Hypertension Krause

8/11/2019 Hypertension Krause

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Hypertension is a common public heakh problem in developed countries. In the Unired States nearly one in threeadults has high blood pressure (Fields et a1., 2!". Untreated hypertension leads to rnany degenerativediseases, including heart #ailure, end$stager enal disease,a nd peripheral vasculard iseaseI.t is o#ten called a%silent killer% because people &ith hyperrension can be asymptomatic #or years and then have a #aral stroke orhearr attack. 'lthough no cure is available, h"ertension is easily detected and usually controllable. Some o# thedecline in cardiovascular disease ()*r+" mortality over the last t&o decades has been attributed to the increaseddetection and control o# hypertension. he emphasis on li#estyle modi#ications has given diet a prominent role in

both the primary prevention and nranag emento # hyper tension.-# those &ith high blood pressute,%/o to 0%/o have essential or primary hypertension #or &hich the causecannot be determined. ost likely, the cause is multi#actorial, including a combination o# environmental andgeneric #actors. ecently vascular in#lammation has been ti%tea &ith the initiation and development o#hyperrension (#ian$3un et al.,20". In the remaining 0o/%, hypertension arises as the resulto# another disease, usually endocrine, and thus is re#erred to as secondaryh ypertension+. epending on thee4tent o# the underlying disease,s econdaryh ypertension can be cured.

+err5rrro5'5+ )I5SSIFI)'I-5' generald e#initiono # hypertensionis persistentlyh igh arterialb loodp ressuret,h e #orcee 4ertedp erunit areao n the &alls o# arteries. o be de#ined as hypertension, the systolicb loodp ressure(S 67",t

he blood pressured uring the contraction phase o# the cardiac cycle, has to be 1! mm Hg or higher8or the diastolic blood pressure (+67", the pressured uring the rela4ationp haseo # thecardiac rycle, has to be mm Hg or higher, and they are reporteda s 1!/m m Hg. henormotensivien dividual hasa blood pressureo # lesst han 12m m Hg and a diastolicblood pressure o# less than 9 mm Hg8 read as a blood pressureo # 1219I.n the Seventh eport o#the 3oint 5ational )ommittee on 7revention, +etection, :valuation, and teatment o# High 6lood7ressure ()hobanian et al., 2;", hypertension is classi#ied in stagesb asedo n the risk o#developing)


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7nev'?:5c:' 5+I r,rcI+:5c:'bout 0 million 'merican adults age 19 and older have hypertension or are taking antihypertensive medication(Fields et al., 2!". +espite improvements in detection, the prevalence o# hlpertension has not declined. In 1and 2, 2o/% o# the adult U.S. population had high blood pressure,a ;.@o/oin crease# rom 199t o 11( HaAAarand Botchen, 2;". he increased prevalence may be related to an increase in body mass inde4 (6I" reportedover this decade. 6lack adults have a higher age$adAusted prevalence o# hypertension (;@C o# men8 ;C o#&omen" than non$Hispanic &hites (2!o/% o# men8 2;@o o# &omen" or e4ican$'mericans (2;Do o# men82;@% o#&omen". he prevalence o# high blood pressure in blacks is one o# the highest rates seen any&here in the &orld.6ecause blacks develop hypertension earlier in li#e and maintain higher blood pressure levels, their risk o# #atal

