Impact Of Cucumber As A DASH Diet Component On Controlling Hypertension In The UK Population

Chapter 1: Literature Overview/Background

Approximately 26.2% of the adult population, that is 11.8 million of adults aged 16 years or more, were found to be experiencing hypertension in the United Kingdom during 2017 (Public Health England 2017). Hypertension is caused primarily due to a sedentary lifestyle and the consumption of foods which are high in sodium, such as processed, packaged and junk foods. If not controlled, hypertension can contribute to severe cardiovascular diseases such as stroke. The Dietary Approaches to Stop Hypertension or the DASH is a healthy pattern of food selection and eating which has been evidenced to be useful for controlling hypertension (Filippou et al. 2020). The DASH diet focuses on the consumption of a number of ingredients like fruits, whole grains and vegetables – one of them being cucumber. There lies limited research exploring the how cucumber as a DASH diet component can help control hypertension in the UK population (Soltani et al. 2020). Cucumber has been evidenced to be useful for its potassium and diuretic qualities based on which this paper hypothesizes that cucumber as a DASH diet component can instil a positive impact on decreasing hypertension in the UK population (Bricarello et al. 2018). With respect to this hypothesis, this research aims to provide evidence based answers to the following research questions:

1. How effective is cucumber in reducing Hypertension?
2. What is the impact of cucumber to in reducing hypertension in individuals aged 16 years and above?
3. What is the impact of cucumber as a DASH component in reducing hypertension in the UK population?

To address these questions, this paper will first review existing grey literature on hypertension and the DASH diet. This is then be followed by implementing a search strategy and collecting secondary data on the topic of cucumber and its hypertensive impact. The findings are then analysed thematically, compared with existing literature and then used to draw conclusions and recommendations for future practice.  

The literature review discusses the past literary works which provide a profound insights into what type of conclusions have been obtained in a particular topic. In regard diets are important to maintaining a good health. Hypertension is a disorder which is caused by genetics, old age, food habits, smoking and many other causes. High blood pressure or hypertension is the disorder in which a human being experiences high pressure exerted by the blood flow within their body (Juraschek et al. 2017). The main ways of preventing hypertensions are through regular exercise, eating less caffeine, avoiding smoking and drinking of alcohol and intake of sodium in diet apart from eating healthy foods. Doctors suggest the use of DASH to regulate hypertension. DASH of Dietary Approaches to Stop Hypertension is the inclusion of foods with high potassium, sodium and magnesium content. Some of foods under the DASH diet are fruits like apples, bananas, pear, peach, grapes; vegetables like spinach, cucumber, radish, cabbage and eggplant and low fat diary items like milk, yoghurt and cottage cheese. Cucumber is highly effective in reducing hypertension as suggested by studies (Siti, Adi and Mohamad 2020). Studies have suggested that both cucumber and tomato juice helps in reducing the systolic and diastolic blood pressure. Using juice of cucumber to reduce hypertension is a good alternative to having medicines (Soesanto and Zulino 2021).

Body

However if one controls hypertension one can reduce the risk of having such heart diseases. High blood pressure can be cured by application of medicines but simple and effective long-run application of certain foods to raise the intake of minerals and vitamins help one get rid of high blood pressure or hypertension. The diets that one might intake contains the needed vitamins and minerals which are essential to reduce the impact of high blood pressure.  Under such diets is the use of certain vegetables and fruits like cucumber are widely accepted and practiced in the global medical community (Psara et al. 2020). Studies have concluded that use of dietary approaches are highly recommended to reduce the medicine intake and increase the dependency on foods to cure hypertension are all long run and highly stable that could be used by all who have diagnosed with high blood pressure in any age.

Seravalle and Grassi (2017) in their paper have dealt with how hypertension is related to many other health risks like dementia, fractures and physical disability. These long term relationship between hypertension and other chronic disease is evident. In essence the obesity and heart diseases are highly related each other. Visceral fats deposition alters the hormonal cycles and can create inflammatory and endothelial damages. These leads to hypertension and other cardiovascular morbidity through a stimulation procedure. Corsino et al. (2017) depicted that insulin resistance has an important role to play to stimulate and potentiating mechanisms. The study also deals with focus on organ damages due to hypertension and obesity. The author have suggested that to cure hypertensive obesity doctors should administer drugs that reduce obesity and hence it would also reduce hypertension (Corsino et al. 2017). 

