Ben Greenfield [00:00:00]: My name is Ben Greenfield, and on this episode of the Boundless Life podcast.

Dr. Jay Shah [00:00:04]: It is the number one preventable cause of death in the world. By far. It causes 11 million deaths per year. Roughly one in three of the world's adults has high blood pressure. 50% of people don't even know that they have it. It is the number one sort of preventable chronic disease in the world. It's something to track and optimize. It exceeds almost every other biomarker in importance that I can think of.

Dr. Jay Shah [00:00:31]: High blood pressure isn't just a disease of elderly. High blood pressure often starts in our 20s and 30s of life. And the thing is, it's silent, right? You don't feel high blood pressure. It's insidious, it's silent. And over time is where it does its damage, such that by the time someone's 55, 60 and has a heart attack, has a stroke, has kidney disease, has some other major event caused, hypertension, it's way too late. But that's when we identify it, oftentimes because of the acute event that happens at the end of 20 to 30 years.

Ben Greenfield [00:01:06]: Welcome to the Boundless Life with me, your host, Ben Greenfield.

Ben Greenfield [00:01:11]: I'm a personal trainer, exercise physiologist and nutritionist. And I'm passionate about helping you discover.

Ben Greenfield [00:01:17]: Unparalleled levels of health, fitness, longevity and beyond.

Ben Greenfield [00:01:27]: Well, I've been called sometimes in the past a self quantification nerd. I don't wear that many wearables, okay? Even my watch. I have like this cheapo, like $12 Timex watch because I'm notorious for losing my timepieces. But I do wear a continuous glucose monitor, cgm, back of my arm here. If you're watching the video, I wear a self quantification ring and bounce all over the place. I've used the aura, I've used an ultra human, I've used Luna. But I've been messing around with this thing Again. If you're watching the video, I'm holding up my wrist right now.

Ben Greenfield [00:02:06]: It's this little black circular or. Well, of course it's circular, it's around my wrist. But this little black device, and it's my new continuous monitor. I'm going to let you guess maybe as you're listening in, what this thing is actually tracking in real time. But a big clue for you could be my guest on today's show. His name is Dr. Jay Shah. He's a cardiologist and now the chief medical officer at a company that's currently called Actea Medical.

Ben Greenfield [00:02:40]: And he has brought this new continuous monitoring technology to the world to allow us to track what is a big silent killer that addresses one in two adults globally. So if you are seasoned in epidemiology and medicine, you might know what I'm referring to. But if not, you're about to find out. So, Dr. Shah, welcome to the show.

Dr. Jay Shah [00:03:08]: Yeah, thanks very much for having me, Ben. It's great to be here.

Ben Greenfield [00:03:11]: Yeah. So I guess let's address the elephant in the room right now. What is this thing on my wrist actually measuring it? And how did it come to be.

Dr. Jay Shah [00:03:20]: Yeah, blood pressure. Yeah, it's a continuous blood pressure monitor. It's the first of its kind, the first to be commercialized. It's been developed over 20 years, although the company has been in existence really 6. Spun out of a Swiss research institute, and the founders have developed this technology. It's based on optical sensors, so it uses just green LED lights that we're familiar with in most smart wearable devices. And it shines a reflection into the skin, gets a reflection back, creates a waveform in our model, which is the real secret sauce. The real IP is in the cloud, and it analyzes those waveforms and delivers back a blood pressure and heart rate values.

Dr. Jay Shah [00:04:06]: It is a Class 2 medical device. It has to have regulatory approval in all markets that we sell and market in. And that's what it is. It's the first of its kind, a real time continuous blood pressure monitor.

Ben Greenfield [00:04:18]: Okay, I'm going to play total skeptic here. Even though I have been wearing this thing for like four weeks, you graciously sent me one to experiment with. You see, a lot of these devices come out. Like, a lot of people raise their eyes at sleep trackers when they first came out and said that they really couldn't match what you get in an actual sleep plasmography lab or other people. They think this device that you blow into that can measure your calories or your carbs or fat could in no way match what we get out of an exercise physiology lab using calorimetry measurements. Now, when it comes to blood pressure, how much does this actually correlate or how accurately does it correlate to the traditional blood pressure cuff?

Dr. Jay Shah [00:05:04]: Yeah, it's a good question. I would say the first thing to say is that all blood pressure monitors that are designed for use at home and the most common one is the one that you're just referring to this thing. This is 130-year-old piece of technology that we've been using over a century to try to estimate Blood pressure. The only way to measure blood pressure is to put a catheter into the artery with a pressure transducer. All at home devices are some version of estimating blood pressure based on some algorithm. And that's what cuffs are as well, with how we've developed the product. And remember, It's a Class 2 medical device. So it's not just some consumer electronics gadget or technology.

Dr. Jay Shah [00:05:49]: It has to get regulatory approval for us to sell and to get regulatory approval, which means that we have to do the clinical validation studies and demonstrate to the notified bodies, regulatory authorities that we meet the same precision or similar precision and accuracy to a standard reference device. And we can go into how we do that. But basically we use a manual upper arm cuff as our gold standard. That's what we test against, against. We show our data of precision and accuracy to the regulatory bodies and they have made the decision to make, you know, in the countries we're in, to give us approval.

Ben Greenfield [00:06:25]: Yeah. When the package that you sent me showed up to my house, there was actually a cuff in there. And when I first put the bracelet on, I had like a five minute measurement where I was sitting at my table, staying still, not talking. And the cuff was, what do you call it, you know, pressurizing, was doing what a normal blood pressure cuff would do. And I'm assuming that's some kind of an initial calibration that you do with the cuff that comes with the wrist monitor.

Dr. Jay Shah [00:06:53]: That's exactly right. So when and as per our indication for use and labeling, every that step happens every 30 days. So on day zero, when you take it out of the box, you do an initial calibration where we get simultaneous bracelet data and cuff data and then every 30 days that step is repeated. Now why does that happen? Well, the first thing is that that step, even though it's a point of friction in our product, has helped us really train our models over time to get better and better because we have this simultaneous cuff and bracelet data now on over 100,000 of our users and counting and so hundreds of millions of annotated data points. So that's the primary point is it's really helped train our models for precision and accuracy and it gives the bracelet sort of a ground truth measurement. That's what that calibration step is used for.