stroke, heart disease, or end$stage kidney disease is higher than in &hites ('merican Heart 'ssociation, 20".6lood pressure elevations are seen across the li#e span.'s much as 0@o o# the pediatric population, or appro4imately @ million 'merican children have high bloodpressure ('merican Heart 'ssociation, 20". Eith aging, the prevalenceo #high blood pressureincreases( Figure ;;$1". 6e#ore the age o# 00 more men than &omen have high blood pressure. '#ter age 00 therates o# high blood pressure among &omen in each racial group surpass those o# the men in their group (HaAAarand Botchen, 2;". 6ecause the prevalence o# hypertension rises &ith increasing age, more than hal# the olderadult population (G0 years o# age" in any racial group has hlryertension. 'lthough Ii#estyle interventions targetedto persons &ho are older may signi#icantly reduce the prevalence o# hlryertension, early intervention programsprovide the greatest longterm potential #or reducing the overall burden o# blood pressure$related complications(5ational High 6lood 7ressure :ducation 7rogram Eorking roup on High 6lood 7ressure in )hildren and'dolescents,2!".Individual a&areness o# hypertension has leveled o## since 1!. 6ased on analysis o# 5ational Health and5utrition :4amination Survey (5H'5:S" III data, GC o# people &ith hypertension are a&are that they have it

(ureshi et al, 20". )urrent hypertension control rates, although up #rom 1!, are still #ar belo& the Heahhy7eople 21 goal o# 0%/% o# the hypertensive population normali>ing their blood pressure &ith treatmentJ5though 0C o# hlpertensive adults are reportedly receiving treatment, only ;1%/% >re maintained at or belo& goal


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blood pressure levels (HaAAar and Botchen, 2;". In 2, &omen, older individuals, and e4ican$'mericanshad lo&er rates o# blood pressure control compared &ith men, younger individuals, and non$Hispanic &hites.Improving hypertension treatment among these %at risk% individuals through targeted intervention programsshould have a signi#icant impact on improved )*l+ outcomes in the United States.he relationship bet&een blood pressure and risk o# )*r+ events is continuous, consistent, and independent o#other risk #actors (5IH, 2!". he higher the blood pressure, the greater the chance o# target organ damage,including le#t ventricular hypertrophy, congestive heart #ailure, stroke, and kidney disease. 's evidence o# this, in

the 5H'5:S III survey, GGC o# adults &ith prehypertension had one maAor )esthe need #or increased education o# health care pro#essionals and the public about the importance o# earlydetection and treatment #or elevated blood pressure (5IH, 2!". Fortu$

nately e##ective screening and li#estyle modi#ication approaches are available to achieve this obAective.?o&ering blood pressure in patients &ith diabetes and hypertension is associated &ith a decrease in )*r+ eventsand renal #ailure (So&ers, 2;". he target blood pressure goal #or antihypertensive therapy in individuals &ithdiabetes is 1;/9 mm Hg. In 2 only 20%/% o# individuals &ith diabetes receiving antihypertension therapy metthis blood pressure goal (F=aAAar and Botchen, 2;". Eith the increased prevalence o# diabetes in the UnitedStates, uncontrolled hypertension &ith diabetes is an important public health problem that &arranrs artention.

-56I+ID '5+ on'?ID'lthough hlpertensive patienrs are o#ten asymptomatic, hypertension is not a benign disease. )ardiac,

cerebrovascular, and renal systems are a##ected by chronically elevated blood pressure (able ;;$2".High blood pressure &ast he primary or a contributory causein 2G1,o # the2.! million U.S. deaths in 22 ('H', 20". 6et&een 12a nd2 2t he age$adAustede athr ate #romhypertension increasedby 2@C8 overall deaths #rom hypertension increased by 0@o/%. +eath rates#rom hypertension are about ;.0 times higher in blacks than in &hites ('H', 20".H ypertensioni s a

maAor contributing# actort o atherosclerosist, h e underlying causeo # much )


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7nrHo7HDsro?ocy6lood pressure is a #unction o# cardiac output multiplied by peripheral resistance (the resistance in the bloodvessels to the #lo& o# blood". he diameter o# the blood vessel markedly a##ects blood #lo&. Ehen the diameter isdecreased (as in atherosclerosis" resistance and blood pressure increase. )onversely, &hen the diameter isincreased (as &ith vasodilator drug therapy", resistance decreases and blood pressure is lo&ered.any systems maintain homeostatic control o# blood pressure. he maAor regrrlators are the ryrnpathetic nervoussystem (#or short$term control" and the kidney (#or longterm control". In response to a #all in blood pressure, thes1Jrnpathetic nervous system secretes norepinephrine, a vasoconstrictor, &hich acts on small arteries andarterioles to increase peripheral resistance and raise blood pressure. he kidney regulates blood pressure by

controlling the e4tracellular #luid volume and secreting renin, &hich activates the renin$angiotensin system(Figure ;;$2". Ehen the regulatory mechanisms #alter, hypertension develops.


