Documented lifestyle education among young adults with incident hypertension

Challenges and Opportunities for the Prevention and Treatment of Cardiovascular Disease Among Young Adults: Report From a National Heart, Lung, and Blood Institute Working Group

Improvements in cardiovascular disease (CVD) rates among young adults in the past 2 decades have been offset by increasing racial/ethnic and gender disparities, persistence of unhealthy lifestyle habits, overweight and obesity, and other CVD risk factors. To enhance the promotion of cardiovascular health among young adults 18 to 39 years old, the medical and broader public health community must understand the biological, interpersonal, and behavioral features of this life stage. Therefore, the National Heart, Lung, and Blood Institute, with support from the Office of Behavioral and Social Science Research, convened a 2-day workshop in Bethesda, Maryland, in September 2017 to identify research challenges and opportunities related to the cardiovascular health of young adults. The current generation of young adults live in an environment undergoing substantial economic, social, and technological transformations, differentiating them from prior research cohorts of young adults. Although the accumulation of clinical and behavioral risk factors for CVD begins early in life, and research suggests early risk is an important determinant of future events, few trials have studied prevention and treatment of CVD in participants <40 years old. Building an evidence base for CVD prevention in this population will require the engagement of young adults, who are often disconnected from the healthcare system and may not prioritize long-term health. These changes demand a repositioning of existing evidence-based treatments to accommodate new sociotechnical contexts. In this article, the authors review the recent literature and current research opportunities to advance the cardiovascular health of today's young adults.

Identifying patterns and predictors of lifestyle modification in electronic health record documentation using statistical and machine learning methods

Just under half of the 85.7 million US adults with hypertension have uncontrolled blood pressure using a hypertension threshold of systolic pressure ≥ 140 or diastolic pressure ≥ 90. Uncontrolled hypertension increases risks of death, stroke, heart failure, and myocardial infarction. Guidelines on hypertension management include lifestyle modification such as diet and exercise. In order to improve hypertension control, it is important to identify predictors of lifestyle modification assessment or advice to tailor future interventions using these effective, low-risk interventions. Electronic health record data from 14,360 adult hypertension patients at an academic medical center were analyzed using statistical and machine learning methods to identify predictors and timing of lifestyle modification. Multiple variables were statistically significant in analysis of lifestyle modification documentation at multiple time points. Random Forest was the best machine learning method to classify lifestyle modification documentation at any time with Area Under the Receiver Operator Curve (AUROC) 0.831. Logistic regression was the best machine learning method for classifying lifestyle modification documentation at ≤3 months with an AUROC of 0.685. Analyzing narrative and coded data from electronic health records can improve understanding of timing of lifestyle modification and patient, clinic and provider characteristics that are correlated with or predictive of documentation of lifestyle modification for hypertension. This information can inform improvement efforts in hypertension care processes, treatment implementation, and ultimately hypertension control.

Evaluating the feasibility of a pharmacist-guided patient-driven intervention to improve blood pressure control in patients with CKD

Background

Methods

Results

Conclusion

The effects of aquatic and land exercise on resting blood pressure and post-exercise hypotension response in elderly hypertensives

OBJECTIVE

This study compared resting blood pressure (BP) using ambulatory BP monitoring (ABPM) responses in two groups of subjects trained in land exercise (LE) and aquatic exercise (AE), and assessed post-exercise hypotension (PEH) using ABPM, after land- and aquatic-based exercises.

METHODS

ABPM (24 hours) was used to measure the baseline BP in elderly hypertensive women trained in LE and AE and the PEH induced by exercise. For this, 40 subjects were evaluated at rest and after a land- or aquatic-based exercise session (aerobic: 75% of reserve heart rate combined with resistance exercise).

RESULTS

The daytime BP was lower for AE [systolic BP (SBP) 124 ± 1.0 mmHg, diastolic BP (DBP) 70 ± 1.5 mmHg] than for LE (SBP 134 ± 0.9 mmHg, DBP 76 ± 0.9 mmHg), but there were no differences at night-time. The aquatic exercise-induced PEH in the second hour was maintained at the 24th hour post-exercise. For land exercise-induced PEH, it was maintained at the 12th hour post-exercise. The SBP and DBP were lower at the 24th hour for AE than for LE.

