.
SD standard deviation.
ical aspects of overweight and weight reduction. Every session took about 1.5 hour; thus the total number of lectures was about 40 hrs. The subjects also received leaflets on the reduction of salt and fat consumption and on the increase of physical activity. The programs are detailed in Table I. The control group only had their normal visits every three months to the nurses, but no personal counceling or advice. Both the intervention and follow-up of the control group took 12 months. After the intervention period the study group moved to the normal hypertension follow-up program with visits to the nurses every three months. The nurses also recorded the changes in 'weight and tried to advise the patients on how to avoid relapse. The control group started the intervention program when the intervention group had completed it. The doctors of the subjects \yere asked to keep the dosage of antihypertensive drugs at the initial level. hfeasurernenrs The examinations included an interview by a nutritionist, pertinent laboratory tests, and a medical examination. The laboratory tests included blood samples taken three times from fasting subjects to be analysed for total serum cholesterol, UDL-cholesterol and triglycerides using an AutoAnalyzer I1 apparatus (Technican Instruments, Tarrytown. NY) in the laboratory of the National Public Health Institute, The blood pressure of each subject was measured at the local clinic by a trained nurse using an automated recorder (Infrasonde SR-2, Sphygmetrics, he.). Blood pressure readings were obtained on the right arm after the subject had been sitting quietly for five minutes. The mean of the two readings was used for further analysis. The subjects collected three 24-hour urine samples in order t o determine salt intake and sodium and potassium excretion, which were analysed by flame photometry in the laboratory of the National Public Health Institute. In the intervention group, the subjects were weighed during the meetings and in the control group during the visits to the
Table I1 presents weight changes in both groups. T h e mean weight reduction in the intervention group was 5 kg. Altogether 83% of the subjects in the intervention group responded to the weight reduction. T h e control group showed no significant change in weight. T h e difference of means in weight reduction was significant also between thc groups (p < 0.05).
Blood presslire T h e systolic blood pressure decreased significantly both in t h e intervention group (8 m m Hg), and in the control group (15 m m Hg). The diastolic blood pressure decreased significantly in both groups (11 mm Hg). T h e decrease in the diastolic blood pressure significantly correlated with t h e decrease in t h e weight in t h e intervention group (r = 0.5, p < 0.05). During the intervention there was no need for t h e changes in the medication. After t h e intervention 5 patients started gradually to reduce their antihypertensive medication (Table 11).
Table 111. The ritearts of total serittii cholesterol,
HDL-cholesterol arid triglycerides at the beginning
arid at tlte end of a 12-niotith intervention progrant. Intervention group Control group I t =.22 R SD ji SD
n = 22
*
Total cholestrol I mmoVl I1
6.0 f 1.0 5.8 f 1.0'
6.1 & 1.0 6.3 1.0'
HDL-cholesterol I mmoVl I1
1.3 & 0.4 1.4 f 0.3'
1.4 f 0.4 1.4 -I 0.4
Triglycerides I mmoVl I1
1.8 f 0.7 1.3 f 0.6"
1.8 f 0.8 1.8 f 0.8
* p < 0.05. ** p < 0.01.
I
at the begining.
Scand J Soc hled 19
Downloaded from sjp.sagepub.com at GEORGE MASON UNIV on March 19, 2015
11 at the end.
R mean.
SD standard deviation.
Weight rediictiori progratti Table IV. The ineatis of riritie potassiittn (K) arid sodiiirii (Na) excretion at the beginning arid at the end of n 12-montli intervention prograni. Intervention group Control group = 23 11 = 22 R SD R SD II
KI mmol/day I1
6 9 f 13 85 f 25**
75 I 2 0 78 f 26
Na I mmol/day I1
165 f 57 200 f 68**
142 f 51 171 f 99'
* p < 0.05. * * p < 0.01. I at the begining.
I1 at the end. R mean. SD standard deviation.
Blood lipids Total cholesterol decreased significantly in the intervention group (0.2 p o l / l ) and increased in the control group (0.2 pmoV1). The significant changes in both directions were among the subjects treated with antihypertensive drugs. HDL-cholesterol and triglycerides changed significantly in the intervention group. HDL-cholesterol increased by 0.1 pnoV1 and triglycerides decreased by 0.5 pmolll. The difference of means in the reduction of triglycerides was significant between the groups (p < 0.05) (Table 111). Potmsiritn arid sodirrtti excretions There were significant changes in the excretions of potassium and sodium in the intervention group. The increase in the excretion of potassium was 16 pmol/day and of sodium 35 pnoVday. In the control group a significant increase in the excretion of sodium was also found (Table IV). Dietary factors In the intervention group, there was a significant decrease (14 d d a y ) and, in the control group, there was a significant increase (9 dday) in the daily use of fats. The decrease was seen among both medicated and non-medicated subjects in the intervention group, but the increase in the control group was confined to the medicated subjects. The intake of proteins decreased significantly in the intervention group (by 6 @day) and increased in the control group (by 7 dday) (Table V).