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7lausible causes o# hypertension are a hyperactive s".npathetic nervous system, an over$stimulated renin$angiotensin system, a lo&$potassium diet, and use o# the drug cyclosporine (Figure ;;$;". 'II o# these cause

renal vasoconstriction, &hich results in ischemia or arterial changes.)hronic in#lammation may be involved in the development o# hypertension as &ell. In#lammatory markers, inparticular )$reactive protein, have been sho&n to be elevated in patients &ith hypertension (Sesso et al, 2;".)$reactive protein inhibits #ormation o# nitric o4ide by endothelial cells, &hich in turn may promotevasoconstriction, leukocyte adherence, platelet activation, and thrombosis (6autista et al., 21".he etiology o# abnormal blood pressure is likely multi#actorial.In most cases o# hypertension, peripheral resistance increases. his resistance #orces the le#t venricle o#the heart to increase its e##ort in pumping blood through the system. Eith time, le#t ventricular hlpertrophy andeventually congestive heart #ailure can develop.

7I'D 7:


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a&arenessa, nd treatment o# hypertension have improved over the ; 0 years sincei ts inception.hesec hangesh avec ontributedt o the declinei n cardiovasculamr ortality seend uring the sametime period.7rimary prevention o# hypertension can improve Kuality o# li#e and costs associated& ith medicalmanagemento # hypertensiona nd its complications'. strategy# or the population &ould be to reduceblood pressurei n those &ith prehlpertension (above 12/9" but belo& the cut points #or

stage t h"ertension. ' do&n&ard shi#t o# ; mm Hg in S67 &ould decreaseth e mortality #rom strokeby 9%/% and #rom coronary heart disease tLy 0C ('ppel, 2;". 7ersons at highestr isk (6o4 ;;$2"shouldb e suongly encouragedto adopth ealthierl i#estyles.)hanging li#estyle #actors has documented e##icary in the primary prevention and control o#hypertension.hese# actorsa rep resentedin hble ;;$; andi ncludel osing &eight i# over&eight8li miting alcoholintake8a dopting a dietary pattern that emphasi>es#r uits, vegetablesa, nd lo&$#at dairy products8reducing #at, especiallys aturated #at, and cholesterol8 reducing intake o# dietary sodium8increasingp hysicala ctivity8 and stoppings moking( 5IH, 2!".In individuals& ith normal bloodpressurem, odi#ication o# these li#estyle #actors has been sho&n to lo&er blood pressure and therebyhas the potential to prevent hypertensiona nd lo&er the risk o#blood pressure$related complications. 'substantial body o# evidence strongly supports these li#estyle modi#ications as a means o#signi#icantlyl o&ering blood pressurei n individuals& ith hvpertension.

Eeight educt ionhere is a strong association bet&een 6I and hlpertension among men and &omen in all race or ethnic groupsand in most age$groups. 6ased on the 5H'5:S III survey, the prevalence o# high blood pressure in persons &itha 6I greater than ; kglm2 is !2%/% #or men and ;9@% #or &omen, compared &ith 10C #or men and &omen &ith

a normal 6I (M20 kglm2" (6ro&n, 2". he risk o# developing elevatedb lood pressurei s t&o to si4 timeshigher in over&eight than in normal$&eight persons (5rIH, 2!". isk estimates#r om populationstudiess uggesth at ;C or more o#caseso #hypertensionc anb e directlya ttributedt o obesity('H', 21". Eeight gain during adult li#e is responsible #or much o# the rise in blood pressures een&ith aging. Someo # the physiologicc hangesp roposedt o e4plaint he relationshipb et&eene 4cessb ody&eight and blood pressure are overactivation o# the sympathetic nervous and reninangiotensinsystems (:ngeli and Sharma, 21" and elevated levels o# in#lammatory path&ays (eerarani et a1.,2G".*!rnrally all clinical trials on &eight reduction and blood pressure support the e##icacy o# &eight loss on lo&eringblood pressure. In phase I o# the iial o# Hlpertension 7revention (FIe et al., 2", normotensive individuals &ho

lost an average o# ;.0 kg in an lS$month intervention reduced their S67 and +67 by 0.9 mm Hg and ;.2 mm Hg,respectively.Seven years a#ter trea##nent cessation, the incidence o# hlpertension &as 19.C in the &eight3oss group and!.0%/% in the control group. hese #indings suggest that improvements in blood pressure persist long a#tertrea##nent cessauon.' metaanalysis o# 20 randomi>ed controlled trials, totaling nearly 0 participants #rom di##erent ethnic groups,sho&ed a blood pressure reduction o# !.!/;.; mm Hg #or a 0$kg &eight loss by means o# energy restriction,increased physical activity, or both .=eter et al., 2;". eductions in blood pressure occurred &ithoutattainment o# desirable body &eight in most participants. ?arger blood pressure reductions &ere achieved inparticipants &ho lost more &eight and &ho &ere also taking antihypertensive medications.his latter #inding suggests a possible srnergistic e##ect bet&een &eight loss and drug therapy.Eeight reduction and maintenance o# a healthy body &eight ii a maAor e##ort #or many persons, especially &omen.Interventions to prevent &eight gain are ideal, particularly be#ore an individual reaches midli#e. 6I isrecommended as a screening tool in adolescence #or #uture health risk (ardin eta1.,22".In adults a 6I above; is the cuto## #or obesity, and re#erral to a registered dietitian (+" is &arranted.

Ehen alarge percentage o# the population is obese and hypertensive, better strategies are needed to prevente4cess &eight gain and improve compliance &ith treatrnent (5rIH,2!" (see )hapter 21".


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+ietary7 atterns

Several dietary patterns have been sho&n to lo&er blood pressure.


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Speci#icall yth, e +ietary' pproachetso Stop Hypertension (+'SH" +iet Study sho&s that this lo&$#atdietary pattern (including lean meats and nus &hile emphasi>ing #ruits, vegetablesa, nd non#at dairyproducts"d ecreasedS 67 an average o# G to 11 mm Hg and +67 by ; to G mm Hg('pp%l et al., 1@". he +'SH diet is #ound to be more e##ectivet han Aust adding #ruits andvegetablesto a lo&$#at dietary pattern (5IIH, 2G".he -mniHeart tial e4amined the e##ecs o# tluee versionso # the +'SH diet on blood pressurea nd

seruml ipids. he dies studied included the original +'SH diet, a highprotein version o# the +'SH dret(20%/% o# energy #rom protein, about hal##rom plant sources"a, nd a high$unsaturated#at +'SH diet (;1C o# calories# rom unsaturated#a t, mosdy monounsaturated"'. lthough eachd ietlo&eredS 67,s ubstituting some o# the carbohydrate (appro4imately 1C o# total calories" in the +'SHdiet &ith either protein or monounsaturated#a t achievedt he best reduction in bloodpressurea nd blood cholesterol( 'pp.l et al., 208 iller et al., 2G". his could be achieved bysubstituting some more nuts #or some o# the #ruit, bread, or cereal servings.6ecausem any hype#tensivep atientsa re over&eight,h ypocaloric versions o# the +'SH diet have alsobeen tested #or e##icacy in promoting &eight loss and blood pressure reduction. he E:?? diet study(5o&son et al., 20" #ound that, #or the same 0$kg &eight loss, a hlpocaloric +'SH diet versus a lo&$calorie#lo&$#at diet produced a greater reduction in S67 and +67.'lthough the +'SH diet is sa#e and currendy being advocated by the35) @ anek et al., 2;". In general, individuals&ho are more sensitive to the e##ects o# salt/sodium tend to be individuals &ho are black, obese, ormiddle$agea nd older, or those& ho have diabetes,c hronic kidney diseaseo, r hypertension( ohnsonet al., 22".) urrendy there are no practical methods #or identiS>ing the salt$sensitivein dividual #romthe salt$resistanitn dividual.

7hysica'l ctivity?ess active persons are ;o/o to 0o/o more likely to develop hypertension than their active counterparts.+espite the bene#is o# activity and e4ercise in reducing disease, many 'mericans remain inactive. Hispanics(;;o/o men, !Do &omen", blaclMs (2@C men,;!o/o &omen", and &hites (19olo men, 22o/o &omen" all have ahigh prevalence o# sedentary li#estyles ('II' 20".&o metaanalyses have demonstrated the bene#icial e##ects o# e4ercise on blood pressure. he #irst analysissho&ed that &alking reduced blood pressure in adults by an average o# 2C (Belley et al., 21". Second, in 0!randomi>ed clinical trials. aerobic e4ercise reduced blood pressure an average o# ! mm Hg #or S67 and 2 mmHg #or +67 in patients &ith and &ithout high blood pressure, irrespective o# body &eight change Ohelton et al.,22".hus increasing the amount o# physical activity o# lo&$tomoderate intensity to 3 to !0 minutes most days o# the&eek is an important adAunct to other strategies #or the primary prevention o# hypertension.

'lcoho)l onsumption


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Five to @C o# the hlpertension in the population is the result o# alcohol consumption ('pp%l et al.,2G". ' three drink$per$day amount (a total o# ; o> o# alcohol" is the threshold# or raisingb loodpressurea nd is associate&d ith a ;$mm Hg rise in S67. For preventing high blood pressure,alcohol intake should be less than t&o drinks per day (2! o> o# beer, l o> o# &ine, or ; o> o# 9$proo#&hiskey" in men. In &omen and lighter$&eight men, no more than one drink a day is recommended-IIH, 2!".

7otassiumIn observationasl tudiesd ietary potassiuma nd blood pressurea re inverselyr elated( i.e.,h igherpotassium intakes are associate&d ith lo&er blood pressures". esults# rom clinical trials onpotassium and blood pressure have been less consistent.H o&ever, a metaanalysiso # these trials#ound that high dietary potassiurn may help prevent and control hlpertension Ohelton et al., 1@".-n average a median doseo # 2.! g/day o# supplementapl otassiumre ducedS 67 and +67 by !.!and2.0 mm Hg in hlpertensivesa, nd 1.9 and I mm Hg in normotensives. he e##ectso # potassium&ere greater in blacks than &hites and in those &ith higher intakes o# sodium.7otassiumin take has alsob een relatedt o stroke mortality. In a large population$basedc oho#t, ahigher potassium intake &as associated& ith a ;9C lo&er risk o# stroke (#ucherio et al., 19". +ata#rom the 5FI'5:S III survey suggeststh at lo& dieary potassiumin take is associate&d ithan increasedr isk o# stroke (6a>>anoe t al., 21".H o&ever, more statistically signi#icant e##ects are#ound #or improved diet, aerobic e4ercise, alcohol and sodium restriction, and #ish oil supplements

than #or potassium supplements (+ickinson et al., 2Ga".he largen umber o# #ruits andv egetablesre commendedin the +'SH diet makes it easy to meetdietary poussium recommendations o# the 35) @ and the 'PI'$appro4imately !.@ g/day -IIH, 2!8'ppel et al., 2G". In individuals &ith medical conditions that could impair potassium e4cretion(e.g., chronic renal #ailure, diabetes, and congestive heart #ailure", a potassiumi ntake lesst han !.@g/day &ould be appropriate to prevent hyperkalemia.

