Lifestyle:
Evidence and Practical Use

Lifestyle changes have been shown to effectively reduce blood pressure and decrease the risk of cardiovascular disease.

Weight-reducing diets.

A systematic review found that weight-reducing diets for overweight, hypertensive patients are effective in achieving modest weight reduction, and are probably associated with modest reductions in blood pressure. Level A evidence
Weight-reducing diets may allow a decrease in the required dose of antihypertensive medications. Level A evidence.
Two subsequent randomized controlled trials (RCTs) have confirmed these results. Level B evidence.

Salt reduction.

A systematic review of people adhering to a reduced salt diet for >4 weeks found benefits in terms of blood pressure reduction both in those with normal blood pressure initially and those with hypertension. Level A evidence
One of the RCTs included in the review assessed the effect on blood pressure when subjects were assigned to three groups with different salt level intakes: 150, 100, and 50mmol/day (8.6, 5.7, and 2.9g/day, respectively) for 30 days. It found a significantly greater reduction in blood pressure in the group eating the lowest level of salt vs the group with the highest salt intake. Level A evidence

Potassium supplementation.

A systematic review and an RCT both found reductions in systolic blood pressure in people with hypertension taking a potassium supplement (60-100mmol/day in the systematic review and 60mmol/day in the subsequent RCT) vs placebo or no supplement. However, the RCT did not find a significant reduction in diastolic blood pressure. Level A evidence
There is potential for harm in potassium supplementation so potassium supplements are not recommended without regular monitoring for serum potassium levels, and are contraindicated in certain patients

Fish oil supplementation.

A systematic review found that people with hypertension taking fish oil supplements had a significantly reduced blood pressure compared with placebo. Level A evidence
The trials included in the review used a median dose of 3.7g/day of fish oil. This is a lot higher than the dose of fish oil taken in the diet of most westernized populations

Calcium supplementation.

Although a systematic review found a significant, but small reduction in blood pressure in people taking calcium supplementation vs no supplements or placebo, it did not analyze people with and without hypertension separately. Level B evidence

Magnesium supplementation.

A systematic review was unable to find a significant reduction in blood pressure in people with hypertension taking magnesium supplements vs placebo. Level A evidence

Exercise.

A systematic review found that sedentary adults randomized to an exercise group for at least 2 weeks had reduced blood pressure compared with patients in a nonexercising control group. Level B evidence

Alcohol reduction.

A meta-analysis of RCTs found that reduced alcohol intake is associated with a significant reduction in blood pressure. Level B evidence

Stress Relief

Stress relief is clearly one of the major risk factors in cardiovascular disease, and methods for dealing with stress are very important (see Chap. 86)

IMPACT OF STRESS ON CARDIOVASCULAR DISEASE RISK FACTORS.
Stress may lead to hypertension through repeated blood pressure elevations and by increasing the amount of vasoconstricting hormones (see Chap. 40). Stress factors leading to hypertension include job strain, social environment, emotional stress, race, and white coat hypertension. In the Framingham study,[4] hypertension was involved in over 80 percent of all cardiovascular deaths. In addition, hypertension was at least twice as strong a predictor of death as smoking or elevated blood cholesterol level. Over 50 million Americans are currently hypertensive.

Stress Management

• PET OWNERSHIP.
  Pet ownership reduces stress and can convey a sense of companionship and purpose. Pet ownership has been shown to increase heart rate variability in patients with cardiovascular disease.
• MINDFULNESS-BASED STRESS REDUCTION.
  Mindfulness-based stress reduction (MBSR) uses the techniques of mindfulness meditation, gentle yoga, and coordinated deep breathing to decrease pain and anxiety. In a meta-analysis, MBSR has been shown to help individuals alleviate stress and suffering associated with various diseases.
• REIKI.
  Reiki, an ancient Japanese healing art, in the Western world sometimes referred to as ‘Touch to Heal’, is a technique that can be applied by a practitioner as well as by the patient him/herself. The underlying mechanisms are still unclear, yet is has proven to be an effective tool in creating self- and health awareness and relaxation, thus improving blood pressure.
• GUIDED IMAGERY.
  Guided imagery is a therapeutic technique that allows a person to use his or her own imagination to connect body and mind to achieve desirable outcomes, such as decreased pain perception and reduced anxiety. Guided imagery has been studied for patients both pre- and postsurgical intervention. A recent study of cardiothoracic surgery patients demonstrated that both pain and anxiety decreased significantly with guided imagery. An ongoing trial at Scripps Clinic using guided imagery and healing touch pre- and postcardiothoracic surgery has demonstrated a 50 percent reduction in pain and anxiety in the treatment group.
• TRANSCENDENTAL MEDITATION.
  Transcendental meditation (TM) offers a unique technique for meditation and relaxation and is one of the most studied CAM therapies, with research dating back to the 1970s. TM has been shown not only to improve blood pressure but also the insulin resistance components of the metabolic syndrome and cardiac autonomic nervous system tone.
• BIOFEEDBACK.
  Biofeedback is a technique to train people to change habitual reactions to stress. In patients with coronary artery disease, biofeedback increases heart rate variability (HRV).