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 29 th , 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.

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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.

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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

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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)

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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

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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.

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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.

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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.

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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.

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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 co morbidities 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

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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

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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. The changes I want to make are… 2. Most important reasons… 3. My main goals are… 4. The steps I plan to take are… 5. Specific, concrete first steps… 6. Other people who could help… 7. I will know my plan is working if… 8. Some people & things that could interfere with my plan… 52

Program Results

Results Fall 2011

Weight

P=0.030

234 232 230 228 226 224 222 220 218 P=0.028

Pre-Program Post-Program Weight DBP decreased by 6.4 mmHg, Weight decreased by 8.7 lbs. SBP decreased by 3.9 mmHg (not significant)

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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

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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

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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 – Cardiac exam: auscultation in both supine and standing positions – – Assessment of femoral arteries Physical stigmata of Marfan’s syndrome – Brachial blood pressure

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Contraindications to Exercise

Absolute Contraindications – – – 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 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

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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.

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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 = 220 age in women and 205- ½ age in men.

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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

138 136 134 132 130 128 126 124 122 120 P < 0.001

Pre-Program Post-Program Systolic BP 83 82,5 82 81,5 81 80,5 80 79,5 79 78,5 78 77,5 Pre-Program P < 0.05

Post-Program SBP – decreased by 10.5 mmHg DBP – decreased by 3.3 mmHg Weight – decreased by 3.6 lbs Diastolic BP

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

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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.

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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, 663 668.

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?