Season 2 is Now Live! Listen to the Fourth Episode Here

Season 2, Episode 3: A Functional Medicine Approach to Hypertension with Dr. Mark Houston

Show Notes

Dr. Mark Houston, Internist, and hypertension and cardiovascular specialist, is the cofounder of The Hypertension Institute, which immediately received national acclaim as one of the leading Institutes in the US for the treatment of hypertension and related cardiovascular disorders. Dr. Houston has presented over 10,000 lectures, nationally and internationally, and published over 250 medical articles, and scientific abstracts in peer-reviewed medical journals, books, and book chapters. He is an author, teacher, clinician, and researcher and is triple-boarded in hypertension as an American Society of Hypertension (ASH) specialist and Fellow of the American Society of Hypertension (FASH), Internal Medicine (ABIM), and Anti-aging Medicine (ABAARM). He also has a Master’s degree in Human Nutrition from the University of Bridgeport, Connecticut, and a Master of Science degree in Functional and Metabolic Medicine from the University of South Florida in Tampa.

Together Dr. Houston and I discuss a functional medicine approach to hypertension, including supplements, diagnosis, endothelial glycocalyx, and more. He shares hypertension statistics, why high blood pressure is so prevalent in the US, and the consequences of high blood pressure that physicians need to share with their patients. He offers insights into clinical trials and results of key blood pressure testing, the nutrients, dietary supplements, and lifestyle changes that can better support endothelial dysfunction, and key diet and lifestyle recommendations for hypertension including meat, fish oil, and sodium chloride intake. As Dr. Houston notes, hypertension can be impacted by both genetics and environment, and our conversation is filled with clinical pearls for physicians to share with their patients today for healthier blood pressure tomorrow.

I’m your host, Evelyne Lambrecht, thank you for designing a well world with us.

Episode Resources:

Dr. Mark Houston

Design for Health Resources:

Designs for Health

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[2:45] Dr. Houston shares the family history that started his journey into integrative medicine.

[4:32] Hypertension statistics, why it is so prevalent in the US, and the consequences of high blood pressure that physicians need to share with their patients.

[7:06] Correctly diagnosing hypertension starts with properly testing blood pressure in the office and prescribing the correct medication to be taken at the right time of day.

[12:03] Key concerns with medicines that result in low blood pressure and appropriate testing options.

[15:57] The pathophysiology of hypertension as it relates to the arteries and endothelial glycocalyx.

[18:32] Nutrients, dietary supplements, and lifestyle changes that can better support endothelial dysfunction to enhance nitrous oxide production and viability.

[20:23] Dr. Houston highlights the clinical trials and results of key blood pressure testing.

[24:17] Blood pressure medications and common nutrients that can be helpful for reducing blood pressure.

[28:47] The relationships between nitric oxide production and the endothelial lining.

[31:02] Physical improvements that accompany increased nitric oxide production and its potential impact on low blood pressure.

[33:05] Dr. Houston’s diet and lifestyle recommendations for hypertension including meat, fish oil, and sodium chloride intake.

[38:38] The impact of genetics, stress, and exercise on hypertension.

[44:10] The connection between the oral microbiome and blood pressure and cardiovascular health.

[46:36] The relationship between iron and cardiovascular health.

[49:03] Dr. Houston shares what he is most excited about in the future of the field of integrative and functional cardiology.

[52:14] Dr. Houston highlights the greatest change he made over the course of his career, his three personal favorite supplements, and his preferred health practices.


Voiceover: Conversations for Health, dedicated to engaging discussions with industry experts, exploring evidence-based, cutting edge research and practical tips. Our mission is to empower you with knowledge, debunk myths, and provide you with clinical insights. This podcast is provided as an educational resource for healthcare practitioners only. This podcast represents the views and opinions of the host and their guests, and does not represent the views or opinions of Designs for Health Inc. This podcast does not constitute medical advice. The statements contained in this podcast have not been evaluated by the Food and Drug Administration. Any products mentioned are not intended to diagnose, treat, cure, or prevent any disease. Now let’s embark on a journey towards optimal wellbeing, one conversation at a time. Here’s your host, Evelyne Lambrecht.

Evelyne: Welcome to Conversations for Health. I’m Evelyne, and I’m excited to welcome the Dr. Mark Houston legend in integrative and functional cardiology to the show today. Hi, Mark.

Mark Houston: Hey, Evelyne. Good to see you.

Evelyne: Good to see you too. I last interviewed you 10 years ago on my own podcast. Can you believe that?

Mark Houston: Wow. And you still look the same. That’s amazing.

Evelyne: So do you. That was so fun.

Mark Houston: Kindergarten.

Evelyne: I’m so glad to do this again. We were actually in your office recording that. It’s still on YouTube.

Mark Houston: Wow. Amazing.

Evelyne: Today we’re talking about a functional medicine approach to hypertension, supplements, diagnosis, the endothelial glycocalyx, and so much more. Dr. Houston has presented over 10,000 lectures nationally and internationally, published over 250 medical articles, scientific abstracts in peer-reviewed medical journals, books and book chapters on the topics of hypertension, dyslipidemia, vascular aging, vascular biology, metabolic and functional medicine, and integrative and preventive cardiovascular medicine. That’s a mouthful. Dr. Houston has an active clinical practice, teaches and does clinical research at St. Thomas Medical Group and Hospital in Nashville, Tennessee. He founded and is director of the Hypertension Institute at St. Thomas. He’s a professor. He has four board certifications and two master’s degrees in human nutrition and in metabolic and nutritional medicine. He has published seven bestselling books, the most recent one being Nutrition and Integrative Strategies in Cardiovascular Medicine. Mark, I shortened your bio a little bit because you’ve done this for a while. You have quite a lot of accolades.

