Implementation of non-pharmacological interventions for the treatment of hypertension in primary care: a narrative review of effectiveness, cost-effectiveness, barriers, and facilitators.

BACKGROUND: The current guidelines for the prevention, detection, evaluation, and management of hypertension recommend six types of non-pharmacological interventions: alcohol reduction, salt intake reduction, increased potassium intake, physical activity, weight loss, and heart-healthy diets. However, the non-pharmacological interventions are still not widely used in primary care. In this paper, we, therefore, reviewed and summarised the evidence on the effectiveness, cost-effectiveness, barriers, and facilitators of non-pharmacological interventions for the treatment of hypertension in primary care. METHODS: A thorough literature search was conducted in Embase, Google Scholar, and PubMed databases, to identify the most recent reviews or, in their absence, primary studies on alcohol reduction, salt intake reduction, potassium supplementation, physical activity, weight reduction, heart-healthy diets, and other non-pharmacological interventions for the treatment of hypertension in primary care. RESULTS: Alcohol reduction is a non-pharmacological intervention for the treatment of hypertension in primary care with proven effectiveness, feasibility, and acceptability. Interventions for sodium intake reduction, physical activity, and weight reduction are effective but there is insufficient evidence regarding their feasibility and acceptability in primary care settings. Evidence on the effectiveness of potassium intake and heart-healthy diets is limited and inconsistent. There is a lack of evidence on the cost-effectiveness of non-pharmacological interventions in the treatment of hypertension. The most common barriers to deliver such interventions related to healthcare providers include a lack of time, knowledge, self-confidence, resources, clear guidelines, and financial incentives. The most common barriers related to patients include a lack of motivation and educational resources. Less evidence is available on facilitators of implementing non-pharmacological interventions in primary care. Besides, facilitators differed by different types of interventions. CONCLUSIONS: Available evidence suggests that more pragmatic, clinically feasible, and logistically simple interventions are required for sodium intake reduction, physical activity, and weight reduction in primary care settings. Future studies should provide further evidence on the effectiveness of weight control, potassium intake, and heart-healthy diets. More research is also needed on cost-effectiveness and facilitators of all types of effective non-pharmacological interventions for the treatment of hypertension in primary care.

Effects of high-intensity interval training (HIIT) and sprint interval training (SIT) on fat oxidation during exercise: a systematic review and meta-analysis.

OBJECTIVE: To investigate the effects of high-intensity interval training (HIIT) and sprint interval training (SIT) on fat oxidation during exercise (FatOx) and how they compare with the effects of moderate-intensity continuous training (MICT). DESIGN: Systematic review and meta-analysis. DATA SOURCES: Academic Search Ultimate, CINAHL, Networked Digital Library of Theses and Dissertations, Open Access Theses and Dissertations, OpenDissertations, PubMed/MEDLINE, Scopus, SPORTDiscus and Web of Science. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies using a between-group design, involving adult participants who were not trained athletes, and evaluating effects of HIIT or SIT on FatOx (vs no exercise or MICT) were included. RESULTS: Eighteen studies of fair-to-good quality were included; nine comparing HIIT or SIT with no exercise and eleven comparing HIIT or SIT with MICT. A significant pooled effect of these types of interval training on FatOx was found (mean difference in g/min (MD)=0.08; 95% confidence interval (CI) 0.04 to 0.12; p<0.001). Significant effects were found for exercise regimens lasting ≥4 weeks, and they increased with every additional week of training (ß=0.01; 95% CI 0.00 to 0.02; p=0.003). HIIT and/or SIT were slightly more effective than MICT (MD=0.03; 95% CI 0.01 to 0.05; p=0.005). The effects on FatOx were larger among individuals with overweight/obesity. CONCLUSION: Engaging in HIIT or SIT can improve FatOx, with larger effects expected for longer training regimens and individuals with overweight/obesity. While some effects seem small, they may be important in holistic approaches to enhance metabolic health and manage obesity.

Effects of sodium bicarbonate supplementation on exercise performance: an umbrella review.

