BP Concerns In Autoimmune Disorders

Christina Miller, MD, FACEP

I’m good. Thank you. Hi, Laurie. It’s nice to be here.

Laurie Marbas, MD, MBA

Yes, this is going to be amazing because you have quite a journey with lupus and with yourself. I think there’s so much information we can draw from not only your experience with your journey but also with patients because so many patients have come to you when the regular lifestyle interventions didn’t work. As I said, I’m excited to dig into autoimmune disease about hypertension, but maybe some high-level stuff with autoimmune disease people can do to help themselves. But so maybe, just to get started, can you share how autoimmune disease can directly or indirectly contribute to hypertension? What does that entail?

Christina Miller, MD, FACEP

Yes, that’s a good question. I’m glad you asked me to do this summit because autoimmune diseases are very much linked with high blood pressure, and there is an increased prevalence of high blood pressure in people who have an autoimmune disease. There’s a direct link, and for many reasons, it’s multifactorial. Just think of some of the reasons. If someone has an autoimmune disease, it can be related to inflammation itself, which raises blood pressure. When you have inflammatory markers circulating throughout the body that are going to cause endovascular and endovascular inflammation, people start secreting less nitric oxide. It’s stiffer blood vessel walls, and in fact, there was a study done on people with rheumatoid arthritis. The longer they had rheumatoid arthritis, the more they worked at stiffer blood vessels, and the more they worked over the years if the blood pressure started to go up. Inflammation and avascular inflammation are the cause of it. Then there’s the endocrine role of it, hormonal role. We know that there’s a link between hormones and autoimmune diseases. 

For example, women get more autoimmune diseases in general than men do for the most part, and there is a link. Making sure that hormones are in balance plays a role, along with blood pressure and other things that play a role. Our kidney function is a significant factor in oxidative stress. In people with autoimmune disease, a hallmark of the disease is increased oxidative stress. What that means is that our mitochondria, every cell, everybody makes waste products. That’s the stress that’s an internal waste product. From being alive, from using muscles, from breathing, from eating food, from everything that we do, we build up this oxidative stress. Autoimmune people have increased acid stress and tend to not handle it as well. As far as getting rid of it, which is part of our body’s function. All of this contributes to autoimmune disease, and then I didn’t even touch on lifestyle. Lifestyle factors are a huge component when people have an autoimmune disease; maybe they don’t feel well, they’re not as active, they’re not exercising, or maybe obesity plays a role. These are reasons why people with autoimmune diseases have increased blood pressure.

Laurie Marbas, MD, MBA

There’s a lot here. Maybe we can go back even a little bit further upriver. Can we understand why autoimmune disease is number one, and maybe what are some of the working theories and what’s the cause of autoimmune disease?

Christina Miller, MD, FACEP

Yes, an autoimmune disease is a blanket statement for people who have or are making antibodies against themselves. You could have Hashimoto’s, and that’s where antibodies against your thyroid. You could have rheumatoid arthritis, and that’s where you’re making antibodies against your joints. If you have Crohn’s disease, you have antibodies against your intestines. Depending on where the autoimmune MS occurs when you have antibodies against your myelin sheath. Those nerves sheath around your nerves. So all these are different, there’s over 100 autoimmune diseases, and they’re all the same. It’s just a matter of where their antibodies are attacking. That’s one thing, and that’s what they are. Why do we have all these autoimmune? Well, we don’t; no one knows for sure. But some of the working theories, as you say, are that a lot of it comes from at least one source: the gut. The microbiome gets out of balance, and in the lining of the gut, the microbiome protects it. When the microbiome is out of balance, the lining of the gut gets disrupted. It’s no longer protected. It loses its mucus layer. That layer of the gut is a single-cell layer. That single-cell layer helps us digest and absorb nutrients. It’s also keeping toxins out. It keeps the microbiome out, and there’s a lot of sensitization that goes between the microbiome and it is directly talking with our immune system, which is below that single cell layer of the gut. All that crosstalk is happening. 

