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H E A L T H Y P E O P L E L I B R A R Y P R O J E CAmerican Association for the Advancement of Science

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High Blood Pressur


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High Blood Pressure: TheScience Inside

HEALTHY PEOPLE LIBRARY PROJECTAmerican Association for the Advancement of Science


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Published 2004 by The American Association for the Advancement of Science (AAAS)

1200 New York Avenue, NW Washington, DC 20005

Copyright 2004 by AAAS

0-87168-694-5

All rights reserved. Permission to reproduce this document for not-for-profit educa-tional purposes or for use in a review is hereby granted. No part of this book may bereproduced, stored in a retrieval system, or transmitted in any form, or by any means,electronic, mechanical,photocopy, recording, or otherwise, for commercial purposeswithout prior permission of AAAS.

This booklet is a product of the Healthy People 2010 Library Initiative funded by theNational Institutes of Health (Grant # 5R25RR15601).

Any interpretations and conclusions contained in this booklet are those of the authorsand do not represent the views of the AAAS Board of Directors, the Council of AAAS,its membership or the National Institutes of Health.


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INTRODUCTION: HIGH BLOOD PRESSURE, A CONTROLLABLEDISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

PART 1: THE DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Healthy blood pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Blood pressure problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Symptoms of high blood pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7How high blood pressure affects the body . . . . . . . . . . . . . . . . . . . . . 7Causes of high blood pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Health problems from high blood pressure . . . . . . . . . . . . . . . . . . . . 10

PART 2: THE IMPACT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Rising incidence of high blood pressure . . . . . . . . . . . . . . . . . . . . . . 15Uneven impact of high blood pressure . . . . . . . . . . . . . . . . . . . . . . . 16Reasons for uneven impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

PART 3: CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Diagnosing high blood pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Preventing and controlling high blood pressure . . . . . . . . . . . . . . . . 26Maintaining the right weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Eating properly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Getting exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Avoiding alcohol and tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Monitoring health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Taking blood pressure medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Blood pressure treatment plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

PART 4: RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Current lines of research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41The important role of volunteers. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

CONCLUSION: LETS BRING DOWN HIGH BLOOD PRESSURE . . . . . . . 5

T A B L E O F C O N T E N T S


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APPENDIX 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Questions to Ask Your Doctor about High Blood Pressure

APPENDIX 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Taking Part in Research StudiesQuestions To Ask

RESOURCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65


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Your heart is the hardest work-ing muscle in your body. No big-ger than a fist, this powerfulpump circulates blood throughoutyour entire body, providing theoxygen and nutrients you need tolive. Unlike most pumps, howev-er, this pump never stops as long

as youre alive. In fact, the aver-age human heart works at a rateof 100,000 beats a day, or anincredible 2.5 billion beats over alifetime of 70 years!

Every time your heart beats, itpumps blood through arteries ,exerting pressure (or force) onthe inside of your blood vessels .This is called blood pressure .To understand this, think of awater pump and hose. When youturn the pump on, it pusheswater into the hose, creatingpressure against the inner wallsof the hose and causing thewater to flow. Now, if you inter-rupt the flow of waterforexample, by putting a bend inthe hoseyou create a blockagethat stops up the water. Thewater will build up behind theblockage, exerting more pressureand pushing out the walls of thehose. If you keep the hose bent,eventually either the hose willburst or the pump will shut

down. If you get rid of the block-age, water will once again flowsmoothly through the hose.

You can think of high bloodpressure , or hypertension , inthe same way. It is a condition inwhich the pressure of the bloodinside the arteries is too high. If the condition is left untreated, itwill cause damage to the arteriesand put strain on the heart. Youcan develop serious complica-tions of high blood pressure,including stroke , heartattacks , heart failure, kidneyfailure, and eyesight problems oreven blindness. Developing theseand other related illnesses canlead to a life of considerable suf-fering or premature death.

INTRODUCTION: HIGH BLOODPRESSURE, A CONTROLLABLE

DISORDER

There areno clear-cut

symptoms for high blood

pressurewhichis part of thereason it hasbecome known asthe silent killer.


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H i g h B l o o d P r e s s u r e : T h e S c i e n c e I n s i d e

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Research shows that more than50 million Americans over the ageof 6 have high blood pressure.Roughly 1 in every 4 Americanadults has the disorder. In 1999alone, high blood pressure con-tributed to the deaths of morethan 227,000 Americans. Thisnumber is expected to rise in theyears ahead.

Sadly, millions of Americans arewalking around with high bloodpressure and dont even know it. Itseems that most people find outthey have the disorder only whentheir doctors bring it to theirattention during an office visit.This is due to the fact that thereare no clear-cut symptoms forhigh blood pressurewhich is partof the reason it has become knownas the silent killer.

One basic marker that people canuse to keep tabs on their bloodpressure is their age. As peoplegrow older, their chance of devel-oping the condition becomesgreater. Health experts have deter-mined that roughly 54% of peopleover 60 have high blood pressureand that two out of three

Americans will have it by the ageof 70. For this simple fact alone,it is important for people tobecome more aware of their bloodpressure, have it measured period-ically, and learn healthy ways toprevent or control this potentiallydeadly condition.

High blood pressure does not affectall people in the same way. African

Americans and older people areparticularly hard hit by the disor-der. Those with lower incomes andlower educational backgroundsalso tend to be at greater risk fordeveloping high blood pressure.In addition, research studies haveshown that people living in thesoutheastern United States haveaverage blood pressure levels thatare higher than Americans livingin other parts of the country. Theexact reasons for this still remainunclear.

What is clear is that people cantake many actions to reduce theirchances of developing high bloodpressure. This involves havingblood pressure checked regularly,since high blood pressure is simpleto detect, and making changes inlifestyle, such as increasing physi-cal activity, reducing the amountof salt consumed, and committingto a lifetime of healthier eating.

For those suffering from highblood pressure, medical scienceand modern research since the1940s and 1950s have come a longway in understanding and treatingthis silent condition. Many med-ications have been developed andproven effective in helping to getblood pressure levels under con-trol, to limit or avoid further com-plications, and to prolong life.


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Introduction

Ongoing research and technolog-ical advances also have enableddoctors to better adjust treat-ment plans to the individual,since medical remedies do notnecessarily work for everyone inthe same way.

Medical advances and greaterpublic awareness about highblood pressure are critical forsaving the lives of millions of

Americans in the future. Whatmay be more important, howev-er, is to realize that there are anumber of healthy, natural waysthat people can prevent theirblood pressure from getting outof control in the first place.

Retired from Teaching But Not fromLearning about Her HealthSome people with high blood pressure ignore the problem or think it canthurt them.

Not Marge Prioleau.

High blood pressure can lead to stroke and having problems with theheart. There are so many things that can come from high blood pressure.

Prioleau is a retired school teacher who lives in Beaufort, South Carolina.She found out that she had high blood pressure about 14 years ago.

I started to feel dizzy and went to the schools nurse. She took my bloodpressure and said it was high.

Following health advice is easier said than done, but somehow Prioleaumanages to do it. She keeps her blood pressure under control by gettingexercise, eating healthy foods, and taking blood pressure medications.

Her main exercise is walking around a quarter-mile running track at anearby school. She gets up early to beat the heat, which in South Carolinacan sap even the most determined persons willpower to exercise. She does16 to 20 laps, which equals four to five miles.

She makes sure her shoes are comfortable. Unlike many people who runand walk for their health, she doesnt wear a Walkman.


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I like to take time to take an inventory of myself, says Prioleau. It gives metime to think.

She has banned fried food from her diet except for fish and a special treat offried chicken on New Years. She makes juice from carrots and apples anddrinks a lot of water.

And does Prioleau eat grits, the porridge-like dish made from corn thatSoutherners crave? Of course, she says laughing, but I dont eat themwith salt.

Like many people with high blood pressure, Prioleau cant keep it undercontrol with diet alone. She was originally prescribed Lotrel, a calcium-channelblocker, but her blood pressure started going up again. Now she takes Norvasc,a calcium-channel blocker; Cozaar, an angiotensin II receptor blocker; and adiuretic.

Prioleau says her doctor, Dr. William Bestermann, deserves part of the creditfor her outlook. On a scale of 1 to 10, I would say Dr. Besterman is a 10.He promotes a healthy way of life.

Many of us take our health for granted. We just go along assuming well staywell or that doctors will be able to treat us if anything goes wrong. Prioleausees her health as something she has to work for.

I am the sort of person who if there is something that is going to help mehave a better way of life, then I am going to try to do it.


