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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension (2010)

Chapter: 4 Interventions Directed at the General Population

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Suggested Citation:"4 Interventions Directed at the General Population." 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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4
Interventions Directed at the General Population

This chapter focuses on a number of interventions to address population- based risk factors—overweight, obesity, high sodium intake, low intake of potassium, unhealthy diet, high levels of alcohol consumption, low levels of physical activity—that are known to increase the risk of hypertension in the general population. Some trends in these risk factors, as noted in Chapter 2, are concerning because they are on the rise or have not decreased over time. This chapter includes an examination of the attributable fraction of hypertension due to each risk factor and an estimate of the benefit associated with interventions directed toward reducing these risk factors and their potential effectiveness relative to one another. Estimating the percentage of hypertension cases in a population attributable to different risk factors is useful as part of the process of setting public health priorities. However, these estimates do not apply to individual patients with hypertension, who may each have a different combination of factors contributing to their elevation in blood pressure.

The chapter also discusses community and environmental health determinants of hypertension, and the importance of considering health disparities. Potential interventions such as community and environmental interventions, and public education and media and social marketing campaigns are considered. Finally, the chapter ends with a concluding statement and recommendations.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

METHODOLOGY

This section addresses the methodology used in prioritizing modifiable risk factors for intervention. The committee’s selection of priority interventions was based primarily on the potential impact on the population if the risk factor were eliminated (population attributable risk). One method to compute population attributable fractions for hypertension is to identify prospective observational studies that have analyzed the association between a given risk factor and the incidence of hypertension. Using the relative risk (RR) between a given risk factor and incident hypertension, as well as the prevalence of that risk factor in the population, the attributable fraction can be computed as follows, where Pe is the prevalence of the exposure in the population:

To compute the attributable fractions for various risk factors, the committee used dichotomized RR estimates and estimates of the prevalence of these risk factors in the population.

Prospective studies pertaining to each of the modifiable risk factors (i.e., overweight and obesity, physical inactivity, heavy alcohol use, high salt intake, low potassium intake, and Western-style diet) were examined. A range of relative risks or odds ratios were extracted from these analyses, and accordingly, a range of attributable fractions for hypertension were computed. In addition, an aggregate relative risk was derived from the available literature, and a corresponding aggregate attributable fraction was computed.

A second method to compute population attributable fractions for hypertension is to identify randomized controlled trials, which report the effect of lifestyle modification interventions on blood pressure. Preferably, large-scale systemic reviews that pool the data from multiple randomized trials could provide a useful aggregate effect estimate (and range of estimates). In order to use these effect estimates to compute attributable fractions, a estimation of the mean blood pressure (and standard deviation) among the exposed population (i.e., the population with the risk factor) must be made, and two assumptions must also then be made: (1) that the blood pressure follows a normal distribution and (2) that applying the intervention to the exposed population would lead to a change in the mean blood pressure of that population that is identical to the pooled estimates reported from meta-analyses. Using a normal distribution function for systolic blood pressure (because most hypertension is systolic hypertension) and computing the percent of exposed individuals with a systolic blood pressure ≥140 mm Hg, the change in hypertension prevalence as a result of the intervention

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

can then be estimated as the change in prevalence of hypertension using the normal distribution multiplied by the prevalence of the risk factor in the population. Finally, the attributable fraction of hypertension due to the risk factor can then be computed by dividing the intervention-induced change in hypertension prevalence by the prevalence of hypertension in the whole population. Using this methodology, attributable risks were computed for the viable modifiable risk factors.

The committee also notes that much of the evidence contained in the following sections comes primarily from observational epidemiological investigations, which are mainly cross-sectional or prospective in nature, and randomized intervention trials. Each of these has its strengths and limitations. The observational studies are often large and long term and are thus able to evaluate both the incidence of hypertension and blood pressure as outcomes, but results can be distorted by unmeasured or poorly measured confounding factors. Randomized trials can directly evaluate an intervention, or change in exposure, and reduce the likelihood of confounding, thus providing valuable evidence for causation. However, most of these trials have only evaluated changes in blood pressure rather than incidence of hypertensions because of their limited size and duration. Estimates of attributable risks were generally similar when obtained using the different approaches, which enhances the validity of conclusions.

PROMOTE WEIGHT LOSS AMONG OVERWEIGHT PERSONS

According to data from the National Center for Health Statistics, approximately two-thirds of U.S. adults are overweight or obese (Table 4-1). In the prospective studies that have examined body mass index (BMI) in relation to adjusted risks of incident hypertension, overweight and obesity have been consistently and significantly associated with a higher risk of incident hypertension (Ascherio et al., 1992; Friedman et al., 1988; Gelber et al., 2007; Hu et al., 2004; Huang et al., 1998; Ishikawa-Takata et al., 2002). The most modest association was observed in 17,441 Finnish men and women who were followed for 11 years (Hu et al., 2004). Compared to individuals with a normal BMI, the adjusted relative risk for hypertension among those who were overweight was 1.24 (1.05-1.46) in women and 1.18 (1.01-1.39) in men; among obese individuals, the relative risk of hypertension was 1.32 (1.07-1.62) in women and 1.66 (1.35-2.04) in men. The authors did not provide a summary estimate for a BMI ≥ 25 compared to normal-weight men, but if these relative risks are projected onto the current U.S. population (with roughly equal proportions of overweight—34 percent—and obese—32 percent), then an average relative risk of 1.3 may be a reasonable estimate of the association of overweight and obesity with hypertension among women (and a somewhat stronger association among

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

TABLE 4-1 Risk Factor: Overweight and Obesity

Modifiable Risk Factor

Definition

Prevalence (source)

Overweight and obesity

BMI ≥ 25 kg/m2

Relative risk, mean (range)

1.7 (1.3-2.6)

0.66 (NCHS, 2006)

Attributable fraction, mean (range)

32% (17-51%)

Lifestyle intervention

References

Initial SBPa

Change in SBP

Anticipated change in HTNb prevalence

Attributable fraction

Weight loss

(Horvath et al., 2008)

(Ebrahim and Smith, 1998)

135 (18)

–6 (–3 to –10)

8% (4-13%)

28%

 

–5 (–2 to –8)

7% (3-10%)

24%

a Systolic blood pressure.

b Hypertension.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

men). The prospective study with the strongest association between BMI and hypertension was the Nurses’ Health Study. Nurses who had a BMI of 25.0 to 25.9 had a 2.6-fold (2.3-2.8) increased risk of developing hypertension during the subsequent 16 years compared to the leanest women, and the risk increased stepwise with higher BMIs (Huang et al., 1998). The relative risk estimates for the other prospective studies fell between these values, and the mean relative risk was 1.7. Using this mean and range of effect estimates and a population prevalence of overweight and obesity of 66 percent, it can be estimated that approximately 32 percent (range between 17 and 51 percent) of new hypertension cases occurring in the United States can be attributed to overweight and obesity (Table 4-1).

Important supportive evidence for these epidemiological findings has been provided by a series of randomized trials that have analyzed the effect of weight loss interventions on blood pressure; the majority of these studies succeeded in reducing weight in the intervention group by about 5 kg (Anderssen et al., 1995; Croft et al., 1986; Jalkanen, 1991; Stevens et al., 2001; The Trials of Hypertension Prevention Collaborative Research Group, 1992, 1997; Wassertheil-Smoller et al., 1992). Two meta-analyses have been performed that pool the results of these trials. The more recent meta-analysis, by Horvath et al. (2008), demonstrated a 6 mm Hg (−3 to −10 mm Hg) decrease in systolic blood pressure with weight loss. The older study by Ebrahim and Smith (1998) found a 5 mm Hg (−2 to −8 mm Hg) fall in systolic blood pressure with weight loss Based on these results, an intervention (to reduce weight by about 5 kg, or 10 lbs) applied to overweight and obese members of the population would hypothetically reduce the overall population prevalence of hypertension by 7 to 8 percent. Additionally, an estimated 24-28 percent of hypertension in the United States may be attributable to overweight and obesity, an estimate that is consistent with the attributable fractions computed using observational data.

