text:
High blood pressureHypertension
An in-depth report on the causes, diagnosis, treatment, and prevention of high blood pressure.
Blood Pressure Measurements
Blood pressure is measured in millimeters of mercury (mm Hg). The higher numberis the systolic blood pressure, the pressure in your arteries while your heart is pumping blood. The lower number is the diastolic blood pressure, the pressure when your heart is relaxing and refilling with blood between beats. For adults:
- Normal blood pressure readings are below 120/80 mm Hg.
- High blood pressure (hypertension) is generally considered to be a blood pressure reading greater than or equal to 140 mm Hg (systolic) or greater than or equal to 90 mm Hg (diastolic).
- Blood pressure readings in the prehypertension category (120 -139 systolic or 80 - 89 diastolic) indicate an increased risk for developing hypertension.
- A blood pressure reading below 140/90 mm Hg should be the minimum goal for everyone. People with certain health conditions (heart disease, peripheral artery disease) may benefit from a lower target goal.
Blood Pressure Screening Guidelines
Current guidelines from the U.S. Preventive Services Task Force recommend that all adults, ages 18 and older, have their blood pressure measured.
The U.S. Preventive Services Task Force also recommends that allpeople with blood pressure readings of 135/80 mm Hg or higher be screened for type 2 diabetes. (The American Diabetes Association recommends diabetes screening forpeople with blood pressure greater than 140/90.)
Home Blood Pressure Monitoring
Mostpeople with high blood pressure will benefit from monitoring their blood pressure at home on a regular basis. Home monitoring can help show if blood pressure medications are working or if they need to be adjusted.
Lifestyle Changes and High Blood Pressure
Lifestyle changes are important for preventing and treating high blood pressure. Healthy choices include:
- Maintaining a normal weight
- Exercising regularly
- Quitting smoking
- Limiting alcohol consumption to no more than one or two drinks a day
- Reducing sodium (salt) intake
- Increasing potassium intake
The DASH diet is a plan proven to improve blood pressure.
Medications for High Blood Pressure
Drug treatment for high blood pressure is tailored to the individual. There are many different types of blood pressure medications. Although some people need only one drug to control blood pressure, recent guidelines from the American College of Cardiology and the American Heart Association recommend a combination of two or more medications forpeople with blood pressure above 140/90 mm Hg.
Blood pressure measurements can fluctuate throughout the day and in different environments. The decision to start or increase blood pressure medications should not be based on a single blood pressure reading. To obtain the most accurate estimate of your true blood pressure, your doctor will use an average of multiple readings. These may include repeated readings made in the doctor's office as well as blood pressure measurements you performed at home.
High blood pressure, also called hypertension, is elevated pressure of the blood in the arteries. Hypertension results from two major factors that can occur independently or together.
- The heart pumps blood with excessive force.
- The body's smaller blood vessels (known as the arterioles) narrow so that blood flow exerts more pressure against the vessels' walls.
Blood pressure is the force applied against the walls of the arteries as the heart pumps blood through the body. The pressure is determined by the force and amount of blood pumped and the size and flexibility of the arteries.
High blood pressure makes the body's heart work harder, which over time can lead to damage in blood vessels throughout the body. Damaged blood vessels affect function in the heart, kidneys, brain, and eyes.
Two numbers are used to describe a blood pressure reading:
- Systolic blood pressure (the first and higher number) is the force that blood exerts on the artery walls as the heart contracts to pump out the blood. It shows the pressure in the arteries when the heart is beating.
- Diastolic blood pressure (the second and lower number) is the measurement of force as the heart relaxes to allow the blood to flow into the heart. It shows the pressure in the arteries when the heart is resting between heartbeats.
A third number, pulse pressure, is the difference between the systolic and the diastolic readings. It indicates stiffness and inflammation in blood vessel walls. The greater the difference between systolic and diastolic numbers, the greater the risk to health.
Hypertension Categories
There are a number of ways to categorize or describe hypertension.
- Primary hypertension, also called essential or idiopathic hypertension, is high blood pressure without a known cause. About 90% of all high blood pressure cases are this type.
- Secondary hypertension is high blood pressure caused by an underlying medical condition, such as kidney or endocrine disorders. It comprises about 5% of high blood pressure cases.
Doctors may also categorize hypertension based on what portion of the blood pressure reading is abnormal:
- Isolated systolic hypertension occurs when systolic pressure is high (over 139 mm Hg) but diastolic pressure is normal (under 90 mm Hg). It is related to arteriosclerosis (hardening of the arteries). Isolated systolic hypertension is the most common form of hypertension in people older than age 50.
- Diastolic hypertension refers to an elevated diastolic blood pressure reading (over 89 mm Hg). This subtype is most common inpeople age 30 - 50.
Blood Pressure Guidelines
Blood pressure is measured in millimeters of mercury (mm Hg). Blood pressure is categorized as:
- Normal blood pressure is below 120/80 mm Hg.
- Prehypertension blood pressure (120 -139 systolic or 80 - 89 diastolic) indicates an increased risk for developing high blood pressure.
- High blood pressure (hypertension) is greater than or equal to 140 mm Hg (systolic) or greater than or equal to 90 mm Hg (diastolic). Hypertension is further divided into stages 1 and 2 depending on severity.
Blood Pressure Ranges
Blood Pressure Category
Ranges for Most Adults (systolic/diastolic)
Normal Blood Pressure (systolic/diastolic)
Systolic below 120 mm Hg
Diastolic below 80 mm Hg
Systolic 120 - 139 mm Hg
Diastolic 80 - 89 mm Hg
(NOTE: 139/89 or below should be the minimum goal for everyone. People with heart disease or peripheral artery disease may benefit from levels of 130/80 or less. Blood pressure goals are being reexamined for African-Americans and for people with diabetes and chronic kidney disease.)
Mild Hypertension (Stage 1)
Systolic 140 - 159 mm Hg
Diastolic 90 - 99 mm Hg
Moderate-to-Severe Hypertension (Stage 2)
Systolic over 160 mm Hg or
Diastolic over 100 mm Hg
NOTE: If one of the measurements is in a higher category than the other, the higher measurement is usually used to determine the stage. For example, if systolic pressure is 165 (Stage 2) and diastolic is 92 (Stage 1), the person would still be diagnosed with Stage 2 hypertension. A high systolic pressure compared to a normal or low diastolic pressure should be a major focus of concern in most adults.
Blood Pressure in Children
For children, blood pressure readings are based on percentile ranges for a child's body size. Hypertension in children is defined as average systolic and diastolic readings that are greater than the 95th percentile for gender, age, and height on at least three occasions.
Prehypertension in children is diagnosed when average systolic or diastolic blood pressure levels are at least in the 90th percentile, but less than the 95th percentile. For adolescents as with adults, blood pressure readings greater than 120/80 are considered prehypertensive. Increasing rates of childhood obesity have led to higher rates of hypertension and prehypertension among children and adolescents.
Causes of Primary Hypertension
Hypertension is referred to as primary (essential) when the doctor is unable to identify a specific cause. It is by far the most common type of high blood pressure. Primary hypertension may be due to a combination of genetic, environmental, and other factors.
Genetic factors. A number of genetic factors or interactions between genes play a major role in primary hypertension. Genes under investigation include:
- Genes that regulate a group of hormones known collectively as the angiotensin-renin-aldosterone system. This system influences all aspects of blood pressure control, including blood vessel contraction, sodium and water balance, and cell development in the heart.
- Genes that cause abnormalities of the sympathetic nervous system. This is the part of the autonomic nervous system that controls heart rate, blood pressure, and the diameter of the blood vessels.
Causes of Secondary Hypertension
Secondary hypertension is caused by an underlying medical condition or other factor (such as medications) that elevates blood pressure. Many different medical conditions are associated with secondary hypertension. These conditions can also make high blood pressure more difficult to control.
Diabetes. Hypertension is strongly associated with diabetes, both types 1 and 2. Kidney damage (diabetic nephropathy) is generally the cause of high blood pressure in people with diabetes.
Kidney disease. Kidney disease is the most common cause of secondary hypertension, particularly in older people. In addition to diabetic nephropathy, many other types of kidney diseases can cause hypertension. Renal artery stenosis involves the narrowing of the renal artery and is usually caused by atherosclerosis. Other types of kidney disease associated with hypertension are polycystic kidney disease and renal parenchymal disease.
Coarctation of the aorta.This is a birth defect that causes narrowing of the aorta, the main artery of the heart.
Endocrine disorders. Adrenal tumors (pheochromocytoma, aldosteronism), thyroid disorders, and Cushing syndrome can all cause secondary hypertension.
Medications. Many different prescription and over-the-counter drugs can temporarily raise blood pressure or worsen existing high blood pressure, including:
- Corticosteroids when given by mouth or intravenously
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin, generic), naproxen (Aleve, generic), and aspirin
- Cold medicine decongestants containing pseudoephedrine can increase blood pressure in people with high blood pressure, although they appear to pose no danger for those with normal blood pressure.
- Oral contraceptives (birth control pills) increase the risk for high blood pressure, particularly in women who are older than 35 years, obese, smokers, have strong family history of hypertension, or some combination of these factors. Stopping the pill nearly always reduces blood pressure.
Risk Factors
In the United States, about 1 in 3 adults has high blood pressure.Many people with high blood pressure don't knowthey have it.
About 30% of American adults have prehypertension (blood pressure ranges from 120 - 139/80 - 89 mm Hg). People who are diagnosed with prehypertension are at increased risk of developing high blood pressure.
Age and Gender
Age is the major risk factor of hypertension. Men over age 45 and women over age 55 are at increased risk for high blood pressure. Over half of Americans over age 60 have hypertension. After age 65, high blood pressure affects more women than men.Hypertension is also becoming more common in children and teenagers. Among younger people, boys are at higher risk for high blood pressure than girls.
Race and Ethnicity
Compared to Caucasians and other ethnic groups, African-Americans are more likely to have high blood pressure. More than 40% of African-American men and women have hypertension. (African-American women have a higher risk than African-American men.)High blood pressure tends to start at a younger age among African-Americans, is often more severe, and causes greater risks for premature death from heart attack, stroke, heart failure, and kidney failure.
Family History
People with parents or other close relatives who have high blood pressure have an increased risk of developing it themselves.
About a third of people with high blood pressure are overweight. Even moderately obese adults have double the risk of hypertension than people with normal weights. Children and adolescents who are obese are at increased risk for high blood pressure when they reach adulthood.
Obstructive Sleep Apnea
Obstructive sleep apnea, a disorder in which breathing halts briefly but repeatedly during sleep, is present in manypeople with hypertension. The relationship between sleep apnea and hypertension has been thought to be largely due to obesity. But studies are finding a higher rate of hypertension in people with sleep apnea regardless of their weight.
Lifestyle Factors
Smoking. Cigarette smoking is a major risk factor for high blood pressure.
Sodium (salt) and potassium. Eating too much sodium (salt) can increase the risk for developing high blood pressure. Similarly, a diet that is too low in potassium can make the body accumulate too much sodium. Sodium and potassium are important regulators of fluid balance in cells.
Alcohol. Chronic heavy alcohol use can increase blood pressure. Women may be more sensitive than men to the blood pressure effects of alcohol.
Physical inactivity. A sedentary lifestyle and lack of physical activity can increase the risk of becoming overweight.
Stress. Mental and emotional stress can cause a temporary increase in blood pressure. Chronic stress can lead to engaging in unhealthy behaviors (overeating, smoking, alcohol use, lack of exercise) that contribute to high blood pressure.
High blood pressure, or hypertension,is a disorder characterized by chronically high blood pressure. It must be monitored, treated, and controlled by medication, lifestyle changes, or a combination of both.
