Elevated blood pressure Dr. Heidi Fritz 1 October 2013 Elevated blood pressure - A naturopathic approach By: Heidi Fritz MA, ND Bolton Naturopathic Clinic 64 King St W, Bolton, ON L7E1C7 www.boltonnaturopathic.ca email@example.com Jump to: Part 1 Part 2 Part 3Part 4 Part I: High Blood Pressure High blood pressure, medically known as hypertension, is a well-recognized risk factor for cardiovascular disease, including stroke, angina, and heart attack, as well as other complications such as kidney disease and eye disease.(1) It is important to control high blood pressure from the outset in order to reduce your long-term risk for these diseases. Normal blood pressure is considered to be between 90/60 on the low end, and 120/80 on the high end. High blood pressure is diagnosed after two separate readings done in office with your physician, in which the value reads greater than or equal to 140/90. The two numbers in a blood pressure reading refer to the pressure in the arteries a) when the heart is contracting and b) when the heart is relaxing. This pumping action results in a wave-like pattern of pressure through the arteries, and results in a flux of high pressure values (systolic blood pressure) and lower blood pressure values (diastolic blood pressure). Think of blood pressure as a long hose with high water pressure inside it. If blood pressure is too high, over time it leads to damage to the blood vessels, as well as heart damage due to having to pump harder against so much pressure. Readings between 120/80 (upper range of normal) and 140/90 (lower limit for diagnosis of high blood pressure) are considered borderline, and serve as a warning sign that lifestyle changes may be necessary to prevent progression to hypertension. Furthermore, borderline readings are one of the criteria for the metabolic syndrome, which is in fact associated with increased risk of heart disease.(2) High blood pressure is normally treated with a combination of one or more medications. These include diuretics (so called “water pills”), as well as medications called ACE inhibitors, calcium channel blockers (CCBs), and angiotensin receptor blockers (ARBs). Nutritional and lifestyle strategies are also an important aspect of blood pressure control, especially as for many people, they can correct underlying problems contributing to the problem, such as obesity, poor diet, inactivity, and poor stress management. The American Heart Association has stated that “It is the consensus of the writing group that it is reasonable for all individuals with blood pressure levels >120/80 mm Hg to consider trials of alternative approaches as adjuvant methods to help lower blood pressure when clinically appropriate”.(3) In this series we will discuss the role of diet & lifestyle, nutritional supplements, and meditation as ways to help control elevated blood pressure. References : 1. Rosendorff C. Hypertension and coronary artery disease: a summary of the American Heart Association scientific statement. J Clin Hypertens (Greenwich). 2007;9(10):790-5. 2. Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005;112(17):2735-52. 3. Brook RD, Appel LJ, Rubenfire M, Ogedegbe G, Bisognano JD, Elliott WJ, et al. Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the american heart association. Hypertension. 2013;61(6):1360-83. Elevated blood pressure - A naturopathic approach Part II: Diet & Exercise for High Blood Pressure By: Heidi Fritz MA, ND Bolton Naturopathic Clinic 64 King St W, Bolton, ON L7E1C7 www.boltonnaturopathic.ca firstname.lastname@example.org In Part I, we reviewed the definition of hypertension and some of its long term consequences if left untreated. We also saw that dietary & lifestyle strategies are well recognized for their role in helping prevent and treat this condition. In this section, we will discuss the role of the DASH diet as well as exercise in controlling blood pressure.(1) The Dietary Approaches to Stop Hypertension diet, otherwise known as the DASH diet, is a dietary pattern limiting sodium, saturated and trans fat, and cholesterol, while emphasizing whole foods high in fibre and other nutrients, such as whole grains, fruits and vegetables, lean protein such as fish and chicken, nuts and legumes, and low fat diary products.(2) Specifically, sodium should be limited to <2300mg per day; in high risk populations, such as those who already have hypertension, or for African Americans, sodium should be limited to <1500mg per day.(2) In addition, on the DASH diet, at least five servings each of fruits and vegetables are recommended. According to the Mayo Clinic, following the DASH diet can lower blood pressure by up to 12 points, similar in effect to that of an entry level medication.(2) Studies on the DASH diet show similar effects. In a study of 459 adults with blood pressure under 160/95, following the DASH diet for eight weeks results in a lowering of blood pressure equal to 5.5/3.0 points.