Blood Pressure Targets Just Changed

Is there something dark happening right under our noses? So, there's a change that's quietly crept up on us over the past few decades and has been so slow that we've barely noticed. So, since the 1970s, doctors have slowly lowered blood pressure targets and that's provided justification to prescribe more and more blood pressure pills to an everinccreasing percentage of the population. So, is there some grand conspiracy here going on to push big farmer drugs onto people? or is there genuine evidence to adopt more aggressive blood pressure targets, particularly since the new blood pressure guidelines published in August of this year have changed their wordings on what levels we should target. So, let's take a careful look at what's going on. Because if the medical community is pushing certain blood pressure targets just to line the pockets of big drug companies, that's obviously a huge problem. And I want to start with this question. Why might someone think that that's what's truly going on? Because on the surface, there is some data that does look suspicious. So each time that we've moved the threshold as to what counts for high blood pressure lower, we've expanded the number of people who will be diagnosed with a medical problem that needs attention. So if someone was diagnosed with a blood pressure of say 140 in 1980, their doctor would say, "No problem. You're healthy." But now you'd be diagnosed with stage 2 hypertension, which sounds pretty bad. And wouldn't you know it, Big Farmer sells pills that can take our blood pressure levels down. So as the thresholds have changed, we've gone from a place where hypertension, so that's the medical term for high blood pressure, was relatively rare to where it's nearly half of the adult population in the US that have this condition. And that number reaches almost 72% for those 60 years and older. So that's a proportionally huge number of prescriptions for anti-hypertensive medications. And all that translates into huge sums of money. So in 2025, the global market for these medications is estimated to be over $22 billion. and demand is rising. So, the worry that you'll see on social media is this. It's really big farmer that's behind the changes in blood pressure targets just so that there's more justification to prescribe more of their pills. But your doctor is going to tell you, "No, it's all about the research. Our blood pressure targets are driven by evidence from compelling studies and that they're changing because our understanding is getting better." So, who's right? Well, to sort this out, we need to look at how we got here. So, let's back up to the 1940s. At that time, the idea of what counted as high blood pressure was pretty high. So, in a cardiology textbook published in 1848, the author said that high blood pressure was above 180 on 110. And what's more amazing is that they didn't think that high blood pressure by itself was necessarily something to worry about. It was only a problem if it caused problems. So, if for example, the heart muscle was swelling. And that's a strange attitude to have even back then because we already had evidence from several decades earlier that elevated blood pressure was linked to a higher risk of early death. So let's take it even further back into 1925. So one of the most important medical discoveries ever was just published. And believe it or not, it wasn't by a group of doctors or scientists. Instead, it came from a group of mathematicians. So these were people who crunched the numbers for life insurance companies to figure out who was at greatest risk of dying young. and their data was telling an unmistakable story. So there was one basic health indicator that was strongly linked to eventually having heart attacks, strokes or suffering from early death and the indicator was blood pressure. So blood pressure measurements were relatively new at that time and life insurance companies had started checking this metric when people applied for new policies only a decade before. But by 1925, they had enough data that the trend was abundantly clear. And that simple link wasn't all that they discovered. They uncovered a dose response relationship. So what I mean by this is that the higher the blood pressure, the greater the risk. And this conclusion was based on the records from over 700,000 individuals. So it was incredibly suggestive data, but it was largely ignored at the time by the medical community, which is why the medical textbook from 1948 wasn't too worried about high blood pressure in most cases. But all of that was going to change in 1957 when early results from a groundbreaking study were published. So that study was the Framingham Heart Study. So it started in 1948 and it wanted to investigate the causes of heart disease and the goal was to analyze a large group of people over the long term. Researchers wanted to see what factors were linked to those who developed heart disease. So they recruited over 5,000 adults between the ages of 32 to 62 from the town of Framingham, Massachusetts. And after only 4 years into the study, something jumped out from the data. So it was clear that there was a significant association between high blood pressure and the development of heart disease. This had profound significance. So it raised the possibility that high blood pressure by itself was a key health risk factor. But we needed data from clinical trials to confirm these findings and one of the most important early trials was completed by the US Veterans Administration and it was published in 1967. It included a group of 140 men with severe hypertension. So there was a group who were taking blood pressure medications and a placebo group and over the study period there were 27 severe blood pressure related health problems in the placebo group but in the treatment group there were just two and the researchers concluded that getting blood pressure under control provided significant benefits and evidence from studies like this as well as the Framingham study began to mount by the 1970s and the first set of authoritative guidelines for blood pressure were published. They came from the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure in the US. So, it's a bit of a mouthful and it goes by JNC for short. And their 1977 report included two other important things. First, it suggested that blood pressure levels needed to be monitored. So, basically, doctors were told to keep a close eye on anything over 160 on 95 and levels over 140 on 90 should also be monitored to see if they were going up over time. No treatment was called for though until the diastolic number hit 105. So that's the second lower number on a blood pressure reading. 