Category: Blood pressure

Observation:

Improving patient care has become a priority for all healthcare providers with the overall objective of achieving a high degree of patient satisfaction. A number of contributing factors to improving patient care include greater awareness among the public, increasing demand for better care, keener competition, and more healthcare regulations. One of the greatest methods of enhancing patient care is self-reflection. Reflective practice is a requirement for career progression in healthcare. However, if done properly, it can greatly enhance the skills of a healthcare provider. The process of becoming a reflective practitioner takes time, effort, and practice. Hence, it is critical to start early in education in order to strengthen the reflective skills required as a medical radiation technologist. As the first step into self-reflection practice, I will be writing about my experience that evoked a response in myself during one of the labs in the patient care course. In the vital signs lab, when assessing the blood pressure of my partner, I ran into a problem. I could not take his blood pressure properly due to the defective blood pressure meter. Specifically, the inflation blub was not working well, therefore I could not inflate the cuff and take my partner’s blood pressure.

Reflection:

The experience that I encountered during the vital sign lab aroused emotions in me. Even though it was not my first time taking blood pressure, at first, I doubted myself. I thought that I was doing something wrong and as a result, I got really frustrated and nervous. My partner was really cooperative, but I could tell that he was getting impatient as time passed. After a couple of minutes of trying to take the blood pressure, I finally gave up and addressed my issue to my lab instructor. He looked into it and he told me that the inflation bulb on this blood pressure meter was not working properly and I should use another meter. This was a slight relief for me, however, I still had all those feelings and thoughts in my mind about not being able to take my blood pressure. This resulted in me not being able to take my blood pressure even with the fully functional meter. I asked my lab instructor to help me again and I felt really embarrassed because every other student was done with taking blood pressure and they were doing some new activity. I kept questioning myself why a procedure that normally takes a couple of minutes to do is taking me a long time. I felt really bad as I was holding my partner and me behind, so I let my partner try and he took my blood pressure with no problem. After that, as a result of all those emotions I did not try anymore, and I moved on to the next activity. The experience I had with defective tools in the lab brought back some memories. I remember a few years ago, I went to my doctor to freeze a small wart I had on my feet with liquid nitrogen. During the preparation of the procedure, my doctor realized that the liquid nitrogen can was empty and there was no new replacement for it. They have told me that it would take a week for the new one to arrive and I should come back in a week. In order to get to my appointment that day I had to miss my classes. I was annoyed and angry that I had to miss two days of my classes for a medical procedure that usually takes 20 minutes to do. Now I realize that I have been in the position of both the patient and the healthcare provider during a medical tool malfunction.

Interpretation:

Having fully functional equipment and tools is the essence of providing good patient care. A defect in medical equipment, even minor, could result in multiple problems in a healthcare setting and not delivering the best patient care to the patients. For example, in my case, a problem with a blood pressure meter may not seem like a big problem but in a clinical setting, these minor defects usually lead to bigger problems. Imagine, as a healthcare provider, you struggle with taking the patient’s blood pressure because of an equipment malfunction, this may make the patient uncomfortable questioning the skillsets of their healthcare provider. Another scenario is that if your blood pressure meter is not functioning properly and you want to move the patient to another room with a functional meter and your patient has difficulty walking, you put the patient in a really unpleasant situation and even cause them harm. So, something as little as a defect with the inflation pump of a blood pressure meter could elongate the assessment time and waiting time could ultimately result in an unlikable and uncomfortable experience for our patient. Also, it could even affect us, healthcare providers, in a way that we are no longer able to provide the best care to our patients.

Decision:

As it was mentioned before, having the right and functional equipment in the healthcare setting is important to both patients and healthcare providers. Therefore, medical equipment must be checked periodically in order to maximize efficiency in a healthcare setting. Doing quality control and checking each piece of equipment is not the only solution to this problem. Machinery malfunction could happen at any point and time, even during patient assessment. Back-up plans are something that every healthcare provider should have in such a situation. These plans could be having replacement equipment and asking for help. A combination of the above-mentioned solutions could be used to provide better care and a more pleasant experience for patients. As a result, I have decided that in my clinical placement, I will regularly check the quality and functionality of my equipment and prepare backup plans in case something goes wrong during the assessment. To measure the efficiency of my work, I will keep a record of the duration of each assessment and note if a medical defect was observed during the assessment. I will therefore have an average time estimate of how long each assessment would take (with or without a medical defect). In case of a defect, I can confidently explain to my patient that I am an experienced and trusted individual who can solve this problem in a timely manner. This will build trust in my patient and keep the stress away, ultimately delivering better patient care.

Hypertension is the most hazardous disease seen in the modern world today. It is also referred to as a silent killer due to its silent nature affecting the lives of several people. As per the research it is being stated that hypertension is not a disorder of separate characteristics however, its appearance exists as a symptom of some other disorders. In many cases, you will never find one single recognized cause of hypertension.

You should collect hypertension information to know about the basics of it. Since this is a widely spreading disorder, it is important to know the remedies for the same. Some of the effective and useful hypertension tips are as follows. If you prefer to treat it in a natural way, then you have to get accomplished to a strict dietary pattern that includes most of the vitamins, minerals, and proteins needed for the body to function properly.

Good sleep and a well-developed sleeping pattern are key to good health. You can avoid most of the diseases if you develop a schedule for the same and follow it consistently.

Exercising keeps your body fit and away from several disorders. It is vital to exercise for about 30 minutes every day to enjoy different health benefits for yourself. The world seems to you, the way you perceive it. If you feel that life is full of tensions and worries, it will be the same and simply you will be stressed. Rather have a positive approach towards life and your work. Develop a daily routine and plan a schedule for the day in order to keep your day well organized. Avoid stress at any cost.

It is strongly recommended that people with hypertension should avoid eating hydrogenated oils, chocolate, spicy foods, other sweets, salt, foods with high amounts of carbohydrates, and red meat. Instead, you can focus on the consumption of garlic, parsley, different types of herbs, alfalfa that showers light on one looking for natural hypertension care.

Fish oil offers great relief in this case. It helps to lower the pressure and safeguards the heart. Vegetarians can give a try to flaxseed oil that offers similar benefits. Apple cider vinegar is the most popular herbal remedy to lower blood pressure levels. This is os because it contains a good source of Vitamins B6, B2, B1, E, C, and A. Take 2 spoons with a glass of water and honey. One of the best tips to follow for the treatment of hypertension is by doing a few healthy lifestyle changes. One should do a few lifestyle changes for lowering hypertension include quit smoking, eat a healthy diet, get regular aerobic exercise, lose weight and limit the consumption of alcohol.

Using drugs for the treatment of hypertension is best. Drugs that can be used for treating hypertension are Angiotensin receptor blockers, beta-blockers, diuretics, alpha-agonists, and combination medications. Many doctors suggest using diuretics as the first step of treatment for hypertension as they effectively work for hypertension. If you are suffering from a few medical issues then your doctor can suggest you take other medicine rather than diuretic as the first step of the treatment. For example, people suffering from diabetes have been suggested to take ACE inhibitors as the best treatment. If one drug can not work then other kinds of drugs are also available. If the blood pressure of a person is above 20/10 mmHg higher than it must be, then a doctor suggests taking two drugs.

INTRODUCTION

The stable West-African country Ghana is a nation on the rise, recently being upgraded from a low- to a lower middle income country (1). However, economy and welfare are not exclusively rising in Ghana: hypertension and consequently cardiovascular diseases (CVDs) are on the rise as well (2–4).

Hypertension, defined by a blood pressure (BP) >140/90 mmHg, affects 1.13 billion people globally (5). It is the largest single contributor to burden of disease worldwide (6) and one of the most important causes of premature deaths (5), being a major risk factor for CVDs. CVDs are the biggest group of non-communicable diseases (NCDs) and the leading cause of death worldwide (31%) (7). Hypertension is referred to as a “silent killer”, since the majority of hypertensive people are asymptomatic, even though they are at risk of sudden fatal CVDs (8). Two-third of the total hypertensive population lives in low-and-middle income countries (LMIC) (5). The prevalence of hypertension in sub-Saharan Africa (SSA) is among the highest in the world and is predicted to increase over the coming decade (9,10).

The World Health Organization (WHO) set the prevalence of hypertension in Ghana at 20% in 2015 (11). However, recent population-based studies show a prevalence ranging from 13% to as high as 64% (2–4), depending on the included age groups and settings of the study. Risk groups in Ghana include older age groups (>45 years), urban residents, the physically inactive and obese, and wealthy and higher educated Ghanaians (4,9).

Awareness, treatment and control of hypertension are low in Ghana (table 2) (2,3,17). Political focus on hypertension only started to develop in recent years (2). A longer delay in having sufficient health care policies attacking hypertension will most likely lead to an even bigger challenge on Ghana’s already overwhelmed health care system (18).

