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  • Fatigue, cognitive problems and depression: Depression

    The incidence of depression amongst people with Multiple Sclerosis has been a matter of controversy for many years. In the early years of research it was thought that relatively few people with the condition had ‘clinical’ depression, but more recent research indicates that the level of depression is far higher than was previously thought.
    Recent research suggests that up to 50% of people with MS (compared to only 5–15% of people without) will experience serious depression at some point in their lives, and at any one time perhaps one in seven may be experiencing this kind of depression. It is a very broad subject and could fill a book in its own right. An inspirational personal account on coping in MS is given in Multiple Sclerosis – a personal exploration by Dr Sandy Burnfield.
    Sometimes people ask about the incidence of suicide amongst people with Multiple Sclerosis. Although it is difficult to give precise figures, it does appear that the rate of suicide is higher for people with MS compared with the general population. There may be many reasons for this:

    • Depression is associated with a higher rate of suicide – and as we have indicated people with MS have a higher rate of depression.
    • There are also many other life crisis-based circumstances that may be linked with suicide whether or not people have MS.
    • The consequences of having MS may, however, be linked more with things like general stress, employment problems, and problems with money, family or relationships, than for some other people.
    • Also, when people feel a lack of hope for the future, sometimes suicide may seem an option.

    In all these circumstances, it is very important that all avenues are explored for help, for through the management of depression and feelings of hopelessness, often situations that seem hopeless at the time are then viewed differently. Psychotherapy and or medication can assist greatly here.
    Of course there is a related major debate under way, which is about the extent to which people can, or should be able to end their life if they
    wish – if necessary with assistance – if they are acting rationally knowing what they are doing and in full command of all their faculties. Such assistance is currently illegal in Great Britain and a number of recent high profile court cases have confirmed this position. This debate raises considerable emotions on all sides and no doubt will continue to be a matter of great controversy.

    Management

    As far as depression is concerned, it is important that you seek medical help partly because there are various forms of depression that may require dif ferent kinds of management. It is good that you have recognized that you may need help, because much can be done for you. Initially you may feel that seeking such help is a ‘waste of time’, or indeed carries with it some kind of stigma, similar to what people some- times feel is associated with mental illness or ‘weakness’, but a sensible approach can substantially prevent you feeling miserable and improve your relationships.

    Counselling and cognitive behaviour therapy
    Depending on the nature of the depression, you may be of fered counselling – and this is increasingly available both in general and hospital practice – or, rather more rarely, psychotherapy in larger and more specialist centres. In certain situations, where it may be helpful to discuss the depression in a family context, family therapy might be offered, although this again is very likely to be at the largest and most specialist centres. It is possible that these more specialist forms of therapy will involve onward referral, for assessment through a psychiatrist, for example. Cognitive behaviour therapy has been found very effective in some people with Multiple Sclerosis.

    Drugs
    More usually, you may be prescribed one of the antidepressant medications. Until recently, ‘tricyclic antidepressants’ were the most commonly used drugs, such as imipramine (Tofranil), amitryptiline (Elavil) and nortriptyline (Pamelor). However, another family of antidepressants, called ‘serotinergic antidepressants’, is now being prescribed much more regularly, drugs such as fluoxetine (Prozac), for example. These drugs have to be carefully administered and monitored, so it is important to follow medical advice. A combination of counselling and drug therapy may be needed.

  • Fatigue, cognitive problems and depression: Cognitive problems

    Research has identified two broad areas where Multiple Sclerosis seems to be involved or has effects that are not so much to do with the mind in general, but with what are more neatly and technically considered as cognitive issues on the one hand, and attitudinal and emotional issues on the other.
    Cognitive issues are those that concern our thinking, memory and other skills, which we use to form and understand language; how we learn and remember things; how we process information; how we plan and carry out tasks; how we recognize objects, and how we calculate. It was thought until recently that memory loss and some other cognitive problems were a rare occurrence. However, more recent research has suggested that a range of cognitive problems varying widely in type and severity may be present in many people with MS.
    Of course people with MS, just like anyone else of a similar age and sex, can suffer mental illness or dementia but, clinically, people with MS do appear to have more depression (see next section) compared to other people, and perhaps have what might be called mood swings rather more often. More recently, studies have shown that many people with Multiple Sclerosis have some problems with memory and with what are called their cognitive abilities, and these seem to be associated with the effects of the disease. It is thought that MS could lead to a subcortical dementia but this is not inevitable. We discuss depression and mood swings later in this chapter.

    How to recognize the problem

    We can all change without necessarily realizing the nature or extent of that change – until someone tells us. Sometimes people with MS may be so depressed or anxious that they think their cognitive problems are worse than in fact they are; on the other hand, they may not want to acknowledge them at all, for they do not want to think that MS may affect their cognitive as well as their physical functions. In addition to the general variability of symptoms, an issue that we have indicated is characteristic of MS, we have also noted that previously it has been very difficult to link cognitive performance to any other aspect of MS. However, more recently, studies using MRI (magnetic resonance imaging) have shown that the more general the demyelination the more likely it is that significant cognitive problems will also exist. Moreover, MS lesions in certain areas of the brain seem to be associated with cognitive difficulties. Further work will, it is hoped, be able to identify more precisely the relationship between certain kinds of cognitive problems and areas of the brain affected by Multiple Sclerosis.
    In addition, during acute attacks of MS, it has been observed that cognitive performance – memory and concentration, for example – may get significantly worse and then improve again; on the other hand, if the cognitive problems have arisen gradually and have been present for some time, then it is unlikely that they will improve substantially.
    Family perceptions may be more accurate on occasions but, although we all suffer from memory lapses from time to time, it may be tempting for you or some family members to put down every piece of forgetfulness to the Multiple Sclerosis. To avoid possible uncertainties, concerns or perhaps even recriminations, you should seek an objective assessment of any cognitive problems, if possible with a referral to a clinical psychologist, or more specifically to a neuropsychologist – usually from your neurologist.

    Professional opinions
    Until the results of recent research, many GPs and neurologists did not consider cognitive symptoms to be a major issue in relation to MS. Because the understanding and use of language is quite good in people with MS, in a single or occasional interview or consultation, it may be hard for a doctor to pick up more subtle but still important cognitive prob- lems. As we have suggested, it is far more likely that those who are with you, and see you everyday, will notice these things first. People with MS have found that cognitive problems can be one of the main reasons why they have to go into residential care or why they become unemployed.

    Tests
    Formally, the range and extent of any cognitive problems can be measured and monitored through what are known as ‘neuropsycho- logical tests’, usually given by a psychologist. They would involve some verbal and written tests focusing on things like your memory and your ability to solve problems of various kinds. These tests are becoming more sophisticated and you may be given a group (often called a ‘battery’) of tests that could take perhaps an hour or more to do. Your performance on these tests is then compared to those of normal healthy adults, and it is assumed that, unless there are other explanations, a much lower performance on one or more tests is due to MS. These tests are only given routinely in some clinical centres at present and, because this is still one of the developing areas of research and clinical practice in MS, you may need to attend specialist centres to obtain such an assessment.
    Because some medications may affect your performance in tests, you should make the person who is testing you aware of what medication you are currently taking. The testing process itself may be problematic for other reasons. For example, many of the tests used for people with MS require a degree of coordination and manual dexterity, and this may be compromised by other ef fects of Multiple Sclerosis. Also, a problem in one area of cognition can affect performance in a test in an unrelated area, or it may be difficult to compare tests involving spoken responses with tests involving written or manual responses.

