(Implication of the Treaty of Waitangi in improving Maori health outcomes)

INTRODUCTION

Ministry of Health plays a crucial role in developing various strategies, policies, and legislation that further guide how to achieve the maximum health outcomes for the Maori population keeping in mind regarding the articles of the Treaty of Waitangi and its principles.  As the Treaty of Waitangi is recognized as a founding document of New Zealand which helps to promote health equities among Maori and non-Maori. Therefore, this essay will provide a description regarding the Treaty of Waitangi, as to how it effectively involved in New Zealand Public Health and Disability Act (2000), New Zealand Disability Strategy, Maori Health Strategy, Whanau Ora Programme, and Maori Health Plan. In the end, this essay will consider the role of the Treaty of Waitangi in Health promotion and overall conclusion by concluding health outcomes for Maori; as Maori population is getting any benefits from these strategies and acts or not.

Treaty of Waitangi

Treaty of Waitangi is the “founding document” of New Zealand. Treaty of Waitangi was first signed on 6

^th

February 1840 in the Bay of Islands. It is an agreement between Maori chiefs and the British Crown. Approximately, 40 chiefs, starting with Hone Heke signed the Maori version of the treaty. On the other side, William Hobson, a naval officer represents the British crown and Government ( New Zealand Government, 2005).

Treaty of Waitangi has three articles which are described as follows:

Article 1 Kawanatanga

: According to this article “Maori gave the right of conduct to Britishers and in the back they want protection and authority to manage their own events, but in the English version it says Maori give up sovereignty”. (Waikato Regional Council, 2019).

Article 2 Tino Rangatiratanga

: This article explains that “Maori chiefs guaranteed the chiefs ‘te tino rangatiratanga ’and they agreed to give the Crown a right to deal with them over land transactions. However, in the English version, it confirmed and guaranteed to the chiefs ‘exclusive and undisturbed possession of their lands and estates, forests, fisheries, and other properties”. (New Zealand Government, n.d.)

Article 3 Oritetanga

: This article states that “Queen will be responsible for the protection of Maori population in New Zealand and Maori people will get the same rights as British people and can have the same equality like that of other New Zealanders”. (Wilson, 2016)

In 1998, the Royal Commission on Social party recognized the treaty principles and authorized that Treaty Principles should be used in present activities to improve Maori health status. Treaty of Waitangi has three ‘Ps ’principles

i.e.

Partnership, Participation, and Protection which formulate actions in Maori Health Strategy (He Korowai Oranga) with the main objective to involve the Maori population in the health sector.  As well as DHBs are taking more responsibility to engage Maori participation to achieve maximum health outcomes (Ministry of Health, 2002).

New Zealand Health Legislation and Strategies

New Zealand Public Health and Disability Act (2000)

The New Zealand Public Health and Disability Act (2000) was established to produce forceful changes to the general public health funding and provision of public health services and disability support services. As well as, this act conjointly encompasses a similar objective to reduce health disparities among Maori and perpetually improve their health outcomes (Ministry of Health, 2019). District Health Boards and therefore the Ministry of Health and other agencies are working collaboratively to produce the best health services for Maori through equitable funding distribution and disability support services. DHBs also encourage Maori communities to participate in healthcare improvement policies and tries to develop numerous ways to improve their health outcomes (Ministry of Health, 2000).

Moreover, in 2016/2017, the Ministry of Health spent $2.879 billion for health and disability services and support (Ministry of Health, 2016). Its main focus is to promote independency and participation of disabilities in the community. On the other side; funding for hospitals has inflated to $21 million annually (Tan, Carr, & Reidy, 2012). Apart from this, in 2004- 2005 lower cost of GP visits at primary health care organizations promotes to overcome the cost barrier for Maori. Moreover, it shows that more than 50% of Maori and low- income populations were successfully enrolled in primary health organizations in the view of increasing accessibility of health services and reducing health disparities. In addition to this, life expectancy for New Zealanders has increased for males it is 79.5 years and for females is 83.2 years and it is above the OECD average (New Zealand Government, 2016).

