5 Steps to Controlling High Blood Pressure provides reliable, practical information on preventing and managing high blood pressure. Much of the information comes directly from the experience of health care professionals at Mayo Clinic. This book supplements the advice of your personal physician, whom you should consult for individual medical conditions.

5 Steps to Controlling Blood Pressure does not endorse any company or product. MAYO, MAYO CLINIC and the Mayo triple-shield logo are marks of Mayo Foundation for Medical Education and Research.

All rights reserved. No part of this book may be reproduced or used in any form or by any means, electronic or mechanical, including photocopying and recording, or by any information storage and retrieval system, without permission in writing from the publisher, except by a reviewer, who may quote brief passages in review.

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Published by Mayo Clinic

© 2015 Mayo Foundation for Medical Education and Research (MFMER)
ISBN e-Pub edition: 9780795347788

Library of Congress Control Number: 2014950079

Second Edition

1 2 3 4 5 6 7 8 9 10

Editorial staff

Medical Editor

Sheldon G. Sheps, M.D.

Managing Editor

Stephanie K. Vaughan

Editorial Director

Paula M. Marlow Limbeck

Product Manager

Christopher C. Frye

Art Directors

Stewart (Jay) J. Koski

Richard A. Resnick

Production Artist

Gunnar T. Soroos

Illustration and Photography

John V. Hagen

Joanna R. King

Michael A. King

Richard Madsen

Kent McDaniel

Jodi O’Shaughnessy Olson

Jay Rostvold

Veneliza Salcedo

Chris Srnka

Research Manager

Deirdre A. Herman

Research Librarians

Anthony J. Cook

Amanda K. Golden

Erika A. Riggin

Proofreading

Miranda M. Attlesey

Donna L. Hanson

Julie M. Maas

Indexing

Steve Rath

Contributors

Brent A. Bauer, M.D.

Robert D. Brown Jr., M.D.

Matthew M. Clark, Ph.D., L.P.

Carl H. Cramer II, M.D.

John W. Graves, M.D.

Roger W. Harms, M.D.

Donald D. Hensrud, M.D.

Richard D. Hurt, M.D.

Carrie A. Krieger, Pharm.D., R.Ph.

Edward R. Laskowski, M.D.

Carol A. Nash, R.N.

Jennifer K. Nelson, R.D., L.D.

Heather R. Preston

Dennis M. Robertson, M.D.

Gary L. Schwartz, M.D.

Virend Somers, M.D., Ph.D.

Sandra J. Taler, M.D.

Stephen T. Turner, M.D.

Kristin S. Vickers Douglas, Ph.D., L.P.

Administrative Assistant

Michelle L. Griffis

Preface

High blood pressure is a serious problem. According to the American Heart Association, more than 76 million American adults have been diagnosed with high blood pressure, but less than half of them have their condition well-managed.

A primary goal of 5 Steps to Controlling High Blood Pressure is to inform you about how high blood pressure develops, what puts you at risk, how it’s diagnosed and how it’s treated. You’ll also learn how to reduce your risk of the many conditions associated with high blood pressure, such as coronary artery disease, heart failure, kidney failure, stroke and dementia. You’ll read about the proper use of medications, home monitoring and regular follow-up care. You’ll also find the latest on issues of concern to women, children and special at-risk populations. All of this will help as you work with your doctor to make informed decisions regarding your health care.

5 Steps to Controlling High Blood Pressure focuses on the central role you play in a treatment program. It highlights five key steps you can take to manage your blood pressure: eating a healthy diet, managing salt intake, getting regular physical activity, avoiding use of tobacco and limiting alcohol and how well you take medications. Separately, each step can improve your overall health and lower your blood pressure. When combined, the steps form a personalized program suited to your needs.

High blood pressure can almost always be successfully managed. This book, along with the advice of your personal physician, can assist you in living a longer, healthier life.

Sheldon G. Sheps, M.D.
Medical Editor

Introduction

A plan for life

Contrary to what you may believe, you were not born to have high blood pressure. Your health is influenced as much by lifestyle as it is by genes. While family history is important, your weight, activity level, stress level and health habits play large roles in determining your future.

What this means is that your future isn’t predestined. You are in the driver’s seat — you can play a vital role in managing your blood pressure and your overall health. The sooner you commit yourself to improving your lifestyle, the greater your chances of enjoying a long, productive life.

You may already know some facts about high blood pressure. It’s a common condition, especially among older adults. It’s associated with other conditions such as stroke, heart attack, heart failure, kidney failure and dementia. It’s called the “silent killer” because it develops with no signs or symptoms — you may not know that you have the condition until after it has caused serious damage to your organs.

Here’s something else that you should know: You can almost always control high blood pressure at levels that reduce your risk of serious cardiovascular disease. Medications are an important element of this control. But equally important is how well you take care of yourself. Weight, diet, exercise, tobacco and alcohol use, and stress are all aspects of your life that you can manage and try to change.

Throughout the chapters in this book are assessments to help you evaluate the health habits that most often influence your blood pressure: Are you physically fit? Are you eating well? Are you bothered by stress? Are you getting enough sleep? Keep in mind that good health is more than good physical health. It also includes good mental health. Mind and body are intricately intertwined — the state of one greatly influences that of the other.

Use the results from these assessments to identify general areas or specific behaviors that you can work on to control your blood pressure and put you on the path to better overall health.

For example, you may find that you’re getting enough physical activity but your diet could use a nutritional boost. Or you may feel that stress is preventing you from getting enough sleep.

The simple steps you take now to improve your health will, over time, turn into sustainable, healthy behaviors that can improve your nutrition and level of physical activity, as well as lower your blood pressure. You’ll not only reduce your risk of disease and illness but also feel better and look great!

An important note: Don’t view these assessments as a substitute for seeing your doctor. As you’ll learn in this book, regular exams are important for tracking your progress, identifying problems, getting direction and coaching, and adjusting medications. For a complete health assessment, it’s important to enlist the expertise of a health care professional.

Good luck as you begin your lifelong journey to manage your blood pressure, and all the best to you as you step up to a healthy future.

Part 1

5 key steps

Chapter 1

Eat better (and enjoy it!)

Of all the factors that influence blood pressure, your diet may be one that you can do the most about. You can’t change your genes and you can’t stop aging, but you can certainly decide what food to put on your plate.

By choosing healthier foods, you can lower your blood pressure and keep it under better control. Even modest changes can make a significant difference. A healthy diet, along with physical activity and other lifestyle changes, can lessen the chance that you’ll need medication to treat high blood pressure. Or it may mean you’ll take fewer medications or at a lower dose.

As the assessment below suggests, the benefits of a healthy diet extend beyond blood pressure. A healthy diet reduces your risk of stroke, heart attack, heart failure and kidney failure. Eating well can also help you lose weight or avoid gaining weight, important factors in managing your blood pressure.

Eating smart to manage high blood pressure involves more than just cutting down on your salt intake. For decades, public health officials told people with high blood pressure to limit sodium in their diets. This advice still holds, but it turns out that salt is just one part of the story. Recent studies have shown that other aspects of your diet can affect blood pressure. A comprehensive approach to food makes more sense than focusing solely on salt.

And eating smart doesn’t mean counting calories and giving up the foods you like. You can enjoy a variety of foods that keep you healthy in the years ahead. Read on to learn more about what to eat more of, what to eat less of and how to incorporate good eating behaviors into your daily life.

• • • • •

Are your weight and eating habits healthy?

1.  How do you score on the BMI chart?

➊ Obese

➋ Underweight or overweight

➌ Healthy

2.  What’s your waist measurement?

➊ Considerably more than the recommended measurement

➋ Slightly above the recommended measurement

➌ At or below the recommended measurement

3.  Do you have a health condition that would improve if you lost weight?

➊ Yes

➋ Possibly

➌ No

4.  Do you eat for emotional reasons, such as when you feel anxious, depressed, stressed, angry or excited?

➊ Always or quite often

➋ Sometimes

➌ Never or infrequently

5.  Do you sit down and eat three regularly scheduled meals?

➊ Never or infrequently

➋ Sometimes

➌ Always or most of the time

6.  How long does it generally take you to eat a meal?

➊ Five minutes or less

➋ Between five and 20 minutes

➌ 20 minutes or more

7.  Do you snack a lot or substitute snacks for meals?

➊ Yes or quite often

➋ Occasionally

➌ No or infrequently

» How did you score?

To the left of the answer you chose is a point value — 1, 2 or 3 points. Add upthe points from your answers for your total score.

A: If your total score was 18 to 21 points, congratulations! Your weight and your eating habits appear to be healthy.

B: If your score was 13 to 17 points, you’re on track, but you may consider losing a few pounds and improving some of your eating habits.

C: If your score was 7 to 12 points, work toward making a healthy weight and better eating habits your priorities.

• • • • •

Healthy-eating basics

Over the years, many studies have demonstrated the benefits of eating healthy. But exactly what is meant by a “healthy diet?” A healthy diet is more than just calorie counting. Quite simply, a healthy diet is plant based (rich in vegetables and fruits) and also includes whole grains, beans, nuts, fish, lean sources of protein, and low-fat or fat-free dairy products. By emphasizing these foods, such a diet provides plentiful amounts of nutrients and fiber while limiting unhealthy fats (saturated fat and trans fat) and cholesterol. This type of approach also limits calories when weight loss is a goal.

One such approach is the DASH diet. Known officially as Dietary Approaches to Stop Hypertension (DASH), it provides a lifelong approach to healthy eating. The DASH diet stems from several key studies that compared various eating plans.

In the first study, people with or at risk of high blood pressure followed one of three diets — a “typical” American diet, the DASH diet, or a diet that promoted fruits and vegetables but didn’t limit dairy products or fat. Participants who ate the DASH diet were able to reduce their blood pressure significantly — and within two weeks. African-American participants and those with high blood pressure experienced the most dramatic drops. The DASH diet also lowered levels of low-density lipoprotein (LDL, or “bad”) cholesterol.

The initial DASH diet included about 3,000 milligrams (mg) daily of sodium — less than what most Americans consume on a daily basis. A follow-up study, called DASH-Sodium study, found that consuming less salt lowered blood pressure even more. Participants who consumed no more than 1,500 mg of sodium a day experienced the greatest reductions in blood pressure.

A recent study found that people with prehypertension and stage 1 hypertension who combined the DASH diet with comprehensive lifestyle changes that included weight loss, physical activity, and reduced sodium and alcohol intake were able to achieve better blood pressure control.

In the OmniHeart Trial, researchers modified the DASH diet by replacing some carbohydrates with either more protein or more unsaturated fat. Both diets lowered blood pressure further and also improved triglyceride and cholesterol levels, possibly reducing the risk of coronary artery disease.

• • • • •

A lower carb approach

The OmniHeart Trial showed that replacing some carbohydrates with either protein or monounsaturated fat lowers blood pressure even more than in the regular DASH diet (see below for more information on DASH). But increased protein intake doesn’t translate into just eating more. About two-thirds of the added protein in the study came from plant sources, including legumes, grains, nuts and seeds. The diet higher in monounsaturated fat included more olive, canola and safflower oils, as well as nuts and seeds.

If you’re interested in a lower carb approach, don’t forget to pay attention to overall calories. Fats have more calories a serving than carbohydrates and proteins do. If you substitute fats for carbohydrates, make sure to adjust daily servings to meet your calorie goal.

• • • • •

Other dietary options

Other eating plans share a similar premise as the DASH diet. One such plan is the Mayo Clinic Healthy Weight Pyramid (below), which is designed to help you achieve and maintain a healthy weight. The pyramid is similar to the DASH diet in that it promotes eating more whole grains, fruits and vegetables and recommends eating fewer animal products, including meat, poultry and fish. The DASH plan differs in that it separates vegetable proteins from animal proteins — the DASH plan recommends getting four to five servings a week of nuts, seeds and legumes (vegetable protein sources).

Mayo Clinic Healthy Weight Pyramid The DASH diet is similar in many respects to the Mayo Clinic Healthy Weight Pyramid — the principles of which can provide a healthy-eating plan for most Americans. Both dietary approaches emphasize greater consumption of fruits, vegetables and carbohydrate-containing whole-grain products and less consumption of meat.

Another eating plan that can help control high blood pressure is known as the Mediterranean diet. Rooted in the traditional diets of countries such as Greece and Italy, the Mediterranean diet includes a generous amount of fruits, vegetables, olive oil, legumes, nuts, pasta, rice and bread. Moderate amounts of fish, dairy products, wine and beans are consumed, while red meat is eaten sparingly.

Compared with the DASH diet, the Mediterranean diet includes more unsaturated fats, mainly from the use of olive oil, nuts and fish. Considered heart healthy, unsaturated fats do not raise blood cholesterol levels.

To lower blood pressure and prevent hypertension, research shows that the best combination of dietary choices includes following a Mediterranean diet or the DASH diet, eating less saturated fat and total fat, getting plenty of potassium, and limiting sodium and alcohol.

While many people with high blood pressure have found that it makes sense to start with the DASH diet, choosing a healthy-eating plan is a very individual decision — no one diet is best for everyone. Talk to your doctor or a registered dietitian about the pros and cons of each eating plan and which one may suit your health and eating preferences.

• • • • •

Daily calorie goals

The number of calories that most adults should eat in a day is based on age, gender and physical activity level. For sedentary adults over age 50, for example, a servings guide for the DASH diet is set at 1,600 daily calories for women and 2,000 daily calories for men. To lose weight, it’s recommended that an average woman set her calorie goal at 1,200 calories, and an average man at 1,400 calories — if weight is at or below 250 pounds. Consult your doctor or registered dietitian for a specific meal plan.

• • • • •

The DASH diet

The DASH eating plan focuses on foods rich in nutrients that can help lower blood pressure, including essential minerals such as potassium, calcium and magnesium.

In addition to plentiful amounts of fruits and vegetables, DASH includes whole grains, low-fat dairy products, poultry, fish and nuts. This diet follows heart-healthy guidelines by limiting saturated fat and cholesterol, as well as reducing intake of red meat, sweets and sugary beverages. The DASH-Sodium study demonstrated that the greatest reduction in blood pressure occurred by including lower sodium intake with a healthy diet.

• • • • •

The DASH eating plan

Food group | Daily servings* | Serving sizes

Whole grains

6 to 8

½ cup (3 oz./90 g) cooked rice, pasta or cereal

1 oz. (30 g) ready-to-eat (dry) cereal (serving size varies between

½ cup and 1¼ cups, depending on cereal type)

1 slice bread

½ English muffin

Vegetables

4 to 5

1 cup (2 oz./60 g) raw leafy vegetables

½ cup (3 oz./90 g) cut-up raw or cooked vegetables

1 medium potato

½ cup (4 fl. oz./120 g) vegetable juice

Fruits

4 to 5

1 medium fruit, such as apple or banana

17 grapes

½ cup (3 oz./60 g) fresh, frozen or canned fruit

¼ cup (1½ oz./45 g) dried fruit, such as raisins

½ cup (4 fl. oz./180 mL) 100 percent fruit juice

Fat-free or low-fat milk and milk products | 2 to 3 | 1 cup (8 fl. oz./250 mL) milk or 1 cup (8 oz./250 g) low-fat yogurt 1½ oz (45 g) cheese 2 cups (16 oz./500 g) low-fat or fat-free cottage cheese
Lean meats, poultry and fish | 6 or fewer | 1 oz. (30 g) cooked meats, poultry or fish 1 egg (no more than 4 egg yolks a week); 2 egg whites equal 1 egg

Nuts, seeds and legumes

4 to 5 a week

¹⁄³ cup (1½ oz./45 g) nuts

2 tablespoons (1 oz./32 g) peanut butter

2 tablespoons (½ oz./15 g) seeds

½ cup (3½ oz./100 g) cooked legumes (dry beans or peas)

Fats and oils

2 to 3

1 teaspoon soft margarine

1 teaspoon vegetable oil

1 tablespoon mayonnaise

2 tablespoons regular salad dressing

4 tablespoons low-fat salad dressing

Sweets

5 or fewer a week

1 tablespoon sugar

1 tablespoon jelly or jam

½ cup sorbet or gelatin

1 cup lemonade

The lower number of recommended servings provides about 1,600 calories, midrange provides about 2,000 calories and the higher number provides about 2,400 calories.

Most Americans need between 1,600 and 2,400 calories daily, depending on age, sex and activity level. To lower the number of calories on the DASH diet, see this section, or talk to a registered dietitian.

The DASH eating plan may be found on the National Heart, Lung, and Blood Institute website at www.nhlbi.nih.gov.

• • • • •

The following sections provide more detail on the types of food you may choose when using the DASH diet to help control blood pressure.

Whole grains: 6 to 8 servings. Whole grains include foods such as whole-wheat bread and pasta, oatmeal, brown rice, grits, and unsalted popcorn. Whole grains provide more natural fiber and nutrients than do highly processed or refined grains, such as white rice and white bread. Select plain, whole-grain yeast breads rather than quick breads, sweet rolls or other baked goods that have added fat.

»TIP: Whole-grain breads and pasta are naturally low in fat and calories. To keep bread low in fat and calories, be cautious about what type of spread you slather on it. Avoid cream and cheese sauces on pasta — opt for vegetable or tomato-based sauces instead.

Vegetables and fruits: 4 to 5 servings each. Eating more vegetables and fruits may be one of the best things you can do to improve your blood pressure and your overall health. In addition to being virtually fat-free and low in calories, vegetables and fruits provide fiber, potassium and other wholesome nutrients that help lower blood pressure. Fruits and vegetables also contain phytochemicals — substances that may help reduce your risk of heart disease and some cancers.

Eating more vegetables and fruits can also help you reduce calories without cutting back on the amount you eat. These foods have a low energy density, meaning there are few calories in a large volume of food. They fill your stomach without adding many pounds. The key is to eat vegetables and fruits plain or with a few herbs and spices and to avoid smothering them with high-fat dips or sauces.

Potatoes, corn and peas make up nearly half the vegetables in the typical American diet. It’s time to think beyond the french fry. Top-rated vegetables include dark green vegetables, such as broccoli, Brussels sprouts and spinach. Other nutritious selections include romaine lettuce, tomatoes, bell peppers, onions, carrots and avocados.

Top-rated nutritious fruits include cantaloupe, tangerines, oranges, grapefruit, varieties of berries, apricots, kiwi and watermelon.

»TIP: With abundant servings of vegetables, fruits and whole grains, the DASH diet is high in fiber. But increasing your fiber intake can sometimes cause bloating and diarrhea. To avoid these problems, take a gradual approach to increasing your consumption of these foods. You can also try taking Beano, an over-the-counter dietary supplement that helps prevent gas.

Fat-free or low-fat milk and milk products: 2 to 3 servings. Dairy products are sources of calcium as well as vitamin D, which helps your body absorb calcium. Dairy products are also valuable sources of protein in your diet.

When choosing dairy products, choose low-fat or fat-free varieties and avoid whole-fat varieties. Select skim or low-fat (1 percent) milk and yogurt, and fat-free or low-fat or reduced-fat cheeses. Because cheese is higher in sodium, be sure to stay within recommended amounts (1 serving is 1.5 ounces).

In recipes, substitute lower fat dairy products, such as skim or low-fat milk, for higher fat items. Note, however, that reduced-fat cream cheese and sour cream are higher in sodium than are their higher fat counterparts, so use them prudently.

»TIP: If you’re lactose intolerant and have problems digesting dairy products, you may benefit from foods containing the enzyme lactase, which can reduce or prevent the symptoms of lactose intolerance. You can also take lactase tablets before eating the foods.

• • • • •

Probiotics and blood pressure

A 2014 review of research found that regularly consuming foods that contain probiotics may help lower blood pressure. The results of this research review showed that probiotic-containing foods lowered blood pressure by 3.56 mm Hg (systolic, the top number) and 2.38 mm Hg (diastolic, the bottom number) – the same blood pressure-lowering power as reducing the amount of salt in your diet to less than 2 grams a day.

This reduction in blood pressure may be important in other ways, too: The Heart Outcome Prevention Evaluation study showed that reducing your blood pressure by just this much can lower your risk of heart attack, stroke and death from heart disease by 22 percent.

Most of the trials in the 2014 review that showed a reduction in blood pressure used fermented dairy products. Trials that focused on probiotic supplements were limited and conclusions could not be made. The review also showed that regularly consuming more and a larger variety of probiotics for at least 2 months was important.

It’s still too early to tell what kind, how much and what probiotic-containing foods are best. For now, switching a portion of your daily consumption of low-fat dairy foods to those that are fermented doesn’t hurt. Fermented dairy products include cultured yogurt, milk (buttermilk, kefir), acidophilus milk, cultured (low-fat) sour cream and cheese.

• • • • •

Lean meats, poultry and fish: 6 or fewer servings. These foods are rich sources of protein, B vitamins, magnesium, iron and zinc. Choose lean cuts of meat, such as tenderloin, round or sirloin, and trim away the fat. When preparing poultry, remove the skin to reduce fat by about half. Keep in mind that even lean varieties of meat contain plenty of fat and cholesterol, so it’s important to try to limit all animal food sources in your healthy-eating plan.

Fish provides one of the healthiest animal protein sources. Some fish contain high amounts of omega-3 fatty acids, which may reduce the risk of coronary artery disease and sudden cardiac death and lower blood pressure.

»TIP: Choose fresh meat, poultry and fish rather than processed, smoked or cured products. These often contain more than 200 mg of sodium a serving. Broiling, roasting and poaching are the healthiest ways to prepare meat, poultry and fish. You can cook fish in parchment paper or foil to seal in flavor and juices.

• • • • •

Fish vs. fish oil supplements

Experts recommend at least two meals of fish every week for heart and general health benefits. Some fish — particularly fatty or oily types prevalent in cold water, such as salmon, mackerel, tuna, trout and herring — contain high amounts of omega-3 fatty acids, a type of unsaturated fat. Eating omega-3 fatty acids may reduce your risk of heart disease and help lower blood pressure.

But certain fish, such as swordfish, tilefish, king mackerel and shark, contain significant amounts of environmental contaminants, including mercury and polychlorinated biphenyls (PCBs). The amount of toxins depends on the type of fish and where it’s caught. Because children and women who are pregnant or considering pregnancy are most susceptible to toxicity in fish, they should limit their consumption to between 8 and 12 ounces a week. In general, when it comes to a healthy heart, the benefits of eating fish usually outweigh the possible risks of toxic exposure.

Some researchers advocate taking fish oil supplements to gain the benefits of omega-3 fatty acids without the risks of toxins. But the American Heart Association recommends fish oil supplements only for people with heart disease or high levels of triglycerides. In high doses (3 grams or more), fish oil capsules pose risks, especially if you regularly take aspirin or a blood thinner, such as warfarin (Coumadin). Before you take fish oil capsules, consult your doctor.

To avoid some of the dangers associated with eating fish, follow these guidelines:

•  Pay attention to the type of fish you eat and how much you eat. Check with your state or local health department for advisories.

•  Eat a variety of fish, including shellfish, canned fish or smaller ocean fish. You can safely eat 12 ounces a week of cooked fish. Fatty fish, such as salmon, mackerel, herring, lake trout, sardines and albacore tuna, are high in omega-3 fatty acids.

•  Avoid eating large predatory fish, such as shark, swordfish, king mackerel and tilefish. Eat no more than 6 ounces of canned albacore tuna a week and aim for 8 to no more than 12 ounces of most other fish, including canned light tuna.

•  There is debate about farm-raised salmon having higher levels of PCBs than wild salmon does. But contamination is found in farm-raised fish as well as in wild fish.

• • • • •

Nuts, seeds and legumes: 4 to 5 servings a week. These foods range from almonds, peanuts, walnuts, hazelnuts, peanut butter and sunflower seeds to legumes such as beans, split peas and lentils. They’re an excellent source of protein and have no cholesterol. They also provide a variety of nutrients, including magnesium and potassium, plus phytochemicals and fiber. Nuts and seeds contain fat, but most of it is unsaturated, the type that helps protect against coronary artery disease.

»TIP: Be careful about salted nuts. Choose products with less than 200 mg of sodium a serving.

Fats and oils: 2 to 3 servings. Many people are surprised to learn that certain fats are essential for good health. Fats provide reserves of stored energy and play vital roles in different body processes. But your consumption of fats should be limited to the monounsaturated varieties. All fats contain approximately 45 calories a serving and are high in caloric density. That means there are a lot of calories in a small amount.

In the DASH studies, 27 percent of calories in the daily diet came from fats, including the fat in or added to food.

Animal products — meat, dairy products and eggs and foods made with them — are the main source of fat in the American diet. Vegetables, fruits and grains are relatively low in fat. Healthy fats include soft margarine and olive, canola, corn and safflower oils.

»TIP: Invest in nonstick pans to cook foods. If you normally add a tablespoon of vegetable oil to a skillet, you can save about 120 calories and 14 grams of fat by using a nonstick skillet instead. Vegetable oil cooking spray adds only about 1 gram of fat and just a few calories.

• • • • •

Choose fats wisely

Not all fats are created equal. Most plans for healthy eating, including the DASH diet, call on you to sharply limit the amount of saturated fat you consume. Foods high in saturated fats include red meat, whole-fat dairy products, and tropical oils made from palm and palm kernels.

Another type of unhealthy fat is trans fat, which can raise your “bad” or LDL, cholesterol levels and increase your risk of cardiovascular disease. Trans fats are found in partially hydrogenated oil, an ingredient found in many processed foods, such as crackers, cookies and deep-fried foods. Checking food labels can help you steer clear of these bad fats.

The healthier fats include monounsaturated fats — found in olive oil, canola oil, peanut oil, nuts and avocados — and omega-3 fatty acids. Fatty fish such as salmon, mackerel and herring contain high amounts of omega-3 fatty acids, while smaller amounts are found in green leafy vegetables, soybeans, nuts, flaxseed and canola oil.

Omega-3 fatty acids can benefit your heart by lowering your blood triglyceride level and reducing your risk of blood clots, artery-clogging plaques and sudden death from abnormal heart rhythms. They also lower blood pressure.

• • • • •

Sweets: 5 or fewer a week. Sweets are a high source of calories but offer little nutrition. They include candies, cookies, cakes, pies and other desserts. The table sugar you add to cereal, fruit and beverages counts, too.

You don’t have to give up sweets entirely, but be smart about what you select and how much you eat. When you do eat sweets, choose low-fat items rather than sugary treats made with oil or butter.

Best choices include fruit-based desserts and those made with whole grains. Try frozen grapes, grilled pineapple, baked apples or a fruit cobbler topped with rolled oats.

»TIP: Replace all or part of the sugar in recipes with cinnamon, nutmeg, vanilla and fruit to enhance sweetness.

• • • • •

Chocolate and blood pressure

Research has linked chocolate to lower blood pressure. Cocoa beans contain substances thought to enhance the production of nitric oxide in the body (flavonols), which can improve blood vessel function and blood flow.

But you can’t eat just any chocolate off the shelf and get the benefits of flavonols. Standard processing techniques have eliminated these natural chemicals from most commercial chocolate products.

Scientists have experimented with ways of processing cocoa beans that don’t destroy the flavonols.

Still, even the healthiest chocolate adds calories to your diet. People who need to watch their weight might be better off turning to other sources of flavonols, such as berries, grapes, apples and tea.

• • • • •

Important minerals and vitamins

The DASH diet emphasizes the benefits of three minerals that can play a role in managing high blood pressure: potassium, calcium and magnesium. Of the three, potassium packs the biggest punch. Researchers have found that a high potassium intake is associated with lower blood pressure, especially in blacks.

The Institute of Medicine advises that all adult Americans boost their intake of potassium by eating more potassium-rich foods, such as fruits and vegetables. Eating eight to 10 servings a day of fruits and vegetables can help you get the recommended potassium intake of 4.7 grams a day. Unfortunately, very few adults consume that amount.

Some people have to be cautious about their potassium intake, however. If you have kidney disease, congestive heart failure or diabetes, talk to your doctor about the levels of potassium and other minerals in your diet.

Calcium is needed to support your bones and teeth and for the proper function of your heart, muscles and nerves. And contrary to popular belief, the need for calcium actually increases as you get older. That’s because the human body needs a constant replenishment of calcium and, with age, your body will become less efficient at absorbing calcium from the food you eat. It’s recommended that most adults get between 1,000 and 1,200 mg of calcium each day (see this chart for sources of calcium). Unfortunately, many adults don’t consume enough calcium. If you’re trying to lose weight, you may need to monitor calcium intake because of your reduced calorie consumption.

Magnesium has many biochemical functions in the body. For example, it helps you maintain a normal heart rhythm. It’s found in a variety of foods and in drinking water. You can get enough magnesium by regularly eating green leafy vegetables, whole grains, legumes, and small amounts of meat, poultry and fish. Nuts and seeds also are good sources of magnesium (see this chart).

• • • • •

Sources of potassium, calcium and magnesium

Mineral | How it works | Where it’s found
Potassium | Balances the amount of sodium in your cells; high intake reduces blood pressure | Many fruits and vegetables, whole grains, legumes, dairy products, potatoes

Good sources of potassium include: Apricots, bananas, cantaloupe, cherries, dates, figs, honeydew melon, kiwi, mango, nectarine, orange, papaya, prunes and tangerines, apple juice, grapefruit juice, grape juice, orange juice, pineapple juice, artichokes, beans (dried), beets, broccoli, Brussels sprouts, leafy vegetables (beet greens, collard greens, spinach), kohlrabi (cooked), lentils, mushrooms, parsley, potatoes, pumpkin, soy products, squash, zucchini, cocoa mix (powder), milk (fat-free or low-fat), peanut butter, tofu, yogurt (fat-free or low-fat)

Mineral | How it works | Where it’s found
Calcium | Not proved to prevent high blood pressure, but eating too little is linked with high blood pressure | Dairy products, green leafy vegetables, fish with edible bones, calcium-fortified foods

Good sources of calcium include: Milk (fat-free or low-fat), tofu set with calcium, yogurt (fat-free or low-fat), orange juice (calcium-fortified), cereal (calcium-fortified), canned sardines and salmon with bones, mozzarella cheese (part-skim), kale and collard greens (cooked), cottage and ricotta cheeses (low-fat and low-sodium), navy beans (cooked), broccoli (cooked)

Mineral | How it works | Where it’s found
Magnesium | Deficient levels are linked with higher blood pressure | Legumes, green leafy vegetables, nuts and seeds, whole grains, lean meats

Good sources of magnesium include: Eating a wide variety of foods as well as drinking water. Foods include green leafy vegetables, whole grains, legumes, nuts and seeds, and even small amounts of meat, poultry and fish.

• • • • •

Vitamin D also plays an important role in your blood pressure. It helps build strong bones and is important for overall health.

Researchers don’t know for sure if too little vitamin D causes high blood pressure — or whether vitamin D supplements may have any role in the treatment of high blood pressure. But research does show that too little vitamin D may be linked to heart disease and a higher risk of hypertension.

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What about mineral supplements?

A healthy diet should provide adequate amounts of potassium, calcium and magnesium. Studies indicate that getting these nutrients from foods rather than supplements helps ensure the right mix of the nutrients.

Potassium supplements can have serious side effects. And some blood pressure medications, such as potassium-retaining diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin ll receptor blockers and renin inhibitors, can increase potassium levels in your blood. Take potassium supplements only if your doctor recommends them.

If you take a diuretic medication that causes your body to lose potassium, your doctor may recommend that you take a potassium supplement. Calcium and magnesium supplements generally aren’t required to control high blood pressure.

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Fresh approach to shopping

Success with the DASH diet starts with the foods you buy. When you’re shopping, think fresh and unprocessed. Those are the types of foods to focus on. Try to spend most of your time in the produce section, where you can stock up on fruits and vegetables. Here are other tips for healthier shopping with the DASH diet in mind:

Plan. Decide on the meals you’re going to make during the coming week and write the ingredients you need on a grocery list. Don’t forget about what you’ll need for breakfast and snacks. Include plenty of fruits, vegetables, whole-grain breads and cereals on your list. When you’re thinking of protein sources, consider legumes such as lentils or kidney beans.

Buy fresh. Fresh foods are usually better than ready-to-eat foods because you can control what ingredients go into your meals. Fresh foods generally have more flavor, color, and health-promoting vitamins, minerals and fiber than do their prepackaged counterparts. Note that the freshest and healthiest foods tend to be located around the perimeter of a grocery store.

Don’t shop on an empty stomach. It’s hard to resist the bright packaging of many snack items. To reduce the temptation, go shopping after you’ve eaten a good meal. If you find yourself shopping when you’re hungry, buy a piece of fresh fruit to munch on.

Read the labels. Take time to read food labels on products before buying them. The labels inform you about which foods are healthy and warn you about those that aren’t so healthy. They also can help you compare the ingredients of similar foods and select items that are the most nutritious.

How to read food labels

Since the early 1990s, packaged goods sold in the United States have carried the Nutrition Facts label. These labels provide valuable information that helps you fit different foods into your eating plan. Because the Nutrition Facts label contains a lot of different information, it may seem confusing at first. But once you understand the label, you’ll start to see how it can make it easier for you to plan meals and comparison shop.

Each Nutrition Facts label contains detailed information based on a single serving of the contents. The Nutrition Facts label includes these important pieces of information:

Food label example This example provides a breakdown of calories, fat, carbohydrates, protein, vitamins and minerals in a single serving.

Serving size. The label indicates the quantity that’s considered a single serving and how many servings are in the container. If you eat more or less than the indicated serving, you need to adjust the calorie and nutrient information accordingly.

Calories from fat. This information allows you to add up the amount of fat you eat and to compare the fat content of different products. Try to limit fat to about 65 grams a day. This amount keeps fat at the recommended level — less than 30 percent of your daily calories, based on a 2,000-calorie diet.

Percent Daily Value. These percentages indicate how much of the recommended daily amounts are in one serving of a food, based on a 2,000-calorie diet. In the food label example above, one serving provides 95 mg of sodium, or 9 percent of the Daily Value.

In general, any product with 5 percent of the Daily Value for sodium a serving is considered low, and 20 percent or more is high. For fat, saturated fat and cholesterol, choose foods with a low Daily Value. For dietary fiber, vitamins and minerals, try to reach a higher Daily Value.

Sodium. Most sodium that Americans consume comes from processed foods, so it’s important to choose foods with less than 200 mg of sodium in a serving, or under 8 percent of the Daily Value. The above food label is a good example of what to look for, but it’s not always easy to find products that are low in sodium.

Eating smart for weight control

If you’re overweight, losing even a few pounds can improve your blood pressure. Losing weight brings other health benefits as well, such as a reduced risk of diabetes and heart disease.

The most successful method for losing weight is to change your eating and activity habits and to slim down gradually. The DASH eating plan and a regular physical activity program can help you do this.

Just because the task may seem daunting doesn’t mean that you shouldn’t try it — and keep trying to reach and maintain a healthy weight. Many people have successfully changed their habits to maintain weight loss.

Your efforts can pay off for a lifetime. Not only does losing weight lower your blood pressure but studies also show that the effect can last for many years as you keep the weight off.

A little can mean a lot

What is a healthy weight? It’s not essential that you become thin. But you can aim for achieving or maintaining a weight that improves your blood pressure and also lessens your risks of other health problems.

Losing as little as 10 pounds may reduce your blood pressure to a healthier level. If you’re overweight, reducing your weight by 5 to 10 percent may be a good goal. Once you’ve achieved that goal, you can try for another 5 to 10 percent if you need to lose more weight. Over time, these losses can add up to a significant improvement in your health.

The DASH diet and weight loss

If you’re planning to lose weight, you’ll probably need to consume fewer calories than you consume now (and burn more calories through exercise).

To lower the standard DASH eating plan from a calorie level of 2,000 to 1,600 a day, use the serving guidelines table that follows. This will help ensure that you’re getting enough of each food group.

Food groups | Daily servings
Whole grains | 6
Vegetables | 3 to 4
Fruits | 4
Fat-free or low-fat milk and milk products | 2 to 3
Lean meats, poultry, fish | 3 to 4 or less
Nuts, seeds, legumes | 3 to 4 a week
Fats and oils | 2
Sweets and added sugars | 3 or less a week
National Heart, Lung, and Blood Institute, DASH Eating Plan — Number of Food Servings by Calorie Level, 2014

To trim calories from the DASH diet, start by replacing higher calorie foods with more fruits and vegetables. This also helps control your blood pressure. Here are other ways to cut calories from your eating plan.

•  Pay attention to energy density. Some foods are energy dense, meaning that they pack a lot of calories into a small portion. Other foods, such as fruits and vegetables, have fewer calories in a greater volume. When you choose foods that have a low energy density, you can eat more of them while consuming fewer calories.

•  Prepare stews, casseroles and stir-fries with half the meat the recipe calls for, adding extra vegetables or tofu instead. For example, instead of 5 ounces of chicken, prepare a stir-fry with 2 ounces of chicken and 1½ cups of vegetables. Use a small amount of vegetable oil.

•  Use fat-free or low-fat condiments.

•  Limit foods with added sugar, such as candy bars, pie, flavored yogurts, regular soft drinks and ice cream.

•  Don’t forget about the calories in beverages, including juice, alcohol, and coffee with milk, sugar, cocoa or whipping cream.

•  Saute onions, mushrooms or other vegetables in a small amount of water instead of butter or oil.

•  Grill, broil, poach, roast or stir-fry foods instead of frying them.

Eating well when eating out

Restaurants can be a minefield of temptations. Sights and smells tantalize your senses, challenging your best intentions to make healthy choices.

But you can eat nutritiously away from home. To do this, it helps to be menu savvy to healthy choices. From there, it’s important to be mindful of two common eating-out challenges: the urge to order more food than you need and the impulse to eat every bit of food on your plate, even when the portion sizes are too large.

When an entree is larger than you want — which is more often than not — ask if you can have the lunch portion, even if you’re eating dinner. You can also request a take-home bag when the meal is served. Or you might choose an appetizer for an entree or split a meal with a companion.

Hidden calories refer to the extra calories added to many dishes that come from ingredients you may not be aware of. That’s why they’re such a problem when you’re trying to lose weight. Ingredients are often added to enhance the flavor, color or texture of food — for example, seasonings, sauces or dressings. And sometimes they’re part of the preparation process — for example, oil or butter used in cooking. These calories add up in subtle ways.

What to order

Many restaurants provide healthy choices. Some restaurants even reserve a special section of their menu for healthier fare. Many restaurants will honor special requests to prepare an item with less fat and sodium.

When reviewing a restaurant menu, use these guidelines to help you keep your eating plan on target:

Appetizer. Choose appetizers with fresh vegetables, fruit or fish. Avoid fried or breaded appetizers.

Soup. You’re often better off avoiding soup and choosing fruit or a salad. Broth- or tomato-based soups are often high in sodium. Creamed soups, pureed soups, chowders and some fruit soups contain heavy cream and egg yolks and may also be high in sodium.

Salad. Order a lettuce or spinach salad with the dressing on the side, and limit yourself to one soupspoon of dressing. Try olive oil with vinegar for a salad topping. Caesar salads and chef salads are high in fat, cholesterol and sodium. Taco salads aren’t good choices because they contain high-fat, high-sodium items such as cheese, guacamole, ground beef and a fried shell.

Bread. While it’s best to avoid it, when offered a bread basket, choose whole-grain bread, rolls, breadsticks or bagels. Eat them plain or with a little honey, jam or jelly. These fat-free toppings add few calories when used sparingly. Muffins, garlic toast and croissants have more fat. Crackers can be high in sodium and fat.

Entree. Look for entrees with descriptions that indicate low-fat content, such as London broil, grilled chicken breast, baked or poached fish, or broiled beef or chicken kebabs.

Avoid marinated items or those with descriptions indicating higher fat content. Examples include prime rib of beef, veal parmesan, stuffed shrimp, fried chicken and filet mignon with bearnaise sauce.

Not sure how much fat is in a sauce? Ask for it on the side so that you can control how much you add. Ask your server to ask the chef not add salt or monosodium glutamate. Finally, ask for a lemon wedge. A spritz of lemon juice adds extra flavor without adding salt.

Side dish. Choose a baked potato, boiled new potatoes, steamed vegetables, rice or fresh fruit instead of french fries, hash browns, twice-baked potatoes, potato chips, onion rings or mayonnaise-based salads, such as potato salad. Ask that no butter, margarine or salt be used to prepare the dish.

Condiments. Choose items such as fresh tomato, cucumber and lettuce for sandwiches. Avoid olives, pickles and sauerkraut, and use ketchup, mustard and mayonnaise sparingly. Taste your food first instead of reaching for the salt shaker right away.

