Introduction

It has been established that hypertension contributes significantly to the high morbidity and mortality rates in developing and developed countries. In Nigeria, hypertension is one of the most common causes of cardiovascular diseases like stroke.

Several factors have been implicated in its growing prevalence in Nigeria and the world at large. These risk factors include a poor diet, excessive salt intake, a sedentary lifestyle, and excessive intake of alcohol and tobacco. These risk factors have been shown to treat, control, and prevent hypertension to varying degrees when modified. These modifications are advocated for because they are less expensive than using antihypertensive medications, and thy are more beneficial to the patient’s sense of wellbeing. A combination of these modifications with antihypertensive medication may result in a reduction in the dosage of the drugs prescribed.

Recommended Lifestyle Modifications for Hypertension in Nigeria

These are the recommended non – dietary lifestyle modifications that have been shown to help in the control and prevention of hypertension.

Weight Reduction

Hypertension has been closely related to excess body weight. Abdominal or truncal obesity is a condition where there is an excessive amount of fat around the abdomen. Truncal obesity has negative impact on health, and has also been associated with cardiovascular diseases, diabetes, hypertension, dyslipidemia, and other morbidities.

Truncal obesity is seen when the waist-to-hip ratio is above 0.85 for women and 0.95 for men. The ideal body weight is a Body Mass Index (BMI) between 20 – 25kg/m². A weight reduction regiment has effectively reduced blood pressure in a large proportion of hypertensive individuals who are way more than 10% above the ideal body weight.

Apart from its blood pressure lowering effects, weight reduction also increases the effectiveness of antihypertensive medications. This effect is also complemented by other lifestyle modifications like stoppage of alcohol intake, stress management, and physical activity.

In order for weight reduction to be efficacious for BP reduction, the aim should be to reduce the BMI to a value between 20 and 25kg/m². The waist-to-hip ratio should be reduced to below 0.85 in women and below 0.9 in men. The waist circumference should be decreased to a value below 100cm in men and 85 in women. These weight reduction targets are recommended for blood pressure reduction in hypertensive patients as well for the prevention of hypertension in non-hypertensive individuals.

A systolic blood pressure (SBP) reduction of about 5mmHg should be expected and should be the initial target. However, further weight loss could be recommended by a physician as deemed appropriate.

A practical approach to weight reduction for effective results includes:

• A reduction in calories intake
• Increased physical activity
• Nutritional and lifestyle counseling
• In some cases, surgery and medications may be required to aid weight reduction

A reduction in blood pressure can usually be seen in the early stages of weight reduction. A 5kg weight loss is sufficient to cause a reduction in blood pressure. As earlier mentioned, a systolic blood pressure reduction of 5mmHg is expected.

Physical Activity

Physical activity which is regularly performed at a certain level of intensity has been found to reduce blood pressure. It is important to note that not all forms of exercise have the same level of efficacy in lowering blood pressure. Recommended forms of exercise include:

• Jogging
• Cycling
• Swimming
• Brisk walking

These exercises are known as Isotonic exercises which occur when the muscle is shortened as it contracts against a load. Isotonic exercises have been shown to increase the heart rate, increase oxygen consumption levels and reduce the risk of cardiovascular disease. It is also useful in burning calories and maintaining cholesterol and blood sugar levels.

These exercises should be done for at least 30 minutes a day for a minimum of 5 days a week. They should also be done regularly and must cause sweating during every session. A decrease in the SBP value of up to 10mmHg may be expected when effective exercises are done.

However, if it is not possible to incorporate regular exercises into one’s lifestyle, an increase in the physical work level both at home and in the workplace should be encouraged. Housework and the routine movements of day-to-day life may also qualify as isotonic exercise.

In order to make physical activity a consistent and sustainable practice, it is advised to use the available facilities. Based on one’s environment and circumstances, jogging, walking on the streets, climbing stairs, or using a treadmill may easily be the best available option and should be selected.

Exercise should be done gradually and increased in intensity as time goes by under the supervision of a licensed physician or physiotherapist.

Reduction or Stoppage of Alcohol Intake

Heavy alcohol consumption is associated with an increased incidence of cardiovascular diseases while consumption of smaller amounts of alcohol is associated with reduced cardiovascular risk. It has been established that moderation of alcohol intake has a blood pressure lowering effect. Therefore, if the alcohol intake is reduced to about 20 to 30g of ethanol per day in men and 10 to 15g per day in women, a significant lowering of the blood pressure should be expected. In a week, the total alcohol consumption should be less than 80g per week for women and 140g per week for men.

It is important to note that there are some sources of alcohol that are unrecognized and may be unknowingly ingested. Some of these sources include bitters as well as traditional herbal preparations.

Heart conditions affecting the heart muscle require the drastic reduction or complete elimination of alcohol consumption because of its depressant effect on the heart muscle. It is important to note that there might be a transient increase in the blood pressure once alcohol consumption has been significantly reduced, however it is expected to normalize with time.

Here are some practical tips for moderate alcohol consumption:

• Attend social events where alternatives to alcohol are served
• Indulge in one to two glasses of alcohol once in a while
• Avoid binge drinking alcohol
• Reduce alcohol content in your drinks by mixing them with water, juice, or other appropriate mixers
• Offer to be the designate driver to stary sober at social outings
• Ultimately the goal is to reduce alcohol intake to less than 15ml daily and eventually stop alcohol completely

Alcohol has been associated with obesity, coronary artery disease as well as irregular heartbeats. It is highly recommended to reduce alcohol intake even if there is no diagnosis of hypertension or any other morbidities.

