Prehypertension in the College
Student Population: A Review of the
Literature and Presentation of a
Novel Multidisciplinary Program for
the Treatment of Prehypertension
Kelly Roberts, MD
Thomas Hall, MSW
University of Central Florida
May 29th, 2012
HEART
Alcohol
What is Prehypertension?
• JNC -7 Guideline (2003)
• Normal blood pressure: SBP < 120 AND DBP <
80.
• Prehypertension: SBP 120-139 OR DBP 80-89.
• Stage 1 Hypertension: SBP 140-159 OR DBP
90-99.
• Stage 2 Hypertension: SBP >=160 OR DBP >=
100.
Incidence of Prehypertension
• As of 2006, Estimates from the National Health and Nutrition
Examination Survey (NHANES III), more than 83 million people
have prehypertension. This equates to approximately 37% of
the adult population.
• In the 18-39 age group, the prevalence of prehypertension is
32%
• Because obesity and prehypertension are closely linked, the
rates of prehypertension are rising rapidly along with the
obesity crisis.
Weight
Why Care About Prehypertension?
• Any blood pressure elevation above 115/75 leads to an
increase risk of heart disease. For every rise of 20 mmHg in
systolic blood pressure OR 10 mmHg in diastolic blood
pressure, the risk of Coronary Vascular Disease doubles.
• 37% of the population with prehypertension with progress to
hypertension over the next four (4) years. Prehypertension is
also associated with an almost two (2) fold higher risk of
diabetes.
• Compared with a normal blood pressure, prehypertension is
associated with a 27% increase in all causes of death and a
66% increase in cardiovascular deaths.
Why Care About Prehypertension?
Prehypertension During Young Adulthood and
Coronary Calcium Later in Life
• Of the 3,560 participants from the CARDIA study, 635 (18%)
developed prehypertension before age 35. This study
evaluated the effect of elevated BP, measured in mmHg-years.
• Exposure to prehypertension before age 35, especially SBP,
showed a graded association with coronary calcium later in
life.
• Damage from BP elevation seems to accumulate over time,
such that damage from past exposure may not be completely
reversible with treatment later in life.
DASH
High-Normal Blood Pressure is Associated
with Poor Cognitive Performance
• 2,200 Community dwelling individuals. Age
range 44-82
• The relationship between blood pressure and
cognitive performance was linear, even in the
normotensive and prehypertensive ranges.
• A subgroup analysis showed that the
association of SBP and cognition was driven by
the results in middle aged individuals.
Lowering Blood Pressure
What Can We Hope to Accomplish?
• In summary, studies have shown that blood
pressure can be lowered using the following
modalities:
– 1. Diet
– 2. Exercise
– 3. Weight Loss
– 4. Decreased Alcohol Intake
WALL
DASH Diet – What is It?
•
•
•
•
•
•
Rich in fruits and vegetables
Limited amounts of meats and sweets
Reduction of total and saturated fat
High in calcium (from low fat dairy)
Whole grains, poultry, fish, and nuts
Rich in potassium, magnesium (from fruits
and vegetables), protein, and fiber
Benefits of Dietary Changes
• DASH trial – reduced systolic blood pressure by 5.5
mmHg and diastolic BP by 3.0 mmHg
• DASH + Sodium (normotensive individuals) – reduced
systolic blood pressure by 7.1 mmHg
• A sustained weight loss of 9.7 pounds can reduce
systolic and diastolic BP by 5.0 and 7.0 mmHg
respectively
• Potassium supplementation – lowered systolic blood
pressure by 1.8 mmHg and diastolic BP by 1.0 mmHg
POWER
Benefits of Exercise
• All Cause Mortality
•
•
•
•
•
•
•
Coronary Artery Disease
Stroke
Colon Cancer
Breast Cancer
Prostate Cancer
Other Cancers
Type 2 Diabetes Mellitus
• Hypertension
• Prehypertension
• Osteoporosis
•
•
•
•
•
•
•
•
•
•
Dyslipidemia
Enhance Lipid Sensitivity
Obesity
Anxiety
Depression
Economic Benefits (of Health
Programs)
Increased Energy
Improved Concentration
Lower risk of Cognitive Decline and
Dementia
Improved immune function
Tobacco and Alcohol
• Studies show no direct effect on Blood Pressure for
tobacco cessation, however tobacco use is a known
cardiovascular risk factor.
