Exercise & Sauna Therapy For Hypertension

Ari Whitten, MS

Thank you so much for having me.

Laurie Marbas, MD, MBA

Wonderful. In the context of hypertension, any lifestyle intervention that’s moving towards a healthier journey is going to make a difference. But today we’re going to highlight exercise, particularly sauna therapy and things like that, which is your expertise. Could you give us a little bit of a broad background on where you’re coming from and then maybe highlight how we can start looking at helping people with their hypertension?

Ari Whitten, MS

Do you want to hear about my personal story or just my philosophy?

Laurie Marbas, MD, MBA

The philosophy or your background, whatever you feel would be helpful for us to understand where you’re coming from in reference.

Ari Whitten, MS

I guess very briefly about me in particular: my background is in studying exercise science, and nutrition from a very young age. I’m 40 now. I’ve been studying this since I was about 12 years old, originally in the context of being an athlete and being into fitness and bodybuilding. My expertise is a bit different from most people who are probably on this summit in the sense that my background is in health science, not in studying pathology and disease science, and this is a very big distinction. The older I get and the more I have conversations with people, the more I realize what a big distinction it is. I guess as an analogy, if the way I perceive things is a philosophy of how we need to look at human health, you could say that if we wanted to build a beautiful garden, there might be two different kinds of experts that we might enlist in the process of trying to do that. One might be to develop a whole body of expertise on the types of pathologies that might afflict that garden, like weeds and garden pests, and to develop a large body of expertise on the different types of chemicals that would be appropriate to use to get rid of each one of those types of garden pests or weeds. It’s an entirely different body of expertise that one might have that’s about how to cultivate and nurture a wide diversity of plants that yield abundant food or that build a beautiful garden. These are different kinds of expertise. One is about combating the negative. One is about building the positive. The more that I study health, the more that I’ve learned about disease, and I have taken lots of graduate-level pathology courses in pharmacology, genetics, immunology, and all kinds of stuff. The more I realized that building the positive generally is a more effective approach than trying to combat the negative, in other words, think about cultivating positive function, performance, and health rather than trying to fight against a particular disease, Pathology tends to be more beneficial. That’s one of my core philosophies and biases. 

I also come from a very strong experiential background in health, meaning I’ve been experimenting with my body to enhance performance for almost three decades now, as opposed to just studying intellectually in a classroom about different diseases and different pharmaceuticals that might be appropriate to prescribe for those diseases. The other thing I would say is that my background or my bias is strongly in favor of an evolutionary bias, looking at health through the lens of evolutionary biology. One thing that might be important in this particular context through that lens is as we look at hypertension and the consequences of hypertension, let’s say heart disease, heart attacks, strokes, things like that, or even other brain conditions. What are the incidents of those very same problems in traditional living humans and, for example, hunter-gatherer tribes that have been studied over the last few decades that still exist? We don’t have to invoke theories based on looking at bones from gravesites from 10,000 years ago. But hunter-gatherers still exist in many places around the world. I shouldn’t say many, but in some places around the world, we can study them. They have been studied. We know about these kinds of things. For example, the Simone Tribe in Bolivia has been well studied for its incidence of cardiovascular disease and heart health. They have almost zero incidence of cardiovascular disease, heart attacks, atherosclerosis, and hypertension. It almost doesn’t exist in traditional living human populations. Now, in any group of scientists that wasn’t so uniquely obsessed with pharmaceutical interventions for diseases, that would be an extraordinarily important finding, because what it would tell us is maybe the answer isn’t to study disease, people with this disease should figure out the mechanisms of this disease so that they can go into a chemistry lab and synthesize man-made chemicals to fight it. Maybe a better approach would be to study people who don’t have this disease, figure out why they don’t, and mimic their behaviors. That’s a bit about my philosophies and biases.

Laurie Marbas, MD, MBA

We’re very strongly aligned. I came out of allopathic training as a physician, but I am also a family medicine physician and I am also a double board-certified in lifestyle medicine. So it’s taking people back to those healthy behaviors and aligning them with the understanding that they can change. Unfortunately, we catch them when they’re sick in the traditional medical system. We’re reacting, and it’s going upstream. I like your effect there. Maybe we can start with how far upstream you are and what your expertise is in the exercise. Where does that come from, and what have you seen working with people across your 30 years of study?

