Review

Meditation and blood pressure: a meta-analysis

of randomized clinical trials
Lu Shia, Donglan Zhangb, Liang Wangc, Junyang Zhuangd, Rebecca Cooke, and Liwei Chena

techniques; HE, health education; MBSR, mindfulness-

based stress reduction; SP, social support; TAU, treatment
ns through a systematic literature search of the PubMed, ABI/INFORM, MEDLINE, EMBASE,
as usual; PsycINFO, and
TM, transcendental meditation
by type of meditation (transcendental meditation vs. non- transcendental meditation intervention) and by type of BP measurement [ambulatory BP m
P effect estimate was —2.49 mmHg [95%
BACKGROUND

H
ypertension is a costly chronic condition that leads
to various cardiovascular diseases and premature
deaths [1,2]. The prevalence of hypertension is
expected to rise worldwide, in both developed countries
and developing countries, with the global demographic
trend of aging [3– 5]. Despite various proven approaches
in treating hypertension, blood pressure (BP) remains
uncon- trolled in many hypertensive patients. Hypertension
is continuing to be one of the leading causes of undesirable
morbidity and mortality in the modern society, as well as
healthcare expenditure [6,7].
An increasingly popular approach to lower BP is to
reduce stress via various stress-reduction techniques such
confidence interval (CI): —7.51, 2.53] for transcendental as meditation [8]. The effects of meditation techniques on
meditation intervention (statistically insignificant) and stress relief and BP reduction have been evaluated over the
—3.77 mmHg (95% CI: —5.33, —2.21) for non- past 20 years [9– 12]. As a meditation format that became
popular earlier in industrialized countries, transcendental
transcendental meditation interventions, whereas the meditation has been extensively studied for its effect on BP
pooled DBP effect estimate was —4.26 mmHg (95% CI: reduction [13,14]. In 2008, in a meta-analysis of nine pub-
—6.21, —2.31) for transcendental meditation interventions lished randomized-controlled trials (RCTs), it was shown
and —2.18 mmHg (95% CI: —4.28, —0.09) for non- that people assigned to the transcendental meditation
intervention had lower SBP and DBP by 4.7 [95% confi-
ate from transcendental meditation interventions was —5.57 mmHg (95% CI:dence
—7.41,interval
—3.73)(CI):
and was7.4—5.09
to 1.9]
mmHgandwith3.2 mmHg (95%
—non-transcendental medita
CI:
—
—5.4 to 1.3), respectively —
[15]. In 2015, a meta-analysis
—
with 12 RCTs updates the estimate of transcendental med-
itation’s effect on BP: on average, SBP was reduced by
intervention (95% CI: —6.34, —3.85), whereas the pooled 4.26 mmHg (95% CI: —6.06, —2.23) and DBP was reduced
effect size in DBP change for transcendental meditation
interventions was —2.86 mmHg (95% CI: —4.27, —1.44)
and was —2.57 mmHg (95% CI: —3.36, —1.79) for non-
Journal of Hypertension 2017, 35:696–706
a
Department of Public Health Sciences, Clemson University, Clemson, South
both SBP and DBP. More ABPM-measured transcendental meditation interventions might be needed to examine the benefit of transcendental medita
Carolina, bDepartment of Health Policy and Management, College of Public
is, meta- regression, mindfulness, mindfulness-based stress reduction, transcendental meditation
Health, University of Georgia, Athens, Georgia, cDepartment of Biostatistics and
T, contemplative meditation combined with breathing Epidemiology, College of Public Health, East Tennessee State University,
Johnson City, Tennessee, dDepartment of Mathematical Sciences and
e
Department of Psychology, Clemson University, Clemson, South Carolina, USA
Correspondence to Donglan Zhang, Department of Health Policy and
Management, College of Public Health, University of Georgia, 100 Foster Road,
Wright Hall, Athens, Georgia, USA. Tel: +1 706 713 2755; e-mail:
[email protected]
Received 11 April 2016 Revised 23 August 2016 Accepted 18 November 2016
J Hypertens 35:696–706 Copyright © 2017 Wolters Kluwer Health, Inc. All rights
reserved.
DOI:10.1097/HJH.0000000000001217

