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In this episode of the Living Heart Smart podcast, cardiologists Dr. Matt DeVane and Dr. Carolyn Lacey discuss the seven pillars of blood pressure management with guest Dr. Christopher Chen. They emphasize the importance of lifestyle modifications, such as weight loss, exercise, alcohol moderation, and the DASH diet, in reducing blood pressure. They also mention the role of sleep, stress management, and mindful practices in maintaining overall cardiovascular health.


Matthew DeVane, DO, FACC: [00:00:08] Hi, I'm Dr. Matt Devane.

Carolyn Lacey, MD, FACC: [00:00:09] And I'm Dr. Carolyn Lacey. We are cardiologists at John Muir Health, and this is our podcast, Living Heart Smart.

Matthew DeVane, DO, FACC: [00:00:16] Our physician partners and colleagues are going to help guide you through many different and important cardiovascular topics to help keep your heart happy and healthy.

Carolyn Lacey, MD, FACC: [00:00:24] Thank you for listening and we hope you enjoy our show. We're [00:00:30] in for a real treat today. How many race car driving state champion, cellist, super cardiologists who are following mindfulness practices, do you know? Well, I know one. And his name is Dr. Christopher Chen. He's here today to talk to us about the seven pillars of blood pressure management that you can do to help keep you off of medications. Here's our episode.

Christopher Chen, MD: [00:00:53] Thanks so much, Dr. Lacey. When we start with lifestyle modification, we're talking about modifiable risk factors. And those pillars [00:01:00] that I think about are obesity, diet, alcohol use, tobacco use, how much you sleep, and the quality of your sleep, exercise and other iatrogenic or medication-related factors. And so usually during a first counseling session, my goal is just to identify what can we do to help you before your next visit. Because the first question that comes [00:01:30] to us is, do I really need to be on medications? And usually, I'd like to give you a chance not to be on medications.

Matthew DeVane, DO, FACC: [00:01:37] Yeah, it's so hard because they feel fine, right? There's no symptoms. They don't want to take pills for a problem. They don't think they even it's not a concern for them. So when people are feeling good, adding more medicines to their regimen is not doesn't go over well.

Christopher Chen, MD: [00:01:50] So it doesn't always go over well. And what I remind them is every medication, it's a double-edged sword, right? So every time you start a new medication, I have to warn [00:02:00] them about the side effects that might occur with that medication. And so ideally, if we can manage things non-pharmacologically, that's the first step. So one of the things that we mentioned, the first one we mentioned was obesity or specifically metabolic syndrome. And so I'd like to dive a little bit into that, please. From an obesity standpoint, the most simple definition is a BMI over 30. And there's been a lot of work on BMI, [00:02:30] on why it's good and why it's bad. And I do think it has to be incorporated into the rest of the context of the patient. But that said, that is what a lot of our research is based on. Can we just.

Matthew DeVane, DO, FACC: [00:02:40] One second here define BMI. Body mass index for a lot of patients may not be too familiar with that word. Absolutely.

Christopher Chen, MD: [00:02:47] So a body mass index is based on your weight and your height. And so based on your weight and your height and your body surface area, we come up with a body mass index. 20 to 25 is normal, [00:03:00] 25 to 30 is considered in the overweight category, and above 30 is considered in the obese category. And so that's kind of the cutoffs that we go by.

Matthew DeVane, DO, FACC: [00:03:12] So looking at weight alone isn't perfect because people come in different shapes and sizes and muscles and all those sort of things. So the BMI is more helpful. So how do we go? How does treating obesity or too much weight affect blood pressure?

Christopher Chen, MD: [00:03:27] There's a linear correlation with [00:03:30] weight and blood pressure that seems like there's really no ceiling effect to. So as someone's weight comes up, the blood pressure usually comes up with it once you're in that category. And conversely, as weight comes down, the blood pressure usually gets better. So a lot of patients, if we are starting thinking about pharmacologic therapy and they're still working on their weight and tell them that goes hand in hand. How's your blood pressure gets as your weight comes down and your blood pressure gets [00:04:00] better, your pharmacologic therapy may decrease as well. And our goals are just to address your risks while your blood pressure is high.

