Patients with hypertension are advised to lower their blood pressure to <140/90 mm Hg through sustained lifestyle modification and/or pharmacotherapy. To describe the use of lifestyle changes for blood pressure control and to identify the barriers to these behaviors, the data from 6,142 Canadians with hypertension who responded to the 2009 Survey on Living With Chronic Diseases in Canada were analyzed. Most Canadians with diagnosed hypertension reported limiting salt consumption (89%), having changed the types of food they eat (89%), engaging in physical activity (80%), trying to control or lose weight if overweight (77%), quitting smoking if currently smoking (78%), and reducing alcohol intake if currently drinking more than the recommended levels (57%) at least some of the time to control their blood pressure. Men, those aged 20 to 44 years, and those with lower educational attainment and lower income were, in general, less likely to report engaging in lifestyle behaviors for blood pressure control. A low desire, interest, or awareness were commonly reported barriers to salt restriction, changes in diet, weight loss, smoking cessation, and alcohol reduction. In contrast, the most common barrier to engaging in physical activity to regulate blood pressure was the self-reported challenge of managing a coexisting physical condition or time constraints. In conclusion, programs and interventions to improve the adherence to lifestyle changes to treat hypertension may need to consider the identified barriers to lifestyle behaviors in their design.
Hypertension, or high blood pressure, is a leading risk factor for cardiovascular disease and stroke. High blood pressure can be controlled by reducing dietary salt, eating a balanced diet that is low in saturated fat and that emphasizes fruit and vegetables, limiting alcohol consumption to ≤14 drinks/week in men or ≤9 drinks/week in women, participating in 30 to 60 minutes of aerobic exercise 4 to 7 days/week, and maintaining a healthy body weight (body mass index 18.5 to 24.9 kg/m 2 and waist circumference <102 cm for men and <88 cm for women). Few studies have examined the use of, and barriers to, these behaviors. The findings from a recent nationally representative Canadian study showed that only a small percentage of Canadians improved their lifestyle within 2 years of a hypertension diagnosis, with the main lifestyle changes being smoking cessation and increased physical activity. A recent study in Ontario, Canada, found that <1/2 of subjects diagnosed with hypertension used lifestyle behaviors combined with their drug treatment, without distinguishing among the various behaviors. Thus, the objective of the present study was to better specify the prevalence of Canadian adults with hypertension who use lifestyle changes to control their blood pressure. Moreover, we sought to identify the barriers to self-managing elevated blood pressure.
Methods
Data from the 2009 Survey on Living with Chronic Diseases in Canada (SLCDC) were analyzed. Subjects aged ≥20 years who reported having high blood pressure as a part of the 2008 Canadian Community Health Survey were eligible for participation in the SLCDC. Of the 7,862 respondents contacted, 6,142 agreed to take part and confirmed having been diagnosed with high blood pressure at follow-up, resulting in a response rate of 78%. The respondents who reported having hypertension only during pregnancy, members of the Canadian Forces, First Nations people living on reservations, those residing in institutions, and residents of Canada’s 3 territories, Nunavut, Northwest Territories, and Yukon Territory, were excluded from the sampling frame.
Participants were asked whether, because of being diagnosed with high blood pressure, they ever: limited their daily salt intake, changed the types of food they eat (choosing more fruits and vegetables, fish or lean meats, foods high in fiber, or foods low in fat), exercised or participated in physical activities, and tried to control or lose weight. The latter was described among those who were overweight or obese (body mass index ≥25 kg/m 2 derived from the self-reported height and weight obtained from the Canadian Community Health Survey ). Those who reported smoking at any time since first being diagnosed with high blood pressure were asked if they had ever quit or cut down on smoking to help control their blood pressure. Respondents who reported regularly drinking >14 drinks/week of alcohol for men or >9 drinks/week of alcohol for women weekly at any time since first being diagnosed with high blood pressure were asked if they ever stopped or limited their alcohol consumption to help control their blood pressure.
