Effect of lifestyle on blood pressure in patients under antihypertensive medication: An analysis from the Portuguese Health Examination Survey

Re Po Ca diol. 2019;38(10):697---705 www. e po ca diol.o g Re is a Po uguesa de Ca diologia Po uguese Jou nal o Ca diology ORIGINAL ARTICLE E ec o li es yle on blood p essu e in pa ien s unde an ihype ensi e medica ion: An analysis om he Po uguese Heal h Examina ion Su ey Má io Rui Sal ado a,d,∗, Susana Cunha Gonc¸al esb,d, Guilhe me Quinaz Romanac,d, Bal aza Nunesd, I ina Kislayad, Ca los Ma ias Diasd, Ana Paula Rod iguesd aUnidade de Saúde Pública, ACES Dão La ões, Viseu, Po ugal bUnidade de Saúde Pública, ACES Médio Tejo, Alcanena, Po ugal cUnidade de Saúde Pública, ACES Lisboa No e, Lisboa, Po ugal dDepa amen o de Epidemiologia, Ins i u o Nacional de Saúde Dou o Rica do Jo ge, Lisboa, Po ugal Recei ed 3 Sep embe 2018; accep ed 27 Decembe 2018 A ailable online 16 Janua y 2020 KEYWORDS Blood p essu e; Die ; Physical ac i i y; Smoking; Alcohol Abs ac In oduc ion and Objec i es: Hype ension is one o he main isk ac o s o disabili y and dea h om ca dio ascula disease. Cu en guidelines include ini ia i es o con ol blood p es- su e in hype ensi e pa ien s ha ocus on li es yle changes. The main objec i e o his s udy was o analyze he associa ion be ween li es yle and blood p essu e in pa ien s unde an ihy- pe ensi e medica ion. Me hods: Da a collec ed in he Po uguese Na ional Heal h Examina ion Su ey (INSEF) we e analyzed. Indi iduals who me INSEF inclusion c i e ia and epo ed being unde an ihype en- si e medica ion in he wo weeks p io o he ques ionnai e we e s udied. Li es yle a iables (alcohol consump ion, smoking, added sal in ake, ui and ege able consump ion, and phys- ical ac i i y) we e assessed by ques ionnai e, and sys olic and dias olic blood p essu e we e measu ed by physical examina ion. Associa ions be ween li es yle ac o s and blood p essu e, s a ified by gende and adjus ed o sociodemog aphic a iables and obesi y, we e es ima ed h ough a mul iple linea eg ession model. Resul s: Alcohol consump ion (be a=6.31, p=0.007) and smoking (be a=4.72, p=0.018) we e posi i ely associa ed wi h sys olic blood p essu e in men. Added sal in ake, ui and ege able consump ion, and physical ac i i y we e no associa ed wi h blood p essu e in men. In women, no associa ion was obse ed o any beha io al a iable. ∗Co esponding au ho . E-mail add ess: [email p o ec ed] (M.R. Sal ado ). h ps://doi.o g/10.1016/j. epc.2018.12.006 0870-2551/© 2019 Sociedade Po uguesa de Ca diologia. Published by Else ie Espa˜ na, S.L.U. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/). 698 M.R. Sal ado e al. Conclusions: These conclusions highligh he need in he popula ion unde an ihype ensi e medica ion, pa icula ly in men, o ocus on he figh agains high sys olic blood p essu e in he wo modifiable and p e en able beha io s o smoking and alcohol consump ion. © 2019 Sociedade Po uguesa de Ca diologia. Published by Else ie Espa˜ na, S.L.U. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by- nc-nd/4.0/). PALAVRAS-CHAVE P essão a e ial; Die a; A i idade ísica; Tabaco; Álcool E ei o do es ilo de ida na p essão a e ial em indi íduos sob medicac¸ão an i-hipe ensi a: uma análise do Inqué i o Nacional de Saúde com Exame Físico Resumo In oduc¸ão e obje i os: A hipe ensão a e ial é um dos p incipais a o es de isco pa a inca- pacidade e mo e po doenc¸as ca dio ascula es. O ien ac¸ões a uais de con olo da p essão a e ial em indi íduos hipe ensos ocam-se em al e ac¸ões do es ilo de ida. O p incipal obje- i o des e es udo oi es ima a associac¸ão en e o es ilo de ida e a p essão a e ial em indi íduos sob medicac¸ão an i-hipe ensi a. Mé odos: P ocedeu-se a uma análise dos dados colhidos no Inqué i o Nacional de Saúde com Exame Físico. Indi íduos que cump i am os c i é ios de inclusão e que e e i am encon a -se sob medicac¸ão an i-hipe ensi a o am es udados. Va iá eis de es ilo de ida (consumo de álcool, hábi o abágico, consumo adicional de sal, consumo de u a e ege ais, p á ica de a i idade ísica) o am medidas po ques ioná io e os alo es de p essão a e ial o am ob idos po exame ísico. Associac¸ões en e a o es do es ilo de ida e p essão a e ial, es a ificadas pa a o sexo e ajus adas a a iá eis sociodemog áficas e obesidade, o am es imadas a a és