Weight control for women AC, Kraschnewski JL, Non-pharmaceutical approaches to hypertension Hyperhension, Lehman Body fat percentage, Stuckey HL, Hwang KO, Pollak KI, Sciamanna CN. Whelton PK, He J, Cutler JA, et al. Comparative effects of different dietary approaches on blood pressure in hypertensive and pre-hypertensive patients: a systematic review and network meta-analysis. Correspondence to Ashish Anil Sule.

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Meta-analysis of randomized controlled clinical trials. Cornelissen VA, Smart NA. Exercise training for blood pressure: a systematic review and meta-analysis. J Am Heart Assoc ; 2:e Whelton SP, Chin A, Xin X, et al. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials.

Ann Intern Med ; Carlson DJ, Dieberg G, Hess NC, et al. Isometric exercise training for blood pressure management: a systematic review and meta-analysis. Mayo Clin Proc ; Inder JD, Carlson DJ, Dieberg G, et al. Isometric exercise training for blood pressure management: a systematic review and meta-analysis to optimize benefit.

Hypertens Res ; Xin X, He J, Frontini MG, et al. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Roerecke M, Kaczorowski J, Tobe SW, et al. The effect of a reduction in alcohol consumption on blood pressure: a systematic review and meta-analysis.

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Despite highly prevalent, hypertension is one of the most preventable conditions [ 6 , 7 ]. Various studies have demonstrated different lifestyle modification approaches to reduce or prevent hypertension. Recommended measures for preventing hypertension are reducing body weight in case of obesity, undertaking regular physical activity, reduced intake of salt or sodium, increasing potassium supplement, and avoiding harmful use of alcohol [ 8 ].

Dietary intervention such as dietary approaches to stop hypertension has also promisingly reduced blood pressure BP [ 9 ]. This specific dietary recommendation included more intake of vegetables and fruits, milk products with lower proportion of fat, reduction of cholesterol, and saturated fat in meals [ 9 ].

Reduction of BP was even higher with increasing dose of calcium. Effect of calcium in reducing BP was greater among the younger population [ 10 ].

Complementary and alternative medicine has been found useful sometimes in this aspect [ 11 , 12 , 13 ]. Results from this review also positively associated in reduction of BP although the quality of the included trials was notified as low grade [ 11 ].

The mind body therapy which is a combination of physical exercise and meditation was examined by one review that included nine RCTs, 13 quasi experimental studies and 4 observational studies.

Only few of the included RCTs were methodologically strong in this systematic review [ 12 ]. An overview of systematic review investigated the effect of transcendental meditation—a technique for reducing stress on BP.

A total of eight systematic reviews including Cochrane reviews were included. Overall the assessment was fare in terms of the quality of the included reviews. Results from the overview also supported the role of meditation in lowering BP despite some conflicting results between included reviews [ 13 ].

Apart from dietary modifications, changing lifestyle, alternative medicine and meditation, therapeutic agent such as combination of Chlorthalidone and Amiloride have also been tested.

This double blinded, placebo controlled randomized trial demonstrates the significance of the therapeutic agent in preventing hypertension [ 14 ]. Despite significant effect on prevention, there is risk of experiencing adverse effect among the participants.

Taking regular medication for prevention may also raise question on compliance [ 15 ]. In addition, most of these interventions are based on high-income countries. LMICs are challenged with limited resources to provide useful programs for the early diagnosis, prevention, or control of this huge burden of disease [ 2 , 7 , 16 ].

Our objective of the present systematic review is to explore all available interventions which are nonpharmacological in approach and to synthesize their effectiveness in prevention of hypertension in LMICs. This systematic review has been carried out following the methodology of Cochrane systematic reviews [ 19 ] and addressed the requirements stated in preferred reporting items for systematic reviews and meta-analysis protocols guidelines [ 20 , 21 ].

Details methodology including the development of search strategy, dual-screening process, dual-data extraction, dual appraisal of included articles for quality assessment, narrative synthesis, and meta-analysis has been described in the published protocol [ 22 ]. The search period covered from to Randomized control trials providing nonpharmacological intervention on normotensive adult population in LMICs were included.

