Prevention and Treatment
Subgroup Members: Simon L. Bacon, PhD; Janusz Kaczorowski, PhD; Luc Trudeau, MD; Swapnil Hiremath, MD MPH; Norman RC. Campbell, MD; Michael Roerecke, PhD; Joanne Arcand, PhD RD
Central Review Committee: Stella S. Daskalopoulou, MD MSc DIC PhD (Chair); Kaberi Dasgupta, MD MSc; Kelly B. Zarnke, MD MSc; Kara Nerenberg, MD, MSc; Alexander A. Leung, MD MPH; Kevin C. Harris, MD MHSc; Kerry McBrien, MD MPH; Sonia Butalia, BSc MD MSc; Meranda Nakhla, MD MSc
Co-Chairs: Doreen M. Rabi, MD MSc, Stella S. Daskalopoulou, MD MSc DIC PhD
This information is based on the Hypertension Canada guidelines published in Nerenberg, Kara A. et al. Hypertension Canada’s 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children. Can J Cardiol.
- Physical exercise
- For non-hypertensive individuals (to reduce the possibility of becoming hypertensive) or for hypertensive patients (to reduce their BP), prescribe the accumulation of 30-60 minutes of moderate intensity dynamic exercise (e.g., walking, jogging, cycling, or swimming) 4-7 days per week in addition to the routine activities of daily living (Grade D). Higher intensities of exercise are not more effective (Grade D). For non-hypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise (such as free weight lifting, fixed weight lifting, or handgrip exercise) does not adversely influence BP (Grade D).
- Weight reduction
- Height, weight, and waist circumference should be measured and body mass index calculated for all adults (Grade D).
- Maintenance of a healthy body weight (body mass index of 18.5 to 24.9 kg/m2, and waist circumference <102 cm for men and <88 cm for women) is recommended for non-hypertensive individuals to prevent hypertension (Grade C) and for hypertensive patients to reduce BP (Grade B). All overweight hypertensive individuals should be advised to lose weight (Grade B).
- Weight loss strategies should use a multidisciplinary approach that includes dietary education, increased physical activity, and behavioural intervention (Grade B).
- Alcohol consumption
- To prevent hypertension and reduce BP in adults, individuals should limit alcohol consumption to ≤2 drinks per day, and consumption should not exceed 14 standard drinks per week for men and 9 standard drinks per week for women (Grade B). (Note: One standard drink is considered to be equivalent of 13.6 g or 17.2 mL of ethanol or approximately 44 mL [1.5 oz] of 80 proof [40%] spirits, 355 mL [12 oz] of 5% beer, or 148 mL [5 oz] of 12% wine.)
- It is recommended that hypertensive patients and normotensive individuals at increased risk of developing hypertension consume a diet that emphasizes fruits, vegetables, low-fat dairy products, whole grain foods rich in dietary fibre, and protein from plant sources that is reduced in saturated fat and cholesterol (Dietary Approaches to Stop Hypertension [DASH] diet (34-37); Supplemental Table S9) (Grade B).
- Sodium intake
- To prevent hypertension and reduce BP in hypertensive adults, consider reducing sodium intake toward 2000 mg (5 g of salt or 87 mmol of sodium) per day (Grade A).
- Calcium and magnesium intake
- Supplementation of calcium and magnesium is not recommended for the prevention or treatment of hypertension (Grade B).
- Potassium intake
- In patients not at risk of hyperkalemia (see Table 2), increase dietary potassium intake to reduce BP (Grade A).
- Stress management
- In hypertensive patients in whom stress might be a contributor to high BP, stress management should be considered as an intervention (Grade D). Individualized cognitive-behavioural interventions are more likely to be effective when relaxation techniques are used (Grade B).
A. Physical Exercise
1. For non-hypertensive individuals (to reduce the possibility of becoming hypertensive) or for hypertensive patients (to reduce their BP), prescribe the accumulation of 30-60 minutes of moderate intensity dynamic exercise (e.g., walking, jogging, cycling, or swimming) 4-7 days per week in addition to the routine activities of daily living (Grade D). Higher intensities of exercise are not more effective (Grade D). For non-hypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise (such as free weight lifting, fixed weight lifting, or handgrip exercise) does not adversely influence BP (Grade D).
Because of an acute increase in blood pressure (BP), and potential use of the Valsalva manoeuvre during weight training, there are concerns this form of exercise could adversely raise BP levels, leading to an increased risk of hemorrhagic stroke or subarachnoid hemorrhage. In a meta-analysis of 28 randomized controlled trials examining the effect of resistance training on BP, 33 study groups were pooled (1012 participants in total) (1). Most of these trials examined dynamic resistance training (30 study groups), largely with the use of weight or resistance machines (27 study groups). Twenty-two of the trials involved supervised exercise. For individuals with a baseline BP of 139/89 mm Hg, reductions in systolic BP (SBP) (mean change -3.9 mm Hg; 95%confidence interval [CI], -6.4 to -1.2) and in diastolic BP (DBP) (mean change -3.9 mm Hg; 95%CI, -5.6 to -2.2) were observed. In subjects with hypertension, statistically non-significant reductions in mean SBP and DBP occurred (-1.7 mm Hg systolic; 95%CI, -5.5 to +2.0, and -1.1 mm Hg diastolic; 95%CI, -3.1 to +0.91). Maximum baseline systolic and diastolic values were 154 mm Hg and 95 mm Hg, respectively, with no serious adverse events reported.
Overall, this meta-analysis might have been underpowered to detect statistically significant reductions in BP in hypertensive patients. However, absence of adverse effects provides reassurance regarding safety of resistance training in hypertensive individuals. Considering resistance training is associated with additional benefits on cardio-metabolic risk factor levels, the CHEP Guideline recommend that this type of exercise need not be avoided for fear of affecting adversely BP levels.
Meta-analyses of randomized trials confirm moderate intensity dynamic exercise (such as walking, jogging, cycling or swimming) reduces resting BP (up to 7.4/5.8 mm Hg in hypertensives, and 2.6/1.8 mm Hg in non-hypertensives) (6,7,10,11). Clinically important improvements in both SBP and DBP may be achieved from as little as 30 minutes to 60 minutes per week of moderate intensity aerobic exercise, particularly in adults (2-7). Greater frequencies of exercise (i.e., four to seven days per week) may produce greater reductions in BP (8-10) and may aid in weight loss.
B. Weight reduction
1. Height, weight, and waist circumference should be measured and body mass index calculated for all adults (Grade D).
Extensive epidemiologic data support a positive association between obesity and elevated blood pressure. Although BMI does not directly measure body fat, it is the metric most often used as an index of adiposity because is simple to calculate, is based on readily available clinical data, and predicts the development of obesity-related complications and death. The incidence of hypertension and associated cardiovascular risk factors increases substantially within the overweight and obese BMI categories (42,50,54). Prospective cohort studies also show a association between weight gain and increases in blood pressure (55,56,57). In the Framingham Study, for each 4.5 kg of weight gain, there was an associated increase in SBP of 4 mm Hg in both men and women (59). Furthermore, BP is reduced by 1.6 mmHg/1.1 mmHg for each 1 kg of weight loss (59).
High amounts of abdominal fat predicts development of hypertension to an even greater extent (43). Within each BMI category including normal weight (18.5 kg/m² to 24.9 kg/m²), overweight (25.0 to 29.9 kg/m²) and class I obesity (30.0 to 34.9 kg/m²), a high WC (greater than 102 cm in men and greater than 88 cm in women) is associated with a higher risk of hypertension (44-50). The standard method of measuring WC is by positioning the measuring tape horizontally, midway between the iliac crest and the bottom of the rib cage, in a standing patient at end-expiration (53).
2. Maintenance of a healthy body weight (body mass index of 18.5 to 24.9 kg/m2, and waist circumference <102 cm for men and <88 cm for women) is recommended for non-hypertensive individuals to prevent hypertension (Grade C) and for hypertensive patients to reduce BP (Grade B). All overweight hypertensive individuals should be advised to lose weight (Grade B).
The phase I study of The Trials of Hypertension Prevention showed that weight reduction was more effective than other lifestyle strategies in preventing hypertension (61). Data from randomized controlled weight reduction trials (including this trial), show that in this population, weight reduction is associated with a reduction in blood pressure (BP), which indicates the potential utility of weight reduction in preventing hypertension (60-62). Several randomized controlled trials of weight loss demonstrate that a reduction in weight is associated with a reduction in blood pressure in overweight hypertensive patients (52,63-70). For overweight patients, efficacy of weight loss in reducing BP is similar to that of single antihypertensive drug therapy (66,67).
3. Weight loss strategies should use a multidisciplinary approach that includes dietary education, increased physical activity, and behavioural intervention (Grade B).
Multidisciplinary approaches to weight loss appear to be more effective in reducing BP and promoting weight loss (54,74,75).
C. Alcohol consumption
1. To prevent hypertension and reduce BP in adults, individuals should limit alcohol consumption to ≤2 drinks per day, and consumption should not exceed 14 standard drinks per week for men and 9 standard drinks per week for women (Grade B). (Note: One standard drink is considered to be equivalent of 13.6 g or 17.2 mL of ethanol or approximately 44 mL [1.5 oz] of 80 proof [40%] spirits, 355 mL [12 oz] of 5% beer, or 148 mL [5 oz] of 12% wine.)