Carolyn Lacey, MD, FACC: [00:04:07] I've seen that over and over, over the years. You know, patients that started out on 3 or 4, five medications at times, and something's changed in their life and they've over the period of time have dropped a significant amount of weight. And so I'm talking over a couple of years that they've dropped a significant amount of weight. And I see them [00:04:30] come into the office and I'm recognizing that, oh, we dropped this medication, Oh, we scaled back on this, Oh, we're off medicines and your blood pressure is 110. Awesome. That's a huge win for the patient. Yeah.

Matthew DeVane, DO, FACC: [00:04:44] Yeah, that's great. Yeah. So that does play a huge part of, of blood pressure control is the weight. But the other part that you also mentioned was the metabolic syndrome. Can you tell us what that is and how that ties into blood pressure as well?

Christopher Chen, MD: [00:04:57] Yeah. So metabolic syndrome, we [00:05:00] initially defined obesity as simply a BMI measure and think metabolic syndrome ties in a little bit more than just the BMI. So metabolic syndrome refers to the syndrome that's defined by glucose and or impaired insulin resistance. So increase abdominal circumference, elevated fasting glucose, elevated weight, and elevated blood pressure. There's a number of factors that goes into it. But what we think about with the metabolic syndrome is that it's typically [00:05:30] a modifiable risk factor that if we can address helps prevent diabetes down the line, it helps prevent high blood pressure down the line. And with resolution of metabolic syndrome, we can fix the sequela.

Matthew DeVane, DO, FACC: [00:05:47] Okay. So we're talking we talked a little bit about sugars and metabolic syndrome and being overweight and how that can affect blood pressure. Another point of your pillars of modifiable risk factors for high blood pressure was exercise. [00:06:00] Talk to me about what you tell your patients and how that may help blood pressure over time.

Christopher Chen, MD: [00:06:04] Our recommendations on exercise are at least 30 minutes of moderate exercise 3 to 5 times a week. Ask them that they get their blood pressure or their heart rates going during the exercise session really should be moderate intensity. And the way I define that is you should be able to still carry talk to someone that's standing next to you, but it's not going to be easy. So if you're walking at a pace where you're [00:06:30] conversing freely, that's considered light exercise.

Carolyn Lacey, MD, FACC: [00:06:35] That's important. I think people I think people don't really think that they're like, Oh, I'm going on my walk. I'm on the phone chatting the whole way, but they don't sound like they're walking. And I like how you also focus on sort of their symptoms, you know, vigorous, moderately vigorous exercise. It's not only exercising to a heart rate level, it's exercising to this rate of perceived exertion. [00:07:00] You want to feel like, okay, I'm working, I'm walking. You want to be a little short of breath, You want to feel like you're working hard and that's okay. That's okay to do that. I think sometimes people get a little bit nervous about feeling not great while they exercise because they're afraid something's wrong. But you can you want to focus on the. Okay, I got this.

Matthew DeVane, DO, FACC: [00:07:25] Okay. Sure. Yeah. I think that's also the perceived [00:07:30] exertion, as you said, mean a lot of people I talk to when I ask them what the most active thing they do is. They say they walk, you know, daily, but then you kind of dig into it. Yes, they do take their little puppy out for a walk twice a day, big.

Carolyn Lacey, MD, FACC: [00:07:42] Dog or little.

Matthew DeVane, DO, FACC: [00:07:43] Dog. But it's not a workout. You know, they're stopping every mailbox or whatever. So I think pushing patients beyond their comfort level a little bit does help. That's what it's going to take to get blood pressure to change.

