The Role of Lifestyle Modifications in Preventing and Managing Systemic Hypertension: Current Guidelines and Future Directions

Abstract

Hypertension (HTN) is a widely prevalent global health problem. Recent reports indicate that it affects approximately one-third of the world’s population. HTN is considered one of the major and modifiable risk factors for cardiovascular disease. Lifestyle changes play a vital role not only in prevention but also in managing HTN. Healthcare workers must adopt and implement these changes as far as they can. Notably, the current global HTN management guidelines emphasize that lifestyle modifications (LSMs) besides improving HTN control also have positive impacts on other HTN comorbidities such as diabetes mellitus, obesity, dyslipidemia, and metabolic syndrome. These facts encourage individuals with HTN to take an active part in their care, leading to long-term sustainable improvements that enhance overall well-being. Lifestyle strategies encompass a range of factors, including dietary changes, increased physical activity, weight optimization, alcohol moderation or avoidance, smoking cessation, and stress reduction. However, the successful implementation and long-term maintenance of these lifestyle changes remain challenging due to various barriers. Furthermore, there is a notable scarcity of information regarding the effectiveness of lifestyle interventions among diverse patient populations. To address these critical knowledge gaps, future research is essential. Exploring and understanding the barriers to implementing and sustaining lifestyle interventions is crucial for optimizing HTN management and reducing the substantial burden of cardiovascular disease globally. This comprehensive review discusses the latest evidence-based literature regarding key LSMs and their role in HTN prevention and management. Moreover, it highlights the barriers to applying these modifications and the strategies to overcome the barriers. The main aim of this article is to enhance awareness among healthcare workers in effectively implementing lifestyle-based approaches among hypertensive patients.

INTRODUCTION AND BACKGROUND

Systemic hypertension (HTN) is a common chronic medical problem characterized by persistent elevation of blood pressure (BP) within the arteries.[1] HTN remains a global public health issue and a major risk factor for cardiovascular disease, stroke, chronic kidney disease, and premature mortality.[2,3] According to the latest (2017) American Heart Association (AHA) and the American College of Cardiology (ACC) guidelines, HTN Stage 1 is having a systolic BP (SBP) between 130 and 139 mmHg and diastolic BP (DBP) between 80 and 89 mmHg. HTN Stage 2 is defined as having a SBP of 140 mmHg or higher, and a DBP of 90 mmHg or higher.[4] On the other hand, based on the latest-published European guidelines, HTN is having an SBP of 140 mmHg or more and a DBP of 90 mmHg or more.[5,6] The prevalence of HTN is not uniform across the world. It is affected by various demographic and lifestyle-related factors.[7] Recent research suggests that around 33% of the global population, which equates to approximately 2.64 billion people out of the current estimated 8 billion global population, are living with HTN.[8]

In Saudi Arabia, a recently published study demonstrated that the prevalence of HTN among adults was 9.2%. Notably, the prevalence of HTN was relatively higher among women.[7] The prevalence of HTN tends to increase with age and is more common in older adults. It also exhibits disparities among different racial and ethnic groups. For instance, individuals of African descent have been shown to have a higher prevalence of HTN and are more likely to develop it at an earlier age compared to other ethnicities.[9] Interestingly, lowering BP has been found to effectively reduce the risk of cardiovascular insults. Maintaining a SBP below 130 mm Hg is crucial in preventing complications in individuals with cardiovascular diseases. Moreover, early and accurate diagnosis and regular BP monitoring are integral parts of HTN management.[10]

Lifestyle modifications (LSMs) include (but are not limited to) diet, physical activity, weight management, alcohol consumption, smoking, stress reduction, sleep hygiene, and caffeine consumption.[8,11,12] LSMs play a vital role in the management of HTN and are often recommended as the first-choice approach, with or without pharmacological agents. LSMs have been shown to effectively lower BP levels not only in individuals with controlled HTN but also in those with resistant HTN as demonstrated in a randomized controlled trial (RCT) conducted by Blumenthal et al.[13] In newly diagnosed patients with stage 1 HTN, current recommendations suggest initiating antihypertensive agents if the patient has a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher. The target BP for these patients is set at <130/80 mmHg to reduce the risk of cardiovascular events. On the other hand, for patients with stage 1 HTN and a 10-year ASCVD risk of <10%, LSMs are recommended as the primary approach to managing such cases.[14] When LSMs are combined with pharmacological agents, they can enhance their effectiveness, and improve medication response, allowing for better HTN control. Thus, by engaging in LSMs, individuals with HTN play an important role in their self-management and contribute to better adherence to treatment plans.[15]

