Medically Supervised Water-Only Fasting

in the Treatment of Hypertension

(Goldhamer et al Fasting and Hypertension)

Alan Goldhamer, D.C.

Center for Conservative Therapy and Bastyr University

Douglas J. Lisle, Ph.D.

Center for Conservative Therapy

Banoo Parpia, Ph.D.

Cornell University

Scott V. Anderson, M.D.

Center for Conservative Therapy

T. Colin Campbell, Ph.D.

Cornell University

Corresponding Author

Alan Goldhamer

6010 Commerce Blvd. #152

Rohnert Park, CA 94928

Phone (707) 586-5555

FAX (707) 586-5554

E-Mail: dracg@worldnet.att.net

Medically Supervised Water-Only Fasting

in the Treatment of Hypertension

ABSTRACT

Background: Hypertension-related diseases are the leading causes of morbidity and mortality in industrially developed societies. Although antihypertensive drugs are extensively used, dietary and lifestyle modifications also are effective in the treatment of hypertension. One such lifestyle intervention is the use of medically supervised, water-only fasting as a safe and effective means of normalizing blood pressure and initiating health promoting behavioral changes.

Methods: One hundred seventy-four consecutive hypertensive patients, with blood pressure in excess of 140 mm Hg systolic and/or 90 mm Hg diastolic (140/90 mm Hg), were treated in an inpatient setting under medical supervision. The treatment program consisted of a short pre-fasting period (approximately 2-3 days on average) during which food consumption was limited to fruits and vegetables, followed by medically supervised water-only fasting (approximately 10-11 days on average), and a re-feeding period (approximately 6-7 days on average) introducing a low-fat, low-sodium, vegan diet.

Results: Almost 90 percent of the subjects achieved blood pressure below 140/90 mm Hg by the end of the treatment program. The average reduction in blood pressure was 37/13 mm Hg, with the greatest decrease being observed for subjects with the most severe hypertension. Stage 3 hypertensives (those with systolic blood pressure above 180 mg Hg and/or diastolic blood pressure above 110 mg Hg) experienced an average reduction of 60/17 mm Hg at the conclusion of treatment. All of the subjects on antihypertensive medication at entry (6.3% of the total sample) successfully discontinued the use of medication.

Conclusions: Medically supervised water-only fasting appears to be a safe and effective means of normalizing blood pressure and may assist in motivating health promoting diet and lifestyle changes.

Key Words: Hypertension, water-only fasting, complete fasting, vegan, vegetarian, non-drug treatment, complementary and alternative medicine

Hypertension-related diseases are the most common causes of morbidity and mortality among industrially advanced societies.[1] Each year in the U.S. there are 500,000 victims of stroke. Hypertension is the major cause in these incidents, one-third of which are fatal.[2] Hypertension also is thought to be the most readily controlled preventable factor in congestive heart failure, a disease involved in more than 400,000 deaths and 2,000,000 events each year in the United States.[3] Given the magnitude of the causal role played by hypertension in these disease processes, it is not surprising that many treatment alternatives have received considerable research investigation.[4]

Surprisingly, the effectiveness of drug interventions for hypertension has been relatively disappointing.5-10 More encouraging are results from both epidemiological and experimental studies suggesting that alteration of patient lifestyle practices may provide a more promising avenue of treatment (see Table 1). 11-16

Though medication may have a net positive benefit for certain patients, the more relevant message is disquieting: most people who die of coronary artery disease, congestive heart failure, or stroke do not have BP in ranges sufficiently elevated to warrant drug treatment.17 Given the current limitations of drug treatment, the exploration of alternative, noninvasive methods of BP control should be sought.

There exists an impressive body of scientific literature indicating substantial effects of conservative health promoting interventions on BP control.11-16 These interventions include regular aerobic exercise, bodyweight reduction, smoking cessation, increased dietary fiber intake, alcoholic beverage restriction, consumption of a vegan-vegetarian diet, and sodium intake restriction. The advantages of these interventions are threefold. First, there are virtually no iatrogenic effects. Second, the degree of BP reduction is in some cases greater than the average reduction of 12/6 mm Hg commonly obtained by drug therapies.18 Third, not only are these approaches typically devoid of iatrogenic effects, but each is associated with known comprehensive health benefits.

