Let’s Talk About Blood Pressure

I’m Dr. Michael Greger and this is Nutrition Facts.

There’s one thing we’ve been thinking about a lot lately, and that’s how to stay healthy in the middle of a global pandemic. Especially since we’ve learned that those with underlying health problems like obesity, hypertension, diabetes, and heart disease are more likely to have serious complications if they contract COVID-19. So what do we do? We try to stay healthy with evidence-based nutrition.

Did you know that natural approaches to lowering high blood pressure can work better than drugs?  Why?  Because you’re treating the underlying cause, and can end up having only good side effects. Here’s our first story.

The number one killer in the United States and on the planet Earth is a bad diet. That is why I’ve dedicated my life to the study of nutrition.  Killer #2 is high blood pressure. The reason it’s so deadly is that it increases your risk of dying from so many different diseases: heart disease and stroke, to heart and kidney failure.

We’re talking an exponential increase in risk of dying from a stroke as our pressures go up, starting from around 110 over 70, an exponential increase in the risk of dying from heart disease, again starting at a blood pressure of about 110/70. We used to consider a blood pressure as high as 175 to be normal––normal if you wanted to die from the normal diseases, like heart attack and stroke. A “normal” of 175 over 110 could put you at over a thousand percent higher risk of having you croak from a stroke compared to the ideal—not the normal, but the ideal, which is down around 110/70.

The definition of high blood pressure, hypertension, dropped from as high as 190/110 down to 160/95, with treatment thresholds for high-risk groups starting at 150/90 down to 140/90, and then, most recently, 130/80. Now, instead of one in three Americans having hypertension, with the new definition, it’s closer to one in two, or more like two-thirds of those over the age of 45. Every time the threshold drops, labeling tens of millions more people as diseased, there’s this backlash. Same thing every time the cholesterol guidelines get more and more stringent; but don’t blame the guidelines. Americans are diseased. That’s the real problem. The American way of life is the problem, not the guidelines.

Maybe we should focus on that instead.

After all, the number one killer of men and women is heart disease, a disease that can be prevented, arrested, and reversed with a healthy-enough diet.

So, even though a cholesterol of 200 may be normal, maybe we should tell people to strive for under 150. Even though a BMI of 24.9 is technically not overweight, an average height woman, for example, would be better off down around 120 pounds than 145. And, similarly, though a blood pressure of 120/80 may be normal, 110 would be a better top number, and 70 a better lower number, as even down in that range between 70 to 75, or 75 to 80, each 5-point increment is associated with a third more stroke, and at least a fifth more heart disease.

So, why are the new guidelines up at 130 over 80? With an average of three different blood-pressure drugs, you can force people’s blood pressures from 140 down to 120, compared to just giving them two blood-pressure drugs, and high-risk people live longer because of it. Significantly less death in the intensive treatment group, but, because of the higher doses and drugs, had more side effects. So, you have to weigh the risks versus benefits.

One to 2% of people on the drugs for five years will benefit, not having a cardiovascular event when they otherwise might have, and that has to be balanced against the higher risk of adverse side effects. So, you’ll hear commentators saying things like, yeah, the drugs decreased your risk of “events” by 25%, but increased your risk of a serious side effect by 88%. Okay, but those events can include things like death, whereas the side effects are more on the order of fainting.

“These adverse events do need to be weighed against the benefits with respect to cardiovascular events and death that are associated with intensive control of systolic blood pressure.” Like, if we use drugs to push high-risk people down to a top number of 120, we might prevent over 100,000 deaths and 46,000 cases of heart failure every year, but could cause “43,000 cases of electrolyte abnormalities and 88,000 cases of acute kidney injury.” Not great, but better than dying.

So, you can see the conundrum guidelines committees are in. On one hand, lowering blood pressure is good for your heart, kidneys, and brain, but at a certain point the side effects from the drugs could outweigh the benefits. Ideally, we want to get patients’ blood pressures as low as possible, but only want to use drugs to do it “when the effects of treatment are likely to be less destructive than the elevated blood pressure.”

The problem is that most people who die from heart disease, heart failure, and stroke may be in that borderline range not sufficiently elevated to warrant drug treatment.

If only there were some way to lower blood pressures without drugs to get the best of both worlds. Thankfully, there are. Regular aerobic exercise, weight loss, smoking cessation, increased dietary fiber intake, decreased alcoholic beverage intake, consumption of a more plant-based diet, and cutting down on salt. The advantage is, first of all, no bad side effects. Some lifestyle interventions can actually work better than the drugs, because you’re treating the cause, and actually have instead good side effects. So, not 1 or 2% benefit over five years—everybody benefits.

In our next story, the effect of fasting to lower blood pressure compared to medications, cutting down on alcohol, meat and salt, eating more fruits and vegetables, or eating completely plant-based.

Fasting has been practiced for thousands of years, but only recently have we started to put it to the test.  But what about fasting for treating and preventing other diseases?

One of the side effects noticed in the early weight loss studies was a consistent fall in blood pressure––so much so you typically have to stop taking blood pressure medications while your fasting, or else your pressures fall too low. Once you start eating again, your pressures go back up, but remarkably, not as high as they were before. But, of course, it depends on what you start eating again.

For example, a case report of a woman who used fasting to drive her rheumatoid arthritis into remission. Systolic blood pressure started up around 170, despite multiple blood pressure medications; was put on a whole-food, plant-based diet for eight weeks. That dropped her down from 170 down to 130––off of all her medications before starting the fast, and then normalizing down to 110 after the fast. But, is that just because of all the weight loss? She lost 22 pounds on the fast, and 27 pounds on the plant-based diet. So yeah, it’s extraordinary to drop your pressures from 170 to 110, but that was after losing about 50 pounds.