For each of these lifestyle changes, the subjects who answered “yes” to ever engaging in these activities were asked if they continued to maintain these changes “all of the time,” “most of the time,” “some of the time” or “none of the time.” Those who indicated having never engaged or no longer engaging in a respective behavior were asked the reasons for not doing so. For example, those who reported never or no longer limiting salt consumption were asked the open-ended question “what are the reasons that you are not limiting your daily salt intake to help control your blood pressure?” A substantial number of respondents reported not engaging in behaviors for blood pressure control because they were already doing so “for other reasons” and they were thus categorized separately. In the case of weight control, a number of respondents (n = 677) reported not trying to control or lose weight because they believed they were “already (at) a healthy weight”; these subjects were considered in a separate category.
As previously described, those who reported never or no longer engaging in their noted lifestyle behaviors were asked to specify the reason for not doing so. The interviewer marked all barriers that applied. The barriers that could be specified for each lifestyle behavior are listed in the on-line Appendix Table A . Answers that did not immediately fit into the predefined categories at the interview were recorded as a long answer text and were coded into the existing categories, where possible, during data processing. Because of the smaller sample sizes for some categories, only the most commonly reported barriers are reported, according to a minimum prevalence of 10%.
Engagement in lifestyle changes for blood pressure control was described in terms of sociodemographic characteristics (i.e., gender, ethnicity, educational attainment, total household income) and hypertension management characteristics (i.e., interval since diagnosis, medication use and compliance, and self-reported blood pressure control). Information on the sociodemographic characteristics was obtained through data linkage with the 2008 Canadian Community Health Survey and 2009 SLCDC.
The data were analyzed using the SAS Enterprise Guide, version 4 (SAS Institute, Cary, North Carolina). Point estimates were weighted to reflect the Canadian adult household population. Associations between descriptors and engaging in lifestyle behaviors were examined using age-adjusted prevalence rate ratios (RRs), estimated using a series of binomial regression models. Each lifestyle behavior was treated as a 5-level categorical variable (all the time, most of the time, some of the time, for reasons other than blood pressure control, and never/no longer). For all behaviors, the “never” and “no longer” categories were combined owing to the small numbers. Furthermore, for smoking cessation, only the “all the time” and “never/no longer” categories were robust enough to describe. Limiting alcohol consumption could not be described according to individual characteristics owing to the small sample size. Only associations with never/no longer engaging in the behaviors are presented, with additional analyses available in the on-line appendixes. To account for stratification and clustering in the SLCDC design, 95% confidence intervals were calculated using exact standard errors generated through bootstrap resampling methods.
Results
The characteristics of the study population have been previously described. Most Canadians with self-reported diagnosed hypertension reported limiting salt consumption (89%), changing the types of food they eat (89%), engaging in physical activity (80%), trying to control or lose weight (77%, among those who were overweight or obese), quitting smoking (78%, among those who smoked), and reducing alcohol intake (57%, among those who drank >9 drinks/week for women and >14 drinks/week for men) at least some of the time to control their blood pressure. Fewer than ½ reported engaging in these behaviors all of the time ( Table 1 ).
