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Does regular walking improve lipid levels in adults?
Evidence summary
Walking’s impact on cholesterol levels is modest, inconsistent
A 2022 systematic review and meta-analysis of 21 studies (n = 1129) evaluated the effects of walking on lipids and lipoproteins in women older than 18 years who were overweight or obese and were not taking any lipid-lowering medications. Median TC was 206 mg/dL and median LDL was 126 mg/dL.1
The primary outcome found that walking decreased TC and LDL levels independent of diet and weight loss. Twenty studies reported on TC and showed that walking significantly decreased TC levels compared to the control groups (raw mean difference [RMD] = 6.7 mg/dL; 95% CI, 0.4-12.9; P = .04). Fifteen studies examined LDL and showed a significant decrease in LDL levels with walking compared to control groups (RMD = 7.4 mg/dL; 95% CI, 0.3-14.5; P = .04). However, the small magnitude of the changes may have little clinical impact.1
There were no significant changes in the walking groups compared to the control groups for triglycerides (17 studies; RMD = 2.2 mg/dL; 95% CI, –8.4 to 12.8; P = .68) or high-density lipoprotein (HDL) (18 studies; RMD = 1.5 mg/dL; 95% CI, –0.4 to 3.3; P = .12). Included studies were required to be controlled but were otherwise not described. The overall risk for bias was determined to be low.1
A 2020 RCT (n = 22) assessed the effects of a walking intervention on cholesterol and cardiovascular disease (CVD) risk in individuals ages 40 to 65 years with moderate CVD risk but without diabetes or CVD.2 Moderate CVD risk was defined as a 2% to 5% 10-year risk for a CVD event using the European HeartScore, which incorporates age, sex, blood pressure, lipid levels, and smoking status3; however, study participants were not required to have hyperlipidemia. Participants were enrolled in a 12-week, nurse-led intervention of moderate-paced walking for 30 to 45 minutes 5 times weekly.
Individuals in the intervention group had significant decreases in average TC levels from baseline to follow-up (244.6 mg/dL vs 213.7 mg/dL; P = .001). As a result, participants’ average 10-year CVD risk was significantly reduced from moderate risk to low risk (2.6% vs 1.8%; P = 038) and was significantly lower in the intervention group than in the control group at follow-up (1.8% vs 3.1%; P = .019). No blinding was used, and the use of lipid-lowering medications was not reported, which could have impacted the results.2
A 2008 RCT (n = 67) examined the effect of a home-based walking program (12 weeks of brisk walking, at least 30 min/d and at least 5 d/wk, with at least 300 kcal burned per walk) vs a sedentary control group in men ages 45 to 65 years with hyperlipidemia (TC > 240 mg/dL and/or TC/HDL-C ratio ≥ 6) who were not receiving lipid-lowering medication. There were no significant changes from baseline to follow-up in the walking group compared to the control group in TC (adjusted mean difference [AMD] = –9.3 mg/dL; 95% CI, –22.8 to 4.64; P = .19), HDL-C (AMD = 2.7 mg/dL; 95% CI, –0.4 to 5.4; P = .07) or triglycerides (AMD = –26.6 mg/dL; 95% CI, –56.7 to 2.7; P = .07).4
A 2002 RCT (n = 111) of sedentary men and women (BMI, 25-35; ages, 40-65 years) with dyslipidemia (LDL of 130-190 mg/dL, or HDL < 40 mg/dL for men or < 45 mg/dL for women) examined the impact of various physical activity levels for 8 months when compared to a control group observed for 6 months. The group assigned to low-amount, moderate-intensity physical activity walked an equivalent of 12 miles per week.5
Continue to: In this group...
In this group, there was a significant decrease in average triglyceride concentrations from baseline to follow-up (mean ± standard error = 196.8 ± 30.5 mg/dL vs 145.2 ± 16.0 mg/dL; P < .001). Significance of the change compared with changes in the control group was not reported, although triglycerides in the control group increased from baseline to follow-up (132.1 ± 11.0 vs 155.8 ± 14.9 mg/dL). There were no significant changes from baseline to follow-up in TC (194 ± 4.8 vs 197.9 ± 5.4 mg/dL), LDL (122.7 ± 4.0 vs 127.8 ± 4.1 mg/dL), or HDL (42.0 ± 1.9 vs 43.1 ± 2.5 mg/dL); P values of pre-post changes and comparison to control group were not reported.5
Recommendations from others
The Physical Activity Guidelines for Americans, published by the Department of Health and Human Services and updated in 2018, cite adherence to the published guidelines as a protective factor against high LDL and total lipids in both adults and children.6 The guidelines for adults recommend 150 to 300 minutes of moderate-intensity or 75 to 150 minutes of vigorous-intensity aerobic exercise per week, as well as muscle-strengthening activities of moderate or greater intensity 2 or more days per week. Brisk walking is included as an example of a moderate-intensity activity. These same guidelines are cited and endorsed by the American College of Sports Medicine and the American Heart Association.7,8
Editor’s takeaway
The lipid reductions achieved from walking—if any—are minimal. By themselves, these small reductions will not accomplish our lipid-lowering goals. However, cholesterol goals are primarily disease oriented. This evidence does not directly inform us of important patient-oriented outcomes, such as morbidity, mortality, and vitality.