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

 Meditation Blood Pressure

by 2.33 mmHg (95% CI: 3.70, 0.97) in transcendental

—
meditation groups as compared with control groups [16]. meditation as a primary intervention, using BP changes
In recent years, other meditation interventions have as primary or secondary outcomes, and published in
become increasingly popular in clinical treatment of stress, Eng- lish. We excluded those neither measuring the SBP
including mindfulness-based stress reduction (MBSR) and nor measuring DBP. Participant status includes both
breathing awareness meditation [10,17]. These non- those with hypertension and those with normal BP
transcen- dental meditation interventions deliver their levels.
instruction in less-individualized format than
transcendental meditation and have different emphases on Data extraction
setting session goals and choosing meditation methods, The data recorded from each study were name of article,
providing a variety of options for individuals with different author names, sample size, mean changes (before and
preferences for meditation techniques [18]. According to a after the trial in the intervention and control groups,
recent review [19], MBSR could be offered at a relatively respect- ively) and standard deviations (SDs) of the
affordable price such as $400 per person for an 8-week mean changes in SBP and DBP, estimated mean
training program, whereas a recent comparative difference in mean changes, standard error (SE), and
effectiveness analysis [18] reports that the stand- ard 95% CI.
transcendental meditation price in southern California is Three authors (R.C., J.Z., and D.Z.) independently
$1450. As transcendental meditation might not be the reviewed the studies to extract data, and if they had dis-
sole meditation protocol that suits the need of every agreements, they discussed with other authors (L.W., L.C.,
hypertension or prehypertension patient, there is a need and L.S.). In total, 19 studies were included in the meta-
to evaluate the effect of non-transcendental meditation on analysis.
BP [11,12,16,20]. It is not impossible that meditation
(especially non-tran- scendental meditation) mainly Statistical analysis
acted on the ‘white-coat’ effect (whereby BP elevates in Data on mean difference in BP (both SBP and DBP,
a medical setting) [21]: BP reduction based on clinical measured by mmHg) between the intervention and
measurements after meditation intervention could be control groups were extracted from the original studies,
questionable as they might capture the placebo effect as with SDs. Meta-analysis was conducted separately by
patients with stress reduction training might feel less SBP and DBP, with the random-effects approach to
stressed in a doctor’s office. Ambulatory BP monitor- ing account for the possible heterogeneity between different
(ABPM), which records BP for 24 h at regular intervals trials. As we focused specifically on the effects of
under ambulatory setting to capture the mean level as different types of intervention on BP change, we
well as the variability of BP, serves a more robust synthesized the evidence by type of intervention
measure of BP than office or home measurements [22]. (transcendental meditation vs. non- transcendental
Therefore, non-ABPM measurements should be meditation) and by type of BP measurement (ABPM vs.
compared with ABPM measure- non-ABPM).
ments to examine meditation’s effect on BP. We also conducted four meta-regressions to identify
The objective of this study was to perform a whether the effect size significantly differed by type of
systematic review and meta-analysis to evaluate the intervention (transcendental meditation vs. non-transcen-
effect of medi- tation intervention on BP, based on more dental meditation), as stratified by the type of measurement
comprehensive and updated data with ABPM and non- (ABPM vs. non-ABPM). Age (age 65 vs. below 65 years)
ABPM that included both transcendental meditation and þ (hypertensive vs.
and baseline patient hypertension status
non-transcendental meditation interventions. nonhypertensive) were also included in the meta-
regressions, although the dichotomous age variables were
METHODS not included in the two meta-regressions of ABPM-
measured studies as there were no study conducted among
Literature search those aged 65 years or above using ABPM measurement.
Based on the guidelines of the Preferred Reporting Items for We conducted sensitivity analyses to examine the influ-
Systematic Reviews and Meta-Analyses Protocol [23], we ence of each individual study by excluding each study from
searched in PubMed, ABI/INFORM, MEDLINE, EMBASE, the meta-analyses and comparing the point estimates
PsycINFO, CINAHL, and Cochrane Library for articles pub- before and after excluding each specific individual study.
lished from January 1980 to October 2015, using the follow- We examined publication bias through funnel plots and
ing terms – Interventions: ‘meditation’ OR ‘mindfulness’ OR tested their symmetry. All analyses were performed by
‘transcendental’; Outcomes: ‘blood pressure’ OR using STATA 14.0 software (Stata Corporation, College
‘arterial pressure’ OR ‘pulmonary wedge pressure’ OR Station, Texas, USA).
‘venous pressure’ OR ‘portal pressure’ OR ‘hypertension’
OR ‘hypo- tension’; Study type: ‘clinical trial’ OR RESULTS
‘comparative study’ OR ‘control’ OR ‘controlled clinical
trial’ OR ‘crossover’ OR ‘experimental’ OR Search results and study characteristics
‘randomization’ OR ‘RCT’. In addition, we manually The literature search resulted in 735 studies, of which 19
searched the reference lists of relevant pub- lications to identify met our inclusion criteria and were included in this meta-
possible more studies. analysis (Fig. 1). Among the 19 studies, 12 (three with
ABPM and nine non-ABPM) used the transcendental
Study selection meditation intervention [24– 35] and seven (four with
To be included in the meta-analysis, a study must have ABPM and three non-ABPM) used non-transcendental
been an RCT with intervention and control groups, using meditation interven- tions [36– 42]; 16 of the 19 studies
used health education for

Journal of Hypertension www.jhypertension.com 697

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Shi et al.

