Effects of Labeling Patients as Prehypertensive

Setting and Recruitment

This study took place in a stand-alone family medicine center affiliated with a public university. The center provides comprehensive primary care to a wide variety of patients. More than 200 patients are seen daily (43,254 visits in 2005 to 2006); 65% are women. Approximately 29% are African American and 2% are Hispanic. Twelve percent receive Medicaid and 23% receive Medicare. Benign essential hypertension is the most frequently coded diagnosis during patient visits.

Patients were recruited via signs announcing a “Preventing High Blood Pressure Study.” Signs were posted in examination rooms and at vital sign stations. Patients were eligible if they (1) were at least 24 years of age, (2) had recently had a BP measurement at the center that was 120 to 139 mm Hg systolic or between 80 to 89 mm Hg diastolic with neither ≥140/90 mm Hg, (3) spoke and read English, and (4) were able to be contacted by telephone. Exclusion criteria were (1) diagnosis of hypertension or use of antihypertensive medications, (2) diagnosis of diabetes or chronic kidney disease, or (3) pregnancy.

Interested patients contacted the study coordinator (KL), who confirmed preliminary eligibility and scheduled the patient for a study visit. During this visit informed consent was obtained and the previous visit's recorded BP was confirmed, via electronic record review, to be in the prehypertension range. Patients whose most recent BP was not in the prehypertensive range were ineligible to continue. After a 10- to 15-minute period of sitting, the BP of the participant was obtained using a validated oscillometric office BP monitor (Vital Signs, Welch Allyn, Inc., Skaneateles, NY) using recommended positioning and a cuff appropriate for upper-arm circumference. Thirty to 60 seconds later the measurement was repeated on the same arm (this is a technique that has been shown to avoid venous congestion while minimizing variability).¹³ The 2 measurements were averaged to yield a single BP reading for the visit. Participants whose mean BP from these measurements was not in the prehypertensive range were ineligible to continue. This study was approved by the Office of Human Subjects Research of the University of North Carolina at Chapel Hill.

Baseline Data and Randomization

Participants who were confirmed to have prehypertension based on 2 readings^10,12 (the previous office visit and the initial study visit) completed a baseline self-administered questionnaire containing demographic items, medical history questions (including history of known prehypertension), and a standard self-reported health question from the 36-item Short Form (SF-36) questionnaire.¹⁴ We chose to include the SF-36 self-reported health question because of its simplicity and the fact that it is widely known and valid across a wide variety of populations. The questionnaire's overall Flesch Kincaid reading level was grade 4.4. Participants were then randomized in permuted blocks (sizes 4, 4, and 6) to a “label” or “no label” group. To conceal allocation, we used sequentially numbered, opaque, sealed envelopes of equal size and weight, lined on the inside with aluminum foil.

Intervention

Those in the “label” group received a standardized message delivered by a trained research assistant. The scripted message (Appendix 1) was adapted from materials on the National Heart, Lung, and Blood Institute website¹⁵ designed to teach people about lifestyle modifications to lower high BP. The participant was told that he/she had prehypertension; that was followed by a description of various lifestyle recommendations. Within the message the term “prehypertension” was mentioned several times. Those in the “no label” group received a very similar standardized message (Appendix 2) about lifestyle modifications without any mention of prehypertension. Printed summaries of the messages were provided to participants in both groups. Participants were given a $20 cash incentive for completing the baseline visit.

Follow-up Assessments

Three months after the baseline visit, participants were sent a brief written questionnaire (reading level, grade 5.7) with a pre-addressed, stamped return envelope and a $5 cash incentive. One question asked, Compared with 3 months ago, how would you rate your health in general now? Response choices were: “much better now than 3 months ago,” “somewhat better now than 3 months ago,” “about the same as 3 months ago,” “somewhat worse than 3 months ago,” or “much worse now than 3 months ago.” We also again included the self-reported health status question from the SF-36, as well as questions from module 5 of the 2005 Behavior Risk factor Surveillance System, which was adapted to reflect actions being taken to “prevent” high BP rather than actions being taken to “lower or control” high BP.¹⁶ Participants whose follow-up questionnaires were not received within 2 weeks were contacted by phone and offered the opportunity to provide answers at that time.

