Elevated blood pressure (hypertension) is a common health issue today.

High blood pressure isn’t necessarily something you can feel, but it remains the most important commonly identified risk factor for serious conditions such as strokes and heart attacks.1

Therefore, it is very helpful to know your numbers, understand what they mean, as well as what we can do about it.2

The good news

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

Medications are often prescribed to treat high blood pressure. In some cases this is often reasonable. But what if you could achieve improved, if not perfect, blood pressure with fewer pills or no pills at all? What if you could also experience improved weight, improved overall health, and no side effects?

We at DietDoctor are here to help! This guide will review the evidence and give you resources on how to normalize your blood pressure naturally.

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

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

The most recent update to the AHA hypertension guidelines refined how we classify hypertension.3 A systolic pressure between 120-129 and a diastolic above 80 is now classified as “elevated blood pressure.”4

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.

Almost half of U.S. adults are now classified as having high blood pressure based on the updated definitions.5 But does this mean everyone with a diagnosis of hypertension needs medications? That depends on a detailed analysis of the risks, benefits, and alternatives to drug therapy.

Observational studies suggest that health risks begin to increase as we enter into the “elevated blood pressure” category, and conversely, having lower blood pressure correlates with less heart disease and longer life.6

This, however, is different than saying drug therapy to achieve lower blood pressure is universally beneficial. Instead, it shows that having naturally low blood pressure is beneficial.

What if we lowered blood pressure to normal levels with medications – wouldn’t that be just as beneficial?

The SPRINT trial

A 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 120.7

Unfortunately, this benefit comes with a significantly increased risk of side effects including the risk of falls, kidney disease, and loss of consciousness.8

Furthermore, the SPRINT trial studied people at high risk of heart disease such that only 1 in 6 people with hypertension would be included in the study.9 This means that for the vast majority of people, there is no evidence to support the practice of pushing blood pressure to 120 with medication.

While naturally low blood pressures are associated with longer life, reducing blood pressure to these levels with medications comes with risk.

Lifestyle first

To their credit, the guidelines recommend lifestyle therapy as a fundamental treatment for all stages of hypertension.10 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.11

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 data exists showing the relative ineffectiveness of standard weight loss advice.12

Medications aren’t always better

The ineffectiveness of standard lifestyle interventions is problematic, especially when there is a lack of convincing evidence that medication improves the outcomes of otherwise healthy people with Stage 2 hypertension.13

Another study was an extensive chart review of over 38,000 patients at low risk for heart disease with stage two hypertension treated with blood pressure medications. Over an average follow-up of almost six years, they found no reduction in the risk of heart 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.14 The authors suggested that physicians exercise generalizing findings from data on high-risk individuals to those at lower risk.

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

Recommendations for blood pressure control for type 2 diabetes are inconsistent. Since people living with type 2 diabetes are at increased risk of heart disease, guidelines from the AHA and ACC recommend a blood pressure goal of 130/80.15

However, the ACCORD trial as well as a meta-analysis of randomized trials suggest aggressive treatment to this level does not reduce cardiovascular events but may increase significant adverse events.16Thus, the latest recommendations from the American Diabetes Association set the target blood pressure for those with diabetes at 140/90.17

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 risk factors.

Summary

The following are approximate limits for the levels of blood pressure at which evidence supports that medications are appropriate:18

  • Otherwise healthy individuals: Over 160/10019
  • People living with diabetes or heart disease: Over 140/90
  • Over age 50 with other cardiovascular risk factors who have not improved their BP with lifestyle interventions: Over 140/90

2. Reasons for 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 of their elevated blood pressure. These less common causes of high blood pressure comprise about 10% of all cases (such as kidney or adrenal disorders, certain medications or supplements, etc.).20

By far and away, the most common type of elevated blood pressure is called primary or essential hypertension. Essential hypertension is often part of metabolic syndrome, also known as syndrome X or insulin resistance syndrome.21

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.22

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
It is often difficult to find one solitary cause for hypertension. Age, obesity, sedentary lifestyle, smoking and others all increase the risk for hypertension.23

However, metabolic syndrome has become a global epidemic and a major cause of not only hypertension but fatty liver, type 2 diabetes, heart attack and stroke. The major forces fuelling this epidemic are consumption of ultra-processed high-calorie, high-carbohydrate foods.24 The end result is increased insulin levels with increasing insulin resistance.25

High insulin and high blood pressure

Insulin is the main energy-storing hormone in the body. Too much insulin can therefore lead to becoming overweight in the long run.26 Elevated insulin levels can lead to the accumulation of fluid and salt in the body which increases blood pressure.27

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.28 In addition, hyperinsulinemia can directly contribute to other processes that lead directly to heart disease.29

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



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 addresses the most common cause of high blood pressure:

1. Address metabolic syndrome with low-carb nutrition

There is growing evidence that reducing sugars and starches (carbohydrates) in the diet can improve metabolic syndrome and hypertension, especially as part of a low-carb diet.30 Despite this, many guidelines for hypertension recommend eating a DASH diet that is low in fat and emphasizes increased intake of whole grains.31 That may be a shortsighted recommendation given the data suggesting low-carb diets are equally, if not more, effective than low-fat diets for improving high blood pressure and metabolic syndrome.

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.32 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.33

As a bonus, low-carb nutrition not only improves blood pressure, but it also improves all five markers of the metabolic syndrome.34

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.