69
DISCUSSION The aim of this study was to test the effect of a practical non-pharmacological weight reduction program on cardiovascular risk factors among overweight hypertensives in a primary health care setting. Altogether 50 persons were gathered from two hypertension clinics in the county of North Karelia, Finland. The area is well-known for its high mortality and morbidity of cardiovascular diseases. The population has elevated serum cholesterol in general, and hypertension and overweight are common (25-28). The intervention program consisted of an energyrestricted diet, meetings with lessons on overweight, choice of food etc., leaflets of recommended foods and physical activity. The whole study took 12 months. The study population was randomly allocated to the intervention group and the control group, where there was an equal number of drug and non-drug treated hypertensive patients. The intervention group lost significantly its extra weight, which is known to be one of the most important risk factors in hypertension (10-12). The blood pressure dropped significantly, which is at least partly related to the decreased weight. The other risk factor of CVD, high serum lipids, also changed significantly. The total serum cholesterol decreased by 0.2 pnolll in the intervention group whereas there was an increase of 0.2 pnoVI in the control group. In the intervention group, HDL-cholesterol Table V. The trieati intake of carbohydrates, fats, proteins arid total energy at the begitinitig atid at the end of a 12-rnorith iriterveritioti program. Intervention group Control group n = 23 11 = 22 R SD R SD Carbohydrates I @day 11
232 f 98 242 f 91
246 f 82 284 f 97
Fats I dday 11
93 f 37 79 f 35**
85 f 30 91 f 40**
Proteins I g/day I1
85 f 40 79 f 24*
75 f 22 82 f 29'
Total energy I kcaVday I1
2115 f 852 1995 f 650
* p < 0.05. * * p < 0.01. I at the begining.
2145 f 600 2210 i 700
I1 at the end. mean. SD standard deviation.
x
Scand J Sac Aied 19
Downloaded from sjp.sagepub.com at GEORGE MASON UNIV on March 19, 2015
70
L. Jnlknnw
increased by 0.1 poV1 and triglycerides decreascd by 0.5 pmol/l. T h e main reasons for decreased \veight and changes in serum lipids in the intervention group were obviously the decreased consumption of fats. In the control group, the intake of fats increased. Another positive dietary change was the increased intake of potassium. T h e elevated intake of potassium might be caused by the increased consumption of fruit and bread, because also the carbohydrate intake increased (29). T h e increase of the excretion of sodium in both groups suggests that the restriction of salt may be difficult in every day living without using special food items. In the intervention group, the weight could also be reduced by increased physical activity, which was recom,mended by giving lectures on the subjects, but also by organising bicycle trips and distributing free tickets for local swimming baths. Increased physical activity may help in the control of weight (24). The decrcase of blood pressure in the control group was as large as in the intervention group. A closer analysis of the data showed that, in the control group, there were few persons whose weight as well as blood pressure decreased significantly. These persons were also under anti-hypertensive drug therapy which they had started less than five years ago, some of them in the previous year. During the study, the medication might have reached its maximal effect because of the regular use of the drug and its control by the nurses. The total change in the weight of the control group was still very small because, in this group, the general change was increasing body weight . As follows from the results, the intervention was feasible and the main objective, the reduction of cardiovascular risk factors, was achieved. This kind of an intervention program can apparently be organised as a part of the routine treatment and the follow-up of high risk subjects in primary health care: Also the costs are low because the whole program can easily be carried out by the general health care center personnel.
REFERENCES
Early intervention. Med Clin North Am 1984; 68:
477-90.
3. Keys A. Coronary heart diseases in seven' countries. Circulation 1970; Suppl 1: 41-2. 4. Keys A, Anderson JT, Grande F. Serum cholesterol respo&e to changes in the diet. Metabolism 1965; 14: 747-87.
5. Posner BM, DeRusso PA, Norquist SL, Erich MA. Preventive nutrition intervention in coronary heart disease: Risk assessment and formulating dietary goals. J Am Diet Ass 1986; 10: 1395-1401. 6. Andrew G, hlachlahon S W , Austin A, Byrne DG. Hypertension: comparison of drug and non-drug treatments. Br hled J 1982; 284: 1523-26. 7. Kaplan Nhl. Non-drug treatment of hypertension. Ann Int hled 1985; 102: 359-73. 8. Gillum RF, Prineas RJ, Jeffery RW et al. Non-pharmacologic therapy of hypertension: the independent effects of weight reduction and sodium restriction in overweight borderline hypertensive patients. Am Heart J 1983; 105: 128-33. 9. Stamler R, Stamler J, Grimm R et al. Nutritional therapy for high blood pressure. .) Am hled Ass 1987; 11:
1484-91. 10. Cohen N, Flamenbaum W. Obesity and hypertension. Demonstration of a "Floor Effect:. J Am bled Ass 1986; 80: 177-81. 11. Anonymous. Weight reduction in hypertension (Editorial). Lancet 1985; i: 1251-2. 12. Sims EA, Berchtold P. Obesity and hypertension.