Ari Whitten, MS

More broadly, if I can zoom out for a second, it places hypertension in the context of diseases of civilization. These are modern diseases of the modern environment and lifestyle, and they are also, alternatively, sometimes called diseases of aging or chronic diseases of aging. This includes things like heart disease, diabetes, cancer, stroke, dementia, Alzheimer’s, and several other diseases. But what’s interesting is that the number one risk factor for these diseases is aging itself, which means being old. It is a much more powerful risk factor than any other risk factor, including things like smoking, physical inactivity, or something like that. Now, the reason why that happens is that many of these diseases are essentially the consequences of accumulated damage to the structures and functions of key organ systems in our body. I’m trying to think about how deep to go into this answer, but the issue with that is that our common way of approaching many of these diseases is twofold. Number one is that once you have accumulated a very large amount of physical activity, it’s not just changes in your biochemistry. This is a thing that many people think. They think that when they go to the doctor, they get a blood test. Their blood test shows them chemicals floating around their blood, and their health is a reflection of that. 

Your health is also largely a product of the actual physical structure of the cells, tissues, organs, and systems of your body. If you accumulate enough damage to that structure, it’s very hard and, at a certain point, impossible to reverse it and bring it back to a youthful, healthy structure. That’s one thing. The other thing I want to add to this is that it is also largely an illusion that we’re just working on one thing. When we look at most of these chronic diseases of aging, they almost co-occur with other kinds of dysfunction or disease and damage to structures and organ systems in many other systems of the body. The body is highly interconnected, and we generally don’t have isolated dysfunction and damage in just one system without it occurring in several other systems. This bears out in the statistics when we look at these diseases: most people who are over the age of 65 or 70 have multiple conditions and are on multiple different drugs for different symptoms or different diseases. So this is the reality. It’s a very common misconception that many people have because we list causes of death. This person had a heart attack, this person had cancer, and this person had diabetes. We have, I would say, in the general public, the illusion that we’re fighting against just one thing, one isolated disease. But what I’m trying to do is paint a picture that what we’re trying to do and what is most effective in minimizing these different diseases of civilization or diseases of aging is prevention, being healthy, and doing interventions upstream before you have decades and decades of incurring lots of damage, dysfunction, and physical alteration of the structures of your tissues. That’s the broad answer to that question.

Laurie Marbas, MD, MBA

I guess my question is: how do you get people to participate in this society that we’ve built? This environment, I feel, triggers. How do we get people interested outside of those who are looking to optimize human potential? There are those athletes and others who like to do like, in one set of experiments, how do we encourage or get people interested in this proactive element? Because it’s so hard to envision yourself older now when you get there, because I’m like, in my mid-fifties now, like, I get it. But when you get a young person and they’re like a 56-year-old so far away, I’m going to enjoy myself now. How do we start that conversation? Any thoughts?

Ari Whitten, MS

What you’re getting at is psychology, behavior, and paradigms. and this is a very complex question. If I had all the answers to that, then we could solve over 80% of the disease burden because over 80% of the chronic disease burden is caused by these diseases of lifestyle and civilization. If you can effectively do it, what you’re asking and what you’re alluding to in this question is to get people, the entire population, to make smart decisions when they’re young, before they have health problems, instead of trying to wait till they have health problems and then react to them and say, Doc, what? What drug should I take for this problem? If you can do that, you could eliminate 80 percent of the disease burden. Now, as far as being very blunt, look, I’m the way I look at health. Since I’m not a clinician working one-on-one, I’m more of a teacher of health science than I am a clinician who works one-on-one with people who have a disease. There’s a place for both. But given that I’m in that position if it allows me to look at things from a more meta perspective if you’ve got somebody sitting in front of you who says, “I’m 65, I’m 70 years old, I’ve got hypertension, I’ve got kids, and I’ve got to support my family.” You have to help that person. What are the interventions that you can do to try to lower that blood pressure and get that person as healthy as possible or functioning as best as possible? I’m looking at things more on the population level from the metaphor aspect and saying, as I said before, that this population over here that lives this way doesn’t have this problem at all. Maybe we should mimic those behaviors. Now, to answer your question, how do we get more people to do that? Number one is education. We can only make those kinds of decisions if we know. If you have people out there teaching science so that they even understand this, I would say the vast majority of the population isn’t even aware that there are human populations that exist without these problems and that that is even a possibility. 

