Amanda D. Hyre

Effect of dietary fiber intake on blood pressure: a meta-analysis of randomized, controlled clinical trials

Objective We conducted a meta-analysis of 25 randomized controlled trials published in English-language journals before February 2004, to assess the effect of dietary fiber intake on blood pressure (BP). Design Using a standardized protocol, information on study design, sample size, participant characteristics, duration of follow-up and change in mean BP, was abstracted. The data from each study were pooled using a random effects model to provide an overall estimate of dietary fiber intake on BP. Intervention Dietary fiber intake was the only significant intervention difference between the active and control groups. Results Overall, dietary fiber intake was associated with a significant −1.65 mmHg [95% confidence interval (CI), −2.70 to −0.61] reduction in diastolic BP (DBP) and a non-significant −1.15 mmHg (95% CI, −2.68 to 0.39) reduction in systolic BP (SBP). A significant reduction in both SBP and DBP was observed in trials conducted among patients with hypertension (SBP −5.95 mmHg, 95% CI, −9.50 to −2.40; DBP −4.20 mmHg, 95% CI, −6.55 to −1.85) and in trials with a duration of intervention ≥ 8 weeks (SBP −3.12 mmHg, 95% CI, −5.68 to −0.56; DBP −2.57 mmHg, 95% CI, −4.01 to −1.14). Conclusions Our results indicate that increased intake of dietary fiber may reduce BP in patients with hypertension and suggests a smaller, non-conclusive, reduction in normotensives. An intervention period of at least 8 weeks may be necessary to achieve the maximum reduction in BP. Our findings warrant conduct of additional clinical trials with a larger sample size and longer period of intervention to examine the effect of dietary fiber intake on BP.

Prevalence and Predictors of Poor Antihypertensive Medication Adherence in an Urban Health Clinic Setting

Poor medication adherence may contribute to low hypertension control rates. In 2005, 295 hypertensive patients who reported taking antihypertensive medication were administered a telephone questionnaire including an 8‐item scale assessing medication adherence. Overall, 35.6%,36.0%, and 28.4% of patients were determined to have good, medium, and poor medication adherence, respectively. After multivariable adjustment, adults younger than 50 years and 51 to 60 years were 1.39 (95% confidence interval [CI], 0.56–3.42) and 1.53 (95% CI, 0.64–3.66),respectively, times more likely to be less adherent when compared with their counterparts who were older than 60 years. Black adults and men were 4.30 (95% CI, 1.06–17.5) and 2.45 (95% CI, 1.04–5.78) times more likely to be less adherent, respectively. Additionally, caring for dependents, an initial diagnosis of hypertension within 10 years, being uncomfortable about asking the doctor questions, and wanting to spend more time with the doctor if possible were associated with poor medication adherence. The current study identified a set of risk factors for poor antihypertensive medication adherence in the urban setting.

Methods to improve medication adherence in patients with hypertension: current status and future directions.

Purpose of review Efficacious pharmacologic treatments are available for the management of hypertension, yet only about 50% of patients treated with antihypertensive medications have their blood pressure controlled. A key factor contributing to poor blood pressure control is suboptimal adherence to prescribed therapy. Despite numerous studies conducted over the last 50 years to identify the best method for increasing patient compliance, no single intervention has emerged as superior to the others. This article reviews the effectiveness of methods to improve antihypertensive medication adherence, discusses the effect of drug benefit caps on compliance, and proposes a framework for future clinical and research directions. Recent findings Several recent systematic reviews and meta-analyses have attempted to quantify the effectiveness of various methods to improve adherence. As a result of the multiple factors influencing medication adherence, a patient-centered approach that tailors interventions aimed at overcoming barriers to adherence may be necessary. Summary Physicians and other health care professionals should consider nonadherence to medication when evaluating a patient with poor blood pressure control. In selecting an intervention to improve compliance to medications, clinicians should consider engaging the patient in an intervention that overcomes patient-specific barriers. Future research should target development of adherence models, which simultaneously examine the effects and interactions of social, psychological, and biologic variables on antihypertensive medication adherence.

