Lifestyle Modifications +/- Drug Therapy
Key Points:
- Lifestyle modifications should be the cornerstone of the initial therapy for hypertension.
Clinical studies show that the blood pressure-lowering effects of lifestyle modifications can be equivalent to drug monotherapy [A]. Lifestyle modification is best initiated and sustained through an educational partnership between the patient and a multidisciplinary health care team. While team members may vary by clinical setting, behavior change strategies should include nutrition, exercise, and smoking cessation services. Lifestyle modifications should be reviewed and re-emphasized at least annually.
Some patient education should occur and be documented at every visit. For recommended education messages, see Appendix C, "Recommended Education Messages," in the original guideline document.
Table. Lifestyle Modifications to Prevent and Manage Hypertension*
Modification |
Recommendation |
Approximate Systolic Blood Pressure Reduction (Range)** |
Weight reduction |
Maintain normal body weight (body mass index 18.5 to 24.9 kg/m2) |
5 to 20 mm Hg/10 kg |
Adopt Dietary Approaches to Stop Hypertension (DASH) eating plan |
Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat. |
8 to 14 mm Hg |
Dietary sodium reduction |
Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). |
2 to 8 mm Hg |
Physical activity |
Engage in regular aerobic physical activity such as brisk walking (at least 30-45 minutes per day, most days of the week) |
4 to 9 mm Hg |
Moderation of alcohol consumption |
Limit consumption to no more than 2 drinks (e.g., 24 oz. beer, 10 oz. wine, or 3 oz. 80 proof whiskey) per day in most men and to no more than one drink per day in women and lighter-weight persons. |
2 to 4 mm Hg |
*For overall cardiovascular risk reduction, stop smoking
**The effects of implementing these modifications are dose- and time-dependent and could be greater for some individuals.
Taken from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52. (Class R)
Weight Reduction and Maintenance
Hypertension is closely correlated with excess body weight [R]. Approximately 50% of hypertensive patients are overweight [D]. In the Framingham study, 60% to 70% of hypertension could be attributed to being overweight or obese [B].
Research studies have documented the positive effects of weight reduction as a strategy for blood pressure control [A]. In adults with hypertension, meta-analysis shows that weight loss through diet or use of orlistat is related to a modest reduction of blood pressure by up to 6 mm Hg systolic and 3 mm Hg diastolic; however, use of sibutramine increased blood pressure despite weight loss [M]. Whenever indicated, weight reduction should be recommended. Even an initial loss of as little as 10 pounds can have a positive effect on blood pressure. Weight loss can also improve the efficacy of antihypertensive medications and the cardiovascular risk profile.
Initial weight loss and long-term weight control are both enhanced by a regular exercise program.
Patient education and/or nutritional counseling should be provided.
[A], [D], [R]
Dietary Interventions
Use of a Dietary Approaches to Stop Hypertension (DASH) eating plan has been shown in cohort studies to reduce incidence of congestive heart failure by 25% and incidence of stroke by 17% in women [B].
A relationship between dietary sodium intake and blood pressure has been demonstrated in multiple clinical and epidemiological studies [R]. Modest sodium restriction may also reduce the amount of antihypertensive medications required [A]. However, individuals vary in response to a reduced sodium intake. Among hypertensives, African Americans, older patients, and patients with renal disease seem to be more sodium sensitive [A].
Moderation of Alcohol Intake
Alcohol consumption has complex effects on the cardiovascular system. Alcohol consumption raises both systolic and diastolic pressures, but its effects appear to be greater on systolic pressure. Significant elevations in blood pressure have been shown in individuals who consumed an average of at least three standard drinks per day compared with non-drinkers. Alcoholism may cause hypertension, and an alcoholic is less likely to respond to any hypertension treatment recommendations [R]. Some persons may develop transitory hypertension during the first days of detoxification. Alcohol is a concentrated calorie source that does not provide any nutrients, so reducing alcohol intake can hasten weight reduction and may decrease triglyceride levels. Although cohort studies suggest that modest alcohol consumption may reduce the rate of myocardial ischemic events, alcohol use of up to 2 ounces per day neither increases nor decreases total mortality or cardiovascular mortality in those with hypertension [B]. The recommendation is to not exceed a daily alcohol intake of 1 ounce of ethanol. One ounce (30 mL) of ethanol is equivalent to two drinks per day. It is recommended that men have no more than one ounce of ethanol per day (two drinks) and women have no more than 0.5 ounce of ethanol per day (one drink). One drink is 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80 proof liquor [D].
Adequate Physical Activity
Epidemiological studies suggest that regular aerobic physical activity may be beneficial for both prevention and treatment of hypertension, to enable weight loss, for functional health status, and to diminish all-cause mortality and risk of cardiovascular disease. Thirty to forty-five minutes of brisk walking or other activity most days of the week at target heart rate ([220-age] x 75% = target heart rate) is adequate, inexpensive, and effective [R]. However, regular physical activity of even lower intensity and duration has been shown to be associated with about a 20% decrease in mortality in cohort studies [B]. Other aerobic activities (biking, swimming, jogging, etc.) may be more enjoyable. Resistive isotonic activities, when done as the only form of exercise training, are not recommended to lower blood pressure in hypertensive patients [R].