On the other side, from 1 July 2017, the Ministry of social development has considered $11.38 million in funds to support Whanau Ora outcomes for many vulnerable families, particularly Maori and Pacific. As well as it follows Maori Health Strategy to support Whanau Ora (Ministry of Social Development, n.d.).

Regardless of the high quantity of funding, DHBs are still not able to tackle health disparities among Maori. As stated by, Teresa O’ Connor “14 out of the 20 DHBs addresses the pathway to reduce disparities for Maori.  However, descriptions were usually general rather than specific and mostly involved workforce, governance and process initiatives, rather than health services.” Holistic approach care is not delivered properly and Whanau ora support is not efficiently carried out. As well as, lack of cultural awareness and lack of support and critical resources negatively affecting the health and well- being of Maori (O’Connor, 2012).

According to the report, “Maori health funding are poorly targeted and barely monitored. The report shows that Crown has rebuked for breaching the Treaty of Waitangi, both in its failure to close the persistent gap between Maori and non-Maori and its failure to guarantee Tino rangatiratanga, or Maori sovereignty and self- determination.” (Radio New Zealand, 2019)

New Zealand Disability Strategy

The first New Zealand disability strategy was established in 2001 to overcome the barriers that come in the way of disabled people and stop them to reach their goals. However rather than its progress, still several disabled children and adults are facing a lot of barriers to succeed in their potentials. Keeping in view of this, New Zealand Disability Strategy 2016- 2026 was initiated by the Minister of Disability Issues “Hon Nicky Wagner” on 29 November 2016 (Ministry of Social Development, 2017).

The main aim of this 2016-2026 strategy is to make New Zealand as a non-disabling society, and wherever disabled people can have equal opportunities to attain their goals and aspirations. This strategy is going to be guided by the three ‘Ps’ principles of Te Tiriti o Waitangi, which equally promotes the participation of the disabled Maori population by improving their quality of life and promoting Whanau Ora.

The New Zealand Disability Strategy will provide guidelines to the government agencies on disability issues from 2016 to 2026. In addition to this, other action plans are also going to start in order to implement this strategy. For instance, a combination of New Zealand Maori health strategy (He Korowai Oranga) and Maori Disability Action Plan for Disability Support Services (Whaia te Ao Marama) that are aiming to provide pathways to enhance maximum outcomes for disabled Maori (New Zealand Government , 2016).  By considering the Maori Health Strategy, the New Zealand Disability Strategy tries to promote the usage of Maori  language by healthcare providers to reduce the language barrier and to support Whanau Ora.

Despite this disability strategy, the New Zealand Disability survey report shows that, in 2013, 26% of the Maori population (176,000 people) was recognized as a disabled and therefore the rate of disability was slightly above than that of the entire population. Nevertheless, 13% of all disabled Maori adults faced discrimination as compared with 6% of non- disabled Maori (Statistics New Zealand, 2015).

Lastly, in order to effectively implement this strategy, equitable health services should be distributed among disabled and non- disabled populations, awareness campaigns should be organized especially in rural areas.

Maori Health strategy (He Korowai Oranga)

Maori health strategy was first developed in November 2002. Its main target is to provide support to all Maori families (Whanau Ora) in order to maintain their health status and well-being.  He Korowai Oranga is a method that the health system acknowledges and respects the principles of the Treaty of Waitangi (Health Navigator, 2019). Four steps are used to implement this strategy and to achieve its outcomes which are as follows:

1. “Development of whanau, hapu, iwi and Maori population.
2. Maori participation with in the health and disability areas.
3. Effective health and disability services.
4. Working across sectors.” (Ministry of Health, 2003)

Ministry of health is working collaboratively with other health sectors to evolve the Maori Health Action Plan that authorized more co-ordinately and collectively to implement He Korowai Oranga. This action plan is the basic key to get rid of health disparities among the Maori population by providing the best quality and effective services (Ministry of Health, 2019).

He Korowai Oranga provides the pathways for Maori to think about their own desires and issues for health and disability. District Health Boards will provide support to Maori by delivering effective services (He Korowai Oranga Maori Health Strategy, 2001).

Despite Government efforts, still 75% of the Maori population have poor health status; according to Ted Alcorn; in 2006 and therefore the main reason behind this is often low income (Alcorn, 2011).  Also there is a difference in a delivery of primary and secondary care health services among the Maori population which further creates poor health conditions.