• Decreased consumption of alcohol was associated
with a reduction in blood pressure that was dose
dependent
• Recommend moderate consumption of alcohol (two
(2) drinks for men and one (1) drink for women per
day)
What Do We Hope to Accomplish?
The Premier Trial
• 810 Adults; four (4) Centers; Prehypertension and Stage I
Hypertension, not taking medications.
• Randomized to 1) Advice Only, 2) Established Behavioral
Intervention, and 3) Established Plus DASH
• Outcome: Over a six (6) month period, the following
decreases in systolic blood pressure were found:
– Advice Only: 6.6 mmHg
– Established Group: 10.5 mmHg
– Established Plus DASH: 11.1 mmHg
WORDS
What Do We Hope to Accomplish?
The ENCORE Trial
• 144 overweight or obese, unmedicated outpatients
with high BP
• Interventions and Results:
– Usual diet controls – SBP/DBP decreased by 3.4/3.8
– DASH diet alone – SBP / DBP decreased by 11.2/7.5
– DASH diet plus weight management – SBP / DBP decreased
by 16.1/9.9
• The addition of exercise and weight loss to the DASH
diet resulted in greater improvements in vascular
and autonomic function, and reduced left ventricular
mass.
What Do We Hope to Accomplish?
Effects of Labeling Patients as
Prehypertensive
• Study determined that the label of Prehypertension
did not cause any adverse effects.
• Non-intensive study – brief message delivered by
research assistant.
• Proportions of people adopting the lifestyle
modifications at three (3) months was very high from
this simple intervention.
Weight
What Do We Hope to Accomplish?
Reducing Blood Pressure in the Potentially
Hypertensive Young Adult
• 69 Student with Blood Pressures between 130-149/80-89 at
the University of Delaware
• Intervention: Three (3) teaching sessions at 4,8, and 12 weeks
• Results: 18 Students completed the study (Nine (9) in control
group, nine (9) in experimental group)
• 66% of Experimental group maintained an average decrease
of 9 mm Hg in SBP from the initial screening period to the
final visit at 12 weeks.
• Sample size was too small for statistical significance.
Lifestyle Modification – Is it Enough?
• Add it Up! (decreases in systolic BP)
–
–
–
–
–
DASH diet: 8-14 mmHg
Weight loss: 5-20 mmHg / 10 kg lost
Reduced sodium intake: 2-8 mmHg
Physical activity: 4-9 mmHg
Moderation of alcohol intake: 2-4 mmHg
• Combination Studies
– Premier Study: 11.1 mmHg (DASH, exercise, weight loss)
– Encore Study: 16.1 mmHg (DASH, exercise, weight loss)
• BUT, longest study only 6 months long, except for TOPH trials,
which lasted 3 years.
POWER
When to Treat with Medications
• JNC-7 recommends a BP goal of <140/90 for all patients
EXCEPT:
– Diabetes Mellitus
– Chronic Kidney Disease
– These have a goal of <130/80
• Antihypertensives are used in secondary prevention of MI and
in primary prevention in patients with CHF and diabetes
mellitus. A meta-regression analysis reported in Lancet
indicates that the benefit of antihypertensive medications
used could be explained by blood pressure lowering effect
alone.
The Case for Antihypertensive Therapy
in Stage 2 Prehypertension
• American Heart Association suggested a BP goal of < 130 / 80 mm Hg for
all patients with a 10 year CHD risk of 10% or more.
• TROPHY trial: used ARB to prevent progression to hypertension.
• PHARAO trial: used ACE inhibitor in patients with high normal BP to
reduce progression to hypertension.
• Is it reasonable to start low dose antihypertensives for patients w/o comorbidities who do not respond to the prescription of lifestyle
modification?
• Study that is needed: Head to head comparison of drug vs. lifestyle
management, looking at intermediate outcomes
HEART
Prehypertension and Public Health
• The Challenge Facing Public Health
– 122 million Americans are overweight or obese
– Mean sodium intake is 4,100 mg per day of sodium in men and 2,750
in women, 75% from processed food
– Less than 20% of Americans engage in regular physical activity (39% of
UCF students according to ACHA-NCHA data)
– Fewer than 25% consume 5 or more servings of fruits and vegetables
daily (4.5% of UCF students according to ACHA-NCHA data)
• 1960’s antismoking public health services – steady decrease in
per capita cigarette consumption from 1965 to 2000
• Public health messaging on the dangers of saturated fat and
cholesterol was successful
• What is the role of health and wellness centers on college and
university campuses?