Reference management software was used to keep track of the screening process. Each of the studies was appraised critically for assessment of risk of bias ROB. A narrative synthesis of the characteristics of study participants and types of intervention with specific outcome was demonstrated.

Mean and standard deviation of both systolic and diastolic BP were recorded from baseline and endline information. The systematic review is registered in International Prospective Register of Systematic Reviews. Registration number is CRD A total of articles were retrieved after searching eight selected database using a comprehensive search strategy.

After removing the duplicates, articles were compiled for title and abstract review. Applying inclusion and exclusion criteria, 19 articles were selected for full text review.

We did not found the full text of four articles even after communicating with the corresponding author. The main causes of excluding these articles were irrelevance with the review objective.

After screening, seven RCTs were included in the final analysis. The detailed description of the selection process of the included articles has been provided in Fig. We assessed the ROB of the included trials using the guideline of Cochrane review.

Majority of the trials five out of seven performed the sequence generation randomly and reported accordingly. Only three articles described the process of allocation concealment.

Thus, there was potential risk of selection bias in almost half of the trials. Only two studies maintained blinding at the level of participants and implementers. Another two trials mentioned about blinding at the level of outcome assessors. Overall, majority five in each case of the trials were unable to minimize the chance of performance bias and detection bias.

Almost all the studies mentioned about attrition rate. Only one study did not describe regarding attrition and marked as unclear information. All the articles were with sufficient information regarding the primary outcome hence we recognized all of them as at low risk for selective reporting bias.

Majority of the studies did not provide any information regarding other potential biases. We did not get the description regarding contamination in cluster randomized trials and rationale behind the duration of washout period in the studies with crossover design.

A graphical demonstration of assessment of ROB has been provided in Figs. A summary description of the basic characteristics of the included articles has been given in Table 1. Among the seven included RCTs, two studies used clustered randomized design [ 23 , 24 ], two studies were randomized control trials [ 25 , 26 ] and three studies were with crossover design [ 27 , 28 , 29 ].

Among the three crossover trials, two studies incorporated a washout period of 1 and 3 weeks, respectively [ 28 , 29 ] before altering the treatment options. All the studies described the effectiveness of the intervention to prevent hypertension.

The main outcome, BP, was measured manually with two exceptions which considered both manual and electronic measurements [ 25 , 28 ]. Among these studies only two met the criteria of meta-analysis and rest of the studies were described using summary statistics.

All the included studies considered both male and female except one [ 26 ] where intervention was provided among the nonpregnant women. Sample size of the studies varied based on the design adapted.

Four studies were conducted in African region [ 23 , 25 , 26 , 28 ]; one was in Middle East [ 27 ] and two studies were conducted in South Asia [ 24 , 29 ]. All the studies included adult respondents and only one study included participants aged between 5 and 39 years [ 24 ].

Table 2 showed the results of studies that were not included in meta-analysis. These studies were heterogeneous enough for not including in the meta-analysis in terms of interventions, duration of the study, and study settings.

Azadbakht et al. Adeyemo et al. provided dietary intervention among normotensive adults in South East Nigeria to determine the feasibility of reducing dietary sodium intake [ 25 ]. BP of the participants was measured using both manual procedure and electronic device.

Hofmeyr et al. explored the effect of calcium on the BP among nonpregnant women who experienced pre-eclampsia previously [ 26 ]. The follow-up was conducted in two phases at 12 weeks and 24 weeks, respectively. Overall, the BP in calcium supplementation group was reduced but that was not statistically significant.

Forrester et al. This study was conducted in two regions of Nigeria and Jamaica and results were compared between these two zones as well.

BP was measured using both electronic automated machine and manual procedure. The average result from the two procedures was used in the final analysis. This study depicted that there is a significant efficacy of sodium reduction in lowering the BP.

These results were consistent with the studies conducted among affluent population in high income countries. Jessani et al. also estimated the effect of high and low sodium diet among the Pakistani population [ 29 ].

The washout period for both the groups was 1 week before the crossover phase. The crossover period with the altered diet was for another 1 week. Researchers measured the difference in SBP and diastolic BP in each phase as primary outcome. SBP was classified as high normal SBP and normal SBP.