When the microbiome is out of balance and then the gut lining gets disrupted, this is called leaky gut, where it’s disrupted and now particles and microbiome bacteria start migrating across the immune systems underneath and acting out on it. It starts attacking all these foreign substances coming across, and then it overattacks them. It starts attacking yourself because some of these particles that move across these proteins start mimicking ourselves. It’s called molecular mimicry. That’s when we start it, which leads to inflammation from these particles coming across, and now we start attacking our cells. Then it leads to the B cells and T cells of the immune system starting to overproduce, losing regulation, no longer recognizing cells from foreign sources, and the whole process is born. That is one working theory, a second working theory that I should probably mention because COVID just happened. But when we get attacked by a virus or bacteria, or any infectious process, our immune system starts acting out against that virus. We start making antibodies to attack that virus. That’s what our immune system is supposed to do. It’s our army. We start attacking it. Because the virus is so aggressive, we start making so many antibodies, and we overproduce. That virus, the proteins of the virus start mimicking our own. Because of certain viruses, people start making antibodies against themselves. Again, it’s the same idea, but this time it’s about the virus. We do see autoimmune diseases after COVID, and we also see other viruses. It’s not just unique to COVID, but autoimmune diseases can be born following a bad infection, or they can be caused by the microbiome getting out of balance for all the reasons that the microbiome gets out of balance.

Laurie Marbas, MD, MBA

When should someone be concerned that they have an autoimmune disease? Are there any particular signs or symptoms that will lead someone down the path of understanding? Okay, maybe hypertension was secondary to a primary autoimmune disease. Are there any clues that we should be looking for?

Christina Miller, MD, FACEP

Autoimmune diseases are hard to diagnose. They’re notorious for that because they’re so vague. There are so many different things. One of the hallmarks of an autoimmune disease is fatigue. Anyone with anatomy knows you just feel exhausted and can’t figure out why. That is, your immune system can cause a lack of energy, and you can get joint pain, depending on your autoimmune rate. If it’s in your gut, you can have gut issues. If it is, many of them have joint pain. You get rashes, you can have headaches, you can have neurologic things. Lupus attacks all over your body, so you can have kidney disease, and you get high blood pressure. That could be a direct hallmark. It could be your autoimmune disease causing it. It depends on where it is. But it’s hard. If you start having these signs or symptoms, you want to go get bloodwork, get tested, and see if you can find out. You have elevated inflammation. Do you have antibodies to something? Go get a look and start making some lifestyle adjustments, which is what I would recommend at that time.

Laurie Marbas, MD, MBA

Perfect. Let’s say someone goes to the doctor; maybe they’re having these bizarre, vague symptoms for a while. I don’t know if there are any particular tests they could ask the doctor to run, as the doctor hasn’t brought this subject up to them.

Christina Miller, MD, FACEP

Yes. Would you want to check? Well, first of all, you always want to check the basic labs. Basic electrolytes. Look at your kidney function, look at your liver function, and look at your glucose. Your metabolic health, you want to look at that; look at your vitals, your blood pressure, those types of things. Look at your blood counts; make sure you’re not anemic. Then you can look at your thyroid function because that can cause vague symptoms. Yes, you want to have a full thyroid panel, including antibodies—not just TSH but TSH to T4, and maybe T3 antibodies. You want to check nutrient status. Vitamin D deficiency is strongly linked to autoimmune diseases. It’s also linked with blood pressure. People who are vitamin D deficient are more likely to have an autoimmune disease and to have high blood pressure. But so you check some of these nutrients, and then, if someone has an autoimmune disease, you should check basic inflammation markers. a high-sensitivity CRP and the said rate of ESR at the erythrocyte sedimentation rate, and then you can check specific ones as well.

An ANA, an antinuclear antibody that looks for at least 11 different types of autoimmune diseases, including lupus, Sjögren’s, and scleroderma. Several different ones follow. These are all connective tissue types of diseases, and I would recommend a rheumatoid factor and anti-CCP because rheumatoid arthritis is very common and you want to check for that as well. I would start with something like that. Uric acid is typically as well as you start with something like that. If you want to get your baseline, see what all these labs are in. Just because they’re normal does not mean you’re in the clear. I would tell people. If you’re having these symptoms, then that’s the time to start making some diet and lifestyle changes to get rid of these symptoms. Don’t let it turn into a full-blown autoimmune disease. If you do have anything positive, then you want to be jumping on making some changes and getting that under control.

