Hypertension affects approximately one third of the world’s adult population and is a major cause of premature death despite considerable advances in pharmacological treatments. Growing evidence supports the use of lifestyle interventions for the prevention and adjuvant treatment of hypertension. In this Review, we provide a summary of the epidemiological research supporting the preventive and antihypertensive effects of major lifestyle interventions (regular physical exercise, body weight management and healthy dietary patterns), as well as other less traditional recommendations such as stress management and the promotion of adequate sleep patterns coupled with circadian entrainment. We also discuss the physiological mechanisms underlying the beneficial effects of these lifestyle interventions on hypertension, which include not only the prevention of traditional risk factors (such as obesity and insulin resistance) and improvements in vascular health through an improved redox and inflammatory status, but also reduced sympathetic overactivation and non-traditional mechanisms such as increased secretion of myokines.
Strong evidence supports the benefits of regular physical activity and exercise for the prevention and management of hypertension.
Reducing body weight to normal in individuals with overweight or obesity reduces the risk of hypertension, but further evidence is needed on the long-term efficacy of this strategy.
Sodium intake restriction reduces blood pressure, particularly in patients with hypertension, and the Dietary Approaches to Stop Hypertension (DASH) diet is the most effective dietary approach to prevent hypertension and to reduce blood pressure in individuals with pre-hypertension or hypertension.
Shift work, short sleep duration or poor sleep and other forms of circadian disruption might increase the risk of hypertension.
Some forms of psychological stress, such as post-traumatic stress disorder, seem to be associated with a higher risk of hypertension, but strong evidence on the potential antihypertensive benefits of stress management techniques is lacking.
In contrast to common antihypertensive medications, lifestyle interventions, especially exercise, reduce blood pressure through multisystemic and ‘non-traditional’ mechanisms (for example, not only by improving vascular health or reducing sympathetic overactivation).
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Work by P.L.V. is supported by University of Alcalá (FPI2016). Research by G.R.-H., L.M.R. and A.L. is funded by the Spanish Ministry of Economy and Competitiveness and Fondos FEDER (PI18/00139, PI17/01093 and PI17/01193). G.R.-H. holds a Miguel Servet research contract (CP15/00129). The authors thank K. McCreath (Madrid, Spain) for editorial assistance and A. Castillo-García (Fissac-Physiology, Health and Physical Activity, Madrid, Spain) for assistance with generating the figures for submission.
The authors declare no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
- Clinic (or office) blood pressure
Blood pressure (BP) measured in the clinical setting (for example, an outpatient clinic). In this Review, ‘BP’ refers to ‘clinic BP’ unless otherwise stated.
- Resistant hypertension
Clinic (or office) systolic blood pressure/diastolic blood pressure ≥140/90 mmHg (or ≥130/80 mmHg according to the 2017 ACC/AHA guidelines) in patients receiving at least three antihypertensive drugs (including one diuretic) at maximally tolerated doses.
- Physical exercise
Also termed ‘exercise training’ or simply ‘exercise’. A subset of physical activity that is planned, structured and repetitive and has a final or an intermediate objective of improving or maintaining physical fitness. In this Review, physical activity and exercise are sometimes used interchangeably to ease readability.
- Non-westernized populations
Hunter–gatherers, traditional horticulturalists, pastoralists and farmers, and other populations minimally affected by western habits.
- Non-westernized dietary patterns
Composed mainly of universal fresh food sources very low in refined oils, margarine, refined cereal grains, added sugars and ultra-processed foods.
- Physical activity
Any bodily movement produced by skeletal muscles that requires energy expenditure.
- Dietary Approaches to Stop Hypertension
(DASH). A lifelong approach to healthy eating that is designed to help treat or prevent hypertension without medication, sponsored by the NIH. This diet is rich in fruits, vegetables, whole grains and low-fat dairy products, includes poultry, fish and nuts, contains small amounts of red meat, sweets and sugar-containing beverages, and results in a sodium intake within normal limits.
