The 5 Proven Habits That Protect Your Heart | How to Prevent High Blood Pressure and Hypertension

Before

we get into all things lifestyle and and

medications, what people can do to lower

their blood pressure, can you tell us a

little bit about how much

someone can lower their risk of having a

heart attack, a stroke, or kidney

failure by lowering their blood

pressure.

>> Yeah. And I can tell you based on some

reasonably good evidence that when you

measure blood pressure, we use units

called millimeters of mercury. So when

you go and they say, "Oh, your blood

pressure is 120 over 80." That's 120

millm of mercury over 80 millimeters of

mercury. Much of our understanding of

blood pressure is based on what happens

to the upper number, the systolic,

especially as you pass your 50th

birthday age into the the Medicare type

age and social security type age. But

the rule of thumb is that for every 1

millimeter that you reduce that upper

number, you reduce your risks of

cardiovascular badness by 2%. So if you

in if you take a you make a change and

it reduces your upper number by five

millimeters. So you go from 120 or let's

say 150 to 145 you've now reduced your

likelihood of a heart attack, stroke,

heart failure, cardiovascular death and

bad things by 10%. So the five times

two, it's a two for one kind of

exchange. So that's the rough percentage

change and that's that's over the next

10 years. So, it's most of our risks now

are assessed over a 10-year time period.

So, if you had an 8% chance, you have a

lesser chance if you reduce your

systolic blood pressure. And your

diastolic usually falls in line, the

lower number as well. And we spoke about

kind of what is the optimal systolic

blood pressure. But if we're thinking

about that that kind of 2% risk

reduction for every 1 mm of mercury

reduction in systolic blood pressure,

how far down does that go? Is that is

that down to that 115 mm of mercury mark

and thereafter it kind of tapers off or

we just don't have the data there? So

the 1 millimeter 2% rule of thumb is a

back of the envelope rough idea of what

you can expect. When we look at how

blood pressure is related to risk would

that it were a straight line. It' be

really easy if that were the case. But

of course it's not. It's actually kind

of parabolic with the side facing

upwards. So that every time you increase

your upper number by 20 points. So going

for example from 140 to 160 you doubled

your risk by that. From 160 to 180

you've doubled it again. So let's you

start at 120 to 140 that's twofold. 140

to 160 that's four-fold. 160 180 that's

eightfold. So the risk is proportionate

but it's proportionate in what's called

a geometric fashion instead of a

straight linear fashion. So the moral of

the story is that if you're looking at a

blood pressure of 170 or 180, you get a

lot of benefit just getting it down 20

points, much more than if you're 140,

getting it down to 120 for the same 20

points. So the higher it is, the worse

your risk categories are, and the more

important it is to lower it, no matter

how you choose to lower it, but getting

it down is really helpful. But the risks

are proportionately less as you get

close to that magic number of 120 that

the American Heart and the American

College of Cardiology and everybody else

with an A in their name tells us is

currently the cutoff for what's

considered good in terms of an upper

number for your blood pressure.

>> And does that include kidney disease,

kidney failure? Is the risk the same

there?

>> Okay, so that's one of the skeletons in

the closet here. I am a kidney doctor.

And one of the things I would love to

tell you is that oh sure it's just as

true for the kidney as for the heart and

the brain and the circulation and your

legs and other things. But sadly enough

we are hardpressed with our existing

knowledge base to say that the same

benefits on stroke risk on heart failure

on heart attack and on cardiovascular

related death are equally true at all

levels of blood pressure reduction for

the kidney. And the reason why is not

perfectly clear, but we see very little

additional benefit when you lower the

blood pressure below 140 for the upper

number to preserve kidney function over

time. And we measure that by a blood

test called the creatinine and

creatinine is a waste product. Kidney is

the only way to get rid of it. So if

your kidneys reduce their function, the

creatinine levels rise in the blood. And

that's what we use to gauge the

effectiveness of treating blood pressure

in a trial where we enroll people who

already have some measure of kidney

damage and their creatines are a bit

high. And when we look at the change

over time, it's really hard to say that

120 is better than 140 or 130 is better

than 140, but 140 is better than 160 or

180. So our level of good is at 140, not

the current 120 to 130 that the American

Heart Association and the other dog do

good or groups for blood pressure say we

should aim for. That said, one last

thing, the kidney disease improving

global outcome, so we call KDGO for

short. That's a group that meets

periodically to say what should the

blood pressure goal be in a patient with

chronic kidney disease. They still stick

to the 120 that the American heart and

other people say is a really good blood

pressure. Not because it preserves

kidney function, but because everybody

who has kidneys also has a brain and a

heart. So for the sake of the other

target organs, they are claiming that we

should still aim for values less than

120 using any measure we have at our

disposal to get there. following our

last episode, so part one of this

conversation where we mostly focused on

on what high blood pressure is and and

what are the the risk factors for that.

I had a lot of people in the community

say,

I wish people would speak a little bit

more about diastolic blood pressure and

I do think it's it's very common place

and I'm sure you would agree that most

of the attention is on systolic, that

top number. So my question to you would

be is systolic blood pressure more

important than diastolic or is there

another reason why we kind of focus

mostly on systolic and what does it mean

if someone has a normal systolic blood

pressure but their diastolic blood

pressure is unusually high.

>> That's a great question and a good

follow through. So let's back up a

second and ask what does the upper

number tell us? What does the lower

number tell us? We kind of look at blood

pressure, especially blood pressure

elevation, what makes a blood pressure

higher as resulting from two things. One

is the squeeze, the resistance that the

body puts up to flow. And it has to do

that because if you need blood going to

your brain and your heart all the time,

you're not going to want to peruse your

skeletal muscle or your liver or

whatever maximally. So the way in which

the blood circulation controls the flow

to each of the organs is through

resistance. And so when you don't need

blood, resistance is higher. When you do

need blood, resistance falls. And so if

you start to run, okay, your muscles

will get more blood. But if you're not

running, they get less blood. And it's

controlled by resistance. And the

diastolic blood pressure is our marker

of resistance.

the systolic at the upper number. That's

due to a different factor. And the

factor that more relates to the upper

number is how stiff the vessels are.

Particularly the big ones like the

aorta, the femoral arteries that go to

your legs, the brachial arteries that go

to your arms and that sort of thing.

When the stiffness in your vessels

increases, it gets harder to distend

them. That's the upper number. So every

time the heart beats and pushes out

blood, it pushes out blood against the

higher load. And so the systolic rises

and every time your heart beats and

shoots some blood into your major

arteries, you have two basic protein

components in your blood vessel wall.

One's called elastin. Guess what that

does? And one's called collagen or

gristle. If you've ever had a steak with

that little, you know, light colored

thing down the center, which you can't

chew, that is collagen or gristle. So

elastin's your friend. Every time the

thing expands to hold the blood, the

elastin helps bring it back down again.

But if you think about it, every time

you do that, you know, you're dealing

with a protein, you know, a tissue. It's

not indestructible. Over time, the

protein fibers of the elastin crack or

even break into little pieces. And so

you lose elastin and you think, "Okay,

so I'll just make more." Well, guess

what? You don't make more after you pass

puberty. So elastin is a protein that is

really hardy compared to any other

protein in the body. It has like a

40year halflife. So it's you got tons of

it. But if you have a little more

stretch or more frequent stretches, so a

little bit more, you know, change in

size or number of heartbeats per minute,

you're going to lose your elastin a

little more quickly. And when you lose

elastin, what the body replaces it with

is the other one, collagen. So as you

age, especially after the age of 50 or

so, you see that the diastolic stops

rising with age because prior to 50, the

two track together, but after 50, the

diastolic falls and the systolic

continues to rise because the types of

blood pressure patterns we see in the

young are more driven by vascular

resistance because they haven't

accumulated enough elastin damage to get

to the point where they're stiff.

But then as they pass 50, now stiffness

takes over. So where do most

cardiovascular events occur? They ain't

in the 40 year olds. Otherwise, we

wouldn't insure them, right? They had

high blood pressure. They tend to happen

in older people. And that's why we aim

at the systolic pressure so much because

as you age, it becomes the 800 lb

elephant in the room when we're dealing

with blood pressure. Plus, one of the

things I've often taught my students and

fellows and residents in the past is the

diastolic blood pressure, the lower

number that tends to melt on medication.

You can usually control the diastolic

with anything you do, lifestyle

measures, drugs, whatever it is.

Systolic much more difficult beast,

harder to get control of because now

you're dealing with that gristle protein

in the vessel wall. The collagen is hard

to to reason with. And so it's a bit

more challenging to lower the systolic.

So to your question, suppose my blood

pressure is 120 over 95. Is that bad for

me? And the answer is it depends a bit

on your age. If you're younger, yeah,

you probably are dealing with a higher

resistance. If there's no other good

reason for it to be 120 over 95. And

currently we treat that even though

there's not much evidence on how much

benefit you get by treating a isolated

elevation in the diastolic blood

pressure. But the argument is okay their

vascular resistance is higher and we're

planning on the future. So we're doing

this for the sake of their brain and

cognitive function in the future. We're

doing it for the sake of their heart so

they don't have heart failure, the

dreaded complication of high blood

pressure in the Medicare crowd because

heart failure is the most common thing

that people are admitted to the hospital

for when they're on Medicare. So, it's

expensive. It's repeated and it's

clearly linked to blood pressure

control. Maybe not so much when you're

young, but certainly some, but

especially when you get older. So, the

we do treat it and you know what

outcomes? Well, we we're kind of banking

on the future, so we're holding the

carrot on the stick out here saying we

think it's a good idea and it's usually

possible to manage it with modest

amounts of either lifestyle change and

or medication. Is a challenge there when

when treating an isolated elevated

diastolic blood pressure that whatever

interventions you're choosing are also

going to lower systolic blood pressure

and not lowering that too much. One of

the fascinating things is that there's a

principle in medicine called wilders or

because it's German builders w i lb er

wilder rule or wilder's law and it what

it says is that the higher a biologic

variable is whether that's your blood

sugar your diastolic blood pressure your

systolic blood pressure your cholesterol

whatever it is the higher it is the

greater it falls when you intervene. So

if you have a systolic of 120, honestly

that's not so high. But if you have a

diastolic of 95, that is high. So when

you treat that, you're going to get a

disproportionate effect in general on

the diastolic compared to the systolic

pressure. And the same happens when

you're dealing with a blood pressure of

170 over 70. you're going to get much

more collapse in the 170, much less in

the 70 when you're looking at a, for

example, an 80year-old who's got stiff

circulation and has that 170 over 70

type blood pressure. So, you'll get some

change in the systolic, but

proportionately in general, you'll see a

little bit more benefit on the

diastolic. It is so easy to do a bad job

at measuring blood pressure if you

measure too quickly. If your feet aren't

supported, if your arms at the wrong

place, if your bladder's full, if you

just had a cigarette or a cup of coffee,

there's a dozen different things that

can screw up a measurement. And almost

all the time, Simon, when the errors

occur, they raise rather than lower the

result. So most times you get a falsely

elevated blood pressure type reading.

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a few months ago, the new AHACA

guideline, one of those guidelines with

the A at the beginning that you

mentioned

>> on prevention, detection, and management

of high blood pressure in adults was was

published. And in fact, I think we

postponed the recording of this episode

to wait for for that to come out.

Compared to the 2017

guidelines from the same groups, what

would you say are the major headline

changes or updates? So there's a couple

of things that are I won't say new but

more emp emphasiz better emphasized in

the current guidelines for people that

are into thinking they are now focusing

on cognitive function and if you wait

till someone starts down the Alzheimer

or the vascular dementia pathway you're

too late. We know that there's a risk of

cognitive decline in your later years

when you look at the middle age and even

younger ages. So you're investing in

cognitive function in the future by

treating blood pressure now. And so

that's another goat or incentive to

manage blood pressure when people are in

their 40s and 50s rather than waiting

till they're in their 60s and 70s to do

that. Second thing that's kind of new,

um there is an emphasis on risk. Again,

you know, guidelines go back and forth

about the role of risk, overall risk in

managing blood pressure, a single risk

factor, but now they're using a thing

called the prevent guideline. This is

kind of new. This is the first uh

hypertension guideline in the US to

recommend that. So, if you go to a

website called MDCAC, mdcalc.com, and

you put in prevent, you'll see the

prevent calculator. And we are enlarging

our scope, if you will, on things that

we put into the calculator to look at

risk. And you can put in everything.

