Primary Prevention 

of Hypertension:

Clinical and Public Health

Advisory from the National

High Blood Pressure

Education Program

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

NATIONAL INSTITUTES OF HEALTH

NATIONAL HEART, LUNG, AND BLOOD INSTITUTE

National High Blood Pressure Education Program

National Institutes 

of Health

National Heart, Lung, 

and Blood Institute

National High Blood Pressure

Education Program

NIH PUBLICATION

NO. 02-5076

NOVEMBER 2002

Primary Prevention 

of Hypertension:

Clinical and Public Health

Advisory from the National

High Blood Pressure

Education Program

PRIMARY PREVENTION OF HYPERTENSION CLINICAL AND PUBLIC HEALTH ADVISORY 

FROM THE NATIONAL HIGH BLOOD PRESSURE EDUCATION PROGRAM 

The Working Group iv

THE NATIONAL HIGH BLOOD PRESSURE EDUCATION PROGRAM COORDINATING 

COMMITTEE MEMBER ORGANIZATIONS v

FOREWORD vi

BACKGROUND 1

Method of guideline development 1

Evidence of classifications 2

LIFETIME BURDEN OF ELEVATED BLOOD PRESSURE 3

APPROACHES TO PRIMARY PREVENTION OF HYPERTENSION 4

Population-based strategy 4

Intensive targeted strategy 4

INTERVENTIONS WITH DOCUMENTED EFFICACY 6

Weight loss 6

Dietary sodium reduction 6

Increased physical activity 8

Moderation of alcohol consumption 8

Potassium supplementation 8

Modification of whole diets 8

INTERVENTIONS WITH UNCERTAIN OR LESS PROVEN EFFICACY 10

Calcium supplementation 10

Fish oil supplementation 10

Herbal or botanical dietary supplements 10

PRIMARY PREVENTION IN CHILDREN 11

ADDITIONAL RESEARCH 12

BARRIERS TO IMPROVEMENT 13

SUMMARY 14

REFERENCES 15

Contents
iv

COCHAIR

Paul K. Whelton, M.D., M.Sc.

Senior Vice President for Health Sciences

Professor of Epidemiology and Medicine

Tulane University Health Sciences Center

New Orleans, LA

COCHAIR

Jiang He, M.D., Ph.D.

Associate Professor of Epidemiology 

and Medicine 

Department of Epidemiology

Tulane University

School of Public Health and Tropical Medicine

New Orleans, LA

Lawrence J. Appel, M.D., M.P.H.

Professor of Medicine

Epidemiology and International Health

Johns Hopkins Medical Institutions

Baltimore, MD

Jeffrey A. Cutler, M.D., M.P.H.

Senior Scientific Advisor

Division of Epidemiology 

and Clinical Applications

National Heart, Lung, and Blood Institute

National Institutes of Health

Bethesda, MD

Stephen Havas, M.D., M.P.H., M.S.

Professor

Department of Epidemiology and 

Preventive Medicine 

University of Maryland School of Medicine

Baltimore, MD

Theodore A. Kotchen, M.D.

Professor of Medicine

Associate Dean for Clinical Research

Medical College of Wisconsin

Milwaukee, WI 

Edward J. Roccella, Ph.D., M.P.H.

Coordinator

National High Blood Pressure 

Education Program

Office of Prevention, Education, and Control

National Heart, Lung, and Blood Institute

National Institutes of Health

Bethesda, MD

Ron Stout, M.D., M.P.H.

Associate Director, Medical, Health Care

The Procter and Gamble Company

Health Care Research Center

Mason, OH

Carlos Vallbona, M.D.

Distinguished Service Professor

Department of Family and 

Community Medicine

Baylor College of Medicine

Houston, TX

Mary C. Winston, Ed.D., R.D.

Senior Science Consultant

American Heart Association

Dallas, TX

STAFF

Joanne Karimbakas, M.S., R.D.