However, 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.35

In addition, it’s unclear if sodium reduction is as important as increasing potassium.36 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.37

Lastly, large observational trials such as the PURE study, suggest the healthiest populations eat a moderate amount of sodium, with higher risk seen at extremely high and low levels of sodium intake.38

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 or about 2 to 3 teaspoons of salt) without excess risk.39

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:40

  • 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(prednisone), dexamethasone, or hydrocortisone
  • 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
  • Black 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 can play an important role in blood pressure management. Although exercise can increase blood pressure acutely, it tends to lower blood pressure long-term.41

Exercise not only reduces blood pressure but is also associated with a reduced risk of death and many other chronic conditions.42 A large review of almost 400 randomized trials among ~40,000 patients showed that exercise and anti-hypertensive drugs were similarly effective in patients with hypertension.43

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 as intermittent fasting can reduce insulin and improve weight loss, both of which can improve blood pressure.44 Some studies show intermittent fasting is associated with reduced systolic blood pressure.45

However, not all studies agree, and varying definitions of intermittent fasting limit the generalization of the data.46

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. 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.


Conclusion:

The definitions of elevated blood pressure have changed recently, which acknowledges the importance of being aware of blood pressure and the importance of lifestyle interventions to naturally improve it.

Too often medications are resorted to when lifestyle interventions may be a better option.

We should focus on the lifestyle interventions that reverse the root cause of hypertension by addressing the underlying metabolic diseases.

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 suppressing the symptom.


  1. American Journal of Hypertension 1994: Established risk factors and coronary artery disease: the Framingham Study [overview article; ungraded]

  2. NEJM 1999: Hypertension. Silent killer [overview article; ungraded]

  3. 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]

  4. 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

  5. This data is from the CDC statistics from 2019 as posted on the government website https://www.cdc.gov/bloodpressure/facts.htm

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

  7. 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]

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

  9. Journal of the American College of Cardiology 2016: Generalizability of SPRINT Results to the U.S. Adult Population [nonrandomized study, weak evidence]

  10. 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]

  11. Many people will have high blood pressure in the office and normal blood pressure at home – so called “white coat hypertension.”

    Clinical and Experimental Pharmacology and Physiology 2014: White-coat hypertension [overview; ungraded]

  12. Journal of the American Medical Association 2019: Trends in self-perceived weight status, weight loss attempts, and weight loss strategies among adults in the United States, 1999-2016 [observational study; very weak evidence]

    The following meta-analysis of RCTs suggested only one commercial weight loss program has evidence showing a 5% weight loss, but the attrition rate in the multiple programs was as high as 67% at 1 year.

    Annals of Internal Medicine 2005: Systematic review: an evaluation of major commercial weight loss programs in the United States
    [systematic review of randomized trials; strong evidence]

  13. this means when the blood pressure is 140-159 systolic and/or 90-99 diastolic.

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

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

  15. 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]

  16. 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]

  17. Lower targets of less than 130/80 could be considered in certain patients where targets can be achieved without undue treatment burden.

    Diabetes care 2018: Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2018 [overview article; ungraded]

  18. Always check with your personal healthcare provider to see if medication if appropriate for you

  19. 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]

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

  21. 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.

    Arteriosclerosis Thrombosis and Vascular Biology 2004: Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition [overview article; ungraded]

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

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

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

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

  25. Canadian Journal of Cardiology 2020: Role of Hyperinsulinemia and Insulin Resistance in Hypertension: Metabolic Syndrome Revisited [overview article; ungraded]

  26. Journal of Endocrinology 2017: A causal role for hyperinsulinemia in obesity [overview article; ungraded]

  27. Hypertension 2018:
    Role of Insulin-Mediated Antinatriuresis in Sodium Homeostasis and Hypertension
    [overview article; ungraded]

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

  28. Molecular Endocrinology 1989: Insulin, insulin-like growth factor I and platelet-derived growth factor interact additively in the induction of the protooncogene c-myc and cellular proliferation in cultured bovine aortic smooth muscle cells [animal study; very weak evidence]

  29. Circulation 1995: Induction of plasminogen activator inhibitor type-1 (PAI-1) by proinsulin and insulin in vivo [animal study report; very weak evidence]

  30. 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]

  31. Advances in Nutrition 2020: Dietary Approaches to Stop Hypertension (DASH) Diet and Blood Pressure Reduction in Adults with and without Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials [randomized trial; moderate evidence]

  32. 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]

  33. 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]

  34. 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]

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

    In addition, in contrast to the WHO and AHA, the National Academy of Medicine concluded that there was no consistent evidence between sodium intake and direct health outcomes or death

    Advances in Nutrition 2014: Institute of Medicine. 2013. “Sodium intake in populations: assessment of evidence.” Washington, DC: The National Academies Press, 2013 [overview article; ungraded]

  36. 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]

  37. 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]

  38. While these 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]

  39. 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 sodium may be needed to replenish salt losses during the first few weeks of a ketogenic diet, during hot weather, or 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.

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

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

  42. These conditions include cardiovascular disease, diabetes, lipid disorders, breast and colon cancer, weight gain, frailty, and bone disease.

    International Journal of Behavior, Nutrition, and Physicial Activity 2020 A systematic review of the evidence for Canada’s Physical Activity Guidelines for Adults [review of randomized and nonrandomized studies, weak evidence]

  43. British Journal of Sports Medicine 2019: How does exercise treatment compare with antihypertensive medications? A network meta-analysis of 391 randomised controlled trials assessing exercise and medication effects on systolic blood pressure [systematic review of randomized trials; strong evidence]

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

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

    Journal of Diabetes and Metabolic Discordes 2013: The effects of modified alternate-day fasting diet on weight loss and CAD risk factors in overweight and obese women [nonrandomized study, weak evidence]

    Journal of the American Society of Hypertension 2018: The effect of intermittent fasting on blood pressure variability in patients with newly diagnosed hypertension or prehypertension [nonrandomized study, weak evidence]

  46. Blood Pressure Monitoring 2017: Trend of blood pressure in hypertensive and normotensive volunteers during Ramadan fasting [nonrandomized study, weak evidence]