Meditate on This: Hypertension

By Yoon Hang "John" Kim, MD, MPH, and Dorothy Carey, MEd, RN. Dr. Kim is Director of Georgia Integrative Medicine in Tyrone, GA; Ms. Carey is an intern at Georgia Integrative Medicine; they report no financial relationship to this field of study.

For more than a decade, organizations like the american Heart Association (AHA) and the Centers for Disease Control and Prevention (CDC) have been drawing attention to the prevalence and effects of cardiovascular disease (CVD) among women. In fact, February brings two annual awareness programs: The AHA's Go Red for Women campaign begins February 1st with National Wear Red Day and the CDC has designated February as American Heart Month.

Although CVD is the leading cause of death in women and kills more women than men each year, a 2003 survey by the AHA revealed that only 13% of women identified heart disease and stroke as the most significant health risks to women.1 The importance of raising awareness of CVD in women is magnified by the fact that age is a risk factor for CVD and the number of American women age 50 and older is increasing; in 2003, this group topped 45 million.1

With the average lifetime risk of CVD in women approaching one in two, awareness and prevention interventions are paramount.2 Hypertension is one aspect of primary intervention that warrants clinical attention—not only do more than 30% of women have hypertension (and this jumps to more than 43% of African-American women), one-third of women with hypertension are not aware of it.3

Meditation has been studied clinically for nearly 40 years and has shown positive results in the realm of CVD, especially with regard to hypertension. The role meditation can play in a multifactorial CVD prevention strategy is the focus of this review.

Meditation

Meditation has been practiced for more than 5,000 years.4 Meditation is a practice by which one can explore beyond the conditioned thinking mind through deeper states of relaxation or awareness.5 Most forms of meditation originated from ancient religious and spiritual traditions. However, there has been an increased effort to create a secularized experience of meditation focusing on the health benefits with less emphasis on the religious or mystic teachings. Two such examples that developed in academic health care centers include Herbert Benson's Relaxation Response and Jon Kabat-Zinn's Mindfulness-based Stress Reduction.

It is estimated that more than 10 million people practice meditation in the United States.4 A commonality of many meditation practices is often a focus on breath and awareness into a single point of reference. Meditation has been defined as "self regulation of attention, in the service of self-inquiry, in the here and now."6

The two major classifications of meditation are mindfulness meditation and concentrative meditation. Mindfulness meditation focuses on present awareness of perception and experience in a non-judgmental frame of mind. Examples of mindfulness meditation include Vipassana, Zen Meditation, and Mindfulness-based Stress Reduction (MBSR).

In contrast to the mindfulness meditation where there is an open focus on observation of present awareness of being, in concentration meditation the awareness is focused on a particular object (e.g., a repetitive prayer, sound, or breath) while minimizing distractions and bringing the mind back to concentrate on the chosen object.7 Examples of concentrative meditation include Transcendental Meditation and Relaxation Response.

In practice, the lines can blur as many mindfulness meditations utilize breath as an anchoring tool to focus the present awareness on the here and now and use the awareness for observing without judgment.

Transcendental Meditation

Transcendental Meditation, or TM, is the trademarked name of a meditation technique introduced in 1958 by Maharishi Mahesh Yogi (1917-2008). Research studies have described specific physiological effects that occur during the practice of the TM. Results from the first of these studies were published in the early 1970s, in Science, American Journal of Physiology, and Scientific American.8-10 This research found that TM produced a physiological state that the researchers called a "wakeful hypometabolic state." During the practice of the technique the researchers found significant reductions in respiration, minute ventilation, tidal volume, blood lactate, and significant increases in basal skin resistance, while EEG measurements showed increased coherence and integration of brain functioning.11

In 2004, Walton et al published a review paper on the study of controlled research on TM and cardiovascular disease.12 The results showed a benefit of TM for reduction of cardiovascular diseases through the following mechanisms: 1) decreases in blood pressure, 2) reduced use of tobacco and alcohol, 3) lowering of high cholesterol and lipid oxidation, and 4) decreased psychosocial stress.

