ISH position paper: Lifestyle changes crucial in managing blood pressure |

Holistic lifestyle changes are urgently needed early in life for better prevention and control of hypertension, as recommended by an international panel of experts in the International Society of Hypertension (ISH) position paper. [J Hypertens 2024;42:23–49]

At the recent 19th Annual Scientific Congress of the Malaysian Society of Hypertension in Kuala Lumpur, lead author of the ISH position paper Professor Dr Fadi J Charchar, highlighted physical activity, sleep quality and stress management, while co-author Professor Dr Maciej Tomaszewski focused on healthy eating and drinking for better management of hypertension.

The effect of physical activity, sleep quality and stress management on hypertension

“We know that lifestyle is a controllable factor … and that’s what contributes to prevention [of hypertension],” said Charchar, director, Health Innovation and Transformation Centre, University of Leicester, UK. Clearly, the message is not reaching the general population worldwide because the WHO noted that in 2022, about 1.8 billion adults did not fulfil the recommended levels of physical activity. [https://www.who.int/news/item/26-06-2024-nearly-1.8-billion-adults-at-risk-of-disease-from-not-doing-enough-physical-activity, Lancet Glob Health 2024;12:e1232–e1243]

A similar situation prevails in Malaysia as shown by the National Health and Morbidity Survey 2023 where one in three adults are not physically active, one in two adults lead sedentary lifestyles (spend >2 hours a day sitting or lying down), 84 percent are not active in sports, fitness and leisure activities, and 84 percent do not walk or cycle during their daily commute. [https://iku.nih.gov.my/images/nhms2023/key-findings-nhms-2023.pdf]

Many studies have documented the benefits of physical activities in blood pressure (BP) reduction. Endurance, isometric resistance, and dynamic resistance training all result in reduced systolic and diastolic BP as shown in a meta-analysis of randomized, controlled trials involving more than 5,000 subjects. [J Am Heart Assoc 2013;2:e004473] A more recent meta-analysis of 270 studies involving more than 15,000 patients confirmed the effectiveness of physical activity in reducing BP. Isometric resistance training was again shown to produce the highest BP reduction (-8.24/-4.00 mmHg, p<0.001) compared to dynamic resistance training (-4.55/-3.04 mmHg, p<0.001), aerobic exercise (-4.49/-2.53 mmHg, p<0.001), and a combination of dynamic resistance training and aerobic exercise (-6.04/-2.54 mmHg, p<0.001). [Br J Sports Med 2023;57(20):1317–1326]

Hence, the ISH position paper recommends that everyone should be physically active and perform aerobic and dynamic resistance exercises for 150-300 minutes (moderate-intensity exercises) or 75-150 minutes (vigorous exercises) each week (Table 1). Physical activity should be started from childhood and carried out lifelong. The amount and intensity should be based on starting fitness level, comorbidities, pharmacological treatment, and situations, and slowly increased over time. The basic principle is to progressively increase movement and decrease sedentary time day by day.

Sleep quality is another important lifestyle factor that has a role in BP regulation because lack of sleep leads to sympathetic hyperactivity, which increases the risk of hypertension. However, healthy sleep of 7–8 hours is linked to lower risks of hypertension, abnormal sleep patterns and sleep apnea. Sleep disordered breathing by itself is thought to be the leading cause of secondary hypertension as well as a risk factor for nocturnal and resistant hypertension. Thus, having a good quality sleep is important in preventing hypertension.

Stress can cause maladaptive behavior such as smoking, drinking alcohol, lack of physical activity, and poor nutrition, likely resulting in hypertension. Stress management can help with BP reduction, studies show. Mindfulness-based therapy, cognitive therapy, meditation, progressive muscle relaxation techniques, yoga, deep breathing, and listening to music, are some of the stress management techniques that can reduce BP.

Impact of healthy eating and drinking on hypertension

“Intuitively, as clinicians, we know that healthy lifestyle is important to prevent and treat hypertension, but we should realize that the reasons why [healthy lifestyle] is so well embedded in the management plan is because the individual risk factors do contribute to the biology of blood pressure regulation and the development of hypertension,”said Tomaszewski, Professor of Cardiovascular Medicine, University of Manchester, UK. He mainly talked about the recommended consumption of sodium, potassium, sugar, and fiber.

Sodium/salt

Salt, in the form of sodium chloride, is estimated to contribute 30 percent to the global prevalence of cardiovascular (CV) disease and increases BP at 5 g/day. While households in low-income countries add salt to cooked food, those in high-income countries consume ultra-processed foods high in salt. In Malaysia, the Malaysian Community Salt Survey (MyCoSS) found the mean salt consumption is about 7.9 g/day. [J Health Popul Nutr 2021;40(Suppl 1):23]

ISH recommends salt intake of below 5 g/day in line with the European Society of Hypertension guidelines, 2022 World Hypertension League Resolve To Save Lives and ISH dietary sodium (salt) global call to action. To minimize sodium consumption, low-sodium salt substitutes such as potassium chloride has been recommended. The Malaysian Society for World Action on Salt, Sugar and Health (MyWASSH) initiative by Professor Dr Chia Yook-Chin advocates practical ways such as low-salt recipes and salt substitutes for the public, and works with the food industry, policy makers, media and healthcare professionals to instill salt reduction strategies.

Potassium

The Salt Substitute and Stroke Study (SSaSS) study showed that substituting 25 percent of sodium chloride with potassium chloride is linked to lower rates of CVD and mortality. ISH recommends potassium intake of >3.5 g/day which is in line with WHO’s recommendation. Eating four to five servings of fruit and vegetables every day as well as using potassium chloride in cooking, if needed, is sufficient to fulfil the daily potassium intake. The risk of hyperkalemia due to potassium intake in people with healthy kidneys and even those with chronic kidney disease may be minimal.

Sugar

Refined sugar in its raw form as well as in processed food, drinks and sweets should be limited. Awareness of the different forms of sugar like glucose and fructose is important in reducing consumption. Studies have shown that added sugar consumption can increase the risk of CV death.

Fiber

Fiber, a relatively new addition to the lifestyle recommendations, is linked to CV death when dietary intake is lower than the recommended 25–29 g/day. Adequate fiber can be obtained by eating enough fruit and vegetables.

Overall, high sodium, low potassium, high sugar and low fiber are linked to ultra-processed foods, which are particularly hazardous to CV health and should be reduced as much as possible. Instead, the DASH and Mediterranean diets containing high fiber and potassium, enough lean protein, and low saturated fats and salt, are recommended for healthy BP levels. Alcohol should either be limited to two standard drinks for men and 1 standard drink for women or avoided for the best CV outcomes. Moderate amounts of coffee (without sugar), beetroot juice, karkade (Hibiscus sabdariffa L., roselle) tea, pomegranate juice, and cocoa are potentially beneficial.