Western Journal of Nursing Research

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Randomized Controlled Trial on Lifestyle Modification in Hypertensive Patients

Hulya Cakir and Rukiye Pinar
West J Nurs Res 2006 28: 190
DOI: 10.1177/0193945905283367

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 Western Journal of
Western
10.1177/0193945905283367
Cakir, Pinar
Journal
/ Lifestyle
of Nursing
Modification
Researchin Hypertensive Patients
Nursing Research
Volume 28 Number 2
March 2006 190-209

Randomized Controlled © 2006 Sage Publications

10.1177/0193945905283367
http://wjn.sagepub.com
Trial on Lifestyle hosted at
http://online.sagepub.com
Modification in
Hypertensive Patients
Hulya Cakir
Rukiye Pinar
Marmara University, College of Nursing, Istanbul, Turkey

The authors examined the effects of a comprehensive lifestyle modification

intervention on blood pressure (BP) and other cardiovascular risk factors in
hypertensive patients. A total of 70 participants were randomly placed into
either a lifestyle intervention or a control group. Four education classes and
individual counseling sessions were held for the intervention group. Partici-
pants in the control group were provided with routine outpatient services and
were asked to maintain their usual lifestyle. Data were gathered at baseline and
at the end of 6 months. At the end of 6 months, BP, body weight, body
mass index, waist circumference, and fasting lipids, apart from high-density
lipoprotein cholesterol, significantly declined in the intervention group. Health-
promoting lifestyle scores of the intervention group had increased signifi-
cantly compared to those of the control group. In conclusion, the results dem-
onstrate the feasibility of comprehensive lifestyle modification and show its
beneficial effects.

Keywords: hypertension; lifestyle modification; patient education; cardiac;

risk factors

H ypertension affects about 20% of the adult population around the

world. There are 3.45 billion adults (20 years and older) with hyper-
tension in the world (Mulrow, 1999). Hypertension is a common, powerful,
and independent risk factor for cardiovascular disease and stroke (Bacon,

Authors’ Note: Author Hulya Cakir introduced the lifestyle modification education to the par-
ticipants in the intervention group, performed the statistical analysis, and interpreted the results.
Author Rukiye Pinar designed the investigation, supervised all educational sessions, and assisted
in the statistical analysis, interpretation of results, and preparation of the manuscript. Both
authors read and approved the final manuscript.

190

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 Cakir, Pinar / Lifestyle Modification in Hypertensive Patients 191

Sherwood, Hinderliter, & Blumental, 2004; Joint National Committee on

Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
[JNC-VII], 2003; MacMahon et al., 1990; Muntner, He, Roccella, &
Whelton, 2002; Onat, 2001; Stamler, Stamler, & Neaton, 1993; Svetkey
et al., 2005). This risk further increases with progressive elevations in blood
pressure (BP), beginning at even normal levels of BP (JNC-VII, 2003;
MacMahon et al., 1990; Stamler et al., 1993). Reduction of BP to optimal
levels, control of hypertension in the hypertensive population, and preven-
tion of the development of hypertension in the general population, therefore,
are major public health priorities. Efforts to prevent or control BP-related
cardiovascular disease and stroke include not only pharmacological therapy
but also public health approaches that reduce high BP throughout the whole
population. Lifestyle modification strategies are available to achieve these
goals (JNC-VII, 2003).

Lifestyle Modification in
Hypertensive Patients
Lifestyle modification, previously termed nonpharmacologic therapy,
has an important role to play in the lives of hypertensive and nonhypertensive
individuals. In hypertensive individuals, it can serve as initial treatment be-
fore the start of drug therapy and as an adjunct to medication in persons
already on drug therapy (Appel, 2003; JNC-VII, 2003; Svetkey et al., 2005;
Vestfold Heartcare Study Group, 2003). Major lifestyle modifications seen
to lower BP include weight reduction in those individuals who are over-
weight or obese, adoption of the eating plan known as Dietary Approaches to
Stop Hypertension (DASH), dietary sodium reduction, physical activity, and
moderation of alcohol consumption (Bacon et al., 2004; JNC-VII, 2003;
Svetkey et al., 2005; P. K. Whelton, He, et al., 2002).
Many studies have demonstrated that each of these lifestyle modifica-
tions will decrease BP levels (Appel et al., 1997; Bacon et al., 2004;
Blumental et al., 2000; Bray et al., 2004; Cutler, Follmann, & Allender,
1997; Grimm et al., 1997; Miller et al., 2002; Sacks et al., 2001; Svetkey
et al., 2004, 2005; Writing Group of the PREMIER Collaborative Research
Group, 2003). Even an apparently small reduction in BP can have enormous
benefits on cardiovascular events. A 3 mmHg reduction in systolic BP
(SBP), for instance, might lead to an 8% reduction in stroke mortality and a
5% reduction in mortality from coronary heart disease (Stamler et al., 1989).
In contrast to most drug therapies, lifestyle modifications that reduce BP can
also prevent or control other chronic conditions (Knowler et al., 2002;
Stamler et al., 1989).

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192 Western Journal of Nursing Research

Lifestyle modifications are useful and necessary in helping an individual

to develop healthy lifestyle behaviors. Supportive measures, such as smok-
ing cessation and stress management, should therefore be considered when
lifestyle modifications are targeted (Sands & Wilson, 1999; Vestfold Heart-
care Study Group, 2003). Lifestyle modifications are generally recom-
mended to be implemented as a group (JNC-VII, 2003); however, only a
few of the previous studies have evaluated the effects of implementing
these modifications, including the cessation of smoking (Pater et al., 2000;
Piestrzeniewicz, Navarro-Kuczborska, Bolinska, Jegier, & Maciejewski,
2004) and stress management (Kennedy et al., 2003), or both (Vestfold
Heartcare Study Group, 2003), either on a two-fold basis or all at the same
time.

