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Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
×

A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension

Committee on Public Health Priorities to Reduce and Control Hypertension in the U.S. Population

Board on Population Health and Public Health Practice

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
×

THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W.
Washington, DC 20001

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract No. 200-2005-13434, TO 18 between the National Academy of Sciences and the Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

Library of Congress Cataloging-in-Publication Data

Institute of Medicine (U.S.). Committee on Public Health Priorities to Reduce and Control Hypertension in the U.S. Population.

A population-based policy and systems change approach to prevent and control hypertension / Committee on Public Health Priorities to Reduce and Control Hypertension in the U.S. Population, Board on Population Health and Public Health Practice.

p. ; cm.

Includes bibliographical references.

ISBN 978-0-309-14809-2 (pbk.) — ISBN 978-0-309-14810-8 (pdf) 1. Hypertension—Prevention—Government policy—United States. 2. Centers for Disease Control and Prevention (U.S.) Division for Heart Disease and Stroke Prevention. I. Title.

[DNLM: 1. Centers for Disease Control and Prevention (U.S.) Division for Heart Disease and Stroke Prevention. 2. Hypertension—prevention & control—United States. 3. Community Health Planning—United States. 4. Health Policy—United States. 5. United States Government Agencies—United States. WG 340 N279907p 2010]

RA645.H9N38 2010

362.196’132—dc22

2010014536

Additional copies of this report are available from

The National Academies Press,

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The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

Suggested citation: IOM (Institute of Medicine). 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
×

“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES


Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine


The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.


The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.


The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.


The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.


www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
×

COMMITTEE ON PUBLIC HEALTH PRIORITIES TO REDUCE AND CONTROL HYPERTENSION IN THE U.S. POPULATION

DAVID W. FLEMING (Chair, March 2009-February 2010), Director and Health Officer,

Public Health-Seattle & King County, Seattle, WA

HOWARD KOH (Chair, January-March 2009), Professor of the Practice of Public Health,

Department of Health Policy and Management, Harvard School of Public Health, Boston, MA

ANA V. DIEZ ROUX, Professor of Epidemiology and Director,

Center for Integrative Approaches to Health Disparities, and

Associate Director,

Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, Ann Arbor, MI

JIANG HE, Joseph S. Copes Chair and Professor,

Department of Epidemiology, Tulane University, New Orleans, LA

KATHY HEBERT, Associate Professor of Medicine,

Division of Cardiology and

Director,

Disease Management and Outcomes Research, Miller School of Medicine, University of Miami, Miami, FL

CORINNE HUSTEN, Executive Vice President for Program and Policy,

Partnership for Prevention (January-October 2009) and

Senior Medical Advisor,

Center for Tobacco Products, Food and Drug Administration (October 2009-February 2010), Washington DC

SHERMAN A. JAMES, Susan B. King Professor of Public Policy Studies, Professor of Family and Community Medicine,

Sociology and African and African-American Studies, Duke University, Durham, NC

THOMAS G. PICKERING (deceased), Director of the Behavior Cardiovascular Health and Hypertension Program,

Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY

GEOFFRY ROSENTHAL,

Department of Pediatrics, Cardiology Division, University of Maryland Medical Center, Baltimore, MD

WALTER C. WILLETT, Fredrick John Stare Professor of Epidemiology and Nutrition, Chair,

Department of Nutrition, Harvard School of Public Health, Boston, MA

IOM Staff

ROSE MARIE MARTINEZ, Director,

Board on Population Health and Public Health Practice

RITA DENG, Associate Program Officer

NORA HENNESSY, Associate Program Officer

RAINA SHARMA, Senior Program Assistant

FLORENCE POILLON, Senior Editor

Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
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Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
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Reviewers

This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following for their review of the report:

Lawrence J. Appel, Johns Hopkins Bloomberg School of Public Health

Valentin Fuster, Mount Sinai School of Medicine

Maxine Hayes, State of Washington, Department of Health

Christine Johnson, New York City Department of Health and Mental Hygiene

Michael Klag, Johns Hopkins Bloomberg School of Public Health

M.A. “Tonette” Krousel-Wood, Tulane University

Claude Lenfant, National Heart, Lung, and Blood Institute

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by Kristine M. Gebbie,

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
×

City University of New York. Appointed by the National Research Council and the Institute of Medicine, she was responsible for making certain that an independent examination of the report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests with the author committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
×

