A: An estimated 10 to 20 percent of older adults have orthostatic hypotension, which is a drop in blood pressure when you go from sitting or lying down to standing. The sudden drop in blood pressure means less blood is flowing to the brain and muscles. Pos­tural hypotension increases fall risks. You can reduce that risk by taking your time shifting positions and holding on to something secure when you stand up. You may be able to increase blood flow before you stand up by moving your legs and feet and clenching your fists. Talk with your doctor about other steps that might be helpful. Unlike most of us, you may be encouraged to add more salt to your diet, as it can sometimes help raise blood pres­sure. If you have low blood pressure all the time, and not just when you rise, it may be that your “normal” blood pressure is just lower than what it is for others. Still, pay attention to signs that your blood pressure may need atten­tion or that you may have to adjust your activi­ties accordingly. If you frequently feel tired or weak, be sure to tell your doctor.

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A person whose blood pressure is usually normal has an appointment at a clinic or medical center. There is a bit of anxiety about the visit. Anxiety elevates blood pressure, and having it checked is a routine procedure.

Blood pressure is taken by a physician or other provider who often wears a white coat that symbolizes medical professionalism. The reading is higher than it normally would be when not in a clinical setting. The presumed result: white coat syndrome.

Until recently, white coat syndrome had been considered a temporary spike—no harm, no foul. But not anymore.

Real—Dangerous for Some

White coat syndrome/hypertension was first described more than 40 years ago. Since then, multiple studies have confirmed that it’s a real thing. The original scenario is the same—anxiety can elevate blood pressure in a clinical setting. But current research suggests that white coat syndrome may also be a symptom of something more concerning.

In February 2022, a review of studies in the journal Hypertension became the first to provide evidence that white coat syndrome in patients (with no previous organ damage) had an increased risk of mortality, new hypertension, and new organ damage. This study and others have resulted in a decidedly different approach to white coat syndrome diagnosis and treatment. (https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.121.18792)

Blood Pressure—How High is Too High?

To be clear, white coat hypertension for most people is still a one-time event that needs attention only in combination with other cardiovascular conditions. According to Cleveland Clinic and other medical centers, the syndrome affects 15-30 percent of people who already have high blood pressure. Patients who don’t normally have high blood pressure can also have the syndrome. (https://my.clevelandclinic.org/health/diseases/23989-white-coat-syndrome)

The definition of high blood pressure has been a moving target and remains a number that your physician determines is right for you. The American Heart Association defines “normal” as less than 120 for the upper (systolic) number; less than 80 for the bottom (diastolic) number. “Elevated” is 120-129 over 79 or less. For numbers defining three advanced stages of hypertension, go to https://www.heart.org/en/health-topics/high-blood-pressure.

The definition of normal can change, depending on a person’s age and health conditions. The AHA’s guideline for those 65 and older is lower than 130/80.  Normal for patients over the age of 80 may be higher.

Diagnosis— Multiple Readings

Diagnosis of white coat syndrome requires at least three separate blood pressure readings at a clinic, as well as elevated numbers when checked at home. Home blood pressure kits and regular checks are a good idea, regardless of the white coat issue.

When you take your blood pressure (BP) at home, follow these CDC guidelines: 1) nothing to eat or drink 30 minutes before taking BP; 2) empty bladder; 3) feet flat on the floor, legs uncrossed; 4) arm resting on a surface, chest high; 5) cuff snugly against bare skin, not over clothing; 6) no talking; 7) same time every day; 8) at least two readings, 1-2 minutes apart. (https://universityhealthnews.com/daily/heart-health/how-to-get-an-accurate-blood-pressure-reading/)

Treatment—Lifestyle Changes, Medications

If blood pressure is found to be slightly elevated—your doctor makes that call—you may be asked to consider lifestyle changes. You’ve heard them; all easier said than done. Here’s a review:

• Lose weight.
• Sit less, exercise more.
• Eat more fruits and vegetables, less red meat and processed foods.
• Limit daily salt intake to 2300 mg.
• Don’t smoke.
• Work on managing stress. (https://universityhealthnews.com/daily/stress-anxiety/how-to-deal-with-stress/)

If your blood pressure is more than slightly elevated, your doctor may prescribe medications to lower it. Examples are diuretics, alpha- and beta-blockers, ACE inhibitors, and calcium blockers. The Hypertension study mentioned earlier also found that patients with white coat syndrome who take medications to control blood pressure don’t have elevated risks of cardiovascular disease.