de um modelo de eg essão lineal múl ipla. Resul ados: Consumo de álcool (b=6,31, p=0,007) e hábi o abágico (b=4,72, p=0,018) o am posi i amen e associadas à p essão a e ial sis ólica em homens. Consumo adicional de sal, consumo de u a e ege ais e p á ica de a i idade ísica não se encon a am associados à p essão a e ial em homens. Em mulhe es, nenhuma associac¸ão oi iden ificada pa a qualque a iá el compo amen al. Conclusões: Es as conclusões e o c¸am a necessidade, ambém na populac¸ão sob medicac¸ão an i-hipe ensi a, pa icula men e no sexo masculino, de cen a o comba e à p essão a e ial sis ólica nes es dois compo amen os modificá eis e p e ení eis: hábi o abágico e consumo de álcool. © 2019 Sociedade Po uguesa de Ca diologia. Publicado po Else ie Espa˜ na, S.L.U. Es e ´ e um a igo Open Access sob uma licenc¸a CC BY-NC-ND (h p://c ea i ecommons.o g/licenses/by- nc-nd/4.0/). In oduc ion Hype ension is one o he main isk ac o s o disabili y and dea h om ca dio ascula disease.1,2 Wo ldwide, hype en- sion a ec s a ound one billion people and is esponsible o 7.5 million dea hs a yea .3Hype ension accoun ed o mo e han hal o global dea hs and disabili y-adjus ed li e yea s o ischemic hea disease and ce eb o ascula disease in 2016.4 In Po ugal, in 2012, 42.2% o he popula ion had hype - ension, and o hese, 55.6% had con olled hype ension.5 Simila p e alences we e obse ed in 2003.6 Ele a ed blood p essu e (BP) esul s om en i onmen al and gene ic ac o s and hei in e ac ion. The en i onmen- al ac o s in ol ed in he e iology o hype ension include a ious die a y and li es yle ac o s.7 E o s o educe he p e alence o hype ension ocus on pha macological and non-pha macological app oaches. Among non-pha macological app oaches, he guidelines ecommend weigh con ol, educ ion o sal in ake and alcohol consump ion, physical ac i i y, and a die high in ui s, ege ables and low- a dai y p oduc s and low in sa u a ed and o al a .7Smoking is also associa ed wi h he isk o hype ension and cessa ion is ad ised as pa o hype ension con ol.8 The e ec s o li es yle ac o s on BP le els in he gen- e al popula ion a e well s udied. Al hough a ious goals and ini ia i es ha e been de eloped by public heal h se ices, globally and na ionally, aimed a he beha io al de e mi- nan s o heal h, p e alences o li es yles ha un coun e o he guidelines emain high.9 E idence sugges s ha he e ec o li es yle in e en- ions on BP is mo e p onounced in hype ensi e indi iduals.10 Howe e , o he bes o ou knowledge, ew da a a e a ail- able in Po ugal in his field, pa icula ly in hype ensi e popula ions unde pha macological ea men . E ec o li es yle on blood p essu e in pa ien s unde an ihype ensi e d ugs 699 The p esen s udy aims o analyze associa ions be ween li es yle ac o s (added sal in ake, ui and ege able consump ion, alcohol consump ion, smoking and physical ac i i y) and BP in pa ien s unde an ihype ensi e medica- ion in Po ugal, adjus ed o obesi y and sociodemog aphic a iables. Me hods S udy se ing This s udy is based on da a om he fi s Po uguese Na ional Heal h Examina ion Su ey (INSEF).11 INSEF was a c oss-sec ional popula ion-based su ey ca ied ou in 2015 by he Na ional Heal h Ins i u e Dou o Rica do Jo ge (INSA) in pa ne ship wi h he fi e Regional Heal h Adminis a ions o mainland Po ugal, he wo Regional Heal h Sec e a ia s o he au onomous island egions o he Azo es and Madei a, and he No wegian Ins i u e o Public Heal h. The INSEF a ge popula ion included non- ins i u ionalized indi iduals aged be ween 25 and 74 yea s, esiden in Po ugal and able o ollow an in e iew in Po uguese. The INSEF sample (n=4911) was selec ed using a complex mul is age p obabilis ic design. Fo each esponden , in addi ion o he physical examina- ion (BP, heigh and weigh ), da a on socioeconomic s a us, medica ion in ake, li es yles and heal hca e use we e collec ed h ough compu e -assis ed pe sonal in e iew. De ailed desc ip ions o he me hodology and p ocedu es o sample selec ion, ec ui men , in e iew and examina ion ha e been published elsewhe e.11,12 INSEF was app o ed by he E hics Commi ee o INSA and by he Na ional Da a P o ec ion Au ho i y. Fo his s udy, analysis was es ic ed o he subsample o INSEF pa icipan s who epo ed using p esc ibed an ihype - ensi e medica ion in he wo weeks p io o he in e iew. Measu emen s Va