Most people are walking around thinking that this disease runs in my family. Heart attacks or high blood pressure run in my family. It’s genetic. My dad had it, and there’s nothing I can do about it. I go to the doctor, and they prescribe a drug that’s evidence-based medicine. That’s most people’s perception; number one is realizing, no, this is not a genetic disease. This is a disease of lifestyle. It is possible to not have this disease if you have a healthy lifestyle. And then, secondarily, what are the components of a healthy lifestyle? How do you implement that so that you can be free of this disease or avoid it in the first place? if you catch it early enough to reverse it? Psychologically and behaviorally, that’s very problematic because, as you were alluding to, many people operate in a frame where they’re only interested in doing something about it. When they have a problem, when they’re experiencing enough pain that they go, I’ve got to do something about it now. I’m willing to make changes. The reality is harsh. This is, again, something that I can do as more of a teacher of health science than a clinician. I can look at things from this population perspective. The reality is that some people are going to be smart enough to realize and educate themselves about the care of this physical body that exists, and some people are not. Some people are going to learn enough about it that they realize that the only way to live a long time in good health is to make decisions to care for this physical body before you have widespread degeneration and damage to the different organ systems. Certain people will do that. I would say smarter people who are more motivated will do that, and a certain segment of the population won’t. That’s the harsh reality. Like, if you’re asking me, how do we get all the people who don’t want to do that to do that? That’s a very difficult question. I don’t think you can educate people. You can teach them its importance, and then it’s up to them to decide whether they want to prioritize it or not.

Laurie Marbas, MD, MBA

That goes back to a macro level, that we have to create environments on a societal level that make the healthier choice the default answer, and we take the human element out of it because this is what we do in our society. We’re so far away that I don’t know if we can ever get back, but that’s the easier answer than individual human behavior changing it.

Ari Whitten, MS

If I were in charge of health policy from the government and I was in charge of the government, the way the government regulates the food industry and the way that environments of cities are designed, as far as how it either lends itself to non-conscious physical activity or not, I could create workstations for individuals in every environment that were treadmill desks and whether they worked on cycling desks, where they had to provide electrical power via pedaling the bike to charge up their computer and things like that. Would I do that? Would I design the environment in a way that naturally facilitates that without relying on individual choice, willpower, or education? That’s a great addition to that. The reality is, though, that twofold, number one, we’d be waiting a long time for that to happen. Sadly, there are way too many financial interests that are at odds with that, particularly the food industry and the pharmaceutical industry. We could add to that as well. But certainly, the food industry doesn’t, which is a very, very big industry. All of those financial influences aren’t necessarily too happy with the government deciding, that all this processed food and all this refined food full of added sugars and added oils, we’re just going to get rid of all that because we care about population health and ending diseases. The problem is, they’re going to fight against that. It’s a broader, very complex battle.

Laurie Marbas, MD, MBA

This conversation is so grim, but tell me grim things. When we back up and think, Okay, there will be people who choose to engage in this, and maybe they can have a ripple effect. There is a contagion with behaviors. So I guess my question would be, if we go back to your expertise when you said exercise and the other things that you’ve seen can help people either prevent or even potentially reverse certain chronic diseases, what would you like to highlight, and can you give us some mechanisms for how those things work?

