Hypertension

Resting blood pressure increases are often one of the very first signs a patients health and metabolism are less than optimal (1). The cause of the hypertension is often listed in the patients medical records as “primary essential” despite evidence to the contrary. Hypertension when accompanied by hyperlipidemia, waist circumference increases, weight gain, an increase in fasting blood glucose, increases in triglycerides or lower than normal, high density lipoprotein is highly suggestive that the patient may be also dealing hyperinsulinemia and/or insulin resistance (2,3,6,7,8). Metabolic syndrome is defined by 3 or more of the previously mentioned conditions but it seems that even two of these conditions should be considered progression towards the development of this serious metabolic condition and insulin resistance and/or hyperinsulinemia should be considered as the potential root cause.

If root cause is to be addressed, providers must encourage treatment in the form of structured lifestyle modification, specifically diet, exercise, stress management and healthier habits. These modifications must begin sooner, rather than later if patients are to avoid the onset of more serious and life threatening chronic health conditions. The AACE’s most recent policy statement suggests HTN if associated with insulin-resistance should be considered stage 1 of the four stage, Insulin-Resistance – Prediabetes – T2D – Vascular Complications spectrum with the preferred treatment being the initiation of structured lifestyle modification (7).

Providers should be looking to identify hypertension in association with any of these risk factors, and if seen, counsel patients on the need to change lifestyle components that drive hyperinsulinemia as soon as any of these conditions present. Providers should know that most patients will need to be supported during this modification process. A few words in clinic by the  provider with a handout or two will usually be unsuccessful in motivating or helping the patient be successful. Providers must make a strong statement regarding the need to change in an effort to fully inform them as to their current health trajectory (4) and use primary care-referable resources to help support patients during the change process if reversal of these conditions is to be expected (5).

Failure to refer these patients to an on-going, structured lifestyle modification program and insufficient or inappropriate information in clinic all contribute to patient failure. “Eat less and Move more” will not work as lifestyle counseling. Providers must consider that patients that do are not improving may be “trying” but the advice they are following or the information source they are using are completely useless.

Here at Restore Medical Fitness Center our outcomes with conditions associated with insulin resistance are excellent. Our experience and research suggests these conditions, including hypertension, are reversible. Diet and lifestyle modifications are the foundations to treatment. In patients that have begun our intensive comprehensive program with resting blood pressures above 120/80 we have documented a decrease of 11% in systolic and 12% in diastolic pressures in only 12 weeks. n=120+

In those patients with HTN (systolic >130) and prediabetes we have helped patients reduce resting blood pressure from and average 143/81 down to 121/72 in 90 days (n=25)

References:

1 – Oh, et al.Big Data, Vol 4, Number 1, 2016 – Type 2 Diabetes Mellitus Trajectories and Associated Risks

Abstract: Disease progression models, statistical models that assess a patient’s risk of diabetes progression, are popular tools in clinical practice for prevention and management of chronic conditions. Most, if not all, models currently in use are based on gold standard clinical trial data. The relatively small sample size available from clinical trial limits these models only considering the patient’s state at the time of the assessment and ignoring the trajectory, the sequence of events, that led up to the state. Recent advances in the adoption of electronic health record (EHR) systems and the large sample size they contain have paved the way to build disease progression models that can take trajectories into account, leading to increasingly accurate and personalized assessment. To address these problems, we present a novel method to observe trajectories directly. We demonstrate the effectiveness of the proposed method by studying type 2 diabetes mellitus (T2DM) trajectories. Specifically, using EHR data for a large population-based cohort, we identified a typical trajectory that most people follow, which is a sequence of diseases from hyperlipidemia (HLD) to hypertension (HTN), impaired fasting glucose (IFG), and T2DM. In addition, we also show that patients who follow different trajectories can face significantly increased or decreased risk.

2 – Croft et. al.,  Diabesity 2015; 1 (4): 34-43 doi: 10.15562/diabesity.2015.19, – Hyperinsulinemia: A unifying theory of chronic disease?

Abstract: Globally, there is an increasing prevalence of non-communicable diseases. The morbidity and mortality from these conditions confer a greater economic societal burden. Epidemiological research associates insulin resistance in the etiology of these diseases, but there is limited evidence for the mechanism of damage. Emerging research suggests that hyperinsulinemia, a symptom of insulin resistance, may cause these pathological changes, and therefore be an independent contributor to these diseases. This review shows that hyperinsulinemia, or excessive insulin secretion, should be considered independently to insulin resistance, defined as glucose uptake rate, even though the two conditions are intertwined and will co-exist under normal conditions. Hyperinsulinemia directly and indirectly contributes to a vast array of metabolic diseases including all inflammatory conditions, all vascular diseases, gestational and type 2 diabetes, non-alcoholic fatty liver disease, obesity and certain cancers and dementias. The mechanisms include increased production of: insulin growth factor-1; reactive oxidative species and advanced glycation end-products; and triglyceride and fatty acids. Hyperinsulinemia also directly and indirectly affects many other hormones and cytokine mechanisms including leptin, adiponectin and estrogen. There is limited research standardizing the hyperinsulinemia diagnostic process. Methodological concerns and lack of standardized reference ranges preclude the use of fasting insulin. Most research has also focused on insulin resistance and it is unknown whether these methods translate to hyperinsulinemia.