Healthcare professionals should determine the alcohol consumption of all adult patients. One drink is considered 13.6 g or 17.2 mL of ethanol, or approximately 1.5 oz. of 80 proof (40%) spirits, 12 oz. of 5% beer or 5 oz. of 12% wine. Some randomized controlled trials have shown that that limiting alcohol consumption can blood pressure (SBP) (76-77); however, statistical significance in other trials (79–83), possibly because of low adherence to alcohol reduction interventions. Overall, the data do not provide strong evidence, but are consistent with the conclusion that heavy alcohol consumption leads to increased BP.
1. It is recommended that hypertensive patients and normotensive individuals at increased risk of developing hypertension consume a diet that emphasizes fruits, vegetables, low-fat dairy products, whole grain foods rich in dietary fibre, and protein from plant sources that is reduced in saturated fat and cholesterol (Dietary Approaches to Stop Hypertension [DASH] diet (34-37); Supplemental Table S9) (Grade B).
Among non-hypertensive individuals, the Dietary Approaches to Stop Hypertension (DASH) diet (Table I) reduced BP by 3.5/2.1 mm Hg (SBP/DBP) respectively, while in hypertensive patients, the DASH diet reduced BP by 11.4/5.5 mm Hg (112–117).
E. Sodium Intake
1. To prevent hypertension and reduce BP in hypertensive adults, consider reducing sodium intake toward 2000 mg (5 g of salt or 87 mmol of sodium) per day (Grade A).
This recommendation is primarily based on clinical trial evidence from two systematic reviews published in 2013 (128,129). The evidence focuses on BP as a surrogate endpoint. The RTF noted the inconclusive nature of data examining morbidity and mortality endpoints, and awaits results of further studies examining these endpoints (130).
He and colleagues (128) examined 22 crossover- and parallel-arm randomized controlled trials that enrolled 999 hypertensive individuals and compared reduced salt intake with usual salt intake over a period of 4–52 weeks. Studies documenting a 40–120 mmol reduction in 24-hour urine sodium (equivalent to 920–2760 mg of sodium or 2.3–7 g of salt) were included. The median baseline BP was 148/93 mm Hg and the median baseline 24-hour urine sodium excretion was 162 mmol (range, 125–191 mmol). The pooled estimated reduction in sodium intake between usual intake and reduced intake was 75 mmol per 24 hours (95% confidence interval [CI], 52–112). Therefore, from baseline levels in the usual care arm, interventions reduced sodium intake toward a threshold of 87 mmol (i.e., 162–75 mmol) or 2000 mg per day. Reduced intake led to a 5.39 mm Hg reduction (95%CI, 4.15–6.62) in SBP and a 2.82 mm Hg reduction (95%CI, 2.11–3.54) in DBP (pooled mean effects).
The systematic review by Aburto and colleagues (129) was conducted on behalf of the World Health Organization (WHO) Nutrition Guidance Expert Advisory Group Subgroup on Diet and Health. In 36 randomized controlled trials that enrolled 5508 participants overall and 1478 subjects with hypertension, a reduction in sodium intake resulted in a mean 3.39 mm Hg reduction (95%CI, 2.46–4.31 mm Hg) in SBP in all subjects, and a 4.06 mm Hg SBP reduction (95%CI, 2.96–5.15) in the subgroup with hypertension. A subgroup analysis indicated that a reduction in sodium intake to less than 2000 mg/d led to a decrease in SBP of 3.47 mm Hg (95%CI, 0.76–6.18). Concurrent use of antihypertensive medication did not appear to diminish the effect of decreasing sodium intake. (Additional references: 131–155)
F. Calcium and magnesium intake
1. Supplementation of calcium and magnesium is not recommended for the prevention or treatment of hypertension (Grade B).
The BP-lowering benefits of the DASH diet have been repeatedly demonstrated in hypertensive patients and normotensive individuals at risk of developing hypertension who are consuming a diet deficient in potassium, calcium and magnesium, and high in total and saturated fat (118,156). An adequate intake of potassium, calcium and magnesium is an important component of the DASH diet. It mitigates salt sensitivity and appears to have a wide range of benefits beyond lowering BP including reducing insulin resistance and improving lipid metabolism (156–158).
The weight of evidence from randomized controlled trials indicates that increasing intake of or supplementing diet with magnesium or calcium is not associated with prevention of hypertension, nor does it effectively reduce high BP. Therefore, the importance of ensuring adequate intake of calcium and magnesium cations by dietary means rather than by supplements should be emphasized in hypertensive patients.
G. Potassium intake
1. In patients not at risk of hyperkalemia (see Table 2), increase dietary potassium intake to reduce BP (Grade A).
A meta-analysis of 22 randomized controlled trials b reported that increased potassium intake reduced SBP by 3.49 mm Hg (95% CI, 1.82-5.15 mm Hg) and DBP by 1.96 mm Hg (95% CI, 0.86-3.06 mm Hg) (159). Notably, BP reduction was only seen in those with hypertension. There was no significant dose response according to the amount of potassium consumed. However, BP reduction appeared to be greatest in those who consumed the greatest amount of salt (reduction in SBP of 6.9 vs 2.0 mmHg in those with high [4 g/d] vs low [< 2 g/d] sodium intake). Although the magnitude of BP reduction is largest when the sodium intake is high, there still appears to be evidence of additive benefit when dietary interventions combine potassium increases with sodium reduction strategies (117).
The magnitude of expected BP reduction appears to be similar regardless of whether a potassium intervention is delivered through dietary changes or prescribed supplements (159). If possible, however, we recommend dietary modification as the preferred method of increasing potassium intake because of the additional nutritional benefits of whole foods over prescribed supplements. When appropriate, patients with hypertension should be encouraged to consume foods with higher potassium content (eg, fresh fruits, vegetables, and legumes). Overall, potassium interventions appear to be largely safe with no increase in reported adverse events (159). However, it should be acknowledged that the generalizability of existing studies is limited by stringent exclusion criteria (eg, excluding those with impaired urinary potassium excretion, renal failure or use of medications that predispose to hyperkalemia). As such, although the literature broadly supports increasing potassium intake to lower BP, caution should be exercised in those at higher risk of developing hyperkalemia including:
- Patients receiving renin-angiotensin-aldosterone inhibitors
- Patients receiving other drugs that can cause hyperkalemia (eg, trimethoprim and sulfamethoxazole, amiloride, or triamterene)
- Patients with chronic kidney disease (glomerular filtration rate < 60 mL/min/1.73 m2)
- Patients with baseline serum potassium > 4.5 mmol/L
H. Stress management
1. In hypertensive patients in whom stress might be a contributor to high BP, stress management should be considered as an intervention (Grade D). Individualized cognitive-behavioural interventions are more likely to be effective when relaxation techniques are used (Grade B).
Evidence emerging within the past several decades suggests that psychosocial factors from emotional states such as depression, behavioural dispositions such as hostility, and psychosocial stress can directly influence both physiological function and health outcomes (258,259). A systematic review (260) determined that stress related to depression, social isolation and lack of quality social support increased the risk of coronary artery disease similar to more conventional risk factors such as smoking, dyslipidemia and hypertension.
These findings suggest a link between psychosocial factors and atherosclerosis; however, the specific nature of the association is not known, and it still remains unclear exactly what the role of stress management on long-term outcomes related to hypertension morbidity may be (261–268). However, while there is no evidence that stress management prevents hypertension, there is some evidence that stress management can reduce blood pressure in hypertensive patients.
Although evidence indicated that single-component interventions such as transcendental meditation and relaxation therapy could be efficacious in some centres, meta-analyses showed only small effects or no reduction in blood pressure. In one meta-analysis (269) the change in BP with such interventions was –1.5 to +2.9/–0.8 to +1.2 mm Hg (SBP/DBP) respectively, whereas the change was –9/–6 mm Hg in a second meta-analysis (270). A third meta-analysis (271) showed a similar pattern, although differences between individualized cognitive stress management and other paired or single-component interventions were not as marked (Table 1) (269–271). There was some overlap (approximately two-thirds) in the studies that were included in the meta-analyses, as determined from an examination of the bibliographies of the original papers.
In contrast, multicomponent individualized cognitive behavioural interventions reduce BP to a greater degree and over a longer period of time. Linden and Chambers (270) performed a meta-analysis and found that BP was reduced by 9.7/7.2 mm Hg with multicomponent relaxation techniques. With individualized cognitive stress management, BP was reduced on average by 15.2/9.2 mm Hg. The key to this approach is tailoring the intervention to the patient’s needs.
Strategies used in individualized cognitive behavioural stress therapy include increasing awareness of stressors and stress responses, re-evaluating negative life events, communications skills training (e.g., marital communication and assertiveness training), development of problem- solving skills, management of negative emotions (e.g., anger and anxiety) and techniques for decreasing sympathetic arousal (e.g., relaxation exercises).
- Cornelissen VA, Fagard RH, Coeckelberghs E, Vanhees L. Impact of resistance training on blood pressure and other cardiovascular risk factors: A meta-analysis of randomized, controlled trials. Hypertension 2011;58:950-58.