While hypertension can also bring about ageing among individuals as evident in the study conducted by Buford (2016). The study claims that inflammation and oxidative states and endothelial dysfunction contribute to late life hypertension. The author have discussed about the multidimensional risks inherent with hypertension among aged elderly people. The study also focuses on the strategies of treatment that can be provided to the patients. 

In face of Covid 19 pandemic co morbidity has been a concerning issues which have had led to most patients dying. Evidently Covid 19 virus and hypertension have coexisted with other cardiovascular disorders are again matter of great importance. The pandemic have induced the social life to change and changes in how one might contract both communicable and non-communicable diseases. While hypertension leads to development of other cardiovascular disorders and kidney diseases, the risk of severe disease like the Covid 19 is high. Shibata et al. (2020) conducted a study in Japan where natural disaster recently have shock the economy along with the pandemic leading to severe health complications among the people. The doctor suggest anti hypertension medication to reduce the risk of future chronic illnesses. 

In their paper Dzau and Balatbat (2019) provided evidences that there needs to be a transformation in the public health system to reduce the pressure of hypertension on the global level. Aging, lifestyle, work pressure, food habits are increasing the number of people with hypertension and the degree of acuteness is rising. Global disparities in treatment, medications, and awareness make the situation more critical. When there is awareness people try to go for early detection which gives the health care time to come up with the proper management of patients, their array of treatment and medications. Hypertension can be a silent killer as if goes undetected later stages result into heart diseases which can be fatal. So there is a need to transform to system to understand the hypertension but there are lack of growth of drug development.

While Siervo et al. (2015) deals with the dietary approaches to stop hypertension and its effects on the cardio metabolic biomakers. DASH impact on cardiovascular risks have been found out using the randomised controlled trials. From 2-24 weeks the participants have been monitored and by meta-analysis the results suggest that BP both for systolic and diastolic have decreased due to the consumption of DASH diets. Overall the impact of DASH to control Blood pressure is impressive by reducing the risks by 13%. Patients with increased cardio metabolic risks have been highly beneficial when administered with Dash diets. 

On the other hand Chiu et al. (2016) have shown how DASH diets are different from higher fat Dash diets, the impact of these two types of diets on blood pressure and lipids and lipoproteins. The study have been conducted on a sample size of 36 health individuals aged above 21 years who have an average blood pressure of 80/95 mmHg. The main aim of the study is to check how a higher fat content diets can be replaced for low fat dairy foods such that blood pressure is reduced but reduces sugar intake and increases the fat intake. The study have found that with both dash and high fat Dash blood pressure have fallen. While HF dash have reduced triglycerides low density lipoproteins only dash diet was able to reduce LDL cholesterol. So in essence HF dash is more effective as it have good impact on reducing cholesterol (Chiu et al. 2016). 

Fulay et al.  (2018) investigated into a different aspect of hypertension altogether. The authors’ study have been a rich collection to the literature since it have studied the impact of DASH diet on pregnant woman. The study have been conducted on 1760 women from the Boston area where Dash scores have been calculated based on the data gathered from the longitudinal cohort. The results suggest that there was positive correlation between gestational weight gain and dash diet suggesting that there is no negative impact on the health of the pregnant women. The authors concluded that Dash diet does not have any protective effect against Hypertensive Disorders of Pregnancy or other complications. 

To find out the impact of cucumber a DASH diet food in reducing hypertension among the citizens of UK

• To investigate into the degree of effectives of cucumber in reducing Hypertension
• To find out through an analysis into the literatures the impact of cucumber to reduce hypertension.
• To check for studies conducted specifically for United Kingdom to include cucumber in DASH diet to reduce hypertension.