3 – DeMarco, V. G. et al., Nat. Rev. Endocrinol. advance online publication 15 April 2014; doi:10.1038/nrendo.2014.44, – The pathophysiology of hypertension in patients with obesity

Abstract: The combination of obesity and hypertension is associated with high morbidity and mortality because it leads to cardiovascular and kidney disease. Potential mechanisms linking obesity to hypertension include dietary factors, metabolic, endothelial and vascular dysfunction, neuroendocrine imbalances, sodium retention, glomerular hyperfiltration, proteinuria, and maladaptive immune and inflammatory responses. Visceral adipose tissue also becomes resistant to insulin and leptin and is the site of altered secretion of molecules and hormones such as adiponectin, leptin, resistin, TNF and IL‐6, which exacerbate obesity-associated cardiovascular disease. Accumulating evidence also suggests that the gut microbiome is important for modulating these mechanisms. Uric acid and altered incretin or dipeptidyl peptidase 4 activity further contribute to the development of hypertension in obesity. The pathophysiology of obesity-related hypertension is especially relevant to premenopausal women with obesity and type 2 diabetes mellitus who are at high risk of developing arterial stiffness and endothelial dysfunction. In this Review we discuss the relationship between obesity and hypertension with special emphasis on potential mechanisms and therapeutic targeting that might be used in a clinical setting.

Conclusions: Hypertension related to obesity can occur via multiple mechanisms: insulin resistance; adipokine alterations; inappropriate SNS and RAAS activation; structural and functional abnormalities in the kidney, heart and vasculature; and maladaptive immunity.

4 – Washburn, P.J., International Journal of User-Driven Healthcare, 6, 1, 2016 – Health Ballistics: Multiple Reference Point Informed Probability Theory

Conclusion: If an individual is afflicted with a chronic disease and does not know the realistic end point of their current health trajectory, they will never be fully ready, willing, motivated or able to make an informed, reliable, accurate and precise healthy behavioral decision in their current state of partially health informed reality. Alteration of health reality is accomplished by health informing the individual about the negatives of unhealthy behavior and the positives of healthy behavior.

5 – Curry et. al., Annals of Internal Medicine, 160, 6, 2014 – Behavioral Counseling Research and Evidence-Based Practice Recommendations: U.S. Preventive Services Task Force Perspectives

Conclusion: Behavioral counseling interventions are important primary and secondary preventive care strategies, and the USPSTF is committed to developing and disseminating recommendations to ensure that effective interventions achieve the broadest reach into health care delivery. Effective synthesis and incorporation of evidence for behavioral counseling interventions into USPSTF recommendations is challenged by gaps in the current evidence base. The behavioral science community can better align primary care–based intervention studies with the key questions that guide the development of evidence-based recommendations. This commentary joins other voices calling for careful attention to study populations and the pragmatic aspects of intervention protocols in the design and dissemination of research, for greater consistency in key behavioral measures, and for further research that links behavior change to health outcomes.

6 – Xun et. al., American Journal of Clinical Nutrition, 2013;98: 1543-1554 – Fasting insulin concentration and incidence of hypertension, stroke and coronary heart disease: a meta-analysis of prospective cohort studies 1-3

Conclusions: A higher fasting insulin concentration or hyperinsulinemia was significantly associated with an increased risk of hypertension and CHD but not stroke. This meta-analysis suggests that early fasting insulin ascertainment in the general population may help clinicians identify those who are potentially at high risk of CVD.

7- Mechanick, J et. al., Endocrine Practice Vol 24 No. 11 November 2018 – Dysglycemia-Based Chronic Disease (DBCD): An American Association of Clinical Endocrinologists Position Statement

From the Abstract: …In this context, stage 1 represents “insulin resistance,” stage 2 prediabetes,” stage 3 “type 2 diabetes,” and stage 4 “vascular complications.” This model encourages earliest intervention focusing on structured lifestyle change. Further scientific research may eventually reclassify stage 2 DBCD prediabetes from a predisease to a true disease state. This position statement is consistent with a portfolio of AACE endocrine disease care models, including adiposity-based chronic disease, that prioritize patient-centered care, evidence-based medicine, complexity, multimorbid chronic disease, the current health care environment, and a societal mandate for a higher value attributed to good health. Ultimately, transformative changes in diagnostic coding and reimbursement structures for prediabetes and T2D can provide improvements in population-based endocrine health care.  (Endocr Pract. 2018;24:995-1011)

Conclusion: Recognizing and managing prediabetes is a necessary component for an effective personalized and population-based T2D care plan. In order to substantiate this position, AACE has formulated a DBCD multimorbidity care model consisting of four distinct stages in the general context of ABCD (adiposity based chronic disease) and cardiometabolic health and specific context along with insulin resistance-prediabetes-T2D spectrum that are actionable in a preventive care paradiagm.

8 – Muscelli, et. al., The American Journal of Hypertension Vol. 9 No. 8 Part 1 August 1996 – Effect of Insulin on Renal Sodium and Uric Acid Handling in Essential Hypertension