Sample Size Calculation

Our aim was to have at least 30 patients in each group complete the 3-month follow-up questionnaire. We derived this sample size using the following question as the primary outcome: Compared with 3 months ago, how would you rate your health in general now? We believed that there would be a large proportion of respondents who would report no change in health status during the 3-month follow-up period (70% to 90%) and we hypothesized that there would be a larger proportion of respondents in the label group who reported worse health compared with those in the no label group. Using the sample size methods proposed by Zhao et al¹⁷ for the Wilcoxon-Mann-Whitney test adjusting for ties, we developed 3 scenarios in which we would achieve 80% power for α = 0.05 and approximately 30 patients per group (Appendix 3). In the first scenario, 10% of the label group had “much worse” health compared with 0% of the no label group. We calculated power to be approximately the same for the scenarios even if the data were collapsed into a 3-point Likert scale (worse, the same, better). For example, in the second scenario, 25% of the label group would report “much worse” or “somewhat worse” compared with 5% of the no label group. In the third scenario, 20% of the label group would report worse health compared with 0% in the no label group.

Analysis

Baseline characteristics of the groups were compared using the χ² test of association (or Fisher's exact test, when appropriate) or t test. For our primary outcome of health status at 3 months compared with baseline, ordinal responses of “much better now than 3 months ago” and “somewhat better now than 3 months ago” were combined as an outcome of “better.” Similarly, responses of “somewhat worse than 3 months ago” and “much worse now than 3 months ago” were combined as an outcome of “worse.” We compared the distribution of the outcome for the label and no label groups using the Wilcoxon-Mann-Whitney test.^{18, 19} We also examined for a shift in the median of the distribution in overall self-reported health status at 3-month follow-up using the Wilcoxon-Mann-Whitney test. Finally, we estimated the proportions of respondents taking each action to prevent high BP in the label and no label groups and reported difference in these proportions using risk ratios with 95% CIs. Participants were analyzed in the group to which they were randomized.

Study Participants

During the 2 years of this project, 142 people contacted the study coordinator and expressed interest in participating; 100 of these 142 were randomized to either the label group or no label group (Figure 1). Three people indicated at baseline that they previously had been told by a health care professional that they had “prehypertension” and were therefore excluded from analysis. Except for a higher proportion of asthma in the label group, the 2 groups were similar in terms of demographics and medical history (Table 1). The mean (±SD) age of participants was 41 (±11) years (range, 24–67 years). Our 3-month follow-up response rate was 72% (70 of 97). Differential loss to follow-up was 8%, and nonrespondents were more likely to have less education, be of a race/ethnicity other than white, and be smokers (Table 2).

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Figure 1.

Participant flow-through study. BP, blood pressure.

Effects on Perceived Health

At 3 months there was no significant difference between the 2 groups in change of self-reported health compared with baseline or in overall self-reported health status (Table 3). Among the label group, 58% indicated that their health at 3 months was the same; among the no label group, 56% indicated that their health status at 3 months was the same. Approximately 43% of respondents indicated that their health was either “much better” or “somewhat better” than at baseline, but the difference between the 3 groups was not significant. Only one respondent (in the no label group) indicated that his/her health was worse. There was no significant difference in the median overall self-reported health between the 2 groups.

Effects on Lifestyle Modifications

At 3 months there were no significant differences in the proportions of respondents who reported adopting recommended lifestyle modifications to prevent high BP (Table 4). The proportions of people who reported adopting the lifestyle modifications at 3 months were high (66% for reducing alcohol, 84% for changing eating habits, 79% for exercising, and 90% for cutting down on salt), but there were no significant differences between the 2 groups. Risk ratios ranged from 0.99 to 1.23, and 95% CI limits ranged from 0.80 to 1.90.

Considerations

In actual clinical practice, a health care provider rather than a research assistant would inform a patient about prehypertension and discuss the lifestyle recommendations. We chose to use a trained research assistant to deliver the messages so that they could be standardized. Our aim in developing what we considered to be the “labeling” message was to try to present a balance of information that might actually occur in the clinical setting when a health care provider informs a patient that he or she has prehypertension. That is, after the diagnosis of prehypertension is discussed, its meaning for the patient and the management options would also be discussed. We assumed that such labeling could have positive effects, negative effects, both, or neither. Although a physician might tailor the message he or she presents to a specific patient, and a relationship between a patient and his/her personal physician might contribute to the effects of labeling (either positively or negatively), in our experimental design we tried to isolate as much as possible the actual effect of the label itself compared with a more general preventive message.