Ben Greenfield [00:07:49]: You know how when you go to the doctor or go to give or not? Well, yeah, give blood, but give blood for laboratory analysis, which I've done three times since I got the blood pressure monitor, they take your blood pressure. So I was just curious. And every time they took my blood pressure, I would simultaneously pull open the app that correlates to this continuous blood pressure monitor and compare the values they got to what my averages had been. And even though you can't push a button to make it take an acute measurement, I was basically seeing how closely the values from the wearable correlated what the doctor was getting. And it was within like a couple of points. They were actually really surprised. The doctors were. There was, there was even one clinic that I went to, they'd probably get in trouble if I said this, but they couldn't get their cuff to work so they just had me use the bracelet.

Dr. Jay Shah [00:08:44]: That's not uncommon. You know, there's a, there's a, it's, it's not, it's a double digit plus percentage of cuffs in offices and hospitals aren't functioning properly. So it's not an uncommon thing. And beyond that, our perspective is that any single point in time, measurement of blood pressure is fundamentally not that important because that's not how blood pressure works physiologically. That's not what the risk is over to your body over the long term. It's what is happening over long periods of time. Weeks, months, years, not any one point in time.

Ben Greenfield [00:09:17]: Right. Same reason you'd use a continuous glucose monitor versus just going to the doctor once a month and getting your fasted glucose taken, which could be elevated from a cortisolic response to driving through traffic to the doctor's office to maybe you forgot you were supposed to be fasting and put sugar in your coffee morning. A host of variables. So this idea of continuous data obviously makes sense, but I want to backpedal a little bit to the big why that you would think about this in the first place. It's my perception, Dr. Shah, in the health, fitness and biohacking industry that people do recognize things like say visceral fat accumulation and body fat percentage. They really pay a lot of attention to glucose monitoring, to blood and biomarker analysis these days, even hrv, sleep activity, et cetera. But I don't see hypertension or high blood pressure talked about that often.

Ben Greenfield [00:10:17]: I think it's kind of perceived to be the old person care, home issue and not something you really got to worry about until you get older. But talk to you about hypertension and why it is that this would be something helpful in the first place and how big of a deal hypertension actually is.

Dr. Jay Shah [00:10:34]: You mentioned all those things that people look at and measure and try to sort of gain insights from arguably high blood Pressure and hypertension is bigger than all of them combined. I'm not even sure it's arguable. It is the number one preventable cause of death in the world by far. It causes 11 million deaths per year. One in roughly one in three of the world's adults has high blood pressure. 50% of people don't even know that they have it. And so it is, it is the number one sort of preventable chronic disease in the world. And in terms of as a biomarker, as something to track and optimize, it exceeds almost every other biomarker in importance that I can think of.

Dr. Jay Shah [00:11:23]: And why is that? It's because, first of all, high blood pressure isn't just a disease of elderly.

Ben Greenfield [00:11:31]: My dad growing up, he was a paramedic and a firefighter. Every week I used to go with him to the local care center where we do blood pressure measurements on people. So for like two hours a day, once a week. Growing up, for two years of my life as a kid, I'd go and see old people and help my dad give old people blood pressure measurements. So for me, it was just kind of like built in. This is what old people do. But I don't take my own blood pressure that often.

Dr. Jay Shah [00:11:57]: Exactly. But that's where the misconceptions start, is that high blood pressure often starts in our 20s and 30s of life. And the thing is, it's silent, right? You don't feel high blood pressure, you don't feel it in your back the way you feel back pain or knee pain or some other symptom, physical symptoms. And the thing is that it's insidious, it's silent. And over time is where it does its damage, such that by the time someone's 55, 60 and has a heart attack, has a stroke, has kidney disease, has some other major event caused by hypertension, it's way too late. But that's when we identify it. Oftentimes because of the acute event that happens at the end of 20 to 30 years. For women, this is even more important.

Dr. Jay Shah [00:12:42]: Pregnancy induced hypertension or postpartum hypertension, meaning high blood pressure that can happen during or after a pregnancy. It's actually one of the key, and I wouldn't say it's exceedingly common, but it's one of the most serious complications of pregnancy. And again, completely under diagnosed and underrepresented because we are often told that cardiovascular diseases and high blood pressure are disease of older people, maybe more so men. That's the perception. So women kind of feel like, okay, they're kind of safe, so to speak, until they get into their 50s and 60s. That's not true. So it's an important, really important parameter that we need to be paying attention to earlier in life, actually, that's when it matters.

Ben Greenfield [00:13:28]: Diabetes, let's say nonalcoholic fatty liver disease. Those are two I can think of off the top of my head, that we're now seeing with increasing frequency in younger populations. Can you say the same thing for high blood pressure?

Dr. Jay Shah [00:13:43]: Yeah, the thing is, it's just underdiagnosed. As I said, 50% of people don't even know that they have it. And the end results of high blood pressure are so varied and different from aneurysms in the brain. Strokes, eye problems, retinal issues, heart issues from heart attacks, heart failure, arrhythmias, aortic aneurysms. I mentioned pregnancy related complications, kidney disease, kidney failure, all of these things happen. And it. And again, we're seeing that more and more in younger, you know, shifting towards younger people. But this problem of high blood pressure, hypertension starts in young people, quote, unquote, young people.

Dr. Jay Shah [00:14:29]: And that's really where we're missing it.

Ben Greenfield [00:14:31]: Yeah, and obviously there's, there's kind of like the reactionary approach, which would be beginning to measure it and pay attention to it and address it after someone present with their first stroke, heart attack, et cetera. And then there is the preventive approach. It kind of reminds me of something I've said before a few times on this podcast. I think that sometimes for men, erectile dysfunction can be a canary in the coal mine for gradual onset of cardiovascular disease. I think probably hypertension could fall into that same category. But why is it what's occurring in either medical school or medical education or in the medical community in general that would cause high blood pressure to be something that we look at from a more reactionary than say, a preventive, continuous monitoring standpoint.