DECREASE SODIUM INTAKE

Based upon 2004 statistics using calculated intakes of sodium, 87 percent of U.S. adults consumed what is considered excess sodium based on the Dietary Guidelines for Americans (>100 mmol of sodium >2,400 mg sodium >6,000 mg of salt [sodium chloride]) (NCHS, 2008) (Table 4-2).1 Further, the Dietary Guidelines for Americans, 2005, and the American

1

Conversion factors: In view of the variability of the published data referred to in this report the following conversion information is provided. To convert millimoles (mmol) to milligrams (mg) of sodium, chloride, or sodium chloride, multiply mmol by 23, 35.5, or 58.5 (the respective molecular weights of sodium, chloride, and sodium chloride), respectively. To convert millimoles (mmol) of potassium to mg of potassium, multiply by 39, the molecular weight of potassium.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

TABLE 4-2 Risk Factor: High Salt Intake

Modifiable Risk Factor

Definition

Prevalence (source)

High salt intake

≥ 2,400 mg/day sodium

Relative risk, mean (range)

1.3 (1.2-1.4)

0.87 (HHS, 2008)

Attributable fraction, mean (range)

32% (17-51%)

Lifestyle intervention

References

Initial SBPa

Change in SBP

Anticipated change in HTNb prevalence

Attributable fraction

Reduce salt intake

(He and MacGregor, 2004)

131 (19)

−4 (−3 to −5)

6% (5-8%)

21%

a Systolic blood pressure.

b Hypertension.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

Heart Association recommend that African Americans and persons who are middle aged or older or who have hypertension should consume less than 1,500 mg of sodium daily; with this added criterion the number consuming excess sodium is substantially higher than 87 percent (AHA, 2009; HHS and USDA, 2005). However, calculated sodium intake may not be accurate because the large majority of sodium in the U.S. food supply is added in the processing and manufacturing of foods and a large and increasing amount is used in the fast food industry. The amounts added can vary widely by brand and with time, making calculations difficult, and the smaller amounts added at home can also be challenging to quantify. Unfortunately, 24-hour urinary sodium excretion, which provides the best measure of sodium intake, has never been assessed in a nationally representative sample of the U.S. population, so that the true distribution of intakes in the United States is not known.

Very few prospective studies have addressed the association between antecedent dietary salt intake and the risk of developing hypertension. This is probably due mainly to the difficulty in accurately ascertaining sodium intake in large cohorts because most sodium is added in the manufacturing and processing of food rather than being intrinsic to food itself. As mentioned by the authors, misclassification of sodium intake potentially explains the absence of an association between estimated sodium intake and hypertension in the Nurses’ Health Study and the Health Professionals Follow-up Study (Ascherio et al., 1992, 1996). In cross-sectional observational studies, positive associations have been seen between sodium intake (as assessed by 24-hour urine collections) and blood pressure or prevalent hypertension (Karppanen and Mervaala, 2006; Stamler, 1997).

Numerous interventional studies of salt intake and blood pressure (analyzed as a continuous variable) of various quality and duration have been performed. Some of these sodium reduction trials had sufficiently long periods of follow-up to ascertain hypertension as a secondary end point (Goldstein, 1990; The Trials of Hypertension Prevention Collaborative Research Group, 1992, 1997). The Hypertension Prevention Trial randomized men and women ages 25-49 years to one of five counseling groups, including no counseling, counseling to reduce sodium, counseling to reduce sodium and increase potassium, counseling to reduce sodium and calories, and counseling to reduce calories. After 3 years of follow-up, sodium intake was reduced 10 percent (34 mmol per day), and the odds ratio for incident hypertension among the no-counseling group compared to the low-sodium group was 1.4. Phase I of The Trials of Hypertension Prevention (TOHP-I) enrolled more than 2,000 men and women ages 30 to 54 years with diastolic blood pressures of 80 to 89 mm Hg and randomized them to one of four groups: control (no intervention), low sodium, weight loss, and stress reduction (The Trials of Hypertension Prevention Collaborative Research

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

Group, 1992). Participants were followed for 18 months. Compared to the control, the sodium intervention led to a reduction in sodium intake of 44 mmol per day; the odds ratio for incident hypertension among controls was 1.3 (The Trials of Hypertension Prevention Collaborative Research Group, 1992). Phase II (TOHP-II) randomized more than 2,000 overweight men and women ages 30 to 54 years with diastolic blood pressures of 83-89 mm Hg and systolic blood pressures <140 mm Hg to usual care, counseling to achieve an 80-mmol-per-day (2 grams) sodium diet, weight loss, or a combination of weight loss and low-sodium diet (The Trials of Hypertension Prevention Collaborative Research Group, 1997). Counseling on sodium restriction led to a 40-mmol-per-day reduction in sodium intake. Through four years of follow-up, the odds ratio of incident hypertension among the control group compared to the sodium restriction group was 1.2 (The Trials of Hypertension Prevention Collaborative Research Group, 1997). While other randomized trials that included sodium restriction as one intervention also had extended follow-up and ascertainment of hypertension incidence (e.g., the Primary Prevention Trial and the PREMIER clinical trial of comprehensive lifestyle modification for blood pressure control; (Elmer et al., 2006; Stamler et al., 1989), sodium restriction was examined in combination with other factors rather than in isolation. Using this range of effect estimates and a population prevalence of 87 percent for high salt intake, it can be estimated that between 15 and 26 percent of new hypertension cases occurring in the United States could be attributed to a high salt intake with an average estimate from the available studies of 21 percent.

The most up-to-date systematic reviews of blood pressure-lowering trials via sodium restriction were published by He and MacGregor (2004) and Dickinson et al. (2006); both studies reported essentially identical pooled estimates. He and MacGregor (2004) analyzed 31 trials of at least one-month duration in which the sodium intake (measured by sodium excreted in 24-hour urine) in the treatment group was reduced by at least 40 mmol (approximately 1,000 mg of sodium, or 2,300 mg of salt-sodium chloride). The average sodium reduction in these studies was 76 mmol (about 1,750 mg of sodium, or 4,438 mg of salt); this represents less than half the daily salt intake (9-12 grams) of average Americans (He and MacGregor, 2004). The pooled estimate for systolic blood pressure reduction from sodium restriction was 4 mm Hg (–3 to –5 mm Hg). By using these estimates and a prevalence of sodium excess in the general population of 0.87, the prevalence of hypertension could potentially be reduced by 5 to 8 percent if all Americans consuming a high-salt diet lowered their salt intake by about 4.5 grams per day. The corresponding attributable fraction of hypertension due to sodium excess is approximately 21 percent, precisely what was found when data from intervention studies with hypertension as the dichotomous outcome were analyzed.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

INCREASE POTASSIUM AND INTAKE OF FRUITS AND VEGETABLES

Of all of the modifiable risk factors for hypertension, one of the most prevalent is an inadequate consumption of potassium based on the current Dietary Reference Intake (DRI) criteria (IOM, 2005). In a recent report from the CDC (NCHS, 2008), approximately 2 percent of U.S. adults met the current guidelines for dietary potassium intake (≥4.7 grams per day, or 4,700 mg), but insufficient potassium intake is most prevalent among blacks and Hispanics, among whom the proportion consuming an adequate amount of potassium was close to zero percent. Of note, the primary basis for the DRI of 4.7 grams per day for potassium is its beneficial effect on blood pressure and stroke (IOM, 2005). Specifically, this amount of potassium, provided as a supplement, was needed to counteract the effect of a high salt load among 10 black men; among white men, 2.7 grams per day appeared to be adequate. In the 2005 U.S. Dietary Guidelines, the value of 4.7 grams per day based on supplemental potassium was translated into recommendations for high consumption of fruits, vegetables, and dairy products, which are major sources of this nutrient (HHS and USDA, 2005) (Table 4-3).

Observational studies that have examined the association between potassium intake and incident hypertension are conflicting (Ascherio et al., 1992, 1996; Chien et al., 2008; Dyer et al., 1994; Lever et al., 1981). While some cross-sectional analyses of 24-hour urinary potassium excretion and blood pressure have demonstrated an inverse association (Dyer et al., 1994; Lever et al., 1981), prospective studies have not shown clear associations. In both the large-scale Nurses’ Health Study and the Health Professionals Follow-up Study, higher intakes of potassium ascertained from repeated food-frequency questionnaires were inversely associated with risk of hypertension, but it was difficult to determine the independence from other dietary factors in multivariate analyses (Ascherio et al., 1992, 1996). In a recent study among 1,523 men and women in Taiwan, the incidence of hypertension was ascertained during eight years of follow-up after a baseline 24-hour urine collection; the relative risk comparing the highest to lowest quartile of potassium excretion was 0.98 (0.78-1.23) after multivariate adjustment (Chien et al., 2008). Whether a single measure of urinary potassium is adequate for characterizing long-term potassium intake in this population is unclear.

