Hypertension is a common public heakh problem in developed countries.

In the Unired States nearly one in three

adults has high blood pressure (Fields et a1., 2!". Untreated hypertension leads to rnany degenerative
diseases, including heart #ailure, end$stager enal disease,a nd peripheral vasculard iseaseI.t is o#ten called a
%silent killer% because people &ith hyperrension can be asymptomatic #or years and then have a #aral stroke or
hearr attack. 'lthough no cure is available, h"(ertension is easily detected and usually controllable. Some o# the
decline in cardiovascular disease ()*r+" mortality over the last t&o decades has been attributed to the increased
detection and control o# hypertension. ,he emphasis on li#estyle modi#ications has given diet a prominent role in
both the primary prevention and nranag emento # hyper tension
.
-# those &ith high blood pressute,.%/o to .0%/o have essential or primary hypertension #or &hich the cause
cannot be determined. 1ost likely, the cause is multi#actorial, including a combination o# environmental and
generic #actors. 2ecently vascular in#lammation has been ti%tea &ith the initiation and development o#
hyperrension (#ian$3un et al.,20". In the remaining 0o/%, hypertension arises as the result
o# another disease, usually endocrine, and thus is re#erred to as secondaryh ypertension+. epending on the
e4tent o# the underlying disease,s econdaryh ypertension can be cured.
+err5rrro5
'5+ )I5SSIFI)',I-5
' generald e#initiono # hypertensionis persistentlyh igh arterialb loodp ressuret,h e #orcee 4ertedp er
unit areao n the &alls o# arteries. ,o be de#ined as hypertension, the systolicb loodp ressure(S 67",t
he blood pressured uring the contraction phase o# the cardiac cycle, has to be 1! mm Hg or higher8
or the diastolic blood pressure (+67", the pressured uring the rela4ationp haseo # the
cardiac rycle, has to be . mm Hg or higher, and they are reporteda s 1!/.m m Hg. ,he
normotensivien dividual hasa blood pressureo # lesst han 12m m Hg and a diastolic
blood pressure o# less than 9 mm Hg8 read as a blood pressureo # 1219I.n the Seventh2 eport o#
the 3oint 5ational )ommittee on 7revention, +etection, :valuation, and teatment o# High 6lood
7ressure ()hobanian et al., 2;", hypertension is classi#ied in stagesb asedo n the risk o#
developing) <+ (,able; ;$1". Individualsd iagnosed& ith prehypertensiohna vea S67
be&een1 2a nd 1;.m m Hg or a +67 bet&een9 and9 . mm Hg, and they are at high risk #or
developinge ssential hypertensio(nh irpertensioon# unkno&ne tiology"a nd) <+.
StageI hypertension(1 !t o 10./.t o .. mm Hg" is the most prevalentl evel seeni n adults.I n other
&ords,t his is the group most likely to have a myocardial in#arction or suoke. ,he de#ining point #or
hypertension is arbitrary becausea ny level o# elevatedb lood pressureis associate&d ith
increasedi ncidenceo # )*=+ and renal disease,. here#ore normali>ationo # bloodp ressureis important#
or all stageso #hlpertension
7nev'?:5c:' 5+I r,rcI+:5c:
'bout 0. million 'merican adults age 19 and older have hypertension or are taking antihypertensive medication
(Fields et al., 2!". +espite improvements in detection, the prevalence o# hlpertension has not declined. In 1...
and 2, 2.o/% o# the adult U.S. population had high blood pressure,a ;.@o/oin crease# rom 1.99t o 1..1( HaAAar
and Botchen, 2;". ,he increased prevalence may be related to an increase in body mass inde4 (61I" reported
over this decade. 6lack adults have a higher age$adAusted prevalence o# hypertension (;@C o# men8 ;.C o#
&omen" than non$Hispanic &hites (2!o/% o# men8 2;@o o# &omen" or 1e4ican$'mericans (2;Do o# men82;@% o#
&omen". ,he prevalence o# high blood pressure in blacks is one o# the highest rates seen any&here in the &orld.
6ecause blacks develop hypertension earlier in li#e and maintain higher blood pressure levels, their risk o# #atal
stroke, heart disease, or end$stage kidney disease is higher than in &hites ('merican Heart 'ssociation, 20".
6lood pressure elevations are seen across the li#e span.
's much as 0@o o# the pediatric population, or appro4imately @ million 'merican children have high blood
pressure ('merican Heart 'ssociation, 20". Eith aging, the prevalenceo #high blood pressurei
ncreases( Figure ;;$1". 6e#ore the age o# 00 more men than &omen have high blood pressure. '#ter age 00 the
rates o# high blood pressure among &omen in each racial group surpass those o# the men in their group (HaAAar
and Botchen, 2;". 6ecause the prevalence o# hypertension rises &ith increasing age, more than hal# the older
adult population (FG0 years o# age" in any racial group has hlryertension. 'lthough Ii#estyle interventions targeted
to persons &ho are older may signi#icantly reduce the prevalence o# hlryertension, early intervention programs
provide the greatest longterm potential #or reducing the overall burden o# blood pressure$related complications
(5ational High 6lood 7ressure :ducation 7rogram Eorking Hroup on High 6lood 7ressure in )hildren and
'dolescents,2!".
