Saturday, November 23, 2013

Causes of High Blood Pressure

High blood pressure is a complex condition that has many causes and contributing factors. These factors are associated with your physiology, diet, lifestyle, stress level, environment, genetics, and other factors.

Here is a list of the many causes and co-factors associated with high blood pressure. Use this information to help figure out what is causing your high blood pressure so that you can implement the necessary corrective actions.

High blood glucose
High insulin levels
Insulin resistance
Cellular inflammation
Oxidative stress
Hormonal imbalance
Being overweight or obese
Narrowing of the arteries (large blood vessels) supplying the kidneys
High blood viscosity
Enzyme deficiencies
Impaired digestion
Impaired immunity

Kidney Disease
ObesityHormonal conditions, such as Cushing's syndrome 
Conditions that affect the body’s tissue, such as lupus
Obstructive sleep apnea
Adrenal gland tumors
Thyroid problems

Macronutrient imbalance
Vitamin deficiency (A, B, C, D, K2)
Mineral deficiency (magnesium, potassium, calcium)
Excess salt
Other nutrient deficiency(Omega-3 EFAs, probiotics)
Excess processed foods, trans fats, HFCS, etc.
Drinking large amounts of alcohol

Nutritional Supplements
Synthetic vitamins
Herbal remedies, such as herbal supplements

Painkillers known as nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen  
Recreational drugs, such as cocaine, amphetamines and crystal methamphetamine
Other  medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain relievers and some prescription drugs

High stress environment
Lack of exercise

Emotional stability
Stressful work environment
Financial problems
Lack of knowledge

Race (being of African or Caribbean origin)
Certain defects in blood vessels you're born with (congenital)
Family cooking habits

Racism, sexism, etc.
Other isms

In most cases, most people will have multiple causes and co-factors that contribute to their high blood pressure.

Note: For more information about high blood pressure, refer to the Death to Diabetes book, Heart Disease ebook, training program, online training course; and, the Death to Diabetes website, blog and Facebook Page.

Additional References: 

Friday, November 22, 2013

High Blood Pressure -- The Number 1 Silent Killer

High blood pressure is the Number 1 silent killer disease. This silent killer is characterized by subtle symptoms that often go undetected.

High blood pressure (or hypertension) is a silent killer because it is deadly and has no early significant symptoms.

The American Heart Association estimates that up to one third of people living with high blood pressure are unaware of the fact that their blood pressure is high, and many people are unaware of the risks of high blood pressure.

Some of the statistics associated with high blood pressure and its impact include the following:
  • 67 million American adults (31%) have high blood pressure—that’s 1 in every 3 American adults.
  • 69% of people who have a first heart attack, 77% of people who have a first stroke, and 74% of people with chronic heart failure have high blood pressure. High blood pressure is also a major risk factor for kidney disease.
  • More than 348,000 American deaths in 2009 included high blood pressure as a primary or contributing cause.
  • High blood pressure costs the nation $47.5 billion annually in direct medical expenses and $3.5 billion each year in lost productivity.
  • About half (47%) of people with high blood pressure have their condition under control.
  • Almost 30% of American adults have pre-hypertension—blood pressure numbers that are higher than normal, but not yet in the high blood pressure range. Pre-hypertension raises your risk of developing high blood pressure.
  • Reducing average population sodium intake from 3,300 mg to 2,300 mg per day may reduce cases of high blood pressure by 11 million and save 18 billion health care dollars annually.
  • About 1 in 5 (20.4%) U.S. adults with high blood pressure don't know that they have it.
  • About 7 in 10 U.S. adults (69.9%) with high blood pressure use medications to treat the condition.
  • Team-based care that includes the patient, primary care provider, and other health care providers is a recommended strategy to reduce and control blood pressure
The chart below shows normal, at-risk, and high blood pressure levels.
Blood Pressure Levels
Normalsystolic: less than 120 mm Hg
diastolic: less than 80mmHg
At risk (prehypertension)systolic: 120–139 mm Hg
diastolic: 80–89 mm Hg
Highsystolic: 140 mm Hg or higher
diastolic: 90 mm Hg or higher

The danger from high blood pressure is the extra load on the heart, leading to complications such as hypertensive heart disease, a heart attack, a stroke and congestive heart failure. High blood pressure can also seriously damage the kidneys.

And it does all this silently, without any major symptoms, except when the high blood pressure gets extreme.

Always get your blood pressure checked to rule out hypertension as part of regular medical checkups. 

High blood pressure affects millions of people around the world. This condition goes unnoticed for years unless we have the insurance to receive annual physicals and blood tests from our primary care physician.

For the people who are able to afford insurance and get annual physical exams, they end up "controlling" their blood pressure by taking drugs that mask the real problem and give us the false sense of security that everything is fine. But, over a period of years, we find ourselves having to take more and more medication to 'control" our blood pressure. Until one day, you discover that you have problems with your kidneys, liver, or heart due to taking these medications for so many years.

What to Do
So, what if you have high blood pressure, but you don't know it? We recommend that you visit your primary care physician at least once a year for a complete medical exam. A complete medical exam will uncover a problem such as high blood pressure. At that point, your doctor may recommend one or more medications to help lower your blood pressure.

Blood pressure checkup

However, we don't believe that you should rely solely on medications because they don't help to get rid of the disease in your body that is causing your high blood pressure. As a result, you would be required to take high blood pressure meds for the rest of your life.

Please Note: Recent studies show that long-term use of these medications can lead to more health problems, so, be careful. 

Next Steps
Once your physician has diagnosed you with high blood pressure, ask him/her to identify what type of high blood pressure you have. For example, if the systolic number is high and the diastolic number is normal, this is an indication of atherosclerotic hypertension -- a pre-cursor to atherosclerosis and heart disease. In that case, you may need to modify your nutritional program to help heal and repair your arteries.

