# Maritime Health Research and Education-NET/Early diagnostics of hypertension via routine medical exams
#### References

Global Hypertension practice Guidelines
Recommendations for reporting of clinical research data (attached article) The so-called “fit-for-duty” medical health examinations for fishers, seafarers and transport personnel aim to determine workers’ fitness to stay healthy during long-distance travel at sea and on roads far from health services. The results of the “fit-for-duty” medical health examinations can have serious consequences for the seafarers and so there is a need to consider special careful clinical management for them. Register data studies have shown that fishers, seafarers and transport personnel are at high risk of Type 2 diabetes (T2D) and hypertension (HTN), both as part of the metabolic syndrome and often related to overweight and obesity. The importance of an early and precise diagnosis and prevention, cannot be underestimated. HTN is one of the most important measurable and preventable indicators of the metabolic syndrome, but highly valid measurements are hampered by a.o. "white coat effect". In a Danish study 44.7% and 41.8% of seafarers were hypertensive and pre-hypertensive respectively while the use of antihypertensive treatment was low. Many authors have recommended primary-care physicians to change their current clinical practice to align with the shift toward a confirmation process for ambulatory-based hypertension diagnoses to improve population health.To get a HTN diagnose can have serious consequences for the worked to get "grounded"and kept away for personal income. By taking focus of early diagnostics and prevention of hypertension and pre-hypertension,the intention is to contribute to the prevention of the metabolic syndrome, T2DM, overweight and obesity in the target group of fishers, seafarers and other transport workers. To prevent effectively, we need data of high validity, meaning high sensitivity and specificity. The data we get from the routine health examinations are most probably not accurate because of the "white-coat" effect. We need precise methods to measure blood pressure in the health examinations: 1. Blood pressure measurement done in the fit for the duty health examinations in few minutes, with results that are not sufficiently accurate 2: For research, we need methods that gives accurate measurement of blood pressure, even by spending more time. The challenge is to describe a method for accurate measurement of blood pressure that is economically acceptable (low time consume) and with the desired high sensibility and specificity of the measurements. Also to describe which type of risk variable should be collected besides: age, gender, hight and weight, medicine, knowledge whether having hypertension, +/- diabetes and use of medicine. Like for T2DM we want to find the "real" (unbiased) hypertension and pre-hypertension prevalences in the job- , age-, and gender groups.
HTN is the most attributable modifiable cardiovascular disease (CVD) events risk factor. In recent years the incidence and prevalence of HTN have increased while rates of HTN control have declined. Measuring blood pressure is one of the most common procedures performed at a medical office. Yet, studies have shown that nurses, medical assistants and even doctors make numerous mistakes when taking readings.
Accurate measurement of blood pressure is essential to classify individuals, to ascertain blood pressure–related risk, and to guide management. The auscultatory technique with a trained observer and mercury sphygmomanometer continues to be the method of choice for measurement in the office, using the first and fifth phases of the Korotkoff sounds. The use of mercury is declining, and alternatives are needed. Aneroid devices are suitable, but they require frequent calibration. Hybrid devices that use electronic transducers instead of mercury have promise. Guidelines on diagnosing HTN recommend certain aspects that we must take into account and certain things that we must avoid:
* In the 30 minutes before your blood pressure is taken, no smoking, no caffeine and no exercise. In the 5 minutes before your blood pressure is taken sit still.
* During blood pressure is taken make sure the cuff is the right size and in the right place, keep your cuffed arm on a flat surface, like a table and at heart level, sit upright, feet flat on floor and don`t talk.
Avoid this things:
▪ Putting the cuff over clothing, rather than a bare arm, can add 10-40 mm Hg to a measurement.
▪ Having a full bladder can tack on 10-15 mm Hg.
▪ Talking or having a conversation: an additional 10-15 mm Hg.
▪ Failing to support the arm at heart level can add 10 mm Hg.
▪ An unsupported back can increase a measurement by 5-10 mm Hg. That same range applies to feet left dangling from an exam table or high chair.
▪ Crossing legs means an extra 2-8 mm Hg
DRAFT PROTOCOL
"Green Ship" project include diabetes and hypertension
Purposes
* To measure the unbiased prevalences of pre-hypertension and hypertension in random samples in jobs with mandatory health examinations.
* To describe and try out in practice valid methods for diagnosis, prevention, and follow-up of the effect of interventions.
* To propose and help to implement organization changes of the work routines, so that hypertensive employees can continue employment
* To develop information and teaching with the shareholders to take care for workers with hypertension and diabetes.

