Q: Why is blood pressure one value on one occasion but a different value on another?
A. There may be many answers to this, but one answer may certainly be related to the technique used for checking blood pressure. Although taking a proper blood pressure reading may not be the most difficult thing in the world, a well-trained individual can do so at the optimum level. Often improper technique leads to inaccurate readings. When you take a wrong reading at home, this may lead you to think incorrectly that blood pressure is within appropriate limits. And of course, one sometimes can experience “white-coat high blood pressure”.

On the other hand, when a medical office takes an erroneous reading, this can even have worse implications and lead to incorrect treatment. The proper technique of accurate BP measurement is typically taught very early during medical and nursing training but sometimes gets taken for granted. It is important to use well-trained staff to take accurate readings.  Clinics use medical assistants rather than doctors or nurses to take blood pressure.

Q: Is it impossible for me to take home blood pressure readings? You’ve recommended home blood pressure measuring devices.
A: Fortunately, the technology for accurate and reproducible BP measurement outside the traditional medical environment has improved greatly over the last 30 years.  Many convenient, inexpensive and relatively accurate devices are now available. Even patients with hearing difficulties, problems with hand-eye coordination, and other disabilities can estimate BP with semiautomatic devices that have digital readouts and printers.
 
Some authorities believe that such devices should be provided to every person with elevated BP, but others are concerned about their use because they have not been commonly used in clinical decisions making in clinical trials.

Q: What is the proper way to take a blood pressure reading and when should someone be diagnosed with high blood pressure?
A: To answer the second part of the question, as I mentioned briefly in Chapter One, high blood pressure is diagnosed only after three readings are elevated on separate occasions. The reason is that blood pressure measurements have much natural variability even with the most accurate device on the market.

Although you can get an accurate blood pressure reading at any given time, blood pressure isn't always the same. It can vary considerably in a short amount of time—sometimes from one heartbeat to the next, depending on body position, breathing rhythm, stress level, physical condition, medications you take, what you eat and drink, and even the time of day.

No matter the technology used for taking blood pressure measurements and no matter the conditions of your body and environment, expert panels have made recommendations regarding how you should measure BP. First and foremost, the blood pressure cuff itself must be appropriately sized for the size of the patient’s arm. There are three general sizes to use: one for young children, one for average adults, and a larger cuff in obese adults and others with particularly large arms.

Some other factors that can be controlled also lead to incorrect readings. Positioning of the blood pressure cuff as well as proper size is also very important.  There is an artery that is key to obtaining accurate blood pressure readings called the brachial artery, and the cuff should be positioned relative to this landmark. The cuff usually indicates which end faces the shoulder and which end faces the elbow. There is usually an arrow on the cuff that points to the brachial artery. Line up this arrow with the brachial artery.

Q: How should I prepare for having my blood pressure checked?
A: Too often, blood pressure readings are made without any concern for prior activity.  It’s important to avoid caffeine, alcohol and tobacco for at least thirty minutes before a blood pressure measurement. The stimulants caffeine and tobacco in particular may acutely increase blood pressure.

You may think you’re safer drinking several glasses of water or juice before a blood pressure reading. However, having a full bladder and needing a bowel movement may also affect blood pressure control. Make sure, however, that you are properly hydrated.

Heat also affects your readings. This is why signs posted above public hot tubs warn about prolonged soaking. High surrounding temperature typically causes blood pressure to drop as blood vessels dilate in order to keep body temperature constant.  That drop in blood pressure can cause you to faint, especially if you are already taking anti-high blood pressure medication.
 
A properly recorded blood pressure should only be taken after at least five minutes of comfortable rest. You may find it helpful to relax and take several deep breaths. A mini-meditation may also calm your body and dilate your blood vessels. Then, have your blood pressure taken (or take it at home) at the level of the heart and the arm. Taking the blood pressure below that level may lead to falsely high readings, and the opposite is true of taking the blood pressure with the arm positioned above the heart and the other arm. Tip: Measure BP in both arms at first and in the arm with the higher BP thereafter if the difference is greater than 10/5 mmHg.