Antihypertensive drugs carry risks, mostly mild, for some patients. Ask your doctor about medications that might lower your blood pressure too much. Hypotension, as it’s called, could cause dizziness, lightheadedness, passing out, weakness, nausea, and other symptoms.

How low is too low? The National Library of Medicine says that while there is no universally-accepted standard, blood pressure readings under 90/60 indicate hypotension.

White Coat Syndrome—Answers and Actions

It’s real—well documented. It can be dangerous for some, leading to a variety of conditions that require medical intervention. High blood pressure, whether conventional or white coat, is treatable. It starts with lifestyle changes, and for more serious cases, advances to effective and safe antihypertensive medications.

Don’t dismiss white coat hypertension if it shows up at your next doctor’s appointment. Have it checked or regularly check it yourself.

Other Helpful Links from University Health News

https://universityhealthnews.com/daily/heart-health/uhn-blog-whats-the-right-blood-pressure-for-you-it-depends/

https://universityhealthnews.com/daily/heart-health/is-the-blood-pressure-reading-from-your-doctors-visit-accurate/

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A: One of the more common reasons this can occur is a condition called orthostatic hypotension, sometimes called postural hypotension. It refers to a sudden drop in blood pressure upon standing from a sitting or lying down position. It can increase the risk of falls, cardiovascular diseases, dementia, and depression. Clinically speaking, this is diagnosed by a sustained drop in systolic blood pressure of 10 mmHg (millimeters of mercury) within three minutes of standing after lying/sitting down for five minutes and/or a drop in diastolic blood pressure more than or equal to 10 mmHg. What’s happening is that there is a delayed response to shifts in the body’s fluid upon standing. This exaggerated drop can make you feel lightheaded and/or dizzy. In what we call “classic” orthostatic hypotension, this typically occurs within three minutes of standing up. But some people may experience the effect of the drop in blood pressure after three minutes, which we then refer to as “delayed” orthostatic hypotension. There are numerous potential causes, including neurodegenerative diseases such as Parkinson disease, and peripheral neuropathy, diabetes, vitamin B₁₂ deficiency, rheumatological conditions and cardiovascular diseases. It also can be due to a side effect of some medications. For example, diuretics, alpha-blockers, beta-blockers and some antidepressants can be culprits. Other causes can be dehydration and frailty or physical deconditioning. Orthostatic hypotension is more likely to occur in people over age 65. I recommend you monitor and report your symptoms to your doctor. Take note of what you did before (for example did you eat a large meal, drink alcohol, or recently take medications). Meanwhile, a recent study reported that tensing the muscles of the legs prior to standing increases the amount of blood pumped by the heart and prevented blood pressure from dropping so significantly. Compressing the muscles of the lower body by crossing the legs and continuing to compress the muscles after standing was even more effective at alleviating the symptoms of orthostatic hypotension. It’s also wise to stand up slowly instead of quickly. In addition, make sure you are staying well hydrated. Avoid alcohol, hot baths and showers, and large meals, as some people experience drops in blood pressure when they eat a lot of food in one sitting.

Q: Sometimes my heart flutters for several hours. When I check my blood pressure, it hovers on the lower side, around 100/80. The pulse is not extreme either, yet I feel this uncomfortable quivering. Could this be A-fib?

A: Atrial fibrillation (A-fib) can be tricky to diagnose because it often occurs with no symptoms. If you do have symptoms, you may notice them only occasionally. The symptom of quivering that you mention is what we consider “vague or nonspecific,” meaning there can be many reasons why you are experiencing heart palpitations. Stress or anxiety can cause them, as can dehydration, not eating enough, too much caffeine, alcohol, or a medication side effect. Generally, heart palpitations are not considered dangerous, especially if they occur only occasionally. However, if you have a history of heart disease and have palpitations that occur frequently or worsen, you should talk to your doctor. You may need heart-monitoring tests to see if they are caused by a more serious heart problem. The most common symptom of A-fib is extreme tiredness. Other symptoms include heart palpitations, or feeling like your heart is skipping a beat, fluttering, pounding, or beating too hard or too fast. Low blood pressure, dizziness, and chest pain also are associated with A-fib. Undiagnosed or if left untreated, A-fib can cause serious and even life-threatening complications, including stroke and heart failure. Keep track of when and how often your symptoms occur and what you feel and any suspected contributing factors. They are all important clues to help your health-care providers diagnose atrial fibrillation or another condition that may be causing your symptoms.

