Hypertension: THE Lifestyle Challenge
Nurses can help many patients implement changes that may control blood pressure without medication
By Jean A. Massey, PhD, ANP
Do you have patients with hypertension who believe that medication is the only way to control their condition? They might be surprised to learn that an "exercise prescription"--coupled with a balanced diet, less alcohol consumption and no cigarette smoking--may control their blood pressure without medication. Your support and direction could be what it takes to get them started.
Hypertension has been called the "silent killer" by the American Heart Association because it often is an asyptomatic disease. An estimated 50 million people in the United States are being treated for hypertension.1 Another estimate is that 25 percent of all Americans have hypertension; however, not all of these individuals are receiving treatment or have been diagnosed as hypertensive.2, 3 For a majority of patients the cause is unknown. This is known as essential hypertension.4
Patients who have hypertension are at risk for stroke, myocardial infarction, congestive heart failure, renal insufficiency and peripheral vascular disease. Studies suggest that elevated blood pressure can increase the risk of such events by two to three times.5
Hypertension is defined as blood pressure readings persistently above 140/90 mm Hg on three or more occasions.6 The Sixth Report of the Joint Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI) classifies patients with high blood pressure into different stages and risk categories. The stages are: High-normal, 130-139/85-89; Stage 1-BP, 140-159/90-99; Stage 2-BP, 160-179/100-109; Stage 3-BP, >180/>110 (see Table 1).
The risk categories take into account conditions for heart disease
such as diabetes, cigarette smoking, hyperlipidemia, left ventricular
hypertrophy, and other target organ diseases. Risk Group A has no
risk factors and no target organ disease (TOD) or clinical cardiovascular disease (CCD); Risk Group B has at least one risk factor, not including diabetes, and no TOD/CCD; Risk Group C has TOD/CCV and/or diabetes with or without other risk factors.5
The JNC VI recommends lifestyle changes as the first treatment modality in all patients except those classified as Stages 2 and 3 or in Risk Group C (see Table 1). Lifestyle change is considered an important adjunct to treating these patients in addition to medication. In fact, all hypertensive patients can benefit from lifestyle changes.1, 3, 6
SENSIBLE LIFESTYLE CHOICES
Nurses can play a major role in helping most hypertensive patients implement lifestyle changes that may control blood pressure without medication. These changes are sensible approaches to attaining and maintaining a healthy lifestyle. You can advise them to:
* Lose weight if they are overweight;
* Participate in 30-45 minutes of physical activity five-seven days per week;
* Reduce daily sodium intake to less than 100 millimoles a day, or about one teaspoon of salt;
* Limit alcohol intake. For men, the daily recommendation is 1 oz. of ethanol, i.e. 24 oz. of beer, 10 oz. of wine, or 3 oz. of 80-proof distilled spirits like gin, rum, vodka, whiskey, etc. For women, the recommendation is 0.5 oz. of ethanol a day;
* Eat foods rich in potassium such as bananas, orange juice, potatoes, yogurt and prunes--potassium intake should be about 3.5 g per day; and
* Quit smoking if they smoke cigarettes.3,5,6
The Dash Diet (short for Dietary Approaches to Stop Hypertension) is recommended by the JNC VI. This well-balanced eating plan focuses on high fruit and vegetable consumption, and limits dairy products to low and non-fat. It recommends sodium restriction and high potassium intake as previously mentioned. A balanced diet that is low in fat (less than 30 percent of calories from fat), contains plenty of fiber from fruits and vegetables, and controls sodium intake is what the hypertensive patient should follow. Teaching the patient and the primary food preparer to read food labels will assist in starting the eating plan.5,7
In order to help your hypertensive patients make beneficial dietary changes, start with a 24-hour dietary recall to determine what foods they consume. Be sure to inquire if this is a typical day's consumption of food. Ask if the foods were canned, fresh or frozen, and also gather information about the number of servings. Once this recall is obtained, then you can direct attention to the appropriate choices in conjunction with the JNC IV guidelines. A follow-up visit with another dietary recall will help to determine dietary compliance.
Free educational materials on diet and hypertension is available from the American Heart Association and the National Heart, Lung and Blood Institute and offers details on appropriate menus and recipes. By making these materials available, you can help your patients choose foods that they like and that are similar to foods they already eat. The key with dietary change is to praise appropriate food choices rather than focus on choices that are not in the food plan. "Bad" food choices can be addressed, but the thrust of your intervention is to encourage positive choices.
