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Blood Pressure

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blood pressure tools

What is blood pressure?

Blood pressure is a measure of the force of blood inside an artery. If the pressure of blood is higher than normal on two or more occasions, you may have high blood pressure (hypertension).

The measurement is taken by temporarily stopping the flow of blood in an artery, usually by inflating a cuff around the upper arm and then listening for the sound of the blood beginning to flow through the artery again as air is released from the cuff.

As blood flows through the artery, it can be heard through a stethoscope placed on the skin over the artery inside the elbow.

Blood pressure is recorded as 2 measurements.

  • The reading on the gauge when blood flow is first heard is called the systolic pressure. Systolic pressure represents the peak blood pressure that occurs when the heart contracts.

  • The reading on the gauge when blood flow can no longer be heard is the diastolic pressure. Diastolic pressure represents the lowest blood pressure that occurs when the heart relaxes between beats.

These 2 pressures are expressed in millimeters of mercury (mm Hg). Systolic pressure, the higher of the two readings, is measured first.

Diastolic pressure is the lower reading. These blood pressure measurements are recorded as systolic/diastolic.

i.e., if your systolic pressure is 120 mm Hg and your diastolic pressure is 80 mm Hg, your blood pressure is recorded as 120/80 and read as "120 over 80."

source: Yahoo Health

blood pressure cuff

Monitoring your blood pressure at home


Key points

  • High blood pressure often is referred to as the "silent killer," because it usually has no obvious symptoms & most people can't tell if their blood pressure is high unless it's measured.

  • Home blood pressure monitors make it easy for people to measure their blood pressure at home. If you're concerned that you might have high blood pressure, or if your family has a history of high blood pressure, you may want to consider getting a home blood pressure monitor.

  • The Seventh Joint National Committee (JNC 7) on Prevention, Detection, Evaluation & Treatment of High Blood Pressure recommends that healthy adults with normal blood pressure (119/79 mm Hg or below) should have their blood pressure checked at least every 1 to 2 years. This can be done during any routine medical visit. 1

    • Adults who are prehypertensive (120–139 &/or 80–89 mm Hg) should have their blood pressure checked as often as recommended by their doctor, or at least annually. This can be done during any routine medical visit.

    • Adults with other risk factors for heart or blood vessel disease or evidence of disease caused by high blood pressure need to have their blood pressure checked more often.

source: Yahoo Health



How do I take my blood pressure?

You shouldn't:

  • eat
  • use tobacco products
  • use medications known to raise blood pressure (such as certain nasal decongestant sprays)
  • or exercise (for at least 30 minutes)

before taking your blood pressure.

Avoid taking your blood pressure if you are nervous or upset. Rest at least 15 minutes before taking a reading.

When you first obtain a blood pressure device, check its accuracy by comparing readings from it with readings obtained by a doctor or nurse taken in the doctor's office. Ask your doctor or nurse to observe your technique to make sure that you're using the device correctly. It's a good idea to have your device checked every year.

The size and position of the blood pressure cuff can greatly affect the accuracy of blood pressure readings. If the cuff is too small or too large, the measurements will be inaccurate. As a general rule, the inflatable part of the cuff needs to be at least as long as the widest measurement around your upper arm. Hospital and medical supply stores generally carry a variety of cuff sizes.

Record your blood pressure while you're seated in a comfortable, relaxed position. Try not to move or talk while you're measuring your blood pressure.

Be aware that the blood pressure readings may be 10 to 20 mm Hg different between your right arm and your left arm. For this reason, you may want to use the same arm for every reading.

Blood pressure readings also vary throughout the day. They usually are highest in the morning after you wake up and move around, decrease throughout the day and are lowest in the evening.

The instructions for using blood pressure monitors vary depending upon the specific device you choose. Here are the basic principles.

Manual blood pressure monitors: Sit with your arm slightly bent and resting comfortably on a table so that your upper arm is on the same level as your heart.

Expose your upper arm by rolling up your sleeve but not so tightly as to constrict blood flow. If you're unable to roll up your sleeve, remove your arm from the sleeve or take off your shirt.

Wrap the blood pressure cuff snugly around your upper arm so that the lower edge of the cuff is about 1 in. (2.54 cm) above the bend of your elbow.

See an illustration of blood pressure cuff placement.


A large artery, the brachial artery, is located slightly above the inside of your elbow. You can check its location by feeling for a pulse in the artery with the fingers of your other hand.