High blood pressure places stress on several organs (called target organs), including the kidneys, eyes, and heart. The stress causes them to deteriorate over time.
High blood pressure contributes to 75% of all strokes and heart attacks. It is particularly deadly in African-Americans.
Combined with significantly high blood pressure, other risk factors can increase the likelihood of complications. These risk factors include:
- Increasing age
- Smoking
- Abnormal cholesterol levels
- Family history of premature heart disease
- Obesity
- Diabetes
- Coronary artery disease, or other evidence of vascular disease
Heart Complications
High blood pressure is a major risk factor for hypertensive heart disease, the leading cause of illness and death from high blood pressure. Hypertensive heart disease is a group of complications that include:
- Coronary artery disease. High blood pressure contributes to the thickening of the blood vessel walls, which can cause or worsen atherosclerosis (accumulated deposits of cholesterol in the blood vessels). The end result is coronary artery disease (CAD), also called ischemic heart disease. CAD increases the risk for angina (chest pain), heart attack, stroke, and death. High blood pressure is the most common risk factor for heart attack and stroke.
- Heart failure. High blood pressure increases the heart's workload. Over time, this can cause the heart muscle to thicken (cardiac hypertrophy), which makes it more difficult for the heart to pump out sufficient blood. This process can eventually lead to heart failure.
- Cardiac arrhythmias. High blood pressure increases the risk for cardiac arrhythmias (disturbances and irregularities in heartbeats). Arrhythmias include atrial fibrillation, premature ventricular contractions, and ventricular tachycardia.
About two-thirds of people who suffer a first stroke have moderate elevated blood pressure (160/95 mm Hg or above). Hypertensive people have up to 10 times the normal risk of stroke, depending on the severity of the blood pressure in the presence of other risk factors. Hypertension is also an important cause of silent cerebral infarcts, which are blockages in the blood vessels in the brain (mini-strokes) that may predict major stroke or progress to dementia over time.
Diabetes and Kidney Disease
Diabetes. High blood pressure, and some of the medications used to treat it, can increase the risk for developing diabetes. There are strong biologic links between insulin resistance (with or without diabetes) and hypertension. It is unclear if one condition causes the other.
In general, people with diabetes should strive for blood pressure levels of less than 140/90 mm Hg (systolic/diastolic). For some people, especially younger people, a systolic blood pressure goal of less than 130 mm Hg may be appropriate. People with diabetes and high blood pressure need an individualized approach to drug treatment, based on their particular health profile.
The United States Preventive Services Task Force recommends screening for type 2 diabetes in all people with blood pressure higher than 135/80 mm Hg.
End-stage kidney disease. High blood pressure causes about30% of all cases of end-stage kidney disease (referred to as end-stage renal disease, or ESRD). Only diabetes leads to more cases of kidney failure.People with diabetes and hypertension need to be monitored very closely for the development of kidney disease.
Isolated systolic hypertension may pose a particular risk for dementia, or memory loss.
Eye Damage
High blood pressure can injure the blood vessels in the eye's retina, causing a condition called retinopathy.
Sexual Dysfunction
Sexual dysfunction is more common and more severe in smokers and men with hypertensionthan it isin the general population. Although older drugs used to treat hypertension caused erectile dysfunction as a side effect, the disease process that causes hypertension is itself a major cause of erectile dysfunction.
Oral phosphodiesterase type 5 (PDE5) inhibitors -- such as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra) -- do not appear to pose a risk for most men who have both high blood pressure and erectile dysfunction. But men who have uncontrolled or unstable hypertension should not take these medications.
Men who take nitrate medications for heart disease cannot take erectile dysfunction pills.
Pregnancy and High Blood Pressure
Many women who are likely to develop hypertension when they are older have their first elevated blood pressure readings during pregnancy. Elevated blood pressure readings generally show up early in pregnancy, before 16 - 20 weeks. These women often require antihypertensive medications during pregnancy and closer monitoring of themselves and the fetus. Continued hypertension after the pregnancy is also not uncommon.
Severe and sudden high blood pressure in pregnant women is one component of a condition called preeclampsia (also called toxemia) that can be very serious for both mother and child. Preeclampsia occurs in up to 10% of all pregnancies, usually in the third trimester of a first pregnancy, and resolves immediately after delivery. Other symptoms and signs of preeclampsia include protein in the urine, severe headaches, and swollen ankles.
The reduced supply of blood to the placenta can cause low birth weight and eye or brain damage in the fetus. Severe cases of preeclampsia can cause kidney damage, convulsion, and coma in the mother and can be lethal to both mother and child. Women at risk for preeclampsia (particularly those with existing hypertension) are monitored carefully for its presence. Both mother and fetus are monitored closely after a diagnosis. Blood pressure medications may be required.
Delivery is the main cure for preeclampsia. In severe cases, the obstetrician will need to induce pre-term birth.
High blood pressure increases slowly over the years. It is often called the "silent killer" because it usually produces no symptoms until vital organs are damaged, like the heart, brain, and kidneys.
Everyone, 18 years and older, should have their blood pressure measured on a regular basis. It is particularly important for anyone with risk factors to have their blood pressure checked regularly and to make appropriate lifestyle changes. Such recommendations are especially important for people who:
- Have prehypertension or hypertension
- Have a family history of hypertension
- Are overweight
- Are over age 40
Symptoms of Malignant Hypertension
Malignant hypertension is very high blood pressure that comes on suddenly and quickly. The lower (diastolic) blood pressure reading, which is normally around 80 mm Hg, is often above 130 mm Hg. This rare disorder affects about 1% of people with high blood pressure, including both children and adults. It is more common in younger adults, especially African-American men.
Malignant hypertension is a life-threatening condition and must be treated immediately. People with uncontrolled hypertension or a history of heart failure are at increased risk for this crisis.
People should call a doctor immediately if these symptoms occur:
- Drowsiness
- Confusion
- Headache
- Nausea
- Loss of vision
- Difficulty breathing
Most physical exams at the doctor's office include a blood pressure reading. People should not smoke, exercise, or drink caffeinated beverages within 30 minutes before their blood pressure measurement.
Measuring Blood Pressure
The standard instrument used to measure blood pressure is called a sphygmomanometer, more often referred to as a blood pressure cuff. Measurements are given as units of mercury, which was used to fill the central column in standard sphygmomanometers for many years. Modern devices do not use mercury.
- While seated with your back supported, an inflatable cuff with a meter attached is placed around your upper arm, over the artery. The arm being used for measurement is around the level of your heart. The inflated cuff briefly interrupts the flow of blood in your artery, which then resumes as the cuff is slowly deflated.
- As the cuff is slowly deflated, the person taking your blood pressure listens to the blood pumping through the artery with a stethoscope.
- The first pumping sound is recorded as the systolic pressure, and the last sound is the diastolic pressure.
- If a first blood pressure reading is above normal, the health professional may take two or more measurements separated by 2 minutes with you sitting or lying down. Another measurement may be taken after you have been standing for 2 minutes. If the measurements are still elevated, your health care provider should take blood pressure readings from both arms.
Decisions on starting or increasing medications should be based on multiple blood pressure readings, taken at both the doctor's office and at home.
Although this test has been used for more than 90 years, it is not completely accurate or sensitive. The following factors can cause a falsely low pressure reading:
- An arm cuff that is too wide
- Dehydration
Falsely high pressure readings can result from:
- An arm cuff that is too small
- Stress
- Recently consuming foods or beverages (such as coffee) that raise blood pressure
- Recent tobacco exposure
- Recent exercise
Blood pressure readings taken by a doctor are more likely to be higher than readings measured at home. This can be due to "white coat hypertension," which is blood pressure that is only elevated during a doctor's office visit. People with white coat hypertension have:
- High readings in the doctor's office
- Daytime blood pressure readings away from the doctor's office of less than 135/85 mg Hg
- No evidence of complications of blood pressure elsewhere in the body
These people may require additional blood pressure monitoring.
Ambulatory Monitoring
Doctors may ask some people to use a special ambulatory monitoring device for a 24-hour period. The device checks blood pressure about every 15 - 30 minutes during the day and night and provides a read-out of blood pressure measurements for the doctor. Ambulatory monitoring may be used for people who have borderline high blood pressure or for those who have had difficulty keeping their blood pressure under control. It can also help distinguish between true and white coat hypertension and it can detect masked hypertension (readings that are normal in a doctor's office but high during daily life). Ambulatory monitoring can also be helpful for diagnosing children with suspected high blood pressure.
Home Monitoring
The American Heart Association (AHA) recommends that all people with high blood pressure monitor their blood pressure at home on a regular basis. In addition to other benefits, home monitoring can help show if blood pressure medications are working.
The AHA recommends:
- Purchase a blood pressure monitor with cuffs that fit on the upper arm. Wrist monitors are not recommended. Make sure that the cuff is the right size. One size does not fit all.
- Ask your doctor to show you the proper way to use the monitor. Your arm should be supported with your upper arm at heart level, your feet on the floor, back supported, and legs uncrossed.
- Take two or three readings at a sitting, 1 minute apart, while resting in a seated position. It is important to take the readings at the same time each day. Your doctor may suggest specific times your readings should be taken.
- The target goal of a reading is under 135/85 mm Hg or less than 130/80 mm Hg in high-risk people.
Blood pressure variations at home. In general, everyone's blood pressure varies throughout the day. In monitoring at home, it is important to note that blood pressure is usually highest from morning to mid-afternoon. Upon waking, blood pressure in most people typically increases suddenly. Early morning is the highest risk period for heart attack and stroke.
Blood pressure normally dips to its lowest level during sleep, although some people (particularly postmenopausal women) have a condition called non-dipper hypertension, in which blood pressure does not fall at night.
Physical Examination for Complications of Hypertension
If your blood pressure is elevated, the doctor will:
- Check your pulse rate
- Examine the back of your eyes
- Examine your neck for distended veins or an enlarged thyroid gland
- Check your heart for enlargement and murmurs
- Examine your abdomen
- Check your leg pulses
Medical History
If hypertension is suspected, your doctor may ask about:
- Your family and personal medical history, especially relating to high blood pressure, stroke, heart problems, kidney disease, or diabetes.
- Risk factors for heart disease and stroke, including tobacco use, salt intake, obesity, physical inactivity, and unhealthy cholesterol levels.
- Any medications you are taking.
- Any symptom that might indicate secondary hypertension (high blood pressure caused by another disorder). Such symptoms include headache, heart palpitations, excessive sweating, muscle cramps or weakness, or excessive urination.
- Any emotional or environmental factors that could affect blood pressure.
Laboratory and Other Tests
If a physical examination indicates hypertension, additional tests may help determine whether organ damage is present.
Blood tests and urinalysis. These tests are performed to check for a number of factors, including:
- Potassium levels
- Cholesterol
- Blood sugar (to screen for diabetes)
- Infection
- Kidney function
Measuring blood levels of the protein creatinine, for example, is important for all hypertensive people in order to determine kidney damage.
Tests to evaluate the heart. These tests include:
- An electrocardiogram (ECG) in the doctor's office.
- An exercise stress test for people who also have symptoms of coronary artery disease (CAD).
- An echocardiogram, when it would help the doctor decide whether to start treatment. Most of the time this test is not necessary for people who have only hypertension and no other symptoms.
Tests to evaluate the kidneys. These tests include:
- A Doppler or duplex test to see whether one of the arteries supplying blood to the kidney is narrowed, a condition called renal artery stenosis.
