Drugs Don't Work If You Don't Take Them? DUH!

High blood pressure patients who don't take their medications are at major risk of medical complications, according to a new report in the journal Circulation. 

Sure, drug therapy can be exensive and have bothersome side effects.  Medical skeptics invoke Big Pharma conspiracy theories to impugn physician motives for prescribing.  But there's little doubt that blood pressure drugs are effective in reducing rates of cardiovascular events such as heart attacks, strokes, and cardiac deaths.

Italian primary care physicians followed almost 19,000 newly diagnosed high blood pressure patients over the course of five years.  Average age was 62 and they were free of heart disease and strokes at baseline.  One or more drugs for daily use were prescribed.  Adherence to the medication regimen was noted as either high (taking the drugs at least eight of every 10 days), intermediate (taking drugs four to eight of every 10 days), or low (taking drugs less than four of every 10 days). 

Guess how many patients were in the low adherence group . . . . . . . . . . half of them!  Compliance may not be much different in the U.S. 

Compared with the low adherence group, the high adherence group had 38% fewer cardiovascular events such as heart attacks, chest pain, strokes, and heart-related deaths. 

The lesson is clear: If you have high blood pressure and want to reduce the associated medical risks, take your drugs. 

-Steve Parker, M.D.

References: 

Mazzaglia, G., et al.  Adherence to antihypertensive medications and cardiovascular morbidity among newly diagnosed hypertensive patients.  Circulation, 120 (2009): 1598-1605.  Published online ahead of print October 5, 2009

Lowry, Fran.  High adherence to antihypertensive therapy lowers cardiovascular risk.  TheHeart.org, October 9, 2009.

Salt Restriction: Good In Theory, But Impossible to Implement?

Reducing salt intake might be a good idea, but it may not matter since our bodies have irresistible physiologic mechanisms to defend a higher level of salt intake, according to a new report in the Clinical Journal of the American Society of Nephrology.

Another push to lower salt (actually, sodium) intake in the American public started a few years ago.  The idea is that sodium restriction will lower blood pressures, leading to fewer heart attacks and strokes.  That proposition itself is debatable.  The medical/nutrition community hotly debated it 20 years ago.  There are reasonable arguments on both sides.

The authors of the study at hand don't address whether sodium restriction would be healthful.  They question whether any measures at the public health level can even work.  Their answer: probably not.

The Institute of Medicine in 2003 recommended 2,300 mg/day as the upper limit of dietary sodium.  The USDA's 2005 Dietary Guidelines recommend 1,500 mg/day for people at risk of hypertension.

The authors conclude that the average person has powerful physiologic mechanisms working to keep sodium intake around 3,000 mg/day, at least. 

They studied the salt consumption of widespread, diverse populations, including those who were carefully instructed and motivated to reduce salt intake.  In this case, it seems you just can't fight Mother Nature.

I think perhaps two of every 10 people may have blood pressures sensitive to salt intake.  Let's try to identify and target them for intervention rather than attempting sweeping societal changes that affect us all.

If I had elevated blood pressures, I'd make an attempt to reduce my sodium intake over a two or three month trial and note the effect.  You can calculate and monitor your sodium intake with NutritionData's "My ND/My Tracking" feature.  I'd also start exercising regularly and lose my excess body fat.

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

References:  McCarron, David, et al.  Can dietary sodium intake be modified by public policy?  Clinical Journal of the American Society of Nephrology.  4 (2009): 1,878-1,882.

Will Mercury in Fish Make You "Mad as a Hatter"?

A new study published in Hypertension suggests that mercury in consumed fish may raise blood pressure, a risk factor for heart disease.  Readers of this blog may recall that I advocate fish consumption for its heart-healthy benefits. 

The news was covered by HealthDay (MedlinePlus), who quotes the lead investigator, Dr. Eric DeWailly, saying, " For every 10 percent increase in blood mercury level, there is a 0.2 millimeter increase in blood pressure.  Even if you apply that to an entire population, that is a small effect."

I agree!  I wouldn't worry about it.

But the report reminded me of the fear of mercury poisoning that inhibits fish consumption by a number of people.  Mercury toxicity is potentially much more dangerous than these tiny blood pressure elevations among Inuit with very high fish consumption.

What does mercury poisoning - methylmercury, actually - from fish look like in an adult? It mainly affects the nervous system and kidneys. 