Laurie Marbas, MD, MBA

When it comes to hypertension and autoimmune disease, do you have anything unique in that scenario, or does it end up being strictly hypertension? Are there usually some other signs and symptoms that correlate with them saying, This might be autoimmune disease or this is because of your autoimmune disease?

Christina Miller, MD, FACEP

It’s not that you can correlate it that directly. But what I think is unique is that people with autoimmune disease are women, they’re often diagnosed younger in life, and they may have high blood pressure, which may be blown off. Don’t blow on pressure. Probably 30 to 40%, I think, is the study that I read about people, women especially, but younger than 40 years old, who had autoimmune disease and had high blood pressure, and most of them are not being treated. Check your blood pressure. Make sure you know if you have it or not. That’s one thing I would say, and you have to be aggressive. For some of these, it may be because they have stiffening of their vasculature. That’s a little bit harder to treat. It might be because they have involvement in their kidneys. That’s harder to treat. These are more resistant blood pressures, and so what’s different is that we may need to be more aggressive. That’s okay. If you need to be more aggressive, be more aggressive. But you do want to get that treated and get that down. The third thing I would say is that what’s unique is autoimmune. People are often on medications that raise blood pressure. If you’re on NSAIDs, if you’re on prednisone, some of the demand is that the specific medications for autoimmune diseases can raise blood pressure as well. You may need these medications to calm your immune system, but you do need to pay attention to your blood pressure. That’s all unique to autoimmune people.

Laurie Marbas, MD, MBA

I am a big fan of looking inside the effects of medications. When someone comes in with a new complaint or something that’s not improving, Well, let’s look at the symphony of your medications and indeterminacy. It’s a good point to bring out. You mentioned the lifestyle components. Was there anything in particular about a lifestyle that you would recommend across the board? Or maybe someone approaches what you see as very beneficial for someone with autoimmune disease.

Christina Miller, MD, FACEP

Yes. I’m so glad you asked. This is my favorite thing to talk about. I’m not going to talk about diet yet because that’s a whole separate category. But lifestyle is so important, and this is what I talk about my patients right away when I meet them. Number one, I would say, is mind-body work. Stress is a huge component of an autoimmune condition. When people get diagnosed with something, you have it. It’s always with you, It’s very stressful to have these diagnoses. You’re told you have it for the rest of your life. They’re scary. That right there is increased stress, which sends off stress hormones, which raise blood pressure. Very high cortisol levels raise blood pressure. We know this. We, as autoimmune people, want to be working on lots of deep breathing and lots of meditation. For me personally, I do a lot of yoga that helps me. Getting out in nature; laughter; journaling; whatever it is. You and I were talking about this, Laurie. Everybody’s individual, and finding what speaks to them, but whatever it is that calms you down. I can’t stress enough how important that is. One is to calm down the immune system, and two is for blood pressure control.  Mind-body work. The one that I use personally and teach to my patients is the four, seven, and eight breath work, where you breathe in four, four, hold for the count of seven, and breathe out for the count of eight. You do it through your nose, and you do four rounds of that while you’re sitting. It takes a minute, but you can lower your blood pressure by up to 20 points by doing that. I know I haven’t seen it, so if you have high blood pressure, sit there and do your four, seven, and eight. Think happy thoughts. What you’re doing is tapping into your heart rate variability. You’re slowing down; you’re using your vagal nerve to be parasympathetic. You can do that through your breathing, which is essential for our immune systems and essential for blood pressure. They are strongly linked together. That is the most important thing I can advise is to work on our minds and bodies every day. It has to be a priority for people with autoimmune diseases and high blood pressure. 