(1) This is impressive because this group also included people with normal blood pressure. When only those people with high blood pressure were analysed, the drop was much larger: on average, blood pressure was reduced by 11.6/5.3 points! In addition, since African Americans are at higher risk for hypertension, the results were also analysed by ethnic group: blood pressure was reduced by 6.9/3.7 points in African Americans, and by 3.3/2.4 points in Caucasians. Clearly, dietary strategies can have a large impact on blood pressure control Regular physical activity is also crucial in lowering high blood pressure. In a study of elderly patients medicated for hypertension, an exercise program of combined aerobic and strength training for a period of six months significantly improved walking distance, muscle strength, and lowered both systolic and diastolic blood pressure.(3) The program was structured so that it was done three times per week, with one day of rest in between each session. In the PREMIER study, a randomized clinical trial, researchers assessed the effect of combining sodium and alcohol restriction, weight loss, and physical exercise on lowering high blood pressure.(4) A total of 810 participants with above-optimal blood pressure but not yet on medication were included. At the beginning of the study, 38% of the study participants had high blood pressure, while others had borderline high blood pressure. After six months in the combined intervention, only 12% of participants still had high blood pressure. In Part III, we will address the role of nutritional supplementation in managing high blood pressure. References : 1. Sacks FM, Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, et al. A dietary approach to prevent hypertension: a review of the Dietary Approaches to Stop Hypertension (DASH) Study. Clin Cardiol. 1999;22(7 Suppl):III6-10. 2. The Mayo Clinic. DASH diet: Healthy eating to lower your blood pressure. Updated 13 July 2013. URL: http://www.mayoclinic.com/health/dash-diet/HI00047 Accessed 20 Sept 2013. 3. Guirado GN, Damatto RL, Matsubara BB, Roscani MG, Fusco DR, Cicchetto LA, et al. Combined exercise training in asymptomatic elderly with controlled hypertension: effects on functional capacity and cardiac diastolic function. Med Sci Monit. 2012;18(7):CR461-5. 4. Appel LJ, Champagne CM, Harsha DW, Cooper LS, Obarzanek E, Elmer PJ, et al. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA. 2003;289(16):2083-93. Elevated blood pressure - A naturopathic approach Part III: Nutritional Supplementation for High Blood Pressure By: Heidi Fritz MA, ND Bolton Naturopathic Clinic 64 King St W, Bolton, ON L7E1C7 www.boltonnaturopathic.ca email@example.com In previous sections, we discussed the role of diet and exercise programs in management of hypertension. We have seen that these can have an impact comparable to that of an entry-level blood pressure medication, and can even return blood pressure to normal in those with early stage disease. In this section, we will address the role of select nutritional supplements in further lowering blood pressure where appropriate. Coenzyme Q10 is perhaps the best- studied natural agent in the context of blood pressure control. Coenzyme Q10 improves something called “endothelial function.” The endothelium consists of the inner layer of cells lining the arteries and blood vessels. The endothelial cells secrete chemical substances such as nitric oxide that signal to the blood vessel muscle layer to relax. Coenzyme Q10 also help strengthen the muscle pumping ability of the heart by helping the heart muscle produce more energy. A meta analysis of 12 clinical trials of 362 participants showed that coenzyme Q10 supplementation in the range of 200-300m per day can reduce systolic blood pressure (the top number) by up to 16 points compared to placebo.(1) Diastolic blood pressure (the bottom number) was reduced by over 9 points.(1) Hibiscus is another natural agent with impressive documented effects on blood pressure.(2,3) Hibiscus is one our favourite agents here at Naturopathic Currents, and our regular readers will notice that is has been mentioned often in regards to metabolic syndrome, diabetes, cholesterol, and blood pressure. Studies have shown that consumption of three 240-mL cups of tea per day for six weeks lowered blood pressure by over 7 points for systolic BP and 3 points for diastolic in patients with mild hypertension.(2) Another study found that hibiscus was able to lower systolic blood pressure from an average of 146 to 129 (difference of 17 points) in subjects with stage I-II hypertension.(2) Another novel, lesser-known but studied agent for lowering blood pressure is lycopene. Lycopene is a tomato compound an antioxidant better known for its effects on the prostate, however a couple of studies have begun investigating its effects in humans for high blood pressure.(4,5) In one study, 31 participants with stage I hypertension were given the lycopene containing tomato extract, Lyc-O-mato 250mg per day for eight weeks.(4) Systolic blood pressure decreased from 144 to 134 points, and diastolic blood pressure decreased from 87 to 83 points, compared to no changes in the placebo group. A second study found patients who were medicated but not adequately controlled for their hypertension.(5) It is important to have your physician monitor your blood pressure while you are adding therapies, natural or pharmaceutical, to your regimen. Blood pressure that is below 90/60 can lead to dizziness or falls. Although natural agents typically do not lower blood pressure to abnormal levels, it is nevertheless prudent for people who may be on medication to monitor any changes; this will help you monitor therapeutic change as well as safety. In Part IV we will discuss the role of meditation in managing blood pressure. References : 1. Rosenfeldt FL, Haas SJ, Krum H, Hadj A, Ng K, Leong JY, et al. Coenzyme Q10 in the treatment of hypertension: a meta-analysis of the clinical trials. J Hum Hypertens. 