1. What is high Blood Pressure?

      BP is the level of pressure that the blood is under in the blood vessels. The body is made up of cells that require glucose and oxygen in order for those to function well. The blood transmits the essential chemicals and nutrients to each part of the body. (Halls Dally, 2013).  Therefore, in order for the blood to function efficiently and effectively, it requires clean blood vessels that it could flow completely and it needs under pressure to move through. The BP arises mainly from the action of the heart, the specific muscle that performs as the pump that squeezes the blood through the blood vessel. Therefore, the extra blood the heart pumps and the more narrow the arteries are, results in high BP. (Chhajer, 2014).

2. Type II Diabetes and Hypertension complication.

      Type II diabetes increases the possibility of developing a high BP, other Cardiovascular Disease and Diabetic Nephropathy, eyes and other organs of the body, since diabetes has an adverse effects in the arteries. When the BP is high, the energy and force applied on the arteries is excessively high. It’s so high that it produces microscopic tears in the walls of the artery then that tears turn into microscopic nerve.  When the arteries have been damaged, they gather circulating materials like cholesterol, platelets, fats and that cause atherosclerosis-the buildup of cholesterol and extra blood lipids alongside the walls of the blood vessel. (Mogensen, 2015).

     On the other hand, some people with Type II diabetes might likewise experience an intense fall in BP through exertion or force. Specifically, once diabetes compensates the nerves that control BP levels, BP levels have the possibility to decrease significantly through persistent standing or moderate physical exercise and body movements. (Ram, 2014). 

3.  How is high BP treated?

     ACE (angiotensin converting enzyme) inhibitors are clusters of medications that are frequently used to cure and manage high BP in people suffering from diabetes. While there are other high BP drugs available, ACE inhibitors have proven not simply to be a useful medication in treating high BP, nevertheless have been shown to inhibit or delay the development of kidney illness in people with diabetes. The other drugs that have been used to cure and manage high BP in people suffering from diabetes consist of a class of medications normally recognized as ‘water medications’ or diuretics. Since sufficient regulator of BP frequently needs more than one drug, most of the diabetic patients have been initially administered with ACE inhibitors and then with anti-hypertensive medications if necessary.  (Breitkreuz, 2014). 

4. How do we prevent high BP?

       To assist in preventing high BP, need to have healthy diet and keep a healthy body weight. Regular exercises are recommended; limit salt consumption and increasing potassium intake.  Quitting smoking and limiting alcohol consumptions could also help prevent high BP. (Mitchell, 2014).

 

(HKUST, 2016)  

Untreated hypertension in patients with diabetes type 2 often results in the increased risk of cardiovascular diseases such as myocardial infarction and congestive heart failure and microvascular disease such as nephropathy (Fisher, 2012). Therefore the regulation and monitoring of blood pressure in diabetes type 2 patients is integral to reducing the aforementioned risks associated.

Blood pressure lowering targets for people with diabetes type 2 are lower and the use of multiple anti-hypertensives may be implemented in order to achieve these targets (Fisher, 2012). Medication such as Losarten, an angiotensin-II receptor antagonist, in was found to be highly successful in reducing stroke, cardiovascular death and myocardial infarction (Fisher, 2012). This was a trial called "Losarten Intervention For Endpoint reduction in hypertension (LIFE)" (Fisher, 2012), which compared the actions of losarten and atenolol-based therapy in a set of patient with hypertension and diabetes type 2. 

 Similarly in order to manage blood pressure, antihypertensive is also commonly used. However, researches show that antihypertensive can reduce gray matter circulation nearly up to 15% in elderly patient. This can lead to hyponferfusion in the brain for the patient with cardiovascular disease. Also, as the brain perfusion is reliant on the pressure of the arteries and the vains, lowering blood pressure in patient with type two diabetes lead to imbalance of intracranial pressure that may eventually lead to complications such as brain ischemia (Farrell & Dempsey, 2010). In addition, lower BP can also lead to cognitive decline as well as to Alzheimer disease (Kim et al., 2011). 

Similarly, strict blood pressure control can contribute to other adverse effects such as hypotension, angioedema, renal failure, hypokalaemia, bradycardia, arrhythmia and syncope. This can also increase the risk of adverse reaction of antihypertensive drugs. In some cases the risk of adverse effect of medication is equivalent to the risk of having stroke for which type II diabetes patient is recommended to have antihypertensive medication (Rabi et al., 2013). Therefore, it would not be wise to take blood pressure management as a gold card to minimise all co-morbidities for the patient with types two diabetes.   