BACKGROUND: We aimed to perform an umbrella review of meta-analyses examining the effects of sodium bicarbonate supplementation on exercise performance. METHODS: We systematically searched for meta-analyses that examined the effects of sodium bicarbonate supplementation on exercise performance. The methodological quality of the included reviews was evaluated using the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) checklist. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework for downgrading the certainty in evidence was used, which included assessments of risk of bias, inconsistency, indirectness, imprecision, and publication bias. RESULTS: Eight reviews of moderate and high methodological quality met inclusion criteria. Using the GRADE framework, evidence for the ergogenic effects of sodium bicarbonate supplementation on peak and mean power in the Wingate test and Yo-Yo test performance was classified as being of moderate quality. The evidence for these outcomes did not receive a point on the indirectness GRADE item, as "serious indirectness" was detected. Low-quality evidence was found for the ergogenic effect of sodium bicarbonate supplementation on endurance events lasting ∼45 s to 8 min, muscle endurance, and 2000-m rowing performance. Evidence for these outcomes was classified as low quality, given that risk of bias, indirectness, and publication bias were assessed as "unclear", "serious", and "strongly suspected", respectively. The ergogenic effects ranged from trivial (pooled effect size: 0.09) to large (pooled effect size: 1.26). Still, for most outcomes, sodium bicarbonate elicited comparable ergogenic effects. For example, sodium bicarbonate produced similar effects on performance in endurance events lasting ∼45 s to 8 min, muscle endurance tests, and Yo-Yo test (pooled effect size range: 0.36 to 0.40). No significant differences between the effects of sodium bicarbonate and placebo were found for general mean power, muscle strength, and repeated-sprint ability. CONCLUSION: Based on meta-analyses of moderate to high quality, it can be concluded that sodium bicarbonate supplementation acutely enhances peak anaerobic power, anaerobic capacity, performance in endurance events lasting ∼45 s to 8 min, muscle endurance, 2000-m rowing performance, and high-intensity intermittent running. More research is needed among women to improve the generalizability of findings.

Yoga for hypertensive patients: a study on barriers and facilitators of its implementation in primary care.

BACKGROUND: International guidelines for hypertension treatment recommend the use of yoga, particularly among low-risk patients. However, evidence is lacking on the implementation potential of health-worker-led yoga interventions in low-resource, primary care settings. OBJECTIVE: To assess barriers to and facilitators of the implementation of a yoga intervention for hypertensive patients in primary care in Nepal. METHODS: The study was conducted using focus group discussions, in-depth interviews, key informant interviews, and telephone interviews. Data were collected from the 'Yoga and Hypertension' (YoH) trial participants, YoH intervention implementers, and officials from the Ministry of Health and Population in Nepal. RESULTS: Most YoH trial participants stated that: (1) it was easy to learn yoga during a five-day training period and practise it for three months at home; (2) practising yoga improved their health; and (3) group yoga sessions in a community centre would help them practise yoga more regularly. Most YoH intervention implementers stated that: (1) they were highly motivated to implement the intervention; (2) the cost of implementation was acceptable; (3) they did not need additional staff to effectively implement the intervention; (4) providing remuneration to the staff involved in the intervention would increase their motivation; and (5) the yoga programme was 'simple and easy to follow' and 'easily performed by participants of any age'. The government officials stated that: (1) yoga is considered as a key health promotional activity in Nepal; and (2) the integration of the yoga intervention into the existing health care programme would not be too challenging, because the existing personnel and other resources can be utilised. CONCLUSION: While there is a good potential that a yoga intervention can be implemented in primary care, capacity development for health workers and the involvement of community yoga centres in the delivery of the interventions may be required to facilitate this implementation.

Effects of a health worker-led 3-month yoga intervention on blood pressure of hypertensive patients: a randomised controlled multicentre trial in the primary care setting.

BACKGROUND: Hypertension control remains a major challenge globally. A recent systematic review suggested that yoga has beneficial effects on reducing blood pressure. However, the role of yoga in hypertension management in primary health care has received little attention, and no studies have evaluated the impact of a yoga program fully delivered by health care staff on hypertension. This study, therefore, assessed the effects of a health worker-led yoga intervention on blood pressure reduction among hypertensives patients in the primary care setting. METHODS: This was a multicentric, two-arm, randomised trial conducted among hypertensive patients in seven Ayurveda Health Centres in Nepal between March 2017 and June 2018. One hundred and twenty-one participants who were on or without medications were randomised to intervention (n = 61) and wait-list control (n = 60) groups using stratified block randomisation. Participants in the intervention arm received an intervention consisting of an initial five-day structured yoga training at the centres and then a further home-based practice of yoga for five days a week for the following 90 days. Both intervention and control groups also participated in a 2-h health education session. The primary outcome of this trial was systolic blood pressure at 90-day follow-up. Data were analysed on an intention-to-treat basis using linear mixed-effects regression models. RESULTS: We included all 121 study participants (intervention/control = 61/60) in the primary analysis (52.1% males; mean ± SD age = 47.8 ± 10.8 years). The difference in systolic blood pressure between the intervention group and the control group was - 7.66 mmHg (95% CI: - 10.4, - 4.93). For diastolic blood pressure, the difference was - 3.86 mmHg (95% CI: - 6.65, - 1.06). No adverse events were reported by the participants. CONCLUSIONS: A yoga program for hypertensive patients consisting of a five-day training in health centres and 90 days of practice at home is effective for reducing blood pressure. Significant benefits for hypertensive patients could be expected if such programmes would become a part of the standard treatment practice. TRIAL REGISTRATION: This trial was prospectively registered with the Clinical Trial Registry of India [ CTRI/2017/02/007822 ] on 10/02/2017.

ADOR2A C Allele Carriers Exhibit Ergogenic Responses to Caffeine Supplementation.

Caffeine's ergogenic effects on exercise performance are generally explained by its ability to bind to adenosine receptors. ADORA2A is the gene that encodes A2A subtypes of adenosine receptors. It has been suggested that ADORA2A gene polymorphisms may be responsible for the inter-individual variations in the effects of caffeine on exercise performance. In the only study that explored the influence of variation in ADORA2A-in this case, a common polymorphism (rs5751876)-on the ergogenic effects of caffeine on exercise performance, C allele carriers were identified as "non-responders" to caffeine. To explore if C allele carriers are true "non-responders" to the ergogenic effects of caffeine, in this randomized, double-blind study, we examined the acute effects of caffeine ingestion among a sample consisting exclusively of ADORA2A C allele carriers. Twenty resistance-trained men identified as ADORA2A C allele carriers (CC/CT genotype) were tested on two occasions, following the ingestion of caffeine (3 mg/kg) and a placebo. Exercise performance was evaluated with movement velocity, power output, and muscle endurance during the bench press exercise, countermovement jump height, and power output during a Wingate test. Out of the 25 analyzed variables, caffeine was ergogenic in 21 (effect size range: 0.14 to 0.96). In conclusion, ADORA2A (rs5751876) C allele carriers exhibited ergogenic responses to caffeine ingestion, with the magnitude of improvements similar to what was previously reported in the literature among samples that were not genotype-specific. Therefore, individuals with the CT/CC genotype may still consider supplementing with caffeine for acute improvements in performance.

Effects of Sodium Bicarbonate Supplementation on Muscular Strength and Endurance: A Systematic Review and Meta-analysis.

BACKGROUND: The effects of sodium bicarbonate on muscular strength and muscular endurance are commonly acknowledged as unclear due to the contrasting evidence on the topic. OBJECTIVE: To conduct a systematic review and meta-analysis of studies exploring the acute effects of sodium bicarbonate supplementation on muscular strength and endurance. METHODS: A search for studies was performed using five databases. Meta-analyses of standardized mean differences (SMDs) were performed using a random-effects model to determine the effects of sodium bicarbonate supplementation on muscular strength (assessed by changes in peak force [N], peak torque [N m], or maximum load lifted [kg]) and muscular endurance (assessed by changes in the number of repetitions performed, isokinetic total work, or time to maintain isometric force production). Subgroup meta-analyses were conducted for the muscular endurance of small vs. large muscle groups and muscular strength tested in a rested vs. fatigued state. A random-effects meta-regression analysis was used to explore possible trends in the effects of: (a) timing of sodium bicarbonate ingestion; and (b) acute increase in blood bicarbonate concentration (from baseline to pre-exercise), on muscular endurance and muscular strength. RESULTS: Thirteen studies explored the effects of sodium bicarbonate on muscular endurance and 11 on muscular strength. Sodium bicarbonate supplementation was found to be ergogenic for muscular endurance (SMD = 0.37; 95% confidence interval [CI]: 0.15, 0.59; p = 0.001). The performance-enhancing effects of sodium bicarbonate were significant for both small (SMD = 0.31; 95% CI: 0.04, 0.59; p = 0.025) and large muscle groups (SMD = 0.40; 95% CI: 0.13, 0.66; p = 0.003). Sodium bicarbonate ingestion was not found to enhance muscular strength (SMD = - 0.03; 95% CI: - 0.18, 0.12; p = 0.725). No significant effects were found regardless of whether the testing was carried out in a rested (SMD = 0.02; 95% CI: - 0.09, 0.13; p = 0.694) or fatigued (SMD = - 0.16; 95% CI: - 0.59, 0.28; p = 0.483) state. No significant linear trends in the effects of timing of sodium bicarbonate ingestion or acute increase in blood bicarbonate concentrations on muscular endurance or muscular strength were found. CONCLUSIONS: Overall, sodium bicarbonate supplementation acutely improves muscular endurance of small and large muscle groups, but no significant ergogenic effect on muscular strength was found.