If you're using a stethoscope, place the earpieces in your ears and the bell of the stethoscope over the artery, just below the cuff. The stethoscope should not rub on the cuff or your clothing, since this may cause noises that can make your pulse hard to hear.

If you're using a cuff with a built-in stethoscope bell, be sure the part of the cuff with the stethoscope is positioned just over the artery. The accuracy of a blood pressure recording depends on the correct positioning of the stethoscope over the artery. You may want to have another person who can use a stethoscope properly help you take your blood pressure.

Close the valve on the rubber inflating bulb. Squeeze the bulb rapidly with your opposite hand to inflate the cuff until the dial or column of mercury reads about 30 mm Hg higher than your usual systolic pressure. (If you don't know your usual pressure, inflate the cuff to 210 mm Hg.) The pressure in the cuff will stop all blood flow within the artery temporarily.

Now open the pressure valve just slightly by twisting or pressing the valve on the bulb. The pressure should fall gradually at about 2 to 3 mm Hg per second.

Some blood pressure devices have a valve that automatically controls the fall at this rate. As you watch the pressure slowly fall, note the level on the dial or mercury tube at which you first start to hear a pulsing or tapping sound through the stethoscope.

The sound is caused by the blood starting to move through the closed artery. This is your systolic blood pressure.

Continue letting the air out slowly. The sounds will become muffled and finally will disappear. Note the pressure when the sounds completely disappear. Record this as your diastolic blood pressure. Finally, let out all the remaining air to relieve the pressure on your arm.

Electronic blood pressure monitors: For electronic models, press the on/off button on the electronic monitor and wait until the ready-to-measure "heart" symbol appears next to zero in the display window.

Then press the start button. The cuff will inflate automatically to approximately 180 mm Hg (unless the monitor determines that you require a higher value). It then begins to deflate automatically and the numbers on the screen will begin to drop. When the measurement is complete, the heart symbol stops flashing and your blood pressure and pulse readings are displayed alternately.

All blood pressure monitors: Repeat the same procedure 2 more times, for a total of 3 readings. Wait 5 to 10 minutes between recordings while the blood flows unimpeded in your arm.

Record your systolic and diastolic pressures, the date and time, which arm you used (left or right) and your position (sitting, standing, lying). Once you become accustomed to taking your own blood pressure, you probably will need to take it only once or twice.

Inspect your blood pressure cuff frequently to see whether the rubber tubing, bulb, valves and cuff are in good condition. Even a small hole or crack in the tubing can lead to inaccurate results.

You may feel some discomfort when the blood pressure cuff inflates, squeezing your arm.

If you have poor hearing or eyesight or limited manual dexterity, you may not be able to use a manual blood pressure monitor well enough to get accurate results. For people with these limitations, an electronic arm or wrist-cuff model is a better choice.



How much weight do you need to lose to lower blood pressure?

(January 2002)

The January 2, 2001 issue of the Annals of Internal Medicine includes a very important article on the effects of weight loss on those with diastolic blood pressures in the upper part of the normal range (being in the upper part of the normal range is a risk factor for heart attacks and strokes); a high blood pressure, that is above the normal range, is an even greater risk factor.

The investigators studied 595 men and women who were 10% to 65% above ideal weight (a little overweight to a lot overweight), average age 43 years, with an average systolic pressure of 127 millimeters of mercury (a little bit above what is desirable) and an average diastolic pressure of 86 millimeters of mercury (in the upper part of the normal range).

The participants received a lot of counseling to achieve weight loss. They were compared with 596 controls who were not given any weight reduction counseling.

The results, in part, show the problems involved in weight reduction and keeping the weight off. At 6 months, on average, the diet group lost almost 10 pounds. At 18 months, the group was attending fewer counseling sessions and the weight loss was an average 4.5 pounds.

By 3 years, they were, on average, back to their original weights, but still differed from the control group who had, on average, gained 4 pounds. At 6 months, when the weight loss was greatest, the diastolic blood pressure fell, on average, 2.7 millimeters of mercury (that does not sound like a lot, but it really is quite significant).


Those who lost the most weight (almost 20 pounds) dropped their diastolic blood pressure by 7 millimeters of mercury and their systolic pressures by 5 millimeters of mercury (in both cases, very significant drops). Those who managed to keep the weight off during the 3-year period maintained their lower blood pressures.

The authors concluded "significant long-term reductions in blood pressure and reduced risk for hypertension can be achieved with even modest weight loss".