Antihypertensive Prescriptions for Newly Treated Patients Before and After the Main Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Results and Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Guidelines

Main results of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial were published in December 2002. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, published in May 2003, recommended thiazide-type diuretics as initial pharmacological treatment alone or in combination with another drug in most patients with hypertension. To assess changes from before to after these publications, we compared antihypertensive medication prescriptions filled by patients who initiated pharmacological antihypertensive treatment in a large managed care organization during 3 time periods: (1) July 1, 2001, to June 30, 2002 (before these publications; n=1354); (2) July 1, 2003, to June 30, 2004 (to assess short-term changes; n=1542); and (3) July 1, 2004, to June 30, 2005 (to assess extended changes; n=1865). The percentage of patients initiating antihypertensive treatment with a thiazide-type diuretic increased from 30.6% to 39.4% (P<0.001) between 2001–2002 and 2003–2004, and the increase was maintained at 36.5% in 2004–2005 (P<0.001 compared with 2001–2002 and P=0.33 compared with 2003–2004). Among patients without diabetes mellitus, renal disease, a history of myocardial infarction, or heart failure, the percentage initiating pharmacological antihypertensive treatment with a thiazide-type diuretic increased from 33.1% in 2001–2002 to 43.4% in 2003–2004 (P<0.001) and remained increased (41.0%) in 2004–2005 (P<0.001 and P=0.23 compared with 2001–2002 and 2003–2004, respectively). Despite a sustained increase in the use of thiazide-type diuretics, this study indicates that an opportunity exists to increase adherence to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines.

Association of Serum Intact Parathyroid Hormone with Lower Estimated Glomerular Filtration Rate

BACKGROUND AND OBJECTIVES The prevalence of mineral metabolism abnormalities is almost universal in stage 5 chronic kidney disease (CKD), but the presence of abnormalities in milder CKD is not well characterized. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data on adults > or =20 yr of age from the National Health and Nutrition Examination Survey 2003-2004 (N = 3949) were analyzed to determine the association between moderate declines in estimated GFR (eGFR), calculated using the Modfication of Diet in Renal Disease formula, and serum intact parathyroid hormone (iPTH) > or = 70 pg/ml. RESULTS The geometric mean iPTH level was 39.3 pg/ml. The age-standardized prevalence of elevated iPTH was 8.2%, 19.3%, and 38.3% for participants with eGFR > or = 60, 45 to 59, and 30 to 44 ml/min/1.73 m(2), respectively (P-trend < 0.001). After adjustment for age; race/ethnicity; sex; menopausal status; education; income; cigarette smoking; alcohol consumption; body mass index; hypertension; diabetes mellitus; vitamin D supplement use; total calorie and calcium intake; and serum calcium, phosphorus, and 25-hydroxyvitamin D levels-and compared with their counterparts with an eGFR > or = 60 ml/min/1.73 m(2)-the prevalence ratios of elevated iPTH were 2.30 and 4.69 for participants with an eGFR of 45 to 59 and 30 to 44 ml/min/1.73 m(2), respectively (P-trend < 0.001). Serum phosphorus > or = 4.2 mg/dl and 25-hydroxyvitamin D < 17.6 ng/ml were more common at lower eGFR levels. No association was present between lower eGFR and serum calcium < 9.4 mg/dl. CONCLUSIONS This study indicates that elevated iPTH levels are common among patients with moderate CKD.

Does waiver of written informed consent from the institutional review board affect response rate in a low-risk research study?

Background Requiring written informed consent for a minimal-risk survey may result in limited participation rates. Methods Data from a cross-sectional survey of 177 older patients (87 blacks and 90 whites) with hypertension enrolled in the managed care Medicare risk product were used to assess participation rates pre- and postwaiver of written informed consent and Health Insurance Portability and Accountability Act (HIPAA) authorization. Prior to the waivers being granted, patients were contacted two times via mail with an introductory letter and an informed consent document. Those who completed and returned the informed consent document were administered the questionnaire. After 6 weeks, a waiver of written informed consent and HIPAA authorization was obtained from the Institutional Review Board. Nonparticipants were reapproached and asked to complete the questionnaire. Participation rates were recorded before and after receiving the waivers. Results Participation rates increased from 21.5% in the prewaiver period to 57.4% in the postwaiver period (p < .001). Prewaiver participation differed by demographic subgroup and was higher among whites (26.7%) versus blacks (16.1%; p = .087), men (31.6%) versus women (16.7%; p = .024), and participants ≥ 75 years old (28.4%) versus < 75 years old (14.6%; p = .025). In contrast, the postwaiver participation rate did not differ significantly across race, gender, or age subgroupings. Significant increases in participation rates from the pre- to the postwaiver time period were noted within each demographic subgroup (all p < .01). Conclusions We identified a substantial increase in participation rates postwaiver of written informed consent and HIPAA authorization in a minimal-risk survey. The need for written documentation for minimal-risk surveys may negatively impact recruitment of blacks, women, and patients < 75 years old.