iables we e di ided in o ou come a iables (sys olic [SBP] and dias olic [DBP] blood p essu e); li es yle a ia- bles (added sal in ake, ui and ege able consump ion, le el o physical ac i i y, alcohol consump ion and smok- ing); an h opome ic a iable (obesi y); sociodemog aphic a iables (gende , age g oup [25-44, 45-54, 55-64, 65- 74 yea s], esiden ial a ea [ u al/u ban], educa ion le el [none/elemen a y, middle school, high school, uni e si y], and income [quin ile o equi alized household income acco ding o he modified OECD scale]), and las consul- a ion wi h a gene al p ac i ione in a heal h cen e [<12 mon hs/≥12 mon hs be o e he in e iew]). BP was measu ed du ing a single examina ion wi h he subjec in a sea ed posi ion a e 5 min es . Th ee consec- u i e BP eadings we e ob ained and he mean o he second and hi d eadings o SBP and DBP was used. F ui and ege able in ake was assessed by he ques- ion ‘‘How o en do you ea ui / ege ables (excluding juice and po a oes)?’’ Indi iduals who epo ed ea ing ui / ege ables less han ou imes a day we e conside ed o ha e low consump ion. Added sal in ake was measu ed by he ques ion ‘‘How o en do you add sal o you pla e?’’ Indi iduals who epo ed adding sal o hei pla e ‘‘ a ely’’, ‘‘some imes’’, ‘‘usually’’ and ‘‘always’’ we e conside ed o ha e added sal in ake. Le els o physical ac i i y we e measu ed by he ques- ion ‘‘Which o hese si ua ions bes desc ibes you leisu e ime ac i i ies du ing he las 12 mon hs?’’ Indi iduals who answe ed ‘‘Reading, wa ching TV and o he seden a y ac i - i ies’’ we e conside ed o be seden a y. Alcohol consump ion was measu ed by he ques ion ‘‘Ha e you d unk any alcoholic be e age in he pas 12 mon hs?’’ Indi iduals who eplied in he a fi ma i e we e conside ed o consume alcohol. Smoking was measu ed by he ques ion ‘‘Do you smoke?’’ Indi iduals who esponded ha hey smoked ‘‘daily’’ o ‘‘occasionally’’ we e conside ed o be smoke s. Pa icipan s we e conside ed obese i hei body mass index (BMI) calcula ed om measu ed weigh and heigh was ≥30 kg/m2. S a is ical analysis The s udy sample was cha ac e ized using desc ip i e s a is ics (means and s anda d de ia ions o con inuous a iables, coun s and pe cen ages o ca ego ical a iables). Fo each gende , ela ionships be ween SBP and DBP, li es yle and sociodemog aphic a iables we e assessed using linea eg ession models ha p o ided eg ession coe - ficien s (be a) and espec i e 95% confidence in e al (CI). Addi ional adjus men o obesi y was also pe o med. Da a we e analyzed using IBM SPSS®S a is ics so wa e. The significance le el o all analyses was se a 5%. Sampling weigh s we e used in he da a analysis o accoun o he complex sample design. Mo e de ailed in o ma ion on INSEF sampling and sampling weigh s is p o ided elsewhe e.12 Resul s Pa icipan s’ cha ac e is ics and die a y and li es yle pa - e ns a e p esen ed in Table 1. A o al o 1277 pa icipan s me he inclusion c i e ia, 710 (54.3%) women and 567 (45.7%) men. Mos o he popula ion (74.7%) we e aged 55 yea s o mo e. Mean SBP was 132.9 mmHg (95% CI 130.9-133.9) and mean DBP was 75.8 mmHg (95% CI 74.7- 76.8). Mean SBP was highe in men (134.7 mmHg, 95% CI 133.26-136.15) han in women (130.53 mmHg, 95% CI 128.49-132.57), as was mean DBP (76.97 mmHg, 95% CI 76.05-77.90 in men; 74.74 mmHg, 95% CI 73.25-76.23 in women). Rega ding li es yle pa e ns among he s udy popula ion, he p e alences o seden a y beha io (50.3%), alcohol con- sump ion (75.3%), added sal in ake (13.2%) and smoking (9.8%) we e high, while consump ion o ui and ege ables was low (29.7%). S a ifica ion by gende showed ha 47.4% o men and 52.8% o women we e seden a y, 89.1% o men and 63.6% o women had high alcohol consump ion, 78.0% o men and 63.8% o women had low ui and ege able con- sump ion, 16.6% o men and 10.3% o women epo ed high added sal in ake and 12.8% o men and 7.2% o women we e smoke s. 700 M.R. Sal ado e al. Table 1 Cha ac e is ics o he s udy popula ion. Va iables All (n=1277) Men (n=567) Women (n=710) Mean (SD) 95% CI Mean (SD) 95% CI Mean 95% CI SBP, mmHg 132.44 (0.74) 130.94-133.94 134.70 (0.71) 133.26-136.15 130.53 (1.00) 128.49-132.57 DBP, mmHg 75.76 (0.51) 74.72-76.80 76.97 (0.47) 76.05-77.90 74.74 (0.73) 73.25-76.23 Va iables/ca ego ies n %a95% CI n %a95% CI n %a95% CI Gende Women 710 54.3 50.4-58.1 Men 567 45.7 41.9-49.6 