Lifestyle modification and hypertension prevention

Sima Ghezelbash(1), Azam Ghorbani(1)

Abstract
BACKGROUND: Hypertension, a clear risk factor for cardiovascular diseases, affects nearly one
billion people worldwide. Recent statistics have reported increasing mortality due to
hypertension which reveals the importance of prophylactic strategies in controlling blood
pressure. Lifestyle changes are one of the most effective ways to prevent and control
hypertension.
METHODS: This study was a comprehensive literature review performed through searches in
databases such as Medline, PubMed, Science Direct, Scopus, and Google Scholar using the
terms "lifestyle", "hypertension", "lifestyle modification", "risk factors for hypertension",
"nonpharmacologic treatment of hypertension", and "dietary and activity factors".
RESULTS: Lifestyle factors such as dietary behaviors and physical activity are associated with
hypertension. Several studies have indicated direct and indirect associations between
overweight and increased risk of hypertension. Increased consumption of grains, fruits,
vegetables, and milk and reduced consumption of sodium, fat, and alcohol are effective in
preventing and controlling hypertension. In addition, some studies have reported a 35%
reduction in risk of developing hypertension among individuals who engage in regular physical
activity compared to sedentary people.
CONCLUSION: Since lifestyle- and diet-related factors are often modifiable, perceptions of
their effects have specific importance in hypertension prevention and treatment.

Keywords: Blood Pressure, Lifestyle, Overweight, Physical Activity, Nutrition

ARYA Atherosclerosis Journal 2012, 8(Special Issue in National Hypertension Treatment): S202-S207
Date of submission: 17 Jan 2012, Date of acceptance: 13 Jun 2012

Introduction Although hypertension is an important and

Hypertension is an increasingly important medical common cardiovascular disease risk factor,4 it is not
and public health issue. It is among the most always taken seriously and is often poorly controlled.5
important life-threatening conditions in both Undiagnosed, untreated, and uncontrolled
industrial and developing countries.1 While as many as hypertension place a substantial strain on the
1 billion cases of hypertension are estimated healthcare delivery system.6,7 One reason for
worldwide, approximately 7.1 million deaths annually underdiagnosis is lack of symptoms which can leave
may be attributable to hypertension. The World people unaware of their high blood pressure.8 The
Health Organization (WHO) reported that Canadian Heart Health Survey (1985-92) found that
hypertension is responsible for 62% of cases of while 22% of adults 18-74 years of age had high
cerebrovascular disease and 49% of cases of ischemic blood pressure, 43% of them were unaware they had
heart disease. In addition, hypertension is the topmost hypertension, 22% were aware but untreated, 21%
risk factor for death worldwide.2 Moreover, were treated but not controlled, and only 13% were
hypertension is a main risk factor for stroke and treated and controlled.8
coronary heart disease and a major contributor to the Increased blood pressure is the leading cause of
onset and progression of chronic heart and kidney death and the second leading cause of disability
failure.3 worldwide.9 Each year, hypertension is responsible
Various studies have indicated that the prevalence for approximately 6 million disability-adjusted life
of hypertension and its related clinical events and years (DALYs) in the European Union.10 Over 90%
complications (e.g. myocardial infarction and stroke) of those living an average life span are expected to
appear to be increasing. The prevalence of develop hypertension4 which is largely reflective of
hypertension in Saudi Arabia is about 10% and a third their sedentary behavior, poor dietary habits, and
of the cases is poorly controlled.2 obesity.11,12 Much of the risk associated with

1- MSc, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran
Correspondence To: Azam Ghorbani, Email: [email protected]

