Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To investigate the association between habitually high levels of physical activity and the compliance of the large and small arteries in men and women throughout the life span.

Design. Cross-sectional study.

Setting and participants. 83 healthy men (n = 44) and women (n = 39) aged between 18 and 78 years were recruited to participate in the study. Potential participants were recruited via flyers designed to elicit responses from either very highly active (participate in regular, vigorous exercise more than 5 times per week) or less active/sedentary individuals (participate in light to moderate exercise less than 3 times per week or none at all). Both groups subjectively reported maintaining the specified activity level for at least the past 5 years. The highly active subjects performed regular vigorous swimming as their primary mode of exercise training as most were members of a varsity or masters swim team. All subjects were free of overt chronic diseases, nonsmokers, and none were taking vasoactive medications as assessed by a medical history questionnaire. All subjects provided written informed consent to participate. The study was reviewed and approved by the institutional review board at Indiana University.

Physical activity was self-assessed in all subject groups with a log detailing their activity over the previous 7 days. To ensure the older highly active population performed vigorous physical activity ≥ 5 days per week, the subjective activity log was verified by a 7-day previously validated, commercially available heart rate monitor and accelerometer (Actiheart, CamNtech, Cambridge, UK).

Main outcome measure. Compliance of the small and large arteries (inverse of stiffness) measured using a commercial pulse wave analyzer (Model CR-2000, Hypertension Diagnositics, Eagen, MN), which according to the manufacturer measures proximal capacitive compliance (C1, or estimate of large artery compliance) and distal oscillatory compliance (C2, or small artery compliance) [1].

Results. The study found a positive association between routine vigorous physical activity and arterial compliance. Specifically, the results suggest that vigorous physical activity is associated with greater compliance of the small and large arteries in both younger and older adults (P < 0.05). In addition, both the highly active and less active younger groups as well as the highly active older group demonstrated greater large arterial compliance compared to the less active older group (P < 0.008). No significant differences were found between men and women.

Conclusion. Researchers concluded that participation in habitual vigorous physical activity is associated with benefits to the compliance of the small and large arteries. Habitual vigorous physical activity over time may attenuate age-associated cardiovascular impairments.

Commentary

Arterial compliance declines with age, and increased arterial stiffness is associated with an increased risk of cardiovascular events [2]. Evidence suggests that physical activity may delay or prevent age-related increases in arterial stiffness [3]. Previous research regarding age-related arterial stiffness and exercise has focused primarily on the large arteries. For example, Tanaka found that regular aerobic-endurance exercise attenuates age-related reductions in central arterial compliance and restores levels in previously sedentary healthy middle-aged and older men [3]. More recently, a study by Duprez [4] found that small artery elasticity was superior to large artery elasticity with regard to predicting future CHD, stroke, and heart failure.

In this study, researchers cross-sectionally investigated the relationship of intense and continuous physical activity in young and older adults. The form of vigorous activity in this study was competitive swimming, as participants were recruited from a collegiate varsity and masters swim team. The study found a statistically strong association between routine vigorous physical activity and arterial compliance. These findings agree with several studies showing the benefits of vigorous exercise, but go beyond these by presenting findings on small artery compliance.

Methodologically, this study has some limitations. With the small sample, the study may not have been adequately powered. Further, physical activity assessment was by self-report in the main. Even though researchers had the participants keep a log, self-report measures may be inaccurate. Another limitation was the indirect method of measuring compliance, in which the radial waveform is calibrated to brachial blood pressure values. However, the researchers followed a valid model using the same BP level–based procedures reported in previous studies [1].

Applications for Clinical Practice

CVD is a major cause of disability and mortality in the United States. Health care professionals have a significant role to play in reducing cardiovascular risk factors in their patients, including encouraging aerobic exercise. The American Heart Association recommends at least 30 minutes of moderate-intensity aerobic activity at least 5 days per week or at least 25 minutes of vigorous aerobic activity at least 3 days per week, or a combination of moderate- and vigorous-intensity aerobic activity [4]. Patients can also be reminded that even modest levels of physical activity are associated with health benefits.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To investigate the association between habitually high levels of physical activity and the compliance of the large and small arteries in men and women throughout the life span.

Design. Cross-sectional study.

Setting and participants. 83 healthy men (n = 44) and women (n = 39) aged between 18 and 78 years were recruited to participate in the study. Potential participants were recruited via flyers designed to elicit responses from either very highly active (participate in regular, vigorous exercise more than 5 times per week) or less active/sedentary individuals (participate in light to moderate exercise less than 3 times per week or none at all). Both groups subjectively reported maintaining the specified activity level for at least the past 5 years. The highly active subjects performed regular vigorous swimming as their primary mode of exercise training as most were members of a varsity or masters swim team. All subjects were free of overt chronic diseases, nonsmokers, and none were taking vasoactive medications as assessed by a medical history questionnaire. All subjects provided written informed consent to participate. The study was reviewed and approved by the institutional review board at Indiana University.

Physical activity was self-assessed in all subject groups with a log detailing their activity over the previous 7 days. To ensure the older highly active population performed vigorous physical activity ≥ 5 days per week, the subjective activity log was verified by a 7-day previously validated, commercially available heart rate monitor and accelerometer (Actiheart, CamNtech, Cambridge, UK).

Main outcome measure. Compliance of the small and large arteries (inverse of stiffness) measured using a commercial pulse wave analyzer (Model CR-2000, Hypertension Diagnositics, Eagen, MN), which according to the manufacturer measures proximal capacitive compliance (C1, or estimate of large artery compliance) and distal oscillatory compliance (C2, or small artery compliance) [1].

Results. The study found a positive association between routine vigorous physical activity and arterial compliance. Specifically, the results suggest that vigorous physical activity is associated with greater compliance of the small and large arteries in both younger and older adults (P < 0.05). In addition, both the highly active and less active younger groups as well as the highly active older group demonstrated greater large arterial compliance compared to the less active older group (P < 0.008). No significant differences were found between men and women.

Conclusion. Researchers concluded that participation in habitual vigorous physical activity is associated with benefits to the compliance of the small and large arteries. Habitual vigorous physical activity over time may attenuate age-associated cardiovascular impairments.

Commentary

Arterial compliance declines with age, and increased arterial stiffness is associated with an increased risk of cardiovascular events [2]. Evidence suggests that physical activity may delay or prevent age-related increases in arterial stiffness [3]. Previous research regarding age-related arterial stiffness and exercise has focused primarily on the large arteries. For example, Tanaka found that regular aerobic-endurance exercise attenuates age-related reductions in central arterial compliance and restores levels in previously sedentary healthy middle-aged and older men [3]. More recently, a study by Duprez [4] found that small artery elasticity was superior to large artery elasticity with regard to predicting future CHD, stroke, and heart failure.

In this study, researchers cross-sectionally investigated the relationship of intense and continuous physical activity in young and older adults. The form of vigorous activity in this study was competitive swimming, as participants were recruited from a collegiate varsity and masters swim team. The study found a statistically strong association between routine vigorous physical activity and arterial compliance. These findings agree with several studies showing the benefits of vigorous exercise, but go beyond these by presenting findings on small artery compliance.

Methodologically, this study has some limitations. With the small sample, the study may not have been adequately powered. Further, physical activity assessment was by self-report in the main. Even though researchers had the participants keep a log, self-report measures may be inaccurate. Another limitation was the indirect method of measuring compliance, in which the radial waveform is calibrated to brachial blood pressure values. However, the researchers followed a valid model using the same BP level–based procedures reported in previous studies [1].

Applications for Clinical Practice

CVD is a major cause of disability and mortality in the United States. Health care professionals have a significant role to play in reducing cardiovascular risk factors in their patients, including encouraging aerobic exercise. The American Heart Association recommends at least 30 minutes of moderate-intensity aerobic activity at least 5 days per week or at least 25 minutes of vigorous aerobic activity at least 3 days per week, or a combination of moderate- and vigorous-intensity aerobic activity [4]. Patients can also be reminded that even modest levels of physical activity are associated with health benefits.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To investigate the association between habitually high levels of physical activity and the compliance of the large and small arteries in men and women throughout the life span.

Design. Cross-sectional study.

Setting and participants. 83 healthy men (n = 44) and women (n = 39) aged between 18 and 78 years were recruited to participate in the study. Potential participants were recruited via flyers designed to elicit responses from either very highly active (participate in regular, vigorous exercise more than 5 times per week) or less active/sedentary individuals (participate in light to moderate exercise less than 3 times per week or none at all). Both groups subjectively reported maintaining the specified activity level for at least the past 5 years. The highly active subjects performed regular vigorous swimming as their primary mode of exercise training as most were members of a varsity or masters swim team. All subjects were free of overt chronic diseases, nonsmokers, and none were taking vasoactive medications as assessed by a medical history questionnaire. All subjects provided written informed consent to participate. The study was reviewed and approved by the institutional review board at Indiana University.

Physical activity was self-assessed in all subject groups with a log detailing their activity over the previous 7 days. To ensure the older highly active population performed vigorous physical activity ≥ 5 days per week, the subjective activity log was verified by a 7-day previously validated, commercially available heart rate monitor and accelerometer (Actiheart, CamNtech, Cambridge, UK).

Main outcome measure. Compliance of the small and large arteries (inverse of stiffness) measured using a commercial pulse wave analyzer (Model CR-2000, Hypertension Diagnositics, Eagen, MN), which according to the manufacturer measures proximal capacitive compliance (C1, or estimate of large artery compliance) and distal oscillatory compliance (C2, or small artery compliance) [1].

Results. The study found a positive association between routine vigorous physical activity and arterial compliance. Specifically, the results suggest that vigorous physical activity is associated with greater compliance of the small and large arteries in both younger and older adults (P < 0.05). In addition, both the highly active and less active younger groups as well as the highly active older group demonstrated greater large arterial compliance compared to the less active older group (P < 0.008). No significant differences were found between men and women.

Conclusion. Researchers concluded that participation in habitual vigorous physical activity is associated with benefits to the compliance of the small and large arteries. Habitual vigorous physical activity over time may attenuate age-associated cardiovascular impairments.

Commentary

Arterial compliance declines with age, and increased arterial stiffness is associated with an increased risk of cardiovascular events [2]. Evidence suggests that physical activity may delay or prevent age-related increases in arterial stiffness [3]. Previous research regarding age-related arterial stiffness and exercise has focused primarily on the large arteries. For example, Tanaka found that regular aerobic-endurance exercise attenuates age-related reductions in central arterial compliance and restores levels in previously sedentary healthy middle-aged and older men [3]. More recently, a study by Duprez [4] found that small artery elasticity was superior to large artery elasticity with regard to predicting future CHD, stroke, and heart failure.

