The 2017 American College of Cardiology (ACC) and American Heart Association (AHA) guidelines for the treatment of hypertension recommend several evidence-based nonpharmacological interventions that can lower blood pressure (BP).1 Interventions that had the strongest evidence included weight loss, a heart healthy diet, such as the DASH diet, sodium reduction, potassium supplementation, increased physical activity, and alcohol restriction.2
Other dietary interventions to lower BP have been studied, but the evidence to date is not yet strong enough to recommend them.1 These include garlic,3,4 green tea,5 probiotics,6 dietary protein,7 fiber,8 flaxseed,9 fish oil,10 dark chocolate,11,12 calcium,13 and magnesium.14
Some behavioral therapies also show promise for short-term benefits, but lack rigorous studies evaluating a longer-term BP-lowering effect.1,15 These include stress reduction,16,17 yoga,18 and transcendental meditation.19–21
Diet and Nutrition
Weight loss in people who are overweight and have hypertension has been shown to be effective in lowering BP.22 Neter et al. conducted a meta-analysis of 25 (total n=4,874) randomized controlled trials to estimate the impact of weight reduction on BP and found that, on average, weight loss of 5.1 kg (11.2 pounds) by diet or exercise reduced systolic BP by 4.44 mm Hg (95% confidence interval [CI] [2.95 – 5.93]) and diastolic BP by 3.57 (95% CI [2.25 – 4.88]).22 The BP-lowering effect was even greater in people who were also taking antihypertensive medications. A 2016 Cochrane systematic review concluded that while weight loss reduces BP, it is difficult to estimate the magnitude of the impact on BP and all cause morbidity and mortality because of the small number of randomized controlled studies of adequate duration that have studied these effects.23
Eating foods that are high in sodium and low in potassium increases the risk for high BP.24 Both reductions in sodium and increases in dietary potassium appear to improve BP levels, especially among people who are overweight or obese.25–28 Depending on the degree of salt reduction, systolic BP may drop as much as 3 – 4 mm Hg and diastolic BP by 1 – 2 mm Hg, and more in individuals with hypertension at baseline.26,28 Increasing potassium in the diet of people with hypertension was shown to lower mean systolic BP by 3 – 4 mm Hg and diastolic by 1 – 2 mm Hg.27
The DASH dietary pattern (Dietary Approaches to Stop Hypertension) has been tested in randomized clinical control studies to evaluate its effect on cardiovascular risk factors.29,30 The DASH Sodium trial and other studies demonstrated the diet’s beneficial effect on BP and serum cholesterol, particularly among people with very high BP.31,32 Depending on baseline levels of BP the DASH diet has been shown to lower systolic BP by 5 – 7 mm Hg and diastolic BP by 3 – 4 mmHg.29-30,32 Even greater reduction in BP may be seen in patients with hypertension at baseline.32
Dietary patterns, other than the DASH diet, including low carbohydrate, vegetarian, and Mediterranean diets, have also been shown to lower BP, but further study is needed before they can be recommended specifically as an antihypertensive strategy.1,33,34
Although the quality of the overall evidence is varied, the most recent meta-analyses confirm that moderate-intensity aerobic exercise can significantly lower BP within a few months of initiation. It is generally felt that at least 30 minutes per day of aerobic exercise on most days of the week is needed to achieve a BP-lowering effect.35,36 Because there is a risk of musculoskeletal injury and cardiovascular risk in some individuals, this level of aerobic exercise is recommended when there is no medical contraindication. A meta-analysis of aerobic exercise interventions found such training could reduce systolic BP by 3 – 4 mm Hg and diastolic BP by 2- 4 mm Hg.35 Even greater BP reductions were seen among people with hypertension at baseline.