Dessert. Choose fresh fruit, poached spiced fruit, plain cake with fruit puree, or sorbet or sherbet.

Alcohol. Alcohol is high in calories. Drinking too much alcohol can also raise your blood pressure. If you choose to drink alcohol, limit the amount to one drink a day if you’re a woman and one or two drinks if you’re a man. Learn more about the relationship between alcohol and high blood pressure in Chapter 4.

Dining out can be a great time to try different cuisines as long as you don’t forget all you know about choosing healthy foods. When dining out, keep in mind that the same eating principles you follow at home apply to your decisions when dining out.

Putting it in perspective

If the suggestions in this chapter seem overwhelming, remember that eating well isn’t an all-or-nothing proposition. Each food you eat doesn’t have to be perfect. Perfection isn’t the goal — being persistent in your pursuit of healthy eating is what’s most important.

Over time, this approach will become a habit that will help you manage your blood pressure, improve your health, control your weight and feel better about yourself.

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Wrap-up

Key points to remember:

•  A healthy diet can reduce your blood pressure as much as some medications can.

•  The DASH diet can help lower your blood pressure by promoting vegetables, fruits and whole-grain products. The diet is low in sodium and fat and high in minerals such as potassium, calcium and magnesium.

•  Sodium can significantly increase blood pressure if you have sodium sensitivity.

•  Whether you have high blood pressure or not, limiting sodium to less than 2,300 mg daily is reasonable and safe.

•  Blood pressure generally increases with weight gain and decreases with weight loss. Losing as few as 10 pounds can help lower your blood pressure.

•  The best approach to slow, steady weight loss is based on eating nutritious foods and getting regular physical activity.

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Chapter 2

Watch the salt

Of all the issues related to high blood pressure, none has been more heavily debated than salt — specifically, the sodium in sodium chloride, or salt. The research on sodium reveals a complicated picture. And in the real world, just saying no to salt is not so easy or simple.

Despite the controversy, research continues to support limiting sodium as a means to lower blood pressure. The effects of a lower sodium intake are greater for people with high blood pressure, older adults, blacks, and people with diabetes or long-term kidney disease. But moderating salt consumption can benefit anyone, regardless of age, race, sex or health status.

Sodium’s role

An essential mineral, sodium helps maintain the right balance of fluids in your body. It also helps transmit nerve impulses and influences the contraction and relaxation of muscles.

You get sodium from the foods you eat. Many foods naturally contain sodium, but about 77 percent of your sodium intake comes from compounds added to food during commercial processing and about 11 percent from meal preparation at home — added during cooking or while eating. Table salt, which is a compound of sodium and chloride, is the most common source of sodium.

Recommendations for sodium intake range from 1,500 mg a day to an upper limit of 2,300 mg for most healthy adults. Most Americans consume much more than that — the estimated average daily sodium intake for Americans ranges from 3,100 to 4,700 mg.

Your kidneys regulate the amount of sodium in your body. When sodium levels fall, your kidneys conserve sodium. When your sodium levels are high, the kidneys flush out the excess amount of sodium through your urine. Genetic factors, medications, and heart, kidney, liver and lung diseases all can interfere with your ability to regulate sodium.

When your kidneys can’t eliminate enough sodium, the mineral starts to accumulate in your blood. Because sodium attracts and holds water, your blood volume increases. Your heart has to work harder to move the increased volume of blood, increasing the pressure on your arteries.

Sodium sensitivity

How people’s bodies react to sodium varies. Some healthy adults, including some with high blood pressure, can consume varying amounts of sodium with little or no effect on their blood pressure.

For others, too much sodium quickly leads to higher blood pressure, often triggering chronic high blood pressure. This response is referred to as sodium sensitivity or salt sensitivity.

About 60 percent of Americans with high blood pressure and 25 percent of Americans with normal blood pressure are sodium sensitive. The condition is more common in blacks and older adults. In addition, people with diabetes or long-term kidney disease tend to be more sensitive to high levels of sodium.

Exactly what causes sodium sensitivity isn’t known, but genetic factors likely affect the way your body handles salt. The sensitivity can be passed down through families, and researchers have identified several genes associated with higher blood pressure (as well as lower blood pressure).

There’s no easy way to tell if you’re sodium sensitive. Some researchers have developed blood tests that can detect salt sensitivity, but more studies are needed to confirm the reliability of these tests.

Reducing sodium is important for another reason. At least one study found that sodium sensitivity increases your risk of death due to heart disease and other health-related causes, whether or not you have high blood pressure. In addition to increasing your blood pressure, sodium sensitivity can increase your risk of kidney problems and cardiovascular disease.

The controversy

Ever since the recommendation that all Americans — not just those with hypertension — limit sodium to control blood pressure, the issue has sparked controversy. While limiting sodium helps some people, when others cut back on sodium, their blood pressure decreases very little, if at all.

Critics point out that studies linking a low-sodium diet to lower blood pressure don’t show improvements in actual outcomes. In other words, the studies don’t prove that a low-sodium diet results in fewer deaths from conditions associated with high blood pressure such as heart disease and stroke.

Many large studies, however, show that when people consume less sodium, their blood pressure will fall and, furthermore, fewer deaths occur from heart attack and stroke. Reducing sodium intake can also lower your risk of osteoporosis, kidney disease and stomach cancer. So while limiting sodium may benefit some people just a little, it has a major impact on the general population in preventing high blood pressure and reducing death and disability.

Even a small reduction in average blood pressure across a large population — perhaps just 2 millimeters of mercury (mm Hg) in pressure — can lead to significant positive outcomes for the overall health and well-being of that population.

The American Heart Association, the American Medical Association and various U.S. government agencies continue to monitor scientific information about sodium and blood pressure. Their positions support limiting sodium as a reasonable and safe step toward good health.

One thing that the DASH-Sodium study and other research make clear is that limiting sodium works best in the context of an overall healthy diet. For example, limiting sodium intake in combination with losing weight and eating a healthy diet are more effective in managing high blood pressure than is limiting sodium intake alone.

Current recommendations

The Centers for Disease Control and Prevention recommends that all Americans, including children and teens, limit sodium to less than 2,300 mg a day. That’s the amount of sodium in about a teaspoon of salt.

If you have high blood pressure, your doctor may advise eating even less sodium. Making sure you eat enough potassium-rich foods will help further to control your blood pressure levels.

Many health professionals and organizations, including Mayo Clinic, support a lower sodium diet. Here’s why:

If you have high blood pressure, reducing sodium can lower your blood pressure. Limiting sodium in combination with other lifestyle changes may be enough to keep you from having to take medication to control your blood pressure.

If you’re taking blood pressure medication, limiting sodium can help increase the effectiveness of the drug. Even if you’re taking a diuretic, it’s still important to reduce sodium in your diet. (Learn more about medications in Chapter 5.)

If you’re at risk of high blood pressure, limiting sodium and making other lifestyle changes may prevent its development.

If you don’t have high blood pressure, limiting sodium is still safe and reasonable. It also may lower your risk of high blood pressure as you get older. Many doctors say that curbing salt intake should begin in childhood, to help prevent blood pressure-related problems that may begin as early as the teen years.

The challenge of eating less salt

If your doctor or registered dietitian has advised you to cut back on sodium to lower your blood pressure, it’s good advice to follow. Even if you haven’t been told to reduce sodium, try to moderate the amount you eat each day.

Of course, that’s easier said than done. Research shows that reducing salt in your diet is notoriously difficult. Salt makes food taste good, and it acts as a preservative.

Many doctors believe that the real problem isn’t overuse of the saltshaker but rather the hidden salt added to processed foods. More than three-fourths of the salt people consume comes from processed and restaurant foods rather than salt added at the table.

Many commercially prepared foods, snack foods, fast foods and restaurant foods contain much more sodium than you need. For example, a serving of regular canned chicken noodle soup may have about 1,100 mg of sodium per cup; a cheese Danish may have 750 mg. As consumers rely more and more on convenience and ready-to-eat foods, responsibility for sodium intake increasingly falls on the food industry.

For this reason, health organizations are emphasizing a public health approach to lowering sodium intake, in addition to advocating changes in individual behavior.

The American Medical Association and the American Public Health Association have called on food companies and restaurants to take steps toward reducing by at least half the amount of sodium in processed foods, fast-food products and restaurant meals in the next decade.

Public health officials suggest that by slowly reducing the salt in processed foods, people will adjust to the lower salt taste. This practice is already underway in countries such as England, and the New York City Health Department is coordinating a partnership to reduce the amount of salt in packaged and restaurant foods.

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Your sodium guide

The following guide is meant to complement the DASH diet. It lists foods that are low in sodium and can be eaten frequently.

Whole grains and starches

•  Whole-grain bread, rolls and cereals with less than 200 mg of sodium in a serving

•  Quick breads such as pancakes or biscuits made from home recipes that use no buttermilk and little or no salt

•  Potatoes, rice and pasta

•  Unsalted popcorn, pretzels, chips and crackers

Vegetables

•  Fresh, unsalted frozen or low-sodium canned vegetables

•  No-salt-added or low-sodium tomato juice and vegetable juice

•  No-salt-added canned tomato products

Fruits

•  Fresh and frozen fruit and canned fruit in juice or water

Dairy products

•  Fat-free or low-fat milk, low-fat and low-sodium ricotta and cottage cheese

•  Reduced-fat cheeses with less than 200 mg of sodium per ounce

Limit (2-3 times a week):

•  Regular cottage cheese and aged natural cheese such as brick cheese, Monterey Jack and mild cheddar

Beverages

•  Bottled water and beverages with less than 70 mg of sodium in a serving

•  Tap water (Sodium content varies with the local water supply.)

Limit (1-2 servings a day):

•  Alcoholic beverages

•  Coffee and tea

•  Cocoa (made with cocoa powder)

Condiments

•  No-salt-added ketchup, mustard, barbecue sauce, others

Lean meats, poultry and fish

•  Fresh or frozen meat and poultry without added salt or saline

•  Fresh or frozen fish and shellfish (unbreaded and not packed in brine or with added sodium)

•  Water-packed canned tuna or other seafood, canned salmon with no added salt

•  Egg whites

Limit (2-3 times a week):

•  Canned tuna and other canned seafood packed with 50 to 60 percent less salt than usual

•  Reduced-sodium processed meats and cheeses

•  Lobster and crab

Main dish items

•  Homemade dishes and soups without added salt or canned vegetables as ingredients

•  Frozen and microwave dinners that have less than 600 mg of sodium in a dinner

•  Low-sodium canned broth, soups and bouillon

Nuts, seeds and legumes

•  Low-sodium or no-salt-added peanut butter

•  Unsalted nuts and seeds

•  Dried peas, beans and lentils

Fats and oils (use sparingly)

•  Oil, margarine or butter

•  Salad dressings with less than 200 mg of sodium in a serving

•  Mayonnaise and unsalted gravy

•  Cream cheese and sour cream

Desserts and sweets (use sparingly)

•  Homemade desserts, cooked pudding and box mixes with less than 200 mg sodium in a serving

•  Fresh fruit, gelatin, sherbet, plain cake, meringue, ice cream and frozen yogurt

•  Jams, jellies, honey, hard candy and jelly beans

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Limiting sodium intake is challenging — but small changes can bring positive results. As you decrease your salt use gradually, your taste buds will have time to adjust and your preference for sodium will lessen, allowing you to enjoy the taste of the food itself.

The following steps can help you reduce the amount of salt and sodium in your diet:

Eat more fresh foods. Fresh produce such as vegetables and fruits naturally contain less sodium than do processed foods. Canned vegetables and vegetable juices usually contain added salt.

Fresh meat is lower in sodium than are smoked or cured meats, such as luncheon meat, bacon, hot dogs, sausage and ham. These foods have sodium added for flavor and to help preserve them. Some fresh meats also have salt injected into them and may be labeled “Flavor enhanced with saline solution.” Check the Nutrition Facts label and avoid meats with more than 200 mg of sodium a serving.

Soups, frozen dinners, sauces, mixes and other instant products typically have added salt. Snacks such as potato chips, corn chips, pretzels, popcorn, crackers and nuts often contain a large amount of added salt. It’s best to eat them sparingly. Choose fresh fruits and raw vegetables for snacking, and buy unsalted nuts and seeds.

Choose lower sodium products. Some processed foods that are high in sodium are also prepared in lower sodium versions. You’ll often see these foods labeled as low salt or low sodium. These include soups, broths, canned vegetables, processed lean meats, ketchup and soy sauce. But keep in mind that just because food is low in fat or calories doesn’t mean it’s low also in sodium. Sometimes extra sodium is added to low-fat products to make them taste more flavorful.

Read labels. The Nutrition Facts label tells you how much sodium is in each serving. Choose foods that have less than 200 mg of sodium a serving. In general, any product with 5 percent of the Daily Value for sodium a serving is low, while any product with 20 percent of the Daily Value is high. You may be surprised to know that some over-the-counter drugs contain large amounts of sodium. They include some antacids, alkalizers, laxatives and cough medicines. If you use such a product often, check the label or ask a pharmacist about its sodium content.

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Making sense of sodium labeling

Here’s what sodium-related terms on many food labels mean:

•  Sodium-free or salt-free. Each serving in this product contains less than 5 mg of sodium.

•  Very low sodium. Each serving contains 35 mg of sodium or less.

•  Low sodium. Each serving contains 140 mg of sodium or less.

•  Reduced or less sodium. The product contains at least 25 percent less sodium than the regular version.

•  Lite or light in sodium. The sodium content has been reduced by at least 50 percent from the regular version.

•  Unsalted or no salt added. No salt is added during processing of a food that normally contains salt. However, some foods with these labels may still be high in sodium.

Don’t be fooled — foods labeled reduced sodium or light in sodium may still contain a lot of salt. If the regular product starts out high in sodium, reducing it by 25 or 50 percent may make little difference. For example, a serving of regular canned chicken noodle soup may have about 1,100 mg of sodium per cup, while the reduced-sodium version may still have 820 mg a cup. The bottom line? Read the labels carefully.

• • • • •

Don’t add salt when cooking. Cook rice, pasta and hot cereals without adding salt. Remove salt from recipes whenever possible — keep in mind that a dash of salt contains 1/8 teaspoon (300 mg) of sodium. In some recipes, you can use a no-salt product and a regular product. For example, if your recipe calls for 16 ounces of tomato sauce, try using 8 ounces of no-salt-added sauce and 8 ounces of regular sauce.

Don’t add salt at the table. Don’t salt food before you’ve tasted it. If you think your food needs more flavor, try another seasoning, such as lemon, pepper or a sodium-free herb blend. If you have a favorite seasoning blend that contains salt, look at the ingredients to see what’s flavoring it besides salt and try to find an alternative. For example, use garlic or onion powder rather than garlic or onion salt.

• • • • •

Spice it up

It’s easy to make food taste good without using salt. Try these suggestions for herbs, spices and flavorings to enhance the taste of various foods. Here’s an extra tip: Place dried herbs in a little liquid a few minutes before adding them to a recipe to help release flavors.

Meat, poultry, fish
Beef | Bay leaf, dry mustard, horseradish, marjoram, nutmeg, onion, pepper, sage, thyme
Chicken | Basil, dill, fresh tomatoes, ginger, oregano, paprika, parsley, rosemary, sage, tarragon, thyme
Fish | Bay leaf, curry powder, dill, dry mustard, lemon juice, paprika
Lamb | Cranberry, curry powder, garlic, rosemary
Pork | Cranberry, garlic, onion, oregano, pepper, sage
Veal | Bay leaf, curry powder, ginger, oregano
Vegetables
Broccoli | Lemon juice, oregano
Carrots | Cinnamon, honey, nutmeg, orange juice, rosemary, sage
Cauliflower | Nutmeg, tarragon
Corn | Chives, cumin, fresh tomatoes, green pepper, paprika, parsley
Green beans | Dill, lemon juice, nutmeg, tarragon, unsalted French dressing
Peas | Mint, onion, parsley
Potatoes | Dill, garlic, green pepper, onion, parsley, sage
Tomatoes | Basil, dill, onion, oregano, parsley, sage
Low-sodium soups
Creamed | Bay leaf, dill, paprika, peppercorns, tarragon
Vegetable | Basil, bay leaf, curry, dill, garlic, onion, oregano
Other
Popcorn | Curry, garlic powder, onion powder
Rice | Basil, cumin, curry, green pepper, oregano
Salads | Basil, dill, lemon juice, parsley, vinegar

• • • • •

Rinse canned foods. Rinsing canned vegetables and meats helps remove some of the sodium, but it’s not a great way to reduce sodium in your diet. In fact, it only removes about one-third of the sodium. It’s best to use fresh or frozen vegetables.

Limit your use of condiments. Salad dressings, sauces, ketchup, mustard, relish and other condiments all are high in amount of sodium, as do pickles and olives. Make your meals more flavorful with herbs, spices, garlic powder, onion powder and pepper, unsalted versions of ketchup, mustard and barbecue sauce, lemon juice, flavoring extracts and vinegar, prepared horseradish, and table wine (not cooking wine).

Use caution with salt substitutes. Before you try a salt substitute, check with your doctor. Some contain a mixture of sodium chloride (salt) and other compounds. To achieve that familiar salty taste, you may end up using more of the salt substitute than you would regular salt.

In addition, potassium chloride is a common ingredient in some low-sodium products such as broth or bouillon. Too much potassium can be dangerous if you have kidney problems or you’re taking certain medications, such as a potassium-sparing diuretic, to treat high blood pressure or heart failure.

• • • • •

How long will it take to get over my cravings for salt?

It will take your taste buds several weeks to several months to fully adjust to the taste of food prepared with less salt. But if you persevere, highly salted food will soon begin to taste unpleasant. Salt substitutes may help you taper down, but use them with care.

Here’s another dietary example: To reduce fat intake, many people have switched from whole milk to skim milk. When they first made the switch, skim milk probably seemed tasteless and watered down. But as they adjusted to skim, they found that whole milk products began to taste too thick and rich.

• • • • •

Remove salt from kosher meats. To kosher meat without using salt, broil the meat in a flat pan that allows the juices to run off. To remove salt in kosher meats, place the raw meat in a large pot filled with cold water and bring the pot to a boil. Then remove the pot from the heat and drain the water. Most of the salt will drain away. You can also do this twice if you need to remove all of the salt.

For people who will not eat meat if it hasn’t been koshered in some way, here’s another option. First, soak the nonkoshered meat in water for 30 minutes. Then, add table salt instead of koshering salt for 30 minutes as opposed to the regular 60 minutes. Next, instead of simply rinsing the meat, soak it again for 30 minutes. Soak it twice if needed.

• • • • •

Wrap-up

Key points to remember:

•  Sodium can significantly increase blood pressure if you have sodium sensitivity.

•  Whether you have high blood pressure or not, limiting sodium to less than 2,300 mg daily is reasonable and safe.

• • • • •

Chapter 3

Get more active

Physical activity, along with healthy eating, is vital for reducing and controlling your blood pressure. Regular activity can lower your blood pressure by about the same amount as many blood pressure medications can.

Conversely, one reason why high blood pressure is so common may be that people aren’t active enough. Modern conveniences and a shortage of free time have caused Americans to become increasingly sedentary.

According to a 2012 Centers for Disease Control and Prevention survey, only 20 percent of American adults get the amount of aerobic activity and strength training recommended by the 2008 Physical Activity Guidelines for Americans. Almost half of American adults don’t get enough of either type.

Using physical activity to help lower your blood pressure doesn’t mean spending long hours at the gym. It’s not necessary to live by the motto of “No pain, no gain,” pushing yourself to your limits of endurance. It’s enough that you remain committed and make every effort to include physical activity in your daily routine.

Moderate activity can be very beneficial to your cardiovascular health and to your overall health. A key element to receiving these benefits, however, is that you exercise with regularity.

One way to do this is to find activities that you find interesting and enjoyable. Remember: Anything that gets you moving counts, whether it’s a brisk walk, swimming or any other activity you like to do.

• • • • •

Are you fit?

1.  Do you have enough energy to enjoy the leisure activities you like to do?

➊ Rarely or never

➋ Sometimes

➌ Always or most of the time

2.  Do you have enough stamina and strength to carry out the daily tasks of your life?

➊ Rarely or never

➋ Sometimes

➌ Always or most of the time

3.  Can you walk a mile without feeling winded or fatigued?

➊ No

➋ Sometimes

➌ Yes

4.  Can you climb two flights of stairs without feeling winded or fatigued?

➊ No

➋ Sometimes

➌ Yes

5.  Are you flexible enough to touch your toes?

➊ No

➋ Sometimes

➌ Yes

6.  Can you carry on a conversation while doing light to moderately intense activities, such as brisk walking?

➊ No

➋ Sometimes

➌ Yes

7.  About how many days a week do you spend doing at least 30 minutes of moderately vigorous activity, such as walking briskly or raking leaves?

➊ Zero to two days

➋ Three to four days

➌ Five to seven days

» How did you score?

To the left of the answer you chose is a point value — 1, 2 or 3 points. Add up the points from your answers for your total score.

A: If your total score was 18 to 21 points, congratulations! You’re well on your way to overall fitness.

B: If your score was 13 to 17 points, you’re on the right track, but your activity level could use a little boost.

C: If your score was 7 to 12 points, it’s time to put getting in shape at the top of your to-do list.

• • • • •

Benefits of regular activity

Physical activity is important for controlling blood pressure because it makes your heart stronger. With greater strength, your heart is able to pump more blood with less effort. And the more efficient your heart is at pumping blood, the less force will need to be exerted on your arteries.

Regular physical activity can lower your blood pressure by 4 to 9 millimeters of mercury (mm Hg). If you’re at risk of high blood pressure, that’s low enough to keep the condition from ever developing. If you have high blood pressure, a slight reduction may be enough to prevent you from having to take medication to control it. If you’re taking medication, this is enough to help it lower your blood pressure more effectively.

Being physically active can improve your health in many ways. In addition to helping control blood pressure, regular physical activity also reduces your risk of heart attack, high cholesterol, diabetes, osteoporosis and some types of cancer. It gives you more energy, improves your mood, helps you get better sleep and helps you manage stress.

In addition, regular activity helps promote weight loss. When you gain weight, your blood pressure often increases. And when you lose weight, your blood pressure often goes down. The most successful method of losing weight includes doing regular activity of moderate intensity on most days of the week.

• • • • •

How do I find the time to exercise?

Lack of time seems to be a common obstacle to exercise. But often, it’s priorities rather than time that’s the real issue. Being more physically active may require you to spend less time doing something else — perhaps a half-hour less spent watching television or surfing the Web. Here are some ways to fit exercise into your daily schedule.

•  Walk for 10 minutes over your lunch hour, or get up a few minutes earlier in the morning and go for a short walk.

•  Get up from your desk to stretch and walk around during your workday.

•  Instead of looking for shortcuts from one location to another, look for opportunities to add an extra minute or two of walking.

•  Schedule time with a friend to do physical activities together on a regular basis. This helps keep you motivated.

• • • • •

Activity vs. intensity

For many years, the belief was that you had to exercise vigorously to be physically fit and to improve your health. As a result, people developed an all-or-nothing attitude toward exercise. And this led to a high dropout rate.

But studies show that light activity is also good for your blood pressure and overall health — and it’s definitely better than doing nothing at all.

• • • • •

Physical activity vs. exercise

The terms physical activity and exercise are closely related — and often overlap — but there’s a difference. Physical activity refers to any body movement that burns calories, such as raking leaves or taking the dog for a walk. Exercise is a more structured form of physical activity. It generally involves repetitive movements that strengthen or develop a part of your body and improve your cardiovascular fitness. Exercise includes walking, swimming and biking.

Therefore, exercise is a form of physical activity, but not all physical activity fits the definition of exercise. Either way, many health benefits may be gained through regular physical activity, even if it’s not in a structured, repetitive form.

• • • • •

For most healthy adults, the Department of Health and Human Services recommends these exercise guidelines:

Aerobic activity. Get at least 150 minutes a week of moderate aerobic activity or 75 minutes a week of vigorous aerobic activity. Moderate activity should be “moderately intense,” which means that your breathing quickens and you feel your heart beat a little faster. You can gauge this effort as being somewhere between 11 and 14 on the perceived exertion scale (see the table above). You can also do a combination of moderate and vigorous activity. The guidelines suggest that you spread out this exercise during the course of a week.

Strength training. Do strength training exercises at least twice a week. No specific amount of time for each strength training session is included in the guidelines.

In addition to common recreational activities, such as walking, bicycling and dancing, the guidelines promote routine activities such as mowing your lawn, gardening, washing the car, cleaning the house and climbing stairs. The more you move about during the day, the less you sit, and the more calories you burn during the day through the activities of daily life, such as tapping your foot, washing clothes and sweeping the floor (known as nonexercise activity thermogenesis, or NEAT), the more health benefits you’ll gain.

An activity doesn’t have to be condensed into one block of time in your busy schedule. The cumulative effect of physical activity throughout the day is what matters.

For example, taking a short bike ride in the morning, using the stairs instead of the elevator at work, and spending time working your flower beds in the afternoon can add up to be the equivalent of a single workout session at the gym. It all leads to better health.

However, not all types of daily activity count. The activity should be moderately intense, which means that your breathing quickens and you feel your heart beat a little faster. You can gauge this effort as being somewhere between 11 and 14 on the perceived exertion scale below.

• • • • •

Perceived exertion scale

Exercise intensity reflects the amount of oxygen your body uses. The perceived exertion scale estimates exercise intensity. Perceived exertion is the total amount of effort and stress you feel during activity, including heart rate, breathing rate, perspiration and muscle fatigue.

The scale ranges from 6, representing your body at rest, to 20, representing maximal effort. Moderate activity ranges from 11 to 14. You can gauge your perceived effort while you exercise. For example, you adjust a brisk beach walk to what you perceive as about an 11 on the exertion scale in order to maintain a moderate pace.

6 | 10 | 14 | 18
7 - Very, very light | 11 - Fairly light | 15 - Hard | 19 - Very, very hard
8 | 12 | 16 | 20
9 - Very light | 13 - Somewhat hard | 17 - Very hard |

© Borg G. Borg Rating of Perceived Exertion Scale. 1998.

Your perception of exercise intensity is more important than your absolute level of exertion. For example, brisk walking at 3 to 4 mph may feel like light exercise to a physically fit person but like strenuous exercise to someone who’s not in shape. Both individuals will benefit from what they perceive as moderate exercise, although they’ll walk at a different pace.

• • • • •

That said, don’t discount the benefits of vigorous exercise. The guidelines are meant to complement — not replace — previous advice promoting high-intensity activities for people who are conditioned appropriately. More vigorous activity can bring greater health benefits. For example, interval training — short, 60- to 90-second bouts of intense exercise performed during your exercise session — has been shown to be particularly beneficial in improving fitness in an effective and efficient manner. This is true even for people with a history of heart disease.

The main point is that you take part in some type of physical activity for 30 to 60 minutes on most days of the week.

• • • • •

How do I know if I’m fit enough to exercise?

Fitness is an individual quality that’s influenced by your age, sex, genetic makeup, eating habits, regular activity level and the presence of a chronic health condition. You’ll know that you’re fit if you can:

•  Carry out daily tasks without getting overly tired and still have energy to enjoy leisurely pursuits

•  Walk a mile or climb a few flights of stairs without becoming winded or feeling heaviness or fatigue in your legs

•  Carry on a brief conversation using short sentences during moderate exercise such as brisk walking

If you’re out of shape, you feel tired much of the time and fatigue quickly, you’re unable to keep up with others your age, and you avoid certain activities because you know you’ll soon tire.

• • • • •

What kind of activity?

Physical fitness typically involves three components — aerobic activity to improve your heart and lung capacity (cardiovascular health), flexibility exercises to improve flexibility in your joints and muscles, and strengthening exercises to build and maintain bone and muscle mass.

Of these three components, aerobic activity has the greatest effect on blood pressure. But it’s still important to practice all three components.

An activity is aerobic when it places added demands on your heart, lungs and muscles, increasing your body’s ability to use oxygen. As a result, you can produce more energy and won’t fatigue as quickly. Aerobic activity increases your endurance and stamina, which helps you do the things you want to do.

Cleaning house, playing golf or swimming laps all are aerobic activities if they require a fairly light to somewhat hard effort. Other common forms of aerobic activity include:

Walking

Walking appeals to many people because it doesn’t require special athletic skills or instruction. It’s convenient and inexpensive, and you can vary the route to keep it interesting. Walking is an activity that you can enjoy alone or with friends.

When walking, make sure you wear good shoes that give your feet support and traction. If you’ve been inactive and are out of shape, begin by walking at a very light pace for five to 10 minutes. Gradually increase the intensity and duration of your walks as you can tolerate it. Your goal is to reach 30 to 60 minutes of exercise with each walk.

Jogging

Jogging is an excellent form of aerobic exercise because it provides a good workout for your heart, lungs and muscles in a relatively brief period of time. At the same time, jogging doesn’t have to be strenuous to have a positive effect. You can go at your own pace. Like walking, jogging doesn’t require a lot of equipment — you just need a good pair of shoes.

Be advised, however, that jogging requires some cardiovascular conditioning and muscle strengthening before you start. If you haven’t been active for several months, begin by walking. When you’re able to walk 2 miles in 30 minutes comfortably, you’re ready to try alternating jogging with walking. Gradually increase the amount of time you spend jogging and decrease the amount of time you spend walking.

To minimize your risk of injury and muscle and joint discomfort, don’t jog more than three or four times a week and try to jog on alternate days. If you have arthritis, this form of exercise can contribute to pain or discomfort in your knees, hips or ankles.

Bicycling

Like walking, bicycling is a good choice if you’re starting a regular exercise program. This low-impact activity is great for people with joint problems such as arthritis. And bicycling offers a change of scenery with each session. Start slowly and build up to about 30 minutes or more three to six times a week.

You may be tempted to challenge yourself by setting the gears to make pedaling hard, producing a strain resembling that of a hard run. This gives you muscle fatigue but often doesn’t work your heart and lungs effectively. Pedaling at a higher cadence — 80 to 100 revolutions a minute — decreases the stress on your knees but still offers the benefits of aerobic activity.

Worried about traffic or don’t care to chance the outdoors? A stationary bike is a good alternative. These machines can be upright or reclining (recumbent), and one type is not inherently better than the other — the choice is yours.

Stationary bikes give you mainly a lower body workout, but some have moving handlebars that increase the demands on your heart and lungs. If you have knee problems, adjust the resistance to a low setting, and keep your knees bent in the pedaling cycle.

Swimming and water exercise

Swimming is an excellent form of cardiovascular exercise because it conditions your heart and lungs as well as all the muscles in your body. It’s also gentle to your joints. If you have arthritis or another joint disease, swimming is a good way to increase aerobic activity. Try to swim for 30 minutes several times each week.

If lap swimming isn’t your style, consider water aerobics or just walking in the pool. Because water provides about 12 times the resistance of air, walking in water about chest-high requires you to exert a certain amount of power to overcome the resistance. The water’s buoyancy prevents falls and may aid circulation in people with blood flow problems in their lower extremities.

Exercise machines

Each of the six basic exercise machines offers specific fitness benefits to help you build aerobic capacity. In addition to the stationary bicycles mentioned previously, there are rowing machines, treadmills, stair climbers, cross-country machines and elliptical machines.

In general, you get what you pay for when you purchase an exercise machine. Look at the warranty — it’s usually a sign of quality. Make sure the device is solidly built, with no exposed cables or chains, and that it operates smoothly. Avoid equipment with spring-operated components.

You can consult an expert at a local gym or fitness club to get recommendations. You may be able to try out different models.

• • • • •

Activity guide

Activity | Calories burned per hour for a 150-pound adult
Basketball (playing a game) | 544
Basketball (shooting baskets) | 306
Bicycling | 510
Dancing | 530
Gardening | 258
Lawn mowing (push mower) | 374
Playing touch football | 544
Playing volleyball | 272
Raking leaves | 258
Running (13 minutes per mile) | 408
Shoveling snow (by hand, moderate effort) | 360
Stair climbing (slow pace) | 272
Swimming laps (freestyle, front crawl, slow, light or moderate effort) | 394
Walking (moderate pace on a level, firm surface) | 238
Walking (very, very brisk on a level, firm surface) | 476
Washing and waxing a car | 136
Washing windows and floors | 238
Water aerobics | 374
Wheeling self in wheelchair (firm, flat surface, 2 mph) | 224

Based on © Ainsworth BE, et al. 2011 compendium of physical activities: A second update of codes and MET values. Medicine & Science in Sports & Exercise. 2011;43:1575.

• • • • •

How much activity?

No matter what activity you choose to do, your muscles and joints need time to get accustomed to different demands. If you’ve been inactive, start with five- or 10-minute periods of activity at a time and build up gradually in one-minute increments.

At first, try to exercise three times a week. Add more days after you’ve gotten used to exercise. Increasing the time gradually reduces the risk of injury and discomfort.

Your goal is to be as active as you can each day. At a minimum, work toward getting at least 150 minutes a week of moderate aerobic activity a week. (See “Activity guide” above.) For moderately intense activities, that equals about 30 minutes. Lighter activities require more time, and more-vigorous activities require less time.

The more you weigh, the less time it takes to burn calories. Likewise, the less you weigh, the more time it takes to burn calories. However, if you use 30 minutes as your guide, you’ll be close to getting the minimum amount of activity you need.

Remember, if it’s difficult to carve 30 minutes out of your busy schedule, you can accumulate your activities in short intervals throughout the day. Go for a short walk before breakfast or during your lunch hour. Park your car farther away from work for a longer walk to the office door. Look for any opportunity to include more activity within your regular routine.

The basic fitness plan that follows outlines how to start an activity program, how to add time or distance as your fitness improves, and how to add strength training to round out your overall fitness.

• • • • •

Exercise and your blood pressure

To get a true picture of your blood pressure level when you’re home monitoring, measure it before you exercise instead of afterward. That’s because your blood pressure may fall to a temporarily low level for a certain amount of time after exercising.

• • • • •

Basic fitness plan

Anyone can become more physically active. It’s never too late to start, regardless of your age, weight or experience. But taking those first steps to being more active sometimes isn’t as easy as it may seem.

Many people start to exercise but don’t stick with it, often because they try to do too much too soon. An all-or-nothing mentality is a recipe for discouragement, not to mention possible injury. Tailor your expectations to your fitness level, health concerns, available time and motivation.

If you have a chronic health condition or are at significant risk of cardiovascular disease, special precautions may apply.

Check with your doctor before starting an exercise program if you have cardiovascular or lung disease, diabetes, arthritis, kidney disease, or any condition requiring medical care.

It’s also important to check with your doctor if you have symptoms of heart, lung or other serious disease. These symptoms include:

•  Pain or discomfort in your chest, neck, jaw or arms during physical activity

•  Dizziness or fainting with exercise or exertion

•  Shortness of breath with mild exertion, at rest, or when lying down or going to bed

•  Ankle swelling, especially at night

•  A rapid or pronounced heartbeat

•  A heart murmur that your doctor has previously diagnosed

•  Lower leg pain when you walk, which goes away with rest

Finally, talk with your doctor before engaging in vigorous physical activity if two or more of the following apply:

•  You’re a man older than age 45 or a woman older than age 55.

•  You have a family history of heart-related problems before age 55 in men and age 65 in women.

•  You smoke or quit smoking in the past six months.

•  You’re overweight or obese.

•  You haven’t exercised for at least 30 minutes, three days a week for three months or more.

•  You have high blood pressure or high cholesterol.

•  You have prediabetes.

If you take medication, ask your doctor whether physical activity will change how the medication works. Drugs for diabetes and cardiovascular disease may cause dehydration, impaired balance and blurred vision. Some medications also can affect the way your body reacts to exercise.

Set your goals

Goal setting is a way to work toward meeting your expectations and keep yourself motivated. When you set your goals, consider your personal fitness level, health concerns, available time and motivation. Try setting simple goals that are achievable in a reasonably short amount of time. It’s easy to get frustrated and give up on goals that are too ambitious or that take too long to achieve.

Often, your overall goals (outcome goals) can be met through a series of smaller goals (process goals) that build on each other.

For example, if you have high blood pressure, one of your outcome goals should be to reach a target blood pressure level set by you and your doctor. Another might be to lose weight. These outcome goals may be:

•  I will lower my systolic blood pressure by 4 mm Hg and my diastolic pressure by 2 mm Hg within six months.

•  I will lose 5 pounds in six months.

You can plan to achieve these outcomes with a series of process goals. Here are some examples:

•  I will avoid the elevator at work and use the stairs.

•  I will be active at least 15 minutes every afternoon doing gardening, yardwork or housework.

•  I will walk for 30 to 60 minutes three days a week.

•  I will do strengthening exercises two days a week.

•  I will stretch before and after all exercise.

Note that process goals generally involve specific actions. Write all your goals down. Always be prepared to change or adjust them to suit your needs or to set new goals. Within a few days, if your goals aren’t working for you, try something new and keep experimenting until you find what works for you. Keep in mind that each experiment you try is a step you’re taking toward achieving your goals and reaching your wellness vision. Whether it’s successful or not, each experiment can help you learn about yourself and give you new ideas to try.

Outcome goals help you focus on the desired result and keep you moving forward. People who can stay physically active for six months usually end up making it a habit.

Assemble your clothing and equipment

Your choice of exercise clothing depends on your activity and the weather or location where you exercise.

Choose comfortable, nonrestrictive items that help you feel safe, supported and dry. It’s better to underdress than to overdress because exercise generates body heat.

Today’s activewear often uses high-tech performance fabrics that draw sweat away from the skin to the outer surface of the garment, where it can evaporate more quickly. These fabrics won’t stop you from sweating, but they’ll keep your skin drier.

Athletic footwear may be the single most important exercise item because for many activities, your feet take the biggest beating. Shoes should be the proper width, with cushioning or shock absorption, arch support, some flexibility, and wiggle room for your toes.

Good walking shoes are stable from side to side and have a rocker sole design that encourages the foot to roll and push off the toes in a natural walking motion. It’s fine to wear running shoes if your primary activity is walking, as long as your feet feel comfortable and supported.

If you primarily jog or run, steer clear of shoes designed for walking. Your feet sustain a more forceful impact when you run. The shoes should provide extra cushioning to protect bones and joints.

If you plan to bicycle, look for a helmet that’s well-ventilated and easy to use with snug straps. If you have trouble adjusting the helmet to fit your head, you’re less likely to use it.

A helmet should stay in place when pushed upward from the front and shouldn’t tilt in any direction or slide. Try the helmet on before you buy it.

Make sure your bicycle is adjusted for your height and arm length. When you’re seated with your foot on the pedal nearest the ground, your leg should be almost fully extended. You should be able to reach the handlebars and work the brakes and shift while keeping your eyes on the road.

Take time to stretch

Flexibility is the ability to move your joints through their full range of motion. You increase or maintain flexibility by regularly stretching your muscles, particularly before and after exercise. Stretching improves your coordination and posture, relieves stress and reduces your risk of injury.

Stretching for five to 10 minutes before an activity helps prepare your body for upcoming aerobic exercise. Be sure to warm up briefly before you stretch because stretching a cold muscle can strain the tissue. Simple stretches are illustrated on below.

If you have time to stretch only once during a workout, stretch for five to 10 minutes after you exercise, when your muscles are loosened up and more receptive to stretching. This improves overall flexibility in your muscles and joints and helps prevent soreness.

• • • • •

Warm-up and cool-down stretches

Calf stretch

Stand an arm’s length from the wall. Lean into the wall. Place one leg forward with knee bent. Keep other leg back with your knee straight and your heel down. Keeping back straight, move hips toward the wall until you feel a stretch. Hold for 30 seconds. Relax. Repeat with the other leg.

Hamstring stretch

Sit securely on a low table or a chair with one leg propped on another chair. Without bending your knee, keep your back straight and lean forward until you feel a gentle pull at the back of your thigh. Hold the position for 30 seconds. Relax. Repeat with the other leg. (You can also do this exercise sitting on the floor with one leg out front and the other bent backward.)

Upper thigh stretch

Lie on a table or bed with one leg and hip as near the edge as possible and your lower leg hanging relaxed over the edge. Pull your other thigh and knee firmly toward your chest until your lower back flattens against the table. Hold for 30 seconds. Relax. Repeat with the other leg.

Lower back stretch

Lie on a flat surface, such as the floor or a table, with your knees bent and feet flat on the surface. Grasp one knee and pull toward your shoulders. Stop when you feel a stretch in your lower back. Hold for 30 seconds. Relax. Repeat with the other leg.

