Lifestyle modification advice provided by health care professionals in the treatment and management of hypertension in Kenya

International Journal of Community Medicine and Public Health Mbogori T. Int J Community Med Public Health. 2020 Jun;7(6):2018-2026 http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20202447

Original Research Article

Lifestyle modification advice provided by health care professionals in

the treatment and management of hypertension in Kenya

Teresia Mbogori*

Department of Nutrition and Health Sciences, Ball State University, Indiana, USA Received: 27 March 2020 Revised: 25 April 2020 Accepted: 28 April 2020 *Correspondence: Dr. Teresia Mbogori, E-mail: tnmbogori@bsu.edu Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT Background: Hypertension is one of the main modifiable risk factors for cardiovascular disease morbidity and mortality. Pharmacological and lifestyle modification approaches are used in the treatment and management of hypertension. The purpose of this study was to identify lifestyle modification advice provided to the general population and to those diagnosed with hypertension by health care providers (HCP) in Kenya. Methods: A secondary data analysis of cross-sectional data collected among 4500 Kenyans participating in the 2015 Kenya stepwise approach to surveillance study was conducted. Questions related to the consumption of salt, sugar, fat, fruits and vegetables as well as physical activity and weight management were evaluated. Results: Among all the participants, only 12.5%, 20.7%, 12.2%, 10.7%, 10.3% and 11.6% were advised to either reduce salt intake, eat 5 or more servings of fruits and vegetables, reduce fat intake, reduce intake of sugary beverages, lose or maintain weight and start or do more physical activity respectively. Of those diagnosed with HTN, 37% were advised to increase intake fruits and vegetables, 37%, 27% and 25% were advised to reduce, salt, fat and sugary beverages intake respectively, 21% and 22% were advised to start or do more physical activity and maintain a healthy body weight or lose weight respectively. Conclusions: Majority of Kenyans had not received dietary modification advice from HCP despite this being a policy recommendation in Kenya. Policy makers need to work closely with HCP to develop appropriate policy implementation strategies. Keywords: Diet, Exercise, Hypertension, Lifestyle

INTRODUCTION

In 2016, 71% of all the deaths worldwide were attributed to non-communicable diseases (NCD)s with the majority of those deaths observed in low and middle income countries (LMICs) especially in sub-Saharan Africa (SSA).1 The double burden of disease exists in SSA where communicable diseases such as malaria and tuberculosis and NCDs such as CVDs and diabetes coexist.2,3 In some LMICs, morbidity and mortality from NCDs has surpassed that of infectious diseases. Currently, cardiovascular diseases account for the highest

deaths associated with NCDs and studies have indicated that the prevalence of chronic diseases especially cardiovascular diseases will continue to rise.4

Hypertension is the main modifiable risk factor for cardiovascular disease morbidity and mortality. Prevalence of hypertension in LMIC has shown an increasing trend whereas in high income countries, prevalence of hypertension has been steady or decreasing.5-7 The World Health Organization (WHO) estimates that 1.13 billion people live with hypertension globally with two thirds living in the low and middle

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income countries.8 According to the Kenya stepwise approach to chronic disease risk factor surveillance study (STEPs) conducted in 2015, more than half (56%) of Kenyans had not been screened for hypertension and 24% of Kenyans were either on treatment for hypertension or had elevated blood pressure (<140 mmHg systolic and or <70 mmHg diastolic). The study also concluded that only 15% of those with hypertension were aware of their status, only 8% with hypertension were on treatment, and only 4.6% of those on treatment had their blood pressure well controlled. Treatment of hypertension involves both pharmacological approach and lifestyle modification. Modification of lifestyle factors can delay onset of hypertension, contribute to lowering of blood pressure in treated patients and in some cases abolish need for antihypertensive medications.9 The modifiable risk factors for hypertension include smoking, alcohol intake, obesity, excessive salt intake, physical inactivity, high fat diet, inadequate intake of fruits and vegetables and excessive intake of sugar sweetened beverages.10-12 Even though lifestyle modification has been identified as an approach that can modulate development of chronic diseases, the extent to which messages related to lifestyle changes are communicated to the public, especially in many sub-Saharan African countries is not documented.