Other types of high blood pressure include: Secondary Hypertension, Isolated Systolic Hypertension Diastolic Hypertension, Malignant Hypertension, Renal Hypertension, Pulmonary Hypertension, Resistant Hypertension.

If your physician can't identify what type of high blood pressure you have, then, whatever medications he/she recommends will be just a wild guess. And, once you start on medications, it will be difficult to get off the medications. In fact, the number of medications and their dosages will increase over time as your body becomes more dependent on the drug's effects.

When you see your physician for your annual exam, get your blood tested for other factors so that you have a broader picture of your overall health state. Some of the additional tests include: fasting blood glucose, hemoglobin A1C, inflammation markers, lipid panel, kidney tests, hormone levels, vitamin levels, mineral levels and other blood tests listed in the Death to Diabetes book and on the Death to Diabetes website.

It is very important that you make sure that you do not have any (marginal) nutritional deficiencies, i.e. macronutrient, vitamin, or mineral. Some of the key nutritional deficiencies that may affect your blood pressure include: magnesium, potassium, calcium, Vitamin D, Vitamin A and fats.

Next, change your dietary program to a plant-based diet such as the Death to Diabetes Diet. Start eating a lot more vegetables, drinking raw juices and avoid eating the major "dead" processed foods, and a regular exercise regimen of brisk walking, stretching, and resistance training 4 to 6 times a week.

And, based on your blood tests, add the necessary nutritional supplementation -- but, make that you use wholefood-based supplements and avoid synthetic supplements.

Some Additional Steps to Consider:
  • Get a home blood pressure monitor so that you can check your blood pressure on a regular basis.
  • Make sure that you're getting 8 hours of quality sleep every night.
  • Address the stress in your life and learn how to control your emotions -- getting upset over events that you have no control over will raise your blood pressure.
  • Use meditation techniques to change the way you think about the world around you.
  • Educate yourself about diabetes, blood pressure, nutrition, etc. Without education, we live with a lot of anxiety and uncertainty. This, in turn, leads to fear, which creates anger and more anxiety and raises your blood pressure.
Please Note: The Death to Diabetes Diet is not just for diabetics! Non-diabetics can also use this diet program.

Please Note: Because of their impact on our health, nutritional deficiencies will be discussed in more detail in a future blog post.

Warning! More than 87% of people who end up in the hospital because of high blood pressure, do not change their eating habits or lifestyle. As a result, 91% of them return to the hospital or end up in the graveyard.

FYI: Ironically, this top silent killer disease is fueled by what the author calls the "triple-killer foods" along with the 5 "dead" foods. So, make sure that you avoid these foods, especially if this silent killer is stalking you.

Laboratory and Other Tests

If a physical examination indicates hypertension, additional tests may help determine whether it is secondary hypertension caused by another medical disorder) and whether organ damage is present.

Blood Tests and Urinalysis. These tests are performed to check for a number of factors, including potassium levels, cholesterol, blood sugar (to screen for diabetes), infection, kidney function, and other possible problems. Measuring blood levels of the protein creatinine, for example, is important for all hypertensive patients in order to determine kidney damage.
Tests to Evaluate the Heart. These tests include:
  • An electrocardiogram (ECG) is performed on most patients in the doctor's office.
  • An exercise stress test may be needed for patients who also have symptoms of coronary artery disease.
  • An echocardiogram is needed when it would help the doctor decide whether to start treatment. Most of the time this test is not necessary for patients who have only hypertension and no other symptoms.
Tests To Evaluate the Kidneys. These tests include:
  • A Doppler or duplex test may be performed to see whether one of the arteries supplying blood to the kidney is narrowed, a condition called renal artery stenosis.
  • An ultrasound may also be performed to examine the kidneys.
  1. Kochanek KD, Xu JQ, Murphy SL, MiniƱo AM, Kung HC. Deaths: final data for 2009. National vital statistics reports. 2011;60(3).
  2. CDC. Vital signs: prevalence, treatment, and control of hypertension—United States, 1999-2002 and 2005-2008. MMWR. 2011;60(4):103-8.
  3. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2–220.
  4. Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123(8):933-44. Epub 2011 Jan 24.
  5. Palar K, Sturm R. Potential societal savings from reduced sodium consumption in the U.S. adult population. American Journal of Health Promotion. 2009;24(1):49–57.
  6. Hing E, Hall MJ, Ashman JJ, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 Outpatient Department Summary. National health statistics reports. 2012; no 28.
  7. Guide to Community Preventive Services. Cardiovascular disease prevention and control: team-based care to improve blood pressure control. 2012. Accessed July 27, 2012.
Note: One of the key risk factors for developing cardiovascular disease is high blood pressure.

Cardiovascular Disease Risk Factors (incl. High Blood Pressure)

Kidney Dialysis

When people with diabetes experience kidney failure, they must undergo either dialysis or a kidney transplant. Almost 200,000 people in the United States are living with kidney failure as a result of diabetes.
Kidney dialysis diagram

Dialysis works well in the short run, but, it takes a toll on the person with diabetes -- physically and emotionally. Unfortunately, people with diabetes who receive transplants or dialysis experience higher morbidity and mortality because of coexisting complications of diabetes—such as damage to the heart, eyes, and nerves.

Dialysis is a treatment that removes wastes and excess fluid from your blood. Like healthy kidneys, dialysis keeps your body in balance. You do not need dialysis in the early stages of chronic kidney disease. If your kidneys start to fail, you will need a kidney transplant or dialysis to stay alive.

Your doctor will help you decide when to start dialysis, based on results of lab tests that measure how much kidney function you have left and on your symptoms.

Dialysis is done with a unique liquid called dialysate. This fluid is a combination of pure water and carefully measured chemicals. It removes wastes from your blood without taking out any of the substances you need to stay healthy.

A semi-permeable membrane (having minuscule holes allowing only specific types of particles to pass through) keeps your blood separate from the dialysate. This lets the wastes and fluid in your blood travel into the dialysate. Blood cells and proteins that you need cannot fit through the holes.