The central nervous system would be affected first: numbness or tingling around the mouth, malaise, loss of peripheral vision, hearing loss, unsteady gait. You could see one of these, or all.   Later, the kidneys start losing protein into the urine, leading to nephrotic syndrome: swollen legs, fluid retention, and low blood albumin level. 

Remember The Mad Hatter in Alice in Wonderland?  Felt hat makers formerly used mercury in the manufacturing process.  Severe poisoning with mercury, usually by inhalation, can cause psychiatric changes including insanity or "madness."  Mercury poisoning from fish won't make you go crazy.

How common is fish-related mercury poisoning in the U.S.?  In over 20 years of practice, I've never seen a case of it.  Nor have the physicians in my circle of colleagues.  And I worked on the Gulf Coast for twelve years.  If you think you may have mercury poisoning, have your doctor check a blood or urine level. 

For more information on mercury, visit MedlinePlus.

Also search Monica Reinagel's Nutrition Data Blog.  She's written extensively about fish, including Fishing for Answers.

-Steve Parker, M.D.

Reference: DeWailly, Eric, et al.  Environmental mercury exposure and blood pressure among Nunavik Inuit adults.  Hypertension online October 5, 2009.  doi: 10.1161/HYPERTENSIONAHA.109.135046 

Higher Whole Grains, Lower Blood Pressure

Whole grain consumption is linked to lower risk of high blood pressure in men, according to the current issue of American Journal of Clinical Nutrition. 

Harvard researchers studied over 31,000 men in the Health Professionals Follow-Up Study over the course of 18 years.  At the time of enrollment in the study, the men were free of high blood pressure.  Over 18 years, 9,200 developed high blood pressure.

Compared with men eating the very least amount of whole grains, the men in the highest consumption category had a 19% lower rate of high blood pressure. 

The Womens' Health study found evidence for a similar anti-hypertensive action of whole grains in women.

A meta-analysis published last year looked at whole grain consumption and cardiovascular disease, which includes heart attacks and strokes.  Compared with low intake, people with high intake (2.5 servings a day) had 21% lower risk of cardiovascular disease events, such as heart disease, stroke, and death from cardiovascular disease.  Refined grain intake, such as standard white bread, was not associated with cardiovascular disease one way or the other.

These associations of whole grain consumption and lower cardiovascular disease rates don't prove the whole grains prevent cardiovascular disease.  Proof would require a 10-year study involving 20,000 people, half of whom are forced to eat whole grains, and the other half must abstain.  I'm not holding my breath;  I'm inclined to eat whole grains now.

Very often we have to make food decisions before we have all the information we'd like.

For those interested, I've also written about unusual diet modifications to lower blood pressure, and, of course, the DASH diet for lowering blood pressure. 

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

References: 

Flint, Alan, et al.  Whole grains and incident hypertension in men.  American Journal of Clinical Nutrition, 90 (2009): 493-498.

Mellen, Philip, et al.  Whole grain intake and cardiovascular disease: A meta-analysis.  Nutrition, Metabolism & Cardiovascular Diseases, 18, (2008): 283-290.

Coffin Nails and Cancerettes: Stop Smoking Already!

Of all the ways smoking can kill you, heart disease is the leader.  Smoking causes death by heart attack, stroke, lung cancer, emphysema, and chronic obstructive pulmonary disease, to name a few. 

How does smoking cause heart disease?  Let me count the ways:

1. Speeds up atherosclerosis (hardening of the arteries)
2. Increases our blood's tendency to clot (clotting plays a major role in heart attack and stroke)
3. Raises blood pressure
4. Decreases oxygen delivery to the heart, a muscle that beats 100,000 time every day, year after year

According to the American Heart Association, smoking is the number one cause of preventable death in the U.S., accounting for almost 440,000 deaths yearly.  By contast, only 40,000 people die from motor vehicle accidents. 

Let's do a thought experiment.  Say you're a 30-year-old cigarette smoker of one or two packs a day and eating an average American diet.  You want to "get healthier" - avoid disease, feel better, have more stamina, and live longer.  Which of the following healthy lifestyle choices would pay the greater dividend:

1. Eat healthier? . . . OR . . .
2. Stop smoking?

DING! DING! DING! DING!  Congratulations if you picked curtain No. 2!  You're right!  [I knew you were smart because your're at NutritionData.com.]

If you or someone you love is ready to quit smoking, visit the Smoking Cessation Health Center at WebMD.com. 

-Steve Parker, M.D.