Research philosophy implies the overall framework and approach which will be taken while exploring a research issue or phenomenon, as well as the ways by which data will be collected and evaluated. Pragmatism is based on the understanding that the methods which will be used for the purpose of data collection and analysis must be chosen as per the research question and issue being focused upon. The research philosophy of pragmatism is based on the principle that a research issue is best explored from objective and statistical terms (Dougherty, Slevc and Grand 2019). Likewise, the research philosophy of interpretivism is based on the understanding that a research issue is best understood from the perspective of its social impact or the experiences of communities and individuals. An interpretivist research philosophy was rejected for this study since the research questions focused only upon reviewing existing literature and not the perspectives of human participants. The research philosophy of pragmatism was also rejected for this study since the research questions do not focus on collecting any form of primary data for statistical analysis (Qutoshi 2018). The research philosophy of pragmatism was considered to be the most appropriate for this study since the research questions focused specifically on the collection and review of existing studies exploring the role of cucumber as a DASH diet component for reducing hypertension in the population of the United Kingdom. Based on a pragmatist research philosophy, implementing a systematic review for this study was the most appropriate (Žukauskas, Vveinhardt and Andriukaitien? 2018).

Research approach implies the logical and systematic framework which will be followed when selecting and implementing data collection and data evaluation methods for a study. A qualitative research approach is when the researcher explores a research topic or phenomenon in detail based on comprehensive reviewing of individual experiences or existing published data. A quantitative research approach, on the other hand, aims to explore the significance of the relationship between two variables using statistical or computational techniques (Gilad 2021). A mixed methods research, as the name suggests, aims to examine a research question using a combination of both qualitative as well as quantitative research approaches. For this study, a quantitative approach was rejected since no statistical analysis of primary data was implemented (Ahmad et al. 2019). Likewise, a mixed methods research approach was also rejected, since both quantitative and qualitative were not used collectively for this study. Since this study and its research questions aimed to critically review existing research exploring impact of cucumber as a DASH diet component for reducing hypertension in the population of the United Kingdom, a qualitative study was thus considered the most effective (Strijker, Bosworth and Bouter 2020).

Research design implies the ways by which the data so collected will be evaluated and analysed to answer the research questions of the study. For this study, a grounded theory approach was considered for the research design. Grounded theory design is focused on the development of a theory. This theory is ‘grounded’ or based on data which collected, reviewed and analyzed systematically. For this study, a grounded theory design was considered to be the most appropriate since the research questions aim to develop an understanding of the impact of cucumber as a DASH diet component for reducing hypertension in the population of the United Kingdom by systematically collecting and reviewing existing published data (Chun Tie, Birks and Francis 2019).

For collecting, an electronic search strategy was implemented across digital databases like Google Scholar and PubMed which are freely accessible and contain journal articles on subjects like healthcare, medicine and nutrition which are relevant for this study. To address the same, keywords which were relevant to the study were implemented, such as ‘DASH’, ‘diet’, ‘hypertension’, ‘cucumber’ and ‘United Kingdom’. Boolean operators like ‘AND’ and ‘OR’ were also used to broaden the search results and include papers which contained these keywords (Goosen et al. 2018). Details of the search strategy have been outlined in Appendix 1.

The research strategy produced multiple article results of which only a few were selected as per their relevance to the inclusion criteria. A total of 6 articles were selected for systematic review based on the following inclusion and exclusion criteria.

1. Scholarly articles published in the last 7 years were included in the study to ensure that the most recent data.
2. Articles which focused on the impact of cucumber as a DASH diet component in the management of hypertension.

1. Scholarly articles older than the last 7 years or studies with poor methodological quality, such as opinion editorials.
2. Articles focused on ingredients and diseases other than cucumber and hypertension.

Data process or data analysis implies the strategies by which the findings are evaluated to understand their relevance to the research questions. For this study, the collected data in the form of secondary findings was analysed using thematic analysis. Thematic analysis is the process of identifying and segregating significant statements in qualitative data into themes and codes which are relevant to the research questions (Braun and Clarke 2019). For this study, findings from the systematic review were thematically analysed using the thematic analysis framework by Braun and Clarke (2021) which comprised of the following steps:

1. The collected secondary data was first familiarized with by the researcher.
2. Significant or similar findings were segregated into codes.
3. Themes were generated by grouping similar codes.
4. The themes were reviewed using data from the literature review and the research questions.
5. The themes were named and defined as per the research questions.
6. The final set of themes were included in the paper.

