When I was working as a Senior Medical Researcher at the Institute for Medical Research in Malaysia in the 1960’s till the mid 1990’s, we conducted thousands of health surveys among tens of hundreds of thousands of villagers and city-dwellers throughout the length and breadth of Malaysia.
We found two most common chronic lifestyle diseases were high blood pressure and diabetes especially among the urban and city dwellers, probably due to their stress, and lifestyles, especially their dietary lifestyles.
Even today this is the same disease scenario that overcrowds all the public hospitals. These patients who come to crowd the hospitals are not new patients who already got cured by their previous medications, but they are the same patients coming for their follow-up with the same mediccations that never cured them, followed by new patients crowding and seeking the same treatment.
We shall first look at
hypertension first as the most common disorder that afflicts most people.
In a voluminous 1123-page 4th edition textbook on Integrative
Medicine chapters contributed by several dozen specialist clinicians,
conventional as well as alternative medical specialists or combined. edited by
Dr. David Rakel M, Professor and Chair of the Department Family and Community
Medicine at University of New Mexico School of Medicine, Albuquerque, New
Mexico, Dr. Gregory A. Plotnikoff MD, MST & Jeffery Susek, PhD have this to
say together with mine.
Hypertension
is the most important risk factor for cardiovascular morbidity and mortality in
all industrialized and affluent countries. At least 65 % of the population of
United States, Europe and Southeast Asian countries like Malaysia, Singapore,
Philippines, especially those living in the cities have high blood pressure
that place them at significantly higher risk of coronary artery disease, heart
failure, renal failure, thoracic, and abnormal aneurysms, myocardial infarction
and stroke. Hypertension is also associated with cognitive dysfunction,
erectile dysfunction, and loss of vision. The higher the pressure the greater
the risk of complications.
However,
hypertension frequently is asymptomatic, in the absence of symptoms, elevated
blood pressure may not hold particular significance for patients. In many
cultures of the world, if there is no pain, there is no disease. This means
that clinicians face three challenges. First, is there a shared awareness? Is
hypertension even an issue for patients? Second, will the patient accept any
intervention to treat an abstract number? Third, will the patient accept a
long-term intervention with no immediate benefit? For these reasons, patients
benefit when integrative clinicians initially explore the meanings, beliefs and
interpretations the patients bring to their experience of numbers from
ambulatory blood pressure measurements. The patient’s answer should both guide
the clinician’s approach and foster a working partnership.
Hypertension
prevention and treatment represents an ideal opportunity to co-develop a
customized action plan that addresses options regarding diet, exercise,
supplementation, smoking cessation, mind-body self-care skill development.
Additional insight may also come from Ayurvedic, naturopathic and traditional
Eastern medicine traditions. This individual intervention can contribute to
improved health and well-being.
There is no
question that every clinician must be well versed in the treatment of
hypertension. However, there is still considerable confusion regarding
optimal hypertension management. For instance, in 2014 JAMA published the eight
reports of the Joint National Committee on Prevention, Detection, Evaluation
and the Treatment of High Blood Pressure (JNC 8). This was greatly anticipated
as the previous report JNC 7 was published in 2003. Nine new recommendations
were made, the most controversial of which was to redefine the goal blood
pressure for those greater than 60 years of age to < 150 / 90 mm Hg For all
others aged over 18 years, the goal blood pressure was recommended as < 140
/ 90, preferably 120 / 80. This same goal was recommended for patients with
chronic kidney disease or diabetes.
Significant
confusion followed the publication of JNC 8. Critics noted the marked lack of
consistency with JNC 7; the lack of consensus among the JNC 8 committee members
in hypertension, with 5 of 17 authors quickly publishing a dissent, and the
lack of clarity in definable quality measurement in hypertension by which to
grade the physicians. The American Heart Association (AHA) and American College
of Cardiology (ACC) continue to recognize JNC 7 and are currently preparing
their own guidelines.
The confusion
follows from the mixed conclusions of the two JNC reports. The 2003 JNC 7
reports defined a normal BP as less than 120 mm Hg, systolic and less than 80
mm Hg diastolic. The report similarly defined stage 1 hypertension as 140 – 139
mm Hg systolic and 90 -99 mm Hg diastolic. In between normal and stage 1 values
is a category the JNC 7 report termed as prehypertension. This term was introduced
to heighten awareness of both risk and opportunities for prevention. The JNC 7
report also noted that the BP treatment goal is less than 130 / 80 mm Hg for
persons with diabetes or renal disease and hypertension. In marked contrast JNC
8 did not define a “normal” blood pressure, eliminated the stages of
hypertension, and revised upwards the thresholds for treatment, including those
persons with comorbidities.
How could this
happen? JNC 7 recommendations were based upon experts’ consensus derived from a
thorough but nonsystematic literature review that included observational
studies. In contrast, JNC 8 recommendations followed from a formal systematic
review by methodologies who were restricted to consideration of randomized
controlled trials (RCT) with more than100 hypertensive participants who were
followed for at least 1 year. This eliminated approximately 98 % of all
previously published clinical studies of hypertension treatment, including
observational studies, systematic reviews, and meta-analysis. The JNC 8
committee also restricted their analysis to three questions. First, does
initiation of antihypertensive pharmacological treatment at specific threshold
improve health outcomes? Second, do attempts to reach specific blood pressure
goals lead to improvement in health outcomes? Third, do the various
antihypertensive drugs or drug classes differ in regard to health outcomes? The
panel did not address whether therapy-associated adverse effects harms resulted
in significant changes in important health outcomes.
