Why is it so important to keep blood pressure in check? | Ethan Weiss & Peter Attia

Summary

The transcript discusses the importance of blood pressure management for overall health, particularly in relation to kidney function. It emphasizes the kidney's sensitivity to high blood pressure and the need to maintain a blood pressure close to 120/80 mmHg throughout life, challenging the notion that higher blood pressure is a normal part of aging. The conversation highlights the significance of clinical trials in shaping current understanding and treatment approaches to hypertension.

Takeaways

• 🧐 The speaker expresses a growing interest in blood pressure and its impact on kidney health, highlighting the kidney's sensitivity to high blood pressure.
• 🌟 The importance of the kidney is emphasized, often overlooked, but it plays a crucial role in regulating blood pressure and is sensitive to changes in it.
• 🕰 The concept of 'bootstrapping' to live longer is introduced, suggesting that maintaining the health standards of a younger age group can contribute to longevity.
• 📉 The use of Systatin C over creatinine to measure glomerular filtration rate (GFR) is mentioned, indicating a shift in medical practice for more accurate kidney function assessment.
• 🚫 The speaker argues against the complacency of considering a GFR of 70 mL/min at age 55 as 'good enough', stressing that it's far from ideal for kidney health.
• 💡 The idea that even slight elevations in blood pressure can negatively affect long-term kidney, heart, and brain health is presented, advocating for normalization of blood pressure.
• 👨‍⚕️ The speaker acknowledges the neglect of the kidney in medical education and practice, sharing personal experiences teaching about hypertension and kidney pathology.
• 🔍 The impact of high blood pressure on the kidney's vasculature is discussed, suggesting the organ's small size and high blood flow make it particularly vulnerable to pressure changes.
• 📈 The speaker reflects on the variability of blood pressure throughout the day and the lack of awareness people have about their own blood pressure fluctuations.
• 🐘 A comparison is made to different animal species, questioning why humans share similar blood pressure levels with much smaller creatures, hinting at evolutionary conservation of the vascular system.
• 🛑 The notion that blood pressure naturally increases with age is challenged, with recent clinical trials suggesting that maintaining a blood pressure close to 120/80 mmHg is beneficial at any age.

Q & A

Why has the speaker become more interested in blood pressure over the past year?

The speaker has become more interested in blood pressure due to its connection with kidney health, which has been a growing concern for them, especially when considering the long-term effects on kidney function and overall health.

What is the speaker's approach to aging and health?

The speaker suggests a 'bootstrapping' approach to aging, where one should aim to maintain the health standards of a younger age group to potentially live an extra few years. This includes maintaining the health of the mind, body, coronary arteries, bone density, and kidneys.

What is the glomerular filtration rate (GFR) and why is it important?

The glomerular filtration rate is a measure of how well the kidneys are functioning, indicating the rate at which the kidneys filter waste from the blood. It is important because it helps in assessing kidney health and is sensitive to high blood pressure.

Why has the use of creatinine been largely abandoned in measuring GFR?

The use of creatinine has been largely abandoned because it has been replaced by cystatin C, which is a more accurate measure for estimating GFR, especially in elderly populations.

How does the speaker view the kidneys in relation to high blood pressure?

The speaker views the kidneys as being exquisitely sensitive to high blood pressure due to their small size and the high volume of cardiac output they receive, making them vulnerable to damage from even slight elevations in blood pressure.

What is the speaker's perspective on the importance of normalizing blood pressure?

The speaker believes that normalizing blood pressure is crucial for long-term health, particularly for the kidneys, heart, and brain, and that even minor elevations in blood pressure can interfere with these organs' health.

What does the speaker suggest about the standard blood pressure reading of 120 over 80 mmHg?

The speaker suggests that while 120 over 80 mmHg is considered normal, it may not be optimal for maintaining long-term kidney, heart, and brain health, and that striving for a lower blood pressure could be beneficial.

How does the speaker's view on treating high blood pressure differ from past practices?