Ari Whitten, MS

I would say one of the big things we need to look out for when we’re talking about hypertension is vasculature remodeling. the way that blood vessels remodel themselves over time, and in particular in the absence of certain forces that are present in, for example, those hunter-gatherer populations that I was speaking about earlier, and in the absence of those forces, the vasculature remodels in a way where it becomes stiffer and more fibrotic. In particular, the middle layer of the arterial vessels develops more of what are called synthetic fibers instead of contractile fibers. If you want to think about it, think of it as stiff, fibrotic tissue instead of the muscle that can move. The more that your vessels remodel themselves over time to have more of those synthetic fibers as opposed to the contractile fibers, the stiffer those vessels get and the more total peripheral resistance you get. This is a term that describes, essentially, how much resistance the heart has to push against when it contracts. How much if you have a physical pump? Like when I was a kid, I did aquariums a lot. I was very into coral reef aquariums. I worked in a coral reef aquarium shop. I was very into marine biology. I experimented a lot with plumbing. If you take a pump and you have to pump through a longer distance of tubes or the tubes are thinner, or those kinds of things, it influences very heavily how effectively, how fast, and how much water will be pumped through those tubes. The same thing is true with the vasculature in our body, and what most people don’t realize is just how malleable that vasculature is. That is, we all have, let’s say, in the aorta. There’s something we have; we all have certain vessels. But there’s a big difference between a high-level athlete’s vessels and a sedentary person’s vessels. One of the things that exercise does is stimulate capillary action. You get to build a whole bunch more capillaries in the different tissues of your body. You also build the ability to profuse those tissues more effectively and to pump blood into those tissues. You also develop adaptive changes in the heart muscle itself to be able to pump blood more effectively. All those vessels themselves, including the bigger vessels, also have more of the contractile fibers instead of the synthetic fibers, so that they can expand and contract more easily instead of being stiffer and stuck in a more rigid position. All of those changes hugely influence, essentially, how easily the heart pumps fluid through all of those vessels. The stiffer those vessels become, the more they lose their elasticity, and the more peripheral resistance you get. the more, and this is a hugely predictive factor for generating hypertension or developing hypertension, I should say. 

One of the biggest risk factors for developing hypertension is a lack of physical activity. This is a major reason why hunter-gatherer populations don’t have this condition. They do lots of physical activity. There are many different studies, and you can measure this in a variety of different ways. You can measure it like the total amount of sedentary time during the day. There have been studies that show that people who spend more sedentary time versus less sedentary time during the day are 50 to 60% more likely to develop hypertension. You can also measure it in terms of total physical activity per week, and this differs depending on the country in which you measure it. You have studies in the United States where there’s a 50 to 60%, 70% increased risk for developing hypertension if you have lower levels of physical activity in other countries, I found a broad review of studies from Ethiopia, and in the population there, the difference between which is, you would say, more traditional living people, where I’m well, there’s probably a broad range of differences, but maybe less contribution from factors like a processed diet in a population like that. The studies there generally show somewhere between 250 and 700% differences in the prevalence of hypertension among physically active and physically inactive people. This is a huge factor. It can also be measured as a function of VO2 max, which is your body’s maximal oxygen utilization capacity, essentially a function of how fit you are. It’s a reflection of your built capacity—a combination of your muscles, your cardiovascular and respiratory systems, and your mitochondria—to utilize oxygen. That shows about 90% increased risk, or, you could say, 90% reduced risk, over five years in people with high levels of VO2 max versus low levels of VO2 max. This is not; I’m not talking about 5% or 10% increased or decreased risk. We’re talking about very, very huge numbers in terms of how much this one factor alone—physical activity—influences our risk of developing high blood pressure. Of course, there are lots of other factors, like smoking and alcohol consumption, night shift work, stress, and a poor diet. One of the other big factors is excess body fat itself. 

