Alternatives to Drug Therapy for Patients with

Hypertension: A Literature Review

By David Kauffman

Faculty Advisor: Marcus W. De Geer, MD, DC

Logan College of Chiropractic

October 1, 2011

1

Abstract

Introduction:

Hypertension is a common condition that can lead to serious health problems such as

cardiovascular disease, stroke, or renal failure. While effective medications are used for the

control of hypertension, there are alternative treatments that do not carry the side effects of the

drugs that are commonly prescribed for hypertension. However, an analysis of the efficacy of

different types of alternative care for hypertension is needed.

Alternatives to drug therapy:

The alternatives to drug therapy that were analyzed in this review of the literature include the

following: vitamin D, salt restriction, the DASH diet, fish oil, CoQ10, garlic, magnesium,

chocolate, calcium, tai chi, qi gong, other exercise, weight loss, biofeedback, meditation,

acupuncture, and chiropractic adjustments.

Discussion:

The blood pressure lowering methods that have the most comprehensive and promising research

for their efficacy include salt restriction and the DASH diet, chocolate, CoQ10, garlic,

magnesium supplementation, fish oil, weight loss, and meditation.

Conclusion:

The aforementioned efficacious alternative methods for reducing blood pressure should be

considered for the management of a patient with hypertension.

Key Words: Hypertension, Salt restriction, Vitamin D, DASH diet, Fish Oil, CoQ10, Garlic,

Magnesium, Chocolate, Calcium, Tai Chi, Qi Gong, Exercise, Weight Loss, Biofeedback,

Meditation, Acupuncture, Chiropractic Adjustments

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Introduction

The World Health Organization has defined hypertension as systolic blood pressure greater than

140 mmHg and diastolic blood pressure greater than 90 mmHg. Diabetic patients and those

individuals who have had a previous myocardial infarction have a definition of high blood

pressure that is 130/85 mmHg or above.1 In order to diagnose an individual with hypertension, a

measurement of high blood pressure must be recorded three times on different occasions.

Hypertension is a condition that most people have at some point in their lives according to the

National Institutes of Health (NIH).5 Essential (primary) hypertension accounts for over 90% of

people with hypertension. Essential hypertension is an idiopathic condition, meaning that the

underlying cause of the condition is unknown. Therefore, less than 10% of those with

hypertension have secondary hypertension, which is caused by a defined disease such as

Cushing’s syndrome, Conn’s syndrome, renal disease, obesity, or pheochromocytoma. This

review will focus on the treatment of essential hypertension, because the treatment for secondary

hypertension is fundamentally to treat the underlying known disease or diseases.1

The importance of effective treatment of hypertension is that this condition can lead to organ

damage. The organs that can be negatively affected by hypertension are the heart, the brain, the

kidneys, the eyes, and the arteries. Vasquez2 stated that “HTN [hypertension] is the single most

important risk factor for developing CVD [cardiovascular disease].” More specifically, the

cardiovascular system can be compromised by hypertension via left ventricular hypertrophy,

diastolic or systolic heart failure, coronary artery disease, myocardial infarction, arteriosclerosis,

or aneurysm formation due to hypertension. Stroke, chronic renal failure, or papilledema can also

occur due to hypertension.1 Worldwide, hypertension has been identified as the cause of more

than seven million premature deaths. 7

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Discussion

The National Institutes of Health (NIH) defines prehypertension as systolic blood pressure

between 120-140mmHg, or diastolic blood pressure between 80-90mmHg.5 It is necessary to

treat patients with prehypertension because 68% of all mortality attributed to high blood pressure

occurs with systolic blood pressure between 120 and 140 mmHg, and diastolic blood pressure

below 90 mmHg.4 Obviously, it is extremely important to treat patients with prehypertension as

well as hypertension, however, medical treatments for prehypertension and hypertension are not

without dangerous side effects.

Pharmacological treatment:

There are numerous medications that are used by medical doctors to treat hypertension. Often

pharmaceutical agents are used in combination for greater effect. According to the National

Heart Foundation Guidelines of 2008, Angiotensin-converting enzyme inhibitors (ACE

inhibitors), Angiotensin II receptor blockers (ARBs), and thiazide diuretics are to be considered

first-line pharmaceutical agents.6 Unfortunately, there are numerous side effects attributed to all

of these pharmaceutical agents. Because of these side effects, it is necessary to pursue alternative

treatments for patients with hypertension.

Angiotensin-converting enzyme (ACE) inhibitors are known to be very effective

antihypertensive medications. The side effects reported for these medications include dry cough,

angioedema, hyperkalemia and postural hypotension. The side-effects of a specific brand of ACE

inhibitors called Vasotec® includes low blood pressure, dizziness, fatigue, headache, nausea,

vomiting, diarrhea, chest pain, and rash. Taking Vasotec during the second or third trimesters of

pregnancy could cause serious problems or even death to the baby.3 Obviously, the number and

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severity of side effects associated with ACE inhibitors like Vasotec drives the need for

alternative treatments for patients with hypertension.

Angiotensin II receptor blockers (ARBs) are also effective antihypertensive medications.

The side effects associated with an ARB called Benicar include aching muscles, hematuria,

chest pain, diarrhea, dizziness, flu symptoms, headache, irregular heartbeat, nasal infection, rash,

sinus infection, sore throat, upset stomach, and low blood pressure.3

Thiazide diuretics are a cheaper agent with moderate potency in lowering blood pressure.