ther+ ietaryF actors)alciumHigher dairy calcium versus nondairy calcium has been associated &ith a lo&er incidence o# strokeamong men and &omen (#ucherio et al, 19". hese #indings suggest that the e##ecs o# calcium maydi##er, depending on the #ood source, or alternatively that other constituents o# dairy may beresponsible# or the observeda ssociations7. eptidesd erived #rom milk proteins, especially #ermented

milk products, have been sho&n to #unction as angiotensin$converting enrymes, thereby lo&eringblood pressure (Seppo et al, 2;".' t presentt he35) @ repon recommendsa diet richin #ruits, vegetablesa, nd lo&$#at dairy productso ver calcium supplementation#o r the preventiona ndmanagemenot # elevatedb lood pressure( )hobaniane t al., 2;".' n intake o# dietary calcium tomeer the goal o# 1 to 2 mg daily is recommended.

agnesiumagnesium is a potent inhibitor o# vascular smooth$muscle contraction and may play a role in bloodpressure regulation as a vasodilator. In observational studies dietary magnesium&as inversely related to blood pressure ('scherio etil., 19". ?ess consistent #indings have beenreported #rom randomi>ed clinical trials o# magnesium supplementation #or blood pressure control(+ickinson et al., 2Gb". he +'SH dietaryp attern emphasi>es#o ods rich in magnesium,including green lea#irv egetablesn, uts, and &hole grain breads and cereals. -verall #ood sources o#magnesium rather than supplemental doses o# the nutrient are encouraged to prevent or control

hlpertension ()hobaniane t al, 2;".

?ipidsFe&er vegans have hypertension than omnivores, even though their salt intake is not signi#icandydi##erent. he vegand iet tendst o be higher in polyunsaturated#a tKJ acids (7UF#u", among othernutrients, and lo&er in total #at, saturated# atKJ acids,a nd cholesterol.7 UF's are precursorso#prostaglandins, &hose actions a##ect renal sodium e4cretion andr ela4v ascularm usculature. husan e##ecto n blood pressureis plausible.6oth the amount and type o# #at have been studied &ith respect to blood pressure. In several largeprospective observationasl tudiesa nd clinical trials, intake o# total #at and speci#ic# atty acidsh ad litdee##ecto n blood pressure( 'scherio et al, 19". ore recendy, studies have sho&n thatsupplementation& ith large doseso # #ish oil (mediand oseo #;.@ g/da#l can give a modest reduction inS67 and +67, especially in older hlryertensive persons (eleiAnse et al.,22". Side e##ecs o#

supplementation &ith #ish oils are #reKuent and include belching,g astrointestinadl istressa, ndhalitosis. For this reason and the high dose reKuirement, #ish oils are not routinely recommendeda sameanso # lo&ering blood pressure ('pp.l etal,2G".


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Factors other than dietary #at, such as increased potassium levels, appear to lo&er blood pressure invegans. 'lthough dietary lipids do not seem to a##ect blood pressure, they strongly a##ect )ing li#estyle modi#ication and drugtherapies to target coe4isting abnormalities (5IH, 2!". Health problems related to the metabolicsyndrome are e4pected to rise dramaticallyu nlesse ##ectivep opulation$basedh ealth promotionstrategies are promoted. Fortunately li#estyle modi#ications can prevent metabolic syndrome #romdeveloping (see )hapter ;2, and )linical InsigbtL he etabolic Syndrome in )hapter ".

edications' number o# medications either raise blood pressure or inter#ere &ith the e##ectivenesso #antihlpertensive drugs. hese include oral contraceptives, steroids, nonsteroidal antiin#lammatorydrugs, nasal decongestants and other cold remedies,a ppetite suppressantsc,y closporin tricyclicantidepressants,a nd monoamine$o4idasei nhibitors (see )hapter 1G and 'ppendi4 ;1".