Additionally, the validity and relevance of the studies collected for the systematic review were also critically appraisal using checklists form the Critical Appraisal Skills Programme (CASP). This is because CASP checklists, which are available for a range of research designs, are useful for critically evaluate the quality of the methods and findings of a particular study. CASP checklists were especially useful for identifying limitations and strengths in the studies collected for systematic reviewing in this study (CASP 2022). Details of the appraisal have been outlined in Appendix 2.

In order to understand the extent to which qualitative data was useful in answering the research questions, it is important to evaluate and analyse the same using relevant data processing and management methods (Sundler et al. 2019). As mentioned previously, a comprehensive electronic search strategy was undertaken for the purpose of collecting secondary data to systematically review the impact of cucumber as a DASH component in managing hypertension across the UK population. With this respect, the following chapter aims to provide detailed and extensive analysis on the key themes which were derived from the thematic analysis of systematic review articles exploring the anti-hypertensive components of cucumber.

The search strategy revealed a total of six articles which were then reviewed thematically using Braun and Clarke’s (2019) six step thematic analysis framework. This resulted in the emergence of three themes which have been tabulated in Table 1 as follows. The secondary findings under each theme have been expanded upon as follows.

Table 1: Thematic Analysis (Source: Created by the Author)

One of the most themes which emerged was the protective role of cucumber and cucumber juice in controlling hypertension in the elderly (Evania et al. 2022). The narrative review by Evania et al. (2022) aimed to existing literature exploring the role and impact of cucumber in decreasing blood pressure in elderly with hypertension. To address the same, the authors collected and reviewed articles from scholarly databases such as PubMed, Lipi and Google Scholar. A total of 435 articles were screened and reviewed by the authors. As per the findings, it was observed that the consumption of cucumber juice resulted in a significant reduction at the rate of approximately 100 to 200 mg per day. Such findings thus demonstrated that intake of cucumber juice is associated with beneficial impacts in terms of decreasing blood pressure in the elderly (Evania et al. 2022). However, in criticism, it must be noted that the review by Evania et al. (2022) was primarily narrative in nature and devoid of any form of statistical analysis which could have added reliability, validity and credibility to the findings.

Similar findings were also reported by the quasi experimental study by Wibowo and Anita (2021) aimed to explore the role cucumber juice as a treatment of diastolic and systolic pressure in the blood pressure of the elderly. To address the same, the authors used saturated sampling to recruit 10 elderly hypertensive patients, aged 65 years and above, from an elderly home in Indonesia. These participants were required to consume cucumber juice twice during the afternoon and morning for 6 hours and a total period of 7 days. The diastolic and systolic pressure were measured within 2 hours, prior to and also after the intervention. The pre-test measures of average blood pressure across the sample were found to 145.43/90.57 mmHg and the post-test measures were reported to be 143.29/83.71 mmHg. As per the Wilcoxon Signed Rank Test with α = 0.025, significant reductions in the systolic (0.013) as well as diastolic blood pressure (0.000) were reported after the administration of cucumber juice in the participants (Wibowo and Anita 2021). Thus, based on these findings, it can be implied that cucumber juice is useful for the purpose of decreasing blood pressure across the elderly. However, in criticism, it must be noted that the study by Wibowo and Anita (2021) recruited a relatively small sample size and was devoid of any controls due to its quasi-experimental and saturated sampling nature. Despite the usefulness of its findings, such limitations can hinder the internal validity, reliability and overall statistical power of the paper.

Likewise, similar findings were also observed with respect to the pre-test post-test only design by Vimala, Mangalagowri and Ali (2018) which aimed to explore the impact of whole cucumber in the reduction of hypertension across elderly situated in rural areas of South India. To address the same, a total of 60 hypertensive clients aged 40 to 60 years were selected using simple random sampling and were then divided equally between an experimental and control group. As a part of interventions, participants in the experimental group were administered with 100 grams of cucumber once a day, during the mid-morning, for a period of two weeks. The control group did not receive any other intervention other than standard treatment. After four weeks, participants’ blood pressure were measured using a sphygmomanometer. As compared to pretest findings, diastolic and systolic pressure were found to reduce by 3.67% and 1.84% during post-test in the control group. In the experimental group which consumed cucumber, diastolic and systolic pressure were found to reduce by 9.8% and 6.9% in comparison to the post test. Such findings thus demonstrate the usefulness of cucumber of decreasing blood pressure across elderly with hypertension (Vimala, Mangalagowri and Ali 2018). However, in criticism, the study by Vimala, Mangalagowri and Ali (2018) was found to be associated with limitations with respect to reliability and generalizability of findings due to a low sample size and restricting the sample to only the rural regions of a developing country.

