Adopting healthier habits

Adopting a healthy lifestyle — which means cutting back on salt, losing excess weight, and maintaining a diet high in fruits, vegetables, and whole grains — is the cornerstone for preventing and treating hypertension. If you don’t have diabetes or damage to the heart, brain, kidneys, or eyes, lifestyle changes alone may be enough to bring a high blood pressure reading into the normal range.

The May 2003 JNC guidelines recommend lifestyle modifications as the best approach for bringing prehypertensive blood pressures (120/80 mm Hg – 139/89 mm Hg) into a healthy range. In addition, people with stage 1 hypertension (140/90 mm Hg – 159/99 mm Hg) who don’t have any other health conditions can often try making lifestyle changes before resorting to medications.

A March 1998 study published in the Journal of the American Medical Association lends support to the emphasis on lifestyle changes. Researchers found that many people with hypertension were able to stop taking their blood pressure medications if they reduced their salt intake and lost weight. The trial included 975 volunteers, ages 60–80, who were taking blood pressure drugs. The 390 normal-weight participants received either counseling to reduce their salt intake or no dietary advice. The other 585 people, who were overweight, were divided into four equal groups. People in the first three groups were asked respectively to lose weight, reduce salt consumption, or do both. The fourth group received no special instructions. After three months, the researchers began to gradually withdraw the subjects from their blood pressure drugs.

More than two years later, the people assigned to both weight loss and salt reduction were 53% less likely to have high blood pressure, require a drug to treat hypertension, or have cardiovascular problems than those who made no changes. People who only lost weight or reduced salt were each a third less likely to have high blood pressure, require a drug to treat hypertension, or have cardiovascular problems than those who didn’t make any lifestyle changes.

Even if you need to use drugs to treat hypertension and control your blood pressure, you should still adopt healthy habits. The lifestyle changes described in this section of the report can substantially improve your blood pressure. For example, diet and exercise are an essential part of treatment because they help medications control your blood pressure, making it possible for you to get good results with a lower dosage.

Tips for keeping your high blood pressure in check Take your blood pressure medication as prescribed by your doctor. If you experience side effects, talk to your doctor. Try to maintain a healthy weight. Increase your physical activity. Do at least 30 minutes of moderate aerobic activity, such as walking, on most days. You can split the session into three 10-minute segments during the day. Eat foods low in salt and sodium. Read nutrition labels to determine how much sodium is in packaged foods. Eat more fruits, vegetables, and whole grains, and choose low-fat dairy foods. Include foods rich in potassium and calcium in your diet. If you consume alcohol, do so moderately. If you smoke, quit. Reduce your stress. Tell your family and friends you have high blood pressure, especially the person who prepares the meals. Source: National Heart, Lung, and Blood Institute

Eat well

Hypertension, stroke, and heart disease are common in the United States and most other western industrialized nations. Epidemiologists attribute much of their prevalence to diet. After decades of research, scientists have concluded that the typical American diet is a recipe for hypertension and cardiovascular disease: too much salt, too much saturated fat, too many calories, and not enough fruits and vegetables. But the good news is that you can take an active role in preventing and controlling high blood pressure by watching what you eat.

The DASH diet

Results of the first Dietary Approaches to Stop Hypertension (DASH) study, published in the New England Journal of Medicine in 1997, offered some of the most encouraging news that diet can help control blood pressure. In fact, the results were so promising that the JNC guidelines recommend all Americans — not just those with hypertension — follow the DASH diet. Low in fat and rich in fruits, vegetables, whole grains, and low-fat dairy products, this eating plan significantly and quickly lowered blood pressure in people with hypertension enrolled in a multicenter study.

The 459 volunteers were randomly assigned three diets. One was based on what most Americans eat, with 37% of calories from fat. The second was a similar regimen with fruits and vegetables added. The third was a “combination” diet (the DASH diet), containing 27% of calories from fat, plus plenty of fruits and vegetables, whole grains, low-fat or nonfat dairy products, and small amounts of meat, fish, poultry, and nuts. After following the DASH plan for eight weeks, participants with hypertension enjoyed average reductions of 11.4 mm Hg in systolic pressure and 5.5 mm Hg in diastolic pressure. These results are comparable to the effects of some drugs that treat hypertension. Participants with borderline high blood pressure experienced improvements as well, suggesting that the DASH diet may keep some people from developing hypertension in the first place. The second diet, which was higher in fats but also rich in fruits and vegetables, also lowered blood pressure, although not as much as the DASH plan. All reductions occurred without people changing their salt intake, alcohol consumption, or weight — factors known to influence blood pressure.