| Lifestyle Change for Blood Pressure Control | Overall | ||
|---|---|---|---|
| n | % | 95% CI | |
| Limits salt consumption | |||
| All the time | 2,731 | 43.8% | 41.3–46.4 |
| Most of the time | 1,338 | 22.0% | 20.2–23.8 |
| Some of the time | 380 | 6.9% | 5.7–8.1 |
| Already doing so for other reasons | 961 | 16.5% | 14.5–18.5 |
| No longer does so | F | F | |
| Never did so | 688 | 10.4% | 8.8–12.1 |
| Missing data | 15 | ||
| Changes foods eaten | |||
| All the time | 2,031 | 34.9% | 32.6–37.2 |
| Most of the time | 1,641 | 26.5% | 24.5–28.6 |
| Some of the time | 404 | 8.1% | 6.7–9.5 |
| Already doing so for other reasons | 1,303 | 19.8% | 18.1–21.6 |
| No longer does so | F | F | |
| Never did so | 745 | 10.4% | 9.0–11.9 |
| Missing data | 9 | ||
| Physical activity | |||
| All the time | 1,558 | 25.2% | 23.1–27.2 |
| Most of the time | 1,218 | 20.7% | 18.7–22.6 |
| Some of the time | 1,060 | 17.8% | 16.0–19.5 |
| Already doing so for other reasons | 1,115 | 16.0% | 14.4–17.5 |
| No longer does so | 153 | 2.8% | 1.9–3.8 ⁎ |
| Never did so | 1,027 | 17.6% | 15.6–19.6 |
| Missing data | 11 | ||
| Controls/reduces weight (among those overweight or obese, n = 4,214) | |||
| All the time | 1,272 | 31.7% | 28.8–34.6 |
| Most of the time | 975 | 22.6% | 20.5–24.8 |
| Some of the time | 654 | 18.0% | 15.6–20.3 |
| Already doing so for other reasons | 234 | 4.6% | 3.6–5.6 |
| No longer does so | 59 | 0.9% | 0.5–1.1 ⁎ |
| Never did so | 331 | 7.8% | 5.7–10.0 |
| Not doing so because already a healthy weight | 689 | 14.2% | 12.6–15.8 |
| Missing data | 6 | ||
| Quit/reduced smoking (of those who smoked since diagnosis, n = 1,484) | |||
| All the time | 638 | 43.3% | 38.8–47.9 |
| Most of the time | 213 | 15.0% | 11.7–18.4 |
| Some of the time | 138 | 9.1% | 6.7–11.6 |
| Already doing so for other reasons | 156 | 8.0% | 6.3–9.8 |
| No longer does so | 47 | 3.6% | 1.7–5.6 |
| Never did so | 292 | 20.8% | 17.0–24.6 ⁎ |
| Missing data | 3 | ||
| Limits alcohol consumption (of those consuming >9 drinks/week for women or 14 drinks/week for men since diagnosis, n = 603) | |||
| All the time | 135 | 22.7% | 17.0–28.5 |
| Most of the time | 116 | 20.7% | 15.0–26.3 |
| Some of the time | 58 | 7.1% | 4.1–10.2 ⁎ |
| Already doing so for other reasons | 52 | 6.9% | 4.1–9.6 ⁎ |
| No longer does so | F | F | |
| Never did so | 238 | 41.5% | 34.3–48.6 |
| Missing data | 1 | ||
⁎ Interpret with caution (coefficient of variation 16.6–33.3%).
The barriers commonly reported by those not engaging in lifestyle behaviors are listed in Table 2 . “Not wanting to do so,” “not liking to do so,” “not knowing it is important” and “not knowing it is recommended” were commonly reported barriers for limiting salt intake, changing one’s diet, and limiting alcohol consumption. A lack of will power/self-discipline was commonly reported as a barrier to engaging in physical activity, controlling weight, and quitting smoking. Other important perceived barriers unique to physical activity were time constraints and the presence of a coexisting physical condition or health problem. Among those citing a physical condition/health problem as a perceived barrier to physical activity, the most common self-reported chronic conditions were arthritis (60%), back problems (41%), diabetes (27%), heart disease or stroke (27%), asthma (23%), and chronic obstructive pulmonary disease (22%). Other barriers (as listed in Appendix A ) were not reported with sufficient frequency to allow reliable reporting (i.e., the coefficient of variation was >33.3% or n <30). The types of barriers reported did not differ by gender ( Table 2 ), age (data not shown), or income (data not shown).
