HEALTHBest hypertension treatment: Doctor-patient partnershipNew recommendations to lower blood pressure give a nod of approval to potassium supplements but not herbal products. But the key continues to be counseling.By Susan J. Landers, amednews staff. Nov. 4, 2002. Washington -- The evidence continues to pile up: High blood pressure leads to heart attacks, strokes and heart and kidney failure. But how many patients try to lower their blood pressure by cutting down on salt, trimming meal portions or taking a vigorous walk most days of the week? Not nearly enough. Architects of a new set of recommendations hope to reverse this trend by arming physicians to better counsel patients with evidence-based information about what definitely works, and what doesn't. One in two adults older than 60 has hypertension today and about 90% of all adults older than middle age have a lifetime risk for elevated blood pressure unless they act to prevent it, said Edward Roccella, PhD, MPH, coordinator of the National High Blood Pressure Education Program, which generated the recommendations. Dr. Roccella is on a mission to spread the word about the changes that must be made in patients' diets and lifestyles to counter the high risk of heart attacks and strokes that accompany hypertension. "The good news is that there is now solid evidence that we can keep blood pressure from rising and we can prevent most of this hypertension," said Dr. Roccella. First issued in 1993, NHBPEP recommendations were updated and published in the Oct. 16 JAMA.
The recommendations include such tried-and-true dietary changes as cutting down on salt and alcohol. But it also includes some new suggestions, such as maintaining a diet rich in fruits, vegetables and low-fat dairy products, as well as those low in saturated and total fats; and supplying an adequate supply of potassium. Exercising at least 30 minutes a day on most days of the week is also promoted. But the recommendations cast doubt on the ability of calcium and fish oil supplements to lower blood pressure significantly and note that there is little evidence that herbal products can safely reduce hypertension. Herbal products may also interact adversely with medications, warns the NHBPEP. Ross Black, MD, a family physician in Cuyahoga Falls, Ohio, spends time during office visits urging his patients with high blood pressure to adopt a healthy routine that includes dietary change and more physical activity. But despite good intentions, most patients do not adhere to their new regimens for very long. Even patients who have had heart attacks and begin new programs with enthusiasm may stop after two or three years, said Dr. Black. Typical excuses include: "The holidays, a recent cruise or 'I was sick,' " said Dr. Black. But as often as his patients keep falling off the wagon, he keeps trying to get them back on.
There's a partnership at work, said Dr. Black. The physician points the way and talks through the whys and wherefores of exercise and diet change, but it's only the patient who can make it work. In trying to convince patients of the need to follow a regimen, Dr. Black walks them through their family histories. For example, he may explain to a patient: "Your mother had high blood pressure, you had high blood pressure when you were pregnant, there are people with strokes and heart attacks in your family. "You have the greatest likelihood of having a stroke or heart attack because of family history. I can't change your genes, but what we can do is try to reduce your risk by keeping your blood pressure and cholesterol under control." Counseling patients to change their eating and exercise habits is never accomplished in only one visit. "It would be in an ongoing, continuing basis," he said. Talking takes timeJiang He, MD, PhD, co-chair of the working group that developed the latest recommendations, would like to see physicians like Dr. Black adequately reimbursed for the time that goes into discussing the prevention of hypertension. "Most physicians really do not talk with patients about prevention or lifestyle modification because health insurance does not provide reimbursement for prevention services," Dr. He said. Physicians have been faulted in past studies for failing to adequately monitor their patients' blood pressure and work with their patients to lower it. But patients' failure to adhere to a program is also a major problem. "We could say doctors need to do more, but, boy, the public needs to do more," stressed Dr. Roccella. He would like to make the patients' tasks easier. Lifestyle changes don't have to be major ones to produce measurable results, he said. One study cited in the recommendations found that a weight loss program that yielded a loss of 7.7 pounds resulted in a noticeable drop in blood pressure. Those results also seemed to hold up over time, said Dr. Roccella. In a seven-year follow-up study, the incidence of hypertension was 18% in the weight loss group and 40.5% in the control group. And patients could be counseled that one way to lose weight would be to consume 500 fewer calories a day or burn 500 additional calories a day, said Dr. Roccella. He suggests asking patients: "Do you have to eat the whole piece of apple pie or the whole bag of French fries?" "What we are asking people to make are some simple changes," said Dr. Roccella. "We aren't asking for the moon." During the past 30 years the message has been honed and the case for changes in diet and exercise is more convincing now, he said. At one time even the sodium reduction goal was challenged, but no longer, he said. ADDITIONAL INFORMATION:Easing pressureThe National High Blood Pressure Education Program recommends physicians urge patients to adopt these lifestyle changes to prevent hypertension:
WeblinkArticle, "Primary Prevention of Hypertension: Clinical and Public Health Advisory From the National High Blood Pressure Education Program," JAMA, Oct. 16 (http://jama.ama-assn.org/issues/v288n15/rfull/jsc20296.html) Copyright 2002 American Medical Association. All rights reserved.
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