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You’re at greater risk of falling if you suffer from a chronic health condition, such as arthritis, or take multiple medications (drugs that treat high blood pressure and insomnia are a major culprit, since they may cause dizziness). Vision impairment raises your risk too, as does a lack of physical activity. The latter has been a problem for many older adults since the beginning of the COVID-19 pandemic, according to survey results from the University of Michigan’s National Poll on Healthy Aging. In 2021, the poll asked a national sample of people ages 50 to 80 about their levels of physical activity and whether they had experienced a fall since the pandemic began, in March 2020. One-quarter of poll respondents reported having at least one fall between March 2020 and January 2021, with falls more likely among people who reported that their physical activity levels had decreased.

Effective Fallproofing

The poll results underline how important it is reduce the risk of falls among older adults, and a recent study review (Journal of the American Geriatrics Society, October 2021) points to the most effective strategies for doing so. The review looked at 192 studies including nearly 100,000 community-dwelling participants, ages 65 and older. “The researchers analyzed how effective a range of single and combined strategies were,” says Dr. Bloom. “The data confirmed that exercise is the most effective single intervention for helping older adults avoid falls.” Numerous studies have pointed to balance training, aerobic and strength exercise, and exercise regimens that boost flexibility (such as tai chi, covered in this issue) as being beneficial when it comes to helping you avoid falls. Regimens that involve at least three hours per week of physical activity are most effective.

Lowering Your Fracture Risk

Regular exercise, along with having undergone a fall risk assessment, was associated with a lower risk of fractures in older adults who fell during study follow-up. “During a fall risk assessment, your doctor will ask if you have ever suffered a fall and whether you have balance issues,” Dr. Bloom says. “He or she also will have you do a range of simple tests to assess your muscle strength and how steadily you walk. A medication review will be performed to assess whether any drugs you take are associated with an increased fall risk.” Your doctor also will ask about tripping hazards in your home, such as throw rugs and poor lighting.

Keep in mind that you’re more susceptible to fractures if you have the bonethinning disease osteoporosis. Women ages 65 and older are advised to get screened for the condition, as are younger women with certain risk factors.

Mobility Aids and Vitamin D

In one surprising finding, the use of mobility aids, such as canes, was associated with an increase in the number of fall-related fractures. “It’s possible that people who were using mobility aids may have been more physically frail than those who were not, and this may factor into the results,” Dr. Bloom says. It also is possible they may have been trying to do too much simply because they had a cane.

While some research has suggested that supplementing vitamin D may reduce the risk of falls and fall-related fractures, the review found no association. It is possible that the participants had adequate levels of vitamin D and that people with low vitamin D levels might benefit. “If your doctor thinks you are at risk of falls, he or she may suggest checking your vitamin D levels,” Dr. Bloom says.

Combined Interventions

Combination approaches that reduced falls included using mobility aids and undergoing a fall risk assessment; and using mobility aids, education about fall risks, a fall risk assessment, and home modification (for example, installing grab bars in the bathroom). The data also pointed to the importance of managing orthostatic hypotension. “The latter is low blood pressure that occurs when you stand upright after sitting or lying down. It can result in sudden dizziness and fainting,” Dr. Bloom says. People who take certain drugs, including some that treat high blood pressure, depression, and Parkinson’s disease (PD), and those who have heart failure and other heart-related issues, diabetes, or PD are more vulnerable to orthostatic hypotension. “Rising slowly and pausing for a moment before walking can help,” Dr. Bloom says, “but be sure to alert your doctor if you feel dizzy upon standing.”

Overall, Dr. Bloom says the review offers useful insights about the effectiveness of individual fall prevention strategies. “The data may help clinicians devise a more personalized prevention regimen for older adults based on their specific fall risks,” she concludes. See Resources for more information.

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The broad term for cognitive impairment triggered by changes in blood flow is vascular dementia, but many experts in the field say a more accurate description is “vascular contributions to impairment and dementia” (VCID), which encompasses brain changes both mild and severe related to blood flow.

