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Reversing High Blood Pressure with Lifestyle Medicine

David DeRose, MD, MPHPhysician

8/29/2018

1

Seven Key Blood Pressure Messages

That help us focus on a vital area of health ministry

Key Message #1 We Are in the Midst of a Truly Global Pandemic

Across international lines, rates for high blood pressure among adult populations generally varies between 30 and 50%

World Health Organization, 2011

Prevalence estimates for 2008 were given for raised blood pressure based on the percentage of the population aged 25 or older having:

• systolic blood pressure ≥ 140 mmHg and/or

• diastolic blood pressure ≥ 90 mmHg

• or on medication to lower bloodpressure

World Health Organization. Monograph: Noncommunicable Diseases Country Profiles, 2011

High Blood Pressure Prevalence in Various Nations (WHO, 2011)

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Prevalence by WHO Region

• Highest in Africa - 46% for both sexes combined

• Lowest in the Americas - 35% for both sexes

World Health Organization. Global Health Observatory (GHO) data. Accessed 10 April 2018 at http://www.who.int/gho/ncd/risk_factors/blood_pressure_prevalence_text/en/

Key Message #2 It’s not just someone else’s problem…

If you don’t have high blood pressure today, it’s likely waiting for you down the road 6%

16%

31%

48%

65%

78%

0%10%20%30%40%50%60%70%80%90%

18-34 35-44 45-54 55-64 65-74 75+

Egan BM, et al. JAMA. 2010 May 26;303(20):2043-50.Fields LE, et al. Hypertension. 2004; 44:398- 404

Greater Likelihood of High Blood Pressure as U.S. Adults Age

(using JNC 7 Guidelines)

http://www.who.int/gho/ncd/risk_factors/blood_pressure_prevalence_text/en/

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Greater Likelihood of High Blood as Adults Age Worldwide

(Data from 90 Countries, pub. 2016Segregated by Hi vs Lo-Mid Income Countries)

10.718.5

31

48.5

60.8

73.6

4.39.1

22

41

60.9

77.5

15.222.1

31.2

43

55.365.6

10.417.4

30.6

47.2

61.9

74.7

0

20

40

60

80

100

20–29 30–39 40–49 50–59 60–69 ≥70

HI Men HI Women Lo-Mid Men Lo-Mid Women

Mills KT, et al. Circulation. 2016;134:441-450

Greater Likelihood of High Blood Pressure as U.S. Adults Age

(using November 2017 Expert Guidelines)

30%

50%

70%77% 79%

19%

44%

63%

75%85%

0%

20%

40%

60%

80%

100%

20–44 45-54 55-64 65-74 75+

Men Women

2017 High Blood Pressure Clinical Practice Guideline: Executive SummaryHypertension, November 13, 2017, Page 22

With Current Lifestyle Practices…

High blood pressure (even using older guidelines) seems inevitable for the majority of us

• In the Framingham Heart Study, approximately 90% of adults without high blood pressure between the ages of 55 and 65 developed high blood pressure during their lifetime

Vasan RS, et al. JAMA. 2002;287:1003-10.

With Current Lifestyle Practices…

High blood pressure (even using older guidelines) seems inevitable for the majority of us

• If you are 45 years old and don’t have high blood pressure, your risk of developing high blood pressure sometime over the next 40 years is:

– 86% if White

– 92% or higher in other demographic groups (e.g., African-American or Hispanic)

Carson AP, et al. Hypertension. 2011;57:1101-7

Intersecting Lines of Influence…

In 2016, we published a new book on high blood pressure.

Since its release:

• The Kindle edition has been consistently ranking among the top 20 Preventive Medicine titles on Amazon

• The soft cover book has been consistently among Amazon’s top 20 high blood pressure titles

Connecting the Dots…

• The book and related DVD resources have been generating considerable interest among both lay people and health professionals– Our book has won three national

awards

– It receives consistently high reader reviews

– It presents a lifestyle message consistent with one shown to help treat or prevent diabetes

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Connecting the Dots…

Could our work with high blood pressure provide an additional tool in Indian Country to help patients embrace and adhere to a diabetes-preventive lifestyle?

