Season 2 | Episode 2
>> Dr. Bakris: I'm going to summarize for you 50 years of research in one paragraph. If you want to protect your heart, it's all about cholesterol management. Blood pressure helps, but cholesterol is king. If you want to protect your kidneys and your brain, it's all about blood pressure. Cholesterol is important, but blood pressure is king. And if you have diabetes and you want to protect your eyes and your nerves and your vasculature, it's all about sugar control. And there you have it.
>> Joe: Hello, and welcome to the Merck Manual's Medical Myths podcast, where we set the record straight on today's most talked about medical topics and questions. I'm your host, Joe McIntyre, and on this episode, we welcome Dr. George Bakris. Dr. Bakris is a professor of medicine at the University of Chicago School of Medicine. He is a director of the University's Comprehensive Hypertension Center and specializes in the diagnosis and reduction of high blood pressure, particularly in complicated and refractory cases. Dr. Bakris also authors the hypertension sections of the Merck Manual. Dr. Bakris, welcome.
>> Dr. Bakris: Thank you. Good to be here.
>> Joe: Today we're going talk to Dr. Bakris about some of the most common myths surrounding blood pressure, cholesterol and hypertension. First, let's begin with a question I'm sure you hear a lot as a doctor and one we've seen asked quite often on the Merck Manuals. So, when it comes to high blood pressure, is it always caused by poor diet and lack of activity, or is it a little bit more than that?
>> Dr. Bakris: So poor diet and activity obviously contributes to earlier development of hypertension. But hypertension is a genetic disease that has many genes that have been identified. And if you have a family history of hypertension, then you're more likely to develop it at an earlier age. But in all of us, as we get older, salt intake and potassium intakes of sodium and potassium both impact the severity of hypertension and when we're going to develop it. If you have genes that are going to preclude you to develop hypertension, and you're eating a high fat diet, you're going to develop it even earlier and may be more severe. If you don't have that genetic load, then you're still going to develop elevated pressures when you get into your 60s and 70s, and, again, a salt diet there will make things worse.
>> Joe: So, you know, when someone has hypertension, let's say, is it something that can be cured, or are they stuck with it for the rest of their lives? How does that work?
>> Dr. Bakris: Hypertension is not an infectious disease, meaning infectious diseases can be cured with antibiotics. Hypertension is a disease for life. Things in your lifestyle can modify it and make it easier to treat, like weight loss, reduced salt, good sleep, exercise. All of those things help in reducing the load of blood pressure and making it much easier to manage. But in addition to that, you're probably going to need medications. And the number of medications is going to depend, a, on the severity, and the severity, as we just said, is going to be a function of what you do in your lifestyle to modify salt, increase exercise, get appropriate sleep, etcetera.
>> Joe: One myth that we see quite a bit online is this idea that high blood pressure is the same thing as having a high heart rate. Is that actually the case? It doesn't sound like it, but tell me if I'm wrong.
>> Dr. Bakris: No, no, you're absolutely wrong. It is a myth. A high heart rate does not necessarily predict mortality. High blood pressure does. Number two, heart rate is dependent on multiple things and high heart rate itself, by the way, can raise blood pressure. So, it is important to understand why your heart rate is high. And if you've lowered blood pressure with medications and lifestyle, and you still have a high heart rate and your blood pressure’s still not quite where it needs to be, then using drugs to lower heart rate will help the blood pressure. So that's the reason to give drugs, to lower heart rate, is for blood pressure control more than just heart rate reduction. But no, they’re very different, and diagnostically very different.
>> Joe: So, Dr. Bakris, does cholesterol matter more than blood pressure? You know, what's the difference between the two of them? And is one more dangerous than the other? Is it more dangerous to have high cholesterol versus high blood pressure?
>> Dr. Bakris: I'm going to summarize for you 50 years of research in one paragraph. And that is, if you want to protect your heart, it's all about cholesterol management. Blood pressure helps, but cholesterol is king. If you want to protect your kidneys and your brain, it's all about blood pressure. Cholesterol is important, but blood pressure is king. And if you have diabetes and you want to protect your eyes and the nerves and your vasculature, it's all about sugar control. And there you have it. So cholesterol is very important to keep your arteries open and keep things functional. On the other hand, blood pressure potentially can make high cholesterol worse by the pressure changes to level the artery. So it's not one or the other. It’s not a multiple choice. The answer is all of the above because you really want to maintain a healthy menu in the environment of your arteries because, fundamentally, those are the pipes feeding the brain, the heart and the kidneys and other organs.
