Stress and Diabetes (Part 3) - Reducing Blood Pressure
Ryan Bradley, ND, MPH April, 2010
Stress, and our response to it, has profound effects on our both our physical and mental health. When it feels like stress is taking over our lives, it does by negatively impacting our health, raising blood sugar and blood pressure among other things. However, we can also learn to use this link to our advantage learning to use the mind to improve the physical functioning of the body! In this month’s review, I discuss the ways in which we can use the mind-body connection to improve blood pressure.
Controlling high blood pressure, or hypertension, is important to reduce the risk of health problems related to the blood vessels including heart disease, stroke, vision loss, kidney damage, sexual dysfunction, and less serious but bothersome problems like varicose veins. The maximum recommended blood pressure for most people is less than 140/90. For people with diabetes or existing heart or kidney disease, blood pressure should not be above 130/80. Optimal or normal blood pressure is less than 120/80.
Hypertension is very common and, for the majority of people, it is often inadequately managed.Nearly 30% of the U.S. population has high blood pressure.1 Among people who have elevated blood pressure, only 70% are aware of their condition, 59% are receiving treatment, and only 34% have their blood pressure well controlled. Furthermore, 34% of patients report drug side effects associated with their antihypertensive treatment. Unacceptable side effects were cited as the top reason for noncompliance, followed by the cost of medication.2Most people with high blood pressure need to try a combination of approaches to bring their blood pressure down.
Chronic stress long has been thought to be the underlying mechanism of much of hypertension. Recall from recent Complementary Corner articles on stress: (Stress Reduction Part 1 - Optimal Stress or Optimal Response? and Stress Reduction Part 2 - Interventions in Diabetes), that in an acute situation, stress triggers a sympathetic (fight or flight) response. The increase in sympathetic function, besides increasing blood sugar to fuel your brain, also increases blood pressure to move blood to the muscles and brain so you can “run from the bear.” When we are under stress every day for years on end this persistently increased activation of the sympathetic nervous system leads to high blood pressure. Over time, the prolonged elevation of stress hormones can also lead to increases in heart and vessel, both of which can also contribute to chronic high blood pressure.
Stress is unavoidable, but we can learn how to modulate our reaction to it. As I’ve mentioned before, one of the largest population studies, INTERHEART, has characterized the relationship between stress and disease. In this study, hypertension and heart attacks were associated with chronic stress to a degree that is equivalent to (but in addition to) traditional cardiovascular disease risk factor like smoking, obesity, and diabetes. For example, there is a nearly 50% increase risk of having a heart attack after several periods of recent general stress and a two-fold increase for permanent or chronic stress!3
Underlying many of the techniques that modulate stress is the concept of biofeedback and cultivating a “relaxation response” that shifts our inner chemistry from sympathetic (“fight or flight”) to parasympathetic (“rest and digest”). In a relaxed parasympathetic state, stress hormone output diminishes. Oxygen consumption decreases, along with heart and respiratory rates.4 As breathing slows, elimination of carbon dioxide slows and exhaled nitric oxide increases, which help to brings the mind and body into a state of relaxation.
In general, the goal of many "mind-body" therapies is to be able to achieve this intentional awareness of the mind-body connection, turning the attention to the inner state of being. The benefits are worth it! Almost all trials of mind-body techniques have shown positive, if sometimes small, benefits compared to usual care over relatively short time periods (mean study duration = 8 weeks)5, 6 These techniques are also likely to have beneficial “side-effects” in other dimensions including improved mood, well-being, and quality of life. 7 Overall, relaxation techniques focus attention on some aspect of the physical body such as breathing, heartbeat, or muscle tension as a means to cultivate the mind-body technique. You can try as many of the mind-body techniques as you want, and they are safe to combine with blood pressure medications. Just keep monitoring your blood pressure so you know when it’s time to talk to your doctor about reducing your medications (if you take any)!
Biofeedback is a strategy that works by using an external device to help you focus on the relaxation response it is a tool that gives you “feedback” about the functioning of your body.