Records identified from database PubMed, ABI/INFORM, MEDLINE, EMBASE, PsycINFO, CINAHL, and measurement, the pooled SBP effect estimate from tran-
Cochrane Library (N = 735)
scendental meditation interventions was 5.57 mmHg
(95% CI: 7.41, 3.73) and was — 5.09 mmHg with
Records excluded by screening
—
non-tran- —
the titles and abstracts (N =
704):
scendental — meditation intervention (95% CI: — 6.34, 3.85)
(1) Non-RCT studies (N = 152) (Fig. 4), whereas the pooled effect size in DBP change
(2) Intervention
irrelevant (N = 354)
for transcendental meditation interventions — was 2.86
mmHg (95% CI: 4.27, 1.44) and was 2.57 mmHg
(95% CI: — —
(3) Blood pressure not
measured (N = 23)

—3.36, 1.79) for—non-transcendental meditation interven-

(4) Insufficient
Potentially relevant articles (N = 31) information (N = 65)

Records further excluded:

Review articles and
tions (Fig. 5).
commentaries (N = 4) The meta-regressions showed that among the studies
Articles not provided sufficient using ABPM measurements, no statistically significant
information (N = 8) difference was observed for meditation type (non-tran-
scendental meditation vs. transcendental meditation inter-
Studies selected for review (N = 19)
ventions) on either SBP (b 1.30, P 0.173) or DBP (b
1.77, P 0.542) (Table 3) and ¼for baseline hyperten- sion
¼ —of the participants (hypertensive vs. nonhyper-
status
tensive) on either SBP (b 0.76, P 0.549) or DBP (b
1.44, P 0.542). ¼
Among those studies using non-ABPM, again no
Transcendental
meditation (N = 12)
Non-TM intervention
(N = 7)
¼ —
statisti- cally significant difference was observed for
meditation type (non-transcendental meditation vs.
FIGURE 1 Selection of randomized clinical trials (RCT) on meditation transcendental meditation interventions) on either
interventions for blood pressure reduction, 1980–2015. Note: Searched SBP (b 1.36, P 0.482) or DBP (b 1.00, P 0.586) ¼ and
keywords – Interven- tions: ‘meditation’ OR ‘mindfulness’ OR ‘transcendental’; ¼ baseline hypertension
for —
¼ — status of the participants on
Outcomes: ‘blood pres- sure’ OR ‘arterial pressure’ OR ‘pulmonary wedge
pressure’ OR ‘venous pressure’ OR ‘portal pressure’ OR ‘hypertension’ OR either SBP (b 0.02, P ¼ 0.992) or DBP (b 1.50, P 0.363).
‘hypotension’; and Study type: ‘clinical trial’ OR ‘comparative study’ OR ‘control’ The ¼— ¼ ¼
OR ‘controlled clinical trial’ OR ‘cross- over’ OR ‘experimental’ OR patient age, however,
¼ was a significant predictor of
‘randomization’ OR ‘RCT’. both SBP (b ¼4.147,— P < 0.001) and DBP (b ¼4.601, P
< 0.001). —
Sensitivity analysis shows that excluding the
Wenneberg et al.’s study changes the results
the control groups, 11 were conducted in healthy non- substantially in the effect of transcendental meditation
hypertensive individuals, and eight were among adoles- on SBP using ABPM measure- ment, with pooled
cents. Table 1 shows the characteristics of the 19 included change in SBP from 2.49 to —
studies. In total, 853 patients enrolled in the control groups —4.63 mmHg (95% CI:—8.10, 1.16). No other single study
and 793 patients enrolled in the intervention groups. In all had a large impact on other
studies, the completion of two groups was more than 80%, — pooled effect estimates. Funnel
plot had a roughly symmetrical distribution, suggesting a
and studies lasted less than 1 year (range: 8– 52 marginally significant publication bias (P ¼ 0.051) (Fig.
weeks). Only two of the 19 studies included in the meta- 6).
analysis had a sample size larger than 200 [34,35].
Table 2 shows the value for SBP and DBP at baseline
and end of trials, as well as changes in BPs between DISCUSSION
intervention and control groups (BPs in control – BPs in
intervention). Although 15 of the 19 studies reported The current meta-analysis of meditation and BP that
significant decrease in SBP among the intervention group included non-transcendental meditation interventions is
as compared with the control group (Table 2), four reported the first one. We found that non-transcendental
no significant differ- ence [28,29,32,42] between the two meditation intervention can result in a consistent
study groups. For the outcome of DBP (Table 2), five of reduction of SBP and DBP across different measurement
the 17 studies reported insignificant difference between the approaches. On the other hand, the pooled estimate of
intervention group and the control group [29,30,31,41,42], SBP change for the three ABPM-measured
whereas the other 12 reported significant decreases among transcendental meditation interven- tions was not
the intervention group as compared with the control significantly different from the null effect. The earliest
group. of the three ABPM-measured transcendental med- itation
We then did meta-analysis summarizing the change interventions yielded a statistically insignificant SBP
in SBP and DBP, stratified by type of meditation and by increase [28], driving the pool estimate toward the null
type of BP measurement. Among the studies using the hypothesis. Although our sensitivity analysis suggested
ABPM measurement, the pooled SBP effect estimate was the 1997 study reporting a statistically insignificant SBP
— 2.49 mmHg (95% CI: 7.51, 2.53) for transcendental increase [28] might be an outlier (particularly as the
med- itation intervention
¼ (P 0.16) and same study [28] reported a significant DBP change of
3.77 mmHg (95% CI: 5.33, 2.21) for non- 5.30 and a 95% CI between 9.38 and 1.22), — more
— ABPM-measured transcendental meditation interventions
transcendental meditation interven- tions (Fig. 2), — to better understand the impact of
whereas the pooled DBP effect estimate was 4.26 might be needed
— mmHg (95% CI:—6.21, 2.31) for transcendental transcendental medita- tion on ABPM-measured SBP
meditation interventions —and — 2.18 mmHg (95% CI: outcome. After all, it is not ideal to have only three
— 4.28, 0.09) for non-transcendental meditation inter- RCTs for a meta-analysis.
ventions (Fig. 3). Among the studies using the non- Although the intellectual attempts to understand the
ABPM biomedical mechanisms behind meditation’s impact on