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hypertension can be prevented by establishing controlled trials (RCT), the Dietary Approaches to
effective blood pressure control measures.13 Stop Hypertension (DASH), and the seventh report
Although there is increasing emphasis on of the Joint National Committee on prevention,
treatment with medication, lifestyle modification is an detection, evaluation, and treatment of high blood
important part of hypertension management.14,15 pressure (JNC 7) guidelines/recommendations, and
Blood pressure increases with weight, excessive expert panel discussions.
alcohol consumption, and high sodium intake but
decreases with regular physical activity.16 Discussion
Lifestyle modification is the foundation of Hypertension affects many people worldwide and
preventive management in individuals with available evidence suggests a beneficial influence of
cardiovascular disease risks such as obesity, lifestyle modification and dietary interventions. The
hypertension, dyslipidemia, and diabetes.17 In challenge for healthcare decision makers and
hypertensive individuals, lifestyle modification can be healthcare providers is to devise and implement
recommended as an initial treatment before the start clinical and public health strategies that help promote
of drug therapy and as an adjunct to medication in and maintain a combination of healthy diets and
those already on drug therapy. In hypertensive additional lifestyle modifications. Previous efforts to
individuals with medication-controlled blood prevent morbidity and mortality from hypertension
pressure, lifestyle modification may facilitate drug have focused mainly on the management of
step-down and drug withdrawal in highly motivated individuals with existing diseases.
individuals who achieve and maintain lifestyle Lifestyle modifications are an important part of
changes. In nonhypertensives, lifestyle modification hypertension management and include weight
has the potential to prevent hypertension, and more reduction, following the DASH eating plan with
broadly, to reduce blood pressure and thus lower the sodium restrictions, daily physical activity, and
risk of blood pressure-related clinical complications in moderate alcohol consumption. In addition, all
general populations. In fact, even an apparently small patients should be advised to stop smoking to reduce
reduction in blood pressure, if applied to an entire the risk of cardiovascular diseases.19,20 The JNC 7
population, may have an enormous beneficial effect advises primary care practitioners to recommend
on cardiovascular events. For instance, a 3-mmHg lifestyle modifications for all their prehypertensive
reduction in systolic blood pressure could lead to an and hypertensive patients (Table 1).7
8% reduction in stroke mortality and a 5% reduction Previous studies have shown that reducing dietary
in mortality from coronary heart disease.18 sodium by approximately 1700 mg (75 mmol) per day
Adoption of healthy lifestyle is critical for the can lower systolic blood pressure by 4-5 mmHg in
prevention of high blood pressure and is an hypertensive individuals and by 2 mmHg in
indispensable part of the management of individuals normotensive individuals.21,22 Reducing sodium intake
with hypertension.2 The purpose of this article was to may lessen the need for antihypertensive drugs. Some
evaluate lifestyle modification factors and their clinical trials have suggested that increasing dietary
relationship to the prevention of hypertension. potassium by approximately 2100 mg (54 mmol) per
day can reduce systolic blood pressure by 4-8 mmHg
Materials and Methods in hypertensive individuals and by 2 mmHg in
We reviewed numerous studies about lifestyle normotensive individuals. Potassium-rich whole
modification factors and the prevention of foods, such as bananas, kiwi fruit, avocado, potatoes
hypertension. Online literature searches were (with skin), nuts, and yogurt, are more effective in
performed to identify published studies on lifestyle reducing blood pressure than potassium supplements
modification in hypertension. We searched Medline, which are potentially toxic.23 High potassium intake
PubMed, Science Direct, and Scopus using the terms can produce hyperkalemia in people with impaired
"lifestyle", "hypertension", "risk factors for renal function and is therefore recommended only for
hypertension", "nonpharmacologic treatment of individuals with normal renal function.23
hypertension", "lifestyle modification", and "dietary Studies have suggested several possible
and activity factors". The searches were performed on mechanisms by which lifestyle modifications may
studies published between 2000 and 2011, from the decrease blood pressure. These mechanisms include
dates of origin of each database. This study included reduced oxidative stress due to decreased intake of
review articles, systematic review articles, randomized saturated fats, endothelium-dependent vascular

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Lifestyle modification and hypertension

Table 1. Recommendations of the seventh report of the Joint National Committee on prevention, detection, evaluation,
and treatment of high blood pressure (JNC 7) and the associated reductions in systolic blood pressure (SBP)
SBP Reduction
Modification Recommendation
Range*
Achieve and maintain normal body weight as measured by body 5-20 mmHg per10 kg
Weight reduction
mass index. Normal values range from 18.5-24.9 kg/m2. weight loss

Adopt a diet rich in fruits, vegetables, and low-fat dairy products

with reduced amount of saturated fat (DASH† eating plan is
DASH eating plan 8-14 mmHg
high in fiber, low in total and saturated fat, low in sodium, and
high in potassium)

Dietary sodium Reduce dietary sodium intake to ≤ 100 mmol/day

2-8 mmHg
reduction (2.4 g sodium or 6 g sodium chloride)

Aerobic physical Regular aerobic physical activity (e.g. brisk walking) at least 30
4-9 mmHg
activity minutes/day, most days of the week

Moderation of Men should drink less than 3 drinks per day. Women and
alcohol consumption lighter-weight men should not drink more than 1 drink per day 2-4 mmHg
(1 drink = 12 oz beer, 5 oz wine, 1.5 oz 80-proof alcohol).
*Effects of modifications are dose- and time-dependent.
† DASH: Dietary Approaches to Stop Hypertension

