The optimal first step to address mild to moderately elevated blood pressure (BP) and cholesterol in otherwise healthy adults is a “prescription” to sit less and move more, the American Heart Association (AHA) said in a statement.
"The current American Heart Association guidelines for diagnosing high [BP] and cholesterol recognise that otherwise healthy individuals with mildly or moderately elevated levels of these [CV] risk factors should actively attempt to reduce these risks," said Bethany Barone Gibbs, PhD, chair of the statement writing group.
"The first treatment strategy for many of these patients should be healthy lifestyle changes beginning with increasing physical activity," said Gibbs, from the University of Pittsburgh, Pennsylvania.
The scientific statement was called Physical Activity as a Critical Component of First-Line Treatment for Elevated Blood Pressure or Cholesterol: Who, What, and How?
According to the AHA, about 21% of American adults have systolic blood pressure (SBP) between 120 mm Hg and 139 mm Hg, or diastolic blood pressure (DBP) between 80 mm Hg and 89 mm Hg, which meets the criteria for lifestyle-only treatment for elevated BP outlined in the American College of Cardiology (ACC)/AHA high BP guideline.
In addition, about 28% of American adults have low-density lipoprotein cholesterol (LDL-C) above 70 mg/dL and otherwise meet the low-risk criteria for heart disease or stroke. These individuals would meet the criteria for lifestyle-only treatment outlined in the 2018 ACC/AHA cholesterol treatment guidelines, which include increased physical activity, weight loss, better diet, smoking cessation, and moderating alcohol intake.
"Of the recommended lifestyle changes, increasing physical activity has extensive benefits, including improving both [BP] and blood cholesterol, that are comparable, superior, or complementary to other healthy lifestyle changes," the writing group said.
"Physical activity assessment and prescription are an excellent lifestyle behaviour treatment option for all patients, including for the large population of mild-moderate-risk patients with elevated [BP] and blood cholesterol," they noted.
Research has shown that increasing physical activity can lead to clinically meaningful 3- or 4-mm Hg reductions in SBP and DBP, and 3-mg/dL to 6- mg/dL decreases in LDL-C, the authors pointed out.
Previous evidence also shows that physically active people have a 21% lower risk of developing cardiovascular disease (CVD) and a 36% lower risk for death from CVD than those persons who are not physically active.
Physical activity also has benefits beyond heart health, including a lower risk for some cancers; improved bone, brain, and mental health; and better sleep, they noted.
The US Department of Health and Human Services (HHS) 2018 physical activity guidelines advised Americans to log 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous aerobic activity each week and to participate in two or more weekly strength training sessions; however, there is no minimum amount of time to receive benefits from physical activity.
"Every little bit of activity is better than none. Even small initial increases of 5 to 10 minutes a day can yield health benefits," Gibbs said.
Translational advice for clinicians
The AHA statement encourages clinicians to ask patients about their physical activity at every interaction; provide ideas and resources to help patients improve and sustain regular life-long physical activity; and encourage and celebrate small increases in activity, such as walking more or taking the stairs, to help with motivation.
"In our world where physical activity is increasingly engineered out of our lives and the overwhelming default is to sit, and even more so now as the nation and the world is practicing quarantine and isolation to reduce the spread of coronavirus, the message that we must be relentless in our pursuit to 'sit less and move more' throughout the day is more important than ever," said Gibbs.
The statement was prepared by a volunteer writing group on behalf of the AHA Council on Lifestyle and Cardiometabolic Health; the Council on Cardiovascular and Stroke Nursing; and the Council on Clinical Cardiology.
Study highlights
Among US adults aged 40 to 75 years, mild- to moderate-risk BP (SBP 120-139 mm Hg or DBP 80-89 mm Hg) occurs in ~ 21% and mild- to moderate-risk cholesterol (LDL-C > 70 mg/dL and low atherosclerotic cardiovascular disease [ASCVD] risk scores [ 70 mg/dL, intermediate ASCVD risk scores (7.5%-20%), low coronary artery calcium score (< 100 Agatston units), and low burden of other risk factors, lifestyle- only treatment is also an option during clinician/patient shared decision making.
Increasing physical activity has extensive BP, cholesterol, and other benefits comparable, superior, or complementary to other healthy lifestyle changes.
It can result in clinically meaningful 3-mm Hg to 4-mm Hg reductions in SBP and DBP; 3- to 6-mg/dL decreases in LDL-C; and 21% lower risk of developing CVD and 36% lower risk for CVD death compared with people who are not physically active. Aerobic exercise tends to increase high-density lipoprotein cholesterol (HDL-C) and decrease triglycerides but has less consistent effects on LDL-C. Resistance training has been shown to significantly reduce LDL-C and triglycerides, with no effect on HDL-C. A recent review suggests that adding resistance to aerobic training could supplement and possibly enhance effects.
Additional benefits of physical activity include lower risk for some cancers; better sleep; better bone, brain, and mental health; and better physical function and quality of life. Physical activity evaluation/prescription is an excellent lifestyle behaviour treatment option for all patients, including for the large population with mild to moderate risk with elevated BP/cholesterol. Individuals with socioeconomic risk factors (eg, low family income, low educational level, and underrepresented racial and ethnic groups) are disproportionately affected by CV risk factors and less likely to achieve healthy lifestyle behaviours, such as physical activity. Lifestyle-only treatment with physical activity is an intervention targeting both elevated BP and cholesterol that may also reduce these disparities.