Purpose

The purpose of this study is to examine the effects of a comprehensive

lifestyle intervention on BP and other cardiovascular risk factors in hyperten-
sive patients. The main components of comprehensive lifestyle intervention
were to reduce weight, to reduce sodium intake, to reduce alcohol consump-
tion, to increase physical exercise to a moderate degree, to give up cigarette
smoking, and to learn stress management. Cardiovascular risk factors inves-
tigated in the present study were hypertension; increased total cholesterol
(TC), low-density lipoprotein cholesterol (LDL-C), and triglycerides;
decreased high-density lipoprotein cholesterol (HDL-C); obesity; decreased
physical activity; and increased alcohol consumption, smoking, and stress.

Design

The study was designed as a randomized controlled trial.

Sample

The study was performed in the outpatient hypertension clinic at a univer-

sity hospital in Istanbul, Turkey. A proposed study group consisted of all per-
sons (N = 320) who had visited the outpatient hypertension clinic between
November 2000 and September 2001. Approval for the study was obtained
from the local ethical committee. Persons were eligible if they were between
18 and 65 years of age, had been diagnosed with hypertension (i.e., mean
systolic BP of ≥ 140 mmHg and/or mean diastolic BP, DBP, of ≥ 90 mmHg

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 Cakir, Pinar / Lifestyle Modification in Hypertensive Patients 193

on 3 separate occasions during a 3-week period), and were able to complete

the questionnaire unaided. Major exclusion criteria were currently partici-
pating in a structured dietary program aimed at weight reduction, regular
participation in physical activity during the previous 3 months, regular use
of drugs that affect dyslipidemia, use of weight-loss medications, a prior
cardiovascular event, or ischemic heart disease.
In all, 76 persons met the eligibility criteria, but 6 of them did not agree to
participate in the study. Thus, 70 participants were initially included in the
study. Informed consent was obtained from each participant. A computer
program made randomization assignments centrally. Clinical staff then noti-
fied participants of their assigned group. Eligible participants were then ran-
domly assigned into a comprehensive lifestyle intervention (n = 32) or a con-
trol (n = 38) group. Of the 70 participants thus randomized, 60 (85.5%)
completed the study, and 10 were withdrawn from the study. Of these
patients, 1 (from the intervention group) moved to another city, 1 (from the
intervention group) was withdrawn owing to her failure to attend education
classes, and 8 (from the control group) failed to come for final evaluation for
various reasons such as not feeling well, transportation problems, or being on
vacation. Demographic and clinic data were obtained by using a question-
naire and medical records.
Table 1 shows the baseline characteristics of the 60 participants. The
mean age of the intervention group was 52.2 (SD = 8.6), and that of the con-
trol group was 55.6 (SD = 8.0) years. The majority of participants were
women (n = 37), married (n = 49), and had a primary school education (n =
32). In all, 15 of the participants were using their medication irregularly.
More than half of the participants (n = 34) were on a salt-reduced diet, 16 par-
ticipants were currently cigarette smokers, and 11 were consuming alcohol at
a rate ≥ 30 ml of ethanol per day.

Method

Education on Comprehensive
Lifestyle Modification
The main components of the comprehensive lifestyle modification were
to reduce weight, to reduce sodium intake, to reduce alcohol consumption, to
increase physical exercise to a moderate degree, to give up cigarette smok-
ing, and to learn stress management. Shortly after randomization, a class was
held for all participants in the intervention group. This class consisted of a
30-minute lecture by a nurse on how to control hypertension to prevent heart

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194 Western Journal of Nursing Research

Table 1
Baseline Characteristics of Participants
a a
Intervention Group n Control Group n

Sex
Female 19 18
Male 11 12
Age
M 52.2 55.6
SD 8.6 8.0
Education
Primary school education 13 19
Secondary school and/or more education 17 11
Marital status
Married 26 23
Unmarried 4 7
Antihypertensive medication
Regular 22 23
Irregular 8 7
Using salt-lowered dietb
Yes 17 17
No 13 13
Using fat-lowered dietb
Yes 6 5
No 24 25
Smoker 10 6
Nonsmoker 20 24
Alcohol consuming (≥30 ml ethanol/day)
Yes 5 6
No 25 24

Intervention Groupa Control Group

a

M SD M SD

Blood pressure (BP)

Systolic BP 144.2 11.8 141.5 9.7
Diastolic BP 91.0 8.9 86.9 6.9
Lipid values (mg/dl)
Total cholesterol 212.3 31.7 220.7 40.2
HDL cholesterol 42.7 9.6 41.7 10.6
LDL cholesterol 138.2 34.3 141.8 26.9
Triglyceridec 145.7 46.7 199.9 99.9
Obesity parameters
Weight (kg) 77.6 12.0 78.5 15.3
Body mass index (kg/m2) 29.3 4.8 30.2 6.1
Waist circumference (cm) 99.1 9.7 100.4 12.3

(continued)

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 Cakir, Pinar / Lifestyle Modification in Hypertensive Patients 195

Table 1 (continued)
a a
Intervention Group Control Group
M SD M SD

Health Promotion Lifestyle Profile (HPLP)

HPLP total 123.9 19.6 117.7 23.2
Self-realization 38.9 6.4 36.2 7.9
Health responsibility 23.1 6.2 22.4 6.4
Exercise 7.5 2.6 7.1 2.4
Nutrition 16.7 4.0 16.3 3.9
Interpersonal support 21.6 2.8 21.1 4.0
Stress management 16.0 3.2 14.6 3.9

a. n = 30.
b. Some participants used salt-lowered and fat-lowered diets together.
c. t = 2.69, p < .05.

