non-pharmacological treatment of hypertension

Last edited 09/2019 and last reviewed 08/2021

Non - drug treatment is indicated for all patients with hypertension.

• clinical studies show that the BP-lowering effects of targeted lifestyle modifications can be equivalent to drug monotherapy
• appropriate lifestyle changes may
• safely and effectively delay or prevent hypertension in non-hypertensive subjects,
• delay or prevent medical therapy in grade I hypertensive patients
• contribute to BP reduction in hypertensive individuals already on medical therapy, allowing reduction of the number and doses of antihypertensive agents
• major drawback is the low level of adherence over time—which requires special action to be overcome (1)

Suitable measures include:

• stop smoking
• give all smokers advice to quit smoking and offer assistance.

• lose weight (1)
  • relate to BMI; aim to maintain normal weight for adults (BMI of about 25 kg/m2 ) and waist circumference (<102 cm for men and <88 cm for women) for non-hypertensive individuals to prevent hypertension and for hypertensive patients to reduce BP
• in a meta-analysis, the mean SBP and DBP reductions were associated with an average weight loss of 5.1 kg were 4.4 and 3.6 mmHg, respectively (1)
• weight loss can also improve the efficacy of antihypertensive medications and the CV risk profile (1)

• review and advise on diet:
  • avoid foods high in cholesterol or animal fat
• encourage greater intake of
• fresh fruits and vegetables - 300–400 g/day of fruit and vegetables
• fish - at least twice a week
• low-fat dairy products - soy milk appeared to lower BP when compared with skimmed cows’ milk
• dietary and soluble fibre
• whole grains and protein from plant sources
• reduced in saturated fat and cholesterol.
• discourage excessive consumption of coffee and other caffeine-rich products
• a recent systematic review found that most of the available studies (10 RCTs and 5 cohort studies) were of insufficient quality to allow a firm recommendation to be given for or against coffee consumption as related to hypertension
• should be accompanied by other lifestyle changes -  diet with exercise and weight loss

• review alcohol consumption - ideally:
  • in hypertensive patients, the total amount of alcohol consumption
• per day for men should be no more than 20–30 g, and for women no more than 10–20 g
• per week should not exceed 140 g for men and 80 g per for women.

• reduce salt intake *:
  • usual salt intake is between 9 and 12 g/day in many countries
• it has been shown that reduction to about 5 g/day
• has a modest (1–2 mmHg) SBP-lowering effect in normotensive individuals and a somewhat more pronounced effect (4–5 mmHg) in hypertensive individuals.
• the effect of sodium restriction is greater in black people, older people and in individuals with diabetes, metabolic syndrome or CKD
• give advice to patient
• reduce amount of salt used in food preparation
• avoid foods which have a high salt content

• take regular exercise
  • patients should be advised to participate in at least 30 min of moderate-intensity dynamic aerobic exercise (walking, jogging, cycling or swimming) on 5–7 days per week
• a meta-analysis of randomized controlled trials has shown that aerobic endurance training reduces resting SBP and DBP by 3.0/2.4 mmHg overall and even by 6.9/4.9 mmHg in hypertensive participants (1,2)

Consider other techniques as appropriate - for example, relaxation therapy - NICE note though (3) that there is less evidence for benefit of this intervention compared with other lifestyle interventions or pharmacological treatment

*salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin-II receptor blockers. Encourage salt reduction in these groups

Reference:

• (1) Mancia G et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31(7):1281-357.  
• (2) Appel LJ et al. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003; 289:2083-93.
• (3) NICE (August 2019). Hypertension in adults: diagnosis and management