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Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

J Clin Hypertens (Greenwich). 2010;12:784-792. © 2010 Wiley Periodicals, Inc.

Lifestyle changes, such as changes in diet and exercise, are recommended to lower blood pressure (BP) in adults. Using data from the 2008 HealthStyles survey, the authors estimated the prevalence of self-reported hypertension, advice received from health professionals, and actions taken to reduce BP. Among 5399 respondents, 25.8% had hypertension and 79.8% of these were currently taking antihypertensive medications. Overall, 21.0% to 24.4% reported receiving advice to adopt specific behavior changes, with younger adults and women having a lower prevalence of receiving advice. Blacks had the highest prevalence among the racial/ethnic groups of receiving advice, and household income was associated with receiving advice. More than half of respondents took action following the receipt of advice. Women were more likely than men to follow advice to go on a diet. Although many patients were following advice from their health professional and making lifestyle changes to decrease BP, the proportion of patients making changes remains suboptimal. Receiving advice from health professionals and following recommendations to reduce or control high BP are essential to hypertension management. Counseling on lifestyle modification should continue to be an integral component of visits to health professionals.

More than 73 million adults in the United States have hypertension (HTN), and the estimated direct and indirect costs for this disease in 2009 totaled $73.4 billion.1 Although awareness of this condition has improved and levels of treatment and control have gotten better, fewer than two thirds of people with HTN have their blood pressure (BP) under control.1–4 The many causal factors for HTN include age; family history and genetics; race/ethnicity; psychosocial stressors; excess body weight; excess dietary sodium intake; physical inactivity; inadequate intake of fruits, vegetables, and potassium; and excess alcohol intake.1–3 HTN is a major risk factor for cardiovascular diseases, including heart attack, stroke, and congestive heart failure, and it is associated with end-stage renal disease and a shorter life expectancy.1,3

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) recommends making a variety of healthy lifestyle changes to reduce BP, such as decreasing dietary salt/sodium, exercising, losing weight, and stopping smoking.3 These recommendations are for those with HTN or pre-HTN and those at risk for developing HTN. Adopting a healthy lifestyle can ameliorate several of the causal factors for HTN, potentially prevent HTN in nonhypertensive persons, and ultimately result in a lowered risk of HTN-related complications.2 Thus, it is not surprising that one of the Healthy People 2010 objectives is to increase the proportion of adults with HTN who are taking action to help control their BP (objective 12–11).3 In addition, Healthy People 2010 objective 12–9 is to reduce the proportion of adults with high BP.

The purpose of this study was to examine the 2008 HealthStyles survey to estimate the prevalence of HTN, the use of antihypertensive medication, the advice received from health professionals for specific lifestyle behavior changes, and the actions taken to reduce BP among persons receiving advice.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Study Population

The HealthStyles survey, an annual questionnaire mailed out to US adults aged 18 years and older, is administered by the public relations firm Porter Novelli with technical assistance from the Centers for Disease Control and Prevention (CDC). Households were invited to participate in the consumer opinion panel through a recruitment survey; the list of households was obtained from a large credit-report agency. Approximately 340,000 households agreed to complete the mail panel. In return for their participation, respondents were given a small monetary incentive (cash or coupon totaling <$5) and were entered into a sweepstakes with a first-place prize of $1000 and 20 second-place prizes of $50. The survey was performed in two phases. First, a list of 20,000 households was selected to participate in the ConsumerStyles survey according to region, household income, population density, age, and household size to create a nationally representative sample. A low-income/minority supplement was used to ensure adequate representation of these groups. A total of 10,108 households completed the ConsumerStyles survey, yielding a 50.6% response rate. Second, the HealthStyles questionnaire was sent to 7000 households that responded to the ConsumerStyles survey; responses were received from 5399 (77%) participants. No information was available for nonresponders. The HealthStyles survey is designed to collect data about people’s health beliefs, attitudes, behaviors, conditions, and knowledge.

Independent Variables

The selected demographic variables studied were age (18–34, 35–44, 45–64, ≥65 years), sex, race/ethnicity (white, black, Hispanic, other), household income in thousands of dollars (<$25, $25–39.9, $40–59.9, ≥$60), and education level (less than high school graduate, high school graduate, some college, college graduate or higher).

