Understanding High Blood Pressure

Are We Over-Treating High Blood Pressure?

This month the medical journal JAMA Internal Medicine released an opinion piece that is sure to start some fights. In it, Iona Heath, a retired, well-regarded general practitioner in the UK argues that we are over-treating mild high blood pressure. To understand her arguments, we have to dig a bit into what we know.

Hypertension (high blood pressure) affects about a third of American adults. Most Americans who have heart attacks, strokes, or heart failure have hypertension. It's estimated that high blood pressure contributes to over a third of a million deaths yearly in the U.S. It's also under-treated, with fewer than half of hypertensive patients having their condition under control.

(Photo credit: Wikipedia)

But it's more complex than that. We divide treatment of blood pressure into primary prevention and secondary prevention. Secondary prevention is simple: once you have had a hypertension-related problem such as heart attack or stroke, the statistics clearly show that tight control of blood pressure prevents another event. Anyone who argues otherwise is, in my opinion, out of their mind.

Primary prevention is a bit murkier, and the subject of Dr. Heath's article. The idea is that by treating high blood pressure before the heart attack (or stroke, or kidney failure, etc.) we can prevent these from happening in the first place. There is little debate about this, but over the years there have been vigorous discussions about what levels of blood pressure to treat. In the U.S. we often rely on the Joint National Commission, a panel of experts who review the data every few years and make recommendations.

The current recommendations are based on decades of evidence that shows the risk of heart disease doubles with each increase of 20mmHg to the systolic blood pressure (the top number). In people who do not have other risk factors for heart disease, the goal is to keep the blood pressure under 140/90.

Heath argues that this is too aggressive, and that we over-treat people whose BPs run in the 140-160/90s range. She bases her opinion on a recent review published by the Cochrane Collaboration, an evidence-based medicine group that keeps an eye on such things. The review included data from four studies (they use fairly strict selection criteria).

Cochrane's conclusions were fairly clear: when data from the four studies were analyzed, the treatment of mild hypertension did not prevent important outcomes such as heart attack and stroke, but did cause side-effects.

At what level to treat high blood pressure is a hugely important question, given it's impact on the nation's health. As I said above, we're talking about people who don't already have other heart risks, and we're talking about whether or not to commit them to long-term treatment. We're also talking about patients who have not been able to bring their pressures down through proper diet and exercise (which, unfortunately, is a whole lot of people).

So what evidence is there to treat so-called low risk people with mild high blood pressure?

The World Health Organization and the JNC both recommend an aggressive approach to treating high blood pressure, even in so-called low-risk patient. They do this for a variety of reasons, including some pretty compelling data. Heart and kidney risk rises with blood pressure: there is no "safe" level of high blood pressure. In patients with other risks, the benefit is clear, but what about low-risk patients? Given that many if not all of them will progress with age, and that heart and kidney damage is cumulative, it seems unwise to wait until they either get very high or develop a complication of their hypertension.

It's not that the evidence is conclusive; the Cochrane report reminds us that there may be hazards and costs to treating those with lowest risk---which, statistically, is nearly a tautology. Of course those with less risk will show less immediate benefit. The real question, one which is difficult to study due to ethical considerations, is how much are we helping our mildly hypertensive patients by lowering their numbers.

One Cochrane report combining four studies is not about to change the way most of us practice medicine. Given the disease burden caused by high blood pressure, none of us should rush to raise our treatment thresholds. While Dr. Heath raises some interesting points, her call for significantly raising the treatment threshold (to 160/100) should be discarded until stronger evidence supports her ideas.

High Blood Pressure Hoax by Sherry A. Rogers

By Katherine Czapp 4 Comments

A Thumb Up Book Review

The High Blood Pressure Hoax

By Sherry A. Rogers, MD

Sand Key Company, 2005

Reviewed by Katherine Czapp

The first thing to understand about The High Blood Pressure Hoax is that author Sherry Rogers considers hypertension itself to be no hoax at all, but a very real and serious symptom of vascular dysfunction that can be associated with numerous illnesses such as diabetes, heart disease and Alzheimer’s. As a marker of something out of balance in the body, high blood pressure is not to be ignored, Dr. Rogers emphasizes, and in fact she completely endorses, the recently recalibrated “normal” blood pressure reading of 120/70 along with the new symptom designation of “prehypertension”–also known as the not-long-ago “normal” measurement of 140/90.