There's multiple models that you can

choose from. And then you could play

with the blood pressure numbers to see

what the benefits are. But that's in the

current guidelines because they

recommend using the prevent calculator

to decide how aggressively to aim for a

blood pressure less than 120. I've been

debating this issue with some of the

deities that exist in the hypertension

guideline world. I am not currently one

of those deities. I've been dethroned as

of 2014 when the JNC8 guideline came

out. But sometimes, Simon, it is really

hard to get a systolic down below 120

without causing a lot of symptoms and a

lot of extra lab testing and a lot of

extra honestly coaching. You know,

sidelines cheerleader, you know, please

take this medicine. and it will benefit

you in the long run. I promise you. But

the issue about where the systolic goal

should be, everybody kind of agrees less

than 130 is a good goal. But some people

have stated imprint in the guideline

that you should really aim for less than

120 when your prevent risk calculator

says that you're at more than seven and

a half% likelihood over the next 10

years. So that's another aspect that's

kind of new. The other thing is that

when we treat high blood pressure, a lot

of it's treated by, you know, a guy or

gal who's in a practice, private

practice often, who's got a very busy

schedule trying to see four or five

patients an hour. And meanwhile, you

know what we have to do at least

according to guidelines to really get a

good handle on blood pressure is to make

sure patients understand the role of how

to measure it properly if they do it at

home. The role of their diet in that

especially you mentioned salt a little

while ago when we were talking salt is

an important component. It's not the

only one however and medication and how

often what do you do if you miss a dose

or miss a couple days dose. you went to

Europe for a week and you forgot to take

your bills with you and no one would

write a script for you in Copenhagen or

whatever. What do you do in that

circumstance? And it turns out you have

to document everything you do to get

paid. And so we're asking a lot of our

primary care folks in order to do a good

job of measuring blood pressure,

teaching patients about blood pressure,

prescribing the correct things, etc. So

the guidelines to emphasize the role of

some of the other ways we do this like

team-based care when you have the luxury

of having a dietician for example or a

good nurse, nurse practitioner, whatever

who can spend a few minutes with a

patient going over their diet and

saying, "Okay, look, you know, the call

out for Chinese with extra soy sauce,

that has to stop." And having three

margaritas every night, that's not a

good idea either. So in that

individualized approach to look at the

lifestyle measures, the average guy or

gal doing high blood pressure care

amongst all the other things that

primary care does is really hardressed

to have the time to do that. So the

guidelines do mention the value of team-

based care and shared decisionmaking

when it comes to what should be done

next. And I think those are some of the

highlights that are in the current

guidelines that make it a little bit

more concurrent, contemporary, that are

really getting at some of the things

we're able to do, especially the home

blood pressure aspect.

>> Actually just recently spent a week in

Copenhagen. Funny you mentioned that and

and I have to say love lovely city for

those who maybe haven't been there and a

lot of bike riding which I'm sure is is

a good thing for for blood pressure.

>> Agreed. If we were to come back to the

guidelines and and kind of just think

about the different classifications of

elevated blood pressure and maybe some

of the big buckets of of people that you

might see with increased blood pressure

when someone presents to you in what

situations are you saying to that

person, okay, I'm recommending for you,

you you just go away and focus on

lifestyle ABC D and I think that could

be enough versus someone that comes to

you and you're like

your blood for sure is at a level where

I I think that you need to commence

medications straight away with some

lifestyle modifications as well.

>> Yeah, good question and it's faced all

the time. So, let's back up for a second

and just, you know, if we're going to

use information, we have to have good

information. So that old garbage in

garbage out, that is so true in high

blood pressure care because it is so

easy to do a bad job at measuring blood

pressure. If you measure too quickly, if

your feet aren't supported, if your arms

at the wrong place, if your bladder's

full, if you just had a cigarette or a

cup of coffee, there's a dozen different

things that can screw up a measurement.

And almost all the time, Simon, when the

errors occur, they raise rather than

lower the result. So most times you get

a falsely elevated blood pressure type

reading. So my first pillar in doing

high blood pressure care is to make sure

we're dealing with good information. And

we know that some people, and it's a

debated figure, but a safe figure was 15

to 20%. Some people just when they go to

a doctor's office or have it measured in

a clinic, even a part of a hospital or

whatever, their blood pressure goes a

little haywire because they're scared to

death of what they're going to be told.

And then you weigh them and tell them

you're overweight. And then, you know,

you do other unsavory things and you

stick them in a room, it's cold, and

then you slap this blood pressure cuff

on them and guess what? It's 145. So,

you know, making sure that not only is

the blood pressure done correctly, but

whenever possible, looking for a blood

pressure outside the office so that you

can be relatively sure that what you see

in the office outside the office is

still high. We call that a white coat

effect or office hypertension. There's a

lot of debate over what the best

terminology is, but everybody sort of

knows that there's, you know, every time

I go to the doctor, the dang thing's

elevated. So, when you're able to check

it outside the office, whether you wear

a monitor for 24 hours or whether you

invest in a blood pressure cuff and

measure it at home, it's helpful to know

that it's truly high outside the office.

Because once you commit someone to a

therapy, whether it's lifestyle or more

importantly a drug therapy, it's usually

for life. Most blood pressure is what we

call essential or primary hypertension.

You got it because you got it. You know,

your parents probably gave you some

tendency toward it and you probably

contributed to it by virtue of your

lifestyle choices. So once you're

treating it, you're usually treating it

for a good long time until you know

maybe a person loses a lot of weight or

they take leg or ompic or something and

they lose a lot of weight. But in the

absence of a great deal of weight loss,

most times it's there to stay. So when

do we push the trigger and actually

treat it? And there it becomes something

of a numbers game. When blood pressures

are 130 to 140 for the upper number or

80 to 89 for the lower number, we call

that stage one hypertension. Now that's

a paradigm shift that occurred with the

2017 guidelines labeling that

hypertension. When that's the case, if

all other things seem reasonable, I

mean, they're relatively young, they're

physically active, they haven't had a

heart attack, they haven't been admitted

for heart failure, no evidence of

cardiovascular compromise. We measure

risk factors for all those things,

cholesterol, glucose, kidney function,

that kind of thing. But in the absence

of that, we'll try the lifestyle

measures. But if they're already at

ideal body weight and their resting

heart rate is 58 and they're they avoid

salt like they avoid the plague is not a

lot of benefit you're going to see with

lifestyle measures. But most people are

not so gifted in terms of their

lifestyle choices. The average person in

America is a little heavy. And so we'll

try the lifestyle measures and we commit

for a period of time. And this is the

important thing. We we have a contract

with the patient. that says, "Okay,

we're going to give this 6 months, 3

months, whatever you think is

reasonable." But at the end of that

time, you have to be prepared to move on

and start something because we do aim

for values less than 130 when we can get

them safely in in our office practice or

in our at home as long as we can trust

the at home blood pressures are done

correctly. So 130 to 140, we'll give it

3 to six months with lifestyle. What do

we aim for in lifestyle? weight loss if

overweight, sodium reduction if they are

an average American, eating roughly

twice the amount of salt we really need,

enhancing potassium intake when we can.

One of the most overlooked things is if

you happen to use a salt shaker and you

have good kidney function, using a salt

substitute, actually like a potassium

chloride may not quite be as savory as

sodium chloride, but it's healthier for

you as long as your kidneys are okay.

alcohol. We recommend two for a guy, one

for a girl and exercise. And you can

write you we could do it the whole two

hours on exercise alone because there's

so many flavors of exercise, but it's

sort of like, you know, Washington DC,

everybody kind of knows where it is. So

exercise, everybody kind of knows that

it's a good idea periodically to

actually do something for the purposes

of your health that makes you break into

a sweat and raises your heart rate a

little bit. When we fail, and we often

do fail, then we start meds. If they're

140 to 160,

the typical thinking is to do meds and

lifestyle side by side. But, you know,

we go kind of easy at first because most

of the time, these are people that are

in their 30 to 60 age range and often

not much in terms of additional risk.

When it's 160 or higher, it's mandatory.

We we should treat that. No question

about it. Remember that risk

proportional to every 20 millimeter

increase in systolic. Now we're dealing

at four to eight times as much blood

pressure related risk. So we treat that

and with 180 it's a judgment call

whether even to admit someone depending

on whether they have some shortness of

breath, pressing chest discomfort or

some other thing that makes you think

there's an impending target organ

collapse here present. But we kind of

graduate that and most of it's based on

what we think the systolic pressure is

up to more so I think than diastolic.

But 80 to 89 is our diastolic for stage

one. Above 90 and above is our diastolic

for stage two. When the diastolic run

more than 120, we get concerned because

that is real tightness. And the

coronaries and the brain and the kidneys

can be affected by that degree of

vascular resistance. And so we're

usually thinking pretty hard about how

aggressively to manage that. If we have

a really reliable patient who can come

back maybe twice a week for the short

term to make sure we get blood pressure

going in the correct direction and who

can measure it at home, we'll do an

outpatient approach as long as there's

no sign of something about to have a

catastrophe in their circulation. But

when it's not the case, we don't know

them and they look sick and maybe

there's some change, subtle change or

even obvious changes on their

cardiogram, electroc cardiogram, heart

rate, heart rhythm test, then we not not

uncommonly will admit them to the

hospital to make sure we get things

started to manage their blood pressure.

But honestly, Simon, that's uncommon

anymore. Most of the time people have

had at least a couple of blood pressure

checks in their life because the message

about checking it in an office practice

when they come in for you know their

their get their cast off or a well baby

check or you know we even check kids now

or even such things as like managing

their gout or some other thing we

typically a blood pressure is going to

get done and when it's elevated

attention's paid I think that exercise

is helpful as second in all for the

following ing reason. When you exercise,

a couple of things happen. Number one,

you burn calories. If you've got a lot

of energy stored in your fat tissue,

then you either reduce the intake of

energy, so less calories, or you

increase the usage of the energy. That's

where exercise comes in. So, exercise is

helpful as a component to a weight loss

regimen. Eating less and expending more,

that's the magic in terms of a non-drug

approach to weight loss. So, it's good

for that. Second thing, exercise is good

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All right. So, if you have a a patient

that presents to you, let's say they're

late 40s or early 50s and their blood

pressure reliably is sitting in the kind

of maybe mid 140s or or 150 that that

would be a conversation of perhaps they

do medication plus lifestyle. But if

they were someone that, let's say, was

overweight, was smoking, was drinking a

lot, was consuming a diet that had a lot

of salt, and they were kind of very

committed to making lifestyle changes.

In that instance, you could send them

away and say, "Hey, okay, if you're

willing to make kind of aggressive

lifestyle changes, you might be able to

get this in control without

medications."

>> In general, I wish I could say, I mean,

that sounds real good, but in real life,

it often isn't all that effective. So

what I tell patients if I'm happen to be

the first one to take a crack at

managing their blood pressure and they

come in like you said 145 to 150 they're

40 years old. I'll tell them look you

need to be treated. We're going to start

both medication and lifestyle measures.

Your BMI is 32. Your target BMI is 24.

You're about 50 lbs overweight. You lose

those 50 pounds. We'll revisit the Mets.

And weight is our biggest win when it

comes to high blood pressure care

because weight loss is probably the

single most important factor from a

lifestyle non-drug standpoint to lower

blood pressure. And so I put the I put

it out in that particular way. I'll

reconsider the meds. And you know I've

had a couple of patients that have lost

the 50 to 60 pounds. They off almost

always had an incentive. They wanted to

get into a tux and look nice for the

kids wedding. Okay, that's one incentive

to lose lots of weight and maybe you

have eight months to do that. Or they've

had oral surgery and their jaw has been

wired shut. You know, they can't eat.

It's another time I've seen that kind of

weight loss. And now with the things

called the GLP1 receptor agonists, the

WGO, the tides, teepide, semiglutide,

you know, he's in clinics for this. That

kind of weight loss has some blood

pressure improvement associated with it.

I'm not recommending that right on this

because there's a whole discussion that

has to take place for that, let alone

how much it costs. But that aside, to

answer your question, I do both and I

offer to re, you know, to back off on

the medication if they can do the

lifestyle changes. But, you know,

honestly, Simon, I'm kind of a Calvinist

at heart. I believe that people are

inherently not as good as they think

they are. And consequently, even the

most highly motivated person, I don't

want to waste six months to a year

waiting for their blood pressure to come

down when it sits at 150 for a year. I

just don't think that's a great idea.

