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What lifestyle changes should we recommend for the patient with newly diagnosed hypertension?
Hypertensive patients should reduce sodium intake (strength of recommendation [SOR]: A). The Dietary Approaches to Stop Hypertension diet (DASH diet)—with salt restriction and increased fruit, vegetable, calcium, and potassium intake—reduces blood pressure and should be recommended (SOR: A).
Aerobic exercise is effective in the general, as well as elderly, populations for reducing blood pressure (SOR: A). Patients should be encouraged to reduce alcohol consumption (SOR: A). Evidence that weight loss is significantly associated with blood pressure reduction is inconclusive (SOR: C). Smoking cessation should be encouraged for all hypertensive patients for prevention of cardiovascular disease (SOR: A).
When advising patients to make lifestyle changes, be participatory, personalized, practical, and persistent
Linda N. Meurer, MD, MPH
Medical College of Wisconsin
Lifestyle modifications can prevent and lessen hypertension, but persuading patients to make lasting changes in their long-held eating and activity patterns is challenging. When advising patients to make meaningful lifestyle changes, remember these 4 “Ps”: Participatory, Personalized, Practical, and Persistent. First, engage patients in a conversation about their lifestyle habits and partner with them to develop specific, personalized strategies to make improvements. For example, target significant sources of sodium in the specific foods they eat and find practical opportunities for physical activity in the context of their own schedule and circumstances.
Most importantly, persist in your advice by revisiting lifestyle recommendations and the patients’ progress at each visit, and modify as needed. Often, once medications are prescribed, patients disregard the lifestyle changes, and may need repeated encouragement to adopt regular, healthful habits.
Evidence summary
Healthy lifestyles are an important part of both prevention and management of hypertension. These changes include maintenance of normal body weight, regular aerobic exercise, dietary salt reduction, alcohol consumption reduction, and consumption of diets rich in potassium, fruits, and vegetables. These recommendations have been reviewed in recent meta-analyses (TABLE).
Lifestyle changes that have not shown any significant effect on blood pressure or that are still under review include dietary omega-3 fatty acid supplementation and antioxidant supplementation.10
TABLE
Summary of recommendations
| INTERVENTION | OUTCOME | STUDY DETAILS | SOR |
|---|---|---|---|
| Reduction of dietary sodium intake | Lowers SBP by 4.97 mm Hg (95% CI,–5.76 to –4.18) | 2004 Cochrane review1,2 (17 trials; 734 participants) | A |
| DASH diet | Lowers SBP by 4.3 mm Hg (P<.001) | Multicenter randomized control trial (810 adults)2,3 | A |
| Regular aerobic exercise | Lowers SBP by 4.0 mm Hg (95% CI,–5.32 to –2.75) | Meta-analysis of 54 RCTs (2419 participants)4,5 | A |
| Reduced alcohol consumption | Lowers SBP by 3.31mm Hg (95% CI,–4.10 to –2.52 | Meta-analysis of 15 RCTs (2234 participants)6 | A |
| Smoking cessation | 36% relative risk reduction in mortality (RR=0.64; 95% CI,0.58 to 0.71) | 2004 Cochrane review (20 prospective cohort studies)7 | A |
| Weight loss | 3%–9% body weight loss may be associated with decrease in blood pressure by 3 mm Hg; not statistically significant (95% CI,–6.8 to 0.7). | 2000 Cochrane review of 18 trials (though 1997; 361 participants in the primary 6 studies)8,9 | C |
| SOR, strength of recommendation; SBP, systolic blood pressure; CI, confidence interval; RR, relative risk; RCT, randomized controlled trial. | |||
Recommendations from others
The National High Blood Pressure Education Program recommends the following for primary prevention of hypertension:11
- Maintain normal body weight for adults
- Reduce dietary sodium intake to no more than 100 mmol/d
- Engage in regular aerobic physical activity
- Limit alcohol consumption to 30 mL ethanol per day for men, and 15 mL ethanol per day for women or lighter persons
- Maintain adequate intake of dietary potassium (>90 mmol/d)
- Consume a diet rich in fruits, vegetables, and low-fat dairy, with reduced content of saturated and total fat.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure agrees with the recommendations in the TABLE.12
1. He FJ, MacGregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database Syst Rev 2004;(3):CD004937.-
2. Bray GA, Vollmer WM, Sacks FM, Obarzanek E, Svetkey LP, Appel LJ. DASH Collaborative Research Group. A further subgroup analysis of the effects of the DASH diet and three dietary sodium levels on blood pressure: results of the DASH-Sodium Trial. Am J Cardiol 2004;94:222-227.
