A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension (2010) / Chapter Skim
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4 Interventions Directed at the General Population
4 Interventions Directed at the General Population
Pages 91-134
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From page 91... ...
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.
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From page 92... ...
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.
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From page 93... ...
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.
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32% (17-51%) Lifestyle Anticipated change in intervention References Initial SBPa Change in SBP HTNb prevalence Attributable fraction Weight loss (Horvath et al., 2008)
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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)
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32% (17-51%) Lifestyle Anticipated change in intervention References Initial SBPa Change in SBP HTNb prevalence Attributable fraction Reduce salt intake (He and MacGregor, 131 (19)
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From page 97... ...
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.
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From page 98... ...
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)
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. 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)
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Lifestyle Anticipated change in intervention References Initial SBPa Change in SBP HTNb prevalence Attributable fraction Increase potassium (Whelton et al., 131 (19)
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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)
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From page 102... ...
, 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.
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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)
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31% (13-40%) Lifestyle Anticipated change in intervention References Initial SBPa Change in SBP HTNb prevalence Attributable fraction DASH eating plan (Appel et al., 1997)
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. 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)
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3% (1-6%) Lifestyle Anticipated change in intervention References Initial SBPa Change in SBP HTNb prevalence Attributable fraction Reduce alcohol intake (xin et al., 2001)
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. 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.,
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From page 108... ...
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 Westernstyle diet or the DASH diet and to one of three levels of sodium intake (150 mmol, 100 mmol, and 50 mmol)
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(NCHS, 2003) physical activity lasting ≥10 minutes Relative risk, mean (range)
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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.
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b Hypertension. TAbLE 4-8 Modifiable Risk Factors and Attributable Fractions Based on Interventional Studies Anticipated change Attributable Lifestyle intervention References Initial SBPa Change in SBP in HTNb prevalence fraction Weight loss (Horvath et al., 2008)
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From page 112... ...
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)
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From page 113... ...
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.
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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
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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 antihypertensive medication regimens. A decrease in cardiovascular morbidity and mortality was observed during the intervention period; however, this occurred similarly in the control cities.
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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.
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From page 117... ...
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.
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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)
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From page 119... ...
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)
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risk factors by place of residence are less well studied in other racial or ethnic minorities. Again, using data from MESA, Osypuk et al.
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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.
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From page 122... ...
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)
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• 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)
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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.
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From page 125... ...
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 de velop 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.
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From page 126... ...
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)
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1995. The Pawtucket Heart Health Program: Community changes in cardiovascular risk factors and projected disease risk.
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2009. Diet and lifestyle risk factors associ ated with incident hypertension in women.
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2006. The effectiveness of urban design and land use and transport policies and practices to increase physical activity: A systematic review.
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2005. Effects of a mass media campaign to increase physical activity among children: Year-1 results of the VERB campaign.
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1994. Community education for cardiovascular disease prevention: Risk factor changes in the Minnesota Heart Health Program.
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1999. Physical activity and incident hypertension in black and white adults: The Atherosclerosis Risk in Communities Study.
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American Journal of Clinical Nutrition 65(2 Suppl)
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From page 134... ...
American Journal of Public Health 95(4)
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