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Hello. Is that any better? Can anyone see or hear? Oh, wonderful. I'm so sorry about that. I have absolutely no clue what's happened there. Um I was just in another meeting using teams and the people on there couldn't hear me. So I have no idea what the problem is. But if you can see and hear me now, I'm so sorry for um the past few minutes of confusion, but hopefully everyone was still with us and we can make more of a start now. So welcome again to this share the pressure session. My name's John Horse, I'm the clinical director of Smart Health Solutions. And um I also clinical director of loan were nurses and do various other things around cardiovascular disease. Um You may have joined us on some of the previous share the pressure webinars or seen some of our on demand or other educational resources and share the pressure as a joint project that we're running between ourselves at smart Health Solutions along with the race Equality Foundation, Younger Lives and BP UK. And the aim of this is to address the disproportionate burden of high BP amongst Black African and Caribbean people using a shared decision making tool. Now, the shared decision making tool that uses heart age is not new, that's been around for a little while. But we've actually, or our colleagues at younger lives have relaunched the resource, particularly aiming to reach the particular population that um we are looking to support with this bit of the program. And this is, we're working directly with all the boroughs in Southeast London for this bit of the project. Now, we do hope that we're going to be able to extend and work with other areas. It's absolutely relevant to all areas, but some of the resources that I'm going to share our local two areas of Southeast London. So if you're from the, then that will suit you perfectly if you're not there, still fantastic resources. Um but it might be uh the next phase that we're able to get towards you. But the good news is anybody can access the share the pressure tool and have a look at it. So give it a try, give it a try on yourself, give it a try with patient's with family members and see what you think. So as I say, I'm Joe, I've also got uh Michaela and David colleagues who are delivering some of this training and you may have seen them on some of the other webinars or heard them on our podcasts we're using medal. Congratulations. You found your way this far and now it seems to be working. Um If you're new to Medal, you'll have seen there's a few little slide e buttons to move across to be able to request catch up content, which basically means being able to access these slides afterwards and also to generate your all important attendance certificate. Any problems with Medal, there's a little blue chat speech bubble in the bottom right hand corner of your screen. If you pop onto that, that will take you through to the wonderful team at Medal who will be able to help you if you're struggling to access anything that you need. So back to share the pressure and why are we looking at this? Well, we know that ethnicity is a significant risk factor when it comes to cardiovascular disease and people from different ethnic backgrounds are affected in different ways by different risk factors. But we know ethnicity has a real part to play in this. And in the case of high BP, we know that this disproportionately affects black people of African and Caribbean descent so much so that we see a higher incidence of stroke and end stage renal failure in this population. Now, this is confounded by the fact that this population generally are found to be less likely to come forward for routine screening and health checks and men in particular and are also less likely to have that high BP controlled than members of the white population. Once it is actually found. So there are questions there around the services that we offer and how relevant they are to all members of our population and reaching everybody. But particularly when there are groups of people who we know are at higher risk, but we also know are struggling to reach the services that are needed to find problems and to address them. Then we need to consider how we're doing things and try to find a way that's gonna be better for this higher risk population. Now, this has been the case for some time. But as you might expect, COVID 19 has made the situation worse. In general, we've taken a lot less blood pressures. We've done a lot less hypertension reviews. So we've fallen behind when it comes to finding people making the diagnosis and offering the treatments to reduce risk in our population. Now, nice, the guidelines that we follow here in England recommend that we offer guidance and advice about a variety of lifestyle issues to people with high BP and those focus around diet with a specific uh look there at sodium and caffeine intake, at exercise and physical activity, at the consumption of alcohol and at smoking. It's also recommended that we provide information to people about the benefits of antihypertensive medication and any side effects that they could possibly experience. We also offer them information about patient organizations, BP UK, our, our partner in this and they are the only um patient folk, but facing charity for BP here in the UK. And they have some amazing resources for patient's and the healthcare professionals. It also says that we must offer an annual review of care to all people with hypertension, not just those who happen to be on medication. So it's very clear that there's an important role that lifestyle has to play in the management of high BP or hypertension. Now, I mentioned that we're looking locally at the different boroughs in Southeast London. We're working with them directly for this project and