RESEARCH

Literature Review

Virginia Nzolewane

Stratford University

NSG 410: Research and Evidence-Based Nursing Practice.

12/4/2021

Dr. Karen Benson

Introduction

Clinical research in nursing is conducted to investigate a specific issue. In any research, theoretical framework provides support and justification for the research problem. For this particular case, Dorothea Orem’s theory of self-care deficit serves as the theoretical framework upon which the literature review will be based. Self-care, theory of nursing systems, and the concept of self-care deficit were used to identify the need of the patients (Aga et al., 2019). In the theory of self-care, Dorothea Orem defines self-care as the daily living activities that can be done as an individual to maintain one’s well-being. In this stage the individual should be able to understand their level of functioning such as being able to be independent. This self-care is usually carried out to fulfill self-care requisites (such as universal, self-developmental and health) (Smith, 2019). A patient will be considered in self-care deficit if any of the aforementioned self-care requisites are lacking. The self-care deficit simply indicates that there is a need, and this need will necessitate the use of nursing systems to provide care. This care can either be carried out by a provider or care giver depending on the degree of the deficit the individual is presenting with. Nursing systems will also be used to evaluate care provided to measure if the goals were met.

The research question is; Does lifestyle modification improve clinical health outcomes in hypertension management?

The chosen population already has a deficit. This deficit is hypertension, and the plan is to educate the chosen population about the advantageous effects that lifestyle modifications has compared to pharmacological therapy in managing hypertension. Orem’s nursing process will be used to guide this research. Orem’s nursing process follows the following steps:

· Assessment – In this step, the provider will gather the patient’s history. Within the gathered history, lifestyle habits questions will also be gathered (e.g. medication regimen compliance, diet and exercise regimen).

· Diagnosis – The information compiled from the assessment above will help the provider arrive at a diagnosis.

· Plan – Here, the provider comes up with a plan of action which is also known as the care plan. This plan includes the procedural tactics to achieve the goals that will be set by the patient and the provider.

· Implementation – During this step, the plan mentioned above will be set into motion.

· Evaluation – Finally, the entire nursing practice is evaluated. This process is also done during the implementation phase to make changes.

In conducting this literature review, Google Scholar was used to search for articles related to this PICOT question. Specifically, this literature review aims to answer: does lifestyle modification improve clinical health outcomes in hypertension management?

Key words used: blood pressure, hypertension, dietary therapy, physical activity, pharmacotherapy, digital therapeutics, lifestyle modification, ambulatory blood pressure, home blood pressure.

Literature Review

Hypertension (also known as high blood pressure) is a condition in which the pressure of the blood in the vessels is higher than normal. High blood pressure is also known as the silent killer; high blood pressure is a prevalent and dangerous condition. This condition can be known as the silent killer because many individuals with hypertension are asymptomatic until the condition progresses to a stroke, kidney failure, or heart failure (Centers for Disease Control and Prevention [CDC], 2019). This can be prevented or well managed through diet, exercise and adherence to treatment regimen. Two of the top causes of mortality in the United States are heart disease and stroke, which can be caused by uncontrolled hypertension. One out of every three adults (about 75 million people in the United Sates) has been diagnosed with hypertension and only 50% of these individuals have controlled hypertension. In 2013 alone, approximately 360,000 deaths were reported from hypertension (CDC, 2019). Therefore, 29% of adults in the United States have hypertension; men (30.2%) have slightly higher hypertension prevalence than women (27.7%). Hypertension becomes more common with the aging population; 63.1% of individuals with hypertension are aged 60 years or older, while 33.2% of adults with hypertension are in the 40-59 age group. Adults between the ages of 18-39 have a prevalence of 7.5%. (CDC, 2019). Hypertension has become a public health issue due to the increment in incidence and prevalence; with this continuous increase, it has been estimated that in 2025 one out of three people will be diagnosed with this disease (Ashoorkhani et al., 2018).