The second thing I would say is exercise. Exercise is absolutely good for us. It’s going to make those blood vessels more pliable. It’s going to help lower blood pressure. It controls inflammation. It helps with autoimmune diseases. Even you know, I think of it as a tin man from The Wizard of Oz, and it lubricates your joints when you’re moving. You get the blood flowing, drink plenty of fluids, get the blood flowing, lubricate your joints, get rid of these pains and aches, and move these inflammatory markers out of your body. You hydrate and exercise. and you do what works for you. If you can do more, if you can do some resistance training, we need to be working on muscle mass, balance, and strength work. But also moving our bodies, whatever works for a person. Exercise. The third lifestyle factor that I’m going to talk about now is sleep, which is so important. For both blood pressure and the immune system, cortisol is lower, stress hormones are lower, and it becomes more vagal when we’re in a vagal tone and parasympathetic when we’re sleeping. Then, if we can get good quality sleep, that’s important to work and sleep, hygiene to pick up work, figuring out why you’re not sleeping if you’re not, and if you need to journal, do cognitive behavioral therapy, get more sunlight in the morning, or whatever it is, so that each of us can sleep. But it’s important. It calms your immune system down, and it will also help lower your blood pressure. Those are the lifestyle factors. They all make a dramatic difference in blood pressure; we control it with our immune systems.

Laurie Marbas, MD, MBA

Yes, there’s a lot there, just even in that bed. I want to ask a little bit more specifically about exercise. Is there any particular type of exercise that’s been shown to be more beneficial than others? Or is it a balance? What’s the best approach?

Christina Miller, MD, FACEP

Yes, there’s been a lot of data with exercise. The first one I’ll talk about is one that I happen to love, and that’s yoga. There’s quite a bit of data showing that they took people with rheumatoid arthritis and did yoga twice a week for eight weeks, and the classes were at least an hour or an hour and 15 minutes. They did that for eight weeks, and they reported over 60% of a significant reduction in joint pain and that’s real. It’s hard to get rid of joint pain if you have an autoimmune disease. Sometimes people are hurt all the time. When we wake up in the morning, we have joint pains. so doing yoga significantly reduced it. That’s why I started it when I read that data, and I was like, Well if that’s going to help my joint pain, I’m going to do it. Sure enough, it does. I don’t know if it’s the mind-body work, the breathing that goes with it, or the movement of your body, but that can be significantly lower. That’s one thing. 

Then there is also data with regular exercise, just cardiovascular exercise that also lowers inflammatory markers. There’s also a little bit of exercise with high intensity, but I don’t recommend that for everyone with an autoimmune disease until you’re cleared by your doctor to make sure you’re okay to do that. But cardiovascular disease, whether you go for a speed walk, a power walk type thing, or you ride a bike or something, that’s also what it does while you’re exercising: it raises your inflammatory markers just a little bit. That’s the part where it may be a little bit hard for people, but afterward, it’s been shown to lower your inflammatory markers, your systemic inflammatory markers, and it persists after exercise. Exercise is a powerful tool for lowering inflammation and helping with joint pain.

Laurie Marbas, MD, MBA

But could it be as simple as walking as well, or is someone already struggling?

Christina Miller, MD, FACEP

Yes. You start wherever you are. I know when I was hurting a lot, I started super simple. But you progress as you get better.

Laurie Marbas, MD, MBA

Perfect. I think this is a great place to remind everyone that we are thankful for you joining us today. I hope you’re finding this conversation insightful and engaging. If you’re a summit purchaser, stay right here, because we’re about to dive even deeper into this lovely conversation. 

If you’re not, please click on the button below or to the side and get access to the rest of our conversation. If you’re watching this, thank you for being a valuable member of our community. Let’s continue. I want to speak to diet because you mentioned that in and of itself is quite an hour’s talk. What do you recommend as far as diet when someone is dealing with an autoimmune disease component?