Our method of recruiting participants probably attracted people who are generally more interested in their health and in health promotion. However, most people who would be counseled about prehypertension would probably be told at a wellness or health maintenance visit when there is time to explain it and the lifestyle recommendations designed to prevent or delay hypertension. People who make health maintenance visits are generally more interested in their health and in preventive care than those who do not make such visits.²⁶ Therefore, we feel that the study population was representative of those who would be told about prehypertension in true patient care situations. Further, the goal of informing patients about prehypertension is to delay or prevent hypertension, which is what the recruitment title of the study reflected.

The potential for measurement bias must be considered and could arise for 3 main reasons. First, the questions we used to assess potential negative effects on perceived health may not have been sensitive enough, or 3 months may be too long a time to wait to detect negative perceptions. However, the necessity of either a more sensitive instrument or a more immediate assessment to detect potential psychological effects probably means that such effects are small or transient. Second, we recognize the self-reporting bias inherent in our outcome measure. However, this bias should be the same in both groups. Finally, a nonresponse bias may exist if those who are not white, those who had less education, or smokers would report changes in perceived health status or measures being taken to prevent hypertension differently than respondents.

Message “L”

The research assistant introduces him/her self and explains that he/she has been trained by the physician to deliver the following health messages.

Blood pressure is the force of blood against the walls of arteries. Your blood pressure rises and falls during the day. When blood pressure stays elevated over time, it is called “high blood pressure.” The medical term for high blood pressure is “hypertension.” High blood pressure is dangerous because it makes the heart work too hard and contributes to atherosclerosis, also known as “hardening of the arteries.” It increases the risk of heart disease and stroke, which are the first- and third-leading causes of death among Americans. High blood pressure also can result in other conditions, such as congestive heart failure, kidney disease, and blindness.

A blood pressure level of 140/90 mm Hg or higher is considered high. People with blood pressure in this range have hypertension. A normal blood pressure is considered <120/80 mm Hg. Based on your blood pressure readings, you have what doctors call “prehypertension.” This means that you don’t have high blood pressure now but are likely to develop it in the future.

You can take steps to treat your prehypertension and prevent high blood pressure by adopting a healthy lifestyle. These steps include maintaining a healthy weight; being physically active; following a healthy eating plan that emphasizes fruits, vegetables, and low-fat dairy foods; choosing and preparing foods with less salt and sodium; and, if you drink alcoholic beverages, drinking in moderation. I am going to talk a little bit more about each of these.

Following a healthy eating plan can reduce your risk of developing high blood pressure from your prehypertension. For an overall eating plan, you should consider the DASH eating plan. DASH stands for Dietary Approaches to Stop Hypertension, a clinical study that tested the effects of nutrients in food on blood pressure. Study results indicated that blood pressures were reduced by an eating plan that emphasizes fruits, vegetables, and low-fat dairy foods and is low in saturated fat, total fat, and cholesterol. The DASH eating plan includes whole grains, poultry, fish, and nuts and has lower amounts of fats, red meats, sweets, and sugared beverages.

A second clinical study, called “DASH-Sodium,” looked at the effect of a reduced dietary sodium intake on blood pressure as people followed either the DASH eating plan or a typical American diet. Sodium is what is found in common “table salt” and in many processed and canned foods. Results showed that reducing dietary sodium lowered blood pressure among people on both the DASH eating plan and the typical American diet. The biggest blood pressure–lowering benefits were for those eating the DASH eating plan at the lowest sodium level. In that study, those individuals had less than 1,500 mg of sodium per day. A key to healthy eating is choosing foods lower in salt and sodium. Most Americans consume more salt than they need. The current recommendation is to consume less than 2.4 grams (2,400 milligrams) of sodium a day. That equals 6 grams (about 1 teaspoon) of table salt a day. The 6 grams include all salt and sodium consumed, including that used in cooking and at the table.

Fats—especially saturated fat—affect the health of your heart and blood vessels. There are various types of fat. Saturated fat is often found in foods from animals. This includes fatty meats, the skin of poultry, and whole-milk dairy products, such as butter, cheese, cream, and ice cream. It also is in coconut, palm kernel, and palm oils. These oils are found mostly in processed foods, such as baked goods, snack foods, and crackers. If you use saturated fat, keep the amount small. Instead of saturated fat, try soft or liquid margarine and such oils as canola, safflower, and olive. However, all kinds of fats have the same amount of calories and need to be limited to help you lose weight.