Mark Houston: Well, thanks for what you did, Evelyne.

Evelyne: Thank you. How did you get into the integrative side? I’d actually love for you to share this story because you told me this at our last Cassie conference when we saw each other, and it was actually through Designs for Health, so I thought this was a really cool story.

Mark Houston: My father got really ill with prostate cancer and was told he only had about a year to live, and I went into the alternative medicine literature as they called it then, and looked at different nutrition and supplement things that I could give him. And lo and behold, he made it for another four years with pretty good quality of health, so when I determined that I didn’t know anything about oncology, but figured something out that I might be able to do even more with cardiology. So that’s when I started looking at supplements and nutrition and cardiovascular medicine and hypertension and lipids. And that was back in ’97, ’98. And from there, it’s just the story of learning and taking master’s degrees and teaching yourself all about it and doing clinical studies.

Evelyne: And you said you came to some Designs for Health conferences, right?

Mark Houston: Yes. I started with Robert Crayon in gosh, 2000, and that was the beginning of my dipping into the world of supplemental nutritional medicine, and it was really good. And then after I did that, I went back in 2003 and got my first master’s at University of Bridgeport in nutrition, and then got another master’s about four years ago in metabolic integrative cardiology.

Evelyne: I love it. Never stop learning.

Mark Houston: No.

Evelyne: It’s very inspiring. Let’s talk about hypertension. I was reading just on the CDC website, I couldn’t believe these statistics actually that nearly half of adults have hypertension, almost 120 million people or are taking medication for hypertension. And only one in four adults with hypertension have it under control. What is going on? How is this so prevalent?

Mark Houston: It’s pretty sad that you find it and then they don’t take their medications. A lot of it has to do, I think, with the physician patient interaction, unless you are really firm with them and explain to them what’s going to happen if they don’t take their meds, make things easy, make sure the medicines don’t have side effects, have them come in frequently for checkups, we’re pretty good. In our clinic, our statistics are way better than CDC and any others. We have about, I’d say, close to a 90, 95% adherence rate to the hypertension program. And that includes everything. It’s nutrition, it’s supplements, and it’s drugs, so we don’t have those terrible statistics. And most of these patients that come in have pressures that are controlled 120 over 80, which is our goal.

Evelyne: That’s amazing. And you said something there about how physicians don’t explain to their patients the consequences of following a program. And since this podcast is geared to practitioners, what are some of those consequences of constant high blood pressure?

Mark Houston: Well, the main ones are stroke, which is ischemic myocardial infarction, congestive heart failure, renal failure, and aneurysms, all of which can be prevented. And the educational piece that we have that maybe others don’t have, we have a full-time nutritionist who talks to them about appropriate diets. And we have the hypertension handbook that I wrote, and we have all of them read that book and understand it. And then we have educational material handouts, CDs, all kinds of things. They leave there with a lot of educational material. And I think that’s the key. Once you get them educated, they realize this is not so difficult to do, and if I don’t do it, I’m not going to live very long.

Evelyne: For sure. Let’s talk about the diagnosis first. What is the correct way to diagnose it? And I want to talk about in-office testing versus at home testing versus 24 hour testing. What do practitioners need to know about those?

Mark Houston: Well, the first thing you have to do is be sure you know how to check a blood pressure correctly in the office, so you need to read the American Heart Association guidelines for checking a blood pressure correctly. Simple things like making sure they’re sitting, their feet are on the ground, their arms bare, the cuff is in the right place, et cetera. Honestly, most physicians and nurses don’t even do it right, so that’s the first problem. And then once you get three office readings that are elevated, you pretty well have the diagnosis. Now that’s good for the first step, but longterm, and initially you have to do 24 blood pressure monitoring and home monitoring to find out if they have things like labile hypertension, dipping, high nocturnal blood pressure. There are other things you can’t pick up on routine measurements at home or in the office. The 24-hour ABM is the standard. It’s the gold standard. And I think everybody who’s treating hypertension should have access to that sort of a monitor. They’re not expensive and you can get reimbursed for them too.

Evelyne: And what are the kinds of things that you find out from 24-hour testing? What is clinically meaningful versus testing or the regular at home test that’s not 24 hours?

Mark Houston: For example, the driving force for target organ damage, cardiovascular damage is the nocturnal blood pressure. Well, you don’t get that if you’re checking it with a regular cuff in your office. That’s only done on a 24-hour blood pressure monitor. Also, do they dip at night? Do they drop their pressure adequately? Do they have liability during the day? What’s their blood pressure load over 24 hours? Do they have spikes early morning hours? All these things you can’t pick up unless you do the ABM.

Evelyne: And then with that information, are you choosing different medications and or supplements based on what you see from that?

Mark Houston: Yeah. Because if your blood pressure is not dipping at night, you would want to give your antihypertensive meds at night. But if you’re a normal dipper or excessive dipper, you don’t want to give them at night because they get low blood pressure. You want to give it during the morning hours, so it makes a difference in not only the timing, but also the dose and the particular medicine you’re giving.