diseases and stroke and included core knowledge and information on the
behavioral skills necessary to manage hypertension. In the first month, two
60-minute classes were also held for groups of 6 to 8 participants. In these
classes, participants were provided with information and detailed guidelines,
especially on the daily number of servings from each of the six food groups
(meats and protein, grains, vegetables, fruits, dairy, and fats and oils) and the
requisite amount of fat intake, sodium intake, alcohol consumption, and
physical activity.
The diet recommendations were mainly based on the DASH diet,
which emphasizes fruits, vegetables, and low-fat dairy foods; includes whole
grains, poultry, fish, and nuts; and recommends smaller amounts of red meat,
sweets, and sugar-containing beverages. Compared to the typical diet, the
DASH diet contains smaller amounts of total and saturated fats and choles-
terol and larger amounts of potassium, calcium, magnesium, dietary fiber,
and protein (JNC-VII, 2003; P. K. Whelton, He, et al., 2002). Individual
counseling was conducted at the end of each class.
The expected goal was that participants would have a weight loss of 0.5 kg
per week achieved gradually by decreasing energy and fat intake and increas-
ing physical activity through lifestyle changes during the first 12 weeks of
intervention. To attain this goal, participants were recommended a diet with a
calorie level that was 500 kcal per day less than projected isocaloric needs.
This level of calorie reduction was expected to result in an average weight
loss of 0.4 kg (1 pound) per week if exercise patterns were unchanged. We
estimated that the increased energy expenditure from increased activity
would lead to an additional weight loss of at least 0.1 kg (0.25 pounds) per

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196 Western Journal of Nursing Research

week. Daily food servings were recommended on an individual basis by esti-

mating the daily energy intake required to achieve the desired weight loss.
Daily fat intake was prescribed at ≤ 20% of the estimated daily energy intake.
Participants were encouraged to maintain a daily intake of no more than
100 mmol (2.4 g sodium or 6 g sodium chloride) of dietary sodium. Unsalted
or low-sodium varieties were recommended in the lower sodium diet. Alco-
hol consumption was limited to a maximum of 30 ml or less (two drinks) for
men and 15 ml (one drink) for women per day. The physical exercise goal of
the lifestyle modification was 30 minutes of walking 3 days per week. Partic-
ipants who had not previously been physically active started with 20 minutes
of walking per session and increased the duration of exercise during several
weeks until their goal was met. We followed a clinical practice guideline to
help participants who smoked to decrease tobacco use and dependence
(Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and
Consortium Representatives, 2000).
After having been provided with basic information on the health hazards
of smoking, participants were encouraged to stop smoking, were given an
appropriately planned time in which to quit smoking (within 2 weeks), were
motivated, and were monitored on a follow-up basis. Patients were also
informed of the availability of support groups and state and community re-
sources where they could get additional professional help.
Basic guidelines in stress management were to describe the factors that
cause stress for participants; to encourage them to express their fears and
concerns about their health; to assist them in establishing realistic and
achievable goals; to support them in using appropriate coping strategies such
as rational thinking, positive thinking, imagery, deep breathing, progressive
muscular relaxation, and provision of sufficient sound sleep; to praise their
accomplishments and progress; and to give assistance in obtaining referral
to a social worker or psychologist for further counseling if the need was
indicated.
The final educational class was held at the end of the 3rd month. The goal
of the final class was to maintain active behavioral changes among the partic-
ipants and attempt to reengage inactive participants. Education classes were
held in a quiet, well-lit room at the hospital that provided an atmosphere in
which patients could concentrate on education without being interrupted. To
enhance compliance, participants were provided with diaries and were en-
couraged to keep records (24 hour diet recall) of their diet (daily number
of food serving, intake of fat, intake of sodium), weight, physical activity
(activity routine and duration), alcohol consumption (number of drinks per
day), smoking (number of cigarettes per day), and coping strategies for
stressful events (type of stressful events and coping strategies) twice a

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 Cakir, Pinar / Lifestyle Modification in Hypertensive Patients 197

week (once on a weekday and once on a weekend day). These records

were reviewed by the researchers at least once a month and were used for
both self-monitoring and providing individualized feedback on the partici-
pants’ progress.

Control Group
Participants in the control group were provided with routine outpatient
services and were asked to maintain their usual lifestyles, including dietary
and exercise habits, for 6 months until they were reexamined.

Measurement of BP, Lipids, Obesity Parameters,

and Behavioral Changes
The primary outcome was SBP, which was measured after a 6-month
interval. Additional outcomes included DBP, fasting lipids, obesity parame-
ters, alcohol consumption, smoking, and stress management at 6 months. A
trained nurse took BP measurements, and the trained nurse who measured
and recorded these BP results was blinded to whether the participant be-
longed to the intervention or the control group.
The BP measurement protocol was similar to the protocol used in a prior
study (The Trial of Hypertension Prevention Collaborative Research Group,
1992). BP measurements were done at the hospital in an education room
that was quiet and free from temperature extremes. Prior to the taking of a
BP reading, the participant was seated in a chair with a back support and
instructed to place his or her feet flat on the floor. Each participant was
instructed to remove constricting clothing (e.g., coats, sweaters, shirts).
After resting for a minimum of 5 minutes, the participant’s right arm was
positioned comfortably at heart level with the palm of the hand upward and
supported on a table. The brachial artery was palpated, and the appropriately
sized cuff was placed on the participant’s right arm with the arrow directly
over the brachial artery. An appropriate cuff size was determined from the
mid-arm circumference of the participant. The participant was instructed to
refrain from talking or moving during the procedure. Both at baseline and at
the end of 6 months, three BP measurements were conducted in a standard-
ized manner at 2-minute intervals for both intervention and control groups.
The average of the three measurements represented the BP. Fasting blood
specimens were obtained by venous puncture from each of the participants.
From the fasting blood specimen, TC, HDL-C, and triglycerides were mea-
sured. LDL-C was estimated by the equation LDL = TC – HDL – triglyceride
÷ 5 (Friedewald, Levy, & Fredrickson, 1972). Body Mass Index (BMI) was

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198 Western Journal of Nursing Research

calculated as weight (kg) divided by the square of the height (m2). A BMI of
≥ 25.5 kg/m2 for men and ≥ 26.6 kg/m2 for women was regarded as over-
weight. Waist circumference was measured on the metric scale (National
Institute of Health, 1998).
Health Promoting Lifestyle Profile (HPLP; Walker, Sechrist, & Pender,
1987) evaluated behavioral changes on lifestyle modification. The HPLP is a
48-item tool that assesses the frequency with which individuals report
engaging in activities aimed at increasing their level of health and well-
being. Responses are scaled from 1 (never) to 4 (routinely), with higher
scores indicating more frequent practice of health behavior measures. This
instrument is composed of 6 subscales: self-realization, health responsibility,
exercise, nutrition, interpersonal support, and stress management. There are
different scores for every subscale in the HPLP, as shown in parentheses:
self-realization (13-52), health responsibility (10-40), exercise (5-20), nutri-
tion (6-24), interpersonal support (7-28), and stress management (7-28). The
subscales in HPLP can be evaluated independently or as a total of all sub-
scales. The total score of HPLP ranges from 48 to 192 (lowest and highest
score). In the present study Cronbach’s alpha ranged between .72 to .89 for
the subscales and was .94 for the total scale. Incidence of alcohol consump-
tion and smoking was obtained from a questionnaire and self-reported
patient diaries. All data were gathered at baseline and at the end of 6 months,
except for data on sociodemographics.

