Health Objectives for the Nation Progress Toward Achieving the 1990 High Blood Pressure Objectives

In the United States, an estimated 58 million persons have high blood pressure (HBP (hypertension)), placing them at increased risk for stroke, heart disease, and kidney failure (1). Many federal, state, and community programs and professional societies have targeted control of HBP, and nine of the 1990 Health Objectives for the Nation addressed HBP (2). Seven of the objectives have been met, all or in part, and one will not be met; the status of one is unknown. This report summarizes progress toward achieving the 1990 objectives for HBP.By 1990, at least 50 percent of adults should be able to state the principal risk factors for coronary heart disease and stroke, i.e., high blood pressure, cigarette smoking, elevated blood cholesterol levels, diabetes.

This objective has been met. The 1985 National Health Interview Survey, conducted by CDC's National Center for Health Statistics (NCHS), determined that 91% of the population recognized HBP as a risk factor for coronary heart disease and stroke; 90%, cigarette smoking; 86%, elevated blood cholesterol; and 60%, diabetes (3).By 1990, at least 90 percent of adults should be able to state whether their current blood pressure is normal (below 140/90) or elevated, based on a reading taken at the most recent visit to a medical or dental professional or other trained reader.

This objective has been met. In 1985, 94% of adults who had ever had their blood pressure measured reportedly knew their blood pressure by categories of "high," "low," or "normal" at their last reading (3). Data from CDC's 1988 Behavioral Risk Factor Surveillance System (BRFSS) indicate that 99.8% of adults have had their blood pressure measured, 95.4% within the past 2 years.By 1990, no geopolitical area of the United States should be without an effective public program to identify persons with high blood pressure and to follow up on their treatment.

This objective has been met. All state health departments have HBP control programs, although limited resources constrain many states from reaching and providing follow-up to all persons in need.By 1985, at least 50 percent of processed food sold in grocery stores should be labeled to inform the consumer of sodium and caloric content, employing understandable, standardized, quantitative terms.

This objective has been met. In 1988, approximately 65% of processed food sold in grocery stores had sodium and caloric content labeling that employed standard quantitative terms (4).By 1985, a methodology should be developed to assess categories of high blood pressure control, and a National baseline study of this status should be completed. Five categories are suggested: (1) Unaware; (2) Aware, not under care; (3) Aware, under care, not controlled; (4) Aware, under care, controlled; and (5) Aware, monitored without therapy.

This objective has been met. The 1984 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure established categories of blood pressure control (5); the Third National Health and Nutrition Examination Survey (NHANES III), conducted by NCHS, includes methodology to assess these categories and will provide baseline data.By 1985, a system should be developed to determine the incidence of high blood pressure, coronary heart disease, congestive heart failure and hemorrhagic and occlusive strokes. After demonstrated feasibility, by 1990 ongoing sets of these data should be developed.

The first portion of this objective has been met. Regional data sets have been or are being collected in time-limited studies that will permit estimations of national cardiovascular disease incidence. In particular, three studies by the National Heart, Lung, and Blood Institute (NHLBI) should provide adequate incidence data for adults of all ages: the Coronary Artery Disease Risk Development in Young Adults, for persons aged 18-30 years; the Atherosclerosis Risk in Community program, for persons aged 35-74; and the Cardiovascular Health Study, for persons aged greater than or equal to 65 years. In addition, a follow-up analysis of NHANES I will provide incidence data for coronary artery disease. However, ongoing surveillance of cardiovascular disease is not yet institutionalized but will be required to regularly produce data for state and national estimates of disease prevalence and incidence.By 1990, at least 60 percent of the estimated population having definite high blood pressure (160/95)* should have attained successful long term blood pressure control, i.e., a blood pressure at or below 140/90 for two or more years.

The Public Health Service has been tracking this objective at two levels: 1) the level of 160/95 mm Hg that was used as the standard for hypertension control when the objective was written in 1979 and 2) the level of 140/90 mm Hg that was adopted as the standard for hypertension control in 1984. This report addresses progress toward both standards.

This objective has most likely been met at the measurement defined for HBP when the objective was written (160/95 mm Hg). For 1976-1980, NHANES II indicated that 34% of persons with HBP were controlling their blood pressure at the level of 160/95 mm Hg. During 1982-1984, 57% of persons with HBP in a seven-state area were controlling their blood pressure at 160/95 mm Hg (6). In 1987, 65% of a sample of persons in South Carolina were controlling their HBP at the 160/95 mm Hg level (7).

