How to normalize your blood pressure

Elevated blood pressure is a common health issue today. Almost a third of U.S. adults have high blood pressure – perhaps you or someone in your family does?1 High blood pressure isn’t necessarily something you can feel, but it increases the risk of serious conditions such as strokes and heart attacks.

The good news is that you can improve your blood pressure by way of simple lifestyle changes.

The usual treatment for elevated blood pressure today is medication. In some cases this is often reasonable. But what if you could achieve perfect blood pressure without pills or side-effects – with improved health and weight as welcome side-bonuses, instead?

For more background information on blood pressure, see our evidence based guides What is normal blood pressure and High blood pressure- What you need to know

This guide will build upon those and show you how to normalize your blood pressure naturally.

Contents

  1. Who needs blood pressure medication?
  2. Causes of blood pressure
  3. Five ways to lower your blood pressure



1. When should hypertension be medicated?

pills

As detailed in our previous blood pressure guides, the most recent update to the AHA hypertension guidelines created a much more aggressive definition of elevated blood pressure. Systolic pressure between 120-129 and diastolic above 80, formerly in the normal range, is now considered “elevated blood pressure.” A systolic pressure between 130-139 and diastolic 80-89 is now stage 1 hypertension, and a systolic greater than 140 or diastolic greater than 90 is now stage 2 hypertension.

But does this mean everyone with a diagnosis of hypertension needs medications?

To their credit, the guidelines recommend lifestyle therapy for stage 1 hypertension, but they do recommend immediate medications for stage 2 and above. We would argue that just about everyone, except at the extreme levels, deserves a dedicated trial of lifestyle intervention before committing to medical therapy with potential adverse effects.

Observational studies suggest having lower blood pressure correlates with fewer cardiovascular events and longer life.2 This, however, is different than saying drug therapy to achieve lower levels is universally beneficial. Instead, it shows that having naturally low blood pressure is beneficial. Naturally low. That can be achieved through healthy lifestyles.

If your blood pressure is elevated, however, there are circumstances where medications may be helpful.

If it is severely elevated (over 160 systolic or over 100 in diastolic), medication in addition to lifestyle interventions is likely wise. If you have other risk factors for heart disease (like smoking or diabetes), starting medication may be beneficial even for a lower elevation in blood pressure (over 140/90).3

Up until recently there was a lack of convincing evidence that medication improves the health of otherwise healthy people with mildly elevated blood pressure (140-159 systolic and/or 90-99 diastolic).4 This meant it was unclear whether it was worth risking the side effects of the medication if all you have is a mild elevation in the absence of other cardiovascular risk factors.

A new large study, however, showed that people over age 50 with hypertension and additional cardiovascular risk factors lived longer and reduced the risk of heart disease if they used multiple medications to lower their systolic blood pressure all the way to 120.5 Unfortunately this benefit comes with significantly increased risk of side effects including the risk of falls, kidney disease and loss of consciousness.6

Would these results translate to “real-world” practice? One study suggests potentially not. This study was an extensive chart review of over 38,000 patients at low risk for heart disease who had stage two hypertension (blood pressure between 149/90 and 159/99) and were treated with blood pressure medications. Over an average follow-up time of almost six years, they found no reduction in the risk of cardiovascular disease events or risk of death with medication use. They did, however, find an increased risk for low blood pressure, fainting, and acute kidney injury among those treated with medications.7

In the end, it appears that the data are not as conclusive as guidelines may suggest. That is why we suggest working with your doctor to try lifestyle interventions before medications if it is safe.

Patients with diabetes

The data is also inconsistent for patients with diabetes. Guidelines from the AHA and ACC treat diabetics the same as the high risk population and recommend medical treatment for blood pressure above 130/80.8

However, the ACCORD trial as well as a meta-analysis of RCTs suggest aggressive treatment to this level does not reduce cardiovascular events but may increase significant adverse events.9Thus, the latest recommendations from the American Diabetes Association) set the target blood pressure for those with diabetes at 140/90.

Keep in mind, however, that these were drug intervention trials. While treating with drugs to lower BP further my not benefit diabetics, we can hypothesize that lifestyle interventions would. After all, medications come with side effects and risks that most lifestyle interventions do not.

To summarize, the following are approximate limits for the levels of blood pressure at which there is little debate that medication are appropriate:

  • Otherwise healthy individuals: Over 160/100
  • Diabetics/people with heart disease: Over 140/90
  • Over age 50 with other CVD risk factors who have not improved their BP with lifestyle interventions: Over 140/90

With that said, current guidelines recommend much more aggressive medication therapy for blood pressure despite conflicting outcome results, especially for those at lower risk of cardiovascular disease.