• • • • •

Emphasize aerobic fitness

On most days, spend at least 30 minutes doing an activity such as walking, jogging, biking and swimming. This will develop your aerobic capacity, which means your heart, lungs and blood vessels can efficiently transport large amounts of oxygen throughout your body. As a result, you can produce more energy and won’t fatigue as quickly. You’ll also burn more calories, control your appetite, increase your stamina and sleep better at night.

Depending on your level of fitness, aerobic activity should be fairly light to somewhat hard. If you have been inactive and are out of shape, begin with just three to five minutes at a very light pace. Then gradually increase your time by one to three minutes per session and increase your pace. Many people start a program with frenzied zeal and then quit when their muscles and joints become sore or injured.

After you’ve been active for a while and you feel you’re ready, gradually pick up the pace or increase the time you spend doing your activity by a few minutes each day. For example, if you’ve been exercising for 30 minutes most days of the week, try aiming for 45 to 60 minutes.

When doing aerobic activities keep these suggestions in mind:

Mix your activities. Doing the same thing all of the time increases the chance that you’ll get bored and lose interest in your program. Think of more uncommon aerobic activities, such as canoeing, ballroom dancing or water exercise. In addition, try to alternate among activities that emphasize lower and upper body fitness. Participating in more than one activity (cross-training) reduces your chance of overusing or straining a muscle or joint while underusing another.

Be flexible. On days when you’re overly tired or not feeling well, don’t force yourself to exercise. Be willing to take a short break from your program. And as soon as you’re able, get back on track with an activity you enjoy.

Listen to your body. Start slowly and give your body a chance to get used to increased activity. Stretching is key to staying flexible and maintaining a range of motion in your muscles and joints. Muscle soreness after exercise is common, especially if it’s new activity, but pain during exercise may send a different signal. Be aware of signs of overexertion or stress. (See “Avoiding injury”.)

Build strength

At least twice a week, spend 20 to 30 minutes doing exercises that help build the strength and endurance of your muscles. Strength training is also called resistance training or weight training. This doesn’t mean you’ll bulk up. The increased lean muscle mass from these exercises simply provides you with a bigger “engine” to burn calories and control your weight.

Strength training is especially important as you get older because your muscle mass diminishes with age. Having greater muscle strength also makes aerobic activity easier. In addition, stronger muscles, tendons and ligaments around your joints help protect you from falls and fractures and reduce your risk of injury.

• • • • •

Guidelines for strength training

•  Complete all movements slowly and with control. If you’re unable to maintain good form and posture, decrease the weight or number of repetitions.

•  If you have high blood pressure, consult your doctor before lifting heavy weights. The strain of lifting can cause a sharp increase in your blood pressure. This could possibly be dangerous if your high blood pressure is uncontrolled.

•  Breathe normally and freely, exhaling as you lift a weight and inhaling as you lower it. Holding your breath during lifting can raise your blood pressure dramatically.

•  Stop exercising immediately at the moment you feel any pain.

•  Stretch your muscles before and after your workout. When stretching beforehand, warm up first by walking.

•  It’s normal to experience mild muscle soreness for a few days after starting strength training. Always allow at least one day in between strength training sessions so that your muscles can rest.

• • • • •

You build strength when your muscles push or pull against an opposing force, such as weight or gravity. The resistance can be achieved in many ways — moving or pushing against your own body weight, pulling on an elastic band, or lifting weighted objects such as barbells and dumbbells.

The amount of weight or resistance you need to build muscle depends on your current strength. Choose a resistance that makes you feel as though you’re working at a somewhat hard level. As you become stronger, you can increase the weight or resistance or the number of repetitions. See “Guidelines for strength training” above.

It’s important to get instruction if you’ve never used strength training equipment before. You’ll want to learn proper technique, safety precautions and different kinds of exercises to do with the equipment.

You can make your own weights by filling old socks with beans or pennies, or partially filling a half-gallon milk jug with water or sand. Or you can purchase used weights by the pound at some athletic equipment stores. A resistance band can help you work major muscle groups.

Start with a weight you can lift comfortably eight times and build up to 12 repetitions. If you’re a beginner, you may find that you’re able to lift only 1 or 2 pounds in a set. That’s OK. The weight should be heavy enough to tire your muscles but not cause pain.

If you start with too much resistance or too many repetitions, you may damage muscles and joints. Wait for your body to become accustomed to the exercise before gradually increasing intensity.

• • • • •

Simple strengthening exercises

Wall push-up

Face the wall and stand far enough away that you can place your palms on the wall with your elbows slightly bent. Slowly bend your elbows and lean toward the wall, supporting your weight with your arms. Straighten your arms and return to a standing position. This strengthens muscles in your arms and chest.

Step-up

Get a small step stool or stand in front of your stairs. Pushing primarily through your lead foot, lift your body up onto the step. Then step backward to the starting position. When you’re doing step-ups, keep your back straight and your abdominal muscles nice and tight. Make sure your foot is planted entirely on the step. It’s fine to start with a low step height, as well. For this exercise, your form is more important than the step height. When you step up, alternate your lead foot each time.

Arm curl

Stand with your feet shoulder-width apart. For resistance, hold a partially filled half-gallon milk jug. Flex your elbow until your hand reaches shoulder height. Hold, then lower your arm slowly. This tones your biceps and helps in carrying and lifting. Remember to keep your wrist rigid while lifting — don’t bend or curl your wrist.

• • • • •

Find ways to stay motivated

Most people achieve a desirable level of fitness within three to nine months of starting their programs. Your goal from then on is to maintain that level of physical fitness. Take these steps to keep yourself motivated:

Track your progress. Measure your progress with a written log or diary. Seeing on paper how your fitness has improved can help keep you motivated to continue and do more.

Adapt your activities. As you become more fit, fine-tune the intensity and duration of your activities to better suit your interests and lifestyle.

Try new activities. Keep your workouts enjoyable by including different and more challenging activities. Also look for ways to include family members in your physical activities.

Exercise and weight control

When it’s combined with proper nutrition, regular physical activity does what hundreds of fad diets promise but never seem to deliver. Regular physical activity helps you lose weight and keep it off. Simply put, exercise burns calories. And when you burn more calories than you take in, you can reduce your body fat.

Here’s how it works. Your body requires a certain amount of energy to maintain the functions you need to sustain life. When you exercise, your body works harder and needs more fuel (calories) to function. Even after you stop exercising, your body continues to burn calories at a modestly increased rate for a few hours. The more intensely you exercise, the more calories you burn.

According to the Department of Health and Human Services, people trying to lose weight should aim for 300 minutes of moderately intense exercise a week or 150 minutes a week of vigorous physical activity. Moderately intense exercise includes activities such as brisk walking, biking and swimming. If you can’t reach this goal right away, that’s OK. Work toward it.

Weight control combined with regular exercise reduces the risk of high blood pressure, even if you’re already at a higher risk. Most studies have found that blood pressure is reduced relatively early — three to four weeks — after starting an exercise program.

Although the generally recommended amount of exercise can make positive changes, there’s a caveat: When you stop exercising, blood pressure typically returns to its prior level.

Physical activity helps you not only to lose weight but also to keep it off. So don’t stop exercising just because you’ve lost a few pounds. People who are at a healthy weight require just as much physical activity as do those who are trying to reach a healthy weight.

Avoiding injury

Occasional soreness, stiffness, or minor aches and pains are to be expected with physical activity. Muscle soreness for a day or two after exercise is normal, especially if you have been inactive or are trying a new activity.

Most injuries that occur during physical activity stem from the “terrible toos:” too much, too hard, too fast, too soon, too long. If you feel pain during exercise, this can be a warning sign of impending injury. Gasping for breath and having sore joints are other signals that you need to slow down.

Remember: If what you’re doing hurts, then you’re likely overdoing it. Consider reducing the intensity of the exercise or trying a different activity.

Another common cause of aches and pains is doing the same activities over and over without variation. This can lead to overuse injuries, caused by repeated stress on a particular part of your body.

Take these steps to reduce your risk of injury from exercise:

•  Drink plenty of water. Exercise causes you to lose some of the fluid in your body that helps maintain your normal body temperature and cool working muscles. Help replenish those fluids by drinking water before, during and after activity.

•  Warm up and cool down. Stretching before a workout prepares your body for physical activity. Stretching afterward helps improve your flexibility. Warm up briefly before stretching cold muscles to avoid muscle strains.

•  Be active regularly. In general, the less fit you are, the greater your chance of getting injured. Avoid being a weekend warrior, getting most of your activity on two days of the week. Going back and forth between intense workouts and inactivity increases your risk of injury.

•  Follow the 10 percent rule. If you plan to make your exercise more intense, limit increases to about 10 percent. For example, if you swim laps for 30 minutes this week, plan to increase your workout to 33 minutes for the next week, and so on.

•  Avoid abrupt change of direction during activity. A controlled, continuous activity, such as walking or cycling, generally carries less risk of a muscle pull or other injury than do activities in which you change direction quickly and frequently, such as basketball or tennis.

•  Don’t compete. Unless you thrive on competition, avoid the physical and emotional intensity that often accompanies competitive sports. A less stressful environment typically allows you to stay in control of your body and not overextend yourself.

•  Let food digest. Wait three to four hours after eating a large meal before being physically active. Digestion directs blood toward your digestive system and away from your heart.

•  Tailor your activity to the environment. When it’s hot and humid outside, reduce your speed and distance. Or exercise early in the morning or late in the evening when it’s cooler. Avoid activity near heavy traffic. Breathing carbon monoxide given off by automobiles reduces the oxygen supply to your heart.

•  Know the warning signs. Seek immediate care if you experience any of these signs and symptoms:

♦  Tightness in your chest

♦  Severe shortness of breath

♦  Chest pain or pain in your arms or jaw, often on the left side

♦  Fast, irregular heartbeats (palpitations)

♦  Dizziness, faintness or feeling sick to your stomach

• • • • •

How can I exercise when I have painful arthritis in both of my knees?

For many people with pain problems, exercise can be beneficial. In the case of arthritis, proper exercise can help you better maintain joint mobility.

•  Try water exercises. The buoyancy of water takes the weight off your joints. You can swim laps on your own, or you might try a water aerobics class.

•  Use a stationary or recumbent bicycle. This takes pressure off your knees.

•  Consider joining a basic yoga or tai chi class to increase strength and flexibility in your joints.

•  See a physical therapist who can offer recommendations on the best type of exercises for you and teach you how to do them properly to avoid injury and further pain.

• • • • •

What about illness?

If you feel tired or achy, should you exercise? The answer may depend on your illness. If you have a cold, moderate exercise won’t make it worse or prolong it. But if you have an infection and a fever, exercising increases the risk of dehydration, dangerously high body temperature and even heart failure.

One common guideline for determining whether or not you should exercise is to do a “neck check.” If your signs and symptoms are above the neck — a stuffy or runny nose, sneezing, or a sore throat — then moderate exercise is generally safe, although with caution. If you start feeling miserable, stop exercising.

Avoid intense activity if your signs and symptoms are below the neck. These include muscle aches, hacking cough, fever, extreme fatigue, vomiting, diarrhea, chills and swollen lymph glands.

Getting more than just exercise

Do you generally get up to stretch your legs and move around after you’ve been seated for an hour while at work or at play? If you answered no, you may need to change your habits. Moving more throughout your day — in addition to getting structured exercise — is important for your health.

Cutting back on the time you spend sitting is a step in the right direction. Overwhelming research finds that too much sedentary time, which includes time spent sitting while watching TV, working on a computer or traveling in an automobile, can contribute to many health conditions. This is true even for people who are very active and fit.

You may have heard the notion that sitting is as bad for you as smoking. While this claim has gotten a lot of people talking about the effects of personal habits on health risks, the research doesn’t quite bear this out — but both are clearly hazardous to your heart. Here are some ways that they differ.

Smoking is an addictive behavior. No level of smoking — including exposure to secondhand smoke — is safe. It can damage your heart and your lungs and lead to serious health effects. Read more about tobacco use and high blood pressure — as well as how to quit smoking — in Chapter 4 of this book.

Sitting, on the other hand, isn’t a health risk on its own in the same way that tobacco use is — it’s when you sit all day and don’t get enough physical activity that sitting becomes a health risk. And research shows that most people sit for too long each day — many U.S. workers sit for 15 hours a day. Sitting too much can largely negate many of the health benefits of moderate exercise.

Sitting is something that most people have to do from time to time out of necessity. The trick is to balance your sitting time with periods of movement, through physical activity and structured exercise. When you move around or even just stand, the largest muscles of your body are actively working to keep you upright and moving, and sucking up fats and sugar from your bloodstream.

Aim for five to 10 minutes of low-intensity physical activity each hour, working toward a total of 150 minutes of low-intensity physical activity each day. Getting a drink, going to the bathroom and simply walking to prepare for a meeting are great ways to break up prolonged sedentary time. If you have a desk job or regularly sit at work, think of creative ways to cut down on the amount of time you spend sitting. Consider setting a reminder in your email calendar or on your smartphone to prompt you to get up and move.

•  Finally, one of the best things you can do at home is to not sit in front of the TV for hours on end. But there are plenty of other ways to reduce your sitting time throughout the day.

•  Limit your TV, computer and video game use. Set a timer if you need to.

•  Stand while talking on the phone. Put a notepad on a bookcase at home and work, so you can take notes without sitting.

•  Raise your desk surface so that you can stand while you work.

•  When you need to meet with someone (for work or volunteer activities), suggest a walking meeting.

•  Do jumping jacks, crunches or stretches while you watch TV.

• • • • •

Wrap-up

Key points to remember:

•  Regular physical activity usually can reduce your blood pressure by 4 to 9 mm Hg.

•  Exercising regularly is more important than the intensity of exercise.

•  Get at least 150 minutes of moderate physical activity, 75 minutes of vigorous physical activity, or a combination of the two each week.

•  Aerobic activity has the greatest effect on blood pressure.

•  If time for exercise is a problem, look for ways to include more activity in your daily routine.

• • • • •

Chapter 4

Avoid tobacco and limit alcohol

About 1 in 3 people with high blood pressure smokes. Simply having high blood pressure (hypertension) puts you at a higher risk of complications. While smoking has not been conclusively proved to cause high blood pressure, each cigarette your smoke temporarily increases your blood pressure and increases your risk of heart attack and stroke. These are clear warnings about the dangers of smoking.

Tobacco and blood pressure

Tobacco contains a highly addictive drug called nicotine — the substance that makes it so difficult to stop smoking, even though you want to. Nicotine is also what causes your blood pressure to increase shortly after you take the first puff.

Like many other chemicals in tobacco smoke, nicotine is picked up by tiny blood vessels in your lungs and carried through your bloodstream. It takes only a few seconds for the drug to reach your brain. Your brain reacts to nicotine by signaling your adrenal glands to release epinephrine (adrenaline). This powerful hormone narrows your blood vessels, forcing your heart to pump harder under higher pressure.

The carbon monoxide in tobacco smoke replaces some of the oxygen in your blood. When your body doesn’t get all of the oxygen it needs, your heart and lungs have to work even harder. After smoking just two cigarettes, both your systolic and diastolic pressures increase an average of about 10 millimeters of mercury (mm Hg). Your blood pressure remains at this higher level for about 30 minutes after you finish smoking.

As the effects of smoking wear off, your blood pressure gradually decreases. However, if you smoke regularly, your blood pressure will stay higher throughout the day. If you smoke, regularly measure your blood pressure at home. Let your doctor know if your home readings are higher than those during your checkups.

Another important note: Nicotine adds to the effect that caffeine has on your blood pressure. Consuming caffeinated coffee, tea and soft drinks while smoking can raise your blood pressure even more than nicotine does on its own.

Smoking has other damaging effects on your body. The chemicals absorbed from tobacco smoke affect the inner walls of your arteries, making them stiff and unable to expand. Over time, this leaves them more susceptible to the buildup of fatty deposits (plaques) that permanently narrow your arteries. Tobacco also triggers the release of hormones that cause your body to retain fluid. Both of these factors can lead to higher blood pressure.

Exposure to secondhand smoke is also a serious health hazard. It can cause lung cancer in nonsmokers and has been linked to heart disease in adults and sudden infant death syndrome, asthma attacks and ear infections in children. There is no safe level of exposure to secondhand smoke.

Each year in the United States, 34,000 nonsmokers die of heart disease caused by secondhand smoke. If you have other risk factors for heart disease, it’s imperative to completely avoid secondhand smoke. Even without other risk factors, exposure to secondhand smoke is hazardous to your health.

• • • • •

Ex-smokers do win

Many people continue to smoke because they believe they can’t undo the damage already done to their bodies. Or they know too many other smokers who have tried to stop and failed. These assumptions are wrong.

Your body has an incredible capacity to repair itself. Within just a few hours of quitting smoking, the level of carbon monoxide in your blood will begin to decline. After a few weeks, your circulation will improve and you won’t cough or wheeze as often. After several months, your lungs will work significantly better. You’ll also notice an improved sense of smell, and food will taste better to you.

About 6 out of 10 smokers aren’t able to quit smoking on the first try. But stopping smoking is like learning anything else new. It often takes several attempts, and one bad experience shouldn’t keep you from trying again. In fact, you can learn from previous attempts, increasing your chances for being successful in the future.

You can also enhance your chances for success by getting help from your doctor or by using a program that specializes in helping smokers stop. There also are more medications than ever before to assist you.

It’s true that many people gain weight after stopping smoking. But the negative consequences of the added weight are more than offset by the positive health benefits of stopping smoking.

• • • • •

Why stopping is crucial

Not smoking may only slightly reduce your usual blood pressure. But it’s still important to stop. Here’s why:

First, smoking can interfere with some blood pressure medications, preventing them from working as well as they should, or sometimes preventing them from working at all. Second, having high blood pressure puts you at increased risk of a heart attack, heart failure and stroke because of the damage it can cause to your circulatory and neurological systems.

Smoking damages your arteries, producing the same cardiovascular risks as does high blood pressure. Therefore, when you combine high blood pressure with smoking, your odds of heart disease are much greater.

Breaking tobacco’s grip

Some people can simply stop and never smoke again. Most people require several tries. But you can stop — many people have. And as you try, you can work with your doctor to stay in control of your blood pressure.

Becoming smoke-free is a result of planning and commitment, not luck. The two strategies that have been shown to be effective are behavioral counseling by a counselor or tobacco treatment specialist and medication.

All smokers are not alike. Work with your health care team to develop a treatment plan that combines various strategies for:

•  Coping with the symptoms of nicotine withdrawal

•  Improving overall physical and emotional health

•  Gaining social support and guidance, when necessary

•  Resisting urges to smoke

Don’t expect to find a ready-made treatment plan to use. No single plan works for everybody — there’s no “right way” to stop smoking. Build a stop plan that suits your needs. Studies show that using or combining more than one strategy increases your chance of success. These strategies may include eating better, exercising, getting enough sleep and reducing stress.

Almost everyone experiences some symptoms of nicotine withdrawal when stopping smoking. For most smokers, the symptoms last for a few weeks, becoming less intense and less frequent over time. Common symptoms include irritability, anxiety, nervousness and loss of concentration. Using one or more kinds of medication may help ease these symptoms.

Many weeks after your stop date, you may still have the desire to light up, particularly in familiar smoking situations such as after a meal. These urges and cravings are generally brief, but can be very strong and hard to resist.

Certain strategies in your treatment plan may be to change behaviors or avoid situations that cause you to smoke. You may also identify alternative activities or distractions that help you resist the urges and cravings.

Most people who quit smoking relapse within the first three months. Often, people relapse because they get an overwhelming urge to smoke and hadn’t developed a “fire escape” plan.

The following guidelines can increase your chances of success:

Do your homework. Read about the dangers of tobacco products and talk to people who have stopped or are trying to stop smoking. Think about your smoking behaviors and plan for ways to prevent or avoid them. Consider why you want to give up cigarettes. This preparation will help you when the day finally comes to stop smoking.

Set a stop day. Although setting a firm date to stop smoking is best, you can choose to cut back gradually as long as you have a stop date set in the foreseeable future. So carefully select a day when you throw your cigarettes away and no longer light up. It’s unlikely that you’ll have a time when you’re totally stress-free, so don’t let this get in the way of setting and sticking to your stop date.

Consider medication and counseling. Medications are available that can lessen nicotine withdrawal symptoms and increase your comfort and sense of control as you work toward becoming tobacco-free (see “Medications to help you stop smoking”). Medications can’t do all of the work, but they can provide you with a better chance of success.

Research indicates that medication paired with counseling from a trained health care professional is even more effective. Ask your doctor about counseling services. In addition, many states and health organizations have telephone quit lines that provide advice and counseling. Some provide free nicotine patches or nicotine gum.

Tell others about your decision to stop. The support of family, friends and co-workers can help you reach your goal sooner. But many smokers choose to keep their plans a secret. That’s because they don’t want to look like a failure if they return to smoking. Keep in mind that it’s better to be open and honest with yourself and those who support you.

Remember, it can take many tries — sometimes as many as 10 or more — before you can stop smoking for good. So there’s no reason to feel like a failure just because your effort doesn’t work out this time. Enlisting the support of at least one person can help you through a lapse.

Change your routine. Try to reduce the number of routine activities or situations that you identify with smoking before your stop day. That will make it easier to stop completely. For example, stop smoking inside your car or your house. This will help you become more comfortable being in those places without smoking.

You can also reduce the number of cigarettes you smoke before your stop day, but remember that your goal is to stop completely.

• • • • •

How do I change my smoking routine?

Before your stop day, try to separate smoking from everything else in your day-to-day life. Choose one location as a place to smoke, and don’t smoke anywhere else. Here are other tips that can help.

•  Buy cigarettes at a different location each time. Never return to the same place.

•  Buy cigarettes in a single pack only. Never have more than one pack available at a time.

•  When you smoke, do nothing else. Don’t start associating smoking with any activity.

•  Don’t carry cigarettes with you. Keep your one pack in your designated smoking place.

•  Don’t carry a lighter or matches with you. Keep them (as well as ashtrays) with your one cigarette pack.

• • • • •

Take one day at a time. On your stop day, stop completely and on each day following, focus on staying tobacco-free. Don’t worry about tomorrow, next week or the rest of your life. Just take it one day at a time, one urge at a time.

Avoid smoking situations. Stay away from situations in which you used to smoke. Leave the table right after a meal if this was a time when you used to light up, and go for a walk instead. If you always smoked while you talked on the telephone with friends, avoid long phone conversations or change the location where you talk. If you had a favorite smoking chair, don’t sit in it anymore. And avoid secondhand smoke — exposure to secondhand smoke can be a powerful trigger to smoke.

To some degree, you’ll be able to tell when you’re about to have an urge to smoke. Before it hits, start doing something that makes smoking inconvenient, such as making the bed, clearing the dinner table or washing the dishes. Smoking behavior is deeply ingrained and automatic — so you need to anticipate your reflex response to this urge and plan alternatives.

Time each urge. Check your watch when an urge to smoke hits. Most are short. Once you realize this, it may be easier to resist. Remind yourself, “I can make it another few minutes, and then the urge will pass.”

• • • • •

How do I cope with an urge to smoke?

•  Remind yourself that the urge goes away in a few minutes.

•  Keep your hands busy.

•  Brush your teeth.

•  Think about some aspect of smoking that’s negative to you.

•  If you can, leave the situation for a few moments.

•  Clear your mind and think about an enjoyable activity or relaxing place for a brief time.

•  Call someone and talk about your feelings.

• • • • •

Use medications along with other strategies to stop smoking. Remember that medications are just one part of an overall plan to change your behavior.

• • • • •

Medications to help you stop smoking

Most people use at least one medication when they try to stop smoking, but many find that a combination of medications is the most comfortable and effective approach. Use them according to your doctor’s instructions or, in the case of over-the-counter (OTC) medications, according to instructions on the label.

Nicotine replacement products deliver doses of nicotine to help relieve withdrawal symptoms but don’t keep a smoker addicted to the substance. These products are considered temporary aids — usually for several weeks or for several months. Consult your doctor about tapering off these medications.

Nicotine patches. A nicotine patch is placed on your skin and gradually releases nicotine into your body. It’s an over-the-counter product and comes in different sizes — the larger the patch, the more nicotine delivered. If the patch irritates your skin, rotate the site of the patch and apply an OTC cortisone cream.

Nicotine gum. This OTC product is not intended to be chewed like regular gum. Bite into the nicotine gum a few times, then “park” it between your cheek and gum and leave it there. The lining of your mouth absorbs the nicotine that the gum releases. Two doses are available — 2 milligrams (mg) and 4 mg. Chew enough gum to relieve symptoms.

Nicotine lozenges. The nicotine lozenge looks like a hard candy and releases nicotine as it slowly dissolves in the mouth. Doses are available in 2-mg and 4-mg amounts — the 4-mg lozenge is used by heavier smokers. Nicotine lozenges come in regular and mini sizes.

Nicotine nasal spray. You spray this product into your nose with a bottle dispenser. The nicotine is absorbed into your bloodstream through the lining of your nose, providing a quicker response to nicotine cravings than the other products provide. It’s intended mainly for when you need immediate relief from withdrawal symptoms, and often used with nicotine patch therapy or with bupropion medication. The product is available only by prescription.

Nicotine inhaler. This device looks like a plastic cigarette that you put to your mouth and puff on, releasing a nicotine vapor into your mouth. Although it’s called an inhaler, it doesn’t deliver nicotine to the lungs. This product is available only by prescription and the dose is individualized. Using an inhaler can help smokers who miss the hand-to-mouth ritual that’s part of smoking a cigarette.

Non-nicotine medications. Bupropion (Zyban) is a nonaddicting, non-nicotine medication approved by the Food and Drug Administration (FDA) as a stop-smoking aid. It’s not clear exactly how the drug works, although it releases dopamine, a brain chemical that causes a feel-good response similar to that produced by nicotine and other drugs of addiction. Bupropion is available only by prescription.

Varenicline (Chantix) is another nonaddicting, non-nicotine medication approved by the FDA to stop smoking. This medication stimulates the same brain receptors that are usually activated by the nicotine in tobacco products. Chantix also blocks some of the pleasure you get from smoking, making smoking less rewarding.

• • • • •

Alcohol and blood pressure

There’s a clear link between how much alcohol you drink and its effect on your blood pressure. If you drink alcohol, the best advice is to do so in moderation. Small amounts of alcohol don’t seem to increase blood pressure.

Some evidence suggests that moderate drinking may have certain cardiovascular benefits. For example, studies indicate that it can lower the risk of heart attack, heart disease and the most common type of stroke.

Moderate drinking also can boost the production of high-density lipoprotein (HDL, or “good”) cholesterol — the cholesterol that may help protect your arteries from the buildup of plaques. But even with this potential health benefit, there’s no reason to start drinking alcohol now if you don’t drink already. Drinking alcohol can lead to many potential problems. For example, the extra calories in alcohol can lead to weight gain and weight-related issues, such as diabetes.

Unlike moderate consumption, excessive alcohol consumption is a problem for your cardiovascular system — along with many other negative health consequences. Drinking too much alcohol can increase your blood pressure and interfere with the function of your blood pressure medication.

• • • • •

What’s the best way to cut back on alcohol?

If you drink too much alcohol and you want to cut back, it’s best to gradually reduce how much you drink over a period of one to two weeks.

People who drink heavily and suddenly stop consuming alcohol can develop severe high blood pressure that lasts for several days. One explanation is that when you suddenly remove alcohol from your bloodstream, your body releases abnormal amounts of the hormone epinephrine (adrenaline), which causes your blood pressure to rise sharply.

If you have high blood pressure and you drink more than a moderate amount of alcohol, talk with your doctor about the safest and most successful way to limit or avoid alcohol.

• • • • •

Moderate drinking — Less than you think?

Alcoholic drinks contain various amounts of the chemical ethanol (ethyl alcohol) — the more ethanol, the stronger the drink. For most men, moderate drinking is two drinks a day. Two drinks are equal to two 12-ounce bottles of beer, two 5-ounce glasses of wine or two 1.5-ounce shot glasses of 80-proof liquor.

For women and small-framed men, moderate drinking is half that — one drink a day. The amount is less for women because they metabolize alcohol differently from men, and less for small-framed men because they have less blood volume, which results in a higher concentration of ethanol in their systems. For men of any frame size who are age 65 and older, moderate drinking is one drink a day.

Remember that the effects of alcohol on your health are still being studied. Even moderate drinking may not be good for certain people. Be sure to consult your doctor about how alcohol consumption may affect your overall health and blood pressure.

How alcohol affects blood pressure

Exactly how excess alcohol — more than a moderate amount — increases blood pressure is unknown.

One theory is that alcohol consumption triggers the release of epinephrine (adrenaline) and other hormones that constrict your blood vessels or cause your kidneys to retain more sodium and water. This, in turn, raises your blood pressure.

Excessive drinking is also associated with poor nutrition, which can deplete your levels of calcium and magnesium. A lack of these minerals in your body is associated with higher blood pressure. Your genes may also play a role in how alcohol affects blood pressure.

It’s not only the amount of alcohol you consume but also when you consume alcohol that can affect your blood pressure. A recent study suggests that people who drink alcohol outside of meals will have a much higher risk of high blood pressure, no matter how much they drink.

Regardless, it’s clear that by reducing your alcohol consumption, you can reduce your blood pressure. Heavy drinkers who cut back to moderate levels can lower their systolic blood pressure by about 7 to 12 mm Hg and their diastolic pressure about 3 mm Hg.

Combining a healthy diet with reduced alcohol intake can produce an even larger reduction — a drop of about 10 mm Hg in systolic pressure and 7 mm Hg in diastolic pressure. One reason for this effect is that people who consume too much alcohol generally don’t get adequate amounts of the minerals that help control blood pressure, such as potassium, calcium and magnesium.

Alcohol and medications

If you take blood pressure medication, pay attention to when and how you consume alcohol. Alcohol can interfere with the effectiveness of some high blood pressure medications and increase their side effects.

If you mix alcohol with a beta blocker, which relaxes your blood vessels and slows your heart rate, you may feel lightheaded or faint — especially if you’re overheated or if you stand up suddenly.

You can experience the same symptoms if you drink alcohol close to the time you take an angiotensin-converting enzyme (ACE) inhibitor, which widens your blood vessels, or certain calcium channel blockers, which can slow your heart rate. If you do feel dizzy or faint, sit until the feeling passes. Drinking water also may help. In general, any medication that causes drowsiness shouldn’t be taken with alcohol. Read the medication label before you decide to consume alcohol.

And listen to your body. If you feel lightheaded or depressed after a drink or two, talk to your doctor about how much alcohol you can safely drink and when is the best time you can do it.

What about caffeine?

Caffeine is a mild stimulant found in coffee, tea, soft drinks and chocolate. It can fight fatigue, improve your concentration and lighten your mood. But if you use too much — something that’s easy to do — caffeine can leave you jittery, cause your hands to tremble and even possibly increase your blood pressure.

The amount of caffeine in two to three cups of coffee — 200 to 250 milligrams — has been shown to raise systolic pressure 3 to 14 mm Hg and diastolic pressure 4 to 13 mm Hg in people without high blood pressure.

How caffeine affects blood pressure remains an ongoing topic of debate. Some studies have found that people who consume caffeine regularly throughout the day will end up with higher average blood pressure than if they didn’t consume any caffeine at all.

• • • • •

How do I reduce caffeine intake?

Caffeine can be habit-forming, so any attempts to stop or lessen the amount you normally consume can be challenging. An abrupt decrease in caffeine can cause withdrawal symptoms, such as headaches, fatigue, irritability and nervousness. These symptoms usually resolve after several days. To adopt new caffeine habits, try these tips:

•  Gradually reduce the amount of caffeine you consume. For example, drink one fewer can of soda or drink a smaller cup of coffee each day. This will help your body get used to the lower levels of caffeine and thereby lessen the effects of withdrawal.

•  Replace caffeinated coffee, tea and soda with their decaffeinated counterparts. Most decaffeinated drinks look and taste the same.

•  When preparing tea, brew for less time to cut down on its caffeine content. Or choose herbal teas, which don’t contain this stimulant.

•  Check the caffeine content in over-the-counter medications that you take. Pain relief or headache medications can contain from 65 to 130 mg of caffeine in one dose. Switch to caffeine-free versions, if possible.

• • • • •

However, other research shows that people who regularly consume caffeine develop a tolerance to the stimulant. After consuming caffeine regularly for a while, caffeinated products don’t have much effect on blood pressure.

Among people who don’t consume caffeine on a regular basis or who consume more than they’re used to, caffeine can cause a temporary but sharp increase in blood pressure.

Exactly what causes this blood pressure spike is unknown. Some researchers suggest that caffeine narrows your blood vessels by blocking the effects of adenosine (uh-DEN-o-seen), a hormone that helps keep the vessels widened. Caffeine may also stimulate the adrenal gland to release more cortisol and epinephrine.

Researchers have also found that people who take monoamine oxidase inhibitors (MAOIs) for depression and take in large amounts of caffeine may experience severe high blood pressure.As a general precaution, many doctors advise people with high blood pressure to limit daily caffeine intake to no more than two cups of coffee, four cups of tea or two to four cans of caffeinated soda to prevent any effects.

In addition, it’s good practice to avoid caffeine right before activities that naturally increase your blood pressure, such as exercise or hard physical labor. Limiting caffeine is also good for your general health.

• • • • •

Wrap-up

Key points to remember:

•  If you have high blood pressure and you smoke tobacco products, your risk of death from a heart attack, heart failure or stroke is much higher than if you don’t smoke.

•  It takes planning and commitment to stop smoking. Develop your own stop plan with coping skills, social support and strategies to deal with the symptoms of nicotine withdrawal.

•  For many people, moderate alcohol use doesn’t seem to affect blood pressure, but excessive alcohol use can have serious consequences for your cardiovascular system.

•  Alcohol use may interfere with some high blood pressure medications or increase their side effects.

•  Caffeine can cause a temporary but sharp rise in blood pressure, particularly among people who don’t regularly consume caffeine. If you have high blood pressure, you may want to limit daily caffeine intake.

• • • • •

Chapter 5

Take the right medication

Making lifestyle changes is a fundamental way and a first line of therapy to manage blood pressure. But often, lifestyle changes aren’t enough and medication is needed.

With stage 2 high blood pressure (at least 160 millimeters of mercury, or mm Hg, systolic pressure or at least 100 mm Hg diastolic pressure), medication is often required to lower blood pressure further and more rapidly than any lifestyle change can. If you have other conditions as well as high blood pressure, medications may also be necessary. Blood pressure medications, also known as antihypertensives, are a major success story in modern medicine. They’re quite effective, and most people aren’t bothered by their side effects. These drugs can allow you to live normally with controlled blood pressure but also provide benefits by reducing your risk of other health concerns.

There are several classes of blood pressure medication, and each class affects blood pressure in a different way. If your doctor prescribes one drug but it doesn’t lower your blood pressure to a safe level, your doctor may substitute a drug from a different class of medications or add another medication to your prescription. Together, two or more low-dose drugs may lower your blood pressure as well as or better than one drug alone can at full dose. Using lower doses of medications together may also produce fewer side effects.

Finding the right medication or combination of medications may take time. Factors to consider include your age, ethnicity and overall health, other medications you are taking, how often you take the drugs, how you feel when you take them, and the total cost of the medication.

Taking blood pressure medication once a day may not control blood pressure for 24 hours in some people. This can be detected with home blood pressure monitoring. If this is the case, it will be necessary to split the doses between the morning and the evening.

Sometimes it’s possible to treat two or more conditions with one medication, so talk with your doctor about any other conditions you have. What’s most important is that you’re working with your doctor to develop a treatment plan that’s tolerable, cost-effective and personalized.

Many options

The major classes of medication used to control high blood pressure include:

•  Diuretics

•  Beta blockers

•  Angiotensin-converting enzyme (ACE) inhibitors

•  Angiotensin II receptor blockers (ARBs)

•  Renin inhibitors

•  Calcium channel blockers (calcium antagonists)

•  Alpha blockers

•  Alpha-beta blockers

•  Central-acting agents

•  Direct vasodilators

The following sections list medication names alphabetically, with the generic name first. If you have questions about a medication, talk with your doctor.

Diuretics

Diuretics were first introduced in the 1950s and are still some of the most commonly used medications to lower blood pressure.

Diuretics and your kidneys Nephrons are the filtering units of your kidneys — tiny bundles of intertwining blood vessels and tubules. Each organ is packed with about 1 million of them. The different types of diuretics act on different parts of the nephron.

When compared with other high blood pressure drugs, diuretics have two major advantages. First, they’re the least expensive of all the blood pressure drugs. Second, they’ve repeatedly proved their effectiveness over the years. For example, in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), published in late 2002, researchers found that among about 33,000 people age 55 and older, treatment programs based on diuretics were more effective than were those for ACE inhibitors or calcium channel blockers in controlling high blood pressure and preventing heart disease. A 2010 study reaffirmed these conclusions.

Known as water pills, diuretics reduce the volume of fluid in your body. They tell your kidneys to excrete more sodium in your urine than they would normally. The sodium takes with it water from your blood so that there’s a smaller volume of blood pushing through your arteries. This means less pressure on your artery walls. Diuretics also cause changes in your blood vessels that cause them to dilate, which reduces your blood pressure.

Diuretics are often the first medication a doctor will prescribe for people with stage 1 high blood pressure. They’re highly effective in blacks and older adults, who more frequently are sodium sensitive. In addition, they’re commonly used in combination with other medications.

If you take a diuretic, it’s important that you also limit sodium and get enough potassium in your diet. This will help the drug work more effectively and with fewer side effects.

Types of diuretics

There are three types of diuretics. Each works by affecting the nephrons, the filtering units of your kidneys.

Thiazides. Listed below are thiazide and thiazide-like diuretics:

•  Chlorothiazide (Diuril)

•  Chlorthalidone

•  Hydrochlorothiazide (Microzide)

•  Indapamide

•  Methyclothiazide

•  Metolazone (Zaroxolyn)

In addition to controlling high blood pressure, thiazide diuretics provide other potential benefits. They’ve been shown to reduce the risk of stroke, heart attack and heart failure. They also reduce the amount of calcium in your urine, so less calcium is available for kidney stone formation. Less calcium in your urine means more of this mineral remains in your blood, helping to reduce your risk of osteoporosis and hip fracture.

Loop. These diuretics are more powerful than thiazides, removing a greater amount of sodium from your kidneys. They may also remove more calcium, although proper monitoring can prevent complications. Your doctor may recommend a loop diuretic if thiazides aren’t effective, particularly if you have chronic kidney disease, or if you have other conditions that cause your body to retain fluid.

Loop diuretics include:

•  Bumetanide (Bumex)

•  Ethacrynic acid (Edecrin)

•  Furosemide (Lasix)

•  Torsemide (Demadex)

Potassium-sparing. In addition to removing sodium from your blood, thiazide and loop diuretics remove potassium. Potassium-sparing diuretics, on the other hand, help your body retain needed potassium.

Potassium-sparing diuretics mainly are used with other diuretics because they aren’t as powerful as the other types. When taken with other medications, the potassium-sparing diuretic spironolactone also reduces death from heart failure and is particularly effective with resistant high blood pressure. Eplerenone is an improved version of spir-onolactone that appears to have fewer side effects.

Potassium-sparing diuretics include:

•  Amiloride (Midamor)

•  Eplerenone (Inspra)

•  Spironolactone (Aldactone)

•  Triamterene (Dyrenium)

Side effects and cautions

The most common side effect of diuretics is increased urination. Thiazide and loop diuretics can also cause low potassium levels, so they’re often used with a potassium-sparing diuretic, ACE inhibitor or ARB. In rare cases, your magnesium level may need to be corrected before your potassium level is addressed; changes in magnesium may worsen changes in potassium.

In older adults, diuretics may also cause dizziness upon standing. These medications can also cause impotence in some men, although this is uncommon. In addition, thiazides in high doses can slightly increase your blood sugar and cholesterol levels. They also increase the level of uric acid in your blood. In rare cases, this can lead to the development of gout, a joint disorder.

Another rare condition, known as hyponatremia, involves low levels of sodium in your blood. It often occurs in older adults who are taking thiazide diuretics and who drink too much water. Hyponatremia causes headache and confusion, and can lead to coma.

Potassium-sparing diuretics may raise your potassium level too much. Blood tests can detect this. If you have impaired kidney function, you shouldn’t take a potassium-sparing diuretic.

Your doctor may want to check your sodium, potassium and creatinine levels within three months after you start taking a diuretic.

• • • • •

I’m afraid of medication side effects. What can I do?