In hemodialysis, an artificial kidney (hemodialyzer) is used to remove waste and extra chemicals and fluid from your blood. Your doctor will make an access point into your blood vessels using minor surgery. This access point allows your blood to travel to the hemodialyzer for flushing. Sometimes access is created by joining an artery to a vein under your skin, making a bigger blood vessel or fistula.

If your blood vessels are not the right size for a fistula, the doctor may use a soft plastic tube to join an artery and a vein under your skin. This is called a graft.

Sometimes, access is made using a narrow plastic tube called a catheter, which is inserted into a large vein in your neck. Your blood is then cleaned and returned to your body. This type of treatment needs to be done several times a week and usually lasts about three to four hours.

In peritoneal dialysis, your blood is cleaned right inside your body. Your doctor surgically places a plastic tube called a catheter into your abdomen to create an access point. During your treatment, your abdominal area (or peritoneal cavity) is slowly filled with dialysate through the catheter. Your blood stays in the veins and arteries that line your peritoneal cavity while extra fluid and waste products are drawn out of your blood and into the dialysate. This is a daily form of dialysis, and can sometimes be preformed at your home.

Discussing with your doctor what dialysis option is the best for you will help you manage your chronic kidney disease and keep you feeling as well as possible.

Physical Side Effects of Dialysis and How to Prevent Them
Dialysis is a lifesaving treatment for those with end stage renal disease (ESRD). However, with both peritoneal dialysis (PD) and hemodialysis, there are occasions when a patient may have side effects from the treatment.

These side effects can be mild or severe, depending on the patient’s condition and whether or not they are following their dietary and fluid restrictions. Most of these side effects can be managed if the patient carefully follows their healthcare team’s recommendations regarding diet and fluid intake.

Side Effects of Peritoneal Dialysis (PD)
Infection. PD is a method of home dialysis. All three types of peritoneal dialysis—Continuous Ambulatory Peritoneal Dialysis (CAPD), Continuous Cycler-assisted Peritoneal Dialysis (CCPD) and Nocturnal Intermittent Peritoneal Dialysis (NIPD)—need a small rubber tube called a catheter. The catheter, a soft, straw-like tube is positioned both inside and outside of the body to allow dialysis solution into and out of the abdominal cavity. Exchanges (the process of filling, dwelling and draining dialysis solution) must be done carefully because there is a risk of infection from bacteria on the outside of the body.

The frequent handling of the catheter means greater risk for infection. Specifically, there is a chance of peritonitis, which is an infection of the peritoneum (where the catheter is placed in the abdomen.) This infection is the most common side effect of PD. Peritonitis can cause fever, nausea, vomiting and stomach pain. Patients may notice their dialysis solution looks cloudy. Treating peritonitis quickly is the key to stopping widespread infection. The doctor will likely prescribe antibiotics. 

Skin infections around the catheter insertion site are also common. If the area becomes red or inflamed, a visit to the doctor is recommended.

Preventing infection
To decrease the chance of infection, patients are advised to perform each exchange carefully. Exchange should be performed in a clean area. Keeping the catheter area clean and touching it with washed hands or sterile gloves can minimize the transfer of bacteria. Patients may also be advised to apply an antibiotic preparation at their catheter exit site to prevent infection.

Some patients have problems attaching or detaching the dialysis solution bag, which could put stress on the catheter, causing tiny tears that could allow in germs. If a patient has difficulties handling the bag, a renal nurse can provide tips on how to properly connect the bag to the catheter.

If a patient notices any sign of infection, it’s best to call the doctor immediately.

Hernias. A hernia is another potential side effect of PD. The muscles of the abdominal wall protect the internal organs and keep them in place. The insertion of a catheter can weaken these muscles. When patients do an exchange, the pressure from the dialysis solution in the peritoneum pushes against these already weak muscles. This pressure could cause a tear, and organs from the abdominal cavity could emerge through the opening.

Surgery is the only way to repair a hernia. Patients who have a history of hernias are advised not to exert themselves or participate in activities that could strain the abdominal muscles.

Eating Discomfort. Some PD patients find eating uncomfortable, because of the full feeling from the dialysis solution in their stomach area.  Although eating less feels better, it can lead to malnutrition.

The PD renal diet is designed to meet patients’ nutritional needs. If patients eat less, they may not get enough of the proteins and minerals that are important for good health. Timing exchanges (generally after meals) helps relieve some of the discomfort.

Bloating and weight gain. Bloating and weight gain are common complaints while on PD. Some of the weight gain is fluid bloat from the dialysis solution sitting in the peritoneum. The dialysis solution filters not only the toxins from the bloodstream, but also removes excess fluid. When the dialysis solution is drained, a patient will normally remove more fluid (dialysis solution plus the excess fluid filtered from the blood) than what was originally placed in the peritoneum.

Weight gain not associated with fluid bloat can come from the sugar in the dialysis solution being absorbed by the body. These extra calories could lead to extra pounds. Talking to a renal dietitian and nurse for some insight on how to balance nutritional needs and achieve comfort while on PD is advised.  

Side Effects of Hemodialysis
Low blood pressure. The most common side effect of hemodialysis is low blood pressure (also called hypotension). Low blood pressure occurs when too much fluid is removed from the blood during hemodialysis. This causes pressure to drop, and nausea and dizziness can result. Letting a dialysis team member know about these issue is highly recommended. The dialysis machine can be programmed so that the right amount of fluid is removed.

Medication for high blood pressure should usually not be taken before treatment, unless the doctor prescribes it that way. This could cause further drops in pressure and more discomfort. Watching and limiting fluid intake as recommended by the healthcare team may also prevent low pressure during treatments. Patients who drink more than what is advised usually need to have more fluid removed which can cause nausea and dizziness.