Christopher Chen, MD: [00:07:55] Absolutely. This is a little bit of a Segway, but cardiac [00:08:00] rehab. Right. We send a lot of our patients to cardiac rehab after stents, after cabbage, after, you know, once they have chronic stable angina people, the outcomes from cardiac rehab are fantastic, right? People that complete cardiac rehab, they have decreased event rates of 25%. But it's not because they attended 36 exercise sessions. It's because they got all the learning along the way. They've been able to apply that to their lives. So I think that's probably one of the strongest [00:08:30] evidence we have behind lifestyle modification is what people take away from how they can manage themselves a little bit better at home, exercising regularly, how to change your diet, how to eat better, and the importance of the medications that if you're on any that you're taking.

Carolyn Lacey, MD, FACC: [00:08:47] I think in how you said exercising regularly. I found for me in my own exercise journey is that consistency matters. It matters less than working [00:09:00] to a certain intensity. You do need to try to work to the intensity, but you have to start somewhere. So I find a lot of people myself included at times would really try to dive in. Okay, I'm starting a new exercise routine. I'm in, I'm going for it, and then that'll last for a couple of weeks, maybe a couple months, and then it will stop. It'll slowly trickle away and stop for a variety of reasons. But when you really try to focus on consistency, that's the most important [00:09:30] thing. That's when you're going to see the long-term benefits. You'll see some short-term benefits if you start and stop. But you won't really you won't really see the full effect of the exercise unless you're being very consistent about it.

Matthew DeVane, DO, FACC: [00:09:46] All right. Doctor Chen and Carolyn, thanks you so much for that great review about the importance of exercise and even more specifically, the importance of being consistent with exercise and how that hopefully will help people bring down their blood pressure. I'd [00:10:00] like to move over to another one of the one of Doctor Chen's pillars of high blood pressure, and that's alcohol. Hall use. It's a question we all get asked a lot as physicians, and it's what I think of as one of the great American pastimes. Drinking, I think, is important that we at least talk about it here. So, Doctor Chin, do you mind if you can give us some comments on what you tell your patients about alcohol use? And is alcohol even related to high blood pressure? And does cutting back help people lower their blood pressure?

Christopher Chen, MD: [00:10:28] Yeah. So yeah, so alcohol [00:10:30] is associated with hypertension and we see that increasing alcohol use also causes increasing blood pressure. Our recommendations are limiting drinks to one drink. If you're a lady a day and two drinks for guys and that one drink is defined as one ounce of alcohol or four ounces of wine. And so that's our recommendation. When we see alcohol use go up, like we mentioned, blood pressure does tend to go up with it. And it's also associated with other things like [00:11:00] increased risk of arrhythmia, which is a big one.

Carolyn Lacey, MD, FACC: [00:11:03] I think we should also say 12oz of beer. Yes, there's a lot.

Matthew DeVane, DO, FACC: [00:11:06] Of that's one drink as well, right?

Carolyn Lacey, MD, FACC: [00:11:08] That's that's not a pint glass. That's less than a pint glass. Yeah.

Matthew DeVane, DO, FACC: [00:11:11] Yeah. I think when I talked to patients about alcohol, moderation I think is okay. But a lot of our patients have either too much weight. So alcohol is a sort of empty source of calories. So that's a concern also can affect the triglycerides. So we just want to make sure that that's not already an issue as well. But all things being equal, there may be [00:11:30] some benefits and anxiety relief and how people relax at night. Those things are beneficial to the blood pressure. So every patient is different. But I think moderation to the defined levels that Dr. Chen outlined does make some sense. Okay. So we talked about that. Now, I wrote down these numbers because I think when we talk about any one measure, I mean, I think people are looking for a quick fix to avoid medications. And if I could just change this one thing, it'll be all [00:12:00] good. I just want to be realistic about how these changes we're talking about affect real-life blood pressure and I wrote down some numbers here. So weight loss may bring it down by 5 to 7 points. Millimeters of mercury exercise, 4 or 5mm of mercury, moderating alcohol, something similar. So all of these things chip away at it, but you're not going to see your blood pressure go from 170 or 160 down to 120. So it's not going to normalize. But each thing that you [00:12:30] can do does add benefit. And the biggest one that I could find has the biggest effect on blood pressure is the dash diet. So what do you put in your mouth? Seems to play a big role in your blood pressure and the dash diet of all the things we're talking about seems to maybe even give you the most benefit as far as blood pressure lowering goes. Dr. Chen, can you talk about what the dash diet is, what those letters even stand for, and why we think it may be beneficial for patients? The data does show it helps.