Commentary: This is a very good study. It agrees with many other studies. Moderate weight loss can be very helpful not only for those with elevated blood pressures, but also for those with blood pressures in the upper part of the normal range who are at some increased risk of heart attack and stroke, and also at increased risk of becoming hypertensive with resulting further increase in risk of heart attack and stroke.

But there is a warning in this report. Even this motivated group given extensive counseling had trouble with weight management. As a group, they showed decreasing interest in the counseling and weight loss over the 3 years, and did not maintain either the weight loss or blood pressure reduction. Only 13% lost 10 pounds or more, and then kept it off for the 3-year study period.

source site: click here



Behavioral Counseling in Primary Care to Promote a Healthy Diet

Summary of Recommendations

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients in primary care settings.

I recommendation.

The USPSTF found fair evidence that brief, low to medium-intensity behavioral dietary counseling in the primary care setting can produce small to medium changes in average daily intake of core components of an overall healthy diet (especially saturated fat and fruit and vegetables) in unselected patients (see “Scientific Evidence” for discussion of patient populations and intensity of interventions).

The strength of this evidence, however, is limited by:

  • reliance on self-reported diet outcomes
  • limited use of measures corroborating reported changes in diet
  • limited follow-up data beyond 6 to 12 months
  • enrollment of study participants who may not be fully representative of primary care patients

In addition, there is limited evidence to assess possible harms (see “Clinical Considerations”). As a result, the USPSTF concluded that there is insufficient evidence to determine the significance and magnitude of the benefit of routine counseling to promote a healthy diet in adults.

Although community-based studies have evaluated measures to reduce dietary fat intake in children, no controlled trials of routine behavioral dietary counseling for children or adolescents in the primary care setting were identified.

The USPSTF recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease.

Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.

B recommendation.

The USPSTF found good evidence that medium to high-intensity counseling interventions can produce medium to large changes in average daily intake of core components of a healthy diet (including saturated fat, fiber, fruit, and vegetables) among adult patients at increased risk for diet-related chronic disease.

Intensive counseling interventions that have been examined in controlled trials among at-risk adult patients have combined nutrition education with behavioral dietary counseling provided by a nutritionist, dietitian, or specially trained primary care clinician (e.g.; physician, nurse, or nurse practitioner).

The USPSTF concluded that such counseling is likely to improve important health outcomes and that benefits outweigh potential harms. No controlled trials of intensive counseling in children or adolescents that measured diet were identified.3,4


Clinical Considerations

Several brief dietary assessment questionnaires have been validated for use in the primary care setting.5,6 These instruments can identify dietary counseling needs, guide interventions, and monitor changes in patients’ dietary patterns.

However, these instruments are susceptible to the bias of the respondent. Therefore, when used to evaluate the efficacy of counseling, efforts to verify self-reported information are recommended since patients receiving dietary interventions may be more likely to report positive changes in dietary behavior than control patients.7-10

Effective interventions combine nutrition education with behaviorally-oriented counseling to help patients acquire the skills, motivation, and support needed to alter their daily eating patterns and food preparation practices.

Examples of behaviorally-oriented counseling interventions include:

  • teaching self-monitoring,
  • training to overcome common barriers to selecting a healthy diet,
  • helping patients to set their own goals,
  • providing guidance in shopping and food preparation,
  • role playing, 
  • arranging for intra-treatment social support.

In general, these interventions can be described with reference to the 5-A behavioral counseling framework11:

  • Assess dietary practices and related risk factors,
  • Advise to change dietary practices,
  • Agree on individual diet change goals,
  • Assist to change dietary practices or address motivational barriers, 
  • Arrange regular follow-up and support or refer to more intensive behavioral nutritional counseling (e.g.; medical nutrition therapy) if needed.

Two approaches appear promising for the general population of adult patients in primary care settings:

(1) medium-intensity face-to-face dietary counseling (2 to 3 group or individual sessions) delivered by a dietitian or nutritionist or by a specially trained primary care physician or nurse practitioner, and

(2) lower-intensity interventions that involve 5 minutes or less of primary care provider counseling supplemented by patient self-help materials, telephone counseling, or other interactive health communications.

However, more research is needed to assess the long-term efficacy of these treatments and the balance of benefits and harms.

The largest effect of dietary counseling in asymptomatic adults has been observed with more intensive interventions (multiple sessions lasting 30 minutes or longer) among patients with hyperlipidemia or hypertension, and among others at increased risk for diet-related  chronic disease.

