BACKGROUND Lifestyle modification is recommended for all patients with the diagnosis of hypertension. METHODS We examined 3,497 adult hypertensive participants (representing 42 million Americans), from the National Health and Nutrition Examination Survey (NHANES) 1999-2004. We analyzed the rate, demographic, and clinical factors of participants who reported receiving lifestyle counseling and their adherence. RESULTS Of the 3,497 participants with hypertension, 84% reported receiving lifestyle modification counseling. After adjustment for demographic and clinical characteristics, non-Hispanic blacks were more likely to report receiving counseling (odds ratio (OR), 2.5; P < 0.001) when compared to whites. Men (OR, 1.5; P = 0.02) reported receiving counseling more often than women as well as those with Medicare insurance (OR, 1.5; P = 0.02) compared to the privately insured. Participants who were hypercholesterolemic (OR, 1.7; P < 0.001), diabetic (OR, 3.5; P < 0.001), overweight (OR, 1.5; P < 0.001), or obese (OR 3.0; P < 0.001) reported receiving lifestyle counseling more often than those without these conditions. Of those receiving counseling, 88% reported adhering to those recommendations. After adjustment for demographic and clinical characteristics, only non-Hispanic blacks (OR, 2.8; P < 0.001) and those aged >60 (OR, 1.9; P = 0.04) were more likely to report adhering when advised. CONCLUSIONS High cardiovascular risk hypertensive patients had high rates of lifestyle counseling. However, gaps exist in lifestyle counseling for young and low cardiovascular risk hypertensive patients. In addition, differences in rates of adherence exist especially in those with high cardiovascular risk comorbid conditions. Future work is needed to increase adherence to lifestyle counseling for all hypertensive patients.