Lifestyle Management of Hypertension .3

ISH Paper
Lifestyle management of hypertension: International

Society of Hypertension position paper endorsed by
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the World Hypertension League and European

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Society of Hypertension
Fadi J. Charchar a,b,c, Priscilla R. Prestes a, Charlotte Mills d, Siew Mooi Ching e,f,
Dinesh Neupane g, Francine Z. Marques h,i, James E. Sharman j, Liffert Vogt k, Louise M. Burrell l,
Lyudmila Korostovtseva m, Manja Zec n,o, Mansi Patil p,q, Martin G. Schultz k, Matthew P. Wallen r,
s F. Renna s, Sheikh Mohammed Shariful Islam t, Swapnil Hiremath u, Tshewang Gyeltshen v,
Nicola
Yook-Chin Chia w,x, Abhinav Gupta y, Aletta E. Schutte z,aa,bb, Britt Klein a, Claudio Borghi cc,
Colette J. Browning a, Marta Czesnikiewicz-Guzik dd,ee, Hae-Young Lee ff, Hiroshi Itoh gg,
Katsuyuki Miura hh, Mattias Brunstro € m ii, Norm R.C. Campbell jj, Olutope Arinola Akinnibossun a,
Praveen Veerabhadrappa , Richard D. Wainford ll,mm, Ruan Kruger nn,oo, Shane A. Thomas a,
kk
Takahiro Komori pp, Udaya Ralapanawa qq, Ve ronique A. Cornelissen rr, Vikas Kapil ss,tt,
uu vv ww,xx
Yan Li , Yuqing Zhang , Tazeen H. Jafar , Nadia Khan yy, Bryan Williams zz,
aaa bbb,ccc
George Stergiou , and Maciej Tomaszewski
Journal of Hypertension 2024, 42:23–49

a
Health Innovation and Transformation Centre, Federation University Australia, Ballarat, Australia, bDepartment of Physiology, University of Melbourne, Melbourne, Australia,
c
Department of Cardiovascular Sciences, University of Leicester, Leicester, UK, dDepartment of Food and Nutritional Sciences, University of Reading, Reading, UK, eDepartment of
Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, fDepartment of Medical Sciences, School of Medical and Live Sciences, Sunway
University, Bandar Sunway, Selangor, Malaysia, gDepartment of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA,
h
Hypertension Research Laboratory, School of Biological Sciences, Monash University, iHeart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, jMenzies
Institute for Medical Research, University of Tasmania, Hobart, Australia, kDepartment of Internal Medicine, Section Nephrology, Amsterdam UMC, University of Amsterdam,
Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, The Netherlands, lDepartment of Medicine, University of Melbourne, Austin Health, Melbourne, Australia,
m
Department of Hypertension, Almazov National Medical Research Centre, St Petersburg, Russia, nSchool of Nutritional Sciences and Wellness, University of Arizona, Tucson, USA,
o
Colorado Program for Musculoskeletal Research, Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, USA, pDepartment of Nutrition and
Dietetics, Asha Kiran JHC Hospital, Chinchwad, qHypertension and Nutrition, Core Group of IAPEN India, India, rCaring Futures Institute, Flinders University, Adelaide, Australia,
s
Unit of Hypertension, Hospital Espanol de Mendoza, School of Medicine, National University of Cuyo, IMBECU-CONICET, Mendoza, Argentina, tInstitute for Physical Activity and
Nutrition, Deakin University, Geelong, Australia, uDepartment of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Canada, vGraduate School of Public Health, St.
Luke’s International University, Tokyo, Japan, wDepartment of Medical Sciences, School of Medical and Life Sciences, Sunway University, Selangor, xDepartment of Primary Care
Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, yDepartment of Medicine, Acharya Shri Chander College of Medical Sciences and Hospital, Jammu,
India, zSchool of Population Health, University of New South Wales, The George Institute for Global Health, Sydney, New South Wales, Australia, aaHypertension in Africa Research
Team, SAMRC Unit for Hypertension and Cardiovascular Disease, North-West University, bbSAMRC Developmental Pathways for Health Research Unit, School of Clinical Medicine,
University of the Witwatersrand, Johannesburg, South Africa, ccDepartment of Medical and Surgical Sciences, Faculty of Medicine, University of Bologna, Bologna, Italy, ddSchool
of Medicine, Dentistry and Nursing-Dental School, University of Glasgow, UK, eeDepartment of Periodontology, Prophylaxis and Oral Medicine; Jagiellonian University, Krakow,
Poland, ffDivision of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea, ggDepartment of Internal Medicine (Nephrology, Endocrinology
and Metabolism), Keio University, Tokyo, hhNCD Epidemiology Research Center, Shiga University of Medical Science, Otsu, Japan, iiDepartment of Public Health and Clinical
Medicine, Ume8a University, Ume8a, Sweden, jjLibin Cardiovascular Institute, Department of Medicine, University of Calgary, Calgary, Canada, kkKinesiology, Division of Science,
The Pennsylvania State University, Reading, Pennsylvania, llDepartment of Pharmacology and Experimental Therapeutics, The Whitaker Cardiovascular Institute, Boston University
School of Medicine, Boston, mmDivision of Cardiology, Emory University, Atlanta, USA, nnHypertension in Africa Research Team (HART), North-West University, Potchefstroom,
oo
MRC Research Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa, ppDivision of Cardiovascular Medicine, Department of
Medicine, Jichi Medical University School of Medicine, Tochigi, Japan, qqFaculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka, rrDepartment of Rehabilitation
Sciences, KU Leuven, Leuven, Belgium, ssWilliam Harvey Research Institute, Centre for Cardiovascular Medicine and Devices, NIHR Barts Biomedical Research Centre, BRC, Faculty
of Medicine and Dentistry, Queen Mary University London, ttBarts BP Centre of Excellence, Barts Heart Centre, Barts Health NHS Trust, London, UK, uuDepartment of
Cardiovascular Medicine, Shanghai Institute of Hypertension, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, vvDepartment of Cardiology,
Fu Wai Hospital, Chinese Academy of Medical Sciences, Chinese Hypertension League, Beijing, China, wwProgram in Health Services and Systems Research, Duke-NUS Medical
School, Singapore, xxDuke Global Health Institute, Duke University, Durham, North Carolina, USA, yyDepartment of Medicine, University of British Columbia, Vancouver, Canada,
zz
University College London (UCL), Institute of Cardiovascular Science, National Institute for Health Research (NIHR), UCL Hospitals Biomedical Research Centre, London, UK,
aaa
Hypertension Centre STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece, bbbDivision
of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester and cccManchester Academic Health Science Centre, Manchester Royal Infirmary,
Manchester University NHS Foundation Trust, Manchester, UK
Correspondence to Fadi J. Charchar, Federation University Australia, Ballarat, VIC, Australia. Tel: +61 03 5327 6098; e-mail: [email protected]
Received 5 June 2023 Revised 12 August 2023 Accepted 22 August 2023
J Hypertens 42:23–49 Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work
cannot be changed in any way or used commercially without permission from the journal.
DOI:10.1097/HJH.0000000000003563
Journal of Hypertension www.jhypertension.com 23

Charchar et al.
E. Alcohol 33
Hypertension, defined as persistently elevated systolic
blood pressure (SBP) >140 mmHg and/or diastolic blood
F. Non-alcoholic beverages 33
VII, INTERMITTENT FASTING 34
pressure (DBP) at least 90 mmHg (International Society of
VIII. STRESS REDUCTION AND MINDFULNESS 34
Hypertension guidelines), affects over 1.5 billion people
worldwide. Hypertension is associated with increased risk
IX. SLEEP 35
X. SMOKING 36
of cardiovascular disease (CVD) events (e.g. coronary heart
XI. POLLUTION EXPOSURE 37
disease, heart failure and stroke) and death. An
XII. NONPRESCRIPTION MEDICINE, INCLUDING

international panel of experts convened by the
International Society of Hypertension College of Experts
VITAMIN INTAKE 38
compiled lifestyle management recommendations as first-

XIII. BEHAVIOURAL INTERVENTIONS, DIGITAL
line strategy to prevent and control hypertension in
HEALTH, AND WEARABLES 38
adulthood. We also recommend that lifestyle changes be
XIV. HOLISTIC APPROACH TO BP PREVENTION
continued even when blood pressure-lowering medications
ACROSS THE GLOBE 39
are prescribed. Specific recommendations based on
XV. OVERALL SUMMARY AND A GLIMPSE INTO
literature evidence are summarized with advice to start
THE FUTURE FOR ASSISTED LIFESTYLE INTER-
these measures early in life, including maintaining a
VENTIONS 40
healthy body weight, increased levels of different types of
ACKNOWLEDGMENTS 40
physical activity, healthy eating and drinking, avoidance
REFERENCES 40
and cessation of smoking and alcohol use, management of
stress and sleep levels. We also discuss the relevance of
specific approaches including consumption of sodium, I. INTRODUCTION
potassium, sugar, fibre, coffee, tea, intermittent fasting as
H
ypertension is the single most significant modifi-
well as integrated strategies to implement these able risk factor for all-cause morbidity and mortal-
recommendations using, for example, behaviour change- ity worldwide. Approximately 33% of the global
related technologies and digital tools. population of 8 billion live with hypertension [1,2]. Lifestyle
Keywords: Blood pressure, hypertension, lifestyle, holistic changes are the cornerstone of prevention and treatment of
approach, nutrition, diet, exercise, mindfulness, obesity, hypertension and both governments and industry are fun-
pollution damental to endorse and implement these changes [3].
Abbreviations: ACE, angiotensin-converting enzyme; BP,
Moreover, lifestyle changes may not only reduce blood
blood pressure; CARDIA, Coronary Artery Risk
pressure (BP) and improve hypertension control but also
Development in Young Adults; CI, confidence interval;
improve cardiovascular and general health [4–11]. Patients
CPAP, continuous positive airway pressure; CRF,
also often view lifestyle changes as their highest priority
cardiorespiratory fitness; CVD, cardiovascular disease;
area in their hypertension management [12]. Consequently,
DALYS, disability-adjusted life years; DASH, Dietary
lifestyle modifications are the first-line recommendation in
Approaches to Stop Hypertension; DBP, diastolic blood
all major hypertension management guidelines to reduce
pressure; ESADA, European Sleep Apnea Database; GLP-1,
the risk of CVD [13–17]. The importance of lifestyle changes
glucagon-like peptide-1; ISH, International Society of
in both treatment and prevention of hypertension is further
Hypertension; MBSR, mindfulness-based stress reduction;
emphasized in the ISH’s Hypertension Zero Declaration [2]
MET, one-metabolic equivalent increment; OSA,
and the Society’s public campaigns championing healthy
obstructive sleep apnoea; PRS, polygenic risk scores; RCT,
lifestyle [18]. In addition to direct benefits, lifestyle mod-
randomized controlled trials; RPE, rating of perceived
ifications can also amplify the effect of the pharmacological
exertion; SBP, systolic blood pressure; SGLT2, sodium-
treatment of hypertension, if needed [13]. Of importance,
glucose cotransporter-2; SSaSS, salt substitution and stroke
the well known lifestyle interventions such as change in
study; WHO, World Health Organization
diet, alcohol moderation, smoking cessation and aerobic
exercise, have now been extended to less obvious strate-
gies such as stress reduction, isometric exercise and reduc-
ing exposure to pollution [19–21]. Although lifestyle
changes are effective, they remain difficult to implement
Table of Contents and maintain long-term because many people live in envi-
ronments that are not conducive to achieving and then
I . INTRODUCTION 24 sustaining a healthy lifestyle. Moreover, clinicians are often
II. PROCESS OF WRITING 25 poorly trained in assisting patients to engage in healthy
III. GENERAL RECOMMENDATION 25 behaviours. This is further compounded by the paucity of
IV. WEIGHT MANAGEMENT 25 information about lifestyle changes in people from different
V. PHYSICAL ACTIVITY 27 ethnic and cultural backgrounds and their health literacy
VI. GENERAL NUTRITION 29 and cultural beliefs concerning hypertension prevention
A. Salt 30 and management. In this position paper, we discuss the
B.Potassium 31 updated evidence supporting the use of lifestyle interven-
C. Sugar 31 tions in patients with hypertension or people at risk of
D. Fibre 32 developing hypertension. Importantly, we also aim to
24 www.jhypertension.com Volume 42 Number 1 January 2024