Effective interventions include individual or group counseling  delivered by nutritionists, dietitians, or specially trained primary care practitioners or health educators in the primary care setting or in other clinical settings by referral.

Most studies of these interventions have enrolled selected patients, many of whom had known diet-related risk factors such as hyperlipidemia or hypertension. Similar approaches may be effective with unselected adult patients, but adherence to dietary advice may be lower, and health benefits smaller, than in patients who have been told they are at higher risk for diet-related chronic disease.12

Office-level systems supports (prompts, reminders, and counseling algorithms) have been found to significantly improve the delivery of appropriate dietary counseling by primary care clinicians.13-15

Possible harms of dietary counseling have not been well defined or measured. Some have raised concerns that if patients focus only on reducing total fat intake without attention to reducing caloric intake, an increase in carbohydrate intake (e.g.; reduced-fat or low-fat food products) may lead to weight gain, elevated triglyceride levels, or insulin resistance.

Nationally, obesity rates have increased despite declining fat consumption, but studies did not consistently examine effects of counseling on outcomes such as caloric intake and weight.

Little is known about effective dietary counseling for children or adolescents in the primary care setting. Most studies of nutritional  interventions for children and adolescents have focused on non-clinical settings (such as schools) or have used physiologic outcomes such as cholesterol or weight rather than more comprehensive measures of a healthy diet.3,4


Scientific Evidence

Epidemiology and Clinical Consequences

Consuming a healthy diet is associated with lower risks for chronic disease morbidity and mortality. 4 of the 10 leading causes of death - coronary heart disease, some types of cancer, stroke, and type 2 diabetes - are associated with unhealthy diets.2

The relationships between dietary patterns and health outcomes have been examined in a wide range of observational studies and randomized trials with patients at risk for diet-related chronic disease. The majority of studies show that people consuming diets that are low in fat, saturated fat, trans-fatty acids, and cholesterol and high in fruits, vegetables, and whole grain products containing fiber have lower rates of morbidity and mortality from coronary heart disease, and possibly several forms of cancer.

In addition, one needs to balance calories with physical activity to maintain a healthy weight. The Dietary Guidelines for Americans16 recommend 3 to 5 daily servings of vegetables and vegetable juices, 2 to 4 daily servings of fruits and fruit juices, and 6 to 11 daily servings of grain products, depending on caloric needs.

In addition, they recommend a diet that contains less than 10% of calories from saturated fat, no more than 30% of calories from total fat, and limited consumption of trans-fatty acids.

Despite well-established benefits of consuming a healthy diet, more than 80% of Americans of all ages eat fewer than the recommended number of daily servings of fruit, vegetables, and grain products and more than the recommended proportions of daily calories from saturated fat and total fat.17

In 1994-1996, 28% of people aged 2 years and older consumed at least 2 daily servings of fruit, 49% consumed at least 3 daily servings of vegetables, 51% consumed at least 6 daily servings of grain products, 36% consumed less than 10% of daily calories from saturated fat, and 33% consumed 30% or less of daily calories from total fat.17

Dietary counseling practices of primary care clinicians indicate limited attention to diet modification. In a 1999-2000 survey of U.S. adults, 33% of respondents reported past-year physician advice to eat more fruits and vegetables, and 29% reported similar advice to reduce dietary fat.18

In another recent survey, 25% of adult patients from four community-based group family medicine clinics indicated that their physicians had advised them to limit or reduce the amount of fat in their diets.19


Effectiveness of Dietary Counseling

The ideal evidence to support behavioral dietary counseling would link counseling directly to improved health outcomes in randomized controlled clinical trials. In the absence of such evidence, the clinical logic behind counseling is based on a chain of critical assumptions:

(1) the clinician must be able to assess whether a patient is consuming a healthy diet,

(2) critical components of counseling must be routinely replicable,

(3) counseling must lead to sustained improvements in diet, and

(4) the health benefits of these changes in diet must be established and known to exceed the potential harms of intervention.11

A review conducted for the USPSTF identified 21 fair to good quality randomized controlled clinical trials of dietary counseling among patients without existing diet related chronic disease (e.g.; coronary heart disease or cancer).

Trials had to include follow-up of at least 3 months after intervention for at least 50% of the enrolled subjects and include measures of dietary intake. Studies that assessed only physiologic measures (e.g.; lipid levels, weight, or body mass index [BMI]) were not included.