- Rice T, An P, Gagnon J, et al. Heritability of HR and BP response to exercise training in the HERITAGE Family Study. Med Sci Sports Exerc 2002;34:972-9.
- Murphy M, Nevill A, Neville C, Biddle S, Hardman A. Accumulating brisk walking for fitness, cardiovascular risk and psychological health. Med Sci Sports Exerc 2002;34:1468-74.
- Nishikawa-Takata K, Ohta T, Tanaka H. How much exercise is required to reduce blood pressure in essential hypertensives: A dose-response study. Am J Hypertens 2003;16:629-33.
- Kelley GA, Kelley KS, Train ZV. The effects of exercise on resting blood pressure in children and adolescents: A meta-analysis of randomized controlled trials. Prev Cardiol 2003;6:8-16.
- Fagard RH. Exercise characteristics and the blood pressure response to dynamic physical training. Med Sci Sports Exerc 2001;33(6 Suppl):S484-92.
- Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: A meta-analysis of randomized, controlled trials. Ann Intern Med 2002;136:493-503.
- Jennings G, Nelson L, Nestel P, et al. The effects of changes in physical activity on major cardiovascular risk factors, hemodynamics, sympathetic function, and glucose utilization in man: A controlled study of four levels of activity. Circulation 1986;73:30-40.
- Nelson L, Jennings GL, Esler MD, Korner Pl. Effect of changing levels of physical activity on blood-pressure and haemodynamics in essential hypertension. Lancet 1986;2:473-6.
- Halbert JA, Silagy CA, Finucane P, Withers RT, Hamdorf PA, Andrews GR. The effectiveness of exercise training in lowering blood pressure: A meta-analysis of randomized controlled trials of 4 weeks or longer. J Hum Hypertens 1997;11:641-9.
- Pescatello LS, Kulikowich JM. The aftereffects of dynamic exercise on ambulatory blood pressure. Med Sci Sports Exerc 2001;33:I855-61.
- Kelley GA, Kelley KS. Progressive resistance exercise and resting blood pressure: A meta-analysis of randomized controlled trials. Hypertension 2000;35:838-43.
- Kesaniemi A, Danforth YE Jr, Jensen MD, Kopelman PG, Lefebvre P, Reeder BA. Consensus statement: Dose-response issues concerning physical activity and health: An evidence based symposium. Med Sci Sports Exerc 2001;33:5351-8.
- Thompson PD, Crouse S F, Goodpaster B, Kelley D, Moyna N, Pescatello L. The acute versus chronic response to exercise. Med Sci Sports Exerc 2001;33:S438-45.
- Kelley GA. Aerobic exercise and resting blood pressure among women: a meta-analysis. Prev Med 1999;28:264-75.
- Fagard RH, Tipton CM. Physical activity, fitness, and hypertension. In: Bouchard CB, Shephard R, Stephens T, editors. Physical activity, fitness and health: consensus statement. Champaign (IL): Human Kinetics Books; 1994. p. 633-55.
- Marceau M, Kouamé N, Lacourcière Y, Cléroux J. Effects of different training intensities on 24-hour blood pressure in hypertensive subjects. Circulation 1993;88:2803-11.
- Tashiro E, Miura S, Koga M, Sasaguri M, Ideishi M, Ikeda M, et al. Crossover comparison between the depressor effects of low and high work-rate exercise in mild hypertension. Clin Exp Pharmacol Physiol 1993;20:689-96.
- De Plaen JF, Detry JM. Hemodynamic effects of physical training in established hypertension. Acta Cardiol 1980;35:179-88.
- Kukkonen K, Raurammaa R, Voutilainen E, Länsimies E. Physical training of middle-age men with borderline hypertension. Ann Clin Res 1982;14(Suppl 34):139-45.
- Duncan JJ, Farr JE, Upton J, Hagan RD, Oglesby ME, Blair SN. The effects of aerobic exercise on plasma catecholamines and blood pressure in patients with mild essential hypertension. JAMA 1985;254:2609-13.
- Urata H, Tanabe Y, Kiyonaga A, Ikeda M, Tanaka H, Shindo M, et al. Antihypertensive and volume-depleting effects of mild exercise on essential hypertension. Hypertension 1987;9:245- 52.
- Kinoshita A, Urata H, Tanabe Y, Ikeda M, Tanaka H, Shindo M, et al. What types of hypertensives respond better to mild exercise therapy? J Hypertens 1988;6(Suppl 4):S631-3.
- Hagberg JM, Montain JS, Martin WI, Ehsani AA. Effect of exercise training in 60- to 69-year-old persons with essential hypertension. Am J Cardiol 1989;64:348-53.
- Martin JE, Dubbert PM, Cushman WC. Controlled trial of aerobic exercise in hypertension. Circulation 1990;81:1560-7.
- Cononie CC, Graves JE, Pollock ML, Philips MI, Sumners C, Hagberg JM. Effect of exercise training on blood pressure in 70- to 79-year-old men and women. Med Sci Sports Exerc 1991;23:505-11.
- Blumenthal J, Siegel W, Appelbaum M. Failure of exercise to reduce blood pressure in patients with mild hypertension: Results of a randomized controlled trial. JAMA 1991;266:2098-104.
- Rogers MW, Probst MM, Gruber JJ, Berger R, Boone JB. Differential effects of exercise training intensity on blood pressure and cardiovascular responses to stress in borderline hypertensive humans. J Hypertens 1996;14:1369-75.
- Bonnano JA, Lies JE. Effects of physical training on coronary risk factors. Am J Cardiol 1974;33:760-4.
- Akinpelu AO. Response of the African hypertensive to exercise training: Preliminary observations. J Hum Hypertens 1990;4:74-6.
- Baglivo HP, Fabregues G, Burrieza H, Esper RC, Talarico M, Esper RJ. Effect of moderate physical training on left ventricular mass in mild hypertensive persons. Hypertension 1990;15(Suppl I):I153-6.
- Seals DR, Reiling MJ. Effect of regular exercise on 24-hour arterial pressure in older hypertensive humans. Hypertension 1991;18:583-92.
- Koga M, Ideishi M, Matsusaki M, Tashiro E, Kinoshita A, Ikeda M, et al. Mild exercise decreases plasma endogenous digitalis-like substance in hypertensive individuals. Hypertension 1992;19(Suppl II):II231-6.
- Miura S, Tashiro E, Sakai T, Koga M, Kinoshita A, Sasaguri M, et al. Urinary kallikrein is increased during the first few weeks of exercise training in essential hypertension. J Hypertens 1994;12:815-23.
- Tanaka H, Bassett DR, Howley ET, Thompson DL, Ashraf M, Rawson FL. Swimming training lowers the resting blood pressure in individuals with hypertension.J Hypertens 1997;15:651-7.
- Filipovsky J, Simon J, Chrastek J, Rosolova H, Haman P, Petrikova V. Changes of blood pressure and lipid pattern during a physical training course in hypertensive subjects. Cardiology 1991;78:31-8.
- Somers VK, Conway J, Johnston J, Sleight P. Effects of endurance training on baroreflex sensitivity and blood pressure in borderline hypertension. Lancet 1991;337:1363-8.
- Roman O, Camuzzi AL, Villalon E, Klenner C. Physical training program in arterial hypertension: A long-term prospective follow-up. Cardiology 1981;67:230-43.
- Kiyonaga A, Arakawa K, Tanaka H, Shindo M. Blood pressure and hormonal responses to aerobic exercise. Hypertension 1985;7:125-31.
- Gilders RM, Voner C, Dudley GA. Endurance training and blood pressure in normotensive and hypertensive adults. Med Sci Sports Exerc 1989;21:629-36.
- Matsusaki M, Ikeda M, Tashiro E, Koga M, Miura S, Ideishi M, et al. Influence of workload on the antihypertensive effect of exercise. Clin Exp Pharmacol Physiol 1992;19:471-9.
- Manson JE, Willett WC, Stampfer MJ, Colditz GA, Hunter DJ, Hankinson SE, et al. Body weight and mortality among women. N Engl J Med 1995;333(11):677-85.
- Ledoux M, Lambert J, Reeder BA, Després JP, Canadian Heart Health Sur- veys Research Group. A comparative analysis of weight to height and waist to hip circumference indices as indicators of the presence of cardiovascular disease risk factors. CMAJ 1997;157(1 Suppl):S32- 8.
- Willett WC, Dien WH, Coldiu GA. Guidelines for healthy weight. N Engl J Med 1999;341:427-34.
- Gus M, Fuchs SC, Moreira LB, et al. Association between different measurements of obesity and the incidence of hypertension. Am J Hypertens 2004;17:50-3.
- Foucan L, Hanley]. Deloumeaux J, Suissa S. Body mass index (BMI) and waist circumference (WC) as screening tools for cardiovascular risk factors in Guadaloupean women. J Clin Epidemiol 2002;55:990-6.
- Dalton M, Cameron A), Zimmer PZ, et al; AusDiab Steering Committee. Waist circumference, waist-to-hip ratio and body mass index and their correlation with cardiovascular disease risk factors in Australian adults. J Intern Med 2003;254:555-63.
- Hayashi T, Boyko EJ, Leonetti DL, et al. Visceral adiposity and the prevalence of hypertension in Japanese Americans. Circulation 2003;108:1718-23.
