Non-drug approaches to lowering blood pressure -
Rehm et al. recommended several strategies to reduce alcohol intake among hypertensive patients in primary care [ 44 ]. The recommendations include screening for harmful alcohol use and applying Brief Advice [alcohol reduction] for newly diagnosed or untreated hypertensive patients in primary care [ 44 ].
Studies have shown that implementing a brief alcohol intervention in the primary healthcare setting is a cost-effective strategy to reduce alcohol consumption [ 45 ]. However, evidence on the effectiveness of this intervention among individuals with severe alcohol dependence, women, older adults, younger adults, minority groups, and those from low- and middle-income countries is scarce [ 38 , 42 ].
Several challenges have been identified when implementing brief alcohol interventions in the primary care setting Table 1. The use of electronic devices and mobile phones to deliver the intervention may address some of the barriers in the implementation process [ 49 , 50 , 51 , 52 ], but further research is required to confirm their usefulness specifically in the primary care setting.
Furthermore, delegating work to a non-physician specialist and tailoring interventions to patient needs could also facilitate the implementation of brief alcohol interventions in primary care [ 48 ].
Informational interventions and dietary counselling are the most common strategies applied to reduce salt intake in hypertensive patients [ 77 ].
Hooper et al. Similarly, Ferrara et al. They found that the intervention significantly reduced sodium intake and systolic blood pressure [ 79 ]. Lin et al. Both patient and physician targeted interventions significantly reduced sodium intake and blood pressure [ 80 ].
In a systematic review, Ruzicka et al. The interventions that were not limited to mere counselling, but included provision of food, prepared meals, or intensive inpatient training sessions were difficult to be implemented by primary care providers due to a lack of time.
Alternatively, clinically feasible and logistically simple method such as single-session dietary counselling by dieticians in the outpatients setting could be effective for reducing salt intake [ 81 ]. However, further studies are required to test the effectiveness and cost effectiveness of more structured outpatient dietary counselling methods for salt reduction in the primary care setting.
Low adherence to sodium reduction interventions is a key barrier for their implementation in primary care [ 56 ]. The low adherence of patients to such interventions is usually due to their poor knowledge, attitude, and behaviour related to dietary salt intake [ 56 , 82 ].
Some of the reasons for non-adherence to dietary advice are a lack of clear labelling of food products and limited choice of low-salt foods [ 83 ] and low self-efficacy for low sodium diet among hypertensive individuals [ 57 ].
A systematic review found that people are not fully aware that the food they are eating daily, such as bread and rolls, pizzas, sandwiches, tacos and burritos, cured meats and cold cuts, chicken, eggs and omelettes, soups, and cheese often contain a high amount of salt [ 82 , 84 ].
Liem et al. At primary care physician level, the barriers to implementation of dietary sodium reducing counselling are lack of time and lack of reimbursement [ 36 ]. Furthermore, the implementation of salt-reduction interventions in primary care may be further complicated by challenges in the monitoring of dietary salt intake.
For example, the use of multiple h urine sodium tests may not always be feasible in primary care, particularly in low resource settings [ 58 ].
Despite these challenges, health worker-led brief advice and counselling seem to be best-buy salt reduction strategies. Increasing number of healthcare providers have positive attitudes towards their role to provide guidance on salt reduction to their patients [ 36 ].
Capacity building training for health workers is required to facilitate patient counselling about sodium reduction in primary care. The World Health Organisation highlighted the importance of behaviour change communication in reducing salt intake, which would work best in the environment that promotes healthy eating [ 86 ].
The common potassium supplementation interventions in hypertensive individuals include increasing potassium intake from fruit and vegetables or using potassium supplements [ 19 , 62 ].
Studies examined the effects of potassium-rich diet e. DASH diet and combined interventions that promoted potassium-rich diet, physical activity, and salt reduction on blood pressure.
A study conducted in a primary care unit in Finland investigated the effect of a behavioural intervention consisting of a nurse-led counselling session to increase intake of dietary potassium, promote physical activity, and reduce salt intake on blood pressure among hypertensive patients [ 61 ].
They found no significant effects of the intervention on potassium intake and blood pressure [ 61 ]. Most of the potassium supplementation trials were conducted in controlled clinical settings rather than in primary care settings [ 62 ].
Therefore, there is a dearth of information relating to the implementation and cost of potassium supplementation interventions in primary care.