Thalitone is an example of a thiazide diuretic that has side effects that include anemia, changes

in blood sugar, hypokalemia, thirst, tiredness, drowsiness, restlessness, muscle pains, nausea,

increased heart rate or pulse, constipation, cramping, diarrhea, dizziness, headache, impotence,

inflammation of the pancreas, loss of appetite, low blood pressure, muscle spasms, nausea, rash,

restlessness, sensitivity to light, stomach irritation, vomiting, weakness, and yellow eyes and

skin.3

Additionally, simply treating hypertension with drugs will not help decrease comorbid factors

such as diabetes, obesity, hyperuricemia, and nutritional deficiencies. If the hypertensive patient

is treated with a combination of alternative therapies such as certain exercise programs, changing

dietary habits, and stress reduction techniques such as meditation, some of the comormid

conditions that a hypertensive patient may have could be treated as well. By decreasing the

comorbid factors, the patient’s overall risk of mortality can be decreased (which is the major

reason for treating hypertension). Obviously there is a need for alternative treatments for treating

5

patients with hypertension. The efficacy of a number of the better recognized alternative

treatments for hypertension are described in this review of the literature.

Alternatives to Drug Therapy

Nutrition

Salt restriction and the DASH diet:

A systematic review found that salt restriction in eight different randomized controlled clinical

trials led to a decrease in mean systolic blood pressure of 2.9 mmHg, and a decrease in mean

diastolic blood pressure of 2.1 mm Hg.8 Another overview article of thirty-two trials showed that

a 100mmol decrease in urine sodium excretion per day led to decreases in systolic and diastolic

blood pressure by 5.8 and 2.3 mmHg respectively for hypertensive individuals.19

It is unknown if

this decrease in blood pressure would be sustained as the trial was only one month in duration.

The Trial of Antihypertensive Interventions and Management study by Langford et al.20

was a

multicenter randomized clinical trial that analyzed both pharmacological and dietary changes on

diastolic blood pressure only. This was a large study with 787 total participants who had a mean

diastolic blood pressure of 93.8 mmHg. Although the pharmacological interventions (diuretics

and beta-blockers) lowered blood pressure significantly more than diet or exercise (by 4.5 mmHg

and 3.4 mmHg respectively), lowering salt intake and increasing potassium intake decreased the

diastolic blood pressure by 7.9 mmHg on average. Losing 4.7 kg of weight resulted in an 8.8

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mmHg decrease in diastolic blood pressure. This trial was done over six months and therefore

provides some data on long-term effects of these interventions. Another large study by Langford

et al.24

involving 584 participants showed that 78% of mild hypertensives who practiced salt

restriction experienced a decrease in blood pressure.

The DASH diet is described as follows; “it emphasizes fruits, vegetables, and low-fat dairy

products, that includes whole grains, poultry, fish, and nuts, that contains only small amounts of

red meat, sweets, and sugar-containing beverages, and that contains decreased amounts of total

and saturated fat and cholesterol” according to Sacks et al.35

Sacks also stated “The DASH diet

lowers blood pressure substantially both in people with hypertension and those without

hypertension, as compared with a typical diet in the United States.” A study that was published

in the New England Journal of Medicine in 2001 explored the relationship of salt intake, the

DASH diet, and blood pressure.35

198 subjects completed the DASH diet protocol, and 192

completed the control group diet over a 30-day trial period. Each of the two groups was divided

into three subgroups of high sodium, intermediate sodium, and low sodium diets. The results

showed that reducing sodium intakes from the high to intermediate, as well as intermediate to

low levels of sodium for both the DASH diet group and the control group led to decreases in

systolic blood pressure. When the DASH diet with low sodium group was compared with the

control group with high sodium, the DASH diet proved to lower systolic blood pressure in

normotensive subjects by 7.1 mmHg, and 11.5 mmHg in hypertensive subjects. Therefore it is

recommended that people with hypertension consume less than 2.3 grams of sodium per day, and

eat a diet consistent with that of the DASH diet protocol.

Chocolate:

7

Chocolate can be found as an ingredient in many unhealthy snacks and candy bars, however, the

evidence for the beneficial effects of eating small amounts of dark chocolate rich in cocoa is

gaining. Over the past decade the topic of chocolate and blood pressure has gained substantial

evidence in the peer reviewed literature. The proposed mechanism of action for chocolate’s

effects on blood pressure is founded on the polyphenols contained in cocoa. Particular

polyphenols, called flavanols increase the formation of endothelial nitric oxide, which promotes

vasodilation and therefore decreases blood pressure. A culmination of this evidence was put

together by Ried et al. in a meta-analysis.27

The authors searched for randomized controlled trials

from 1955 to 2009 and analyzed fifteen total trials. The analysis included trials that explore the

effect of taking cocoa-rich foods daily for at least two weeks as compared with a placebo. Nine

trials used 50-70% cacao, and six trials used flavanol dosages (found in chocolate) from 30-1000

mg. The pooled results showed that for hypertensive and pre-hypertensive patients cacao-

chocolate compared to control groups had experienced a decrease in systolic blood pressure of

5.0 mmHg and a decrease in diastolic blood pressure of 2.7 mmHg. Normotensive subjects did

not experience a statistically significant decrease in blood pressure. Although the authors found

four studies that did not show a significant difference between the chocolate-consuming group

and the control group, the overwhelming evidence shows that cacao-rich chocolate foods do have

an antihypertensive effect.