Muscle cramps. Patients sometimes experience muscle cramps while undergoing hemodialysis. These muscle cramps, usually in the legs, can be uncomfortable or sometimes painful. The exact cause of muscle cramps can vary from patient to patient. Sometimes when fluid is taken out of the body at a fast rate during dialysis or too much fluid is removed, the muscles react by cramping. A patient should alert a healthcare team member as soon as a cramp happens to get help in alleviating the discomfort. A doctor may be able to recommend some remedies if muscle cramps are making dialysis treatment uncomfortable.

Infection and clotting. Proper care for the access (either a fistula or a graft) is important in hemodialysis. The access can become infected or inflamed. Pressure on the access (from clothing or from sleeping on the side where the access is located) can cause the site to become irritated. Keeping the area clean can help prevent infection.

An access can become clotted with blood. Clotting prevents blood flow, so that a patient will not be able to get dialysis treatment. Patients are advised to monitor the access daily by checking for the thrill (the pulse feeling in the fistula or graft) to ensure it is working properly.

Itching. Many dialysis patients complain about itchy skin. There may be several causes, but it is commonly thought that high phosphorous levels are responsible for this side effect. Phosphorous is not effectively removed by dialysis. That’s why foods with phosphorus are restricted on the renal diet. Following the dietitian’s guidelines can help prevent this side effect. Remembering to take a phosphorus binder as prescribed (usually before every meal) is another way to help prevent or stop itching.

Dialysis patients are also prone to dry skin, which can be the cause of itching. Using very hot water for showers or baths can dry skin more. Harsh soaps can cause irritation and more itching. Moisturizing creams can alleviate some of the discomfort.

Sexual problems. Dialysis can affect a patient’s sex life. The sexual side effects can include loss of desire, erectile dysfunction and vaginal dryness. Loss of desire can be a psychological side effect. Patients on dialysis may deal with anxiety, depression and a change in self-image. These mental challenges can diminish the sex drive.

Hormone levels while on dialysis can also lead to a loss of desire, as well as physical side effects such as erectile dysfunction and vaginal dryness. Certain blood pressure medications can impair the ability to maintain an erection.

Other Health Problems Associated with Kidney Dialysis
Amyloidosis. Dialysis-related amyloidosis develops when proteins in blood are deposited on joints and tendons, causing pain, stiffness and fluid in the joints. The condition is more common in people who have undergone hemodialysis for more than five years.
Anemia. Not having enough red blood cells in your blood (anemia) is a common complication of kidney failure and hemodialysis. Failing kidneys reduce production of a hormone called erythropoietin, which stimulates formation of red blood cells. Diet restrictions, poor absorption of iron, frequent blood tests, or removal of iron and vitamins by hemodialysis also can contribute to anemia.

Bone diseases. If your damaged kidneys are no longer able to process vitamin D, which helps you absorb calcium, your bones may weaken. In addition, overproduction of parathyroid hormone — a common complication of kidney failure — can release calcium from your bones.
Fluid overload. Since fluid is removed from your body during hemodialysis, drinking more fluids than recommended between hemodialysis treatments may cause life-threatening complications, such as heart failure or fluid accumulation in your lungs (pulmonary edema).
High potassium levels (hyperkalemia). Potassium is a mineral that is normally removed from the body by the kidneys. If you eat more potassium than recommended, your potassium level may become too high. In severe cases, too much potassium can cause your heart to stop.
Inflammation of the membrane surrounding the heart (pericarditis). Insufficient hemodialysis can lead to inflammation of the membrane surrounding the heart, which can interfere with your heart's ability to pump blood to the rest of your body.
Sleep problems. People receiving hemodialysis often have trouble sleeping, sometimes because of breaks in breathing during sleep (sleep apnea) or because of aching, uncomfortable or restless legs.

Patients should talk to their social workers or doctors if they experience any of these problems.

Keep an open communication with the healthcare team. Let them know about any reactions to treatment so adjustments can be made. Side effects should not discourage a patient from continuing dialysis, especially since many of these side effects can be controlled.

Emotional Effects of Kidney Dialysis
Coping with kidney failure isn't just about managing the physical symptoms with treatment. It is a major life change that can cause a great deal of stress and can give rise to a range of emotional reactions:
  • Anxiety
  • Depression
  • Anger or a feeling of frustration about the illness
  • Sexual problems
Taking care of your emotional well-being is just as important as looking after your health. Please do not be afraid of discussing emotional or sexual problems with your healthcare team. They will be familiar with the kind of problems you may encounter and will be supportive. They may also be able to offer practical solutions to some of your difficulties.

Coming to Terms with  the Diagnosis
People who are diagnosed with kidney failure are confronted with a range of emotions. Different people react in different ways. Even so, there is a pattern to the way that most people react.

It may help to know about the emotional stages that patients may go through:
  • Shock: Often, newly diagnosed patients (and sometimes their family members) go into a state of shock. This is the feeling that life is going on around you but you are not really involved.
  • Grief: People may feel overwhelmed by grief and loss, as if they have been bereaved. They may feel helpless and have difficulty thinking clearly or dealing with day to day life.
  • Denial: It's common for people to decide, at this stage, that they "won't think about it." This denial that the disease exists is like a "defense mechanism" that can help patients escape from feeling overwhelmed until they are more able to cope.
  • Acceptance: Gradually, reality of kidney failure is acknowledged, and people begin to be able to think about the implications and the changes that need to be made. At this point of acceptance, they begin to adjust successfully to their condition.
One of the main causes of stress is change. All human beings find change stressful - even change that we are looking forward to, like moving house, raises our stress levels.

As a person with renal failure you will have to deal with more change than most people do. Not just the initial change of lifestyle that comes with the diagnosis, but ongoing change as you deal with alterations to your diet, medication and forms of treatment.

All these changes will mean you have to take in a great deal of new information, make decisions, learn new practical skills. You also have to adjust to new ways of doing things, to doing less than you would like to, and to asking for help... This is all extremely stressful - and it comes in addition to coping with the physical effects of kidney failure.