Ascertainment of Outcomes

Respondents were classified as having self-reported HTN if they answered “Yes” to the following question, “Have you ever been told on two or more different doctor visits that you had high blood pressure?” and did not answer “Yes” to the question “Was this only during pregnancy?” A total of 129 respondents (7%) reported having only pregnancy-related HTN and were considered not hypertensive in this analysis.

Current antihypertensive medication use was noted when respondents answered “Yes” to the questions, “Has a doctor ever prescribed medication to help lower your blood pressure?” and “Are you now taking this medication to help lower your blood pressure?” among the respondents with HTN as defined above.

All respondents, regardless of HTN status, were also asked whether they had received advice from a doctor or other health professional to go on a diet or change their eating habits, cut down on salt/sodium in their diet, or exercise to lower their BP. Additionally, they were asked whether they were engaged in any of those actions to lower their BP after they received the advice.

Data Analysis

The sample was weighted for age, sex, race/ethnicity, household income, and household size to represent the US census population. Weighted frequency analyses provided information by selected characteristics on the percentage of respondents with self-reported HTN, current use of antihypertensive medication, advice received from a health care provider for specific lifestyle behavior changes, and actions taken to lower BP after receiving advice. Multiple logistic regression analyses were conducted to determine the independent associations of each of the selected characteristics with each outcome. Adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs) were obtained for each model after controlling for age, sex, race/ethnicity, household income, and education level. A P value at the level of .05 was considered to be significant, and all statistical analyses were performed with the statistical software package SAS, Release 9.1 (SAS Institute, Cary, NC).

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Among the 5399 respondents, 25.8% reported having HTN based on the criteria described above (Table I). The prevalence of HTN differed by age, sex, and race/ethnicity. Younger age groups were less likely to report having HTN than those aged 65 years or older. Women were less likely to report having HTN than were men (AOR, 0.8; 95% CI, 0.7–0.9), and blacks were more likely than whites to report having HTN (AOR, 1.4; 95% CI, 1.1–1.7).

Table I.   Weighted Proportion of Respondents With Self-Reported Hypertension and Percentage of Those Adults Taking Antihypertensive Medication: HealthStyles Survey, 2008
CharacteristicTotalSelf-Reported HypertensionCurrently Taking Antihypertensive Medication
No. (Weighted %)Adjusted Odds Ratiosa (95% CI)No. (Weighted %)Adjusted Odds Ratiosa (95% CI)
  1. Abbreviations: CI, confidence interval; HS, high school. aAdjusted for age, sex, race/ethnicity, household income, and education level. bStatistically significant. cMissing information on education level for 63 respondents.

Overall53991612 (25.8) 1327 (79.8) 
Age, y
 18–34662 (30.6)90 (12.0)0.17 (0.12–0.25)b41 (49.9)0.05 (0.03–0.11)b
 35–441073 (19.2)181 (17.3)0.25 (0.20–0.32)b118 (65.8)0.12 (0.07–0.21)b
 45–642628 (34.0)874 (34.1)0.65 (0.55–0.77)b731 (84.9)0.38 (0.24–0.61)b
 ≥651036 (16.2)467 (44.6)Reference437 (93.5)Reference
Sex
 Male2408 (48.4)768 (28.2)Reference637 (79.3)Reference
 Female2991 (51.6)844 (23.6)0.80 (0.68–0.94)b690 (80.5)0.99 (0.68–1.44)
Race/ethnicity
 White3664 (68.2)1097 (26.9)Reference915 (80.6)Reference
 Black670 (11.8)252 (29.6)1.36 (1.08–1.70)b212 (82.7)1.59 (0.98–2.60)
 Hispanic656 (13.3)159 (19.3)0.80 (0.62–1.04)123 (73.4)0.64 (0.37–1.12)
 Other409 (6.7)104 (20.8)0.91 (0.65–1.26)77 (74.6)0.85 (0.42–1.72)
Household income (in thousands of dollars)
 <$251466 (25.1)509 (27.1)1.19 (0.96–1.48)421 (79.3)0.82 (0.52–1.29)
 $25–$39.9723 (16.6)204 (21.8)0.89 (0.69–1.15)166 (77.2)0.83 (0.49–1.42)
 $40–$59.9852 (17.6)260 (27.2)1.25 (0.95–1.66)225 (85.6)2.32 (1.07–5.03)b
 ≥$602358 (40.6)639 (26.1)Reference515 (78.5)Reference
Education levelc
 <HS graduate361 (6.5)108 (22.0)0.83 (0.58–1.17)92 (82.7)1.44 (0.69–3.02)
 HS graduate1376 (22.8)450 (28.7)1.05 (0.83–1.32)380 (82.8)1.24 (0.75–2.03)
 Some college1973 (38.5)586 (24.7)1.00 (0.79–1.27)484 (79.9)1.29 (0.77–2.16)
 College graduate or more1626 (32.2)455 (26.7)Reference363 (77.2)Reference