Individual a&areness o# hypertension has leveled o## since 1..!. 6ased on analysis o# 5ational Health and
5utrition :4amination Survey (5H'5:S" III data, G.C o# people &ith hypertension are a&are that they have it
(Iureshi et al, 20". )urrent hypertension control rates, although up #rom 1..!, are still #ar belo& the Heahhy
7eople 21 goal o# 0%/% o# the hypertensive population normali>ing their blood pressure &ith treatmentJ
5though 0.C o# hlpertensive adults are reportedly receiving treatment, only ;1%/% >re maintained at or belo& goal
blood pressure levels (HaAAar and Botchen, 2;". In 2, &omen, older individuals, and 1e4ican$'mericans
had lo&er rates o# blood pressure control compared &ith men, younger individuals, and non$Hispanic &hites.
Improving hypertension treatment among these %at risk% individuals through targeted intervention programs
should have a signi#icant impact on improved )*l+ outcomes in the United States.
,he relationship bet&een blood pressure and risk o# )*r+ events is continuous, consistent, and independent o#
other risk #actors (5IH, 2!". ,he higher the blood pressure, the greater the chance o# target organ damage,
including le#t ventricular hypertrophy, congestive heart #ailure, stroke, and kidney disease. 's evidence o# this, in
the 5H'5:S III survey, GGC o# adults &ith prehypertension had one maAor )<+ risk #actor8 and 2.@% had )*=+,
diabetes, or target organ disease (1unter et a1.,22". Un#orrunately many physicians do not begin treating
elevated blood pressure until stage I levels, especially in older patients (Hlnnan and 7avlik, 21". ,o decrease
the public health burden o#hlpertension, changes in physician practice must occur. ,he 35) @ report emphasi>es
the need #or increased education o# health care pro#essionals and the public about the importance o# early
detection and treatment #or elevated blood pressure (5IH, 2!". Fortu$
nately e##ective screening and li#estyle modi#ication approaches are available to achieve this obAective.
?o&ering blood pressure in patients &ith diabetes and hypertension is associated &ith a decrease in )*r+ events
and renal #ailure (So&ers, 2;". ,he target blood pressure goal #or antihypertensive therapy in individuals &ith
diabetes is 1;/9 mm Hg. In 2 only 20%/% o# individuals &ith diabetes receiving antihypertension therapy met
this blood pressure goal (F=aAAar and Botchen, 2;". Eith the increased prevalence o# diabetes in the United
States, uncontrolled hypertension &ith diabetes is an important public health problem that &arranrs artention.
1-56I+I,D '5+ 1on,'?I,D
'lthough hlpertensive patienrs are o#ten asymptomatic, hypertension is not a benign disease. )ardiac,
cerebrovascular, and renal systems are a##ected by chronically elevated blood pressure (,able ;;$2".
High blood pressure &ast he primary or a contributory causein 2G1,o # the
2.! million U.S. deaths in 22 ('H', 20". 6et&een 1..2a nd2 2t he age$adAustede athr ate #rom
hypertension increasedby 2@C8 overall deaths #rom hypertension increased by 0@o/%. +eath rates
#rom hypertension are about ;.0 times higher in blacks than in &hites ('H', 20".H ypertensioni s a
maAor contributing# actort o atherosclerosist, h e underlying causeo # much )<+ (Bher
and 1arch, 2!".In adults& ith blood pressuresra nging #rom 110/@0t o 190/ll0 mm Hg, the risk o#
)<+ doubles &ith a 2 mm Hg increasein S67o r a 1m m Hg increase in +67 (?e&ington et
a1.,22".S troke and myocardial in#arction also are maAor contributors to morbidity8 bet&een
0, and a million people have non#atal events eachy ear., he #actorsa ssociate&d ith a poor
prognosisin hypertensiona res ho&ni n 6o4 ;;$1.
7nrHo7HDsro?ocy
6lood pressure is a #unction o# cardiac output multiplied by peripheral resistance (the resistance in the blood
vessels to the #lo& o# blood". ,he diameter o# the blood vessel markedly a##ects blood #lo&. Ehen the diameter is
decreased (as in atherosclerosis" resistance and blood pressure increase. )onversely, &hen the diameter is
increased (as &ith vasodilator drug therapy", resistance decreases and blood pressure is lo&ered.
1any systems maintain homeostatic control o# blood pressure. ,he maAor regrrlators are the ryrnpathetic nervous
system (#or short$term control" and the kidney (#or longterm control". In response to a #all in blood pressure, the
s1Jrnpathetic nervous system secretes norepinephrine, a vasoconstrictor, &hich acts on small arteries and
arterioles to increase peripheral resistance and raise blood pressure. ,he kidney regulates blood pressure by
controlling the e4tracellular #luid volume and secreting renin, &hich activates the renin$angiotensin system
(Figure ;;$2". Ehen the regulatory mechanisms #alter, hypertension develops.
7lausible causes o# hypertension are a hyperactive s".,npathetic nervous system, an over$stimulated renin$
angiotensin system, a lo&$potassium diet, and use o# the drug cyclosporine (Figure ;;$;". 'II o# these cause
renal vasoconstriction, &hich results in ischemia or arterial changes.
)hronic in#lammation may be involved in the development o# hypertension as &ell. In#lammatory markers, in
particular )$reactive protein, have been sho&n to be elevated in patients &ith hypertension (Sesso et al, 2;".
)$reactive protein inhibits #ormation o# nitric o4ide by endothelial cells, &hich in turn may promote
vasoconstriction, leukocyte adherence, platelet activation, and thrombosis (6autista et al., 21".
,he etiology o# abnormal blood pressure is likely multi#actorial.
In most cases o# hypertension, peripheral resistance increases. ,his resistance #orces the le#t venricle o#
the heart to increase its e##ort in pumping blood through the system. Eith time, le#t ventricular hlpertrophy and
eventually congestive heart #ailure can develop.