Q: What does hydration have to do with blood pressure?
A. Blood pressure is usually lowest at night and rises sharply on waking. With poor hydration, the levels fall drastically. You need to drink plenty of fluids before you have your blood pressure checked or you take it yourself.

Preventing dehydration is easy if you follow fluid intake guidelines from the Institute of Medicine for “healthy sedentary adults living in temperate climates” (i.e. with season changes). Men should take in approximately 125 ounces or 3.7 liters of water per day from all dietary sources. Most women on the other hand should get about 91 ounces (or 2.7 liters) of water per day from all dietary sources.  Food intake actually usually supplies about 20 percent of our daily fluid intake, so that means men need to drink approximately three quarts per day and women  over two quarts per day.  Low-sugar fruit ices, sugar-free frozen pops, and sugar-free gelatin desserts are good supplements to increase amount of overall fluid intake.

Q: How do home blood pressure readings compare?
A: Several reports show a benefit to supplementing clinical blood pressure readings with home self-monitoring. Home readings can be helpful in evaluating symptoms, especially ones that aren’t chronic, that are suggestive of high blood pressure. Often these symptoms aren’t present during the few minutes of a typical physician office visit.  In fact, when done correctly, home monitoring can actually save quite a bit in costs related to follow-up office visits.

Because people typically feel less stressed taking BP at home, BP readings are typically lower than measurements taken in the traditional medical environment, even in persons with normal blood pressure. Also, routine home BP monitoring gives you an advantage when you undertake a blood pressure-lowering plan. This is primarily because you are paying close attention to the condition. I concur with many physicians who say an individual prognosis is better predicted by home readings than by one or two “casual” office BP measurements.

One long-term study has shown that people with much lower home BP readings suffer fewer major cardiovascular events than do people who have elevated readings both in the office and at home. Thus, if the home BP reading differs widely from the office BP reading, this is possibly a favorable sign of improved hearth health.

In addition, the use of home blood pressure monitoring is a practical way to evaluate therapies for lowering blood pressure and to assess BP response out of the office prior to using ambulatory blood pressure monitoring. Blood pressure checks at home may also be especially helpful for smokers and patients who don’t always comply with physician instructions.

I will caution that home readings should be interpreted cautiously, carefully, and conservatively.  Many of the factors that contribute to blood pressure variability are more difficult to control in the home environment—such as food and alcohol ingestion, activity levels, and stress. If home readings are taken, the home measuring device should be calibrated against the standard clinical BP measuring device in a physician’s office. Any device that is used at home should pass the Aggressive Standards for Advancement of Medical Instruments.

Q: What should I look for when doing blood pressure monitoring at home?
A: If you record home measurements of greater than 135/85 mmHg, you have high blood pressure. However, false readings can occur. You should use the same techniques at home that are used in the doctor’s office, most importantly sitting quietly for 5 minutes first and making sure that the cuff covers 80 percent of the circumference of the arm.  Also, you may find it beneficial to keep a record of the blood pressures measured and the time and date they are taken to share with the doctor at the next appointment.

Q: You mentioned “ambulatory blood pressure monitoring”. What is this?
A: Since we don’t sit still with BP monitors attached to our arms all day, scientists have devised another way to measure blood pressure. This method uses automated blood pressure measurement over a 24-hour period during a person’s usual daily activities. Scientists think of ambulatory blood pressure monitoring devices (ABMP) as “the gold standard,” the best method of measuring blood pressure in controlled research trials. ABMP devices are beginning to have a greater place in clinical practice in the United States because insurers have increased their reimbursement for ABMP technology.

The advantages of ABMP devices include the number of measurements obtained during a 24-hour period, including during sleep and daily activities. ABMP can identify and diagnose white-coat high blood pressure. However, a few of the disadvantages include the cost, limited availability, disruption of daily life because of noise or discomfort, and lack of prospectively defined “normal values”. Also, there are no standard guidelines for treatment or long-term studies demonstrating the superiority of this practice.

