Hypertension, abnormally high blood pressure, is a cardiovascular disease that affects an estimated 50 million North Americans. It strikes without warning, and when left unchecked, can lead to peripheral artery disease, heart attack, stroke,and even death. Now, Dr. Whitaker, one of this countrys premier exponents of preventive medicine, advocates a bold and effective program that can reduce or even eliminate dependence on blood pressure medications. He outlines a preventative approach using diet, nutritional supplements, exercise, and other lifestyle alterations to control hypertension and enhance cardiovascular performance.

Julian Whitaker, M.D., a medical practitioner for over twenty-five years, treats thousands of patients a year at his Whitaker Wellness Institute in Newport Beach, California.

Chapter One

Hypertension: Action Alert

Hypertension affects an estimated 50 million Americans-more than one in three American adults. It is the lit fuse of a bomb waiting to go off. Hypertension triples your risk of dying from a heart attack and increases your risk of stroke sevenfold over someone with normal blood pressure. Yet hypertension is largely symptom-free-until it's too late. Hypertension is classified as a cardiovascular disease (CVD), a disorder afflicting the heart or blood vessels. According to 1999 American Heart Association (AHA) statistics, 58.8 million Americans suffer one or more of the cardiovascular diseases, making CVD an epidemic of unbelievable proportions. CVD mortality rates actually outrank our country's next seven leading causes of death combined (including cancer). Every year 959,227 Americans die of CVD. That's 2,600 per day, or 1 every 33 seconds, which accounts for 41.4 percent of the total deaths in the United States. Imagine, nearly half of all Americans will die from cardiovascular disease-and hypertension is a primary contributor to many of these deaths. If you don't take control of and effectively manage your blood pressure, it will take control of you.

Although hypertension is extremely common, it is painless and usually symptom-free. Hypertension does occasionally give subtle warning signs. You might, for example, experience troublesome headaches. These are usually located in the back of the head and upper neck and are most acute in the morning, when blood pressure is relatively low. Vision problems, dizziness, fatigue, abnormal sweating, insomnia, shortness of breath, and excessive flushing of the face are other symptoms you might experience. Any one or a combination of these might signal hypertension. Although these symptoms could also stem from other conditions, if you are experiencing any of them I urge you to consult your physician immediately and have your blood pressure monitored.

Many people with hypertension are completely unaware that they have this insidious condition: of the 50 million Americans with hypertension, only 68.4 percent are aware that their blood pressure is high. This is why I recommend that everyone over age 35 have their blood pressure checked regularly. Although hypertension can strike at any age, blood pressure tends to increase steadily with age, so regular checkups become even more important as you get older.

Measuring Blood Pressure Having your blood pressure checked is quick and painless. It is usually done with a stethoscope and a sphygmomanometer (sphygmo means "pulse"), which consists of an inflatable arm cuff attached to a column of mercury and a gauge (see Figure 1). Although newer technologies in monitoring-including wrist and finger cuffs with digital readouts-are becoming more and more popular for home and clinic use, the sphygmomanometer remains the standard.

Here's how a sphygmomanometer works. The cuff, which is wrapped around the upper arm just above the elbow, is inflated with air to compress the brachial artery, the major artery in the arm. The cuff is first inflated to a pressure that shuts off all of the blood flow through the artery. As the cuff is slowly deflated, the person taking the blood pressure reading listens through a stethoscope placed on the brachial artery for the first audible beat-the sound of blood rushing back into the compressed artery-and notes the number on the gauge. (A computer chip in the electronic versions does this for you.) This indicates the systolic blood pressure, or pressure generated by the heart immediately after it contracts, or beats, and represents the top number of the blood pressure reading.

As pressure from the cuff continues to be released, the beats become stronger and more distinct, then taper off and disappear. The number at which the last beat is audible indicates the diastolic pressure, or the arterial pressure maintained between heartbeats, when the heart is at rest. The combined ratio of systolic over diastolic reveals the relative pressure generated by the heart as it alternately pumps blood through the arteries and rests. The fraction is expressed in millimeters of mercury (mm Hg), which refers to the amount of mercury displaced by the arterial pressure during the reading. So a blood pressure reading of 120/80 mm Hg represents a systolic pressure of 120 and a diastolic pressure of 80. A blood pressure reading will indicate one of three states: hypotension (low blood pressure), normotension (normal blood pressure), or hypertension (high blood pressure). Normotension is, of course, the ideal. In fact, it's one of the best predictors of a long life. Low blood pressure may not be entirely desirable, but because it is relatively rare, it will not be discussed in this book. If the reading indicates hypertension, your health is in danger, and you need to take immediate steps to bring your blood pressure down to healthier levels.

