A cross-sectional analysis of associations between lifestyle advice and behavior changes in patients with hypertension or diabetes: NHANES 2015-2018

Health behavior interventions among people with lower socio-economic position: a scoping review of behavior change techniques and effectiveness

Background

Behavior change interventions can unintendedly widen existing socio-economic health inequalities. Understanding why interventions are (in)effective among people with lower socio-economic position (SEP) is essential. Therefore, this scoping review aims to describe what is reported about the behavior change techniques (BCTs) applied within interventions and their effectiveness in encouraging physical activity and healthy eating, and reducing smoking and alcohol consumption according to SEP.

Methods

A systematic search was conducted in 12 electronic databases, and 151 studies meeting the eligibility criteria were included and coded for health behavioral outcomes, SEP-operationalization, BCTs (type and number) and effectiveness.

Results

Findings suggest that approaches for measuring, defining and substantiating lower SEP vary. Current studies of behavior change interventions for people of different SEP do not systematically identify BCTs, making systematic evaluation of BCT effectiveness impossible. The effectiveness of interventions is mainly evaluated by overall intervention outcomes and SEP-moderation effects are mostly not assessed.

Conclusion

Using different SEP-operationalizations and not specifying BCTs hampers systematic evidence accumulation regarding effective (combinations of) BCTs for the low SEP population. To learn which BCTs effectively improve health behaviors among people with lower SEP, future intervention developers should justify how SEP is operationalized and must systematically describe and examine BCTs.

Common barriers and enablers to the use of non-drug interventions for managing common chronic conditions in primary care: an overview of reviews

BACKGROUND

Non-drug interventions are recommended for chronic condition prevention and management yet are underused in clinical practice. Understanding barriers and enablers to using non-drug interventions may help implement non-drug interventions in primary care. We aimed to conduct an overview of reviews to identify and summarise common barriers and enablers for using non-drug interventions for common chronic conditions in primary care.

METHODS

We included qualitative and quantitative reviews that used systematic process or methods to examine barriers and enablers to using non-drug interventions for chronic condition prevention and management in primary care settings. We searched 5 electronic databases (PubMed, Cochrane Database of Systematic Reviews, EMBASE, PsycInfo and CINAHL) from inception to September 2022. Two authors independently screened reviews. One author extracted and deductively coded data to Consolidated Framework of Implementation Research (CFIR) (and where relevant, Theoretical Domains Framework [TDF]). A second author validated 10% of extracted data and coding. Data was synthesised thematically using CFIR and TDF. One author assessed the methodological quality of included reviews using a modified AMSTAR 2 tool, with 10% validated by a second author. We assessed overlap between primary studies in included reviews.

RESULTS

From 5324 records, we included 25 reviews, with data predominately from patients. Overall, 130 subthemes (71 barrier and 59 enabler) were identified across 4 CFIR domains (Innovation, Outer Setting, Inner Setting, and Individuals), and all TDF domains. Common barrier and enabler subthemes were identified for CFIR constructs of Innovation Adaptability, Innovation Cost, Innovation Relative Advantage, Local Attitudes, External Pressure, Local Conditions, Relational Connections, Available Resources, and Access to Knowledge and Information. For TDF domains, important barrier and enabler subthemes were identified for Knowledge, Skills, Environmental Context and Resources, Beliefs about Consequences, Reinforcement, and Emotion.

CONCLUSIONS

We synthesised reviews to provide new insight into common barriers and enablers for using non-drug interventions to prevent and manage chronic conditions in primary care. The factors identified can inform the development of generalisable implementation interventions to enhance uptake of multiple non-drug interventions simultaneously.

TRIAL REGISTRATION

This study was registered in PROSPERO (CRD42022357583).

Prevalence and determinants of self-reported low-fat-, low-salt-, and vegetarian diets in patients with cardiovascular disease between 1996 and 2019

BACKGROUND AND AIMS

Guidelines no longer recommend low-fat diets and currently recommend more plant-based diets to reduce atherosclerotic cardiovascular disease (ASCVD) risk. Furthermore, these guidelines have consistently recommended salt-reduced diets. This article describes current self-reported use and time-trends in the self-reported use of low-fat, low-salt and vegetarian diets in ASCVD patients and examines patient characteristics associated with each diet.

METHODS AND RESULTS

9005 patients with ASCVD included between 1996 and 2019 in the UCC-SMART cohort were studied. The prevalence of self-reported diets was assessed and multi-variable logistic regression was used to identify the determinants of each diet. Between 1996-1997 and 2018-2019, low-fat diets declined from 22.4 % to 3.8 %, and low-salt diets from 14.7 % to 4.6 %. The prevalence of vegetarian diets increased from 1.1 % in 1996-1997 to 2.3 % in 2018-2019. Patients with cerebrovascular disease (CeVD) and peripheral artery disease or an abdominal aortic aneurysm (PAD/AAA) were less likely to report a low-salt diet than coronary artery disease (CAD) patients (OR 0.62 [95%CI 0.49-0.77] and 0.55 [95%CI 0.41-0.72]).

CONCLUSION

In the period 1996 to 2019 amongst patients with ASCVD, the prevalence of self-reported low-fat diets was low and decreased in line with changes in recommendations in major guidelines. The prevalence of self-reported vegetarian diets was low but increased in line with societal and guideline changes. The prevalence of self-reported low-salt diets was low, especially in CeVD and PAD/AAA patients compared to CAD patients, and decreased over time. Renewed action is needed to promote low-salt diets in ASCVD patients.

Developing cue-behavior association for habit formation: A qualitative study to explore the role of avatar in hypertension

Background

Electronic health (eHealth) has been widely adopted in chronic disease management. Prior studies focused on time-based reminders as a cue to facilitate behavior change intentions, ignoring the development of automatic cue-behavior associations via other cue types.

Objective

Hence, this study utilized avatar appearance as a visual-based cue to help establish the automatic association between appearance transformation and health behavior to form habits without intention.

Methods

To better understand users' attitudes and experiences toward applying changes in avatar appearance to develop cue-behavior associations for hypertensive patients. Fifteen participants were recruited in a 14-day experiment. After excluding one participant who dropped out of the experiment, others were randomly assigned to two groups. One group consisted of a visual-based cue (a virtual plant) and basic behavior change techniques (BCTs). The other group only included basic BCTs. Attitudes and experience outcomes were collected by interview, and qualitative data were analyzed using thematic analysis.

Results

57% of participants had been diagnosed with hypertension for more than five years, and more than 50% of participants have experience using mobile apps or wearables. 66% of participants did physical activity more than three times every week. The result shows that tailored time-based reminders, blood pressure monitoring, and daily dietary intake were the most attractive features. Additionally, hypertensive participants have positive attitudes toward avatar appearance as a visual-based cue to develop cue-behavior association, which enhances self-management motivation.

Conclusion

This study proposes a visual-based cue design for habit formation and conducts a qualitative method to explore hypertensive patients' perceptions. The findings offer insights from user's perspectives into hypertensive patients' attitudes toward visual-based cues and perception of the connection between avatar appearance and health behavior for self-management. Subsequent discussions present eHealth design guidelines of habit formation from intention, automatic cue-behavior association, and self-management perspectives.

Associations between blood pressure control and clinical events suggestive of nutrition care documented in electronic health records of patients with hypertension

BACKGROUND

Clinical events suggestive of nutrition care found in electronic health records (EHRs) are rarely explored for their associations with hypertension outcomes.

METHODS

Longitudinal analysis using structured EHR data from primary care visits at a health system in the US from December 2017-December 2020 of adult patients with hypertension (n = 4,237) tested for associations between last visit blood pressure (BP) control (≤ 140 Systolic BP and ≤ 90 Diastolic BP) and ≥ 1 nutrition care clinical event operationalized as (overweight or obesity (BMI > 25 or 30, respectively) diagnoses, preventive care visits, or provision of patient education materials (PEM)). Descriptive statistics and longitudinal targeted maximum likelihood estimation (LTMLE) models were conducted to explore average treatment effects (ATE) of timing and dose response from these clinical events on blood pressure control overall and by race.

RESULTS

The median age was 62 years, 29% were male, 52% were Black, 25% were from rural areas and 50% had controlled BP at baseline. Annual documentation of overweight/obesity diagnoses ranged 3.0-7.8%, preventive care visits ranged 6.2-15.7%, and PEM with dietary and hypertension content were distributed to 8.5-28.8% patients. LTMLE models stratified by race showed differences in timing, dose, and type of nutrition care. Black patients who had nutrition care in Year 3 only compared to none had lower odds for BP control (ATE -0.23, 95% CI: -0.38,-0.08, p = 0.003), preventive visits in the last 2 years high higher odds for BP control (ATE 0.31, 95% CI: 0.07,0.54, p = 0.01), and early or late PEMs had lower odds for BP control (ATE -0.08, 95% CI: -0.15,-0.01, p = 0.03 and ATE -0.23, 95% CI: -0.41,-0.05, p = 0.01, respectively).

CONCLUSIONS

In this study, clinical events suggestive of nutrition care are significantly associated with BP control, but are infrequent and effects differ by type, timing, and patient race. Preventive visits appear to have the most effect; additional research should include examining clinical notes for evidence of nutrition care among different populations, which may uncover areas for improving nutrition care for patients with chronic disease.

Associations between Blood Pressure Control and Documented Nutrition Care Using Structured Data from Electronic Health Records of Patients with Hypertension

Background

Documentation in Electronic Health Records (EHRs) of nutrition care events (overweight or obesity (BMI > 25 or 30, respectively) diagnoses, preventive care visits, or provision of patient education materials (PEM)) for chronic diseases is unclear.

Methods

Cross-sectional analysis using structured EHR data from primary care visits at a health system in the US from January 2018 - December 2020 of adult patients with hypertension (n = 6,419) tested for associations between last visit blood pressure (BP) control (≤ 140 Systolic BP and ≤ 90 Diastolic BP) and aggregate nutrition care events. Descriptive statistics and multiple logistic regression models were constructed to examine the predictive power of nutrition care events for blood pressure control.

Results

The median age was 62 years, 32% were male, 48% were Black, 26% were from rural areas and 35.9% had controlled BP at last visit. For the 62% of patients with documented nutrition care, 14.6% had an overweight/obesity diagnosis, 26.2% had a preventive care visit, and 42% received PEM with dietary and hypertension content. The models showed patients who had more preventive care visits (aOR 1.12; CL 1.06, 1.18) had higher odds for BP control. Whereas Black patients compared with white patients (aOR 0.84; CL 0.74, 0.95), those with more hypertension medications (aOR 0.97; CL 0.96, 0.99) and more primary care visits over the study period (aOR 0.98; CL 0.97, 0.99) had lower odds for BP control.

Conclusions

In this study, documented nutrition care in preventive care visits is significantly associated with BP control, but documentation is infrequent. Additional research should include examining clinical notes for evidence of nutrition care, which may uncover areas that show promise for improving nutrition care for patients with chronic disease.

Underuse of lifestyle recommendations in hypertension management in France: The Esteban study

Lifestyle recommendations are first‐line elements in the management of arterial hypertension. This cross‐sectional study aimed to analyze the level to which lifestyle recommendations are used in hypertension management in France, using data from the Esteban study, which was implemented by Santé Publique France, France's public health agency, from 2014 to 2016 on a representative sample of the French population. The study sample comprised 440 adult Esteban participants who were aware they had hypertension and were aged 18–74 years old. The main outcomes were the proportion of participants who received lifestyle recommendations in their hypertension management plan, and the proportion of recommendations according to the three following dimensions: physical activity, weight loss, and changes in diet. Over half (57.0%) of the 440 participants declared they did not receive lifestyle recommendations as part of their hypertension management plan in the year preceding the study. Of these, 39.0% did not receive pharmacological treatment either. Physical activity was recommended to 31.8% of sedentary participants and weight loss to 26.8% of participants with overweight or obesity. One‐fifth of the study sample (20.1%) received dietary recommendations. Of these, 69% and 10.7% were advised to limit their salt and alcohol intake, respectively. Lifestyle interventions are too rarely recommended in hypertension management plans in France. Adherence to lifestyle recommendations needs in‐depth discussion not only at the time of diagnosis but also throughout follow‐up.