Journal of Human Hypertension (2004) 18, 127–131
& 2004 Nature Publishing Group All rights reserved 0950-9240/04 $25.00
ORIGINAL ARTICLE
Intensive training of patients with
hypertension is effective in modifying
lifestyle risk factors
EH Fleischmann, A Friedrich, E Danzer, K Gallert, H Walter and RE Schmieder
Institute for Preventive Medicine, University of Erlangen-Nuremberg and Klinikum Nuremberg, Germany
The burden of insufficiently treated arterial hypertension
is still underestimated. In addition to pharmacological
therapy, patient training is a valuable therapeutic option.
During 1998–1999, the Institute for Preventive Medicine
conducted an intensive training programme in coopera-
tion with regional practitioners. The goal of this
programme was to educate patients about their disease
and motivate them to comply with the therapy. To
evaluate the effectivity of this programme, 126 patients
with arterial hypertension were trained. They received
eight training sessions of 90 min each. In 90 patients
blood pressure measurements before and 6 months
after training were available. In addition, data concern-
ing health status and lifestyle risk factors were analysed
with standardised questionnaires. There was a marked
reduction in blood pressure after 6 months (152 7 6/
89 7 10 vs. 145 7 12/85 7 8 mmHg, Po0.001). In parallel,
mean body weight declined by 0.9 7 2.9 kg (Po0.001)
and body mass index (BMI) by 0.33 7 1.04 kg/m2
(Po0.001). Further analysis revealed that weight loss
Keywords: treatment of hypertension; patient education; SF 36 questionnaire; body weight; body mass index;
weight loss
Introduction
Arterial hypertension is an important risk factor for
cardiovascular disease, whose treatment is com-
monly based on pharmacological intervention. The
number of effectively treated patients with arterial
hypertension is not satisfying. This is partly due to
low compliance of the patients, which itself is
linked to the patients’ poor knowledge about their
disease. Blood pressure self-measurement is a
powerful tool to keep the patients attention on their
disease. Another important approach is the educa-
Correspondence: Professor Dr RE Schmieder, Institute for Pre-
ventive Medicine, University of Erlangen-Nuremberg and Klini-
kum Nuremberg, Breslauer Str. 201, 90475 Nuremberg, Germany.
E-mail: Roland.Schmieder@rzmail.uni-erlangen.de
Received 1 September 2001; revised 25 June 2003; accepted 25
August 2003
www.nature.com/jhh
was more marked in obese patients
(Po 0.01) than in lean subjects. Similarly, the decline
of blood pressure was also greater in obese
patients, but did not reach statistical significance. The
activity score for physical exercise increased overall
from 2.1 7 0.4 to 2.8 7 3.1 h/week (Po0.01). Moreover,
knowledge about hypertension increased as well
(Po0.01). Of all the quality life measurements, the
vitality index improved from 53 7 19 to 59 7 19
(Po0.05) according to the patients’ self-estimation.
In conclusion, training of hypertensive patients has
a profound effect on blood pressure control. It
motivates patients to change lifestyle risk factors,
namely to lose weight, and increases the patients’
physical activity level, thereby decreasing the
patients’ blood pressure. Thus, intensive training pro-
grammes are effective and should be used on a
widespread basis.
Journal of Human Hypertension (2004) 18, 127–131.
doi:10.1038/sj.jhh.1001648
tion of the patients by intensive training in order
to modify the patients’ behaviour and lifestyle
factors.
Various studies performed in different countries
and different societies indicated that the teaching of
hypertensive patients is effective in lowering blood
pressure.1–5 From 1998 until 1999, the Institute for
Preventive Medicine (IPM) of the University of
Erlangen-Nuremberg in Germany in collaboration
with general practitioners conducted a structured
intensive training programme for patients with
essential hypertension. The goals of the training
included the achievement of better blood pressure
control, the reduction of other concomitant cardio-
vascular risk factors, the strengthening of beneficial
health-related behavior and education of blood
pressure self-measurement as well nonpharmacolo-
gical strategies to lower blood pressure. Each of
the eight training sessions lasted 90 min. To evaluate
the programme and prove the effectiveness of the
 Training of hypertensives in modifying lifestyle risk factors
EH Fleischmann et al
128
training, the patients were evaluated before and 6 as body mass index (BMI) 430 kg/m2, 42% were
months after training. overweight with a BMI of 25.00–29.99 kg/m2 and
