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high blood pressure

Symptoms of OSA include loud snoring. Stock photo
Difficult-to-control high blood pressure may be a sign of OSA

By David Dunaief, M.D.

Dr. David Dunaief

Sleep is a crucial factor for our physical and mental health, yet many people struggle to get quality restful sleep. For those with obstructive sleep apnea (OSA), this occurs frequently and can lead to consequences more significant than exhaustion.

Sleep apnea is an abnormal pause in breathing that occurs at least five times an hour while sleeping and can be caused by either airway obstruction (OSA), brain signal failure (central sleep apnea), or a combination of these two (complex sleep apnea). There are a surprising number of people in the United States with sleep apnea. Its prevalence may be as high as 20 percent of the population (1). 

Here, our focus is on OSA, which can be classified as either mild, moderate or severe. It’s estimated that 80 percent of moderate and severe OSA are undiagnosed.

Risk factors for OSA include chronic nasal congestion, large neck circumference, excess weight or obesity, alcohol use, smoking and a family history. Not surprisingly, about two-thirds of OSA patients are overweight or obese. Smoking increases risk threefold, while nasal congestion increases risk twofold (2). Fortunately, many of the risk factors are modifiable.

Significant symptoms of OSA include daytime fatigue, loud snoring, breathing cessation observed by another, impaired concentration and morning headaches. These symptoms, while significant, are not the worst problems. OSA is also associated with a list of serious complications, such as cardiovascular disease, high blood pressure and cancer.

There are several treatments for OSA. Among them are continuous positive airway pressure (CPAP) devices; lifestyle modifications, including diet, exercise, smoking cessation and reduced alcohol intake; oral appliances; and some medications.

Cardiovascular disease

In an observational study, the risk of cardiovascular mortality increased in a linear fashion to the severity of OSA (3). In other words, in those with mild-to-moderate untreated sleep apnea, there was a 60 percent increased risk of death; and in the severe group, this risk jumped considerably, 250 percent. However, the good news is that treating patients with CPAP considerably decreased their risk by 81 percent for mild-to-moderate patients and 45 percent for severe OSA patients. This study involved 1,116 women over a six-year duration.

Not to leave out men, another observational study showed similar risks of cardiovascular disease with sleep apnea and benefits of CPAP treatment (4). There were more than 1,500 men in this study with a follow-up of 10 years. The authors concluded that severe sleep apnea increases the risk of nonfatal and fatal cardiovascular events, and CPAP was effective in stemming these occurrences.

In a third study, this time involving the elderly, OSA increased the risk of cardiovascular death in mild-to-moderate patients and in those with severe OSA 38 and 125 percent, respectively (5). But, just like in the previous studies, CPAP decreased the risk in both groups significantly. In the elderly, an increased risk of falls, cognitive decline and difficult-to-control high blood pressure may be signs of OSA.

Though all three studies were observational, it seems that OSA affects both genders and all ages when it comes to increased risk of cardiovascular disease and death, and CPAP may be effective in reducing these risks.

Cancer association

In sleep apnea patients under 65 years old, a study showed an increased risk of cancer (6). The authors believe that intermittent low levels of oxygen, which are caused by the many frequent short bouts of breathing cessation during sleep, may be responsible for the development of tumors and their subsequent growth.

The greater the percentage of time patients spend in hypoxia (low oxygen) at night, the greater the risk of cancer. So, for those patients with more than 12 percent low-oxygen levels at night, there is a twofold increased risk of cancer development, when compared to those with less than 1.2 percent low-oxygen levels.

Sexual function

It appears that erectile dysfunction may also be associated with OSA. CPAP may decrease the incidence of ED in these men. This was demonstrated in a small study involving 92 men with ED (7). The surprising aspect of this study was that, at baseline, the participants were overweight, not obese, on average and were young, at 45 years old. In those with mild OSA, the CPAP had a beneficial effect in over half of the men. For those with moderate and severe OSA, the effect was still significant, though not as robust, at 29 and 27 percent, respectively.

Dietary effect

Although CPAP can be quite effective, it may not be well tolerated by everyone. In some of my patients, their goal is to discontinue their CPAP. Diet may be an alternative to CPAP, or may be used in combination with CPAP.