Age g oup 25-44 80 7.7 6.1-9.8 39 9.1 5.9-13.6 41 6.6 4.1-10.6 45-54 241 17.5 15.0-20.3 92 15.6 11.9-20.2 149 19.0 15.6-23.1 55-64 490 36.3 31.4-41.6 222 38.3 34.5-42.3 268 34.7 28.2-41.7 65-74 466 38.4 33.5-43.7 214 37.0 30.3-44.2 252 39.7 35.3-44.3 Residen ial a ea Ru al 369 27.7 22.8-33.2 167 26.4 18.8-35.7 202 28.8 24.3-33.8 U ban 908 72.3 66.8-77.2 400 73.6 64.3-81.2 508 71.2 66.2-75.7 Educa ion le el None/elemen a y 711 54.0 50.3-57.7 313 51.1 45.0-57.2 398 56.5 52.5-60.5 Middle school 317 26.1 22.4-30.2 140 27.8 23.3-32.9 177 24.8 19.9-30.4 High school 148 12.4 9.2-16.5 80 13.8 10.1-18.6 68 11.2 7.8-15.9 Uni e si y 101 7.4 5.0-10.9 34 7.3 4.1-13.0 67 7.5 5.1-10.7 Income (modified OECD scale) Unknown 86 - - 30 - - 56 - - Low 272 20.2 16.5-24.6 105 15.4 11.5-20.3 167 24.6 19.5-30.7 Medium-low 260 21.5 18.4-25.0 109 21.5 18.4-25.1 151 21.5 16.8-27.1 Medium 231 21.1 17.8-24.8 98 19.7 15.4-24.9 133 22.3 17.9-27.3 Medium-high 224 19.4 16.5-22.7 119 22.5 18.6-27.0 105 16.6 12.7-21.5 High 204 17.7 14.1-22.1 106 20.8 17.2-25.0 98 14.9 10.6-20.7 Las consul a ion wi h GP Unknown 6 - - 3 - - 3 - - <12 mon hs 1029 85.2 80.7-88.8 443 82.2 76.5-86.7 586 87.8 82.4-91.7 ≥12 mon hs 242 14.8 2.0 121 17.8 13.3-23.5 121 12.2 8.3-17.6 Ne e 0 - - 0 - - 0 - - Obesi y Unknown 7 - - 5 - - 2 - - Non-obese 638 48.6 43.3-54.0 311 52.8 45.8-59.7 327 45.1 39.5-50.9 Obese 632 51.4 46.0-56.7 251 47.2 40.3-54.2 381 54.9 49.1-60.5 Added sal in ake No 1119 86.8 81.5-90.8 484 83.4 76.8-88.5 635 89.7 84.4-93.3 Yes 158 13.2 9.2-18.5 83 16.6 11.5-23.2 75 10.3 6.7-15.6 F ui and ege able consump ion ≥4 imes a day 350 29.7 26.4-33.2 124 22.0 17.0-27.9 226 36.2 32.0-40.5 <4 imes a day 927 70.3 66.8-73.6 443 78.0 72.1-83.0 484 63.8 59.5-68.0 Alcohol consump ion No 317 24.7 21.0-28.9 61 10.9 7.7-15.1 256 36.4 30.0-43.3 Yes 960 75.3 71.1-79.0 506 89.1 84.9-92.3 454 63.6 56.7-70.0 Smoking Unknown 2 - - - - - 2 - - No 1138 90.2 86.4-93.1 486 87.2 81.7-91.2 652 92.8 88.4-95.6 Yes 137 9.8 6.9-13.6 81 12.8 8.8-18.3 56 7.2 4.4-11.6 E ec o li es yle on blood p essu e in pa ien s unde an ihype ensi e d ugs 701 Table 1 (Con inued) Va iables All (n=1277) Men (n=567) Women (n=710) Mean (SD) 95% CI Mean (SD) 95% CI Mean 95% CI SBP, mmHg 132.44 (0.74) 130.94-133.94 134.70 (0.71) 133.26-136.15 130.53 (1.00) 128.49-132.57 DBP, mmHg 75.76 (0.51) 74.72-76.80 76.97 (0.47) 76.05-77.90 74.74 (0.73) 73.25-76.23 Va iables/ca ego ies n %a95% CI n %a95% CI n %a95% CI Physical ac i i y Unknown 10 - - 4 - - 6 - - Ac i e 652 49.7 44.6-54.8 325 52.6 44.0-61.2 327 47.2 43.5-51.0 Seden a y 615 50.3 45.2-55.4 238 47.4 38.8-56.0 377 52.8 49.0-56.5 CI: confidence in e al; DBP: dias olic blood p essu e; GP: gene al p ac i ione ; SBP: sys olic blood p essu e; SD: s anda d de ia ion. aWeigh ed o he dis ibu ion o he Po uguese popula ion by egion, gende and age g oup. Mo e han hal o he s udy popula ion (51.4%) we e obese (BMI ≥30 kg/m2) (47.2% o men and 54.9% o women). The gende -s a ified associa ions be ween SBP and li es yle ac o s a e shown in Table 2. In men, a posi i e asso- cia ion be ween SBP and alcohol consump ion (be a=3.36, p=0.007) was obse ed. In women, SBP was no significan ly associa ed wi h any a iable. The ela ionships wi h DBP a e no epo ed because he esul s we e simila o he associa ions ound o SBP (Supplemen a y Table 1). Fu he mo e, SBP is he mos impo an BP pa ame e associa ed wi h hype ension complica ions.13 The esul s o mul iple linea eg ession analysis a e shown in Table 3. S a ifica ion by gende and adjus men o sociodemog aphic a iables showed a significan pos- i i e associa ion be ween SBP and alcohol consump ion (be a=6.43, p=0.003) and smoking (be a=4.26, p=0.019) in men, bu he e was no associa ion in he emaining beha - io al a iables. In women, no significan associa ions we e iden ified o any o he a iables unde s udy. An addi ional mul i a ia e model was es ablished o bo h sexes by adding obesi y, bu his did no change he p e iously ound associa ions. In men, he posi i e associa ion be ween SBP and alcohol consump ion (be a=6.31, p=0.007) and smoking (be a=4.72, p=0.018) emained, ega dless o obesi y. SBP was 6.3 mmHg highe in hose who consumed alcohol (p=0.007) compa ed o non-consume s and was 4.7 mmHg highe in smoke s (p=0.018) compa ed o non-smoke s. In women, no such associa ion was