Northwestern`s Dr. Jeremiah Stamler, one of the world`s leaders in the study of the epidemiological patterns of high blood pressure, has found that nutritional therapy can also control mild hypertension. In a 1987 paper, his research team reported that patients who reduced their overweight and excess alcohol and salt consumption were able to control mild hypertension. In another study published in 1989, Stamler`s team reported that weight loss was especially effective in controlling blood pressure. Even a moderate reduction in risk factors (weight, salt, alcohol) contributes to primary prevention, he concluded.
Nephrologists such as Levin and Batlle became interested in hypertension because it attacks and destroys the kidneys. Many of their hypertensive patients are in kidney dialysis, and many of them are black.
For reasons that remain unclear, high blood pressure is three times more common among black Americans than among whites.
Blacks are also three to five times more likely to suffer serious complications of hypertension, including strokes and kidney disease. Hypertension-related diseases kill up to 100 times more black people than does sickle cell anemia.
Batlle says that inadequate medical care, delays in treatment and noncompliance with therapy may explain some of this.
ALTHOUGH PHYSICIANS have more than 80 drugs at their disposal to try to control hypertension, this has not proven to be a match for human nature. Hypertension is a lifelong condition and, once started on medication, the patient is married to it for life. Because the side effects of anti-hypertensive drugs can, however, include impotence among men, many patients find it easy to divorce themselves from their drugs.
The reason is simple, Levin says. ”Since you don`t feel sick with high blood pressure, then the medicine can`t make you feel better and, in fact, it usually makes you feel worse. So, people think, `Hey, what good is this?` And people do not like to give up their lifestyles.
”The challenge,” he adds, ”is for physicians to learn how to custom-tailor medication both for the patient`s medical needs for his personal satisfaction with the quality of his life. Only then will patients comply with what their doctors tell them to do.”
The U.S. pharmaceutical industry, mindful of both the medical needs and the billion-dollar market (the average patient spends $1 a day to control high blood pressure), emphasizes treatment compliance. The new drugs coming on the market, they emphasize, are not only effective but also have fewer and less severe side effects.
Drug firms hope-and are sponsoring educational programs-to spread the word that if physicians use the new generation of medications to reduce side effects and if patients are satisfied with their medication and have strong personal support from family and friends, then the trend of non-compliance can be reversed.
Previously, physicians used a ”stepped-care” approach to prescribing drugs to control blood pressure. Stepped care is a standardized form of treatment that begins with diuretics (to flush out excess water and reduce blood volume) and/or beta blockers (to reduce the heart`s output of blood volume), and, if this is insufficient, adds different medications one by one until blood pressure is controlled.
These front-line drugs, however, carry unpleasant side-effects. Diuretics can cause weakness, leg cramps, impotence, pain in the joints and can aggravate other medical problems such as levels of cholesterol, blood glucose and uric acid. Side effects associated with beta blockers include lethargy, slow heartbeat, shortness of breath, depression and nightmares. And 10 percent of all male hypertensives treated with beta blockers develop impotence. (See story on page 60.)
Scientists know how blood pressure rises (increased heart output and increased vessel resistance), but what causes these dynamics?
”Ah, my friend,” Batlle says. ”This is the million-dollar question. If I knew, I would be on my way to Stockholm (for a Nobel Prize).” Batlle is studying the interaction of cellular acids, electrolytes and fluids to try to learn how basic alterations at the cellular level can eventually damage vessel tone and stiffen and narrow the arteries, which is the No. 1 cause of hypertension.
He adds, ”One of the biggest problems in contemporary medicine is the combination of high blood pressure with Type II diabetes. In my opinion, this is second only to AIDS as a medical problem because a combination of uncontrolled blood pressure and uncontrolled diabetes can destroy the kidneys.
”Type I diabetes occurs early in life, has pronounced symptoms and is usually quickly treated and brought under control. Type II diabetes, however, occurs later in life, usually after 50, is much more subtle, and often goes undetected. Type II diabetes is related not to a lack of insulin circulating in the body but to the resistance of the body`s tissues to absorbing insulin. This, in turn, is often associated with obesity. The fatty tissues require more and more insulin to regulate the body`s blood sugars, and this leads to late-onset diabetes. If this happens when you also have uncontrolled high blood pressure, it can be catastrophic to your kidneys.”
The ultimate answer to high blood pressure, Levin believes, may be found through the emerging genetic research. ”There may be a certain gene that is predisposed for a certain type of hypertension he says, and we may eventually get a one-shot answer by treating or replacing the defective gene.
”In the meantime, though, we need to diagnose more accurately the different causes of essential hypertension among different patients and custom-tailor their treatment for personal satisfaction and maximum effectiveness with minimum side effects. And then keep them on the program.” Levin, 54, brought his blood pressure down from 145/90 to 134/84 by first losing 20 pounds and then keeping the extra weight off by faithfully working out on a rowing machine.
Batlle, 40, has trouble doing his favorite exercise-soccer-but stays at 120/70 by briskly walking back and forth between his office at the Northwestern Medical School complex to his research lab six blocks away at the Lakeside V.A. hospital.
Both say that hypertensive patients should try to lower their blood pressure without drugs, if at all possible. However, they emphasize, if this fails, then drugs must be prescribed and taken-for a lifetime.