Vitamin D:

A study utilizing 24-hour recall data to determine calcium and vitamin D intakes of 86 women

showed promising results for a relationship between vitamin D intake and hypertension. The

8

older population of women (ages 55-80) who consumed less than the RDA of vitamin D had a

greater likelihood of having high blood pressure. However, these women also had a lower intake

of calcium than the RDA. The researchers did not account for the possibility that the women

with a lower vitamin D intake may also have generally poorer health. In the younger population

(ages 20-35) there was a statistically significant inverse relationship between vitamin D intake

and high blood pressure after adjusting for other confounding variables such as body size and

alcohol consumption. Again, not all confounding variables were accounted for, however, this

study shows promise for further research to be done on the topic.12

A study by Forman et al.9 had concluded the following; “higher intake of vitamin D is not

associated with a lower risk of incident hypertension.” These results were derived from analysis

of three large prospective cohort studies. The studies included the Nurses Health Study I, the

Nurses Health Study II, and the Health Professionals Follow Up Study. Each cohort was

followed for at least eight years. The study compared participants who consumed over 1600 IUs

of vitamin D per day to those who consumed less than 400 IUs per day, and over 1000IUs to less

than 200 IUs. The data showed no statistical difference between these categories as related to

blood pressure.9

A study conducted in Norway of over 15,000 subjects, both male and female, found no statistical

significance between vitamin D intake from dairy and blood pressure values.13

This study had

accounted for confounding variables including age, body mass index, alcohol and caffeine

intake, physical activity and cigarette smoking. Obviously, there is conflicting evidence for

whether or not vitamin D intake affects blood pressure. More studies need to be done with

9

controlled vitamin D supplementation or controlled dietary intakes of vitamin D. Also, the

amount of time in the sun and the skin complexion must be controlled in order to be more precise

with total vitamin D intake. It should also be noted that vitamin D plays a vital role in promoting

calcium absorption, which is a proposed mechanism of having any effect on lowering blood

pressure. The effect of calcium intake on hypertension is explored in the next section.

Calcium:

Sowers et al.12

found through a cross sectional study that there was no significant association

between blood pressure and level of daily calcium intake in women 20-35, or 55-80 years of age.

Jorde and Bonaa13

reported results just opposite of those found by Sowers et al. In this cross-

sectional study only calcium and vitamin D intake from dairy products was evaluated as a

possible mechanism of lowering blood pressure. The authors found a correlation between those

who consumed more calcium through dairy and lower blood pressure measurements.

Although the studies including overall calcium intake that were performed in the above articles

showed conflicting results, the data on calcium supplementation is more clear cut. Mierlo et al.34

performed a meta-analysis of randomized controlled trials on blood pressure response to calcium

supplementation in 2006. 40 randomized controlled studies met the inclusion criteria of this

analysis. The authors found that calcium supplementation of a mean daily dose of 1200 mg per

day led to a decrease in systolic blood pressure of 1.86 mmHg, and a decrease in diastolic blood

pressure of 0.99 mmHg. In those individuals with relatively low calcium intake (under 800 mg

10

per day) supplementation led to a decrease in systolic blood pressure of 2.63 mmHg and diastolic

of 1.30 mmHg.

An evidence-based review was completed by the FDA in 2007 that showed mixed findings on

the effects of calcium supplementation on blood pressure in hypertensives.33

However, the

majority of the studies did show that increased intakes of supplemental calcium were associated

with lower blood pressure measurements. The amount of supplementation used in these studies

ranged from 600 mg to 2.0 grams of supplemental calcium per day over two to six months of

intervention. The study concluded the following: “there was a low level of comfort for a claim

about supplemental calcium intake and reduced risk of hypertension…there is some credible

evidence that suggests a relationship between supplemental calcium intake and reduced risk of

hypertension.”

Fish Oil and omega 3 fatty acids:

Both omega 3 fatty acids in supplements as well as those found in fish have been shown to

reduce the risk of cardiovascular disease.44

One of the risk factors of cardiovascular disease that

omega 3 fatty acid can reduce is high blood pressure. Sources of omega 3 fatty acids include fish

(especially salmon, sardines, and herring), vegetable oils (soybean, canola, walnut, and flaxseed)

and whole foods such as walnuts or flaxseeds.44

A review was published by Mori39

in 2006 that outlined the studies that have been done to

discover the effect of omega-3 fatty acids on blood pressure. Eicosapentaenoic acid (EPA) and

docosahexaenoic acid (DHA) are the two main forms of omega-3 fatty acids that have been

11

studied. Mori stated that omega-3 fatty acids in fish oils or dietary fish “provide unequivocal

evidence for a blood pressure-lowering effect.” A meta analysis of 31 placebo controlled trials

done by Morris et al.40

showed a decrease in blood pressure by approximately 3 mmHg systolic

and 1.5 mm Hg diastolic with additional fish or fish oil consumption. Hypertensives were the

most responsive group with an average decrease in blood pressure by 3.4 mm Hg with

consumption of 5.6 grams of fish oil per day. The effect was shown to be dose dependent (the

higher the dose of fish oil given, the more the blood pressure dropped). At the highest doses

studied (15g/day), a decrease of 8.1 mmHg systolic and 5.8 mmHg diastolic was measured.

Appel et al.41

concluded that untreated hypertensives with intakes of more than 3 grams per day

of omega-3 fatty acids led to average decreases in systolic blood pressure by 5.5 mm Hg, and

diastolic by 3.5 mm Hg.

Included in the review by Mori et al.39

was a study by Bao et al.42

that examined whether dietary

omega-3 fatty acids in fish had independent and additive effects to weight control on blood

pressure in overweight patients with hypertension. There were four groups that were created for

this study: a daily fish meal diet, a low fat low calorie weight loss program, a low fat low calorie

weight loss with daily fish added, and a control group. The amount of fish that was consumed by

each subject that was assigned to eating fish contained 3.65 grams of omega-3 fatty acids. The

weight loss group lost an average of 5.6 kg (12 lbs). These diets were followed for three months

and the blood pressures were measured again. The results showed that there was a significant

independent and additive effect of consuming fish and losing weight. The group that was

assigned to eat one daily meal with fish had a decrease in diastolic blood pressure by 6.0 mmHg

and 3.0mmHg for diastolic. The group that only lost weight had a decrease of 5.5 mmHg systolic

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and 2.2 mmHg diastolic. Most importantly, the largest decrease in blood pressure was found in

the group that ate fish and lost weight. This group had an average decrease of 13.0 mmHg

systolic and 9.3 mmHg diastolic blood pressures.