Lifestyle changes in hypertension
provide unique global perspectives on ways to implement pharmacotherapy should not be delayed when instituting
these changes, taking into consideration different ethnici- lifestyle change in patients, for instance, in those with hyper-
ties and age groups, to aid healthcare providers and the tension-mediated organ damage or at high level of risk
scientific community to navigate and apply the current for cardiovascular events [23]. Lastly, we recommend
knowledge. that healthcare providers and clinicians receive adequate
training in working with patients to adopt lifestyle changes
II. PROCESS OF WRITING and take an active role in the implementation of these
recommendations. These consensus recommendations are

This position paper summarizes recommendations com- targeted towards primary care providers and public health
piled by an international panel of experts convened by the
programmers. In addition to the recommendations, we pro-

International Society of Hypertension (ISH) College of vide an international perspective to consider different
Experts from 18 countries. Separate groups of experts were resources, practices and cultural considerations for differing
then assigned specific topics based on their area of exper- regions and implementation guidance at the individual and
tise and developed draft recommendations by consensus population level.
based upon review of the literature and existing guidelines.
Revisions were made by all authors and then submitted for IV. WEIGHT MANAGEMENT
external review internationally. Both World Hypertension
League and the European Society of Hypertension What is known and what is new?
reviewed and endorsed the recommendations. Obesity is a worldwide epidemic with increasing preva-
lence in many countries. Over the past three decades,
obesity prevalence in adults almost tripled worldwide,
III. GENERAL RECOMMENDATION while in children and adolescents, the prevalence increased
We recommend lifestyle goals (summarized in Table 1 and more than four-fold from 4 to 18% [24]. At the same time,
Fig. 1) to prevent or delay the onset of high BP and to reduce globally, obesity-related deaths and disabilities have almost
CVD risk. Lifestyle modifications should be the first line of doubled. Obesity should be addressed with an extensive
antihypertensive treatment in grade 1 hypertension. Howev- and encompassing methodology, including government
er, if BP control is not achieved with lifestyle changes alone, and public health policies, clinical and self-directed
we recommend a combination of lifestyle modifications and approaches. Increased body mass measures have a well
antihypertensive medications for diagnosed hypertension as established causal effect on the development of hyperten-
the former enhance the effect of treatment [22]. Importantly, sion, the risk of cardiovascular and kidney diseases as well
TABLE 1. Lifestyle modification for the management of hypertension recommended by the International Society of Hypertension
Recommendation Action
Early start in life Encourage healthy habits from childhood (governments/parents/carer)
Increase awareness of healthy food types (parents/schools/governments)
Healthy eating Increase consumption of vegetables, fresh fruits, fish, nuts, unsaturated fatty acids, low-fat dairy
products and low consumption of red meat
Reduce salt and sugar intake
Increase dietary potassium intake
Increase consumption of plant-based food and dietary fibre
Improve food labelling (governments/policy makers)
Implement food taxation (governments/policy makers)
Healthy drinking Avoid or limit alcohol intake (if you do not drink, do not start)
Avoid binge drinking
Moderate consumption of unsweetened coffee and tea
Consider hibiscus tea, pomegranate juice, beetroot juice and cocoa
Physical activity Increase aerobic exercise and muscle strengthening exercise
Increase incidental exercise
Decrease prolonged periods of time seated
Engage in regular physical exercise and avoid sedentary behaviour early in life
Advocate for implementation of government and industry supported programs, environment, facilities,
and infrastructure (governments/policy makers)
Healthy body weight Ethnic-specific cut-offs for BMI and waist-to-height ratio or other indices
Waist circumference and weight values to be monitored
Healthy stress levels and sleep Improve sleep hygiene and increase quality sleep time
Practice sleep stimulus control methods
Promote mindfulness/stress reduction practice
Consider meditation/yoga/breathing techniques
Consider music therapy/self-soothing techniques/gratitude/acts of kindness
Reduce exposure to pollution and passive smoke Promote smoking cessation
Consider limiting time spent outdoors when pollution is high
Consider ventilation systems with filtration
Use digital tools Use apps to track calories, steps, and sleep patterns
Recommendations are aimed for individuals, unless stated otherwise.

Charchar et al.
FIGURE 1 Lifestyle changes recommended in this position paper. In green are changes that should be encouraged, increased, and adhered to, for example, consumption
of dietary fibre, improved sleep habits, increased exercise and adoption of mindfulness strategies. In red are changes to decrease or avoid, for example, smoking and
alcohol use, sedentarism, consumption of refined sugars and salt and pollution exposure.

as cardiovascular mortality [25–27]. A meta-analysis of 57 Recommendation

prospective cohort studies, pooling 2.3 million individuals, 1. Weight loss should be incorporated into everyday
reported a 1–2-fold increase in risk of developing hyper- life, that is, increasing incidental exercise, walking, or
tension with the increment of various obesity indices such cycling more, or playing sports regularly, sitting for
as body mass index, waist circumference and waist-to- less hours, and so forth.
height ratio [28]. In addition, obesity is also associated with 2. Emphasis should be placed upon early-life interven-
a higher risk of developing other cardiometabolic distur- tion and health education programs to sustain a
bances, including insulin resistance, type 2 diabetes, dysli- healthy weight throughout life [44].
pidaemia and metabolic syndrome, which can improve 3. A modest weight loss that can be maintained over a
with weight loss [27]. The effect of obesity on BP is additive long period of time is recommended for people with
to other lifestyle components such as physical inactivity, hypertension along with calorie-intake reduction.
diet, smoking and alcohol consumption [29]. 4. Weight loss interventions should be based on cogni-
All major hypertension guidelines recommend weight tive–behavioural strategies (e.g. appetite awareness
loss for the management of BP among those with over- training, a self-monitoring strategy in which individ-
weight or obesity [30]. Furthermore, several large epidemi- uals learn to identify internal cues of moderate hun-
ological studies have shown an association between body ger and fullness and to use these cues to guide their
weight and BP over the life course [31–34]. Weight gain eating behaviour) [45].
from early ages and in adult life, related to nutrition and/or 5. Abdominal obesity should be managed. Ethnic-spe-
lack of physical activity, is an important risk factor for cific cut-offs for body mass index and waist circum-
hypertension development [3]. Weight loss has been rec- ference should be used. Alternatively, a waist-to-
ommended for patients with hypertension who are obese height ratio less than 0.5 is recommended for all
as an effective nonpharmacological treatment approach. populations [46].
However, long-term results of weight loss programmes 6. The chosen type of weight loss programmes should
are disappointing as patients often regain most of the weight be tailored, considering individual baseline weight,
initially lost. A gradual and moderate weight loss approach, age, sex, comorbidities and situational context with
with support of dieticians, is more likely to be maintained support from a dietician.
over a longer period of time. The use of calorie-intake 7. Use of innovative approaches based on behavioural
reduction, weight loss medication therapy or bariatric sur- change technologies (e.g. apps, text messaging [47–
gery for patients with significant obesity is an effective, 49]) are encouraged for all people with overweight
longer lasting strategy for weight loss [35–37]. Furthermore, or obesity.
emerging treatment option for obesity include semaglutide
and other glucagon-like peptide-1 (GLP-1) receptor agonist
in effective management of obesity [38,39]. Implementation
Weight reducing diets in overweight people with hyper- Continual support for people with overweight or obesity is
tension, leading to a modest weight loss (3–10% of baseline required to make a sustainable behavioural change and
body weight), decreased/discontinued dosage require- encourage healthy weight levels over the life course. The
ments of antihypertensive medications and reduced SBP development of government-supported and industry-sup-
and DBP by 3 mmHg resulting in lower BP levels even ported programmes, environment, facilities and infrastruc-
without reaching ideal weight [40]. Additionally, a meta- ture promoting healthy eating and weight reduction is
analysis of randomized controlled trials (RCTs) reported an paramount [50].
average reduction of 1 mmHg SBP and DBP per kilogram of In the primary care of hypertension, healthcare providers
weight loss [41]. The BP-lowering effect of weight loss is should (whenever available) refer patients to appropriate
most likely a result of a decrease in sympathetic nervous weight loss programmes and prescribe individualized exer-
system activity and an improvement in insulin sensitivity cise and physical activity. Behavioural change techniques
[42] and occurs independent of salt restriction. Importantly, and coaching that include goal setting, monitoring and
weight reduction following bariatric surgery reduced mor- feedback should be considered to reduce overweight and
tality and morbidity related to CVD [43]. maintain a healthy weight.
International perspective V. PHYSICAL ACTIVITY

Currently, there is no global consensus on optimal weight
reduction and preventive strategies and advice are not What is known and what is new?
tailored at individual level considering bias, socioeconomic The CVD prevention and hypertension management guide-
status and socio-cultural barriers and beliefs to weight loss lines [15,16,51–53] recommend exercise/physical activity
in different parts of the world. Formalized, structured and/ across the lifespan, including childhood and adolescence,
or supervised weight loss programs are not always possible because of its demonstrated antihypertensive effects and
or available. Furthermore, barriers to accessing appropriate also its favourable effects on other modifiable CVD risk
exercise or diet guidance and professional advice are factors. Guidelines follow current knowledge that regular
prevalent in some socio-economic and cultural back- engagement in physical activity leads to improved cardio-
grounds and the dissemination of many nonscience-based respiratory fitness (CRF) [54] and body habitus, as well as
diets tends to be more harmful to some individuals with more favourable measures, of cardiometabolic health [55]
underlying conditions. and reduced inflammation [56], lowering the risk of