In this study, researchers cross-sectionally investigated the relationship of intense and continuous physical activity in young and older adults. The form of vigorous activity in this study was competitive swimming, as participants were recruited from a collegiate varsity and masters swim team. The study found a statistically strong association between routine vigorous physical activity and arterial compliance. These findings agree with several studies showing the benefits of vigorous exercise, but go beyond these by presenting findings on small artery compliance.

Methodologically, this study has some limitations. With the small sample, the study may not have been adequately powered. Further, physical activity assessment was by self-report in the main. Even though researchers had the participants keep a log, self-report measures may be inaccurate. Another limitation was the indirect method of measuring compliance, in which the radial waveform is calibrated to brachial blood pressure values. However, the researchers followed a valid model using the same BP level–based procedures reported in previous studies [1].

Applications for Clinical Practice

CVD is a major cause of disability and mortality in the United States. Health care professionals have a significant role to play in reducing cardiovascular risk factors in their patients, including encouraging aerobic exercise. The American Heart Association recommends at least 30 minutes of moderate-intensity aerobic activity at least 5 days per week or at least 25 minutes of vigorous aerobic activity at least 3 days per week, or a combination of moderate- and vigorous-intensity aerobic activity [4]. Patients can also be reminded that even modest levels of physical activity are associated with health benefits.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To determine the prevalence of hypotension using both clinic and ambulatory blood pressure monitoring (ABPM) in treated hypertensive patients and the factors associated with its presence.

Design. Registry-based study.

Setting and participants. Researchers studied patients in the Spanish Society of Hypertension ABPM Registry, which was established to evaluate the utility of the wider use of ABPM with the distribution of >1000 ambulatory BP monitors for routine use by primary care physicians and physicians from specialist units across Spain. The registry continues to expand since the first patient was recruited in June 2004. In June 2015, a total of 135,500 hypertensive patients were in the registry.

Measurements. Blood pressure readings in the clinic were taken according to current recommendations, with the patients in a seated position and their backs supported, after a 5-minute rest, using calibrated sphygmomanometers or validated automatic devices. The visit BP was the average of 2 separate readings. Validated devices (Spacelabs) were used for ABPM, which was performed during a working day with measurements taken every 30 minutes. Patients were told to keep their activity normal and to extend the arm without any movement during BP measurements. ABPM was considered successful in ≥ 80% systolic and diastolic BP valid readings. Patients were classified into 3 categories: hypotension, adequate BP control, or poor BP control for each type of blood pressure (office, daytime, nighttime, and 24-hour). The definitions for hypotension for each BP type were mainly based of the PROVE IT-TIMI study, ie, < 110 and/or 70 mm Hg for office, < 105 and/or 65 mm Hg for daytime ABPM, < 90 and or 50 mm Hg for nightime ABPM, and < 100 and/or 60 mm Hg for 24-hr ABPM.

Results. Of the 135,500 patients in the registry, only data from treated hypertensive patients were analyzed (n = 70,997). Mean age was 61.8 ± 12.8 years and 52.5% were men. The prevalence of hypotension was 8.2% with office BP, 12.2% with daytime ABPM, 3.9% with nightime ABPM, and 6.8% with 24-hour ABPM. Low diastolic BP values were responsible for the majority of hypotension. More than 68% of patients with hypotension detected with ABPM did not have hypotension according to office BP. Patients with hypotension were older, more likely to be female, and more likely to have high pulse pressue, lower heart rate, ischemic heart disease, and renal insufficiency. They were also more likely to be taking 3 or more drugs for hypertension.

Conclusion. The prevalence of hypotension is relatively high in treated hypertensive patients, and two-thirds are not identified with office BP measurement. Prevalence was higher in patients who were very elderly or with coronary or renal disease.

Commentary

Hypertension is a major public health concern worldwide [1]. In 2011–12 among US adults with hypertension, only 51.9% had their blood pressure controlled [2]. High blood pressure can effectively be reduced with antihypertensive treatment, and efforts are needed to improve clinical management of hypertension. However, excessive BP reduction may lead to patient harm.

In this study, researchers aimed to determine the prevalence of hypotension using both clinic and ABPM in hypertensive-treated patients and the factors associated with its presence, using descriptive statistics and multivariate analysis. The results highlight the need for health care providers to be aware of the individual response to antihypertensives in patients with high blood pressure and to individualize treatment to avoid complications of hypotension. A strength of this study was it large sample size.

Adherence to treatment recommendations was not a variable taken into consideration for this study and could be considered a confounder. Diet and behavioral interventions can have a significantly beneficial effect on hypertension and can reduce the need for drug therapy [3]. If patients were highly engaged and adopted lifestyle habits that can contribute to better blood pressure levels along with taking prescribed medications, this could have contributed to levels of hypotension.

Hypotension among hypertensive patients can be difficult to identify during clinical consultations due the “white coat effect.” This syndrome is characterized by a peak of high blood pressure caused by the stress of the individual in the presence of a healthcare provider or in a stressful medical environment [4]. This study showed that more than half of the patients in the sample with detected hypotension in the ABPM did not show hypotension during consultation at the medical office. This finding highlights the challenge in identifying hypotension and making adjustments to antihypertensive medication regimens as needed.

Women, patients with low body weight, and elderly patients were the groups more likely to develop hypo-tension. Thus, strategies specifically targeting these vulnerable groups are required. As suggested by the authors of this study, further longitudinal research is needed in order to identify gaps in the state of science in regards this topic and changes in the prevalence this population. The replication of this study in different populations is also encouraged.

Applications for Clinical Practice

The prevalence of hypotension is relatively high and may not be detected during office BP measurement. In patients with a higher risk of hypotension, such as the elderly those with cardiovascular disease, the use of ABPM should be considered.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To determine the prevalence of hypotension using both clinic and ambulatory blood pressure monitoring (ABPM) in treated hypertensive patients and the factors associated with its presence.

Design. Registry-based study.

Setting and participants. Researchers studied patients in the Spanish Society of Hypertension ABPM Registry, which was established to evaluate the utility of the wider use of ABPM with the distribution of >1000 ambulatory BP monitors for routine use by primary care physicians and physicians from specialist units across Spain. The registry continues to expand since the first patient was recruited in June 2004. In June 2015, a total of 135,500 hypertensive patients were in the registry.

Measurements. Blood pressure readings in the clinic were taken according to current recommendations, with the patients in a seated position and their backs supported, after a 5-minute rest, using calibrated sphygmomanometers or validated automatic devices. The visit BP was the average of 2 separate readings. Validated devices (Spacelabs) were used for ABPM, which was performed during a working day with measurements taken every 30 minutes. Patients were told to keep their activity normal and to extend the arm without any movement during BP measurements. ABPM was considered successful in ≥ 80% systolic and diastolic BP valid readings. Patients were classified into 3 categories: hypotension, adequate BP control, or poor BP control for each type of blood pressure (office, daytime, nighttime, and 24-hour). The definitions for hypotension for each BP type were mainly based of the PROVE IT-TIMI study, ie, < 110 and/or 70 mm Hg for office, < 105 and/or 65 mm Hg for daytime ABPM, < 90 and or 50 mm Hg for nightime ABPM, and < 100 and/or 60 mm Hg for 24-hr ABPM.

Results. Of the 135,500 patients in the registry, only data from treated hypertensive patients were analyzed (n = 70,997). Mean age was 61.8 ± 12.8 years and 52.5% were men. The prevalence of hypotension was 8.2% with office BP, 12.2% with daytime ABPM, 3.9% with nightime ABPM, and 6.8% with 24-hour ABPM. Low diastolic BP values were responsible for the majority of hypotension. More than 68% of patients with hypotension detected with ABPM did not have hypotension according to office BP. Patients with hypotension were older, more likely to be female, and more likely to have high pulse pressue, lower heart rate, ischemic heart disease, and renal insufficiency. They were also more likely to be taking 3 or more drugs for hypertension.

Conclusion. The prevalence of hypotension is relatively high in treated hypertensive patients, and two-thirds are not identified with office BP measurement. Prevalence was higher in patients who were very elderly or with coronary or renal disease.

Commentary

Hypertension is a major public health concern worldwide [1]. In 2011–12 among US adults with hypertension, only 51.9% had their blood pressure controlled [2]. High blood pressure can effectively be reduced with antihypertensive treatment, and efforts are needed to improve clinical management of hypertension. However, excessive BP reduction may lead to patient harm.

In this study, researchers aimed to determine the prevalence of hypotension using both clinic and ABPM in hypertensive-treated patients and the factors associated with its presence, using descriptive statistics and multivariate analysis. The results highlight the need for health care providers to be aware of the individual response to antihypertensives in patients with high blood pressure and to individualize treatment to avoid complications of hypotension. A strength of this study was it large sample size.

Adherence to treatment recommendations was not a variable taken into consideration for this study and could be considered a confounder. Diet and behavioral interventions can have a significantly beneficial effect on hypertension and can reduce the need for drug therapy [3]. If patients were highly engaged and adopted lifestyle habits that can contribute to better blood pressure levels along with taking prescribed medications, this could have contributed to levels of hypotension.

Hypotension among hypertensive patients can be difficult to identify during clinical consultations due the “white coat effect.” This syndrome is characterized by a peak of high blood pressure caused by the stress of the individual in the presence of a healthcare provider or in a stressful medical environment [4]. This study showed that more than half of the patients in the sample with detected hypotension in the ABPM did not show hypotension during consultation at the medical office. This finding highlights the challenge in identifying hypotension and making adjustments to antihypertensive medication regimens as needed.

Women, patients with low body weight, and elderly patients were the groups more likely to develop hypo-tension. Thus, strategies specifically targeting these vulnerable groups are required. As suggested by the authors of this study, further longitudinal research is needed in order to identify gaps in the state of science in regards this topic and changes in the prevalence this population. The replication of this study in different populations is also encouraged.

Applications for Clinical Practice

The prevalence of hypotension is relatively high and may not be detected during office BP measurement. In patients with a higher risk of hypotension, such as the elderly those with cardiovascular disease, the use of ABPM should be considered.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To determine the prevalence of hypotension using both clinic and ambulatory blood pressure monitoring (ABPM) in treated hypertensive patients and the factors associated with its presence.

Design. Registry-based study.

