What is Hypertension?

Hypertension is defined as a sustained elevated blood pressure of 140mmhg (Systolic) over 90mmhg (diastolic) or higher.  The gold standard for diagnosing hypertension is by 24hr ambulatory blood pressure monitoring, where an automatic digital blood pressure machine is fitted and worn by the person for 24hrs, during which time the machine measures blood pressure twice per hour during waking hours, and at least once per hour during the night.  The mean wake and sleep blood pressures, along with a number of other blood pressure values are calculated to determine hypertension.

There are 2 parts to a blood pressure reading.  The highest number or systolic blood pressure is the maximum pressure created when the heart contracts.  This can be felt as the pulse moving through an artery.  The lower number or diastolic pressure, is the minimum pressure in the arteries when the heart is at rest between beats.  In a normalised, healthy population of people we would expect the blood pressure to be around 120/80mmhg +/- ~20mmhg.  It is generally regarded that the lower the resting blood pressure then better, as long as it does not become too low as to become symptomatic (Hypotension).

There are 2 main forms of hypertension:

Essential (primary) hypertension is an elevated blood pressure that has no known or specific cause.  Essential hypertension is the most common form of high blood pressure, and one of the most common symptoms of cardiovascular and cardiometabolic disease.

Secondary hypertension is when there is a known cause for the blood pressure to be elevated.  Often this is associated with kidney disease, adrenal disease, thyroid dysfunctions or obstructive sleep apnoea, or it can be a side effect of some medications.

The body uses 3 main, complex physiological mechanisms to control blood pressure:

Myocardial contractile force is the strength of the heart's muscle contraction when the heart beats.  The higher the force the more blood that is ejected from the heart into the arteries with each beat resulting in a short term rise in blood pressure.  The body will generally use this to adjust to sudden changes in posture such as moving from a lying to standing position.

The second way the body can adjust blood pressure is by dilating and contracting the blood vessels, known as vasodilation and vasoconstriction.  When blood vessels dilate there is more space for the total blood volume resulting in a drop in blood pressure, and when the blood vessels contract there is less room and therefore a rise in blood pressure.  The body will use this mechanism to adjust to sudden or short term changes in blood pressure, as well as to regulate blood pressure through longer periods of rest or physical activity.

Thirdly, the body controls blood pressure over a longer period of time by regulating total blood volume, by increasing or decreasing the fluid (water) component of blood.  If a higher blood pressure needs to be sustained for a period of time the body will reabsorb fluid from the kidneys and other parts of the body to increase blood volume, and when blood pressure needs to reduce, the body will filter water out of the circulating blood volume via the kidneys, or by sending fluids to other parts of the body.

These three mechanisms don’t work independently, but collectively to regulate blood pressure within normal parameters.

Primary hypertension occurs when there is an interruption or dysregulation to the neuro-endocrine and other structural and physiological processes underlying these complex mechanisms.

Raven, P. & Chapleau, M. (2014) Blood pressure regulation XI: Overview and future research directions, Eur J Applied Physiol, 114(3); 579-586, doi:10.1007/s00421-014-2823-z

The conventional approach

According to the Australian guidelines for the diagnosis and management of hypertension, hypertension (high blood pressure) is defined by a sustained elevated blood pressure of 140mmhg (systolic) over 90mmhg (diastolic).

Once hypertension  has been diagnosed, treatment will usually consist of:

Lifestyle advice to address physical activity, weight management, diet, smoking cessation and alcohol intake.

If the above strategies are not sufficient to reduce blood pressure to lower risk levels then prescription medications are used either selectively or in combination.  The types of medications used include Angiotensin Converting Enzyme (ACE) inhibitors, Angiotensin Receptor Blockers (ARB), calcium channel blockers, and beta-blockers which are used to reduce the strength of the heart's contraction force.  In some cases diuretics may also be used to reduce circulating fluid volume.  In some cases up to 3 different medications may be used in combination to help control blood pressure.

Whilst early intervention to reduce blood pressure and risk of adverse events is necessary, these strategies alone do not address the underlying factors that have resulted in hypertension.  Addressing the neuro-endocrine and inflammatory dysregulation for effective risk reduction and reversal of hypertension is essential.

National Heart Foundation of Australia. (2016)  Guideline for the diagnosis and management of hypertension in adults, Melbourne. Retrieved https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwi-hNn0vMXxAhUZyTgGHbeFANwQFnoECAQQAA&url=https%3A%2F%2Fwww.heartfoundation.org.au%2Fgetmedia%2Fc83511ab-835a-4fcf-96f5-88d770582ddc%2FPRO-167_Hypertension-guideline-2016_WEB.pdf&usg=AOvVaw3Eqe7dt-RrzZ5uVAG2jeET

Signs and symptoms

Unfortunately most people who develop hypertension will have no overt signs and symptoms, and the elevated blood pressure is only discovered by chance when the blood pressure is checked.  This is why it is vitally important to have your blood pressure checked regularly especially if you are 40+ years of age, overweight or obese, smoke, have excessive alcohol intake, consume a diet high in saturated fats and low in fibre, lead a sedentary lifestyle or have a family history of hypertension or cardiovascular disease.

