Helping Patients Stick With Lifestyle Modification


SAN FRANCISCO — Most physicians believe in urging hypertensive patients to alter their lifestyle in beneficial ways, even though this seldom happens, Norman Kaplan, M.D., said at the annual meeting of the American Society of Hypertension.

“I'm not sure that we're going to be depending as much on lifestyle modifications as we have in the past” because of the recognition that high blood pressures need to be lowered quickly, said Dr. Kaplan, professor of medicine at the University of Texas, Dallas. He described lifestyle modifications that do and don't work in treating hypertension:

Smoking cessation. Usually found at the bottom of lists of lifestyle modifications for treating hypertension, smoking cessation deserves first mention because it is the major reversible cardiovascular risk factor in hypertensive smokers. Until recently, physicians didn't recognize the pressor effects of nicotine because patients weren't allowed to smoke during blood pressure measurements. Ambulatory monitoring consistently shows higher blood pressures while smoking.

Advise patients repeatedly to stop smoking, and explain or show to them the pressor effect of smoking, Dr. Kaplan said. Nicotine replacement products such as patches should not have persistent pressor effects but advise patients to check their blood pressure on these products because some people may be particularly sensitive.

Weight loss. Significant weight loss reduces blood pressure, but most dieters put the pounds back on in a short amount of time. Studies comparing weight loss diets suggest that the cheapest and “probably the most logical” method—Weight Watchers—may be the best diet strategy, he said.

For morbidly obese people (body mass index greater than 40 kg/m

Gastric banding surgeries have been less successful in morbidly obese patients. It appears that enough food is forced past the banded stomach over time that the patient regains the weight initially lost after surgery.

Physical activity. Unhealthy diets and physical inactivity share equal blame for Americans' march toward morbid obesity.

Duration is more important than intensity of physical activity for lowering blood pressure, studies show. Thirty minutes on a treadmill at 50%–75% of maximal heart rate significantly reduced blood pressure with effects persisting over 24 hours, one study found, he said.

A metaanalysis of studies on diabetic patients found that walking as little as 2 hours or more each week reduced mortality by about 40%, compared with less active patients, Dr. Kaplan said.

Sodium reduction. Patients who reduce their sodium intake typically return to old habits over time. The result is that no difference is seen after 5 years, according to an analysis of about 30 studies.

High-sodium foods abound in U.S. culture, with 1,000–3,000 mg sodium in some fast food items. “Most people have no perception of what they're eating when they eat this kind of food,” he said.

Moderation of alcohol. Drinking modest amounts of alcohol while eating food does not increase the risk of hypertension and may even provide some cardiovascular benefits, he said. Consuming alcohol without food or having more than three drinks per day increases the risk for hypertension and other health problems.

Increasing potassium. Hypertensive patients can reduce their blood pressure by taking 40–80 mmol/day of supplemental potassium, but it's better to recommend that patients eat more fruits and vegetables to boost their potassium intake. One reason the Dietary Approaches to Stop Hypertension diet works is that it triples the typical potassium intake, Dr. Kaplan noted.

Reducing caffeine. Be aware that the first cup of the day causes a pressor effect in many people. Advise patients monitoring their blood pressure to check before and after drinking coffee or tea containing caffeine, he advised.

Calcium or magnesium. These minerals, in the form of supplements, have no significant effect on hypertension, Dr. Kaplan said.

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