Key Message #3

High Blood Pressure isDangerous


“Common, preventable risk factors underlie most NCDs. These risk factors are a leading cause of the death and disability burden in nearly all countries, regardless of economic development…”



“The leading risk factor globally for mortality is raised blood pressure (responsible for 13% of deaths globally)”


High Blood Pressure Complications

Brain:▪ Stroke

▪ Hypertensiveencephalopathy

▪ Headaches

▪ Dementia

Eye:▪ Hypertensive

retinopathy

▪ Glaucoma

Vessels: ▪ Aneurisms

▪ Atherosclerosis

Heart: ▪ Heart attack

▪ Heart failure

▪ Heart rhythm problems

Kidney: ▪ Hypertensive

nephropathy (chronic renal failure)

Prostate: ▪ Slow, weak

urine stream

▪ Trouble voiding

Take Home Point #1

If we are interested in ministering to the health needs of our communities and our own ability to minister effectively, we must be doing something about high blood pressure

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Key Message #4Not Only is High Blood Pressure Bad….

But treating it—getting your numbers down to normal levels—

is good

Benefits of High Blood Pressure Treatment

Sheridan S, et al. Screening for high blood pressure: review of the evidence. Am J Prev Med 2003;25:151-8.

Key Message #5Confusion About Blood Pressure Guidelines

Has Primed Lay People and Professionals for Messages About Non-Drug Treatment

JNC 7:U.S. Blood Pressure

Guidelines for Over a Decade2003 – 2013

JNC7 Definitions of High Blood Pressure

Classification SBP DBP

Normal <120 and <80

Prehypertension 120-139 or 80-89

Stage 1 hypertension 140-159 or 90-99

Stage 2 hypertension160 or higher

100 or higher

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)

Current World Health Organization Guidelines

Hypertension is diagnosed if readings on separate occasions consistently show blood pressure to be 140/90 mmHg or higher. • Regional office for Europe: Accessed 10 April 2018

http://www.euro.who.int/en/about-us/whd/past-themes-of-world-health-day/world-health-day-2013-focus-on-high-blood-pressure/about-hypertension

http://www.euro.who.int/en/about-us/whd/past-themes-of-world-health-day/world-health-day-2013-focus-on-high-blood-pressure/about-hypertension

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Target BPs from the European Guidelines on CVD Prevention in Clinical Practice

(Version 2016)

• <140/90 mmHg in the general population

• <140/85 mmHg in subjects with DM type 2

• <130/80 mmHg in DM type 1

Piepoli MF, Hoes AW, et al. European guidelines on cardiovascular disease prevention in clinical practice: the sixth joint task force of the European Society of Cardiology and Other Societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts): developed with the special contribution of the European Association for Cardiovascular Prevention & rehabilitation (EACPR). Eur J Prev Cardiol. 2016:2016.

November 2017Blood Pressure Guidelines

• Determined by a diverse group of experts spearheaded by the American College of Cardiology (ACC) and the American Heart Association (AHA)

• The following organizations contributed to writing the guidelines (as part of the writing committee) and approved (through their governing body) the final published document: ACC, AHA, American Academy of Physician Assistants (AAPA), Association of Black Cardiologists (ABC), American College of Preventive Medicine (ACPM), American Geriatrics Society (AGS), American Pharmacists Association (APhA), American Society of Hypertension (ASH), American Society for Preventive Cardiology (ASPC), National Medical Association (NMA), and Preventive Cardiovascular Nurses Association (PCNA).

2017 High Blood Pressure Clinical Practice Guideline: Executive SummaryHypertension, November 13, 2017

November 2017 Expert Guidelines


Normal <120 and <80

Elevated 120-129 and <80

Stage 1 hypertension 130–139 or 80-89

Stage 2 hypertension 140 or higher or 90 or higher

Hypertensive Crisis 180 or higher or 120 or higher

For Whom is Medication Recommended?


• Individuals with cardiovascular disease, chronic kidney disease, or diabetes

≥130 or ≥80

• Individuals without the conditions above but with an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of ≥10%

≥130 or ≥80

• Individuals without the above conditions and with 10-year ASCVD risk <10%

≥140 or ≥90

2017 High Blood Pressure Clinical Practice Guideline: Executive SummaryHypertension, November 13, 2017

Worldwide Data Suggest Significant Lifestyle Contributions

European Examples

Germany1379 participants without CVD were studied with a mean age of 53.1 ± 11.9 years, 52.9% female.– 30.8% were physically inactive– 55.2% overweight– 19.3% current smokers. – 31.8% had hypertension (above 140/90)– 57.6% had dyslipidemiaNote: presumably some hypertensives were excluded due to the presence of CVD

Tiffe T, Wagner M, et al. BMC Cardiovasc Disord. 2017 Nov 2;17(1):276.