A huge proportion of the population in the U.S. is overweight or obese. The last time I checked, it was 70ish. Percent is overweight or obese. There are a few different mechanisms at play as far as how excess body fat relates to this. One is how it modulates the autonomic nervous system. You get an increased sympathetic nervous system tone and a decreased parasympathetic tone. But there is another factor at play, which is that the actual physical fat itself compresses the vasculature in many places, particularly the kidneys, for example, which is another way that increases this peripheral resistance and increases the amount of force that’s necessary to pump blood through the arteries and the vasculature. When we look at things from the perspective that I like to look at things from, which is this evolutionary biology perspective, it becomes very obvious that, hey, if we just did two very simple things, if we weren’t overweight or if we didn’t have an epidemic of overweight and obesity, and if we were physically active, we would probably reduce the epidemic of high blood pressure by, I don’t know the exact figure, but I want to say maybe 80–90%. just those two things alone. These are huge things. The key message that I would say to people is to realize, like, get out of the mentality of, number one, thinking that there’s a remedy for your condition, that either it’s a chemical drug that is going to solve that issue, which is an issue that is caused by lifestyle factors over many years or decades, or even a natural remedy. Whether it’s garlic extract or whatever supplement, some supplements can help, and it’s not that I’m opposed to doing that. It’s that we need to think about root causes first and foremost.

Laurie Marbas, MD, MBA

It’s 100%. But let me just take a moment here to thank everyone for joining us. Thank you so much for joining us today. I hope you found this conversation insightful and engaging. Now, if you’re a summer purchaser, stay right here because we have a little bit deeper dive into this captivating discussion. If not, click on the button below or decide to access the rest of the conversation. If you’re watching this, thank you for being such a valuable member of our community. I want to continue with the question, Ari: Is there a particular type of exercise or a regimen that you like to encourage people to partake in to help with their overall health?

Ari Whitten, MS

Great question. I would say a few things about this. Number one, before we get into types of exercise or structuring a routine, one point that I would make is that almost all types of exercise that have been tested have a beneficial effect on reducing blood pressure. We can quantify the differences between different types of exercise and say, This one’s better than that one. This question is also more complicated than just what type of exercise is most effective for reducing blood pressure. We have to realize that blood pressure itself isn’t the end goal. Blood pressure is a physiological marker. We’re measuring something that is predictive of other bad things happening to us, in particular heart attacks, strokes, and things like that. We have to make sure that we’re not so obsessed with the marker that, as the famous Chinese proverb says, don’t focus on the finger pointing to the moon. Focus on the moon. We have to remember what the actual end goal is. We can talk about types of exercise that have a greater or lesser impact on blood pressure, specifically. But we need to think about the bigger picture context of also what is the best type of exercise or best exercise regimen that is effective for reducing the thing we are trying to prevent when we’re talking about blood pressure, like heart attacks and strokes, and that changes the discussion a bit, and I’ll tell you why in a minute. We could further expand it out, which is what we care about not dying from a specific disease but dying at all from anything. So that’s even a bigger picture in context. What’s the most effective exercise regimen as far as reducing all-cause mortality and improving the reverse way of saying that, which is improving the overall health of most systems of our body most effectively? Now, in terms of specifics, let me say first of all that there’s research showing that there’s a transient effect from exercise and a longer-term effect of exercise. One is a transient effect: if you do a workout for the next 15 minutes or hour and for the next 24 hours after that, you will have a reduction in blood pressure, maybe five, or ten millimeters, or mercury. and that’s a nice thing. We should capitalize on that. The way we capitalize on that is to exercise every day—some type of exercise, something significant beyond just walking. Some like real exercise, and walking doesn’t count. Walking’s great. It’s a great start, but we shouldn’t count walking as exercise. We should think of exercise as something with a bit more intensity than not. But we should number one, make sure we are doing some moderate-intensity or vigorous exercise daily, irrespective of what type of exercise it is now in terms of types of exercise. That’s a transient effect. 

The longer-term effect is that when we exercise, we are creating stress on the system, and fortunately for us, we have this magical ability to sense these stress signals and adapt to them. We have the ability to adapt at many different levels in our system. We can sense when there is a need to have bigger, stronger muscles, and we can do that. We can sense when there’s a need to grow faster or to develop more balance or stability. We can sense when there’s a need to develop more mobility. We can sense when there’s a need to do all kinds of things. We can sense when there’s a need to grow more mitochondria in our muscle cells. We can sense when there’s a need for our hearts to become stronger, for our vessels to become more elastic, and for our lungs to develop greater capacity. We can make many different layers of adaptations in many different systems of the body, and those longer-term adaptations are particularly important. When we’re talking about hypertension, particularly at the level of the heart and the vasculature, it has a big impact on baseline levels of blood pressure beyond just the 24-hour period after you do a workout. But we’re talking about regulating your blood pressure at a lower level than you did before. That’s what we’re after. The transient effect of reducing it for 24 hours is that we should just look at that as an added bonus. You do some type of exercise every day to get that added bonus effect. But what we’re trying to do is change the physical structure of our systems, particularly the elasticity of our vasculature, so that we can regulate our blood pressure at a new lower baseline. Now, how do we do that? There are various studies, each with its own set of limitations based on how they approach the subject. There was an interesting study that got a lot of press that just came out a few months ago, in October 2023, that compared different types of exercise in terms of their effects on blood pressure, and they compared high-intensity interval training to aerobic endurance training to resistance training or weightlifting to combined resistance with aerobic training versus isometric training. The big press and the big headlines from all of the studies were that surprise, isometric training was the most effective. 

Going back to what I was saying earlier about the importance of context, we might conclude from this study that, okay, well, I don’t need to do all those other types of training. I just need to focus on isometric training because that’s the best one. It reduced blood pressure by eight or ten millimeters of mercury, versus four or six from these other types of training. Therefore, that’s the one I should focus on. However, when we expand our context to what I was describing earlier, how do we prevent heart attacks and strokes? How do we prevent dementia and Alzheimer’s? How do we prevent diabetes? How do we prevent cancer? How do we prevent dying from all causes? How do we have the most energy and vitality in terms of positive function, but not just this fixation on disease, combating disease, or preventing disease? But how do we have a higher-performing and more energetic body and brain, reduce our risk of dying from any cause, and live a longer time with a longer health span than just our lifespan? When we expand into that context, which is what we should be doing, we don’t want to become fixated on one disease or one marker of a disease. Then we realize, well, resistance training induces many different adaptations that are unique to resistance training and that are beneficial. For example, one of the leading causes of early death in people over the age of 65 is sarcopenia and frailty, loss of muscle mass, and physical weakness. Resistance training is uniquely good at that and also has a benefit in combating hypertension and lots of other benefits, including combating osteoporosis. Uniquely good at, aerobic exercise is uniquely good at inducing adaptations at the level of the heart and the vasculature, inducing more capillary development, reducing peripheral resistance, reducing our risk of heart attacks and strokes, and inducing beneficial changes at the level of mitochondria throughout our body, which improve our energy and our overall metabolic function and metabolic health, which translates into a reduced risk of all kinds of other diseases, even psychiatric diseases, diabetes, or all kinds of different things, and improves our overall function and energy levels. What I would say is that when we expand to that bigger perspective, we want to have endurance training and we want to have resistance training. We probably also want to have some high-intensity anaerobic training, like high-intensity interval training or sprint training. If you want to add as a bonus some exercise that has been found recently to be uniquely beneficial in reducing hypertension, add in some isometric training, which is easy to do in the context of your weight training and resistance training workouts. Add a few minutes while squatting, which was, in that study, the single most effective exercise in terms of reducing hypertension. You can, every time you work out in the gym, do a two-minute squat, build on it, and try to do two minutes and 10 seconds. The next time you do two minutes and 20 minutes, build up to five minutes and build up to eight minutes. As long as you do that, you can have that effect. But again, it’s in the context of an overall structured regimen that includes many of these different types of exercises that together create broad protection against a whole range of different diseases while affecting hypertension, boosting positive function, and boosting energy and performance. At the same time.

Laurie Marbas, MD, MBA

You’ve painted a beautiful picture of getting out and moving in your either, describing endurance training, strength training, and, of course, flexibility and balance training, especially as we get older. The wall squats and there’s a cool study. I read it a while back, and it was like, remember those times when you’re in the gym and you’re a kid and they make you say, But this is great? If this doesn’t encourage everyone, get out and move their bodies a little bit more than they did yesterday. I don’t know what will happen, but thank you so much for your time today. It was interesting, and I enjoyed the conversation.

Ari Whitten, MS

It was a pleasure. Thank you so much for having me.