Analysis of Data

Data were coded to the information form, transferred to computer, and

analyzed by a statistician who was blinded to the intervention group. All data
analyses were run on SPSS, version 11.0. We used Cronbach’s alpha analy-
ses for internal consistency in the HPLP. Data are presented as numbers, per-
centages, means, and standard deviations, where appropriate. The mean val-
ues of BP and other continuous variables at baseline and at the end of 6
months were compared by using Student’s t test for both the intervention and
control groups. Nonparametric values were tested by a chi-square test. Sta-
tistical significance for all analysis was taken at the 5% level with 95%
confidence intervals.

Findings

Randomization did not result in any statistically significant differences

among the participants assigned to the two groups, except for the triglyceride

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 Cakir, Pinar / Lifestyle Modification in Hypertensive Patients 199

level. The average distribution of the BP values, lipid values (except for
triglyceride level), obesity parameters, and HPLP total and subscales scores
in the two groups were also similar. The triglyceride level was slightly higher
in the control group than in the intervention group (p < .05; see Table 1).

Effects of Comprehensive
Lifestyle Modification
Differences in BP, fasting lipids, obesity parameters, and HPLP among
the participants in the intervention group were achieved. Table 2 displays the
effects of comprehensive lifestyle modification on outcomes and shows the
mean value of the differences reached by participants in the intervention
group in comparison with the control group.

BP
Both SBP and DBP decreased in the intervention group but not in the con-
trol group. From baseline to 6 months, the mean reductions in SBP and DBP
were 8.8 (SD = 5.2) and 6.9 (SD = 5.3) mmHg, respectively. In the control
group, both SBP and DBP increased over time. These increases were 1.2
(SD = 5.3) mmHg for SBP and 1.6 (SD = 4.6) mmHg for DBP (see Table 2).

Fasting Lipids
Participants in the intervention group had significantly lower levels of TC,
LDL-C, and triglicerides at 6 months from the baseline. The mean decrease
in the TC, LDL-C, and triglicerides was significant. HDL-C slightly in-
creased after comprehensive lifestyle modification, but this increase was not
effective in making a meaningful statistical difference (see Table 2).

Obesity Parameters
There were significant differences in weight loss, BMI, and waist circum-
ference between the two groups at the end of 6 months. Participants in the
intervention group displayed an average weight loss of 3.8 (SD = 2.3) kg,
compared with a mean gain of 0.4 (SD = 2.4) kg for those in the control
group. A similar pattern emerged for BMI and waist circumference, with the
participants in the intervention group showing significant changes compared
to those in the control group, who showed no change on those variables (see
Table 2).

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 Table 2

200
Differences in Blood Pressure (BP), Fasting Lipids, Obesity Parameters, and
Health Promotion Lifestyle Profile (HPLP) Scores From Baseline to 6 Months in the Two Groups
a a
Intervention Group Control Group
Between
b
Baseline 6 Months Changeb Baseline 6 Months Change Group
M SD M SD M SD p Value M SD M SD M SD p Value p Value

BP
Systolic BP 144.2 11.8 135.3 9.9 –8.8 –5.2 p < .001 141.5 9.7 142.6 8.6 1.2 5.3 p > .05 p < .001
Diastolic BP 91.0 8.9 84.0 6.9 –6.9 –5.3 p < .001 86.9 6.9 88.5 6.3 1.6 4.6 p > .05 p < .001
Lipid values (mg/dl)
Total cholesterol 212.3 31.8 184.6 19.6 –27.7 –35.3 p < .001 220.7 40.2 222.5 29.0 1.8 19.3 p > .05 p < .001
HDL cholesterol 42.8 9.6 44.2 10.4 1.5 5.2 p > .05 41.7 10.6 41.5 8.7 –0.2 –3.9 p > .05 p > .05
LDL cholesterol 138.3 34.3 109.4 16.9 –28.9 –38.2 p < .001 141.8 26.9 136.6 18.4 –5.1 –15.6 p > .05 p < .01
Trygliceride 145.8 46.7 131.8 38.6 –14.0 –25.9 p < .01 199.9 99.9 188.7 76.5 –11.2 –35.0 p > .05 p > .05
Obesity parameters
Weight (kg) 77.6 12.0 73.8 10.8 –3.80 –2.31 p < .001 78.5 15.3 78.9 14.4 0.46 2.43 p > .05 p < .001
Body mass index (kg/m2) 29.3 4.9 27.7 4.3 –1.50 –0.84 p < .001 30.2 6.1 30.3 5.9 0.13 0.89 p > .05 p < .001
Waist circumference (cm) 99.1 9.7 95.3 8.9 –3.83 –2.32 p < .001 100.4 12.3 100.9 12.0 0.53 0.43 p > .05 p < .001
HPLP
HPLP total 123.9 19.6 141.9 14.8 18.0 1.0 p < .001 117.6 23.2 113.3 20.5 –4.4 –4.4 p < .001 p < .001
Self-realization 38.8 6.4 41.5 4.9 2.6 2.9 p < .001 36.2 7.9 36.4 7.1 0.2 1.7 p > .05 p < .001
Health responsibility 23.4 6.2 27.4 5.0 4.3 3.1 p < .001 22.3 6.4 20.9 5.4 –1.5 –1.8 p < .001 p < .001
Exercise 7.5 2.5 10.4 2.0 2.8 1.5 p < .001 7.1 2.4 6.7 1.9 –0.4 –0.7 p < .05 p < .001