We feel the evidence supports that stage 1 hypertension and stage 2 in otherwise healthy individuals are best treated with lifestyle interventions. These lifestyle changes should target the underlying causes of high blood pressure and decrease the risk of long term complications. The use of medications should be individualized based on response to lifestyle changes, individual preference, and cardiovascular other risk factors.


2. Reasons for high blood pressure

There are several less common causes of high blood pressure comprising about 10% of all cases (such as kidney or adrenal disorders, certain medications or supplements, etc.).10 Therefore, anyone with a new diagnosis of hypertension should see their healthcare provider for an initial evaluation to ensure there isn’t a reversible or dangerous cause of their elevated blood pressure.

However, the overwhelmingly most common type of elevated blood pressure is the kind that doesn’t have an underlying medical cause, so-called primary or essential hypertension. In these cases it can also be part of what’s called “metabolic syndrome”, also known as the disease of the Western world:11

4-western disease

The above health problems are grouped together because they often appear as a cluster of symptoms in one individual. People with elevated blood pressure often carry extra weight around their belly, and they’re also likely to be at risk for high blood sugar and type 2 diabetes.

The good news is: if you can get to the root cause, you can often improve all these markers with one simple lifestyle change.12

Read more about causes of hypertension in our guide on high blood pressure

The common cause

Double Cheese Burger with Glass of Cola and Fries
As described in our guide on high blood pressure, it is difficult to find one solitary cause for hypertension. Age, obesity, sedentary lifestyle, smoking and others all increase the risk for hypertension.13

However, when it comes to the metabolic syndrome, many believe the main cause is eating more high-calorie, high-carbohydrate foods than the body can handle.14 The end result is increased insulin levels with increasing insulin resistance.

High insulin and high blood pressure

Insulin is the main fat-storing hormone in the body, and too much insulin can therefore lead to becoming overweight in the long run. What’s more, elevated insulin levels can lead to the accumulation of fluid and salt in the body which increases blood pressure.15

In addition, high levels of insulin can thicken the tissue around blood vessels (the so-called smooth muscle), which also may contribute to an elevated blood pressure.

Therefore, it makes sense that interventions aimed at reducing insulin levels will greatly improve hypertension and metabolic syndrome.


3. Lifestyle changes for a healthier blood pressure

There are several possible lifestyle changes you can make to lower your blood pressure, five of which we list below. The first one is likely the most important since it eliminates the most common cause of high blood pressure:

1. Cure the Western disease with low-carb nutrition

Multiple studies on low-carbohydrate diets show improved blood pressure even when compared to other diets.16

For example, one study demonstrated that a low-carb diet improved blood pressure more than a low-fat diet plus the weight loss drug Orlistat.17 In addition, a review of multiple randomized controlled trials concluded that low-carb diets were more effective than low-fat diets for weight loss and reducing blood pressure and other cardiovascular risk factors.18

As a bonus, low-carb nutrition not only improves blood pressure, but it also improves all five markers of the metabolic syndrome.19

This not only works in scientific studies but also in real life with numerous anecdotal reports of success.

A low-carb diet for beginners

2. To salt or not to saltsalt

Eating less salt may lower your blood pressure a little. Research has shown that this effect is, however, small for most people in the long term.20

Despite various trials showing a slight reduction of blood pressure with lower sodium diets, we lack contemporary evidence that less salt in our food will affect the risk of heart disease or death. This was shown in a recent meta-study of all RCTs on the subject.21 In addition, it’s unclear if sodium reduction is as important as increasing potassium.22 Since potassium comes from whole foods, such and veggies and avocados, it’s possible that a diet with higher sodium minimally-processed-foods would still have a beneficial effect on blood pressure.

