What lifestyle modification is recommended for a patient with hypertension?

Despite all that is known about its adverse health consequences, high blood pressure still is poorly controlled in the United States.1–5 Only about one third of patients with hypertension have achieved the National High Blood Pressure Education Program goal of 140/90 mm Hg or lower.1 With the mainstay of hypertensive therapy in the United States being pharmacotherapy, interventions such as lifestyle and dietary modification often are overlooked. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)1 recommends lifestyle modification for all patients with hypertension (i.e., blood pressure of 140/90 mm Hg or higher) or prehypertension (i.e., blood pressure of 120/80 to 139/89 mm Hg), a new category developed by JNC 7 to draw attention to earlier intervention. Although some lifestyle modifications may seem to offer only minimal blood pressure–lowering effects, they should not be discounted. A reduction in systolic blood pressure of 5 mm Hg has been associated in observational studies with reductions of 14 percent in mortality caused by stroke, 9 percent in mortality caused by heart disease, and 7 percent in all-cause mortality.6 In addition, a weight loss of 10 lb (4.5 kg), a realistic goal for most individuals who are overweight, can reduce or prevent hypertension.7

Recommended Lifestyle Modifications

Five lifestyle modifications are recommended by JNC 7 for reducing blood pressure: (1) reducing sodium intake, (2) increasing exercise, (3) moderating alcohol consumption, (4) following the Dietary Approaches to Stop Hypertension (DASH) eating plan (Table 1),8–10 and (5) losing weight.1 These modifications have been proven to reduce blood pressure, although their direct impact on morbidity and mortality is not yet known.

In the Trial Of Nonpharmacologic interventions in the Elderly (TONE) study,11 patients were randomized to a low-sodium diet (80 mEq per L [1.9 g; 80 mmol per L] per day) or usual care (i.e., no study-related counseling in lifestyle change). The intervention group had a 2.8 mm Hg greater reduction in systolic blood pressure than the control group. A later study12 assessed the impact on blood pressure of three levels of daily sodium intake: 150, 100, and 50 mEq per L (3.6, 2.4, and 1.2 g; 150, 100, and 50 mmol per L), representing a typical American diet, the upper end of recommended intake, and a limited intake, respectively. Results demonstrated a graded blood pressure response, with a correlation between greater reduction in blood pressure and lower sodium consumption. The recommended sodium intake is less than 100 mEq per L per day for all patients with hypertension or prehypertension.1,12

Aerobic exercise has positive effects on blood pressure whether or not a person has hypertension, producing average reductions of 4 mm Hg in systolic blood pressure and 3 mm Hg in diastolic blood pressure.13 Physicians should help patients find an activity that they enjoy, because enjoyment will increase their adherence. If a patient finds it difficult to make time to exercise, one suggestion might be a brisk walk at lunch, which helps break up the day and requires no additional time commitment. Physicians also could suggest that patients listen to books on tape while walking, which may help to maintain interest level. It is recommended that patients with prehypertension or hypertension exercise for 30 minutes on most days of the week.1

LIMITING ALCOHOL CONSUMPTION

Limiting alcohol consumption is an important lifestyle modification for reducing blood pressure. One meta-analysis14 indicated a dose-response relationship between decreased alcohol consumption and blood pressure reduction. Pooled results showed reductions of 3 mm Hg in systolic blood pressure and 2 mm Hg in diastolic blood pressure for patients in the alcohol reduction groups (average reduction of 67 percent from an average intake of three to six drinks per day at baseline).14 As part of a comprehensive lifestyle program, men should have no more than two alcoholic drinks per day and women no more than one per day.1,14

The DASH eating plan outlines a diet rich in fruits and vegetables; high in low-fat dairy products, potassium, magnesium, and calcium; and low in total saturated fats (Table 1).8–10 Following this plan has been shown to produce mean reductions of 6 mm Hg in systolic blood pressure and 3 mm Hg in diastolic blood pressure,12 and combining the plan with a reduction in sodium intake produces additional blood pressure reduction.12

In the PREMIER clinical trial,15 researchers assessed the impact on blood pressure of comprehensive lifestyle changes (i.e., reduced sodium intake, increased activity, moderate alcohol consumption, and weight loss) in addition to the DASH eating plan, compared with lifestyle changes alone or usual care (i.e., advice only). Participants in the lifestyle changes only group had a greater reduction in blood pressure than those in the usual care group, and this was further enhanced with the addition of the DASH eating plan. This was the first trial to demonstrate that all recommended lifestyle changes can be combined to reduce blood pressure successfully.

Potassium and sodium fluctuate antagonistically—a decrease in potassium leads to sodium retention, whereas an increase in potassium leads to sodium excretion, thereby promoting diuresis and natriuresis.16 Although the mechanism by which a diet low in potassium contributes to increased blood pressure is not known, it has been estimated that, in persons with essential hypertension, a diet low in potassium results in a systolic increase of 7 mm Hg because of increased sodium retention.17 Additionally, potassium supplementation appears to play an enhanced role in individuals with an initially high sodium intake.6 A meta-regression analysis of randomized trials that assessed blood pressure response to changes in potassium and sodium intake showed that increased intake of potassium could play a major role in the prevention of hypertension.18 Increased potassium resulted in a reduction of 2.42 mm Hg in systolic blood pressure and a drop of 1.57 mm Hg in diastolic blood pressure.18 Current recommendations, however, are to obtain adequate potassium intake through a healthy diet.1 Some of the organizations that provide helpful information about and support for the implementation of lifestyle modifications are listed in Table 2.

Weight loss is an important lifestyle modification in reducing blood pressure. A reduction of 10 lb can help reduce blood pressure or prevent hypertension.1 A reduction of approximately 20 lb (9 kg) may produce a reduction in systolic blood pressure of 5 to 20 mm Hg.1

Other Lifestyle Interventions

Nicotine released while smoking cigarettes is believed to impact blood pressure through arousal of the sympathetic nervous system followed by the release of norepinephrine and epinephrine.19 Cigarette use causes a 4-mm Hg increase in systolic blood pressure and a 3-mm Hg increase in diastolic blood pressure compared with placebo.20

Hypertension is a well-documented risk factor for cardiovascular disease and stroke.2 In patients with hypertension, there is an increase in cardiovascular events in those who smoke compared with those who do not. Studies have shown that men with high blood pressure who smoke have an increased risk of total, ischemic, and hemorrhagic stroke, and that this risk is related to the number of cigarettes smoked.21,22 Smoking cessation should be part of any comprehensive lifestyle modification plan to reduce the risk of high blood pressure and cardiovascular disease.

Vitamin C, omega-3 fatty acids, coenzyme Q10, and magnesium have been purported to reduce blood pressure. However, their use in management of hypertension is not recommended because of the lack of data from well-designed randomized controlled trials.

Meditation includes a variety of techniques, such as repetition of a word or phrase (the mantra) and careful attention to the process of breathing, to achieve a state of inner calm, detachment, and focus. Meditation was shown to reduce blood pressure in one well-designed study that addressed baseline blood pressure measurements adequately,23 although other studies have been inconsistent.24 Long-term follow-up of 202 patients in two small studies indicated that transcendental meditation may even reduce mortality in patients with hypertension.25 Meditation may have other benefits and does not appear to be harmful except to patients with psychosis.26