Prevention of Hypertension: Public Health Challenges

The prevention and management of hypertension are major public health challenges for the United States. If the rise in BP with age could be prevented or diminished, much of hypertension, cardiovascular and renal disease, and stroke might be prevented. A number of important causal factors for hypertension have been identified, including excess body weight; excess dietary sodium intake; reduced physical activity; inadequate intake of fruits, vegetables, and potassium; and excess alcohol intake.10,32 The prevalence of these characteristics is high. At least 122 million Americans are overweight or obese.33 Mean sodium intake is approximately 4,100 mg per day for men and 2,750 mg per day for women, 75 percent of which comes from processed foods.34,35 Fewer than 20 percent of Americans engage in regular physical activity,36 and fewer than 25 percent consume five or more servings of fruits and vegetables daily.37

Because the lifetime risk of developing hypertension is very high (figure 8), a public health strategy, which complements the hypertension treatment strategy, is warranted. To prevent BP levels from rising, primary prevention measures should be introduced to reduce or minimize these causal factors in the population, particularly in individuals with prehypertension. A population approach that decreases the BP level in the general population by even modest amounts has the potential to substantially reduce morbidity and mortality or at least delay the onset of hypertension. For example, it has been estimated that a 5 mmHg reduction of SBP in the population would result in a 14 percent overall reduction in mortality due to stroke, a 9 percent reduction in mortality due to CHD, and a 7 percent decrease in all-cause mortality (figure 15).10,38

Figure 15

Figure 15

Systolic blood pressure distributions BP, blood pressure; CHD, coronary heart disease; SBP, systolic blood pressure

Barriers to prevention include cultural norms; insufficient attention to health education by health care practitioners; lack of reimbursement for health education services; lack of access to places to engage in physical activity; larger servings of food in restaurants; lack of availability of healthy food choices in many schools, worksites, and restaurants; lack of exercise programs in schools; large amounts of sodium added to foods by the food industry and restaurants; and the higher cost of food products that are lower in sodium and calories.10 Overcoming the barriers will require a multipronged approach directed not only to high-risk populations, but also to communities, schools, worksites, and the food industry. The recent recommendations by the American Public Health Association and the NHBPEP Coordinating Committee that the food industry, including manufacturers and restaurants, reduce sodium in the food supply by 50 percent over the next decade is the type of approach which, if implemented, would reduce BP in the population.39,40

Community Programs

Healthy People 2010 has identified the community as a significant partner and vital point of intervention for attaining healthy goals and outcomes.41 Partnerships with community groups such as civic, philanthropic, religious, and senior citizen organizations provide locally focused orientation to the health needs of diverse populations. The probability of success increases as interventional strategies more aptly address the diversity of racial, ethnic, cultural, linguistic, religious, and social factors in the delivery of medical services. Community service organizations can promote the prevention of hypertension by providing culturally sensitive educational messages and lifestyle support services and by establishing cardiovascular risk factor screening and referral programs. Community-based strategies and programs have been addressed in prior NHLBI publications and other documents (Facts About the DASH Eating Plan,42 Your Guide to Lowering High Blood Pressure,43 National High Blood Pressure Education Month,44 The Heart Truth: A National Awareness Campaign for Women About Heart Disease,45 Mobilizing African American Communities to Address Disparities in Cardiovascular Health: The Baltimore City Health Partnership Strategy Development Workshop Summary Report,46 NHLBI Healthy People 2010 Gateway,47 Cardiovascular Disease Enhanced Dissemination and Utilization Centers [EDUCs] Awardees,48 Hearts N' Parks,49 Healthbeat Radio Network,50 Salud para su Corazón [For the Health of Your Heart]51).