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Reducing the risk of stroke.

In a culture of car phones computerized coffee makers, where pizza makes house calls and fast food franchises penetrate every town, it's no surprise that more than 60 million Americans have high blood pressure, and 2 million more develop the disorder each year.

"Hypertension in the United States is an epidemic," says Dr. Paul K. Whelton, professor of epidemiology and medicine at the Johns Hopkins Medical Institutions in Baltimore. "History teaches us that a disease occurs in epidemic proportions only when large numbers of people are exposed to environmental factors that foster the illness." For high blood pressure, he notes, these factors include physical inactivity, obesity, and excess salt and alcohol consumption.

High blood pressure is the top risk factor for stroke and a major contributor to heart disease and kidney failure, noted Whelton and a host of other prominent physicians who released a new report in October, detailing a national strategy to decrease the prevalence of hypertension in America. Issued on the 20th anniversary of the National High Blood Pressure Education Program--a government and private sector coalition of health organizations--the report is the first national recommendation of this type in any country.

"The complications caused by high blood pressure are insidious, progressive, and costly," says Dr. Claude Lenfant, director of the National Heart Lung and Blood Institute (NHLBI). "And they can begin before blood pressure rises above the normal range. So it is not enough to treat the condition. We need to help Americans avoid its development."

To help prevent high blood pressure, the new report urges Americans to take four steps:

1. Become physically active. Regularly perform some moderate-intensity, low-resistance, dynamic exercise, such as walking, cycling, dancing, swimming, or gardening.

2. Control weight. The overweight have a two- to six-fold higher risk of developing high blood pressure than those of regular body weight. About 20 to 30 percent of hypertension in the United States can be attributed to this one health problem alone.

3. Avaid excessive table salt intake. Consume no more than 6 grams daily.

4. Avoid excessive alcohol consumption. Limit alcohol consumption to no more than two drinks daily. About 5-7 percent of hypertension in the United States can be attributed to consumption of three or more alcoholic drinks a day.

Becoming physically active can be central to making all these positive lifestyle changes, experts note, because physical activity can help people lose weight and reduce the stress that can contribute to excess drinking and eating.

High blood pressure is "a disease of civilization" that is a direct result of our sedentary lifestyle, notes Dr. Michael Horan, associate director for cardiology at NHLBI. In societies where people get a great deal of physical activity in their daily lives, he says, "you don't see the prevalence of obesity. hypertension, or high cholesterol."

The idea that inactivity is at the root of much ill health is relatively new.

As recently as 15 years ago, "it was common to tell hypertensives not to exercise because activity elevates the blood pressure," says Dr. Samuel M. Fox, professor of medicine and director of preventive cardiology at Georgetown University Medical Center. While systolic (pumping) blood pressure does rise during exercise, he notes, the long-term effect of aerobic exercise can be a small, but significant, reduction in overall blood pressure.

New studies show that regular aerobic exercise may help prevent the development of hypertension, keep those with borderline high blood pressure off medication and, possibly, reduce the hypertensive patient's risk of death.

Exercise is not a panacea, Fox cautions, and should be part of a comprehensive program to lower elevated blood pressure that includes keeping weight down, eliminating cigarettes, and restricting consumption of fat, sodium, and alcohol. But properly supervised by a physician, Fox notes, "Exercise can help some hypertensives cut back or eliminate expensive and troublesome medication. I had one patient in his mid-40s who, over a year and a half, was able to cut out his diuretic and go completely off his beta blocker through a program of regular exercise."

But it is essential that people over 45 and those under 45 with risk factors for heart disease--such as obesity or inactivity--consult a physician before beginning an exercise program because one of the main problems surrounding hypertension is that frequently there are no symptoms until it's too late.

The first sign of trouble is often a heart attack or stroke, notes physician Kenneth Cooper, the man who helped launch America's fitness revolution with his 1968 book Aerobics. To defend against this silent killer, Cooper first advises non-drug strategies including regular aerobic exercise, stress management, weight loss, and dietary controls such as reducing sodium intake, restricting alcohol, reducing saturated fat intake, and eating potassium-rich foods. Only if these approaches fail does Cooper encourage use of medication. But, he contends, "an awful lot of people are on medication who don't need it."

