Prehypertension in the College Student Population: A Review of the Literature and Presentation of a Novel Multidisciplinary Program for the Treatment of Prehypertension

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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

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HEART
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Alcohol
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What is Prehypertension?

• JNC -7 Guideline (2003)
• Normal blood pressure SBP lt 120 AND DBP lt 80.
• Prehypertension SBP 120-139 OR DBP 80-89.
• Stage 1 Hypertension SBP 140-159 OR DBP 90-99.
• Stage 2 Hypertension SBP gt160 OR DBP gt 100.

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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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Weight
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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.

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Why Care About Prehypertension?
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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.

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• DASH

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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 PressureWhat 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

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WALL
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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

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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

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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

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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.

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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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Weight
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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 lt140/90 for all
  patients EXCEPT
• Diabetes Mellitus
• Chronic Kidney Disease
• These have a goal of lt130/80
• 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
  lt 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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HEART
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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)
• 1960s 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?

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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.

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Alcohol
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SNAP

• Success with
• Nutrition and
• Activity for
• Prehypertension

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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

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Taking Charge of Your Lifestyle
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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 participants supporting one another to
  maintain goals for desired lifestyle changes.

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What is Motivational Interviewing?

• Motivational Interviewing is a client-centered,
  yet directive method of exploring and resolving a
  students ambivalence about change by eliciting
  the students own intrinsic motivation
• Paraphrase of a definition by William R. Miller

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Motivational Interviewing Principles

1. Express Empathy
2. Develop Discrepancy
3. Roll With Resistance
4. Support Self-Efficacy

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Express Empathy

• Acceptance Facilitates Change
• Skillful Reflective Listening is Fundamental
• Ambivalence is Normal
• Engagement and rapport help to establish a
  working alliance with the student

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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)

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Roll with Resistance

1. Arguments are Counterproductive
2. Defending Breeds Defensiveness
3. Getting Resistance? Change Strategies
4. Labeling is Unnecessary and Harmful

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Support Self-Efficacy

• Belief in Possibility of Change is an Important
  Motivator (Self-Fulfilling Prophecy)
• The Client is Responsible for Choosing and
  Carrying Out Personal Change (Autonomy)
• There is Hope in the Range of Alternatives
  Approaches Available (Optimism)

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Motivational Interviewing Strategies

• Goal Eliciting Self-Motivational Statements
  (Change Talk)
• Method MI OARS
• Open-Ended Questions
• Affirming the student
• Reflective Listening
• Summarizing

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Eliciting Change Talk

• Self-Motivational Statements (Change Talk)
• Demonstrating Problem Recognition
• Expressing Concern about the Problem
• Showing an Intention to Change
• Reflecting Optimism about Changing

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Open-Ended Questions

• Open-ended questions have several purposes
• To gather information from a client
• To understand the clients perspective in detail
• To guide clients to pursue a specific issue or
  subject matter related to high risk behaviors
• To reduce a clients confusion and increase
  clarity of thought or feeling about an issue or
  topic

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Reflective Listening Suspends

1. Advice or Suggestions
2. Agreement or Disagreement
3. Teaching or Instructing
4. Warning about Consequences

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Affirming the Client

• Affirmations
• Reinforce self-motivational statements
• Enhance the clients self-esteem
• Enhance the clients self-efficacy
• Strengthen the relationship

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Summarizing A Collection of Reflections

• Summarize periodically within the session
  and add a grand summary at the end
• Strategically repeat a clients self-motivational
  statements
• Include reluctance/resistance in the summary
• Reflect optimism for client self-change

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Change Planning

• The Change Plan Worksheet
• 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

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Program Results
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Results Fall 2011
P0.028
P0.030
DBP decreased by 6.4 mmHg, Weight decreased by
8.7 lbs. SBP decreased by 3.9 mmHg (not
significant)
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HEART
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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
• lt35 years old Hypertrophic cardiomyopathy,
  Marfans syndrome, myocarditis, and anomalous
  coronary artery anatomy
• gt 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 Marfans 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

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WORDS
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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
• Diagnosed disease (cardiac, pulmonary, metabolic)
• Symptoms of cardiovascular disease
• More than one major risk factor (Family history,
  tobacco use, hypertension, hyperlipidemia, or
  diabetes mellitus)
• Men over 40 or women over 50
• Key Point Educate patients regarding specific
  warning signs angina, nausea, discomfort,
  dizziness, or fatigue.

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Exercise PrescriptionAmerican College of Sports
Medicine Position Stand

• Cardiovascular Exercise
• Moderate Intensity 30 minutes per day gt 5 days
  per week OR
• Vigorous intensity exercise gt 20 minutes / day
  gt 3 days/week OR
• Combination of vigorous and moderate intensity
  exercise to achieve a total of gt 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).

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Results SNAP Spring 2012
P lt 0.05
P lt 0.001
SBP decreased by 10.5 mmHg DBP decreased by
3.3 mmHg Weight decreased by 3.6 lbs
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• DASH

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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!

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3. Components of Prehypertension Plan
DASH Diet / Exercise Weight Loss Limit
Alcohol
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Thickened Heart Wall
2. Prehypertension is Important
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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, OConnor 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.

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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.

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Questions?