Different people react differently to stress - some get anxious or feel overwhelmed, others may get irritable or hostile, others may deny there is a problem and keep pushing themselves to "cope."

The best way of coping with stress is to recognize that it can be a problem in its own right and that if you are suffering from it, it is with good reason. Accept that you need to actively take time to "de-stress". There are many ways of doing so and they can all contribute to helping you cope with kidney failure.

There are a number of ways of dealing with stress:
  • Talking to someone who understands
  • Doing an activity that you enjoy
  • Relaxing, perhaps by listening to music
  • Doing some physical activity (within safe limits)
  • Take a short break, a day off or a vacation
This can be a specific "worry" related to something in particular, or a more general sense of "being on edge" or "not feeling safe."

Specific anxieties that renal patients may have include:
  • Worries about how the illness will affect your relationships,
  • Your ability to work,
  • Your finances
  • Your quality of life
  • You may also be anxious about understanding your condition or managing your treatment.
Ways of reducing anxiety include:
  • To see if there is something practical you could do to help you feel better. Make that appointment to see the doctor/dietitian/social worker/counsellor about what is worrying you. Ask a nurse about that part of the procedure you don't understand.There will of course be things that worry you that you can do nothing practical about. Most patients will say, however, that they find it helpful simply to talk about their worries to people who understand. Whether it's another patient, a nurse, a family member or a counselor, don't keep yourself alone with your anxiety.
  • Generalized anxiety is just as difficult to live with as anxiety that has an obvious cause.
  • Feeling generally "unsafe" may have something to do with a sense of "having no control" over your own body and life.
  • Many patients find that they can regain a sense of control by learning as much as they can about kidney failure and its treatment. Becoming an "expert" enables them to participate more actively in making decisions and to feel that they are working with the medical staff to control the condition rather than being passive.
  • Other people find that setting reasonable goals for themselves, such as going out, exercising, or keeping up certain activities - and achieving them - gives them a feeling of control.
Like anyone else, you will have times when you feel a bit down and less able to cope with life in general. You may also feel sad and "need a good cry" sometimes. If, however, the sadness turns into a real sense of despair that goes on for some time, this is depression.

You may feel depressed because you are having difficulty coming to terms with some of the changes their condition is imposing on you.

These changes might include:
  • The loss of your previous lifestyle
  • The loss of independence and self-confidence
  • The changes to your body and appearance
  • Difficulties with sex or with having children
  • Awareness of your own mortality
If you are feeling depressed it may help you feel less isolated if you talk to others who understand. This may be one of the renal unit nurses, the renal social worker, a counselor or even a good friend. Sometimes a short course of anti-depressant medication may be useful to get over these acute problems.

It seems quite appropriate for people who are going through these experiences to feel angry at times. It can even be energizing, sometimes, to feel angry.

Where problems arise, however, is if you get "locked into" your anger in a way which makes you unhappy and you can't seem to move through it into some degree of acceptance.

Anger is also a problem when it is expressed in destructive or self-destructive ways - when the feelings of anger and frustration lead to rebellion against diet and fluid restrictions, for example, or to aggressive behavior towards friends, relatives and staff. When people are angry, they may tend to "push away" the people who want to support them.

Anger expressed in these ways is self-destructive because it puts your health at risk, and - on an emotional level - leaves you feeling even more isolated.

It can feel like the hardest thing in the world to reach out for support when you are feeling angry. Paradoxically, it may be the one thing you can do to regain a real sense of power and control in your life. 

Sexual Problems
Some kidney patients never have sexual problems, but many do.
The reasons for these problems may include:
  • Hormonal problems: The hormones that control sexual urges may be too high or too low.
  • Medication: Some of the medication prescribed to renal patients may inhibit sexual desire.
  • Tiredness: This can be caused by anemia or by not having dialysis sufficiently.
  • Emotional factors: When people feel stressed, depressed or anxious, they often do not feel like having sex.
  • Relationship difficulties: The stress of kidney failure on a relationship may affect the couple's sex life.
Sexual problems in men
Impotence (the inability to get or maintain an erection) may be a problem in male kidney patients.

There are various approaches to treating impotence. Initially, doctors will look at possible causes such as anemia, under-dialysis and medication, and consider the treatments for them. There are physical treatments for impotence that can be considered including physical techniques and drugs.

Sexual problems in women
When women patients experience a lack of sexual desire or inability to have orgasms, causes related to anemia, under-dialysis and medication can be investigated.

There may be changes in the menstrual cycle and there is no doubt that the chances of getting pregnant if the kidneys have failed are much reduced. If kidney function is only mildly impaired and the blood pressure is under control before and during pregnancy, it is likely that pregnancy will progress as normal, but there will be a close liaison between the kidney doctor and the obstetrician. Some drugs particularly ACE inhibitors will need to stop before pregnancy and the blood pressure will be checked very carefully.

If you want to know more about the effects of kidney failure on pregnancy then speak to your doctor. And discuss any changes in your periods so that things can be checked out.

Kidney dialysis

Kidney dialysis

Kidney dialysis diagram

Thursday, November 21, 2013

Diabetic Amputations

Our primary focus is to educate and provide health-related information about diabetes management and prevention. However, during the past several months, we have received more than the usual number of phone calls and emails about being people losing their toe or leg due to diabetic complications.
Diabetic amputation

During these phone calls, most of the callers tell us that they wished they had heard about our diabetes management and prevention program sooner. They all admitted that they didn't think they would ever face an amputation.

For those who were told that they would have to lose a toe, foot or leg, they called us looking for a miracle. But, we had to tell them that there is no miracle -- in fact, there is very little that we can do to prevent person from losing their toe, foot or leg once the doctor has identified the need for amputation.