In addition to its whole form and juice, the anti-hypertensive effects of cucumber was also found to be effects when administered as an infusion with other vegetables and ingredients (Fandizal, Sani and Astuti 2020). The quasi-experimental study by Fandizal, Sani and Astuti (2020) aimed to explore the impact of water infused with lemon, cucumber and watermelon in controlling the blood pressure of adults with hypertension in Indonesia. To address the same, purposive sampling was used to recruit 45 adults with hypertension who were then administered with infused water prepared using 250 ml water, 50 grams lemon, 50 grams of watermelon and 50 grams of cucumber for 4 weeks. Based on t-test analysis, statistically significant reductions were observed in the blood pressure of participants (ρ 0.030; 0.000; 0.000 <0.05) (Fandizal, Sani and Astuti 2020). Such findings thus demonstrate that cucumber, when used as an ingredient in infused water, is equally effect in decreasing blood pressure in hypertensive patients as compared to cucumber juice and whole cucumber. Nevertheless, the findings of this study were limited to a nation other than the UK and demonstrated a small size thus limiting internal validity and reliability (Fandizal, Sani and Astuti 2020).

Cucumber was also found to be effective in decreasing blood pressure in comparison with physical activity such as brisk walking (Chalida et al. 2019). The quasi-experimental study by Chalida et al. (2019) aimed to explore the impact of brisk walking and cucumber juice in decreasing the blood pressure in elderly patients with hypertension. A pre-test and post-test design coupled with purposive sampling techniques were used to recruit 40 participants who were then divided equally into cucumber juice intervention group and exercise intervention group. The cucumber juice group were required to consume 150 ml of cucumber juice for seven days while the exercise group were required to engage in 20 to 30 minutes of brisk walking for 2 weeks. Blood pressure was measured before and after the intervention and analysed using t test. In the exercise group, t test results for systolic and diastolic blood pressure were reported to 0.017 while in the exercise group it was reported to be 0.04 (p < 0.05). Thus, the findings revealed that both brisk walking and cucumber juice significantly reduced blood pressure in hypertensive individuals with latter being more significantly effective than the latter. Such findings thus demonstrated cucumber is an effective anti-hypertensive ingredient and can be used as an alternative to exercise in decreasing hypertension (Chalida et al. 2019). In criticism, the study by Chalida et al. (2019) also demonstrated several limitations in the form of a low sample and limiting the sample to only Indonesia.

Lastly, cucumber was also found to be effective in decreasing hypertension when included as an ingredient in the DASH diet (Obaroh 2018). The pre-test and post-test study by Obaroh (2018) aimed to explore the role of daily physical activity and the consumption of a DASH diet in controlling blood pressure in hypertensive adults. To address the same, a total of 40 participants were recruited and were required to engage in daily exercise and DASH diet where cucumber was included in the form of cucumber salad for 3 months (Obaroh 2018). The pre-intervention and standard deviation of both systolic as well as diastolic blood pressure was recorded to be 138.15/76.60 and 11.06/8.65. In comparison, a reduction was observed in post-intervention and standard deviation of both systolic as well as diastolic blood pressure and was recorded to be 124.5/68 and 4.05/7.10 (p <0.05; CI: 95%). Such findings thus demonstrate that cucumber as a component of the DASH diet can be useful in decreasing blood pressure in hypertensive adults. However, in criticism, the findings of this study were derived from a low sample size and were limited only to a sample living in the United States (Obaroh 2018).