#### Goals

* Highly sensitive blood pressure measurements to give precise prevalence rates of hypertension and pre-hypertension in the target groups.
* Systematisation and centralisation of the results of the mandatory medical examinations.
* Epidemiological based prevention trials

#### Study design

Cross-sectional clinical study using data collected in private health clinics and public health-clinics (supplemental ambulatories)

#### Time frame for data collection

Data are collected from xxx to xxxx. The data collection stops when xxx participants is included.

#### Inclusion criteria

* All transport workers, seafarers, and fishermen, coming to routine health examinations are included in a given time period.
* Participants are invited randomly irrespective of risk status, for example, not only those with visible higher risk status for example with obesity.
* Retrospective random samples of medical records for 1/2 year for all, with inclusion of all coming to medical examination without any selection due to risk status
* Those with normal pressure in the test are included as positive hypertension if they have answered "yes" having hypertension in the interview scheme.
* To get unbiased samples of prevalence data, then all seafarers/fishers/transport workers coming for routine medical examination must be included in the study irrespective of their (visible) risk (while daily practice is something else) The study example below shows that if only those at higher risk (obesity and overweight) are included, then pre- and hypertension prevalence results will be biased to higher prevalences like 20.0% and 33.4% in these IMC groups respectively.
Demographics Clinic name, age, gender, seafarer, fisherman, nationality.

#### Laboratory data

Together with the diabetes data. Blood pressure, height in cm and weight in kg

#### Diagnostics

The valid clinical monitoring of hypertension the target group is the basis for an effective, evidence-based intervention plan.
Classification and automatic coding is under development
https://www.excelforum.com/excel-general/776923-how-to-categorize-blood-pressure-readings-into-groups.html
| DIABETES TYPE 2 | | HbA1c | Fasting Glucose |
| | Value Measurement today: -> | | |
| | Mark Preliminary Diagnosis | | |
| Normal | | ≤ 5,6% | ≤ 100 mg/dl |
| Prediabetes | | 5.7-6.4% | 100 -125 mg/dl |
| Diabetes | | ≥ 6,5% | ≥126 mg/dl |
| Diabetes (=taking anti-DM) | | | |
| HYPERTENSION (HTN) | | Diastolic | Systolic |
| | Value Measurement today: -> | | |
| | Mark preliminary diagnosis | | |
| Normal | | 80 | 130 |
| Prehypertension | | 80-89 | 130-139 |
| Hypertension Stage 1 | | 90-99 | 140-159 |
| Hypertension Stage 2 | | 100+ | 160+ |
| HTN=anti-hypertensive med. | | | |
Inform seafarer whether (s)he is Non-diabetic, Pre-diabetec or Diabetic give advice and refer to specialist, if needed
Inform seafarer whether: non-hypertensive/pre-hypertensive/ hypertensive (see definitions), give advice and refer to hypertensive specialist if needed.
Use standardized reporting for research purposes, send data to designated international researcher contact (MAHRE-Net)

#### Prevention

Simple lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes. To help prevent hypertension and its complications, people should:
* Achieve and maintain healthy body weight
* Physically active – doing at least 30 minutes of regular, moderate-intensity activity on most days. More activity is required for weight control
* Eat a healthy diet, avoiding sugar and saturated fats; and
* Avoid tobacco use – smoking increases the risk of diabetes and cardiovascular disease

#### Intervention with the shareholders

Information and training is needed for the shareholders on how to take care to keep the workers with hypertension and diabetes in their job position. The shareholders in the respective job groups need to have knowledge to establish the needed specific conditions available for keeping good health practices for employees with T2DM and hypertension in the job. This in order to have good opportunities during the working day to have time and allowance for relevant work breaks, restroom visits, access to healthy meals in a good social company, and possibilities for adequate physical activities. These conditions are different for each job group and the analysis of these conditions and suggestions on how it can be made optimal is part of the project. Installations for the adequate structural change in the workplaces, time for meal breaks and restroom visits, cooks are hired to make healthy lunches, fitness room, and other relevant installations.

