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Prisoner Self Care: Hypertension
This article is about high blood pressure, also called hypertension. Hypertension is a common chronic disease that arises slowly and continues for years. It generally causes few or no symptoms. Treatment is directed at controlling the blood pressure, not curing the underlying disease. Hypertension does not “get better”. A lifetime of uncontrolled high blood pressure may result in disability or death.
What is Hypertension
When the heart pumps there is a squeezing time when the blood is pushed out. The highest pressure occurs at this time. Then there is a relaxed time when the heart is filling up with blood when the lowest pressure occurs. Both the high peak and the low trough are measured with a blood pressure cuff inflated on the upper arm. The blood pressure is reported as the high and the low, for example “110 over 70” and written down like a fraction, 110/70.
Blood pressure greater than 140/90 is too high. Hypertension generally does not have warning symptoms. You would never know you had it unless they take your blood pressure as part of a nursing assessment at the clinic. Hypertension causes long term complications by damaging the heart, kidneys, and arteries. This damage in turn can result in heart attack, heart failure, kidney failure, and stroke.
Hypertension is only one of the common conditions that cause organ damage over time. High blood fats (like cholesterol and triglycerides), obesity, smoking, and diabetes are all common conditions that act together to cause heart attack, heart failure, stroke and blocked arteries.
Diagnosis of Hypertension
The diagnosis of hypertension is based on the blood pressure measurements.
• Normal blood pressures are when the high pressures are in the 110’s to 120’s and low pressures are in the 60’s and 70’s.
• Pre-hypertension blood pressures are when the high is in the 130’s or lows in the 80’s. These pressures are abnormal, but not yet high enough to be called a disease and treated with medicine.
• Stage 1 hypertension is when the high is in the 140’s or 150’s or the low is in the 90’s.
• Stage 2 hypertension is when the high is over 160 or the low is over 100.
Since there are usually no symptoms to alert you that your blood pressure is too high, you have to get health care from a doctor or clinic to be diagnosed. Blood pressure should be measured sitting down, at rest and relaxed. The pressure must be found to be elevated on three separate visits to confirm the diagnosis of hypertension.
Each time a nurse or doctor takes your blood pressure they should share the results with you. You need to know your usual blood pressure. If you know what your pressure is, you can keep track for yourself. Is it normal? Has it risen above the normal range, but not yet high enough to treat? Stage 1? Stage 2? Are you doing better, worse or the same since the last time it was measured?
As people get older, they are more likely to develop hypertension. One of the important reasons to have regular health assessments is to diagnose new problems, like hypertension. It is best to begin treatment as soon after onset of the disease as possible.
Different Types of Hypertension
There are a few different types of hypertension. The most common is called “essential hypertension”. It can only be controlled, not cured. There are also a few uncommon but curable diseases that can cause hypertension. For example, when the artery to a kidney is partially blocked, the kidney may produce a hormone that causes high blood pressure. In that case, opening the artery cures the blood pressure problem. Also, some rare tumors produce a substance that causes high blood pressure. Finding and removing the tumor will cure the problem. The pressure tends to be quite high when these conditions are present.
Kidney disease, thyroid disease and other hormone diseases can cause hypertension too.
Occasionally the pressure goes so high that there are symptoms such as headache, blurred vision, dizziness, altered consciousness and seizures. This is called “malignant hypertension”. It is a medical emergency because it can cause brain swelling or literally blow out an artery in the brain causing bleeding and stroke.
Why Treat Hypertension?
If the pressure doesn’t cause symptoms that bother you, why does hypertension need to be treated? Over time, hypertension damages the heart, kidneys and arteries causing heart attacks, heart failure, kidney failure or stroke that can result in long term disability and death. Treatment of hypertension is intended to control the blood pressure close to normal levels. Successful treatment over a lifetime prevents or reduces the long term damage to the heart, kidneys and arteries.
What you do now to control your blood pressure can save you from death or disability later. Even though you may not feel it, the high pressures are doing you harm every minute of every day.
For most people, the treatment goal is to control the blood pressure to less than 140/90. For people with diabetes or chronic kidney disease, the goal is less than 130/80. These lower levels are needed because hypertension is more damaging to people who already have kidney disease or diabetes.
Taking Care of Yourself
What you do to take care of yourself can make all the difference to your health.
Most people who survive well in prison have a strong will and self-discipline. You can use those strengths to help you lose weight, choose what to eat, reduce salt intake, exercise more, take your medicines regularly and advocate for your needs with health staff.
Choosing to limit your diet is hard for everyone whether free or in prison. It is particularly hard in prison for three important reasons. First, there are very few choices available. Second, deciding what to eat is one of the last freedoms that a prisoner still has. It’s hard to give that up to manage a disease. Third, satisfying desires for sweets or favorite snacks is one of the few true pleasures you can give yourself.