This literature review aims to identify and describe the social determinants of hypertension in Ghana. Being addressed to the minister of health, I hope this review will contribute to a better understanding, providing a basis for development of sustainable health policies.

METHODS

Search strategy

This is a literature review. Table 3 lists the search terms I used. In addition, I used the ‘snowball’ technique to find additional articles. I screened the articles for applicability. Both quantitative and qualitative studies relating to non-pregnant adults with primary hypertension were included. I focused on essential hypertension (also primary or idiopathic hypertension; hypertension without an underlying disease, affecting 95% of hypertension patients (19)), as secondary hypertension (hypertension caused by another medical condition) doesn’t share the same determinants. Articles written in any other language than English or Dutch were excluded. In case data from Ghana was lacking, I used data from (West-) Africa or global literature.

Conceptual model

The model of Dahlgren and Whitehead (20) was used to describe social determinants of hypertension in Ghana. This widely used model is comprehensive and well organized, and covers all relevant determinants of hypertension.

FINDINGS

A variety of studies covering the determinants of hypertension in Ghana were found.

Age, sex and constitutional factors

Age, sex and constitutional factors are the most important non-modifiable determinants of hypertension (21).

Age

Ageing is characterized by an increase in endothelial dysfunction and diminished vascular elasticity which can lead to hypertension (22). The adverse effects of certain lifestyle factors (section 3.2) on hypertension are piling up as age progresses as well. Socio-economic development and improved health systems are causal factors of Ghana’s ageing population (table 1) (23).

Sex

Due to the protective effect of the female sex hormone estrogen on endothelial function and vasodilation, women have a lower BP compared to men until they reach menopause (25). The risk of hypertension increases rapidly after the age of 60 for women (24). Some Ghanaian studies indicate a higher prevalence among women in the general population (64% versus 54% in men) (3). Most likely, this can be explained by gender differences: e.g. women are more likely to be obese (section 3.2.2 and 3.5.2) and have a sedentary occupation, like table-top selling (section 3.2.1).

Constitutional factors

A family history of hypertension is a risk factor for developing hypertension (26). One’s genetic make-up can also cause predisposition to obesity or addictions (27), which in their turn increase the risk of hypertension. No significant difference in odds of becoming hypertensive was found between different ethnic groups in Ghana (table 6) (4).

Most important medical conditions related to primary hypertension are previous cardiovascular disease (including pregnancy induced hypertension and (pre-)eclampsia), diabetes, high cholesterol, and renal disease (22). This can partially be explained by overlapping biological factors, but similar lifestyle choices elevating the risk of these diseases play a role as well.

Individual lifestyle factors

Individual lifestyle factors are modifiable risk factors for hypertension. Often, these individual lifestyle choices go hand in hand (28).

Physical inactivity

Physical inactivity is a large-scale issue in Ghana, especially in urban areas: 94.7% of young females and 70.5% of young males in Accra are physically inactive (29). Although the mechanism is not yet fully understood, physical activity is thought to lower the BP by a decrease in peripheral vascular resistance (30). Inactivity is closely related to obesity (section 3.2.2). Being physically active decreases the odds of becoming hypertensive in Ghanaians (table 6) (4).

Obesity

Obesity (Body Mass Index (BMI) > 30 kg/m2) is on the rise in Ghana (table 1) (11). Women are more likely to be obese than men (15% versus 4%) (11). Physical inactivity, unhealthy diets and psychological factors (e.g. depression) contribute to this fact (31). The relationship between obesity and hypertension is partly explained by these common risk factors, but obesity in itself is a risk factor for hypertension as well (31). Obesity leads to increased peripheral vascular resistance and circulating blood volume (31).

Dietary factors

Excessive intake of salt can lead to hypertension due to retention of circulating sodium, leading to an increase in blood volume (32). WHO advises a maximum of 2 gram sodium per day for adults (33). Ghana has one of the highest sodium intakes of SSA (average 6 gram/day for both men and women (11)) (34). The rise of highly salted processed fast foods in Ghana seem to present a bigger problem than the use of salt in food seasoning (34). These processed foods are not only highly salted, but also rich in saturated fats, another risk factor for hypertension. Diets rich in saturated fats increase cholesterol level, which contributes to the development of hypertension (35).

Smoking

Smoking has an acute hypertensive effect (by stimulation of the sympathetic nervous system) and a chronic hypertensive effect (by causing endothelial dysfunction and arterial stiffness) (36). Prevalence of smoking is low in Ghana (4%), with a clear gender difference (7% of men versus 0.3% of women) (11,37). Cultural and religious influences, community-level interactions and effective public health policies are influencing the prevalence of smoking in Ghana (38).

Alcohol consumption

The relationship between alcohol use and hypertension is complex. Next to the biological effects that intake of larger amounts of alcohol have on hypertension, different pathways lead to inflammation and circulation changes, multiple behavioral and lifestyle connections influence the relationship as well (39). Harmful alcohol use (>4 units/day) in Ghana is higher among men (5%) versus women (1%) (11), and in urban versus rural populations (3).

Social and community networks

Community networks can influence the prevalence and awareness of hypertension indirectly through lifestyle choices and common health care seeking behavior.

Perception and knowledge of hypertension

Perception and knowledge of hypertension differs greatly among communities in Ghana. Lack of knowledge is associated with low educational background and rural residency (40). In Northern Ghana, hypertension is experienced as spiritual attack or even witchcraft in some communities (41), influencing health seeking behavior.

Religion

Compared to Muslims and Traditionalists, Christians have the highest odds of becoming hypertensive (table 1 and 6) (4). Christians are found to often defer their hypertensive disorder to an “active and divine Deity (God)”, taking a passive role in dealing with the condition (e.g. not adhering to lifestyle advises) (42).

Community initiatives

Community involvement and -initiatives could be an important factor influencing lifestyle choices and contributing to prevention and control of hypertension. Only one community program was found specifically directed towards hypertension in ghana, showing promising results (table 4) (43,44).

Marital status

Divorced/widowed Ghanaian women have a higher chance of developing hypertension compared to married or single women (table 6) (4). Increased psychological stress might be an explanation for this. Long lasting psychological stress has a biological effect on hypertension, but is also associated with an inactive lifestyle, obesity, smoking, and alcohol abuse (30).

Living and working conditions

Living and working conditions are influencing all other layers of the conceptual model, but in their turn, are being influenced by all other layers as well, creating a complex integrated web (20).

Agriculture and food production

Food availability and affordability is affecting dietary factors contributing to hypertension. Interestingly, prevalence of hypertension in the rural Volta region was found to be relatively high compared to other rural areas (33%). In rural Ghana, agriculture is the most common occupation. In the Volta region however, being home to lake Volta, fishing and salt production are more common. Dietary levels of sodium are thought to be higher in this region (45).

Education

Educated Ghanaians are more likely to become hypertensive, compared to their uneducated countrymen (table 6) (4). There is a positive association between education and pro-active health care seeking behavior, probably influencing the prevalence of hypertension in this group (46). Education influences other determinants of hypertension, like work environment, SES, urbanization and thus lifestyle choices (4).

Work environment

Economic growth and urbanization have led to an increase in sedentary occupations in Ghana, and thus a more inactive lifestyle compared to e.g. agricultural occupations. Women and higher educated individuals are more likely to have a sedentary occupation (47).

Unemployment

Unemployed Ghanaians have higher odds of developing hypertension compared to the employed (table 6) (4). The underlying relationship between unemployment and hypertension is not entirely clear, since determinants related to employment (e.g. high education and SES) are known to increase the odds of developing hypertension in Ghana. Possible factors to take into account could be psychological stress related to joblessness (e.g. financial worries, one’s place in society) and a possible inactive lifestyle (4).

Health care services

Awareness, treatment, and control of hypertension are low in Ghana (table 2) (3), partly due to multiple barriers in accessibility of health services. Regarding to availability: Ghanaian health services are more likely to be adequately supplied with malaria medications (85%), than with essential hypertension drugs (35%) (49). Regarding to affordability: poor Ghanaians suffer from out-of-pocket (OOP) payments for hypertensive medications (50). Overall enrollment in the National Health Insurance Scheme (NHIS) remains low (40%) (51), as poorer Ghanaians can’t afford the premiums (52). Wealthy, educated Ghanaians living in urban areas are most likely to be covered by the NHIS (53). Individuals covered by the NHIS are more likely to have their BP measured and adhere to treatment (table 2) (2,50). Awareness is higher among younger Ghanaians (table 5) compared to the general population (table 2) and among women compared to men (table 2).

Housing & water and sanitation

No data could be found on water and sanitation and housing as individual determinants for hypertension in adults, although one study suggests a link between household air pollution and BP levels in pregnant women in Ghana (54).