Q: I have been diagnosed with high blood pressure and am following the recommendations I was given. When and how often should I go back for a check-up?
A: Although it is important to follow your physician's instructions, here are some general guidelines:  There are a few recommendations that can be made on follow-ups based on initial blood pressure measurements for adults.  For example, if the initial blood pressure measurement (measured in mmHg) is normal, you need to have a follow-up in two years.  If the initial blood pressure measurement is pre-high blood pressure, a follow-up should be made in one year.
 
If the initial blood pressure is Stage 1, a confirmation follow-up should be done within two months. If the initial blood pressure reading reveals Stage 2 high blood pressure, an evaluation or referral to a source of care should take place within a month.  If the blood pressure is greater than 180/110 mmHg, evaluation and treatment should take place within a week if not immediately.

It is important for physicians and other clinicians to monitor and anticipate problems complying with prescribed treatment, especially for young men.  Anyone with high blood pressure and/or being evaluated for high blood pressure should always bring all medicines from all physicians and other sources (prescription, complementary, or over-the-counter) to each visit for review. This helps a physician to determine if blood pressure is being affected by unnecessary causes.  Fortunately, many patients with high blood pressure are treated in primary care with well-controlled blood pressure. However, with surveys estimating only 30 percent of all Americans who have high blood pressure controlling the condition, physicians need to strive in their practices to ensure that all patients with high blood pressure have it under control.

At the other end of the spectrum, we have mentioned low blood pressure briefly.  Some people who are healthy and eat a balanced diet and exercise regularly but still have a blood pressure that is regularly on the low side wonder if they should be concerned.  On the contrary, they should ask for a reduced rate on their life insurance.  If you feel healthy, having a relatively low blood pressure is good for the cardiovascular system, since it puts less stress on the blood vessels. However, low blood pressure can indicate a few disorders in those that are not healthy.

Q: Can my blood pressure be too low?
A: You can never be too rich, too thin, or too low-blood-pressure…right? That’s where this business of measuring blood pressure gets tricky (as if it wasn’t already). Low blood pressure, called hypotension, is much harder to quantify, but it is worth a mention. Some experts define low blood pressure as readings lower than 90 systolic or 60 diastolic. Unlike your numbers for high blood pressure, you only need to have one number in the low range for your blood pressure to be considered lower than normal. If your systolic pressure is a perfect 115 but your diastolic pressure is 50, the medical establishment judges that you have lower than normal pressure.

Yet as with much medical data, these numbers can be misleading simply because one size does not fit all. What’s considered low blood pressure for you may be normal for someone else. For that reason, doctors often consider chronically low blood pressure too low only if it causes noticeable symptoms.

On the other hand, a sudden fall in blood pressure can be dangerous. A change of just 20 mmHg, for example, a drop from 130 systolic to 110 systolic (top number) can cause dizziness and fainting when the brain fails to receive an adequate supply of blood. And big plunges, especially those caused by uncontrolled bleeding, severe infections or allergic reactions, can be life-threatening.

Q: What causes low blood pressure?
A: Athletes as well as people who exercise regularly tend to have lower blood pressure than do people who aren’t as fit. So, in general, do nonsmokers and people who eat well and maintain a normal weight. However, in some instances, low blood pressure can be a sign of serious, even life-threatening disorders. The American Heart Association advises that the following are possible causes of low blood pressure:

1. The first and second trimesters of pregnancy
2. Medications such as those used to treat Parkinson’s Disease, Viagra (particularly in combination with nitroglycerine) and even heart medication such as beta-blockers
3. Narcotic and alcohol abuse
4. Heart problems
5. Endocrine problems
6. Dehydration
7. Blood loss
8. Septic shock (blood infection) and anaphylaxis (as in peanut or food allergies)
9. Nutritional deficiencies
10. Postprandial low blood pressure found in adults with high blood pressure or automatic nervous system disorders (such as Parkinson’s Disease).
11. Postural low blood pressure, occurring in adults who stand abruptly from a sitting or prone position and can be caused by conditions including heatstroke, dehydration, heart problems and excessive bed rest as well as certain medications such as ACE inhibitors and medication for Parkinson’s Disease
12. Neutrally mediated low blood pressure occurring in young people who stand for long periods. 