While the modification of a single lifestyle variable might not result in BP reductions comparable to those expected with medication, the use of multiple modifications undertaken simultaneously has greater promise.16 This paper reports the results of such an effort – wherein multiple lifestyle variables were controlled in an inpatient environment. Suspension of smoking and alcoholic beverage use, bodyweight loss, sodium restriction, and dietary modifications were simultaneously applied in a short-term inpatient experience which also included a period of medically supervised water-only fasting.

The purpose of this investigation was to document the effects on BP of water-only fasting together with multiple lifestyle modifications in a medically supervised controlled environment. The water-only fast also facilitated bodyweight reduction. After the fasting process was completed, a low-fat, vegan diet was provided. It was our expectation that the reduction in BP obtainable with this safe noninvasive approach might exceed the results typically demonstrated by drug intervention or by any single lifestyle modification employed independently.

Methods

Patients were 174 self-referred adults, consecutively admitted for inpatient care for the treatment of essential hypertension and other health problems over a period of 12 years (1985 to 1997). A presenting systolic BP of at least 140 mm Hg and/or diastolic BP of at least 90 mm Hg were required for inclusion. Initial mean BP levels were 159.1/89.2 mm Hg (Table 2). All patients who met these specific inclusion criteria during this 12-year period were included in the study.

BP measurements were made by staff doctors utilizing standard recommended procedures.19 A single BP measurement was taken daily at morning rounds between 7:30 a.m. and 9:00 a.m. with a portable Baumanometer Mercury Syphgmomanometer, with the patients in the supine position. Pulse and BP were measured using the same arm, recording Karotokof sounds 1 and 5.

For at least 2 full days prior to (or in some cases after) their arrival at the clinic, patients were instructed to eat a diet consisting exclusively of fresh raw fruits and vegetables and steamed vegetables. Once this transition diet program and examination procedures were completed, patients began the water-only fasting program. BP medications used at entry were phased down gradually. Diuretics were discontinued when BP levels dropped below 160/104 mm. Dosages for beta-blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers were reduced by approximately 50% every three days. Whenever possible, medications were phased out prior to initiating the water-only fasting process. BP medications for all subjects were successfully discontinued with this protocol.

Therapy

Patients were administered the water-only fasting regimen in an inpatient environment for periods ranging from 4 to 28 days. Water-only fasting is the complete abstinence from all substances – food, tea, juice, non-caloric beverages, etc., with the sole exception of distilled water ad libitum (with a minimum of 40 ounces daily). Patients’ activities were restricted, as even moderate activity during a water-only fast can double energy utilization.20 It has been observed by these authors, after supervising the fasts of over 4000 patients, that restricted activity appears to minimize the frequency of orthostatic hypotension, arrythmia, dehydration, and electrolyte disturbances-side effects reported by others who have encouraged unrestricted activity during fasting.21 Allowable quiet activities included reading, listening to music, and watching instructional videos. Patients were also allowed to participate in group lectures, food preparation demonstrations and classes, and individual medical and psychological consultations.

Water-only fasting periods were terminated during periods of relative symptom stability and after BP normalization. In a few cases, non-clinical issues, such as limited time available, precipitated the premature termination of fasting. The water-only fasting period was followed by a period of supervised re-feeding initiated by the consumption of juices made from fresh raw fruits and vegetables. Patients received 12 ounces of fresh juice every 3 hours during the juice phase (approximately one day of juices only for each week of water-only fasting). The juice phase was then followed by a diet of fresh raw fruits and vegetables (approximately one day for each week of water-only fasting). Subsequent to these transitional regimens, a diet of whole natural foods was introduced. This diet included fresh fruits and vegetables, steamed and baked vegetables, whole grains and legumes, and very small quantities of raw unsalted nuts and seeds. The diet specifically excluded any meat, fish, fowl, eggs, dairy products, or added oil, salt, or sugar. Bread products and other processed foods were also excluded. Cooked meals were prepared utilizing recipes exclusively from the Health Promoting Cookbook.22 After the juice phase, patients were allowed gradual reintroduction of moderate exercise.