General socioeconomic, cultural and environmental conditions

This overlapping layer of the conceptual model is affecting all other determinants. On the contrary, this layer is also influenced by the underlying layers, as well as by globalization (54).

Socioeconomic conditions

Ghanaians with a higher income/SES have increased odds of becoming hypertensive (table 6) (4). Higher SES is often achieved by higher educated, urban residents (18). As previously described, these factors often relate to lifestyle changes. Physical inactivity (including less labor intense occupations), obesity, unhealthy diets, alcohol consumption and smoking are associated with urban areas (47).

Cultural conditions

Gender roles play an important role in the determinants of hypertension for men and women, as has already been highlighted in the previous sections. The ideal female body image in Accra appears to be slightly overweight (56). A higher BMI is being associated with wealth and success (56). Desirable activities from a socioeconomic point of view also play an important role: driving to work is seen as a status symbol (56). Religion and perception of hypertension have been addressed in section 3.3.

Environmental conditions

Environmental conditions are different in rural versus urban settings, whereby cities usually present less healthy environments, predisposing its inhabitants to hypertension (table 6) (18). Accra has very few sidewalks, parks and fitness facilities, attributing to an inactive lifestyle of its residents (57). In 2013, 68% of restaurants in the urban ‘Greater Accra Region’ served fast food (58). The effect of globalization is especially noticeable in urban areas, influencing the determinants of hypertension on a population level, health care sector level and economical and political level (55). Figure 2 lists some of the most important effects of globalization on the determinants of hypertension in Ghana. This figure tries to be illustrative instead of comprehensive, as this goes beyond the scope of this article.

National attention for hypertension and NCDs only started to develop recently (59). An estimated 80% of Ghana’s health care budget annually is spent on communicable diseases (49). Lack of reliable data and research, limited political interest and donor investments which are not directed at NCDs are barriers to implementation of policies targeting hypertension (59). The current health sector’s response to hypertension is mainly focusing on treatment rather than prevention (60).

DISCUSSION

It is clear that hypertension is a major health concern. Taking into account the most important social determinants of hypertension in Ghana – age, physical inactivity, obesity, high educational level, high SES, and urban residency – one can expect hypertension prevalence to rise over the coming decades in Ghana, as the population is expected to continue to age and economic growth and urbanization are striving.

Limitations of this study are that the majority of data being used originates from the population-based “Study on global AGEing and adult health (SAGE)”, commissioned by the WHO in 2008 (23). The two most important epidemiological reviews after this period use this study’s database (3,4). Next to the fact that the data is over decade old, part of the results were ‘self-reported’, making them susceptible to selection bias. Another review cited in this article (2) used the database of a large population-based study performed in 2014, the “Ghana Demographic and Health Survey” (61). However, the included age group in this study was restricted to 15-49 years. Virtually all other population-based studies on hypertension in Ghana have been carried out in subpopulations (e.g. ‘women of reproductive age’ or ‘rural communities’). This highlights the need for more hypertension research in Ghana.

The biggest strenght of this article is that it is the first to list all important social determinants of hypertension in Ghana in a clear order, using a comprehensive conceptual model. It shows what political policies and public health care programs should focus on to turn the tide.

The low awareness, treatment and control of hypertension among Ghanaians (table 2 and 5) means that a large amount of people with hypertension are unaware of their increased risk of CVDs, like sudden fatal heart attack or stroke. In order to improve awareness, measures to reduce health inequities have to be developed. Furthermore, the ongoing trend of making lifestyle choices which are not beneficial to one’s health, often being influenced by longstanding cultural conditions in combination with recent economic growth, urbanization and globalization, should be put to a halt.

CONCLUSION/RECOMMENDATIONS

This article created a basis for policy making by unraveling the determinants of hypertension. Practical recommendations to the minister of health include:

• Create an enabling environment, encouraging healthy lifestyle choices, with a focus on women, and highly educated, urban residents with high SES.
• Promote healthy diets and physical activity
• Ban global fast food companies
• Create parks and walkways in urban areas
• Encourage community involvement and –initiatives
• Include health education and sports in the educational curriculum
• Improve the access of hypertension related health services, with a focus on the poor, men and elderly (>49 years).
• Expand the NHIS coverage
• Provide adequate stockings of hypertensive treatment

Hypertension can be described as, the level of blood pressure reached when treatment is advantageous to an individual. Ideal blood pressure is seen to be between 90/60mmHg and 120/80mmHg1. Within the population, it is described as normally distributed2. People are not classified into subgroups of normotensive and hypertensive as many factors come into play2. There are two main types of hypertension and these are classified as primary (essential) and secondary. Essential hypertension is a condition in which there are no specific causes, genetics and environmental factors each play a significant role. When a specific cause can be found, the condition is called secondary hypertension. For example, these causes could be underlying renal or adrenal diseases3.

Many factors are to be considered when deliberating the cause of essential hypertension. Genetics contribute as high blood pressure can run in families. This is not due to one gene, but a combination of 27, however this only changes blood pressure by 1-2mmHg4. Some environmental factors that could lead to an increased blood pressure include salt, potassium, calcium and magnesium intake, weight, alcohol consumption, stress levels, exercise and other dietary factors such as a vegetarian diet5.

High blood pressure can directly or indirectly damage the kidneys, heart and brain. Some life-threatening conditions hypertension can lead to include heart disease, heart attacks, strokes, heart failure, peripheral arterial disease, aortic aneurysms, kidney disease and vascular dementia1. Strokes and cardiovascular diseases, account for more deaths than any other common medical conditions6.

There are many non-pharmacological ways to decrease blood pressure, which are specifically advised when a patient’s blood pressure is between 120/80mmHg and 140/90mmHg, as they could be at risk of hypertension1, however any patient with a high blood pressure, at any stage of hypertension should be advised this too7. These non-pharmacological treatments are life style changes, including: weight reduction, salt restriction, monitoring alcohol consumption, exercising more and maintaining a healthy diet8. These lifestyle changes have been proved to decrease blood pressure as seen in various studies9.

It is generally considered that patients with a blood pressure of >160/100mmHg, or have conditions such as renal disease or diabetes will benefit from drugs that reduce blood pressure10, 11 . It is advised by the NICE guidelines12 if aged under 55 an ACE inhibitor or low-cost angiotensin II receptor blocker should be used and if over 55 or black person of African or Caribbean family origin of any age, calcium-channel blockers should be used, this is treatment for stage 1 hypertension. When following the flow chart of the NICE guidelines12 the next step should be offered if the previous hasn’t controlled blood pressure levels. As you progress down the flow chart previous treatments become combined, then thiazide-like diuretic becomes introduced. Resistant hypertension, step 4 in the NICE flow chart12, is a stage at which blood pressure remains at or above 140/90mmHg after maximum possible treatment13 at this stage there are 2 treatments to consider, stated by the NICE guidelines14. Patients should then refer to an expert if the blood pressure is still uncontrolled13.

In conclusion hypertension has many causes. These can be treated in a number of ways including both pharmacological and non-pharmacological methods.

References

1. NHS Choices. High blood pressure (Hypertension). Available from: https://www.nhs.uk/conditions/blood-pressure-(high)/pages/introduction.aspx [Accessed 20th October 2017)
2. MacGregor GA, KM Norman. Fast Facts: Hypertension. 3rd ed. Oxford: Health Press Limited; 2006. p.10
3. Beevers DG, Lip GYH, O’Brien E. ABC of Hypertension. 6th ed. Chichester: John Wiley & Sons; 2015. p.5.
4. 4Beevers DG, Lip GYH, O’Brien E. ABC of Hypertension. 6th ed. Chichester: John Wiley & Sons; 2015. p.1.
5. Beevers DG, Lip GYH, O’Brien E. ABC of Hypertension. 6th ed. Chichester: John Wiley & Sons; 2015. p.5-8.
6. Beevers DG, Lip GYH, O’Brien E. ABC of Hypertension. 6th ed. Chichester: John Wiley & Sons; 2015. p.2.
7. Williams H. Hypertension: Management. 2015. p.2.
8. Beevers DG, Lip GYH, O’Brien E. ABC of Hypertension. 6th ed. Chichester: John Wiley & Sons; 2015. p.63-66.
9. Beevers DG, Lip GYH, O’Brien E. ABC of Hypertension. 6th ed. Chichester: John Wiley & Sons; 2015. p.64-66, figures 8.1, 8.2, 8.3, 8.4.
10. Williams H. Hypertension: Management. 2015. p.1.
11. Beevers DG, Lip GYH, O’Brien E. ABC of Hypertension. 6th ed. Chichester: John Wiley & Sons; 2015. p.68.
12. NICE. Treatment steps for hypertension. Available from: https://pathways.nice.org.uk/pathways/hypertension#content=view-index&path=view%3A/pathways/hypertension/treatment-steps-for-hypertension.xml [Accessed 21st October 2017].
13. Williams H. Hypertension: Management. 2015. p.6.
14. NICE. Treatment steps for hypertension. Available from: https://pathways.nice.org.uk/pathways/hypertension#content=view-node%3Anodes-step-4-resistant-hypertension&path=view%3A/pathways/hypertension/treatment-steps-for-hypertension.xml [Accessed 21st October 2017].

