As refugees acculturate to the U.S., they may adopt diet and lifestyle behaviors that can contribute to the onset of chronic diseases, including hypertension. The new-arrival screening is an opportunity to discuss diet and exercise and emphasize the importance of regular preventive health visits. Similarly, for those refugees who are no longer new arrivals, it is appropriate to address behaviors that contribute to diabetes, such as diet, exercise, and physical activity. According to the CDC, refugees should be screened for cardiovascular and lipid disorders in accordance with the U.S. Preventive Services Task Force (USPSTF) guidelines [1].

One in three U.S. adults has hypertension, a disease that is associated with increased rates of heart failure, stroke, heart disease, kidney disease, and death [2]. Another 25% of U.S. adults have pre-hypertension, a risk factor for the development of hypertension. As more literature has been published on the trends of non-infectious health conditions among U.S. refugees, more and more refugees with hypertension are now being identified [3,4].

Screening
Blood pressure measurements should be obtained on all adult U.S. refugees at the time of the initial exam. In addition, adolescents who are at risk for hypertension should also be screened (i.e., those with obesity and family history of hypertension). Symptoms of hypertension may be present in individuals, but do not need to be present in order for the diagnosis of hypertension to be made. These symptoms may include headaches, blurry vision, nose bleeds, chest pain, shortness of breath, and facial flushing.

Diagnosis and Treatment
Blood pressure diagnosis and treatment is based on the Seventh Report on the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). [5] According to the JNC VII guidelines, diagnosis and treatment recommendations are as follows:

Category:	Systolic (mm Hg)	Diastolic (mm Hg)	Treatment
Normal	<120	and <80	Lifestyle
Prehypertension	120-139	or 80-89	Lifestyle
Stage 1	140-159	or 90-99	One drug
Stage 2	≥160	or ≥100	Two drugs

Numerous categories of antihypertensive medications are available, but there are challenges to achieving goal blood pressures in hypertensive patients. Less than half of the U.S. adult population with hypertension is at goal blood pressure. In the context of these challenges, screening and treatment of hypertension remain important. Physicians caring for the U.S. refugee population should adequately screen for hypertension and initiate treatment strategies based on the JNC VII guidelines.

Contributed by Marc Altshuler, M.D. and Kevin Scott, M.D.

References
1. Centers for Disease Control and Prevention. General Refugee Health Guidelines.
2. Centers for Disease Control and Prevention. High Blood Pressure Facts.
3. Geltman PL, Dookeran NM, Battaglia T, & Cochran J (2010). Chronic disease and its risk factors among refugees and asylees in Massachusetts, 2001-2005. Prev Chronic Dis, 7(3), A51.
4. Health of resettled Iraqi refugees – San Diego County, California, October 2007-September 2009. (2010). MMWR Morb Mortal Wkly Rep, 59(49), 1614-1618.
5. National Heart Lung and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 2003.