This review article aims to highlight the existing scientific literature and evidence on the impact of LSMs on BP reduction and HTN management aiming to increase awareness among healthcare workers. Moreover, it aims to provide an overview of the key studies, findings, and trends in this field.

LIFESTYLE MODIFICATIONS AND BLOOD PRESSURE REDUCTION

The concept of lifestyle is multifaceted and has been interpreted and defined diversely within scientific research. In the field of medicine, it is common to characterize lifestyle as individual behavior patterns that impact disease status such as HTN.

Moreover, these patterns have the potential to be altered through focused educational programs.[16] HTN is influenced by a variety of modifiable and nonmodifiable risk factors. The modifiable risk factors of HTN are incorporated in Table 1.[17] LSMs play a crucial role in managing and reducing the modifiable risk factors associated with HTN by making positive changes. Interestingly, adopting a healthy LSM is also an essential requirement for all patients who are taking antihypertensive medications. It is a crucial component without which optimal results and benefits from the medication may not be achieved.[5] Here are the key LSMs recommended for the management and prevention of HTN:

Table 1.

Modifiable risk factors of hypertension

Excessive salt intake

Inadequate potassium intake

Overweight and obesity

Physical inactivity

Tobacco smoking

Excessive alcohol consumption

Psychosocial stressors

Diabetes mellitus

• Follow a healthy diet (e.g., dietary approaches to stop hypertension [DASH] diet)

• Engage in regular physical activity

• Maintain an optimal weight (body mass index [BMI] = 18.5–25)

• Avoid or limit alcohol consumption

• Avoid or quit smoking

• Reduce stress

• Limit caffeine consumption

• Prioritize quality sleep.[8,13]

Dietary measures: Dietary approaches to stop hypertension diet

DASH is a type of diet plan designed, especially to support the management of HTN and the enhancement of general cardiovascular health.[4,13,18,19,20]

Eating nutrient-dense foods high in fiber, potassium, calcium, and magnesium and low in sodium, saturated fats, and cholesterol is the cornerstone of the DASH diet. Research has indicated that adhering to the DASH diet can lead to significant drops in BP.[4,13,18,19,20]

The DASH diet is supported by extensive research and is recommended by the leading health organizations worldwide, including the AHA and the National Heart, Lung, and Blood Institute.[4,8]

In both individuals with HTN and those without HTN, the DASH diet has been shown to lead to significant reductions in SBP. On average, the DASH diet has been found to lower SBP by approximately 11 mm Hg in hypertensive adults and 3 mm Hg in nonhypertensive adults. Moreover, the DASH diet has demonstrated particular effectiveness in reducing BP among Black individuals.[21,22]

Notably, the DASH eating plan is a flexible approach that emphasizes daily and weekly nutritional goals. It promotes the consumption of vegetables, fruits, and whole grains, along with fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils. At the same time, it encourages individuals to limit their intake of foods high in saturated fat, such as fatty meats and full-fat dairy products, as well as tropical oils such as coconut, palm kernel, and palm oils.[4,8,21,23] Additionally, the DASH eating plan advises against excessive consumption of sugar-sweetened beverages and sweets. It focuses on long-term dietary changes rather than short-term restrictions.[4,8]

It is well-documented that high sodium intake is associated with increased BP. Reducing sodium consumption, typically by limiting processed foods, canned goods, and adding less salt to meals, helps BP.[4,5,6,24] Dietary sodium intake should be restricted to <2 g per day, which is approximately equivalent to <5 g of salt per day (or <1 small teaspoon of salt). The current guidelines suggest a moderate limit on sodium intake to promote better health outcomes. In the United States, the recommendations are even more stringent, with a recommendation of <1.5 g of sodium per day.[4]

