Non-pharmacologic Approaches for the Management of Prehypertension

  • Reuven ZimlichmanEmail author
Part of the Updates in Hypertension and Cardiovascular Protection book series (UHCP)


Non-pharmacological interventions have been shown not only to reduce blood pressure and delay the appearance of hypertension but also to improve glucose and cholesterol metabolism. They also affect other aspects of metabolism and have also beneficial psychological aspects.

Thus, non-pharmacological interventions should be recommended to the entire public including healthy subjects, prehypertensive and hypertensive subjects as well as all those with increased CVD risk. Generally, the greater the risk of CVD, the greater the benefit of intervention. Lifestyle interventions remain the cornerstone of therapeutic approach with or without pharmacological treatment.

However, things are not so simple, the evidence of the beneficial effect of such interventions is proven only in RCT’s (Randomized controlled studies) and not in real life setting. Subjects that are included in a RCT are in a “laboratory” surrounding with specific support and supervision, the data may be different in “wild” unsupervised settings. These methods are associated with difficulties in compliance implementation and persistence.

Prehypertension is the gray zone between normotension and hypertension and is associated with gradual increase in blood pressure until becoming hypertensive. These subjects are at increased CVD risk and the majority of them will become eventually hypertensive. While the pharmacological treatment of prehypertension is still disputed there is no dispute regarding the justification to use the non-pharmacological approach in prehypertensive patients in order to delay transition to hypertension and to lower CVD risk.