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Nutrition 16.7 4.0 20.5 2.1 3.7 2.6 p < .001 16.3 3.9 14.7 3.2 –1.6 –1.7 p < .001 p < .001
Interpersonal support 21.6 2.8 22.6 2.7 1.0 1.4 p < .01 21.1 4.0 20.7 3.9 –0.4 –1.3 p > .05 p < .001
Stress management 16.0 3.2 19.6 2.7 3.6 2.2 p < .001 14.6 3.9 13.9 3.4 –0.6 –1.0 p < .05 p < .001

a. n = 30.
b. Change is calculated as 6 months minus baseline.
 Cakir, Pinar / Lifestyle Modification in Hypertensive Patients 201

Use of Regular Antihypertensive Drugs,

Salt-Reduced Diet, Fat-Reduced Diet,
Reduction of Cigarette Smoking,
and Alcohol Consumption
In the intervention group, all participants started using their antihyper-
tensive medication regularly and started using a salt-reduced diet as well. At
the end of 6 months, the number of participants in the intervention group who
were on a fat-reduced diet increased significantly, whereas there were no sig-
nificant changes in the related parameters in the control group (see Table 3).
Two participants in the intervention group quit cigarette smoking, whereas
the number of smokers in the control group did not change. Alcohol intake
was low at the baseline and did not significantly change in any group at the
end of 6 months (see Table 3).

Health Promoting Lifestyle

The comprehensive lifestyle modification of the intervention group, as
compared with the control group, resulted in a significant increase of total
HPLP and subscale scores. In this group, in the period from baseline to 6
months, the mean increases in the scores of total HPLP, self-realization,
health responsibility, exercise, nutrition, interpersonal support, and stress
management were 18.0 (SD = 1.0), 2.6 (SD = 2.9), 4.3 (SD = 3.1), 2.8 (SD =
1.5), 3.7 (SD = 2.6), 1.0 (SD = 1.4), and 3.6 (SD = 2.2), respectively. In the
control group, scores of total HPLP and all subscales in the HPLP, except for
self-realization and interpersonal support, decreased significantly over time
(see Table 2).

Discussion

To date, some trials have tested the effects of comprehensive lifestyle

modification (Iso et al., 1996; Kennedy et al., 2003; Miller et al., 2002;
Pater et al., 2000; Svetkey et al., 2005; Vestfold Heartcare Study Group,
2003; Writing Group of the PREMIER Collaborative Research Group,
2003), whereas few have tested the effects of it on improving a health-
promoting lifestyle including the cessation of smoking (Pater et al., 2000;
Piestrzeniewicz et al., 2004) or stress management (Kennedy et al., 2003), or
both (Vestfold Heartcare Study Group, 2003). Most previous trials have
attempted to isolate the effects of a single factor on BP, such as weight loss
alone, sodium reduction alone (Sacks et al., 2001; Vollmer et al., 2001), and
physical activity alone (Duncan et al., 1985; Martin, Dubbert, & Cushman,

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 202

Table 3
Differences Between Baseline and Last Appointments of
Drug Therapy, Diet, Cigarette Smoking, and Alcohol Consuming
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Intervention Groupa Control Groupa

b b
Baseline 6 Months Significance Baseline 6 Months Significance

Antihypertensive medication
Regular 22 30 p < .01 23 23 p > .05
Irregular 8 0 7 7
Using salt-lowered dietc
Yes 17 30 p < .001 17 18 p > .05
No 13 0 13 12
Using fat-lowered dietc
Yes 6 22 p < .001 5 7 p > .05
No 24 8 25 23
Cigarette smoking
Smoker 10 8 p > .05 6 6 p > .05
Nonsmoker 20 22 24 24
Alcohol consuming (≥30 ml ethanol/day)
Yes 5 4 p > .05 6 5 p > .05
No 25 26 24 25

a. n = 30.
b. McNemar test was used.
c. Some participants used salt-lowered and fat-lowered diet together.
 Cakir, Pinar / Lifestyle Modification in Hypertensive Patients 203

1990; Urata et al., 1987), or of two factors, typically sodium reduction and
weight loss (P. K. Whelton et al., 1998), exercise and weight loss (Blumental
et al., 2000), or sodium reduction and DASH diet (Bray et al., 2004; Svetkey
et al., 2004). The present randomized controlled trial done by nurses demon-
strated the feasibility of a simultaneous comprehensive lifestyle modifi-
cation and its beneficial effects.

BP, Fasting Lipids, and Obesity Parameters

The results of the present study highlight the efficiency of comprehensive
lifestyle changes: most important of all, lifestyle modification, if achieved,
can substantially lower BP. This result is especially important in view of the
study’s data, which indicate hypertension control rates as less than 25% in
developed countries, and less than 10% in developing countries (Mulrow,
1999).
Our findings extend those of study reports from the DASH-Sodium Trials
(Appel et al., 1997; Bray et al., 2004; Sacks et al., 2001; Svetkey et al., 2004;
Vollmer et al., 2001) and the trial of nonpharmacologic interventions in the
elderly (TONE; P. K. Whelton et al., 1998), which document the benefit of
using a DASH diet and reducing sodium intake. The results of the present
study are also comparable, in general, with findings from other randomized
clinical trials that document the benefit of exercise (Duncan et al., 1985;
Martin et al., 1990; Urata et al., 1987; S. P. Whelton, Chin, Xin, & He, 2002).
A consistent body of evidence from observational studies and clinical tri-
als indicates that weight is positively associated with BP. Virtually all clinic
trials that have examined the influence of weight loss on BP have docu-
mented that weight reduction lowers BP (National Institute of Health, 1998;
Svetkey et al., 2005).
Lifestyle modification is known to be more effective when it is compre-
hensively implemented (JNC-VII, 2003; Svetkey et al., 2005; Vestfold
Heartcare Study Group, 2003). The PREMIER Clinical Trial, established
with the addition of DASH intervention, made a greater contribution to de-
creasing BP and losing weight rather than advice only and established inter-
vention (Writing Group of the PREMIER Collaborative Research Group,
2003). Blumental et al. (2000) suggested that exercise was associated with
modest BP reduction, and that adding a behavioral weight loss program to an
exercise intervention would result in even greater BP reduction than the
reduction observed when using exercise alone. The 5-year coronary heart
disease calculated risk in males resulted in a relative risk reduction of 22% as
a result of a lifestyle intervention study which included a low fat diet, regular
exercise, smoking cessation, psychosocial support, and education by nurses
(Vestfold Heartcare Study Group, 2003).