Kenya is one of the countries in Africa that is experiencing a rapid economic development and an increase in the prevalence of chronic diseases. In a bid to encourage primary prevention of non-communicable diseases, the Kenyan government launched the national NCD strategic plan in 2015. One of the main tenets of the plan was to promote healthy lifestyles by implementing interventions to reduce intake of unhealthy diets and physical inactivity among others. Currently, there are limited studies that document the implementation of such interventions. Therefore, the purpose of this study was to determine the proportion of individuals diagnosed with high blood pressure that were provided with lifestyle modification advise by a health care professionals to either, reduce salt intake, increase vegetable intake, reduce fat intake, increase physical activity, maintain healthy body weight, reduce intake of sugary drinks and, to identify the factors associated with the likelihood of receiving advice such as residence (rural/urban), age, gender, wealth status and education level.

METHODS

This study analyzed cross-sectional data collected among 4500 Kenyan adults (18- 69 years) participating in the 2015 Kenya STEP wise approach to surveillance study (STEPs) sponsored by the World Health Organization (WHO).13 The overall aim of the STEPS study was to provide estimates on the indicators of non-communicable diseases among adults (18-69 years). This was the first and only nationwide survey on the risk factors for chronic diseases in Kenya.

Sampling and data collection

The study utilized the National Sample Surveys and Evaluation Program (NASSEP V) sampling frame that was developed and is maintained by the Kenya Bureau of Statistics (KNBS), using the enumeration areas generated from the 2009 population and housing census. Participants were recruited using multistage stratified sampling that allowed national estimates by sex (male/female) and residence (rural/urban). Inclusion criteria was individuals aged 18-69 years who were willing and able to provide informed consent. Data was collected from April 2015 to June 2015. Detailed information on sampling procedure and sample size determination are available in the STEPs report.13 Data were collected using a structured questionnaire adapted from the WHO STEPs tool with modifications to suit the Kenyan context.

Measures

The demographic data collected included age, sex, marital status, education, and occupation. The behavioral data included information on lifestyle advice which was assessed using the following question: “During any of your visits to a doctor or other health worker in the past 12 months, were you advised to do any of the following? a) Eat at least five servings of fruit and/or vegetables each day, b) Reduce fat in your diet c) Reduce sugary beverages in your diet d) Start or do more physical activity e) Maintain a healthy body weight or lose weight” The participants answered yes or no. History of high blood pressure diagnosis was determined by the response to the question, “Have you ever been told by a doctor or other health worker that you have raised blood pressure or hypertension?” to which the participants responded yes or no.

Statistical analysis

Complete data were available for 4495 participants and were analyzed using IBM SPSS statistics 26. Descriptive statistics were analyzed using means and percentages. Chi square statistics were used to determine the proportion of the population advised to adapt lifestyle behaviors according to various demographic and behavioral characteristics.

RESULTS

Majority of the participants were female (60%) had primary education and higher (58.8%) and were below 45 years old (71.1%) as shown on Table 1. The sample was stratified for wealth status and residence hence equal representations under the two categories. Almost half of the participants (2218; 49%) reported that they had a health worker check their blood pressure in the past.

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Table 1: Demographic characteristics by screening and diagnosis of hypertension.

Table 2: Percentage advised to reduce salt intake among all participants (n=4495) and those diagnosed with HTN

(n=484).

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Men, individuals without any formal schooling, individuals from the poorest wealth status, those residing in the rural areas, and those within the 60-69 years’ age range were less likely to have had their blood pressure previously checked by a health professional (Table 1). Among those who had been checked for HTN, 484 (21.8%) reported that they were told to have had HTN by the health care provider. Lifestyle modification advise to all participants (n=4495) and those diagnosed with HTN (n=484).

Reduce salt intake

Only 12.5% of all the participants had been advised to reduce their salt intake. Significant differences between demographic characteristics and likelihood of receiving advice to reduce salt intake are summarized in Table 2.