On the other hand, the DASH diet emphasizes the importance of including foods that are rich in potassium, calcium, and magnesium. These nutrients play a crucial role in preventing the blood vessels’ endothelial dysfunction and promoting the relaxation of endothelial and smooth muscle.[21] While the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines document does not provide specific recommendations for potassium intake, the AHA/ACC guidelines document suggests a daily dietary potassium intake of 3500–5000 mg. The AHA/ACC guidelines emphasize obtaining potassium through a potassium-rich diet. This indicates that consuming foods that are naturally high in potassium is the preferred approach for meeting the recommended potassium intake range.[4,21] Potassium-rich foods such as bananas, oranges, and spinach are recommended. Calcium can be obtained from dairy products and green leafy vegetables. Magnesium is found in a variety of whole grains, leafy vegetables, nuts, and seeds. A summary of the key DASH components with daily serving is presented in Table 2.[4,8,21,23]

Table 2.

Components of the dietary approaches to stop hypertension diet

Food item	Serving
Vegetables	4–5/day
Fruits	4–5/day
Carbohydrates	6–8/day
Low-fat dairy	2/day
Lean meat	2 or less/day
Fiber	25–29 g/day
Nuts, seeds, legumes	2–3/week
Sweets and added sugar	Limited consumption
Sodium	1–2 g/day
Potassium	3.5-5 g/day

Numerous studies have provided evidence that the DASH diet is effective in improving the common comorbidities of HTN in addition to having a positive impact on other medical conditions, as shown in Table 3.[21] Furthermore, several studies have consistently shown that the DASH diet is associated with a reduction in all-cause mortality among adults. These findings highlight the significant impact of the DASH diet on improving overall longevity and decreasing the risk of death from various causes.[25] One of the advantages of the DASH diet over other dietary patterns is its clear guidelines on serving sizes and food groups. This feature makes it easier for physicians to prescribe and monitor their patients’ progress, enhancing the overall efficiency of treatment.[21]

Table 3.

Conditions positively impacted by the dietary approaches to stop hypertension diet

HTN

Diabetes mellitus

Obesity

Dyslipidemia

Metabolic syndrome

Insulin resistance

Heart failure

Chronic liver disease

Colorectal cancer

All-cause mortality

HTN=Hypertension

However, some studies have shown that still there is low compliance with the DASH diet among hypertensive individuals.[18,26] Another recommended dietary approach is the Mediterranean diet, which emphasizes the consumption of fruits, vegetables, whole grains, fish, and healthy fats. This eating pattern has been linked to lower BP levels and a reduced risk of HTN. By following the Mediterranean diet, individuals with HTN can benefit from the wide array of nutrients and antioxidants provided by fruits and vegetables, the heart-healthy properties of whole grains, the omega-3 fatty acids found in fish, and the beneficial effects of healthy fats. Incorporating these food items into the diet can contribute to better BP management and overall cardiovascular health.[5,27,28,29] Both the DASH and the Mediterranean diets are highly beneficial for controlling BP when followed consistently. They are recommended by the ESC/ESH guidelines.[5]

Physical activity

According to the latest guidelines including the ACC/AHA and the ESC/ESH, adopting regular aerobic exercises such as brisk walking, jogging, cycling, or swimming has demonstrated significant BP-lowering effects.[4,5,6,30] Aerobic exercise has also been shown to have beneficial effects on other modifiable risk factors for cardiovascular disease. Furthermore, meta-analyses of RCTs have found that combining aerobic and resistance training, such as weightlifting or using resistance bands, can lead to reductions in SBP of 5.2–8.3 mmHg.[8] Moreover, evidence from RCTs suggests that exercise training interventions can produce BP reductions comparable to those seen with antihypertensive medications. Interestingly, the combination of exercise and antihypertensive medications results in even greater BP reductions than medications alone.[31,32]