All the selected papers for the thematic analysed were appraised critically using CASP checklists (Appendix 3). Based on the critical appraisal findings, it was observed that while there existed abundant literature exploring the impact of cucumber in reducing blood pressure in hypertensive patients, they however contain a range of limitations pertaining to the quality of findings and methodology.

This chapter thus provided a detailed and critical review of the secondary data which was obtained from articles collected after an electronic search strategy implementation. Data was processed using thematic analysis which result in the emergence of four themes. Based on thematic analysis, it was observed that cucumber is useful for controlling BP in the elderly and its effects continue to be potent when included as a part of the DASH diet, when consumed as an infusion and when consumed as an alternative to exercise. However, critical appraisal using CASP assessment demonstrated key limitations in the quality, reliability and validity of findings and the methodology of the selected articles. Comparison of findings with grey literature have been discussed in the succeeding chapters.

Thematic analysis was used for the purpose of evaluating the findings of the selected studies. Based on the same, a total of four themes were derived from six of the selected studies. The first theme focused on the role of cucumber – either in juice or whole forms – in decreasing blood pressure within elderly people with hypertension (Vimala, Mangalagowri and Ali 2018; Wibowo and Anita 2021; Evania et al. 2022). The second theme focused on the effectiveness of cucumber in decreasing blood pressure and controlling hypertension when consumed in the form of a water infusion with other ingredients (Fandizal, Sani and Astuti 2020). Thirdly, the thematic analysis also revealed that cucumber was an effective alternative to physical activity in the control of blood pressure for patients with hypertension (Chalida et al. 2019). Lastly, in the fourth theme, it was found that cucumber, when added as a component of the DASH and when combined with physical activity – was effective in decreasing blood pressure in hypertensive patients (Obaroh 2018).

The importance of the findings from the thematic analysis were important in terms of providing insights into the way by which cucumber can be included as a component of medical nutritional therapy for hypertension treatment. For instance, the findings demonstrated the usefulness of cucumber in decreasing blood pressure for elderly patients with hypertension. This can be integrated in future practice in the form of practitioners and dieticians educating the elderly on the importance of including cucumber daily as a part of a DASH diet (Vimala, Mangalagowri and Ali 2018; Wibowo and Anita 2021; Evania et al. 2022). Further, the thematic analysis was also useful in terms of demonstrating how cucumber can be used as an infusion with other ingredients or also as a juice on its own for hypertension management in adults and the elderly. Such findings demonstrate useful implications in the form of highlighting how cucumber is a feasible ingredient and can be incorporate in various forms for hypertensive patients in need of a liquid diet or variety in their diets without however, having its therapeutic properties changed (Fandizal, Sani and Astuti 2020). Additionally, the findings in this study also indicated the effectiveness of cucumber as a regulator in the blood pressure of hypertensive patients in comparison to exercise. Thus, it can be implied that for elderly patients experiencing complications in their mobility and associated difficulties in physical activity participation, cucumber can still be used as a dietary component for the sustained management of blood pressure during hypertension respectively (Chalida et al. 2019). Lastly, the final research question aimed to explore the role of cucumber as a DASH diet component in decreasing hypertension in the UK population. While UK based studies were not found, the findings revealed that cucumber coupled with physical activity can be effective in decreasing blood pressure for hypertensive patients following a DASH diet. With this respect, it can thus be implied that cucumber can be integrated as a part of a DASH diet intervention in hypertension treatment across populations from a developed nation (Obaroh 2018).

The findings obtained from the selected articles can also be compared to that of existing grey literature which was reviewed in previous chapters. According to Siti, Adi and Mohamad (2020), a combination of dietary and lifestyle interventions are required to ensure long mitigation of hypertension. Lifestyle changes include, engagement in regular exercises, reducing intake of caffeine and foods containing added salt and avoidance of smoking and drinking. Dietary interventions for controlling hypertension comprises of the consumption of the DASH which contains foods like low fat dairy products, grapes, apples, pear, bananas, peach, spinach, eggplant, radish, cucumber and cabbage (Siti, Adi and Mohamad 2020). Of these, cucumber has been postulated by Siti, Adi and Mohamad (2020) as being beneficial for hypertension management. Such findings on comparison with the systematic review, can be well related to the findings in the pre-test and post-test study by Obaroh (2018) which aimed to explore the role of daily physical activity and the consumption of a DASH diet in controlling blood pressure in hypertensive adults. Upon implementation of combined interventions of regular exercise and consumption of a DASH diet containing cucumber, a reduction was observed in post-intervention and standard deviation of both systolic as well as diastolic blood pressure [124.5/68 and 4.05/7.10 (p <0.05; CI: 95%)]. Such findings thus demonstrate that cucumber as a component of the DASH diet and in combination with lifestyle interventions such as physical activity can be useful in decreasing blood pressure in hypertensive adults (Obaroh 2018).

Further, similarities in the literature review were also observed with respect to populations focused upon by both grey literature as well as the systematic review findings. For instance, according to Buford (2016) oxidative stress and inflammation result in the dysfunction of endothelial tissues – the tissues lining the blood vessels responsible for regulating blood pressure during circulation. This can result in increased risk of hypertension in elderly (Buford 2016). Similarly, three of the findings mentioned in the systematic also focused on how cucumber juice and while cucumber can be useful for controlling blood pressure in elderly people with hypertension (Vimala, Mangalagowri and Ali 2018; Wibowo and Anita 2021; Evania et al. 2022). For instance, the narrative review by Evania et al. (2022) aimed to existing literature exploring the role and impact of cucumber in decreasing blood pressure in elderly with hypertension. As per the findings, it was observed that the intake of cucumber juice can contribute to a decrease in blood pressure by almost 100 to 200 mg in elderly people with hypertension when consumed on a daily basis. Similarly, the quasi-experimental study by Wibowo and Anita (2021) aimed to explore the role cucumber juice as a treatment of diastolic and systolic pressure in the blood pressure of the elderly. The pre-test measures of average blood pressure across the sample were found to 145.43/90.57 mmHg and the post-test measures after cucumber juice intake were reported to be 143.29/83.71 mmHg. As per the Wilcoxon Signed Rank Test with α = 0.025, significant reductions in the systolic (0.013) as well as diastolic blood pressure (0.000) were reported after the administration of cucumber juice in the participants (Wibowo and Anita 2021). Likewise, the pre-test post-test only design by Vimala, Mangalagowri and Ali (2018) aimed to explore the impact of whole cucumber in the reduction of hypertension across elderly situated in rural areas of South India. As compared to pre-test findings, diastolic and systolic pressure were found to reduce by 3.67% and 1.84% during post-test in the control group which received standard treatment. In the experimental group which consumed cucumber, diastolic and systolic pressure were found to reduce by 9.8% and 6.9% in comparison to the post test (Vimala, Mangalagowri and Ali 2018). Such findings thus demonstrated similarities with grey literature, in the form of focusing on population groups which were at risk for hypertension – such as the elderly – followed by focusing on dietary interventions, such as the consumption of cucumber, which can prove to be useful for hypertension management respectively (Vimala, Mangalagowri and Ali 2018; Wibowo and Anita 2021; Evania et al. 2022).

However, limitations and differences were also observed with respect to the specific aspects of the DASH diet which were explored by grey literature. For instance, the study by Chiu et al. (2016) aimed to examine the impact of both DASH as well as high fat DASH diets on lipoproteins, lipids and blood pressure across adults. Findings revealed that while both DASH as well as high fat DASH diets were able to induce reductions in blood pressure, only the DASH diet induced reductions in lipid profiles and LDL cholesterol of the participants respectively. Such in-depth analyses were missing in the articles selected for systematic review, because this study focused primarily on exploring specifically cucumber and not the overall DASH diet as a whole. Such differences however rationalize the need to conduct further research on other components, forms and ingredients of the DASH regarding their effectiveness in controlling blood pressure in hypertensive patients (Buford).  

