wileyonlinelibrary.com/journal/jch J Clin Hypertens. 2018;20:528–531.
©2018 Wiley Periodicals, Inc.
Towards better blood pressure: Do non- pharmacological
strategies provide the right path?
Swapnil Hiremath MD, MPH
Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
Swapnil Hiremath, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada.
A scene like this plays out many times every day: A patient with newly
diagnosed hypertension, confirmed with out- of- office readings, is seen
in the clinic. What happens next depends on the patient, the doctor, and
other less understood dynamics of that interaction. In most settings, the
patient walks out with a plan to change their lifestyle, a prescription for
a pill, or sometimes both. On one hand, most individuals demonstrate
significant pill disutility, defined as the longevity gain desired by an in-
dividual to offset the inconvenience of taking a preventative tablet for
This can vary considerably, ranging from >1 month for about two-
thirds of patients, to 12% demonstrating extreme pill disutility (border-
ing on pill hatred),
actually desiring ≥10 year increased life expectancy
before taking any new medication.
On the other hand, undoubtedly,
giving a prescription for a medication is a much faster and easier option
for the physician. Data from a large health maintenance organization,
which has achieved an enviable 85% hypertension control, demon-
strate that the path to lower blood pressure does go through optimal
Additionally, a successful non- pharmacological
strategy should take into account the patient motivation for lifestyle
changes and the pieces needed for actual execution, not just counsel-
ling for eating less salt. The paper by Liu et al tackle the latter aspect,
using data from the National Health and Nutrition Examination Survey
(NHANES) 1999- 2004 survey of the 4000 hypertensive patients who
reported that a recommendation from their doctor for any 1 (or more) of
4 non- pharmacologic strategies (less sodium, less alcohol, more physical
activity, or weight loss).
As expected, reducing sodium intake was the
most common (68%) and alcohol reduction the most uncommon (26%)
recommendation. The self- reported adoption rates of these strategies
were very high (ranging from 59% to 87%), but despite this, almost half
the patients (47%) still had uncontrolled hypertension.
1 | NON-PHARMACOLOGICALSTRATEGIES
Blood pressure decreases quite nicely with changes in diet (de-
creased sodium and alcohol and increased potassium and fruits and
vegetables), increased exercise, and successful weight loss. Indeed,
data from interventional trials report ~4- 7 mm Hg decrease with
these lifestyle modifications. Unsurprisingly, the World Health
Organization, Hypertension Canada, and the recently revised 2017
American Heart Association/American College of Cardiology (AHA/
ACC) guidelines, all recommend most of these measures (Table).
The second part, however, is more important: what change have
these guidelines had in terms of physician and patient behavior?
Unfortunately, the evidence suggests that along with the increasing
prevalence of hypertension and obesity globally, there has not been
much of a decrease in sodium intake, nor an appreciable increase in
physical activity. The global burden of disease study shows an in-
creasing prevalence of hypertension (defined as systolic blood pres-
sure >140) from 17 307 to 20 526 per 100 000 in the last 25 years.
Obesity has doubled in 70 of 195 countries and continuously in-
creased in most others.
The global mean sodium intake is also well
over the 2000 mg recommended level, at 3.95 g/d, with the range
being 2.18- 5.51 g/d.
Thus, not a single country studied averages
a sodium intake in the desired level. This reflects the knowledge to
implementation gap that still exists despite these well- intentioned
Some of this surely stems from the paucity of effective-
ness that would help us more than the current crop of efficacy trials.
2 | EFFICACYVSEFFECTIVENESS
Efficacy trials determine whether an intervention produces the
expected result under ideal circumstances. Effectiveness trials
measure the degree of beneficial effect under real world clinical set-
For these lifestyle modifications in hypertension, efficacy
has been well established, but effectiveness less so. For diet, as an
example, decreasing sodium intake is a robust and well- accepted
lifestyle modification. However, most, if not all, trials of reduction in
sodium intake were feeding trials, which did establish efficacy, but
used interventions such as extended inpatient counselling sessions,
cooking lessons, and/or provision of meals (eg, Dietary Approaches