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Diet in the treatment and prevention of hypertension


Authors
Norman M Kaplan, MD
John P Forman, MD, MSc

Section Editor
George L Bakris, MD

Deputy Editor
Alice M Sheridan, MD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2015. | This topic last updated: Jan 22, 2015.
INTRODUCTION A variety of dietary modifications are beneficial in the treatment of hypertension, including reduction
of sodium intake, moderation of alcohol, weight loss in the overweight or obese, and a diet rich in fruits, vegetables,
legumes, and low-fat dairy products and low in snacks, sweets, meat, and saturated fat. Individual dietary factors may
also reduce blood pressure (BP) [1].
Nondietary modalities of lifestyle modification should also be considered, including cessation of smoking and institution
of an aerobic exercise regimen. (See "Smoking and hypertension" and "Exercise in the treatment and prevention of
hypertension".)
Most of the studies on nonpharmacologic therapy evaluated only a single factor to prove its efficacy (eg, weight
reduction without sodium restriction). In making recommendations to the individual patient, however, the clinician will try
to modify all of the factors that may be contributing to the elevation in BP, although it is uncertain if the effects of different
modifications are additive.
In those with prehypertension or stage 1 hypertension, lifestyle changes may control the BP adequately [2]. However, in
those with either higher BP or additional risk (eg, diabetes or chronic kidney disease), drug therapies should first be
used to more quickly and effectively control the BP. Once BP is well controlled, lifestyle changes should be strongly
advised. If these are successfully achieved, reduction of medications may be possible.
This topic will review the effect of comprehensive dietary modification, as well as the effects of individual dietary
interventions on BP.
COMPREHENSIVE DIETARY MODIFICATION Several studies have looked at the efficacy of comprehensive dietary
modification [3]. In one, antihypertensive therapy was discontinued in patients who had been well controlled for two or
more years [4]. The patients were then randomized into two groups: one maintained on a relatively standard diet and
one on a diet that stressed salt restriction, weight reduction, and avoidance of excess alcohol intake. At four years,
hypertension had recurred in over 90 percent in the control group but in only 60 percent with dietary intervention, with
evidence of a plateau between the third and fourth years (figure 1).
Treatment of Mild Hypertension Study In the Treatment of Mild Hypertension Study (TOMHS), 902 patients with
mild diastolic hypertension (90 to 100 mmHg) were started on a program consisting of weight reduction, sodium and
alcohol restriction, and increased physical activity. Patients were then randomly assigned to placebo or to one of five
different antihypertensive drugs [5]. There were initial improvements in all of the dietary parameters that tended to
diminish over time (figure 2). Despite the difficulty in maintaining optimal compliance, those patients who remained on
the lifestyle program had an average 8.6/8.6 mmHg fall in blood pressure (BP) at four years.
Although the response to nonpharmacologic therapy alone was less than that seen if drug therapy were added [5],
dietary modifications have the additional cardiovascular advantage of lowering plasma total and low-density lipoprotein
(LDL)-cholesterol and raising high-density lipoprotein (HDL)-cholesterol. (See "Antihypertensive drugs and lipids".)
Dietary Approaches to Stop Hypertension trial A different approach was evaluated in the Dietary Approaches to
Stop Hypertension (DASH) trial [6]. Rather than evaluating sodium intake or weight loss, DASH randomly assigned 459
patients with BPs of less than 160/80 to 95 mmHg to one of three diets:

