n e w e ng l a n d j o u r na l
m e dic i n e
Dietary Therapy in Hypertension
Frank M. Sacks, M.D., and Hannia Campos, Ph.D.
This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinicaluse of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines, if they exist, are presented. The article ends with the authors’ clinical recommendations.
From the Department of Nutrition, Harvard School of Public Health (F.M.S., H.C.); and Channing Laboratory and Cardiology Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School(F.M.S.) ― all in Boston. Address reprint requests to Dr. Sacks at the Department of Nutrition, Harvard School of Public Health, Bldg. 1, 2nd Fl., Boston, MA 02115, or at fsacks@hsph .harvard.edu. N Engl J Med 2010:362:2102-12.
Copyright © 2010 Massachusetts Medical Society.
A 57-year-old woman presents to an outpatient clinic for evaluation of hypertension. She has no history or symptoms ofcardiovascular disease and reports having gained 15 kg over the past 30 years. Her blood pressure is 155/95 mm Hg, her weight 86 kg, her height 165 cm, her body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) 31, and her waist circumference 98 cm. Her serum triglyceride level is 175 mg per deciliter (2.0 mmol per liter), high-density lipoprotein cholesterol 42mg per deciliter (1.1 mmol per liter), low-density lipoprotein cholesterol 110 mg per deciliter (2.8 mmol per liter), and glucose 85 mg per deciliter (4.7 mmol per liter). Her clinical profile is thus consistent with the metabolic syndrome.1 She is a nonsmoker, is sedentary, and eats a diet that is high in white bread, processed meats, and snacks and drinks containing sugars and sodium and is lowin fruits and vegetables. She is interested in adopting a healthier lifestyle.
The Cl inic a l Probl em
Hypertension is defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher.2 However, morbidity increases among persons whose blood pressure is above 115/75 mm Hg. High blood pressure is associated with an increased risk of stroke,myocardial infarction, heart failure, renal failure, and cognitive impairment.2-4 Systolic blood pressure above 115 mm Hg is the most important determinant of the risk of death worldwide,2 being responsible for 7.6 million cardiovascular deaths annually.3 From 1960 through 1991, blood pressure decreased in the United States, and after the first 10 years of this interval, the rate of cardiovascular deathsdecreased.2 Effective hypertension screening and treatment were probably the reason for these beneficial trends. However, from 1990 through 2002, blood pressure increased.5,6 Intake of fruits and vegetables and adherence to healthful dietary patterns declined during this period7,8 and the prevalence of abdominal obesity increased9; both trends have contributed to hypertension. Among mostpopulations in industrialized countries, the prevalence of hypertension increases dramatically with age; in the United States it rises from about 10% in persons 30 years of age to 50% in those 60 years of age.6 However, some persons, including strict vegetarians,10-12 populations whose diet consists mostly of vegetable products,11,13 and those whose sodium intake is low,13-15 have virtually no increase inhypertension with age.
S t r ategie s a nd E v idence
Pathophysiology and Effect of Therapy
Essential hypertension is the name for hypertension that cannot be attributed to a specific renal or adrenal disease, such as chronic renal failure or an adrenal tumor;
n engl j med 362;22 nejm.org june 3, 2010
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