only 23% were normal weight (BMI o25 kg/m2). In
60% of the patients, an LDL-cholesterol 4130 mg/dl
Methods was prevalent. The number and class of blood
pressure medications remained constant before
All hypertensive patients, who were interested in and after 6 months training, as were the number of
the self-control of blood pressure and were able to pills per day (Table 1).
visit our training courses, were evaluated before and The average blood pressure decreased from
6 months after the training sessions. Information 152 7 2/89 7 1 mmHg before training to 145 7 1/
about basic patient characteristics, cardiovascular 85 7 1 mmHg after 6 months (Po0.001). By capti-
diseases, blood pressure, 24 h blood pressure values, vating the patients according to their self blood
blood pressure medication and laboratory data pressure measurement, the percentage of normoten-
including a lipid and renal profile, urinary sodium sive blood pressure values increased from 3.3% to
excretion and blood cell count was obtained by a 10% (Table 2).
questionnaire from the patients’ practitioner. Further analysis showed that the decrease in
The patients were asked to return three ques- systolic and diastolic blood pressure was greater in
tionnaires at the beginning and after 6 months: The obese patients than in overweight and normal-
first questionnaire included questions about com- weight patients, without reaching our predefined
pliance, arterial hypertension and cardiovascular level of significance (P ¼ 0.09; two-sided) (Figure 1).
risk factors like smoking, hyperlipidaemia, diabetes No significant change in the prevalence of normo-
mellitus, physical activity (expressed as hours of tension and hypertension was observed 6 months
sports activity per week) and alcohol consumption. after training in obese, overweight and normal-
The second questionnaire consisted of 14 multiple weight patients. Analysis of other cardiovascular
choice-based questions regarding the patients’ risk factors like lipid profile, consumption of
knowledge about hypertension and the third ques- alcohol and smoking revealed a nonsignificant trend
tionnaire was a modified standardised question- towards improvement for cholesterol, LDL-choles-
naire for the evaluation of self-estimated general terol, HDL-cholesterol and alcohol consumption.
health (SF-36).6,7 The topics included in the Physi- More important, body weight and BMI decreased
cal Component Score were Physical Functioning (Po0.001) and physical activity increased (Po0.02)
Index, Role-Physical Index, Pain Index and General (Table 1).
Health Perceptions Index. The Mental Component There was an overall loss of body weight of
Score included Vitality Index, Social Functioning 0.88 7 2.85 kg after 6 months. Patients with
Index, Role-Emotional Index and Mental Health obesity had a significantly greater loss of body
Index. Each questionnaire was pretested and reva- weight (1.89 7 3.28) than overweight patients
lidated in Germany in the German language.8
Table 1 Patient characteristics at the beginning and after 6
months
Statistics
Training
Statistical analysis was performed with SPSS 8.0 for
Windows. Continuous data were analysed by the t- Before After P
test for dependent variables or analysis of variance 6 months
(ANOVA). Nominal data were analysed by w2
analysis followed by Fisher’s test for least signifi- Systolic blood pressure 152 7 1.5 149 7 1.6 o0.001
cance. An error probability of Po0.05 (two-sided) (mmHg)
Diastolic blood pressure 89 7 0.9 87 7 0.9 o0.001
was considered significant for all tests. The results (mmHg)
are presented as mean 7 s.e.m. (standard error of Cholesterol (mg/dl) 232 7 4 222 7 6 NS
the mean). LDL-cholesterol (mg/dl) 152 7 9 140 7 5 NS
HDL-cholesterol (mg/dl) 55 7 2 56 7 3 NS
Body weight (kg) 81.0 7 1.5 79.7 7 1.6 o0.001
BMI (kg/m2) 28.6 7 0.4 28.3 7 0.4 o0.05
Results Alcohol consumption (g/day) 127 7 19 100 7 16 NS
Percentage of smoker (%) 8.2% 6.2% NS
A total of 126 patients with essential hypertension Physical activity (h/week) 2.1 7 0.3 2.8 7 0.3 o0.01
were included in our training programme. In all, 90 Classes of antihypertensive
patients of this group, who were followed prospec- drugs
tively for 6 months and had blood pressure data 1 (%) 38.5% 28.7% NS
2 (%) 31.1% 27.9% NS
before and 6 months after training available, were 3 (%) 22.1% 27% NS
included in our final analysis. The patients’ mean Other (%) 4.9% 7.3% NS
age was 62.1 7 0.8 years (range 40–83 years); 57% Count of antihypertensive drugs 2.0 7 0.1 2.2 7 0.1 NS
were male patients. In all, 14% were diabetic and
7% smoked; 31% of the patients had obesity defined NS: not significant.