A trial overview carried out by Ozemek et. al. (2020) sought to assess the value of exercise and diet in lowering blood pressure in patients with resistant hypertension. In this trial, a randomized sampling of one hundred forty patients with a mean age of 63 years diagnosed with resistant hypertension were separated into a group that delivered lifestyle intervention through a center-based cardiac rehabilitation facility (C-LIF) and another group that underwent standardized education and physician advice (SEPA). The DASH (Dietary Approaches to Stop Hypertension) diet was mentioned as one of the recommended food intake plans to help manage resistant hypertension. The investigation revealed that reduction in clinic systolic blood pressure was greater in patients under C-LIF compared to SEPA. 24-hours ambulatory systolic blood pressure was also reduced in C-LIF with no reported change in patients under the SEPA group. While hypertension is a condition that can vary among different people, it was shown in this study that a regulated program of diet and exercise can lower blood pressure in patients with resistant hypertension. This literature is vital in the improvement of discourse about patient education and hypertension management since it suggests ways of improving the care that the nursing service seeks to provide (Ozemek et. al., 2020).

A descriptive cross-sectional study done in Kenya by Kimani et. al. (2020) investigated the association of lifestyle modification and pharmacological adherence among patients with hypertension in a national referral hospital. 229 patients diagnosed with primary hypertension were chosen at random for this study. The study found that respondents on antihypertensive medication that also engaged in healthy lifestyle and had proper adherence to medication had lower mean blood pressure than those only on medication. The study also showed that ageing, being female, having fast food and animal fat intake were associated with missed blood pressure targets and hypertension-related complications. Pharmacological interventions for hypertension are used in healthcare, but there is great emphasis on non-pharmacological approaches such as lifestyle modifications. Lifestyle modifications (such as diet and exercise) can be implemented to prevent hypertension in pre hypertensive patients, and these lifestyle modifications can be implemented as an adjunct therapy or primary therapy in hypertensive patients prior to drug therapy initiation. This study was limited in its cross-sectional design and by the restriction of assessing lifestyle choices (e.g., smoking, alcohol consumption) to just one point in time might have contributed to gaps in the study about the association of lifestyle modifications and hypertension management (Kimani et. al., 2020).

Other risk factors related to hypertension were also studied in a quantitative, epidemiologic, and cross-sectional research design by Guptha. (2021). Specifically, the study examined the effect of National Institute of Health and Clinical Excellence and American Diabetes Association consensus adjusted BMI on the risk of T2DM in a representative sample of ~ 6,000 Asian Indians to narrow the knowledge gap and achieve population specificity. It was shown that both lifestyle changes and medical treatment were beneficial and had a significant effect on hypertension management.  This study fills in the knowledge gaps about reducing systolic and diastolic BP and the decrease of cardiovascular risk by non-pharmacological (lifestyle measures) as well as pharmacological means. Like the previous cross-sectional study, this research was also limited to this design in which hidden biases might have emerged and confounded the variables and its results in the study. The study did not also include respondents from rural areas, which is where more than half of the people in India reside, possibly limiting the extrapolation of results to only urban regions of India and risking misrepresentation of the target population (Guptha., 2021).

To further expound the effect of nonpharmacologic treatment, a Bayesian network meta-analysis by Fu et. al. (2020) was reviewed and showed that nonpharmacologic interventions, including dietary approaches, are a cornerstone for the prevention and treatment of hypertension. A total of 60,166 articles were identified in the initial systematic search, and 888 potentially eligible articles were narrowed down and retrieved as full text. Overall, 120 articles (corresponding to 126 randomized controlled trials) with 14,923 participants met the inclusion criteria and were included in the network meta‐analysis. This study affirms that DASH is a potent effector in modulating dietary changes and decisions of patients with hypertension. However, the study reported only the effectiveness of nonpharmacologic interventions in lowering BP, lacking secondary end points such as rate of BP control, incidence of hypertension, and mortality due to complications of hypertension. In addition, upon further review of this meta-analysis, it was found that only 8 interventions were only directly compared with usual care. Smoking as a lifestyle risk factor was excluded from this study because existing randomized controlled trials on smoking cessation in patients with hypertension or prehypertension were not truly implemented. This network meta‐analysis showed that, among 22 nonpharmacologic interventions, DASH was the most effective intervention in lowering BP for adults with prehypertension to established hypertension. Aerobic exercise, isometric training, low‐sodium and high‐potassium salt, comprehensive lifestyle modification, breathing control, meditation, and low‐calorie diet also have obvious effects in lowering BP. Moreover, the findings suggest that salt restriction be used for lowering BP, especially in patients with hypertension (Fu et. al., 2020).