National High Blood Pressure 

Education Program Partnership Leader

American Institutes for Research

Prospect Center

Silver Spring, MD

PRIMARY PREVENTION OF HYPERTENSION CLINICAL AND PUBLIC HEALTH ADVISORY 

FROM THE NATIONAL HIGH BLOOD PRESSURE EDUCATION PROGRAM

The Working Group
v

American Academy of Family Physicians

American Academy of Insurance Medicine

American Academy of Neurology

American Academy of Ophthalmology

American Academy of Physician Assistants

American Association of Occupational 

Health Nurses

American College of Cardiology

American College of Chest Physicians

American College of Occupational 

and Environmental Medicine

American College of Physicians—

American Society of Internal Medicine

American College of Preventive Medicine

American Dental Association

American Diabetes Association

American Dietetic Association

American Heart Association

American Hospital Association

American Medical Association

American Nurses Association

American Optometric Association

American Osteopathic Association

American Pharmaceutical Association

American Podiatric Medical Association

American Public Health Association

American Red Cross

American Society of Health-System Pharmacists

American Society of Hypertension

Association of Black Cardiologists

Citizens for Public Action on High Blood 

Pressure and Cholesterol, Inc.

International Society on Hypertension in Blacks

National Black Nurses Association, Inc.

National Hypertension Association, Inc.

National Kidney Foundation, Inc.

National Medical Association

National Optometric Association

National Stroke Association

NHLBI Ad Hoc Committee on 

Minority Populations

Society of Geriatric Cardiology

Society for Nutrition Education

Federal Agencies:

Agency for Healthcare Research and Quality

Centers for Medicare and Medicaid Services

Department of Veterans Affairs

Health Resources and Services Administration

National Center for Health Statistics, Centers for

Disease Control and Prevention

National Heart, Lung, and Blood Institute

National Institute of Diabetes and Digestive and

Kidney Diseases

THE NATIONAL HIGH BLOOD PRESSURE EDUCATION PROGRAM 

COORDINATING COMMITTEE MEMBER ORGANIZATIONS

The NHBPEP Coordinating Committee includes representatives from the following member organizations:
vi

Foreword

As part of its mission to translate research results into

practice, the National High Blood Pressure Education

Program (NHBPEP) Coordinating Committee

develops guidelines, advisories, and statements for

the clinical and public health community.

Its first statement on the primary prevention 

of hypertension was published in 1993. Since 

then, additional evidence supporting those recommendations has emerged.

A distinguished panel reviewed the scientific literature and worked with the NHBPEP Coordinating

Committee to develop this new advisory, which

updates the 1993 National High Blood Pressure

Education Program Working Group Report on Primary

Prevention of Hypertension. The new statement

recommends prevention of hypertension through

both a population-based strategy and an intensive

strategy focused on individuals at high risk 

for hypertension.

These two strategies are complementary and

emphasize six approaches: Engage in moderate

physical activity; maintain normal body weight;

limit alcohol consumption; reduce sodium intake;

maintain adequate intake of potassium; and consume a diet rich in fruits, vegetables, and lowfat

dairy products and reduced in saturated and total

fat. Applying these approaches can prevent blood

pressure from rising in the general population 

and can lower blood pressure in persons with high

normal blood pressure or hypertension.

Drs. Whelton and He are to be congratulated for

coordinating the efforts of updating the advisory to

reflect the latest scientific information on preventing

and managing elevated blood pressure, which

remains an important public health imperative.

Claude Lenfant, M.D.

Director

National Heart, Lung, and Blood Institute 

and

Chair

National High Blood Pressure Education 

Program Coordinating Committee
Background

A direct positive relationship between blood pressure

and cardiovascular risk has long been recognized.

This relationship is strong, continuous, graded,

consistent, independent, predictive, and etiologically

significant for those with and without coronary heart

disease (CHD);1F,2F it has been identified in both

men and women, younger and older adults, different

racial and ethnic groups, and different countries;

and applies to those with high-normal blood pressure

as well as those with hypertension.1F,3F

Despite progress in prevention, detection, treatment

and control of high blood pressure, hypertension

remains an important public health problem. 

Based on the Third National Health and Nutrition

Examination Survey (NHANES III), approximately

43 million noninstitutionalized U.S. adults, 18 years

of age or older, met the criteria for diagnosis of

hypertension (systolic blood pressure ≥ 140 mmHg

or diastolic blood pressure ≥ 90 mmHg, or taking

antihypertensive medication) recommended in 

The Sixth Report of the Joint National Committee on

Prevention, Detection, Evaluation, and Treatment 

of High Blood Pressure ( JNC VI).

4X,5Pr,6X Almost

13 million additional persons had been diagnosed

as having hypertension by a health care professional

but did not meet the previously mentioned JNC VI

criteria.6X Approximately 20 million of the estimated 43 million persons with hypertension were

not being treated with antihypertensive medication,

and almost 12 million of the nearly 23 million for

whom such medication was being prescribed had

inadequately controlled hypertension.6X More than

23 million adults had high-normal blood pressure

(130–139 mmHg systolic or 85–89 mmHg

diastolic),

and almost

38 million had

normal but above optimal

blood pressure levels (120–129

mmHg systolic or 80–84 mmHg diastolic).