relaxation due to increased potassium intake, and this relationship is highlighted by the increasingly high
increased magnesium and calcium intake due to prevalence of overweight and obesity throughout the
greater fruit and vegetable consumption.24 world. Almost every clinical trial that has examined
Numerous studies have evaluated the effect of the influence of weight loss on blood pressure has
lifestyle modification on blood pressure. A recent documented weight reduction to lower blood
meta-analysis of 27 randomized trials documented a 4 pressure.18 Every 1% decrease in body weight lowers
mmHg net reduction in systolic blood pressure systolic blood pressure by an average of 1 mmHg.26
among Indonesian individuals assigned to an aerobic Surprisingly, reductions in blood pressure occur
exercise program.25 Interestingly, the magnitude of before (and sometimes without) achieving desirable
the change in blood pressure appeared to be body weights.18 In a meta-analysis, Dickson examined
independent of exercise intensity.18 Regular exercise is the effects of multiple lifestyle factors on blood
associated with an increase in high-density lipoprotein pressure in hypertensive adult patients (systolic blood
cholesterol and reductions in body weight, waist pressure ≥ 140 mmHg and diastolic blood pressure ≥
circumference, body fat percentage, insulin resistance, 85 mmHg). The authors found that an improved diet
systemic vascular resistance, plasma noradrenaline, (according to DASH) and aerobic exercise reduced
and plasma renin activity. A meta-analysis by Fagard systolic blood pressure by 5.0 mmHg and 4.6 mmHg,
and Cornelissen on the effects of dynamic aerobic respectively. On the other hand, restrictions in
endurance training or resistance training in alcohol and salt intake lowered systolic blood pressure
hypertensive and normotensive patients showed that by 3.8 mmHg and 3.6 mmHg, respectively. The
resistance training was associated with significant authors suggested that hypertensive patients should
reductions in blood pressure and cardiovascular risks, follow a weight-loss diet, participate in regular
such as systemic vascular resistance, norepinephrine exercise, and restrict their salt and alcohol
levels, and plasma renin activity.21 In a meta-analysis consumption.27 In another study, Viera et al. found a
on the effects of resistance training on resting blood significant mean weight reduction and an increase in
pressure, the authors concluded that moderate physical activity among males and females who
intensity resistance training may be an effective participated a 15-month lifestyle intervention
intervention for preventing and combating compared to the control group.17
hypertension.7 Thus, exercise is a cornerstone for In contrast to the direct relationship of salt intake
prevention, treatment, and control of blood pressure. with blood pressure, high levels of potassium are
Observational studies and clinical trials have associated with low blood pressure. Although
indicated that weight is positively associated with observational data has been reasonably consistent, data
blood pressure and hypertension. The importance of from individual clinical trials have been less consistent

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 S. Ghezelbash, A. Ghorbani

and persuasive.18,23 In a meta-analysis, He and patients incorporate TLC into their daily lives. In
MacGregor examined the effects of restricting salt addition, providers may not be familiar with the
intake on blood pressure in children (≤ 18 years). In guidelines for hypertension management, and patient
this study, salt reduction was associated with significant access to care may be limited by the lack of insurance
reductions in systolic blood pressure.28 Viera et al or by transportation problems in getting to the
concluded that a relatively intense 27-month doctor's office. Similarly, the number and complexity
intervention program was effective in improving of therapy-related factors associated with TLC (e.g.
lifestyle behaviors and decreasing cardiovascular the extent of dietary change and having to address
disease risks by the end of the program.17 smoking, diet, and exercise simultaneously) may
The relationship between high alcohol reduce adherence. Adverse effects such as injuries
consumption (typically 3 or more drinks daily) and may limit adherence to an exercise regimen, while
elevated blood pressure has been documented in cost may affect food choices. The manner in which
many epidemiologic studies. Trial studies have also providers view their relationship with their patients
reported that reductions in alcohol drinking can lower will influence their approach to sharing information
blood pressure in normotensive and hypertensive and responding to the needs articulated by the
male heavy drinkers.18 patient. Providers should elicit information to assess
Despite the beneficial effects of preventing the specific barriers in each individual case.29
hypertension and reducing blood pressure, designing There are 3 wide-range strategies to overcome
and implementing effective strategies that lead to barriers to TLC in hypertension management: 1)
sustained lifestyle modifications are difficult.29 There empowering patients; 2) enhancing cultural
are many barriers to the adoption of therapeutic competence of providers; and 3) targeting multiple
lifestyle changes (TLC) aimed at improving blood factors. Empowering patients involves patient-
pressure control.30,31 We grouped factors into centered care that emphasizes self-management
categories focusing on the patient, provider, therapy, supported by providers, family, and the community.
and medical/physical environment. We then assessed Increasing the cultural competence of providers and
the relationships between these categories (Figure 1). healthcare organizations enhances the use of
Various demographic, psychological, and strategies addressing the heritage, beliefs, and
sociocultural factors influence the extent to which behaviors of those receiving care. The likelihood of

Figure 1. Barriers to the adoption of therapeutic lifestyle changes

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Lifestyle modification and hypertension

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Authors have no conflict of interests. 2005 Canadian Hypertension Education Program
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