Resistance (dynamic and isometric) training has been shown to lower BP.35,37–40 Ninety to 150 minutes per week of dynamic resistance activity or three sessions per week of isometric resistance work for a minimum of eight to ten weeks is estimated to be needed to see BP effects.1 Although meta-analyses of the effects of isometric resistance exercise are limited by small numbers, the effects of blood pressure have been shown to be large after sustained programs of 4 weeks or more. Drops in systolic BP range from 6 – 13 mm Hg and in diastolic BP from 4 – 6 mm Hg.37-40
Consumption of alcohol is known to have a direct effect on BP and 2017 ACC/AHA guidelines recommend that alcohol be limited to no more than two drinks per day for adult men and one drink per day for adult women.1 Hypertensive individuals who drink in excess of this recommendation can be expected to reduce their systolic BP on average by 4 mm Hg if they adopt the recommended level of consumption.41–43
Other Natural Interventions
Scientists have studied other possible nonpharmacological non-dietary approaches to lowering BP including meditation, yoga, relaxation therapies, biofeedback, device-guided breathing, and acupuncture.44 The AHA reviewed the strength of evidence for these non-pharmacological approaches to lowering blood pressure and issued a scientific statement.44 It is the consensus in this statement that it is reasonable for all individuals with BP levels >120/80 mm Hg to consider trials of alternative approaches as adjuvant methods to help lower BP when clinically appropriate. Some individuals with stage 1 hypertension who desire avoiding medications can use alternatives to drug therapy for a trial of six to twelve months to see if BP <140/90 mm Hg can be maintained or lowered without medication. The AHA recommends that other individuals with Stage 1 or 2 hypertension use non-pharmacologic treatments as a supplement to drug therapy.
Alternative modalities that were identified with some promising but insufficient evidence to recommend as an antihypertension treatment might be considered as adjuvant methods to lower BP. These are summarized below.
Meditation and Yoga
Originally designed as a path to improve awareness by transcending thought, transcendental meditation (TM) has been incorporated into a mindfulness-based stress reduction technique.19 The practice has been studied by several high quality randomized control studies with respect to its effect on lowering BP that found modest, but statistically significant reductions in clinic systolic and diastolic BP among those practicing TM compared to controls.17,20,21 A more recent systematic review and meta-analysis included studies that compared individuals participating in a combined yoga and mindfulness-based stress reduction program to a control group and reviewed their effect on physiological parameters, including BP.15 Average BP dropped about 5/3 mm Hg after intervention, compared to controls. Studies of yoga alone as an intervention to reduce blood pressure are generally of poorer quality, and because yoga can be associated with musculoskeletal risks, evidence is currently insufficient to recommend yoga as a BP-lowering treatment whose benefits outweigh its potential risks.44
The Food and Drug Administration has approved a device designed to achieve slow breathing for use in stress reduction and BP management.45 The device uses a belt around the chest that feeds information about the respiratory rate to a control box that generates musical tones as feedback to the user. The device has been shown to be an effective way for people to modulate their breathing with the goal of stress reduction. A number of studies have been conducted to evaluate its effectiveness in reducing BP. Although some clinical trials exist that demonstrate a BP-lowering effect, others do not.46 The quality of the existing studies are variable. In one study in the office setting, device-guided breathing resulted in an average drop in BP of about 3/2 mm Hg, a significant difference compared to controls.46 The AHA position statement felt that the preponderance of evidence suggested the device can significantly lower BP and that it was reasonable to use device-guided breathing techniques to lower BP in a clinical setting.44
Biofeedback techniques to control BP provide information feedback that can be used by an individual to lower BP.44 Techniques that are included under this heading are cognitive behavior therapy, behavioral training, relaxation therapy, guided imagery, and psychological education. BP responses are provided to the patient during active therapy to identify thoughts or activities that could be responsible for the change in BP. Some recent trials have suggested that certain biofeedback techniques can reduce BP, but overall the results are inconsistent, and more study is needed.47–49
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. J Am Coll Cardiol 2018; 71 (19): e127-e248.
- Appel LJ, Champagne CM, Harsha DW, et al. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003; 289 (16): 2083-2093.
