CLINICAL It is possible to prevent the development of hypertension and to lower blood pressure levels by simply adopting a healthy lifestyle. Implementing these changes can also reduce the development of other cardiovascular diseases. Health care workers can only assess and manage hypertension adequately if the patient is educated and convinced that lifestyle changes are essential and the most cost-effective method of obviating cardiovascular disease.

An approach to preventing and treating HYPERTENSION through LIFESTYLE MODIFICATION Only blood pressure levels below 120/80 mmHg are considered optimal 1 and, even at these levels, patients are at risk for developing cardiovascular disease. The other important risk factors associated with developing cardiovascular disease are type two diabetes, smoking, abnormal lipid levels, a family history of early cardiovascular disease and abdominal obesity. This implies that one must do more than treat or optimise blood pressure in order to lower cardiovascular risk. Furthermore, the relationship between blood pressure and the risk of cardiovascular events is continuous, consistent and independent of other risk factors. This means that, even if the other risk factors are absent or normal, a patient will have an increased risk of suffering from a heart attack, heart failure, stroke and kidney disease as blood pressure levels are rising. In fact, for every 20 mmHg increase in systolic or 10 mmHg increase in diastolic blood pressure, there is a doubling of mortality from both ischaemic heart disease and stroke. 2 This direct relationship between raised blood pressure levels and the risk to die from cardiovascular disease can, fortunately, also be reversed by lowering blood pressure levels. It has been estimated that a 5 mmHg reduction in systolic blood pressure, for instance, will result in a 14% overall reduction in mortality due to stroke, a 9% reduction in coronary heart disease and a 7% decrease in all-cause mortality. 3,4

Preventing primary/essential hypertension

Dr Douw Greeff, MBChB, MPharmMed Medical Writer, Medpharm Publications (Pty) Ltd

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In essential or primary hypertension, there is not a specific identifiable cause or disease associated with the raised blood pressure levels, like drug-induced hypertension, pheochromocytoma, chronic kidney disease etc. These so-called, identifiable causes are usually prevalent in specific patient populations and will be discussed in a

subsequent article. This section deals with factors that will contribute to the development of essential hypertension in the absence of specific conditions or diseases. Increasing age is an unmodifiable risk factor for developing hypertension. More than 50% of people aged 60-69 years and approximately three-quarters of those aged 70 years or older will be hypertensive. The lifetime risk for developing hypertension is therefore of significant importance. In the Framingham Heart Study 5 , investigators reported that the lifetime risk of hypertension is approximately 90% for those patients, male and female, who are normotensive at age 55 or 65 years of age and who have survived to age 80 to 85 years of age. Another study 6 found that a group of 65 year old patients with a blood pressure of 120129/80-84 mmHg had a 26% chance of developing hypertension in the next four years, and a 50% chance if they had blood pressure readings of 130-139/85-89 mmHg. Everyone is, therefore, at risk and it is impossible to predict who will not develop hypertension with increasing age. However, there are a number of important causative factors for essential hypertension. 3,7 These include being overweight, increased daily sodium, fat and alcohol intake and the lack of physical activity. Eating too little fruit and vegetables or wholegrain foods has also been implicated. Most of these are modifiable lifestyle factors and are also directly related to the other risk factors associated with the development of cardiovascular disease. By addressing these one will reduce the risk to develop hypertension as well as other cardiovascular diseases.

SA Pharmaceutical Journal – May 2006

CLINICAL Table 1 summarises these modifiable factors. The effects are not additive, but this table can be instrumental in educating and motivating patients that lifestyle changes can, in fact, make a significant difference to the development of any cardiovascular disease. Smoking increases the risk for cardiovascular diseases and all patients should be encouraged to quit smoking. It is furthermore important that patients do not smoke, eat or consume caffeine 30 minutes before blood pressure is taken, as these practices may lead to temporary raised blood pressure levels.