Evelyne: That’s really interesting. Forgive my ignorance, I just haven’t heard this before because I’ve never been to a cardiologists. Well, I’ve been to your office, but not for a workup.

Mark Houston: Well, it’s really not well known, honestly. A lot of physicians, unless they’re a hypertension specialist, they don’t really know about dipping status or ABMs that well and what they can get from them.

Evelyne: Interesting. You’re telling me that it’s not standard for a physician who’s recommending blood pressure medication to tell a patient whether to take it during the morning or at night?

Mark Houston: Well, they wouldn’t know if they don’t do the ABM, and most of them don’t do the ABM, so they’re just guessing.

Evelyne: Interesting. And what are some of the consequences? You’re saying that a dip in blood pressure is normal at night, but what are the consequences of, say, you’re taking blood pressure medication at night and then it’s dipping even more? Is that worse than having high blood pressure during the day? What happens?

Mark Houston: The normal dipping is 10% of your average daytime. And if you hit 10%, you’re good to go. But let’s say you don’t hit 10%, you only hit 5%. That means you’re a non-dipper. That means you give you any hypertensive drugs at night, so you don’t have high pressures at night, but if you’re dipping, let’s say 15%, which is more than normal, you don’t want to give it at night because then you drop the pressure too low, so that’s when you give it in the mornings.

Evelyne: And then what are the physiological consequences of having blood pressure that drops too low during the night while also having high blood pressure during the day?

Mark Houston: There’s two issues there. One is if your blood pressure is high at night, your arteries never get to rest, so they’re under constant pressure, which means you have more strokes and heart attacks and heart failure, kidney disease. On the other hand, if it drops too much at night, you can have also a stroke from hypoperfusion of the brain, or you can have a heart attack from hypoperfusion of the coronary arteries, so it goes both ways.

Evelyne: Interesting. And I know we’re talking about high blood pressure today, but I’m curious about low blood pressure as well because I generally have low blood pressure. I remember hearing that there’s a higher risk of, I believe it was dementia, with low blood pressure in the elderly. Can you talk a little bit more about that?

Mark Houston: Well, if your blood pressure is low normally, there is no risk. If your blood pressure becomes too low on medication, particularly in an older patient and you’re hypo perfusing the brain, then you can end up with strokes or you can end up with decreased arterial flow with vascular dementia. But that’s uncommon. It’s actually more common to have hypertensive vascular dementia. And that’s very common in older patients.

Evelyne: And with the medications, is it common for a patient to be taking medication? Is it like the amount that they’re taking or is it a duration of time that they’re taking it that could lead to somebody then developing low blood pressure? Is that something you see a lot, or is that something you don’t worry about so much?

Mark Houston: Well, if you give the right medicine at the right time and the dosing is correct, you shouldn’t get someone hypotensive. That happens. You’re not treating the patient correctly, obviously. But there are patients who have very difficult pressures to control because they’re older and their arteries are very stiff, for example. You might get their systolic pressure not down much, and that’s not good. But then their diastolic pressure drops a lot to what’s called an increase in pulse pressure, so there’s a lot of nuances in the hypertension war beyond just the number. And that’s why we do a lot of other vascular tests like vascular stiffness, endothelial dysfunction, all these tests help to determine not just what medication, but also what supplements you might want to give to improve RT elasticity.

Evelyne: Can you talk about those tests a little bit more?

Mark Houston: Yeah. We use ENDOPATH for endothelial dysfunction, and that’s looking at nitric oxide bioavailability. We use a machine called Computerized Arterial Pulse Wave Analysis, and that actually measures the arterial stiffness, both the small arteries, medium-sized and large ones. We have a plasmography, which looks at coronary artery blood flow and cardiovascular function and plaque formation. We have ATCOR, which looks at central arterial pressure, and it’s a arterial elasticity measurement called Augmentation Index. And of course we do ABIs and echoes and carotid duplex and all those things. But with that information, you can really tell somebody their vascular age and what they need.

Evelyne: And is it common for a patient who comes to see you to do all of that testing or is it determined based on their symptoms and maybe some of their lab work or their blood pressure?

Mark Houston: No. We pretty much do this on anybody comes in with hypertension or any sort of vascular disease because unless you get the whole picture, you really don’t know how to treat patients appropriately.

Evelyne: That’s amazing. We need more people specializing in this like you. It’s awesome.

Mark Houston: Well, it’s interesting that the specialty hypertension, there’s not that many in the country actually. I don’t know how many there are exactly. But when I first became certified, I think there were only about 400 or 500 in the whole country.

Evelyne: Wow. And I want to go back a little bit. You mentioned the health of the vessels. I want to talk about what is actually happening with high blood pressure. What is the pathophysiology of hypertension, and then how does that relate to the arteries and then the endothelial glycocalyx?

Mark Houston: The first thing that happens is endothelial dysfunction and glycocalyx dysfunction, and that can precede the onset of hypertension by decades.

Evelyne: Wow.

Mark Houston: That means you lose nitric oxide and you have increased oxidative stress and inflammation in the arteries. And then that leads to initially small artery resistance, and that’s something that’s measured by one of the machines we have. It’s called C2 compliance. And then after the small arteries are very stiff, it starts to transmit disease and stiffness to the medium size and eventually to the large arteries, so the complexity of hypertension is primarily glycocalyx dysfunction, endothelial dysfunction and complexities and arterial compliance of all arterial sizes. But initially the small arteries.