    What might affect cognition?

    Emotional state
    Your emotional state may affect your cognitive performance, but the exact relationship and mechanism is not yet clear. Some studies have shown that depression seems to be related to cognitive performance, and others have shown the opposite.

    Heat
    Heat, or getting hot, may affect your cognitive performance, as it may influence other symptoms from time to time. Although little research has been undertaken on heat and cognition, on the basis of research on other symptoms it would be reasonable to conclude that if, for example, your memory could have been affected in this way, it would be likely to return to normal with a reduction in the temperature.

    Medication
    Medication may also affect cognition, particularly those that have cen- tral nervous system effects, such as sedatives, tranquillizers, certain pain killers and some steroid treatments. You should be aware of this possi- bility while you are doing everyday tasks that require concentration.

    Cognitive problems found in Multiple Sclerosis

    We must re-emphasise that the variability of cognitive problems in MS is very wide, some people do not have any cognitive problems and in others they are very mild. However, for information, the sort of problems that research has revealed are as follows. Memory loss is the most frequently found cognitive problem in MS. This may involve problems with short- term memory – failing to remember meetings or appointments, forgetting where things are and so on. There is also some evidence that people with MS may find it harder to learn new information. There are also difficulties with what is called abstract reasoning in some people with MS – that is the capacity to work with ideas and undertake analysis or decision-making in relation to such ideas. Sometimes speed of information processing may be af fected in Multiple Sclerosis – things seem to take longer to think about and do. It may be more difficult to find words, and concentration can tend to wander more readily. In addition it is possible that capacity to organize things spatially becomes more difficult – for example putting together self-assembly furniture is more of a problem.

    Management

    Drugs
    At present there are no drugs approved and accepted for the management of such problems as memory or concentration in MS. Memory problems are, of course, not limited to people with MS, and there is considerable research in this area. However, the cause of memory problems varies between different conditions, so drugs that might be helpful for people with Alzheimer’s disease, who have very severe memory problems, would not necessarily be useful for people with MS. Nevertheless, there is increasing research to see whether a number of drugs, often originally developed for other purposes, might help people with MS.
    There is some evidence that drugs used to assist fatigue may have modest effects on some cognitive problems. There are currently trials to see whether the drug pemoline might help cognitive function, and preliminary research on amantadine has suggested that it might have some ef fect on information processing. A drug with the proprietary name of Aricept, used for the treatment of memory disorders in Alzheimer’s disease, is being studied to see whether it has any similar effects in people with MS. However, whilst in Alzheimer’s disease this drug appears to increase the availability of a substance called acetylcholine, a neurotransmitter, this does not seem to be relevant to the cognitive problems in MS.
    It is possible that beta-interferons and other recent drugs used to help manage Multiple Sclerosis itself may have some effect on cognitive function, for, as we have noted, that function tends to be more problematic the larger the number of lesions in the CNS. If the speed with which this increase is lessened, then there could be some effect on cognitive function. However, until recently, it has not been usual to include neuropsychological tests in clinical trials of such drugs, so further detailed research is needed and is now being undertaken.
    Finally there has been publicity recently about the possible use of preparations of ginkgo biloba (made from the leaves of the Ginkgo biloba tree which grows in the Far East) for problems of memory and concen- tration. Trials of ginkgo biloba in people without MS have produced mixed results, early trials being promising but a major recent trial suggesting that it has little or no effect on memory and concentration. There have been no systematic trials on people with MS as yet and so no formal evidence that it could assist with their cognitive problems. In any case there are always problems in ensuring the purity of the active ingredient in such a product, and you should be cautious about its use.
    Overall the investigation of possible drug therapies for cognitive problems is a large area of current research and it is hoped that major advances will be made in the next few years in this area.

    Professional help
    This is a very rapidly developing area of professional interest in relation to cognitive problems. Until recently, the main professions in these aspects of everyday living have been occupational and speech therapy. So, as part of the process of managing everyday activities, occupational therapy helps you to organize your environment, as well as your skills, to the maximum advantage. Speech therapy helps you with speech production problems, particularly if you take some time to articulate what you wish to say.
    Some occupational therapists, particularly in North America and now in Britain, are developing special skills to help people with their memory and cognitive problems – often described collectively as cognitive rehabilitation. This is an approach designed to try and improve the everyday functioning of people with cognitive impairments resulting not only from Multiple Sclerosis but also other central nervous system disorders, such as head injury or stroke.
    There are two broad approaches to cognitive rehabilitation. The first of these is to try to restore the lost functions, often through retraining, with the use of repetitive techniques such as learning lists, and helping people to re-acquire skills with progressively more complex tasks. The second is based on the idea that, because it will be difficult to regain the lost functions, compensatory strategies are needed, in which other devices and procedures are used, such as trying to minimize distractions, or using other means of reminding you about activities that you need to do. Both of these approaches are designed to help people manage their everyday lives better despite any cognitive impairment.
    We need to repeat that cognitive rehabilitation, as a formal programme, is not available everywhere for people with MS. At present, following assessments, you will probably have most contact with an occupational therapist, whose skills focus substantially on the abilities needed to accomplish everyday activities, but we expect that many such therapists will increasingly be using at least some of the key techniques for managing problems that you may have in the area of memory or concentration.

    Self-help
    People with MS can be affected by a range of cognitive problems, and it is difficult to advise you precisely without knowing exactly what they are.
    The difficulties often mentioned specifically – concentration and memory
    – are quite common.
    Concentration. Everyone has occasional problems concentrating on things. Sometimes the problem is that we have many things going on at the same time – television, other people talking and a whole range of other activities going on. However, for someone with MS, concentrating on one of these activities – a conversation, for example – can be quite difficult, when so much else is happening. So the key thing is to try and have only one thing going on at a time – a conversation or the television, not both at the same time. You might have to move between rooms to achieve this. Find out when and where problems for you are most difficult, and then work on reducing the distractions to the minimum. Obviously changing your pattern of normal activities to help you concentrate may not be easy, but may be preferable to having continuing concentration problems.
    Memory. There are many ways in which you can jog your memory. Some of these are routine, and may appear overpedantic or fussy for someone who has only minor memory difficulties, but all help to deal with shor t-term memory problems. For example, just making sure that clocks and watches show the right time; ensuring that today’s date is prominently displayed somewhere; having a message board to note activities for today and tomorrow; having a list of activities that you are intending to do, with times and dates, perhaps in the form of a diar y or similar record. Although this might seem almost too formal, note things down that you have agreed to do, or that you and other s think impor tant, so that it doesn’ t appear that you have forgotten it.
    If you have difficulty with reading, check with your doctor whether you have any of the several potential eye problems associated with MS, that may interfere with your ability to read. Secondly, try and find a strategy to read in a particular way to maximize your ability to retain a story line.
    As a broad guideline, the more of your senses that you use, the more likely you are to remember and retain ideas. Most people read things silently. It may be worth repeating what you read out loud, or at least key parts of it; or relate some elements of the story to another person; or write key ideas down. In this way, using more than one of your senses – writing, seeing, hearing and saying – you stand a better chance of remembering the story, or indeed other material. Admittedly, this approach may require some tolerant support from those around you but, if you are making a big ef fort to improve your memory, they will probably feel that they are gaining too.
    You may find that you do not need to go to these lengths to help your memory – you could work out the main lines of the story or newspaper article by ‘skim reading’ so that, although you may have lost the element of surprise (about the ending of a story, for example!), you will have got an overall view of the text.

