Lifestyle changes are important in the prevention and management of hypertension

There is ample evidence that lifestyle changes lower blood pressure and can prevent the onset and progression of hypertension. A healthy lifestyle is the cornerstone of hypertension prevention and management. Lifestyle changes with documented efficacy include weight loss, increased physical activity, modification of diet such as increased fruit and vegetable consumptions, dietary sodium restriction, and moderation of alcohol consumption (Whelton et al., 2002b). For a complete overview see Lifestyle modifications for hypertension prevention and management.

Even moderate weight loss lowers blood pressure

Weight loss is important for the prevention and treatment of hypertension. Weight loss, achieved by energy restriction, physical activity, or both, transfers directly into blood pressure reduction. Pooled data from intervention studies show that both systolic and diastolic blood pressure decrease approximately 1 mmHg per kilogram of weight loss (systolic BP -1.05 mmHg, diastolic BP – 0.92 mmHg) (Neter et al., 2003). The effect of weight loss on blood pressure is more pronounced with a more substantial weight loss of >5 kg. Weight reduction, however, is difficult to maintain in the long-run. But studies show that even modest weight reductions, defined as 5% to 10% of initial weight, lower blood pressure significantly (Mertens & Van Gaal, 2000; Stevens et al., 2001). Therefore, even a modest weight reduction, if maintained over a longer period, is a desirable goal in hypertension prevention and management.

Regular physical activity leads to blood pressure reduction

Increased physical activity or fitness is associated with lower blood pressure (Whelton et al., 2002; Fagard, 2001; Cornelissen & Fagard, 2005). Pooled data from intervention studies show that dynamic endurance training (e.g. walking, jogging, swimming) reduces both systolic and diastolic blood pressure by approximately 3 mmHg (Cornelissen & Fagard, 2005). Blood pressure reductions are greater in persons with hypertension than in people with a normal blood pressure (systolic BP/ diastolic BP reductions of approximately -7/-5 mmHg vs. -2/-1.5 mmHg). Dynamic resistance training (activities that use muscular strength to move a weight or work against a resistance load) also lowers blood pressure by approximately 3 mmHg (Cornelissen & Fagard, 2005b). Intensive isometric exercise such as heavy weight lifting should be avoided by people with high blood pressure. Increased physical activity reduces the risk for cardiovascular disease beyond blood pressure. Physical training also reduces body weight, waist circumference and body fat, and leads to an increase in insulin sensitivity and HDL-cholesterol (ESH/ESC Task Force, 2007). The positive effects of physical activity are seen even at moderate exercise levels (Fagard, 2001). Therefore, physical exercise of moderate intensity for about 30-45 minutes per day on most days of the week is an important component of hypertension prevention and treatment. For more detailed information about the benefits of physical activity see the EUphact Physical activity.

Multiple dietary factors can effectively lower blood pressure

Dietary modifications which contribute to blood pressure reduction are restriction of sodium intake, increased potassium consumption, moderation of alcohol consumption, and an overall healthy diet according to the DASH eating plan (Appel et al., 2006). See for more information: Diet-related lifestyle modifications that effectively lower blood pressure.

Analysis of pooled data show that sodium restriction lowers systolic and diastolic blood pressure by about 2 to 5 mmHg and 1 to 3 mm Hg, respectively (He & MacGregor, 2002; Dickinson et al., 2006, Sacks et al., 2001). Blood pressure reduction appears to be greater in subjects with high blood pressure. The individual response to sodium restriction varies and also depends on dietary and genetic factors (Appel et al., 2006). An increase in potassium intake is recommended to lower blood pressure, though studies and also meta-analysis analyses have found inconsistent results (Appel et al., 2006, Dickinson et al., 2006, Jiang He & Whelton, 1997). Studies show that a reduction of alcohol consumption leads on average to blood pressure reductions of approximately 3 mmHg systolic and 2 mmHg diastolic (Xin et al., 2001). Blood pressure reductions appear to be greater with greater alcohol reduction and in those with higher initial blood pressure. For more information on the consequences of alcohol consumption see the EUphact Alcohol use.

The DASH diet has also been shown to be an effective intervention method. It has been successful in reducing systolic and diastolic blood pressures by 5.5 and 3 mmHg, respectively (Appel et al., 1997). A diet emphasizing only fruits and vegetables also reduces blood pressure though only achieving about half the effect observed with the full DASH diet. The dietary effects on blood pressure seem to occur rapidly (within weeks). Fish oil supplementation, due to its side effects and the high dose required, is not routinely recommended to lower blood pressure, though pooled data from studies show that high-dose supplementation is associated with blood pressure reduction (Geleijnse et al., 2002; Dickinson et al., 2006). Calcium and magnesium supplementation are also discussed as a potential means to lower blood pressure, but data are inconsistent and insufficient to recommend supplementation (Appel et al., 2006).

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Effective medication is available to lower blood pressure

If lifestyle modifications are insufficient to lower blood pressure or if the initial blood pressure is substantially raised (grade 3 hypertension according to ESC/ ESH guidelines), pharmacological treatment is required. The primary goal of treatment is to achieve maximum reduction in the long-term risk of cardiovascular disease which requires treatment of raised blood pressure per se as well as of all other modifiable cardiovascular risk factors such as smoking, raised cholesterol levels, raised blood glucose/ diabetes (ESH/ESC Task Force, 2007). Several classes of medications are available for blood pressure lowering and have been shown to be effective and safe. In studies, this so-called antihypertensive medication has been associated with reductions in stroke incidence (on average 35-40%), myocardial infarction (20-25%), and heart failure (50%) (Neal et al., 2000). More detailed information on pharmacological treatment can be found in national and European hypertension guidelines, as shown in the Definition and Scope.

A public health strategy is warranted in primary prevention of hypertension

A small decrease in population blood pressure is likely to result in a substantial reduction in cardiovascular disease and mortality. For example, an average reduction of approx. 1 mmHg among males and 2 mmHg among females in population diastolic blood pressure between 2000 and 2010 is estimated to prevent about 6,500 annual deaths in the UK (Unal et al., 2005b). Because of the high prevalence of high blood pressure and the high lifetime risk of hypertension, a population-based strategy aiming at a downward shift of blood pressure in the general population is an important component of hypertension prevention. A high-risk approach aiming at blood pressure reductions in those who are at particular risk to develop hypertension (e.g. with a family history of hypertension, those who are overweight, obese or sedentary) is recommended to complement the population approach (Whelton et al., 2002b).