#### Ethics for protection of personal data

Confidentiality in the handling of personal data is in accordance with the rules of the national data protection agencies and the General Data Protection Regulation (GDPR) and is prepared with. No personally sensitive information is included in the data set given to the researchers, so approval from the Ethics Committee is not necessary. All questionnaires ask for informed consent as the first question.
TABLE 2. MAHRE-Net Hypertension draft research- and education plan
| Organisation­ | 2022 | 2023 | 2024 | 2025 | 2026 | 2027 | 2028 | 2029 | 2030 | 2031 |
| Create international HYPERTENSION maritime/transport workers research group | x | x | x | x | x | x | x | x | x | x |
| Int. Guide Maritime HYPERTENSION diagnostic, control, prevention (Appendix ) | x | x | x | | | | | | | |
| National/international Maritime/Transport HYPERTENSION prevalence Register | x | x | x | x | | | | | | |
| Joint ETF/ Euro-peche HYPERTENSION maritime health promotion guides | x | x | x | x | x | x | x | x | x | x |
| Epidemiological studies | | | | | | | | | | |
| Monitoring prevalence HYPERTENSION (repeated random sampling) | x | x | x | x | x | x | x | x | x | x |
| Monitoring HYPERTENSION complications and prevention guide | x | x | x | x | x | x | x | x | x | x |
| Loss of working years for seafarers with HYPERTENSION diagnose | x | x | x | | | | | | | |
| How to keep working at sea with HYPERTENSION | | | | | | | | | | |
| Guide to manage HYPERTENSION -workplace at sea ILO | x | x | x | x | | | | | | |
| Best clinical practices for maritime HYPERTENSION caretake | | | | | | | | | | |
| Guidelines for best choice HYPERTENSION diagnostics | x | x | | | | | | | | |
| Pilot test Ambulatory BP (Holter) | x | x | x | | | | | | | |
| Education: Best practices for care for HYPERTENSION seafarers onshore/onboard | x | x | x | x | | | | | | |
| Program for new diagnosed cases | | | | | | | | | | |
| Non-pharm maritime epidemiological intervention studies | | | | | | | | | | |
| Review of effects of interventions | x | x | x | x | x | x | x | x | x | x |
| Pilot intervention among seafarers with high risk | | x | x | x | | | | | | |
| Pharmacological maritime epidemiological Intervention studies | | | | | | | | | | |
| Review methods and effect pharmacological intervention | x | x | x | x | x | x | x | x | x | x |
| Review combined pharm and non-pharm prevention | x | x | x | x | | | | | | |
| Protocol for combined pharm and non-pharm prevention | | x | x | x | | | | | | |
References
* ↑ Tu, Mingshan, og Jorgen Riis Jepsen. “Hypertension among Danish Seafarers”. International Maritime Health 67, nr. 4 (2016): 196–204. https://doi.org/10.5603/IMH.2016.0037
* ↑ Bos MJ, Buis S. Thirty-Minute Office Blood Pressure Monitoring in Primary Care. Ann Fam Med. 2017 Mar;15(2):120–3.
* ↑ Carter BU, Kaylor MB. The use of ambulatory blood pressure monitoring to confirm a diagnosis of high blood pressure by primary-care physicians in Oregon. Blood Press Monit. 2016 Apr;21(2):95–102.
* ↑ Khosravi AR, Rowzati M, Gharipour M, Fesharaki MG, Shirani S, Shahrokhi S, et al. Hypertension control in industrial employees: findings from SHIMSCO study. ARYA Atheroscler. 2012;7(4):191–6.
* ↑ Lovibond K, Jowett S, Barton P, Caulfield M, Heneghan C, Hobbs FDR, et al. Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study. Lancet. 2011 Oct 1;378(9798):1219–30
* ↑ Guidelines for hypertension [Internet]. [cited 2021 Dec 31]. Available from: https://www.who.int/teams/noncommunicable-diseases/guidelines-for-hypertension
* ↑ "New Guidance on Blood Pressure Management in Low-Risk Adults with Stage 1 Hypertension". American College of Cardiology. Retrieved 2022-01-19.
* ↑ Pickering, Thomas G.; Hall, John E.; Appel, Lawrence J.; Falkner, Bonita E.; Graves, John; Hill, Martha N.; Jones, Daniel W.; Kurtz, Theodore et al. (2005-02-08). "Recommendations for Blood Pressure Measurement in Humans and Experimental Animals". Circulation 111 (5): 697–716. doi:10.1161/01.CIR.0000154900.76284.F6. https://www.ahajournals.org/doi/full/10.1161/01.cir.0000154900.76284.f6.
* ↑ "How to accurately measure blood pressure at home". www.heart.org. Retrieved 2022-01-19.
* ↑ Handler, Joel (2009). "The Importance of Accurate Blood Pressure Measurement". The Permanente Journal 13 (3): 51–54. ISSN 1552-5767. PMID 20740091. PMC 2911816. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911816/.
* ↑ Bloomfield DA, Park A. Decoding white coat hypertension. World J Clin Cases. 2017 Mar 16;5(3):82–92
* ↑ Ambulatory blood pressure