Effective Treatment of Hypertension Without Medication: Is It Possible?

Marvin Moser, MD

Disclosures
In This Article

Introduction and Lifestyle Changes

In this issue of The Journal of Clinical Hypertension, Wilburn and associates review data on the management of hypertension using vitamins, minerals, herbs, and other botanicals and discuss specific agents that were found, in a review of the literature, to lower blood pressure to a degree that was considered clinically significant.[1] It is important to put these and other nonpharmacologic approaches to the treatment of hypertension in perspective.

For many years, the media has advised the general public that losing weight, reducing sodium intake, performing moderate exercise, and moderating alcohol intake are sufficient to reduce blood pressure in a large number of patients. National committees also appropriately suggest this approach as initial therapy for hypertensive individuals[2] -- but how well does this work, and in how many patients is it effective without some medication?

Numerous studies have demonstrated that in a number of people, blood pressure can be reduced by following a low-sodium diet. Many of these trials were short term, many involved a reduction in sodium that would be impractical for most people, and many lacked adequate controls. However, based on long-term epidemiologic data and the overall results of studies that demonstrated the benefits of dietary sodium reduction, national guideline committees have recommended a reduction in sodium for all hypertensive patients and indeed for most everyone.[3] This is a reasonable recommendation. As a nation we ingest far too much sodium. As a public health measure, a decrease in sodium intake is to be encouraged. But sodium restriction alone will not lower blood pressure to goal levels except in some cases of stage 1 hypertension.

Another nonpharmacologic recommendation for hypertension treatment is weight loss, and there is little doubt that weight loss is an effective treatment for many patients (in fact, probably the most effective of all recommended strategies). However, persistent weight loss is difficult to maintain over time. If weight loss is achieved and maintained and blood pressure is reduced, no further action is needed. But this approach should not be considered definitive treatment for most persons with hypertension. If, in the course of medical management with specific antihypertensive drugs, a weight loss of 15 or 20 lb occurs and goal blood pressures have been achieved, medication can be stopped to see if blood pressures remain at acceptable levels.[4]

There is little doubt that increasing exercise can reduce blood pressure. Again, however, there are few data indicating that this modality can be depended on as definitive treatment for the majority of persons with hypertension, especially if the newer goals of blood pressure control are to be met.

Moderation of alcohol from an intake of more than four or five drinks per day to one or two drinks per day has also been shown to reduce blood pressure to some degree in some patients.

If all of the interventions that have proven most effective (weight loss, sodium intake reduction, and a program of moderate exercise) are followed, it is possible that as many as 20% of patients with hypertension will not have to be treated with medication (exact numbers have not been quantified in real-world situations). This is a considerable number, but the large remaining percentage of the population will require pharmacologic therapy to control blood pressure.

Under ideal conditions, a weight reduction of about 20 lb will reduce systolic blood pressure by about 10-20 mm Hg, sodium restriction by about 3-6 mm Hg, physical activity by about 5-8 mm Hg, and moderation of alcohol intake by 2-4 mm Hg. If a Dietary Approaches to Stop Hypertension (DASH) diet eating plan (emphasizing fruits, vegetables, and low-fat dairy products) can be followed, a decrease of about 10-12 mm Hg can be expected.[5] These are not insignificant changes but are not as readily achievable in practice as they are in specialized clinics or studies.

The bottom line is that the nonpharmacologic approach to management of hypertension with lifestyle changes may be effective in some patients but should not be depended on by most as definitive treatment.

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