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Stanford University School of Medicine

Too high: For high blood pressure, lifestyle changes are the most effective and safest drug

In the fourth post in a series on high blood pressure, Randall Stafford, MD, PhD, lays out lifestyle changes that can improve health.

Lifestyle changes are vital to prevent and treat hypertension, but patients and physicians frequently neglect them. If health behaviors are modified in a gradual and sustainable way, these personal changes in diet or exercise rarely cause side effects, make medications work more effectively, increase one’s sense of well-being, and have many health and mental health benefits beyond reducing high blood pressure.

Let’s check in on Margaret.

As a 53-year-old with hypertension, Margaret wishes she could find a way to stop her two high blood pressure drugs, rather than start a third one. 

But since her last doctor’s visit, her weight is up by 3 pounds to 218. Her blood pressure was 142/92 when last checked. She gets about six hours of sleep each night. Her ankle swelling interferes with her evening walks with her husband. She knows that many lifestyle factors contribute to her high blood pressure, but feels overwhelmed and doesn’t know where to start.

Changing behavior is a personal process, but several general principles can help Margaret and others:

  • Recognize that changes are complicated and will take time.
  • Have a plan for maintaining changes long term.
  • Track your progress towards goals that are under your control.
  • Get started with changes in one area at a time.
  • Beware of unreliable information and myths about lifestyle changes.

As for specific areas to focus on:

To keep blood pressure under control long term, lower salt, lower saturated fats, reduce sweets and sugar-containing beverages, increase fiber, vegetables and fruit, and, in general, reduce calories.

There's a myth that no one agrees on what’s a healthy diet. In reality, there is remarkable consensus about key goals. The best advice is to:

  1. Find several fibrous vegetables (such as broccoli or carrots) you really like and eat more of them.
  2. Eat slowly — without looking at a device — and using small portion sizes.
  3. Consume primarily foods that come from plants; limit consumption of animal-based foods.
  4. Limit alcohol use to no more than one drink per day for women, two for men.

Physical activity:
A reasonable long-term target is to include 30 to 60 minutes of at least moderate physical activity, such as brisk walking, each day (this is about 4,000 to 8,000 steps).

A common myth is that exercise is beneficial only if it’s exhausting. But in reality, any movement is good and low-level daily activity is beneficial. The best advice is to:

  1. Do something fun that involves movement.
  2. Combine physical activity with other activities (meetings, errands, socializing).
  3. Realize that multiple, short episodes of physical activity are beneficial.

Weight loss:
Long-term goals include preventing further weight gain and reducing body weight by 5 percent through both dietary changes and increased physical activity.

Some people incorrectly believe that to be healthy, they must return to their weight in their teens or 20s. But in reality, modest weight loss can significantly reverse weight-related metabolic problems, including high blood pressure. The best advice is to:

  1. Weigh yourself only once a week.
  2. Learn to live with a small amount of hunger during the day.
  3. Realize that setbacks are common and focus on long-term progress.

Overall, aim to get at least seven hours of high quality sleep per night.

It's a myth that you can make up for sleep deprivation by sleeping in on the weekends. In reality, any reduction in sleep can have unfavorable health effects. The best advice is to:

  1. Adopt a regular schedule for sleep with no more than an extra hour on weekend days.
  2. Reduce distractions before sleep — put away your phone and turn off the television.
  3. Reduce distractions while sleeping: minimize light and noise.
  4. If you struggle to calm your mind or experience anxiety, explore developing a mindfulness-based sleep practice.

As a long-term goal, incorporate at least 30 minutes of relaxation and contemplation into your day.

Stress is a natural reaction, but we are not powerless -- we can develop skills to cope with outside pressures and it is possible to react with resilience. The best advice is to develop a plan for incorporating this mental break. A variety of practices are beneficial, some choices include yoga, journaling, taking a relaxing walk outdoors or developing a mindfulness-based stress reduction practice.

The bottom-line is to take time to consider whether you’re on target with each of these five lifestyle goals. If not, reach out to your physician or other trusted resource to help develop a plan to take these important steps to improve your health.

This is the fourth piece in a five-part series, “Too High,” created for those with high blood pressure and their family and friends. The final article will discuss appropriate blood pressure targets. Previous pieces addressed the prevalence of high blood pressure, the most common medications and drug side effects. Some data in this series come from QuintilesIMS. For additional information, please contact

Randall Stafford, MD, PhD, a professor of medicine and director of the Program on Prevention Outcomes and Practices, practices primary care internal medicine at Stanford. He is developing practical strategies to improve how physicians and consumers approach chronic disease treatment and prevention.

Previously: Too high: Despite drugs, blood pressure rates continue to soar in the United States, Too high: Older drugs work well for hypertension, new medications show little innovation and Too high: Side effects hamper many blood pressure medications
Photo by jchoate7

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