Numerous randomized trials have examined whether potassium supplementation lowers blood pressure, and the overall evidence indicates a benefit although this has not been seen in all studies (Appel et al., 2006). Four meta-analyses have been published that have pooled these studies (Cappuccio and MacGregor, 1991; Dickinson et al., 2006; Geleijnse et

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

TABLE 4-3 Risk Factor: Low Potassium Intake

Modifiable Risk Factor

Definition

Prevalence (source)

Low potassium intake

<4,700 mg/day potassium

0.98 (Sondik, 2008)

Lifestyle intervention

References

Initial SBPa

Change in SBP

Anticipated change in HTNb prevalence

Attributable fraction

Increase potassium intake

(Whelton et al., 1997)

131 (19)

−3 (−2 to −4)

5% (4-7%)

17%

a Systolic blood pressure.

b Hypertension.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

al., 2003; Whelton et al., 1997). Three studies found significant pooled blood pressure reductions with potassium supplementation (Cappuccio and MacGregor, 1991; Geleijnse et al., 2003; Whelton et al., 1997), while the most recent (which excluded trials of very short duration, those that included children and pregnant women, and those that included participants on blood pressure medications that were altered during the study period) did not detect a significant effect (Dickinson et al., 2006). Nevertheless, the pooled estimate from that meta-analysis suggested a favorable effect of potassium (a 3.9 mm Hg decrease in blood pressure), despite the insignificant p-value (Dickinson et al., 2006). In the most comprehensive of these metaanalyses, Whelton et al. synthesized 33 randomized trials of potassium supplementation and reported a pooled reduction of systolic blood pressure by 3 mm Hg (−2 to −4 mm Hg), and a pooled reduction in diastolic blood pressure of 2 mm Hg (−1 to −4 mm Hg) (Whelton et al., 1997).

Although recommendations for high intakes of fruits and vegetables in the U.S. Dietary Guidelines are based largely on studies of potassium supplementation and blood pressure, the effect of increasing fruits and vegetables on blood pressure was investigated directly in the Dietary Approaches to Stop Hypertension (DASH) study (Appel et al., 1997). In this study, one intervention group was fed 8.5 servings of fruits and vegetables (analyzed potassium intake 4,101 mg per day), whereas the comparison group received 3.6 servings per day (analyzed potassium intake 1,752 mg per day). The fruits-and-vegetables diet reduced systolic blood pressure by 2.8 mm Hg more (p < 0.001) and diastolic blood pressure by 1.1 mm Hg more than the control diet (p = 0.07), which is consistent with the potassium content of these foods. DASH results showing reduced systolic and diastolic blood pressure with an increase in dietary fruit and vegetables have also been reported by researchers in the United Kingdom (John et al., 2002).

Using the results of the meta-analysis of Whelton and colleagues in which the dose of potassium supplementation was typically 60 mmol per day, and the assumption that the entire population could increase its intake to 4,700 mg per day, the prevalence of hypertension could hypothetically be reduced by 4 to 7 percent. Further, the attributable fraction corresponding to insufficient potassium intake is approximately 17 percent.

There is evidence that increasing the potassium intake of the general U.S. population would have favorable effects on blood pressure, but the methods of doing this need to be considered. The high intake of fruits and vegetables in the DASH study (8.5 servings per day) is a desirable goal, but increases to this level will be difficult to achieve in the medium-term future because there has been little increase in these foods in the United States (if french-fried potatoes are not included) despite strong encouragement to do so. Whether smaller increases would have similar benefits is not clear. Potas-

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

sium supplements for the general population are not usually advised because of possible adverse gastrointestinal effects (Cohn et al., 2000) and concern about the development of hyperkalemia among individuals with chronic renal failure or on potassium-sparing diuretics. However, maintenance of normal potassium homeostasis typically does not become problematic in people with kidney disease until the glomerular filtration rate falls below 20 mL/min. This severity of kidney disease is uncommon in the general population (about 0.1 percent of the population), and awareness is higher among these individuals (Coresh et al., 2005). Another strategy to increase potassium intake is by the use of “modified salt” in food preparation in which part of the sodium chloride is replaced by potassium chloride. This has the double advantage of decreasing sodium and increasing potassium intake, and the likelihood of excessive potassium intake is limited by its effect on flavor. The more widespread use of these substitutes, accompanied by clear labeling for those whose intake of potassium should be limited for medical reasons, deserves further consideration.

CONSUME A HEALTHY DIET

In many studies of vegetarians and rural populations of developing countries, the eating patterns of these groups have been associated with lower blood pressure and lower rates of hypertension (Armstrong et al., 1977; Cruz-Coke et al., 1964; He et al., 1991; Klag et al., 1995; Poulter et al., 1985, 1990; Sacks and Kass, 1988; Sacks et al., 1974; Sever et al., 1980). For example, among young men and women living in the Boston area, the prevalence of hypertension was approximately 20 percent among nonvegetarians vs. zero percent among vegetarians (Sacks and Kass, 1988). In a study of South African blacks, the odds ratio for prevalent hypertension comparing urban vs. tribal dwelling Xhosa and Zulu people was 2.1, although this was unadjusted. When comparing migrants from a rural to an urban area of China with those who had not migrated, the adjusted odds ratio for prevalent hypertension was 1.91 (standardized for slightly different odds ratios in men and women) (He et al., 1991). These observations led to the hypothesis that interventions involving a healthy overall eating pattern might be more clearly related to lower blood pressure than those focused on single nutrients. This led investigators of the DASH trial to propose a healthy eating plan that would lower blood pressure (Appel et al., 2006). This diet was high in fruits, vegetables, and low-fat dairy products and low in saturated fat and sweets (Appel et al., 1997), and was thus high in potassium, calcium, magnesium, and fiber.

Published data from observational studies that provide an estimate of the association between an overall healthy diet or the DASH dietary pattern and incident hypertension are generally limited. Investigators at the

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

European Investigation into Cancer and Nutrition (EPIC)-Potsdam Study did analyze the association between a DASH dietary pattern and incident hypertension, but among the population with sufficient dietary data, only 123 incident hypertension cases occurred; a DASH-style diet was inversely associated with hypertension, but this was not statistically significant (Schulze et al., 2003). The one prospective study that did find a significant association between a DASH-style diet and incident hypertension was the Nurses’ Health Study II (Forman et al., 2009). Among more than 83,000 women followed for 14 years, those in the lowest compared to the highest quintile of DASH score (a score generated from factor analysis to reflect a DASH eating style) had a 1.22-fold increased risk of incident hypertension (1.15-1.30) after adjustment for multiple factors (Forman et al., 2009).

The DASH trial itself had insufficiently long-term follow-up to demonstrate a persistent change in blood pressure at one year, or a change in hypertension incidence (Ard et al., 2004), despite providing clear evidence that the DASH diet lowers blood pressure. Although the PREMIER trial analyzed incident hypertension at 18 months of follow-up, the DASH diet was not analyzed in isolation (Elmer et al., 2006). Rather, the DASH diet was combined with weight loss, sodium restriction, and physical activity. Compared to the group receiving weight loss, sodium restriction, and physical activity without the DASH eating plan, the addition of the DASH eating plan was associated with a relative risk for incident hypertension of 0.93 (0.75-1.15) (Elmer et al., 2006). By using the range of effect estimates from comparisons of populations and cohort studies and a conservative estimate of the population prevalence of a Western-style diet of 75 percent (it is probably higher), it can be estimated that between 13 and 40 percent of new hypertension cases occurring in the United States can be attributed to a Western-style diet, with an aggregate estimate from the few available studies of 31 percent (Table 4-4).

There are no meta-analyses of dietary pattern interventions and blood pressure lowering. Therefore, the attributable fraction of hypertension as a consequence of a Western-style diet was computed from the DASH randomized trial, in which the combination (DASH) diet lowered blood pressure by approximately 6 mm Hg (−4 to −7 mm Hg) (Appel et al., 1997). The reduction in blood pressure on the DASH diet was greater than in a parallel intervention that only increased fruit and vegetable consumption; however, the DASH diet also contained more fruits and vegetables, thus complicating the conclusions. The DASH-sodium trial is not included in this estimation because dietary pattern change was not the sole intervention (Sacks et al., 2001). Again, by assuming a prevalence of a Western-style diet in the United States of 0.75, a DASH diet intervention targeted to all adults who ate this type of diet could potentially reduce the prevalence of hypertension in the population by 6 to 10 percent. The estimated attributable fraction

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

TABLE 4-4 Risk Factor: Western-Style (Unhealthy) Diet

Modifiable Risk Factor

Definition

Prevalence (source)

Western-style diet

A diet emphasizing red and processed meats, refined grains, fats, and sweetened foods

0.75 (conservative estimate)

Relative risk, mean (range)

1.6 (1.2-1.9)

Attributable fraction, mean (range)

31% (13-40%)

Lifestyle intervention

References

Initial SBPa

Change in SBP

Anticipated change in HTNb prevalence

Attributable fraction

DASH eating plan

(Appel et al., 1997)

131 (11)

−6 (−4 to −7)

8% (6-10%)

28%

a Systolic blood pressure.

b Hypertension.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

of hypertension prevalence due to a Western-style diet is consequently 28 percent.