they benefit from some fantastic guidance. One for each borough put together by the clinical effectiveness, Southeast London group. And um and I think these are amazing that they've got lots of really useful information in. You can find them on Google, but you could also find them on our resources page for our share the pressure and I'll show you how to find that towards the end. But it's one of the key messages there that the Cecil group have put forward is that we really need to encourage people when it comes to their lifestyle and that lifestyle changes can prevent or reduce the need for medication when it comes to managing the BP. And that we need to review this at least annually. Now, we know we all know that having a healthier lifestyle, improve your overall health and well being. And it's certainly very, very important when it comes to cardiovascular disease. But there are really, really strong evidence base is for making lifestyle changes and the impact that they will have in this case, particularly looking at BP and the numbers that are quoted here. Now, I have taken this directly from the South East London Guidance, but this is well documented. Um and we have a number of articles, meta analyses all available. They're showing what these lifestyle changes can do in terms of reducing BP. So at the top of the list, reducing weight. Now, obviously, this is all relative to how much weight you have to lose. But maintaining a healthy body weight can reduce up to 20 millimeters of mercury from your systolic BP. That's associated with a 10 kg loss of weight, which we know is also associated with a reduced risk of diabetes and a party uh vascular disease in general, 20 millimeters of mercury is better than we can achieve with many medications. Um Obviously, there's a bit of a scale there depending on how much weight you have to lose and it will be different. You know, some people will respond differently better, more effectively than others in this. But it can make a massive difference as can having a healthier diet. So the Dash diet stands for dietary approaches to stopping hypertension. This is something that's been with us for a long time. I can remember having tear off pads with leaflets about the dash diet. 20 years ago using in practice. So this is as you might expect a cardio protective diet that's rich in fruits and vegetables, low fat dairy products and reduced saturated and overall fats. And that can achieve up to a 14 millimeters of mercury reduction in systolic BP through improving on diet. We know salt is a major culprit when it comes to BP. And by reducing our dietary sodium intake, we can achieve significant reductions up to eight millimeters of mercury and our BP. Now, that's not just about obviously salt that's sprinkled over food at the table. It's really about those hidden salts that are in everyday processed foods in takeaway foods and just often in places, we wouldn't expect to see it. Bread cereals, all the stuff that wouldn't instantly smack of being full of salt often are. So it's something to be aware of being physically active, increasing our exercise. Now, the recommendation is that we do mostly half an hour day on most days of the week, but that may not be realistic for some people, but any physical activity is better than no physical activity. And if you can move a bit more, then you have done previously that can only be a benefit to you and then keeping alcohol intake within the recommended limits as well. So less than 14 units a week, hopefully not all on a Friday or a Saturday night can also support that BP to come down, there could be a cumulative effect on some of these. There's no doubt that improving lifestyle will improve your BP. But of course, with any changes you have to make them and then you have to stick to them. And unfortunately, that's where many of us fall down. I think the evidence suggests that most of us can stick to a change for a maximum of about 12 weeks before we start two slippery slide back to our old ways. So it's important that people have the information that they need to be able to make their decisions and that any changes, any goals that they make are realistic and achievable for them. So it's worth thinking about what support is available for people within your area. Now, if you happen to be in Lambeth where this particular guideline is set, but there is one for each of the boroughs in Southeast London. Then within the guidance, there are some links and also within the share the pressure tool, there will be some links to specific support. Now, some of this is national support and international support. So BP UK, for example, we have patient information leaflets and they're translated into 32 different languages. There are also local support services. So within the Lambeth area, there is a dedicated Wellness clinic for Black and Asian people. There is the Lambeth Health and well being information and support service. There is an early intervention program, there's the Silver Fit Physical Activity Program for older people. There are walking schemes and there's also um active maps showing you which pharmacies which community pharmacists are involved in the local BP checking service and also local gps that patient's can register with if they are not currently registered. So lots of information there to be able to um support people and then BP UK. As I've mentioned, there is a link to BP UK on our website as well and they really do have some great resources and are currently developing more resources as we speak as well. There's stuff that's downloadable that you can give out to people. There's stuff that people can just access on their own. There are BP diaries and such like plus information around making lifestyle changes and what will be beneficial to people. So do you have a