1. Ballard AM, Davis A, Wong B, et al. The effects of exclusive walking on lipids and lipoproteins in women with overweight and obesity: a systematic review and meta-analysis. Am J Health Promot. 2022;36:328-339. doi: 10.1177/08901171211048135
2. Akgöz AD, Gözüm S. Effectiveness of a nurse-led physical activity intervention to decrease cardiovascular disease risk in middle-aged adults: a pilot randomized controlled study. J Vasc Nurs. 2020;38:140-148. doi: 10.1016/j.jvn.2020.05.002
3. European Association of Preventive Cardiology. HeartScore. Accessed December 23, 2022. www.heartscore.org/en_GB
4. Coghill N, Cooper AR. The effect of a home-based walking program on risk factors for coronary heart disease in hypercholesterolaemic men: a randomized controlled trial. Prev Med. 2008; 46:545-551. doi: 10.1016/j.ypmed.2008.01.002
5. Kraus WE, Houmard JA, Duscha BD, et al. Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med. 2002;347:1483-1492. doi: 10.1056/NEJMoa020194
6. US Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. Washington, DC: US Department of Health and Human Services; 2018. Accessed December 23, 2022. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
7. American Heart Association. Recommendations for physical activity in adults and kids. Accessed December 23, 2022. www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults
8. American College of Sports Medicine. Trending topic: physical activity guidelines. Accessed December 23, 2022. www.acsm.org/education-resources/trending-topics-resources/physical-activity-guidelines
Evidence summary
Walking’s impact on cholesterol levels is modest, inconsistent
A 2022 systematic review and meta-analysis of 21 studies (n = 1129) evaluated the effects of walking on lipids and lipoproteins in women older than 18 years who were overweight or obese and were not taking any lipid-lowering medications. Median TC was 206 mg/dL and median LDL was 126 mg/dL.1
The primary outcome found that walking decreased TC and LDL levels independent of diet and weight loss. Twenty studies reported on TC and showed that walking significantly decreased TC levels compared to the control groups (raw mean difference [RMD] = 6.7 mg/dL; 95% CI, 0.4-12.9; P = .04). Fifteen studies examined LDL and showed a significant decrease in LDL levels with walking compared to control groups (RMD = 7.4 mg/dL; 95% CI, 0.3-14.5; P = .04). However, the small magnitude of the changes may have little clinical impact.1
There were no significant changes in the walking groups compared to the control groups for triglycerides (17 studies; RMD = 2.2 mg/dL; 95% CI, –8.4 to 12.8; P = .68) or high-density lipoprotein (HDL) (18 studies; RMD = 1.5 mg/dL; 95% CI, –0.4 to 3.3; P = .12). Included studies were required to be controlled but were otherwise not described. The overall risk for bias was determined to be low.1
A 2020 RCT (n = 22) assessed the effects of a walking intervention on cholesterol and cardiovascular disease (CVD) risk in individuals ages 40 to 65 years with moderate CVD risk but without diabetes or CVD.2 Moderate CVD risk was defined as a 2% to 5% 10-year risk for a CVD event using the European HeartScore, which incorporates age, sex, blood pressure, lipid levels, and smoking status3; however, study participants were not required to have hyperlipidemia. Participants were enrolled in a 12-week, nurse-led intervention of moderate-paced walking for 30 to 45 minutes 5 times weekly.
Individuals in the intervention group had significant decreases in average TC levels from baseline to follow-up (244.6 mg/dL vs 213.7 mg/dL; P = .001). As a result, participants’ average 10-year CVD risk was significantly reduced from moderate risk to low risk (2.6% vs 1.8%; P = 038) and was significantly lower in the intervention group than in the control group at follow-up (1.8% vs 3.1%; P = .019). No blinding was used, and the use of lipid-lowering medications was not reported, which could have impacted the results.2
A 2008 RCT (n = 67) examined the effect of a home-based walking program (12 weeks of brisk walking, at least 30 min/d and at least 5 d/wk, with at least 300 kcal burned per walk) vs a sedentary control group in men ages 45 to 65 years with hyperlipidemia (TC > 240 mg/dL and/or TC/HDL-C ratio ≥ 6) who were not receiving lipid-lowering medication. There were no significant changes from baseline to follow-up in the walking group compared to the control group in TC (adjusted mean difference [AMD] = –9.3 mg/dL; 95% CI, –22.8 to 4.64; P = .19), HDL-C (AMD = 2.7 mg/dL; 95% CI, –0.4 to 5.4; P = .07) or triglycerides (AMD = –26.6 mg/dL; 95% CI, –56.7 to 2.7; P = .07).4
A 2002 RCT (n = 111) of sedentary men and women (BMI, 25-35; ages, 40-65 years) with dyslipidemia (LDL of 130-190 mg/dL, or HDL < 40 mg/dL for men or < 45 mg/dL for women) examined the impact of various physical activity levels for 8 months when compared to a control group observed for 6 months. The group assigned to low-amount, moderate-intensity physical activity walked an equivalent of 12 miles per week.5
Continue to: In this group...
In this group, there was a significant decrease in average triglyceride concentrations from baseline to follow-up (mean ± standard error = 196.8 ± 30.5 mg/dL vs 145.2 ± 16.0 mg/dL; P < .001). Significance of the change compared with changes in the control group was not reported, although triglycerides in the control group increased from baseline to follow-up (132.1 ± 11.0 vs 155.8 ± 14.9 mg/dL). There were no significant changes from baseline to follow-up in TC (194 ± 4.8 vs 197.9 ± 5.4 mg/dL), LDL (122.7 ± 4.0 vs 127.8 ± 4.1 mg/dL), or HDL (42.0 ± 1.9 vs 43.1 ± 2.5 mg/dL); P values of pre-post changes and comparison to control group were not reported.5
Recommendations from others
The Physical Activity Guidelines for Americans, published by the Department of Health and Human Services and updated in 2018, cite adherence to the published guidelines as a protective factor against high LDL and total lipids in both adults and children.6 The guidelines for adults recommend 150 to 300 minutes of moderate-intensity or 75 to 150 minutes of vigorous-intensity aerobic exercise per week, as well as muscle-strengthening activities of moderate or greater intensity 2 or more days per week. Brisk walking is included as an example of a moderate-intensity activity. These same guidelines are cited and endorsed by the American College of Sports Medicine and the American Heart Association.7,8
Editor’s takeaway
The lipid reductions achieved from walking—if any—are minimal. By themselves, these small reductions will not accomplish our lipid-lowering goals. However, cholesterol goals are primarily disease oriented. This evidence does not directly inform us of important patient-oriented outcomes, such as morbidity, mortality, and vitality.
