How to Lower Blood Pressure: What the Evidence Shows for Salt, Diet, Weight, Alcohol and Exercise
Table of Contents
Key Takeaways: How to Lower Blood Pressure
- High blood pressure often goes unrecognised. In 2019, only 59% of women and 49% of men with hypertension worldwide reported a previous diagnosis [1].
- Less salt lowers blood pressure. Cutting salt intake by about 4.4 g per day lowered systolic pressure by 4.18 mmHg on average, and by 5.39 mmHg in people with hypertension [2]. In a 2023 crossover trial, after one week, mean systolic pressure was 8 mmHg lower in participants assigned to a low-sodium diet than in those assigned to a high-sodium diet [3]. In Finland, the recommended maximum is under 5 g of salt per day [4], and in my experience a single salty, processed meal can cover a large part of that.
- Potassium helps people with hypertension, with a caveat. Higher potassium intake lowered blood pressure in people with hypertension [5], and a potassium-enriched salt substitute lowered rates of stroke, major cardiovascular events and death in a large trial of older, high-risk adults [6]. People with chronic kidney disease or on potassium-sparing medication may need their blood potassium monitored when increasing potassium intake [7].
- The DASH diet lowered blood pressure by 3.2/2.5 mmHg compared with control diets, in people with and without hypertension [8].
- In a meta-analysis, systolic pressure fell by about 1.05 mmHg per kilogram of weight lost [9].
- Cutting down on alcohol lowered blood pressure in people drinking more than two drinks a day, but not significantly in those drinking two or fewer [10].
- All main types of exercise lower resting blood pressure. In a network meta-analysis of 270 trials, isometric training produced the largest average reduction (8.24/4.00 mmHg) [11]. In my view, for many sedentary patients, everyday activity such as walking the dog may not be enough on its own, depending on how long and brisk the walks are.
- Lifestyle is not always enough on its own. The 2024 ESC guideline recommends starting medication promptly, alongside lifestyle measures, when hypertension is confirmed (office blood pressure 140/90 mmHg or higher) [7].
- In my clinical experience, natural methods alone are often not enough for genuinely high blood pressure. If your blood pressure is genuinely high, have it assessed by a doctor rather than relying on home remedies alone, but there is still a lot you can do yourself.
- One office reading can mislead. White-coat hypertension is fairly common in practice, so I often ask patients to measure their blood pressure at home, morning and evening, for one to two weeks.
- Stress can keep blood pressure up. In my experience, measuring over and over can feed the cycle, and comparing readings taken at work and at home often reveals a clear work-related pattern.
Introduction: How to Lower Blood Pressure Without Guesswork
Between 1990 and 2019, the number of people aged 30–79 years with hypertension doubled worldwide, from 331 million women and 317 million men to 626 million women and 652 million men [1]. Many of them do not know it: in this pooled analysis of 1201 population-representative studies, only 59% of women and 49% of men with hypertension reported a previous diagnosis in 2019, and only 23% of women and 18% of men had their blood pressure controlled below 140/90 mmHg [1].
Searching for how to lower blood pressure brings up long lists of foods, supplements and “natural” fixes. The randomised evidence is narrower, but more useful. A handful of measures have been tested in controlled trials and pooled in meta-analyses: eating less salt, getting more potassium, following the DASH diet, losing excess weight, drinking less alcohol and exercising regularly.
As a physician and former competitive athlete, I want to separate what has been measured from what only sounds plausible. This article covers what counts as high blood pressure, how much each lifestyle measure has lowered blood pressure in trials, how exercise fits in, how to check at home whether your changes are working, and when medication should be part of the plan.
Traditionally, high blood pressure has been treated with medication at the doctor’s office, but there are other ways to influence it as well. In my experience, however, natural methods alone are often not enough to bring genuinely high blood pressure under control, and antihypertensive medication is frequently needed, at least in my own patient population. If your blood pressure is genuinely high, my advice is to have it assessed by a doctor and to discuss with your own doctor whether medication should be started, rather than trying to manage it with home remedies alone. That said, there are many ways to lower blood pressure, or at least to help prevent it from rising, and you can do quite a lot yourself.
What Counts as High Blood Pressure?
The 2024 European Society of Cardiology (ESC) guideline uses three categories based on office measurements [7]:
| Category | Office blood pressure |
|---|---|
| Non-elevated | Below 120/70 mmHg |
| Elevated blood pressure | Systolic 120–139 mmHg or diastolic 70–89 mmHg |
| Hypertension | Systolic 140 mmHg or higher, or diastolic 90 mmHg or higher |
The guideline bases this approach on evidence that the cardiovascular risk linked to blood pressure rises along a continuous scale, rather than a simple split between normal blood pressure and hypertension [7]. It also describes hypertension as the most important modifiable risk factor for all-cause and cardiovascular illness and death worldwide [7].