Subsequent to the initial DASH study, two important enhancements have been documented. The first is salt reduction, discussed later under “Multiple Dietary Interventions,” which led to an additional decrease in blood pressure. The second is partial replacement (10 percent of energy) of the high amount of carbohydrate in the DASH diet with either unsaturated fat or protein, which was addressed in the OmniHeart study (Appel et al., 2005). Both substitutions significantly reduced systolic blood pressure (by 1.3 to 1.4 mm Hg overall and by about 3 mm among those with hypertension) and also improved blood lipids. The finding that replacement of carbohydrate by either unsaturated fat or protein reduces blood pressure suggests a role of carbohydrate reduction rather than increased intake of protein or unsaturated fat in control of hypertension.

The initial DASH diet has an important benefit in reducing blood pressure, but the OmniHeart study showed that further reduction in blood pressure is possible if the high carbohydrate content of the DASH diet is reduced by partial replacement with either protein or unsaturated fat and that blood lipids are also improved. These findings are consistent with many controlled feeding studies that show improvements in blood lipids when carbohydrate is replaced with unsaturated fats (Mensink et al., 2003). Also, in the Nurses’ Health Study a dietary pattern lower in carbohydrates and higher in unsaturated fats and vegetable sources of protein was associated with lower risk of coronary heart disease and type 2 diabetes (Halton et al., 2006, 2008). The high consumption of dairy products in the DASH diet is of concern because many studies have found this to be associated with fatal prostate cancer, particularly the aggressive form, and a recent review concluded that high consumption of dairy products probably increases the risk of prostate cancer (World Cancer Research Fund, 2007). Thus, an overall diet for good health would probably include lower amounts of carbohydrate and dairy products than the original DASH diet.

REDUCE EXCESSIVE ALCOHOL INTAKE

According to 2001-2007 government data, the prevalence of heavy drinking (defined as ≥3 drinks per day in men and ≥2 drinks per day in women) among U.S. adults is 5 percent (CDC, 2008a) (Table 4-5). At least nine prospective cohort studies have examined the independent association between alcohol consumption and the risk of hypertension (Ascherio et al., 1992; Friedman et al., 1988; Fuchs et al., 2001; Lorenzo et al., 2002; Ohmori et al., 2002; Sesso et al., 2008; Stranges et al., 2004; Thadhani et al., 2002; Witteman et al., 1990). Although they varied in the way in which alcohol intake was classified and not all examined the association using cur-

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

TABLE 4-5 Risk Factor: Heavy Alcohol Intake

Modifiable Risk Factor

Definition

Prevalence (source)

Heavy alcohol intake

Mean of ≥3 (in men) or ≥2 (in women) alcoholic beverages per day

0.05 (CDC, 2008b)

Relative risk, mean (range)

1.7 (1.2-2.3)

Attributable fraction, mean (range)

3% (1-6%)

Lifestyle intervention

References

Initial SBPa

Change in SBP

Anticipated change in HTNb prevalence

Attributable fraction

Reduce alcohol intake

(Xin et al., 2001)

132 (18)

−3 (−2 to −4)

0.3% (0.2-0.4%)

1%

a Systolic blood pressure.

b Hypertension.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

rently recommended thresholds of ≥3 alcoholic beverages per day for men and ≥2 alcoholic beverages per day for women (on average), they provide useful information in determining the attributable risk of alcohol use for hypertension. The lowest relative risk was observed among white men in the Atherosclerosis Risk in Communities (ARIC) Study who consumed 3 or more alcoholic beverages per day (RR = 1.2 [0.85-1.67]) (Fuchs et al., 2001). The same study also reported the strongest association (RR = 2.3 [1.11-4.86]) among black men who drank 3 or more alcoholic beverages per day. The other eight studies reported risk estimates that fell between 1.2 and 2.3. The average relative risk of hypertension for those drinking alcohol in excess from all nine cohorts was 1.7. Supportive evidence regarding the potential benefit of interventions to reduce alcohol use comes from a systematic review of 15 randomized controlled trials of alcohol reduction in heavy drinkers that demonstrated a significant pooled reduction in blood pressure (Xin et al., 2001). Given the consistency of observational and interventional evidence, a program to reduce alcohol consumption among adults drinking excessive amounts is a viable option to reduce the prevalence of hypertension. However, based upon a relative risk of 1.7 and a prevalence of heavy alcohol use of 5 percent, the estimated fraction of hypertension attributable to excess alcohol use is low: 3 percent (range, 1-6 percent) (Forman, 2009).

One meta-analysis pooled results from 14 randomized trials of alcohol reduction among heavy drinkers, with 13 of the 14 studies having a follow-up of at least one month (Xin et al., 2001). The authors reported that alcohol restriction resulted in a pooled reduction of systolic blood pressure of 3 mm Hg (−2 to −4 mm Hg). Using these figures in conjunction with the prevalence of excess alcohol intake, an alcohol restriction program applied in all population members who drink alcohol to excess (i.e., ≥2 drinks per day in women and ≥3 drinks per day in men) may reduce the overall population prevalence of hypertension by 0.2 to 0.4 percent. The estimated attributable fraction of hypertension due to alcohol excess using this method (1 percent) is consistent with the estimates derived from observational studies.

INCREASE PHYSICAL ACTIVITY

Approximately 69 percent of the U.S. adult population in 2001 did not meet the CDC guidelines for leisure time physical activity of 5 days per week of moderate-intensity exercise or 3 days per week of vigorous exercise (CDC, 2003). Several large, prospective, cohort studies have examined the association between physical activity and incident hypertension, although none has categorized physical activity according to current guidelines for moderate or vigorous physical activity (Graham et al., 2007; Hayashi et al.,

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

1999; Hu et al., 2004; Parker et al., 2007; Pereira et al., 1999). Although most of these studies supported an inverse relation between physical activity and risk of hypertension, the ARIC study reported an inverse association only among white men. The lack of apparent benefit in other demographic groups may have been due to their lower levels of recreational activity (Pereira et al., 1999). However, the Coronary Artery Risk Development in Young Adults (CARDIA) study found that increased levels of physical activity reduced the risk of incident hypertension, and the association remained constant after adjusting for race, gender, and other variables (Parker et al., 2007). The most impressive association was present among Finnish men, in whom a lack of moderate or vigorous regular physical activity was associated with a 64 percent increase in the risk of developing hypertension (Hu et al., 2004). Other cohort studies reported more modest, although significant, inverse associations. The mean relative risk estimate from these cohort studies is 1.3. Using this estimate and a population prevalence of 69 percent for lack of regular exercise, it can be estimated that 17 percent of new hypertension cases (range 0 to 29 percent) occurring in the United States can be attributed to lack of regular exercise (Table 4-6).

Two large scale meta-analyses have analyzed randomized trials of exercise interventions and reduction in blood pressure (Kelley and Sharpe Kelley, 2001; Whelton et al., 2002). The more recent, by Whelton and colleagues, reported that exercise led to a 4 mm Hg (−3 to −5 mm Hg) reduction in systolic blood pressure. The older study by Kelley and Sharpe Kelley (2001) documented a more modest reduction by 2 mm Hg (–1 to −4 mm Hg) (Kelley and Sharpe Kelley, 2001; Whelton et al., 2002). The meta-analysis published by Dickinson et al. (2006) examining multiple lifestyle interventions found a pooled effect for exercise similar to that found by Whelton et al. (2002). As with overweight and obesity, the anticipated change in hypertension prevalence and the attributable fraction can be estimated from these values using similar techniques. Implementation of an exercise program among members of the population who are physically inactive would hypothetically reduce the overall prevalence of hypertension by 4 to 6 percent. Furthermore, the fraction of hypertension attributable to physical inactivity is estimated by this method to be 14-21 percent, consistent with estimates using observational data.

MULTIPLE DIETARY INTERVENTIONS

Several high-quality randomized trials have investigated the effects of multiple risk factor reduction on blood pressure. The DASH-sodium trial was a 2 × 2 factorial trial that randomized participants to either a Western-style diet or the DASH diet and to one of three levels of sodium intake (150 mmol, 100 mmol, and 50 mmol) (Sacks et al., 2001). The achieved

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

TABLE 4-6 Risk Factors: Physical Inactivity

Modifiable Risk Factor

Definition

Prevalence (source)

Physical inactivity

No sessions of light/moderate or vigorous physical activity lasting 10 minutes

0.69 (NHIS 2006 survey) (NCHS, 2003)

Relative risk, mean (range)

1.3 (1.0-1.6)

Attributable fraction, mean (range)

17% (0-29%)

Lifestyle intervention

References

Initial SBPa

Change in SBP

Anticipated change in HTNb prevalence

Attributable fraction

Increase physical activity

(Whelton et al., 2002) (Kelley and Sharpe Kelley, 2001)

131 (17)

−4 (−3 to −5)

6% (4-7%)

21%

 

−2 (−1 to −4)

4% (1-6%)

14%

a Systolic blood pressure.

b Hypertension.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

sodium intakes were similar to these targeted intakes, and the highest- vs. lowest-sodium groups were separated by 77 mmol per day. Comparing the Western-style, high-sodium diet with the DASH lowest-sodium diet, the reduction in systolic blood pressure was approximately 9 mm Hg (−4 to −14 mm Hg). If U.S. adults on a Western-style, high-salt diet were fed a DASH-style, low-salt diet, hypertension prevalence might be reduced by 14 to 22 percent (Table 4-7). The corresponding attributable fraction of hypertension due to a Western-style, high-salt diet is estimated to be 59 percent.

