Observational studies suggest that health risks begin to increase as we enter into the “elevated blood pressure” category.6
This implies that you should keep your blood pressure within the normal range. But what’s the best way to do that? We suggest that if you can normalize blood pressure with lifestyle modifications, that will likely be better than normalizing it with medications.7
The SPRINT trial
A large 2015 study 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 120.8
Although the benefit of intensive treatment was significant, there was also an increased risk of side effects including kidney injury, fainting, and electrolyte abnormalities.9
We should also note that the SPRINT trial studied people at high risk of heart disease, making it difficult to extrapolate the benefits of intensive treatment to people at lower risk.10
This means that for lower risk individuals, it’s unclear if the risks of intensive treatment outweigh the benefits.
To their credit, the guidelines recommend lifestyle therapy as a fundamental treatment for all stages of hypertension.11 For stage 1 hypertension, they recommend three months of lifestyle efforts before initiating medications.
For stage 2 hypertension without other serious risk factors for heart disease (as long as the blood pressure is less than 160/100 in a doctor’s office), the guidelines recommend confirmation with home blood pressure monitoring before initiating therapy.12
But how often do clinicians start with drug therapy rather than providing detailed lifestyle guidance? And if they do provide lifestyle guidance, how often is it the standard “low-fat, eat less, move more” advice? Aside from anecdotal reports, we don’t have good data on how often that occurs, but we do have studies showing the relative ineffectiveness of standard weight loss advice.13
Medications aren’t always better
Randomized controlled trial evidence suggests that medication either does not improve or barely improves the outcomes of otherwise healthy people with Stage 2 hypertension.14
Observational studies of low-risk patients with mild hypertension, like one extensive chart review of over 38,000 patients, have found no reduction in the risk of heart disease events or risk of death with medication use.15
We believe that it is inappropriate to generalize the findings from data examining high-risk individuals to those at lower risk. Not only is the benefit of treatment questionable, but the risk of significant side effects is clearly elevated.
Therefore, if your blood pressure is mildly elevated and you are otherwise healthy, we suggest discussing with your doctor if it is appropriate for you to try lifestyle interventions before medications.
Patients with diabetes
People with type 2 diabetes have an increased risk of heart disease, so the findings from trials looking at low-risk subjects with mild hypertension cannot necessarily be applied to them.
Current American Heart Association/American College of Cardiology guidelines recommend a blood pressure goal of less than 130/80. The American Diabetes Association recommends treating most people with diabetes to less than 140/90, reserving the lower goal of 130/80 for higher-risk people in whom the potential benefits outweigh the risks.16
Although the evidence is clear that risk is reduced by lowering blood pressure to less than 140/90, it is less clear that targeting blood pressure to even lower levels further reduces risk in people with diabetes. One major trial (ACCORD) attempted to answer this question and found that lowering systolic blood pressure to less than 120 did not reduce total atherosclerotic cardiovascular events, but it did significantly increase the risk of serious side effects.17
The following are approximate limits for the levels of blood pressure at which evidence supports that medications are appropriate:18
Otherwise healthy individuals: Guidelines suggest starting medication AND lifestyle therapy if blood pressure is above 140/90.19 However, we suggest discussing with your doctor if lifestyle therapy alone is a reasonable first step.
People living with diabetes: Over 140/90
Over age 50 with other cardiovascular risk factors who have not improved their BP with lifestyle interventions: Over 140/90
2. What causes high blood pressure?
Anyone with a new diagnosis of hypertension should see their healthcare provider to ensure there isn’t a reversible or dangerous cause that requires specific treatment. These so-called “secondary” causes of high blood pressure comprise about 5-10% of all cases (such as kidney or endocrine disorders, sleep apnea, vascular abnormalities, certain medications or supplements, etc.).20
The most common type of elevated blood pressure, however, is called primary or essential hypertension. Essential hypertension typically does not have a single, discernible cause.