- Minimum physical activity levels
WHO recommends that adults engage in ≥150 min per week of moderate-intensity physical activity (such as brisk walking) or ≥75 min per week of vigorous physical activity (such as very brisk walking or jogging), or a combination thereof, as well as in muscle-strengthening activities involving major muscle groups on ≥2 days per week.
- 24-h ambulatory BP
Also termed ‘24-h BP’. The mean result of blood pressure (BP) levels measured with a portable automated device at regular intervals during normal daily life over 24 h.
- Endurance exercise
Also termed ‘aerobic exercise’. A type of exercise that is performed for more than a few minutes and preferentially involves aerobic metabolism for energy production (for example, brisk walking, jogging, bicycling and swimming).
- Resistance exercise
Also termed ‘strength exercise’. A type of exercise that is performed against a load or resistance (for example, weight lifting and leg press).
- Isometric exercise
A type of exercise that usually involves small muscle groups and results in no displacement or joint movement (such as handgrip).
- Renal sympathetic nerve activity
An important nerve regulator of the function of the renal vasculature, tubules and juxtaglomerular granular cells and, therefore, of renal haemodynamics, tubular reabsorption and renin secretion rate.
- Renin–angiotensin–aldosterone system
(RAAS). A hormonal system that is a critical regulator of blood volume and systemic vascular resistance.
From the Greek adipo (fat), cytos (cell) and kinos (movement); also termed adipokines. Cytokines secreted by adipose tissue.
- Sympathetic nervous system
(SNS). One of the two main divisions of the autonomic nervous system, the other being the parasympathetic nervous system. Although its primary function is to stimulate the ‘fight, flight or freeze’ response, the SNS is constantly active at a basal level to maintain homeostasis in haemodynamics by inducing a vasoconstrictor effect in most vessels.
- Conduit arteries
Also known as conducting arteries or elastic arteries. Arteries with many collagen and elastin filaments in the tunica media, which provides the capacity to stretch in response to each pulse. Conduit arteries include the largest arteries in the body (pulmonary arteries, the aorta and its branches).
- Resistance arteries
Small-diameter blood vessels in the microcirculation with thick muscular walls and narrow lumen (usually arterioles and end point arteries) that contribute the most to the resistance to blood flow.
- Nitric oxide
(NO). A volatile gas produced by endothelial cells that acts to relax vascular tone.
- Oxidative stress
A process of cellular damage related to uncontrolled action of reactive oxygen species, a group of molecules, including oxygen and its derivatives, produced by the normal process of aerobic metabolism.
- Chronic systemic inflammation
Usually referred to as simply ‘inflammation’. A state of low-grade, non-infective (‘sterile’) inflammation at the systemic level that is characterized by activation of immune components that are often distinct from those engaged during an acute immune response and that can lead to major alterations in all cells, tissues and organs. This state is reflected by high baseline levels of specific biomarkers such as high-sensitive C-reactive protein.
From the Greek myo (muscle) and kinos (movement). Molecules (mostly, but not only, small peptides such as cytokines) released from muscles, usually during exercise.
Mechanical receptors that sense blood pressure changes in both carotid sinuses and the aortic arch.
- Arterial baroreflex
Also known as the baroreceptor reflex. A rapid negative feedback loop in which elevated blood pressure is sensed by baroreceptors, with their subsequent activation leading to rapid increases in parasympathetic outflow and decreases in sympathetic outflow and therefore to restoration of blood pressure levels.
- Peripheral chemoreceptors
Located in the carotid and aortic bodies. Sensory extensions of the peripheral nervous system into blood vessels that detect changes in chemical homeostasis (hypoxaemia, hypercapnia and acidosis), which increases their firing with a subsequent increase in ventilation and sympathetic nervous system outflow.
- Obstructive sleep apnoea
(OSA). A sleep-related breathing disorder characterized by repeated episodes of complete or partial upper-airway occlusion (and subsequent arterial hypoxaemia) during sleep.