There is also a piece of evidence that Maori have less accessibility to healthcare services than Non- Maori groups. According to the survey report, 38% of Maori adults are facing problems in obtaining health care services in their local area, as compared to 16% of non- Maori population. As per Loschmann and Pearce, in order to overcome these disparities: more involvement of Maori providers should be considered in the rural areas, and cultural safety education must be given to all non- Maori health providers to reduce cultural barriers and to enhance Maori health status (Loschmann & Pearce, 2006). Moreover, Pae ora is that the Government’s vision for Maori Health and it is derived from He Korowai Oranga. As well as, it is an integrated approach that delivers pathways for Maori to stay healthy in an environment that promotes a better quality of life. Pae ora has three main elements that are interrelated to each other: 1. “Mauri ora- healthy individuals, 2. Whanau ora- healthy families, and 3. Wai ora- healthy environment” (Ministry of Health, 2014). Maori healthy strategy effectively promotes the treaty principle

i.e.

partnership which directly involves Maori contribution in decision making and delivery of better services for Maori groups. An evidence shows that 46% of Maori participate in healthcare delivery and decision-making process. Maori contributors play an integral role in improving the health status of their community. Government agency which is known as “Te Puni Kokiri” monitors programme delivery for Maori and their development. However, Maori Development Organisation (MDO) was set up to assist the Maori health and disability areas (Oh, 2005).

He Korowai Oranga is that the high-level strategy that assists the Ministry of Health and District Health Boards to improve Maori health status by following: Whanau Ora programme, New Zealand Disability Strategy, and New Zealand Public Health and Disability Act 2000 (Ministry of Health, 2019).

Whanau Ora Programme

The word “Whanau” is the base of Maori society. Whanau provides them a sense of support, strength, and identity. Whanau Ora programme was executed by the Ministry of Health, Te Puni Kokiri and the Ministry of Social Development. Whanau Ora acknowledges that whanau well-being is closely joined to Maori cultural values, along with social and economic as well. The main point of this programme is to improve health outcomes, education level, housing and employment levels of Maori and their Whanau (Ministry of Health, 2018).

In order to improve its efficiency; in 2010/2011; $6.6 million were allocated to develop stronger connections for Whanau and for the development of whanau leadership (Ministry of Maori Development, n.d).

According to the “Whanau Ora Minister, Peeni Henare”, the number of funds is going to be enhanced by up to $80 million for Whanau Ora support over 4 years. According to him, Whanau plays an integral role in the decision- making process regarding Whanau Ora’s support. In addition to this, an extra $19.8 million are going to be used for te Reo Maori with the aim of getting one million people speaking basic te Reo Maori by 2040, because it will produce more stronger relation between Crown and Maori (Radio New Zealand, 2019).

Moreover, the Treaty of Waitangi principles plays an important role in developing Whanau Ora by securing Maori rights and well- being, by providing equitable health services and by safely protecting Maori culture, and tradition. In addition to this, Maori Health Plan, DHBs Annual Plan, Public Health Plan, and Regional Services Plan, are contributing together as a team to support Whanau Ora.

Maori Health Plan

The main task of the Maori Health Plan is to provide fundamental planning, reporting and monitoring documents to DHBs and Primary Health Organizations to obtain equality in health services and to enhance outcomes for Maori health status. The main motive of this plan is to promote the principle of health equity, Whanau Ora support and Maori participation which is also the important objectives of Maori Health Strategy. Auckland and Waitemata DHBs are working together and have one joint Maori health team known as ‘He Kamaka Wairoa’. Moreover, the Maori health plan provides a description to DHBs regarding the Maori population and their needs. After making interventions and actions DHBs make plans to fulfill the health needs of Maori (District Health Board, 2016).

Similarly, Auckland and Waitemata DHBs follows the principles and articles of the Treaty of Waitangi and provides a framework for Maori development, health, and well-being by involving Maori participation in health decision making. The ambition of this plan is to see that, “Maori are enjoying a better quality of life, living happily and longer in their region by 2020.” (Auckland and Waitemata DHBs, 2017).