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Lawes CM, et al. Stroke. 2004;35:1024-1033. Yusuf S. Circulation. 2006 May 9;113(18):2166-8.

Why Controversy with the Guidelines?

…to some extent, any elevation above your physiologically lowest attainable pressure may be increasing your risk of long-term problems.

But at once you reach a certain BP level, lowering your blood pressure with medications may cause more problems than benefits

Lawes CM, et al. Stroke. 2004;35:1024-1033. Yusuf S. Circulation. 2006 May 9;113(18):2166-8.

If not on high blood pressure medications…

there are continuous, graded benefits from getting one’s blood pressure down to at least 110/75 if not lower.

Risk of Heart Disease Death According to Blood Pressure (mm Hg): MRFIT

Adding Medications Changes the Equation…

Dangers of Overtreating HypertensionResearch performed on telmisartan (ARB),

ramipril (ACEi), or both, in high risk patients

0

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.5 y

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ts*

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)

* Composite of cardiovascular death, heart attack, stroke

or hospitalization for heart failure

112 121 126 130 133 136 140 144 149 161

Treated Systolic BP Level

Sleight P, et al. J Hypertens. 2009 Jul; 27( 7): 1360-9.

Key Message #5

• Naturally controlling your blood pressure appears to be superior to controlling it with medications

• The same is true of diabetes

• (Nonetheless, make sure your blood pressure and blood sugar is controlled, however you accomplish it)

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KEY MESSAGE #6: MOST AMERICANS

ARE NOT DOING WELL WHEN IT COMES

TO BLOOD PRESSURE CONTROL

U.S. Trends in Awareness, Treatment, and Control of High Blood Pressure

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Aware Treated Controlled

NHANES II 1976-1980

NHANES III 1988-1991

NHANES III 1991-1994

NHANES 1999-2000

NHANES 2007-2008

Adapted from: JNC 7. JAMA 2003; 289:2560, and JAMA 2010; 303:2043.

Perc

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on

Could the less than optimal rates of control . . .

relate to patients’ lack of acceptance regarding the conventional approach

to high blood pressure?

The “Cornerstone” of High Blood Pressure Therapy

Although all experts recognize the power of lifestyle . . .

Medications seem to end up as the foundation of therapy for most patients

See, for example: Kronish IM, et al. Circulation 2011;123:1611-1621.

Comparing Symptoms of Medication-Based BP Treatment with Untreated BP

Common Symptoms of Blood Pressure Medications:

▪ Frequent urination

▪ Fatigue

▪ Dizziness

▪ Uncontrollable cough

▪ Exercise limitations

▪ Sexual dysfunction

▪ Depression

Typical Symptoms of Untreated High Blood Pressure:

▪ None

Medication Adherence Based on a Series of Studies, Most Lasting 12 Months or Less

28.40%

51.00% 52.00%57.60%

64.90%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

BBs Diuretics CCBs ACEIs ARBs

Kronish IM, et al. Meta-analysis: impact of drug class on adherence to antihypertensive. Circulation. 2011 Apr 19;123(15):1611-21.

Key

ARBs = Angiotensin II receptor blockers

ACEIs = Angiotensin converting enzyme inhibitors

CCBs = Calcium channel blockers

BBs = Beta blockers

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In Other Words…

The common solution for high blood pressure (medications) may create more “pressure” (or stress) than the hypertension itself!

Might There Be a Better Way?

Could there be a“no pressure”

solution to blood pressure?

Key Message #7“No Pressure” is…

A Framework for Controlling Your Blood Pressure

Naturally

“No Pressure”

Don’t Forget These Two Words

NutritionOptimal choice of beverages

Physical exerciseRestEnvironment Stress managementSocial supportUse of natural adjuncts Refraining from pressors &

excessesExercising faith in God

Data from Three Community Programs Using “Thirty Days to Natural Blood Pressure Control” and Related Videos (Participants with Baseline SBP ≥140; n = 25)

157.5

86.8

140.4

78.8

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Initial

Post-program

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P < .001 for changes in both SBP and DBP

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Free Resources

Free resources and information on the CompassHealth website: www.compasshealth.net

http://www.compasshealth.net/hypertension/

Other Resources NutritionOptimal choice of beverages



http://www.compasshealth.net/

http://www.compasshealth.net/hypertension/

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Three Key Nutrition Principles

▪ Increase Plant Food Consumption

▪ Control Calories (Lose Weight if Overweight)

▪ Decrease Salt Intake

Do Typical Diet Practices Make a

Difference?