72I1'2D 72:<:5,I-5
,he 5ational High 6lood 7ressure :ducation 7rogram (5H67:7" is one o# the most success#upl
reventionp rograms in the t&entieth century (1oser, 22". ,hrough educationale ##orts the detection,
a&arenessa, nd treatment o# hypertension have improved over the ; 0 years sincei ts inception.,
hesec hangesh avec ontributedt o the declinei n cardiovasculamr ortality seend uring the same
time period.
7rimary prevention o# hypertension can improve Kuality o# li#e and costs associated& ith medical
managemento # hypertensiona nd its complications'. strategy# or the population &ould be to reduceb
lood pressurei n those &ith prehlpertension (above 12/9" but belo& the cut points #or
stage t h"(ertension. ' do&n&ard shi#t o# ; mm Hg in S67 &ould decreaseth e mortality #rom stroke
by 9%/% and #rom coronary heart disease tLy 0C ('ppel, 2;". 7ersons at highestr isk (6o4 ;;$2"
shouldb e suongly encouragedto adopth ealthierl i#estyles.
)hanging li#estyle #actors has documented e##icary in the primary prevention and control o#
hypertension.
,hese# actorsa rep resentedin ,hble ;;$; andi ncludel osing &eight i# over&eight8li miting alcoholi
ntake8a dopting a dietary pattern that emphasi>es#r uits, vegetablesa, nd lo&$#at dairy products8r
educing #at, especiallys aturated #at, and cholesterol8 reducing intake o# dietary sodium8
increasingp hysicala ctivity8 and stoppings moking( 5,IH, 2!".In individuals& ith normal blood
pressurem, odi#ication o# these li#estyle #actors has been sho&n to lo&er blood pressure and thereby
has the potential to prevent hypertensiona nd lo&er the risk o#blood pressure$related complications. '
substantial body o# evidence strongly supports these li#estyle modi#ications as a means o#
signi#icantlyl o&ering blood pressurei n individuals& ith hvpertension.
Eeigh2t educt ion
,here is a strong association bet&een 61I and hlpertension among men and &omen in all race or ethnic groups
and in most age$groups. 6ased on the 5H'5:S III survey, the prevalence o# high blood pressure in persons &ith
a 61I greater than ; kglm2 is !2%/% #or men and ;9@% #or &omen, compared &ith 10C #or men and &omen &ith
a normal 61I (M20 kglm2" (6ro&n, 2". ,he risk o# developing elevatedb lood pressurei s t&o to si4 times
higher in over&eight than in normal$&eight persons (5rIH, 2!". 2isk estimates#r om populations
tudiess uggesth at ;C or more o#caseso #hypertensionc anb e directlya ttributedt o obesity
('H', 21". Eeight gain during adult li#e is responsible #or much o# the rise in blood pressures een&
ith aging. Someo # the physiologicc hangesp roposedt o e4plaint he relationshipb et&eene 4cessb ody
&eight and blood pressure are overactivation o# the sympathetic nervous and reninangiotensin
systems (:ngeli and Sharma, 21" and elevated levels o# in#lammatory path&ays (1eerarani et a1.,2G".
*!rnrally all clinical trials on &eight reduction and blood pressure support the e##icacy o# &eight loss on lo&ering
blood pressure. In phase I o# the ,iial o# Hlpertension 7revention (FIe et al., 2", normotensive individuals &ho
lost an average o# ;.0 kg in an lS$month intervention reduced their S67 and +67 by 0.9 mm Hg and ;.2 mm Hg,
respectively.
Seven years a#ter trea##nent cessation, the incidence o# hlpertension &as 19..C in the &eight3oss group and
!.0%/% in the control group. ,hese #indings suggest that improvements in blood pressure persist long a#ter
trea##nent cessauon.
' metaanalysis o# 20 randomi>ed controlled trials, totaling nearly 0 participants #rom di##erent ethnic groups,
sho&ed a blood pressure reduction o# !.!/;.; mm Hg #or a 0$kg &eight loss by means o# energy restriction,
increased physical activity, or both I.=eter et al., 2;". 2eductions in blood pressure occurred &ithout
attainment o# desirable body &eight in most participants. ?arger blood pressure reductions &ere achieved in
participants &ho lost more &eight and &ho &ere also taking antihypertensive medications.
,his latter #inding suggests a possible srnergistic e##ect bet&een &eight loss and drug therapy.
Eeight reduction and maintenance o# a healthy body &eight ii a maAor e##ort #or many persons, especially &omen.
Interventions to prevent &eight gain are ideal, particularly be#ore an individual reaches midli#e. 61I is
recommended as a screening tool in adolescence #or #uture health risk (Hardin eta1.,22".In adults a 61I above
; is the cuto## #or obesity, and re#erral to a registered dietitian (2+" is &arranted.
Ehen alarge percentage o# the population is obese and hypertensive, better strategies are needed to prevent
e4cess &eight gain and improve compliance &ith treatrnent (5rIH,2!" (see )hapter 21".
+ietary7 atterns
Several dietary patterns have been sho&n to lo&er blood pressure. <egetarian dietary pa##erns have been
associated &ith lo&er S67 in observationasl tudiesa nd clinical trials.
'verage S67 reductions o# 0 to G mm Hg have been reponed.
Speci#icall yth, e +ietary' pproachetso Stop Hypertension (+'SH" +iet Study sho&s that this lo&$#at
dietary pattern (including lean meats and nus &hile emphasi>ing #ruits, vegetablesa, nd non#at dairy
products"d ecreasedS 67 an average o# G to 11 mm Hg and +67 by ; to G mm Hg
('pp%l et al., 1..@". ,he +'SH diet is #ound to be more e##ectivet han Aust adding #ruits and
vegetablesto a lo&$#at dietary pattern (5IIH, 2G".
