British researcher Malcolm Law suggests that all older people should take an anti-hypertensive medication. He bases this assertion on an analysis of 147 clinical trials which showed that all classes of blood pressure-lowering drugs reduced the risk of heart attacks and strokes, even in those who were not hypertensive.

This recommendation makes some sense since many studies have shown that risk of premature cardiovascular disease increases even at somewhat higher blood pressures within the "normal" range. And because about 30 percent of those over the age of 18 (and considerably more than 50 percent of those older than age 65) have high blood pressure, this disorder is more common than the other major risk factors for premature cardiovascular disease--and so presents the greatest danger. Of concern, too, is the fact that only one-third of those with hypertension actually have their blood pressure under control.

I can't agree with Law

But because of the possible side effects and costs of anti-hypertensive drugs, I do not agree with Law's recommendation. I will say, however, that the use of medications to achieve lower blood pressure is already recommended for those with diabetes or kidney disease. And I do think that doctors should consider prescribing an anti-hypertensive drug for those persons who are at greatest risk for developing high blood pressure or cardiovascular complications.

So perhaps it's possible that the use of such drugs might be expanded to people with borderline blood pressures or with multiple other risk factors for cardiovascular disease, such as high cholesterol, cigarette smoking, and a strong family history of cardiovascular disease (and, of course, hypertension).

Lifestyle changes can prevent most cases of high blood pressure

Obviously, the best approach is to prevent high blood pressure and its complications in the first place. Results from the Nurses' Health Study reported in the July 22 issue of the Journal of the American Medical Association (JAMA) found that most women could prevent hypertension by following a healthy lifestyle and diet. (Don't fret men: Though the study was carried out in women, most of the preventive measures have also been documented in men.)

Since obesity accounted for about 40 percent of the risk for developing hypertension in this study, the most important steps to prevent high blood pressure are:

• calorie restriction and exercise to prevent obesity.
• weight loss in those who are already overweight.

Other lifestyle and dietary measures to consider include the following (in order of importance, according to this study):

• Avoid the daily use of over-the-counter analgesics like acetaminophen (Tylenol®), and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil®) and naproxen (Aleve®), since these can elevate blood pressure. (Also heed the recent warnings that high daily doses of acetaminophen are associated with liver disease.) Notably, aspirin has not been implicated in raising the blood pressure.
• Follow the DASH diet, which is low in sodium and rich in fruits, vegetables, and low-fat dairy products. (See High Blood Pressure: Using the DASH diet.)
• Engage in at least 30 minutes of vigorous exercise daily. Besides working off weight, exercise will also lower blood pressure independent of its effects on weight.
• Don't drink too much alcohol. According to major studies, the ideal intake for heart health is 1 drink per day for women and 2 drinks daily for men.
• Take a daily supplement of 400 μg of folic acid per day. (This last recommendation has the least supporting evidence, and I'm not an advocate of taking folic acid except during pregnancy.)