“I don’t like to take drugs.” And “What can I just do myself?”
Robert Brook, an internist at the University of Michigan Health System in Ann Arbor, hears these two comments more than any others when he talk to patients about controlling their blood pressure.
Often called a silent disease, hypertension has no symptoms beyond the readings that come from a blood pressure cuff. And yet, high blood pressure is a risk factor for a slew of other conditions, including heart attack, congestive heart failure, stroke, kidney disease and vision loss. So treating hypertension is all about lowering your risk for these diseases.
More than a quarter of U.S. adults have hypertension, and three out of four of them are on medication to keep their blood pressure in check. Those drugs come with side effects, such as needing to urinate more often (diuretics), insomnia (beta blockers) and constipation (calcium channel blockers).
You can see why people might want to avoid such medications.
Here’s the latest on the possibilities for controlling hypertension without drugs.
Diet is the method that doctors say has the biggest benefit and for which there is the best evidence, much of it garnered in the late 1990s and early 2000s through a series of studies called DASH (Dietary Approaches to Stop Hypertension).
Research since then has only bolstered the claim that eating a diet low in salt and fat and high in fruits and vegetables can reduce high blood pressure. For someone with blood pressure at or above the hypertension threshold of 140/90 mm Hg mercury, following the DASH diet can lower systolic blood pressure (the top number) by 11.6 mm and diastolic pressure by 5.3 mm. By comparison, medications can achieve larger decreases: Drops of 20 and 10 mm, respectively, are considered a good response.
However, Brook says, patients often want options beyond diet, because they doubt they can or will change their eating habits enough to make a difference. “They want some evidence-based methods, short of taking medication,” he says.
Brook recently co-authored a scientific statement for the American Heart Association that reviewed evidence-based studies of a wide variety of non-drug approaches for reducing high blood pressure, including Transcendental Meditation, yoga, acupuncture, slow-breathing techniques, biofeedback and various types of exercise
They found a mixed picture.
What worked best? Aerobic exercise.
“The typical recommendation is 30 minutes on most days, or five times per week, at a moderate intensity, such as 4 miles per hour walking or light jogging,” Brook says. Although the studies varied in their exercise methods, overall the reductions in blood pressure approached that of diet intervention.
There are fewer studies on the effects of resistance exercise or weight training, and the reductions in blood pressure that result are generally much smaller: less than 3 and 2 mm for systolic and diastolic blood pressure, respectively. Still, the evidence was sufficient for the authors of the AHA statement to conclude that “dynamic resistance exercise is reasonable to perform in clinical practice in order to reduce blood pressure.”
Device-guiding breathing, similarly, had an impact, but not very large.
The techniques involve wearing a breathing monitor while listening to musical chimes that tell you when to inhale and exhale. The goal is to slow your breathing to fewer than 10 breaths a minute and to prolong the exhalation. Studies have found a reduction (4 mm systolic, 3 mm diastolic) in blood pressure in patients who use the device for 15-minute sessions at least three times per week.
Data on the benefits of Transcendental Meditation and biofeedback are weaker, with some studies showing effects and others not. Still, these methods may be worth a try, according to the statement. With biofeedback, patients monitor their blood pressure in real time while participating in a relaxation exercise or guided imagery. As for other forms of meditation, not enough evidence exists to recommend them.
Another exercise approach is isometrics, most commonly done with a hand grip device that is squeezed and held for several minutes. Some studies have reported impressive results — more than 10 mm decrease in systolic and nearly 8 mm in diastolic blood pressure. The caveat is that the studies are few and the number of participants small — 13 here, 42 there. The AHA statement said only that it “may be considered.”
Some doctors worry that isometrics’ sustained muscle contractions might be unsafe and lead to blood pressure spikes, Brook says, but studies reported no such ill effects.
“I was fascinated by the robustness of its effect on blood pressure,” Brook says. “It should get more focus, both in terms of effectiveness and safety.”
While meditation, relaxation techniques, acupuncture and yoga can provide many health benefits, there was no consistent evidence of their efficacy in reducing blood pressure. The AHA statement recommends against these practices for controlling blood pressure.
One thing is clear to doctors, Brook says: Different people respond to different things. The AHA statement focuses on average responses, but often a subset of people are very good responders. “We’ve all had patients who experience a 10 to 20 mm Hg drop” with a lifestyle change, he says. “But others have no improvement.”
Even with small effects, Brooks says, using Transcendental Meditation, exercise or device-guided breathing may help a person limit the dose or number of blood pressure drugs he or she must take.
The AHA statement offers doctors evidence-based tools beyond diet to recommend to their patients with high blood pressure, says Domenic Sica, a professor of medicine at Virginia Commonwealth University Medical Center in Richmond and soon-to-be president of the American Society of Hypertension.
“Not too many people will make dramatic changes in their lifestyle,” said Lawrence Appel, a doctor at the Johns Hopkins School of Medicine who worked on the AHA statement. “They inch in the right direction. They don’t go from five servings of veggies to 10, but maybe to six or seven. We hope that small benefits accrue from [multiple small changes] across several dimensions.”