- Sironi AM, Gasraldelli A, MariA, et al. Visceral fat in hypertension: Influence on insulin resistance and beta-cell function. Hypertension 2004;44:127-33. (Erratum in 2004;44:e8)
- Janssen I, Katzmarzyk PR, Ross R. Body mass index, waist circumference, and health risk: Evidence in support of current National Institutes of Health guidelines. Arch Intern Med 2002;162:2074-9.
- He J, Whelton PK, Appel LJ, Charleston J, Klag MJ. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension 2000;35:544-9.
- Lean MEJ, Han T S, Morrison C E. Waist circumference as a measure for indicating need for weight management. BMJ 1995;311:158-61.
- NHLBI Obesity Education Initiative. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The Evidence Report. Bethesda: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute; 1998. NIH publication no. 98-4083.
- Gledhill N, Jamnik V, eds; Canadian Society for Exercise Physiology and Health Canada. The Canadian Physical Activity, Fitness and Lifestyle Approach. Ottawa: Health Canada, 2003.
- Rabkin SW, Chen Y, Leiter L, Liu L, Reeder BA, Canadian Heart Health Surveys Research Group. Risk factor correlates of body mass index. CMAJ 1997;157(1 Suppl):S26-31.
- Huang Z, Willett WC, Manson JE, Rosner B, Stampfer MJ, Speizer FE, et al. Body weight, weight change and risk of hypertension in women. Ann Intern Med 1998;128:81-8.
- Stamler R, Stamler J, Riedlinger WF, Algera G, Roberts RH. Weight and blood pressure. JAMA 1978;240:1607-10.
- Higgins M, Kamel W, Garrison R, Pinsky J, Stokes J. Hazards of obesity — the Framingham experience. Acta Med Scand 1998;723(Suppl):23-36.
- Chiriac S, Dirna-Cozma C, Georgescu T, Turcanu D, Pandele Gl. The beneficial effect of physical training in hypertension. Rev Med Chir Soc Med Nat lasi 2002;107:258-63.
- The Trials of Hypertension Prevention Research Group. The Trials of Hypertension Prevention: three-year effects of dietary changes on blood pressure. Arch Intern Med 1990;150:153-62.
- Stevens VJ, Corrigan SA, Obanzanek E, Bernauer E, Cook NR, Hebert P, et al. Weight loss intervention in Phase I of The Trials of Hypertension Prevention. i 1993;153:849- 58.
- The Trials of Hypertension Prevention Collaborative Research Group. Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure. Arch Intern Med 1997;157:657-67.
- Ramsay LE, Ramsay MH, Hettiarachchi J, Davies DL, Winchester J. Weight reduction in a blood pressure clinic. BMAJ 1978;2:244-5.
- Reisin E, Abel R, Modan M, Silverberg DS, Eliahou HE, Modan B. Effect of weight loss without salt restriction on the reduction of blood pressure in over- weight hypertensive patients. N Engl J Med 1978;298:1-6.
- Haynes RB, Harper AC, Costley R, Johnston M, Logan AG, Flanagan PT, et al. Failure of weight reduction to reduce mildly elevated blood pressure: a randomized trial. J Hypertens 1984;2(5):535-9.
- MacMahon SW, Macdonald GJ, Bernstein L, Andrews G, Balcket RB. Comparison of weight reduction with metoprolol in treatment of hypertension in young overweight patients. Lancet 1985;1:1233-96.
- Oberman A, Wassertheil-Smoller S, Langford HG, Blaufox MD, Davis BR, Blaszkowski T, et al. Pharmacologic and nutritional treatment of mild hyper- tension: changes in cardiovascular risk status. Ann Intern Med 1990;112:89-95.
- Kolanowski J, Younnis LT, Vanbutsele R, Detry JM. Effect of dexfenfluramine treatment on body weight, blood pressure and noradrenergic activity in obese hypertensive patients. Eur J Clin Pharmacol 1992;42:599-605.
- Fagerberg B, Berglund A, Andersson OK, Berglund G. Weight reduction versus antihypertensive drug therapy in obese men with high blood pressure: effects upon plasma insulin. J Hypertens 1992;10:1053-61.
- Whelton PK, Appel LJ, Espelund MA. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of non-pharmacologic interventions in the elderly (TONE). JAMA 1998;279:839-46.
- Elmer P, Grimm R, Laing S, Grandits G, Svendsen K, Van Heal N, et al. Lifestyle intervention: results of the Treatment of Mild Hypertension Study (TOMHS). Prev Med 1995;24:378-88.
- Wassertheil-Smoller W, Blaufox MD, Oberman AS, Langford HG, Davis BR, Wylie-Rosett JW. The Trial of Antihypertensive Interventions and Management (TAIM) study. Arch Intern Med 1992;152:131-6.
- Gordon NF, Scott CB, Levine BD. Comparison of single versus multiple lifestyle interventions: are the antihypertensive effects of exercise training and diet-induced weight loss additive? Am J Cardiol 1997;79:763-7.
- Appel LJ, Champagne CM, Harsha DW, et al., for the Writing Group of the PREMIER Collaborative Research Group. Effects of comprehensive lifestyle modification on blood pressure control: Main results of the PREMIER clinical trial. JAMA 2003;289:2083-93.
- Miller ER III, Erlinger TP, Young DR, et al. Results of the Diet, Exercise, and Weight Loss Intervention Trial (DEW-IT). Hypertension 2002;40:612-8.
- Xin X, He J, Frontini MG. Effects of alcohol reduction on blood pressure: A meta-analysis of randomized controlled trials. Hypertension 2001;38:1112-7.
- Nakanishi N, Makino K, Nishina K, Suzuki K, Tatara K. Relationship of light to moderate alcohol consumption and risk of hypertension in Japanese male office workers. Alcohol Clin Exp Res 2002;26:988-94.
- Zilkens RR, Rich L, Burke V, Beilin LJ, Watts GF, Puddey lB. Effects of alcohol intake on endothelial function in men: A randomized controlled trial. J Hypertens 2003;21:97-103.
- Kristenson H, Ohlin H, Hulten-Nosslin M, Trell E, Hood B. Identification and intervention of heavy drinking in middle-aged men: results and follow-up of 24-60 months of long-term study with randomized controls. Alcohol Clin Exp Res 1983;7:203- 9.
- Kahan M, Wilson L, Becker L. Effectiveness of physician-based interventions with problem drinkers: a review. CMAJ 1995;152(6):851-9.
- Sanchez-Craig M. Random assignment to abstinence or controlled drinking in a cognitive– behavioral program: short-term effects on drinking behavior. Addict Behav 1980;5:35-9.
- Chick J, Lloyd G, Crombie E. Counselling problem drinkers in medical wards: a controlled study. BMJ 1985;290:965-7.
- Anderson P. Effectiveness of general practice interventions for patients with harmful alcohol consumption. Br J Gen Pract 1993;43:386-9.
- Cushman WC, Cutler JA, Hanna E, et al. The Prevention and Treatment of Hypertension Study (PATHS) primary results: effects of an alcohol treatment program on blood pressure [abstract]. Epidemiol Prev 1996:631.
- Tuomilehto J, Puska P, Nissinen A, Salonen J, Tanskanen A, Pietinen P, et al. Community- based prevention of hypertension in North Karelia, Finland. Ann Clin Res 1984;16(Suppl 43):18- 27.
- Potter JF, Beevers DG. Pressor effect of alcohol in hypertension. Lancet 1984;1:119-22.
- Bannan LT, Potter JF, Beevers DG, Saunders JB, Walters JR, Ingram MC. Effect of alcohol withdrawal on blood pressure, plasma renin activity, aldosterone, cortisol and dopamine beta hydroxylase. Clin Sci 1984;66:659-63.
- Dowse GK, Gareeboo H, Alberti KGM, Zimmet P, Tuomilehto J, Purran A, et al. Changes in population cholesterol concentrations and other cardiovascular risk factor levels after five years of the non-communicable disease intervention programme in Mauritius. BMJ 1995;311:1255-9.
- Friedman GD, Selby JV, Quesenberry CP Jr, Armstrong MA, Klatsky AL. Precursors of essential hypertension: body weight, alcohol and salt use, and parental history of hypertension. Prev Med 1988;17:387-402.
- D’Alonzo CA, Pell S. Cardiovascular disease among problem drinkers. J Occup Med 1968;10:344-50.
- Myrhed M. Alcohol consumption in relation to factors associated with ischemic heart disease. Acta Med Scand 1974;1:1-93.
- Carmelli D, Robinette D, Fabsitz R. Concordance, discordance and prevalence of hypertension in World War II male veteran twins. J Hypertens 1994;12:323-8.
- Fournier AM, Hoenig LJ, Sosenko JM. The degree of blood pressure evaluation and end organ damage with severe hypertension: a case-controlled study. Am J Med Sci 1993;306:367-70.
- Stamler R, Stamler J, Grimm R, Gosch FC, Elmer P, Dyer A, et al. Nutritional therapy for high blood pressure. Final report of a four-year randomized controlled trial — the Hypertension Control Program. JAMA 1987;257:1484-91.
- Stamler R, Stamler J, Gosch FC, Civinelli J, Fishman J, McKeever P, et al. Primary prevention of hypertension by nutritional-hygienic means. Final report of a randomized, controlled trial [published erratum appears in JAMA 1989;262(22):3132]. JAMA 1989;262:1801-7.