698 www.jhypertension.com Volume 35 ● Number 4 ● April 2017

 Jo
ur
na
l
of
H
yp TABLE 1. Characteristics of the studies
ert
Study Sample size
C en Hypertension Blood pressure Control duration control/ Mean
op Study Patient characteristic baseline measurement Intervention group (weeks) intervention % age (years) Completion (%)
Male
yri Bagga et al., 1983 [21] Undergraduate students No Nonambulatory TM Relaxation 12 6\6 0 19 100
gh Alexander et al., 1989 [22] Elderly retirement home No Mean of 3 readings TM Untreated 13 11\21 17.8 81 81
resident
t Schneider et al., 1995[19] Elderly hypertensive Yes 3 readings, mean TM HE 13 38\36 41 66 85
© of last 2
Alexander et al., 1996 [20] Older African-American Yes 3 readings, mean TM HE 12 44\41 38.8 66 100
20 of last 2
17 Wenneberg et al., 1997 Normotensive men No Ambulatory TM HE 15 32\32 100 25 63
[23]
W Castillo-Richmond et al., Hypertensive adults Yes 3 readings in each TM HE 29 67\71 31.5 54 44
olt 2000 [24] of the 3 visits.
Mean of last 2
er visits
Barnes et al., 2001 [26] Adolescents Yes Ambulatory TM HE 8 18\17 54.5 17 94
s Barnes et al., 2004 [32] Adolescents Yes Ambulatory TM HE 17 77\79 63 16 64
Kl Barnes et al., 2004 [27] African-American No Ambulatory BAM HE 12 39\17 42.4 15 84.8
adolescents
u Schneider et al., 2005 [28] Hypertensive adults Yes Mean of 3 readings TM HE 52 44\54 48.5 48 69
w Paul-Labrador et al., 2006
[29]
Patients with coronary
heart disease
Yes Mean of 3 readings TM HE 16 52\51 81.6 67 82

er Barnes et al., 2008 [33] African-American Yes Ambulatory BAM HE 12 20\46 42.4 15 84.8
H Manikonda et al., 2008
adolescents
Hypertensive adults Yes Ambulatory CMBT HE 8 26\26 65.4 53 94.2
ea [34]
University students No 3 readings, mean TM HE 12 93\114 41.1 26 100
lth Nidich et al., 2009 [30]
of last 2
, Gregiski et al., 2011 [35] Ninth-grade students No 3 readings, mean BAM HE 12 44\53 39.2 15 80.6
of last 2
In Schneider et al. 2012 [31] African-Americans with Yes Mean of 3 readings TM HE 12 99\102 57.2 59 100
jh
c. yp coronary heart disease
Hughes et al., 2013 [36] Normotensive middle- No Mean of 3 readings BAM HE 12 17\21 43 50 67.9
All ert school student
M
rig en Parswani et al., 2013 [37] Male patients with
coronary heart disease
No Nonambulatory MBSR TAU 8 15\15 100 49 100
ed
ht si
on
Blom et al., 2014 [38] Hypertensive Yes Ambulatory MBSR HE 48 51\51 38 56 70.3 ita
s .c BAM, breathing awareness meditation; CMBT, contemplative meditation combined with breathing techniques; HE, health education; MBSR, mindfulness-based stress reduction; SP, social support; TAU, treatment as usual; TM, tio
transcendental meditation.
n
o
Bl
m
oo
d
Pr
es
69 su
9 re
Shi et al.