Potassium
There is no direct evidence that potassium supplementation lowers blood pressure chronically [A], [M].
Tobacco Avoidance
Recent data using ambulatory blood pressure monitoring suggests that nicotine may indeed increase blood pressure and could account for some degree of blood pressure lability [C]. In addition, it is a major risk factor for atherosclerotic cardiovascular disease. At each visit, establish tobacco use status.
Relaxation and Stress Management
Although studies have not demonstrated a significant long-term effect of relaxation methods on blood pressure reduction, relaxation therapy may enhance an individual's quality of life and may have independent effects on lowering coronary heart disease risk [M], [R].
Drug Therapy
A thiazide-type diuretic should be considered as initial therapy in most patients with uncomplicated hypertension [R]. Because thiazide-type diuretics have been shown to be as good as or superior to other drug classes in preventing cardiovascular disease morbidity and mortality, they should be considered preferred initial therapy in most patients [R]. However, studies support the use of specific alternative drugs as initial therapy in the presence of specific co-existing diseases. Thiazide-type diuretics are especially useful for patients age 55 years or older with hypertension and additional risk factors for cardiovascular disease including the metabolic syndrome and for patients age 60 years or older with isolated systolic hypertension [A]. The risk of diabetes mellitus is higher with diuretic and beta-blockers than other first-line choices, and this may be a consideration for patients at higher risk for this disorder [M]. Studies have demonstrated the cost effectiveness in older patients of selecting drugs using evidence-based guidelines [M]. In patients for whom diuretics are contraindicated or poorly tolerated, use of an angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, beta-blocker, or calcium antagonist is appropriate. Other considerations when selecting initial drug therapy include age, race, cost, drug interactions, side effects, and quality of life issues. See Appendix F, "Therapies," and Appendix G, "Cost of Antihypertensive Drugs" in the original guideline document. In general, diuretics and calcium channel blockers appear to be more effective as an initial treatment of hypertension in African Americans. The lowest recommended dose of the chosen drug should be used initially. If tolerated, the dose can be increased or additional medications added to achieve goal blood pressure.
Other classes of drugs should be reserved for special situations or as additive therapy. See Appendix F, "Therapies" in the original guideline document. Co-existing medical conditions may also justify the use of one of these classes of drugs. An example is the use of an ACE inhibitor in a patient with heart failure or diabetic nephropathy. Please see the NGC summary of the ICSI guideline Diagnosis and Management of Type 2 Diabetes Mellitus in Adults for further information. ACE-inhibitors and angiotensin receptor blockers have been shown to be beneficial for patients with renal disease (both diabetic and non-diabetic) by reducing proteinuria and slowing the rate of decline in renal function [A], [M]. ACE inhibitors have also been shown to provide symptomatic relief and prolong life for patients with heart failure and are the initial drug of choice for this condition. ACE inhibitors and angiotensin-receptor blockers have similar blood-pressure-lowering effects, but angiotensin-receptor blockers are less often associated with the side effect of cough [M]. Initial monotherapy with one of these agents is appropriate in these patient populations. A diuretic should be added if blood pressure response is not satisfactory. Evidence from a recent large trial suggests that ACE inhibitors may be less effective in African Americans than thiazide-type diuretics in controlling blood pressure and in preventing stroke and cardiovascular disease [R].
Based on meta-analyses of previous studies, beta-blockers may be less efficacious than other first-line alternatives in patients who are 60 years and older, especially for stroke prevention [M]. Thus, use of these drugs as initial therapy in older patients probably should be restricted to situations where there is another indication for their use (e.g., heart failure, previous myocardial infarction, angina.) They still should be considered alternative first-line agents in younger patients, where they appear to lessen cardiovascular morbidity as well as other recommended drugs. Beta-blockers reduce the risk of sudden death and recurrent myocardial infarction for patients with an initial myocardial infarction. ACE inhibitors also reduce the risk of subsequent myocardial infarction and progression to heart failure for patients who experience a large myocardial infarction associated with impairment of left ventricular function. They also may reduce risk for patients with (or at high risk for) cardiovascular disease [A].
Long-acting dihydropyridine calcium antagonists have been shown to be effective for patients age 60 years or older with isolated systolic hypertension. Co-existing medical conditions may also justify the use of one of these classes of drugs. Evidence from a recent large study refutes concerns about increased risk of myocardial infarction, cancer or gastrointestinal bleeding from use of long-acting calcium antagonists. However, data does suggest that this class of drugs may be less effective in preventing heart failure [A). The work group suggests these drugs be limited to those conditions listed in Appendix F, "Therapies," in the original guideline document. Data supporting potential dangers of calcium antagonists are limited to short-acting preparations (especially nifedipine) that are not approved for the treatment of hypertension.
A majority of patients will require more than one drug for blood pressure control. Combination therapies that include a diuretic are often effective, lessen the risk for side effects (by use of low doses of each component drug), and enhance adherence by simplification of the treatment program. For patients with chronic kidney disease three or more drugs may be needed to achieve goal [A], [B], [M].