Stoppage and Avoidance of Tobacco

Tobacco smoking has been associated with an acute increase in blood pressure, however there have been no recognized chronic effects of tobacco on blood pressure. It is worthy of note that smoking is a very important risk factor for cardiovascular conditions. Discontinuing smoking is a very important lifestyle modification that is necessary to prevent cardiovascular diseases.

Individuals who are hypertensive should totally avoid all tobacco products. It is well known that a reduction in blood pressure helps to protect one from cardiovascular diseases, however, this protection is lost in the presence of tobacco smoking. Habitual smokers may be placed on nicotine replacement therapy or other appropriate medical therapy if necessary.

Cessation of cigarette smoking is one of the most effective ways to prevent sudden death as smoking is one of the most common avoidable causes of sudden death.

Here are some tips to reduce tobacco consumption and quit smoking:

• Consciously decide on a day to quite smoking and start preparing to quit well before the day
• Write a list of reasons why you need to quit smoking
• Keep tracks of your smoking pattern by keeping a cigarette sheet and planning for situations where you might be tempted to smoke
• Avoid caffeinated drinks. Instead drink water and juices
• Be positive about quitting
• Resist temptation by avoiding people and places where you might be tempted to smoke
• Use the money which would be have been spent on cigarettes to treat yourself
• If you have a relapse, simply go through the steps and review your actions to prevent further relapse

Stress Reduction

Transient elevation of the blood pressure is an acute response to stress. During stressful situations, the body produces adrenaline and cortisol (the stress hormones) which cause muscle contraction and increased heart rate. This in turn will increase blood pressure. This increase in blood pressure is temporary and normalizes as soon as the stressful situation is overcome.

Chronic stress has not been directly linked to an increase in blood pressure though further studies are being carried out. However, stress causes one to engage in unhealthy behaviours such as neglecting exercise, poor sleep habits, eating an unhealthy diet, smoking, drinking, and drug abuse. These are prime risk factors for hypertension.

Forms of stress include work/occupational stress, marital stress, mental stress, and emotional stress among others. Occupational stress has been associated with increased blood pressure levels in the workplace, the home setting, and even during sleep. It has also been linked with an increased left ventricular mass which is an effect of sustained, chronically elevated blood pressure.

Stress management has been effective in reducing blood pressure as well as reducing the likelihood of hypertension. Non-pharmacological methods of stress management that have been found to be effective include meditation, music therapy, acupressure, and biofeedback.

Stress can also be reduced by exercising regularly, getting enough high-quality sleep, eating a healthy diet, avoiding stressful situations/people as well as embracing meditation and relaxation habits.

Adequate Sleep

Inadequate sleep has been shown to acutely increase blood pressure. Chronic sleep deprivation could lead to hypertension due to chronically elevated blood pressure. Poor sleep makes for poor blood pressure control in hypertensive people.

Sleep disorders have been linked with cardiovascular diseases in hypertensive people.

Obstructive Sleep Apnea (OSA) is a sleep order that is characterized by irregular breathing during sleep. OSA has been linked with snoring, poor sleep quality, and tiredness even after a full night of sleep.

Getting adequate, high-quality sleep is essential for the prevention and control of hypertension, especially in hypertensive patients. Some antihypertensive drugs like Lisinopril and Valsartan may cause insomnia as a side effect.

Some practical tips for sleeping better include:

• Ensure that you’re sleeping on a comfortable mattress that is appropriate for your age and health conditions such as back pain if any
• Eat a light dinner early in the day to allow for proper digestion and avoid heartburn
• Avoid screens from one hour before bed
• Read a book or take a warm shower right before bed
• Once in bed, focus on sleeping, and do not do any other activity while in bed. This will help your body to associate sleep with your bed

Home Blood Pressure Monitoring

Home blood pressure monitoring is the measurement of the blood pressure in the home environment by oneself and it is essential for better management of hypertension. Monitoring is also recommended in patients who are pre-hypertensive or who want to avoid hypertension.

It is also beneficial to measure the blood pressure in the home environment, away from the clinical environment, especially in people who have White Coat Hypertension. White coat hypertension is a condition whereby patients experience elevated blood pressure caused by fear or apprehension of the clinical environment. In such patients, measuring the blood pressure at home is a more reliable assessment of the true blood pressure rather than that taken in the clinic.

Home blood pressure monitoring may be used for the initial assessment of the blood pressure and it could also be used to assess the effectiveness of the treatment.

Based on the physician’s orders, home monitoring may be done:

• For a seven-day period before a clinic visit
• For a four-week period after a change in medication
• It may also be done in regular long-time intervals for the purpose of assessing the risk factors for hypertension

Guidelines for home pressure monitoring:

• The blood pressure measurement should be taken after five minutes of quiet sitting and before any medication, food or vigorous exercise
• Ensure that both feet are flat on the floor. The upper arm should be bare while the back and the arm are in a relaxed position with the blood pressure cuff at the heart level
• Take two blood pressure measurements one minute apart. Record the values in a safe place and remember to take a copy of your blood pressure readings to your next doctor’s appointment
• Blood pressure is not to be measured if one feels uncomfortable, stressed, or in pain as this would give an inaccurate pressure value
• Record the blood pressure with a well-functioning blood pressure device that is automated, has memory storage, has been validated, and has a correctly sized upper arm cuff
• It is best to measure the blood pressure in the morning and in the evening every day, especially for patients with increased blood pressure
• Home blood pressure measurements should be done for a minimum of five days and can be done for as long as seven days, based on the doctor’s instructions
• The average of the values derived over the period of home measurement is the average home BP measurement value

Conclusion

Non-pharmacological management of hypertension can be practiced as a lifestyle even if there is no diagnosis of hypertension. It is also beneficial for pre-hypertensive people. There should be increased public health awareness about the benefits of non-pharmacological management of hypertension.