Coenzyme Q10:

Coenzyme Q10 is best known as a part of the mitochondrial electron transport chain. However, it

has recently been touted as an effective supplement for individuals with hypertension.

Interestingly, patients who have hypertension have been shown to have lower serum levels of

CoQ10.18

A meta-analysis of clinical trials of CoQ10 and hypertension was done by Rosenfeldt

et al25

. 12 trials and 362 patients in total were analyzed for this meta-analysis. The results

showed that supplementation of 75 to 360 mg (mostly between 100-150 mg/day) of CoQ10 per

day was sufficient to decrease systolic blood pressure by 16 mmHg, and diastolic blood pressure

by 10 mmHg. CoQ10 is thought to have its blood pressure lowering effects by acting as an

antioxidant that breaks the chain of oxidative stress that leads to vasoconstriction and

hypertension. CoQ10 has a vasodilation-type effect on blood vessels in hypertensives people.

Garlic:

There is a plethora of evidence in support of consuming garlic as an antihypertensive measure. A

systematic review and meta-analysis by Ried et al.14

showed that for hypertensive patients there

was a mean decrease of 8.4 mmHg for systolic, and 7.3 mmHg for diastolic blood pressure while

in the garlic consuming group as compared to the placebo groups. This review was done on 25

studies, 11 of which met the inclusion criteria of the systematic review. The studies that were

used gave the garlic group either garlic powder, supplements, or oil. The individuals assigned to

13

the garlic consumption group were given 600-900 mg of garlic per day for 12 to 23 weeks. This

level of garlic consumption is useful for reducing high blood pressure in hypertensive patients.14

Another meta-analysis was performed by Reinhart et al.15

in 2008 to determine the effectiveness

of garlic on hypertension. There were 10 trials that met the inclusion criteria for the study. Three

of the studies included patients with elevated systolic blood pressure, which demonstrated a

decrease in systolic blood pressure by 16.3 mmHg and diastolic by 9.3 mm Hg. The doses that

were used for the studies ranged from 12.3 mg to 2.4 grams, however, in the three elevated

systolic studies only 600 mg or 900 mg were used. Garlic powder was the form of garlic that was

used in these studies. Garlic was shown not to decrease blood pressure in people without

elevated systolic blood pressure.

According to Phelps1, any of the following forms of garlic may be utilized to help decrease blood

pressure: fresh, minced garlic bulb: 2-5 g/day, dried powder: 0.4-1.2 g/day, aged garlic extracts:

2.4-7.2 g/day, oil: 2-5 mg/day, fluid extract (1:1): 0.5-2.0 ml three times daily, tincture 1:5: 20

ml/day. However, according to the meta-analyses that were performed, only supplements, oil, or

the powder form of garlic has been analyzed as a method of reducing blood pressure.

Magnesium:

Magnesium supplementation has been suggested as an effective means of reducing blood

pressure in those individuals with diagnosed hypertension. Kawano et al.43

found in their trial

that magnesium supplementation in hypertensives can reduce blood pressure. The trial involved

sixty subjects (male and female) that were either put into a control group or a supplementation

group. The subjects that were assigned to the magnesium supplementation group were given 20

14

mmol/day of magnesium. The trial lasted eight weeks. Both systolic and diastolic blood

pressures were shown to drop in the magnesium supplement group by averages of 2.5 mmHg,

and 1.4 mmHg respectively in a 24 hour blood pressure screen. The results also showed that the

higher an individual’s blood pressure, the more blood pressure would decrease by the end of the

eight week trial.

Magnesium supplements prescribed at 10 mmol to 40 mmol daily has been shown to produced a

modest, dose-dependent antihypertensive effect, according to a meta-analysis done by Jee et al11

.

The meta-analysis was done on 20 studies that included 1220 subjects in total. 14 of the 20

studies were double blinded and included hypertensive subjects. The studies lasted from three

weeks to two years. Systolic blood pressure was shown to decrease by 3.3 mmHg, and diastolic

by 2.3 mmHg, with the addition of a magnesium supplement compared to placebo in the 14

double blind studies that were conducted on hypertensive subjects. Also, with each additional 10

mmol/day that were administered, there was an average decrease of 4.3 mmHg systolic, and 2.3

mmHg diastolic blood pressure. This shows promising evidence for reducing high blood pressure

with higher doses of magnesium supplementation.

Exercise and Lifestyle Modification

Tai Chi

A systematic review of the literature was done by Yeh et al. 31

to determine the effectiveness of

the exercise of tai chi in reducing blood pressure. 26 studies were reviewed, with only eight of

the studies that specifically evaluated patients with hypertension and only three of those were

randomized controlled clinical trials. The tai chi training that was done in the studies ranged

15

from 12 weeks to three years and yielded results of a decrease in systolic and diastolic blood

pressures by 7-32 mmHg, and 2.4-18 mmHg respectively. The randomized controlled clinical

trials compared tai chi with other exercise for reducing blood pressure and no significant

differences were found. However, it should be noted that higher compliance was found for the

patients assigned to tai chi rather than other exercise groups.

One of the randomized controlled clinical trials that were included in Yeh et al. was done by

Thomas et al.32

in 2005. In this study 207 subjects were divided into three groups; a tai chi group

(3 times per week), a resistance training group (3 times per week), and a control group that was

instructed to continue their usual level of physical activity. This study was done over a 12-month

period, and the results showed that there was no significant difference in blood pressure between

the tai chi group compared with either of the control groups. However, waist circumference and

heart rate were both reduced in the intervention groups. The results show that tai chi has limited

benefit compared with exercise, but still the evidence supports the use of exercise including tai

chi as a possible method of blood pressure reduction.