- Iso H, Shimamoto T, Yokota K, Sankai T, Jacobs DR Jr, Komachi Y. Community-based education classes for hypertension control. A 1.5-year randomized controlled trial. Hypertension 1996;27(4):968-74.
- Ohmori S, Kiyohara Y, Kato I, et al. Alcohol intake and future incidence of hypertension in a general Japanese population: The Hisayama study. Alcohol Clin Exp Res 2002;26:1010-6.
- Puddey IB, Beilin LJ, Vandongen R, Rouse IL, Rogers P. Evidence for a direct effect of alcohol consumption on blood pressure in normotensive men. A randomized controlled trial. Hypertension 1985;7:707-13.
- Puddey IB, Parker M, Beilin LJ, Vandongen R, Masarei JRL. Effects of alcohol and caloric restrictions on blood pressure and serum lipids in overweight men. Hypertension 1992;20:533-41.
- Cox KL, Puddey IB, Morton AR, Beilin LJ, Vandongen R, Masarei JR. The combined effects of aerobic exercise and alcohol restriction on blood pressure and serum lipids: a two-way factorial study in sedentary men. J Hypertens 1993;11:191- 201.
- Howes LG, Macgilchrist A, Hawksby C, Sumner D, Reid JL. Plasma [3H]-noradrenaline kinetics and blood pressure following regular, moderate ethanol consumption. Br J Clin Pharmacol 1986;22:521-6.
- Howes LG, Reid JL. Changes in blood pressure and autonomic reflexes following regular, moderate alcohol consumption. J Hypertens 1986;4:421-5.
- Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ 1988;297:663-8.
- Howes LG, Reid JL. Decreased vascular responsiveness to noradrenaline following regular ethanol consumption. Br J Clin Pharmacol 1985;20:669-74.
- Cushman WC, Cutler JA, Bingham SF, Harford T, Hanna E, Dubbert P, et al. Prevention and Treatment of Hypertension Study (PATHS). Rationale and design. Am J Hypertens 1994;7(9 pt 1):814-23.
- Parker M, Puddey IB, Beilin LJ, Vandongen R. Two-way factorial study of alcohol and salt restriction in treated hypertensive men. Hypertension 1990;16:398-406.
- Maheswaran R, Beevers M, Beevers DG. Effectiveness of advice to reduce alcohol consumption in hypertensive patients. Hypertension 1992;19:79-84.
- Puddey IB, Beilin LJ, Vandongen R. Regular alcohol use raises blood pressure in treated hypertensive subjects. A randomised controlled trial. Lancet 1987;1:647-51.
- Ueshima H, Mikawa K, Baba S, Sasaki S, Ozawa H, Tsushima M, et al. Effect of reduced alcohol consumption on blood pressure in untreated hypertensive men. Hypertension 1993;21:248-52.
- Ueshima H, Ogihara T, Baba S, Tabuchi Y, Mikawa K, Hashizume K, et al. The effect of reduced alcohol consumption on blood pressure: a randomised, controlled, single blind study. J Hum Hypertens 1987;1:113-9.
- Lang T, Nicaud V, Darne B, Rueff B. Improving hypertension control among excessive alcohol drinkers: a randomised controlled trial in France. J Epidemiol Community Health 1995;49:610-6.
- Sacks FM, Svetkey LP, Vollmer WM, et al., for the DASH-Sodium Collaborative Research Group. 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.
- Conlin PR, Chow D, Miller ER III, et al. The effect of dietary patterns on blood pressure control in hypertensive patients: Results from the Dietary Approaches to Stop Hypertension (DASH) trial. Am J Hypertens 2000;13:949-55.
- Akita S, Sacks FM, Svetkey LP, Conlin PR, Kimura G, for the DASH-Sodium Trial Collaborative Research Group. Effects of the Dietary Approaches to Stop Hypertension (DASH) diet on the pressure-natriuresis relationship. Hypertension 2003;42:8-13.
- Conlin PR, Erlinger TP, Bohannon A, et al. The DASH diet enhances the blood pressure response to losartan in hypertensive patients. Am J Hypertens 2003;16:337-42.
- John JH, Ziebland S, Yudkin P, Roe LS, Neil HA, for the Oxford Fruit and Vegetable Study Group. Effects of fruit and vegetable consumption on plasma antioxidant concentrations and blood pressure: A randomised controlled trial. Lancet 2002;359:1969-74.
- Lopes HF, Martin KL, Nashar K, Morrow JD, Goodfriend TL, Egan BM. DASH diet lowers blood pressure and lipid-induced oxidative stress in obesity. Hypertension 2003;41:422-30.
- Canada’s Food Guide to Healthy Eating. Ottawa: Health and Welfare Canada; 1992. Catalogue no.: H39-252/1992E.
- Canada’s Food Guide to Healthy Eating. Ottawa: Health Canada, 1991. 6-6-9940.
- Kelley GA, Sharpe KK. Aerobic exercise and resting blood pressure in older adults: a meta-analytic review of randomized controlled trials. J Gerontal A Bioi Sci Med Sci 2001;56:M298-303.
- Kawano Y, Abe H, Takishita S, Omae T. Effects of alcohol restriction on 24-hour ambulatory blood pressure in Japanese men with hypertension. Am J Med 1998;105:307-11.
- Hunyor SN, Henderson RJ, Lal SK, et al. Placebo-controlled biofeedback blood pressure effect in hypertensive humans. Hypertension 1997;29:1225-31.
- Henderson RJ, Hart MG, Lal SK, Hunyor SN. The effect of home training with direct blood pressure biofeedback of hypertensives: a placebo-controlled study. J Hypertens 1998;16:771-8.
- Griffith LE, Guyatt GH, Cook RJ, Bucher HC, Cook D. The influence of dietary and non-dietary calcium supplementation on blood pressure: an updated meta-analysis of randomized controlled trials. AmJ Hypertens 1999;12:84-92.
- Kawano Y, Minami J, Takishita S, Omae T. Effects of potassium supplementation on office, home, and 24-hr blood pressure in patients with essential hypertension. Am J Hypertens 1998;11:1141-6.
- Kawano Y, Matsuoka H, Takishira S, Omae T. Effects of magnesium supplementation in hypertensive patients: assessment by office, home, and ambulatory blood pressures. Hypertension 1998;32:260-5.
- Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997;336:1117-24.
- He FJ, Li J, Macgregor GA. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ 2013;346:f1325.
- Aburto NJ, Ziolkovska A, Hooper L, et al. Effect of lower sodium intake on health: systematic review and meta-analyses. BMJ 2013;346:f1326.
- Institute of Medicine of the National Academies. Sodium intake in populations: assessment of evidence. Available at: www.iom.edu/ sodiumconsequences. Accessed March 19, 2014.
- Institute of Medicine Panel on Dietary Reference Intakes for Electrolytes and Water. Dietary reference intakes for water, potassium, sodium, chloride, and sulfate. Panel on Dietary Reference Intakes for Electrolytes and Water, Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board. Washington: National Academies Press, 2009.
- Cook NR, Cutler JA, Obarzanek E, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: Observational follow-up of the Trials of Hypertension Prevention (TOHP). BMJ 2007;334:885.
- Joffres MR, Campbell NR, Manns B, Tu K. Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related health care costs in Canada. Can J Cardiol 2007;23:437-43.
- World Health Organization. Preventing chronic diseases: A vital investment. <www.who.int/chp/chronic_disease_report/contents/en/index.html> (Version current at April 26, 2007).
- Stamler R. Implications of the INTERSALT study. Hypertension 1991;17(1 Suppl):I16-20.
- MacMahon S, Peto R, Cutler J, et al. Blood pressure, stroke, and coronary heart disease. Part 1, Prolonged differences in blood pressure: Prospective observational studies corrected for the regression dilution bias. Lancet 1990;335:765-74.
- Appel LJ, Sacks FM, Carey VJ, et al; OmniHeart Collaborative Research Group. Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids. JAMA 2005;294:2455-64.
- He J, Gu D, Wu X, et al. Effect of soybean protein on blood pressure: A randomized, controlled trial. Ann Intern Med 2005:143:1-9.
- Rasmussen BM, Vessby B, Uusitupa M, et al; The KANWU Study Group. Effects of dietary saturated, monounsaturated, and n-3 fatty acids on blood pressure in healthy subjects. Am J Clin Nutr 2006;83:221-6.
- Miller ER Jr, Erlinger TP, Young DR, Prokopowicz GP, Appel LJ. Lifestyle changes that reduce blood pressure: Implementation in clinical practice. J Clin Hypertens (Greenwich) 1999;1:191-8.
- Appel LJ. Lifestyle modification as a means to prevent and treat high blood pressure. J Am Soc Nephrol 2003;14:S99-S102.
- Knowler WC, Barrett-Connor E, Fowler SE, et al; 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.
- Kemmler W, Lauber D, Weineck J, Hensen J, Kalender W, Engelke K. Benefits of 2 years of intense exercise on bone density, physical fitness, and blood lipids in early postmenopausal osteopenic women: Results of the Erlangen Fitness Osteoporosis Prevention Study (EFOPS). Arch Intern Med 2004;164:1084-91.