As we have chosen to agree that blood pressure lowering strategies have the most impact on preventing co-morbidity and mortality in people with type 2 diabetes, we have also looked at evidence base research opposing the statement. Research findings against this argument have shown that using antihypertensive medications to reduce high blood pressure can cause other health issues  such as brain ischemia, hypo perfusion, hypotension, angioedema, renal failure, hypokalemia, braycardia, arrhythmia and syncope and as well as antihypertensive drug adverse reactions (Farrell & Dempsey, 2010).  Therefore the evidence that has been researched opposing this statement mainly focuses on the health issues caused by antihypertensive medications and highlights that they are not recommended for diminishing all co-morbidities for patients with types two diabetes. 

The research that was used to support blood pressure lowering strategies had findings towards patients who had types two diabetes with a baseline BP of 140mm hg and greater. These findings showed that patients with types 2 diabetes would most benefit using medications for blood pressure lowering as they improve mortality and other clinical outcomes such as lowering stroke events and the risk of vascular disease (Emdin et al, 2015).

Individuals who have hypertension tend to be uneducated towards the understanding of the disease and how to prevent or control hypertension (Rasjo Wrakk, Tornkvist, Hesselstrom, Wandell, & Josefsson, 2015).  As health care professionals it’s our duty as nurses to be able to help educate our patients about lowering strategies towards hypertension and how they can control the disease.  Many patients avoid taking antihypertensive drugs because of two reasons, one they avoid taking medications due to their side effects, which was stated in the disagreement of this statement and two because they don’t know how these drugs works (Farrell & Dempsey, 2010). 

Education towards antihypertensive drugs towards patients can reduce their anxiety towards the medication (Rasjo Wrakk, Tornkvist, Hesselstrom, Wandell, & Josefsson, 2015). It can also provide patients an understanding of how these drugs can reduce their risk of obtaining other health issues due to their high blood pressure which was stated in the evidence based research for blood pressure lowering strategies  (Rasjo Wrakk, Tornkvist, Hesselstrom, Wandell, & Josefsson, 2015). Therefore after looking into the evidence for and against blood pressure lowering strategies on preventing co-morbidity and mortality in people with Types two diabetes, we have chosen to agree as the benefits of reducing hypertension in patients greatly outweighs the arguments posed against.

 
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D'Adamo, E., & Caprio, S. (2011, May). Type 2 diabetes in youth: epidemiology and pathophysiology. Diabetes Care, 34(5), S161+. Retrieved from http://go.galegroup.com.ezproxy2.acu.edu.au/ps/i.do?id=GALE%7CA256070060&v=2.1&u=acuni&it=r&p=AONE&sw=w&asid=5494c3a2df6b072b2bcd47708548376a

 

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Emdin, C., Rahimi, K., Neal, B., Callender, T., Perkovic, V., & Patel, A. (2015). Blood Pressure Lowering in Type 2 Diabetes: A Systematic Review and Meta Analysis. American Medical Association, 313(6), 603-615. http://dx.doi.org/10.1001/jama           

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Rabi, D., Padwal, R., Tobe, S., Gilbert, R., Leiter, L., Quinn, R., & Khan, N. (2013). Risks and benefits of intensive blood pressure lowering in patients with type 2 diabetes. Canadian Medical Association Journal, 185(11), 963-967. http://dx.doi.org/10.1503/cmaj.120112

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Type I Diabetes (T1D): It is also known as insulin-dependent diabetes where the pancreas doesn’t produce insulin. 
 

Type II Diabetes (T2D): It is the most common diabetes which is characterised by two conditions. i) the beta cells of the pancreas struggle to produce enough insulin to process the increasing blood sugar levels which is called insulin deficiency and ii) the insulin which is being made does not function  properly. This is called insulin resistance (Torpy & Golub, 2011).  
Type II Diabetes (T2D) is caused by poor lifestyle like lack of physical activities, poor nutrition, obesity, stress etc .Also, individual with family history of Diabetes II have greater chance of developing Diabetes II (Torpy & Golub, 2011). 

 Pathophysiology of Diabetes II

Diabetes II occurs when there is insulin deficiency and insulin resistance in the body. Insulin resistance occurs within liver, fat tissue and muscles. In the liver, glucose is blocked by insulin. During the insulin resistance the liver releases glucose in the blood. As a result, there is variance in the ratio of insulin resistance and beta cells (cell which stores or releases insulin) in the body. It is not necessary that people with insulin resistance develop diabetes since damage of insulin section is also essential (D’Adamo & Caprio, 2011).

 

The complications of T2D can be divided into two groups: microvascular complications (damage of small blood vessel) and macrovascular complication (damage of large vessel).

·       T2D is the primary cause of blindness. Many visual problems like Glaucoma, punctuate keratitis, cataract accompany DM2.

·       T2D can damage kidney (nephropathy) by destroying small blood vessels which filters waste from blood.

·       For patient with T2D there is higher risk of mortality during hospital stay than patients without diabetes because of joint infection, wound infection, delay in wound healing, hypoglycemia, etc.

·       People with T2D have higher risk of cardiovascular disease like narrowing of arteries, heart attack, strokes, etc.  (Blair, 2016).