Christopher Chen, MD: [00:12:59] Absolutely. [00:13:00] So a dash diet and love the dash diet because it's a dietary pattern, right? It doesn't ascribe you to a certain pattern, a certain diet. It's a pattern that's rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced saturated and total fat intake. Right. So it's generally a healthy diet that limits animal products, increases vegetable and fruit intake. And we also want to decrease your sodium [00:13:30] intake with dash diets And the average reduction in blood pressure you see from a dash diet is like you mentioned, it's worth the equivalent of one medication. It's minus ten, you know, millimeters. That's huge.

Matthew DeVane, DO, FACC: [00:13:40] It is like a pill. I mean, this diet works a pill.

Christopher Chen, MD: [00:13:43] Yeah. And the average sodium intake for the our recommendations tend to be you should take less than two grams of sodium a day. The average American diet is four grams a day. And in case you're wondering, the average Chinese diet is nine grams a day. [00:14:00] Wow. So making those dietary reductions makes a big difference in terms of our patient's blood pressure. I think it's.

Matthew DeVane, DO, FACC: [00:14:06] Important to mention, too, you I've heard that four grams per day for the average American before. And so I asked patients a lot if their diet is high in salt and almost all of them say no because they don't add salt. Like I don't even have a salt shaker on the table. But I think they're missing the fact that so many of our foods are already so rich in sodium that adding more salt [00:14:30] doesn't really matter.

Christopher Chen, MD: [00:14:31] Yeah, exactly. So especially if you're eating processed foods, right? That's why the Dash diet focuses on fresh foods that are vegetable and fruit or vegetable, high in fruits, vegetables, and whole grains. Right. Things that you're preparing on your own. You know, what you're adding in.

Matthew DeVane, DO, FACC: [00:14:47] Anything that's frozen, anything in a box, and anything in a can. The reason it can sit on the shelf for a year at a time before you purchase it and it still tastes good. This is partially because of the added salts.

Christopher Chen, MD: [00:14:58] And if you really, [00:15:00] really love salt, salt substitutes, maybe something to talk about with your doctor. As it has been, there's some evidence behind using a salt substitute and having your blood pressure come down and.

Carolyn Lacey, MD, FACC: [00:15:13] The processed foods, too. I think, you know, one of the things that you said about the dash diet, avoiding meats. Oh, that can be a throw-down argument in some for some people. And but the processed foods like bacon, [00:15:30] deli meat, salami, those sort of things.

Matthew DeVane, DO, FACC: [00:15:34] They're making me thirsty just talking about it.

Carolyn Lacey, MD, FACC: [00:15:36] I know. They really that really adds a lot of sodium into your diet. So being aware of those sort of foods.

Matthew DeVane, DO, FACC: [00:15:43] And also, I'll just add eating out. I mean, the reason food tastes so good when you're at a restaurant partially is because it's just loaded with salt. So be careful eating out. Be careful. Anything in a can or frozen, those are easy ways to modify your salt intake to bring down blood pressures. [00:16:00] Relatively easy.

Carolyn Lacey, MD, FACC: [00:16:01] Not easy in the restaurant. It's hidden. Yeah. You don't taste salty food, but there's. That's how some of the food tastes so good is because salt has been used in so many layers of the cooking.

Christopher Chen, MD: [00:16:12] Yeah, there's a lot of the, you know, and those are things that we should be aware of. Another thing that I found interesting was increasing dietary potassium intake.

Matthew DeVane, DO, FACC: [00:16:24] Was just going to bring that up because I'm just learning more about this as I was prepping for the show.

