JIACM 2004; 5(4): 306-9
EDITOR’S CHOICE
Essential Hypertension- Primary Prevention
JS Sandhu*, A Berri**, D Gupta**, M Arya**, R Singh**, P Sandhu***,
Introduction
Hypertension is the most common disorder encountered
in outdoor patients1. The seventh report of the Joint
National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC-VII report) has
recommended a new classification for adults – 18 years
or older 2.

Normal: < 120/80 mm Hg.

Pre-hypertension: 120-139/80-90 mm Hg.

Hypertension – stage 1: 140-159/90-99 mm Hg.

Hypertension – stage 2: ≥160/≥100 mm Hg.
As estimated in the Framingham Heart Study3, the residual
lifetime risk of incident hypertension (≥140/90 mm Hg)
was 90% for both 55 and 65-year-old subjects and lifetime
probability of receiving antihypertensives was 60%.
In a meta-analysis of 34 epidemiological studies from rural
and urban populations of India, it was concluded that
hypertension is emerging as a major health problem in
India and is more in urban than in rural subjects. The
prevalence of hypertension in recent studies was almost
similar to those in USA4.
In view of high prevalence and very high residual lifetime
risk of hypertension in the population and a significant
associated morbidity and mortality, especially the
cardiovascular and renal, primary prevention of
hypertension remains very important. Two strategies have
been recommended for the prevention of essential
hypertension. These include a population-based strategy
and an intensive targeted strategy directed at those with
increased risk of developing hypertension5.
A. Population based strategy
Because most persons in the general population are
candidates for primary prevention intervention, a
small change in blood pressure is likely to yield
* Professor, ** Resident, Department of Nephrology, *** Associate Professor, Department of Radiology,
Dayanand Medical College and Hospital, Ludhiana-141 001, Punjab (India).
substantial health benefits. A 17% reduction in the
prevalence of hypertension, a 14% decrease in the risk
of stroke and transient ischemic attacks (TIA), and a
6% reduction in the risk of coronary artery disease
occurs by a 2 mm reduction in the population average
of diastolic blood pressure (Framingham Heart
Study)6.
Various population-based strategies for primary
prevention of essential hypertension include
decreasing sodium content in diet, decreasing caloric
density in processed food, and providing safe and
convenient opportunities for exercise2.
B. Intensive targeted strategy for high risk groups
High risk groups of hypertension include: individuals
with a high normal blood pressure; a family history of
hypertension; African American ancestry; overweight;
excess consumption of salt; physical inactivity; and
excessive alcohol consumption5.
Lifestyle modifications
Lifestyle modifications should be encouraged whenever
appropriate. These are generally beneficial in reducing blood
pressure and other risks especially cardiac and these should
be tailored to the individual characteristics7. A reasonable
generalised approach includes: (1) weight loss for the
overweight; (2) regular physical activity; (3) moderation in
alcohol consumption; (4) dietary modifications to reduce
sodium and fat, and increase in calcium, potassium,
magnesium, vitamins, and fibre in food sources.
1. Weight reduction
Epidemiological studies have revealed a strong
relation between obesity and hypertension8. Obesity
alone possibly accounts for 78% and 65% of essential
hypertension in men and women as revealed in the
Framingham study9.
 Weight loss counselling is an effective approach for
the prevention of hypertension. The incidence of
obesity has increased to 30.5% in USA and there is a
pandemic of obesity worldwide10. Several large
epidemiological and clinical studies of weight
reduction have explored the role of obesity in the
aetiology of hypertension and the effect of weight
loss on blood pressure (a 51% and 77% decrease in
the incidence of hypertension at 18 months and 7
year follow-up respectively)5.
Excess of body fat predisposes to raised blood
pressure and hypertension. Weight reduction
reduces blood pressure in overweight individuals
and has beneficial effects on associated risk factors.
The blood pressure lowering effect of weight
reduction may be enhanced by a simultaneous
increase in physical exercise and alcohol moderation
in overweight drinkers and by reduction in sodium
intake11.
A meta-analysis of randomised controlled trials of
weight reduction in normotensive ≥ 45 years old
individuals showed a net reduction of 2.8 mm and
2.3 mm Hg in systolic and diastolic blood pressure
respectively at 6 months of follow-up12. Based on the
overwhelming evidence from clinical trials and meta-
analysis, weight reduction is recommended as an
important intervention for primary prevention of
hypertension. Because sustained weight reduction is
so difficult to achieve, more emphasis should be
placed on prevention of weight gain, particularly in
the young individuals with a high normal blood
pressure and in families with a high prevalence of
hypertension.
2. Physical activity
Physical inactivity has been related to high blood
pressure. Aerobic exercise trial meta-analysis in
normotensive persons has shown a 4.04- mm and 2.33
mm Hg decrease in systolic and diastolic blood
pressure respectively13. Additional benefits of regular
physical activity include weight loss, enhanced sense
of well being, improved functional health status, and
reduced risk of cardiovascular disease and mortality
from all causes.
Journal, Indian Academy of Clinical Medicine
Vol. 5, No. 4
The regular aerobic physical activity, like brisk walking,
swimming, cycling, or treadmill, for at least 30 minutes
daily for most days of week is recommended for
primary prevention of essential hypertension.
However, isometric exercise such as heavy weight
lifting can have a pressor effect and should be
avoided5.
3. Moderation in alcohol consumption
Alcohol consumption elevates blood pressure both
acutely and chronically. In cross-sectional and
prospective studies involving all kinds of populations,
the relationship between alcohol consumption, blood
pressure levels, and the prevalence of hypertension
has been remarkably consistent5. The relationship is
linear. Alcohol consumption ≥ 210 Grams of alcohol/
week (approximately 3 drinks/day) was shown to be
associated with an increased risk of hypertension14.
The effect increases with age, is independent of the
type of alcoholic beverage, and is additive but
independent of the effects of obesity, oral
contraceptives, and high salt intake. It is estimated that
in men, the contribution of alcohol to the prevalence
of hypertension is 11%15.
A meta-analysis of randomised trials to assess the
effects of alcohol reduction on blood pressure
showed a dose dependant decline in blood pressure16.
Clinical studies show that blood pressure falls 4 to 5
mm Hg in days or weeks with abstinence from alcohol.
For unrelated health reasons, alcohol consumption is
not recommended for non-drinkers. However, those
who drink alcohol should be advised to limit their
consumption to no more than 20-30 g ethanol/day
for men and no more than 10-20 g ethanol/day for
women11. Thus, reduction in alcohol consumption,
especially among heavy drinkers, has been
recommended as an important mean of primary
prevention of hypertension.
4. Dietary modification
The dietary approaches to stop hypertension (DASH)
trial17 showed reduction in blood pressure of 3.5/2.1
mm Hg in normotensive individuals on fruit/vegetarian
diet combined with reduced fat and cholesterol intake.