Making the Diagnosis There is general agreement that optimal blood pressure is 120/80 or less. However, exactly what blood pressure constitutes hypertension is subject to some interpretation. In the past a diagnosis of hypertension was often based exclusively on diastolic blood pressure (the bottom number in the blood pressure reading). If your diastolic pressure was over 90, you had high blood pressure. It was felt that because the heart takes longer to rest than it does to beat, the diastolic measurement was more significant. However, more recent research has made it clear that an elevated diastolic pressure is no more hazardous than a high systolic reading-and the latter appears to be an even more accurate predictor of cardiovascular risk. The current consensus is that elevations in either systolic or diastolic blood pressure readings should be taken seriously. This is particularly true among older people, who may have dangerously high systolic readings while maintaining virtually normal diastolic blood pressure.

According to current American Heart Association guidelines, hypertension is clinically defined as a systolic blood pressure greater than 140 or a diastolic pressure greater than 90. This echoes the recommendations of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), a widely respected National Institutes of Health task force of physicians who are experts in hypertension and whose recommendations are approved by most major organizations. The JNC, which updates its recommendations periodically, published its sixth and latest report of guidelines in November 1997. The committee devised an updated system of diagnosis using both systolic and diastolic blood pressures to assess a patient's health risk. The guidelines also recommend that clinicians specify other known risk factors, including smoking, immoderate drinking, and routine overeating. All of this information is then combined to determine the stage of risk for a specific patient. The higher the stage, the greater the patient's risk of a heart attack or stroke.

However, more recent research suggests that blood pressure readings for a diagnosis of hypertension might need to be adjusted downward. In June 1998, results of the Hypertension Optimal Treatment (HOT) trial, a five-year study involving almost 19,000 patients from 26 countries, were published in The Lancet, one of the world's leading medical journals. Researchers found that patients who were able to lower their systolic blood pressure to an average of 138.5 mm Hg and their diastolic blood pressure to an average of 82.6 had major reductions in heart attack and stroke risk. In early 1999, the World Health Organization and the International Society of Hypertension recommended that the upper limit for high normal blood pressure be lower, 130/85 (down from the JNC's upper limit of 139/89). They based this on findings of the HOT trial and other studies showing that stroke and heart attack risk are dramatically reduced when diastolic blood pressure is less than 85.

You may be thinking, "Why quibble over such small numbers? What's the difference between 85 and 89?" According to an article published in the Journal of the American Medical Association in March 1999, a decrease in diastolic blood pressure of only 5 to 6 points lowers your risk for stroke 42 percent.

So when should you be concerned about your blood pressure? Since risk factors decrease as blood pressure goes down, I'd have to agree with the most recent findings. If your blood pressure is above 130/85, you should institute the measures outlined in this book for reversing hypertension and aim to get into the optimal range of 120/80 or lower.

Check and Recheck Your Blood Pressure If you have high blood pressure based on a blood pressure reading in your doctor's office, don't panic. Before a true diagnosis is made you should return to the clinic on at least three separate occasions (six return visits for monitoring are even better), so your doctor can evaluate whether your blood pressure is consistently elevated. Your blood pressure changes constantly throughout the day, depending on your environment, activities, diet, emotions, medication, and other factors. Even so simple a thing as talking can dramatically raise your blood pressure. In a 1998 study carried out at the Clinique Cardiologique in Paris, researchers measured the blood pressures of 50 patients with hypertension while they were actively talking, silently reading, or sitting quietly. During the talking period blood pressure significantly increased-by an average of 17 mm Hg systolic and 13 mm Hg diastolic-and it remained elevated, although to a lesser degree, for a time afterward. Silent reading actually lowered blood pressure more than did merely sitting quietly.

Another cause of elevated blood pressure readings-in the absence of true hypertension-is what is known as "white-coat hypertension." For many people, visiting a doctor is stressful, and the sheer anxiety of being examined by a health professional temporarily elevates blood pressure. When this reaction occurs, an inexperienced or hasty medical practitioner may misdiagnose the patient as having hypertension solely on the basis of one or two in-office blood pressure readings. White-coat hypertension is an all-too-common phenomenon that can result in expensive, unnecessary, and potentially hazardous treatment. Despite frequent and supposedly accurate measurements of blood pressure, as many as 12 million patients in the United States may be misclassified as hypertensive.