What is the Significance of These
Changes in Blood Pressure?
• Greatest long-term potential for preventing
hypertension.
• Pharyngitis – NNT to prevent tonsillar abscess is 27.
• NNT = 300,000 – 400,000 to prevent one death from
rheumatic fever.
• NNT – Achieving a 12 mm Hg drop in blood pressure
will prevent 1 cardiovascular event for every 11
patients treated.
Alcohol
SNAP
Success with
Nutrition and
Activity for
Prehypertension
SNAP Fall 2011 Program
• 15 minute intervention with UCF Health
Services Provider.
– Focus on importance of Prehypertension
– Brief history and physical exam, including two (2) blood
pressures
– Very brief description of the DASH diet with two (2) page
handout
– Laboratory testing, based on history and prior testing
– Referral to the recreation center for fitness assessment
– Referral to Wellness Center for majority of the intervention
– Follow up with provider in 8 weeks
Taking Charge of Your Lifestyle
Wellness Coaching
CHOICES is a 6-week program designed to help
UCF students lose weight, increase physical
activity, and improve their nutritional intake.
Weekly one-hour sessions with Healthy Lifestyle
Coaches focus on participant’s supporting one
another to maintain goals for desired lifestyle
changes.
What is Motivational Interviewing?
“Motivational Interviewing is a client-centered, yet
directive method of exploring and resolving a
student’s ambivalence about change by eliciting
the student’s own intrinsic motivation”
Paraphrase of a definition by William R. Miller
40
Motivational Interviewing Principles
1. Express Empathy
2. Develop Discrepancy
3. Roll With Resistance
4. Support Self-Efficacy
41
Express Empathy
1. Acceptance Facilitates Change
2. Skillful Reflective Listening is
Fundamental
3. Ambivalence is Normal
4. Engagement and rapport help to establish
a working alliance with the student
42
Develop Discrepancy
1. Awareness of Consequences is Important
2. Discrepancy between Current Behavior and
Goals are Important to the Client Motivation to
Change
3. Let the Client Present the Arguments for Change
(Self-Motivational Statements or “Change Talk”)
43
Roll with Resistance
1. Arguments are Counterproductive
2. Defending Breeds Defensiveness
3. Getting Resistance? Change Strategies
4. Labeling is Unnecessary and Harmful
44
Support Self-Efficacy
1. Belief in Possibility of Change is an Important
Motivator (Self-Fulfilling Prophecy)
2. The Client is Responsible for Choosing and
Carrying Out Personal Change (Autonomy)
3. There is Hope in the Range of Alternatives
Approaches Available (Optimism)
45
Motivational Interviewing Strategies
Goal: Eliciting Self-Motivational Statements
(Change Talk)
Method: MI OARS
•
Open-Ended Questions
•
Affirming the student
•
Reflective Listening
•
Summarizing
46
Eliciting ‘Change Talk’
Self-Motivational Statements (Change Talk):
1. Demonstrating Problem Recognition
2. Expressing Concern about the Problem
3. Showing an Intention to Change
4. Reflecting Optimism about Changing
47
Open-Ended Questions
Open-ended questions have several purposes:
1. To gather information from a client
2. To understand the client’s perspective in detail
3. To guide clients to pursue a specific issue or
subject matter related to high risk behaviors
4. To reduce a client’s confusion and increase clarity
of thought or feeling about an issue or topic
48
Reflective Listening Suspends…
1. Advice or Suggestions
2. Agreement or Disagreement
3. Teaching or Instructing
4. Warning about Consequences
49
Affirming the Client
Affirmations:
1. Reinforce self-motivational statements
2. Enhance the client’s self-esteem
3. Enhance the client’s self-efficacy
4. Strengthen the relationship
50
Summarizing:
A Collection of Reflections
1. Summarize periodically within the session
and add a grand summary at the end
2. Strategically repeat a client’s self-motivational
statements
3. Include reluctance/resistance in the summary
4. Reflect optimism for client self-change
51
Change Planning
The Change Plan Worksheet
1.
2.
3.
4.
5.
6.
7.
8.