3. Appel LJ, Champagne CM, Harsha DW, et al. Writing Group of the PREMIER Collaborative Research Group. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003;289:2083-2093.
4. Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002;136:493-503.
5. Kelley GA, Sharpe Kelley K. Aerobic exercise and resting blood pressure in older adults: a meta-analytic review of randomized controlled trials. J Gerontol A Biol Sci Med Sci 2001;56:M298-303.
6. Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2001;38:1112-1117.
7. Critchley J, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev 2004;(1):CD003041.-
8. Mulrow CD, Chiquette E, Angel L, et al. Dieting to reduce body weight for controlling hypertension in adults. Cochrane Database Syst Rev 2000;(2):CD000484.-
9. He J, Whelton PK, Appel LJ, Charleston J, Klag MJ. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension 2000;35:544-549.
10. Hooper L, Thompson RL, Harrison RA, et al. Omega 3 fatty acids for prevention and treatment of cardiovascular disease. Cochrane Database Syst Rev 2004;(4):CD003177.-
11. Whelton PK, He J, Appel LJ, et al. National High Blood Pressure Education Program Coordinating Committee. Primary prevention of hypertension: clinical and public health advisory from The National High Blood Pressure Education Program. JAMA 2002;288:1882-1888.
12. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung and Blood Institute; National High Blood Pressure Education Program Coordinating Committee Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-1252.
Hypertensive patients should reduce sodium intake (strength of recommendation [SOR]: A). The Dietary Approaches to Stop Hypertension diet (DASH diet)—with salt restriction and increased fruit, vegetable, calcium, and potassium intake—reduces blood pressure and should be recommended (SOR: A).
Aerobic exercise is effective in the general, as well as elderly, populations for reducing blood pressure (SOR: A). Patients should be encouraged to reduce alcohol consumption (SOR: A). Evidence that weight loss is significantly associated with blood pressure reduction is inconclusive (SOR: C). Smoking cessation should be encouraged for all hypertensive patients for prevention of cardiovascular disease (SOR: A).
When advising patients to make lifestyle changes, be participatory, personalized, practical, and persistent
Linda N. Meurer, MD, MPH
Medical College of Wisconsin
Lifestyle modifications can prevent and lessen hypertension, but persuading patients to make lasting changes in their long-held eating and activity patterns is challenging. When advising patients to make meaningful lifestyle changes, remember these 4 “Ps”: Participatory, Personalized, Practical, and Persistent. First, engage patients in a conversation about their lifestyle habits and partner with them to develop specific, personalized strategies to make improvements. For example, target significant sources of sodium in the specific foods they eat and find practical opportunities for physical activity in the context of their own schedule and circumstances.
Most importantly, persist in your advice by revisiting lifestyle recommendations and the patients’ progress at each visit, and modify as needed. Often, once medications are prescribed, patients disregard the lifestyle changes, and may need repeated encouragement to adopt regular, healthful habits.
Evidence summary
Healthy lifestyles are an important part of both prevention and management of hypertension. These changes include maintenance of normal body weight, regular aerobic exercise, dietary salt reduction, alcohol consumption reduction, and consumption of diets rich in potassium, fruits, and vegetables. These recommendations have been reviewed in recent meta-analyses (TABLE).