High blood glucose levels are responsible for the biological  processes that impair the neurological, vascular, and immune systems, leading to damaged nerves, damaged blood vessels and a weakened immune system. Damaged nerves and blood vessels lead to circulatory problems in the feet and legs, which leads to sores, ulcers and deformed feet. A compromised circulatory system fails to bring enough fresh oxygenated blood, nutrients, and antibiotics to a traumatic wound, and the (weakened) immune system cannot resolve an infection by fighting bacteria and cleansing the wound site on a cellular level.

More than 80% of diabetics will develop one or more of the major diabetic complications (amputation, blindness, kidney failure, heart attack, or stroke) -- if they live long enough and fail to change their diet and lifestyle while relying solely on diabetic medications. Approximately 67% of people with diabetes will develop a mild to severe form of nervous system damage, which can lead to a toe, foot or lower leg amputation. Worldwide, there are more than 1 million amputation procedures performed each year, at the rate of one every 30 seconds.

The most common reason for an amputation is poor circulation. The lack of circulation is caused by narrowing of the arteries or damage to the arteries from diseases such as diabetes and atherosclerosis. When the blood vessels become damaged and the blood flow is impaired to the extremities, the tissue starts to die and may become infected.

Another reason for an amputation is the damage to the foot’s sensory nerves due to diabetic neuropathy. This contributes to foot deformities and/or ulcers that increase the chance of lower-extremity amputations unless treated.

Factors that predict the need for lower extremity amputation in patients with extremity ischemia include tissue loss, end-stage renal disease, poor functional status and diabetes mellitus. Patients with diabetes have a  10-fold increased risk for lower extremity amputation compared with those who do not have diabetes.

Foot ulcers and nerve disease caused by Type 2 diabetes is the leading cause of amputation of feet, toes, legs, hands and arms among diabetes sufferers. Collectively, the disorders which cause these amputations are called Diabetic Neuropathies. Neuropathies lead to numbness and sometimes pain and weakness in the hands, arms, feet, and legs. Problems may also occur in other areas of the body, including the digestive tract, heart, and sex organs. However, complications with the feet and legs are more common.

Treatments for leg and foot ulcers vary depending on the severity of the wound. In general, the treatment employs methods to remove dead tissues or debris, keep the wound clean, and promote healing. But, if the diabetic fails to change their eating habits and lifestyle, healing will either occur very slowly or will not occur at all.

When the condition results in a severe loss of tissue or a life-threatening infection, an amputation is usually the only option. Unfortunately, when a doctor identifies the need for a (diabetic) amputation because the toe (or leg) is "dead", there is very little that the patient can do -- especially, if there is an infection that could spread leading to further damage and possible death.

For a foot or toe to be considered dead, the blood supply must be so completely impeded that infarction and necrosis (dead tissue) develop. Infarction results in dry gangrene, with nonviable tissue becoming dry and black in color (because of the presence of iron sulfide, a product of the hemoglobin released by lysed erythrocytes).

The method of toe amputation (disarticulation versus osteotomy) and the level of amputation (partial or whole phalanx versus whole digit versus ray) depend on numerous circumstances but are mainly determined by the extent of disease and the anatomy.

A surgeon removes the damaged tissue and preserves as much healthy tissue as possible. After surgery, the patient will be monitored in the hospital for a number of days. It may take four to eight weeks for the wound to heal completely.

Possible Complications After an Amputation
Patients with diabetes, heart disease, or infection have a higher risk of complications from amputation than persons without these conditions. In addition, persons receiving above-knee amputations are more likely to be in poor health; therefore, these surgeries can be riskier than below-knee amputations.

As with any surgical procedure, complications can occur. Some possible complications that can occur specifically from an amputation procedure include a joint deformity, a hematoma (a bruised area with blood that collects underneath the skin), infection, wound opening, or necrosis (death of the skin flaps).

A stroke, heart attack, or a pulmonary embolism (due to deep vein thrombosis (DVT)) are additional health problems that pose a risk after an amputation primarily due to blood clots, heart muscle strain, or prolonged immobilization after surgery.

If you have this operation under general anesthetic, there is a risk of complications related to your heart and lungs. The tests that you have before the operation will ensure that you have the operation in the safest possible way to reduce the chances of such complications.

The chances for heart or lung complications are higher for elderly people with other health problems such as diabetes, or disease of the arteries that feed the heart with blood.

Usually, it is important to have the operation as soon as possible. If you delay things then the condition of your toe will get worse and it might get infected and become necrotic. This can make you very ill and significantly increase the chances of complications because of the anesthetic or the operation.

If you have an anesthetic injection in the back, there is a very small chance of a blood clot forming on top of your spine. This can cause a feeling of numbness or pins and needles in your legs. The clot usually dissolves on its own and this solves the problem. Extremely rarely the injections can cause permanent damage to your spine.

Chest infections may arise, particularly in smokers or obese patients. Do not smoke. Being as mobile as possible and cooperating with the physiotherapists to clear the air passages is important in preventing a chest infection.

Another possible complication is the formation of clots in the deep veins (draining pipes for the blood) of your legs (deep vein thrombosis). Although this complication happens more frequently when the leg is amputated either above or below the knee, it can also happen after a toe amputation, especially if you stay in the hospital longer than expected and you are not particularly mobile.

A piece of one of these clots can get detached and travel to your lungs. There it can cause partial or complete obstruction of the blood vessels in the lungs, which can be lethal. Consequently, you will be given injections of blood thinners (heparin) after the operation to prevent a DVT.

In addition, being as mobile as possible and co-operating with the nurses and physiotherapists after the operation are very important in preventing a DVT.

Slow healing is a possibility and this will be apparent within the first week or two. The doctors will discuss this with you. Studies show that the chances of complete healing after a toe amputation are 40 to 60 per cent.
If complete healing doesn’t happen, you might need another operation to clean any dying (necrotic) tissue or tissue that is not healing. You might also need to have the leg amputated higher up.

