Friday, November 2, 2007

What else can I do for high blood pressure, I get enough exercise at work .........(warehouse/construction/daycare)

When addressing patients for the first time or those that have been taking medicines for a while, I always ask, do you watch your diet and are you exercising. (For those with a large waist to hip ratio it's more of a rhetorical question.) But most will answer they are doing or have tried to do alot of exertion in the form of walking. Most will think of exercise as a form of walking. That is soooo 90's. Most of the articles on introducing exercise into a life style would safely say, try walking first. This was meant to be an intro for the first 6-8 weeks with the idea of progressing on if you didnt suffer and injury or drop of a heart attack. When I see a couple in jogging suits, both with grey hair smiling on a neighborhood trail, I think that is great, I can't wait till retirement! For a 30-40 year old, we should be thinking of "smoking" that speed walking couple but fact is that most of the construction workers, warehouse workers or moms chasing after 2 generations of children would run out of gas in 5 minutes. Remeber the tortois and the hare? The rabbit in this story enventually goes for angioplasty and gets placed on 2 medicines with a blood thinner. This is the threat I give to most of my 30-40 year/olds that are too busy to worry about a little blood pressure issue or slightly elevated cholesterol. True, its easier to take a pill than make a major lifestyle change and cut back on hours at work....but that way of thinking doesnt prepare for the next medical issue that comes then the next one after that. So like most people, someone comes in for a regular check up and without symptoms ends up on 2-3 medicines with medical problems and problem lists that would dwarf the 10 commandments. I always touch on the current life style of high pressure, fast food, poor family communication and lack of proper preventive medicine.

Just that title alone is a misnomer now a days. Preventive Medicine is supposed to be what primary care doctors are teaching in the community but most of the family practice docs, internists I know are finding medical problems and managing them but no one has time to teach exercise, diet, lifestyle modification. Its usually after the diagnosis and after the first or second pill that we highly suggest cutting back hours or sending to a dietician since the sugars are not responding to first line meds. We also have steps in place to check at intervals to find when the changes are going to occur but that is usually the only contact. "Ok Mr Smith, come back in a year and we'll check if the diabetes has begun. Or, keep on checking that blood pressure, 3 random times in a comfortable environment and when they all are above 120/80, I'll start you on something. I would like to develop a branch of medicine to establish nutrition based changes in addition to supplement design that would integrate into current hierarchy of modern medicine. Insurance would probably not pay for this but patients have already showed they would pay for it out of pocket. Imagine, after paying the 400-1000 per month for insurance just in case you get sick, paying even more money to prevent needing to use the insurance plan your dishing out monthly mortgage payments to. Medicine is so screwed up! Sorry, I am trying to redirect my anger and frustration into constructive development of something good for everyone.

Back to hypertension, exercise is supposed to be in the form of 20-30 minutes of any activity that would keep the heart rate in the 140-160 range,(personally I shoot for 160-170 but can only do this 1 time a week for 20 minutes, the rest of the week is standard 150 beats per minute for 60 minutes all preceded by yoga.) One is supposed to repeat this regime 5 times a week. For those on a limited timetable, more bang for the buck with yoga or tai chi. Most people have heard of yoga, a limited amount know tai chi but these two forms of exercise don't get the credit they need. I have had a handfull of patients able to get off medicines running, yoga and tai chi were the only ways. Some did it through fast aggressive weight loss but this was dietary directed with some form of cardio.

There are studies out that have reported stress control throughout the day with 10 minutes of yoga/meditation in the morning. Same with daily tai chi. Eastern philosophy will show if one is well "grounded" that the body is healthier and will repsond to daily stress and infection better. The chakras or meridias of the body communicate and flow better so to make the external layers of the body impenetrable to the environment. In more western terms, someone at peace will be harder to coax into a fight than someone already on the 3rd cup of coffee and running 10 minutes behind to get to the first appointment. This also can be achieved in the form of prayer. If we could all start the day like Bob Marley says; "don't worry"! we may do better in rush hour. Most people I would see in the office with high blood pressure would say "I just ran up a flight of steps for the appointment" or "I was stressed in the waiting room." My come back is if that is what happens in a waiting room, can you imagine what happens to you throughout the day several times a day with confrontations and problems? Bottom line is the heart and brain don't like the high pressure fronts placed on them and soon will suffer with blood vessel damage, muscle enlargement and ischemia. For the rare person that says I'm ready to die, I say the hospital will probably save your life and you will live, being cared for by your family, unable to work, with no medical insurance. Not a pretty picture but I believe it's the job of a doctor and a friend to help see the worst case scenario.

Standard cardio work outs are great. They give the all the organs, the heart in particular, great blood flow, more efficient muscle with millions of hard working mitochondria. When the heart is more efficient with its beating and contraction, it doesnt have to work as hard throughout the day. Lungs work better at extracting oxygen from air, liver gets blood flow so it can get rid of toxins and run it's multistep break down of things that would normally kill us. Even cells will be able to absorb glucose better and in many cases without the need of insulin when exercise excedes a certain level. The endorphin and enkephalin release post exercise is something only an avid exerciser can relate to. One of the reasons we get "bitten" by exercise. It is addictive due to the hypothalamus being stimulated by the hormone release. This would be the same spot morphine works on. Finally, during the 60-120 minutes after exercise, there is usually a blood pressure drop that occurs like after and orgasm. Yes, exercise can be fun. Something a doctor or therapist or personal trainer can do would be to figure which kind of exercise would be appealing enough to catch the attention of a particular individual. If that person can make it through the first 8-12 weeks without injury, they are probably on their way. The enthusiasm drops rapidly with failure to progress or injury. With the diversity of jobs and hours and facilities and paychecks, an advisor has to be well versed with what is available or at least what has worked for others in the same predicament.

From 5K's to rock climbing to martial arts to dance, find what fits the schedule, what is economically feasable and what sounds like fun. The "Saguil Approach" says working a 5 pound sledge hammer 8 hours a day is something a regular person can't do and I am impressed the muscles will tolerate that but that type of exercise is not what the heart considers relaxing and helpful, if anything, that form of exercise can induce a heart attack. Exercise should be prescribed, and I believe it should be paid for (hopefully soon a health savings account will allow this). Activity should be part of anyones rehab and treatment program for staying healthy. Even if you are already "active" and hypertension is found, you may still have to rethink what has to be done to avoid the pills or more urgently, "avoid the knife".

cut and paste to see the ACSM's stance on exercise: