Monday, June 8, 2015

Lowering blood pressure with behavior change instead of medication

- Jennifer Middleton, MD, MPH

I've had several patients over the years who, when diagnosed with hypertension, ask what they can do to treat it instead of starting a medication. In the June 1 issue of AFP, an article about Nonpharmacologic Management of Hypertension discusses options we can share with patients.

I discussed the JNC 8 recommendations for pharmacologic management on the blog last December, and now a subgroup of the JNC 8 has released a lifestyle management guideline discussing the evidence behind nonpharmacologic treatments. The AFP article authors outline these treatments including nutrition and exercise recommendations. While the evidence base behind these healthy behaviors is robust, helping patients to make and sustain significant lifestyle changes can be challenging. Determining where patients are regarding change and then applying an appropriate counseling tool can improve success rates.

A 2000 AFP article outlines the Stages of Change. The process of making a sustainable lifestyle change is a gradual one for most people, beginning with a lack of awareness about change and/or an unwillingness to change (pre-contemplation), to considering change, (contemplation), preparing to change (preparation), making the change (action), and sustaining the change (maintenance). Identifying what stage a patient is at enables the physician to appropriately target his or her counseling. For example, directive techniques like discussing a quit date may discourage a patient who is pre-contemplative about quitting smoking but would be entirely appropriate for a patient who is in preparation stage, ready to develop a quit plan. Here are the recommended behavioral interventions for patients based on their stage of change from that 2000 AFP article and a 2015 JFP article:

Pre-contemplation: Motivational interviewing techniques are appropriate for all stages but especially this one. Ask the patient for permission to discuss the behavior change and, if granted, explore where the patient's interest in change currently stands, possibly using a 1-10 scale ("On a scale of 1-10, how interested are you in exercising?" "Why did you choose that number and not a lower/higher number?")

Contemplation: Patients in contemplation are stuck between the pros and cons of a behavior change. This stage can be a good time to use narrative techniques, exploring with the patients how they might imagine life being different if they do or do not make a change ("What might life be like in ten years if you do lose twenty pounds? What might it be like if you didn't?"). The 2000 AFP article provides several other prompts for discussion.

Preparation: Now (and only now) is the time to begin setting goals and making directed plans. Tools like FRAMES and the 5 As can be helpful.

Action & Maintenance: All of the above tools work well for patients in these stages. Exploring risks for pitfalls, setbacks, and/or relapses and problem-solving around these can be especially helpful.

Meeting our patients where they are, instead of telling them what to do, can result in a better experience for both patient and physician. Patients who wish to avoid medication for hypertension may be highly motivated to make these beneficial lifestyle changes, but it's up to us to help them capitalize on that opportunity.