ound. Discussion Alcohol consump ion and smoking we e significan ly associ- a ed wi h SBP in men, bu no in women. Added sal in ake, ui and ege able consump ion, and le el o physical ac i - i y we e no associa ed wi h SBP alues in men o women. The esul s o he bi a ia e analysis a e in line wi h he e idence ega ding he exis ence o associa ions be ween ele a ed SBP alues and alcohol consump ion and obesi y.14,15 S a ifica ion by gende and adjus men o beha io al a iables and sociodemog aphic a iables a e discussed below. Alcohol consump ion A e adjus men o sociodemog aphic a iables, alcohol consump ion main ained a significan associa ion wi h SBP, bu only in men. In women, he e was no s a is ically sig- nifican associa ion a e adjus men . These esul s a e in line wi h he e idence.14 Howe e , a me a-analysis showed di e ences be ween he sexes in e ms o he e ec o alcohol consump ion on BP: while in men, highe consump- ion was associa ed wi h an inc eased isk o hype ension, in women ligh consump ion was p o ec i e.16 The expla- na ion o he appa en in e se ela ionship be ween mild o mode a e alcohol consump ion and he isk o hype en- sion seems o lie in plasma high-densi y lipop o ein (HDL) concen a ions,17 since women physiologically ha e highe HDL concen a ions han men.18 Howe e , despi e his di - e ence be ween he sexes, i has been sugges ed ha he e a e in ac di e ences in pa e ns o d inking and ype o be e age, no measu ed in his s udy, ha explain he obse ed di e ences in BP be ween men and women.19 Smoking The associa ion be ween smoking and SBP was s a is ically significan in ou analysis, bu no in women. Se e al s ud- ies ha e sugges ed ha BP is inc eased in smoke s bu , pa adoxically, o he s udies ha e concluded ha smoke s ha e lowe BP han non-smoke s. The esul s ob ained o men in ou s udy, wi h highe BP alues in smoke s han in non-smoke s and significan ly so o SBP, a e in line wi h published s udies.20 In women, he e we e no s a is ically significan associa ions be ween SBP alues and smoking, a simila esul o ha obse ed in a 2001 s udy.21 F ui and ege able consump ion F ui and ege able consump ion los i s s a is ical associa- ion wi h SBP a e adjus men , in bo h men and women, in con as o he findings o published s udies.22 Some esea ch sugges s ha di e ences be ween ui and eg- e able ypes and how he oods hemsel es a e p epa ed, leading o di e ences in he final concen a ion o com- pounds (fibe s and fla onoids) and consequen ly in hei e ec on BP, could explain he lack o associa ion be ween 702 M.R. Sal ado e al. Table 2 Associa ions be ween li es yle ac o s and sys olic blood p essu e in men and women (n=1277). Va iable Values/ca ego ies SBP Men Women Mean Be a 95% CI p Mean Be a 95% CI p Age g oup 1 25-44 136.04 1.36 -4.82 o 7.55 0.657 128.61 -3.84 -14.09 o 6.41 0.452 2 45-54 134.74 0.07 -7.65 o 7.78 0.986 130.57 -1.89 -7.03 o 3.25 0.460 3 55-64 134.40 -0.27 -3.52 o 2.97 0.865 128.67 -3.78 -8.12 o 0.56 0.086 4 65-74 ( e ) 134.67 - - - 132.45 - - - Residen ial a ea 0 Ru al 138.33 4.93 1.75 o 8.12 0.003 130.10 -0.61 -3.58 o 2.37 0.682 1 U ban ( e ) 133.40 - - - 130.70 - - - Educa ion le el 1 None/elemen a y ( e ) 134.76 3.11 -3.28 o 9.50 0.330 133.41 8.72 -0.10 o 17.54 0.053 2 Middle school 135.32 3.68 3.73 o 11.08 0.320 127.46 2.77 -7.15 o 12.69 0.574 3 High school 134.90 3.25 -3.47 o 9.97 0.332 126.63 1.94 -4.34 o 8.22 0.535 4 Uni e si y 131.64 - - - 124.69 - - - Income (OECD modified scale) 1 Low 135.26 -0.24 -8.99 o 8.51 0.956 133.36 8.12 2.08 o 14.16 0.010 2 Medium-low 135.81 0.31 -6.86 o 7.48 0.931 133.13 7.88 2.06 o 13.69 0.009 3 Medium 131.27 -4.23 -10.12 o 1.65 0.153 128.79 3.55 -1.69 o 8.78 0.178 4 Medium-high 135.29 -0.21 -5.50 o 5.09 0.938 129.80 4.55 -2.54 o 11.64 0.201 5 High ( e ) 135.50 - - - 125.35 - - - Las consul a ion wi h GP 0 <12 mon hs 134.39 -1.31 -6.45 o 3.84 0.609 130.95 2.68 -4.45 o 9.81 0.451 1 ≥12 mon hs ( e ) 135.70 - - - 128.28 - - - Obesi y 0 Non-obese 133.75 - - - 127.94 - - - 1 Obese ( e ) 135.48 1.73 -3.82 o 7.29 0.531 132.63 4.70 -0.06 o 9.45 0.053 Added sal in ake 0 No ( e ) 135.04 - - - 130.72 - - - 1 Yes 133.02 -2.02 -8.79 o 4.74 0.548 128.87 -1.85 -5.81 o 2.12 0.351 F ui and ege able consump ion 0 ≥4 imes a day ( e ) 133.60 - - - 129.50 - - - 1 <4 imes a day 135.01 1.41 -2.23 o 5.05 0.437 131.11 1.62 -1.88 