- An ultrasound to examine the kidneys.
Peoplewith hypertension should work with their doctors to set blood pressure goals based on their individual risk factors, including:
- Family history of heart disease
- Smoking
- Unhealthy cholesterol and lipid levels
- Diabetes
- Age, especially people over 60
The decision to start or increase blood pressure medications should not be based on a single blood pressure reading in the doctor's office, but on repeated readings. Your doctor may ask you for a list of your home blood pressure readings to help provide a more accurate estimate of your true blood pressure. It may be necessary to check blood pressure as many as five or six times to get the best estimate.
Drug treatment must be individualized. In some people, a single-drug regimen can control mild to moderate hypertension. But the latest guidelines recommend combination therapy with two or more drugs if a person's blood pressure remains above 140/90 mm Hg despite lifestyle changes (diet, exercise, and weight control).
Drug Treatment
Each drug has specific benefits. But their effects may vary depending on the individual. The major anti-hypertensive medications fall into the following 5 categories:
- Diuretics rid the body of extra water and salt. Thiazide diuretics are usually the first-line treatment for high blood pressure.
- Beta blockers block the effects of adrenaline and ease the heart's pumping action.
- Angiotensin converting enzyme (ACE) inhibitors reduce the production of angiotensin, a chemical that causes arteries to narrow.
- Angiotensin-receptor blockers (ARBs) block the action of angiotensin.
- Calcium-channel blockers (CCBs) decrease the contractions of the heart and widen blood vessels.
Side effects and problems in compliance. One of the most difficult issues that people face is that the treatment may make them feel worse than the disease, which usually has no symptoms. Whatever the difficulties, compliance with a drug and lifestyle program is worth the effort. It is very important to discuss any medication concerns with your doctor. If your current blood pressure drugs are causing uncomfortable side effects, your doctor may adjust your dosages or combinations.
Withdrawal from anti-hypertensive medications. People whose blood pressure has been well-controlled and who are able to maintain a healthy lifestyle may be able to withdraw from medications. They should do so in a step-down manner (gradual reduction) and be monitored regularly. Stopping too quickly can have adverse effects, including serious effects on the heart. People who are most likely to stop using medications include
- Those who were able to lose weight and reduce sodium intake
- Those treated with a single drug
- Those who maintained lower systolic blood pressure during treatment
People over 75 years old may have more trouble than younger adults maintaining normal blood pressure after withdrawal.
Treatment of Resistant Hypertension
Some people are unable to meet target blood pressure goals despite consistently following a treatment plan that includes three or more medications. Factors that contribute to treatment resistant hypertension include:
- Older age (especially age 75 or older)
- High baseline blood pressure
- Medical conditions such as obesity, sleep apnea, diabetes, and chronic kidney disease
Treating any underlying medical condition is important for helping control blood pressure. People should be sure to adhere to healthy lifestyle changes and may require modifications to their drug regimens. Those with severe resistant hypertension should consult with a doctor who specializes in treating high blood pressure.
Treatment of Older Adults
High blood pressure is very common in older adults and can be challenging to control. In general, older adults usually have an elevated systolic blood pressure and a normal or low diastolic blood pressure, a condition known as isolated systolic hypertension.
Medications can be very effective for controlling high blood pressure in older adults, even in those over age 80. The choice of medications will depend in part on a person's history of other heart problems. Blood pressure drugs prescribed for older people are generally started at the lowest dose and then gradually increased as necessary. As with all people with high blood pressure, lifestyle changes are an essential component of treatment.
Older adults should have their blood pressure monitored on a regular basis. Blood pressure readings should be taken while in a standing position, as well as while seated.
Treatment of Children
Results of studies evaluating outcomes of children with hypertension suggest that early abnormalities, including anenlarged heart and abnormalities in the kidney and eyes, may occur even in children with mild hypertension. Children and adolescents with hypertension should be monitored and evaluated for any early organ damage. Secondary hypertension (high blood pressure due to another disease or drug) is more common in children than adults.
Children with high blood pressure should first be treated with lifestyle changes, including:
- Weight reduction
- Increased physical activity
- Diet modification
If blood pressure is not controlled with lifestyle changes, drug treatment may be required.
Lifestyle Changes
Healthy lifestyle changes are an important first step for lowering blood pressure. Current guidelines recommend that people should:
- Exercise at least 30 minutes a day.
- Maintain normal weight.
- Reduce sodium (salt) intake.
- Increase potassium intake.
- Limit alcohol consumption to no more than one or two drinks a day.
- Consume a heart-healthy diet rich in fruits, vegetables, and low-fat dairy products while reducing total and saturated fat intake. (The DASH diet is one way to reach this goal.)
- Quit smoking.
Restricting Sodium (Salt)
In general, everyone should restrict their sodium intake to no more than 2,300 mg a day (less than 1 teaspoon of salt). This is particularly important for people over age 50, all African-Americans, and everyone with high blood pressure. The American Heart Association recommends that people with heart disease risk factors limit sodium intake to no more than 1,500 mg a day (about ½ teaspoon). Sodium restriction lowers blood pressure and also helps protect against heart failure and heart disease.
Some people are salt sensitive. This means their blood pressure responds much more to salt than other people. People with salt sensitivity have a higher than average risk of developing high blood pressure, as well as other heart problems. Sodium restriction is particularly important for people with salt sensitivity, which includes:
- African-Americans
- Older adults
- People with diabetes
- Overweight people
- People with a family history of hypertension
Salt substitutes such as Nu-Salt and AlsoSalt are available. But they can be risky for people with kidney disease or those who take blood pressure medications that can cause potassium retention.
Some tips for lowering your salt and sodium intake include:
- Look for foods that are labeled low-sodium, sodium-free, no salt added, or unsalted. Check the total sodium content on food labels. Be especially careful of canned, packaged, frozen, and processed foods. A nutritionist can teach you how to understand these labels.
- Don't cook with salt or add salt to what you are eating. Instead, try pepper, garlic, lemon, or other spices for flavor, such as salt-free blends from McCormick or Mrs. Dash. Be sure to read the ingredients on packaged spice blends. They may contain salt or salt products (like monosodium glutamate, MSG).
- Avoid processed meats, especially cured meats, bacon, hot dogs, sausage, bologna, ham, and salami.
- Avoid foods that are naturally high in sodium, like anchovies, nuts, olives, pickles, sauerkraut, soy and Worcestershire sauces, tomato and other vegetable juices, and cheese.
- Take care when eating out. Stick to steamed, grilled, baked, boiled, and broiled foods with no added salt, sauce, or cheese.
- On salads, use oil and vinegar, rather than bottled dressings.
- Eat fresh fruit or sorbet for dessert.
Increasing Potassium
A potassium-rich diet may help reduce blood pressure. Potassium-rich foods include:
- Bananas
- Oranges
- Pears
- Prunes
- Cantaloupes
- Tomatoes
- Dried peas and beans
- Nuts
- Potatoes
- Avocados
The recommended daily intake of potassium is 3,500 mg a day for people without risk factors for excess potassium levels.
Some people may need to take potassium supplements. However, people who take medications that limit the kidney's ability to excrete potassium, such as ACE inhibitors, digoxin, or potassium-sparing diuretics, should not take potassium supplements and should be aware of excess potassium in their diet.
DASH Diet
The salt-restrictive DASH diet (Dietary Approaches to Stop Hypertension) is proven to help lower blood pressure, and may have additional benefits for preventing heart disease and stroke. Effects on blood pressure are sometimes seen within a few weeks. This diet is not only rich in important nutrients and fiber but also includes foods that contain far more potassium (4,700 mg/day), calcium (1,250 mg/day), and magnesium (500 mg/day), and much less sodium (salt) than the typical American diet.
DASH diet recommendations include:
- Limit sodium (salt) intake to no more than 2,300 mg a day. Some people may benefit from reducing sodium intake to no more than 1,500 mg a day.
- Reduce saturated fat intake to no more than 6% of daily calories and total fat to 27% of daily calories.
- Include dairy products that are non- or low-fat. Low-fat dairy products appear to be especially beneficial for lowering systolic blood pressure.
- When choosing fats, select monounsaturated oils, such as olive or canola oils.
- Choose whole grains over white flour or pasta products.
- Choose fresh fruits and vegetables every day. Many of these foods are rich in potassium, fiber, or both.
- Eat nuts, seeds, or legumes (dried beans or peas) daily.
- Choose modest amounts of protein (no more than 18% of total daily calories). Fish, skinless poultry, and soy products are the best protein sources.
- Limitcarbohydrates to 55% of daily calories.
- Limit daily dietary cholesterol intaketo 150 mg.
- Try to get at least 30 g of daily fiber.
Other Dietary Considerations
Fiber. Increasing fiber in the diet may help reduce blood pressure levels.
Fish oil and omega-3 fatty acids. The omega-3 fatty acids docosahexaenoic acid (DHA) and eicosapentaneoic acids (EPA) are found in oily fish. Studies indicate that omega-3s from diet may have benefits for many medical conditions, including heart disease and hypertension. They help keep blood vessels flexible and may help protect the nervous system. Omega-3 fatty acids are also available in supplement form. Buteating fish protects the heart more than taking fish oil supplements.
Calcium. Hypertension increases calcium loss from the body. Calcium regulates the tone of the smooth muscles lining blood vessels. Studies have found that people who consume adequate dietary calcium on a daily basis have lower blood pressure than those who do not.
Consuming too much dietary calcium may have a negative effect: Some studies indicate that excess calcium intake (from dietary or supplement sources) may increase blood pressure and other heart disease risk factors.
Weight Loss
Even modest weight loss in overweight people, particularly in the abdominal area, can immediately lower blood pressure. When accompanied by salt restriction, weight loss may allow people with mild hypertension to safely reduce or go off medications. The benefits of weight loss on blood pressure are long-lasting.
Regular exercise helps keep arteries elastic, even in older people. This ensures blood flow and normal blood pressure. Doctors recommend at least 30 minutes of exercise on most days.
High-intensity exercise may not lower blood pressure as effectively as moderate intensity exercise and may be dangerous in people with hypertension. Older people and those with uncontrolled hypertension or other serious medical conditions should check with their doctors before starting an exercise program.
Quit Smoking
Everyone should quit smoking, especially people with high blood pressureand other heart disease risk factors.
Good Sleep Habits
Certain sleep disorders, especially sleep apnea, are associated with hypertension. Even chronic, insufficient sleep may raise blood pressure in people with hypertension, placing them at increased risk of heart disease and death. Stress hormone levels increase with sleeplessness, which can activate the sympathetic nervous system, a strong player in hypertension.
People who have chronic insomnia or other severe sleep disturbances may want to consult a doctor who specializes in sleep disorders. People with hypertension who are habitually poor sleepers should consider long-acting blood pressure medications to help counteract the increase in blood pressure that occurs in the early morning hours.
Stress Reduction
Stress reduction may help blood pressure control. Yoga, Tai chi, and relaxation techniques such as meditation may be beneficial.
Several classes of drugs are used to treat hypertension.
Diuretics help the kidneys get rid of excess salt and water. Thiazide diuretics are the mainstays of anti-hypertensive therapy and are often the first type of drug selected for most people with hypertension. They are also especially helpful for treating people with heart failure, people with isolated systolic hypertension, the elderly, and African-Americans. (African-Americans are more likely to be salt-sensitive, so they respond well to these drugs.) They also work well for people with diabetes. Diuretics are often used in combination with other antihypertensive drugs.
There is strong evidence that diuretics work just as well as newer drugs in lowering blood pressure and are more effective in preventing heart failure, heart attack, and stroke.
The3 main types of diuretics include:
