um, since sometimes your recommendations deviate from the, the standards that one would find online or in the typical doctor's office, at what point do you get concerned? Well, I'm, I actually find myself, uh, quite in line with the most recent available data on blood pressure. And this has been, um, obviously there's a topic that's of high concern to any doctor who's taking care of patients who even pays a fraction of attention to the available literature, which is that basically with each subsequent blood pressure trial, the data are becoming clearer and clearer that the more aggressively you manage blood pressure to be within the one 20 over 80 range, the better.

So, you know, there's a recent study that even looked at going from what used to be considered acceptable, which was one 30 to one 35 over 80 to 85. We used to basically say that's kind of the first level of hypertension. And we would say, well, you know, do you really need to be better than that?

And the answer turns out to be, yes, you do. If you want to reduce heart attacks and strokes B, it's better to be one 20 over 80 than one 35 over 85. Now this is a whole other rabbit hole that we don't need to go down, but it's a total obsession of mine, which is how do you measure a person's blood pressure?

I think this is potentially, I'd have to give it thought, but honestly I could say top three under diagnosed fixable problems is the high blood pressure. It's one of the highest fixable problems in the United States today and probably globally. In other words, there are too many people walking around with high blood pressure who don't know it.

And I think part of the problem is it's something that is mostly done in the doctor's office and the readings that you get in the doctor's office can be often misleading. You've heard of this phenomenon of white coat hypertension. So you go to the doctor, your blood pressure is virtually never measured correctly in the doctor's office.

He's bold. Yeah. If you, if you look at the rigor with which you need to measure a person's blood pressure, the right way to do it is the person has to be sitting like this for five minutes doing nothing. Okay, folks. So when you go to the doctors now, you don't let them, don't let them take your blood pressure.

Sitting for five minutes and that doesn't include in the waiting room because if you walk, because then you get up and walk over. Right. Okay. So make them stand there. Right. So you, you want to be sitting there like this. A manual cuff is better than an automated cuff, but not enough people use manual blood pressure.

So a manual blood pressure means they put a cuff on you and they actually put a stethoscope on the brachial artery and they're, you know, using the human ear to listen, which believe it or not, you would think a machine is better, but it's not. The machine can be misled by different sounds.

Now I don't want to suggest that automated cuffs are useless. They're not. But when an automated cuff gives you an answer that is, you know, potentially suspect, always back it up with a manual. I'm pretty relentless about checking my blood pressure. And so I'll do side to side manual versus automated every day.

And there's easily a 10 to 15 point difference between them. Maybe this is a silly question, but can people check their own blood pressure? Meaning manually? Yeah. Just could it, could I get it, get a cuff and a bulb and learn how to do it? Yeah, I think so.

I mean, I can do it, but honestly, I usually have my wife do it. She's a nurse. But it's not rocket science to check blood pressure. I guarantee you, there's a great video on YouTube that explains the physiology of it. And if you're willing to splurge on a good enough stethoscope and cuff, like the cuff I have is really easy to use.

Like it's once you put it on, you know, it's in a single thing I'm squeezing the bulb and looking at the pressure gauge while I've got the, you know, stethoscope on my artery. I mean, given the importance of blood pressure and this arteriosclerosis being at the top of the list of risks for dying.

It seems to me it might be worth the expense. What, what's a typical range of costs for, for the quality? I don't, it's not, it's not an ordinate. Like I feel like my blood pressure cuff is 40 bucks and the stethoscope is a couple hundred bucks if you're getting a good one.

And you know, good automated cuff. There's, I, I have no affiliation with any of these companies. I use a, I use two automated cuffs. One's called Withings and the other one's made by a company called Omron, O-M-R-O-N. And they're both decent, but again, they tend to run high and I have yet to find a credible explanation from cardiologists as to why.

Everybody acknowledges that the manual one when done correctly is the answer, but I've heard wonky answers about why automated ones are sometimes incorrect. And again, it's just made me realize we're not checking blood pressure often enough on people. We're overly relying on blood pressures in the doctor's office, which are not being done correctly.

So we basically have our patients do this relentlessly. So how often, let's say someone buys this, cause I think for $240, I mean, I realize that's prohibitive for some people, but given the cost of some of the other things that are discussed on this and many other podcasts, I would just have people start with an automated cuff to begin with and just start with there.

We generally have people do it for two weeks. You know, we give our patients a little spreadsheet that automatically calculates averages and stuff like that. Tells them what to record and where. And we just say, look, for two weeks, we want to see two recordings a day. And you know, do in morning and an afternoon slash PM recording twice a day for two weeks and let us see those numbers and we'll scrutinize them further.

And if those numbers come in fine, let's revisit in a year. Will a day ever come when a watch or a wristband can do this really well? So I hope so. And I'm investigating it. I I'm actually going to be trying one out in a couple of weeks with a company that I tried two years ago, two years ago when I tried it, I was not impressed.

So I kind of punted on it. The company, which I guess I'll not share the name of the company just yet, but they, they claim that it's significantly better. So I'm going to put it to the test again and it's basically a continuous monitor. So it, it's a wrist device that about every 15 minutes throughout the course of the day, we'll check your blood pressure.

To me, this would be honestly probably more important. You know, you know how much emphasis I place on CGM as a great thing to be able to test glucose monitor, right? I would argue this would be more important when the day comes that we can continuously assess people's blood pressure.

It would be an integral part of a person's, you know, health checkup once a year is do two weeks of continuous blood pressure monitoring right now to do that, which I've done as well is so cumbersome that it borders on absurd. You actually have to wear a blood pressure cuff that is attached to a clumsy device that goes through the whole insufflation exercise every 15 minutes, including while you're sleeping.

You know, it provides some insight, but it's so disruptive that it's not what we really want. What we, the dream would be like a patch that you could put, I don't know, over your chest that can somehow impute changes in blood flow or something like that and regulate. But we'll see, you know, between optical sensors and things like that.

I hope that we're getting closer to having something. . .