With the help of the Maori Health Plan, Auckland district health board has achieved the success to improve the health outcomes for the Maori community. It shows that the rate of smoking has decreased by 11% for Maori from 2006 to 2013. 78% Maori are enrolled at PHOs and 95% Maori children were fully immunized. Although, life expectancy at birth in Auckland DHB has increased by 1.1 years over the last ten years. Nevertheless, there are still health disparities are present in between Maori and non-Maori population which can be easily seen from the Auckland district health board plan. As it shows that, life expectancy for Maori is 79.3 years which is 3.9 years shorter than other non-Maori groups. However, the main reason behind their high mortality rates is ischaemic heart disease, lung cancer, suicide and diabetes (Auckland DHB, 2015). Apart from this, use of tobacco and smoking prevalence is higher in Maori (38%) than Pacific (25%) and other New Zealand Europeans (15%) and this habit badly affecting the health of Maori community (Gifford, Tautolo, Erick, Hoek, & Gray, 2019).

Well, it is the responsibility of the Maori Health Plan to make strategic health plans by acknowledging the Maori culture and Maori language in order to deliver a better quality of services and universal healthcare services for everyone and for the Maori population. Health counselling sessions must be organized to support Whanau Ora.

Role of the Treaty of Waitangi in Health Promotion

The relationship of the Treaty of Waitangi to health promotion is well established and it can be easily through New Zealand Public Health and Disability Act (2000) which tries to eliminate the health inequalities between Maori and non- Maori populations (Came & Cornes, 2018). It has been stated that there are inaccessible health services and health inequalities are present between Maori and non-Maori population. Therefore, in order to overcome these disparities, the Treaty of Waitangi plays an important role in promoting the health status of Maori. Since the 1970s, awareness regarding the Treaty of Waitangi has increased continuously and resulting in growing the Maori aspiration for self- determination. Also, the Government has started programme of accessible services of public health and Maori health promotion programs, as well as appointing Maori health workers to contribute more to Maori communities.

Owing to the Treaty of Waitangi, life expectancy for Maori has been increasing consistently at almost the same rate as non-Maori since the late 1990s. Also, the gap in life expectancy between Maori and non- Maori had decreased to 7.1 years. In 2013, life expectancy at birth for Maori male was 73.0 years and for Maori females was 77.1 years; while for non- Maori males were 80.3 years and for non- Maori female was 83.9 years (Ministry of Health, 2018).Furthermore, in 1991 major reformation of health services was begun and the level of funding was elevated to improve the accessible services for Maori by an engaging Maori healthcare provider and by developing cultural safety education programs. Similarly, the number of Maori health providers has increased from 13 to 240 and, even that, Maori health leaders played an important role in promoting health promotion and prevention of disease occurrence with in Maori communities (Loschmann & Pearce, 2006).

Conclusion

The overall conclusion of this essay is to indulge Maori participation in decision- making the process at different levels in order to reduce health disparities between Maori and non- Maori and to promote a universal healthcare system for everyone. Also, funds for whanau ora development has increased up to $80 million. This essay concludes that how Maori Health strategy and health strategies, programs and act is beneficial for Maori health and wellbeing.

However, despite all these strategies and policies, this essay explains that Maori health needs are not fully met, and still Maori are living in deprived areas with no access to health services. Even though, higher incidence of mortality rate, risk of cardiovascular disease and a higher rate of cancer is present among Maori than in non- Maori. As cardiovascular disease death rates were 2.3 times higher for Maori and cancer mortality rates were 77% higher. As well as, Lack of Maori health providers, lack of cultural education, and language barriers are becoming obstacles for the Maori population. Consequently, everything must be considered, while delivering equitable health services for everybody.

References

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Diagram of digestive system

Pharynx

Mouth

Oesophagus

Stomach

Liver

Pancreas

Gall bladder

Jejunum

Ileum

Duodenum

Large intestine

Small intestine

Rectum

Anus

Colon

Caecum

Appendix

Anal canal

Functions of the digestive system’s features

Mouth

The mouth is the start of the digestive system. The mouth is where food is chewed and broken down into very small pieces. The salvia in the mouth is mixed with the food to easily help digest the food. After the food is digested it is absorbed in the small intestine. The intense smell of foods causes the salivary glands in the mouth to produce salvia. This causes the mouth to water and increase salvia when tasting the food.