TABLE 2. Blood pressure values by trial arms

SBP DBP
Baseline Final Mean Baseline Final Mean
Study Group mean (SD) mean (SD) change (mmHg) mean (SD) mean (SD) change (mmHg)
Bagga and Ganddhi, 1983 [21] Control 119.6 (3.2) 120.0 (3.3) 0.4 (2.7) 78.3 (4.1) 79.3 (2.6) 1 (2.8)
Intervention 117.6 (7.5) 110.4 (4.9) —7.3 (5.8) 77.6 (4.1) 73.7 (4.1) —3.9 (5.2)
Alexander et al., 1989 [22] Control NA 135.3 0 (12.8) NA NA NA
Intervention NA 125.4 —9.9 (11.5) NA NA NA
Schneider et al., 1995 [19] Control 150.4 (14.3) NA —0.2 (12.3) 91.7 (9.2) NA 0.8 (9.9)
Intervention 145.4 (12.3) NA —10.9 (12.6) 93.7 (9.3) NA —5.6 (6.6)
Alexander et al., 1996 [20] Control NA NA —1.5 (2.7) NA NA 0.6 (1.4)
Intervention (MBSR) NA NA —10.4 (1.6) NA NA —5.7 (1.2)
Wenneberg et al., 1997 [23] Control 128.8 (6.2) NA —1.3 (8) 70.6 (3.8) NA 0.5 (7.6)
Intervention 128.8 (6.7) NA 1.4 (7.1) 70.6 (4.9) NA —4.8 (9)
Castillo-Richmond et al., 2000 [24] Control 149.7 (13.7) NA —6.7 (12.8) 87.6 (10.2) NA —5.9 (8.6)
Intervention 145.5 (13.2) NA —7.8 (10.3) 83.4 (9.9) NA —3.5 (7.6)
Barnes et al., 2001 [26] Control 118.8 (8.2) 121.4 (11.2) 2.6 (8.1) 59.7 (5.8) 60.8 (7.9) 1.2 (5.8)
Intervention 124.7 (9.1) 119.9 (9.1) —4.8 (8.3) 61.6 (7.1) 58.1 (8.5) —3.5 (9.9)
Barnes et al., 2004 [32] Control 130.6 (7.8) 130.5 (8.5) —0.1 (6.7) 75.8 (5.7) 75.9 (8.1) 0.1 (5.9)
Intervention 129.2 (7.8) 125.7 (8.5) —3.6 (7.5) 75.3 (6.4) 71.7 (8.1) —3.7 (9.2)
Barnes et al., 2004 [27] Control NA NA —0.9 (1) NA NA —1.5 (0.9)
Intervention (MBSR) NA NA —4.7 (1.6) NA NA —1.8 (1.4)
Schneider et al., 2005 [28] Control 144.4 (17.2) NA —0.9 (17.2) 95.7 (3.6) NA —2.6 (6.4)
Intervention 142.1 (13.5) NA —3.1 (13.5) 95.1 (4.1) NA —5.7 (6)
Paul-Labrador et al. 2006 [29] Control 127.4 (15.5) 130.5 (16.1) 2.8 (2.1) 76.2 (9.2) 76.5 (9.9) NA
Intervention 126.4 (14.4) 123.5 (14.9) —3.4 (2.0) 73.8 (9.7) 73.4 (8.4) NA
Barnes et al., 2008 [33] Control 127.6 (7.3) 126.4 (8.4) —0.9 (1.0) 76.0 (5.7) 75.4 (6.7) —0.4 (0.9)
Intervention (MBSR) 124.7 (8.6) 120.5 (9.1) —4.7 (1.6) 73.3 (8.1) 71.0 (7.9) —2.9 (1.3)
Manikonda et al., 2008 [34] Control 147 (7.9) 150 (11.5) 0 (10.2) 100 (8.4) 94 (7.1) —2 (7.4)
Intervention (CMBT) 151 (10.2) 136 (10.5) —11 (6.6) 96 (7.7) 84 (6.6) —13 (8.9)
Nidich et al. 2009 [30] Control 117.9 (13.7) NA 0.4 (1.1) 76.6 (8.7) NA 0.5 (0.8)
Intervention 116.7 (12.8) NA —2.0 (1.2) 74.7 (8.4) NA —1.2 (0.9)
Gregoski et al., 2011 [35] Control 121.4 (6.5) NA —0.4 (0.9) 69.3 (5.6) NA —0.6 (0.1)
Intervention (MBSR) 119.4 (6.4) NA —3.7 (0.5) 68.1 (5.7) NA —1.8 (0.1)
Schneider et al., 2012 [31] Control 131.5 (18.0) NA 4.9 (1.2) 76.8 (11.4) —1.9 (0.6)
Intervention 133.0 (18.7) NA 0.02 (1.3) 77.5 (12.3) NA —3.4 (0.7)
Hughes et al., 2013 [36] Control NA 125.3 (7.4) —0.7 (1.6) NA 79.4 (8) 1.2 (1.2)
Intervention (MBSR) NA 128.1 (9.1) —4.9 (1.7) NA 75.4 (5.1) —1.9 (1.1)
Parswani et al., 2013 [37] Control 125.3 (32.5) 135.5 (8.7) 10.2 (37.3) 85.5 (5.7) 83.9 (5.3) —1.6 (6.7)
Intervention 135.7 (13.4) 124.5 (9.0) —11.2 (9.2) 84.2 (5.5) 81.6 (5.2) —2.6 (6.0)
Blom et al., 2014 [38] Control 134 (7.4) NA —0.4 (7.8) 82 (5.3) NA —0.4 (4.6)
Intervention (MBSR) 135 (8.4) NA —0.4 (6.7) 82 (6.2) NA 0.04 (4.9)