Christopher Chen, MD: [00:16:29] And so we [00:16:30] see increasing dietary potassium intake to 3500 or 5000mg a day, lowers blood pressure by another 4 or 5mm of mercury. So if you're replacing your sodium intake with a salt substitute that has some potassium in it, you may potentially get both benefits. And so that nine grams of sodium figure that I quoted earlier from the average Chinese diet, they changed those patients' diet to they gave them salt substitutes instead that had potassium [00:17:00] iodide in it and it reduced their blood pressure significant amount.

Carolyn Lacey, MD, FACC: [00:17:03] They're probably they're probably a lot of foods that you can get that have high potassium in them as well. You know you have some do you have some lists that you tell patients right away?

Matthew DeVane, DO, FACC: [00:17:14] I've got a list. Okay. So what do you think of it? Tell people increase their potassium intake. Everybody's going to go to the banana. Right. So I wanted to get an idea of what you can tell patients that where does potassium come from? So bananas [00:17:30] are on the list as too high, having a high concentration of potassium. But you're much better off with here's my top five raisins and dates. Yummy prunes, spinach, beans, avocados, then bananas. So bananas take the avocado right of that list there. You know, you pick and choose what your favorites are. But it's an interesting I mean, guess low potassium diets [00:18:00] make you more salt sensitive. So the body is going to retain more salt if you don't have enough potassium in the diet. And when you retain sodium, that's when blood pressure goes up. That's how a lot of these treatments are going to work. So less salt in your diet. You're going to be have lower blood pressures as you get a lot of our medications that we use help you get rid of salt in the urine. That's so it's all tied together. So I'm very pleasantly surprised to learn more about potassium supplements and foods that you can use to increase your potassium [00:18:30] levels as a real benefit when it comes to blood pressure. Just another tool in our belt.

Carolyn Lacey, MD, FACC: [00:18:34] Just a word of caution, though. While it sounds it sounds excellent. Right? There are so many medications that we use specifically for blood pressure. So if you're already on antihypertensive therapy, there are medications that are going to raise your potassium. So having a high level of potassium in your bloodstream is pretty dangerous. So just make sure you're talking with your doctor about is the high potassium [00:19:00] diet right for me or should I try to avoid these sort of high potassium?

Matthew DeVane, DO, FACC: [00:19:05] Yeah, Thank you for adding that. And if you have kidney disease as well, that could be potentially a problem. So it's not for everybody. But talk to your doctor. Okay. So we talked about exercise. We talked about weight loss. We talked about moderation of alcohol. Of course, no smoking, no smoking, no smoking, no smoking. And are there any other modifiable risks [00:19:30] that we talk to patients about that we should be talking to our patients about that will help lower blood pressures before we start writing prescriptions?

Christopher Chen, MD: [00:19:38] Yeah. So one of the things I think about is sleep, right? Some of our evidence has shown that if you don't sleep well or if you're on a graveyard shift, that changes the body physiology where your blood pressure is going to be higher, you're going to have more trouble with metabolic syndrome. And so so sleep is very important for maintaining the body's homeostasis. [00:20:00] One thing we think about is sleep apnea. Sleep apnea is when patients don't breathe at. Night. They have episodes of apnea. Episodes of not breathing. That puts a lot of stress on the cardiovascular system that's seen throughout the rest of the day. Patients who have sleep apnea, their blood pressures are higher throughout the day. They are more likely to gain weight. Their bodies are under stress more throughout the day. And so if you do have sleep apnea, if you think you could have sleep apnea, if your partner tells you you're snoring, if you're fatigued throughout the day, that's something [00:20:30] to bring up to your doctor to say, hi. I know I might not meet the typical sleep apnea patient profile, but I'm experiencing these fatigue symptoms. I'm snoring at night. I'm not, you know, energized when I wake up and my blood pressure is high. Do you think I have sleep apnea? Yeah.

Matthew DeVane, DO, FACC: [00:20:46] Yeah, that's super important. Yeah. The other thing that goes along with other things that we can think about when it comes to high blood pressure and patients ask me a lot. Anyway, I'm sure you guys get the same question is how does stress and anxiety play [00:21:00] into this? Because we do talk. I mean, think there's some data on yoga and meditation, some other wellness things. People can be doing, which is kind of a simple thing patients can do on their own. What do you tell patients who tell you they have you know, everybody has stress, right? So how do how do we deal with that when it comes to blood pressure?