In a small study, a low-energy diet showed positive results in potentially treating OSA. It makes sense, since weight loss is important. But even more impressively, almost 50 percent of those who followed this type of diet were able to discontinue CPAP (8). The results endured for at least one year. Patients studied were those who suffered from moderate-to-severe levels of sleep apnea. Low-energy diet implies a low-calorie approach, such as a diet that is plant-based and nutrient-rich.

The bottom line is that if you think you or someone else is suffering from sleep apnea, it is very important to go to a sleep lab to be evaluated, and then go to your doctor for a follow-up. Don’t suffer from sleep apnea and, more importantly, don’t let obstructive sleep apnea cause severe complications, possibly robbing you of more than sleep. There are effective treatments for this disorder, including diet and CPAP.

References:

(1) sleepapnea.org. (2) JAMA. 2004;291(16):2013. (3) Ann Intern Med. 2012 Jan 17;156(2):115-122. (4) Lancet. 2005 Mar 19-25;365(9464):1046-1053. (5) Am J Respir Crit Care Med. 2012;186(9):909-916. (6) Am J Respir Crit Care Med. 2012 Nov. 15. (7) APSS annual meeting: abstract No. 0574. (8) BMJ. 2011;342:d3017.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.     

Sticking to a plant-rich diet that can reduce high blood pressure. Stock photo
Call to arms to reverse high blood pressure, once and for all

By David Dunaief, M.D.

Dr. David Dunaief

Hypertension (high blood pressure) and COVID-19 are intertwined. Those who have hypertension are more susceptible to COVID-19 and are more likely to get a severe form and experience complications from the virus. A study done in China captured the statistics: of 1099 patients infected, 15 percent had hypertension, and of those with severe cases, 23.7 percent had hypertension (1). Ultimately, those with hypertension are at higher risk, but we don’t at this point understand the specifics of why.

Even before the COVID-19 pandemic, a recent study showed that the number of deaths from hypertension had increased a whopping 26 percent overall from 2007 to 2017 (2). 

What about medications to blunt the association? There is a THEORY, not a study, that angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) may be harmful by increasing ACE2 in the lungs, which is a receptor that COVID-19 binds to; however, there is also a case for these medications having benefits (3). Do not stop or change your hypertension medications without talking to your doctor. Remember, this is just a theory, and theories are very dangerous; we don’t have research to support them, by definition (4).

I view this as a call to arms to control and, even more importantly, treat and reverse hypertension. Presently, only 54 percent of hypertension patients are controlled with medication (5). 

Potential to control and reverse hypertension through diet

We have the capability to treat and reverse hypertension with lifestyle modifications, including diet, exercise, sleep and stress management. We are going to focus on diet.

A whole foods plant-based diet (WFPBD) that is dark green leafy vegetable-rich has been shown to help prevent, control and possibly reverse hypertension. I call this the LIFE diet, which stands for Low Inflammatory Foods Everyday. The most researched type of WFPBD is the DASH (dietary approach to stopping hypertension) diet, which emphasizes fruits, vegetables, grains and reductions in saturated fats and total fat. DASH was the first randomized control trial to show that a predominantly whole food plant-based approach reduces blood pressure (6).

Why does diet have an effect? There are several factors, including inflammation; electrolytes, specifically sodium and potassium; and phytochemicals (plant nutrients and fiber content).

Why is inflammation so important?

Inflammation is a culprit in most chronic diseases, including hypertension. It also plays a crucial role in the severity of COVID-19. Those who take a turn for the worse in COVID-19 have high inflammation. On the news, an ER doctor noted that while COVID-19 patients may come in stable, they need to be watched carefully; in 3-24 hours, they could show high inflammation and fluid in their lungs and need to be on a ventilator.

There are several studies that show a direct relationship between high sensitivity C-reactive protein, one of the most well-studied biomarkers for inflammation, and hypertension in both men and women (7)(8). In the Physicians Health Study, those men who had high hsCRP (>3 mg/L) and hypertension had a 40 percent increased risk of stroke compared to those without hypertension and with hsCRP <1, which is optimal. Not to leave women out, the CARDIA study found that premenopausal women with elevated hsCRP were significantly more likely to have hypertension.

How can we decrease inflammation?

Anti-inflammatory drugs, including NSAIDS like ibuprofen, may suppress the immune system and make patients more susceptible to COVID-19. They also worsen hypertension and may increase the risk for cardiovascular events, such as a heart attack. In fact, prescription NSAIDS carry an FDA black box warning about this dangerous side effect. Anti-inflammatory drugs should not be the “go-to” solution.