>> Joe: On the topic of cholesterol, something we see in advertisements all the time on TV is, you know, some food is low cholesterol or eggs are high in cholesterol and you should avoid them. How much do the foods that you eat directly correlate to high blood pressure, or is it a combination of different factors?
>> Dr. Bakris: One of the things that I instruct all my patients on is how to read food labels. And when you're looking at food labels, obviously the cardiologist has done an excellent job in teaching you how to look at cholesterol. But I focus on sodium content, and the general thing that I tell the patients is, you have 2300 milligrams of sodium allowed for the day. Some societies want you to eat less, like the American Heart, which talks about 1500, and other societies are keeping it around 2300. Easier to be 2300 because that's one level teaspoon of salt. Lot of people think, oh my God, that's a lot. Turns out that one level teaspoon of salt is about 50% of what the daily sodium intake of an American diet is. So if you think of 2300 as a debit card, then every time you're eating something, if you're paying attention to the salt, you will be able to keep it at 2300. If you eat out, it's a little more of a task because you have to ask these to prepare food without salt. You have to avoid soups. So basically reading labels is great if you're eating at home. But if you're eating out, you need to avoid fast food places, and you need to avoid places that have a lot of ready-made meals because the salt will already be in the meal.
>> Joe: One thing you mentioned a little bit earlier that I want to touch on really quick. You mentioned that cardiovascular issues are the silent killer. Hypertension is a silent killer. Can you actually feel when you have high blood pressure?
>> Dr. Bakris: The majority of people that have elevated pressures have nonspecific symptoms, so everyone goes, well, if I have a headache, my pressure must be up. That’s not necessarily true. If your pressure is really up at very high levels, yes, you can have headaches. Generally, it's a tension-type headache that people have. And that's because a lot of stress can precipitate elevations in pressure. And you get these tension headaches where the back of your neck is very sore. It hurts. And then it feels like a band is going around your head. That can be related to pressure, but pressure itself isn’t causing that. It's probably underlying stress that is causing that. If you're really having a headache from very high pressures, then that's one of the preambles of potentially having a stroke. And you really need to go on that. The majority of people, and, when I say the majority, I'm talking about over 90%, do not have any symptoms of elevated pressure at all. If you ask them they say they're feeling fine. So, again, do not depend on symptoms to give you any kind of hint about your blood
>> Joe: Good to know. Good to know. You know, we talked a lot about high blood pressure and when blood pressure is elevated. Is it possible to have unusually low blood pressure?
>> Dr. Bakris: Yes, it is possible. Are there specific conditions that are associated with very low blood pressure? The good news is it's not common. In fact, it’s distinctly uncommon. One of the most common causes of the low blood pressure, interestingly, is diabetes. Diabetes, if you have it for many, many years, and it's been poorly controlled, you can develop what's called an autonomic neuropathy, which means that, when you lay down, you’re pressure is very high. When you stand up, your pressure goes to 90. There's no ability to buffer the changes in your blood pressure when you stand up, and there's treatment for that, and it's very specific treatment because you do need blood pressure medicine that is short-acting that you would give a bedtime. But during the day, believe it or not, you need to intake higher amounts of salt to maintain your blood pressure when you're standing up or you’ll fall over. And there are other conditions like Parkinson's disease and other diseases that have this kind of problem, but it's nowhere near as common as hypertension.
>> Joe: One point I'm going to take a little bit of a personal note here. So my own father has a bit of an issue with higher blood pressure that he's working to handle. My mother does not. They have similar diets, obviously different genetics. But for the most part, it's only my father who has it. Is it a matter of men having more, or a greater risk, of higher blood pressure than women? Or is it, you know, a combination of different things?
>> Dr. Bakris: You know, it's a combination of things. It's not that men have hypertension more than women or women more than men. It's pretty similar. Men are a little more than a woman. But the difference is that women, especially older women, can have more cardiac problems because of the differences in coronary circulation that are now coming to be appreciated, that are not necessarily, I should say, symptomatic. They can be asymptomatic.
>> Joe: Is there a specific age, for example, that someone should be much more conscious of it? Or, you know, is it as long as you have your annual checkup and the doctor or nurse checks your blood pressure you should be okay? Or is there a certain age where you should really focus on this idea that I may have higher blood pressure?