  • High Blood Pressure in Special Groups

    Although high blood pressure is a common disease among all Americans, some groups are at higher risk, for reasons that are not fully understood. People in some racial or ethnic groups are more likely to develop high blood pressure. Some people are at higher risk because of other dis- eases, such as diabetes. Often these factors are interrelated; for instance, diabetes occurs frequently in people who are overweight, people with diabetes often have high blood pressure, and overweight is a contribut- ing factor in high blood pressure. Metabolic syndrome—also called insulin resistance syndrome—is a constellation of related factors such as obesity, high cholesterol levels, diabetes, and high blood pressure. The point is to know the factors that put you at risk for high blood pressure and then to take steps to bring your blood pressure under control.

    Black Americans

    No one knows why, but black men and women are more likely to develop high blood pressure than white Americans. It often develops at a younger

    age, and it tends to be more severe. As a result, blacks are also more likely than whites to develop hypertension-related health problems such as an enlarged heart, retinopathy (damage to the blood vessels in the eye), heart disease, kidney disease, and stroke. The solution to these dispro- portionate common health problems is awareness and treatment:
    • If you are black, it is especially important to have your blood pres- sure checked regularly. If it is elevated, you and your doctor can begin treatment immediately.
    • A healthy lifestyle will go a long way to prevent and control your high blood pressure and reduce your risk of serious problems. Understanding that you are in a high-risk group is good motiva- tion to, for instance, start building eight or nine 1?2-cup servings of fruits or vegetables per day into your diet.

    Women

    Almost half the 65 million Americans with high blood pressure are women. The disease is more common among black and Hispanic women than in any other group. As a woman grows older, her chance of having high blood pressure becomes greater than a man’s. A woman may have had normal blood pressure throughout her life, but after menopause, she is considerably more likely to develop hypertension.
    A woman’s reproductive life may also affect her blood pressure. In some women, using birth control pills or becoming pregnant can raise blood pressure. Here are some considerations to keep in mind:
    • If you have high blood pressure and you are pregnant or consid- ering pregnancy, work with your doctor to control your blood pressure before and during the pregnancy. Many women with high blood pressure have healthy babies, but prenatal health care is especially important. If you are on medications for high blood pressure, talk to your doctor about whether you should be taking them while you are pregnant. Some blood pressure medications such as ACE inhibitors should not be used during pregnancy. However, do not stop taking the medications without consulting your doctor ?rst.
    • High blood pressure during pregnancy (called gestational hyper- tension) occurs in about 6 to 8 percent of pregnancies. It is more common among women with chronic hypertension or diabetes. Gestational hypertension can lead to a condition called preeclamp- sia, which can be life-threatening to both the mother and the fetus.
    • If you have had gestational hypertension or preeclampsia during a pregnancy at some time in your life, you may be at higher risk for developing high blood pressure or other cardiovascular problems later in life. Your doctor should know about this part of your med- ical history.
    • Blood pressure usually does not increase signi?cantly as a result of hormone therapy for menopause in most women, with or without high blood pressure. However, hormone therapy can increase blood pressure in some women, so if you need to take hormone therapy for menopausal symptoms, your doctor will want to check your blood pressure initially and then monitor your blood pres- sure regularly. Also, using oral contraceptives may cause blood pressure to rise.
    • Even if high blood pressure has never been a problem for you, take extra care to monitor yourself after menopause. Get your blood pressure checked regularly.
    • Every woman can reduce her risk of developing high blood pressure, or help control high blood pressure, by eating more healthfully, being physically active, and drinking in moderation. High blood pressure is a highly preventable condition.

    People with Diabetes

    Diabetes, a condition in which your body cannot make or respond properly to the hormone insulin, is occurring at an ever-increasing rate among Americans. Research suggests that, for reasons that are not completely understood, as many as 60 million Americans may have a condition called insulin resistance—an inadequate response to their own insulin—that greatly increases their chances of developing diabetes and heart disease at some time in their lives. Many authorities attribute the increase in the number of individuals with insulin resistance to lifestyle changes in the population, particularly weight gain and lack of exercise. The most common cause of diabetes-related death is cardiovascular disease, but many people are unaware of this link.

    Diabetes has a hereditary component, and people who have family members with diabetes are at greater risk for developing the disease. More women are affected than men, and black, Hispanic, and Native American people are especially susceptible. People with diabetes often have high blood pressure, high cholesterol, or both, which increases their likelihood of developing heart disease still further.
    People with diabetes are classi?ed by whether they produce suf?cient amounts of insulin. A person with type 1 diabetes does not produce any and must take insulin as a medication. Most people with diabetes (more than 90 percent) have type 2, meaning that they produce insulin (a hormone that changes glucose, or “blood sugar,” into energy), but their bodies are resist- ant to insulin’s action, and they do not utilize it prop- erly. As a result the body cannot transfer sufficient amounts of energy from food to body cells. Because the cells are not taking in glucose, it builds up in the blood, leading to “high blood sugar” (hyperglycemia), or diabetes.
    If you have type 2 diabetes, the changes in your body’s chemistry brought on by high glucose levels can increase the buildup of fatty deposits inside the arter- ies (atherosclerosis; see page 152), which can impede blood ?ow. These changes can also make the blood clot more easily, which can lead to a heart attack or a stroke. High blood pressure and high blood choles-

    terol combined with diabetes make the risk for heart attack or stroke greater than the risk from either one. The bottom line is that if you have diabetes you can greatly reduce your chances of cardiovascu- lar disease by bringing down your blood pressure or cholesterol as needed.
    Awareness of these links is the place to start to improve your health. By working with your doctor to control your high blood pressure, you can help reduce the risk of complications from diabetes. Controlling your blood pressure and cholesterol levels is likely to prolong your life and greatly improve its quality.

    Secondary High Blood
    Pressure

    About 5 to 10 percent of people diagnosed with high blood pressure have secondary hypertension, meaning that their condition is a secondary result of another prob- lem. These underlying problems may include a kidney abnormality, a structural abnormality of the aorta, a narrowing of certain arteries, or certain types of hor- mone abnormalities. These sec- ondary causes of high blood pressure are more common in children and young adults.
    These problems can usually be corrected, causing blood pressure levels to drop to healthy levels. For example, a surgeon can repair a narrowed or defective artery.
    When your doctor examines you, he or she can usually rule out these problems as causes of high blood pressure by taking a careful medical history, giving a thorough physical examination, taking blood tests, performing urinalysis, and taking some fur- ther tests. These tests generally do not require a hospital stay.