look at that if you haven't found them already? Something that um is a really key issue here is around people, us as individuals, what influences change, how we go about making changes and how we stick to them. And I love this quote and it completely sums me up from Miller and Rolnick who really are the godfathers of behavior change and particularly motivational interviewing saying that if you're told what to do, there's a good chance that you'll do the opposite. And that's absolutely me. None of us like being told what to do. Information is power and I do prefer the term information rather than advice when it comes to talking to people about lifestyle and about the potential benefits of making changes and finding out what they already know what they're already doing before we're bombarding with unsolicited lifestyle advice can be a really good place to start. Like with most problems. If we come up with solutions ourselves, it's far more likely that that's going to be effective and that we're going to be able to stick with it. What we might need to do is potentially to dispel any myths that people may have about lifestyle and what works well and doesn't work so well, um, in helping people to control their BP and sign, posting people to reliable sources of information and also to support. But people will often know quite a bit about this already and what they will know very well, much better than we ever will is about themselves and what's important to them and what their lifestyle currently looks like and what's gonna, what kind of changes are gonna fit in with them and work for them and which ones aren't really. So, it's so important that we do a lot of listening, a bit of talking, but a lot of listening with people to be able to provide them with the support that they need, they want to be able to influence their BP through lifestyle change if indeed they do. But some people might not wish to might not be a priority for them at the moment depending on what else is going on in life. So we very much need to be led by them. And that's where this whole notion of shared decision making comes in with a lion's share, really needing to come from the patient. So within smart health solutions dot co dot UK, hopefully you've found are tab here for share the pressure on the main website. This explains what share the pressure is all about and also provides a whole load of resources for healthcare professionals for patient's. And there's a link through to the share the pressure website. Now, Michaela and I have both done webinars um within the past few weeks on using heart age and that should take you through practical demonstration of how to use the tools. So in the interest of time, I'm not going to do that now, but it's a quick assessment where an individual or a healthcare professional can pop in details around their own cardiovascular risk markers. So, so as much information as they know um BP cholesterol if they have it, but things like their weight, their height, any family history, all of the stuff that we know we need to find out about to be able to make an assessment of somebody's cardiovascular risk. And in doing that, it will generate a heart age for people. So this heart age can then be compared to your natural chronological age and can really help with the communication of risk to people because it is quite a complex matter, understanding what risk, absolute risk, relative risk, what all of that means. But most of us would understand if we were 50 years old are heart, age was 65 that that's possibly not a positive thing to be hearing. And it might help to motivate us to consider whether it would be worth making any changes or not and share the pressure will take them through that process. And it will also so assess their motivation to look at this, their confidence in making changes and really help them with making decisions about where to go with this information and what to do about it. So it can be an incredibly helpful tool. So if you haven't had a chance to have a look at that yet, then do have a look and test it out and see what you think. And this is what the whole share the pressure program is built around. Now, that annual review that I mentioned um at the top of this session, nice recommend there's at least an annual review for everybody with hypertension regardless of whether or not they're on medication. And so this is quite a nice um task and activity list that again comes from the South East London guidelines around the actual planning and making those reviews happen, the call and the recall um situation what to do before seeing the patient. So around any blood tests that might be required, getting BP measurements done and then a step by step review with the individual around any symptoms, they may have reviewing any investigations, talking about cardiovascular risk and that all important self management shared decision making this annual review, as well as the opportunity for healthcare professionals to capture the information that we need um to review how somebody is doing. It's also really and and and quite importantly the opportunity for them to ask any questions and get any information that they need to be able to carry on managing their condition for the rest of the year, which is really what we're doing because we're only going to be seeing people um intermittently at practice level or wherever we're reviewing them, but they're going to be dealing with this condition all of the time themselves. So the other resources that we have available, we have a number of these webinars. This is number three in a series of four. There's another one coming up. I think it's later on this week. Actually, I think it might be Thursday evening um looking at medicines for managing hypertension. Um So do you feel free to join me