Men were less likely than women to report being advised to reduce salt intake (X2=19.8; p<0.0001). Similarly, those underweight (X2=55.6; p<0.0001), of poorer wealth status (X2=31.9, p<0.0001), with no formal schooling (X2=16.8; p=0.001) and those between 18-25 years old (X2=44.8; p<0.0001) were less likely to report that they were told to reduce salt intake. Among participants who had been diagnosed with hypertension (n=484), 36.8% had been advised to reduce their intake of salt. In this

case, those between 18-25 years old (X2=20.7; p<0.0001) and only those with no formal schooling (X2=8.5; p<0.36) reported that they had not been advised to reduce their salt intake as shown on Table 2.

Eat at least five servings of fruit and/or vegetables each day

About a fifth (20.7%) of the participants had been advised to eat 5 or more servings of fruit and vegetables a day as shown on Table 3. Significant differences were found among various demographic characteristics namely weight status (X2=34.8; p<0.0001), wealth status (X2=86.1; p<0.0001), rural/urban residence (X2=8.3; p=0.004), education level (X2=92.8; P<0.0001) and gender (X2=73.4; p<0.0001).

About 37% of the participants diagnosed with HTN reported that to had been advised to consume 5 or more servings of fruits and vegetables a day. Those who lived in rural areas were less likely to report that they had been advised to consume more fruits and vegetables (X2=4.6; p=0.03). Similarly, more of those in the poorest wealth status category also reported that they were not advised to consume more fruits and vegetables as compared to the other wealth categories (X2=10.7; p=0.03). See Table 3Reduce fat in your diet

Table 3: Percentage advised to consume 5 servings or more of fruits and vegetables among all participants (n=4495)

and those diagnosed with HTN (n=484).

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Table 4: Percentage advised to reduce fat intake among all participants (n=4495) and those diagnosed with HTN

(n=484).

Table 5: Percentage advised to reduce intake of sweetened beverages among all participants (n=4495) and those

diagnosed with HTN (n=484).

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About 12% of all the participants reported to have been advised to reduce their dietary fat intake. As shown in Table 4, significant differences were found among BMI categories (X2=53.6 p<0.0001), residence (X2=8.44; p=0.004), education level (X2=56.1; p <0.0001), gender (X2=34.0; p<0.0001), wealth status (X2=40.5; p<0.0001), and age group (X2=11.3; p=0.01). Among those diagnosed with HTN, about 27% had been advised to reduce their fat intake. Those less likely to report that they had been advised to reduce their fat intake were male (X2=4.29; p=0.038), 18-25 years old (X2=15.5; p=0.001), and underweight (X2=14.3; p=0.003).

Reduce sugary beverages in your diet

Approximately 11% of the all the participants reported that they had been advised to reduce intake of sugary beverages in their diet (Table 5). Those more likely to report that they had not been told to reduce their intake of sugary beverages were 60-69 years old (X2=30.0; p<0.0001), male (X2=6.5;p=0.01), poorest wealth category (X2=20.4; p<0.0001), with no formal schooling (X2=21.1; p<0.0001) and underweight (X2=23.0; p<0.001 Twenty-five percent of those diagnosed with HTN reported to have been advised on reducing intake of

sugary beverages. As shown on Table 5, significant differences were only found in the age group category where those 18-25 years being less likely to report that they had been told to reduce intake of sugary drinks as compared to the other age categories (X2=14.0; p=0.003).

Start or do more physical activity, and maintain a healthy body weight or lose weight

About 12% of the participants reported that they had been advised to begin or do more physical activity (Table 6). Similarly, only about 10% of all the participants reported that they had been advised to lose weight or to maintain a healthy body weight (Table 7).There were significant differences (p<0.005) between all the demographic characteristics assessed and the likelihood of being advised to start or do more physical activity as well as maintain or lose weight except for age groups as shown in Tables 6 and 7.

Among those diagnosed with HTN, those from the poorest wealth status, with no formal schooling and underweight were less likely to report that they had been advised to start or do more physical activity or lose of maintain a healthy weight status (Table 6 and Table 7).