Evidence summary
Walking’s impact on cholesterol levels is modest, inconsistent
A 2022 systematic review and meta-analysis of 21 studies (n = 1129) evaluated the effects of walking on lipids and lipoproteins in women older than 18 years who were overweight or obese and were not taking any lipid-lowering medications. Median TC was 206 mg/dL and median LDL was 126 mg/dL.1
The primary outcome found that walking decreased TC and LDL levels independent of diet and weight loss. Twenty studies reported on TC and showed that walking significantly decreased TC levels compared to the control groups (raw mean difference [RMD] = 6.7 mg/dL; 95% CI, 0.4-12.9; P = .04). Fifteen studies examined LDL and showed a significant decrease in LDL levels with walking compared to control groups (RMD = 7.4 mg/dL; 95% CI, 0.3-14.5; P = .04). However, the small magnitude of the changes may have little clinical impact.1
There were no significant changes in the walking groups compared to the control groups for triglycerides (17 studies; RMD = 2.2 mg/dL; 95% CI, –8.4 to 12.8; P = .68) or high-density lipoprotein (HDL) (18 studies; RMD = 1.5 mg/dL; 95% CI, –0.4 to 3.3; P = .12). Included studies were required to be controlled but were otherwise not described. The overall risk for bias was determined to be low.1
A 2020 RCT (n = 22) assessed the effects of a walking intervention on cholesterol and cardiovascular disease (CVD) risk in individuals ages 40 to 65 years with moderate CVD risk but without diabetes or CVD.2 Moderate CVD risk was defined as a 2% to 5% 10-year risk for a CVD event using the European HeartScore, which incorporates age, sex, blood pressure, lipid levels, and smoking status3; however, study participants were not required to have hyperlipidemia. Participants were enrolled in a 12-week, nurse-led intervention of moderate-paced walking for 30 to 45 minutes 5 times weekly.
Individuals in the intervention group had significant decreases in average TC levels from baseline to follow-up (244.6 mg/dL vs 213.7 mg/dL; P = .001). As a result, participants’ average 10-year CVD risk was significantly reduced from moderate risk to low risk (2.6% vs 1.8%; P = 038) and was significantly lower in the intervention group than in the control group at follow-up (1.8% vs 3.1%; P = .019). No blinding was used, and the use of lipid-lowering medications was not reported, which could have impacted the results.2
A 2008 RCT (n = 67) examined the effect of a home-based walking program (12 weeks of brisk walking, at least 30 min/d and at least 5 d/wk, with at least 300 kcal burned per walk) vs a sedentary control group in men ages 45 to 65 years with hyperlipidemia (TC > 240 mg/dL and/or TC/HDL-C ratio ≥ 6) who were not receiving lipid-lowering medication. There were no significant changes from baseline to follow-up in the walking group compared to the control group in TC (adjusted mean difference [AMD] = –9.3 mg/dL; 95% CI, –22.8 to 4.64; P = .19), HDL-C (AMD = 2.7 mg/dL; 95% CI, –0.4 to 5.4; P = .07) or triglycerides (AMD = –26.6 mg/dL; 95% CI, –56.7 to 2.7; P = .07).4
A 2002 RCT (n = 111) of sedentary men and women (BMI, 25-35; ages, 40-65 years) with dyslipidemia (LDL of 130-190 mg/dL, or HDL < 40 mg/dL for men or < 45 mg/dL for women) examined the impact of various physical activity levels for 8 months when compared to a control group observed for 6 months. The group assigned to low-amount, moderate-intensity physical activity walked an equivalent of 12 miles per week.5
Continue to: In this group...
In this group, there was a significant decrease in average triglyceride concentrations from baseline to follow-up (mean ± standard error = 196.8 ± 30.5 mg/dL vs 145.2 ± 16.0 mg/dL; P < .001). Significance of the change compared with changes in the control group was not reported, although triglycerides in the control group increased from baseline to follow-up (132.1 ± 11.0 vs 155.8 ± 14.9 mg/dL). There were no significant changes from baseline to follow-up in TC (194 ± 4.8 vs 197.9 ± 5.4 mg/dL), LDL (122.7 ± 4.0 vs 127.8 ± 4.1 mg/dL), or HDL (42.0 ± 1.9 vs 43.1 ± 2.5 mg/dL); P values of pre-post changes and comparison to control group were not reported.5
Recommendations from others
The Physical Activity Guidelines for Americans, published by the Department of Health and Human Services and updated in 2018, cite adherence to the published guidelines as a protective factor against high LDL and total lipids in both adults and children.6 The guidelines for adults recommend 150 to 300 minutes of moderate-intensity or 75 to 150 minutes of vigorous-intensity aerobic exercise per week, as well as muscle-strengthening activities of moderate or greater intensity 2 or more days per week. Brisk walking is included as an example of a moderate-intensity activity. These same guidelines are cited and endorsed by the American College of Sports Medicine and the American Heart Association.7,8
Editor’s takeaway
The lipid reductions achieved from walking—if any—are minimal. By themselves, these small reductions will not accomplish our lipid-lowering goals. However, cholesterol goals are primarily disease oriented. This evidence does not directly inform us of important patient-oriented outcomes, such as morbidity, mortality, and vitality.
1. Ballard AM, Davis A, Wong B, et al. The effects of exclusive walking on lipids and lipoproteins in women with overweight and obesity: a systematic review and meta-analysis. Am J Health Promot. 2022;36:328-339. doi: 10.1177/08901171211048135
2. Akgöz AD, Gözüm S. Effectiveness of a nurse-led physical activity intervention to decrease cardiovascular disease risk in middle-aged adults: a pilot randomized controlled study. J Vasc Nurs. 2020;38:140-148. doi: 10.1016/j.jvn.2020.05.002
3. European Association of Preventive Cardiology. HeartScore. Accessed December 23, 2022. www.heartscore.org/en_GB
4. Coghill N, Cooper AR. The effect of a home-based walking program on risk factors for coronary heart disease in hypercholesterolaemic men: a randomized controlled trial. Prev Med. 2008; 46:545-551. doi: 10.1016/j.ypmed.2008.01.002
5. Kraus WE, Houmard JA, Duscha BD, et al. Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med. 2002;347:1483-1492. doi: 10.1056/NEJMoa020194
6. US Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. Washington, DC: US Department of Health and Human Services; 2018. Accessed December 23, 2022. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
7. American Heart Association. Recommendations for physical activity in adults and kids. Accessed December 23, 2022. www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults
8. American College of Sports Medicine. Trending topic: physical activity guidelines. Accessed December 23, 2022. www.acsm.org/education-resources/trending-topics-resources/physical-activity-guidelines
1. Ballard AM, Davis A, Wong B, et al. The effects of exclusive walking on lipids and lipoproteins in women with overweight and obesity: a systematic review and meta-analysis. Am J Health Promot. 2022;36:328-339. doi: 10.1177/08901171211048135
2. Akgöz AD, Gözüm S. Effectiveness of a nurse-led physical activity intervention to decrease cardiovascular disease risk in middle-aged adults: a pilot randomized controlled study. J Vasc Nurs. 2020;38:140-148. doi: 10.1016/j.jvn.2020.05.002
3. European Association of Preventive Cardiology. HeartScore. Accessed December 23, 2022. www.heartscore.org/en_GB
4. Coghill N, Cooper AR. The effect of a home-based walking program on risk factors for coronary heart disease in hypercholesterolaemic men: a randomized controlled trial. Prev Med. 2008; 46:545-551. doi: 10.1016/j.ypmed.2008.01.002
5. Kraus WE, Houmard JA, Duscha BD, et al. Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med. 2002;347:1483-1492. doi: 10.1056/NEJMoa020194
6. US Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. Washington, DC: US Department of Health and Human Services; 2018. Accessed December 23, 2022. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
7. American Heart Association. Recommendations for physical activity in adults and kids. Accessed December 23, 2022. www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults
8. American College of Sports Medicine. Trending topic: physical activity guidelines. Accessed December 23, 2022. www.acsm.org/education-resources/trending-topics-resources/physical-activity-guidelines
EVIDENCE-BASED ANSWER:
Minimally. Regular moderate- intensity walking for a period of 4 or more weeks minimally decreased total cholesterol (TC) and low-density lipoprotein (LDL) levels by about 7 mg/dL in women with overweight or obesity (strength of recommendation [SOR]: C, systematic review and meta-analysis on disease-oriented evidence). For adults ages 40 to 65 years, regular walking for 3 or more months inconsistently affected cholesterol and triglyceride levels (SOR: C, based on 3 randomized controlled trials [RCTs] with disease-oriented evidence).