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204 Western Journal of Nursing Research

Our study demonstrated that a comprehensive lifestyle modification, in

addition to lowering BP, is likely to improve overall cardiovascular disease
risk status as a result of its favorable effects on body weight, BMI, waist cir-
cumference, TC, LDL-C, HDL-C, and triglicerides. Similar results, apart
from HDL-C, were shown in a trial that was performed by Miller et al. (2002).
Another study has proven that education was effective in losing weight and
reducing lipid levels (Grimm et al., 1997). Two other studies have demon-
strated that weight reduction and a BP lowering diet were effective in decreas-
ing blood lipids (Dattilo & Kris-Etherton, 1992; Obarzanek et al., 2001).

Use of Regular Antihypertensive Drugs,

Salt-Reduced Diet, Fat-Reduced Diet,
Cessation of Cigarette Smoking, and
Reduced Alcohol Consumption
Our study results demonstrate the beneficial effects of a comprehensive
lifestyle modification on the compliance of regular medication use and rec-
ommended diet. Markers of adherence, such as records of daily food, fat, and
sodium intake and details of exercise taken, confirmed that participants in the
behavioral interventions achieved lifestyle changes. The number of partici-
pants in the intervention group who used antihypertensive medication regu-
larly increased after education.
Our result was consistent with data given in other studies (Konrady,
Brodskaya, Soboleva, & Polunicheva, 2001; Morisky et al., 1983; Patton,
Meyers, & Lewis, 1997; Saounatsou et al., 2001). In our study, two patients
in the intervention group quit smoking, although statistically the result did
not indicate any meaningful difference. This finding agrees with the data
from two studies (Konrady et al., 2001; Piestrzeniewicz et al., 2004). In con-
trast with the present study, a lifestyle intervention program was effective on
smoking cessation during 2 years (Vestfold Heartcare Study Group, 2003).
Smoking cessation is a complex and difficult process; it requires a planned,
long-term education, psychological interventions, medical interventions,
and monitoring. For these reasons, education alone may not be effective in
helping patients quit smoking.
The relationship between high alcohol intake and elevated BP has been
documented in many studies. In the present study, alcohol intake was low at
the baseline and did not significantly change at the end of 6 months. In the
Prevention and Treatment of Hypertension Study, a reduction in alcohol
intake lowered BP to a small, nonsignificant extent (Cushman et al., 1998).
Another study (Iso et al., 1996) has shown that reduction of alcohol intake
was associated with reduction in SBP, not in DBP. On aggregate, the avail-

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 Cakir, Pinar / Lifestyle Modification in Hypertensive Patients 205

able evidence supports a recommendation to limit alcohol intake to no more

than two drinks per day (men) and one drink per day (women) among those
who drink.

Health Promoting Lifestyle

All subscales of the HPLP and total HPLP improved significantly in the
intervention group after comprehensive lifestyle modification. Participants
in this group took more responsibility for their health. They therefore per-
formed exercises and complied with their drug regimen and recommended
special diet and managed their stress effectively. As they felt they were suc-
cessful in controlling their BP, their self-realization and interpersonal sup-
port scores increased. We believe that the effects of education on all these
parameters overlapped (Sands & Wilson, 1999; Vestfold Heartcare Study
Group, 2003). Yeh, Lu, and Wang (2002) identified a significant improve-
ment in SBP, body weight and health responsibility, interpersonal support,
nutrition, and exercise after a health-promoting program encompassing
health education was given to hypertensive patients. Our data are parallel to
those of the researchers who emphasize the importance of education in the
promotion of healthy lifestyle behavior (Appel, 2003; Lai & Cohen, 1999;
Vestfold Heartcare Study Group, 2003; Yeh et al., 2002).

Conclusion

In conclusion, our study results demonstrate the feasibility of comprehen-

sive lifestyle modification and document its beneficial effects on BP and
other cardiovascular risks and on promoting a healthy lifestyle. Our findings
can provide a scientific rationale for routinely implementing comprehensive
lifestyle intervention programs designed to control BP and ultimately pre-
vent BP-related cardiovascular disease. One possible limitation of the study
is the relatively small sample size. Data therefore should be interpreted cau-
tiously. The use of some self-report data from the diaries may also limit the
clinical relevance of our results.

References
Appel, L. J. (2003). Lifestyle modification as a means to prevent and treat high blood pressure.
Journal of American Society Nephrology, 14(Suppl. 2), 99-102.
Appel, L. J., Moore, T. J., Obarzanek, E., Volmerr, W. M., Svetkey, L. P., Sacks, F. M., et al.
(1997). A clinical trial of the effects of dietary patterns on blood pressure. New England
Journal of Medicine, 336, 1117-1124.