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Diabetes

Hypertension

NonVegetarian

SemiVegetarian

PescoVegetarian

Lacto-ovoVegetarian

Vegan

*SemiVegetarians eat red meat, poultry, and fish less than once a week

Fraser GE. Am J Clin Nutr. 2009 May;89(5):1607S-1612S.

Do Typical Diet Practices Make a Difference?

Adventist Health Study-2; n = 89,224

Multiple Studies Confirm the Power of the Vegetarian Diet

After reviewing 80 scientific studies, Drs. Susan Berkow and Neal Barnard concluded:

“Randomized clinical trials have shown that BP [blood pressure] is lowered when animal products are replaced with vegetable products in both normotensives and hypertensives.”

Berkow SE, Barnard ND. Blood pressure regulation and vegetarian diets. Nutr Rev. 2005 Jan;63(1):1-8.

Why Are Plant Foods So

Powerful?

Dietary Substances That Can Help Induce Smooth Muscle Relaxation

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Magnesium and Calcium

Nuts and SeedsLegumesGreen Leafy Vegetables

Magnesium Champions

the top food sources of

magnesium in the 2015 USDA

database based on amount of

magnesium found in a one cup serving

Potassium Champions

the top food sources of

potassium in the 2015 USDA

database based on nutrient density, mg of potassium

per calorie

CalciumChampions

the top food sources of calcium in the 2015 USDA

database based on nutrient density,

mg of calcium per calorie

PhytochemicalsDietary Substances that Have

ACE Inhibition Properties

© A.Rad from wikipedia.org

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Guang C, Phillips RD. Plant food-derived Angiotensin I converting enzyme inhibitory peptides. J AgricFood Chem. 2009 Jun 24; 57(12):5113-20.




Socially Connect to

Lower Blood Pressure

The Blood Pressure-Lowering Power of Social Support

Social Support and Hypertension

Swiss researchers studied 22 individuals with high blood pressure and compared them to 26 subjects who were normotensive. They discovered:

▪ Lower perceived social support characterized those with high blood pressure compared to normotensives (P < 0.01).

Wirtz PH, et al. J Clin Endocrinol Metab. 2006 Oct;91(10):3857-65.

Social Support and Hypertension

▪ Low social support was associated with elevated stress hormone reactivity.

▪ Secretion of the stress hormone, epinephrine (adrenaline), was highest in hypertensives with low social support.

Wirtz PH, et al. J Clin Endocrinol Metab. 2006 Oct;91(10):3857-65.

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Social Support and Social Connectedness

From the prestigious Nature journal family…

From the Nature Study…• “Obesity prevalence is increasing in many countries at

alarming levels. A difficulty in the conception of policies to reverse these trends is the identification of the drivers behind the obesity epidemics.

• “Here, we implement a spatial spreading analysis to investigate whether obesity shows spatial correlations…

• “We find a regularity in the spatial fluctuations… deviating in a fundamental way from the weaker correlations found in the underlying population distribution indicating the presence of collective behavior,

• “i.e., individual habits may have negligible influence in shaping the patterns of spreading.”

Possible Implications

• Social and societal factors may ultimately be greater determinants of obesity than our personal choices

• Where we live and who we keep company with may be among the most important factors when it comes to weight optimization

An Amazing, Cutting-Edge Study on a Unique Form of Social Support

“Delegating Responsibility from Clinicians to Nonprofessional Personnel: The Example of

Hypertension Control”

Margolius D, et al. J Am Board Fam Med. 2012 Mar;25(2):209-15.

Benefits of “Health Coaches” or “Health Advocates”

▪ Role supported by many clinicians

▪ High frequency of coach–patient interactions

▪ Appears to assist lifestyle and medication adherence

▪ Allows for home titration of medications

▪ Helps clinicians understand patients’ barriers to hypertension control

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Daily Water Drinking and Relative Risk of Fatal Heart Disease

Chan J, et al. Water, other fluids, and fatal coronary heart disease: the Adventist Health Study. Am J Epidemiol 2002 May 1;155(9):827-33

.59

.46

Daily Consumption of Fluids Other than Water and Risk of Fatal Heart Disease

Chan J, et al. Water, other fluids, and fatal coronary heart disease: the Adventist Health Study. Am J Epidemiol 2002 May 1;155(9):827-33

2.47

1.46

Other Conditions Potentially Helped By Drinking More Water

• Constipation

• Diabetic Complications

• Urinary Infections

• Kidney Stones

• Gallbladder Disease

Water for Weight Loss?