Primary prevention of hypertension provides an

opportunity to interrupt and prevent the continuing costly cycle of managing hypertension and its

complications.7Pr The purpose of this article is to

update the 1993 National High Blood Pressure

Education Program Working Group Report on Primary

Prevention of Hypertension7Pr and to address the 

public health challenges of hypertension described

in the JNC VI report.5Pr

METHOD OF GUIDELINE DEVELOPMENT 

The National High Blood Pressure Education

Program (NHBPEP) Coordinating Committee

consists of representatives from 38 national

professional, public, and voluntary health

organizations and seven Federal agencies. As part of

the mission to translate research results into practice,

the NHBPEP Coordinating Committee develops

guidelines, advisories, and statements for the clinical

and public health communities. Since the first statement on the primary prevention of hypertension

was published in 1993,7Pr new and further evidence

supporting those recommendations has emerged.

The National Heart, Lung, and Blood Institute

(NHLBI) staff identified research suggesting the

need to update the NHBPEP 1993 report.7 The 

chair of the NHBPEP Coordinating Committee

appointed cochairs and additional members to 

1

1
2

serve as a working group on behalf of the

Coordinating Committee.

To assist the cochairs, NHLBI staff conducted a

MEDLINE search of the English-language, peerreviewed scientific literature since 1993 through

2002 using key Medical Subject Headings (MeSH)

terms hypertension, blood pressure, primary prevention,

exercise, weight loss, alcohol drinking, diet sodium-restricted,

dietary potassium, and diet.

The cochairs reviewed the MEDLINE search results,

identified new areas to be addressed, and, with the

assistance of NHLBI staff, developed an outline 

and subsequently assembled a working draft of the

document. The draft document was distributed to

the members of the working group for additions 

and modifications.

Thereafter, the additions and modifications were

tabulated and discussed via teleconferencing and

electronic mail. This process continued among

members of the working group, NHLBI staff, 

and cochairs in a reiterative fashion. The cochairs

adjudicated differences of opinions. The assembled

document was mailed to the working group members for their final comments. The cochairs then

revised the document and forwarded it to the entire

Coordinating Committee for review and comment.

A working group member presented the report to

the entire NHBPEP Coordinating Committee at

their February 2002 meeting, and they provided

oral and written comments to be included in the

document. Two meetings of NHLBI staff and the

cochairs were held to address and incorporate the

Coordinating Committee comments. Thereafter, 

the penultimate draft of the report was prepared

and sent to the Coordinating Committee, who

unanimously voted to approve it.

The development of this report was funded entirely

by the NHLBI. The members of the working group,

NHBPEP Coordinating Committee, and reviewers

served as volunteers without remuneration.

EVIDENCE OF CLASSIFICATIONS

The studies that provided evidence supporting the

recommendations of this report were classified and

reviewed by the staff, cochairs, and working group

members. The scheme used for classification of the

evidence is adapted from Last and Abramson.8

M Meta-analysis; use of statistical methods 

to combine the results from clinical trials

Ra Randomized controlled trials; also known 

as experimental studies

Re Retrospective analysis; also known as 

case-control studies

F Prospective study; also known as cohort

studies, including historical or prospective

followup studies

X Cross-sectional survey; also known as

prevalence studies

Pr Previous review or position statements

C Clinical interventions (nonrandomized)

These symbols are appended to the citations in 

the text and reference list.
Lifetime Burden of

Elevated Blood Pressure

Age-related increase in blood pressure is a typical

occurrence in most but not all populations.

Accordingly, the prevalence of hypertension increases

with increasing age, such that more than one of

every two adults older than 60 years of age has

hypertension.6X Experience in the Framingham Heart

Study suggests that the residual lifetime risk for

hypertension is 90 percent and the probability of

receiving antihypertensive medication is 60 percent

for middle-aged and elderly individuals.9F High

blood pressure increases morbidity and mortality

from CHD, stroke, congestive heart failure, and endstage renal disease.1F,10F,11F There is no convincing

evidence of a J-shaped relationship or a “threshold”

below which the relationship between level of blood

pressure and risk of cardiovascular and renal diseases

is not observed.12Pr The association of systolic blood

pressure with risk of cardiovascular and renal diseases

is stronger than the corresponding relationship 

for diastolic blood pressure.13M In light of such

knowledge, this advisory is

primarily focused on systolic

blood pressure.