Which Drug is Best to Lower Blood Pressure?

Which anti-hypertensive drug is best?  In other words, which drug is best at preventing hypertension-related outcomes, such as heart attacks, strokes, and death, while minimizing adverse drug effects?  All five major drug classes are pretty good, according to a recent article in the British Medical Journal.

Contrary to popular belief, physicians do not choose drugs based on the recommendation of the cute drug rep ("pharmaceutical representative") who brought lunch and free pens to the office last week.

U.K. researchers re-examined 147 separate studies that looked at blood pressure-lowering drugs mostly in people who had high blood blood pressure, but also in people using the drugs for other reasons.  The drug trials involved 464,000 patients.

The five major classes of anti-hypertensive drugs are:

• thiazides (example: hydrochlorothiazide)
• angiotensin-converting-enzyme (ACE) inhibitors (example: lisinopril)
• beta-blockers (example: metoprolol)
• calcium-channel blockers (example: amlodipine)
• angiotensin-receptor blockers (example: losartan)

Compared with placebo or no treatment, these drugs were associated with 13% lower risk of death from any cause.  They drugs reduced stroke rates by 41%, and heart attacks and sudden cardiac death by 22%.  With the exception of a few beta-blockers (called "non-cardioselective"), they all lessened the risk of heart failure. 

Two classes of drugs dominated the others in two situations:

1. For people with a heart attack in the last two years, beta-blocker users had better outcomes.
2. Calcium-channel blockers were better than the others at preventing strokes, although all drugs were better than placebo or no treatment.

Talk to your personal physician about a beta-blocker if you've had a heart attack in the last two years.  Most heart attack patients are sent home from the hospital on one.  If you've have high blood pressure and a stroke, or a strong family history of strokes, ask your physician about calcium-channel blockers. 

And don't forget non-pharmaceutical ways to control blood pressure, such as regular exercise, weight management, and salt restriction.

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

References:  Law, M.R., et al.  Use of blood pressure lowering drugs in the prevention of cardiovascular disease: Meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies.  British Medical Journal, 338 (2009): b1665.

What is Ambulatory Blood Pressure Monitoring?

Ambulatory blood pressure monitoring (ABPM) is a useful technique to see if someone has "white coat hypertension" or adequate control of high blood pressure under treatment.  

Recall that white coat hypertension is when you have high blood pressures in the doctor's office (over 140/90 mmHg) but low pressures elsewhere, such as at work or home.  White coat hypertension does not require treatment.  

Sometimes I see patients I'm treating for high blood pressure who are not responding as expected to drug therapy.  I'm prescribing more and more drugs, the pateint is taking them, but the pressure just isn't coming down.  This is "resistant hypertension."  Many people with resistant hypertension acually have normal pressures by APBM.

These situations can be clarified with ambulatory blood pressure monitoring.  The patient wears a blood pressure monitor for 24-48 hours.  The automated device checks and records a blood pressure reading every 15-30 minutes, less often during sleep. If average pressures are under 135/85, you're doing OK as is: no need to start or intensify treatment.  

Unfortunately, some health insurers don't pay for ABPM.  The doctor has to pay $5,000-6,000 to acquire the device and software, so the office must charge $200-300 or more to defray expenses.

The low-tech alternative is to check blood pressure youself outside the doctor's office, over time, under various circumstances.  Review my post on getting an accurate reading.  Many pharmacies have installed free automated blood pressure monitors.  Who knows if they are accurate?  Some fire stations and EMS stations will check your blood pressure as a public service.  Or you can buy an automated pressure monitor for about $50 (US).  If so, have your doctor check it for accuracy at least once, if not periodically.  If your blood pressure averages under 135/85, be happy.  Even better is 120/80.

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes. 

What is "White Coat" Hypertension?

At least 10 to 20% of patients visiting a doctor's office have elevated blood pressures when in the doctor's office, but normal pressures elsewhere, such as at home, school, or work.  This is called "white coat hypertension" and is usually a benign condition not requiring drug therapy.  Normal blood pressures are under 140/90.  

By the way, most doctors use "hypertension" and "high blood pressure" interchangeably.    

A related issue is that many patients found to have mild to moderate high blood pressure on a first visit to a new doctor will have normal blood pressures three to six visits later.  Maybe anxiety plays a role.  Systolic pressures fall an average of 15 mmHg, and diastolic falls 7 mmHg over that time span.  And this is without any intervention such as drug therapy or lifestyle modification.  That's why it's best to have blood pressures checked at several visits over time before accepting a diagnosis of hypertension.

