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http://www.nytimes.com/2002/06/25/health/25BROD.html?tntemail0

Hard Facts of Hypertension Elude Too Many

By JANE E. BRODY

he news about blood pressure is decidedly mixed.

First, over the course of their remaining lives, Americans now 55 or over face a 90 percent chance of developing high blood pressure, or hypertension, a major risk factor for heart attacks, strokes, congestive heart failure, circulatory failure, kidney disease and loss of vision.

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This finding emerged recently from a 22-year follow-up study of 1,298 residents of Framingham, Mass., who were from 55 to 65 in 1976.

If applied to the whole population, the risk of developing hypertension represents a huge public health burden, in addition to the costs to the health of those affected. Hypertension is a primary or contributing cause of more than 10 percent of American deaths each year.

Complicating the picture is more bad news: of the 50 million Americans with hypertension, only 27 percent are receiving treatment that restores blood pressure to normal. Fifteen percent are not receiving any treatment, and of those who are being treated, 26 percent are not receiving adequate treatment and still have blood pressure that is too high. Furthermore, nearly a third of patients with hypertension do not even know they have it.

Despite three decades of efforts to educate physicians and the public, there is still profound ignorance about what is normal blood pressure. And many physicians seem reluctant to provide adequate treatment and guidance.

What Is Normal?

Your blood pressure should be measured at every visit to a health professional, regardless of the reason for the visit.

In most cases, hypertension is a silent disease, producing either no symptoms or symptoms readily attributed to other causes — headaches, ringing in the ears, lightheadedness, fatigue. The only way to be sure your pressure is normal is to have it taken.

The test is fast, cheap, noninvasive and painless. A cuff is wrapped around your upper arm, inflated to temporarily stop blood flow and then slowly deflated as the examiner listens through a stethoscope to your blood flowing through an artery just above the elbow, recording the number when a pulse noise is first heard and the number when the noise stops.

The two numbers, expressed in millimeters of mercury, represent the force of blood pushing against the walls of your arteries when your heart pumps, the systolic pressure, and when your heart rests between beats, the diastolic pressure. The final reading is the systolic pressure (the higher number) over the diastolic.

Normal blood pressure would be 120 over 80 or lower, and as long as you do not feel faint or dizzy, the lower the pressure, the better (up to a point, of course). For example, among people who are lean and regularly do aerobic activities, blood pressures of 100 or 110 over 60 or 70 are not uncommon.

In traditional societies where people remain lean and physically active throughout life, blood pressure does not usually rise with age. The story is quite different in developed countries like the United States, where blood pressure nearly always rises with advancing age as body fat increases, activity declines and arteries become stiff and narrowed by accumulating plaque.

Hypertension is defined as a systolic blood pressure of 140 or more, a diastolic pressure of 90 or more, or both. Both numbers are important; when either is elevated, so is the risk of developing heart and blood vessel disorders.

Contrary to the practice of some physicians, bringing only the diastolic pressure down to normal is not enough to protect against complications.

Dr. Susan A. Oliveria, a public health specialist at the Weill Medical College of Cornell in New York, and colleagues recently reported that although systolic pressures were above 140 in 93 percent of 270 doctor visits by hypertensive patients, medication was prescribed or changed only 38 percent of the time.

Dr. Oliveria concluded that doctors were not managing hypertension aggressively enough and were especially uncertain about the role of systolic pressure, which now appears to be even more important than diastolic pressure in determining risk of cardiovascular disease.

Further, when a person already has a disease affected by hypertension, like heart or kidney disease, current medical guidelines call for lowering blood pressure even more, well below the 140-over-90 cutoff.

Finally, Some Good News
How people live can make a big difference in their risk of becoming hypertensive.

Several major factors have already proved effective in controlling blood pressure. Other minor influences that can help keep blood pressure under control are continually being discovered.

First, the main actors: diet, weight control and exercise.

In a major collaborative study sponsored by the National Heart, Lung and Blood Institute, the so-called DASH diet rich in fruits, vegetables and low-fat dairy products and moderate in fat, saturated fat, red meat, sweets and sugar-containing drinks not only lowered blood pressure, it lowered blood levels of L.D.L. cholesterol and homocysteine, each increasing the risk of heart disease.

In a second study, a reduction in dietary sodium combined with the DASH diet was even more effective in lowering blood pressure than DASH alone.

These studies were conducted among a wide variety of people — white and black, normal weight and obese, with and without hypertension or a family history of the disorder, active and sedentary, large abdomen and small, rich and poor — all groups experienced a reduction in blood pressure on this wholesome diet. And many of the participants who had high blood pressure were able to reduce or eliminate the need for medication.

The DASH diet can also go a long way toward preventing another major contributor to hypertension: being overweight, now an epidemic in our society.

The third main factor in preventing hypertension, regular physical activity, can also help control the second, being overweight. Even among those who already have hypertension, aerobic activities like brisk walking, jogging, lap-swimming and cycling at least five days a week can reduce blood pressure, sometimes to the point where no drug treatment is needed.

Among other recent findings about the relationship of diet to blood pressure is one from a study of 23 hypertensive patients conducted in Naples, Italy. It showed that the use of olive oil, which is mono-unsaturated, but not polyunsaturated sunflower oil, significantly lowered blood pressure, reducing and sometimes eliminating the need for drug therapy.

Another new study by researchers at the University of Minnesota Medical School and HealthPartners Research Foundation demonstrated that daily consumption of whole oats (in contrast to whole wheat) helped control blood pressure, along with improving blood levels of fats, cholesterol and glucose.

If all these nondrug measures are not enough to bring high blood pressure under control, there are now numerous effective and safe drugs that can drastically reduce the risks associated with this condition.

For more information, see the booklet "High Blood Pressure: What You Should Know About It and What You Can Do to Help Your Doctor Treat It," available on the Web at www.hypertensionfoundation.org.

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