Interestingly, high blood pressure is connected to low blood pressure in at least one of the causes, so let’s return to our "King Kong" of diseases.

Q: My doctor referred me to a high blood pressure specialist at a high blood pressure clinic. Is this a good move?
A: Sometimes it may be necessary for your doctor to refer you to a high blood pressure specialist.  This is not because he or she doesn’t want to deal with the issue. It simply means that the provider is trying to get you to the most knowledgeable person to help your condition.

A local high blood pressure clinic may be an obvious place that a doctor will refer a patient, but not all general practitioners have such a local clinic. Where there is no specialist clinic, your doctor will most likely refer you to the local cardiologist. But your local cardiologist may not have any specialist training or an interest in high blood pressure, and may actually have less overall experience of managing hypertension than you do. A better alternative may be a local vascular or stroke physician, an elderly care physician or a general practitioner with a specific interest (GPSI). Many GPSIs have completed training in high blood pressure treatment.

The specialist, GPSI or other doctor needs to have as many facts to hand as possible when they see the patient. If they have to arrange tests, this just delays implementing treatment. A local specialist or GPSI will often want or need to see the results of the following:

• a prevention screen, including lipids and blood glucose.
• routine lab tests such as microalbuminuria.
• 24-hour urine test for sodium, urea and electrolytes, estimated glomerular filtration rate (eGFR), serum urate, thyroid-stimulating hormone and gamma gluteryl transferase.
• routine electrocardiogram (ECG), especially when left ventricular hypertrophy has been previously seen, with a copy of the new ECG to be sent with the referral.

Q: I don’t have high blood pressure right now, is there any reason for me to pay attention to it?
A: You’re reading this book, so the odds are that you are concerned or somewhat curious, with good reason. Primary prevention of high blood pressure can improve quality of life and costs associated with medical management of high blood pressure and its complications. A viable strategy for the general population would be to reduce blood pressure in those with higher than optimal levels but below the cut points for diagnosis.

Recent research shows that higher than normal blood pressures that didn’t meet the criteria for high blood pressure were associated with an increased risk of cardiovascular disease. A downward shift of 3 mmHg in systolic (top number) BP would decrease the mortality from stroke by 8 percent and from coronary heart disease by 5 percent. People at highest risk should be strongly encouraged to adopt healthier lifestyle changes, which are essential for both prevention and management of high blood pressure. 

Q: What is secondary high blood pressure and why should I be worried?
A: Other conditions can cause high blood pressure. As you read in Chapter One, this book focuses on primary high blood pressure. Secondary high blood pressure, however, is of great concern and needs to be explained.

When something goes wrong in one part of your body, a ripple effect can create problems elsewhere, such as high blood pressure. In fact, 5 to 10 percent of high blood pressure cases are caused by an underlying condition, according to the American Heart Association. This type of high blood pressure, known as secondary hypertension, tends to appear suddenly.

Various conditions can cause secondary high blood pressure. However, there’s good news: Treating these underlying conditions can control, or cure, your high blood pressure. This reduces the risk of serious complications that include heart disease, kidney failure and stroke.

Q: What are the possible causes of secondary high blood pressure?
A: Here is a partial list:

