A 2006 healthy lifestyle initiative led by the government noted that approximately 21 percent of the Bahamian populace had hypertension. And according to a 2012 PAHO report, the number one cause of death in The Bahamas between 2006 and 2009 was related to hypertensive disease with 688 deaths.
According to the report, hypertensive diseases led the way among the 10 leading causes of death of all ages and both sexes, followed by ischemic heart disease (607), HIV disease (566), cerebrovascular disease (517), diabetes (399), assault (homicide) (306), land transport accidents (197), malignant neoplasm of female breast (183), certain conditions originating in the perinatal period (113) and influenza and pneumonia (105).
Dr. Don Diego Deveaux, internal medicine, nephrology and clinical hypertension specialist described hypertension and kidney disease as a common problem, and an "epidemic" in The Bahamas which makes for a
"critical" situation. An epidemic is a disease or condition that is highly prevalent in a community or large geographical area.
A hypertension diagnosis is generally a blood pressure reading greater than 140/90.
"Once it develops [hypertension] usually lasts for a lifetime," said Dr. Deveaux, who spoke at the recent Doctors Hospital Distinguished Lecture Series. But, if people adhere to lifestyle changes, sometimes they can revert to normal.
Dr. Deveaux said the disease is described as a "silent killer", as people are usually asymptomatic. The only times high blood pressure announces itself sometimes is "when the horse is out of the barn".
"They would say they have a headache, and you check their blood pressure and it's greater than 200 or so. But if they didn't have the headache they would have gone on fine without any other warning symptoms," he said. "Even then, when I diagnose patients with hypertension, with headaches, they say once the headache's gone they feel fine, and forget about everything you just told them, so it's a real problem."
Blood pressure is recorded in two numbers. Normal blood pressure is generally 120/80 -- the top number is the systolic blood pressure (and is generally highest when the heart is pumping blood from out of the heart and into the rest of the body), and the lower number is the diastolic blood pressure (when your heart is at rest and the blood is going into the heart). The doctor says you are considered to be pre-hypersensitive if your systolic blood pressure is 120-139 and your diastolic is 80-89, and if greater than 140/90, it is usually considered a diagnosis of hypertension.
"You have variations in blood pressure. Generally at nighttime, your blood pressure should be the lowest. However, in patients who have poorly controlled hypertension, what tends to happen is this normal nocturnal blood pressure that's usually low sometimes actually surges at night, and herein lies the problem and that's why generally patients who have strokes, heart attacks, its generally during the early morning hours when you have that surge of elevated blood pressure."
Consequences for inadequate treatment
"The consequences of untreated or inadequately treated hypertension are patients who are very prone to strokes; prone to congestive heart failure; at risk for coronary arterial disease (heart attacks); chronic kidney disease and hypertension is the number two cause for being on dialysis throughout the world, and you're at risk for peripheral vascular disease and prone for gangrenous limbs or dead limbs which ultimately ends in the leg being amputated. And amputation of any extremity poses significant morbidity and mortality for patients," said the doctor.
The most common form of hypertension, according to Dr. Deveaux, is essential hypertension. This is the category that at least 90 percent of patients fall into. He also said that many times, medical practitioners cannot figure out the cause for a person's hypertension, but often it's due to genetics.
"Sometimes you could not have it, but significant history plays an important part," he said.
Secondary hypertension, he said, is usually related to hormonal excess and that there are often issues with the kidneys.
Causes of resistant hypertension
Resistant hypertension, he said, is essentially a patient on three blood pressure medications who is still not controlled. Causes of resistant hypertension include excess sodium (salt) intake, which is key in The Bahamas. The normal diet sodium intake is anywhere from two to three grams. In The Bahamas, he said, the norm is anywhere from eight to 12 grams.
Other common reasons for non-adherence include patients who no longer take their blood pressure medication once their headaches are gone; men who do not want their libidos to wane; and the intake of non-steroidal anti-inflammatory drugs, common painkiller people use for arthritis and generalized pain which can affect hypertension because they actually cause the kidneys to reabsorb more fluid and sodium and make blood pressure harder to control. Using nasal decongestants during the cold and flu season he said could also raise a person's blood pressure through the roof. Excess alcohol intake also plays a significant part of hypertension controls.
Laboratory tests
"When someone is diagnosed with hypertension, there are several basic tests one should have don: electrocardiogram to assess the damage, if any, the hypertension has caused to the heart. The urinalysis is a non-invasive test to see if the kidneys are putting out any protein because that also shows us if there's any damage to the kidneys as it relates to the hypertension.
Other common stuff we would use include general blood work which would include your potassium; your creatinine, which would give us an indication if you have any underlying kidney disorders, as patients who have kidney disorders are actually prone to hypertension, as hypertension causes kidney disease and kidney disease causes hypertension. They go hand in hand." The patient's lipid profile is also assessed to check their overall cardiac risk factors.
