Developing a Successful Treatment Plan for High Blood Pressure

In this article:

  • Taking a serious look at your treatment goal
  • Fitting goals to your lifestyle and lifestyle to your goals
  • Laughing up a storm while lowering your blood pressure

Two truths should motivate you to create a successful treatment plan for your high blood pressure:

  • High blood pressure must be brought under control to prevent the devastating consequences of uncontrolled high blood pressure — heart, kidney, and brain damage (we cover these in Part II).
  • High blood pressure can be brought under control in any patient using the tools that are currently available.

Surprisingly, the progress in people’s awareness, amounts of treatment, and amounts of successful treatment of high blood pressure in the last few decades has been little.

  • In the United States in the 1980s, 73 percent of the population with high blood pressure was aware of their condition, but in the first decade of the twenty-first century, this number has dropped to 70 percent.
  • In the 1980s, 55 percent of the people with high blood pressure were being treated, but that number has gone up only 4 percent in recent years.
  • Of those treated in the 1980s, 29 percent were under control. In recent years the figure is 34 percent.

These figures mean almost a third of the people with high blood pressure don’t know they have it, two-fifths of the people who do know it aren’t receiving treatment, and two-thirds of patients receiving treatment are not meeting their goals.

This performance is unacceptable. Other countries are doing no better and are generally worse. You and your physician are the ones who can turn this around. Start right now — sit down and write an outline for the elements of a successful treatment plan. This article can help you.

Achieving Your Treatment Goal

You need a goal to know where you’re going. Your particular goal depends on your present blood pressure.

  • If you have normal blood pressure (less than 120/80 mm Hg), you want to keep it normal.
  • If you already have prehypertension (see article 2 for an explanation of this term) or high blood pressure, you want to lower it into the normal range and keep it there.
  • If you already have complications of high blood pressure, you want to prevent them from progressing and even reverse them if possible.

Damage due to high blood pressure is continuous. Target-organ damage (damage to organs of the body from high blood pressure) doesn’t start suddenly at 120/80 mm Hg; it creeps up on you slowly. As a result, people on the high side of normal blood pressure have a greater chance of suffering complications associated with their blood pressure than people on the low side of normal blood pressure, and people in the pre-hypertension range average more medical complications than those in the normal range.

The table below shows what category your blood pressure falls into and the recommended follow-up. (Also, see the table on blood pressure classifications in article 2.) If you already have diabetes mellitus or kidney disease and your reading is greater than 130/80, you have stage 1 high blood pressure.

Recommended Follow-up Based on Initial Blood Pressure Measurements
Category Systolic (mmHG) Diastolic (mmHG) Follow-up by physician
Normal <120 <80 Recheck in 2 years
Prehypertension 120-139 80-89 Recheck in 1 year. Give lifestyle advice
Stage 1 HBP 140-159 90-99 Confirm in 2 months; use one blood pressure medication plus lifestyle advice if still present
Stage 2 HBP Greater than or equal to 160 Greater than or equal to 100
Evaluate/refer to care within 1 month; use two BP medications plus lifestyle advice

Courtesy of The National Heart, Lung and Blood Institute of the National Institutes of Health in the Seventh Report of the Joint National Committee (JNC7) on Detection, Evaluation, and Treatment of High Blood Pressure (2003)

The National Heart, Lung and Blood Institute of the National Institutes of Health in the Seventh Report of the Joint National Committee (JNC 7) on Detection, Evaluation, and Treatment of High Blood Pressure (2003) provides a list of important risk factors for high blood pressure (see article 3 for more details). The risk factors are:

  • Age (older than 55 for men, 65 for women)
  • Diabetes
  • Family history of heart disease
  • High blood cholesterol
  • Microalbuminuria (the presence of more than 30 but less than 300 milligrams of albumin in the urine in 24 hours)
  • Obesity
  • Physical inactivity
  • Smoking

A new recommendation of the JNC 7 is that every patient with stage 1 or stage 2 high blood pressure — with or without the previous list of risk factors — should be treated. The risk factors (also called compelling indications for treatment) only increase the urgency of treatment.

JNC 7 offers a treatment algorithm (a series of logical steps) to bring the blood pressure to normal:

  • 1. If you have prehypertension, modify your lifestyle.
  • 2. If high blood pressure is present, use lifestyle modifications (which we discuss later in this article).
  • 3. If lifestyle modification is unsuccessful, begin drugs (see article 13 for full details on blood pressure medication).
    • If no compelling indications are present with stage 1 high blood pressure, most people can begin with thiazide diuretics.
    • If no compelling indications are present with stage 2 high blood pressure, use two drugs, a thiazide diuretic, and another class of drugs.
    • If compelling indications exist — regardless of the stage — use a specific drug for the indication plus other classes of drugs.
  • 4. If blood pressure goals are still not achieved, increase dosages of the drugs and add other drugs until blood pressure is under control.