Pharynx

The pharynx is the throat, the function of the muscular walls helps as a pathway for the movement of food to the oesophagus from the mouth. The respiratory and digestive system consists of the pharynx. the pharynx is connected by two small tubes and the middle ears, this enables air pressure on the eardrum to be stable. Chewed food is rolled by the tongue into a ball-like (bolus) shape, this is pushed against the roof of the mouth to the pharynx where the process of swallowing occurs.

Oesophagus

The oesophagus is a muscular tube will a wall made of four layers. The mucous membrane helps secrete mucus, resulting in a smooth pathway for food. Submucosa hols the mucous membrane in place. This consists of a moderately thick layer containing smooth and long muscle fibres. This tube connects the throat to the stomach for the food/drink to travel down. When finished eating and drinking, the sphincters close from the oesophagus so that stomach acid and food doesn’t not flow back up the oesophagus, and during eating and drink the sphincters.

Stomach

The role of the stomach is to secrete enzymes and acids that digest food. The muscles of the stomach are contracted to mix food and enable digestion. The stomach is lined with muscle tissue called rugae. The secretion of gastric juices helps to coat the lining of the muscle tissue. Gastric juices are mixed with food in the stomach to enable digestion. The muscle valve, pyloric sphincter, opens to enable food to pass from the stomach to the small intestine. The food in the stomach is mixed with enzymes from the pancreas and bile, then from the gall bladder. These enzymes function is then to break down the food.

Small intestine –


Duodenum/Jejunum/Ileum

The role of the small intestine is to absorb nutrients and minerals from food in the stomach. The stomach consists of three regions; jejunum, duodenum and ileum. The duodenum is fixed to the dorsal abdominal wall, this contains layers of smooth muscle cells that is line with epithelium. This is the shortest part of the intestine and where absorption initiates.  The duodenum roles are to receive pancreatic juice and bile through the pancreatic duct to complete the first stage of digestion. The role of the jejunum is to also absorb nutrients from digesting food then allows this into the bloodstream. Villi (finger-like projections) is lined in the jejunum; this enables the jejunum to absorb the nutrients. The nutrients that are absorbed are amino acids, fatty acids and sugars. The function of the ileum is to also absorb nutrients, however, to absorb the ones that may have not got absorbed buy the duodenum and jejunum, important nutrients for example, bile salts and vitamin B12. The wall of the ileum folds up, these have tiny villi on its surface. This increases the surface area for absorption. The ileum absorbs the nutrients and water from food in the stomach so they can be used by the body. The ileum is supported on a mesentery, this is a membrane. The jejunum is also supported on a membrane.

Large intestine – rectum/colon/appendix/caecum/anal canal

The role of the large intestine is to absorb water from the remaining food that has been digested and transmit the useless waste material from the body. The caecum is the sac of the large intestine. The appendix contains a lot of lymphoid tissue. The appendix is a part of the gastrointestinal tract. The appendix acts a storage place for good bacteria, “restarting” the digestive system later after diarrheal illnesses. This allows the body to release stool and cleans out the intestines allowing the digestive system to be healthy. The appendix stores good bacteria in the intestines. It is located in the lower right side of the abdomen. The function of the colon is to reabsorb fluids and process waste products from the body. The role of the cecum is the absorption of fluids and salts that are remained after accomplishment of intestinal digestion. The role of the rectum is to stores faces only temporarily, until you are needed to go. The anal sphincter relaxes in the anal canal resulting it that the blood in the cushions drains away, enabling a smooth passage of the stool to travel through the anal canal.

Anus

The anus is the last region of the digestive tract. The anus detects rectal contents by the lining of the upper anus. This also gives away if the contents are solid, liquid or gas. As faeces are forced into the anal canal, a voluntary response is given from impulses to the brain as to decide to open the external anal sphincter. The stretchy wall from the anus enables the defaecation reflex. The anus ends at the last region of the colon, this is the larger intestine, and start at the bottom region of the rectum. The anus and rectum are separated from the anorectal line.