Qi Gong

A meta-analysis of randomized controlled trials was done in 2008 evaluating the effectiveness of

qigong on reducing high blood pressure.28

The authors of this analysis found 92 relevant trials,

nine of which met the inclusion criteria for this review. The data showed that compared to a

control group that included no other intervention, practicing qigong for less than one year

reduced systolic blood pressure by 17 mmHg, and diastolic blood pressure by 9.98 mmHg.

16

However, compared to control subjects who were taking antihypertensive medication and control

subjects who were involved in a conventional exercise program, qi gong was not superior in

reducing blood pressure. Conventional exercises that were noted in the analysis included jogging

and progressive muscle relaxation techniques. Sancier29

reported that four retrospective studies

done on a total of over one thousand subjects showed that qigong combined with drug therapy

was effective in reducing both stroke and mortality in subjects practicing qigong.

A randomized controlled trial was done by Cheung et al. 30

that compared the effects of

practicing qigong compared to conventional exercise on blood pressure in hypertensive subjects.

The 91 subjects included in the study were 18-75 years old and had blood pressures of 140-170

mmHg systolic and 90-105 mmHg diastolic. The study was done over seven months in which the

intervention group was taught and performed qigong every day (60 minutes in the morning and

15 minutes in the evening). The control group that performed conventional exercises did

stretching, stepping, and walking for approximately the same amount of time as the intervention

group. The results of the study showed that both qigong and conventional exercise lowered blood

pressure in the hypertensive subjects, and there was no significant difference between the two

groups. Systolic blood pressure for the qigong group decreased 10.8 mmHg and diastolic

decreased by 5.9 mmHg. Systolic blood pressure for the exercise group decreased by 11.2

mmHg and diastolic decreased by 7.1 mmHg. This study was lacking a control group without

physical activity, which would have validated the changes in blood pressure from the baseline

values.

17

Based on the evidence that was analyzed in this review, qigong has been proven to be an

effective means of reducing blood pressure. However, the data does not support the notion that qi

gong is any more or less effective than conventional exercise for reduction of high blood

pressure in hypertensives. Another important point that was described by Cheung et al. was that

both subjects who began exercise programs or subjects who began to practice qigong reaped the

benefits of weight reduction, waist circumference reduction, and reduction in urinary protein

excretion.

Other Exercise and Weight Loss

In Ebrahim’s systematic review8, eight trials on the effect of exercise on hypertensive subjects

were analyzed. The pooled results showed that there was no significant difference in blood

pressure before the exercise trials began, and at the end of the trials. However, many other

studies have shown a beneficial effect of exercise on hypertension. Stewart et al.45

reported that

their randomized controlled clinical trial of exercise for elder hypertensives resulted in a drop in

diastolic blood pressure by 2.2 mmHg, but no change in systolic pressure. This study was done

over a 6 month trial with exercise groups consisting of resistance exercise or aerobic exercise, a

control group, and a group that received diet counseling. According to Guo et al.28

conventional

exercise such as jogging and progressive muscle relaxation techniques were as effective as

qigong in reducing blood pressure. The decreases in blood pressure for this study were

approximately 17 mmHg systolic, and 10 mmHg diastolic.

Obviously, a great benefit of exercise is increased calorie expenditure. As more calories are

burned, a patient will experience weight loss. As stated previously, a study was done by

18

Langford et al.20

that showed that a decrease in body weight by 4.7 kg led to a decrease in

diastolic blood pressure by 8.8 mmHg. Although the method of weight loss was not closely

scrutinized by the researchers in this study, it is assumed that weight loss by exercise would have

similar results to what was found in this study.

A study published in the Annals of Internal Medicine in 2001 by Stevens et al.38

was done to

determine the efficacy of weight loss as an intervention for reducing blood pressure on a long

term trial (3 to 4 years). The subjects that were included were all overweight or obese and were

30 to 54 years old. All of the subjects had starting blood pressures of 83-89 mmHg diastolic, and

less than 140 mmHg systolic. Therefore the subjects were pre-hypertensive. The subjects were

assigned to one of four different groups: weight loss, sodium reduction, weight loss and sodium

reduction, or usual care (controls). Blood pressure was taken for the subjects in each group at the

beginning of the study, and every six months after that for 3 to 4 years. The weight loss group

was to lose at least 4.5 kg (10lbs.) within six months and maintain that weight for the remainder

of the study. The weight loss program involved counseling and diet and exercise modifications

(most commonly brisk walking for 30-45 minutes per day). Participants who lost the most

weight had the biggest decrease in blood pressure, but on average after six months diastolic

blood pressure dropped 2.7 mmHg, and systolic blood pressure dropped 3.7 mmHg. This study

showed that weight loss can lead to a decrease in blood pressure, but it did not investigate this in

hypertensives.

19

Mental training and relaxation techniques

Surprisingly, according to a systematic review conducted by Ebrahim et al.8 stress reduction

techniques that were included in eight different trials showed minimal reductions in high blood

pressure. It was reported that the average reduction in blood pressure was 1.0 mmHg systolic and

1.1 mmHg diastolic.

It has been researched that psychological treatment for patients with hypertension have been

linked with a decrease in progression of hypertension and a decrease in the number of deaths

associated with the condition. Linden et al.10

found that individuals who had no psychological

support had an increase in their chance of dying from heart disease by 70%.

