High blood pressure (hypertension), in short

Mr. Jones, a fifty-four year old man, had been into the office several times in the last year. He was reasonably thin, walked regularly, and felt great. Each time his blood pressure was slightly elevated, around 142/84. Each time I reminded him of the importance of blood pressure control.

He was already on blood pressure medications, but he was resistant to the idea of taking more medication. I knew though that, despite his protests, his diet (as he was a bachelor) was loaded with salt and that he could possibly control his blood pressure simply by lowering the salt in his diet. Each visit we discussed the sources of sodium in his diet, and I encouraged changes.

Otherwise, I told him, we needed to increase his blood pressure medications. A mild elevation in his blood pressure would unlikely kill him in the near future, but an increased risk of a stroke or a heart attack over time was real. Each time he reassured me that he would start watching the sodium in his diet and get his blood pressure under control.

In the end the decision on what to do was his, but short of twisting his arm I strongly pushed for changes. How important to him was the salt in his meals? While life is not only about quantity (years lived) but also the quality of those years, perhaps he was able and willing to make a few simple lifestyle changes. I couldn’t say that better blood pressure control would necessarily prevent a heart attack or stroke (we all have to die of something), but it would certainly lower his risk and potentially delay the possibility.

Several months later at his next appointment Mr. Jones, a statistician, returned with excitement. To my surprise and admittedly even to his own surprise, he finally decided to heed my advice.

Statistically significant

He started looking at the labels of foods, and he was amazed by how much sodium was in just about everything he ate. He then didn’t just reduce his sodium intake, but he decided to test the hypothesis and followed his blood pressure over several months with the same care and exactness with which he had done everything in his life. Once he had collected enough blood pressure readings, he performed a full statistical analysis and was surprised to discover, as he said, that not only was his doctor right but how much cutting down on sodium lowered his blood pressure.

Hypertension as a silent killer

While hypertension occurs in over half of people over sixty-five years of age, it is actually quite prevalent in the population as a whole. Population data from the United States around the year 2000 suggest that hypertension is present in about one third of people eighteen years and older.

What are the symptoms of high blood pressure? None. How do patients with high blood pressure feel? Great.

Because there are no symptoms, people often don’t know that they have hypertension, and once diagnosed the lack of symptoms and lack of immediate risks add to people’s poor compliance with treatment. The problem is that blood pressure elevations, even mild elevations, are associated with significant medical problems: heart disease (such as thickening of the heart, heart attacks, and heart failure), strokes, bleeding strokes, and kidney failure.

The risks of high blood pressure, including death, are correlated with the degree of elevation. The risk lies as a continuum on blood pressure readings. There is no magical blood pressure; the body doesn’t know numbers. The risks are also not immediate, except in special circumstances, but cumulative over time.

What is the number one risk of death to man or woman in the United States? Prostate cancer? Breast cancer? Colon cancer? By far, heart attacks and strokes.

“So my blood pressure is elevated. I’ve had high blood pressure all my life. That’s just the way my body is...”

That nothing has happened to you does not mean you are healthy and that something won’t happen. High blood pressure is a high-stakes numbers game. That you’ve walked into the middle of traffic without looking and weren’t killed doesn’t mean that it’s safe or that if you continue to do so that you won’t be hit and killed the next time you venture out.

Things worse than death…

In fact, getting killed instantly is not necessarily a bad way to pass, but as in motor vehicle accidents that’s not usually what happens with high blood pressure. Living with a disability the rest of your life (such as not being able to move the right side of your body and needing someone to feed you and wipe you, not being able to talk, or not being able to walk three feet without stopping due to shortness of breath) – feeling terrible and not being able to do the activities you want to do with your friends and family – that is the typical consequence and misery of poorly controlled hypertension.

Causes of blood pressure

There are numerous causes of hypertension. The most common by far, the one most people think about when hypertension is mentioned, is called essential or primary hypertension (high blood pressure not due to other identifiable causes), and is the focus of this entry. Other explanations for high blood pressure include white coat hypertension (being in the doctor’s office), medicines such as oral contraceptives, kidney diseases, sleep apnea, and thyroid and other endocrine abnormalities. Ruling out these secondary causes is part of a doctor’s initial evaluation of a patient’s hypertension.

Am I doomed?

Thankfully there are therapies to lower blood pressure, and plenty of studies show that lowering blood pressure significantly reduces risks. Clinical trials suggest mean reductions of a quarter to a third of strokes or heart attacks with control of blood pressure. The benefits are generally seen with long-term reductions in blood pressure; however, the elderly, given their overall greater risk, are more likely to benefit even from short term reductions in blood pressure.

Many medications are available to lower blood pressure (including various diuretics, ACE inhibitors, angiotensin receptor blockers - ARBs, calcium channel blockers and beta blockers), but lifestyle changes, such as Mr. Jones’ reduction in dietary sodium, can have significant effects on blood pressure. Lifestyle changes, in fact, are recommended as the first treatment option in people with mild hypertension. Only when a patient has failed lifestyle changes are medications recommended, according to national guidelines.