>> Dr. Bakris: Well, I think if you have a strong family history, in other words, both parents have hypertension, you should be getting your blood pressure checked not necessarily every year but certainly every other year when you're in your 30s. And in your 40s, I would probably continue that. And at the first demonstration that you have elevated blood pressure, which could be in your 40s, almost certainly is going to be in your 50s, you need to start making lifestyle changes even before that if you know you're at risk. If you're above 150, you can certainly try lifestyle interventions. You can give them about a month. And if they haven't really resolved the issue, you probably should go on some form of antihypertensive medication.
>> Joe: We'll be back with more from Dr. Bakris right after this.
>> Joe: Did you know you can you can use merckmanuals.com to find in-depth content about hundreds of medical topics, including those that may be difficult to spell? Simply browse by using the letter spine search function on our website. It’s the best first place to go for easy-to-understand medical content.
>> Joe: So another question that we've seen a lot comes when people go to the doctor's office, and they get their blood pressure taken, and it may be a little bit higher than they want it to be. And they’ll say, hey, doc, you know, I'm nervous because I'm at the doctor's office. Let's do this again and see if it's a little lower in a week. Is that actually a real thing? Is there a reason that someone's blood pressure would be higher at the doctor's office?
>> Dr. Bakris: Oh, absolutely. It's well known, well described in the literature, so-called white coat syndrome. And again, it's called white coat syndrome because most physicians wear white coats. Person comes into the doctor’s office, hence white coat. And it was demonstrated earlier that if a nurse checks your pressure, that it won't be as bad. And again, the physician is given blame. It turns out that if you actually look at people with white coat hypertension, in general, they have some type of anxiety component. It's not this fear of the doctor. It's fear of the unknown. It's fear of these situations. And their pressure definitely will get elevated. And in fact, the older you are, the more elevated the pressure will be. You know, we've had numerous patients that have this problem. And one of the things that we do is use the guideline recommended method to check blood pressure, and we will have the patients sit for five minutes. The nurse is checking the blood pressure, not us. It's an automated machine. We don't talk to the patient. The patient is not talking. We're sitting there quietly for five minutes, and then the machine goes off. It gives you three consecutive reads. The first reading is thrown out, and the second and third readings are averaged. And if you do that, you'll see that pressures are much lower when you do it that way, then if you get the patient to come in, you’re talking to them, you’re checking their pressure, that's going to be much higher.
>> Joe: So I assume before someone goes into the doctor's office to see you, they should think about, you know, what kind of stressors may be in their lives, and they should talk to you about what's going on in their lives separately from this appointment, whether it's a surgery like you just mentioned or their daughter's wedding or they're stressed about a job or something. They should talk to you about these things before they even consider medication of any kind.
>> Dr. Bakris: Yeah, you’re right about that, and there are patients who I’ve actually referred to two psychologists for stress management who were on one blood pressure medicine and subsequently came off of that medicine. You can definitely, if you make sure that you’re sleeping well, and you have your anxiety under control, definitely for mild cases of hypertension come off medicine. But let’s be clear: if you’ve got the family history, and there are many people that have clear hypertension and, on top of that, have a white coat component, those aren’t people who are going to come off meds, but they may be able to reduce the number of meds if they control their anxiety.
>> Joe: Now, one thing I want to touch back on that you mentioned earlier is this idea that sleep has an effect on blood pressure. It's not something we'd seen before. And I wouldn't be considered a myth until I heard you say it earlier. What effect does sleep have on blood pressure? And is there a recommended amount of sleep that someone should get to reduce their blood pressure?
>> Dr. Bakris: So there's a number of different kinds of sleep disorders. But I'm going to make it very simple. Poor sleep quality, people either can't get to sleep, or they can get to sleep, can't stay asleep. Or in the case of the older person, they can get sleep, but every three hours you're getting up, going to the bathroom. You need six hours of uninterrupted sleep, ideally seven to eight. But a minimum of six. If you get less than that on a few nights, it's not a big deal. But if you do it consistently for months, it becomes a big deal. The brain is not fully rested, and, as a result, you're going to be eating a little bit more. These people gain weight and they don’t even notice. You’re eating more, meaning you're nibbling. Eating a little here, a little there, and you're going to be more irritable and more vulnerable to stress. And these people have high pressures. Sleep apnea is your neck is too big. You can't breathe well when you're sleeping, and then they give you a machine to basically force your airway open, so you can breathe well while you sleep. But that effect on blood pressure is minimal believe it or not. Your brain is thankful, you have oxygen, but your blood pressure effect is minimal. So I tell the patients that if they really want to maximize their lifestyle, there's two s-words that they need to remember. One is a four letter word: salt. And the other one is sleep. And if you can get six hours of uninterrupted sleep every night and keep your salt intake to a maximum of 2300 milligrams a day, you're going to do just fine.