A follow-up analysis of the trial’s results found that the DASH diet reduced blood pressures in virtually all groups tested regardless of such factors as age, sex, race, and hypertension status. Its effects were most pronounced, though, in African Americans and people with hypertension.

Researchers do not attribute the blood pressure reductions of the DASH trial to any single nutrient. Compared with the typical American diet, the DASH eating plan had a relatively higher calcium content and less salt, total fat, saturated fat, and cholesterol. It also had 173% more magnesium, 150% more potassium, 240% more fiber, and 30% more protein.

Calculating the benefits of lifestyle changes There can be no doubt about the value of a healthy lifestyle when it comes to controlling your blood pressure. Many studies have documented precisely how much of a reduction in systolic blood pressure you can gain from certain lifestyle changes. By making a diligent effort to improve your lifestyle, you can take your blood pressure from the hypertensive range down to normal without popping a pill. Or at the very least, lifestyle changes can aid your medication in bringing your blood pressure into a healthier range. Keep in mind, too, that the more lifestyle changes you make, the greater the gains.

Table 2: Keeping score
Lifestyle change	What to do	Potential reduction in systolic blood pressure
Lose weight	Reach and maintain a normal body mass index (BMI)	5–20 mm Hg for every 22 pounds lost
Adopt the DASH diet	Eat plenty of fruits and vegetables, choose low-fat dairy products, and reduce total fat consumption	8–14 mm Hg
Reduce salt	Consume no more than 2,400 mg of sodium a day (or 6,000 mg of sodium chloride)	2–8 mm Hg
Exercise regularly	Get at least 30 minutes of moderate aerobic exercise on all or most days of the week	4–9 mm Hg
Limit alcohol	Have no more than two drinks per day if you’re male, or one drink per day if you’re female	2–4 mm Hg
Source: Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

Consume less salt

While it’s generally accepted that salt plays a significant role in blood pressure, the question of whether everyone should reduce their salt intake is the source of a longstanding, vigorous debate.

According to one study, about 26% of people with normal blood pressure and nearly 50% of people with hypertension are salt sensitive, meaning eating too much sodium elevates their blood pressure. If you’re salt sensitive, a low-salt diet is likely to lower your blood pressure and reduce your subsequent risk of stroke and heart attack. A 2001 Hypertension study also demonstrated that people identified as salt sensitive faced a higher risk of death even if their blood pressure stayed within normal ranges. In addition, those who were salt sensitive and had normal blood pressure at the beginning of the study had a higher likelihood of developing hypertension as they aged.

Most experts agree that elderly, obese, and diabetic people are more sensitive to salt consumption and should consider cutting back. Many African Americans are also salt sensitive and should restrict their sodium intake. So too should people who have prehypertension or hypertension.

But what if you don’t fall into one of these categories? Can you reach for the salt shaker? That’s where the controversy lies. Some scientists say there isn’t evidence that cutting back dramatically on salt benefits healthy people. Instead, they argue that for the average American, following the DASH diet is more important than cutting back on salt and that restricting salt intake has only a modest effect on blood pressure. But before you sprinkle away, be aware that other experts argue just as vehemently that cutting back on salt is good for you, even if you don’t have high blood pressure. Keep in mind that there’s no easy way to determine if you’re salt sensitive; even if your blood pressure is normal now, you may be salt sensitive and, therefore, have a higher risk of developing hypertension in the future.

The results of the second DASH study (the DASH-Sodium trial), which were published in the New England Journal of Medicine in 2001, suggest that reducing your salt intake may dramatically lower your blood pressure even if you don’t have hypertension. More than 400 subjects followed either a typical American diet or the DASH diet for 12 weeks, but their sodium intake was randomly changed every four weeks. The sodium intake varied from 3,300 mg (about what a typical American consumes) to 2,400 mg (the upper limit established by the National High Blood Pressure Education Program) to a more restrictive 1,500 mg. With either diet, the researchers found that the lower the sodium intake, the lower the blood pressure. But at each sodium level, blood pressure was consistently lower for those on the DASH diet. Therefore, the largest reductions in blood pressure were found among those who followed the DASH diet and consumed just 1,500 mg of sodium per day. This combination worked best for all participants — with or without hypertension, African American or Caucasian, male or female — but was most pronounced for those with hypertension.

