Rethinking Hypertension

Every so often, we doctors see a patient who surprises us. I experienced this recently when a perfectly fit, health-conscious 47-year-old woman came to me with a diagnosis of high blood pressure. I expect this diagnosis in junk-food-eating couch potatoes—not in someone who has worked out, taken yoga classes, and eaten a whole foods diet for years. She gave me a new appreciation for how sneaky hypertension can be.

Nicknamed the “silent killer” because it can cause injury without obvious symptoms—and, as this case reveals, without any apparent risk factors—hypertension can damage blood vessels and the heart itself.

Nicknamed the “silent killer” because it can cause injury without obvious symptoms—and, as this case reveals, without any apparent risk factors—hypertension can damage blood vessels and the heart itself. This damage sets us up for various forms of heart disease and strokes—the first and fourth most common causes of mortality in the United States. Hypertension also quietly and insidiously damages small blood vessels in the kidneys and eyes, which can lead to kidney failure and visual impairment.

The Centers for Disease Control and Prevention ranks hypertension as the most common primary diagnosis in the United States and estimates that 68 million Americans—roughly one of every three adults—have it. Ninety-five percent of the time there’s no clear cause (a condition called essential hypertension), but we do know that African Americans and people who are obese, consume too much processed food, drink too much alcohol, have diabetes, smoke cigarettes, have family members with high blood pressure, or have high stress levels face an increased risk for the condition.

How Did We Get to This Point?

Blood pressure normally varies throughout our day in response to exertion, speaking, and thinking. Measurements of the pressure in the upper arm when the heart is contracting (systole) and when it is relaxing and filling with blood (diastole) produce the two numbers you hear when someone takes your blood pressure.

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7), issued in 2003, states, “Most patients will require two or more anti-hypertensive medications to achieve goal blood pressure.”

Conventional treatment seeks to get blood pressure into what it calls the normal range—below 140/90, and ideally at or below 120/80 (read “one twenty over eighty”). To accomplish this, doctors urge patients to make lifestyle changes: a low salt diet, weight loss, and exercise. However, most doctors do not expect these adjustments to work. Therefore, the majority of hypertensive patients end up on at least one blood pressure lowering medication. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7), issued in 2003, states, “Most patients will require two or more anti-hypertensive medications to achieve goal blood pressure.” And once a patient starts taking medications, there is little push toward finding and correcting root causes—only to “manage” the condition.

While JNC7 touts 120/80 or less as the ideal pressure, lots of variations exist: Athletes and young women often have readings as low as 90/60, and elderly adults can register blood pressure in 160s/90s and not be in grave danger. Blood pressure rises naturally with age as our blood vessels lose some of their elasticity. For decades doctors simply added 100 to your age to arrive at your target systolic blood pressure, so a 130 reading at 30 could become 160 at 60 and be perfectly normal. Newer, more stringent guidelines have cast that rough measure aside and made high blood pressure in the aging population so common (JNC7 states that individuals who have normal blood pressure at age 55 have a 90 percent lifetime risk of developing hypertension) that many conventional docs just see it as part of the aging package. My parents, for example, who are quite active and healthy in their early 70s, were put on anti-hypertensive medications recently, partly because of these new guidelines and partly because of their doctor’s expectations.

It is hard to know what directs the modern medical world—some would say it’s the sale of pharmaceuticals, and that seems to be the case with high blood pressure treatment. (Nine of the 11 authors of the JNC7 had ties to major drug companies, as did 17 of the 18 panel members who established the 1999 World Health Organization hypertension treatment guidelines.) To assume that most hypertensives (which will be more than half of all people over the age of 60 under the current guidelines) will need two or more drugs to control their blood pressure seems outrageous on many levels. Especially after a study published this summer found that treating people with mild hypertension—defined as 140–159/90–99—and no prior cardiovascular events did not reduce total mortality, heart attacks, or stroke

While conventional medicine focuses on dietary salt reduction, there is little evidence that salt is actually the main problem. Numerous studies show that eating less meat and embracing a diet rich in beans, whole grains, vegetables, fruits, and low-fat dairy can drop blood pressure by 8 to 14 points.