Pancreas

The pancreas is located in the abdomen and converts food into fuel for the body’s cells. The pancreas releases juices right from the bloodstream. It has both an endocrine and exocrine function as it releases juices into ducts. The exocrine function is to help digestion and the endocrine regulates blood sugar. Enzymes are secreted by the pancreas which is within the small intestine. It then continues to breaks down food. Beta cells in the islets of the pancreas secret insulin, which is a hormone, in response to the increased blood glucose level. This insulin helps muscle and liver, including many different cells, takes up more glucose, in so doing lowering blood glucose level. The glucose is transformed into glycogen in muscle and liver cells. Alpha cells secret glycogen, in doing so this decreases blood glucose level. This causes deposited glycogen in the liver to be broken down to glucose then released into the blood.

Liver

The role of the liver is to filter blood coming from the digestive tract. The liver secretes bile that after ends up back in the intestines. In addition to this, the lover purifies chemicals and metabolizes drugs. The liver if found in the abdomen, front of the stomach, and is a large gland.  The liver sores glycogen, this helps regulate blood glucose level and makes plasma proteins. Furthermore, this also metabolises alcohol, drugs and other toxins and stores fat-soluble vitamins. The glycogen breaks down excess amino acids to make urea for removal at the kidneys. Oxygenated blood enters the liver from the hepatic artery. Deoxygenated blood leaves the liver in the hepatic vein.

Gall bladder

The gall bladder is found under the liver on the abdomens right side. This is to store and concentrate bile (digestive enzyme) that is produced by the liver. The gall bladder is a region of the biliary tract. Bile helps to break down the fat and absorb them. When the liver produces bile, the gall bladder then stores this extra bile to break down and absorb fat. bile continues to travel to reach the small intestine. The gall bladder releases the bile by the bile duct, then into the duodenum at the sphincter at the Oddi, when the food enters the duodenum of the stomach.

Irritable bowel syndrome (IBS)

Irritable bowel syndrome is a chronic condition that affects the large intestine. However, it doesn’t cause any changes in the bowel tissue. This condition affects the digestive system, and cause symptoms such as abdominal pain, and either constipation and diarrhoea, bloating, and stomach cramps. The symptoms of this tend to come and go; couple of days to a couple of months at a time. IBS can be a lifelong problem however, there are treatments that can control the symptoms, as there is no cure for irritable bowel syndrome. The cause of this condition is related to food that passes through your system either too slowly or too quickly. Family history, stress and nerves in the gut also are factors that is linked causes. Twice as many women are affected by bowel syndrome then men (nhs.uk, 2019). As there is no cure, there are several ways to help the diet and lifestyle you are living to reduce and manage the symptoms. Vitamin D deficiency occurs in irritable bowel syndrome. This can ease and help the condition. To reduce the symptoms, increasing the level of vitamin can help. Irritable bowel syndrome is caused by the decreased levels of vitamin D in the body. Vitamin D is important for the bones, as this helps the body custom calcium from the diet as this is an important role nerve cell communication the function of the immune system.  An inflammatory response occurs in the gut when vitamin D levels are low.

Symptoms of irritable bowel syndrome

The symptoms of IBS are; constipation, diarrhoea, abdominal pain, and stanch cramps.  Vitamin D deficiency symptoms can be unclear and can lead to not knowing of what the condition is.

• Diarrhoea – this is one of the common symptoms of IBS. This is caused by abdominal pain and the is related with the consistency of stool. Suffers of IBS also endure constipation along with the diarrhoea.

• Constipation – this is also caused by abdominal pain. The pain is related with the consistency of bowel habit. Constipation can mean infrequent stools, difficult to empty during bowel movement and straining feeling when want to go. Bloating is also a symptom that causes constipation.

• Abdominal pain – this occurs in the lower abdomen and is a feeling that is caused in the gut. Abdominal pain is caused by excessive gut muscle contractions and this can also lead to stomach cramps in the lower abdomen.