o 5.11 0.354 Alcohol consump ion 0 No ( e ) 129.03 - - - 130.55 - - - 1 Yes 135.39 6.36 1.83 o 10.90 0.007 130.52 -0.03 -2.75 o 2.68 0.981 Smoking 0 No ( e ) 134.26 - - - 130.76 - - - 1 Yes 137.74 3.48 -0.28 o 7.24 0.069 127.54 -3.22 -7.38 o 0.94 0.125 Physical ac i i y 0 Ac i e ( e ) 134.92 - - - 130.91 - - - 1 Seden a y 134.48 -0.43 -3.62 o 2.75 0.783 130.21 -0.70 -4.77 o 3.37 0.729 CI: confidence in e al; Be a: eg ession coe ficien ; e : e e ence; SBP: sys olic blood p essu e. E ec o li es yle on blood p essu e in pa ien s unde an ihype ensi e d ugs 703 Table 3 Mul i a ia e associa ion be ween li es yle ac o s and sys olic blood p essu e in men and women, adjus ed o li es yle ac o s and o sociodemog aphic ac o s and obesi y (n=1277). Model SBP Adjus ed o li es yle ac o s Adjus ed o sociodemog aphic ac o s and obesi y Be a (95% CI) p Be a (95% CI) p Men Added sal in ake -2.24 (-7.75 o 3.28) 0.416 -2.31 (-7.77 o 3.15) 0.395 F ui and ege able consump ion -1.13 (-4.60 o 2.33) 0.511 -1.22 (-4.88 o 2.43) 0.680 Alcohol consump ion 6.43 (2.31 o 10.54) 0.003 6.31 (1.88 o 10.74) 0.007 Smoking 4.26 (0.74 o 7.77) 0.019 4.72 (-0.85 o -8.60) 0.018 Physical ac i i y 0.94 (2.30 o 4.17) 0.558 1.31 (-2.08 o 4.70) 0.787 Obesi y 1.64 (-4.14 o 7.42) 0.568 Women Added sal in ake -1.65 (-4.96 o 1.66) 0.319 -1.15 (-4.39 o 2.09) 0.475 F ui and ege able consump ion -0.55 (-4.04 o 2.93) 0.750 -0.36 (-3.82 o 3.11) 0.836 Alcohol consump ion 0.52 (-2.98 o 3.12) 0.687 0.25 (-2.19 o 2.68) 0.839 Smoking -1.33 (-6.31 o 3.65) 0.591 -0.47 (-4.72 o 3.79) 0.826 Physical ac i i y 1.29 (-2.27 o 4.85) 0.467 2.08 (-1.60 o 5.75) 0.259 Obesi y 4.432 (-0.79 o 9.65) 0.094 CI: confidence in e al; Be a: eg ession coe ficien . ui and ege able consump ion and BP alues.23 Un o u- na ely, he p esen s udy was no able o measu e hese di e ences. Added sal in ake Added sal in ake was no associa ed wi h SBP in men o women. Al hough s udies ha e epo ed a posi i e associa- ion be ween sal in ake and inc eased BP,24,25 ou esul s a e in line wi h ecen s udies ha ound no associa ion be ween hem.5,22 The explana ion may lie in he indi idual biolog- ical a iabili y o sal sensi i i y, as BP is sal -sensi i e in some indi iduals and no in o he s,26 o in a pa allel mecha- nism o sodium egula ion ha depends on he non-osmo ic accumula ion o sodium in he in e s i ial space.27 Ano he explana ion may be ha added sal , as measu ed in his s udy, ep esen s a small p opo ion o he o al die a y sal in ake in he popula ion; in ac , in Wes e n socie ies, 75% o daily die a y sal in ake comes om p ocessed oods.28 So measu ing his ype o in ake may unde es ima e o al sal in ake. Physical ac i i y Le els o physical ac i i y we e no associa ed wi h SBP in ei he men o women a e adjus men . Nume ous epidemi- ological s udies ha e demons a ed he an ihype ensi e e ec s o exe cise.29,30 The esul s o ou s udy, which con- flic wi h his e idence, can be explained by di e ences in ypes o physical ac i i y, which a y in equency, in en- si y and du a ion, ha he p esen s udy was no able o measu e. Obesi y Seden a y beha io , low consump ion o ui and ege a- bles, high consump ion o sal and alcohol, and smoking a e associa ed wi h obesi y,31 and his condi ion is known o be an impo an media o o he e ec o li es yle on BP le els. Howe e , in he p esen s udy, adjus men o obesi y did no al e he associa ions ound, wi h a significan posi i e associa ion be ween SBP and alcohol consump ion and smok- ing being ound. In women, no associa ion eached s a is ical significance. S eng hs and limi a ions The main s eng h o his s udy is i s in es iga ion o he associa ion be ween BP, measu ed using a s anda dized p o- ocol, and li es yle ac o s, measu ed h ough a alida ed ques ionnai e, in a popula ion o Po uguese adul s who epo ed aking an ihype ensi e medica ion, enabling his associa ion o be adjus ed o sociodemog aphic a iables and obesi y. The di e ences in he dis ibu ion o he sample in ela- ion o he a ge popula ion we e minimized by he use o sampling weigh s o age, gende and egion o he coun y. The sample is ep esen a i e o he na ional popula ion, so he s udy findings can be gene alized o he Po uguese popula ion aged be ween 25 and 74 yea s. Ne e heless, he e a e some limi a ions. The e may be selec ion bias, since he hype ensi e indi iduals who