Journal of Human Hypertension

 Training of hypertensives in modifying lifestyle risk factors
EH Fleischmann et al
129
Table 2 Blood pressure classification before training and 6 months after training

Classification of blood pressure before training Classification of blood pressure 6 months after training
Total
o135/85 mmHg 135/85–150/95 mmHg >150/95 mmHg
N (%) N (%) N (%) N (%)

o135/85 mmHg 0 (0%) 2 (2.2%) 1 (1.1%) 3 (3.3%)

135/85–150/95 mmHg 6 (6.7%) 17 (18.9%) 14 (15.6%) 37 (41.1%)
>150/95 mmHg 3 (3.3%) 14 (15.6%) 33 (36.7%) 50 (55.6%)
Total 9 (10.0%) 33 (36.7%) 48 (53.3%) 90 (100%)

Figure 1 Decline of systolic (left panel) and diastolic (right panel) blood pressure after 6 months. Mean 7 s.e.m. (mmHg) in obese,
overweight and normal-weight patients. ANOVA disclosed a P-value of 0.09 (two-sided).

(0.52+2.79) (Po0.01) and overweight patients had
a greater loss of body weight than normal-weight
patients (0.15 7 1.65) (Po0.01). A loss equal and
more than 1 kg body weight was observed in 43.7%
of the patients, whereas stable body weight and gain
of body weight were found in 33.6 and 22.7%,
respectively (Po0.05). BMI behaved likewise.
Overall, a small decrease of 0.33 7 1.04 kg/m2
(Po0.01) was observed in the total group, with a
greater decrease in obese (0.73 7 1.15 kg/m2)
and overweight patients (0.21 7 0.99 kg/m2) than
in normal-weight subjects (0.002 7 0.73 kg/m2)
(Po0.01).
Accordingly, the percentage of patients with a
decrease in BMI was more prevalent in the obese
than in the overweight or normal-weight group
(Po0.05) (Figure 2).
The physical activity score increased in the whole
group after 6 months (2.1 7 0.3 to 2.8 7 0.3 h/week)
(Po0.01). The increase of physical activity was
similar in obese, overweight and normal-weight
patients (0.6 7 0.6 vs 0.5 7 0.8 and 0.8 7 0.3 h/
week). The decrease of body weight was not
correlated to the increase of physical activity.
The patients’ knowledge about specific topics
regarding arterial hypertension increased also mark-
edly from 67 to 74% of correct answers (Po0.01). It
is noteworthy that at the beginning of the training
programme, 67% of the patients answered the
questions about hypertension completely correct,
which suggests a high pretraining knowledge in our
patients. Nevertheless, the educational training
obviously increased their knowledge further.
None of the physical or mental indices for quality
of life were significantly different 6 months after the
training programme, with the exception of the
vitality index. The self-estimated vitality increased
from a score of 53.2 to 59.2 (Po0.05).
Discussion
Treatment of arterial hypertension is a major target
for the prevention of cardiovascular disease. Com-
monly, treatment is based on antihypertensive
medication only, but nonpharmacologic treatment
strategies are increasingly recognised to be impor-
tant tools for blood pressure control.9,10 Our study
emphasises the importance of structured patient
education programmes in topics on arterial hyper-
tension. Our intensive patient training lowered
blood pressure significantly after 6 months, and