- Koertge J, Weidner G, Elliott-Eller M, et al. Improvement in medical risk factors and quality of life in women and men with coronary artery disease in the Multicenter Lifestyle Demonstration Project. Am J Cardiol 2003;91:1316-22.
- Appel LJ, Brands MW, Daniels SR, Karanja N, Elmer PJ, Sacks FM; American Heart Association. Dietary approaches to prevent and treat hypertension: A scientific statement from the American Heart Association. Hypertension 2006;47:296-308.
- US Department of Health and Human Services. Dietary Guidelines for Americans 2005. <www.health.gov/dietaryguidelines/dga2005/document/pdf/DGA2005.pdf> (Version current at April 26, 2007).
- Karppanen H, Karppanen P, Mervaala E. Why and how to implement sodium, potassium, calcium, and magnesium changes in food items and diets? J Hum Hypertens 2005;19(Suppl 3):S10-9.
- Chang HY, Hu YW, Yue CS, et al. Effect of potassium-enriched salt on cardiovascular mortality and medical expenses of elderly men. Am J Clin Nutr 2006;83:1289-96.
- He FJ, MacGregor GA. Effect of modest salt reduction on blood pressure: A meta-analysis of randomized trials. Implications for public health. J Hum Hypertens 2002;16:761-70.
- Hooper L, Bartlett C, Davey SM, Ebrahim S. Reduced dietary salt for prevention of cardiovascular disease. Cochrane Database Syst Rev 2003;2:CD003656.
- Jurgens G, Graudal NA. Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterols, and triglyceride. Cochrane Database Syst Rev 2003; 1:CD0040 22.
- Obarzanek E, Proschan MA, Vollmer WM, et al. Individual blood pressure responses to changes in salt intake. Hypertension 2003;42:459-67.
- Cappuccio FP, Markandu NO, Carney C, Sagnella GA, MacGregor GA. Double-blind randomized trial of modest salt restriction in older people. Lancet 1997;350:850-4.
- Midgley JP, Matthew AG, Greenwood CM, Logan AG. Effect of reduced dietary sodium on blood pressure: a meta-analysis of randomized controlled trials. JAMA 1996;275(20):1590-7.
- Alderman MH, Madhavan S, Cohen H, Sealey JE, Laragh JH. Low urinary sodium associated with greater risk of myocardial infarction among treated hypertensive men. Hypertension 1995;25:1144-52.
- Jee SH, Miller ER III, Guallar E, Singh VK, Appel LJ, Klag MJ. The effect of magnesium supplementation on blood pressure: A meta-analysis of randomized clinical trials. Am J Hypertens 2002;15:691-6.
- Geleijnse JM, Kok FJ, Grobbee DE. Blood pressure response to changes in sodium and potassium intake: A meta-regression analysis of randomised trials. J Hum Hypertens 2003;17:471-80.
- Naismith DJ, Braschi A. The effect of low-dose potassium supplementation on blood pressure in apparently healthy volunteers. Br J Nutr 2003;90:53-60.
- Aburto NJ, Hanson S, Gutierrez H, et al. Effect of increased potassium intake on cardiovascular risk factors and disease: systematic review and meta-analyses. BMJ 2013;346:f1378.
- Khaw KT, Barrett-Connor E. Dietary potassium and stroke-associated mortality. A 12-year prospective population study. N Engl J Med 1987;316:235-40.
- Walker WG, Whelton PK, Saito H, Russell RP, Hermann J. Relation between blood pressure and renin, renin substrate, angiotensin II, aldosterone and urinary sodium and potassium in 574 ambulatory subjects. Hypertension 1979;1:287-91.
- Watson RL, Langford HG, Abernethy J, Barnes TY, Watson MJ. Urinary electrolytes, body weight, and blood pressure. Pooled cross-sectional results among four groups of adolescent females. Hypertension 1980;2(Suppl I):I93-8.
- Grim CE, Luft FC, Miller JZ, Meneely GR, Battarbee HD, Hames CG, et al. Racial differences in blood pressure in Evans County, Georgia: relationship to sodium and potassium intake and plasma renin activity. J Chron Dis 1980;33:87-94.
- Lever AF, Beretta-Piccoli C, Brown JJ, Davies DL, Fraser R, Robertson JIS. Sodium and potassium in essential hypertension. BMJ 1981;283:463-8.
- Ophir O, Peer G, Gilad J, Blum M, Aviram A. Low blood pressure in vegetar- ians: the possible role of potassium. Am J Clin Nutr 1983;37:755-62.
- Khaw KT, Barrett-Connor E. Dietary potassium and blood pressure in a population. Am J Clin Nutr 1984;39:963-8.
- Dai WS, Kuller LH, Miller G. Arterial blood pressure and urinary electrolytes. J Chron Dis 1984;37:75-84.
- Kihara M, Fujikawa J, Ohtaka M, Mano M, Nara Y, Horie R, et al. Inter-relationships between blood pressure, sodium, potassium, serum cholesterol, and protein intake in Japanese. Hypertension 1984;6:736-42.
- Frisancho AR, Leonard WR, Bollettino LA. Blood pressure in blacks and whites and its relationship to dietary sodium and potassium intake. J Chron Dis 1984;37:515-9.
- Reed D, McGee D, Yano K, Hankin J. Diet, blood pressure, and multicollinearity. Hypertension 1985;7:405-10.
- Smith WCS, Crombie IK, Tavendale RT, Gulland SK, Tunstall-Pedoe HD. Urinary electrolyte excretion, alcohol consumption, and blood pressure in the Scottish Heart Health study. BMJ 1988;297:329-30.
- INTERSALT Cooperative Research Group. INTERSALT: an international study of electrolyte excretion and blood pressure. Results for 24-hour urinary sodium and potassium excretion. BMJ 1988;297:319-28.
- Khaw KT, Barrett-Connor E. The association between blood pressure, age, and dietary sodium and potassium: a population study. Circulation 1988;77:53-61.
- Witteman JCM, Willett WC, Stampfer MJ, Colditz GA, Sacks FM, Speizer FE, et al. A prospective study of nutritional factors and hypertension among US women. Circulation 1989;80:1320- 7.
- Ascherio A, Rimm EB, Giovannucci EL, Colditz GA, Rosner B, Willett WC, et al. A prospective study of nutritional factors and hypertension among US men. Circulation 1992;86:1475-84.
- Lai S, Yuanchang T, Weiling H, Peisheng M, Guanqing H. Urinary electrolyes and blood pressure in three Yi farmer populations, China. Hypertension 1989;13:22-30.
- Ascherio A, Hennekens C, Willett WC, Sacks F, Rosner B, Manson J, et al. Prospective study of nutritional factors, blood pressure, and hypertension among US women. Hypertension 1996;27:1065-72.
- Grimm RH, Neaton JD, Elmer PJ, Svendsen KH, Levin J, Segal M, et al. The influence of oral potassium on blood pressure in hypertensive men on a low-sodium diet. N Engl J Med 1990;322:569-74.
- Medical Research Council Working Party. Comparison of the antihypertensive efficacy and adverse reactions of two doses of bendrofluazide and hydrochlorothiazide and the effect of potassium supplementation on the hypotensive action of bendrofluazide: substudies of the Medical Research Council’s trial of treatment of mild hypertension. J Clin Pharmacol 1987;27:271-7.
- Langford HG, Davis BR, Blaufox D, Oberman A, Wassertheil-Smoller S, Hawkins M, et al. Effect of drug and diet treatment of mild hypertension on diastolic blood pressure. Hypertension 1991;17:210-7.
- Grimm RH, Kofron PM, Neaton JD, Svendson KH, Elmer PJ, Holland L, et al. Effect of potassium supplementation combined with dietary sodium reduction on blood pressure in men taking antihypertensive medication. J Hypertens 1988;6(Suppl 4):S591-3.
- Siani A, Strazzullo P, Giacco A, Pacioni D, Celentano E, Mancini M. Increasing the dietary potassium intake reduces the need for antihypertensive medications. Ann Intern Med 1991;115:753-9.
- Patki PS, Singh P, Gokhale SV, Bulakh PM, Shrotri DS, Patwardham B. Effect of potassium and magnesium in essential hypertension: a double blind, placebo-controlled crossover study. BMJ 1990;301:521-3.
- Obel AO. Placebo-controlled trial of potassium supplements in black patients with mild essential hypertension. J Cardiovasc Pharmacol 1989;14:294-6.
- Siani A, Strazzullo P, Russo L, Guglielmi S, Iacoviello L, Ferrara LA, et al. Controlled trial of long-term oral potassium supplements in patients with mild hypertension. BMJ 1987;294:1453-6.
- Svetky LP, Yarger WE, Feussner JR, DeLong E, Klotman PE. Double-blind, placebo-controlled trial of potassium chloride in the treatment of mild hypertension. Hypertension 1987;9:444-50.
- Matlou SM, Isles CG, Higgs A, Milne FJ, Murray GD, Schultz E, et al. Potassium supplementation in blacks with mild to moderate essential hypertension. J Hypertens 1986;4:61-4.
- Grobbee DE, Hofman A, Roelandt JT, Boomsma F, Schalekamp MA, Valkenburg HA. Sodium restriction and potassium supplementation in young people with mildly elevated blood pressure. J Hypertens 1987;5:115-9.