The speaker's view differs from past practices in that they now believe that 120 over 80 mmHg should be the target for all ages, rather than accepting higher blood pressures as a normal part of aging.

What evidence does the speaker refer to that supports the idea that 120 over 80 mmHg is the normal blood pressure?

The speaker refers to recent well-designed clinical trials that have shown that being closer to 120 over 80 mmHg impacts mortality rates and that permitting higher blood pressures can lead to significant health risks.

What are the potential harms associated with treating high blood pressure too aggressively?

The potential harms include side effects from medication, impacts on lifestyle, and serious health issues such as hyperkalemia or an increased risk of death.

How does the speaker connect the aging process with changes in blood pressure?

The speaker connects the aging process with changes in blood pressure by suggesting that while blood pressure does increase with age, it may not be a normal part of aging but rather a consequence of underlying health issues such as decreased kidney function or increased vascular stiffness.

Outlines

00:00

🧬 The Importance of Blood Pressure and Kidney Health

The speaker expresses a growing interest in blood pressure and its impact on kidney health over the past couple of years. They emphasize the need to maintain blood pressure at a level that would be considered healthy for a younger individual, as part of a strategy to extend life. The speaker discusses the kidney's sensitivity to high blood pressure due to its unique vasculature and small size, which handles a large portion of cardiac output. They suggest that even slight increases in blood pressure can negatively affect long-term kidney health, as well as heart and brain health, advocating for the normalization of blood pressure to mitigate these risks.

05:01

🌡 Understanding Blood Pressure Variations and Aging

This paragraph delves into the dynamics of blood pressure throughout the day and how it changes under various conditions such as sleep, physical activity, and stress. The speaker ponders the concept of 'normal' blood pressure, questioning why humans share similar blood pressure levels with other species and why it increases with age. They challenge the traditional acceptance of higher blood pressure in the elderly, suggesting that it might not be a natural part of aging but rather a symptom of underlying health issues. The speaker reflects on the evolution of medical understanding, moving from a permissive attitude towards high blood pressure in the elderly to a more evidence-based approach that aims to lower blood pressure to levels considered normal for younger individuals, based on recent clinical trials.

10:03

📉 Blood Pressure and the Myth of 'Normal' Aging

The speaker continues the discussion on blood pressure, challenging the notion that elevated blood pressure is a natural part of the aging process. They argue that clinical trials have provided evidence that blood pressure levels drifting up to 125/130/135/140 mmHg in older individuals are pathological and not simply a consequence of aging. The speaker aligns with the idea that maintaining blood pressure closer to 120/80 mmHg is beneficial for health outcomes and impacts mortality rates. They acknowledge the potential risks of lowering blood pressure too much but emphasize the importance of striving for optimal levels without causing harm.

Keywords

💡Blood Pressure

Blood pressure is the force exerted by circulating blood on the walls of blood vessels. It is a critical parameter in cardiovascular health, and in the script, it is discussed in the context of its impact on kidney function and overall health. The video emphasizes the importance of normalizing blood pressure to preserve long-term kidney, heart, and brain health.

💡Kidney

The kidney is an organ that filters waste products from the blood and regulates electrolyte balance. It is highlighted in the script as being particularly sensitive to high blood pressure, which can lead to kidney disease. The glomerular filtration rate (GFR) is mentioned as a key measure of kidney health, and the script discusses the importance of maintaining kidney function as part of a healthy lifestyle.

💡Glomerular Filtration Rate (GFR)

GFR is a measure of how efficiently the kidneys are filtering the blood. It is an important indicator of kidney health. In the script, it is mentioned that GFR is estimated using serum creatinine and that a lower GFR can be a sign of reduced kidney function, which is a concern due to the sensitivity of the kidneys to blood pressure.

💡Creatinine

Creatinine is a waste product that is normally excreted by the kidneys and can be measured in the blood to estimate kidney function. The script notes a shift away from using creatinine to estimate GFR, suggesting that other markers like cystatin C may provide a more accurate assessment of kidney health.

