Handbook of Psychology

Hypertension 355

severe hypertension and those with cardiovascular disease,
CVD risk factors, and/or organ damage, pharmacological ther-
apy should be initiated in conjunction with lifestyle changes.
The JNC IV (1997) recommends that pharmacological therapy
include diuretics and/or beta-blockers. Other drugs are contro-
versially used, including ACE inhibitors and calcium channel
blockers. Pharmaceutical treatments of hypertension continues
to be an active area of research and more clinical trials are
needed to prove these drugs ability to decrease CVD morbidity
and mortality (Carretero & Oparil, 2000b).

Weight Loss and Dietary Changes

The reduction of weight, as little as 10 pounds, lowers blood
pressure in the majority of overweight hypertensive patients
(Trials of Hypertension Prevention Collaborative Research
Group, 1997; Whelton, Applegate, & Ettinger, 1996). Addi-
tionally, this weight reduction enhances the ef“cacy of hy-
pertension medications (Neaton et al., 1993). In addition, the
direct effects on blood pressure weight loss has a bene“cial
effect on risk factors for other cardiovascular diseases and
may enhance patients overall sense of well-being. The ability
of weight loss to decrease comorbidities as well as lower
blood pressure makes it the most effective nonpharmacolog-
ical treatment for hypertension. Appetite suppressant drugs
are contradicted in this population because of the cardiotoxi-
city associated with their use. Weight loss should be achieved
with moderate calorie restriction and increased physical ac-
tivity (Carretero & Oparil, 2000b).
High sodium intake has traditionally been associated with
high blood pressure. While this hypothesis is supported by
clinical trials, individual response to sodium varies. Re-
stricted sodium diets are more effective at lowering blood
pressure in certain individuals and speci“c populations, in-
cluding African American and older patients (Weinberger,
1996). High potassium levels and high calcium levels, prefer-
ably from food sources, are recommended to help control
blood pressure (Allender et al., 1996). Recently, the effects of
the overall diet of an individual are being appreciated. The
Dietary Approaches to Stop Hypertension Study (DASH)
demonstrated signi“cant reductions in blood pressure in
moderately hypertensive subjects, regardless of age, gender,
race, weight, family history, physical activity level, or so-
cioeconomic status, when placed on a diet rich in fruits, veg-
etables, and low-fat dairy products compared to those control
subjects maintained on a •usual American dietŽ (Colin et al.,
2000). The food in the DASH trial contained a variety of
combinations of vitamins, minerals, “ber, and other nutrients
that could have alone or in combination created the dramatic
results in the study.

Exercise Training

Thirty minutes of moderately intense aerobic physical activ-

ity at least three times per week has been shown to lower

blood pressure in hypertensive and normotensive individuals

and is advised by the National Institute of Health (1996) and

the Centers for Disease Control (Pate et al., 1995). The

additional bene“ts of physical activity include weight loss,

improved sense of well-being, and reduced risk of cardiovas-

cular disease. The Nurse•s Health Study saw substantial re-

duction in stroke, caused by high blood pressure, associated

with regularly performed moderately intense aerobic activity

(Hu, Stampfer, Colditz, et al., 2000). Isometric exercise, such

as lifting weight is not advised because it may increase blood

pressure. The effect of exercise independent of weight loss is

not determined and remains an active area of research.

Stress Management, Biofeedback,

and Cognitive Interventions

Early studies suggested that techniques such as biofeedback

and stress management could be used to alleviate the stress-

induced components of high blood pressure, thereby reduc-

ing blood pressure in hypertensive patients. Several studies

have reported that small but signi“cant decreases in blood

pressure can be achieved in hypertensives after a series of

biofeedback or relaxation training sessions (including yoga

and meditation) (see Dubbert, 1995; Eisenberg et al., 1993;

Johnston et al., 1993). Patel and colleagues (Patel, Marmot,

& Terry, 1981; Patel et al., 1985) found a positive effect by

assessing the effect of eight weekly group sessions of training

in breathing techniques, deep muscle relaxation, mediation,

and stress management. Subjects were also told to partake in

relaxation, and mediation for 15 to 20 minutes daily, and also

to relax during daily stressful events. Subjects who received

this relaxation training showed decreases in both systolic and

diastolic blood pressure (approximately 7mgHg for both)

over a four-year follow-up period, as compared with a control

group who did not receive the training. A comparative study

of the various behavioral techniques showed none superior to

the others, with each independently producing modest de-

clines in blood pressure (Shapiro, Schwartz, Ferguson,

Redmond, & Weiss, 1977). Some studies have shown bene-

“ts from meditation and stress management in relation to hy-

pertension. Nakao et al. (1997) assigned patients to either a

biofeedback group or a control group that would later un-

dergo the biofeedback treatment. The researchers found that

those who had the four sessions of biofeedback had less of

a response to mental stressors and had generally lower

pressures at rest than those in the control group whose blood