The researchers say this proves we can all benefit from reducing our sodium intake, but the study has done little to settle the controversy. Critics charge the study didn’t last long enough to make such generalizations or expose any possible health risks that might be associated with a very-low-sodium diet. They also argue that cutting back on salt had only a small impact for those with normal blood pressure. Furthermore, the most relevant question — would a reduction in salt consumption actually reduce the risk of hypertension and its complications — wasn’t tested.

Researchers will most likely continue to study and debate this issue. In the meantime, it’s best to keep your sodium intake below 2,400 mg, even if your blood pressure is currently normal. Individuals who have prehypertension, hypertension, or are at high risk for high blood pressure may benefit even more from dropping their sodium intake further — to 1,500 mg a day or less. The same is true for people who are obese, diabetic, or elderly.

Table 3: The DASH diet
The DASH (Dietary Approaches to Stop Hypertension) studies have found that this diet can substantially reduce blood pressure. One goal of the program was to devise a diet that people could easily follow on their own, so the DASH diet relies on common, readily available foods. The plan is based on 2,000 calories per day.
Food group	Daily servings	Serving sizes	Examples	Significance to the DASH diet
Grains and grain products	7–8	1 slice bread 1 ounce dry cereal 1/2 cup cooked rice, pasta, or cereal	Whole-wheat bread, English muffins, pita bread, bagels, cereals, grits, oatmeal	Major sources of energy and fiber
Vegetables	4–5	1 cup raw leafy vegetable 1/2 cup cooked vegetable 6 ounces vegetable juice	Tomatoes, potatoes, carrots, peas, squash, broccoli, turnip greens, collards, kale, spinach, artichokes, beans, sweet potatoes	Rich sources of potassium, magnesium, and fiber
Fruits	4–5	6 ounces fruit juice 1 medium fruit 1/4 cup dried fruit 1/2 cup fresh, frozen, or canned fruit	Apricots, bananas, dates, grapefruit, mangoes, melons, oranges, peaches, pineapples, prunes, raisins, strawberries, tangerines	Important sources of potassium, magnesium, and fiber
Low-fat or nonfat dairy foods	2–3	8 ounces milk 1 cup yogurt 1 1/2 ounces cheese	Skim or 1% milk, skim or low-fat buttermilk, nonfat or low-fat yogurt, nonfat or low-fat cheese	Major sources of calcium and protein
Meats, poultry, fish	2 or less	3 ounces cooked meats, poultry, or fish	Select only lean; trim away visible fats; broil, roast, or boil instead of frying; remove skin from poultry	Rich sources of protein and magnesium
Nuts, seeds, legumes	4–5 per week	1 1/2 ounces or 1/3 cup nuts 1/2 ounce or 2 tablespoons seeds 1/2 cup cooked legumes	Almonds, filberts, mixed nuts, peanuts, walnuts, sunflower seeds, kidney beans, lentils	Rich sources of energy, magnesium, potassium, protein, and fiber
Fats and oils	2–3	1 teaspoon vegetable oil 1 tablespoon low-fat mayonnaise 2 tablespoons light salad dressing	Margarine, low-fat mayonnaise, light salad dressing, vegetable oil (olive, canola, corn, or safflower)	DASH has 27% of calories as fat, including fat in or added to foods
Sweets	5 per week	1 tablespoon sugar 8 ounces lemonade 1 tablespoon jelly or jam	Maple syrup, sugar, jelly, jam, fruit-flavored gelatin, hard candy, sorbet	Sweets should be low in fat
Source: “Dietary Approaches to Stop Hypertension” (DASH) study, National Institutes of Health