A control diet low in fruits, vegetables, and legumes and high in snacks, sweets, meats, and saturated fat.
A diet rich in fruits, vegetables, legumes and low in snacks and sweets.
A combination diet rich in fruits, vegetables, legumes, and low-fat dairy products and low in snacks, sweets, meats,
and saturated and total fat (this combination diet is called the "DASH diet"). The DASH diet is comprised of four to
five servings of fruit, four to five servings of vegetables, two to three servings of low-fat dairy per day, and <25
percent fat.
The following observations were noted in which the BP reductions were expressed in relation to the fall in BP seen with
the control diet:
The fruits and vegetables diet reduced the BP by 2.8/1.1 mmHg, and the combination diet reduced the BP by
5.5/3.0.
These effects were more pronounced in patients with hypertension. With the combination diet, for example, the BP
fell 11.4/5.5 mmHg in hypertensives versus 3.5/2.1 mmHg in the normotensives.
The antihypertensive effects were maximal by the end of week 2 with any of the diets and were then maintained for
eight weeks.
Low-sodium DASH The low-sodium DASH trial evaluated the effect of varying sodium intake in combination with
consuming the DASH diet described above [7]. In this study, 412 participants were randomly assigned to a control or
DASH diet and, within each diet, ate foods with three levels of sodium content (3.5, 2.3, and 1.2 g) for 30 days each. The
following results were reported:
Independent of sodium intake, the DASH diet resulted in significantly lower systolic and diastolic BP levels than the
control diet. With the high-, intermediate-, and low-sodium intakes, the systolic pressure was 5.9, 5.0, and 2.2
mmHg lower with the DASH diet than with the control diet, respectively. Comparable values for the diastolic
pressure were 2.9, 2.5, and 1.0 mmHg lower with the DASH diet.
With either diet, lowering the sodium intake reduced BP levels, an effect observed among those with and without
hypertension and among different races and sex.
When different phases of diet were compared, the most significant decrease in BP was observed between the
high-sodium control diet and low-sodium DASH diets as a comparative overall reduction of 8.9 and 4.5 mmHg in
systolic and diastolic BPs, respectively, was noted with the low-sodium DASH diet. This benefit was even more
significant among hypertensive individuals. The mean fall in systolic BP was 11.5 mmHg.
Thus, the combination of a low-sodium and DASH diet resulted in the most significant benefit, with decreases in BP
comparable with those observed with antihypertensive agents.
PREMIER trial The PREMIER trial was designed to assess the additive BP effects of two different behavioral
interventions [8]. In this study, 810 patients with above optimal blood pressure (120 to 159 mmHg systolic pressure
and/or 80 to 95 mmHg diastolic pressure) were randomly assigned to one of three groups: 1) "established behavioral
intervention" (eg, weight loss, physical activity, and limitations in sodium and alcohol intake); 2) the DASH diet plus
"established behavioral intervention"; and 3) one-time advice only. Unlike the original DASH study, the subjects prepared
their own food. To assess the effects on BP of the interventions, the effect of advice only (6.6/3.8 mmHg decrease) was
subtracted from the BP change in the intervention groups.
At six months, the DASH diet plus behavioral intervention produced a small additional decrease in BP versus that
observed with behavioral intervention alone (4.3/2.6 mmHg and 3.7/1.7 mmHg, respectively). The prevalence of mild
hypertension at study end was significantly less in the two intervention groups (12 and 17 percent in DASH plus
established and established group, respectively) than in the advice-only arm (26 percent). At 18-month follow-up, the
prevalence of hypertension had increased in all three groups, but remained lowest in the two intervention groups (22 and
24 percent in DASH plus established and established group, respectively, versus 32 percent in the advice only) [9]. (See