Despite doctors being well aware of these guidelines and the importance of lifestyle changes for their patients, doctors find themselves over time reaching more often and sooner for medications. Doctors, after seeing many failed attempts at lifestyle changes, may come to expect the next patient to fail as well. They may fear patients will not follow-up in a timely way and instead be left with poorly controlled blood pressure. Then, not only is the patient exposed to health risks, but the doctor fears his own malpractice risks. In addition, to counsel a patient on diet and exercise and changing habits is time consuming. In the age of insurance-imposed short visits, doctor usually don’t have the time to properly or effectively do so. Giving a pill is much easier. Patients faced with their own monetary and time constraints often cannot make the frequent visits to the doctor needed for this approach.

Lifestyle changes are not easy to make. Losing weight or getting used to lower levels of salt requires a focus and commitment. Patients are typically motivated to improve their health and make changes on first being diagnosed with high blood pressure, but the commitment tends to wane. Taking a pill is much easier.

Lifestyle changes, however, are key. Possible lifestyle changes include but are not limited to cutting down on dietary sodium, losing weight, aerobic exercise, avoiding excessive alcohol intake, and better handling stress. While each have an impact on blood pressure and your health, together they have a much greater impact.

Doctors treat high blood pressure because doctors can easily measure it and treat it. Taking a medicine to lower your blood pressure may be effective in lowering your blood pressure, but it does nothing for the other chemical changes occurring in your body that doctors do not routinely measure and that are detrimental to your health. Hypertension for many people is merely a sign of more significant underlying health issues developing from a poor diet, little exercise, and excess weight. The analogy frequently used is that of the tip of the iceberg with the remainder of the massive iceberg underwater and out of view.

Dietary sodium

Sodium clearly plays a role in high blood pressure as hypertension is mainly seen in societies in which people eat more than 2.3 g of sodium per day. The excess sodium intake over many years is thought to play a role. In societies in which people take in less than 1.2 g sodium per day, hypertension is actually rare.

Lowering dietary sodium intake lowers blood pressure. Some people are more sensitive to changes in dietary sodium intake, but on average the drop in blood pressure is about 5 points (mm Hg). The full effect is generally seen within a month, with other further benefits over the long term.

Where is the sodium in your diet? Everywhere. Any food you haven’t made yourself is loaded with salt. Virtually all prepared foods, frozen dinners, soups, restaurant meals, condiments, and sauces for instance are loaded with sodium. Even foods labeled “low sodium” have excessive amounts of sodium. Even food in the local hospital cafeteria has way too much sodium. (Beware: any food that is truly low in sodium is probably high in sugar or fat.) Food companies are in the business of selling food, and salt enhances flavor.

To all those that love salt in their meals and can’t imagine living without it, the taste of salt is a habit. The more salt you regularly have in your meals the more you’ll want and vice versa. You have to be willing to let your taste buds adjust over time.

Just a little overweight

Being overweight is thought to contribute to about a quarter to a third of cases of high blood pressure, and being overweight not only increases your risk of high blood pressure but also your risk of diabetes mellitus, high LDL cholesterol, low HDL cholesterol, and a thickened heart among other medical issues.

Not unexpectedly there are benefits to your blood pressure from losing weight. In those with high blood pressure, one study showed that a 10 percent reduction in weight resulted in a 4 point (mm Hg) drop in blood pressure. Other studies demonstrate 5-20 mm Hg drops in blood pressure for each 10 kg of weight loss. In overweight individuals a sustained loss of weight results in a lower risk of developing hypertension down the road.

Note that even by eating less you will be reducing your sodium content, but the benefits of weight loss are independent of the reduction in sodium intake.

Exercise

Regular, continued aerobic exercise lowers blood pressure about 5 mm Hg, and certainly exercise has other benefits, including weight loss, a lower cholesterol, an increase in HDL (good cholesterol), and a decrease in overall mortality. (All the benefits of exercise, countless – a discussion for another entry.)

Alcohol

Although there appears to be a health benefit from small amounts of alcohol, alcohol consumption is another example of when more is not necessarily better. There is a clear association between excess alcohol intake and health risks including hypertension, independent of its extra calories and the associated extra weight. A maximum of one drink per day is recommended for women, two drinks per day for men.

Personality traits and stress

Stress and personality traits have been implicated in high blood pressure but a direct link is difficult to prove. There is a concern, however, that while their effects on blood pressure and the body in the short term may be reversible, that over time they may result in chronic, physiological changes.

And to those without high blood pressure, are there benefits from lifestyle changes?

In people with normal blood pressure, the decrease in blood pressure from lifestyle changes are small, but even small changes could over long periods possibly have benefits as well. To the degree that people are able and willing to make changes, there is no reason for them not to do so.

So…

So while there is clearly more to be said about high blood pressure, hopefully this will induce people to have their blood pressure checked and managed – not only with medications but also with lifestyle changes. How to make change (changing habits) is also a discussion for another entry…

What other questions about high blood pressure do people have that perhaps their doctors haven’t discussed with them?