Lifestyle coaching may be superior to enhanced pharmacotherapy in uncontrolled hypertension

Despite all the efforts, the burden of hypertension, the most modifiable risk factor for cardiovascular disease and stroke, is still enormous in the contemporary society. Moreover, ethnic minorities such as black US citizens have a higher prevalence of cardiovascular disease and are less likely to achieve adequate blood pressure (BP) control and experience a greater impact on stroke risk compared with White adults. Eliminating disparity in BP control could avert thousands of deaths due to cardiovascular disease and reduce the population burden of dementia. To assess the utility of different approaches to improving BP control rates in Black adults, a new cluster randomized clinical trial was conducted within the Kaiser Permanente Northern California health care delivery system. The results appeared online in JAMA Network Open on May 18, 2022. 

Within this study, panels of Black adult members of the health care delivery system with BP of at least 140/90 mm Hg from 98 adult primary care physicians were randomly assigned at the primary care physician level to usual care (UC, n = 1129), enhanced pharmacotherapy monitoring (EP, n = 346), or diet and lifestyle coaching which was culturally appropriate for Black adults (LC, n = 286). Enrollment was completed during a 12-month period and interventions were implemented for 12 months. The enhanced pharmacotherapy monitoring, delivered by a research nurse coordinator and a pharmacist, was designed to increase use of medical assistant BP check visits, to optimize thiazide diuretic dosing, and to increase prescribing of spironolactone for resistant hypertension. This intervention also included education on hypertension and the importance of BP control. The lifestyle coaching group offered participants as many as 16 individual telephone coaching sessions with a lifestyle coach, and the study target was to have at least 50% of the participants completing 6 sessions or more. Both lifestyle coaches were registered dieticians with additional training in motivational interviewing techniques. The main lifestyle goal was to achieve and maintain a low-salt diet based on the Dietary Approaches to Stop Hypertension (DASH) diet. Follow-up lasted 48 months after enrollment.

Among the 1761 participants, the mean (SD) age was 61 (13) years, and 1214 (68.9%) were women. At the end of the 12-month intervention period, there was no significant difference in BP control rate among study groups. However, greater BP control was present in the LC group vs UC at 24 months (UC, 61.2% [95% CI, 57.3%-64.7%]; EP, 67.6% [95% CI, 61.9%-72.8%]; LC, 72.4% [95% CI, 66.9%-78.1%]; LC vs UC, P = .001), and 48 months (UC, 64.5% [95% CI, 61.6%-67.2%]; EP, 66.5% [95% CI, 61.3%-71.3%]; LC, 73.1% [95% CI, 67.6%-77.9%]; LC vs UC, P = .006) after enrollment. The contribution of BP medication adherence did not explain the differences.

That is, in this cluster randomized clinical trial, the group receiving lifestyle coaching achieved better blood pressure control compared with usual care at 24 and 48 months after enrollment, whereas the group receiving enhanced pharmacotherapy did not.