The changes I want to make are…
Most important reasons…
My main goals are…
The steps I plan to take are…
Specific, concrete first steps…
Other people who could help…
I will know my plan is working if…
Some people & things that could interfere
with my plan…
52
Program Results
Results Fall 2011
Weight
234
P=0.030
P=0.028
232
230
228
Weight
226
224
222
220
218
Pre-Program
Post-Program
DBP decreased by 6.4 mmHg, Weight decreased by 8.7 lbs.
SBP decreased by 3.9 mmHg (not significant)
HEART
SNAP Program Spring 2012
•
•
•
•
•
•
•
•
Changed to Provider Based Intervention
30 Minute Appointment
More Extensive History and Physical Exam
Discussion on Diet, Weight Loss, Alcohol
Consumption, and Tobacco use
Handout on DASH Diet
Exercise Prescription
Referral to Health Center Dietitian
Referral for Fitness Assessment and to CHOICES
Program
Efficacy of Provider Short Term Counseling
• “Can Primary Care Doctors Prescribe Exercise to Improve
Fitness? The Step Test Exercise Prescription (STEP) Project,”
Am J Prev Med 2003; 24 (4), 316-322
– 11% increase in fitness based on a 12 minute counseling session.
• “Brief Opportunistic Smoking Cessation Interventions: A
systemic Review and Meta-analysis to Compare Advice to Quit
and Offer of Assistance,” Addiction 107, 1066-1073.
– 47% increase in abstinence rate for discussion medical harms
– Offering NRT doubled quit rates
• “Alcohol Screening and Brief Intervention in a College Student
Health Center: A Randomized Controlled Trial,” J. Stud.
Alcohol Drugs, Supple No. 16: 131-141, 2009.
– Significant reductions in alcohol consumption, high-risk drinking, and
alcohol-related harms
WALL
History and Physical
• The goal of the History and Physical: Reduce risks of physical
activity
• 1. Cardiovascular
– <35 years old: Hypertrophic cardiomyopathy, Marfan’s syndrome, myocarditis, and
anomalous coronary artery anatomy
– > 35 years old: 80% of sudden death in athletes due to CAD. Most predictive parameter
of CAD are description of chest pain, gender, age, and concurrent medical conditions
• 2. Musculoskeletal Injuries: most can be avoided with
appropriate conditioning and gradual increase in duration and
intensity
• Physical Exam: Basically a sports medicine physical
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–
–
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Cardiac exam: auscultation in both supine and standing positions
Assessment of femoral arteries
Physical stigmata of Marfan’s syndrome
Brachial blood pressure
Contraindications to Exercise
• Absolute Contraindications
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–
–
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Recent acute myocardial infarction
Unstable angina
Ventricular tachycardia and other dangerous
dysrhythmias
Dissecting aortic aneurysm
– Acute congestive heart failure
–
–
–
–
Severe Aortic stenosis
Active or suspected myocarditis or
pericarditis
Thrombophlebitis or intracardiac thrombi
Recent systemic or pulmonary embolus
– Acute infection
• Relative Contraindications
–
Untreated or uncontrolled severe
hypertension
– Moderate aortic stenosis
–
–
–
–
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Severe subaortic stenosis
Supraventricular dysrhythmias
Ventricular aneurysm
Frequent or complex ventricular ectopy
Cardiomyopathy
– Uncontrolled metabolic disease
or electrolyte abnormality
–
Chronic or recurrent infectious disease
–
Neuromuscular, musculoskeletal, or
rheumatoid diseases that are exacerbated by
exercise
Complicated Pregnancy
–
WORDS
When to Recommend an Exercise
Stress Test
When to Recommend an Exercise
Stress Test
• Four reasons why a patient needs a stress test
1. Diagnosed disease (cardiac, pulmonary, metabolic)
2. Symptoms of cardiovascular disease
3. More than one major risk factor (Family history, tobacco
use, hypertension, hyperlipidemia, or diabetes mellitus)
4. Men over 40 or women over 50
Key Point: Educate patient’s regarding specific warning
signs: angina, nausea, discomfort, dizziness, or fatigue.
Exercise Prescription
American College of Sports Medicine Position Stand
• Cardiovascular Exercise
– Moderate Intensity: 30 minutes per day; >= 5 days per
week OR
– Vigorous intensity exercise: >= 20 minutes / day; >= 3
days/week OR
– Combination of vigorous and moderate intensity exercise
to achieve a total of >= 500-1000 MET min / week
– Mode of activity – any activity which utilizes large muscle
groups in a continuous and rhythmic fashion
• Target Heart rate = (Max heart rate – resting heart rate) x
training intensity % + resting heart rate. Max heart rate = 220age in women and 205- ½ age in men.
