Running head: DECREASING BLOOD PRESSURE BY DIET AND EXERCISE

Decreasing High Blood Pressure in Adults by Diet and Exercise

Shawn Hekkanen
University of South Florida

DECREASING BLOOD PRESSURE BY DIET AND EXERCISE

Abstract
Clinical Problem: Patients with high blood pressure have increased risk for first episode, repeat
episodes, or exacerbations of heart attack, heart attack, stroke, and kidney failure.
Objective: To ascertain whether single approaches of diet and exercise or dual approaches of diet
and exercise are effective in sustainably reducing blood pressure. CINAHL, PubMed, and the
National Guideline Clearinghouse were used to gather both studies and guidelines of various
blood pressure reduction techniques. Keywords used for searching include blood pressure,
hypertension, DASH, diet, and exercise.
Results: The clinical guidelines currently recommend diets high in potassium, fiber, and
unsaturated fats are effective for lowering blood pressure (Emergency Care Research Institute
[ECRI], 2013). Exercise guidelines propose at least three times weekly sessions for periods of
30-45 minutes (ECRI, 2013). The literature supported a reduction in blood pressure by either
light to moderate exercise or dietary changes based upon scientifically investigated blood
pressure alleviating dietary components. However, multiple interventions performed
simultaneously has ambivalent results in practical application and needs further research, as does
the most efficient dietary advice that will also be safest for long term health benefits.
Conclusion: Blood pressure was significantly lowered for participants with elevated blood
pressures performing single intervention of diet or exercise, as well as performing both
interventions simultaneously. There is debate whether dual interventions are helpful in all
situations. Further research needs to be performed to pair specific blood pressure complications
to family history. Further research can develop the most efficient dieting and exercise approaches
that are also safe.

DECREASING BLOOD PRESSURE BY DIET AND EXERCISE

Decreasing High Blood Pressure in Adults by Diet and Exercise

Diet and exercise are separately associated with lowering above normal systolic blood
pressure (SBP), which reduces the risk of complications from high blood pressure, such as heart
attack, heart failure, stroke, eye problems, and kidney failure (Agency for Healthcare Research
and Quality, 2014). High blood pressure silently accumulates arterial vessel damage to change
durable elastic walls into rigid, thickened vessels that fail to adequately perfuse the body
(Osborn, Wraa, Watson, & Holleran, 2014). However, clinical symptoms of high blood pressure,
such as chest pain, shortness of breath, and cognition changes, may be delayed for many years
(Osborn et al., 2014). Various laboratory-controlled interventions have been used to improve
persistently high blood pressure, with earlier intervention producing more effective outcomes.
General exercise sessions of 30-45 minutes three times weekly reduce chronic blood pressure
(Osborn et al., 2014). Principles of Dietary Approaches to Stop Hypertension (DASH) dieting
consist of eating low-fat or non-fat dairy products, fruits, and vegetables, which are high in
dietary fiber, potassium, magnesium, and calcium (Osborn et al., 2014). DASH principles are
used for intake unsaturated and polyunsaturated sources, with overall lowered fat intake. In nonelderly adults diagnosed with hypertension (P) does a single intervention consisting of a heart
healthy diet or exercise (I) compared to simultaneous interventions of exercise with a hearthealthy diet (C) reduce resting systolic blood pressure levels (O) over four months (T)? The
expected clinical outcome for these patients includes reduced blood pressure levels for all
intervention groups, described as SBP of 120 mmHg. Blood pressure reductions are expected to
be greater in patients performing multiple interventions, both by speed of improvement and
greater improvement achieved overall.

DECREASING BLOOD PRESSURE BY DIET AND EXERCISE

Literature Search
CINAHL, PubMed, and National Guidelines Clearinghouse databases were used to filter
randomized clinical trials and clinical practice guidelines related to arterial hypertension
recommendations for treatment by exercise and nutrition. Keyword terms included blood
pressure, hypertension, DASH, diet, and exercise.
Literature Review
To evaluate the practical application of diet and exercise upon chronic blood pressure,
three randomized controlled trials and one guideline were used. Blumenthal et al. (2010)
conducted a cluster-randomized controlled trial, using groupings of two to five participants, to
study the practical effects of routine DASH dieting and exercise on reducing blood pressures
over a four-month period, while living in the community. Included in this study were 144
participants randomly assigned by computer program into one of two treatment groups or a
control group. Random assignment of groups was equally distributed by participants similarities
of initial blood pressures, body mass indices, and ages. Intervention group one included 46
participants, who used only the DASH diet intervention principles, maintained an equal overall
calorie count from prior to beginning study, and were instructed not to exercise. The control
group included 49 participants, who maintained a diet derived from the calculated average
reported intake of American citizens using the National Health and Nutrition Examination
Survey. Both treatment groups achieved significantly lower SBP than the control group (p<.001).
Blood pressures in the multiple intervention group decreased blood pressure to a level similar to
patients taking antihypertensive medications, and had significantly lower SBP than the DASH
diet-only group (p=.02). The multiple intervention group achieved a reduced SBP by 16.1 mmHg
(95% CI, 13-19.2 mmHg). The DASH diet-only group achieved SBP lowered by 11.2 mmHg