▪ Michael Boschmann and colleagues demonstrated that drinking a half liter of water raises metabolism 24% for one hour.

▪ In a carefully controlled study, they found that a similar amount of isosmotic saline—or a minimal amount of water (50 ml)—had no such effect.

Boschmann M, et al. Water drinking induces thermogenesis through osmosensitive mechanisms. The Journal of Clinical Endocrinology & Metabolism 92(8):3334–3337

Impressive Research by Dr. Goldhamer

• Subjects:

–174 consecutive patients with blood pressure in excess of 140 mm Hg systolic, 90 mm Hg diastolic or both

– treated in an inpatient setting under medical supervision.

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The treatment program:

–2 to 3 days fruits and vegetables,

–medically supervised water-only fasting (10 to 11 days on average)

– refeeding period (6 to 7 days on average) introducing a low-fat, low-sodium, vegan diet.


RESULTS:

• Almost 90% of the subjects achieved BP less than 140/90 mm Hg by the end of the program.

• average reduction in BP of 37/13 mm Hg

Special Fasting Considerations in Hypertension and/or Diabetes

• Only recommended if medically supervised or guided.

–Need to evaluate medication therapy

–Downward adjustments (or discontinuation) needed for any medications that have the potential to lower normal blood sugar or blood pressure

– Special concern with diuretics




Are “Natural” Pills Better Than

Medications?

Anti-Hypertensive Botanicals of Promise

▪ Not substitutes for lifestyle therapy

▪ May have effects that aid in lifestyle goals (e.g., a supplement that helps curb appetite)

▪ Can decrease dependence on medications whose side-effects may undermine lifestyle goals (e.g., fatigue interfering with exercise)

▪ May have adjunctive effects that further enhance health

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Which Supplements Are Being Used for

Hypertension?

2011 Bastyr University Study of a Seattle Naturopathic Practice

0.00% 10.00%20.00%30.00%40.00%50.00%60.00%

Omega-3 Oil (marine)

Magnesium

Coenzyme Q10

Hawthorne

Potassium

Bradley R, et al. Evid Based Complement Alternat Med. 2011;2011:826751.

Percent of Patients

Receiving Various Supplements for

Hypertension

March 6, 2014

Begg DP, et al. Hypertension induced by omega-3 polyunsaturated fatty acid deficiency is alleviated by alpha-linolenic acid regardless of dietary source. Hypertens Res. 2010 Aug;33(8):808-13.

• “Omega-3 polyunsaturated fatty acid deficiency, particularly during the prenatal period, can cause hypertension in later life.”

• In an animal model, researchers demonstrated that dietary alpha-linolenic acid (canola oil or flaxseed oil) given to mothers prior to mating and to offspring after birth could prevent the development of hypertension in the offspring.

• Offspring on the diet of plant-sources of omega-3 fats also had lowered body weight, adiposity, and food intake.

Selected Omega-3 Fat Benefits Increasing Omega-3 Intake

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Omega-3 Sources

Systolic Blood Pressure Changes Compared to Placebo; Fish Oil vs. Ground Flax

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Ground Flax

Fish Oil

• Fish oil: ≥8 week studies, 17 RCTs (25 comparisons) with 1,524 pts (800 –13,330 mg daily)

• Ground flax: 6 month study, 110 pts; 30 gm daily of milled flax

2017 High Blood Pressure Clinical Practice Guideline: Data SupplementHypertension, November 13, 2017, Pages 33-34




Blood Pressure Soothing

Surroundings

Three Key Environmental Factors

▪ Quiet

▪ Sunshine

▪ Fresh Air


▪ Quiet

▪ Sunshine

▪ Fresh Air

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Road Traffic Noise Linked to High Blood Pressure

▪ A 2010 meta-analysis was performed on the connection between road traffic noise and blood pressure.

Ndrepepa A, Twardella D. Noise Health. 2011 May-Jun;13(52):251-9.

Road Traffic Noise Linked to High Blood Pressure

▪ “The results of this meta-analysis demonstrated the existence of a positive and significant association between noise annoyance from road traffic and the risk of arterial hypertension”


Evidence Suggests…▪ The closer you live to a

major road, the worse your blood pressure will respond to the noise stress

▪ If you sleep on the side of your house facing a road, you will tend to have higher blood pressure than if you sleep in a room on the opposite side of the house.

Biological Mechanisms Linking Noise and BP

▪ Evidence suggests that noise exposure or noise annoyance activates the sympathetic nervous system


Biological Mechanisms Linking Noise and BP

▪ This, in turn, raises circulating levels of stress-related hormones, the catecholamines and cortisol.