- Thiazide diuretics. These include chlorothiazide (Diuril), chlorthalidone (Thalitone, Clorpres), indapamide (Lozol), hydrochlorothiazide (HydroDiuril), bendroflumethiazide (Naturetin), methylclothiazide, (Enduran), and metolazone (Zaroxolyn). All of these prescription drugs are available in generic form. In most cases, thiazides are preferred to other diuretics for treatment of high blood pressure. Some recent research favors chlorthalidone.
- Potassium-sparing diuretics. These include amiloride (Midamor, generic), spironolactone (Aldactone, generic), and triamterene (Dyrenium, generic).
- Loop diuretics. Because loop diuretics act faster than other diuretics it is important to avoid dehydration and potassium loss. Loop diuretics include bumetanide (Bumex, generic), furosemide (Lasix, generic), ethacrynic acid (Edecrin, generic), and torsemide (Demadex, generic).
Loop and thiazide diuretics reduce the body's supply of potassium (hypokalemia), which, if left untreated, increases the risk for arrhythmias. Arrhythmias are heart rhythm disturbances that can lead to cardiac arrest, although they rarely do. If you experience reduced potassium, your doctor will prescribe a lower dose ofyour current diuretic, recommend potassium supplements, or switch to a potassium-sparing diuretic either alone or in combination with a thiazide.
- Potassium-sparing drugs have their own risks, which include dangerously high levels of potassium in people with existing elevated levels of potassium or in those with damaged kidneys. However, all diuretics are generally more beneficial than harmful.
- Thiazide diuretics may increase blood sugar levels.
- Erectile dysfunction (impotence) may be a side effect of thiazides.
- Elevated uric acid levels, and possibly gout, may be caused by thiazide diuretics.
Common diuretic side effect symptoms include:
- Fatigue
- Depression and irritability
- Urinary incontinence
- Reduced sexual drive and problems with obtaining and maintaining an erection
Beta Blockers
Beta blockers help slow your heart rate and lower blood pressure. They are usually used in combination with other drugs such as ACE inhibitors and diuretics. Beta blockers are more likely to be used to treat hypertension in people with angina, previous heart attack, arrhythmias with fast heart rates, or migraine headaches. With careful use, they can be beneficial for people with heart failure.
Brands. Propranolol (Inderal), acebutolol (Sectral), atenolol (Tenormin), betaxolol (Kerlone), carteolol (Cartrol), metoprolol (Lopressor), nadolol (Corgard), penbutolol (Levatol), pindolol (Visken), carvedilol (Coreg), timolol (Blocadren), and nebivolol (Bystolic). The drugs may differ in their effects and benefits. With the exception of nebivolol, all of these drugs are available in generic form.
When taking beta blockers:
- Do NOT suddenly stop taking these drugs. The sudden withdrawal of beta blockers can rapidly increase heart rate and blood pressure and potentially cause angina or heart attack. If you need to stop your beta blocker, yourdoctor may want you to slowly decrease the dose before stopping completely.
- Beta blockers are categorized as non-selective or selective. Non-selective beta blockers, such as carvedilol and propranolol, may sometimes narrow bronchial airways. People with asthma, emphysema, or chronic bronchitis should not use these medicines.
- These drugs can hide warning signs of low blood sugar (hypoglycemia) in people with diabetes. When combined with a diuretic, the risk of diabetes may increase.
- They may be less effective than other drugs for preventing stroke.
Common side effect symptoms of beta blockers include:
- Fatigue and lethargy
- Vivid dreams and nightmares
- Depression
- Memory loss
- Dizziness and lightheadedness
- Reduced ability to exercise
- Coldness in extremities (legs, toes, arms, and hands)
- Reduced sexual drive and problems with obtaining and maintaining an erection
Check with your doctor about any side effects. DoNOT stop taking these drugs on your own.
ACE Inhibitors
Angiotensin-converting enzyme (ACE) inhibitors widen blood vessels and decrease the workload of the heart. They treat high blood pressure and can also help protect the heart and kidneys.
people with heart failure or an enlarged left ventricle, previous heart attack, diabetes, or kidney disease are considered particularly good candidates for ACE inhibitors as part of treatment for high blood pressure.
Aspirin is recommended for reducing the risk of cardiac problems in people with heart disease, and can safely be used in combination with ACE inhibitors, particularly at lower dosages of aspirin (75 - 81 mg).
Brands. ACE inhibitors include captopril (Capoten, generic), enalapril (Vasotec, generic), quinapril (Accupril, generic), benazepril (Lotensin, generic), ramipril (Altace, generic), perindopril (Aceon, generic), and lisinopril (Prinivil, Zestril, generic).
Common side effect symptoms of ACE inhibitors include:
- Low blood pressure is the main side effect of ACE inhibitors. This can be severe in some people, especially at the start of therapy.
- An irritating cough is a common side effect, which some people find intolerable.
- ACE inhibitors can harm a developing fetus and should not be used during pregnancy. Women who become pregnant should change from ACE inhibitors to another type of blood pressure drug as soon as possible. Women of child-bearing age who are considering becoming pregnant should also discuss other medications with their doctors.
- ACE inhibitors can increase potassium levels, particularly in people with kidney disease.
Uncommon Side Effects of ACE Inhibitors.
- ACE inhibitors protect against kidney disease, but they may also increase potassium retention by the kidneys. If potassium levels become extremely high (hyperkalemia), they can cause the heart to stop beating (cardiac arrest). This side effect is uncommon, except in people with significant kidney disease. Because of this risk, ACE inhibitors are not usually used in combination with potassium-sparing diuretics or potassium supplements.
- A rare but severe side effect is granulocytopenia, an extreme reduction in infection-fighting white blood cells.
- In very rare cases, people suffer a sudden and severe allergic reaction, called angioedema that causes swelling in the eyes and mouth and may close off the throat.
People who have difficulty tolerating ACE inhibitor side effects are usually switched to an angiotensin-receptor blocker (ARB).
Angiotensin-Receptor Blockers (ARBs)
ARBs, also known as angiotensin II receptor antagonists, are similar to ACE inhibitors in their ability to widen blood vessels and lower blood pressure. They may have fewer or less-severe side effects than ACE inhibitors, especially coughing, and are sometimes prescribed as an alternative to ACE inhibitors. In general they are prescribed to people who cannot tolerate or did not respond to ACE inhibitors.
Brands. Losartan (Cozaar, Hyzaar, generic), olmesartan (Benicar) candesartan (Atacand), telmisartan (Micardis), eprosartan (Teveten), irbesartan (Avapro), valsartan (Diovan), and azilsartan (Edarbi).
A combination medication containing candesartan and the diuretic hydrochlorothiazide (Diovan HCT, Atacand HCT) is also available. Exforge HCT is a triple-combination medication that combines in one pill valsartan along with the calcium-channel blocker amlodipine and the diuretic hydrochlorothiazide. Tribenzor combines in one pill olmesartan, amlodipine, and hydrochlorothiazide.
Side Effects.
- Low blood pressure
- Dizziness and lightheadedness
- Raised potassium levels
- Drowsiness
- Nasal congestion
NOTE: ARBs should not be used during pregnancy.
Calcium-Channel Blockers (CCBs)
Calcium-channel blockers (CCBs), also known as calcium antagonists, help relax blood vessels. Along with diuretics, CCBs may work better than other drug classes for lowering blood pressure in African-Americans. Recent research indicates that newer types of drugs (CCBs, ACE inhibitors) may be a better treatment option for some people than older drugs (especially beta blockers).
Brands. Diltiazem (Cardizem, Dilacor), amlodipine (Norvasc), felodipine (Plendil), isradipine (DynaCirc), verapamil (Calan, Isoptin, Verelan), nisoldipine (Sular), nicardipine (Cardene), and nifedipine (Adalat, Procardia).
All these prescription medications are available as generics. For people who have both high blood pressure and high cholesterol, Caduet combines in one pill amlodipine and the statin drug atorvastatin.
Side Effects.
- Swelling in the feet
- Constipation
- Fatigue
- Erectile dysfunction
- Gingivitis
- Rash
- Food interactions (Do NOTtake CCBs with grapefruit or Seville orange products.)
Alpha Blockers
Alpha blockers such as doxazosin (Cardura, generic), prazosin (Minipress, generic), and terazosin (Hytrin, generic) help widen small blood vessels. They are generally not used as first-line drugs for high blood pressure, but are prescribed if other drugs do not work or as add-on medication.
Vasodilators help open blood vessels by relaxing muscles in the blood vessel walls. These drugs are usually used in combination with a diuretic or a beta blocker. They are rarely used by themselves.
Brands. Hydralazine (Apresoline, generic), clonidine (Catapres, generic), and Minoxidil (Loniten, generic).
Some of these drugs should be used with caution or not at all in people who have angina or who have had a heart attack.
Other Drugs
Aliskiren (Tekturna). Aliskiren (Tekturna, Amturnide) is a new kind of antihypertensive drug called a direct renin inhibitor. It blocks renin, a kidney enzyme associated with high blood pressure. Aliskiren is also available in the 2-in-1 combination pills Tekturna HCT (aliskiren and the diuretic hydrochlorothiazide) and Tekamlo (aliskiren and the calcium channel blocker amlodipine). Aliskiren is prescribed either alone or in combination with other blood pressure medications. However, people with diabetes or kidney impairment should not take aliskiren along with ACE inhibitors or ARBs because of increased risk for kidney damage and other problems. Aliskiren should not be used during pregnancy as it can cause injury or death to the fetus.
- American College of Cardiology -- www.acc.org
- American Heart Association -- www.heart.org
- American Society of Hypertension -- www.ash-us.org
- National Heart, Lung, and Blood Institute -- www.nhlbi.nih.gov
Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Coll Cardiol. 2011;57(20):2037-2114.
Blood Pressure Lowering Treatment Trialists' Collaboration, Turnbull F, Neal B, et al. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ. 2008;336(7653):1121-1123.
Blumenthal JA, Babyak MA, Hinderliter A, et al. Effects of the DASH diet alone and in combination with exercise and weight loss on blood pressure and cardiovascular biomarkers in men and women with high blood pressure: the ENCORE study. Arch Intern Med. 2010;170(2):126-35.
Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation. 2008;117(25):e510-e526.
Centers for Disease Control and Prevention (CDC). Vital signs: awareness and treatment of uncontrolled hypertension among adults -- United States, 2003-2010. MMWR. 2012;61(35):703-9.
Cook NR, Obarzanek E, Cutler JA, et al. Joint effects of sodium and potassium intake on subsequent cardiovascular disease: the Trials of Hypertension Prevention follow-up study. Arch Intern Med. 2009;169(1):32-40.
Din-Dzietham R, Liu Y, Bielo MV, Shamsa F. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation. 2007;116(13):1488-1496.
Drozda J Jr, Messer JV, Spertus J, et al. ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association-Physician Consortium for Performance Improvement. Circulation. 2011;124(2):248-70.
Ernst ME, Moser M. Use of diuretics in patients with hypertension. N Engl J Med. 2009;361(22):2153-2164.
Flack JM, Sica DA, Bakris G, et al. Management of high blood pressure in Blacks: an update of the International Society on Hypertension in Blacks consensus statement. Hypertension. 2010;56(5):780-800.
Forman JP, Stampfer MJ, Curhan GC. Diet and lifestyle risk factors associated with incident hypertension in women. JAMA. 2009;302(4):401-411.
Goldstein LB, Bushnell CD, Adams RJ, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(2):517-584.
Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298(8):874-879.
Sodium intake in populations: assessment of evidence. Institute of Medicine of the National Academies Website. http://www.iom.edu/~/media/Files/Report%20Files/2013/Sodium-Intake-Populations/SodiumIntakeinPopulations_RB.pdf. May 3013. Accessed August 6,2013.
Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665. doi: 10.1136/bmj.b1665.
Magnussen EB, Vatten LJ, Lund-Nilsen TI, et al. Prepregnancy cardiovascular risk factors as predictors of pre-eclampsia: population based cohort study. BMJ. 2007;335(7627):978.
Pickering TG, Miller NH, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008;52(1):10-29.
Selassie A, Wagner CS, Laken ML, et al. Progression is accelerated from prehypertension to hypertension in blacks. Hypertension. 2011;58(4):579-587.
Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association. J Am Coll Cardiol. 2011;58(23):2432-2446.
Urbina E, Alpert B, Flynn J, et al. Ambulatory blood pressure monitoring in children and adolescents: recommendations for standard assessment: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the council on cardiovascular disease in the young and the council for high blood pressure research. Hypertension. 2008;52(3):433-451.
Whelton PK, Appel LJ, Sacco RL, et al. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Circulation. 2012;126(24):2880-2889.
Wolff T, Miller T. Evidence for the reaffirmation of the U.S. Preventive Services Task Force recommendation on screening for high blood pressure. Ann Intern Med. 2007;147(11):787-791.
Advanced Studyec
Related Informationec
Review Date: 6/27/2013�
Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Bethanne Black, and the A.D.A.M. Editorial team.