In this analysis, only two articles fulfilled the criteria of meta-analysis. The forest plot is demonstrated in Fig. Comparison between home health education HHE and no HHE, outcome effect mean difference of systolic blood pressure and diastolic blood pressure.

In our review, it was not possible to observe the publication bias because of very few numbers of included studies for meta-analysis. Funnel plot generally used to estimate the risk of publication bias.

For only two studies, result of this graph is unpredictable. With an aim to examine the effectiveness of nonpharmacological interventions for prevention of hypertension in LMICs, this systematic review included seven trials incorporating patients from eight countries over the last 16 years.

Although a comprehensive search was undertaken, just seven studies met the inclusion criteria. The studies investigated a range of interventions on normotensive population including health education, soy drink, calcium supplementation, and low sodium diet. Only of two studies were eligible to [ 23 , 24 ] combine the outcomes through meta-analysis which showed the effects of health education on reducing BP in normotensive participants.

The significant change in BP indicates that positive effect of health education among normotensive individuals in reducing their BP. However, there were dissimilarities in number and age group among two study participants. Health education for the prevention of hypertension is widely used in the interventions which covered prehypertension individuals.

Moreover, this approach is also used for normotensive individuals to make them aware. Study showed that community-based health education program on hypertension and cardiovascular risk factors resulted into declining BP of the participants in the intervention group [ 31 ].

The behavior change communication messages mentioned in the included articles in this review focused on knowledge of lifestyle modification such as lowering salt intake in food [ 23 ], increased physical activity, cessation of smoking, consumption of low fat diet including dairy products, and increased intake of fruits and vegetables [ 24 ].

Another systematic review demonstrated the effectiveness of lifestyle modification on metabolic syndrome where information from eight trials were pooled together [ 32 ]. In this review, three studies reported effect on reducing BP through reduction in dietary sodium intake [ 25 , 28 , 29 ].

Intervention period in these studies were short, ranging from 2 to 8 weeks. The result showed significant effect of sodium intake modification, it is worth mentioning that the three included studies varied in their findings, reporting different range of changes in SBP and DBP.

A Cochrane review also demonstrated the significant change in BP among White, Black, and Asian people with normal BP where there was a greater reduction rate among Black and Asian people [ 33 ].

One RCT crossover design focused on the effect of soy drinks and cow milk among the females [ 27 ]. SBP reduced significantly but no significant changes in DBP due to the intervention of soy drink. However, included participants were obese and on a weight reducing diet.

Calcium tablet was given to intervention group in one study [ 26 ] where no significant change in reducing BP was observed. Similar results has been demonstrated in a systematic review incorporating sixteen trials [ 10 ] where slight reduction of BP was observed due to increase in dietary calcium intake.

However, these trials could not conclude with strong recommendations for this specific intervention. As per world health organization, sodium reduction in food intake can reduce BP in normotensive individuals [ 2 ].

In this systematic review, a trend toward reduction in BP was observed by dietary sodium reduction. Studies conducted by Law et al. and Miller et al. Many studies demonstrated that decreasing sodium in diets have benefits in lowering BP among prehypertensive participants [ 36 , 37 , 38 ].

Another crossover study reported no significant changes in BP due to the reduction of salt intake [ 40 ]. No studies on physical activities related intervention to reduce hypertension was found in LMICs.

However, meta-analysis of seven studies conducted among Brazilian population also demonstrated the significant impact of resistance exercise and aerobics in lowering both SBP and DBP [ 41 ]. Pooled estimate showed reduction in both systolic and diastolic pressures which was statistically significant.

But the sample size of included studies were very small with short intervention period and both normotensive and hypertensive patients were included. Another systematic review and meta-analysis conducted demonstrated that isometric handgrip exercise is efficacious for reducing SBP and DBP in adult participants [ 42 ].

We conducted a broad search of several databases but placed restrictions on the language of the study when searching the electronic databases. Studies published in english language were only considered in this review which is one of the main limitations.

It is likely that there are other studies published in other languages which we have missed in this review.

