Physical Activity and Blood Pressure

Question 1: Which disease is the single biggest killer in India in the age group of 50-69?

A. Hypertension

B. Tuberculosis

C. Cancer

D. Malaria

The answer is A. Hypertension or high blood pressure (Fig. 1) is the single biggest killer in India. In 2019, approximately 570,000 people died due to hypertension, amounting to 19.8% of all deaths in this age group. Across all age groups, the number of deaths attributable to hypertension was 1.35 million or 13.5 lakhs, accounting for 14.37% of all deaths.

Fig. 1: A comparative chart of causes of death in the 50-69 age group in India

Hypertension is elevated blood pressure. The systolic (upper) or the diastolic (lower) or both values can be high. Both should be normal. The accepted cut-offs for a long time were values greater than 140 systolic and 90 diastolic [1], but the definition of hypertension was changed to values above 130 systolic and/or 80 diastolic in 2017 by ACC/AHA [2]. Many studies have shown that the lower the blood pressure, the longer people live disease free [3].

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Question 2: How many people are said to have hypertension in India above the age of 18 as defined by the 140/90 cut-off?

A. 100 million (10 crores)

B. 200 million (20 crores)

C. 300 million (30 crores)

D. 400 million (40 crores)

The correct answer lies between B and C.  234 million people out of 762 million adults above the age of 18, as per the 2011 census have high blood pressure, as reported by a study, where blood pressure measurements performed on a single day in camps across India in 2015 [4]. If the new guidelines of 130/80 are applied to this same study, then the number of people with hypertension in India goes up to 460 million which is a prevalence of 3 out of 5 or 60% [5]. Whether 30% or 60%, the number is alarmingly high.

As individuals, what should we be doing?

All of us need to measure our own cardiovascular (CV) risk ourselves using either QRISK3 or the Framingham ACC/AHA method as I had written about earlier. We should also measure our own blood pressure over a few days at different times using any standard home based instrument (I use OMRON, but you can use whatever is available and accessible). Home blood pressure (HBP) measurements are now considered quite reliable and accurate [6].

If your 10 years CV risk is low (less than 10%) and the blood pressure is normal, that’s great news. However, with a low CV risk, if the blood pressure is mildly high (130-139 or 80-89), you can try and manage without medication.

Question 3: Which of these non-pharmacologic methods helps with hypertension control?

A. Physical activity

B. Sensible eating and low sodium

C. Cessation of smoking

D. All of the above

E. None of the above

The correct answer is D. All the first 3 help, though the most effective is physical activity (PA).  A new scientific statement by AHA, published earlier this week [7] places PA front and centre in the management of hypertension, whether it is without drugs (mild hypertension, low CV risk) or supplementing medications (moderate to severe hypertension, high CV risk).

If your CV risk is high, and/or the HBP measurements are consistently above 140/90, then it is best to first see a doctor to plan further management. But even then, PA must supplement medication.

Question 4: What is the minimum PA recommended ?

A. 30 minutes of walking every day for 5 days

B. 30 minutes of running every day for 5 days

C. 30 minutes of strength training every day for 5 days

D. Mix of walking, running, strength training on different days

E. All of the above

F. None of the above

The correct answer is E.

The PA guidelines in the scientific statement are directly taken from the Physical Activity Guidelines for Americans, which mention 150-300 mins / week of moderate intensity exercise  (brisk walking) or 75-150 minutes of vigorous intensity PA (running) or a combination of the two. So basically at the bare minimum, 30 minutes of brisk walking 5 times a week or 30 minutes of running 2-3 times a week would work and you can mix and match. Walk one day, run another day, longer walks and runs over weekends and similar combinations are all fine. To these we have to add some form of strength training at least twice a week, which could be with free weights or machines, or include yoga, tai-chi or any other method that allows resistance muscle training.

And if any of this is difficult, remember any movement is better than none, as I had spoken and written about a month or so ago.

In short, PA helps us control our blood pressure and along with sensible eating, sodium control, cessation of smoking, weight loss and adequate sleep, helps at least 1/3rd of us with hypertension manage without medication, thus helping us in our quest to be “atmasvasth” (Fig. 2).

Footnotes

1. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 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 Feb 5;311(5):507-20. doi: 10.1001/jama.2013.284427. Erratum in: JAMA. 2014 May 7;311(17):1809. PMID: 24352797.

2. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC Jr, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018 Oct 23;138(17):e426-e483. doi: 10.1161/CIR.0000000000000597. PMID: 30354655.

3. SPRINT Research Group, Lewis CE, Fine LJ, Beddhu S, Cheung AK, Cushman WC, Cutler JA, Evans GW, Johnson KC, Kitzman DW, Oparil S, Rahman M, Reboussin DM, Rocco MV, Sink KM, Snyder JK, Whelton PK, Williamson JD, Wright JT Jr, Ambrosius WT. Final Report of a Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2021 May 20;384(20):1921-1930. doi: 10.1056/NEJMoa1901281. PMID: 34010531.

4. Ramakrishanan S, Gupta K. Prevalence of hypertension among Indian adults: Results from the great India blood pressure survey. Indian Heart J. 2020 May-Jun;72(3):217. doi: 10.1016/j.ihj.2020.04.013. Epub 2020 May 12. PMID: 32768029; PMCID: PMC7411092.

5. Gupta K, Ramakrishnan S, Zachariah G, Rao JS, Mohanan PP, Venugopal K, Sateesh S, Sethi R, Jain D, Bardolei N, Mani K, Kakar TS, Jain V, Gupta P, Gupta R, Bansal S, Nath RK, Tyagi S, Wander GS, Gupta S, Mandal S, Senguttuvan NB, Subramanyam G, Roy D, Datta S, Ganguly K, Routray SN, Mishra SS, Singh BP, Bharti BB, Das MK, Deb PK, Deedwania P, Seth A; CSI-Great India BP Campaign Investigators. Impact of the 2017 ACC/AHA guidelines on the prevalence of hypertension among Indian adults: Results from a cross-sectional survey. Int J Cardiol Hypertens. 2020 Oct 7;7:100055. doi: 10.1016/j.ijchy.2020.100055. PMID: 33465185; PMCID: PMC7803035.

6. Schwartz JE, Muntner P, Kronish IM, Burg MM, Pickering TG, Bigger JT, Shimbo D. Reliability of Office, Home, and Ambulatory Blood Pressure Measurements and Correlation With Left Ventricular Mass. J Am Coll Cardiol. 2020 Dec 22;76(25):2911-2922. doi: 10.1016/j.jacc.2020.10.039. PMID: 33334418; PMCID: PMC7749264.

7. Barone Gibbs B, Hivert MF, Jerome GJ, Kraus WE, Rosenkranz SK, Schorr EN, Spartano NL, Lobelo F; American Heart Association Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular and Stroke Nursing; and Council on Clinical Cardiology. Physical Activity as a Critical Component of First-Line Treatment for Elevated Blood Pressure or Cholesterol: Who, What, and How?: A Scientific Statement From the American Heart Association. Hypertension. 2021 Jun 2:HYP0000000000000196. doi: 10.1161/HYP.0000000000000196. Epub ahead of print. PMID: 34074137.