On this page:

• What is blood pressure? Systolic vs diastolic figures
• How to measure your blood pressure in eight steps
• Is it normal for blood pressure to vary?
• When is the optimal time to measure blood pressure?
• How long does it take to get a blood pressure reading?
• Ensuring the accuracy of your blood pressure monitor over time
• What's a normal blood pressure, and what's high?
• Managing high blood pressure

Follow our eight simple steps for blood pressure peace of mind and results you can trust.

What is blood pressure? Systolic vs diastolic figures

Blood pressure is created by the heart pumping blood through the arteries. It’s measured in millimetres of mercury (mmHg), and given as two numbers – 120/80 mmHg, for example, or ‘120 over 80’.

The first number is what’s called systolic pressure, caused by your contracting (beating) heart. The second number is what’s called diastolic pressure, and is the pressure between beats when your heart relaxes.

High blood pressure, or hypertension, can increase your risk of heart attack, stroke, heart failure and kidney disease. When weighing up your risk, your GP will consider factors such as your age, sex, family history and weight, and whether or not you smoke.

How to measure your blood pressure in eight steps

1. Don’t exercise, have a bath, smoke, or drink coffee, tea, cola or other stimulating drinks for a couple of hours before you plan to take a measurement.
2. Sit comfortably at a table.
3. Remove watches, jewellery or anything that may interfere with the measurement, and have a bare arm or wrist (depending on the type of monitor you’re using).
4. Make sure you’re comfortable – relax for a few minutes before you start.
5. Ensure you take measurements using the same arm each time, as your blood pressure is different in each arm.
6. If you’re using an arm monitor, put on the cuff so that its centre is at heart height and your arm is resting on the table. If you’re using a wrist monitor, put on the cuff and raise the wrist to heart height
7. Follow the monitor’s instructions and take two measurements within a couple of minutes of each other. If they differ by more than 10mmHg (e.g. one reading of 120/80 and another of 135/80, a difference of 15mmHg), take a third measurement.
8. Keep a record of all results, and make a note of events that might explain an unusual result (for example, if you had an argument earlier that day, or if the grandkids were running around you while you took the measurement).

Is it normal for blood pressure to vary?

Your blood pressure can vary by as much as 30–50mmHg over the course of a day and it’s influenced by a range of factors, including food and drink, caffeine and alcohol consumption, physical exertion, stress (including the stress of going to the doctor to get your blood pressure measured – known as white-coat hypertension), and even busting for a wee will have an effect on your blood pressure.

Your blood pressure is usually higher in the afternoon than in the morning. That’s why it’s important to measure it at the same time, and under the same conditions each day. It’s also why it’s more important to look at changes over time rather than focusing on a single reading.

When is the optimal time to measure blood pressure?

To get comparable, consistent measurements, you need to measure your blood pressure at the same time of day and under the same conditions every time, ideally twice daily – in the morning before breakfast and again in the evening. You should also take two or three measurements each time. This gives you the best possible chance of taking accurate, consistent readings and of spotting any changes over time.

If in doubt, your GP can advise you on the best time to measure your blood pressure and how often you should measure it, and they can also check that you’re using your own blood pressure monitor correctly.

How long does it take to get a blood pressure reading?

Taking a blood pressure reading only takes a few seconds, but while the reading itself is quick, you need to take some time to prepare beforehand. You should abstain from food, caffeine, tobacco and alcohol for at least half an hour before taking a measurement, and visit the bathroom – a full bladder can raise your blood pressure a little, reducing accuracy.

You should also sit still in a comfortable chair with arms and legs uncrossed for five minutes before taking a reading, and don’t talk while taking your blood pressure.

Ensuring the accuracy of your blood pressure monitor over time

To ensure accuracy, manufacturers strongly recommend visiting your GP for your first measurement, where you should measure your blood pressure using both the GP’s monitor and your own (we recommend testing at least three times and working out an average). 

According to Dr Brian Morton from the Australian Medical Association, a fluctuation of about +/- 10mmHg is acceptable between different monitors, and we haven’t found an average fluctuation beyond this for any monitors we’ve reviewed.

You should go back and check your monitor’s readings against your GP’s machine every six months or so. Some monitor instructions also recommend sending the monitor back to the manufacturer every year for calibration.

What blood pressure cuff size do you need?

Most blood pressure monitors come with a medium-sized cuff already fitted. While this will be suitable for the majority of users, there are different sized cuffs available for several of the monitors in our test if your arm is exceptionally large or small.

To get the right cuff size for an arm model, measure your arm’s circumference halfway between your shoulder and elbow, while standing with your arm hanging at your side. A circumference of 18–22cm requires a small cuff, 22–32cm requires a medium cuff, and above 32cm you’ll need a large cuff – but check the measurements against the manufacturer’s instructions on the product you intend to buy.

What’s a normal blood pressure, and what’s high?

High blood pressure is usually asymptomatic, so you may not even be aware you have it. That’s why the disease is often called “the silent killer”.