Cohn et al. Patients with a comorbid condition such as congestive heart failure or chronic kidneys diseases who need to strictly maintain a given potassium level and those who use non—potassium-sparing diuretics should take precautions before commencing with potassium supplementation [ 89 ].
Recently, potassium-enriched salt substitutes were found to be effective in reducing high blood pressure [ 90 , 91 ].
A study conducted in sample of 20, adults found that low-sodium high-potassium salt substitute not only reduced blood pressure by on average 3. Potassium-enriched salt substitute is a promising strategy to deal with both high dietary sodium intake and low potassium intake, while ensuring higher patient adherence, compared with low salt-high potassium diets.
However, further studies are required to confirm its safety and long-term benefits in the context of hypertension. Brief Intervention and exercise referral schemes are two common physical activity promoting approaches in primary care patients.
Such interventions are mostly delivered by primary care practitioners such as exercise professionals, general practitioners, health coaches, health visitors, mental health professionals, midwives, pharmacists, physiotherapists, and general practice nurses [ 63 ].
A systematic review found that Brief advice on physical activity is more effective than usual care in increasing physical activity among patients [ 63 ]. The brief intervention is also cost-effective [ 65 ].
However, there is insufficient evidence regarding its effect on blood pressure, feasibility, and acceptability [ 92 ]. An exercise referral scheme, that is, a referral by a primary care or allied health professional to a physical activity specialist or service [ 93 ] was also found to be effective in increasing physical activity [ 64 , 94 ].
The patients who received exercise referral increased their time in physical activity on average by 55 min more than the patients who received usual care [ 64 ]. Evidence also suggests that the compliance to physical activity recommendations following exercise referral is higher than for brief interventions [ 94 ].
However, further studies are required to confirm its cost-effectiveness. Importantly, there is a lack of evidence on the impact of exercise referral on blood pressure in hypertensive patients.
It is also challenging to provide a generic recommendation for the use of exercise referral schemes in primary care, because various forms of exercise referral are being practised globally [ 95 ]. Several other types of interventions have been utilised with the aim to increase physical activity in primary care.
However, they generally showed inconsistent results in increasing physical activity and lowering blood pressure. For example, three out of five studies included in the systematic review by Eden et al. In another systematic review, an intervention delivered face-to-face by health professionals was not found to be effective in increasing physical activity among patients [ 97 ].
However, for a similar intervention implemented by non-health professionals peer health facilitators, exercise trainers this review found a significant positive effect on physical activity [ 97 ].
Likewise, a recently published pilot study suggested that physical activity counselling for 14 weeks increases the number of steps taken per day, but has no effect on the blood pressure of hypertensive patients [ 98 ]. Significant effects on blood pressure of hypertensive patients can be expected when physical activity is combined with dietary counselling [ 99 ].
A systematic review showed that behavioural counselling on physical activity and diet reduces systolic blood pressure by on average 4.
Healthcare workers reported a lack of time and limited resources as key barriers for promoting physical activity among their patients [ 66 ]. The key influencing factors at the patients level are related to their motivation, the level of understanding and recall of the received advice on physical activity, fitness level, cost, lack of time, and professional, peer, family and social support [ 63 , 67 ].
To address some of the barriers to promoting physical activity, Patrick et al. For example, healthcare centre-based screening and advice on physical activity, followed by community support, could be a viable strategy to promote physical activity among primary care patients.
Behaviour change interventions and restrictive diet are commonly used with the aim to reduce weight of primary care patients. For example, a meta-analysis of 15 randomised controlled trials found an average weight reduction of 1. The behavioural change interventions are usually delivered by primary care physicians and nurses, psychologists, health educators, and nutritionists [ 68 ].
They encompass self-monitoring of diet and exercise behaviour, followed by behavioural goal setting and barrier identification or problem-solving [ 68 ].
Likewise, a brief counselling provided by a primary care physician resulted in an average weight loss of around 2. Daumit et al. by telephone than in person. The former was found to be more cost-effective for the routine treatment of obesity in healthcare settings [ 71 ].
Evidence also indicates that low-energy diets are more effective for weight reduction in the short term, compared with behavioural therapy [ 69 , 71 , ].
However, their use is recommended only when a rapid weight reduction is required, and they should only be provided by trained professionals and alongside regular medical monitoring to prevent adverse events [ 69 ]. This may reduce their feasibility in the primary care setting. Although restrictive diets are associated with a reduction in blood pressure [ , , ], very little is known about their long-term impact on other aspects of health of people with hypertension [ ].