Journal of Human Hypertension

 Training of hypertensives in modifying lifestyle risk factors
EH Fleischmann et al
130
Figure 2 Percentage of patients with weight loss, weight gain or stable weight in obese, overweight and normal-weight patients.
influenced patients to modify their lifestyle with the
consequence of decreases in body weight, BMI, and
increases in physical activity. The magnitude of
blood pressure lowering is similar to the results
published by Grosser et al11 (158 7 18/91 7 9 vs
148 7 17/86+9 mm Hg), which may be anticipated to
some extent, since both studies were performed on
German hypertensive patients. However, they are
also comparable to the difference of blood pressure
between an intervention and control group observed
by Cuspidi et al12 which was even more favourable
(152 7 15/91+11 vs 138 7 14/83 7 7 mmHg) than
our results.
These effects were achieved without changes in
pharmacological treatment of arterial hypertension.
Although it is possible that the prolonged duration
of antihypertensive treatment may have contributed
to the observed fall of blood pressure, patient
training must be considered as an important part
of the patients’ treatment. Finally, these two aspects
cannot be separated in our study.
Thereby, patient training acts on modifying multi-
ple risk factors and may potentiate the effect of
pharmacological treatment on cardiovascular pre-
vention.
Interestingly, we observed an effect on patients
still 6 months after the intensive training pro-
gramme, suggesting a long-lasting influence on the
patients’ lifestyle by increasing the general aware-
ness of their disease.
Body weight and BMI remained significantly
lower after 6 months in our trained patients. New
guidelines on obesity13,14 state that stabilisation of
body weight and BMI alone is an important clinical
achievement. Under this consideration, the ob-
served decrease of body weight and BMI is an
Journal of Human Hypertension
excellent result. Moreover, our training was not
focusing on weight loss in particular. The stabilisa-
tion of BMI was achieved by merely sensitising the
patients for general health topics, practical guide-
lines and advices from both sides, the teacher and
the programme participants.
Naturally, these lessons contained topics about
dietary issues such as low salt diet and other diets.
Increased knowledge about these issues might have
contributed to weight loss. However, neither was
salt intake measured by sodium excretion, nor was a
strict dietary regimen prescribed or monitored. It
was not in the intention of the staff to conduct a
strict weight loss programme.
Surprisingly, weight loss was greatest in the group
at highest risk, namely in the hypertensive patients
who had additional obesity. Therefore, it seems that
these people with excessive risk profited most from
our intensive training programme. It must be re-
emphasised that weight loss is accepted as an
effective nonpharmacological treatment for arterial
hypertension15 and weight loss is listed as a major
goal in guidelines for the treatment of arterial
hypertension.6,16 Indeed, blood pressure was sig-
nificantly lowered after 6 months. The greatest effect
was seen in obese patients. Since this group also had
the greatest weight loss, but changes in physical
activity were not different between obese, over-
weight and normal-weight patients, it may be
speculated that the observed weight loss may have
induced the decline in blood pressure. Of note, this
improvement of body weight control was not
accompanied by any loss of quality of life. On the
contrary, the Vitality Index increased, perhaps due
to the patients’ feeling of success of weight loss and
due to the patients’ increased physical activity.