- Kaplan NM, Carnegie A, Raskin P, Heller JA, Simmons M. Potassium supplementation in hypertensive patients with diuretic-induced hypokalemia. N Engl J Med 1985;312:746-9.
- Richards AM, Nicholls MG, Espiner EA, Ikram H, Maslowski AH, Hamilton EJ, et al. Blood-pressure response to moderate sodium restriction and to potassium supplementation in mild essential hypertension. Lancet 1984;2:757-61.
- Smith SJ, Markandu ND, Sagnella GA, MacGregor GA. Moderate potassium chloride supplementation in essential hypertension: Is it additive to moderate sodium restriction? BMJ 1985;290:110-3.
- MacGregor GA, Smith SJ, Markandu ND, Banks RA, Sagnella GA. Moderate potassium supplementation in essential hypertension. Lancet 1982;2:567-70.
- Valdes G, Vio CP, Montera J, Avendano R. Potassium supplementation lowers blood pressure and increases urinary kallikrein in essential hypertensives. J Hum Hypertens 1991;5:91- 6.
- Fotherby MD, Potter JF. Potassium supplementation reduces clinic and ambulatory blood pressure in elderly hypertensive patients. J Hypertens 1992;10:1403-8.
- Khaw KT, Thom S. Randomized double-blind cross-over trial of potassium on blood pressure in normal subjects. Lancet 1982;2:1127-8.
- Zoccali C, Cumming AMM, Hutcheson MJ, Barnett P, Semple PF. Effects of potassium on sodium balance, renin, noradrenaline and arterial pressure. J Hypertens 1985;3:67-72.
- Overlack AO, Conrad H, Stumpe KO. The influence of oral potassium citrate/bicarbonate on blood pressure in essential hypertension during unrestricted salt intake. Klin Wochenschr 1991;69(Suppl 25):79-83.
- Smith SR, Klotman PE, Svetlkey LP. Potassium chloride lowers blood pressure and causes natriuresis in older patients with hypertension. J Am Soc Nephrol 1992;2:1302-9.
- Iimura O, Kijima T, Kikuchi K, Miyama A, Ando T, Nakao T, et al. Studies on the hypotensive effect of high potassium intake in patients with essential hypertension. Clin Sci 1981;61:77s-80s.
- Overlack A, Muller HM, Kolloch R, Ollig A, Moch B, Kleinmann R, et al. Long-term antihypertensive effect of oral potassium in essential hypertension. J Hypertens 1983;1(Suppl 2):S165- 7.
- Smith SJ, Markandu ND, Sagnella GA, Poston L, Hilton PJ, MacGregor GA. Does potassium lower blood pressure by increasing sodium excretion? A metabolic study in patients with mild to moderate essential hypertension. J Hypertens 1983;1(Suppl 2):S27-30.
- Chalmers J, Morgan T, Doyle A, Dickson B, Hopper J, Mathews J, et al. Australian National Health and Medical Research Council dietary salt study in mild hypertension. J Hypertens 1986;4(Suppl 6):S629-7.
- Sacks FM, Brown LE, Appel L, Borhani NO, Evans D, Whelton P. Combinations of potassium, calcium, and magnesium supplements in hypertension. Hypertension 1995;26(6 Pt 1):950-6.
- Geleijnse JM, Witteman JCM, Bak AAA, den Breeijen JN, Grobbee DE. Reduction in blood pressure with a low sodium, high potassium, high magnesium salt in older subjects with mild to moderate hypertension. BMJ 1994;309:436-40.
- Brancati FL, Appel LJ, Seidler AJ, Whelton PK. Effect of potassium supplementation on blood pressure in African Americans on a low-potassium diet. A randomized, double-blind, placebo-controlled trial. Arch Intern Med 1996;156:61-7.
- Cappuccio FP, MacGregor GA. Does potassium supplementation lower blood pressure? A meta-analysis of published trials. J Hypertens 1991;9:465-73.
- Whelton PK, He J, Cutler JA, Brancati FI, Appel LJ, Follmann D, et al. Effects of oral potassium on blood pressure. Meta-analysis of randomized controlled clinical trials. JAMA 1997;277:1624-32.
- Hypertension Prevention Trial Research Group. The Hypertension Prevention Trial: three-year effects of dietary changes on blood pressure. Arch Intern Med 1990;150:153-62.
- Trials of Hypertension Prevention Collaborative Research Group. The effects of non-pharmacologic interventions on blood pressure of persons with high normal levels. Results of the Trials of Hypertension Prevention, phase 1 [published erratum appears in JAMA 1992;267(17):2330]. JAMA 1992;267:1213-20.
- Barden AE, Vandongen R, Beilin LJ, Margets B, Rogers P. Potassium supplementation does not lower blood pressure in normotensive women. J Hypertens 1986;4:339-43.
- Mullen JT, O’Connor DT. Potassium effects on blood pressure: Is the conjugate anion important? J Hum Hypertens 1990;4:589-96.
- Weissberg PL, West MJ, Kendall MJ, Ingram M, Woods KL. Effect of changes in dietary sodium and potassium on blood pressure and cellular electrolyte handling in young normotensive subjects. J Hypertens 1985;3:475-80.
- Miller JZ, Weinberger MH, Christian JC. Blood pressure response to potassium supplementation in normotensive adults and children. Hypertension 1987;10:437-42.
- Parfrey PS, Vandenburg MJ, Wright P. Blood pressure and hormonal changes following alteration in dietary sodium and potassium in mild essential hypertension. Lancet 1981;1:113-7.
- Skrabal F, Aubock J, Hortnagi H. Low sodium/high potassium diet for prevention of hypertension: probable mechanism of action. Lancet 1981;2:895-900.
- Kesteloot H, Joossens JV. Relationship of dietary sodium, potassium, calcium, and magnesium with blood pressure. Belgian interuniversity research on nutrition and health. Hypertension 1988;12:594-9.
- Joffres MR, Reed DM, Yano K. Relationship of magnesium intake and other dietary factors to blood pressure: the Honolulu Heart Study. Am J Clin Nutr 1987;45:469-75.
- Witteman JCM, Grobbee DE, Derkx FHM, Bouillon R, de Bruijn AM, Hofman A. Reduction of blood pressure with oral magnesium supplementation in women with mild to moderate hypertension. Am J Clin Nutr 1994;60:129-35.
- Cappuccio FP, Markandu ND, Beynon GW, Shore AC, Sampson B, MacGregor GA. Lack of effect of oral magnesium on high blood pressure: a double blind study. BMJ 1985;291:235-8.
- Henderson DG, Schierup J, Schodt T. Effect of magnesium supplementation on blood pressure and electrolyte concentration in hypertensive patients receiving long term diuretic treatment. BMJ 1986;293:664-5.
- Nowson CA, Morgan TO. Magnesium supplementation in mild hypertensive patients on a moderately low sodium diet. Clin Exp Pharmacol Physiol 1989;16:299-302.
- Zemel PC, Zemel MB, Urberg M, Douglas FL, Geiser R, Sowers JR. Metabolic and hemodynamic effects of magnesium supplementation in patients with essential hypertension. Am J Clin Nutr 1990;51:665-9.
- Lind L, Lithell H, Pollare T, Ljunghall S. Blood pressure response during long-term treatment with magnesium is dependent on magnesium status. Am J Med 1991;4:674-9.
- Ferrara LA, Iannuzzi R, Castaldo A, Iannuzzi A, Dello Russo A, Mancini M. Long-term magnesium supplementation in essential hypertension. Gen Cardiol 1992;81:25-33.
- Widman L, Wester PO, Stegmayr BK, Wirell M. The dose-dependent reduction in blood pressure through administration of magnesium — a double blind placebo controlled cross-over study. Am J Hypertens 1993;6:41-5.
- Wirell NP, Wester PO, Stegmayr BG. Nutritional dose of magnesium in hypertensive patients on beta-blockers lowers systolic blood pressure: a double-blind cross-over study. J Intern Med 1994;236:189-95.
- Reyes AJ, Leary WP, Acosta-Barrios TN, Davis WH. Magnesium supplementation in hypertension treated with hydrochlorthiazide. Curr Ther Res 1984;36:332-40.
- Motoyama T, Sano H, Suzuki H, Kawavuchi K, Saito K, Furuta Y, et al. Oral magnesium treatment and the erythrocyte sodium pump in patients with essential hypertension. J Hypertens 1986;4(Suppl 6):S682-4.
- Dyckner T, Wester PO. Effect of magnesium on blood pressure. BMJ 1983;286:1847-49.
- McCarron DA, Morris CD, Henry HJ, Stanton JL. Blood pressure and nutrient intake in the United States. Science 1984;224:1392-8.
- Gruchow HW, Sobocinski KA, Barboriak JJ. Calcium intake and the relationship of dietary sodium and potassium to blood pressure. Am J Clin Nutr 1988;48:1463-70.
- Sempos C, Cooper R, Kovar MG, Johnson C, Drizd T, Yetley E. Dietary cal-cium and blood pressure in National Health and Nutrition Examination Surveys I and II. Hypertension 1986;8:1067-74.
