A plant-based diet and hypertension

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Journal of Geriatric Cardiology (2017) 14: 327330
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Perspective  Open Access 
A plant-based diet and hypertension
Sarah Alexander1,*, Robert J Ostfeld2, Kathleen Allen3, Kim A Williams1
1Rush University Medical Center, Division of Cardiology, Chicago, IL, USA
2Montefiore Medical Center, Division of Cardiology, Bronx, NY, USA
3New York University, Department of Nutrition & Food Studies, NY, USA
J Geriatr Cardiol 2017; 14: 327330. doi:10.11909/j.issn.1671-5411.2017.05.014
Keywords: Hypertension; Vegan; Vegetarian; Plant-based diet
Hypertension is an insidious, common, and deadly dis-
ease, often detected incidentally at a routine doctor’s visit or
workplace health screening. Worldwide, it is estimated that
one billion people have hypertension and approximately 80
million Americans 20 years of age and older are hyperten-
sive.[1] The National Health and Nutrition Data Examination
Survey found that only 54% of hypertensive adults in the
United States had their high blood pressure controlled and
17% remained undiagnosed.[1] These findings translate into
poor outcomes as the number of deaths due to hypertension
increased by 35% from 2003–2013.[1] In the Global Burden
of Disease 2010 study, hypertension was identified as the
number one risk factor worldwide for deaths and disabil-
ity-adjusted life years.[2] In the United States, clinic visits,
medications and the treatment of complications from hy-
pertension, including heart failure, stroke, and renal disease
now account for a substantial portion of the Medicare
budget.[3] 
First line therapies for all stages of hypertension include
exercise and weight loss.[4] However, results from one small
cross-sectional study suggest that a plant-based diet is the
more important intervention. This study compared the blood
pressure of sedentary vegans, endurance athletes (matched
for body mass index with the vegan group) consuming a
Western diet and running an average of 48 miles per week,
and sedentary subjects consuming a Western diet. Blood
pressure was significantly lower in the vegan group.[5] Al-
though the benefits of exercise and weight loss seem to be
inherently understood by most, the definition and perception
of a “healthy” diet is one that has not yet reached consensus.
In the late 1930 s, Dr. Walter Kempner of Duke Univer-
sity introduced the “rice diet” as therapy for renal failure
and hypothesized that “we could radically alter the patients’
diets and thereby save lives.”[6] The rice diet was high in
*Correspondence to: sarah_alexander@rush.edu
complex carbohydrates, consisting mainly of rice and fruit,
and low in fat, protein (< 20 g/day) and sodium (< 150
mg/day). He first demonstrated its effectiveness in a dia-
betic, hypertensive patient with renal and congestive heart
failure: post intervention, this patient exhibited decreased
cardiac silhouette size as measured by chest X-ray, nor-
malization of a left ventricular strain pattern on ECG, and
improvement in hypertensive retinopathy. Similarly, in his
first cohort of hypertensive patients, 107 of 192 patients
demonstrated marked improvement, including decreased
blood pressure, cholesterol levels, retinopathy, and cardiac
silhouette size. Despite his findings, Kempner’s work was
not widely accepted by the scientific community, which
favored randomized control trials to substantiate these findings.
The first, major randomized control trial to evaluate diet
and hypertension was the Dietary Approaches to Stop Hy-
pertension (DASH) study of the mid-1990s. DASH, a con-
trolled feeding study, examined three different diets: (1) a
control diet, representative of a “typical” American diet, (2)
the DASH diet, high in fruits and vegetables and low in
saturated and total fat, and (3) a diet high in fruits and vege-
tables but otherwise similar to the control diet. Patients were
given standardized meals, and their weight and dietary so-
dium intake were kept stable.[7] The DASH diet reduced
both systolic and diastolic blood pressure by 5.5 mmHg and
3.0 mmHg, respectively, when compared to control. The
diet high in fruits and vegetables but otherwise similar to the
control diet also lowered blood pressure but not to the same
extent as the DASH diet. The DASH collaborative research
group stated that they could not identify the individual
components of the DASH diet that made it effective, but
other studies have shown that specific components of the
DASH diet, such as fruits, vegetables, whole grains, and
nuts were each associated with decreased blood pres-
sure.[816]

328 Alexander S. Plant-based diet and hypertension
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The Coronary Artery Risk Development in Young Adults
(CARDIA) study prospectively followed 5115 young (aged
18 to 30 years), black and white men and women over a 15
year time period and monitored them for the development of
cardiovascular disease risk factors.[10] A CARDIA hyper-
tension sub-study of 4304 subjects revealed a dose de-
pendent inverse relationship between plant-based food con-
sumption, including fruits, whole grains, and nuts, and blood
pressure. The opposite relationship was found, however,
with meat intake. Greater red and processed meat intake
was associated with higher blood pressure. Accordingly, in
a cross-sectional analysis of 11,004 British men and women
in the European Prospective Investigation into Cancer and
Nutrition-Oxford study, among four dietary types: (1) meat
eaters, (2) fish eaters, (3) vegetarians, and (4) vegans, the
vegans had the lowest prevalence of hypertension.[17]
Similarly, Borgi, et al.,[18] found a positive association
between animal flesh consumption and hypertension risk in
an analysis of three prospective cohorts [Nurses’ Health
Study I (NHS I), Nurses’ Health Study II (NHS II), and
Health Professionals Follow-up Study (HPFS)] totaling
188,518 participants with 2,936,359 person-years of fol-
low-up. In this largest prospective study to date on animal
consumption and incident hypertension, the positive rela-
tionship between animal flesh (including red and processed
meat, poultry and seafood) and hypertension was inde-
pendent of fruit, vegetable, and whole grain consumption.
