Non-Pharmacological Treatment of Hypertension

Hypertension is the leading risk factor for cardiovascular, cerebrovascular, and renal diseases.
The goal of therapy is to reduce blood pressure below 140/90 mmHg in most patients. However, the optimal target range is a systolic pressure between 120 and 129 mmHg and a diastolic pressure between 70 and 79 mmHg, which provides the maximum benefit in terms of cardiovascular risk reduction. In elderly or frail patients, blood pressure targets should be adjusted to prevent hypoperfusion, with ideal values between 130 and 139 mmHg for systolic and 80 and 89 mmHg for diastolic pressure, ensuring adequate cerebral and renal perfusion.

Therapeutic management is based on two fundamental strategies: lifestyle modifications, which play a crucial role in both preventing and treating hypertension, and pharmacological therapy, indicated when non-pharmacological interventions are insufficient or in patients with more severe hypertension.

Lifestyle Modifications

Lifestyle modifications are essential not only for prevention but also as a therapeutic measure, as they contribute to lowering blood pressure levels. They should always complement pharmacological therapy and, in low-risk patients, represent the first-line treatment, potentially bringing blood pressure to target levels without the need for medications.

The three pillars of non-pharmacological therapy are the elimination of harmful habits (smoking and alcohol), a healthy diet, and regular physical activity. Smoking accelerates arterial stiffness, promotes endothelial dysfunction, and significantly increases overall cardiovascular risk. Quitting smoking is a top priority for reducing the risk of cardiovascular events and improving the effectiveness of antihypertensive therapy.
Alcohol has a dose-dependent hypertensive effect. Ideally, it should be completely avoided, especially in patients with severe hypertension, diabetes, liver disease, or very high cardiovascular risk. If elimination is not possible, consumption should be limited to less than 10 g/day for women and less than 20 g/day for men, equivalent to approximately one small glass of wine for men and half a glass for women. Exceeding these amounts increases the risk of resistant hypertension and cardiovascular complications.

Weight control is the most effective modifiable factor for lowering blood pressure. A 5-10% reduction in body weight can lead to a significant decrease in blood pressure, especially in overweight or obese patients. The optimal Body Mass Index (BMI) falls between 18.5 and 24.9 kg/m², while abdominal circumference should not exceed 102 cm in men and 88 cm in women, as visceral fat accumulation is strongly associated with hypertension. The best approach to weight loss combines moderate caloric restriction with regular physical activity.

A healthy diet with the right balance of macronutrients and micronutrients contributes to both weight reduction and blood pressure lowering.
The DASH (Dietary Approaches to Stop Hypertension) diet, developed in the 1990s by the National Institutes of Health (NIH), is a dietary regimen designed to lower blood pressure. It features a high intake of fruits, vegetables, whole grains, low-fat dairy products, lean proteins, and unsaturated fats, while reducing sodium, added sugars, and saturated fats.

Limiting sodium intake is one of the most effective strategies for lowering blood pressure. Daily sodium consumption should be less than 2 g, equivalent to about 5 g of table salt. Excess sodium promotes fluid retention and increases blood pressure, making it essential to avoid processed foods, cured meats, salty snacks, aged cheeses, and ready-made meals. Substituting salt with herbs and spices is recommended to enhance the flavor of food without increasing sodium content.

Increasing potassium intake promotes vasodilation and counteracts the effects of sodium. Potassium is abundant in foods such as fruits (bananas, citrus fruits, apricots), vegetables (spinach, potatoes, tomatoes), legumes, and nuts. However, in patients with renal insufficiency, excessive potassium intake can be dangerous, requiring careful monitoring.

Carbohydrates should come primarily from whole-grain sources, such as unrefined cereals (spelt, barley, quinoa, brown rice, oats) and legumes. These foods provide a gradual release of glucose into the bloodstream, improve insulin sensitivity, and help reduce vascular inflammation. The consumption of simple sugars and refined carbohydrates should be limited, as they promote insulin resistance and increase cardiovascular risk.

Proteins should be balanced between plant and animal sources. Plant-based proteins, found in legumes, nuts, and soy, have shown beneficial effects on blood pressure. Animal proteins should primarily come from oily fish, rich in omega-3 fatty acids, lean white meats, and low-fat dairy products. The intake of red meat and processed meats should be reduced, as these foods can increase arterial stiffness and promote endothelial dysfunction.

Fats should primarily come from unsaturated sources, such as extra virgin olive oil, nuts, seeds, and omega-3-rich fish. These fats promote vasodilation, improve endothelial function, and reduce cardiovascular risk. Saturated fats, found in butter, fatty meats, and whole dairy products, should be consumed in moderation, while trans fats, found in industrial baked goods and margarine, should be avoided entirely.

Additionally, the DASH diet encourages a high intake of fruits and vegetables, which provide potassium, magnesium, fiber, and antioxidants, all of which help regulate blood pressure. Calcium, found in low-fat dairy products, and magnesium, abundant in nuts and legumes, also play important roles in blood pressure regulation.

Regular physical activity is another fundamental pillar in hypertension management, as it contributes to lowering blood pressure by improving vascular function and insulin sensitivity. Aerobic exercise, such as brisk walking, swimming, or cycling, should be performed for at least 30 minutes daily to promote arterial relaxation and improve circulation. Resistance training with light weights, although less studied than aerobic activity, can be useful for enhancing muscle tone and metabolism, with beneficial effects on blood pressure regulation.

"Non-pharmacological therapy is essential in the treatment of hypertension. In low-risk patients, it represents the first-line therapeutic approach, while in moderate or high-risk patients, it is always combined with pharmacological therapy."

References
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