A 53-year-old man comes to the office due to newly diagnosed hypertension. The patient has no symptoms. Medical history is significant for type 2 diabetes mellitus. He has a 50-pack-year smoking history and has consumed 1 or 2 cans of beer daily for the past 25 years. Blood pressure is 150/95 mm Hg and pulse is 80/min. Height is 183 cm (6 ft) and weight is 109 kg (240.3 lb). BMI is 32.5 kg/m². Physical examination is normal. The physician recommends medication and lifestyle changes to lower blood pressure and decrease the risk of future cardiovascular events. Which of the following nonpharmacologic measures would be the most effective in decreasing this patient's blood pressure?

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Explanation: 11ec2b69_be5d_ee0f_8f63_7961a14cade3_MD0005_00 This patient has a new diagnosis of hypertension and additional cardiovascular risk factors (eg, diabetes mellitus, smoking). Current guidelines recommend that all patients with hypertension should initiate nonpharmacologic measures to lower blood pressure, including engaging in regular aerobic exercise, avoiding excessive alcohol intake, and following 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 approximately 6 mm Hg; therefore, weight loss is one of the most effective nonpharmacologic interventions for lowering blood pressure in these patients. (Choice B) Daily heavy alcohol consumption (≥3 drinks/day in men, ≥2/day in women) or binge drinking can raise blood pressure and is a common cause of refractory hypertension (ie, hypertension that remains uncontrolled despite multiple medications). However, moderate alcohol intake, as in this patient, does not significantly affect blood pressure. (Choice C) Sodium restriction can lower blood pressure when implemented as part of the DASH diet (ie, low in sodium and saturated fat; high in potassium, calcium, and dietary fiber). However, sodium restriction alone is somewhat less effective and inconsistent, with the greatest effect in individuals age >65 and patients with chronic kidney disease. (Choice D) Moderate-intensity exercise can lower blood pressure in both hypertensive and normotensive individuals and facilitates weight loss. However, a 20-kg weight loss has a greater impact on blood pressure than exercise alone. (Choice E) Smoking cessation is an important component of lifestyle modification to reduce the risk of cardiovascular events and all-cause mortality. However, many studies indicate that chronic smoking is not clearly related to increased blood pressure. Weight loss would be more effective in lowering this patient's blood pressure. Educational objective: Weight loss is one of the most effective nonpharmacologic measures for decreasing blood pressure in overweight and obese individuals with hypertension. Other effective measures include the Dietary Approaches to Stop Hypertension (DASH) diet, moderation of alcohol intake, and regular moderate exercise. 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 53-Year-Old Man Comes to the Office Due to Newly