At this point the research assistant goes over the following information, adapted from the National Heart, Lung, and Blood Institute website.¹⁵ These could be formatted into handouts to be provided to patients.

Getting Started with DASH

It's easy to adopt the DASH eating plan. Here are some ways to get started:

Change gradually.

• If you now eat one or two vegetables a day, add a serving at lunch and another at dinner.

• If you don’t eat fruit now or have only juice at breakfast, add a serving to your meals or have it as a snack.

• Use only half the butter, margarine, or salad dressing you do now.

• Try low-fat or fat-free condiments, such as fat-free salad dressings.

• Gradually increase dairy products to 3 servings per day. For example, drink milk with lunch or dinner instead of soda, alcohol, or sugar-sweetened tea. Choose low-fat (1%) or fat-free (skim) dairy products to reduce total fat intake.

Treat meat as one part of the whole meal, instead of the focus.

• Buy less meat. If it's not there, you won’t eat it.

• Limit meat to 6 oz a day (2 servings)—all that's needed. Three to 4 oz is about the size of a deck of cards.

• If you now eat large portions of meat, cut them back gradually, by a half or a third at each meal.

• Include 2 or more vegetarian-style (meatless) meals each week.

• Increase servings of vegetables, rice, pasta, and dry beans in meals. Try casseroles, pasta, and stir-fry dishes, which have less meat and more vegetables, grains, and dry beans.

Use fruits or low-fat foods as desserts and snacks.

• Fruits and low-fat foods offer great taste and variety. Use fruits canned in their own juice. Fresh fruits require little or no preparation. Dried fruits are easy to carry with you.

• Try these snack ideas: unsalted pretzels or nuts mixed with raisins; graham crackers; low-fat and fat-free yogurt and frozen yogurt; plain popcorn with no salt or butter added; and raw vegetables.

Tips for Reducing Sodium in Your Diet

• Buy fresh, plain frozen, or canned “with no salt added” vegetables.

• Use fresh poultry, fish, and lean meat rather than canned or processed types.

• Use herbs, spices, and salt-free seasoning blends in cooking and at the table.

• Cook rice, pasta, and hot cereals without salt. Cut back on instant or flavored rice, pasta, and cereal mixes, which usually have added salt.

• Choose “convenience” foods that are lower in sodium. Cut back on frozen dinners, pizza, packaged mixes, canned soups or broths, and salad dressings—these often contain a lot of sodium.

• Rinse canned foods, such as tune, to remove some sodium.

• When available, buy low- or reduced-sodium or no-salt-added versions of foods.

• Choose ready-to-eat breakfast cereals that are lower in sodium.

Continuing the Discussion

Let's continue our discussion of things you can do to treat your prehypertension and try to prevent high blood pressure.

Being overweight increases your risk of developing high blood pressure. In fact, blood pressure rises as body weight increases. Losing even 10 pounds can lower blood pressure.

Being physically active is one of the most important steps you can do to help control prehypertension. Exercise also helps reduce your risk of heart disease. It doesn’t take a lot of effort to become physically active. You can get started by doing 30 minutes of a moderate-level activity on most—and preferably all—days of the week. Brisk walking, bicycling, and gardening are examples. You can even divide the 30 minutes into shorter periods of at least 10 minutes each.

If you already engage in 30 minutes of moderate-level physical activity a day, you can get added benefits by doing more. Engage a moderate-level activity for a longer period each day or engage in a more vigorous activity.

I just have a couple more things to tell you about.

Drinking too much alcohol can raise blood pressure. It also can harm the liver, brain, and heart. Alcoholic drinks also contain calories, which matter if you are trying to lose weight. If you drink alcoholic beverages, have only a moderate amount—one drink a day for women; 2 drinks a day for men. You may be wondering: What counts as a drink?

• 12 oz of beer (regular or light, 150 calories), or

• 5 oz of wine (100 calories), or

• 1½ oz of 80-proof whiskey (100 calories).

One last thing. We know that smoking injures blood vessel walls and speeds up the process of hardening of the arteries. This even applies to filtered cigarettes. So even though it does not cause high blood pressure, smoking is bad for anyone, especially those who have high blood pressure. So, if you smoke, quit. Once you quit, your risk of having a heart attack is reduced after the first year. If you don’t smoke, don’t start.

