Hypertension: The Silent Killer

High blood pressure (hypertension) affects almost a third of our population, with 75 percent of those individuals prescribed medications to manage their pressure. Only about half of this group is pretty well controlled, but because there are few, if any symptoms, hypertension is often coined the "silent killer."

When blood pressure is high and goes untreated, our organs suffer. They receive less oxygen which in time, can create organ failure. Sometimes this happens in many of our organs simultaneously, called end-organ damage. This may also result in stroke, kidney dysfunction, and vascular disease. Although hypertension often runs in families, obesity, smoking, and alcohol makes this all the worse. Dietary changes are critical for managing hypertension, as is daily movement.

First though, a proper diagnosis is important. Our blood pressure can elevate simply because we are anxious or uncomfortable, which is often the scenario when we are in the clinician's office being evaluated. We call this "white coat syndrome," and for this reason, a single elevated blood pressure will not result in diagnosis, but two elevated pressures at two separate visits, will. Better even is a blood pressure log from home. I use to ask clients to obtain random blood pressures, at various times of the day, under a variety of circumstances, for two weeks and bring them back into the office and this does work well, but today we offer our clients a home blood pressure monitor which they wear for 24 to 48 hours so it can obtain automatic blood pressures around the clock. This helps us identify how significant the blood pressure elevations are and during what parts of the day, which can help guide medication management.

Lifestyle modifications are absolutely necessary for improved cardiac health (ACC/AHA, 2017 & ESC/ESH, 2018). It is unfortunate that a diagnosis of hypertension is necessary before we begin to implement these, but I get it. Life passes us so quickly and prioritizing ourselves is tough. These steps though are crucial and not implementing them sooner is why we end up with a diagnosis of hypertension into our fourth and fifth decades. Movement may potentially offer us the greatest impact. Start slow; don't go too aggressive too soon, but as you build your new routine, integrate resistance exercises, along with aerobic exercise. We have a pretty through physical health program for those seeking a bit more guidance.

Aerobic exercise is well known however, to lower blood pressure. Even an hour a day is as effective as medical therapy in controlling blood pressure in hypertensive subjects (Murugesan et al., 2000). Yoga, together with relaxation, biofeedback, transcendental meditation, and psychotherapy have been found to have a convincing antihypertensive effect (Anand, 1999). Yoga's impact on blood pressure reduction may be attributed to its beneficial effects on the autonomic neurological function, and an impaired baroreflex sensitivity has been increasingly postulated as one of the major factors contributing to hypertension (Sengupta, 2012). Yoga postures restore baroreflex sensitivity, especially those with the head either up or down. The literature also demonstrates that the more we practice yoga, the better our sympatho-adrenal and renin-angiotensin activity becomes, and ultimately our blood pressure reduces. Further, yoga has shown to reduce secondary cardiac complications related to chronic hypertension.

The DASH diet, also know as the Dietary Approaches to Stop Hypertension, recommends fruits, vegetables, and low-fat dairy while also minimizing fat and cholesterol. Appropriate intake of magnesium and potassium should be assured, with no more than 3 grams of sodium daily. This step can reduce your systolic blood pressure by as much as 11 points, followed by 8 points for aerobic exercise, and then 4-5 points when alcohol is minimized or eliminated (no amount of alcohol has found to be safe for your brain).

What's really crazy about all this, is the American College of Cardiology and the American Heart Association wrote in their most recent guidelines for hypertension management that they recognize physicians mostly "fail to appropriately counsel patients on lifestyle modifications" (2018, p 3021), so have created a handout for "another healthcare professional" to offer the patient, such as a nurse or nutritionist. Further, they acknowledge that "there is no substitute for clinical judgment and discussion of risk and the suggested approach with an individual patient," but also recognize that their greatest challenge is identifying how to "properly achieve the high quality [of care] required to assess BP, council and educate patients, and get patients involved in their care in the short time allowed by payers" (ACC/AHA, 2018, p. 3024).

They know their model is failing clients, and recognize what needs to happen - education and counseling are key, but they just can't do it because they have to move clients through the clinic so fast all they have to offer is pharmaceutical management. What they propose is having the client arrive 30 minutes prior to their appointment, and then having a nurse:

• measure the blood pressure according to specific guidelines in 7 to 8 minutes;

• review blood pressure medications with the client and then updates those medications in the chart, taking only 3 to 4 minutes;

• then the nurse can spend the next 7-10 minutes reviewing lifestyle modifications appropriate for this client and their individual needs;

• calculate their cardiovascular risk based on history and current symptoms using the ASCVD app, taking another minute; and then

• present all of this to the physician, all of which would take approximately 23 to 28 minutes.