Setting and participants. Researchers studied patients in the Spanish Society of Hypertension ABPM Registry, which was established to evaluate the utility of the wider use of ABPM with the distribution of >1000 ambulatory BP monitors for routine use by primary care physicians and physicians from specialist units across Spain. The registry continues to expand since the first patient was recruited in June 2004. In June 2015, a total of 135,500 hypertensive patients were in the registry.

Measurements. Blood pressure readings in the clinic were taken according to current recommendations, with the patients in a seated position and their backs supported, after a 5-minute rest, using calibrated sphygmomanometers or validated automatic devices. The visit BP was the average of 2 separate readings. Validated devices (Spacelabs) were used for ABPM, which was performed during a working day with measurements taken every 30 minutes. Patients were told to keep their activity normal and to extend the arm without any movement during BP measurements. ABPM was considered successful in ≥ 80% systolic and diastolic BP valid readings. Patients were classified into 3 categories: hypotension, adequate BP control, or poor BP control for each type of blood pressure (office, daytime, nighttime, and 24-hour). The definitions for hypotension for each BP type were mainly based of the PROVE IT-TIMI study, ie, < 110 and/or 70 mm Hg for office, < 105 and/or 65 mm Hg for daytime ABPM, < 90 and or 50 mm Hg for nightime ABPM, and < 100 and/or 60 mm Hg for 24-hr ABPM.

Results. Of the 135,500 patients in the registry, only data from treated hypertensive patients were analyzed (n = 70,997). Mean age was 61.8 ± 12.8 years and 52.5% were men. The prevalence of hypotension was 8.2% with office BP, 12.2% with daytime ABPM, 3.9% with nightime ABPM, and 6.8% with 24-hour ABPM. Low diastolic BP values were responsible for the majority of hypotension. More than 68% of patients with hypotension detected with ABPM did not have hypotension according to office BP. Patients with hypotension were older, more likely to be female, and more likely to have high pulse pressue, lower heart rate, ischemic heart disease, and renal insufficiency. They were also more likely to be taking 3 or more drugs for hypertension.

Conclusion. The prevalence of hypotension is relatively high in treated hypertensive patients, and two-thirds are not identified with office BP measurement. Prevalence was higher in patients who were very elderly or with coronary or renal disease.

Commentary

Hypertension is a major public health concern worldwide [1]. In 2011–12 among US adults with hypertension, only 51.9% had their blood pressure controlled [2]. High blood pressure can effectively be reduced with antihypertensive treatment, and efforts are needed to improve clinical management of hypertension. However, excessive BP reduction may lead to patient harm.

In this study, researchers aimed to determine the prevalence of hypotension using both clinic and ABPM in hypertensive-treated patients and the factors associated with its presence, using descriptive statistics and multivariate analysis. The results highlight the need for health care providers to be aware of the individual response to antihypertensives in patients with high blood pressure and to individualize treatment to avoid complications of hypotension. A strength of this study was it large sample size.

Adherence to treatment recommendations was not a variable taken into consideration for this study and could be considered a confounder. Diet and behavioral interventions can have a significantly beneficial effect on hypertension and can reduce the need for drug therapy [3]. If patients were highly engaged and adopted lifestyle habits that can contribute to better blood pressure levels along with taking prescribed medications, this could have contributed to levels of hypotension.

Hypotension among hypertensive patients can be difficult to identify during clinical consultations due the “white coat effect.” This syndrome is characterized by a peak of high blood pressure caused by the stress of the individual in the presence of a healthcare provider or in a stressful medical environment [4]. This study showed that more than half of the patients in the sample with detected hypotension in the ABPM did not show hypotension during consultation at the medical office. This finding highlights the challenge in identifying hypotension and making adjustments to antihypertensive medication regimens as needed.

Women, patients with low body weight, and elderly patients were the groups more likely to develop hypo-tension. Thus, strategies specifically targeting these vulnerable groups are required. As suggested by the authors of this study, further longitudinal research is needed in order to identify gaps in the state of science in regards this topic and changes in the prevalence this population. The replication of this study in different populations is also encouraged.

Applications for Clinical Practice

The prevalence of hypotension is relatively high and may not be detected during office BP measurement. In patients with a higher risk of hypotension, such as the elderly those with cardiovascular disease, the use of ABPM should be considered.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To determine the association between antihypertensive medication adherence and visit-to-visit variability of blood pressure (BP).

Design. Post hoc analysis of ALLHAT, a randomized, double-blind, multicenter trial to determine whether treatment with calcium-channel blockers, angiotensin-converting enzyme inhibitors, or α-adrenergic blockers, all newer antihypertensive classes at the time of the study, was superior to treatment with a thiazide diuretic for lowering risk for fatal coronary heart disease (CHD) or nonfatal myocardial infarction (MI) (primary outcomes), with secondary outcomes including all-cause mortality, stroke, and combined cardiovascular disease (CHD death, nonfatal MI, stroke, angina, coronary revascularization, congestive heart failure, and peripheral arterial disease).

Setting and participants. Participants who had BP and medication adherence data from at least 5 of the 7 study visits conducted 6 to 28 months after randomization. Only patients who had no outcome events within the 28 months were included in the analysis (ie, no fatal CHD or nonfatal MI, stroke, all-cause mortality, or heart failure). In a secondary analysis, participants who had data from 5 of the 7 study visits between 32 to 56 months after randomization were included.

Measures. Adherence to medication was assessed at each visit by a study clinician using the Adherence Survival Kit developed for ALLHAT. Participants were asked whether they had taken at least 80% of their assigned study drug since the last follow-up visit. For primary analyses, participants were categorized as nonadherent if they reported having taken < 80% of their assigned antihypertensive medication at ≥ 1 visits during the 6- to 28-month time period after randomization. For secondary analyses, participants were categorized as nonadherent if they reported having taken < 80% of their assigned medication at ≥ 1 visits during the 32 to 56 months after randomization. In a sensitivity analysis, participants were categorized as nonadherent if they reported taking < 80% of the prescribed antihypertensive medication at ≥ 2 visits during the 6 to 28 months post-randomization time period. Visit-to-visit variability of BP was calculated using 3 metrics based on each ALLHAT participants’ BP measurements: standard deviation independent of mean (SDIM), SD, and average real variability. The BP used for these calculations was the mean of 2 measurements taken during each follow-up study visit according to a standardized BP measurement protocol. Participants were followed from the end of the visit-to-visit variability of BP assessment period to the date of each outcome, their date of death, or end of active ALLHAT follow-up.

Results. Of 33,357 participants randomized, 19,970 participants met eligibility criteria for primary analyses. Of these, 2912 participants (15%) were considered nonadherent. Compared with adherent participants, nonadherent participants were slightly older and more likely to be Hispanic or black. Nonadherent participants were more likely to have evidence of end-organ damage as signified by major ST segment depression or T wave inversion or left ventricular hypertrophy on electrocardiogram but were less likely to have a history of MI, stroke, or coronary revascularization. Nonadherent participants were also less likely to have used BP medications before randomization and less likely to use statins during follow-up. Nonadherent participants were more likely to have changes in BP medication classes during follow-up, were more likely to have uncontrolled BP between 6 and 28 months after randomization, and had higher mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the visits. The association between nonadherence and higher BP remained statistically significant in adjusted analyses.

SDIM of SBP was higher among those who were nonadherent (11.4 ± 4.9 versus 10.5 ± 4.5; P < 0.001). After full adjustment, nonadherent participants had 0.8 (95% CI, 0.7–1.0; P < 0.001) higher SDIM of SBP than adherent participants. In addition, compared with adherent participants, nonadherent participants had higher SD and average real variability of SBP. Researcher found the same pattern when the sample was restricted to 11,290 participants without antihypertensive medication changes. The association between adherence status and visit-to-visit variability of SBP was consistent across antihypertensive drug randomization assignment for interaction term for all definitions of visit-to-visit variability of SBP (P > 0.8). Nonadherent participants also had higher visit-to-visit variability of DBP.

Overall, 4.6% of participants had ≥ 2 visits with < 80% adherence. SDIM of SBP was higher among nonadherent participants versus adherent participants according to this more stringent categorization of nonadherence (11.0 ± 4.6 vs. 10.6 ± 4.6; P = 0.01). After full multivariable adjustment, SDIM of SBP was 0.5 (95% CI, 0.2–0.9; P = 0.001) higher among nonadherent than among adherent participants. Participants who were nonadherent in both the early and late study periods had higher SDIMs of SBP than those who were adherent in both study periods. Minimal changes were found in the SDIM of SBP between the early and late study periods for participants who were adherent in both study periods and nonadherent in both study periods. However, a significant number of participants, had a change in adherence between the early and late study period, with 6.5% switching from adherent to nonadherent and 10.0% switching from nonadherent to adherent. Compared with participants who were adherent in both time periods, participants who changed from adherent to non-adherent had an increase in SDIM of SBP (0.9; 95% CI, 0.5–1.3; P < 0.001), whereas participants who changed from nonadherent to adherent had a decrease in SDIM of SBP (−0.7; 95% CI, −1.0 to −0.3; P < 0.001). Among participants in the primary analysis without a cardiovascular event before the 28-month visit (n = 18 442), being in the highest versus lowest quintile of SDIM of SBP was associated with increased risk of fatal CHD or nonfatal MI, stroke, heart failure, and all-cause mortality after multivariable adjustment. In a mediation analysis, further adjustment for adherence status did not explain the association between SDIM of SBP and any of our cardiovascular or mortality outcomes.

Conclusion. The study provided significant evidence that medication adherence reduces visit-to-visit variability of BP. However, visit-to-visit variability of BP is associated with cardiovascular outcomes independent of medication adherence. Further work is needed to examine both the mechanisms underlying the association between visit-to-visit variability of BP and cardiovascular outcomes and whether decreasing visit-to-visit variability of BP can improve health outcomes.

Commentary

Hypertension remains one of the most important preventable contributors to disease and death [1]. Health care providers continue to reinforce the importance of adherence to medication treatment in conjunction with the adoption of healthy lifestyle habits, which have been shown to be effective interventions [2]. Low adherence to antihypertensive medication has been hypothesized to increase visit-to-visit variability of BP. Literature has shown that visit-to-visit variability of BP is associated with increased risk for stroke, CHD, and mortality [3]. In this post hoc analysis of ALLHAT, the researchers found that nonadherence was associated with increased visit-to-visit variability of BP. The study extended the findings of only a few studies that have tested this association.