It is unknown as to how long the effects of the
intensive training programme will last. Sawicki
et al2 reported effects even 18 months after training.
However, it can be speculated that repeated training
sessions might enhance and prolong the beneficial
effects on blood pressure control and modifying
lifestyle risk factors for atherosclerosis.
One limitation of this study might be that the
patients included in this study were already more
motivated and educated than the general popula-
tion. However, our patients’ performance at the
beginning of the study revealed similar levels of
knowledge about hypertension as the group of
Italian patients tested with a different question-
naire,17 suggesting that a normal level of knowledge
about hypertension exists in our group. Neverthe-
less, by using an intraindividual comparison, we
could still demonstrate that our intensive patient
training has been effective. Extending the training
programme into less educated patient groups might
actually enhance the overall benefit from patients’
training sessions.
In conclusion, we could prove our intensive
training programme to be effective in modifying
lifestyle risk factors, especially for obese, hyperten-
sive patients. Future studies are needed to demon-
strate the cost effectiveness of this programme.
Nevertheless, all efforts should be made to wide-
spread an intensive training programme for hyper-
tensive patients as a preventive strategy to reduce
their cardiovascular risk.
References
1 Hovell MF et al. The effects of lay counseling on
medication adherence and blood pressure: adjunctive
treatment for hypertension. Patient Educ Couns 1984;
6: 91–94.
2 Sawicki PT, Muhlhauser I, Didjurgeit U, Berger M.
Improvement of hypertension care by a structured
treatment and teaching programme. J Hum Hypertens
1993; 7: 571–573.
3 Iso H et al. A randomized controlled trail of intensive
and usual community-based education for blood
pressure control. Nippon Koshu Eisei Zasshi 1994;
41: 1015–1026.
Training of hypertensives in modifying lifestyle risk factors
EH Fleischmann et al
131
4 Cuspidi C et al. Short and long-term impact of a
structured educational program on the patient’s knowl-
edge of hypertension. Ital Heart J 2000; 1: 839–843.
5 Zernike W, Henderson A. Evaluating the effectiveness
of two teaching strategies for patients diagnosed with
hypertension. J Clin Nurs 1998; 7: 37–44.
6 Garratt AM, Ruta DA, Abdalla Ml, Russell IT. SF 36
health survey questionnaire: II. esponsiveness to
changes in health status in four common clinical
conditions. Qual Health Care 1994; 3: 186–192.
7 McHorney CA, Ware Jr JE, Lu JF, Sherbourne CD. The
MOS 36-item Short-Form Health Survey (SF-36):
III.Tests of data quality, scaling assumptions, and
reliability across diverse patient groups. Med Care
1994; 32: 40–66.
8 Bullinger M. German translation and psychometric
testing of the SF-36 Health Survey: preliminary results
from the IQOLA Project. International Quality of Life
Assessment. Soc Sci Med 1995; 41: 1359–1366.
9 Marley J, Davis N, Joy M. Is the non-pharmacological
treatment of hypertension neglected? J R Soc Med
1991; 84: 540–541.
10 Saradeth T, Kaynar A, Resch KL, Ernst E. Treatment of
hypertension-the value of non-drug measures. Fortschr
Med 1994; 112: 509–511.
11 Gruesser M et al. Structured patient education for out-
patients with hypertension in general practice: a
model project in Germany. J Hum Hypertens 1997;
11: 501–506.
12 Cuspidi C et al. To better know hypertension: educa-
tional meetings for hypertensive patients. Blood Press
2000; 9: 255–259.
13 WHO Consultation on Obesity. Obesity Prevention and
Managing the Global Epidemia. WHO: 1997; pp 1–276.
14 Executive summary of the clinical guidelines on the
identification, evaluation and treatment of overweight
and obesity. Arch Intern Med 1998; 158: 1855–1867.
15 Mertens IL, Van Gaal LF. Overweight, obesity, and
blood pressure: the effects of modest weight reduction.
Obes Res 2000; 8: 270–278.
16 Leiter LA et al. Lifestyle modifications to prevent and
control hypertension. 2. Recommendations on obesity
and weight loss. Canadian Hypertension Society,
Canadian Coalition for High Blood Pressure Preven-
tion and Control, Laboratory Centre for Disease Control
at Health Canada, Heart and Stroke Foundation of
Canada. Can Med Assoc J1999; 160: S7–S12.
17 Cuspidi C et al. Improvement of patients’ knowledge
by a single educational meeting on hypertension.
J Hum Hypertens 2001; 15: 57–61.
Journal of Human Hypertension
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