Salt and salt substitutes Despite the controversy over how much salt the average person should consume, it’s clear that many people, especially African Americans, are salt sensitive and should curtail their salt intake to control their blood pressure. But we love salt. An adult requires just 250 mg of sodium a day, but most Americans consume at least 3,300 mg a day — even though many health organizations recommend that people keep their intake below 2,400 mg. The bulk of most people’s sodium intake — as much as 75% — comes from processed foods, including soups (canned, dried, or frozen), lunch meats, cold cereals, frozen dinners, salad dressings, cheese, pizza, bread and rolls, crackers, olives, pickles, steak sauce, Worcestershire sauce, cured meats, kosher meats, hot dogs, potato chips, corn chips, pretzels, and nuts. Another 15% of sodium in the typical American diet is added during cooking. Some comes as table salt, which consists of about 40% sodium and 60% chloride. Other sources include seasoned salt (garlic, onion, and celery salts, for example), baking powder, baking soda, soy sauce, steak sauce, Worcestershire sauce, and monosodium glutamate. Sodium is also found naturally in some foods: One cup of skim or low-fat milk contains 120 mg of sodium; three ounces of meat, fish, or poultry has 75 mg; and half a cup of fresh vegetables may have anywhere from 5 mg to 25 mg of sodium. If you’re trying to cut back on salt, you’ll find tasty alternatives on your grocer’s shelves. Adventurous cooks often rely on herbs and spices to beef up flavor while cutting down on sodium. For more timid souls, the answer may be ready-made salt-free mixtures. Another option is “lite” salt, which substitutes potassium chloride for about half the sodium chloride found in regular salt. Many doctors advise their hypertensive patients not just to cut back on sodium but also to switch to this type of salt, because it helps replace potassium, which gets washed out of the body by some diuretics prescribed to treat hypertension. However, even “lite” salt contains too much sodium for many people who have been advised to limit their salt intake. While one-fourth of a teaspoon of “lite” salt contains 244 mg of sodium, some people tend to use more of it at the table to compensate for its light taste. Also, it’s not recommended for use in cooking because potassium chloride gives food a bitter taste when heated to high temperatures. Before using a salt substitute with extra potassium, be sure to check with your doctor. Some people — for example, those with kidney disease — may need to avoid potassium as well as salt.

Nine tips to reduce the salt in your diet Buy vegetables that are fresh, frozen, or canned “with no salt added.” Use fresh poultry, fish, and lean meat, rather than canned or processed types. Use herbs, spices, and salt-free seasoning blends in cooking and at the table. Cook rice, pasta, and hot cereals without salt. Cut back on instant or flavored rice, pasta, and cereal mixes. Choose convenience foods that are lower in sodium. Cut back on frozen dinners, packaged mixes, canned soups or broths, and salad dressings. Rinse canned foods, such as tuna, to remove some sodium. When available, buy low-sodium, reduced-sodium, or no-salt-added versions of foods. Choose breakfast cereals that are lower in sodium. Snack on fruits and vegetables instead of chips.

Keep an eye on fat

A diet low in saturated fat can reduce cholesterol levels, but its effect on blood pressure is not well established. In the early 1970s, researchers observed that vegetarians tended to have lower blood pressures than people who ate meat. Vegetarian diets tend to be lower in fat, particularly saturated fat, but there are many other differences. Vegetarians generally consume more fiber and minerals and less protein than meat-eaters. Furthermore, vegetables, fruits, grains, and dairy products are rich sources of potassium, magnesium, and calcium. Diets high in these minerals are associated with low blood pressure. The DASH diet, for instance, is a low-fat, high-mineral eating plan.

Quit smoking

When it comes to heart disease and blood pressure, smoking packs a devastating wallop. Nicotine raises your blood pressure, lowers “good” HDL cholesterol, reduces your body’s supply of oxygen, and makes blood clots more likely.

It can be difficult to quit smoking, despite all the health reasons to do so, because this habit is psychologically and physically addictive. Smoking cessation programs primarily address the psychological facets of addiction by helping participants change ingrained behaviors. Nicotine replacement systems — such as patches, chewing gum, and nasal sprays — target physical craving by delivering the addictive substance in another form, allowing the user to taper off gradually, minimizing withdrawal symptoms. According to the American Lung Association, research has found that using a nicotine replacement product and participating in a smoking cessation program doubles your chances of successfully quitting.

Quitting isn’t easy, but it offers enormous benefits. Within hours of stopping smoking, your heart rate and blood pressure decrease, although it may take up to a month for them to return to normal. Within a year of quitting, your heart disease risk is cut in half. Within 15 years of giving up smoking, your risk of heart disease is close to that of nonsmokers.

Cut back on alcohol

Heavy drinking increases blood pressure and interferes with blood pressure medication. Drinking has dietary drawbacks, too. For people battling their weight, alcohol adds “empty” calories with no nutritional value. A bottle of beer contains 146 calories (100 calories if it’s light beer) and a glass of wine has 123 calories. Some mixed drinks add fat and cholesterol, too. Eggnog with brandy, for example, serves up 288 calories with six grams of saturated fat, 11 grams of total fat, and 84 mg of cholesterol.