DECREASING BLOOD PRESSURE BY DIET AND EXERCISE

(95% CI, 8.1-14.3 mmHg). The control group reduced blood pressure by 3.4 mmHg (95% CI,
0.4-6.4 mmHg). The study strengths include computer randomization of participant group
assignment concealed from enrollers, experimenters were blind during measurements, groups
were unaware of comparison group differences, reasons were provided for small participant
dropout, standardized manual blood pressure measurement confirmed by simultaneous electronic
measurement used for appropriately defined outcomes, analysis appropriate to group assignment,
appropriateness of control group with verifications for unchanging lifestyle, practical application
among many clinical settings, and appropriate stratification of demographics and initial blood
pressure measurements among groups. The cluster-randomization design controlled outside-thelaboratory factors and limited contamination with intragroup participants that occurred through
observation of each others behaviors during weekly group sessions. A weakness of the study is
the length was too short to track any reduction of cardiovascular events from lowered blood
pressure. Another weakness was possible differences in participant motivation to perform
exercise and dietary interventions in real-world application. The multiple intervention group also
received cognitive-behavioral instruction, which introduced another variable that may have
caused chronic mood alterations that influence blood pressure.
Edwards et al. (2011) used a randomized controlled trial to study the effects of DASH
dieting alone versus DASH dieting with exercise on reducing above-normal blood pressures,
over a three-month period, for sedentary participants living in the community. Included in the
study were 52 participants recruited with SBP of 121-169 mmHg for random assignment
between an exercise-only group, exercise with DASH dieting, and control group. In both
intervention groups, supervised exercise was performed twice weekly with encouragement to
perform another three unsupervised exercise sessions for a maximum of five weekly exercise

DECREASING BLOOD PRESSURE BY DIET AND EXERCISE

sessions. In the multiple intervention group, calories were also restricted by an average of 5001000 calories per day. Both the exercise-only group and DASH dieting with exercise group
achieved significant reductions in resting SBP from pre-intervention to post-intervention when
compared with the non-intervention group (p=.006). A 95% confidence interval was adopted.
Respective SBP reductions occurred of 6.7 mmHg, 12.1 mmHg, and 2 mmHg. However, no
significant difference existed between both intervention groups (p =.053), though the trend
showed greater blood pressure reduction in multiple intervention group. Differences in level of
reduction between both intervention groups were not statistically significant. Study strengths
include computer random assignment of participants, blindness between participant groups and
the relative differences, supervision of workouts was displaced onto instructed YMCA trainers
ignorant of study aim, reasons were given for participant elimination which was primarily
missing two consecutive workout sessions in without performing mandatory makeup session,
valid instruments to measure repeated electronic blood pressures with participant instruction for
consistent orientation during measurement, appropriate control group, evenly distributed
demographics and baseline clinical measures, appropriately tracked clinical outcomes, and
feasible for clinical application. Weaknesses include participant attrition that shrank an already
small sample size and lead to imbalanced stratification of comparison groups that was
augmented via statistical methods, lack of moderately hypertensive and severely hypertensive
participants in overall sample, distribution of participants between groups did not control for age,
short length of study that weakened any summary statement on the overall influence on a
participants health with blood pressure reduction, and the large dropout rate means that
supplementary incentives would be needed to make these interventions appropriate for clinical
application.

DECREASING BLOOD PRESSURE BY DIET AND EXERCISE

Ziv et al. (2013) designed a four-month randomized controlled trial that studied the
effects of the DASH diet with exercise versus a comprehensive blood pressure reduction
approach, using participants receiving antihypertensive medications. The Comprehensive
Approach to Lowering Measured Blood Pressure (CALM-BP) approach included low to
moderate exercise, rice dieting, and relaxation techniques. This diet consists of low protein, low
fat, low sodium and high fiber (Huether & McCance, 2012). All 113 participants were prescribed
at least one antihypertensive medication and had a mean systolic blood pressure between 120180 mmHg. Enrolled participants were randomly assigned to either intervention group and blood
pressure ranges were evenly distributed. Both groups performed exercise for an equal amount of
time. Weekly sessions of relaxation and stress management were included for CALM-BP group.
The participants antihypertensive medication dosages were reduced incrementally if mean SBP
measurements reduced below 110mmHg with reported clinical symptoms of hypotension.
Reduced SBP primarily occurred until week five of CALM-BP group, while SBP reductions
were of a steady reduction rate in DASH group (p<.0001). A 24-hour systolic blood pressure
mean decrease was 4.33 mmHg in CALM-BP group (p=.004) and reduced 4 mmHg in the
DASH group (p=.013), including patients who required a medication reduction.
Antihypertensive medication reductions occurred in 70.7% of CALM-BP participants, while
32.7% of DASH dieters required a medication reduction (p<.0001). Regarding participants who
prescribed a medication reduction from either group, none experienced any further significant
blood pressure reduction after dosage change within the study time period. Strengths of this
study include randomized assignment of groups, participant blindness to activities of comparison
group, participant rate of study completion between above 90% with reasons given for attrition,
appropriated analysis of participants to assigned group, valid electronic instrumentation was used