POWER
Exercise Prescription
• Resistance Training: One set of 8-12 exercises
that condition the major muscle groups. 2-3
days per week
• Flexibility Training: static, ballastic, or
modified proprioceptive neuromuscular
fasciculation (PNF) techniques. At least 4 reps
per muscle group, 2-3 days per week (greater
benefit with daily training).
Results SNAP Spring 2012
Systolic BP
Diastolic BP
138
83
136
82.5
P < 0.001
134
P < 0.05
82
81.5
132
81
130
Systolic BP
80.5
128
80
126
79.5
Diastolic BP
79
124
78.5
122
78
120
77.5
Pre-Program
Post-Program
Pre-Program
SBP – decreased by 10.5 mmHg
DBP – decreased by 3.3 mmHg
Weight – decreased by 3.6 lbs
Post-Program
DASH
Challenges Faced and Lessons Learned
• Challenges
– Provider recruitment
– Need to repeat many blood pressures
– Availability of dietitian
• Lessons Learned
– Students are very hesitant to commit their time
–Your Words Have Power!
3. Components of Prehypertension
Plan
DASH Diet / Exercise
Weight Loss
Limit Alcohol
2. Prehypertension is Important
Thickened Heart Wall
1. Brief Provider Intervention
Your Words Have Power
Selected References
• Appel LJ, Champagne CM, Harsha DW, et. al, Effects of Comprehensive
Lifestyle Modification on Blood Pressure Control: Main Results of the
PREMIER Clinical Trial. JAMA 2003; 289 (16): 2083-2093.
• Blumenthal JA, Babyak MA, Hinderliter A, Effects of the DASH Diet Alone
and in Combination with Exercise and Weight Loss on Blood Pressure and
Cardiovascular Biomarkers in Men and Women with High Blood Pressure:
The ENCORE Study. Arch Intern Med, 170 (2), 126-135.
• Chobanian AV, Bakris GL, Black HR, et al, The Seventh Report of the Joint
National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure: The JNC 7 Report. JAMA May 21, 2003; 289 (19),
2560 – 2572.
• Drukteinis JS, Roman MJ, Fabsitz RR, et al, Cardiac and Systemic
Hemodynamic Characteristics of Hypertension and Perhypertension in
Adolescents and Young Adults: The Strong Heart Study. Circulation 2007,
115, 221-227.
Selected References
• Gauer RL, O’Connor FG, How to write an exercise prescription. The U.S.
Army Center for Health Promotion and Preventive Medicine, 2001.
• Griffin L, Kee JL, Waters L, Reducing Blood Pressure in the Potentially
Hypertensive Young Adult. Journal of American College Health, 1990, 38
(4), 193-194.
• Knecht S, Wersching H, Lohmann H, et al, High-Normal Blood Pressure is
Associated with Poor Cognitive Performance. Hypertension 2008, 51, 663668.
• Petrella RJ, Koval JJ, Cunningham DA, et al, Can Primary Care Doctors
Prescribe Exercise to Improve Fitness: The Step Test Exercise Prescription
(STEP) Project. Am J Prev Med 2003; 24 (4), 316-322.
• Pletcher MJ, Bibbins-Domingo K, Lewis CE, et al, Prehypertension during
Young Adulthood and Coronary Calcium Later in Life. Ann Intern Med
2008, 149, 91-99.
Selected References
• Svetkey LP, Management of Prehypertension. Hypertension 2005; 45,
1056-1061.
• Svetkey LP, Simons-Morton D, Vollmer WM, et al, Effects of Dietary
Patterns on Blood Pressure: Subgroup Analysis of the Dietary Approaches
to Stop Hypertension (DASH) Randomized Clinical Trial. Arch Intern Med,
159, 285-293.
• Urbina EM, Khoury PR, McCoy C, et al, Cardiac and Vascular Consequences
of Pre-Hypertension in Youth. The Journal of Clinical Hypertension, 13 (5),
332-342.
• Viera AJ, Lingley K, Esserman D, Effects of Labeling Patients as
Prehypertensive. J Am Board Fam Med 2010, 23, 571-583.
Questions?