And coming back to what you said

earlier, the at least your approach is

aiming to get that person below 130, but

you said the new guidelines and there

might be some people out there that that

are suggesting that well it would it

might be better to get them under 120 if

they're someone that's high risk of

cardiovascular disease.

>> Yeah. So that's that's in the current

guidelines. I won't say that it's you

know on every page so that you know you

when you really want to get a message

across you kind of insert it multiple

sections so that if you I mean the

guidelines are 100 pages long right who

sits down and reads a 100 page PDF

especially when it's single spaced in

two columns so you know if you're going

to put something in there that you

really think's important you kind of put

it in several sections either under

diagnosis under management under special

circumstances is under really bad blood

pressure control, that kind of thing.

But when you look at the recommendations

for doing the less than 120, my concern

for that particular recommendation is

it's based largely in studies almost

exclusively in studies done in China.

And that's fine. I mean, Chinese know

how to do clinical trials in

hypertension. Not this is not a

criticism of an Asian population study

where high blood pressure has been the

target 140 versus 120. What bothers me

about it is is that Asian pure Asian

especially populations have a different

outcome profile for blood pressure

elevation compared to the mixture of

peoples that we have in the US and

stroke is a big one in China especially.

Though stroke benefits are remarkable

when you lower blood pressure and that

the stroke and the heart fail are the

two biggest wins when it comes to

treating high blood pressure and looking

for improvement. The other problem not

the other the other issue with the 120

with high cardiovascular risk is much of

the three studies one and a half are

diabetics. And so diabetics are a a

population where we know the uh risks

are enhanced because you've got now

another risk factor besides hypertension

that collude with one another because

diabetes and high blood pressure both

attack the circulation through

independent processes but also because

they're interlin. If you're diabetic you

twice the likelihood of hypertension. If

you're hypertensive you get twice the

likelihood of developing diabetes. So

when you have partners in crime like

that, it's a different issue than just,

you know, generic hypertension alone. So

when you base recommendations on that

kind of uh epidemiology, even though

it's clinical trial data, not done in

the US, I've got an issue with the

feasibility of getting to those levels

because the Chinese look a little more

drugsensitive to me. We usually need

three or more drugs to get below 120 in

the US, but the Chinese can do it with

one and a half to two drugs. You know,

one and a half, that's an average. So,

some are on one, some are on two, but

the sensitivity of the Chinese

populations to blood pressure medicine

looks a little bit more

they are more amanable to blood pressure

reduction with the pharmarmacology

available. They're the same drugs we

have. They just seem to respond a little

bit better than we do in the US because,

you know, is a black American the same

as a Chinese American, the same as a

Hispanic American, the same as a white

American in terms of the likelihood of

not only blood pressure reduction, but

benefit from blood pressure reduction.

So, we have populations of risk that are

at higher risk. You take a black

American and a white American, same age,

same gender, and you lower the blood

pressure on both, you're going to get

more benefit in general in the white

compared to the black American because

they are inherently at greater risk. So

the sub ethos ethnos that are present in

our population are different in terms of

outcomes and that's why I just am a

little concerned about force

reaching a 120 millimeter systolic blood

pressure goal when your prevent risk is

more than 7 and a half% in the coming

decade. The reason I asked that question

was I'm sure there are many people

listening to this show that are having

this conversation with their doctor and

what I'm taking away is that would you

would you agree would it be the case

that most physicians

at least in the United States if they're

dealing with someone who has a blood

pressure of 150 160 they would be having

a conversation with that patient that

what they're trying to do is is is at

least initially get them below 130. Is

that the kind of the shared goal?

>> Right. Right. Getting below 130 is step

one. Getting below 120 is an option that

I think you can exercise. If you get if

you get them down to 126 to 130 on maybe

two drugs and they feel okay. I mean,

hardly anybody's going to feel great

taking two medications for blood

pressure, but you know, maybe you get

lucky one or two people that do. That

said, if you think you can reasonably

lower it the extra 6 to 8 points to get

them to 118, 116 without causing them to

be excessively dizzy, without nausea,

without falling asleep in the middle of

the afternoon, and a number of the other

things that patients over the years have

told me about. I know the drugs are

helping, but I have this concern about

them. So if you think you can add or

titrate, give a little bit more of

something to get them a little further

down the systolic line to less than 120

and they have high cardiovascular risk.

That's the population that I think

you're going to get the biggest

likelihood of not only achieving that

but keeping them on it. Our biggest ch

at least to me the biggest challenge we

have in high blood pressure care is not

that we don't have enough medications or

ideas about lifestyle for it to work.

Our biggest challenge is keeping people

doing it. Keeping them on their meds,

keeping their weight down, keeping the

exercise at how many minutes a week,

whatever it is. You know, when you first

do that, it's like, okay, I'll do it.

But that, you know, after a year or two,

it gets a little more challenging to

stay the course. And that's where the

cheerleading aspect of blood pressure

care comes into play.

>> Yeah. And goes back to what you

mentioned in in our last episode,

specific to adherence, the importance of

listening to the patient and

understanding their individual

experience so that they feel connected

to you as a physician, as someone a

carer and uh trusting what the

information that you're providing them.

>> Absolutely essential. So just to double

click on the medications here, Raymond,

what do you wish patients or physicians

understood when it comes to the kind of

suite of medications that exist to lower

blood pressure? And this is an area of

science that's evolved over over decades

when when we look at these these new

guidelines,

what do they make clear about whether

it's diuretics or ACE inhibitors or

ARBs? How are we approaching this

problem of lowering blood pressure or

elevated blood pressure from a

pharmarmacology point of view with the

things that you've raised in mind which

are treatment goals and symptoms? What

would you say is kind of like the best

practice way of navigating this?

>> So we we we kind of teach the ABC

approach to blood pressure medications.

My premise, my op priority here is that

the average person when you're going to

treat the blood pressure with medication

often is going to need two drugs. Wish

to heavens it was possible in the

majority of people to treat them with

one medication. Sometimes it's possible

when you start at 134, odds are you're

going to get below 130 with a single

med. But once you pass the 140 mark, it

the average blood pressure med lowers

your upper number by 10 to 12 and your

lower number by about eight. It wouldn't

get approved if it didn't probably meet

those standards. And the company that

manufactures it did the testing to show

that it does that especially compared to

a placebo in an 8 to 12 week time period

in a double blind and randomized

fashion. That said, what are the A's? So

the A's are the angotensin system

blocking drugs, ACE inhibitors and

angotensin receptor blockers. years ago

when Nancy Brown the chair of medicine

at Vanderbilt came to our institution to

give a lecture on hypertension this

issue came up what do you use first we

think blocking the angotensin system the

arena and angotensin system with drugs

ACE inhibitors or angotensin receptor

blockers called ARBs for short seems to

be a good idea lots of data to show

benefit generally one among the best

tolerated of the blood pressure

medication classes so she said how How

many of you use an ACE inhibitor first

in the audience? Some hands went up. How

many of you use an ARB first? Other

hands went up. How many of you are

cardiologists? The same ACE inhibitor

hands went up. How many of you are

nephrologist? The same ARB hands went

up. So cardiac centered approaches to

blood pressure care. Typically you'll

pick an ACE inhibitor. Kidney centered

blood pressure care often we use an ARB

first. What's the difference between the

two? ACE inhibitors do a little bit more

than than interfere with angotensin.

They do things with a hormone called

bradyinine that may be beneficial.

Angotensin receptor blockers do not have

the most common side effect of an ACE

inhibitor which is a dry cough. So

cardiologists love it because there's

tons of data in cardiology on ACE

inhibitor use. Nephologists like ARBs

because some of our most important

clinical trials in diabetic kidney

disease were done in the late 90s and

early 2000s and they were both done two

different trials with ARBs. So

nefologists tend to use ARBs,

cardiologists tend to use ACE

inhibitors. What do we add when you're

not at goal? So in general we usually

add a diuretic because diuretics and

ACES or ARBs are complimementaryary. For

example, use a diuretic, your renan

system becomes more active. So if you've

got that block now, you get a little bit

more bang for your milligram with the

diuretic than you did just using the

diuretic by itself. Others like calcium

channel, long acting calcium channel

blockers with the ACE inhibitors because

the diuretics do a little bit of damage

to glucose control. Diuretics can raise

your uric acid and cause the occasional

gout episode which is not pleasant if

you happen to be that one or two% that

gets galp in terms of that kind of

therapy. So long acting calcium channel

blocker tends to be nice and the most

common side effect of those is swelling

around your ankles which is lessened

when you use an ACE or an ARB with it.

We trade the complimentary mechanisms of

action, how they lower blood pressure

and also the tradeoff in side effects

because diuretics lower potassium, but

when you have an ACE inhibitor or an

ARB, the potassium loss isn't as great.

So that combination makes sense. A long

acting calcium channel blocker ACE ARB,

that makes sense. So two drugs may that

may control 60 to 80% of people with

high blood pressure. And when you come

to that point where you're on a

combination of the two and you're still

uncontrolled, we add the one that's

missing. So if you're on the diuretic AC

or R, we add the calcium channel block.

You're on a calcium channel blocker or

razor R, we add the diuretic. And at

that point, if they're still in control,

we find our friendly neighborhood

hypertension specialists and off they

go. Because when you're at that point,

if you really believe they're taking the

medication and doing a as much a

credible job as they can and controlling

their salt intake and doing the other

heart-healthy things that are lifestyle

control, it's usually helps to have

another set of eyes look at this and

have the patient hear from a quote

authority on hypertension. Often a

cardiologist, h nefologist, or an

endocrinologist. All three specialties

tend to put the sign out for

hypertension underneath whatever their

subsp specialty is. And then having the

extra set of eyes, maybe a test or two

that wasn't thought of. Sometimes you

you're a little you better at lowering

blood pressure, then this triple drug

combination of the A, B, and C drug type

things will get you. It's actually AC

and D. The B is a beta blocker. We tend

not to use beta blockers as much earlier

on in blood pressure care now as we used

to do in times gone past.

>> Okay. So to kind of throw that back to

you, most commonly someone is on an ACE

or an ARB.

>> Yep.

>> In and then possibly in combination with

a a diuretic or a calcium channel

blocker,

>> right? And then often if that's not

enough, the other the other additional

medicine is added, be it a diuretic or a

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What would you say, Raymond? And I'm

sure you've come across this. I've seen

various comments online where people

have a view that and this is the same

for cholesterol where they say, you

know, over the years the guidelines have

lowered the treatment threshold and

doctors just want to prescribe more

drugs and and the guidelines have have

simply lowered the thresholds in order

to create a pharmaceutical industry

that's more profitable.

>> Well, since all the drugs are now

generic, we no longer have the trade

name advantage. So, if I'm a drug

manufacturer and I I I make a

hypertension drug, hypertens,

and now I can sell it and maybe charge a

hundred or $150 for a month's supply.

Once it goes generic, you're looking at

$5 to $10 for a month's supply. I'm

making the numbers up, but they're

roughly proportionally what the

differences are. At this point in time,

we have generic ACE inhibitors. We have

generic angotensin receptor blockers,

generic long acting calcium channel

blockers, and generic diuretics. So

there's no longer an industry incentive

here to be prescribing meds. We also

have literally millions of patients

treated for blood pressure to reinforce

the benefit of blood pressure reduction.

And so we've got good data on blood

pressure reduction and benefit. and we

no longer have the economic incentive

that might have been present in years

gone by to treat with specific ACE

inhibitors or specific angotensin

receptor blockers. So I think the

pharmarmacologic aspect of blood

pressure therapy is dwarfed by the just

the current realities that we have. We

have lots of generic meds and you know

it's usually possible for a reasonably

small amount of money a month to treat

blood pressure and the blood pressure

monitors now have gotten pretty good and

you can get a decent one for anywhere

from 60 to 80 bucks or so and those give

you a good sense of how well your

control was maintained at home which is

really an important aspect that I think

we often undervalue

>> and in terms of troubleshooting symptoms

or or side effects someone could be

exper experiencing from a medication or

multiple medications.

You've you've mentioned a couple of

things that you'd be thinking about. Is

there anything outside of the medication

that they're they're taking and and

potentially changing that or the dose of

that medication? Is there anything

outside of that that you would be

thinking about that could help someone

manage symptoms?

>> There's a couple of things we do.

Sometimes it's not the med, it's what we

call the exipience. So when you make a

pill, let's say you go and you're on

lysinil, a standard ACE inhibitor, and

you go to your pharmacy and you get a

little bottle full of lysinil tablets.