A lack of self-motivation, a lack of self-control, inability to afford healthy foods and exercise equipment, inability to resist the temptation for unhealthy foods, competing priorities, and comorbidities are some of the impediments for weight loss [ 72 , 73 ]. By contrast, higher self-motivation, incentives, rewards, and peer, professional and social support could facilitate weight loss in the long term [ 72 ].
Primary care-based weight-reduction interventions consisting of both reduced energy intake and increased physical activity are more effective than interventions with any of these components individually [ ]. Enabling access to dieticians and exercise professionals, and addressing barriers at the levels of providers and patients should be a priority in future interventions.
Heart-healthy diets typically include the diets with high intake of fruits and vegetables, low fat intake, consumption of whole grains, and low sodium intake. The two most commonly used dietary approaches for hypertension control are DASH and Mediterranean diet [ 28 , ].
They are mostly delivered by dietary education through face-to-face counselling [ 60 ] or via telephone or email [ 59 ]. They are usually delivered by primary care physicians [ ], nurses, dieticians [ 59 ], nutritionists [ 60 ], and other health workers [ ].
The dietary interventions are often combined with exercise, weight loss, and salt reduction interventions to achieve better results [ , ]. The effectiveness of DASH diet for reducing blood pressure in primary care is limited. Recent studies from Brazil [ 60 ] and Hong Kong [ ] did not find a significant effect of dietary counselling on blood pressure in primary care patients.
Furthermore, while implementing dietary intervention in a primary care setting it may be challenging to provide heart-healthy meals to patients and adequate counselling [ 55 ].
In addition, it is found that adherence to dietary recommendations is relatively low among patients [ ]. Some of the reasons for non-adherence to DASH diet as perceived by the healthcare providers are low patient motivation, lack of provider time, and lack of educational resources for patients [ 75 ].
The physicians from Canada also stated that the use of electronic medical record tools that support dietary screening or counselling, access to dietitian support, and nutrition education as part of medical training would help them provide dietary advice to patients [ 76 ].
Emerging evidence suggests that other non-pharmacological interventions such as yoga, stress reduction, and healthy drinks could be beneficial for reducing blood pressure [ 27 , 30 , 34 ]. A systematic review suggested that a mindfulness-based stress reduction program is a promising behavioural therapy for reducing blood pressure in people with hypertension [ ].
Studies also suggested that moderate consumption of coffee and green tea could be beneficial for reducing blood pressure [ , ]. However, evidence on the effectiveness of these interventions in the primary care setting is limited. Only a few studies investigated the effects of yoga interventions delivered in the primary care setting on blood pressure of hypertensive patients while utilising a primary care physician to provide yoga instruction.
For example, Wolf et al. conducted two such studies in Sweden [ , ]. Their first study found an average reduction in diastolic blood pressure of around 4 mmHg, following a 12 weeks intervention. However, in their subsequent study, they did not find a statistically significant effect [ ].
Dhungana et al. found that a health worker-led 3-month yoga intervention significantly reduced systolic blood pressure in hypertensive patients on average by 7. Regarding stress reduction, a private clinic-based study found that participation in eight 2.
Although there is a dearth of evidence on the effect of stress reduction interventions on blood pressure in primary care settings, a number of studies indicated that mindfulness-based interventions are promising for improving mental health and are feasible to be implemented in primary care settings [ , ].
Studies have also explored the potential role of green and black tea for blood pressure reduction [ ]. However, no studies have investigated their applicability by physicians and health care providers for hypertension management in primary care.
Non-pharmacological interventions for the treatment of hypertension in primary care with proven effectiveness include alcohol reduction. Intervention for sodium intake reduction, physical activity, and weight reduction is effective for blood pressure reduction, but it requires more pragmatic, clinically feasible, and logistically simple method in outpatients setting.
Given that studies have estimated only the overall cost-effectiveness of implementing non-pharmacological interventions e. reduced alcohol intake, increased physical activity, weight loss , there is a lack of specific information on the cost-effectiveness of these interventions in the treatment of hypertension.
Based on the current evidence, healthcare providers should consider implementing alcohol reduction, sodium intake reduction, physical activity, and weight reduction interventions for blood pressure reduction in the primary care setting. Roerecke M, Tobe SW, Kaczorowski J, Bacon SL, Vafaei A, Hasan OSM, Krishnan RJ, Raifu AO, Rehm J.