Efforts to improve adherence could impact the occurrence of visit-to-visit variability of BP. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective. Awareness and commitment are essential to promote and ensure adherence in the treatment of disease [4]. Advances in this field of research are needed, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements outcomes that patients care about [4].

However, in this study, medication nonadherence did not explain the association between visit-to-visit variability of BP levels and cardiovascular risk. The researchers posit that in light of this, improving adherence is unlikely to offset the increased risk associated with visit-to-visit variability of BP found in treated patients with hypertension.

Limitations of this study include the use of self-report for adherence measurement, use of a summary measure for adherence, and the exclusion of a substantial number of participants who had < 5 visits in which adherence was assessed.

Applications for Clinical Practice

Although nonadherence to medication treatment contributed to visit-to-visit variability of BP, nonadherence did not explain why individuals with higher visit-to-visit of BP were at increased cardiovascular risk. Additional research is suggested in order to better understand how visit-to-visit variability of BP levels influences prognosis of hypertension.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To determine the association between antihypertensive medication adherence and visit-to-visit variability of blood pressure (BP).

Design. Post hoc analysis of ALLHAT, a randomized, double-blind, multicenter trial to determine whether treatment with calcium-channel blockers, angiotensin-converting enzyme inhibitors, or α-adrenergic blockers, all newer antihypertensive classes at the time of the study, was superior to treatment with a thiazide diuretic for lowering risk for fatal coronary heart disease (CHD) or nonfatal myocardial infarction (MI) (primary outcomes), with secondary outcomes including all-cause mortality, stroke, and combined cardiovascular disease (CHD death, nonfatal MI, stroke, angina, coronary revascularization, congestive heart failure, and peripheral arterial disease).

Setting and participants. Participants who had BP and medication adherence data from at least 5 of the 7 study visits conducted 6 to 28 months after randomization. Only patients who had no outcome events within the 28 months were included in the analysis (ie, no fatal CHD or nonfatal MI, stroke, all-cause mortality, or heart failure). In a secondary analysis, participants who had data from 5 of the 7 study visits between 32 to 56 months after randomization were included.

Measures. Adherence to medication was assessed at each visit by a study clinician using the Adherence Survival Kit developed for ALLHAT. Participants were asked whether they had taken at least 80% of their assigned study drug since the last follow-up visit. For primary analyses, participants were categorized as nonadherent if they reported having taken < 80% of their assigned antihypertensive medication at ≥ 1 visits during the 6- to 28-month time period after randomization. For secondary analyses, participants were categorized as nonadherent if they reported having taken < 80% of their assigned medication at ≥ 1 visits during the 32 to 56 months after randomization. In a sensitivity analysis, participants were categorized as nonadherent if they reported taking < 80% of the prescribed antihypertensive medication at ≥ 2 visits during the 6 to 28 months post-randomization time period. Visit-to-visit variability of BP was calculated using 3 metrics based on each ALLHAT participants’ BP measurements: standard deviation independent of mean (SDIM), SD, and average real variability. The BP used for these calculations was the mean of 2 measurements taken during each follow-up study visit according to a standardized BP measurement protocol. Participants were followed from the end of the visit-to-visit variability of BP assessment period to the date of each outcome, their date of death, or end of active ALLHAT follow-up.

Results. Of 33,357 participants randomized, 19,970 participants met eligibility criteria for primary analyses. Of these, 2912 participants (15%) were considered nonadherent. Compared with adherent participants, nonadherent participants were slightly older and more likely to be Hispanic or black. Nonadherent participants were more likely to have evidence of end-organ damage as signified by major ST segment depression or T wave inversion or left ventricular hypertrophy on electrocardiogram but were less likely to have a history of MI, stroke, or coronary revascularization. Nonadherent participants were also less likely to have used BP medications before randomization and less likely to use statins during follow-up. Nonadherent participants were more likely to have changes in BP medication classes during follow-up, were more likely to have uncontrolled BP between 6 and 28 months after randomization, and had higher mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the visits. The association between nonadherence and higher BP remained statistically significant in adjusted analyses.

SDIM of SBP was higher among those who were nonadherent (11.4 ± 4.9 versus 10.5 ± 4.5; P < 0.001). After full adjustment, nonadherent participants had 0.8 (95% CI, 0.7–1.0; P < 0.001) higher SDIM of SBP than adherent participants. In addition, compared with adherent participants, nonadherent participants had higher SD and average real variability of SBP. Researcher found the same pattern when the sample was restricted to 11,290 participants without antihypertensive medication changes. The association between adherence status and visit-to-visit variability of SBP was consistent across antihypertensive drug randomization assignment for interaction term for all definitions of visit-to-visit variability of SBP (P > 0.8). Nonadherent participants also had higher visit-to-visit variability of DBP.

Overall, 4.6% of participants had ≥ 2 visits with < 80% adherence. SDIM of SBP was higher among nonadherent participants versus adherent participants according to this more stringent categorization of nonadherence (11.0 ± 4.6 vs. 10.6 ± 4.6; P = 0.01). After full multivariable adjustment, SDIM of SBP was 0.5 (95% CI, 0.2–0.9; P = 0.001) higher among nonadherent than among adherent participants. Participants who were nonadherent in both the early and late study periods had higher SDIMs of SBP than those who were adherent in both study periods. Minimal changes were found in the SDIM of SBP between the early and late study periods for participants who were adherent in both study periods and nonadherent in both study periods. However, a significant number of participants, had a change in adherence between the early and late study period, with 6.5% switching from adherent to nonadherent and 10.0% switching from nonadherent to adherent. Compared with participants who were adherent in both time periods, participants who changed from adherent to non-adherent had an increase in SDIM of SBP (0.9; 95% CI, 0.5–1.3; P < 0.001), whereas participants who changed from nonadherent to adherent had a decrease in SDIM of SBP (−0.7; 95% CI, −1.0 to −0.3; P < 0.001). Among participants in the primary analysis without a cardiovascular event before the 28-month visit (n = 18 442), being in the highest versus lowest quintile of SDIM of SBP was associated with increased risk of fatal CHD or nonfatal MI, stroke, heart failure, and all-cause mortality after multivariable adjustment. In a mediation analysis, further adjustment for adherence status did not explain the association between SDIM of SBP and any of our cardiovascular or mortality outcomes.

Conclusion. The study provided significant evidence that medication adherence reduces visit-to-visit variability of BP. However, visit-to-visit variability of BP is associated with cardiovascular outcomes independent of medication adherence. Further work is needed to examine both the mechanisms underlying the association between visit-to-visit variability of BP and cardiovascular outcomes and whether decreasing visit-to-visit variability of BP can improve health outcomes.

Commentary

Hypertension remains one of the most important preventable contributors to disease and death [1]. Health care providers continue to reinforce the importance of adherence to medication treatment in conjunction with the adoption of healthy lifestyle habits, which have been shown to be effective interventions [2]. Low adherence to antihypertensive medication has been hypothesized to increase visit-to-visit variability of BP. Literature has shown that visit-to-visit variability of BP is associated with increased risk for stroke, CHD, and mortality [3]. In this post hoc analysis of ALLHAT, the researchers found that nonadherence was associated with increased visit-to-visit variability of BP. The study extended the findings of only a few studies that have tested this association.

Efforts to improve adherence could impact the occurrence of visit-to-visit variability of BP. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective. Awareness and commitment are essential to promote and ensure adherence in the treatment of disease [4]. Advances in this field of research are needed, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements outcomes that patients care about [4].

However, in this study, medication nonadherence did not explain the association between visit-to-visit variability of BP levels and cardiovascular risk. The researchers posit that in light of this, improving adherence is unlikely to offset the increased risk associated with visit-to-visit variability of BP found in treated patients with hypertension.

Limitations of this study include the use of self-report for adherence measurement, use of a summary measure for adherence, and the exclusion of a substantial number of participants who had < 5 visits in which adherence was assessed.

Applications for Clinical Practice

Although nonadherence to medication treatment contributed to visit-to-visit variability of BP, nonadherence did not explain why individuals with higher visit-to-visit of BP were at increased cardiovascular risk. Additional research is suggested in order to better understand how visit-to-visit variability of BP levels influences prognosis of hypertension.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To determine the association between antihypertensive medication adherence and visit-to-visit variability of blood pressure (BP).

Design. Post hoc analysis of ALLHAT, a randomized, double-blind, multicenter trial to determine whether treatment with calcium-channel blockers, angiotensin-converting enzyme inhibitors, or α-adrenergic blockers, all newer antihypertensive classes at the time of the study, was superior to treatment with a thiazide diuretic for lowering risk for fatal coronary heart disease (CHD) or nonfatal myocardial infarction (MI) (primary outcomes), with secondary outcomes including all-cause mortality, stroke, and combined cardiovascular disease (CHD death, nonfatal MI, stroke, angina, coronary revascularization, congestive heart failure, and peripheral arterial disease).

Setting and participants. Participants who had BP and medication adherence data from at least 5 of the 7 study visits conducted 6 to 28 months after randomization. Only patients who had no outcome events within the 28 months were included in the analysis (ie, no fatal CHD or nonfatal MI, stroke, all-cause mortality, or heart failure). In a secondary analysis, participants who had data from 5 of the 7 study visits between 32 to 56 months after randomization were included.

Measures. Adherence to medication was assessed at each visit by a study clinician using the Adherence Survival Kit developed for ALLHAT. Participants were asked whether they had taken at least 80% of their assigned study drug since the last follow-up visit. For primary analyses, participants were categorized as nonadherent if they reported having taken < 80% of their assigned antihypertensive medication at ≥ 1 visits during the 6- to 28-month time period after randomization. For secondary analyses, participants were categorized as nonadherent if they reported having taken < 80% of their assigned medication at ≥ 1 visits during the 32 to 56 months after randomization. In a sensitivity analysis, participants were categorized as nonadherent if they reported taking < 80% of the prescribed antihypertensive medication at ≥ 2 visits during the 6 to 28 months post-randomization time period. Visit-to-visit variability of BP was calculated using 3 metrics based on each ALLHAT participants’ BP measurements: standard deviation independent of mean (SDIM), SD, and average real variability. The BP used for these calculations was the mean of 2 measurements taken during each follow-up study visit according to a standardized BP measurement protocol. Participants were followed from the end of the visit-to-visit variability of BP assessment period to the date of each outcome, their date of death, or end of active ALLHAT follow-up.