Rounding out this literature review is a randomized, open-label HERB-DH1 study by Kario et. al. (2021) which showed that the HERB-DH1 pivotal study showed the superiority of digital therapeutics compared with standard lifestyle modification alone to reduce 24-h ambulatory, home, and office BPs in the absence of antihypertensive medications. All 390 respondents were 20-64 years old (mean age range of 52-52.4)) and diagnosed with essential hypertension were randomly grouped into the digital therapeutics group and the control group. Digital therapeutics is a novel approach to managing non-pharmacological treatment of hypertension. The HERB system helps the user to make lifestyle modifications to reduce BP by the use of an interactive smartphone app. For the duration of the study, pharmacological interventions were prohibited and discouraged with physician monitoring so as to avoid confounding the results. Being a pilot study, the research was limited to the variables that could be studied and numerous knowledge gaps were identified. The time period of monitoring BP change through non-pharmacological methods was also inadequate (12 weeks) to properly determine whether the lifestyle modifications were able to provide significant change to the patient’s blood pressure (Kario et. al., 2021).

Conclusion

Conducting this literature review gave me the opportunity to peruse various sources for the evaluation of non-pharmaceutical methods in managing hypertension among patients 40-70 years of age. I realized that the worldwide disease burden of hypertension is too big to ignore and has become a significant public health issue over the decades. With more and more people becoming obese and acquiring hypertension and hypertension-related complications, it is imperative to study and research about the protocols that can be put in place to mitigate this condition. It must also be noted that medications alone will not have a significant effect. The patient must be able to make health decisions on their diet, exercise, and other lifestyle choices by being well-informed, and this patient education begins with the nurse at the helm of the care team as a patient advocate.

Better designed researches must also be conducted to fill in the gaps of knowledge established by prior researches. The studies reviewed here had similarities other than the inclusion criteria of having a respondent diagnosed with hypertension, the studies also were designed to study multiple therapeutic approaches to gain a better insight. Overall, the weaknesses of the studies, other than the ones detailed in the literature review above, was only prominent in descriptive and cross-sectional studies, as the variation in research variables can be significant enough to affect the results of the study. The level of scientific evidence must also be taken into account when designing a research study, wherein the most apt and highest yield study design must be chosen.

References

Ademe, S., Aga, F., & Gela, D. (2019). Hypertension self-care practice and associated factors among patients in public health facilities of Dessie town, Ethiopia. BMC health services research, 19(1), 1-9.

Fu, J., Liu, Y., Zhang, L., Zhou, L., Li, D., Quan, H., ... & Zhao, Y. (2020). Nonpharmacologic interventions for reducing blood pressure in adults with prehypertension to established hypertension. Journal of the American Heart Association, 9(19), e016804.

Guptha, L. S. (2021). A Cross-Sectional Epidemiology Study of the Relationships between Body Mass Index and the Risk of Diabetes, and Diabetes and the QRISK2 10-Year Cardiovascular Risk Score Using India Heart Watch Data (Doctoral dissertation, Trident University International).

Hypertension. (2019). Retrieved from https://www.cdc.gov/bloodpressure/index.html

Kario, K., Nomura, A., Harada, N., Okura, A., Nakagawa, K., Tanigawa, T., & Hida, E. (2021). Efficacy of a digital therapeutics system in the management of essential hypertension: the HERB-DH1 pivotal trial. European heart journal, 42(40), 4111-4122.

Kimani S, Mirie W, Chege M, et al (2020) Association of lifestyle modification and pharmacological adherence on blood pressure control among patients with hypertension at Kenyatta National Hospital, Kenya: a cross-sectional study BMJ Open 2019;9:e023995. doi: 10.1136/bmjopen-2018-023995

Ozemek, C., Tiwari, S., Sabbahi, A., Carbone, S., & Lavie, C. J. (2020). Impact of therapeutic lifestyle changes in resistant hypertension. Progress in cardiovascular diseases, 63(1), 4-9.

Smith, M. C. (2019). Nursing theories and nursing practice. FA Davis.