In the first part of our interview with Janet Ajuluchukwu, a professor of Medicine and consultant cardiologist at the College of Medicine, Lagos University Teaching Hospital (LUTH), she spoke about conditions that expose people to certain organ failures. However, in the concluding part of her interview with CHINWE MADUAGWU, the renowned cardiologist said Kano City has highest hypertension prevalence and offer useful tips on how to stay healthy.
NE: In the past, hypertension was assumed a disease of old age. Does the assumption still hold?
Let us start with why it was called an aging disease. We have a certain amount of blood pressure that we have found useful. Naturally, when a baby is born, the blood pressure is very low and as the baby grows older, the blood pressure goes up. Until 1999, the World Health Organisation said for someone to be said to have hypertension, the partition level for the blood pressure should be 160/95. This, of course, was an arbitrary cut-off. However, in 1999, they changed it to 140/90 and said if we start doing things either with drugs or without drugs to keep your blood pressure lower than 140/90 the world would be a better place. Before 1999, it was accepted that a blood pressure of 170 in a 70-year-old man was normal for him because as you grow older your blood pressure goes up. But with better research and better observation, it was noticed that if you are 70 years and your blood pressure is 140, you are not likely to have a stroke but if you are 70 years and even though nature is pushing your blood pressure up to 170, that status will give you a stroke.
We also have what we call a ‘rule of thumb’ that the systolic blood pressure should be your age plus 100 and we still use it. Now WHO says that for us to characterise somebody as hypertensive, the blood pressure will be 140/90 and above, but if a 30-year-old comes to me with a blood pressure of 135, I will do that 100 plus 35 and I will keep him under surveillance. A 16-year-old should have 116 and below if he or she comes with 120 or 125 blood pressure, even though it has not got to the WHO cut off, I will still keep that person under surveillance and lifestyle modifications might just have to start early. From some of the studies carried out by the Nigerian government, it was seen that about 16 percent of some 15-year-olds were hypertensive, having a blood pressure level higher than what it should be. Therefore, hypertension is not an old age disease anymore.
NE: So how serious a problem is hypertension in Nigeria?
With figures, hypertension is the biggest, most common, most independent risk factor for heart failure, stroke, heart attack, kidney disease and failure and sometimes eye problem. It is one risk factor that can affect many parts of the body. Coming to the numbers, remember we have said that in 1999, WHO changed its partition from 160/95 to 140/90. The Nigerian government was able to sponsor a very big national study that was published in 1997 using WHO figures of 160/95 and the people that were seen then were 15 years and above and it was seen that 11 percent of Nigerians using 160/95 had hypertension. It was commoner in the urban centres than in the rural areas. Then when WHO said it was 140/90, they now used the same figure and changed the partition level and we got about 20 percent. However, different people have been doing different studies. In a study using Lagos State as a pilot to do another national study, we saw that the prevalence of hypertension in Lagos in 2003 went up to 30 percent and we are still seeing the increases.
NE: In your inaugural lecture a few years back, you said Kano city was the hypertension capital of Nigeria, can you explain?
It is still from this National Health Survey sponsored by the Federal Government and this was not political or anything since it was done by the federal ministry of health and in different locations in Nigeria, supervised and controlled at a central level. It was found that Kano town had the highest level of hypertension. At that time, we were still doing 160/95, some towns like Mangu and Malumfasi had 6 to 7 percent, but in certain areas of Kano, they were having 30 to 40 percent. So, they now used those values and made something like a map and Kano was just there standing by itself.
NE: Is it known why the prevalence is so in Kano?
We just have conjectures and scientific debates on why it might be so. Not that it has been proven because after you have an observation and or a scientific thought, you go back and prove it by really doing comparisons to know what is it there that is different.. But the things that we have observed are dietary, all the dressing that they put on the meat preparation, the part of meat that is attractive to the man on the street, the high creamy milk dishes they would have because cholesterol and salt are part of the things that would cause the blood pressure to rise. With these, we feel it is dietary. I am sure in the North and around Kano, the very poor people can have some meat and all those fatty parts people might throw away. These poor pick up the fatty parts and eat them, therefore, bringing socio-cultural status into play. The national survey also showed that very rich people and very poor people had hypertension with very little in the middle. We also feel that the suya type of dressings might be highly salted. Again, because of the nomadic kind of living there, we heard that meat is prepared and preserved in such a way that it does not spoil easily. So the question is what are they using to preserve the meat?
NE: We have been talking about high blood pressure. There is also low blood pressure. What constitutes low blood pressure and is it as dangerous as high blood pressure?