Which detoxification regimens are effective for alcohol withdrawal syndrome?
EVIDENCE SUMMARY
Benzodiazepines work—but how do they compare?
A 2010 Cochrane meta-analysis of 64 RCTs and controlled clinical trials (CCTs; N = 4309) evaluated the use of benzodiazepines for treatment of AWS in adults.1 This systematic review compared benzodiazepines
- vs placebo (10 studies)
- vs other drugs, including phenobarbital, carbamazepine, topiramate, lamotrigine, gabapentin, haloperidol, clonidine, hydroxyzine, propranolol, and baclofen (42 studies)
- to other benzodiazepines, including chlordiazepoxide, alprazolam, diazepam, and lorazepam (18 studies)
- in combination with other drugs vs other drugs alone (3 studies)
- administered on a fixed schedule vs symptom-triggered administration (3 studies).
Primary outcomes included efficacy (alcohol withdrawal seizures, alcohol withdrawal delirium, alcohol withdrawal symptoms, global improvement), safety (adverse events and severe, life-threatening adverse events), and acceptability (dropouts and dropouts due to adverse events).
Benzodiazepines performed better than placebo for seizures in 3 studies (N = 324), with a relative risk (RR) of 0.16 (95% confidence interval [CI], 0.04-0.69). Studies assessing the described outcomes between benzodiazepines and other drugs were often of small sample size and heterogeneous in interventions and outcomes, limiting the ability to draw clear conclusions regarding benzodiazepine superiority. Comparisons of different benzodiazepines with each other and comparisons of benzodiazepines combined with other drugs vs other drugs alone did not reach statistical significance. Data on harms of benzodiazepines were lacking.
Anticonvulsants are not better than placebo for AWS
Another 2010 Cochrane meta-analysis of 56 RCTs and CCTs (N = 4076) evaluated the use of anticonvulsants for AWS.2 This systematic review compared anticonvulsants
- vs placebo (17 studies)
- vs other drugs, such as bromocriptine, piracetam, gamma-hydroxybutyric acid, trifluoperazine, clonidine, and various benzodiazepines (32 studies)
- to other anticonvulsants (10 studies)
- in combination with other drugs vs other drugs alone (6 studies)
- in combination with other drugs vs different anticonvulsants (1 study).
Primary outcomes included reductions in alcohol withdrawal seizures, adverse events, and acceptability of medication as indicated by participant dropouts.
Anticonvulsants were not superior to placebo for any outcome. Three studies (N = 260) favored carbamazepine over benzodiazepine (oxazepam or lorazepam) for 1 secondary outcome: a reduction of Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) score (maximum score of 7; mean difference [MD] = –1 [95% CI, –1.9 to –0.2]).
Continue to: Gabapentin is effective; less sedating than chlordiazepoxide
Gabapentin is effective; less sedating than chlordiazepoxide
A 2013 RCT of US veterans with AWS (N = 26; 25 men; average age, 53.5 years) compared gabapentin and chlordiazepoxide.3 Endpoints were ratings on the Epworth Sleepiness Scale (ESS; maximum score = 24), Penn Alcohol Craving Scale (PACS; maximum score, 30), and CIWA-Ar.
In the early treatment period (Days 1-4), ESS and PACS scores did not differ significantly between groups. At end of treatment (Days 5-7), ESS and PACS scores were lower in gabapentin-treated patients (ESS: MD = –3.7; 95% CI, –7.2 to –0.19; P = .04; PACS: MD = –6.05; 95% CI –12.82 to 0.72; P = .08). CIWA-Ar did not differ between treatment groups.
Recommendations from others
In January 2020, the American Society of Addiction Medicine (ASAM) published a clinical practice guideline for alcohol withdrawal management. Protocols for diagnosis, assessment, level of care determination, and management are delineated.4
Benzodiazepines are the first-line treatment for moderate-to-severe AWS, or when there is risk for severe AWS. In the ambulatory setting, when AWS is mild and there is no risk for worsening, AWS can be managed with supportive care or with either benzodiazepines, gabapentin, or carbamazepine as monotherapy. ASAM recommends long-acting benzodiazepines (eg, chlordiazepoxide or diazepam) over short-acting benzodiazepines (eg, alprazolam or lorazepam), except in the elderly and those with liver or lung disease.5
Editor’s takeaway
Dozens of small trials and meta-analyses confirm the benefits (sometimes marginal) of sedation to treat alcohol withdrawal. Given that the evidence fails to point to the superiority of 1 agent over another, it seems reasonable to make treatment decisions based on physician and perhaps patient preference. This review does not support a change in clinical practice.
1. Amato L, Minozzi S, Vecchi S, et al. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. 2010;(3):CD005063.
2. Minozzi S, Amato L, Vecchi S, et al. Anticonvulsants for alcohol withdrawal. Cochrane Database Syst Rev. 2010;(3):CD005064.
3. Stock CJ, Carpenter L, Ying J, et al. Gabapentin versus chlordiazepoxide for outpatient alcohol detoxification treatment. Ann Pharmacother. 2013;47:961-969.