Hypertension is a very dangerous condition, and it is because of the heart problems that it can cause a person. “Hypertension is a disease whose chief characteristic is high blood pressure. High blood pressure occurs when the blood being pumped from your heart, pushes too hard against the walls of your veins” (Jenkins 2). Mainly it is very detrimental when a child has high blood pressure, when they have this heart disease it can affect them more in their adult life. Even for adults, it is very dangerous for their health as well.

People who consume too much salt have a probability of developing high blood pressure because sodium which is found in salt increases blood volume. Salt is a mineral that people cannot live without, it is what gives their food that appealing taste this is why it is so difficult to stop consuming salt. “In large amounts, sodium pulls fluids from the body’s tissues and into the blood, which raises the blood volume and compels the heart to pump more forcefully” (Moss 268). This heart condition affects one in four Americans, and they do not even realize it. “Doctor groups help press conferences to sound the alarm that many patients did not even know they had high blood pressure until they developed more evident complications” (Moss 267). When it comes to high blood pressure it can be very dangerous, because if it is not controlled, it can lead to organ damage that is permanent or worse.

In addition, people that purchase processed foods do not have a clue of how much sodium is being put in the product they are consuming. “About 3 quarts of salt was being consumed just in a week or so, all this came from processed foods” (Moss 270). Companies who make processed food products poured bags and more bags into their products, which is very unhealthy for people to consume. Products that are high in sodium and are processed foods are, “boxed macaroni and cheese, their tomato sauce, canned spaghetti and meatballs, salad dressings, pizzas and soups” (Moss 270). “Among older children and adults, however, excessive salt intake leads to volume expansion and arterial hypertension. Children who are overweight, born preterm, or small for gestational age and African American children are at increased risk of developing high blood pressure due to a high salt intake because they are more likely to be salt-sensitive”. High blood pressure can get out of control if there is no change in diet, also if the medications are not being used as prescribed. If someone is not eating properly, they will have a greater risk of developing high blood pressure. “Even items that manufacturers were making expressly for people who wanted to lose weight or manage afflictions like diabetes—the low-fat, low-sugar versions of their brands—were delivering huge doses of salt”. “Salt is a mineral that is very well known to people and it is not something they love, but it is how much they crave for salt”.

“In children, there is increasing evidence that obesity and high salt intake are not only important risk factors for hypertension but possibly also the two most important modifiable risk factors”. Salt intake in people is very dangerous, this is what causes one’s blood pressure to increase. Around the world, children have increased their intake of salt which is very bad for their health.

“2,300 is the maximum amount of sodium, measured in milligrams, that the federal government recommends people to eat every day. In 2010, the government lowered this target for people who are especially vulnerable to the hazards of salt: people fifty-one years or older, blacks of any age, and anyone with diabetes, hypertension, or chronic kidney disease. These 143 million people – a majority of American adults – were now being urged to keep their sodium intake below 1,500 milligrams a day – less than a teaspoon a day”.

It is very important that children or even adults have a reduction in the consumption of salt. “Elevated blood pressure in obese individuals is usually associated with a volume-dependent increase in stroke volume, sodium retention, and higher salt sensitivity, probably due to the combined effects of hyperinsulinemia, hyperaldosteronism, and increased activity of the sympathetic nervous system”. “When it comes to hyperinsulinemia it corresponds with the blood pressure when it is elevated”.

Salt is something that the industry needs to reduce in their products because people’s health is at risk.

“But the more the industry looked at salt, the more it realized that the consumer was only part of the problem. The manufacturers themselves were utterly, inexorably hooked on the stuff. Each year, food companies use an amount of salt that is every bit as staggering as it sounds: 5 billion pounds. And that’s because, for them, the salty taste that drives people to keep eating popcorn until the bag is empty is just the start of salt’s powers. Manufacturers view salt as perhaps the most magical of the three pillars of processed foods, for all the things it can do beyond exciting the taste buds. In the world of processed foods, salt is the great fixer”.

The food industry does whatever it can to get large amounts of salts in people’s bloodstreams. The way that they do this is by adding sodium into their products, they are like additives, there are a few different types of sodium, all these different types of sodiums are added to the products. “The different types of sodiums are with names like sodium citrate, sodium phosphate, and sodium acid pyrophosphate, these compounds have become essential components in processed foods, making them look and taste attractive and last longer on the shelf”. This is why consumers need to pay attention to what they are purchasing.

In conclusion, sodium is a mineral that needs to be reduced in consumption. Since heart disease like high blood pressure (hypertension) can be developed due to this mineral. High blood pressure as stated in the previous paragraphs is a heart disease that is very dangerous especially when the person does not control it. High blood pressure can affect anyone from any age, but mostly when a person is obese.

Cardiovascular Diseases (CVDs) are the number one cause of death globally, as many people still their lives to deaths from CVDs than from any other cause. An estimated 17.9 million people died from CVDs in 2016, representing 31% of all global deaths. Out of these deaths, 85% are due to heart attack and stroke. Hypertension, also known as high or raised blood pressure is a global public health issue. It attributes to the burden of heart disease, stroke and kidney failure, premature mortality, and disability. It disproportionately affects the population in low and middle-income countries and is arising as a significant general wellbeing worry in developing countries like India [3]. One of the worldwide focuses for noncommunicable diseases venture is to diminish the predominance of hypertension by 25% by 2025 (benchmark 2010) as hypertension has credited 19% of worldwide deaths.

Treating hypertension only reduces cardiovascular risk by 25% but treating increased cholesterol in hypertension clients reduces the residual cardiovascular risk for more than 35% as 61% to 65% of hypertensives are hypercholesterolemic. The relationship between serum cholesterol and high blood pressure will not only increase the risk of cardiovascular diseases but also indulges in the elevation of other critical significant modulation of blood glucose, electrolytes, and renal parameters. Hence it is mandatory to treat the hypertensive clients not only for the increased blood pressure but also the increased cholesterol, alterations in serum electrolytes, glucose levels, and renal parameters thereby decreasing the complications of heart attack, heart failure, stroke, aneurysm, and renal failure.

Chocolate is best known as an indulgent confection with its blessed ingredient of cocoa extracted from cocoa beans had varied beneficial effects on human life. Cocoa lowers the risk of cardiovascular diseases, rich in anti-oxidants improves endothelial function, thereby reducing the formation of atherosclerotic plaque in the coronary arteries, increases nitric oxide bioavailability and protects vascular endothelium, alleviates stress considerably, decreases body weight by reducing mesenteric white adipose tissue weight and serum triglycerides, increases the cerebral blood flow, reduces dementia, reduces blood glucose level and decreases the risk of stroke, inhibits lipoxygenase pathways, by directly binding to the active sites of the enzymes lipoxygenase and exhibits anti-inflammatory actions. Every 10 mmHg reduction in SBP significantly reduces the risk of major cardiovascular events, CHD, stroke, and heart failure, which leads to a significant 13% reduction in all-cause mortality. A recent meta-analysis of intervention studies looking at the BP-lowering effect of flavanol-rich cocoa found a significant reduction of 4.5 mm Hg for systolic BP (SBP) and 2.5 mm Hg for diastolic BP (DBP).

The diagnosis of hypertension and its co-morbidities continues to generate fear and turmoil in the lives of the families. It is widely advisable to take easily available, feasible measures to reduce the cardiovascular risk whereby the people voluntarily adopt them for their healthy life other than medications. As hypertension and other comorbidities go hand in hand, it is advisable to check the selected biochemical parameters of hypertension among the hypertensive clients to warn them of the hidden risk factors related to high blood pressure which eventually protect them from the hilarious evident cardiovascular struggles in their lifetime. Instead of taking treatment separately for all the possible cardiovascular risk factors of hypertension with high-cost medications, the researcher planned to render a single remedy for all these multiple risk factors. Cocoa products will play the role of this single remedy which by its consumption reduces all the notable risk factors and increases the health compliance of hypertensive clients.

Framingham risk scores of various studies had suggested that cocoa flavanols reduced the age-related risk of cardiovascular diseases. The bioavailability of the cocoa seemed to enlighten the endothelial function which encompassed the total hypertensive picture into a healthy cardiac outfit outranged by many meta-analysis studies. The objectives of the study were to compare the pretest and posttest levels of selected biochemical parameters of hypertension among clients with hypertension within and between the control and experimental category of clients to evaluate the effectiveness of cocoa powder.