,he -mniHeart tial e4amined the e##ecs o# tluee versionso # the +'SH diet on blood pressurea nd
seruml ipids. ,he dies studied included the original +'SH diet, a highprotein version o# the +'SH dret
(20%/% o# energy #rom protein, about hal##rom plant sources"a, nd a high$unsaturated
#at +'SH diet (;1C o# calories# rom unsaturated#a t, mosdy monounsaturated"'. lthough eachd iet
lo&eredS 67,s ubstituting some o# the carbohydrate (appro4imately 1C o# total calories" in the +'SH
diet &ith either protein or monounsaturated#a t achievedt he best reduction in blood
pressurea nd blood cholesterol( 'pp.l et al., 2081 iller et al., 2G". ,his could be achieved by
substituting some more nuts #or some o# the #ruit, bread, or cereal servings.
6ecausem any hype#tensivep atientsa re over&eight,h ypocaloric versions o# the +'SH diet have also
been tested #or e##icacy in promoting &eight loss and blood pressure reduction. ,he E:?? diet study
(5o&son et al., 20" #ound that, #or the same 0$kg &eight loss, a hlpocaloric +'SH diet versus a lo&$
calorie#lo&$#at diet produced a greater reduction in S67 and +67.
'lthough the +'SH diet is sa#e and currendy being advocated by the35) @ I<IH, 2!" and the
'merican Heart #usociation ('H'" ('pp.l et al., 2G" #or preventing and treating prehypertensiona nd
hlpertension, the diet is high in poassium,p hosphorusa, nd protein, dependingo n ho& it is planned.
For this reason the +'SH diet &ould not be advisable#o r individuals& ith end$stagere nal disease('
pp%let al., 2G".
:4cessivHeo nsumptioon# SodiumH hloride
:vidence #rom a variety o# sources (i.e., epidemiologic studies, intervention trials and metaanalyses" suppon
lo&ering blood pressure by reducing dietary sodium. ?arge population studies have demonstrated a positive
association bet&een dietary sodium intake and blood pressure over a &ide range o# sodium intakes. Intervention
studies such as the 7hase 2 o# the tials o# Hlpertension 7revention (,-H7" have sho&n that sodium reduction
&ith or &ithout &eight loss can reduce the incidence o# hlpertension by 2C (,-H7 )ollaborative 2esearch
Hroup, 1..@".
Several metaanalyses (FIe and 1acHregor, 22,2N" o# randomi>ed sodium reduction trials have con#irmed
positive e##ects o# sodium reduction on blood pressure in both normotensive and hypertensive individuals. ' high
salt intake has also been implicated in hlpertensive target organ disease, including cardiovascular and renal
damage (1ilan etal,22". Such data provide the basis #or current dietary guidelines #or all 'mericans to limit salt
intake to G g/day or sodium intake to 2.! g/day, and #or those &ith hlpertension to limit sodium intake to
1.0 g/day (US+HHS, 20" (see )hapter 12".
,here is heterogeneityi n individual responsivenestso sodium. Some persons &ith hlpertension sho&
a greater decreasein their blood pressuresin responset o reduced sodiumi nake than others., he term
%salt$sensitiveh ypertension% has been used to identitJ these individuals. ,his versus% salt$resistanht
ypertensionr&% hich re#erst o individuals &ith hypertension &hose blood pressures do not
change signi#icandy &ith lo&ered salt intakes. )urrent thinking on salt sensitivity is that the
relationship bet&een salt and blood pressureis %not binary% Opp.l et al., 2G".
Salt sensitivity has a continuous distribution &ithin diverse populations& ith individualsh avingg
reatero r lesserd egrees o# blood pressure reduction (-bar>anek et al., 2;". In general, individuals
&ho are more sensitive to the e##ects o# salt/sodium tend to be individuals &ho are black, obese, or
middle$agea nd older, or those& ho have diabetes,c hronic kidney diseaseo, r hypertension( ohnson
et al., 22".) urrendy there are no practical methods #or identiS>ing the salt$sensitivein dividual #rom
the salt$resistanitn dividual.
7hysica'l ctivity
?ess active persons are ;o/o to 0o/o more likely to develop hypertension than their active counterparts.
+espite the bene#is o# activity and e4ercise in reducing disease, many 'mericans remain inactive. Hispanics
(;;o/o men, !Do &omen", blaclMs (2@C men,;!o/o &omen", and &hites (19olo men, 22o/o &omen" all have a
high prevalence o# sedentary li#estyles ('II' 20".
,&o metaanalyses have demonstrated the bene#icial e##ects o# e4ercise on blood pressure. ,he #irst analysis
sho&ed that &alking reduced blood pressure in adults by an average o# 2C (Belley et al., 21". Second, in 0!
randomi>ed clinical trials. aerobic e4ercise reduced blood pressure an average o# ! mm Hg #or S67 and 2 mm
Hg #or +67 in patients &ith and &ithout high blood pressure, irrespective o# body &eight change Ohelton et al.,
22".
,hus increasing the amount o# physical activity o# lo&$tomoderate intensity to 3 to !0 minutes most days o# the
&eek is an important adAunct to other strategies #or the primary prevention o# hypertension.
'lcoho)l onsumption
Five to @C o# the hlpertension in the population is the result o# alcohol consumption ('pp%l et al.,
2G". ' three drink$per$day amount (a total o# ; o> o# alcohol" is the threshold# or raisingb lood
pressurea nd is associate&d ith a ;$mm Hg rise in S67. For preventing high blood pressure,
alcohol intake should be less than t&o drinks per day (2! o> o# beer, l o> o# &ine, or ; o> o# 9$proo#
&hiskey" in men. In &omen and lighter$&eight men, no more than one drink a day is recommended-
IIH, 2!".
