Why stress can cause a stroke in midlife (and how to prevent it)

It’s never too late to start stroke-proofing our lives – not least by cutting down on stress. We ask the experts how to do it

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The colloquialism “you’ll give yourself a stroke” cuts a bit close to the bone these days – particularly if you’re middle-aged. Annual figures show a steep rise in strokes among those in their 50s, with experts blaming rising obesity, high cholesterol, diabetes and poor lifestyle. 
According to Dr Joseph Kwan, a specialist in hyperacute stroke and stroke rehabilitation, midlifers need to start eating better, exercising more – and stop being so stressed. “We’ve known for the past 10 years that in the age group 45 to 55 the numbers are increasing faster than in older age brackets. They’re coming into my department with very big strokes,” says Kwan, who is also a senior consultant at the Imperial Stroke Centre at Charing Cross hospital, one of the busiest stroke departments in the country. 
“They tend to have all the traditional vascular risk factors – hypertension, diabetes, smoking – yet what strikes me about this age group is the reduced physical activity. Home working and Netflix have created a generation of couch potatoes.” 
A stroke occurs when the blood supply to part of the brain is cut off either by a blockage or a burst blood vessel, which can cause brain cells to die. Without emergency treatment a stroke can be fatal or cause long-term disabilities such as paralysis, memory loss and communication problems. It is the fourth single leading cause of death in this country, with 38,000 stroke-related deaths each year. 
However survival rates have improved markedly during Kwan’s career thanks to clot-busting drugs and thrombectomies, where the clot is cleared from the artery. “It’s a game changing procedure. People come in paralysed, unable to talk or see – and then after the operation they can be walking home the following day,” he says. “In the old days you’d be destined for a nursing home or you’d die but now you can go back to driving, working, playing sport and looking after your kids.” Most strokes are ischemic (where a blood clot blocks a blood vessel in the brain and reduces blood flow), although one in seven are haemorrhagic, which causes a brain haemorrhage (where blood leaks into the brain) and are more complicated to treat. 
While it’s difficult to prove that strokes are stress-related, there’s a clear relationship between high stress levels and stroke risk, Kwan says. “When you are stressed, you have higher adrenaline levels, which pushes up blood pressure and increases inflammation in the body, both of which damage arteries.” Meanwhile, drinking, smoking, comfort eating and watching too much television – traditional de-stress habits – also raise the stroke risk. “In the old days, people would come home from work, have some dinner, go for a walk, see some friends, go out dancing – but now they get home, pour themselves a glass of wine, eat and put on the television,” Kwan says. “Delivery food has made the situation even worse – you don’t even have to leave the house to eat unhealthily.”
Medical conditions that increase stroke risk include high blood pressure, atrial fibrillation (a type of irregular heartbeat), high cholesterol and diabetes. Lack of sleep is a major risk factor for strokes, as is obesity, but stress feeds into all of these factors, Kwan says. “When you’re stressed, you don’t sleep well and are less likely to exercise and look after your body,” he says. Recreational drugs such as cocaine also raise the risk of a stroke. According to Dr Sarah White, the associate clinical director of Bupa Health Clinics, you are at greater risk of a stroke if you are male, and if you have a family history of strokes. 
The key is to focus on building resilience to stress, which means looking after our bodies, says Sheldon, who via her business, Midlife Management, helps those in their 40s and 50s to take control of their health. “There are always going to be burdens in our lives: you need to give yourself the resources to cope.” 
Knowing your numbers can be the kick you need to get off the sofa and do some exercise, which will reduce stress levels and promote the release of nitric oxide, which improves the health of the interior of blood vessels. It also has the added benefit of increasing social interaction – loneliness has also been found to have a negative impact on heart and brain health.
Given that high blood pressure and cholesterol don’t have symptoms, many people don’t know they have these conditions. “The best thing you can do is buy a blood pressure machine,” Kwan says. “We should all aim to know our blood pressure as well as our cholesterol, our weight, our BMI and how many units we’re drinking.” Meanwhile, Dr Ben Turner, a consultant neurologist at Nuffield Health at St Bartholomew’s Hospital, recommends regular checks for diabetes and hypertension. The more obsessive we are about our numbers, the more control we have of our lifestyle, Kwan continues. “Know how much protein and calories you’re eating and how many steps you’re walking. It’s what’s called biohacking.” 