Acknowledgements

The committee acknowledges the valuable contributions made by the many persons who shared their experience and knowledge with the committee. First the committee wishes to thank Howard Koh, who chaired the committee before assuming responsibility as Assistant Secretary for Health. The committee appreciates the time and insight of the presenters during the public sessions: Kathryn Gallagher, Yuling Hong, Darwin Labarthe, and Michael Schooley, Centers for Disease Control and Prevention; Aram Chobanian, Boston University; Eduardo Ortiz, National Heart, Lung, and Blood Institute; Ed Rocella, retired National Heart, Lung, and Blood Institute; Sonia Angell, New York City Department of Health and Mental Hygiene; Susan Cooper, Tennessee Department of Health; Barry Davis, University of Texas School of Public Health; Richard Cooper, Loyola University; Russell Luepker, University of Minnesota; Stephen Lim, University of Washington; David Goff, Wake Forest University; and Frank Sacks, Harvard University. The committee also thanks John Forman, Brigham and Women’s Hospital, for the background paper on modifiable risk factors and population attributable fractions that informed the committee’s deliberations.

This report would not have been possible without the diligent assistance of technical monitors Diane Dunet and Rashon Lane, and statistician Cathleen Gillespie, Centers for Disease Control and Prevention. The committee thanks the staff members of the Institute of Medicine, the National Research Council, and the National Academies Press who contributed to the development, production, and dissemination of this report. The com-

Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
×

mittee thanks Rose Marie Martinez, study director, Rita Deng, associate program officer, and Nora Hennessy, associate program officer, for their work in navigating this complex topic with the committee, Raina Sharma for her diligent management of the committee logistics, and Hope Hare for her attention to report production.

This report was made possible by the support of the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention.

Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
×
Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
×

3

 

THE ROLE OF THE DIVISION FOR HEART DISEASE AND STROKE PREVENTION IN THE PREVENTION AND CONTROL OF HYPERTENSION

 

75

   

 Programmatic Funding,

 

76

   

 National Heart Disease and Stroke Prevention Program,

 

76

   

 Wisewoman (Well-Integrated Screening and Evaluation for Women Across the Nation),

 

79

   

 The Paul Coverdell National Acute Stroke Registry,

 

80

   

 State Cardiovascular Health Examination Survey,

 

81

   

 Activities to Reduce Sodium Intake,

 

81

   

 Other Programmatic Activities,

 

82

   

 Division for Heart Disease and Stroke Prevention Strategic Plan,

 

87

   

 DHDSP Collaboration with Other CDC Units,

 

87

   

 References,

 

90

4

 

INTERVENTIONS DIRECTED AT THE GENERAL POPULATION

 

91

   

 Methodology,

 

92

   

 Promote Weight Loss Among Overweight Persons,

 

93

   

 Decrease Sodium Intake,

 

95

   

 Increase Potassium and Intake of Fruits and Vegetables,

 

99

   

 Consume a Healthy Diet,

 

102

   

 Reduce Excessive Alcohol Intake,

 

105

   

 Increase Physical Activity,

 

107

   

 Multiple Dietary Interventions,

 

108

   

 Other Potential Interventions,

 

110

   

 Community and Environmental Interventions,

 

112

   

 Relative Costs of Population-Based Interventions,

 

117

   

 Population-Based Interventions and Health Disparities,

 

119

   

 Conclusions,

 

122

   

 References,

 

126

5

 

INTERVENTIONS DIRECTED AT INDIVIDUALS WITH HYPERTENSION

 

135

   

 Access to Care and Control of Hypertension,

 

135

   

 Employer Initiatives to Address Hypertension,

 

159

   

 Community Health Workers and Hypertension,

 

161

   

 Conclusions,

 

163

   

 References,

 

167

Page xiii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
×

TABLES AND FIGURES

Tables

S-1

 

Healthy People 2010 Focus Area 12: Heart and Stroke, Blood Pressure Objectives,

 

3

S-2

 

Priority Recommendations,

 

18

1-1

 

Healthy People 2010 Focus Area 12: Heart and Stroke, Blood Pressure Objectives,

 

37

1-2

 

Criteria Considered for Selecting Priority Areas for the Prevention and Control of Hypertension,

 

43

2-1

 

Age-Specific Prevalence (Standard Error) of Hypertension in the U.S. Adult Population: NHANES 1999-2004,

 

51

2-2

 

Prevalence (Standard Error) of Elevated Blood Pressure Among Children and Adolescents Ages 8 Through 17 Years: NHANES 2003-2006,

 

53

2-3

 

Hypertension Awareness, Treatment, and Control in the U.S. Adult Hypertensive Population: NHANES 1988-1994 and NHANES 1999-2004,

 

62

2-4

 

