Diet and Hypertension

Pharmacologic intervention is one of the cornerstones of management for hypertension. However, potential adverse drug reactions, drug-drug interaction, as well as safety and effectiveness in certain medical conditions such as chronic kidney disease, end-stage kidney disease, pregnancy, postsurgery, or transplantation limit the flexible use of some antihypertensive medications. Therefore, nonpharmacologic interventions are another therapeutic option for hypertension. Several modalities of nonpharmacologic intervention have been proven to be effective for blood pressure management, and among those, dietary intervention is one of the most widely used options and has long been of interest to every stakeholder involved in hypertensive care including health care providers, public health professionals, patients and their caregivers, and public health policymakers. Specific main nutrients, both micro- and macronutrients, which contribute to elevated blood pressure with different mechanisms are sodium, phosphorus, carbohydrate, protein, saturated, monounsaturated, and trans unsaturated fatty acids; while potassium, calcium, vitamin D, and polyunsaturated fatty acid are protective for hypertension. However, instead of a single nutrient, a dietary pattern is a practical approach to implement the dietary intervention, and a variety of “healthy” diets have been recommended for blood pressure management. Plant-dominant and plant-forward diets, such as Dietary Approaches to Stop Hypertension (DASH), Mediterranean, and vegetarian diets, have been shown to have a favorable effect on blood pressure. Apart from increased effective circulatory blood volume, enhanced renin-angiotensin-aldosterone system, and activated sympathetic nervous system, inflammatory milieu and dysregulation of the immune system originating from gut microbiome dysbiosis are proposed to link those pathophysiologic changes and responsible organs including the brain, heart, intestine, and kidney to initiate and perpetuate hypertension. Particularly, some underlying medical conditions, especially chronic diseases such as CKD or novel diseases like coronavirus disease 2019 (COVID-19) causing perturbation of physiologic and involved organ systems, can be challenging in blood pressure control with only antihypertensive medications and multi-modal therapies including dietary intervention is crucial.