October-December, 2004 307
 The various dietary modifications recommended for
primary prevention are described hereunder.
a. Dietary sodium reduction
Various randomised controlled clinical trials,
observational studies across and within population,
migration studies and animal experimental data, over
the last several decades have shown convincingly
causal relationship between dietary salt intake and
elevated blood pressure18. In a meta-analysis of 12
randomised controlled clinical trials in 1,689
normotensive individuals, an average reduction of 77
mmol/day in dietary sodium intake resulted in 1.9 mm
Hg decrement in systolic blood pressure19.
Based on the results of DASH trial and other studies,
the National High Blood Pressure Education Programme
Coordinating Committee has recommended reduction
of dietary sodium intake to not more than 100 mmol/
day (2.4 gm. sodium or 6.0 gm. salt). Even lower levels
of dietary sodium intake (< 70 mmol/day) may result
in a greater reduction in blood pressure17.
b. Potassium supplementation
Over the last several decades, meta-analysis of
epidemiological and clinical studies have shown that
potassium supplementation lowers blood pressure in
normotensive and hypertensive individuals20,21. The
blood pressure effect of potassium administration
seems to be greater in those who take high salt diet.
Based on the data, it is recommended that adequate
intake of potassium (> 90 mmol or 3500 mg daily) be
taken. The diets rich in potassium include fruits, fruit
juices, and vegetables.
c. Macronutrient alteration
Based on the results of DASH trial and other studies, a
diet rich in fruits, vegetables, and reduced in saturated
and total fats is recommended for primary prevention
of hypertension. Only 30% of calories should be from
fats, with only 7% to 10% of calories from saturated
fats. Saturated fats are found in meats, cheese, butter,
poultry, and snack foods4, 22.
Vegetarian diets have shown reduction in blood
308 Journal, Indian Academy of Clinical Medicine
pressure in both normotensive and hypertensive
individuals23. The effect seems to be due to high fibre
and low fat content of vegetarian diet as compared
to non-vegetarian diet.
Increased calcium24 and fish oil25 and reduced caffeine
consumption26 have shown small blood pressure
lowering effects. Observational studies have shown a
strong relationship between dietary protein and fibre
intake and blood pressure, but clinical trials are scanty27.
5. Stress reduction and biofeedback
The role of stress in causing hypertension is still not
very clear. However, there is evidence of a link
between job stress to long term blood pressure
elevation. A meta-analysis of 26 studies of blood
pressure control through behavioural or cognitive
modifications by techniques such as stress reduction,
progressive relaxation, and biofeedback or meditation
did not show any superiority to no therapy at all28, 29.
6. Yoga, meditation (Mind-body techniques)
These are widely practiced for stress reduction. So far
no substantial evidence in support of benefits of
yoga/meditation is available. Yet, the availability of
some controlled research, its overall cost-
effectiveness, and the lack of side effects make further
investigations of yoga a topmost priority29.
Conclusion
Thus, the main thrust of primary prevention of
hypertension includes a sustained effort on lifestyle
changes. These include: weight reduction in the
overweight; increased physical activity; consumption of a
diet that is rich in fruits and vegetables, and low in dairy
fat and sodium; and avoidance of excessive alcohol
consumption. This would go a long way to prevent the
occurrence of hypertension in the general population and
decrease the load of chronic diseases (cardiovascular,
cerebrovascular, and renal) that are associated with
hypertension.
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ANNOUNCEMENT
EMERGENCY MEDICINE
UPDATE 2004
30th October, 2004
All India Institute of Medical Sciences
Department of Emergency Medicine, AIIMS
Last date : 15th October, 2004
For details contact :
Dr. Sanjeev Bhoi, AP
(Organising Secretary)
Department of Emergency Medicine, AIIMS
Ansari Nagar, New Delhi-110 029 (India)
Tel. : 91-11-26589029 Mobile : 91-9811044309
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