Downloaded from wjn.sagepub.com at UNIV OF PITTSBURGH on May 26, 2014

206 Western Journal of Nursing Research

Bacon, S. L., Sherwood, A., Hinderliter, A., & Blumental, J. A. (2004). Effects of exercise, diet
and weight loss on high blood pressure. Sports Medicine, 34, 307-316.
Blumental, J. A., Sherwood, A., Gullette, E. C., Babyak, M., Waugh, R., Georgiades, A., et al.
(2000). Exercise and weight loss reduce blood pressure in men and women with mild hyper-
tension: Effects on cardiovascular, metabolic, and hemodynamic functioning. Archives of
Internal Medicine, 160, 1947-1958.
Bray, G. A., Vollmer, W. M., Sacks, F. M., Obarzanek, E., Svetkey, L. P., & Appel, L. J. (2004). A
further subgroup analysis of the effects of the DASH diet and three dietary sodium levels on
blood pressure: Results of the DASH-Sodium Trial. American Journal of Cardiology, 94,
222-227.
Cushman, W. C., Cutler, J. A., Hanna, E., Bingham, S. F., Follman, D., Harford, T., et al. (1998).
Prevention and Treatment of Hypertension Study (PATHS): Effects of an alcohol treatment
program on blood pressure. Archives of Internal Medicine, 158, 1197-1207.
Cutler, J. A., Follmann, D., & Allender, P. S. (1997). Randomized trials of sodium reduction: An
overview. American Journal of Clinical Nutrition, 65(Suppl. 2), 643-651.
Dattilo, A. M., & Kris-Etherton, P. M. (1992). Effects of weight reduction on blood lipids and
lipoproteins: A meta-analysis. American Journal of Clinical Nutrition, 56, 320-328.
Duncan, J. J., Farr, J. E., Upton, S. J., Hagan, R. D., Oglesby, M. E., & Blair, S. N. (1985). The
effects of aerobic exercise on plasma catecholamines and blood pressure in patients with
mild essential hypertension. The Journal of the American Medical Association, 254, 2609-
2613.
Friedewald, W. T., Levy, R. I., & Fredrickson, D. S. (1972). Estimation of the concentration of
low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge.
Clinical Chemistry, 18, 499-502.
Grimm, R. H., Grandits, G. A., Cutler, J. A., Stewart, A. L., McDonald, R. H., Svendsen, K., et al.
(1997). Relationships of quality of life measures to long-term lifestyle and drug treatment in
the Treatment of Mild Hypertension Study (TOMHS). Archives of Internal Medicine, 157,
638-648.
Iso, H., Shimamoto, T., Yokota, K., Sankai, T., Jacobs, D. R., & Komachi, Y. (1996). Community
based education classes for hypertension control. Hypertension, 27, 968-974.
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure. (2003). The seventh report of the Joint National Committee on Prevention, Detec-
tion, Evaluation, and Treatment of High Blood Pressure (NIH Publication No. 03-5233).
Washington, DC: U.S. Department of Health and Human Services.
Kennedy, M. D., Haykowsky, M., Daub, B., Van Lohuizen, K., Knapik, G., & Black, B. (2003).
Effects of a comprehensive cardiac rehabilitation program on quality of life and exercise tol-
erance in women: A retrospective analysis. Current Controlled Trials in Cardiovascular
Medicine, 4, 1-7.
Knowler, W. C., Barrett-Connor, E., Fowler, S. E., Hamman, R. F., Lachin, J. M., Walker, E. A.,
et al. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or
metformin. New England Journal of Medicine, 346, 393-403.
Konrady, A. O., Brodskaya, I. S., Soboleva, A. V., & Polunicheva, Y. V. (2001). Benefits of the
implementation of structured educational program in hypertension management. Medical
Science Monitoring, 7, 397-402.
Lai, S. C., & Cohen, M. N. (1999). Promoting lifestyle changes. American Journal of Nursing,
99, 63-67.
MacMahon, S., Peto, R., Cutler, J. A., Collins, R., Sorlie, P., Neaton, J., et al. (1990). Blood pres-
sure, stroke, and coronary heart disease. Part 1, prolonged differences in blood pressure: Pro-
spective observational studies corrected for the regression dilution bias. The Lancet, 335,
765-774.

Downloaded from wjn.sagepub.com at UNIV OF PITTSBURGH on May 26, 2014

 Cakir, Pinar / Lifestyle Modification in Hypertensive Patients 207

Martin, J. E., Dubbert, P. M., & Cushman, W. C. (1990). Controlled trial of aerobic exercise in
hypertension. Circulation, 81, 1560-1567.
Miller, E. R., Erlinger, T. P., Young, D. R., Jehn, M., Charleston, J., Rhodes, D., et al. (2002).
Results of the diet, exercise, and weight loss intervention trial (DEW-IT). Hypertension, 40,
612-618.
Morisky, D. E., Levine, D. M., Gren, L. W., Shapiro, S., Russell, R. P., & Smith, C. R. (1983).
Five-year blood pressure control and mortality following health education for hypertensive
patients. American Journal of Public Health, 73, 153-162.
Mulrow, P. J. (1999). Hypertension a worldwide epidemic. In J. L. Izzo & H. R. Black (Eds.),
Hypertension primer (pp. 271-273). Baltimore: Lippincott Williams & Wilkins.
Muntner, P., He, J., Roccella, E. J., & Whelton, P. K. (2002). The impact of JNC-VI guidelines on
treatment recommendations in the U.S. population. Hypertension, 39, 897-902.
National Institute of Health. (1998). Clinical guidelines on the identification, evaluation, and
treatment of overweight and obesity in adults: The evidence report. Journal of Obesity
Research, 6(Suppl. 2), 51-209.
Obarzanek, E., Sacks, F. M., Vollmer, W. M., Bray, G. A., Miller, E. R., Lin, P. H., et al. (2001).
Effects on blood lipids of a blood pressure lowering diet: The dietary approaches to stop
hypertension (DASH) trial. American Journal of Clinical Nutrition, 74, 80-89.
Onat, A. (2001). Risk factors and cardiovascular disease in Turkey. Atherosclerosis, 156, 1-10.
Pater, C., Jacobsen, C. D., Rollag, A., Sandvik, L., Erikssen, J., & Kogstad, E. K. (2000). Design
of a randomised controlled trial of comprehensive rehabilitation in patients with myocardial
infarction, stabilized acute coronary syndrome, percutaneous transluminal coronary angio-
plasty or coronary artery bypass grafting: Akershus Comprehensive Cardiac Rehabilitation
Trial (the CORE study). Current Controlled Trials in Cardiovascular Medicine, 1, 177-189.
Patton, K., Meyers, J., & Lewis, B. E. (1997). Enhancement of compliance among patients with
hypertension. American Journal of Managed Care, 3, 1693-1698.
Piestrzeniewicz, K., Navarro-Kuczborska, N., Bolinska, H., Jegier, A., & Maciejewski, M.
(2004). The impact of comprehensive cardiac rehabilitation in patients up to 55 years
old after acute myocardial infarction treated with primary coronary intervention. Polskie
Archiwum Medycyny Wewnetrznej, 111, 309-317.
Sacks, F. M., Svetkey, L. P., Vollmer, W. M., Appel, L. J., Bray, G. A., Harsha, D., et al. (2001).
Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop
hypertension (DASH) diet. New England Journal of Medicine, 344, 3-10.
Sands, K. J., & Wilson, A. (1999). Promoting healthy lifestyles. In K. J. Sands & J. F. Marek
(Eds.), Medical-surgical nursing: Concepts and clinical practice (pp. 49-70). Baltimore:
Mosby-Year Book.
Saounatsou, M., Patsi, O., Fasoi, G., Stylianou, M., Kavga, A., Economou, O., et al. (2001). The
influence of the hypertensive patient’s education in compliance with their medication. Pub-
lic Health Nursing, 18, 436-442.
Stamler, J., Rose, G., Stamler, R., Elliott, P., Dyer, A., & Marmot, M. (1989). INTERSALT study
findings: Public health and medical care implications. Hypertension, 14, 570-577.
Stamler, J., Stamler, R., & Neaton, J. D. (1993). Blood pressure, systolic and diastolic, and car-
diovascular risks: U.S. population data. Archives of Internal Medicine, 153, 598-615.
Svetkey, L. P., Erlinger, T. P., Vollmer, W. M., Feldstein, A., Cooper, L. S., Appel L. J., et al.
(2005). Effect of lifestyle modifications on blood pressure by race, sex, hypertension status,
and age. Journal of Human Hypertension, 19, 21-31.
Svetkey, L. P., Simons-Morton, D. G., Proschan, M. A., Sacks, F. M., Conlin, P. R., Harsha, D.,
et al. (2004). Effect of the dietary approaches to stop hypertension diet and reduced sodium
intake on blood pressure control. Journal of Clinical Hypertension (Greenwich), 6, 373-381.