The research work was performed between the months of July and December 2020 in a rural area, Vallam, Thanjavur District, Tamil Nadu. The cocoa powder was obtained by freshly compressed cocoa beans manufactured by The Lotus Chocolate Company Limited, Telangana, Hyderabad. The study protocol was approved by the Institutional Ethical Committee of Saveetha Medical College Hospital, Chennai. The target population of the selected rural area was screened by the investigator and the pilot study was carried out to substantiate the reliability, validity, and feasibility of the study.

Inclusion requirements for the research study included hypertensive clients with stage I hypertension (systolic 130-139 mm Hg and diastolic 80-89 mm Hg), stage II hypertension (systolic 140-179 mm Hg and diastolic 90-119 mm Hg), aged between 30 and 70 years, of both sexes, under regular hypertensive treatment, increased cholesterol levels and able to understand Tamil and English. Hypertensive clients who were pregnant, had other significant cardiovascular problems during the lactation period, were not willing to intervene, and were not available at the time of data collection were exempted from the research sample selection.

The data collection tool consisted of demographic variables and the observational schedule of selected biochemical hypertension parameters. Demographic variables comprised of age in years, gender, education, occupation, monthly income, religion, marital status, type of family, dietary habits, intake of fruits and vegetables daily, duration of hypertension, regular treatment, family background of hypertension, the habit of tobacco chewing, the habit of smoking, the habit of alcohol intake, abdominal obesity, amount of salt intake per day, history of daily physical activity and history of a stressful lifestyle. The observation schedule encompassed blood pressure and biochemical parameters (random blood sugar, total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, serum sodium, serum potassium, serum chloride, serum urea, serum creatinine, and serum uric acid).

After getting informed consent from the research participants, 2 ml of blood was taken for the biochemical investigations. The cocoa powder was given as 5 grams in 125 ml of water for each day in the first part of the prior day nourishment for ninety days along with their antihypertensive drugs after the pretest for the experimental group. Blinding was not done for cocoa administration. However, the person estimating the biochemical parameters was blinded from the study. The control group received the standard hypertensive pharmacologic treatment. The experimental clients were monitored for any side effects. On the 91st day, a posttest was done for the samples of both groups and the findings were recorded. The primary outcome of the study was a significant reduction in blood pressure, lipid profile, and blood glucose levels. The minimal significant reduction in serum sodium and renal parameters were recorded as a secondary outcome.

Finally, it is concluded that hypertension has multi-risk co-morbidities which when left unnoticed will ultimately end up with end-stage complications and cocoa powder has multi-beneficial cardio effects which will embrace all these risk factors to lead the hypertensive clients in a healthy platform of their lives. This research study can be replicated by applying the findings with large samples and with other underlined morbidities of cardiovascular diseases.

The management of hypertension in patients can improve their overall health and reduce the risk of other comorbidities that can arise from being untreated, especially those newly diagnosed. Orem’s theory poses the concept of self-care and the abilities that patients have to improve their self-care. An individual’s ability to perform self-care is defined as the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being. This can include the use of self-blood pressure checks/logs, managing diet and exercise, and following their directed medication regimen. Nurses may need to interfere in the utilization of this self-care when the patient is unable to perform continuous self-care. Her theory strongly correlates to health promotion and can easily be applied to this topic. The application of the Orem self-care model can improve blood pressure control through the use of management techniques that increase self-agency and will be described within this paper.

Dorothea Orem Theory of Self- care deficit, a grand theory, focuses on each individual’s ability to elicit self-care on their own in order to maintain health and well-being. This theory becomes activated when a patient is incapable of meeting the demands of their own self-care within their health. The assumptions of Dorothea Orem’s Self-Care Theory are in order to stay alive and remain functional, humans must remain in constant communication within their environment. Human agency is discovered through developing other ways to identify needs for, and make inputs into, self and others. Her self-care theory was a conceptualized framework surrounded around the deficit within the patient. Surrounding that were self-care agency, nurse agency, and self-care demands. Nurses must have their own self-care agency in order to meet the demands of the patient, our job is to increase their awareness of self-care and assist them on the path to gaining that.

Denyes et al. (2001) state that “from this theoretical view, it is essential that nurses have substantive knowledge about self-care and understand that human beings are both the focus of their own actions and the agents of their actions”. The major relational statement that will be discussed with application to her theory is ‘inadequate management of blood pressure/non-adherence to the treatment plan can increase the risk of comorbidities and alter the quality of life among patients that are poorly treating their new diagnosis. We can also look at how when an individual is unable to meet the self-care requisites (universal, developmental, or health deviation), a self-care deficit can occur. The assumption is that the patient is alert and oriented and has a willingness to participate in care. The nurse is expected to manage these educational interventions and assist in increasing self-care agency as mentioned. Orem suggested that patients had a stronger outcome when they were able to become managers over their own self-care.

The applicability of Orem theory to newly diagnosed hypertension patients who have an apparent lack of self-care is evident. We can provide these patients with educational interventions that can improve those self-care capabilities and create operational definitions within the theory. We can instruct them on the use of a blood pressure journal log, they must monitor their BP every 2-3 days during the week and track their systolic and diastolic quantities. They must learn to evaluate the concerning values that may appear and when to reach out to their health care providers when those values are out of range for themselves. This will allow us to operationalize and track progress towards self-care, this gives them a sense they are in control of their health care goals. Another intervention is in relation to medication if that patient is requiring drug therapy for their new diagnosis. We of course know this is dependent on how advanced their hypertension has become, and presenting new medication treatment into their lifestyle may be overwhelming for the patient. As APRN, we must assist in education on the drug itself, as well as the importance of adhering to the directed dosage and timing of the prescription. This exemplifies the use of self-care by proving that the patient has the ability to manage their own condition through following the directed regimen. It indicates that they have a willingness to abide by directed therapy and maintain wellness. The last operationalized intervention is one of the most challenging ones for patients, that is the adjustment of their diet and increasing their exercise. This can become problematic for those who lead a busier lifestyle, work full time, or have children and household requirements to meet as well. This is where we can truly see where nurse agency may be obligatory. We must provide them with feasible weekly exercise routines that can easily be incorporated into their lives and potentially discuss the addition of a dietitian to follow with. Together the APRN and patient will discuss the means to achieve therapeutic self-care demands to reach the directed goal of hypertension reduction. This is done in order to reduce co-morbidities, such as heart attack and stroke, that can arise from high blood pressure, not to mention improve quality of life.

The University of Cincinnati Health Sciences Library Summon online, CINAHL, and inclusion criteria internet searches were used to conduct a literature review pertaining to this theory and topic. Search terms such as “Orem theory of self-care”, “Orem theory related to hypertension”, and “hypertension management” in relation to drugs and diet/exercise. Criteria that had to be met were research conducted within the last five years, primary research, and full-text online articles. Meta-analyses and systematic reviews were excluded. Four articles will be summarized and applied to the theory of self-care within these newly diagnosed patients in an effort to rationalize the importance of self-care amongst our patient populations.

Khademian, Kazemi Ara, & Gholamzadeh (2020), conducted a quasi-experimental study that aimed to determine the effect of Orem theory in relation to the quality of life and self-efficacy of patients with hypertension. This was a strong illustration of a research study that applied this theory to real people through the use of convenient sampling and randomization. 40 patients in the control and 40 in the experimental group completed the study. Sample sizing was stopped at 88 people due to a predicted potential for a 10% attrition rate. Patients completed the Quality of Life of Cardiac Patients questionnaire in order to assess the effects of cardiac disease and the patient’s physical, emotional, and communal activities in order to determine their ability for self-care requisites.

Each question had a 7-point Likert scale and the scores ranged from 27-189, with higher scores indicating a stronger quality of life. Internal consistencies were confirmed by a Cronbach alpha coefficient of 0.95 for social and emotional dimensions, and 0.93 for physical measurement; this indicates strong validity and internal consistency within the study and that this measurement tool was effective. The experimental group also completed an educational intervention consisting of different classes based on Orem nursing theory with self-care requisites incorporated. The control group was still evaluated through blood pressure checks and monthly visits by a physician. Khademian et al determined that “According to the findings of this study, designing and implementing Orem self-care educational program based on the needs of patients with hypertension along with follow-ups can be effective in improving the quality of life of these patients”. There was a statistical significance found that this intervention does work and the importance of the nurse being available to answer any questions the patient may have. One of the limitations of this study was the concern that it wasn’t followed over a long enough period of time so that the effects of self-efficacy could be studied more longitudinally. According to the Facchiano & Synder (2012) scale, this article was considered a Level II due to the nature of the RCT study design. Participants were placed into groups based on simple randomization. Another limitation of the study mentioned was the process of blinding towards the researchers and participants. It was also determined that the questionnaire was given, although applied to patients with hypertension was more than likely suited for patients post MI rather. This study was still applicable in ways to Orem theory and does allow for independence in individuals and their functional participation in self-care.