However, in 2004, Canter and Ernst published findings of a systematic review of randomized clinical trials concluding that there was insufficient evidence to conclude whether TM decreased blood pressure.13 The seemingly contradictory conclusion was due to the methodological weaknesses of the existing studies. The authors also noted the potential bias due to the authors' affiliation with TM.

In 2005, Schneider et al published a review of two studies that looked at stress reduction with the TM technique and mortality among patients receiving treatment for high blood pressure.14 This long-term, randomized trial evaluated the death rates of 202 men and women, average age 71, with mildly elevated blood pressure. The study tracked subjects for up to 18 years and found that the group practicing TM had death rates that were reduced by 23%.

Also in 2005, Schneider published the results of a randomized controlled trial of stress reduction for treating hypertension. The conclusion of the study found that TM may be useful as an adjunct in the long-term treatment of hypertension among African Americans.15

In 2006, Paul-Labrador et al published the results of a randomized controlled trial investigating the effect of TM on metabolic syndrome in coronary artery disease.16 The authors concluded that the practice of TM for 16 weeks resulted in improved blood pressure and insulin resistance components of the metabolic syndrome as well as cardiac autonomic nervous system tone compared with a control group receiving health education.

Helping Patients Control Blood Pressure

Approximately one in three american adults has hypertension, or high blood pressure, which increases one's chance for developing heart disease, a stroke, and other serious conditions. Often called the "silent killer," hypertension usually has no noticeable warning signs or symptoms, so many people do not know they have it. Fortunately, high blood pressure is easily detectable and usually can be controlled. Maintaining a healthy blood pressure is an important public health strategy.1

The Center for Disease Control and Prevention outlines several steps people can take to help maintain a healthy blood pressure.2

• Maintain a healthy weight. Being overweight or obese (BMI ≥ 25 kg/m2) can raise blood pressure, and losing weight can help you lower your blood pressure. Following a healthy diet and regular physical activity can help to maintain a healthy weight (BMI, 18-24.9 kg/m2).

• Be physically active. The Surgeon General recommends that adults engage in moderate-level physical activities for at least 30 minutes on most days of the week.

• Follow a healthy diet. Eating a healthy diet—including eating fresh fruits and vegetables, increasing potassium, and reducing sodium—can help maintain healthy blood pressure levels. The Dietary Approaches to Stop Hypertension (DASH) trial showed that diet can significantly lower blood pressure.

• Limit alcohol use. Excessive alcohol consumption is related to increased blood pressure. Current dietary guidelines define moderate drinking for women as an average of one drink or less per day.

• Prevent and control diabetes. Diabetics have a higher risk of high blood pressure. Recent studies suggest that healthy diet, weight loss, and regular physical activity can help reduce the risk of developing diabetes.

• Stop smoking. Smoking, a major risk for heart disease and stroke, damages blood vessels and leads to hardening of the arteries.

The best weapons for fighting heart disease are a healthy diet and lifestyle.3 When making food choices, it is important to consider American Heart Association recommendations:

• Lower LDL cholesterol. Limit saturated fat and trans fat, usually found in meat, dairy products, and commercially baked and fried foods. Cutting back on foods containing partially hydrogenated vegetable oils will help reduce trans fats in the diet.

• Choose lean meats and poultry without skin. Cuts that are labeled "loin" and "round" usually have the least amount of fat.

• Limit intake of whole-fat dairy products. Instead select fat-free, 1% fat, and low-fat dairy foods.

• Cut back on food and beverages that contain added sugars. This includes beverages containing sucrose, glucose, fructose, maltose, dextrose, corn syrups, high-fructose corn syrup, concentrated fruit juice, and honey. Try to choose items that don't list added sugars in their first four ingredients.