Here’s how The Heart Foundation defines normal and high blood pressure:

• Less than 120/80: normal
• Between 120/80 and 140/90: normal to high
• Equal or greater than 140/90: high
• Equal or greater than 180/110: very high

What causes high blood pressure?

High pressure or hypertension can potentially put a strain on your arteries and organs, increasing the risk of heart attack or stroke.

Your lifestyle is a big contributor to the risk of hypertension – being overweight, drinking and smoking can all raise your blood pressure.

What you eat also has a big impact – a diet high in sugar can lead to weight gain, which in turn can elevate your blood pressure. Similarly, a diet high in saturated fat can raise blood cholesterol, which also affects your cardiovascular system.

Your blood pressure also gets higher as you get older.

Managing high blood pressure

To prevent high blood pressure, or to manage it once you’ve been diagnosed, follow these tips.

• Visit your GP regularly for a check-up, especially when you know you have high blood pressure.
• Quit smoking.
• Limit the amount of alcohol you drink.
• Exercise regularly (but note that there are certain sports to avoid when you have high blood pressure, such as lifting heavy weights) and consider stress-reducing techniques like yoga and meditation.
• Eat less red meat, and avoid salty and fatty foods.
• Eat more cereals, fish, fruit and vegetables.
• Maintain a healthy body weight.

Medication for high blood pressure

If lifestyle changes don’t lower your blood pressure enough, your doctor may prescribe medication. Make sure you take it, and don’t adjust the dosage yourself based on your own blood pressure measurements. This is known as “self diagnosis”, and fiddling with your medication yourself can have serious consequences.

Low blood pressure

Low blood pressure, or hypotension, isn’t as serious as high blood pressure but it’s still worth addressing as it can cause dizziness and fainting, which may in turn result in further injuries from falling and hitting your head.

What causes low blood pressure?

Low blood pressure can be the result of genetics, or may be caused by an illness or other health issue such as diabetes, neurological conditions, heart problems, or serious injury and shock.

Can blood pressure monitors detect a heart attack?

Not necessarily. During a heart attack your blood pressure may rise as your fight or flight mechanism feeds adrenaline into your system, or it might fall as your damaged heart weakens, or it might stay exactly the same. Conversely, there’s a whole slew of (non-heart attack related) factors that can affect your blood pressure in the short term. As a result, a change in blood pressure alone without other symptoms is not a reliable sign of a heart attack.

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Here’s how we put blood pressure monitors through their paces to find out which ones are the most accurate, which ones are easiest to use, and which ones we recommend to help keep track of your blood pressure at home (though as always, see your GP for more advice).

Our expert testers

Our expert tester, Matthew Tung, has many years experience testing home health devices and child safety products for ÌÇÐÄVlog. Matthew compiles a panel of 10 test subjects of diverse ages and fitness levels to assist in the testing process, which is conducted under controlled conditions in our laboratory. 

By using a panel of volunteer test subjects we’re able to assess each of the monitors for ease of use, as well as accuracy across a range of different physiologies.

How we choose which blood pressure monitors we test

With a range of products on the market, what makes us choose one blood pressure monitor to test over another? As with most of our product testing, our aim is to test the majority of brands on the market and focus on what you’re most likely to see in stores.

We research the blood pressure monitors available in stores and survey manufacturers to find out about the range of products available and to identify the newest and most popular blood pressure monitors in the market. 

Armed with this list, our buyers head to pharmacies, online stores and other retailers and purchase each product, just as a regular consumer would. We do this so we can be sure what we buy is the same as you’d find it and not ‘tweaked’ in any way for better performance.

How we assess blood pressure monitors

Our testing of blood pressure monitors is a measure of both accuracy and ease of use.

Accuracy

This is assessed by taking two measurements for each monitor on our test from each of our 10 triallists, and comparing them with a reading taken from a freshly calibrated hospital-grade blood pressure monitor*. The differences in measurements from the monitor on test and our reference monitor are then averaged to give us our accuracy results.

Before testing begins, we make sure each triallist is well rested and our tester, Matthew, implements a one-minute interval between each reading to allow the test subject’s blood pressure to return to normal. Our test panel is made up of volunteers from a wide range of ages and fitness levels.

Ease of use

This score is an assessment of a number of elements when using the blood pressure monitor, including the instructions, ease of fitting and operating the monitor, comfort, screen quality and the information displayed on the screen or, in the case of app-based monitors, via your phone. Our triallists are asked to fit each cuff themselves so we can evaluate ease of use from the perspective of the home user.

Validation

This is separate to our testing and is a specification note where we research whether the blood pressure monitor has been validated by any to see whether it is giving accurate results. Where a blood pressure is not validated, it means we cannot recommend it.

Test criteria explained

The ÌÇÐÄVlog Expert Rating, our overall score that determines which products we recommend, is made up of:

• accuracy (80%)
• ease of use (20%).

*Special thanks to GE Healthcare for providing a GE Carescape V100 hospital grade monitor for use as a reference blood pressure monitor in our testing.