text:
...end of disclaimer...
Hotel Arista
Time Estimates: The time noted next to an agenda item is only an estimate of the amount of time that will be spent during the meeting on that particular item. Accordingly, these estimates should not be relied on in determining when a matter will be heard, especially since agenda items are often re-ordered during a meeting and may be discussed at any time.
(10 mins) CALL TO ORDER:
PUBLIC COMMENTS: (This section of the agenda is for audience comments for items NOT on the agenda.)
(15 mins) APPROVAL OF CONSENT CALENDAR:
A. Motion to Waive Full Reading
B. Acquisition of Property on Cherry Hill Lane (Niemeyer Land and Farming Partnership, Assessor Parcel Nos. 7572-007-011 & 7572-007-012) (Fox)
C. FY12-13 Budget Adjustments (Downs)
Recommendation: Approve the amended City Council Policy No. 41 - Reserve Policies.
# # # # # #
(5 mins) 1. Introduction of Ordinance - Annual Budget Document (Downs)
(60 mins) 2. Draft FY13 -14 Budget (Downs)
(15 mins) 4. Infrastructure Management Plan (Downs)
ADJOURNMENT: Adjourn to 6:00 P.M. on Tuesday, April 30, 2013 for a Closed Session to be followed by an Adjourned Regular Meeting/Budget Workshop to be held at Fred Hesse Community Park.
Based on Government Code Section 54954.5
(All Statutory References are to California Government Code Sections)
Conference with Legal Counsel
Existing Litigation:
Potential Initiation of Litigation:
The City Council is meeting with Legal Counsel to determine whether to initiate litigation.
Number of Potential Cases (1)
Conference with Real Property Negotiators
Property: Lot 8 of Tract No. 20856 in the City of Rancho Palos Verdes
City Negotiators: Senior Engineer Ron Dragoo, San Ramon Canyon Project Manager Alan Braatvedt, and City Attorney Carol Lynch
Negotiating Parties: Jeffrey Richards and Sheri Richards on behalf of the Richards Revocable Family Trust dated January 26, 1989
Under Negotiation: Price and Terms of Payment
The property is located at 1805 W. Ninth St., San Pedro California 90732, within the City of Rancho Palos Verdes, at the Park's southwestern corner. (APN# 7561-025-900).
City Negotiators: Senior Engineer Ron Dragoo, San Ramon Canyon Project Manager Alan Braatvedt, and City Attorney Carol Lynch
Negotiating Parties: Kathline King and James Barber of the Los Angeles County Department of Parks and Recreation on behalf of the County of Los AngelesUnder Negotiation: Terms of Payment
NOTE: Staff reports are available for inspection at City Hall, 30940 Hawthorne Boulevard during regular business hours, 7:30 A.M. to 5:30 P.M. Monday – Thursday and 7:30 A.M. to 4:30 P.M. on Friday. The agenda and staff reports can also be viewed at Hesse Community Park, 29301 Hawthorne Boulevard during regular business hours: Monday – Friday from 9:00 A.M. until dusk; Saturday and Sunday from 10:00 A.M. until dusk.
Written materials, including emails, submitted to the City are public records and may be posted on the City's website. In addition, City meetings may be televised and may be accessed through the City's website. Accordingly, you may wish to omit personal information from your oral presentation or written materials as it may become part of the public record regarding an agendized item.
Materials related to an item on this Agenda submitted to the City Council after distribution of the agenda packet are available for public inspection at the front counter of the lobby of the City Hall Administration Building at 30940 Hawthorne Boulevard, Rancho Palos Verdes during normal business hours.
You can also view the agenda and staff reports at the City's website www.palosverdes.com/RPV.