Evelyne: And you said that the endothelial dysfunction happens a decade or decades before, so how do you test for that? Can you test it now so that you could potentially prevent or see if somebody might be prone to developing hypertension in the future?

Mark Houston: Absolutely. And that’s why we do these tests because if we do the ENDOPATH and the pulse wave analysis, we can immediately pick up endothelial dysfunction and arterial compliance stiffness.

Evelyne: Tell me a little bit more about what that means. Arterial compliance stiffness, I don’t know that term.

Mark Houston: All right. Endothelial dysfunction is pretty straightforward. That’s the lining just below the glycocalyx and just before the arterial smooth muscle. All three of those communicate back and forth. And then if the nitric oxide levels get low and you start having inflammation in the artery, the arterial wall gets stiff. A stiff arterial wall means it doesn’t dilate well, so the blood that goes in there creates a higher pressure and eventually the artery becomes more diseased and it can rupture or clot, depending on where it’s located, you can have a stroke or heart attack.

Evelyne: Regarding the endothelial glycocalyx, what are some of the things that you find useful to do either prior to maybe somebody developing hypertension? I don’t know if you see those patients, maybe family members in your office or when somebody already has that dysfunction. What are some of the maybe nutrients, herbs, any kind of supplements that you use or diet and lifestyle?

Mark Houston: If you’re talking about the arterial glycocalyx, the only thing that’s going to work there is glycocalyx replacement. And the only one that I presently use and recommend is Arterosil.

Evelyne: And you were involved in the clinical trials, right? I want to get into that more.

Mark Houston: Yeah. We did Arterosil clinical studies. If you’re talking about endothelial dysfunction, you want to do everything to enhance nitric oxide production and bioavailability, and there’s a lot of ways to do that. But if you look at everything that’s out there, the best nitric oxide bioavailability product is Vascanox.

Evelyne: And you also did a study on that? Sorry, can you repeat that one more time? What’s the first part that you do before the endothelial glycocalyx? What are the two parts?

Mark Houston: The glycocalyx is Arterosil. And the endothelial dysfunction is Vascanox.

Evelyne: And do you recommend for your patients that both are used or does it just depend on the full picture of what’s going on?

Mark Houston: They typically go bad together, so when I see the endothelial dysfunction, I just assume the glycocalyx is also messed up, so we tend to use both of them together.

Evelyne: Got you. Since you did do clinical trials at the Hypertension Institute on both of those, can you tell us about the trials and the results and all of that?

Mark Houston: Yeah. Our first trial was with Arterosil and we placed patients on Arterosil, or a placebo, and then we measured their 24-hour blood pressure, their office pressure, and we also looked at their arterial compliance and their endothelial function. We found that Arterosil lowered blood pressure, it improved endothelial dysfunction, it improved arterial elasticity without any adverse effects, so that was very favorable and we didn’t do this trial, but others have done studies showing that Arterosil actually prevents formation of carotid plaque.

Evelyne: And the trial that you did, how long were patients taking the Arterosil or the placebo?

Mark Houston: I think it was a four-month study. The results were seen pretty quick.

Evelyne: And when you put your own patients on it, is it something that they’re taking forever? Is it something that’s a couple months while you’re doing other things? How do you determine that?

Mark Houston: Once we determine that they have dysfunction with endothelial or with the arterial compliance, I recommend they take it for life.

Evelyne: Wow. Not studies maybe, but you’re seeing so many patients and keeping data, do you have patients who have been on it for a long time and do you see continued improvement or anything else you’ve noticed?

Mark Houston: We’ve got patients that have been on it for years with Arterosil and Vascanox for one year. It’s only been out for one year. But yeah, we’ll say that Arterosil, we’ll see changes in four months usually, and they tend to get better as they’re on it. Their arteries are getting healthier. We see the same thing with Vascanox. We may see that at three months or four months, they’re improving, come back at six or eight months and they’re normal. And then at a year they may be super normal. It gets better and better, meaning the arterial health and nitric oxide levels are getting better with time.

Evelyne: That’s really cool. And what was the trial on Vascanox?

Mark Houston: Vascanox was, again, a small study. I think we used one capsule twice a day and placebo, and we had significant reductions in blood pressure for anybody who was even moderately hypertensive. And the higher the blood pressure, the greater the reduction in blood pressure. Those who had normal tension did not have any reduction in blood pressure, which is very interesting. What that study told us is that if you’re hypertensive by definition, you’re going to get a reduction in blood pressure, significant equivalent to one antihypertensive drug. But if you’re not hypertensive, your blood pressure doesn’t go down, so not like a drug, you’re not going to get hypotensive, so it’s very safe.

Evelyne: That’s really good. And do you still sometimes use things like Arterosil, Vascanox in conjunction with blood pressure medication?

Mark Houston: Absolutely. The combination of those three is very powerful.

Evelyne: And then I’m curious because I don’t know a ton about blood pressure medications in general. I know you have calcium channel blockers, and then you have, what’s the other big one? The main one?

Mark Houston: Well, we have ACE inhibitors, angiotensin receptor blockers, and those are the three that we use the most. They’re the most common. And then there’s one diuretic that we recommend called Indapamide. And then there’s one combination beta blocker called Bystolic that’s pretty good. It raises nitric oxide levels. But a lot of the older drugs, like Hydrochlorothiazide for example, we’re not using that now. And some of the older beta blockers, like Metoprolol, Propranolol, we don’t use those for hypertension either.