Well, each tablet, each 20 mgram

leinipil tablet is not 20 milligs of

lysinil and that's it. It's got

magnesium steroid and citric acid and

all these other things to make it into a

pill. And so it holds its form with the

20 milligrams of lysinopril in it. So we

have oh 10 or 11 ACE inhibitors out

there and if you develop a problem with

lysinipril other than the cough all the

ACE inhibitors cause cough but let's say

you have something else I mean I don't

know your your ear buzzes or something

and you think it might be the lysinipril

you can switch to trendolapril or one of

the other pills and in that circumstance

the exipients are going to be different

and you may see the symptom abate or it

may be due to the ACE inhibitor

approach. So we usually if we have a

good response but we have a side effect

we're going to try and maintain that

good response by an alternate agent in

that same class and sometimes it's just

related to the compounding in the pill

itself. So we'll try that. The other

thing um is that we know some symptoms

are just class related effects. So that

edema, the swelling in your ankles

that's associated with every one of the

long acting calcium channel blockers,

variable degrees, granted, but

nonetheless, it happens. And the marker

for it is is that your ankles aren't so

swollen when you get up in the morning,

but by 3:00 in the afternoon, you have

Italian grandmother feet. You know, the

swollen things that look like pillars.

And so that is a standard what we call

dihydropiritine, calcium channel blocker

side effect. And it may be that if you

need another agent, you can add an ace

or an ARB, you're going to have reduced

by 50%. The likelihood of that swelling

being such a problem. Doesn't erase it.

Reduces it by a half. But nonetheless,

there's the other half where it still

stays. In that sense, we give up. If

they can tolerate it, it's not a health

hazard by and large. It's just

cosmetically unsightly. It's hard to

wear high heels when your foot is

slipping all around the sides of your

heels. So in that circumstance, we'll

stop the drug or we'll try a dose

reduction. Once in a while, dose

reduction will reduce the side effect.

And honestly, Simon, sometimes people

just they get more tolerant of the side

effect. We always kind of hope for that

because most side effects that we still

try and keep the drug in play are

annoying but not life-threatening or

limbthreatening or organ threatening in

terms of their effects. So the the the

management of side effects that's you

know that's where I wish I had done a

psychiatry residency along with my

internal medicine residency cuz

sometimes some people are just I mean

they have physical symptoms you like I

said we listen to them we try and be

empathic and hear them but you know when

you're on your fifth class of medication

and the person has the same side effects

on every single thing you do it's really

hard to believe that it's truly the drug

in each case and not some psychologic

component to the drug in each case. And

it's not easy to just say I think you

should see a psychologist about this

particular thing because that that

breaks the physician patient trust

issue. They now think you think they're

a croc or some other equally projorative

term. So, you know, trying to manage

side effects is especially when you're

at a place like Penn where I work and

you have patients who come in on four or

five drugs and they don't feel good in

the first place and you're sitting there

thinking which of these could be

responsible for that and how am I going

to manage this when they're still high

and I need to do more for their blood

pressure not less in terms of taking

meds away. So, it becomes an individual

case by kind of thing. We know there are

certain side effects that we expect,

some side effects that can happen

possibly related. And then there's some

things that just there's a psychologic

component here. I got to really deal

with that if I can and maybe uncover one

or two things that might be leading to

that sort of thing. Steering the person

away from blaming the med and maybe

blaming the fact that they have

underlying COPD, you know, chronic

obstructive pulmonary disease and that's

why they're coughing on the anotensin

receptor blocker, which typically

doesn't have cough as a side effect.

>> Yeah. Oh, I have to I have to imagine

that keeps medicine in interesting

dealing with with humans who are

complex, not not just just treating

biology and and data points.

>> Yeah, it's challenging. Tell you about

day it's challenging.

>> Coming back to lifestyle and I know my

audience is going to be super interested

in this. So, you mentioned that weight

loss is probably the biggest lever from

a lifestyle point of view that someone

can kind of pull to bring their blood

pressure down. If you had to just at a

high level here kind of rank the top two

or three lifestyle levers in order their

magnitude of effect on blood pressure,

weight loss being number one. What are

what are number two and number three? So

they vary a little bit because some

people are more benefited than others by

some things. So let me give an example.

If I have a black American, 50% chance

they're salt sensitive. If I have a

white American, 20% chance they're salt

sensitive. So the likelihood of blood

pressure reducing by virtue of reducing

sodium intake is higher in my black

American patient than it is in my white

American patient. So I'm going to

emphasize it more in the black American.

I'll emphasize it, but not to the same

degree in the white American. So but in

general, I think that exercise is

helpful as second in all for the

following reason. When you exercise, a

couple of things happen. Number one, you

burn calories. In order to lose weight

loss, if you believe Newton's second

law, I think it's the second law of

thermodynamics, you can't create energy,

you can just change it from one form to

another. If you've got a lot of energy

stored in your fat tissue, then you

either reduce the intake of energy, so

less calories, or you increase the usage

of the energy. That's where exercise

comes in. So, exercise is helpful as a

component to a weight loss regimen.

eating less and expending more. That's

the magic in terms of a non-drug

approach to weight loss. So, it's good

for that. Second thing exercise is good

for is that it improves things like your

blood sugar and your triglyceride level

and the good form of cholesterol, which

we call highdensity lipoprotein or HDL

for short. So exercise gets you a little

bit better what we call profile, glucose

and lipid profile because it it improves

the ability of insulin to work as

insulin was meant to do. Insulin helps

your glucose to be stable. Insulin keeps

your triglycerides in the cells not

circulating and insulin is also good for

not raising your HDL cholesterol. So

when you need less insulin to do its

job, your HDL cholesterol tends to be

better. And for guys, one of the only

things we can do to increase our HDL

cholesterol is to exercise just short of

drugs. And the third thing is is

probably I don't know where to rank it

with the other two, but exercise

improves your heart rate. And the reason

I I've mentioned before that the two

things that damage elastin is the

stretch and the number of heartbeats. If

you exercise, yeah, for the time you're

exercising, your heart rate goes up, but

your resting heart rate comes down. That

means that there's fewer heartbeats

around the clock. And I think one of the

other things about the pulse rate, aside

from the fact that it's sort of fun to

capture it on your, you know, your Apple

Watch or your Fitbit or your Aurora ring

or whatever, is that when you look at

the relationship of the heart rate to

longevity, it's dang near as good as the

blood pressure to longevity. So lesser

heart rates, people tend to live longer.

So exercise is useful for that as well.

I rank alcohol fourth behind salt. So

weight loss, exercise, salt, alcohol,

and then potassium intake

>> on exercise. Raymond, as a nephrologist,

and from a a blood pressure perspective,

do you have any views on the type of

exercise that is most effective, be it,

you know, going out and doing a kind of

steady state run or bike ride or doing

sprints or lifting weights.

>> So I can tell you what I do. So, this is

one of those things where what does he

say versus what does he do? My goal each

day is 12,000 steps and I try at least

once and often twice a week to get to

the gym because my cardio I I see a

cardiologist and he says to me, "What do

you do that you know causes you to break

into a sweat with exercise?" So, that's

where the gym comes in. The walk

doesn't, but the gym does. Unless the

walk's in the middle of August and it's

108 degrees outside. So, I think that

steps are something that mostly

everybody can do. You don't have to jog.

You don't have to run. But if you do

steps, you're burning calories. Every

time you walk a mile, you burn roughly

100 calories. And so, I aim American

Hearts is 8,000, but I aim for 12

because I'm interested in more than just

getting my heart into better shape in

terms of my resting heart rate. I'm also

trying to keep my weight from doing

that, you know, older age person thing

where it just kind of rises with every

decade. So, I aim for 12,000 steps. I

hit it most days. I used to be at 15,

but I just have trouble getting to that

level at this point. So, I don't get my

extra credit points now. That takes me

almost hour and 40 minutes to two hours

a day of walking in order to do that.

But if you're going to invest in your

health, you know, it's better that than,

you know, watching some, you know,

Netflix whatever Amazon whatever

some binge type of thing. So that's, you

know, when it comes to resist, you know,

resistive exercise like, you know,

isometrics and either bench pressing,

I'm not as keen on those mostly because

I'm just not as I don't understand the

benefits of those as much because they

don't affect the if anything, they slow

heart rate when you're doing them

because of this vala effect that people

get when they weightlift or do

isometrics. And there are people that

believe a mix of aerobic heart rate

increasing versus anorobic heart rate

reducing like isometrics and bench

pressing type things. A mix is probably

a good idea, but I'm kind of the old

school camp here and I probably should

be educated more about this. But I tend

to do what I can do, which is to walk

and try and visit the gym at least once.

Best case scenario, twice a week, 30 to

40 minutes at a crack when I get to the

gym. Yeah, I think I think that the

guidelines call out a combination of of

both perhaps being the if if someone has

the time to do some of that that

cardiovascular exercise, the walking or

jogging or whatever they can they can do

at their level of fitness and then

>> some form of resistance training. And

there was even things in the guidelines

and and some research that stood out to

me that I thought was interesting. some

of those isometric exercises that people

don't really even they don't need a gym

or equipment to do. And I called out

some of those in a previous episode, but

I can perhaps put a link to that into

the show notes because there are things

you can do up against the wall at home

or in in the office without any

equipment that seems to have a

significant impact on on blood pressure.

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That's betterhelp hp.comthe

salt. So you said salt was number three

on that list and and perhaps perhaps

more important for black Americans than

than white Americans. Can you explain to

us how how does sodium salt affect blood

pressure? What's the mechanism there?

Yeah, I'm sure there's a Nobel Prize

somewhere for this, but

it goes back to work that was done at

the University of Mississippi in Jackson

by a guy named Arthur Gayton. So Arthur

Gton studied dogs, instrumented dogs,

and looked at the long-term control of

blood pressure in this environment where

all the dogs had ways to measure their

blood pressure continually. And you

could tweak them. You could give them a

highfat diet, have them gain weight. You

could give them salt and look at the

effects. But of all the things that have

a long-term effect on blood pressure,

many things affect blood pressure in the

short hall. Caffeine, for example, will

do that. Cocaine and illicit drugs can

do that. They wear off pretty quickly in

general. But the one thing that doesn't

wear off is the tendency of sodium to

cause blood pressure to elevate over

time. Every liter of saline, you know,

blood without the red cells, just the

blood, the liquid portion of blood.

Every liter of saline has 159 mill

equivalents of sodium chloride in it. If

your body is set up in such a way that

you just happen to retain 1 mill

equivalent of sodium per month, one of

about 159, but over the course of a

year, you would you would retain 12 mill

equivalents. In 10 years, that would be

120. This is 1 mill equivalent. You

can't even measure that in terms of a

balance study. If you put a person in a

test tube and try and measure sodium in

and sodium out, the precision in our

ability to measure is not that good. So

the kidneys do a marvelous job in most

people of making sure that they put out

in the urine each day or each period of

time. What you get in and we vary our

salt intake all the time. I mean, some

days we'd have, you know, light salt and

some days we just go nuts with the salt

shaker and whatever, you know, food you

happen to like that is really savory and

crunches because you've got so much

sodium laid on the top of it. So, that

issue about a tiny bit of sodium

retention over time, we think under one

of the most prevalent theories about why

high blood pressure develops in the

first place. Because as the volume of

the body expands, I mean, sodium

chloride is the thing that gives your

blood volume, its volume. It's the salt

that keeps all the water around it that

keeps your blood vessels expanded. If

you have a problem getting that

controlled, one of the ways you can get

rid of that extra mill equivalent per

per month that you were retaining is to

raise your blood pressure slightly. When

you raise your blood pressure, that

excretes a little bit more sodium in the

urine. It's called a pressure natures.