On the other hand, modest alcohol consumption has different effects. Numerous studies have shown that people who drink in moderation are at significantly lower risk for coronary artery disease than those who don’t drink. Moderate alcohol use for men is defined as no more than one ounce of alcohol (two drinks) a day. However, women absorb more alcohol than men and should limit their daily intake to half an ounce (one drink). Small or underweight people are more susceptible to the effects of alcohol than heavier people and should consume no more than half an ounce daily (see “How much alcohol is in your drink?”).

How much alcohol is in your drink? The following drinks contain about an ounce of alcohol: one ounce of 100-proof liquor 1 1/2 ounces (a jigger) of 80-proof liquor (bourbon, gin, rum, scotch, tequila, vodka, or whiskey) three ounces of fortified wine (sherry, port, marsala, or Madeira) four to five ounces of table wine 12 ounces of regular or light beer

Be active

Not only does regular exercise help prevent high blood pressure (see “Sedentary lifestyle”), but it’s also a proven treatment for existing hypertension.

The American College of Sports Medicine reviewed 40 studies on the effect of exercise on blood pressure. With regular aerobic exercise, participants were able to reduce their systolic and diastolic pressures an average of 11 mm Hg and 9 mm Hg, respectively. Although many studies focused on high-intensity exercises like running, several evaluated the impact of moderate activities such as walking. Surprisingly, moderate-intensity training provided the same or even better blood pressure–lowering benefits.

Need more reasons to get up and moving? In a study of severely hypertensive African American men, 10 of the 14 who rode a stationary bike for 45 minutes three times a week were able to lower their dosage of drugs that treat hypertension at the end of the 32-week trial. In addition, echocardiograms showed that thickness of the heart wall had diminished in all the men who exercised. A thickened heart wall, known as left ventricular hypertrophy, raises your risk of stroke, abnormal heart rhythm, and heart attack.

Study after study has shown that aerobic exercise — walking briskly, running, or cycling — provides a host of other health benefits, including weight loss and reduced cholesterol levels. Experts recommend that you get at least 30 minutes of moderate physical activity on all or most days of the week. Longer sessions can yield even greater health rewards. But it’s important to start any exercise program slowly and to gradually build up the intensity level and length of sessions. People with heart disease or other health problems should consult their doctors before starting an exercise program.

Regular exercise is a proven treatment for hypertension.

Attain a healthy weight

Not only can being overweight raise your blood pressure (see “Obesity”), but it can also increase your risk for diabetes, arthritis, sleep apnea, and some cancers. Achieving and maintaining a healthy weight is an important step in fighting these and many other illnesses.

People with hypertension who are more than 10% over their ideal weight may be able to reduce their blood pressure by weight loss alone. According to the May 2003 JNC report, you can reduce your systolic blood pressure by five mm Hg to 20 mm Hg for every 22 pounds you lose. A smaller weight loss can have an effect, too. Losing as few as 10 pounds can reduce your blood pressure.

What’s a healthy weight for you? Let the body mass index (BMI) guide you. To calculate your BMI, multiply your weight (in pounds) by 700 and divide that by the square of your height (in inches). Or see the chart below. The normal range for BMI is 19–24. A BMI of 25–29 indicates that the individual is overweight, while a BMI of 30 or above designates obesity.

Table 4: What’s your body mass index?
BMI (kg/m2)	19	20	21	22	23	24	25	26	27	28	29	30	35	40
Height	Weight
4’10”	91	96	100	105	110	115	119	124	129	134	138	143	167	191
4’11”	94	99	104	109	114	119	124	128	133	138	143	148	173	198
5’0”	97	102	107	112	118	123	128	133	138	143	148	153	179	204
5’1”	100	106	111	116	122	127	132	137	143	148	153	158	185	211
5’2”	104	109	115	120	126	131	136	142	147	153	158	164	191	218
5’3”	107	113	118	124	130	135	141	146	152	158	163	169	197	225
5’4”	110	116	122	128	134	140	145	151	157	163	169	174	204	232
5’5”	114	120	126	132	138	144	150	156	162	168	174	180	210	240
5’6”	118	124	130	136	142	148	155	161	167	173	179	186	216	247
5’7”	121	127	134	140	146	153	159	166	172	178	185	191	223	255
5’8”	125	131	138	144	151	158	164	171	177	184	190	197	230	262
5’9”	128	135	142	149	155	162	169	176	182	189	196	203	236	270
5’10”	132	139	146	153	160	167	174	181	188	195	202	209	243	278
5’11”	136	143	150	157	165	172	179	186	193	200	208	215	250	286
6’0”	140	147	154	162	169	177	184	191	199	206	213	221	258	294
6’1”	144	151	15	166	174	182	189	197	204	212	219	227	265	302
6’2”	148	155	163	171	179	186	194	202	210	218	225	233	272	311
6’3”	152	160	168	176	186	194	202	208	216	224	232	240	279	319
6’4”	156	164	172	180	189	197	205	213	221	230	238	246	287	328
To use this table, find your height in the left-hand column. Move across to your weight. The number at the top of the column is your BMI.
BMI			Under 19			19–24			25–29			30 and above
Interpretation			Underweight			Normal			Overweight			Obese