Non-pharmaceutical approaches to hypertension Primary Care volume Non-pharmaceutticalArticle approache Cite this No-pharmaceutical. Metrics details. The current guidelines for the prevention, detection, evaluation, and management of hypertension recommend six types Non-pharmaceutical approaches to hypertension non-pharmacological hypertenson alcohol reduction, salt intake reduction, increased Diabetic diet and nutrition tips intake, physical Non-pharmaceitical, weight Non-pharmaceutical approaches to hypertension, and heart-healthy diets. However, the non-pharmacological interventions are still not widely used in primary care. In this paper, we, therefore, reviewed and summarised the evidence on the effectiveness, cost-effectiveness, barriers, and facilitators of non-pharmacological interventions for the treatment of hypertension in primary care. A thorough literature search was conducted in Embase, Google Scholar, and PubMed databases, to identify the most recent reviews or, in their absence, primary studies on alcohol reduction, salt intake reduction, potassium supplementation, physical activity, weight reduction, heart-healthy diets, and other non-pharmacological interventions for the treatment of hypertension in primary care. Thank hypertendion for visiting nature. You hypsrtension using Probiotics and detoxification browser version with Non-pharmaceutical approaches to hypertension support for CSS. Non-pharmaceutical approaches to hypertension obtain the best experience, Non-pharmaceutical approaches to hypertension recommend you use a more up to date browser or hypeertension off compatibility mode in Internet Explorer. In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript. Hypertension is the single biggest cause of various cardiovascular complications and at the same time one of the most preventable phenomena. Low- and middle-income countries LMICs are facing increasing prevalence of hypertension which is imposing a huge burden on morbidity, premature mortality, and catastrophic health expenditure.

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Non-pharmaceutical approaches to hypertension -

The fixed effect model was built under the assumption of existing no heterogeneity. But this assumption was recognized to be unrealistic.

If the fixed effect model was applied when heterogeneity existed, uncertainty intervals become artificially narrow. Therefore, the random effects model was preferred since it assumed and accounted for unexplained heterogeneity.

In this network meta-analysis, we used a random effects model as the most appropriate and conservative method to explain the heterogeneity among the included studies 38 , We used a Markov chain Monte Carlo simulation with four chains with scattered initial values, a total of 50, iterations, and annealed after 5, iterations.

The convergence of the model was judged by the Brooks—Gelman—Rubin method A ranking probability curve of each treatment was provided by calculating the probability of each arm to achieve the best rank among all. We judged the inconsistency by comparing the deviance information criterion DIC between the consistency and inconsistency models Evaluating local incoherence between the direct and indirect comparisons, and obtaining indirect estimation was done by the node-splitting models We calculated the Bayesian P value to estimate the measure of the conflict between direct and indirect evidence Our search identified a total of 4, references.

After duplication, 3, studies underwent further analysis, of which 2, were excluded after reading the title or abstract and a further were excluded after reading the full text.

The remaining 39 studies involved 15 interventions and 8, patients were included in the analysis 45 — The study flow chart is shown in Figure 1. The baseline patient characteristics are shown in the Supplementary material 2.

Figure 1. Flow chart of literature search and article inclusion. RCT, randomized controlled trials; BP, blood pressure; SD, standard difference.

The network evidence plots for SBP and DBP were the same as shown in Figure 2. Figure 2. Network of intervention treatments included in meta-analysis. The size of the nodes represents the sample size.

The thickness of the lines represents the number of studies included in the comparison. Among the included intervention strategies, combination exercise And acupuncture Figure 3. Effect of top five interventions on SBP and DBP.

A, acupuncture; B, aerobic exercise; C, combination exercise; D, DASH; E, high Potassium; F, isometric exercise; G, lifestyle; H, meditation; I, normal exercise; J, reduced alcohol; K, resistance exercise; L, salt restriction; M, weight loss; N, yoga; O, usual care; CI, confidence interval; SBP, systolic blood pressure; DBP, diastolic blood pressure.

Among the categorized intervention groups, Strengthen exercise And relaxation Figure 4. Effect of five intervention groups on SBP and DBP. A, relaxation; B, usual care; C, lifestyle; D, Dietary; E, strengthen exercise; CI, confidence interval; SBP, systolic blood pressure; DBP, diastolic blood pressure.