Indigenous persons or those from an African heritage also have a hereditary predisposition to developing hypertension and cardiovascular disease and so should be proactive in having their blood pressure checked regularly.

In some cases people may experience some general or non-specific symptoms that may indicate a need to have their blood pressure checked.  These may include mild headaches, a flushed appearance to the face, or clearly visible blood vessels in the white parts of the eye.  In men, erectile dysfunction has also been linked to hypertension and cardiovascular disease.

If significant symptoms such as breathlessness, loss of body functions, severe headaches, heart palpitations or reduced urine output occur you should immediately seek the advice of your doctor as these signs and symptoms may indicate a rare but serious condition known as hypertensive crisis.

Root causes

The functional medicine perspective considers primary hypertension as a sign that there is a chronic and progressive interruption and dysregulation of the complex neuro-endocrine physiology that regulates blood pressure, and in most cases this will be driven by an underlying immuno-inflammatory process affecting the heart and blood vessels.

The root cause of these disrupted processes will in most cases be influenced by modifiable diet and lifestyle factors as well as a number of psycho-social and physiological determinants.  Prolonged stress, gut health, thyroid disorders, food allergies and sensitivities, heavy metal and environmental toxicities, and autoimmune and inflammatory conditions have all been associated with hypertension.

Carretero, OA. & Oparil, S. (2020) Essential hypertension: Part 1: Definition and etiology, Circulation, 101(3); 329-335, https://doi.org/10.1161/01.CIR.101.3.329

Pilakkadavath, Z. & Shaffi, M. (2016) Modifiable risk factors of hypertension: A hospital-base case-control study from Kerala, India, J Family Med Prim Care, 5(1); 114-119, doi:10.4103/2249-4863.184634

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Common misconceptions

The most common misconception about hypertension is that it is a disease.  Instead, hypertension should be viewed as a sign of disruption and dysregulation of a number of complex neuro-endocrine and immuno-inflammatory pathways in the body.

Furthermore many people believe that taking medication to manage blood pressure is all that is required.  However, medications can be effective for reducing blood pressure, but do not address the underlying root cause for hypertension.  If medication is the only approach used to control blood pressure a person may be at risk of developing chronic cardiovascular and cardiometabolic disease.

What causes eczema?

There isn’t one single cause of eczema but a range of potential contributing factors that are unique to each person. These include:

Genetics

Research has found people with the ‘atopic triad’ have a defective barrier of the skin and upper and lower respiratory tracts.

These genetic alterations cause a loss of function of filaggrin (filament aggregating protein), which is a protein in the skin that normally breaks down to create natural moisturisation and protect the skin from penetration by pathogens and allergens.

Filaggrin mutations are found in approximately 30 percent of people with atopic dermatitis, and also predispose people to asthma, allergic rhinitis (hayfever), keratosis pilaris (dry rough patches and bumps on the skin), and ichthyosis vulgaris (a chronic condition which causes thick, dry, scaly skin.)If one parent carries this genetic alteration, there is a 50 percent chance their child will develop atopic symptoms. And that risk increases to 80 percent if both parents are affected. 

Food allergy and sensitivity

Food hypersensitivity has been found to cause or exacerbate atopic dermatitis in 10-30% of cases, and 90% of these are caused by eggs, milk, peanuts, soy and wheat.

Compromised gut health

The connection between the gut microbiome and skin health is complex, however, research has found the microbiota contributes to the development, persistence, and severity of atopic dermatitis through immunologic, metabolic and neuroendocrine pathways.

Nutritional deficiencies

Deficiency of Omega-6 essential fatty acids (EFA) has been linked with the increased incidence of atopic dermatitis, along with the inability for the body to efficiently metabolise EFA’s to gamma linoleic acids (GLA) and arachidonic acids (AA).

Weather and environment

Changing weather conditions can certainly aggravate eczema symptoms, but the triggers are subject to change among individuals.

Hormones

Hormones also play a role in the course of atopic dermatitis, including the stress hormone cortisol which triggers an inflammatory immune response affecting all organs of the body, including the skin.

Mould exposure

Mould exposure and susceptibility to mould can cause Chronic Inflammatory Response Syndrome (CIRS), of which dermatitis is a manifestation.

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