But lest we throw the blood pressure meds out with the bathwater, let me say that they definitely have their place, especially in extreme cases. But as the first treatment option? Not so much. Instead, we should do what we can to support our body’s natural methods of maintaining healthy blood pressure levels. 

What You Can Do

Holistic approaches to high blood pressure include the same lifestyle modifications that conventional medicine advocates. However, integrative clinicians assess other risks and look to support the body in healing from this imbalance in multiple ways. Here are four steps to take now:

Eat a whole foods diet. While conventional medicine focuses on dietary salt reduction, there is little evidence that salt is actually the main problem. Numerous studies show that eating less meat and embracing a diet rich in beans, whole grains, vegetables, fruits, and low-fat dairy can drop blood pressure by 8 to 14 points, because such foods provide more minerals like potassium, magnesium, and calcium—all of which support normal pressure.

A whole foods diet also provides more fiber, which studies show lowers blood pressure by 4 to 6 points. That may seem insignificant, but drops in pressure this small are associated with a 40 percent reduction in the risk of stroke and a 25 percent decrease in heart attack risk.

Exercise, exercise, exercise.

Deep, slow breathing calms the parasympathetic nervous system, so alternate nostril breathing and 2:1 breathing can help counter chronic stress.

Studies have repeatedly shown that physical activity creates cardiovascular fitness: that is, a system that is strong and efficient. Multiple studies show an 11- to 16-point drop in pressure after 10 weeks of aerobic exercise for one hour three times a week. Choose aerobic activities that make you move and raise your breathing and heart rate, such as swimming, biking, jogging, running, and walking, or working out on an elliptical machine, treadmill, or stationary bicycle.

All of the recommendations above will help you lose weight, which may lower your blood pressure. Studies suggest that blood pressure can normalize completely after a 10 percent weight loss (e.g., if you weigh 200 pounds, lose 20 pounds).

Breathe. Deep, slow breathing calms the parasympathetic nervous system, so alternate nostril breathing and 2:1 breathing can help counter chronic stress. I also recommend that my patients practice a 10- to 15-minute relaxation in shavasana (corpse pose) or makarasana (crocodile pose) every day and for a few minutes before every meal. Not coincidentally, the only non-drug FDA-approved treatment for high blood pressure is a small personal biofeedback machine called RESPeRATE that coaches the user to deepen and slow her breath. Multiple studies have shown that 15 minutes of practice on this device most days of the week creates a significant decrease in blood pressure (14 to 18 points) over 4 to 8 weeks. The effect was sustained throughout the day, and the participants continued using the machine even after the study was completed (good compliance). For more info: resperate.com (no prescription needed).

Meditate. Multiple studies over decades have demonstrated the benefits of meditation on heart disease and blood pressure. Recently, The International Journal of Hypertension published an article that reported “clinically significant” reductions in both systolic and diastolic blood pressure from both transcendental meditation (TM) and mindfulness-based stress reduction (MBSR).

What You Can Take

A number of supplements can help the body maintain healthy blood pressure levels, but these four top the list:

Minerals. Imbalances or deficiencies in magnesium, calcium, and potassium can cause high blood pressure. Theoretically, we should get what we need from good quality food: calcium from dairy products, leafy greens, and sesame seeds; potassium from bananas, peas, beans, and squashes; and magnesium from nuts, pumpkin seeds, sunflower seeds, tofu, black beans, and quinoa.

Ayurveda and holistic medicine view high blood pressure as a pittic or fire energy imbalance. When we live our lives with too much intensity, too much focus and drive, we push our nervous systems into fight-or-flight mode all the time. This revved-up state can lead to chronically elevated blood pressure.