Of persons with HTN, 79.8% were currently taking antihypertensive medication. Age was significantly associated with medication use, with younger adults being less likely to take this medication than those aged 65 years and older. Household income was significantly associated with current antihypertensive medication use; persons with a household income of $40,000 to $59,900 were more likely to take antihypertensive medication than were those with a household income of $60,000 or more (AOR, 2.3; 95% CI, 1.1–5.0). Race/ethnicity and education level were not associated with antihypertensive medication use.

Among all respondents, the prevalence of reporting receipt of advice to go on a diet (or change eating habits) was 21.0% (Table II). Adults aged 18 to 34 years (AOR, 0.2; 95% CI, 0.2–0.3) and 35 to 44 years (AOR, 0.5; 95% CI, 0.4–0.6) were significantly less likely than those aged 65 years or older to report receipt of advice to go on a diet. Women were less likely than men and blacks were more likely than whites to report receipt of advice to go on a diet. Respondents with a household income less than $25,000 were more likely to report receiving this advice than were those with a household income of $60,000 or more (AOR, 1.6; 95% CI, 1.2–1.9).

Table II.   Weighted Proportion of Respondents Who Received Advice to Go on a Diet, Cut Down on Salt/Sodium, or Exercise to Lower Blood Pressure: HealthStyles Survey, 2008
CharacteristicReceived Advice to Go on a DietReceived Advice to Cut Down on Salt/SodiumReceived Advice to Exercise
No. (Weighted %)Adjusted Odds Ratiosa (95% CI)No. (Weighted %)Adjusted Odds Ratiosa (95% CI)No. (Weighted %)Adjusted Odds Ratiosa (95% CI)
  1. Abbreviations: CI, confidence interval; HS, high school. aAdjusted for age, sex, race/ethnicity, household income, and education level. bStatistically significant. cMissing information on education level for 63 respondents.

