THE JOURNAL OF CLINICAL HYPERTENSION VOL. V NO. VI NOVEMBER/DECEMBER 2003408

COMPREHENSIVE LIFESTYLE MODIFICATIONHAS MAJOR EFFECT ON BLOOD PRESSUREHigh blood pressure is an independent risk factor forcardiovascular disease. Starting at 115/75 mm Hg,mortality rates for heart attack, stroke, and othervascular disease doubles for every 20/10 mm Hgincrease in blood pressure. Hypertension will occurin 90% of Americans by the time they reach 65 yearsof age. Accordingly, the Seventh Report of the JointNational Committee on Prevention, Detection,Evaluation, and Treatment of High Blood Pressure(JNC 7) recommends lifestyle changes including alow-sodium diet, exercise, weight loss, limitation ofalcohol consumption, and the Dietary Approaches toStop Hypertension (DASH) diet in all Americanswith a blood pressure greater than 120/80 mm Hgnot only to lower blood pressure, but also to possi-bly prevent hypertension from occurring.

In the PREMIER trial, 810 adults from four clin-ical centers (mean age 50 years, 62% women, 34%African-Americans) with systolic blood pressures(SBP) of 120–159 mm Hg and diastolic blood pres-sures (DBP) of 80–95 mm Hg were randomized toone of three nonpharmacologic behavioral inter-ventions. One group, the “established” lifestylemodification only group (n=268), was encouragedto use established recommendations and loseweight, exercise more, eat less sodium, and reducetheir intake of alcohol. The second group (n=269)also adopted the fruit-, dairy-, and vegetable-richDASH diet in addition to the established interven-tions used for group 1. The third group (n=273)received advice only in one 30-minute session ongeneric lifestyle and dietary changes to reduce bloodpressure. No further contact with the intervention-ist after randomization occurred in this group untilafter completion of the trial.

Mean SBP and DBP on entry were 135 mm Hg and85 mm Hg, respectively. Among the 38% of partici-pants with hypertension, mean SBP and DBP were 144mm Hg and 88 mm Hg, respectively. In the other peo-ple, blood pressures were 130/83 mm Hg. Using tele-phone reminders and up to 18 intensive office follow-up visits, the primary outcome was the change in SBPat 6 months. The changes in DBP and hypertensionstatus were secondary outcomes. Hypertension wasdefined as a mean blood pressure of 140/90 mm Hg orgreater or the use of antihypertensive medication.

By 6 months, those in the advice-only group low-ered their SBP by 6.6 mm Hg and DBP by 3.8 mmHg. Those in the established group lowered their SBP10.5 mm Hg and their DBP 5.5 mm Hg while thosein the established-plus-DASH-diet group achieved aSBP reduction of 11.1 mm Hg and DBP reduction of6.4 mm Hg. After subtracting the change in theadvice-only group, the mean net reduction in SBPwas 3.7 mm Hg in the established group and 4.3 mmHg in the established-plus-DASH-diet group. Theprevalence of hypertension was reduced from 38%at baseline to 26% in the advice-only group, reducedto 17% in the established intervention group, and12% in the established-plus-DASH-diet group. Theprevalence of normal blood pressure (<120 mm Hgsystolic and <80 mm Hg diastolic) was 19% in theadvice-only group, 30% in the established group,and 35% in the established-plus-DASH-diet-group.While both intervention groups achieved favorableeffects for all end points compared with the advice-only group, no significant difference was seenbetween the established and the established-plusDASH-diet-group.

Lifestyle modification may prevent hyperten-sion without the need for drug therapy. TheDASH diet, which emphasizes fruits, vegetables,and low-fat dairy products and includes wholegrains, fish, poultry, and nuts, reduces bloodpressure slightly more than lifestyle advice alone.Whether these changes in blood pressure can beachieved in clinical practice over the long term isuncertain.—Appel LJ, Champagne CM, HarshaDW, et al. Effects of comprehensive lifestyle

A n a l y s i s o f R e c e n t P a p e r s i n H y p e r t e n s i o nJ a n B a s i l e , M D , S e c t i o n E d i t o r

Jan Basile, MD

From the Ralph H. Johnson VA Medical Center,Medical University of South Carolina, Charleston, SCAddress for correspondence:Jan N. Basile, MD, Ralph H. Johnson VA MedicalCenter, 1090 Bee Street, Charleston, SC 29403

www.lejacq.com ID: 2834

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modification on blood pressure control: mainresults of the PREMIER clinical trial. JAMA.2003;289:2083–2093.

CommentHypertension remains one of the most importantand preventable risk factors for cardiovascular dis-ease, and its prevention is an important publichealth issue. The National High Blood PressureEducation Program (NHBPEP) Working GroupReport on The Primary Prevention of Hypertension(JAMA. 2002;288:1882–1888) provides a consen-sus guideline that emphasizes two complementarystrategies to prevent hypertension for people athigh-risk: a population-based strategy and an indi-vidually targeted approach. High-risk subjects arepersons with prehypertension, which was recentlydefined as a SBP of 120–139 mm Hg and/or a DBPof 80–89 mm Hg (22% of the adult US population).These individuals tend to be older; have a family his-tory of hypertension; are overweight or obese; areliving a sedentary lifestyle; or consume a diet high insalt, low in potassium, or high in alcohol consump-tion. Current lifestyle recommendations includeengaging in moderate physical activity such as briskwalking for at least 30 minutes on most days, main-taining normal body weight (body mass index of18.5–24.9), limiting alcohol intake to no more that1 oz ethanol per day for men (i.e., 24 oz beer, 10 ozwine, or 2 oz 100-proof whiskey) and half thatamount for women or lighter-weight individuals,and reducing sodium intake to no more than 2.4 g/d(approximately 1 tsp salt). In addition, a diet rich infruits and vegetables and low in high-fat dairy prod-ucts as used in the DASH trial is recommended.