On this point of raising the alarm with regard to blood pressure readings, Dr. Rogers temporarily parts company with a number of thoughtful physicians, both old school and of alternative persuasions. Dr. William Campbell Douglass, for example, provides good arguments for leaving moderate hypertension alone, noting that in the absence of other symptoms, untreated hypertension may be of little concern, while treatment with the known classes of antihypertensive drugs inevitably results in serious health-damaging side effects that tend to worsen the longer treatment continues. Even with drug management, fully half of those with high blood pressure still cannot control it, all the while feeling worse while on the drugs.

Dr. Tom Cowan, in his book The Fourfold Path to Healing, outlines an approach to normalizing blood pressure through diet, supplements and movement plus meditation. His take on blood pressure readings is similar to Dr. William Campbell Douglass’s in that both recall being taught in medical school that normal blood pressure was the person’s age plus 100 over 90; a tenet that would be considered irresponsible in modern practice. However, keeping calm about these numbers can go a long way toward reducing hypertension in the patient, or reader, since it is clear that the real impetus for the recalibrating of “normal” blood pressure is to instantly create more customers for the pharmaceutical companies.

But don’t misunderstand: Dr. Rogers is fully aware that drug companies are cold-blooded pushers of their wares and not to be trusted with patient health and welfare. Further, she does not consider high blood pressure to be a disease in itself, and decries the current medical trend to treat it as such and to aggressively medicate the condition without understanding its presence in relation to the overall health of the individual struggling with it. She describes the mechanisms of each of the major classes of antihypertensive drugs and their damaging effects on the body, usually worsening the very condition they are meant to help, while putting the person taking them at greater risk of cardiovascular and other diseases. These drugs make “the sick get sicker quicker,” she repeatedly warns.

Dr. Rogers has over 35 years of experience as a doctor of environmental medicine, and views human health from a perspective of diminishing nutrition coupled with ever-growing toxic burdens from the countless poisons in our water, food and air. Because she considers most Americans at risk for being undernourished and overly toxic–not at all an unrealistic conclusion–this may be the reason for her acceptance of the lower “normal” blood pressure readings in persons younger than 70. (Dr. Rogers acknowledges that dizziness, weakness and brain fog often result from lowering blood pressure too much for those past 70.) In other words, it is most prudent to act at the first sign of disharmony in the body as worse things may be afoot. But please, Dr. Rogers urges, don’t think you have only pharmaceuticals as a solution.

The bulk of The High Blood Pressure Hoax is a compilation of strategies Dr. Rogers feels can provide real answers for those seeking to normalize their blood pressure naturally. Some of her pointers are very basic, but nevertheless usually overlooked approaches, such as testing for potassium and magnesium levels in the red blood cells. Deficiencies of these two minerals–common among Americans–can cause hypertension in certain people, and yet medications that include diuretics (often the first class of antihypertensive drugs to be prescribed) actually cause these very minerals to be lost in the urine, creating even higher blood pressure and the inevitable prescribing of more drugs. Dr. Rogers directs the reader to the exact type of blood test to have the doctor order to reveal accurate mineral levels, warns of what to avoid, and then recommends reputable sources for supplementation. Each of her chapters is accompanied by a reference section to collaborative studies, as well as to labs and resources to equip readers to help themselves.

Dr. Rogers briefly explains several mechanisms of normal blood pressure regulation and the many conditions that may arise in the body to confound this self-regulatory process as well as recommendations to correct the condition, usually through supplementation with nutrients.

Dr. Rogers strongly recommends an “oil change” as a first line of defense, directing the reader to avoid trans fats, as well as hydrogenated, polyunsaturated and fake fats such as Olestra. She recommends coconut butter and cod liver oil as repair oils, explaining that cell membranes must be made of healthy fats for proper intercommunication to proceed at the cellular level. Trans fats and rancid, toxic vegetable oils damage the cells that house the calcium and potassium channels and can cause hypertension as one result; cod liver oil can repair this damage, along with a complete avoidance of the damaging fats. Dr. Rogers further notes that since some high blood pressure can be the result of “silent” viral or bacterial infection of the blood vessels, coconut butter, with its high monolaurin content which disarms viral cell membranes, is the safest response to those infections.

