New year is a good time to control the silent killer.

Sunrise at Haleakala Volcano summit in Maui, Hawaii. (Dr. Noorali Bharwani)
Sunrise at Haleakala Volcano summit in Maui, Hawaii. (Dr. Noorali Bharwani)

In the new year, you can wish for many things and make many resolutions. But don’t forget to take care of the silent killer – your blood pressure.

The lifetime risk for developing hypertension (high blood pressure) among adults aged 55 to 65 years is 90 per cent. Our New Year’s resolution should be to keep our blood pressure under control.

More about that later. First, I have a question for you: when is the best time to take your blood pressure pill?

Currently, there are no guidelines on when to take your blood pressure pills – is it better to take it in the morning or at bedtime?

The answer is in an article recently published in the British Medical Journal (BMJ 23 October 2019) titled “Taking antihypertensives at bedtime nearly halves cardiovascular deaths when compared with morning dosing.”

A study of nearly 20,000 hypertensive patients in primary care has shown taking pills for high blood pressure at bedtime is associated with improved blood pressure controls. Besides, the risk of dying from cardiovascular causes is reduced by half when compared with morning dosing.

The Hygia Chronotherapy Trial randomly assigned 19,084 hypertensive patients (median age 60.5 years) to take their entire daily dose of one or more antihypertensives at bedtime or on waking in the morning. The patients were followed up with ambulatory blood pressure monitoring, for a median follow-up period of 6.3 years.

The results show these patients have better controlled blood pressure and, most importantly, a significantly decreased risk of death or illness from heart and blood vessel problems.

The researchers found there was enough evidence from this study to recommend patients consider taking their blood pressure medication at bedtime.

It should be noted that this recommendation does not apply to medicines that need to be taken more than once a day or to blood pressure medicines that are prescribed for other problems, such as angina or heart failure.

Do not change your medication schedule without consult your doctor.

What is considered to be high blood pressure?

Blood pressure that is consistently more than 140/90 mmHg is considered high, but if you have diabetes or chronic kidney disease, 130/80 mmHg is high, says Health Canada website.

High blood pressure significantly increases risk for stroke, ischemic heart disease, peripheral vascular disease and heart failure.

Some facts about high blood pressure (hypertension):

  1. Hypertension affects more than one in five people.
  2. Approximately 17 per cent of individuals with hypertension are not aware of their condition, the true prevalence of hypertension is likely higher.
  3. Hypertension is the most common reason to visit a doctor.
  4. Hypertension is the number one reason for taking medication.
  5. The lifetime risk for developing hypertension among adults aged 55 to 65 years with normal blood pressure is 90 per cent.
  6. It is estimated that almost 30 per cent of hypertension can be attributed to excess dietary sodium. Reduction in daily sodium intake to recommended levels could result in one million fewer Canadians with hypertension.
  7. Smoking, being overweight or obese, lack of physical activity, too much salt, stress, genetics and family history can induce hypertension.

That is it for this year. Let me wish you all Merry Christmas, Season’s Greetings, Happy Healthy Safe and Sober New Year! Remember what Earl Wilson (American Athlete) said, “One way to get high blood pressure is to go mountain climbing over molehills.” Talk to you next year.

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High Blood Pressure is a Silent Killer

Fishing - one way to relax. (Dr. Noorali Bharwani)
Fishing - one way to relax. (Dr. Noorali Bharwani)

A new study shows that lowering blood pressure more with a target of 120 instead of 140 mm Hg systolic can cut deaths by 25 per cent. A third of U.S. and Canadian adults have high blood pressure. So millions could be affected by the new findings. But U.S. government-funded researchers who ran the study say it’s too soon for anyone to change what they are doing just yet.

“This is huge – I mean, 25 per cent less deaths and a third – 33 percent – less heart attacks, strokes and heart failure – that’s huge,” says Dr. Julia Lewis, a kidney specialist at Vanderbilt University who took part in the new study.

Normally, systolic blood pressure should be less than 140 mm Hg (mercury) and diastolic pressure of less than 90 mm Hg. It is written as – systolic over diastolic (for example 120/80 mm Hg). Blood pressure is lowest in the early morning, rises as the day progresses, and then dips down during the night and earliest hours of the morning. Blood pressure can fluctuate under different circumstances.

World Health Organization says that hypertension (high blood pressure) causes seven million premature deaths worldwide each year. Hypertension affects 22 percent of Canadians. It is estimated that 25 percent of the 42 million people with high blood pressure in the United States are unaware that they have hypertension. These patients probably have no symptoms. That is dangerous. That is why it is called a silent killer.

The incidence of hypertension increases with age. Most elderly Canadians have high blood pressure – probably due to thickening of blood vessels. No cause is identified in 80 to 95 percent of people with hypertension. This is known as idiopathic or essential hypertension. Others have hypertension due to primary disease of kidneys or due to certain hormonal disorders.

Blood pressure also varies from minute to minute, depending on levels of stress and physical activity. “White-coat hypertension” means a person’s blood pressure is up in the doctor’s office but not elsewhere.

Hypertension can be prevented and treated with lifestyle changes – with or without medication. Eat a healthy diet, lose weight if you are overweight, do not smoke, limit alcohol intake, eat a low salt diet, minimize sugar intake, do regular exercise, relax and learn to manage stress with laughter and meditation.