There are many tools and techniques including thermometers, heart rate monitors, and various computer-assisted devices that monitor breathing, pulse, and muscle tension. I am particularly fond of the Resp-e-Rate device. This instrument is a simple to use, breathing monitor that is FDA approved as a treatment for hypertension. The device consists of headphone and audio tracks linked to a breathing monitor. The user wears the monitoring device around their rib cage. The device then senses the breathing pattern and provides audio guidance about how to change your breathing patterns to optimize a parasympathetic respiratory pattern (longer, slower breaths). In clinical trials, Resp-E-Rate users have reduced their blood pressure an average of 14 mmHg systolic (the top number) and 8 mmHg diastolic (the bottom number).8 Another similar device is Healing Rhythms. Even better, each of these devices is covered by some insurers!
Even without a device you can practice breathing exercises to improve blood pressure. Practice inhaling for a count of two, then exhaling for a count of two, gradually lengthen the breathing to counts of 3, 4 or more for a target breathing rate of 6-7 breaths per minute. It is important to note that as soon as it feels like a struggle or competition, you are no longer in the parasympathetic zone! Breathing exercises by themselves show a 6- to 9 mmHg reduction in blood pressure!9
Progressive Muscle Relaxation
You can lead yourself (or listen to a recording) with other types of self-guided relaxation. Progressive muscle relaxation encourages relaxation through awareness of the sensations present in the main muscle groups. For example, first take a few quieting breaths and then focus on your feet, either first simply bringing awareness to any muscle tension there or intentionally contracting the muscles, then, exhaling, relaxing and releasing the tension. Next, move your attention to the lower leg and repeat the tensing and relaxing. This technique aims to elicit the relaxation response through this repetitive mental focus and intentional adoption of a relaxed state.10 In studies, this technique only brings down blood pressure a few points, but at the same time, you are helping your blood sugar control! As a side note, this is also a great way to work with sleeplessness and insomnia!
HeartMath is a series of techniques that helps people focus on their emotional responses to stress. We all know what it feels like to “get our blood pumping” when we are angry; that is an example of an emotional response to stress causing high blood pressure! In fact, it is thought that the expression “seeing red” relates to blood vessels dilating in the eyes in response to really high blood pressure!
HeartMath has nothing to do with arithmetic; it uses a concept called rhythm coherence based on the premise that modern life stressors influence the coherence of heart rhythms, and that the coherence itself can be influenced by intentionally and sincerely focusing on positive feelings. In general, the techniques help you focus on remembering positive experiences (and how the mind-body feel in those situations) and then cultivating the ability to “interrupt” yourself when negative feelings begin. There are many specific exercises used to teach participants to develop this pattern. HeartMath focuses attention on the heart, uses heart-centered breathing (described as extending the exhalation longer than the inhalation) and other mind-body exercises such as “freeze-frame.”11People who practice HeartMath principles generally experience blood pressure reductions of about 10 mmHg.
Meditation can be defined as “the intentional self-regulation of attention” or the “systematic mental focus on particular aspects of the inner and outer experiences”. There are many meditation practices including mindfulness-based stress reduction and movement-oriented techniques like T’ai Chi and Qi Gong that we talked about in the last article, Stress Reduction Part 2 - Interventions in Diabetes. There is another well-studied technique called “transcendental meditation” or "TM". This is the technique that usually comes to mind when we think of meditating - it focuses on repetition of a word or phrase as a point of focus to quiet the mind and achieve a state of internal peace. Interestingly, across the many cultures that practice types of meditation, the repeated words are strikingly similar: Ohm, Shalom, Amen, etc. Also key to meditation is the concept of non-judgment, or simply observing the thoughts, emotions, and perceptions that come to mind without judging them. That is, if during meditation you are constantly scolding yourself for not meditating, then you are not meditating!
