This is Your Wake Up Call

Precursors to hypertension, diabetes, and osteoporosis don't have to turn info full-blown disease. Here's how to stay healthy.
By James Keough

Not so long ago, you either had high blood pressure or you didn’t. Your blood pressure could even flirt with the high normal range without anyone getting overly worked up about it. The same held true for elevated-but-still-normal blood sugar levels. But all that changed over a 10-year period as the medical profession established new benchmarks and reclassified the old “normal” as “preconditions.”

For blood pressure, that happened in 2003. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) set guidelines for pre-hypertension by defining normal blood pressure as less than 120/80 and setting the optimal level at 115/75. That same year, the term pre-diabetes gained new meaning and considerable traction when then-Health Secretary Tommy Thompson used it to warn Americans of their high risk of developing diabetes. Ten years earlier a committee hosted by the World Health Organization had established bone mineral density readings as the new measure for osteoporosis and at the same time created a new precursor called osteopenia.

At first blush, the concept of preconditions makes perfect sense. If you have a disease like diabetes, then ipso facto, at some point prior to your diagnosis your blood sugar levels became pre-diabetic—not in the sense of “before” diabetes, but rather as in “leading up to” the disease. And theoretically, once you learned that, you and your doctor could take action to make those levels normal again and thus prevent the onset of the disease. And in an ideal—and perhaps less complicated—world that’s what would happen.

The value of a precondition
When asked about the value of reclassifying “high-normal blood pressure” as pre-hypertension, a doctor joked that previously the only thing his patients heard when he used the old term was “Hi, your blood pressure is normal.” For him—and for a good deal of the medical profession—the new precondition underscores the seriousness of the situation for patients. How bad is it? Studies show that compared to people who have normal blood pressure, those with pre-hypertension (120/80 to 139/89) have three and a half times the risk of heart attack and more than one and a half times the risk of coronary artery disease. Other studies have shown that starting at the new optimal level (115/75), the risk of heart attack doubles with each 20-point increase in systolic blood pressure (the top number) or 10-point increase in diastolic blood pressure (the bottom number). Pre-hypertensives also face a vastly increased risk of developing high blood pressure. The Framingham Heart Study found that within four years of baseline testing, 39 to 53 percent of people with high-normal blood pressure (the top half of the current pre-hypertension range) progressed to stage 1 hypertension.

These are not good odds—and they get worse the older you are when first diagnosed with pre-hypertension and the longer you have it. But progressing from precondition to disease doesn’t have to be inevitable, and the medical societies stress that people with a precondition do not have the disorder. More importantly you can make lifestyle changes that can lower blood pressure and move you away from hypertension.

The same holds true for pre-diabetes. Studies have shown that some pre-diabetics already have the beginnings of microvascular damage—one of the characteristic effects of diabetes—and that about 10 percent of them will progress to type-2 diabetes every year. On an individual level, research shows that 44 percent of the people in the upper half of the pre-diabetes range (fasting glucose levels between 110 and 126 mg/ dl) become type-2 diabetics. Type-2 has strong links to heart disease and can lead to blindness, kidney failure, and severe circulatory problems that can require the amputation of limbs.

It’s all about lifestyle
Once again, though, lifestyle changes can head you in the opposite direction. Two studies, one in Finland (known as Mr. Fit) and one in the US, found that lifestyle intervention produced a 58 percent reduction in the progression to diabetes. The changes consisted of losing weight by 5 percent, cutting fat to 30 percent of total calories (and saturated fats to 10 percent), and getting more than 150 minutes of moderate exercise a week. The US study, the Dietary Prevention Program, found that those same lifestyle changes reduced the onset of diabetes nearly twice as well as the popular diabetic drug metformin. Using the same data as the DPP, a later study found that a lifestyle change program could delay the onset of diabetes by 11 years and lower the risk of progressing to the disease by 20 percent. In comparison, twice daily doses of metformin delayed onset by three years and overall risk by 8 percent.

All three of the big medical associations, the American Society of Hypertension, the American Diabetes Association, and The National Osteoporosis Foundation, recommend changing the lifestyle risk factors associated with their respective preconditions. For pre-hypertension and pre-diabetes that means losing weight, getting more exercise, eating a healthier diet (and perhaps augmenting it with supplements), and cleaning up your bad habits—quit smoking and drink alcohol in moderation. Weight is not usually an issue with osteopenia unless someone loses too much of it. To stave off the condition, eat bone-friendly foods, get regular weight-bearing exercise, take supplements (specifically vitamins C and D), and try to eliminate risk factors such as smoking, excessive alcohol consumption, caffeine, stress, and certain pharmaceuticals like steroids (Prednisone) and proton pump inhibitors (Nexium, Prevacid, or Prilosec).

The other side of the coin
The concept of preconditions is more than just the proverbial warning shot across the bow, however. Like it or not, all three of these preconditions extend the shadow of the disease itself over people recently thought of as healthy or even normal. And that has some unexpected consequences. One study found that patients labeled as hypertensive miss more days of work, report more marital discord, rate their health and their quality of life lower, and take longer to recover from unrelated acute illnesses. Arguably that makes them less healthy.