• Limit salt intake to less than 1,500 mg/day. Foods low in salt lower the risk for high blood pressure.4

Sources

1. Centers for Disease Control and Prevention. High blood pressure. Available at: www.cdc.gov/bloodpressure. Accessed Jan. 9, 2009.

2. Centers for Disease Control and Prevention. Preventing and controlling blood pressure. Available at: www.cdc.gov/bloodpressure/prevention.htm. Accessed Jan. 9, 2009.

3. Centers for Disease Control and Prevention. CDC Features. Healthy lifestyle: Diet and nutrition, exercise and fitness. Available at: www.cdc.gov/Features/HeartMonth/. Accessed Jan. 9, 2009.

4. American Heart Association. Eat less of the nutrient-poor foods. Available at: www.americanheart.org/presenter.jhtml?identifier=3040349. Accessed Jan. 9, 2009.

Anderson et al published the finding of a meta-analysis of blood pressure response to TM in 2008.17 This study was performed by an independent institution without affiliation to TM. The study pooled results of randomized, controlled trials comparing blood pressure responses to TM. Primary outcome measures were changes in systolic and diastolic blood pressure after practicing TM or following control procedures. The authors concluded that the regular practice of TM may have the potential to reduce systolic and diastolic blood pressure by approximately 4.7 and 3.2 mm Hg, respectively.

Relaxation Training

In 2008, Dickinson et al published the findings of a systematic review on the use of relaxation therapies for the management of primary hypertension in adults.18 The authors reviewed 29 randomized clinical trials meeting the inclusion criteria. The results showed that relaxation therapies resulted in small, statistically significant reductions; the relaxation therapies may have the potential to reduce systolic and diastolic blood pressure by approximately 5.5 and 3.5 mm Hg, respectively. This result is similar to the meta-analysis performed by Anderson et al, which focused on the effect of TM on blood pressure reduction.

Mindfulness Meditation

Vipassana, or observation meditation, is considered the form of meditation practiced by the Buddha more than 2,500 years ago.19 Vipassana is the oldest of the Buddhist meditation techniques that include Zen and Tibetan Tantra.20 The goal of Vipassana is said to be the understanding of the true nature of impermanence, suffering, and non-existence. According to the tenets of Vipassana, practitioners can obtain sensitivity, receptivity, and objectivity of their perceptions and thoughts without emotional attachments.

Zen meditation is a form of Buddhist meditation that emphasizes the acquisition of experiential wisdom in the present awareness drawing on both the conscious and unconscious mind. As such, it de-emphasizes both theoretical knowledge and the study of religious texts in favor of direct, experiential realization through meditation and dharma practice.21 This form of Buddhist practice developed in China and became popular in Korea, Japan, and Vietnam.

Mindfulness-based Stress Reduction emerged in 1979 as a way to teach the essence of Zen Buddhist meditation without the religious doctrine, enabling this approach to reach a broader audience especially in health care settings.22 Originally developed by Jon Kabat-Zinn at the University of Massachusetts Medical Center, the MBSR program was a group- based program designed to treat patients with chronic pain.23 Since then, mindfulness meditation has been taught to people for coping with stress, anxiety, and illness.

In 1998, Kabat-Zinn published the results of a landmark study demonstrating the effectiveness of MBSR for improving rates of skin clearing in patients with psoriasis undergoing phototherapy.24 Since the study, more broad applications for MBSR have been explored.

In 2004, Grossman et al published the results of a meta-analysis on the health benefits of MBSR. The authors included 20 studies that met the inclusion criteria looking at a wide spectrum of clinic conditions including pain, cancer, heart disease, depression, and anxiety.25 The authors concluded that MBSR has a beneficial role for individuals in coping with their illness. The wide diversity of conditions and the small numbers of studies included make it difficult to draw specific comparisons.

Conclusion

There is compelling evidence for the inclusion of concentrative meditation (TM or Relaxation Response) in a comprehensive approach to lowering high blood pressure. The health benefits of lowering blood pressure appear to be similar for TM and Relaxation Response. At this time, systematic reviews do not show benefit from MBSR; however, many of these reviews show quality of life improvements.