Natrium is the Latin word for sodium. So

when we say naturium, we mean salt. And

so that rise in blood pressure, a little

bit of natureratic out in the urine type

of thing and it reduces the body's

sodium content. But you keep doing that

over time and then it's less efficient

over time and you can see how the blood

pressure starts to creep in response to

the sodium retention. That's one

mechanism by which sodium causes blood

pressure to elevate over time. That's

the volume aspect of it. The other thing

that sodium does is it makes every one

of your constricting factors. So things

like adrenaline that makes blood vessels

squeeze, things like angotensin which

you block with an ACE inhibitor or an

angotensin receptor blocker. But if you

give a person angotensin 2, their blood

vessels squeeze immediately in response

to getting that and other hormones like

thromboxins and all those there's a

variety of vasoc constricting blood

blood vessel squeezing type hormones in

the body and when you sprinkle sodium in

there they work more effectively. So the

angotensin 2 effect is enhanced when

there's more sodium present. How do we

know that? Well, we've done experiments

where we've looked at the effect of

angotensin 2 on blood pressure dose

related. Then we give them saline for

either sodium tablets for a month or

saline infusion. And then we look at the

effects of blood pressure of the

angotensin 2 infusion. Same doses and

now it's magnified. So we know that salt

enhances the constrictor effects of

other hormones and it also increases

volume which in turn pushes the blood

pressure up. So it gets it on both

sides. Some people in the world are

splitters. say one of many little piles

and other people are lumpers and when it

comes to blood pressure the lumpers say

there's only two things in blood

pressure ultimately volume and the vasoc

constriction the resistance in the body

and so what sodium does is it bridges

both camps it gets volume side and it

gets vasoc constrictor side that's why

it's helpful I mean if you have no need

for salt then taking salt in just kind

of taxes your system if you live in the

middle of the Gobi desert or someplace

where you're risk of losing salt through

your skin. It's very helpful to have

systems that conserve it. But we live in

a society where there's free access to

salt and consequently it we don't need

it and you know we are we are

predisposed to being a little thrifty

with retaining sodium when we take it

in. And consequently, the con and the

the effect of that is to raise blood

pressure in people that are sensitive to

the sodium aspect either in the short

term like the black Americans or in the

long term like everybody we think has

ultimately a role of sodium in their

blood pressure at some point.

>> What's the difference between

sodium chloride and potassium chloride?

Other than the obvious in terms of the

mineral that we're talking about, but

what's the difference in terms of the

effect on blood pressure?

>> There was a decision made at some point

about what the most important cation

positively charged ion should be inside

cell water or outside the water outside

the cell. We live in a an osmotic

environment. We don't live in pure

water. We live in water that has a

certain dissolved number of particles.

The most important of which are sodium

and chloride in the blood and potassium

in the cell. So we have if you measure

your blood blood sodium level Simon it's

going to be about 140 not the 159

because blood is a you're only measuring

the sodium content in in 93% of blood

when you do the 135 to 140 because 7% of

blood is solid. So when you look at

that, it's the 140 mill equivalents per

930 mls of blood. That said, when I

measure it in your blood, it's 140. If I

measure the sodium inside your cells,

it's 8 n 140. So what's making up the

other positive charge in your cell? And

the answer is potassium. So inside a

cell, potassium is king. Outside the

cell, sodium is king. And the magnitudes

are about the same. So the relative plus

outside the cell and inside the cell

runs around 140 to 150 on both sides of

the cell membrane. It's just that

potassium is more important in the cell.

Sodium is more important in the tissues

and the fluids around your cells and the

tissues that circulate the blood volume

itself. When you eat potassium, you take

potassium in. Potassium has a couple of

beneficial effects in the body. One

thing it does is it helps improve the

way the lining of the blood vessel talks

to the muscle layer. So blood vessels

have three layers. The lining, the

muscle, and the outer layers. It's

called the adventicia.

What the muscle layer does is it waits

for signals from the inner layer. It's

called the inima. And one of the things

potassium does, it helps the inima make

the signals a little nicer that relax

guys. We got this under control kind of

thing. So potassium has a beneficial

effect on what's called endothelium

because that's the name of the cells

that line the inner lining. It has good

effects on the endothelium. Potassium

also has some other benefits. It reduces

stroke risk in animal models of high

blood pressure that are stroke grown.

And so we think it's a good idea because

when we measure the effect of dietary

sodium on blood pressure, it's it's

clear that in populations that eat lots

of salt, there's a relationship. But if

you look within those populations, the

effect of sodium intake on blood

pressure is mitigated by the amount of

potassium. So we have a diet where we

have a lot of sodium and relatively

smaller amounts of potassium in most of

our foods because a lot of it's

processed foods and sodium just tastes

better. Honestly, it's a savory issue.

But if you look at peoples that have

very high potassium intakes and very low

sodium intakes, a couple of Aboriginal

tribes around the world, their blood

pressure doesn't change across the

lifespan and it's normal. So the

potassium and sodium balance in the body

is what we really think is important

now. And if you work on it by reducing

your sodium intake and increasing your

potassium intake, you help alleviate

that component of the support for blood

pressure being elevated. So we kind of

emphasize potassium because of its

benefits on the endothelial lining and

it's just its generic benefits in terms

of outcomes like stroke. So it seems

that this is another kind of mismatch

between our biology which is has evolved

through adaptation over time and the

environment that we find ourselves in

today. So at some point hundreds of

thousands of years ago perhaps this like

significant drive for sodium kind of

what you pointed out before if you were

living in the desert served us in an

environment where sodium availability

was low.

Whereas today, we still have that same

drive, biological drive and reward for

sodium, but we live often in an

environment where we're sweating less,

moving less, and surrounded by very high

sodium foods.

>> And the other side of it, Simon, is that

if you look at a sort of agrarian

approach to life as opposed to an urban,

you know, city dwelling approach to

life, what does a farmer eat? vegetables

and fruits maybe lux meat is a luxury

but vegetables and fruits tend to be

higher in potassium and lower in sodium

so a vegetarian will tell you that you

know that's the way God planned it here

is to have that kind of intake as

opposed to eating animal protein I enjoy

a nice ribeye so sorry about that but

occasionally the animal protein just I

think is more satisfying from a taste

standpoint but it also makes sense from

the fact that an agrarian approach which

you know early human beings tended to be

farmers. A lot of you know

susceptibility to the environment as a

result of that. But that kind of intake

favored potassium and most fruits and

vegetables are low in salt.

>> And then coming back to what you were

saying earlier. So it's a two-fold

effect. We have higher sodium intake. we

have lower potassium intake and the

lower potassium intake makes us more

sensitive in a sense to sodium.

>> That's the thinking right and but that

sensitivity does vary somewhat depending

upon your your ethnic background. The

other thing, Simon, honestly, is that

one of the things the sodium literature

had as a plague on it is that when you

look at the studies of salt sensitivity,

one of the things we struggle with is

what's the definition of being salt

sensitive? How many millimeters of

mercury does your blood pressure have to

go up over what period of time to say

that x number of milligrams or mill

equivalents of sodium sodium chloride

did that because it's sodium chloride

that's the issue sodium gluconate sodium

bicarbonate doesn't have quite the

effect sodium chloride that has the

effect

>> well I think the colloquial definition

of salt sensitive raymond the one that I

hear quite often is when People go out

and and have a a night of lots of fried

food and a lot of salt intake and then

wake up the next morning and you hear

people saying, "I I have a salt

hangover." Or they, you know, they feel

puffy in the eyes and feel hung over.

>> Yep. Yep. They bought the economy sized

bag of potato chips and they were you

know watching power rings of power on

Netflix or something and the next

morning after they consumed you know a

16 bag they have something related to a

headache like that. Yep. That that's not

uncommon.

>> If we're thinking practically here to

think about food swaps and what this

means for the average person's diet. So

I think earlier you mentioned the

current person living in a western

country is is consuming about double the

recommended sodium intake. And so if if

we're thinking about solving this

problem here and having the greatest

impact on blood pressure, what I'm

hearing is that you want to try and

reduce your sodium intake. My

understanding is that most of that's

coming from ultrarocessed foods, not

necessarily the salt shaker, although

that could could be the case for some

people. So it would be leaning a little

bit away from the ultrarocessed foods

that are sort of high in sodium to make

them taste good and at the same time

eating more fruits and vegetables which

naturally contain more potassium would

seem like a very favorable kind of

shift. What if someone is thinking, "Oh,

maybe I can just keep my diet as it is

and and take a potassium supplement."

That's been done actually in some of the

studies where what's the effect of just

adding a potassium supplement to the

diet. And it turns out the potassium

supplement has some benefit even though

you don't change the background diet. So

it's worth it to do that. But the caveat

two two caveats actually. One is that

when the kidneys aren't working so well,

your ability to excrete a potassium load

may be compromised. And potassium if it

rises in the bloodstream, potassium is

very tightly controlled. The normal

value is between three and a half and

five. And that's a narrow range for most

things in the body. So if you lose some

kidney function, it may it still tries

to keep it between three and a half and

five. But if you throw a load at it by,

you know, a generous helping of a

potassium related salt substitute in a

meal, it could pop up over six or even

seven. And the problem with potassium,

the biggest problem, is there a problem

with this? Yeah. The problem is that

there's no sympto, no reliable symptom

for high levels of potassium. So there's

not something where you can say, "Oo, I

think I should get my potassium checked

because I feel X, Y, or Z type

symptoms." Where potassium manifests

itself as overtly high is when it stops

the heart. And that gets most people's

attention when that happens. But there

may not be any pre-monetary signs. So

that's why I'm always telling people the

caveat of if your kidney function is

normal about salt substitutes. The other

thing is that ACEs and ARBs, they affect

one of the hormones, eldoststerone, that

helps get rid of potassium. You got to

when you eat it, you can't store it

anywhere. So you got to get rid of it.

And the controller mechanisms that do

that among other things include a

hormone from your adrenal gland called

aldoststerone or aldoststerone depending

on where you put the accent there. And

aces and arbs affect eldoststerone. So

you're not as able to handle a potassium

load in some people when you're on those

drugs. So that's why the you know the

moderate approach here. Add some but

don't go crazy in terms of the amount

makes perfect sense. And then the one

that the other swap that you mentioned

earlier is is swapping out regular salt

potentially for a potassium chloride

kind of low salt option which are now

pretty widely available in countries

like America and Australia.

>> Correct. Correct. And the other thing it

does help to look at labels. I mean what

people often don't appreciate is there's

a fair amount of salt in dairy products

for example. You know ice cream. You

look at the the labels on ice cream. I

mean, it's just fascinating how it

doesn't taste like salt unless you get

the salt caramel type of ice cream. But

in general, sodium content in dairy is

pretty high. Pizza is notorious for

salt. To make V8s, when we were doing a

study where we had to get people on a

high salt diet, a really high over, you

know, about twice what the average

American eats, we we supplemented them

with V8. You know, we give them little

six packs of V8. is a great way to push

your sodium levels up for a short term,

like a couple weeks. I mean, we weren't

trying to, you know, create hypertension

in the process. But looking at labels is

extremely helpful. The goal, what are we

aiming for? We're aiming for 2,00 to

2500 milligrams per day. That's

achievable most of the time. the 1,500

milligrams per day that American Heart

Association and others touted. I don't I

never tell patients that because I don't

think it's possible with what dietary

availability we have to really get down

that low without the help of a

dietician. And some of the la the labels

or the foods I should say that I think

kind of sneak up on people are the ones

that you would think are healthy or

relatively healthier. Like falafel for

example, sometimes you can buy falafel

and there's like a,000 milligs of sodium

per serve. Even some of the pasta

sauces, the tomato pasta sauces that you

can buy, you know, again, they're kind

of like the V8 where the base you think

it's it's tomato. So it this is a

healthy food, but the sodium can be very

high as well.

>> Lunch meats are another source and

bread. Bread has salt in it. I mean,

it's very enlightening to look at

labels, especially good labels that have

not only the, you know, the fat and the

protein and the carbohydrate, but also

the minerals underneath it. And keep in

mind, a serving is sometimes

conservative in terms of what you

consider a serving. So, you know,

having, you know, 1 oz of potato chips

or so, that just to me, I just put that

aside. I know I'm going to eat more than

that if I'm committed to having a bag of

chips or something like that. But the

amount of sodium in some foods is just

really well hidden. Lean turkey is safe,

but you know, bologoney and things like

that, a pepperoni. Look at the labels. I

mean, it's incredible. Does someone need

to worry about their salt or sodium

intake if their blood pressure is

currently

120 over 80, 115 over 80?

>> Yeah. I used to say, "Oh, don't worry

about it." And then I met Graham

McGregor from the United Kingdom.

There's a thing called WASH, which was a

movement in the UK to reduce the amount

of sodium in food and it was successful.