But unlike the early symptoms of Alzheimer’s disease (AD), which primarily include memory problems and sometimes non-memory concerns, such as impaired reasoning and difficulty finding the right words in conversation, memory loss isn’t always an early sign of VCID. Initial symptoms often include confusion, impaired executive function (planning, organizing and decision making), and noticeable changes in mood and behavior.

Neurologist Anand Viswanathan, MD, PhD, with the Memory Disorders Unit at Massachusetts General Hospital and the Massachusetts Alzheimer’s Disease Research Center, explains one theory of why mood and executive function are so often affected early on: blood flow problems in the brain affect networks that involve several regions of the brain. In AD, the neighboring memory centers of the hippocampus and entorhinal cortex are usually the first areas of the brain to undergo a change. Damage to other parts of the brain usually occurs later on as AD progresses.

“Memory loss isn’t as prominent as it is in Alzheimer’s, and the speculation is that it is because the damage isn’t centered in one region,” Dr. Viswanathan says of VCID. “The higher brain processes involving executive function and mood, as well as gait, involve multiple brain regions.”

But VCID can eventually produce a wide range of symptoms, depending on the cause, location, and severity of vascular injury to the brain.

Causes of VCID

Three of the main causes of vascular cognitive impairment include:

• Atherosclerosis
• Stroke
• Silent vascular brain injury (or silent strokes)

Atherosclerosis is the formation of plaques along the inner walls of arteries. The plaques are made up of cholesterol, fats, calcium, fibrin (a bloodclotting material), and waste materials. Atherosclerosis can occur anywhere from the brain to the feet. It causes the arteries to become less elastic, and it narrows the channel through which blood can flow, reducing the volume of oxygen-rich blood circulating in various parts of the body. Atherosclerosis in the brain doesn’t always cause symptoms, but it can lead to brain cell injury
or even death.

The two main types of strokes are hemorrhagic and ischemic. A hemorrhagic stroke occurs when an artery leaks or ruptures. Ischemic strokes, which make up more than 80 percent of all strokes, occur when blood flow through an artery supplying the brain becomes blocked.

A silent stroke is usually caused by a blood clot that temporarily interrupts blood flow in the brain. You may never know you had one or more silent strokes because there are no obvious symptoms. But over time, the cumulative effect of silent strokes can affect cognition or other brain functions. It’s estimated that by the age of 80 about one in four people has had at least one silent stroke.

Reducing Your Risk

Preserving the health of your body’s vast vascular network means adopting a lifestyle that provides benefits far beyond a healthy brain. “Reducing the risk of vascular lesions that contribute to VICD includes treating high blood pressure and diabetes and quitting smoking,” Dr. Viswanathan says, adding that these steps also support the heart, lungs and your overall health.

At the top of the to-do list for vascular health is maintaining a healthy blood pressure. High blood pressure is undertreated in about 30 to 40 percent of people with hypertension, and Dr. Viswanathan notes that those numbers haven’t changed much in 20 years. But he adds that one way to make sure your blood pressure is being properly treated is to buy and use a home blood pressure monitoring kit. By taking your blood pressure regularly and reporting the numbers to your doctor, you both can see how well treatment is working and whether changes are needed.

If you aren’t currently taking medication for hypertension, observing spikes in blood pressure at home or a steady increase in your blood pressure can alert you and your physician that some intervention may be necessary. Home monitoring may also reveal whether you are experiencing low blood pressure (hypotension), which can lead to insufficient blood flow to the brain. “There is some evidence that low blood pressure in late life may actually increase the risk of cognitive impairment,” Dr. Viswanathan says, adding that determining safe low and high numbers can be challenging.

Many older adults, for example, function quite well with blood pressure that is slightly above the recommended level of 120/80 millimeters of mercury (mmHg). Likewise, some older adults may thrive with blood pressure slightly below that figure.

In addition to medications that help control blood pressure, the following strategies should also be employed:

• Get at least 150 minutes a week of aerobic exercise.
• Follow a Mediterranean-style diet or other eating plan that focuses on fruits, vegetables, whole grains, lean proteins and little saturated fat, sodium, and added sugars.
• Maintain a healthy weight. If you are overweight or obese, losing just 10 pounds can result in a lower blood pressure for many people.
• Manage your stress.