ag eed o pa icipa e in he s udy may be di e en om hose who e used o do so. We a emp ed o minimize his bias by cha ac e izing non-pa icipan s h ough he applica- ion o a ques ionnai e, which made i possible o conclude ha he use o sel - epo ed an ihype ensi e medica ion was simila in he wo g oups (25.0% in pa icipan s and 704 M.R. Sal ado e al. 26.0% in non-pa icipan s) o he o al popula ion s udied in INSEF, so he e ec o his bias may be small (Supplemen a y Table 2). The e may also be measu emen bias ela ed o he ype o ques ions used o measu e beha io s. Alcohol con- sump ion was measu ed h ough a ques ion abou alcohol consump ion in he p e ious 12 mon hs, wi hou ques ioning he equency o consump ion. The ques ion used o mea- su e he equency o consump ion o ui and ege ables in he popula ion did no speci y he ype o ui and ege a- bles consumed o he o m o p epa a ion and consump ion. Also, he ques ion abou he equency o sal added o p e- pa ed dishes did no p o ide in o ma ion on he baseline amoun o sal used in he p epa a ion o ood. Ano he limi a ion o he s udy conce ns he lack o addi ional in o ma ion --- numbe , ype and dose --- on he an ihype ensi e medica ion ha he pa icipan s epo ed aking. The e ec i eness o he di e en classes o an ihype ensi e d ugs and whe he hey a e used in mono he apy o combined he apy a ec he apeu ic adhe - ence and hence BP le els.32 Conclusion The mos impo an esul o he s udy is ha , o all he beha io al li es yle ac o s mos equen ly desc ibed in he li e a u e as associa ed wi h ele a ed BP, alcohol con- sump ion and smoking a e hose associa ed wi h SBP le els in medica ed hype ensi e men, whe he o no hey a e obese. The significan posi i e associa ions ound and he high p e alence o hese beha io s in he hype ensi e popula- ion highligh he need o public heal h s a egies aimed a he popula ion unde an ihype ensi e medica ion ha ocus on he figh agains high BP in he wo modifiable and p e en able beha io s o alcohol consump ion and smoking. Fu u e esea ch in his a ea should design ollow-up pe i- ods ha will enable causal links be ween li es yle and BP le els o be de e mined. The limi a ions o his s udy should also be bo ne in mind, pa icula ly hose ela ed o he issues o measu ing equency o alcohol and sal in ake and o he lack o knowledge o he numbe and ype o an ihype en- si e d ugs used by hype ensi e indi iduals. Funding In his s udy, a seconda y analysis o da a collec ed by INSEF was conduc ed. INSEF was de eloped as pa o a p e- defined p ojec o he Public Heal h Ini ia i es P og am, ‘‘Imp o emen o epidemiological heal h in o ma ion o suppo public heal h decision and managemen in Po ugal. Towa ds educed inequali ies, imp o ed heal h, and bila - e al coope a ion’’, which ecei ed a D 1 500 000 g an om Iceland, Liech ens ein and No way h ough he EEA G an s. Conflic s o in e es s The au ho s ha e no conflic s o in e es o decla e. Acknowledgmen s The au ho s would like o hank he INSEF g oup and all hose in ol ed in he INSEF fieldwo k. Appendix A. Supplemen a y ma e ial Supplemen a y ma e ial associa ed wi h his a icle can be ound in he online e sion a doi:10.1016/j. epc.2018.12.006. Re e ences 1. He FJ, MacG ego GA. Blood p essu e is he mos impo an cause o dea h and disabili y in he wo ld. Eu Hea J. 2007;9 Suppl. B:23---8. 2. Sousa U a M, Vic o ino P, Roque e R, e al. In es igac¸ão epidemiológica sob e p e alência e incidência de hipe ensão a e ial na populac¸ão po uguesa - uma e isão de âmbi o. Re Po Ca diol. 2014;33:451---63. 3. Chobanian AV, Bak is GL, Black HR, e al., Na ional Hea , Lung, and Blood Ins i u e Join Na ional Commi ee on P e en ion, De ec ion, E alua ion, and T ea men o High Blood P essu e; Na ional High Blood P essu e Educa ion P og am Coo dina ing Commi ee. The Se en h Repo o he Join Na ional Commi - ee on P e en ion, De ec ion, E alua ion, and T ea men o High Blood P essu e: he JNC 7 epo . JAMA. 2003;289:2560---72. 4. Ins i u e o Heal h Me ics and E alua ion (IHME). Global Bu den o Disease: dea hs and DALY due o high sys olic blood p essu e, bo h sexes, all ages. Washing on, DC; 2016. A ailable a : h ps:// izhub.heal hda a.o g/gbd-compa e/ [accessed 02.11.17]. 5. Polonia J, Ma ins L, Pin o F, e al. P e alence, awa eness, ea - men and con ol o hype ension and sal in ake in Po ugal. J Hype ens. 2014;32:1211---21. 