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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e143

had at least moderate-quality evidence but were judged to be less effective than lifestyle interventions.14 It is important to note that BP response to any given inter­ vention will vary across subgroups and individuals and is a function of the fidelity and intensity of the interven­ tion, patient adherence, and in some cases, the starting BP level.

Recommendation-Specific Supportive Text

1 In adults who have overweight or obesity (defined as

body mass index [BMI] 25.0-29.9 and ≥30 kg/m2 for non-Asian populations and BMI 23.0-27.4 and ≥27.5 kg/m2 for individuals of Asian heritage50), weight loss is a core strategy to improve current health and reduce risk for multiple diseases, and for manage­ ment of chronic conditions, including elevated BP and hypertension.51,52 It is somewhat difficult to tease out the effects of weight loss per se on BP lowering from the means by which weight loss is achieved (ie, dietary changes and exercise, which have their own direct effects). Nonetheless, evidence consistently demonstrates BP reduction with weight loss regard­ less of the mechanism (lifestyle, cognitive behavioral therapy, medication, surgery).7,9,10,53–55 In general, there is a reduction in BP of approximately 1/1 mm Hg (systolic/diastolic) for each 1 kg (2.2 lbs) of weight loss.2 Weight reduction ≥5% of body weight or ≥3 kg/m2 of BMI, compared with lesser amounts, pro­ duces greater BP lowering in patients with and with­ out hypertension.1,2,4–6,8–10,52 Weight loss can amplify the BP-lowering effects of the DASH diet or sodium reduction interventions.1,4,9 For patients who do not meet weight loss goals with nonpharmacological interventions, pharmacotherapy54,56 or bariatric sur­ gery53 can be considered; BP lowering correlates with the amount of weight loss using these approaches, although there is greater potential for adverse effects or harm.53,57 In the short term, glucagon-like peptide-1 (GLP-1) receptor agonist medications used for other indications (diabetes, obesity) appear to provide con­ comitant BP lowering.55,58–60

2 The DASH eating plan emphasizes fruits, vege­

tables, low-fat or nonfat dairy, and whole grains, providing high potassium, magnesium, calcium, and fiber intake.61 It is the most effective eating pattern for lowering BP and has a large and con­ sistent evidence base across BP levels.10–15,61–64 Conversely, the eating pattern in the Southern United States appears to be the largest media­ tor of the higher hypertension incidence in Black adults compared with White adults.65 Reduction in BP with the DASH eating plan varies across tri­ als, from 1 to 13 mm Hg for SBP and from 1 to 10 mm Hg for DBP. BP reduction with the DASH eating plan is generally greater among Black individuals66 and individuals with higher baseline BP, younger age (<50 years), or higher sodium intake (>2400 mg/d).13,63 The DASH eating plan has been effective in both short-term feeding and longer-term behavioral intervention studies,9–11 and the effect on BP is significantly greater when combined with weight loss or sodium reduc­ tion.9,10,12 Patient information regarding the DASH eating plan is available publicly.67–69 Counseling by a registered dietician/nutritionist is useful to enhance efficacy.70 Other eating patterns, includ­ ing Mediterranean, low-carbohydrate, Paleolithic, high-protein, vegetarian, low-glycemic index, lowsodium, and low-fat dietary approaches, have been shown to lower BP when compared with various control diets, although less effectively than the DASH eating plan.14,15,64,71–74

3 Interventions that decrease sodium intake reduce

BP elevation across the life course, prevent inci­ dent hypertension, and lower BP in adults with hypertension.17,18,20,22–24,75–87 Sodium substitu­ tion interventions prevent CVD events and mor­ tality,20,21 and dietary interventions that reduce sodium appear to do the same.19,48,49 There is a linear dose response of BP to sodium intake manipulation, with steeper BP declines at higher than lower baseline BP levels.17,18,77 On average, low-sodium (≤1500-2300 mg/d) versus highsodium (≥4500 mg/d) diets safely result in BP reductions of approximately 3/2 mm Hg (sys­ tolic/diastolic) in normotensive and 7/3 mm Hg in hypertensive individuals.4,5,10,16,18 There is greater responsiveness to sodium reduction in older adults and those with salt-sensitive BP.18,77,86–88 Sodium reduction has additive BP-lowering effects to the DASH eating plan and weight loss.4,12 Behavioral interventions targeting lower sodium intake, espe­ cially if advice is provided by a registered dietitian or low-sodium meals are provided, are most effec­ tive in sodium reduction.22,70,76,78,79,82,83 In the United States, most dietary sodium comes from additions during food processing or during food prepara­ tion in restaurants,89–91 so successful reduction at the population level requires not just a focus on individual behaviors but on societal changes in eating patterns and broad food reformulation strategies and policies.81 Such population-level strategies could have a profound impact on CVD event reduction.92

4 Compared with the use of regular table salt, use

of a potassium-enriched salt substitute (in which 100% sodium chloride is partially replaced by potassium chloride and, variably, flavoring agents) causes approximately a 5/1.5 mm Hg (systolic/ diastolic) reduction with variability depending on the subgroup and the amount of sodium replace­ ment.20,22–24,93 In the largest trial to date, 20 995

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