We’ve known for decades that any kind of weight loss can lower blood pressure. Even minor weight loss can lower blood pressures in obese persons, even if they remain significantly overweight. But most of the drop in blood pressures with severe caloric restriction happens within the first two days, before significant loss of body fat. So, it may also be a reduction in the fight-or-flight stress hormones, like adrenaline and noradrenaline, both before and after exercise, after just two weeks of just a few hundred calories a day.

So, that may be one reason why a very low-calorie diets have been found useful in lowering blood pressures, even in those for whom blood pressure medications fail: the changes in those hormones. But, low-calorie diets also tend to be more plant-based. So, there’s fiber and potassium-rich foods, less saturated fat. Even just adding fruits and vegetables to the diets of hypertensives can lower their systolic blood pressure—the top number—by seven points. That’s the kind of blood pressure improvement you might get losing 10 pounds, just by eating more fruits and vegetables. And, if you combine that with a drop in meat consumption, not only doubling fruit and vegetable intake, but combining that with trying to slash saturated fat and cholesterol, you can cut pressures by 11 points.

What else can we do? Restricting alcohol intake in regular daily drinkers can drop you five points. So, let’s keep track here: alcohol restriction can drop your systolic blood pressure five points, losing ten pounds can drop you seven, as can just eating the recommended eight to 10 servings of fruits and vegetables a day. Regular aerobic exercise for at least three months can drop you nine. Combine the fruits and vegetables with meat reduction, and you can drop it 11. Blood pressure medications can have side effects, but on their own, can drop pressures by 15 points.

What about cutting down on salt? Note in the other diet study they kept the sodium levels the same. Cut sodium enough, and it can edge out drugs at 16: the drugs 15, sodium restriction 16. Is that the best we can do with diet? Put people on a purely plant-based diet, even one moderate in sodium, and you can drop hypertensives by 18 points, even after nine out of 10 reduced their blood pressure medications or stopped them entirely, all within just seven days. That’s pretty impressive. Now, what if you took that same diet, but added fasting? 37 points!

Finally today, a whole food plant-based diet can be used to help lock in the benefits of fasting to kickstart the reversal of high blood pressure.

Medically supervised water-only fasting in the treatment of high blood pressure. A hundred seventy-four consecutive patients were treated in an inpatient setting. First, a few days of fruits and vegetables. This is to clear out the gut so they don’t become constipated, followed by 10 or 11 days of water-only fasting, before transitioning them back to a whole-food, plant-based diet: fruits, vegetables, whole grains, legumes, which are beans, split peas, chickpeas, and lentils, and nuts and seeds with no animal products, processed foods, or added salt, oil, or sugar.

They all came in hypertensive, over 140/90, but 9 out of 10—89%—walked out with pressures under 140/90. The average reduction in systolic blood pressure was 37 points, which is remarkable compared to other interventions, including drugs. And that was just the average drop. Those that came in with really high pressures, like over 180, experienced a 60-point drop. “This is arguably the largest effect ever published in the scientific literature.” And that was after they had all stopped all their blood pressure medications!

They conclude that “medically supervised water-only fasting appears to be a safe and effective means of normalizing blood pressure.” Extraordinarily effective, but for how long? I mean, fasting is the least sustainable diet out there. Interestingly, when they resumed feeding them, their blood pressures dropped even further, suggesting fasting could be used to kickstart the normalization of blood pressure, and then you could keep it down from then on with a healthy-enough diet.

They were able to track down a few dozen patients much later, and, on average, their pressures remained down. We don’t know what happened to the rest, but it shows that, at least, it can provide more lasting benefits for some. A subsequent smaller study followed up people up to a year later, and the blood pressure reduction seemed to hold, along with the weight loss; so, presumably, they stuck with the healthier diet. Now, no one should be fasting for more than a day or two unsupervised. So, this treatment certainly carries a cost, but the entire cost appears to have been recouped within the first year just from decreased medical care costs alone.

An alternative is the Buchinger method of fasting, popular in Europe, where instead of water only, people get like 300 calories a day of fruit juice and vegetable broth. It still needs to be done under professional supervision, but at least people don’t have to take time off of work. People are randomized to seven days of that, and then followed up four months later. After four months, you’d think any benefit from the one week quasi-fast would have disappeared, but their blood pressures ended up fifteen points lower than the control group.

“Although long-term follow-up of these subjects has been sporadic, the available data suggest that these large reductions in blood pressure can be conserved in patients who remain compliant with the follow-up diet. In other words, a ‘cure’ for hypertension may be feasible;” though, of course, if they resumed the original diet that had made them hypertensive in the first place, that would presumably lead to a resurgence of their blood pressures. And, the fast may actually help with that. The preliminary fast may help people stick to healthier “diets that would ordinarily have little appeal to people accustomed to meretriciously salty and greasy meals”—that is an SAT word if I ever saw one. I had to google that one: “apparently attractive but having in reality no value.” Sounds about right.

The secret to long-term benefits may be in helping kickstart the healthier diet by cleansing our palate, which has been so deadened by hypersweet, hypersalty, hyper-fatty foods. After not eating for a week, your regular, normal, healthy real food tastes good again. Like the ripest peach in the world would taste sour after a bowl of Fruit Loops, but fasting may re-sensitize our taste buds, such that you can enjoy something like corn on the cob without the added butter and salt; so, you get the best of both worlds: tastes great and less killing.

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For recipes, check out my How Not to Die Cookbook. It’s beautifully designed, with more than 100 recipes for delicious and nutritious meals. Speaking of new books, I have a new book just out – How to Survive a Pandemic – now out in audiobook, read by me, and e-book with physical copies out in August. Pre-order the physical copy now or download the e-book and audiobook now as well.

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Thanks for listening to Nutrition Facts. I’m your host, Dr. Michael Greger.