Symptoms of vitamin D deficiency related to irritable bowel syndrome

• Depression – vitamin D deficiency can cause depression conflicting of irritable bowel syndrome. Suffers with depression have shown to have high prevalence of vitamin D deficiency. Vitamin D is safe in the body, and depression is very dangerous to the body. Physicla depression symptoms are feeling sick or muscle aches, and even flu. Depression link to IBS as when the feeling of pain becomes to much, suffers become fed up and feeling useless, this can cause depression.

• Hair loss – this is associated with stress and can be severe when resulting in a nutrient deficiency.  Low vitamin D levels are linked to IBS in in the way that the causing of abdominal pain, constipation affects sufferers’ lives and a cause stress leading to hair loss.

• Muscle pain – vitamin D deficiency is a cause of muscle pain. The receptor in vitamin D is current in nerve cells, this is named nociceptors, they sense pain. The abdominal pain that is caused by IBS, cause muscle pain as constipation and straining went trying to go can tear and damage muscle tissue.

Corrective for treatments of vitamin D deficiency

The treatment for vitamin D deficiency in irritable bowel syndrome is used to alleviate the symptoms; constipation, abdominal pain and diarrhoea. vitamin D supplements is used to manage the nutrient deficiency in IBS. These supplements should be taken with a meal that consist of fat. There are supplements that can be taken on a daily, weekly, or monthly basis and taken orally by the mouth. The treatment regimes are different for every type of person. For children, aged 1-18 should for at least six weeks, once a week accomplish the maintenance of vitamin D. adults who are vitamin D deficient should be treated once a week, for eight weeks, daily to maintain the vitamin D storage in the body. To treat deficiency, vitamin D can be administered orally.

Bibliography

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  Diagram Link. (2019).
  
  
  
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Calcium-channel blockers or calcium antagonist have several possible modes of action in hypertension. In general, these agents block the slow channel in the cell membrane and prevent calcium entry into the cell. This blocking action reduces the mechanical activity of vascular smooth muscle and leads to vasodilation. Another possible mode of action is that they block norepinephrine-mediated vasoconstriction. This may occur because alpha sympathetic vasoconstriction is produced by enhanced calcium influx into the cell. If calcium influx is decreased, then norepinephrine vasoconstriction is reduced. Another system regulated by intracellular calcium is the release of renin by the cells of the kidney. Because calcium-channel blockers inhibit renin release, the renin-angiotensin system may also be suppressed. Calcium-channel blockers prove to be useful in hypertensive patients who also have stable angina and spastic angina (Brunton, Chabner, & Knollman, 2011). The vasodilation properties of calcium-channel blockers lead to a reduction in after-load, and their regional smooth muscle relaxant properties are useful in relieving coronary spasms. Calcium-channel blockers are also useful in treating patients who cannot take beta-blocking agents (Katzung, Mastes, & Trevor, 2012). African-American patients may benefit more from CCBs as a first line of hypertensive treatment than others. Grapefruit products should be avoided as they interfere with normal operation of the medication. CCBs can also cause low blood glucose particularly those whose dosage is more than 60 mg daily. CCBs are mainly intended to be used for isolated systolic hypertension, and may be used in combination with other antihypertensive medications such as diuretics and ACE Inhibitors (Frank, 2008).

Verapamil hydrochloride

– (Calan, Isoptin) is given in doses of 240-640 mg daily to control essential hypertension. The oral dose is almost completely absorbed from the gastrointestinal tract, and there is a large first-pass hepatic effect. Side effects include constipation, headache, flushing, peripheral edema, and AV nodal effects such as first- and second-degree heart blocks. Verapamil has significant negative inotropic effects and should not be used in patients with congestive heart failure. Verapamil applies antihypertensive results by decreasing systemic vascular resistance usually without orthostatic decreases in blood pressure or response tachycardia. Verapamil reduces arterial pressure at rest and at a given level of exercise by reducing the total peripheral resistance or afterload against which the heart works. The dosage should be titrated for the individual. The usual daily dose of sustained release verapamil, Verelan, is 240 mg daily, however, the initial dosage of 120 mg may be necessary for patients who may have an increased reaction (e.g. Elderly or small people). If adequate control is not obtained with 120 mg, the dose may be titrated in the following manner: 180-240-360-480 mg daily (Chen, et al., 2010).