'Prevention' below.)
Overall, the absolute effects on BP of DASH plus those of behavioral intervention were not additive. Possible reasons for
this less than expected effect of the DASH diet included the requirement that the subjects prepared their own food, so
there was less rigorous adherence to the diet than in the other DASH studies, where all the food was provided; a large
BP decrease in the advice-only control group; and a possible similar physiologic mechanism for BP lowering for both
interventions [10].
Diet versus antihypertensive agents There are limited data concerning the relative efficacy of lifestyle interventions
(particularly diet) versus antihypertensive agents on BP control or cardiovascular outcomes [11].
Despite this absence of evidence of relative effectiveness, we and most experts feel that diet plays an important role in
many susceptible patients in the genesis and maintenance of hypertension [1].
SALT RESTRICTION AND WEIGHT REDUCTION The potential beneficial effects of salt restriction and, in
overweight patients, weight reduction in hypertensive patients are discussed separately. (See "Salt intake, salt
restriction, and primary (essential) hypertension" and "Obesity and weight reduction in hypertension".)
OTHER DIETARY INTERVENTIONS Potassium supplements, 40 to 80 mEq/day, lower blood pressure (BP), an
effect that is largely lost in patients who are also on a low-sodium diet [12]. Other modalities, such as stress reduction
and supplements of calcium, magnesium, or fish oil, appear to induce a small and less predictable reduction in BP in
most patients [13-15]. Moreover, in a meta-analysis covering 7 clinical trials and 32 observational studies, the
consumption of a vegetarian diet was associated with a 4.8/2.2 mmHg lower BP, compared with those consuming an
omnivorous diet [16]. However, these data are almost entirely derived from cross-sectional studies.
Potassium Potassium supplementation may modestly lower the BP. This issue is discussed separately. (See
"Potassium and hypertension".)
Magnesium Higher magnesium intake has been associated with lower BP [17,18].
Fish oil High-dose, but not low-dose, fish oil supplements may reduce systemic BP by up to 6/4 mmHg [19-22]. A
metaregression analysis of 36 trials of fish oil, of which 22 had a double-blind design, found that the intake of a median
dose of 3.7 g/day of fish oil provided statistically significant reductions of both systolic and diastolic pressures (2.1/1.6
mmHg) [23].
The long-term safety of fish oil in doses high enough to lower the BP is at present unknown. Potential toxicities include a
bleeding tendency due to prolongation of the bleeding time, a possible decline in renal function due to decreased
production of the renal vasodilator prostaglandin E2, eructations, the sensation of a fishy taste, and a possible
deleterious effect on lipid metabolism [19,22]. These considerations plus the generally modest antihypertensive effect
argue against the routine use of fish oil supplements.
Fish intake Fish intake in combination with weight loss may have additive effects on BP reduction [24,25]. In one
16-week randomized trial, fish intake plus weight loss was associated with a reduction in BP from 133/77 mmHg to
119/68 mmHg, twice that observed with either intervention alone [24].
Calcium Although there appears to be an inverse relation between dietary calcium intake and BP [26], both dietary
calcium and calcium supplements have a relatively small effect on BP. This was illustrated in a meta-analysis including
all 40 randomized, controlled trials available up to June 2003 relating to the relationship between hypertension and
either dietary (dairy) or nondietary supplements of calcium, which found a reduction in BP of 1.86/0.99 mmHg, with a
trend toward larger effects in those with low baseline calcium intake [27].
The effect of supplemental calcium on BP is too small to recommend the use of calcium supplements for the therapy or
prevention of hypertension. Moreover, in a community-based, prospective, longitudinal cohort study, high intake of
calcium was associated with higher death rates from all causes and cardiovascular disease [28].
High-fiber diet A higher intake of dietary fiber is associated with decreased systemic pressures [29]. Multiple meta-

