A 43-year-old man with a 2-year history of type 2 diabetes mellitus comes to the office for a routine preventive examination. He feels well and has no symptoms. Medications include metformin and aspirin. The patient works as a computer programmer and has a sedentary lifestyle. He drinks 1 or 2 cans of beer on weekends and has a 20-pack-year smoking history. The patient is 183 cm (6 ft) tall and weighs 109 kg (240 lb); BMI is 32.5 kg/m². Blood pressure is 153/94 mm Hg and pulse is 82/min. The remainder of the physical examination is unremarkable. Hemoglobin A1c is 7.6%. At a previous visit 3 months ago, blood pressure was 149/92 mm Hg. Which of the following interventions would most likely cause the largest decrease in this patient's blood pressure?

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11ec25c8_d2d9_f8f4_bc81_7d5af1781460_MD0003_00 This patient has hypertension, defined as systolic blood pressure ≥130 mm Hg and/or diastolic blood pressure ≥80 mm Hg. Current guidelines recommend that all patients with hypertension be advised to get regular aerobic exercise, avoid excessive alcohol intake, and follow a dietary program proven to lower blood pressure (eg, Dietary Approaches to Stop Hypertension [DASH] diet). In addition, patients who are overweight (BMI 25-29.9 kg/m²) or obese (BMI ≥30 kg/m²) should be advised to lose weight to achieve and maintain a healthy weight. Obesity, particularly central/visceral obesity, is the single greatest lifestyle risk factor for hypertension, with an attributable risk of approximately 60%-70%. In patients with obesity, each 10 kg (22 lb) of weight loss can lower blood pressure by ~6 mm Hg; therefore, weight loss is one of the most effective nonpharmacologic interventions for lowering blood pressure. However, additional lifestyle modifications, including dietary changes and exercise, are typically implemented concurrently. (Choice B) Moderate-intensity aerobic exercise can lower blood pressure in both hypertensive and normotensive individuals and facilitates weight loss. However, weight loss has a greater impact on blood pressure than exercise alone. (Choice C) Daily heavy alcohol consumption (≥3 drinks per day in men, ≥2 in women) or binge drinking can raise blood pressure and is a common cause of refractory hypertension (hypertension that remains uncontrolled despite multiple medications). However, moderate alcohol intake, as in this patient, does not significantly affect blood pressure. (Choice D) Sodium restriction can lower blood pressure when implemented as part of the DASH diet (low in sodium and saturated fat; high in potassium, calcium, and dietary fiber). Sodium restriction alone is somewhat less effective and inconsistent, with the greatest effect in individuals age >65, the African American population, and patients with chronic kidney disease. (Choice E) Smoking cessation is an important component of lifestyle modification that reduces the risk of future cardiovascular events and all-cause mortality. However, many studies indicate that chronic smoking is not clearly related to an increased incidence of hypertension. Weight loss would be more effective in controlling this patient's blood pressure. Educational objective: Obesity is the single greatest contributing lifestyle risk factor for hypertension; weight loss and the Dietary Approaches to Stop Hypertension (DASH) diet are the most effective nonpharmacologic interventions for lowering blood pressure. References: Non-pharmacological aspects of blood pressure management: what are the data? (http://www.ncbi.nlm.nih.gov/pubmed/21389976) Long-term effects of weight-reducing diets in people with hypertension. (http://www.ncbi.nlm.nih.gov/pubmed/26934541)

A 43-Year-Old Man with a 2-Year History of Type 2