Downloaded from wjn.sagepub.com at UNIV OF PITTSBURGH on May 26, 2014

208 Western Journal of Nursing Research

Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Repre-
sentatives. (2000). A clinical practice guideline for treating tobacco use and dependence: A
US Public Health Service report. The Journal of the American Medical Association, 283,
3244-3254.
The Trial of Hypertension Prevention Collaborative Research Group. (1992). The effects of
nonpharmacologic interventions on blood pressure of persons with high-normal levels:
Results of the trials of hypertension prevention, phase I. The Journal of the American Medi-
cal Association, 267, 1213-1220.
Urata, H., Tanabe, Y., Kiyonage, A., Ikeda, M., Tanaka, H., Shindo, M., et al. (1987). Antihyper-
tensive and volume-depleting effects of mild exercise on essential hypertension. Hyperten-
sion, 9, 245-252.
Vestfold Heartcare Study Group. (2003). Influence on lifestyle measures and five-year coronary
risk by a comprehensive lifestyle intervention programme in patients with coronary heart
disease. European Journal of Cardiovascular Prevention and Rehabilitation, 10, 429-437.
Vollmer, W. M., Sacks, F. M., Ard, J., Appel, L. J., Bray, G. A., Simons-Morton, D. G., et al.
(2001). Effects of diet and sodium intake on blood pressure: Subgroups analysis of the
DASH-Sodium Trial. Annals of Internal Medicine, 135, 1019-1028.
Walker, S. N., Sechrist, K. R., & Pender, N. J. (1987). The Health-Promoting Lifestyle Profile:
Development and psychometric characteristics. Nursing Research, 36, 76-81.
Whelton, P. K., Appel, L. J., Espeland, M. A., Applegate, W. B., Ettinger, W. H., Kostis, J. B.,
et al. (1998). Efficacy of sodium reduction and weight loss in the treatment of hypertension in
older persons: A randomized controlled trial of nonpharmacologic interventions in the
elderly (TONE). TONE Collaborative Research Group. The Journal of the American Medi-
cal Association, 279, 839-846.
Whelton, P. K., He, J., Appel, L. J., Cutler, J. A., Havas, S., Kotchen, T. A., et al. (2002). Primary
prevention of hypertension: Clinical and public health advisory from the National High
Blood Pressure Education Program. The Journal of the American Medical Association, 288,
1882-1888.
Whelton, S. P., Chin, A., Xin, X., & He, J. (2002). Effect of aerobic exercise on blood pressure: A
meta-analysis of randomized, controlled trials. Annals of Internal Medicine, 136, 493-503.
Writing Group of the PREMIER Collaborative Research Group. (2003). Effects of comprehen-
sive lifestyle modification on blood pressure control. The Journal of the American Medical
Association, 289, 2083-2093.
Yeh, L., Lu, F. H., & Wang, C. J. (2002). A preliminary study on the health promotion outcomes
of high-risk hypertensive freshmen. Kaohsiung Journal of Medical Sciences, 18, 557-565.

Huyla Cakir graduated from the college of nursing in 1994 and acquired her master’s degree in
2003. She has worked with the Cardiology Institute for 7 years in Istanbul. At the end of 2003, she
was appointed as director nurse at a hospital in Eskisehir, Turkey.

Rukiye Pinar is a chairperson of the Department of Medical Nursing at the Marmara University,
College of Nursing in Istanbul, Turkey. She graduated from the college of nursing in 1988,
acquired her master’s degree in 1991, doctorate degree in 1995, associate’s degree in 1998, and
professor degree in 2005. After receiving her doctorate degree she completed an advanced
diploma program on diabetes at Surrey University, London, United Kingdom, for 1 year. She has
also been in Toronto, Canada, for 3 months as an observer on adult education. Her main study
topics are quality of life, health promotion, and adult patient education. She has worked as an
executive committee member and/or active member for many international organizations on

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 Cakir, Pinar / Lifestyle Modification in Hypertensive Patients 209

diabetes education (European Diabetes Nurse Working Group, Federation of European Nurses
on Diabetes [FEND], Diabetes Education Consultative Section of International Diabetes Feder-
ation). She currently works as thesis director for students who are in master’s or doctorate degree
programs besides nursing education.

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