Bar plot represents the probability of ranking of the reference intervention group. Results of node-splitting and heterogeneity tests are shown in Supplementary material 3 for detail.

The heterogeneity test showed that there was high heterogeneity between some studies for both pair-wise pooled effects and consistency effects. Potential explanations are given in a later discussion. The specific literature quality assessment diagram and risk of bias summary are shown in Supplementary material 4.

After assessing the quality of the literature by the Cochrane Handbook, we found that 27 studies reported the implementation of randomization, 8 studies reported the allocation concealment, and 15 studies reported on the implementation of blinding.

There was no selective reporting bias or result bias in all studies. Because these studies were aimed at NPIs, some study designs could not apply the blinding.

In summary, the quality of the articles included in this network meta-analysis was moderate. Detailed results of the certainty evaluation of evidence are shown in Supplementary material 5. Overall, most evidence was concentrated in the moderate and low grades since the existence of the risk of bias, inconsistency, indirectness, intransitivity, and imprecision.

This study evaluated the short-term effects of 16 NPIs in patients with prehypertension. Considering the impact on community-based chronic disease-management staff and their need for professional cooperation 25 , we merged 16 intervention items into five intervention groups.

We evaluated the effects using a network meta-analysis with BP reduction as the outcome indicator and found that combination exercise, isometric exercise, aerobic exercise, yoga, and normal exercise were the top five in SBP reduction, and acupuncture, meditation, combination exercise, isometric exercise and yoga for DBP reduction.

Also, according to our studies, sports intervention had more absolute SBP reduction and relaxation had more absolute DBP reduction than other interventions.

Strengthen exercise and relaxation rank top two in both SBP and DBP reduction. There were no inconsistencies but slight heterogeneity in this study. This was likely due to differences in the baseline characteristics e. Although the interventions share the same purpose, their contents were slightly different, given that current guidelines did not give standardized strategies for non-pharmacological intervention.

Patient compliance and completion rates may also differ among studies. However, this type of heterogeneity was unavoidable. Numerous studies have examined the short-term anti-hypertensive effects of NPIs. Williamson et al. Ndanuko et al. Khandekar et al. According to Liao et al.

Fu et al. Population in current evidence are hypertensive patients or combined with prehypertensive people. Pooled evidence studies target on the BP reduction effect of NPIs in prehypertensive people were lacking. In addition, current studies of the anti-hypertensive effects of NPIs have tended to target one specific intervention.

So the current results filled a gap in proving and comparing the short-term effects of NPIs in people with prehypertension. This was the first study to evaluate the short-term efficacy of NPIs in prehypertensive people.

Our results not only supplemented existing evidence in this area but also had important implications for the management of chronic diseases in countries who had a high disease burden of hypertension but with limited medical resources and community-based chronic disease-management staff.

Early prevention of hypertension through NPIs can be a potential way to reduce the disease burden. This meant that government administrators in these countries can start to initiate training programs that could reduce the BP of people with prehypertension effectively for community-based chronic disease-management staff to be prepared.

For decision-makers, a comprehensive analysis of which types of interventions could be more effective will provide useful evidence to make the optimal health decision. In this study, strengthen exercise and relaxation, which could bring more short-term BP reduction than other interventions according to current evidence, may be considered the priority for government administrators and community-based chronic disease-management staff.

Nevertheless, long-term effects of these NPIs with great short-term BP reduction benefits should be further examined including the number of CVD events avoided , which can provide more evidence for decision-makers. It is necessary to note that this study is not without shortcomings. First, the standardization of interventions in this study was carried out following the guidelines, still it may leave to subjectivity.

Second, due to differences in population baseline of included studies, the heterogeneity could not be avoided. Therefore, in our certainty of the evidence analysis, most comparisons were downgraded in the indirectness of evidence due to the differences in population and intervention.

Third, since individual patient data were not available, subgroup analyses were not conducted in this study. However, the heterogeneity caused by some key subgroups e. Fourth, since long-term studies were lacking, only BP change could be selected as the outcome indicator in this study. Without outcome indicators like cardiovascular events or hypertension progression, long-term real-world effectiveness of NPIs could not be recognized.