Another article that was found during research guides us with the intervention previously revealed, the importance of adhering to a diet regimen in order to recover poor blood pressure management. This devotion to an improved diet should also coincide with an exercise routine. If a patient can maintain follow through with this it can enhance their ability to provide self-care and allow us to operationalize success by tracking weight loss in relation to a reduction in BP. A diet in itself was created to improve the management of hypertension referred to as the DASH diet (Dietary Approach to Stop Hypertension). A randomized control trial was conducted in patients diagnosed with new grade I hypertension. Subjects were either provided the standard education or usual care, whereas the intervention group was given that usual care plus the DASH education delivered by a dietician. There were concerns that true evidence existed up to this point on whether the DASH diet could actually improve in reducing long-term cardiovascular risk. Subjects had to be Chinese patients that were aged 40-70, newly diagnosed with grade I hypertension, and not currently receiving antihypertensive agents. Wong et al stated that “the individualized DASH diet goals were recommended with respect to high consumption of fruits (4–5 serves/day) and vegetables (4–5 serves/day), low-fat dairy products (2–3 serves/day), lean meats, poultry, and fish (≤ 6 serves/day), and nuts, seeds, and legumes (4–5 serves/week).

No significant between-arm blood pressure differences were found between groups, besides that the intervention group reported marginally higher consumption of vegetables and dairy at the 12-month mark. Regression analysis and odds ratio were conducted to determine the results of the study and their usefulness. The estimated ten-year CV risk diminished considerably in both groups, yet the DASH recommendation produced no additional benefits. The ten-year risk does play part in some of the limitations of the study though, there was concern that the use of the ten-year risk rather than actual CV events causes a higher retention rate. The use of the DASH diet, despite the limitations of the study, still does prove primary prevention for furthered cardiac threat. This article was classified as a level II as well, being that it was a randomized control trial. This type of study attempts to reduce bias and allows for comparison among groups. This study was compared to other analyses of this diet conducted in similarity with this one, the researchers attempted many comparisons of their research with others. The only discussion of validity was a general critique with respect to how closely the predicted outcomes agree with the actual outcomes. They did make mention of the strict adherence to baseline guidelines to become part of the testing, as well as adherence to the protocols to ensure a reliable study.

Another intervention related to self-care that can be considered is the use of a blood pressure log. A retrospective cohort study was performed amongst men and women with hypertension to identify the efficiency of self-measured blood pressure. Participants who frequently checked their BP readings compared to those who didn’t have a greater reduction in hypertension. After modifying for sex, race, and ethnicity, the chances of blood pressure decline was 4.88 times greater for applicants who checked their BP readings frequently, compared to those who did not frequently check their BP readings (Swaminathan et al., 2020). There was no apparent IRB approval or informed consent openly mentioned, thus creating a considered limitation to this study. This would be classified as a level IV study on the evidence scale due to the nature of the cohort study, all shared the defining characteristic of hypertension.

The fourth article that was found was in relation to the adherence to a drug regimen if necessary, for patients with hypertension. There is a constant debate over which medications should be provided dependent on patient status and severity of hypertension. There is also an argument over whether to start a patient on combination or monotherapy with their drug routine. A 1-year, double-blind, randomized control trial was conducted to evaluate the effects of this concept, different phases of medication introduction were performed along with altered combinations of medication. Inclusion and exclusion criteria for the study was listed, patients aged 18-79 were selected and must have a systolic BP of Summary of the State of Evidence

All four articles coincide with the discussion of Orem’s theory of self-care in relation to hypertension management, especially those newly diagnosed. We had considered the different operationalized interventions that can be put into place for these patients and the use of these different research studies, can offer assistance towards proving their usefulness. With the use of randomized control trials and cohort studies, it was apparent that the researchers utilized non-biased, outcome-driven research. A majority of the studies discoursed were at a level II for evidence, considered one of the higher stages of evidence.

The validity and reliability weren’t always revealed but it was mentioned by Wong et al (2016) that, “our study, in contrast, was performed in the real clinical setting wherein the dietary counseling practices are often delivered to grade 1 hypertensive patient on a one-off basis without follow-up prompts”. There is also unmentioned reliability in the use of questionnaires that were utilized within certain studies, it is presumed that people would answer honestly for themselves. All of the findings within each study were strongly applicable to those suffering from hypertension, it remained constant across all analyses.

Within this theory and clinical concern of poorly managed hypertension in those newly diagnosed, two APRN-led interventions will be evaluated. The first is the use of a blood pressure journal to monitor adherence to treatment and to show an improvement in SBP/DBP values. The client will be instructed to purchase an at-home blood pressure monitor device and to log values throughout the week. For this example, we can state that they must monitor their BP every 2-3 days twice daily. We don’t want them to develop an obsession with constantly checking these values, as it can end up falsely increasing their statistics if they are incessantly examining their vital signs. The utilization of such intervention can provide the patient with the ability to perform self-care and shows their willingness to increase their health and wellness. They will soon realize their unmet self-care needs or deficit of uncontrolled hypertension. This may be related to poor diet, lack of knowledge or resources, and an inability to be aware of the pending symptoms of high blood pressure. An important step in Orem’s self-care theory is the APRN selecting methods that assist the client to compensate for those deficits, we can do so with the education of a blood pressure log. The log can also allow for measurable outcomes directly within itself, we can chart and trend progress, or determine if other modalities need to be supplemented if success isn’t being met. The applicants who monitored their BP readings frequently using a self-management plan at home have improved blood pressure control (Swaminathan et al., 2020).

A second intervention that can be related to this theory and applied is the adjustment in diet that must be made to improve blood pressure. The success of the DASH diet was demonstrated in detail and it has been shown to greatly enhance the lifestyle and welfare of hypertensive patients. In relation to Orem theory, the APN must create an environment yet again of supportive education with actions that are directed by nursing diagnosis. The patient must become aware of the importance of adherence to improved nutrition and thus creating a sense of self-care demand for the patient. We can measure the outcomes of an improved diet through weight loss and cholesterol levels; classified as precursors that can affect hypertension. We can also monitor a reduction in the actual blood pressure values of the patient that can be seen when these lifestyle modifications are potentially made.

Abstract

Hypertension is a serious health problemoriginates from a combination of genetic, environmental, and social factors.Environmental factors are overweight/obesity, bad diet, high dietary sodium, stress, lack of physical activity, smokingand alcohol consumption. Higher degree of BP control can be achieved by providing a care source, maximum adherence, and minimizing therapeutic lethargy. The targeted technique to be followed includes many interventions to raise the awareness among people, provide the right treatment, and control for individuals. Team-base care system is the latest and ideal model needed to get an appropriate care, control, prevention and recognition of hypertension. This model is a multilevel relationship among patient, physician, pharmacist and other health care provider.

Introduction

Hypertension is a very common cardiovascular disease recognized by the elevation in blood pressure, pressure exerted by blood circulated in the vessels against its walls. This illness is diagnosed by high systolic blood pressure readings and/or high diastolic blood pressure readings which are ≥140 mmHg, ≥90 mmHg respectively. It is a leading cause of death globally reaching 9 million every year (Jamie Kitt, 2019). The incidence of hypertension shown to be lowered by a successful counteraction between Population-based and/or individual interventions. The application of such interventions requires full understanding about the impact of modifiable lifestyle factors (MLFs) and how these factors interact with each other’s(Andriolo, 2019).Many people assumed that HTN occurs only in older ages while more than 2.1 million individuals below 45 years old had this disease. This prevalence among adults is high and still rises in U.S. reaching 31.9% of total cases and expected to be 45.6% in the next decades. Moreover, a household survey done in small cities and country side of Iran where only 34% of hypertension individuals were aware of it while big cities has a higher degree of awareness reaching 50% in Tehran and 43.8% in Isfahan(Masoud M. MALEKZADEH, 2013). A detailed information on risk factors, management, control and prevention of hypertension will be discussed.

Methods

Systematic search was performed to get an accurate information about the topic from various articles published between 2013-2019 retrieved from PubMed, science direct and google scholar. The search terms were a combination of “hypertension”, “prevention”, “management”, “risk factors”, “overview”, “review” and “control”. The search was precise to get most relevant and up to date literature. No restriction applied on language,geographical location or specific population. The Referencelists for most of the articles were searched manually forany relevant studies.