Lifestyle changes that have not shown any significant effect on blood pressure or that are still under review include dietary omega-3 fatty acid supplementation and antioxidant supplementation.10
TABLE
Summary of recommendations
| INTERVENTION | OUTCOME | STUDY DETAILS | SOR |
|---|---|---|---|
| Reduction of dietary sodium intake | Lowers SBP by 4.97 mm Hg (95% CI,–5.76 to –4.18) | 2004 Cochrane review1,2 (17 trials; 734 participants) | A |
| DASH diet | Lowers SBP by 4.3 mm Hg (P<.001) | Multicenter randomized control trial (810 adults)2,3 | A |
| Regular aerobic exercise | Lowers SBP by 4.0 mm Hg (95% CI,–5.32 to –2.75) | Meta-analysis of 54 RCTs (2419 participants)4,5 | A |
| Reduced alcohol consumption | Lowers SBP by 3.31mm Hg (95% CI,–4.10 to –2.52 | Meta-analysis of 15 RCTs (2234 participants)6 | A |
| Smoking cessation | 36% relative risk reduction in mortality (RR=0.64; 95% CI,0.58 to 0.71) | 2004 Cochrane review (20 prospective cohort studies)7 | A |
| Weight loss | 3%–9% body weight loss may be associated with decrease in blood pressure by 3 mm Hg; not statistically significant (95% CI,–6.8 to 0.7). | 2000 Cochrane review of 18 trials (though 1997; 361 participants in the primary 6 studies)8,9 | C |
| SOR, strength of recommendation; SBP, systolic blood pressure; CI, confidence interval; RR, relative risk; RCT, randomized controlled trial. | |||
Recommendations from others
The National High Blood Pressure Education Program recommends the following for primary prevention of hypertension:11
- Maintain normal body weight for adults
- Reduce dietary sodium intake to no more than 100 mmol/d
- Engage in regular aerobic physical activity
- Limit alcohol consumption to 30 mL ethanol per day for men, and 15 mL ethanol per day for women or lighter persons
- Maintain adequate intake of dietary potassium (>90 mmol/d)
- Consume a diet rich in fruits, vegetables, and low-fat dairy, with reduced content of saturated and total fat.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure agrees with the recommendations in the TABLE.12
Hypertensive patients should reduce sodium intake (strength of recommendation [SOR]: A). The Dietary Approaches to Stop Hypertension diet (DASH diet)—with salt restriction and increased fruit, vegetable, calcium, and potassium intake—reduces blood pressure and should be recommended (SOR: A).
Aerobic exercise is effective in the general, as well as elderly, populations for reducing blood pressure (SOR: A). Patients should be encouraged to reduce alcohol consumption (SOR: A). Evidence that weight loss is significantly associated with blood pressure reduction is inconclusive (SOR: C). Smoking cessation should be encouraged for all hypertensive patients for prevention of cardiovascular disease (SOR: A).
When advising patients to make lifestyle changes, be participatory, personalized, practical, and persistent
Linda N. Meurer, MD, MPH
Medical College of Wisconsin
Lifestyle modifications can prevent and lessen hypertension, but persuading patients to make lasting changes in their long-held eating and activity patterns is challenging. When advising patients to make meaningful lifestyle changes, remember these 4 “Ps”: Participatory, Personalized, Practical, and Persistent. First, engage patients in a conversation about their lifestyle habits and partner with them to develop specific, personalized strategies to make improvements. For example, target significant sources of sodium in the specific foods they eat and find practical opportunities for physical activity in the context of their own schedule and circumstances.
Most importantly, persist in your advice by revisiting lifestyle recommendations and the patients’ progress at each visit, and modify as needed. Often, once medications are prescribed, patients disregard the lifestyle changes, and may need repeated encouragement to adopt regular, healthful habits.
Evidence summary
Healthy lifestyles are an important part of both prevention and management of hypertension. These changes include maintenance of normal body weight, regular aerobic exercise, dietary salt reduction, alcohol consumption reduction, and consumption of diets rich in potassium, fruits, and vegetables. These recommendations have been reviewed in recent meta-analyses (TABLE).
Lifestyle changes that have not shown any significant effect on blood pressure or that are still under review include dietary omega-3 fatty acid supplementation and antioxidant supplementation.10
TABLE
Summary of recommendations
| INTERVENTION | OUTCOME | STUDY DETAILS | SOR |
|---|---|---|---|
| Reduction of dietary sodium intake | Lowers SBP by 4.97 mm Hg (95% CI,–5.76 to –4.18) | 2004 Cochrane review1,2 (17 trials; 734 participants) | A |
| DASH diet | Lowers SBP by 4.3 mm Hg (P<.001) | Multicenter randomized control trial (810 adults)2,3 | A |
| Regular aerobic exercise | Lowers SBP by 4.0 mm Hg (95% CI,–5.32 to –2.75) | Meta-analysis of 54 RCTs (2419 participants)4,5 | A |
| Reduced alcohol consumption | Lowers SBP by 3.31mm Hg (95% CI,–4.10 to –2.52 | Meta-analysis of 15 RCTs (2234 participants)6 | A |
| Smoking cessation | 36% relative risk reduction in mortality (RR=0.64; 95% CI,0.58 to 0.71) | 2004 Cochrane review (20 prospective cohort studies)7 | A |
| Weight loss | 3%–9% body weight loss may be associated with decrease in blood pressure by 3 mm Hg; not statistically significant (95% CI,–6.8 to 0.7). | 2000 Cochrane review of 18 trials (though 1997; 361 participants in the primary 6 studies)8,9 | C |
| SOR, strength of recommendation; SBP, systolic blood pressure; CI, confidence interval; RR, relative risk; RCT, randomized controlled trial. | |||
Recommendations from others
The National High Blood Pressure Education Program recommends the following for primary prevention of hypertension:11
- Maintain normal body weight for adults
- Reduce dietary sodium intake to no more than 100 mmol/d
- Engage in regular aerobic physical activity
- Limit alcohol consumption to 30 mL ethanol per day for men, and 15 mL ethanol per day for women or lighter persons
- Maintain adequate intake of dietary potassium (>90 mmol/d)
- Consume a diet rich in fruits, vegetables, and low-fat dairy, with reduced content of saturated and total fat.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure agrees with the recommendations in the TABLE.12
1. He FJ, MacGregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database Syst Rev 2004;(3):CD004937.-
2. Bray GA, Vollmer WM, Sacks FM, Obarzanek E, Svetkey LP, Appel LJ. DASH Collaborative Research Group. A further subgroup analysis of the effects of the DASH diet and three dietary sodium levels on blood pressure: results of the DASH-Sodium Trial. Am J Cardiol 2004;94:222-227.
