Prescribing Medication Versus Promoting Behavioural Change: A Trial of the Use of Lifestyle Management to Replace Drug Treatment of Hypertension in General Practice

Abstract

Antihypertensive drug therapy may reverse the cardiac and vascular structural changes associated with sustained hypertension. This may enable appropriate blood pressure levels to be maintained with milder forms of therapy (such as lifestyle interventions) which will minimise any potential adverse effects of pharmacological therapy. The HEART project was conducted in the general practice setting and aimed to determine whether lifestyle strategies, such as increased physical activity and dietary modification, could be substituted for drug therapy in patients who had been well controlled on antihypertensive medication. In addition to objective measures of blood pressure and risk factor outcomes, attitudes and perceptions of general practitioners (GPs) and patients involved in the trial were assessed through focus group discussion and personal interviews. Of the 44 patients recruited to the trial, 41 (93%) participated in structured interviews of 20–40 minutes duration conducted in person or by telephone. Of 78 GPs working in the western suburbs of Melbourne who were approached about the trial, 50% were willing to participate. Of these, 13 (34%) recruited study patients. Of these 13, 10 (77%) participated in a 2-hour focus group discussion which was audiotaped for later transcription and analysis. Despite being enthusiastic about lifestyle interventions in principle, nearly all of these GPs felt resistant to the concept of withdrawing medication in well-controlled subjects. They were generally surprised to see that many patients (15 of 20 patients: 75%) were able to maintain appropriate blood pressure levels following drug therapy withdrawal and adoption of minimal lifestyle changes. GPs felt that the patients' eagerness to come off medication was the major incentive for patients to participate in the trial. This was corroborated by many patients indicating a desire not to be taking any medication. The majority of patients reported making minor changes in lifestyle behaviours leading to most being able to remain off therapy or to have drug dosage requirements reduced. The major barriers to maintaining lifestyle change were family and work stresses and the perception of the intervention not being treated as a therapy thus not at the same level of importance as a treatment method as drug therapy. It appears that a select group of hypertensive patients, highly motivated by the prospect of drug therapy withdrawal, were interested in and willing to trial a lifestyle behaviour change approach for their blood pressure management. The majority reported that they had been able to adopt small but meaningful changes in exercise and dietary habits through the provision of stand-alone self-help materials and support from their GP. Of these patients, 75% remained normotensive without drug therapy after a 9-month follow-up period.