Fortunately, a WFPBD is associated with reduction in inflammation, specifically hsCRP. We recently published a study showing that the LIFE diet has an inverse relationship between blood levels of beta carotene, a phytonutrient, and hsCRP (9). As you increase the intake of dark green leafy vegetables, the higher the beta carotene and the lower the hsCRP. There was a 75 percent reduction in inflammation with those that increased their beta carotene over the normal level compared to those who were non-adherent. The DASH diet also emphasizes an increased intake of vegetables.

There are studies to suggest that, as we lower animal protein intake, we are able to better reduce blood pressure. In the EPIC study, those who at who reduced animal protein to none had the biggest impact on blood pressure. This study compared meat-eaters, fish-eaters, vegetarians and vegans (10). 

Electrolytes – sodium and potassium

The optimal approach for these electrolytes is to have a sodium to potassium ratio that is less than one. For most, this means consuming less sodium and more potassium (11). The American Heart Association emphasizes low sodium, less than 1500 mg of sodium per day and higher potassium intake (12). 

What I find in my practice is that blood levels that are south of 140 mmol/L are better and that the bottom of the range is ideal; the range is between 135-145 mmol/L. This way, whether you are sodium-sensitive or not, you can either help control blood pressure or rule it out as a factor. Potassium should be 4.5 (units) or higher. These electrolytes should come from vegetables, especially dark green leafy vegetables, which have a natural balance of potassium and sodium. Other good sources of potassium are beans and nuts.

Ultimately, the power is in your hands. By changing your diet to one that is more plant-based and vegetable-rich, you can reduce inflammation, strengthen your immune system, possibly reduce or even get off anti-hypertension medications, reverse the trend of dying from hypertension, and reduce your susceptibility to severe COVID-19.

References:

(1) N Engl J Med. Online Feb 28, 2020. (2) J Am Coll Cardiol. Online March 19, 2020). (3) Nephron. Online Mar 23, 2020.) (4) Nature. Feb 2020, 579:270–273. (5) Circulation. 2016;133:e38–e360. (6) N Engl J Med. 1997 Apr 17; 336(16):1117-24. (7) JAMA.2015 Sep:4(9):e002073 (8) Menopause. 2016 Jun; 23(6):662. (9) AJLM Online. Dec. 21, 2019. (10) Oybkuc Gektg Bytr, 2002 Oct; 5(5):645-54. (11) Circulation Online. Oct 11 2017. (12) heart.org.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.  

The effects of high sodium are insidious

By David Dunaief, M.D.

Dr. David Dunaief

By now, most of us have been hit over the head with the fact that too much salt in our diets is unhealthy. Still, we respond with “I don’t use salt,” “I use very little,” or “I don’t have high blood pressure, so I don’t have to worry.” Unfortunately, these are myths. All of us should be concerned about salt or, more specifically, our sodium intake.

Excessive sodium in the diet does increase the risk of high blood pressure (hypertension); the consequences are stroke or heart disease. Approximately 90 percent of Americans consume too much sodium (1).

Now comes the interesting part. Sodium has a nefarious effect on the kidneys. In the Nurses Health Study, approximately 3,200 women were evaluated in terms of kidney function, looking at the estimated glomerular filtration rate (GFR) as related to sodium intake (2). Over 14 years, those with a sodium intake of 2,300 mg had a much greater chance of an at least 30 percent reduction in kidney function, compared to those who consumed 1,700 mg per day.

Why is this study important? Kidneys are one of our main systems for removing toxins and waste. The kidneys are where many initial high blood pressure medications work, including ACE inhibitors, such as lisinopril; ARBs, such as Diovan or Cozaar; and diuretics (water pills). If the kidney loses function, it may be harder to treat high blood pressure. Worse, it could lead to chronic kidney disease and dialysis. Once someone has reached dialysis, most blood pressure medications are not very effective.

Ironically, the current recommended maximum sodium intake is 2,300 mg per day, or one teaspoon, the same level that led to negative effects in the study. However, Americans’ mean intake is twice that level.

Excessive sodium in one’s diet can increase the risk of high blood pressure, which can lead to a stroke or heart disease. Stock photo

If we reduced our consumption by even a modest 20 percent, we could reduce the incidence of heart disease dramatically. Current recommendations from the American Heart Association indicate an upper limit of 2,300 mg per day, with an “ideal” limit of no more than 1,500 mg per day (3).