Dr. Jay Shah [00:15:23]: Well, and as a product of the modern medical system, I would say, reflecting on it and my time, almost 20 years practicing, it's not designed to be for preventive care at all. It's designed entirely, almost for reactive care. It's designed to take care of people when something happens, when you get sick, when you have symptoms, when there's some issue, that's really what it's designed for. And everything from how primary care and secondary care and specialty care works to the alignment of reimbursement and resourcing is all aligned towards reactive care. So that's the first thing to really shift focus from reactive care to preventive care and relying on traditional medicines. The sort of medical establishment to do that would take a really sort of like a seismic type of shift. And so, you know, for blood pressure, it's not a mystery. I mean people, medical specialists and physicians know that this is a giant problem and they've known about it, we've known about it for decades.

Dr. Jay Shah [00:16:30]: This is not some new problem. And I think the sort of assumption where there's a major disconnect is just assuming that approaching the problem in the same way that it has been approached for the last 30 years, which is just a standard and stale call to just screen people with cuffs and even though they don't do it, just say it again and say it again and say it again. To, to sort of assume that that approach is going to move the needle here, I think is a complete, there's a complete disconnect and there's a, just a gap in, in reality and perception from the medical establishment.

Ben Greenfield [00:17:09]: Yeah, that makes sense. Hopefully. This is a dumb question, but if you didn't have a blood pressure cuff or continuous blood pressure monitor, are there ways that you could know like symptomatically if you had high blood pressure?

Dr. Jay Shah [00:17:23]: Not good ones. So that's the thing, that's why it's called the silent killer. Until it becomes extreme, you know, 200 millimeters systolic, the top number 200 and above, the bottom number 120 and above. So extreme values of high blood pressure, it generally is asymptomatic. If anything, it might cause a mild headache or some sort of fatigue, but that's it. It does not cause significant symptoms until it becomes this extreme values that might cause a sudden rupture of a blood vessel or severe headache or some severe problem. And that's not that common. Most of the time it happens where someone has high blood pressure, but it's not so extreme.

Dr. Jay Shah [00:18:11]: They just live at that high blood pressure level for long periods of time and just don't know it.

Ben Greenfield [00:18:16]: Yeah, I'm curious about how this kind of occurs in the first place. I'm sure it's multifactorial. In the exercise science or the fitness world, you often see people taking pre workout pump me up supplements with arginine, citrulline, beetroot extract, nitric oxide precursors. You see that in the sex industry too, in the men's health and women's health industry. Viagra, cialis, vasodilatory substances, all designed for increasing exercise performance or sexual performance. And related to that, you often see people advised to avoid things that could cause vasoconstriction pre workout or to, for let's say men who have erectile dysfunction. Back to that issue. To increase the consumption of foods that might cause more bioavailable nitric oxide like arugula, watermelon juice, beet juice, et cetera.

Ben Greenfield [00:19:15]: When it comes to hypertension, is it just the absence of good vasodilatory substances that people should be consuming in their diets or from a supplement standpoint, or does it go beyond that as far as the reasons that people are getting this in the first place?

Dr. Jay Shah [00:19:30]: That's one of the reasons, but it probably goes beyond it. And as you suspected, it is multifactorial. There isn't some clear, one clear cause of high blood pressure for general population. In fact, for about 80 to 85% of people who have high blood pressure, there's no real known cause. So it's probably a mixture of genetics to lifestyle factors, to endothelial dysfunction, which is what you're mentioning, to other external factors, smoking, stress, et cetera, that can cause it. And then for about 15% of people, there are actually some hormonal changes that can be treated called secondary hypertension, imbalances in certain hormones that cause higher levels of blood pressure. But for the vast majority of people, there isn't some clear cause. And so it is multifactorial.

Dr. Jay Shah [00:20:24]: It goes far beyond any one specific cause. Generally speaking, yes, the vasodilatory dysfunction is a part of it. It often can be the end effects. But the reasons that that is happening are oftentimes many.

Ben Greenfield [00:20:41]: Yeah, but like if you're sitting with, let's say you're a doctor, you're sitting with a patient, they present with high blood pressure, you've got a few minutes to chat with them about it. What are some of the main things that you would tell them to look at from a diet, an exercise or a lifestyle standpoint to address what might be causing hypertension?

Dr. Jay Shah [00:21:01]: So here's the thing that, and I've done this for many, many years, like where medicine I think really falls flat for hypertension in the. How is hypertension looked at in the medical community? Generally it's with medications. So when already that's like a first distinction to make is that if a physician or healthcare practitioner is really gonna focus on lifestyle, there are some pretty clear seven lifestyle changes. And we can go through them given the sort of time and resources that physicians and health organizations have. Probably they tend more towards look at medications, but on the lifestyle side, they're what you Think they are. So increase exercise, aerobic exercise specifically, about 150 minutes a week would be sort of the general recommendation from a physician with the exercise.

Ben Greenfield [00:21:54]: That's obviously my jam in many cases. That's my formal educational background. When you lift weights, you do see a pretty significant increase in peripheral blood pressure. And I've seen a little bit of data on this that might cause an adaptive response in the body to help to control blood pressure or stabilize blood pressure once the weight training session is done. Is there any evidence that beyond aerobic exercise, that weight training could positively affect blood pressure as well?

Dr. Jay Shah [00:22:25]: Yes, but there's a caveat to it. Yes, there is, but not for the sort of muscle hypertrophy effects that sometimes people go for. Meaning that lighter weights done at higher repetitions likely have some of those effects. Super heavy weights done with very low repetition actually are probably either neutral to sometimes negative in terms of blood pressure effects because.

Ben Greenfield [00:22:52]: And you're not talking about for acute blood pressure raising, you're talking about like chronic increases in blood pressure from lifting very heavy weights in the absence of aerobic fitness.

Dr. Jay Shah [00:23:01]: No, I'm talking about. So on the super heavyweight side, it's more of an acute change. It's while you're actually doing the isometric lifting that you can get severe elevations in your central blood pressure if the weights are really excessive. Very, very. But this, this, think of this as like bodybuilding sort of weights, super heavy deadlift, squats, that kind of thing. For the vast majority of people generally it's going to either have a net neutral or to slightly beneficial effect, I would say.