The second trial of multiple risk factor reduction was the PREMIER trial, which randomized participants either to usual counseling; to a behavioral intervention targeted to reduce sodium intake, reduce weight, and improve physical conditioning; or to a behavioral intervention that combined these interventions with the DASH diet (Elmer et al., 2006). The PREMIER trial, unlike DASH-sodium, was not a feeding trial, and as a consequence the separation between the groups was not as dramatic; this has been seen in most lifestyle intervention studies conducted in environments that are generally not supportive of healthy behaviors. For example, the sodium intake at 18 months of follow-up was 168 mmol per day (nearly 10 grams of salt) in the control group and 153 mmol (nearly 9 grams of salt) in the targeted multiple intervention groups (Elmer et al., 2006). Both of these sodium intake levels would be considered sodium excess. At 18 months, systolic blood pressure was reduced by 2 mm Hg (0 to −4 mm Hg).

The overall potential for reduction of hypertension by dietary factors, weight control, and regular physical activity has not been addressed directly. The attributable risks shown for individual factors in Table 4-8 cannot simply be added because this would not take into account their interactions, and for this reason the sum can be more than 100 percent. However, if the 59 percent of risk attributable to the DASH diet with sodium reduction is taken as a base, to which reduction in carbohydrate, weight loss, and increased physical activity could be added, it can be appreciated qualitatively that a very large majority of hypertension is potentially preventable.

OTHER POTENTIAL INTERVENTIONS

The committee considered other interventions that have been hypothesized to reduce blood pressure including increasing intakes of calcium, magnesium, folic acid, fiber, fish oil, and vitamin D and reducing stress and use of analgesics. For each, the evidence was considered to be inadequate to consider as a priority area of intervention.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

TABLE 4-7 Risk Factors: Multiple Interventions

Lifestyle intervention

References

Initial SBPa

Change in SBP

Anticipated change in HTNb prevalence

Attributable fraction

 

(Sacks et al., 2001)

134 (10)

−9 (−4 to −14)

17% (14-22%)

59%

 

(Elmer et al., 2006)

135 (10)

−2 (0 to −4)

6% (0-11%)

21%

a Systolic blood pressure.

b Hypertension.

TABLE 4-8 Modifiable Risk Factors and Attributable Fractions Based on Interventional Studies

Lifestyle intervention

References

Initial SBPa

Change in SBP

Anticipated change in HTNb prevalence

Attributable fraction

Weight loss

(Horvath et al., 2008)

135 (18)

−6 (−3 to −10)

8% (4-13%)

28%

 

(Ebrahim, 1998)

 

−5 (−2 to −8)

7% (3-10%)

24%

Reduce salt intake

(He and MacGregor, 2004)

131 (19)

−4 (−3 to −5)

6% (5-8%)

21%

DASH eating plan (healthy eating)

(Appel et al., 1997)

131 (11)

−6 (−4 to −7)

8% (6-10%)

28%

Increase potassium intake

(Whelton et al., 1997)

131 (19)

−3 (−2 to −4)

5% (4-7%)

17%

Increase physical activity

(Kelley and Sharpe Kelley, 2001)

131 (17)

−4 (−3 to −5)

6% (4-7%)

21%

 

(Whelton et al., 2002)

 

−2 (–1 to –4)

4% (1-6%)

14%

Reduce alcohol intake

(Xin et al., 2001)

132 (18)

–3 (–2 to –4)

0.3% (0.2-0.4%)

1%

a Systolic blood pressure.

b Hypertension.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

COMMUNITY AND ENVIRONMENTAL INTERVENTIONS

Public health policies that make it easier for Americans to engage in regular, physical activity (leisure time and transportation) and reduce exposure to foods containing high levels of sodium while increasing exposure to foods containing appropriately high levels of potassium are likely to be the most effective means to lower the mean blood pressure of the U.S. population as a whole (Rose, 1992). Thus, approaches to shift the population distribution of blood pressure through the behavioral strategies described above will require addressing community and environmental factors that may limit the ability of individuals to make healthy behavioral choices in the communities where they live and work.

A growing body of work has examined features of neighborhood built environments such as land use patterns, density, and access to destinations; street connectivity and transportation systems; features of urban design; and access to healthy foods and recreational resources in relation to the behaviors of diet and physical activity and related health outcomes of obesity, diabetes, and hypertension. Observational studies have generally concluded that greater population density, land use mix, proximity of nonresidential destinations, pedestrian infrastructure, aesthetics, and safety are linked to more walking (Saelens and Handy, 2008). There is also observational evidence that the presence of resources for physical activity in parks and recreational facilities relates to residents’ physical activity levels (Kaczynski and Henderson, 2008). A growing body of work has linked access to healthy foods (as proxied by the presence of supermarkets or other measures of availability) to better diets (Franco et al., 2009; Larson et al., 2009; Moore et al., 2008). Recent work has also shown that neighborhood physical activity and food environments are related to levels and changes over time in obesity, hypertension, and diabetes (Black and Macinko, 2008; Larson et al., 2009; Mujahid et al., 2008a; Papas et al., 2007; Sturm and Datar, 2005, 2008).

Although existing evidence remains limited due to its observational nature, there is growing consensus that efforts to improve population levels of physical activity, diet, and related conditions will have to encompass interventions that address the environments that promote and sustain healthy behaviors (IOM, 2009a). For example, it has been argued that public health efforts to improve physical activity should include design and land use policies that support physical activity, as well as creating and/or increasing access to places for physical activity (Heath et al., 2006; Kahn et al., 2002). Similarly, public health efforts to improve diet will need to address the limited access to healthy foods that has been documented in many communities (Franco et al., 2008; Moore and Diez Roux, 2006; Morland et al.,

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

2002). Rigorous evaluation of efforts to improve physical activity and food environments will be necessary to guide future action.

Public Education and Media and Social Marketing Campaigns

Public education is an important component of many public health intervention activities. Public education campaigns use a variety of methods and tools—from the dissemination of printed educational materials to very sophisticated, targeted social marketing techniques. Public education campaigns generally strive to raise awareness and disseminate messages, while social marketing techniques focus on changing behaviors. This section discusses the impact of the National High Blood Pressure Education Program and the results of local efforts associated with the Pawtucket Heart Health Program, Minnesota Heart Health Program, and Stanford Five City Project, which were funded by the National Heart, Lung, and Blood Institute (NHLBI) between 1978 and 1980 and included public education efforts to reduce risk factors associated with cardiovascular disease. The section also reviews the VERB™ campaign that targeted physical activity as an example of a successful public education campaign.

National High Blood Pressure Education Program

The National High Blood Pressure Education Program (NHBPEP) was initiated in 1972 and is coordinated by the NHLBI of the National Institutes of Health. The program engages the efforts of federal agencies, professional and voluntary health organizations, state health departments, and community groups to “reduce death and disability related to high blood pressure through programs of professional, patient, and public education.” The NHBPEP utilizes strategic partnerships and the development and dissemination of educational materials and programs to work toward achieving the Healthy People 2010 heart disease and stroke objectives. The coordinating committee is engaged in examining critical issues, promoting national activities, and fostering collaboration between organizations, as well as identifying national priorities for the NHBPEP. The mass media efforts directed by the NHBPEP employ the use of fact sheets, brochures, planning kits, posters, print ads, and radio messages to promote professional, patient, and public education. The program also publishes the Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure, which provides current guidelines and recommendations for clinicians and community organizations and is widely distributed to state health departments, primary care clinicians, and hypertension control programs. The most recent version of the report was published in 2003,

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

and its update will be released in summer of 2010. The issues and scope identified on the NHBPEP website include the following:

  • Excessive stroke mortality in the southeastern United States

  • Effective treatment practices

  • Utility of lowering the systolic blood pressure in older Americans

  • Role of lifestyle changes in preventing and treating hypertension

  • Population-based strategies for primary prevention of high blood pressure

  • Issues regarding special populations and situations (e.g., African Americans, renal disease, women, children, adolescents)

  • Educational strategies directed at professional, patient, and public audiences and community organizations

  • Development and support of HEDIS (Healthcare Effectiveness Data and Information Set) hypertension measures.