If the salt shaker is not the problem, what is? Most of our sodium comes from processed foods, packaged foods and restaurants. There is nothing wrong with eating out on occasion, but you can’t control how much salt goes into your food. My wife is a great barometer of restaurant salt use. If food from the night before was salty, she complains of not being able to get her rings off.

Do you want to lose 5 to 10 pounds quickly? Decreasing your salt intake will allow you to achieve this goal. Excess sodium causes the body to retain fluids. 

One approach is to choose products that have 200 mg or fewer per serving indicated on the label. Foods labeled “low sodium” have fewer than 140 mg of sodium, but foods labeled “reduced sodium” have 25 percent less than the full-sodium version, which doesn’t necessarily mean much. Soy sauce has 1,000 mg of sodium per tablespoon, but low-sodium soy sauce still has about 600 mg per tablespoon. Salad dressings and other condiments, where serving sizes are small, add up very quickly. Mustard has 120 mg per teaspoon. Most of us use far more than one teaspoon of mustard. Caveat emptor: Make sure to read labels on all packaged foods very carefully.

Is sea salt better than table salt? High amounts of salt are harmful, and the type is not as important. The only difference between them is slight taste and texture variation. I recommend not buying either. In addition to the health issues, salt tends to dampen your taste buds, masking the flavors of food.

If you are working to decrease your sodium intake, become an avid label reader. Sodium hides in all kinds of foods that don’t necessarily taste salty, such as breads, soups, cheeses and salad dressings. I also recommend getting all sauces on the side, so you can control how much — if any — you choose to use.

As you reduce your sodium intake, you might be surprised at how quickly your taste buds adjust. In just a few weeks, foods you previously thought didn’t taste salty will seem overwhelmingly salty, and you will notice new flavors in unsalted foods.

If you have a salt shaker and don’t know what to do with all the excess salt, don’t despair. There are several uses for salt that are actually beneficial. According to the Mayo Clinic, gargling with ¼ to ½ teaspoon of salt in eight ounces of warm water significantly reduces symptoms of a sore throat from infectious disease, such as mononucleosis, strep throat and the common cold. Having had mono, I can attest that this works.

Remember, if you want to season your food at a meal, you are much better off asking for the pepper than the salt.

References:

(1) cdc.gov. (2) Clin J Am Soc Nephrol. 2010;5:836-843. (3) heart.org.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Hypertension risk factors include poor diet, lack of exercise, age and depression.
Complications are highest during sleeping hours

By David Dunaief, M.D.

Dr. David Dunaief

Hypertension (high blood pressure) deserves a substantial amount of attention. There are currently about 76 million people with high blood pressure in the U.S. Put another way, one in three adults have this disorder (1). If that isn’t scary enough, the Centers for Disease Control and Prevention reports that the number of people dying from complications of hypertension increased by 23 percent from 2000 to 2013 (2).

And talk about scary, it turns out that fear of the boogie man should take a back seat to high blood pressure during nighttime sleeping hours. This is when the probability of complications, such as cardiovascular events and mortality, may have their highest incidence.

Unfortunately, as adults, it does not matter what age or what sex you are; we are all at increased risk of complications from high blood pressure, even isolated systolic (top number) blood pressure, which means without having the diastolic (bottom number) elevated as well. Fortunately, hypertension is highly modifiable in terms of reducing the risk of cardiovascular disease and mortality (3). At least some of the risk factors are probably familiar to you. These include being significantly overweight and obese (BMI >27.5 kg/m²), smoking, poor diet, lack of exercise, family history, age, increased sodium, depression, low vitamin D, diabetes and too much alcohol (4).

Of course, antihypertensive (blood pressure) medications treat this disorder. In addition, there are nonpharmacological approaches that have benefits. These include lifestyle modifications with diet, exercise and potentially supplements. An item on the game show “Jeopardy” read: “You can treat it with diet and lifestyle changes as well as drugs: HBP.” The corresponding answer was, “What is high blood pressure?” We made the big time!

