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The Pressure Is On
Hypertension and Diabetes

by Craig G. Hurwitz, MD

In people who don’t have diabetes but do have blood pressures above 130/80 mm Hg, a period of treatment with lifestyle changes alone can be considered. In people with diabetes, the risk of heart disease, stroke, and kidney failure is so much higher that current guidelines recommend initiating drug therapy at the same time as lifestyle changes.

Lifestyle changes
There is enormous overlap between the lifestyle measures that are beneficial for high blood pressure and those that are helpful for controlling diabetes. Performing regular exercise, losing excess weight and keeping it off, and getting adequate sleep are a start. Studies suggest that your blood pressure may decrease 3–5 mm Hg for every 10 pounds of excess weight lost.

Losing weight is extremely challenging, but the health benefits of doing it are substantial. A sensible reduction in calorie intake along with a regular exercise program is the best way to gradually reduce your weight. Moderate-intensity exercise such as brisk walking is felt to be safer than very vigorous exercise. Intense exercise such as heavy lifting or snow shoveling can raise the blood pressure briefly and stress the heart too much. On the other end of the spectrum, very slow movements such as those done in yoga or tai chi may lower blood pressure.

Reducing sodium intake can be effective in lowering blood pressure. Some people are more sensitive to salt than others, meaning that their blood pressure has a more exaggerated response to salt. People with diabetes and people who are obese tend to be salt sensitive. A low-salt diet has been associated with a reduced risk of cardiovascular disease. Reducing sodium intake to below 2400 milligrams daily has significant benefits for blood pressure, but it can’t be done by just avoiding table salt since the majority of sodium in American diets comes from processed foods. Reading food package labels to select low-sodium foods is therefore also important. Other dietary changes that are helpful include moderating intake of alcohol and caffeine.

It is unclear why, but a vegetarian diet has been shown to have beneficial effects on blood pressure. This is possibly related to an increased intake in fruits and vegetables as well as lower saturated and total fat intake. The DASH diet (Dietary Approaches to Stop Hypertension) is rich in fruits, vegetables, and low-fat dairy products while avoiding saturated fats. It also provides plenty of calcium, potassium, and magnesium, which are important for lowering blood pressure. The combination of salt restriction and the DASH diet is a great start to improving your blood pressure. Information on the DASH diet is readily available on the Internet at www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf.

Just as sleep disorders are known to increase blood pressure, good sleep habits benefit blood pressure. In people without hypertension, blood pressure has been found to be higher in the morning after a poor night’s sleep. Psychological stress plays a role in hypertension, and stress-reduction and relaxation techniques are beneficial and important parts of a complete treatment program.

Drug therapy
In people with diabetes diagnosed with high blood pressure, drug therapy is initiated along with lifestyle changes. Many advances have been made in the understanding of what causes hypertension. This has resulted in the development of a number of different types, or classes, of drugs that lower blood pressure. The major classes of blood-pressure-lowering drugs include diuretics (often called water pills), angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, alpha-blockers, and calcium channel blockers.

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