So, in summary, you have prehypertension, but there are things you can do to try to prevent the development of hypertension. You should adopt the DASH eating plan, increase your physical activity, cut down on the sodium in your diet, and lose weight, especially if you are overweight now. Finally, if you drink more alcohol than what we talked about, you should cut down, and if you smoke, you should quit.

Do you have any questions I can try to answer for you at this time? Thank you again for participating in our study. Be on the lookout for a questionnaire to be arriving in your mailbox in about 3 months, and be sure to fill it out and mail it back to us!

Message “N”

A research assistant introduces him/her self and explains that he/she has been trained by physician to deliver the following health messages.

Blood pressure is the force of blood against the walls of arteries. Your blood pressure rises and falls during the day. When blood pressure stays elevated over time, it is called “high blood pressure.” The medical term for high blood pressure is “hypertension.” High blood pressure is dangerous because it makes the heart work too hard and contributes to atherosclerosis, also known as “hardening of the arteries.” It increases the risk of heart disease and stroke, which are the first- and third-leading causes of death among Americans. High blood pressure also can result in other conditions, such as congestive heart failure, kidney disease, and blindness.

A blood pressure level of 140/90 mm Hg or higher is considered high. People with blood pressure in this range have hypertension. Hypertension is a very common risk factor for heart disease and stroke. Many people develop hypertension and are prescribed medications to reduce their risk of heart disease and stroke.

You can take steps now to try to prevent high blood pressure by adopting a healthy lifestyle. These steps include maintaining a healthy weight; being physically active; following a healthy eating plan that emphasizes fruits, vegetables, and low-fat dairy foods; choosing and preparing foods with less salt and sodium; and, if you drink alcoholic beverages, drinking in moderation. I am going to talk a little bit more about each of these.

Following a healthy eating plan can reduce your risk of developing high blood pressure. For an overall eating plan, you should consider the DASH eating plan. DASH stands for Dietary Approaches to Stop Hypertension, a clinical study that tested the effects of nutrients in food on blood pressure. Study results indicated that blood pressure was reduced by following an eating plan that emphasizes fruits, vegetables, and low-fat dairy foods and is low in saturated fat, total fat, and cholesterol. The DASH eating plan includes whole grains, poultry, fish, and nuts and has lower amounts of fats, red meats, sweets, and sugared beverages.

A second clinical study, called DASH-Sodium, looked at the effect of a reduced dietary sodium intake on blood pressure as people followed either the DASH eating plan or a typical American diet. Sodium is what is found in common “table salt” and in many processed and canned foods. Results showed that reducing dietary sodium lowered blood pressure for both the DASH eating plan and the typical American diet. The biggest blood pressure–lowering benefits were for those who followed the DASH eating plan at the lowest sodium level. In that study, those individuals had less than 1,500 mg of sodium per day. A key to healthy eating is choosing foods that are lower in salt and sodium. Most Americans consume more salt than they need. The current recommendation is to consume less than 2.4 grams (2,400 milligrams) of sodium a day. That equals 6 grams (about 1 teaspoon) of table salt a day. The 6 grams include all salt and sodium consumed, including that used in cooking and at the table.

Fats—especially saturated fat—affect the health of your heart and blood vessels. There are various types of fat. Saturated fat is often found in foods from animals. This includes fatty meats, the skin of poultry, and whole-milk dairy products such as butter, cheese, cream, and ice cream. It also is in coconut, palm kernel, and palm oils. These oils are found mostly in processed foods, such as baked goods, snack foods, and crackers. If you use saturated fat, keep the amount small. Instead of saturated fat, try soft or liquid margarine and such oils as canola, safflower, and olive. However, all kinds of fats have the same amount of calories and need to be limited to help you lose weight.

At this point the research assistant goes over the following information, adapted from the National Heart, Lung, and Blood Institute website.¹⁵ These could be formatted into handouts to be provided to patients.

Getting Started with DASH

It's easy to adopt the DASH eating plan. Here are some ways to get started:

Change gradually.

• If you now eat one or two vegetables a day, add a serving at lunch and another at dinner.

• If you don’t eat fruit now or have only juice at breakfast, add a serving to your meals or have it as a snack.