    Children

    Even babies and children can have high blood pressure. Doctors used to think that high blood pressure in children was secondary (caused by some other condition). But now they know that children can have primary hypertension—that is, high blood pressure—for unknown reasons. The condition may be hereditary. It is more frequent and severe in black families, although scientists do not know why.
    The average blood pressure level for children and teenagers has risen considerably over the past 25 years, mainly because of the increase in overweight and obesity. Today, guidelines for blood pressure in chil- dren include a prehypertension category, just as adult guidelines do. Like adults, children can have a syndrome of risk factors—including overweight, high blood pressure, and insulin resistance—that increases their risk of diabetes and heart disease.
    Treatment for children with high blood pressure usually involves the same types of lifestyle changes that bene?t adults: weight control, a healthful diet, and regular exercise. Doctors will prescribe medications if necessary. Ensuring that a child has a healthy weight and blood pres- sure early in life gives him or her a head start on preventing serious dis- ease later on.

    Living with High Blood Pressure

    If you are being treated for prehypertension or hypertension, you can monitor your own health in several important ways:
    • Be your own best advocate. Stay with your treatment plan—healthy lifestyle habits and medication—to get the best results.
    • Know your blood pressure and have it checked regularly. Those already being treated for high blood pressure should have theirs checked more frequently; ask your doctor how often. Make sure that your family mem- bers (parents, brothers and sisters, children) have theirs checked regularly, too.
    • Keep appointments with your doctor so that he or she can monitor your treatment and make adjustments if necessary. Ask your doc- tor or other health-care provider any ques- tions that interest or concern you about your treatment.
    • Follow a healthful diet, cutting down on fatty foods such as red meat and increasing your intake of fruits and vegetables and whole grains; also, exercise 5 times a week (or, more ideally, every day).
    • Keep track of your blood pressure. Remember, you cannot tell from the way you feel how high your blood pressure might be.
    • Keep a diary of your blood pressure reading every time you measure it at home, or have it checked by a health-care professional. Record the date and the reading. Find a handy placeto keep the diary. Bring your diary to your doctor’s appointment.
    • Talk to your doctor about the names and dosages of your blood pressure medications and how to take them. Don’t hesitate to ask questions. Again, keep a written record that you can refer to and show to family members. Keep a written list of your medications, including dosages, in your purse or wallet.
    • If you notice any problems (side effects) that you think could be related to your medica- tions, talk to your doctor about them. The problems may not be related to your medi- cine. Or you may need a change in dose, or perhaps another medicine might work for you without side effects.
    • Refill your blood pressure medications before they run out, even though you feel fine.
    • Tell your family members that you have high blood pressure and get their support for your treatment plan. If possible, have your partner or a family member go with you to your doc- tor’s office to hear firsthand about your medications and how to make lifestyle changes.
    • If you have a severe headache, changes in your vision, numbness on one side, or dizzi- ness, seek emergency medical treatment immediately. You could be having a stroke.
    • Have your eyes checked periodically by a qual- ified physician such as an ophthalmologist.

  • Medications for High Blood Pressure

    In addition to lifestyle changes, many people with high blood pressure must take at least one medication or a combination of drugs to keep their blood pressure at a healthy level. These drugs, called antihyper- tensives, are highly effective and are an extremely important factor in reducing your risk of stroke, heart disease, and other major diseases related to high blood pressure. Many different types of drugs and combinations of drugs have been developed, so you and your doctor can work together to ?nd the ones that will successfully control your blood pressure with the fewest possible side effects. Although antihyperten- sives are powerful drugs, they have fewer unpleasant side effects today than ever before.
    If you have not been taking medications until now, and especially if you feel ?ne, you may not look forward to the idea of taking drugs that may have side effects and may be expensive. It could take some time to tailor your drug regimen to your needs, but do not get discouraged. Tell your doctor as much as you can about how the drugs make you feel. If

    you experience side effects, your doctor will probably substitute another medication that does not have the same effect on your body. Some peo- ple are able to reduce their need for medication if they can bring their blood pressure down and maintain it for a year or more, particularly if they lose weight as needed and adopt a healthier lifestyle generally. But you usually cannot stop treatment altogether. If the cost of your drugs is a problem, talk to your doctor about that, too. There may be lower- priced alternatives.
    Once you start taking prescription medications, do not stop or change your regimen without talking to your doctor ?rst. Even if the medicine is working and your blood pressure goes down, you need to continue taking the drug in order to get the bene?t. If you hear about a new drug or you talk to someone who is taking something different from what you are taking, talk it over with your doctor. Everyone responds differently to these medications and has a different medical history, so not every drug will be right for you. The most important goal is to get your blood pressure to a healthy level and keep it there for the rest of your life. Make sure to take your medication every day, even if you feel ?ne; if you have forgotten a dose, look at the patient informa- tion sheet that comes with your prescription to determine if you should take a “catch-up” dose or if it is preferable to wait till the next dose is due.
    There are eight major categories of antihypertensive medications, each with a different mechanism of action in your body. Within these eight categories, individual drugs have generic names and a brand name registered to a particular pharmaceutical company. Whatever the cate- gory of medication, taking medication may lead to a decrease of up to
    10 percent in your systolic blood pressure and 5 percent in your dias- tolic blood pressure. Many of these drugs are also prescribed for heart disease, so you can find more information about them on pages
    165–173 and 241–246. Here is a summary of the broad categories and their method of action:
    • Diuretics rid your body of excess ?uids and sodium through uri- nation, lessening the volume of blood that your heart has to pump. Your treatment will almost certainly begin with a diuretic, alone or in combination with another medication. Diuretics are some- times also used to enhance the blood-pressure-lowering effects of other drugs. Common examples include amiloride, bumetanide, chlorothiazide, chlorthalidone, hydrochlorothiazide, indapamide, metalozone, and spironolactone. The adverse effects of diuretics may include urinary frequency and low potassium levels.• Angiotensin-converting enzyme (ACE) inhibitors lower the levels of angiotensin, a chemical in your body that constricts your blood vessels, so your vessels expand, reducing resistance to blood ?ow, and allowing your heart to pump more ef?ciently. Examples include benazepril, captopril, enalapril maleate, and lisinopril. ACE inhibitors should not be used in pregnancy. They have a low incidence of side effects compared to other medications for high blood pressure. The most common side effect is a cough, which develops in 5 to 15 percent of cases. Rarely, people will have swelling in the face, a potentially dangerous side effect that means you should discontinue the drug immediately. However, talk to your doctor promptly to report your reaction and get another prescription.

    • Angiotensin-2 receptor blockers inhibit the effect of angiotensin (rather than lowering the level), so they too prevent angiotensin’s effects on your heart and vessels. They are often pre- scribed for people who cannot take ACE inhibitors. Examples include losartan, candesartan, and valsartan. Side effects may include nausea or a headache.

    • Alpha-blockers prevent your arteries from constricting and block the effects of the stress hormone epinephrine, which elevates blood pressure. These drugs are no longer highly recommended but are prescribed occasionally. Examples include doxazosin, prazosin, and terazosin. The major side effect is dizziness.

    • Beta-blockers (see illustration on page 62) decrease your heart rate and cardiac output, which lowers your blood pressure. Exam- ples include atenolol, metoprolol, and propranolol. Beta-blockers are commonly used to treat angina and are good choices for peo- ple with coronary artery disease and hypertension. Fatigue is a common side effect.

    • Calcium channel blockers inhibit the movement of calcium into your heart and blood vessels, which relaxes the muscles in the arterial wall that constrict the artery, preventing the narrowing of the artery. Examples include diltiazem, amlodipine, and vera- pamil. Side effects include leg swelling and constipation.