If your doctor wants you to take pills to control your blood pressure then make sure you take it regularly. Research has shown that 50 per cent of the patients with high blood pressure discontinue their antihypertensive medications by the first year. This is not good.

The U.S.-funded study is not quite finished but the effects on the heart were strong and clear. Getting blood pressure to 120 or lower reduced rates of cardiovascular events, such as heart attack, stroke and heart failure by a third. It reduced the deaths from any cause by 25 percent.

The research team is still studying the effects of lower blood pressure on dementia, memory loss and kidney function. Other studies have suggested lower blood pressure can help reduce or delay dementia symptoms and boost kidney function.

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A Pinch of Salt – The Rest of the Story

An overweight man getting his blood pressure checked. (Digital Vision/Thinkstock)
An overweight man getting his blood pressure checked. (Digital Vision/Thinkstock)

In my column last week, I discussed the adverse effects of dietary salt on your health. The conclusion was that if you want to stay healthy and have your blood pressure under control then you need to eat less than one teaspoon table salt a day.

After that, a reader sent me a link to a Scientific American article, “It’s Time to End the War on Salt,” written by Melinda Wenner Moyer.

Moyer says, “The zealous drive by politicians to limit our salt intake has little basis in science.”

Moyer’s argument is based on a meta-analysis of seven studies involving a total of 6,250 subjects in the American Journal of Hypertension found no strong evidence that cutting salt intake reduces the risk for heart attacks, strokes or death in people with normal or high blood pressure.

Moyer goes on to quote several more studies from all over the world. She goes on to say, “These findings call into question the common wisdom that excess salt is bad for you, but the evidence linking salt to heart disease has always been tenuous.” She concludes the article by saying there is little evidence for long-term benefit from reducing salt intake.

Point well taken. However, there is evidence that shows too much or too little salt in the diet can lead to muscle cramps, dizziness, or electrolyte disturbance, which can cause neurological problems or death. Generally, more emphasis is given to the evidence showing an association between salt intake and blood pressure among adults. We also know reduced salt intake results in a small reduction in blood pressure. Evidence suggests that high salt intake causes enlargement of the heart and swelling of the legs. The evidence may be tenuous but it is there.

Like many things in science and particularly in medicine, strong evidence is lacking in many of the things doctors advise their patients about good health. Some advice is based on “tenuous” evidence as there is nothing better to suggest. When we have strong evidence that certain habits can lead to bad health and even cancer (e.g. smoking, sun worshipping) generally people ignore the advice.

The story of salt intake is a just a small pinch in the overall story of healthy eating and exercise in maintaining good cardiovascular system and good health. The message is, eat in moderation, it is not what you do and eat, it is how much you do and eat to stay healthy and happy.

Less salt won’t hurt you. Too much salt is not good for you.

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Salty Advice About Dietary Salt

A spilled salt shaker. (iStockphoto/Thinkstock)
A spilled salt shaker. (iStockphoto/Thinkstock)

None of us are strangers to table salt. Everytime you eat something, you probably make a remark regarding the amount of salt in the food. Some people may think it is just right, some may find it too salty and some may feel extra salt is required.

Our body contains many salts. Table salt (sodium chloride) is a major one making up around 0.4 per cent of the body’s weight at a concentration pretty much equivalent to that in seawater. Somebody has calculated a 50 kg person would have around 200 gm of sodium chloride in his body. That makes around 40 teaspoons.

We continually lose salt when we lose water from our body as salt is in a solution. So when we are sweating, vomiting, having diarrhea or voiding water by act of urination, we are losing salt. Salt cannot be made in our body so we have to replenish it otherwise there can be serious consequences.

Salt is needed to maintain our blood volume and blood pressure. Sodium is also needed for nerves and muscles to work properly. Low levels of body sodium can make our brain swell and cause confusion.

Too much sodium is bad for us as well. Excessive consumption of sodium can increase blood pressure, and that salt is a major determinant of population blood pressure levels. Some research estimates suggest the numbers of deaths averted by moderate reductions in population salt consumption would be at least as many as those achieved by plausible reductions in population smoking rates (CMAJ June 12, 2012).

The fast food industry is making its own contribution towards increasing the general population’s salt intake. Fairly large population is relying on fast food industry to provide their daily food needs. Fast food tends to be more energy dense, contain more saturated fat and salt, contain fewer micronutrients and be eaten in larger portions than other foods, says the CMAJ article.

Fast food items such as fried potatoes, pizzas and sugar-sweetened soft drinks typically provide between one-third and one-half of daily energy intake but less than one-quarter of most micronutrients.

Now what? Too much or too little salt in the diet can lead to muscle cramps, dizziness, or electrolyte disturbance, which can cause neurological problems, or death. Generally, more emphasis is given to the evidence showing an association between salt intakes and blood pressure among adults. We also know reduced salt intake results in a small reduction in blood pressure. Evidence suggests that high salt intake causes enlargement of the heart and swelling of the legs.

There is a clear scientific evidence that a modest and long term reduction in population salt intake can result in a lower population blood pressure, and a reduction in strokes, heart attacks and heart failure.

Then what are we waiting for? Most of us consume more salt than we need. General recommendation is no more than six grams (about one teaspoon) of table salt a day. This includes salt used in cooking and at the table. If you have high blood pressure or heart disease then less than two grams of table salt per day will be helpful. Are you willing to try that?

So, how is your food tasting today?

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