Another Hard Hitting Title

Overweight, air and noise pollution: Universal risk factors for pediatric pre-hypertension

J Res Med Sci. 2011 September; 16(9): 1234–1250.

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Noise Linked to Childhood Prehypertension

"In children, in addition to impairing reading comprehension and long-term memory, chronic noise exposure may be associated with increased BP and a pre-HTN state. Such association is reported even in pre-school age children."

J Res Med Sci. 2011 September; 16(9): 1234–1250.


▪ Quiet

▪ Sunshine

▪ Fresh Air

Deficient Vitamin D Levels May Contribute to Hypertension

Epidemiology suggests a link:▪ Darker races (esp. individuals of African

origin) tend to have higher BP

▪ Racial factors being equal, the further one lives from the equator, the greater the tendency for high BP

▪ BP tends to be higher in the winter than the summer

Nahas R. Can Fam Physician. 2008 Nov;54(11):1529-33.

Deficient Vitamin D Levels May Contribute to Hypertension

Basic science suggests a link:

▪ Activated vitamin D (1,25-OH vitamin D) inhibits production of the blood pressure-raising hormone, renin.

▪ Adequate vitamin D status is important for optimal microvascular health (blocks proliferation of vascular smooth muscle cells)

Nahas R. Can Fam Physician. 2008 Nov;54(11):1529-33.

Key Messages

▪ Ensure adequate levels of vitamin D—especially in the winter months.

▪ Shoot for a 25-OH vitamin D level of at least 50 mg/ml.

Place of Residence and Vitamin D

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Place of Residence and Vitamin D

If you live at a latitude further than 35 degrees north or south of the equator you will need to take a vitamin D supplement at least during some portion of the winter.

Holick MF. Vitamin D deficiency. N Engl J Med. 2007 Jul 19;357( 3): 266-81.


▪ Quiet

▪ Sunshine

▪ Fresh Air

Make Sure You Breathe High

Quality Air

Tobacco Use and High Blood Pressure▪ Every cigarette raises

blood pressure▪ The effect is relatively

short-lived with pressure typically returning to normal within 30 minutes

▪ The blood pressure rise may be greatest with the first cigarette of the day

Groppelli A, et al. J Hypertens. 1992 May;10(5):495-9.

First Cigarette of the Day Raises Blood PressureIs It Safe To Dip?

Conclusions from a meta-analysis of 12 pertinent articles from among 875 dealing with smokeless tobacco:

▪ Smokeless tobacco caused a clinically significant acute elevation of systolic blood pressure, diastolic blood pressure, or pulse in 5 of 6 experimental trials.

▪ Smokeless tobacco was associated with chronic hypertension in 4 of 6 cross-sectional studies.

Westman EC. Does smokeless tobacco cause hypertension? South Med J. 1995 Jul;88(7):716-20.

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The Conclusions . . .“Health care practitioners should be aware that smokeless tobacco may elevate blood pressure up to 90 minutes after use.”

“Smokeless tobacco use should be considered a potential cause of sodium retention and poor blood pressure control because of its nicotine, sodium, and licorice content.”

Westman EC. Does smokeless tobacco cause hypertension? South Med J. 1995 Jul;88(7):716-20




Making Exercise Work

for You

Exercise and Hypertension

Facts about exercise and blood pressure:▪ Pooled studies (meta-analyses) show that regular

exercise typically lowers systolic blood pressure by 4 to 6 points and diastolic BP by 3 points

▪ Selected individuals may lower their blood pressure by as much as 15 mmHg

▪ The younger you are, the more benefit you tend to get.

Exercise and Hypertension

Facts about exercise and blood pressure:▪ Pooled studies (meta-analyses) show that regular

exercise typically lowers systolic blood pressure by 4 to 6 points and diastolic BP by 3 points

▪ Selected individuals may lower their blood pressure by as much as 15 mmHg

▪ The younger you are, the more benefit you tend to get.

“How much exercise is required to reduce blood pressure in essential hypertensives: a dose–response study”Ishikawa-Takata K, et al.

Am J Hypertens (2003) 16 (8): 629-633.

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Results of Moderate Exercise on Blood Pressure

0 2 4 6 8 10 12 14 16

SBP Decrease

Control

30-60 min/wk

61-90 min/wk

91-120 min/wk

> 120 min/wk

8-week program at 50% of VO2 max

Decrease in Systolic Blood Pressure

*

*

* Significantly different than level below

Whether in Work, Worship, or Play, Exercise was Generally

Part of Their Daily Routine

How They Till the Soil and Plant

LeMoyne found an industrious people who tilled the land and raised vegetable crops

Is All Exercise Created Equal?

