Welcome to part two of our discussion about high blood pressure. For those who missed it, a previous column examined new blood pressure guidelines released by the American Heart Association and the American College of Cardiology, in which normal is now a range below 120/80. It's a conservative definition that puts people with blood pressure in the range of 120-129/80 into the "elevated" category. This is not a diagnosis of high blood pressure, or hypertension. Rather, it's a warning sign that, without certain lifestyle changes, hypertension may well be in your future.

Now we'd like to expand on the techniques that can be helpful in getting better numbers.

-- Lose weight: Weight gain increases body mass, which means the heart has to pump harder to deliver blood throughout the body. At the same time, that increase in body mass offers greater resistance and results in elevated blood pressure. Studies show that a weight gain of even 5 pounds can cause blood pressure to rise.

-- Stop smoking: Not only do smokers face double the risk for stroke and heart attack as nonsmokers, they are also at increased risk of a range of cancers. In addition, the nicotine and other substances in cigarettes and other tobacco products make blood pressure go up.

-- Exercise regularly: Exercise strengthens the heart and makes it more efficient. Regular physical activity like brisk walks, cycling, swimming, dancing, hiking or active sports can lower your top (systolic) blood pressure number by four points. That's on par with what blood pressure medications will do. Aim for 150 minutes per week of moderate aerobic activity, or 75 minutes of vigorous activity.

-- Watch your diet: When it comes to food, the DASH diet (Dietary Approaches to Stop Hypertension) is a good guide. Not only does it naturally limit salt intake, but it also incorporates a healthful range of foods into your life. These include fresh fruits and vegetables, whole grains, legumes, nuts, lean proteins, limited saturated fats and limited amounts of sugar. You can get full details at: https://www.nhlbi.nih.gov/health-topics/dash-eating-plan.

-- Cut back on salt: New research suggests the relationship between salt and blood pressure is more complex than previously understood. Still, hidden salt in processed food means many Americans are getting far too much sodium. Switching to fresh foods and the rest of the DASH diet recommendations can make a difference.

-- Limit alcohol: Although we still don't know exactly how or why, drinking alcohol raises blood pressure. If you're a regular drinker, quitting can lower your top blood pressure number by several points.

-- Cut back on caffeine: As with alcohol, the mechanism behind the brief blood pressure spike that accompanies caffeine intake isn't fully understood. If you're looking to lower your blood pressure, though, we recommend cutting back on or quitting caffeine.

-- Reduce stress: Easier said than done, we know. But regular exercise, meditation, breathing exercises, yoga, a daily nap or just a bit of quiet time to yourself can help relieve tension.

-- Keep track: Make note of your blood pressure readings to track which direction you're trending. The American Heart Association supports self-monitoring, which can be done with a home blood pressure monitor and in partnership with your primary care physician.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctor: I had problems with acid reflux for years -- until I started taking a proton pump inhibitor. Now I read they may raise the risk of stomach cancer. I don't want to go back to the days before my PPI, but I don't want cancer either. What should I do?

Dear Reader: I understand the life-changing potential of proton pump inhibitors (PPIs). These drugs are potent inhibitors of the acidity of the stomach. They help heal stomach ulcers, treat acid reflux and, in combination with antibiotics, combat Helicobacter pylori (H. pylori) infections. These infections increase the risk of stomach cancer, and eradicating the bacteria reduces the rate of cancer among those infected by 33 to 47 percent. Many people take the drugs long-term to decrease acid reflux and relieve stomach discomfort, so it's reasonable to question the safety of this, especially in light of the recent study.

But let's take a closer look at that study. It assessed the impact on 63,397 individuals successfully treated with drugs for H. pylori in Hong Kong, comparing those who then took a proton pump inhibitor to people who then didn't take any medication and to people who then took drugs known as histamine 2-blockers or H2 blockers, such as Zantac, Pepcid or Tagamet.

