Lifestyle Changes to Treat High Blood Pressure
Lifestyle Changes to Treat High Blood Pressure
– Dr Cróchán O’Sullivan MD, PhD, FESC
Healthy lifestyle choices can prevent or delay the onset of high blood pressure or hypertension, defined as a blood pressure ³140/90mmHg.1
Hypertension is categorised as:
- Grade 1: 140-159/90-99mmHg.
- Grade 2: 160-179/100-109mmHg.
- Grade 3: ³180/110mmHg.1
What is the target blood pressure range for hypertensive individuals?
According the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) hypertension guideline document1 the target BP for hypertensive patients is:
- <65 years: 120-130/70-80mmHg
- >65 years: 130-140/70-80mmHg.1
In the United States, hypertension is defined as a blood pressure ³130/80mmHg and the target blood pressure is <130/80mmHg for all patients.2
The reason for the discrepancies between American and European guidelines are due to different interpretation of the same data and is beyond the scope of this article. Overall, however, there is >90% concordance between the US and European guideline documents.3
The cornerstone of successful blood pressure control is a healthy lifestyle and that is the focus of this article.
When are medications necessary to control high blood pressure?
Medications are necessary in patients at high cardiovascular risk with grade I hypertension, those with high normal BP (130-139/85-89mmHg) with established coronary artery disease, and in all patients with ³grade 2 hypertension.1
However, healthy lifestyle modification is also a sine qua non for all patients taking antihypertensive medications.1
Why is control of high blood pressure so important?
High blood pressure is a leading global contributor to premature death. For example, in 2015, hypertension accounted for almost 10 million deaths.4 The largest number of systolic blood pressure related deaths were due to ischaemic heart disease (e.g. heart attacks) (4.9 million), haemorrhagic stroke (stroke caused by a brain bleed) (2.0 million) and ischaemic stroke (stroke caused by blood clot) (1.5 million).4
High diastolic blood pressure is associated with increased cardiovascular risk and is more commonly elevated in younger (<50 years) vs. older patients. Diastolic blood pressure tends to decline from midlife as a consequence of arterial stiffening. Therefore, systolic blood pressure assumes even greater importance as a risk factor from midlife.5
Hypertension can lead to hypertensive mediated organ damage (HMOD) of the following organs:
Hypertension can result in an enlarged heart muscle (left ventricular hypertrophy), impaired relaxation of the heart muscle (diastolic dysfunction), left atrial enlargement, an increased risk of arrhythmias, especially atrial fibrillation, and an increased risk of heart failure.1
- Blood vessels
Hypertension can lead to coronary artery disease, carotid artery disease and other forms of peripheral vascular disease including aortic aneurysms.1
Hypertension is the second most important cause of chronic kidney disease after diabetes mellitus. Hypertension may also be the presenting feature of asymptomatic primary renal disease. The diagnosis of hypertension induced renal damage is based on the finding of reduced renal function (using the estimated glomerular filtration rate or eGFR) and/or the detection of albuminuria (using the albumin:creatinine ratio).1
Hypertensive changes detected in the eyes on fundoscopy include retinal haemorrhages, microaneurysms, hard exudates, cotton wool spots, and papilloedema. These changes indicate severe hypertensive retinopathy and are highly predictive of mortality. Fundoscopy (an eye test) should be performed in patients with grade 2 or 3 hypertension or hypertensive patients with diabetes, in whom significant retinopathy is more likely.1
Hypertension increases the prevalence of brain damage, of which transient ischaemic attack (TIA) and stroke are the most acute clinical manifestations. Brain damage can be detected in the asymptomatic phase by MRI, which may be recognized as white matter hyperintensities, silent microinfarcts, microbleeds, and brain atrophy. White matter hyperintensities and silent infarcts are associated with an increased risk of stroke and cognitive decline due to degenerative and vascular dementia. A family history of cerebral haemorrhage at middle age and early-onset dementia should prompt an MRI of the brain.1
What are the most important lifestyle changes that can control high blood pressure?