Evelyne: And how do some of those work to lower blood pressure? And how do you determine whether you use a beta blocker, calcium channel blocker, or I forgot the other one again. ACE inhibitor.

Mark Houston: Basically you do testing, measuring what’s called plasma renin activity and aldosterone levels, and you then stratify the ability or likelihood for them to respond to one of those classes of drugs. For example, if they’re high renin hypertension, they do better on ACEs and ARBs. If they’re low renin hypertension, they do better on calcium blockers and Indapamide. And by doing that, you don’t have to guess so much. You know exactly what they’re going to respond to. If you do that in conjunction with micronutrient testing to see if they’re deficient in something. And then you also do the different tests we talked about with endothelial dysfunction and arterial stiffness, got a pretty good idea of what they need.

Evelyne: Interesting. And what are some of the other nutrients, aside from the two that we talked about, which are combinations of the different nutrients that you think can be helpful for reducing blood pressure? And I think a lot of our practitioners who listen, some of them do prescribe, but I work with many who don’t prescribe drugs. And I have seen that people can significantly lower blood pressure with certain supplements, but it just depends on the person.

Mark Houston: There’s a lot of supplements that lower blood pressure. If you look in the last book I wrote on hypertension, it’s I think about a year and a half old now, but it’s still very up to date. In there, we go through all the different clinical studies on supplements that work for high blood pressure. I just mentioned a few. Magnesium, coenzyme Q10, lipoic acid, grape seed extract, whey protein. The list is pretty long, but if you use those either by themselves or in conjunction with medication, they do work better when you use them together.

Evelyne: And I’m curious, when you’re using co-Q10, is there a certain amount that you see working better? I don’t know what the research says.

Mark Houston: Yeah. You give whatever dose you need to get the blood level above three.

Evelyne: And then what about magnesium?

Mark Houston: Magnesium, we use a chelated usually like magnesium malate, glycinate, there’s different forms. Typically, about 500 milligrams twice a day.

Evelyne: Wow. Twice a day.

Mark Houston: And you’ve got to measure red cell magnesium because the serum is not accurate for magnesium.

Evelyne: I’m curious, with the micronutrient testing that you’re doing, is that just generally to know what they’re deficient in or is it specific to, say, hypertension or cardiovascular disease that you’re looking at?

Mark Houston: It’s for anything general internal medicine, cardiovascular hypertension. But what’s interesting, if you find deficiencies, and a lot of these nutrients, they relate to arterial health and high blood pressure, so if you replace the deficiencies, the blood pressure actually gets better.

Evelyne: Just without changing other things?

Mark Houston: Yeah. For example, if they were mildly hypertensive and severely low in magnesium, sometimes giving them high dose of magnesium, it’ll bring their blood pressure back to normal. Same thing with co-Q10.

Evelyne: I want to go back to the nitric oxide production. I feel like there’s just so much more to talk about there. How does nitric oxide production relate to the health of our endothelial lining?

Mark Houston: Nitric oxide is a antihypertensive, it’s an anti-atherosclerotic. It reduces arterial inflammation, oxidative stress and balances the immune system, reduces growth. It does all the good things you want it to do, and that improves your arterial health and reduces strokes and heart attacks, heart failure, renal failure, so unless you have a really good nitric oxide level, you’re at higher risk for having some sort of vascular problem in the future.

Evelyne: And how do you measure nitric oxide production?

Mark Houston: There’s a lot of ways you can do it. You have the little sticks you can put in your mouth, and that measures it immediately within two seconds or so. You can measure blood tests with what’s called a symmetric dimethyl arginine, ADMA. And that’s done through Cleveland Heart Lab, which is part of Quest. And then the tests that we have, as I mentioned earlier, the ENDOPATH and the pulse wave analysis indirectly measure nitric oxide levels, so if you do all three of those, you’ve got a pretty good handle on it.

Evelyne: And is it common for people to have low nitric oxide because of certain things like bad diet, lifestyle? Is it something that decreases as we age?

Mark Houston: Yeah. All of the above. Bad diet, not eating lots of dark green leafy vegetables, aging, certain drugs you take, smoking, high cholesterol, high homocysteine, diabetes. The list goes on and on that things that lower nitric oxide, so it’s very common to have low NO levels in patients.

Evelyne: And what are some of the things physically that people notice once you boost that nitric oxide production?

Mark Houston: They get more energy. They’ll notice improvement in their mental function. They can exercise better. Their blood pressure tends to get better, they’ll have better profusion. For example, if they have something called Raynaud’s phenomena where their blood flow to their fingers, gets a little bit decreased, it’ll dilate the arteries and warm them up a bit.

Evelyne: Just like last time I interviewed Mark 10 years ago, I had an episode of Raynaud’s, and you can actually see my gray hands in that video. What about nitric oxide for low blood pressure? Could it also boost blood pressure if somebody needs that?

Mark Houston: No, it won’t do that. If your pressure’s low, there’s other reasons for it, but nitric oxide doesn’t typically help low blood pressures.

Evelyne: But is it harmful in low blood pressure or no?