4. American Society of Addiction Medicine. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management 2020. Accessed March 2, 2021. www.asam.org/docs/default-source/quality-science/the_asam_clinical_practice_guideline_on_alcohol-1.pdf
5. Ries RK, Fiellin DA, Miller SC, et al. The ASAM Principles of Addiction Medicine. 4th ed. Lippincott Williams & Wilkins; 2014.
EVIDENCE SUMMARY
Benzodiazepines work—but how do they compare?
A 2010 Cochrane meta-analysis of 64 RCTs and controlled clinical trials (CCTs; N = 4309) evaluated the use of benzodiazepines for treatment of AWS in adults.1 This systematic review compared benzodiazepines
- vs placebo (10 studies)
- vs other drugs, including phenobarbital, carbamazepine, topiramate, lamotrigine, gabapentin, haloperidol, clonidine, hydroxyzine, propranolol, and baclofen (42 studies)
- to other benzodiazepines, including chlordiazepoxide, alprazolam, diazepam, and lorazepam (18 studies)
- in combination with other drugs vs other drugs alone (3 studies)
- administered on a fixed schedule vs symptom-triggered administration (3 studies).
Primary outcomes included efficacy (alcohol withdrawal seizures, alcohol withdrawal delirium, alcohol withdrawal symptoms, global improvement), safety (adverse events and severe, life-threatening adverse events), and acceptability (dropouts and dropouts due to adverse events).
Benzodiazepines performed better than placebo for seizures in 3 studies (N = 324), with a relative risk (RR) of 0.16 (95% confidence interval [CI], 0.04-0.69). Studies assessing the described outcomes between benzodiazepines and other drugs were often of small sample size and heterogeneous in interventions and outcomes, limiting the ability to draw clear conclusions regarding benzodiazepine superiority. Comparisons of different benzodiazepines with each other and comparisons of benzodiazepines combined with other drugs vs other drugs alone did not reach statistical significance. Data on harms of benzodiazepines were lacking.
Anticonvulsants are not better than placebo for AWS
Another 2010 Cochrane meta-analysis of 56 RCTs and CCTs (N = 4076) evaluated the use of anticonvulsants for AWS.2 This systematic review compared anticonvulsants
- vs placebo (17 studies)
- vs other drugs, such as bromocriptine, piracetam, gamma-hydroxybutyric acid, trifluoperazine, clonidine, and various benzodiazepines (32 studies)
- to other anticonvulsants (10 studies)
- in combination with other drugs vs other drugs alone (6 studies)
- in combination with other drugs vs different anticonvulsants (1 study).
Primary outcomes included reductions in alcohol withdrawal seizures, adverse events, and acceptability of medication as indicated by participant dropouts.
Anticonvulsants were not superior to placebo for any outcome. Three studies (N = 260) favored carbamazepine over benzodiazepine (oxazepam or lorazepam) for 1 secondary outcome: a reduction of Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) score (maximum score of 7; mean difference [MD] = –1 [95% CI, –1.9 to –0.2]).
Continue to: Gabapentin is effective; less sedating than chlordiazepoxide
Gabapentin is effective; less sedating than chlordiazepoxide
A 2013 RCT of US veterans with AWS (N = 26; 25 men; average age, 53.5 years) compared gabapentin and chlordiazepoxide.3 Endpoints were ratings on the Epworth Sleepiness Scale (ESS; maximum score = 24), Penn Alcohol Craving Scale (PACS; maximum score, 30), and CIWA-Ar.
In the early treatment period (Days 1-4), ESS and PACS scores did not differ significantly between groups. At end of treatment (Days 5-7), ESS and PACS scores were lower in gabapentin-treated patients (ESS: MD = –3.7; 95% CI, –7.2 to –0.19; P = .04; PACS: MD = –6.05; 95% CI –12.82 to 0.72; P = .08). CIWA-Ar did not differ between treatment groups.
Recommendations from others
In January 2020, the American Society of Addiction Medicine (ASAM) published a clinical practice guideline for alcohol withdrawal management. Protocols for diagnosis, assessment, level of care determination, and management are delineated.4
Benzodiazepines are the first-line treatment for moderate-to-severe AWS, or when there is risk for severe AWS. In the ambulatory setting, when AWS is mild and there is no risk for worsening, AWS can be managed with supportive care or with either benzodiazepines, gabapentin, or carbamazepine as monotherapy. ASAM recommends long-acting benzodiazepines (eg, chlordiazepoxide or diazepam) over short-acting benzodiazepines (eg, alprazolam or lorazepam), except in the elderly and those with liver or lung disease.5
Editor’s takeaway
Dozens of small trials and meta-analyses confirm the benefits (sometimes marginal) of sedation to treat alcohol withdrawal. Given that the evidence fails to point to the superiority of 1 agent over another, it seems reasonable to make treatment decisions based on physician and perhaps patient preference. This review does not support a change in clinical practice.
EVIDENCE SUMMARY
Benzodiazepines work—but how do they compare?
A 2010 Cochrane meta-analysis of 64 RCTs and controlled clinical trials (CCTs; N = 4309) evaluated the use of benzodiazepines for treatment of AWS in adults.1 This systematic review compared benzodiazepines
- vs placebo (10 studies)
- vs other drugs, including phenobarbital, carbamazepine, topiramate, lamotrigine, gabapentin, haloperidol, clonidine, hydroxyzine, propranolol, and baclofen (42 studies)
- to other benzodiazepines, including chlordiazepoxide, alprazolam, diazepam, and lorazepam (18 studies)
- in combination with other drugs vs other drugs alone (3 studies)
- administered on a fixed schedule vs symptom-triggered administration (3 studies).
Primary outcomes included efficacy (alcohol withdrawal seizures, alcohol withdrawal delirium, alcohol withdrawal symptoms, global improvement), safety (adverse events and severe, life-threatening adverse events), and acceptability (dropouts and dropouts due to adverse events).
Benzodiazepines performed better than placebo for seizures in 3 studies (N = 324), with a relative risk (RR) of 0.16 (95% confidence interval [CI], 0.04-0.69). Studies assessing the described outcomes between benzodiazepines and other drugs were often of small sample size and heterogeneous in interventions and outcomes, limiting the ability to draw clear conclusions regarding benzodiazepine superiority. Comparisons of different benzodiazepines with each other and comparisons of benzodiazepines combined with other drugs vs other drugs alone did not reach statistical significance. Data on harms of benzodiazepines were lacking.