Blood Pressure we know is the force imparted by the heart in its effort to push out blood into the vessels. So, if the heart itself does not have a lot of force, it will not push out blood into the vessels. Everybody has a blood pressure though arbitrarily, WHO fixed it at 140/90. There is also pressure in the vessels that would not give enough force for the blood to move upwards against gravity to the brain and all the other parts of the body. This is because the heart pumps once and the blood keeps moving until it finds its way back. We do not have a very good level for low blood pressure but we would be worried if people have blood pressures that are less than 100/60. Any blood pressure that is associated with symptoms is not good. If your natural blood pressure is 90/60 and you are running marathons and doing all you are supposed to do, then it is not bad. However, if you are usually about 120 and then one day you get to 90/60 and you are feeling weak, dizzy and your heart is beating, then that blood pressure is a problem and we will take it as low blood pressure. Is it dangerous? Yes. Part of the dying process is that the heart gets weaker and the pressure gets lower until there is no blood pressure at all. Simply, if somebody is vomiting, having diarrhea and losing the usual quantity of fluid that should be in the body, it will affect the blood pressure. If somebody is having a serious diabetic problem, passing a large volume of urine and very frequently, then the BP will drop. Again if the heart itself which is the pumping organ is weak or somebody is having a heart attack, the BP will drop.
NE: Is it proper to share hypertension drugs?
It is not proper at all. People should not share any drugs. With hypertension though, the drugs are targeted at certain problems. For instance, some hypertensive patients have shown proneness to kidney failure, we give them kidney saving drugs. Some have shown proneness to heart enlargement, so we give them specific drugs, some patients are diabetic and they have their own drugs that are more suited to them. We should not share drugs. The numbers may be the same but the internal arrangement may not be.
NE: In your inaugural lecture, you said anti-hypertensive drugs work better when taken at night. Why is that so?
It has been noticed that the different organs of the body and their natural workings have rates that can be up or down depending on the time of the day. So there is an internal clock that the body has that tells your body that night is coming and that you should be preparing to go to sleep and during sleep, the body and its organs are more relaxed. The blood pressure that we have at our workplace with stress and everything is not the blood pressure we have at home; it goes down a little bit. When you are asleep, your blood pressure must go down 10 units than when you are awake. As we are trying to wake up, certain things happen inside our body to put the body into the process of waking up and it involves adrenaline and certain stress hormones. People are surprised that when they wake up their blood pressure is up and that is even why people have heart attacks and strokes in the morning.
We have studied it and we have proven in our own practice that when we gave part or all of the treatment at night because of those nighttime changes, the drugs worked better and in our own values, the blood pressure went down. We had two groups of people, they had the same blood pressure, the same number of men and women, we checked the level of heart enlargement they have had due to hypertension and we gave them treatment for three months, daytime and night, we found good changes consistent with science. We found that some of the physiological activities that are switched on or switched off at night worked well with our drugs at night and we saw those effects. It is called Chrono Biology and that is why jobs like shift work can cause certain changes because people are sitting down and working at night when they should be lying down.
NE: What are your parting words?
Well! Nothing beats knowledge. I have observed in my over 35 years of being a medical doctor there is a lot of bravado with ignorance. People make statements like ‘my forefathers did this or that.” It is very painful to me. Your ancestors were not using telephones; they were not flying in airplanes. They did what they could do and they did well. We are losing many people, especially young people due to ignorance. I had a patient who came in with a BP 250/190 and this happened because she stopped taking her drugs because she said she had faith she had been cured. Faith is good but people should check their BP especially if you are already diagnosed. People should also go for regular checkups. We should use the information and knowledge this age and time have given us. We cannot be in 2017 and have healthcare issues of 450BC.
Prevention is important. Prevention is at different levels. At the governmental level, they should give us wholesome food, help our agriculture, and educate us in school as to the proper and healthy things to eat, minimise the importation of things that are injurious to our health and not chasing women in the market when the things are already in the country.
At the individual level, people have to make the conscious effort to know their health status. WHO has started a programme called ‘Knowing your Numbers.’ Everybody has to know how old he or she is because age has an impact on health and the level of blood pressure. We should not merely say that the doctor said it is normal. We must know the value and what it means. People need to know their blood sugar. We must know that if it is 88, it is normal or if it is 150, it is not normal and what next to do. They need to know their cholesterol level and finally the measures of obesity, which is their weight against their age to determine if their Body Mass Index is right. Do the little tests before going into secondary school, university or starting a new job. These are important avenues to find out things because the earlier one can pick up these non-communicable diseases and intervene, the better the outcome and the slower the processes of damage. People should invest in their health just as they invest in education. We have said that hypertension is the biggest risk factor for heart failure, stroke, and kidney failure. You can imagine what will happen if we can take out avoidable hypertension.