Results. Of 33,357 participants randomized, 19,970 participants met eligibility criteria for primary analyses. Of these, 2912 participants (15%) were considered nonadherent. Compared with adherent participants, nonadherent participants were slightly older and more likely to be Hispanic or black. Nonadherent participants were more likely to have evidence of end-organ damage as signified by major ST segment depression or T wave inversion or left ventricular hypertrophy on electrocardiogram but were less likely to have a history of MI, stroke, or coronary revascularization. Nonadherent participants were also less likely to have used BP medications before randomization and less likely to use statins during follow-up. Nonadherent participants were more likely to have changes in BP medication classes during follow-up, were more likely to have uncontrolled BP between 6 and 28 months after randomization, and had higher mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the visits. The association between nonadherence and higher BP remained statistically significant in adjusted analyses.

SDIM of SBP was higher among those who were nonadherent (11.4 ± 4.9 versus 10.5 ± 4.5; P < 0.001). After full adjustment, nonadherent participants had 0.8 (95% CI, 0.7–1.0; P < 0.001) higher SDIM of SBP than adherent participants. In addition, compared with adherent participants, nonadherent participants had higher SD and average real variability of SBP. Researcher found the same pattern when the sample was restricted to 11,290 participants without antihypertensive medication changes. The association between adherence status and visit-to-visit variability of SBP was consistent across antihypertensive drug randomization assignment for interaction term for all definitions of visit-to-visit variability of SBP (P > 0.8). Nonadherent participants also had higher visit-to-visit variability of DBP.

Overall, 4.6% of participants had ≥ 2 visits with < 80% adherence. SDIM of SBP was higher among nonadherent participants versus adherent participants according to this more stringent categorization of nonadherence (11.0 ± 4.6 vs. 10.6 ± 4.6; P = 0.01). After full multivariable adjustment, SDIM of SBP was 0.5 (95% CI, 0.2–0.9; P = 0.001) higher among nonadherent than among adherent participants. Participants who were nonadherent in both the early and late study periods had higher SDIMs of SBP than those who were adherent in both study periods. Minimal changes were found in the SDIM of SBP between the early and late study periods for participants who were adherent in both study periods and nonadherent in both study periods. However, a significant number of participants, had a change in adherence between the early and late study period, with 6.5% switching from adherent to nonadherent and 10.0% switching from nonadherent to adherent. Compared with participants who were adherent in both time periods, participants who changed from adherent to non-adherent had an increase in SDIM of SBP (0.9; 95% CI, 0.5–1.3; P < 0.001), whereas participants who changed from nonadherent to adherent had a decrease in SDIM of SBP (−0.7; 95% CI, −1.0 to −0.3; P < 0.001). Among participants in the primary analysis without a cardiovascular event before the 28-month visit (n = 18 442), being in the highest versus lowest quintile of SDIM of SBP was associated with increased risk of fatal CHD or nonfatal MI, stroke, heart failure, and all-cause mortality after multivariable adjustment. In a mediation analysis, further adjustment for adherence status did not explain the association between SDIM of SBP and any of our cardiovascular or mortality outcomes.

Conclusion. The study provided significant evidence that medication adherence reduces visit-to-visit variability of BP. However, visit-to-visit variability of BP is associated with cardiovascular outcomes independent of medication adherence. Further work is needed to examine both the mechanisms underlying the association between visit-to-visit variability of BP and cardiovascular outcomes and whether decreasing visit-to-visit variability of BP can improve health outcomes.

Commentary

Hypertension remains one of the most important preventable contributors to disease and death [1]. Health care providers continue to reinforce the importance of adherence to medication treatment in conjunction with the adoption of healthy lifestyle habits, which have been shown to be effective interventions [2]. Low adherence to antihypertensive medication has been hypothesized to increase visit-to-visit variability of BP. Literature has shown that visit-to-visit variability of BP is associated with increased risk for stroke, CHD, and mortality [3]. In this post hoc analysis of ALLHAT, the researchers found that nonadherence was associated with increased visit-to-visit variability of BP. The study extended the findings of only a few studies that have tested this association.

Efforts to improve adherence could impact the occurrence of visit-to-visit variability of BP. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective. Awareness and commitment are essential to promote and ensure adherence in the treatment of disease [4]. Advances in this field of research are needed, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements outcomes that patients care about [4].

However, in this study, medication nonadherence did not explain the association between visit-to-visit variability of BP levels and cardiovascular risk. The researchers posit that in light of this, improving adherence is unlikely to offset the increased risk associated with visit-to-visit variability of BP found in treated patients with hypertension.

Limitations of this study include the use of self-report for adherence measurement, use of a summary measure for adherence, and the exclusion of a substantial number of participants who had < 5 visits in which adherence was assessed.

Applications for Clinical Practice

Although nonadherence to medication treatment contributed to visit-to-visit variability of BP, nonadherence did not explain why individuals with higher visit-to-visit of BP were at increased cardiovascular risk. Additional research is suggested in order to better understand how visit-to-visit variability of BP levels influences prognosis of hypertension.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To describe the feasibility of a primary care–based group visit model focused on advance care planning.

Design. Qualitative study.

Setting and participants. Participants were patients attending the Senior Clinic, a patient-centered medical home at the University of Colorado Hospital in Aurora, CO. Patients had to be aged 65, English speakers, and receiving primary care at the Clinic. Participants could be referred by their primary care clinician, a partner or friend, or self-refer in response to flyers. Clinicians were not asked to prioritize patients with poor health status or known end-of-life needs.

Intervention. Groups of patients met for 2 sessions (1 month apart), each 2 hours in length, facilitated by a geriatrician and a social worker. About 1 hour was spent on discussion of advance care planning concepts, including sharing experiences and considering values. Other time in the session was for introductions/rapport building, individual goal setting, and optional completion or directives and/or individual clinical visits. Facilitators were supported by a Facilitator’s Communication Guide and used educational materials and handouts with the group.

Main outcome measures. Researchers used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate the project.

Main results. Patients were referred by 10 out of 11 clinicians. Of 80 patients approached, 32 participated in 5 group visit cohorts (40% participation rate) and 27 participated in both sessions (84% retention rate). Mean age was 79 years; 59% of participants were female and 72% white. Most evaluated the group visit as better than usual clinic visits for discussing advance care planning. Patients reported increases in detailed advance care planning conversations after participating (19% to 41%, P = 0.02). Patients were willing to share personal values and challenges related to advance care planning and they initiated discussions about a broad range of relevant topics.

Conclusion. A group visit to facilitate discussions about advance care planning and increase patient engagement is feasible. This model warrants further evaluation for effectiveness in improving advance care planning outcomes for patients, clinicians, and the system.

Commentary

An understanding of patients’ care goals is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient [1]. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress [1]. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs; however, significant barriers to having advance care planning discussions exist [2], including communication issues and lack of appropriate counseling by clinicians in primary care. Clinicians cite limited time and lack of clinic-based support as factors that impede discussions with patients about advance care planning.

New models are being developed in order to facilitate the process. Group medical visits have been recognized as a useful and effective strategy for approaching patients [1]. The current study describes what the authorssay is the first advance care planning group visit, which they named the “Conversation Group Medical Visit” (CGMV). Its aim is to engage patients in a discussion of key advance care planning concepts and support patient-initiated advance care planning actions, such as choosing surrogate decision makers, deciding on preferences during serious illness, discussing preferences with decision makers and health care providers, and documenting advance directives in the electronic health record [3].

As part of the group medical visits, participants receive an agenda, a personal copy of their EHR highlighting current advance care planning documentation, if any, and a blank medical durable power of attorney form. Facilitators use educational materials including videos from the PREPARE website (prepareforyourcare.org) that demonstrate a family’s conversation, advance directives, and various degrees of flexibility in the decision-making role. A Conversation Starter Kit is also used, which prompts individuals to think about their values and guides conversations about preferences.

Researcher used the RE-AIM framework [4] to evaluate the implementation of this group medical visit model. This framework looks at Reach (if older adults would participate in the medical group visits), Effectiveness (related to participant’s engagement in the conversations), the Adoption of the model by health providers (clinician referral patterns), Implementation (related to the attendance of patients at both clinical and group visits and aspects of planning discussed), and Maintenance (not assessed in this study).

There was a 40% participation rate. Reasons given for declining to participate were having participated in past advance care planning conversation or having an existing advance directive (30%), lack of interest (13%), illness (3.3%), lack of transportation (3.3%), and other/unknown (50%). Regarding effectiveness, the majority of patients rated the group visit as better than usual clinic visits for talking about advance care planning. Participants reported that they received useful information and felt comfortable talking about advance care planning in the group. In addition, participants reported finding it helpful to talk with others about advance care planning (92%). Participants also reported an overall increase (19% to 41%) in advance care planning conversations with family members after participating in the group visit (P =0.02). Participants said these conversations included enough details that they felt confident that their family members knew their wishes. Thus, enrollment in a CGMV led to improvements in conversation not only between patient and health care provider but also between family members.

Several themes were identified during discussions. Patients shared personal values and challenges related to advance care planning. Also, the facilitated discussions introduced key advance care planning concepts and encouraged patients to share related experiences, questions, successes, and challenges in regards to these topics. An interesting finding was that patients in groups of 4 or 5 seemed less engaged in the discussion than those in groups of 7 to 9 patients.

Applications for Clinical Practice

This novel strategy to faciliate discussions about advance care planning showed promising results and appears feasible, but further study is needed to evaluate the model. It may prove useful as a new model of advance care planning in primary care. Further longitudinal research is encouraged.

 —Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To describe the feasibility of a primary care–based group visit model focused on advance care planning.

Design. Qualitative study.

Setting and participants. Participants were patients attending the Senior Clinic, a patient-centered medical home at the University of Colorado Hospital in Aurora, CO. Patients had to be aged 65, English speakers, and receiving primary care at the Clinic. Participants could be referred by their primary care clinician, a partner or friend, or self-refer in response to flyers. Clinicians were not asked to prioritize patients with poor health status or known end-of-life needs.

Intervention. Groups of patients met for 2 sessions (1 month apart), each 2 hours in length, facilitated by a geriatrician and a social worker. About 1 hour was spent on discussion of advance care planning concepts, including sharing experiences and considering values. Other time in the session was for introductions/rapport building, individual goal setting, and optional completion or directives and/or individual clinical visits. Facilitators were supported by a Facilitator’s Communication Guide and used educational materials and handouts with the group.

Main outcome measures. Researchers used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate the project.

Main results. Patients were referred by 10 out of 11 clinicians. Of 80 patients approached, 32 participated in 5 group visit cohorts (40% participation rate) and 27 participated in both sessions (84% retention rate). Mean age was 79 years; 59% of participants were female and 72% white. Most evaluated the group visit as better than usual clinic visits for discussing advance care planning. Patients reported increases in detailed advance care planning conversations after participating (19% to 41%, P = 0.02). Patients were willing to share personal values and challenges related to advance care planning and they initiated discussions about a broad range of relevant topics.

Conclusion. A group visit to facilitate discussions about advance care planning and increase patient engagement is feasible. This model warrants further evaluation for effectiveness in improving advance care planning outcomes for patients, clinicians, and the system.

Commentary

An understanding of patients’ care goals is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient [1]. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress [1]. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs; however, significant barriers to having advance care planning discussions exist [2], including communication issues and lack of appropriate counseling by clinicians in primary care. Clinicians cite limited time and lack of clinic-based support as factors that impede discussions with patients about advance care planning.

New models are being developed in order to facilitate the process. Group medical visits have been recognized as a useful and effective strategy for approaching patients [1]. The current study describes what the authorssay is the first advance care planning group visit, which they named the “Conversation Group Medical Visit” (CGMV). Its aim is to engage patients in a discussion of key advance care planning concepts and support patient-initiated advance care planning actions, such as choosing surrogate decision makers, deciding on preferences during serious illness, discussing preferences with decision makers and health care providers, and documenting advance directives in the electronic health record [3].

As part of the group medical visits, participants receive an agenda, a personal copy of their EHR highlighting current advance care planning documentation, if any, and a blank medical durable power of attorney form. Facilitators use educational materials including videos from the PREPARE website (prepareforyourcare.org) that demonstrate a family’s conversation, advance directives, and various degrees of flexibility in the decision-making role. A Conversation Starter Kit is also used, which prompts individuals to think about their values and guides conversations about preferences.

Researcher used the RE-AIM framework [4] to evaluate the implementation of this group medical visit model. This framework looks at Reach (if older adults would participate in the medical group visits), Effectiveness (related to participant’s engagement in the conversations), the Adoption of the model by health providers (clinician referral patterns), Implementation (related to the attendance of patients at both clinical and group visits and aspects of planning discussed), and Maintenance (not assessed in this study).

There was a 40% participation rate. Reasons given for declining to participate were having participated in past advance care planning conversation or having an existing advance directive (30%), lack of interest (13%), illness (3.3%), lack of transportation (3.3%), and other/unknown (50%). Regarding effectiveness, the majority of patients rated the group visit as better than usual clinic visits for talking about advance care planning. Participants reported that they received useful information and felt comfortable talking about advance care planning in the group. In addition, participants reported finding it helpful to talk with others about advance care planning (92%). Participants also reported an overall increase (19% to 41%) in advance care planning conversations with family members after participating in the group visit (P =0.02). Participants said these conversations included enough details that they felt confident that their family members knew their wishes. Thus, enrollment in a CGMV led to improvements in conversation not only between patient and health care provider but also between family members.

Several themes were identified during discussions. Patients shared personal values and challenges related to advance care planning. Also, the facilitated discussions introduced key advance care planning concepts and encouraged patients to share related experiences, questions, successes, and challenges in regards to these topics. An interesting finding was that patients in groups of 4 or 5 seemed less engaged in the discussion than those in groups of 7 to 9 patients.

Applications for Clinical Practice

This novel strategy to faciliate discussions about advance care planning showed promising results and appears feasible, but further study is needed to evaluate the model. It may prove useful as a new model of advance care planning in primary care. Further longitudinal research is encouraged.

 —Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To describe the feasibility of a primary care–based group visit model focused on advance care planning.

Design. Qualitative study.

Setting and participants. Participants were patients attending the Senior Clinic, a patient-centered medical home at the University of Colorado Hospital in Aurora, CO. Patients had to be aged 65, English speakers, and receiving primary care at the Clinic. Participants could be referred by their primary care clinician, a partner or friend, or self-refer in response to flyers. Clinicians were not asked to prioritize patients with poor health status or known end-of-life needs.

Intervention. Groups of patients met for 2 sessions (1 month apart), each 2 hours in length, facilitated by a geriatrician and a social worker. About 1 hour was spent on discussion of advance care planning concepts, including sharing experiences and considering values. Other time in the session was for introductions/rapport building, individual goal setting, and optional completion or directives and/or individual clinical visits. Facilitators were supported by a Facilitator’s Communication Guide and used educational materials and handouts with the group.

Main outcome measures. Researchers used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate the project.

Main results. Patients were referred by 10 out of 11 clinicians. Of 80 patients approached, 32 participated in 5 group visit cohorts (40% participation rate) and 27 participated in both sessions (84% retention rate). Mean age was 79 years; 59% of participants were female and 72% white. Most evaluated the group visit as better than usual clinic visits for discussing advance care planning. Patients reported increases in detailed advance care planning conversations after participating (19% to 41%, P = 0.02). Patients were willing to share personal values and challenges related to advance care planning and they initiated discussions about a broad range of relevant topics.

Conclusion. A group visit to facilitate discussions about advance care planning and increase patient engagement is feasible. This model warrants further evaluation for effectiveness in improving advance care planning outcomes for patients, clinicians, and the system.

Commentary

An understanding of patients’ care goals is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient [1]. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress [1]. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs; however, significant barriers to having advance care planning discussions exist [2], including communication issues and lack of appropriate counseling by clinicians in primary care. Clinicians cite limited time and lack of clinic-based support as factors that impede discussions with patients about advance care planning.

New models are being developed in order to facilitate the process. Group medical visits have been recognized as a useful and effective strategy for approaching patients [1]. The current study describes what the authorssay is the first advance care planning group visit, which they named the “Conversation Group Medical Visit” (CGMV). Its aim is to engage patients in a discussion of key advance care planning concepts and support patient-initiated advance care planning actions, such as choosing surrogate decision makers, deciding on preferences during serious illness, discussing preferences with decision makers and health care providers, and documenting advance directives in the electronic health record [3].

As part of the group medical visits, participants receive an agenda, a personal copy of their EHR highlighting current advance care planning documentation, if any, and a blank medical durable power of attorney form. Facilitators use educational materials including videos from the PREPARE website (prepareforyourcare.org) that demonstrate a family’s conversation, advance directives, and various degrees of flexibility in the decision-making role. A Conversation Starter Kit is also used, which prompts individuals to think about their values and guides conversations about preferences.

Researcher used the RE-AIM framework [4] to evaluate the implementation of this group medical visit model. This framework looks at Reach (if older adults would participate in the medical group visits), Effectiveness (related to participant’s engagement in the conversations), the Adoption of the model by health providers (clinician referral patterns), Implementation (related to the attendance of patients at both clinical and group visits and aspects of planning discussed), and Maintenance (not assessed in this study).

There was a 40% participation rate. Reasons given for declining to participate were having participated in past advance care planning conversation or having an existing advance directive (30%), lack of interest (13%), illness (3.3%), lack of transportation (3.3%), and other/unknown (50%). Regarding effectiveness, the majority of patients rated the group visit as better than usual clinic visits for talking about advance care planning. Participants reported that they received useful information and felt comfortable talking about advance care planning in the group. In addition, participants reported finding it helpful to talk with others about advance care planning (92%). Participants also reported an overall increase (19% to 41%) in advance care planning conversations with family members after participating in the group visit (P =0.02). Participants said these conversations included enough details that they felt confident that their family members knew their wishes. Thus, enrollment in a CGMV led to improvements in conversation not only between patient and health care provider but also between family members.

Several themes were identified during discussions. Patients shared personal values and challenges related to advance care planning. Also, the facilitated discussions introduced key advance care planning concepts and encouraged patients to share related experiences, questions, successes, and challenges in regards to these topics. An interesting finding was that patients in groups of 4 or 5 seemed less engaged in the discussion than those in groups of 7 to 9 patients.

Applications for Clinical Practice

This novel strategy to faciliate discussions about advance care planning showed promising results and appears feasible, but further study is needed to evaluate the model. It may prove useful as a new model of advance care planning in primary care. Further longitudinal research is encouraged.

 —Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To examine the association of individual fruit and vegetable intake with the risk of developing hypertension.

Design. Meta-analysis.

Setting and participants. Subjects were derived from the Nurses’ Health Study (n = 121,700 women, aged 30–55 years in 1976), the Nurses’ Health Study II (n = 116,430 women, aged 25–42 years in 1989), and the Health Professionals Follow-up Study (n = 51,529 men, aged 40–75 years in 1986). Participants returned a questionnaire every 2 years reporting a diagnosis of hypertension by a health care provider. Participants also answered qualitative–quantitative food frequency questionnaires (FFQs) every 4 years, reporting an intake of > 130 foods and beverages. Participants who reported a diagnosis of hypertension at the baseline questionnaire were excluded from the analysis.

Main outcome measures. Self-reported incident hypertension.

Results. Compared to participants whose consumption of fruits and vegetables was ≤ 4 servings/week, those whose intake was ≥ 4 servings/day had multivariable pooled hazard ratios for incident hypertension of 0.92 (95% confidence interval [CI], 0.87–0.97) for total whole fruit intake and 0.95 (CI, 0.86–1.04) for total vegetable intake. Similarly, compared to participants who did not increase their fruit or vegetable consumption, the pooled hazard ratios for those whose intake increased by ≥ 7 servings/week were 0.94 (0.90–0.97) for total whole fruit intake and 0.98 (0.94–1.01) for total vegetable intake. When individual fruit and vegetable consumption was analyzed, consumption levels of ≥ 4 servings/week (as opposed to < 1 serving/month) of broccoli, carrots, tofu or soybeans, raisins, and apples were associated with lower hypertension risk. String beans, brussel sprouts, and cantaloupe were associated with increased risk of hypertension.

Conclusion. The study findings suggested that greater long-term intake and increased consumption of whole fruits may reduce the risk of developing hypertension.

Commentary

Hypertension is a major risk factor for cardiovascular disease and a growing public health concern. Effective public health interventions that will lead to population-wide reductions in blood pressure are needed. The adoption of a healthy diet and low sodium intake is recommended by the American Heart Association in order to prevent hypertension in adults [1]. However, specific information about the benefits of long-term intake and individual foods is limited.

This study aimed to examine the association of individual fruit and vegetable intake with the risk of developing hypertension in 3 large prospective cohort studies in the United States. It was found that greater long-term intake and increased consumption of whole fruits may reduce risk of developing hypertension. Participants with higher fruit and vegetable intakes were more physically active, older, had higher daily caloric intakes, and were less likely to be smokers.