Table 6: Percentage advised to lose or maintain weight among all participants (n=4495) and those diagnosed with

HTN (n=484).

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Table 7: Percentage advised to start or do more physical activity among all participants (n=4495) and those

diagnosed with HTN (n=484).

DISCUSSION

The purpose of this study was to identify lifestyle modification advice related to the treatment and management of hypertension provided by health care providers to the general population and to those diagnosed with hypertension in Kenya. Unfortunately, only a small proportion of the population in this study reported to have received these messages despite the wealth of evidence linking lifestyle and chronic diseases. In addition, those from more vulnerable categories such as those from poor wealth status and those with no formal of schooling were more likely to report that they had not received such advice. Lifestyle modification has been identified to be effective in the prevention, treatment and management of hypertension. One example of lifestyle modification that has shown positive outcomes with hypertension is the use of DASH (Dietary approaches to stop hypertension) eating plan. This plan emphasizes high consumption of fruits, vegetables and whole grains, and encourages limiting intake of saturated and trans fats, sugar sweetened beverages and sodium.14

There is a great amount of literature that supports the beneficial effects of the DASH diet in the prevention and management of hypertension.15-17 Therefore, most dietary recommendations around the world on the prevention of hypertension are adopted or are similar to the DASH

eating plan including the Kenyan healthy diets and physical activity recommendations.18

The Ministry of Health in Kenya through the Nutrition and Dietetics unit developed comprehensive guidelines for healthy diets and physical activity.18 These guidelines were are similar to the DASH eating plan with some modifications to fit the Kenyan context. They recommend intake of 5 servings of vegetables per day (1/2 cup cooked or 1 cup raw), use of iodized salt sparingly and avoiding foods and condiments high in salt as well as adding salt after cooking, limited solid fat use and use of fortified oils instead, limit intake of sugar sweetened foods and drinks and 150 minutes of physical activity per week that can be accumulated from doing normal chores and walking. In addition to recommendation of particular foods, these guidelines provide an implementation framework and collaborative opportunities with other sectors of the government to ensure that the guidelines are received by the intended audience. Prior to formation of these guidelines, healthy eating and active lifestyle were promoted through National Nutrition Action plan (2012- 2017) based on the Food and Nutrition Security policy implemented in 2011.19,20 Considering the presence of policies and guidelines to ensure Kenyans have a healthy lifestyle to prevent chronic disease development, it is imperative then to assess whether these messages are getting to the general population and especially those who

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already have been diagnosed with hypertension hence the purpose of this study. Only a small proportion of the general population had received lifestyle modification advice while a slightly higher proportion of those who had been diagnosed with hypertension reported to have received these messages. This observation indicated that there is still very low awareness among the general population on the importance of lifestyle modification on the prevention and management of hypertension which may indicate that this information is not being provided by health care providers. Similar studies in Africa could not be identified. However, one study using the NHANES dataset (2015-2016) found slightly higher proportions of individuals diagnosed with hypertension reporting to have received lifestyle modification advice such as to exercise more, reduce fat and calories intake, and control or lose weight (49.7%, 41.1%, and 41.3% respectively) in the united states.21

Studies among health care providers in African countries have indicated a low adherence by health care providers on providing lifestyle modification recommendations. One study among 16 South African doctors found that they all considered lifestyle modification as an important aspect in the management of hypertension but only half of them recommended lifestyle modification to their patients.22 In another study, 450 medical records on hypertensive patients in four hospitals in rural South Africa were evaluated for documentation on lifestyle modification advice recommended by physicians. Results showed that the rate of recommending physical activity 31.2%) and dietary modification (46.5%).23 In contrast, an online study on primary care physicians practicing in USA found that majority of the doctors reported providing lifestyle modification advice such as healthy diet consumption (92.2%), reduction in salt intake (96.1%), maintaining healthy weight (94.4%) limiting alcohol (74.4%) and being physically active (94.4%).24 Findings from the health care provider’s perspective may imply that more individuals are provided lifestyle modification advise by health care providers but do not report it as so. Therefore, suggesting a need for more than one exposure to these messages.