Safeguards

Patients were cautioned throughout the water-only fasting period regarding orthostatic hypotension. Patients received twice-daily consultations with a staff doctor. All fasting protocols were carried out according to the standards set forth by the International Association of Hygienic Physicians (IAHP).23 The study was approved by the Human Subjects Committee of the IAHP.

Additional Measures

Patients were additionally monitored with at least twice-weekly urinalyses and once-weekly blood tests including a complete blood count with differential, a multiple clinical chemistry panel including electrolytes, liver enzymes, serum proteins, creatinine, uric acid, bilirubin, glucose, lipids, and erythrocyte sedimentation rate. Patients with arrythmias were monitored with electrocardiography. Additional testing was performed when clinically indicated.

Statistical Analysis

Descriptive statistics, including means and standard deviations, for the outcome variables of interest were computed for the 174 eligible inpatients at four relevant time-points: (1) baseline, (2) start of water-only fasting, (3) end of water-only fasting, and (4) end of supervised re-feeding (Table 2). The last measurement at the end of the supervised re-feeding denoted the conclusion of treatment for each subject. Exploratory analyses revealed no significant differences in systolic or diastolic BP values by sex or age-group, hence results are not shown separately for age or gender. In addition, study subjects were classified by JNC criteria into stages of hypertension at baseline.24 Mean BP was computed for each stage of hypertension (Table 3). In addition to analyzing the total treatment response, that is, the response from baseline to the end of treatment, patient responses to the fasting process alone also were analyzed. The daily fasting response was computed by dividing the total fasting response by duration of fast for each patient. Analyses of variance (ANOVA) procedures were used to test statistical significance of the effect of fasting on BP. The probability levels of significance reported are based on the two-tailed t-test. These results are presented in Table 2. All statistical analyses were conducted using SAS version 6.1.25

Results

The substantial effects of medically supervised water-only fasting and re-feeding on BP were statistically highly significant. The water-only fasting period was preceded by a variable period (average of 2.8 days) of feeding with a low-fat, plant-based diet, and was followed by a supervised re-feeding period for a length of time (average of 6.8 days) of at least one-half as long as the water-only fasting period (average of 10.6 days). The average length of treatment from admission to discharge was less than 3 weeks (20.2 days). A small percentage of patients (6.3%) were using antihypertensive drugs upon entry into the program; all subjects suspended their use of these drugs during the fast and throughout the supervised re-feeding. Bodyweight over the entire treatment period (pre-fasting supervised diet, water-only fasting period, and supervised re-feeding period) decreased by an average of 6.9 kg. During the water-only fasting period, bodyweight declined an average of 5.9 kg, and mean BMI declined from 28.7 to 26.5.

BP dropped during the pre-fasting, water-only fasting, and post-fasting (supervised re-feeding) periods (Table 2). Most of the decrease occurred during the water-only fasting period. The overall mean drop of 37.1/13.3 mm Hg is substantially in excess of the combined effects either of a "vegetarian diet,” alcohol restriction, sodium restriction, or exercise (Table 1). Moreover, it is also in excess of the combined 17/13 mm Hg decrease observed in a study utilizing a vegan, low-fat, low-sodium diet, with exercise.16

The extent of the drop in BP was strongly dependent on the baseline BP reading at entry, with more severe cases demonstrating the most striking results (Table 3). When the responses are grouped according to the traditional classification24 of hypertension, 89% of subjects achieved normotensive status. The final mean BP of these 154 subjects was 117.5/78.7.

Discussion

These findings document the effectiveness of water-only fasting and dietary restriction for the treatment of hypertension. Nearly 9 out of 10 patients (89%) who were hypertensive at entry were normotensive by the conclusion of their supervised re-feeding period. All patients who were initially taking anti-hypertensive medication were off medication by the conclusion of their fast – and remained off medication throughout the supervised re-feeding period.

