Medical Advice for the New Year: Don't Get Sick

I have a family history of high blood pressure, so naturally when I saw that the Wall Street Journal had a piece up on "starting early for cardiovascular health", I clicked through.  This is what I found:

In a report published last week in the journal Circulation, Dr. Allen and her team analyzed more than 60,000 patient records using data collected in other research studies spanning 60 years. The researchers compared blood-pressure measurements for each patient taken on average at 41 years of age and again at 55. The team then tracked whether the patients suffered strokes, coronary heart disease or cardiovascular diseases over the next few decades of their lives.

The conclusion: Bringing high blood pressure under control at any time reduces risk of disease. But not letting it creep up in the first place can be even better. For example, men with high blood pressure--above 140/90--in their 40s who reduced the measurement to between 120/80 and 139/89, a moderately elevated level, lowered their risk of cardiovascular disease by their mid-50s to 59% from 65%.

By comparison, men who maintained moderately elevated blood pressure during the study period had a 51% chance of cardiovascular disease in the remaining years of their life. And men with consistently low blood pressure, below 120/80, had a 41% risk. But risk for cardiovascular disease jumped to 69% for men who had low blood pressure in their 40s and ended up with hypertension.

Emphasis mine.

I emphasize because you'd really be surprised to learn how little control hypertension patients have over their condition. Yes, there are risk factors.  But without medication, my blood pressure routinely spikes over 155 even though I have a perfectly normal BMI.  It began creeping up in my mid-thirties for no obvious reason.

That did not stop my doctor from offering ridiculous suggestions as to how I might control it.  In her defense, she was a resident in internal medicine, and was presumably required to give me ludicrous advice by whatever shadowy figure was supervising her and actually making the decisions.  First she came back and told me that a glass of wine with dinner more nights than not was "really a lot" of drinking, in a tone that would have been more appropriate had I confessed that I frequently woke up on the floor of our living room, surrounded by empty scotch bottles that I couldn't remember having purchased.

Then, after another trip to consult her dark overlord attending, she told me that I should cut down on my salt intake by eschewing pretzels, potato chips, and that sort of thing.  The following dialogue is an approximation of our discussion.

"I don't eat chips more than once a month."

"Maybe it's your lunches, and your dinners out, then.  Restaurant meals use a lot of salt."

"95% of my meals come from my own kitchen."

"And of course, the cold cuts  you buy in the grocery store . . . "

"I don't like sandwiches."

"Well, processed foods in general have high sodium.  You should cut them out."

"You want me to make everything I eat from scratch?"  I asked. 

"It's much healthier," she said weakly.

"Do you make everything you eat from scratch?" I asked, somewhat incredulously.

"I work eighty hours a week," she explained.

I decided that it wasn't really worth telling her that no, really, some of the rest of us have demanding jobs and travel schedules too.  It made more sense just to ignore her advice, as I'm sure that everyone else she gave it to did.  (And with good reason: the evidence that reducing your salt intake has a big impact on your blood pressure is pretty mixed.)

I am sure that it would, in theory, have been better for me to not have developed high blood pressure in the first place.  It might also have been better for me to be 5'10 instead of 6'2--and unfortunately, I have no idea how I could have achieved either stunt.  

Nor did most of the people in the study cited by the WSJ; according to the authors: "The prevalence of hypertension treatment in this study is low because of the time period during which these cohorts were initiated".  The Journal compresses this to "patients who curbed their levels in the Circulation study did so only with lifestyle changes " but that is not actually what the authors said.  Rather, they said that they don't know why people's blood pressure fell.  People whose blood pressure fell did see smaller increases in body mass index and cholesterol than those whose blood pressure rose.  But those things were still increasing, not decreasing.  So:

Decreases in BP may have been due to lifestyle changes, as suggested by the changes in body mass index and total cholesterol, although it is possible that differences were due to random variation or regression to the mean.

So what we really know is that if your blood pressure is high, and then falls, it is better than if it just stays high--and it's even better if it doesn't get high in the first place.  Except we knew that before.  Having high blood pressure is bad for you.  So is getting Lou Gehrig's disease.  But it is not very useful to tell people that they will be better off not contracting these conditions.

You can treat the condition, of course--but to my chagrin, even well-controlled hypertension is not the same thing as having normal blood pressure.  Whatever underlying process is causing my blood pressure to rise is also probably damaging my cardiovascular system, even when the blood-pressure itself reads normal.  Moreover, at least as far as I know, doctors don't give you blood pressure meds when your BP hits 121.  They wait until you're, well, hypertensive, or close to it.  That's because there's substantial error in blood pressure readings (you're having a bad day, you were late and ran up the stairs, you're scared of hospitals).  They don't want to put you on diuretics for years to treat that rumor you heard that your company might be having layoffs.

Of course, you should exercise--but research seems to indicate that it's good for a few points, not a drop from "Stage 2 hypertension" to "normal".  And you should quit smoking--but much to my surprise, smoking apparently doesn't cause high blood pressure.  Maybe you should eat less salt, too, but the evidence that this will improve your hypertension is not all that convincing.  Even losing weight, the most plausible intervention, seems to generate modest improvement, not radical reduction. All of these things together, at the most generous estimates, would not have reduced my blood pressure below 120/80.

Don't get me wrong: hypertension is a serious condition; it's imperative to treat it, and it would be even better if we could avoid it entirely.  But I only know one sure-fire way to keep your blood pressure from rising, and that's to avoid reading articles telling you that you really shouldn't have become hypertensive in the first place.