Risk factors matter, but not equally

In a study, results showed that those with poor diets had 2.19 times increased risk of developing high blood pressure. This was the greatest contributor to developing this disorder (5). Another risk factor with a significant impact was being at least modestly overweight (BMI >27.5 kg/m²) at 1.87 times increased risk. This surprisingly, albeit slightly, trumped cigarette smoking at 1.83 times increased risk. Interestingly, weekly binge drinking at 1.87 times increased risk was equivalent to being overweight. This study was observational and involved 2,763 participants. The moral is that a freewheeling lifestyle can have a detrimental impact on blood pressure and cause at least stage 1 hypertension (systolic between 140 and 159 mmHg and/or diastolic between 90 and 99 mmHg).

High blood pressure doesn’t discriminate

One of the most feared complications of hypertension is cardiovascular disease, because it can result in death. In a study, isolated systolic hypertension was shown to increase the risk of cardiovascular disease and death in both young and middle-aged men and women between 18 and 49 years old, compared to those who had optimal blood pressure (6). The effect was greatest in women, with a 55 percent increased risk in cardiovascular disease and 112 percent increased risk in heart disease death. High blood pressure has complications associated with it, regardless of onset age. Though this study was observational, which is not the best, it was very large and had a 31-year duration.

Nightmares that may be real

Measuring blood pressure in the clinic can be useful. However, in a meta-analysis (involving nine studies from Europe, South America and Asia), the results showed that high blood pressure measured at nighttime was potentially a better predictor of myocardial infarctions (heart attacks) and strokes, compared to daytime and clinic readings (7).

For every 10 mmHg rise in nighttime systolic blood pressure, there was a corresponding 25 percent increase in cardiovascular events. This was a large meta-analysis that utilized studies that were at least one year in duration. Does this mean that nighttime readings are superior in predicting risk? Not necessarily, but the results are interesting. The nighttime readings were made using 24-hour ambulatory blood pressure measurements (ABPM).

There is something referred to as masked uncontrolled hypertension (MUCH) that may increase the risk of cardiovascular events in the nighttime. MUCH occurs in those who are well-controlled during clinic readings for blood pressure; however, their nocturnal blood pressure is uncontrolled. In the Spanish Society of Hypertension ABPM Registry, MUCH was most commonly seen during nocturnal hours (8). Thus, the authors suggest that ABPM may be a better way to monitor those who have higher risk factors for MUCH, such as those whose pressure is borderline in the clinic and those who are smokers, obese or have diabetes.

Previously, a study suggested that taking at least one antihypertensive medication at night may be more effective than taking them all in the morning (9). Those who took one or more blood pressure medications at night saw a two-thirds reduction in cardiovascular event risk. Now we can potentially see why. These were patients who had chronic kidney disease (CKD). Generally, 85 to 95 percent of those with CKD have hypertension.

Dietary tidbits

Diet plays a role in controlling high blood pressure. In a study, blueberry powder (22 grams) in a daily equivalent to one cup of fresh blueberries reduced systolic blood pressure by a respectable 7 mmHg and diastolic blood pressure by 5 mmHg over 2 months (10). This is not bad, especially since the patients were prehypertensive, not hypertensive, at baseline, with a mean systolic blood pressure of 138 mmHg.

This is a modest amount of fruit with a significant impact, demonstrating exciting results in a small, preliminary, double-blind, placebo-controlled randomized trial. Blueberries increase a substance called nitric oxide, which helps blood vessels relax, reducing blood pressure.

The results of another study showed that girls who consumed higher levels of potassium-rich foods had a significant reduction in both systolic and diastolic blood pressure (11). The highest group consumed at least 2,400 mg of potassium daily, whereas the lowest group consumed less than 1,800 mg. The girls were 9 and 10 years old and were followed for a 10-year duration. Though the absolute change was not large, the baseline blood pressure was already optimal for both groups, so it is impressive to see a significant change.

In conclusion, nighttime can be scary for high blood pressure and its cardiovascular complications, but lifestyle modifications, such as taking antihypertensive medications at night and making dietary changes, can have a big impact in altering these serious risks.

References: (1) Health Stat Report 2011. (2) CDC.gov. (3) Diabetes Care 2011;34 Suppl 2:S308-312. (4) uptodate.com. (5) BMC Fam Pract 2015;16(26). (6) J Am Coll Cardiol 2015;65(4):327-335. (7) J Am Coll Cardiol 2015;65(4):327-335. (8) Eur Heart J 2015;35(46):3304-3312. (9) J Am Soc Nephrol 2011 Dec;22(12):2313-2321. (10) J Acad Nutr Diet 2015;115(3):369-377. (11) JAMA Pediatr online April 27, 2015.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.