Because certain side effects are associated with a medication doesn’t guarantee that you’ll experience them. These signs and symptoms are generally reported among only a small number of users. Discuss any concerns you may have with your doctor. There are ways to test your reaction to a drug, for example, by starting at a low dose and gradually raising the dose. Also, many side effects tend to subside after a short amount of use.

• • • • •

Beta blockers

Beta blockers lower blood pressure by blocking many of the effects of the hormone epinephrine (ep-ih-NEF-rin), also known as adrenaline (uh-DREN-uh-lin). This action makes your heart beat more slowly and less forcefully, thus helping to lower your blood pressure.

Beta blockers also slow your kidneys’ release of the enzyme renin. Renin is involved in the production of a substance called angiotensin (an-jee-o-TEN-sin) II, which narrows your blood vessels and increases your blood pressure. (See “Renin-angiotensin-aldosterone system.”)

Like diuretics, beta blockers have been used for many years and lower blood pressure in most people who try these medications.

Beta blockers alone may not be the first choice for cases of uncomplicated high blood pressure (hypertension) — a better choice may be in combination or with another drug option — but beta blockers are especially helpful if high blood pressure is accompanied by cardiovascular conditions such as chest pain (angina), irregular heart rhythm (arrhythmia), heart failure or previous heart attack. They help control these conditions and reduce your risk of a second heart attack.

Beta blockers work especially well in older adults who have heart disease. However, blacks don’t respond as well as whites do when taking most types of beta blockers as a single drug.

These drugs were originally developed to treat coronary artery disease and were later approved for the treatment of high blood pressure after studies found they could lower blood pressure. They may also be used to treat glaucoma, migraines, anxiety, hyperthyroidism and some tremors.

Types of beta blockers

Beta blockers can affect your heart (cardioselective) or both your heart and blood vessels (noncardioselective). Cardioselective drugs generally produce fewer side effects. Cardioselective beta blockers include:

•  Acebutolol (Sectral)

•  Atenolol (Tenormin)

•  Betaxolol

•  Bisoprolol (Zebeta)

•  Nebivolol (Bystolic)

•  Metoprolol (Lopressor, Toprol-XL)

Noncardioselective types include:

•  Nadolol (Corgard)

•  Penbutolol

•  Pindolol

•  Propranolol (Inderal LA)

•  Timolol

Drugs that combine both alpha and beta blockade are listed later.

If you have liver or kidney problems, your choice of a beta blocker may be limited. Beta blockers are broken down in your liver or in your kidneys or in both organs. If your kidneys aren’t working properly, for example, a beta blocker that’s normally removed by your kidneys may build to toxic levels.

Side effects and cautions

Although side effects may occur when taking beta blockers, many people who take beta blockers won’t have any. Two notable side effects of beta blockers are fatigue and a reduced capacity for strenuous physical activity. Other side effects may include cold hands, trouble sleeping, impotence, loss of sex drive, a slight rise in your triglyceride level, a small weight gain and a slight decrease in your high-density lipoprotein (HDL, or “good”) cholesterol level.

If you’re an active person or an athlete, beta blockers won’t be your first choice of treatment because beta blockers can limit your ability to be fully active. The drugs also aren’t recommended if you have asthma or severe blockage in the conducting system of your heart.

ACE inhibitors

Angiotensin-converting enzyme (ACE) inhibitors help reduce blood pressure by preventing the enzyme from producing angiotensin II. This substance causes your blood vessels to contract and stimulates release of the hormone aldosterone (see the illustration of the process).

Limiting the action of the angiotensin-converting enzyme also allows another substance called bradykinin (brad-e-KIE-nin) — which keeps your blood vessels dilated — to remain in your bloodstream, reducing blood pressure.

ACE inhibitors are a common choice among doctors for treating high blood pressure because they’re effective and produce few side effects. Among blacks, ACE inhibitors are most effective when they’re combined with a diuretic.

In addition to lowering blood pressure, ACE inhibitors help prevent and treat cardiovascular disease, including coronary artery disease, left ventricular hypertrophy, heart failure and stroke. ACE inhibitors also delay progression of kidney disease and may protect against diabetes.

ACE inhibitors include:

•  Benazepril (Lotensin)

•  Captopril (Capoten)

•  Enalapril (Vasotec)

•  Fosinopril (Monopril)

•  Lisinopril (Zestril, Prinivil)

•  Moexipril (Univasc)

•  Perindopril (Aceon)

•  Quinapril (Accupril)

•  Ramipril (Altace)

•  Trandolapril (Mavik)

Side effects and cautions

ACE inhibitors generally cause few side effects. However, one side effect can be a dry cough. This side effect occurs more commonly in women than in men. In some people, the cough can be persistent and annoying enough to warrant switching to another medication. ACE inhibitors may also elevate your potassium level, which can be dangerous if the level rises too high.

Other possible side effects may include rash, altered sense of taste and reduced appetite. For some people and in some situations, ACE inhibitor use requires special consideration and attention. For example, if you have severe kidney disease, an ACE inhibitor should be used with caution because it can contribute to kidney failure. In addition, ACE inhibitors aren’t recommended for women who are pregnant or plan to become pregnant because the drugs can cause birth defects.

Rarely — but more commonly in blacks and in smokers — this medication may cause small areas of tissue swelling (angioedema). This can be a potentially life-threatening condition if the swelling occurs in the throat, obstructing breathing.

Angiotensin II receptor blockers

Angiotensin II receptor blockers (ARBs) block the action of the chemical angiotensin II. ACE inhibitors, on the other hand, block the formation of angiotensin II (see this illustration for more information). Angiotensin II receptor blockers are also different from ACE inhibitors in that they don’t affect the levels of bradykinin in your bloodstream.

Studies indicate that ARBs are about as effective as ACE inhibitors in treating high blood pressure and heart failure. They’ve also been shown to be more effective in treating advanced kidney failure. ARBs can be used to treat heart disease, including coronary artery disease and stroke. They also provide the benefit of rarely causing a dry cough.

Angiotensin II receptor blockers include:

•  Azilsartan (Edarbi)

•  Candesartan (Atacand)

•  Eprosartan (Teveten)

•  Irbesartan (Avapro)

•  Losartan (Cozaar)

•  Olmesartan (Benicar)

•  Telmisartan (Micardis)

•  Valsartan (Diovan)

Side effects and cautions

Side effects are uncommon, but in some people ARBs can cause dizziness, nasal congestion, diarrhea, indigestion and insomnia. In rare cases, ARBs may cause localized tissue swelling (angioedema). Like ACE inhibitors, these drugs should be taken with caution if you have severe kidney disease, and not at all by women who are pregnant or may become pregnant. Olmesartan has also been reported to cause a sprue-like gastrointestinal illness that resolves with stopping the medication.

Renin inhibitor

The renin inhibitor aliskiren (Tekturna) works to lower blood pressure by reducing the ability of the enzyme renin to initiate the process that produces angiotensin II. This medication affects this process at a much earlier stage than do other drugs (see the illustration of the process).

Various studies have demonstrated the effectiveness of aliskiren, although results indicate that blacks tend to have smaller reductions in blood pressure than do whites. Results also show that aliskiren is most effective when used in combination with other medications, especially with a diuretic. Aliskiren should not be used with ACE inhibitors or ARBs.

Side effects are uncommon but include diarrhea and an allergic reaction that causes face swelling and difficulty breathing.

One important note: Don’t use aliskiren if you are pregnant or may become pregnant.

Calcium channel blockers

Calcium channel blockers — also called calcium antagonists — affect the muscle cells in the walls of your arteries. These muscle cells contain tiny passages in their membranes called calcium channels. When calcium carried in your bloodstream flows into them, the muscle cells contract and your arteries narrow. Calcium channel blockers prevent the calcium from getting into the muscle cells by blocking the channels.

Calcium channel blockers do not affect the levels of calcium used by your body to build bone and maintain your musculoskeletal system. They are effective and generally well-tolerated. Calcium channel blockers may work better for blacks than do drugs such as beta blockers, ACE inhibitors and angiotensin II receptor blockers. Some calcium channel blockers also offer the added benefit of slowing your heart rate, potentially reducing blood pressure, relieving angina and controlling irregular heartbeat. Calcium channel blockers have also been shown to help prevent migraines and Raynaud’s disease, a condition that affects the circulation of blood in your hands and feet.

Types of calcium channel blockers

The two types of calcium channel blockers are determined by the length of time these drugs are effective in your circulatory system.

Short acting

This type lowers your blood pressure rapidly, often within a mere half-hour. But the effect lasts for only a few hours.

Short-acting calcium channel blockers aren’t recommended for treating chronic high blood pressure because it would require you to take the drug three or four times a day. This generally results in poor control of your blood pressure. Some studies have linked the short-acting forms to increased risk of heart attack and sudden cardiac death.

Long acting

These drugs are absorbed into your body at a much slower rate than the short-acting drugs are. Although it takes them longer to lower your blood pressure, they control the pressure for a longer period of time.

Studies show that long-acting calcium channel blockers aren’t as effective as diuretics and beta blockers at controlling blood pressure. Compared with ACE inhibitors, calcium channel blockers are less effective at reducing heart failure and heart attacks, but more effective at reducing stroke. Referred to earlier in this chapter, research from ALLHAT showed that diuretics were better able to lower blood pressure and prevent heart failure than were calcium channel blockers.

Long-acting calcium channel blockers include:

•  Amlodipine (Norvasc)

•  Diltiazem (Cardizem, Tiazac, others)*

•  Felodipine (Plendil)

•  Isradipine (DynaCirc CR)

•  Nicardipine (Cardene SR)

•  Nifedipine (Procardia, Adalat CC)

•  Nisoldipine (Sular)

•  Verapamil (Calan, Covera-HS, others)*

These drugs also slow your heart rate, can treat certain heart arrhythmias and angina, and prevent second heart attacks and migraines.

Side effects and cautions

Possible side effects include constipation, headache, rapid heartbeat, rash, swollen feet and lower legs, swollen gums, fatigue, flushing, and nausea.

An important note: Don’t consume grapefruit, grapefruit juice, sour oranges or pomelos if you’re taking felodipine, nifedipine, nisoldipine or verapamil. A substance in the juice of these fruits seems to impair the breakdown (metabolism) of these medications, allowing them to build up in your body and become toxic.

Alpha blockers

Alpha blockers reduce the effect of the hormone norepinephrine (noradrenaline), which stimulates muscles in the walls of your smaller arteries. As a result, the walls don’t narrow as much as they might normally. For older men with prostate problems, alpha blockers also improve urine flow and reduce the number of awakenings at night to go to the bathroom.

Alpha blockers have been used to treat hypertension for more than two decades. They used to be prescribed on their own but now are used with other high blood pressure drugs. New 2014 guidelines do not recommend alpha blockers as first line therapy because in one study, initial therapy resulted in poorer cerebrovascular, heart failure and combined cardiovascular outcomes than initial therapy with a diuretic.

Alpha blockers are available in both short-acting and long-acting forms. Alpha blockers include:

•  Doxazosin (Cardura, Cardura XL), a long-acting drug

•  Prazosin (Minipress), a short-acting drug

•  Terazosin, a long-acting drug

•  Side effects and cautions

Alpha blockers are generally well-tolerated and should be taken just before bedtime. However, when you first begin taking them or if you’re older, they can cause you to feel dizzy or faint when you stand up. That’s because alpha blockers slow the time it takes your body to respond to natural changes in blood pressure when you move from a sitting or lying position to a standing position. Other possible side effects include headache, pounding heartbeat, nausea and weakness.

• • • • •

Alpha-beta blockers

Certain drugs combine the effects of an alpha blocker and a beta blocker. Alpha-beta blockers such as carvedilol (Coreg) and labetalol lower blood pressure by reducing nerve impulses as alpha blockers do and slowing your heartbeat as beta blockers do. The same precautions are necessary for these drugs as for beta blockers and alpha blockers. Possible side effects include fatigue, dizziness, lightheadedness, slow heartbeat, increased blood sugar and eye dryness.

• • • • •

Central-acting agents

Unlike other blood pressure drugs that work primarily on your heart and blood vessels, central-acting agents work on your nervous system. They prevent centers in your brain from signaling your nerves to speed up your heart rate and narrow your blood vessels. As a result, your heart doesn’t pump as hard, which helps your blood flow more easily through your arteries.

Also called central adrenergic (ad-ren-UR-jik) inhibitors, these drugs aren’t used often because they can produce strong side effects. However, they’re still prescribed in certain circumstances. Your doctor may recommend a central-acting agent if you are prone to panic attacks, have hot flashes or incidents of low blood sugar, or are going through alcohol or drug withdrawal.

One central-acting agent, clonidine, is available as a skin patch, which is helpful if you have trouble taking pills. Another agent, methyldopa, is often recommended to pregnant women with high blood pressure to lower risks to themselves and the baby. Central-acting agents include:

•  Clonidine (Catapres, Kapvay)

•  Guanfacine (Tenex, Intuniv)

•  Methyldopa

•  Reserpine*

*Reserpine works primarily on the peripheral nervous system outside of the brain.

Side effects and cautions

Side effects that central-acting agents can produce include extreme fatigue, drowsiness, dizziness or sedation. They can also cause impotence, dry mouth, weight gain, impaired thinking and psychological problems, including depression.

Stopping the use of some central-acting agents can cause your blood pressure to increase rapidly to dangerously high levels. If you’re bothered by side effects and want to quit taking the drug, consult your doctor on how to gradually taper its use.

Direct vasodilators

These potent medications are used primarily to treat high blood pressure that doesn’t respond well to other medications. Direct vasodilators work directly on muscles in your artery walls, preventing the arteries from narrowing.

Direct vasodilators include:

•  Hydralazine

•  Minoxidil

Side effects and cautions

Common side effects include a fast heartbeat, dizziness and fluid retention — none of which is desirable if you have high blood pressure. That’s why doctors typically prescribe direct vasodilators with a beta blocker and diuretic, which can reduce the incidence of these symptoms.

Other side effects may include gastrointestinal problems, headache, nasal congestion and swelling of your gums. Minoxidil also may result in excessive hair growth. Hydralazine taken in large doses can increase your risk of lupus, an autoimmune disorder that affects your connective tissues.

Combination drug therapy

If your blood pressure medication isn’t effective, know that you’re not alone. According to 2013 research, the majority of people with high blood pressure need two or more medications to reach optimal blood pressure control.

If your blood pressure medication isn’t working, your doctor may first increase the dosage, provided you aren’t experiencing any significant side effects, or try a completely different drug. Another option your doctor may consider is to add a second drug to the one you’re already taking — an approach known as combination drug therapy.

Combination therapy involves the use of two or more drugs with different mechanisms of action, and can be particularly effective if your blood pressure needs to be lowered substantially (more than 20/10 mm Hg, for example). Your doctor looks for two medications that will enhance each other’s effectiveness or reduce side effects, for example, combining a thiazide diuretic — which can lower your potassium level — with a potassium-sparing diuretic, which retains the mineral.

A different example is the combination drug Caduet, which combines amlodipine, a calcium channel blocker, with atorvastatin, a statin used to treat high cholesterol. Since high blood pressure and high cholesterol are often present in the same individual, both disorders can be treated conveniently with a single medication.

Another benefit of combination drugs is that you may be using them at lower doses. For example, certain blood pressure medications, such as thiazide diuretics and statins, increase the risk of new-onset diabetes when used at higher doses or for long duration.

The use of these drugs at lower doses in combination with another medication can neutralize this risk, especially if the potassium is kept normal, in controlling high blood pressure.

If, after you start using one drug, your blood pressure still exceeds your blood pressure goal by more than 20/10 mm Hg — this includes everyone with stage 2 high blood pressure — the doctor may initiate a new therapy combining two drugs, usually a diuretic and the initial drug. (Generally, if a diuretic isn’t the first drug that’s prescribed, it’s often the second used in combination.)

Sometimes you may need three or more blood pressure medications. For more on these situations, see Chapter 11.

• • • • •

Medications that lower blood pressure as a side effect

This is a partial list of medications that may cause a drop in blood pressure and affect treatment of hypertension. Drugs are listed by the condition they are used to treat or by their drug type or class.

Alzheimer’s disease drugs

•  Donepezil (Aricept)

•  Galantamine (Razadyne)

Antidepressants

•  Trazodone (Oleptro)

•  Tricyclic antidepressants

Antiparkinsonian drugs

•  Pramipexole (Mirapex)

•  Ropinirole (Requip)

Antipsychotics

•  Olanzapine (Zyprexa)

•  Quetiapine (Seroquel)

•  Risperidone (Risperdal)

Narcotic analgesics

•  Codeine

•  Morphine

Erectile dysfunction medications

•  Sildenafil (Viagra, Revatio)

•  Tadalafil (Cialis, Adcirca)

•  Vardenafil (Levitra, Staxyn)

Anti-diabetic drugs known as SGLT2 inhibitors

•  Canagliflozin (Invokana)

•  Dapagliflozin (Farxiga)

•  Empagliflozin (Jardiance)

• • • • •

Emergency medications

If your blood pressure reaches a dangerously high level, it may be necessary to reduce it rapidly to avoid serious damage to your organs, and even death. A dangerously high blood pressure can cause a heart attack, heart failure, stroke, sudden blindness or a rupture in the wall of your aorta.

In a blood pressure emergency, doctors inject a blood pressure lowering drug directly into your bloodstream. The goal is to lower your pressure in progressive, controlled stages. Reducing it too quickly can have serious, even fatal, consequences. The first step is to lower your blood pressure by 25 percent within several minutes to two hours. Once your blood pressure is reduced by 25 percent, the goal is to lower your blood pressure to near 160/100 mm Hg within six hours.

Injectable medications used in hypertensive emergencies include:

•  Vasodilators, such as fenoldopam, nitroglycerin, nitroprusside and hydralazine

•  Alpha and beta blockers, such as phentolamine mesylate, esmolol and labetalol hydrochloride

•  The ACE inhibitor enalaprilat

• • • • •

Working in combination

Two medications may be mixed together into the same tablet or capsule. Examples of these combination drugs are listed below.

ACE inhibitor and diuretic

•  Benazepril and hydrochlorothiazide (Lotensin HCT)

•  Captopril and hydrochlorothiazide

•  Enalapril and hydrochlorothiazide (Vaseretic)

•  Lisinopril and hydrochlorothiazide (Prinzide, Zestoretic)

ARB and diuretic

•  Losartan and hydrochlorothiazide (Hyzaar)

•  Valsartan and hydrochlorothiazide (Diovan HCT)

Beta blocker and diuretic

•  Atenolol and chlorthalidone (Tenoretic)

•  Bisoprolol and hydrochlorothiazide (Ziac)

•  Metoprolol and hydrochlorothiazide (Lopressor HCT, Dutoprol)

•  Nadolol and bendroflumethiazide (Corzide)

•  Propranolol and hydrochlorothiazide (Inderide)

Two diuretics

•  Amiloride and hydrochlorothiazide

•  Spironolactone and hydrochlorothiazide (Aldactazide)

•  Triamterene and hydrochlorothiazide (Dyazide, Maxzide)

Calcium channel blocker and ACE inhibitor

•  Amlodipine and benazepril (Lotrel)

•  Verapamil and trandolapril (Tarka)

•  ARB and calcium channel blocker

•  Valsartan and amlodipine (Exforge)

In some cases, combinations of three medications are used to treat hypertension.

• • • • •

Finding the right medication

Finding the right blood pressure drug or combination of medications is often a trial-and-error process. That’s because doctors must consider each person’s physiological makeup, lifestyle and behaviors, and test the impact of different and ever-changing environments.

Nevertheless, almost everyone who takes blood pressure medications is eventually able to come up with a drug regimen that will help achieve his or her target goal. These drugs will allow the individual to feel good and to be fully active. And they will produce few, if any, side effects.

In addition to how well the drug lowers blood pressure and reduces health risks, your doctor also will consider:

Your tolerance to the drug. If taking a certain medication produces side effects that are unpleasant to live with, such as impotence or headache, then it’s probably not the best drug for you. In fact, the medication’s side effects may seem worse to live with than your high blood pressure — which generally produces no symptoms.

But don’t stop taking a medication without your doctor’s guidance. Some drugs need to be tapered off gradually to prevent a rebound of your high blood pressure.

Your adherence to the prescription. If a medication is complicated to take and you have a busy schedule, you may forget to take it or simply choose to skip one dose. Because it’s vital that you take your blood pressure medication in the proper way and at the right times, the drug your doctor prescribes needs to fit within your lifestyle. In most cases, it’s possible to find a medication or combination drug to take once a day.

One note about once-a-day medications: These drugs may not control blood pressure for a full 24 hours. This can be detected through home blood pressure monitoring. If this is the case for you, you’ll need to take some portion of your medication at bedtime rather than taking all of it in the morning.

Your ability to pay for the medication. Your blood pressure medication won’t do you any good if you can’t take it regularly because you can’t afford it. Let your doctor know if you can’t pay for your medication. Very often with drug combinations, you may have fewer copayments on prescription refills.

• • • • •

How can I reduce my medication costs?

Following a healthy lifestyle program can reduce the number of medications or the dosage required to reach and maintain your blood pressure goals. Often, after medications have helped control your blood pressure for some months, it may be possible to slowly taper down on the dosage — but do this only under your doctor’s guidance. Talk with your doctor about generic equivalent medications. It may also be possible to receive assistance with cost from the manufacturer. For more on cost savings, see Chapter 10.

• • • • •

On the horizon

Your genes can affect how you respond to medication, including drug therapy for high blood pressure. If promising gene research is successful, it may lead to the development of new drugs to treat high blood pressure.

This research may also assist in the decisions regarding your treatment program. By knowing your genetic makeup, your doctor may be able to make a better selection of drugs to suit your needs and determine the type of medication that’s most likely to be effective and beneficial for you.

For example, a team of researchers, including doctors at Mayo Clinic, have identified several genes that may play a role in how people respond to the actions of certain diuretics. They have found that people with one variation of the gene responded better to the medication and had lower blood pressures than did people with another variation of the gene.

An implantable device is under study that’s designed to help people with severe resistant hypertension. The Rheos Baroreflex Hypertension Therapy System includes pulse generators that are implanted on the carotid arteries — the two major arteries that carry blood from the heart to the brain. The pulse generators stimulate baroreceptors located on the arteries (see information on baroreceptors here), which signal your brain to adjust your blood pressure to within a normal range. This device is approved for sale in Europe but not in the U.S.

Renal denervation is another procedure that is being evaluated for treating resistant hypertension. This minimally invasive procedure involves placing a catheter into the arteries entering your kidneys and applying radiofrequency energy to them. Learn more about resistant hypertension in Chapter 11 of this book.

• • • • •

Wrap-up

Key points to remember:

•  Medication may be necessary if lifestyle changes aren’t effective, you have stage 2 high blood pressure or you have another medical condition that could benefit from drug use.

•  While many people can control their blood pressure with just one drug, others need a combination of two or three drugs.

•  Diuretics, ACE inhibitors or calcium channel blockers are often prescribed for uncomplicated high blood pressure because of their proven success. Beta blockers are being used less now than before as a single drug for high blood pressure but more for certain conditions that may accompany the disorder.

•  Finding the right drug or combination of drugs to control your blood pressure is a process that requires time and patience.

• • • • •

Part 2

Understanding high blood pressure

Chapter 6

Blood pressure basics

If you’re like many Americans, your blood pressure may be too high. Unfortunately, many people think that having high blood pressure isn’t a big deal at all. But in fact, it is.

Left untreated, high blood pressure can cause your heart to work too hard and the walls of your arteries to harden, which makes it harder for blood to flow throughout your body. This is why high blood pressure is so dangerous. It’s one of the leading causes of disability and death. It can lead to a stroke, a heart attack, heart failure, kidney failure, vision loss and dementia.

Fortunately, regular checkups, a good treatment plan and personal commitment can help you take control of the condition and reduce your risks of serious health complications.

Take the condition seriously

High blood pressure — also called hypertension — is the most common condition seen in primary care.

According to the Centers for Disease Control and Prevention, more than 67 million — or about 1 in 3 — American adults have been diagnosed with high blood pressure.

In addition, it’s estimated that nearly 1 in 3 American adults also has prehypertension. These individuals have a blood pressure level that falls just below the “high” category. Researchers are beginning to study a possible connection between prehypertension and cardiovascular disease.

High blood pressure isn’t given the attention it deserves. It’s often called a “silent killer” because many people affected by high blood pressure don’t even know they have it. The disease generally doesn’t produce signs and symptoms until it has progressed to an advanced stage. Among adults with hypertension, only about half have their condition under control.

Control means lowering your blood pressure to a level that reduces your risk of cardiovascular disease and other complications. But in controlling blood pressure, several factors may complicate the picture. One is age. People can develop high blood pressure at any age, but the risk increases as they grow older. According to the National Heart, Lung, and Blood Institute’s landmark Framingham Heart Study published in 2002, Americans who have normal blood pressure at age 55 still face a 90 percent lifetime risk of developing high blood pressure.

Another factor is race. About a third of white Americans age 18 and older have high blood pressure. Among African-Americans, the number jumps to 43 percent for men and nearly 46 percent for women. For Mexican-Americans, it’s 28 percent, and almost 25 percent of Asians have high blood pressure.

High blood pressure doesn’t have to be deadly or disabling. This condition is one of the most treatable forms of cardiovascular disease. If you know you have high blood pressure, there are steps you can take to lower it.

By managing your blood pressure, you can lower your risk of heart attack, heart failure, stroke, peripheral artery disease and kidney disease. Earlier and better treatment of high blood pressure helps reduce the risk of death from these diseases.

In Part 1 of this book, you learned about five specific steps you can take to control your blood pressure. Ideally, you learned that you can adopt simple, easy-to-follow strategies that can help you get your blood pressure under control.

Starting with this chapter, Part 2 describes the basics of high blood pressure, including risk factors, screening and diagnosis. You’ll also learn about treatment options, as well as how to monitor your blood pressure at home, avoid drug interactions and recognize an emergency. Finally, Part 2 offers high blood pressure guidance for specific groups, such as women and children and those who have other health conditions, such as heart disease or diabetes.

Understanding blood pressure

A good first step toward managing high blood pressure is understanding how it develops. To understand how high blood pressure develops and why it becomes so harmful to your health, it’s useful to know some of the basics about your cardiovascular system and the organs that help regulate it.

Cardiovascular system

Each beat of your heart releases a surge of nutrient- and oxygen-rich blood from your heart’s main pumping chamber (left ventricle) into an intricate network of blood vessels (see illustration below). Your arteries are the blood vessels that carry blood from your heart to the rest of your body. The largest artery, called the aorta, is connected to the left ventricle and serves as the main channel from your heart. The aorta branches into smaller arteries, which branch into even smaller arteries, called arterioles.

Cardiovascular system Each time your heart beats, blood is released from the left side of your heart (left ventricle) into the large blood vessel (aorta) that transports blood to your arteries (in red). Blood returns to your heart through your veins (in blue). Before being recirculated, the blood is sent to your lungs through the pulmonary artery to release waste products and load up on fresh oxygen.

Microscopic vessels called capillaries carry blood from the arterioles into your body’s tissues and organs. The capillaries exchange nutrients and fresh oxygen for carbon dioxide and other waste products produced by your cells. This oxygen-depleted blood returns to your heart through a system of blood vessels called veins.

When the blood in your veins reaches your heart, it’s routed to your lungs, where it releases the carbon dioxide and picks up a new supply of oxygen. The freshly oxygenated blood is sent back to your heart, ready to resume the journey through your cardiovascular system. Other waste products are removed as your blood passes through your kidneys and liver.

A certain amount of pressure is required to maintain this circulation and keep all 11 pints of blood moving through your body. Your blood pressure is the amount of force exerted on your artery walls to keep your blood flowing.

Blood pressure is often compared to the pressure inside a garden hose. Without an exerting force, the water can’t get from one end of the hose to the other.

Regulators of blood pressure

Working together, several organs and body chemicals help control your blood pressure and keep it from rising too high or falling too low. They include your heart, arteries and kidneys, and other factors, such as your central nervous system and various hormones and enzymes. Here’s how they work.

Your heart

The flow of blood in your body starts with your heart. When your heart releases blood from the left ventricle into your main artery (called the aorta), a certain amount of force is created by the pumping action of your heart muscle. The harder your heart muscle has to work to pump blood, the greater the force exerted on your arteries and the higher your blood pressure will rise.

Pumping action of the heart During systole (left), your heart muscle squeezes blood out of your heart’s pumping chambers (ventricles). Blood on the right side of your heart goes to your lungs, and blood on the left side is pumped into the large blood vessel (aorta) that feeds your arteries. During diastole (right), your heart muscle relaxes and expands to allow blood to flow into the pumping chambers from your heart’s holding chambers (atria).

Your arteries

To accommodate the surge of blood coming from your heart, your arteries are lined with smooth muscles that allow the vessels to expand and contract as blood courses through them. The more elastic your arteries are, the less resistant they are to the flow of blood, and less force needs to be exerted by the heart on artery walls. When arteries lose their elasticity, resistance to blood flow increases and the heart has to pump harder. This increased force causes an increase in blood pressure.

Your kidneys

Your kidneys remove waste products from your blood and regulate levels of minerals such as sodium. The more sodium in your bloodstream, the more water you retain. This extra fluid can increase blood pressure. In addition, too much sodium can cause your blood vessels to narrow, making the heart work harder and increasing pressure.

Other factors

Your central nervous system, along with body chemicals, also influences your blood pressure. Following are several examples.

Baroreceptors. Within the walls of your heart and certain blood vessels are special cells called baroreceptors. They’re located near your heart and neck arteries. Similar to a thermostat that regulates the temperature of your house, baroreceptors monitor your blood pressure. If they sense a pressure change, they send signals through your nerves to your brain, telling it to adjust your blood pressure to a normal range. This may involve slowing down or speeding up your heart rate or widening or narrowing your arteries. However, the “normal” range used by the baroreceptors is variable and can be reset in response to short-term changes in your blood pressure.

Epinephrine. Your brain acts on messages from baroreceptors by signaling the release of hormones and enzymes affecting the function of your heart, blood vessels and kidneys. One of the most important hormones to affect blood pressure is epinephrine (ep-ih-NEF-rin), also known as adrenaline.

Epinephrine causes your arteries to narrow and your heart to pump harder and more rapidly. Both of these actions increase the pressure exerted on your arteries. People often refer to the effect of epinephrine release as feeling pumped up or being on an adrenaline high. Epinephrine is released into your body during periods of high stress or tension, such as when you’re scared, in the midst of an argument or in a hurry.

The renin-angiotensin-aldosterone system. Your kidneys release the enzyme renin (REE-nin) into your bloodstream when blood pressure decreases. Renin works on the angiotensinogen protein, which triggers a complex process forming angiotensin (an-jee-o-TEN-sin) II. This substance constricts your blood vessels, increasing blood pressure (the process is illustrated blow).

Angiotensin II also stimulates release of a hormone called aldosterone (al-DOS-tur-own) from the adrenal glands located on top of your kidneys. Increased levels of aldosterone cause the kidneys to retain more sodium and water, also increasing pressure.

The effects of these compounds help the body make short-term adjustments to blood pressure. In some people, this system may be more active long term than necessary to maintain body systems. These changes — which make the heart work harder — help lead to a gradual thickening of the heart muscle and blood vessel walls, leading to impaired function.

Renin-angiotensin-aldosterone system

The endothelium. The walls of your arteries and veins are lined with an extremely thin layer of cells called the endothelium. This tissue layer plays a crucial role in regulating blood pressure by secreting chemicals that cause blood vessels to relax or contract. For example, the endothelium contains nitric oxide that, when released, signals the smooth muscles in blood vessel walls to relax and expand, increasing blood flow and lowering pressure.

The endothelium also contains a protein called endothelin (en-doe-THEE-lin), which acts as a potent vasoconstrictor. The narrowed vessel walls reduce blood flow and raise pressure.

An imbalance between these substances can lead to narrow blood vessels and contribute to high blood pressure.

What the numbers mean

An instrument called a sphygmomanometer (sfig-moe-muh-NOM-uh-tur) measures the blood pressure in your arteries. The device includes an inflatable cuff that’s wrapped around your upper arm, air pump and digital meter. The cuff is inflated to squeeze the blood vessels in your arm. Today, most devices are automated. They determine your blood pressure by sensing the movement of the arterial wall beneath the cuff as the pressure is deflated. As you learned earlier in this book, blood pressure is expressed in terms of millimeters of mercury (mm Hg). The measurement refers to how high the pressure in your arteries is able to raise a column of mercury in the pressure gauge on a sphygmomanometer.

Your doctor will likely take two to three blood pressure readings each at three or more separate appointments before diagnosing you with high blood pressure. Each time, you will be in a seated position. Your doctor may monitor your blood pressure in both of your arms to determine if there’s a difference.

Two numbers are included in a blood pressure reading, and both are important. The first of the pair is your systolic (sis-TOL-ik) pressure. This is the amount of pressure in your arteries when your heart contracts — called systole (SIS-toe-lee) — and pumps blood into the aorta.

The second number is your diastolic (die-uh-STOL-ik) pressure. This is the amount of pressure that remains in your arteries between beats as your heart relaxes — called diastole (die-AS-toe-lee). Your heart muscle must relax fully before it contracts again. During this time, your blood pressure decreases until the next contraction. The two numbers in a blood pressure reading are often written to look like a fraction. Systolic pressure is placed above or to the left, and diastolic pressure is placed below or to the right. When stated verbally, the word over is generally used to separate the two numbers. For example, if your systolic pressure is 115 mm Hg and your diastolic pressure is 82 mm Hg, your blood pressure is written as 115/82, and spoken as “115 over 82.”

Blood pressure increases as a child grows and is related to a child’s sex, height and weight. A baby’s blood pressure reading is often much lower than an adult’s reading. An ideal or normal blood pressure for an adult of any age is below 120/80 mm Hg. This is a reading you should always aim for through lifestyle changes, if possible.

While it may seem natural that blood pressure medication be used to help you reach a normal blood pressure level, clinical trials haven’t confirmed that taking medication reduces the complications of hypertension when it’s used to lower blood pressure to a level lower than 140/90 mm Hg. For adults over age 60, the blood pressure goal in the doctor’s office is under 150 mm Hg for systolic pressure. But some recent advisories maintain the cut point at age 80. Individual blood pressure goals depend on age, other medical conditions and personal concerns. Your doctor will help you decide on the plan that’s best for you.

Blood pressures between 120/80 and 139/89 mm Hg are classified as prehypertension. This means that your blood pressure is higher than normal but isn’t in the high blood pressure range. It also means you have a higher risk of heart disease, kidney disease and stroke. If you have prehypertension, your blood pressure should be regularly monitored as you try to control it.

High blood pressure is generally diagnosed in individuals with blood pressure that’s 140/90 mm Hg and higher. As the table below indicates, blood pressure at 160/100 mm Hg represents a dividing line between stage 1 and stage 2 categories of hypertension.

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Classification of blood pressure

| Systolic (mm Hg) (top number) | Diastolic (mm Hg) (bottom number)
Normal* Prehypertension | Less than 120 120 to 139 | Less than 80 or 80 to 89
Hypertension Stage 1† Stage 2† | 140 to 159 160 or higher | or 90 to 99 or 100 or higher

Normal means the preferred range in terms of cardiovascular risk.

Based on the average of two or more readings taken in a seated position, and taken at each of two or more visits. Systolic hypertension is a major risk factor for cardiovascular disease, even without elevated diastolic pressure, especially in older people.

Based on Chobanian AV, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206.

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Daily ups and downs

A single blood pressure reading shows only what your pressure is at the moment when it’s measured. Your blood pressure changes throughout the day. It increases during activity when your heart works harder; it decreases with rest or sleep when there’s less demand on your heart. Your blood pressure also fluctuates with changes in body position, such as when you move from a lying or sitting position to a standing position.

Food, alcohol, pain, stress and strong emotions also increase your blood pressure. While you sleep, dreaming can raise your blood pressure. These ups and downs are perfectly normal changes in a typical day.

Your blood pressure even changes with the time of day. Pressure in your arteries follows natural fluctuations during a 24-hour period. It’s usually at its highest in the morning after you awaken and become active. It generally stays at approximately the same level throughout the day. Then late in the evening, it begins to decrease. Your blood pressure usually reaches its lowest level in the early morning hours while you’re sleeping. This cycle is known as a circadian (sur-KAY-dee-un) rhythm. Your body has several circadian rhythms, and each influences a different body function — for example, sleep patterns or body temperature.

If you work during an evening or are an overnight shift worker, the circadian rhythm of your blood pressure will differ from that of a day worker because your circadian rhythm is closely aligned to your schedule of work and rest. That’s because many circadian rhythms change with altered patterns of activity.

Getting an accurate reading

To get a good indication of your average blood pressure, it’s best to measure it during the day after you’ve been moderately active for a few hours. If you exercise in the morning, measure blood pressure beforehand. After strenuous physical activity, your blood pressure fluctuates before readjusting to your average pressure.

It’s also important to avoid eating, smoking, or drinking caffeine or alcohol 30 minutes before measuring your blood pressure. Caffeine and tobacco can temporarily increase pressure. Alcohol may temporarily decrease it, but the opposite effect occurs in some people. Some over-the-counter medications, including decongestants, anti-inflammatory drugs and certain diet aids, can increase your blood pressure for hours or even days after you take them.

Before taking a reading, sit down and wait five minutes so that your blood pressure has time to adjust to your change in position and activity. Measuring your blood pressure under controlled conditions offers a more accurate view of how you’re doing over time.

If you have high blood pressure, your treatment plan may include measuring your blood pressure at home. See Chapter 10 for detailed instructions.

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When your blood pressure drops too low

Generally, the lower your blood pressure reading, the better. But in some cases, your blood pressure can drop too low, just as it can rise too high. Low blood pressure, called hypotension, can be life-threatening if it falls to dangerously low levels. However, this is rare.

Chronic low blood pressure — blood pressure that’s below normal but not hazardously so — is fairly common. It can result from factors such as high blood pressure medications, complications of diabetes and the second trimester of pregnancy.

A potentially dangerous side effect of chronic low blood pressure is postural hypotension, a condition in which you feel dizzy or faint when you stand up too quickly. In the action of standing up, the force of gravity will cause blood to pool in your legs, producing a sudden drop in blood pressure.

Normally, your body counteracts a sudden pressure decrease by simultaneously narrowing your blood vessels and increasing the blood flow from your heart. When your blood pressure is chronically low, however, it takes longer for your body to respond to the change. Postural hypotension is more common with advanced age as nerve signals and regulatory system responses slow down.

You can often avoid this problem by standing up slowly and holding on to something while you stand. Wait a few seconds after standing and before you try to walk so that your body can adjust to the pressure change.

Some older adults, particularly those on medication for high blood pressure, may be at risk of fainting or falling after eating a meal. The cause can be a drop in blood pressure. If you’ve experienced falling or fainting after a meal, take steps to prevent this by eating slowly and avoiding large meals. After you eat, rest for an hour.

See your doctor if you experience persistent dizziness or fainting. You may have another health condition that’s causing the symptoms or that’s making them worse than usual.

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When pressure is persistently high

When the complex system regulating your blood pressure doesn’t work as it’s supposed to, too much pressure may build up within your arteries. When increased pressure in your arteries continues on a persistent basis, your doctor may diagnose you as having high blood pressure. Hypertension is the medical term for this condition. Hypertension doesn’t mean nervous tension, as many people believe. Even if you’re generally a calm, relaxed person, you can still have high blood pressure.

In the past, doctors assumed that diastolic blood pressure was the best indicator of the health risks associated with high blood pressure. But today, that’s no longer strictly believed to be the case. While diastolic pressure remains an important indicator of risk, researchers are now showing that a high systolic reading also is a serious warning sign of potential health risks, regardless of age.

High blood pressure generally develops slowly. Most often, people start out with normal blood pressure. Over time, it progresses to prehypertension and, eventually, it progresses to to stage 1 hypertension.

Left untreated, high blood pressure can damage many of your body’s organs and tissues. The higher the blood pressure and the longer it goes untreated, the greater the risk that it will cause damage. When high blood pressure is combined with other factors or conditions, such as diabetes, obesity or tobacco use, your risk of injury from high blood pressure increases.

Incidentally, it was conventional wisdom that an ideal systolic blood pressure was 100 plus your age. But that’s not true. Following this adage can lead you to believe that blood pressure at stage 1 or stage 2 levels is normal.

Signs and symptoms

High blood pressure is called a silent killer because it often doesn’t produce any signs or symptoms. Some people believe headaches, dizziness or nosebleeds are indications of high blood pressure. Although a few people may experience some nosebleeds or dizziness when their blood pressure rises, research has found no direct link between headaches and hypertension.