Ben Greenfield [00:23:28]: Okay, yeah, but I guess what I was saying was like if you get those really big acute rises in blood pressure while training, would it, would it long term help you to manage blood pressure more effectively? You know, almost like a, like a hormetic effect. In the same way that like getting really hot in the sauna causes a high increase in heart rate that results in a lower heart rate the rest of the day.

Dr. Jay Shah [00:23:50]: I don't have evidence to suggest on the weightlifting side, but on the high intensity aerobic side that that actually is what happens is that you get this when you, let's say when you're running or sprinting or doing a high intensity, your blood pressure actually goes up quite a lot as normal, a normal physiologic response. But that is adaptive in the long term to better vasodilation, better sort of smooth muscle activation and vasodilatory effect in the chronic side. That's where I have seen evidence of that, yes.

Ben Greenfield [00:24:23]: Okay, so we have aerobic exercise, including high intensity interval training as one good way to stabilize blood pressure. What else?

Dr. Jay Shah [00:24:31]: Yeah, so aerobic exercise, then there's, then there's stress, which is a huge bucket. But reducing stress in whatever ways are possible is clearly can be beneficial to some people. But that's complicated, right? I mean that involves mental state and mental health as well as sort of lifestyle factors.

Ben Greenfield [00:24:53]: And is that because of cortisol, by the way, is that the primary culprit when it comes to stress increasing blood pressure?

Dr. Jay Shah [00:24:59]: It can be for some people, but there's lots of different types of stress. Like there's acute stress events like death in the family or a sudden life event that causes a lot of stress. That probably has a very limited effect on blood pressure maybe during a few weeks or days or weeks. But then there's this long term effects of chronic high stress over months and years. And there, I think, yes, the answer is probably maladaptive responses to stress like higher cortisol. But also the other things that come along generally with high stress. You know, jobs and lifestyles generally have higher weight gain, generally have poorer sleep oftentimes. And so those things also raise cortisol levels, raise can raise insulin resistance and generally lead to weight gain.

Dr. Jay Shah [00:25:50]: So there's sort of a constellation of effects that happen with, with stress. It's not like it's not as straightforward as just high stress equals.

Ben Greenfield [00:25:57]: Okay, all right, got it. You heard it here first, folks. Stress increases blood pressure. I think a lot of people, a lot of people know that. So what else?

Dr. Jay Shah [00:26:06]: Yeah, there's common ones that everyone knows. Smoking, smoking cigarettes, excessive alcohol, excessive weight. So weight loss can be really helpful for, for generally most people.

Ben Greenfield [00:26:20]: How about nicotine? Obviously smoking that might be one of the reasons that it raises blood pressure due to the vasoconstrictive effects of the nicotine. But a lot of people use nicotine now as a focus and performance enhancing aid. And I've said before to be careful with that because you may have seen this before. Dr. Shah, the data showing a link between excess nicotine use and erectile dysfunction due specifically to the vasoconstrictive constrictive effects, which means it's obviously impacting blood pressure.

Dr. Jay Shah [00:26:49]: I think there's a, so for cigarette smoking it's like a no brainer. I mean there's nicotine, but then there's the 600 plus chemicals and tar and all kinds of other stuff that cause super dysfunctional vaso vascular tone. And then I think for like vaping and for nicotine and for all these other sort of nicotine delivery methods, I think it's becoming more and more clear. It's certainly not helpful and there are clearly some potential downsides and harm. So I would say generally, if possible, it's better than smoking cigarettes. But if you can get off, off of a nicotine addiction entirely, that would be best.

Ben Greenfield [00:27:28]: And obviously now with continuous blood pressure monitoring, you could literally test that. You could either, you know, because some people I know are doing like 200 migs of nicotine a day. I'm not saying quit cold turkey, but maybe, you know, cut that to 20 and see what happens to your blood pressure. If you can monitor it in real time, I can pretty much guarantee it's going to go down.

Dr. Jay Shah [00:27:45]: Well, that's a good point. You know, like all these things that I just mentioned, these lifestyle changes, each one of them is a huge, it would take a huge behavioral change to try to affect it in a person's life. Right? And here's the catch. Like we rattled these seven things off as a physician's medical to people like in two minutes and expect them to walk out and be like, yeah, okay, I'm going to, oh, salt intake, I'm going to quit smoking, reduce my salt intake, stop drinking, I'll do all this stuff and then no one ever does anything. And the thing is that it's very difficult to see cause and effect in blood pressure because you get this one time episodic measurements with a cuff and you can't really understand is this change actually causing a benefit? That's another real benefit of continuous monitoring is like, you can see for me, for my body, I made this one change. What happened? Did it help? Did it not help? Did it hurt? Like you can really start to understand and understand your own body and how these changes affect you.

Ben Greenfield [00:28:45]: Why not just get on one of the medications? Like is there a problem with them or how do they work exactly?

Dr. Jay Shah [00:28:50]: Well, first of all, they're generally very safe and we've used them for decades and they're almost all generic now. And they do work, I mean, to lower blood pressure. But all medicines have side effects. Nobody really likes taking them. And so there's a couple issues. One, compliance with medications is a huge problem because again, medicines for high blood pressure will never make that person feel better physically. Right? You don't feel bad with high blood pressure. So now you're taking a pill for something you don't feel, you can't see.

Dr. Jay Shah [00:29:24]: And what is it? It could have side effects. So it could make you feel worse, but it's not going to make you feel better in some significant way. So what's the only realistic way for someone to say, sort of get confirmation that. To say, look, I should keep taking this medicine because it's actually helping me. The only realistic way is to see data of their numbers getting better and staying better. And that really doesn't exist. That feedback loop doesn't exist with, you know, current standard of care, cuff measurements and blood pressure. So that's one of the biggest things.