Previous investigations have also noted short-term positive effects of diet and lifestyle modifications. McDougall et al.16 reported average BP reductions of 17/13 mm Hg for hypertensive patients in a 12-day inpatient program utilizing a vegan-vegetarian diet and daily exercise, whereas MacGregor et al.12 found average BP reductions of 16/9 mm Hg for hypertensive patients on a very low-sodium diet. The present treatment produced an average diastolic BP reduction of 13 mm Hg, which is consistent with these prior studies. More notable, however, was the 37 mm Hg decrease in mean systolic BP. Stage 3 hypertensive subjects’ mean systolic BP was reduced from 194 to 134 mm Hg, a remarkable 60 mm Hg decrease. The results also suggest that this intervention is relatively safe: no morbidity was observed at any point in the study for any subject, except for occasional mild nausea and orthostatic hypotension during the water-only fasting period. Interestingly, hunger was not reported to be a problem after the 2^nd or 3^rd day of water-only fasting.

Twenty (11%) of the patients, although exhibiting substantial decreases in BP, nonetheless remained hypertensive at the conclusion of treatment. These partially responsive patients fasted somewhat fewer days than the 154 fully responsive subjects (8.9 vs.10.8 days), although this difference did not reach statistical significance. These partial responders also had a significantly higher average systolic BP at entry, although, during the fasting period, the rate of systolic and diastolic reductions actually exceeded (but not significantly) the reductions of fully responsive subjects. This finding suggests that if these partial responders had extended their fasts, some or all may have become normotensive. For some patients with very high initial BP, it may be necessary to conduct longer fasts, or multiple fasts, to obtain the desired results.

Another notable result is the 5.5/1.8 mm Hg reduction in BP observed during the supervised re-feeding period (average of 6.8 days). This finding suggests that the rapid normalization of BP possible with this intervention strategy may be indefinitely sustainable with a low-sodium vegan diet. This possibility is consistent with epidemiological findings suggesting that elevated BP is by no means inevitable for most people.26 In fact, such findings suggest that blood pressure-normalizing diet and lifestyle modifications, if sustained indefinitely, might be expected to have indefinitely protective effects. While no longitudinal studies have examined whether the effects of diet and lifestyle methods for normalizing BP are as ultimately protective as drug treatment, there are no in-principle reasons to suspect that they would be less effective. On the contrary, provided that such behavioral modifications can be sustained, the protective effects of diet and lifestyle interventions might be expected to be at least as effective as current drug treatments, given the absence of iatrogenic effects.

Despite the encouraging results of the present study, many questions remain unanswered. Further investigation of the long-term effectiveness of this strategy on hypertension and its disease sequelae will be required. At present, we can only offer a limited follow-up report suggesting that the effect may not be transient. We have collected follow-up data on 42 of our original 174 subjects, after an average post-treatment period of 27 weeks. The mean BP for these subjects was 123/77 mm Hg. While no generalizations can be made from these limited data, the results are nonetheless suggestive that this approach may have some sustainable benefits. We believe that further research efforts may be useful in determining whether medically supervised water-only fasting and other diet and lifestyle oriented interventions can be useful adjunctive treatment strategies for the management of clinical hypertension.

Acknowledgments

This study was funded in part by a grant from the ANHS-National Health Association and the International Association of Hygienic Physicians.

We would like to thank the following individuals who were instrumental in the successful collection of data and completion of this study: Jennifer Marano, D.C., Alec Isabeau, D.C., Erwin Linzner, D.C., Rick Dina, D.C., Ron Cridland, M.D., David Aukamp, D.C., Chris Postma, D.C., Joel Fuhrman, M.D., Roger Walker, D.C., Kelli Greene, D.C., Danny Keret, M.D., Ben Kim, D.C., Harold Goldhamer, Joan Chilton, and James Lennon.

Table 1. Results of Previous Studies Reporting Blood Pressure Reductions Associated with Various Intervention Strategies

	Systolic (mm Hg)	Diastolic (mm Hg)	Source
Bodyweight Loss^*	- 1.6	- 1.3	Staessen et al. (198911)#
Sodium Restriction^†	- 16.0	- 9.0	MacGregor et al. (198912)
Vegetarian/High-Fiber Diet	- 2.8	- 1.1	Appel et al. (199713)
Alcohol Intake‡	- 4.8	- 3.3	Puddey et al. (199214)
Exercise§	- 6.0-7.0	- 6.0-7.0	Arroll and Beaglehole (199215)#
Combination of Low-fat, Low-salt, Vegan Diet, and Exercise	- 17.0	- 13.0	McDougall et al. (199516)
Effects of Standard Antihypertensive Drug Treatment	- 12.0	- 6.0	Kaplan (199817)

*BP reduction per kg of bodyweight loss.