6. de Macedo ME, Lima MJ, Sil a AO, e al. P e alência, conheci- men o, a amen o e con olo da hipe ensão em Po ugal. Re Po Ca diol. 2007;26:21---39. 7. Appel LJ, B ands MW, Daniels SR, e al. Die a y app oaches o p e en and ea hype ension: a scien ific s a emen om he Ame ican Hea Associa ion. Hype ension. 2006;47:296---308. 8. Piepoli MF, Villani GQ. Li es yle modifica ion in seconda y p e- en ion. Eu J P e Ca diol. 2017;24:101---7. 9. Wo ld Heal h O ganiza ion. Global ac ion plan o he p e en- ion and con ol o noncommunicable diseases 2013-2020. Wo ld Heal O gan. 2013:102. 10. Kaspe DL, Fauci AS, Hause SL, e al. Ha ison’s p inciples o in e nal medicine. 19 h ed. McG aw-Hill; 2017. 11. San os AJ, Gil AP, Kislaya I, An unes L, Ba e o M, Namo ado S, Gaio V, Nunes B, Dias CM. 1◦Inqué i o Nacional de Saúde com Exame Físico (INSEF 2015): ela ó io me odológico. Lisboa: INSA IP, 2016. 12. Ba e o M, Kislaya I, Gaio V, e al. P e alence, awa eness, ea - men and con ol o diabe es in Po ugal: esul s om he fi s Na ional Heal h examina ion Su ey (INSEF 2015). Diabe es Res Clin P ac . 2018;140:271---8. 13. B own DW, Giles WH, G eenlund KJ. Blood p essu e pa ame- e s and isk o a al s oke, NHANES II mo ali y s udy. Am J Hype ens. 2007;20:338---41. 14. Xin X, He J, F on ini MG, e al. E ec s o alcohol educ ion on blood p essu e: a me a-analysis o andomized con olled ials. Hype ension. 2001;38:1112---7. 15. Ne e JE, S am BE, Kok FJ, e al. Influence o weigh educ ion on blood p essu e: a me a-analysis o andomized con olled ials. Hype ension. 2003;42:878---84. E ec o li es yle on blood p essu e in pa ien s unde an ihype ensi e d ugs 705 16. Taylo B, I ing HM, Baliunas D, e al. Alcohol and hype - ension: gende di e ences in dose--- esponse ela ionships de e mined h ough sys ema ic e iew and me a-analysis. Addic ion. 2009;104:1981---90. 17. De Oli ei a ER, Fos e D, Ha pe MM, e al. Alcohol consump ion aises HDL choles e ol le els by inc easing he anspo a e o apolipop o eins A-I and A-II. Ci cula ion. 2000:2347---52. 18. F eedman DS, O os JD, Jeya ajah EJ, e al. Sex and age di e - ences in lipop o ein subclasses measu ed by nuclea magne ic esonance spec oscopy: he F amingham s udy. Clin Chem. 2004;50:1189---200. 19. Sesso HD, Cook NR, Bu ing JE, e al. Alcohol consump ion and he isk o hype ension in women and men. Hype ension. 2008;51:1080---7. 20. Halpe in RO, Gaziano JM, Sesso HD. Smoking and he isk o inciden hype ension in middle-aged and olde men. Am J Hype ens. 2008;21:148---52. 21. P ima es a P, Falasche i E, Gup a S, e al. Associa ion be ween smoking and blood p essu e. Hype ension. 2001;37:187---93. 22. Lelong H, Galan P, Kesse-Guyo E, e al. Rela ionship be ween nu i ion and blood p essu e: a c oss-sec ional analysis om he Nu ine -san é s udy, a F ench web-based coho s udy. Am J Hype ens. 2015;28:362---71. 23. Lin CH, Chang CY. Tex u al change and an ioxidan p ope ies o b occoli unde di e en cooking ea men s. Food Chem. 2005;90:9---15. 24. Coope a i e I, In e sal Coope a i e Resea ch G oup. In e - sal : an in e na ional s udy o elec oly e exc e ion and blood p essu e. Resul s o 24 hou u ina y sodium and po assium exc e ion. BMJ. 1988;297:319---28. 25. F os CD, Law MR, Wald NJ. By how much does die a y sal educ ion lowe blood p essu e? II --- Analysis o obse a ional da a wi hin popula ions. BMJ. 1991;302:815---8. 26. Hamme GD, McPhee SJ. Pa hophysiology o disease: an in o- duc ion o clinical medicine. 7 h ed. McG aw-Hill; 2017. 27. Olde Engbe ink RHG, Ro ije NMG, Homan an de Heide JJ, e al. Role o he ascula wall in sodium homeos asis and sal sensi i i y. J Am Soc Neph ol. 2015;26:777---83. 28. Wo ld Heal h O ganiza ion. Global s a us epo on noncommu- nicable diseases. Wo ld Heal O gan; 2010. p. 51. 29. Co nelissen VA, Faga d RH, Coeckelbe ghs E, e al. Impac o esis ance aining on blood p essu e and o he ca dio ascula isk ac o s: a me a-analysis o andomized, con olled ials. Hype ension. 2011;58:950---8. 30. Faga d RH, Co nelissen VA. E ec o exe cise on blood p essu e con ol in hype ensi e pa ien s. Eu J Ca dio asc P e Rehabil. 2007;14:12---7. 31. Jebb SA. Die a y de e minan s o obesi y. Obes Re . 2007;8 Suppl. 1:93---7. 32. Paz MA, De-La-Sie a A, Sáez M, e al. T ea men e ficacy o an i- hype ensi e d ugs in mono he apy o combina ion. Medicine (Bal imo e). 2016;95:e4071.