Effective lifestyle changes may be enough to delay or prevent the need for drug therapy in patients with grade 1 hypertension.1 Lifestyle changes can augment the effects of drug therapy but cannot replace drug therapy in patients with HMOD or those at a high level of cardiovascular risk. The major disadvantage of lifestyle modification is the poor compliance over time.6 The recommended lifestyle measures that have been shown to reduce blood pressure are sodium restriction, moderation of alcohol consumption, high consumption of vegetables and fruits, weight reduction and maintenance of an ideal body weight, regular physical activity and smoking cessation.1,2
Dietary sodium restriction
Dietary sodium should be limited to less than 2 g per day, which is roughly equivalent to less than 5g of salt per day (less than one small teaspoon of salt per day).1 In the United States, the recommendations are stricter i.e. less than 1.5 g of sodium per day.2
There is a direct relationship between sodium intake and BP, and excessive sodium consumption (more than 5g per day) has been shown to have a blood pressure raising effect and is associated with an increased prevalence of hypertension and a rise in systolic blood pressure with age.7
Conversely, sodium restriction has been shown to have a blood pressure lowering effect in may trials. A reduction of 1.75g sodium per day (4.4g salt/day) was associated with a mean 4.2/2.1mmHg reduction in SBP/DBP, with a more pronounced effect (5.4/2.8mmHg) in hypertensive patients.8
The blood pressure lowering effect of sodium restriction is greater in black people, in older patients, and in patients with diabetes, metabolic syndrome or chronic kidney disease.9 Sodium restriction in patients already taking BP lowering drugs may reduce the number or dose of BP-lowering drugs that are necessary to control blood pressure.10,11
The usual sodium intake on a global scale is between 3.5 and 5.5g per day (which corresponds to 9-12 g of salt per day), with marked differences between countries.1 The 2018 ESC/ESH guideline document recommends sodium intake to be limited to approximately 2g per day (equivalent to approximately 5g salt per day) in the general population and to try to achieve this goal in all hypertensive patients. Salt reduction is not easy and there is often poor appreciation of which foods contain high salt levels.
Patients with high blood pressure should avoid added salt and high-salt foods. A reduction in population salt intake remains a public health priority but requires a combined effort between the food industry, governments, and the general public, as 80% of salt consumption involves hidden salt in processed foods.
Increased potassium consumption
Increased potassium intake is associated with BP reduction and may have a protective effect, thereby modifying the association between sodium intake, blood pressure and cardiovascular disease.12 Whereas the 2018 ESC/ESH guideline document does not make any specific potassium intake recommendations, the AHA/ACC guidelines document recommends 3,500-5,000 mg/day of dietary potassium, preferable by eating a diet rich in potassium.2,3 Examples of foods rich in potassium include bananas, oranges, apricots, spinach, sweet potatoes, potatoes, mushrooms, peas and cucumbers among many others.
Moderation of alcohol consumption.
There is a direct correlation between alcohol consumption and blood pressure and cardiovascular risk.1 Binge drinking can have a strong blood pressure raising effect.1 Hypertensive men who drink alcohol should be advised to limit their consumption to 14 units per week and women to 8 units per week (1 unit is equal to 125mL of wine or 250mL of beer).1 Alcohol free days during the week and avoidance of binge drinking are advised.1
Hypertensive patients are advised to eat a healthy balanced diet containing vegetables, legumes (e.g. peas, beans, soybeans, lentils), fresh fruits, low-fat dairy products, wholegrains, fish, and unsaturated fatty acids (especially olive oil – see recent article on omega 3 fatty acids here) and to have a low consumption of red meat and saturated fatty acids.1
The Mediterranean diet includes many of these nutrients and foods, with a moderate consumption of alcohol (mostly wine with meals). A randomised controlled trial in high-risk individuals on the Mediterranean diet over 5 years showed a 29% cardiovascular risk reduction compared with a low-fat control diet, and a 39% reduction in stroke.13 The Mediterranean diet also significantly reduced blood pressure, blood glucose and lipid levels.14 The diet should be accompanied by other lifestyle changes such as physical exercise and weight loss.1
DASH stands for Dietary Approaches to Stop Hypertension and includes foods low in total fat, saturated fat, and cholesterol and lots of fruits, vegetables, and whole grains.2 Protein is supplied by low-fat dairy, fish, poultry, and nuts. Red meat, sweets, and sugary drinks are limited. DASH is high in fibre, potassium, calcium, and magnesium and low in sodium.2
Mediterranean or DASH diet?