Anticonvulsants are not better than placebo for AWS
Another 2010 Cochrane meta-analysis of 56 RCTs and CCTs (N = 4076) evaluated the use of anticonvulsants for AWS.2 This systematic review compared anticonvulsants
- vs placebo (17 studies)
- vs other drugs, such as bromocriptine, piracetam, gamma-hydroxybutyric acid, trifluoperazine, clonidine, and various benzodiazepines (32 studies)
- to other anticonvulsants (10 studies)
- in combination with other drugs vs other drugs alone (6 studies)
- in combination with other drugs vs different anticonvulsants (1 study).
Primary outcomes included reductions in alcohol withdrawal seizures, adverse events, and acceptability of medication as indicated by participant dropouts.
Anticonvulsants were not superior to placebo for any outcome. Three studies (N = 260) favored carbamazepine over benzodiazepine (oxazepam or lorazepam) for 1 secondary outcome: a reduction of Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) score (maximum score of 7; mean difference [MD] = –1 [95% CI, –1.9 to –0.2]).
Continue to: Gabapentin is effective; less sedating than chlordiazepoxide
Gabapentin is effective; less sedating than chlordiazepoxide
A 2013 RCT of US veterans with AWS (N = 26; 25 men; average age, 53.5 years) compared gabapentin and chlordiazepoxide.3 Endpoints were ratings on the Epworth Sleepiness Scale (ESS; maximum score = 24), Penn Alcohol Craving Scale (PACS; maximum score, 30), and CIWA-Ar.
In the early treatment period (Days 1-4), ESS and PACS scores did not differ significantly between groups. At end of treatment (Days 5-7), ESS and PACS scores were lower in gabapentin-treated patients (ESS: MD = –3.7; 95% CI, –7.2 to –0.19; P = .04; PACS: MD = –6.05; 95% CI –12.82 to 0.72; P = .08). CIWA-Ar did not differ between treatment groups.
Recommendations from others
In January 2020, the American Society of Addiction Medicine (ASAM) published a clinical practice guideline for alcohol withdrawal management. Protocols for diagnosis, assessment, level of care determination, and management are delineated.4
Benzodiazepines are the first-line treatment for moderate-to-severe AWS, or when there is risk for severe AWS. In the ambulatory setting, when AWS is mild and there is no risk for worsening, AWS can be managed with supportive care or with either benzodiazepines, gabapentin, or carbamazepine as monotherapy. ASAM recommends long-acting benzodiazepines (eg, chlordiazepoxide or diazepam) over short-acting benzodiazepines (eg, alprazolam or lorazepam), except in the elderly and those with liver or lung disease.5
Editor’s takeaway
Dozens of small trials and meta-analyses confirm the benefits (sometimes marginal) of sedation to treat alcohol withdrawal. Given that the evidence fails to point to the superiority of 1 agent over another, it seems reasonable to make treatment decisions based on physician and perhaps patient preference. This review does not support a change in clinical practice.
1. Amato L, Minozzi S, Vecchi S, et al. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. 2010;(3):CD005063.
2. Minozzi S, Amato L, Vecchi S, et al. Anticonvulsants for alcohol withdrawal. Cochrane Database Syst Rev. 2010;(3):CD005064.
3. Stock CJ, Carpenter L, Ying J, et al. Gabapentin versus chlordiazepoxide for outpatient alcohol detoxification treatment. Ann Pharmacother. 2013;47:961-969.
4. American Society of Addiction Medicine. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management 2020. Accessed March 2, 2021. www.asam.org/docs/default-source/quality-science/the_asam_clinical_practice_guideline_on_alcohol-1.pdf
5. Ries RK, Fiellin DA, Miller SC, et al. The ASAM Principles of Addiction Medicine. 4th ed. Lippincott Williams & Wilkins; 2014.
1. Amato L, Minozzi S, Vecchi S, et al. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. 2010;(3):CD005063.
2. Minozzi S, Amato L, Vecchi S, et al. Anticonvulsants for alcohol withdrawal. Cochrane Database Syst Rev. 2010;(3):CD005064.
3. Stock CJ, Carpenter L, Ying J, et al. Gabapentin versus chlordiazepoxide for outpatient alcohol detoxification treatment. Ann Pharmacother. 2013;47:961-969.
4. American Society of Addiction Medicine. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management 2020. Accessed March 2, 2021. www.asam.org/docs/default-source/quality-science/the_asam_clinical_practice_guideline_on_alcohol-1.pdf
5. Ries RK, Fiellin DA, Miller SC, et al. The ASAM Principles of Addiction Medicine. 4th ed. Lippincott Williams & Wilkins; 2014.
EVIDENCE-BASED ANSWER:
Benzodiazepines remain the first-line regimen for alcohol withdrawal syndrome (AWS) and are the only class more effective than placebo for reducing seizure (strength of recommendation [SOR]: B, based on 3 medium-quality randomized controlled trials [RCTs]). Anticonvulsants are no more effective than placebo at reducing seizures (SOR: B, based on 10 moderate-quality RCTs). Gabapentin reduces withdrawal symptoms and is less sedating than benzodiazepines (SOR: B, based on 1 medium-quality RCT). Carbamazepine also reduces withdrawal symptoms (SOR: B, based on 3 RCTs). Evidence of benzodiazepine superiority to other drugs with respect to safety is lacking (SOR: A, based on a meta-analysis).
How much does weight loss affect hypertension?
WEIGHT LOSS OF 4 KG by diet reduces systolic and diastolic blood pressure (BP) by 4.5 and 3.2 mm Hg, respectively (SOR: A, systematic review with consistent findings).
Weight loss of 1 to 1.2 kg by exercise may produce small reductions in systolic or diastolic BP (SOR: B, mixed quality of studies).
Available evidence is inadequate to examine the combined effects of diet and exercise.
Evidence summary
A meta-analysis of 8 randomized controlled trials (RCTs) with a total of 2000 patients found that weight loss through diet reduced BP in hypertensive patients.1 Investigators recruited adult outpatients, 45 to 66 years of age, with primary hypertension (systolic BP, 128-178 mm Hg, diastolic BP, 72-107 mm Hg) and randomized them to dietary advice or usual care for 6 to 12 months.