Infection sometimes happens. This is usually localized in the wound area and very rarely spreads into your blood stream. You will be given antibiotics to prevent this and you will be given more if an infection actually occurs. The antibiotics take care of the problem in most cases, but there is a chance that you will need another operation to clean the infected tissues.

At the beginning, some patients feel that the leg or toe is still there (phantom leg/toe). It is also not uncommon for patients to also feel pain in the amputated area (phantom pain). This is usually mild to moderate and rarely severe pain and will usually get better over time. In some cases the pain can last for a long time. If this happens your doctors will discuss the problem with you.

Aches and twinges in the wound may be felt for six months or more but will usually settle down.
Occasionally there are numb patches in the skin around the wound that get better after two to three months.

Trouble with your circulation or diabetes causing the toe to be diseased needs to be watched very carefully.

Note: Because of a weakened immune system, you may be susceptible to other risks depending on your age, lifestyle, and specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Any Alternatives to an Amputation?
If you leave things as they are, your toe (or foot) will certainly get worse. Infection may spread to your other toes and foot. An operation to bypass or core out your leg arteries to improve the blood supply to the toe will not work in your case. Laser treatment and X-ray guided stretching of the arteries will not work for you. Injecting the nerve to your blood vessels will not work. Antibiotics are not enough by themselves.

An alternative to a toe amputation is an amputation higher up. This may help the healing process at the cost of loss of part of your limb. Unfortunately, most amputations through the foot do not heal very much better than toe amputations, but an amputation just below your knee would heal very well. Overall, usually your best plan is a toe amputation unless your doctor says otherwise.

Problems with the lower extremities respond best when treated by a multidisciplinary team of medical specialists. These specialists may include: endocrinologists, neurologists, diabetes educators, diabetes health coaches. vascular surgeons, orthopedic surgeons, podiatrists, nurses, pharmacists, infectious disease specialists, wound care specialists, nutritionists, and specialists in prosthetic and orthotic services, physical medicine and rehabilitation. Comprehensive foot care programs can reduce amputation rates by 45% to 85%.

The direct cost of an amputation associated with the diabetic foot is estimated to be between $30,000 and $60,000. Three years of subsequent care for individuals whose ulcer has healed without the need for amputation has been estimated to cost between $16,000 and $27,000. The corresponding cost for someone who eventually needs an amputation ranges from $43,000 to $63,000, mainly due to the increased need for home care and social services.

The mortality rate after amputations is about 40% at one year and 80% at five years. Five-year mortality rates after new-onset diabetic ulceration are between 43% and 55% and up to 74% for patients with lower-extremity amputation. These rates are higher than those for several types of cancer including prostate, breast, colon, and Hodgkin’s disease.

Next Steps After an Amputation
It is critical that you see a podiatrist, podiatric surgeon, or foot surgeon specializing in diabetic limb salvage if you start to get any open sore or wounds on your feet. Do not wait until it is infected! With these simple interventions you can keep  prevent more amputations.

It is also critical that the patient make some serious changes to his diet and lifestyle to better manage one's blood glucose level and strengthen the immune system. Otherwise, further amputations and other diabetic complications will occur such as infections, blindness, kidney dialysis, heart attack and/or stroke.

Prevention and early detection of future disease should be discussed with the patient. Education on pressure-area pathogenesis is useful for engaging patients. Efforts should be made to encourage regular visits with a podiatrist, who can assist with provision of well-fitted enclosed shoes. Thick cotton socks act as a barrier to both pressure areas and foreign bodies. Daily self-inspection of feet should be promoted. Informed content must be obtained.

Appropriate preventive care includes professional foot care for timely debridment of the keratosis, padding, accommodative insoles, or biomechanical orthotics with accommodations to offload the pressure sites. Shoe modifications, diabetic shoes or custom molded shoes may also be considered. Prophylactic surgical care to eliminate the bony pressure point is also an accepted method of care.

Too often, toenails are overlooked. The nails can become thick and deformed due to mold, yeast and fungal infections Shoe pressure against these deformed toenails can cause a subungual abscess. Additionally, a long, thick or deformed nail can lacerate an adjacent digit, which can trigger the process of infection that can lead to amputation.

Topical antifungal medications are not FDA approved and are ineffective against this type of nail infection. Oral terbinafine or itraconazole are effective against this type of infection, but patient selection is critical for the safe and effective use of these medications. Confirmation of mycotic nail infection before prescribing medication is essential to minimize costs and potential drug-related complications. Testing for nail mold, yeast or fungal infections should be done before prescribing an oral antifungal medication. Foot care specialists should consider nail debridement and ongoing foot care to decrease the risk of a triggering event, such as a digital laceration during self nail care, that could lead to amputation.

Psychological Impact of an Amputation
Loss of a limb can have a considerable psychological impact. Many people who have had an amputation report feeling emotions such as grief and bereavement, similar to experiencing the death of a loved one.

Coming to terms with the psychological impact of an amputation is therefore often as important as coping with the physical demands.

Having an amputation can have an intense psychological impact for three main reasons:
  • You have to cope with the loss of sensation from your amputated limb
  • You have to cope with the loss of function from your amputated limb
  • Your sense of body image, and other people’s perception of your body image, has changed
It is common to experience negative thoughts and emotions after an amputation. This is especially true in people who had an emergency amputation, as they did not have time to mentally prepare themselves for the effects of surgery.

Common negative emotions and thoughts experienced by people after an amputation include:
  • depression
  • anxiety
  • anger
  • denial (refusing to accept they need to make changes, such as having physiotherapy, to adapt to life with an amputation)
  • grief (a profound sense of loss and bereavement)
  • feeling suicidal 
Talk to your care team about your thoughts and feelings, especially if you are feeling depressed or suicidal. You may require additional treatment, such as antidepressants or counseling, to improve your ability to cope with living with an amputation. 