DECREASING BLOOD PRESSURE BY DIET AND EXERCISE

to measure blood pressure multiple times uniformly, and generalizability to multiple clinical
settings. Weaknesses of the study include lack of participant concealment during randomization
and lack of adequate control group that may did not perform either intervention. An adequate
control group who did not receive any intervention would be important for controlling potential
for psychological effects on blood pressure due to newsworthy events in the community, such as
perceptions of resource availability like gasoline, food, school crowding, etcetera. Another
weakness is demographics and baseline variables were not controlled during random assignment.
Reducing blood pressure guidelines for the prevention of heart attack, stroke, eye
problems, kidney failure, and other complications, were accessed from the National Guidelines
Clearinghouse (ECRI, 2013). The data indicate recommendations for diet and exercise.
Combinations of non-pharmacological measures are not effective. However, a person can be
recommended to start each non-pharmacological measure separately, but it is more clinically
effective to look at sustainability until optimum benefit. Diets rich in fruits and vegetables are
recommended, mostly due to high potassium, but also for fiber. Omega-3 fats can be
recommended up to three times weekly, which are in nuts. Calcium and magnesium supplements
are not generally recommended for hypertension, however, the rice diet is deficient in these
factors to meet recommended daily intake. Recommended exercise includes 30-45 minute
sessions at least three times weekly (ECRI, 2013). Weight loss should be managed by a
professional, an A grade. Controlling stress by itself is not recommended for the treatment of
hypertension, which was a component of Zia et al. (2013).
Synthesis
Blumenthal et al. (2010) reported results that indicated a significant benefit from using
dietary approach alone (p<.001), but both dietary and exercise approaches were significantly

DECREASING BLOOD PRESSURE BY DIET AND EXERCISE

better at reducing blood pressure (p=.02) over four months. Edwards et al. (2011), also found
significant benefit to lowering blood pressure from either exercise only or a joint exercise and
dietary approach blood pressure (p=.006). However, the study did not support a significant
benefit in performing multiple interventions at the same time (p=.053). Zia et al. (2013)
demonstrated significant reductions of blood pressure in both multiple intervention groups with
greater numbers of participants receiving the benefit that used the rice diet instead of the DASH
diet. Since clinical guidelines do not support using stress reduction techniques to lower chronic
blood pressures, it is reasonable to suppose a greater effect achieved from the drastic difference
in dieting, as there were similarities in exercise. From blood pressure clinical guidelines of the
Emergency Care Research Institute (2013), it is proposed that exercise should be performed as an
every-other-day routine for a minimum of 30-45 minutes. These guidelines confirm high
potassium diets, supports unsaturated fat intake, and does not support emphasizing stress
reduction.
Research supports that either exercise or heart-healthy dietary changes are effective to
lower blood pressure. However, in regards to safety, effective implementation, and sustainability,
one definite choice of dieting is not currently supported the evidence. Multiple interventions
performed at the same time may not be easily generalizable to clinical practice, as it is difficult to
duplicate the more highly motivated persons that are innately more likely to enroll in a study
aimed at lowering blood pressure. More research is needed for which diet is the most effective at
lowering blood pressure safely and sustainably for patients of various clinical venues. The rice
diet, although more effective than DASH diet principles at lower blood pressure in patients
already taking antihypertensive medications, probably should not be followed strictly due to
requiring supplementation to achieve recommended daily values. Supplements are shown to be

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not as effective in achieving desired benefits (Huether & McCance, 2012).

Clinical Recommendations
The guidelines and studies demonstrate that both exercise and diet are effective
approaches to lowering blood pressure. Further developments should be done to determine what
exercise and what dietary approaches are most effective in lowering blood pressure safely, and
should be based upon past dietary history and overall clinical picture. Sustainability of these
methods as practical applications must be further researched and adapted to suit a wide variety of
communities with varying access to resources. Hypertension remodels vascularity and alters
perfusion over time, so it will take extended intervention time to achieve reduction of risk
through targeting blood pressure by diet and/or exercise. Teaching a patient with the family to be
more mindful of exercise and diet can easily spur a person to start performing research on the
internet to make different choices in either diet or exercise, whichever a person instinctively
favors. If multiple interventions are performed that would involve extreme weight loss, then the
plan should have professional guidance.

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References
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Edwards, K. M., Wilson, K. L., Sadja, J., Ziegler, M. G., & Mills, P. J. (2011). Effects on blood
pressure and autonomic nervous system function of a 12-week exercise or exercise plus
DASH-diet intervention in individuals with elevated blood pressure. Acta Physiologica,
203(3), 343350. doi: 10.1111/j.1748-1716.2011.02329.x
Emergency Care Research Institute (2013). Clinical practice guidelines on arterial hypertension.
Retrieved from http://www.guideline.gov/content.aspx?id=15712
Huether, S.E., & McCance, K.L. (2012). Understanding Pathophysiology (5th ed.). St. Louis,
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Comprehensive approach to lower blood pressure: A randomized controlled trial of a
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doi: 10.1038/jhh.2013.29