Dr. Jay Shah [00:29:56]: Like it's almost half of the people who get prescribed medications either never take them or stop taking them within six months. It's a huge problem. And then of course, there's side effects that of all the medicines have different side effects. And of course, dealing with those side effects is frustrating and annoying for patients as well as physicians.

Ben Greenfield [00:30:16]: I might be one of like 3.7 listeners who actually care about this, but what's the actual mechanism of action of the medication to lower blood pressure?

Dr. Jay Shah [00:30:26]: They're all different. So there's five different sort of standard categories. And let's just take one as an example. These are very common medicines called angiotensin receptor blockers or arb. These are medicine like Losartan or Candesartan or anything with Sartan on the end of it. And these block a specific receptor of the angiotensin hormone. And angiotensin causes vasoconstriction, that's a natural hormone. But if it blocks a certain receptor, then that vasoconstrictor effect is no longer there.

Dr. Jay Shah [00:31:00]: And so it leads to relaxation of the vessels. And so in different ways, in the end, that's what these medicines are trying to do. Some block beta receptors, some block alpha receptors, some block, you know, do other things. But the point is that's in the end, it's trying to affect more of a relaxation of the vascular tone. They work by multitude of different effects.

Ben Greenfield [00:31:23]: Yeah. Did you ever have high blood pressure? I'm just curious what got you into being interested in something like cuffless blood pressure monitoring technology in the first place?

Dr. Jay Shah [00:31:31]: I personally didn't, but I have my. Almost everyone will have someone, either themselves or in their family that is affected by blood pressure. But it's just, it's almost a guarantee.

Ben Greenfield [00:31:41]: My, my mom and my wife has the. She doesn't have high blood pressure, but she has the genetics for high blood pressure. She actually takes a nitric oxide supplement daily to help with that.

Dr. Jay Shah [00:31:51]: Yeah. And so my grandfather basically died of complications from high blood pressure. My. Both my parents have it. And then my professional life for 20 years was taken care of. People after they had events, largely one of the most common causes was from high blood pressure. So I did that for 20 years and then really said, maybe there's a different way to approach this. Maybe I can take this knowledge and then apply it into a more novel, exciting way to affect many more people and hopefully prevent these problems for some people in the future.

Ben Greenfield [00:32:24]: I had a friend who recently had to go to the hospital for. He actually wasn't super duper clear. I didn't talk with him directly. He did a Facebook post about it, but it was either a stroke or a heart attack. And he said that he laid down in bed and he did have one of these at home. Standard blood pressure cuffs. Measured it and I think his systolic was something like 180. The reason I'm telling you this is that I could imagine that if a lot of people were wearing a bracelet like this, they could get some kind of an alert.

Ben Greenfield [00:33:01]: You know, like your continuous blood glucose monitor will tell you if you're hyper or hypoglycemic. Could, for example. Could I give this to my mom and get an alert if her blood pressure was reaching concerning levels?

Dr. Jay Shah [00:33:16]: Yes. There's no. It's just a software, you know, just putting it in the software. Now. There. There are one other complicating factor to it. There's no question we can do that. We also will notify people, even if it's not a severe level, that your blood pressure is trending on the higher side.

Dr. Jay Shah [00:33:34]: And maybe you should look at, you know, checking in with your physician and so on so we can do that even earlier. And there's just a question about where you set the alert levels. There's also the complicating. One of the complicating factors is about. On the alert side is that that plays into the. On the regulator side, anytime you start giving alerts, that actually complicates the regulatory filings and what you have to do in your product. So it's actually for probably good underlying reasons, it actually limits us here a little bit on how quickly we can iterate on the product. But it's clearly somewhere where we're going.

Dr. Jay Shah [00:34:13]: Where we're going.

Ben Greenfield [00:34:14]: Yeah. And kind of related to that. I mean, I think there are a lot of doctors who would argue that continuous monitoring would create some kind of a data overload for patients or physicians. Could you see that occurring to where there's just too much data creating too much confusion among people using something like.

Dr. Jay Shah [00:34:32]: This, first thing I would say is that there already is data overload. For physicians. There's no shortage of data. And for just drowning in it, the question is, how do you get. Take this data, encapsulate it, and present it to both a physician and a person in a very simple but meaningful way. And I think this is the real trick. Our goal here is not to provide hundreds of thousands of data points that someone will have to look through and then try to figure out what to do with the goal with this continuous data set. And I'll tell you, there's an incremental goal and then there's a transformational goal.

Dr. Jay Shah [00:35:14]: The incremental goal is, first of all just to provide any blood pressure data. Most of the time we get no blood pressure data at all from people. And so that's just a simple automated, passive way to get some blood pressure data and to present it in terms of averages. No, you don't need to look at 200 readings. Actually, what you really care about is what was my average weekly measurement for the last two weeks? That's what physicians care about. That's what I look for. I didn't really necessarily want each underlying point in time measurement. That's the incremental value, the transformational value.

Dr. Jay Shah [00:35:50]: The real transformational value of continuous data sets, and we've seen this on the CGM side for glucose, is that for the first time, it will open up our ability to look at blood pressure in terms other than just millimeters of mercury and point in time measurements. So what do I mean by that? How does blood pressure act on your body? I think I mentioned this. It's about time. It's how much time is your blood pressure above your optimal range higher than your optimal range for your body? This is a concept in glucose and diabetes called time and target range. And this is what a lot of CGMs now are measuring or will display. And this is actually a lot of what diabetes experts and doctors will look at even if they have diabetes. Not so much. What was your finger stick or what was your glucose at 9am on this day? Is that over the last three months, how much time did your body spend in the optimal glucose range?

Ben Greenfield [00:36:49]: And also, by the way, not to rabbit hole too much the actual glycemic variability, right? Because you could have, let's say your target range was, I don't know, 100, and you were rapidly fluctuating throughout the day between 50 and 150. You could technically manipulate that data to show that you had a high amount of Time and target range of 100, whereas in fact, it was going up and down all day long. You still want to pay attention to not just time and target range, but whether that was achieved with stabilized values throughout the day or with excursions that were very low and very high.