    Beta-blocker action
    7Beta-blocker drugs, often prescribed for hypertension, work by blocking the effects of epinephrine and norepi- nephrine—hormones that stimulate heart muscle cells and cause a more rapid heart rate. The drugs occupy receptor sites on the muscle cells to interfere with the hormones, preventing the increase in heart rate and low- ering the force of heart contractions. Both the heart rate and the strength of the contractions are controlled by neurons that carry nerve signals from the brain to the heart (see figure at right).

    • Centrally acting drugs (or central alpha agonists) act on the brain and the nervous system to lower your heart rate and prevent the arteries from narrowing but are rarely used now. Examples include clonidine, guanfacine, and methyldopa. Clonidine is unique in that in addition to being available in oral form, it is available in a skin patch, which is applied once a week. Side effects of centrally acting drugs include sedation, dizziness, dry mouth, and fatigue.

    • Vasodilators cause the muscular walls of the blood vessels to relax so that the vessels can dilate (widen). These drugs are used only in emergencies or for people whose blood pressure cannot be con- trolled with other drugs. Examples are hydralazine and minoxidil. Minoxidil may cause you to retain ?uids, so it should be used in combination with diuretics, which will help remove ?uid from your system.

    The more familiar you are with your drug program, the easier it will be to talk to your doctor about it and take the medications correctly so that they work as they should. Here are some important points to know about your high blood pressure medication or that of a family member whom you are assisting:
    • The name of the medication
    • What it does in your body
    • How often to take it and how much to take
    • What time of day to take it
    • What food, drink, or other medications you should avoid while taking it
    • How to store it (is it sensitive to heat or dampness?)
    • What reactions or side effects might occur and what to do if you get them
    • What to do if you miss a dose
    • Speci?c side effects if you are a woman and you become pregnant
    • When you need to re?ll your prescrip- tion so you do not run out.

    WARNING!

    Cold and Flu Medications
    Most over-the-counter cold and flu prod- ucts contain decongestants that can raise your blood pressure or interfere with your blood pressure medication. If you are on blood pressure medication, consult your doctor before you use any over-the-counter remedies. If your blood pressure is well con- trolled, your doctor may allow you to take cold and flu products for a few days. How- ever, decongestant-free products are avail- able that are safe and effective for coughs, colds, or flus. Always read the label carefully on any over-the-counter drug to be sure it does not contain any ingredients that raise your blood pressure or interfere with your treatment. In addition, if you are taking the over-the-counter medications ibuprofen or naproxen sodium for another problem such as arthritis pain, be sure to tell your doctor; these drugs can raise your blood pressure.

  • Home Monitoring of High Blood Pressure

    Your doctor may ask you to start taking your blood pressure at home and recording it. Doing so will give both you and your doctor a more complete understanding of how much your blood pressure varies during the day, and how well your medication is working to control your con- dition. It also eliminates the “white-coat hypertension” factor (see page
    39), which can complicate the process of diagnosis. Self-measurement is never a substitute for having your blood pressure checked by a health- care professional; it complements and con?rms the measurements taken at your doctor’s of?ce. If there is a large discrepancy between readings at home and in the doctor’s of?ce, bring in your home blood pressure monitor for your doctor or nurse to check for you.

    You will need to purchase a blood pressure monitor (see below) that you feel comfortable using at home. You can ?nd a selection of these devices at any pharmacy or medical supply store. You may wish to learn more about them by reading a consumer review magazine, and your doctor can help you decide which one will work best for you. You can choose between two basic types: a digital monitor or an aneroid monitor.

    Digital Monitors

    A digital, or automatic, monitor is the most popular blood pressure measuring device because it is easy to use. The gauge and the stetho- scope are in one unit, the digital screen is easy to read, and the de?ation is automatic. You can choose between an automatic or a manual in?a- tion device. The chance of human error is much less than it is when using an aneroid monitor. To use a digital monitor, follow these steps:
    1. Place the cuff around your upper arm. Turn on the machine.
    2. Push the button to activate the in?ation device, or squeeze the hand bulb on a semiautomatic model. After the cuff is in?ated, the instrument will automatically start to de?ate.
    3. Look at the digital screen to see your reading. Both your systolic and diastolic measurements will appear. Write the numbers down, with the systolic reading over the diastolic reading.
    4. Press the exhaust button to fully de?ate the cuff.
    5. If you want to repeat the measurement, wait 2 or 3 minutes.
    A drawback of the digital monitor is that it is highly sensitive, and body movements or an irregular heartbeat can affect its accuracy. Be careful about the placement of your arm and application of the cuff. The device requires batteries and needs factory repair or readjustment when problems arise. Digital monitors are somewhat more expensive than aneroid devices, depending on what model you choose. A fully automatic model may be twice the cost of an aneroid device, and the most expensive ones can be several hundred dollars.

    Aneroid Monitors

    An aneroid, sometimes called a spring gauge, monitor is relatively inexpensive, lightweight, and portable. (Aneroid means “containing

    no liquid.”) Some cuffs have a built-in stethoscope, which is easy to work with. The gauge has a round dial that indicates the amount of pressure in the cuff, and you can read it easily in just about any posi- tion, as long as you are looking directly at it. Some models have a large, easy-to-read gauge, a cuff with a ring closure for one-handed use, and a de?ation valve that works automatically. To use an aneroid monitor, follow these steps:
    1. Put the earpieces for the stethoscope into your ears, with the ear- pieces facing forward.
    2. Extend your arm at about the level of your heart on a table or a chair arm, and wrap the cuff snugly around your upper arm, with the lower edge of the cuff about an inch above your elbow. Place the dial where you can see it clearly.
    3. Place the stethoscope disk on the inner side of your elbow crease
    (over the pulse).
    4. Rapidly in?ate the cuff by squeezing the rubber hand bulb to a reading 20 or 30 points above your last systolic (top) measure- ment. (In?ating the cuff a little at a time gives an inaccurate read- ing.) When you stop pumping, you will not hear any pulse sound because the cuff is temporarily stopping the ?ow of blood through your artery.
    5. De?ate the cuff slowly (about 2 or 3 mm Hg per second on the dial). Keep your eye on the dial and listen carefully for the ?rst sound of the blood ?ow returning. Write down the number the pointer is on; that is your systolic blood pressure.
    6. Continue de?ating the cuff. Listen until you no longer hear your heartbeat, and note the reading. This number is your diastolic blood pressure.
    7. Record the numbers with the systolic reading over the diastolic reading (for example, 140/80).
    8. If you want to repeat the procedure to con?rm your reading, wait
    2 or 3 minutes before you rein?ate the cuff.
    There are some disadvantages to using an aneroid monitor. It is a fairly delicate, complex device that can be easily damaged. You will need to have it checked for accuracy at your doctor’s of?ce or pharmacy at least once a year, or if you drop it or bump it. If it is damaged, it will need factory repair. It may be dif?cult to use if your hearing or sight is impaired, or if you have dif?culty squeezing the hand bulb.

    Other Types of Monitors

    You may see mercury monitors, which are considered the standard for blood pressure measurement. The mechanism is simple and works by gravity, giving consistent, accurate readings. However, a mercury monitor is generally not recommended for home use because of the danger of mercury spills. The device has a long glass or plastic mercury tube that must be carefully protected against breakage. The device is bulky and must be kept upright, and the gauge must be read at eye level. It is dif?cult to use if you have a hearing or vision impairment.
    You may see ?nger or wrist monitors that look convenient. These devices are not very accurate, however. They are highly sensitive to position and body temperature and are usually significantly more expensive than other types of monitors.
    You can also buy portable devices that continuously monitor and record your blood pressure day and night. For some people, this method is the most effective way to get a clear picture of blood pressure variances and the effect of medications. Your doctor will tell you whether you require this type of monitoring.