Wake up and smell the coffee: caffeine supplementation and exercise performance-an umbrella review of 21 published meta-analyses.

OBJECTIVE: To systematically review, summarise and appraise findings of published meta-analyses that examined the effects of caffeine on exercise performance. DESIGN: Umbrella review. DATA SOURCES: Twelve databases. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Meta-analyses that examined the effects of caffeine ingestion on exercise performance. RESULTS: Eleven reviews (with a total of 21 meta-analyses) were included, all being of moderate or high methodological quality (assessed using the Assessing the Methodological Quality of Systematic Reviews 2 checklist). In the meta-analyses, caffeine was ergogenic for aerobic endurance, muscle strength, muscle endurance, power, jumping performance and exercise speed. However, not all analyses provided a definite direction for the effect of caffeine when considering the 95% prediction interval. Using the Grading of Recommendations Assessment, Development and Evaluation criteria the quality of evidence was generally categorised as moderate (with some low to very low quality of evidence). Most individual studies included in the published meta-analyses were conducted among young men. SUMMARY/CONCLUSION: Synthesis of the currently available meta-analyses suggest that caffeine ingestion improves exercise performance in a broad range of exercise tasks. Ergogenic effects of caffeine on muscle endurance, muscle strength, anaerobic power and aerobic endurance were substantiated by moderate quality of evidence coming from moderate-to-high quality systematic reviews. For other outcomes, we found moderate quality reviews that presented evidence of very low or low quality. It seems that the magnitude of the effect of caffeine is generally greater for aerobic as compared with anaerobic exercise. More primary studies should be conducted among women, middle-aged and older adults to improve the generalisability of these findings.

The Influence of Caffeine Supplementation on Resistance Exercise: A Review.

This paper aims to critically evaluate and thoroughly discuss the evidence on the topic of caffeine supplementation when performing resistance exercise, as well as provide practical guidelines for the ingestion of caffeine prior to resistance exercise. Based on the current evidence, it seems that caffeine increases both maximal strength and muscular endurance. Furthermore, power appears to be enhanced with caffeine supplementation, although this effect might, to a certain extent, be caffeine dose- and external load-dependent. A reduction in rating of perceived exertion (RPE) might contribute to the performance-enhancing effects of caffeine supplementation as some studies have observed decreases in RPE coupled with increases in performance following caffeine ingestion. However, the same does not seem to be the case for pain perception as there is evidence showing acute increases in resistance exercise performance without any significant effects of caffeine ingestion on pain perception. Some studies have reported that caffeine ingestion did not affect exercise-induced muscle damage, but that it might reduce perceived resistance exercise-induced delayed-onset muscle soreness; however, this needs to be explored further. There is some evidence that caffeine ingestion, compared with a placebo, may lead to greater increases in the production of testosterone and cortisol following resistance exercise. However, given that the acute changes in hormone levels seem to be weakly correlated with hallmark adaptations to resistance exercise, such as hypertrophy and increased muscular strength, these findings are likely of questionable practical significance. Although not without contrasting findings, the available evidence suggests that caffeine ingestion can lead to acute increases in blood pressure (primarily systolic), and thus caution is needed regarding caffeine supplementation among individuals with high blood pressure. In the vast majority of studies, caffeine was administered in capsule or powder forms, and therefore the effects of alternative forms of caffeine, such as chewing gums or mouth rinses, on resistance exercise performance remain unclear. The emerging evidence suggests that coffee might be at least equally ergogenic as caffeine alone when the caffeine dose is matched. Doses in the range of 3-9 mg·kg-1 seem to be adequate for eliciting an ergogenic effect when administered 60 min pre-exercise. In general, caffeine seems to be safe when taken in the recommended doses. However, at doses as high as 9 mg·kg-1 or higher, side effects such as insomnia might be more pronounced. It remains unclear whether habituation reduces the ergogenic benefits of caffeine on resistance exercise as no evidence exists for this type of exercise. Caution is needed when extrapolating these conclusions to females as the vast majority of studies involved only male participants.

Relationship of back and neck pain with quality of life in the Croatian general population.