Recommendation

Meditation is a popular self-care, mind-body technique. Meditation is relatively safe and offers many benefits for improving quality of life. For reduction of blood pressure, the evidence-based recommendation is to use a form of concentrative meditation such as TM or Relaxation Response.

References

1. American Heart Association. Facts about women and heart disease. Available at: www.americanheart.org/presenter.jhtml?identifier=2876. Accessed Jan. 9, 2009.

2. Lloyd-Jones DM, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation 2006;113:791-798.

3. Centers for Disease Control and Prevention. High blood pressure facts. Available at: www.cdc.gov/bloodpressure/facts.htm. Accessed Jan. 9, 2009.

4. Abbey SE. Mindfulness based stress reduction for oncology patients. Psychooncology 1999;8:53.

5. Tart C. Adapting Eastern spiritual teachings to Western culture. J Transpersonal Psychol 1990; 22:149-165.

6. Astin JA. Stress Reduction through mindfulness meditation. Effects of psychosocial symptomatology, sense of control, and spiritual experiences. Psychother Psychosom 1997;66:97-106.

7. Perez-De-Albeniz A, Holmes J. Meditation: Concepts, effects and uses in therapy. International Journal of Psychotherapy 2000;5:49-59.

8. Wallace RK. Physiological effects of transcendental meditation. Science 1970;167:1751-1754.

9. Wallace RK, et al. A wakeful hypometabolic physiologic state. Am J Physiol 1971;221:795-799.

10. Wallace RK. The physiology of meditation. Scientific American 1972;226:84-90.

11. Dillbeck MC, Bronson EC. Short-term longitudinal effects of the transcendental meditation technique on EEG power and coherence. Int J Neurosci 1981; 14:147-151.

12. Walton KG, et al. Review of controlled research on the transcendental meditation program and cardiovascular disease. Risk factors, morbidity, and mortality. Cardiol Rev 2004;12:262-266.

13. Canter PH, Ernst E. Insufficient evidence to conclude whether or not Transcendental Meditation decreases blood pressure: Results of a systematic review of randomized clinical trials. J Hypertens 2004;22: 2049-2054.

14. Schneider RH, et al. Long-term effects of stress reduction on mortality in persons ≥ 55 years of age with systemic hypertension. Am J Cardiol 2005;95: 1060-1064.

15. Schneider RH. A randomized controlled trial of stress reduction in African Americans treated for hypertension for over one year. Am J Hypertens 2005;18:88-98.

16. Paul-Labrador M, et al. Effects of a randomized controlled trial of transcendental meditation on components of the metabolic syndrome in subjects with coronary heart disease. Arch Intern Med 2006;166: 1218-1224.

17. Anderson JW, et al. Blood pressure response to transcendental meditation: A meta-analysis. Am J Hypertens 2008;21:310-316.

18. Dickinson HO, et al. Relaxation therapies for the management of primary hypertension in adults. Cochrane Database Syst Rev 2008;(1):CD004935; doi: 10.1002/14651858.CD004935.pub2.

19. Brown KW, Ryan RM. The benefits of being present: Mindfulness and its role in psychological well-being. J Pers Soc Psychol 2003;84:822-848.

20. Brown DP, Engler J. The stages of mindfulness meditation. J Transpersonal Psychol 1980;12:143-192.

21. Suzuki DT. Essays in Zen Buddhism. New York: Grove Press; 1949.

22. University of Massachusetts Medical School. Available at: www.umassmed.edu/content.aspx?id=41252. Accessed Jan. 9, 2009.

23. Kim YH. Mindfulness meditation and chronic pain. Altern Med Alert 2004;7:33-35.

24. Kabat-Zinn J, et al. Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychosomat Med 1998; 60:625-632.

25. Grossman P, et al. Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res 2004;57:35-43.