Risk factors

Overweight or Obesity

Obesity- hypertension relationship can be cleared as there are many alterations occurs within high weight individuals’ bodies such as increased blood flow, and retention of renal sodium which leads to hypertension. One of obesity problems is abnormal LV [left ventricular] geometry which is more in obese than non-obese patients (49% vs 44%) as it leads to hypertension. Studies in U.S. shows that about 40% of their hypertension adults are obese (BMI >30 kg/m2), and more than one-third of the obese individuals has hypertension (SBP/DBP >140/90 mmHg or taking antihypertensive medication (Robert M. Carey, 2018).

High salt (sodium) intake

High sodium consumption in human diet >5 g sodium per day can be a leading cause of hypertension as it is known that salt results in fluid retention so more pressure will be present on the arteries as its more constricted. One study shows that reduction in salt intake of 5 g per day results in 2.8% reduction in carotid femoral PWV readings about arteries stiffness. Low salt intake should be combined with DASH eating plan to get better reduction in BP (Robert M. Carey, 2018). Dash (Dietary Approaches to Stop Hypertension) eating plan consists of fruits, vegetables, whole grains, nuts, legumes, lean protein, and low-fat dairy products.

Lack of physical activities

As it is directly related to gaining weight, it is very essential to exercise at least 3 to 4 times a week in proper and right manner. Exercising is known for its effect on increasing blood flow to the arteries so natural hormones and cytokines will be released to relax these vessels which eventually reduce the pressure on them. WHO studies show that physical exercise can reduce systolic blood pressure by 5 mmHg.Moreover, reduction in deaths from strokes by 14% and deaths from coronary heart disease by 9%(Ihab Hajjar, 2006).

High alcohol consumption

Too much alcohol drinking seems to have an effect on the activation of adrenergic nervous system which leads to blood vessels constriction so blood flow will increase with a raise in heart rate.

Stress

Many people underestimate the psychological problems effects on various body organs. Stress does have a temporary but dramatic effect on blood pressure as its increasing so relaxing and meditation is the key to lower such an elevation.

Social determents

Social determents are linked with hypertension causes along with environmental and genetic risk factors. These determents are defined as the collection of circumstances related to where people born, grow, live, work, and age, and the systems used to deal and treat a disease. In U.S., a strong linkage presents between social determinants of health and hypertension, specifically within blacks and Hispanics societies who are minority populations. Black people show more prevalence of hypertension compared to white people which leads to high rates of stroke risk and end-stage kidney disease. Moreover, unstable and uncontrolled hypertension is more in blacks because of weak control on BP while taking antihypertensive medication (Robert M. Carey, 2018).

Another determent is Neighborhood characteristics which has a great influence on prevalence of this disease. A higher chance to have high BP seems to be in people who live in most economically deprived neighborhoods. Geographic areas may also have a link to hypertension as it is prevalent in southeastern United States (Robert M. Carey, 2018). However, it is necessary to put these factors in consideration as they are critically important in the control and prevention of this disease.

Management

Hypertension is controlled by using non-pharmacological methods to lower blood pressure. These methods are associated with higher control BP. Non-pharmacological and pharmacological management decrease the risk of CVD and all cause of deaths are reduced by 20% to 40%. Hyper tension has been classified from self-monitoring tele-monitoring to virtual clinics and artificial intelligence. (Robert M. Carey, 2018)

1. Self-monitoring of BP will lead to enhance the management of BP and it is the most remarkable part of hypertension control. It is acceptable by patients. Self-monitoring trials represent the enhancement for the management of BP. As result patients may use remote monitoring for BP at home. To improve the self-monitoring outcome by using BP monitoring apps. (Jamie Kitt, 2019)
2. Tele-monitoring is an application of tele-medicine -transfer data remotely- which is transferring of BP readings automatically. Moreover heart rate, oxygen saturation and pacemaker data can be sending with the BP form patients to professionals. Tele-monitoring programs are present but it varies in their modality of data collection, transmission, and reporting. Digital involvement now afford the users with further support over the simple tele-monitoring which can lead to lower BP than the normal care. (Jamie Kitt, 2019)
3. Virtual clinics supply system-level choice for the technology use and include structured asynchronous online communication between patients and professionals to increase the medical care instead of office visit.(Jamie Kitt, 2019)
4. Artificial intelligence support mediator such as Alexa and Siri which can set up a reminder and renew the medication lists wirelessly. There is a clear evidence of the important of these and their usage raised by time. Consolidation of tele-monitored data on BP into advance social health care program can now additionally permit combination with other physiological factors including blood glucose, heart rate and exercise permitting adjustment of management recommendations based on pre-determined variables such us user demographics, indicated morbidities and co morbidities.(Jamie Kitt, 2019)

Prevention and control

Application and population-based strategies is a way to help in prevention and control hypertension among the society. A traditional strategy is used to reach the targeted approach in healthcare and to achieve a noticeable reduction in BP for individuals with high BP whom are in the upper end of the BP distribution. Management of patients with hypertension and prevention of hypertension share a similar approach, which is the targeted approach strategy. In approaching a smaller reduction they go for the population-based strategy which is derived from public health mass environmental control experiences, therefore this approach results in a small downward shift in the entire BP distribution. Modeling studies consistently provide greater potential to prevent CVD versus the targeted strategy. The large number of people whom are exposed to small increased CVD risk may generate many more cases than a small number of people exposed to a large increased risk based on the findings of the principal.(Robert M. Carey, 2018)

Conclusion

In conclusion, hypertension has been a major risk of morbidity and mortality by WHO. Many Patients are unaware of the disease and the control rate of disease is low.Despite the management, treatment, many studies had showed that many patients will remain sub-optimally controlled. New strategies and technologies are needed to improve detection and control of raised blood pressure in the community. Possible ways to decrease the prevalence of hypertension is to provide a care source, maximum adherence, minimizing therapeutic lethargy, and increasehypertension awareness and accessibility to health services

Hypertension is another term used for high blood pressure, where it is measured in pressure units and typically found in patients at 160mmHg/100mmg. It is measured at the systolic and diastolic. The hyperlipemia is combined with the hypertension, where it is known as a high lipid/cholesterol count, where the LDL levels are at 2mmol/L are known as a high risk. The key drugs available for this are either Thiazide diuretics, b1- adrenoreceptors antagonists and ACE inhibitors which would work alongside the HMG-Coa reductive inhibitors.

The thiazide diuretics acts on the distal tubule of kidney at the point of transition of water and salts, where the site of action is on the specific transporter proteins allowing the reabsorption of salts from the tubule to the bloodstream. Which have hormonal and therapeutic control points. The thiazide drug binds to the C1 transporter, also known as the Cl- binding site of the sodium chloride co transporter system, which essentially means there will no longer be the binding of the chloride ions, which the inhibit the salt reabsorption into the bloodstream. The blood volume will decrease, since there is no uptake of water and salt as the water will remain in the distal tubule due to the retention of the osmotic balance, which means it will be excreted. Hence, the side effect of frequent urination. The thiazides have effects of having vasodilator action on the vascular tissue, regulating the Ca+ ions and reducing the blood volume in the increased renin secretion

Another drug to treat hypertension is β1- adrenoceptor antagonists, which is situated on the cell membranes of cardiac, intestinal, bronchial, and vascular smooth muscle. The endogenous neurotransmitter ‘noradrenaline’ activates the β1- adrenoceptor, which is released from the post ganglionic nerve terminal. This will then activate the GPCR mediated pathway and adenylyl cyclase pathway by interacting with the GPCR on the cardiac cell. To be able to increase the likelihood of the channel opening there should be a phosphorylation by protein kinase A, on the alpha 1 subunit of the calcium ion channels, which are on the cardiac cell membrane. The bioavailability of the intracellular calcium ions will increase, leading to the increased rate and force of contraction. There are also nonselective versions of the β1- adrenoceptor antagonists like propanol, which can have an effect on asthmatics as it causes bioconstruction due to the sympathetic nerves which have innervated on the bronchioles which typically activate the β2 adrenoreceptors that promote bronchodilation. The selective agents like atenolol are concentration dependent. When the selective β1 receptors have a high concentration or dosage they are found to be poor in intact cells and then β1 selective actually have a higher affinity for the β2 adrenoreceptors, hence why there needs to be more development of selective β-antagonists. Both examples have a level of cross reactivity, which makes an effect on the drug development.