The JNC 8
recommendations were graded based upon the quality of evidence reviewed, Not
considered for the first two questions were any RCT ‘s that included
participants with a normal blood pressure such as with diabetes. Studies
considered for the third question were limited to those that examined one class
of medication versus another. This eliminated all single agent
placebo-controlled trials from consideration.
Based upon
such a rigorous evidence-based review, only the two grade A “strong”
recommendations could be made. First, for those ≥ 60 years of age,
antihypertensive pharmacotherapy should be initiated at threshold of ≥ 150 mm Hg systolic blood pressure or ≥ 90 mm Hg
diastolic blood pressure with a goal blood pressure of < 150 mm Hg systolic
and < 90 mm hg diastolic. Second, those < 60 years of age,
pharmacological therapy should be initiated at a diastolic blood pressure ≥ 90
mm Hg with a treatment goal of achieving a pressure < 90 mm Hg.
Likewise, only
three Grade B “moderate” recommendations could be made. Generally, including
those with diabetes, initial therapy should include a thiazide diuretic, a
calcium channel blocker (CCB), an angiotensin converting enzyme inhibitor
(ACE), or an angiotensin receptor blocker (ARB).
Initial therapy
is to advise the patient to cut down his salt (sodium) intake, followed if not
successful by a thiazide diuretic to throw out excessive water that increases
hydrostatic pressures or given a CCB. For those aged ≥ 18 years with chronic
kidney disease, the initial or add-on pharmaceutical should be an ACE or ARB to
improve kidney outcomes.
Grade C or
“weak” recommendations were based upon RCT’s with major limitations, such as
the presence of post hoc analysis of non-prespecified subgroups. Only the
recommendation was possible for diabetics, initial therapy should be a thiazide
diuretic or a CCB.
Every other
recommendation made by the JNC 8 committee was labeled grade E, the category
representing consensus expert opinion. This means that the evidence based on
the gold standard of randomized -controlled trials was too weak to make a
definitive recommendation. Further, any other clinical intervention for the
prevention and treatment of hypertension fails the strictest definition of
“evidence-based” practice. Given contradictory clinical trial data, these
guidelines will likely remain controversial.
Although
observational studies and association studies have demonstrated a strong
relationship between lower blood pressure and reduced risk, all the way down to
very low blood pressures, evidence from RCT’s does not indicate any patient
benefit from treatment with pharmaceuticals to achieve lower blood pressures.
Two significant implications exist for integrative clinicians and their
patients. First, JNC 8 widens the range of acceptable blood pressures for
patients. Second, JNC 8 reduces the pressure to prescribe pharmaceuticals for
patients who decline or wish to avoid pharmaceuticals.
In fact, JNC 8
explicitly supports the role of conventional risk modifications including
reducing sodium intake, increasing exercise, moderating alcohol consumption,
weight reduction, and following the Dietary Approaches to Stop Hypertension
(DASH) eating plans and nutrition.
The American
Heart Association has gone even further. In 2013, it affirmed that all
individuals with blood pressure > 120/ 80 mm Hg should consider trials of
alternative approaches as adjuvant methods to help lower blood pressure when
clinically appropriate.
Because most
people wish to avoid drug therapies, clinicians in alternative approaches are
often highly sought who can counsel from evidence-based regarding the most
appropriate treatment option available. This is a very sound logical approach
in the treatment of hypertension as in all chronic disorders, especially
lifestyle diseases.
Non-drug
approaches using integrative medicine are found in the JNC 8 report and they
include the following:
Lifestyle
non-medication such as:
1.
Smoking Cessation
2.
Nutrition and the Mediterranean Diet
3.
Olive Oil
4.
Cocoa
5.
Red Wine
6.
Omega-3 Fatty Acids
7.
Dietary Fiber
8.
Flax Seed
9.
Inorganic Nitrites
10.
Exercise
11.
Weight Loss
12.
Sleep
13.
Transcendental Meditation
14.
Dietary Supplementations
15.
CoQ10
16.
Vitamin D
17.
Magnesium
18.
Botanicals such as
19.
Garlic
20.
Hawthorn (Crataegus monogyna)
21.
Mind-Body Therapy
22.
Biofeedback
23.
Mindfulness-Based Stress Reduction
24.
Yoga
25.
Qi Gong
26.
Tai Chi
27.
Earthing
28.
Ayurveda
29.
Traditional Chinese Medicine and East Asian Medicine
We shall
discuss these therapeutic modalities which are much safer, more permanent and
much more appropriate than using synthetic chemical pharmaceutical drugs that
only temporarily inhibit high blood pressure and other morbidities. Drugs do
more harm than ‘cure”, and does not “cure” any disease, but the patient asked
to come back for the same titrated to a higher dose or replaced by another
agent to repeat the same.
As discussions
on these other therapeutic modalities would run into hundreds of pages, we
shall stop here and put these to another day.
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