And Graham McGregor was one of the

forces behind that. And I was with him

at a at a luncheon that the American

Society of Hypertension held. And I went

to reach I am embarrassed to say this,

but it's a true story. I went to reach

for the salt shaker and he almost cut my

hand off at the wrist. He says, "What

the?" And insert your favorite

expletative. What the blank are you

doing? And I said, "Oh, I'm suppressing

my re inactivity." Which is what, you

know, it's one of the clever things we

argue for sodium intake. And he said,

"Are you out of your mind?" I said,

"Well, my blood pressure is okay." He

said, "So what? Don't you realize that

sodium also drives calcium out of your

bones?" And I'm like, "Oh, I didn't know

that." And it turns out he's right. The

sodium intake is linked to bone health

in some certain not everyone, but in

some people, and it's enough that when

you enhance your sodium intake, you

leech some calcium out of your bone. So

the answer to your question is, yeah, it

does make a difference for some people

in terms of osteopenia. Osteoporosis is

a bone diagnosis. Osteopenia is what we

usually see when we X-ray bones and say,

"Oh, they look osteoporotic,

but it's osteopenia. There's less

calcium in the bone." That's the

technical term for it. But yeah, there

are health consequences to higher sodium

intake over and above blood pressure. I

have a colleague at the University of

Delaware and he's looked at the effect

of sodium intake in people with chronic

kidney disease who have normal blood

pressure and in a small amount it

doesn't affect the blood pressure but it

does affect the way the blood vessels

respond to stimuli that should relax

them. So they're less able to relax.

That's called endothelial function. So

sodium remember I mentioned before about

that whole thing with potassium

improving endothelial function. Sodium

reduces endothelial function. It's

another effect and it can do that

independently of elevating the blood

pressure.

>> How do you feel about athletes who are

sweating a lot and have normal blood

pressure and are replacing using kind of

an electrolyte mix that has sodium and

potassium and magnesium?

Are those types of supplements, products

safe for athletes at a certain dose?

>> You know, I think that because we don't

have, you know, a queue at every urgy

center with people that have passed out

or in our hypertensive crisis as a

result of downing 2 lers of Gatorade

after a vigorous workout. When we when

you look at what athletes go through in

terms of the periodic stress to their

system, it's not like you're walking

across a desert, the Sahara, and you

have the same 24-hour type of

circumstances that the body will adapt

to. They have a limited time where

they're going all out and they're

sweating up a storm and they're losing

sodium through the skin when they do

that. There's no question about that.

And because it's isolated, they have a

lot of time to recover. So they're not

making permanent changes in terms of

conserving salt loss through the sweat

glands of the skin over time. They're

doing it periodically. So they're still

having a sweating episode. And by and

large, they're young. And consequently,

when you're young, the body is a little

more tolerant of a lot of the things

that we do, including if you take

Gatorade or the what's that called?

There some kind of water. It's it's like

perfect water or something. When you

take those water compounds with

electrolytes in them, the kidney's

function is usually pretty good in these

people and it'll handle the excess of

any mineral that it doesn't need and

excrete that and it will also save the

sodium that it does need in order to

replenish what was lost through the

skin. They can lose quite a bit of salt.

So um I generally don't have big

reticence about that kind of

circumstance in people that are pretty

young and pretty healthy and do work up

quite a sweat. So in general, but the

idea of a 55year-old overweight guy

who's going out for a onem walk who

takes a liter of Gatorade beforehand

that just that's where I would draw the

line.

>> Right. Context matters.

>> Context. in the in the literature

there's there's quite a a bit of

evidence on the DASH dietary pattern for

lowering blood pressure and in fact it's

mentioned in the dietary guidelines.

What is it about the DASH dietary

pattern that you think helps lower blood

pressure? Is it that it's low in sodium

and rich in potassium or is it something

else?

>> It's it's a mix of things actually.

You're right about the sodium and the

potassium balance. it's crafted that

particular way. It's also relatively low

in some of the bad forms of saturated

fat, for example. So, it's it's

specifically designed to meet both the

fat issues as well as the electrolyte

issues. Sodium is one of the many

electrolytes to help balance the ideal

intake of food. The thing about the

original DASH diets, and people kind of

forget this, is that the patients

enrolled in those studies that ate the

DASH diet didn't make the food. They

went to a center. They got a cooler

sometimes twice a week. They took that

food home. They ate only what was

supposed to be in the cooler. No

exceptions was the rule. And so that you

had your diet handed to you. And so you

didn't make the food choices. It was

done for you. and you have very careful

dieticians in the background making sure

that the food is weighed and it's, you

know, it's personalized to you. When you

look at like a website that says how to

follow a DASH diet, it'll have helpful

suggestions for how to achieve the

relatively low sodium concentrations in

food and how to reduce saturated and

trans fat and the other things that are

considered bad for you. But the DASH

diet when properly applied has almost as

much blood pressure benefit as a drug.

And so when you have the especially the

low sodium DASH diets, you get a 10 or

11 millimeter drop in the systolic blood

pressure in people who are not on

medications but have blood pressures

that are in the 130 to 140 range. So I

think in that particular respect, it's

good. It's just it's hard to follow

diets that are low in salt for the long

haul. Well, it gets back to that whole

thing about the fact that people wear

out when it comes to behaving. It's like

being in a a very strict school

environment with your hands folded in

front of you and paying very close

attention to the teacher all day.

Sometimes you just want to break. I

mean, I I want to go out and I want to

have a spaghetti carbonara and I want to

have two glasses of, you know, giant

with it. So, periodically, people are

going to just break the rules. But by

and large, the DASH diet is a good

thing. The Mediterranean diet, which

emphasizes olive oil, among other

things, is also a good diet.

>> Yeah. And I think I think with these

types of dietary changes, when you're

changing an entire dietary pattern, at

least from my experience, it's much more

noticeable in the acute early periods

when you transition from a diet that's

loaded in saturated fat and salt and

fried foods to a diet that is very low

in sodium. That's a big difference

acutely.

But over time, like I I can at least

speak from my perspective and and you

know, my context and circumstances are

different to everyone else out there.

So, take this take this with a grain of

salt, pun intended. Um, I I found that

my craving and thirst for for salty

foods is nowhere near what it used to

be. Um, that said, of course, I still,

like you, you know, I want to go out and

enjoy myself and and have the high

sodium ice cream from time to time, but

I think my body has adapted over time

where it feels easier almost to eat a

low sodium diet than it did early on.

>> Yeah. The It's interesting because our

drive to eat salt is not genetic. So far

as we're known, as so far as is known,

our sodium appetite is partly dependent

upon what we were fed as a child. So if

you had a parent that made your food

that mixed it up and oh, this needs a

little salt and added a little salt to

it, you're more likely to to take that

over in terms of your young years, your

adolescent, and your young adult life.

Salt intake is learned, not programmed,

as far as we know. So when you reduce

your sodium intake, especially if you do

it abruptly, stuff tastes bland,

absolutely bland for a couple of weeks,

maybe a month, and then suddenly it

starts to taste okay. And then when you

eat foods you used to just enjoy, now

they're too salty for you because your

systems change based upon your intake.

So the the the sensory response is

secondary to the intake. It's not that

the intake is secondary to the thing

here telling you eat more salt. The

things up here that determine your your

appreciation of salt through the salt

receptors on your tongue are secondary

to your intake. And so the our ability

to have our thresholds met for

satisfaction from sodium intake are

learned as opposed to programmed. It's

fascinating. If someone's listening and

thinking,

I' i'd like to first understand if I am

someone who is quote unquote salt

sensitive, so I understand how much

these changes are likely to affect my

blood pressure. Are there any biomarkers

or tests that someone can do to say,

"Oh, actually I am a salt sensitive

person." There are a number of them. I

won't put my quarter down and say this

one's the best one of the group, but the

simplest one is a measurement of a

hormone we call reenin. So rein comes

from the kidney. In in Greek, the kids

the kidneys are the renown or renown in

Spanish the renown. And the the rein is

a hormone that the kidney makes. When

you restrict salt, the reanin will go

up. when you give salt, the reanin goes

down. So, one of the things that we use

to look for salt sensitivity is that the

rein if it's low is a marker of someone

who's likely eating more salt or at

least their body is treating their

sodium intake in such a fashion that we

don't need anymore if we got plenty on

board. So, anything you eat additional

is not needed to have our circumstances

met. And when you look at the rean

activities in white versus black

American populations, for example, black

Americans are far more likely to have

low rean activity because they're more

salt sensitive than white populations

are. And so that's one marker for it.

Another marker is a very strange thing

called 20

or 20 heat for example. And this is a a

designer type of biioarker. It's not

something that the average doc is even

going to ever have heard of, but 20 heat

sensitivity is another thing that marks

your likelihood of being salt sensitive

versus not being salt sensitive. And

lastly, the ability of the salt intake

to suppress the other key hormone in

sodium metabolism, the one from the

adrenal gland called aldoststerone.

We're at the point in medical care right

now where we're beginning to realize

that there are patients with high blood

pressure whose renan is suppressed and

their body is telling you we got plenty

of salt on board. Maybe a diuretic or

something like that would be a good idea

here but their aldoststerone levels are

not similarly suppressed the way the

rean activity is. So we're looking at a

thing we call disregulation like

disease. Well, this is disregulation.

So, a Y instead of an I. But some people

have an aldoststerone or an

aldoststerone level that's squarely in

the middle of the normal range. Normal

range is about 3 to 15. Maybe they're

10. Meanwhile, their reins are low at

one, but their aldoststerone is not low

at three. It's up there at 10 where it's

saying that I'm still active retaining

salt for this person. And so that

eldoststerone to rein disregulation is a

kind of new thinking process that we're

beginning to look more closely at as a

means to understand why it is that some

people are so salt sensitive or better

yet are responsive more responsive to

blood pressure medicines that

specifically interfere with

aldoststerone and its effects. So is

there a specific ratio that you would be

looking for?

>> Right. So the ratio has been

unfortunately a difficult concept for

people to understand. We measure when I

when we see a new patient at Penn and

they don't have an obvious explanation

for why their blood pressure is so hard

to control. We usually measure

aldoststerone and reinactivity.

We don't usually apply the ratio until

the eldoststerone is clearly elevated

and that's usually above 20. So even

though 15 to 17 depending on the labs

the upper limit of normal we don't

usually apply the ratio until it's over

20 for the following reason. Let's say

your aldoststerone is 10 right in the

middle of the normal range but your

renan activity is 0.3.

So when you do the 10 /.3

what do you get? You get a big number.

But if you do the 10 divided by a normal

rean of two you get five. So that's a

normal aldoststerone to rean ratio. But

if you happen to be a low rean person

now your ratio is elevated to the point

where it's pointing to aldoststerone as

being the problem. I mentioned we're

rethinking that whole paradigm. But in

the meantime to use the ratios

effectively, they're driven mainly by

the reanactivity. So we don't usually

use the ratio to say someone has an

aldoststerone or an aldoststerone excess

until the aldoststerone level in the

blood is clearly above the upper limit

of normal. So we don't apply the ratio

until it's over the aldoststerone levels

over 20 and then we use the ratio and

typically the aldo's high and the

renan's suppressed or even really

suppressed and that leads us to saying

okay this person seems to have an

aldoststerone excess problem and then we

talk to them because if they're willing

to have surgery we may find a tumor some

of the time in the adrenal gland that

makes aldoststerone in the first place.

Removing that tumor can help control

their blood pressure or even if they're

young and recently hypertensive, even

cure their blood pressure in some

circumstances until the aldoststerone is

elevated.

>> I was just curious if there were any

commercial tests that someone could

quickly do that would say you're salt

sensitive or not.

>> No, no, no test for saying definitively

on that. The the usual test, I mean, the

the group at Indianapolis kind of set

the bar here for us. They would take

patients into their clinical research

center and these are all walks of life

on a Friday. They put them on a high

salt diet for the two days and then

check their blood pressure on Sunday

night, Monday morning. And look at the

difference when they came in on Friday

versus when they go home on sat Monday

morning. and they would put them on a

high salt diet and then they bring them

back on a different weekend and now

they'd fill them full of a diuretic

called fioamide and they would salt

deplete them. So you got the extremes

salt excess salt depletion and then they

would look at the blood pressure

responses on the two different regimens

and they would say that oh here's what

you were high salt here's what you were

on the diuretic thing if that's more

than 10 millimeters of blood pressure

reduction you're salt sensitive. If it's

not, you're salt resistant. And it was

as simple as that. And they did

thousands of patients at Indianapolis in

years gone by to come to that

conclusion. Other people have been a

week long type of sodium excess and then

a week long of severe sodium

restriction. I've done those kind of

studies in the past. There you might

argue that the difference could be as

little as five millimeters of mercury

different between the two because now

you've done it in a longer fashion as

opposed to, you know, hitting them with

a 2x4. you're tapping them with a straw

instead by braing 7 days instead of 2

and 1/2 days to get the response.