• Diabetic nephropathy: Your kidneys contain millions of tiny blood vessels that filter waste from your blood and eliminate it in your urine. But diabetes can damage this delicate filtering system. In fact, diabetic nephropathy is the most common type of kidney failure, which is nearly always associated with high blood pressure. The high blood pressure can be treated with diet, exercise and medication. If your kidney function dips too low, you may need dialysis or a kidney transplant.
• Polycystic kidney disease: In this inherited condition, cysts in the kidneys disrupt normal function and raise blood pressure. The high blood pressure can be treated with diet, exercise and medication. The polycystic disease may ultimately require dialysis or a kidney transplant.
• Glomerular disease: Your kidneys filter waste and sodium using microscopic filters called glomeruli. Inflammation of these filters is called glomerulonephritis. If the inflamed glomeruli can't function normally, you may develop high blood pressure. The high blood pressure can be treated with diet, exercise and medication. Glomerulonephritis may be treated with medication, dialysis or a kidney transplant.
• Hydronephrosis: When certain parts of one or both kidneys become plugged, that causes urine flow blockage, which raises blood pressure. Some blockages resolve without treatment, but others require drainage or surgery. Once the blockage is removed, blood pressure often returns to normal.
• Renovascular high blood pressure: This is a type of secondary high blood pressure caused by narrowing (stenosis) of one or both renal arteries. Renovascular high blood pressure can cause severe hypertension and irreversible kidney damage. It's often caused by the same type of fatty plaques that can damage your coronary arteries (atherosclerosis) or a condition in which the muscle and fibrous tissues of the renal artery wall thicken and harden into rings (fibromuscular dysplasia). In mild cases, the high blood pressure may be treated with diet, exercise and medication while kidney function is simply monitored. In more severe cases, the doctor may open clogged arteries with a procedure known as angioplasty. Wire mesh tubes (stents) may be used to hold the arteries open. Another option is to surgically bypass blood flow around the affected arteries. Once blood flow to the kidneys improves, blood pressure usually returns to normal.
• Cushing’s Syndrome: Corticosteroid medications, a pituitary tumor or other factors cause the adrenal glands to produce too much of the hormone cortisol. This raises blood pressure. Treatment may include surgery, radiation therapy or medication to return both cortisol and blood pressure to normal.
• Aldosteronism: A tumor in the adrenal gland, increased growth of normal cells or other factors cause the adrenal glands to release an excessive amount of the hormone aldosterone. This makes your kidneys retain salt and water and lose too much potassium, which, as you have read, raises blood pressure. Treatment may include medication to block the action of aldosterone and surgery to remove a tumor in the adrenal gland, complemented by a proper diet, exercise and medication to treat the high blood pressure.
• Pheochromocytoma: This rare tumor in the adrenal gland increases production of the hormones adrenaline and noradrenaline, which can lead to persistent high blood pressure or marked fluctuations in blood pressure. Surgery to remove the tumor returns blood pressure to normal.
• Hypothyroidism: The thyroid gland doesn't produce enough thyroid hormone, which can cause high blood pressure. Hypothyroidism may have various causes, including inflammation, surgery, radiation treatment, certain medications or pituitary problems. Treatment with synthetic thyroid hormones usually returns blood pressure to normal.
• Hyperthyroidism: The thyroid gland produces too much thyroid hormone, which increases the activity of epinephrine and norepinephrine, which in turn can increase blood pressure. Treatment may include medication, radioactive iodine therapy or surgery, all of which can restore normal blood pressure.
• Hyperparathyroidism: The parathyroid glands regulate levels of calcium and phosphorus in your body. If the glands secrete too much parathyroid hormone, the amount of calcium in your blood rises, which triggers a rise in blood pressure. Treatment is typically removal of the parathyroid glands. This returns blood pressure to normal.
• Coarctation of the aorta: With this congenital defect of the body's main artery (aorta), a constriction (coarctation) in part of the aorta forces the heart to pump harder to get blood through the aorta and to the rest of your body. This, in turn, raises blood pressure, particularly in your arms. Surgery to repair the aorta can restore normal blood pressure.
• Sleep apnea: Your breathing repeatedly stops and starts during sleep. The repeated episodes of oxygen deprivation may damage the cellular lining of the blood vessel walls, which may deprive blood vessels of the elasticity they need to regulate blood pressure. Treating sleep apnea with a pressure mask, nasal devices, surgery, weight loss or other steps can help control the high blood pressure.
• Obesity: As you gain weight, the amount of blood circulating through your body increases. This puts added pressure on your artery walls. In addition, excess weight often is associated with an increase in heart rate and a reduction in the capacity of your blood vessels to transport blood. All of these factors can increase blood pressure.
• Medications, supplements and illicit drugs: Various prescription medications from pain relievers to antidepressants and drugs used after organ transplants can cause or aggravate high blood pressure. Birth control pills, decongestants and certain herbal supplements, including ginseng and St. John's Wort, may have the same effect. Many illicit drugs, such as cocaine and methamphetamine, also increase blood pressure.