The NHBPEP measures its progress against the National Health and Nutrition Examination Survey (NHANES) trends in hypertension awareness, treatment, and control, as well as the progress made toward the Healthy People 2010 goals. At the program’s outset, less than one-quarter of Americans were aware of the relationship between hypertension and stroke and hypertension and heart disease. Hypertension awareness has increased to three-quarters of the population, and three-quarters of Americans have their blood pressure measured every six months. In 1972, only 16 percent of hypertensive individuals had blood pressure at or below 160/95 mm Hg (the goal at that time). Recent data show that 64 percent would meet the old goal of 160/95 mm Hg, and 29 percent would meet the current goal of 140/90 mm Hg (Jones and Hall, 2002). Hypertension has become a leading reason for physician visits among adults. There has been a 59.6 percent decline in age-adjusted mortality for stroke in the total population since the program’s inception and a 55.6 percent decline in coronary heart disease.

Pawtucket Heart Health Program

The Pawtucket Heart Health Program (PHHP) was a community-based research and demonstration project that took place in Pawtucket, Rhode Island, between 1981 and 1993. The program utilized a mass media campaign as well as screening and counseling, grocery store shelf labeling, and educational programs offered in schools and libraries. It focused on modifying major risk factors for cardiovascular disease including high blood cholesterol levels, high blood pressure, smoking, sedentary lifestyle, and obesity. Random-sample, cross-sectional surveys were administered

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

to residents of Pawtucket and residents of a comparison community who were between the ages of 18 and 64. The resulting analysis showed small, statistically insignificant reductions in blood cholesterol and blood pressure in the Pawtucket community. The projected cardiovascular disease rates were 16 percent lower in Pawtucket during the education program, but fell to 8 percent in the post-intervention period. A study by Carleton et al. (1995) concluded that “[a]ccelerating risk factor changes will likely require a sustained community effort with reinforcement from state, regional, and national policies and programs” (p. 777).

Minnesota Heart Health Program

The Minnesota Heart Health Program took place between 1980 and 1989 and included approximately 400,000 persons in six communities (three intervention and three comparison communities). The program utilized mass and personalized media; adult, youth, and professional education; and community-based health promotion activities. The intervention communities experienced a modest but statistically insignificant decline in measures of systolic and diastolic blood pressure. Baseline and follow-up surveys demonstrated that “[m]any intervention components proved effective in targeted groups. However, against a background of strong secular trends of increasing health promotion and declining risk factors, the overall program effects were modest in size and duration and generally within chance levels” (Luepker et al., 1994) The authors further concluded that “even such an intense program may not be able to generate enough additional exposure to risk reduction messages and activities in a large enough fraction of the population to accelerate the remarkably favorable secular trends in health promotion activities and in most coronary heart disease risk factors present in the study communities” (p. 1383).

Sanford Five City Project

The Stanford Five City Project took place between 1979 and 1992. The program involved the use of multiple media, educational, and health promotion activities to reduce risk factors including blood pressure, blood cholesterol, salt intake, smoking, physical activity, and adherence to anti-hypertensive medication regimens. A decrease in cardiovascular morbidity and mortality was observed during the intervention period; however, this occurred similarly in the control cities.

In summary, of the four public education efforts, the findings of the NHBPEP were most remarkable for achieving both a significant increase in awareness and a reduction in blood pressure. The program, however, currently functions at a lower level of activity than in the past. It was recently

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

described as “a virtual program,” with much of the educational materials and other resources provided online.2 Results from the public education efforts in Pawtucket and Minnesota, although significant, were very modest and the Stanford Five City Project failed to detect significant differences between the intervention and control groups.

The VERB™ Campaig

The VERB™ campaign was an effort of the Centers for Disease Control and Prevention to increase and maintain physical activity among youth ages 9 to 13 (“tweens”). The campaign was conducted between 2002 and 2006 and involved the use of social marketing strategies such as paid advertisements, school and community promotions, and Internet activities. The campaign included television commercials as well as national print and radio advertisements. Advertisements were targeted to multiple ethnic groups, including African-American, Asian, Hispanic or Latino, and Native American audiences. The goals of the campaign were the following:

  • Increase knowledge and improve attitudes and beliefs about tweens’ regular participation in physical activity.

  • Increase parental and influencer support and encouragement of tweens’ participation in physical activity.

  • Heighten awareness of options and opportunities for tween participation in physical activity.

  • Facilitate opportunities for tweens to participate in regular physical activity.

  • Increase and maintain the number of tweens who regularly participate in physical activity.

A 2005 study by Huhman et al. utilized a prospective, longitudinal, quasi-experimental design to determine the effects of the VERB™ capaign on physical activity among the target audience. Participants included 3,120 parent-child pairs. Baseline and follow-up surveys using random-digit dialing were used to measure the campaign’s influence on awareness and physical activity. The authors found that after 1 year, 74 percent of children surveyed were aware of the VERB™ campaign—a 24 percent increase over the campaign’s goal for the first year. Median free-time physical activity increased for several subgroups, including 9- to 10-year-old children, girls, children whose parents had less than a high school education, children in urban areas, and children engaging in low levels of physical activity at baseline. Among 9- to 10-year-olds, physical activity increased by 34 per-

2

Personal comment by Dr. Ed Roccella in a presentation to the committee, June 2009.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

cent compared to youth who were unaware of the program. The authors concluded that “promoting physical activity with child-focused commercial advertising shows promise” (Huhman et al., 2005, p. 277).

A recent report by the Institute of Medicine (IOM, 2009a) identified promising actions that local governments can take to prevent childhood obesity, and specified media and social marketing as a recommended action. Developing media campaigns and utilizing multiple channels to promote healthy eating and physical activity using consistent messages were recommended. The rationale supporting the goal and action step was based on the positive outcomes of the VERB™ campaign (Berkowitz et al., 2008), and research that shows that high-frequency television and radio advertising, as well as signage, may stimulate improvements in attitudes toward a healthy diet (Beaudoin et al., 2007).

RELATIVE COSTS OF POPULATION-BASED INTERVENTIONS

The comparative cost-effectiveness of population-based interventions compared to individual-level approaches to reduce blood pressure and cardiovascular disease risk has been the focus of researchers at the international level. Murray and colleagues conducted a review of the effectiveness and costs of a number of strategies to reduce blood pressure and cholesterol with the ultimate goal of reducing cardiovascular disease risk (Murray et al., 2003). They compared the effectiveness of four community-based interventions targeted at changing diets (salt reduction through voluntary agreements with industry, population-wide reduction in salt intake through legislation, health education through mass media, and a combination of salt intake legislation and mass media education) to individual-based interventions based on the pharmacological management of hypertension and cholesterol (individual-based hypertension treatment and education, individual treatment and education for high cholesterol concentration, individual treatment and health education for systolic blood pressure and cholesterol concentration, and absolute risk approach).3

The researchers found that population-wide interventions were more cost-effective than individual-based approaches. There was a 30 percent reduction in the salt content of food through legislative action and a 15 percent reduction in the salt content of food through voluntary agreements. The mass media campaign to reduce cholesterol through better diets and increased physical activity came in third. Based on the analysis, the

3

The absolute risk approach consisted of providing individuals with an estimated combined risk of a cardiovascular event (35 percent, 25 percent, 15 percent, 5 percent) over the next decade above a given specific threshold of risk with a statin, diuretic, beta-blocker, and aspirin based on their risk level.

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

researchers suggest that population-based interventions could avert more than 21 million disability-adjusted life-years (DALYs). These interventions, although more cost-effective, have a smaller absolute effect on population health than individual-based strategies. Individual-based strategies, on the other hand, were shown to have a greater potential to reduce cardiovascular disease burden and improve population health, albeit at a higher cost. Pharmacological treatment based on the absolute-risk approach at a threshold of 35 percent risk would avert 65 million DALYs. This intervention was not as cost-effective as the population-based interventions. The authors suggest that a combination of population-based and individual-based strategies could lower the incidence of cardiovascular events by as much as 50 percent.

Palar and Sturm (2009) recently reported on the potential societal savings from policies that reduce sodium consumption in the United States. The researchers used the NHANES 1999-2004 data (blood pressure, antihypertension medication use, and salt intake) to model a number of sodium-reduction scenarios to determine the change in health care costs and quality of life that could be expected from a reduction in population-level sodium consumption. The scenarios simulated reductions in sodium intake from 3,400 mg per day to one of the following levels: 2,300 mg, 1,700 mg, 1,500 mg, and 1,200 mg per day. The model used dose-response estimates for sodium and hypertension reported in the literature to calculate changes in hypertension prevalence that would result from the associated decrease in salt intake (100 mmol reduction in sodium intake results in a 7.2 mm Hg reduction in systolic blood pressure and a 3.8 mm Hg reduction in diastolic blood pressure). The model input for annual hypertension costs per case was $1,598 (based on 2005 data) and is based on analyses of Medical Expenditure Panel Survey data for 2000-2003 (Trogdon et al., 2007).