2007;21(4):297-306. 2. McKay DL, Chen CY, Saltzman E, Blumberg JB. Hibiscus sabdariffa L. tea (tisane) lowers blood pressure in prehypertensive and mildly hypertensive adults. J Nutr. 2010;140(2):298-303. 3. Herrera-Arellano A, Miranda-Sánchez J, Avila-Castro P, Herrera-Alvarez S, Jiménez-Ferrer JE, Zamilpa A, et al. Clinical effects produced by a standardized herbal medicinal product of Hibiscus sabdariffa on patients with hypertension. A randomized, double-blind, lisinopril-controlled clinical trial. Planta Med. 2007;73(1):6-12. 4. Engelhard YN, Gazer B, Paran E. Natural antioxidants from tomato extract reduce blood pressure in patients with grade-1 hypertension: a double-blind, placebo-controlled pilot study. Am Heart J. 2006;151(1):100. 5. Paran E, Novack V, Engelhard YN, Hazan-Halevy I. The effects of natural antioxidants from tomato extract in treated but uncontrolled hypertensive patients. Cardiovasc Drugs Ther. 2009;23(2):145-51. Elevated blood pressure - A naturopathic approach Part IV: Meditation for High Blood Pressure By: Heidi Fritz MA, ND Bolton Naturopathic Clinic 64 King St W, Bolton, ON L7E1C7 www.boltonnaturopathic.ca firstname.lastname@example.org In earlier sections, we reviewed the role of the DASH diet, exercise, and select nutritional supplements as ways to naturally help lower hypertension. In this section, we will discuss an often- neglected topic: stress reduction through the practice of medication. Perhaps surprisingly to some, this has also been a well studied area, and deserves to be addressed as another lifestyle foundation for managing high blood pressure. In one study, a total of 52 participants with no previous meditation experience were randomized to eight weeks of contemplative meditation or no intervention.(1) These subjects had systolic blood pressure of over 140 but under 180 points (stage I-II). All subjects received one session of lifestyle counselling as recommended by current guidelines. Then, in the contemplation group, two 40-Min sessions were held in the early morning and the evening. The first phase (10–12min) prepared the participants for the session and focused on breathing exercises, with slow abdominal breathing to achieve a general muscle tension release. The second phase (30min) dealt with exercising various meditation techniques. Impressively, this study reported that after eight weeks, not only was average in-office systolic blood pressure reduced by 15 points, but participants blood pressure responses to stressful situations was reduced. In the no treatment group, there was just a 3 point reduction in average systolic blood pressure. At follow-up, 75% of the subjects in the CMBT group but none of the controls had office BP levels <130/80. Under a simulated situation of mental stress, blood pressure in the participants who had done the mediation program was 11 points lower than that of control subjects. Other forms of meditation, yoga, and breathing exercise have reported similar effects. Studies of transcendental meditation and yoga meditation have showed reductions in blood pressure of up to 9 points.(2,3) In African American youth, a program of breathing awareness meditation (BAM) was shown to reduce blood pressure by approximately 5 points, and also reduce urinary sodium excretion.(4) A recent meta analysis of 17 studies of yoga practice found that yoga had “a modest but significant effect on systolic blood pressure [approximately 4 points] and diastolic blood pressure (DBP) [approximately 4 points]”.(5) Elements of the technique which were associated with benefit on blood pressure appeared to include postures, meditation, and breathing.(5) In conclusion, we see that a comprehensive approach incorporating foundational diet and lifestyle strategies, rounded out with nutritional supplementation and mediation/ breathing exercises known to reduce the effects of stress on the body can have an important role in controlling high blood pressure. References : 1. Manikonda JP, Störk S, Tögel S, Lobmüller A, Grünberg I, Bedel S, et al. Contemplative meditation reduces ambulatory blood pressure and stress-induced hypertension: a randomized pilot trial. J Hum Hypertens. 2008;22(2):138-40. 2. Wenneberg SR, Schneider RH, Walton KG, Maclean CR, Levitsky DK, Salerno JW, et al. A controlled study of the effects of the Transcendental Meditation program on cardiovascular reactivity and ambulatory blood pressure. Int J Neurosci. 1997 Jan;89(1-2):15-28. 3. Chung SC, Brooks MM, Rai M, Balk JL, Rai S. Effect of Sahaja yoga meditation on quality of life, anxiety, and blood pressure control. J Altern Complement Med. 2012 Jun;18(6):589-96. 4. Barnes VA, Pendergrast RA, Harshfield GA, Treiber FA. Impact of breathing awareness meditation on ambulatory blood pressure and sodium handling in prehypertensive African American adolescents. Ethn Dis. 2008;18(1):1-5. 5. Hagins M, States R, Selfe T, Innes K. Effectiveness of yoga for hypertension: systematic review and meta-analysis. Evid Based Complement Alternat Med. 2013;2013:649836.