Nonpharmacological interventions

Lifestyle intervention inspires a sense of well-being, may be less expensive than pharmacological interventions and has no known harmful effects. In impaired glucose tolerance, progression to diabetes can be prevented or postponed by lifestyle modifications, such as dietary manipulation and physical activity (Pan etal., 1997; Tuomilehto etal., 2001) (see also Chapter 10).

A variety of lifestyle modifications reduce blood pressure and the incidence of hypertension (Ebrahim and Smith, 1998; He etal., 2000; Sacks etal., 2001; Whelton etal., 2002). Non-pharmacological interventions include weight loss in the overweight (He etal., 2000, Whelton etal., 2001), exercise programmes (Whelton etal., 2002), moderation of alcohol intake (Xin etal., 2001) and a diet with increased fruit and vegetables and reduced saturated fat content (Sacks etal., 2001), reduction in dietary sodium intake (Whelton etal., 1998; Sacks etal., 2001) and increased dietary potassium intake (He and Whelton, 1999) (Table 6.2). When adherence is optimal, systolic blood pressure is reduced by > 10mmHg (Sacks etal., 2001). Reductions are more modest in clinical practice (Ebrahim and Smith, 1998) and studies were not designed or powered to evaluate changes in overall or cardiac mortality. However, in long-term, large-scale population studies, even small reductions in blood pressure are associated with reduced cardiovascular disease risk (Cook etal., 1995).

Lifestyle modification should be provided for all people with high blood pressure and those with borderline or high-normal blood pressure. Such interventions are recommended even when antihypertensive drugs are prescribed as the blood pressure effects of drugs are complemented and thus the dose or number of drugs required to control blood pressure is reduced.

Table 6.2 Lifestyle measures recommended in management of Hypertension. Modified from Williams B, Poulter NR, Brown MJ et al. (2004). Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004 - BHS IV. Journal of Human Hypertension 18: 139-85.

• Maintain normal weight for adults (body mass index 20-25 kg/m2)

• Reduce salt intake to < 100mmol/day (< 6g NaCl or < 2.5 g sodium/day)

• Limit alcohol consumption to < 3 units/day for men or < 2 units/day for women

• Engage in regular aerobic physical exercise (brisk walking rather than weightlifting) for > 30 minutes/day, ideally on most days of the week but at least on three days/week

• Consume at least five portions/day of fresh fruit and vegetables

• Reduce intake of total and saturated fat

Dietary modification

Weight gain is a critical factor in the progression to type 2 diabetes (Colditz etal., 1995). A key component of management is to avoid overweight, particularly by calorie restriction and decrease of sodium intake because of the strong relationship between obesity, hypertension, sodium sensitivity and insulin resistance (Rocchini, 2000).

Physical activity and weight loss

The increasingly sedentary lifestyle of the general population has contributed to an epidemic of obesity and the metabolic syndrome. A graded exercise programme is strongly recommended (Wasserman and Zinman, 1994; Whelton etal., 2002).

Tobacco cessation

The combination of smoking and diabetes enhances the risk of microvascular and macrovascular disease as well as premature mortality. Patients with diabetes should be counselled about smoking cessation, the enhanced risks of smoking and diabetes for morbidity and mortality, and the proven efficacy and cost-effectiveness of cessation strategies (Kawachi etal., 1994; Haire-Joshu etal., 1999).

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