CONCLUSIONS

Elderly hypertensive people trained in AE had lower baseline BP during the daytime. SBP and DBP values were lower for individuals trained in AE, and their PEH was more rapid and longer lasting after AE.

Resistant Hypertension: Diagnosis and Management

Resistant hypertension is defined as high blood pressure requiring 3 or more medications for adequate control or controlled blood pressure requiring 4 or more medications. Considering the growing prevalence of hypertension and the strong link with cardiovascular disease, it is vital to understand the causes and treatment of resistant hypertension. This review article starts with an overview of the prevalence and little-known pathophysiology of resistant hypertension. Afterward, we discuss the evaluation and management of suspected secondary resistant hypertension in 2 broad categories: pseudoresistant hypertension and true resistant hypertension. Strategies for the identification and management of pseudoresistant hypertension are addressed. In addition, causes of true resistant hypertension, such as obstructive sleep apnea, primary aldosteronism, and renal artery stenosis, are examined along with their respective treatments. Finally, treatment of resistant hypertension is reviewed including pharmacologic treatments and novel procedural interventions for resistant hypertension. Overall, the review hopes to provide practitioners with a cohesive approach for the diagnosis and treatment of resistant hypertension.

Rationale and study design of the MyHEART study: A young adult hypertension self-management randomized controlled trial

Young adults (18-39 year-olds) with hypertension have a higher lifetime risk for cardiovascular disease. However, less than 50% of young adults achieve hypertension control in the United States. Hypertension self-management programs are recommended to improve control, but have been targeted to middle-aged and older populations. Young adults need hypertension self-management programs (i.e., home blood pressure monitoring and lifestyle modifications) tailored to their unique needs to lower blood pressure and reduce the risks and medication burden they may face over a lifetime. To address the unmet need in hypertensive care for young adults, we developed MyHEART (My Hypertension Education And Reaching Target), a multi-component, theoretically-based intervention designed to achieve self-management among young adults with uncontrolled hypertension. MyHEART is a patient-centered program, based upon the Self-Determination Theory, that uses evidence-based health behavior approaches to lower blood pressure. Therefore, the objective of this study is to evaluate MyHEART's impact on changes in systolic and diastolic blood pressure compared to usual care after 6 and 12 months in 310 geographically and racially/ethnically diverse young adults with uncontrolled hypertension. Secondary outcomes include MyHEART's impact on behavioral outcomes at 6 and 12 months, compared to usual clinical care (increased physical activity, decreased sodium intake) and to examine whether MyHEART's effects on self-management behavior are mediated through variables of perceived competence, autonomy, motivation, and activation (mediation outcomes). MyHEART is one of the first multicenter, randomized controlled hypertension trials tailored to young adults with primary care. The design and methodology will maximize the generalizability of this study. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03158051.

Public awareness of oral cancer among adults in Jakarta, Indonesia

AIM

The aim of the present study was to investigate the awareness of oral cancer among adults in Jakarta, Indonesia, and explore the factors influencing it.

METHODS

A previously-tested questionnaire on 1000 adults in Jakarta was used in the present study. The data included sociodemographic factors and answers to assess the awareness of oral cancer, early signs and symptoms, risks factors, lifestyles, and history of dental visits.

RESULTS

Only 53.2% of participants were aware of oral cancer. The level of awareness significantly differed by level of education, occupation, and experience of dental visits. Only 30% of patients had been asked about their tobacco and alcohol habits, and had been informed about the hazards of these by their dentists. All of the smokers knew that tobacco increased the risk for oral cancer. However, only a few participants considered alcohol, betel quid chewing, UV light exposure, poor diet, and genetics to play role in the development of oral cancer. Health warnings were the main source of information about oral cancer; the role of health professionals is still quite low and needs to be emphasized.

CONCLUSION

Oral cancer awareness is still low among adults in Jakarta; this finding was consistent with other studies conducted in Asia. Educational material suited to particular communities is warranted.

Low use of routine medical care among African Americans with high CKD risk: the Jackson Heart Study

Background

Use of routine medical care (RMC) is advocated to address ethnic/racial disparities in chronic kidney disease (CKD) risks, but use is less frequent among African Americans. Factors associated with low RMC use among African Americans at risk of renal outcomes have not been well studied.