Additional details of the inclusion and exclusion criteria, and methods for assessing quality of studies, are described elsewhere.2,20

Most of these trials focused exclusively on dietary counseling, though some targeted diet as part of a broader risk-factor modification program that also addressed smoking and sedentary lifestyle.21-24 Most studies targeted reductions in total fat or saturated fat intake (n=17).7-9,13-15,21-33

Ten studies targeted increased fruit and vegetable intake 8,9,12,21,25-27,32,34,35 and 7 targeted increased intake of fiber and whole grains.7,13,22,26,27,32,36

Most studies (n=11) focused on a single nutrient, although 10 focused on changes in 2 or more nutrients.7-9,13,21,22,25-27,32

Studies were classified by intensity of the interventions evaluated, based on the number and length of counseling sessions, the magnitude and intensity of educational materials provided, and the use of supplemental interventions such as support group sessions or cooking classes.

Low-intensity interventions involved 1 contact lasting less than 30 minutes. High-intensity interventions involved more than 6 contacts lasting more than 30 minutes. Medium-intensity interventions fell between low and high-intensity.

Effects of counseling were classified as “large,” “medium,” or “small” for each component of diet measured.2 With reference to these specific, defined categories, the USPSTF concluded that large  effects sustained over time were likely to produce important health benefits (reductions in morbidity and mortality).37-41

Given the large attributable risk associated with these dietary components, it is possible that medium or even small changes in diet would yield important health benefits across a large population.

However, to date, there is little direct evidence about the effect of small and medium dietary changes on the future risk for coronary heart disease, making it difficult to determine with certainty whether such changes will translate into changes in the incidence of chronic disease. Better data about these linkages are needed.


Assessing Dietary Behaviors in Primary Care Patients

A number of brief, validated dietary assessment instruments can identify dietary counseling needs, guide intervention, and monitor change among adult patients in primary care and other clinical settings. Most of these instruments can be self administered, are easily scored, have fewer than 40 items, and take 10 minutes or less to administer.

However, these instruments are susceptible to bias (i.e.; patients report healthier diets than they actually consume); some studies indicate that underreporting of caloric intake is common, especially among obese patients.10 When used to evaluate counseling efficacy, efforts to verify self-reported information are recommended. 7-10,13,24,42

For children aged 9 years and older, food frequency questionnaires administered directly to children can provide a reasonably accurate picture of usual dietary patterns, with correlations with criterion measures ranging from 0.46 to 0.79.6 No brief valid dietary screening instruments were identified for children below the age of 9 years. The optimal interval for screening adults or children is not known.


Effectiveness of Routine Counseling in Primary Care

The USPSTF found 9 fair to good quality randomized controlled trials of behavioral dietary counseling in unselected populations in primary care settings. The majority of these interventions focused on change in more than one nutrient (i.e.; fat/saturated fat, fruit/vegetables, and/or fiber).7,9,13,25-27,32

Most of these trials combined basic nutrition education with behaviorally-oriented counseling to help patients acquire the skills, motivation, or support needed to alter their daily eating patterns and food selection and preparation practices. Duration of interventions lasted from 1 week to 1 year.

No controlled trials with children or adolescents were identified. The 9 studies varied in the amount of face-to-face counseling involved. Two studies of medium-intensity interventions evaluated multiple face-to-face sessions of behavioral dietary counseling provided in the primary care setting by a dietitian or nutritionist, or by a primary care physician or nurse practitioner who had received brief training in dietary counseling.32,36

These interventions involved 2 to 3 group or individual sessions lasting 30 minutes, with follow-up visits at 1 and 3 months. Baron et al reported an 84% patient recruitment / participation rate.36 Seven studies involved little or no face-to-face counseling and placed greater emphasis on patient self-help materials, manuals, and varied forms of interactive health communication.

Two were studies of low-intensity interventions that combined brief (<5 minutes) face-to-face counseling sessions with a primary care physician or nurse with self-help materials.7,13

Three others were studies of low intensity interventions that relied either on mailed self-help materials25,34 or on health behavior  change messages delivered via an automated computer-based voice system.27

Campbell et al25 found significantly greater benefits from tailored than non-tailored self help materials; Lutz et al34 did not. The  remaining 2 were medium-intensity interventions that combined a computer-generated personalized letter and motivational phone call(s) from a trained health educator with a series of self-help mailings and newsletters.9,26

Patient recruitment and participation in this second group of studies ranged from 16%34 to 80%,25 with most in the 40% to 70% range.