Lifestyle changes can be a very daunting task for patients who expect a pill to cure everything. The initial intervention that can reap the most benefit is to begin an exercise program. You can give the patient an exercise prescription just as if it was a prescription for medication. Usually, patients will lose weight, start to feel better and notice lower blood pressure readings within two months.1,3 A walking program is best for most patients because it requires no special equipment, and is something most people do every day.1
To get your hypertensive patients started on a suitable exercise program, ask them if they are currently engaged in a regular exercise routine. If so, have them describe it to you. Many patients are making an attempt to exercise, but need the direction that an exercise prescription can provide to make their exercise program an effective component in controlling hypertension. Entering into a "contract" with your patients is a method that is effective in monitoring compliance. Each component of the exercise prescription is reviewed and a final goal is set that is consistent with the JNC IV guidelines. The patient also may want to keep a record of changes that they notice as they become more fit, such as increases in stamina, less shortness of breath, and decreasing weight and blood pressure. The contract and the patient's exercise diary should be reviewed at monthly intervals to assess the progression of exercise.
Many hospitals offer walking or other organized exercise programs. Such activities provide opportunities for socialization as well as exercise. These types of programs are ideal for many patients and provide you with a list of programs to offer along with the exercise prescription. For patients who prefer to exercise alone, safety is an important consideration. Tell them to be sure that the time of day, route of exercise and expected time of return are known by someone just in case an emergency should arise.
The components of an exercise program are mode, intensity, frequency, duration, and rate of progression of exercise.8 The mode of exercise is the physical activity in which the patient engages. Walking, cycling, jogging and swimming all are appropriate activities.
The intensity is how hard the patient is working. The intensity should be great enough to stress the cardiovascular system without overworking it. Intensity can be prescribed by setting a target heart rate range for the patient.8
To determine the patient's target heart rate range, first determine the maximum heart rate by subtracting the patient's age from 220. Then set the target heart rate for the lower and upper limits of activity by taking a percentage of the maximum heart rate. The percentages can be adjusted based on the physical condition of the patient. Seventy percent-85 percent of the maximum heart rate is a good target heart rate range, which provides good aerobic activity.8 See Table 2.
Patients should be instructed to check their pulse rate at 5-minute intervals during their workout. If the pulse rate is below the lower limit of the target heart rate range, they should pick up the pace of the exercise activity. If the pulse rate is above the upper limit of the target heart range, they should exercise a little less intensely.8
FIVE-SEVEN TIMES PER WEEK
Frequency of exercise is how many times a week the activity is performed. According to JNC VI, the frequency goal should be five-seven times per week. It is better that your patient start at a frequency of three times a week and work toward the goal of five-seven than not exercise at all. Likewise, with duration, or length of exercise, the JNC VI goal is 30-45 minutes. Fifteen-20 minutes may be a reasonable duration if your patient is in poor physical condition or overweight. Again, they can work toward the goal of 30-45 minutes.
Progression of exercise is how the intensity, frequency and duration are changed based on the patient's response to exercise. Once a patient is comfortable at an exercise level, the duration, frequency and/or intensity may be changed. This should be evaluated about every three months as they work toward the JNC VI goals.1,5
By encouraging your hypertensive patients to begin an exercise program as a cornerstone of lifestyle change, you can give them the ability to control their blood pressure without drug therapy. Once the exercise habit is in place, you can assist them in selecting other lifestyle changes.
Many patients may be able to control their high blood pressure by making a few changes in their lives. They can most effectively implement these changes with the expertise, support, encouragement and knowledge of nurses.
1. Bove, A.A., & Sherman, C. (1998). Active control of hypertension. The Physician and Sportsmedicine, 26(4), 45-54.
2. Chandrasoma, P., & Taylor, C. R. (1995). Concise pathology (pp. 315-317). New London, CT: Appleton & Lange.
3. Dumas, M.A. (1999). Hypertension in primary care. American Journal for Nurse Practitioners, 3(2), 7-32.
4. Alpert, J.S. (1996). Cardiology for the primary care physician. St. Louis: Mosby.
5. National High Blood Pressure Education Program. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (NIH Publication No. 98-4080). Bethesda, MD: National Heart, Lung and Blood Institute.
6. Tobin, L.J. (1999). Evaluating mild to moderate hypertension. Nurse Pract, 24(5). 22-41.
7. Mahan, L.K., & Arlin, M. (1992). Krause's nutrition and diet therapy (pp. 387-394). Philadelphia: W. B. Saunders.
8. Heyward, V.H. (1991). Advanced fitness assessment & exercise prescription (pp. 71-96). Champaign, IL: Human Kinetics Books.
Jean Massey is a nurse practitioner at Palmetto Baptist Physician Partners, Columbia, SC.