On the other hand, Herawati et al. have summarized the benefits of breathing exercises like yoga in lowering BP among hypertensive patients. They reviewed 20 studies. Those studies have shown a wide range of effects, with SBP decreasing by 4–54.22 mmHg and DBP decreasing by 3–17 mmHg. Worth noting, the available evidence indicates that breathing exercises, such as those in yoga, show promise in improving cardiovascular measures among hypertensive subjects.[33] The research findings underscore the crucial role of exercise in both preventing and managing hypertensive patients. Additionally, research highlights the effectiveness of diverse exercise approaches – including aerobic, resistance, and breathing exercises – in improving cardiovascular measures, lowering BP, and potentially reducing HTN risk. However, further research is still needed to determine the optimal exercise protocols and better understand the mechanisms responsible for these beneficial effects.[33] The World Health Organization’s guidelines recommend that adults engage in 150–300 min per week of moderate-intensity exercise, 75–150 min per week of vigorous exercise, or an equivalent combination of both. These WHO guidelines emphasize the significance of regular physical activity for achieving and maintaining a healthy lifestyle.[34]

The Physical Activity Guidelines for Americans, which were updated in 2018, provide practical and clinically relevant recommendations for the general population. These guidelines emphasize the importance of individuals engaging in regular physical activity and reducing sedentary behavior. In line with the principle of “Better something than nothing,” the guidelines encourage people to move during their daily lives and highlight the fact that even engaging in some physical activity, even if it is below the recommended levels, is still beneficial compared to being completely inactive.[35]

However, the integration of exercise as a therapy for hypertensive patients remains limited within healthcare systems worldwide. This is often due to various socioeconomic and cultural barriers that exist in many regions. To address these barriers, it is essential to provide hypertensive individuals with appropriate health education. Additionally, healthcare practitioners should receive training to effectively assist individuals in reducing sedentary behavior and adopting healthy LSMs.[8]

Weight management

It is well-established that being overweight or obese significantly increases the risk of developing HTN and various cardiovascular diseases.[4,5,6,36]

Obese individuals may experience several mechanisms that contribute to the development of HTN. These include insulin and leptin resistance, dysfunction of perivascular adipose tissue, renal impairment, activation of the renin–angiotensin–aldosterone system, and increased activity of the sympathetic nervous system.[37] A meta-analysis involving 57 prospective cohort studies and 2.3 million individuals found that there was a 1- to 2-fold higher risk of developing HTN associated with increases in obesity indices, such as BMI, waist circumference, and waist-to-height ratio.[38] Furthermore, estimates from the Global Burden of Disease Obesity Collaborators suggest that cardiovascular disease accounted for over two-thirds of deaths associated with high BMI.[39] On the other hand, losing weight, particularly abdominal fat, can significantly reduce BP levels. There is a consensus among experts who set the latest American and European HTN guidelines that weight reduction is recommended for individuals with HTN who are overweight or obese.[5] Additionally, weight loss can enhance the effectiveness of antihypertensive medications and improve the overall cardiovascular risk profile.[5,40] Both the ESC and the AHA emphasize the importance of weight reduction and maintaining weight loss as essential LSMs. The AHA further highlights that weight reduction among obese individuals can decrease the risk of developing HTN to a level comparable to individuals who have never been obese.[37]

According to a meta-analysis, significant reductions in SBP and DBP were observed after 6–12 months of adopting weight loss in comparison to a placebo. These findings highlight the beneficial effects of weight loss on BP management among individuals with HTN and overweight or obesity.[39,41] Moreover, another meta-analysis of RCTs) that included a total of 25 RCTs, involving 4,874 participants, found that, on average, there was a reduction of 1 mmHg in both SBP and DBP per kilogram of weight loss.[8]

Fantin et al. examined the impact of weight loss on BP and found a consistent association between weight loss and a decrease in BP across both interventional and observational studies. Various weight loss strategies were assessed, including diet and LSMs, pharmacological interventions, and bariatric surgery. While all the studies demonstrated a positive effect of weight loss on BP, the key distinction was the extent and durability of BP reduction over time.[37] Moreover, combining healthy eating habits and regular physical activity can lead to weight loss and subsequent BP reduction. For effective weight loss, it is recommended to adopt a multidisciplinary approach that incorporates dietary guidance, regular exercise, and motivational counseling. This comprehensive approach recognizes that sustainable weight loss requires more than just short-term efforts.[8,42] It is important to note that the effectiveness of LSMs may vary among individuals, and a personalized approach is often necessary. Additionally, adopting multiple LSMs together can have a synergistic effect on BP reduction.