These studies in unselected populations produced mostly small (n=9) and medium (n=8) as opposed to large (n=3) improvements in self reported dietary behaviors, most of which were statistically significant. Most studies followed patients for 6 months or less post-intervention; 4 followed patients for as long as 12 months.9,13,32,36

Only 2 of them assessed impacts on intermediate biological endpoints (e.g.; serum cholesterol, weight, or BMI), of which none reported significant treatment effects.13,36 No studies examined adverse treatment effects.

The USPSTF also reviewed 2 additional studies that enrolled predominantly healthy pre-menopausal women, a large proportion of whom were overweight or obese. These studies employed high-intensity interventions involving multiple dietitian-led individual12 or group33 counseling sessions.

One intervention extended over a 6-month period and aimed at increasing fruit and vegetable intake12; the other extended over a 5-year period and focused on dietary fat reduction. Both trials reported large treatment effects in self-reported dietary behavior at 6-month post-intervention follow-up, and both reported favorable changes in biological risk factors or markers.

However, participants in these studies were highly selected and motivated volunteers. The USPSTF concluded that results could not be generalized to more representative primary care populations.


Effectiveness of Intensive Counseling in Patients at Risk for Chronic Disease

The USPSTF found 10 fair to good quality randomized controlled trials that tested whether medium to high-intensity interventions delivered in primary care or other clinical settings led to improved dietary outcomes among adults who were identified as being at increased risk for diet-related chronic disease.8,14,15,21-24,28-31,35

For 2 of these trials, 2 research reports for each were  reviewed. 14,15,28,29 No controlled trials with children or adolescents at risk for chronic disease were identified that reported dietary outcomes.

The interventions involved a two-step assessment:

  • screening to identify a patient’s risk status using chart audit/clinical exam/laboratory testing to screen for hyperlipidemia, hypertension, family history of heart disease or breast cancer, overweight, obesity, smoking status, and sedentary lifestyle,
  • followed by assessment of dietary practices using a variety of dietary assessment tools and protocols (e.g.; food frequency questionnaires, 3-4 day food records, and brief dietary assessment instruments).

Hyperlipidemia was included as a risk factor in most of these studies. Four trials addressed diet along with physical activity and/or smoking.21-24 Most of the trials tested multi-session group or individual counseling that combined nutrition education with behaviorally-oriented counseling.

Most studies focused on reducing saturated fat and/or total fat intake; 2 of these studies also targeted fiber or fruit and vegetable intake,21,22 and one focused on increasing fruit and vegetable intake only.35

Most studies also reported intermediate health outcomes, such as serum lipid levels, blood pressure, weight, and/or BMI. Follow-up in most studies (n=6) was 12 months or longer, some as long as 4 to 6 years.21-24,28-30

Six of the trials took place outside of primary care settings, where counseling was provided by an experienced nutritionist, dietitian, and/or health educator in 8 to 20 sessions over a period ranging from 4 months to 5 to 6 years.8,21,23,28,29,31,35

Four trials took place within primary care settings,14,15,22,24,30 where counseling was provided by specially trained primary care physicians or nurses (training ranging from 60 minutes to 3 days) in 3 to 6 special sessions supplemented by follow-up phone calls and/or newsletters, and follow-up at routine visits over a period of 4 to 18 months.

In two primary care based studies,14,15,30 behavioral dietary counseling for patients with hyperlipidemia was supplemented, if needed, with lipid-lowering medication and/or referral to outside counseling by a dietitian. Ockene et al15 found that implementing office-level systems supports (prompts, reminders, and counseling algorithms) significantly improved primary care provider adherence to the comprehensive dietary counseling.

In summary, interventions for patients at risk for chronic disease resulted in dietary behavior changes that were small (n=3),14,15,21,22 medium (n=6),8,21,22,24,30,35 and large (n=4),8,23,28,31 most of which were statistically significant. The magnitude and duration of these changes were greater with higher intensity interventions than with interventions of lower intensity.

More than 1/2 of these studies found that self-reported dietary changes were accompanied by significant improvements in serum lipids, weight, or BMI.8,21,22,28-30 These findings help corroborate patients’ self-reported dietary changes and confirm the overall health benefits of the observed changes in diet.



Medium to high-intensity behavioral interventions appear to produce consistent, sustained, and clinically important changes in dietary intake of total fat, saturated fat, fruit and vegetables, and fiber. However, these trials were generally either conducted with patients with known risk factors for diet-related chronic disease, or performed in special clinics with highly selected patients and specially trained providers.

