Beyond salt: lifestyle modifications and blood pressure.

Lifestyle changes have been shown to effect significant blood pressure (BP) reductions. Although there are several proposed neurohormonal links between weight loss and BP, body mass index itself appears to be the most powerful mediator of the weight-BP relationship. There appears to be a mostly linear relationship between weight and BP; as weight is regained, the BP benefit is mostly lost. Physical activity, but more so physical fitness (the physiological benefit obtained from physical activity), has a dose-dependent BP benefit but reaches a plateau at which there is no further benefit. However, even just a modest physical activity can have a meaningful BP effect. A diet rich in fruits and vegetables with low-fat dairy products and low in saturated and total fat (DASH) is independently effective in reducing BP. Of the dietary mineral nutrients, the strongest data exist for increased potassium intake, which reduces BP and stroke risk. Vitamin D is associated with BP benefit, but no causal relationship has been established. Flavonoids such as those found in cocoa and berries may have a modest BP benefit. Neither caffeine nor nicotine has any significant, lasting BP effect. Biofeedback therapies such as those obtained with device-guided breathing have a modest and safe BP benefit; more research is needed before such therapies move beyond those having an adjunctive treatment role. There is a strong, linear relationship between alcohol intake and BP; however, the alcohol effects on BP and coronary heart disease are divergent. The greatest BP benefit seems to be obtained with one drink per day for women and with two per day for men. This benefit is lost or attenuated if the drinking occurs in a binge form or without food. Overall, the greatest and most sustained BP benefit is obtained when multiple lifestyle interventions are incorporated simultaneously.