Overall1345 (21.0) 1494 (23.7) 1499 (24.4) 
Age, y
 18–3474 (9.6)0.24 (0.16–0.34)b73 (11.1)0.13 (0.08–0.20)b79 (12.4)0.20 (0.14–0.30)b
 35–44180 (16.5)0.47 (0.37–0.59)b149 (14.0)0.18 (0.14–0.23)b179 (17.4)0.31 (0.25–0.39)b
 45–64772 (29.8)1.04 (0.87–1.24)797 (30.2)0.52 (0.44–0.62)b831 (32.3)0.73 (0.62–0.87)b
 ≥65+319 (29.6)Reference475 (45.4)Reference410 (38.9)Reference
Sex
 Male650 (22.9)Reference735 (26.2)Reference764 (28.4)Reference
 Female695 (19.3)0.77 (0.66–0.91)b759 (21.3)0.75 (0.63–0.91)b735 (20.6)0.64 (0.55–0.76)b
Race/ethnicity
 White850 (20.1)Reference934 (22.7)Reference964 (23.9)Reference
 Black243 (30.3)1.92 (1.49–2.48)b282 (34.2)2.26 (1.74–2.94)b253 (32.1)1.87 (1.43–2.45)b
 Hispanic158 (19.1)1.06 (0.82–1.37)185 (21.7)1.15 (0.88–1.49)167 (20.0)0.96 (0.74–1.23)
 Other94 (17.7)1.04 (0.76–1.43)93 (19.6)0.88 (0.63–1.23)115 (24.8)1.21 (0.88–1.67)
Household income (in thousands of dollars)
 <$25449 (25.5)1.55 (1.24–1.94)b531 (29.1)1.41 (1.13–1.77)b460 (26.8)1.28 (1.02–1.61)b
 $25 –$39.9162 (16.7)0.92 (0.70–1.19)185 (19.2)0.87 (0.67–1.12)176 (18.5)0.77 (0.59–0.99)b
 $40 –$59.9214 (20.3)1.19 (0.94–1.51)234 (23.6)1.25 (0.92–1.71)229 (23.5)1.07 (0.82–1.39)
 ≥$60+520 (20.3)Reference544 (22.2)Reference634 (25.8)Reference
Education levelc
 <HS graduate96 (21.5)1.00 (0.66–1.52)124 (27.0)1.19 (0.79–1.80)90 (21.1)0.77 (0.50–1.20)
 HS graduate372 (23.8)1.10 (0.88–1.37)448 (28.4)1.24 (0.96–1.60)391 (24.6)0.91 (0.72–1.14)
 Some college484 (20.3)1.05 (0.85–1.30)515 (21.1)0.98 (0.76–1.26)560 (24.0)1.03 (0.82–1.29)
 College graduate or more377 (20.1)Reference387 (22.5)Reference440 (25.5)Reference

The prevalence of reporting receipt of advice to cut down on salt/sodium was 23.7%. Compared with those aged 65 years or older, younger respondents were less likely to report receiving advice to cut down on salt/sodium. Women were significantly less likely than men, while blacks were more likely than whites, to report receiving advice to cut down on salt/sodium. Adults with a household income <$25,000 were more likely to report receiving the advice than were those with a household income of $60,000 or more (AOR, 1.4, 95% CI, 1.1–1.8).

The prevalence of reporting receipt of advice to exercise was 24.4%. Age, sex, race/ethnicity, and household income were associated with receiving such advice. Younger respondents were less likely to report receiving advice to exercise as compared with respondents aged 65 and older. Women were significantly less likely than men to report receiving advice (AOR, 0.6, 95% CI, 0.6–0.8), while blacks were more likely than whites to report receiving advice to exercise (AOR, 1.9, 95% CI, 1.4–2.5). Adults with a household income <$25,000 (AOR, 1.3, 95% CI, 1.02–1.6) were more likely to report receiving advice to exercise than were those with a household income of $60,000 or more, while those with a household income of $25,000 to $39,900 (AOR, 0.8, 95% CI, 0.6–0.99) were less likely to report receiving that advice.

Overall, more than half of respondents who received advice took action (Table III). The prevalence of taking action following advice to go on a diet was 65%, and sex was the only factor associated with this action. Women were more likely than men to report taking action following advice to go on a diet (AOR, 1.5, 95% CI, 1.1–2.0). The prevalence of taking action after receiving advice to cut down on salt/sodium or exercise was 87.3% and 62.3%, respectively. Compared with persons aged 65 years or older, respondents aged 18 to 34 years were significantly less likely to report taking action following receipt of advice to cut down on salt/sodium (AOR, 0.4; 95% CI, 0.2–0.8), while those aged 45 to 64 years were significantly less likely to take action following advice to exercise (AOR, 0.7; 95% CI, 0.5–0.9). Race/ethnicity was found to be associated with taking action after receiving advice to exercise, with blacks more likely to take action than whites (AOR, 1.5; 95% CI, 1.02–2.18). Overall, household income and education level were not associated with taking action after receipt of advice to go on a diet, reduce salt/sodium, or exercise.

Table III.   Weighted Proportion of Respondents Who Reported Following Advice to Go on a Diet, Cut Down on Salt/Sodium, or Exercise to Lower Blood Pressure: HealthStyles Survey, 2008
CharacteristicFollowed Advice to Go on a DietFollowed Advice to Cut Down on Salt/SodiumFollowed Advice to Exercise
No. (Weighted %)Adjusted Odds Ratiosa (95% CI)No. (Weighted %)Adjusted Odds Ratiosa (95% CI)No. (Weighted %)Adjusted Odds Ratiosa (95% CI)
  1. Abbreviations: CI, confidence interval; HS, high school. aAdjusted for age, sex, race/ethnicity, household income, and education level. bStatistically significant. cMissing information on education level for 63 respondents.