Charchar et al.
developing hypertension and CVD. Importantly, recent need to receive training to assist people to reduce sedentary
pooled-data highlights a dose–response relationship be- behaviour and adopt lifestyle changes.
tween CRF and relative risk of hypertension where a one-
metabolic equivalent increment (MET) in CRF is associated Recommendation
with 8% hypertension risk reduction [57]. Recent data from 1. All individuals should be encouraged to be physically
the UK Biobank are consistent with these observations, active for the prevention or management of hyper-
with an adjusted inverse dose–response relationship for tension and CVD [16,51,52,68,81].
CVD risk observed between accelerometer-measured phys- 2. Emphasis should be placed upon early-life interven-
ical activity and stroke incidence, coronary artery disease tion (from childhood) and health education pro-
and CVD and all-cause mortality, with no upper limit of grammes to sustain physical activity throughout the
activity (intensity or volume) detrimental in those with life-course (Table 1) [44].
established hypertension [58]. 3. Both aerobic and dynamic resistance exercise or their
Evidence from RCTs suggest that exercise training inter- combinations can be used in prevention and man-
ventions may provide equivalent reductions in BP to that of agement of hypertension and CVD (Box 1) [70].
antihypertensive medication [59]. When exercise is com-
bined with pharmacotherapy, the magnitude of BP reduc-
tion is greater than with medication alone [60]. Meta- Box 1 General physical activity recommendations for general health,
analysis of randomized studies has shown that, indeed, wellness and cardiovascular disease prevention in (a) adults 18–64 years
aerobic and dynamic resistance training interventions of and (b) individuals aged at least 65 years [355]
varying designs reduce office and daytime ambulatory BP, (a) Physical activity recommendations in adults (18–64
with greater reductions occurring in those with established years)
hypertension (up to 8.3/5.2 mmHg office BP reductions)
Adults should aim to be active on most days, preferably all days of
[61–64]. Isometric resistance training also significantly the week. This should include either:
reduces BP, which is supported by several meta-analyses 150–300 min of physical activity per week performed at a
[61,65–67] and is included as a nonpharmacological thera- moderate intensity, or
75–150 min of physical activity per week performed at a vigorous
py in the American College of Cardiology/American Heart intensity, or
Association Task Force Guidelines on the Primary Preven- An equivalent combination of moderate and vigorous physical
tion of Cardiovascular Disease [68]. activities.
AND
Exercise of moderate-to-high intensity (including aero- Include resistance (muscle strengthening) exercise on at least two
bic and dynamic resistance training; see Supplementary nonconsecutive days each week, and
Box 1, http://links.lww.com/HJH/C287, for example is Increase incidental physical activity.
considered safe and currently recommended for hyperten-

(b) Physical activity recommendations in older adults
sion management [20,69–71]. Adding a time-efficiency as- (þ65 years)
pect, emerging data indicate that high-intensity interval
training (a form of exercise training, which consists of Perform at least 30 min physical activity at a moderate intensity on
most, preferably all days, of the week.
repeated short and intense exercise), appropriately pre- If 30 min is difficult to achieve currently, it is recommended to
scribed and supervised, can provide comparable BP reduc- commence at 10 min once or twice daily, which can be
progressively increased.
tions to that of moderate-intensity exercise training [72,73]. Try to incorporate different activities over the week, which may
However, even modest intensity physical activity such as include:
walking will have a BP-lowering effect [74,75], as does Aerobic (endurance) activities to maintain and improve
cardiovascular health such as brisk walking, swimming, and cycling.
isometric resistance training of the upper or lower limb Dynamic resistance (muscle strengthening) activities to
performed at 30% of maximal voluntary contraction [20]. maintain and improve muscle and bone strength such as weight-
based, body weight, and resistance band exercises.
Flexibility activities to assist with ease of movement such as
stretching, yoga and tai chi.
International perspective Balancing activities to improve balance and prevent falls such as
Exercise as a therapy for hypertension is still not widely semi-tandem, tandem and single leg standing.
Try and reduce the amount of time spent sitting by breaking the
integrated into healthcare systems or insurance schemes time up as often and feasible as possible and increasing the
worldwide. Indeed, socioeconomic and cultural barriers to amount of incidental exercise.
structured exercise exist in many parts of the world [76],
often combined with limited access to exercise facilities and
lack of formalized physical activity guidance [77].
Neighbourhood safety, lack of community support, reli- 4. Adults should engage in 150–300 min of moderate-
gious beliefs, financial position, employment, and social intensity or 75–150 min of vigorous exercise, or an
barriers may influence physical activity participation in equivalent combination, weekly (Box 1 and see
certain groups with hypertension, especially ethnic minori- Supplementary Box 1, http://links.lww.com/HJH/
ties [78]. C287 for examples) [82].
To overcome such barriers, individuals should be of- 5. The chosen type of activity/exercise should be indi-
fered appropriate health education and be encouraged to vidually tailored, consider baseline fitness, comorbid-
use any means possible to be physically active, while ities, pharmacological treatment, situational context
creating facilities and programs that consider sensitive and be progressive in nature (i.e. start slow and
cultural needs [79,80]. Furthermore, healthcare practitioners gradually build the amount/intensity of activity).

6. Emphasis should be on reducing daily sedentary time The DASH diet, rich in calcium, potassium, magnesium
and increasing movement wherever possible [83]. and micronutrients, emphasizes consumption of fruits,
7. Any type, amount and intensity of regular exercise/ vegetables, low-fat dairy products and reduced saturated
activity will be beneficial with minimum recommen- fat and cholesterol, is recommended as an effective dietary
dations for maintenance of health and CVD preven- intervention to reduce BP and maintain a healthy weight
tion. [15,93,94]. The adoption of the DASH diet was accompa-
nied by substantial BP reduction in adults with and without
Implementation hypertension with greater BP lowering among African

Regular exercise should start early in life, and children and Americans [88]. In addition, vegetarian diet has also been
adolescents should aim to be active most days, decrease associated with lower BP in comparison to unrestricted
screen time and sedentary behaviours. This can be promot- omnivore diets (no salt, sugar or saturated and trans-fat
ed and motivated by parents, guardians and educators and restrictions) [95]. Vegetarian diets have a higher portion of
be implemented through the educational system’s regular glutamic acid and plant-based protein, which has blood-
activities. pressure-lowering effects [96–98]. Moreover, higher con-
Healthcare professionals should encourage activities that tent of fibre, antioxidants and potassium as well as lower
are enjoyable to increase adherence and sustain life-long saturated fat and sodium content in healthy vegetarian diets
activity. Governments and town developers should plan can contribute to a lower body mass index and BP readings
environments conducive and safer to walk, cycle and [99–101]. Vegetarian diet is thought to reduce BP via several
exercise at all ages. mechanisms, including improving blood viscosity, vasodi-
It is crucial to provide support and education to people lation and insulin sensitivity; by altering the baroreceptors,
at all life stages and levels of readiness for exercise to renin–angiotensin and sympathetic nervous system; by its
empower people to initiate/increase physical activity. Con- antioxidant and anti-inflammatory properties and by
sumer resources and wearable devices are available at low changing the colony and strain of gut microflora [102–107].
cost, and may assist with and prompt increased incidental It is recommended that adopting the DASH diet or similar
exercise [84]. composition diet (Supplementary Box 2, http://links.lww.
Although exercise is considered generally very safe for com/HJH/C287), where calorie-appropriate intake is con-
those with high BP, first-time exercisers or those with sidered depending on age, sex, build and levels of physical
complex medical history or chronic disease should be activity, is essential for maintenance of a healthy weight and
encouraged to seek guidance and approval to exercise should be considered a part of local hypertension manage-
from a doctor and or seek referral to/consult an exercise ment guidelines and introduced to people at risk of
physiologist. developing hypertension.
Behavioural change techniques and coaching that in- Long-term health benefits will depend on people’s abili-
clude goal setting, monitoring and feedback may increase ty to make long-lasting dietary changes as long-term ad-
physical activity uptake, sustainability and intervention herence/persistence to DASH and other diets remains a
effectiveness [85]. major concern. However, many population-level dietary
recommendations are not followed, for example, 12% of
Europeans and only 5% of the Australian population
VI. GENERAL NUTRITION achieve the recommended five serves of fruit and vegeta-
bles per day (one serve is equivalent to 75–150 g depending
Diet plays an important role in the healthy functioning of on the type) [108–110]. There are also several barriers to
the body. Many different dietary patterns are hailed as adoption or adherence to these diets, which include lack of
useful for improving BP control, most without adequate education (both with respect to health and/or food and
evidence to substantiate their benefits. Studies show no nutrition) on a population level and by healthcare pro-
age-related rise in BP or atherosclerosis in isolated non- viders, food availability, including food insecurity or cost
Westernized tribal populations that live as hunter-gatherers and difficulty or unwillingness to adhere because of cultural
and gardeners in remote regions in Brazil and Africa and heritage, beliefs and behavioural norms [111]. To achieve
consume diets low in fat and salt and high in fruit and fibre long-term dietary change, healthcare professionals require
[86,87]. specific training in effective behaviour change techniques
The Dietary Approaches to Stop Hypertension (DASH) to assist their patients in adopting new behaviours. There
low-sodium [88,89] and the Mediterranean diet [90] are most have been efforts to address some of these issues (e.g.
widely acknowledged for their benefits to reducing BP and reshaping of the UK medicine curriculum [112,113] and
improving cardiovascular health, albeit not always being introduction of continuing professional development pro-
viable because of food costs, availability and insecurity, grammes for medical professionals [114]); however, the
incompatibility with a culturally and ethnically diverse general public may be confused by (social) media reports
society or food allergies. Broadly, both recommend low delivering conflicting nutrition information [115,116], which
saturated fat, low salt, high fibre (from wholegrains, fruits leads to uncertainty and lack of trust in nutrition advice
and vegetables) and adequate lean protein. Both align with given by qualified professionals. Furthermore, many
the World Health Organisation (WHO) guidance to reduce healthcare professions’ training does not incorporate suffi-
the risk of noncommunicable disease [91]. Such approaches cient nutrition education and training in their undergradu-
are evidence-based and endorsed in ACC/AHA (USA), ate and professional development courses [114] and
European and NICE (UK) guidelines [17,51,68,92]. clinicians report a lack of time and confidence to deliver