High blood pressure is only 

one of several proven major

modifiable risk factors for

cardiovascular disease (CVD).

In combination, these factors

provide a powerful basis for

predicting risk and preventing

cardiovascular complications in

the general population. A recent

report of large cohort studies

conducted in 366,559 young 

and middle-aged men and

women indicated that persons with a low CVD-risk

profile (serum cholesterol level <200 mg/dL [5.18

mmol/L], blood pressure ≤ 120/80 mmHg, and 

no current cigarette smoking) have a 72 percent 

to 85 percent lower mortality from CVD and a 

40 percent to 58 percent lower mortality from 

all causes compared with persons who have one or

more of three modifiable cardiovascular risk factors.14F

The estimated greater life expectancy for the low-risk

group ranged from 5.8 to 9.5 years. Computer programs and risk-calculating charts are available to assist

clinicians and public health workers in determining

risk (http://www.nhlbi.nih.gov).15M

3

2
Approaches to Primary Prevention 

of Hypertension

Hypertension can be prevented by complementary

application of strategies that target the general

population and individuals and groups at higher risk

for high blood pressure. Lifestyle interventions are

more likely to be successful and the absolute reductions in risk of hypertension are likely to be greater

when targeted in persons who are older and those

who have a higher risk of developing hypertension

compared with their counterparts who are younger

or have a lower risk. However, prevention strategies

applied early in life provide the greatest long-term

potential for avoiding the precursors that lead to

hypertension and elevated blood pressure levels and

for reducing the overall burden of blood pressure

related complications in the community.

POPULATION-BASED STRATEGY

A population-based approach aimed at achieving a

downward shift in the distribution of blood pressure

in the general population is an important component

for any comprehensive plan to prevent hypertension.

As shown in the Figure on the next page, a small

decrement in the distribution of systolic blood

pressure is likely to result in a substantial reduction

in the burden of blood pressure-related illness.16Pr

In an analysis based on

Framingham Heart Study

experience, Cook et al.

concluded that a 2 mmHg

reduction in the population

average of diastolic blood

pressure for white U.S. residents 35 to 64 years of age

would result in a 17 percent

decrease in the prevalence of

hypertension, a 14 percent

reduction in the risk of stroke

and transient ischemic attacks,

and a 6 percent reduction in 

the risk of CHD.17F Public

health approaches, such as lowering

sodium content or caloric density in the food supply,

and providing attractive, safe, and convenient

opportunities for exercise are ideal population-based

approaches for reduction of average blood pressure

in the community. Enhancing access to appropriate

facilities (parks, walking trails, bike paths) and 

to effective behavior change models is a useful

strategy for increasing physical activity in the

general population.18

INTENSIVE TARGETED STRATEGY

More intensive targeted approaches, aimed at

achieving a greater reduction in blood pressure in

those who are most likely to develop hypertension,

complement the previously mentioned populationbased strategies for prevention of hypertension.

Groups at high risk for hypertension include those

with a high-normal blood pressure, a family history

of hypertension, African American (black) ancestry,

3

4

The greatest long-term 

potential for avoiding hypertension is to apply prevention

strategies early in life.
5

overweight or obesity, a sedentary lifestyle, excess

intake of dietary sodium and/or insufficient intake

of potassium, and/or excess consumption of alcohol.

Contexts in which intensive targeted interventions

can be conducted to prevent hypertension in

African Americans and older Americans include not

only health care settings but also senior centers and

faith-based organizations that have blood pressure

screening and referral programs.

Reducing the average diastolic

blood pressure in the U.S.

population by 2 mmHg 

would result in a 17 percent

decrease in the prevalence 

of hypertension...

FIGURE: Systolic Blood Pressure Distributions

Stamler R. Hypertension. 1991;17(Suppl 1):I16–20.

Reduction in BP % Reduction in Mortality

(mmHg) Stroke CHD Total

2 -6 -4 -3

3 -8 -5 -4

5 -14 -9 -7

Reduction in BP

Blood pressure, mmHg

Prevalence, %

After intervention Before intervention
Interventions With Documented Efficacy

The 1993 recommendations included weight loss,

reduced intake of dietary sodium, moderation in

alcohol consumption, and increased physical activity

as the best proven interventions for prevention of

hypertension. Since then, further evidence in

support of these recommendations has emerged. 