Participants were then followed for an average of 7.6 years, with 153 of them developing stomach cancer. Although this type of cancer is rare in the population, people who used PPIs at least once a week had a more than twofold risk of developing stomach cancer compared to the group using H2 blockers. Those who used PPIs daily had an eightfold risk of developing stomach cancer compared to the other group.

Length of use was linked to greater cancer risk as well. Thus, the study appeared to show a dose-dependent increase in the risk of gastric cancer. This correlation was specific to PPIs because H2 blockers did not show this increase.

But there are problems with this study. First, the average age of the PPI users was more than 10 years greater than that of the non-PPI users. Greater age itself is a risk factor for cancer. Second, participants in the group using PPIs were more likely to be obese, have diabetes, and be smokers or users of alcohol -- all of which are risk factors for gastric cancer. Of note, this study was in a mostly Asian population, which generally has a greater rate of gastric cancer.

Still, a 2017 Swedish study reached a similar conclusion. It looked at 797,067 people who consistently used PPIs, and researchers found that the rate of stomach cancer was three times greater in this population than in the general population. Again, this increased risk was not seen among people who used H2 blockers. But this study, too, was less than clear. Here, the rate of stomach cancer incrementally decreased such that people who took PPIs more than five years had a lower rate of stomach cancer than the general population.

In short, the data on PPI use and stomach cancer risk is not absolutely convincing. But I would still be wary of using proton pump inhibitors long-term, especially if you've been diagnosed with H. pylori infection. I'd recommend that you talk to your doctor about using an H2 blocker instead.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctor: I'm so confused by the new blood pressure guidelines. Yesterday, my blood pressure was normal. With the new guidelines, though, I'm now considered to have high blood pressure. Is my doctor going to put me on medication?

Dear Reader: Ever since the new blood pressure guidelines were released by the American College of Cardiology and the American Heart Association in November, we've been getting quite an earful. We're hearing not only from our patients, but from family and friends as well. People are surprised, upset, worried and, as you state in your letter, just plain confused.

The truth is that blood pressure goals have long been (and quite likely will always remain) controversial among the medical community. Back in 2014, when a panel of medical experts loosened blood pressure guidelines for some older Americans, there was an immediate backlash. Now, with guidelines being tightened, the debate has erupted again. Rather than focus on the history of blood pressure guidelines and the various schools of thought behind each iteration, we think it's more useful to talk about where things stand now, how the current guidelines affect us and what changes each of us can make to get better numbers.

Heart disease, which accounts for one quarter of all deaths in the United States, is the leading cause of death among both women and men. High blood pressure, or hypertension, is second only to smoking as a preventable cause of heart attack and stroke. At this time, guidelines state that normal blood pressure falls into a range below 120/80. The top number, known as systolic pressure, refers to the pressure in your arteries as your heart contracts. The bottom number is diastolic pressure, which is the pressure in your arteries between heartbeats. When taken together, the numbers offer a snapshot of your cardiac health.

People with a top number that falls between 120 and 129, and whose bottom number falls below 80, are considered to have "elevated" blood pressure. A top number of 130 to 139, and a bottom number of between 80 and 89, is considered to be stage 1 high blood pressure. Readings greater than 140/90 are stage 2 high blood pressure. Both stage 1 and 2 require medication.

Part of the uproar over these new guidelines is they are likely to push close to half of all Americans out of the normal range. However, this doesn't automatically mean blood pressure medication for everyone. In fact, the aim of the guidelines update is to give people ample warning of pending blood pressure problems. Because it has no obvious symptoms, high blood pressure is known as the silent killer. By catching changes early, people with elevated blood pressure can take steps to achieve healthier numbers through lifestyle changes and interventions.

-- Lose weight.

-- Stop smoking.

-- Exercise regularly.

-- Watch your diet.

-- Cut back on salt.

-- Limit alcohol.

-- Cut back on caffeine.

-- Reduce stress.

-- Keep regular track of your blood pressure.

We're sure you've heard this all before. But knowing what to do isn't the same as actually doing it. We believe this is an important discussion, so we'll be back next week with details about how and why each of these steps is important to your good health.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)