7otassium
In observationasl tudiesd ietary potassiuma nd blood pressurea re inverselyr elated( i.e.,h igher
potassium intakes are associate&d ith lo&er blood pressures"2. esults# rom clinical trials on
potassium and blood pressure have been less consistent.H o&ever, a metaanalysiso # these trials
#ound that high dietary potassiurn may help prevent and control hlpertension Ohelton et al., 1..@".
-n average a median doseo # 2.! g/day o# supplementapl otassiumre ducedS 67 and +67 by !.!
and2.0 mm Hg in hlpertensivesa, nd 1.9 and I mm Hg in normotensives., he e##ectso # potassium
&ere greater in blacks than &hites and in those &ith higher intakes o# sodium.
7otassiumin take has alsob een relatedt o stroke mortality. In a large population$basedc oho#t, a
higher potassium intake &as associated& ith a ;9C lo&er risk o# stroke (#ucherio et al., 1..9". +ata
#rom the 5FI'5:S III survey suggeststh at lo& dieary potassiumin take is associate&d ith
an increasedr isk o# stroke (6a>>anoe t al., 21".H o&ever, more statistically signi#icant e##ects are
#ound #or improved diet, aerobic e4ercise, alcohol and sodium restriction, and #ish oil supplements
than #or potassium supplements (+ickinson et al., 2Ga".
,he largen umber o# #ruits andv egetablesre commendedin the +'SH diet makes it easy to meet
dietary poussium recommendations o# the 35) @ and the 'PI'$appro4imately !.@ g/day -IIH, 2!8
'ppel et al., 2G". In individuals &ith medical conditions that could impair potassium e4cretion
(e.g., chronic renal #ailure, diabetes, and congestive heart #ailure", a potassiumi ntake lesst han !.@
g/day &ould be appropriate to prevent hyperkalemia.
ther+ ietaryF actors
)alcium
Higher dairy calcium versus nondairy calcium has been associated &ith a lo&er incidence o# stroke
among men and &omen (#ucherio et al, 1..9". ,hese #indings suggest that the e##ecs o# calcium may
di##er, depending on the #ood source, or alternatively that other constituents o# dairy may be
responsible# or the observeda ssociations7. eptidesd erived #rom milk proteins, especially #ermented
milk products, have been sho&n to #unction as angiotensin$converting enrymes, thereby lo&ering
blood pressure (Seppo et al, 2;".' t presentt he35) @ repon recommendsa diet rich
in #ruits, vegetablesa, nd lo&$#at dairy productso ver calcium supplementation#o r the preventiona nd
managemenot # elevatedb lood pressure( )hobaniane t al., 2;".' n intake o# dietary calcium to
meer the goal o# 1 to 2 mg daily is recommended.
1agnesium
1agnesium is a potent inhibitor o# vascular smooth$muscle contraction and may play a role in blood
pressure regulation as a vasodilator. In observational studies dietary magnesium
&as inversely related to blood pressure ('scherio etil., 1..9". ?ess consistent #indings have been
reported #rom randomi>ed clinical trials o# magnesium supplementation #or blood pressure control
(+ickinson et al., 2Gb". ,he +'SH dietaryp attern emphasi>es#o ods rich in magnesium,
including green lea#irv egetablesn, uts, and &hole grain breads and cereals. -verall #ood sources o#
magnesium rather than supplemental doses o# the nutrient are encouraged to prevent or control
hlpertension ()hobaniane t al, 2;".
?ipids
Fe&er vegans have hypertension than omnivores, even though their salt intake is not signi#icandy
di##erent. ,he vegand iet tendst o be higher in polyunsaturated#a tKJ acids (7UF#u", among other
nutrients, and lo&er in total #at, saturated# atKJ acids,a nd cholesterol.7 UF's are precursors
o#prostaglandins, &hose actions a##ect renal sodium e4cretion andr ela4v ascularm usculature,. hus
an e##ecto n blood pressureis plausible.
6oth the amount and type o# #at have been studied &ith respect to blood pressure. In several large
prospective observationasl tudiesa nd clinical trials, intake o# total #at and speci#ic# atty acidsh ad litde
e##ecto n blood pressure( 'scherio et al, 1..9". 1ore recendy, studies have sho&n that
supplementation& ith large doseso # #ish oil (mediand oseo #;.@ g/da#l can give a modest reduction in
S67 and +67, especially in older hlryertensive persons (HeleiAnse et al.,22". Side e##ecs o#
supplementation &ith #ish oils are #reKuent and include belching,g astrointestinadl istressa, nd
halitosis. For this reason and the high dose reKuirement, #ish oils are not routinely recommendeda sa
meanso # lo&ering blood pressure ('pp.l etal,2G".
Factors other than dietary #at, such as increased potassium levels, appear to lo&er blood pressure in
vegans. 'lthough dietary lipids do not seem to a##ect blood pressure, they strongly a##ect )<+ rislK
thus the ,herapeutic ?i#estyle )hanged iet is recommended#o r preventingc omplications
#rom hlpertension and )<+ (see )hapter ;2". 5though #aay acidsm ay not direcdy a##ectb lood
pressurea, n olive oil$enriched diet has been sho&n to result in a !9%/% reduction in need #or
antihlpe#tensive medication Oerrara et al., 2". Soy protein is another #actor that may contribute
to the lo&ering o# blood pressure (Hecker,2l".
