The 2017 American College of Cardiology (ACC) and American Heart Association (AHA) hypertension guidelines state that doctors should promote nonpharmacological therapy to everyone with elevated blood pressure or diagnosed hypertension.1 Nonpharmacological therapy includes healthy diet,1-4 weight loss,1,5 sodium reduction,1,6-8 exercise,1,9-20 enhanced intake of dietary potassium,1,21-25 smoking cessation,1,26-28 and moderating alcohol consumption.1,29-34 Doctors should reassess blood pressure in three to six months for people just adopting healthy habits. People adopting healthy habits and started on antihypertensive medication should be assessed in one month.
Evidence shows that lowering blood pressure decreases the risk of adverse cardiovascular outcomes such as heart disease, stroke, and death.35-38 It may also slow the progression of kidney damage in people with chronic kidney disease.39 Further, meta-analyses as well as national and international guidelines suggest that lowering blood pressure decreases risk of these outcomes regardless of which hypertensive-lowering method is used. 35-38
A summary of blood pressure reduction for each nonpharmacological modality is given below. The details of systematic reviews, meta-analyses, clinical guidelines, and studies cited to support the recommendation for each therapy are explained in depth in the specific PALS article dedicated to that lifestyle recommendation.
The 2017 ACC/AHA guidelines recommend a heart-healthy diet as it will help people with elevated or high blood pressure (>120/80 mm Hg) meet their weight goals. [Strong Recommendation (Level A)].1 Adopting a healthy diet can result in a significant blood pressure reduction.1-3 In normotensive patients, systolic blood pressure is reduced by about 3 mm Hg and in hypertensives by about 11 mm Hg.
In the 2017 ACC/AHA guidelines, weight loss is specifically recommended for adults with elevated or high blood pressure who are overweight or obese [Strong Recommendation (Level A)].1 The best goal is an individual’s ideal body weight which is a body mass index (BMI) between 18.5 and 25. But recognizing this is unrealistic for many overweight and obese people, they recommend most overweight adults should aim to lower body weight by at least 1 kg (2.2 lbs). People can expect about 1 mm Hg reduction for every 1 kg (2.2 lbs) of weight loss.
Adults should ultimately aim for less than 1500 mg/day of sodium in their diet but at a minimum should reduce their intake by at least 1000 mg/day.1 Reducing dietary sodium can result in about a 5 mm Hg reduction in systolic blood pressure.1,6-8
Increasing dietary potassium to between 3500 to 5000 mg/day can lower systolic blood pressure by about 4 – 5 mm Hg.1,21
Alcohol in Moderation
According to the 2017 ACC/AHA Hypertension Guidelines alcohol is a substance that has the potential to impair blood pressure control.1 They recommend limiting alcohol to ≤1 drink daily for women and ≤2 drinks for men. In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).1,29,30 Evidence reviewed by the panel shows that for heavy drinkers, reducing alcohol intake to this amount may result in a reduction of blood pressure by 4 mm Hg systolic and 3mm Hg diastolic or more, regardless of other interventions.1,31-34
Increased physical activity that includes a structured program of exercise is recommended for adults with elevated blood pressure or hypertension.1 Studies show that aerobic exercise for 90 – 150 minutes a week can result in a blood pressure reduction of 5/8 mm Hg in hypertensive people.17,18 All studies included were a minimum of four weeks duration. Dynamic resistance exercise for 90 – 150 minutes a week can result in a systolic blood pressure reduction of 4 mm Hg.17 Isometric resistance exercise can result in a 5 mm Hg systolic blood pressure reduction in about eight to ten weeks.19,20
Cigarette smoking is known to increase the risk of heart attacks and stroke.40,41 It raises blood pressure acutely, an effect that lasts 15 minutes or more.26 It damages the endothelial lining of the blood vessels over time causing vascular stiffening, inflammation, and the development of atherosclerotic plaque which leads to cardiovascular events.41,42 It is not clear if smoking increases the risk of hypertension. Some studies have shown a positive association between smoking and hypertension5,6 while others have failed to show an association.43,44
- 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: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2017.
- 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.
- Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997; 336 (16): 1117-1124.
- Gay HC, Rao SG, Vaccarino V, Ali MK. Effects of different dietary interventions on blood pressure: systematic review and meta-analysis of randomized controlled trials. Hypertension 2016; 67 (4): 733-739.
- Expert panel report: guidelines (2013) for the management of overweight and obesity in adults. Obesity (Silver Spring) 2014; 22 Suppl 2: S41-410.
- 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.
- He FJ, Li J, Macgregor GA. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ 2013; 346: f1325.
- 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.
- Whitworth JA. 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens 2003; 21 (11): 1983-1992.
- Diaz KM, Shimbo D. Physical activity and the prevention of hypertension. Curr Hypertens Rep 2013; 15 (6): 659-668.
