Hypertension a critical issue

Page 29

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.

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

"I am a kidney specialist and am very interested in diabetic kidney failure," said Dr. George Pylypchuk, head of Nephrology at the university of Saskatchewan. "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."

Joan Wentworth is the home care director with BTC Indian Health Services.

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

Pylypchuk explained.

"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. 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 a team of 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. 1 had any impact on risk factors and the amount of kidney problems.

"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," said George Pylypchuk.

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 noted that blood pressure medication can slow down the progression of diabetic kidney diseases and probably reverse it, but that means 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," said Pylypchuk. "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.

Pylypchuk said, "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. 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 revers 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.

The hope is to compare whether or not using a dedicated nurse to look after blood pressures and the microproteinuria problem is more effective than just usual physician care.

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

"We certainly are planning a D.R.E.A.M. 4," said Pylypchuk, "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."

"The D.R.E.A.M. projects," Joan Wentworth concluded, "have the underlying philosophy of empowering our community members to be active participants of their own health care."