:orc'? nn'c::5he goal o# hypertension management is to reduce morbidity and mortality #rom stroke, hlpertension$

associated heart diseasea, nd renal disease'. ccordingt o the 35) @ recommendations, threeobAectives #or evaluating patients &ith hypertension are to (l" identi#r the possible causes8(2" assessth e presenceo r absenceo # target organ disease and clinical )


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Eeight loss is an e##ective means o# lo&ering blood pressure in hypertensive individuals. For eachkilogram o# &eight lost, reductions in S67 and +67 o# appro4imately I mm Hg are e4pected( 5eter etal., 2;".H lryertensive patients &ho &eigh more than 1 I 0 C o# ideal body &eight should be placedon an individuali>ed &eight$reduction program that #ocuses on both hlpocaloric dietary intakeand e4ercise. 7ractical suggestions #or assisting clients in increasing physical activity and reducingcalories include reducing time spent &atching television or being online,increasing time spent &alking

or in activities that raise the heart rate, reducing portion si>es #or meals and snacks,reducing the si>eand #reKuency o# calorie$containing drinls, and limiting #at intake.In the +iet, :4ercise, and Eeight ?oss Intervention study, the goal #or energJy intake to #acilitate&eight loss &as 20 kcal/kg minus appro4imately 0 kcal daily to produce a -.!$kgl&eek (about l$lb"de#icit that &ould reach a total &eight loss o# !.0 kg (iller et al., 22". his modest caloric reduction&as associated &ith a signi#icant lo&ering o# S67 and +67, and lo&$density$lipoprotein cholesterollevels. For the same degree o# &eight loss, hypocaloric diets that include a lo&$sodium +'SH dietarypattern have produced more signi#icant blood pressure reductions than lo&$calorie diets emphasi>ingonly lo&$#at #oods (5o&son et al., 20".'nother bene#it o# &eight loss on blood pressure is the synergistic e##ect &ith drug therapy. In subAecs&ho lost &eight and &ere aking one antihlpertensive drug, lo&ering o# blood pressure &as greaterthan in those taking the drug alone .=eter et al., 2;". here#ore &eight loss should bean adAunctt o drug therapyb ecauseit may decreaseth e dose or number o#drugs necessaryto control

blood pressure. -nce &eight is lost, maintenance is critical. Un#ornrnately relapse and &eight gainsare common #ollo&ing dieting to lose &eight. Some #actors associated& ith e##ective&eight maintenance are e4ercise, positive sel#$statements related to &eight$reduction e##orts, sel#$monitoring activities (use o# a #ood diary goal setting, early attention to &eight regarn", and problem$solving skills in lieu o# eating during stress#irlt imes (see) hapter 21".


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)hangin+g ietary7 atternshe +'SH diet is used #or both preventing and controlling high blood pressure( see' ppendi4 ;;". Success#ualdoption o# this diet reKuires many behavioral changesL eating t&ice the average number o# daily servings o# #ruits,vegetables, and dairy products8 limiting by one third the usual intake o# bee#, pork, and ham8 eating hal# thetypical amounts o# #ats, oils, and salad dressings8 and eating one Kua#ter the number o# snacks and s&eets

(6lackburn, 21". ?actose$intolerant persons may need to incorporate lactase en>l#me or use other strategies toreplace milk (see )hapter 2@". #usessing patientsJreadiness to change and engaging patients in problemsolving, decision making, and goal setting are behavioral strategies that may improve adherence (Eindhauser etal., 1" (6o4 ;;$;8 see )hapter l".he high number o# #ruits and vegetables consumed onthe +'SH diet is a marked change #rom typical patterns o# 'mericans. o achieve the 9 to 1 servings, t&o tothree #ruits and vegetables should be consumed at each meal (see 'ppendi4 ;;". Importandy, because the+'SH diet is high in #iber, gradual increases in #ruit, vegetables, and &hole grain #oods should be made overtime. Slo& changes can reduce potential short$term gastrointestinal disturbances associated &ith a high$#iber dietsuch as bloating and diarrhea. he +'SH pattern has been incorporated into the current 'H' nutrition guidelines(I(rauss et al., 2".