3. Appel LJ, Champagne CM, Harsha DW, et al. Writing Group of the PREMIER Collaborative Research Group. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003;289:2083-2093.
4. Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002;136:493-503.
5. Kelley GA, Sharpe Kelley K. Aerobic exercise and resting blood pressure in older adults: a meta-analytic review of randomized controlled trials. J Gerontol A Biol Sci Med Sci 2001;56:M298-303.
6. Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2001;38:1112-1117.
7. Critchley J, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev 2004;(1):CD003041.-
8. Mulrow CD, Chiquette E, Angel L, et al. Dieting to reduce body weight for controlling hypertension in adults. Cochrane Database Syst Rev 2000;(2):CD000484.-
9. He J, Whelton PK, Appel LJ, Charleston J, Klag MJ. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension 2000;35:544-549.
10. Hooper L, Thompson RL, Harrison RA, et al. Omega 3 fatty acids for prevention and treatment of cardiovascular disease. Cochrane Database Syst Rev 2004;(4):CD003177.-
11. Whelton PK, He J, Appel LJ, et al. National High Blood Pressure Education Program Coordinating Committee. Primary prevention of hypertension: clinical and public health advisory from The National High Blood Pressure Education Program. JAMA 2002;288:1882-1888.
12. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung and Blood Institute; National High Blood Pressure Education Program Coordinating Committee Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-1252.
1. He FJ, MacGregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database Syst Rev 2004;(3):CD004937.-
2. Bray GA, Vollmer WM, Sacks FM, Obarzanek E, Svetkey LP, Appel LJ. DASH Collaborative Research Group. A further subgroup analysis of the effects of the DASH diet and three dietary sodium levels on blood pressure: results of the DASH-Sodium Trial. Am J Cardiol 2004;94:222-227.
3. Appel LJ, Champagne CM, Harsha DW, et al. Writing Group of the PREMIER Collaborative Research Group. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003;289:2083-2093.
4. Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002;136:493-503.
5. Kelley GA, Sharpe Kelley K. Aerobic exercise and resting blood pressure in older adults: a meta-analytic review of randomized controlled trials. J Gerontol A Biol Sci Med Sci 2001;56:M298-303.
6. Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2001;38:1112-1117.
7. Critchley J, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev 2004;(1):CD003041.-
8. Mulrow CD, Chiquette E, Angel L, et al. Dieting to reduce body weight for controlling hypertension in adults. Cochrane Database Syst Rev 2000;(2):CD000484.-
9. He J, Whelton PK, Appel LJ, Charleston J, Klag MJ. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension 2000;35:544-549.
10. Hooper L, Thompson RL, Harrison RA, et al. Omega 3 fatty acids for prevention and treatment of cardiovascular disease. Cochrane Database Syst Rev 2004;(4):CD003177.-
11. Whelton PK, He J, Appel LJ, et al. National High Blood Pressure Education Program Coordinating Committee. Primary prevention of hypertension: clinical and public health advisory from The National High Blood Pressure Education Program. JAMA 2002;288:1882-1888.
12. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung and Blood Institute; National High Blood Pressure Education Program Coordinating Committee Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-1252.
Evidence-based answers from the Family Physicians Inquiries Network