Anthony J. Viera, MD, from the University of North Carolina, Chapel Hill, also wonders if creating preconditions, in this case pre-hypertension, will lead inexorably to the wider use of drug therapy. He points out that in other situations where counseling lifestyle changes fails as a first line of defense, doctors “turn to what they know best. They write prescriptions.”

No one should underestimate the fierce commitment it takes to turn back the clock on any of these preconditions or how difficult it can be. When you look at the Mr. Fit and DPP studies, you get an idea of what’s required. In the Finnish study, participants received seven sessions with a nutritionist in the first year and a session every three months thereafter. They got individualized guidance on increasing their physical activity, and in the first year of the study more than half of them got supervised, progressive, and individually tailored physical training sessions. And they were offered free health club memberships. The average weight loss after the first year: 9.2 pounds. After two years it dropped to 7.7 pounds and 4.6 after five. Of course that’s better than actually gaining weight over five years, but what health insurance plan pays for that kind of treatment?

And there, in a nutshell, lies the problem with the lifestyle interventions offered as the antidotes to these preconditions—without concerted effort, they won’t work. Some critics of preconditions suspect that may be the point. In an article originally published in 2003 in response to the new JNC-7 guidelines, Paul J. Rosch, MD, president of the American Institute of Stress, writes that “people with pre-hypertension usually discover that none of these lifestyle modifications will normalize their blood pressure, which means that medications will be required.” In a recent interview he says that’s the primary mission of establishing a precondition—“You just redefine it so you can sell more drugs.”

That may seem a bit extreme, but one can’t be blamed for thinking it contains a bit of truth, given the way some of the new guidelines were promulgated. Osteopenia appears to be a special case. John Abramson, MD, clinical instructor at Harvard Medical School and author of Overdosed America, (HarperCollins 2004), calls it “a made-up precursor of a made- up disease.” The disease in this case—osteoporosis. According to Abramson, the committee that both redefined osteoporosis and established osteopenia was funded by three drug companies, the Rorer Foundation, Sandoz, and SmithKline Beecham. Perhaps it’s just coincidental that, as Abramson points out, several new osteoporosis drugs were in various stages of development at the same time; Fosamax, a billion-dollar superstar for Merck, received FDA approval in 1995. (For more, see “Bones of Contention” at

Before cynicism overtakes you, let’s acknowledge that no new drugs waited in the wings for the advent of pre-hypertension. But did the guideline committee members have any conflicts of interest? “I think that’s been shown actually,” says Rosch. “They all have ties to pharmaceutical industries.” As Abramson and a number of others have pointed out, conflicts of interest like this occur throughout medical research.

The potential revenue from expanding drug therapy to these new preconditions staggers the mind. According to the Centers for Disease Control, some 28 percent of American adults have pre-hypertension. Based on an adult population of roughly 220 million, that’s almost 62 million people. The ADA says 54 million have pre-diabetes, and National Osteoporosis Foundation puts the number of people with osteopenia at 34 million. Numbers this size would catch any marketer’s eye, and it should come as no surprise that a number of studies have already tested the drugs used for diabetes, hypertension, and osteoporosis against their respective preconditions and reported varying degrees of success. Can the TV ads be far behind?

Healthy alternatives
Despite some well-grounded reservations, even the harshest critics of these new guidelines acknowledge that the concept of preconditions has some value. “In a world where there was accurate health information that represented the best of our scientific evidence and was epidemiologically balanced instead of doctors trying to sell drugs and tests and procedures,” says Abramson, “then I think preconditions would set off a little bit of an alarm that a person needs to put more energy in lifestyle modification.” Speaking about osteopenia, he says there’s “an opportunity cost” when women focus on arbitrary endpoints like bone mineral density instead of their overall bone health and overall health. “I think women ought to take the energy that is causing them to contemplate getting a bone density test and reinvest it in exercising and taking adequate amounts of calcium and vitamin D.”

And, he says, that lost opportunity applies to all three of these preconditions. Yes, drug therapy will control the end points that determine whether or not you have pre-diabetes, pre-hypertension, or osteopenia, but “when you look at the interventions that really make a difference,” says Abramson, “it’s the lifestyle intervention—and lo and behold, it’s the same lifestyle interventions that produce the true reduction of risk to all these conditions.”

So if you have pre-hypertension, you need to eat well, lose weight, and exercise regularly so your vascular system stays healthy with as much elasticity and as little inflammation as possible. That way your heart won’t have to work so hard to pump blood throughout your body. And consider practicing Transcendental Meditation; multiple studies have demonstrated its ability to lower blood pressure.

A diagnosis of pre-diabetes should prompt you to lose weight, especially excess abdominal fat, which is a major risk factor for glucose intolerance. You should also eat a low glycemic diet so your body won’t need to cope with so much glucose, and you should exercise regularly to rev up your metabolism.

And if you want to avoid hip fractures, do your best to build and maintain your peak bone mass in your 30s and 40s so you come through the natural bone loss that occurs during menopause with still-strong bones. And no matter what your age, you need to eat a diet rich in bone-building nutrients (See “19 Key Bone-Building Nutrients” at and one that is less acidic than the standard American diet. You also need exercise to build bone mass and improve muscle tone and balance, both of which prevent falls—the primary cause of hip fractures.