But, you are also free to choose to lose weight, eat a better diet, be physically active, control chronic disease, and stay healthy. One man I know had the right idea about taking care of his chronic disease. He wants to stay healthy to beat the system and walk out of prison one day ready and able to live actively in the world.
Treatment of any chronic disease is a partnership between patients and health professionals. Patients need to do the things that will help reduce blood pressure: lose weight, eat a healthy diet, reduce salt intake, stop smoking, exercise regularly, and take the medicine as directed. Health professionals need to listen to the patients well, understand their problems, keep them informed and genuinely try to help. Patients need to advocate for themselves to make sure they get the care they need: medication renewals before they run out, follow-up visits to check their weight and blood pressure, second or third drugs if blood pressure is not coming down toward normal levels, and periodic lab tests to look for side effects of medicines. Doctors and prison health systems need to follow established national treatment guidelines and be ready to intensify treatment when pressures are not coming down enough.
Lose Weight if You are Overweight
People who are overweight should lose weight to stay healthy in general and to help control blood pressure. The only way to lose weight is to do more and eat less. You do more by deciding to exercise regularly and keeping to a schedule. You eat less by deciding to choose on purpose what you eat and how much you eat. The first step in dieting is deciding to stop eating high fat snacks like candy bars and chips and high fat desserts like cake and ice cream. The simplest diet plan that actually works is this: take your usual servings at each meal, push half of it to one side of the plate and only eat the other half. Eating half a piece of cake satisfies a desire for sweets and is better than eating the whole piece.
Eat a Healthy Diet
Public health organizations have made recommendations for a healthy diet for people with hypertension. They recommend less salt, more fruit, more vegetables, only low fat or no fat dairy products, and reducing both total fat and saturated fat (mostly animal fat) in the diet.
Unfortunately, most prison diets have few fruits and vegetables and are relatively high in salt and fat. To eat a healthy diet, you have to take advantage of every opportunity available to you. For example:
• Cole slaw is often the only fresh vegetable that is regularly provided on prison menus. Eat it whenever you have the chance.
• Locally grown fruits are often on the menu, apples in the northeast and northwest for example, because they are cheap. Even though it is boring and they are usually not the best quality, eat them whenever you have the chance to do so. Fresh fruit is an important part of a healthy diet.
• If you can, trade high fat menu items like hamburgers, hot dogs, and cake for more fruit and vegetables. Apples, oranges and bananas can be carried out of the mess hall to use as snacks instead of chips and candy bars.
Most prisons sell food at a commissary. You can get some of the food you need from commissary, but the processed foods often have too much salt or too much fat. Learn to read the nutrition labels on foods you buy. The labels tell you about sodium (salt), total fat and saturated fat, among other things. Don’t use high sodium or high fat foods very much. Here are some more tips about commissary foods:
• Canned vegetables are better than no vegetables, but a lot of salt is added to them in the processing. Pour off the water and rinse the vegetables with fresh water several times to remove that extra salt before you cook it up.
• The flavor packages with Ramen noodle are very high in salt. Use only half the flavor package, or less, if you can. A small amount really can give it enough flavor to satisfy your taste.
• Canned tomatoes, tomato sauce, tomato juice and V-8 juice all have enormous amounts of salt in them. Use them sparingly for flavor only.
• Salami, “summer sausage”, and other sausage products are very high in animal fat. Use them sparingly for flavor only. Also, processed deli meats of all sorts, even turkey, are very high in salt.
• Chips of all kinds are very high in salt and fat.
• Canned tuna and other canned fish are pretty good as they are low in saturated fat and have fish oils that contain special fats that are necessary for good health. Fish oils are better for you than animal fat from red meat.
• Peanut butter and jelly or tuna salad sandwiches on whole wheat bread are good snacks or meals to make for yourself.
The first thing to do to reduce salt in the diet is to stop adding salt to food at the table. If you never touch the salt shaker you have taken a very big step toward improving your diet. At first, people who are used to a lot of salt on their food find meals without added salt tasteless. But over a pretty short time, maybe a week or two, the food starts to have taste again. You may even begin to notice subtle flavors that you couldn’t appreciate before. Instead of table salt use herbs like dill or cilantro to add flavor, if you can get them.
Many prisoners work out a lot, so there is little need to give advice about exercise. But for those who don’t already work out regularly, remember: doing something is better than doing nothing. You don’t have to be Hercules to improve your health through exercise. In fact, people who over do it at first get too sore and often give up. If you are older and have not been doing much physical activity recently, start out with a limited program and build up slowly. Walking for 20 minutes or a half hour daily or every other day is a good start and does provide health benefits. Activities that build up muscles, like weight lifting, do not improve heart and lung health as much as sustained activities like walking, climbing stairs, and running.
Standards of Care
Most hypertension will be well controlled when guidelines based on national recommendations for treatment of hypertension are followed. Adequate prison health programs have written clinical guidelines for management of hypertension. Guidelines provide direction to the doctors on how to proceed, step by step, to manage blood pressure in their patients. Guidelines establish a basic standard of care for the system that the doctors and other providers are expected to follow.
