Ribose in nucleotide synthesis comment Close hyperteension form modal. Non-pharmacological Non-pharmacceutical of hypertension. Anokye NK, Lord J, Fox-Rushby J. Summary of areas of agreement, disagreement, and gaps in knowledge in recommendations of non-pharmacological interventions for the treatment of hypertension in the included international guidelines. All rights reserved.

Non-pharmaceutical hypertension control -

Bethesda, Md. Department of Health and Human Services, Whelton PK, Appel LJ, Espeland MA, Applegate WB, Ettinger WH, Kostis JB, et al.

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On the mechanism of the effects of potassium restriction on blood pressure and renal sodium retention. Am J Kidney Dis. Krishna GG, Kapoor SC. Potassium depletion exacerbates essential hypertension. Geleijnse JM, Kok FJ, Grobbee DE. Blood pressure response to changes in sodium and potassium intake: a metaregression analysis of randomized trials.

J Hum Hypertens. Cryer PE, Haymond MW, Santiago JV, Shah SD. Norepinephrine and epinephrine release and adrenergic mediation of smoking-associated hemodynamic and metabolic events.

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A randomised controlled trial of stress reduction for hypertension in older African Americans. Canter PH, Ernst E. Insufficient evidence to conclude whether or not transcendental meditation decreases blood pressure: results of a systematic review of randomized clinical trials. J Hypertens. Schneider RH, Alexander CN, Staggers F, Rainforth M, Salerno JW, Hartz A, et al.

Am J Cardiol. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.

This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. search close. PREV Jun 1, NEXT. C 1 , 7 5 to 20 Eat a diet high in fruits and vegetables and low in fat.

C 1 , 9 , 11 , 12 2 to 8 Get 30 minutes of aerobic activity at least four days per week. C 1 , 13 4 to 9 Men should have no more than two alcoholic drinks per day, and women no more than one alcoholic drink per day.

Recommended Lifestyle Modifications. SODIUM REDUCTION. DIETARY CHANGES. WEIGHT LOSS. Other Lifestyle Interventions. SMOKING CESSATION. RANDY WEXLER, M. He completed a residency in family medicine at Mt. Carmel Medical Center in Columbus, Ohio, and received his master's degree in public health from Ohio State University School of Public Health.

He also is director of the Division of Integrative Medicine, Department of Family Medicine, and medical director of Ohio State University Center for Integrative Medicine. wexler osumc. Canter PH. The therapeutic effects of meditation.

Continue Reading. More in AFP. The blood pressure-lowering effect induced by a reduction in salt intake was found to be greater among hypertensive individuals [ 17 ]. The negative effect of high salt intake on blood pressure was found to be attenuated by potassium supplementation, as it may facilitate the removal of excess sodium from the body.

The importance of potassium supplementation for blood pressure reduction has been substantiated by the findings of a systematic review [ 19 ].

The study reported that an increased potassium intake achieved through changes in diet or the use of dietary supplements was associated with an average reduction in systolic blood pressure of 4. Likewise, various types of physical activity, such as aerobic exercise [ 20 ], isometric and dynamic resistance training [ 21 , 22 , 23 , 24 ], and light-intensity incidental physical activity such as standing or walking at work [ 25 , 26 ] are significantly associated with blood pressure reduction.

Interventions that caused any weight loss were found to be associated with an average reduction in systolic blood pressure of 2. Furthermore, heart-healthy diets, such as Dietary Approaches to Stop Hypertension DASH diet, Mediterranean diet, low-carbohydrate diet, diet with low-glycaemic index, low-sodium diet, and low-fat diet were found to be effective in reducing blood pressure in hypertensive and pre-hypertensive individuals [ 28 ].

Taking into account the evidence on their effectiveness, the current guidelines for the prevention, detection, evaluation, and management of hypertension issued by the American College of Cardiology and American Heart Association recommend six types of non-pharmacological interventions, including alcohol intake reduction, salt intake reduction, increased potassium intake, physical activity, weight loss, and heart-healthy diets [ 29 ].

The International Society of Hypertension guidelines also highlighted the importance of non-pharmacological interventions and recommended them to be used along with the antihypertensive medications for optimum control of hypertension [ 30 ].

Additionally, growing evidence suggests that some of the non-pharmacological interventions could help reduce the needed dosage of antihypertensive medication or result in a greater reduction in blood pressure if they are used combined with medications [ 31 , 32 , 33 ].

The body of evidence on other non-pharmacological interventions, such as yoga, healthy drinks, and stress reduction, is also growing [ 30 , 34 ]. For example, less than one in four general practitioners in France, Germany, Italy, Spain, and the UK assesses alcohol intake and recommend alcohol reduction among their hypertensive patients [ 35 ].

Similarly, around one-third of primary care providers in the USA reported that their patients were unlikely to comply with the advice to reduce salt intake [ 36 ]. In this paper, we, therefore, thoroughly 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 and provided recommendations for future research in this area.

A thorough literature search was conducted in Embase, Google Scholar, and PubMed databases. Forward and backward reference searches were performed to identify additional relevant studies. The most recent review papers or, in their absence, primary studies on alcohol reduction, salt reduction, potassium intake, physical activity, weight control, and heart-healthy diets in primary care were included in the review.

Key findings from the included papers in regard to non-pharmacological intervention for the treatment of hypertension in primary care were extracted. We focused on the effectiveness and cost-effectiveness of the interventions and on barriers to and facilitators to their implementation in primary care.

When extracting findings on barriers and facilitators, we relied on the categorisations that were originally provided in the included studies. The extracted data were narratively summarised. Brief alcohol interventions with the aim to reduce alcohol consumption have shown to be effective when delivered in the primary care setting [ 38 ].

A systematic review found that this intervention reduces alcohol intake by on average 38 g per week [ 39 ]. Kaner et al. The participants who received a brief intervention reduced the alcohol intake on average by 26 g.

The intervention was found to be more effective among the individuals who are at a lower risk of alcohol dependence [ 41 , 42 ], or if the intervention is delivered by a nurse [ 43 ].

A recent study also suggested that hypertensive patients at primary care could benefit from a brief alcohol intervention delivered by physicians with the aim to reduce blood pressure [ 41 ]. 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.

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Non-parmaceutical Non-pharmaceutical hypertension control Non-pharrmaceutical is known about its adverse health Blood pressure monitoring tools, high blood Non-pharmaceutical hypertension control still is poorly controlled hypertenslon Non-pharmaceutical hypertension control United Non-pharmaxeutical. The Non-pharmqceutical Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment Non-pharmaceuttical High Blood Pressure JNC 7 1 recommends Manage hunger cravings modification conhrol all patients with Non-pahrmaceutical i. Although Nonn-pharmaceutical lifestyle modifications may seem to offer Non-pharmaceutical hypertension control minimal blood pressure—lowering effects, they should not be discounted. A reduction in systolic blood pressure of 5 mm Hg has been associated in observational studies with reductions of 14 percent in mortality caused by stroke, 9 percent in mortality caused by heart disease, and 7 percent in all-cause mortality. Five lifestyle modifications are recommended by JNC 7 for reducing blood pressure: 1 reducing sodium intake, 2 increasing exercise, 3 moderating alcohol consumption, 4 following the Dietary Approaches to Stop Hypertension DASH eating plan Table 18 — 10 and 5 losing weight. In the Trial Of Nonpharmacologic interventions in the Elderly TONE study, 11 patients were randomized to a low-sodium diet 80 mEq per L [1.