Overall861 (65.0) 1312 (87.3) 922 (62.3) 
Age, y
 18–3451 (70.0)1.10 (0.56–2.17)54 (77.8)0.39 (0.18–0.84)b47 (63.4)0.98 (0.49–1.94)
 35–44109 (62.5)0.72 (0.47–1.12)128 (87.0)0.76 (0.42–1.40)111 (61.0)0.71 (0.46–1.09)
 45–64491 (63.9)0.85 (0.62–1.16)701 (88.6)0.94 (0.62–1.41)496 (60.1)0.71 (0.54–0.93)b
 ≥65210 (65.8)Reference429 (89.9)Reference268 (66.1)Reference
Sex
 Male400 (62.3)Reference638 (86.1)Reference459 (60.4)Reference
 Female461 (68.0)1.46 (1.09–1.95)b674 (88.6)1.19 (0.76–1.86)463 (64.7)1.17 (0.89–1.52)
Race/ethnicity
 White531 (63.8)Reference815 (88.2)Reference586 (61.1)Reference
 Black159 (65.1)1.05 (0.71–1.57)252 (84.8)0.80 (0.45–1.40)165 (69.8)1.49 (1.02–2.18)b
 Hispanic108 (69.0)1.21 (0.76–1.92)167 (88.0)0.93 (0.49–1.77)99 (59.3)1.12 (0.73–1.72)
 Other63 (69.6)1.06 (0.61–1.85)78 (81.9)0.87 (0.40–1.90)72 (62.2)1.18 (0.71–1.98)
Household income (in thousands of dollars)
 <$25279 (62.5)0.77 (0.53–1.13)477 (86.6)1.37 (0.78–2.40)273 (63.1)0.83 (0.58–1.20)
 $25–$39.9100 (65.1)0.86 (0.55–1.33)159 (87.3)1.07 (0.60–1.92)111 (65.7)1.03 (0.68–1.58)
 $40–$59.9143 (66.5)0.98 (0.66–1.47)211 (91.4)1.86 (0.95–3.62)141 (58.5)0.76 (0.48–1.18)
 ≥$60339 (66.3)Reference465 (85.9)Reference397 (62.3)Reference
Education levelc
 <HS graduate58 (55.2)0.63 (0.30–1.31)109 (78.1)0.55 (0.22–1.38)53 (65.0)1.05 (0.54–2.03)
 HS graduate221 (62.0)0.79 (0.54–1.16)397 (88.9)1.15 (0.66–2.02)213 (56.0)0.76 (0.52–1.11)
 Some college312 (65.5)0.91 (0.64–1.31)461 (90.0)1.37 (0.80–2.34)358 (66.7)1.20 (0.84–1.71)
 College graduate or more258 (67.5)Reference331 (86.0)Reference288 (62.9)Reference

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

In this study of US adults, 25.8% of respondents reported having HTN and 79.8% of those with self-reported HTN were currently taking antihypertensive medication. Recent data from the National Health and Nutrition Examination Survey (NHANES) showed an increase in the prevalence of HTN from 1988–1994 (24.4%) to 1999–2004 (28.9%, P<.001).5 Moreover, several studies using NHANES data have noted a significant increase in the use of antihypertensive medication.5,6 The increased prevalence of such use could be attributed to treating patients at lower BP levels.7 Regardless, adherence to the use of antihypertensive medication is critical to avoiding HTN-related morbidity, mortality, and related economic costs to patients, such as the cost of additional prescriptions, emergency department visits, hospitalizations, physician office visits, and lost productivity.8