However, we know that a number of risk factors predispose individuals to developing essential hypertension. These risk factors include obesity, sedentary lifestyle, high levels of alcohol consumption, smoking, stress, family history, and genetics.21
We are particularly interested in the role that obesity plays in the development of high blood pressure, as studies suggest that roughly 70% of the risk for primary hypertension is attributable to obesity. This is especially true for weight gain around the midsection, which tends to be associated with accumulation of fat in and around abdominal organs such as the liver, and can also be associated with insulin resistance.22
There are numerous complex mechanisms — incompletely understood — by which obesity appears to raise blood pressure. Suffice it to say that weight gain causes multiple hormonal changes within the kidneys, adrenal glands, and elsewhere that contribute to high blood pressure. In addition, obesity activates the sympathetic nervous system, which also affects blood pressure. Finally, obesity leads to insulin resistance, glucose intolerance, abnormal lipid levels, and inflammation, all of which can be associated with high blood pressure.23
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 describe below. The first one is likely the most important since it addresses the most common risk factor for high blood pressure:
1. Address obesity and metabolic syndrome with low-carb nutrition
Abdominal obesity and hypertension are often found together with other cardiovascular disease risk factors – this is referred to as metabolic syndrome.24 There is growing evidence that reducing sugars and starches (carbohydrates) in the diet can improve metabolic syndrome and hypertension.25
Further, there have been many trials over the years showing that low-carb diets are either better or equivalent to low-fat diets when it comes to weight loss and improvement in cardiovascular risk markers.26
Many individuals who adopt a low-carb or ketogenic diet see a rapid reduction in blood pressure. The Virta study of cardiovascular disease markers found that diastolic blood pressure measurements dropped significantly in participants and 11.5% were able to stop high blood pressure medications.27
However, there is still uncertainty about the long term blood pressure-lowering benefits of a low-carb diet, and whether the effect is due to weight loss alone or from an added benefit of lowering carbohydrates.28
Why does low-carb nutrition work? Research is still preliminary, but a number of mechanisms are theorized: weight loss, lower levels of circulating insulin, reduced insulin resistance, improved insulin sensitivity, reduction in sodium retention by the kidney, lowered blood sugar, and others.29
Eating less salt may lower your blood pressure a little.
However, despite various trials showing a slight reduction of blood pressure with lower sodium diets, we lack definitive evidence that less salt in our food will reduce the risk of heart disease or death.30
In addition, it’s unclear if sodium reduction is as important as increasing potassium.31 Some studies suggest that the sodium-to-potassium ratio is better at predicting cardiovascular disease and death than the intake of either nutrient alone.32
Regardless of whether sodium or potassium is more important, we should note that much of the salt we ingest comes from fast food, ready-made meals, bread and soft drinks. Therefore, most low-carb diets automatically lower salt intake, because these foods are avoided.33 Furthermore, when starting a low-carb diet, insulin levels tend to drop, which is thought to help explain why blood pressure drops on low carb.34
Lastly, large observational trials, such as the PURE study, suggest that the risk of heart attack and death increases with sodium intakes less than 3000mg and greater than 7000mg per day. Moderate intakes between these amounts were not associated with increased risk.35
With all the conflicting evidence, it’s unclear whether you will become healthier by eating less salt. 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 or about 2 to 3 teaspoons of salt) without excess risk.36
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:37
Medications: a number of prescriptions and over-the-counter drugs have side effects that include increasing blood pressure. These include:
Oral contraceptives and hormone replacement therapy, especially with higher estrogen doses.38
Oral decongestants found in some cold and allergy medications.39
Non-steroidal anti-inflammatories (NSAIDs) for pain relief and inflammation.40
Stimulant drugs used to treat Attention Deficit Hyperactivity Disorder (ADHD), especially mixed amphetamine salts (Adderall).41
Alcohol in large amounts.
Nicotine (smoking and smokeless tobacco) can give dramatic short-lived rises in blood pressure of 15-20 points.
Herbal supplements including St. John’s Wort, ginseng, ginkgo, blue kohosh.42
Recreational drugs such as methamphetamine and cocaine.
Licorice. A compound in licorice root called glycyrrhizin — which is found in licorice-flavored herbal teas, candies, lozenges, and herbal remedies — is a very potent blood pressure-raising agent. Its use has prompted a number of case studies and a warning from the US Food and Drug Administration.43
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.