Changing lifestyle Motivating patients to implement lifestyle changes is probably one of the most difficult aspects of managing hypertension. It is relatively easy to measure blood pressure, do screening investigations for risk factors or secondary causes, identify target organ damage and prescribe drugs according to the latest evidence and national guidelines. To change behaviour is difficult. Even a simple risk reduction model like that of HIV/AIDS, where people know they can obviate a deadly, incurable disease simply by abstinence, being faithful to one sexual partner and practising safe sex, is ignored by millions. Even greater are the challenges for hypertension. Patients are often asymptomatic and are expected to change the way they eat three times a day, to lose weight, exercise and stop smoking for no immediate tangible benefits. Building a trusting relationship between the healthcare worker and the patient is one of the most important aspects when motivating patients. Patients are more likely to comply with suggested lifestyle interventions and medication if they simply like the healthcare worker and understand and trust him or her. Trust is sometimes hard to earn but very few patients will object if the clinician is friendly, caring, interested, empathetic, honest and knowledgeable. Apologising for long waiting periods, thanking patients for attending the clinic, complimenting patients, praising them for compliance,

SA Pharmaceutical Journal – May 2006

Table 1: Blood pressure lowering effects of lifestyle interventions1 Modifiable lifestyle factors

Recommended change

1. Weight reduction Normal BMI: 18.5-24.9 kg/m2

2. Adopt the DASH* a) Five servings of fruit/vegetable per day. eating plan (This will reduce the risk for stroke by 26%.) b) High intake of highfibre wholegrain foods. c) Fish rather than red meat. d) Reduce daily fat intake to < 30% of total calories consumed. e) Consume low-fat dairy products. f) Maximum fat intake: Normal weight: Female: less than70 g/day Male: 95 g/day Overweight: Female: 50 g/day Male: 70 g/day

Systolic blood pressure lowering effect 5-20 mmHg/10kg weight reduction8,9 8-14 mmHg10, 11

2-8 mmHg10-12

3. Reduce dietary salt intake

Reduce salt intake to < 2400 mg sodium per day or < 6000 NaCl per day.

4. Limit (daily) alcohol intake

Males: 2 standard drinks per day (< 20 g ethanol/day) • < 50ml spirits/day OR • < 250 ml wine /day OR • < 680ml beer/day OR • < 120 ml sherry /day OR • < 50ml liqueur/day Females: 1 standard drink per day • < 25ml spirits/day OR • < 125 ml wine /day OR • < 340ml beer/day OR • < 60 ml sherry /day OR • < 25 ml liqueur/day13

2-4 mmHg

5. Physical activity

Regular aerobic exercises (brisk walking) for 30 minutes per day, or at least 150 minutes per week.

4-9 mmHg14,15

* Obarzanek E, Proschan AM, Voller WM, et al. Individual blood pressure responses to change in salt intake; results from the DASH-Sodium trial. Hypertension. 2003;42:459-467.

and speaking a couple of words and phrases in the patient’s mother tongue are very basic, but powerful tools in building a good relationship. Interpreters are often used in public health care consultations and play an enormous role in translating healthcare messages into a patient’s cultural context. Adherence to lifestyle interventions by the healthcare workers themselves is probably the best starting point when attempting to motivate and convince patients. Self-disclosure is very effective in motivational interviewing and will add credibility to what healthcare workers advocate.

Clinical inertia is described in the JNC 7-report 1 as: “Failure to titrate or combine medications and to reinforce lifestyle modifications despite knowing that the patient is not at goal blood pressure.” This may be due to a lack of familiarity with clinical guidelines, not being able to apply guidelines to a patient’s situation, or may even be due to work overload and a symptom of “burn-out”. The latest local hypertension guidelines 16 combine those of the South African Hypertension Society and the Department of Health and every healthcare worker should obtain a copy. This document can be downloaded from www.hypertension.org.za.

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CLINICAL

Encourage customers to read food labels – check the sodium and fat content

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SA Pharmaceutical Journal – May 2006

CLINICAL

Box 1: Fighting clinical inertia (Adapted from reference 1 table 26, 27, 28, 29, 30)