OBJECTIVE: The purpose of this study was to determine the prevalence of back pain and neck pain and their relationship with the quality of life in the Croatian general population. METHODS: This was a cross-sectional study using home-based face-to-face interviews of 1030 participants (51.6% females) 15 years or older. Back and neck pain frequencies were assessed using single items and quality of life using the Short Form Survey and Satisfaction with Life Scale. Analysis of covariance was conducted, where back pain or neck pain frequency was used as the categorical predictor; physical component summary or mental component summary, as the dependent variable; and age, body mass index, and physical activity level, as covariates. RESULTS: The prevalence of back pain was 66.3% (95% confidence interval [CI], 62.3%-70.3%) and 62.9% (95% CI, 58.7%-67.2%) in females and males, respectively. The prevalence of neck pain was 58.0% (95% CI, 53.8%-62.2%) for females and 53.6 (95% CI, 49.2%-58.0%) for males. Differences between men and women were not significant (P>.05). Adjusted mean values for physical component summary and mental component summary were substantially lower in participants who reported back or neck pain often/almost always compared with those without pain. Differences ranged from 8.11 to 11.86 points (95% CI, 5.54-13.99) and from 9.61 to 10.99 points (95% CI, 7.35-13.45) in females and males, respectively. CONCLUSIONS: The findings of this study showed that back and neck pain are highly prevalent and negatively related to quality of life in the Croatian general population. These data might raise the awareness of local government health authorities and lead to improvements in health care service for people with back and neck pain.

Reliability of a photographic method for assessing standing posture of elementary school students.

OBJECTIVE: A high prevalence of poor standing posture among elementary schoolchildren indicates the need for the introduction of school-based interventions for improvement of postural alignments. For assessing the effect of intervention programs, reliable quantitative measures of standing posture should be used. Therefore, the purpose of this study was to examine the reliability of a photographic method for assessment of standing posture among elementary schoolchildren. METHODS: The study was conducted on a convenience sample of 273 male students between 10 and 13 years old. Each subject was photographed in habitual standing posture, 3 times in a front view and 3 times in a side view. Deviations from ideal postural alignment were calculated with Posture Image Analyzer software and UTHSCSA ImageTool software. Interitem reliability was estimated using intraclass correlation coefficient. RESULTS: Intraclass correlation coefficients for posture deviations assessed with Posture Image Analyzer ranged from 0.81 for knee joints deviation and ankle joints deviation in the coronal plane to 0.92 for trunk deviation and knee joints deviation in the sagittal plane. Intraclass correlation coefficients for posture deviations assessed with UTHSCSA ImageTool ranged from 0.80 for knee joints deviation in the coronal plane to 0.91 for trunk deviation and knee joints deviation in the sagittal plane. CONCLUSIONS: This study showed a satisfactory interitem reliability of a photographic method for the assessment of standing posture among elementary schoolchildren.

Construction and reproducibility of a questionnaire aimed for evaluation of dietary habits in physically active individuals.

The aim of this study was to develop a comprehensive food frequency questionnaire (FFQ), and a complementary general questionnaire associated to it, specifically tailored for the assessment of dietary habits among athletes and other physically active individuals in Croatia, and to determine the reproducibility of the questions and nutrient intake estimations. The study included 83 students (42 males and 41 females) from the Faculty of Kinesiology, University of Zagreb. Construction of the initial version of the questionnaire was done according to the literature and the results of a pre-testing interview conducted on 15 subjects. The final version of FFQ consisted of 74 questions on usual consumption frequency of particular food and beverage items and usual food preparation methods. The final version of the general questionnaire consisted of 30 questions on age, gender, body height, body weight, energy expenditure, specific dietary regimen, general dietary habits, diet characteristics before, during and after training, and cigarette smoking habits. Reproducibility of the questionnaires was assessed by a repeated administration of the questionnaire after one month. Pearson correlation coefficients and proportions of agreement were used to present reproducibility of quantitative and qualitative data, respectively. In the sample of male students, Pearson correlations ranged from 0.51 for copper to 0.95 for alcohol, with an average correlation of 0.68. In the sample of female students, correlations ranged from 0.30 for alcohol to 0.78 for calcium, with an average correlation of 0.60. Average reproducibility of items in the general questionnaire was 0.83 and 0.86 for male and female students, respectively. In conclusion, the newly developed FFQ enables cost-effective assessment of dietary habits in Croatian athletes and other physically active individuals, as well as demonstrates acceptable reproducibility.