CMBT, contemplative meditation combined with breathing techniques; MBSR, mindfulness-based stress reduction.

BP are still in their early stage of hypothesis formulation and budget to purchase and install. More importantly,
and pilot study [43,44], the effects of meditation on maintaining regular meditation sessions assumes fewer
reducing BP have been addressed in 19 RCTs since the physical fitness conditions for the patient, making it a
1980s. Although previous meta-analyses showed that widely feasible option for the aging population.
transcendental medi- tation significantly lowers SBP and
DBP, our results pro- vided new evidence that non- One important possible pathway between meditation
transcendental meditation interventions had the similar and BP reduction might be through the improved
effect as the transcendental meditation interventions adherence among patients who have become more
among non-ABPM-measured interventions. These mindful of the hypertension treatment schedule after the
findings have important clinical and public health mindfulness train- ing, as mindfulness-based intervention
implications. It has been estimated that a 3 mmHg has been shown as effective in increasing the adherence
reduction in SBP should reduce stroke mortality by 8% to dietary intervention among prostate cancer survivors
and CHD mortality by 5% [11,45– 48]. Meditation, a [51]. Although more studies are still needed to understand
noninvasive, nonpharmacological approach, may serve the possible link between mindfulness and better
as an effective lifestyle modification for hypertensive adherence to treatment protocol, our meta-regression
patients in addition to dietary and physical activity showing an insignificant difference in effec- tiveness
approaches. In addition, meditation practice does not between the studies among hypertension patients and
require certain environmental resources such as safe those among normotensive individuals hints that at least
neighborhood [49] and easy access to healthy food the pathway through improved adherence to medication,
outlets [50]. Nor does it require costly indoor exercise even if existent, might not be the only explanatory factor
equipment that takes time for meditation’s impact on BP reduction.

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 Meditation Blood Pressure

Study
ID
WMD (95% CI)

TM
Wenneberg (1997)
Barnes (2001) 2.70 (−1.01, 6.41)
Barnes (2004) −7.40 (−12.83, −1.97)
Subtotal (I-squared = 82.5%, P = 0.003) −3.50 (−5.73, −1.27)
−2.49 (−7.51, 2.53)

Non-TM Barnes (2004)

Barnes (2008)
Manikonda (2008) −3.80 (−4.49, −3.11)
Blom (2014) −3.80 (−4.56, −3.04)
Subtotal (I-squared = 81.3%, P = 0.001) −11.00 (−15.67, −6.33)
0.00 (−2.82, 2.82)
−3.77 (−5.33, −2.21)

Overall (I-squared = 79.6%, P = 0.000) −3.34 (−4.85, −1.83)

NOTE: Weights are from random effects analysis

−20-50510
FIGURE 2 Effect of meditation interventions on SBP measured by ambulatory blood pressure monitoring: transcendental meditation vs. non-transcendental meditation
intervention.