General approach to the patient • Build a trusting relationship (friendliness, caring, knowledgeable) • Listen to patients and ask questions about their current lifestyle and family history • Praise good practices already implemented (non-smoking, normal weight, exercise) • Anticipate non-adherence in certain patient groups • Identify socio-economic factors that will hamper adherence • Ensure that the technique of blood pressure measuring is correct, that equipment is in good calibrated order and that the patient has not eaten, smoked or consumed caffeine 30 minutes prior to taking the blood pressure • Document the most probable reason for non-adherence, not reaching the goal or sudden loss of control • Consider drug-related side-effects or compliance issues for not reaching the goal blood pressure (long duration of therapy, complicated regimens, expensive medication, side-effects) • Consider other causes for not reaching the goal blood pressure: resistant hypertension • Ask patients what they use for pain relief • Be willing to suggest to clinicians change of unsuccessful regimens Patient education and other patient related factors • Assess the patient’s understanding and acceptance of the diagnosis of hypertension • Discuss and communicate blood pressure goals clearly and assess the patient’s understanding of the goals • Discuss the interventions and assess the patient’s understanding of the interventions and regimens needed to reach the goal • Include the patient in the decision-making process • Simplify the regimen • Incorporate treatment into a patient’s daily lifestyle • Agree with the patient on realistic, short-term objectives • Encourage discussion of diet and physical activity • Encourage gradual weight reduction • Encourage discussion of adverse drug effects and concerns • Encourage self-monitoring with validated devices • Minimise cost • Indicate that lifestyle interventions will be the discussion of every visit • Recognise events that may influence the patient’s general mood (death in the family, unemployment, recent trauma etc), depression and other psychiatric illnesses, anxiety and panic attacks and manage or refer appropriately • Discuss the patient’s concerns and clarify misunderstandings and myths • Tell the patient the blood pressure readings and encourage patient-held records • Ask patients to rate the likelihood of them staying on treatment (1-10) • Involve family members in the treatment plan and encourage family members to accompany the patient to the healthcare facility Care delivery system • Accessible and patient-friendly healthcare facility (check transport routes, comfortable waiting areas, etc) • Consistency in the level of care: knowledgeable and motivated pharmacist • Motivated, trained and friendly clinic staff • Available interpreter if necessary • Health talks and hand-outs in pharmacies • Keep appropriate records • have contact details for referral of patients to other health professionals (social workers, community nurse, dieticians, etc) • Involve community leaders or church leaders to assist and motivate patients to comply Pharmacy clinics using an appointment system • Patient-orientated appointment system: Use appointment reminders Schedule the next appointment before the patient leaves Follow up patients who have missed appointments Shorten waiting times by instituting smaller and more manageable hypertension clinics and do not overbook clinic days Make sure patients know when the clinic is closed Accommodate patients who attend the clinic on the “wrong” day Accept or book blank spaces for patients who attend without an appointment

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CLINICAL

Benefits of restricting daily alcohol consumption • • •

Blood pressure reduction of 2-4 mmHg Reduced risk for heart attacks, heart failure and stroke Reduced daily calorie intake – weight reduction, or maintenance of normal weight, lowers the risk of developing type 2 diabetes and high cholesterol

MALES

FEMALES

(≤ 2 standard drinks/day) (≤ 20 g ethanol/day)

(≤1 standard drink/day) (≤10 g ethanol/day)

WINE

125 ml

125 ml

125 ml

OR

BEER

340 ml

340 ml

OR

340 ml

SPIRITS

25 ml

25 ml

OR

25 ml

SHERRY 60 ml

60 ml

60 ml

OR

LIQUEUR 25 ml

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25 ml

25 ml

SA Pharmaceutical Journal – May 2006

CLINICAL Other actions that can be taken to fight clinical inertia include general guidelines on approaching the patient and educational factors as well as institutional factors and the way clinics are operated and organised. These are summarised and adapted from the JNC 7 Report in Box 1. Patients’ natural response to implement behavioural change and characteristics Implementing behavioural change is more successful if a patient progresses through the five “natural” stages of behavioural change. The following five stages have been identified: precontemplation, contemplation, preparation, action and maintenance. It may help to identify in which phase the patient is to decide how much counselling may be needed to further encourage the patient to progress to the maintenance phase, or to encourage him or her to continue with the maintenance phase. A patient will need constant reinforcement and encouragement from the clinician, nursing staff, pharmacist, family members and community. Patient handouts, reminders to visit the clinic, letters to the family, SMS-messages to cell phones or e-mails to patients and regular health talks can all be utilised to support the patient. Simple questions like: “Have you considered giving up smoking yet?”, “You look good, let’s see how much weight you have lost”, “Your blood pressure is well controlled, have you been taking your medication regularly?”, “Are you managing to restrict your salt intake?”, “Is your wife/ family supporting you in restricting salt intake, eating a low fat diet, limiting alcohol intake?”, “How much walking do you do in a week?” may all give indications of whether the patient is engaging in making lifestyle modifications. An analysis 17 of 727 hypertensive patients’ characteristics categorised this study population into four groups. It is interesting what one can learn from patients’ behaviour and attitudes towards lifestyle changes: • First group (39%): Health orientated, informed about hypertension, took medication. • Second group (23%): Male, young,

SA Pharmaceutical Journal – May 2006

•

•

knew less about hypertension, were least afraid of consequences of hypertension or failure to take medication, were most likely to consume alcohol, abuse tobacco, stop medication without informing their doctor. Third group (22%): Highest BMIs, did not practice health-promoting lifestyle except for alcohol consumption and tobacco abuse, forgot to take their medication, had lower BP control rates. Fourth group (16%): Rely on medication rather on lifestyle to control their BP.