Dietary advice resulted in greater weight loss over 6 to 12 months of follow-up (weighted mean difference [WMD], –4.0 kg; 95% confidence interval [CI], –4.8 to –3.2 kg) and greater BP reduction (WMD for systolic BP, –4.5 mm Hg; 95% CI, –7.2 to –1.8 mm Hg; WMD for diastolic BP, –3.2 mm Hg; 95% CI, –4.8 to –1.5 mm Hg).
Investigators didn’t report how long patients maintained the weight loss. Although 3 RCTs included encouragement to exercise, this meta-analysis didn’t evaluate benefits of combining these interventions.
The effects of exercise are less clear
A meta-analysis of 24 RCTs examined exercise and weight loss in adult outpatients with a mean age of 51.6 years; baseline body mass index (BMI), 25.9 kg/m2; resting systolic BP, 127 mm Hg; and resting diastolic BP, 77.7 mm Hg.2 On average, participants walked for 38.3 minutes, 4.4 days per week, for 34.9 weeks at a relative intensity of 70.1% of predicted maximum heart rate (in 6 studies) or 56.3% oxygen consumption intensity (VO2) (in 14 studies).
Walking significantly reduced body weight (WMD, –0.95 kg; P<.001) and BMI (WMD, –0.28 kg/m2; P = .015), leading to a significant reduction in diastolic BP (WMD, –1.54 mm Hg; P = .026) but not systolic BP (WMD, –1.06 mm Hg; P = .316). The authors didn’t report whether participants maintained the weight loss after the interventions.
In a meta-analysis of 8 RCTs and 18 observational studies, adult outpatients described as generally normotensive and overweight (mean age 49 years) wore pedometers to encourage weight loss with the goal of decreasing BP.3
Pedometer use for 3 to 104 weeks increased physical activity (for RCTs, a 2491-steps-per-day increase; 95% CI, 1098-3885 steps per day; for observational studies, a 2183-steps-per-day increase; 95% CI, 1571-2796 steps per day) and decreased BMI by 0.38 kg/m2 (95% CI, 0.05-0.72 kg/m2). For an 80-kg, 170-cm tall person with a BMI of 27.7 kg/m2, reducing BMI by 0.4 units translates to a 1.2-kg weight loss. This weight loss reduced systolic BP by 3.8 mm Hg (95% CI, 1.7-5.9 mm Hg), but not diastolic BP (–0.3 mm Hg; 95% CI, 0.02 to –0.46). Using a 10,000-steps-per-day goal (P = .001) and a step diary (P<.001) further increased walking.
Recommendations
The National Heart, Lung, and Blood Institute’s Joint National Committee says that healthy lifestyles are critical to preventing hypertension and reducing BP in people who are already hypertensive.4 Specifically, the Committee recommends weight reduction in overweight or obese individuals by increasing physical activity and using the Dietary Approaches to Stop Hypertension (DASH) eating plan. Combining 2 or more lifestyle modifications may enhance results.
The Committee also notes that a positive, empathetic relationship with a clinician is crucial in building trust and enhancing motivation to make lifestyle changes. It recommends setting mutual goals, ensuring adequate patient education, using frequent feedback, and involving all members of the health care team.
1. Siebenhofer A, Jeitler K, Berghold A, et al. Long-term effects of weight-reducing diets in hypertensive patients. Cochrane Database Syst Rev. 2011;(9):CD008274.-
2. Murphy MH, Nevill AM, Murtagh EM, et al. The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials. Prev Med. 2007;44:377-385.
3. Bravata DM, Smith-Spangler C, Sundaram V, et al. Using pedometers to increase physical activity and improve health: a systematic review. JAMA. 2007;298:2296-2304.
4. United States Department of Health and Human Services. The seventh report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure. Available at: http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf. Accessed March 13, 2013.
WEIGHT LOSS OF 4 KG by diet reduces systolic and diastolic blood pressure (BP) by 4.5 and 3.2 mm Hg, respectively (SOR: A, systematic review with consistent findings).
Weight loss of 1 to 1.2 kg by exercise may produce small reductions in systolic or diastolic BP (SOR: B, mixed quality of studies).
Available evidence is inadequate to examine the combined effects of diet and exercise.
Evidence summary
A meta-analysis of 8 randomized controlled trials (RCTs) with a total of 2000 patients found that weight loss through diet reduced BP in hypertensive patients.1 Investigators recruited adult outpatients, 45 to 66 years of age, with primary hypertension (systolic BP, 128-178 mm Hg, diastolic BP, 72-107 mm Hg) and randomized them to dietary advice or usual care for 6 to 12 months.
Dietary advice resulted in greater weight loss over 6 to 12 months of follow-up (weighted mean difference [WMD], –4.0 kg; 95% confidence interval [CI], –4.8 to –3.2 kg) and greater BP reduction (WMD for systolic BP, –4.5 mm Hg; 95% CI, –7.2 to –1.8 mm Hg; WMD for diastolic BP, –3.2 mm Hg; 95% CI, –4.8 to –1.5 mm Hg).
Investigators didn’t report how long patients maintained the weight loss. Although 3 RCTs included encouragement to exercise, this meta-analysis didn’t evaluate benefits of combining these interventions.
The effects of exercise are less clear
A meta-analysis of 24 RCTs examined exercise and weight loss in adult outpatients with a mean age of 51.6 years; baseline body mass index (BMI), 25.9 kg/m2; resting systolic BP, 127 mm Hg; and resting diastolic BP, 77.7 mm Hg.2 On average, participants walked for 38.3 minutes, 4.4 days per week, for 34.9 weeks at a relative intensity of 70.1% of predicted maximum heart rate (in 6 studies) or 56.3% oxygen consumption intensity (VO2) (in 14 studies).
Walking significantly reduced body weight (WMD, –0.95 kg; P<.001) and BMI (WMD, –0.28 kg/m2; P = .015), leading to a significant reduction in diastolic BP (WMD, –1.54 mm Hg; P = .026) but not systolic BP (WMD, –1.06 mm Hg; P = .316). The authors didn’t report whether participants maintained the weight loss after the interventions.
