Hypertension a critical issue for diabetes patients

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An increase in the number of community members starting on dialysis prompted the Battleford Tribal Council (BTC) Indian Health Services Home Care program to take action against kidney disease.

"In 1998, Dr. George Pylypchuk, head of Nephrology, University of Saskatchewan and kidney specialist with the Saskatoon Health Region, was contacted to assist in identifying community members at risk for renal disease," said Joan Wentworth, home care director for BTC Indian Health Services. "The goal was early detection and early intervention."

"I am a kidney specialist and am very interested in diabetic kidney failure," said Pylypchuk. "The chiefs were very supportive and through their efforts, and because they wanted something done, the Diabetes Risk Evaluation and Microalbuminuria project, D.R.E.A.M. 1, was created."

The Battleford Tribal Council First Nations include Little Pine, Poundmaker, Sweetgrass, Moosomin, Mosquito, Red Pheasant, Lucky Man and Saulteaux, located northwest of Saskatoon.

"The first D.R.E.A.M. project was a massive screening of adult community members," said Wentworth. "This project showed high rates of diabetes, hypertension and elevated cholesterol levels."

"We brought out as many adults as we could to screening days on the reserves, screening for diabetes and for risk factors including cholesterol, weight, high blood pressure (hypertension), smoking and we looked at microproteinuria," Pylypcuk said. "We wanted to find out whether there was a large extent of health problems on the reserve and in fact there was. We found 22 per cent of the adult population were diabetic. They had a lot of cardiac and kidney (renal) risk factors, smoking, high blood pressure, and cholesterol. About a quarter of the diabetics already had microproteinuria, which is the first sign of diabetic kidney disease."

With the problem identified, the next step was to see what could be done to treat it and, with the help of a team of very well organized home care nurses, an awareness program began.

"A lot of posters went up on reserve, posters about risk factors. Instead of fried foods, meeting menus often included fruits and vegetables. It was a start to try to change the lifestyle," said Pylypchuk.

Two years later D.R.E.A.M. 2 was rolled out to see if D.R.E.A.M. 1had any impact on risk factors and the amount of kidney problems.

"D.R.E.A.M. 2 provided interventions based on increased client education and physician referrals," Wentworth said.

"At that time we screened some diabetics that had been in our first project," said Pylypchuk. " Although there was improvement, more exercise, better eating, better blood pressure control, less smoking, the kidney problems were still high and blood sugar control had not improved. It became clear that you can do lifestyle intervention, but at least in this situation, it wasn't going to be enough. We would need to be more aggressive if we were to have an impact on renal disease."

"With D.R.E.A.M. 3, Wentworth said, "BTC Indian Health Services teamed with nephrologists Dr. Pylypchuk and Dr.(Sheldon)Tobe from Sunnybrook and the University of Toronto. The purpose of D.R.E.A.M. 3 is to demonstrate the effectiveness of a home care nurse-administered treatment program for diabetic clients with hypertension, using evidence based guidelines. There are two study arms. In one arm the home care nurses are following a specific blood pressure treatment protocol overseen by the nephrologists. In the other, referrals are made to the clients' doctors. Diabetes and lifestyle education is offered to all clients."

D.R.E.A.M. 3 took a serious look at hypertension management (control of blood pressure). For a diabetic, it is critical that the blood pressure is well controlled if you want to prevent complications, not only kidney problems but heart and stroke. The doctor notes that blood pressure medication can slow down the progression of diabetic kidney diseases and probably reverse it, but that mens very intensive blood pressure lowering, below the normal that you might think of-140 over 90.

"You actually have to get lower to 130 over 80," Pylypchuk said. "Knowing this, we got government and pharmaceutical grants so we could initiate a very intensive project in how to get blood pressures really low."

The BTC communities are not isolated in the same way as First Nations communities in other parts of the country, but there are distance issues involved with accessing health care.

"The idea of D.R.E.A.M. 3 was to use the infrastructure of the home care nurses and a nurse co-ordinator following a protocol under supervision of a nephrologist," Pylypchuk explained. "The nurses ensure the patients get their pills, that they are reviewed on a regular basis and that patients have their blood pressures down to the goals. By providing the service in this manner, on reserve, we hope to be able to improve blood pressures to low levels and hopefully to reverse a lot of the kidney abnormalities that we've been seeing."

The goal is to include 150 people in the project, divided into two groups of 75 diabetes patients each, one treated with the hypertension protocol administered by the home care nurses and the second group treated in the usual fashion. The home care nurses still sees them, but this group goes back to a family doctor to get treatment for their high blood pressure and diabetes.

"What Dr. Sheldon Tobe, my associate from Toronto, and I are hoping to do is to compare whether or not using a dedicated nurse to look after blood pressures and this microproteinuria problem is more effective than just usual physician care," George Pylypchuk said.

"We certainly are planning a D.R.E.A.M. 4, which will probably be a more comprehensive program. We have looked at just one complication of diabetes which is the kidney problem and diabetes, of course, affects everything."

D.R.E.A.M. 4 will depend on the results of the hypertension project in D.R.E.A.M. 3. Results shoul be ready in 2004 and will impact on funding for future projects.

"The D.R.E.A.M. projects have the underlying philosophy of empowering our community members to be active participants of their own health care," Joan Wentworth explained. "Take Charge Today for a Healthier Tomorrow is our theme."