This is comical for a number of different reasons, and demonstrates how out of touch these physicians are because where does this nurse come from? Nurses don't room patients because they are too costly, so if a clinic is lucky, they have a trained medical assistant for this role, and they may allot them 10 minutes to review history, obtain vital signs and weight, reconcile medications, enter this information into the chart, potentially run any additional tests, and report to the clinician. It's also a bit outside their scope to counsel clients on an individualized exercise and diet plan, and certainly outside their scope to counsel them on medications, so to make all this even funnier, the ACC/AHA suggested that this nurse be a physician assistant. Again, where does that salary come from and additional rooms in the clinic to have these conversations outside the already booked clinic schedule, not to mention all of this is specific just to hypertension, so what are we doing for diabetes, heart disease, liver disease, kidney disease, and the plethora of other issues we need to discuss with clients?

In truth though, the guidance you deserve and need to be healthy is just not available in conventional medicine. They can offer six-minute consultations on which pharmaceutical might best manage your symptoms but real healthcare is going to have to be outside the current system, more likely with a primary care provider that is functionally and integratively-minded. Not only can I offer all that is discussed above in my consultation with you, but beyond our consult, I have a number of educational programs that work to empower you as a healthcare consumer. The next step is investing in yourself.

Sodium Restriction is Controversial

For centuries it has been the belief that a low sodium diet was optimal for those with higher blood pressure, and early studies supported this. The DASH diet study, a large and well respected study, gave three different levels of sodium (high, medium, and low) and after thirty days, the group with the lowest sodium had the greatest reduction in blood pressure. Thus, the low sodium diet has been advocated.

More recently though, the PURE study, evaluating more than 150K individuals, found a more moderate sodium intake was associated with the lowest overall mortality. That same year, 2014, another study, a meta-analysis, supported this finding in that those with the highest and lowest levels of sodium had the worst outcomes. It seems a happy medium is the best approach, as is true in so many areas of our health and wellness.

The Centers for Disease Control and Prevention (CDC) however, continues to advocate for a lower-sodium diet for the management of hypertension, recommending that most Americans eat less than 1,500mg/d of sodium for ideal cardiovascular health. This is a bit controversial in light of newer research.

Most of us do eat an excess of sodium though, on a daily basis, as processed foods are engorged with sodium, as is prepackaged foods and restaurant meals. Not adding salt to your food is not enough. Dietary changes, such as the DASH diet and the addition of potassium-rich foods, can counterbalance the deleterious effects of excess sodium, and should therefore be recommended.

Nitric Oxide & Heart Disease

Another cause of hypertension is the less than fabulous response of our vessels to increased blood flow. When healthy, our vessels dilate when blood flow is increased so the pressure remains fairly stable, but nitric oxide is essential to this response and in some, this isn't as available or abundant.

When our nitric oxide is low and our vessels are a bit too restrictive then sodium retention occurs, all of which invites cardiovascular disease. Fruits and vegetables provide a substrate for reduction of nitrate to nitrite and nitric oxide, which leads to more relaxation of the vessels and ultimately, a decrease in blood pressure. The production of nitric oxide can also reduce inflammation and even platelet aggregation or clot formation. By aiding in healthy endothelial function, nitric oxide production can aid in prevention of cardiovascular disease, hypertension, atherosclerosis, and #stroke.

You might find some reports that suggest nitrates cause gastric cancer, and certainly this is true when they are concentrated in preservation of meats, but nitrites from vegetables are associated with reduced gastric cancer. Again, balance is key. The most recent guidelines from The International Agency for Research for Cancer states that processed meat does indeed cause #cancer (level 1 evidence) and that red meat was probably carcinogenic. Eek!

L-arginine is a precursor to nitric oxide and a recent meta-analysis, evaluating eleven randomized controlled trials, found that L-arginine supplementation did indeed lower both systolic blood pressure and the diastolic blood pressure, but this may differ among various subsets of the population. It isn't clear if this is helpful for individuals who have suffered a recent heart attack, for example.

Foods with higher levels of nitrates, from fresh foods, include celery, chard, lettuce, beetroot, spinach, arugula, and watercress. Endive, sweet leaf, parsley, and leek are additional options, as are cabbage, turnip and dill.

Nutraceuticals for Optimal Heart Health

Several nutrients can be helpful in optimizing cardiovascular health, but a diet rich in fruits and vegetables, whole grains, low dairy fat, and with lean protein offers many of these nutrients without additional need for supplementation. Evaluate your diet. Supplement wherever necessary.