This study was novel in that it examined individual fruit and vegetable consumption. All 3 studies provided a large sample, which increased precision and power in the statistical analysis. Researchers were focused on establishing an association between the risk of hypertension and fruit and vegetable consumption; therefore, hazard ratios were presented and Cox regression and multivariate analysis were used, which are appropriate statistical methods for this type of study.

Some limitations should be mentioned. Blood pressure was not directly measured. Food intake was measured using a dietary questionnaire and may not have accurately represented actual intake. Also, participants were mostly non-Hispanic white men and women and other population groups were not well represented.

Applications for Clinical Practice

Reducing the risk for hypertension by increasing fruit consumption needs to be examined in other population groups and studies. In the meantime, clinicians can continue to recommend an eating plan that is rich in fruits, vegetables, and low-fat dairy products and reduced in saturated fat, total fat, and cholesterol.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To examine the association of individual fruit and vegetable intake with the risk of developing hypertension.

Design. Meta-analysis.

Setting and participants. Subjects were derived from the Nurses’ Health Study (n = 121,700 women, aged 30–55 years in 1976), the Nurses’ Health Study II (n = 116,430 women, aged 25–42 years in 1989), and the Health Professionals Follow-up Study (n = 51,529 men, aged 40–75 years in 1986). Participants returned a questionnaire every 2 years reporting a diagnosis of hypertension by a health care provider. Participants also answered qualitative–quantitative food frequency questionnaires (FFQs) every 4 years, reporting an intake of > 130 foods and beverages. Participants who reported a diagnosis of hypertension at the baseline questionnaire were excluded from the analysis.

Main outcome measures. Self-reported incident hypertension.

Results. Compared to participants whose consumption of fruits and vegetables was ≤ 4 servings/week, those whose intake was ≥ 4 servings/day had multivariable pooled hazard ratios for incident hypertension of 0.92 (95% confidence interval [CI], 0.87–0.97) for total whole fruit intake and 0.95 (CI, 0.86–1.04) for total vegetable intake. Similarly, compared to participants who did not increase their fruit or vegetable consumption, the pooled hazard ratios for those whose intake increased by ≥ 7 servings/week were 0.94 (0.90–0.97) for total whole fruit intake and 0.98 (0.94–1.01) for total vegetable intake. When individual fruit and vegetable consumption was analyzed, consumption levels of ≥ 4 servings/week (as opposed to < 1 serving/month) of broccoli, carrots, tofu or soybeans, raisins, and apples were associated with lower hypertension risk. String beans, brussel sprouts, and cantaloupe were associated with increased risk of hypertension.

Conclusion. The study findings suggested that greater long-term intake and increased consumption of whole fruits may reduce the risk of developing hypertension.

Commentary

Hypertension is a major risk factor for cardiovascular disease and a growing public health concern. Effective public health interventions that will lead to population-wide reductions in blood pressure are needed. The adoption of a healthy diet and low sodium intake is recommended by the American Heart Association in order to prevent hypertension in adults [1]. However, specific information about the benefits of long-term intake and individual foods is limited.

This study aimed to examine the association of individual fruit and vegetable intake with the risk of developing hypertension in 3 large prospective cohort studies in the United States. It was found that greater long-term intake and increased consumption of whole fruits may reduce risk of developing hypertension. Participants with higher fruit and vegetable intakes were more physically active, older, had higher daily caloric intakes, and were less likely to be smokers.

This study was novel in that it examined individual fruit and vegetable consumption. All 3 studies provided a large sample, which increased precision and power in the statistical analysis. Researchers were focused on establishing an association between the risk of hypertension and fruit and vegetable consumption; therefore, hazard ratios were presented and Cox regression and multivariate analysis were used, which are appropriate statistical methods for this type of study.

Some limitations should be mentioned. Blood pressure was not directly measured. Food intake was measured using a dietary questionnaire and may not have accurately represented actual intake. Also, participants were mostly non-Hispanic white men and women and other population groups were not well represented.

Applications for Clinical Practice

Reducing the risk for hypertension by increasing fruit consumption needs to be examined in other population groups and studies. In the meantime, clinicians can continue to recommend an eating plan that is rich in fruits, vegetables, and low-fat dairy products and reduced in saturated fat, total fat, and cholesterol.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To examine the association of individual fruit and vegetable intake with the risk of developing hypertension.

Design. Meta-analysis.

Setting and participants. Subjects were derived from the Nurses’ Health Study (n = 121,700 women, aged 30–55 years in 1976), the Nurses’ Health Study II (n = 116,430 women, aged 25–42 years in 1989), and the Health Professionals Follow-up Study (n = 51,529 men, aged 40–75 years in 1986). Participants returned a questionnaire every 2 years reporting a diagnosis of hypertension by a health care provider. Participants also answered qualitative–quantitative food frequency questionnaires (FFQs) every 4 years, reporting an intake of > 130 foods and beverages. Participants who reported a diagnosis of hypertension at the baseline questionnaire were excluded from the analysis.

Main outcome measures. Self-reported incident hypertension.

Results. Compared to participants whose consumption of fruits and vegetables was ≤ 4 servings/week, those whose intake was ≥ 4 servings/day had multivariable pooled hazard ratios for incident hypertension of 0.92 (95% confidence interval [CI], 0.87–0.97) for total whole fruit intake and 0.95 (CI, 0.86–1.04) for total vegetable intake. Similarly, compared to participants who did not increase their fruit or vegetable consumption, the pooled hazard ratios for those whose intake increased by ≥ 7 servings/week were 0.94 (0.90–0.97) for total whole fruit intake and 0.98 (0.94–1.01) for total vegetable intake. When individual fruit and vegetable consumption was analyzed, consumption levels of ≥ 4 servings/week (as opposed to < 1 serving/month) of broccoli, carrots, tofu or soybeans, raisins, and apples were associated with lower hypertension risk. String beans, brussel sprouts, and cantaloupe were associated with increased risk of hypertension.

Conclusion. The study findings suggested that greater long-term intake and increased consumption of whole fruits may reduce the risk of developing hypertension.

Commentary

Hypertension is a major risk factor for cardiovascular disease and a growing public health concern. Effective public health interventions that will lead to population-wide reductions in blood pressure are needed. The adoption of a healthy diet and low sodium intake is recommended by the American Heart Association in order to prevent hypertension in adults [1]. However, specific information about the benefits of long-term intake and individual foods is limited.

This study aimed to examine the association of individual fruit and vegetable intake with the risk of developing hypertension in 3 large prospective cohort studies in the United States. It was found that greater long-term intake and increased consumption of whole fruits may reduce risk of developing hypertension. Participants with higher fruit and vegetable intakes were more physically active, older, had higher daily caloric intakes, and were less likely to be smokers.

This study was novel in that it examined individual fruit and vegetable consumption. All 3 studies provided a large sample, which increased precision and power in the statistical analysis. Researchers were focused on establishing an association between the risk of hypertension and fruit and vegetable consumption; therefore, hazard ratios were presented and Cox regression and multivariate analysis were used, which are appropriate statistical methods for this type of study.

Some limitations should be mentioned. Blood pressure was not directly measured. Food intake was measured using a dietary questionnaire and may not have accurately represented actual intake. Also, participants were mostly non-Hispanic white men and women and other population groups were not well represented.

Applications for Clinical Practice

Reducing the risk for hypertension by increasing fruit consumption needs to be examined in other population groups and studies. In the meantime, clinicians can continue to recommend an eating plan that is rich in fruits, vegetables, and low-fat dairy products and reduced in saturated fat, total fat, and cholesterol.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To examine the cross-sectional relationships between standing time, obesity, and metabolic syndrome.

Design. Cross-sectional study.

Setting and participants. Participants were patients aged 20–79 years old attending Cooper Clinic in Dallas for a preventive medicine visit who enrolled in the Cooper Center Longitudinal Study, an ongoing prospective investigation established in 1970 to explore the effects of physical activity on morbidity and mortality [1]. Included in the analysis were those enrolled starting in 2010, when questions pertaining to standing patterns began to be included in the medical history. Patients who did not have complete information or who had a history of myocardial infarction, stroke, or cancer were excluded.

Measures. Obesity was directly measured using body mass index (≥ 30), waist circumference (men: ≥ 102 cm; women: ≥ 88 cm), and body fat percentage (men: ≥ 25%; women ≥ 30%) and was adjusted for history of diabetes and hypertension. Metabolic syndrome, a clustering of risk factors that increase the risk for heart disease, stroke, and diabetes, was assessed. Participants’ standing patterns were ascertained from responses to survey questions derived from the Canada Fitness Survey Questionnaire (“For those activities that you do most days of the week, such as work, school, and housework, how much time do you spend standing: Almost all of the time, ¾ of the time, ½ of the time, ¼ of the time, almost none of the time?”). Leisure-time physical activity was determined based on responses to survey questions, and answers were used to categorize participants as either meeting or not meeting the Physical Activity Guidelines for Americans.

Results. The study sample consisted of 7075 participants, who were primarily white and college educated. Over two-thirds were men and the mean age was 50.0 ± 10.1 years. Multivariable analysis showed that in men, increased standing was significantly associated with a lower likelihood of elevated body fat percentage. Specifically, standing a quarter of the time was linked to a 32% reduced likelihood of obesity (body fat percentage), standing half the time was associated with a 59% reduced likelihood of obesity, but standing more than three-quarters of the time was not associated with a lower risk of obesity. In women, standing a quarter, half, and three-quarters of the time was associated with 35%, 47%, and 57% respective reductions in the likelihood of abdominal obesity (waist circumference). No relationship between standing and metabolic syndrome was found among women or men.

The study also examined whether physical activity in conjunction with standing provided additional reduction risk for obesity. The study showed that 150 minutes of moderate activity and/or 75 minutes of vigorous activity per week added to standing time was associated with significant reduction in the probability of obesity and metabolic syndrome in both women and men.

Conclusion. Standing a quarter of the time per day or more is associated with reduced odds of obesity. The inverse relationship of standing to obesity and metabolic syndrome is more robust when combined with health-promoting leisure-time physical activity.

Commentary

Obesity is considered one of the main risk factors for cardiovascular diseases worldwide. Obesity-related conditions include heart disease, stroke, type 2 diabetes, and certain types of cancer, some of the leading causes of preventable death. The effects of obesity among Americans add more than $147 billion in medical costs to the U.S. economy annually [2].