Whereas, red and processed meats were associated with
increased hypertension risk in all three cohorts, poultry and
seafood intake were correlated with higher rates in two
(NHS II, HPFS). The findings of greater animal flesh (red
meat, processed meat, and poultry) consumption and in-
creased hypertension risk are consistent with other prospec-
tive cohort studies.[1921] In the few published prospective
studies of seafood consumption and hypertension risk, greater
seafood consumption appears either positively associated
with hypertension risk or neutral.[18,20,22]
The first study to compare blood pressure among habit-
ual vegans, lacto-ovo vegetarians, and non-vegetarians was
the Adventist Health Study-2 (AHS-2) calibration sub-study,
which included a cohort of 500 mostly white subjects.[23] Of
note, non-vegetarian Seventh Day Adventists tend to consume
less meat than persons consuming a typical Western diet.[24,25]
Nevertheless, the investigators found that vegans and
lacto-ovo vegetarians had significantly lower systolic and
diastolic blood pressure, and significantly lower odds of
hypertension (0.37 and 0.57, respectively), when compared
to non-vegetarians. Furthermore, the vegan group, as com-
pared to lacto-ovo vegetarians, not only was taking fewer
antihypertensive medications but, after adjustment for body
mass index, also had lower blood pressure readings. An-
other sub-study of AHS-2 examined hypertension in a black
population and found that the combined vegetarian/vegan
group had significantly lower odds of hypertension (0.56)
compared to non-vegetarians.[26]
Other studies found similar results. In a prospective co-
hort study of 1546 non-hypertensive subjects followed for
three years, those consuming more phytochemical rich
foods (plant-based foods) had lower risk of developing hy-
pertension.[27] In a matched cohort study of 4109 non-hy-
pertensive subjects followed for a median of 1.6 years,
vegetarians had a 34% lower risk of developing hyperten-
sion than non-vegetarians.[28] In studies of 5046 and 1615
subjects encouraged to adopt a plant-based diet as part of a
health improvement program for 30 days and 7 days, re-
spectively, systolic and diastolic blood pressure fell signifi-
cantly in both.[29,30] In a study of 26 subjects with medically
treated hypertension and then placed on a vegan diet for one
year, blood pressure fell, and 20 of the 26 subjects were able
to discontinue their anti-hypertensive medications.[31] In a
cohort study of 272 non-hypertensive men followed for five
years, greater plant protein intake was associated with lower
blood pressure.[32] The totality of evidence taken from these
studies indicates that plant-based diets have a meaningful
effect on both prevention and treatment of hypertension.
There are a variety of mechanisms proposed by which
plant-based nutrition leads to decrease in blood pressure.
They include improved vasodilation,[3336] greater antioxidant
content and anti-inflammatory effects,[3744] improved insu-
lin sensitivity,[33,4548] decreased blood viscosity,[49,50] altered
baroreceptors,[33] modifications in both the renin-angioten-
sin,[36,5153] and sympathetic nervous systems,[33,54] and mo-
dification of the gut microbiota.[53]
Long-term randomized controlled trials examining the
impact of plant-based diets on various health outcomes,
including hypertension, will further inform medical guide-
line creation and refine our understanding of the relationship
between diet and disease. However, in lieu of such informa-
tion and in the context of the data within this Special Issue,
we believe that consuming a diet that is mostly or exclu-
sively plant-based appears prudent for the prevention and
treatment of hypertension.
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This article is part of a Special Issue “A plant-based diet and cardiovascular disease”.
Guest Editors: Robert J Ostfeld & Kathleen E Allen