Regular exercise can play an important role in blood pressure management. Although exercise can increase blood pressure acutely, it tends to modestly lower blood pressure long-term.44
Exercise not only reduces blood pressure but is also associated with a reduced risk of death and many other chronic conditions.45
A large review of almost 400 randomized trials including ~40,000 patients showed that exercise and anti-hypertensive drugs were similarly effective in patients with hypertension.46
Learn more about the beneficial effects of exercise in our evidence-based guide on exercise and health.
5. Intermittent fasting
Intermittent fasting makes sense from a mechanistic perspective, because it can reduce insulin and improve weight loss, both of which can improve blood pressure.47 Some studies show intermittent fasting is associated with reduced systolic blood pressure.48
However, not all studies show an effect, and varying definitions of intermittent fasting limit the generalizability of the data.49
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. Just make sure you bring your home blood pressure monitor in to your doctor’s office on occasion to make sure it matches with their readings.
We should focus on lifestyle interventions that address some of the root causes of hypertension, reserving medications for blood pressure that is very high or isn’t responsive to these interventions.
With good diet, exercise, and avoidance of substances that raise blood pressure, it is often possible to improve hypertension without medications.
The guide contains scientific references. You can find these in the notes throughout the text, and click the links to read the peer-reviewed scientific papers. When appropriate we include a grading of the strength of the evidence, with a link to our policy on this. Our evidence-based guides are updated at least once per year to reflect and reference the latest science on the topic.
All our evidence-based health guides are written or reviewed by medical doctors who are experts on the topic. To stay unbiased we show no ads, sell no physical products, and take no money from the industry. We're fully funded by the people, via an optional membership. Most information at Diet Doctor is free forever.
Systolic refers to the upper number and ist the pressure when then heart contracts to pump out blood. Diastolic refers to the bottom number which is the pressure that remains when the heart relaxes. Blood pressure of 120-129/80 was previously in the pre-hypertension range, a category the AHA has now eliminated. ↩
We are not aware of any studies that explicitly compare normal BP achieved naturally versus with medications. However, it makes sense that you would want to avoid potential medication side effects. In addition, lifestyles that improve BP also frequently help with weight loss and improve blood sugar, thereby providing extra benefits. ↩
The subjects in this study were over age 50 and at high risk for cardiovascular disease. The “intensive-treatment” group achieved an average systolic of 121.4, while the “standard-treatment” group was treated to 136.2.
This systematic review, unlike the one above, included trials with large numbers of subjects with diabetes. It showed statistically significant improvements for some cardiovascular endpoints, but the magnitude of benefit was very small. For example, the cohort without diabetes showed an absolute risk reduction for cardiovascular events of 0.3 percent over 5 years.
The following study looked at subjects over an average six year period. It found no benefit to treatment but did find that medications increased the risk of low blood pressure, fainting, electrolyte abnormalities, and acute kidney injury.
Similarly, this meta-analysis of RCTs showed that the risk of stroke continued to decline with more intensive blood pressure control, but there was no reduction of risk for the blood vessels of the heart, kidneys, or eyes. There was, however, a dramatic increase in adverse events related to intensive treatment.
This 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.
Although the original paper found a mild benefit of salt restriction in certain subgroups, the authors published a correction to their paper with an updated statistical analysis that they believe more accurately reflects the conclusions that can be drawn from the available evidence. Their corrected analysis shows no benefit of salt restriction on mortality in normotensive or hypertensive people.
In addition, in contrast to the WHO and AHA, the Institute of Medicine (IOM) concluded that there was no convincing evidence that lowering sodium intake to less than 2300mg per day improves health outcomes or death.
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].
Occasionally, increased salt may be needed to replenish sodium losses during the first few weeks of a low-carb or ketogenic diet, during hot weather, or with strenuous physical activity. Just keep in mind that if you have salt-sensitive hypertension, you will need to be more cautious than most.
If you have medical conditions such as high blood pressure, swelling, liver disease, heart failure, or are on blood pressure medications it is important to work with your health care provider.