💡Kidney Pathologist

A kidney pathologist is a specialist who diagnoses diseases by examining tissue samples from the kidneys. In the script, the speaker mentions a kidney pathologist named Gene Olson, who contributed to their understanding of the kidney's role in blood pressure regulation and the pathological effects of high blood pressure on the kidneys.

💡Hypertension

Hypertension, or high blood pressure, is a condition where the force of the blood against the artery walls is consistently too high. The script discusses how hypertension is a risk factor for various health issues, including kidney disease, and emphasizes the need for managing blood pressure to prevent such complications.

💡Aging

Aging is the natural process of growing older, which can be associated with a decline in various bodily functions. The script explores the idea that elevated blood pressure with age may not be a normal part of aging but could be a pathological process that should be addressed to maintain health.

💡Clinical Trials

Clinical trials are research studies that help to determine whether a medical intervention is effective and safe. The script refers to clinical trials as evidence supporting the idea that maintaining blood pressure close to 120/80 mmHg is beneficial across all ages and that deviations from this norm can increase health risks.

💡Epidemiological

Epidemiological refers to the study of the distribution and determinants of health-related conditions in populations. The script uses the term to discuss the 'normal' blood pressure levels observed in populations and how these levels change with age, questioning whether this change is part of healthy aging or a sign of pathology.

💡Vascular System

The vascular system, also known as the circulatory system, includes the heart and blood vessels. It is responsible for transporting blood throughout the body. The script suggests that the conservation of the vascular system may explain why different species, including humans, have similar blood pressures despite differences in size and lifestyle.

💡Risk Factors

Risk factors are characteristics or behaviors that increase the likelihood of developing a particular condition. In the script, the speaker discusses blood pressure in the context of other 'heavy hitting' risk factors like smoking and high APO B levels, indicating that managing blood pressure is part of a broader strategy for reducing health risks.

Highlights

The speaker expresses a growing interest in blood pressure and its impact on kidney health over the past two years.

The kidney is described as an underappreciated organ, crucial to maintaining overall health and longevity.

A 'bootstrapping approach' to living longer involves thinking of oneself as a younger version, including kidney health.

Glomerular filtration rate (GFR) is discussed as a critical measure of kidney function, with concerns about its adequacy in older individuals.

The sensitivity of the kidney's vasculature to high blood pressure is emphasized, highlighting its importance in overall health.

The speaker posits that even slight elevations in blood pressure can interfere with long-term kidney, heart, and brain health.

The importance of normalizing blood pressure to improve health outcomes is discussed.

The neglect of the kidney in medical education and practice is acknowledged.

The role of the kidney in regulating blood pressure and its genetic basis is explored.

The speaker discusses the variability of blood pressure throughout the day and its normal range in different situations.

The assumption that 120/80 mmHg is the standard for blood pressure across all ages is questioned.

The idea that blood pressure naturally increases with age is challenged, suggesting it may not be a normal part of aging.

Clinical trials are mentioned as evidence that blood pressure closer to 120/80 mmHg is beneficial for all ages.

The potential harms of treating blood pressure too low are acknowledged, such as side effects and lifestyle impacts.

The speaker's philosophy on blood pressure management is to aim for 120/80 mmHg without causing harm.

The reduction in GFR with age is compared to other age-related declines, suggesting it may not be an unavoidable part of aging.

The importance of clinical trials in guiding the understanding of what constitutes normal blood pressure is emphasized.

The speaker concludes that higher blood pressure in the elderly should not be accepted as a normal part of aging but actively managed.