You can have high blood pressure for years without ever knowing it. The condition is most often discovered during routine physical examinations. Symptoms such as shortness of breath typically don’t occur until high blood pressure has advanced to an extremely high — possibly life-threatening — stage. And even with very high blood pressure, some people experience no signs or symptoms.

Complications

It’s important to control high blood pressure because if it’s ignored over time, excessive force on your artery walls can seriously damage vital organs and tissues. The parts of your body typically affected by high blood pressure include your arteries, heart, brain, kidneys and eyes (see illustration below). Sometimes, complications of high blood pressure may require emergency treatment (see “Recognizing an emergency”).

Complications of uncontrolled high blood pressure Left untreated, high blood pressure can damage tissues and organs throughout your body. Sites in your body most affected by high blood pressure include your arteries, heart, brain, kidneys and eyes.

Damage to your cardiovascular system

Persistent high blood pressure creates a heavier workload for your heart and the network of arteries that carry blood throughout your body. Read on to learn about the complications it can cause.

Arteriosclerosis

Healthy arteries are flexible, strong and elastic. Their inside lining is smooth, so blood can flow through them unrestricted.

Over a period of years, too much pressure in your arteries can make the walls thick, stiff and less elastic, and can make it hard for blood to flow. The term arteriosclerosis (ahr-teer-e-o-skluh-ROE-sis) comes from the Greek word sklerosis, meaning “hardening.”

Atherosclerosis

High blood pressure speeds the buildup of fatty deposits in your arteries. Ather in the term atherosclerosis (ath-ur-o-skluh-ROE-sis) comes from the Greek word for “porridge,” because the fatty deposits have a consistency of porridge.

When the inner wall of an artery is damaged, blood cells and fat cells often clump together at the injury site. They invade and scar deeper layers of the artery walls. Large accumulations of these fatty deposits are called plaques. Over time, the plaques harden. The greatest danger of having plaques on your blood vessel walls is that organs and tissues served by these narrowed arteries don’t get enough blood. In turn, your heart increases pressure to maintain adequate blood flow. Increased pressure leads to further blood vessel damage.

Atherosclerosis The buildup of fatty deposits in your arteries leads to the formation of plaques, which can obstruct or block blood flow.

Plaques also can cause other problems. As blood flows past the blockage, plaques may cause blood clots to form. In addition, inflammation often occurs in areas around plaques. Sometimes, plaques break apart, and the pieces combine with fresh blood clots to block the artery. Debris may also travel in your bloodstream and lodge in a smaller artery.

Arteriosclerosis and atherosclerosis can occur anywhere in your body but most often affect arteries in your heart, legs, neck, brain, kidneys and abdominal aorta.

Aneurysm

When a blood vessel is damaged, part of the wall may bulge outward. This bulge is called an aneurysm. An aneurysm commonly occurs in a brain artery or abdominal aorta. If the aneurysm leaks or bursts, it can cause life-threatening internal bleeding. In their early stages, aneurysms generally don’t produce any signs or symptoms.

But in more-advanced stages, an aneurysm in a brain artery can lead to a sudden, extremely severe headache that’s unlike any headache you’ve ever experienced before. An advanced abdominal aneurysm may cause constant pain in your abdomen or lower back. Occasionally, a blood clot lining the aneurysm wall breaks off and obstructs an artery downstream.

Coronary artery disease

The accumulation of plaques in the major arteries serving your heart is called coronary artery disease. It’s common among people who have high blood pressure.

A temporary drop in blood supply to the heart causes chest pain, also known as angina. If the heart muscle is too deprived of blood, a heart attack may follow. The complications of coronary artery disease are the major causes of death in people with uncontrolled high blood pressure.

Reduced blood flow in the coronary arteries calls for an immediate trip to the emergency room and treatment with medication or a procedure for opening blood vessels (angioplasty).

Left ventricular hypertrophy

When your heart pumps blood into your aorta, it has to push the blood out against the resistance to flow that has built up in the arteries. Higher resistance causes higher pressure. The higher the pressure, the harder the heart has to work and the larger your heart gets.

Eventually, the muscular wall of the heart’s main pumping chamber starts to thicken (hypertrophy) from the excessive workload. The enlarged left ventricle needs more blood. Because high blood pressure also causes the blood vessels feeding your heart to narrow, there’s often not enough blood going to your heart. Controlling high blood pressure can prevent this.

Heart failure

Heart failure occurs when your heart doesn’t pump effectively and can’t circulate enough blood to meet your body’s needs. As a result, fluid backs up and accumulates in your lungs, legs and other tissues, a condition called edema (uh-DEE-muh).

Fluid in your lungs leads to shortness of breath; fluid buildup in your legs causes swelling. By controlling high blood pressure, you can help reduce your risk of heart failure.

Your brain

High blood pressure increases your odds of having a stroke, also called a brain attack. A stroke is a type of brain injury caused by blocked or ruptured blood vessels that disrupt your brain’s blood supply. Deprived of nutrients, brain cells are damaged or die. Blood pressure is a high risk factor for stroke.

According to the National Heart, Lung, and Blood Institute, 77 percent of people who’ve had a stroke have blood pressure over 140/90 mm Hg. Research also suggests that prehypertension may be a risk factor for stroke.

There are two basic types of stroke, characterized by the disturbance in the blood supply and by its location.

Ischemic strokes

Ischemic (is-KEE-mik) strokes are the most common type, accounting for nearly 90 percent of all strokes. They usually affect the part of your brain called the cerebrum, which controls movement, language and the senses.

An ischemic stroke may result from a blood clot that formed due to blockage from plaques. This type of stroke occurs if an artery that supplies oxygen-rich blood to the brain becomes blocked.

Ischemic stroke When blood flow in an artery leading to the brain is obstructed, nerve cells are deprived of oxygen and nutrients. Brain tissue quickly may be damaged or die.

An ischemic stroke may also occur if a small piece of clotted blood breaks loose and is swept through larger arteries into smaller arteries in your brain. The moving (embolic) clot may become lodged and block blood flow, resulting in a stroke. Clot-busting drugs given within the first few hours after an ischemic stroke begins can greatly reduce disability from the stroke. Sometimes, blood supply to the brain is briefly disrupted — for less than 24 hours. This is known as a transient ischemic attack (TIA), sometimes called a ministroke. Its symptoms are similar to those of a stroke, but a TIA usually lasts only a few minutes and causes no permanent damage.

A TIA may be a warning — about 1 in 3 people who has a TIA will eventually have a stroke.

Hemorrhagic strokes

A hemorrhagic (hem-uh-RAJ-ik) stroke occurs when a blood vessel in the brain leaks or ruptures. This is usually caused by a development such as an aneurysm. Blood from the hemorrhage damages the surrounding brain tissue. In addition, tissue over a broader area is damaged because it’s deprived of blood. High blood pressure can increase your risk of having a hemorrhagic stroke in the smaller arteries.

Improved detection and treatment of high blood pressure have helped lead to a dramatic reduction in the number of strokes. When treatment lowers your blood pressure, your risk of stroke decreases remarkably.

Even if you’ve had a stroke or TIA, lowering your blood pressure can help prevent these problems from recurring.

Dementia

Studies suggest that damaged blood vessels in the brain caused by high blood pressure can lead to dementia, a progressive mental disorder that often includes memory loss, disorientation and personality change.

As you age, your risk of Alzheimer’s disease, vascular dementia and other types of dementia greatly increases. After a diagnosis of high blood pressure, dementia can appear anywhere from a few years to as many as several decades later. Recent evidence suggests that controlling high blood pressure with the help of medication may reduce the risk of dementia.

Your kidneys

When blood circulates through your kidneys, the organs filter out waste products and regulate the balance of minerals, acids and fluids in blood. Each kidney has over 1 million nephrons, tiny filtering systems consisting of small blood vessels and attached tubes. The kidneys help control blood pressure by regulating the levels of sodium and water. They also produce chemicals that control blood vessel size. High blood pressure can interfere with these functions. Atherosclerosis due to high blood pressure can reduce blood flow to the kidneys, preventing them from eliminating enough waste from your bloodstream. The waste builds up and your kidneys may stop functioning, leading to kidney failure.

How your kidneys work Waste filtered from your blood by your kidneys is stored in your bladder as urine. Each kidney has more than a million nephrons that filter waste from the blood.

The single most important thing you can do to prevent worsening of your kidney function over time is to control your blood pressure, lowering it to less than 140/90 mm Hg.

If your kidneys stop functioning, you’ll need to undergo kidney dialysis, a process by which the waste products in blood are filtered out by machine, or you may need a kidney transplant.

Your eyes

Occasionally, a simple eye exam leads to a diagnosis of hypertension because the small blood vessels of the retina often reflect the earliest and clearest indicators of high blood pressure.

In early stages, the tiny retinal arteries narrow. Eventually, the arterial walls thicken, compressing the adjacent veins and interfering with blood flow in the veins. Retinal blood vessels may leak blood and fluid into the retinal tissue (see image “Damage to the retina”).

In severe cases of high blood pressure, fluid may also leak into the optic nerve, which causes swelling in the nerve (papilledema). Severe hemorrhaging in the retina and optic nerve leads to vision loss. Control of high blood pressure can almost always prevent these retinal complications.

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Wrap-up

Key points to remember:

•  Blood pressure is necessary for the continuous flow of blood that pulsates through your heart and blood vessels.

•  High blood pressure means you have high readings on a persistent basis. That means systolic blood pressure is consistently 140 mm Hg or higher, diastolic pressure is consistently 90 mm Hg or higher, or both.

•  High blood pressure typically doesn’t produce any signs or symptoms.

•  Left untreated, high blood pressure can lead to stroke, heart attack, heart and kidney failure, blindness, and dementia.

•  By controlling high blood pressure, you significantly reduce your risk of disability or death related to the disease.

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Chapter 7

Who’s at risk?

With any disease, you naturally want to know its cause. Why does a condition occur in some people but not in others? Why does it develop in most adults after a certain age, but for some people, the symptoms appear 10 or 20 years earlier? Unfortunately, the reasons why high blood pressure occurs in most people are unknown.

However, it’s also clear that certain factors can put you at greater risk of high blood pressure. By knowing what these factors are, you can take steps to minimize the risk and delay or even prevent it from occurring.

To understand your risk, it’s important to understand the two forms of high blood pressure — essential and secondary. Essential high blood pressure is the most common form; it’s also known as primary high blood pressure. Essential high blood pressure is estimated to occur in 90 to 95 percent of people with high blood pressure. Essential high blood pressure has no obvious cause, but certain genetic traits and lifestyle habits — such as diet, lack of physical activity and being overweight — play important roles in its development.

In 5 to 10 percent of all blood pressure cases, a cause can be identified. This is called secondary high blood pressure, which means that the condition is due to — or secondary to — another condition. Unlike the essential, or primary, form of blood pressure, secondary high blood pressure may be correctable. When the underlying condition is treated, blood pressure may decrease or even return to normal, reducing your risk of complications.

Essential high blood pressure

Among a majority of Americans with high blood pressure, it’s difficult to pinpoint the exact cause of the pressure increase. This condition is essential high blood pressure.

Made up of DNA and inherited from your parents, genes provide instructions for your body — and may play an important role in the development of high blood pressure.

But researchers are discovering that high blood pressure is a complex illness that typically doesn’t follow the classic rules of genetic inheritance. Instead of stemming from a single defective gene, the condition appears to be a multifaceted disorder that, except in rare cases, involves interaction among several genes.

Essential high blood pressure results from a combination of various physiological factors related to:

•  Motion (widening and narrowing) of your blood vessels

•  Increased fluid in your blood

•  Functioning of your blood flow sensors (baroreceptors)

•  Production of chemicals that influence blood vessel function

•  Secretion of hormones that affect your cardiovascular system

•  Volume of blood pumped by your heart muscle

•  Nerve control of your cardiovascular system

Risk factors such as weight, sodium use and physical activity also appear to interact with genetic factors.

Generally, the more of these risk factors you have, the greater the odds that you’ll have high blood pressure in your lifetime.

Risk factors you can’t change

There are four major risk factors for high blood pressure that you can’t change or control.

Race

About a third of white Americans age 18 and older have high blood pressure. Among African-Americans, the number jumps to 43 percent for men and nearly 46 percent for women. High blood pressure affects 28 percent of Mexican-Americans and almost 25 percent of Asians.

Age

Your risk of high blood pressure increases with age. As noted in Chapter 6, Americans who have normal blood pressure at age 55 still have a 90 percent lifetime risk of developing high blood pressure. It’s fairly common for changes that affect your heart, blood vessels and hormones to occur naturally with age. These changes, coupled with other risk factors, may lead to high blood pressure.

Family history

High blood pressure tends to run in families. If your parents or close relatives have had high blood pressure, you are more likely to develop it, too.

An important note to keep in mind: Just because high blood pressure runs in your family doesn’t mean you’re going to develop it. Even in families in which high blood pressure is prevalent, some members never develop it.

Sex

Through about age 45, high blood pressure is more common in men. But after age 65, women are more likely than men to develop the condition.

Risk factors you can change

There also are many risk factors for high blood pressure that you can change and control.

Obesity

Being overweight increases your risk of high blood pressure for several reasons. The greater your body mass, the more blood you need to nourish your cells. More blood circulating through your arteries requires your heart to pump with greater force. Obesity is also associated with increased activity in the sympathetic nervous system and higher levels of aldosterone, both of which can raise blood pressure.

Excess weight can increase your heart rate. It also increases the level of insulin in your blood, causing your body to retain more sodium and water.

In addition, some people who are overweight follow a diet that’s too high in saturated fat and trans fat. These fats promote atherosclerosis, which causes your arteries to narrow. See Chapter 1 in this book for more information on how much fat to include in your diet.

Inactivity

Lack of physical activity increases your risk of high blood pressure by increasing your risk of becoming overweight. People who are inactive also tend to have higher heart rates, and their heart has to work harder with each contraction. The harder and more often your heart has to pump, the greater the force being exerted on your arteries. Some research shows that a half-hour of TV viewing may shorten an adult’s life as much as smoking a single cigarette.

• • • • •

The fattening of America

It’s now estimated that 78 million adults are obese. According to data from the National Health and Nutrition Examination Survey (NHANES), more than a third of American adults were obese between 2011 and 2012. Overweight is defined as having a body mass index (BMI) between 25 and 29.9. Obesity is defined as having a BMI of 30 or greater.

According to a report published in the Journal of the American Medical Association, comparing the years between 1999 and 2010, the rate of obesity in adult men and adult women was just over 35 percent. The report indicates that these rates were largely unchanged when compared with data taken between 2003 and 2008.

But adults aren’t the only ones putting on excess weight. In data from a 2013 worldwide analysis, nearly 1 in 4 children in developed countries — boys and girls alike — was overweight or obese. For children and adolescents in developing countries, the rate is also on the rise.

Problems with weight are high in adults ages 40-59. The latest data shows that in 2014, obesity was highest in adults in this age group. Adults age 60 and older also had a high rate of obesity at just over 35 percent.

Excess weight is second only to smoking as a leading cause of preventable death in the United States. In 2000, about 400,000 U.S. deaths a year were associated with overweight or obesity. In comparison, it’s estimated that 480,000 deaths a year were associated with cigarette smoking.

• • • • •

Metabolic syndrome

This is a cluster of modifiable conditions that occur together — including high blood pressure, elevated blood sugar, excess body weight and abnormal cholesterol levels. These conditions make you more likely to develop diabetes, heart disease and stroke.

If you have all — or some — of the syndrome’s components, take steps to reduce your risks of life-threatening illnesses. See this section for more information on metabolic syndrome.

Tobacco use

The chemicals in tobacco can damage the lining of your artery walls, making them more prone to the buildup of plaques. Nicotine also makes your heart work harder by temporarily narrowing your blood vessels, which increases your heart rate and blood pressure. These effects occur because tobacco use triggers hormone production, including increased levels of epinephrine (adrenaline).

In addition, carbon monoxide in cigarette smoke replaces oxygen in your blood. This can increase blood pressure by forcing your heart to work harder supplying adequate oxygen to your body’s cells. For details on stopping smoking, see Chapter 4 in this book.

Sodium sensitivity

Your body’s cells need a certain amount of the essential mineral sodium in order to stay healthy. A common source of sodium is table salt (sodium chloride), which is composed of about 40 percent sodium and 60 percent chloride.

Some people are more sensitive to sodium in their bloodstreams than are others. If you’re sodium sensitive, you retain sodium more easily, leading to greater fluid retention and higher blood pressure.

Unfortunately, sodium sensitivity is difficult to assess. Remember that most dietary salt comes as an added ingredient in foods. On average, the salt in processed foods makes up 75 percent of your sodium intake. Since there’s no health reason to consume excess salt, almost everyone can benefit from reducing sodium intake. For more on sodium intake, see Chapter 1 in this book.

Low potassium

Potassium is a mineral that helps balance the amount of sodium in your body’s cells. It gets rid of excess sodium by way of your kidneys, which filter out the sodium that will be excreted in your urine. If you don’t get enough potassium in your diet or your body can’t retain a proper amount, too much sodium can build up, increasing your risk of high blood pressure. Learn more about potassium in Chapter 1.

Low potassium levels also stimulate the release of aldosterone, a hormone that increases retention of sodium and water, raising the risk of hypertension.

Alcohol consumption

Consuming three or more drinks of alcohol a day approximately doubles your risk of high blood pressure. How or why alcohol increases blood pressure isn’t fully understood. But over time, heavy drinking can damage your heart and other organs.

The safest course is to drink moderately or not at all. For most men, moderate drinking means no more than two alcoholic drinks a day. For women, the limit is one drink daily.

Note that these are general recommendations for alcohol consumption, and individual guidelines may vary. For more on alcohol and high blood pressure, see Chapter 4 in this book.

Stress

If stress episodes occur often enough, they can damage your blood vessels, heart and kidneys.

Although blood pressure may increase temporarily when you’re under stress, stress has not been proven to cause chronic high blood pressure. However, recent research shows that people who have an anxiety disorder may be four times as likely to develop high blood pressure. Stress can also promote unhealthy habits that are known to increase the risk of hypertension. For example, some people turn to smoking, drinking alcohol or overeating to relieve stress. For more on stress and high blood pressure, see Chapter 10 in this book.

Other conditions

A chronic condition may put you at increased risk of developing high blood pressure or making it more difficult to control. The following describes several of these conditions.

In addition, women, children, older adults and people in certain ethnic groups may have specific concerns in controlling blood pressure. For details, see Chapter 11.

High cholesterol

High levels of cholesterol, a fat-like substance in your blood, promote the accumulation of plaques in your arteries (atherosclerosis), causing them to narrow and be too stiff to widen. These changes increase your blood pressure.

Diabetes

Too much glucose in your blood can damage many of your organs and tissues, leading to conditions that affect blood pressure, including atherosclerosis, kidney disease and coronary artery disease. Learn more more about diabetes here.

Sleep apnea

Obstructive sleep apnea is a severe form of snoring that interrupts your breathing during sleep. Interrupted sleep can also be due to a disturbance in brain function. Studies show a link between the interrupted breathing that happens during sleep apnea and the onset of high blood pressure. See this section for more on sleep apnea.

If you consistently have trouble getting a restful night’s sleep, awaken at night choking or gasping, and have difficulty staying awake during the day, talk to your doctor. These can all be signs and symptoms of sleep apnea. Being overweight or obese also contributes to your risk.

Treatment may include losing weight, sleeping on your side rather than on your back, and using a mask device that gently blows air through your airway with just enough pressure to keep the passage open.

Chronic kidney failure

Kidney failure is both a cause and an effect of chronic high blood pressure. Added force on the tiny blood vessels within your kidneys can cause scarring and a slow, progressive loss of function. Your kidneys will no longer be able to filter waste, resulting in a buildup of waste and fluid in your blood. Chronic kidney failure can progress to a point where either dialysis or a kidney transplant is the only treatment option available.

Heart failure

If your heart muscle is damaged or weakened, possibly due to a heart attack, it has to work harder to pump blood. Having uncontrolled high blood pressure puts a much greater demand on your weakened heart. Over time, the heart muscle may become thicker to make up for the extra work it must perform.

Eventually, your heart muscle may become too stiff or weak to effectively pump blood. This is known as heart failure. Heart failure means that your heart can’t pump enough blood to meet your body’s needs.

Other indicators of increased cardiovascular risk include blood circulation changes in your retina, thickening of the wall of the main pumping chamber of your heart (left ventricle), changes in the amount of waste product excreted by your kidneys (creatinine) and changes in the amount of protein in your urine. Treating high blood pressure often can slow or reverse these risk factors.

Heart failure The heart may try to compensate for reduced pumping ability by getting larger.

A multiplying effect

Risk factors usually don’t exist independently of each other and often interact. For example, if you’re overweight and inactive, your odds of having high blood pressure are much higher than if you have just one of these risk factors.

By the same token, working to reduce one risk factor may help you reduce your other risk factors. Your total reduction in risk may be more than the sum of that one factor alone.

An important note to keep in mind: Although having risk factors affects your chances of developing high blood pressure, it’s no guarantee of that happening. At the same time, it’s possible to develop high blood pressure even if you have no risk factors.

Bottom line: Reducing or controlling modifiable risks factors lowers your chance of getting the disease.

Secondary high blood pressure

The previous section described essential high blood pressure as a condition likely caused by multiple factors, although it can be hard to identify each factor and the role it plays. Secondary high blood pressure, on the other hand, is a direct result of another disorder.

Secondary high blood pressure usually has a more rapid onset and pushes blood pressure to higher levels than essential blood pressure does. When the underlying disease or condition is corrected, blood pressure typically decreases. In some people, blood pressure levels may return to normal. Secondary high blood pressure tends to appear suddenly and cause higher blood pressure than does primary hypertension.

Major causes

Secondary hypertension can be caused by a variety of conditions. Here are some of the primary causes.

Kidney problems

Kidneys are important regulators of blood pressure, and various kidney problems may account for a large number of secondary high blood pressure cases.

Kidney diseases such as polycystic kidney disease, diabetic kidney disease, glomerulonephritis, scleroderma and hypertension cause damage that can lead to kidney failure.

How do kidney diseases lead to hypertension? The scarring of kidney tissue and narrowing of kidney blood vessels cause the kidneys to no longer get rid of sodium, water and waste products as they normally do. This leads to a buildup of salt and water in the body, which raises blood pressure. Damaged kidneys may also release chemicals within the body that raise blood pressure.

If kidney disease is suspected, your doctor will perform a physical examination. Tests that detect elevated levels of waste products in your blood and excess protein in your urine may indicate kidney malfunction. Imaging tests such as ultrasound, computerized tomography (CT) or magnetic resonance imaging (MRI) can reveal cysts or scars caused by kidney disease.

Surgery is rarely performed for cysts unless they are infected or causing significant pain. In severe cases of polycystic disease in which kidney function has declined severely, kidney transplantation may be required.

Kidney problems Among common causes of secondary hypertension are kidney disease, narrowing of the renal artery and a tumor in the adrenal gland (pheochromocytoma).

Obstruction of the renal artery

The renal artery is the main vessel supplying blood to each kidney. Obstruction is often due to a narrowing of the artery caused by atherosclerosis. When the obstruction is severe, the kidney may shrink and scar irreversibly.

Obstruction can also be caused by a condition called fibromuscular dysplasia. In this condition the middle layer of the artery wall (known as the media) thickens, narrowing the artery. The artery may have narrowed sections alternating with widened sections, which may form small aneurysms. One or both kidneys may be affected.

Narrowing of the arteries can impair kidney function and lead to the production of a hormone that raises blood pressure. If this form of high blood pressure doesn’t respond to drug treatment or if kidney function is severely impaired, the obstruction may be opened with catheters and stents similar to those used in treating narrowed coronary arteries.

Sometimes, narrowed renal arteries can be diagnosed with a stethoscope — the turbulent blood flow produces distinctive sounds. Narrowed arteries and changes in your kidneys can also be detected through imaging involving ultrasound, angiography, CT and MRI.

Pheochromocytoma

This condition occurs when a tumor forms in the inner layer of an adrenal gland. You have two adrenal glands, one on top of each of your kidneys. The tumors, which can occur in other parts of your body and in multiple locations, secrete the hormones epinephrine and norepinephrine and other chemicals.

Pheochromocytoma almost always causes noticeable signs and symptoms. If you have one of these tumors, you may experience spells of sudden and severe headache, heart palpitations and profuse perspiration, during which time you appear pale. These spells may last from minutes to an hour. They may recur daily or infrequently. Your blood pressure is almost always markedly elevated during a spell, and may also be high between spells.

Diagnostic tests include blood and urine tests and imaging with CT, MRI or isotopes. Genetic tests also may be helpful, because this condition can run in families. The tumor is rarely malignant and can be removed by surgery.

Coarctation of the aorta

This condition involves a narrowing of the primary artery (aorta) from your heart. It usually occurs in the part of the aorta in your chest and rarely in your abdomen. It’s usually seen at birth, but occasionally a person may reach adulthood before it’s detected.

A narrowed aorta results in high blood pressure in your arms and low blood pressure in your legs. Your doctor can detect this when feeling the artery in your groin and at your wrist at the same time. The pulse in your groin will be slightly delayed and less forceful than the pulse at your wrist. A chest X-ray and imaging with ultrasound or MRI can establish the diagnosis.

Coarctation is repaired surgically by removing the narrowed portion of the aorta and rejoining the ends of the vessel. In some cases, angioplasty is used to stretch open the narrow section using a balloon on the end of a catheter (balloon dilatation). If angioplasty fails to permanently expand the area, a metallic stent may be inserted through a catheter to hold the area open.

Thyroid dysfunction

The thyroid gland regulates your metabolism, from how fast your heart beats to how quickly you burn calories. As long as your thyroid gland produces the right amount of the hormone thyroxine, your metabolism functions normally. But sometimes the gland produces too much or too little thyroxine, upsetting the balance of chemical reactions in your body.

Hyperthyroidism. Overproduction of thyroxine may raise your systolic blood pressure and heart rate. Signs and symptoms of hyperthyroidism include:

•  Nervousness

•  Weight loss

•  Excessive perspiration

•  Prominent eyes (exophthalmos)

•  Heat intolerance

•  Palpitations

•  Enlarged thyroid or presence of nodules on your thyroid

•  Tremor

•  Fatigue

Hyperthyroidism may run in families. Treatment for hyperthyroidism can restore normal blood pressure and may include medication, radioactive iodine and, rarely, surgery.

Hypothyroidism. Underproduction of thyroxine also causes high blood pressure — both systolic and diastolic. Signs and symptoms include:

•  Cold intolerance

•  Coarse skin

•  Fatigue

•  Low, husky voice

•  Slowing of body functions

•  Puffiness of eyes, legs and hands

•  Weight gain

Thyroid gland Abnormal hormone production in the butterfly-shaped thyroid gland can cause hyperthyroidism or hypothyroidism.

Hypothyroidism may occur after you’ve been treated for an overactive thyroid or for inflammation of the thyroid gland. Treatment with thyroxine usually restores your thyroid level to normal.

Cushing syndrome and aldosteronism

Cushing syndrome is the result of having too much of the hormone cortisol in your body. Cortisol can be produced by the adrenal glands or come from medication such as prednisone. Adrenal gland disorders can run in families. Excess cortisol can cause:

•  Increased fatty deposits on your face, neck and trunk

•  Thinned skin, purple stretch marks, easy bruising and excessive hair growth

•  Emotional instability

•  Weight gain

•  High blood pressure

•  Weakness

•  Diabetes

•  Osteoporosis

Treatment for Cushing syndrome is directed at reducing the excess amounts of cortisol and can include eliminating or changing medications and having surgery if the problem is internal in origin.

Excessive secretion of aldosterone from your adrenal gland (aldosteronism) also can cause high blood pressure. Aldosterone causes your body to retain sodium and water and may also result in the loss of potassium by your kidneys. Although you won’t experience generalized tissue swelling, it can contribute to the thickening of your heart and blood vessels.

If you have aldosteronism, your high blood pressure may be resistant to ordinary drug treatment. A low level of potassium in your blood also is a clue. Diagnostic steps include endocrine tests of the blood and urine, genetic tests and imaging with CT or MRI. Sampling of adrenal veins can help locate a tumor, particularly when it’s too small to be seen using an imaging test. Treatment may include drugs to block the action of aldosterone and surgery to remove a tumor.

Preeclampsia

After the 20th week of pregnancy, up to 7.5 percent of pregnant women develop preeclampsia (pre-uh-KLAMP-see-uh). This condition is characterized by a significant increase in blood pressure and other symptoms, which may include excess protein in urine. Left untreated, this condition can lead to serious, even deadly, complications for the mother and child. That’s why blood pressure checks and urinalysis are routinely performed, especially after midpregnancy.

After the baby is born, a woman’s blood pressure usually returns to normal within several days to several weeks.

Preeclampsia may recur during later pregnancies, or it may indicate the possible development of future nonpregnancy hypertension. Read more about preeclampsia in this section.

Illicit drug use

Street drugs, such as cocaine and amphetamines, can lead to high blood pressure by narrowing certain arteries, increasing your heart rate or damaging your heart muscle.

Medications

Several types of drugs can increase blood pressure in some people.

Over-the-counter medications that may have this effect include:

•  Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve)

•  Appetite suppressants

•  Cold remedies

•  Nasal decongestants, including sprays

Prescription medications that can affect blood pressure include:

•  Steroids (prednisolone, methylprednisolone)

•  Antidepressants (bupropion; desipramine and other tricyclic antidepressants; phenelzine and other monoamine oxidase inhibitors; venlafaxine and desvenlafaxine; others)

•  Immunosuppressants (cyclosporine, tacrolimus, others)

•  COX-2 inhibitors (celecoxib)

•  Others (epoetin alfa, also known as erythropoietin; darbepoetin alfa; methylphenidate and other stimulants; ergot alkaloids; some monoclonal antibodies, such as bevacizumab; and some kinase inhibitors, such as sorafenib and sunitinib)

Most birth control pills can increase blood pressure, but the effect may be less pronounced in birth control pills that have lower levels of progestin and estrogen. Drospirenone, a component of a contraceptive pill (Yasmin, Yaz, others), can cause the body to retain potassium and interfere with certain medications that are used to treat high blood pressure.

Herbal supplements

Certain products associated with complementary and alternative medicine (CAM) can increase blood pressure or interfere with the effectiveness of blood pressure medications. These include bitter orange, ginseng, caffeinated energy drinks, licorice root, yohimbine and St. John’s wort.

Bring an updated list of all the medications you take to each medical visit. Include prescription drugs, nonprescription drugs, supplements and herbal products. This is especially important if you’re taking medication for high blood pressure.

Identifying secondary high blood pressure

Similar to essential high blood pressure, you may not know you have secondary high blood pressure until your doctor has examined you and confirms it. Generally, with the secondary form, symptoms associated with the underlying condition may be what brought you to see the doctor. If it’s discovered that you have high blood pressure, your doctor will want to know details of your medical history as well as of your family history. He or she likely will look for evidence of heart attack, heart disease, hardening of the arteries, weight change, leg pain during exercise, weakness and fatigue. The doctor will also check for signs and symptoms of conditions that can cause secondary high blood pressure.

Lifestyle tips for treatment, prevention

High blood pressure is often preventable. You can help reduce your blood pressure and the risk of other cardiovascular diseases by eliminating or changing the risk factors that you can control. They include:

•  Losing weight, if you’re overweight

•  Eating a healthy diet

•  Becoming more physically active

•  Stopping tobacco use

•  Limiting alcohol

A healthy diet emphasizes lower fat and sodium intake, more vegetables, fruits and fiber, and reduced calories. A healthy diet can reduce your blood pressure as much as some medications. It should be plant based — rich in vegetables and fruit — and include whole grains, beans, nuts, fish, lean sources of protein, and low-fat or fat-free dairy products. Unhealthy fats (saturated fat and trans fat), sodium and alcohol intake are limited. For more on a healthy diet, see Chapter 1 in this book.

Regular physical activity is important for your health in many ways, including lowering blood pressure. It can reduce your risk of hypertension, help you manage high blood pressure and help blood pressure medication work more effectively. Work toward getting 150 minutes a week of moderate physical activity, 75 minutes a week of vigorous physical activity or a combination of the two. If you want to lose weight or maintain weight loss, work toward getting 300 minutes a week of moderate physical activity.

In addition to regular physical activity, try to limit the time you spend sitting. The more you sit, the greater your health risks. For more on physical activity, see Chapter 3 in this book.

For many years, as long as your blood pressure was below the cutoff for being high (140/90 mm Hg for adults younger than 60 years old), it was still considered to be at an acceptable level (see “What the numbers mean” for more information). However, as your blood pressure rises toward that cutoff (sometimes called prehypertension), your risk of developing heart disease increases.

If you find that your systolic blood pressure is often between 120 and 139 mm Hg, your diastolic pressure is between 80 and 89 mm Hg, or both, taking preventive measures is particularly important.

Weight and blood pressure

Changes in weight and blood pressure often go hand in hand. When your weight increases, your blood pressure often does, too. Likewise, as you lose weight, your blood pressure usually goes down. Losing as little as 10 to 20 pounds can help lower your blood pressure and heart disease risk. Weight loss can also improve your cholesterol levels and reduce your risk of heart attack, stroke, diabetes and arthritis.

What’s the link between body weight and blood pressure? As you put on weight, you gain mostly fatty tissue, and this tissue relies on the nutrients in your blood to survive. As the demand for nutrients increases, the amount of circulating blood increases. More blood traveling through your arteries means greater pressure on your artery walls. Fatty tissue also is an active endocrine organ that produces substances having local and generalized actions on blood vessels, kidneys and the heart.

Another reason why blood pressure often increases when you’re overweight is that additional weight typically raises your insulin level. More insulin is associated with the retention of sodium and water, which raises blood volume. In addition, excess body weight can increase your heart rate and reduce the capacity of your blood vessels to transport blood. Both factors can raise blood pressure.

Finding your healthy weight

So how do you know what your healthy weight is supposed to be? Technically, a healthy weight means you have the right amount of body fat in relation to your overall body mass. A healthy weight reduces your health risks, gives you energy, helps prevent premature aging and improves your quality of life. Guidelines released in 2013 from the American College of Cardiology, the Obesity Society and the American Heart Association take a threefold approach to determining a healthy weight. This approach is based on the following components:

•  Body mass index

•  Waist circumference

•  Risk factors for diseases and conditions associated with obesity

The following do-it-yourself evaluations can help you determine whether you could benefit from losing a few more pounds. Doing so can help you control your blood pressure and lessen your risks of other health problems.

Body mass index

Body mass index (BMI) is a standard formula that factors in your weight and height in determining whether you have a healthy or unhealthy percentage of body fat. Except in very muscular people such as athletes, this measurement correlates well with total body fat.

To determine your BMI, locate your height on the chart below and follow it across until you reach the weight nearest yours. Look for the number at the top of the column to find your BMI. If your weight is less than the weight nearest yours, your BMI may be slightly less. If your weight is greater than the weight nearest yours, your BMI may be slightly greater.

A BMI of 18.5 to 24.9 is considered healthy. A BMI of 25 to 29.9 signifies overweight, and a BMI of 30 or more indicates obesity. Your risk of developing a weight-related disease, such as hypertension, is higher if your BMI is 25 or greater. For Asians, a BMI of 23 or greater may indicate an increased risk of health problems; a BMI of at least 27.5 indicates even higher risk.

• • • • •

What’s your BMI?

You can determine your body mass index (BMI) by finding your height and weight on this chart. A BMI of 18.5 to 24.9 is considered the healthiest. People with a BMI under 18.5 are considered underweight. People with a BMI between 25 and 29.9 are considered overweight. People with a BMI of 30 or greater are considered obese.

National Institutes of Health, 1998

Note: Asians with a BMI of 23 or higher may have an increased risk of health problems.

• • • • •

Waist circumference

This measurement — used in combination with your BMI — is also important in evaluating a healthy weight. It indicates where most of your fat is located.

Fat distribution can be described in terms of an apple shape or pear shape. If you carry most of your fat around your waist or upper body, you’re referred to as apple shaped. If you carry most of your fat around your hips and thighs or lower body, you’re referred to as pear shaped.

It’s better to have a pear shape than an apple shape. If you have an apple shape, you carry fat around your abdominal organs, which increases your risk of high blood pressure, diabetes, abnormal cholesterol levels, metabolic syndrome, coronary artery disease, stroke and some types of cancer. If you have a pear shape, your risks of these conditions aren’t as high. In short, the bigger your waistline, the greater your health risks.

To determine whether you have too much weight around your abdomen, measure your waist circumference. Place a tape measure around your bare abdomen, just above your hipbone. Make sure that the tape is parallel to the floor and that it’s snug but doesn’t compress your skin. Relax, exhale and measure your waist.

A waist circumference of more than 35 inches for women and more than 40 inches for men indicates increased health risks.

Risk factors for diseases and conditions associated with obesity

Numbers alone aren’t enough. It’s also important to know how likely it is that you will have a disease or condition that’s linked to being overweight. Consider the following questions:

•  Do you have a condition such as high blood pressure, type 2 diabetes or arthritis that would improve if you lost weight?

•  Do you have a family history of a weight-related illness, such as high blood pressure, type 2 diabetes, high cholesterol, high triglycerides or sleep apnea?

•  Do you have any other risk factors, such as smoking or inactivity?

You can think of the BMI and waist measurement as snapshots of your current health status. Your medical history helps provide a more complete picture by revealing more about your risk of being overweight or developing weight-related diseases.

Adding up the results

If your BMI indicates you’re not overweight and you’re not carrying too much weight around your abdomen, there’s probably no health advantage to changing your weight. You can consider your weight to be healthy.

If your BMI is between 25 and 29.9, you may benefit from losing a few pounds, particularly if your waist circumference exceeds healthy guidelines or you answered yes to at least one of the medical history questions. Discuss options with your doctor at your next checkup.

If your BMI is 30 or more, losing some weight will likely improve your health and reduce your risk of developing a weight-related illness.

Keys to successful weight loss

Plenty of people successfully lose weight and keep it off, and you can be one of them. Just because the task seems daunting doesn’t mean that you shouldn’t try. With a little knowledge, a positive attitude and a good plan, you can do it. Here are guidelines that may help you lose weight safely and keep the pounds off permanently.

Make a commitment

Losing weight requires a full-time commitment. Don’t dwell on what you have to give up to lose weight. Concentrate instead on what you’ll be gaining, including improved health and lower blood pressure.

Choose the right time

Timing is critical. If you’re distracted or experiencing a difficult phase in your life, you may be less able to follow through on good intentions. It might be wise to postpone — but not cancel — weight loss until you resolve these problems.

Set realistic goals

Healthy weight loss is slow and steady. It involves losing no more than 1 to 2 pounds a week.

Learn new behaviors

Chances are that you’ve learned many eating habits in response to factors other than your empty stomach — social and emotional factors often come into play. The good news is that learned behaviors can also be unlearned over time. But discarding a behavior or adopting a new one can take anywhere from three to 30 tries before you’re successful. There’s no magic formula that everyone can follow. You’ll need to discover what’s most effective for you.

Change gradually

The first rule of change is to not change too quickly — it’s not a race. You’re trying to develop a whole new lifestyle. This doesn’t happen overnight.

Don’t starve yourself

Extremely low-calorie diets and special food combinations aren’t the answer to long-term weight control. Eating less than 1,200 calories makes it difficult for your body to get adequate amounts of nutrients. It also promotes temporary loss of fluids and of healthy muscle rather than the permanent loss of fat.

Get and stay active

Dieting by itself will help you lose weight, but physical activity is the most important factor related to long-term weight loss. Exercise helps you lose body fat and build muscle, making it easier to maintain weight loss.

Maintain your progress

Don’t let minor setbacks weaken your resolve to lose weight. There will be days when you eat more than you’d planned or move less than you’d intended. It’s inevitable that you’ll occasionally lapse. It’s important not to use a lapse as an excuse to give up. When it happens, rethink what you can do to put the healthy behavior back in your daily routine and stick with your plan.

Why act now?

You may wonder why it’s so important to take steps to prevent high blood pressure. Why not simply wait for the condition to develop and then treat it, possibly with a little better diet and a little more activity?

In fact, there are many reasons why it’s better to act now instead of waiting for later. Generally, the younger you are when you try to change your lifestyle, the better your chances are of succeeding at it. The longer you’re able to maintain a healthy weight, the lower your risk of weight-related diseases.

Even with successful blood pressure treatment, changes to your heart and arteries may not reverse completely back to normal. It’s better to prevent the damage from ever happening.

