Reducing Risk Factors for Hypertension
Ellie Franges, MSN
Hypertension awareness, treatment and control are major health promotion initiatives spurred on by the Joint National Committee for Detection, Evaluation and Treatment of High Blood Pressure. Initiatives have improved over the last three decades but have slowed since the JNC V guidelines were published (JNC VI, 1997). Because treating hypertension almost always involves making lifestyle changes to control risk factors it is an excellent as topic for a teaching plan.
In a primary care practice or other health care provider the Nurse Practitioner can have a positive impact on prevention and management of hypertension through patient education and counseling. The nurse practitioner is often the first provider seen when a new patient comes to the provider. The Nurse Practitioner performs the initial evaluation and sets up a care plan that includes primary and secondary prevention strategies.
Cardiovascular disease accounts for a large portion of morbidity and mortality in developed countries. With the current focus of cardiovascular research it has become broadly accepted that recognition and treatment of high blood pressure and high cholesterol have a much greater impact on the development of disease than was previously recognized. (Murray, 2003) Epidemiologic data suggests that a five mmHg reduction in systolic BP on average, in Americans would reduce stroke mortality by 14%, heart disease mortality by 9% and overall mortality by 7% (Duluth, 2003).
Primary prevention of hypertension is an essential component to reduction of morbidity and mortality of cardiovascular disease. According to the JNCVI guidelines: Effective population wide strategies to prevent blood pressure rise with age and to reduce overall blood pressure even by a little would effect overall cardiovascular morbidity and mortality as much if not more than only treating those with established disease (JNC IV, 1997). This theme is repeated throughout the cardiovascular literature. Hypertension is one of the most important and reversible risk factors for cardiovascular disease. Prevention is key and it has become clear that there are very effective ways to accomplish this (Duluth, 2003).
Risk factors for developing hypertension include smoking, dyslipidemia, diabetes, age greater than 60 years, family history of cardiovascular disease that occurred early (under age 65 in women, under age 55 in men), and any signs of clinical cardiovascular disease. (JNC VI, 1997). An additional risk factor clearly identified in the literature is obesity. Two out of three adults in the United States are classified as overweight or obese (Manson, 2003). Weight reduction has been shown in many studies to reduce blood pressure. Recent studies also demonstrate a relationship between the weight loss, decrease in blood pressure and insulin sensitivity (Reaven, 2003).
Every geographical area has it’s own idiosyncrasies. For example the Lehigh Valley - Pennsylvania area, is rich with Pennsylvania Dutch culture and the untoward consequences of the dietary habits associated with it. Review of risk factors specific to this area indicate that 45% of the population are greater than age 55, 35 % of the population are more than 10% above ideal body weight, and less than 25 % of the adult population admits to participating in moderate physical activity at least three days per week.
Many practices see a large proportion of overweight patients with multiple risk factors for the development of hypertension. Patients were interviewed with identified risk factors or with already diagnosed hypertension in the early part of this clinical rotation I found a mix of awareness regarding their own risk factors, and potential strategies to reduce risk. Interestingly many patients that were already being treated with antihypertension agents and lipid lowering drugs responded to risk management questions, saying they were already being treated so it was of little importance to them to change their lifestyle. “ I’m taking the pills so I don’t have to change” is a common response.
According to the JNC VI guidelines a risk stratification approach should be used for treatment of hypertension, which includes blood pressure, presence of cardiac risk factors, and target organ damage. Those with the highest risk in this approach should receive the most aggressive treatment. In the primary prevention mode all patients should follow lifestyle modification recommendations ( Buttaro, 1999).
Essential components of lifestyle modification for management of hypertension include weight loss, increased aerobic activity, smoking cessation, reduction of dietary saturated fat and cholesterol and limiting daily alcohol intake (JNC VI, 1997).
The patient with risk factors for hypertension will be able to:
Identify personal risk factors that increase the likelihood of developing (or worsening) hypertension as evidenced by completion of a personal inventory survey and interview with healthcare provider.