Biofeedback

A meta-analysis was performed by Nakao et al.47

in 2003 about the blood pressure lowering

effects of biofeedback. The meta-analysis was performed on a total of 22 randomized controlled

clinical trials that included 905 essential hypertensives. The trials consisted of follow-up periods

from 3 months to 12 months. The results showed an average decrease in systolic blood pressure

of 7.3 mmHg and diastolic blood pressure by 5.8 mmHg for the biofeedback groups. When

compared with sham trials, there was still a significant decrease of blood pressures by 3.9 and

3.5 mmHg systolic and diastolic respectively. However, this result was only seen in biofeedback

combined with other relaxation techniques. Since the trials did consist of results from 0-12

months, it is fair to state that long-term effects of biofeedback with relaxation techniques can aid

in blood pressure reduction in hypertensives.

20

Wang et al.46

studied the effects of slow abdominal breathing with biofeedback on pre-

hypertensive individuals in a study done in 2010. The study included 22 postmenopausal pre-

hypertensive women. The study used a control group and an experimental group, which engaged

in slow abdominal breathing combined with frontal electromyographic feedback. All participants

were trained in abdominal breathing, but only the experimental group received biofeedback

treatment. The results showed that slow abdominal breathing alone (the control group) lowered

systolic blood pressure by 4.3 mmHg, and did not significantly change diastolic blood pressure.

The experimental group resulted in greater reductions of blood pressure; 8.4 mmHg systolic and

3.9 mmHg diastolic. These results show that there is indeed an effect of biofeedback on blood

pressure independent of relaxation, but both combined seems to have a greater effect. The

authors therefore concluded the following; “Slow abdominal breathing combined with EMG

biofeedback is an effective intervention to manage prehypertension.” However, this was a small

study and the total length of the study was only 30 days. Therefore long term effects of

biofeedback on prehypertension were not studied here.

Meditation

A study by Charles et al. 21

was done to determine the effect of Transcendental Meditation and

muscle relaxation on blood pressure as compared with life style education on older African

Americans. For women, the Transcendental Meditation technique showed that systolic and

diastolic pressures decreased 10.4 mmHg and 5.9 mmHg respectively. For men, systolic and

diastolic pressures declined as well, 12.7 mmHg and 8.1 mmHg respectively. The muscle

relaxation technique did not show any decrease in blood pressure for women, but resulted in a

21

6.2 mm Hg reduction in diastolic blood pressure on average. 111 subjects completed the 3-month

randomized, controlled, single-blind trial. The subjects that were included in the study had

baseline diastolic blood pressures from 90 to 104 mm Hg, and systolic blood pressures less than

179 mm Hg. Some of the subjects were taking blood pressure medication and some were not,

which may have been a confounding variable in this study. All subjects that changed any of their

hypertension medications during the trial were excluded. This study showed great promise for

the use of meditation to decrease blood pressure.

Another randomized clinical controlled study was done on African Americans over a one year

time period22

. Again, Transcendental Meditation proved to be more successful in lowering blood

pressure than a muscle relaxation technique, or a health education class. The group that was

assigned to transcendental meditation for 20 minutes twice per day experienced an average of 3.5

mmHg decrease in systolic blood pressure, and a 5.7 mmHg drop in diastolic blood pressure. A

total of 150 hypertensive subjects were involved in this year long trial, which involved the

participants meditating at home every day for a full year. Compliance was tracked and accounted

for in the results. This study was especially promising as the length of time shows that this

technique may be useful in reducing high blood pressure long term. A meta-analysis done by

Anderson et al.23

explored the response of blood pressure to transcendental meditation, and

found that only three of nine studies were of high quality. However, the analysis did conclude

that “the regular practice of Transcendental Meditation may have the potential to reduce systolic

and diastolic blood pressure by approximately 4.7 and 3.2 mm Hg, respectively. These are

clinically meaningful changes.” More studies are needed, but the evidence so far is in favor of

Transcendental Meditation for reducing blood pressure on a long-term basis.

22

Acupuncture

According to a systematic review and meta-analysis by Lee et al. 16

, there is no conclusive

evidence to support that acupuncture can lower blood pressure in hypertensive patients. 11

randomized clinical trials were reviewed in this study, which all together included 847 patients.

Three of the trials were sham-controlled. The data from these three studies showed a marginal

reduction in diastolic blood pressure, but no statistical change in systolic blood pressure. Only

two of these three studies were of high quality, so more positive-resulting high quality studies

will be needed to form a conclusion about the efficacy of acupuncture for treatment of

hypertension.

One of the high quality sham-controlled studies referred to by Lee et al. was the Stop

Hypertension With the Acupuncture Research Program (SHARP) by Macklin et al17

. This study

involved 192 participants with high blood pressure. Three groups were constructed, including a

sham acupuncture group, a standardized acupuncture group (with preselected acupuncture

points), and an individualized (traditional Chinese medicine) acupuncture group. All participants

were taken off of their hypertension medication and started on their determined treatments/ sham

treatments. All three groups experienced an average decrease in systolic blood pressure between

3.55 and 3.84 mmHg, and a decrease in diastolic blood pressure between 2.81 and 4.67 mmHg

with no statistical significant difference between groups. This study shows that while there is no

difference in effectiveness of real acupuncture versus sham treatment, there were decreases in

blood pressure with both groups. Therefore, there was likely something that caused this decrease

in blood pressure other than the treatments. The authors of this study did not address this fact. It

23

is possible that the placebo effect was the cause of the decrease in blood pressure in all groups,

which shows that mental training techniques may have a beneficial effect on lowering blood

pressure.

Chiropractic Adjustments

There is limited evidence in support of chiropractic adjustments reducing blood pressure,

however, there are a few studies that show promise for this methodology. One study by

Knutson26

involved two separate testing procedures, both done in the private practice of Dr.