In addition, potassium supplementation and

modification of eating patterns has been shown to

be beneficial in prevention of hypertension. Brief

descriptions of the six recommended lifestyles with

proven efficacy for prevention of hypertension are

presented in the Box on page 9. A summary of

selected intervention efficacy experience published

since 1993 is presented in the following sections.

WEIGHT LOSS

A comprehensive review of the evidence supporting

the value of modest reductions in body weight is

provided in the Clinical Guidelines for the Identification,

Evaluation, and Treatment of Overweight and Obesity

in Adults.19Pr He et al. reported on the experience of

181 normotensive persons who had participated in

Phase I of the Trials of Hypertension Prevention.20F

During their initial 18 months of active intervention

those assigned to the weight loss group reduced

their body weight by 7.7 lb (3.5 kg) and their

systolic and diastolic blood pressures by 5.8 and 

3.2 mmHg, respectively. After 7 years of followup,

the incidence of hypertension was 18.9 percent 

in the weight loss group and 40.5 percent in the

control group. These findings suggest that weight

loss interventions produce benefits that persist long

after the cessation of the active intervention. In

phase II of the Trials of Hypertension Prevention,

the 595 participants assigned to a weight loss counseling intervention experienced a 21 percent reduction

in incidence compared with 596 counterparts assigned

to usual care.21Ra Weight loss participants who were

able to lose 9.7 lb (4.4 kg) or more and to sustain this

weight loss through the 36 month period of followup

experienced average reduction in systolic and diastolic

blood pressure of 5.0 and 7.0 mmHg, respectively.22Ra

DIETARY SODIUM REDUCTION

At least three meta-analysis of the efficacy of

reduced sodium intake in lowering blood pressure

have been published since 1993.23M,24M,25M In all

three reports, sodium reduction was associated with

a small but significant reduction in systolic blood

pressure in normotensive persons. ln a meta-analysis

of 12 randomized controlled trials conducted in

1,689 normotensive participants, Cutler and

colleagues estimated that an average reduction of

77 mmol/d in dietary intake of sodium resulted in

a 1.9 mmHg (95 percent confidence interval [CI],

1.2–2.6 mmHg) decrement in systolic blood pressure

and a 1.1 mmHg (95 percent CI, 0.6–1.6 mmHg)

decline in diastolic blood pressure.23M

4

6

A sustained weight loss of 

9.7 lb (4.4kg) or more can

reduce systolic and diastolic

blood pressure by 5.0 and 

7.0 mmHg, respectively.
7

In a randomized controlled trial (Dietary Approaches

to Stop Hypertension [DASH]-Sodium Trial) conducted in 412 persons with an average systolic blood

pressure of 120 to 159 mmHg and an average diastolic blood pressure of 80 to 95 mmHg, a reduction

in sodium intake from a high level (mean urinary

sodium excretion, 142 mmol/d) to an intermediate

level (mean urinary sodium excretion, 107 mmol/d)

reduced systolic blood pressure by 2.1 mmHg

(P<.001) during consumption of a usual American

control diet and by 1.3 mmHg (P=.03) during consumption of a DASH diet that was high in fruits and

vegetables and lowfat dairy products.26Ra Reducing

sodium intake from the intermediate level to a lower

level (mean urinary sodium excretion, 65 mmol/d)

resulted in an additional reduction in systolic blood

pressure of 4.6 mmHg during consumption of the

control diet (P<.001) and 1.7 mmHg reduction

during consumption of the DASH diet (P<.01). The

effects of sodium reduction were greater for those

who ate the typical American diet, compared with

those on the DASH diet.26Ra These findings are

consistent with current national recommendations

for a moderately low intake of dietary sodium (no

more than 100 mmol/d: approximately <6 g of

sodium chloride or <2.4 g of sodium per day) by

all Americans5Pr and suggest that an even lower

level of dietary sodium intake may result in a

greater reduction in blood pressure.

