International Society of Hypertension publishes position paper on lifestyle management of hypertension

The International Society of Hypertension (ISH) has recently put out a position paper that addresses lifestyle management of hypertension. The paper is endorsed by the World Hypertension League and European Society of Hypertension. [DOI:10.1097/HJH.0000000000003563]

The paper makes several important recommendations and observations that are vital action points for healthcare providers. These are:

1. That lifestyle modifications should be the first line of antihypertensive treatment in grade 1 hypertension.

2. If blood pressure control is not achieved with lifestyle changes alone, a combination of lifestyle modifications and antihypertensive medications is recommended.

3. Healthcare providers and clinicians should receive adequate training in working with patients to adopt lifestyle changes and play an active role in their implementation.

4. Weight management is crucial, and individuals should be encouraged to achieve and maintain a healthy weight. To promote and maintain a healthy weight throughout their life, it is essential to focus on early-life interventions and health education programs. For individuals with hypertension, it is advisable to aim for gradual and sustainable weight loss while reducing calorie intake. Weight loss strategies should incorporate cognitive-behavioural techniques, such as appetite awareness training and self-monitoring. Managing abdominal obesity is crucial, with consideration for ethnicity-specific guidelines or a waist-to-height ratio less than 0.5 for all populations. When choosing weight loss programs, customization is key, considering factors like baseline weight, age, sex, comorbidities, and the individual’s situation, with support from a dietitian. Furthermore, innovative approaches using behavioural change technologies like apps and text messaging are encouraged for individuals with overweight or obesity.

5. Physical activity is important for the prevention and management of hypertension and cardiovascular disease. Emphasis should be placed on early-life intervention and health education programs. The position paper recommends both aerobic exercise and dynamic resistance exercise, or a combination of both, for the prevention and management of hypertension and cardiovascular disease. It emphasizes the importance of engaging in regular physical activity throughout the lifespan, starting from childhood. The guidelines suggest that adults should aim for 150-300 minutes of moderate-intensity exercise or 75-150 minutes of vigorous exercise per week. The paper also highlights the need to reduce sedentary behaviour and incorporate incidental exercise into daily routines.

6. The paper recommends the Dietary Approaches to Stop Hypertension (DASH) diet, which emphasizes consumption of fruits, vegetables, low-fat dairy products, and reduced saturated fat and cholesterol. Patients should consider a vegetarian diet, which has been associated with lower blood pressure compared to unrestricted omnivore diets. Other recommendations include increasing the consumption of dietary fibre, which can be found in whole grains, fruits, and vegetables; limiting sugar intake, both in raw form and in processed food, drinks, and sweets; reducing salt intake and being mindful of sodium content in packaged food items. Basically, incorporating healthy eating habits into everyday life.  

7. Other lifestyle factors such as stress reduction, mindfulness, sleep, smoking cessation, and reducing pollution exposure are also important in managing hypertension.

The importance of digital health and wearables was also highlighted in the paper. Both play a significant role in managing hypertension as they offer various tools and interventions to support individuals in monitoring and improving their blood pressure control. Web-based programs and smartphone apps provide educational resources, self-monitoring tools, and behaviour change support for patients with hypertension. These interventions can help individuals track their blood pressure, medication adherence, physical activity, and dietary habits. Furthermore, digital health interventions can be personalized to the individual’s needs and preferences. They can offer tailored content, reminders for medication intake, goal setting, and decision support. This personalization enhances user adherence, motivation, and self-efficacy.

Wearables have also come of age, with validated digital wearables, such as smartwatches and fitness trackers increasingly being used to monitor physical activity, heart rate, and sleep patterns. These wearables provide real-time data that can be integrated into digital interventions, offering personalized feedback, and encouraging behaviour change.

Professor Datin Dr Chia Yook Chin, one of the authors of the position paper, said: “We know that 1-in-3 adults in Malaysia have hypertension. The sad part is that half of them do not know they have hypertension and are therefore, left untreated, and hence do not benefit from the antihypertensive medications, which are very effective with very little side-effects and are not costly at all. But to help ourselves from getting hypertension, and even when we have hypertension, we can lower our blood pressure levels by making lifestyle changes.”

“This important paper, put together by experts from many countries including Malaysia, have reviewed and recommended various lifestyle changes that can bring about meaningful reductions in blood pressure. It highlights the important changes we can make to get lower blood pressure thus reducing cardiovascular mortality and morbidity.  Some of these lifestyles are of particular importance in Malaysia as our prevalence of overweight and obesity exceed 50 percent, diabetes prevalence of 25 percent and a high salt intake (7.9 gram of salt per day) that is above the 5 gram per day recommended by the World Health Organization. By making these much-needed lifestyle changes we hope to help reduce cardiovascular morbidity and mortality.”

Hypertension, characterized by consistently elevated systolic blood pressure (SBP) exceeding 140 mmHg and/or diastolic blood pressure (DBP) reaching at least 90 mmHg—as per the guidelines of the ISH—impacts the lives of more than 1.5 billion individuals globally. This condition is closely linked to a heightened risk of cardiovascular disease (CVD) events, including conditions such as coronary heart disease, heart failure, and stroke, as well as an increased risk of mortality.