There are many different drugs to treat hypertension. There are five different classes of medicine that are commonly used, and 5 or more different drugs in each class. Some medicines are available that have two different drugs in one pill. The names of the five classes are related to their chemical actions on the body. The five classes are: thiazide type diuretics; calcium channel blockers; angiotensin converting enzyme (ACE) inhibitors; angiotensin receptor blockers; and beta blockers.
Treatment must be adjusted to the needs of each individual patient. Generally doctors establish a treatment goal with the patient and start with one drug at a relatively low dose.
If that works and the goal blood pressure is achieved, simply maintain that drug and dose.
If pressure is not at the goal, the dose is increased. If the goal is not achieved with one drug at maximum dose, a second drug is added from a different class. Later, if needed, a third drug may be added from a third class. That is why it is worthwhile to know the names of your drugs and what class each one comes from.
Each patient responds differently to the medicines, so drugs and doses must be adjusted to suit each individual. Dose adjustment and adding second or third drugs in patient care is not “experimenting”. “Experiments” or research studies are done to show that a drug works on populations in general. Experiments are highly structured and human subjects must be informed about the research study and consent to their participation. Dose adjustments are done to tailor the available medicines to the needs of individual patients.
For stage one hypertension, treatment generally starts with one drug, usually a thiazide type diuretic. Thiazide diuretics work well and have been used for decades. There is a lot of good evidence that they lower blood pressure and prevent long term complications of hypertension. They are inexpensive and readily available from generic drug makers.
For stage two hypertension, doctors often start with two drugs, usually a thiazide plus another drug from a different class.
Medicine won’t work unless the pills are taken regularly as ordered by the doctor. It doesn’t work well to skip doses, or to start and stop medicine over and over again.
Followup and Monitoring
The facility’s clinical guidelines usually establish the frequency and content of medical followup for patients with hypertension. People with high blood pressure need regular followup by health staff to check how their blood pressure is responding to treatment. It is also important to check your weight and ask about side effects of medicines. Blood tests for potassium and kidney function need to be done every 6 months to one year to make sure there are no new complications from the drugs.
At first, people with stage one hypertension need to be checked monthly. Followup should be more frequent for people with stage two hypertension or those with other serious chronic diseases such as diabetes, heart disease or kidney disease. It may take many visits over 6 months or a year to arrive at a treatment program that works for some patients.
Followup can be less frequent once the medicines have been adjusted to achieve the patient’s blood pressure goal. When blood pressure is stable at the patient’s goal pressure, followup may be reduced to every 3 to 6 months.
When doctors fail to take action to improve blood pressure control in a patient, it is called “clinical inertia”. When your blood pressure is not at your goal pressure, but the doctor doesn’t increase the dose or add another drug or seek specialist consultation to help with management of a difficult case, that is clinical inertia.
You need to know what your blood pressure is and what pressure you are trying to reach through treatment. You need to do your part. Take your medicine regularly as prescribed, try to lose weight, limit salt intake, exercise regularly, quit smoking if you can. If you are doing these things but are not at your goal, you need to advocate for more treatment. Ask the doctor: Can the dose be safely increased? Maybe we need to add another drug?
When the patient is doing everything he can, including taking the medicine as ordered, and the doctor has prescribed three or more different drugs, and blood pressure is still not at goal, then additional medical evaluation is needed. Tests need to be done to determine if one of the unusual forms of hypertension is causing the disease. Such tests would include ultrasound of the kidneys to look at the renal arteries, and blood tests for various hormones and chemical substances called catecholamines. When the doctor’s usual approach to hypertension has not succeeded, it is necessary to consult a specialist in blood pressure management.
Hypertension is a common chronic disease characterized by high blood pressure. Over time high blood pressure damages the heart, kidneys and arteries leading to heart attacks, heart failure, stroke and kidney failure. There are usually no symptoms with hypertension.
The diagnosis is made at regular health care visits when blood pressure is measured.
Treatment controls the blood pressure but does not cure the condition. Effective treatment brings the blood pressure down to near normal levels and prevents long term complications.
People can do a lot for themselves to help control their blood pressure such as losing weight if they are overweight and eating a diet with many servings of fruits and vegetables that is low in fat and saturated fat. Other things people can do for themselves include reducing salt in the diet, exercising regularly, stopping smoking, and taking medicines regularly. A doctor will prescribe medicine to control blood pressure and followup to see if the goal pressure has been achieved. You can advocate for yourself to get more treatment or specialty consultation if you are taking your medicine as prescribed and blood pressure control has not been achieved.
National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. US Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute. NIH Publication No. 03-5233. December 2003. http://www.nhlbi.nih.gov.
Michael D. Cohen MD
Prisoner Self Care
PO Box 116
Rensselaer, NY 12144
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