Nora L. Keenan

Social support, stress, and blood pressure in black adults

Psychosocial factors arising from socioeconomic disadvantage and discrimination may contribute to the excess risk of elevated blood pressure in African‐Americans. The purpose of this study was to assess the association of social support and stress with blood pressure in a community‐based sample of 25‐ to 50‐year‐old black adults in Pitt County, NC. A stratified random sample of dwellings was selected in 1988, and 1,784 black adults (80% of those eligible) were interviewed. Analyses were sex specific and adjusted for age, obesity, and waist/hip ratio. In separate analyses of emotional support, instrumental support, and stress with blood pressure, all associations were in the predicted direction (inverse for support, direct for stress) but were stronger for systolic than for diastolic blood pressure. Differences in systolic blood pressure associated with low support or high stress ranged from 5.2 to 3.6 mmHg in women and 3.5 to 2.5 mmHg in men. In simultaneous regression analyses of support and stress, each of the separate effects was reduced for women, but a sizable aggregate effect of low support and high stress remained [+7.2 mmHg (95% confidence limits = +1.3, +13.1) for systolic blood pressure and +4.0 mmHg (95% confidence limits = +0.1, +7.9) for diastolic blood pressure].

Physical activity and hypertension in black adults: the Pitt County Study.

The relation of physical activity to hypertension was examined in 1751 Black adults in Pitt County, NC. More women (65%) than men (44%) were classified as sedentary. Sedentary behavior was not associated with the prevalence of hypertension in men, but was associated with a 31% increase in prevalence for women (sedentary-26.2%; active-20.0%; P less than .01). The association in women was independent of other risk factors for hypertension.

Impact of patient incompetence on decisions to use or withhold life-sustaining treatment

PURPOSE To study the relationship of patient incompetence to decisions to withhold life-sustaining treatments. DESIGN AND PATIENTS This prospective cohort study consisted of 311 inpatients with end-stage congestive heart failure, chronic obstructive pulmonary disease, cancer, and cirrhosis. METHODS Daily assessments were used to classify patients as incompetent if they had depressed consciousness, major psychiatric disease, or cognitive impairment throughout their hospital stay. Treatment decisions were assessed by observation and medical record review. RESULTS Forty-eight (15%) patients were incompetent: 33 had depressed consciousness, 11 failed cognitive screens, and 4 had major psychoses. Incompetent patients were more severely ill (APACHE II score 14.9 versus 12.6, P < or = 0.05) and more commonly had cancer (73% versus 44%, P < or = 0.05). Decisions were made to withhold cardiopulmonary resuscitation (CPR) for 71% of incompetent patients, but for only 21% of competent patients (P < or = 0.001). Decisions to withhold other treatments were also more common for incompetent patients (42% versus 16%, P < or = 0.001). After controlling for differences in severity of illness, diagnosis, race, and insurance status, patient incompetence remained strongly associated with a decision to withhold CPR (odds ratio 4.0, 95% confidence interval 1.8 to 8.9) and with decisions to withhold other treatments (odds ratio 2.4, 95% confidence interval 1.1 to 5.3). Decisions for incompetent patients were made by physicians with family surrogates 79% of the time. No decision was based on a written advanced directive. Patient preference was the rationale for 41% of decisions to withhold CPR from incompetent patients. Major conflict occurred in only 1% of all cases where a decision was made to withhold treatment. CONCLUSIONS Despite current legal and ethical debate, incompetent patients are far more likely than competent patients to have life-sustaining treatment withheld. Most decisions are made by a consensus of physicians and family surrogates, and major conflicts rarely occur.