In a meta-analysis of 8 RCTs and 18 observational studies, adult outpatients described as generally normotensive and overweight (mean age 49 years) wore pedometers to encourage weight loss with the goal of decreasing BP.3
Pedometer use for 3 to 104 weeks increased physical activity (for RCTs, a 2491-steps-per-day increase; 95% CI, 1098-3885 steps per day; for observational studies, a 2183-steps-per-day increase; 95% CI, 1571-2796 steps per day) and decreased BMI by 0.38 kg/m2 (95% CI, 0.05-0.72 kg/m2). For an 80-kg, 170-cm tall person with a BMI of 27.7 kg/m2, reducing BMI by 0.4 units translates to a 1.2-kg weight loss. This weight loss reduced systolic BP by 3.8 mm Hg (95% CI, 1.7-5.9 mm Hg), but not diastolic BP (–0.3 mm Hg; 95% CI, 0.02 to –0.46). Using a 10,000-steps-per-day goal (P = .001) and a step diary (P<.001) further increased walking.
Recommendations
The National Heart, Lung, and Blood Institute’s Joint National Committee says that healthy lifestyles are critical to preventing hypertension and reducing BP in people who are already hypertensive.4 Specifically, the Committee recommends weight reduction in overweight or obese individuals by increasing physical activity and using the Dietary Approaches to Stop Hypertension (DASH) eating plan. Combining 2 or more lifestyle modifications may enhance results.
The Committee also notes that a positive, empathetic relationship with a clinician is crucial in building trust and enhancing motivation to make lifestyle changes. It recommends setting mutual goals, ensuring adequate patient education, using frequent feedback, and involving all members of the health care team.
WEIGHT LOSS OF 4 KG by diet reduces systolic and diastolic blood pressure (BP) by 4.5 and 3.2 mm Hg, respectively (SOR: A, systematic review with consistent findings).
Weight loss of 1 to 1.2 kg by exercise may produce small reductions in systolic or diastolic BP (SOR: B, mixed quality of studies).
Available evidence is inadequate to examine the combined effects of diet and exercise.
Evidence summary
A meta-analysis of 8 randomized controlled trials (RCTs) with a total of 2000 patients found that weight loss through diet reduced BP in hypertensive patients.1 Investigators recruited adult outpatients, 45 to 66 years of age, with primary hypertension (systolic BP, 128-178 mm Hg, diastolic BP, 72-107 mm Hg) and randomized them to dietary advice or usual care for 6 to 12 months.
Dietary advice resulted in greater weight loss over 6 to 12 months of follow-up (weighted mean difference [WMD], –4.0 kg; 95% confidence interval [CI], –4.8 to –3.2 kg) and greater BP reduction (WMD for systolic BP, –4.5 mm Hg; 95% CI, –7.2 to –1.8 mm Hg; WMD for diastolic BP, –3.2 mm Hg; 95% CI, –4.8 to –1.5 mm Hg).
Investigators didn’t report how long patients maintained the weight loss. Although 3 RCTs included encouragement to exercise, this meta-analysis didn’t evaluate benefits of combining these interventions.
The effects of exercise are less clear
A meta-analysis of 24 RCTs examined exercise and weight loss in adult outpatients with a mean age of 51.6 years; baseline body mass index (BMI), 25.9 kg/m2; resting systolic BP, 127 mm Hg; and resting diastolic BP, 77.7 mm Hg.2 On average, participants walked for 38.3 minutes, 4.4 days per week, for 34.9 weeks at a relative intensity of 70.1% of predicted maximum heart rate (in 6 studies) or 56.3% oxygen consumption intensity (VO2) (in 14 studies).
Walking significantly reduced body weight (WMD, –0.95 kg; P<.001) and BMI (WMD, –0.28 kg/m2; P = .015), leading to a significant reduction in diastolic BP (WMD, –1.54 mm Hg; P = .026) but not systolic BP (WMD, –1.06 mm Hg; P = .316). The authors didn’t report whether participants maintained the weight loss after the interventions.
In a meta-analysis of 8 RCTs and 18 observational studies, adult outpatients described as generally normotensive and overweight (mean age 49 years) wore pedometers to encourage weight loss with the goal of decreasing BP.3
Pedometer use for 3 to 104 weeks increased physical activity (for RCTs, a 2491-steps-per-day increase; 95% CI, 1098-3885 steps per day; for observational studies, a 2183-steps-per-day increase; 95% CI, 1571-2796 steps per day) and decreased BMI by 0.38 kg/m2 (95% CI, 0.05-0.72 kg/m2). For an 80-kg, 170-cm tall person with a BMI of 27.7 kg/m2, reducing BMI by 0.4 units translates to a 1.2-kg weight loss. This weight loss reduced systolic BP by 3.8 mm Hg (95% CI, 1.7-5.9 mm Hg), but not diastolic BP (–0.3 mm Hg; 95% CI, 0.02 to –0.46). Using a 10,000-steps-per-day goal (P = .001) and a step diary (P<.001) further increased walking.
Recommendations
The National Heart, Lung, and Blood Institute’s Joint National Committee says that healthy lifestyles are critical to preventing hypertension and reducing BP in people who are already hypertensive.4 Specifically, the Committee recommends weight reduction in overweight or obese individuals by increasing physical activity and using the Dietary Approaches to Stop Hypertension (DASH) eating plan. Combining 2 or more lifestyle modifications may enhance results.
The Committee also notes that a positive, empathetic relationship with a clinician is crucial in building trust and enhancing motivation to make lifestyle changes. It recommends setting mutual goals, ensuring adequate patient education, using frequent feedback, and involving all members of the health care team.
1. Siebenhofer A, Jeitler K, Berghold A, et al. Long-term effects of weight-reducing diets in hypertensive patients. Cochrane Database Syst Rev. 2011;(9):CD008274.-
2. Murphy MH, Nevill AM, Murtagh EM, et al. The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials. Prev Med. 2007;44:377-385.
3. Bravata DM, Smith-Spangler C, Sundaram V, et al. Using pedometers to increase physical activity and improve health: a systematic review. JAMA. 2007;298:2296-2304.
4. United States Department of Health and Human Services. The seventh report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure. Available at: http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf. Accessed March 13, 2013.
1. Siebenhofer A, Jeitler K, Berghold A, et al. Long-term effects of weight-reducing diets in hypertensive patients. Cochrane Database Syst Rev. 2011;(9):CD008274.-
2. Murphy MH, Nevill AM, Murtagh EM, et al. The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials. Prev Med. 2007;44:377-385.
3. Bravata DM, Smith-Spangler C, Sundaram V, et al. Using pedometers to increase physical activity and improve health: a systematic review. JAMA. 2007;298:2296-2304.
4. United States Department of Health and Human Services. The seventh report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure. Available at: http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf. Accessed March 13, 2013.
Evidence-based answers from the Family Physicians Inquiries Network