In a large, long-term community-based

randomized controlled trial,

Whelton et al. reported that a

moderate reduction of dietary

sodium intake resulted in an

additional 4.3 mmHg reduction in systolic blood

pressure among older

persons with hypertension whose blood

pressures were

already well controlled by a single

antihypertensive

medication.27Ra For those assigned to a combined

sodium reduction and weight loss intervention, the

corresponding additional reduction in systolic blood

pressure was 5.5 mmHg. The need for antihypertensive medication during a subsequent 18 month

period of followup was reduced by 31 percent and

53 percent in those assigned to sodium reduction

and combined sodium reduction and weight loss,

respectively. Although not directly relevant to prevention of hypertension, the results of this trial provide

additional evidence in support of the role of weight

loss and moderate sodium reduction as means to

reduce blood pressure, even for persons who have

been taking antihypertensive medication.

In the NHANES I Epidemiologic Follow-up Study,

He et al. reported that a 100 mmol higher level of

sodium intake in overweight persons was associated

with a 32 percent increase in stroke incidence, a 

89 percent increase in stroke mortality, a 44 percent

increase in CHD mortality, a 61 percent increase 

in CVD mortality, and a 39 percent increase in

mortality from all causes.28F In Finland in a prospective population-based cohort study conducted in

1,173 men and 1,263 women 25 to 64 years of

age, the hazard ratios for CHD, CVD, and all-cause

mortality, associated with a 100 mmol higher level of

The upper limit of dietary

sodium intake is 2,400 mg

per day.

Lower intake of dietary

sodium reduces the risk 

of cardiovascular disease, 

especially in those who 

are also overweight.
8

24 h urinary sodium excretion, were 1.51 (95 percent

CI, 1.14–2.00), 1.45 (95 percent CI, 1.14–1.84),

and 1.26 (95 percent CI, 1.06–1.50), respectively.29F

There was a significant interaction between sodium

excretion and body mass index for cardiovascular and

total mortality, with sodium being a stronger predictor

of mortality in men who were overweight. These data

support the premise that a lower intake of dietary

sodium reduces the risk of subsequent CVD, especially

in those who are also overweight.

INCREASED PHYSICAL ACTIVITY

A meta-analysis by Whelton et al. in which the

experience of 1,108 normotensive persons enrolled

in 27 randomized controlled trials was included,

identified a 4.04 mmHg (95 percent CI, 2.75–5.32)

reduction in systolic blood pressure in those assigned

to aerobic exercise compared with the control

group.30M The magnitude of the intervention effect

appears to be independent of the intensity of the

exercise program. In the Physical Activity and Health:

A Report of the Surgeon General it is recommended that

persons exercise for at least 30 minutes on most, if

not all, days of the week.31Pr

MODERATION OF ALCOHOL CONSUMPTION

In a meta-analysis of 15 randomized controlled trials,

Xin et al. reported that decreased consumption of

alcohol (the median reduction in self-reported consumption of alcohol was 76 percent, with a range

from 16 percent to 100 percent) was associated

with a reduction in blood pressure, and that the

relationship between reduction in mean percentage

of alcohol and decline in blood pressure was 

dose-dependent.32M Pooling of the experience 

of 269 normotensive participants enrolled in 

6 randomized controlled trials identified a reduced

consumption of alcohol as being associated with 

a 3.56 mmHg (95 percent CI, 2.51–4.61) lower

level of systolic blood pressure and a 1.80 mmHg

(95 percent CI, 0.58–3.03) lower level of diastolic

blood pressure.32M Therefore, it is recommended

that alcohol consumption be limited to no more

than 1 oz (30 mL) ethanol (e.g., 24 oz [720 mL]

beer, 10 oz [300 mL] wine, or 2 oz [60 mL] 

100-proof whiskey) per day in most men and to 

no more than 0.5 oz (15 mL) ethanol per day in

women and lighter weight persons.

POTASSIUM SUPPLEMENTATION

Clinical trials and meta-analysis indicate that

potassium supplementation lowers blood pressure

in both hypertensive and normotensive persons. 

In a meta-analysis of the results from 12 trials 

with 1,049 normotensive participants, Whelton 

et al. reported that potassium supplementation

(median, 75 mmol/d) lowered systolic blood pressure by 1.8 mmHg (95 percent CI, 0.6–2.9) and

diastolic blood pressure by 1.0 mmHg (95 percent

CI, 0.0–2.1).33M The effects of potassium supplementation appeared greater in those with higher

levels of sodium intake.

MODIFICATION OF WHOLE DIETS

The DASH and DASH-Sodium trials used dietary

interventions that incorporated several nutritional

recommendations for lowering blood pressure.26Ra,34Ra

In the 8 week DASH trial, study participants with a

systolic blood pressure less than 160 mmHg and a

diastolic blood pressure between 80 and 95 mmHg

It is recommended that persons

exercise for at least 30 minutes

on most, if not all, days of 

the week.