Hombinatioon# 2iskF actors#o r
Hardiovascul+airs ease
Hlpertension o#ten ocsurs &ith other risk #actors #or )<+. In the 5II'5:S III survey (1ust et
al.,1...",!C% o# persons &ith hypenension also had high blood cholesterol
levels (F2N mgldl". Fi#ty$#ive percent o# over&eight men have hypertension compared &ith 2@%/% o#
normal&eight men. 2esearchersh ave long noted a larger than normal clustering o# )<+ risk #actors,
including abdominal obesity, high triglyceride levels, lo& high$density$lipoprotein
cholesterol, high blood pressure, and high #asting glucose. ,he 5ational )holesterol :ducation
7rogram (5):7" recommendations #or cholesterol management de#ine the occurrence o# three or
more o# these risk #actors as the metabolic syndrome (I.I):7, 21".
2ecent blood pressure treatment guidelines highlight the importance o# evaluating patients #or the
presence o# multiple )<+ risk #actors (see 6o4 ;;$2", nd individuali>ing li#estyle modi#ication and drug
therapies to target coe4isting abnormalities (5IH, 2!". Health problems related to the metabolic
syndrome are e4pected to rise dramaticallyu nlesse ##ectivep opulation$basedh ealth promotion
strategies are promoted. Fortunately li#estyle modi#ications can prevent metabolic syndrome #rom
developing (see )hapter ;2, and )linical InsigbtL ,he 1etabolic Syndrome in )hapter .".
1edications
' number o# medications either raise blood pressure or inter#ere &ith the e##ectivenesso #
antihlpertensive drugs. ,hese include oral contraceptives, steroids, nonsteroidal antiin#lammatory
drugs, nasal decongestants and other cold remedies,a ppetite suppressantsc,y closporin tricyclic
antidepressants,a nd monoamine$o4idasei nhibitors (see )hapter 1G and 'ppendi4 ;1".
1 :orc'? 1nn'c:1:5,
,he goal o# hypertension management is to reduce morbidity and mortality #rom stroke, hlpertension$
associated heart diseasea, nd renal disease'. ccordingt o the 35) @ recommendations, three
obAectives #or evaluating patients &ith hypertension are to (l" identi#r the possible causes8
(2" assessth e presenceo r absenceo # target organ disease and clinical )<+8 and (;" identi#r other
)<+ risk #actors that &ill help guide treatrnent (5IIH, 2!". Eeight history8 leisure$time physical
activity8 and assessmenot # dietary sodium, alcohol, saturated #at, and other patterns
(e.g.,i ntake o# #ruits, vegetablesa, nd dairy producs" are essential components o# the medical and diet
history. ,he presence o# risk #actors and target organ damage determinest reatrnenta
ggressivenes'ss. sho&n in ,hble ;;$;, li#estyle changes are primary therapy in all patients &ith
hypertension. Ho&ever, pharmacologic therapy is necessary m many
7harmacolog,irce atment
I# blood pressure remains elevated a#ter G to 12 months o# li#estyle changes, antihlpertensive medications are
started. 1ost patients &ith hypertension more severe than stage 1 hypertension reKuire drug ueatrnent8 ho&ever,
li#estyle modi#ications are still a part o# therapy even &hen drugs are used. ,he standard treatment #or
hlpertension includes diuretics and p$blockers, although other drugs (6$angiotensinconverting
en>yme inhibitors, a$receptor blockers, and calcium antagonists" are eKually e##ective. 'll these drugs
can a##ect nutrition status (see )hapter 1G".
+iuretics lo&er blood pressure in some patients by promoting volume depletion and sodium loss8 ho&ever,
thia>ide diuretics increase urinary potassium e4cretion,especially in the presence o# a high salt intake, thus
leading to potassium loss and possibly hypokalemia. :4cept in the case o# a potassium$sparing diuretic such as
spironolactone or triamterene, additional potassium is usually reKuired.
?i#estyle1 odi#ications
?i#estyle modi#ications are de#initive therapy #or some and adAunctive therapy #or all persons &ith
hypertension. Several months o# compliant li#estyle modi#ications should be tried be#ore drug therapy
is initiated. 'n algorithm #or treatrnento # hypertension,e stablishedb y the 35) @ committee,
is sho&n in Figure ;;$! (5rIH, 2!". :ven i# li#estyle modi#ications cannot completely correct the
blood pressure, they &ill help increase the e##icacy o# pharmacologic agents and improve other )<+
risk #actors. 1anagement o# hypertension reKuires a li#elong commitrnent.
Eeight2 eduction
Eeight loss is an e##ective means o# lo&ering blood pressure in hypertensive individuals. For each
kilogram o# &eight lost, reductions in S67 and +67 o# appro4imately I mm Hg are e4pected( 5eter et
al., 2;".H lryertensive patients &ho &eigh more than 1 I 0 C o# ideal body &eight should be placed
on an individuali>ed &eight$reduction program that #ocuses on both hlpocaloric dietary intake
and e4ercise. 7ractical suggestions #or assisting clients in increasing physical activity and reducing
calories include reducing time spent &atching television or being online,increasing time spent &alking
or in activities that raise the heart rate, reducing portion si>es #or meals and snacks,reducing the si>e
and #reKuency o# calorie$containing drinls, and limiting #at intake.
In the +iet, :4ercise, and Eeight ?oss Intervention study, the goal #or energJy intake to #acilitate
&eight loss &as 20 kcal/kg minus appro4imately 0 kcal daily to produce a -.!$kgl&eek (about l$lb"
de#icit that &ould reach a total &eight loss o# !.0 kg (1iller et al., 22". ,his modest caloric reduction
&as associated &ith a signi#icant lo&ering o# S67 and +67, and lo&$density$lipoprotein cholesterol
levels. For the same degree o# &eight loss, hypocaloric diets that include a lo&$sodium +'SH dietary
pattern have produced more signi#icant blood pressure reductions than lo&$calorie diets emphasi>ing
only lo&$#at #oods (5o&son et al., 20".