analyses have shown benefits with dietary fiber intake on BP [29,30]. As an example, a 2005 meta-analysis of 24
randomized, placebo-controlled trials published between 1966 and 2003 on the effects of fiber supplementation found an
average fall of 1.2/1.3 mmHg with fiber intake (average dose of 11.5 g/day) [29]. More significant reductions were
observed in older (greater than 40 years) and hypertensive individuals.
In a prospective, double-blinded, placebo-controlled, randomized trial of 110 subjects, individuals given 30 g of milled
flaxseed had a systolic/diastolic lower BP of 10/7 mm Hg [31].
Protein intake Replacing carbohydrate intake with soy (vegetable) or dairy protein may reduce BP [32-37]. As an
example, one study randomly assigned 302 Chinese subjects with untreated hypertension (systolic BP between 130 to
159 mmHg) to soybean protein or carbohydrate complex control [34]. After 12 weeks, systolic and diastolic BPs were 4.3
and 2.8 mmHg lower among those taking the protein supplement, compared with the control group. There was a greater
effect among those with hypertension at baseline (BP >140/90 mmHg).
Folate An inverse association of folate intake with BP or hypertension has been shown in three large, prospective,
cohort studies [38,39], as well as in several randomized trials [40-42]. In a meta-analysis of 12 randomized trials,
supplemental folic acid (5 mg/day or more) significantly reduced systolic, but not diastolic, BP by 2.0 mmHg as
compared with placebo [42].
Flavonoids The beneficial effect of fruits and vegetables on BP may be due in part to an increased intake of
polyphenols (eg, flavonoids). Significant sources of these compounds in Western countries include tea and cocoa
products. The effect of cocoa on BP was evaluated in a 2012 Cochrane meta-analysis of 20 studies consisting of 856
subjects [43]. At a median duration of intake of 4.4 weeks, flavanol-rich cocoa products significantly reduced both
systolic and diastolic pressure compared with placebo (mean reduction, 2.8/2.2 mmHg). A discussion of BP and tea
ingestion is presented separately. (See "Cardiovascular effects of caffeine and caffeinated beverages", section on 'Blood
pressure'.)
PREVENTION Dietary and lifestyle modifications have been evaluated in a number of studies for the prevention
rather than treatment of hypertension [20,44-50]. As illustrated by the following observations, the optimal effect on blood
pressure (BP) is achieved with correction of multiple contributors to hypertension, including salt intake, obesity, and
excess alcohol intake. (See "Salt intake, salt restriction, and primary (essential) hypertension" and "Obesity and weight
reduction in hypertension" and "Cardiovascular benefits and risks of moderate alcohol consumption", section on
'Hypertension'.)
The relative efficacy of such interventions can be illustrated by the results of two randomized trials and a large
observational study:
The Trials of Hypertension Prevention, phase II randomized 2382 men and women (aged 30 to 54 years) with a BP
<140/83-89 who were 110 to 165 percent of ideal body weight [44]. The patients were randomly assigned to usual
care, salt restriction, weight reduction, or both. Sodium restriction was associated with a 50 and 40 mEq decline in
sodium intake and a 4.4 and 2.0 kg weight reduction at 6 and 36 months, respectively. Compared with usual care,
the BP fell at six months by 3.7/2.7 with weight loss, 2.9/1.6 with salt restriction, and 4.0/2.0 with combined therapy.
These effects were attenuated at 36 months, but, at 48 months, the likelihood of progressing to hypertension was
reduced with nonpharmacologic therapy (relative risk 0.78 to 0.82).
The TONE trial evaluated 975 older people (aged 60 to 80 years) who had a BP <145/<85 mmHg on one
antihypertensive medication; 585 were obese [45]. The patients were randomly assigned to usual care or to salt
restriction, weight loss (in obese patients), or both. Those assigned to salt restriction had a 40 mEq/day decrease
in sodium excretion, while, in obese patients, a regimen of diminished caloric intake and increased physical activity
was associated with a persistent weight loss of 4 to 5 kg; these parameters were unchanged in the usual-care
group. After three months of intervention, withdrawal of the antihypertensive drug was attempted.
The primary endpoint was a diagnosis of high BP at one or more follow-up visits, treatment with antihypertensive
drugs, or a cardiovascular event. The reduction in BP compared with usual care was 2.6/1.1 mmHg with salt

