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.



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4 Interventions Directed at the General Population T  his 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 hyperten- sion 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 attribut- able 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 dif- ferent 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 de- terminants of hypertension, and the importance of considering health dis- parities. Potential interventions such as community and environmental interventions, and public education and media and social marketing cam- paigns are considered. Finally, the chapter ends with a concluding statement and recommendations. 91

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92 APPROACH TO PREVENT AND CONTROL HYPERTENSION METHODOLOGy This section addresses the methodology used in prioritizing modifiable risk factors for intervention. The committee’s selection of priority inter- ventions 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 iden- tify 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 attribut- able fraction can be computed as follows, where Pe is the prevalence of the exposure in the population: AF = { (RR-1) × Pe }f ÷ { ([RR-1] × Pe) + 1 } To compute the attributable fractions for various risk factors, the com- mittee 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 hy- pertension 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 pres- sure (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

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9 INTERVENTIONS DIRECTED AT THE GENERAL POPULATION 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 in- vestigations, which are mainly cross-sectional or prospective in nature, and randomized intervention trials. Each of these has its strengths and limita- tions. 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 interven- tion, 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, ap- proximately 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 hyperten- sion 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 cur- rent 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

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9 TAbLE 4-1 Risk Factor: Overweight and Obesity Modifiable Risk Factor Definition Prevalence (source) Overweight and obesity 0.66 (NCHS, 2006) BMI ≥25 kg/m2 Relative risk, mean (range) Attributable fraction, mean (range) 1.7 (1.3-2.6) 32% (17-51%) Lifestyle Anticipated change in intervention References Initial SBPa Change in SBP HTNb prevalence Attributable fraction Weight loss (Horvath et al., 2008) 135 (18) –6 (–3 to –10) 8% (4-13%) 28% (Ebrahim and Smith, 1998) –5 (–2 to –8) 7% (3-10%) 24% a Systolic blood pressure. b Hypertension.

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9 INTERVENTIONS DIRECTED AT THE GENERAL POPULATION 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 hyperten- sion 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 ef- fect 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 ef- fect 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 over- weight and obese members of the population would hypothetically reduce the overall population prevalence of hypertension by 7 to 8 percent. Ad- ditionally, 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 per- cent 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.

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9 TAbLE 4-2 Risk Factor: High Salt Intake Modifiable Risk Factor Definition Prevalence (source) High salt intake 0.87 (HHS, 2008) ≥2,400 mg/day sodium Relative risk, mean (range) Attributable fraction, mean (range) 1.3 (1.2-1.4) 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) –4 (–3 to –5) 6% (5-8%) 21% 2004) a Systolic blood pressure. b Hypertension.

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9 INTERVENTIONS DIRECTED AT THE GENERAL POPULATION 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 in- take, 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 manufactur- ing 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 observa- tional 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 random- ized 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 dia- stolic 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

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9 APPROACH TO PREVENT AND CONTROL HYPERTENSION 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 com- bination 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 com- prehensive lifestyle modification for blood pressure control; (Elmer et al., 2006; Stamler et al., 1989), sodium restriction was examined in combina- tion 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 tri- als 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 preva- lence 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.

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99 INTERVENTIONS DIRECTED AT THE GENERAL POPULATION 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 potas- sium, 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 excre- tion 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 multivari- ate 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 sup- plementation 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

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100 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 Anticipated change in intervention References Initial SBPa Change in SBP HTNb prevalence Attributable fraction Increase potassium (Whelton et al., 131 (19) –3 (–2 to –4) 5% (4-7%) 17% intake 1997) a Systolic blood pressure. b Hypertension.

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101 INTERVENTIONS DIRECTED AT THE GENERAL POPULATION 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 in- cluded 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 po- tassium (a 3.9 mm Hg decrease in blood pressure), despite the insignificant p-value (Dickinson et al., 2006). In the most comprehensive of these meta- analyses, 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 Ap- proaches 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 potas- sium 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-

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12 APPROACH TO PREVENT AND CONTROL HYPERTENSION and effectiveness and their specific impact on hypertension prevalence and control. The committee notes that, consistent with the DHDSP’s focus on sec- ondary prevention activities, its state program grantees have also focused heavily on secondary prevention. 4.3 To create a better balance between primary and secondary preven- tion 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 hy- pertension) 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 po- sitioned 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 part- ners 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 Com- mittee on Strategies to Reduce Sodium Intake; therefore, it did not develop

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12 INTERVENTIONS DIRECTED AT THE GENERAL POPULATION 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 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. 4.7 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 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 hyperten- sion among subgroups of the U.S. population as described in Chapter 2. It is equally concerned that some population-based interventions aimed at pre- venting 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

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12 APPROACH TO PREVENT AND CONTROL HYPERTENSION 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 cam- paigns 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 Edu- cation Program, less than 25 percent of Americans were aware of the re- lationship 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; how- ever, 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. REFERENCES Acevedo-Garcia, D., T. L. Osypuk, N. McArdle, and D. R. Williams. 2008. Toward a policy- relevant analysis of geographic and racial/ethnic disparities in child health. Health Affairs 27(2):321-333. AHA (American Heart Association). 2009. Make healthy food choices. http://www.american heart.org/presenter.jhtml?identifier=537 (accessed November 5, 2009). Anderssen, S., I. Holme, P. Urdal, and I. Hjermann. 1995. Diet and exercise intervention have favourable effects on blood pressure in mild hypertensives: The Oslo Diet and Exercise Study (ODES). Blood Pressure 4(6):343-349.

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