  1. 1.
    Guo X, Zhang X, Guo L, et al. Association between pre-hypertension and cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. Curr Hypertens Rep. 2013;15:703–16.CrossRefGoogle Scholar
  2. 2.
    Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA. 2003;289:2560–71.CrossRefGoogle Scholar
  3. 3.
    Greenlund KJ, Croft JB, Mensah GA. Prevalence of heart disease and stroke risk factors in persons with prehypertension in the United States, 1999–2000. Arch Intern Med. 2004;164:2113–8.CrossRefGoogle Scholar
  4. 4.
    Nesbitt SD. Treatment options for prehypertension. Curr Opin Nephrol Hypertens. 2007;16:250–5.CrossRefPubMedGoogle Scholar
  5. 5.
    Egan BM, Nesbitt SD, Julius S. Prehypertension: should we be treating with pharmacologic therapy? Ther Adv Cardiovasc Dis. 2008;2:305–14.CrossRefGoogle Scholar
  6. 6.
    Rose G. Strategy of prevention: lessons from cardiovascular disease. Br Med J (Clin Res Ed). 1981;282:1847.CrossRefGoogle Scholar
  7. 7.
    Huang Y, Cai X, Li Y, et al. Prehypertension and the risk of stroke a meta-analysis. Neurology. 2014;82:1153–61.CrossRefGoogle Scholar
  8. 8.
    Huang Y, Su L, Cai X, et al. Association of all-cause and cardiovascular mortality with prehypertension: a meta-analysis. Am Heart J. 2014;167:160–8.CrossRefGoogle Scholar
  9. 9.
    Huang Y, Wang S, Cai X, et al. Prehypertension and incidence of cardiovascular disease: a meta-analysis. BMC Med. 2013;11:177.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Guo X, Zhang X, Zheng L, et al. Prehypertension is not associated with all-cause mortality: a systematic review and meta-analysis of prospective studies. PLoS One. 2013;8:e61796.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Egan BM, Stevens-Fabry S. Prehypertension [mdash] prevalence, health risks, and management strategies. Nat Rev Cardiol. 2015;12:289–300.CrossRefGoogle Scholar
  12. 12.
    Zhang Y, Lee ET, Devereux RB, et al. Prehypertension, diabetes, and cardiovascular disease risk in a population-based sample. Hypertension. 2006;47:410–4.CrossRefGoogle Scholar
  13. 13.
    Blackburn H. Non-pharmacologic treatment of hypertension. Ann N Y Acad Sci. 1978;304:236–42.CrossRefPubMedGoogle Scholar
  14. 14.
    Fuchs FD. Prehypertension: the rationale for early drug therapy. Cardiovasc Ther. 2010;28:339–43.CrossRefGoogle Scholar
  15. 15.
    Swales JD. Non-pharmacological antihypertensive therapy. Eur Heart J. 1988;9:45–52.CrossRefPubMedGoogle Scholar
  16. 16.
    Rose G, Stamler J, Stamler R, et al. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. Br Med J. 1988;297:319–28.CrossRefGoogle Scholar
  17. 17.
    Alderman MH. Non-pharmacological treatment of hypertension. Lancet. 1994;344:307–11.CrossRefPubMedGoogle Scholar
  18. 18.
    Mozaffarian D, Fahimi S, Singh GM, et al. Global sodium consumption and death from cardiovascular causes. N Engl J Med. 2014;371:624–34.CrossRefGoogle Scholar
  19. 19.
    Van Horn L. Dietary sodium and blood pressure: how low should we go? Prog Cardiovasc Dis. 2015;58:61–8.CrossRefPubMedGoogle Scholar
  20. 20.
    McLaren L, Sumar N, Barberio AM, et al. Population-level interventions in government jurisdictions for dietary sodium reduction. Cochrane Database Syst Rev. 2016;9:CD010166.PubMedGoogle Scholar
  21. 21.
    Reisin E, Abel R, Modan M, et al. Effect of weight loss without salt restriction on the reduction of blood pressure in overweight hypertensive patients. N Engl J Med. 1978;298:1–6.CrossRefGoogle Scholar
  22. 22.
    Dahl LK. Possible role of salt intake in the development of essential hypertension. Int J Epidemiol. 2005;34:967–72.CrossRefPubMedGoogle Scholar
  23. 23.
    Wassertheil-Smoller S, Blaufox MD, Oberman AS, et al. The trial of antihypertensive interventions and management (TAIM) study: adequate weight loss, alone and combined with drug therapy in the treatment of mild hypertension. Arch Intern Med. 1992;152:131–6.CrossRefPubMedGoogle Scholar
  24. 24.
    Lasser VI, Raczynski JM, Stevens VJ, et al. Trials of hypertension prevention, phase II structure and content of the weight loss and dietary sodium reduction interventions. Ann Epidemiol. 1995;5:156–64.CrossRefPubMedGoogle Scholar
  25. 25.
    Hjermann I, et al. Smoking and diet intervention in healthy coronary high risk men. Methods and 5-year-follow-up of risk factors in a randomized trial. The Oslo Study. J Oslo City Hosp. 1980;30:3–17.PubMedGoogle Scholar
  26. 26.
    Hjermann I, Holme I, Byre KV, et al. Effect of diet and smoking intervention on the incidence of coronary heart disease: report from the Oslo Study Group of a randomised trial in healthy men. Lancet. 1981;318:1303–10.CrossRefGoogle Scholar
  27. 27.
    Moser M. A decade of progress in the management of hypertension. Hypertension. 1983;5:808–13.CrossRefPubMedGoogle Scholar
  28. 28.
    Mainous AG, Everett CJ, Liszka H, et al. Prehypertension and mortality in a nationally representative cohort. Am J Cardiol. 2004;94:1496–500.CrossRefGoogle Scholar
  29. 29.