Define the essential components of lifestyle modifications to reduce risk of developing (worsening) hypertension based on risk factors identified in the personal survey as evidenced by discussion with healthcare provider.
Develop a personal plan to achieve lifestyle modification goals based on risk factors identified in personal survey as evidenced by setting of achievable mutually agreed upon goals that will be assessed with each visit .
Essential to the success of any treatment plan is an understanding of the process you are hoping to interrupt, reasons why it is important to avoid or reduce the disease and the effectiveness of the suggested strategies. Essential to the success of your teaching is the patient’s readiness, willingness and ability to learn (Patient Teaching, 2002). To achieve the desired learning outcome you will most likely need to prioritize the topics around the patient’s needs and readiness.
Outline of the Teaching Plan
Overview of hypertension
Risk factors – modifiable vs non modifiable.
Disease progression – complications
Effective non-pharmacologic interventions
When pharmacologic intervention becomes necessary
Identification of personal risk factors
Assessment questions that focus on risk factor identification
Review of results with provider
Timeline for follow-up
Depending on your setting one of two approaches may be taken. Individual counseling and teaching is probably the most reasonable approach in most practice settings, however it is also very possible to hold a general seminar for patients in the practice to provide the basic information on hypertension and risk factors with the follow up in the office being the personal assessment of risk and plan. Funding for the latter approach can be sought from drug company representatives who can sponsor light refreshments, heart healthy of course, in a central location with easy access.
For individual counseling I would ask the patient to complete a questionnaire prior to the visit that answers questions regarding risk factors, similar to the way we ask patients to complete a health history form. A one on one review of their responses would form the basis of the teaching plan and evaluation. Because of time constraints in individual counseling and private practice you will most likely have to provide the teaching over a series of visits, so the initial visit would have to focus on prioritizing the list of controllable risk factors. In place of a questionnaire the assessment questions presented in the teaching plan can be asked as part of a health history interview during the visit.
Printed material to assist your teaching is available through American Heart Association. These patient information flyers are generally one page with simple explanations of the topic and room for the patient to write questions or personal information. It can be copied for individual patient use.
Overview of hypertension
To be successful in reducing hypertension patients should understand what high blood pressure is and the effects of untreated high blood pressure on overall health and well-being. It is also important to demonstrate the relationship that high blood pressure has with the development of other disease. Providing simple explanation through one-on-one discussion with examples is important. Define the values that constitute hypertension . Be specific that the diagnosis is not based on one reading Explain the patients own blood pressure recording and advise the patient of the need for follow-up according to the American Heart Associations recommendations for follow-up based on initial blood pressure measurements for adults. Patients with systolic pressure 130-139 and diastolic pressure 85-89 with other cardiovascular risk factors or target organ disease should be followed closely. If there is no known cardiovascular disease or target organ disease present the patient should begin with lifestyle modifications. Providing the patient with the American Heart Association handout- “What is high blood pressure?” ( AHA, 2000) or another equivalent handout.
At the initial visit provide information on specific risk factors. Using the American Heart Association handout “What are Risk factors for Heart Disease and Stroke?” (AHA, 2000), separate for the patient what risk factors can be changed versus what there is no control over. Age and genetics are not something that you can change but smoking, physical inactivity, high cholesterol, overweight are things you can control. Individual discussion should help them to focus on what is realistic to change. Be sure to include that lifestyle modification alone can be successful but that it may be necessary to couple lifestyle modification with drug therapy (JNC VI, 1997). Most often this is related to the combination of risk factors for each individual patient. Be clear that what works for one patient may not work for another because of the combination of identified risk factors. It is also important for patients to understand that blood pressure elevations are not inevitable consequences of aging. Through healthy lifestyle even with identified risk factors onset of the disease may be delayed. Research has indicated that even modest salt reduction and weight loss has enabled a large number of older adults to discontinue their antihypertensive medicine (Whelton, 1998). Studies have also demonstrated that a nutritional program of weight loss, sodium restriction and alcohol restriction achieved a 39 % success rate in reducing blood pressure without drugs ( Stamler, 1987).