The most effective interventions generally combined education, behaviorally-oriented counseling, and patient reinforcement and follow-up. More intensive interventions, and those of longer duration, are associated with larger magnitude of benefit and more sustained changes in diet.

Available studies do not, however, allow firm conclusions about the essential or most effective elements of these multi-component interventions, their relative effect on specific dietary constituents (e.g.; fat, fruits and vegetables, or fiber), or the relative efficacy of targeting single or multiple dietary risks or addressing diet in the context of broader lifestyle interventions.

Although evidence is stronger for counseling patients who are at increased risk for chronic disease, such as those with  hyperlipidemia, than for the general population of patients, it is not possible to disentangle the effects of patient risk status from the effects of intervention intensity.

Adherence to these intensive interventions and the dietary changes they require may be dependent on patients’ heightened perceived risk and motivation for change. Existing trials of routine dietary interventions in unselected primary care populations have generally produced only small to medium changes in self reported diet.

Although direct comparisons cannot be made, results from medium-intensity, routine face-to-face counseling from:

  • nutritionists
  • dietitians
  • or specially trained primary care practitioners (physicians, nurses, or nurse practitioners)

appear similar to those achieved through less intensive, minimal-contact interventions to supplement brief primary care provider advice/counseling.

The consistently positive effects of such interventions on diet in unselected patient populations establish these interventions as highly promising as part of routine7 preventive care for patients at average risk for chronic disease.

The USPSTF concluded, however, that existing studies do not provide sufficient evidence to recommend these interventions for widespread use due to a number of limitations such as modest overall patient recruitment/participation rates, reliance on self-reported outcome measures, relatively short follow-up periods, uncertainty about the health effects of small and medium changes in diet, and the lack of evidence about possible adverse effects of counseling.

Two studies suggest high intensity interventions can be effective in selected patients at average risk, but the applicability of these findings and the feasibility of these interventions in primary care settings are uncertain.12,33


Recommendations of Others

Dietary guidelines for the general population have been issued by the U.S. Department of Agriculture (USDA)16 and the Department of Health and Human Services; specific dietary objectives for the nation are outlined in Healthy People 2010.17 Guidelines from the American Heart Association (AHA) and the American Cancer Society (ACS) address diets that will lower the risk for heart disease and cancer, respectively.43,44

These guidelines generally agree in recommending a diet that includes a variety of:

  • vegetables
  • and grain products
  • is low in saturated fat and cholesterol 
  • moderate in total fat
  • balances calories with physical activity

to maintain a healthy weight.

A variety of groups have recommended nutritional counseling or dietary advice for patients at average risk for chronic disease, including the American College of Preventive Medicine (ACPM), American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG).45-48

These recommendations are based primarily on the benefits of a healthy diet rather than on evaluations of the efficacy of counseling.

The Canadian Task Force on Preventive Health Care (CTFPHC) concluded in 1994 that there was fair evidence to provide general dietary advice to all patients, based on a limited number of trials of counseling.49

Recommendations on nutritional counseling for patients at risk (e.g.; those who have hypertension or hyperlipidemia) have been issued by the American Dietetic Association (ADA) and two panels sponsored by the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute.

The ADA recommends that primary care providers screen for nutrition-related illnesses, prescribe diets, provide preliminary counseling on specific nutritional needs, follow up with patients, and refer patients to appropriate dietetic professionals when  necessary.50

Similarly, The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends that dietary assessments be included as part of routine medical history and that physicians counsel patients on lifestyle modifications for the prevention and treatment of high blood pressure (lose weight if overweight, limit alcohol intake, reduce sodium intake, reduce saturated fat and cholesterol intake).51

The National Cholesterol Education Program recommends that individuals with elevated levels of low density lipo-protein limit their intake of fats, particularly saturated fats, and cholesterol and increase dietary fiber.52

source site: click here (all references listed at the source site)

Why should I monitor my blood pressure at home?

Home blood pressure monitoring provides a measurement of a person's blood pressure at different times and in different environments, such as at home and at work, throughout the day.

It may be done to:

  • Help establish the diagnosis of high blood pressure.

  • Monitor the effects of medication taken to lower blood pressure.

  • Help people with high blood pressure to see the effects of medications or lifestyle changes on their blood pressure. Home monitoring can help people feel more involved in and more in control of their own health care.

  • Help diagnose low blood pressure that may be caused by irregular heart rhythms (arrhythmias), certain medications, or other medical conditions.

