Measure Description: Percentage of patients with any ACC/AHA stage of HBP (elevated BP, stage 1 HBP, or stage 2 HBP) who have a documented discussion of intensive lifestyle modification in ≥1 visits during the measurement year
Numerator	Patients who have a documented discussion of intensive lifestyle modification at least once in the performance year and in accordance with ACC/AHA guidelines on nonpharmacological therapy
Denominator	All patients 18–85 y of age with any ACC/AHA stage of HBP (elevated BP, stage 1 HBP, or stage 2 HBP) who had at least 1 outpatient encounter with a diagnosis of HBP during the first 6 mo of the measurement year or any time before the measurement period
Denominator Exclusions	BP readings taken during an inpatient stay
Denominator Exceptions	None
Measurement Period	12 mo/measurement year
Sources of Data	Paper medical record/prospective data collection flow sheet, Qualified Electronic Health Record, QCDR, electronic administrative data (claims), expanded (multiple source) administrative data, electronically or telephonically transmitted BP readings
Attribution	Physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system
Care Setting	Outpatient (office, clinic, home, or ambulatory)
Rationale
Effective management of HBP requires intensive lifestyle modification. Dietary modification is a fundamental approach to prevention and management of elevated BP and complements pharmacological management of hypertension. The DASH diet, which is high in fruits, vegetables, potassium, calcium, magnesium, and fiber and low in saturated and total fat, has been demonstrated to be effective in lowering BP. Among those diagnosed with hypertension, the DASH diet produces, on average, overall reductions in SBP and is particularly effective among black patients.71 Conversely, among blacks, a US Southern- style diet characterized by high intake of fried foods, organ meats, processed meats, added fats, high-fat dairy foods, sugar-sweetened beverages, and bread contributes to the disproportionate burden of hypertension.72 The Mediterranean,73,74 low-carbohydrate,75 high-protein,76 and vegetarian dietary patterns77 have been demonstrated to lower BP. There is a strong and dose-dependent association between excessive alcohol consumption (>3 standard drinks per day) and BP.
There is strong evidence that adequate physical activity lowers BP. The average reductions in SBP with aerobic exercise are approximately 2–4 mm Hg and 5–8 mm Hg in adult patients who are normotensive and hypertensive, respectively. In patients with elevated BP, weight loss has been demonstrated to lower BP, with a dose-response relationship of about 1 mm Hg per kilogram of weight loss. Among patients who do not achieve weight-loss goals, pharmacological therapy or surgical procedures may be considered, with careful consideration of complications. SDM78,79 between the provider and patient should be considered in selecting specific lifestyle interventions, with consideration of the patient’s individual values, preferences, socioeconomic status, associated conditions, and comorbidities to enhance adherence to lifestyle modification.
Clinical Recommendations
2017 Hypertension Clinical Practice Guidelines4
1. A heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, that facilitates achieving a desirable weight is recommended for adults with elevated BP or hypertension.80–82 (Class 1, Level of Evidence: A)
2. Sodium reduction is recommended for adults with elevated BP or hypertension.83–87 (Class 1, Level of Evidence: A)
3. Potassium supplementation, preferably in dietary modification, is recommended for adults with elevated BP or hypertension, unless contraindicated by the presence of CKD or use of drugs that reduce potassium excretion.88–92 (Class 1, Level of Evidence: A)
4. Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than 2 and 1 standard drinks* per day, respectively.93–98 (Class 1, Level of Evidence: A)
5. Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension.87,99–105 (Class 1, Level of Evidence: A)
6. Weight loss is recommended to reduce BP in adults with elevated BP or hypertension who are overweight or obese.99,100,106,107 (Class 1, Level of Evidence: A)
7. Effective behavioral and motivational strategies to achieve a healthy lifestyle (ie, tobacco cessation, weight loss, moderation in alcohol intake, increased physical activity, reduced sodium intake, and consumption of a healthy diet) are recommended for adults with hypertension.108,109 (Class 1, Level of Evidence: C-EO)
8. Adults with an elevated BP or stage 1 hypertension who have an estimated 10-y ASCVD risk less than 10% should be managed with nonpharmacological therapy and have a repeat BP evaluation within 3 to 6 months.59,60 (Class 1, Level of Evidence: B-R)
9. Adults with stage 1 hypertension who have an estimated 10-y ASCVD risk of 10% or higher should be managed initially with a combination of nonpharmacological and antihypertensive drug therapy and have a repeat BP evaluation in 1 month.59,60 (Class 1, Level of Evidence: B-R)

^*In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CKD, chronic kidney disease; DASH, Dietary Approaches to Stop Hypertension; HBP, high blood pressure; QCDR, Qualified Clinical Data Registry; SBP, systolic blood pressure; and SDM, shared decision making.