studies also found that lifestyle interventions such as sodium

Another important finding of our study was that older reduction and weight loss are more effec- tive in older
people may benefit more on the BP reduction with non- populations [52,53]. Older persons may have greater ability to
ABPM-measured meditation intervention, although there maintain behavioral interventions because of a higher
were no ABPM-measured studies among those aged 65 motivation to reduce the dependence on antihypertensive
years or above for us to examine the age effect on medications and/or adverse health consequences of elevated BP.
ABPM- measured BP reduction. Of the four studies that Else, people in their
did not report significant reductions in SBP among the
intervention group as compared with the control group
[28,29,32,42], none of them has a mean age more than
54 years. In addition, the five studies not reporting a
significant decrease in DBP among intervention group as
compared with the control group [29,30,31,41,42] have a
maximum mean age of 56 years. The age effect was
evident after we controlled for the baseline hypertension
status of the study participants and the type of meditation
intervention. This finding is consistent with the 2015
meta-analysis on tran- scendental meditation-only
intervention [16]. It is unclear why age might modify the
meditation effect on BP, and the explanations could
include both biological and behavioral reasons. Other
 also be relevant for insurance plans covering the elder
retirement age might have more time available to population. Insurance plans for the retiree population, such
practice meditation than comparable individuals in as Medicare and Medigap in the United States of America,
their working age. An analysis of individual-level might find the meditation approach as a relatively low-risk
data with measures such as the quantity and quality treatment for hypertension among their beneficiaries.
of meditation and adherence to medication during Although the absence of ABPM-measured studies among
and after the meditation intervention might be those 65 con- stitutes a clear research gap, more future
helpful for us to understand the specific mech- ABPM-measured meditation trials among the 65 years or
anism behind the link between age and meditation above can help inform the policy-making about whether to
effect size on BP reduction. Currently, relatively reimburse the meditation service for the retiree population.
few meditation studies include these measures that In addition, despite the fact that the pooled effect esti-
could represent the intervening factors in the trial, mate for SBP among non-transcendental meditation
and thus future studies might benefit by filling inter- ventions seemed to be different between ABPM
these data gaps and research gaps. and non- ABPM (—3.77 vs. —2.57 mmHg), our meta-
The age pattern in meditation effectiveness could regression of

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Shi et al.

Study
ID
WMD (95% CI)

TM
Wenneberg (1997)
Barnes (2001) −5.30 (−9.38, −1.22)
Barnes (2004) −4.70 (−10.04, 0.64)
Subtotal (I-squared = 0.0%, P = 0.813) −3.80 (−6.23, −1.37)
−4.26 (−6.21, −2.31)

Non-TM Barnes (2004)

Barnes (2008)
Manikonda (2008) −0.30 (−0.91, 0.31)
Blom (2014) −2.50 (−3.13, −1.87)
−11.00 (−15.45, −6.55)
0.44 (−1.40, 2.28)
−2.18 (−4.28, −0.09)

Overall (I-squared = 89.0%, P = 0.000) −2.91 (−4.65, −1.18)

NOTE: Weights are from random effects analysis

−15−50515
FIGURE 3 Effect of meditation interventions on DBP measured by ambulatory blood pressure monitoring: transcendental meditation vs. non-transcendental meditation
intervention.

Study
ID WMD (95% CI)

TM
Baggaa (1983) −7.70 (−12.82, −2.58)
Alexander (1989) −9.90 (−18.63, −1.17)
Schneider (1995) −10.70 (−16.37, −5.03)
Alexander (1996) −8.90 (−9.85, −7.95)
Castillo−richmond (2000) −1.10 (−4.97, 2.77)
Schneider (2005) −2.20 (−8.28, 3.88)
Paul−labrador (2006) −6.20 (−6.99, −5.41)
Nidich (2009) −2.40 (−2.72, −2.08)
Schneider (2012) −4.88 (−5.23, −4.53)
Subtotal (I−squared = 97.0%, P = 0.000) −5.57 (−7.41, −3.73)

Non-TM Gregiski (2011)

Hughes (2013) −3.30 (−3.58, −3.02)
Parswani (2013) −4.20 (−5.26, −3.14)
Subtotal (I−squared = 66.1%, P = 0.052) −21.40 (−40.84, −1.96)
−3.74 (−4.93, −2.55)
 NOTE: Weights are from random effects analysis

FIGURE 4 Effect of meditation interventions on SBP measured by non-ambulatory blood pressure monitoring: transcendental meditation vs. non-transcendental
meditation intervention.