Charchar et al.
comprehensive dietary and lifestyle advice during office [132,133]. Moreover, the weighted average reduction in
visits [117]. These barriers need to be overcome if dietary dietary sodium intake from 3646 to 2690 mg/day in RCT
approaches are to be implemented in preventive or primary was associated with approximately 26% reduction in CVD
healthcare and should start from an early age; methods such [134]. Notably, the decrease in BP is greater in people from
as targeted labelling, incentives (e.g. food vouchers) and black African ancestry, people of older age, or with higher
policy change (e.g. taxation and fortification) are additional BP levels but is also observed in differing ethnicities, people
potential avenues but are widely debated by both the with normal BP and in children [134].
public and the food industry (Supplementary Box 3, A recent meta-analysis of prospective cohort studies
http://links.lww.com/HJH/C287). investigating multiple nonconsecutive 24 h urine samples
As nutrition research evolves, more complexity is real- to assess sodium intake (the current recommended stan-
ized. Looking beyond traditional macronutrients and dard) reported a linear association between sodium intake
micronutrients for health benefits might be important, for [1846–5230 mg (equivalent to 4.6–13.8 g salt) per day] and
example, evidence suggests that cocoa flavanol intake cardiovascular events [135]. Unfortunately, these studies do
could be beneficial for CVD risk prevention [118]. Further not define a recommended lower level of sodium intake.
knowledge about how food components interact with each However, many community-based salt reduction programs
other could help maximize dietary approaches, for exam- resulted in decreased salt intake, increased awareness and
ple, saturated fat in dairy may be less detrimental to CVD lowered BP [8,94,129,136–138].
risk than in meat [119]. Evidence suggests that consumption
of omega-3 fatty acids, found in fish, lowers BP, heart rate International perspective
and triglycerides [120]. A recent dose–response meta-anal- About 80% of the salt intake in high-income countries
ysis suggests that the intake of 2–3 g/day of omega-3 fatty comes from manufactured and processed foods, whereas
acids has optimal BP-lowering effects and more than 3 g/ the majority of consumed salt in low-income and middle-
day might be beneficial for groups at higher risk of CVD income countries is added during food preparation or at the
[121]. An RCT showed independent additive effects of table [111,129,139]. Unfortunately, a shift in the future is to
regular fish meals and weight reduction in people with be expected as dietary patterns are transformed by increas-
overweight [122]. Unfortunately, consumption of omega-3 ing production and consumption of processed foods, rapid
fatty acids is below recommended levels in a significant urbanization and changing lifestyles [140]. Studies consis-
proportion of the population and fish meals should be tently show that salt consumption in most parts of the world
considered as an alternative to daily meat meals as part is greater than recommended and require urgent action
of a healthy diet [123]. Emerging data suggest the gut [129,135]. Sub-Saharan Africa and the Caribbean have the
microbiome is an important target for BP regulation lowest consumption of sodium worldwide, just under 3 g/
[124,125], hence diets incorporating probiotics, prebiotics day; whereas, East Asia has the highest intake, close to 8 g/
and/or postbiotics are essential. Indeed, this aligns with the day [130].
relationship between fibre and BP control [126,127].
Personalized/precision nutrition approaches are also
Recommendation
becoming widely appreciated [128], whether that be based
1. Intake of less than 2 g sodium (5 g salt or one
on individuals’ phenotype, genotype or even gut micro-
teaspoon) per day (Supplementary Box 2, http://
biota composition. Arguably they are harder to implement links.lww.com/HJH/C287) [129].
but may prove to be more effective. As the nutrition field
advances, there needs to be a clear pathway for these
recommendations to policy and clinical practice. We have Implementation
included below separate sections for major nutritional Globally reduce mean salt intake in the population by 30%
components. by 2025, as proposed by the WHO and supported by the
World Health Assembly. Approaches should be tailored
A. Salt considering local context, especially in regards to differ-
ences in food and lifestyle-related behaviours, including the
What is known and what is new? source of salt intake [141]. Adopting the WHO SHAKE
High sodium consumption (over 2 g of sodium per day, package at country level provides a unique opportunity
equivalent to 5 g or one teaspoon of salt) resulting in for salt reduction at population and individual levels [141].
increased BP is the leading dietary risk factor for death Importantly, salt substitution with low sodium and high
[129,130]. Sodium intake may influence BP by change of potassium alternatives may provide an opportunity to re-
sodium–water homeostasis, vascular tone, immune cell duce BP at the population level [142]. Translation of funda-
homeostasis and tissue remodelling, but exact mechanisms mental research into practice is crucial as mechanisms
remain subject of study [131]. The global mean sodium explaining how sodium increases BP is partly understood
intake is estimated to be around 6 g/day [130], attributing to [131] and assessment of salt intake on the individual level is
1.89 million deaths and 44.87 million disability-adjusted life poorly associated with actual daily intake – complicating
years (DALYS). Sodium is mainly consumed as salt, from the interpretation of the epidemiological link between
processed foods or discretionary sodium added to food estimated salt intake and health outcomes [143]. To this
during preparation or at the table [129]. Meta-analysis of end, academic organizations and learned societies called on
RCT examining sodium intake reduction to as low as scientists, clinicians, healthcare providers and other stake-
800 mg/day show a relatively linear decrease in BP holders to support global efforts to implement the

reduction in salt [129,144]. The global actors’ policy priori- sodium salt consumption is paramount, as stated above,
ties and funding allocation need to align, making salt and the use of low-sodium salt substitutes should
reduction at the population level a key priority. Finally, be encouraged.
industry and governments play a major role in shaping salt
consumption at the population level. Governments should Recommendation
follow the expert advice and introduce legislation decreas- 1. The European Food and Safety Administration and
ing sodium in processed foods which, in turn should be the WHO recommend potassium intake of over 3.5 g
endorsed by the food industry [129]. per day for adults, while an intake of more than 4.7 g
per day for adults is recommended by the National
B. Potassium Academies of Sciences and Medicine [129,134]. Foods

high in potassium include cooked white cannellini
What is known and what is new? beans (1200 mg/cup), unsalted boiled spinach
Enhancing potassium consumption lowers BP by direct (840 mg/cup), avocado (708 mg/cup) and bananas
effect on the vascular tone and stimulation of natriuresis (450 mg per medium fruit).
[145]. The recent large randomized controlled salt substi- 2. Individual food and nutritional needs because of
tution and stroke study (SSaSS) trial reported that increas- lower body composition between sex and larger
ing potassium intake as a sodium substitute – that is, differences between body mass within and between
replacing 25% sodium chloride with potassium chloride populations need to be considered.
in salt – reduces the risk of stroke, CVD and death in
patients with increased cardiovascular risk and low potas- Implementation
sium intake and high sodium intake at baseline [142]. It is important to emphasize a healthy diet rich in vegetables
Potassium intake is reflective of healthy dietary patterns, and fruits, which will increase potassium intake. Potassium-
as key sources of potassium include fruit, vegetables, nuts enriched salts are also commercially available and could be
and legumes. The DASH diet recommends 4.7 g potassi- used for cooking instead of regular salt in settings where
um per day, possibly accounting for the BP-lowering most of the added salt happens at the household level. For
effect reported. Dietary potassium, potassium supple- other settings, partnership with the food industry is re-
ments and implementation of salt substitutes reduce BP quired to implement the substitution of sodium with potas-
with little effect on the risk of hyperkalaemia in a healthy sium in food processing while preserving taste and other
population [142,146]. requirements. Pricing policies that promote the adoption of
Unlike comprehensive interventions that require imple- healthier diets will reduce sodium while increasing potas-
menting and long-term adherence to dietary or behavioural sium intakes and should be a global priority.
change, the use of salt substitutes containing potassium salt
and/or adoption of potassium-rich diet may represent a C. Sugar
more feasible intervention to implement [147]. Fruits, veg-
etables, legumes, fat-free or low-fat dairy foods and fish What is known and what is new?
represent good natural dietary sources of potassium. Sugar is one of the most commonly used commodities
Hyperkalaemia with higher potassium intake is a concern globally. The term ‘sugar’ is vague, usually referring to
in certain populations such as people with advanced chron- refined sugar, it can be found in most packaged and
ic kidney disease (excluded in the SSaSS trial), but the risk processed foods and is commonly unrecognized by con-
for developing clinically significant hyperkalaemia by in- sumers because manufacturers use terms such as glucose or
creasing dietary potassium intake to recommended levels sucrose in nutritional labels. Recent studies have highlight-
may be limited [148]. These individuals are at higher risk of ed common side effects that accompany consistent con-
adverse cardiovascular outcomes, and a modelling study sumption of sugar [150]. Cardiometabolic changes are well
demonstrates that there would be still a net benefit with established as one of the biggest risk factors of long-term
consumption of a potassium salt in this setting [146]. sugar consumption [151,152]. Regular consumption of
foods and drinks high in fructose (fruit juices, sugar-sweet-
International perspective ened beverages, dried fruits, sweetened yoghurt, honey)
Estimates for potassium intake from cross-sectional studies [151,153] and high glycaemic foods (white potato, white
show marked variations between countries ranging from rice) predispose to the development of non-alcoholic fatty
1.7 to 3.7 g per day, with highest consumption in Europe liver disease and is strongly associated with cardiometa-
and lowest intakes in China [149] and indicate that most bolic changes related to increased adiposity such as hyper-
populations may benefit from increasing their daily potas- tension, dyslipidaemia and insulin resistance [153,154].
sium intake. BP reduction may depend on the population’s Importantly, consumption of added sugar is strongly asso-
background potassium and sodium consumption. Imple- ciated with increased risk of CVD mortality and contributes
mentation of potassium salt substitutes in countries where to the international overweight and obesity epidemic relat-
the main source of salt consists of added salt during cooking ed to chronic illnesses [155].
at the household level (discretionary use) is expected to be Monosaccharides, such as fructose and glucose, have
more feasible and also more efficacious as compared with similar chemical structures; however, their metabolic path-
countries with usually very high potassium intake and low ways differ in both enterocytes and hepatocytes impacting
sodium consumption [147]. Importantly, a reduction of overall health [151,153,156]. High glucose concentration as

