Guest: Dr. Bonita Falkner
Guest Bio: Dr. Bonita Falkner, Thomas Jefferson University, Philadelphia, Pennsylvania
We discuss recommendations for screening and treatment of elevated blood pressure.
Health Professional Radio 0 – elevated blood pressure
Emily: You’re listening to Health Professional Radio. This is Emily, and I’m speaking with Dr. Bonita Falkner from Thomas Jefferson University in Philadelphia, Pennsylvania. Dr. Falkner, thank you so much for speaking with me today.
Dr. Bonita Falkner: Glad to be back, Emily.
Emily: We’ve been talking about a recent study that was just published in The Journal of Hypertension, that suggests that hypertension in children may be linked to sodium intake, which is on the rise because of the kinds of foods that we’ve been eating. Dr. Falkner, can you tell me, have the recommendations for screening in pediatrics changed in light of the study, or will they change?
Dr. Falkner: I think our recommendations for screening probably won’t change that much. The recommendations are that children, beginning at age three, should have their blood pressure measured as part of routine health exams, so that won’t change. We also recommend that children younger than three who have some other health issue or some chronic problem, should also have their blood pressure measured even before they’re three years of age.
For those who have an elevated reading, the blood pressure should be repeated, and the frequency kind of depends on how high the initial blood pressure reading is. If it’s high on a routine measurement, then it should be repeated. If the blood pressure remains high or the average is elevated on three separate visits, then they should have an evaluation for the high blood pressure.
Emily: I see.
Dr. Falkner: The difference with the definition of high blood pressure in children is that it’s not one measurement that’s the cut point for hypertension in all children. We use the 95th percentile of the normal blood pressure distribution. The pediatricians need to have charts that give the right distribution for the 95th percentile, according to the child’s age and sex and height. If the average blood pressure on three separate visits is at or above the 95th percentile, that’s criteria for a diagnosis of hypertension.
Emily: I see.
Dr. Falkner: Those children will require a net evaluation. Sometimes, the blood pressure may be high, and then on repeated measurements, this drops down, and it’s not quite at the 95th percentile. Those children, it’s recommended that they continue to have their blood pressure checked periodically to make sure they’re not on the way to hypertension. That recommendation is not going to change.
The next recommendation is what to do about evaluation, and obviously the standard set of tests that are done to screen for kidney problems, cardiac problems, and metabolism and chemistry in the blood, and a urine test. That recommendation will not change. We also recommend screening for other risk factors such as lipids and glucose metabolism, particularly if there’s a strong family history of diabetes, or any clues on physical exam that there may be some other problem going on. That recommendation will remain the same.
Finally, there’s the recommendation that you consider evaluating for what’s called target organ damage, or that’s some evidence of injury from the high blood pressure. The best screen for that is an echocardiogram for heart size to see if there is any strain on the heart from the blood pressure level. We’re actually finding that that is not uncommon.
Dr. Falkner: That recommendation will not change. I think probably we don’t really have good solid evidence yet. What’s the best time to intervene? The first step— and we do recommend intervening— on, it’s called non-pharmacologic measures, therapeutic lifestyle changes. If they’re overweight, trying to make the diet changes to correct the overweight or the obesity, and trying to change the diet or the salt content of the diet, and not necessarily going on to some rigorous regimen of buying low-salt products and things like that.
But just trying to switch to what’s called the DASH style diet.
Emily: What does that consist of?
Dr. Falkner: Well, the DASH style diet is that there was just feeding study that was done in adults where they compared to the normal western-style diet, they had people eat…switch to a diet with high in fruits, vegetables, grains, and low-fat dairy. They all specifically took the same amounts of salt. Even without salt reduction, there was a significant reduction in blood pressure.
Dr. Falkner: Then when they add some salt reduction, the blood pressure went down further. There is evidence that—this diet really is a non-processed diet, a diet that’s basically composed of non-processed fresh fruits and vegetables and dairy. I would say relative to the paper that we published that this gives us some evidence to really push in children the diets that have less salt in them.
Since we know that 75% of the diet in— every one’s diet is already hidden there, the way you can overcome that is to switch to a diet that’s rich in fruits and vegetables—fresh fruits and vegetables, unprocessed.
Emily: Really the same dietary changes that are going to lead to a decrease in obesity are leading to a decrease in high blood pressure.
Dr. Falkner: Right.
Emily: Do you have hope at this point, as far as the cases that you’ve seen, that as the young person as hypertension due to a high sodium intake, an increased size of their waistline, something like the factors that you’re describing, that really don’t have anything to do with other medical issues, is that a reversible condition? Are we seeing that with the correct dietary changes, with exercise, with stress management perhaps, they’re able to go on to an adulthood that is free of this issue?
Dr. Falkner: Well, that’s a great question. We don’t know the answer to that, but we think if someone can make the lifestyle changes that can lower their blood pressure, and their blood pressure remains low, they should do well. Now that individual probably has that background genetics that makes them vulnerable to certain excess weight, dietary salt, or stress. As long as they can adjust their lifestyle to avoid these factors that raise the blood pressure, they should do well.
Emily: I see. I read a report that you chaired, actually the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescence.
Dr. Falkner: Right.
Emily: That was from 2004, I think.
Dr. Falkner: Right.
Emily: You said in that study that family-based intervention improved success. What kinds of conversations should we be having that we’re not having?
Dr. Falkner: I think it’s hard to treat a child in isolation, as the only person in the family who should not eat high-salt foods, the only one who has to have a special diet, the only one that has to have a smaller portion at a table, because they’re overweight. That probably doesn’t work. The person who is doing the shopping and bringing the food into the house has to be able to comply with this.
What we’re asking families to do is basically eating healthy and getting their children to avoid excessive amounts of screen time with televisions, computers, and so forth, to be physically active and be fit. That’s healthy for the family. It’s very difficult to apply that to one child in the family unless everyone else is engaged in it also.
Emily: Right. That is a difficult thing for many families to do, because we’re busy and we’re stressed and money is tight, and so many other factors. Are you seeing a rise in kids that are ending up on medication because of the challenges that are inherent in lifestyle modification?
Dr. Falkner: It’s hard to say whether I’m seeing an increase. I would say the pediatricians are picking up more children because they’re paying attention to the blood pressure, and the high blood pressure. We try and work together on this, but by the time the child is severely obese, it’s very difficult to correct that and change that. It’s hard for families that both parents are working and somebody’s got to do the shopping.
Dr. Falkner: Sometimes there are grandparents or somebody else who the child stays with after school or whatever. People have complicated lifestyles, and it gets difficult to be totally consistent with making changes that are difficult.
Emily: Sure, sure. You’re listening to Health Professional Radio. This is Emily and my guest today is Dr. Bonita Falkner from Thomas Jefferson University in Philadelphia, Pennsylvania. Dr. Falkner, thanks so much for speaking with me today.
Dr. Falkner: I’m glad to do it.