National High Blood Pressure Education Program
Working Group Report on Primary Prevention of Hypertension
In the United States and most other societies, blood pressure and the prevalence of high blood pressure rise progressively with increasing age. High blood pressure is among the most common and most important of the risk factors for cardiovascular-renal disease. To date, blood-pressure-related risk reduction efforts have almost uniformly revolved around the paradigm of hypertension detection and treatment. Despite the clear benefits of treating established hypertension, this approach alone will not prevent all of the blood-pressure-related cardiovascular-renal disease in the community. Blood-pressure-related vascular complications can occur prior to the onset of established hypertension because the blood pressure-cardiovascular disease risk relationship is continuous and progressive, even within the nor-motensive blood pressure range. Furthermore, it is difficult to ensure that all hypertensives are detected and treated adequately. In addition, many hypertensive treatment regimens are expensive, especially those including new drugs, and almost all carry the potential for some adverse effects. For these reasons, hypertension treatment represents an important but incomplete response to the population burden of blood-pressure-related cardiovascular disease.
Primary prevention of hypertension is a natural extension of hypertension treatment. It provides an attractive opportunity to interrupt and prevent the continuing costly cycle of managing hypertension and its complications. Primary prevention of hypertension can be accomplished through interventions with the general population (population strategy) with the objective of achieving a downward shift in the distribution of blood pressure. This approach can be complemented by special attempts to lower blood pressure among populations that are most likely to develop hypertension (targeted strategy). The latter includes: African Americans, persons with a high normal blood pressure, those with a family history of hypertension, and individuals with one or more lifestyle factors that contribute to age-related increases in blood pressure. These lifestyle factors include a high sodium chloride intake, excessive consumption of calories, physical inactivity, excessive alcohol consumption, and deficient intake of potassium. They have formed the basis for intervention strategies that have shown promise in the prevention of high blood pressure. The evidence is less convincing for stress management and for supplementation with calcium, magnesium, fish oils, or fiber, and for alteration in macronutrient consumption. In many instances, however, the data are insufficient to make a final judgment on the potential role of these factors in the primary prevention of hypertension.
Intervention programs conducted in community-based and practice-based settings indicate that the desired lifestyle changes are potentially feasible. Achievement of the intervention goals has, however, been constrained by a number of societal barriers, including a lack of satisfactory food choices and the absence of a national campaign to foster adoption of the population-based and targeted intervention strategies necessary to prevent high blood pressure. The National High Blood Pressure Education Program is well positioned to provide leadership for such a campaign. Goals of the campaign should include increased efforts to promote foods that are lower in sodium chloride and calorie content and higher in potassium content, and to promote physical activity and moderation in alcohol consumption. To reach these goals, additional public education to underscore the importance of lifestyle factors in the development of hypertension, as well as enhanced education and support of health care providers to encourage and facilitate their active participation in hypertension prevention activities, will be necessary. Objectives for national change in the prevalence of factors that increase the public's risk of developing high blood pressure should be established, where they do not yet exist. Finally, additional attention needs to focus on research questions related to the prevention of high blood pressure. Although challenging, the potential for benefit makes primary prevention of hypertension an important national policy goal for the next decade.
SOURCE: National Institutes of Health, National Heart Lung and Blood Institute, publication No 93-2669.
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