Other lifestyle modifications

In addition to dietary changes, several other LSMs can aid in managing HTN. Epidemiological studies have shown a clear association between tobacco smoking and elevated BP. Thus, quitting smoking can lead to immediate and long-term benefits for BP and overall cardiovascular health.[4,5,6,43,44]

While it is recognized that the combination of tobacco smoking and high BP can have a synergistic effect on cardiovascular events, there has been limited research specifically examining the impact of smoking on BP levels in current smokers.[45] There is evidence suggesting a positive correlation between heavy alcohol consumption and HTN, although the exact nature of this relationship, particularly in women, is still not fully understood. Moreover, excessive alcohol consumption can raise BP and interfere with the effectiveness of medications.[45]

Current guidelines on HTN management have advised individuals to restrict their daily alcohol intake to two or fewer drinks for men and one drink for women.[4,5,6] For optimal cardiovascular outcomes, it is recommended to avoid alcohol consumption entirely. Furthermore, it is advised to refrain from engaging in binge drinking.[46] Chronic psychosocial stress can also contribute to high BP. Implementing stress management techniques, such as relaxation exercises, deep breathing, meditation, yoga, or engaging in hobbies and activities that promote relaxation, can help in BP control. Regular physical activity and maintaining a healthy work-life balance are also important for stress reduction.[47]

According to a systematic review, engaging in 45 min of daily yoga was found to decrease SBP by 6.5 mmHg and DBP by 2.8 mmHg after a 12-week program.[8] Moreover, a systematic review conducted by Kühlmann et al. that included 10 randomized controlled trials (RCTs) revealed that listening to music once a day to three times a week tended to reduce SBP and DBP by approximately 10 mmHg and 6 mmHg, respectively.[48]

Caffeine intake

Consuming coffee and caffeinated beverages like tea has been associated with favorable effects on BP and overall cardiovascular health.

According to the latest guidelines endorsed by the International Society of Hypertension (ISH), ESC, and the ESH, moderate and regular coffee consumption, typically defined as three to four cups per day, has been found to have no adverse effects on BP and the cardiovascular system. Notably, it may even have moderate benefits.[8] On the other hand, a Japanese Cohort Study revealed that heavy coffee consumption among participants with severe HTN was associated with an increased risk of cardiovascular mortality. However, this association was not observed in individuals with mild HTN or those without HTN.[49]

Studies have demonstrated that there is an association between sleep disturbances in terms of quality and duration and the risk of HTN. Moreover, poor sleep and sleep disorders, such as obstructive sleep apnea, can contribute to the development of HTN.[8,50] The guidelines recommend aiming for 7–9 h of quality sleep each night to maintain a healthy BP. Additionally, it is important to maintain a regular sleep schedule and create a comfortable sleep environment.[8,50] Furthermore, there is a need to promote educational programs in the field of sleep and support population-based awareness initiatives that address healthy sleep practices. These efforts can help individuals understand the importance of quality sleep and implement strategies to improve their sleep patterns.[8,50]

Challenges and future directions

Barriers to the treatment and control of high BP can be understood as any factors that impede or restrict patients from engaging in the recommended behaviors necessary for maintaining optimal BP control and treatment. This includes adherence to prescribed medications as well as the adoption of LSMs.[51,52]

The studies conducted in low- and middle-income countries have revealed numerous barriers, misconceptions, and misunderstandings surrounding the implementation of lifestyle changes to manage high BP. These findings hold valuable insights for academics, researchers, and policymakers in related fields, serving as a reference point for designing intervention programs that address the identified issues. Furthermore, these studies underscore the need for additional research to enhance the overall management and control of BP among hypertensive patients.[51,52]