Useful Work in the Beginning?

“Then the Lord God took the man and put him in the garden of Eden

to tend and keep it.”

Genesis 2:15, NKJV

While in the “Garden of Eden,” what type of exercise do you think Adam and Eve engaged in?




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De-Stress and Decrease

Medications?

Stress and Hypertension

Two Key Points:▪ Stress-related

psychosocial factors have been linked to the development of high blood pressure

▪ Addressing stress-related issues has been associated with lowering of blood pressure

Framingham Study: Psychosocial Predictors of Hypertension

Markovitz JH, et al. Psychological predictors of hypertension in the Framingham Study. Is there tension in hypertension? JAMA. 1993 Nov 24;270(20):2439-43.

Examples of Other Studies Across Cultural Lines Showing a Connection Between Stress and

Hypertension

▪ Anger and lack of coping behaviors associated with higher systolic blood pressure among male Japanese workers.

▪ Meditation for stress management was associated with a lowering of blood pressure in a 2007 meta-analysis of 17 studies.

Ohira T, et al. Environ Health Prev Med. 2000 Apr;5(1):37-42Rainforth MV, et al. Curr Hypertens Rep. 2007 Dec;9(6):520-8.See also: Kaplan MS, Nunes A. Nutr Metab Cardiovasc Dis. 2003 Feb;13(1):52-9.

The CARDIA Study Looked at Stress-Related Factors and the Development of Hypertension

▪ Conducted in 4 US metropolitan areas

▪ Involved 3308 black and white adults aged 18 to 30 years (when recruited in 1985 and 1986)

▪ Data based on follow-up through 2000 to 2001.

Yan LL, et al. JAMA. 2003 Oct 22;290(16):2138-48.

Hostility and the Development of Hypertension in the CARDIA Study

Yan LL, et al. JAMA. 2003 Oct 22;290(16):2138-48.

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Time Urgency/Impatience Score Used in the CARDIA Study

0 – 4 Points Based On…

▪ Feeling pressured for time in general

▪ Feeling pressured at the end of an average work or housework day

▪ Eating too quickly

▪ Getting quite upset when having to wait for anything

Yan LL, et al. JAMA. 2003 Oct 22;290(16):2138-48. Yan LL, et al. JAMA. 2003 Oct 22;290(16):2138-48.

Development of Hypertension over 15 Years Associated with Time Urgency/Impatience Scores

PTSD: A Special Stress Concern with Blood Pressure Implications

Posttraumatic stress disorder

Posttraumatic Stress Disorder (PTSD) and High Blood Pressure

▪ Researchers at Nova Southeastern University studied data from the US National Comorbidity Survey

▪ Their main finding:whether or not a person has depression…

PTSD is associated with higher blood pressures

Kibler JL, et al. Behav Med. 2009 Winter;34(4):125-32.

Additional Mechanisms for Stress-Related BP Elevation

Baltrus PT, et al. Socioeconomic position, stress, and cortisol in relation to waist circumference in African American and white women.

Ethn Dis. 2010 Autumn;20(4):376-82.

Additional Mechanisms for Stress-Related BP Elevation

Stress

Abdominal Obesity

Higher Cortisol Levels

High Blood Pressure

Baltrus PT, et al. Socioeconomic position, stress, and cortisol in relation to waist circumference in African American and white women. Ethn Dis. 2010 Autumn;20(4):376-82.

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Implications

Exercise may not only help to deal with stress, but also address overweight which may further amplify stress-related BP problems.

A Lion in Your Bedroom: Selected Responses

Play dead Befriend him

Ignore him

Hide

Pray

Call for help

Run/Escape

Fight

Kill or otherwise remove

him (tranquilize him)

Is There Help For Stress?“Come unto me, all ye that labour and are heavy laden, and I will give you rest. Take my yoke upon you, and learn of me; for I am meek and lowly in heart: and ye shall find rest unto your souls. For my yoke is easy, and my burden is light.”

Matthew 11:28-30


Physical exerciseRestEnvironment Stress managementSocial supportUse of natural adjuncts Refraining from pressors & excessesExercising faith in God

Temperance: Ancient Concept,Modern Remedy….not only moderation in the good, but total avoidance of that which is harmful.

