By Joseph E. Scherger, MD, MPH

Core Faculty, Eisenhower Health Family Medicine, Residency Program, Eisenhower Health Center, La Quinta, CA; Clinical Professor, Keck School of Medicine, University of Southern California, Los Angeles

Dr. Scherger reports no financial relationships relevant to this field of study.

SYNOPSIS: High flavanol intake was associated with lower blood pressure in men and women comparable to what is seen with a Mediterranean diet or moderate salt restriction.

SOURCE: Ottaviani JI, Britten A, Lucarelli D, et al. Biomarker-estimated flavan-3-ol intake is associated with lower blood pressure in cross-sectional analysis in EPIC Norfolk. Sci Rep 2020;10:17964.

Investigators from Cambridge, UK, studied data from 25,618 participants in the European Prospective Investigation into Cancer (EPIC) trial (Norfolk cohort). They examined an association between diet and blood pressure, specifically the effect of regular flavanol intake. The authors observed significantly lower systolic blood pressure in men (1.9 mmHg) and women (2.5 mmHg). Other studies have shown flavanols are bioactive compounds that improve vascular function. The blood pressure reductions were similar to what has been found with adherence to a Mediterranean diet and moderate salt restriction.


Hypertension is the grandfather of chronic ailments that lead to cardiovascular disease. It remains the top risk factor for stroke, and a leading risk factor for heart disease. About 90% of hypertension is labeled as “essential,” meaning there is no secondary cause. It is estimated nearly half of American adults are hypertensive.1 Why? Do patients with hypertension need to live with this lifelong chronic disease? Are drugs always necessary to control hypertension?

This work by Ottaviani et al and other related investigations I have written about for Internal Medicine Alert concerns the role of healthy nutrition in lowering blood pressure (and improving health in other ways). Plants are rich in the antioxidants called flavanols (sometimes spelled flavonols). They are found in many plants, especially berries, citrus fruits, apples, pears, and strawberries.

In my medical practice, I strive to eliminate hypertension from patients’ problem lists, and help wean them off medications. My healthy lifestyle focus for reversing hypertension includes better nutrition, regular exercise, stress reduction, meditation, and restful sleep. Reducing weight and cutting alcohol consumption are especially helpful in lowering blood pressure. Herbert Benson, MD, at Harvard has used meditation in his hypertension clinic since the 1970s.2

Medical decisions about hypertension are based on resting blood pressure. Research has shown that home blood pressure readings may be more accurate than in our office, where we do not take the time to create an environment for rest.3 If a patient records a home blood pressure of 120/80 mmHg, their pulse pressure is 40 mmHg. If their office blood pressure is 160/80 mmHg, I know the high systolic reading is caused by some stress, either mental or physical. We should not be treating stress with blood pressure medications.

Lifestyle modification usually receives “lip service” in most hypertension guidelines. I learned that every medication causes its own disease. The more we can avoid them in patients and teach a healthy lifestyle, the better off our patients will be.


  1. Centers for Disease Control and Prevention. Facts about hypertension in the United States. Page last reviewed Sept. 8, 2020.
  2. Benson H. The Relaxation Response. HarperCollins; 1975.
  3. Beitelshees AL, Gong Y, Bailey KR, et al. Comparison of office, ambulatory, and home blood pressure antihypertensive response to atenolol and hydrochlorothiazide. J Clin Hypertens 2010;12:14-21.