In his book, Overcoming Hypertension, Cooper writes:

"It's quite easy simply to prescribe a drug that will control or mask hypertension. Unfortunately, that's the approach taken by many physicians with the result that, almost invariably, the patient builds up tolerance to the medication. When this happens, either the dose must be increased, the medication changed, or a combination of medications prescribed. A vicious, seemingly endless cycle may then arise, shifting the patient from medication, to tolerance, to more medication."

Because drugs for high blood pressure can be costly and have significant side effects, Cooper recommends first adopting lifestyle changes that could help prevent or control hypertension without medication. Chief among these is exercise, he says, "since so many times, when people start to exercise, it prompts them to do other things that are good for them. For example, the Centers for Disease Control in Atlanta reports that the best known way to break the cigarette habit permanently is to start an exercise program."

Exercise can help combat high blood pressure in several ways, Cooper says. First, regular aerobic exercise itself has been shown to decrease resting systolic and diastolic blood pressure by about 10 millimeters of mercury. Second, exercise often results in weight loss, which typically produces a decline in blood pressure. Third, aerobic exercise reduces stress, which also may help combat hypertension.

"The more physically fit you are," Cooper says, "the less likely you are to suffer from hypertension. The more sedentary you are, the greater your risk of developing high blood pressure. Regular aerobic exercise, such as jogging, cycling, swimming, and vigorous walking, is one of the most effective non-drug 'medicines' for those at risk for hypertension."

Aerobic activity should be performed regularly--at least three times a week for 20 to 30 minutes per session-to have a beneficial impact on blood pressure. And some muscletensing activities, such as heavy weightlifting and highly resistant calisthenics like push-ups, may be dangerous for people with hypertension. Heavy weightlifting results in an exaggerated increase in blood pressure, notes Cooper, who advises against such activity by anyone, hypertensives and those with normal blood pressure alike. People who do lift heavy weights should have their blood pressure monitored frequently, he says.

Cooper also warns against vigorous aerobic exercise for people with extremely high blood pressure. "Certain people with severe hypertension shouldn't do any strenuous exercise unless their blood pressure can be controlled with drugs," he says. "This is because athletic activity may trigger a serious health complication, like a stroke, for those whose blood pressure remains too high."

Hypertensives whose blood pressure is greater than 175/110 should avoid vigorous exercise, he says, but could do easy walking or swimming with their physician's guidance. Even at lower levels of hypertension, the decision regarding exercise should be made by a physician, says Cooper, who adds these guidelines:

* Be sure to have a thorough physical exam before embarking on an exercise program. If hypertension is diagnosed, proceed only with the full knowledge and supervision of your physician.

* If your blood pressure is 160/105 or higher, begin an exercise program only after your doctor has started you on appropriate drug therapy. Your response to such therapy will determine the point at which you can embark on an exercise program.

* If you are on drugs for hypertension when you begin this program, reduce the dosages of those drugs only with the permission of your physician.

Blood pressure readings may vary considerably during the day in response to such factors as caffeine, smoking, a full bladder, being cold, or even the stress of being in the doctor's office. "So the key to diagnosing hypertension is your average blood pressure, which means the average of multiple readings taken over one to two months," Cooper says.

He advises people with a genetic predisposition to high blood pressure to invest in a home monitor. People with risk factors for the disease, such as family history of hypertension, obesity, high stress, and being sedentary, should begin exercising regularly and eating wisely, he says, before hypertension strikes.

"There's a danger that, as our lives become more pressure-ridden and unliveable, the numbers of those at risk of hypertension will rise," he warns. "We don't just die anymore; we kill ourselves."
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Title Annotation:Heartbeat: The Healthy Heart Report
Author:Krucoff, Carol
Publication:Saturday Evening Post
Date:Mar 1, 1993
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