Step up to better blood pressure

To stay in the healthy zone, lock in the basics and talk to your doctor about escalating your medications.

Are you being treated for high blood pressure but your numbers are still higher than you want them to be? Your situation is fairly common, and there is much you can do. First, lock in on the basic moves, like regular exercise, that will help bring blood pressure into line. Then you and your doctor can take additional steps, such as home blood pressure monitoring or reducing salt intake further.

When self-help measures fail, doctors are sometimes forced to add more medication, says Dr. William Kormos, editor in chief of Harvard Men's Health Watch and a primary care physician at Massachusetts General Hospital. "There are many men who are always resistant to you adding on another pill, but if people aren't doing the other things, then our only choice is to use the medications."

Out of control

Whatever your blood pressure, the risk for harm persists continuously until your pressure dips below 120 systolic (the upper number) and 80 diastolic (the lower number). Above this threshold, the risks increase. For anyone diagnosed with high blood pressure (hypertension), the first goal is to bring blood pressure under control. To your doctor, that means getting the numbers below 140/90 millimeters of mercury (mm Hg).

In a report in Circulation, researchers took a look at information about people with hypertension obtained from the National Health and Nutrition Examination Survey (NHANES). The people surveyed included more than 13,000 adults with high blood pressure. Based on 2007–2008 NHANES survey data, some 68 million Americans have hypertension, and only about half of them have their blood pressure under control.

Among the 33 million out of control is a special class of people with hypertension known to doctors as "treated but uncontrolled." These are people who have sought medical treatment to get blood pressure below 140/90—or perhaps even lower if they have diabetes or kidney disease—but for whom treatment is not working well enough.

Lock in the basics

Fortunately, we know what to do about hypertension. True lifetime control requires a healthy lifestyle and optimizing medications. All of the components of a healthy lifestyle act to control blood pressure. Indeed, not following these basics is what leads to hypertension.

• Maintain a healthy weight.

• Eat a healthy diet rich in fruits, vegetables, and whole grains Get regular physical exercise.

• Drink alcohol in moderation (one to two drinks per day for men).

• Don't smoke.

What more can you do?

Have you done your best with the basics and want to escalate your hypertension care? Here are some things you and your doctor can work on together.

Adopt the DASH diet: The medically proven Dietary Approaches to Stop Hypertension (DASH) plan, especially the low-sodium version, can lower your blood pressure by 10 points or more. (You can get more details about the DASH diet at health.harvard.edu/122.) The DASH diet emphasizes fruits and vegetables and reduces saturated fat, sugar, and salt.

Reduce salt: The basic DASH diet calls for limiting sodium to 2,300 milligrams (mg) daily. Studies show that for middle-aged or older people, African Americans, and those with hypertension, limiting sodium to 1,500 mg works even better for lowering blood pressure.

Monitor your own blood pressure: There are a couple of important things home monitoring of blood pressure can do. For one, it can provide a more accurate, long-term portrait of your pressure. Also, some people experience "white coat hypertension," in which blood pressure spikes higher than normal when measured at the doctor's office. Home monitoring can prevent the white coat effect.

Make your meds work for you

In established hypertension, medication plays a vital role in achieving your blood pressure goals. Taking medications as recommended is fundamental to maintaining good control. An inadequate level of medication therapy—either because you are not being prescribed enough medication, or are not taking those you are prescribed as directed—is often at the root of uncontrolled hypertension.

The NHANES survey provides some insight. In the 2005–2008 survey data, about one-third of all people with uncontrolled hypertension were already taking medication. However, seven out of 10 people in this group (treated but uncontrolled) were taking only one or two medications. These folks were older and were at significantly higher risk of cardiovascular problems than people whose hypertension was adequately controlled with the same number of medications.

Naturally, many men would prefer not to take additional medications with the added expense and potential for side effects that comes with them. But over time, inadequate blood pressure control can have devastating consequences (see box below). By combining medications that work to lower blood pressure via different physiological "control circuits" in the body, your doctor can help you reach your target pressure. "You have to add medications for some people just to get their blood pressure better controlled," Dr. Kormos says. "You try to pick medications in different classes that complement each other and won't just be redundant."

On the other hand, nutrition, exercise, and other lifestyle measures can reduce the need for such medications and potentially enable you to stop taking some of them eventually. Is it time to schedule a reality check with your doctor about your blood pressure?