| Variable | Overall | Men | Women | |||
|---|---|---|---|---|---|---|
| n (%) | 95% CI | n (%) | 95% CI | n (%) | 95% CI | |
| Limiting salt intake | 717 | 404 | 313 | |||
| Does not like to do so | 192 (32.5) | 25.3–39.7 | 93 (30.5) | 20.2–40.9 † | 99 (35.5) | 27.2–43.8 |
| Does not think it is important | 84 (12.2) | 8.5–15.9 | 51 (13.7) | 8.6–18.9 † | 33 (9.8) | 4.8–14.9 † |
| Other reason (not specified) | 128 (15.6) | 10.8–20.3 | 68 (12.3) | 7.4–17.1 † | 60 (20.8) | 12.0–29.6 † |
| No reason specified | 234 (26.6) | 21.7–31.6 | 148 (27.5) | 20.4–34.6 | 86 (25.3) | 18.8–31.8 |
| Changing foods eaten | 754 | 434 | 320 | |||
| Does not like to do so | 107 (14.8) | 9.9–19.7 † | 63 (15.0) | 9.5–20.5 † | 44 (14.5) | 5.9–23.2 † |
| Does not think it is important | 103 (12.2) | 8.9–15.5 | 63 (13.9) | 9.2–18.6 † | 40 (9.9) | 5.3–14.6 † |
| Does not know it is recommended | 57 (11.4) | 7.4–15.3 † | 39 (14.0) | 9.2–18.6 † | 18 (8.0) | 3.1–12.9 † |
| Other reason (not specified) | 160 (20.5) | 15.3–25.7 | 74 (19.6) | 12.3–26.9 † | 86 (21.6) | 14.5–29.8 † |
| No reason specified | 238 (27.2) | 21.8–32.6 | 146 (30.3) | 23.2–37.4 | 92 (23.2) | 15.6–30.7 † |
| Participating in physical activity | 1,180 | 490 | 690 | |||
| Physical condition or a health problem | 488 (42.1) | 35.8–48.4 | 179 (41.3) | 31.1–51.5 | 309 (42.7) | 35.1–50.4 |
| Time constraints | 126 (15.6) | 10.5–20.8 | 60 (16.8) | 10.5–23.1 † | 66 (14.8) | 7.2–22.4 † |
| Lack of will power/self-discipline | 149 (13.8) | 9.4–18.2 | 62 (12.9) | 6.6–19.2 † | 87 (14.5) | 8.6–20.4 † |
| Other reason | 159 (13.5) | 9.4–17.6 | 73 (13.0) | 7.6–18.4 | 86 (13.9) | 7.8–20 † |
| Controlling/losing weight | 390 | 205 | 185 | |||
| Lack of will power/self-discipline | 75 (24.1) | 9.7–38.5 † | 39 | F | 36 (17.8) | 8.3–27.3 † |
| Physical condition or a health problem | 45 (12.9) | 5.0–20.8 † | F | F | F (13.0) | 5.0–21.0 † |
| Other reason | 80 (20.5) | 12.7–31.4 † | 30 | F | 50 (24.9) | 13.2–36.7 † |
| No reason | 81 (16.8) | 10.9–22.6 † | 56 (20.7) | 11.3–30.0 † | F (11.4) | 4.5–18.4 † |
| Quitting smoking | 339 | 170 | 169 | |||
| Does not want to | 104 (37.4) | 27.7–47.1 | 49 (39.1) | 24.3–53.9 | 55 (35.4) | 22.8–48.1 † |
| Lack of will power/self-discipline | 59 (21.3) | 12.4–30.1 † | 33 (26.7) | 11.4–41.9 | F (15.1) | 7.2–22.9 † |
| Tried to/did not work | 63 (14.6) | 9.8–19.4 † | F (8.5) | 3.6–13.5 | 36 (21.5) | 13.3–29.7 † |
| Other reason | 70 (20.7) | 12.3–29.0 † | 36 (23.6) | 10.1–37.2 | 34 (17.3) | 8.9–25.7 † |
| No reason | 41 (11.3) | 6.0–16.5 † | F | F | F (12.8) | 4.7–20.9 † |
| Limiting alcohol consumption | 242 | 181 | 61 | |||
| Does not want to | 87 (45.6) | 32.9–58.2 | 71 (48.9) | 34.7–63.2 | F | F |
| Does not think it is important | 39 (14.9) | 7.4–22.4 † | F (14.3) | 5.5–23.0 † | F | F |
| Other reason | 43 (15.2) | 7.8–22.7 † | 33 (16.8) | 7.7–25.9 † | F | F |
| No reason | 45 (16.2) | 7.0–25.4 † | 35 (18.0) | 6.9–29.0 † | F | F |
⁎ Barriers are not mutually exclusive.
† Interpret with caution (coefficient of variation 16.6–33.3%).