'nother bene#it o# &eight loss on blood pressure is the synergistic e##ect &ith drug therapy. In subAecs
&ho lost &eight and &ere aking one antihlpertensive drug, lo&ering o# blood pressure &as greater
than in those taking the drug alone I.=eter et al., 2;". ,here#ore &eight loss should be
an adAunctt o drug therapyb ecauseit may decreaseth e dose or number o#drugs necessaryto control
blood pressure. -nce &eight is lost, maintenance is critical. Un#ornrnately relapse and &eight gains
are common #ollo&ing dieting to lose &eight. Some #actors associated& ith e##ective
&eight maintenance are e4ercise, positive sel#$statements related to &eight$reduction e##orts, sel#$
monitoring activities (use o# a #ood diary goal setting, early attention to &eight regarn", and problem$
solving skills in lieu o# eating during stress#irlt imes (see) hapter 21".
)hangin+g ietary7 atterns
,he +'SH diet is used #or both preventing and controlling high blood pressure( see' ppendi4 ;;". Success#ual
doption o# this diet reKuires many behavioral changesL eating t&ice the average number o# daily servings o# #ruits,
vegetables, and dairy products8 limiting by one third the usual intake o# bee#, pork, and ham8 eating hal# the
typical amounts o# #ats, oils, and salad dressings8 and eating one Kua#ter the number o# snacks and s&eets
(6lackburn, 21". ?actose$intolerant persons may need to incorporate lactase en>l#me or use other strategies to
replace milk (see )hapter 2@". #usessing patientsJreadiness to change and engaging patients in problem
solving, decision making, and goal setting are behavioral strategies that may improve adherence (Eindhauser et
al., 1..." (6o4 ;;$;8 see )hapter l.".,he high number o# #ruits and vegetables consumed on
the +'SH diet is a marked change #rom typical patterns o# 'mericans. ,o achieve the 9 to 1 servings, t&o to
three #ruits and vegetables should be consumed at each meal (see 'ppendi4 ;;". Importandy, because the
+'SH diet is high in #iber, gradual increases in #ruit, vegetables, and &hole grain #oods should be made over
time. Slo& changes can reduce potential short$term gastrointestinal disturbances associated &ith a high$#iber diet
such as bloating and diarrhea. ,he +'SH pattern has been incorporated into the current 'H' nutrition guidelines
(I(rauss et al., 2".
Servings #or di##erent calorie levels are sho&n in 'ppendi4 ;;. ' Kuick assessment tool can help 2+s and
patients monitor progress (lable ;;$!".
Salt 2estriction
1oderate sodium restriction (2; mg sodium daily or G g o# salt" is recommended #or trea##nent o#
hypertension GrIH, 2!". ,o achieven utrient adeKuacy,a n adeKuate inake ('I" level o# sodium has
been set at 1.0 g/day (Institute o# 1edicine, 2!". ,he +'SH$Sodium trial sho&ed
that people consuming dies o# l.0glday o# sodium had greater blood pressure bene#its than those &ith
higher intakes ('ppel et al., 1..@". ?o&er$sodium diets &ere also sho&n to maintain lo& blood
pressure over time and enhancet he e##icacyo # certainb lood pressure$lo&eringm edications.
'lthough it may be advisable #or individuals &ith elevated blood pressure to restrict sodium to 'I
levels, adherence to diets containing less than 2 g/day o# sodium is di##icult to achieve.
6ecause most dietary salt comes #rom processed #oods and eating out, changesin #ood preparationa
nd processing can help patients reach the sodium goal. Sensory studies sho& that commercial processing
could develop and revise recipes using lo&er sodium concentrations and reduce added sodium &ithout a##ecting
consumer acceptance. In addition to advice to select minimally processed #oods, dietary counseling to lo&er
sodium should include instruction on reading #ood labels #or sodium content, avoidance o# discretionary salt in
cooking or meal preparation (1 tsp salt L 2! mg sodium", and use o# alternative #lavorings to satis#ii individual
taste. 6ecause the +'SH eating plan is rich in #ruits and vegetables, &hich are nanrrally lo&er in sodium that
many other #oods, adopting the +'SH diet&ill enable individuals to consume less salt and sodium. Focus ->L
Sodium and the Food Industry discusses ho& di##icult it is to #ollo& a sodium$restricted diet in 'merican society.
-ther+ ietary1 odi#ications
1inerals
)onsuming a diet rich in potassium has been sho&n to lo&er blood pressure and blunt the e##ects o# salt on blood
pressurei n some individuals( 'pp.l et al., 2G"., he recommendedintakeo # potassium#o r aduls is!.@
g/day (Institute o# 1edicine, 2N". 7otassium$rich #ruits and vegetablesi ncludel ea#r greenv
egetables#r, uits, andr ootvegetables. :4ampleso # such# oods include oranges,b eet greens,& hite
beans, spinach, bananas, and s&eet potatoes. 'lthough meat, milk, and cereal products contain
potassium, the potassium #rom these sources is not as &ell$absorbed as that #rom #ruits and
vegetables- S+'% 20".
Increasedin takeso # calciuma nd magnesiumm ay have blood pressureb ene#its,a lthought here is not
enoughd ata at presentt o support a speci#icr ecommendation#o r increasingl evelso # intake. 2ather,r
ecommendationss uggest meeting the 'I intake #or calcium and the recommended dietary allo&ance
#or magnesium #rom #ood sourcesr ather than supplements,. he +'SH diet plan encourage#so odst
hat &ould be good sourceso #both nutrients, including lo&$#at dairy products, dark green leaS>
vegetablesb, eans,a nd nuts.