Christopher Chen, MD: [00:21:17] I think everyone can deal with stress their own way. But meditation techniques, including mindfulness yoga, have shown to reduce blood pressure. And so I came across [00:21:30] something interesting yesterday, which was stress response in people who meditate, and people who meditate, they actually experience pain more so than people that don't meditate. But when they're confronted with a trigger that says pain is going to come, they don't respond to that. And then after the pain, they don't. They go right back to baseline. And that differs from non-meditators Non-meditators When they know pain is coming, [00:22:00] the pain response goes up and after the pain, the pain response stays. And so there are levels of average stress are much higher than meditators. And so what meditation seems to do is, yes, everyone experiences stress, they experience the same stress, but it doesn't they don't there's no anxiety before it and they return to baseline much faster. And I thought that was really interesting. When we start thinking about metabolic [00:22:30] syndrome, obesity, hypertension, what can we do to mitigate our stress, to improve those things?

Matthew DeVane, DO, FACC: [00:22:36] That's awesome. Yeah. And so I would wonder and I don't know if you have this information is because when I think of meditation, I think of going into a dark room and closing the blinds and trying to be by myself and sitting there for 30 minutes. But I think there's kind of micro-meditations that we can do kind of throughout the day that probably have similar effects.

Carolyn Lacey, MD, FACC: [00:22:54] So we're talking about meditation and that's so fascinating and interesting. And can you just [00:23:00] tell us a little bit more about this particular study you read? Was it did they say a certain amount of meditation, a type of meditation when.

Christopher Chen, MD: [00:23:08] They did mindfulness training? So so this particular study, they did a mindfulness training and they combined it with education and what's important to control from a blood pressure standpoint. And so what we did find was that teaching people mindfulness techniques, whether that's washing your hands and being aware of just just how it feels or mindfulness [00:23:30] when you're sitting there at work and feeling stress and taking ten minutes to yourself, Those techniques, combined with understanding why you should be doing what you're doing from a hypertension standpoint, have led to significant improvements in blood pressure. Now, how long should you do it for? How many minutes a day? Those things are still be still to be figured out. And I think ultimately what I counsel patients on is you should do whatever works for you from a stress relief standpoint, take some time during the day to care for yourself, take some time to love [00:24:00] yourself throughout the day. It's really important.

Matthew DeVane, DO, FACC: [00:24:04] That's nice.

Carolyn Lacey, MD, FACC: [00:24:04] Yeah, that's nice. Thank you. Thank.

Matthew DeVane, DO, FACC: [00:24:07] Doctors need to take some of that advice. Take time for yourself.

Carolyn Lacey, MD, FACC: [00:24:11] Take time.

Christopher Chen, MD: [00:24:12] Love yourself.

Matthew DeVane, DO, FACC: [00:24:13] Love yourself. Right. We're good at giving the advice. Not so always so good at taking the advice. But that's. That's well said. Yeah, that's great.

Carolyn Lacey, MD, FACC: [00:24:20] Yeah, that is great. Dr. Chen, thank you so much. This has been really, really important. You know, listening to the patient, talking [00:24:30] to the patient, helping them understand how they work with us as a partner, and the way you describe the pillars, especially the pillars of diet, exercise, mindfulness, not smoking, alcohol, all those things are so important to feel like we can continue to empower our patients. And so I'm just really thankful that you've been here and appreciate all your information.

Christopher Chen, MD: [00:24:53] Thanks so much for having me, guys.

Matthew DeVane, DO, FACC: [00:24:55] You're welcome. Thank you, Dr. Chen. Appreciate it. This [00:25:00] is Dr. Matt Devane, and on behalf of my co-host, Dr. Carolyn Lacey, and our partners at John Muir Health, we hope that you enjoyed this show and we really hope that you keep living heart smart.

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