And if you smoke, talk with your doctor about programs in your community and nicotine-replacement products or other therapies designed to help people quit smoking.  If you have tried before and been unsuccessful, just know that it often takes five or six attempts for someone to be successful and quit cigarettes for good. Smoking damages blood vessels, reduces blood oxygen levels, and increases inflammation— all factors that contribute to cognitive impairment. Elevated glucose (sugar) levels in the blood can also injure blood vessels. Research suggests that blood glucose levels that haven’t yet risen to the threshold that defines diabetes may already be causing damage. There are several tests used to diagnose diabetes, but two common screenings are a glycated hemoglobin (A1C) test and a fasting blood glucose test. An A1C level of at least 6.5 percent on two tests indicates diabetes, as do two fasting blood glucose test results of at least 126 milligrams per deciliter (mg/dL).

Keep Your Mind Interested

Preserving brain health is more than just a matter of healthy circulation. Dr. Viswanathan advises his patients to spend time in cognitively engaging activities to fuel the birth of new brain cells and activate your neural networks.

“Find something you’re really interested in and which also requires true personal engagement. These are activities where you learn new skills, acquire new knowledge, or put yourself in challenging situations that require personal growth,” Dr. Viswanathan recommends. “It could be making large-scale photographs, becoming an elite gardener, or being the best tennis player in your age group. The idea is that if you have something like this in your life, you’ll talk about it with friends, you’ll do research, and you’ll get out to work on it. That kind of social activity is really important. Just remember, there is no one-size-fits-all activity. If it’s special to you, then it’s worth doing.”

Looking Ahead

Reducing the impact of vascular disease on cognition is the goal of research efforts around the world. MGH is leading the way in two major projects. The first is a research program funded by the National Institutes of Health called the MarkVCID consortium. MGH is the coordinating center of this multimillion-dollar research effort. It consists of numerous prominent research groups across the country working on ways to better predict and diagnose small blood vessel disease in the brain and to develop a greater understanding of how it contributes to VCID.

MGH is also leading another NIHfunded collaborative effort called DISCOVERY (Determinants of
Incident Stroke Cognitive Outcomes and Vascular Effects on RecoverY). The goal is to better understand the mechanisms of post-stroke cognitive impairment, with the ultimate aim of developing personalized treatments that will reduce rates of stroke-induced cognitive and functional disability.

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A. While low blood pressure (hypotension) doesn’t get as much attention as high blood pressure, it is not without potential complications. Research suggests that low blood pressure can lead to brain damage and cognitive impairment. Reduced blood flow to the brain can lead to neuron damage in key parts of the brain related to memory and cognition. Hypotension may also harm the myelin sheath that protects nerve fibers in the brain, further raising the risk of cognitive troubles.

Depending on the severity of your low blood pressure, you may be able to increase it into a healthy range with a few simple solutions. Using more salt may help. Your doctor may also advise that you drink more water, as increasing the body’s fluid levels can help prevent dehydration and bring up low blood pressure. Wearing compression stockings may also help, but be sure to talk with your doctor first about any steps needed to get your blood pressure in the safe range.

Q. I’m considering therapy to help deal with a lot of changes in my life recently. I know I’ll get asked a lot of questions up front, but
what questions should I ask at the beginning?

A. It’s smart to think about these things ahead of time, rather than try to come up with questions on the spot or realize later you had important questions about your therapy. Once you’ve found a licensed therapist with experience working with individuals such as yourself, and all matters of insurance and cost have been covered, there are two main issues to consider: Are you and the therapist a good match, and how will you both set goals for therapy?

You could start by asking about the therapist’s philosophy and general approach to therapy. If this is your first time in therapy, you may want someone who will guide you. People with experience in therapy may be more comfortable with someone being more direct with them. You could also ask about the therapist’s strengths and whether the person has ever been in therapy. You may feel more comfortable knowing that your therapist has been in your position before.

When it comes to goal-setting, your therapist is likely to ask what you want out of therapy. That can be a tricky question to answer, so it’s worth thinking about what change you want to see in your life. Whatever it may be, you should also ask your therapist to define success or a positive outcome in your situation. Ask how goals are established and what is a roadmap to achieve them. Ask about a reasonable therapy schedule—the frequency of sessions and the anticipated duration of therapy. You should also know what kind of “homework” you’ll get and how you should prepare for your first session.