Charchar et al.
well as high sodium in digested food are demonstrated to some of the top dietary risks attributed to death globally,
up-regulate the expression of sodium-glucose transporters. especially due to CVD [166]. A recent meta-analysis of
Therefore, the higher the consumption of sugar and salt, the 15 RCTs comparing fibre intake in 1064 patients and
more the gut absorbs glucose and sodium (‘greedy gut’) 988 controls showed an average 1.3 mmHg [95% confi-
[152]. The same mechanism is observed in the kidney for re- dence interval (CI):2.5 to 0.04] decrease in SBP [127].
absorption of glucose and sodium as for the expression of However, studies using around 135 million person-years of
sodium-glucose cotransporter-2 (SGLT2) [152]. Recently, data found that high fibre intake reduced all-cause and
SGLT2 inhibitors have been highlighted not only in blood cardiovascular mortality by 15–30% [127,166]. The effect of
glucose lowering and body weight reducing effects but also high fibre intake on CVD is mainly because of its high
for their renal and cardioprotective actions. It is recognized degree of fermentation by the gut microbiota, resulting in
that SGLT2 inhibitors exert BP reduction possibly through the release of short-chain fatty acids, which act on immune-
renal sodium handling as well as body weight reduction dependent and independent mechanisms (e.g. vasodila-
[152,157]. tion) [125,165,167]. A recent phase II RCT showed that
short-chain fatty acids reduced SBP in untreated people
International perspective with hypertension [167].
Diabetes linked with increased BP is rising, particularly in
Asia. Furthermore, diabetes in Asians differs from that in International perspective
Caucasians, commonly referred to as the ‘‘Asian pheno- Inadequate fibre consumption is a worldwide concern and
type’’ [158]. This phenotype is related to the impaired often seen as a result of diets rich in processed foods and
secretion of insulin by the pancreas and lower capacity low in whole foods. The Westernized diet, characteristic of
of triglyceride storage by adipocytes [159]. USA and Canada and the Westernization of traditional
Currently, 118 countries and jurisdictions (including Fiji, European diets (high in fat, refined grain and sugar and
Germany, India, Mexico, Morocco, Nigeria, Qatar, South low on milk, fruits and vegetables) can be linked to an
Africa, UK, Vietnam, some USA states) have introduced increase in CVD [168,169]. This contrast between low-fibre
taxes on sugar-sweetened beverages, which have facilitated and high-fibre intake and its relationship with the incidence
a decrease in sugar consumption, especially among those of of CVD is also observed in Australia [168–170]. Interesting-
lower socioeconomic backgrounds, and led to a trending ly, the high-fibre diet ingested by African hunter-gatherers
decline in overweight and obesity rates, which could po- seems to result in a protective gut microbiome and high
tentially contribute to lowering the BP levels [160–164]. production of short-chain fatty acids, preventing the devel-
opment of chronic illnesses [171].
Recommendation Lastly, undernutrition, present widely in sub-Saharan
1. Reduce or limit sugar intake both in raw form and in Africa and South Asia, also leads to an imbalance of the
processed food, drinks and sweets (Supplementary gut microbiota and morbidities, especially in childhood
Box 2, http://links.lww.com/HJH/C287). [168].
Implementation Recommendation
Governments should introduce a simpler food labelling 1. Fibre intake of 25–29 g/day conferred the greatest
system, such as ‘traffic light’ or ‘health stars’ to simplify risk reduction, but dose–response data suggested
the understanding of nutritional values by consumers. more than 30 g/day results in additional benefits
Meanwhile, it is important to educate the public on the [127].
importance of nutritional labels as sugar is present in most
packaged food items, even the savoury type and especially Implementation
low-fat products. This includes learning to read the nutri- Considering most people consume less than 20 g/day of
tion label and recognize the terminology/wording for ‘sug- fibre, community awareness programs, policies and tax
ars’. There should be more emphasis on replacing fruit incentives to promote an increase intake of foods high in
drinks for whole fruit (which contains fibre that can help in fibre is recommended.
slowing the spike in blood sugar levels). Finally, everyone The consumption of high-fibre foods, particularly those
should be able to recognize that all forms of sugar are high in fermentable fibre, should be increased, and sub-
calorically equal, regardless of its origins, that is, table stitutions be made instead of refined grain products (with
sugar, honey, jaggery or coconut sugar and that the main low fibre content) to reach the recommended daily intake.
difference between refined sugar and other forms of sugar For instance, lentils (16 g fibre per cup) and other beans
is the lack of essential micronutrients in the former. such as edamame (9 g fibre per cup) are rich in fibre. Other
foods high in fibre include brassica vegetables (kale, cab-
D. Fibre bage, cauliflower and broccoli – which contain an average
of 5 g fibre per cup), blueberries (4 g fibre per cup), avocado
What is known and what is new? (10 g fibre per cup) and whole grains (Supplementary Box 2,
Dietary fibres are carbohydrates with a minimum degree http://links.lww.com/HJH/C287) [172,173]. Importantly,
of polymerization that are neither digested nor absorbed people on diets with restrictive intake of carbohydrates
in the small intestine [165]. Low intake of whole grains, (e.g. gluten-free diet) are at increased risk of poor fibre
fruits, nuts, seeds, vegetables and, thus, overall fibre are intake [174]. Lastly, the addition of high fibre flours (e.g.

beans, high amylose maize starch, green banana) in baked consumption is two standard drinks for men and 1 for
goods can also help increase fibre intake [172,173,175]. women (10 g alcohol/standard drink), while ac-
knowledging that there is no safe limit for alcohol
E. Alcohol consumption to prevent hypertension and adverse
cardiovascular outcomes.
2. Binge drinking should be avoided [185].
What is known and what is new?
The relationship between alcohol intake and high BP was
established over a century ago [176], albeit clarity on the Implementation

mechanisms involved is still lacking. Large-scale observa- Explicit assessment of alcohol intake should be a routine
tional studies report that the incidence of hypertension part of the history in the initial diagnosis and subsequent
increases with any amount of alcohol consumed by men management of hypertension. The effect of counselling
and with more than two standard drinks per day by women alone is uncertain, though data from several RCTs support
[177]. Moreover, a systematic review and meta-analysis of 36 the effect of brief interventions such as motivational inter-
RCTs, described a significant reduction in BP associated with views in reducing alcohol intake [186,187].
a decrease in alcohol consumption in people with hyperten-
sion who consumed three or more drinks per day in a dose- F. Non-alcoholic beverages
dependent manner [178]. The largest reduction in BP [SBP:
5.5 mmHg (95% CI: 6.7 to 4.3) and DBP: 4.0 mmHg What is known and what is new?
(95% CI: 4.7 to 3.3)] was reported in individuals with a Coffee and caffeinated drinks such as tea have beneficial
baseline consumption of six or more drinks per day. Addi- effects on BP and overall cardiovascular health [188]. Drink-
tionally, both trial data and observational literature support ing coffee shows a consistent nonlinear association with the
the hypertensive effect of binge drinking [179,180]. reduced risk in cardiovascular mortality with the greatest
Even though previous observational data have sug- benefits seen with three cups a day [189]. A recent study in
gested a decrease in CVD with light drinking compared the UK Biobank showed that those drinking two to three
with abstainers, these analyses are limited by selection bias cups per day of coffee or tea 32 or 28%, respectively, have
and confounding with other associated health behaviours reduced risk of having a stroke and dementia when com-
[181]. Mendelian randomization studies do not support the pared with nondrinkers [190]. It appears that a consumption
purported protective effects of moderate alcohol consump- greater than three cups daily is safe but the benefits (in
tion and suggest that the lowest risks for cardiovascular terms of reduction in cardiovascular risk) were less appar-
outcomes are in abstainers and that any amount of alcohol ent [189]. Interestingly, an inverse dose–response in coffee
uniformly increases BP [181,182]. consumption has been associated with a 2% risk reduction
of hypertension (relative risk ¼ 0.98, 95% CI: 0.98–0.99) for
International perspective each cup of coffee ingested daily [191]. In contrast, a
Patterns of alcohol intake vary widely across the world, in Japanese study reported that consumption of more than
terms of frequency, type of alcohol (e.g. beer, wine, spirits), two cups of coffee daily increased risk of CVD mortality in
and associated behaviours. Globally, the annual average people with grade 2–3 hypertension [192]. This increased
consumption of pure alcohol per person is 6.18 l (the risk was not observed amongst green tea drinkers [192].
equivalent of 1 l of wine per week at 12% alcohol content) Increased coffee consumption has also been associated
[183,184]. Consumption varies from particularly low across with increased risk of aortic valve stenosis in a Swedish
North Africa and Middle East (close to zero) to high in prospective population study [193].
Europe (highest as 15 l per person annually or the equiva- Emerging data also suggests the benefits of the con-
lent of over two bottles of wine per week in the Czech sumption of nitrate compounds found in beetroot juice in
Republic) [183,184]. Binge or heavy drinking (defined as lowering BP. A recent meta-analysis showed beetroot juice
consuming at least 60 g of pure alcohol or six standard significantly decreases SBP but not DBP in patients with
alcoholic drinks on one occasion in the past 30 days) also arterial hypertension [194]. Interestingly, the BP-lowering
varies internationally, and is more common in parts of effects of beetroot juice in SBP and pulse pressure are
Central and West Africa, as well as Russia [184]. Sex and enhanced when combined with grapefruit juice [195]. Other
gender differences in alcohol consumption (men drinking beverages that can be beneficial include karkade (hibiscus)
more) are wider when the average consumption in a tea, pomegranate juice and cocoa [196]. In contrast, the
country is low (e.g. in North Africa and Middle East) regular consumption of energy drinks, which have large
[184]. The type of alcoholic beverage consumed also varies, amounts of caffeine [197], and liquorice root tea [198]
with spirits being predominant in countries such as India, promote a spike in SBP and heart rate leading to metabolic
Philippines and China, whereas beer is commonly con- changes. The effects of prolonged consumption of energy
sumed in Eastern Europe and wine in Western Europe [184]. drinks have not been determined but may be relevant to
individuals at risk of CVD.
Recommendation
1. Alcohol consumption should be zero for the best International perspective
cardiovascular outcomes (Supplementary Box 2, Coffee and tea consumption varies between countries
http://links.lww.com/HJH/C287) [185]. However, worldwide. However, studies suggest that coffee and tea
the recommended daily upper limit for alcohol intake may be accompanied by smoking, which may

Charchar et al.
revoke their benefits and could also be associated with BP disease [207]. Further, there was no statistically significant
differences in regions with high smoking rates. increase in worsening renal outcomes associated with
fasting [208,209]. However, these studies included general-
Recommendation ly low-risk or moderate-risk groups, and these results may
1. Moderate regular coffee consumption (three to four not be extrapolated to high-risk patients including those
cups per day) does not adversely affect BP and the with end-stage renal disease or severe or uncontrolled
cardiovascular system and can be moderately bene- hypertension.
ficial [81,199,200].
2. The addition of nitrate-rich beverages, such as beet- International perspective
root juice, pomegranate juice and cocoa, may Fasting is practiced around the globe across multiple
be considered. regions, and the effects on health and BP can be affected
by additional factors, including environmental climate,
Implementation temperature, food availability, duration of daylight, culture
The moderate consumption of unsweetened coffee and and religious beliefs (e.g. Ramadan or Lent). Further, the
tea can be assessed by healthcare professionals and timing of meals is heavily influenced by culture and region
recommended for potentially cardioprotective and/or BP- with some cultures typically consuming dinner after 10 pm.
lowering effects. Finally, fasting is implemented for a variety of reasons and
the patient-centred outcomes may extend beyond physical
VII. INTERMITTENT FASTING health, weight loss and BP. Therefore, the acceptability of
intermittent fasting needs to consider the patient’s personal
What is known and what is new? preference. Lack of adequately powered longer term RCTs
Fasting is the voluntary abstinence or restriction of food of fasting limit our understanding on the long-term effects
and/or drink consumption for short or long time periods. of this strategy.
For over a thousand years, fasting has been used across the
world for cultural, traditional, religious or health reasons. Recommendations
More recently, the use of short-term, intermittent fasting 1. Intermittent fasting with calorie restrictions may be
became a popular strategy for weight loss and improving beneficial for weight loss and BP reduction but is not
metabolic health. This strategy gained interest with the superior to general calorie-restricted diet. Therefore,
recognition that periods of energy consumption have ex- use of intermittent fasting should depend on patient
tended to predominately later into the evening, and this preferences, and other considerations.
time factor, may contribute to chronic disease epidemics 2. Fasting, including during Ramadan or Lent, is gener-
including obesity and hypertension [201,202]. ally safe in low-risk to moderate-risk populations.
There are various forms of intermittent fasting, including
alternate day fasting where caloric intake varies on alternate
days; daily time-restricted eating includes usual eating Implementation
during an 8–12 h window and abstinence of food for the Patients with chronic conditions should seek guidance from
remaining time; and modified fasting where caloric intake is their healthcare provider before initiating fasting.
restricted on certain days (e.g. 5 : 2 diet) and ad libitum on
other days of the week. Religious fasting, such as during the VIII. STRESS REDUCTION AND
month of Ramadan, is a form of daily time-restricted fasting, MINDFULNESS
where food and drink including medications are restricted
from dawn until dusk. What is known and what is new?
It is postulated that intermittent fasting triggers a meta- Psychosocial stress is associated with an increased risk of
bolic switch from hepatic glucose metabolism to adipose- hypertension and cardiovascular events [210,211]. Patients
derived ketone production during fasting periods. with psychological distress may develop a sudden increase
Independent of weight loss, fasting lowers sympathetic in BP, which may usually normalize when the distress is
nervous system activity, suppresses inflammation and relieved [212]. However, people who suffer from stress
improves glucose regulation [203]. Longer term clinical data related to posttraumatic stress disorder have an increased
on the safety and efficacy of intermittent fasting is emerging risk of hypertension and history of poor medication adher-
but is still limited. Several small studies demonstrate re- ence [213,214]. Importantly, post-COVID-19 pandemic-re-
duced BP among those who lose weight during intermittent lated stress, anxiety and depression may contribute to
fasting [204,205]. However, in a large clinical trial compar- poorer BP control in patients with hypertension [215–
ing intermittent fasting with reduced caloric intake versus a 218]. Stress is also associated with unhealthy habits such
general calorie-restricted diet, both strategies were associ- as poor diet or overeating and weight gain, heavy drinking
ated with reduced weight and BP, but there was no signifi- and/or smoking and sedentary behaviours, increasing risk
cant difference between the groups [206]. In a meta-analysis of hypertension and CVD [211].
of 33 studies (n ¼ 3213), fasting was associated with lower Stress reduction can be achieved through a number of
BP at end of Ramadan compared with before Ramadan, strategies, such as meditation, progressive muscle relaxa-
among those with diabetes, normotension and hyperten- tion, yoga, deep breathing exercise and mindfulness [211].
sion but no change in BP in those with chronic kidney In recent years, mindfulness practices, defined as the

awareness, including self-understanding, wisdom and Implementation

compassion that comes from intentionally focusing on All healthcare professionals should assess psychological
the present moment, have received interest as an alternative distress in all their patients with hypertension via visualized
approach for the treatment of chronic diseases [219,220]. analogue scales or screening tools.
The mindfulness-based stress reduction (MBSR) pro- Patients with hypertension should seek to reduce stress
gram has been demonstrated to have a broad efficacy in and improve overall well being using mindfulness techni-
improving physical and mental well being, as well as ques. MBSR is a safe option and well accepted practice [19].
promoting office BP reduction [19,219]. A recent meta-

analysis encompassing 12 studies reported that MBSR les- IX. SLEEP
sons of at least 8 weekly sessions of MBSR and over 30 min

of meditation practices daily reduced stress, mood swings What is known and what is new?
and SBP and DBP by 6.6 and 2.5 mmHg, respectively, in Sleep hygiene is important for vital function maintenance.
patients with hypertension [19]. Meanwhile, poor sleep hygiene, including that related to
A systematic review also reported that 45 min of yoga behavioural deviations, and sleep disruptions are associat-
every day reduced SBP by 6.5 mmHg and DBP by ed with adverse health effects [228,229]. Inadequate sleep
2.8 mmHg after a 12-week program [221]. duration, both acute and chronic sleep deprivation and
Cognitive behavioural therapy helps individuals to iden- sleep disorders cause sympathetic hyperactivity resulting in
tify and change negative thoughts and behaviours that blunted BP regulation, mainly absence or reversal of noc-
contribute to stress. A meta-analysis of 15 RCTs revealed turnal BP dipping and/or nocturnal hypertension [229–
a reduction in SBP (8.7 mmHg), DBP (5.8 mmHg), choles- 231]. Sleep characteristics, including sleep quality, sleep
terol levels, depressive and anxiety symptoms and im- duration and sleep efficiency, are associated with the risk of
proved sleep [222]. Alternatively, other stress reduction hypertension based on office BP [68,232]. According to the
techniques such as deep breathing, progressive muscle Coronary Artery Risk Development in Young Adults (CAR-
relaxation, self-soothing, gratitude and acts of kindness, DIA) study, shorter sleep duration and lower sleep efficien-
learning problem-solving and goal-setting techniques can cy were associated with higher office BP and BP increase
reduce stress levels and are better accepted than MBSR by over 5 years follow-up [233]. Prospective study from the UK
some patients [7,210,223]. In addition, increasing physical Biobank showed that healthy sleep (sleep duration 7–8 h,
activity, social connectedness and sleep hygiene (where no insomnia, no snoring, no excessive daytime sleepiness,
warranted) can also be explored. early chronotype) is associated with lower incident hyper-
Overall, the best stress reduction interventions to reduce tension risk [234] and, in hypertensive patients, it is inverse-
BP and hypertension are those that are maintainable and ly associated with the incidence of cardiometabolic
can be combined into daily life. A mixture of different morbidities, including coronary heart disease, diabetes
approaches, such as MBSR, exercise and yoga, may be mellitus and stroke [235]. Mendelian randomization analy-
most effective and tolerated by individuals with hyperten- ses suggest potentially deleterious effects of more frequent
sion. Importantly, it is vital to consult a healthcare profes- daytime napping on cardiometabolic health (BP and ab-
sional to determine the best approach for each individual. dominal obesity) [236]. A retrospective analysis from the UK
Another systematic review also reported that listening to Biobank suggested that frequent daytime napping is asso-
music 1/day to 3/week showed a trend towards lower ciated with a 12% increased risk of developing high BP
SBP and DBP by 10 and 6 mmHg, respectively [224]. More- [237]. Although both night-time sleep and daytime napping
over, patients with hypertension who listened to 25 min of are associated with the decline in BP [238], and single cohort
classical music over a 4-week period showed an average studies demonstrate negative association between daytime
decrease of 6.6 mmHg in SBP [225]. nap duration and hypertension presence [239], the evi-
dence on long-term outcomes is lacking. Aligning sleep
International perspective behaviours with endogenous circadian rhythms may be
Evidence suggests that MBSR did not differ in reducing BP important in increasing SBP dipping, particularly if a part
in patients between eastern and western countries [19]. of the sleep period overlaps with the circadian peak in BP
Estimates for MBSR sessions from cross-sectional studies that occurs early in the evening [233,240,241].
show a variation between countries ranging from 90 min/ Abnormal sleep patterns and obstructive sleep apnoea
session in Iran [226] to 120 min/session in Spain over (OSA) are often associated with cardiometabolic risk fac-
8 weeks [227]. These studies indicate that patients with tors, such as obesity, insulin resistance, impaired lipid and
hypertension may benefit from practicing MBSR to reduce glucose metabolism, atherosclerosis and chronic inflamma-
mental stress and BP, yet data on long-term BP effects and tion [242–245]. Lifestyle factors and lifestyle interventions
impact on future CVD risk are unknown. (in particular, weight reduction, diet, exercise training)
significantly affect OSA severity metrics [246,247]. Salt in-
Recommendation take might play a significant role in OSA severity in states
1. Practice stress reductions techniques at least 3 h per associated with fluid retention and its redistribution in
week to reduce mental stress and BP [226,227]. recumbent position (in particular, resistant hypertension
2. Alternatively, practice activities such as yoga, medi- and hyperaldosteronism) [248].
tation or tai chi at least 45 min a day [221]. Sleep-disordered breathing, in particular, OSA, is consid-
3. Listen to music once a day to three times a week for at ered a leading cause of secondary hypertension [249] and a
least 25 min [224]. risk factor for nocturnal and also resistant hypertension in up

Charchar et al.
to 85% of cases [17]. However, the antihypertensive effect of exposure to bright light and exercise during the day
OSA treatment through the use of continuous positive airway and their restriction before sleep.
pressure (CPAP) or other oral appliances is rather modest, 4. Stimulus control and building a strong association
comprising of a decrease in only 2–4 mmHg and depends on between the bed/bedroom and sleep should be
a number of other factors, including pretherapy BP, adher- implemented: go to bed only when you are sleepy;
ence and tolerance to the procedure (more than 6 h per establish a sleep routine; apply the 20 min rule (i.e. if
night) and daytime sleepiness [250,251]. The effects of OSA you cannot get to sleep in 20 min, get up and go to
another room and do nonstimulating activities).
treatment on metabolic disorders are partly inconsistent; it

appears that some OSA patients’ subgroups might benefit 5. Daytime napping for more than 30 min should not be
routinely recommended given its effects on sleep
more than others [252]. An analysis from the European Sleep