The researchers found that lowering dietary sodium is likely to have sizable financial and health benefits. Reducing salt intake from 3,400 mg to 2,300 mg per day, for example, could reduce the number of individuals with hypertension by an estimated 11.1 million. A substantial reduction of salt intake down to 1,200 mg was estimated to reduce hypertension cases by 17.7 million. The annual, direct, health care costs saved related to a reduction in population sodium consumption was equally significant. The reduction from 3,400 mg to 2,300 mg of sodium per day was estimated to result in $17.8 billion (in 2005) in annual, direct, health care cost savings and a reduction of sodium to 1,200 mg per day was associated with an estimated $28.3 billion in annual, direct, health care cost savings. With respect to quality-of-life savings, the reduction to 2,300 mg of sodium per day was associated with 312,021 QALYs saved annually, and the 1,200 mg per day was associated with 496,897 QALYs saved. Finally, the value of the

Suggested Citation:"4 Interventions Directed at the General Population." 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.
×

QALYs saved with a reduction to 2,300 mg and 1,200 mg of sodium per day was $31.6 billion and $50.3 billion, respectively.

POPULATION-BASED INTERVENTIONS AND HEALTH DISPARITIES

Not only are highly educated and affluent subgroups better positioned than the poor to benefit from innovations in medical care, they are also better positioned to respond quickly to public health messages and policies designed to either prevent or postpone lifestyle-related diseases such as hypertension. Hence, population-based interventions aimed at increasing physical activity and promoting healthy eating that fail to give due attention to differential response capabilities by race, ethnicity, socioeconomic position, and geographical location may inadvertently contribute to an increase in health disparities even as overall population health improves (Link and Phelan, 1995; Mechanic, 2007; Phelan and Link, 2005). Even if such increases in health disparities are time limited (i.e., returning to the baseline difference once disadvantaged populations make appropriate lifestyle adjustments), this nevertheless constitutes an unsatisfactory outcome if the objective is to reduce the overall population burden of hypertension while also reducing related health disparities.

Achieving these dual objectives will not be easy. A large and growing body of research (Acevedo-Garcia et al., 2008; Cutler et al., 1999, 2008; Massey and Denton, 1993; Williams and Collins, 2001b) documents that U.S. racial and ethnic minorities, especially African Americans and Hispanics, are overrepresented in urban areas that lack community-level resources to support healthy living. African Americans are simultaneously the most highly segregated racial group in the country (Acevedo-Garcia et al., 2008; Massey and Denton, 1993; Williams and Collins, 2001) and the group at highest risk for hypertension and its serious clinical sequelae. As discussed by Williams and Collins (2001), a high level of racial residential segregation can contribute to health disparities (hypertension and otherwise) through multiple pathways. These pathways include restricted opportunities for stable, meaningful employment that provides adequate family income and health care benefits; restricted access to high-quality, primary health care; restricted access to supermarkets containing fresh produce and foods low in sodium; restricted access to safe, well-maintained parks where residents can easily engage in regular, leisure-time physical activity; and finally, heightened exposure to air pollution, noise, and violence, which generate high levels of psychological stress.

More than 30 years ago, Harburg and colleagues (1973) were the first to demonstrate that mean blood pressures among African Americans in the city of Detroit varied with their place of residence. Specifically, blacks

Suggested Citation:"4 Interventions Directed at the General Population." 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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(especially black males under age 40) who lived in census tracts characterized by high unemployment, low median household income and educational attainment, high rates of crime, and high rates of marital breakup had significantly higher age- and BMI-adjusted hypertension prevalence than blacks living in more socioeconomically stable census tracts (Harburg, 1973). Interestingly, the mean blood pressure of whites did not vary by residence in high vs. low “socio-ecological stress” areas, suggesting either a differential impact of socioenvironmental stressors on the blood pressure of blacks or substantive inequalities in the cut-points used to define “high”- and “low”-stress neighborhoods for blacks vs. whites in a place that was fast becoming the country’s most racially segregated metropolitan area (Cutler et al., 1999).

The scientific literature documenting the relative lack of community-level resources to support healthy living in geographical areas characterized by low neighborhood wealth or high levels of racial residential segregation continues to grow. Morland and colleagues, for example, reported that the prevalence of supermarkets in the Atherosclerosis Risk in Communities Study increased linearly with increasing median home values and decreased linearly as the percentage of African-American residents increased (Morland et al., 2002). Franco and colleagues rated 226 food stores in Baltimore City and County on a healthy food availability index (HFAI) and found that HFAI scores were positively correlated with median household income of census tracts and inversely correlated with the percentage of African-American residents (Franco et al., 2008). Using data from the Multi-Ethnic Study of Atherosclerosis (MESA), Mujahid et al. (2008a) found that residents in neighborhoods characterized by greater (self-reported) walkability, availability of healthy foods, aesthetic quality, safety, and social cohesion had lower BMIs (especially among women) than residents in neighborhoods with lower scores on these dimensions. Using this same indicator of neighborhood quality, Mujahid et al. (2008b) observed an inverse association between neighborhood quality and hypertension prevalence in the MESA sample; however, the association was significantly attenuated when race or ethnicity was controlled, suggesting that neighborhood social cohesion, safety, walkability, food availability, and so forth, may play an important role in racial or ethnic differences in risk of hypertension in urban settings (Mujahid et al., 2008a).

Compared to African Americans, disparities in hypertension and selected cardiovascular disease (CVD) risk factors by place of residence are less well studied in other racial or ethnic minorities. Again, using data from MESA, Osypuk et al. (2009) found that living in census tracts with higher proportions of foreign-born persons from China was associated with lower consumption of high-fat foods. Although living in census tracts with higher proportions of recent immigrants from Latin America was also associ-

Suggested Citation:"4 Interventions Directed at the General Population." 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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ated with lower consumption of high-fat foods, residents of these census tracts reported significantly lower levels of physical activity. Osypuk and colleagues also found that residents of neighborhoods with higher proportions of foreign-born persons reported greater healthy food availability, but their neighborhoods were also reported to be less walkable, to have fewer exercise resources, and to have lower social cohesion. The researchers concluded that living in a contemporary immigrant enclave in the United States is not uniformly beneficial since these enclaves have varying patterns of healthy and unhealthy behaviors that can contribute to CVD risk (Osypuk et al., 2009).

Finally, in the Chicago Community Adult Health Study, Morenoff et al. (2007) found that mean blood pressure was inversely associated with neighborhood affluence (i.e., a concentration of well-educated residents with high-paying, managerial jobs). Although the prevalence of hypertension among blacks and whites was statistically significant even after controlling for individual-level income and education, adjusting for neighborhood affluence score completely eliminated this difference between the races. Interestingly, awareness of being hypertensive was greater in more disadvantaged neighborhoods and in areas containing large percentages of African Americans. Conversely, awareness levels were lower in neighborhoods containing large percentages of Hispanics and immigrants. After controlling for awareness, no differences in treated hypertension by race or ethnicity were observed; however, among persons taking antihypertensive medication, blacks were only 40-50 percent as likely as whites to be controlled. Neighborhood affluence did not modify hypertension control levels.

The above research findings of how mean blood pressures and hypertension prevalence vary within U.S. communities by race, ethnicity, and neighborhood affluence underscore the need to be attentive to the differential capacity of population subgroups to respond quickly and appropriately to population-based interventions aimed at reducing the overall burden of hypertension in this country. Healthy food has become increasingly scarce in many of our nation’s older inner cities (Franco et al., 2008; IOM, 2009b; Morland et al., 2002; Zenk et al., 2005), where large numbers of new immigrants and historically disadvantaged native-born Americans (e.g., black Americans) live. Whereas the passage of national or state-level policies designed to reduce the exposure of Americans to foods high in sodium and increase their exposure to foods high in potassium will benefit all Americans to some extent, extra steps would seem to be necessary to ensure that residents in isolated, low-wealth communities benefit just as much as their wealthier counterparts. One example of a step in this direction is the CDC’s partnership with the National Urban League’s Health and Wellness Initiative (National Urban League, 2009) to increase access by African Americans and other inner-city populations to community-level resources

Suggested Citation:"4 Interventions Directed at the General Population." 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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(e.g., supermarkets, community gardens, safe places for physical activity, affordable primary health care) that would increase the capacity of these populations to fully benefit from a national hypertension reduction initiative. Similar opportunities are potentially available through other partnerships such as the Mexican American Grocers Association (BUSCA pique Network, 2004) to ensure that healthy, affordable foods remain available to the country’s Hispanic population, especially in new settlement areas such as the U.S. South.