Correlates of Postural Hypotension in a Community Sample of Elderly Blacks and Whites

Postural hypotension is thought to be prevalent among the elderly, but few community‐based studies of this condition have been conducted. In addition, little is known about postural hypotension in blacks despite well documented racial differences in hypertension and stroke. Data on 659 elderly (≥60 years of age) participants in a survey of two rural, biracial townships were analyzed to describe the frequency and correlates of postural hypotension. Twelve percent of the 659 adults experienced a drop of 10 mmHg or greater in systolic blood pressure on going from sitting to standing (supine measures were not available). This degree of postural hypotension was twice as common for whites as for blacks (14.5% vs 7.5%, P = 0.01). Postural hypotension was associated with elevated sitting blood pressure and showed positive but statistically non‐significant relationships with anti‐hypertensive medications and leanness. The association between race and postural hypotension persisted after adjusting for these and other risk factors (OR = 2.2, 95% CI:1.2,4.0).

Health-related quality of life and hypertension status, awareness, treatment, and control : National Health and Nutrition Examination Survey, 2001-2004

Objective We examined health-related quality of life measures by hypertension status, awareness, treatment, and control. Methods Five unfavorable health-related quality of life measures were analyzed among 8303 adults aged 20 years or older who participated in the 2001–2004 National Health and Nutrition Examination Survey. Multivariable logistic regression analyses examined differences in health-related quality of life with adjustment for age, race, sex, healthcare coverage, and other medical conditions. Results The 30% of respondents with hypertension were more likely to report fair or poor health status (adjusted odds ratio 1.72, 95% confidence interval 1.44–2.05), 14 or more unhealthy days in the past 30 days (1.23, 1.06–1.43), 14 or more physically unhealthy days (1.39, 1.15–1.67), and 14 or more activity-limited days (1.55, 1.17–2.04) than those without hypertension. Among adults with hypertension, the 73.2% who were aware of their condition were more likely to report fair or poor health status (2.19, 1.54–3.12), 14 or more unhealthy days (1.53, 1.12–2.09), 14 or more physically unhealthy days (1.49, 1.10–2.03), 14 or more mentally unhealthy days (1.70, 1.05–2.75), and 14 or more activity-limited days (2.38, 1.39–4.05) than those who were unaware. Among those aware they had hypertension, 14 or more physically unhealthy days (0.50, 0.28–0.90) was associated with current treatment. Health-related quality of life measures did not differ by blood pressure control status. Conclusions Having hypertension and being aware of it was related to lower health-related quality of life. Antihypertensive medication was associated with more physically unhealthy days, while there were no differences in health-related quality of life by control status. Further study is needed to examine these differences including: disease severity, sex and racial/ethnic differences, comorbidities not examined, and impact of health-related quality of life and its changes on outcomes.

Primary health care providers' attitudes and counseling behaviors related to dietary sodium reduction.

High sodium intake is associated with increased blood pressure.1 Average sodium intake among US adults far exceeds recommendations.2 Primary care physicians and nurse practitioners are the first line of medical care and can influence opinions and behaviors of their patients.3,4 Although some information exists about perceived advice from health professionals related to sodium reduction,5 little is known about health care providers’ own perceptions about sodium intake and patient counseling behaviors about reducing sodium intake. We used data from DocStyles, aWeb-based survey of health care providers. Participants included health care providers who practiced in the United States; worked in an individual, group, or hospital setting; and had practiced medicine for a minimum of 3 years. In 2010, family/general practitioners (FGPs), internists, and nurse practitioners were asked questions on sodium. Response rates were 45.2% for FGPs and internists combined and 52.6% for nurse practitioners. The sodium intake component of this survey consisted of 6 questions assessing health care providers’ opinions and perceived counseling behaviors related to reducing dietary sodium intake. The survey also included questions about health care provider characteristics, including sociodemographic (age, sex, and race/ethnicity), medical practice (type of practitioner, practice setting, years of practice, whether they practice at a teaching hospital, and the financial situation of the majority of their patients), and health-related behavior (self- reported height and weight; the number of days per week they eat at least 5 cups of fruit or vegetables; smoke cigarettes, cigars, or pipes; and exercise or keep their heart rate up for at least 30 min/d). Differences in response frequency were determined with 2 tests for categorical variables and Mann-Whitney test for Likert scales. All analyses were conducted using SPSS statistical software (SPSS Inc).