Dr. Jay Shah [00:37:26]: Glucose fluctuates a bit more rapidly than blood pressure, but that same concept exists. And there's a concept of time and target range, which is one example of this. But there's also a concept called cumulative blood pressure load, which is exactly what you were alluding to, which is time and magnitude out of range. So time and target range is just binary, right? You're either in range or you're not in range. And to your point, you could be 1 millimeter of mercury out of range, or you could be 200 out of range, and the value would be the same for time and target range. What you really care about and what your heart, your brain, your eyes, your kidneys care about is time and magnitude or area under the curve. Again, that can only be measured and calculated, which we're already putting in our product by a continuous monitor, getting continuous data streams. And that's really where these are the transformational ideas around continuous data.

Ben Greenfield [00:38:18]: Yeah, yeah, that makes sense. When you go to the doctor or anywhere else to get your blood pressure taken, you're advised to sit still, to not talk, your arm is rested, your back is supported, et cetera. So with the blood pressure monitor, obviously, if you're taking measurements all day long, like I'm walking on a treadmill right now while I'm talking to you, obviously that's going to affect values. So it's my understanding from the brief conversations we've had in the past, that this is monitoring my blood pressure when I'm in a still position.

Dr. Jay Shah [00:38:48]: That's correct. So the first gate, there's lots of gates of quality that we have in the product. The first one is motion. Because when you're walking on the treadmill, you're swinging your arms, or anyone's just walking or moving, or I'm talking like this. There's so much motion here, and the artifact of the optical signal would be highly distorted. So there's an accelerometer in here, and we just don't take measurements when your arm is moving significantly. So, yeah, your arm. And therefore, generally the person has to be relatively still for about 30 seconds for it to take a measurement.

Dr. Jay Shah [00:39:22]: So that's the first gate of quality. Then, on average, it takes measurements about once an hour. Sometimes it's a couple times an hour. Sometimes it's once every two hours, but again, it's based on the movement patterns of that person. So that's how it takes measurements. But to your point, you, someone could be standing and take some measurements, sitting, lying down, your arms like this, your arms down by your side. The first thing is we validated our device in all those body positions. We actually, in our validation studies, have nurses get down on the floor with a person laying down on the floor with the reference device and measure that no cuff has ever been validated in any other body position other than seated.

Dr. Jay Shah [00:40:03]: Relaxed arm like this. Very still never been validated, but we do, we have it and it's published. It's on our website, it's on our publications. That's. So we publish our performance. And what is it. Does it fundamentally. Do you really care about what is your blood pressure in this very highly controlled static position after you haven't eaten, eaten, talked, drank any water, caffeine, haven't exercised, your kids aren't around, you have.

Dr. Jay Shah [00:40:33]: No. Is that, is that how we live life?

Ben Greenfield [00:40:36]: Yeah. I want to know how high my blood pressure gets when I'm like checking emails.

Dr. Jay Shah [00:40:40]: Yeah, right. So it's like, you know, meetings, checking emails, kids are running around like all the sort of routine things of life. You want to understand what your blood pressure is doing during your real life, not just in highly controlled settings. Which is why the. That's why we've really tried to design it, this technology the way we have.

Ben Greenfield [00:40:58]: Yeah. Mine, by the way, seems to be the lowest because when I open up the app, it shows me, basically I can select daily curves, weekly curves or monthly curves. And my lowest is between about 2 and 4am, which is obviously pretty intuitive because I'm just flat out with my ass in bed during that period of time, hopefully. Is that pretty common to see the lowest blood pressure occur during the deepest stages of sleep or something like that?

Dr. Jay Shah [00:41:27]: Yeah, exactly. There is a nocturnal pattern and there is a systematic reduction in your blood pressure, the healthy blood pressure pattern at night. So generally you will see the lowest readings at that time of day, assuming someone has a normal sleep schedule and cycle roughly around what you just said, early morning, very early morning, and then you'll see that as you arouse yourself, arise in the morning, then that blood pressure will climb back to sort of daytime values.

Ben Greenfield [00:41:59]: The thing with reference ranges is, let's say testosterone, for example. Some men feel incredible at a value of let's say 500, whereas others feel hypogonadal and poor recovery, poor muscle building, et cetera at that value and feel better when their levels are 800 or 900. Reference ranges obviously value wildly across many biomarkers when it comes to blood pressure. How helpful are the actual reference ranges if I'm tracking this and then comparing my data to what would be considered healthy.

Dr. Jay Shah [00:42:34]: So this is where we are kind of on the forefront of medicine. So there's the reference ranges that we can take from cuffs. Right. Because that the existing body of literature for the last 50 years has been based on single point in time measurements of cuffs. So the normal values of under 120 millimeters of mercury on the systolic top number, under 80 on the bottom number, we would take those for now and just sort of say that, yeah, those reference values, those reference measure ranges, I would say we're going to roughly use those. But I would say just like we're seeing in CGMs, the world will change the more this sort of continuous data is used. Now you look at you, you have a CGM on. We used to say your fasting glucose in the morning should be less than 100 based on finger stick glucose measurements.

Dr. Jay Shah [00:43:26]: But most people who wear CGMs can see that their glucose range at night and even in the morning doesn't necessarily dip below 100, especially if someone's doing like intermittent fasting or some of these other sort of diet programs. Is that normal? Is that abnormal? I think there's got to be new definitions of reference values that get defined as we get more data sets. And that's finally happening with CGM data on the blood pressure side. We're still, I would say, years away from that.

Ben Greenfield [00:43:55]: Yeah, yeah, that's a good point. I mean, you mentioned intermittent fasting. A low carb lifestyle would be another example in which because you don't have a lot of exogenous sugars coming in, you tend to see upregulation of glycogenolysis like the liver will release more glucose into the bloodstream. So paradoxically, someone following a low carb diet will often average between 95 and 105 for blood glucose. And someone eating a standard carbohydrate diet yet engaging in metabolically healthy activities might see 80 to 90. So yeah, it is very subjective. The, the thing with something like cgms, let's say levels, they're a very popular CGM monitoring company as far as their app, the data they're collecting, they have a lot of data points and they're now able to see, based on that big data, the impact that cold thermogenesis or a cryotherapy practice might have on blood glucose or having oatmeal for breakfast versus eggs for breakfast, so on and so forth with you guys. I mean, I think you shared with me, you've got what, close to like 50,000 users, several million data points.