- Mediterranean diet
A diet abundant in fruits, vegetables, legumes, whole grains, olives, nuts and seeds, and containing extra-virgin olive oil associated with frequent consumption of fish, moderate consumption of dairy products and red wine, and low consumption of red meat and isolated sugars.
- Advanced glycation end-products
(AGEs). Proteins or lipids that become non-enzymatically glycated as a result of exposure to sugars.
A main class of plant secondary metabolite, existing in a wide variety of foods, typically divided into flavonoids and non-flavonoid polyphenols.
A type of flavonoid with antioxidant and colouring effects that give certain plants that are rich in these compounds (blueberry, raspberry, red and black grapes and black soybean, among many others) a red, blue, purple or black colour.
Sometimes referred to as ‘flavanols’, not to be confused with flavonols. Derivatives of flavans that include catechin, epicatechin gallate, epigallocatechin, epigallocatechin gallate, proanthocyanidins, theaflavins and thearubigins.
- Gut microbiota
The collective microorganisms (bacteria, archaea, fungi and viruses) that reside in the gastrointestinal tract.
Live microorganisms with purported health benefits when consumed, mainly as a result of improving or restoring the gut microbiota.
Chemical substances found within an organism that are not naturally produced or expected to be present within the organism.
- Bisphenol A
A ubiquitous plasticizing agent used in the manufacture of polycarbonate plastics and epoxy resins, found in food and beverage cans as well as in thermal receipt paper. Owing to a structural similarity to oestrogen, bisphenol affects various phenotypes that are regulated by the natural hormone oestrogen.
- Suprachiasmatic nucleus
(SCN). A small region of the brain in the hypothalamus, situated directly above the optic chiasm, that is responsible for controlling circadian rhythms.
- Sleep quality
The self-reported, retrospective appraisal of the sleep experience. A good sleep quality typically means falling asleep in ≤30 min and sleeping soundly through the night (one or no awakenings and drifting back to sleep within 20 min of waking up).
- Sleep-maintenance insomnia
A condition characterized by difficulty staying asleep, nocturnal awakenings and, in particular, waking too early and struggling to get back to sleep.
- Slow-wave sleep
The phase of sleep that is considered to be restorative and is associated with the highest arousal threshold.
- Low non-rapid eye movement sleep
The phase of sleep associated with better performance and learning as well as with decreased sympathetic nervous system activity and increased parasympathetic nervous system activity during the night.
- Psychosocial stress
Also frequently referred to as ‘mental stress’. The feeling of being overwhelmed or unable to cope as a result of pressures that are unmanageable.
- White-coat syndrome
Also known as ‘white-coat hypertension’. A phenomenon in which people exhibit a blood pressure above the normal range in a clinical setting but not in other settings (at home or with 24-h ambulatory assessments).
- Post-traumatic stress disorder
(PTSD). A mental health condition triggered by a terrifying event, either experiencing it or witnessing it, with symptoms including flashbacks, nightmares, severe anxiety or uncontrollable thoughts about the event.
- Dietary acid load
The balance of net acid-yielding food items (meats, fish, shellfish, eggs, cheese, cereal grains and salt) and net base-producing food items (fruits, tubers, roots and vegetables).
A type of polyphenol whose subclasses (for example, flavanols, flavonones and isoflavones) are present mostly in fruits, certain vegetables, seeds (such as flax), soy, whole grains, honey, tea, coffee, cocoa, some alcoholic beverages (such as wine) and a few spices.
The most abundant dietary flavonol, mainly found in onions, apples and berries.
A flowering plant whose rhizome is frequently used as a spice, containing several bioactive compounds (such as gingerols) with the potential to affect human health.
A seed from the flax plant with moderate-to-high contents of α-linolenic acid (an omega-3 fatty acid), lignans (a group of polyphenols), and soluble and insoluble fibre.
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Valenzuela, P.L., Carrera-Bastos, P., Gálvez, B.G. et al. Lifestyle interventions for the prevention and treatment of hypertension. Nat Rev Cardiol 18, 251–275 (2021). https://doi.org/10.1038/s41569-020-00437-9
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