Knutson. The first test group involved 40 patients that were treated with upper cervical specific

adjustments, and 40 control patients that did not receive treatment. In the second test group, all

30 patients received treatment and their blood pressures were taken in two positions pre-

treatment, and once post-treatment. The average change in blood pressure in the first test group

for those treated was a 10.3 mmHg decrease in systolic blood pressure, as compared with a

decrease of systolic pressure of 0.5 mmHg in the control group. There was no statistical

difference in diastolic pressures. The second test group also showed a significant decrease from

pre to post systolic blood pressures, and again no significant change in diastolic pressures. The

major limitations of this study include lack of randomization, blinding, and a sham adjustment

group, as well as the size of the subject group. Also, this study only examined short-term

changes in blood pressure.

Another study examining the effects of cervical spine manipulation on blood pressure was done

at Palmer College of Chiropractic in 198836

. This study was done on 75 normotensive student

volunteers. The subjects were divided into two groups, one of which received chiropractic

24

adjustments to the cervical spine, and the control group that only received motion palpation. The

doctors that took blood pressure measurements were blinded as to which groups the subjects

were assigned. Both systolic and diastolic blood pressure measurements were determined to be

statistically significantly lowered in the experimental versus the control group. This data was

achieved in a 10 minute time span between the first blood pressure measurement and the second.

The blood pressures were not taken again after the trial, and therefore no conclusions can be

made about the effect of this manipulation on any long term blood pressure readings. Also, this

study was done on normotensive subjects, which does not necessarily correlate with hypertensive

subjects.

A randomized controlled trial was also done in the same year by researchers at Canadian

Memorial Chiropractic College37

. This study was done on 21 hypertensive subjects. Three

groups were formed with an active treatment group that received chiropractic adjustments using

a device on T1-T5 of the thoracic spine, a placebo treatment group, and a control group with no

treatment. Systolic and Diastolic blood pressures were both significantly decreased post-

adjustment, while the placebo and non-treatment groups showed no significant changes in blood

pressures. Again, this study only shows effects on a very small sample size and does not give any

insight as to whether blood pressure can be reduced by chiropractic adjustments on a long-term

basis.

Many mechanisms have been proposed by numerous authors as to why the chiropractic

adjustment may lower blood pressure. One possible mechanism is that vertebral segmental

dysfunction can influence the sympathetic chain, increase sympathetic tone, cause

25

vasoconstriction, and therefore result in increased blood pressure26

. Another proposed

mechanism was put forth after a study was done showing that serum aldosterone decreased after

a chiropractic adjustment, as compared with a control group. Therefore there may be hormonal

changes that occur post adjustment that contribute to a decrease in blood pressure as well. The

hormone aldosterone is released by the adrenal cortex and promotes sodium and water

reabsorption, causing a subsequent increase in blood pressure. Two more mechanisms were

proposed by Knutson, including activation of the cervicosympathetic reflex causing a decrease in

blood pressure, or the pressor reflex (wherein hypertonic musculature causes altered blood

pressure).

Recommended Management of Hypertension

Based on the data that has been described in this review of the literature, it is evident that many

alternatives to drug therapy exist for the treatment of patients with essential hypertension. All of

the therapies that have been discussed need further evidence to solidify them as proven blood

pressure lowering methods. However, many of the therapies discussed show promise as effective

antihypertensive treatments without any of the dangerous and life altering side effects associated

with antihypertensive drugs.

The blood pressure lowering methods that had the most comprehensive and promising research

for their efficacy includes salt restriction and the DASH diet, chocolate, CoQ10, garlic,

magnesium supplementation, fish oil, weight loss, and meditation. The research supports the use

of salt restriction as an effective means of reducing systolic pressure by 2.9 to 5.8 mmHg and

26

diastolic blood pressure by 2.1 to 7.9 mmHg.8,19

Also, salt restriction to less than 2.3 grams of

sodium per day combined with the DASH diet can reduce systolic blood pressure in

hypertensives by 11.5 mmHg.35

Chocolate rich in flavanols (at least 500 mg) taken for at least

two weeks has sufficient evidence to be consumed as a measure to reduce high blood pressure by

5 mmHg systolic and 2.7 mmHg diastolic.27

Dark chocolate (about 6.7 grams per day, the

equivalent of two to three squares per week) is the appropriate amount. 75 to 360 mg of CoQ10

supplementation per day is recommended for reduction of systolic blood pressure by 16 mmHg

and diastolic blood pressure by 10 mmHg.25

One meta-analysis showed that 600-900 mg of

garlic per day for 12 to 23 weeks is sufficient to reduce systolic blood pressure by 8.4 mmHg and

diastolic by 7.3 mmHg.14

Another showed that either 600 or 900 mg of garlic powder

supplement can decrease blood pressure in hypertensives by 16.3 mmHg and 9.3 mmHg systolic

and diastolic respectively.15

A meta-analysis for the use of magnesium supplementation (10-40

mmol, or 240 to 960 mg per day) showed that systolic blood pressure decreased by 3.3 mmHg,

and diastolic by 2.3 mmHg when taken from 3 weeks to 2 years.11

Also, with each additional 10

mmol/day that were administered, there was an average decrease of 4.3 mmHg systolic, and 2.3

mmHg diastolic blood pressure. The omega-3 fatty acids found in fish oil can reduce blood

pressure, which has been reported in meta-analyses and reviews.39, 41

A dose of 3 grams per day

of omega-3 fatty acids led to average decreases in systolic blood pressure by 5.5 mm Hg, and

diastolic by 3.5 mm Hg41

, with even more impressive results with higher intakes.39

A loss of

4.5kg (10 lbs) of body weight can result in decreases in blood pressure by 2.7 mmHg systolic,

and 3.7 mmHg diastolic.38

Transcendental Meditation has been shown in numerous studies to

have a beneficial effect on lowering blood pressure by 4.7 and 3.2 mmHg systolic and diastolic

pressures respectively.23

One study that showed a reduction in blood pressures had participants

27

meditate for 20 minutes twice per day.22

Alternative treatments for hypertension that had modest evidence or limited studies on their

effects include the following: calcium, exercise alone, and biofeedback when compared with

relaxation. Dietary calcium increases have conflicting results on blood pressure reduction.