Potassium supplementation

lowers blood pressure in 

both hypertensive and

normotensive persons.
9

were randomly assigned to one of the following diet

groups: (1) a control diet that was low in fruits, vegetables, and dairy products, with a fat content typical

of the average diet in the United States, (2) a similar

diet that was rich in fruits and vegetables, or (3) a

DASH diet that was rich in fruits, vegetables and

low-fat dairy products but reduced in saturated and

total fat.35 Among the 326 normotensive DASH

participants (blood pressure <140/90 mmHg), 

the DASH diet reduced systolic blood pressure by

3.5 mmHg (P<.001).34Ra In a subsequent DASHSodium study, normotensive persons assigned to 

the DASH diet and a low level of urinary sodium

excretion (67 mmol/d) reduced their systolic blood

pressure by 7.1 mmHg (7.2 mmHg for blacks and

6.9 mmHg for others) compared with counterparts

who were assigned to the control diet and a high

level of urinary sodium excretion (141 mmol/d).26Ra

A significant reduction in diastolic blood pressure

was also observed. Furthermore, the beneficial effects

of the DASH diet and the DASH diet with reduced

sodium occurred broadly in all major subgroups of

the population.36Ra

The beneficial effects of the

low sodium DASH diet

occurred in all major subgroups of the population.

1. Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes 

per day, most days of the week).

2. Maintain normal body weight for adults (body mass index 18.5–24.9 kg/m2

).

3. Limit alcohol consumption to no more than 1 oz (30 mL) ethanol (e.g., 24 oz [720 mL] 

of beer, 10 oz [300 mL] of wine, or 2 oz [60 mL] 100-proof whiskey) per day in most 

men and to no more than 0.5 oz (15 mL) of ethanol per day in women and lighter 

weight persons.

4. Reduce dietary sodium intake to no more than 100 mmol per day (approximately 

2.4 g of sodium or 6 g of sodium chloride).

5. Maintain adequate intake of dietary potassium (more than 90 mmol [3,500 mg] per day). 

6. Consume a diet that is rich in fruits and vegetables and in lowfat dairy products with 

a reduced content of saturated and total fat (Dietary Approaches to Stop Hypertension

[DASH] eating plan). 

Lifestyle Modifications for Primary Prevention of Hypertension
Interventions With Uncertain

or Less Proven Efficacy

CALCIUM SUPPLEMENTATION

Consistent with previous observations, a recent metaanalysis of randomized controlled clinical trials suggests

that calcium supplementation results in only a small

reduction in blood pressure.37M This effect has only

been observed in those with hypertension. However,

for general health, it is prudent to recommend

adequate calcium intake as a component of any 

diet (1,000–1,200 mg/d for adults).38Pr

FISH OIL SUPPLEMENTATION

Two meta-analysis of clinical trials indicate that supplementation with relatively high doses of omega-3

polyunsaturated fatty acids (omega-3 PUFA) lowers

blood pressure in hypertensive patients, especially 

in those with untreated hypertension.39M,40M In normotensive persons, however, the effect seems to be

small. For example, in a pooled analysis of 11 trials

with 728 normotensive participants, Appel et al.

reported that fish oil supplementation (3.4 g/d)

lowered systolic blood pressure by only 1.0 mmHg

(95 percent CI, 0.0–2.0) and diastolic blood pressure

by 0.5 mmHg (95 percent CI, –0.2–1.2).39M Adverse

effects, including eructation and a fishy taste, were

more common in those assigned to fish oil capsules

than in their controls. Although evidence for a blood

pressure-lowering effect of fish oil is modest, observational epidemiological studies and clinical trials

have suggested that an increased intake of fish oil

may reduce the risk of CHD and stroke.41Ra,42F

HERBAL OR BOTANICAL DIETARY SUPPLEMENTS

There has been considerable increase in the use of

herbal products in the United States. Results from

the 1998–1999 Slone Survey indicated that about 

14 percent of U.S. adults were taking herbal products.43X The 10 most commonly used herbal products

are ginseng, Ginko biloba extract, Allium sativum,

glucosamine, St. John’s wort, Echinacea augustifolia,

lecithin, chondroitin, creatine, and Serenoa repens.