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−20−50510
 Meditation Blood Pressure

Study
ID WMD (95% CI)

TM
Baggaa (1983) −4.90 (−9.63, −0.17)
Schneider (1995) −6.40 (−10.26, −2.54)
Alexander (1996) −6.30 (−6.86, −5.74)
Castillo−richmond (2000) 2.40 (−0.30, 5.10)
Schneider (2005) −3.10 (−5.56, −0.64)
Nidich (2009) −1.70 (−1.93, −1.47)
Schneider (2012) −1.50 (−1.68, −1.32)
Subtotal (I−squared = 97.9%, P = 0.000) −2.86 (−4.27, −1.44)

Non-TM Gregiski (2011)

Hughes (2013) −1.20 (−1.24, −1.16)
Parswani (2013) −3.10 (−3.83, −2.37)
Subtotal (I−squared = 92.2%, P = 0.000) −1.00 (−5.55, 3.55)
−1.99 (−3.69, −0.29)

Overall (I−squared = 97.7%, P = 0.000) −2.57 (−3.36, −1.79)

NOTE: Weights are from random effects analysis

−15−50515
FIGURE 5 Effect of meditation interventions on DBP measured by non-ambulatory blood pressure monitoring: transcendental meditation vs. non-transcendental
meditation intervention.

non-transcendental meditation interventions showed that professionals. Meanwhile, patients with prehypertension
the difference in SBP reduction between the two measure- may consider transcendental meditation or MBSR as a
ments was not statistically significant. The average prevention method, in combination with dietary and
reduction of 3.77 mmHg in ambulatory SBP achieved after other lifestyle approaches, to lower the BP.
the meditation interventions was unlikely to be a sole result
of placebo effect, as the placebo effect usually lasts for a The current study could be limited in that we only
short period of time or only works in a clinical setting in included articles published in English. We could miss
which some patients may have ‘white-coat’ high BP [21]. qualified trials published in non-English journals. Also,
We are aware that meditation is unlikely to replace our search terms are limited to ‘meditation’ or
current pharmacological therapy and lifestyle recommen- ‘mindfulness’ or ‘transcendental’, which might not catch
dations for people with hypertension. Patients adopting all interventions that have a meditation focus. Qigong and
meditation as a BP control strategy need to be informed Yoga, for instance, both have certain variants that include
that meditation might be a complementary to their meditation [44,54,55], but it is possible that the term
pharmaco- logical therapy and need to be prescribed by ‘meditation’ was not used when a trial of Qigong or Yoga
healthcare meditation on BP was published. Systematic reviews have
suggested that

TABLE 3. Meta-regressions of intervention effects by types of measurement

Intervention effect on SB Intervention effect on DBP
P Regression coefficient
(standard error)
ABPM
Non-TM vs. TM 1.303 (0.955) —1.770 (2.902)
Age group (≤65 vs. <65) – –
 Hypertensive vs. normotensive at baseline 0.758 (1.258) —1.440 (3.315)
Non-ABPM
Non-TM vs. TM —1.363 (1.940) —1.004 (1.843)
Age group (≤65 vs. <65) —4.147mmm (1.026) —4.601mmm (0.908)
Hypertensive vs. normotensive at baseline —0.016 (1.801) 1.496 (1.640)
N 19 17

t statistics in parentheses. ABPM, ambulatory blood pressure monitoring; TM, transcendental meditation.
P < 0.001.
mmm

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Shi et al.

Funnel plot with pseudo 95% confidence limits Funnel plot with pseudo 95% confidence limits

0
2

Standard error
Standard error
4
6

2
8
10

3
−30 −20 −100102030 −10 −5 0 510
Mean difference in systolicMean difference in diastolic blood pressureblood pressure

FIGURE 6 Diagnosis of publication bias in the combined effect on SBP and DBP.

Qigong and Yoga practice have a BP-lowering effect interventions, still question their usefulness in everyday
[56– 58], but it is difficult to determine whether these practice.
trials have a strong ‘meditation’ component.
Though the issue of small sample sizes of studies is not
uncommon in the field of complementary and alternative ACKNOWLEDGEMENTS
medicine, the limited sample sizes might be one of the
reasons why institutional payers are still hesitant in reim- Study is funded by Institute for Advancing Healthcare,
bursing for meditation intervention despite consistent Greenville Health System. Part of the work has been pre-
results from different studies and meta-analyses. Thus, even sented at the 2015 Meeting of American College of Pre-
though our meta-analysis confirms the effectiveness of ventive Medicine, Atlanta, GA, United States.
meditation intervention on BP among different demo-
graphic groups, this field will nonetheless benefit from Conflicts of interest
large-scale, well designed RCTs. There are no conflicts of interest.
In summary, so far, most insurance plans are
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Reviewers’ Summary Evaluations

particularly high, also the individual cardiovascular
Reviewer 2 impact is unknown and unlikely to be tested. The
This study suggests a small effect of meditation on BP. It results are comforting and reassure that meditation can
should be noted that baseline BPs in the studies were not be recommended, but probably not without regular
review.

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