Lifestyle Changes and Blood Pressure Control: A Community‐Based Cross‐Sectional Survey (2006 Ontario Survey on the Prevalence and Control of Hypertension)

To the Editor :

We read with interest the Fodor and colleagues ¹ article in your January issue wherein the authors asserted, in our opinion most erroneously, that “when a comparison is made between drug treatment and lifestyle changes, the outcomes of lifestyle interventions in real life are disappointing.”

We would counter that drug therapy is not the only proven method of reducing blood pressure (BP) and most guidelines that recommend lifestyle changes for BP reduction are based on solid efficacy trials, including the Trials of Hypertension Prevention (TOHP), Dietary Approaches to Stop Hypertension (DASH), Prevention of Myocardial Infarction Early Remodeling (PREMIER), and Trial of Nonpharmacologic Interventions in the Elderly (TONE), to mention a few. This is especially true for patients who have stage 1 hypertension. In a recent PREMIER follow‐up study, patients assessed 18 months later continued to have reduced BP, demonstrating the effectiveness of lifestyle changes. ² In the TONE trial, a greater percentage (23%) of older adults who received the lifestyle intervention remained normotensive (following medication withdrawal) at the 48‐month follow‐up than those who received usual care (7%). ³

Furthermore, the conclusion that “practicing lifestyle changes did not add a beneficial effect to BP control compared with antihypertensive treatment with medications only” cannot be supported by this data. First, the authors’ comment is based on cross‐sectional surveys with a relatively small sample of 733 hypertensive individuals, rather than on studies designed to test the comparative effectiveness of drug therapy vs lifestyle changes on BP control. Second, data were not presented on the actual degree of medication adherence or amount of lifestyle change. Rather, the assessment asked participants “whether they were using any nonpharmacologic and/or lifestyle treatments for BP control.” Although the authors note this limitation, they nevertheless reach beyond the limits of their data to minimize the effectiveness of lifestyle change for BP reduction.

That lifestyle changes are difficult to enact is true, but that is also true for adherence to antihypertensive medications. Our studies indicate an adherence rate of 42% to 56% among hypertensive black patients followed in primary care practices, ⁴ , ⁵ similar to rates reported by others. ⁶ , ⁷ Other factors, ignored in this paper, and often in the literature, include clinical uncertainty and physicians’ awareness of evidence‐based hypertension treatment guidelines when counseling patients. At the patient level, BP control can be hampered by lack of knowledge about the benefits of healthy lifestyle behaviors on BP reduction, side effects of prescribed medications, and comorbidity. ⁸ , ⁹ , ¹⁰ Such factors also contribute to the often intractable multifactorial nature of BP control.

We also take issue with the authors’ assertion that “relying on the effectiveness of lifestyle changes can lead to the postponement of efficacious drug treatment with serious consequences.” No data is presented in this paper to support this assertion, and there are no studies we are aware of that demonstrate “reliance on the effectiveness of lifestyle changes” leads to clinical inertia.

Finally, the authors’ focus on the lack of significant between‐group differences in BP control diminishes the positive finding that approximately half (42%) of the population reported adopting lifestyle changes in addition to using medications as part of their treatment. This rate is 2‐fold higher than the prevalence reported in US adults when examining the 2006 Behavioral Risk Factor Surveillance System dataset (approximately 22% of the sample reported being adherent to heart‐healthy behaviors). ¹¹

In our work, we have found group‐based lifestyle interventions not only improve clinical outcomes such as BP reduction but also provide individuals with the impetus to sustain these interventions in their communities.

In summary, we believe significant cardiovascular risk reduction can be achieved through multilevel interventions targeted at potentially reversible adverse lifestyle behaviors such as poor dietary intake and physical inactivity, particularly in high‐risk patient populations. Suggestions to the contrary by Fodor and colleagues are simply unsupported.—