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Talk to a health care provider about developing an exercise program. Eating a diet rich in whole grains, fruits, vegetables and low-fat dairy products and low in saturated fat and cholesterol can lower high blood pressure by up to 11 mm Hg. Examples of eating plans that can help control blood pressure are the Dietary Approaches to Stop Hypertension DASH diet and the Mediterranean diet.
Potassium in the diet can lessen the effects of salt sodium on blood pressure. The best sources of potassium are foods, such as fruits and vegetables, rather than supplements. Aim for 3, to 5, mg a day, which might lower blood pressure 4 to 5 mm Hg.
Ask your care provider how much potassium you should have. Even a small reduction of sodium in the diet can improve heart health and reduce high blood pressure by about 5 to 6 mm Hg. The effect of sodium intake on blood pressure varies among groups of people.
In general, limit sodium to 2, milligrams mg a day or less. However, a lower sodium intake — 1, mg a day or less — is ideal for most adults. Limiting alcohol to less than one drink a day for women or two drinks a day for men can help lower blood pressure by about 4 mm Hg.
One drink equals 12 ounces of beer, 5 ounces of wine or 1. But drinking too much alcohol can raise blood pressure by several points. It can also reduce the effectiveness of blood pressure medications. Smoking increases blood pressure.
Stopping smoking helps lower blood pressure. It can also reduce the risk of heart disease and improve overall health, possibly leading to a longer life.
Poor sleep quality — getting fewer than six hours of sleep every night for several weeks — can contribute to hypertension. A number of issues can disrupt sleep, including sleep apnea, restless leg syndrome and general sleeplessness insomnia.
Let your health care provider know if you often have trouble sleeping. Finding and treating the cause can help improve sleep. However, if you don't have sleep apnea or restless leg syndrome, follow these simple tips for getting more restful sleep.
Long-term chronic emotional stress may contribute to high blood pressure. More research is needed on the effects of stress reduction techniques to find out whether they can reduce blood pressure.
However, it can't hurt to determine what causes stress, such as work, family, finances or illness, and find ways to reduce stress. Try the following:. Home monitoring can help you keep tabs on your blood pressure. It can make certain your medications and lifestyle changes are working.
Home blood pressure monitors are available widely and without a prescription. Talk to a health care provider about home monitoring before you get started. Regular visits with a provider are also key to controlling blood pressure. If your blood pressure is well controlled, ask your provider how often you need to check it.
You might be able to check it only once a day or less often. Supportive family and friends are important to good health. They may encourage you to take care of yourself, drive you to the care provider's office or start an exercise program with you to keep your blood pressure low.
If you find you need support beyond your family and friends, consider joining a support group. This may put you in touch with people who can give you an emotional or morale boost and who can offer practical tips to cope with your condition.
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Elsevier; Accessed April 20, Hypertension adult. Mayo Clinic; Hall ME, et al. Weight-loss strategies for prevention and treatment of hypertension: A scientific statement from the American Heart Association. Shimbo D, et al. Self-measured blood pressure monitoring at home: A joint policy statement from the American Heart Association and the American Medical Association.
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John D Bisognano. Resistant hypertension is defined Non-drugg the failure to reach Non-drug approaches to lowering blood pressure target Magnesium for migraines pressure BP despite lwering to a regimen of the maximum tolerated doses Magnesium for migraines three antihypertensive medications, one loweeing which lowerimg a Non-drug approaches to lowering blood pressure. Age and Fatigue management Uncovering sports nutrition truths strong risk factors and the incidence and prevalence of resistant hypertension may be rising as the population ages and the number of people who are overweight increases. The specific prognostic implications of resistant hypertension have not been analysed. Several studies point to the poor outcome associated with elevated BP; the outcome of resistant hypertension is likely impaired relative to hypertension that can be controlled with medication. These unique approaches have so far demonstrated promising efficacy and safety and are likely to benefit patients who fail antihypertensive medical therapy. BMC Primary Care volume 23Pressute number: Cite this article. Metrics details. The current guidelines for Selenium with C# prevention, detection, evaluation, and management of Fatigue management recommend preasure Magnesium for migraines preessure non-pharmacological interventions: alcohol reduction, salt intake reduction, increased potassium intake, physical activity, weight loss, and heart-healthy diets. However, the non-pharmacological interventions are still not widely used in primary care. In this paper, we, therefore, reviewed and summarised the evidence on the effectiveness, cost-effectiveness, barriers, and facilitators of non-pharmacological interventions for the treatment of hypertension in primary care.
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