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Recent research by the George Institute for Global Health analysed the sodium content of 15,680 products across 15 food categories from 2011 to 2013, comparing branded products with supermarket own brand or “private label” products.

Overall, salt content was lower in the private label products, and in 2013 (the most recent figures) it was 17% lower. The notable exception was breakfast cereal, where private label products were higher in salt than branded products.

The breakdown

Breaking it down by category, salt in private label products was:

• Lower by 27% in desserts
• Lower by 24% in biscuits
• Lower by 22% in processed meats
• Lower by 7% in breads
• Higher by 37% in breakfast cereals

There were no significant differences within in other categories, including cakes, muffins and pastries; cereal bars; cheese, chips and snacks; nuts and seeds; processed fish; ready meals; sauces; soup; and vegetables.

While three of the major supermarket chains – Coles, Woolworths and Aldi – made voluntary commitments to reduce sodium in some of their foods, Aldi was singled out for its “very encouraging reduction in mean sodium content across its private-label range”. Conversely, IGA (Metcash) products had consistently higher sodium than other chains.

Aussies exceeding daily targets for salt

The authors note that Australians are eating an average of 9g of salt per day, more than double the suggested dietary target of 4g per day, most of it coming from packaged processed foods. Sodium is implicated in 11% of deaths from ischemic heart disease and 15% of deaths from stroke. Lower income earners are disproportionately affected by cardiovascular disease.

Lead Author Helen Trevena, from the George Institute, says “This is good news, especially for families shopping on tight budgets who are more likely to buy private label products, but are also most likely to suffer from health problems caused by high blood pressure.”

Choose food based on overall merits

Professor Bruce Neal, Head of the Food Policy Division at the George Institute for Global Health, points out that the research didn’t looks at other nutrients, including sugar and fat, warning that consumers should still judge food products on overall merits.

“Salt is important, but it’s one of many nutrients that people should consider and compare when making healthy food choices.

“However, this research is potentially a great help to people with high blood pressure who need to try to choose low salt options.”

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Many forms of treatments exist to suit individual cases, personal preferences and budgets. One of the newer treatments on the market is endovenous laser therapy – a less invasive alternative to surgery performed by experienced and skilled practitioners, with good success rates reported 

In this article we explain what varicose veins are, who gets them, and what treatment options are available, as well as management strategies to help reduce discomfort.

What are varicose veins?

There are two venous systems in our legs – deep veins and superficial veins – which are connected by smaller perforator veins. Most varicosities are a result of problems with the main superficial, or saphenous, veins that collect blood from other surface veins.

One-way valves in veins direct the flow of blood back to the heart. In the legs – the most common site of varicose veins – these valves are particularly important because the blood is flowing against gravity. When one or more valves fail, blood can pool in the section, causing the bulgy, tortuous appearance of varicose veins. Weak vein walls also make the problem worse.

When the blood flows backwards because of weak valves, it’s known as reflux. Deeper veins, which lie within and between muscles, aren’t affected in the same way, because muscular contraction (when walking and so on) compresses the veins, creating a pumping action that returns blood to the heart and provides support. The veins near the surface, however, have very little support overall.

Not all varicosities are caused by problems in the saphenous or perforating veins though; any superficial leg vein can become varicose, although these lesser veins are usually quite small and cause few symptoms. However, the severity of the symptoms isn’t always related to the appearance of the veins, and even large, obvious ones may cause little or no discomfort.

Varicose veins serve no useful purpose; alternative pathways have already been formed to bypass the abnormal varicose veins and return blood to the heart. Compressing, closing off or eliminating varicose veins improves circulation and relieves many of the symptoms.

Who gets varicose veins and why?

In Western nations it’s estimated about 40% of people suffer from varicose veins, and it appears to be hereditary. Susceptibility varies among cultures, although it’s not clear if this is genetic or lifestyle-related (poor diet and lack of physical activity may be partly responsible).

Women seem to get varicose veins more than men, probably because of the hormone oestrogen. Taking oestrogen-based contraceptive pills or hormone replacement therapy also appears to increase risk. Women who have had children are more likely to get varicose veins in the future, as hormones released during pregnancy relax vein walls, and the weight of the baby puts more pressure on leg veins. Varicose veins that occur during pregnancy often go away within a few months of giving birth though. 

Poor diet, obesity, smoking and a sedentary lifestyle increase risk, as does standing still for long periods of time.

Getting treatment

As there’s no cure for varicose veins, there’s also no guarantee that one treatment will fix the problem for life. The earlier you treat varicose veins though, the more successful the outcome will be.

Your first port of call should be your GP, who can refer you to a phlebologist, vascular specialist or other surgeon who practises phlebology (the diagnosis and treatment of venal disorders). An ultrasound “map” of your blood vessels will provide an overview of how they’re functioning and where the problems lie, and can give you insight into what the future holds if you choose to do nothing.

Treatment may require several stages. For severe cases, the first stage is usually to treat the root of the problem – the saphenous veins. The reflux in these veins affects the tributary veins that run from them. Once the saphenous veins have been fixed, secondary incidences can then be treated. Spider veins are almost always associated with deeper vein problems, so further investigation is needed to identify the cause (which should then be treated first).

Most treatments are done in an office or clinic setting with local or no anaesthetic. Ligation and stripping takes place in hospital and may require general anaesthetic.

After any treatment, patients have to wear compression stockings day and night for about two weeks to help in sealing veins and preventing clots. Regular walking is an important part of healing too, though you may have to avoid more strenuous exercise for a while. Your physician will perform an ultrasound soon after the treatment to ensure there are no clots.

Managing varicose veins without surgery

If your varicose veins aren’t too severe, or you’re trying to slow down their recurrence, the following strategies may help:

• Regular exercise, a low-fat diet with plenty of fruit and vegetables, and keeping your weight at a healthy level can help prevent varicose veins becoming a problem.
• Elevating your legs when possible can provide relief, as can compression stockings, which are elastic stockings that use graduated pressure to squeeze your veins and stop blood from pooling or flowing backwards.
• Clinical trials of horse chestnut tablets found the naturally-occurring chemical, aescin, reduced pain, itching and swelling, at least in the short term. It appears to be safe, although it may interact with some medicines (check with your doctor), and its long-term effectiveness hasn’t been established.
• Some cosmetic creams claim to reduce the appearance of spider veins, but there’s no evidence they have anything more than a minor effect.

Procedures, risks and costs

Microsclerotherapy and ultrasound-guided sclerotherapy

An irritating liquid or foam is injected into the blood vessel, causing it to swell and stick together, aided by external pressure from compression stockings. The blood vessel is eventually absorbed by surrounding tissue and fades. This treatment is often used together with vascular ultrasound to guide the injections in larger and/or deeper veins.

Ultrasound-guided sclerotherapy costs about $800-$1000; sclerotherapy for small veins and spider veins is more like $300-$500.

Ambulatory phlebectomy

A tiny cut is made over the vein which, using a phlebectomy hook, is then pulled out until it breaks or cannot be pulled any further. The process is repeated along the entire length of the vein to be extracted, and no stitches are needed.

Costs: About $900.

Endovenous laser therapy

This is one of the most recent treatments to become available. The vein is punctured near the knee or ankle, depending on which part of the vein is being treated, and a fine laser probe is inserted. The laser’s activated, causing the vein walls to close off as it’s withdrawn. The procedure involves some discomfort and local anaesthetic is used to reduce pain. This therapy may be used in conjunction with ultrasound-guided sclerotherapy.

Costs: Between $2500 and $4000 per treatment, depending on the scale of the problem. See below for more about endovenous laser therapy.

Radiofrequency ablation

Similar in technique and outcome to endovenous laser therapy, radiofrequency ablation uses a catheter to heat the blood and destroy the vein.

Costs: Costs and risks are similar to endovenous laser therapy.

Surgery

An incision is made at the top of the leg over the vein, which is then cut and tied off (ligation). A thin wire is then inserted down the length of the vein and the vein is pulled out (stripping). Smaller incisions may be needed to separate connecting veins along the way.

Costs: About $2000, plus hospital and anaesthetic costs.

Treatment risks

All types of treatment are likely to result in temporary bruising, aching, discolouration and inflammation. Deep vein thrombosis (DVT) and temporary numbness due to nerve damage are rare. For one treatment, sclerotherapy, additional but rare risks include pockets of blood trapped in veins (this is different from DVT), pigmentation along treated veins, allergic reaction to the solution and skin ulceration.

Costs and rebates

Medicare rebates apply to most procedures considered medically necessary, so your varicose vein treatment needs to be more than just a cosmetic concern, and veins should be 2.5mm or more in diameter and have reflux in order to be eligible for rebates. But the amount of the rebate can depend on the severity of the veins and your individual Medicare circumstances (i.e. your Safety Net Threshold). And any rebate will most likely only cover a fraction of the overall cost.

The costs we’ve provided are only a guide for comparative purposes. Your doctor can give you a more accurate guide to overall costs and any applicable rebates. Private health insurers don’t cover most treatments because it doesn’t take place in a hospital, but they may cover part of the cost of post-operative compression stockings.

Accreditation

Endovenous laser therapy isn’t cheap, and in the wrong hands it can be ineffective or even dangerous. If you’re undergoing endovenous laser therapy, it’s important to know the person performing the procedure is an accredited professional trained in its operation.

The machines are readily available, so in theory anyone could buy and use one. Although they’re expensive, some companies overseas are giving the machines away for free, relying on recouping their expenses from the high cost of consumables, such as the laser probes themselves. According to the Australasian College of Phlebology, this has led to sometimes disastrous results in the US, such as probes breaking off in the blood vessels (because they were used too often) and long-term complications from incorrect use by unqualified operators.