Stress less

Even though it’s vital to survival, stress has a bad reputation. When you perceive stress, your sympathetic nervous system triggers the “fight or flight” response to prepare your body for action. A release of hormones quickens your heart rate and breathing, and extra blood is pumped to your muscles and organs to provide them with a burst of energy. Stress keeps drivers alert, helps students excel, and spurs competitors to win. But ongoing stress has harmful long-term effects, including raising your blood pressure.

One study suggests that mental stress not only affects blood pressure, but may also thicken artery walls, a condition that can trigger heart attacks and strokes. Finnish researchers asked 901 men, ages 46–60, to perform a series of tests designed to provoke mild stress. Before the tests, the men had ultrasound images taken of their carotid arteries, the vessels in the neck that deliver blood to the brain. During the exams, the investigators electronically measured the participants’ blood pressure and heart rate. Men who showed the most exaggerated spikes in blood pressure while under stress had greater thickening of their artery walls than those who had smaller increases in blood pressure.

If you are often tense, the following stress reduction strategies can help.

Get enough sleep. Lack of sound sleep can affect your mood, mental alertness, energy level, and physical health.

Exercise. Physical activity alleviates stress and reduces your risk of becoming depressed.

Learn relaxation techniques. Meditation, progressive muscle relaxation, guided imagery, deep breathing exercises, and yoga are the mainstays of stress relief. Your local hospital may offer meditation or yoga classes, or you can learn about these techniques from books or videotapes.

Strengthen your social network. Studies show that social ties significantly protect health and well-being. Try to connect with others by taking a class, joining an organization, or participating in a support group.

Learn time-management skills. These skills can help you juggle work and family demands.

Confront stressful situations head-on. Don’t let stressful situations fester. Hold family problem-solving sessions and use negotiation skills at work.

Nurture yourself. Treat yourself to a massage. Truly savor an experience: Eat slowly, focusing on each bite of that orange, or soak up the warm rays of the sun or the scent of blooming flowers during a walk outdoors. Take a nap. Enjoy the sounds of music you find calming.

Talk to your doctor. If stress and anxiety persist, talk to your doctor about whether anti-anxiety medications could be helpful.

Quick stress relief exercises When you’ve got one minute. Place your hand just beneath your navel so you can feel the gentle rise and fall of your belly as you breathe. Breathe in. Pause for a count of three. Breathe out. Pause for a count of three. Continue to breathe deeply for one minute, pausing for a count of three after each inhalation and exhalation. When you’ve got 3 minutes. While sitting down, take a break from whatever you’re doing and check your body for tension. Relax your facial muscles and allow your jaw to fall open slightly. Let your shoulders drop. Let your arms fall to your sides. Allow your hands to loosen so that there are spaces between your fingers. Uncross your legs or ankles. Feel your thighs sink into your chair, letting your legs fall comfortably apart. Feel your shins and calves become heavier and your feet grow roots into the floor. Now breathe in slowly and breathe out slowly. Each time you breathe out, try to relax even more. When you’ve got 10 minutes. Try imagery. Start by sitting comfortably in a quiet room. Breathe deeply and evenly for a few minutes. Now picture yourself in a special place. Choose an image that conjures up good memories. What do you smell — the heavy scent of roses on a hot day, crisp fall air, the aroma of baking bread? What do you hear? Drink in the colors and shapes that surround you. Focus on sensory pleasures: the swoosh of a gentle wind, the soft cool grass tickling your feet. Passively observe intrusive thoughts and then gently disengage from them to return to the world you’ve created.