Mark Houston: Well, our study indicated that it didn’t do that because when we had patients who had normal blood pressure taking Vascanox, their pressure didn’t drop at all, so you want to be careful, don’t get me wrong, but if you have low blood pressure and you’re dehydrated and sweating a lot, you have to be careful taking anything that raises nitric oxide because it might lower your blood pressure.

Evelyne: Interesting. Thank you for clarifying that. I feel like there are always caveats because you’re telling me that the NO is good for my Raynaud’s, but then I don’t want to lower my blood pressure more.

Mark Houston: I don’t think that you would notice any reduction in your blood pressure. You might want to start out with a low dose and make sure you’re hydrated. I noticed you’re drinking a lot there, so that’s good. Make sure it doesn’t drop too much.

Evelyne: Let’s get into diet and lifestyle a little bit, diet and then stress specifically. In regards to diet, what do you recommend to most of your patients?

Mark Houston: We have rewritten the most effective antihypertensive diet. And it’s actually in the hypertension book that I wrote, which by the way, you can get on Amazon. And there’s two chapters in there on nutrition and hypertension. What we did, we took the science of the Mediterranean diet, the science of the dash two diet and others, and made it very low in sodium, very high potassium, high in protein, low in refined carbohydrates, low in saturated fats, low in trans fats. But in the book, it’s easy to follow because we give you the guidelines, but also lots of recipes that are quite tasty. And the diet you’re going to love, the name we call their diet, it’s called HIP.

Evelyne: Nice.

Mark Houston: It’s the HIP diet. We thought people if they do you want to do a HIP diet, they’d really jump all over this. I want to do the hip. But it stands for Hypertension Institute Program.

Evelyne: And is it plant-based? Is there meat on it? I know meat is controversial when it comes to cardiovascular disease.

Mark Houston: Actually, that’s a misconception about meat and hypertension. What you really want to know about hypertension in meat is pretty simple. Avoid processed meat. That will raise your blood pressure. Avoid meat that’s primarily from areas where the cattle or the whatever, the chickens are fed corn and they’re pesticides and ides and all kinds of other things, hormones. That’s not good meat. What you want is organic meat. You want farm raised chickens and turkeys if you can get them and get fresh salmon and tuna, get all the good stuff, but avoid the artificial thing, so if you do that, meat is actually good for blood pressure, actually lowers blood pressure.

Evelyne: Interesting. And since you mentioned fish, do you use fish oil as well?

Mark Houston: We use omega three fatty acids, yes. And typically the dose would depend on what you’re treating. It can be anywhere from a thousand to 5,000 milligrams a day.

Evelyne: And is there a certain ratio of EPA to DHA that you prefer for hypertension that works better?

Mark Houston: Typically, we like a ratio of three to two of EPA to DHA.

Evelyne: Interesting. And I want to talk about, since we’re talking about diet, salt, so I heard you mention low sodium, and there’s a resurgence right now, I guess in our field, of we all need enough salt, we need electrolytes. I see a lot of electrolyte formulas with very high sodium content, and I know that we want to keep it balanced, but what are your thoughts on that? Is that dangerous for hypertension? Will that lead to hypertension?

Mark Houston: Let’s clarify what salt means. There are all kinds of salts. You have sodium chloride salt, potassium chloride salt, magnesium chloride salt and Himalayan salt and sea salt, all these different salts. Related to blood pressure, what you don’t want is sodium chloride. That does increase blood pressure, causes arterial elasticity issues, heart disease, heart failure, kidney problems, proteinuria. Sodium chloride, you need to limit to 1.5 grams a day. That’s hard to do because most foods contain probably 70% of your sodium chloride. You’ve got to look at labels and you want to increase potassium and magnesium salt. That’s easy to do. You could buy K-Mag salts. You’ve got potassium chloride over the counter. It’s called NoSalt, and get your potassium and chloride high. Excuse me, get your potassium magnesium high, so your ratio of potassium and magnesium to sodium is higher than it normally would be in a typical American diet.

Evelyne: And we’re talking now about treating hypertension, but will following a higher sodium chloride diet lead to hypertension?

Mark Houston: Yes. There’s been clinical studies that show if you increase sodium chloride in your diet at a young age, you’re more likely to get hypertension. And if you decrease sodium chloride at a young age, you have a better likelihood of preventing hypertension. And you couple that with high potassium and high magnesium intake, it works even better.

Evelyne: Interesting. Thank you for sharing that. I want to switch topics a little bit, or no, sorry. I want to finish up the diet and lifestyle conversation. With the causes of high blood pressure, is it always stress, whether it’s mental stress or physical stress from inflammation, or are there other things related to it that are not stress related?

Mark Houston: 90% of hypertension is genetic.

Evelyne: 90%. Wow.

Mark Houston: 90%. And they’re genes that we measure for hypertension, so that helps in your treatment. We also know that 10% have secondary causes, and that can include a lot of different things like renal artery stenosis, primary aldosteronism, pheochromocytoma and other things. But stress by itself can cause hypertension and it will exacerbate preexisting hypertension. Mental stress increases norepinephrine levels, cortisol levels. I can see people coming in with normal pressure and then something happens and they come in, they’ve had a parent die or child die, or the IRS is investigating them or something, and their pressure can be extremely high just from anxiety related to that.

Evelyne: And is that part of what you address in your program at the Hypertension Institute?

Mark Houston: Right. We have a whole program to help reduce stress and also address that in the book as well.

Evelyne: Great.