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Healthy blood pressureBefore we can understand theharmful problems related to highblood pressure, it is important tohave a basic understanding of howa normal, healthy body functions.To this end, we will examine theworkings of the cardiovascularsystem .

The cardiovascular system is madeup of the heart and blood vessels.The heart is a very powerful muscu-lar pump that delivers blood to theorgans, tissues, and cells through-out the body. The blood sends oxy-gen and nutrients that our cellsneed to live and removes the car-bon dioxide and other wastes thatcells produce. From the heart, oxy-gen-rich blood is circulated througha vast network of arteries , arteri-oles , and capillaries , and oxygen-poor blood is pushed back to theheart through venules and veins .

As mentioned earlier, blood pres-

sure is the force that blood exertsagainst the arteries as it circulatesthroughout the body. The flow of blood around the body is not con-stant, but is based on the beats of the pumping heart. On average,

about two ounces of blood per heart-beat is pumped through the leftventricle of the heart and into the60,000mile (96,500-kilometer)long network of blood vessels thatmake up the human body.

It is also important to note thatblood pressure does not stay thesame all the time and is based onthe activities people do (and howhard or rapidly their hearts arepumping). For example, the heartmuscle can pump nearly three timesfaster during periods of exercise ascompared to times of rest. The heartpauses, or rests, between beats inorder to prepare itself for the nextbeat.

Using a sphygmomanometer , orblood pressure cuff, doctors measure

Part 1: The Disease

Blood pressure isthe measurement of force applied toartery walls


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two key blood pressure numbers the systolic pressure and diastolicpressure . The systolic pressureshows the highest pressure in thearteries. This is when the blood isforcefully pumped out of the heartand into the blood vessels during aheartbeat. The diastolic pressurerepresents the lowest pressure inthe arteries. This is when the heartpauses or relaxes between beats.

The numbers that result from a read-ing usually come in the form of 100mmHg (millimeters of mercury) over70 mmHg, or 100/70 mmHg. Thehigher number represents the systolic

pressure (heart pumping) and thelower represents the diastolic pres-sure (heart resting). A consistentmeasurement of 140/90 mmHg indi-cates that the heart is pumping hard-er than it should and that the personhas high blood pressure. The optimalblood pressure reading for adults is119/79 mmHg or lower.

Blood pressure problemsHypertension is another term for highblood pressure. It is a condition inwhich blood is pushed through thebodys blood vessels at greater forcethan normal. There are three maintypes of hypertension:

Primary hypertension (or essen-tial hypertension)This form of highblood pressure is the most common,affecting over 90% of those people 45years old and over who have hyper-tension. While there is no known

cause, there are a number of factorsthat contribute to its development,including age, heredity, lifestyle, diet,ethnicity, and more.

Secondary hypertension (or nonessential hypertension)Unlike pri-mary hypertension, this form of highblood pressure can be determined bya specific cause. Among the possible

short-term causes are pregnancy andthe use of certain types of medication.The long-term causes include kidneydisorders and head injuries. This typeof hypertension accounts for nearly10% of all high blood pressure cases.


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When the specific cause is identi-fied and properly treated, bloodpressure often returns to normallevels.

Isolated systolic hypertension(ISH) This form of high bloodpressure is most common in olderpeople, affecting over 65% of peoplemore than 60 years of age. ISHcomes with no symptoms, so manypeople may have it and do notknow it. ISH is characterized byhigh pressure levels when theheart is beating (systolic), but nor-malized levels between beats, whenthe heart is resting (diastolic).This large gap between pressurelevels can lead to a straining of the arteries.

Symptoms of high bloodpressureUnlike many other conditions, highblood pressure often causes nosymptoms . However, when symp-

toms do arise, it means that bloodpressure is too high, often causingdamage to such critical organs asthe heart or kidneys . In the most

severe cases, when symptoms canarise, they might come in theform of:

headachesexcessive perspiration (sweating)chest painsmuscle tremorsnosebleeds

fatigue, weaknessnausea, vomiting heart palpitationsvision problemsblood in urineconfusion

How high blood pressureaffects the bodyHigh blood pressure affects thebody in a variety of ways. The most

critical effect is the strain it canput on the heart. High blood pres-sure also damages blood vessels

Part 1: The Disease

Low blood pressureIs it ever a problem?Though generally regarded as a good thing, a persons blood pressure can be toolow and potentially harmful. There may be no symptoms associated with low bloodpressure, and, in certain cases, it may actually be desirable. When blood pressuredrops below 90/60, however, it indicates that there may not be enough blood flow-ing to the heart, brain, kidneys, and other major organs. Causes may include heartdisease, dehydration, gastrointestinal bleeding, and the use or allergic reaction tocertain medications. Most common with the elderly, sudden drops in blood pressuremay lead to symptoms like fatigue, anxiety, depression, or dizzinessespeciallyupon making a sudden change in body movement. In rare cases, treatment isrequired, usually in the form of medication that helps alter blood pressure receptorsor constrict arteries to reduce the likelihood of sudden or frequent drops in bloodpressure.


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and, if left untreated overtime, can greatly impair theheart, brain, kidneys, andeyes. With few or no notice-able symptoms, this silentand potentially deadly con-dition can lead to severephysical damage well beforea person understands whatis happening and seeks med-ical treatment.

High blood pressure is aserious risk factor for differ-ent forms of heart disease ,

including congestive heart failure ,which most commonly affects the eld-erly. As high blood pressure stretchesand damages the heart from over-work, it also strains the blood vesselsand hardens the arteries, makingthem thicker and less flexible, great-ly increasing the chance of heartattack and stroke. Without diagno-sis or treatment, the kidneys can

become stressed and damaged, hurt-ing their ability to clean the bloodand potentially leading to kidneyfailure. Among the temporary or per-manent vision problems that canresult are optic nerve swelling andbleeding in the retina .

To avoid these and other life-threat-ening complications, doctors recom-mend having blood pressure checkedat least once a year, so patients whohave high blood pressure can betreated effectively. This is importantbecause research shows thatcom-pared to people who have received

treatment for high blood pressure those who have hypertension but donot know it are about 6 times morelikely to have congestive heart fail-ure, 7 times more likely to have astroke, and 3 times more likely tohave coronary artery disease .Since high blood pressure has virtu-ally no symptoms until it becomessevere, it is especially important forpeople to monitor and control theirblood pressure on an ongoing basis.

Causes of high bloodpressureDoctors and researchers have notbeen able to determine a specificcause of high blood pressure.Moreover, the cause of hypertension

is unknown in 90 to 95 percent of thecases. Since no single cause seemsapparent, treatment for the conditionhas been based on keeping bloodpressure at normal levels or undercontrol. This involves identifying the


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specific risk factors that, when com-bined, can greatly increase a per-sons chance of developing highblood pressure. These risk factorsinclude:

Controllable Uncontrollable

high salt intake heredityobesity raceexcessive alcohol use genderlack of exercise ageuse of certain

medicationsdrug or chemical use

diabeteskidney diseasestress

Salt has been found to be a risk fac-tor because too much of it can raisefluid levels in the bloodstream, forc-ing the heart to work harder andblood pressure levels to rise. This isparticularly true if the kidneys,which regulate sodium (salt) andwater levels in the body, are notworking properly. Obesity is anoth-er key risk factor. When a persongains weight, his or her blood levelsalso increase, causing the heart topump more blood. The additionalweight also causes a persons bloodpressure to elevate because itincreases cholesterol levels, lead-ing to a further straining and hard-ening of the blood vessels andheart. Excessive alcohol consump-tion can also reduce the hearts abil-ity to function properly, increasingblood pressure levels. Drinking too

much alcohol can also make highblood pressure medication lesseffective.

Luckily, as suggested by the con-trollable factors above, there ismuch that people can do throughouttheir lives to keep their blood pres-sure at a healthy level.Unfortunately, high blood pressuredoesnt affect all people in the sameway. For example, African

Americans are much more likely todevelop the condition earlier andmore severely than whites. Also, interms of gender, men have a greaterchance of developing it between theages of 35 to 55, whereas womenare more likely to develop it afterthe age of 75. What is clear, howev-er, is that as people age, theyincrease their chances of developinghigh blood pressure.

Part 1: The Disease

Obesity is a controllable risk factor for high blood pressure.


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Health problems from highblood pressureIMPORTANT NOTE: The followingcomplications of high blood pressuredescribed below can be avoided ordelayed through prevention and treat-ment. (See the section on care begin-ning on page 25.)