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Servings #or di##erent calorie levels are sho&n in 'ppendi4 ;;. ' Kuick assessment tool can help +s andpatients monitor progress (lable ;;$!".

Salt estrictionoderate sodium restriction (2; mg sodium daily or G g o# salt" is recommended #or trea##nent o#hypertension GrIH, 2!". o achieven utrient adeKuacy,a n adeKuate inake ('I" level o# sodium hasbeen set at 1.0 g/day (Institute o# edicine, 2!". he +'SH$Sodium trial sho&edthat people consuming dies o# l.0glday o# sodium had greater blood pressure bene#its than those &ithhigher intakes ('ppel et al., 1@". ?o&er$sodium diets &ere also sho&n to maintain lo& bloodpressure over time and enhancet he e##icacyo # certainb lood pressure$lo&eringm edications.'lthough it may be advisable #or individuals &ith elevated blood pressure to restrict sodium to 'Ilevels, adherence to diets containing less than 2 g/day o# sodium is di##icult to achieve.6ecause most dietary salt comes #rom processed #oods and eating out, changesin #ood preparationa

nd processing can help patients reach the sodium goal. Sensory studies sho& that commercial processingcould develop and revise recipes using lo&er sodium concentrations and reduce added sodium &ithout a##ectingconsumer acceptance. In addition to advice to select minimally processed #oods, dietary counseling to lo&ersodium should include instruction on reading #ood labels #or sodium content, avoidance o# discretionary salt incooking or meal preparation (1 tsp salt L 2! mg sodium", and use o# alternative #lavorings to satis#ii individualtaste. 6ecause the +'SH eating plan is rich in #ruits and vegetables, &hich are nanrrally lo&er in sodium thatmany other #oods, adopting the +'SH diet&ill enable individuals to consume less salt and sodium. Focus ->LSodium and the Food Industry discusses ho& di##icult it is to #ollo& a sodium$restricted diet in 'merican society.

-ther+ ietary odi#icationsinerals)onsuming a diet rich in potassium has been sho&n to lo&er blood pressure and blunt the e##ects o# salt on blood

pressurei n some individuals( 'pp.l et al., 2G". he recommendedintakeo # potassium#o r aduls is!.@g/day (Institute o# edicine, 2N". 7otassium$rich #ruits and vegetablesi ncludel ea#r greenv

egetables#r, uits, andr ootvegetables. :4ampleso # such# oods include oranges,b eet greens,& hite


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beans, spinach, bananas, and s&eet potatoes. 'lthough meat, milk, and cereal products containpotassium, the potassium #rom these sources is not as &ell$absorbed as that #rom #ruits andvegetables- S+'% 20".Increasedin takeso # calciuma nd magnesiumm ay have blood pressureb ene#its,a lthought here is notenoughd ata at presentt o support a speci#icr ecommendation#o r increasingl evelso # intake. ather,recommendationss uggest meeting the 'I intake #or calcium and the recommended dietary allo&ance

#or magnesium #rom #ood sourcesr ather than supplements. he +'SH diet plan encourage#so odsthat &ould be good sourceso #both nutrients, including lo&$#at dairy products, dark green leaS>vegetablesb, eans,a nd nuts.

?ipids)urrent recommendations #or lipid composition o# the diet are those recommended by the 5):7 (see )hapter

;2" to help control &eight and decrease the risk o# )


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novative nutrition intervention approaches that address the uniKue needs and circumstances o# this age$groupare needed. Strategies #or improving intake patterns among children and adolescents can be #ound in )hapters @and 9.

reatmenot# 6lood7 ressurien lder' dultsore than hal# o# the older population has hypertension8 this is not a normal conseKuenceo # aging,but )


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+rug treatment in the older adult is supported by very strong data. 6ased on these data, the 35)recommendst hat blood pressuresb e controlled regardlesso # age,i nitial blood pressurele vel,o rdurationo #hypertension (5IH, 2N".

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Hypertension Krause