High Blood Pressure in Men vs. Women

Q: Is it true that hot flashes increase blood pressure?
A: New research indicates hot flashes are, in fact, associated with an increase in blood pressure and a decrease in memory as well as quality of sleep.

Among the recent studies linking health problems to hot flashes is one from Weill Medical College of Cornell University, which showed that hot flashes are associated with an increase in blood pressure. The all-female survey revealed that participants who had experienced hot flashes in the two previous weeks had significantly higher systolic blood pressure (the top number) than those who had not.

Thus, your doctor needs to follow your menopausal symptoms and therapy closely as part of your blood pressure treatment. You can reduce or eliminate the effects of hot flashes with the following steps:

• Stop smoking. Tobacco is associated with increased hot flashes.
• Eat more legumes and vegetables.
• Eat one to two teaspoons of ground flaxseed daily.
• Eat more soy foods, especially those that contain naturally occurring phytoestrogens. Tempeh, tofu, soy milk and soy nuts as well as edamame are good sources.
• Exercise! 
• Practice the de-stressing techniques in Chapter Nine.
• Keep your bedroom cool at night.
• Wear loose clothing and dress in layers so you can remove one if necessary.
• Use alternative therapies only under a doctor’s supervision.
• If necessary, avoid alcohol, spicy foods, hot drinks and caffeine, which trigger hot flashes in some women.

Q: How does high blood pressure affect men?
A: We mentioned men’s sexual function in Martin’s Story in Chapter Two. Experts don’t know exactly how high blood pressure causes erectile dysfunction and impotence. One leading theory is that the excess pressure in the blood vessels actually causes damage to small arteries in the penis, according to Dr. Craig Weber. Normally, these arteries dilate in response to sexual stimulation, allowing more blood to flow into the spongy tissue of the penis to produce an erection.
 
Experts think that excessive pressure on these arteries may cause tiny rips, which the body then repairs. In response to these rips, the healed arteries become thicker, allowing them to better resist further damage. These thicker arteries, though, aren’t able to respond as fast, or as completely, to demands for extra blood, so they become a sort of dam in the flow of blood to the erectile tissues of the penis.

One problem with this theory is that some studies seem to show that how long a patient has had high blood pressure is not as important for predicting the risk of erectile dysfunction as is the actual severity of the high blood pressure. In other words, someone who has had moderate high blood pressure (140/90) for twenty years sometimes appears to be at lower risk for erectile dysfunction than a young man who has had very serious high blood pressure (160/100) for only a few months. In light of this, other theories of how high blood pressure contributes to erectile dysfunction have been proposed.

Regardless of the cause, the interruption in your sex life, and the loss of health benefits and intimacy, is certainly serious enough to take care of your ticker and get regular blood pressure checkups.

Q: Are women better at managing high blood pressure than men?
A: Ironically, men are more likely to take care of themselves than women in this regard. Women underestimate their risk for high blood pressure and heart disease, and often put their health secondary to family, job, career, volunteering, and all their other obligations. Let’s put our women first! The NHLBI Heart Truth campaign aims to reach women between the ages of 40 and 60 and women of color who have the highest risk factors for heart disease. The American Heart Association has designated February Red Dress Month, which focuses on heart disease as the leading cause of death in women.

Spousal support (and relatives’ and friends’ support) can make all the difference in helping men and women exercise, manage stress, cut down on salt, and maintain a healthy diet.

Health Habits

Q: What does oral hygiene have to do with high blood pressure and heart disease?
A: You've repeatedly heard it from your dentist since your very first teeth cleaning and checkup: brush twice a day and don't forget to floss. But this advice may contribute even more to your health and savings than just a mouth full of cavity-free teeth.
 
Research demonstrates a connection between gum disease and cardiovascular disease. This information is relatively recent and less well established when compared with other known risk factors for heart disease such as high blood pressure and high cholesterol, but it is solid.