• • • • •

Wrap-up

Key points to remember:

•  There are two forms of high blood pressure — essential and secondary. The cause of essential high blood pressure isn’t known. Secondary high blood pressure results from an underlying illness or condition.

•  Certain genetic or lifestyle factors place you at increased risk of developing high blood pressure. Generally, the more of these factors you have, the greater your risk.

•  You may be able to prevent high blood pressure by eliminating or reducing certain risk factors that you can change. These include losing weight if you need to, maintaining a healthy weight, getting regular physical activity, and adopting a healthy diet that’s both low in sodium and alcohol intake.

•  If you have prehypertension, reducing it to a normal level can help keep you from developing high blood pressure and cardiovascular disease as well as other diseases.

• • • • •

Chapter 8

Diagnosing high blood pressure

Unlike many other chronic health conditions, high blood pressure rarely produces signs and symptoms to warn you that something is wrong. Most people who have high blood pressure, even when the condition has been long term and uncontrolled, will look and feel just fine.

It’s during routine medical examinations that most people learn that their blood pressure is too high. That’s why it’s important to have your blood pressure checked at least once every two years. Otherwise, vital organs, such as your heart and kidneys, could be damaged by high blood pressure without you even being aware of it.

Fortunately, diagnosing high blood pressure is a relatively straightforward process. It generally involves several measurements taken at doctor visits over a period of several weeks or months. This process confirms whether an initial high reading was simply a temporary fluctuation that returns to normal or represents what has become your regular level.

As part of the diagnostic process, your doctor likely will ask you questions about your health and your family’s health, do a physical examination, and have you undergo routine tests. These steps are taken to determine whether any organs have been damaged by the high pressure levels. They may also prevent additional health problems from developing. Results from the examination and lab tests also are important in deciding how best to treat your condition. (See “Key questions to answer” following.)

Two methods for reducing and controlling high blood pressure are lifestyle changes and medication. Whether you’ll need medication depends on your blood pressure, your risk of other health problems and whether any organ damage has occurred.

Taking a blood pressure reading

Measuring blood pressure is a simple procedure that you can learn to do. Readings are typically taken with an electronic sphygmomanometer, which includes a fully automatic monitor.

These electronic units inflate and deflate the cuff, detect your systolic and diastolic pressures by sensing vibrations in the wall of the artery, and then display your blood pressure measurements on a digital screen. To produce accurate readings, the inflatable part of the cuff needs to cover at least three-quarters of your upper arm.

If you will be monitoring your blood pressure at home, see Chapter 10 for instructions and advice on electronic blood pressure monitors. Also ask your doctor for help.

Electronic monitors You can use an electronic monitor at home to check your blood pressure. Learn more about electronic blood pressure monitors and how to use them in Chapter 10.

Making certain

A blood pressure reading of 140/90 millimeters of mercury (mm Hg) in a doctor’s office is considered high. But a single reading of 140/90 mm Hg or higher usually isn’t enough for a diagnosis of high blood pressure. Your blood pressure varies throughout the day, and it’s best to get many readings under similar circumstances. Only if the reading is extremely high — a systolic pressure of 180 mm Hg or higher or a diastolic pressure of 110 mm Hg or higher — is a diagnosis made based on a single measurement. For people over age 60, medication treatment is advised if your systolic pressure is 150 mm Hg. People over age 60 whose systolic blood pressure is between 140 and 150 mm Hg are advised to make lifestyle changes to help lower blood pressure.

Generally, a diagnosis of high blood pressure is made after at least two visits to your doctor. Your blood pressure will be measured at least twice during each visit. In all, you’ll have at least four measurements taken. If the average of your measurements shows your blood pressure to be 140/90 mm Hg or higher, then you have high blood pressure.

If you’re older than 60, you may need even more measurements because, as you get older, there are many more reasons why your blood pressure readings may vary, including stiffened arteries (see below).

As you prepare to have your blood pressure tested, keep these tips in mind to ensure an accurate reading:

•  Don’t smoke, eat a big meal, or drink caffeine or alcohol for at least 30 minutes before taking your blood pressure. And make sure your bladder is empty. All of these factors can change blood pressure for a period of time.

•  Give yourself plenty of time to make it to your appointment. Rushing around can cause stress, and this can temporarily increase your blood pressure.

•  Before you have your blood pressure measured, sit comfortably and quietly for two to five minutes with your back supported and both feet flat on the floor.

•  When having your blood pressure taken, don’t talk. Talking can elevate blood pressure. Some offices now have an automatic device that takes readings every few minutes while you’re alone, quiet and seated properly.

• • • • •

False readings

Sometimes, blood pressure measurements can produce false readings that are too high. This happens most often among older adults with damaged arteries that have become very stiff — and it’s different from what’s known as white coat hypertension. Although many people with stiff arteries have high blood pressure, it may not be as high as the measurements indicate.

The false readings occur because rigid arteries are difficult to collapse. When a blood pressure measurement is taken, the cuff may not be able to collapse the brachial artery until the cuff has been inflated to extremely high pressure. And when pressure in the cuff is released, stiffness causes the artery to open faster than it normally should, which gives an incorrect reading.

Your doctor often can tell whether you have this condition, called pseudohypertension, by feeling your forearm. Normally, when a blood pressure cuff collapses your brachial artery, the doctor is unable to feel the arteries in your forearm below the cuff.

Stiff arteries in the forearm, however, remain open and can be felt even when no blood is flowing through them. People with this condition may find that electronic devices also fail to give accurate readings.

• • • • •

Key questions to answer

Between the time you first learn that you may have high blood pressure and an actual diagnosis, your doctor may want to get your medical history, perform a complete physical exam and have you undergo several lab tests.

These three components can provide answers to important diagnostic questions, such as:

•  Has your high blood pressure damaged any organs?

•  Is your high blood pressure essential (primary) or secondary? Although secondary high blood pressure is uncommon, it’s important that each person with high blood pressure be considered for secondary causes. Some of these conditions are treatable, allowing you to reduce blood pressure.

•  Do you have other risk factors that increase your chances of having a heart attack or stroke, such as tobacco use, too much weight, an inactive lifestyle, high blood cholesterol or diabetes?

If it’s unclear whether you have high blood pressure or prehypertension, these evaluations can help confirm the diagnosis and guide treatment decisions for the condition.

• • • • •

Why do I need to return for more blood pressure readings after my first visit?

Let’s say that at a routine medical exam, your blood pressure reading was above 140/90 mm Hg. Unless your blood pressure was extremely high (180/110 mm Hg or higher), you’ll need to return for additional checks. That’s because many factors can affect your blood pressure, and measurements vary widely throughout the day and from day to day. At least two measurements are taken at each subsequent visit, generally under identical circumstances. A fair gauge of your regular blood pressure is the average of these measurements from all your visits.

• • • • •

Medical history

Your medical history may point to a particular factor or event that has triggered the increase in blood pressure. This history can also help the doctor assess your risk of other health conditions. During an evaluation, you may be asked questions regarding:

•  Previous blood pressure readings

•  Personal history of heart disease, kidney disease, high cholesterol, diabetes and sleep apnea (such as snoring, restless sleep or daytime sleepiness)

•  Family history of high blood pressure, heart attack, stroke, kidney disease, diabetes, high cholesterol or early (premature) death

•  Signs and symptoms that may suggest secondary high blood pressure, such as flushing spells, rapid heart rate, intolerance of heat or unexplained weight loss

You may also be asked questions about your behaviors and habits related to:

•  Alcohol use

•  Diet and use of salt (sodium)

•  Medications you’re currently taking and previous use of high blood pressure drugs

•  Tobacco use

•  Changes in weight

•  Caffeine use

•  Activity level

Tell your doctor about all medications you take — both prescription and over-the-counter (OTC), as well as illicit drugs and herbal and nutritional supplements. Be sure to mention any drugs that you’ve had an adverse reaction or intolerance to.

Some drugs can increase blood pressure, while others don’t react well with some blood pressure medications and can lead to dangerous interactions. As for supplements, more research is needed regarding the health effects of many of them. That’s why it’s important to compile a list of all of the medications and supplements you take, including drug names and dosages. If you don’t have a list, bring the original containers with you to your next doctor visit. For more information about medications, see Chapter 5 in this book.

Keep in mind that blood pressure normally rises and falls over a 24-hour period. Diet, activities, emotions and other factors also affect blood pressure. These variations must be taken into account as you and your doctor consider your use of medications.

• • • • •

White coat hypertension and masked hypertension

Some people become anxious whenever their blood pressure is measured at the doctor’s office. They may have normal blood pressure at other times and at other places, but whenever it’s measured in a medical setting, it’s always going to be high. This condition, called white coat hypertension, occurs in around 14 to almost 38 percent of people with high blood pressure.

For other people, the opposite holds true. Their blood pressure consistently measures higher when they’re at home or at work than it does when they visit the doctor’s office. This condition is called masked hypertension. It may occur for several reasons. For example, the calm, quiet environment at the doctor’s office may be less stressful than the other environments they live in.

If your doctor suspects your high blood pressure is white coat hypertension, you may need to keep track of your blood pressure away from a medical setting. For both white coat and masked hypertension, your doctor may recommend that you wear a portable device (ambulatory monitor) that measures your blood pressure periodically over a 24-hour period while you go about your regular activities. For either condition, this method can generally provide you with a more realistic and accurate assessment of your blood pressure.

Automated machines in stores and shopping malls that measure blood pressure aren’t recommended for this purpose. These machines are not sufficiently accurate, and they’re often equipped with cuffs that don’t fit properly. Furthermore, the settings where these machines are located — which can have a huge impact on blood pressure readings — aren’t controlled and, in fact, can even be chaotic.

Conventional medical thought was that these forms of hypertension were harmless phenomena not requiring treatment. In fact, many people with these conditions will develop true hypertension over time. Research suggests that masked hypertension may put you at higher risk of stroke, kidney disease and death from cardiovascular disease. Both conditions should be carefully monitored and treated. Your doctor may recommend adjustments to your lifestyle and blood pressure medications.

• • • • •

Physical examination

Your doctor will examine your body closely for signs of organ damage. He or she will also check for abnormalities that signal a possible cause for the blood pressure increase.

Physical conditions that your doctor may consider when checking for signs of organ damage include:

Narrowed or leaky blood vessels in your eyes

Damage to the blood vessels in your eyes is a strong indicator that blood vessels elsewhere in your body have been damaged by high pressure (see images below). This may also indicate an increased risk of heart disease.

Damage to the retina Shown on the left, blood vessels in your retina may rupture (A) due to high blood pressure, causing bleeding (hemorrhaging) and a buildup (B) of waste deposits (exudates). Tissue swelling due to a combination of leakage and inflammation (C) may include the optic nerve (papilledema). The image of a healthy retina is shown on the right.

Heart abnormalities

A fast heart rate, a heart that’s enlarged in size, an abnormal rhythm of your heartbeat, or a click or murmur in the sounds of the heart can signal possible heart disease.

Turbulent blood flow

When a blood vessel narrows, it can cause turbulent blood flow. The turbulent flow, called a bruit (bru-we), most often occurs in the carotid arteries in your neck and the major arteries in your abdomen.

Decreased blood pressure when you stand

A side effect of some blood pressure medications is fainting or dizziness when you stand up (postural hypotension). Such dizziness is also a complication of diabetes. The problem is common in older adults particularly after meals, whether or not they have diabetes. For more information, see “When your blood pressure drops too low” here.

Aortic aneurysm

An aneurysm can form at a weak spot in the wall of the aorta. A bulge may be felt during an examination of your abdomen. A stethoscope also may pick up the sound of blood pulsing through the weakened blood vessel.

Aortic aneurysm An aortic aneurysm is a bulging section in the wall of the aorta (arrow) that may rupture or be the location of blood clot formation. Aneurysms can be detected with an ultrasound (inset).

Weakened pulse

A weak pulse in your groin, lower legs and ankles can signal artery damage.

Reduced blood pressure in your ankles

This can result from narrowed or diseased blood vessels in your legs.

Swelling

Accumulation of fluid in your lower legs and ankles is a common sign of heart or kidney failure.

Enlarged kidneys or thyroid gland

If either of these organs becomes enlarged, it may indicate that you have secondary high blood pressure resulting from another condition.

• • • • •

Round-the-clock reading

High blood pressure can, at times, be difficult to diagnose. If your doctor is uncertain whether or not you have high blood pressure and if so, how severe it is, you may need to wear a special device known as an ambulatory monitor.

This device is a portable blood pressure monitor that you can wear for a day. It includes an inflatable cuff that fits around your arm and a small monitoring unit that hangs at your waist using a strap over your shoulder. A thin tube connecting the monitor to the cuff may be secured to your skin with tape to prevent it from twisting or disconnecting.

The monitor is programmed to take your blood pressure about every 15 to 20 minutes during the day and every 30 to 60 minutes during sleep over a period of 24 hours. The device is fully automatic. At selected times, it pumps up the blood pressure cuff, deflates it, takes a reading and stores the information in its memory.

You may be a candidate for ambulatory monitoring if you have white coat hypertension — your blood pressure readings are higher than normal only at medical checkups — or masked hypertension — you show complications of high blood pressure but have normal blood pressure readings at medical checkups. Ambulatory monitoring can also be helpful if your blood pressure fluctuates widely or if you’re not responding to treatment with blood pressure medications. Monitoring your blood pressure over 24 hours can help predict your risk of heart disease caused by high blood pressure. If you’re under age 50, your 24-hour diastolic blood pressure is the most important in determining your heart disease risk. For adults over age 50, systolic blood pressure is the most important. Ambulatory monitoring over 24 hours also can help detect secondary hypertension caused, for example, by sleep apnea.

While wearing the monitor, keep a journal that lists your daily activities and the times you did them, the times you took medications, and any periods of stress, strong emotions or pain. By comparing the journal entries with your blood pressure readings from the ambulatory monitor, your doctor may note where certain events or lifestyle factors are linked to changes in your blood pressure.

• • • • •

Routine tests

The following tests are often included in a routine evaluation for high blood pressure:

Weight

Being overweight or obese may play a role in raising your blood pressure. Your weight usually is taken as part of a general office visit.

Your doctor may calculate your body mass index (BMI) to determine your percentage of body fat (see “Body mass index” for more information). Your doctor may also measure your waist to see if you’re carrying too much weight around your abdomen (see “Waist circumference”).

Urinalysis

The presence of protein or red blood cells in your urine can indicate kidney damage. A form of protein in your urine, called microalbuminuria (my-kroh-al-byoo-min-U-ree-uh), also can signal early-stage kidney disease — a risk factor for future heart disease. In addition, your urine may be tested for the presence of sugar (glucose) resulting from diabetes. Diabetes can make high blood pressure harder to control.

Blood chemistry

The levels of sodium and potassium in your blood are measured. Your blood may also be tested for levels of the compound creatinine (kree-AT-ih-nin), which can indicate damage to your kidneys.

Other common blood tests include measurements of cholesterol-containing blood fats (lipid profile). The higher your total blood cholesterol level and the lower your high-density lipoprotein (HDL, or “good”) cholesterol level, the greater your risk of cardiovascular disease and metabolic syndrome. A higher level of low-density lipoprotein (LDL, or “bad”) cholesterol is a risk factor for cardiovascular disease. It builds up in the walls of your arteries, making them hard and narrow.

The level of glucose (sugar) in your blood also may be measured to check for diabetes.

Complete blood cell count

This test reveals abnormal white and red blood cell counts. Its purpose is to ensure that you don’t have certain health conditions you may not be aware of, such as a low red blood cell count, called anemia (uh-NEE-me-uh).

Electrocardiography

Your heart’s electrical activity is monitored to check for rhythm abnormalities or signs of damage, such as an enlarged heart or inadequate blood supply. The changes in your heart’s electrical activity are recorded on an electrocardiogram (ECG), which can also show high or low levels of potassium.

Additional tests

If your physical examination and laboratory findings are normal, you probably won’t have to undergo additional testing. However, further tests may be necessary if you have:

•  Very high blood pressure (180 mm Hg or higher/110 mm Hg or higher)

•  Sudden onset of high blood pressure or a sharp increase in your normal blood pressure

•  Low blood potassium level

•  Sound of turbulent blood flow (bruit) heard over an artery

•  Evidence of kidney problems

•  Evidence of heart problems

•  Indications of an abdominal aortic aneurysm

•  Evidence of hormonal disorders

If you have narrowed arteries that are interrupting blood flow, imaging tests can identify the location and severity of the problem:

Angiography

During this procedure, a dye that’s highly visible to an X-ray machine is injected into your blood vessels. The X-ray machine rapidly takes a series of images (angiograms) that reveal hidden or subtle features of your arteries.

Magnetic resonance angiography (MRA)

Rather than using X-rays to produce an image, magnetic resonance imaging uses magnetic fields and radio waves. The device detects and stores small energy signals emitted by the atoms that make up body tissue. A computer program reconstructs images based on this information.

Ultrasonography

This procedure uses high-frequency sound waves to track the function of your circulatory system. The waves bounce off internal structures and back to a transducer, which converts the reflected waves into a distinct image (see example here).

If your doctor suspects that you may have a shrunken kidney, an abdominal aortic aneurysm or an adrenal gland tumor, additional tests may include:

Magnetic resonance imaging (MRI)

This procedure is based on the same principles as the MRA, but MRI provides detailed images of organs rather than blood vessels.

Computerized tomography (CT) scan

The image produced in a CT scan is generated by an X-ray beam, but this technology provides much more information than an ordinary X-ray. That’s because the doughnut-shaped machine contains a rotating scanner that emits a series of beams from all angles around your body. A computer gathers these X-ray signals and processes them into highly detailed, 3-D images of your internal organs (see images on the below).

Computerized tomography A computerized tomography (CT) scan involves taking multiple, highly specialized X-rays of an organ such as the heart. With the help of computer programs, highly detailed images of the heart and blood vessels can be created.

Nuclear scanning

After radioactive material is injected into a vein, nuclear images are taken that show the material passing through a specific location or organ. Nuclear scans are used to monitor blood flow and to determine the size and function of organs.

• • • • •

Wrap-up

Key points to remember:

•  Many factors can influence a single blood pressure reading, including diet, activity, fluid intake, stress level, posture and time of day.

•  A high blood pressure diagnosis generally is made after multiple readings show persistently high systolic or diastolic pressure or both.

•  A portable monitor may be used to record blood pressure over a period of time to detect abnormal patterns.

•  A medical history, physical examination and routine lab tests are typically part of the process to diagnose high blood pressure.

• • • • •

Chapter 9

Treating high blood pressure

Treatment of high blood pressure should be tailored to your needs. That’s why the treatment that works for someone else may not be the best fit for you. You and your doctor will need to consider your medical history, a current physical examination and the results of laboratory tests to determine the most effective, personalized plan.

There are two basic approaches to reducing high blood pressure: changing unhealthy aspects of your lifestyle and taking medications. Depending on your health and risk factors, lifestyle changes may include losing weight, getting more active, eating a healthier diet, reducing sodium, stopping smoking, limiting alcohol and managing stress.

Several types of medications are used to control high blood pressure, and there are new developments on the horizon.

These medications affect blood pressure in different ways. It’s important not to share the drugs prescribed for you with anyone else. Their medication may not be the same type as yours.

Latest guidelines

The panel appointed to the Eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, referred to as JNC-8P, released its evidence-based recommendations for blood pressure management in late 2013 as an update to the 2003 guidelines from the previous panel, known as JNC-7.

Blood pressure targets outlined in JNC-7 were refined by JNC-8P based on the latest scientific evidence (see below).

• • • • •

Guidelines for treatment

Blood pressure treatment goals* |
Healthy adults age 60 or older | Less than 150/90 mm Hg
Healthy adults younger than age 60 | Less than 140/90 mm Hg
Adults who have chronic kidney disease or diabetes | Less than 140/90 mm Hg
Although 120/80 mm Hg or lower is the ideal blood pressure goal, doctors are unsure if you need treatment (medications) to reach that level.

Habits that can help high blood pressure treatment | Risks to your body from untreated or poorly treated high blood pressure

•  Eat a healthy diet, which includes limiting sodium

•  Enjoy regular physical activity

•  Reach and maintain a healthy weight

•  Manage stress

•  Avoid tobacco smoke

•  If you drink, limit alcohol

•  Damage to the heart and coronary arteries

•  Stroke

•  Kidney damage

•  Vision loss

•  Erectile dysfunction

•  Memory loss

•  Fluid in the lungs

•  Angina

•  Peripheral artery disease

Based on James PA, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC-8P). Journal of the American Medical Association. 2014;311:507.

• • • • •

Treatment for prehypertension and hypertension depends on several factors, including your systolic and diastolic blood pressure and whether you have heart disease or risk factors for it. While the treatment goal will always be the same — to lower your blood pressure — the number of risk factors you have will determine how aggressively your blood pressure is treated. Special attention will be given to addressing reversible risk factors, such as tobacco use, high cholesterol levels and diabetes.

Recommendations from JNC-8P advise that adults younger than age 60 reach a blood pressure of less than 140/90 millimeters of mercury (mm Hg) and that adults age 60 and older reach a blood pressure of less than 150/90 mm Hg. No change is recommended if systolic blood pressure is already below 140 mm Hg and they’re doing well with treatment. The panel recommended that medication be considered if lifestyle changes alone weren’t enough to lower blood pressure to these levels.

Previously, more aggressive blood pressure goals of 130/80 mm Hg or lower were advised for adults of all ages who had chronic kidney disease, certain heart diseases and diabetes. Research conducted since then shows that achieving these lower goals is not only difficult but also isn’t beneficial.

At the same time, a diastolic blood pressure of 90 mm Hg or more is a sign that treatment is needed.

The most important message here is to work with your health care team to develop a treatment plan that’s suited to your specific situation. There are many different opinions about which blood pressure goals are best to reach for optimal health, especially for older adults and those who have kidney disease or diabetes. By working with your health care team, your blood pressure goal should take into account:

•  Your overall health

•  Your risk of heart disease, stroke and kidney disease

•  Any other medical conditions you have

•  Prescription and over-the-counter therapies you’re taking

•  Your gender and ethnicity

Together, you and your health care team can decide on your treatment goal and medications so that they fit your lifestyle, give you good quality of life, and help you reduce your risk of heart disease, stroke and other consequences of high blood pressure.

• • • • •

Numbers on progress are mixed

Since 1972, when the National Heart, Lung, and Blood Institute began an intensive education campaign, there generally has been steady improvement in awareness, treatment and control of high blood pressure. As a result, death and disability attributed to the disease have declined significantly. This is considered one of the best public health achievements in the 20th century. Death rates from stroke continue to decline, and between 2000 and 2010, the rate of death from heart disease also has declined significantly.

During the early 1990s, those dramatic improvements slowed. The reasons for the slowdown are unclear. An increase in obesity and lack of exercise may be important factors. In Health, United States, 2013, a report by the Surgeon General, it was noted that 3 in 5 adults ages 20 to 74 were overweight and that 1 in 4 Americans was considered to be obese. The report also noted that only 20 percent of adults over 18 years old met the 2008 U.S. physical activity guidelines for aerobic activity and strength training.

Another important factor may be complacency. Above-normal blood pressures too often may be overlooked — both by doctors and their patients — as being “almost” in control and therefore not of great concern. Although general blood pressure goals have changed, that doesn’t mean that they’re any less important to reach. If your blood pressure is higher than your recommended goal, talk to your doctor about it. If you’ve lowered your blood pressure but still haven’t reached your goal, get advice from your health care team about why this is and how you can create a plan to reach your blood pressure goal.

Despite these findings, there is also good news. Data gathered in a recent review article, as well as patient care data from managed care organizations and the Department of Veterans Affairs, shows positive improvement in people with high blood pressure. The control rate in a Veterans Affairs study population improved from 43 percent in 2000 to almost 77 percent in 2010. These improvements were seen in all age and ethnic groups and in both men and women.

• • • • •

Prehypertension

If your systolic pressure (top number) is between 120 and 139 mm Hg or your diastolic pressure (bottom number) is between 80 and 89 mm Hg, you have prehypertension.

Having prehypertension means you have a higher risk of developing hypertension and cardiovascular complications. You’ll be encouraged to adopt lifestyle changes to reduce your blood pressure.

Stage 1 hypertension

If your systolic pressure (top number) is between 140 and 159 mm Hg or your diastolic pressure (bottom number) is between 90 and 99 mm Hg, you have stage 1 hypertension.

Lifestyle changes are part of the first line treatment for stage 1 hypertension. You’ll likely also need medication to bring your blood pressure under control. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs) and thiazide diuretics are all commonly recommended for nonblacks, including those who have diabetes.

For blacks, including those who have diabetes, a calcium channel blocker or a thiazide diuretic is recommended as initial therapy. ACE inhibitors or ARBs are sometimes recommended for people who have chronic kidney disease to help improve kidney function.

Stage 2 hypertension

If your systolic pressure is 160 mm Hg or higher or your diastolic pressure is 100 mm Hg or higher, you have stage 2 hypertension. People who have stage 2 hypertension are at the greatest risk of heart attack, stroke or other problems related to high blood pressure.

A combination of two blood pressure medications along with changes in lifestyle are typically recommended for stage 2 hypertension. Medications used to treat stage 2 hypertension may include a thiazide diuretic used with an ACE inhibitor, ARB or a CCB. Learn more about medications used to treat high blood pressure in Chapter 5.

Refining treatment goals

Your treatment plan will include specific goals that take into account other factors in addition to your blood pressure level and unhealthy behaviors. For example, your doctor also will consider your overall health and the presence of other diseases and conditions when discussing your goals and treatment.

Common misconception

Many people who take high blood pressure medication believe that it’s not as important to make changes in their lifestyle simply because their medication is taking care of the problem. That’s not true. Sometimes, medication can reduce your blood pressure by only a certain amount. And that amount may not be enough to reach your blood pressure target level. However, succeeding with lifestyle changes in addition to taking medication often can help you reach the target pressure.

If you can reach your blood pressure goal with medication, making lifestyle changes may help reduce the amount of medication you need. Less medication usually means less cost.

If your medication causes you to experience bothersome side effects, talk to your doctor about cutting back on the dosage to reduce them. Some people who’ve significantly changed their lifestyles have been able to stop taking medications entirely.

Finally, lifestyle changes are important for everyone with high blood pressure because they help reduce risk of stroke, heart attack, heart failure, kidney failure and dementia. Achieving your blood pressure goals generally requires your full involvement. Meet with your doctor regularly to assess your progress and adjust your treatment plan. Reaching your goal sooner results in lower risk of cardiovascular events occurring, so don’t wait for more than a few months for lifestyle changes or medications to work.

• • • • •

How do I manage the lifestyle changes?

It can be overwhelming to try and adjust your diet, start exercising, lower stress, stop smoking and watch your alcohol intake all at once. Here are general rules that may guide your decisions and keep you on track:

First, keep your goals realistic. If you set your expectations too high or hold yourself to impossible goals, you’re setting yourself up for failure. For example, don’t expect to do 5-mile runs as soon as you start jogging.

Second, don’t try to change too quickly. This is not a race. You’re trying to develop a new lifestyle, and ridding yourself of habits you’ve probably followed for many years. This doesn’t happen overnight.

Third, it’s important that you enjoy and find satisfaction in the changes you’re making to your lifestyle. If you don’t like what you’re doing, it’s unlikely you’ll stay with the plan.

Fourth, it’s inevitable that you’ll have an occasional lapse, for example, when travel or work deadlines cause you to eat poorly and not exercise. When this happens, don’t get discouraged and get back on your plan.

Fifth, stay focused on your health. Remind yourself that being healthy allows you to be energetic, strong, and active and to experience an optimum quality of life.

• • • • •

Being an active partner

You can live a long and healthy life with high blood pressure. But to do so, it’s important to recognize that high blood pressure is a serious condition that you can bring under control. If you’re diagnosed with high blood pressure or considered to be at high risk of the condition, your doctor may ask you to make fundamental changes to your lifestyle. This makes you an active participant in your health care.

Recognize that it takes a team effort to treat high blood pressure. You can’t do it alone, and you can’t depend on your doctor to do it for you. Everyone working together and supporting you, including family and friends, can help you achieve your goals.

• • • • •

Wrap-up

Key points to remember:

•  Appropriate treatment of high blood pressure depends on blood pressure stage, organ damage, cardiovascular risk factors, and the presence of diabetes, kidney disease or other diseases.

•  Even if you take medication, changes in your lifestyle are essential to controlling high blood pressure.

•  It’s important to work with your health care team to establish your blood pressure goal and to work together to achieve it.

• • • • •

Chapter 10

Living well with high blood pressure

High blood pressure isn’t an illness you can treat and then ignore. It’s a condition that you’ll need to manage for the rest of your life.

Sometimes this can be difficult because, with high blood pressure, you typically can’t feel or see that anything is wrong. With many diseases, such as arthritis or allergies, the symptoms you experience motivate you to treat the condition. You feel the flaring pain and stiffness of arthritic joints, or you experience the sneezing and itchy eyes of an allergy attack. You’re motivated to take care of the disease because you want those bothersome signs and symptoms to go away.

The lack of symptoms is one of many reasons why people with high blood pressure often don’t take proper steps to treat their disease. It’s also part of the reason why only about half of Americans with high blood pressure have the condition under control.

Many others may pretend that they have little to worry about. Despite good advice from their doctors, they can go about their everyday lives and whether or not they stick to their treatment programs seems to make little difference — until organ damage and serious complications have occurred. That’s why high blood pressure is often called the “silent killer.”

Participating in your health care and managing your blood pressure — measuring it at home, taking medications properly, eating a healthy diet, getting regular physical activity, scheduling regular visits to your doctor — are essential. These efforts can significantly increase your chances of living a longer, healthier life, despite high blood pressure.

• • • • •

How are your other behaviors?

1.  Do you smoke cigarettes, cigars or pipes or use snuff or chewing tobacco?

➊ Yes

➋ Very infrequently

❸ No

2.  Do you drink more than a moderate amount of alcohol? (A moderate amount is one drink a day for men age 65 and older and women and two drinks a day for men younger than 65.)

➊ Yes or quite often

➋ Sometimes

❸ Never or infrequently

Do you see a health care professional for regular checkups?

➊ No

➋ Sometimes

❸ Yes

3.  Do you wake up multiple times during the night or snore while you’re asleep?

➊ Often

➋ Occasionally

❸ Never or infrequently

4.  Do you often feel sleepy during the day and have trouble functioning because you’re tired?

➊ Often

➋ Occasionally

❸ Never or infrequently

5.  How would you rate your ability to handle daily stress?

➊ Poor

➋ Fair

❸ Good

6.  How often do you feel lonely, depressed or pessimistic about what’s happening around you?

➊ Often or always

➋ Occasionally

❸ Never or infrequently

» How did you score?

To the left of the answer you chose is a point value — 1, 2 or 3 points. Add up the points from your answers for your total score.

A: If your total score was 18 to 21 points, congratulations! You’re making wise decisions regarding your health.

B: If your score was 13 to 17 points, you’re on the right track, but there’s room for improvement.

C: If your score was 7 to 12 points, your behaviors may be putting your health in jeopardy. Select areas where you can try to make improvements.

• • • • •

Manage stress

If you lead a stressful life, you’ll have high blood pressure, right? This commonly held notion is not entirely true. There are many individuals who have high stress and normal blood pressure, just as there are laid-back individuals with high blood pressure. However, a Mayo Clinic study found that people with high stress are more likely to have high blood pressure.

It’s true that when you’re anxious or under a tight deadline, your blood pressure may increase. Then as you relax, your blood pressure generally returns to normal.

But chronic stress, in situations that aren’t short-lived, may compound high blood pressure. Studies show that people who are characteristically impatient or hostile — traits commonly associated with stress — are more likely to develop hypertension.

In a national study of nearly 4,000 Americans over 10 years, those who overreacted to stressors and had the negative emotions of anxiety and avoidance behavior were more likely to report having high blood pressure. If you have high blood pressure, reducing your stress may not lower your blood pressure completely, but managing stress is important for other reasons:

Better long-term control. Even temporary increases in blood pressure caused by stress can make high blood pressure more difficult to manage. With less stress, you may have a better chance of staying in control.

More-positive attitude. Stress can erode your commitment and motivation to control your high blood pressure. It’s much easier to be physically active, eat a healthy diet, lose weight and limit alcohol when you’re more relaxed and happy.

There are many ways to manage stress. By experimenting with different approaches and techniques, you’ll find the stress management strategies that fit your lifestyle and daily routine.

What is stress?

Think of stress as a spice. Too little spice results in a bland-tasting meal. Too much spice can muddle flavors or make the food inedible. When you use the correct amount, spice can provide a memorable eating experience.

Stress works in the same way on your health and well-being. You need some stress to keep your life interesting and challenging, but too much stress can overwhelm you. The issue is finding the right balance.

Positive and negative stress

Stress is a normal part of daily life. It’s what you experience whenever you deal with demands that cause you to feel some degree of emotional or physical pressure that challenges your ability to cope. Stress is not the demands themselves (known as stressors) but rather how you respond to them.

Positive stress. Stress can provide feelings of excitement, opportunity and accomplishment. In these circumstances, you feel confident and motivated. Positive stress often drives athletes to perform well in competition. Other examples of positive stress may include working toward a college degree, getting married, starting a new job and experiencing childbirth.

Negative stress. Stress can make you feel out of control or overwhelmed. You may have trouble staying focused on the task at hand or feel isolated and picked on by others. Family relationships, financial problems, work deadlines and poor health are common sources of negative stress. Stress becomes negative when you face continuous challenges without relief or relaxation between challenges.

Physiologically, your body tends to respond to any stressful challenge in the same way. How you perceive that challenge is what makes the stress positive or negative to you. That’s what makes stress highly individualized. What may be stressful for one person may not be stressful for someone else. Some people generally cope well with difficult or tense situations, while others melt under the pressure. For a multitude of reasons, someone who dealt well with stress one week may have trouble coping with a similar kind of stress during the following week.

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What are the warning signs of stress?

Some of the most common signs and symptoms of stress include:

•  Frequently feeling stressed out

•  Overwhelming feelings of anger, frustration or anxiety

•  Frequent headaches, backaches or colds

•  Insomnia or other sleep disorders

•  Increased use of alcohol or medications

•  Feelings of grief, hopelessness or depression

•  Diminished sense of humor

•  Loss of interest in usual activities

•  Periods of crying or other emotional outbursts

•  Lack of attention to physical health and appearance

Just because you don’t exhibit any of these signs and symptoms does not mean you’re not under stress. You may not recognize the signs and symptoms, or you may be taking medications that mask them.

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The stress response

Racing against a deadline, being stuck in traffic, arguing with a spouse — these intense situations can make your body react as though you were facing a physical threat. The stress response, often referred to as the fight-or-flight response, switches your body into high gear. It provides you with the energy, speed and concentration either to meet the challenge head-on (fight) or to get out of the way (flight).

The fight-or-flight response can occur during any situation that’s perceived — even falsely — as dangerous. In response to your perception of threat, a surge of hormones shifts your body into overdrive. Among the hormones are epinephrine (adrenaline) and cortisol, which cause your heart to beat faster and your blood pressure to increase.

Other physical changes occur. Your breathing quickens, your blood sugar rises, and more blood and nutrients are sent to your brain and large muscles. Your body also releases chemicals that make your blood clot more easily. In a physical attack, this would help slow bleeding from a wound.

Your nervous system also springs into action. The pupils of your eyes dilate to enhance your vision. Facial muscles tense up to make you look more intimidating. Sweating cools your body.

Your mind has ways of letting you know when it’s under too much stress. You may become easily discouraged, irritable, cynical, emotional or even reclusive. All of these feelings affect how you think and act. However, the changes can sometimes be easy to miss because they develop gradually and with little warning.

Physical signs and symptoms of stress aren’t as easy to ignore. They may include headache, stomach upset, insomnia, fatigue and frequent illness. You may revert to nervous habits, such as biting your nails or smoking. In response to stress, you might also turn to alcohol or drugs.

Stress and blood pressure

The hormones epinephrine and cortisol released during periods of high stress increase blood pressure by narrowing your blood vessels and increasing your heart rate. The increase in blood pressure caused by stress varies, depending on how intense your stressor is and on how your body copes with the challenge. In some people, stress causes only a slight increase in blood pressure. In others, stress can produce extreme jumps in blood pressure.

Nevertheless, the effects of stress on your body are usually only temporary. However, if you regularly experience high levels of stress, the increases in blood pressure can over time start to damage your arteries, heart, brain, kidneys and eyes. This cumulative effect of stress often goes unrecognized until the condition manifests itself as persistent high blood pressure.

Strategies for managing stress

Stress can come from many sources. Relationships, work, family and deadlines are some examples. It’s important to identify your sources of stress and then make a decision to manage your stress effectively.

Stress becomes a problem when the demands placed on you threaten to overcome or exceed your ability to cope. To stay on track through stressful times, try this four-step strategy:

1.  Identify your sources of stress. The next time you’re feeling overwhelmed or upset, consider the circumstances that may have caused you to feel this way. Write these factors down in a list and see if you notice a pattern. Keep in mind that stress can be caused by external factors, such as family relations or unpredictable events, as well as by internal factors, such as negative attitudes or unrealistic expectations.

2.  Closely examine your stressors. Try to identify the problem that’s causing you to feel stressed at its root. Then ask yourself, “How can I change this situation?” or “How can I improve my ability to cope with this situation?” Once you know what’s at the root of your stress, you can take steps to cope with it.

3.  Evaluate your needs and responsibilities. Assess the activities in your daily life and prioritize which ones are most important to you. Then, determine the tasks that you can most easily adapt, or change. Finally, identify and prioritize things you have control over, and work toward accepting the things that are out of your control. If you feel overcommitted, can you delegate some of the tasks to others or ask them for help? Can you say no to new responsibilities?

4.  Engage in relaxation strategies. Develop coping strategies that help you relax when you feel yourself becoming stressed. Try exercise, relaxed breathing and muscle relaxation techniques, as well as simply learning to laugh.

Following are additional guidelines to accomplish stress relief.

Changing your lifestyle

Making positive changes in your daily routine can often lessen your stress level and is also good for your overall health. These changes include:

Getting organized. Prepare a written schedule of your weekly activities, highlighting priority tasks. Being organized will help reduce time conflicts, missed appointments and last-minute deadlines. Schedule important tasks — especially those that seem most stressful — at the time of day when you’re feeling your best.

Simplifying your schedule. Try to adopt a more relaxed pace. Assess your time commitments, and don’t feel guilty or obligated if you say no to job or personal requests or social invitations that you know you can’t handle. Look to others for help or delegate responsibilities.

Relieving work-related stress. Job frustration can be a major source of stress. To relieve worry and disappointment, take time to do high-quality work but don’t strive for perfection. Show respect for others and a willingness to resolve conflicts with co-workers. Identify skills you’ll need for your long-term career goals and create a plan for developing those skills.

Building a financial cushion. Try to put aside a portion of every paycheck into a savings account or low-risk investment. Having reserve funds in the bank is one way to cope with unexpected financial stress such as the loss of a job, a salary cut or a large, unplanned-for expense. Even if an emergency use for the money never arrives, just knowing that you have a financial cushion can reduce stress.

Moving more. Add at least 10 minutes of moderate physical activity to what you already do every day. Adding just this much physical activity makes a difference. Did you know that just 60 to 90 minutes a week of physical activity can reduce your heart disease risk by up to half? That’s a big benefit from a pretty small commitment on your part. It doesn’t have to be elaborate. Take the stairs, take a walk — just get moving. As you become more active, work toward increasing your total amount of physical activity every day.

Eating well. Stress and overeating go hand in hand. Many people turn to high-calorie, high-fat comfort food when they’re dealing with a difficult problem or are at a weak emotional point. If the urge strikes, try to distract yourself by calling a friend or going for a walk. When your mind is occupied with something positive, the urge can quickly go away.

A healthy approach to eating includes a wide variety of foods that taste good and are simple to prepare. It emphasizes vegetables, fruits and whole grains, which are packed with nutrition but are low in calories for their bulk — so they fill you up but not out. These foods contain antioxidants, dietary fiber and other disease-fighting substances that help keep your body systems in good working order. Learn more about healthy eating in Chapter 1.

Getting plenty of sleep. Studies show that people who have poor sleep quality are more likely to develop hypertension. Poor sleep quality includes chronic insomnia, reduced sleep duration and disrupted sleep. Sleep apnea can cause and aggravate high blood pressure. (Learn more about sleep apnea in this section.)

When you’re refreshed from a good night’s sleep, you’re better able to manage the stressors that come your way the next day. Going to bed and awakening at consistent times each day can help you sleep better. Slow the pace of your evening activities to establish a calming environment. A bedtime routine, such as reading or listening to music, can aid in falling asleep.

Straightening up. Observe your posture when you feel overly stressed. You may find that you slump your shoulders, your breathing becomes shallow, and you’re less active. Stress may cause you to neglect your appearance.

Good posture helps relieve aches and pain sby placing minimal strain on your muscles and allowing you to move efficiently. To promote good posture, stand with your weight on both feet, shoulders back and stomach muscles tight. Keep your back well-supported when you’re seated. Stick to your regular routines and take time for good grooming.

Taking occasional breaks. Take opportunities to stretch, walk and relax during your regular day. Use brief vacations, even if they’re just for a day or the weekend, to allow yourself time away from stressful environments. Pursue hobbies and recreational activities that you enjoy. Quality leisure time reduces stress and improves your outlook on life.

Maintaining social relationships. In times of high stress, it’s common to isolate yourself from others. But friends and family can provide a valuable release valve when you need to vent your emotions. They can also give you encouragement and helpful advice.

However, try to avoid confiding in people who tend to be negative about everything and who foster bad feelings. Try to surround yourself with people who will support you.

Thinking positively

Studies indicate that an optimistic attitude helps you to cope better with stressful situations, likely reducing the effects that stress has on your body. So it’s not surprising that a pessimistic outlook can make it much harder to deal with even minor stressors.

Monitor self-talk

The endless stream of thoughts that run through your head can be positive or negative. You can reduce stress by learning how to reframe negative thoughts and practice positive thinking. For example, instead of telling yourself “I should never make a mistake because I’ll look foolish,” try thinking, “Everyone makes mistakes. I will learn from this experience.” This approach can make your outlook more realistic and self-affirming.

Manage your anger

Everyday frustrations can cause your temper to flare. But if your blood boils after even minor irritations or you’re constantly seething, you may need to work at getting your anger under control. Anger itself isn’t bad and, when expressed appropriately, can be healthy. But anger that’s out of control is destructive, leading to problems in your relationships, health and enjoyment of life.

How can you control anger? Think carefully before saying something you’ll later regret. Take a moment to pause — count to 10 before reacting or leave the situation entirely if you can. Find ways to calm and soothe yourself. Express your anger as soon as possible in a controlled and appropriate manner that respects the rights of others so that you aren’t left stewing. And avoid holding grudges.

Look for humor

Laughter is a natural high — it doesn’t just lighten your load mentally, it actually induces physical reactions in your body. When you laugh, your heart, lungs and muscles are stimulated. Laughter also releases chemicals in your brain called endorphins that ease pain and enhance a feeling of well-being. If you use humor to deal with setbacks positively, you’re more likely to take a positive approach.

Schedule worry time

Setting aside time for problem-solving can help keep worries from building up inside you or keeping you awake at night. Devote time each day to work on solutions to problems that are causing stress and assess your progress in solving them. If a worry crops up outside of worry time, write it down and worry about it later. Plan a positive activity to engage in after your worry time.

Learning to relax

Not all stress is avoidable. There are certain events in life that you can’t prevent, such as a loved one having health problems or dealing with multiple demands at the same time. But you can reduce the emotional and physical toll these events can take on you.

When you’re feeling stressed, take a moment to relax your body and clear your head. The following strategies are designed to help you achieve this. However, keep in mind that relaxation doesn’t happen automatically. For you to develop this skill, you need to give it time to see results. If you’re not successful, consult a qualified licensed mental health professional.

Relaxed breathing

Stress typically causes rapid, shallow breathing from your chest, which sustains other aspects of the stress reaction, such as rapid heart rate and perspiration. You breathe correctly when you breathe deeply from your diaphragm, and your abdomen — not your chest — moves with each breath.

Deep, slow breathing from your diaphragm is relaxing. It also exchanges more carbon dioxide for oxygen to give you more energy. It acts on centers in your brain that lower blood pressure. If you’re able to control shallow breathing and to relax, the effects of acute stress will decrease (see below).

A medical device called Resperate is designed to help lower blood pressure with deep breathing. The device includes a respiration sensor, headphones and a small unit that looks like a portable CD player. Resperate analyzes your breathing pattern and then creates two distinct melodic tones to guide your inhalation and exhalation. If you’re synchronized to the melody, you can slow your breathing to fewer than 10 breaths a minute.

To achieve a lasting reduction in systolic pressure, you’ll need to use Res-perate for about 15 minutes several days a week. If you stop doing the breathing exercises, your systolic pressure will rise again.

Recent research on Resperate doesn’t show clear evidence of its benefit, but it can be considered when anxiety accompanies high blood pressure or when standard treatments for high blood pressure aren’t well-tolerated.

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Taking a breather

Here’s an exercise to help you practice relaxed breathing.

1.  Wear comfortable clothes that are loose around your waist. You may lie on your back or sit in a chair, whichever you prefer.

2.  Lie with your feet slightly apart, with one hand resting on your abdomen and the other hand on your chest. If you’re sitting, place your feet flat on the floor, relax your shoulders and place your hands in your lap or at your side.

3.  Inhale through your nose, if you can, because this filters and warms the air. Exhale through your mouth.

4.  Concentrate on your breathing for a few minutes, then gently exhale most of the air in your lungs.

5.  Inhale while slowly counting to four, about one second per count. As you inhale, slightly raise your abdomen about 1 inch. You should be able to feel the movement with your hand.

6.  As you breathe in, imagine the air flowing to all parts of your body, supplying you with cleansing, energizing oxygen.

7.  Pause for a second with the air in your lungs. Then slowly exhale, counting to four. You’ll feel your abdomen slowly fall as your diaphragm relaxes. Imagine the tension flowing out of you.

8.  Pause for a moment. Then repeat this exercise for one to two minutes, until you feel better. If you experience lightheadedness, shorten the length or depth of your breathing.

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Muscle tension exercises

Mounting tension and stress can cause your muscles to tighten, especially in your shoulders and neck. To relieve the tightness, roll your shoulders, raising them toward your ears. Then relax your shoulders and neck.

To further reduce neck tension, gently move your head clockwise in a circle, then counterclockwise. To relieve tension in your back and torso, reach toward the ceiling and do side bends. For foot and leg tension, draw circles in the air with your feet while flexing your toes.

Progressive muscle relaxation can help reduce tension, anxiety and stress related to conditions such as high blood pressure and headaches. Starting with your feet and working up through your body to your head and neck, tense each muscle group for at least five seconds and then relax the muscles for up to 30 seconds. Repeat before moving to the next muscle group.

Guided imagery

Also known as visualization, this method of relaxation relies on memories or images to see with your mind’s eye. You experience a peaceful setting with all of your senses, as if you were actually there, imagining the sounds, scents, colors and tactile sensations. The messages your brain receives from this imagery help your body relax.

Meditation

When you meditate, you focus attention on your breathing or on repeating a word, phrase or sound to clear your mind of distracting thoughts. Most types of meditation require four elements: a quiet place, relaxed posture, focused attention and an open attitude that allows distractions to come and go without suppressing them. Rather, you gently bring your attention back to the focus.

Meditation is believed to lead to a state of physical relaxation and psychological balance. It’s also been shown to affect your body’s stress reaction.

Mindfulness

Mindfulness is the act of being intensely aware of what you’re sensing and feeling at every moment — without interpretation or judgment. There are many ways to practice mindfulness. For example, try looking at familiar objects in a new way. Find a few small, familiar objects — such as a toothbrush, apple or cellphone — in your home or office. Look at the objects with fresh eyes. Identify one new detail about each object that you didn’t see before. As you become more aware of your world, you might become fonder of the things around you. This form of meditation can help reduce stress, anxiety and depression. It can also help you reduce negative thoughts and distractions and improve your mood.

Professional help

Sometimes, life’s problems pile up and become more than you can deal with on your own. If you feel overwhelmed by stress, consider getting help from your doctor or a licensed mental health professional. Some people believe that seeking outside help is a sign of weakness. Nothing could be further from the truth. It takes strength of character to admit you need help.

Learning how to control stress won’t guarantee you’ll have a normal blood pressure, let alone a relaxed life and good health. Unexpected stressors will still occur. But having the tools to cope with stress can make those challenges easier to overcome — and your blood pressure easier to control.

Taking your blood pressure at home

The doctor’s office isn’t the only place to measure your blood pressure. Often, you’ll need to regularly monitor your blood pressure on your own at home. Home monitoring allows you to track your blood pressure in daily circumstances separate from a medical office or hospital visit. The record you compile often is vital to your blood pressure treatment program.

If your blood pressure is well-controlled, you may need to only check it at home a few days each month. Take two readings in the morning and two in the evening on a day that you’re working and two pairs of readings on a day that you’re relaxing. If you’re just starting home monitoring, if you’re making changes in medications or if you have other health problems, you may need to check it more often.

Based on the report from the panel members appointed to the Eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, referred to as JNC-8P, 2014 evidence-based guidelines advise keeping your blood pressure less than:

•  150/90 mm Hg if you’re a healthy adult age 60 or older

•  140/90 mm Hg if you’re a healthy adult younger than age 60

•  140/90 mm Hg if you have diabetes or chronic kidney disease

Note: Your blood pressure at home generally will be slightly lower than it is in a medical setting.

Benefits of home monitoring

Measuring your blood pressure at home can help:

Track the progress of your treatment. Because high blood pressure has no symptoms, the only way for you to know if your treatment is working is to check your blood pressure regularly.

Monitoring your blood pressure at home provides vital information between medical visits that you can share with your doctor.

Promote better control. Taking responsibility for measuring your blood pressure tends to motivate you in other areas of your program. It can give you added incentive to eat a better diet, increase your activity level and take your medication properly.

Identify your usual blood pressure. For some people, simply going to a doctor’s office causes their blood pressure to temporarily increase to a high level. For others, the opposite happens — their blood pressure drops during doctor appointments (see “White coat hypertension and masked hypertension”).

Home monitoring can help identify or confirm your usual blood pressure.

Save money. Home monitoring saves you the cost of going to your doctor’s office every time you need a blood pressure reading. This is especially true when you first start taking medications or your doctor adjusts the dosage. With these changes, frequent measurements help ensure better control.

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How to do it

Using an electronic model involves sitting with your arm at heart level, placing the cuff around your upper arm, relaxing, and pressing a button to inflate the cuff and get a reading.

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Types of blood pressure monitors

Not all blood pressure monitors are the same: Some are easier to use, some are more reliable, and some are simply inaccurate and a waste of money. To get an accurate reading, an appropriately sized cuff should be wrapped around your upper arm. It’s important that the cuff fits properly. A cuff that’s too narrow or too wide won’t provide accurate readings.

The inflatable bladder in the cuff should cover about 80 percent of your upper arm and two-thirds of the distance from your elbow to your shoulder. Ideally, the cuff will have a D-ring fastener to securely close it. Have your doctor measure your arm to determine the appropriate size of the cuff, particularly if you have a large upper arm.

Automatic models

Also referred to as digital electronic blood pressure monitors, these models are the most popular and easiest to use for home monitoring. They also tend to be more expensive than aneroid devices, though the cost continues to decline. Automatic blood pressure monitors detect motion in the artery wall rather than the sound of blood flow.

Automatic blood pressure monitors generally require you to do two things — properly wrap the inflatable cuff around your arm and push a button with your finger. The cuff automatically inflates with air and then slowly deflates. Your blood pressure and heart rate are displayed on the digital gauge.If you need a large-sized adult cuff, several automatic monitors come with both regular and large cuffs or a choice between the two sizes when you purchase them.

If you have an irregular heart rhythm, check with your doctor before you buy an automatic model — it may not give you an accurate reading. Some newer digital units can sense an irregular pulse accurately. This feature is generally listed on the unit’s packaging.

Finger or wrist models

To make blood pressure monitors more compact and easy to use, some manufacturers have produced models that measure blood pressure in your wrist or finger, instead of your upper arm. To get an accurate reading at either of these locations, it’s very important that your hand and wrist be at heart level. Unfortunately, the technology of finger monitors is not equal to their simplicity of use. Avoid them because they’re inaccurate. Wrist monitors also are difficult to check for accuracy.

Home monitoring tips

Learning to take a blood pressure reading correctly takes a little training and practice, but the monitors are not difficult to use. A variety of monitors are available at medical supply stores and many pharmacies. (See the Additional Resources section in this book for resources that can help guide your selection.)

After you purchase a monitor, take it with you to your next doctor’s visit. In addition to making sure the device works properly, the doctor or nurse can teach you how to use it and answer your questions. Keep in mind that if you have an irregular heart rhythm, getting an accurate reading from these devices will be more difficult.

To get an accurate reading of your blood pressure, take these steps:

•  Don’t measure your blood pressure right after you get up in the morning. Wait until after you’ve been active for at least an hour. Your blood pressure varies throughout the day, and readings are often a little higher in the morning than they are later in the afternoon and early evening.

•  Take a reading before you eat or wait at least a half hour after you eat, smoke, or use caffeine or alcohol. Tobacco, caffeine and alcohol can temporarily increase your blood pressure. A meal, especially a large one, will decrease your blood pressure temporarily.

•  Go to the bathroom before the reading. A full bladder will slightly increase your blood pressure.

•  Your mood can affect your blood pressure. If you’ve had a difficult day, don’t be alarmed if your blood pressure reflects it.

•  Check your blood pressure before you exercise, not afterward.

To get an accurate reading, it’s important to use proper technique. Follow these seven steps listed here. Ask your doctor for additional instructions if needed.

Step 1: Sit comfortably. Keep your legs and ankles uncrossed and your back supported against the back of a chair. Stretch out your arm, palm upward. Place your feet flat on the floor and rest your arm on a tabletop or the arm of a chair. Your arm should be even with your heart.

If you’re right-handed, you may find it easier to measure pressure in your left arm and vice versa. But first, check the instructions for your device to make sure that it will sense your blood pressure with either arm.

From there, be consistent with which arm you use and take your blood pressure at consistent times, such as always in the morning or in the evening.

Step 2: Wrap the cuff around your bare arm; don’t wrap it over clothing. Rolling up a sleeve until it tightens around your arm can give you an inaccurate reading. You may need to slip your arm out of the sleeve. Place the cuff about about 1 inch above the bend of your elbow. The inflatable portion of the cuff should fit snugly around your arm.

Step 3: When you’re ready to take your blood pressure, sit quietly for three to five minutes.

Step 4: Place the digital screen where you can easily read it. Make sure it registers at zero before you inflate the cuff.

Step 5: Press start on the monitor. Remain still and quiet as the machine begins measuring. The cuff will inflate and then slowly deflate to take your measurement. When the reading is complete, the monitor will display your blood pressure and pulse on the digital panel. If the monitor doesn’t record a reading, reposition the cuff and try again. Rest quietly and wait about one to two minutes before taking another measurement.

Step 6: Wait a minute after the first reading and repeat the procedure to check for accuracy. If you have trouble getting consistent readings, check with your doctor. The problem may be your technique or your equipment. Also contact your doctor if you notice an unusual or persistent increase in your blood pressure.

Step 7: Record your numbers, either by writing the information down or by entering the information into an electronic personal health record. A sample log is shown below. Some monitors can upload your blood pressure readings automatically into a computer or mobile device or send them electronically to your doctor.

To view a video demonstration of how to use an electronic home blood pressure monitor, visit www.MayoClinic.org and search for “measure blood pressure using an automatic monitor.”

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• • • • •

Seeing your doctor regularly

It’s vital that you schedule regular checkups with your doctor to make sure you’re getting your blood pressure under control and your treatment program is progressing with no serious side effects or complications. A review of 22 years’ worth of data from the National Health and Nutrition Examination Survey shows that people with high blood pressure who have health care visits at least twice a year and receive treatment according to current hypertension guidelines can achieve better blood pressure control. When coupled with statin treatment, this approach can lead to fewer cardiovascular events.

If you have stage 1 hypertension and no evidence of organ damage, your doctor likely will want to see you again within one to two months after you start a treatment program.

During that first follow-up visit, your doctor will evaluate your progress, determine if your blood pressure has decreased, ask how efforts are going to change your lifestyle and check if there are any side effects to the medications you’re taking. If your blood pressure hasn’t decreased, your doctor may adjust your program.

If you have stage 2 hypertension and other medical problems that complicate your treatment, you may need to see your doctor more often — perhaps every two to four weeks until your blood pressure is under control.

Once your blood pressure is well-controlled, a visit to your doctor once or twice a year is often all that’s needed, unless you have a coexisting medical condition, such as diabetes, high cholesterol, or heart or kidney disease. Then, you’ll need to see your doctor more frequently. Monitoring your blood pressure at home can help you achieve good blood pressure control between visits, among other benefits. (See this section for more information on home blood pressure monitoring.)

Follow-up visits typically involve measuring your blood pressure at least twice, undergoing a general physical examination and having some routine tests. The tests can alert your doctor to possible problems resulting from medication or to a decline in your heart or kidney function related to high blood pressure. Follow-up visits are also a good time to talk with your doctor about issues related to your weight, diet and activity level, as well as other efforts to improve your lifestyle.

If your blood pressure doesn’t match the target goal you’ve set with your doctor, you may be tempted to give up the program. But don’t. Instead, talk to your doctor about why your treatment plan may not be working and consider the adjustments you can make. Reaching a target goal may simply take more time. You can help by:

•  Learning all you can about high blood pressure

•  Practicing good lifestyle habits, such as controlling your weight, eating well, being physically active, not smoking, limiting alcohol and managing stress

•  Reviewing medications and supplements you’re taking, both prescription and over-the-counter

•  Being optimistic and patient

•  Seeking out a high blood pressure specialist if you feel your treatment plan isn’t helping

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Will I be able to stop taking blood pressure medication?

You’ve taken your medication faithfully, and your blood pressure is within a normal range again. Now you’re wondering if one day you’ll be able to stop using drugs. The most likely answer is no.

Some people with high blood pressure that’s well-controlled are able to reduce the amount of medications they take daily. However, most people continue to take some medications for the rest of their lives. Blood pressure drugs ensure that your blood pressure stays at safe levels and can lower your risk of complications from uncontrolled hypertension — including stroke, heart attack, heart failure, kidney failure and dementia.

In a few cases, people with stage 1 hypertension who have maintained a normal blood pressure for at least a year can discontinue their medications. But to do this, your doctor needs to set up a plan for gradually reducing the medication. He or she will also want to see you frequently to make sure your blood pressure doesn’t increase again as you wean yourself from the drug.

To successfully manage your blood pressure without medication, controlling your weight, staying active, eating well, avoiding tobacco and limiting alcohol are essential. Some people who successfully taper off blood pressure drugs eventually need to go back on medication.

If unpleasant side effects are the main reason why you want to discontinue your medication, a better solution may be to work with your doctor to reduce or eliminate these side effects.

• • • • •

Avoiding drug interactions

The effectiveness of your medication depends in large part on you. When, how and with what you take your pills are important factors.

Taking medications correctly

You need to take your medications exactly as prescribed to get the best results. That may sound obvious, but by some estimates only half the people taking blood pressure medications do so in correct doses at correct times.

If you take your pills too early, you increase the level of the drug in your bloodstream. This overdose can produce symptoms and side effects such as lightheadedness and nausea.

If you take your pills too late or forget to take them, your blood pressure may increase as the drug levels decrease. And if you stop taking your pills entirely, your blood pressure may rebound to levels that are higher than before your condition was diagnosed.

It’s important to know the names and doses of all of the medications you take. To help you remember, keep a list in your purse or wallet and update it when necessary. Keep the original containers. Periodically take them to your doctor to make sure you’re taking the right drug in the proper dosage.

Here are other tips to help you take your medication properly:

•  Use daily activities as reminders. If you take a morning medication, put the pills near your breakfast dishes, toothbrush or razor — so long as it doesn’t endanger children or pets — or put a sticker near these items to remind you to take your pills.

•  Set a clock or wristwatch alarm. The alarm will remind you when it’s time to take your medication.

•  Use a pillbox. If you take several drugs, buy a pillbox with compartments for each day of the week. Load the box once a week to keep track of the pills you take and when.

•  Ask for help from a loved one. Ask a family member or trusted friend to remind you to take your pills, at least until you’ve integrated the habit into your daily routine.

•  Take pills with water. Water helps dissolve the drug. If you generally take your pills with another liquid, check with the doctor or pharmacist to make sure it mixes well with the medication. If you’re supposed to take your pills with food, do so. Otherwise the drug may not be absorbed properly into your bloodstream. At the same time, some medications should not be taken with grapefruit, grapefruit juice, Seville (sour) oranges or pomelos. (See this section for more information.)

•  Use good lighting. Don’t take your medication in the dark. You might unintentionally take the wrong pill or drop the pill and not realize it.

•  Note any side effects. Provide this information to your doctor at your next checkup. Your doctor may adjust the dosage or have you try a different medication. Many blood pressure drugs can produce side effects. However, with the right medication, most people experience few problems.

•  Refill your prescriptions in advance. Plan to refill your prescription at least a couple of weeks ahead, in case the unexpected upsets your routine. Snowstorms, the flu and accidents are just a few examples of surprises that can delay your trip to the pharmacy.

•  Don’t change your dosage. If your blood pressure increases even though you’re taking your medication properly, don’t increase the dosage on your own. Talk with your doctor first. Similarly, don’t decrease your dosage without first consulting your doctor.

Preventing interactions

Many medications can be used to control high blood pressure. Some produce dangerous side effects if they’re mixed with other prescription drugs, over-the-counter (OTC) medicines, nutritional and herbal supplements, illicit drugs, and even some foods. It’s important to tell your doctor about all of the medications you’re taking and ask about any potentially harmful interactions.

Prescription drugs

Many prescription drugs can interfere with certain blood pressure medications. Some prescription drugs, such as hormonal birth control and some antidepressants, can affect your blood pressure level.

Many common anti-inflammatory drugs can interfere with at least four different classes of blood pressure medications: diuretics, beta blockers, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs).

Anti-inflammatory drugs counteract the effects of diuretics by causing your body to retain sodium and fluid. They counteract the effects of beta blockers by preventing the production of chemicals that relax blood vessels. And they reduce the ability of ACE inhibitors and ARBs to widen blood vessels. When used with anti-inflammatory drugs, direct renin inhibitors (aliskiren) may affect kidney function.

If you’re taking a prescription medication, your doctor can adjust the dose of your blood pressure medication to counteract any negative effects. Problems most often develop when you use anti-inflammatory medications intermittently, so it’s important to tell your doctor if you take such drugs, even occasionally. Your doctor may switch your blood pressure medication to something that’s less affected by the prescription drug or recommend or prescribe a different pain medication that won’t interfere with your blood pressure medication.

Over-the-counter products

Pain relievers, decongestants and diet pills can pose problems if you’re taking blood pressure medication. When taken with certain blood pressure medications, some of these over-the-counter (OTC) products may increase your blood pressure.

OTC medications include adult aspirin (325 milligrams, or mg) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve).

People who take acetaminophen (Tylenol, others) daily are more likely to develop high blood pressure than are those who don’t. At the same time, there’s no proof that occasional use of acetaminophen causes any long-term increase in blood pressure. Low-dose aspirin (81 mg) doesn’t affect blood pressure control.

Use cold and allergy products with care. Read labels to see if they contain a decongestant such as pseudoephedrine or phenylephrine (also used in nasal sprays). These compounds relieve congestion by narrowing blood vessels, minimizing blood flow to a localized area. This can increase your blood pressure. Ask your doctor or pharmacist for guidance.

Illicit drugs

Cocaine narrows and inflames your blood vessels and interferes with the effects of blood pressure medications. Street drugs also can cause dangerous drug interactions.

Food

Grapefruit, grapefruit juice, Seville (sour) oranges and pomelos (a form of grapefruit native to India) can interfere with the ability of your intestinal wall to process certain calcium channel blockers. This causes the drug to build up in your body, which can lead to harmful side effects.

If you take the drugs nisoldipine (Sular), felodipine (Plendil), nifedipine (Adalat CC, Procardia, others) or verapamil (Calan SR, Covera-HS, others), don’t eat any of the citrus fruit mentioned above and don’t drink grapefruit juice.

Sweet oranges and tangerines generally don’t interfere with drug absorption.

Natural licorice, the bittersweet ingredient often added to chewing tobacco and some cough drops, can increase your blood pressure because it contains glycyrrhizic acid. This type of acid makes your kidneys retain sodium and fluid. If you take a diuretic to remove excess sodium and fluids, avoid natural licorice. Artificially flavored licorice — the kind often used in candy — isn’t a problem.

• • • • •

Nutritional and herbal supplements

Alternative health practices and products are becoming increasingly popular, but they aren’t always effective or safe. If you’re taking a supplement — or considering using one — talk with your doctor about it.

Supplements promoted to lower blood pressure
Coenzyme Q10 | Study results are inconclusive on whether it controls blood pressure.
Cola nut | The caffeine in cola nut might increase blood pressure in people with hypertension. This doesn’t seem to happen in people who regularly consume cola nut and other caffeinated products.
Fish oil capsules containing omega-3 fatty acids | Many studies show that omega-3 fatty acids may help reduce blood pressure. Effects have generally been small, and other trials have reported no benefit.
Garlic | Study results are mixed. No conclusive evidence it controls blood pressure.
Ginkgo | No conclusive evidence it controls blood pressure.
Green tea | No conclusive evidence it controls blood pressure.

Magnesium, potassium and calcium
Some, but not all, clinical trials have demonstrated a positive effect with magnesium; more research is needed. More research is also needed on the effect potassium may have on blood pressure. The role of dietary calcium for the prevention and treatment of hypertension is controversial. Further research is needed.

Vitamin C | No conclusive evidence it controls blood pressure.
Dark chocolate | Studies report a small decrease in blood pressure in people who eat small amounts of dark chocolate regularly.
Supplements that can increase blood pressure
Ephedra (ephedrine) | Claims to promote weight loss, provide herbal high. Avoid. Banned by Food and Drug Administration. Similar compounds include bitter orange (Citrus aurantium).
Natural licorice | Claims to cure ulcers, coughs and colds. Avoid. Can increase blood pressure.
Yohimbine | Claims to increase sexual desire. Avoid. Can increase blood pressure.

• • • • •

Reducing medication costs

Many blood pressure medications can become expensive if you have to take a drug every day for the rest of your life — a situation that’s magnified if you take two or more drugs daily. However, there are ways you can reduce your medication costs.

Generic drugs

Once a pharmaceutical company’s patent on a drug expires — usually after 20 years — other companies are free to make the drug from the same ingredients. This competition often spurs the original supplier to reduce the price. In addition, the cost of the new generic brands is usually lower because generic manufacturers don’t have to recoup the costs of research and development.

If you switch from a brand-name drug to a generic form, don’t be surprised if the new pills look different from the original. Generic drugs are often another shape and color. Because of this, read the label carefully to make sure that the dosage is the same as it was for the original drug.

A generic drug doesn’t face the same rigorous testing as a new brand-name drug. But the Food and Drug Administration does check to ensure that a generic drug delivers the same amount of active ingredient in the same amount of time as the original brand-name drug.

Generic drugs must meet the same standards of identity, quality and purity as required for brand-name products. Still, it’s a good idea to monitor your blood pressure more frequently when you first start taking a generic drug.

Splitting pills

Pills generally come in several doses. Many times higher dose pills cost only a little more than lower dose versions. For example, if your prescription is for 50-mg tablets, you can buy 100-mg tablets and split them to save money. You can purchase an inexpensive pill splitter at medical supply stores and some pharmacies. It’s more convenient and accurate than using a knife and a cutting board.

However, not all pills can be split. For example, this technique doesn’t work with capsules that have sustained-release granules. Nor should you split pills that are coated, to keep them from dissolving in your stomach. Cutting negates the coating’s effect.

In addition, the medication you take may not come in a larger dose that can be evenly divided. The pills must be cut into equal proportions. If you’re taking several medications or you have a condition that makes cutting difficult, pill splitting may become more of a hassle than help.

Check with your doctor or pharmacist before splitting your pills. Make sure it’s safe to do so. Even if you do split pills, follow up with your doctor to make sure your medication is working.

Buying in bulk

If you have health insurance that includes coverage for prescription medications, it’s important to know what your health plan covers. For example, some plans offer reduced copays when you use a preferred pharmacy or a mail-order pharmacy. Also, quantities dispensed may depend on whether you’re using a retail pharmacy or a mail-order pharmacy.

Comparison shopping for the best buy among pharmacies can be helpful if you do not have insurance coverage for prescription medications. Discount mail-order pharmacies are another option to check into. They can offer prescriptions at prices that are 10 to 35 percent lower than you’ll find at some pharmacies. The discount is available because the clearinghouse buys and sells in bulk.

A disadvantage of buying in bulk is that if you stockpile too much of the medication, some of it may reach its expiration date before you can use it. Also, if your doctor changes your prescription, you may end up with medication you can’t use. It’s best to buy enough for only three to six months.

Another disadvantage to buying from mail-order suppliers is that you miss having a pharmacist who’s familiar with your medical history and all of the medications you’re taking. But if you’re diligent about keeping your doctors updated on your medications, discount suppliers can provide a safe and wallet-friendly alternative.

Combination drugs

Some blood pressure medications are available as combination pills. For some people, these tablets can be less expensive than buying the pills separately. You can also save money on copayments by buying combination pills. Combination medications also decrease the number of pills you have to take.

If you take more than one blood pressure medication, ask your pharmacist if there’s a combination pill available, and if there is, check your health insurance plan to see if it’s covered. Then, talk with your doctor about prescribing a combination pill. If you’re concerned about the cost of your medications, ask your pharmacist whether a combination pill would save you money or if there are less-expensive alternatives.

Assistance programs

Some social service organizations and pharmaceutical companies offer free or reduced-price drugs to people facing financial hardship. Your doctor can refer you to the appropriate social services or drug manufacturer.

For more information on prescription assistance programs, contact the Partnership for Prescription Assistance at 888-4PPA-NOW (888-477-2669) or www.pparx.org.

Recognizing an emergency

Uncontrolled high blood pressure can gradually erode your health by wearing down many of your body systems and by damaging your organs.

Sometimes, though, blood pressure can rise high enough to suddenly become life-threatening, requiring immediate care. This is a hypertensive emergency. Hypertensive emergencies are rare. They happen when your blood pressure increases to a dangerously high level and are often accompanied by other serious symptoms.

Generally, a systolic reading of 180 mm Hg or higher or a diastolic reading of 110 mm Hg or higher is considered a dangerously high level. If you have another medical condition, lower elevations in your blood pressure also can trigger a hypertensive emergency. The danger level in children is lower, depending on age and height.

Causes of hypertensive emergencies may include:

•  Forgetting to take your blood pressure medication

•  Acute stroke

•  Acute heart attack

•  Heart failure

•  Kidney failure

•  Rupture of the aorta

•  Interaction between medications

•  Postoperative complications

•  Convulsions during pregnancy (eclampsia)

To prevent damage to your organs, your blood pressure needs to be lowered immediately but in controlled stages. Lowering it too fast can interfere with normal blood flow, possibly resulting in too little blood to your heart, brain and other organs. Learn more about how hypertensive emergencies are treated here.

• • • • •

Emergency warning signs

In addition to dangerously high blood pressure readings, signs and symptoms that often signal a hypertensive emergency include:

•  Severe headache, accompanied by confusion and blurred vision

•  Severe chest pain

•  Marked shortness of breath

•  Nausea and vomiting

•  Seizures

•  Unresponsiveness

Don’t drink or eat anything and, if you can, lie down until emergency help arrives or you get to a hospital.

• • • • •

Urgency vs. emergency

If at least two blood pressure measurements taken a few minutes apart produce a systolic reading of 180 mm Hg or higher or a diastolic reading of 110 mm Hg or higher — but you aren’t experiencing any other signs and symptoms — contact your doctor or another health care professional as soon as you can. If that isn’t possible, go to a hospital near you. Left untreated for more than a few hours, blood pressures this high could possibly lead to a medical emergency.

• • • • •

Wrap-up

Key points to remember:

•  Stress can increase your blood pressure temporarily and complicate existing high blood pressure.

•  Over time, the physical effects of stress can be damaging to your health and well-being.

•  Lifestyle changes, relaxation techniques and professional help can help you avoid or better manage stress and reduce health risks.

•  Monitoring your blood pressure at home helps you determine your usual blood pressure level, track the progress of your treatment and stay in control of your condition.

•  If you take blood pressure medication, it’s essential that you follow instructions as directed and take the medication at regular times.

•  Keep your doctor informed of all medications and supplements you’re taking because many can interfere with some blood pressure medications or even increase your blood pressure.

• • • • •

Chapter 11

Special concerns and conditions

High blood pressure increases with age. Almost everyone, regardless of race or gender, faces an increased risk of high blood pressure as he or she gets older. But the condition can affect anyone at any time.

Furthermore, researchers are finding that blood pressure is influenced by many different factors, including genetics and environment, often working together. When determining the best way to treat or prevent high blood pressure, all of these factors must be considered.

This chapter looks at factors unique to women and children and among specific populations, high blood pressure accompanied by other conditions and treatment of difficult-to-control high blood pressure. The course of treatment may vary in these situations.

Women

Not too long ago, most studies on high blood pressure primarily examined its effect on men. Yet, nearly half of all Americans diagnosed with high blood pressure are women.

It’s apparent that women often develop the disease for different reasons and at different times in their lives than do men, that they may have a different pattern of signs and symptoms, and that they may respond differently to medication, more studies are focusing on issues that specifically affect women.

Oral contraceptives

Oral contraceptives — the pill — are a common form of birth control. In most women, the pill doesn’t cause high blood pressure. But in some women, it can cause blood pressure to increase, especially if you’re over age 35, overweight or a smoker.

If you do develop high blood pressure while on the pill or you already have high blood pressure before you start taking it, consider a different form of birth control. If alternative birth control isn’t possible and you still want to take the pill, you’ll need to have your blood pressure checked regularly and take steps to lower your blood pressure through lifestyle changes and possibly with the help of medication.

Birth control pills aren’t recommended if you’re over 35 and smoke, because it increases the likelihood that you’ll develop heart disease or have a stroke. Having high blood pressure in addition to these other factors can increase your risks even more.

A word of caution: A contraceptive that combines drospirenone and ethinyl estradiol (Yasmin, YAZ, others) contains a synthetic progestin than can cause you to retain potassium. This could lead to abnormally high levels of potassium in your blood if you’re also taking a potassium-sparing diuretic, angiotensin-converting enzyme (ACE) inhibitor, angiotensin II receptor blocker (ARB) aldosterone antagonist or other medication to manage your high blood pressure. Check with your doctor before combining birth control pills and high blood pressure medications. Also: It’s important to note that drospirenone-containing birth control pills may be associated with a higher risk of blood clots than are other progestin-containing pills. Talk with your doctor about any concerns you have.

Pregnancy

It’s quite possible for women with high blood pressure to have a healthy pregnancy and childbirth, but they should take precautions, starting with regularly scheduled checkups.

In a normal pregnancy, blood pressure tends to fall during the second trimester. This pattern generally occurs for most women with high blood pressure, but some women will experience an increase. Also, if you have high blood pressure, you have a greater risk of complications during your pregnancy, which can affect both you and your unborn child. As a result, your doctor will want to monitor your pregnancy and your blood pressure closely, especially during the last three months (the third trimester), when complications are most likely to occur.

Uncommon, but possible, complications for the mother include heart failure, stroke and other issues related to uncontrolled high blood pressure. Preeclampsia or eclampsia, potentially dangerous conditions related to pregnancy, also may develop. (Read more about preeclampsia and eclampsia in this section).

Possible complications for the baby include impaired growth, greater risk of the placenta separating from the uterine wall and greater risk of getting reduced levels of oxygen during labor. Some of these complications can lead to early delivery of the baby, either through induction or a C-section.

If you have high blood pressure before conceiving, talk with your doctor about the possible health risks of becoming pregnant. Your doctor may recommend changing your medication because some blood pressure drugs shouldn’t be taken during pregnancy.

Also, take measures to keep your blood pressure under control, such as getting regular physical activity, losing weight if you need to and taking your medication as prescribed.

Tell your doctor as soon as you become pregnant. One of the most important things you can do to have a healthy pregnancy is to get early and regular prenatal care. In addition to routine checkups, you may need regular blood and urine tests and frequent ultrasounds of the developing fetus.

If you see more than one doctor during your pregnancy, tell each doctor that you have high blood pressure. Because blood pressure normally decreases during the early and middle stages of pregnancy, a doctor who doesn’t know your medical history may not realize you have high blood pressure.

If you need to take blood pressure medication during pregnancy, your doctor may recommend the central-acting drug methyldopa (Aldomet), labetalol (Trandate) or another type of beta blocker, or a calcium channel blocker.

At the same time, it’s important to know which medications to avoid during pregnancy. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) and renin inhibitors are types of blood pressure medications that can be harmful — and possibly fatal — to the baby. Read more about these medications in Chapter 5.

Gestational hypertension

A small percentage of healthy women develop high blood pressure during their pregnancies. It most often happens during the later stages of pregnancy, and in most cases the increase is mild. Once the pregnancy is complete, blood pressure returns to normal.

If you develop pregnancy-induced high blood pressure, especially if you remain within the stage 1 range, medication generally isn’t necessary. But it will be important to follow a diet that emphasizes whole grains, fruits, vegetables and low-fat dairy products — foods that help control high blood pressure. Only if your blood pressure increases a significant amount — putting your health or your baby’s health in jeopardy — is medication recommended.

Gestational hypertension is an early warning that you’re likely to develop hypertension and diseases related to it — such as heart disease or kidney disease — later in life.

Preeclampsia

Preeclampsia (pre-uh-KLAMP-se-uh) occurs in approximately 3 to 6 percent of pregnant women.

This condition is characterized by high blood pressure and signs of damage to another organ system, often the kidneys. It typically develops after the 20th week of pregnancy. Left untreated, preeclampsia can lead to serious, even deadly, complications.

The exact cause of preeclampsia is unknown, but certain factors can increase your risk. They include:

•  Pre-existing chronic high blood pressure

•  First pregnancy

•  Family history of preeclampsia

•  Carrying multiple fetuses

•  Diabetes

•  Kidney problems before pregnancy

•  Pregnancy at either end of the childbearing years — early teens or late 30s into 40s

Women who develop preeclampsia often have no symptoms at first. By the time they do appear, the condition is often advanced. Although swelling occurs in many normal pregnancies, obvious swelling in the face and hands and sudden weight gain of more than 2 pounds in a week due to fluid retention may be signs of this condition.

Other signs and symptoms include headache, vision problems and upper abdominal pain. If you experience any of these, you should be evaluated by your doctor. Some signs and symptoms occur in normal pregnancies and don’t mean that you have preeclampsia.

Your blood pressure and urine are checked routinely during your pregnancy. Your doctor also may perform blood tests to check your blood platelet count and to see how well your liver and kidneys are functioning. A low blood platelet level and increased liver enzyme values indicate a severe form of preeclampsia called HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome, which can become life-threatening.

If you have mild preeclampsia, your doctor will want to see you frequently to check your blood pressure and urine, do blood tests, and monitor the status of your baby. You also may need to check your blood pressure at home. To prevent the condition from worsening, your doctor may recommmend delivery at 37 weeks instead of waiting until labor begins normally.

Severe preeclampsia often requires a hospital stay so that your health and the health of your baby can be continuously monitored. You may be given medication to help control blood pressure and to prevent seizures. If your health or your baby’s health may be at significant risk, early delivery may be necessary. Labor may be induced or a C-section may be performed.

After delivery, your blood pressure should return to normal within several days to several weeks. If your blood pressure is still at stage 2 when you leave the hospital with your baby, you may need to take blood pressure medication. Most women are able to taper off the medication after a few months.

The American Congress of Obstetricians and Gynecologists recommends low-dose aspirin for women who have a medical history of early-onset preeclampsia, preterm delivery at less than 34 weeks of gestation or preeclampsia in more than one previous pregnancy. A draft recommendation from the U.S. Preventive Services Task Force advises the use of low-dose aspirin after 12 weeks gestation for women who are at high risk of preeclampsia. Aspirin therapy is not recommended to prevent preeclampsia in women who are at a low risk of developing the condition.

Calcium supplementation may also help prevent preeclampsia. Benefits are seen most in women with low calcium intake in their regular diet. The low risk and low cost of calcium supplements make them a consideration for women who are at high risk of preeclampsia.