As an integral part of the education visit should provide information through discussion on the results of untreated high blood pressure. Onset of cardiovascular disease, stroke, diabetes, hyperlipedemia are all a greater risk when coupled with hypertension. Give the patient handouts specific to their risk factors, to reinforce this information.
Non pharmacologic therapy or lifestyle modifications is the initial approach for many young patients with identified risk factors. It involves regular aerobic activity, diet, weight reduction, stress management, reduction of sodium intake, and avoidance of excessive alcohol. After the discussion about what hypertension is and it’s consequences when left untreated, review with the patient the results of their personal inventory. You can then discuss lifestyle modification topics based on prioritization of personal risk factors, and lifestyle assessment. It is important to set the patient up for success, i.e. if he is going to be traveling for the next month it might not be the best time to start a diet, but could be reasonable to increase physical activity.
Assessment question: Do you know your ideal body weight?
Help the patient determine their ideal body weight by checking body mass index (BMI) and waist circumference. At the visit the patients height and weight can be measured, as part of the assessment you can identify what the patient’s BMI is and show them via a chart where they are in the classifications. BMI is determined by multiplying weight in pounds by 703 the dividing by height in inches. There are programs available for downloading onto a PDA (personal digital assistant) that have the automatic calculator and the classification tables to make this easier and take up less time in the process. BMI alone does not identify risk because weight from muscle or from water retention may overestimate body fat. Normal BMI should be between 18.5 and 24.9.
Measure the patients waist circumference as part of the visit and document it in the record. Waist circumference is also a good measure of need for weight loss. Too much body fat in the abdomen increases risk of cardiovascular disease. For women a waist circumference of more than 35 inches and men greater than 40 inches is considered high. Weight loss of just ten pounds can lower blood pressure (Lowering Blood Pressure, 2003).
If the patient falls into the overweight range stress the importance of losing weight slowly. Encourage patient to lose no more than ½ to 2 pounds per week and a reasonable goal is 10 % of their current weight. One pound equals 3,500 calories so to lose one pound per week the patient will need to eat 500 calories less per day or burn 500 calories per day. Provide a handout the gives meal plan examples to aid the patient’s decision making. The best approach would be to eat less and be more physically active. Be careful to stress that serving sizes/amount is as important as what is eaten.
Assessment question: On a daily basis how much physical activity do you do?
Moderate level physical activity on a daily basis will not only help with weight loss but can reduce blood pressure and the risk of cardiovascular disease. Moderate level activity thirty minutes a day for most days of the week is recommended. To start the patient can even divide the thirty minutes into three ten-minute periods. Discuss with the patient simple things to try in the beginning ,use the stairs instead of the elevator, park you car at the far end of the parking lot in the morning. Give the patient the American Heart Association pamphlet “Just Get Moving. (AHA, 2000). At a follow up visit discuss other examples of moderate level physical activity including: walking briskly, mowing the lawn, golf- walking to course, swimming with moderate effort, cycling at moderate speed of 10 miles per hour, general cleaning, home repair such as painting (Lowering Blood Pressure ,2003). Together with the patient, develop a plan for them to incorporate moderate activity into their daily routine so they gradually increase the time spent in physical activity to 60 minutes per day, everyday (Control your Risks, 2003). Give them a log to keep to document the activity and ask them to bring it to subsequent visits.
Avoid Excessive Alcohol
Assessment question: What is your routine alcohol intake?
Many studies suggest that small amounts of alcohol intake can reduce risks of cardiovascular disease. Drinking too much alcohol can raise blood pressure. Some studies say that drinking more than 3-4 ounces per day of 80 proof alcohol will raise blood pressure (Control your risk, 2003). Alcohol consumption should be limited to no more than 1-2 drinks per day. Remind the patient that if he/she is dieting alcohol is high in calories. Define for the patient what constitutes a drink: 12 ounces of beer (150 calories), 5 ounces of wine (100 calories), 1 ½ ounces of 80 proof whiskey (100 calories ) ( Lowering Blood Pressure, 2003). Help the patient fit their alcohol intake into their diet plan.