Despite the effectiveness and positive implications of the findings, a number of limitations were found in the collected secondary data. One of the most common limitations observed were that most of the included studies comprised of a relatively sample size. A low sample size is a major limitation in the internal reliability of a quantitative study since it impacts the statistical power and increases the risk of false positives and false negatives in the findings (Rose and Johnson 2020). Another limitation which was observed was that most of the selected studies were either narrative reviews or followed a quasi-experimental research design. This is because narrative reviews are usually devoid of any form of statistical analysis which can measure the significance of secondary findings (Hayashi Jr, Abib and Hoppen 2019). Additionally, the findings of a quasi-experimental design may also not be fully accurate since participants are selected purposively without any randomization (FitzPatrick 2019). Some of the selection studies were also found to be devoid of any form of controls to compare the effectiveness of the interventions – which again is a key limitation in terms of methodological quality (FitzPatrick 2019). Lastly, another limitation was that the studies so selected were primarily limited to the context of nations other than the UK, such as Indonesia, India and developed nations like the US. Thus, such limitations warrant the need to conduct further research on the potential impact of cucumber, which will comprise of research designs with greater validity, reliability and credibility, such as randomized controlled trials.

Further, the limitations prevalent in this study as a whole must also not be overlooked. For instance, the findings of this study were mainly derived from a systematic review of secondary data without any form of meta-analysis or statistical analysis of experimental data which could have added weight to the overall themes. Further, due to the highly specific focus on as single ingredient and disease, the articles so collected for systematic review and thematic analysis were fairly limited (Hayashi Jr, Abib and Hoppen 2019).

Based on the findings from this study, it is recommended that clinicians and dieticians consider the nutritional and therapeutic benefits of cucumber and include it as a part of medical nutritional therapy for patients with hypertension. Additionally, it is also important that clinicians offer variety to hypertensive patients regarding the form in which they can consume cucumbers based on the patients’ unique dietary or physical needs. For instance, patients with ingestion or gastrointestinal problems can also enjoy the anti-hypertensive benefits of cucumber in alternative forms which are suitable for them, such as cucumber juice and water infused with cucumber and other vegetables acceptable in the DASH diet. Further, as per the findings, it is also recommended that dieticians and clinicians encourage hypertensive patients to include cucumber as a part of a healthy lifestyle for wellbeing maintenance via integrating it in their DASH diet along with daily physical activity. Lastly, with respect to the limited repertoire of research, it is recommended that policy makers and the government provide support to healthcare organizations and academicians to conduct further research regarding the effectiveness of cucumber as a DASH diet component in reducing blood pressure for hypertension across the UK population.

The systematic review revealed that studies exploring the role of cucumber as a key component in the DASH diet for hypertension regulation in populations living in the UK were almost negligible. Thus, in order to answer such country-specific questions, further research must be implemented in the form of experimental studies which can collect real time data on the impact of cucumber in blood pressure changes of hypertensive patients living in the UK. Further, the studies reviewed for this paper demonstrated several limitations in the form of being using research designs with limited strength, validity and reliability – such as quasi-experimental designs and narrative reviews. It is thus recommended that further research be conducted using randomization and blinding of participants to obtain more credible findings on the impact of cucumber in controlling the blood pressure of hypertensive patients living the UK.

Conclusions 

The prevalence of hypertension is high with approximately 26.2% of the adult population that is 11.8 million of adults aged 16 years or more, experiencing hypertension in the United Kingdom during 2017. Lack of physical activity coupled with poor dietary habits such as the high intake of caffeine, sodium rich processed food as well as smoking and alcohol have been evidenced to contribute to hypertension respectively. Lack of control can result in an increased of fatal cardiovascular disorders. The DASH diet, comprising of wholegrain, fruit, vegetable and low fat dairy have been evidenced to be a useful dietary intervention by which, hypertension can be controlled.

Limited studies have explored the role of cucumber in the DASH diet – an ingredient which has been researched for its potassium content and diuretic qualities. This paper thus aimed to systematically review the role of cucumber in controlling blood pressure for hypertensive individuals in the UK. To address the same, an electronic search strategy was conducted and thematic analysis was used to review findings from six selected studies. Based on thematic analysis, it was observed that cucumber is useful for controlling BP in the elderly and its effects continue to be potent when included as a part of the DASH diet, when consumed as an infusion and when consumed as an alternative to exercise. Based on the limitations observed in findings, it is recommended that further experimental data be collected in the context of the UK population. To conclude, patients must be educated on the importance of including cucumber in a DASH diet for therapeutic management of hypertension.

Reference list

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