Q. I started taking a class in computers to improve my understanding of them and to give my mind something challenging. But I find the class more stressful than helpful. Should I stick with it for the brain benefits?

A. Cognitive stimulation, like you get from a challenging class or a taking on a new hobby, is always advisable to help preserve cognition and memory. But if the activity is proving to be too stressful, it could be counterproductive. Too much stress isn’t good for cognition. You may be able to learn more about computers from a friend or relative. And as for the cognitive stimulation, consider finding a subject or a setting that will be inspiring, not discouraging. Keep looking. You’re on the right track. And remember that cognitive stimulation can come from challenging your mind in ways that are fun and interesting. Don’t make yourself miserable taking on a challenge when the only perceived benefit is that it’s making your brain work harder.

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Describing AD & PD. Characteristic features of AD include memory loss, decline in word-finding, impaired reasoning or judgement, and visual/spatial issues. The brain starts to lose neurons in the hippocampus (the part of the brain responsible for long term memories, spatial processing, navigation), cerebral cortex (neural integration), thalamus (alertness and tending), and amygdala (emotions). Neurons are thought to become disconnected when amyloid beta plaques and neurofibrillary, or tau, tangles develop. This buildup impairs neurons from communicating and performing their roles leading to cognitive dysfunction.

Features of PD, such as tremor, slowness in movement, rigidity and postural stability, are accompanied by symptoms people don’t see such as insomnia, fatigue, cognitive impairment, depression, anxiety, pain, urinary incontinence, sweats, postural hypotension, dysphagia, bloating, and constipation. These symptoms are responsible for the majority of the reduction in quality of life that people with PD experience.

In PD, Lewy bodies are abnormal protein groupings that form in the nerve cells of the brain’s substantia nigra (the brain’s reward center that is accountable for movement) preventing neurons from functioning properly. Lewy bodies are also in the autonomic and enteric nervous systems, disabling up to 50 percent of neurons throughout the entire body.

Impaired Neuron Metabolism. Amyloid plaques, tau tangles, and Lewy bodies in similar amounts have also been found in adults without AD and PD, pointing to other causes of disease. For both AD and PD, it’s proposed that brain cells experience defective glucose
metabolism. This is partly due to impaired brain insulin signaling, broken insulin receptors, and mitochondrial abnormalities in the neuron. Dr. Matthew Phillips, Neurologist, Waikato Hospital, New Zealand, explains, “both involve mitochondria damage including deleterious changes in mitochondria shape and structure as well as damage to their respiratory chain complexes. Both [are] primarily metabolic disorders” associated with neurodegeneration.

Nuts and Bolts of the KD: The KD is a high-fat (up to 90 percent) moderate protein (around 7 percent), low carbohydrate eating pattern that typically restricts carbohydrates to below 50 grams a day to mimic a fasting state. The intent is to force the liver to convert fatty acids to ketone bodies to fuel the brain and muscles rather than rely on insulin and glucagon for glucose control. The diet excludes refined sugars, grains, starches, beans, legumes, root vegetables and tubers, and many fruits.

Research. Ketones have shown beneficial effects on AD and PD in several animal and in vitro studies by increasing the metabolic activity in mitochondria. In humans with AD, a small pilot study looking at the effects of KD (with medium-chain triglyceride fat supplements added) reported significant improvement on the cognitive portion of the Alzheimer’s Disease Assessment subscale. A randomized, controlled trial of 44 patients with PD found the KD was associated with improvement in urinary problems, pain, fatigue, daytime sleepiness, and cognitive impairment. More studies are currently underway researching the KD’s effects on PD and AD and a modified Ketogenic-Mediterranean diet on early AD.

Obstacles to overcome:

• One of the greatest concerns regarding the KD is its potential to increase cholesterol, low-density lipoprotein, and very low-density lipoprotein levels, though prolonged use of it with other patient populations has also been associated with increased high-density lipoprotein (HDL or “good” cholesterol) and decreased triglycerides. In clinics, medium-chain triglycerides are often added to a KD to manage dyslipidemia.
• The KD diet may lead to unintended weight loss and some have issues transitioning to and/or maintaining the diet with side effects like nausea, vomiting, dehydration, constipation, low appetite, diarrhea, headache, muscle cramps, rashes, weakness, and halitosis. Nutrient deficiencies are also possible.
• While small, pilot studies have yielded positive results for patients with AD and PD, it has yet to be researched in large, randomized controlled trials.