Psychosocial Status of Hemodialysis Patients One Year After Hurricane Katrina

Background:Hemodialysis patients experience a high degree of psychosocial impairment. Methods:The psychosocial status of hemodialysis patients after Hurricane Katrina was evaluated using the Hurricane Coping Self-Efficacy (HCSE) measure, the Short Form-12 Health Survey (physical component summary [PCS] and mental component summary [MCS]), and the Center for Epidemiologic Studies Short Depression Scale (CES-D). These scales were administered to 391 hemodialysis patients (86% participation rate), 7 to 14 months after Hurricane Katrina. Results:The mean score (standard deviation) was 36.2 (9.6) for the HCSE scale, 37.1 (10.9) and 46.7 (12.7) for the PCS and MCS, respectively, and 10.0 (6.5) on the CES-D. Symptoms of depression (CES-D scores ≥10) were present in 45.5% of patients. After age, race, and gender adjustment, evacuating less than 2 days before Hurricane Katrina making landfall and more fear of dying were associated with less favorable scores on the HCSE, MCS, and CES-D scales. Patients placed in a shelter and with a longer displacement had significantly lower MCS scores and more depressive symptoms. More depressive symptoms were observed among patients hospitalized in the month after the storm. Those who evacuated to a hotel, with more fear of dying and who were hospitalized in the month after Hurricane Katrina had lower scores on the PCS. Conclusions:Impaired psychosocial status was common among dialysis patients surviving Hurricane Katrina and associated with reduced coping. These data demonstrate the need for screening and management of psychosocial issues in hemodialysis patients after disasters.

Psychometric properties of the Hurricane Coping Self-Efficacy measure following Hurricane Katrina

The Hurricane Coping Self-Efficacy (HCSE) measure is a validated tool for assessing self-efficacy appraisals after hurricanes. Data were collected 6 months after Hurricane Katrina from 1542 employed residents of New Orleans, and 181 participants randomly selected to complete a repeat survey to confirm the psychometric properties of the HCSE measure. Overall, coping self-efficacy was greater among men, the most educated and those with the highest income. Confirmatory factor analyses indicated a relatively good fit of the HCSE items into a single construct, with Bentlers comparative fit and McDonalds centrality index scores of 0.92 and 0.87, respectively. The repeatability of scores was high (Pearsons correlation = 0.70). Additionally, HCSE scores were highly correlated with validated scales of perceived stress and posttraumatic stress symptoms, and significantly lower scores were observed among participants who sought counseling after the storm. The HCSE measure exhibited excellent internal consistency, external validity and repeatability after Hurricane Katrina.

345 BLOOD PRESSURE KNOWLEDGE IN URBAN HYPERTENSIVE MINORITIES.

Purpose Knowledge of hypertension risks and consequences can equip patients with the motivation and skills necessary to reduce their blood pressure. However, this knowledge is thought to be limited in indigent, minority populations. Methods Between January and August 2005, a trained interviewer administered a telephone questionnaire to 296 patients identified from an urban public hospital primary care clinic. Blood pressure knowledge was assessed through a validated 10-item/10-point questionnaire and included items measuring patient understanding of the prognosis, treatment, and adverse outcomes of hypertension. Results Overall, 12% (n = 34) of patients answered all 10 questions correctly. Only 8% (n = 23) answered less than half of the questions correctly. Among participants, 98% (n = 290) and 95% (n = 281) of patients knew that high blood pressure was associated with heart attacks and stroke, but only 76% (n = 226) knew it caused kidney disease. Only 42% (n = 124) of respondents knew that high blood pressure did not cause cancer; 8% (n = 24) responded they thought hypertension did cause cancer and 50% (n = 148) were uncertain. A logistic regression model was performed adjusting for age, race, gender, and including time since hypertension diagnosis, comfort asking their doctor questions, having dependents, income level, cigarette smoking, cohabitation status, and education. The odds ratios (95% confidence interval (CI)) of having limited blood pressure knowledge (score # 7 versus

Trends in ATP-III-defined high blood cholesterol prevalence, awareness, treatment and control among U.S. adults.

9) were 2.4 (1.1-5.0) for patients > 60 compared to # 50 years, 5.2 (1.7-15.7) and 3.0 (1.4-6.3) for patients who were first diagnosed with hypertension < 1 year and 1-5 years ago, respectively, compared to > 10 years ago, and 2.3 (1.2-4.3) for patients with less than a high school education compared to completion of high school. Conclusions Knowledge of high blood pressure in these patients receiving care in an urban public health system is good, except in specific areas, such as its relationship to chronic kidney disease. Older patients and those with less formal education are most at risk for insufficient hypertension knowledge. Targeting hypertension education content to select areas and audiences may improve efficiency and effectiveness of hypertension education in urban, minority populations.