Eat Heart Healthy
Assessment questions: What is your sodium intake? Do you know what foods you eat regularly are high in sodium?
Research shows that a healthy eating plan can not only help reduce weight but can lower the risk of developing high blood pressure and reduce already elevated pressure (Control your risk factors, 2003). A key to healthy eating is reducing sodium intake. In general we eat more sodium than we need on a daily basis. 2.4 grams of sodium is the most we should ingest in a day. That equals approximately one teaspoon of salt daily (Control your risk factors ,2003).
Because sodium is found naturally in many products an important part of patient education is teaching the patient and family how to read labels to make good choices regarding the foods they include in their diet. Look for labels that indicate: sodium free, low sodium, light sodium, reduced sodium. Teach comparing labels, a good choice to use is frozen versus canned vegetables. Have the patient identify which is the better choice.
To help the patient plan an overall better diet. Consider teaching the DASH diet. Dietary Approches to Stop Hypertension (DASH) is from a clinical study that looked at the effects of nutrients in food on blood pressure. This study found that blood pressure was reduced by focusing on low saturated fat, total fat and cholesterol and adding foods rich in fruits, vegetables and low fat dairy products (Control your risk factors, 2003).
Through discussion and example teach the patient that because the DASH diet is higher in fruits, vegetables and grain it is normal as you begin to have some bloating and diarrhea. A good way to avoid or minimize that would be to change gradually, i.e. add a vegetable or fruit serving at lunch or dinner. Spread out the servings throughout the day and add fruits as snacks. Treat meats as one part of the meal, try for two or more meatless meals per week (Lowering blood pressure, 2003).
Provide the patient with information on calories, food substitutions, and foods that are rich in certain nutrients. There are many good dietary handouts that can reinforce this information. As the nurse you can choose one that meets the needs of your population. Being successful with dietary changes means an understanding of what it is you eat each day, so you can make the needed changes. Initially ask the patient to keep a diary of what they eat each day. This can provide a starting point for simple but successful dietary changes and can aid in the evaluation of their success.
The caloric intake on the DASH plan can be easily altered so that the overall diet becomes more focused on healthy eating, but reduced caloric intake. An example that can be easily shared with patients can be found on http://www.nhlbi.nih.gov.
Other Risk factor Adjustments
Assessment questions: Are you a smoker? Have you ever been a smoker? How much do you/did you smoke? When did you quit?
Smoking is a key risk factor for the development of heart attack and stroke. Most studies suggest smoking cessation quickly lowers your risk factors within a year after stopping (Jekel, 2001). If the patient is a smoker explore alternatives for smoking cessation. Look for strategies that will work for the individual, ask the patient about personal preferences needs, related to strategies.
Assessment question: Are you under presently under stress?
Recognizing the stressors in your everyday activities is extremely important to minimizing the effects that stress has on your blood pressure management. Discuss with the patient the importance of relaxing for short periods throughout the day. Demonstrate relaxation techniques. Have the patient return demonstrate for you these techniques. Many patients will have to be taught to focus on relaxation techniques, and how to incorporate them into their daily routines. Have the patient identify for you their “daily routine”. Show them where they might “ fit in” some relaxation time. Again as you teach for the information to be useful you need to focus on what is realistic for the patient and what will make them most successful (Patient Teaching, 2002).