Vascular surgeon Professor Michael Grigg pointed out that a thorough diagnostic assessment takes more than just knowledge of the technique, which isn’t difficult to learn, but also a good understanding of vascular medicine. “We have a saying in surgery: it takes about three months to learn how to do a procedure, but it takes three years to learn when to do it.”

Whatever treatment is recommended for you, make sure the treating doctor is accredited by the appropriate professional body:

Accredited practitioners can be located via these websites:

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Relative risk

Cardiovascular disease (CVD) management has traditionally focused on single risk factors, like high cholesterol or being overweight. This is known as a “relative risk” approach. On that scale, a relative risk of two means you’re twice as likely to develop CVD as someone without the same health problems.

Absolute risk

The “absolute risk” approach, introduced in the 1990s, recognises that several CVD risk factors when combined are greater than the sum of the individual parts. It takes a person’s age, gender, cholesterol levels, blood pressure, diabetes status and smoking habits into account, and applies these factors to cardiovascular risk charts.

This information can help you or your GP determine your absolute risk of a CVD event in the next five years. This risk is expressed as a percentage, for example a 20% chance of a CVD event in the next five years.

Assessing your risk

Use the Heart Foundation’s downloadable (it needs to be printed in colour to be effective) to help assess your risk of developing CVD. Alternatively, you can use their interactive CVD risk calculator. In either case, you’ll need to know certain body numbers, including your:

• Blood pressure
• Total cholesterol
• HDL cholesterol, and
• Diabetes status, or recent blood glucose test results.

High risk?

If your five-year CVD event risk exceeds 15%, you’re in the high or very high risk category. You’ll need immediate intervention to reduce your risk of a CVD event.

Your GP can help you develop a cardiovascular health plan that may aim to modify two or three risk factors rather than just one, to get a better result faster.

If you’re over 45, ask your GP to give you an absolute CVD risk assessment as part of your regular health check.

It’s worth noting that the risk charts were developed from data collected by the Framingham Heart Study in the US.

They don’t take the following into account:

• Being overweight
• A lack of exercise, and
• Family history of heart disease.

But inactivity and being overweight have strong indirect influences on your result, because they affect cholesterol levels, blood pressure and risk for diabetes. Future research may well look at body fat percentage and tie it to your CVD five-year risk result.

Understanding your risk factors

Since 2009, the Heart Foundation has been educating GPs about CVD and absolute risk tools.

Risk factors outside your control include:

• Age
• Gender
• Family history of premature CVD
• Ethnicity, and
• Social status.

Family history means a first-degree relative (parent or sibling) has had a stroke or a heart attack, before 55 for men and 65 for women.

Factors you can actively manage include:

• High blood pressure
• Elevated cholesterol and blood lipids (fats)
• Smoking
• Diabetes
• Physical inactivity
• Being overweight
• Excessive use of alcohol, and
• Stress.

Blood pressure

Gone are the days when an estimate of ‘normal’ systolic blood pressure came from adding your age in years to 100.

These days everyone between 18 and 50 should record their blood pressure every two years, and your systolic (heart pumping) pressure should remain less than 120, while diastolic (heart relaxing) pressure should be less than 80. Any higher and you’ll require more frequent checks. You can buy a reasonably accurate, easy-to-use home blood pressure monitor from pharmacies or online for under $100, if you shop around.

Cholesterol levels

Cholesterol levels in the blood are affected by diet, genetics and exercise. Saturated animal fats and some cooking oils (palm oil used by some fast food chains) are major contributors to cholesterol build-up, so dietary changes can help manage your cholesterol.

How individuals handle dietary fats depends on their genetics, though, so the effect of lifestyle changes on cholesterol levels can sometimes be disappointing. Adopting the National Health and Medical Research Council’s (NHMRC) Dietary Guidelines, exercising vigorously and frequently, and maintaining a healthy weight will only reduce cholesterol by up to 30%.

Some very effective prescription medicines, such as statins, can lower blood lipids.

When your GP requests a blood lipid test from a laboratory, your results and a ‘normal’ range (which may differ slightly between laboratories) are both provided.

Aim for the following levels:

• Total triglycerides <2.0 mmol/L
• Total cholesterol < 4.0 mmol/L
• High density lipoprotein (HDL) >1.0 mmol/L
• Low density lipoprotein (LDL) < 2.0 mmol/L
• Total cholesterol/HDL ratio < 5.0 mmol/L

HDL is the “good” cholesterol, since it reduces CVD risk. LDL is the “bad” cholesterol as it lays down fat in blood vessel walls. The lower your LDL levels, the better.

Assessing your weight

You can assess your weight using body-mass index (BMI), waist circumference, or waist-to-hip ratio (WHR) measurement. The build-up of body fat in and around the abdomen rather than on your thighs and buttocks can be a better predictor of future CVD than BMI, so waist circumference or WHR may be more accurate.

The August 2006 edition of the American Journal of Clinical Nutrition asserts that if WHR was to be used instead of BMI, the number of people considered to be at risk of CVD would triple.

A simpler measure is waist circumference (WC) alone

For men, a WC over 94cm is associated with greater risk of chronic diseases including CVD, and a WC over 102cm suggests a greatly increased risk.

For women, a WC over 80cm indicates a greater risk, and over 88cm indicates a greatly increased risk.

Create a cardiovascular action plan

If you fit into a CVD risk category, it’s important to establish a cardiovascular action plan so you can manage particular factors and reduce your overall risk.

Setting goals and applying some of the following techniques can help maintain motivation.

• Blood lipid (cholesterol) monitoring – use diet, and medication if necessary, to lower your cholesterol.
• Blood pressure monitoring – use exercise, diet (including reduced salt intake) and medication if necessary, to lower your blood pressure.
• Diabetes screening for hidden early diabetes – good diet, exercise and weight control can keep type 2 diabetes at bay.
• Stop smoking – ask your GP for help, which may include medication, or call the Quitline on 13 78 48.
• Absolute CVD risk assessment – assess the combined impact of the above four factors with your GP. This applies to people aged 45 to 74, without a known history of CVD. For low risk (less than 10% risk of a CVD event in the next five years), recheck every two years. For moderate risk (10% to 15% risk of a CVD event in the next five years), review every six to 12 months. For high or very high risk (over 15%), review according to clinical requirements.
• Weight control – even if weight loss is difficult for you, regular physical activity can still provide real health benefits for overweight people.
• Regular exercise – ideally, you should do 30 minutes on most days with enough intensity to make you ‘huff and puff’.
• Family history assessment – medication may be suggested even if other risk factors are okay.
• The ‘stress factor’ – this should figure in any life decisions you make. High stress levels have been linked to increased risk of both heart attack and stroke.

Case study – get a second and third opinion

As an experienced nurse, Kathryn is aware of the importance of family history in indicating disease risk. Her father had a heart attack at 42 and a fatal heart attack at 58. On family history alone, Kathryn is considered at ‘very high risk’ of CVD.

Kathryn knew that she should aim for very low LDL cholesterol, and that cholesterol-lowering statins could be beneficial as a preventative action. She knew the risks associated with their use were low if liver function was not affected. Kathryn also knew she was eligible for the PBS subsidy immediately, without attempts at ‘diet therapy’ to reduce cholesterol levels.

She asked two GPs for a prescription without success, because her cholesterol levels were “reasonable”, and they “could not find the entitlements information”. She then downloaded the PBS prescribing guidelines and visited a third GP who gave her the prescription immediately.

Jargon buster

• Cardiovascular disease (CVD) refers collectively to CHD, stroke, and arterial disease in other parts of the body such as peripheral arterial disease and renovascular (kidney) disease.
• Atherosclerosis is sometimes used as an alternative term to CVD. It’s a more descriptive name, alluding to the thickening and hardening of the blood vessel walls, which causes CVD.
• Vascular refers to blood vessels.
• Coronary heart disease (CHD) is the full name for heart disease.
• CVD event includes angina (heart pain), a heart attack (damage to the heart caused by a blocked heart artery), stroke, peripheral vascular disease or CVD-related death.
• Stroke refers to the blockage or bursting of an artery taking blood to the brain.
• Transient ischaemic attack (TIA) is a minor stroke with temporary symptoms.
• Pharmaceutical Benefits Scheme (PBS) is the Federal Government program that determines the eligibility guidelines for government-subsidised medication.
• Body Mass Index (BMI) is a person’s weight divided by height squared (kg/m²). An index of <18.5 is underweight, 18.5 to <24.9 is ideal, 25 to <29.9 is overweight and >30 is obese .
• Waist circumference of 94cm-101cm in men and 80cm-87cm in women at belly button level, represents overweight, and above 101cm and 87cm, respectively, is a measure of obesity.
• Waist-to-hip ratio (WHR) gives a measure of central or abdominal fat relative to peripheral fat. The waist is measured at belly button level and the hips at maximum circumference.

First aid: identifying a stroke

Know the symptoms and limit damage. Use the FAST test:

• Facial weakness – can the person still smile? Has their mouth or an eye dropped?
• Arm weakness – can the person raise both arms?
• Speech – can the person speak clearly and logically and understand what you say?
• Time to act – call 000.

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While it’s true there are side effects associated with statins, especially muscle weakness or pain, most people don’t experience these problems. For people who’ve suffered side effects or who prefer, for various reasons, not to take statins, a quick search on the internet or a chat with a pharmacist, personal trainer or naturopath will turn up a multitude of more ‘natural’ alternatives.

But are these alternatives any good?

ÌÇÐÄVlog sought the advice of people working in the health industry to see what they suggested for lowering a moderately raised total cholesterol level, and then evaluated the evidence behind their recommendations. Sources included pharmacists, naturopaths and other complementary and alternative medicine practitioners, dietitians, and people working in health food/supplement stores.

Here’s what they recommended.