You can take these measures right now: 

  • Determine what your blood pressure is with the help of your physician.
  • Discuss your risk factors and how they affect your treatment.
  • Use the doctor’s expertise to formulate a plan that reverses your reversible risk factors and lowers your blood pressure.

A few examples from a doctor's practice can help you to understand the road ahead.

Joe Chang is a 43-year-old Chinese American who went to the doctor because his blood pressure was elevated. On examination, he was 5 feet and 5 inches tall and weighed 180 pounds. He didn’t have diabetes or any other risk factor. He hadn’t followed a diet and didn’t exercise. On several different occasions, his blood pressure was about 144/95 mm Hg. Based on the table of treatment strategies, I told him to begin a program of diet and exercise and referred him to a dietitian. Three months later, he had lost ten pounds and was exercising regularly. His blood pressure had fallen to 138/86 mm Hg. He has continued the program and lost an additional ten pounds with continued good blood pressure control.

Elaine David, a 38-year-old mother of two children, has diabetes. The doctor had followed her through her two uncomplicated pregnancies. She weighs 160 pounds and is 5 feet 3 inches tall. Recently, her blood pressure has measured 165/98 mm Hg. She doesn’t have any other risk factors (see the earlier list in this section). Elaine needed to lose weight, exercise more, reduce her salt intake, and get on drug treatment. She was started on hydrochlorothiazide (a diuretic) 12.5 milligrams daily; when her blood pressure was still over 140/90 mm Hg, the doctor added enalapril (an ace-inhibitor). On this treatment, plus weight loss and exercise, her blood pressure is now 132/80 mm Hg and she feels well.

Phil Sweeney is a 62-year-old new patient. His weight was appropriate for his height. His blood pressure, however, was 175/105 mm Hg, and he had evidence of eye damage due to high blood pressure as well as an enlarged heart. On this basis, the doctor started him on two medications in view of his stage 2 high blood pressure, asked him to continue his good diet with some salt reduction, and asked him to do a little more exercise. His response has been gratifying — a reduction in the size of his heart and a drop in his blood pressure to 136/88 mm Hg. He has done some meditation as well, which seems to help. He tells me he feels like a new man.

Outlining Lifestyle Modifications

Articles 9 through 12 of this section on high blood pressure discuss suggested lifestyle changes in detail. In this section, we outline these changes so you can see the general approach to high blood pressure treatment. (See article 13 for a complete discussion of treating high blood pressure with medication.) Just for laughs . . . and your good health, I also explain how tickling your funny bone can help your blood pressure drop.

Altering your lifestyle for the better

  • The JNC 7 on Detection, Evaluation and Treatment of High Blood Pressure recommends the following lifestyle modifications:
  • Reduce saturated fat and cholesterol in your diet (article 9)
  • Maintain adequate potassium, calcium, and magnesium in your diet (articles 9 and 10)
  • Reduce salt in your diet (articles 9 and 10)
  • Lose weight (articles 9 and 12)
  • Limit alcohol intake (article 11)
  • Stop smoking or chewing tobacco (article 11)
  • Increase physical activity (article 12)
Starting with small, easy changes

The preceding list contains no surprises, with the possible exception of maintaining potassium, calcium, and magnesium. Doctors have known for years that these minerals help to lower blood pressure. So, you’re wise to get sufficient quantities of them in your diet. These suggestions can help:

For extra potassium, make sure your diet includes plenty of fruits and beans.

Milk and other dairy products can provide the calcium you need, although women often need extra calcium in supplemental form.

To make sure you’re ingesting enough magnesium, increase your intake of green leafy vegetables, nuts, seeds, and whole grains.

Check out the details on these easy steps in articles 9 and 10.

Planning realistic milestones to set the right pace

Modify your lifestyle one step at a time:

  • Start by cutting back or eliminating smoking or chewing tobacco because this habit is by far the most dangerous.
  • Move on to reducing alcohol intake.
  • Go on to strengthen your heart and body through exercise after you’ve rid yourself of these habits (or have dramatically cut back on them).

Pretend for a moment that your blood pressure is 140/85 mm Hg. You don’t have any target-organ damage, but you have several risk factors including high cholesterol and a family history of heart disease. Lifestyle changes are in order. Your doctor warns you that you must quit your pack-a-day smoking habit, drop 20 pounds, and engage in 30 minutes of aerobic activity on a daily basis. You know you can’t just turn your sedentary lifestyle around on a dime, so you chart out a plan like the one in the table below to incorporate your doctor’s advice slowly but surely over a six-month time period.