    Knowler WC, Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393–403.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Dagogo-Jack S, Egbuonu N, Edeoga C. Principles and practice of nonpharmacological interventions to reduce cardiometabolic risk. Med Princ Pract. 2010;19:167.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Reddy KS, Katan MB. Diet, nutrition and the prevention of hypertension and cardiovascular diseases. Public Health Nutr. 2004;7:167–86.CrossRefGoogle Scholar
  32. 32.
    Lelong H, Galan P, Kesse-Guyot E, et al. Relationship between nutrition and blood pressure: a cross-sectional analysis from the NutriNet-sante study, a French web-based cohort study. Am J Hypertens. 2015;28:362–71.CrossRefPubMedGoogle Scholar
  33. 33.
    Fung TT, Rimm EB, Spiegelman D, et al. Association between dietary patterns and plasma biomarkers of obesity and cardiovascular disease risk. Am J Clin Nutr. 2001;73:61–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Vollmer WM, Sacks FM, Ard J, et al. Effects of diet and sodium intake on blood pressure: subgroup analysis of the DASH-sodium trial. Ann Intern Med. 2001;135:1019–28.CrossRefPubMedGoogle Scholar
  35. 35.
    Hinderliter AL, Sherwood A, Craighead LW, et al. The long-term effects of lifestyle change on blood pressure: one-year follow-up of the ENCORE study. Am J Hypertens. 2013;27:734–41.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Allbaugh L. Food and nutrition. In: Crete: a case study of an underdeveloped area. Princeton, NJ: Princeton University Press; 1953. p. 97–135.CrossRefGoogle Scholar
  37. 37.
    Vamvakis A, Gkaliagkousi E, Triantafyllou A, et al. Beneficial effects of nonpharmacological interventions in the management of essential hypertension. JRSM Cardiovasc Dis. 2017;6:2048004016683891.PubMedPubMedCentralGoogle Scholar
  38. 38.
    Estruch R, Martinez-González MA, Corella D, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern Med. 2006;145:1–11.CrossRefPubMedGoogle Scholar
  39. 39.
    Pitsavos C, Chrysohoou C, Panagiotakos DB, et al. Abdominal obesity and inflammation predicts hypertension among prehypertensive men and women: the ATTICA study. Heart Vessel. 2008;23:96–103.CrossRefGoogle Scholar
  40. 40.
    Kastorini C-M, Milionis HJ, Esposito K, et al. The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. J Am Coll Cardiol. 2011;57:1299–313.CrossRefPubMedGoogle Scholar
  41. 41.
    Davy BM, Halliday TM, Davy KP. Sodium intake and blood pressure: new controversies, new labels... New guidelines? J Acad Nutr Diet. 2015;115:200–4.CrossRefPubMedGoogle Scholar
  42. 42.
    Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. N Engl J Med. 2001;344:3–10.CrossRefPubMedGoogle Scholar
  43. 43.
    MacGregor GA, Sagnella GA, Markandu ND, et al. Double-blind study of three sodium intakes and long-term effects of sodium restriction in essential hypertension. Lancet. 1989;334:1244–7.CrossRefGoogle Scholar
  44. 44.
    Khaw K-T, Barrett-Connor E. Dietary potassium and stroke-associated mortality. N Engl J Med. 1987;316:235–40.CrossRefPubMedGoogle Scholar
  45. 45.
    Luft FC. Putative mechanism of blood pressure reduction induced by increases in dietary calcium intake. Am J Hypertens. 1990;3:156S–60S.CrossRefPubMedGoogle Scholar
  46. 46.
    O’Keefe JH, Bhatti SK, Bajwa A, et al. Alcohol and cardiovascular health: the dose makes the poison… or the remedy. Mayo Clin Proc. 2014;89:382–93.CrossRefPubMedGoogle Scholar
  47. 47.
    Piano MR, Mazzuco A, Kang M, et al. Cardiovascular consequences of binge drinking: an integrative review with implications for advocacy, policy, and research. Alcohol Clin Exp Res. 2017;41:487–96.CrossRefPubMedGoogle Scholar
  48. 48.
    Ozemek C, Phillips SA, Popovic D, et al. Nonpharmacologic management of hypertension: a multidisciplinary approach. Curr Opin Cardiol. 2017;32:381–8.CrossRefPubMedGoogle Scholar
  49. 49.
    Xue X, Jiang H, Frontini MG, et al. Effects of alcohol reduction on blood pressure: a meta-analysis of randomised controlled trials. Hypertension. 2001;38:1112–7.CrossRefGoogle Scholar
  50. 50.
    Lackland DT, Voeks JH. Metabolic syndrome and hypertension: regular exercise as part of lifestyle management. Curr Hypertens Rep. 2014;16:492.CrossRefPubMedGoogle Scholar
  51. 51.
    Collier SR, Landram MJ. Treatment of prehypertension: lifestyle and/or medication. Vasc Health Risk Manag. 2012;8:613.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Whelton SP, Chin A, Xin X, et al. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med. 2002;136:493–503.CrossRefGoogle Scholar
  53. 53.
    Kelley GA, Kelley KS. Progressive resistance exercise and resting blood pressure. Hypertension. 2000;35:838–43.CrossRefPubMedGoogle Scholar
  54. 54.
    McGrady A. The effects of biofeedback in diabetes and essential hypertension. Cleve Clin J Med. 2010;77:S68–71.CrossRefPubMedGoogle Scholar
  55. 55.
    Elliott WJ, Izzo JL, White WB, et al. Graded blood pressure reduction in hypertensive outpatients associated with use of a device to assist with slow breathing. J Clin Hypertens. 2004;6:553–9.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Medicine and Hypertension InstituteWolfson Medical CenterHolonIsrael
  2. 2.Brunner Institute for Cardiovascular ResearchSackler Faculty of Medicine, Tel-Aviv UniversityTel Aviv-YafoIsrael
  3. 3.Institute for Quality in MedicineIsraeli Medical AssociationRamat GanIsrael

Personalised recommendations