Obesity is a national epidemic, with more than 78.9 million obese adults in the United States [2]. Studies have shown that Americans are currently less active as compared to past decades [3]. This decline in physical activity combined with other factors, such as the ubiquity of low-cost high-energy foods and beverages, has likely contributed to the high rate of obesity.

This cross-sectional study aimed to assess the relationship between standing time, obesity, and metabolic syndrome alongside and independent of leisure-time physical activity. The researchers found that standing for at least one quarter of the day is linked to lower odds of obesity, which was directly assessed through 3 measures: BMI, body fat percentage, and waist circumference. The apparent benefit of standing is an important finding in light of obesity being such an important public health concern.

The large sample size is a strength of this study in terms of statistical power; however, there are important limitations that must be acknowledged. First, given the cross-sectional design, no causal inferences can be made. Moreover, while obesity and metabolic syndrome were objectively measured, standing and physical activity were based on self-report, which may lead to over- or underestimation of these behaviors. In addition, due to the survey measure used in the study, it is unclear whether study participants were standing still or standing and moving. More information in this regard would be helpful. Longitudinal research is encouraged in order to provide better evidence of these relationships and their effects.

In addition, cultural aspects were not assessed in this study. Racial and ethnic differences may influence the relationship between the variables of physical activity and obesity reduction.

Applications for Clinical Practice

Obesity is a complex but preventable health problem commonly associated with sedentary lifestyle. Physical activity is recommended as a component of weight management for prevention of weight gain and for weight loss [4]. Whether standing more often will aid in reducing obesity cannot be determined from this study.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To examine the cross-sectional relationships between standing time, obesity, and metabolic syndrome.

Design. Cross-sectional study.

Setting and participants. Participants were patients aged 20–79 years old attending Cooper Clinic in Dallas for a preventive medicine visit who enrolled in the Cooper Center Longitudinal Study, an ongoing prospective investigation established in 1970 to explore the effects of physical activity on morbidity and mortality [1]. Included in the analysis were those enrolled starting in 2010, when questions pertaining to standing patterns began to be included in the medical history. Patients who did not have complete information or who had a history of myocardial infarction, stroke, or cancer were excluded.

Measures. Obesity was directly measured using body mass index (≥ 30), waist circumference (men: ≥ 102 cm; women: ≥ 88 cm), and body fat percentage (men: ≥ 25%; women ≥ 30%) and was adjusted for history of diabetes and hypertension. Metabolic syndrome, a clustering of risk factors that increase the risk for heart disease, stroke, and diabetes, was assessed. Participants’ standing patterns were ascertained from responses to survey questions derived from the Canada Fitness Survey Questionnaire (“For those activities that you do most days of the week, such as work, school, and housework, how much time do you spend standing: Almost all of the time, ¾ of the time, ½ of the time, ¼ of the time, almost none of the time?”). Leisure-time physical activity was determined based on responses to survey questions, and answers were used to categorize participants as either meeting or not meeting the Physical Activity Guidelines for Americans.

Results. The study sample consisted of 7075 participants, who were primarily white and college educated. Over two-thirds were men and the mean age was 50.0 ± 10.1 years. Multivariable analysis showed that in men, increased standing was significantly associated with a lower likelihood of elevated body fat percentage. Specifically, standing a quarter of the time was linked to a 32% reduced likelihood of obesity (body fat percentage), standing half the time was associated with a 59% reduced likelihood of obesity, but standing more than three-quarters of the time was not associated with a lower risk of obesity. In women, standing a quarter, half, and three-quarters of the time was associated with 35%, 47%, and 57% respective reductions in the likelihood of abdominal obesity (waist circumference). No relationship between standing and metabolic syndrome was found among women or men.

The study also examined whether physical activity in conjunction with standing provided additional reduction risk for obesity. The study showed that 150 minutes of moderate activity and/or 75 minutes of vigorous activity per week added to standing time was associated with significant reduction in the probability of obesity and metabolic syndrome in both women and men.

Conclusion. Standing a quarter of the time per day or more is associated with reduced odds of obesity. The inverse relationship of standing to obesity and metabolic syndrome is more robust when combined with health-promoting leisure-time physical activity.

Commentary

Obesity is considered one of the main risk factors for cardiovascular diseases worldwide. Obesity-related conditions include heart disease, stroke, type 2 diabetes, and certain types of cancer, some of the leading causes of preventable death. The effects of obesity among Americans add more than $147 billion in medical costs to the U.S. economy annually [2].

Obesity is a national epidemic, with more than 78.9 million obese adults in the United States [2]. Studies have shown that Americans are currently less active as compared to past decades [3]. This decline in physical activity combined with other factors, such as the ubiquity of low-cost high-energy foods and beverages, has likely contributed to the high rate of obesity.

This cross-sectional study aimed to assess the relationship between standing time, obesity, and metabolic syndrome alongside and independent of leisure-time physical activity. The researchers found that standing for at least one quarter of the day is linked to lower odds of obesity, which was directly assessed through 3 measures: BMI, body fat percentage, and waist circumference. The apparent benefit of standing is an important finding in light of obesity being such an important public health concern.

The large sample size is a strength of this study in terms of statistical power; however, there are important limitations that must be acknowledged. First, given the cross-sectional design, no causal inferences can be made. Moreover, while obesity and metabolic syndrome were objectively measured, standing and physical activity were based on self-report, which may lead to over- or underestimation of these behaviors. In addition, due to the survey measure used in the study, it is unclear whether study participants were standing still or standing and moving. More information in this regard would be helpful. Longitudinal research is encouraged in order to provide better evidence of these relationships and their effects.

In addition, cultural aspects were not assessed in this study. Racial and ethnic differences may influence the relationship between the variables of physical activity and obesity reduction.

Applications for Clinical Practice

Obesity is a complex but preventable health problem commonly associated with sedentary lifestyle. Physical activity is recommended as a component of weight management for prevention of weight gain and for weight loss [4]. Whether standing more often will aid in reducing obesity cannot be determined from this study.

—Paloma Cesar de Sales, BS, RN, MS

Study Overview

Objective. To examine the cross-sectional relationships between standing time, obesity, and metabolic syndrome.

Design. Cross-sectional study.

Setting and participants. Participants were patients aged 20–79 years old attending Cooper Clinic in Dallas for a preventive medicine visit who enrolled in the Cooper Center Longitudinal Study, an ongoing prospective investigation established in 1970 to explore the effects of physical activity on morbidity and mortality [1]. Included in the analysis were those enrolled starting in 2010, when questions pertaining to standing patterns began to be included in the medical history. Patients who did not have complete information or who had a history of myocardial infarction, stroke, or cancer were excluded.

Measures. Obesity was directly measured using body mass index (≥ 30), waist circumference (men: ≥ 102 cm; women: ≥ 88 cm), and body fat percentage (men: ≥ 25%; women ≥ 30%) and was adjusted for history of diabetes and hypertension. Metabolic syndrome, a clustering of risk factors that increase the risk for heart disease, stroke, and diabetes, was assessed. Participants’ standing patterns were ascertained from responses to survey questions derived from the Canada Fitness Survey Questionnaire (“For those activities that you do most days of the week, such as work, school, and housework, how much time do you spend standing: Almost all of the time, ¾ of the time, ½ of the time, ¼ of the time, almost none of the time?”). Leisure-time physical activity was determined based on responses to survey questions, and answers were used to categorize participants as either meeting or not meeting the Physical Activity Guidelines for Americans.

Results. The study sample consisted of 7075 participants, who were primarily white and college educated. Over two-thirds were men and the mean age was 50.0 ± 10.1 years. Multivariable analysis showed that in men, increased standing was significantly associated with a lower likelihood of elevated body fat percentage. Specifically, standing a quarter of the time was linked to a 32% reduced likelihood of obesity (body fat percentage), standing half the time was associated with a 59% reduced likelihood of obesity, but standing more than three-quarters of the time was not associated with a lower risk of obesity. In women, standing a quarter, half, and three-quarters of the time was associated with 35%, 47%, and 57% respective reductions in the likelihood of abdominal obesity (waist circumference). No relationship between standing and metabolic syndrome was found among women or men.

The study also examined whether physical activity in conjunction with standing provided additional reduction risk for obesity. The study showed that 150 minutes of moderate activity and/or 75 minutes of vigorous activity per week added to standing time was associated with significant reduction in the probability of obesity and metabolic syndrome in both women and men.

Conclusion. Standing a quarter of the time per day or more is associated with reduced odds of obesity. The inverse relationship of standing to obesity and metabolic syndrome is more robust when combined with health-promoting leisure-time physical activity.

Commentary

Obesity is considered one of the main risk factors for cardiovascular diseases worldwide. Obesity-related conditions include heart disease, stroke, type 2 diabetes, and certain types of cancer, some of the leading causes of preventable death. The effects of obesity among Americans add more than $147 billion in medical costs to the U.S. economy annually [2].

Obesity is a national epidemic, with more than 78.9 million obese adults in the United States [2]. Studies have shown that Americans are currently less active as compared to past decades [3]. This decline in physical activity combined with other factors, such as the ubiquity of low-cost high-energy foods and beverages, has likely contributed to the high rate of obesity.

This cross-sectional study aimed to assess the relationship between standing time, obesity, and metabolic syndrome alongside and independent of leisure-time physical activity. The researchers found that standing for at least one quarter of the day is linked to lower odds of obesity, which was directly assessed through 3 measures: BMI, body fat percentage, and waist circumference. The apparent benefit of standing is an important finding in light of obesity being such an important public health concern.

The large sample size is a strength of this study in terms of statistical power; however, there are important limitations that must be acknowledged. First, given the cross-sectional design, no causal inferences can be made. Moreover, while obesity and metabolic syndrome were objectively measured, standing and physical activity were based on self-report, which may lead to over- or underestimation of these behaviors. In addition, due to the survey measure used in the study, it is unclear whether study participants were standing still or standing and moving. More information in this regard would be helpful. Longitudinal research is encouraged in order to provide better evidence of these relationships and their effects.

In addition, cultural aspects were not assessed in this study. Racial and ethnic differences may influence the relationship between the variables of physical activity and obesity reduction.

Applications for Clinical Practice

Obesity is a complex but preventable health problem commonly associated with sedentary lifestyle. Physical activity is recommended as a component of weight management for prevention of weight gain and for weight loss [4]. Whether standing more often will aid in reducing obesity cannot be determined from this study.

—Paloma Cesar de Sales, BS, RN, MS