at that one if you're free? I think it's according to my diary here, 6 30 on Thursday evening, if you're not free, all of these are available on demand, so you can access them any time to suit you and there was a welcome event that Michaela and I did that will tell you all about share the pressure and more information on that. If you're someone that prefers to listen on the go while you're making dinner or walking the dog or whatever, then we have some podcasts available that you can click on the website and find. And then we also have some written resources. So we have the guidance for all the different areas um within Southeast London, you can see them all listed there. And there's also some links to some articles that we've had published relating to this share the pressure program and specifically looking at that disproportionate burden of high BP in Black African and Caribbean people. So do you have a look and see if there's anything that's going to be useful and interesting to you that's there. So to summarize, we know that lifestyle can have a huge impact on BP and is absolutely a key strategy for managing BP. And that's regardless of whether or not somebody chooses or needs to take medication and lifestyle modifications can actually have a greater effect than BP medications in some cases, if people do them and they managed to keep doing that if lifestyle alone is not enough and people do need to have medications as well. The good news is that we do have some fantastic BP medications out there that if used and taken appropriately. Absolutely. Have the capability to manage high BP in the vast majority of people and as such, reduce their risk of potentially life changing or life limiting cardiovascular disease coming up. And so just to remember that this population that we are trying to reach, particularly with this round of share. The pressure are Black African and Caribbean population who do face significantly increased risk as a direct result from high BP, more strokes, more kidney failure and we know that they are underrepresented when it comes to finding high BP and treating it. So there's a lot of work there to be done to try and reduce this burden in this population and help people to stay healthier for longer and have a better quality of life with their families and loved ones and society as a whole. So thank you very much for listening. Apologies again for the late start because you couldn't hear or see me on the other device. But hopefully we've managed to get through this bit. I'm very happy to take any questions. I'm just going to have a look through and see what's been said. So so far often lots of things that you can't see or hear me. But let's see if we have any questions coming through here. So Sarah is asking about the recommended sodium and salt range for individuals with hypertension. So actually the recommended levels for all of us is less than 6 g of salt per day. Which is about one level teaspoon. So it's not a lot, although it does seem quite a lot. And you think, I don't really have salt added things, but it's those hidden salts and we know that some breakfast cereals, some loaves of bread, you know, pre bought pre slice breads, um convenience food, microwave meals, all of those things. Some of those things can really contain more than our daily recommended amount of salt in one go. Now, if you already know that you have high BP, then the lower, the better really with the salt intake and, and Children should have far less than that 6 g. Anyway, that is for adults. So really as much salt as they can reduce in their diet. Absolutely the better. But let's say an upper limit for all of us is going to be no more than that flat teaspoon full in a day. So label reading can be really, really helpful. And one of the things that often comes up is a traditional African Caribbean diet, um, can often be quite high in salt. And that's one of the things that's often sort of considered as perhaps a reason why there may be this sort of difference in, um, ethnicity, but it may be part of it. If we any of us are eating food, that's very salty, that's got a lot of added salt to it. Whatever that may be, is going to make a difference. But it's also believe that there's some sort of genetic differences to the way salt is um processed and dealt with in the body that, that can contribute to those differences as well. So I think it's multifactorial and of course not everyone from an African African and Caribbean background is solely going to be eating African and Caribbean foods. You know, we, we, we all eat and enjoy a bit of everything. So, um, you know, overall looking at, looking at diet can be really helpful. So Alison is asking, I hope that's answered your question. Um There Sarah, we also have another question, I'm reading these out because if anyone's watching on demand, then they're not able to see the chat box. So our next question is around how to take BP when you do it or over five days or so, how to get a mean average and what is the recommended BP before you worry? So that's a really good question. Um Alison. So if we're going to do some home monitoring for BP, it's recommended that we do about a weeks worth of readings. Um, so that we can, we can see across the course of a week what somebody's BP is doing and we would measure or ask you to measure in the morning and again in the evening. So we're getting different times of the day, but roughly the same sorts of times for the day. And then it's recommended that you do a couple of measurements each time because our BP does fluctuate constantly. So we would note down all of these BP readings and then essentially to get our average daytime, which is what we're interested in, we would add all of them up. So all of the systolics, all of the diastolics and then divide them