>> Joe: One question when it comes to food I want to hit on if we can is a myth that we know we see quite often in the news on Good Morning America, on the Today Show, what have you is that red wine good for you in some sense. Red wine is good for your heart. It's good for your blood. It's good for a bunch of things. Is red wine actually good for your heart?
>> Dr. Bakris: Red wine is good for your heart, and especially if you have certain grapes like Pinot Noir and Cabs and Bordeauxs. Those have certain chemicals in them that’s part of the grape, but are actually quite good from a perspective of lipids. And, now, a little is good, and too much is bad. So I'm not suggesting anybody drink a bottle of wine. We're not talking about that. Usually, the recommendation is four to six ounces, and more than that is not going to give you greater benefit.
>> Joe: So, having a glass of wine with dinner is not going to hurt you, and, in fact, it may actually, in some instances help.
>> Dr. Bakris: It may actually help you, absolutely.
>> Joe: Interesting. All right. So as we kind of wrap up here, Dr. Bakris, what are five quick things that come to mind for you that someone could do to lower their blood pressure?
>> Dr. Bakris: Number one, pay attention to your lifestyle, specifically how much salt are you taking in, how much exercise are you getting, how much sleep are you getting? And also, how much of certain fruits are you taking in and fruits and vegetables? Number two, what is your blood pressure? Check your blood pressure at home and see what it is, and the time to check it is first thing in the morning when you get up before you eat or drink anything. Sit quietly for five minutes, and then check your blood pressure with a machine, a validated machine, and see what it is. And as long as that number is well below 135, certainly below 130, you're in great shape, and you don't need to check it every day. You don't need to check it once a week. You're a relatively young person, 30s, 40s. You can check it once or twice a month. Additionally, if you're doing lifestyle modifications well and you're checking your blood pressure, then obviously you need a physical exam. Again, doesn't have to be annually, but, certainly as you get older, it should be annually, so you can see what you're doing. Obviously, no smoking. Keep alcohol intake to a minimum. Beyond that, common sense things, avoid thing you know are going to raise your pressure or things that, you know, could have an impact on blood pressure effects.
>> Joe: One question that we see a lot online is this idea that if you go into a pharmacy or a drugstore, you see one of those blood pressure machines that they may not give you a correct reading or they may not be the right reading that you should take to your doctor. Are they safe to use to gauge whether you have high blood pressure or not?
>> Dr. Bakris: I’m just going to be very blunt about this. And I'll tell you, I wouldn't waste your time. The good news is I'm seeing fewer and fewer of those. They’re notoriously inaccurate, especially if you’re overweight or obese, and if you use those machines, they will overread your blood pressure many times. So, I don’t recommend them. Frankly, I think they should be taken out, and I would not use them. You’re far better off buying a validated monitor and using it at home than you are using those machines.
>> Joe: So, you mentioned doing it at home. What should folks invest in? Are there things that they should buy? Are there specific machines that are approved to have in the home?
>> Dr. Bakris: Well, yeah. There is a website that I recommend. I have no stock in the company, nor do I do anything for them. But it’s OMRON. The website is called omronhealthcare.com. The model that we used a lot is the OMRON BP5450, and it retails for $65. So, it’s really something of value, and it’s good. You’re guaranteed for a year. They do need to be validated, and the easy way to validate them is, once again, take it to your doctor’s office. And they will check it against what they check, and as long as everything pinpoints, then you’re good. And, some of those monitors can last for years, so it’s not a question of how old it is. It’s a question of how good it is.
>> Joe: It’s good to know that there are options out there for folks to use that are actually highly recommended by doctors. Well, Dr. Bakris, thanks so much for joining us. I think we all learned a lot more information about what hypertension is, how it works and how to reduce one's blood pressure. Thanks again for joining us. And remember, as we say at the Merck Manuals…
>> Dr. Bakris: …Medical knowledge is power. Pass it on.
>> Joe: Wonderful. Thanks so much.