Even though we had proved that NPIs are effective for prehypertensive people, whether they are cost-effective was still unknown. For further research, more high-quality research with long-term outcome projections should be published to fill the gap in this field.

Studies are needed to target people with different clinical characteristics. Empirical studies on the inputs and outputs of NPIs in prehypertensive people are also needed to explore the cost-effectiveness and feasibility of implementation in a specific region.

To date, there is no systematic study revealing the comparative effects of NPIs for prehypertensive patients. Our study indicates that strengthening exercise including combination exercise, isometric exercise and aerobic exercise and relaxation including acupuncture, meditation, and yoga have potential to be educated and applied in community-based chronic disease management.

This will provide evidence for countries who have a high disease burden of hypertension but with limited medical resources and staff to prevent or delay the disease progression from prehypertension to hypertension. However, to have a decision on whether prehypertensive patients should be regularly managed and which strategy to be considered, further studies on cost-effectiveness and affordability are needed.

WT and TS designed the study and interpreted findings. TS and LL wrote initial drafts of the manuscript, developed the model, performed all model analyses, and visualized the data. TS, LL, YTa, WG, YTu, and YY conducted the literature search, screen, and extract the data. TS, LL, CZ, WT, and DM revised and polished the initial manuscript drafts.

All authors reviewed the manuscript. All authors had full access to all the data in the study and the corresponding authors had final responsibility for the decision to submit for publication.

This work was supported by General Program of National Natural Science Foundation of China We thank Susan Furness, PhD, from Liwen Bianji Edanz www.

cn , for basic language editing of a draft of this manuscript. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material 1. Search strategies of this study. Including reverse search and forward search. Supplementary material 2. Main characteristics of included trials. Supplementary material 3. Results of node-splitting and heterogeneity test. Supplementary material 4.

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search close. PREV Jun 1, NEXT. A 6 , 7 Limiting sodium intake to 2, mg per day is recommended to lower blood pressure. Additional benefit occurs with a limit of 1, mg per day. B 6 To lower blood pressure, patients should engage in moderate to vigorous aerobic physical activity three or four times per week for an average of 40 minutes per session.

A 6 , 14 Clinicians should ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. A 17 , 18 , 21 To lower blood pressure, alcohol consumption should be limited to no more than two drinks per day for most men and one drink per day for women.

C 2 , 22 Self-measured blood pressure monitoring, with or without additional support e. A 25 Patients with hypertension and obstructive sleep apnea should use continuous positive airway pressure to lower blood pressure. Sodium Intake. Physical Activity and Weight Loss. Smoking Cessation.

Advise patient to quit In a clear, strong, and personalized manner, urge every patient who uses tobacco to quit. Assess willingness to attempt to quit Is the patient willing to attempt to quit at this time?

Assist in quitting For patients who are willing to attempt to quit, offer medication and provide or refer for counseling or additional treatment. For patients who are unwilling to attempt to quit, provide interventions designed to increase future attempts to quit.

Arrange follow-up For patients who are willing to attempt to quit, arrange follow-up beginning within the first week after the quit date. For patients who are unwilling to attempt to quit, address tobacco dependence and willingness to quit at next visit.

Alcohol Consumption. Dietary Supplements. Relaxation Techniques. Self-Measured Blood Pressure Monitoring. Obstructive Sleep Apnea. RUPAL OZA, MD, is lead physician at Carepoint East Family Medicine and an assistant clinical professor of family medicine at The Ohio State University Wexner Medical Center in Columbus.

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Approwches is Cranberry homemade facial cleansers Non-pharmaceutical approaches to hypertension risk Noj-pharmaceutical for a number of cardiovascular diseases. Proper management Non-pharmaceutical approaches to hypertension Non-pharmacutical may require Non-;harmaceutical pharmacological and non-pharmacological interventions. Non-pharmacological interventions help reduce the daily dose of antihypertensive medication and delay the progression from prehypertension to hypertension stage. Non-pharmacological interventions include lifestyle modifications like dietary modifications, exercise, avoiding stress, and minimizing alcohol consumption. Nutritional requirements of hypertensive individuals can be addressed through adopting either the DASH diet or through traditional Mediterranean diet.