The PREMIER trial compared four generallyestablished lifestyle recommendations, the additiveeffects of combining the DASH diet to those estab-lished lifestyle recommendations, and lifestyle advicegiven once in a 30-minute session. The net changebetween the lifestyle modification treatment groupand the advice-only group was 3.7/1.7 mm Hg,whereas combining lifestyle changes with the DASHdiet decreased blood pressure 4.3/2.6 mm Hg morethan the advice only group. Why did a less thanexpected difference occur when the DASH diet wasadded? Whereas the DASH diet was provided for allparticipants in the original DASH studies, the PRE-MIER study was the first study to investigatewhether the effects of the DASH diet can be achievedwhen patients purchase their own food. In PRE-MIER, patients randomized to the DASH group pur-chased fewer servings of fruits and vegetables than inthe original DASH diet studies. In addition, the

advice-only group achieved a 6-month decrease inblood pressure around 7/4 mm Hg, which is muchgreater than originally anticipated and greater thanthe original DASH study achieved. Finally, in clinicalpractice, combining multiple lifestyle interventionsachieves less blood pressure reduction than whatmight be predicted from adding the effects of theindividual strategies together.

Lifestyle modification continues to be utilized inboth the prevention and treatment of hypertension.JNC 7 states that adoption of these interventions canreduce systolic blood pressure as much as many drugscan. For instance, a 10-kg loss in weight can producea 5–20 mm Hg drop in SBP, while adherence to theDASH diet could reduce SBP by 8–14 mm Hg. Howmany different aspects of lifestyle modifications canbe achieved in the same patient and the incrementalbenefit of each strategy remains unclear. AllAmericans should adopt a more healthful lifestyle,but whether the DASH diet can be widely imple-mented in clinical practice remains uncertain.

THE PREVALENCE OF HYPERTENSION IN THE UNITED STATES IS ON THE RISE AGAINHypertension remains the most common preventa-ble risk factor for cardiovascular disease and is animportant public health problem. Although theprevalence of hypertension has been falling overthe past thirty years, this trend appears to bereversing, according to a recent analysis.

Using data for the civilian, noninstitutionalized,adult population in the United States, investigatorscompared the most recent National Health andNutrition Examination Survey (NHANES), conduct-ed in 1999–2000 (n=5448), with the two phases ofNHANES III, conducted in 1988–1991 (n=9901) and1991–1994 (n=9717), to determine trends in theprevalence, treatment, and control of hypertension.Information including age, gender, self-assignedrace/ethnicity, body mass index (BMI), blood pressuremeasurements, and hypertension and diabetes historywere included. Blood pressure values were the averageof three separate measurements using a mercurysphygmomanometer either at the subjects’ homes or ata mobile examination center. A subject was consideredto be hypertensive if the average systolic blood pres-sure (SBP) was 140 mm Hg or higher, if the averagediastolic blood pressure (DBP) was 90 mm Hg orhigher, or if the participant was currently taking anti-hypertensive medication. They were considered tohave their hypertension controlled if their average SBPwas less than 140 mm Hg and average DBP was lessthan 90 mm Hg on antihypertensive medication.

In 1999–2000, the age-adjusted prevalence ofhypertension was 28.7%, an increase of 3.7% com-pared with the previous NHANES. African Americanscontinued to have the highest prevalence of hyperten-sion and Mexican Americans had the lowest rates inall three surveys. Hypertension prevalence increased toa greater extent in individuals aged 60 years and older.The most recent participants had a higher BMI andprevalence of diabetes. Approximately one-half of theincrease in the prevalence of hypertension wasaccounted for by the increase in BMI. Awarenessremained at 70%, unchanged from 1988 to 2000,although treatment (58%) and overall control (31%)increased by 6% and 6.4%, respectively.

Hypertension now occurs in 58.4 millionAmericans. Women, non-Hispanic blacks, and olderindividuals have the highest rates of hypertension.Despite the improvement in hypertension control,the current level of control is far from the 50% tar-get outlined in Health People 2010. —Hajjar I,Kotchen TA. Trends in prevalence, awareness, treat-ment, and control of hypertension in the UnitedStates, 1988–2000. JAMA. 2003; 290:199–206.

CommentThe prevalence of hypertension, which declinedbetween 1960 and 1991, was 28.7% in 1999–2000—up 3.7% from the previous 1988–1991 NHANES.This most up-to-date analysis indicates that hyper-

tension affects about 58 million Americans. Anincreased BMI accounted for 2% of the 3.7% rise inprevalence, which is more than 50% of the change.Persons aged 60 years and over experienced anincrease of 7.5%, and non-Hispanic African-American women experienced a 7.2% rise in preva-lence. Rates of hypertension for non-Hispanic blackswere the highest of all ethnic subgroups at 33.5%.

Thirty percent of hypertensive Americans remainunaware of their illness, 42% are not being treated,and 69% do not have their blood pressure con-trolled. While awareness rates remain unchanged,treatment and control rates have each improved by6%. African Americans, women, and persons aged60 years or older have lower control rates comparedwith younger people, men, and non-Hispanic whites.

High blood pressure is a major risk factor forstroke, cardiovascular disease, and end-stage renaldisease. The obesity epidemic accounts for more thanhalf the recent increase in the prevalence of hyperten-sion. If the prevalence of hypertension in Americans isto be no more than 16% by the year 2010, greatereffort is needed. We must effectively monitor theweight of our patients and offer effective lifestyleadvice for weight reduction. In addition, blood pres-sure control rates, while somewhat improved, remainunacceptably low. More effective treatment of hyper-tension in all Americans, especially in women,African Americans, and the elderly, needs to occur.

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