43X

Dietary supplements including herbals do not

undergo the same stringent regulatory approval

process as drugs. Food and drug laws do not require

demonstration of safety and efficacy to support legal

marketing of dietary supplements. There is a lack of

standardization among brands of supplements, and

the bioactive ingredient of products can vary widely.

Few clinical trial reports are available to support

the use of herbal and botanical supplements in 

the prevention or treatment of high blood pressure

or heart disease. At a minimum, health care professionals should ask their patients about the use of

herbal products and consider the possibility of 

herb-drug interactions.

5

10

Health care professionals

should ask their patients about

the use of herbal products and

consider the possibility of herb

drug interactions.
Primary Prevention in Children

There is ample evidence that hypertension begins in

childhood. Children with higher than average blood

pressure levels early in life are more likely to develop

hypertension later in life. Efforts to prevent blood

pressure from increasing in childhood are prudent

and best accomplished by application of the same

lifestyle approaches used to prevent and treat

hypertension in adults.44Pr

Accordingly, school administrators are encouraged to

examine their lunch menus and promote the use of

heart healthy foods. Parents are encouraged to read

food labels and make wise choices for lunches prepared at home. In addition, school curricula should

include health education programs that promote

increased physical activity and other healthy lifestyles

aimed at prevention of cardiovascular and other

chronic diseases.

11

6

High blood pressure prevention and treatment should

encourage lifestyle changes in

children, as well as adults.
Additional Research

Further strengthening

of the science that underpins

strategies for implementation and maintenance of

hypertension prevention strategies is warranted.

Some of the most pressing needs include:

(1) attaining a better understanding of physical and

behavioral factors that influence blood pressure

during growth and development,

(2) gaining additional knowledge of the efficacy and

effectiveness of specific dietary interventions, such as

increased dietary protein or dietary fiber intake, and

other modifications of whole diets in the prevention

of hypertension,

(3) testing alternative strategies for implementation of

nonpharmacologic interventions, including nutrition

education, in clinical and community settings,

(4) enhancing the capacity to change general environmental exposures to diet and exercise in a favorable

manner, by working with the food industry and

planning agencies,

(5) identifying and testing culturally specific

approaches for hypertension prevention,

(6) maintaining a strong program of behaviorally

focused research to strengthen the empirical base 

of educational interventions, and

(7) characterizing phenotypic and genetic predictors

of response to interventions for prevention of hypertension in an individual and/or group.

7

12
Barriers to Improvement

Cultural norms, insufficient attention to health education and lack of referral to registered dietitians,

economic disincentives to healthier lifestyles, lack of

reimbursement for hypertension prevention counseling

services by third-party payers, and other barriers to

prevention of hypertension continue to impede

progress. For example, economic disincentives to

healthier lifestyles include higher prices for low

sodium products and lower unit pricing for larger

portions. To overcome this barrier, professional

associations and policy developers should work with

the food industry to increase availability of lower

sodium food products and to provide educational

programs for consumers regarding portion size and

heart healthy food choices. In addition, insufficient

attention to health education, including nutrition

education, by health care providers, school systems,

and public health and voluntary associations is 

an impediment 

to progress.

13

8
Summary

A combination of increased physical activity, moderation in alcohol intake, and consumption of an eating

plan that is lower in sodium content and higher in

fruits, vegetables and lowfat dairy products than the

average American diet represents the best approach

for preventing high blood pressure in the general

population and in high risk groups. The demonstrated reductions in blood pressure using lifestyle

changes can be as large as those seen in drug studies,

occur in virtually all subgroups of the population,

and can be sustained over a long period of time

(more than 3 years). Additional education of health

care professionals and the general public, enhanced

means of support for those attempting to change

their lifestyles, and policies aimed at reducing the

burden in complying with the recommendations for

nonpharmacologic reductions in blood pressure are

essential elements for any national program aimed 

at prevention of hypertension. Given that

sodium added during processing of foods accounts for

approximately three quarters

of an individual’s total

sodium intake, any

meaningful reduction

in sodium intake is

predicated on a

decrease in dietary sodium from food sources.45F This

could be achieved by gradually reducing the amount

of sodium added during processing and by greater

availability and promotion of foods with a lower

sodium content. Reduction in discretionary salt intake

at the table and during cooking is desirable but

unlikely to have a major impact on dietary sodium

intake in most persons. Despite the acknowledged

challenges to implementing these recommendations,

the potential for health benefits makes continued

efforts to achieve prevention of hypertension an

important national objective.

9

14
15

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