Supplements and other products

Psyllium husk

The soluble fibre found in psyllium husk can help reduce LDL cholesterol levels by 5–10%. Soluble fibre is thought to work by binding to bile acids in the gut, which is then excreted rather than being absorbed back into the bloodstream. The liver then uses LDL cholesterol from the blood to make more bile to replace it. Soluble fibre is found in many plant foods, such as oats (see below) and other grains, nuts, legumes and some fruits and vegetables, but is particularly prevalent in psyllium husk.

To be effective, it needs to be taken with food and plenty of water, and you need about 10–12g per day, which is about 1.5 to 2 tablespoons. It can cause gastrointestinal effects such as gas and stomach pain, and also has a laxative effect – it’s what Metamucil is made from – so introduce it gradually to your diet. It can interfere with the action of some common medications, so talk to your doctor before using it.

Beta-glucan / oats

Beta-glucan is a type of soluble fibre found in oats, with amounts of 3g or more per day found to lower total and LDL cholesterol by around five percent. A pharmacy assistant recommended a product called Betaglucare, which are sachets of cereal rich in beta-glucan – each sachet contains the 3g of beta-glucan studies have found to be effective.

You can also find beta-glucan in porridge oats. According to the packet, one serve of Uncle Toby’s oats, or 40g (half a cup), supplies 1.8g of beta-glucan – if you want the recommended 3g, you need to eat 66g of oats (about three-quarters of a cup), which isn’t made clear on the package. If you don’t like porridge, the Betaglucare is a good compromise – you can mix it with your favourite cereal.

Plant (phyto) sterols and stanols

Phytosterols and stanols are cholesterol-like molecules produced by plants, and their similarity to cholesterol means they interfere with cholesterol absorption from food you eat. On their own, they can reduce LDL cholesterol by around 10% and when taken with statins, add to the effect of statins.

To be effective, phytosterols have to be taken with food. They’re available in some processed foods, such as margarine or milk. Read the labels to determine how much you need to eat to get the effect. Consuming more than the recommended amount won’t increase the effect, and consuming less will mean they have little or no effect.

If you don’t normally eat the kinds of foods that contain added sterols, you could take tablets. For example, you’d need to eat about 1–1.5 tablespoons of margarine to get the recommended 2–3g of phytosterols per day. That’s a lot of margarine and if it’s more than you’d normally eat, you may gain weight – which itself impacts on CVD risk.

Red rice yeast

Red rice yeast is a rice product used in Asian cooking (for example in Peking duck and pickled tofu), made by fermenting rice using red yeast fungus. It contains a naturally-occurring substance called a monacolin K, which has the same structure as the statin called lovastatin, and you’ll often find it recommended on the internet for treating high cholesterol.

In certain formulations, red rice yeast has been shown to work in clinical trials. However, the TGA doesn’t permit the ingredient in over-the-counter medicines in Australia, and it’s available by prescription only. This is due to concerns about consumers taking it without the oversight of a doctor or medical professional.  

We were able to buy some from a health supplement shop, where it was (legally) sold in powder form for use in cooking. The shop assistant asked our shopper if it was for reducing cholesterol, and the shopper said yes – no further advice or caution was offered.

Artichoke leaf extract (ALE)

Used in traditional medicine for treatment of liver failure and jaundice, globe artichoke leaf is available in capsule form for treatment of high cholesterol. There’ve been some trials to test the effect of ALE on people with high cholesterol, though unfortunately most studies are too small or of too poor quality to be considered reliable. One fairly reliable six-week study found that 1800mg of ALE per day had a modest effect in reducing total and LDL cholesterol, with only minor side effects reported. However, longer studies are needed.

Garlic

Lowering cholesterol is one of the many reputed benefits of garlic, and numerous trials have been conducted to test its effectiveness. Unfortunately, the better quality studies have failed to find any meaningful impact of garlic supplements on cholesterol levels.

Fish oil tablets

Fish oil is often recommended for reducing cholesterol, although the evidence suggests it’s better for reducing triglycerides.

Diet

Blood cholesterol levels can be reduced through diet. To lower LDL cholesterol, the Dietitians Association of Australia recommends reducing saturated fat and choosing low-fat dairy products; eating healthy fats found in nuts, seeds, avocado, oily fish and olive oil; eating a diet rich in fibre; including plant sterols; and, if you’re overweight, losing weight. Physical activity of 30–60 minutes per day is also recommended.

The so-called diet, developed by Canadian researchers, introduces four different cholesterol-lowering food types to a healthy diet low in saturated fat and salt, high in fibre and rich in fruit and vegetables. Each of the four foods has some cholesterol-lowering effect on its own, and the effects are cumulative.

The four key foods are:

• 2g plant sterols/stanols (which reduce cholesterol by 7–10%)
• 30g almonds or other tree nuts (3% reduction)
• 20g of soluble fibre (5–10% reduction)
• 50g of soy protein (3–10% reduction)

Research has found that when these key foods are eaten in those amounts daily, cholesterol is lowered by 5–24% (average 13%), with people who stick more closely to the diet achieving the greatest reduction.

