Lifestyle Modifications

Several lifestyle factors impact BP and are effective in preventing HTN in normotensive persons, as well as in lowering BP in those with HTN (Table 20.5). Weight reduction is an important step in those who are overweight (body mass index [BMI] >25 kg/m²) or obese (BMI >30 kg/m²) and should involve a combined effort including caloric restriction and increased physical activity. Unfortunately,

• TABLE 20-5. Lifestyle Modifications and Their Effects on Blood Pressure in Patients with Hypertension

significant weight loss is required to reduce BP enough to obviate the need for antihypertensive drugs, and such reductions are often not sustained over time. Pharmacologic adjuncts are of limited value in reducing weight as well as BP, but are worth trying in some patients who have difficulties losing weight despite proven adherence to diet and exercise. Appetite suppressants (phentermine, phen- dimetrazine, and diethylpropion) are Food and Drug Administration (FDA)-approved for short-term therapy up to 12 weeks in duration. Orlistat, a lipase inhibitor, is approved for long-term use for up to 1 year. Bariatric surgery results in improved BP in a substantial number of morbidly obese patients, but there are questions regarding the long-term durability of the BP effect despite relative weight stability. At this time, bariatric procedures cannot yet be recommended in the management of HTN accompanied by obesity, except in the group of morbidly obese patients (BMI of at least 35 kg/m²).

The dietary approach to lowering BP should address not only calories (weight reduction), but also other strategies that may improve BP, such as low sodium and high potassium and calcium contents, and a low fat (especially saturated fat) diet to maximize cardiovascular risk reduction. The Dietary Approaches to Stop Hypertension (DASH) diet is the preferred plan, as it produces BP-lowering results (8 to 14 mmHg) that are better than those historically observed with sodium restriction alone (2 to 8 mmHg). The DASH plan is the combination of low sodium, low saturated fats, and large amounts of fruits and vegetables (details of the plan are found at www.dashdiet.org). It is our practice to recommend the DASH diet to all patients with HTN, with the exception of those with hyperkalemia (especially in chronic kidney disease) in whom potassium intake must be curtailed.

Increased physical activity is modestly effective in decreasing BP. It is also an important adjunct to weight loss, and is associated with decreased cardiovascular disease, depression, and osteoporosis. Thus, engagement in frequent aerobic activity for at least 30 minutes on most days of the week is advisable for all patients who are capable of doing so.

Heavy alcohol use is associated with increased BP. The thresholds for this association vary according to population, gender, and type of alcohol, thus making precise recommendations difficult. If one uses a conservative approach however, hypertensive individuals should limit alcohol consumption to no more than 2 drinks (20 to 30 g ethanol) per day for men and 1 to 1.5 drinks (10 to 20 g ethanol) per day for women.

• 1. The general approach to treatment of HTN is multifaceted, targeting not only BP values per se, but also other variables that modify cardiovascular risk.
• 2. Lifestyle modifications should be advised to all patients.
• 3. The most effective lifestyle interventions are weight loss (in overweight subjects), use of the DASH diet, and increased physical activity.
• 4. The role of appetite suppressants, other weight- loss drugs, and bariatric surgery for improved BP control remain to be seen and are not recommended at this time.