Median and Mean Systolic and Diastolic Blood Pressure and Prevalence of Hypertension for Adults and Children Based on First Blood Pressure Measurement—NHANES Data,

 

65

Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
×

2-5

 

Prevalence of Hypertension (averaged measures), Overweight, Obesity, and Average Intake of Dietary Sodium per 1,000 Adults 1960-2006,

 

69

3-1

 

DHDSP Administrative and Program Budgets (FY 2008),

 

76

3-2

 

CDC Units or Programs, Funding and Program Description,

 

88

4-1

 

Risk Factor: Overweight and Obesity,

 

94

4-2

 

Risk Factor: High Salt Intake,

 

96

4-3

 

Risk Factor: Low Potassium Intake,

 

100

4-4

 

Risk Factor: Western-Style (Unhealthy Diet),

 

104

4-5

 

Risk Factor: Heavy Alcohol Intake,

 

106

4-6

 

Risk Factors: Physical Inactivity,

 

109

4-7

 

Risk Factors: Multiple Interventions,

 

111

4-8

 

Modifiable Risk Factors and Attributable Fractions Based on Interventional Studies,

 

111

5-1

 

Proportion of Cases of Uncontrolled Hypertension in Each Population Subgroup Attributable to Identified Risk Factors,

 

140

5-2

 

HEDIS® and Physician Consortium for Performance Improvement Hypertension Measures,

 

150

6-1

 

Priority Recommendations,

 

186

Figures

1-1

 

Increased risk of death from heart disease associated with blood pressure by decade of life,

 

35

1-2

 

Increased risk of death from stroke associated with blood pressure by decade of life,

 

35

1-3

 

Schematic framework of factors affecting blood pressure,

 

41

2-1

 

Age-specific prevalance of hypertension in U.S. adults ages 60 and older for men and women, NHANES: 1988-1994 and NHANES 1999-2004,

 

56

2-2

 

Prevalence of elevated blood pressure among children and adolescents ages 8 through 17 years: United States, NHANES: 1988-1994, 1999-2002, and 2003-2006,

 

57

2-3

 

Residual lifetime risk of hypertension in women and men aged 65 years,

 

60

2-4

 

Age- and sex-adjusted mean systolic blood pressure (upper panel) and diastolic blood pressure (lower panel) by race or ethnicity in adults ages 20 years or older: United States, NHANES: 1971-1975, 1976-1980, 1988-1994, 1999-2002, and 2003-2006,

 

66

Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
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2-5

 

Age- and sex-adjusted mean systolic blood pressure and diastolic blood pressure by race or ethnicity in children ages 8-17 years,

 

67

2-6

 

Secular trends in hypertension, overweight, obesity and sodium intake in the United States,

 

70

3-1

 

Overall logic model for strategies and interventions to reduce high blood pressure (HBP),

 

78

3-2

 

Progress quotient chart for Healthy People 2010 Focus Area 12: Heart Disease and Stroke,

 

84

5-1

 

The proportion of patients over a 24-month period that was not diagnosed with hypertension, separated by average diastolic and systolic blood pressure,

 

142

5-2

 

The diastolic and systolic blood pressure ranges at which physicians would start drug treatment in patients with uncomplicated hypertension,

 

143

5-3

 

The systolic (A) and diastolic (B) blood pressures of 72 patients with no initiation or change in antihypertensive medication,

 

147

5-4

 

Frequency and distribution of untreated hypertensive individuals by age and hypertension subtype,

 

148

Suggested Citation:"Front Matter." Institute of Medicine. 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press. doi: 10.17226/12819.
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Hypertension is one of the leading causes of death in the United States, affecting nearly one in three Americans. It is prevalent in adults and endemic in the older adult population. Hypertension is a major contributor to cardiovascular morbidity and disability. Although there is a simple test to diagnose hypertension and relatively inexpensive drugs to treat it, the disease is often undiagnosed and uncontrolled.

A Population-Based Policy and Systems Change Approach to the Prevention and Control Hypertension identifies a small set of high-priority areas in which public health officials can focus their efforts to accelerate progress in hypertension reduction and control. It offers several recommendations that embody a population-based approach grounded in the principles of measurement, system change, and accountability. The recommendations are designed to shift current hypertension reduction strategies from an individual-based approach to a population-based approach. They are also designed to improve the quality of care provided to individuals with hypertension and to strengthen the Center for Disease Control and Prevention's leadership in seeking a reduction in the sodium intake in the American diet to meet dietary guidelines.

The book is an important resource for federal public health officials and organizations, especially the Center for Disease Control and Prevention, as well as medical professionals and community health workers.

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