Elevated dietary intake of sodium has been shown to increase the incidence of HTN, and when dietary sodium intake is reduced, BP decreases in people with high or normal values.2,9–12 In addition, clinical trials have shown that reducing sodium intake can prevent or control high BP and can lower BP in persons taking antihypertensive medication.2,13–15 Moreover, observational studies have shown that reducing salt intake is associated with reduced risk of cardiovascular events and congestive heart failure.11,16,17 Current dietary guidelines recommend an upper limit for sodium intake of 2300 mg/d, with a limit of no more than 1500 mg/d for special populations, including those with high BP, blacks, and middle-aged and older adults.18 In 2005–2006, the average sodium intake among US adults was 3436 mg/d,19 much higher than recommended and far more than is biologically necessary. Decreasing daily sodium intake to 2300 mg/d could result in 11.1 million fewer cases of HTN.20 Our study indicates that fewer than one quarter of adults received advice to lower dietary salt, and, of those, about 13% did not take action to reduce this intake.

Several other diet-related changes have been shown to effectively reduce BP or prevent or delay the incidence of HTN, including an increase in potassium intake to 120 mmol/d and limiting daily alcohol intake to no more than 2 drinks for men or 1 drink for women.2,18 The Dietary Approaches to Stop Hypertension (DASH) diet, which is rich in fruits and vegetables and low-fat dairy products and includes reduced amounts of saturated fat and cholesterol, is recommended to many people with HTN or pre-HTN because it has been shown to significantly reduce BP.2,9,21 The present study found that only one fifth of respondents were advised to go on a diet or change their eating habits, and, of those, only two thirds followed that advice. Although this study did not ask about specific dietary changes, advice to go on a diet or change eating habits should incorporate the DASH dietary recommendations. As part of following the advice of a health care provider related to their diet, respondents may have been making some of these dietary changes that are known to reduce BP.

Adherence to a program of aerobic exercise reduces resting systolic and diastolic BP in adults.22–25 Furthermore, a meta-analysis of the effects of randomized controlled trials of aerobic exercise on BP showed significant reductions in BP even when participants did not lose weight overall.26 This finding suggests that exercise reduces BP independently of changes in body weight. Reductions in BP after aerobic exercise have been noted for both normotensive and hypertensive patients and for both normal-weight and overweight patients.26 Moreover, numerous studies have demonstrated a direct relationship between body weight and BP.2 Reductions in BP occur even when a desirable body weight is not achieved; however, greater reductions in BP are observed for those with greater weight lost.2 In addition, weight loss and exercise combined with reduction in dietary sodium is associated with decreases in the incidence of HTN.10,22–26

We found in the present study that only one quarter of respondents were advised to exercise, and fewer than two thirds of those who received that advice were exercising. These low rates of counseling and of action by patients are concerning. With the epidemic of obesity in the US, which has actually worsened over time, health care providers should be counseling all of their patients about healthy diets and exercise, regardless of weight or diagnosis of HTN.

Health care providers have a particular opportunity to discuss changes in behaviors with their patients who have already been diagnosed with HTN or pre-HTN or who may be at risk for developing HTN. Not surprisingly, the success of advice from health care providers related to lifestyle changes is affected by the skills of the provider and available resources.2 The barriers perceived by health care providers also affect whether they even offer advice to patients. These barriers include lack of time, patient noncompliance, inadequate teaching materials, lack of training in counseling, lack of knowledge, inadequate reimbursement, and low physician confidence.27 In addition, health care providers may not consider the time spent counseling patients on lifestyle changes as very cost-effective since many patients do not follow physicians’ advice. They may see more value in other interventions, such as managing comorbidities and medication counseling. An educational intervention for health care providers may help to increase physicians’ knowledge, communication skills, and confidence for delivering advice and may increase the delivery of timely and appropriate educational materials to patients. Additional training in strategies to enhance patients’ confidence in making lifestyle changes may increase the number of patients who attempt to make changes. While several studies have focused specifically on provider advice to lower or control HTN,28–31 others have focused on both the proportion of individuals receiving advice for lifestyle modification and those taking subsequent action to reduce BP.32–38

