9 A Toolkit for Health Care Professionals Unmet Needs in Hypertension For most people who do not have secondary hypertension, nonpharmacologic interventions — or lifestyle modifications — are the first step in treatment. Nonpharmacologic interventions may be sufficient to prevent progression of hypertension in people with elevated BP and to meet BP goal for patients with stage 1 hypertension. Nonpharmacologic management is also integral to the treatment of stage 2 hypertension.1-6.2 The most effective proven nonpharmacologic interventions are: • Weight loss • Heart-healthy diets, such as DASH or Mediterranean diets • Reduced intake of dietary sodium • Enhanced intake of dietary potassium • Increased physical activity • Moderation or abstinence of alcohol consumption • Improved sleep hygiene • Stress management techniques • Smoking cessation1-6.2, Table 15 These interventions can be accomplished by behavioral strategies that change lifestyle, prescription of dietary supplements or kitchen-based changes that directly modify diet and eating patterns.1-6.1 Weight loss is the core recommendation to reduce BP in people with any degree of overweight or obesity. There is an apparent dose-response relationship of about 1 mm Hg reduction per one kilogram of weight loss. A patient can achieve weight loss with a combination of reduced calorie intake and increased physical activity. Other alternatives, such as pharmacotherapy or bariatric surgery, may be necessary.1-6.2.1 The DASH (Dietary Approaches to Stop Hypertension) eating plan is the dietary plan best shown to lower BP. DASH is high in fruits, vegetables and low-fat dairy products. It helps to reduce sodium intake while increasing intake of potassium, calcium, magnesium and fiber. This eating plan also limits sweets and foods that are high in saturated fats. Nonpharmacologic Interventions The Mediterranean diet, which is similar to DASH with increased allowances of fish, poultry, unprocessed red meats and small amounts of alcohol, has reduced BP — as have other dietary patterns that are low in calories from carbohydrates, high in protein or plant-based.1-6.2.2 Interventions to reduce sodium intake can help lower BP and prevent hypertension in adults. Reduction in dietary sodium by 1000 mg/d can lower SBP by 1-3 mm Hg in people who are nonhypertensive. BP reductions can be more than double in people who are salt sensitive, have hypertension or are on a DASH diet or other weight loss interventions. Optimal goal sodium intake is <1500 mg/d. Most dietary sodium in the U.S. comes from salt added during food processing or in fast-food and other restaurant kitchens. People can reduce dietary sodium intake by increasing their consumption of fresh, unprocessed foods, selecting processed foods with “no added sodium,” ordering carefully when eating out, using herbs and spices in place of salt while cooking and not adding salt at the table.1-6.2.3 Dietary potassium is inversely associated with BP and hypertension. Potassium intervention can lower BP, particularly in adults who are Black or consume high levels of sodium. Expect similar BP-lowering effects from potassium pills or from increased consumption of fruits, vegetables, low-fat dairy products, selected fish and meats, nuts and soy products.1-6.2.4 Potassium supplement pills should be used under supervision of medical professional to prevent hyperkalemia. Dynamic aerobic exercise and weight training can both help lower BP. Aerobic exercise can reduce SBP by 5-8 mm Hg in adults with hypertension. Isometric exercise may also result in substantial BP reductions.1-6.2.5 There is a strong, predictable and direct relationship between alcohol consumption and BP, especially above an intake of three standard drinks per day, approximately 36 ounces of standard beer, 15 ounces of wine or 4.5 ounces of distilled spirits. The data on significant BP or CVD consequences from consuming more than two drinks daily are not conclusive.1-6.2.6
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