Nevertheless, if your diastolic pressure (second or bottom number) is over 105, you quite likely have sustained or "essential" hypertension that needs treatment. 

Nevertheless, there are many people with blood pressures always over 140/90 in the doctor's office, but always under 135/85 elsewhere. This white coat hypertension may be related to anxiety.  If you have it, odds are better than 50:50 that you will develop sustained high blood pressure over the next five years. One study indicated that white coat hypertension is associated with higher risk of stroke, but it's debatable.

If your blood pressure at the doctor's office is over 140/90, how do you and your doctor determine if it's just white coat hypertension?  Three options:

• Ambulatory Blood Pressure Monitoring arranged through your doctor.  You wear a blood pressure monitor on your body for 24 hours as it checks BP periodically.  If the average pressure is under 135/85, you don't have sustained hypertension.
• Check your blood pressure yourself over weeks and at various times of day.  Use an automated blood pressure monitor ($50 US) or the free monitors installed at pharmacies and supermarkets.  Your doctor can check the accuracy of your personal monitor at an office visit.
• Drop by your doctor's office for a blood pressure check periodically over the next 3-6 weeks. 

So, what if you have white coat hypertension?  You could ignore it.  But given the high rate of conversion over time to sustained hypertension that needs treatment, consider lifestyle modification to keep blood pressures down: 

• Achieve and maintain a healthy weight
• Don't smoke
• Get regular exercise
• Avoid excessive salt intake   

You don't want a physician labelling you as having high blood pressure if you don't.  It could affect future health insurance premiums, and perhaps even the ability to get health insurance.

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.    

Blood Pressure: How Low Should You Go?

High blood pressure is treated because, if untreated, it leads to strokes, heart attacks, heart failure, and premature death.  The treatment goals for high blood pressure depend on age and other underlying conditions. 

Here are the generally recognized goals:

• Keep systolic pressure - the first or top number - under 140 mmHg
• Keep diastolic pressure - the second or bottom number - under 90 mmHg 
• In people 65 or older, keep the systolic diastolic pressure over 65 mmHg while still under 90 

For people with diabetes or chronic kidney disease:

• Keep pressures under 130/80 mmHg

I hate to admit it, but too many of my physician colleagues don't realize that the goal for people with diabetes is lower than for the general population.  If you have diabetes and are often running higher than 130/80, you may have to tactfully educate your doctor!

Many physicians have an unofficial goal of "under 130/80" for people who have known atherosclerotic cardiovascular disease, such as coronary heart disease or blocked arteries in the neck, head, abdomen, or lower limbs.

NutritionData can help you avoid high blood pressure or reach your blood pressure goals through information on low-salt eating, weight management, exercise, and the DASH diet.

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

High Blood Pressure: Get an Accurate Diagnosis

Untreated high blood pressure is an important cause of heart attacks, heart failure, strokes, and premature death.  So it's important to check your blood pressure periodically to make sure it's not too high.  An initial diagnosis of mild high blood pressure - also called hypertension - requires more than one measurement over time, and under the right conditions.

Normal blood pressures are under 120 mmHg systolic (top or first number) and under 80 mmHg diastolic (bottom or second number).  The numbers are recorded as 120/80 ("120 over 80").   

High blood pressure is present when pressures are 140/90 or greater for several readings under proper circumstances.

The no-man's land between normal and high pressure is called pre-hypertension.  Over time, it often evolves into hypertension.

When being evaluated for possible high blood pressure, have your pressures checked under the following conditions:

• avoid the following in the 60 minutes before measurement: food, strenuous exercise, smoking, caffeine
• don't talk while your blood pressure is being taken
• sit with your back supported
• sit quietly for five minutes before measurement
• check blood pressure in both arms: if one is consistently higher than the other, use that arm for future pressure checks
• check pressures on at least two doctor visits at least a week apart
• take multiple readings at various times of day, even at home or at work

These diagnostic pre-conditions are not necessary if you have very high blood pressures, say 190/104, or your doctor sees physical evidence of damage from persistently high blood pressure, such as in your eyes, heart, or kidneys.

It's important to know if you truly have hypertension.  But you don't want to be labelled as "hypertensive" unnecessarily.  It may, for example, influence future health and life insurance premiums.

-Steve Parker, M.D.