    Take your time making your choice about what kind of home moni- tor to buy. Talk to your doctor about which kind is most suitable for you. As you shop, consider these features:
    • Cuff size. Cuffs come in different sizes—including children’s models—and the right size is very important for accurate meas- urement. Your doctor’s of?ce or pharmacy can tell you what size you will need. If you need a size that is not standard, it can be ordered for you.
    • Readable numbers. Be sure that the numbers on the gauge are easy for you to read.
    • Cost. Do not assume that the most expensive is the best. You have many models to choose from and a wide price range. The most important consideration is accuracy.
    • Care and storage. Some models may require storage in a certain position, protection from bumps, or protection from heat.
    After you have bought a device, take it to your doctor’s of?ce and have it tested for accuracy. Ask a health-care professional to show you exactly how to use it and what to do if you get an elevated reading. Find out how to get your device checked and recalibrated periodically.

  • Managing Your Weight

    One of the most important things you can do to control your blood pressure—and prevent heart disease—is to keep your weight at a healthy level. If you are overweight, you are more than twice as likely to develop high blood pressure than if you maintain a healthy weight. Even if you are only 10 pounds more than you should be, taking off that little bit of extra weight can signi?cantly lower your blood pressure. Your weight interacts with other factors, such as cholesterol levels and risk of diabetes, to affect your overall cardiovascular health in more complicated ways. But the relationship between your weight and high blood pressure is relatively easy to understand.
    As you gain weight, you put on mostly fatty tissue. Like any other tissue in your body, fat requires oxygen and nutrients to live. As your fatty tissue increases, the amount of blood circulating through your body also must increase. You retain more sodium and water, which increase your blood volume, and a larger volume of blood causes greater pressure against your arterial walls. When you take off weight, those negative effects are reversed, and your blood pressure comes down to a
    healthier level.

    Healthful Eating Habits

    Limiting sodium and following a healthful diet that is low in fat helps prevent or control hyper- tension, even in people of normal weight. Potas- sium helps protect against high blood pressure, in part by enhancing the excretion of salt. This nutri- ent occurs in certain foods, especially fruits and vegetables. If you take potassium in supplements, you will not derive the same bene?t that you get from consuming it in your diet. Most people get enough potassium through eating foods that con- tain it; the exception is those on diuretic drugs, who may need to take supplements.
    Your intake of sodium (salt) in foods is a critical factor in controlling blood pressure. Too much salt causes you to retain water, thereby increasing blood volume and blood pressure. Although sodium is an essential mineral, health experts recommend that a person consume less than 2,400 milligrams (mg, or 2.4 g) per day, which is only about 1 teaspoon of table salt. That includes all salt contained in foods, as well as the salt you add while you are cooking or at the table. A typical American diet often includes about 4,000 mg (4 g) of salt—far more than a person needs. To control high blood pressure, or if you are over 50 or black, limit daily sodium intake to 1,500 mg or less.
    All animal products, such as meat and dairy products, contain sodium. Processed and restaurant foods are notoriously high in sodium; to see a clear example of that, check the nutrition label on a can of soup or a bottle of ketchup. You can consume signi?cant quantities of salt without ever picking up a salt shaker. Three-fourths of the salt that peo- ple in the United States consume comes from processed or restaurant food. By contrast, fresh fruits, vegetables, and grains have little or no sodium unless you add it.

    Exercise Regularly

    Being physically active is a great way to help manage your blood pres- sure and bene?t your overall health in many other ways at the same time. During aerobic exercise, the heart works harder and pumps more blood to supply oxygen to the hard-working muscles. You might think that this action would increase blood pressure over time. But the increase in heart output is accompanied by widening of the blood vessels that supply the muscles, substantially reducing the resistance to blood ?ow. Regular exercise actually increases the number of capillaries that supply muscle tissue, further reducing resistance. Your heart, arteries, and lungs become more ?t, helping to protect you against heart disease.
    Also, exercise is the essential calorie-burning partner to sensible dieting as a means of controlling your weight. A moderate exercise program combined with a healthful diet will make it much easier to lose that extra ten pounds (or more), which can signi?cantly lower your blood pressure. The bene?ts of exercise do not stop there: physical activity helps protect against not only high blood pressure, but also against heart disease, diabetes, stroke, and cancer. Plus, exercise lifts your mood, protects against osteoporosis, and helps you manage stress, so it enables you to work toward several of your goals at once.
    You do not need to become an athlete. Aerobic exercise (which means exercise that causes the body to use oxygen to fuel the muscles) includes a broad range of activities such as walking, bicycling, climbing stairs, social dancing, and gardening. In order to get the cardiovascular bene?ts, you should aim for exercising 20 to 30 minutes at a time at least 5 days a week; recent government recommendations advise 1 hour a day if you are overweight. Most people can start a moderate exercise plan without consulting their doctors. If you are already moderately active, you will get greater bene?t from exercising longer or more often, or choosing a more vigorous form of activity. If you are not sure how to get started, try a simple walking program. Set aside time 5 days a week or more to walk around your neighborhood, take a lunchtime break from work, or go to a gym or a shopping mall.
    • Week 1. Walk slowly for 5 minutes to warm up your muscles, walk briskly for 5 minutes to get your heart working, then walk slowly for 5 minutes to cool down.
    • Week 2. Do 5 minutes of warm-up walking, increase your brisk walking to 7 minutes, then cool down for 5 minutes.
    • Week 3 and beyond. Walk slowly for 5 minutes, then increase your brisk walking by 2 minutes each week until you are up to 30 minutes or more, fol- lowed by 5 minutes of slower walking.
    Many people can start their exercise program more intensively, walking 20 minutes briskly, rather than 5 minutes, in week 1, then increasing that baseline of 20 for weeks 2 and 3. However, if you are over 50 and have not been physically active, if you have already had a heart attack, or if you have a family history of heart dis- ease, talk to your doctor before increasing your level of activity. If you have heart disease already, your doctor might use a stress test to assess your capacity to exercise and to individualize your exercise program.
    Even if you do not engage in formal exercise or set aside a special time for walking, you can increase your fitness by becoming more active in your daily life. Examples include walking rather than driving short dis- tances, parking far away from a store or mall entrance, and walking up one ?ight or down two ?ights of stairs. Purchase and use a pedometer to measure how many steps you walk every day, and gradually increase your activity until you walk at least 10,000 steps per day.

    What Is Salt Sensitivity?

    In most people, the body regulates salt concentration carefully, and any excess salt will be eliminated in the urine or in perspiration. But for many people, eating too much salt causes their blood pressure to rise, a condi- tion known as salt sensitivity.
    For reasons that are not clear, some groups of people are more likely to be salt-sensitive than others. For example, as many as 70 percent of black people are salt-sensitive. Older people are also more likely to react this way. Almost half the people with high blood pressure are salt-sen- sitive, which is why salt reduction is such a prominent part of treatment. There is no way to test for salt sensi- tivity except to eat less salt for a while to see if your blood pressure goes down. The cumulative effects of a high-salt diet eventually raise blood pressure in most people.