Transcripts

okay let's let's talk about blood

pressure because I I think this is one

of those areas that I've personally

become more and more interested in over

the past year

um

and it's actually become more of a

concern to Me Maybe over the past two

years through the lens of the kidney

so we have this organ that just doesn't

get much attention I'm trying to think

outside of my podcast with Chris Sonnen

day where we talked about kidney and

liver transplantation

I don't think I've got a single podcast

that deals with the kidney

um and it's a really special organ and I

sort of explained to my patients that

in our bootstrapping approach to

living an extra few years on this planet

a lot of it requires a phase shift in

time right so if you're 50 years old you

really need to be held to the standard

of a healthy 40 year old if you want to

live an extra 10 years that's the way

you want to think about it you want to

think about that in terms of your mind

you want to think about that in terms of

your body you want to think about that

in terms of your coronary arteries you

want to think about it in terms of your

bone density

but you got to think about it in terms

of your kidneys

and so when we look at a person and

estimate their glomerular filtration

rate which we use you know systatin C to

measure that we've largely abandoned a

creatinine

um

it's really tempting to say well you

know

this guy's 55 years old is egfr is 70

mils per minute that's good enough

but in reality it's not actually it's

far from good enough

and

the kidney is not uniquely but

exquisitely sensitive to high blood

pressure

again I'm not a nephrologist and I never

really I don't think I remember much

from Nephrology but I certainly remember

that something about its vasculature is

incredibly sensitive right it probably

has to do with the fact that it's such a

tiny organ that takes such a high amount

of our cardiac output

and I suspect just like the heart and

the Brain it's very sensitive to

pressure

um and so that really is the lens

through which I think about this first

and foremost with with the meaning even

the slightest amount of elevation in in

blood pressure is going to interfere

with long-term Kidney Health and also

with heart and brain health so so really

there's a win across the board if we

just normalize blood pressure so

I'll posit that and and have you just

kind of explain from the

um ascbd perspective the importance of

blood pressure and how it Stacks up with

smoking APO B and some of the other

heavy hitting risk factors

yeah so I I guess I just want to

acknowledge how strongly I agree with

you about the neglect how much we

neglect the kidney is in Oregon and

Nephrology as a sub-specialty of

medicine uh I actually used to give a

lecture on hypertension to the first

year medical students at UCSF and I did

that in conjunction with a kidney

pathologist who interestingly was

uh had been at Hopkins when I was a

medical student was my advisor very

interesting woman who's now retired

named Gene Olson and she she and I

co-game the lecture she gave the

pathology part and I gave the clinical

part and I learned so much about the

importance of the kidney and regulating

blood pressure

in that you know in giving that lecture

with her for however many years it was

10 years

um so it's it's uh it's both an

important cause of blood pressure and in

fact I think if you go back and look at

um you know Rick lifton who's sort of

one of the Premier human geneticists in

in you know history member of the

National Academy had it some probably

should win a Nobel Prize he

characterized all of the single gene

mutations that lead to extreme increases

or decreases in blood pressure

uh

you know I think at the time and this

was 20 years ago they were they were

like you know 10 each 10 10 Single gene

mutations that led to people who had

really really low blood pressure had to

constantly supplement salt and do things

like that and then 10 that led to

extremely high blood pressure and I

think like nine

or whatever it is 19 out of 20 of these

things were located in the same location

in the uh in the proximal collecting

doctor in the tubule it was it was like

you couldn't have picked a place that

was more important evolutionarily for

how we handle volume and and salt and

solute so it's an incredibly important

organ both as a cause of high blood

pressure

and also as a consequence and those

experiments you know Gene showed these

beautiful slides that I'll send along

sometime you know pictures of what

happens to to your kidney after it's

exposed to

low increased levels of blood pressure

over time so

um it was interesting because I was

giving this lecture as a cardiologist

during the kidney block it always felt

I fell out of place

so

most people kind of know that when they

go to their doctor and they get their

blood pressure checked normal is about

120 over 80 millimeters of mercury

um

what do we know about how much that

changes in a healthy person across the

course of the day

so when they're sleeping

when they're ambulatory and walking

around but not under stress I.E not

exercising when they are exercising

vigorously when they're you know under

stress physiologic stress psychological

stress

all of these different things that we do

every single day surely our blood

pressure must change and yet most of us

myself included have virtually no idea

of how our blood pressure is changing