subset: commoncrawl


text:
- Vitamin Guide
- Health Conditions
- Health Centers
- Diet & Weight Loss
- Herbal Remedies
- Current News
- Food Guide
- Recipes
To look at how diet affects the risk of metabolic syndrome in 12- to 19-year-old boys and girls, researchers collected nutrition surveys from 2,128 kids and identified who had metabolic syndrome. Some interesting results on the connections between diet and the risk of metabolic syndrome in adolescents came out of this study:
70% of the teens had at least one risk factor for the condition and 6.4% (138 out of 2,128) of the teens had metabolic syndrome. The biggest factor seemed to point to fiber consumption, as teens who ate the most had the lowest risk of metabolic syndrome:
There was no connection between the amount of saturated fat and cholesterol in the diet and risk of metabolic syndrome in teens.
This study suggests a strong connection between a healthy, fiber-rich diet and lower risk of metabolic syndrome in teens. With a few simple tweaks to your family's nutrition habits, you can put everyone on the path to better long-term health:
(J Am Diet Assoc 2011; 111:1730–4)
Copyright © 2017 Healthnotes, Inc. All rights reserved. www.healthnotes.com


text:
News Release
Help line open for flood questions
Department: Health & Environment
Release Date: Sep 19, 2013
970 498-6750
The Colorado Department of Public Health and Environment has opened its CO-HELP line to answer flood-related public health questions.
Hours are 9-10 M-F and 9-5 Sat + Sun. The number is toll-free at 1-877-462-2911.
Larimer County Health Department staff are available at the Disaster Assistance Center in Loveland to answer local questions and give guidance on how to safely approach clean-up, debris disposal, and personal health issues after the flood. Information is also available on the Health Department's website at www.larimer.org/emergency.


text:
By John Boyle Herald Writer
Russell Wilson is the Seahawks' starting quarterback, that much is certain. Who will back Wilson up, however, is something of a mystery now that Matt Flynn is an Oakland Raider.
After signing Josh Portis last week, and with the draft still three weeks away, the Seahawks apparently have now entered the kicking-the-tires-on-veteran-backups portion of the offseason.
This week, according to a league source, the Seahawks will work out a pair of former first-round picks, Matt Leinart and Brady Quinn, a former Seahawks backup, Seneca Wallace, and former Buffalo, Miami and Kansas City backup Tyler Thigpen. None of those are names that will likely get Seahawks fans too excited, but there's a good chance one of them will be battling Portis and perhaps a rookie to be named later for the right to back up Wilson in 2013.
Portis, who was Seattle's third quarterback in 2011 and on the practice squad for most of last season, re-signed with Seattle last week, but it was clear that was just the first of several moves at the position, not an answer to the question of who will serve as Seattle's backup.
Seahawks coach Pete Carroll is obviously familiar with Leinart, having coached him at USC, and to a lesser extent Quinn, who played against USC while leading Notre Dame's offense. The Seahawks pursued Leinart in 2011 after the lockout, but he elected to sign in Houston instead. And while neither Wallace nor Thigpen have the name recognition of Quinn and Leinart, they might be better fits in Seattle's offense because of their athletic abilities.
Leinart, the No. 10 pick in the 2006 draft, never lived up to his draft status in four seasons in Arizona. He then spent two seasons in Houston and one in Oakland as a backup. In his career, Leinart has started 18 games and completed 57.1 percent of his passes for 4,065 yards, 15 touchdowns, 21 interceptions and a 70.2 passer rating.
Quinn was the 22nd overall pick in 2007 and after three seasons in Cleveland he was traded to Denver, where he spent two years before going to Kansas City last season. The 28-year-old started eight games last season, but threw just two touchdowns and eight interceptions. Quinn has started 20 games in his career, completing 53.8 percent of his passes for 3,043 yards, 12 touchdowns, 17 interceptions and a passer rating of 64.4.
Wallace, 32, has spent the past two seasons in Cleveland where he started seven games. Before that, he had 14 career starts as Matt Hasselbeck's backup in Seattle. Wallace has a career passer rating of 81.3 and has thrown for 31 touchdowns and 18 interceptions.
Thigpen, 28, started 11 games in Kansas City in 2008, but has started just one in four seasons since then. He has completed 54 percent of his passes in his career and has thrown 21 touchdowns and 18 interceptions, good for a career passer rating of 72.5.
The Seahawks will also work out former Pro Bowl cornerback Antoine Winfield, according to Sean Jensen of the Chicago Sun-Times. Winfield, 35, has been a very productive player in Minnesota, playing in three Pro Bowls, but the Vikings released him earlier in the offseason for salary cap reasons. If the Seahawks were to add Winfield, he would be coming in as their third corner in nickel packages. Marcus Trufant played that position last year, but is an unrestricted free agent. If the Seahawks don't want to spend on Winfield, candidates currently on the roster to fill that position include Walter Thurmond, Byron Maxwell and Jeremy Lane, and of course that's also a position the Seahawks could address in the draft, especially given their ability to find impact player on the defensive side of the ball in the later rounds.
Herald Writer John Boyle: email@example.com.


text:
About this item
$99 Delivery
Hathaway Leather Living Room Set - 4 pc. - by Quest
Vintage Leather Craftsman has taken luxury to a whole new level. The Hathaway Leather Furniture Collection is a four piece set that includes a sofa, loveseat, chair and ottoman, all made with 100% top grain leather. Proudly made in the USA, by Vintage Leather Craftsman, with solid kiln-dried hardwood frames and true, 8-way hand tied construction, the Hathaway collection is built to stand up to the test of time. The Hathaway Collection features muslin pocketed coils in the seats for supreme coil on coil comfort.
The four-piece collection invites you to relax with genuine goose down pillow toppers in the seats, giving you ultimate comfort and pleasure, all within a hypoallergenic bag to keep the feathers from penetrating through the seat cushions. The Hathaway Leather Furniture Collection gives the classic, traditional look, with a quality, Made in America feel, which you will love to have in your home for years to come!
- Color/Finish
- Toffee brown top grain leather
- 100% top grain leather
- Solid wood frame
- To request a leather swatch sample, please email email@example.com
- Solid kiln-dried hardwood frames
- True 8-way hand tied construction
- Muslin pocketed coil seats for supreme coil comfort
- Seat pillow-tops are blended with goose down feathers and fiber seat
- Bench made
- Zipper access on all seat and back cushions
- 8-way hand tied construction
- Removable cushions
For any inquiries about this product, please call 1-800-650-0113. To request a sample swatch of the Hathaway leather, please email: email@example.com


text:
Feeling a little sour? The Practice: Drop tart tone. Why?Tone matters.I remember times I felt frazzled or aggravated and then said something with an edge to it that just wasn't necessary or useful. Sometimes it was the words themselves: such as absolutes like "never" or always," or over-the-top phrases like "you're such a flake" or "that was stupid." More often it was the intonation in my voice, a harsh vibe or look, interrupting, or a certain intensity in my body. However I did … [Read more...]
Drop Tart Tone
Lower the Pressure
Is it truly urgent? The Practice: Lower the pressure. Why?Things come at us with so much urgency and demand these days. Phones ring, texts buzz, emails pile up, new balls have to be juggled, work days lengthen and move into evenings and weekends, traffic gets denser, financial demands feel like a knife at the neck, ads and news clamor for attention, push push push PUSH.On top of these external pressures, we deal with internal ones as well. These include all the inner "shoulds," … [Read more...]
See Beings Not Bodies
What happens when you look at someone? The Practice: See beings, not bodies. Why?When we encounter someone, usually the mind automatically slots the person into a category: man, woman, your friend Tom, the kid next door, etc. Watch this happen in your own mind as you meet or talk with a co-worker, salesclerk, or family member.In effect, the mind summarizes and simplifies tons of details into a single thing - a human thing to be sure, but one with an umbrella label that makes it … [Read more...]
Receive Generosity
Do you accept the gift? The Practice: Receive generosity. Why?Life gives to each one of us in so many ways.For starters, there's the bounty of the senses – including chocolate chip cookies, jasmine, sunsets, wind singing through pine trees, and just getting your back scratched.What does life give you?Consider the kindness of friends and family, made more tangible during a holiday season, but of course continuing throughout the year.Or the giving of the people whose hard wor … [Read more...]
Keep Your Eyes on the Prize
What's the most important thing? The Practice: Keep your eyes on the prize. Why?Have you heard this saying?The most important thing is to remember the most important thing.What are the most important things to you? In your life as a whole? During a particular interaction with someone? Right this minute?The most important things often get pushed to the sidelines. Urgent crowds out important. Modern life is full of distracting clamor, from text messages and emails to window … [Read more...]
Give No One Cause to Fear You
What puts people at ease? The Practice: Give no one cause to fear you. Why?We evolved to be afraid.The ancient ancestors that were casual and blithely hopeful, underestimating the risks around them - predators, loss of food, aggression from others of their kind - did not pass on their genes. But the ones that were nervous were very successful - and we are their great-grandchildren, sitting atop the food chain.Consequently, multiple hair-trigger systems in your brain continually … [Read more...]
Hug the Monkey
Longing for love? The Practice: Hug the monkey. Why?Your brain evolved in three stages (to simplify a complex process):Reptile - Brainstem, focused on avoiding harm Mammal - Limbic system, focused on approaching rewards Primate - Cortex, focused on attaching to "us"The first JOT in this series - pet the lizard - was about how to soothe the most ancient structures of the brain, the ones that manage the first emotion of all: fear. The next one - feed the mouse - addressed how … [Read more...]