Ben Greenfield [00:45:01]: Are you beginning to see things that surprised you, that was unexpected or interesting data? When it comes to things that are raising or lowering people's blood pressure or helping them to stabilize it or destabilize.

Dr. Jay Shah [00:45:13]: It, the one thing is, I would say on our product side, we don't have as much external input of data to know a lot of those factors yet that's coming, that we're building that into the product. So unlike sort of more mature products like Levels and others that have been collecting annotated information from their users for a long time, we're just starting that journey. What we can say from our. From our customer feedback and from our user feedback, is that it? And I guess it's not super surprising to me at least, is that there isn't. There is no one clear trend or factor for people. It's. This is. This is why I'm convinced that personalized data sets are the future.

Dr. Jay Shah [00:45:58]: Because our approach historically in medicine, I told you seven lifestyle factors, okay? I have no idea who's going to respond to which one. Doesn't mean everyone doesn't respond to all of those seven factors. We know that. We just don't know how to figure out who responds to what. So the only realistic way is for someone to see that cause and effect with their own data set. And that's exactly what our users are writing in with. They're saying, hey, look, with your data set, I was able to figure out that alcohol was the primary driver of my blood pressure. And when I really reduced that, my blood pressure got into control.

Dr. Jay Shah [00:46:32]: Others say, look, I've been treated by a cardiologist for years, never had my blood pressure controlled, but finally got the medicine regimen dialed in correctly based on this data set. So I don't have enough data to really kind of look at specific trends yet. But what I can say is that each person responds significantly differently. And that's why it's so important for people to understand their own data set of blood pressure in particular and what causes it to fluctuate, you know, up or down.

Ben Greenfield [00:47:03]: Yeah, you've mentioned alcohol a couple of times, so I got to ask. There is some data that shows that a little bit of red wine has benefits for cardiovascular health. Obviously, there are situations in which you'd want to completely swear off alcohol, Breast cancer, esophageal cancer, psoriasis, obviously some other conditions. But when it comes to blood pressure, is it no alcohol or is there almost a beneficial effect of microdosing with small amounts of alcohol, particularly things with polyphenols and flavanols like red wine.

Dr. Jay Shah [00:47:36]: Data shows that mild to moderate amounts of red wine in particular, as you mentioned, could have a potential beneficial effect. But then excessive amounts, which usually for a, for a man means over 3 ounces, over 2 ounces a day. For women, over 1 ounce of alcohol a day.

Ben Greenfield [00:47:54]: That's not very much wine. Oh yeah, well that, that must be. No, that must be the actual amount of like alcohol because that's barely any actual red wine.

Dr. Jay Shah [00:48:02]: No, it's like one to two glass, one to two six ounce bores of red wine. Yeah, yeah. Above that amount, that effect is essentially stabilizes or starts causing other deleterious effects. So it's, it's probably a small amount can be beneficial in some people. But again, remember, these studies have just been done on sort of epidemiologic levels, not necessarily personal levels.

Ben Greenfield [00:48:27]: Yeah, yeah. There's a lot of supplements too that claim to help support blood pressure. Magnesium, you hear about a lot, maybe pre workouts or nitric oxide precursors, no surprises there. But outside of the medication realm, do you actually recommend or even yourself use certain supplements or natural approaches to control blood pressure from the supplement industry?

Dr. Jay Shah [00:48:51]: I personally don't. I think that there are some that if taken on a routine basis, there are some data to support that it has a mild lowering effect. You know, magnesium you mentioned is one. First of all, it's kind of hard to take a significant amount of magnesium without getting like diarrhea. But, and so, and others like potassium can be helpful, but also can be, can be risky in people who have kidney disease and other sort of conditions that, where they are prone to elevated potassium levels. So the first thing I would say is always sort of consult with your physician with that particular supplement if there's some other underlying condition that might be affected by that supplement. And the other point that I guess I would say is that generally, at least from the data I've seen with these supplements, the degree of lowering of blood pressure is not a huge amount. We're talking like 1 or 2 millimeters, maybe 3 millimeters of mercury at most for most people.

Dr. Jay Shah [00:49:53]: Certainly there will be outliers, but that's generally the sort of degree or amount we're talking about. Whereas a medication, and I'm not necessarily just pushing Medications, but just to give the contrast, like one medication, a reasonable effect would be somewhere between 7 to 9 millimeters of mercury reduction.

Ben Greenfield [00:50:10]: Yeah, medications always. They're always a bigger sledgehammer like GLP1. There's so many people jumping on the GLP1 bandwagon, pushing out supplements that I'm not saying they're unhealthy, but I've used GLP1 just as a self experiment to see what it felt like. Nausea, zero, desire to eat these other things that cause you to release a little bit more of your own. GLP1 or it says GLP1 on the front of it, but it's just a bunch of herbs. They're kind of like mild hunger suppression, but nowhere near the actual medication.

Dr. Jay Shah [00:50:40]: Yeah. And that's probably where some of the supplement sort of blends that I've seen. That's kind of what they're playing in. They have an herbal sort of mechanism that's very similar to the medication, but it's just sort of a small dose of it. And that's why you see a smaller effect.

Ben Greenfield [00:50:56]: Yeah. If you could, let's say, wave a magic wand and not just measure blood pressure, but pay attention to a few other, in particular, wearable metrics for cardiovascular health. Is there anything else that you would pull out of the existing technologies right now that you think would pair really well with continuous blood pressure data?

Dr. Jay Shah [00:51:18]: Well, I mean, there's probably countless applications that I can think of. One of the. One of the things that rises to the top that I think would be. Is really interesting and we're already pursuing a couple partnerships in this realm is sleep data. And specifically around sort of even mild or sort of easy ways to screen for sleep apnea. So sleep apnea is a sleep disorder where someone stops breathing multiple times a night and they're usually not aware of it either. Their partner might be aware of it because they sound like the sort of locomotives that start. Yeah, like that.