>> So if someone's doing this at home

though and they let's say they they swap

their salt for a potassium chloride.

They're eating less ultrarocessed foods.

They're eating more of a dash dietary

pattern with more fruits and vegetables.

And they do have the atome blood

pressure cuff and they're using it in a

validated reliable manner like you

discussed in our previous episode. And

over the course of a month, they're

keeping an eye on their blood pressure

and they're adhering to those changes.

That would be long enough for them to

start to see some changes. Absolutely.

So, if you take your blood pressure

twice in the morning, twice in the

evening for a period of at least three,

but preferably five and gold star seven

days in a row. That's your baseline.

Then you make your change whether it's

less salt, more salt, more potassium

supplement, less potassium supplement,

more whatever, less whatever, whatever

it is. And then you check again at the

end of a month. That's certainly enough

time. And by virtue of taking two blood

pressure readings in the morning, two

blood pressure readings in the evening

for at least three, better five, and

absolutely platinum if you do it for all

seven days. That'll really tell you

whether that particular circumstance had

an effect on you or not. That's enough

data. I would argue that that's enough

data.

>> You're taking all those measurements

across a week and then you're taking the

average of is like your blood pressure

for that week. Gotcha.

>> Right. Right. Yep. Yep. So that's 28

readings, right? Four four per day,

seven days, 28 readings. That's a lot of

blood pressure readings. And by doing

morning and evening, you catch the

normal circadian the the daytime

variation in blood pressure by doing it

that way.

>> That was actually one of my questions

that I I wanted to to bring up later,

but let's hit it now. How important is

blood pressure variability? And is that

an emerging area of science similar to

if we're looking at heart rate, heart

rate variability?

>> It's a tough question to answer in a

simplistic way. So, let me try this.

years ago, I wrote a editorial piece on

the choreography of the circulation, the

difference between heart rate

variability, which is good, and blood

pressure variability, which isn't good.

So, you want your heart rate to be

plastic, to be flexible, to change

quickly on any kind of circumstance, the

fight orflight reaction. Oh my gosh,

there's a saber-tooth tiger after me. I

better pour it on here. I got to get my

heart rate up to pump more blood to my

leg so I can run faster. Blood pressure

variability. Blood pressure is so well

controlled by pressure receptors in your

neck, corateed artery and your aortic

arch and pressure sensors in your kidney

that have to do with that sodium

business I talked about before. So blood

pressure variability when you have your

blood pressure doing all sorts of you

know highs and lows across 24 hours that

actually is more of a bad thing than

having a blood pressure with less

variability over 24 hours. And the

reason why, at least one reason why,

there could be a bad side to having

blood pressure variability is that when

your vessels stiffen with age and you

know many years of blood pressure and

you know use of cigarettes, presence of

diabetes, lots of things affect blood

vessel stiffness. Then the ability of

these receptors in your neck, your

aortic arch, their ability to dampen

fluctuations in blood pressure becomes

diminished and consequently you have

wider fluctuations in blood pressure

with activity, with sodium intake, with

watching TV at a horror movie or

whatever and it happens to affect you.

Anything that triggers a response either

in your involuntary nervous system or

directly by some other thing that raises

blood pressure is less dampened so that

the excursions of blood pressure over 24

hours are increased. And years ago, a

guy named Peter Rothell from the UK

showed that in he was studying patients

after strokes and things like that. body

noticed that the people that had the

most fluctuation in blood pressure, the

variability in blood pressure were the

ones more likely to have a recurrent

stroke. And when you think about it,

what those fluctuations likely tell you

is that that person's response to

stimuli that affect blood pressure and

heart rate is affecting blood pressure

more than someone else who's quote

healthier. But also that when you look

at visit to visitto visit variability

and like patients that are seeing you

know a blood pressure doctor for 5 years

and you have 30 visits or some number of

visits over those years and you look at

the variation in blood pressure over

time that's called long-term variation.

If it fluctuates a lot, this is a person

that may forget to take their medicines

at times or has wild fluctuations in

their dietary salt intake or

periodically exercises and then becomes

a couch potato and then periodically

exercises again. They may do things that

affect that. In the short hall, in a

24-hour period, blood pressure

variability again is a marker

particularly of vascular stiffness. And

so we we look at that as a potential

this isn't good type circumstance. But I

can't tell you in the same breath that

we have great ways of reducing

variability in blood pressure. The blood

pressure medicines I mean they dampen

the overall blood pressure curve. So of

course they reduce variability because

they reduce blood pressure. When you

reduce it from here the excursion if

it's this much is now this much. But

there's no good way to eliminate or to

greatly reduce blood pressure

variability that I know of that's been

tested in a clinical trial fashion and

someone says we absolutely need to do

more about variability cuz here's the

data to show it's beneficial. Are you

hopeful, optimistic that we're going to

reach a point where there will be

wearables that are measuring blood

pressure for people in a less cumbersome

way than the current kind of ambulatory

blood pressure systems?

>> I am incredibly hopeful but skeptical.

And here's the skepticism. What we have

currently, okay, so take a step back.

How does a blood pressure monitor appear

on the shelf in a pharmacy and says FDA

something on it? Right. So the FDA has a

process where they say to a manufacturer

of a blood pressure measuring device,

does your do you have validation data?

No, I have no validation data. Well, why

should we clear your device? Oh, because

it's the same as or similar to very

similar to essentially equivalent to

something you've already cleared. Oh,

okay. You get clearance for that. So FDA

doesn't ensure that a even a standard

thing in your doctor's office may or may

not have ever done a validation study.

So we don't know when blood pressure

monitors purport to measure blood

pressure how good a job they do until we

measure 85 people with seven blood

pressure measurements per person. You

know one to set the scene and then we

alternate the device versus the

standard, the device versus the

standard, the device versus the

standard. seven blood pressures on that

person and we have two people blinded to

each other that are listening for that

to be the standard of the blood pressure

effect. this validation difficult thing

to do. You got to do 85 people. It's a

lot of work and it's not cheap to do

that and that's for the type of blood

pressure device that is espoused by

health care professionals saying I will

manage your blood pressure if you use

this particular device and use it well.

The wearables on the other hand like

this guy here or some of the ones that

you stick your cell phone on your chest

and it listens for it or some of the

ones where you press a photosensitive

sensor to your skin and it measures the

plethismographic pulse of the blood as

it comes into the tissues. They're

getting better, but I don't think

they're accurate enough to currently

manage blood pressure given the current

constraints of they don't do a good job

at trends in blood pressure over 24

hours or trends in blood pressure after

you've made a change with the

medication. They require recalibration

and that recalibration issue is the

problem. If you don't recalibrate them

frequently, they lose their ability to

measure blood pressure. But I have a lot

of confidence in the ability of smart

engineers to overcome these

shortcomings. I mean, there are people

using radar in terms of measuring blood

pressure, ultrasound to measure blood

pressure. They can measure the pulse

wave velocity in a segment of your

brachial artery right inside here, you

know, a couple centimeters and they know

how fast the thing is traveling and

that's related to blood pressure. So,

there's a lot of interest in the

wearables because like you say, if you

wear one of those cuffs that I've done a

lot of work with over 24 hours, the

thing goes off every half hour. And when

that goes off at midnight, 12:30, 1:00

a.m., 2 a.m., 3:00 a.m., 3:30 a.m., it

is hard to really believe that that was

a good night's sleep. And those blood

pressures during sleep are truly

representative of what that person does.

And plus, if you're a little chunky,

like a lot of people are, you got to put

the bigger cuff on. Bigger cuff, it

hurts more when it goes off because

you're squeezing with a big cuff instead

of squeezing with a smaller cuff. So,

there's there's always shortcomings to

our current ways of doing things. And I

think there's a lot of hope in the

wearables, but right now and even with

the current AHA, ACC, and you name it

with an A in it type of guideline that

we have in 2025, there's a a class three

do not do this to manage blood pressure.

You want to do it recreationally, go for

it. But in terms of managing blood

pressure, I don't think they're ready

yet, but I think they will be in the not

terribly distant future. Coming back to

some of these lifestyle changes that we

can make. I I have a number of questions

from people in the community. So perhaps

I can throw some of these these extra

ones at you as a bit of a rapid fire and

and feel free to expand upon your answer

where you see fit. Fermented foods,

we've spoken about sodium. Fermented

foods are like kraut and kimchi often

considered very healthy foods but can be

high in sodium. Do you have any

particular views on fermented foods and

and their role in someone's diet?

>> As far as I can tell, Simon, the body

treats sodium chloride as sodium

chloride, no matter how it's filtered

before it gets into you. So, I don't

have a strong feeling about the sodium

aspect of those. There may be other

things in fermented food that has health

benefits independent of the salt that

may outweigh the effect of the salt, but

I don't have enough bandwidth in my set

of facts up here to say one way or the

other. I like kimchi, so you know, I do

eat it, but I don't know enough about it

to recommend it.

>> Me, too. And and I think it's worth

underscoring

at least the stat that I've seen is

about 80% of sodium in the average

person's diet is from ultrarocessed

foods, not from

>> fermented foods. So it's not that not

that we're pointing the finger at

fermented foods, but they are high in

sodium for someone who's trying to

reduce sodium. They could be something

to look at if they're consuming an

unusually high amount. For example,

alcohol, you mentioned earlier, and this

is in the guidelines. Alcohol reduction

being another way to lower blood

pressure. How does alcohol affect blood

pressure? Is it is it through its effect

on calorie intake and body weight or is

there an independent mechanism?

>> So it's you know it's it's not really

clear to me Simon how it does it because

there's a guy in Australia named Larry

Balen has been studying alcohol for

decades and alcohol has what's called a

bifphasic effect on your blood pressure.

So, if you bring a bunch of people into

a clinical research center and you give

them all, you know, two two jiggers of

Jack Daniels at 7:00 at night and, you

know, they're all kind of social, etc.,

what you see is in the hours following

acute alcohol ingestion, there's a drop

a drop in your blood pressure. It's on

the range of 3 to four points. And then

if you compare alcohol versus no alcohol

to what happens the next day 12 to 15

hours later there's a rise in your blood

pressure of about five points. So drop

in three rise in five that's a net of

two. And when you look at what alcohol

typically does to blood pressure in

guidelines where they simply give you a

chart you know sodium intake reduces

blood pressure five points. Exercise

reduces blood pressure six points.

Alcohol reduces blood pressure two to

three points. It's usually that the

bottom of the list of things that have

an effect on blood pressure. Because if

you do an honest study of it, including

24 hours, not just the effects the next

morning, you have a drop and a rise. And

the rise out outweighs the drop when you

have at least a threshold amount of

alcohol to see a blood pressure

response. Alcohol may have things that

it does in terms of lipids and longevity

that ex may explain things like the

French paradox with how they can how

they can eat goose liver with loaded

with fat and drink red wine and they

live forever. How is that the case?

Maybe there are certuins and other

things in the red wine that help. So

sometimes the trappings of what comes

with the alcohol may influence the net

effects. What epidemiologists have been

worried about in the last decade and

even the last five years in particular

is that there appears to be a rise in

cancer incidents especially among

younger people and there's a concern

especially for GI cancers that alcohol

may be a component in that. So you see a

35 or a 40year-old with colon cancer,

it's like, wow, that's unusual. But, you

know, there's there's a fair amount of

alcohol intake, especially in the US.

So, I always treat epidemiology

associations with my wife and I talk

about this all the time with a bit of

skepticism because people that tend not

to do something often tend not to do

something because they have a lifestyle

that doesn't include that something. And

it may be the lifestyle that's the

benefit here, not the not doing

something per se. And so, it may be that

they're healthier because they eat less

salt and they run every day and that

kind of thing. and they just don't have,

you know, tequila sunrise every

particular evening at least or even

several of them. So alcohol in the

current guidelines, they're actually

suggesting when possible don't have any.

And so that's that's more than I think

some people are prepared to give up at

this time, but it does make some sense

from the epidemiology. I'm just a little

skeptical that epidemiology is perfect

in its ability to govern the

recommendations that we make generically

for all people. I mean, epidemiology is

effects on groups and when we take care

of patients, it's an individual

phenomenon. And I believe if I recall

correctly, I think from the guidelines,

the biggest benefit in terms of blood

pressure lowering is if you're coming

from like a higher baseline intake of

like six or more drinks a day and then

coming down to that one or two mark.