The statement recommends 150 to 300 min/wk of moderate or 75 to 150 min/wk vigorous aerobic activity, or an equivalent combination, and ≥ two weekly strength training sessions, involving all major muscle groups.
This recommendation is that of the federal Physical Activity Guidelines for Americans, according to the most extensive, expert review specifically addressing physical activity and health outcomes. There is no minimum amount of time to benefit from physical activity, but exceeding these recommendations results in even greater health benefits.
Moderate intensity corresponds to three metabolic equivalents (METs) to 5.9 METs (eg, brisk walking or any activity that begins to increase breathing and heart rate). Vigorous intensity corresponds to ≥ 6 METs (eg, jogging or brisk walking uphill that results in larger increases in breathing and heart rate). More frequent physical activity might be beneficial, as a single bout of aerobic physical activity has a transient hypotensive effect (−2 to −12 mm Hg) lasting 4 to 16 hours. Overall, higher intensity, frequency, or volume of aerobic training may yield greater benefits in blood cholesterol and triglycerides.
The AHA statement urges clinicians to inquire about patientsʼ physical activity at every interaction; offer ideas and resources to help patients improve and maintain regular lifelong physical activity; and foster small increases in activity, such as walking more or taking the stairs, to increase motivation. The goal is for patients to sit less and move more.
Clinical implications
Physical activity evaluation/prescription is an excellent lifestyle behaviour treatment option for patients with mild to moderate CV risk and for all patients.
Increasing physical activity has extensive BP, cholesterol, and other benefits comparable, superior, or complementary to other healthy lifestyle changes.
Implications for the healthcare team
Clinicians should inquire about patientsʼ physical activity at every interaction and offer ideas and resources to help patients improve and maintain regular lifelong physical activity.
Study details
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
Bethany Barone Gibbs, Marie-France Hivert, Gerald J. Jerome, William E. Kraus, Sara K. Rosenkranz, Erica N. Schorr, Nicole L. Spartano, Felipe Lobelo, and on behalf of the American Heart Association Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular and Stroke Nursing; and Council on Clinical Cardiology
Published in Hypertension on 2 June 2021
Abstract
Current guidelines published by the American Heart Association and the American College of Cardiology broadly recommend lifestyle approaches to prevent and treat elevated blood pressure and cholesterol. For patients with mildly or moderately elevated blood pressure and blood cholesterol, lifestyle-only approaches are the first line of therapy.
The purpose of this scientific statement is to: (1) highlight the mild-moderate–risk patient groups indicated for lifestyle-only treatment for elevated blood pressure or cholesterol; (2) describe recommendations, average effects, and additional considerations when prescribing lifestyle treatment with physical activity; and (3) provide guidance and resources for clinicians to assess, prescribe, counsel, and refer to support increased physical activity in their patients.
An estimated 21% and 28% to 37% of US adults, respectively, have mild-moderate–risk blood pressure and cholesterol and should receive lifestyle-only as first-line treatment. Of the recommended lifestyle changes, increasing physical activity has extensive benefits, including improving both blood pressure and blood cholesterol, that are comparable, superior, or complementary to other healthy lifestyle changes.
Physical activity assessment and prescription are an excellent lifestyle behaviour treatment option for all patients, including for the large population of mild-moderate–risk patients with elevated blood pressure and blood cholesterol.
All adults should strive to adopt and maintain optimal lifestyle behaviours to improve and sustain health, including cardiovascular health. Lifestyle interventions are a key component of primordial and primary prevention in low-risk groups and serve as an important adjunct to pharmacotherapy in higher-risk groups, but for mild-moderate–risk groups, current blood pressure (2017)2 and blood cholesterol (2018)3 management guidelines published by the American Heart Association (AHA) and the American College of Cardiology (ACC) recommend lifestyle-only approaches as the first line of therapy.
Lifestyle treatment options include physical activity and weight loss, dietary modification, smoking cessation, and alcohol moderation, as well. The purpose of this scientific statement is to (1) highlight the mild-moderate–risk patient groups indicated for lifestyle-only treatment for elevated blood pressure or cholesterol; (2) describe recommendations, average effects, and special considerations when prescribing physical activity, including in comparison to, or in combination with, other lifestyle treatment options; and (3) provide guidance and resources for clinicians to assess, prescribe, counsel, and refer to support increased physical activity in their patients.
Conclusion
A healthy lifestyle is the cornerstone of cardiovascular health. Reflecting changes in the most recent guidelines, an estimated 21% and 28% to 37% of US adults, respectively, have mild-moderate–risk blood pressure and cholesterol and should receive lifestyle-only as first-line treatment. Of the recommended lifestyle changes, increasing physical activity has extensive benefits, including on blood pressure and blood cholesterol, which are comparable, superior, or complementary to other healthy lifestyle changes. Assessment and prescription of physical activity is an excellent lifestyle-only treatment option for the large population of mild-moderate–risk patients with elevated blood pressure and blood cholesterol.
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