Risk factors for developing hypertension and prevention
Risk factors for developing hypertension include obesity, family history, excess salt and alcohol intake, older age (over 40 to 50 percent of Bahamians over 60 have hypertension), tobacco use and diabetes. Black people are also more at risk of developing hypertension at an earlier age; having more sever hypertension; and having increased risk of heart attack, stroke and kidney failure.
According to the medical practitioner, before medication is prescribed, doctors like to talk to patients about lifestyle modifications -- exercising regularly for at least 40 minutes five times per week; trying to maintain a healthy body weight; avoiding excess dietary salt and, if possible, seeing a dietitian.
"It is a sad truth... to eat healthy, you need money," he said.
He also said doctors talk to patients about excessive alcohol consumption and tobacco use.
"Weight reduction alone can lower your blood pressure reading. Another suggestion is adopting the DASH eating plan, which generally consists of healthy, natural foods. The plan is focused on vegetables and fruits and also focuses on adequate protein intake. Dietary sodium reduction is one of the prime drivers for hypertension, especially for people in the African diaspora who are prone to salt sensitive hypertension. The major difference is processed salt has iodine in it, which is healthy for the thyroid, but apart from that, salt is salt," said the internal medicine, nephrology and clinical hypertension specialist.
The Joint National Committee (JNC) for hypertension released its eighth hypertension guideline that stresses blood pressure reduction according to the doctor. The guidelines also recommends hypertension treatment of the elderly.
"Patients who are over 60 [years of age] generally we used to treat blood pressure if it's greater than 140/90, but for the more elderly we don't get as aggressive with treating the blood pressure, so we use a higher baseline, so it's now 150/90 and the reason for this primarily was when you try to lower the elderly's blood pressure too much, you actually cause more harm than good," said Dr. Deveaux.
Chronic kidney disease
As hypertension and kidney disease go hand in hand, the doctor said it's a good idea for people to work toward having healthy kidneys. The kidneys are responsible for a lot of functions in the body, including clearing toxins from the body via urine, keeping the body's natural environment in balance, controlling blood pressure and making hormones (EPO, Renin and vitamin D).
"When you think about kidneys, think about balance. It's responsible for a lot of the electrolytes, particularly the sodium, potassium. And it's also responsible for your acid base. The kidneys are also responsible for control of blood pressure. Kidneys also make hormones: EPO which is responsible for making your blood count; Renin which helps with the whole controlling blood pressure and for vitamin D synthesis and excretion.
"Vitamin D is actually produced initially in the skin, goes into the liver, and the kidneys are actually responsible for making vitamin D active. Without Vitamin D, you have elevated PTH levels. PTH attacks the bones and can make the bones weak and brittle and prone to fractures."
He also said that chronic kidney disease (CKD) means that a person's kidneys are damaged and can't filter blood like they should. The damage can cause issues with toxic waste build up toxins in the body.
You can take several steps to keep your kidneys healthier longer by choosing appropriate foods with less salt, keeping your blood pressure at the level set by your primary care physician and keeping your blood glucose in the target range if you have diabetes (the number one cause for kidney disease and renal failure throughout the world). Even if your diabetes is controlled, if your blood pressure isn't controlled, you still can have major kidney issues, according to Dr. Deveaux.
"Choose and prepare foods with less salt. Use less salt at the table. Select the right kinds and amounts of protein. Choose foods that are healthy for your heart, like lean cuts of meat, skinless chicken, fish, fruits, vegetables and beans. And read the nutrition facts label, especially for sodium, to help pick the right foods and drinks."
Dr. Deveaux said hypertension is modifiable, but most people don't take it seriously, even though it can impose a significant health burden on the country at large, a person's family and him or herself; it can also be a burden in terms of going on dialysis.
"It really changes your life," he said. "Dialysis is a process where you blood has to be cleaned majority of the times via machine and is generally three times per week for four hours each session. That is 12 productive hours each week spent on a machine," he said adding that diabetes is the number one cause of kidney disease, and hypertension is second.
Treatment/medications
The two common medications are ACE inhibitors and ARBs, which tend to slow the progression of kidney disease. The doctor also urges patients to drink as much as they can. He encourages water as the drink of choice. He said the darker your soda pop, the more preservatives and phosphorus it has in it. He said phosphorus could have a devastating effect on the heart, blood vessels and bone issues for patients with CKD and elevated phosphorus levels. And that it is important for patients who have severe chronic disease to watch their potassium intake, and not overdo the alcohol.
Moderation he said is key. He also encourages regular medical checkups, controlling blood pressure, monitoring blood pressure weekly, checking your cholesterol (watching saturated fats and fructose), watching your diet (salt), refraining from smoking, drinking in moderation, exercising regularly and managing stress.
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