Both diets are very good for blood pressure control if adhered to. The 2018 ESC/ESH guideline document explicitly mentioned the Mediterranean diet in the hypertension guidelines owing to the positive outcome data.1
Coffee and tea consumption
Caffeine has been shown to have an acute blood pressure raising effect. However, coffee consumption is associated with cardiovascular benefits. Green or black tea consumption may also have a small but significant blood pressure lowering effect.1
Excessive weight gain is associated with hypertension and reducing weight to an ideal body weight reduces blood pressure.15 In a meta-analysis, the mean SBP/DBP reductions associated with an average weight loss of 5.1 kg were 4.4/3.6 mmHg, respectively.16 Both overweight and obesity are associated with an increased risk of cardiovascular death and overall mortality.1 Weight reduction is recommended in overweight and obese hypertensive patients for control of metabolic risk factors, but weight stabilization may be a reasonable goal for many.1
Maintenance of a healthy body weight (BMI of approximately 20-25 kg/m2 in people <60 years of age; higher in older patients) and waist circumference (<94 cm for men and <80 cm for women) is recommended for non-hypertensive individuals to prevent hypertension, and for hypertensive patients to reduce BP.1 Weight loss can also improve the efficacy of antihypertensive medications and the cardiovascular risk profile.1 Weight loss should employ a multidisciplinary approach that includes dietary advice, regular exercise, and motivational counselling, especially since short-term results are often not maintained over the long-term.17
Regular physical activity
Physical activity induces an acute rise in systolic blood pressure, followed by a short-lived decline in blood pressure below baseline.1 Studies suggest that regular aerobic physical activity may be beneficial for both the prevention and treatment of hypertension and lowers cardiovascular risk and mortality. A meta-analysis of randomised controlled trials has shown that aerobic endurance training, dynamic resistance training, and isometric training reduce resting SBP and DBP by 3.5/2.5, 1.8/3.2 and 10.9/6.2 mmHg, respectively, in general populations.18 Endurance training, but not other types of training, reduces BP more in hypertensive patients (8.3/5.2mmHg). Regular physical activity of lower intensity and duration lowers BP less than moderate- or high-intensity training, but is associated with at least a 15% decrease in mortality.19,20
Hypertensive patients are advised to participate in at least 30 min of moderate-intensity dynamic aerobic exercise (walking, jogging, cycling, or swimming) on 5-7 days per week.1 Performance of resistance exercises on 2-3 days per week is also advised.1 For additional benefit in healthy adults, a gradual increase in aerobic physical activity to 300 min a week of moderate intensity or 150 min a week of vigorous-intensity aerobic physical activity, or an equivalent combination thereof, is recommended.1 The impact of isometric exercises on BP and CV risk is less well established.1
Smoking is a major risk factor for cardiovascular disease and cancer. Although the rate of smoking is declining in most European countries, especially in men, it is still common in many regions and age groups, and overall the prevalence remains high at 20-35% in Europe.21 Studies using ambulatory blood pressure monitors have shown that both normotensive subjects and untreated hypertensive smokers present high daily BP values than non-smokers.22 No chronic effect of smoking has been reported for office BP 23, which is not lowered by smoking cessation. Smoking is second only to BP in contributing risk to the global burden of disease, and smoking cessation is probably the single most effective lifestyle measure for the prevention of cardiovascular disease, including stroke, myocardioal infarction and peripheral vascular disease.24,25 Therefore, hypertensive smokers should be urged to quit smoking.1
Take home messages
- All patients with high blood pressure should make healthy lifestyle choices to control blood pressure.
- Healthy lifestyle changes can delay or obviate the need for medications in many cases.
- Dietary sodium restriction, increased potassium consumption, moderation of alcohol consumption, a healthy diet, weight reduction, increased physical activity and smoking cessation are the most important lifestyle interventions to control high blood pressure.
