Guidelines for cardiovascular disease prevention recommend a non-pharmacological approach to reduce cardiovascular risk in those with elevated blood pressure. We assessed guideline adherence in hypertensives. This study was performed in the European Investigation into Cancer and Nutrition-NL cohort, consisting of 40,011 subjects. From 1993 to 1997, participants completed questionnaires (disease history, lifestyle and diet), a physical examination was performed and blood samples were drawn. Differences in proportions of guideline targets met between aware and unaware hypertensives were studied. Of 8779 hypertensive subjects, 90% was aware of their hypertension. They more often adhered to guidelines than unaware hypertensive subjects with respect to intake of polyunsaturated fat:saturated fat (38.6% vs 33.2%), fibres (40.6% vs 34.2%), body mass index <27 kg m(-2) (53.8% vs 46.5%) and alcohol (79.7% vs 72.6%). Despite statistical significance, the magnitude of these differences was small. Our study suggests that prevalence of a healthy lifestyle according to the recommendations in guidelines is slightly better in subjects aware of hypertension. There seems to be ample room for improvement in implementing the guidelines. Probably, patient tailored interventions and a multisiciplinary and multimodality approach can support this improvement.