Yeah, we we we've talked about this even

amongst our our group and our

hypertension case conferences because

every once in a while you'll see someone

that you know claims to have two drinks

a day and they're having episodes where

their blood pressure is nuts and they're

in the ER and it turns out they're

actually binge drinking and they're

having blood pressure crises afterwards

because they have such high alcohol

intake. That's not rampant and common,

but it does happen. So there's clearly

an effect particularly at high levels of

alcohol intake not just on the liver

with cerosis but alcohol affects bone

health as well. It's another factor that

contributes to osteopenia in the bones

and it affects maternal health when

you're you know carrying a kid during a

pregnancy and it can affect blood

pressure. So different to alcohol where

alcohol you said leads to an acute

reduction in blood pressure but then the

next day or 24 hours there's an increase

and there's a net increase.

>> Yeah.

>> Different to that would be the effect of

something like coffee which contains

caffeine. My understanding is that that

will increase blood pressure a little

bit acutely. But at least in the

epidemiological studies that I've seen,

coffee intake is not associated with

hypertension and there's associations

suggesting neutral or a risk a

cardiovascular disease risk reduction.

So when you think of coffee and

caffeine, how do you kind of square all

of that literature with regards to

hypertension and blood pressure? So

every time something is published that

implicates coffee in some bad outcome,

give it two months, there'll be two or

three articles refuting that, showing

the exact opposite. Coffee consumption

is such a common thing that there are

people that will just swear by it and

there are people that are just like it's

the wrath of God descending upon us in a

in a hot beverage format. So I remember

when I was a medical student, this

article came out in the New England

Journal of Medicine saying can

pancreatic cancer was caused by coffee.

And then you looked at where the study

was done. It was done in the waiting

room of people in a GI practice. Well,

that's a little selective. Why are they

in the GI waiting room? Because they

have symptoms that are leading them to a

GI doc. And oh, by the way, they drink

coffee. So you're looking at a very

selective subset. And then there's tons

of epidemiology sense to dispel that

notion. Coffee causes heart disease.

Well, guess what? The filters especially

tend to suck up some of the bad stuff.

So when you put coffee through one of

those paper filters, it tends to have

less effect. And consequently, when you

look at blood pressure, when you look at

heart rate, when you look at a bunch of

things, you take a step back and you

say, what has industry done over the

last hundred years that really has been

a key element of effectiveness? Coffee

breaks for their workers. Why? Because

coffee increases efficiency. Coffee

helps people think better. It gives them

a little extra energy. And yes,

short-term coffee usage can raise blood

pressure and heart rate. But you take a,

you know, someone who's a six cup a day

coffee drinker, the effects on heart

rate and blood pressure are much

lessened in the chronic exposure to it

than they are acute. Someone who never

drinks coffee has a double shot espresso

and then regrets it like an hour later

because they got this pounding in their

chest. There's some people that are

sensitive, but that by and large I can't

tell you that coffee has caused the

complications of hypertension, heart

failure, and all the other things. But

we do recommend a half hour at least

elapsing between previous coffee intake

and blood pressure measurement simply

because we want to know the resting

blood pressure in an individual in terms

of prorating their cardiovascular risk.

That's the reason it's prescribed by our

technique protocol.

>> What if they drink coffee every day all

day though? Would testing them in the

context of not having drunk coffee not

be reflective of the blood pressure

they're actually subjected to?

>> Touche. I'll just leave it at that.

Touche.

>> Okay. I I have to ask you this question.

As a nefologist, there's ongoing debate

around protein and kidney function. Y

>> also blood pressure deate around the

optimal total protein intake but also

protein source animal versus plant and

how these things could affect long-term

kidney health or blood pressure. What

are what are your views based on the

literature today and has that evolved or

changed over the years? So, I'm probably

going to incur the wrath of several of

my more pure kidney colleagues. I'm a

kidney doc who does blood pressure care.

I don't do much in terms of chronic

kidney disease or worse yet dialysis

management because those require very

specialized lifestyle of the kidney

doctor and the ability to walk through a

dialysis unit and you know not put

yourself on Prozac afterwards is is

quite challenging. Those folks have just

amazing lives but a lot of sadness in a

dialysis unit. That said, um, one gram

of protein per kilogram body weight is

often the metric that people use to say

what's a good protein intake for a

person. Animal proteins are said to be

worse for you than plant protein. But we

used to prorrate your protein intake by

virtue of how similar that protein,

whatever it is, steak or whatever, how

similar it is to an egg white. So the

albumin in an egg white is the ideal

protein. And when you look at your

bloodstream, half of your bloodstream's

protein is albumin. So if you're going

to eat a diet with protein, it makes

sense to have it similar to the amino

acid content of albumin. And that said,

that's one way to approach the ideal.

But the kidney is pretty smart. And when

you eat more protein than you need, you

excrete it. You can't store protein. You

can store fat. You can store sugar, but

you can't store protein. Protein is

either use it or lose it. So, the kidney

is your lose it mechanism for getting

rid of it. If you eat more protein

consistently than you need, you generate

ura nitrogen, blood ura nitrogen, that's

a waste product from protein metabolism,

and you excrete it. The other thing that

comes with protein, because protein is

amino acids, is acid, and the kidney is

also your source for excreting acid. And

we tend to have an acid diet by and

large based in part because of the

amount of protein that we eat. But the

kidney is pretty good at keeping the pH,

the overall balance of acid and base in

the body in check because it has other

mechanisms that it can use to balance

the ability to excrete acid coupled with

the ability to generate bicarbonate or

base to balance the acid effects of our

diet. In general, the less animal intake

of protein probably the better. I think

that people that call for that are

probably reasonably

secure in the data that says that. What

lacking here and we had a renal fellow

kidney doc in training years ago that

was really interested in what happens to

your protein when you cook it. You know,

we talk about, you know, what a steak is

like in terms of the amino acid content,

but that's before you cook it. When you

cook it, stuff happens. Crazy stuff

happens. And I listened to that one hour

talk he gave, and I haven't heard

anybody else do it since, but it was

fascinating the changes that occur in

protein when you cook it and broil it,

bake it, boil it, whatever it is, stuff

happens, the chemical bonds and other

stuff in there. So I consider myself a

neopight when it comes to the best

protein intake etc to have. I just think

that there's no reason to down kilograms

of protein in the course of a day. Your

body needs about one gram per kilogram

body weight. So average person that's 80

to 90 gram of protein a day. There is

some school of thought mostly from

exercise literature looking at at really

maximizing hypertrophy or muscle growth.

So how relevant this is to the to the

everyday person is questionable but that

literature is often cited and the

protein intake level that's considered

optimal there is about 1.6 g per

kilogram so higher than what you're

talking about and I know people will be

interested that have come across that

and perhaps are interested in building

muscle and are consuming 1.6 g per

kilogram. Do you think at that level is

it delotterious in any way to kidney

function? Because I know people come

across information where it's like, no,

that high intake level actually could

could be damaging your kidneys and then

they're a bit worried about that, of

course.

>> So, my first knee-jerk here is to say I

just don't know cuz I just don't know

truly. But I'll tell you what I think.

And the issue is that what happens to

the kidney in terms of things like blood

flow, especially the blood flow through

the filter units. Each of your kidneys

has about a million filter units in it.

They're called glomemerieli. And the

blood flow through the glomeili is very

tightly regulated by a balance in the

front end input into the glomemerieli

blood flowing in and the back end blood

flowing out of the glomemeilus. When you

eat protein, you dilate that afrin, that

leading in blood vessel that exposes

your filter units to a little bit more

of the blood pressure down upstream from

them. And consequently, that

hyperiltration has no delotterious

effect in the short term that we know

of. But over time, the glomemerieli

change as a result of the repeated

exposure to hyperiltration and they

generate a thing called meangial

hypertrophy. So within the glomemerieli

are these support cells that keep all

the blood the tangle of blood vessels in

there where the filtration occurs of the

blood to make urine. That tangle in

there is held together by a glue type

cell called the misangium. And when you

repeatedly have hyperiltration, greater

amounts of blood flowing, greater amount

of filtrate made, the meantium often

expand a little bit to handle that.

Typical patient that has that is a

patient with diabetes where diabetes has

affected their blood the blood gl the

glomeilus the blood flow in the

glomeilus and that emulates the same

damage we see with hyperiltration

over years the hyperiltration may wear

out the kidney's reserve and then begin

to take its toll on kidney function but

honestly Simon that takes 10 to 20 years

I think before that happens you won't

see it in a short term three to fiveyear

study that typically we fund for these

kind of things. But that would be my

worry about a 1.6 or higher gram per

kilogram body weight protein intake over

time is that you burn out your kidneys

reserve and then you're going to begin

to chip away a little bit more quickly

at the natural loss of kidney function

over time due to the hyperiltration

that several of the key amino acids in

protein cause a part of the kidney. Is

there anything here? This has been

another master class. I I I really

appreciate

how clear you communicate the science,

how respectful you are to the listener

and your your patience, and how

objective you are. And I I very much

appreciate just before you said the

honest answer is I don't know. And I

think that's that's a response that

deserves to be repopularized and we

should hear that more often from people

in science. So, um, thank you for for

reminding us of that. Is there anything

related to lifestyle changes or lowering

blood pressure that we didn't cover

today or that you wanted to add on to

here at the end?

>> Yeah, just one quick plug for the weight

loss component to blood pressure. You

don't have to lose 40 to 50 pounds. I

may have misled if you if you assume

that, oh, I got to lose 40 pounds to see

a blood pressure response. Actually, you

get a blood pressure response on the

first 10 to 15 pounds. So, you see it

and actually you get more blood pressure

response up front and less over time as

you lose weight. So, the rewards from

weight loss are actually achievable

within a couple month time period. So,

you don't have to like labor for two

years to get, you know, 40 pounds gone

and finally see something happen to your

blood pressure. It's a more short-term

effect than that. And I think it's one

of the one of the incentives to weight

loss is the fact that changes do occur

pretty quickly when people make the

changes in dietary calorie intake and

exercise to see blood pressure improve.

>> And just to be clear, that improvement

in blood pressure is relying on

sustaining that weight loss over time.

If that if the person is to put the

weight back on, you would assume that

that blood pressure would come back.

>> They do lose it. Yep. Yep. Yeah. and the

effects of exercise on blood pressure.

You know, if there are salutoy effects

in an individual, if you go 6 weeks or

longer without exercising, it tends to

fade away after that. It's not a very

long sustained benefit. It It's sort of

like you need to keep at it.

>> Have you come across any of the

literature looking at sauna and blood

pressure?

>> No. I got asked that a long time ago and

I always meant to look that up and I

have not. You know there are some

countries where a lot of business is

conducted. I think in the Scandinavian

countries in particular in saunas and

there was a you know I belong to this

group called North American artery and

there was a couple of presentations a

couple years ago on the effect of you

know heat in a steamy type circumstance

on blood vessel function that looked

salutoy. So I wouldn't be surprised if

it helps but I don't know how much.

Well, that's your homework. Come back to

me on that.

>> Great. Absolutely. It'll be an expert. I

>> I want to leave the audience with

something different today. My question

to you is if you could go back and and

give your 20-year-old self, a piece of

life or career advice before beginning

this 40 plus year journey that you've

had in medicine and science. What would

it be?

>> Good question. And the answer is that

don't adopt a skeptical attitude until

you've really thought it through. Two

aspects to that. I'll quickly do this.

When I was when I was a resident, and

this is when I was in my late 20s, I was

on a kidney service seeing a patient in

the ICU.

And I came in and I did my consult

waiting for my attending to come and

bless my consult. And I wrote up all

these things and the resident, my

colleague, same year as me but running

the ICU side, not my kidney side, came

in and said, "This is what the kidney

people always do. They take over our

patient care." And I just I was

insensed. And then my attending told me,

you know, Ray, every once in a while

when someone says something like that to

you, the first thing you have to do is

not get mad at them, but ask. And he was

Irish. is there a bit of truth in what

they're saying? And so I looked at it

and I thought, "Oh my god, there is."

You know, he's he's he's right. I just

don't like what he said. So the the idea

of immediately reacting to what patients

do or say, that took me a while to get

over. But I think eventually once you

become a better listener and less prone

to react quickly to what people say or

do, I think that's valuable life advice

that I would give my 20-year-old self in

a heartbeat.

>> Amen. Thank you for sharing that and

thank you for coming back and being with

us again.

>> Appreciate it.

>> All right. It's a pleasure, Simon. Best.

>> There you have it, friends. I hope you

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the next episode.