Compared to those aged ≥65 years, the subjects aged 20 to 44 years were significantly less likely to have restricted dietary salt, changed their diet to increase vegetable and fruit intake and decrease fat, or quit smoking ( Table 3 ). After controlling for age, men were less likely than women to have limited salt consumption or changed their diet. In general, those with fewer years of education and a lower income were consistently less likely to have engaged in lifestyle changes to improve their self-management of blood pressure (RR range 1.1 to 1.7), after controlling for age. Those who reported not taking antihypertensive medications were less likely to have limited salt (RR 1.6, 95% confidence interval 1.1 to 2.2) or changed their diet (RR 1.8, 95% confidence interval 1.2 to 2.6). An insufficient sample size precluded characterization of those who failed to limit alcohol consumption. Supplemental analyses characterizing each level of the lifestyle variables are available in the on-line appendixes ( Appendixes B through F ).
| Not Limiting Salt | Not Changing Diet | Not Engaging in Physical Activity | Not Controlling/Losing Weight (Among Those Who were Overweight or Obese, n = 4,214) | Not Quitting Smoking (Among Those Who Smoked, n = 1,484) | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % | RR ⁎ | n | % | RR ⁎ | n | % | RR ⁎ | n | % | RR ⁎ | n | % | RR ⁎ | |
| Age (years) | |||||||||||||||
| ≥65 | 413 | 10.6 | Referent | 455 | 11.0 | Referent | 740 | 19.8 | Referent | 227 | 8.5 | Referent | 136 | 18.4 | Referent |
| 45–64 | 191 | 9.2 | 0.9 (0.6–1.2) | 202 | 9.1 | 0.8 (0.6–1.1) | 335 | 21.1 | 1.1 (0.9–1.3) | 118 | 8.6 | 1.0 (0.6–1.6) | 146 | 24.8 | 1.4 (0.9–1.9) |
| 20–44 | 113 | 19.1 | 1.8 (1.3–2.5) | 97 | 16.0 | 1.4 (1.0–2.0) | 105 | 19.8 | 1.0 (0.7–1.4) | 45 | 9.7 | 1.1 (0.7–1.8) | 57 | 37.6 | 2.0 (1.3–3.2) |
| Age-adjusted | |||||||||||||||
| Gender | |||||||||||||||
| Female | 313 | 8.0 | Referent | 320 | 8.8 | Referent | 690 | 22.0 | Referent | 185 | 7.6 | Referent | 169 | 25.2 | Referent |
| Male | 404 | 13.9 | 1.7 (1.3–2.2) | 434 | 12.7 | 1.5 (1.1–2.0) | 490 | 18.6 | 0.8 (0.7–1.0) | 205 | 9.7 | 1.3 (0.8–2.0) | 170 | 23.8 | 0.9 (0.6–1.3) |
| Education | |||||||||||||||
| Postsecondary graduate | 326 | 10.0 | Referent | 315 | 8.7 | Referent | 435 | 16.8 | Referent | 162 | 8.0 | Referent | 148 | 21.5 | Referent |
| Some postsecondary | 41 | 9.9 | 1.0 (0.6–1.6) | 45 | 11.2 | 1.3 (0.8–2.0) | 65 | 16.1 | 1.0 (0.6–1.5) | F | F | F | F | ||
| Secondary graduate | 113 | 12.4 | 1.3 (0.9–2.0) | 134 | 14.2 | 1.7 (1.1–2.5) | 194 | 25.4 | 1.5 (1.1–2.0) | 61 | 8.9 | 1.1 (0.5–2.4) | 52 | 21.0 | 1.0 (0.6–2.6) |