Dr. Rogers’s other main dietary caveat concerns the connection between insulin levels and hypertension, and the consumption of sugar and refined grain products, which she calls “serial killers.” Most of the crackers, cold breakfast cereals and other refined carbohydrate products also contain damaged oils, and so avoiding them is of course doubly rewarding. Get off dead, devitalized foods, Dr. Rogers exhorts, and replace them with whole foods, recently alive. In Dr. Rogers’s book, this means eating a great deal of raw vegetables, including hard-to-digest raw mushrooms and cruciferous vegetables, as well as nuts, which Dr. Rogers recommends you soak overnight along with, say, some raw buckwheat groats and eat for breakfast with yogurt and fruit. If you find this difficult to stomach, you are directed to heal your gut and then try again. Of course not everyone is going to find her “bird seed cereal” appealing or digestible, and not necessarily because of a compromised gastrointestinal tract. Dr. Rogers does not elaborate much on careful nut and seed preparation or at all on other foods that require some time for proper preparation so that they are best assimilated. She often refers readers to her earlier books, where these directions perhaps might be found. Although she recommends nutrient-dense foods such as eggs, cheese, kefir, and non-farmed fish and chicken, she never mentions butter, organ meats, red meats or bone broths as healing and restorative foods, or as sources of the many nutrients Americans are lacking. She only makes one reference to saturated fat, and that is to say it’s not any worse than trans fat, which is damning praise at best. This is unfortunate, since she implicates the roles of declining hormone levels, vitamin D and CoQ10 deficiencies, and thyroid dysfunction in causing or exacerbating hypertension–all conditions that can be improved through a Nourishing Traditions approach to diet and healing.

Dr. Rogers devotes a good deal of her discussion to causes of hypertension that are related to toxic effects from our environment. These include poisoned water, heavy metals, phthalate and plastic leaching, fluoride contamination of food and water supplies, pesticides and so on. The wide protocol of detoxifying includes everything from far infrared sauna to oral chelation to bowel cleansing, and may be the most daunting aspect of her treatment options. Chelation therapy runs the risk of causing excess mineral depletion and organ stress, and the other detoxification methods require trained technicians and careful monitoring. It is hard to deny the fact that mounting toxin loads are health destroyers, and detoxification procedures such as chelation have turned around some desperate cases, which may be encouraging to some readers of The High Blood Pressure Hoax. Providing information on protective dietary strategies would have been helpful as well, but Dr. Rogers confines her advice mostly to supplements. She does mention that phthalates (or plasticizers) make up the heaviest toxic burden in the body, and a metabolic pathway called glucuronidation is the body’s primary means of eliminating them. Dr. Rogers notes that eating cruciferous vegetables such as cabbage, arugula and cauliflower contribute nutrients needed to help that pathway work. Another remedy not mentioned by Dr. Rogers would be regular use of tea mushroom (kombucha), which recent research has shown inhibits enzymatic breakdown of glucuronic acid conjugates (waste-escorting molecules) and thereby speeds waste and toxin removal from the body and increases the detoxification ability of the liver. An emphasis on other foods–such as butter–that support and protect liver function would have been helpful here as well.

The powerful influence of the psyche and emotions on physical health and therefore on hypertension is touched upon by Dr. Rogers, but her personal approach to mental and spiritual health, which involves religious dedication of a sort she acknowledges is not for everyone, makes for rather limited assistance at best. This is understandable, however, since in the area of the mind and soul, each person must forge his own path and grapple in his own way with “the thousand natural shocks that flesh is heir to.”

“The circulation is really the biological field where the soul lives out its life,” writes Dr. Cowan in The Fourfold Path to Healing, and that concise statement ought to provoke a lot of thought about the struggles of the mind being reflected in struggles in the body.

For its mere 250 terse pages, The High Blood Pressure Hoax packs an enormous amount of information and resources, which will be welcomed by readers already used to taking full responsibility for their health, but which can easily overwhelm a less seasoned reader. This would not be a book to give someone not already fully weaned from the conventional medical establishment, for example. A drawback of the book’s presentation of information is the sense one has that Dr. Rogers was dictating the contents as she was running to catch a cab to the airport. Nevertheless, The High Blood Pressure Hoax does provide many useful pointers toward multiple drug-free approaches to normalizing cardiovascular conditions and other related health conditions, and thereby received a qualified Thumbs Up. By writing this book Dr. Rogers clearly wanted to put the power and knowledge of healing back into the hands and heart and spine of the individual, and we can be grateful for her contribution toward that noble aim.

Cut Back on Sodas to Lower Blood Pressure

Drinking Fewer Sweetened Drinks Reduces Blood Pressure, Study Finds

By Denise Mann

From the WebMD Archives

May 24, 2010 -- Cutting back on sugary sodas and other sweet beverages may help lower blood pressure, according to new research in Circulation.