Nifedipine

– (Procardia) used for essential hypertension the dosage ranges between 10 and 20 mg given three times daily. Doses above 100 mg are not recommended (Chen, et al., 2010). The oral dose is rapidly and fully absorbed from the gastrointestinal tract, with the drug being metabolized in the liver, highly bound to plasma proteins with a half-life of approximately two hours. Nifedipine is more effective than verapamil in dilating peripheral blood vessels. Side effects include reflex tachycardias, stimulation of SA node, flushing, peripheral edema, and headache. CNS symptoms include tremors, nervousness, and mood changes (Wisloff, et al., 2012).

Nifedipine and the other dihydropyridine agents (Norvasc, Caduet, Lotrel, Sular, Calan, Verelan, etc.) are more selective as vasodilators and have less cardiac depressant effect then verapamil and Diltiazem. It is recommended that short acting oral dihydropyridine not be used for hypertension due to the increased risk of myocardial infraction. Oral Nifedipine has been used in emergency treatment of severe hypertension (Chen, et al., 2010). Norvasc is a dihydropyridine; Norvasc usual dosage is 5 to 10 mg daily. Small, fragile, or elderly patients or patients with hepatic insufficiency may be started on 2.5 mg daily and titrated for response (Wisloff, et al., 2012).

Diltiazem

– (Cardizem) dosage is between 30 and 90 mg three to four times daily. It is well absorbed by the gastrointestinal tract, with onset of action in less than 15 minutes, a peak effect in 30 minutes, and a half-life of approximately four hours. Vasodilation is limited almost exclusively to the coronary arteries. The most common side effects include AV block, dry mouth, headache, vertigo, rash, and edema (Chen, et al., 2010). Diltiazem SR is one of several preferred initial therapies for hypertensive patients with high risk of developing coronary artery disease including those with diabetes mellitus. It can be used as a monotherapy for initial management of uncomplicated hypertension with conventional tablets used three to four doses daily before meals and at bedtime. Again, elderly or smaller persons may require a lower dosage and titrate as needed for response (Frank, 2008).

The algorithm for hypertension management according to The National Institute for Health and Clinical Excellence is as follows: KEY: A= ACE Inhibitor or Angiotensin II (ARB); C= Calcium Channel blocker; D= thiazide-like diuretics

Step 1. Under age 55 years Over age 55 or Black person of African or

1. Caribbean family origin of any age

(C)

Step 2. ——- (<55yrs) ————————— (A+ C) ————- (>55 yrs.)—————————————

Step 3. ——— (<55 yrs.)———————- (A+C+D) ————– (>55yrs) ————————-Step 4. Resistant hypertension (A+C+D+ consider further diuretics OR Alpha blockers or Beta blocker) (The National Institute for Health and Clinical Excellence, 2011).

References

Brunton, L., Chabner, B., & Knollman, B. (2011).

Goodman & Gilman’s: The pharmacological basis of therapeutics

(12 ed.). McGraw-Hill.

Chen, N., Zhon, M., Yang, M., Guo, J., Zhu, C., Yang, J.,. .. He, L. (2010, August).

Calcium channel blockers versus other classes of drugs for hypertension

. doi:10.1002/1465/858.CD003654.pub4

Frank, J. (2008, May). Managing hypertension using combination therapy.

American Family Physician, 77

(9), 1279-1286. Retrieved from American Family Physician:

http://www.aafp.org/afp/2008/0501/p1279

Katzung, B., Mastes, S., & Trevor, A. (2012).

Basic & clinical pharmacology

(12 ed.). McGraw-Hill.

The National Institute for Health and Clinical Excellence. (2011, May 2011).

Quick reference guide

. Retrieved from NICE Clinical Guidelines:

http://www.nice.org.uk/nicemedia/live/13561/56015/56015.pdf

Wisloff, T., Selmer, R., Halvorsen, S., Fretheim, A., Novhein, O., & Kristiansen, I. (2012, April 4).

Choice of generic antihypertensive drugs for the primary prevention of cardiovascular disease–a cost-effectiveness analysis

. doi:10.1186/1471-2261-12-26