text:
Bookmark this site
NEW YORK CITY -- New Yorkers for Beverage Choices has signed on 50,000 new members since the city's health department passed Mayor Michael Bloomberg's historic ban on large-size sugary drinks on Sept. 13. Its ranks, which began forming in March, have now reached 300,000 individuals, businesses and organizations united in their opposition to the new rule.
The first-of-its-kind ban in the nation prohibits restaurants, food carts, movie theaters, sports arenas and delis from selling sugary drinks in containers holding more than 16 ounces. It applies only to drinks that contain more than 25 calories per 8-fl.oz. serving, and does not extend to diet sodas, fruit juices, milk-based drinks or alcoholic beverages. | SEE STORY
Vending machines are not included in the ban. However, the National Automatic Merchandising Association has joined the coalition to advocate for giving consumers the right to choose what, and how much, they drink.
"This isn't a game of chicken," said Liz Berman, chairwoman of New Yorkers for Beverage Choices. "We aren't jumping out of the way just because the Board of Health rubber-stamped the mayor's ban on soft drinks. In growing numbers, New Yorkers are standing up for small businesses in the city that will be harmed by this arbitrary policy that puts them at a competitive disadvantage."
Eliot Hoff, spokesperson for New Yorkers for Beverage Choices, said the group is "still looking into every option to ensure that this ban does not go into effect in March.


text:
This full color Jay Cutler ultra cling decal sticks to multiple surfaces and is removable and reusable. This versatile cling can be used indoors or outdoors and will not leave a residue when removed. Measures 5" x 6". Show your support for Chicago's starting quarterback.
Enter full name. We'll ask for delivery information at checkout.
There are currently no items in your shopping cart.
Your web browser's "cookie" feature must be enabled to use the shopping cart. If you added an item and received this message, it is possible the cookie is being blocked. Please adjust your browser's privacy settings to allow acceptance of 1st party cookies and try again.
Web Development by Americaneagle.com 2017


text:
EDU 6387: Math & Science in Cyberspace
Introduction to Webquests
San Diego State University: Webquests Page
An overview of webquests (what they are, what they do) by the Father of Webquests, Bernie Dodge, and friends.
WebQuests.htmlSpartanburg County School District 3: WebQuests
Webquests created by teachers.
Webquest 101 Online Tutorial
A fun and informative way to get to know what webquests are all about.
Evaluation Rubrics for Webquests
Rubrics by Bernie Dodge
Developed by the webquest professionals at San Diego State University.
Webquests 101: Choosing and Assessing Webquests
Guidelines for when and how to use webquests.
Technology Applications Center for Educator Development
Rubrics, help with creating your own rubrics, and other tools you can use to assess your students' technology skills.
Math Web Sites
Math Forum at Drexel University
In the "Resources & Tools" section, a compilation of resources for teaching math. Organized by grade level. Includes some websites.
Science Web Sites
NASA for Educators
Space-related websites for educators (and some for kids), organized by grade level.
National Biological Information Infrastructure
Websites on everything from aquatic biology to insects to mammals.
U.S. Environmental Protection Agency
Click on "Curriculum Resources" for websites and activities on a variety of environmental topics.
American Museum of Natural History
Educational resources on natural history topics especially for teachers.
Multi-Subject Web Sites
GEM: The Gateway to Educational Materials
A number of math and science-related sites. Resources are searchable by grade level, too.
FirstGov for Kids
A variety of kid-friendly math and science websites compiled by government agencies and other groups.
Adventures of Cyberbee
Web links as well as curriculum ideas and examples of web-based projects. A cute mascot, too!
ALA's Great Websites for Kids
Compiled by librarians with the American Library Association, websites for math, sciences, computers, and animals.
Exploratorium The Museum's website offers "cool sites" for educators in math, physics, geology, and more!
Professor Forbes' Selected Web Sites
Ask Dr. Math*
Look up math questions and answers or submit your own question. Questions are categorized into grade levels (elementary, middle, high school, and college).
Cool Math
Site for students, teachers, and parents. One section for ages 3–12, and another for ages "13–100." Includes games, interactivities, puzzles, explanations, lessons, etc.
Explore Math
Highly interactive math activities for students and educators. Also includes lesson plans. Elementary Algebra through Pre-Calculus. Search the "Gizmo" catalog by grade and/or topic.
Frank Potter's Science Gems: Mathematics
Math links by category and grade level.
A large resource of categorized math-related links. Categories include: basic math (arithmetic, algebra, calculus, geometry, number system, Trigonometry, etc.), pure and applied math (discrete math, fractals, probability, etc.), math help desk (calculators, dictionaries, formulas, games, etc.), famous theorems (Axiom of Choice, Riemann Hypothesis, perfect and prime numbers, etc.), and more.
Internet for Mathematicians
A free "teach yourself" tutorial on Internet information skills for finding math resources. Tour key sites for math, discover tools and techniques to improve your Internet searching, review the critical thinking required when using the Internet, and reflect on how to use the Internet for studying, teaching or research. Great for teachers, but also appropriate for high school students.
Kathy Schrock's Guide for Educators: Mathematics
Links to educational sites for math
Kid's Click: Math
Impressive list of links by category (math-general, games, problems, history, algebra, arithmetic, geometry, etc.). Provides description and reading grade level for each site. For students in grades K-7.
Math Realm
Hundreds of award-winning math lessons, learning tools and exploration activities for grades 4–12. Create worksheets and tests for students to complete online that are automatically graded.
PBS TeacherSource: Math
Lesson plans, teachers guides, and activities.
Access Excellence
Resources for health and bioscience teachers and students. Includes lessons, activities, news, and more.
Brain Pop
Science, Biology and Technology subjects that correspond to the National Science Education Standards for 5–8 grades. Each subject contains a 3–4 minute animated movie, an interactive quiz, an experiment, a comic strip, a how-to hands on application, a timeline and a print-able activity page. (Note: Animated movies cannot be downloaded and saved for use in PowerPoint.)
Frank Potter's Science Gems: Great links to Great Science Resources
Links by category and grade level for physical science, earth science, life science, science Web Quests, and other resources for the science student and teacher.
A large resource of categorized science-related links. Categories include: physics, astronomy, biology, chemistry, earth science, environment, and more. The general category of "Science" includes 321 subjects.
Human Anatomy Online
An inner exploration of human anatomy. Each topic has animations, 100′s of graphics, and thousands of descriptive links.
Insecta Inspecta
An award-winning site created by an Intel� Teach to the Future Master Teacher and her middle school students. Includes information and student-created graphics on ants, bees, beetles, butterflies, crickets, fleas, mantids (praying mantis), mosquitoes, and termites, plus links to other insect information.
Internet for Science
Free "teach yourself" tutorials on Internet information skills for a variety of science topics: nature, chemistry, earth science, physics, and history and philosophy of science. Tour key Web sites, discover tools and techniques to improve your Internet searching, review the critical thinking required when using the Internet, and reflect on how to use the Internet for studying, teaching or research. Great for teachers, but also appropriate for high school students.
Kathy Schrock's Guide for Educators: Science, Computing, and Technology
Links to educational sites for science and technology.
Kid's Click: Science
Impressive list of links by category (animals, environment, natural disasters, space, and then specific sub-topics such as general science, biology, dinosaurs, rocks, weather, etc.). Provides description and reading grade level for each site. For students in grades K-7.
Kid's Click: Machines and Transportation
Impressive list of links by category (inventions, navigation, planes, tools, weapons, etc.). Provides description and reading grade level for each site. For students in grades K-7.
NASA: Earth Science Enterprise
Includes science topics: Air, Natural Hazards, Land, Water, People, as well as Games and Teacher Guides. Appropriate for 4–8. Includes articles, quizzes, interactive maps and activities, animations, and more. For more general information about Earth Science (appropriate for grades 9–12), visit: http://earth.nasa.gov/
NASA JPL - Ocean Surface Topography from Space
Resources for studying the oceans, weather, and the satellites providing information on these topics. Site is specifically for students.
National Atlas of the United States
Includes high-quality, small-scale maps, national geospatial and geostatistical data sets (soils, county boundaries, volcanoes, watersheds, crime patterns, population distribution, etc.), easy-to use online interactive maps that can be custom-made, and dynamic multimedia maps designed to animate and illustrate the changing United States.
PBS TeacherSource: Science & Technology
Lesson plans, teachers guides, and activities.
Evaluate Your Information Instruction Class
Please fill out this form to help us improve our program.
Leave a Comment/Suggestion
Do you have information to add? Then please Edit this page. Otherwise to leave a comment, use the box below.
Last Modified on March 21, 2011, at 01:30 PM by Chris DeCristofaro


