Friday, September 26, 2008

Hypertension: Get Meds or Get Moving?

In August, a “HealthDay News” headline reported that “exercise reduces blood pressure…but too few doctors recommend it to their patients.”

I recently got hold of the article:
Halm J, Amoako E. Physical activity recommendation for hypertension management: does healthcare provider advice make a difference? Ethnicity and Disease, 2008 Summer;18(3):278-82. PMID: 18785439.

The researchers drew upon a big, longitudinal health survey to examine specific aspects of hypertension: for patients with hypertension, what portion reported that their physician had urged them to exercise to treat hypertension.

Only a third of these hypertensive patients reported that their physician had urged them to exercise.

A sad finding. Despite evidence that physical exercise lowers blood pressure, and has a range of other “side effects” that are basically good, such as warding off depression, reducing risk of cancer, lowering bad cholesterol, etc., physicians in the U.S. are not advising hypertension patients to exercise.

Why not? Could it be because the recommendations don’t work? Well, according to further questions, that is not the case. Actually, it seems that, for hypertension patients who reported that their physician did recommend exercise, about 70% reported that they were following the recommendation! A much higher rate of regular exercise compared to those who reported receipt of no such advice.

Well, did the advice-giving work? As well as this data set can indicate, the exercisers had great results: average 3-4 blood pressure points lower (in mmHg): average systolic of 126 versus 129.

Now, this type of study has a host of limits. It is possible that hypertensive patients did receive advice, but did not remember it – totally conceivable: it makes more sense that if you as a patient are receptive and ready to act on advice, you will later remember getting that advice. It is also possible that a healthy user effect is operating: those who are willing to figure out anything to do to improve health may ask for advice, and thus actually get advice. Similarly, if a physician judges that a patient is more likely to act on advice, the physician may be more likely to give the advice.

We don’t know. The nature of this data set does not eliminate these alternatives. But, a host of similar research does support the same story: patients do act upon physician advice, and accordingly do achieve decreases in blood pressure, but physicians often do not ask about exercise or give good advice about exercise.

Why? My suspicion is that Big Pharma, and other forces, are creating the belief that hypertension is a medical disorder that needs to be treated with a real treatment – meaning meds. And if the meds don’t work, try more, or try a different med.

Rarely do you hear of a physician doing the full-court press for their patient to begin and maintain a regular aerobic exercise habit. Sad. Despite benefits from hypertensive meds, including proven efficacy in reducing blood pressure, and also reducing the more important outcomes such as stroke and kidney disease, blood pressure meds have host of annoying side effects. Structured instruments for these side effects range from inquiring about 10 or a dozen recognized side effects (nothing to sneeze at) up to 70 or a few more side effects.

And what kind of "CME" are physicians receiving? Well, it is recognized that Big Pharma is a major provider of CME. And yes, you can give enough blood pressure meds to get blood pressure into the normal range. But at what cost? Who is out there in the physician offices advocating for Asics along with or instead of ACE inhibitors?

All the while, the side effects of exercise are, what, blisters? Decrease in quality of life because you have to do more laundry?

Anyway: the article is a nice read: it reviews the problem of hypertension and presents decent detail on the study data (NHANES). Finally, it is yet another piece of data indicating that too many physicians may not be encouraging an effective treatment for a very treacherous disease.

An update: Reuters has just put this out as a headline story:

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