Kwan suggests 20 minutes of moderate intensity exercise each day. “Get on the rowing machine, do yoga or run – it doesn’t matter so long as it makes you puff. Pilates is good, too: there’s a direct relationship between strength in your 40s and how long you’ll live,” he says.
Our daily 10,000 steps do not count as moderate exercise, though – that’s just strolling around, which we should be doing anyway, he continues. If you’ve been doing no exercise at all, Sheldon suggests building up gradually from a brisk walk – too much too soon can cause inflammation. “Ask yourself if you can repeat this level of intensity again tomorrow – if the answer is no, take a step back,” she says. She does reformer Pilates to unwind but also recommends yoga, meditation and breathwork. “You don’t need to spend two hours in a spa each day to reduce stress levels: a little breathwork before a meal can be transformational, switching you from fight-and-flight mode to rest, digest and restore.” 
Giving up smoking, cutting down on alcohol and reducing caffeine are a good starting point. Then it’s a question of eating at regular intervals, Sheldon says, which will prevent insulin spikes, while sticking to wholefoods to keep blood sugar stable. She recommends eating three nutritious, protein-rich meals a day with no snacks in between. “Get rid of the white stuff – flour, sugar, white rice – and replace it with protein, healthy fats and fibre,” she says. Kwan advocates the Mediterranean diet, with plenty of extra-virgin olive oil, nuts, seeds and oily fish, while Sheldon also recommends including foods that are rich in nitric oxide such as leafy greens, cauliflower, pomegranate, radish and celery. 
There’s good evidence that a small amount of alcohol (particularly if it’s wine) is probably protective, most likely because of the antioxidants from the skin of the grapes, Kwan says. “But when you drink more than the weekly limit, you take on board too many calories.” Excess alcohol is also linked with higher blood pressure, higher cholesterol and poor brain health. “You make poor choices when you drink – you end up not eating or sleeping properly,” he continues.
It’s a myth that only overweight people have high cholesterol – those of healthy weight can have it, too, according to Kwan. “Eighty per cent of cholesterol is made by the liver – you make it yourself – we need fat,” he says. The key is to put good fat into our bodies: foods such as oily fish, salmon, trout, sardines, olives and olive oil. Cutting down on drinking helps, too. Kwan concedes, though, that it can be hard to bring down very high cholesterol: you can cut out all bad fats and only reduce it by five to 10 per cent. If this is the case, then it might be time to take statins. 
Ideally we should all be getting seven to eight hours sleep a night, Kwan says, as a lack of sleep can impair the natural dip in blood pressure that occurs when we sleep, causing hypertension. It can also affect our metabolism, pushing up our blood pressure. Between 10 and 15 per cent of sleep should be deep sleep, he adds. “The deep sleep phase heals your brain, clearing proteins – a study of brain fluid in young healthy people showed that those who stayed up all night had similar levels of proteins in their brain fluid as people with Alzheimer’s.” 
Unless you’ve had a stroke already or are at high risk of developing blood clots, there is little evidence to suggest that taking statins or blood thinners will prevent you from suffering one, according to Kwan. It’s better to focus on making lifestyle changes rather than medicating, he says. For similar reasons, Sheldon steers her clients away from nutritional supplements. “Reorganising how you live and eat is usually so powerful that you don’t need them,” she says. 
Stroke symptoms usually come on suddenly. A good way to recognise the signs of a stroke is to use the NHS’s ‘FAST’ test, although Kwan points out that you should call 999 even if you are experiencing just one of the symptoms. 
Other stroke symptoms can include weakness or numbness on one side of the body; feeling confused; blurred vision; severe headache; vertigo; feeling sick or vomiting. 
If a scan reveals a clot in a large brain artery, then doctors can either administer a clot buster injection or perform a thrombectomy to remove the clot from the artery. Recovery can take days or weeks and sometimes months or years – there might be immediate improvement with recovery then continuing at a slower pace. A significant proportion of Kwan’s midlife patients return to a normal life afterwards. “They’ll need to improve their lifestyle and their nutrition, though – the more physicians emphasise this, the better.”
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