?ipids
)urrent recommendations #or lipid composition o# the diet are those recommended by the 5):7 (see )hapter
;2" to help control &eight and decrease the risk o# )<+ (5):2 21".
'lcohol
,he diet history should contain in#ormation about alcohol consumption. #u discussed previously, alcohol intake
should be limited to no more than 2 drinks dailv in men. &hich is eKuivalent to 2 o> o# 1$proo# &hiskey, l
o> o# &ine, or 2! o> o# beer. Eomen or lighter$&eight men should consume hal# this amount.
:4ercise
1oderate physical acrivity, de#ined as 3 to !0 minutes o# brisk &alking on most dayso # the &eek,i s
recommendeda s an adAunct therapy in hlryenension. -ver&eight or obese hypertensive patiens
should strive #or ; to 0 kcal e4pendedi n e4ercisep er day or 1 to 2 kcal./&eekto
promote &eight loss or &eight control. 6ecause e4ercise is strongly associated &ith success in
&eight$reduction and &eight$maintenance programs, any increase in activity level shouldb e
encouragedS. iQty to . minuteso # daily moderateintensity physical activity is recommended #or
individuals trying to maintain a ne& lo&er &eight a#ter having lost &eight (US+', 20".
,reatmenot # 6lood7 ressure
in Hhildreann d' dolescents
,he prevalenceo # primary hypertensiona mongc hildren in the United Statesis increasingin concert&
ith rising obesity rates and increasedin takeso # high$calorie,h igh$salt #oods (1itsne#es, 2G8 1unter
et al., 2!". Hlpertension tracks into adulthood and has been linked &ith carotid intimalmedial
thickness ()III,"8 le#t ventricular hypertrophy (?EI"8 and #ibrotic plaKue #ormation8 all o# &hich are
determinantso # adversec ardiovasculaer ventsi n adults( +avis et al., 218 +aniels, 1..9". In
addition, it has been noted that intrauterine grouth retardation leads to hlpertension in childhood
(Shankaran2, G".S econdaryh lpertension is more commoni n preadolescencth ildren,m osdy #rom
renal diseasep8 rimary hypenensioni s more common in adolescents #rom obesity or a #amily history o#
hlpertension (?uma and Spiotta, 2G".
High blood pressure in youth is based on a normative distribution o# blood pressure in healthy
children. Hypertension is de#ined as a S67 and/or +67 F.0th percentile #or age, se4, and height. 5e&
diaglostic recommendations havei ncludeda designation# or prehypertensionin children &hich is S67
and/or +67 F.th percentile (5IH, 5H?6I and 5H67:2 20"., herapeuticl i#estylec hangesa re
recommended as an initial treatrnent strategy #or children and adolescents& ith prehypertensiono r
hypertension (,hble ;;$0". ,hese li#estyle modi#ications include regular physical activity, avoiding
e4cess& eight gain,l imiting sodium, and consuming a +'SH$type diet. -# these, &eight reduction is
consideredt he primary therapy #or obesity$relatedh lpertension in children and adolescents.
lln#ornrnately sustained& eight lossi s di##icult to achieve in this age$group. ,he Framingham
)hildrenJs Study sho&ed that children &ith higher intakes o# #ruits, vegetR$ bles (a combination o# #our
or more servingp per day" and dairy products (t&o or more servings per day" had lo&er S67
compared &ith those &ith lo&er intakes o# these #oods (1oore et al., 20".6 ecausea dherenceto
dietaryi nterventions may be particularly problematic among children, in
novative nutrition intervention approaches that address the uniKue needs and circumstances o# this age$group
are needed. Strategies #or improving intake patterns among children and adolescents can be #ound in )hapters @
and 9.
,reatmenot# 6lood7 ressurien lder' dults
1ore than hal# o# the older population has hypertension8 this is not a normal conseKuenceo # aging,
but )<+ risk in older aduls is tlvo to three times higher than in the middle$age population. ,he li#estyle
modi#ications discussed previously are the #irst step in treatrnent o# older adults, as &ith younger
populations. ,he ,iial o# 5onpharmacologic Interventions in the :lderly (,-5:" study #ound
that losing &eight (9 to 1 lb" and reducing sodium intake (to 1.9 glday dally" can lessen or eliminate
the need #or drugs in obese, hlpertensive older adults (G to 9 years o# age" (Ehelton et al., 1..9".
't the end o# the ;$month study, ;lo/o o# the sodium$reduction$aloneg roup, 3;o/oo # the &eight$
reduction$aloneg roup, and 0;C o# the combination group &ere o## medications.
'lthough this study sho&ed that losing &eight and decreasing sodium in older aduls &ere very
e##ective in lo&ering blood pressure, kno&ing ho& to #acilitate these changes and promote adherence
remains an obstacle #or health pro#essionals-. nly ;9C in the ,-5: study &ere able to reach the
sodium intake goals. ?ooking at dose response analyses, those &ith greater sodium reduction
had #e&er occurrenceso # averageS 67 over 10 or +67 over . ('pp.l et al., 21".S everes odiumr
esrrictionsa renot adoptedb ecauseth esec ould leadt o volumed epletion in older patiens &ith renal
damage -IIH, 2!".
+rug treatment in the older adult is supported by very strong data. 6ased on these data, the 35)
recommendst hat blood pressuresb e controlled regardlesso # age,i nitial blood pressurele vel,o r
durationo #hypertension (5IH, 2N".