Recommendation…

Unless prescribed by your healthcare provider, generally

avoid any pressors

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These include:

▪Steroids

▪Birth control pills

▪Diet pills

▪Decongestants

▪NSAIDs

Medications That Can Raise Blood Pressure

If You are Taking a Prescription or OTC Non-narcotic Pain Reliever….

Exception:

Acetaminophen (Paracetamol; Tylenol), a pain-reliever that does not have anti-inflammatory properties.

It is likely you are using an NSAID

A 2011 Report in Cardiology Reviews

University of New Mexico researchers Snowden and Nelson found that:

“Non-steroidal anti-inflammatory drugs (NSAIDs)… through a variety of mechanisms related to prostaglandin inhibition, including sodium retention and vasoconstriction, these agents may increase blood pressure.”

Snowden S, Nelson R. Cardiol Rev. 2011 Jul-Aug;19(4):184-91.

Significance of NSAID Effects

▪ Small blood pressure increases in those with normal blood pressure

▪ averaging +1.1 mm Hg.

▪ Patients with treated hypertension have been reported to have elevations up to

▪ +14.3 mm Hg for systolic

▪ +2.3 mm Hg for diastolic BPSnowden S, Nelson R. Cardiol Rev. 2011 Jul-

Aug;19(4):184-91.

A 2011 Report in Cardiology Reviews

Snowden and Nelson concluded:

“If possible, patients who have hypertension should avoid taking NSAIDs.”

Snowden S, Nelson R. Cardiol Rev. 2011 Jul-Aug;19(4):184-91.

Alternatives to Pressors

Beware of NSAIDs! They can raise blood pressure

Consider alternatives:

▪ Hydrotherapy▪ Turmeric▪ Omega-3 fats▪ Boswellia

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Examples from Two Major Categories of Hypertensive Toxins

Mercury

Lead

Dioxins

Furans

• polychlorinated dibenzo-p-dioxins

(PCDDs)

• polychlorinated dibenzofurans

(PCDFs)

Heavy Metals

Persistent Organic Pollutants (POPs)

Arsenic

Cadmium

Polychlorinated biphenyls (PCBs)

Hexachlorobenzene (HCB)

Certain organochlorine pesticides (OCs)

Bisphenol A (BPA)

Heavy Metals as Pressors

In the year 2000, pediatricians worldwide were put on notice:

“Severe systemic arterial hypertension in infants and children is usually secondary to an underlying disease process… In children with severe hypertension and elevated catecholamines, the physician should consider mercury intoxication as well as pheochromocytoma.”

Torres AD, et al. Mercury intoxication and arterial hypertension: report of two patients and review of the literature. Pediatrics. 2000 Mar;105(3):E34.

Supplements Can Raise Blood Pressure

These include:▪ Licorice root▪Kava▪Ma Huang ▪Guarana▪Kola nut▪Ginseng ▪Yohimbine

© Keira from sxc.hu

Selected Herbs Associated with Elevated Blood Pressure

Arnica (Arnica montana) Kava (Piper methysticum)

Bitter orange (Citrus

aurantium)

Kola nut (Cola nitida and Cola

acuminata)

Ephedra or Ma Huang

(Ephedra sinica)Licorice (Glycyrrhiza glabra)

Ginkgo (Ginkgo bilboa) Senna (Cassia senna)

Ginseng (Panax quinquefolias

and Panax ginseng)

St. John's wort (Hypericum

perforatum)

Guarana (Paullinia cupana) Yohimbine (Pausinystalia

yohimbe)

Example: The Case of YohimbineIn 2010, Kearney and colleagues reviewed 238 adverse drug events related to yohimbine-containing products as reported to the California Poison Control System.

Kearney T, et al. Ann Pharmacother. 2010 Jun;44(6):1022-9.

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The Bottom Line

Unless you know definitely otherwise, any non-prescribed supplement should be viewed as a potential contributor to elevated blood pressure.


Physical exerciseRestEnvironment Stress managementSocial supportUse of natural adjuncts Refraining from pressors & excessesExercising faith in God

Faith in God: A Health-Enhancing

Practice

Spiritual Hope as a Remedy for Depression: A Hypertension Connection

• A systematic review identified eight studies relating the impact of depression on antihypertensive medicationadherence.

• A total of 42,790 patients were represented in those studies

• “All studies reported statistically significant relationships between depression and poor adherence to antihypertensive medications.”

Eze-Nliam CM, et al. J Hypertens. 2010 Sep;28(9):1785-95.

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