Dr. Jay Shah [00:51:59]: But generally the person's not aware of it. And so generally also just like high blood pressure goes undiagnosed for long periods of time. And I think that there are likely signals we could find either in our continuous blood pressure data set or with a combination of sleep data plus the blood pressure data to using wearables to kind of identify people at risk or who might have sleep apnea much quicker than the traditional sort of sleep study that you have to go to a doctor with and put on all these things and wear it for a night and then, you know, get diagnosed. So that's where I. I see a real opportunity there. And. And that would be really interesting.

Ben Greenfield [00:52:39]: Yeah. I mean, well, I mean, even this ring that I'm wearing right now, and many other technologies will measure pulse ox or blood oxygenation during the night. Theoretically, you could pair that and correlate it with blood pressure data, and you could see whether hypoxic episodes during the night are correlated to rises in blood pressure and then have a little bit of an answer right there.

Dr. Jay Shah [00:53:01]: Exactly. So there's that, there's even respiratory rate, and some of the sensors, some of the wearables do that, so it might be even closer correlated to breathing patterns. So, yeah.

Ben Greenfield [00:53:12]: Yeah. How much of a legal uphill battle would you fight to have? Back to the idea of my mom wearing this and having her doctor or me notified, or a corporation outfitting all their employees with a blood pressure monitor so that they can monitor employee health and help them out with stress, et cetera. There's a difference between me just messing around with my own data versus having others be able to see it. What's the legal landscape look like right now for that?

Dr. Jay Shah [00:53:38]: Yeah, I mean, personal health data is always protected, and so it doesn't matter. Irrespective of your country, it is highly protected and regulated. So you really have to follow the pathways set by the regulators to make sure you stay within the boundaries and guides of privacy. It's less of a legal issue and more, once you have that framework, it's more of giving the person, the user, the patient, whoever you want to call them, their autonomy to share it. Because if you decide to share it as a user, that's your decision. And so, for example, we're already thinking about how to implement family accounts in our product. Right. So you mentioned your mom.

Dr. Jay Shah [00:54:18]: That's an extremely common scenario across the world where people in millennial generations are caring for or looking after older parents, loved ones, aunts, uncles, whoever, and they're being responsible to try to get their health data set so that when they go see the physician, they have all the data ready and they can figure out what to do with it. So family accounts would do just that. Whereas you could sign up, you could have your mom, your brother, your dad, whoever else is important to you, have on that account, and you have agreed to share your data with each other so that you can get their report, share it with her physician, and, you know, sort of close the loop that way, rather than her having to try to do all that herself. So I think that's a real important factor as well.

Ben Greenfield [00:55:09]: You know, at the time that we're recording this, the app is Actea, but you mentioned to me before we started recording that you guys are looking at using a different title or a different name. I want to make sure when this podcast comes out, people know exactly what to look for. And also, it's kind of a second part to this question, where it's actually available and how to get it. So can you speak to that?

Dr. Jay Shah [00:55:30]: So, first of all, yeah, big, big news that on April 8, we are April 8, 2025, we're changing the trading name of the company to Hilo instead of Aktia, just because it's more worldly, sort of accepted worldwide. People can spell it like H I L O. H I L O. And that would [email protected] we've secured the domain, but that'll start April 8th. So our trading name, if you search for it, well, instead of Actaea, you search for Hilo. And then in terms of the countries we're currently in, we're in most of the Western European countries already. The big ones being the uk, Ireland, Spain. Spain is coming this year.

Dr. Jay Shah [00:56:11]: Germany, Switzerland, France, Italy, the Nordics and Benelux are coming this year. Canada is already available. Australia, New Zealand will be available later this year, and the US is slated for early to mid-2026.

Ben Greenfield [00:56:26]: Okay, yeah, I don't want to confuse you. Like, like I said earlier, like, I'm a podcaster, I'm a journalist, Dr. Shah sent me one, but technically I'm in the US and these aren't available in the US yet.

Dr. Jay Shah [00:56:36]: Yes, that's correct. For the next year, probably.

Ben Greenfield [00:56:40]: Okay. I mean, could somebody, like, if they were in the UK just buy one over there and bring it back to.

Dr. Jay Shah [00:56:45]: The US they can certainly buy one. We've had a lot of people try to do that. The problem is that the app is also part of the regulated device, which is why you're using a test flight version of it just as a tester. But the app would not be available in the US App Store until we have FDA approval.

Ben Greenfield [00:57:04]: Yeah, okay. Well, I mean, like I said in the introduction, like, this is one in two people who deal with this. It is a big, silent killer. I think this is going to save a lot of lives. Had fun geeking out over the data. I don't deal with high blood pressure based on measurements in the past with cuffs or with my current ongoing measurements with this. But, man, it's almost kind of peace of mind knowing I've got it on my wrist and also that I am measuring in this very preventive way that you alluded to earlier. So I think it's fantastic.

Ben Greenfield [00:57:37]: And also if you're listening in right now, if you go to BenGreenfieldLife.com/ blood pressure podcast, I will put links in the show notes to Dr. Shah's website ILO so you can kind of dig in and look at what they're doing yourself. So it's BenGreenfieldLife.com/ Blood Pressurepodcast Dr. Shah, anything else you want to share with people before I let you go?

Dr. Jay Shah [00:57:59]: No, I think this has been great. I mean, we've touched on a lot of great topics. It just mostly want to bring awareness to this idea that for the first time in decades, really there's real, new, real innovation in blood pressure monitoring space and that I think people are going to own their own personalized data sets and be able to be empowered to really refine and help them and their physicians really figure out the right sort of approach for them.

Ben Greenfield [00:58:28]: I love it. I think you're going to help a lot of people. I think you're going to save a lot of lives, actually. So Dr. Jay Shah, folks of High Load, Chief medical officer at HILO. Check out the show [email protected]/ blood pressure podcast. Dr. Shah, thank you so much, man.

Dr. Jay Shah [00:58:43]: Thank you very much, Ben. Appreciate it.

Ben Greenfield [00:58:45]: All right, folks, have an incredible week.

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