Using ACE inhibitors is also an additional drug that you can use to treat hypertension. On the vascular endothelium, the carboxypeptidase ACE cleaves the C-terminal pair of amino acids from the peptide precursors. In order for ACE activity, there is a zinc ion in the active site, the ACE inhibitors will also mimic this same peptide structure ensuring it is stable and still has the absorption properties, however the ACE inhibitors will block the active site and via the sulfhydryl group, there will be reversible binding to the zinc ion and which is normally occupied on the C-terminal leucine of angiotensin I, so proline residue will bind to the site normally. The ACE target degrades ACE to angiotensin II and bradykinin, so it does not accumulate in the bronchial tissues when undergoing ACE inhibitor therapy. The possible option for drugs is Captopril (1ST generation) and Lisinopril. Alongside the ATI receptor antagonists like Losartan, which is newly developed and prevent angiotensin II binding to the ATI receptor, preventing a dry cough which they could possibly get when using the other drugs, however it is still considered as a second choice.

Statins like HMG-Coa reductase inhibitors are used to treat hyperlipidaemia, by inhibiting the rate limiting step of the cholesterol synthesis, converting HMG-Coa to mevalonic acid, subsequently reducing the amount of cholesterol. There is then an increase in LDL uptake as more LDL receptors are presented on the cell surface, overall leading to a decrease of cholesterol in the blood. They cause partial inhibition of the enzyme and impair the synthesis of the isoprenoids which are vital for cellular functions. The reductase inhibitors induce an increase in high affinity of LDL receptors. Options of drugs that could be used are simvastatin, lovastatin, and atorvastatin.

In conclusion, for combined hypertension and hyperlipidaemia it is clear that there should be a dramatic lifestyle changes, like diet change. However, there are an option of 3 drugs for hypertension which needs to be taken alongside HMG-Coa reductase inhibitors.

Introduction

High blood pressure is also referred to as hypertension (HTN), and it can be defined as a disease in which blood pressure in arteries goes up forcing the heart to perform higher in order to supply blood to blood vessels.

It can also be defined as a condition where blood in arteries exerts abnormally high pressure on arterial walls (Al-Nozha & Khalil, 2007, pp. 77-84). The blood pressure in the heart is measured by the quantity of blood the heart pumps and the strength of resistance in arteries. A patient is said to have chronic hypertension if the blood pressure has been consistently high for long.

It is vital for both practitioners and patients to have information about hypertension because such information can help in saving lives. This paper defines hypertension, explores the history of hypertension, discusses the prevalence of hypertension in Saudi Arabia, analyzes the symptoms and causes of hypertension, explores ways in which hypertension can be prevented and treated, and suggests ways in which hypertension can be medically diagnosed.

History of high blood pressure

High blood pressure can be traced in history to as far as 2600 BC. During this time, hypertension was known as heart pulse disease. Great scholars of the past advocated for a method of venesection and bleeding by leeches as a way of treatment. Progress was made in the 20^th century when it became possible to diagnose hypertension.

Medical sympathectomy operations were first conducted in 1923. The first effective oral drugs for hypertension were introduced in 1957. Conversion of enzyme inhibitors then followed in the 1980s. New drug inventions have reduced side effects, and improved affordability and accessibility of treatment for hypertension to most patients.

Prevalence of hypertension in Saudi Arabia

Studies show that in the Kingdom of Saudi Arabia (KSA), hypertension is steadily on the rise because of lifestyle changes. A report by a committee formed to investigate issues related to hypertension among the populace in KSA show an increased prevalence of high blood pressure in KSA among adults who live in urban as well as rural areas.

Causes of high blood pressure

Causes of high blood pressure can be classified as either primary or secondary. Primary causes are normally associated with structural changes in arteries, and the resultant condition is more prevalent in adults (A.D.A.M, 2012, pp. 1-5).

Among secondary causes are changes in hormones as well as diseases of the kidney. Secondary causes account for approximately 10 percent of adult high blood pressure cases. The rest of the percentage affects mostly children under the age of ten. Notably, many cases of hypertension can be linked to diseases of the kidney.

The kidney is the main body organ that stabilizes fluids. In case a patient suffers from kidney disease, the volume of blood in the body rises causing the pressure to increase. This makes the heart pump blood quickly leading to hypertension (O’Brien, Asmar, Beilin, Imai, & Mallion, 2003).

One of the most common kidney diseases that cause high blood pressure is polycystic. This condition is mostly hereditary and it develops through cysts. Secondly, diabetic nephropathy damages the kidney filtration system creating a high-pressure flow of blood. Additionally, hypertension can be caused by a swelling of filters in kidneys caused by a disease referred to as glomerular disease.

Hormonal disorders cause high blood pressure as glands produce less or too much hormones. For instance, the thyroid gland can produce small quantities of thyroid hormone that can lead to a disease called hypothyroidism, which makes the pressure of the blood to rise.

Symptoms of high blood pressure

High blood pressure manifests itself silently in the body. It worsens with age. If one is above the age of 18 years, normal high blood pressure tests should be carried out regularly. Testing is particularly vital for people who are at risk of developing hypertension. For instance, people with a family history of overweight issues, diabetes, and those in their late adulthood have a greater risk.

The most revealing symptom for hypertension is a diastolic pressure of more than 130mmHg. People who have a heart failure history or those with unmanaged hypertension are at more risk of having the aforementioned diastolic pressure. Other alarming symptoms for hypertension include blurred vision, nausea, difficulty in breathing, drowsiness, confusion and a constant headache.

Medical diagnosis of hypertension

The most common diagnosis is done through physical examination. The patient being examined should not smoke, take any caffeine, or exercise 30 minutes before the physical examination. Hypertension is detected through the use of an instrument known as a sphygmomanometer.

Physicians usually undertake an hypertension test by listening to the patients heartbeat using a stethoscope, and by reading units of mercury. The first pumping of the heart is recorded as systolic pressure and the last beat of the heart is recorded as diastolic pressure. If the practitioner notices that the patient may be having hypertension, he/she takes repeated tests separated by a span of around two minutes. If the measurement is still above normal, a similar test is conducted in both arms.

Other diagnostic tests carried out on a patient include ambulatory monitoring, home monitoring, and physical tests to check on any complications related to hypertension. Medical history obtained from family history, any active medical prescription, symptoms that show signs of secondary hypertension, and relevant emotional and environmental factors that affect high blood pressure are considered. Finally, laboratory and other necessary tests can be conducted.

Prevention of high blood pressure

High blood pressure can be prevented through a number of lifestyle changes. These include eating a well balanced diet, participating in various physical activities, maintenance of a standard weight, learning how to keep low levels of stress, limiting of alcohol intake, avoidance of tobacco smoking and adherence to prescriptions for medicines (Marks, 2013).

Understanding high blood pressure is important for both patients and healthy individuals. Hypertension is highly manageable. When a person leads a healthy lifestyle, the risk of developing high blood pressure is substantially reduced. For a patient, a healthy lifestyle can prevent the disease from increasing, thereby reducing the risk of getting a heart attack or heart diseases (Mancia, Fagard, & Narkiewicz, 2013).

Treatment of hypertension

After a hypertension diagnosis, a patient should ensure that he/she frequently consults the doctor in order to manage the condition properly. Lifestyle changes should be made and patients need to check on their blood pressure regularly at home (Williams, Poulter, Brown, & Davis, 2004). Medication also needs to be taken in the right manner.

For those who have mild cases of high blood pressure, it is not always certain when they can start taking medication. To help those who have pre-hypertension, certain institutes have set groups of patients who are diagnosed with the disease, depending on their risk of contracting heart diseases (Parati, Stergiou, & Asmar, 2010).

Conclusion

In conclusion, hypertension affects the heart causing enlargement of blood vessels. It dates back to historical times during which its definition was modified to its current version through various tests and clinical trials. Hypertension is highly prevalent in Saudi Arabia due to urbanization.

Its causes are classified as either primary or secondary. Hypertension has no symptoms but it has several signs that are clinically diagnosable. Management of hypertension as well as its prevention can be achieved by proper dieting and being involved in physical exercises.

Reference List

A.D.A.M. (2012). High Blood Pressure. The New York Times. Retrieved from https://www.nytimes.com/section/well

Al-Nozha, M. M., & Khalil, M. Z. (2007). Hypertension in Saudi Arabia. Saudi Medical Journal, 28(1): 77-84.

Mancia, G., Fagard, R., & Narkiewicz, K. (2013). 2013 ESH/ESC Guidelines for the management of arterial hypertension. Journal of Hypertension , 31(7): 1281-1358.

Marks, J. (2013). High blood pressure facts. Retrieved from https://www.onhealth.com/script/main/hp.asp

O’Brien, E., Asmar, R., Beilin, L., Imai, Y., & Mallion, J.-M. (2003). European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. Journal of Hypertension , 31(4): 821-828.

Parati, G., Stergiou, G., & Asmar, R. (2010). European Society of Hypertension.

Practice Guidelines for home blood pressure monitoring. Journal of Human Hypertension , 24(12): 779-785.

Williams, B., Poulter, N., Brown, M., & Davis, M. (2004). Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004—BHS IV. Journal of Human Hypertension , 18 (3): 138-185.