Christina Miller, MD, FACEP

Yes. It’s a good chance to take a look at what you’re eating. I see food now as being either anti-inflammatory or pro-inflammatory. If you’re eating predominantly pro-inflammatory foods, you’re going to have inflammation. But that’s just how it makes sense. If you eat predominantly anti-inflammatory foods, you’re going to move your body in that direction. You may not immediately be better, but you will move your body. We know now that you can lower inflammation with the food that you eat. You can start changing your microbiome, and you can build a nice, big ecosystem in your gut again. so that lowers inflammation systemically and even blood pressure. This is linked to our gut microbiome and the health of our immune systems all through these mechanisms and our diet. Foods that I would recommend that I think are proven to be anti-inflammatory are vegetables, of course, and especially raw vegetables. I always want people to eat raw vegetables on an anti-inflammatory diet. I typically have people eat breakfast, lunch, and dinner. You want to have that throughout the day. The raw vegetables. Then there are strong anti-inflammatory mediators such as turmeric and ginger. if you can include those, and I love recommending the turmeric root or the ginger root, which is even more powerful than taking supplements. But some people take supplements too, and that can be effective. But if you can get it from the whole food, that’s even better. Then fresh fruit and vegetables, especially berries are going to be so good for the immune system. Fresh fruit and all fresh vegetables, all that’s going to be good. 

Then the next thing, the way I think of it, is that prebiotic fiber is super good. It’s been proven that people who eat prebiotic fiber improve their immune system’s health. That’s going to be things like your beans and your unprocessed whole grains. If you eat things like quinoa, brown rice, or buckwheat, you know that is going to be prebiotic fiber. Those delicious foods are going to feed your microbiome, put out your inflammation, and help you with that for the long term. That type of diet and a little bit of nuts and seeds, especially things like flax seeds, chia seeds, and hemp seeds, are the anti-inflammatory diet. Bright colors, lots of raw greens, fresh fruit and vegetables, and then high-fiber foods to start feeding your microbiome. That’s an anti-inflammatory diet for you right there. If people follow something like that. Then the other thing that I bring in, but maybe not at the beginning, but people start to feel a little better, is fermented foods. You can also start diversifying your microbiome a little more. That type of diet over time can help people feel better.

Laurie Marbas, MD, MBA

These features, I know you dealt with this a lot too, in your journey, as someone is incorporating more of these raw foods or different types of foods and they’re struggling; maybe they’re having some reaction, so maybe some food intolerances. Can you speak to that? Because I know that your food tolerance has changed over time. What is that?

Christina Miller, MD, FACEP

That is a good question. One of the hallmarks of people with autoimmune disease is that we have a lot of food intolerances and food sensitivities, and that’s different from a food allergy. A food allergy. You make IG antibodies, but food sensitivities are when you eat something and your body thinks it’s foreign, which flares up your immune system. You may get joint pains from it, and you may get headaches from it. You might get histamine reactions and turn red or get itchy afterward. These are all related to our immune system being out of balance. This is very abnormal for this to happen. People with autoimmune diseases are known to have guts that are out of balance. Again, they’re strongly linked. What happens it’s linked to the health of your immune system. When you’re sick with an autoimmune flare and you’re having all these symptoms, you might have these food sensitivities. But as you work slowly to get your gut healthier, repair your microbiome, and repair that gut lining, as that starts to happen, then those food sensitivities start to go away. 

For me, I had so many food sensitivities. You’ll remember, I couldn’t even eat at restaurants. Things like strawberries, spinach, and carrots bothered me. It was crazy. Many of the foods I was eating were beans; most beans bothered me at that time, and I wasn’t able to eat any of those foods. But now I can eat all of that because my immune system is healthy and I’ve retrained it. I’ve developed tolerance now that I don’t think everything I eat is foreign anymore. If you’re stuck with food sensitivities, I would recommend working with someone because that should always get better, and that needs to get better. That your immune system heals. You want to work on that. It can be a slow process, but that’s okay. You can reverse it and improve it over time. As you start to heal.

Laurie Marbas, MD, MBA

You’ll see someone has an issue with, let’s say, inflammatory bowel disease. Raw foods might not be so easy on their gut. How do we approach someone who is in the thick of a flare or something that is struggling? How can they start incorporating these anti-inflammatory foods when they’re just the forces on fire, so to speak?

