Rhonda: What sort of blood pressure levels do you like to see?

Peter: We're very aggressive, right? I mean, if you look at the SPRINT trial, I think it's very clear that 120 over 80 or better is the place to be. And that's better than 130 over 85, which used to be the standard. For hypertension, right? That's right. Okay. So we're very aggressive. The good news with blood pressure, unlike the lipid, you know, we spent a lot of time talking about lipids and a listener may come away from that thinking, okay, there's some dietary stuff, but you guys didn't talk about exercise. And you're right, exercise doesn't move lipids that much. Like you're going to be, you're heading down the path of pharmacology much sooner on the lipid front. But blood pressure is just as big a risk factor for cardiovascular disease as lipids. And it's way more amenable to, I hate the word, but lifestyle intervention, you know, losing weight and exercising will fix a lot of people's blood pressure. Not everybody. We have some very lean, fit, healthy people in our practice who still have essential hypertension and it has to be lowered pharmacologically. But for many people, you know, losing 20 pounds and exercising, especially cardio, is going to do amazing things on their blood pressure.

Rhonda: Have you looked at, so I have a relative who exercises, good diet, like the only thing that lowers her blood pressure is hot tubs. Interesting. In addition to the exercise. Interesting. And it's like very, she's also very high stress, like, so she's, which

Peter: is obviously. I wonder if, it's funny, I wonder if it's the impact of, you know, whether it be sauna or or hot tub on hypercortisolemia that might be having the indirect effect on blood pressure.

Rhonda: Because she is absolutely prone to high cortisol. She's like, it's a very high stress. And the other thing is, you know, so Dan, he also, I mean, he exercises a lot, diet, like we have the same diet. My blood pressure, I mean, like I've got phenomenal blood pressure, like always, always, I mean, like really low. Like I'm actually on the side of like, I need to make sure I'm not too low. But he, at times, like when measuring it at home, by the way, people at home should just get an automated cuff, right? I mean, like. Absolutely.

Peter: I mean, it's just. Yeah. And when you finish this story, I'll walk through to make sure everybody's measuring correctly. Because it's very important.

Rhonda: Yes, please do. He has hemochromatosis. Okay. And there's some other relatives that had it and noticed that their blood pressure was high. Like, we're talking people that are like very, like doing lots of. Super healthy. These are like, you know, running marathons. They're doing, you know, like they're very super healthy. And donating blood seemed to help normalize the blood pressure for whatever reason. I don't know.

Peter: Which is important for obviously getting rid of the iron and hemochromatosis. Right.

Rhonda: But the other thing that's really helped, so Dan is doing that now. But the other thing that seems to really help him, I mean, he does sauna, hot tubs, exercise, you know, and there'll be times when he's in his office working and he's like 135 systolic. And it's like, what in the world? That's crazy, right? Green shakes help him. So like tons of like nitrates. So a bunch of like green vegetables. And these are like nasty tasting shakes. These aren't like good tasting ones. That's not AG. No. And that will help him as well. So yeah, exercise is very important. But like there's also like.

Peter: Has he tried like coca flavonoids, things like that? You know,

Rhonda: I give that to him. So another story. No, I wasn't doing that. We haven't been doing that because we take a lot of our vitamins at night. We do take some fish oil in the morning. I did mention that to him because another story, my mother, who is sedentary, she's lost a lot of weight, but she's still overweight. She, you know, she's losing the weight was great. I mean, she's lost like 75 pounds. Like she's lost a lot of weight. You look at the pictures. It's like years to her life have been extended just by that alone. But I can't like I can get her in the sauna sometimes, but it's still it's still like a little bit more of an effort. But one thing about her is she will take the vitamins they give her. And she's got she's homozygous for MTHFR. If she's not taking a high dose like B supplement along with like methylfolate, like her homocysteine will go high and her blood pressure goes up. And she had stopped taking all those because she wasn't over my house all the time when I was giving it to her every day. And so I got her, you know, this like sort of like battery of supplements that I was giving her, including all the methylfolate and lowering her things that were lowering her homocysteine along with magnesium and coco flavanol. So I was giving her coco via. She's getting four of those pills. She gets four and she still takes them. Her blood pressure went from like 155 to like 125. Her doctors are like they wanted to get her on antihypertensive treatment before she came to me. And it's like and this has been like months now. It's it's it's it's happening. She measures it at home. She takes she does logs. I mean, so I'm very happy about that. You know, the fact that she's been able to do that. But again, it just it shows that there are they definitely are the lifestyle factors. I know you hate that word, but, you know, exercise being one of the main ones. But there are people also that in addition to being very physically active, like they still get high blood pressure, you know?

Peter: Yeah. Yeah. And and, you know, I don't think we have the outcome data to look at the direct impact of coco flavonoids or all the suite of B vitamins that are necessary to lower homocysteine and their impact on blood pressure. But here's what we do know. And again, this is mechanistic and it's very strong mechanistic, but that doesn't necessarily equate to outcomes. But we know that as homocysteine is elevated, it impairs the clearance of something called asymmetric and symmetric dimethyl arginine. I don't know if you've talked about ADMA and SDMA and ADMA and SDMA directly and indirectly inhibit nitric oxide synthase. So the we know that homocysteine is associated with poor outcomes in cardiovascular disease. And I think that this mechanism of homocysteine impairing the clearance of ADMA and SDMA is the is the mechanistic link, because when you directly inhibit nitric oxide synthase in the endothelium, you are preventing the creation of nitric oxide. And of course, that's what coco flavonoids actually do the opposite of that. So I think the one two punch of lowering homocysteine and raising nitric oxide synthase activity via coco flavonoid could certainly explain a reduction in blood pressure.

Rhonda: That's really interesting. I was giving her the coco flavonoid just because I had seen the studies on increased blood flow. And I'm like, OK, let's we need that, you know, like we need that. Measuring blood pressure. Yeah.

Peter: So this was established really clearly through the sprint trial. And this has basically been now kind of the gold standard for how we use an automated cuff. So that trial was done by having individuals sit for five minutes, check a blood pressure, no stimulation during that time. So not talking, not looking at a phone, not doing anything, and then repeat that two more times. So it's a 15. I'm not suggesting this is what Dan does or what anybody does. But just so you understand at the level of how the trials are done, you're sitting for 15 minutes having a check at five, 10 and 15 minutes. You're sitting like this. The cuff is two inches above the elbow and the cuff is right at the level of the right atrium. So, you know, you're and by the way, if anybody wants to do this experiment at home, it's really interesting to do. Put an automated cuff on your arm and put your arm here. Put your arm above your head and put your arm in the right spot.

And look at how big a difference you get so measurement errors are a huge problem being over stimulated is a huge problem So you really want to make sure you're getting an accurate reading of that blood pressure and we have our patients do that twice a day You know an early in the day and a late in the day check and then you know We just have everybody do that for two weeks to start and that's that's what's considered your blood pressure So, you know the idea that you're gonna walk into the doctor's office and get a blood pressure is not valuable for most people So when someone says what's your blood pressure? It should be what's the average of those two weeks of twice daily checks? Done where you take the five-minute protocol and test perfectly and I think everybody listening to this should should know that number.