| Less than secondary | 233 | 11.4 | 1.2 (0.9–1.7) | 258 | 12.1 | 1.5 (1.1–2.0) | 476 | 25.6 | 1.6 (1.3–1.9) | 139 | 9.2 | 1.2 (0.8–1.8) | 119 | 30.9 | 1.6 (0.6–1.5) |
| Income ($ CAD) | |||||||||||||||
| ≥$80,000 | 119 | 13.1 | Referent | 111 | 9.6 | Referent | 140 | 18.6 | Referent | 56 | 9.6 | Referent | 46 | 19.9 | Referent |
| $50,000–$79,999 | 152 | 9.9 | 0.7 (0.5–1.1) | 154 | 11.7 | 1.2 (0.8–1.9) | 215 | 18.9 | 1.0 (0.7–1.5) | 75 | 7.7 | 0.8 (0.4–1.8) | 81 | 27.4 | 1.5 (0.8–2.8) |
| $30,000–$49,000 | 144 | 9.4 | 0.7 (0.5–1.1) | 170 | 9.7 | 1.0 (0.7–1.5) | 251 | 21.6 | 1.2 (0.8–1.7) | 99 | 10.3 | 1.1 (0.5–2.4) | 64 | 20.7 | 1.2 (0.6–2.2) |
| $15,000–$29,999 | 164 | 10.2 | 0.8 (0.5–1.3) | 178 | 11.6 | 1.2 (0.8–1.8) | 321 | 20.2 | 1.1 (0.8–1.6) | 95 | 7.8 | 0.8 (0.4–1.8) | 78 | 27.1 | 1.6 (0.9–2.9) |
| <$15,000 | 51 | 8.4 | 0.7 (0.5–1.3) | 72 | 15.6 | 1.7 (1.0–2.8) | 139 | 32.3 | 1.8 (1.2–2.7) | 29 | 11.5 | 1.2 (0.5–3.2) | 45 | 29.4 | 1.6 (0.8–3.4) |
| Interval since diagnosis | |||||||||||||||
| <2 years | 125 | 12.4 | Referent | 108 | 11.9 | Referent | 170 | 18.5 | Referent | 65 | 10.8 | Referent | 55 | 21.9 | Referent |
| 3–5 years | 141 | 12.2 | 1.0 (0.6–1.7) | 148 | 8.9 | 0.8 (0.5–1.3) | 201 | 17.5 | 0.9 (0.6–1.4) | 66 | 8.9 | 0.8 (0.3–2.3) | 64 | 22.1 | 1.0 (0.6–1.7) |
| 6–9 years | 124 | 8.9 | 0.8 (0.5–1.1) | 124 | 9.3 | 0.8 (0.5–1.2) | 174 | 19.5 | 1.1 (0.7–1.6) | 56 | 4.9 | 0.5 (0.2–1.0) | 66 | 30.6 | 1.4 (0.8–2.3) |
| ≥10 years | 299 | 9.7 | 0.8 (0.6–1.2) | 346 | 11.1 | 1.0 (0.6–1.6) | 592 | 22.8 | 1.3 (0.9–1.8) | 195 | 9.6 | 0.9 (0.4–1.9) | 146 | 23.8 | 1.3 (0.8–2.1) |
| Antihypertensive medication use | |||||||||||||||
| Yes, compliant | 451 | 9.4 | Referent | 490 | 9.0 | Referent | 866 | 19.9 | Referent | 282 | 8.7 | Referent | 206 | 21.6 | Referent |
| Yes, not compliant | 63 | 10.5 | 1.1 (0.7–1.8) | 70 | 12.6 | 1.4 (0.9–2.3) | 99 | 22.2 | 1.1 (0.8–1.6) | 34 | 5.1 | 0.6 (0.3–1.1) | 43 | 30.0 | 1.2 (0.7–2.0) |
| No | 195 | 16.4 | 1.6 (1.1–2.2) | 176 | 16.2 | 1.8 (1.2–2.6) | 178 | 21.1 | 1.1 (0.8–1.4) | 64 | 10.9 | 1.2 (0.6–2.4) | 84 | 29.2 | 1.1 (0.7–1.8) |
| Blood pressure control | |||||||||||||||
| Well-controlled or low | 556 | 9.9 | Referent | 607 | 10.6 | Referent | 916 | 19.0 | Referent | 308 | 8.6 | Referent | 248 | 24.5 | Referent |
| Borderline | 108 | 12.6 | 1.2 (0.7–2.0) | 95 | 9.5 | 0.9 (0.6–1.3) | 184 | 25.1 | 1.3 (1.0–1.8) | 64 | 9.6 | 1.1 (0.5–2.5) | 57 | 19.3 | 0.7 (0.4–1.3) |
| High | 35 | 15.9 | 1.6 (1.0–2.5) | 39 | 15.4 | 1.4 (0.9–2.4) | 62 | 26.5 | 1.4 (1.0–2.0) | F | F | — | F | F | — |
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