Conclusion Making lifestyle changes is really hard for some patients. These practices are not even expensive, in fact, most of them are basically free and may also save money (smoking cessation, healthy food, reduce or delay the need for medication) and will afford the patient a healthier, longer and probably higher quality of life. Healthcare workers should spend more time with the patient, understand their difficulties through interviewing and counselling and adopt an attitude of concern. Selfadherence and self-disclosure may be powerful tools in convincing patients. Positive feedback on lifestyle modifications and compliance with medication will hopefully move every patient through the different stages of behavioural change until maintenance becomes part of their every day life.


lifetime risk for developing hypertension in middleaged women and men: The Framingham Heart Study. JAMA 2002;287:1003-1010. F 6. Vasan RS, Larson MG, Leip EP, Kannel WB, Levy D. Assessment of frequency of progression to hypertension in nonhypertensive participants in the Framingham Heart Study: A cohort study. Lancet. 2001;358:1682-1686. F 7. Stamler J, Stamler R, Neaton JD, Wentworth D, Daviglus ML, Garside D et al. Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: findings for 5 large cohorts of young adult and middle-aged men and women. JAMA. 1999;282:2012-2018. F 8. The Trials of Hypertension Prevention Collaborative Research Group. Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure. The Trials of Hypertension Prevention, phase II. Arch Intern Med. 1997;157:657-667 RA 9. He J, Whelton PK, Appel LJ, Charleston J, Klag MJ. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension. 2000;35:544-549. F 10.Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med. 2001;344:3-10. RA 11.Vollmer WM, Sacks FM, Ard J, Appel LJ, Bray GA, Simons-Morton DG, et al. Effects of diet and sodium intake on blood pressure: subgroup analysis of the DASH-sodium trial. Ann Intern Med. 2001;135:1019-1028. RA 12.Chobanian AV, Hill M. National Heart, Lung and Blood Institute Workshop on Sodium and Blood Pressure: a critical review of current scientific evidence. Hypertension. 2000;35-858-863. PR 13.Xin X, He J, Frontini MG, Ogden LG, Motsamai OL, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension. 2001;38:1112117. M 14.Kelley GA, Kelley KS. Progressive resistance exercise and resting blood pressure: a metaanalysis of randomized controlled trials. Hypertension. 2000;35:838-843. M 15.Whelton SP, Chin A, Xin X, He J. Effects of aerobic exercise on blood pressure: a metaanalysis of randomized, controlled trials. Ann Intern Med. 2002;136:493-503. M 16.Seedat YK, Croasdale MA, Milne FJ et al. South African Hypertension Guideline 2006. S Afr Med J 2006;96(4)337-362. 17.Weir Mr, Maibach EW, Bakris GL, Black HR, Chawla P, Messerli FH, et al. Implications of a healthy lifestyle and medication analysis for improving hypertension control. Arch Intern Med. 2000;160:481-490.

ACKNOWLEDGEMENT Full acknowledgement is given to the JNC-7 Report1. This article is merely an attempt to summarise aspects of lifestyle modification, discussed in this comprehensive guideline, to South African primary healthcare workers and does not replace the original text. REFERENCES 1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, I330JL et al. Seventh Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension 2003; 42: 1206-1252. 2. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. Prospective Studies Collaboration. Lancet. 2002:360:1903-1913. M 3. Whelton PK, He J, Appel LJ, Cutler JA, Havas S, Kotchen TA, et al. Primary prevention of hypertension: Clinical and public health advisory from The National High Blood Pressure Education Program. JAMA. 2002;288: 1882-1888. 4. Stamler R. Implications of the INTERSALT study. Hypertension. 1991:17:116-120 5. Vasan RS, Beiser A, Seshadri S , Larson MG. Kannel WB, D’Agostino RB, et al. Residual

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