Stroke. High blood pressure is aleading cause for stroke, which occurswhen blood has trouble flowing to thebrain. High blood pressure can makea blood vessel rupture, causing a

hemorrhage (bleeding) in the brain.Strokes, (or brain attacks) are alsocaused by blood clots and narrowingof the arteries ( atherosclerosis ).They can lead to such complicationsas the inability to speak, braindamage, paralysis, and death. Strokeis the third leading cause of deathin the United States, accounting for1 out of every 15 deaths. It is impor-

tant for high blood pressure patientsin particular to monitor their healthand get effective treatment for thecondition before it leads to a stroke the risk of which doubles every 10years after the age of 35.

Kidney Disease. The kidneys help tokeep blood pressure levels regular bycleaning the blood of extra fluids andwastes. When a person develops highblood pressure, the kidneys canbecome damaged. When the kidneysare no longer able to function proper-ly, the extra fluids and wastes thatremain in the blood can lead to evenhigher blood pressure levels and, ulti-


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A Closer Look at Stressand EmotionsBlood pressure is known to change throughout the

day, depending on ones activities or emotionalstate of mind. People who have a lot of stress intheir livesor who suffer from emotional condi-tions like depression or anxietyare thought tohave at least twice the risk of developing highblood pressure than others. This is because thestress hormone, cortisol, is released from the adre-nal glands in greater amountscausing bloodpressure to increasewhen a person experiencesshort-term or long-term stress. Like adrenaline,cortisol levels rise when a person is under stress.When a persons stress hormone levels are ele-vated on a consistent basis, it can lead to a varietyof health problems, from depression to high bloodpressure to cancer.

Different forms of stress may also prompt peopleto escape their troubles by overeating, smoking, orabusing alcohol, all of which cause blood pressureto rise. Making gradual lifestyle changes thatreduce stress will help to control or lower bloodpressure over the long run.


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mately, illness. If left untreated, aperson suffering from kidney dis-ease may need a kidney transplantor dialysis treatment, which is theuse of a machine to help the kid-neys function and clean blood. Highblood pressure is the second leadingcause of kidney failure, and leads toover 15,000 new cases in the U.Severy year. Research has alsoshown that between 20 to 25 per-cent of patients who must undergodialysis first had slightly elevatedblood pressure that had beenuntreated. Early and effective treat-

ment of high blood pressure canhelp to prevent the occurrence of kidney disease.

Vision Problems. Vision loss orblindness can result from opticnerve damage that is brought on byhigh blood pressure. The conditioncan also lead to bleeding in the reti-na, the light-sensing part of the eye.

This disease is called retinopathy ,which can result in partial or com-plete blindness. Early detection andtreatment can help to preventvision loss brought on by high bloodpressure.

Hardened Arteries. Atheroscler-osis , or a hardening and thickeningof the arteries, can result from highblood pressure. Hardened arteriescan lead to a greater buildup of fatsand cholesterol in the arteries andblood vessels, causing the heart toenlarge and weaken because it isforced to pump harder. This disease

Part 1: The Disease


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can block the proper flow of blood andoxygen that the heart, brain, and vitalorgans need to work properly. Bloodclots may also form in an artery,blocking the flow of blood entirely.While considered a slow and advanc-ing disease that mainly affects theaged, atherosclerosis (also called arte-riosclerosis) may result in a heartattack or stroke if left untreated overtime. In addition to high blood pres-sure, other risk factors that con-tribute to the progression of this dis-ease include smoking, diabetes, obesi-ty, and family history.

Heart Attack. As previously noted,hypertension can contribute to thehardening of arteries, which can leadto a heart attack. In order to functionproperly, the heart muscle itself needsa continuous supply of oxygen-richblood. When arteries become nar-rowed or blocked, this vital flowbecomes lessened, causing muscle

damage and angina (chest pains).Heart attacks result when arteriesand the flow of blood to the heartbecome completely blocked. In gener-al, any disruption in the workings of the heart is life threatening and in

need of prompt medical attention.

Heart Failure. Another aspect of thetoll that high blood pressure can haveon the heart is in the form of heartfailure. As previously mentioned, theheart can be forced to work harderdue to complications of high bloodpressure and atherosclerosis. Underthese unhealthy, untreated conditions,the heart begins to stretch andenlarge (either partially or as awhole). Eventually, the heart fails tofunction effectivelyeither too much,not often enough, or irregularlyandultimately results in congestiveheart failure . This disorder mayinvolve a failing of the entire heart or

just one side of it. When the left sideof the heart fails, blood and other flu-ids get backed up in the lungs. Thefirst signs of this condition arebreathing problems, such as shortnessof breath. When the right side fails,blood may back up into other areas of

the body as the veins fill and leakfluid into the surrounding tissue.Symptoms of right-side failure includefatigue, indigestion, liver damage, andswelling in the legs.


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Part 1: The Disease

DASHing High Blood Pressure

You can bring down high blood pressureby changing the way you eat. Just askJoe Wagner.

Wagners blood pressure was150/100 twoyears ago. Now it is 130/80, which is closeto the 119/79 level that is considered thehealthiest for adults. He also lost 20pounds.

Wagner made the changes by following

a diet called the Dietary Approaches toStop Hypertensionor the DASH diet, for short. He learned about the dietthrough a special computer-based project at his job.

I didnt exactly follow it to the letter, says Wagner. But I basicallyfollowed the advice on the Web site.

Doctors at Harvard Medical School developed the DASH diet several yearsago. It emphasizes fruits, vegetables, and low-fat dairy products. The dietwas developed to test whether eating habits could lower blood pressureas much as blood-pressure pills.

Studies have shown that it does.The results were better than we ever dreamed of, says Dr. Frank Sacks,the Harvard doctor who led the DASH diet studies. Sacks says if peoplefollowed DASH it could be a substitute for the gazillions of dollars spentevery year on blood-pressure pills.

Wagner just wanted to avoid taking pills, period. I dont like takingmedicines for anything. I will take an aspirin for a headache but that isabout it.

Wagner works at a computer company called EMC Corporation outsideof Boston. The computer-based project he enrolled in is part of a BostonUniversity study. The researchers hope to show that weekly e-mails andpostings on a special Web site will help people stick with the DASH diet.They also collect blood pressure and weight information from people so

Wagner, continued on next page


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Rising incidence of highblood pressure

Although heart disease and strokeare the first and third leading caus-es of death in the United States,there has been a continued reduc-

tion in the overall death rates fromthese diseases. The medical commu-nity has attributed these improve-ments to a higher quality of medicaltreatment, lower sodium consump-tion, and more and more people giv-ing up smoking. However, mortali-ty rates from heart disease andstroke are expected to rise as

Americas population grows older.Finding newer and more effectiveways to treat hypertension will helpprevent the number of deaths fromboth heart disease and stroke fromgetting out of control.

While studies have shown that theincidence of high blood pressure in

America is declining, the statisticsand trends related to high bloodpressure remain staggering, if not

mixed. For example, hypertensioncurrently affects over 25% of all

Americansroughly 50 million peo-ple. In the United States in 1999,high blood pressure caused the

death of 42,997 people and con-tributed to the deaths of an addi-tional 227,000 others. (As comparedto the year before, this represents adecrease of 1,438 caused by highblood pressure, and an increase of 17,000 due to complications from

the condition.) What makes highblood pressure a greater health con-cern is that an estimated 31.6% of

Americans have the disorder but donot even know it. Another obstaclein the fight for better treatment andprevention is lack of knowledgeabout treating the condition. The

American Heart Association esti-mates that one-third of all people

Part 2: The Impact

Mortality ratesfrom complica-tions of highblood pressure,heart disease,and stroke areexpected to riseas Americas

populationgrows older.


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who have high blood pressure do notknow how to manage or control iteffectively.

Doctors and researchers alike attrib-ute the slight decline in the develop-ment of high blood pressure to thelifestyle improvements of youngerpeople and more effective drug thera-pies for older patients. However, with

Americas aging society and the sig-nificant lack of awareness about highblood pressure, future trends in thisarea continue to be a great cause forconcern.

For example, in the area of obesityalone, a disturbing 19992000 gov-ernment study found that 31% of all

Americans (almost 59 million people)are obese. When compared to the15% obesity rate in 1980, it meansthat twice as many Americans areobese today as were obese 20 yearsago. Obesity is a major risk for high

blood pressure, heart disease,strokes, diabetes, and different typesof cancer. Adults who are even mod-erately obese are twice as likely todevelop high blood pressure as peo-ple who are not overweight.

Studies also show that obesity maybe the leading cause of high bloodpressure in older adults, and thatchildren and adolescents who areoverweightand babies who areunderweightstand a greaterchance of developing the conditionwhen they become adults. For theseand other reasons, high blood pres-

sure will continue to be a serious andthreatening public health concern forthe United States.