CONCLUSIONS

Based on the review of the literature there is strong evidence linking overweight and obesity, high salt intake, low potassium intake, unhealthy diet, and decreased physical activity to hypertension. These risk factors contribute substantially to the burden of hypertension in the United States; further, the prevalence of many of these risk factors is increasing. The observational and randomized clinical trial literature on interventions to reduce overweight and obesity, decrease salt intake, support eating a healthy diet, increase potassium intake, and increase physical activity also indicate that these risk factors are modifiable (Table 4.8) and that they can help reduce blood pressure levels. The committee concludes in light of: (1) the high prevalence of these risk factors that contribute significantly to the development of high blood pressure, (2) existing interventions to reduce these risk factors, and (3) the potential to reduce the burden of hypertension if the interventions are implemented, that actions to reduce these risk factors merit a high priority. Reducing heavy alcohol consumption was also considered; based on the low attributable fraction and the extremely low anticipated change in hypertension prevalence if heavy drinkers were to reduce their intake; it was not considered a priority for intervention to reduce hypertension.

DHDSP programs as described in Chapter 3 have focused primarily on secondary prevention activities and to a limited degree on the population-based approaches to hypertension. While secondary prevention is critical since it helps identify, treat, and rehabilitate people with established hypertension, stroke, and other cardiovascular disease, these activities should not preclude greater attention to conducting activities that prevent the onset of hypertension (primary prevention).

A stronger focus on primary prevention of hypertension is consistent with the DHDSP’s responsibility as co-lead of Healthy People 2010 in achieving progress in reducing the proportion of adults with high blood pressure, and in increasing the proportion of persons ages 2 years and older who consume ≤2,400 mg of sodium daily. Broad primary prevention of hypertension is also consistent with the DHDSP’s role as co-lead of the Public

Suggested Citation:"4 Interventions Directed at the General Population." 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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Health Action Plan to Prevent Heart Disease and its recommendation for primary prevention activities related to children and youth:

Design, plan, implement, and evaluate a comprehensive intervention for children and youth in school, family, and community settings. This intervention must address dietary imbalances, physical inactivity, tobacco use, and other determinants in order to prevent development of risk factors and progression of atherosclerosis and high blood pressure.

The committee acknowledges that within the CDC, the DHDSP is not the focal point for addressing dietary imbalances, physical inactivity, and other determinants in order to prevent the development of risk factors and progression of high blood pressure. It also acknowledges that the focus of DHDSP activities is primarily adults, not children. The committee is aware that the DHDSP, through the Cardiovascular Health Collaboration of the National Center for Chronic Disease Prevention and Health Promotion, collaborates with units across the CDC. The committee believes, however, that this collaboration can be strengthened and extended to leverage the efforts and resources of those programs to ensure proper attention to the prevention of hypertension and the reduction of risk factors for hypertension.

4.1 The committee recommends that the Division for Heart Disease and Stroke Prevention integrate hypertension prevention and control in programmatic efforts to effect system, environmental, and policy changes through collaboration with other CDC units and their external partners, to ensure that population-based lifestyle or behavior change interventions where delivered, are delivered in a coordinated manner that includes a focus on the prevention of hypertension. High-priority programmatic activities on which to collaborate include interventions for:

  • reducing overweight and obesity

  • promoting the consumption of a healthy diet that includes a higher intake of fruits, vegetables, whole gains, and unsaturated fats and reduced amounts of overall calories, sugar, sugary beverages, refined starches, and saturated and trans fats (for example a diet that is consistent with the OmniHeart diet)

  • increasing potassium-rich fruits and vegetables in the diet

  • increasing physical activity.

4.2 The committee recommends that population-based interventions to improve physical activity and food environments (typically the focus of other CDC units) should include an evaluation of their feasibility

Suggested Citation:"4 Interventions Directed at the General Population." 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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and effectiveness and their specific impact on hypertension prevalence and control.

The committee notes that, consistent with the DHDSP’s focus on secondary prevention activities, its state program grantees have also focused heavily on secondary prevention.

4.3 To create a better balance between primary and secondary prevention of hypertension the committee recommends that the Division for Heart Disease and Stroke Prevention leverage its ability to shape state activities, through its grant making and cooperative agreements, to encourage state activities to shift toward population-based prevention of hypertension.

The committee finds the evidence base to support policies to reduce dietary sodium as a means to shift the population distribution of blood pressure levels in the population convincing. The newly reported analysis of the substantial health benefits (reduced number of individuals with hypertension) and the equally substantial health care cost savings and QALYs saved by reducing sodium intake to the recommended ≤2,300 mg per day, provide resounding support to place a high priority on policies to reduce sodium intake (Palar and Sturm, 2009).

The committee is aware of the congressional directive to the CDC to engage in activities to reduce sodium intake and the DHDSP’s role in these activities. The DHDSP’s sponsorship of an Institute of Medicine study to identify a range of interventions to reduce dietary sodium intake is an important first step. The committee believes that the DHDSP is well positioned at the CDC to take greater leadership in this area through it role as co-leader of Healthy People 2010, co-leader of the National Forum for Heart Disease and Stroke Prevention, and as the sponsor of grants to state health departments and other entities.

4.4 The committee recommends that the Division for Heart Disease and Stroke Prevention take active leadership in convening other partners in federal, state, and local government and industry to advocate for and implement strategies to reduce sodium in the American diet to meet dietary guidelines, which are currently less than 2,300 mg/day (equivalent to 100 mmol/day) for the general population and 1,500 mg/day (equivalent to 70 mmol/day) for blacks, middle-aged and older adults, and individuals with hypertension.

The committee recognizes other work in progress by the IOM Committee on Strategies to Reduce Sodium Intake; therefore, it did not develop

Suggested Citation:"4 Interventions Directed at the General Population." 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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recommendations for specific strategies to reduce sodium in the American diet.

4.5 The committee recommends that the Division for Heart Disease and Stroke Prevention specifically consider as a strategy advocating for the greater use of potassium/sodium chloride combinations as a means of simultaneously reducing sodium intake and increasing potassium intake.

As noted in Chapter 2, accurate information on sodium intake or the content of sodium in specific foods that contribute importantly to sodium intake is necessary for monitoring progress in its reduction. These data are not currently available in a systematic or timely fashion. The lack of data presents a significant gap that will hamper efforts to evaluate the progress made in reducing sodium intake in the American population.

4.6 The committee recommends that the Division for Heart Disease and Stroke Prevention and other CDC units explore methods to develop and implement data-gathering strategies that will allow for more accurate assessment and tracking of specific foods that are important contributors to dietary sodium intake by the American people.


4.7 The committee recommends that the Division for Heart Disease and Stroke Prevention and other CDC units explore methods to develop and implement data-gathering strategies that will allow for a more accurate assessment and the tracking of population-level dietary sodium and potassium intake including the monitoring of 24-hour urinary sodium and potassium excretion.

Possible concerns about the impact on survey participation in national surveys such as the NHANES could be addressed by sampling an additional small number of subjects who would be asked only for a 24-hour urine sample and basic demographic data.

The committee is concerned with the differential burden of hypertension among subgroups of the U.S. population as described in Chapter 2. It is equally concerned that some population-based interventions aimed at preventing or postponing the development of hypertension may increase health disparities even as overall population health improves. This is because some groups have a differential response capability to respond to population-based interventions related to their race, ethnicity, socioeconomic position, and geographical location. To assure that all Americans will benefit from population-based interventions, steps may have to be taken to target these populations specifically. Although the committee is not proposing a specific

Suggested Citation:"4 Interventions Directed at the General Population." 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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recommendation in this area, it strongly encourages the Division for Heart Disease and Stroke Prevention to build community partnerships that will help bring interventions to the populations who might need them the most, especially those in racial or ethnic and low-wealth communities.

The committee considered public education and social marketing campaigns as a potential priority strategy. The committee acknowledges the extraordinary progress that has been made to educate the public about hypertension. In the early days of the National High Blood Pressure Education Program, less than 25 percent of Americans were aware of the relationship between hypertension and stroke, and heart disease. Since that time extraordinary gains have been made in the population’s awareness of hypertension; close to 75 percent of Americans are aware and 75 percent of Americans have their blood pressure measured every 6 months. Results to educate communities at the local level, however, have had mixed results; some changes in blood pressure were modest but statistically insignificant or did not endure over time. Sophisticated social marketing campaigns, such as the VERB™ campaign, are significantly more refined with social change theory underpinnings, targeting of audiences, and expectations for behavioral change than the earlier national and local education campaigns. Given the mixed outcomes associated with public education campaigns, the committee does not consider these efforts to be a priority for the DHDSP. Well-executed social marketing campaigns may have more promise; however, the committee believes that such campaigns should not be focused solely on hypertension. Rather, they should be integrated in general social marketing campaigns to promote healthy living through healthy eating and increased physical activity as suggested in the Institute of Medicine’s 2009 report, Local Government Actions to Prevention Childhood Obesity (IOM, 2009a). The DHDSP’s role, as suggested in Recommendation 4.1, would be to collaborate with other CDC units and external partners, to ensure that social marketing campaigns designed to promote healthy living also include a focus on the prevention of hypertension.

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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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