People who have had an amputation have an increased risk of more amputations. Within one year after a diabetic foot amputation, 26.7% will have another amputation. Three years after the first diabetic amputation, 48.3% will have another amputation. Within 5 years of a diabetes related amputation, 60.7% will have another amputation.

If that isn't bad enough, diabetics with amputations don’t live very long. Approximately 50% of all diabetics with an amputation are dead 3 years after the amputation. About 65% of all of those with a diabetic amputation are dead within 5 years.

But, in spite of this, there is hope... most are preventable. Start eating healthier (i.e. vegetables, juicing) to better control your blood glucose level and to help heal your body. Check your feet every day and see a podiatrist, podiatric surgeon, or foot surgeon specializing in diabetic limb salvage if you start to get any open sore or wounds on your feet. Do not wait until it is infected! With these simple interventions you can keep  prevent more amputations.

Note: We hope this information is of some help and encourages you to take action before it's too late. If you have any queries or problems after surgery, please talk with your podiatrist, other doctors, and the other members of your healthcare team. 

Note: If you haven't had an amputation, refer to our blog post about preventing diabetic amputations.

Warning!! Don't think this can't happen to you! It can ... and, it will -- especially if you don't change ...

Leg amputation

Diabetic toes

Amputated toes

Amputated foot

Wednesday, November 20, 2013

How to Prevent Amputations

In people with diabetes, a trifecta of trouble can set the stage for amputations: Numbness in the feet due to diabetic neuropathy (nerve damage) can make people less aware of injuries and foot ulcers. These ulcers may fail to heal, which can in turn lead to serious infections.

Normally a person with an injury on the bottom of their foot, such as a blister, will change the way they walk. Your gait will alter because you are going to protect that blistered spot until it heals up. But, people with a loss of sensation don't do that -- they will just walk right on top of that blister as though it wasn't there. It can burst, become infected, and turn into a foot ulcer. That ulceration can go right down to the bone and become an avenue for infection into the whole foot. And, that can lead to amputations.

Foot injuries are the most common cause of hospitalizations
About 15% of all diabetics will develop a foot ulcer at some point and up to 24% of people with a foot ulcer need an amputation. You're at extra-high risk if you're black, Hispanic, or Native American. These minority populations are two to three times more likely to have diabetes than non-Hispanic whites, and their rates of amputations are higher. 

Unfortunately, some people with diabetes don't believe that they will face amputation . This belief by some people with diabetes is primarily due to fear, denial and ignorance about the science of diabetes and how diabetes actually rots out the inside of the body.

Check your feet daily
Taking care of your feet is very important. The nerves of the feet are the longest in the body and are often affected by neuropathy.

Foot careThe single most important thing that a person with diabetes can do to prevent a problem is to look at their feet every day, just as they comb their hair or brush their teeth.

Look at your feet every morning and every evening to check for cuts, sores, blisters, redness, calluses, or other problems. You can use a mirror to examine your feet or have a family member check your feet for you.

Here are some tips on preventing foot problems from the National Diabetes Education Program.
  • Quit smoking if you're a smoker. Smoking is considered a likely factor in diabetic foot disease.
  • Be super-vigilant about your controlling your blood sugar. According to results of the United Kingdom Prospective Diabetes Study, people with type 2 diabetes who lower their blood glucose through intensive therapy are at reduced risk for neuropathy.
  • Choose shoes carefully.
  • Cut your toenails carefully or have someone else do it if you already have numbness.
  • Note: An increase in the temperature of your foot, which can be detected with a special infrared thermometer, can be an early sign of trouble. The foot will get hot before the skin breaks down.
Additional Ways to Care for Your Feet [Ref: Death to Diabetes Book, Chapter 15]
  • Wash your feet in warm water every day. Do not soak your feet. Dry your feet well, especially between your toes. Rub lotion on your feet, but do not put lotion between your toes
  • If your skin is dry, especially the heel of your foot, use a salt scrub to carefully remove the dead skin. (Thanks, Cynthia!).
  • Cut your toenails once a week or when needed. Cut toenails when they are soft from washing. Cut them to the shape of the toe and not too short. File the edges with an emery board.
  • Always wear shoes or slippers to protect your feet from injuries.
  • Always wear socks or stockings to avoid blisters. Wear thick, soft socks. Do not wear socks or knee-high stockings that are too tight below your knee.
  • Wear shoes that fit well. Shop for shoes at the end of the day when your feet are bigger.
  • If you have neuropathy, talk to your doctor about orthotics to improve circulation and relieve pressure.
  • Check the temperature of bath water with your hand or arm before getting in the tub.
  • Do not cross your legs when sitting.
  • Make sure your doctor checks your feet at each checkup and performs the filament test by lightly rubbing a feathery filament across the bottom of your feet - to check for a loss of touch sensation.  If you do not feel the filament, it is imperative that you use your eyes to check your feet every morning and night.
  • Note: If your feet do not sweat at all, this may indicate a loss of sweating and eventually a loss of touch sensation.  Unfortunately, this may eventually lead to foot ulcers. Notify your podiatrist and endocrinologist.
  • Use one or more of the following therapies to help improve nerve health and the blood circulation in the feet: massage therapy, water therapy, acupuncture, magnetic insoles.
  • Other natural treatment options for neuropathy may include: relaxation training, hypnosis, biofeedback training, acupuncture, transcutaneous electronic nerve stimulation (TENS) therapy.
In addition, follow a nutrient-dense nutritional program such as the Death to Diabetes Super Meal Diet that will help to control blood glucose levels and prevent the onset of diabetic neuropathy. Key foods, herbs and wholefood-based supplements include green vegetables, bright-colored vegetables, raw juices, beans, wild salmon, Omega-3 EFAs, evening primrose oil, CoQ10, cayenne pepper, garlic onions, ginger, and nattokinase.

Note: For more information about preventing diabetic amputations, refer to the Death to Diabetes website.

Foot care

Foot care