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An observational study recently published in the BMJ found that a healthy plant-based diet was associated with lower blood pressure, but an unhealthy plant-based diet was not. The study compared dietary recall and blood pressure data from over 4,600 men and women ages 40 to 59 living in the United States, United Kingdom, Japan, and China.

Plant-based foods scored as “healthy” included whole grains, fruits, vegetables, nuts, legumes, vegetable oils, and tea/coffee. Less healthy plant-based foods included fruit juices, sugar-sweetened beverages, refined grains, potatoes, and sweets and desserts. Animal foods (dairy products, eggs, fish and shellfish, total meat, and mixed foods like a hamburger on a bun) were also considered less healthy.

Diets that were simply low in animal products were not associated with lower blood pressure. Sugar-sweetened beverages and refined grains are animal-free, but they are associated with negative health effects.

This study supports the concept that, while one does not need to become vegan or vegetarian, minimizing animal proteins and low-quality plant-based foods while emphasizing intake of high-quality plant foods is good for blood pressure.

Coffee is Good for You…But it Might Not be the Caffeine

Good news for coffee drinkers: a review article published in the New England Journal of Medicine concluded that drinking coffee does not increase risk for cardiovascular diseases and cancers, as once thought. In fact, consumption of three to five standard cups of coffee daily has been consistently associated with a reduced risk of several chronic diseases. These effects may not be due to caffeine, however. Coffee contains hundreds of other biologically active phytochemicals that may reduce oxidative stress, improve the gut microbiome, and impact the metabolism of fat and blood sugar.

Any health benefits conferred by drinking coffee are not strong enough to suggest non-coffee drinkers should start. Be aware that unfiltered coffee (such as French press or Turkish coffees) contain a compound called cafestol, which has been shown to increase serum cholesterol levels. Be mindful to minimize the sugar, syrups, and cream often added to that cup of coffee.

Vitamin D Supplements Do Not Help Cholesterol Levels

Researchers from Tufts University and Tufts Medical Center have found that taking vitamin D3 supplements has no effect on serum cholesterol. Their randomized controlled trial, published recently in the American Journal of Clinical Nutrition, does not support results from observational studies that found an association between serum levels of vitamin D and LDL or HDL cholesterol concentrations.

One hundred and twenty-seven participants were given either 4,000 International Units of vitamin D3 a day or a placebo for 24 weeks. At the end of the study period, the supplement group’s serum vitamin D levels were higher, but their cholesterol profiles were not significantly different. There was also no change in how much cholesterol they absorbed from food or how much was manufactured by the body. “Our hypothesis was that raising vitamin D levels would improve cholesterol concentrations by decreasing cholesterol absorption,” says Alice H. Lichtenstein, executive editor of Tufts Health & Nutrition Letter and the study’s senior author. “In fact, our hypothesis was rejected.”

Targets for Reducing Alzheimer’s Risk Identified

A large analysis published in the Journal of Neurology, Neurosurgery & Psychiatry identified ten risk factors that appear to have a significant effect on risk of developing Alzheimer’s disease, and many of these factors can be modified with lifestyle changes. The international team of researchers looked at results from 395 studies to draw its conclusions. Diabetes, high homocysteine levels, high body mass in late life, lower levels of education, hypertension in midlife, dizziness upon standing (orthostatic hypotension), head trauma, low cognitive activity, and high stress and depression were all significantly associated with development of Alzheimer’s disease.

Although we cannot eliminate risk altogether, it is heartening to know that staying mentally (and physically) active and protecting cardiometabolic health can lower our risk for Alzheimer’s disease.

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A normal or healthy resting heart rate for an adult is between 60 and 100 beats a minute. A heart rate near the lower end of that range is considered a good sign. Your heart isn’t working too hard to pump blood effectively throughout the body. It’s one indication of cardiovascular fitness. A very rapid heart rate, on the other hand, raises your risk of heart failure, blood clots, and other problems.

But health risks can develop if a low heart rate gets too low—a condition called bradycardia. Bradycardia is usually diagnosed when your resting heart rate is less than 60 beats per minute (BPM). In some cases, the threshold is less than 50 BPM. Those numbers are guidelines. You may experience heart-related complications if your resting heart rate is 65 or 70 BPM. Or, you may be fine with a resting heart rate that is less than 60 BPM. Long-distance runners and other athletes in top cardiovascular health often have a resting heart rate that is under 60 BPM.