Calcium supplementation has sufficient data supporting that it has small effects on blood

pressure (1200 mg daily for reduction of systolic blood pressure by 1.86 and diastolic by 0.99

mmHg).34

Exercise alone has been shown to have varied results for reducing hypertension.8,45,28

However, this variability may be due to the types of exercises that have been studied and the

intensity, frequency, and duration of the exercise trials. Biofeedback has evidence supporting

that it has blood pressure lowering effects independent of relaxation techniques, but still other

studies show that relaxation techniques alone are just as effective.47,46

Either way, biofeedback

can be used in combination with relaxation techniques to decrease systolic blood pressure by 7.3

mmHg and diastolic blood pressure by 5.8 mmHg in hypertensives.47

Treatments that were studied that have not been shown to be effective for lowering blood

pressure or have very limited data supporting them include vitamin D, tai chi, qi gong,

acupuncture, and chiropractic adjustments. Higher intakes of vitamin D have not been shown to

have an effect on blood pressure.9,13

While tai chi has been shown to reduce blood pressure

substantially, a systematic review has shown that tai chi is no more effective in reducing blood

pressure than conventional exercise.31

A systematic review of qi gong showed similar results to

that of tai chi and conventional exercise.28,30

A systematic review and meta-analysis of

acupuncture has showed there is no conclusive evidence to support the view that acupuncture can

28

lower blood pressure in hypertensive patients.16

While chiropractic adjustments to reduce high

blood pressure has some promising results in small studies,26,36,37

no long term or large high

quality studies have been done to prove its effectiveness, so no conclusions can be made at this

point.

The efficacies of many different types of alternative treatments for hypertension have been

described in this review of the literature. Also, the side effects of common pharmaceutical agents

that are used for the treatment of hypertension have been reported, which is one of the main

reasons that alternative treatments are needed. However, there are beneficial secondary effects

(side effects) of some of the alternative treatments that must be noted. An example of such

effects is included for each of the most effective alternative treatments for reducing blood

pressure. The DASH diet involves eating large amounts of fruits and vegetables, which can

prevent cancer and cardiovascular disease.48

The symptoms of chronic fatigue syndrome may be

lessened by the addition of cocoa-rich chocolate into the diet.49

CoQ10 supplementation can

improve endothelial dysfunction in statin-treated type-2 diabetics.50

Certain compounds found in

garlic may help in the treatment and prevention of breast cancers.51

Magnesium supplementation,

when combined with other vitamins, minerals and herbs, is effective for treating anxiety and

anxiety-related disorders.52

High dietary intakes of omega-3 fatty acids such as those found in

fish oil, can reduce diabetic renal disease.54

Weight loss is indicated for overweight and obese

individuals. Weight loss is useful for the prevention and reversal of chronic diseases such as

metabolic syndrome, type-2 diabetes, cancer, and cardiovascular disease.53

Improved levels of

plasma glucose and insulin levels have been seen with utilization of the Transcendental

Meditation technique.55

29

The beneficial effects of alternative therapies can be contrasted with the potentially dangerous

side effects of blood pressure lowering medications such as Vasotec or Thalitone. “Vasotec,” an

ACE inhibitor, has side effects such as dizziness, fatigue, headache, nausea, vomiting, diarrhea,

chest pain, or rash.3 “Thalitone,” a thiazide diuretic, has side effects that include anemia, changes

in blood sugar, increased heart rate or pulse, constipation, headache, impotence, or inflammation

of the pancreas.3 This is a limited view of the secondary effects of the blood pressure lowering

methods included in this review. However, it is clear that the secondary effects of the alternative

treatments named are not just less dangerous than those of pharmaceutical agents, but are

actually beneficial for one’s health.

While it is unknown whether additive effects would be seen by prescribing multiple alternative

treatments to one patient, there is promising evidence described by Bao et al.42

, and Sacks35

. Bao

showed that consuming fish alone can reduce blood pressure, losing weight alone can reduce

blood pressure, and consuming fish while losing weight can reduce blood pressure more than

twice as much as either of the two alone. Sacks described that salt restriction when combined

with the DASH diet had a larger effect on reducing blood pressure than either separately.

Therefore, the combination of some of the alternative methods that have been outlined may

provide an even greater effect for the reduction of blood pressure. Physicians should consider

adding one or more of these treatments to a hypertensive patient’s regimen. Obviously, all of the

treatments described should only be undertaken if a physician recommends them on an

individual patient basis.

30

Conclusion

The blood pressure lowering methods that had the most comprehensive and promising research

for their efficacy includes salt restriction and the DASH diet, chocolate, CoQ10, garlic,

magnesium supplementation, fish oil, weight loss, and meditation. Alternative treatments for

hypertension that had modest evidence or limited studies on their effects include the following:

calcium, exercise alone, and biofeedback when compared with relaxation. Treatments that were

studied that have not been shown to be effective for lowering blood pressure or have very limited

data supporting them include vitamin D, tai chi, qi gong, acupuncture, and chiropractic

adjustments. Using some of the effective alternative therapies in combination may have a greater

effect on lowering blood pressure than using them alone, such as using the DASH diet along

with salt reduction, or consuming fish oil while losing weight. The side effects of the

antihypertensive medications that are commonly prescribed can be very uncomfortable, or even

dangerous for a patient. The secondary effects of using many of the alternative treatments

described above may actually improve ones health in other ways. Therefore, the effective

alternative therapies that have been described above should be considered for treatment of

hypertensives.

31

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