Gum or periodontal disease is a collection of inflammatory diseases affecting the tissues that surround and support the teeth. The bone reduction related to periodontal disease may lead to loosening and, if periodontal disease is untreated, eventual loss of teeth. Bacteria that adhere to and grow on tooth surfaces, especially in areas under the gum line, cause periodontal disease.
These bacteria can gain access to the bloodstream, triggering inflammation in the body. As with any infectious disease, your body reacts. An inflammatory reaction can be severe with infections such as the flu, in which a fever and increased with blood cell count help fight the illness. With periodontal disease, the level of inflammation is much less severe and is usually not high enough to cause these systemic symptoms. However, the chronic low level of inflammation may be enough to bother the blood vessels and help trigger vascular disease. White blood cells present in atherosclerotic, or hardened, blood vessels, sense the low-level reaction and produce a variety of factors that may worsen the disease process.
 
Also, some evidence suggests that periodontal bacteria can attach to the fatty plaques in blood vessels, amplifying the inflammatory process, which can lead to heart attack or stroke. This mechanism is similar to periodontal bacteria attaching to heart valves, which can lead to a serious infection of the heart lining known as endocarditis.

We’ve mentioned C-reactive protein (CRP). Patients with periodontal disease typically have elevated C-reactive protein (CRP) levels, an independent risk predictor of cardiovascular disease. CRP can be detected via a blood test that detects the level of inflammation in the body.

Q: You talked about the importance of maintaining a healthy weight for optimum blood pressure. How do I know if I am overweight and/or obese—by looking in the mirror?
A: Using a mirror may offer an idea, but too often people are either overly critical or they deny any problem. 

As we saw in Chapter Two, BMI helps determine if someone is overweight. Doctors use BMI and waist circumference measurement to rule whether someone is overweight and/or obese.

One way to determine if you may need to shed a few “lbs” for your health is to simply check your belt—literally. This may sound rude, or even a bit simple, but the truth is that one of the best indicators we have is waist size.  Now, there is a certain place to measure, so wearing your belt around your hips doesn’t count.  In general, take the measurement around the largest part of your belly across the belly button for a fairly good estimate.  Men should have a waist no more than 40” and women should not exceed a waist of 35”.  This does not mean that being an inch or two below these cutoffs is necessarily optimal either.  However, above these sizes, you significantly increase your chance for Type 2 diabetes and ultimately heart disease. Waist size is very closely related to what is called “insulin resistance”, which seems to be a risk factor for high blood pressure and also heart disease.
 
Another easy way to determine if you need to lose weight is to calculate your body mass index (BMI) to see if your weight falls into the healthy, overweight, or obese range. Use this simple formula to calculate your BMI: Weight in pounds × 703 ÷ (height in inches).

If you are overweight or obese, a weight loss of about 10 kg will result in a systolic blood pressure drop of up to 10 mmHg, depending on the level of a patient's obesity. Most people can lose that amount of weight relatively easily.

Q: How does a vegetarian diet help lower blood pressure?
A: Factors other than dietary fat, such as increased potassium levels (see Chapter Three), appear to lower blood pressure in vegans.  Although dietary lipids do not seem to directly affect blood pressure, they strongly affect CVD risk. Thus, a completely vegetarian diet with is recommended for preventing complications from hypertension and CVD.  An olive oil-enriched diet has been shown to decrease blood pressure drug usage by 48 percent, and as we’ve seen, soy protein is another factor that may contribute to the lowering of blood pressure. Soy isoflavones may also be beneficial for menopausal women.

Q: How much alcohol does it take to raise blood pressure?
A. My fellow physicians have reported that five to seven percent of the high blood pressure in the population is due to alcohol consumption. This may depend on the individual. However, as a rule, an intake of three drinks per day (a total of three ounces of alcohol) is the threshold for raising blood pressure and is associated with a 3 mmHg rise. To prevent high blood pressure, men should consume less than two drinks per day.  In women and lighter-weight persons, no more than one drink a day is recommended.
What counts as a drink? Let’s test your Alcohol IQ as it pertains to blood pressure. Think in your mind….is the answer true or false?

