AT THE INTERNATIONAL STROKE CONFERENCE
HOUSTON (FRONTLINE MEDICAL NEWS) – A personalized lifestyle coaching program focused on healthy eating increased blood pressure control by 7%, compared with usual care, among black patients with persistent hypertension.
A year after the program was instituted, the rate of blood pressure control was 69% in the intervention group, compared with 62% in the group that had the usual care offered to hypertensive patients, Mai Nguyen-Huynh, MD , said at the International Stroke Conference sponsored by the American Heart Association.
But exactly how the lifestyle intervention achieved its goal is still a bit of a mystery, said Dr. Nguyen-Huynh. The program focused on teaching patients and their families to make better dietary choices, keeping food selection and preparation in line with the American Heart Association’s Dietary Approaches to Stop Hypertension (DASH) eating plan. The counseling offered a special focus on reducing sodium, but during discussions about the program, patients denied consciously reducing salt intake. And a voluntary 24-hour urine sodium measure didn’t show any changes, supporting their claim.
Still, the intervention worked, said Dr. Nguyen-Huynh, a vascular neurologist with the Kaiser Permanente Northern California Division of Research. More analyses will follow to try to tease out just how.
Kaiser Permanente of Northern California was already in a fairly good place with blood pressure control in 2012, when researchers first started considering the project, she said. That was directly related to a system-wide intensification of hypertension identification and treatment, implemented in the early 2000s. The company started a hypertension registry, added free blood pressure checks for all members, and promoted single-pill combination therapy. For patients with persistent hypertension, the company added free hypertension consultations with pharmacists and primary care providers.
By 2012, 85% of its enrollees had blood pressure control, classified as below 140/90 mm Hg. But for at least a decade, black participants had been lagging behind whites in that regard. And despite these intensified, group-wide efforts to target hypertension, a 5% gap in hypertension control among blacks paralleled rates among whites (80%-85% vs. 85%-90% over 10 years).
“Even with equal utilization and access to care, we continued to see this clear disparity in blacks vs. whites,” Dr. Nguyen-Huynh said.
The “Shake, Rattle, and Roll” blood pressure control trial was an effort to identify a treatment paradigm that could reduce this disparity by 4% within 1 year. The program moniker describes its three goals:
• “Shake” the salt habit.
• “Rattle” the intensity of the existing blood pressure control protocol.
• “Roll” out the results and incorporate into clinical practice.
The study was organized into three arms. Usual care was Kaiser’s typical intensified hypertension management. Patients filled out health and diet questionnaires and could voluntarily undergo a 24-hour urine sodium test.
The enhanced monitoring arm consisted of usual care, plus an in-person session with a nurse to discuss resources and possible barriers to treatment; regular blood pressure checks; intensification of pharmacotherapy, focusing on thiazides; and the addition of spironolactone for patients who had persistent hypertension despite being on three or more medications.
The lifestyle intervention arm consisted of usual care plus personalized coaching, both on the phone and in person. Participants could have up to 16 phone sessions with a specially trained counselor, with the option of bimonthly in-person group sessions.
These were accompanied by a workbook that emphasized healthy eating, from meal planning to shopping and cooking. Restaurant dining was tackled as well, including fast food and carryout. The workbook covered eight sessions. Each session ended with goal-setting for the next meeting, and opened with a review of how the prior month’s goals were accomplished.
Individualization was an important part of the lifestyle intervention program, Dr. Nguyen-Huynh said. Counselors didn’t strive to make each participant fit into a cookie-cutter solution. Instead, they worked as a team to build interventions that would work for each person.
The study group comprised 1,660 subjects. About 70% were women. Diabetes was common (about 33%), and around 10% had a history of coronary artery disease. The mean body mass index was 34 kg/m2.
The primary outcome was rate of blood pressure control in the usual care vs. enhanced monitoring groups, and the usual care vs. lifestyle modification groups after 1 year.
At the end of follow-up, there was no difference in the rate of control between the usual care group and the enhanced monitoring group (62% vs. 64%). However, there was a significant difference in the rate of control between the usual care and the lifestyle modification groups (62% vs. 69%).
Again, Dr. Nguyen-Huynh said, it was tough to pinpoint any particular reason for the improvement. There was no apparent increase in compliance with antihypertensive medication. The Morisky scale, an 8-point self-reported measure of medication compliance, was not different from baseline. Participants didn’t report any big changes in salt intake or salt use in food. This was borne out in the 24-hour urine sodium screens, which were also not different from baseline. There were no significant weight changes and no changes in the use of outpatient primary care.
“What we can say is that it apparently worked,” she said. “This culturally appropriate, telephone-based lifestyle intervention, that focuses on the DASH eating plan, may be something that can help African-Americans with uncontrolled hypertension manage their condition.”
She added that Kaiser will continue to drill down in the data to discover the source of its benefit and follow the participants for at least another year to assess the longevity of the its clinical effect.
Dr. Nguyen-Huynh had no financial disclosures.
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