- Elliott P, Fehily AM, Sweetnam PM, Yarnell JWG. Diet, alcohol, body mass, and social factors in relation to blood pressure: the Caerphilly Heart Study. J Epidemiol Community Health 1987;41:37-43.
- Fodor JG, Rusted IE. Electrolyte profiles in a Newfoundland population: the Newfoundland study. Clin Invest Med 1987;10:586-91.
- Criqui MH, Langer RD, Reed DM. Dietary alcohol, calcium, and potassium — independent and combined effects on blood pressure. Circulation 1989;80:609-14.
- Ford ES, Cooper RS. Risk factors for hypertension in a national cohort study. Hypertension 1991;18:598-606.
- Simon JA, Browner WS, Tao JL, Hulley SB. Calcium intake and blood pressure in elderly women. Am J Epidemiol 1992;136:1241-7.
- Trevisan M, Krogh V, Farinaro E, Panico S, Mancini M. Calcium-rich foods and blood pressure: findings from the Italian National Research Council Study (the Nine Communities Study). Am J Epidemiol 1988;127:1155-63.
- Hamet P, Daignault-Gelinas M, Lambert J, Ledoux M, Whissel-Cambiotti L, Bellavance F, et al. Epidemiological evidence of an interaction between calcium and sodium intake impacting on blood pressure — a Montreal study. Am J Hypertens 1992;5:378-85.
- van Beresteijn ECH, Riedstra M, van der Wel A, Schouten EG, Burema J, Kok FJ. Habitual dietary calcium intake and blood pressure change around the menopause: a longitudinal study. Int J Epidemiol 1992;21:683-9.
- McCarron DA, Morris CA. Blood pressure response to oral calcium in persons with mild to moderate hypertension. Ann Intern Med 1985;103:825-31.
- Grobbee D, Hofman A. Effect of calcium supplementation on diastolic blood pressure in young people with mild hypertension. Lancet 1986;2:703-6.
- Nowson C, Morgan T. Effect of calcium carbonate on blood pressure in normotensive and hypertensive people. Hypertension 1989;13:630-9.
- Zoccali C, Mallamaci F, Delfino D, Ciccarelli M, Parlongo S, Iellamo D, et al. Double-blind randomized, crossover trial of calcium supplementation in essential hypertension. J Hypertens 1988;6:451-5.
- Cappuccio FP, Markandu ND, Singer DRJ, Smith SJ, Shore AC, MacGregor GA. Does oral calcium supplementation lower high blood pressure? A double blind study. J Hypertens 1987;5:67-71.
- Siani A, Strazzullo P, Guglielmi S, Mancini M. Clinical studies of the effects of different oral calcium intakes in essential hypertension. J Hypertens 1987;5(Suppl 5):S311-3.
- Weinberger MH, Wagner UL, Fineberg NS. The blood pressure effects of calcium supplementation in humans of known sodium responsiveness. Am J Hypertens 1993;6:799-805.
- Meese RB, Gonzales DG, Casparian JM, Ram CVS, Pak CM, Kaplan NM. The inconsistent effects of calcium supplements upon blood pressure in primary hypertension. Am J Med Sci 1987;294:219-24.
- Siani A, Srazzullo P, Guglielmi S, Pacioni D, Giacco A, Iacone R, et al. Controlled trial of low calcium versus high calcium intake in mild hypertension. J Hypertens 1988;6:253-6.
- Tanji JL, Lew EY, Wong GY, Treguboff C, Ward JA, Amsterdam EA. Dietary calcium supplementation as a treatment for mild hypertension. J Am Board Fam Pract 1991;4:145-50.
- Morris CA, McCarron DA. Effect of calcium supplementation in an older population with mildly increased blood pressure. Am J Hypertens 1992;5:230-37.
- Levey WA, Manore MM, Vaughan LA, Carroll SS, VanHalderen L, Felicetta J. Blood pressure responses of white men with hypertension to two low-sodium metabolic diets with different levels of dietary calcium. J Am Diet Assoc 1995;95:1280-7.
- Strazzullo P, Siani A, Guglielmi S, DiCarlo A, Galletti F, Cirillo M, et al. Controlled trial of long-term oral calcium supplementation in essential hypertension. Hypertension 1986;8:1084-8.
- Kynast-Gales SA, Massey LK. Effects of dietary calcium from dairy products on ambulatory blood pressure in hypertensive men. J Am Diet Assoc 1992;92:1497-501.
- Luft FC, Aranoff GR, Sloan RS, Fineberg NS, Weinberger MH. Short-term augmented calcium intake has no effect on sodium homeostasis. Clin Pharmacol Ther 1986;39:414-9.
- Bucher HC, Cook RJ, Guyatt GH, Lang JD, Cook DJ, Hatala R, et al. Effects of dietary calcium supplementation on blood pressure — a meta-analysis of randomized trials. JAMA 1996;275:1016-22.
- Allender PS, Cutler JA, Follmann D, Cappuccio FP, Pryer J, Elliot P. Dietary calcium and blood pressure: a meta-analysis of randomized clinical trials. Ann Intern Med 1996;124:825-31.
- McCarron DA. Role of adequate dietary calcium intake in the prevention and management of salt-sensitive hypertension. Am J Clin Nutr 1997;65(Suppl 1):712S-716S.
- Rozanski A, Blumenthal JA , Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 1999;99:2192-217.
- Knox SS, HausdorfJ, Markovitz JH, for the Cardia Study. Reactivity as a predictor of subsequent blood pressure: Racial differences in the Coronary Artery Risk Development in Young Adults Study. Hypertension 2002;40:914-9.
- Bunker J, Colquhoun DM, Esler MD, et al. Stress and coronary heart disease: Psychosocial risk factors. Med J Aust 2003;178:272-6.
- Campbell TS, Ditto B. Exaggeration of blood pressure-related hypoalgesia and reduction of blood pressure with low frequency transcutaneous electrical nerve stimulation. Psychophysiology 2002;39:473-81.
- Marshall T, Anancharachagan A, Choudhary K, Chue C, Kaur I. A randomised controlled trial of the effect of anticipation of a blood test on blood pressure. J Hum Hypertens 2002;16:621-5.
- Nakao M, Yano E, Nomura S, Kuboki T. Blood pressure-lowering effects of biofeedback treatment in hypertension: A meta-analysis of randomized controlled trials. Hypertens Res 2003;26:37-46.
- Overhaus S, Ruddel H, Curio I, Mussgay L, Scholz OB. Biofeedback of baroreflex sensitivity in patients with mild essential hypertension. Int J Behav Med 2003;10:66-78.
- Rau H, Buhrer M, Weitkunat R. Biofeedback of R-wave-to-pulse interval normalizes blood pressure. Appl Psychophysiol Biofeedback 2003;28:37-46.
- Sheu S, Irvin BL, Lin HS, Mar CL. Effects of progressive muscle relaxation on blood pressure and psychosocial status for clients with essential hypertension in Taiwan. Holist Nurs Pract 2003;17:41-7.
- Viskoper R, Shapira I, Priluck R, et al. Non-pharmacologic treatment of resistant hypertensives by device-guided slow breathing exercises. Am J Hypertens 2003;16:484-7.
- Steptoe A, Feldman PJ, Kurn S, Owen M, Willemsen G, Marmot M. Stress responsivity and socioeconomic strata: A mechanism for increased cardiovascular disease risk? Eur Heart J 2002;23:1757-63.
- Eisenberg DM, Delbanco TL, Berkey CS, Kaptchuk TJ, Kupelnick B, Kuhl J, et al. Cognitive behavioral techniques for hypertension: Are they effective? Ann Intern Med 1993;118:964-72.
- Linden W, Chambers L. Clinical effectiveness of non-drug treatment for hypertension: a meta-analysis. Ann Behav Med 1994;16:35-45.
- Jacob RG, Chesney MA, Williams DM, Ding Y, Shapiro AP. Relaxation therapy for hypertension: design effects and treatment effects. Ann Behav Med 1991;13:5-17.
- Andersson L. Intervention against loneliness in a group of elderly women: an impact evaluation. Soc Sci Med 1985;20:355-64.
- Alexander CN, Chandler HM, Langer EJ, Newman RI, Davies JL. Transcendental meditation, mindfulness and longevity: an experimental study with the elderly. J Pers Soc Psychol 1989;37:930-64.
- Bennet P, Wallace L, Carroll D, Smith N. Treating type A behaviours and mild hypertension in middle-aged men. J Psychosom Res 1991;35:209-23.
- Schneider RH, Staggers F, Alexander C, Sheppard W, Rainforth M, Kodwani K, et al. A randomized controlled trial of stress reduction for hypertension in older African Americans. Hypertension 1995;26:820-7.
- Goebel M, Viol GW, Orebaugh C. An incremental model to isolate specific effects of behavioral treatments in essential hypertension. Biofeedback Self Regul 1993;18:255-80.
- Albright GL, Andreassi JL, Brockwell AL. Effects of stress management on blood pressure and other cardiovascular variables. Int J Psychophysiol 1991;11:213-7.
- Shapiro D, Hui KK, Oakley ME, Pasic J, Jamner LD. Reduction in drug requirements by means of a cognitive-behavioral intervention. Am J Hypertens 1997;10:9-17.
- Linden W, Con A, Lenz JW. Individualized stress management for hypertension [abstract]. Psychosom Med 1997;59:80.