Apnea Database (ESADA) cohort demonstrates that some pressure and nocturnal sleep and the lack of long-
drug classes (beta-blockers in monotherapy or in combina- term outcome evidence.
tion) are associated with the better BP control in OSA patients 6. Shift-workers might require an individualized ap-
depending on few clinical characteristics (age, gender, obe- proach to develop sleep–wakefulness patterns. Am-
sity) [253]. There is limited evidence on the association bulatory BP monitoring should be considered for
between habitual snoring at least four nights/week and diagnosis and follow-up evaluations to assess noc-
around 1.5-fold increased incidence and prevalence of hy- turnal BP patterns.
pertension [254–256]. 7. Screening of sleep disorders (in particular, OSA [245])
Recent studies suggest that irregular sleep timing should be performed in resistant hypertension, in
[242,243], circadian disorders (including shift-work) [231], patients with nocturnal hypertension and/or abnor-
insomnia [257,258], parasomnias, periodic limb movements mal BP dipping. If applicable, treatment should be
[258], central hypersomnias [259] and daytime napping [260] implemented, focusing on lifestyle changes and use
are associated with hypertension and other adverse cardi- of specific treatment (CPAP, oral appliances) to aid
ometabolic profiles. However, the evidence is scarce for good sleeping habits.
any definite conclusions. 8. People with known sleep disorders (snoring, OSA,
insomnia, etc.) should undergo regular BP measure-
International perspective ment. Ambulatory BP monitoring should be consid-
Local, national and ethnic sleep-related traditions (e.g. ered for BP nocturnal pattern evaluation.
polyphasic sleep, siesta, midnight sun patterns) as well
as predisposing factors (i.e. ethnic/racial differences in Implementation
sleep apnoea prevalence) should be considered [261– All healthcare professionals should be encouraged to eval-
264]. Furthermore, sleep duration contributes to racial uate sleep in a multimodal manner [270] (sleep satisfaction,
disparities in hypertension risk [265,266]. timing, efficiency, duration, alertness, sleep disorders) in all
In general, data on daytime napping is limited; however, patients with the involvement of partners/relatives, when
in countries with siesta tradition, it should not exceed needed. In case of abnormal sleep habits and/or sleep
30 min daily. patterns, personalized counselling about the role of sleep
In countries with midnight sun, the behavioural in BP management and advice on modification of sleep
approaches are useful and should be recommended includ- habits should be implemented. Clear and achievable goals
ing the use of blackout blinds and sleep masks at night, as should be set in collaboration with the patient, potential
well as blue light blockers or sunglasses in the evening. challenges and barriers and motivating strategies should be
Mendelian randomization studies show an association discussed and strategies implemented. Patients experienc-
between sleeping patterns and BP increase. Interestingly, ing persistent sleep difficulties (4 weeks) should be re-
genetic architecture of daytime napping is shared with BP ferred to a sleep specialist for further evaluation and
traits [236], and genetically predicted short sleep duration is management. Cognitive behavioural therapy for insomnia
associated with risk of hypertension [232]. Meanwhile, data is beneficial for patients with hypertension, improving
is less established related to genetically predicted longer sleep quality and decreasing SBP and DBP by 8.6 and
sleep duration [232,267]. 5.6 mmHg, respectively [222].
At policy level, regulations of working schedules and
Recommendation educational programs in the sleep field must be promoted.
1. Weight control should be considered to improve Population-based awareness programs addressing healthy
sleep quality and management of sleep disorders sleep must be supported.
(specially OSA).
2. Sleep hygiene should be addressed and implemented X. SMOKING
routinely [228,229,268,269]. Sleep duration of 7–9 h
per night is recommended for adults [228,229, What is known and what is new?
268,269]. Smoking is not directly involved in the pathogenesis of
3. Sleep hygiene approaches include appropriate sleep essential hypertension but can cause acute increase of BP
environment, regular sleep timing, sleep routine to and is a known independent and strong risk factor for CVD.
prepare for sleep, avoidance of food intake, caffeine, Smokers may have white coat and masked hypertension in
alcohol and cigarettes close to bedtime and at night, the clinic, which is present on daytime ambulatory or home

BP monitoring [271]. Smoking affects the cardiovascular CVD, respiratory disease and cancer [280–283]. Air pollu-
system structurally and functionally through interaction of tion is a complex mixture of thousands of gaseous and
hundreds of substances present in cigarettes and other particulate matter components, with the primary source of
tobacco products [272]. It serves as a major risk factor for urban air pollution coming from motor vehicle exhausts
atherosclerosis as evidenced from population studies [284].
[273,274]. The main components of air pollution associated with
Emerging data reveals the use of electronic cigarettes detrimental health effects are airborne particulate matter
(e-cigarette) leads to acute increase of BP so we recom- (especially fine particulate with an aerodynamic diameter
mend against their use [275]. 2.5 mm) and gaseous substances including ozone, nitro-
gen dioxide, sulphur dioxide and carbon monoxide [285].

International perspective Inhaled ultrafine particulate matter rapidly passes from
Tobacco is the number one risk factor for global attributable the lungs into the systemic circulation [286] where acute BP-
deaths in men and the sixth in women [276]. Importantly, raising effects are exerted through vasoconstriction of con-
tobacco smoking, including second hand (passive) smok- duit arteries, systemic inflammation, endothelial dysfunc-
ing, is within the top five risk factors for burden of disease tion and autonomic nervous system imbalance [21,282,
worldwide, except sub-Saharan Africa [277]. 287–289].
Global prevalence of smoking has significant geograph- Epidemiological studies show a strong correlation be-
ic, age and gender variation. Countries in Asia and Oceania tween chronic exposure to elements of air pollution and
have the highest prevalence of tobacco smoking among increased BP, as well as incident hypertension and organ
men while higher prevalence among females is seen in damage associated with hypertension [290–296]. Human
America and Western Europe [278]. experimental data also demonstrate a dose–response rela-
tionship between air pollution and SBP [297].
Recommendation Reducing population exposure to air pollution would
Smoking (including e-cigarettes) cessation is strongly significantly improve health, reduce mortality and lower
recommended for its well established health benefits health system expenditure [298,299].
[274]. Importantly, strategies and approaches to avoid Emerging data also indicates that noise pollution may
weight gain following smoking cessation should correlate with increased risk of hypertension [300], and
be implemented. reducing exposure to noise could help control BP. More
Key target populations are those already exposed to data with adjustment for confounding variables is needed to
smoking and those yet to be exposed, composed evaluate this relationship more comprehensively [301].
largely of young generations.
Brief intervention counselling and motivational inter- International perspective
viewing techniques in healthcare centres is shown to Air quality has improved in high-income countries but has
be very effective in tobacco cessation [279]. worsened in most low-income and middle-income coun-
tries alongside increased urbanization and growing econo-
mies [283].
Implementation Inequity regarding increased air pollution exposure is
Smoking cessation is the key factor in lowering risk impact
experienced by the poor and disempowered, and women
on health. Enablers to quit smoking must be created
and children in low-economic settings where polluting
through all levels, from the grass root healthcare settings
fuels have to be used for cooking, heating and lighting [302].
to policy levels. At the healthcare centre level, brief inter-
Policy makers internationally should follow the WHO
vention counselling for smoking and other tobacco use
Global Air Quality Guidelines and Good Practice State-
must be the standard practice care of any health service
ments to inform evidence-based legislation and policies
delivery model. Healthcare providers can be trained on
to improve air quality and mitigate population exposure to
simple modules of motivational interviewing techniques to
air pollution [283]. Use public transport, or travel by walking
reach the broader community. All patients must be assessed
or cycling in preference to car or motorcycle to reduce
for smoking and on readiness to quit. Readiness to quit pollution at population level should be encouraged. These
must be followed up till successful and continuing smoking
guidelines should be used by healthcare professionals and
cessation.
medical societies to raise awareness and advise the public
At policy level, population-based control programs can and patients [283,302]. Individuals can reduce exposure to
be administered. Policy regulations such as tobacco taxa-
air pollution by modifying the location, timing and type of
tion, and separation of smoking and nonsmoking areas at
outdoor activity [303–305].
public places must be sustained and expanded. Population-
based awareness and advocacy programs addressing harm-
ful effects of smoking must be advocated. Recommendations
1. Exercise in parks and gardens away from busy road-
XI. POLLUTION EXPOSURE ways.
2. Limit time spent outdoors during highly polluted
What is known and what is new? periods.
Each year, air pollution causes millions of premature deaths 3. Avoid inefficient burning of biomass for domestic
globally and is recognized as a modifiable risk factor for heating.

Charchar et al.
4. Consider using ventilation systems with filtration for suggested intake of dietary supplements and nonprescrip-
homes in high pollution areas. tion medications for BP optimization.
Micronutrient and bioactive intake personalization
Implementation based on individual characteristics, mainly related to eth-
The greatest benefits to health can be achieved through nicity and genetic background, is an envisaged strategy for
national level policies that reduce air pollution at the point the future of hypertension primary prevention.
of source. These policies are specific to context and place,
and must be applied across sectors, including transport, Recommendation

urban planning, industry, agriculture, energy and power 1. Vitamins, minerals and micronutrients intake should
generation [302]. be obtained as part of a healthy, nutrient-rich and

Governments must play a major role by engaging widely balanced diet.
at regional, national and international levels to advise 2. Health supplements are not a replacement for a
policy options to prevent air pollution exposure and attain balanced diet and are not recommended as a treat-
the greatest health benefits for communities [283,302]. ment to hypertension.
XII. NONPRESCRIPTION MEDICINE Implementation

AND NUTRITIONAL SUPPLEMENTS Considering interpersonal variability in response to a nu-
trient intake, preexisting health concerns and dietary pref-
What is known and what is new? erences, a personalized approach to nutrition and
Nonprescription medicines include an array of medications supplementation is essential for the nutritional manage-
ranging from anti-inflammatories to herbal medications. ment of hypertension, while focusing on higher intake of
Herein, we focused on specific nutrient supplements and certain micronutrients (as part of a normal diet) and func-
their relationship with BP, excluding herbal medicines and tional foods.
nonnutritional foods.
Although the link between vitamin intake and hyperten-
sion is indicated, evidence-based research studies are
XIII. BEHAVIOURAL INTERVENTIONS,
scarce. Studies suggested multivitamin supplementation DIGITAL HEALTH AND WEARABLES
decreases high-BP-related mortality [306,307]. However, What is known and what is new?
these effects were not observed in middle-aged and older Behavioural intervention is an effective approach for the
women [308]. Several studies support the role played by treatment of CVD [320,321]. A recent large-scale systematic
hydrosoluble vitamins in maintaining both SBP and DBP in review [322], including 150 RCTs identified the clinically
various populations [309–311] and a meta-analysis of 29 supervised Patient Self-Management Support, frequently
RCTs revealed that vitamin C supplementation reduced SBP based on Wagner’s Chronic Care Model, the most dominant
and DBP [312]. Circulating micronutrient status is associated intervention method [323]. Importantly, many chronic ill-
with adiposity, SBP and cardiometabolic risk factors, such nesses share the same modifiable behavioural lifestyle
as vitamin D with obesity parameters in women [313–315], risk factors.
imposing alternative pathways for the vitamin D role in Behavioural habits known to modulate cardiovascular
sustaining optimal BP. Importantly, vitamin D metabolism risk and BP control include oral hygiene practices as both
is dependent on the appropriate intake of calcium and dental care access and periodontitis are independently
magnesium. It was reported that daily magnesium supple- linked to hypertension and target organ damage [324]. This
mentation lowers BP [316]. Furthermore, a meta-regression relationship is independent of socioeconomic status [325].
also indicated a decrease in BP with long-term potassium The use of digital technologies for prevention and/or
supplementation of 3500 mg/day, especially in subjects not treatment of health conditions, termed digital health inter-
taking antihypertensives [317]. Similarly, chlorogenic acids, ventions, is an emerging and promising approach to sup-
compounds contained in apples, coffee, tomatoes and port people with hypertension [326,327].
other vegetables, might decrease BP, also indirectly Recent studies showed clinically modest but significant
through effects on adiposity, then hypoglycaemic, hypo- effects of digital interventions to reduce SBP, improve
uricemic effects and similar [318]. medication adherence and lifestyle behavioural changes
Additionally, intake of functional foods based on onion longer term [328,329].
and garlic, rich in flavanols, as well as catechin-containing Use of personalization through digital health (e.g. elec-
green tea with angiotensin-converting enzyme (ACE) in- tronic health records or mobile devices to support health
hibitory properties, can be a food-based nutritional strategy practices) interventions can, especially aid in the delivery of
to aid BP management and CVD prevention [319]. timely precision medicine strategies and be delivered di-
Importantly, extensive research on the impact of these rectly by the healthcare practitioner and/or digitally,
supplementations is needed and evidence of effects on BP through the utilization of end-user manual inputs and/or
is still minimal. digital system-derived inputs [330].
Providing a dynamic and adaptive hypertensive digital
International perspective intervention into the future that can adjust its responses
Lack of adequately powered RCTs does not allow stream- when the individual changes (in real-time) should better
lined and efficient implementation process for the facilitate behaviour change outcomes [331–333]. Additionally,