    Quitting SmokingTobacco smoke contains literally thousands of substances that, alone or in combination, damage your health in many ways. In addition to damaging your lungs, smoking does harm throughout your cardiovas- cular system. It does not directly cause persistent high blood pressure, but it temporarily raises your blood pressure by constricting the diam- eter of the arteries to your heart, depriving your heart muscle of blood and oxygen. Every time you smoke a cigarette, your blood pressure goes up for about 30 minutes. A pack-a-day habit keeps your blood pressure up for 10 hours.
    Exposure to tobacco smoke over time damages the protective lining of your artery walls, making them more susceptible to the formation of plaque. Plaque narrows the arteries and interferes with blood ?ow to your heart, your brain, and the rest of your body. Smoking also causes your blood to clot more easily, for reasons that are not fully understood. The clots more easily adhere to the inner surfaces of arteries roughened by plaque. Smoking also decreases the good cholesterol in your blood; see “Managing Your Cholesterol Level,” .
    Smokeless tobacco products are not the way out. Although it is dif- ?cult to give up any tobacco habit, the enormous health bene?ts make it worth it. So if you smoke, quit. (For tips on aids to help you stop smoking, see the box above.) If you do not smoke now, do not even think about starting.

    Managing Stress

    Though stress does not cause high blood pressure, it can keep your blood pressure up when you are upset. The body normally responds to stress with the so-called ?ght-or-?ight response, which prepares the body either to meet challenges or to avoid them. A temporary increase in heart rate and blood pressure is a part of this physiological response, and it is stronger in some individuals than in others. Although stress is somewhat dif?cult to measure, research demonstrates some general ?ndings:

    • In some individuals, blood pressure spikes in response to stressful situations, and these people are at greater risk of developing high blood pressure.
    • Some people cope with stress in unhealthy ways, such as overeat- ing, smoking, or drinking alcohol, which become contributing factors to high blood pressure.
    You may not be able to alter your body’s unconscious response to stress, and you cannot always avoid stressful situations, but you can learn relaxation techniques or coping activities like physical exercise that will help modify the harm to your health. You can also talk to your doctor about the level of stress in your life as one of the factors involved in your high blood pressure.

    Limiting Alcohol Consumption

    Over time, heavy drinking increases your chances of developing high blood pressure. It also contributes to the development of heart disease in other ways. If you are taking hypertension medications such as beta- blockers, alcohol may interfere with their action. If you have high blood pressure, talk to your doctor speci?cally about how alcohol in large quantities affects your blood pressure. In moderation, drinking has ben- e?cial effects and is associated with lower risk of developing heart dis- ease. Moderation generally means up to two drinks a day for men or one drink a day for women , whether each drink is a glass of wine, a beer, or a mixed drink.

  • The DASH Diet

    The National Heart, Lung, and Blood Institute (part of the National Institutes of Health) has developed a comprehensive eating plan called the DASH (Dietary Approaches to Stop Hypertension) diet. The DASH diet is low in saturated fat, cholesterol, total fat, and sodium. It emphasizes fruits, vegetables, and low-fat dairy foods; it includes whole grain products, ?sh, poultry, and nuts; and it recommends less red meat and fewer sweets. Major studies have demonstrated that the DASH plan works better than other heart-healthy eating plans to help most people reduce their blood pressure. Most people who stick to the plan for a month can signi?cantly lower their blood pressure, and the effect lasts as long as you stay on the plan. The DASH plan also works for people with normal blood pressure who are trying to prevent an increase. In any case, along with following the DASH diet you should make or con- tinue modi?cations to your lifestyle, including exercising and stopping smoking.
    Following the DASH diet may enable some people to go without medication, or to use fewer medications than they otherwise would. However, do not discontinue any medication or lower the dose with- out talking to your doctor ?rst.
    The DASH plan is two-pronged, involving the eating plan itself and

    lowering sodium intake as a means of treating hypertension. The diet can be adapted to different levels of sodium intake, depending on a per- son’s individual sensitivity to salt. The reduction of blood pressure is greatest at the lowest level (1,500 mg or less of dietary sodium per day).
    In many instances, diets or eating plans are based on the ideas or the- ories of one or two people, sometimes doctors but not always. In the case of the DASH diet, you can be assured the bene?ts of the DASH eating plan were proven in two research studies funded by the federal government and conducted in several cities.
    The DASH diet coupled with sodium reduction is a remarkable approach for treatment of high blood pressure for many reasons:
    • It works for a wide variety of people—those with or without high blood pressure, old and young, men and women, blacks and other races, obese or slender, active or inactive.

    • The diet is more effective in lowering blood pressure than other heart-healthy diets, and the low-sodium version is even more effective than other low-sodium diets.
    • The plan works quickly, lowering blood pressure readings in as lit- tle as 2 to 4 weeks.
    • In addition to its effectiveness at lowering blood pressure, it also lowers blood cholesterol levels, another important factor in pre- vention of heart disease (see page 23).
    The DASH eating plan is especially rich in fresh fruits and vegeta- bles (eight or more 1?2-cup servings per day) in part because these foods are low in salt. They are also rich in potassium, calcium, and

    magnesium. Grains and grain products are another major component of the diet (seven to eight servings per day) because they supply energy and ?ber. The plan limits the amount of meat, sweets, and sugary drinks in order to reduce intake of fats and sugars, as well as sodium. The plan teaches you to sharply reduce your salt intake by avoiding processed foods, which are the source of most of the salt that Americans eat.
    If you are on the DASH plan, as with any other diet, the foods that you eat at one meal or over the course of a day may add up to more than the recommended servings. You also might consume more sodium on one day than on another. The important point is that your average for several days or a week should be close to the recommended amounts in order to derive the health bene?t.
    You also need to keep in mind that if your doctor has prescribed medication for your high blood pressure, you should not stop taking it. If you feel that following the DASH diet (or another diet plan) may have lowered your blood pressure, have your blood pressure checked at your doctor’s of?ce and discuss the numbers with him or her.

    Following the DASH Plan

    The abbreviated DASH eating plan shown here gives you an idea of what types of foods are recommended and in what amounts. This plan is based on 2,000 calories per day. Servings can be adjusted depending on your calorie needs and your desired level of sodium intake. You and your doctor can tailor a plan to suit you.

    Cutting Back on Salt and Sodium

    Small amounts of sodium occur naturally in fresh foods, but most processed foods are high in sodium content. Most is added in manufac- turing and processing. Most restaurants add a lot of salt to foods they prepare. The only way to know for sure is to check the nutrition label carefully. You can cut back on sodium substan- tially by remembering a few general tips:
    • Start by eliminating your use of table salt; an herbal salt substitute—available in a variety of flavors—is often helpful.
    • Learn to use spices instead of salt. Flavor your food with herbs, spices, lemon or lime juice, vinegar, or salt-free seasoning blends.
    • When you buy vegetables, choose fresh or frozen without sauce instead of sauced or canned.
    • Rinse canned foods, such as beans or tuna, to remove some of the sodium.
    • Always choose low-salt or no-salt prod- ucts when you can.
    • Buy fresh poultry, fish, and lean meat rather than canned, smoked, or processed forms.