Explore with the patient what over the counter medications (OTC) they might routinely use. There are many preparations that will increase blood pressure or that will interfere with medications used to treat high blood pressure. Classes of drugs to be aware of include, steroids, NSAIDS, nasal decongestants, cold remedies, diet pills, tricyclic antidepressants, and MAO inhibitors. Make sure the patient understands the importance of care when adding OTC medications. An important point to make in addition is the sodium content of many OTC drugs (Herfindal, 2000). They should be encouraged to contact their primary care provider before starting any OTC preparations. Another strategy to reduce the potential adverse side effects for patients with hypertension risk is to provide a list of acceptable OTC remedies for common ailments.
Success to your teaching plan is measured by patient compliance to the prescribed treatment plan. Your teaching should be set up with goals that will enhance compliance. You need to make the assessment with the patient and family to focus on maximum compliance. Each visit should incorporate a review of the goals that were set and examples of how the patient is meeting or not meeting those goals. When you are following up during your visit to assess the success, if the patient has not followed the plan ask for the patient’s help to identify what is preventing him from being successful and revise the plan based on revised goals (Solomon, 2000). If the patient has even had small successes it is important to congratulate them and focus on those positives as you reformulate goals.
Provide the patient with resources to help support his plan. Remember that there are many references out there in the internet. Some are not so accurate, that may have just the opposite effect you and the patient are trying to achieve. By providing the patient with a take home list of resources you can be sure the information is the right information for the patient.
Websites for the Patient
http://www.nhlbi.nih.gov - provides many pamphlets for consumers on blood pressure management.
http://www.kidney.org - provides basic information on blood pressure management and end organ disease.
http://www.stroke.org - provides basic hypertension information and how untreated HTN leads to other diseases
http://www.4women.org - provides hypertension related information – female specific.
After you begin your teaching plan it is important for compliance and success to evaluate where you are. This allows you and the patient to reset goals and stay on target. It will ensure greater success (Patient Teaching, 2001). Evaluation of lifestyle changes should be part of each visit to help the patient stay on track. Follow-up visits are planned based on patient needs. For example if you have a patient with elevated blood pressure and you are using lifestyle modification as an initial treatment plan you may want an every two week follow-up. For many patients a more realistic follow up is monthly. Evaluation and revision of the teaching plan is part of every visit.
American Heart Association (2000), Selected Patient Education References, Dallas Texas: http://www.americanheart.org
Buttaro, T. M., Trybulski, J., Bailey, P. P., & Sandberg-Cook, J., Primary Care A Collaborative Practice. (1999) St Louis Missouri: Mosby.
Duluth, J. (2003). Prevention of HTN necessary and feasible with lifestyle modifications. Geriatrics, 58(1), 20-23.
Facts about lowering blood pressure (2003) [Data file]. National Heart Lung and Blood Institute, National Institutes of health. Available from http://www.nhlbi.nih.gov.
Herfindal, E. T., & Gourley, D. R.. Textbook of Therapeutics Drug and disease Management (7th ed.)(2000) Philadelphia, Pa: Lippincott Williams and Wilkins.
Manson, J. E., & Bassuk, S. S..(2003) Obesity in the United States: A fresh look at it's high toll. The Journal of the American Medical Association, 289(2), 229-233.
Murray, C. J., Lauer, J. A., Hutubessy, R. C., & Niessen, L. (2003). Effectiveness and Costs of interventions to lower systolic blood pressure and cholesterol: A global and regional analysis on reduction of cardiovascular disease risk. The Lancet, 361(9359), 717-731.
Patient Teaching Reference Manual (2002). Springhouse, Pa: Springhouse Corp.
Reaven, G. M..(2003). Importance of identifying the overweight patient who will benefit the most by losing weight. Annuals of Internal Medicine, 138(5), 420-427.
Solomon, J. R. M. (2000). Promoting Compliance Tips for the Healthcare Professional. In Hypertension Disease Management Guide (pp. 501-504). Montvale N.J.: Medical Economics Company.
The Sixth Report of the Joint National Committee on Prevention, Detection , evaluation and treatment of High Blood Pressure (JNC VI) (1997). Retrieved February 23, 2003, from National Heart Lung and Blood Institute National Institute of Health: http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm