Shake, Rattle, and Roll: Strategy Improves BP Control

Nancy A. Melville

March 22, 2017

HOUSTON, Texas — African American patients with persistent hypertension participating in a lifestyle intervention provided at the primary care level and focusing on the Dietary Approaches to Stop Hypertension (DASH) guideline show significantly improved rates of blood pressure control compared with those receiving only usual care, according to new research.

"We saw an absolute difference of 7% better blood pressure control rate in the lifestyle group compared to usual care, and this was a significant difference," senior author, Mai N. Nguyen-Huynh, MD, from the Kaiser Permanente Division of Research in Oakland, California, told Medscape Medical News.

Uncontrolled hypertension is a significant challenge in black communities yet has not been well researched in previous studies, Dr Nguyen-Huynh said.

The current study, presented at the International Stroke Conference (ISC) 2017, strives to fill that gap. The study is dubbed the "Shake, Rattle and Roll" trial: "shake" the salt habit, "rattle" the intensity of current blood pressure management, and design interventions that can be easily adapted and "rolled" out into the community.

The trial included African-American patients at 98 primary care practices in the Kaiser Permanente East Bay healthcare system who had hypertension, with a blood pressure of 140/90 mmHg or above.

Patients were randomly assigned for the 12-month intervention into one of three groups:

  • The first group received usual care (n = 1129).

  • The second group received enhanced monitoring of the Kaiser Permanente blood pressure management protocol (n = 346), which includes an in-person session with a nurse to discuss barriers and resources, a blood pressure check within 2 weeks of a last elevated blood pressure reading, a consultation with a clinical pharmacist if needed, and treatment intensification for resistant hypertension.

  • The third group received culturally tailored lifestyle coaching focused on the DASH dietary plan (n = 286). The diet plan is rich in fruits, vegetables, and low-fat or nonfat dairy.

Patients in the lifestyle group were also provided up to 16 telephone counseling sessions with a lifestyle coach, optional bimonthly in-person group sessions, and educational materials.

Assessment of participants' rates of blood pressure control at 12 months after enrollment showed that those in the enhanced monitoring group had similar rates of people with blood pressure under control, defined as below 140/90 mmHg (64.1%), compared with the usual care group (62.1%; P = .50).

However, rates of control in the lifestyle coaching group (69.3%) were significantly higher than those in the usual care group (P = .03).

Treatment conditions did not significantly differ between the groups.

Of note, following the intervention, patients showed no significant differences in terms of other measures, including adherence to blood pressure medications, change in weight, or use of outpatient primary care, leaving the researchers to speculate about other components of the intervention that may have helped improve blood pressure control.

"One possible important component of the lifestyle arm was to raise patients' awareness of the great impact of salt intake on high blood pressure, and the coaching may have increased their knowledge of alternatives to salt in their everyday diet," Dr Nguyen-Huynh said.

"We are still analyzing the large amount of qualitative data collected from the trial, which may shed more light on this question."

She noted that a common reason given for failure to successfully control blood pressure is simply that patients feel they don't have the time, Dr Nguyen-Huynh said.

"A lot of patients mentioned time as a barrier for them to control their blood pressures," she said.

"This refers to time in going to the clinic, following up on their high blood pressure numbers, as well as time for commitment to the study intervention itself, such as in making all the lifestyle coaching sessions, et cetera."

Dr Nguyen-Huynh added that the Kaiser Permanente system already has a fair amount of success in blood pressure control, with some of the highest rates of control in the country. Because of that, it wasn't necessarily a surprise that the enhanced monitoring program didn't show a significant improvement over the usual care protocol.

"[An 85% blood pressure control rate] was achieved by the usual care, with an evidence-based pharmacotherapy protocol," she said.

"We knew we had a difficult job to push this ceiling even higher with some tweaking of the pharmacotherapy protocol and adding a registered nurse to help educate patients and to explore their potential barriers to therapy."

The findings underscore the potential payoff, however, in relatively easy-to-implement further lifestyle interventions.

"For patients with persistent uncontrolled blood pressure, one should consider lifestyle health coaching with motivational interviewing method focusing on healthy eating using the DASH plan and decreasing salt intake," Dr Nguyen-Huynh said.

Steven M. Greenberg, MD, from Massachusetts General Hospital in Boston, commented that the program shows the potential to make an important difference in the control of hypertension in African Americans.

"The improvement in hypertension in the intervention group looked clinically important to me," he told Medscape Medical News.

"Of all of the factors in the gradually declining stroke risk in the general population, improved recognition and control of hypertension is probably the most important," he said.

"This approach appears particularly promising for reducing the disparity of stroke risk in African Americans."

The study was funded by the National Institute of Neurological Disorders and Stroke. The authors and Dr Greenberg have disclosed no relevant financial relationships.

International Stroke Conference (ISC) 2017. Abstract LB11. Presented February 23, 2017.

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