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.

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.

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Behavioral Counseling in Primary Care to Promote a Healthy Diet

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.

• 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

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

(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

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.

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.

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.

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

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:

• fruits
• 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

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