For this reason, I turn to a test called the twenty-four-hour ambulatory blood pressure monitoring (ABPM) system. This device measures blood pressure every fifteen to thirty minutes and can help determine if a patient has true hypertension. The computerized ABPM monitor is about the size of a paperback book and is attached to a blood pressure cuff. The cuff is worn around the patient's arm, while the monitor is worn on a belt around the waist or over the shoulder like a purse. While the ABPM can take blood pressure readings over a twenty-four-hour period, I have my patients wear it for just twelve to eighteen hours, since I don't want to rob them of a night's sleep. This still gives me the information I need for an accurate evaluation of their blood pressure, allowing me to rule out white-coat hypertension and treat only those patients with true hypertension. Unfortunately, the overwhelming majority of patients are still being diagnosed with hypertension based solely on a few readings taken in a doctor's office. I feel this is a grave mistake. The authors of a 1993 Journal of the American Medical Association study reported that as many as "twenty-one percent of the patients diagnosed as having borderline [high normal] hypertension in the clinic were found to have normal blood pressure readings on ambulatory monitoring." And the sad part about it is that many of these perfectly normal patients are needlessly placed on prescription medications that might actually make them sick.

Guidelines for Having Your Blood Pressure Taken Here are a few things to consider when having your blood pressure taken in your doctor's office to ensure the most accurate readings.

* Don't drink coffee or other caffeine-containing beverages or foods for a couple of hours before your blood pressure is monitored.

* Abstain from smoking for at least thirty minutes prior.

* Don't talk during the reading.

* Request at least two readings, separated by two minutes, one taken in each arm.

If you really want to stay on top of things, I suggest you take your own blood pressure at home. Self-monitoring is easy, economical, and, once you get the hang of it, quite accurate. You could purchase your own sphygmomanometer and stethoscope, which would allow you to take your blood pressure at home anytime. Or contact your local pharmacy or fitness facility and ask if they offer a blood pressure monitoring unit you can use free of charge. (See Appendix D for detailed instructions on measuring your blood pressure with a sphygmomanometer.) Electronic blood pressure monitors are also available. Whatever type of device you choose, take it with you to your next doctor's appointment, so your physician can make sure you are using it properly and it is giving you accurate readings. Remember, although self-monitoring is a viable means of keeping track of your blood pressure, you should do it in conjunction with the professional monitoring and guidance provided by your own physician. Self-monitoring should not be used for self-diagnosis.

What Do You Do If You Have Hypertension? Once a diagnosis of hypertension is firmly established, what do you do? According to a study entitled "Heartstyles: Profiles in Hypertension," based on data analyzed by Dr. Michael Weber of the State University of New York and his colleagues, you might have one of several reactions. These researchers surveyed 727 patients and came up with four distinct responses to the diagnosis of hypertension.

* The Actively Attentives (39 percent of the patients) were the ideal patients. Proactively involved in their health, they educated themselves about their condition and were highly motivated to modify their diets and make other lifestyle changes in an effort to reduce risk factors.

* The Nonchalant Newcomers (23 percent) were more difficult. They essentially refused to take their diagnosis seriously. They had limited knowledge about hypertension and made little effort to learn more. They might take medication, but only to pacify their physician.

* The Honestly Overwhelmed (22 percent) were the most difficult group. They tended to have lots of problems in their lives and were unable to really focus on the seriousness of their condition. They knew little about hypertension and had few resources.

* The Mainly Meds (16 percent) had no motivation to make lifestyle changes, but they were compliant with medications.

If you've gone to the trouble to purchase and read this book, you likely fall into the Actively Attentive group. You're looking for something other than a lifelong dependency on prescription drugs. You understand the implications of hypertension, and you're taking steps to educate yourself about your condition. Furthermore, you probably have the initiative and willpower necessary to make the lifestyle changes that we will discuss in Part II to lower your blood pressure and reduce your risk factors for serious cardiovascular disease. It is for you Actively Attentives that I have written this book.

Copyright © 2000 Julian M. Whitaker, M.D.. All rights reserved.