†Sodium intake reduced from 200 mmoles/day to 50 mmoles/day.

‡Reduction of alcohol intake from 440 ml to 66 ml/week.

§Average of 3 times per week of aerobic activity.

#Meta-analysis.

Table 2. Average Blood Pressure (mm Hg), Weight (kg), and Body Mass Index (BMI)

for a Sample of 174 Hypertensive Patients Measured at Four Time Points Through a

Water-Only Fasting Treatment Program

Variables	Results Mean ± SD
Number of subjects	174
Age (years)	58.6 ± 14.0
1 Baseline
Systolic BP (mm Hg)	159.1 ± 19.4a
Diastolic BP (mm Hg)	89.2 ± 10.2 a
Weight (kg)	78.4 ± 17.2 a
BMI	28.9 ± 5.9 a
Pre-fasting period (days)	2.8 ± 4.8
2 Start of water-only fasting
Systolic BP (mm Hg)	148.5 ± 18.7b
Diastolic BP (mm Hg)	85.9 ± 11.0 b
Weight (kg)	78.0 ± 17.4 a
BMI	28.7 ± 5.9 a
Fasting period (days)	10.6 ± 5.6
3 End of water-only fasting
Systolic BP (mm Hg)	127.4 ± 16.1c
Diastolic BP (mm Hg)	77.7 ± 8.8 c
Weight (kg)	72.1 ± 16.1 b

BMI	26.5 ± 5.5 b
4 End of supervised re-feeding (End of treatment program)
Systolic BP (mm Hg)	121.9 ± 17.8d
Diastolic BP (mm Hg)	75.7 ± 8.7 c
Weight (kg)	71.7 ± 16.6 b
BMI	26.5 ± 5.8 b

Post-fasting re-feeding period (days)	6.8 ± 3.3
Duration of total treatment program (days)	20.2 ± 4.6

a,b,c,dComparable means in each of the four time periods were tested for statistical significance using the ANOVA procedure based on Duncan’s Multiple Range test. Means with a different letter are significantly different (p<0.05) for each variable of interest across each of the four time-points.

Table 3: Effects of Water-Only Fasting and Supervised Re-feeding on Subjects by Stage of

Hypertension* at Start of Treatment

Hypertension

Category *

Baseline

SBP/DBP (mm Hg)

Start of Fasting

SBP/DBP (mm Hg)

End of Fasting

SBP/DBP (mm Hg)

End of Re-feeding

SBP/DBP

(mm Hg)

Total Change

SBP/DBP

(mm Hg)

Stage 1

145.5/

85.7

139.0/

82.2

121.9/

75.7

116.1/

74.3

-29.4/

-11.4

Stage 2

165.8/

91.7

154.1/

88.9

130.9/

79.1

125.9/

76.9

-39.9/

-14.7

Stage 3

193.8/

96.4

170.9/

92.4

140.0/

81.9

134.2/

79.4

-59.6/

-16.9

Total

174

159.1/

89.2

148.5/

85.9

127.5/

77.7

121.9/

75.9

-37.1/

-13.3

* Stages as defined by JNC VI. Stage 1 is defined by SBP of 140-159 mm Hg and/or DBP of 90-99 mm Hg. Stage 2 is defined by SBP of 160-179 mm Hg and/or DBP of 100-109 mm Hg. Stage 3 is defined by SBP > 180 mm Hg, and/or DBP > 110 mm Hg.When the systolic and diastolic BP fall into different categories, the higher category defines BP status.

Center for Conservative Therapy and Bastyr University

Center for Conservative Therapy

Cornell University

Scott V. Anderson, M.D.

Center for Conservative Therapy

T. Colin Campbell, Ph.D.

6010 Commerce Blvd. #152

Rohnert Park, CA 94928

Methods

Therapy

Safeguards

Additional Measures

Statistical Analysis

Discussion

Acknowledgments

Water-Only Fasting Treatment Program

1 Baseline

2 Start of water-only fasting

3 End of water-only fasting