The most common barriers hindering adherence to LSMs include:

• Lack of awareness and knowledge about the importance of LSMs

• Difficulty in making sustained behavior changes

• Lack of social support and encouragement

• Time constraints and competing priorities

• Accessibility and affordability of healthy food options

• Environmental factors that discourage physical activity

• Cultural and personal preferences that may conflict with recommended dietary changes

• Cultural beliefs and traditions

• Psychological factors such as stress, emotional eating, and unhealthy coping mechanisms

• Inadequate patient–healthcare provider communication and support for self-management.[8,52,53,54,55]

Strategies to enhance adherence to LSMs include:

• Patient education and raising awareness about the benefits of LSMs

• Setting realistic goals and providing personalized guidance

• Providing ongoing support through counseling, coaching, or support groups

• Tailoring interventions to individual needs and preferences

• Incorporating behavioral change techniques, such as goal setting, self-monitoring, and problem-solving

• Engaging family members or social networks to provide support and accountability

• Using technology-based tools, such as mobile applications or wearable devices, to track progress and provide feedback

• Employing motivational interviewing techniques to enhance intrinsic motivation

• Collaborating with healthcare professionals, including dietitians, psychologists, and exercise specialists, for comprehensive care

• Use of new technologies and digital health interventions in promoting LSMs such as mobile phones, telehealth, online platforms, and artificial intelligence.[8,53,56,57,58,59,60]

The use of new digital devices for the prevention and treatment of health conditions, termed digital health interventions, is an emerging and promising technique to support individuals with HTN.[53] In addition, implementing a national salt reduction program is a simple and cost-effective way of improving public health.[11]

The existing evidence on the use of telemedicine systems for managing HTN, while promising, highlights the need for continued evaluation and improvement to ensure these systems can be effectively utilized by diverse patient populations, including the elderly, for optimal cardiovascular health outcomes.[57]

The remarkable advancements in information and communication technology (ICT) have opened new possibilities in the field of medicine. Overall, the ICT-based management of HTN is expected to play a pivotal role in reducing the public health burden of cardiovascular diseases and is anticipated to be widely adopted in routine clinical practice in the future.[58]

As research and technology advance, there is growing recognition of the importance of LSMs in managing HTN. Overcoming barriers, enhancing adherence, and integrating personalized approaches are key areas for improvement. By addressing these challenges and embracing new strategies and technologies, healthcare providers can enhance the effectiveness and sustainability of LSMs in HTN management.

CONCLUSION

LSMs play a crucial role in the prevention and management of HTN. LSMs also have additional health benefits, such as improving overall cardiovascular health and quality of life, reducing the risk of other comorbidities, and pharmacological doses. Dietary changes, such as following the DASH diet, reducing sodium intake, and adopting healthy eating habits, can help lower BP. Moreover, regular physical activity, weight management, smoking cessation, stress reduction, and alcohol moderation are important lifestyle factors to consider.

The key barriers to implementing LSMs include lack of awareness, limited social support, time constraints, and environmental factors. Future research is required to identify effective strategies to overcome barriers to LSMs and enhance long-term adherence. Additionally, more research is needed to assess the effectiveness and scalability of new technologies and digital health interventions in promoting and monitoring LSMs. Finally, healthcare providers should stay updated on the latest research and guidelines regarding LSMs to provide evidence-based recommendations and personalized care to patients with HTN.

Take-home messages

• All individuals with HTN need to adopt healthy lifestyle choices to manage their condition effectively

• Healthy lifestyle changes have the potential to delay or even eliminate the need for medications in many cases of high BP

• Lifestyle interventions that are particularly important for controlling high BP include reducing dietary sodium intake, increasing potassium consumption, moderating alcohol consumption, following a healthy diet, achieving weight reduction, engaging in regular physical activity, and quitting smoking

• These LSMs, when implemented together, can have a significant impact on BP management and overall cardiovascular health.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.