That said, many of us have too little of these essential minerals in our systems, either because we don’t eat well or our food comes from depleted soils. We have multiple reasons to be deficient in magnesium: phosphates and potassium in fertilizers bind to it in our soil, making it inaccessible to plants; fluoride leaches it from our drinking water; and it can also be bound up by the tannins, oxalates, and phytic acid in many foods. Nor is the body very good at storing this mineral. To make matters worse, diuretic hypertension medications increase urine flow, which causes the body to waste even more magnesium and potassium. (See “How Much Is Enough” on page 74 for recommendations on how you can maintain healthy levels of these three minerals.)

Vitamin D. Known more for its importance for calcium absorption and bone health, vitamin D also plays a role in maintaining blood pressure. To avoid the low levels linked to hypertension, supplement year-round with 1,000 to 2,000 IU daily, even in summer—unless you get 30 minutes of unfiltered (no sunscreen) sunlight, with much of your arms and legs uncovered, three to four times a week, so your body can make its own vitamin D.

Coenzyme Q10. CoQ10, a substance made in every cell, facilitates the production of energy. About 40 percent of people with high blood pressure have too little of this essential substance, either because of old age, chronic disease, the cholesterol-lowering statin drugs, inflammatory processes, or nutritional deficiencies, especially of omega-3 fats. Studies have shown that rebuilding CoQ10 levels over 4 to 12 weeks can lower blood pressure significantly (6 to 19 points). The standard dose is 100 mg daily in divided doses taken with a fatty meal or a snack. One to two grams of fish oil three times a day can help the body make CoQ10 as well.

Adaptogenic herbs. Ayurveda and holistic medicine view high blood pressure as a pittic or fire energy imbalance. When we live our lives with too much intensity, too much focus and drive, we push our nervous systems into fight-or-flight mode all the time. This revved-up state can lead to chronically elevated blood pressure. To counter this, holistic medicine suggests taking adaptogenic herbs, which will nourish and strengthen the nervous system and the adrenal glands—the source of the fight-or-flight hormones—when they are taxed by stress. Ayurveda, traditional Chinese medicine (TCM), and Western herbalism have identified dozens of these herbs, the more prominent being ashwagandha, licorice, rehmannia, American and Chinese ginseng, eluthero (Siberian ginseng), rhodiola, and schisandra. These herbs can be taken together in combinations such as Bupleurum D Formula (Chai Hu Jia Long Gu Mu Li Tang); Essential Yang Formula (Jia Jian Jin Gui Shen Qi Wan); or Ginseng Nourishing Formula (Ren Shen Yang Ying Wan) tincture or capsules two to three times a day for several weeks. You may want to consult an herbalist, a TCM practitioner, or a naturopath to find a formulation that best suits you.

How Much Is Enough?

Magnesium salt chelates (magnesium citrate or magnesium malate) are fairly well absorbed and can be taken at 3 to 10 mg per pound of body weight (450 mg for a 150-pound person) in divided doses, morning and afternoon. If a laxative effect is achieved (a sign that it is not being well absorbed), halve the dose, take with food, or find a more absorbable form (amino acid chelates like magnesium glycinate or magnesium taurate; or liquid minerals—all more expensive).

Calcium is best taken in its more absorbable forms: calcium citrate or calcium gluconate, 800 to 1,000 mg per day in divided doses. (A recent study linking calcium supplements to heart disease now has everyone rethinking the wisdom of high-dose calcium).

Potassium is most easily acquired through diet since it is so plentiful in the plant world (Swiss chard, spinach, yams, and papayas are tasty sources). However, if you are uncertain of your intake, you can try potassium chloride or aspartate, 1.5 to 3 grams per day, or 20 to 33 milliequivalents (mEq). Too high a dose can cause nausea, vomiting, diarrhea, and ulcers, so you may want to confer with your doctor.

 If you are currently taking anti-hypertensive medications, don’t stop them suddenly. This can cause your blood pressure to rebound to life-threatening levels. Instead, incorporate the lifestyle suggestions here, and, in time, you and your healthcare provider can wean you from the medications.