Previous studies have linked sugary beverages to obesity, type 2 diabetes, and metabolic syndrome, a cluster of risk factors that increase the risk for heart disease and diabetes, but the new study is one of the first to show that drinking too many sweetened beverages can increase blood pressure levels. High blood pressure is considered a major risk factor for heart disease and stroke.

“Cutting back soda consumption will benefit your blood pressure,” says researcher Liwei Chen, MD, PhD, an assistant professor of epidemiology at Louisiana State University Health Science Center School of Public Health in New Orleans.

Sugary Drinks and Blood Pressure

The new study involved 810 adults aged 25 to 79 with prehypertension or early stage 1 hypertension who were taking part in an 18-month study designed to prevent or reduce high blood pressure with weight loss, exercise, and diet.

Prehypertension is defined as a systolic blood pressure reading between 120 and 139 or a diastolic blood pressure of 80 to 89. Stage 1 hypertension is defined as a systolic blood pressure between 140 and 159 or a diastolic blood pressure between 90 and 99. Systolic blood pressure is the upper number in a blood pressure measurement and refers to the pressure when the heart beats. Diastolic blood pressure, the lower number, is the pressure between beats. A blood pressure reading of less than 120/80 is considered ideal.

Most people in the study drank an average of 10.5 fluid ounces of sugar or high fructose corn syrup-sweetened beverages a day including non-diet soft drinks, fruit drinks, lemonade, and fruit punch when the study began.

Halving their soda intake resulted in a 1.8 point reduction in systolic blood pressure and a 1.1 point drop in diastolic pressure.

The public health benefit is “substantial,” she says. A 3-point reduction in systolic blood pressure should reduce risk of death after stroke by 8% and heart disease mortality by 5%, according to information cited in the new report.

Americans drink about 2.3 servings or 28 ounces of sugar-sweetened beverages each day, and one in three adults in the U.S. has high blood pressure, according to the American Heart Association.

“Soda consumption is so popular and high blood pressure is a very significant health problem, and if you reduce sugary drinks, you will reduce your blood pressure in the short term and reduce your risk of heart attack and stroke over the long term,” she tells WebMD.

Sodium, Uric Acid Affect Blood Pressure

Although weight loss accounted for some of these blood pressure-lowering effects, cutting back on sweetened drinks also had an independent effect on blood pressure levels.

Exactly what accounts for this independent effect is not known, but several theories exist. For example, these beverages are often loaded with sodium, which can increase blood pressure, and the sugar in the drinks may increase levels of hormones known as catecholamines, which can cause blood pressure to rise.

George Bakris, MD, a professor of medicine and director of the Hypertension Center at the University of Chicago Pritzker School of Medicine, says that uric acid also plays a role.

“High fructose corn syrup increases uric acid levels, which has been shown to increase high blood pressure,” says Bakris, who is also the president of the American Society of Hypertension.

“Read labels because high fructose corn syrup has to be listed on the label,” he says. “If you even reduce what you are taking in by 50% over time, you will see a benefit,” he says.

It’s not just soft drinks either. “It’s in ketchup and a lot of condiments and sauces that people eat and don’t appreciate,” he says.

More Fuel for the ‘Soda Tax’

“There is a mile-long list of studies that show the negative impact of consumption of sugar-sweetened beverages, and this study is more proof that something needs to be done to change the disease burden caused by these drinks," says Kelly Brownell, PhD, director of the Rudd Center for Food Policy and Obesity at Yale University in New Haven, Conn. He advocates a tax on these beverages.

As it stands, up to 20 cities and states are considering imposing such a levy on soda. “None of the taxes have passed yet, but it is just a matter of time,” he says.

Beverage Group Responds

“This study does not show that there is anything unique about drinking sugar-sweetened beverages that leads to increased blood pressure, or that there is something unique about reducing their consumption that leads to reduced blood pressure,” says Maureen Storey, PhD, senior vice president of the American Beverage Association in Washington, D.C.

“We know that losing weight by decreasing total calories consumed from all foods and beverages and increasing total calories burned through physical activity has the greatest effect on blood pressure, not the specific foods or beverages that are decreased,” she says in a written response.

“It’s important to recognize that this particular study is a secondary analysis of another study designed to look at the impact of weight loss -- not reducing or eliminating specific foods or beverages -- on blood pressure,” she says. “This study only further supports that weight loss is a critical factor to lowering blood pressure. And the key to losing weight involves either decreasing total calories consumed or increasing total calories burned or a combination of the two."