- Williams B, Mancia G, Spiering W et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). European Heart Journal 2018.00.1-98 doi:10.1093/eurheartj/ehy339.
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/SPhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:2199-269.
- Bakris G, Ali W, Parati G. ACC/AHA Versus ESC/ESH on Hypertension Guidelines. JACC guideline comparison. J Am Coll Cardiol 2019;73:3018-26.
- Forouzanfar MH, Liu P, Roth GA et al. Global burden of hypertension and systolic blood pressure of at least 110 to 115 mmHg 1990-2015. JAMA 2017;317:165-182.
- Franklin SS, Khan SA, Wong ND, Larson MG, Levy D. Is pulse pressure useful in predicting risk for coronary heart disease? The Framingham heart study. Circulation 1999;100:354-360.
- Whelton PK, Appel LJ, Espeland MA, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interfventions in the elderly (TONE). TONE Collaborative Research Group. JAMA 1998;279:839-846.
- Elliott P, Stamler J, Nichols R et al. Intersalt revisited: further analyses of 24 hour sodium excretion and blood pressure within and across populations. Intersalt Cooperative Research Group. BMJ 1996;312:1249-1253.
- He FJ, Li J, Macgregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database Syst Rev 2013;4:CD004937.
- Suckling RJ, He FJ, Markandu ND, MacGregor GA. Modest salt reduction lowers blood pressure and albumin excretion in impaired glucose tolerance and type 2 diabetes mellitus: a randomized double-blind trial. Hypertension 2016;67:1189-1195.
- Graudal NA, Hubeck-Graudal T, Jurgens G. Effects of low-sodium diet vs. high-sodium diet on blood pressure, renin, aldosterone, catecholamijnes, cholesterol, and triglyceride (Cochrane Review). Am J Hypertens 2012;25:1-15.
- He FJ, MacGregor FA. How far should salt intake be reduced? Hypertension 2003;42:1093-1099.
- O’Donnell M, Mente A, Rangarajan S, et al. PURE Investigators. Urinary sodium and potassium excretion, mortality, and cardiovascular events. N Engl J Med 2014;371:612-623.
- Estruch R, Ros E, Salas-Salvado J, et al. PREDIMED Study Investigators. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279-1290.
- Domenech M, Roman P, Lapetra J, et al. Mediterranean diet reduces 24-hour ambulatory blood pressure, blood glucose, and lipids: one-year randomized, clinical trial. Hypertension 2014;64:69-76.
- Hall JE, do Carmo JM, da Silva AA, Wang Z, Hall ME. Obesity-induced hypertension: interaction of neurohumoral and renal mechanisms. Circ Res 2015;116:991-1006.
- Neter JE, Stam BE, Kok FJ, Grobbee DE, Geleijnse JM. Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2003;42:878-884.
- Jebb SA, Ahern AL, Olson AD, et al. Primary care referral to a commercial provider for weight loss treatment versus standard care: a randomised controlled trial. Lancet 2011;378:1485-1492.
- Cornelissen VA, Smart NA. Exercise training for blood pressure: a systematic review and meta-analysis. J Am Heart Assoc 2013;2:e004473.
- Leitzmann MF, Park Y, Blair A, et al. Physical activity recommendations and decreased risk of mortality. Arch Intern Med 2007;167:2453-2460.
- Rossi A, Dikareva A, Bacon SL, Daskalopoulou SS. The impact of physical activity on mortality in patients with high blood pressure: a systematic review. J Hypertens 2012;30:1277-1288.
- Kotseva K, Wood D, De Bacquer D et al. EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol 2016;23:636-648.
- Groppelli A, Giorgi DM, Omboni S, Parati G, Mancia G. Persistent blood pressure increase induced by heavy smoking. J Hypertens 1992;10:495-499.
- Primatesta P, Falaschetti E, Gupta S, Marmot MG, Poulter NR. Association between smoking and blood pressure: evidence from the health survey for England. Hypertension 2001;37:187-193.
- Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years’ observations on male British doctors. BMJ 1994;309:901-911.
- Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2224-2260.