    Limit cured foods (such as bacon or ham), foods in brine (such as pickles, olives, and sauerkraut), and condiments (such as MSG, mustard, ketchup, and barbecue sauce). Limit even low-sodium versions of soy sauce or teriyaki sauce (which contain lots of MSG); measure them as you would table salt.

    • Cook rice, pasta, and hot cereals without salt. Cut back on flavored rice, grain, or pasta mixes; they are loaded with salt.

    • Rely less on frozen dinners; canned soups, broths, and sauces; and bottled salad dressings. You can make a large quantity of something like tomato sauce using a low-salt recipe, and freeze it in smaller amounts for later use. You can make sim- ple vinegar-and-oil salad dressings in small quantities to use for a few days.

    • Most restaurants add a lot of salt to the foods they prepare. When you eat in a restaurant, ask which items can be pre- pared without adding salt. Ask if other spices can be used.

  • Prevention: A Healthier Lifestyle

    By now you’ve gotten the picture: preventing your blood pressure from creeping up, or bringing it down to a desirable level, always begins with healthy choices in many areas of your life. The bene?ts are by no means

    limited to your blood pressure alone; they also improve your heart health, reduce your chances of stroke and kidney disease, and give you an overall sense of well-being. No matter how many predisposing fac- tors for high blood pressure apply to you—being male, being black, having hypertension in your family, being older—you can reduce your blood pressure somewhat with changes in lifestyle. These are the areas to work on:
    • Start eating a low-fat, low-salt diet such as the DASH diet (see below).
    • Lose weight if you are overweight.
    • Exercise regularly.
    • Drink alcohol in moderation.
    • If you smoke, quit.
    • Learn to manage stress.
    • Do not take over-the-counter medications that can raise blood pressure, including decongestants or “energy products.”

  • Treatment Strategies

    Lifestyle changes or medication, or a combination of both, can lower your blood pressure. Lifestyle changes are recommended for everyone with elevated readings of any kind. For many people, the results of losing weight, exercising, limiting salt, and generally adopting a healthy eating plan can be as signi?cant as the use of any single medication. Many different types of medications are available, and different drugs or drug combinations work better for some people. You and your doctor have lots of options, and your treatment will be most successful if you work together to ?nd the treatments that work best for you.
    Your doctor will help you set a target reading and determine how to reach it. Do not hesitate to tell your doctor as much as you can about your eating, smoking, and drinking habits; whether you exercise regu- larly; or what other medications or supplements you take. The more you understand about the factors that contribute to your high blood pressure reading, the more likely you are to bring it down.
    Your doctor will approach your treatment by considering three fac- tors: the blood pressure reading itself; whether there is already some damage to your arteries or other organs; and whether you have other conditions, such as diabetes, that might affect your treatment. If you are still in the prehypertensive category and have no other complications, you may be able to bring your blood pressure down to less than 120/80 mm Hg in a year just by changing your lifestyle (see below).
    If you have stage 1 or stage 2 hypertension without organ damage or complicating conditions, the goal will be to bring your reading down to a prehypertensive level. Doctors have found that many people will need to take more than one medication to reach their target blood pressure. If you are at stage 1, lifestyle changes are an essential ?rst step. If lifestyle changes fail to achieve your target blood pressure, your doctor may subsequently prescribe a diuretic and maybe other drugs as well (see page 59). If you are in stage 2 hypertension (a reading of 160/100 mm Hg or higher) without complications, you will almost certainly need to take more than one drug, one of which will probably be a diuretic, to achieve good blood pressure control. But continue making lifestyle modifications—improvements in your diet and exercise habits—while taking the medications.
    If you have high blood pressure (stage 1 or stage 2), and you have another condition—for instance, you have already had a heart attack, you are at high risk for developing coronary artery disease (see page
    211), or you have kidney disease or diabetes—your doctor will prescribe medications that have proven to be bene?cial for your conditions. Of course, a healthier lifestyle is a must as well. With these conditions, achieving a blood pressure goal as low as 130/80 mm Hg may be the wisest course.
    Warning: Be alert for any signs of stroke. These include headache, confusion, weakness, numbness, dif?culty speaking, slurred speech, or weakness on one side of the body. If you have any of these signs, seek emergency treatment at a hospital promptly.
    No matter what your blood pressure reading, personal medical situ- ation, history, or treatment plan, sticking to the treatment is the only way to reach your goal. That goal starts with a number, but it is much more than that.

  • What Your Blood Pressure Reading Means

    National guidelines place your blood pressure into one of three categories: normal, prehypertensive, or hypertensive . Normal blood pressure is considered to be less than 120/80 mm Hg. If your blood pressure is equal to or higher than this for two or more readings on different days, you are classi?ed as either prehypertensive or hypertensive. The guidelines, based on the impact of high blood pressure, are aimed at getting you and your doctor started as soon as possible to bring your blood pressure down to healthy levels.

    Prehypertension

    If you have prehypertension (with readings consistently 120/80 or higher but below 140/90), you are in a group that used to be called high normal. Almost one-third of the U.S. adult population now falls into the prehypertensive category. The most recent guidelines identify this range as a warning zone, because people in it are considerably more likely to develop true hypertension later in life. The designation of “prehypertension” re?ects evidence showing that the risk of heart disease actually begins to climb at readings above 115/75 mm Hg. From that level, every increase of 20/10 mm Hg doubles the risk of death from heart disease. Changing to a healthy lifestyle is the only way to prevent this progression into high blood pressure.
    If you are in the prehypertensive category, you have a good reason to get motivated to start managing your blood pressure immediately through nondrug treatment. Even though you do not have high blood pressure, you can start making changes in your lifestyle that will bring your readings down to a lower, healthier level without medication; see pages 46–47. Lifestyle changes alone are likely to help you at this early stage. You and your doctor can start talking about setting priorities and taking de?nite steps to form some new habits.
    Start with your eating habits. Eat 8 or more servings of fruits and vegetables each day and less fat and saturated fat. Limit salt intake to less than 1,500 mg per day, or about 3?5 of a teaspoon of salt. If you are overweight, losing weight can be important. The bene?ts of weight reduction start early, with a loss of as little as 10 to 15 pounds, because with every 3 pounds you lose, there is an average corresponding drop of about 2 mm Hg in your systolic pressure. Build just 30 minutes of exer- cise into your schedule, at least ?ve days a week. Limit your alcohol intake to no more than one drink per day for women and two drinks for men (whether hard liquor, wine, or beer). These changes may not seem easy at ?rst, but they will pay big dividends if they mean you will not have to take medications.

    Systolic Hypertension

    The guidelines also say that systolic pressure (the top number) of more than 140 mm Hg should be treated regardless of the diastolic level (bottom number). Either your systolic or your diastolic number—or both—may be elevated. As you get older, your diastolic pressure usually decreases and the systolic pressure begins to rise.
    If only your systolic reading is high and your diastolic reading is nor- mal, you have the most common form of high blood pressure. It is called isolated systolic hypertension, and new guidelines emphasize its importance. Treating isolated systolic hypertension early, with lifestyle changes and medications if necessary, reduces the future risk of devel- oping heart disease and stroke. For example, with each reduction of 5 mm Hg in your systolic blood pressure, death from stroke is reduced about 14 percent and from heart disease by 9 percent. The potential impact on your quality of life is enormous.