Table. Sample Plan for Lifestyle Changes
Time period Daily smoking limit Daily exercise Weight loss
Week 1 Half pack    
Week 2 5 cigarettes Walk 1/2 mile  
Week 3 1 cigarette Walk 3/4 mile  
Week 4 none Walk 1 mile  
Weeks 5 to 8 none Walk 1/2 mile & jog 1/2 mile 5 lb
Weeks 9 to 12 none Walk 1/4 mile & jog 3/4 mile 4 lb
Weeks 13 to 16 none Jog 1 mile 4 lb
Weeks 17 to 20 none Jog 1 mile 4 lb
Weeks 21 to 24 none Jog 1 mile 3 lb

Plan and then chart your progress. You may also want to keep a daily diary of how many cigarettes you actually smoke, what you eat, and how much you exercise.

Tracking success and its spiraling effects

To keep a health record, go to and click on My Health Record. You can track your blood pressure, pulse, weight, cholesterol, blood sugar, personal health records, family health records, and a health checklist. The site also has extensive information on every aspect of high blood pressure, diabetes mellitus, cholesterol, and nutrition.

As you work on each change, notice how each new healthy habit affects many of the others. For example, increasing your level of exercise invigorates you and increases your tolerance for stress; as a result, you’re less likely to smoke or drink alcohol when you want to relax. Similarly, the fewer cigarettes you smoke, the more your lung capacity increases and the easier exercising becomes without having to stop and catch your breath. These changes can help you to lose weight as well. Note: You may gain a few pounds as you stop smoking, but the benefits of stopping far outweigh (pun intended) those few pounds. Reducing the fat in your diet helps almost all the other risk factors as well. By the time you’ve gone through the list of lifestyle modifications, you’ll feel like a new person.

Using laughter to lower blood pressure

You rarely find any mention of humor in a book about high blood pressure. This is probably because humor’s place in the management of high blood pressure is so difficult to quantify, and scientists like to study only what they can measure. The effects of humor aren’t in that category. I suppose you can take two groups of people, subject one to humorous experiences and the other to nonhumorous experiences, measuring their blood pressure before and after the experiences. That experiment may tell you about the immediate consequences of humor but not its long-term effects.

Understanding how laughter is good for what ails you

People such as author Norman Cousins and Joel Goodman, the head of the Humor Project, Inc. (see more on the Internet:, advocate humor for the management of most diseases. And high blood pressure, often associated with stress, seems like a natural focus for the positive effects of humor. The psychological and physiological effects of laughter have been demonstrated in a variety of settings — like teaching situations and the corporate environment. And mirth and merriment certainly reduce stress hormone production — the hormones known to raise blood pressure.

An interesting study in the International Journal of Cardiology (August 2001) indicated an inverse relationship between the tendency to find circumstances funny and the occurrence of coronary heart disease. A survey of 300 people assessed their tendency to laugh under a variety of situations in everyday life. The people with coronary heart disease were generally not laughers. Most of those without the disease were laughers. The results suggest that a tendency to laugh protects the heart.

Adding humor to your life

The last 25 years of experience with our patients convinces us that those who experience life with a certain degree of lightness, who are unwilling to take life too seriously, do much better than those who take it too seriously. One doctor carrys a card around from Dr. Joel Goodman that says, “Someday we will laugh about this. Why wait?” For most situations, it’s an excellent prescription. Laughter signifies positive vibes to people. It adds to feelings of closeness, friendliness, and togetherness.

Even without definite proof of the value of humor, we recommend it as an important part of your high blood pressure treatment. How can you go about doing this? Find out for yourself what makes you laugh. Each person has a different source of amusement. Some people like clowns; others like standup comedians. Some prefer comedians like Eddie Murphy, and others think Woody Allen is a scream.

Here are a couple of ideas for bringing more laughter into your life:

  • Find a reference book at your local library that lists movies by categories (humor, mystery, tragedy, and so forth). Pick out a few of the top-rated comedies. You may start with Some Like It Hot, Annie Hall, Babe, Beverly Hills Cop, or Blazing Saddles. Seven Brides for Seven Brothers and Singin’ in the Rain may not make you laugh out loud (then again, they may), but you’ll come away feeling much better about life in general.

The old Marx Brothers and Bob Hope comedies or the newer stuff like the movies of Jack Black and Will Ferrell may appeal to you. Watch one of these at least once a week without fail. (No need to call me in the morning though!)

  • Find a comedian you like and listen to his or her monologues in your car. Just be careful as you drive!

Our bet is that this treatment helps bring your blood pressure down. Maybe lower blood pressure is a direct effect, or maybe humor just puts you into a good mood — a mood that helps you take your medications consistently, stay on your diet, and do your exercises. Either way, it’s easy to swallow and contains no harmful side effects!

Like the other recommendations in this article, turning yourself on to humor is a lifestyle change for most people. So what if it’s not backed up by the latest scientific evidence? You can’t find a more pleasurable lifestyle change. We remember a quote from W. H. Auden in his book, The Dyer’s Hand and Other Essays (Faber): “Among those whom I like or admire, I can find no common denominator. But among those whom I love, I can. All of them make me laugh.”