If you’re not training for a marathon or swimming dozens of laps every day, you should talk with your doctor if you notice a low heart rate.

When to Worry About a Low Heart Rate

One complication related to bradycardia is a condition called syncope. It means a loss of consciousness (fainting), usually due to insufficient blood flow to the brain. A low pulse rate can compromise your circulation. Your heart may not pump fast enough to keep a healthy flow of blood up to your brain and throughout your body. Fainting, of course, can lead to dangerous falls and bone fractures.

The most common symptoms of a low heart rate, according to the American Heart Association, are fatigue, confusion, dizziness, shortness of breath, especially during exercise.

To compensate for a slowly beating heart, your heart muscle might try to pump harder to keep up with your body’s demand for oxygenated blood. This can lead to high blood pressure (hypertension) and even heart failure, if your heart muscle works overtime for too long a period. A low pulse rate is also paired sometimes with low blood pressure, a condition known as hypotension. Low blood pressure is also a cause of syncope.

However, research suggests that bradycardia does not increase the risk of cardiovascular disease—the precursor to a heart attack. A study led by Ajay Dharod, MD, an internal medicine specialist with Wake Forest Baptist Medical Center, found that a low heart rate by itself does not suggest an inevitable slide toward heart disease. “For a large majority of people with a heart rate in the 40s or 50s, who have no symptoms, the prognosis is very good,” Dr. Dharod says. “Our results should be reassuring for those diagnosed with asymptomatic bradycardia.”

Treatment

If you have bradycardia, but not other symptoms, you may not need any treatment. But if you do start to experience fainting or even frequent episodes of feeling lightheaded, or you start to experience chest pain, tell your doctor. If treatment is necessary, your doctor will need to determine the cause first.

In many cases, bradycardia is caused by problems with the sinoatrial (SA) node. This is sometimes referred to as the heart’s “natural pacemaker.” The SA node is a cluster of cells in the upper part of the heart that sends out electrical signals that help control the beating of your heart. If the SA node is damaged or is otherwise not working properly, your heart rate can slow down, speed up, or become inconsistent. An abnormal heart rate of any type is called an arrhythmia. If the problem is serious enough, you may require a pacemaker. This small device is implanted in the chest. When it detects an arrhythmia, it sends an electrical signal to the heart to help restore a healthy rate.

Common causes and risk factors of bradycardia are old age, heart block, and damage from heart disease or heart attack. Another common cause is thyroid disease. Low thyroid function (hypothyroidism) can cause a number of health problems, including low heart rate. Controlling your thyroid disease with medication and lifestyle changes may help correct bradycardia.

A low heart rate may also be a side effect of certain medications, such as digoxin, a common drug used to treat heart failure. Beta blockers, which are often prescribed to treat high blood pressure or tachycardia (abnormally fast heart rate), may also cause your heart to beat too slowly. “Bradycardia may be problematic in people who are taking medications that also slow their heart rate,” Dr. Dharod says. “Further research is needed to determine whether this association is casually linked to heart rate or to the use of these drugs.”

Adjusting your medication dosage may be enough to reset your heart rate.

Measuring Your Heart Rate

Checking your resting heart rate isn’t difficult. Start by sitting quietly for five minutes or so. Then, place two fingers on the thumb side of your wrist, between the bone and the tendon over your radial artery. Once you feel a pulse, count the number of beats for 15 seconds. Then multiply that number by four. That will give you your beats per minute.

It’s a good idea to do this every so often, just to have a baseline number. If you notice a change—up or down—tell your doctor at your next appointment. You should also talk with your doctor about your target heart rate, particularly if you are an older adult or you have risk factor for cardiovascular problems, such as diabetes, family history of heart disease, smoking, obesity, a sedentary lifestyle, or high blood pressure.

Keep in mind that your heart rate should go up when you exercise and then return to a normal resting heart rate soon after you stop. If your heart rate doesn’t rise very much or takes a long time to return to normal, tell your doctor. It may be a sign of a heart that isn’t working optimally. It may not be serious, but it is worth a discussion with your physician.

This article was originally published in 2018. It is regularly updated. 

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