Eclampsia

Eclampsia is a life-threatening condition in which a woman with preeclampsia has seizures but no neurological conditions. Signs and symptoms of eclampsia include:

•  Pain in the upper right side of your abdomen

•  Severe headache and vision problems, including flashing lights in your field of vision

•  Convulsions

•  Altered mental status

•  Shortness of breath

•  Unconsciousness

Eclampsia can permanently damage your brain, liver or kidneys, and it can be fatal for both you and your unborn child. Emergency delivery of the baby is necessary.

Menopause

Blood pressure generally increases after menopause, and so does the risk of high blood pressure. There has been some debate about whether these changes in blood pressure are truly due to menopause or are a consequence of age and weight gain.

After taking various factors into account, researchers have concluded that postmenopausal women are at higher risk of high blood pressure than are premenopausal women and that hormonal changes related to menopause may play a role.

It’s a fact that before menopause, women have a slightly lower diastolic pressure and systolic pressure than men do. After menopause, systolic pressure in women increases by about 5 millimeters of mercury (mm Hg).

Menopause-related increases in blood pressure can be attributed in part to increased salt sensitivity and weight gain, which are in turn associated with hormone changes during menopause. The medications used in hormone therapy for menopause also may contribute to blood pressure increases.

Hormone therapy may be prescribed for a limited time after menopause to reduce troublesome postmenopausal symptoms, such as hot flashes and vaginal dryness. Women older than age 50 who take hormone therapy may have a small increase — usually 1 to 2 mm Hg — in systolic blood pressure.

It’s best to discuss the risks and benefits of hormone therapy with your doctor. However, women who take hormone therapy respond to lifestyle changes and medications just as well as those who don’t take hormone therapy.

Children

At birth, an infant’s blood pressure is a lot lower than an adult’s. As children grow, their blood pressures slowly increase. After puberty, a teenager’s blood pressure values are comparable to that of an adult’s.

Blood pressure isn’t measured routinely in infants and toddlers because it’s hard to get an accurate reading. But young children can develop high blood pressure, and just as with adults, it may not have symptoms. It may not be suspected until more-obvious problems occur, such as unexplained irritability, vomiting, failure to grow properly, headache, chest pain or, in extreme cases, seizures or heart failure.

When your child reaches age 3, it’s appropriate to have his or her blood pressure checked at every well-child visit. To determine whether your child’s blood pressure is truly elevated, his or her blood pressure is rated on a percentile basis, taking into account age and height — charts are available that show this information.

At any age, tall children tend to have higher blood pressures than do children who are short or of average height. A child with a blood pressure reading above the 95th percentile is considered to have high blood pressure. A reading between the 90th and 94th percentile would indicate a child with prehypertension.

Children who are in grade school and younger often have a secondary cause of hypertension, but most adolescents don’t, meaning that they have primary, or essential, hypertension.

Secondary causes of hypertension may include obesity, sleep apnea, narrowing of a kidney artery, kidney failure and hormonal abnormalities. In children, sleep apnea is often due to enlarged tonsils and may be present with noisy breathing during sleep. Head trauma, brain infections and tumors also can cause hypertension. Coarctation of the aorta is a narrowing of the main artery from your heart (see this section for more information). This congenital problem, which causes high blood pressure in the upper part of the body, may escape detection until later in life.

Your doctor will determine if any tests are needed to find a cause for your child’s high blood pressure. If all test results are normal and all other possible causes are eliminated, then a child is considered to have essential hypertension. The condition may be related to lifestyle factors such as obesity, poor diet and lack of exercise. If more than one child in a family has high blood pressure, a genetic link may be suspected.

As an increasing number of young children become less physically active and more obese, more of them run the risk of developing high blood pressure in their teens. Between 1 and 5 percent of children in the U.S. have chronic high blood pressure. This percentage appears to increase substantially among children who are overweight or obese — several studies show that being obese nearly triples a child’s risk of hypertension. High cholesterol or other blood fat abnormalities often coexist with high blood pressure and will need management, as well.

For children with essential hypertension, lifestyle changes are commonly recommended. It can be hard for young people to stick to a healthy diet and regular exercise plan, especially for teenagers wanting to control their own lifestyle choices. Casting these goals as family priorities can reinforce the importance of these changes to your child’s and your family’s future health.

High blood pressure in children that’s ignored or uncontrolled can lead to the same kinds of problems as experienced by adults with the condition, including damage to organs such as the heart, brain, eyes and kidneys.

Your doctor may prescribe medication if your child’s blood pressure is quite high or if lifestyle changes aren’t working after three to six months. The same medications used to control blood pressure in adults are used for children, only in smaller doses. For information on blood pressure medications, see Chapter 5 in this book. Some clearly identifiable causes of the condition may be remedied with surgery.

Ethnic groups

Studies examining the prevalence of high blood pressure in America show that the condition affects many more blacks than it does whites, Hispanics and Asians. Hypertension in blacks also appears to be more likely to develop at a younger age and result in more-severe complications than it does for those in other American ethnic groups.

The reasons for these differences are unclear, although speculation abounds. But until scientists can find the basic causes of high blood pressure, it will likely be impossible to explain differences across populations.

Nonetheless, the risk factors for hypertension — such as obesity, sleep apnea, physical inactivity, too much sodium and not enough potassium, excessive alcohol intake, and not enough fruits and vegetables — remain the same across all ethnic groups. With proper medical care, the risk of stroke, heart attack and progressive kidney failure caused by high blood pressure can be reduced as well in blacks as it is in whites.

For blacks, initial treatment for high blood pressure typically includes a diuretic or a calcium channel blocker. If a combination of blood pressure drugs is needed, a calcium channel blocker is usually combined with an ACE inhibitor or an ARB. For blacks whose blood pressure doesn’t respond to combination therapy with a calcium channel blocker and an ACE inhibitor or ARB, a diuretic is often added.

It’s also important to note that black participants in the DASH-Sodium study had the greatest reduction in their blood pressure. Blacks also seem to benefit more than whites do from increasing their potassium intake.

Rates of high blood pressure can vary among different ethnic groups. The prevalence of high blood pressure among some populations of American Indians is higher than in whites. And among Hispanics and Asians, the rate of high blood pressure is slightly lower than in whites.

• • • • •

Pulse pressure

Pulse pressure is the difference between your systolic pressure and diastolic pressure readings. For example, if your systolic pressure is 120 mm Hg and your diastolic is 80 mm Hg, your pulse pressure is 40.

A pulse pressure greater than 60 is a risk factor for heart disease. A pulse pressure lower than 40 may mean you have poor heart function, while a higher pulse pressure may mean that your heart valves are leaky (valve regurgitation). Other conditions, including severe iron deficiency (anemia) and overactive thyroid (hyperthyroidism), can increase pulse pressure, too.

• • • • •

Other conditions

Often, high blood pressure is accompanied by other medical conditions that make it more difficult to treat and control. So if you have another chronic medical condition in addition to high blood pressure, it’s especially critical that you see your doctor regularly. Several examples follow.

Cardiovascular problems

Cardiovascular conditions that often coexist with hypertension include:

Arrhythmia

High blood pressure can cause your heart to beat in an irregular rhythm. You’re at greater risk of developing this condition if your blood contains low levels of potassium or magnesium. This sometimes happens due to treatment if you’re taking a diuretic. A high pulse pressure and thyroid disease will increase the risk, as well.

Controlling your high blood pressure decreases the pressure on your heart’s pumping ability and reduces the risk of cardiovascular complications such as the enlargement of your heart’s left ventricle. This, in turn, reduces the likelihood that you’ll develop an arrhythmia.

To help control or prevent arrhythmia, with your doctor’s consent, eat plenty of foods containing potassium and magnesium, such as fresh fruits and vegetables. If this doesn’t help, your doctor may recommend that you take supplements to keep your potassium and magnesium levels normal. Eating fish high in omega-3 fatty acids or taking a fish oil supplement also may help lower your risk of sudden death due to arrhythmia. See Chapter 1 to learn more about fish oil dosing and types of fish to eat.

Arteriosclerosis and atherosclerosis

Over time, high pressure in your arteries can make the vessel walls thick and stiff, which often restricts blood flow. This is called arteriosclerosis, or hardening of the arteries. Atherosclerosis is a specific type of arteriosclerosis caused by the buildup of fatty plaques in the walls of the arteries. (Learn more about these conditions in this section.)

In addition to high blood pressure, risk factors include smoking, abnormal blood fats, too much weight, lack of exercise, diabetes and excessive alcohol consumption. Your doctor may ask you to better manage these factors.

Your doctor may also prescribe a diuretic to lower your blood pressure or a beta blocker to lower your heart rate and your blood pressure. Beta blockers reduce your risk of heart attack and some heart rhythm problems. ACE inhibitors and ARBs may help reverse the stiffness in your blood vessels.

Coronary artery disease

High blood pressure often coexists with coronary artery disease. Having high blood pressure puts added force against the walls of your arteries, which can damage the blood vessels and increase your risk of atherosclerosis. Atherosclerosis obstructs blood vessels, including the coronary arteries — your heart’s own circulatory system. The inadequate blood flow damages the heart muscle, increasing your risk of chest pain (angina), heart attack and heart failure.

Diuretics, beta blockers, ACE inhibitors, ARBs and aldosterone antagonists are often used to treat people with high blood pressure and coronary artery disease. That’s because, in addition to lowering blood pressure, they reduce the risk of heart attack and heart failure. A beta blocker and calcium antagonist may be prescribed to relieve angina and, in some cases, reduce the risk of a second heart attack. Beta blockers have been shown to reduce the amount of atherosclerotic plaques in coronary arteries. In certain cases, surgical treatment of the coronary arteries, including angioplasty and the placement of stents, may be considered to keep the vessels open.

Your doctor may suggest daily aspirin therapy if you’ve already had a heart attack or stroke or if you haven’t had a heart attack, but you have had a stent placed in a coronary artery, have had coronary bypass surgery, or have chest pain due to coronary artery disease (angina). If you’ve never had a heart attack, but you’re at high risk of having one, the benefit of aspirin therapy is unclear. Clinical research focused on aspirin use to prevent heart attacks is ongoing. If you are at high risk of having a heart attack, talk to your doctor about whether you should start daily aspirin therapy.

Heart failure

Heart failure can be the result of an enlarged, weakened heart, which has a hard time pumping enough blood to meet your body’s needs. Or the pumping may be normal, but a thickening of the pumping chamber on the left side of the heart doesn’t permit normal expansion and relaxation of the muscle (diastolic heart failure). In some cases, this can cause fluid to build up in your lungs or your feet and legs.

For this reason, your doctor will target a lower blood pressure so that your heart won’t have to work as hard. In fact, the most remarkable benefit of well-controlled high blood pressure is that it can lower your risk of developing heart failure by over 50 percent.

ACE inhibitors, ARBs and diuretics may be prescribed if you have heart failure and high blood pressure. ACE inhibitors and ARBs reduce blood pressure by dilating your blood vessels, without interfering with your heart’s pumping action. Diuretics reduce fluid buildup. The potassium-sparing diuretics spironolactone (Aldactone) and eplerenone (Inspra) — which block aldosterone — can offer lifesaving benefits for people with heart failure.

In most cases, a beta blocker also may be appropriate. If you don’t tolerate ACE inhibitors, your doctor may prescribe an alternative option, such as an ARB. Depending on your circumstances, you may choose to see a heart failure specialist because treatment programs for heart failure are complex and a heart transplant may need to be considered.

High cholesterol

Many people with high blood pressure also have high cholesterol. Because having both conditions increases your risk of heart attack and stroke, you’ll receive additional benefits from being able to lower both cholesterol and blood pressure.

The same lifestyle changes that help lower blood pressure can help lower cholesterol levels. However, many people with high cholesterol also may need a cholesterol-lowering medication. Several studies show that statins, a class of drugs often used to lower cholesterol, also seem to help lower systolic blood pressure, but more research is needed to confirm these results.

As for blood pressure medications, don’t take high doses of thiazide and loop diuretics if you also have high cholesterol. They can increase your cholesterol level and your triglycerides, another type of blood fat. Low doses of these drugs don’t produce the same effects. Beta blockers also may slightly raise your cholesterol. If you need to take high doses of a beta blocker, having a good diet and taking cholesterol-lowering drugs can help counteract the increase.

Medications most often prescribed for high blood pressure and high cholesterol are ACE inhibitors, ARBs, calcium channel blockers, alpha blockers, central-acting agents and low-dose diuretics. A drug combining a calcium channel blocker and a statin also may be available with appropriate dosage of the individual drugs.

If you’re taking a cholesterol-lowering statin, it’s also important to avoid eating Seville (sour) oranges, pomelos or grapefruit, and drinking grapefruit juices. An interaction between the juice of these fruits and the statin can lead to a drug buildup in your blood. The same is true for some calcium channel blockers, so ask your doctor what he or she recommends.

Stroke and transient ischemic attack

Hypertension increases your risk of stroke and transient ischemic attack (TIA). If you’re older than 55 and you have a high pulse pressure, you may be at greater risk. Read more about the different types of stroke in Chapter 6.

The lifetime risk of stroke for adults at age 55 with normal blood pressure is 1 in 5 for women and 1 in 6 for men. In people who have hypertension, the risk of stroke almost doubles.

Thrombolytic therapy can help reduce the effects of an ischemic stroke if it’s given within the first hours after the onset of symptoms. The clot-busting (thrombolytic) drug is injected into your veins or arteries to dissolve a blood clot — a common cause of stroke.

Watch for these signs and symptoms if you think you or someone else may be having a stroke. Note when the following signs and symptoms begin; the length of time they have been present may guide your treatment decisions:

Trouble with walking. You may stumble or experience sudden dizziness, loss of balance or loss of coordination.

Trouble with speaking and understanding. You may experience confusion. You may slur your words or have difficulty understanding speech.

Trouble with seeing in one or both eyes. You may suddenly have blurred or blackened vision in one or both eyes, or you may see double.

Paralysis or numbness of the face, arm or leg. You may develop sudden numbness, weakness or paralysis in your face, arm or leg, especially on one side of your body. Try to raise both arms over your head at the same time. If one arm begins to fall, you may be having a stroke. When you try to smile, one side of your mouth may droop.

Headache. A sudden, severe headache, which may be accompanied by vomiting, dizziness or altered consciousness, may indicate that you’re having a stroke.

If you think that you’re having symptoms of a stroke, including sudden numbness in your face, arm or leg, difficulty speaking, and sudden dizziness, seek emergency medical treatment immediately.

If you’ve had a stroke or TIA, your doctor may have you take a diuretic and an ACE inhibitor to help reduce your risk of a second stroke. ARBs and calcium channel blockers also may be prescribed. Using these drugs to lower blood pressure can reduce the risk of another stroke even if you’ve never had high blood pressure. Research shows that diuretics or the combination of diuretics and an ACE inhibitor is useful in reducing stroke risk.

Aspirin and other drugs that inhibit blood clotting are important in preventing a recurrence. In some cases, angioplasty and stenting or other surgical procedures on the carotid arteries may be performed.

Vascular cognitive impairment

High blood pressure can cause extensive narrowing and blockage of the small and large arteries that supply blood to the brain or make it worse if you already have narrowing or blockage of these arteries. The reduced blood supply can lead to a series of small or even large strokes, leaving multiple areas of damaged brain tissue.

The result is an impairment of many physiological and cognitive skills such as speaking, reasoning, memory, vision and movement. This condition is known as vascular cognitive impairment, or more traditionally, vascular dementia. Although the connection isn’t entirely clear, midlife high blood pressure may increase your risk of developing Alzheimer’s disease. In addition, a 20-year study published in 2014 linked midlife hypertension and elevated systolic blood pressure in midlife to cognitive decline.

Although existing damage to brain tissue can’t be reversed, additional damage can be prevented.

Metabolic syndrome

Metabolic syndrome is a cluster of modifiable conditions that occur together in a recognizable pattern. Although a definition of the syndrome varies, the following conditions are generally involved:

•  Obesity, particularly carrying too much weight around your waist — having an apple shape. This means a waist circumference of over 40 inches in men and over 35 inches in women (among Asians, over 35 inches in men and over 31 inches in women).

•  Blood pressure of 130/85 mm Hg or greater or taking medication for high blood pressure.

•  Elevated level of triglycerides — 150 milligrams per deciliter (mg/dL) or greater — and low level of high-density lipoprotein (HDL, or the “good”) cholesterol (less than 40 mg/dL in men and less than 50 mg/dL in women), or taking medication to lower triglycerides.

•  High blood sugar (fasting blood sugar level of 100 mg/dL or greater) or taking medication to control blood sugar.

Any three of these criteria constitute a diagnosis of metabolic syndrome. Having just one of these conditions increases your risk of heart disease, stroke and diabetes. But in combination, the risk is even greater. Many people with metabolic syndrome may also have sleep apnea.

Research into understanding the complex processes that form this syndrome is ongoing. Many believe it’s caused by a mix of genetic and environmental factors, including insulin resistance, abdominal obesity, genetics, elevated blood pressure and chronic stress.

Metabolic syndrome A cluster of disorders of your body’s metabolism – including high blood pressure, elevated blood sugar, excess body weight, and abnormal cholesterol and triglyceride levels – makes you more likely to develop diabetes, heart disease and stroke.

The different components of metabolic syndrome are generally treated at the same time to reduce risk. Exercising regularly, losing weight, quitting smoking, and reducing intake of sodium, sugar, saturated fat and trans fats help improve all aspects of metabolic syndrome, including lowering blood pressure and reducing cholesterol and blood sugar levels.

If lifestyle modifications aren’t enough, your doctor may prescribe medications to lower blood pressure, control cholesterol or promote weight loss. Insulin sensitizers may help your body use insulin more effectively. If your risks are high, aspirin therapy may help reduce your risk of heart attack and stroke.

Diabetes

Diabetes and high blood pressure have a close association. According to the American Diabetes Association, about two-thirds of adults with diabetes report having high blood pressure and, conversely, people with untreated high blood pressure have a higher incidence of diabetes. Having both conditions is a serious concern.

Many of the complications associated with diabetes can be attributed to having high blood pressure. High blood pressure also increases your chances of death from diabetes. A combination of high blood pressure, diabetes, high cholesterol and tobacco use puts you at extremely high risk of heart attack.

Aim to achieve optimal blood pressure, blood sugar (glucose) and blood fats. If you have diabetes and high blood pressure, you want to reduce your blood pressure to 140/90 mm Hg or lower. Your doctor may want you to aim for 140/80 mm Hg, the blood pressure goal recommended by the American Diabetes Association, for example. If you also have kidney disease, your doctor may recommend setting an even lower goal, such as 130/80 mm Hg or lower, the goal recommended by Kidney Disease Improving Global Outcomes, which is managed by the National Kidney Foundation. Talk to your doctor about the blood pressure goal that makes the most sense for your specific situation. See this section for more on blood pressure and kidney disease.

Lifestyle changes can help reduce your risk of serious complications from both diabetes and high blood pressure: Eat a healthy diet, get regular exercise, limit your use of alcohol, and if you smoke or chew tobacco, stop doing so.

People who also have high cholesterol respond well to aggressive management. Lifestyle changes can reduce the risk of developing diabetes by half if you have prediabetes, impaired fasting glucose or obesity.

Medical therapy usually consists of ACE inhibitors or ARBs. They help protect your kidneys, which are at a higher risk of damage if you have both diseases. These drugs also have relatively few side effects.

Diuretics, beta blockers and calcium channel blockers also may be used to lower blood pressure and to prolong life. Alpha blockers are generally recommended last because they may worsen orthostatic hypotension, a problem in some people with diabetes, and increase the risk of heart failure.

Often, combination drug therapy is needed to reach your target goal. If you’re taking diuretics, your doctor will aim to keep your blood levels of potassium in the normal range — through diet or supplements — to reduce the likelihood of new-onset diabetes. If your blood pressure is controlled, daily aspirin is often advised.

Sleep apnea

Obstructive sleep apnea is a disorder in which breathing stops and starts repeatedly during sleep. It’s relatively common in people with high blood pressure, particularly in people with a difficult-to-control form. Daytime drowsiness, snoring and prolonged pauses in breathing while sleeping are clues that the condition may be present. Obstructed airways as well as disturbances in the way your brain controls breathing can cause sleep apnea.

Although obesity is a risk factor for both hypertension and sleep apnea, recent studies suggest that sleep apnea independently contributes to hypertension, whether a person is obese or not. One theory centers on the fact that when your breathing stops during sleep, these pauses activate sympathetic nerve pathways — the part of your nervous system that prepares your body to react to stress or danger.Activating this system raises blood pressure. Sleep apnea is also associated with frequent arousals in brain activity, after which breathing resumes. The exaggerated activation of sympathetic drive even during wakefulness — which occurs in people with sleep apnea — may result in a sustained increase in blood pressure.

More studies need to be done on the relationship between sleep apnea and hypertension. It’s likely that treating sleep apnea — with continuous positive airway pressure (CPAP) therapy, weight loss and regular exercise — will improve daytime and nighttime blood pressure as well and decrease your risk of cardiovascular disease.

• • • • •

Are your blood pressure readings misleading?

In rare cases, resistant high blood pressure may be the result of a mistake in your diagnosis. Several factors can make your blood pressure appear higher than it actually is. They are:

•  Pseudohypertension

•  White coat hypertension

•  Blood pressure cuff size that’s too small for your arm

See more information on pseudohypertension and white coat hypertension.

• • • • •

Kidney disease

Your kidneys play a vital role in removing extra fluid and waste from your body. This helps keep your blood pressure under control. But if the blood vessels in your kidneys are damaged from high blood pressure, the organs may become less efficient. This allows excess fluid to remain in your circulatory system, making high blood pressure worse. In turn, high blood pressure further weakens your kidneys.

Most people with chronic kidney disease also have high blood pressure. The more impaired the kidneys are, the greater the risk of coronary artery disease, a common cause of disability and death among people who have chronic kidney disease. Eventually, high blood pressure can lead to kidney (renal) failure, a condition in which your kidneys no longer function (kidney, or renal failure). In this end stage, life must be sustained with kidney dialysis or kidney transplant.

If you have kidney and heart disease as a result of high blood pressure, you’ll need to take medications and make lifestyle changes to prevent further damage to your kidneys and cardiovascular system. Blacks in America are more likely than are whites to develop kidney problems from high blood pressure. Early treatment of hypertension is the best option for preventing kidney problems from ever occurring.

If you have high blood pressure and kidney disease, the general goal is to reduce your blood pressure to below 140/90 mm Hg, or lower if you have severe kidney disease. If you have protein in your urine, your doctor may suggest a blood pressure goal of 130/80 mm Hg. Once your blood pressure is lowered, the decline in kidney function also slows. If you have advanced kidney failure, you’ll likely have special dietary needs that are best discussed with a dietitian.

If you have kidney disease, reduced sodium in your diet is important because impaired kidney function increases your level of sodium and fluids in your body.

Your choice of blood pressure medication also is important. Diuretics also help flush out excess fluid. ACE inhibitors and ARBs are often the best medications for preventing further damage to your kidneys, and may be combined with a diuretic. However, they need to be used with caution due to potential side effects, such as too much potassium in your blood (hyperkalemia). Multiple drugs are usually required to reach a blood pressure goal.

A potentially reversible cause of kidney failure is the narrowing of the main artery leading to one or both kidneys (see “Obstruction of the renal artery”). Atherosclerosis is the most common cause. Your doctor may consider widening the narrowed artery through angioplasty, stenting or surgery if your response to aggressive drug therapy is inadequate.

Denervation of the kidney arteries is a new approach being evaluated for treating difficult-to-treat high blood pressure. It’s a minimally invasive procedure that involves using an intra-arterial catheter to apply radiofrequency energy around the internal circumference of the arteries to both kidneys. This damages the nerves of the sympathetic nervous system that closely surround these arteries, changing the signals to the brain, which results in a persistent lower blood pressure.

Clinical research on this procedure is ongoing. However, careful studies on denervation of the kidneys have been conducted, and they have not been able to confirm that it can persistently reduce high blood pressure in people whose high blood pressure is resistant to medical treatment.

Sexual dysfunction

Some evidence shows a higher rate of sexual dysfunction in people who have high blood pressure. Erectile dysfunction (ED) is more likely in men with untreated high blood pressure than in those who take medication. Other risk factors are similar to those for heart disease and include diabetes, abnormal blood fats, obesity and lack of physical activity.

How high blood pressure affects sexual function in women isn’t well-understood, but it’s possible for high blood pressure to affect a woman’s sex life. High blood pressure can reduce blood flow to the vagina. For some women, this leads to a decrease in sexual desire or arousal, vaginal dryness, or difficulty achieving orgasm. Improving arousal and using lubrication can help.

As with men, women can experience anxiety and relationship issues due to sexual dysfunction. That’s why it’s important for both men and women to talk to their doctors if they experience sexual difficulties.

How hypertension and the medications used to treat it affect sexual function is a topic that’s received significant attention in men. Research shows that among frequently used blood pressure medications, thiazide diuretics and beta blockers — especially nonselective types of beta blockers— have been linked to sexual dysfunction in men.

If you do experience problems, you may be able to take a different blood pressure medication that is less likely to affect sexual function. ACE inhibitors, alpha blockers, calcium channel blockers and ARBs are all examples.

In addition, another class of drugs is available for men with erectile dysfunction that includes sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra). Ask your doctor if these medications might be appropriate for you.

Before starting a high blood pressure medication, don’t hesitate to discuss your current sexual function with your doctor. Also, once you start taking a high blood pressure medication, be sure to report any changes you experience.

Difficult-to-control high blood pressure

It’s rare for medications not to lower high blood pressure to the targeted goal in your treatment program. Often, it just takes time and trials with different drugs and doses to find the combination that works best.

But what if you’ve been following your doctor’s orders, watching your weight, getting exercise and taking your medication, but you still aren’t able to lower your blood pressure?

It could be that you’re among a small group of people with hypertension whose blood pressure is resistant, or refractory — which means it doesn’t fully respond to treatment. Resistant high blood pressure is defined as blood pressure that can’t be brought below 140/90 mm Hg despite using a combination of three different types of medication, including a diuretic.

But what if your medication isn’t working? Many times the first step is to try a different type of drug or a different combination of drugs in a single medication. A combination of drugs in a single formulation reduces the number of pills needed a day and can help you stick with your medication routine. Some medications simply work better for some people than for others.

The next step may be to add another medication to the one you’re already taking, perhaps even a third or even a fourth drug. Medications working in combination often have more powerful effects on your blood pressure than they would if you took them separately.

Common issues include inadequate diuretic therapy or the need for a more powerful diuretic, such as a loop diuretic.

Often, resistant high blood pressure stems from not making the lifestyle changes necessary to lower hypertension. If your blood pressure hasn’t responded to drug therapy, ask yourself the following questions:

•  Have I been taking my medication exactly as prescribed? Take your medication exactly as your doctor has ordered, or it may not work. If you think the pills cost too much or you find the regimen too hard to follow, talk to your doctor. Less expensive medications that you take only once a day can often be found.

•  Am I telling my doctor about all of the drugs and herbs I take? Many medications and supplements, including over-the-counter products, may interfere with blood pressure medication. They include nonsteroidal anti-inflammatory drugs (NSAIDs), steroid medications, cold medicines, ephedra-like compounds and herbs such as yohimbe.

•  Have I cut down on sodium? This doesn’t mean table salt alone. Even if you aren’t salting your foods, you may be eating processed foods with too much sodium. Read package labels to determine how much sodium is contained in a serving. Try to choose foods with less than 200 mg in a serving. (See Chapter 2 for more on sodium.)

•  Am I drinking too much alcohol? Alcohol can keep your blood pressure elevated, especially if you consume large amounts within a short time. Your medication may not be able to overcome the effects of alcohol, and alcohol may interfere with the action of the drug. Keep your alcohol use moderate. In general, that’s no more than two drinks a day for most men and no more than one drink a day for women. For more information, see Chapter 4.

•  Have I seriously tried to stop smoking? Like alcohol, tobacco products can keep blood pressure persistently high if you use them frequently.

•  Have I gained weight? Generally, losing weight decreases your blood pressure. Weight gain — as few as 10 pounds — can increase it and make it harder to control.

•  Have I been sleeping well? Sleep apnea can raise your blood pressure. The disorder occurs most frequently in older adults. Relieving sleep apnea can lower your blood pressure.

If you and your doctor have exhausted these possibilities, you still have other options. To start with, you may need to consider stepping up the positive changes to your lifestyle. If you can walk another block, lose one more pound or improve your diet, your high blood pressure treatment may work better. Reconsider the reversible causes of high blood pressure with your doctor, including medications for other conditions, certain supplements or foods, sleep apnea, or conditions such as kidney abnormalities.

Your other options include adding a fourth drug to your daily regimen or increasing the dosage of your current medication. Aldosterone blockers in particular can play an important role in cases of resistant high blood pressure. The danger in increasing dosages is an increased risk of side effects from the medication. If you aren’t already seeing a high blood pressure specialist, ask your doctor for a referral. See the Additional Resources section of this book for more information on finding high blood pressure specialists in your area.

New treatments for resistant high blood pressure are being investigated. They include a group of medications called endothelin receptor antagonists, denervation of the kidney arteries and an implanted device that stimulates the specialized parts of the carotid arteries in the neck that function in the regulation of heart rate and blood pressure (carotid sinus).

• • • • •

Wrap-up

Key points to remember:

•  Women and children have specific issues related to high blood pressure that merit special attention.

•  High blood pressure during pregnancy must be monitored closely because of the risk, if left untreated, to the mother and to the baby.

•  High blood pressure in children is often a sign of another health problem.

•  High blood pressure in blacks appears more likely to develop at a younger age and result in more-severe complications than for individuals in most other American ethnic groups.

•  Aggressive treatment is necessary when high blood pressure is associated with another condition such as diabetes, high cholesterol, cardiovascular disease, stroke or kidney disease.

•  Don’t settle for poorly controlled hypertension. Work with your doctor to achieve your treatment goals.

• • • • •

Glossary

A

aldosterone. A hormone secreted by the adrenal glands that regulates the balance of sodium and water in your body.

alpha blocker. A blood pressure medication that relaxes certain muscles and helps keep small blood vessels open. It’s typically prescribed with other medications.

angiotensin-converting enzyme (ACE) inhibitor. A medication that lowers blood pressure by disrupting the formation of angiotensin II.

angiotensin II. A substance that causes blood vessels to narrow (constrict) and stimulates the release of aldosterone.

angiotensin II receptor blocker (ARB). A blood pressure medication that blocks the action of angiotensin II in blood vessels. This drug affects angiotensin II at a different stage than does the ACE inhibitor.

antihypertensives. A name for all the medications used to control high blood pressure.

aorta. The largest artery, which receives blood from the heart’s left ventricle and supplies the other arteries in your circulatory system.

aortic valve. The valve between the left ventricle of the heart and aorta.

arrhythmia. Abnormal heartbeat.

arteriosclerosis. A condition in which the walls of arteries become hard and thick, sometimes interfering with the circulation of blood.

artery. A blood vessel that carries oxygenated blood from the heart to other tissues of the body.

atherosclerosis. A condition in which fatty deposits (plaque) accumulate in the interior lining of the arteries, resulting in narrowed pathways for blood to flow.

atria. Cavities or chambers, such as the two upper chambers of the heart that receive blood from veins. Singular form is atrium.

autonomic nervous system. Part of the body’s nervous system that controls involuntary actions, such as heart rate.

B

beta blocker. A drug that limits the activity epinephrine, which increases blood pressure and heart rate.

blood pressure. The force involved in keeping blood circulating continuously through your body. Pressure is placed on the inner walls of the arteries by the pumping action of the heart.

bruit. A French word used to describe the sound of turbulent blood flow, heard when a stethoscope is placed over a narrowed artery.

C

calcium channel blocker. A drug that lowers blood pressure by regulating calcium-related activity in the heart and blood vessels.

capillaries. Minute blood vessels that connect the smallest arteries to the smallest veins, forming intricate networks throughout the body.

cardiac. Relating to or situated near the heart.

cardiac cycle. The sequence of events that takes place in the heart from the beginning of one heartbeat to the beginning of the next.

cardiac output. The volume of blood that the heart pumps through the circulatory system in one minute.

cardiology. The study of the heart and its function in good health and with disease.

cardiomyopathy. A muscle disorder that impairs the heart’s ability to pump blood.

cardiopulmonary. Relating to the heart and lungs.

cardiovascular. Relating to the heart and blood vessels.

cardiovascular system. The body system that provides a steady supply of oxygen-rich blood to cells and removes their waste. The system includes the heart, arteries, veins and the lymphatic system.

carotid arteries. The main arteries located in the neck that carry blood to the brain.

cholesterol. A lipid or fat-like substance found in the bloodstream and in body cells. People with high levels of cholesterol over a long period of time are at greater risk of heart disease.

circulatory system. Relating to the heart and blood vessels such as arteries and veins, and to the circulation of blood.

coronary. Relating to blood vessels of the heart.

coronary arteries. The arteries that supply blood to the heart.

coronary artery disease. The narrowing or blockage of one or more of the coronary arteries, resulting in decreased blood supply to the heart muscle.

D

diabetes. A chronic disease characterized by high levels of sugar (glucose) in the blood, often resulting in severe damage to the heart, blood vessels, kidneys and nerves.

diastole. A stage of the heart cycle in which the heart muscle relaxes, allowing blood to enter the ventricles (lower chambers) from the atria (upper chambers). From the ventricles, the blood will be pumped out of the heart and into the aorta.

diastolic pressure. The lowest blood pressure reached when the heart muscle relaxes. Listed as the second, or bottom, number in a blood pressure reading.

diuretic. A medication that increases the flow of urine out of the body. It’s often used to treat conditions involving excess body fluids, such as high blood pressure and congestive heart failure.

E

edema. Swelling of body tissue due to the accumulation of excess fluid.

epinephrine. A naturally occurring hormone, also known as adrenaline, that helps prepare the body for danger or stress. It speeds up respiration and heart rate and increases blood pressure.

G

genetic. Relating to genes and to hereditary inheritance from parent to offspring.

glucose. A carbohydrate, also known as blood sugar, that’s the body’s main energy source.

H

HDL cholesterol. High-density lipoprotein cholesterol, also known as “good” cholesterol. A type of blood cholesterol thought to help protect against the accumulation of fatty deposits in blood vessels.

heart attack. An interruption in blood flow to the heart, causing the death of a part of the heart muscle. Often caused by blockage of one or more coronary arteries.

heart failure. A condition in which a weakened heart muscle is unable to pump enough blood to meet your body’s needs.

heart rate. The number of contractions of the heart in one minute, which may vary according to how much oxygen you need.

heredity. The transmission of genetic traits from parent to offspring.

high blood pressure. A condition in which blood is pumped through the body under abnormally high pressure. This is also commonly referred to as hypertension.

hyperkalemia. A condition caused by higher than normal levels of potassium in your blood.

hypernatremia. A condition caused by higher than normal levels of sodium in your blood.

hypertension. High blood pressure.

hypokalemia. A condition caused by lower than normal levels of potassium in your blood.

hyponatremia. A condition caused by lower than normal levels of sodium in your blood.

hypotension. Low blood pressure.

I

inferior vena cava. A large vein from the lower body that returns blood to the heart.

J

jugular veins. Veins in the neck that carry blood from the brain and head to the heart.

L

LDL cholesterol. Low-density lipoprotein cholesterol, also known as “bad” cholesterol. A type of blood cholesterol that, in excess amounts, tends to accumulate along artery walls, obstructing blood flow.

lipid. A fat or fat-like substance in the bloodstream and in body cells, such as cholesterol.

M

metabolic syndrome. A cluster of disorders of your body’s metabolism, including high blood pressure, elevated blood sugar levels, excess weight, and a combination of elevated triglycerides and a low level of HDL cholesterol.

mm Hg. An abbreviation for millimeters of mercury. Blood pressure is measured in these units.

myocardium. The muscular tissue layer in the wall of your heart.

N

noradrenaline. See norepinephrine.

norepinephrine. A hormone that’s called into action when your body is under stress. This hormone increases heart rate and blood pressure and affects other body functions.

O

orthostatic hypotension. A significant drop in systolic blood pressure when an individual assumes a standing position. May cause dizziness, lightheadedness or fainting.

P

parasympathetic nervous system. A component of the autonomic nervous system that slows heart rate, relaxes the gastrointestinal tract and increases gland activity.

plaque. Deposits of fat cells and other substances in the inner lining of blood vessels, resulting in narrowed, less flexible arteries and obstructed blood flow.

potassium. An essential mineral that helps control heart rhythm. It’s also important to the nervous system and to muscle function.

preeclampsia. A condition that can occur in late pregnancy that’s marked by high blood pressure and signs of damage to another organ system, often the kidneys.

pulmonary artery. A major blood vessel that carries oxygen-depleted blood from the heart to the lungs.

pulmonary veins. Several blood vessels that carry newly oxygenated blood from the lungs back to the heart.

pulse pressure. The difference between systolic blood pressure and diastolic blood pressure readings. A high pulse pressure may mean increased risk of cardiovascular disease and stroke.

R

renin inhibitor. A medication that reduces the production of angiotensin II, a chemical that causes blood vessels to constrict.

risk factors. Factors that increase your chances of developing a disease or condition.

S

sodium. A mineral that helps maintain the body’s fluid balance.

sodium sensitivity. A response in certain individuals to their sodium intake, which can lead to higher blood pressure.

sphygmomanometer. A device used to measure systolic and diastolic blood pressure.

stethoscope. An instrument used for listening to sounds produced in the body, such as the sound of blood flowing through the arteries.

stroke. Damage to the brain caused by a disruption of blood flow, either from blockage of an artery or from a rupture in the artery wall.

superior vena cava. The large vein returning blood from the head and arms to the heart.

sympathetic nervous system. Part of the autonomic nervous system that increases heart rate, constricts blood vessels and reduces digestion.

systole. A stage of the heart cycle in which the heart muscle squeezes (contracts) to push blood out of the heart and into the aorta, followed by the diastole stage.

systolic pressure. The highest blood pressure produced by the contraction of the heart muscle during the systole stage. Listed as the first, or top, number in a blood pressure reading.

T

transient ischemic attack (TIA). A stroke-like event caused by temporary blockage of a blood vessel from something such as a blood clot. It differs from a stroke in that signs and symptoms generally disappear completely within 24 hours.

V

vascular. Relating to blood vessels.

vasodilator. A medication that widens (dilates) blood vessels.

vasopressor. A medication that increases blood pressure.

vein. A blood vessel that returns oxygen-depleted blood to the heart. Pressure in veins tends to be low.

venous. Relating to your veins.

ventricles. The two main pumping chambers of the heart, located below the atria. The left ventricle pumps oxygenated blood to the body, and the right ventricle pumps deoxygenated blood to the lungs.

Additional Resources

Contact these organizations for more information about high blood pressure and associated conditions.

American College of Cardiology

2400 N St. NW
Washington, D.C. 20037
202-375-6000
www.cardiosource.org

American Diabetes Association

1701 N. Beauregard St.
Alexandria, VA 22311
800-DIABETES (800-342-2383)
www.diabetes.org

American Heart Association

7272 Greenville Ave.
Dallas, TX 75231
800-AHA-USA-1 (800-242-8721)
www.heart.org

American Society of Hypertension

45 Main St., Suite #712
Brooklyn, NY 11201
212-696-9099
www.ash-us.org
Note: Find a searchable directory of clinical hypertension specialists at
www.ash-us.org/Physician-Directory.aspx.

dabl Educational Trust

Carraig Court
Georges Avenue, Blackrock, Co.
Dublin, Ireland
http://dableducational.org

International Society of Hypertension

ISH Secretariat
c/o The Conference Collective Ltd.
Suite 2, Churcham House
1 Bridgeman Road
Teddington, Middlesex, TW11 9AJ
United Kingdom
011-44-20-8977-7997
http://ish-world.com/public/background-info.htm

National Heart, Lung,
and Blood Institute

P.O. Box 30105
Bethesda, MD 20824-0105
Recorded information:
301-592-8573
www.nhlbi.nih.gov

National Institute of Diabetes and Digestive and Kidney Diseases

Office of Communications and
Public Liaison
Building 1, Room 344
1 Center Drive, MSC 0188
Bethesda, MD 20892-0188
301-496-3583
www.niddk.nih.gov

National Kidney Foundation

30 E. 33rd St.
New York, NY 10016
800-622-9010
www.kidney.org

National Stroke Association

9707 E. Easter Lane, Suite B
Centennial, CO 80112
800-787-6537
www.stroke.org

World Hypertension League

8888 University Drive
Burnaby, BC
Canada V5A 1S6
406-961-6844
www.worldhypertensionleague.org