Methods

We examined sociodemographic, comorbidity, healthcare access, and psychosocial (discrimination, anger, stress, trust) factors associated with low RMC use in a cross-sectional study. Low RMC use was defined as lack of a physical exam within one year among participants with CKD (estimated glomerular filtration rate < 60 mL/min/1.73m² or urine albumin-to-creatinine ratio > 30 mg/g) or CKD risk factors (diabetes or hypertension). We used multivariable logistic regression to estimate the odds of low RMC use at baseline (2000–2004) for several risk factors.

Results

Among 3191 participants with CKD, diabetes, or hypertension, 2024 (63.4%) were ≥ 55 years of age, and 700 (21.9%) reported low RMC use. After multivariable adjustment, age < 55 years (OR 1.61 95% CI 1.31–1.98), male sex (OR 1.71; 1.41–2.07), <high school diploma (OR 1.31; 1.07–1.62), absence of hypertension (OR 1.74; 1.27–2.39) or diabetes (OR 1.34; 1.09–1.65), and tobacco use (OR 1.43; 1.18–1.72) were associated with low RMC use. Low trust in providers (OR 2.16; 1.42–3.27), high stress (OR 1.41; 1.09–1.82), high daily discrimination (OR 1.30; 1.01–1.67) and low burden of lifetime discrimination (OR 1.52; 1.18–1.94), were also associated with low RMC use.

Conclusions

High-risk African Americans who were younger, male, less-educated, and with low trust in providers were more likely to report low RMC use. Efforts to improve RMC use by targeting these populations could mitigate African Americans’ disparities in CKD risks.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1190-0) contains supplementary material, which is available to authorized users.

My Hypertension Education and Reaching Target (MyHEART): Development and Dissemination of a Patient-Centered Website for Young Adults with Hypertension

Background

Young adults (18 to 39 years old) with hypertension have the lowest rates of blood pressure control (defined as blood pressure less than 140/90 mmHg) compared to other adult age groups. Approximately 1 in 15 young adults have high blood pressure, increasing their risk of future heart attack, stroke, congestive heart failure, and/or chronic kidney disease. Many young adults reported having few resources to address their needs for health education on managing cardiovascular risk.

Objective

The goal of our study was to develop and disseminate a website with evidence-based, clinical information and health behavior resources tailored to young adults with hypertension.

Methods

In collaboration with young adults, health systems, and community stakeholders, the My Hypertension Education and Reaching Target (MyHEART) website was created. A toolkit was also developed for clinicians and healthcare systems to disseminate the website within their organizations. The dissemination plan was guided by the Dissemination Planning Tool of the Agency for Healthcare Research and Quality (AHRQ).

Results

Google Analytics data were acquired for January 1, 2017 to June 29, 2017. The MyHEART website received 1090 visits with 2130 page views; 18.99% (207/1090) were returning visitors. The majority (55.96%, 610/1090) approached the website through organic searches, 34.95% (381/1090) accessed the MyHEART website directly, and 5.96% (65/1090) approached through referrals from other sites. There was a spike in site visits around times of increased efforts to disseminate the website.

Conclusions

The successfully implemented MyHEART website and toolkit reflect collaborative input from community and healthcare stakeholders to provide evidence-based, portable hypertension education to a hard-to-reach population. The MyHEART website and toolkit can support healthcare providers' education and counseling with young adults and organizations' hypertension population health goals.

Compliance with Nutritional and Lifestyle Recommendations in 13,000 Patients with a Cardiometabolic Disease from the Nutrinet-Santé Study

BACKGROUND

A healthy diet has been shown to prevent cardiovascular diseases complications. The objective of this study was to assess dietary intakes and compliance with nutritional and lifestyle recommendations in French adults diagnosed with hypertension, diabetes, dyslipidaemia or cardiovascular disease compared with healthy individuals.

METHODS

Data was collected from 26,570 subjects aged 35 to 70 years (13,285 patients and 13,285 controls matched by sex and age) of the French cohort NutriNet-Santé. Dietary intakes were assessed using three 24-h records. Mean food and nutrient intakes of patients were compared to those of healthy subjects using multivariable mixed logistic and linear regressions.

RESULTS

Compared to healthy controls, adults reporting cardiometabolic diseases had lower intakes of sweetened products, higher intakes of fish and seafood and a better compliance with dairy products. However, overall, they reported unhealthier lifestyles and dietary habits. Indeed, they were less often physically active and had similar habits regarding alcohol and tobacco consumption. They also had lower intakes of fruit, higher intakes of meat, processed meat and added fats. It is noteworthy that diabetic subjects tended to show the highest compliance with certain dietary recommendations (vegetables, pulses and whole grain products).

CONCLUSION

Our study brings into focus the fact that some nutritional aspects still need to be improved among individuals with a cardiometabolic disease. We should encourage higher intakes of fruits and vegetables, whole grain products, and lower intakes of meat and sodium, as well as healthy lifestyle (physical activity, no-smoking and limited intake of alcohol) in order to encourage a healthier management after being diagnosed.

"They're younger… it's harder." Primary providers' perspectives on hypertension management in young adults: a multicenter qualitative study

BACKGROUND

Young adults (18-39 year-olds) have the lowest hypertension control rates among adults with hypertension in the United States. Unique barriers to hypertension management in young adults with primary care access compared to older adults have not been evaluated. Understanding these differences will inform the development of hypertension interventions tailored to young adults. The goals of this multicenter study were to explore primary care providers' perspectives on barriers to diagnosing, treating, and controlling hypertension among young adults with regular primary care.

METHODS

Primary care providers (physicians and advanced practice providers) actively managing young adults with uncontrolled hypertension were recruited by the Wisconsin Research & Education Network (WREN), a statewide practice-based research network. Semi-structured qualitative interviews were conducted in three diverse Midwestern clinical practices (academic, rural, and urban clinics) using a semi-structured interview guide, and content analysis was performed.

RESULTS

Primary care providers identified unique barriers across standard hypertension healthcare delivery practices for young adults. Altered self-identity, greater blood pressure variability, and unintended consequences of medication initiation were critical hypertension control barriers among young adults. Gender differences among young adults were also noted as barriers to hypertension follow-up and antihypertensive medication initiation.

CONCLUSIONS

Tailored interventions addressing the unique barriers of young adults are needed to improve population hypertension control. Augmenting traditional clinic structure to support the "health identity" of young adults and self-management skills are promising next steps to improve hypertension healthcare delivery.

The Unchartered Frontier: Preventive Cardiology Between the Ages of 15 and 35 Years

It is well established that atherosclerosis, the pathological basis of cardiovascular disease (CVD), begins in childhood and progresses steadily between the ages of 15 to 35 years. These adolescent and young adult years are also marked by significant physiological, psychological, and sociodemographic changes that impact both CVD risk factor development and CVD prevention and treatment strategies. In this review, we highlight the importance of the primordial prevention of CVD risk factors before they ever occur and the primary prevention of CVD by treating CVD risk factors in this age group. Although the long time to first CVD event for most young people precludes the availability of clinical trials with hard end-points, findings from epidemiology, health psychology, health services research, and clinical trials with surrogate endpoints are discussed to inform an evidence-based approach to CVD prevention in adolescents and young adults.

Achieving Weight Loss and Hypertension Control Among Obese Adults: A US Multidisciplinary Group Practice Observational Study

BACKGROUND

Among adults with hypertension, obesity independently contributes to cardiovascular disease. Weight loss and hypertension control are critical to reduce cardiovascular events. The purpose of this study was to evaluate rates and predictors of achieving weight loss among adults who achieved hypertension control within 1 year of developing incident hypertension.

METHODS

Retrospective electronic health record analysis was performed of ≥18 year olds with a body mass index ≥30.0kg/m(2), who received regular primary care from 2008 to 2011 and achieved hypertension control. Exclusions were less than 60 days follow-up, prior hypertension diagnosis, prior antihypertensive prescription, or pregnancy. The primary outcome was clinically significant weight loss (≥5kg); the secondary outcome was modest (2.0-4.9kg) weight loss. Multinomial logistic regression identified predictors of achieving weight loss (≥5 or 2.0-4.9kg) compared to no significant weight loss (<2kg).

RESULTS

Of the 2,906 obese patients who achieved hypertension control, 72% (n = 2,089) did not achieve at least 2.0kg weight loss. Overall, 12% (n = 351) achieved ≥5kg weight loss. Young adults (18-39 year olds; odds ratio (OR): 2.47, 95% confidence interval (CI): 1.63-3.47), middle-aged adults (40-59 year olds; OR: 2.32, 95% CI: 1.59-3.37), and patients prescribed antihypertensive medication (OR: 1.37, 95% CI: 1.07-1.76) were more likely to achieve clinically significant weight loss and hypertension control. Age remained a significant predictor for 2.0-4.9kg weight loss.