Uneven impact of highblood pressureHigh blood pressure does not affectall people, races, or genders alike.For example, men are more likely todevelop the condition than women upto the age of 55, while aging womenbetween 55 and 74 become more like-ly than men to get high blood pres-sure. In fact, some statistics indicate

that the condition is harder onwomen than men. In 1999 alone, thehigh blood pressure mortality ratefor men was 17,194 as compared to25,803 for women.

A much more startling difference isthe impact that high blood pressurehas on African Americans, who areamong the most likely groups in theworld to develop the condition. Over50% of African-American males aresaid to have high blood pressure,while a little less than half of womenfrom this group suffer from it. Inaddition, African Americans are alsomuch more likely than white

Americans to develop high bloodpressure at an early age and to havehigher average readings. The overalldeath rate from high blood pressurein 1999 for white men and womenwas 12.8 per 100,000as comparedto 40.3 per 100,000 for black femalesand 46.8 per 100,000 for black males.On average, African Americans with

The overall death ratefrom high

blood pressurein 1999 for white men

and women

was 12.8compared to

40.3 for black females and

46.8 for black males per 100,000.


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Part 2: The Impact

high blood pressure have a muchgreater rate of stroke, heart failure,and other diseases than whites. Inthe area of kidney failure alone,

African Americans between 25 and44 years old are 20 times more like-ly than whites to develop thishypertension-related disease. Onthe positive side, African Americansare considered more salt sensitivethan other groups and can substan-tially improve their blood pressurelevels by losing weight and reducingtheir sodium intake.

Another key group that is morelikely to develop high blood pres-sure is older people, since levelstend to rise as people become older.Over 50% of Americans over 60years old have high blood pressure,and over 65% older than 75 sufferfrom the condition. This is because,as people age, the arteries becomeharder and less flexible, causing theheart to work harder to pump bloodthroughout the body. When thistakes place, only the systolic bloodpressure increases, causing what iscalled isolated systolic hypertension

Performing 30-40 minutesof any physical exercisethree to four times a weekcan help to lower blood

pressure levels.


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18

(ISH). In general, doctors have to becareful when monitoring the bloodpressures of older people becausereadings can vary greatly within thefirst several minutes of an office visit.

On a positive note, older adults wholead stable, active lives may be ableto sustain normal blood pressuresthroughout life. For those who areinactive or have unhealthy lifestyles,studies have shown that medicaltreatment for high blood pressure hasproven to be effective in lowering therisk of heart attacks, strokes, andother complications in older patients.

Geography may also play a role in thedevelopment of high blood pressure inthe United States. For example,research has shown that African

Americans and whites living in thesoutheastern U.S. have a higher riskof high blood pressure and strokethan Americans living in otherregions. Part of the reason for thisdiscrepancy is that people living inthis area are more likely to be fromlower economic and educational back-grounds, which make people in gener-al more susceptible to anxiety, depres-sion, and diets that are high in saltand poor in nutrition. In fact, many of the states within this region have


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10% higher stroke rates than otherparts of the country. The 11 statesthat make up the so-called strokebelt are Alabama, Arkansas,Georgia, Indiana, Kentucky,Louisiana, Mississippi, North

Carolina, South Carolina, Tennessee,and Virginia. It still remains unclearthe extent to which environment orgenetics are influencing thesemarked differences.

The impact of high blood pressure onother racial groups in the country ismore even. For example, Hispanicand Native Americans have similarrates of developing hypertension as

whites, while Asian/Pacific Islandershave the lowest rates among allminority groups. The only problem isthat high blood pressure is not beingadequately addressed or treated

Part 2: The Impact

WOMENAs previously mentioned, women appearto suffer from high blood pressure later inlife, as compared to men. However, highblood pressure does have a particularimpact on women during pregnancy andmenopause.

Studies have shown that high blood pres-sure is common in up to 15% of all preg-nancies. Doctors usually monitor bloodpressure levels closely during the last threemonths of pregnancy, when it can quickly

develop. For mothers who already havehigh blood pressure before their pregnan-cy, their blood pressure levels should beproperly treated and may become evenworse. For mothers who develop hyper-tension during the pregnancy, they facethe risk of harming themselves and theirbaby if it is not treated properly. In manypatients, high blood pressure subsidesafter birth.

Older women are also prone to develophigh blood pressure after menopause,

when hormone changes in their bodiesmake them susceptible to the condition.Though research has not yet uncovered

the kinds of specific effects menopausehas on high blood pressure, doctors rec-ommend that older women carefully mon-itor their blood pressures on a regularbasis.

CHILDRENThough high blood pressure in children islargely uncommonabout 1 percent of allchildren in the U.S.the children of par-ents who have the condition are 20 to 30percent more likely to develop high bloodpressure than those with parents with nor-

mal blood pressures. Another potentialcause is the lifestyle habits that childrenand adolescents learn from their parentsor siblings. For example, children are morelikely to develop high blood pressure asadults if they have poor diets, smoke ordrink, take drugs, or are inactive or over-weight. For these and other reasons, it isrecommended that children have theirblood pressure taken on regular intervalswhen they are as young as three years old.In the rare cases when children developsevere high blood pressure, it is usually a

symptom of a more serious problem, likeheart irregularities or kidney disease.

Uneven Impact of HBPHigh Blood Pressurein Women and Children


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among these groupsparticularly African and Hispanic Americans

causing yearly mortality rates fromheart disease and stroke to be unnec-essarily high.

Reasons for uneven impact Among the other reasons for theuneven impact of high blood pressureare genetics , economics, and culture.

Health research has proven thatgenetics is one of the causes of highblood pressure and cardiovasculardisease . Genetics is the field of sci-ence that looks at how genes arepassed down from one generation to

another to influence traits.Researchers have been able to identi-

fy that certain racial groups like African Americans, for example, carrycertain genes that perhaps mayincrease the likelihood of developinghigh blood pressure. Some studiesnow suggest that 30 to 60 percent of all primary high blood pressure casesmay be genetically inherited. Otherinvestigations also suggest that a per-son is more likely to develop hyper-tension if he or she has a sibling withcoronary artery diseaseas comparedto having a parent with the ailment.The genetics of high blood pressureremain a critical area of study formedical researchers, since future find-ings may help to explain why certain


20

Percent of persons who were ever told they had high blood pressure, Adults aged 20 years and older, 2001

20%24.3%

24.4%26.0%

26.1%27.8%

27.9%32.7%

Age adjusted to the 2000 U.S.population


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individuals or groups of people havea greater genetic predispositionfor high blood pressure than others.

Economics is another key factorthat can further explain the unevenimpact of high blood pressure in

America. For example, millions of Americans with lower incomes andlower educational backgrounds maynot be able to attain health insur-ance without a full-time job. Many

Americans either work in low-pay-ing, part-time jobs or are unem-ployed, which makes them and

their family members more likely tobe without adequate health insur-ance (or treatment if they have highblood pressure). By comparison,people with salaried jobs and higherlevels of income are better able toafford decent health coverage or theadded medical expenses that cancome from developing a conditionlike high blood pressure. Better cov-

erage also increases the likelihoodof receiving better care.

Unfortunately, people from lowersocioeconomic groups also tend tohave diets that are poorer in nutri-tion and to be less physically active,both of which can lead to high bloodpressure. Many struggling familiesmay be unable to afford or fully rec-ognize that fresh fruits and vegeta-bles are the cornerstone of ahealthy diet. Instead, frozenprocessed foods or high-sodiumsnacks may be the affordable foodchoice for many. In addition, peopleliving in poor areas have feweropportunities to develop and sus-

tain physically active lifestyles, dueto safety reasons and fewer parks oraffordable fitness centers.

Cultural, particularly language, dif-ferences is another cause of theuneven rise of high blood pressurein a given population. For example,in the United States, members of minority groups who do not speak

English may have a harder timehearing, reading, or understandingthe basic information about high

blood pressure that istransmitted to the publicthrough television, news-papers, radio, pamphlets,or directly from healthcare providers. The lack of exposure to health careinformation (and treat-

Part 2: The Impact

Some studies now suggest that 30to 60 percent of all primary highblood pressure cases may begenetically inherited.


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ment) is particularly common withminorities who have poor educationsand come from low-income families.Many immigrants also remain unin-formed or indifferent about the disor-der, since they may have come fromcountries or cultures with poor healthcare standards and facilities. Theymay also dispute the effectiveness of medicine, be afraid of doctors, or con-sider prevention efforts to be either aluxury or a waste of time.