Since much of the salt we ingest comes from fast food, ready-made meals, bread and soft drinks, low-carb diets automatically lower salt intake as these foods are avoided. Furthermore, the hormonal effects of LCHF make it easier for the body to dispose of excess salt through urine; this can explain the slight lowering of blood pressure.23

Last, large observational trials such as the PURE study, suggest the healthiest population eats a moderate amount of sodium, with higher risk seen at extremely high and low levels of sodium intake.24

With all the conflicting evidence, it’s unclear whether you will become healthier by eating less salt or not. However, if you stick to a low carb diet, you should be able to enjoy salt in moderation (4-7 grams of sodium per day) without excess risk.25

More about salt and health

3. Eliminate other things which increase blood pressure

Blood pressure can sometimes be lowered simply by avoiding the things that drive it up. Here are a few common causes of elevated blood pressure:26

  • Common painkillers (so-called non-steroidal anti-inflammatory drugs, NSAID), can increase your blood pressure by inhibiting the production of salt in your kidneys. This includes over-the-counter pills such as Ipren, Ibumetin, Ibuprofen, Diklofenak and Naproxen as well as the prescription drug Celebra. Painkillers with the active substance paracetamol are better for your blood pressure.
  • Cortisone pills, such as Prednisolon
  • Birth control pills (for some people this may be an issue, you may want to discuss other options with your health care provider)
  • Coffee (caffeine)
  • Alcohol in large amounts
  • Nicotine (smoking, other forms of tobacco) can give dramatic short-lived rises in blood pressure of 15-20 units
  • Drugs such as amphetamine and cocaine
  • Licorice in large amounts

This doesn’t mean it’s imperative to abstain from coffee or alcohol completely; however, if you are a big “user” it may be wise to decrease your intake. On the other hand, it’s always a good idea to completely stop smoking: kicking a smoking habit is excellent for your health in general, not just your blood pressure.

4. Exercise

Regular exercise has been shown to increase blood pressure acutely, but to also somewhat lower blood pressure long-term.27 And, if nothing else, at least you’ll be burning carbohydrate and therefore increasing your carb tolerance.

5. Intermittent fasting

Variable definitions of intermittent fasting and lack of consistent scientific protocols limits the literature on fasting. However, some studies show intermittent fasting is associated with reduced systolic blood pressure.28

This makes sense from a mechanistic perspective as intermittent fasting can reduce insulin and improve weight loss, both of which can improve blood pressure.29

Read more about intermittent fasting and time restricted eating in our medically reviewed guides.

Follow up your blood pressure

When making lifestyle changes, it is helpful to follow your blood pressure regularly. This can be done at your doctor’s office, or even better on your own with the DIY instruments.


Conclusion:

Although the definitions of elevated blood pressure have changed recently, the approach likely remains the same. We should focus on the lifestyle interventions that reverse the root cause of hypertension, and in doing so, also address the metabolic diseases that accompany it. Medications still have a place for severely elevated pressure or pressure that does not improve with lifestyle interventions. However, if we can reverse the underlying cause, that is a much more powerful intervention than masking the symptom.


  1. This data is from the CDC statistics
    MMWR Morbidity and Mortality Weekly Report 2016: CDC Grand Rounds: A public health approach to detect and control hypertension. [overview article; ungraded]

  2. Hypertension 2005: Blood Pressure in Adulthood and Life Expectancy With Cardiovascular Disease in Men and Women [non-controlled study; weak evidence]

  3. Studies such as the one listed here show greater benefit with medications for those with other cardiovascular risk factors. In the absence of other risk factors, benefits are usually only seen at higher absolute levels.
    BMJ Open 2018: Effectiveness of blood pressure-lowering drug treatment by levels of absolute risk: post hoc analysis of the Australian National Blood Pressure Study [randomized trial; moderate evidence]

  4. Cochrane Reviews 2012: Benefits of antihypertensive drugs for mild hypertension are unclear [systematic review of randomized trials; strong evidence]

  5. The important aspects of this study were that the subjects were over age 50 and at high risk for cardiovascular disease (they were not otherwise healthy people with high blood pressure), and they were monitored monthly initially and then four times per year for potential adverse medication effects. Thus these results may not apply to placing low risk individuals on medications and only following them once or twice per year.

    NEJM 2015: A randomized trial of intensive versus standard blood-pressure control [moderate evidence]

  6. Major New Study: Getting Blood Pressure Below 120 Saves Lives – and Increases Risks

  7. JAMA Internal Medicine 2018: Benefits and harms of antihypertensive treatment in low-risk patients with mild hypertension [observational study, weak evidence]

  8. Hypertension 2018: 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. [overview article; ungraded]

  9. NEJM 2010: Effects of intensive blood-pressure control in type 2 diabetes mellitus.[randomized trial; moderate evidence]

    Circulation 2011: Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose: observations from traditional and bayesian random-effects meta-analyses of randomized trials. [systematic review of randomized trials; strong evidence]

  10. Singapore Medical Journal 2016: Secondary hypertension in adults. [overview article; ungraded]

  11. One definition of metabolic syndrome is having three or more of the following markers:

    • Fasting blood glucose above 100mg/dL (5.5 mmol/L)
    • Elevated triglycerides above 150mg/dL
    • High density lipoproteins (HDL) below 40mg/dL in men and 50 in women
    • Elevated blood pressure above 130/85
    • Increased abdominal obesity with a waist circumference over 40 inches in men and 35 inches in women.

