Q: What are some lifestyle factors that can impact blood pressure (BP)?
A: In November 2017, new BP guidelines were released in a report of the American College of Cardiology and American Heart Association Task Force on Clinical Practice Guidelines (see 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults). The 2017 BP Guideline included changes in classification categories and a reduction in what level of blood pressure constitutes hypertension (1). The category of prehypertension is no longer used and elevated blood pressure was introduced to describe when systolic blood pressure (SBP) is 120 to 129 and diastolic blood pressure (DBP) is less than 80 mmHg. Stage 1 hypertension is defined as SBP 130 to 139 mmHg or DBP 80 to 89 mmHg; stage 2 hypertension includes SBP 140 mmHg or higher or DBP 90 mmHg or higher.
The 2017 BP Guideline classifies cardiovascular disease (CVD) risk factors as modifiable and relatively fixed (1). Relatively fixed risk factors include those that are difficult to change (e.g., chronic kidney disease), those that cannot be changed (e.g., family history, demographic characteristics), or those that may not reduce risk even if changed (e.g., psychological stress). Factors that can be changed, with the potential of reducing CVD risk, include cigarette smoking (current and secondhand), diabetes mellitus, dyslipidemia/hypercholesterolemia, overweight/obesity, physical inactivity/low fitness, and unhealthy diet. On a positive note, lifestyle modifications have the potential to lower risk (1). Avoiding cigarette smoking/tobacco exposure is one (see helpful links on quitting in Box 1). Promoting physical activity and a healthy diet are two additional action items to promote healthy blood pressure and will be the focus of this article.
BOX 1. Web site resources related to being smoke/tobacco free
Approximately 15% of adults in the United States smoke, and smoking is the leading cause of preventable death (2). Cigarette smoking results in 480,000 deaths per year in the United States; this includes more than 41,000 deaths due to exposure to secondhand smoke (2). Thus, becoming smoke/tobacco free is vital for overall health as well as in decreasing risk for hypertension. The following resources provide assistance with quitting:
PHYSICAL ACTIVITY TO PROMOTE HEALTHY BLOOD PRESSURE
Both physical activity and fitness level can impact blood pressure. Physical activity decreases the risk of hypertension, and physical fitness helps to slow the increase in blood pressure with age, decreasing the risk of developing hypertension (1). The 2017 BP Guideline therefore strongly recommends the following based on the highest level of evidence (level A): “Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension” (1). The 2017 Guideline highlights the blood pressure-lowering benefits shown with dynamic aerobic exercise, dynamic resistance training, and static isometric exercise (see Box 2).
BOX 2. Physical activity recommendations in the 2017 Guideline and potential impact on blood pressure
Three areas of physical activity have shown the potential to impact blood pressure (1):
- Aerobic activity (i.e., 90 to 150 minutes/week at 65% to 75% heart rate reserve)
- Lower BP 2 to 4 mmHg in those with normal BP and 5 to 8 mmHg in those with hypertension
- Dynamic resistance exercise (i.e., 90 to 150 minutes/week; 50% to 80% 1-rep max; 6 exercises including 3 sets/exercise and 10 repetitions per set)
- Lower BP 2 mmHg for those with normal BP and 4 mmHg for those with hypertension
- Isometric resistance (i.e., 4 × 2 minutes of hand grip exercise with 1 minute of rest between, 30% to 40% of maximum voluntary contraction, 3 sessions per week)
- Lower BP 4 mmHg for those with normal BP and 5 mmHg for those with hypertension
Within the American College of Sports Medicine (ACSM) Guidelines, recommendations for a complete exercise program for those with hypertension include 5 to 7 days per week of aerobic exercise (≥30 minutes/day), 2 to 3 days per week of resistance training (machines, free weights, and/or body weight), and 2 to 3 days per week of flexibility exercises (3). The myriad of benefits for a complete exercise program beyond the impact on BP have been outlined in the Physical Activity Guidelines for Americans (4) as well as the ACSM Guidelines (3). For those with hypertension who do not have BP controlled (i.e., resting SBP 140 mmHg or higher and/or resting DBP 90 mmHg or higher), ACSM recommends consultation with a physician before exercise (3). An appropriately progressed program should include consideration of level of BP control, medications and their effects, other diseases, and age (3).
DIETARY ASPECTS TO PROMOTE HEALTHY BLOOD PRESSURE
The 2017 Guideline includes various interventions, supported by research studies, which may help lower BP for adults with elevated BP or hypertension, including (1):
- Heart healthy diet — DASH (Dietary Approaches to Stop Hypertension)
- Weight loss for adults who are overweight or obese
- Sodium reduction
- Potassium supplementation (preferably in dietary modification) unless contraindicated by the presence of chronic kidney disease or use of drugs that reduce potassium excretion
- For those who currently consume alcohol, advise to drink no more than 2 standard drinks per day for men, and no more than 1 for women (standard refers to approximately 14 g of alcohol per drink — e.g., 1 regular beer, 5 oz of wine)
BOX 3. DASH eating plan
The following reflects the DASH eating plan (for 2,100 calorie eating plan) (5):
- Fat – 27% of calories (saturated fat 6% of calories)
- Protein – 18% of calories
- Carbohydrate – 55% of calories
- Fiber – 30 mg
- Cholesterol – 150 mg
- Sodium – 2,300 mg (1,500 may be even better for lowering BP)
- Potassium – 4,700 mg
- Calcium – 1,250 mg
- Magnesium – 500 mg
The DASH eating plan is based on research studies that revealed health benefits of the DASH diet (i.e., Dietary Approaches to Stop Hypertension Trial; DASH Diet, Sodium Intake, and Blood Pressure Trial; and the PREMIER Clinical Trail) (6). The DASH eating plan is low in saturated fat, cholesterol, and total fat. DASH emphasizes fruits, vegetables, and fat-free or low-fat milk and milk products and also includes whole grain foods, fish, poultry, and nuts (5). See Box 3 for an overview of the DASH eating plan. Serving suggestions and examples of items are found in Tables 1 and 2. Compared with a control diet (typical of U.S. adult consumption), the DASH diet has been shown to reduce systolic BP by 11.4 mmHg in individuals with hypertension and by 3.5 mmHg in those with normal BP (7). The benefits of the DASH eating plan may be expanded with weight loss or sodium reduction (1). Other dietary approaches (e.g., Mediterranean dietary pattern) also have been used successfully to lower BP (1).
Healthy body weight is another area of focus. A direct relationship has been found between blood pressure and both body mass index (BMI) and waist-to-hip ratio (1). For those with elevated BP or hypertension, weight loss is related to lowering of BP, approximately 1 mmHg per kilogram lost (1). Obesity during youth is associated with future hypertension risk, although if nonobese as adults, the risk for those who were overweight or obese during childhood was similar to those who had continuously maintained a normal BMI (8).
Sodium intake has a positive association with BP (i.e., as one increases, so does the other) as well as increasing risk of other concerns such as stroke and cardiovascular disease (1). For those who are salt sensitive, sodium intake results in an excessive increase in BP (1).
Reduction of sodium intake by approximately 25% has shown a reduction of 2 to 3 mmHg in SBP in those with normal BP, and this reduction can be much greater in those with hypertension as well as when combined with the DASH diet or weight loss (1). Average sodium intake in the United States has been reported to be 3,440 mg per day, which is much higher than the healthy
eating pattern limit of 2,300 mg per day for adults recommended in the Dietary Guidelines for Americans (9).
For those with elevated BP, reduction to 1,500 mg per day has been recommended (9). Packaged and restaurant foods are the source for most of the sodium in the diet (75%), whereas a smaller amount (11%) is from salt added during cooking or eating (10); attention to food and beverage selection is key (for more resources related to sodium reduction, see Box 4).
BOX 4. Resources for reduction of sodium intake
Reducing sodium intake is one dietary modification recommended to potentially reduce BP (1). The following resources provide insights on sources of sodium within the diet and how to reduce intake:
In contrast to sodium, potassium is inversely related to BP and seems to blunt sodium’s impact on BP (1). Although many of the research studies used potassium chloride pills, dietary modifications are preferred given the many heart-healthy benefits of potassium-rich foods, which include fruits, vegetables, and low-fat dairy products (1). Given that the eating pattern for approximately three fourths of the U.S. population is low in fruits, vegetables, and dairy, there is a real opportunity to make lifestyle changes by shifts in dietary choices as outlined in the Dietary Guidelines for Americans (9).
For an overview of these nutritional recommendations, see “Understanding and using the Dietary Guidelines for Americans” in the January/February 2017 issue of ACSM’s Health & Fitness Journal® (11).
Alcohol intake also has a direct relationship with BP. Although a concern with regard to BP, alcohol consumption (modest intake) may lower risk of coronary heart disease and is associated with a higher level of high-density lipoprotein-cholesterol (1). For those who do not consume alcohol, the Dietary Guidelines do not recommend starting; for those who do consume alcohol, moderation is recommended (9). In addition, various circumstances exist in which alcohol should not be consumed (e.g., pregnancy) (9).
Given the relationship between elevated blood pressure and risk of cardiovascular disease, lifestyle choices promoting healthy blood pressure are recommended. In particular, healthy dietary choices and physical activity are two beneficial aspects. The DASH eating pattern along with sodium reduction has been found to help with lowering blood pressure. Maintaining a physical activity program that promotes fitness also helps to lower blood pressure along with numerous other health benefits. For a refresher on how to properly check blood pressure, please watch this video http://links.lww.com/FIT/A90.
1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension
2. U.S. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health Web site [Internet]. Smoking and Tobacco Use: Fast Facts
. Atlanta (GA): Centers for Disease Control and Prevention; [cited 2017 November 29]. Available from: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm
3. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription
. 10th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2017. 472 p.
4. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Washington (DC): U.S. Department of Health and Human Services; 2008. [cited 2017 November 11]. Available from: https://health.gov/paguidelines/guidelines/
5. U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute. Your Guide to Lowering Your Blood Pressure With DASH
. Washington (DC): U.S. Department of Health and Human Services; 2006. 58 p. NIH Publication Number 06–4082.
6. U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung and Blood Institute. DASH Eating Plan
. Bethesda (MD): National Heart, Lung and Blood Institute; [cited 2017 December 4]. Available from: https://www.nhlbi.nih.gov/health/health-topics/topics/dash
7. Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med
8. Juonala M, Magnussen CG, Berenson GS, et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med
9. U.S. Department of Health and Human Services and U.S. Department of Agriculture [Internet]. 2015–2020 Dietary Guidelines for Americans
. 8th ed. Rockville, MD: Office of Disease Prevention and Health Promotion; 2015. [cited 2017 December 4]. Available from: https://health.gov/dietaryguidelines/2015/guidelines/
10. U.S. Food and Drug Administration Web site [Internet]. Sodium in Your Diet: Use the Nutrition Facts Label and Reduce Your Intake
. Silver Spring (MD): U.S. Food and Drug Administration; [cited 2017 December 4]. Available from: https://www.fda.gov/Food/ResourcesForYou/Consumers/ucm315393.htm
11. Bushman BA. Wouldn’t you like to know: understanding and using the Dietary Guidelines for Americans. ACSMs Health Fit J