text:
Washington : Government Printing Office
|Chap. 389
|Title 4, U. S. Code. Codification and enactment into positive law.
|Chap. 389
|Chap. 389
|Chap. 389
|Sec. 2
|Sec. 2
Page 357
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That title 4 of the United States Code, entitled "Flag and seal, Seat of Government, and the States", is codified and enacted into positive law and may be cited as "4 U.S.C., § ", as follows:
(a) All taxes levied by any State, Territory, or the District of Columbia upon, with respect to, or measured by, sales, purchases, storage, or use of gasoline or other motor vehicle fuels may be levied, in the same manner and to the same extent, with respect to such fuels when sold by or through post exchanges, ship stores, ship service stores, commissaries, filling stations, licensed traders, and other similar agencies, located on United States military or other reservations, when such fuels are not for the exclusive use of the United States. Such taxes, so levied, shall be paid to the proper taxing authorities of the State, Territory, or the District of Columbia, within whose borders the reservation affected may be located.
(b) The officer in charge of such reservation shall, on or before the fifteenth day of each month, submit a written statement to the proper taxing authorities of the State, Territory, or the District of Columbia within whose borders the reservation is located, showing the amount of such motor fuel with respect to which taxes are payable under subsection (a) for the preceding month.
(a) No person shall be relieved from liability for payment of, collection of, or accounting for any sales or use tax levied by any State, or by any duly constituted taxing authority therein, having jurisdiction to levy such a tax, on the ground that the sale or use, with respect to which such tax is levied, occurred in whole or in part within a Federal area; and such State or taxing authority shall have full jurisdiction and power to levy and collect any such tax in any Federal area within such State to the same extent and with the same effect as though such area was not a Federal area.
(b) The provisions of subsection (a) shall be applicable only with respect to sales or purchases made, receipt from sales received, or storage or use occurring, after December 31, 1940.
Nothing in sections 105 and 106 of this title shall be deemed to
Page 358
authorize the levy or collection of any tax on or from any Indian not otherwise taxed.
As used in sections 105-109 of this title— (a) The term "person" shall have the meaning assigned to it in section 3797 of title 26.
(b) The term "sales or use tax" means any tax levied on, with respect to, or measured by, sales, receipts from sales, purchases, storage, or use of tangible personal property, except a tax with respect to which the provisions of section 104 of this title are applicable.
(c) The term "income tax" means any tax levied on, with respect to, or measured by, net income, gross income, or gross receipts.
(d) The term "State" includes any Territory or possession of the United States.
(e) The term "Federal area" means any lands or premises held or acquired by or for the use of the United States or any department, establishment, or agency of the United States; and any Federal area, or any part thereof, which is located within the exterior boundaries of any State, shall be deemed to be a Federal area located within such State.
The sections or parts thereof of the Statutes at Large or the Revised Statutes covering provisions codified in this Act are hereby repealed insofar as such provisions appear in title 4, United States Code, 1940 edition, and supplements thereto, as shown by the appended table: Provided, That any rights or liabilities now existing under such repealed sections or parts thereof shall not be affected by such repeal.
Approved, July 30, 1947.


text:
School's Out! Spring Camp - Center for Science Teaching & Learning
Hours: 9am - 4pm
Ages: YE,TW
Price: $50 per child per day
1 Tanglewood Road - 516-764-0045
Rockville Centre, NY 11570
Description: When all the school's are off, CSTL is open for School's Out Camp! Have a blast doing science experiments, getting up close and personal with all the animals in our animal exhibit, and hiking around the beautiful 17-acre nature preserve. Pre-registration is required. Come for 1 day or all 5 days, it's up to you.


text:
Hot Chicks Big Asses Presents
Sexy hottie hoe Britney Stevens sucking and being fucked so hard by a huge hard cock
Want to see more? Visit Hot Chicks Big Asses
Get COMPLETE access to ALL Hot Chicks Big Asses SITES!!!
With just one Hot Chicks Big Asses pass - you can download everything, over 1500 exclusive, original amateur porn movies from the World Famous Hot Chick Big Asses production house!
We add a full-length never-before seen video every week day! Incredible quality, amazing girls and fresh faces. The Hot Chicks Big Asses bring you the best porn the world has seen and you get to download every video we have ever filmed! Over 1500 girls in over 1500 movies! It's amazing, join today and start downloading!


text:
Escapes! DVD by Bill Cooper.
Bill "the grill" Cooper - one of the best American BJJ black belts is the master of the escape and he's here to help you with your game. Cooper shows not just how to get out a bad situation but how to escape to a dominant position where you can submit your opponent. These are tournament tested and Paragon approved escapes!
30 Techniques including escapes from armbar, triangle, omoplata, leglocks, guillotine, shaolin, body triangle, crucifix, back/ RNC.
Cost me $40 + postage from US. Selling for £20 including postage in UK.
As good as new and all region DVD.
PM me if interested (I take paypal)


text:
Autosomal recessiveGenetics - autosomal recessive; Inheritance - autosomal recessive
Autosomal recessive is one of several ways that a trait, disorder, or disease can be passed down through families.
An autosomal recessive disorder means two copies of an abnormal gene must be present in order for the disease or trait to develop.
Inheriting a specific disease, condition, or trait depends on the type of chromosome affected (autosomal or sex chromosome). It also depends on whether the trait is dominant or recessive.
A mutation in a gene on one of the first 22 nonsex chromosomes can lead to an autosomal disorder.
Genes come in pairs. Recessive inheritance means both genes in a pair must be defective to cause disease. People with only one defective gene in the pair are considered carriers. However, they can pass the abnormal gene to their children.
If you are born to parents who both carry an autosomal recessive change (mutation), you have a 1 in 4 chance of getting the malfunctioning genes from both parents and developing the disease. You have a 50% (1 in 2) chance of inheriting one abnormal gene. This would make you a carrier.
In other words, if four children are born to a couple who both carry the gene (but do not have signs of disease), the statistical expectation is as follows:
- One child is born with two normal genes (normal)
- Two children are born with one normal and one abnormal gene (carriers, without disease)
- One child is born with two abnormal genes (at risk for the disease)
Note: This does not mean that children will necessarily be a carrier or have be affected.
See also:
- Autosomal dominant
- Genetic counseling and prenatal diagnosis
- Heredity and disease
- Sex-linked dominant
- Sex-linked recessive
Review Date: 5/16/2012
Reviewed By: Neil K. Kaneshiro, MD, MHA, Clinical Assistant Professor of Pediatrics, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.


text:
For your MMA Fix, Don't Hit the Pit anymore coz its shut. MMAOfficials.co.uk
ok I hate videos in here but this one is quite funny, check on YT for him he has loads
REFEREE with MMA Officials
just jealous cos I can sit on my arse all day while you have to go out to work Deano lol
Originally Posted by ACER
Hahahahahaha!!! LOL ACER - delivering the goods!
"Hell never sell any ice cream going at that speed"
Forum Rules


text:
Back to Articles
LSU and Alabama Remain Atop Latest BCS Standings
Sunday, November 27, 2011
One-Loss Teams Jostle for Position in Top 10While this past week did not provide the upsets of two weeks ago, there was still some noticeable shifting in the latest BCS Standings. LSU and Alabama remain solidly in the top two positions after both posted convincing victories over ranked foes - the Tigers rolled over previously-No. 3 Arkansas, 41-17, and the Crimson Tide rocked then-No. 24 Auburn, 42-14.Oklahoma State moved up one spot, replacing Arkansas at No. 3, followed by Stanford, which jumped two positions to No. 4 after an impressive defeat of then-No. 22 Notre Dame. The Cowboys host No. 10 Oklahoma on Saturday in a de facto Big 12 Championship game, while Stanford has completely its regular season. Virginia Tech remains at No. 5 heading into the ACC title game against Clemson on Saturday. The top two teams in the final BCS Standings (released on Sunday, Dec. 4) will meet in the Allstate BCS National Championship game in New Orleans (Monday, Jan. 9).Houston, which joins LSU as the only undefeated teams in the nation, moved up to an all-time high slot of No. 6 - the Cougars will host No. 24 Southern Miss in the Conference USA Championship game on Saturday. A win will guarantee an automatic bid to a BCS Bowl for the Cougars.Boise State remains at No. 7, followed by Arkansas, the highest-ranked two-loss team, at No. 8. Rounding out the top 10 are Oregon and Oklahoma. The Ducks host unranked UCLA in the Pac-12 Championship game on Friday evening - interestingly, UCLA finds itself in a unique position - if the Bruins defeat the Ducks, they will go to the Rose Bowl, if they lose, they will not be bowl-eligible.At No. 11 Kansas State remains in the mix for a BCS bid, while No. 12 South Carolina is most likely out of the picture due to the two highly-ranked SEC schools. Michigan State is the highest-ranked Big Ten program at No. 13 - the Spartans will meet No. 15 Wisconsin in the inaugural Big Ten title game with a trip to the Rose Bowl on the line.While Georgia is the fifth-highest rated SEC team at No. 14, the Bulldogs still have BCS potential as they will challenge LSU in this weekend's SEC Championship game. A Georgia win sends them to the Allstate Sugar Bowl - interestingly, even with a loss in the SEC title game, LSU could still advance to the Allstate BCS National Championship game if it remains in the top-two in the country.After defeating Ohio State for the first time since 2003, Michigan remained steady at No. 16 in the standings - the Wolverines need to climb into the top-14 to be eligible for a BCS at-large bid and while they don't have any games remaining, teams above them could lose and drop, opening up opportunity. Baylor at No. 17 is in the same position as Michigan, likely needing some teams ranked above it in the rankings to lose, though the Bears have one game remaining, against No. 22 Texas on Saturday. Overall, the Big 12 has six teams in the top 25, while the SEC and the Big Ten each have five. The ACC, Pac-12, Mountain West and Conference USA each have two top-25 programs, while the Big East's lone representative is West Virginia at No. 23.
November 27, 2011
BCS Standings


text:
A-Rod suspended for remainder of 2013, all of 2014 season
Alex Rodriguez, the highest-paid player in baseball history and once regarded as an antidote to the game's steroid era, was suspended on Monday for 211 games after being found in violation of Major League Baseball's anti-drug policy. The suspension begins Thursday.
Rodriguez is appealing the ban – which extends through the 2014 season – and, as a player who has not been suspended previously, can play during the appeal process. He is expected to be in the New York Yankees lineup Monday night for their game against the Chicago White Sox. Rodriguezbecomes the most decorated player to be disciplined over the nearly decade-long program, a list that includes noted sluggers Rafael Palmeiro, Manny Ramirez and, recently, Ryan Braun.
A three-time league MVP, fifth on baseball's career home run list, and recipient of the two largest contracts ever awarded, the New York Yankees third baseman was targeted through the league's investigation into the South Florida anti-aging clinic, Biogenesis of America, and the company's ties to major- and minor-league players.
UPDATE: Players Union responds
The head of the Major League Baseball Players Association doesn't believe Commissioner Bud Selig acted appropriately in the suspension of Yankees infielder Alex Rodriguez. Michael Weiner says the union is supporting A-Rod's appeal of the suspension which carries through next season. He also believes Selig's decision does not fall in line with the collective bargaining agreement. A dozen others were hit with 50-game bans.


text:
Culture Shock is an event which uses Diversity Hypnosis
to inspire some enlightening and inspiring dialogue while having
fun in the process! This event is open to all students; you don't
need to partake in hypnosis in order to participate. Culture
Shock is a part of the Diversity and Unity Month schedule of
events. The full list of events can be found on the MSMC
Share this page