under those situations even if under

perfect optimal conditions I.E sitting

down legs uncross for five minutes it

reads 120 over 80. so what do we know

about the rest of the time

so I guess it's it we don't I don't want

to get too distracted but I think it's

fascinating I've thought about this a

lot and the question of what's normal is

you know we all assume 120 over 80 is

normal

if you look at blood pressures across

different animal species

it's mostly in that range there are some

that are outliers obviously a giraffe is

is the best example of an outlier

species with much higher blood pressure

that it needs to have to be able to pump

blood up to that very hit that head

that's sitting way up high

it is weird to me from an evolutionary

evolutionary perspective why we would

have the same blood pressure as a mouse

right it's a little tiny creature who

walks around on four legs why should we

have the same blood pressure it speaks I

think to the conservation of the sort of

vascular system that we have

I think most people when I was a medical

student I'm sure you were the same we're

taught that 120 over 80 is normal that

that's just normal whether you're uh you

know 7 17 or 75

I don't think we have a good

understanding of well we have an

understanding of what is

epidemiologically normal as we age and

so we know that blood pressure does go

up with each decade of life

if I had access to that lecture I used

to give I could show you what happens

but but certainly with each decade of

Life your blood pressure goes up on

average if you're looking at a

population of people is that normal is

that part of normal healthy aging or is

that just a function of pathology is it

a function of something going wrong over

time to your point is it's something

about decreased kidney function or maybe

as an increased vascular stiffness over

over time I think all those things are

possible and probably probably probable

so for a long time

it was assumed that a blood pressure

that was normal for somebody in their

20s and 30s

was

probably too low and not normal for

somebody who was in their 60s 70s and

80s and so we let had sort of had this

permissive hypertension

in elderly people because we thought

well gosh they

required it's just part of

the aging process and it really hasn't

been until the past really 10 plus years

that we've begun to ask specifically

in really well-designed clinical trials

is that the case and is it the case when

it comes to looking at an important

clinical outcomes and I think uh you

know my take on this now is different

than it was 15 years ago and that is

that 120 over 80 is normal no matter

where you are in life and that anything

above that is abnormal and you know just

to kind of get to the punch line what I

tell patients is that my aspiration is

that we can get you as close to 120 over

80 as we can without harming you because

there are certainly potential harms that

are associated with treating people to

these low numbers they can be in the

form of

side effects or impacts on lifestyle

they can be in the form of real toxicity

you know hyperkalemia have risk of death

I mean there's all kinds of potential

issues that it's not just a simple

intervention

like treating LDL or apob lower and

lower lower there's really no

consequence at all there is a

consequence of lowering blood pressure

too low in this case so that's my

overall kind of philosophy of how to

think about blood pressure is I do think

there's now evidence from good clinical

trials that 120 over 80 is normal and

that we should try to get there as best

we can without making a mess

so through that lens basically we're

saying that the amount of float that we

see in blood pressure again we're all

we're talking about blood pressure in a

very narrow instance which is seated

resting Etc oh yeah yeah we'll come back

to the other point but just to build off

that that when that drifts up to 125 130

135 140 in an aging population

we're actually calling that pathologic

in the same way that I think we would

all agree that the reduction in

glomerular filtration rate the reduction

in ejection fraction the reduction in

pulmonary function

okay yes that occurs with aging but that

doesn't mean that it's not part of an

aging process and therefore part of

something we want to minimize correct

that's right we lose muscle mass as we

age is that something we want to accept

and that's normal or do we want to try

to do it again to preserve the muscle

mass that we had it younger in life and

again I think here the the crutch that

we fall back on and

is good high quality

well done clinical trials and in this

case we have now have them and it's not

just sort of an opinion based thing that

says oh we'll really get closer to 120

over 80. we actually have evidence that

being closer to 120 over 80 impacts

mortality and uh and that permitting

people to run higher to a level that we

used to consider to be just basically

pre-hypertension or just normal even an

older person 140 over 90 that leads to a

significant increase in risk of dieting

so to me I think uh we've learned a lot

and I don't I don't consider it to be a

normal function of Aging I think

there may be a process there's obviously

a process that goes along with aging

that there's a decrease in function of a

lot of different things that combines to

lead to this increase in blood pressure

but I don't leave it alone

foreign

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