CONCLUSIONS

Despite achieving hypertension control, the majority of obese patients did not achieve clinically significant weight loss. Effective weight loss interventions with dedicated hypertension treatment are needed to decrease cardiovascular events in this high-risk population.

Vascular Disease in Young Indians (20-40 years): Role of Hypertension

Hypertension (HTN) being one of the important risk factors for cardiovascular disease (CVD) is a significant health concern, especially in India. With age, prevalence of HTN, especially systolic HTN increases. Special attention needs to be directed to HTN in young ages (20-40 years) due to lower awareness, need for early treatment and better control of HTN. HTN in the age group of 20-40 years needs critical reappraisal. Given the high prevalence of HTN in the general population in India, in this review we attempt to provide current evidence and expert opinion on epidemiology, aetiopathogenesis and treatment of HTN in young (20-40 years) Indians.

"I have to live like I'm old." Young adults' perspectives on managing hypertension: a multi-center qualitative study

BACKGROUND

In the U.S., young adults (18-39 year-olds) have the lowest hypertension control rates among hypertensive adults. Understanding young adults' unique perceptions about hypertension and perceived barriers to hypertension control is critical to develop effective interventions for this population. This multi-center study explored young adults': 1) emotions and reactions after a hypertension diagnosis, 2) attitudes about managing hypertension (lifestyle changes, follow-up visits, antihypertensive medication use), 3) opinions about their healthcare system's hypertension education materials, and 4) opinions about using social media to manage hypertension.

METHODS

Young adults (18-39 year-olds) with a diagnosis of hypertension and regular primary care access were recruited by the Wisconsin Research and Education Network (WREN). Two focus groups (one per age range: 18-29 years, 30-39 years) were conducted in three Midwestern Family Medicine Clinics (academic, rural, and urban). Conventional content analysis was performed.

RESULTS

Thirty-eight young adults (mean: 26.7 [9.6] years old, 34% male, 45% Black, 42% with ≥1 year of college) identified barriers to managing hypertension. Emergent themes overlapped across age groups and geographic regions. Most respondents were surprised and angry about a hypertension diagnosis; they expected to develop hypertension, but at a much older age. A hypertension diagnosis negatively altered their "young" self-identity; suggested behavior changes and antihypertensive medications made them feel "older" than their peers. Young adults missed blood pressure follow-up visits due to co-payments, transportation barriers, and longer than desired wait times for brief visits. Contrary to our hypothesis, most young adults disliked social media or text messaging to support self-management; they were most concerned that their peers would see the hypertension communication. Current hypertension education materials were described as not addressing young adults' health questions and are often discarded before leaving the clinic.

CONCLUSIONS

Targeting interventions to young adults' unique needs is necessary to improve hypertension control and cardiovascular preventive healthcare delivery.

Differential Diagnosis and Treatment Rates Between Systolic and Diastolic Hypertension in Young Adults: A Multidisciplinary Observational Study

Differential rates of diagnosis and treatment by hypertension (HTN) type may contribute to poor HTN control in young adults. The objective of this study was to compare rates of receiving a hypertension diagnosis and antihypertensive agent among young adults with (1) isolated systolic, (2) isolated diastolic, and (3) combined systolic/diastolic HTN. A retrospective analysis was conducted in patients aged 18 to 39 years (n=3003) with incident HTN. Kaplan-Meier survival and Cox proportional hazards analyses were performed. Only 56% with isolated systolic HTN received a diagnosis compared with 63% (systolic/diastolic); 32% with isolated systolic HTN received an initial antihypertensive compared with 52% (systolic/diastolic). Compared with patients with systolic/diastolic HTN, those with isolated systolic HTN had a 50% slower diagnosis rate (hazard ratio [HR], 0.50; 95% confidence interval [CI], 0.41-0.60) and those with isolated diastolic HTN had a 26% slower rate (HR, 0.74; CI, 0.60-0.92). Patients with isolated systolic HTN had 58% slower medication initiation (HR, 0.42; CI, 0.34-0.51) and those with isolated diastolic HTN had 31% slower rates (HR, 0.69; CI, 0.55-0.86). Young adults with isolated systolic HTN have lower diagnosis and treatment rates.