Mark Houston: One of the best ways to reduce stress is exercise.

Evelyne: Oh, I was going to ask about that too. With exercise, what do you recommend? Do you recommend doing cardio walking? Do you recommend high intensity interval training, like maybe sprints? Do you recommend weight training, a combination? Has that been studied specifically for hypertension what exercise is best?

Mark Houston: The first thing you do when you have a patient with hypertension and you want to recommend an exercise program, you’ve got to get their blood pressure controlled first. Then you’ve got to do a stress test to make sure their heart’s okay. And then you recommend a specific program in exercise that’s graduated, start them slow, build up over several months. We use a combination of aerobic and resistance training. And again, in the book on hypertension, sounds like I’m plugging my book.

Evelyne: Little bit.

Mark Houston: We have two chapters on exercise, so you can read that and tells you exactly what to do. The name of the program we have developed, it’s called ABCT Aerobics Bill Contour and Tone. And it’s designed from being a couch potato all the way up to being an Olympic athlete. A one is low end, a five is extremely elite athlete. And you do 40 minutes of resistance training and 20 minutes of aerobic training daily, preferably five days a week, six days a week, take one day off.

Evelyne: That’s a hefty exercise program.

Mark Houston: It is.

Evelyne: Wow.

Mark Houston: But it works. And the data shows that if you do this program, your blood pressure will drop an average of 12 over six once you’re trained.

Evelyne: What about just walking? Does that help reduce?

Mark Houston: Any exercise helps. The more you do, the better your blood pressure’s going to be, but any amount you do will help.

Evelyne: You brought up genetics earlier. 90% of hypertension is genetic. If your parents have hypertension or grandparents, are you automatically doomed? What can you do?

Mark Houston: Pretty much, yeah. If you’ve got one parent, it’s probably 25 to 40%. If you have two parents, it’s maybe 50 to 75% risk.

Evelyne: How much of that though is related to lifestyle? Because if you grow up in the same household, and all those diet and lifestyle factors are the same, then how much of it’s actually genetic versus food or other things?

Mark Houston: It’s a very important point. It’s called gene environmental interaction. And what you’re asking is a very important question. And what it means is that you can turn your hypertension genes on or off depending on your environment, what you eat, for example, your stress level, your exercise program, your weight, et cetera. If you had, let’s say, identical twins, and they’re going to have the same genes, obviously, and one twin follows everything correctly, and the other twin does everything totally inappropriate, that means that the gene expression is going to be different in those two twins. The one who has the good environment will less likely get hypertensive compared to the other one who will definitely get it.

Evelyne: There’s a lot we can do. And I feel like for any practitioner listening, it’s important to look at these, especially because hypertension is so prevalent. I want to talk about the oral microbiome. Totally switching gears here, but what is the connection between our oral health and our blood pressure or cardiovascular health?

Mark Houston: Well, it’s not only oral, but also the rest of the gut as well. For example, if your oral flora are destroyed by mouthwash, for example, your nitric oxide levels drop because the microbiome cannot make good nitric oxide levels. It’s a very complicated pathway, but periodontal disease, mouthwash, dental problems in general, bad diet, low dark green, leafy vegetables, all those things can contribute to bad oral microbiome. And then you add to that your gut microbiome, so that’s related to hypertension as well through a lot of different factors. And you need prebiotics and probiotics and stay off PPIs and H2 blockers and things that drop acid production because that will affect your nitric oxide production as well.

Evelyne: And is the oral microbiome something you test in people?

Mark Houston: Well, you can use the nitric oxide strips, and that will tell you if your nitric oxide levels are low. That’s not just the oral microbiome. It can be just general, but you can ask people questions about what they’re doing and you can figure out their oral microbiome may be a problem.

Evelyne: But you’re not testing which bacteria are present, or if there are any pathogenic bacteria in the mouth?

Mark Houston: You can easily do that. If you’re seeing an integrative dentist, they can actually measure all those bacteria in your mouth. And then you can also do gut packs to measure the bacteria in your GI tract.

Evelyne: I feel like we need more dentists in our field.

Mark Houston: Well, that’s true. We have used some really good dentists in our programs at A4M to talk about the microbiome and heart disease and high blood pressure, and they do totally different things than a typical dentist would do.

Evelyne: That’s awesome. I want to ask you something also random. I heard you talking about this on another podcast about iron. I haven’t talked on this podcast about hemochromatosis, though I’d love to do a whole show on it because I am heterozygous for it. I’ve known this since I was in college, and I know that having high levels of iron basically rust you from the inside out. It’s not good for your cardiovascular health. It’s not good for any of your organs. I’m curious, what is the relationship between iron and cardiovascular health and where do you like to see levels? And is this something you’ve tested people routinely?

Mark Houston: We test everybody who comes in the office for iron. It’s frequently missed. Hemochromatosis occurs in 20% of the population.

Evelyne: I didn’t even know it was that high.

Mark Houston: Elevated iron causes an increase in heart attack and coronary heart disease. Constriction of the coronary arteries, probably also a little bit in stroke. And the way it does it is that iron’s an oxidative stress catalyst, there are probably other things that will, but that causes arteries to become very unhealthy. And you can measure iron, ferritin and TIBC. That’s what you need to measure and get the ferritin level at 80. That’s the level at which there’s low risk for heart disease, but also enough iron to maintain your good metabolic function.