Finally, you should realize that each of these preconditions has been based on statistical analyses of epidemiological and clinical studies, not individuals. “I think patients should understand that you don’t treat numbers and you don’t treat large groups,” says the American Stress Institute’s Rosch, “you treat people, and everybody is different.”

Precondition Action Plan
In addition to improving your diet, losing weight, and exercising—the steps prescribed by mainstream medicine to combat pre-hypertension and pre-diabetes—you can try the following alternatives.

Take lycopene: An Israeli study found that lycopene lowered blood pressure significantly in an eight-week trial. The extract also produced beneficial effects on blood lipids, lipoproteins, and oxidative stress markers, all involved in or risk factors for cardiovascular disease.

Take cod liver oil: Rich in fat-soluble vitamins, especially vitamin D, which studies show plays a role in hypertension, this fish oil also contains DHA, a fatty acid that the body uses to produce prostaglandins—hormone-like substances that help normalize blood pressure.

Take Co-Q10: According to James Roberts, MD, author of Reverse Heart Disease Now (John Wiley & Sons, 2007), studies have shown that Co-Q10 lowers blood pressure in people with established hypertension.

Switch to unrefined salt: Regular refined table salt has lost all of the 80 or so minerals and nutrients found in unrefined salt. Over the last 30 years, the National Health and Nutrition Examination Survey (done every 10 years) has found a correlation between inadequate levels of minerals (particularly potassium and calcium) and the presence of hypertension.

Meditate: Stress plays a major role in hypertension, and overcoming the fight-or-flight response can lower blood pressure. More than 500 studies on Transcendental Meditation have found that it works as well as conventional treatment and medication for high blood pressure.

Vinegar cocktails: Carol S. Johnston, PhD, RN, chairman of the department of nutrition at Arizona State University in Mesa, Arizona, has studied vinegar’s antiglycemic effects since 2000. She found that drinking one to two tablespoons of vinegar before eating a carbohydrate-rich meal reduces the blood sugar spike that normally follows. She advises eating fruits and veggies as well to help balance out the vinegar’s acidity. Johnston used apple cider vinegar, but any type with 5 percent acidity should work.

Sprinkle on the cinnamon: A 2003 study in Diabetes Care found that eating 1 to 6 grams of cinnamon a day lowers the glucose levels in the blood of people with type-2 diabetes. It also lowers triglycerides, LDL cholesterol, and total cholesterol—risk factors for both diabetes and cardiovascular disease.

Bitter melon: Used frequently in India and the Philippines to control diabetes, this relative of the cucumber and watermelon appears to increase glucose tolerance and insulin production, according to a recent Chinese study.

Fenugreek: Multiple studies in India have found that fenugreek seeds improve blood sugar control and decrease insulin resistance in people with mild type-2 diabetes.

Get your protein from plants: Eating lots of animal protein (meat and dairy) increases bone loss; a study in the American Journal of Clinical Nutrition found that eating zero animal protein cut calcium loss in half.

Take your supps: Building strong bones requires the vitamins D, C, and K and the minerals calcium, magnesium, boron, copper, silicon, and zinc. (See “19 Key Bone-Building Nutrients” at for food sources and doses.)

Combat acidosis: Eating the highly acidic foods found in the standard American diet causes bone loss as your body strives to maintain the slightly alkaline arterial blood pH necessary for life. You can help by avoiding sodas and refined flour and sugar, and by eating alkaline-producing foods: leafy greens, sea vegetables, non-starchy veggies, nuts, and seeds.

Accurate Readings
With a lowering of the guidelines and use of the term pre-hypertension to describe the old “normal,” getting an accurate blood pressure reading has become critical. And controversial.

White Coat Syndrome
“Most people don’t realize that blood pressures obtained in the doctor’s office are often absolutely incorrect,” says Paul J. Rosch, MD, of the American Institute of Stress, “especially the first one.” Most of us know the cause of that: Some people get nervous at the beginning of a medical exam and their blood pressure shoots up. If they sit quietly for a few minutes, it usually drops back down. Does it get back to their normal level? Good question.

Doctor’s-office anxiety isn’t the only thing that can inflate blood pressure numbers. “As soon as you talk, your blood pressure goes up,” says Rosch, “and there’s nothing you can do to stop that.” (Studies have shown that the same thing happens when deaf mutes use sign language—but not when they simply wave their hands around meaninglessly.)

Other Impediments
Rosch says the time of day, temperature of the examining room, a full bladder, whether you’ve had anything to eat or drink (or smoke) in the hour before the exam, and the size of the blood monitor cuff can all affect the blood pressure reading.

For all these reasons, you’re more likely to get a truer reading of your blood pressure outside of the doctor’s office. Simply purchase a good-quality blood pressure meter and take your blood pressure yourself or have a family member or friend assist you. Take multiple readings at various times of the day after sitting comfortably and quietly in a chair for 10 minutes. Or ask your doctor to let you wear an ambulatory monitor, a device that takes and records your blood pressure every 15 to 30 minutes throughout the day.