- Fagard RH. Exercise is good for your blood pressure: effects of endurance training and resistance training. Clin Exp Pharmacol Physiol 2006; 33 (9): 853-856.
- Arakawa K. Antihypertensive mechanism of exercise. J Hypertens 1993; 11 (3): 223-229.
- Hagberg JM, Montain SJ, Martin WH, 3rd, Ehsani AA. Effect of exercise training in 60- to 69-year-old persons with essential hypertension. Am J Cardiol 1989; 64 (5): 348-353.
- Kiyonaga A, Arakawa K, Tanaka H, Shindo M. Blood pressure and hormonal responses to aerobic exercise. Hypertension 1985; 7 (1): 125-131.
- Chopra S, Baby C, Jacob JJ. Neuro-endocrine regulation of blood pressure. Indian J Endocrinol Metab 2011; 15 Suppl 4: S281-288.
- Foy CG, Foley KL, D'Agostino RB, Jr., Goff DC, Jr., Mayer-Davis E, Wagenknecht LE. Physical activity, insulin sensitivity, and hypertension among US adults: findings from the Insulin Resistance Atherosclerosis Study. Am J Epidemiol 2006; 163 (10): 921-928.
- Cornelissen VA, Smart NA. Exercise training for blood pressure: a systematic review and meta-analysis. J Am Heart Assoc 2013; 2 (1): e004473.
- Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002; 136 (7): 493-503.
- 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.
- Inder JD, Carlson DJ, Dieberg G, McFarlane JR, Hess NC, Smart NA. Isometric exercise training for blood pressure management: a systematic review and meta-analysis to optimize benefit. Hypertens Res 2016; 39 (2): 88-94.
- Whelton PK, He J, Cutler JA, et al. Effects of oral potassium on blood pressure. Meta-analysis of randomized controlled clinical trials. JAMA 1997; 277 (20): 1624-1632.
- Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation 2012; 125 (1): e2-e220.
- Weaver CM. Potassium and health. Adv Nutr 2013; 4 (3): 368s-377s.
- 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.
- Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the dietary guidelines for Americans, 2005. Washington, DC: U.S. Department of Agriculture, Agricultural Research Service; 2004.
- Groppelli A, Giorgi DM, Omboni S, Parati G, Mancia G. Persistent blood pressure increase induced by heavy smoking. J Hypertens 1992; 10 (5): 495-499.
- Halperin RO, Gaziano JM, Sesso HD. Smoking and the risk of incident hypertension in middle-aged and older men. Am J Hypertens 2008; 21 (2): 148-152.
- Bowman TS, Gaziano JM, Buring JE, Sesso HD. A prospective study of cigarette smoking and risk of incident hypertension in women. J Am Coll Cardiol 2007; 50 (21): 2085-2092.
- National Institute on Alcohol Abuse and Alcoholism (NIAAA). What is a standard drink? 2018; https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/what-standard-drink. Accessed Mar 17, 2018.
- Moyer VA. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2013; 159 (3): 210-218.
- 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 Health 2017; 2 (2): e108-e120.
- Stewart SH, Latham PK, Miller PM, Randall P, Anton RF. Blood pressure reduction during treatment for alcohol dependence: results from the Combining Medications and Behavioral Interventions for Alcoholism (COMBINE) study. Addiction 2008; 103 (10): 1622-1628.
- 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.
- Lang T, Nicaud V, Darne B, Rueff B. Improving hypertension control among excessive alcohol drinkers: a randomised controlled trial in France. The WALPA Group. J Epidemiol Community Health 1995; 49 (6): 610-616.
- Ahluwalia M, Bangalore S. Management of hypertension in 2017: targets and therapies. Curr Opin Cardiol 2017; 32 (4): 413-421.
- James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA 2014; 311 (5): 507-520.
- Pignone M, Viera AJ. Blood pressure treatment targets in adults aged 60 years or older. Ann Intern Med 2017; 166 (6): 445-445.
- Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2017; 166 (6): 430-430.
- KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl (2011) 2013; 3 (1): i-150.
- American Heart Association. Smoking, high blood pressure, and your health. 2016; http://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/smoking-high-blood-pressure-and-your-health. Accessed November 1, 2018.
- Virdis A, Giannarelli C, Neves MF, Taddei S, Ghiadoni L. Cigarette smoking and hypertension. Curr Pharm Des 2010; 16 (23): 2518-2525.
- Takami T, Saito Y. Effects of smoking cessation on central blood pressure and arterial stiffness. Vasc Health Risk Manag 2011; 7: 633-638.
- Thuy AB, Blizzard L, Schmidt MD, Luc PH, Granger RH, Dwyer T. The association between smoking and hypertension in a population-based sample of Vietnamese men. J Hypertens 2010; 28 (2): 245-250.
- Li H, Tong W, Wang A, Lin Z, Zhang Y. Effects of cigarette smoking on blood pressure stratified by BMI in Mongolian population, China. Blood Press 2010; 19 (2): 92-97.