One naturopath we visited recommended drastically reducing or, preferably, eliminating gluten, grain foods, dairy products and legumes from the diet, which is broadly in keeping with a Paleolithic-type diet.

There’s some evidence a “Paleo diet” will help reduce LDL cholesterol in the short-term. However, other eating patterns that emphasise wholefoods rather than highly processed and junk foods, such as a and , which are low in saturated fat, also reduce LDL cholesterol, without the risks of nutritional deficiencies from eliminating entire food groups.

The Royal Australian College of General Practitioners has information on the Mediterranean diet for in its Handbook of Non-Drug Interventions, HANDI.

Exercise

Regular exercise can help improve blood lipid levels, and can provide other cardiovascular benefits such as reduced blood pressure and weight loss.

Different types of exercise have different effects on cholesterol. Moderate aerobic exercise, such as walking, helps increase HDL cholesterol, while vigorous aerobic exercise also reduces LDL cholesterol and triglycerides. Resistance training reduces LDL cholesterol and triglycerides, and may be a more accessible form of exercise for people unable to do vigorous aerobic exercise.

Worried about statins?

High cholesterol on its own isn’t usually enough to warrant medical intervention – it’s your overall cardiovascular disease risk factor that’s important, and that takes into account other risk factors such as high blood pressure, diabetes, Aboriginal or Torres Strait Islander descent, or a family history of CVD.

Try diet and lifestyle changes first. Doctors can only prescribe statins if diet and lifestyle changes have been attempted and haven’t reduced cholesterol. Diet and lifestyle changes may have effects on CVD risks other than high cholesterol – for example, weight loss, lower blood pressure or better blood sugar control. Remember, it’s total CVD risk, not just cholesterol levels, that matters.

None of the alternative products we looked at were able to reduce cholesterol in a clinically meaningful way on their own. Some can be used in conjunction with others, or with statins, to produce a greater overall effect. Talk to your doctor about which ones are worth trying.

If you’ve suffered side effects from one kind of statin, your doctor could prescribe another one, as they’re all slightly different. Diet and lifestyle changes may mean you can take a lower dose of statin, and therefore reduce side effects.

Finally, if you’ve been prescribed statins and you’re not happy with them, talk to your doctor – don’t just stop taking them.

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Last time I went to the doctor for a check-up, my blood pressure was 140 over something. I was shocked – I’ve always been around 110 or 120. The doctor took two more readings and it went down, into the 130s. Reluctant to let me leave with this sort of reading, we went on with the other stuff, and finally with reading number four I was down to 126. Good enough, but not great.

I couldn’t understand this change in my blood pressure. Worse, I couldn’t think of any lifestyle changes I could make to improve it: I eat a healthy diet, not a lot of salt, don’t indulge in too much booze, I get quite a lot of exercise and so on.

Concerned, I ordered a wrist cuff blood pressure monitor on the internet, so I could keep an eye on the numbers. The monitor arrived in the post, and I tried it out, several times. But it didn’t work very well – nothing could make it go above 114. It was usually hovering between 100 and 110. I even tried it when the kids were fighting, but it was still no good. This was rather disappointing because, even though it only cost $50, it was rated the best in testing by (ÌÇÐÄVlog’s American counterpart).

A few weeks later we had some workplace health check-ups, so I took my monitor along to try it out against a proper machine, just to see how wrong it was. Voila, straight up to 136 – same as the professional one. Back at my desk 10 minutes later, it was back down to around 110.

So what is it?

The most likely explanation was white-coat hypertension. This means having an elevated blood pressure reading in a clinical setting, which drops shortly after leaving. The higher reading comes from underlying anxiety about visiting a doctor, with the term referring to the white coats traditionally worn by doctors.

Your blood pressure isn’t always the same, but varies depending on what you’re doing and what’s happening around you. Many people tend to feel tenser in medical settings than in familiar surroundings, but don’t always notice it.

Many people also associate hospitals and clinics with sickness and injury. White-coat syndrome may be triggered by the natural fear of the prospect of a painful procedure, embarrassment about being touched or having to remove clothes, or possibly even fear of being criticised for unhealthy choices or behaviour. There’s also the fear of a bad diagnosis.

Medication danger

Although it affects as many as one-in-four people, white-coat syndrome has been under-recognised, with some patients unnecessarily prescribed medication to lower blood pressure. But when blood pressure is in fact normal, medication could make it drop too low, causing problems such as fainting and fatigue. These days, after high blood pressure readings, doctors may utilise 24-hour blood pressure monitoring away from the clinic before prescribing medication – and if they don’t, you should ask for it.

While it’s a good idea to have regular checks for blood pressure at the doctor’s, having your own blood-pressure monitor as well is pretty convenient. And if it turns out your hypertension was of the white coat variety, it’s a good idea to keep an eye on it anyway; there’s concern that it may indicate a risk of developing high blood pressure as a long-term condition.

Just make sure the monitor’s a good one – you don’t want false assurance that everything’s okay when it’s not. Our blood-pressure monitors test is a good place to start when you’re looking for recommendations.

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