Advice from their physician may motivate patients and increase their confidence in being able to change their lifestyles. Indeed, advice from a health care provider has been shown to be a predictor of attempts to change lifestyle behaviors.39,40 Advice from health care providers is not routine, however, and the amount, method, and quality of physician advice received by patients greatly varies. Providers may not recognize the importance of counseling on lifestyle modification and may miss opportunities to provide advice to patients. Physicians’ offering of general medical advice is affected by several factors, including the patient’s age, sex, race, educational level, insurance status, income, perceived health status, health behaviors, and geographic location.41–45 Studies have shown that those who get advice from health care providers are more likely to make lifestyle changes than those who do not get this advice.32 Simple verbal advice or pamphlets from a physician resulted in increased rates of physical activity in a comparison with usual care.40

The present study revealed disparities in the receipt of provider advice for making lifestyle changes to decrease BP. Men were more likely than women to receive advice to go on a diet, cut down on salt/sodium, and exercise. In contrast, several earlier studies did not find differences by sex of the patient in physician counseling or advice for lifestyle modifications.30,41,42,46,47 Furthermore, our results contradict the findings of two previous studies in which women were more likely than men to receive physician advice for lifestyle modifications.48,49 The reason for these sex differences is unclear. Regardless, even though men in the present study were more likely to receive advice for lifestyle changes, there were no differences by sex in following the advice, except for changing eating habits/dieting (where women had a higher prevalence). Therefore, even those who were more likely to be receiving advice were no more likely to follow it.

Our study showed that blacks were more likely to receive advice to go on a diet, cut down on salt/sodium, and exercise, and this finding has been reported in previous studies examining physician or health care provider advice for lifestyle modifications.31,48 This finding may reflect providers’ knowledge and perception of the problem of HTN in blacks. Compared with whites, blacks develop HTN earlier in life and have higher BPs on average, and blacks have greater rates of HTN-related mortality and morbidity, including fatal and nonfatal stroke, deaths from heart disease, and end-stage renal disease.1

In our study, lower-income groups were more likely to receive advice to go on a diet, cut down on salt/sodium, and exercise. This finding is supported by previous work.49 Many low-income groups are more likely to have risk factors for chronic illnesses and poorer outcomes.49 Perhaps health care providers view lower-income patients as being more at risk and thus provide them with advice more frequently. Although a previous mail survey found that low-income patients were more likely to report attempting to change their behavior based on physician advice,43 the present study found no evidence that low-income respondents were more likely to report changing their behavior as a way to lower BP.

Limitations

This study is subject to several limitations. First, HealthStyles is a mail survey and survey participants volunteered to participate; thus, the sample is not random and is subject to selection bias. No information is available for nonresponders, which may affect the generalizability of the results. The sample was weighted, however, to reduce potential bias related to various demographic variables. Second, the survey relies on self-reports, which are subject to recall and social desirability bias. Respondents may not remember whether they received advice about specific lifestyle modifications, and thus prevalence estimates may be overestimated or underestimated. They may also report taking specific actions they did not take because they see those actions as being socially desirable.50 Third, although the HealthStyles survey asks about whether advice about specific lifestyle interventions was received from a health care provider, it is unable to determine the extent of the advice given. Some providers may have provided more extensive instructions and advice on making lifestyle changes, which may have affected whether the respondent followed that advice. Finally, because this study was cross-sectional, it cannot determine whether the advice from a health care provider led to the specific actions taken. Some individuals may be more prone to making behavior changes than others and would have made lifestyle changes regardless of receiving that advice from a health care provider.

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

The findings in this study indicate that most health care providers do not impart advice for recommended lifestyle changes (or, at least, advice that is remembered by patients). Overall, 79.8% of respondents with self-reported HTN reported taking antihypertensive medication; however, only 21.0% to 24.4% or fewer than one third as many, reported receiving advice to adopt lifestyle behavior changes that are basic to BP management, including going on a diet, cutting down on salt/sodium, and exercising. These lifestyle behaviors were being observed by 65.0%, 87.3%, and 62.3%, respectively, among those who received advice. Therefore, among all survey respondents, few adults are applying known effective interventions that could potentiate the effects of medication and reduce or control BP. Failure to apply these known effective interventions to BP management and control is a failure of current practice with respect to established guidelines. Advice and counseling about lifestyle modification should become more of an integral component of visits to health care providers, and new strategies need to be developed to improve the mental capture of this advice by patients as well as to get them to take action.

Disclosure:  The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References
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