1. People with high blood pressure don't have to limit the amount of alcoholic beverages they drink.
2. Alcoholic drinks contain calories, which is another good reason to cut back on them if you're trying to lose weight and control high blood pressure.
3. A 12-ounce can of beer counts as one drink, the same as five ounces of wine or 1   ounces of whiskey.

Q: Are headaches related to blood pressure?
A: Headaches can be devastating, but they can also just be a nuisance that inhibits our best function. Headaches have also been associated with high blood pressure. The link between headaches, including migraine headaches, and high blood pressure is controversial. Research seems to agree that migraines are linked to a consistent systolic (top number) reading of 140 or a diagnosis of severe high blood pressure. Mild high blood pressure doesn’t produce headaches.

If you have migraines and severe high blood pressure, proper eating habits, such as the one described in this book, can help maintain good flow of energy and blood to the head. Also, eating frequent smaller meals to feed the brain more often certainly makes sense—selecting natural foods with no additives is recommended of course.  A migraine prevention diet is similar to a heart disease prevention diet.

To avoid migraines, eat fiber-rich foods. In addition, green leafy vegetables, parsley, green tea, onions, ginger, pearl barley, carrots, prunes, buckwheat, peach kernels, and almonds have all been recommended by nutrition experts for headache relief, as well as chrysanthemum flowers (I always thought that these were just for decoration).

On the other side of the coin, headache sufferers may want to avoid certain food triggers that include alcohol, chocolate, MSG, nitrates, sulfites, sugar, salt, spicy foods, heavy starchy foods, caffeine and fried/greasy foods—many of the same things that can raise high blood pressure. This does not mean people who have migraines and severe high blood pressure need to avoid everything on this list. These are simply food triggers to watch for.

As with high blood pressure, headaches decrease in intensity with motion. Stretching and (if possible) taking a light walk in fresh air can nip a headache in the bud before it starts. This will stimulate blood flow and allow more oxygen to the head. The relaxation techniques in Chapter Nine (t’ai chi and meditation) are also therapeutic.

It is important to visit your physician an emergency room immediately should you ever experience severe, debilitating headaches that don't respond to simple over the counter medication—or wake up in the middle of the night with an excruciating headache.

Q: How is fatigue related to blood pressure?
A: Fatigue commonly occurs with high blood pressure. On the other hand, blood pressure that is too low may also cause fatigue, lightheadedness and depression.

As with headaches, fatigue that interferes with your daily routine can be conquered using the same methods as those used to treat high blood pressure. There are certainly numerous options to help regain the physical and mental energy needed to enjoy life to its fullest, no matter your sex or age. For example, learn to eat foods that increase your energy levels.  An emphasis on consumption of vegetables, whole grains, and healthy oils is the foundation of this approach. You see, different kinds of foods are converted to energy at different speeds.  For example, simple sugar forms (i.e. candy) can provide a quick lift, followed by a low.  On the other hand, however, unprocessed foods (such as whole grains and healthy unsaturated fats) will provide sustained energy throughout the day. Eat small, frequent meals throughout the day to provide a steady supply of fuel that reduces your brain’s perception of fatigue. Adding a daily multivitamin will ensure that you get the vitamins and minerals you need.

Don't get let yourself get caught up in buying those energy supplements at the grocery or gas station checkout. Most of these supplements merely contain a form of caffeine like coffee and use of these quick fixes can often lead to worsening fatigue problems when any positive effects wear off. In addition, as you learned in Chapter Eight, certain stimulants can actually add stress to the heart and your circulatory (blood) system.

As mentioned in the earlier chapter, stress often contributes to fatigue. Accordingly, relaxation therapy (i.e. self-hypnosis, yoga, massage, aromatherapy, and tai chi) can be an effective tool for reducing stress and naturally boosting your energy. Also, Harvard experts recommend the "progressive muscle relaxation" technique. This involves systematically tightening and releasing sets of muscles, beginning with your toes and progressing up your legs, torso, hands, and arms. I would recommend Harvard Health Publications' Boosting Your Energy report to help you take the first steps toward an energized life.
 

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