by the number that we've done and that would give us our average BP. Now, some practices will have the facility for you to be able to record that via their website. I know mine does and we um we, we do that with my, my father who has hypertension. There's also some printable record sheets on the British and Irish Hypertension Society website. And there's also a downloadable Excel tool on there where you can pop in your blood pressures and it will automatically calculate that average BP for you. So there are a number of different ways of doing it or if you're really clever, you can, you can make your own spreadsheet up of it or get somebody to do it for you. Now, what we would expect for a normal BP in somebody's home environment. Um And this is in the general population, not thinking about people that have got other conditions that made it Tate otherwise or people who are very elderly. For example, for most of us, we would expect our BP at home or want to keep it below 135 over 85 millimeters of mercury as our average. So it will fluctuate a bit over the course of the week. But that would be where we would want the average to be below. Now, when we're taking BP in a clinical setting, we expect that BP to be a little bit higher because we're in a clinical environment. So a cut off level of 1 40/90 millimeters of mercury is where we would start to, I think we need to investigate and do further readings to see if the individual does in fact have persistently high BP or hypertension, which is the same thing. So 13 5/85 is ideally what you're looking for when you're at home. And that's the level that we would ideally like to keep a BP below in people who are on treatment as well. Now, if people have diabetes, if people have got chronic kidney problems, then sometimes we want it to be a bit lower than that to represent, you know, the, the additional risk from the conditions that they have. But 1 35/85 at home is predominantly what we'll be looking for. Um And so the second part of the question was about before you worry. Well, what I would say is, oh, and we, we followed that up with systolic or diastolic being above, for example, 145 over 60 is a concern. Well, for all of us are BP fluctuates throughout the day, throughout the night. That's what it does naturally is respond to what we're, what we're doing and what our body needs us to be able to do to respond to the circumstances that are around us. So I would say it's um, whatever the BP is, isn't something that you want to wait, worry as such about. But what you do want to do is to look and see if a reading that you have that is you've given a couple of examples, 100 and 50 over 5500 and 45/60. What we want to find out is what that BP is doing over the course of say a week. And that was why we would do the home readings and then take an average of it. And if the BP is persistently above that 13585 at home, 1 40/90 in a clinic setting, then it's worth having a look at what we can do to reduce that BP down to within the normal recommended limits. But we never go off one or two readings. We always want a good sort of set of readings to see what's doing over a period of time. So if your BP is above that, the important thing is to get it rechecked and then to have a series of home readings for those then to be interpreted to make a plan. And if you do have hypertension, then what can we be done to improve that? And uh also some other tests to rule out any further problems. And you know, as I said, we have all the tools that we need to be able to manage BP, to help people to stay healthy. It's just making the right plan for the individual and share the pressure can be really helpful for that. So I hope that's helpful. And then another question we've got come up and I'll make this the last question because I see I've ran over time already, but then we did start late. Um is about do we check albumin creatinine ratio annually for all patient's with hypertension? Currently, we check this on diagnosis, but should we be screening more often? That's another really good question. And absolutely, you need to do it on diagnosis and I would say look at your local guidance, your local recommendations and what that says about what you need to do. Now, the vast majority of areas it would be recommended. I've just flashed up the South East London ones here that you would be checking a urine, a cr albumin creatinine ratio annually as part of that annual review because you want to check in the first place to see. Has this BP done any damage to the kidneys yet? Are they starting to leak a little bit of protein now, but then you want to check year on year as to whether that's the case. Now, it's a particular important um in people with diabetes. But actually it would be good practice to check that in everybody. So it may be something that you could add to your list for your regular screening along with the relevant blood test for people at their annual review to make sure that their kidneys are in good working order. Okay. So thank you so much to those of you for submitting questions who have done that? Thank you all for listening. Apologies again for the beginning of the session, but we got there in the end. Um Do you have a look at the rest of the resources and see what we have to say, feel free if you'd like to come and have a chat about medication on Thursday evening to register for that one. Um We will keep updating and putting more stuff, more resources on the website so you can sign up for our community of practice there and then you'll get a little notification when anything new comes along that's going to be helpful. So for now, thank you so much for joining me. Stay safe and well, have a wonderful afternoon and look forward to seeing you on another session soon. Thanks very much. Take care. Bye bye.