Evelyne: And have you noticed any correlations in people who are, say, homozygous versus heterozygous for hemochromatosis? Just curious.

Mark Houston: Well, the homozygous patients typically have very high iron, and they occur in phlebotomy. Those have the highest risk. Heterozygotes may have high iron, but they may not, so you just have to measure and see, even though you have the gene, sometimes your iron levels are not particularly high.

Evelyne: Mine have been up and down over time, but I’d love to do a podcast in the future on hemochromatosis because I know there are definitely things that I can do to make sure my levels don’t go too high. Mark, what are some things that you are excited about in the field of integrative and functional cardiology?

Mark Houston: Well, if you look into the future, what’s going to come along is going to totally change cardiovascular medicine and hypertension. I would say number one is going to be genetic therapies where you literally can go in and change a gene’s expression, which would change your risk for a specific disease. Then you have stem cell therapies, which is really moving quickly. You have, of course, peptides, which you can get easily now. We have some different drug delivery systems, nano-particles, for example, for hypertension, heart disease where a drug gets in better and lasts longer, causes less side effects. And there’s a lot of things related to vaccinations, actually, where they’re looking at vaccines, for example, for hypertension, vaccines for heart disease. And there’s a lot of new drugs that alter micro RNA and messenger RNA, that we already have on the market. For example, for cholesterol, we have one new drug, it’s called Inclisiran, which you take twice a year.

Evelyne: Wow. Interesting.

Mark Houston: It’s injectable. And that controls your blood cholesterol. Drops your LDL, about 50 to 60%.

Evelyne: Wow.

Mark Houston: And we’re developing other micro RNA drugs for everything, for heart disease, for hypertension, lipids, and probably eventually diabetes.

Evelyne: I’m curious. The stem cells caught my ears or eyes. I know that people use stem cells for joint regeneration. Tell me a little bit more about how you’d use stem cells in cardiology.

Mark Houston: There’s different ways to get stem cells, the mesenchymal stem cells from fat tissue and stem cells from bone marrow, and you grow those stem cells in culture, so you get huge numbers, 150, 200 million stem cells, and you can inject those directly into a joint to grow cartilage. You can give them intravenously to help your arterial health. You can’t do it yet in the United States unless there’s research areas doing them. But in some of the Caribbean countries and European countries, they actually do stem cell therapy directly into coronary arteries to regrow blockages and stuff. Also, heart failure. You can use stem cells for just about anything. You just have to know where to inject them and how to do it and have the best stem cell production.

Evelyne: Very interesting. Speaking of interesting things, there are three questions that I love to ask every guest on our show. And the first one is, what is something that you’ve changed your mind about through all of your years in practice?

Mark Houston: The most life-changing thing for me was when I switched from doing just traditional drug related medicine to integrated cardiovascular medicine where I incorporated everything that worked. Drugs, nutrition, supplements, lifestyle like exercise and so forth.

Evelyne: I’m curious. In Nashville where you work, are other doctors following your lead? I know obviously you and I are surrounded by practitioners who already do all this stuff, but in conventional medicine, are people like, “Oh, he’s doing something that works. Maybe I should do that too?”

Mark Houston: I think it’s catching on here. It’s been slow, but there are a lot of integrative functional medicine physicians in Nashville. I’m not sure there’s any other integrative cardiologists that I know about in this area, but for general medicine, yeah. But I think that people are beginning to recognize the importance of that, and they’re going to hopefully learn about it and go back to school and get educated.

Evelyne: And it’s encouraging too, because patients are asking for it.

Mark Houston: They are.

Evelyne: Mark, what are your three favorite supplements?

Mark Houston: Omega three fatty acids, coenzyme Q-10, and probably magnesium.

Evelyne: Nice. The basics. And since you are so busy with all of the things that you’re doing, what are some of your health practices that you do to keep yourself balanced and sane?

Mark Houston: Well, I exercise an hour every day before I go to work.

Evelyne: Wow.

Mark Houston: I actually have a gym in my house, so I don’t have an excuse. I got one. I couldn’t make it to the gym today. It’s right there. Second, I get at least eight hours of sleep. I don’t care what’s going on. I try to get good eight hours of sleep. I follow the best nutrition program I can, which is basically what I mentioned earlier. It’s in the book, stress reduction, deep breathing exercises, meditation, that kind of stuff, and maintaining ideal body composition, body fat, muscle mass.

Evelyne: I love it. You definitely have all the foundational things in place to practice what you preach.

Mark Houston: And then you have to find out if all that’s working, so you do a Guinea pig check every three months on your blood and see what’s going on.

Evelyne: And everything’s good?

Mark Houston: Everything’s good.

Evelyne: Awesome. Well, thank you so much, Mark. I really appreciate having this conversation with you today, all of your expertise and just everything that you have done for the fields of integrative and functional medicine. It’s been awesome having you on today.

Mark Houston: Thank you. It’s been a pleasure getting back with you too, Evelyne. Good luck to you.

Evelyne: Thank you. Thank you for tuning into Conversations for Health. Check out the show notes for resources from our conversation today, including Mark’s book. Please share this podcast with your colleagues. Follow, rate or leave a review wherever you listen. And thank you for designing the well world with us.

Voiceover: This is Conversations for Health with Evelyne Lambrecht, dedicated to engaging discussions with industry experts, exploring evidence-based, cutting edge research and practical tips.

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