Meditation differs from other techniques thus described in that it incorporates a spiritual dimension; people who meditate usually do so with a far greater intent than simply lowering blood pressure—many are seeking a transformative spiritual experience. On average, transcendental meditation reduced blood pressure an average of 5-10 mmHg. Studies have also measured improvement in insulin resistance, stress and quality of life, and even reductions in mortality!12-14 The mortality reductions are particularly striking. In a study of people who had started meditating to reduce blood pressure, those who kept at it 5-7 years later had a 23% reduction in all-cause mortality, a 30% decrease in the rate of cardiovascular mortality, and a 49% decrease in the rate of cancer-related mortality compared with combined controls.15
Stress Management Education
Working on changing our reactions to stress can take many forms and all benefit blood pressure and much more. Traditional approaches to stress such as talk therapy and counseling are also strategies that can be added to a comprehensive approach to blood pressure reduction when they address the underlying emotional responses that contribute to the stress response and keep us out of the relaxation response. Counseling approaches are most useful for people whose high blood pressure relates to their emotional habits - “type A personalities,” - and those with hostility, anger, depression, and repressed emotional responses.6, 16 One clinical trial of stress management education demonstrated an average 9 mmHg reduction in blood pressure.4
All of these strategies are extremely safe, won’t negatively interact with any medications, and are likely to give you positive affects in other aspects of your life! Of course, keep checking your blood pressure regularly; you might be surprised to find you can control it so well you will need to talk to your doctor about reducing or discontinuing medications!
In Health, Ryan Bradley, ND, MPH
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- Lip GY, Beevers DG. Doctors, nurses, pharmacists and patients--the Rational Evaluation and Choice in Hypertension (REACH) survey of hypertension care delivery. Blood Press Suppl. 1997;1:6-10.
- Rosengren A, Hawken S, Ounpuu S, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study. Lancet. Sep 11-17 2004;364(9438):953-962.
- Dusek JA, Hibberd PL, Buczynski B, et al. Stress management versus lifestyle modification on systolic hypertension and medication elimination: a randomized trial. J Altern Complement Med. Mar 2008;14(2):129-138.
- Rainforth MV, Schneider RH, Nidich SI, Gaylord-King C, Salerno JW, Anderson JW. Stress reduction programs in patients with elevated blood pressure: a systematic review and meta-analysis. Curr Hypertens Rep. Dec 2007;9(6):520-528.
- Astin JA, Shapiro SL, Eisenberg DM, Forys KL. Mind-body medicine: state of the science, implications for practice. J Am Board Fam Pract. Mar-Apr 2003;16(2):131-147.
- Stetter F, Kupper S. Autogenic training: a meta-analysis of clinical outcome studies. Appl Psychophysiol Biofeedback. Mar 2002;27(1):45-98.
- Schein MH, Gavish B, Herz M, et al. Treating hypertension with a device that slows and regularises breathing: a randomised, double-blind controlled study. J Hum Hypertens. Apr 2001;15(4):271-278.
- Mori H, Yamamoto H, Kuwashima M, et al. How does deep breathing affect office blood pressure and pulse rate? Hypertens Res. Jun 2005;28(6):499-504.
- Mandle CL, Jacobs SC, Arcari PM, Domar AD. The efficacy of relaxation response interventions with adult patients: a review of the literature. J Cardiovasc Nurs. Apr 1996;10(3):4-26.
- McCraty R, Atkinson M, Tomasino D. Impact of a workplace stress reduction program on blood pressure and emotional health in hypertensive employees. Journal of Alternaive and Complementary Medicine. 2003;9(3):355-369.
- Paul-Labrador M, Polk D, Dwyer JH, et al. Effects of a randomized controlled trial of transcendental meditation on components of the metabolic syndrome in subjects with coronary heart disease. Arch Intern Med. Jun 12 2006;166(11):1218-1224.
- Schneider RH, Walton KG, Salerno JW, Nidich SI. Cardiovascular disease prevention and health promotion with the transcendental meditation program and Maharishi consciousness-based health care. Ethn Dis. Summer 2006;16(3 Suppl 4):S4-15-26.
- Wenneberg SR, Schneider RH, Walton KG, et al. A controlled study of the effects of the Transcendental Meditation program on cardiovascular reactivity and ambulatory blood pressure. Int J Neurosci. Jan 1997;89(1-2):15-28.
- Schneider RH, Alexander CN, Staggers F, et al. Long-term effects of stress reduction on mortality in persons > or = 55 years of age with systemic hypertension. Am J Cardiol. May 1 2005;95(9):1060-1064.
- Kaplan MS, Nunes A. The psychosocial determinants of hypertension.