Christina Miller, MD, FACEP

That’s a good question. That is a specific case where it’s a gut person. Because it’s the food and it’s the gut. People with autoimmune diseases in the GI tract. People with celiac, Crohn’s disease, ulcerative colitis, and microscopic colitis—those types of things are all autoimmune issues that can be hard when people are flaring. At that time, raw foods will be very irritating. You’re right. If you have blood in your stool and if you’re having significant inflammation in your gut, what you want is predigested, easy, soothing food. Because you have inflammation. At this point, you want to cook, eat, and even pre-blend. It’s baby food, things like vegetables, especially squashes and you put them in water, so make it a soup so there’s water in the vegetable, and then you blend it, and now it’s predigested. It doesn’t cause any inflammation. 

You’re starting to calm it down because you think about it. If you rub sandpaper in your hand and it’s irritated, now it’s red and it’s inflamed. Well, fiber movement is like sandpaper, your body is going to heal it. It’s the same thing in the gut; it’s like you’re rubbing sandpaper, and it’s so inflamed. If you eat raw foods, you’re going to rub more sandpaper on them. But if you take that out, then by pre-chopping, blending, and cooking it, it’s now soft and soothing, and your gut is going to heal itself. Then, as it gets better, you can slowly start to bring in more from cooked blended foods than maybe just cooked. Maybe start with a little bit of juice and get some micronutrients without the fiber. It’s still easier in your gut, and then you can start bringing a little bit of raw, maybe blended initially, and it’s very small amounts that you gradually increase, and once it heals, it heals just about any other part of our bodies; it heals the gut. The gut healing from an autoimmune condition. and then you’re just any other autoimmune person you want to start building up your microbiome again and achieving overall health.

Laurie Marbas, MD, MBA

Okay, so we have the lifestyle factors and medications as needed. Are there any other new things that we should be aware of? Maybe in research or so, you’re always reading about things.

Christina Miller, MD, FACEP

What I’ve lately been reading a lot about is the microbiome and how it’s not as straightforward as we thought, with certain bacteria being helpful. With lupus people, for example, there is a bacteria that they gave, and in one study, it helped their kidney disease. Those people who had that bacteria did better. But in another study, they got worse. Now that it’s the type, it’s more specific than just lactobacillus. It’s the exact, specific type. It also has to do with the status of their immune system. When the immune system is very active or hyperactive, it does tolerate the bacteria. When the immune system calmed down, those bacteria became beneficial. It’s very so, and that’s more nuanced than we understand yet. That’s not something one bacteria can do to help fix it yet. We don’t yet know that that’s one thing. 

The second thing I want to say is just about blood pressure. We know that when an autoimmune disease is active and you have antibodies, there is a high amount of antibodies in your blood that are linked with high blood pressure. Those antibodies are directly bothering your endovascular and worsening blood pressure. It’s another reason that you want to get that inflammation and those antibodies under control. I recommend using everything that you’ve got access to, whether that’s diet—that should be diet—or lifestyle—that should be lifestyle. When you need medications, get those antibodies down, get that inflammation down, and don’t risk long-term damage to your organs because those autoimmune diseases can get you. You want to get all that under control, which you can do using all of these modalities. We’re lucky we know so much about it that we can help people calm the immune system down. A lot of times, you can reverse things fully, which is amazing. But certainly, we can halt it. We can prevent that, and we know that.

Laurie Marbas, MD, MBA

Perfect. Now, I think those are all excellent points. This is fantastic. Thank you for sharing your information with us. Are there any final words you want to share with someone, anyone who’s struggling with a disease or hypertension in particular? But yes, any final words?

Christina Miller, MD, FACEP

I would say that don’t give up. Our bodies heal, and everybody’s individual. What works for one person may not be the exact thing for you, but when we get to the root cause and figure out why your body is acting that way, we can get better. Work with someone and know that it’s going to be okay and that we can get better at it. It’s a journey. It’s a process, but it’s okay. It’s a good one. It can be a good one. We can make the best of it, and we can have positives. People are healing and can do better. I want to give people hope that we can do okay. same thing with blood pressure. I would say to pay attention to your blood pressure. Do the mind-body work, do the lifestyle factors, and they do help a lot, make sure you keep that under control. there’s stuff.

Laurie Marbas, MD, MBA

I like that. Don’t give up. It’s important. Thank you, everyone, for listening today. We’ll be back with another very exciting conversation next.