• Use only half the butter, margarine, or salad dressing you do now.

• Try low-fat or fat-free condiments, such as fat-free salad dressings.

• Gradually increase dairy products to 3 servings per day. For example, drink milk with lunch or dinner instead of soda, alcohol, or sugar-sweetened tea. Choose low-fat (1%) or fat-free (skim) dairy products to reduce total fat intake.

Treat meat as one part of the whole meal, instead of the focus.

• Buy less meat. If it's not there, you won’t eat it.

• Limit meat to 6 oz a day (2 servings)—all that's needed. Three to 4 oz is about the size of a deck of cards.

• If you now eat large portions of meat, cut them back gradually, by a half or a third at each meal.

• Include 2 or more vegetarian-style (meatless) meals each week.

• Increase servings of vegetables, rice, pasta, and dry beans in meals. Try casseroles, pasta, and stir-fry dishes, which have less meat and more vegetables, grains, and dry beans.

Use fruits or low-fat foods as desserts and snacks.

• Fruits and low-fat foods offer great taste and variety. Use fruits canned in their own juice. Fresh fruits require little or no preparation. Dried fruits are easy to carry with you.

• Try these snack ideas: unsalted pretzels or nuts mixed with raisins; graham crackers; low-fat and fat-free yogurt and frozen yogurt; plain popcorn with no salt or butter added; and raw vegetables.

Tips for Reducing Sodium in Your Diet

• Buy fresh, plain frozen, or canned “with no salt added” vegetables.

• Use fresh poultry, fish, and lean meat rather than canned or processed types.

• Use herbs, spices, and salt-free seasoning blends in cooking and at the table.

• Cook rice, pasta, and hot cereals without salt. Cut back on instant or flavored rice, pasta, and cereal mixes, which usually have added salt.

• Choose “convenience” foods that are lower in sodium. Cut back on frozen dinners, pizza, packaged mixes, canned soups or broths, and salad dressings—these often contain a lot of sodium.

• Rinse canned foods, such as tune, to remove some sodium.

• When available, buy low- or reduced-sodium or no-salt-added versions of foods.

• Choose ready-to-eat breakfast cereals that are lower in sodium.

Continuing the Discussion

Let's continue our discussion of things you can do try to prevent high blood pressure.

Being overweight increases your risk of developing high blood pressure. In fact, blood pressure rises as body weight increases. Losing even 10 pounds can lower blood pressure.

Being physically active is one of the most important steps you can do to try to prevent hypertension. Exercise also helps reduce your risk of heart disease. It doesn’t take a lot of effort to become physically active. You can get started by doing 30 minutes of a moderate-level activity on most—and preferably all—days of the week. Brisk walking, bicycling, and gardening are examples. You can even divide the 30 minutes into shorter periods of at least 10 minutes each.

If you already engage in 30 minutes of moderate-level physical activity a day, you can get added benefits by doing more. Engage a moderate-level activity for a longer period each day or engage in a more vigorous activity.

I just have a couple more things to tell you about.

Drinking too much alcohol can raise blood pressure. It also can harm the liver, brain, and heart. Alcoholic drinks also contain calories, which matter if you are trying to lose weight. If you drink alcoholic beverages, have only a moderate amount—one drink a day for women; 2 drinks a day for men. You may be wondering: What counts as a drink?

• 12 oz of beer (regular or light, 150 calories), or

• 5 oz of wine (100 calories), or

• 1½ oz of 80-proof whiskey (100 calories).

One last thing. We know that smoking injures blood vessel walls and speeds up the process of hardening of the arteries. This even applies to filtered cigarettes. So even though it does not cause high blood pressure, smoking is bad for anyone, especially those who have high blood pressure. So, if you smoke, quit. Once you quit, your risk of having a heart attack is reduced after the first year. If you don’t smoke, don’t start.

So, in summary, there are things you can do to try to prevent the development of hypertension. You should adopt the DASH eating plan, increase your physical activity, cut down on the sodium in your diet, and lose weight, especially if you are overweight now. Finally, if you drink more alcohol than what we talked about, you should cut down, and if you smoke, you should quit.

Do you have any questions I can try to answer for you at this time? Thank you again for participating in our study. Be on the lookout for a questionnaire to be arriving in your mailbox in about 3 months, and be sure to fill it out and mail it back to us!