For how the American and Finnish categories compare with the European ones, and what the upper and lower numbers each mean, see my article on systolic vs diastolic blood pressure.
How to Lower Blood Pressure by Eating Less Salt
Salt is a natural place to start when thinking about how to lower blood pressure. A Cochrane systematic review and meta-analysis published in the BMJ included randomised trials of modest salt reduction lasting at least four weeks [2]. On average, urinary sodium fell by 75 mmol per 24 hours, which corresponds to eating about 4.4 g less salt per day. With that reduction, systolic pressure fell by 4.18 mmHg and diastolic pressure by 2.06 mmHg. In people with hypertension, the reductions were larger: 5.39 mmHg systolic and 2.82 mmHg diastolic [2]. Blood pressure fell in people with and without hypertension, regardless of sex or ethnic group [2]. The authors argued that cutting salt intake from 9–12 g to 5–6 g per day would have a major effect on blood pressure, and that 3 g per day should become the long-term population target [2].
The effect can appear quickly. In the CARDIA-SSBP crossover trial, 213 adults aged 50–75 years, ranging from normal blood pressure to treated and untreated hypertension, each spent one week on a high-sodium diet and one week on a low-sodium diet of about 500 mg sodium per day [3]. At the end of the first week, 24-hour systolic pressure was 8 mmHg lower (95% CI 4–11 mmHg) in those who started with the low-sodium diet than in those who started with the high-sodium diet [3]. Compared with the high-sodium week, mean arterial pressure fell in 73.4% of participants on the low-sodium diet [3].
The comparison with participants’ usual diet is the most practical one. Compared with what they normally ate, the low-sodium diet cut sodium intake by a median of about 2.3 g per day, roughly one teaspoon of table salt, and lowered systolic pressure by a median of 6 mmHg [3]. The fall in blood pressure from the high- to the low-sodium diet was independent of hypertension status and of blood pressure medication use, and mild adverse events were reported by 8.0% of participants on the low-sodium diet and 9.9% on the high-sodium diet [3].
Two limitations matter. Each diet lasted only one week, so the trial does not show whether people can maintain such a low intake, and measured sodium intake on the low-sodium diet was higher than planned, at roughly 1.3 g per day [3].
From a clinical perspective, one of the easiest and quickest things you can do yourself is to reduce the amount of salt you eat. Many of my patients eat plenty of salt, and in my experience many people are not aware of the recommended intake. In Finland, the national nutrition recommendations set the recommended maximum salt intake at under 5 g per day [4], which is quite little. The same recommendations state that almost all Finns get more salt than recommended [4]. In practice, a single salty, processed hot meal can cover a large part of that daily amount, and many of the patients I see eat considerably more salt than this.
Potassium and Salt Substitutes: Useful, With One Important Caveat
Potassium has also been studied as a way to lower blood pressure. A systematic review and meta-analyses in the BMJ included 22 randomised controlled trials (1606 participants) reporting outcomes such as blood pressure, blood lipids, catecholamines and kidney function, plus 11 cohort studies (127,038 participants) [5]. Increased potassium intake lowered systolic pressure by 3.49 mmHg and diastolic pressure by 1.96 mmHg in adults, an effect seen in people with hypertension but not in those without it [5]. When the higher intake was 90–120 mmol per day, systolic pressure fell by 7.16 mmHg, although the review found no dose response [5]. In the cohort studies, higher potassium intake was associated with a 24% lower risk of stroke, based on evidence rated as moderate quality [5].
Salt substitutes have reduced sodium and increased potassium levels compared with regular salt [6]. The Salt Substitute and Stroke Study (SSaSS) was an open-label, cluster-randomised trial in 600 rural Chinese villages [6]. Its 20,995 participants had a history of stroke, or were 60 years or older with high blood pressure. Villages either switched to a salt substitute made of 75% sodium chloride and 25% potassium chloride, or continued using regular salt [6]. Over a mean follow-up of 4.74 years, with the salt substitute compared with regular salt:
- stroke occurred at a rate of 29.14 vs 33.65 events per 1000 person-years (rate ratio 0.86) [6]
- major cardiovascular events occurred at 49.09 vs 56.29 events per 1000 person-years (rate ratio 0.87) [6]
- death from any cause occurred at 39.28 vs 44.61 events per 1000 person-years (rate ratio 0.88) [6]
- serious adverse events attributed to hyperkalaemia (high blood potassium) were not significantly more common (3.35 vs 3.30 events per 1000 person-years) [6]
The participants had a mean age of 65.4 years, 72.6% had a history of stroke and 88.4% a history of hypertension, and all lived in rural China [6]. That is worth keeping in mind when applying the result to other settings.
Now the caveat. The 2024 ESC guideline states that, in people with hypertension who have a high sodium intake and no moderate-to-advanced chronic kidney disease, an increase in potassium intake of 0.5–1.0 g per day should be considered, for example through a potassium-enriched salt or a diet rich in fruits and vegetables [7]. In people with chronic kidney disease, or those taking potassium-sparing medication such as some diuretics, ACE inhibitors, angiotensin receptor blockers or spironolactone, the guideline advises considering monitoring of blood potassium if dietary potassium is being increased [7]. The authors of the BMJ review similarly limited their conclusion to people without impaired kidney handling of potassium [5]. If that applies to you, talk to your doctor before switching salts. I explain what a blood potassium result does and does not mean in potassium in athletes.
The DASH Diet: An Eating Pattern, Not a Single Food
Beyond single nutrients, an overall eating pattern can also be part of how to lower blood pressure. As the meta-analysis below describes, the Dietary Approaches to Stop Hypertension (DASH) diet was first tested in a controlled feeding trial, in which a “combination” diet rich in fruits, vegetables and low-fat dairy products lowered blood pressure more than both a control diet and a fruit-and-vegetable diet [8].
That 2020 systematic review and meta-analysis pooled 30 randomised trials with 5545 participants [8]. Compared with control diets, the DASH diet lowered systolic pressure by 3.2 mmHg and diastolic pressure by 2.5 mmHg [8]. The meta-analysis did not find a statistically significant difference in effect according to hypertension status [8]. The systolic reduction was larger in trials where sodium intake exceeded 2400 mg per day, and both systolic and diastolic reductions were larger in trials whose participants had a mean age under 50 years [8]. The quality of the evidence was rated moderate [8].
The 2024 ESC guideline recommends a healthy, balanced diet such as the Mediterranean or DASH diet to help reduce blood pressure and cardiovascular risk [7]. It also recommends limiting free sugar to a maximum of 10% of energy intake and discouraging sugar-sweetened drinks such as soft drinks and fruit juices [7].
Weight Loss: 1.05 mmHg per Kilogram Lost
Losing excess weight is another approach to how to lower blood pressure that has been tested in randomised trials. A meta-analysis of 25 randomised controlled trials with 4874 participants examined weight reduction achieved through energy restriction, increased physical activity or both [9]. An average net weight loss of 5.1 kg was associated with reductions of 4.44 mmHg in systolic and 3.57 mmHg in diastolic pressure [9]. The meta-analysis separately reported reductions of 1.05 mmHg systolic and 0.92 mmHg diastolic per kilogram of weight lost [9]. Populations that lost more than 5 kg on average saw larger reductions (6.63 mmHg systolic and 5.12 mmHg diastolic) than those that lost less [9].
This meta-analysis was published in 2003, so it is older than the other sources here. I include it because it reports the effect per kilogram of weight lost [9]. The 2024 ESC guideline recommends aiming for a stable, healthy body mass index of 20–25 kg/m² and a waist circumference below 94 cm in men and below 80 cm in women [7].
Alcohol: The Effect Depends on How Much You Drink
Drinking less can be part of how to lower blood pressure, but the size of the effect depends on how much you drink to begin with [10]. A systematic review and meta-analysis of 36 trials with 2865 participants examined what happens to blood pressure when people drink less, defining one drink as 12 g of pure alcohol [10]. In people who drank two or fewer drinks per day, cutting down was not associated with a significant fall in blood pressure. Above two drinks per day, reducing intake was associated with larger reductions [10]. The largest effect was seen in people drinking six or more drinks per day who reduced their intake by about 50%: systolic pressure fell by 5.50 mmHg and diastolic pressure by 3.97 mmHg [10]. Only three trials reported results for women, so the estimates for women are uncertain [10].
A non-significant blood pressure change at low intake does not mean that drinking is recommended. The 2024 ESC guideline recommends drinking less than an upper limit of about 100 g of pure alcohol per week, and preferably avoiding alcohol altogether for the best health outcomes [7].
Exercise: How to Lower Blood Pressure With Training
Exercise deserves a full article of its own, so here are the main points on how to lower blood pressure with training.
A large pairwise and network meta-analysis published in the British Journal of Sports Medicine included 270 randomised controlled trials with 15,827 participants and exercise interventions lasting at least two weeks [11]. Every main type of training significantly lowered resting blood pressure compared with non-exercising control groups [11]:
| Training type | Systolic reduction | Diastolic reduction |
|---|---|---|
| Aerobic exercise | 4.49 mmHg | 2.53 mmHg |
| Dynamic resistance training | 4.55 mmHg | 3.04 mmHg |
| Combined aerobic and resistance | 6.04 mmHg | 2.54 mmHg |
| High-intensity interval training | 4.08 mmHg | 2.50 mmHg |
| Isometric exercise training | 8.24 mmHg | 4.00 mmHg |
Isometric training, in which muscles hold a contraction without moving the joint, ranked highest of the main training types for both systolic and diastolic pressure in the network meta-analysis [11]. Among individual exercises, the isometric wall squat ranked highest for lowering systolic pressure and running ranked highest for diastolic pressure [11]. The authors describe typical isometric programmes as four 2-minute contractions with 1–4 minutes of rest between them, performed three times a week [11]. I cover isometric training, including its blood pressure effects, in isometric exercise for pain.
Three nuances keep these results in proportion. First, all exercise types lowered systolic pressure in people with normal blood pressure, but the reductions were substantially larger in people with hypertension [11]. Second, the isometric estimate rests on less data (24 effect sizes, compared with 182 for aerobic training), publication bias was detected for its diastolic effect (as it was for aerobic training), and no trials in the network compared isometric training directly with other exercise types, so the authors advised some caution [11]. Third, walking ranked lowest of all exercise types for systolic pressure, and cycling and running were significantly more effective, although walking still lowered systolic pressure by 2.85 mmHg [11].
In practical terms, the 2024 ESC guideline recommends at least 150 minutes per week of moderate-intensity aerobic exercise (at least 30 minutes on 5–7 days), or 75 minutes of vigorous exercise spread over three days, complemented by low- or moderate-intensity dynamic or isometric resistance training two to three times a week [7].
Another pattern I see is that many of my patients exercise fairly little, or understand exercise differently. For many of them, walking the dog counts as exercise. It is physical activity, but compared with the kind of exercise I was used to myself, it can seem fairly modest, and depending on how long and brisk the walk is, it may also fall short of what physical activity guidelines recommend. The World Health Organization’s 2020 guidelines recommend that all adults do 150–300 minutes of moderate-intensity or 75–150 minutes of vigorous-intensity aerobic physical activity per week, or an equivalent combination, together with muscle-strengthening activities at moderate or greater intensity on 2 or more days a week [12]. A sedentary person moves very little, and in my view, many of my patients fall short of these recommendations and could benefit from increasing both the amount and the intensity of their activity.
How to Know It Is Working: Measure at Home
Whichever approach to how to lower blood pressure you choose, home measurement shows whether it is working. A single office reading is usually not enough to establish a diagnosis, and the 2024 ESC guideline recommends self-measured home blood pressure to achieve better blood pressure control [7]. It describes the following routine, using a validated monitor, usually an upper-arm cuff device [7]:
- sit quietly for 5 minutes with your back and arm supported
- take two readings 1–2 minutes apart
- measure in the morning and in the evening for at least 3 days, ideally 7
- average all readings and share the results with your doctor
At home, an average systolic pressure of 135 mmHg or higher, or an average diastolic pressure of 85 mmHg or higher, corresponds to hypertension, and a systolic average of 120–134 mmHg or diastolic average of 70–84 mmHg corresponds to elevated blood pressure [7]. If you have not had your blood pressure checked recently, the guideline suggests opportunistic screening at least every 3 years for adults under 40 and at least yearly from age 40 [7].
High blood pressure is a common finding at the doctor’s office, and in my clinical experience many patients have elevated readings when they come to an appointment. White-coat hypertension, in which blood pressure is above the diagnostic threshold in the office but below it at home [7], is a fairly common phenomenon in practice. For this reason, I often ask patients to measure their blood pressure at home in calm conditions, typically twice a day, in the morning and in the evening, for one to two weeks.
At each session, I ask them to take either two readings and use the average, or three readings and leave out the first. The measurement situation itself can raise blood pressure in some patients: they feel tense, blood pressure rises reactively, and the reading becomes misleading. The aim is to obtain values that reflect the real situation. In my view, a very high reading at the clinic may, on the other hand, in itself suggest that the patient already has high blood pressure, although this still needs to be confirmed.
Stress and Blood Pressure: What I See in Practice
In my clinical experience, stress raises blood pressure in many patients. Some measure their blood pressure while they are still stressed, get a high reading and then keep measuring. Some may measure regularly, even every half an hour, and wonder why their blood pressure is elevated. For these frequent measurers, outside a planned measurement period, I often have to advise measuring less often, for example once a day. In my view, the worry about blood pressure causes them more stress, and once the reading is high, it often seems to stay high as they keep measuring it over and over.
In many stressed patients, blood pressure stays persistently elevated, which could clinically point to hypertension, although the cause may also lie in the stress itself. In my experience, many patients have very high readings at work, while at home their blood pressure settles to a calm level. Because it is so situation-specific, blood pressure in these patients can be somewhat difficult to treat. If blood pressure is elevated for most of the day, however, it still warrants further assessment and, where indicated, treatment, which in many cases means medication. For these patients, I find it useful to take daytime readings both at work and at home and compare them. In practice, a clear trend often emerges: readings are low at home in the evenings and at weekends, and rise during the working day.
What can be done about stress itself is often a difficult question. Some people tend to worry more by nature, and some jobs are stressful by their very nature. Few people can simply switch to a less stressful job, and not everyone has the opportunity to reduce work stress. In my experience in occupational health, employees often have fairly little influence over their own job description and tasks. In practice, we hold occupational health negotiations in which we try to adjust the patient’s job description so that the work becomes more manageable and stress can be reduced. In my view, this may also help lower blood pressure indirectly in patients who are prone to high blood pressure.
Our occupational health services also include occupational health psychologists, who teach stress management methods and various cognitive techniques for managing stress and workload. As an occupational health physician, I also often put patients on sick leave if they have been under too much stress for too long and start to develop significant strain and symptoms of exhaustion. In my view, this may also help bring blood pressure down, although sick leave is not a treatment for hypertension as such.
I discuss stress and its hormonal side in more detail in how to lower cortisol.
When Lifestyle Is Not Enough
Lifestyle change is the foundation of how to lower blood pressure, but it is not always the whole treatment. Under the 2024 ESC guideline [7]:
- Elevated blood pressure with low or moderate cardiovascular risk: lifestyle measures are recommended.
- Elevated blood pressure with sufficiently high cardiovascular risk: if blood pressure is confirmed at 130/80 mmHg or higher after 3 months of lifestyle changes, medication is recommended.
- Hypertension (confirmed, office blood pressure 140/90 mmHg or higher): lifestyle measures and medication should be started promptly, regardless of cardiovascular risk.
For most adults on treatment, the guideline recommends a systolic target of 120–129 mmHg, provided treatment is well tolerated, with more lenient targets possible in some groups, such as people aged 85 or older or those with moderate-to-severe frailty [7]. It also recommends that a reading of 180/110 mmHg or higher should prompt assessment for a hypertensive emergency [7], and that screening for primary aldosteronism, a common form of secondary hypertension, should be considered in all adults with confirmed hypertension [7].
Under the guideline, lifestyle measures and medication are used together rather than as alternatives [7]. In the CARDIA-SSBP trial, the blood pressure response to sodium reduction did not depend on whether participants were taking blood pressure medication [3].
Conclusion: How to Lower Blood Pressure
There is no single trick for how to lower blood pressure, but there is a well-tested set of measures. In trials, eating less salt lowered systolic pressure by 4.18 mmHg on average [2], the DASH diet by 3.2 mmHg [8], weight loss by 1.05 mmHg per kilogram [9], and the five main types of exercise training by 4.08–8.24 mmHg depending on the type [11]. Each of these effects is modest on its own, and they were measured in separate trials rather than added together.
From a clinical perspective, the starting point is an accurate picture of your blood pressure. In my experience, a single office reading can be misleading because of white-coat and stress effects, and home readings taken over one to two weeks, sometimes compared between work and home, give a truer picture. If your blood pressure is genuinely high, I find that natural methods alone are often not enough and medication is frequently needed, so it makes sense to have it assessed by a doctor while still doing what you can yourself.
Home measurements help show whether the changes are working, and the ESC guideline recommends starting medication when hypertension is confirmed (office blood pressure 140/90 mmHg or higher) [7].
References
[1] https://doi.org/10.1016/S0140-6736(21)01330-1
[2] https://doi.org/10.1136/bmj.f1325
[3] https://doi.org/10.1001/jama.2023.23651
[5] https://doi.org/10.1136/bmj.f1378
[6] https://doi.org/10.1056/NEJMoa2105675
[7] https://doi.org/10.1093/eurheartj/ehae178
[8] https://doi.org/10.1093/advances/nmaa041
[9] https://doi.org/10.1161/01.HYP.0000094221.86888.AE
[10] https://doi.org/10.1016/S2468-2667(17)30003-8