  • Monitor the blood pressure of people who are taking medications, such as monoamine oxidase inhibitors (MAOIs), that can cause episodes of high pressure.

Blood pressure normally fluctuates from day to day and even from minute to minute depending upon:

  • activity
  • posture
  • temperature
  • diet
  • drugs
  • emotional and physical state

Home blood pressure monitoring is most effective when the person also records his or her daily activities, such as the time when medication is taken or when a stressful event occurs, in a diary. This can help explain an unusual blood pressure reading and help a doctor adjust medication dosages accurately.

Some people experience a significant rise in blood pressure only when they're in a doctor's office. This is called "white-coat hypertension" and probably is caused by anxiety about the doctor visit.

By monitoring blood pressure at home, these people can often find out whether their blood pressure readings generally are lower when they aren't in the doctor's office.

In some cases, ambulatory blood pressure monitoring (ABPM) also may be done to help diagnose white-coat hypertension.

source: Yahoo Health

The Silent Killer - A Cautionary Tale
By Michael Wooller
It’s often referred to as the “silent killer” and it’s only by some form of divine intervention that it didn’t kill me.

I’m talking about high blood pressure.

According to recent estimates, nearly one in three adults in the industrial nations is likely to have high blood pressure, but because there are no symptoms, nearly one-third of these people don't know they have it. In fact, many people have high blood pressure for years without knowing it. The only way to tell if you have high blood pressure is to have your blood pressure checked.

Uncontrolled high blood pressure can lead to stroke, heart attack, heart failure or kidney failure. Hence high blood pressure is often called the "silent killer."

As I got into my forties I very occasionally chanced to get my blood pressure checked. It was usually on the high side. I would usually say things like “well I have ‘white coat syndrome’ so of course it is high. It’s always high when taken by a doctor”. And in fact if I had it taken at the local chemist it was usually a bit lower, so I wasn’t worried. Besides I didn’t want to be taking tablets for the rest of my life!

I didn’t go to the doctor very often. I was healthy and never had the need. I didn’t smoke, only drank now and then. However, on the rare occasions that I did visit the doctor, he would point out that I may be healthy but I certainly wasn’t fit!
Anyway this particular doctor was so concerned about me that after I left the district he sent me a prescription for blood pressure tablets!
I took them for a while, but I couldn’t see the point. OK, so my blood pressure may be a bit high, but I felt fine. There was nothing wrong with me. I had no symptoms. Hardly ever went to see a GP.

One night I drove home from work. I had been working a late shift so I got home around midnight. Had a glass of wine, checked my emails, as you do…………

First it was just awareness. The beautiful smiling face of my wife, brightly coloured in a sea of gray. It seems we had been talking for a while, though I don’t know what I had said. Penny’s voice is full of love and joy and encouragement.
I have no context to put it in so I just accept it in the now. There is only now. I have no past. The future is not contemplated. I see my daughter’s face and hear words of love, joy and encouragement. I am doing exceptionally well. With regards to what, I wonder? I gradually become aware of the ICU bed and the tubes and the wires and the oxygen mask. And it is all so normal. I’ve always been like this.

I had suffered an aortic dissection. It had been caused by years of high blood pressure. The main blood vessel serving my vital organs had split and was blocking the blood supply and my aortic valve was damaged. But by some miracle I was alive.

The fact that I am writing this piece is one of a series of miracles.

The fact that my youngest daughter was visiting us, sleeping on the lounge but not asleep and heard me fall is a miracle. The fact that I made alive to the hospital was a miracle as well as a testament to the skills of the paramedics who kept me alive. The fact that I survived the eight hour operation is another miracle and a testament to the skills of the surgeons and medical staff. The fact that I was found in time, survived the journey to the hospital, the operation and had no brain or organ damage is another miracle. I am very lucky. Most are not.

I am now on four different blood pressure tablets and will be for the rest of my life. However long that is!

Because my vascular system is weakened and damaged, I have to make sure that I average a blood pressure of less than 120/70 and I get yelled at if I pick my grandchildren up because that sort of muscular activity increases blood pressure.
But then, at least I am still here to be yelled at!

As you get older, keeping blood pressure in check is fundamental if you want a long and happy life.
I now have my own blood pressure meter and keep a constant check on it.

The moral is, take your blood pressure seriously. Buy yourself a meter, talk to your doctor, be proactive. It’s your life.

Prevention is simple. The results of ignorance often can only be rectified by divine intervention.

What is your blood pressure now?


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