- Rohner A, Ried K, Sobenin IA, Bucher HC, Nordmann AJ. A systematic review and metaanalysis on the effects of garlic preparations on blood pressure in individuals with hypertension. Am J Hypertens 2015; 28 (3): 414-423.
- Ried K, Frank OR, Stocks NP, Fakler P, Sullivan T. Effect of garlic on blood pressure : a systematic review and. BMC Cardiovasc Disord 2008; 12 : 1-12.
- Li G, Zhang Y, Thabane L, et al. Effect of green tea supplementation on blood pressure among overweight and obese adults: a systematic review and meta-analysis. J Hypertens 2015; 33 (2): 243-254.
- Khalesi S, Sun J, Buys N, Jayasinghe R. Effect of probiotics on blood pressure: a systematic review and meta-analysis of randomized, controlled trials. Hypertens 2014; 64 (4): 897-903.
- Tielemans SMAJ, Altorf-van der Kuil W, Engberink MF, et al. Intake of total protein, plant protein and animal protein in relation to blood pressure: a meta-analysis of observational and intervention studies. J Hum Hypertens 2013; 27 (9): 564-571.
- Streppel MT, Arends LR, van ’t Veer P, Grobbee DE, Geleijnse JM. Dietary fiber and blood pressure: a meta-analysis of randomized placebo-controlled trials. Arch Intern Med 2005; 165 (2): 150-156.
- Rodriguez-Leyva D, Weighell W, Edel AL, et al. Potent antihypertensive action of dietary flaxseed in hypertensive patients. Hypertens 2013; 62 (6): 1081-1089.
- Campbell F, Dickinson HO, Critchley JA, Ford GA, Bradburn M. A systematic review of fish-oil supplements for the prevention and treatment of hypertension. Eur J Prev Cardiol 2013; 20 (1): 107-120.
- Egan BM, Laken MA, Donovan JL, Woolson RF. Does dark chocolate have a role in the prevention and management of hypertension?: commentary on the evidence. Hypertens 2010; 55 (6): 1289-1295.
- Ried K, Sullivan TR, Fakler P, Frank OR, Stocks NP. Effect of cocoa on blood pressure. Cochrane Database Syst Rev 2012;(8): CD008893.
- Cormick G, Ciapponi A, Cafferata ML, Belizan JM. Calcium supplementation for prevention of primary hypertension. Cochrane Database Syst Rev 2015;(6): CD010037.
- Zhang X, Li Y, Del Gobbo LC, et al. Effects of magnesium supplementation on blood pressure: a meta-analysis of randomized double-blind placebo-controlled trials. Hypertens 2016; 68 (2): 324-333.
- Pascoe MC, Thompson DR, Ski CF. Yoga, mindfulness-based stress reduction and stress-related physiological measures: a meta-analysis. Psychoneuroendocrinology 2017; 86 : 152-168.
- Nagele E, Jeitler K, Horvath K, et al. Clinical effectiveness of stress-reduction techniques in patients with hypertension: systematic review and meta-analysis. J Hypertens 2014; 32 (10): 1936-44.
- Rainforth M V, Schneider RH, Nidich SI, Gaylord-King C, Salerno JW, Anderson JW. Stress reduction programs in patients with elevated blood pressure: a systematic review and meta-analysis. Curr Hypertens Rep 2007; 9 (6): 520-528.
- Wang J, Xiong X, Liu W. Yoga for essential hypertension: a systematic review. PLoS One 2013; 8 (10): e76357.
- Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA 2008; 300 (11): 1350-1352.
- Anderson JW, Liu C, Kryscio RJ. Blood pressure response to transcendental meditation: a meta-analysis. Am J Hypertens 2008; 21 (3): 310-316.
- Nidich SI, Rainforth M V, Haaga DAF, et al. A randomized controlled trial on effects of the Transcendental Meditation program on blood pressure, psychological distress, and coping in young adults. Am J Hypertens 2009; 22 (12): 1326-1331.