antihypertensive digital interventions that can minimize the motivation is declining, alerting the patient (and practition-
amount of manual end-user input may also increase patient er) if symptoms are deteriorating), in real-time.
adherence [328,330,332], especially through the consistent use Lastly, the greater inclusion of wearables and integration
of validated digital wearables to support and maintain lifestyle of smarter programming and artificial intelligence into such
modifications. There is, however, a need to ensure that any interventions is predicted to strengthen behaviour change
digital BP device has its accuracy validated, and we caution the and improve health outcomes [332,338].
use of unvalidated devices.
XIV. HOLISTIC APPROACH TO BLOOD
Importantly, digital health approaches should not sup-

plant the role of clinicians but are tools that clinicians and PRESSURE PREVENTION ACROSS THE
patients can use to improve the efficiency and effectiveness

of clinical objectives. Digital health platforms enable the GLOBE
efficient exchange of clinical data and clinician–patient What is known and what is new?
interactions to achieve effective lifestyle modifications. Urbanization is considered a major contributor to the rising
prevalence of hypertension worldwide. Higher prevalence
International perspective of hypertension in urban areas includes socioeconomic and
Behaviour change techniques are included in the medical lifestyle changes that increase the diagnosis of overweight,
curriculum for healthcare providers in many countries obesity, smoking and diabetes [339]. Other mechanisms are
[334–336] reinforcing the importance of chronic illnesses thought to involve psychosocial stress in urban residents
burden control through effective population-based resulting from financial stress, redefinition of cultural iden-
intervention programs. tity and movement away from traditional coping mecha-
The US Centres for Disease Control and Prevention nisms, including social support from extended family.
websites contain a large compendium of local and global These changes have been reported in different epidemio-
studies centred on the benefits of behavioural interventions logical studies worldwide [340].
upon modifiable risk factors for chronic disease prevalence Another study shows the relationship between educa-
and outcomes. tion and lifestyle and healthcare changes [341]. The risk
factors for unhealthy nutritional habits, stress, poor working
Recommendations conditions or inadequate access to education and appro-
1. Healthcare providers should be trained in behaviour priate medical services are present in a large part of the
change approaches and digital support technologies urban population [342], but evidence is lacking in the rural
to facilitate action and control hypertension [337]. population. Furthermore, these risk factors are more pro-
2. Behavioural changes should be comprehensive and nounced between gender differences.
encompass oral hygiene improvement and mainte- There is undeniable need to change our current stand-
nance to prevent periodontitis and improve BP con- ards of lifestyle approach, such as an integral treatment of
trol [324]. hypertension patients. Implementation of HEARTS-WHO
3. Continuous use of validated digital wearables and model based on the premise that a person needs whole-
digital tools to improve symptom awareness, intro- some care and not just the treatment for the disease should
duce potential reminders (e.g. for medication intake be implemented. The holistic and wholesome patient care
or promote increased incidental exercise), aid behav- approach takes into consideration all patient aspects, in-
iour change (e.g. goal setting, decision support, self- cluding physical, emotional, social, economic, cultural and
monitoring, which may integrate wearable data, re- religious/spiritual needs to provide the most appropriate
minder and alert systems, digital support conversa- advice and treatment [343].
tional agents to improve user adherence, motivation
and self-efficacy, intervention personalization pro- International perspective
gramming) should be encouraged. Worldwide, factors are similar, although inequalities in
4. Introduce communication technologies to facilitate health access between populations have been described
professional guidance and input or social support [344–346], and several studies have shown that diagnosis,
(digital spaces to communicate with healthcare pro- control and treatment of hypertension are worse in rural
viders or peers, SMS messaging) as a standalone areas than in urban areas [347]. Indigenous populations
digital intervention or integrated into a multicompo- worldwide experience a huge gap in access to general
nent intervention [326]. health and health treatments and mortality [348], including
CVD and diabetes [347,349,350]. This divide is observed as a
Implementation combination of racial discrimination, poverty, lifestyle and
The use of digital health interventions that incorporate behav- access to services due to geographical isolation [348,351].
iour change models and include personalization is the most Socioeconomic differences between poorer and richer
promising but reliable RCTs showing efficacy are lacking. countries and populations also impact general health access
Data collection, either using manual or system-based and CVD morbidity and mortality [346,351].
input, can be achieved through smart programming and/or
artificial intelligence software to continually personalize Recommendation
digital intervention (e.g. offering relevant tailored content, 1. Implementation of holistic care for patients, as evi-
sending reminders about targets or encouragement if denced in Bhutan, Latin America, Canada and some

Charchar et al.
countries in Africa, to provide the optimal treatment supported by Resolve to Save Lives. Resolve to Save Lives is
and management of BP [23,352–354]. funded by Bloomberg Philanthropies, the Bill and Melinda
2. Improve access to BP diagnosis, treatment and man- Gates Foundation, and Gates Philanthropy Partners, which
agement in regional and rural areas. is funded with support from the Chan Zuckerberg Initiative.
F.Z.M. is supported by a Senior Medical Research Fellow-
Implementation ship from the Sylvia and Charles Viertel Charitable Foun-
Healthcare providers should consider a holistic, multicom- dation, a National Heart Foundation Future Leader
ponent approach addressing many lifestyle changes simul- Fellowship (105663), and NHMRC Emerging Leader Fel-
taneously. Comprehensive hypertension lifestyle changes lowship (GNT2017382). M.G.S. is supported by a National
such as exercise, education, nutritional habits and policies Heart Foundation of Australia Future Leader Fellowship
should be targeted for both rural and urban areas. (reference 102553). M.T.’s work on hypertension is sup-
Exercise and nutritional habits according to culture, ported by British Heart Foundation and the NIHR Man-
ethnicity and religion should be considered in populations chester Biomedical Research Centre (NIHR203308). R.D.W.
around the world to achieve equitable population outreach. is supported by the National Institutes of Health (NIH) R01
Differential work must be done on vulnerable popula- HL139867, R01 HL141406, R01 AG062515 and R01
tions to adequately identify the necessary policies to be AG075963. S.M.S.I. is funded by the NHMRC and received
implemented and maintained. funding from the National Heart Foundation of Australia.
XV. OVERALL SUMMARY AND A Conflicts of interest

L.V. reports employment with Amsterdam University Medi-
GLIMPSE INTO THE FUTURE FOR cal Centers; consultancy agreements with AstraZeneca,
ASSISTED LIFESTYLE INTERVENTIONS Bayer BV Netherlands, Boehringer Ingelheim and Vifor
In this position paper, we presented recommendations that Pharma; research funding from Dutch Kidney Foundation
support a healthy lifestyle to manage and maintain a healthy and Health Holland. Y.C.C. has received, on behalf of the
BP – more exercise, less salt, sugar and saturated fats in Malaysian Society for World Action on Salt, Sugar and
diet, more fruit, vegetables, and dietary fibre, no smoking Health (MyWASSH), an unrestricted educational grant
and alcohol. We also presented emerging evidence for from Medtronic.
newer modalities and discussed the potential for increased
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ISH Paper

Lifestyle management of hypertension: International

the World Hypertension League and European

Journal of Hypertension 2024, 42:23–49

Journal of Hypertension www.jhypertension.com 23

XII. NONPRESCRIPTION MEDICINE, INCLUDING

compiled lifestyle management recommendations as first-

24 www.jhypertension.com Volume 42 Number 1 January 2024

recommendations. These consensus recommendations are

programmers. In addition to the recommendations, we pro-

Recommendations are aimed for individuals, unless stated otherwise.

Journal of Hypertension www.jhypertension.com 25

26 www.jhypertension.com Volume 42 Number 1 January 2024

as cardiovascular mortality [25–27]. A meta-analysis of 57 Recommendation

International perspective V. PHYSICAL ACTIVITY

Journal of Hypertension www.jhypertension.com 27

considered safe and currently recommended for hyperten-

28 www.jhypertension.com Volume 42 Number 1 January 2024

Implementation hypertension with greater BP lowering among African

Journal of Hypertension www.jhypertension.com 29

30 www.jhypertension.com Volume 42 Number 1 January 2024

B. Potassium Academies of Sciences and Medicine [129,134]. Foods

Journal of Hypertension www.jhypertension.com 31

32 www.jhypertension.com Volume 42 Number 1 January 2024

established over a century ago [176], albeit clarity on the Implementation

Journal of Hypertension www.jhypertension.com 33

34 www.jhypertension.com Volume 42 Number 1 January 2024

awareness, including self-understanding, wisdom and Implementation

promoting office BP reduction [19,219]. A recent meta-

sons of at least 8 weekly sessions of MBSR and over 30 min

Journal of Hypertension www.jhypertension.com 35

treatment on metabolic disorders are partly inconsistent; it

more than others [252]. An analysis from the European Sleep

36 www.jhypertension.com Volume 42 Number 1 January 2024

gen dioxide, sulphur dioxide and carbon monoxide [285].

Journal of Hypertension www.jhypertension.com 37

and must be applied across sectors, including transport, Recommendation

generation [302]. be obtained as part of a healthy, nutrient-rich and

XII. NONPRESCRIPTION MEDICINE Implementation

38 www.jhypertension.com Volume 42 Number 1 January 2024

Importantly, digital health approaches should not sup-

patients can use to improve the efficiency and effectiveness

Journal of Hypertension www.jhypertension.com 39

XV. OVERALL SUMMARY AND A Conflicts of interest

40 www.jhypertension.com Volume 42 Number 1 January 2024

19:1063–1069. 33. Vallee A, Perrine A-L, Deschamps V, Blacher J, Olie V. Relationship

Journal of Hypertension www.jhypertension.com 41

42 www.jhypertension.com Volume 42 Number 1 January 2024

Journal of Hypertension www.jhypertension.com 43

44 www.jhypertension.com Volume 42 Number 1 January 2024

Journal of Hypertension www.jhypertension.com 45

46 www.jhypertension.com Volume 42 Number 1 January 2024

Journal of Hypertension www.jhypertension.com 47

48 www.jhypertension.com Volume 42 Number 1 January 2024

Journal of Hypertension www.jhypertension.com 49

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