When it comes to health, teenagersare often perceived as coming from a

different culture than their parents oradults in general. With their energyand unbridled youth, many teenagersoften take for granted that they willalways be healthy and will live longlives. What they tend to miss or over-

look is the fact that how they livetoday can affect their health whenthey become adults. Eating poorly,avoiding physical activity, smoking,and drinking can cause them to pre-maturely and unnecessarily develophigh blood pressurenot to mention anumber of other serious conditions orillnesses. These and other barriersmake it harder for the medical com-munity to reach and inform teenagersabout the wisdom of prevention andproper treatment.

High blood pressure will continue to

have a disproportional effect on thepeople of the United States until allmajor groups are given the propersupport, information, and access tohealth care on an ongoing basis.


22


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Part 2: The Impact

Saunders, continued on next page

Making Noise about Hypertension and

African AmericansPeople of all races and ethnic groups gethigh blood pressure, but it is an especiallyserious problem for African Americans.

We know that is true partly because of30 years of work by Dr. Elijah Saunders.

Saunders is a professor at the University ofMaryland Medical School in Baltimore and

head of the hypertension section there.

His research has helped show that some blood pressure medications aremore effective than others for African Americans. He helped start anorganization called the International Society on Hypertension in Blacks.

Recently, the organization came up with guidelines telling doctors howthey should treat high blood pressure in their African Americanpatients, which is not always the same way it should be treated inwhites. For example, many African Americans need to start on at leasttwo medications to lower their blood pressure.

Why waste time and effort prescribing just one drug when in mostcases it wont work? asks Saunders.

Saunders was inspired to become a doctor by the example of Dr. RalphReckling, one of the doctors in the segregated west Baltimore neigh-borhood where he grew up.

When Saunders was a medical student in the late 1950s, doctorsthought only people with extremely high blood pressure would benefitfrom treatment. Extremely high meant readings in the 200s and 300s.Blood pressure that high is called malignant hypertension.

The attitude about blood pressure started to change after the resultsof a study by the Veterans Administration were published in 1970. Thestudy included people with what was then considered moderately high


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Part 3: Care

Diagnosing high bloodpressureThe diagnosis for high blood pres-sure is fairly simple and painless. Aspreviously mentioned, to measureblood pressure, a doctor or nursewraps a sphygmomanometer (bloodpressure cuff) around the upper armand pumps it with air, so the instru-ment can cut off the circulation inyour artery. Then, with the use of astethoscope , the doctor or nursegradually lets air out of the cuff inorder to listen to and accuratelymeasure the level of your blood pres-sure when it is being pumped (sys-tolic pressure) and when the beatingstops (diastolic pressure).

Since blood pressure levels andmeasurements can change quicklyand vary in degree, a doctor maydecide to take a patients blood pres-sure more than once. This mayinvolve taking measurements whilethe person is both standing and sit-

ting down or at different points inthe week, since blood pressure maybe high on one day and more nor-malized on another. Factors thatcontribute to these fluctuationsinclude stress, worry, and the kindof usual nervousness that can arise

during a doctors visit(which is alsoreferred to as whitecoat hypertension).This broad-basedapproach enables

doctors to more accu-rately determinewhether a personactually suffers fromhigh blood pressure.

The two numbersthat are measured the systolic and dias-tolic pressurescanvary greatly depend-ing on the health and background of the patient. For example, a readingbelow 120/80 is considered averageor normal for most adults. Doctorsalso consider blood pressure read-ings like 110/70 to be low and,therefore, safe and acceptable.However, doctors identify someoneas having high blood pressurewhen his or her systolic pressure

(top number) is at 140 or higher orwhen his or her diastolic pressure(bottom number) is at 90 or above.For instance, people with blood pres-sure readings of 110/90, 140/70, and150/90 all have high blood pressure.In these cases, patients are usually


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26

prescribed some combination of treat-ment, often involving a healthier diet,physical exercise, and/or medication.

People who have a systolic pressure of 120-139 or diastolic pressure of 80-90have a condition known as prehyper-tension that affects 46 million

Americans. People who are diagnosedwith prehypertension are at high riskfor developing high blood pressurelater on, but making healthy lifestylechanges now can help prevent thatfrom happening. People with prehy-pertension should have their blood

pressure monitored regularly.

As shown in the chart below, highblood pressure is also commonlydiagnosed and classified at differentlevels.

Preventing and controllinghigh blood pressure

Although there is still no cure forhigh blood pressure, it can be effec-tively controlled through treatmentthat may involve lifestyle and dietarychanges, as well as medication. Forthose who have yet to develop the con-dition, maintaining a healthy lifestyleand diet throughout life can go a longway in preventing this potentiallydeadly condition.

There are many ways people of all

ages, races, and family backgroundscan help to prevent or lessen theirchances of developing high bloodpressure. Among the most importantrecommendations are:

Maintain the right weight (loseweight if obese).

American Heart Association recommended blood pressure levels

Blood Pressure Systolic (top number) Diastolic (bottom number)Category (mmHg) (mmHg)

Normal less than 120 and less than 80

Prehypertension 120-139 or 80-89

High

Stage 1 140-159 or 90-99

Stage 2 160 or higher or 100 or higher

mmHg = millimeters of mercury

Diagnosing high blood pressure levels


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2

Eat properly (limit salt intake).

Get exercise.

Practice relaxation techniquesto reduce stress.

Avoid alcohol and tobacco.

Monitor your health (includingregular blood pressure readings).

Take blood pressure medicine,if prescribed.

You can greatly reduce your chanceof developing high blood pressure byfollowing the recommendations list-

ed above. In more serious cases,medication may be necessary tohelp control the condition. However,it is very important to prevent thedevelopment of high blood pressurein the first place.

The following is a more in-depthreview of the key ways that peoplewith and without high blood pres-

sure can help to control or preventthe condition from becoming severeor out of control:

Maintaining the rightweightOver 50% of all Americans are over-weight, with 31% classified asobese. Even more serious is thefact that the percentage of childrenand adolescents who are obese hasdoubled in the last two decades.

The link between weight and bloodpressure is often very strong anddirect. Moreover, as people gain

weight, their blood pressure levelsincrease. The same is true for manypeople who are obese but loseweightthey can expect their bloodpressure levels to decrease. In fact,losing ten pounds or more can helpto lower your blood pressure. This is

why weight loss is considered one of the most important and effectivenatural treatments for preventingor reducing high blood pressure.

So, when is a person consideredobese or overweight? As a gener-al rule, men are considered obesewhen they are 20 percent over theirideal weight, as based on theirheight. Women are considered obeseat 25 percent over ideal. Adults, ingeneral, are considered morbidlyobese when they are 100 pounds ormore overweight. People who areoverweight (as opposed to obese) arebelieved to be two to six times morelikely to develop high blood pressure

Part 3: Care


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than those who are at or maintaintheir healthy, desirable weightlevels.

It is worth noting another factor thatcan influence the likelihoodof a person developing high bloodpressure. This has to do with wherean overweight person carries fat ontheir body. For example, there is evi-dence to suggest that people who areapple-shaped, storing extra weightaround their waists, are more at riskfor health problems than those whoare pear-shaped, storing excess

weight around their thighs and hips.

Weight and shape aside, what is cer-tain is that weight loss can greatlyreduce the possibility of developing

high blood pressure. The key to losingweight is to take in fewer calories(energy) than you burn up. It isimportant to steer clear of weight losspills or the newest, most populardiets, because they can be dangerousand are usually ineffective in keepingweight off over the long term. Thebest way to reduce or keep bloodpressure levels healthy over thecourse of ones life is to develop andcommit to a new lifestyle plan thatstarts with eating better and gettingmore physical activity. In general,maintaining the right weight

throughout life will not only help tolower blood pressure, but will reducethe likelihood of developing other ill-nesses like cancer, heart disease,stroke, diabetes, and kidney disease.

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Eating properlyThe golden rule for living a longand healthy life is maintaining abalanced diet that includes fruits,

vegetables, grains, and fish alongwith limited amounts of salt, fat,and sugar. This is especially impor-tant for people with high bloodpressure who are also striving tolose weight.

As mentioned earlier, more thanhalf of all Americans are over-weight. A natural consequence of

this fact is that Americans eat moresalt and sodium than they should. As a rule, many medical organiza-tions recommended that people con-sume no more than 1 teaspoon(2,400 milligrams) of sodium a day.

Americans, on average, take inbetween 4,000 to 6,500 milligrams aday! This is why more Americans as compared to people in othercountrieshave a greater risk of developing high blood pressure.(African Americans and the elderlyare particularly sensitive to sodi-um.) There are many reasons forthis health disparity , as well asmany healthy actions that peoplecan take to improve their diets,lifestyles, and blood pressures.

One critical change that people suf-fering from high blood pressureneed to make is to reduce theamount of salt and sodium theyconsume. This includes table saltand foods that are high in sodium,

like canned soups, smoked meats,seasonings, and many packaged andprocessed foods. This is why it isimportant to read the NutritionalFacts labels on most goods at thesupermarket in order to determinehow much sodium per serving afood item contains.

Part 3: Care

MONITOR LABELS: Foodswith High Salt or SodiumHot dogs

Canned soupsKetchupSaltinesSausagesCanned vegetablesMustardPretzelsHamPicklesCheesePotato chipsSmoked meat/fish

SauerkrautSoy saucePackaged frozen dinnersCanned meat/fishOlivesTomato sauce/juicePackaged cakes/pastries


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30

Sodium chloride is the equivalentof table salt. It contains about 40percent sodium. Sodium is definedas a silvery, soft, waxy, metallicelement that occurs abundantly innatural compounds, especially in saltwater. Sodium is created naturallyin foods, often in small amounts.These foods include milk, meat,cheese, fish, and some vegetables.

Buying foods that are low in sodiumor that have labels like no salt orlow sodium can help to reduce orprevent the onset of high blood pres-

sure. Since fast food and otherrestaurant meals are high in sodium,it is also important to make healthi-er food choices. While eating out, thismay even require asking waiters tohold the salt in preparing meals.Using doctor-recommended salt sub-stitutes is another good habit thatcould go a long way in improvingblood pressure.

As with weight loss, a long-termreduction in salt consumption candirectly reduce blood pressure levels.In fact, a simple regimen of weightloss and salt reduction can help 20to 25 percent of high blood pressurepatients normalize their levels andeven avoid the need to take specificmedications.

Getting exercise Along with eating properly, regularphysical activity is the key to losingweight, feeling good, and ensuringbetter, lifelong health. In addition tolowering blood pressure, exercisehelps to burn calories, reduceappetites, tone muscles, alleviatestress, lower cholesterol levels, andprevent heart disease and countlessother health problems.

Whether one has high blood pressureor not, it is widely recommended that

people perform at least 30 to 40 min-utes of physical exercise three to fourtimes a week. The benefits are innu-merable. In terms of high blood pres-sure, people who exercise are 20 to50 percent less likely to develop highblood pressure than those who arenot physically active.

There are many forms of exercise

that can meet the standard, weeklyhealth requirement. If done on a con-tinual basis, light-to-moderate activi-ties like walking, climbing stairs, orgardening can have many health

People whoare obese

experiencea greater

decrease inappetite after

physical exercise than

those who areat their ideal body weight.


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benefits. While more aerobic formsof exercise like running, biking, ortennis may appear to have moresubstantial and immediate benefits,there is no concrete proof that thesemore strenuous activities are moreeffective than a regimen of moremoderate and enjoyable ones. Thatis why it is necessary for all peo-pleparticularly those diagnosedwith high blood pressure to develop and commit to long-termexercise routines that they enjoydoing.

For those who are not physicallyactive, it is always a good idea toslowly and gradually adjust to anew and reasonable exercise rou-tine. To avoid injuries and otherserious complications, the choiceand duration of the exercise routineneeds to be consistent and appropri-ate for the age and physical condi-tioning of the person. While most

people do not have to consult with adoctor before starting, there are anumber of health conditions thatrequire a doctors approval,including:

High blood pressure Chest or shoulder pain Dizziness or faintness Being out of breath after light

exercise

History of stroke, diabetes,or heart disease

Other serious medical or physicalconditions

Avoiding alcoholand tobaccoUsing alcohol or tobacco to excesscan greatly raise blood pressure(and lead to numerous other med-ical and personal problems).

While putting a person at greaterrisk for developing high blood pres-sure, excessive alcohol consumptioncan damage the liver, heart, andbrain. High in calories, alcohol caneasily hurt ones efforts to lose

weight. As a result, it is recom-mended that people who chooseto drink do so in moderation.

According the Dietary Guidelinesfor All Americans, women should

Part 3: Care

What is considered a drink?12 ounces of beer, regular or light (150 calories),1.5 ounces of 80-proof whiskey (100 calories),or 5 ounces of wine (100 calories).


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32


limit their consumptionto one drink a day, andmen to two drinks a day.(Blood pressure levels canbe raised by drinkingexcessive amounts of alcohol such as 36 to 48ounces of beer, 3 to 4ounces of 100 proof whiskey, or 18 ouncesof wine.)

A number of recent stud-ies have shown that limit-ed alcohol consumption is

not entirely bad for peo-ple and can have somehealth benefits. Forexample, some clinicaltrials have indicated thatpeople who have one ortwo drinks a day havelower blood pressure andlive longer than thosewho drink too much.

Others have found thatlimited wine consumptioncan prevent the accumu-lation of fat in the arter-ies and raise good bloodcholesterol. However,

these few benefits aside, what isunmistakable is that excessive alco-hol has been and continues to be thesource of countless personal, medical,and social problems throughout theworld. Those who have a history of alcoholism in their families or whohave a particular sensitivity toalcohol should keep from drinkingaltogether.

Another potentially habit-formingand health-threatening substance istobacco. Cigarette smoking increasesthe risk of heart disease, stroke, anda variety of lung diseases, such asemphysema, bronchitis, and lung can-cer. While it has not been proven todirectly increase blood pressure,smoking has played a significant rolein damaging blood vessel walls andspeeding up the hardening of thearteriesall of which lead to thedevelopment of high blood pressure.

The easy answer to the problem of

smoking is not to start in the firstplace. This is particularly true for

American women who, statisticsemphasize, are 2 to 6 times morelikely to have a heart attack thanwomen who dont smoke, with the

What is cholesterol?Cholesterol is a soft, waxysubstance that is found in

all areas of the body suchas the heart, liver, intes-tines, muscle, skin, andnervous system. It is pro-duced by the body andderived from animal-basedfoods (like meat, eggs, andbutter) in the diet.

There are two types ofcholesterol: good and

bad. Good cholesterol(HDL) helps blood vesselsand the liver to clean upand eliminate excess cho-lesterol. Bad cholesterol(LDL) in the diet increasesthe risk of developingplaque in the arteries,which can hamper the flowof blood and lead tostroke or heart attacks. It is

recommended that peoplemaintain blood levels thatare low in bad choles-terol and relatively high ingood cholesterol.


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risk increasing based on the numberof cigarettes smoked each day. Forthose who do smoke, the simple solu-tion is to gain the support you needto quit. The payoffs are remarkable,if not immediate, since the risk of heart disease after the first year of quitting is reduced by more than50 percent.

Monitoring health Another important aspect in pre-venting and treating high bloodpressure and other related condi-tions involves keeping track of andbeing informed about your healthon an ongoing basis. This involvesmeeting with your doctor for regularcheck-ups and having your bloodpressure measured on a regularbasis, particularly if you have highblood pressure or prehypertension.

Again, it is recommended that peoplehave their blood pressure checked atleast once a year. For those withhypertension, it is important tomonitor, treat, and control the disor-der on an ongoing basis.

Doctors or health care providersoften advise their patients withhypertension to keep track of theirblood pressure on a daily basis usingsome form of home monitoring

device. This allows the doctor andpatient to monitor and record howhis or her blood pressure changesover time. It also provides a moreaccurate diagnosis of the fluctuationsat different times of the day and in

between doctor visits. Home monitor-ing also helps in cases where apatients blood pressure levels ormedications change frequently.Overall, it is normal for bloodpressure readings to fluctuate20 to 30 mmHg at different timesof the day, particularly after per-forming some form of physicalactivity or while experiencingmoments of excitement. It is suggest-ed that patients do not become over-ly concerned about these fluctuationsor become obsessive about theirreadings in general.

Today, there are a number of homemonitoring equipment options tochoose from. Theres a portable, one-unit device that includes a sphygmo-manometer and stethoscope. There

are also three types of electronicmonitoring devices to considermer-cury, aneroid (air), and automatic.Though each device has its ownadvantages and disadvantages, mostare affordable, easy to operate,

Part 3: Care

Using homemonitoringdevices arean easy and affordableway for

patients tokeep trackof their blood

pressure ona daily basis.


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widely available in pharmacies anddiscount chain stores, and usually

take less than aminute to attain anaccurate reading.Some devices evenrecord or print outyour readings. It isrecommended thatpatients talk withtheir doctor or healthcare provider aboutwhich type of devicewould best suit theirneeds.

Taking blood pressuremedicineFor those whose high blood pressureis serious enough to require medica-tion, it is important to remember thatchanges in diet and lifestyle are alsoabsolutely necessary. No single won-der drug or large amount of medica-tion will help a person reduce his orher blood pressure to a healthylevelhow one eats and lives willneed to be improved as well. In fact, ithas been shown that only 40 to 50percent of people who rely solely onmedication to reduce their blood pres-sure to normal levels are successful.

Thanks to advancements in medicineand technology, a number of medica-tions have been developed to help peo-ple with severe high blood pressure tolive normal, functional lives well intoold age. In most cases, the addition of medicine to a persons treatment can

help to dramatically improve theirblood pressure in less than a year.

When a person is first diagnosed withhigh blood pressure (and medicine isrequired), doctors typically prescribediuretics , which is in line with a2003 report and recommendation bythe Joint National Committee (JNC)on Prevention, Detection, Evaluation,and Treatment of High BloodPressure. Doctors may also prescribea second medicine, such as a betablocker, to help patients meet theirblood pressure goals. The JNC also

recommends that otherwise healthy African-American patients, who areparticularly sensitive to sodium, begintheir treatment taking only diureticsor a combination of drugs containingadequate doses of a duretic.

Depending on the patient and theseverity of the problem, doctors mayalso choose to combine one medication

with another to help better control orlower the patients blood pressure.Patients are commonly prescribedtwo or more medications from differ-ent classes, since blood pressure med-ications often complement each otherin their efforts to reduce blood pres-sure. A very common example is thecombination of diuretics and ACEinhibitors, which has proven to help75 to 80 percent of people who setgoals of lowering their blood pressurelevels below 140/90 mmHg. (Theuse of only one of these medicationshelped 40 to 50 percent achieve thesame goal.) People with moreserious or unstable high blood


34

Of all peoplewith high blood

pressure: 14.8% are not on

a special diet ormedication

26.2% are oninadequate therapy

27.4% are onadequate therapy


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pressure may need to take vasodila-tors which lower blood pressure byopening up vesselsalong with adiuretic or other anti-hypertensivemedication in order to help lowerfluid retention.

Once a patients blood pressure hasimproved and stabilized for at least12 months, doctors typically imple-ment what is called step-downtherapy. This approach allows doc-tors to gradually lessen either thenumber or dosage of the medications

Part 3: Care

High Blood Pressure Medications A person with high blood pressure may be prescribed one or more of the followingmedications. Each work to lower blood pressure in different ways.

Diuretics also known as water pills for their ability to flush out extra salt andwater from the body and blood vessel walls. This allows blood vessels to open wider,improving the circulation of blood in the body. Diuretics come in many different formsand range in duration, some lasting from 4 to 6 hours while others may last up to 48hours. Proven to effectively lessen the risk of heart attacks and stroke. Often usefulwith other blood pressure medications.

Beta Blockers have been prescribed for over 30 years to make the heart beat slowerby reducing or blocking the effect of nerve impulses to the heart and blood vessels.This helps the heart work less strenuously, therefore lowering blood pressure levels andreducing the chance of heart failure and stroke in many patients.

ACE Inhibitors Angiotensin Converting Enzyme (ACE) inhibitors are a class of drugsthat are commonly used to prevent the production of the hormone angiotensin II,which causes blood vessels to constrict, causing blood pressure to rise. ACE inhibitorshelp the blood vessels relax and open up and lower blood pressure. When combinedwith other blood pressure medications, ACE inhibitors can help to effectively treat peo-ple who have suffered from heart failure or those with diabetes and kidney disease.

Angiotensin Receptor Blockers (ARBs) work by reducing the effects ofangiotensin II. For angiotensin II to cause blood vessels to constrict, it must bind to areceptor in much the same way that a key must fit into a lock to open a door. ARBsblock angiotensin II from binding to its receptor, which helps blood vessels to relax.

Calcium Channel Blockers (CCBs) have been used for over 20 years to prevent cal-cium from entering the muscle cells of the heart and blood vessels, causing the vesselsto relax and open up, and lowering blood pressure.

Alpha Blockers work to reduce or block nerve impulses to blood vessels, causing

them to relax and blood pressure to go down.Alpha-beta Blockers combine the blood vessel relaxing alpha blockers with betablockers, which cause the heart to beat more slowly. The combined effect lessens theamount of blood (and pressure) through the vessels.

Nervous System Inhibitors help to lower blood pressure by controlling nerveimpulses that allow blood vessels to relax and widen.

Vasodilators help to lower blood pressure by causing the muscle in the artery wallsto relax and blood vessels to open up.


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the patient has been taking. The pur-pose is to see if the patient can stillstabilize his or her blood pressurewhile either reducing the number ordosage of the medications being pre-scribed. While some patients cannotafford to reduce their blood pressuremedications, any lifestyle or dietarychanges they undertake can ultimate-ly help to step down their relianceon medications in the long run.

Most patients tolerate blood pressuremedications without side effects.But some patients may experiencea variety of side effects. These includeirritating oneslike dizziness,

drowsiness, or skin rashand poten-tially serious ones, including depres-sion, hallucinations, and heart prob-lems. Diuretics have also been provento cause muscle cramps and fatiguein some patients, while ACE inhibi-tors are known to cause chroniccoughing. However, most people feelfew or no side effects while takinghigh blood pressure medicine.

Patients who are prescribed medica-tions and develop one or more sideeffects should inform their doctors,since there are a number of other

medications or dosage amounts thatcan help to stabilize blood pressurelevels with few or no side effects.This is particularly true for high bloodpressure patients also suffering fromdiabetes, kidney disease, or other dis-orders, since doctors often prescribestronger medications or higherdosages to treat these more threaten-ing illnesses. It may be necessary for

a patient to try different types of blood pressure medications in orderto find the one that works most effec-tively.

As with other medications, it isstrongly recommended that patientscontinue taking the prescribed medi-cine unless a doctor decides different-ly. It is also suggested that patientsconsult with their doctor about othermedications they might be taking,since certain types of drugs cause arise in blood pressure levels. It is alsoimportant to tell your doctor aboutany herbs or other natural or alterna-


36

Medications That Can Causeor Aggravate HypertensionAntidepressants (monoamine

oxidase [MAO] inhibitors andtricyclics)

Anti-inflammatory drugsAppetite suppressantsCold remediesCyclosporineNasal decongestantsOxymetazolinePhenylephrinePhenylpropanolaminePseudoephedrineNonsteroidal anti-inflammatory drugs

(NSAIDs)AspirinIbuprofenNaproxen sodiumOral contraceptives

Excerpted from: Essential Guideto Hypertension, American MedicalAssociation, 1998.


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tive medicines you may be taking.Just because an alternative medicineis considered natural does notmean that it is safe. Some herbs maylower the effectiveness of your med-ication or actually raise your bloodpressure.

Blood pressure treatmentplansOne of the primary purposes of atreatment plan is to bring bloodpressure levels down in order toreduce the chances of health-threat-ening complications, like stroke,heart disease or kidney failure.Depending on the circumstances, thedoctor and patient will work closelytogether to develop an appropriateand individually tailored plan of treatment. The plan itself may take

some time to get used to and willeither be implemented in the hospi-tal, at home (while under closesupervision), or both. Most plansmay involve a number of lifestylechanges, medication, and an ongoingmonitoring of blood pressure levels.

As emphasized earlier, all treatmentplans involve making changes in dietand lifestyle to facilitate weight lossand the lowering of blood pressurelevels. This may include adjusting toa diet that is low in fat and sodium,and lifestyle changes that involve

lots of physical activity and an avoid-ance of alcohol and smoking.

These and other basic, personallifestyle changes will go far in help-ing to reduce ones blood pressure,particularly those who have to rely

Part 3: Care

Ten Ways to Control Your High Blood Pressure

Know your blood pressure. Have it checked regularly.

Know what your weight should be. Keep it at that level or below.

Dont use excessive salt in cooking or at meals. Avoid salty foods.

Eat a low-fat diet according to American Heart Association recommendations.

Dont smoke cigarettes or use tobacco products.

Take your medicine exactly as prescribed. Dont run out of pills even for asingle day.

Keep appointments with the doctor.

Follow your doctors advice about exercise.

Make certain your parents, brothers, sisters and children have their bloodpressure checked regularly.

Live a normal life in every other way.

From the American Heart Association


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Part 3: Care

One Doctors Reasons for Deciding How toTreat High Blood

Pressure

Sometimes the more choices you have, theharder it is to make a decision.

Doctors have that problem when it comes topicking the medication that is best for highblood pressure.

There are five major types to choose from: ACE inhibitors; angiotensin-receptor blockers; beta blockers; calcium-channel blockers; and diuretics.

It gets even more complicated. There are subtypes within those five types.And different medications are combined into a single pill. Lotensin HCT isone example. It is a combination of an ACE inhibitor and a diuretic.

So how do doctors decide what to prescribe?

To see what one doctor does, we spoke with Dr. Sandra Taler. Taler is aphysician at the Mayo Clinic, the world-famous medical center in

Rochester, Minnesota.Taler says the first type of drug that she usually prescribes is a diuretic:I have always been a big fan of diuretics.

She is right in step with new government guidelines that say most peoplewith high blood pressure should try a diuretic first.

Diuretics work by helping the kidneys get rid of sodium (a chemical that ispart of salt) and water from the body. That decreases the volume of theblood, so there is less blood pounding against the walls of your blood ves-

sels, creating high blood pressure.

There are two main types: loop and thiazide (pronounced THIGH-ah-zide).Most people taking a diuretic to control high blood pressure take athiazide diuretic.

Taler, continued on next page


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Many patients worry that the pills will make them have to go to the bathroommore often. At first, a thiazide diuretic does increase urination. But after sev-eral weeks, most peoples bodies adjust and levels return to normal.

Taler takes a different approach with her patients who have had a heartattack or experience the chest pain called angina that comes from the heartpumping without enough blood. For them, shell prescribe a beta blocker.

Beta blockers slow down the heart, so it is not pumping blood through yourblood vessels with as much force. Slowing down the heart helps if youve hadheart trouble, because it means the heart isnt working as hard and can get bywith less blood.

If someone has diabetes, Taler says she orders some kidney tests. Dependingon the results, she would prescribe an ACE inhibitor. ACE inhibitors affectblood pressure by relaxing blood vessels but are less effective with excesssodium and water levels.

But treating high blood pressure with pills is no substitute for avoiding it inthe first place. People get high blood pressure for many reasons, but weightgain and eating too much salty food are two of the main ones. Salty food rais-es blood pressure, and Taler says people dont have any idea just how salty thefood is when they eat out.

Thats true at fancy restaurants, she adds. It is not just McDonalds.


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Current lines of research As science, technology, and the fieldof medicine have advanced over thecenturies, so has humankindsunderstanding about the mysteri-ous nature and widespread effectsof high blood pressure. Over theyears, many researchers have dedi-cated their lives to investigatingand discovering more effective waysof identifying, diagnosing, treating,and reducing the complications of high blood pressure in all kinds of people with all types of conditions.We read or hear about many of these exciting discoveries in thenews. While much has beenlearned, many questions remain to

be answered. The progress so farhas helped to improveif notsavethe lives of millions of peoplewho have developed hypertension.

As with other life-threatening dis-eases and disorders, the hope isthat explorations in the area of high blood pressure will one daylead to a cure.

Today, there are still many ques-tions about high blood pressurethat researchers are trying to deter-mine. They include: How can highblood pressure be prevented ormore effectively treated? Why does

it affect African Americans and theelderly more than other groups of people? How can the medical com-munity more effectively educate thepublic about this potentially deadlycondition? Research conducted inall areas and fields of science ishelping to build upon the reservoir

of knowledge that we presentlyhave about high blood pressure.The following are examples of thetypes of research that are currentlyand actively taking place:

Population Studies. By studyinga group of people over time,researchers learn a great dealabout the nature and mechanics of

the disorder. One such study is theJackson Heart Study (JHS), whichhas been focusing on cardiovasculardisease among African Americansfrom Jackson, Mississippi. Startingin the fall of 2000, the JHS beganto study 6,500 African-Americanmen and women between the agesof 35 and 84. Through question-naires, lab tests, and other investi-gations, the researchers hope todetermine how the common disor-ders of high blood pressure, dia-betes, and obesity influence thedevelopment of cardiovasculardisease in African Americans.

Part 4: Research

Over the years, many researchershave dedicattheir lives to

investigatingand discovering moreeffective wayof identifyindiagnosing,treating, and

reducing thecomplicationof high blood

pressure in akinds of peowith all typeof conditions


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42


The JHS is an extension of the Atherosclerosis Risk in Communities(ARIC) Study that took place in fourU.S. cities more than a decade ago.

The ARIC Study involved a compre-hensive examination of 15,792 peopleover a 12-year period from fourdiverse regions in the U.S.: Minne-apolis, Minnesota; Forysth County,North Carolina; Washington County,Maryland; and Jackson, Mississippi.The purpose of the ARIC Study hasbeen to identify and study genetic andchemical risk factors of cardiovasculardisease.

The JHS represents the largestresearch study of cardiovascular dis-ease on an African-American popula-

tion to date. The research promises toyield significant findings that willhelp to better educate, prevent, andtreat cardiovascular disease and relat-

ed disorders (like high blood pressure)among this particularly susceptiblegroup of Americans.

Another similar study is the clinical African-American Heart Failure Trial(A-HeFT) currently being sponsoredby NitroMed, a pharmaceutical com-pany. The study involves the recruit-ment of about 600 African-Americanmen and women from over 100 clinicsacross the United States who sufferfrom moderate-to-severe heart failure.

Among other things, the trial isdesigned to test the effectiveness of

The JHS representsthe largest research

study of cardiovascular disease on an African- American populationto date, and promises

to yield significant findings that will help

to better educate, prevent, and treat

cardiovascular diseaseand related disorders

like high blood pressure among this

particularly susceptiblegroup of Americans.


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a special nitric oxideenhancedheart medication called BiDil tosee if it can prolong or enhance thequality of the trial members lives.

This important study is also spon-sored by the Association of BlackCardiologists and is bound to shedsignificant light on the relationshipbetween heart failure and highblood pressure in the high-riskgroup of African Americans.

Researchers also continue to inves-tigate the effects that high bloodpressure has on the aging. Onerecent study established a linkbetween depression and heart fail-ure among the elderly who havehigh blood pressure. This studyinvolved 4,538 people over the ageof 60 who were part of the SystolicHypertension and the ElderlyProgram (SHEP). Researchers dis-covered that heart failure developedin 18 of 221 depressed patients(8.1%), while it only affected 138 of 4,317 (3.2%) other patients whowere not depressed. The investiga-tion represents one of the first stud-ies to establish a link betweendepression and the development of heart failure. These and other find-ings from the investigation willhelp in understanding and address-ing the serious long-term complica-

tions of high blood pressure amongthe elderly.

In addition, numerous other highblood pressure studies are beingconducted to search for possiblehidden insights about the disorder

among lower-risk groups. Manyrecent epidemiological studieshave found that small babies whogain weight too rapidly are morelikely than others to develop highblood pressure as adults. Oneparticular study of 346 British menand women found that small babieswho experienced significant weightgain between the ages of one andfive developed higher blood pres-sure in adulthood. These findingshave brought into question the

effectiveness of pediatricians whooften encourage catch up growthfor small, underweight babies. Suchdiscoveries have caused doctors andresearchers to think about how andwhy high blood pressure can devel-op during pregnancy and infancy.

Part 4: Research

Many recent epidemiological studies havefound that small babies who gain weight too rapidly are more likely than others todevelop high blood pressure as adults.


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44

Genetic Research. Diseases and dis-

orders such as stroke, heart disease,and high blood pressure involve high-ly complex and countless interactionsbetween genes. This is whyresearchers across the world are try-ing to identify and isolate the specificgenes that may contribute to thedevelopment of high blood pressure.

Past and present studies have been

able to prove that there is indeed alink between our genetic (family) his-tory and high blood pressure. Thoughsome genes have been identified,researchers have yet to find anygenetic variations that have clearlyand repeatedly proven to influence

the development of hypertension.It has been shown, however, that

genes produce proteins that ultimate-ly regulate body functions. In thissense, some gene-produced proteinscan make blood pressure levels rise,while others can cause them to godown. Under certain circumstances like aging and exercisesome pro-teins can have a stronger effect onblood pressure levels than others.

One of the serious challenges of researching the genetics of high bloodpressure is the amount of resourcesand expertise needed to effectivelystudy the connection. Moreover, manymedical, scientific, and statisticalexperts are needed to properly design

Diseases and disorders such as

stroke, heart disease, and high

blood pressureinvolve highly

complex and countless interac-

tions betweengenes. This is why researchers across

the world aretrying to identify

and isolate the specific genes that

may contributeto the develop-

ment of highblood pressure.


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and implement the study. In addi-tion, researchers need a large poolof participants and a considerableamount of time to thoroug

highbloodpressurebook[1]

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