105 in today's world is relatively high. These days that would land you in stage 2 hypertension. In the 1977 report, however, there was no recommendations based on the systolic number. So that's the first higher number in a blood pressure reading. So we can see the beginnings of a progression here. The textbook that we looked at from 1948 used a threshold of 180 as a level of concern and the JNC report in 1977 moves that target down lower to 160. And again the reason for that change is a mixture of observational studies and clinical trials that establishes an important link between elevated blood pressure and heart related problems. Then the JNC report in 1984 was the first to define hypertension based on systolic blood pressure. Again the higher number on the blood pressure readings. So they placed a threshold at 140. But what was the justification for setting it at that level? Because by that point, much of the existing evidence centered around diastolic blood pressure levels. Well, the 1984 report cites a number of clinical trials showing benefits from treating people with what was considered to be mild hypertension. So that meant a systolic blood pressure of at least 90. And the idea was that the systolic number of about 140 roughly corresponded to the same risk profile as the diastolic number of 90. So you can see that they appeared today on a standard blood pressure chart. But overall they took a more aggressive approach and setting the level at 140 because this much was clear. The lower our blood pressure even within the normal range at the time was better for our health. And that number of 140 for hypertension was the standard in clinical practice for a long period of time. But by the early 2000s there was a series of startling discoveries that would change our understanding once again. So they first landed in the prestigious journal Lancet in 2003. It was a massive analysis of data from 1 million adults contained in 61 separate studies. So the researchers looked at the relationship between blood pressure and death, especially from heart attacks and strokes. But now at this point, we already had plenty of data showing a continuous link between elevated blood pressure and the risks for things like heart attacks. And as we brought blood pressure down, risks fell too. But what we didn't realize is how low we could take our blood pressure and still see improvements in outcomes. So remember the standard recommendation here was to try and keep the number below 140. But researchers behind this new analysis found that the benefits kept coming even if we aimed for lower levels than 140. In fact, they found the relationship between lower blood pressure and better health outcomes went all the way down to at least 115. So the implications here were huge. At 140, we're still leaving significant health potential gains on the table. We're still at an elevated risk compared to lower blood pressure levels. And it was on the strength of evidence like this that the official guidelines made a major change in 2017. So they recommended considering normal blood pressure as under 120 and between 120 and 129 that was considered elevated and 130 to 139 was stage 1 hypertension and 140 and above was stage 2. So in other words the implication here is that ideally we want to have a blood pressure below 120. The authors note that the evidence is substantial that our risks for heart rellated problems. They continue to go up as our blood pressure rises above that level and there was good evidence for those recommendations at the time. But since 2017 there have been three additional studies that have strengthened these conclusions. So the first study is called the sprint trial and it was published in 2021. So people in the study were at high risk for heart disease but they didn't have diabetes or a history of stroke and they were split into two groups. So, one aimed for a blood pressure of below 140 and the other one aimed for a blood pressure of less than 120. Now, here's where it gets really interesting. The results were so clear that they had to stop the study early. So, the study was supposed to last for about 4 to 6 years, but after just 3.3 years, it was obvious that lowering blood pressure to below 120 made a huge difference. There was a 27% lower risk of having a heart attack, stroke, or dying from those causes each year. And when it came to death rates alone, there was a 25% lower risk of dying in the group that aimed for a blood pressure of 120. So just let that sink in for a moment. A 25% reduction in the risk of death just by lowering blood pressure more aggressively. That isn't just a small improvement. That is a gamecher. And the story does not stop there. So recently another study in China tested these findings on an even larger and more diverse group of over 11,000 people. and it included those with diabetes and those who had already had a stroke. Now, think of the study as the sequel to the sprint study, but with an even bigger cast. And guess what? The results were just as powerful. So, lowering systolic blood pressure to less than 120 reduced the risk of heart attacks, strokes, and death from cardiovascular causes by 12%. Plus, it cut the overall risk of death from any cause by 21% over 3 and 1/2 years. And the results just keep coming in. A new analysis of the sprint study focused on dementia and it came out this year. And the same pattern that we've been seeing in other areas holds true when it comes to brain health as well. So those who were in the lower blood pressure target group had a 14% lower chance of developing dementia during the follow-up period. So the takeaway here is clear. The blood pressure thresholds have followed the data. The levels that we used to think was safe in the past, we now know they are dangerous and we should aim for a lower systolic blood pressure of ideally less than 120 to really protect our health. And that is a conclusion that rests on a mountain of observational clinical data as well as randomized clinical data. Now the caveat here though is that for some older adults that I see in the clinic, we may need to have their blood pressure slightly higher because we need to balance the risks versus benefits. And again, in the clinic, it's vital that I tailor the advice to my patients at an individual level. So, we can see that the real culprit in the story is not big farmer. Instead, the culprit is the health influencers who spread confusion and encourage people at high risk to ignore the chance to do something about their blood pressure before it's too late. Now, as I mentioned at the outset of this video, new blood pressure guidelines were just published. So, how do they change the picture? Have they lowered the thresholds yet again? Well, no. that the levels for elevated blood pressure haven't changed, but there's an important shift in the approach that reflects a growing urgency. So, they recommend that those with hypertension and elevated cardiovascular risk should shoot for less than 130, but 120 or below is preferable. And the guidelines also recommend starting treatment for elevated blood pressure earlier. So, in lower risk categories, this starts with lifestyle changes. But medications are appropriate if patients haven't reached their goal in 3 to 6 months. And again, this reflects what I do in the clinic. And part of the reason for a more aggressive approach is that the evidence just keeps getting stronger about the link with dementia. So, when it comes to keeping blood pressure under control, the guidelines now recommend lowering salt intake even if our blood pressure is currently normal. And they emphasize the potential role of salt substitutes. So, these are typically a mixture of ordinary salt plus salt made with potassium. So, that lowers the sodium intake as well as boosting potassium at the same time. So both of those strategies can help reduce blood pressure and the effects that potassium has on blood pressure is part of the reason why I included a small amount of potassium in microvitamin. Now the guidelines also set a weight loss target of 5% as a way to lower blood pressure effectively if we're overweight or obese. So in addition to weight loss, exercise can be an effective tool to lower blood pressure as well. And some recent research has zeroed in on the exact type of exercise with the greatest impact on blood pressure. The surprise is that this particular exercise is quick and easy to do.