restriction, 3.2/0.3 mmHg with weight loss, and 4.5/2.6 mmHg with combined therapy. The primary endpoint at 30
months occurred significantly less often with salt restriction (62 verus 76 percent with usual care), weight reduction
in obese subjects (61 versus 74 percent), and combined salt restriction and weight reduction in obese subjects (56
versus 84 percent).
The importance of risk factors for primary hypertension (formerly called "essential" hypertension) in women was
evaluated in a prospective cohort study of 83,882 adult women from the second Nurses' Health Study who did not
have a history of hypertension, cardiovascular disease, or diabetes [46]. Six lifestyle and dietary factors were
independently associated with a lower risk of developing hypertension during 14 years of follow-up: body mass
index of less than 25 kg/m2, a daily mean of 30 minutes of vigorous exercise, adherence to the Dietary
Approaches to Stop Hypertension (DASH) diet, modest alcohol intake, infrequent use of nonnarcotic analgesics,
and intake of 400 mcg/day or more of folate [46]. The presence of all six factors was associated with a marked
decrease in the risk for hypertension (hazard ratio 0.22, 95% CI 0.10-0.51).
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond
the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient
education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to
your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and
the keyword(s) of interest.)
Basics topic (see "Patient information: Controlling your blood pressure through lifestyle (The Basics)")
Beyond the Basics topic (see "Patient information: High blood pressure, diet, and weight (Beyond the Basics)")
SUMMARY
There are limited data concerning the relative efficacy of lifestyle interventions (particularly diet) versus
antihypertensive agents on blood pressure (BP) control or cardiovascular outcomes. Despite this absence of
evidence of relative effectiveness, we and most experts feel that diet plays an important role in many susceptible
patients in the genesis and maintenance of hypertension. (See 'Comprehensive dietary modification' above.)
High-dose, but not low-dose, fish oil supplements may reduce systemic BP, but the long-term safety of fish oil in
doses high enough to lower the BP is unknown. Fish intake in combination with weight loss may have additive
effects on BP reduction. (See 'Fish oil' above.)
Dietary calcium and calcium supplements have a relatively small effect on BP. The effect of supplemental calcium
on BP is too small to recommend the use of calcium supplements for the therapy or prevention of hypertension.
(See 'Calcium' above.)
Dietary interventions that may be associated with reduced BP include dietary fiber, magnesium, soy (vegetable) or
dairy protein intake, folate, and possibly polyphenols (eg, flavonoids). (See 'Other dietary interventions' above and
"Cardiovascular effects of caffeine and caffeinated beverages", section on 'Blood pressure'.)
Dietary and lifestyle modifications have been evaluated in a number of studies for the prevention rather than
treatment of hypertension. The optimal effect on BP is achieved with correction of multiple contributors to
hypertension, including salt intake, obesity, and excess alcohol intake. (See "Salt intake, salt restriction, and
primary (essential) hypertension" and "Obesity and weight reduction in hypertension" and "Cardiovascular benefits
and risks of moderate alcohol consumption", section on 'Hypertension'.)
Use of UpToDate is subject to the Subscription and License Agreement.

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Topic 3878 Version 12.0

GRAPHICS
Efficacy of dietary modification in mild
hypertension

Ability of combined nutritional intervention - weight loss, salt


restriction, and avoidance of excess alcohol (squares) - to maintain
normotension as compared with a control group without dietary
modification (circles) after cessation of previously successful
antihypertensive therapy. Hypertension recurred in over 90 percent of
control patients, but in only 60 percent with dietary modification.
Data from Stamler R, Stamler J, Grimm R, et al. Nutritional therapy for
high blood pressure. Final report for a four-year randomized controlled trial-the Hypertension Control Program. JAMA 1987; 257:1484.
Graphic 59980 Version 2.0

Diminished compliance with nonpharmacologic antihypertensive


therapy over time

Changes in weight, sodium intake (as estimated from urine sodium excretion), and
exercise (measured by physical activity points) in patients with mild diastolic
hypertension treated with combined dietary modification. Despite initial compliance,
patients tended to return toward but not to baseline levels over a 48-month period.
Although not shown, there was a persistent reduction in the number of alcoholic drinks
from 3.6 to 2.5 drinks per week.
Data from Neaton JD, Grimm RH Jr, Prineas RJ, et al. Treatment of Mild Hypertension Study.
Final results. Treatment of Mild Hypertension Study Research Group. JAMA 1993; 270:713.
Graphic 67978 Version 3.0

Disclosures
Disclosures: Norman M Kaplan, MD Nothing to disclose. John P Forman, MD, MSc Employee of UpToDate, Inc. George L Bakris, MD
Grant/Research/Clinical Trial Support: Medtronic; Relypsa [Hypertension, hyperkalemia]. Consultant/Advisory Boards: Medtronic; Relypsa;
Bayer; Novartis; DSI; Boehringer-Ingelheim; Lexicon; Janssen; Astra-Zeneca; Kona [Diabetes, hyperkalemia, resistant hypertension
(Canagliflozin, dapagliflozin, empagliflozin)]. Alice M Sheridan, MD Employee of UpToDate, Inc.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a
multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is
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