    All of these characteristics tend to be common in insulin resistance as well.

  12. This trial showed greater improvement in metabolic syndrome markers with carbohydrate restriction irrespective of weight loss. Also it does not prove the exact mechanism, we can hypothesize that lowering insulin independently improves metabolic syndrome.

    JCI Insight 2019: Dietary carbohydrate restriction improves metabolic syndrome independent of weight loss. [randomized trial; moderate evidence]

  13. Hypertension 2017: Trends in prehypertension and hypertension risk factors in US adults: 1999-2012. [overview article; ungraded]

  14. Current Hypertension reports 2018: The Global Epidemic of the Metabolic Syndrome. [overview article; ungraded]

  15. Drugs 1993: The inter-relationship between insulin resistance and hypertension. [overview article; ungraded]

  16. Obesity Reviews 2012: Systematic review and meta-analysis of clinical trials of the effects of low carbohydrate diets on cardiovascular risk factors. [systematic review of randomized trials; strong evidence]

  17. Archives of Internal Medicine 2010: A randomized trial of a low-carbohydrate diet vs orlistat plus a low-fat diet for weight loss.[randomized trial; moderate evidence]

  18. Obesity reviews 2009: Systematic review of randomized controlled trials of low-carbohydrate vs. low-fat/low-calorie diets in the management of obesity and its co-morbidities. [strong evidence]

  19. Obesity reviews 2009: Systematic review of randomized controlled trials of low-carbohydrate vs. low-fat/low-calorie diets in the management of obesity and its comorbidities. [strong evidence]

    JCI Insight 2019: Dietary carbohydrate restriction improves metabolic syndrome independent of weight loss. [randomized trial; moderate evidence]

    International Journal of Environmental Research and Public Health 2019: Substantial and sustained improvements in blood pressure, weight and lipid profiles from a carbohydrate restricted diet: an observational study of insulin resistant patients in primary care [cohort study; weak evidence]

  20. This review of RCTs found only a 1mmHg reduction on average:

    Cochrane Reviews 2011: Reduced dietary salt for the prevention of cardiovascular disease [systematic review of randomized trials; strong evidence]

  21. Cochrane reviews 2011: Reduced dietary salt for the prevention of cardiovascular disease [systematic review of randomized trials; strong evidence]

  22. America Journal of Epidemiology 1994: Urinary electrolyte excretion in 24 hours and blood pressure in the INTERSALT Study. II. Estimates of electrolyte-blood pressure associations corrected for regression dilution bias. The INTERSALT Cooperative Research Group. [observational study, weak evidence]

  23. Since increased insulin levels stimulate the kidneys to retain sodium, lowering insulin levels with LCHF stimulates the kidneys to excrete more sodium.
    Diabetologia 1981: The effect of insulin on renal sodium metabolism. A review with clinical implications. [overview article; ungraded]

  24. While thse results may or may not apply to those following a healthy low-carb diet, they did show trends for the general population.
    The Lancet 2018: Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study [observational study, weak evidence]

  25. This is based on clinical experience of low-carb practitioners and was unanimously agreed upon by our low-carb expert panel. You can learn more about our panel here [weak evidence].

  26. Journal of Clinical Hypertension 2008: Secondary hypertension: interfering substances. [overview article; ungraded]

  27. Medicine 2017: Reducing effect of aerobic exercise on blood pressure of essential hypertensive patients [meta-analysis of observational study, weak evidence]

  28. Nutrition Journal 2012: Effects of Ramadan fasting on cardiovascular risk factors: a prospective observational study. [observational study, weak evidence]

  29. If you are not eating, especially if you are not eating carbs, blood sugar is not entering the blood stream at the same rate and insulin is not released to compensate. This should allow the cells the opportunity to recover and become more insulin sensitive. Much like low-carb eating, fasting gives your pancreas a break.

    Nutrition Review 2014: Time-restricted feeding and risk of metabolic disease: a review of human and animal studies [overview article; ungraded]