Many studies have evaluated vitamin C and there is understanding that it can help the vessels better respond to demands. A ten-year-old meta-analysis offered its participants 500mg of vitamin C for eight weeks, and they did demonstrate a lower blood pressure. Certainly this is easy and cost-effective, but for how long this is effective is currently not understood.

Flavonoids, or antioxidants, are the bright colors in our fruits, vegetables, wine, tea, and grains. Think blueberries, eggplant, cherries, and broccoli. This might be part of the success of the DASH diet, but these foods are anti-inflammatory and do support vascular health. Both green and black tea have been shown to reduce blood pressure, in doses upwards of 450mL to 900mL per day.

Lycopene is one of the most powerful antioxidants and is found in abundance in tomatoes. It inhibits oxidative stress, improves vascular function, and works to reduce cardiovascular disease. It certainly does reduce systolic blood pressure, but maybe not so much the diastolic number. Adding tomatoes though, and unprocessed tomato products to your diet is recommended for blood pressure reduction.

Coenzyme Q10 (CoQ10) is another antioxidant and important to the energy center in each of our cells, so found in every organ and tissue within our body, most especially the heart. As we age, our levels decreases, especially so in our third decade. There is evidence of CoQ10 deficiency in hypertension and heart failure, and in individuals on statins for hypercholesterolemia so supplementation may truly be helpful. A meta-analysis in 2007 showed supplementation of CoQ10 can decrease the systolic number by 17 and the diastolic by 10, which is super significant, and this is without side effects. The Cochrane Database doesn't seem to agree however.

Magnesium is an essential nutrient that has a plethora of roles in our body. One of those is the lowering of our blood pressure. A dose of 300mg per day for a month can help raise our magnesium levels within our cells and reduce both systolic and diastolic pressures. Those green leafy vegetables, unrefined grains, and legumes for the win yet again.

Potassium is critical for maintaining our total body fluid volume, electrolyte and acid balance, and many of our cellular functions. Processed foods lowers our potassium levels and of course, if we aren't eating sufficient fruits and vegetables our levels will be especially low. Some blood pressure medications lower our levels as well. Supplementation with as much as 90 to 120 mmol per day is associated with reduced risk of stroke, without any adverse effects on renal function, blood lipids, or catecholamine concentrations.

Zinc levels are important in regulating our blood pressure. Low levels is linked to higher pressure. Add animal proteins, nuts, whole grains, legumes, and yeast to your diet, and be aware that alcoholism will lower zinc, as will some medications and inflammatory bowel disease. Interestingly when your zinc is low, you seek more salt in your diet. Improve your zinc and you'll potentially reduce this craving.

Vitamin D is a steroid hormone, not a vitamin and it too is linked to cardiovascular risks when deficient. Get sun on your face daily. Early morning is best. If you don't know your vitamin D levels, ask your provider to evaluate this with your next annual wellness visit.

Omega-3-fatty acids is probably the nutraceutical I most often recommend, and to no surprise, it too has been found to lower both systolic and diastolic pressures at 2 grams per day or higher. The essential amino acid, Taurine, has also been shown to lower both systolic and diastolic pressures, and the recommended dose is 1.6g daily for at least 12 weeks. Taurine is found, like omega-3s in fish.

Guess what has no support in the literature though, for reducing blood pressure? Apple cider vinegar. Botanical medicine is where things get fun. There are a few good options, such as hawthorn, pomegranate, and cocoa. Movement is also key - everyday. Walk. Stretch. Challenge your muscles. Meditate.

If you have a family history of heart disease or have concerns that you may be at risk, we'd be happy to consult with you and help you create a plan. Call our office with any questions or go ahead and book a visit today.

References

Anand, M. P. (1999). Non-pharmacological management of essential hypertension. Journal of Indian Medicine Association, 97, 220-225.

Bakris, G., Ali, W., & Parati, G. (2019). ACC/AHA versus ESC/ESH on hypertension guidelines. Journal of the American College of Cardiology, 73(23), 3018-3026. https://doi.org/10.1016/j.jacc.2019.03.507

Murugesan, R., Govindarajalu, N., & Bera, T. K. (2000). Effect of selected yogic practices in the management of hypertension. Indian Journal of Physiological Pharmacology, 44, 207-210.

Sengupta, P. (2012). Health impacts of yoga and pranayama: a state-of-the-art review. International Journal of Preventive Medicine, 3(7), 444-458.