Therapeutic management is based on two fundamental strategies: lifestyle modifications, which play a crucial role both in prevention and in the treatment of hypertension, and pharmacological therapy, which is indicated when non-pharmacological interventions are insufficient or in patients with more severe hypertension.
The three pillars of non-pharmacological therapy are the elimination of harmful habits (smoking and alcohol), healthy nutrition, and physical activity.
Smoking accelerates arterial stiffness, promotes endothelial dysfunction, and increases overall cardiovascular risk (not only cardiovascular). Quitting smoking is an absolute priority to reduce the risk of cardiovascular events and to improve 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 failure, or very high cardiovascular risk. If it cannot be eliminated, it is essential to limit intake to less than 10 g/day for women and less than 20 g/day for men, equivalent to about 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 pressure, especially in patients with obesity or overweight. The optimal Body Mass Index (BMI) is between 18.5 and 24.9 kg/m², while waist 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 is the combination of moderate caloric restriction and regular physical activity.
A healthy diet, with the right balance of macro- and micronutrients, not only promotes weight loss but also helps to lower blood pressure.
The DASH diet (Dietary Approaches to Stop Hypertension), developed in the 1990s by the National Institutes of Health (NIH), is a dietary regimen designed to reduce blood pressure. It is characterized by a high intake of fruits, vegetables, whole grains, low-fat dairy products, lean proteins, and unsaturated fats, with reduced sodium, added sugars, and saturated fats.
Limiting sodium intake is one of the most effective strategies for reducing blood pressure. Daily sodium consumption should be less than 2 g, equivalent to about 5 g of table salt. Excess sodium promotes water retention and increases blood pressure, which is why it is essential to avoid processed foods, cured meats, salty snacks, aged cheeses, and ready-to-eat meals. It is advisable to replace salt with spices and aromatic herbs to enhance the flavor of food without increasing its sodium content.
Increasing potassium intake promotes vasodilation and counteracts the effects of sodium. Potassium is abundant in foods such as fruit (bananas, citrus fruits, apricots), vegetables (spinach, potatoes, tomatoes), legumes, and nuts. However, in patients with renal insufficiency, excess potassium can be dangerous; therefore, supplementation must be carefully monitored.
Carbohydrates should mainly come from whole sources, such as unrefined grains (spelt, barley, quinoa, brown rice, oats) and legumes. These foods ensure 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 it favors insulin resistance and increases cardiovascular risk.
Proteins must 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 mainly come from oily fish, rich in omega-3 fatty acids, lean white meat, and low-fat dairy products. The consumption of red meat and processed meats should be reduced, as these foods may increase arterial stiffness and promote endothelial dysfunction.
Fats should primarily come from unsaturated sources, such as extra virgin olive oil, nuts, seeds, and fish rich in omega-3 fatty acids. These fats promote vasodilation, improve endothelial function, and reduce cardiovascular risk. Saturated fats, present in butter, fatty meats, and whole dairy products, should be consumed in moderation, while trans fats, found in industrial baked goods and margarines, should be completely avoided.
The DASH diet also encourages a high intake of fruits and vegetables, which provide potassium, magnesium, fiber, and antioxidants, all of which help regulate blood pressure. Calcium, present in low-fat dairy products, and magnesium, abundant in nuts and legumes, also play an important role in blood pressure regulation.
Regular physical activity is also a fundamental pillar in the management of hypertension, as it helps to reduce 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 a day 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 improving 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, whereas in patients at moderate or higher risk, it is always combined with pharmacological therapy.