- Neter JE, Stam BE, Kok FJ, Grobbee DE, Geleijnse JM. Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. 2003: 878-884.
- Semlitsch T, Jeitler K, Berghold A, et al. Long-term effects of weight-reducing diets in people with hypertension. Cochrane Database Syst Rev 2016; 3 : CD008274.
- Centers for Disease Control and Prevention : High blood pressure fact sheet. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm. Accessed Dec 13, 2018.
- Aaron KJ, Sanders PW. Role of dietary salt and potassium intake in cardiovascular health and disease: a review of the evidence. Mayo Clin Proc 2013; 88 (9): 987-995.
- Aburto NJ, Ziolkovska A, Hooper L, Elliott P, Cappuccio FP, Meerpohl JJ. Effect of lower sodium intake on health: systematic review and meta-analyses. BMJ 2013; 346 : f1326.
- Aburto NJ, Hanson S, Gutierrez H, Hooper L, Elliott P, Cappuccio FP. Effect of increased potassium intake on cardiovascular risk factors and disease: systematic review and meta-analyses. BMJ 2013; 346 : f1378.
- He FJ, Li J, Macgregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database Syst Rev 2013;(4): CD004937.
- Saneei P, Salehi-Abargouei A, Esmaillzadeh A, Azadbakht L. Influence of Dietary Approaches to Stop Hypertension (DASH) diet on blood pressure: a systematic review and meta-analysis on randomized controlled trials. Nutr Metab Cardiovasc Dis 2014; 24 (12): 1253-1261.
- Schwingshackl L, Chaimani A, Schwedhelm C, et al. Comparative effects of different dietary approaches on blood pressure in hypertensive and pre-hypertensive patients: A systematic review and network meta-analysis. Crit Rev Food Sci Nutr May 2018: 1-14.
- Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001; 344 (1): 3-10.
- Juraschek SP, Miller ER 3rd, Weaver CM, Appel LJ. Effects of sodium reduction and the DASH diet in relation to baseline blood pressure. J Am Coll Cardiol 2017; 70 (23): 2841-2848.
- Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts. N Engl J Med 2018; 378 (25): e34.
- Mozaffarian D. The promise of lifestyle for cardiovascular health: time for implementation. J Am Coll Cardiol 2014; 64 (13): 1307-1309.
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- Cornelissen VA, Smart NA. Exercise training for blood pressure: a systematic review and meta-analysis. J Am Heart Assoc 2013; 2 (1): e004473.
- Cornelissen VA, Fagard RH, Coeckelberghs E, Vanhees L. Impact of resistance training on blood pressure and other cardiovascular risk factors: a meta-analysis of randomized, controlled trials. Hypertension 2011; 58 (5): 950-958.
- Carlson DJ, Dieberg G, Hess NC, Millar PJ, Smart NA. Isometric exercise training for blood pressure management: a systematic review and meta-analysis. Mayo Clin Proc 2014; 89 (3): 327-334.
- Kelley GA, Kelley KS. Isometric handgrip exercise and resting blood pressure: a meta-analysis of randomized controlled trials. J Hypertens 2010; 28 (3): 411-418.
- Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2001; 38 (5): 1112-1117.
- Roerecke M, Tobe SW, Kaczorowski J, et al. Sex-specific associations between alcohol consumption and incidence of hypertension: a systematic review and meta-analysis of cohort studies. JAMA 2018; 7 (13).
- Roerecke M, Kaczorowski J, Tobe SW, Gmel G, Hasan OSM, Rehm J. The effect of a reduction in alcohol consumption on blood pressure: a systematic review and meta-analysis. Lancet Public Heal 2017; 2 (2): e108-e120.
- Brook RD, Appel LJ, Rubenfire M, et al. Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Aassociation. Hypertension 2013; 61 (6): 1360-1383.
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