Mechanisms and implications for management. J Am Med Ass 1982; 241: 49-52. 13. Friedman CJ, Falks JM, Patel ST,Kim MII, Newman HA, Barrows H. Serum lipoprotein responses during active and stable weight reduction in reproductive obese females. J Clin Endocrinol Metab 1982; 55: 258-62. 14. Wolf RN, Grundy SM. Influence of weight reduction
on plasma lipoproteins in obese patients. Arteriosclerosis 1983; 3: 160-9. 15. Zimmerman J, Kaufmann NA, Fainaru M et al. Effect of weight loss in moderate obesity on plasma lipoprotein and apolipoprotein levels and on high density lipoprotein composition. Arteriosclerosis 1984; 4: 115-23. 16. Brownell K, Stunkard AJ. Differential changes in
17.
18.
1. MacMahon SW, Cutler JA, Furberg CD, Payne GH.
The effects of drug treatment for hypertension on morbidity and mortality from cardiovascular disease: a review of randomized controlled trials. Prog Cardiovasc Dis 1986'; 29: 3, Suppl 1: 99-118. 2. Grim RH jr. Should mild hypertension be treated.
19.
20.
plasma high-density lipoprotein cholesterol levels in obese men and women during weight reduction. Arch Intern Med 1981; 141: 1142-6. Streja DA, Boyko E, Rabkin SW. Changes in plasma high-density lipoprotein cholesterol concentration af-. ter weight reduction in grossly obese subjects. Br Med J 1980; 281: 770-2. Kuller LH. Hulley SB, LaParte RE, Neaten J, Dai WS. Environmental determinants of liver function, and h,igh density lipoprotein cholesterol levels. Am J Epidem 1983; 117: 406-18. Stamler J. Review of primary prevention trials of coronary heart disease. Acta Med Scand 1985; Suppl701: 100-28. Pietinen P, Dougherty R, Mutanen M et al. Dietary
Srand J SOCbled 19
Downloaded from sjp.sagepub.com at GEORGE MASON UNIV on March 19, 2015
Weight redirctioti program
21.
22. 23. 24.
25.
26.
intervention study among 30 free-living families in Finland. J Am Diet Ass 1984; 3: 313-8. Tuomilehto J, Salonen JT, Nissinen A. Factors associated with changes in serum cholesterol during a community-based hypertension programme. Acta Med Scand 1985; 217: 243-52. Chapman CB, Gibbons TB. The diet and hypertension: a review. hledicine 1949; 29: 29-35. Watt GChl, Foy CJW, Hart JT et al. Dietary sodium and arteral blood pressure. Evidence against genetic susceptibility. Br hled J 1985; 291: 1525-30. Kukkonen K, Rauramaa R, Voutilainen E, Llnsimies E. Physical training of middle-aged men with borderline hypertension. Ann Clin Res 1982; 14, Suppl. 34: 139-45. Nissinen A, Piha T, Tuomilehto J, Romo hl, Puska P. The comparison of the levels of cardiovascular risk factors between eastern and south-western Finland 1982. Acta bled Scand 1987; 222: 389-400. Puska P, Nissinen A, Salonen JT et al. The community-
71
based strategy to prevent coronary heart disease: conclusions from the ten years of the North Karelia project. Ann Rev Public Health 1985; 6: 147-93. 27. Puska P, Tuomilehto J, Salonen J et al. Community control of cardiovascular disease, the North Karelia project. WHO, Copenhagen 1981. 28. Tuomilehto J, Jalkanen L, Salonen JT, Nissinen A. Factors associated with changes in body weight during a five year follow-up of a population with high blood pressure. Scand J SOChled 1985; 13: 173-80. 29. Khan KT, Uarrett-Connor E. Dietary potassium and blood pressure in a population. Am J Clin Nutr 1984; 39: 963-8. Address for reprints: Laura Jalkanen Sandoz Nutrition Ltd hlonbijoustrassc 118 3001 Bern, Switzerland
Scand J SOCNed 19
Downloaded from sjp.sagepub.com at GEORGE MASON UNIV on March 19, 2015
![[Weight reduction for hypertensives? Yes].](/assets/img/hold.png)
