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Kelly Roberts, MD Thomas Hall, MSW University of Central Florida May 29 th , 2012

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.

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Kelly Roberts, MD Thomas Hall, MSW University of Central Florida May 29 th , 2012

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  1. 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

  2. HEART

  3. Alcohol

  4. 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.

  5. 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.

  6. Weight

  7. 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.

  8. Why Care About Prehypertension?

  9. 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.

  10. DASH

  11. 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.

  12. 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

  13. WALL

  14. 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

  15. 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

  16. POWER

  17. 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

  18. 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)

  19. 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

  20. WORDS

  21. 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.

  22. 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.

  23. Weight

  24. 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.

  25. 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.

  26. POWER

  27. 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.

  28. 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

  29. HEART

  30. 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?

  31. 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.

  32. Alcohol

  33. SNAP Success with Nutrition and Activity for Prehypertension

  34. 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

  35. Taking Charge of Your Lifestyle

  36. 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.

  37. 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

  38. Motivational Interviewing Principles • Express Empathy • Develop Discrepancy • Roll With Resistance • Support Self-Efficacy

  39. 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

  40. Develop Discrepancy • Awareness of Consequences is Important • Discrepancy between Current Behavior and Goals are Important to the Client Motivation to Change • Let the Client Present the Arguments for Change(Self-Motivational Statements or “Change Talk”)

  41. Roll with Resistance • Arguments are Counterproductive • Defending Breeds Defensiveness • Getting Resistance? Change Strategies • Labeling is Unnecessary and Harmful

  42. 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)

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

  44. 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

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

  46. Reflective Listening Suspends… • Advice or Suggestions • Agreement or Disagreement • Teaching or Instructing • Warning about Consequences

  47. Affirming the Client Affirmations: • Reinforce self-motivational statements • Enhance the client’s self-esteem • Enhance the client’s self-efficacy • Strengthen the relationship

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