September/October 2024

September/October 2024 Issue

Fitness: Exercise That Lowers Blood Pressure
By Kate Evans, MS, RDN
Today’s Geriatric Medicine
Vol. 17 No. 5 P. 28

Various forms of physical activity can help improve this heart disease risk factor.

Hypertension affects nearly one-half (48.1%) of adults in the United States and is a significant risk factor for heart disease and stroke.1 The prevalence of hypertension increases with age, affecting 22.4% of individuals aged 18 to 39, 54.5% of people aged 40 to 59, and 74.5% of those aged 60 and older.2 This highlights the importance of engaging in health behaviors for the prevention and management of hypertension throughout the lifespan.

In addition to nutrition strategies for reducing blood pressure, such as increasing potassium, calcium, and magnesium intake and decreasing sodium consumption, dietitians and other health care providers can educate patients on the role physical activity plays in managing it. Current clinical practice guidelines from the American College of Cardiology and American Heart Association recommend adults with elevated blood pressure or hypertension increase physical activity through a structured exercise program.3 Following are examples of different types of exercise that can affect blood pressure.

Type of Physical Activity
The types of exercise commonly discussed in the context of blood pressure management can be grouped into the following categories:

• Aerobic exercise: Repetitive movements that can be maintained over a prolonged period of time.4

• Isometric exercise: Physical activity that involves static muscle contractions with no movement at the joint.4

• Dynamic resistance exercise: Physical activity that involves moving resistance through the joint’s range of motion, often using free weights or weight machines.4

• High-intensity interval training (HIIT): Repeated bouts of high-intensity exercise separated by periods of recovery or low-intensity exercise.5

• Combined training: Includes aerobic and strength exercises in the same training session.5

Impacts of Exercise on Blood Pressure
The American College of Cardiology and American Heart Association clinical practice guidelines, published in 2018, estimate that the largest decrease in systolic blood pressure can be achieved with 90 to 150 minutes of aerobic exercise per week. They estimate that three 10-minute sessions of isometric handgrip exercises per week are the next most effective form of exercise for systolic blood pressure reduction, followed by 90 to 150 minutes of dynamic resistance exercise per week.3 While aerobic activities are one of the more commonly recommended forms of exercise for blood pressure reduction based on these guidelines, recent studies have demonstrated that the advantages of other forms of exercise may be greater.

A systematic review published in 2023 that included 270 randomized controlled trials concluded that various forms of exercise improve resting blood pressure, particularly isometric exercise. The results of the review’s analysis rank the following types of exercises in order of effectiveness for lowering systolic vs diastolic blood pressure.5

Systolic Blood Pressure Reduction (Highest to Lowest Efficacy)
1. Isometric exercise training
2. Combined training
3. Dynamic resistance training
4. Aerobic exercise training
5. HIIT

Diastolic Blood Pressure Reduction (Highest to Lowest Efficacy)
1. Isometric exercise training
2. Dynamic resistance training
3. HIIT
4. Combined training
5. Aerobic exercise training

The authors examined isometric handgrip, isometric leg extension, and isometric wall squats as subgroups for isometric exercise, and walking, running, and cycling as subgroups for aerobic exercise. A secondary analysis found that isometric wall squats were the most effective exercise for reducing systolic blood pressure, and running was the most effective exercise for lowering diastolic blood pressure.5

Based on these findings, the authors recommend a greater emphasis on isometric exercise in future guidelines for the prevention and treatment of hypertension. The data also supports the use of resistance training, HIIT, combined training, and aerobic activity—especially running—for blood pressure reduction.5

Exercises for Patients With Hypertension

Isometric Exercises
Isometric exercise programs used for blood pressure management usually include four two-minute holds separated by one- to four-minute rest intervals, performed three times per week.5 Encourage patients to start by choosing one of the exercises below to complete on this schedule, then incorporate additional exercises over time. Patients who are new to these exercises may start with 30- to 60-second holds, then increase gradually to two-minute holds.

• Wall squats: Stand with your back against the wall and feet shoulder-width apart. Step forward about 1 to 2 feet and slide your back down the wall to a sitting position with your thighs parallel to the floor and knees directly over your ankles.

• Hand grip exercises: Squeeze a tennis ball or a hand grip device (available at most sporting goods stores) with 30% of your maximum strength. Hold for two minutes, then switch to the other hand.

• Planks: Lying on the floor in the prone position, ground your toes and forearms into the floor with your elbows aligned below the shoulders, and lift your torso up. Keep your back and legs straight and your neck neutral.

• Bridges: Lie on your back with your knees bent, feet shoulder-width apart and flat on the floor, and arms resting parallel to your body. Raise your hips up until they’re in line with your knees and shoulders. For an added challenge, loop a resistance band around your thighs.

• Overhead hold: In a standing position, grasp a light dumbbell or soup can in each hand and extend arms above your head. Hold your arms straight above your shoulders.

Dynamic Resistance Exercises
In a meta-analysis of dynamic resistance exercise programs for hypertension, participants performed an average of three sets of 10 to 12 repetitions three times per week, completing eight exercises in each training session.7 Advise patients to start with light weights (or no weights for squats and lunges), then increase gradually as they build strength. A few examples of dynamic resistance exercises patients can perform with dumbbells are as follows:

• Shoulder press: Hold a dumbbell in each hand by your shoulders with your palms facing forward and your elbows held out to the side at a 90-degree angle. Extend your arms straight above your head, then slowly lower the dumbbells to the starting position.

• Bicep curls: Hold a dumbbell in each hand with your arms by your sides and palms facing forward. Bend your elbows and raise the dumbbells up toward your shoulders, then slowly lower the dumbbells to the starting position.

• Squats: Stand with your feet hip-width apart and hold a dumbbell in front of your chest with both hands. Keeping your back straight, bend your knees and sink your hips back until your thighs are parallel with the floor, then slowly raise yourself back up to the starting position.

• Lunges: Stand with a dumbbell in each hand and your arms by your sides. Take a step forward with your right leg, then bend your knee until your thigh is parallel to the floor. Slowly raise back up and step back to the starting position, then repeat with your left leg.

HIIT
HIIT workouts typically include 30-second, high-intensity movement periods followed by 15 to 60 seconds of rest. During the movement period, participants can either repeat the same high-intensity exercise or cycle through a circuit of high-intensity exercises.8

• Sample beginner HIIT workout: Patients can do a 30-second sprint followed by 60 seconds of walking. Repeat 10 to 15 times.

• Sample advanced HIIT circuit workout: Patients can do a 30-second treadmill sprint, 30 seconds of rowing, 30 seconds of jumping rope, and 30 seconds of pushups with 30 seconds of rest between each exercise. Repeat five to 10 times.

Aerobic Exercises
The Physical Activity Guidelines for Americans recommend 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity aerobic exercise per week.6 Patients may enjoy the following examples of aerobic exercise.

Moderate-Intensity Aerobic Activities
• brisk walking;
• active forms of yoga, such as Vinyasa;
• yard work;
• water aerobics;
• tennis or pickle ball; and
• ballroom or line dancing.

Vigorous-Intensity Aerobic Activities
• running;
• swimming;
• cycling;
• hiking uphill;
• kickboxing; and
• energetic dancing, such as Zumba.

Counseling Strategies
There are numerous forms of exercise that are beneficial for lowering blood pressure, giving patients a variety of options from which to choose. Encourage patients to choose at least one type of isometric exercise to add to their routine, then select additional forms of physical activity they enjoy that are appropriate for their fitness level. Keep in mind that patients are most likely to be consistent with exercise when they commit to a schedule, when it’s enjoyable, and when they begin with setting small goals. Advise those who take antihypertensive medications to follow up regularly with their prescribing physician, since medication adjustments may be needed as they increase physical activity.

— Kate Evans, MS, RDN, is a clinical dietitian at the UCLA Vatche & Tamar Manoukian Division of Digestive Diseases and a consultant dietitian at Kelly Jones Nutrition, a performance nutrition private practice that supports athletes at every level.

References
1. Facts about hypertension. Centers for Disease Control and Prevention website. https://www.cdc.gov/bloodpressure/facts.htm. Published July 6, 2023. Accessed December 10, 2023.

2. Ostchega Y, Fryar CD, Nwankwo T, Nguyen DT. Hypertension prevalence among adults aged 18 and over: United States, 2017–2018. Centers for Disease Control and Prevention website. https://www.cdc.gov/nchs/products/databriefs/db364.htm. Published April 24, 2020. Accessed December 10, 2023.

3. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary : a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Soc Hypertens. 2018;12(8):579.e1-579.e73. 

4. Gellman MD, Turner JR, eds. Encyclopedia of Behavioral Medicine. New York: Springer; 2013. 

5. Edwards JJ, Deenmamode AHP, Griffiths M, et al. Exercise training and resting blood pressure: a large-scale pairwise and network meta-analysis of randomised controlled trials. Br J Sports Med. 2023;57(20):1317-1326. 

6. US Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd Edition. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf. Published 2019.

7. MacDonald HV, Johnson BT, Huedo‐Medina TB, et al. Dynamic resistance training as stand‐alone antihypertensive lifestyle therapy: a meta‐analysis. J Am Heart Assoc. 2016;5(10):e003231. 

8. HIIT for beginners – tips and workouts. International Sports Sciences Association website. https://www.issaonline.com/blog/post/hiit-for-beginners-tips-and-workouts. Published November 10, 2022. Accessed January 10, 2023.