For the revised measurement promulgated in 1984 (140/90 mm Hg) (5), evidence suggests progress has been made: 1) NHANES II indicated that 11% of persons with HBP were controlling at the level of 140/90 mm Hg; 2) in the study of the seven-state area cited above, 24%; and 3) in South Carolina, 38%. However, progress toward the 140/90 mm Hg level cannot be definitively determined until data from NHANES III become available in the early 1990s. Because none of the rates above include control by nonpharmocologic measures, they may underestimate actual levels of control.By 1990, the prevalence of significant overweight (120 percent of "desired" weight) among the U.S. adult population should be decreased to 10 percent of men and 17 percent of women, without nutritional impairment.

This objective will not be met. Data from NHANES I for 1971-1974 indicated that 14% of adult men and 24% of adult women were greater than 120% above "desired" weight (8). NHANES II data for 1971-1980 indicated no reduction in the percentage of substantially overweight persons (8). In the 1988 BRFSS, 26.7% of adult men and 25.3% of adult women reported weights corresponding to greater than 120% of desired weight.By 1990, the average daily salt** ingestion (as measured by excretion) for adults should be reduced at least to the 3 to 6 gram range.

No data are available to determine if this objective will be met. Because direct measures of sodium consumption by excretion are not available, progress toward achieving this objective was determined by indirect measures of food intake, such as dietary surveys and the Food and Drug Administration's (FDA) Total Diet Study. These measures provide information only for nondiscriminatory sodium intake (i.e., sodium naturally present and sodium added by manufacturers) and exclude sodium added in cooking or at the table. The FDA Total Diet Study indicated that for 1982-1984, excluding salt added at the table or in cooking, daily sodium intake for women was within the desired range but that daily sodium intake for men exceeded 2.6 g (4). More recently, the Continuing Survey of Food Intakes by Individuals indicated that for 1985-1986, excluding salt added at the table or in cooking, the mean 4-day intake for women aged 19-50 years was 2.3 g (9); for men aged 19-50 years, daily sodium intake exceeded 3.4 g (10). However, an FDA survey indicated that in 1988 45% of respondents read the ingredients listed on labels to help them avoid or limit their sodium consumption (4). In addition, from 1972 through 1985 food-grade salt sales in grocery stores, in pounds per capita, declined 36% (6). Reported by: National High Blood Pressure Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health. Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service. Food and Drug Administration. Bur of Community Health Svcs, Health Resources and Svcs Administration. Cardiovascular Health Br, Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Progress toward achieving the 1990 national objectives for HBP is due in large part to the National High Blood Pressure Education Program (NHBPEP). Coordinated by NHLBI with support from federal agencies, state and local health departments, and voluntary organizations, the NHBPEP has led to improvements in blood pressure control that have contributed to a 50% decrease in stroke and a 35% decrease in coronary heart disease since 1972 (11).

Despite this progress, 30 million persons in the United States still have inadequately controlled blood pressure. Sustained attention and resources are needed to decrease the prevalence of HBP, particularly within the black population, which is disproportionately burdened by hypertensive disease. Patients with HBP must be referred into the health-care system, effectively treated, and maintained on treatment.

The same nonpharmacologic strategies used to treat hypertension (e.g., weight loss, physical activity, and restriction of salt and alcohol intake) are epidemiologically associated with lower blood pressure (12). Thus, alterations in physical activity and dietary patterns in the U.S. population have the potential to further reduce the burden of cardiovascular disease through reductions in the prevalence of overweight and HBP (13). The successes of HBP control efforts highlight the value of maintaining or developing similar national programs for other major cardiovascular disease risk factors and chronic disease conditions.

References

1. 1984 Joint National Committee. Hypertension prevalence and

the status of awareness, treatment, and control in the United States: final report of the Subcommittee on Definition and Prevalence of the 1984 Joint National Committee. Hypertension 1985;7:457-68.

2. Public Health Service. Promoting health/preventing disease: objectives for the nation. Washington, DC: US Department of Health and Human Services, Public Health Service, 1980.

3. Roccella E, Bowler A, Ames M, Horan M. Hypertension knowledge, attitudes and behavior: 1985 NHIS findings. Public Health Rep 1986;101:599-606.

4. Center for Food Safety and Applied Nutrition. Health and diet surveys and the food label and package surveys. Washington, DC: Food and Drug Administration, Center for Food Safety and Applied Nutrition, 1988.

5. National Heart, Lung, and Blood Institute. The 1984 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1984;144:1045-57.

6. Roccella EJ, Horan MJ. The National High Blood Pressure Education Program: measuring progress and assessing its impact. Health Psychol 1988;7(suppl):297-307.

7. Lackland DT, Wheeler FC, Mace ML. The ten-year change in prevalence, awareness, treatment and control of high blood pressure (Abstract). Presented at the 1989 National Conference on High Blood Pressure Control, Orlando, Florida, May 6-8, 1989.

8. Office of Disease Prevention and Health Promotion. The 1990 health objectives for the nation: a midcourse review. Washington, DC: US Department of Health and Human Services, Public Health Service, 1987.

9. US Department of Agriculture. National Food Consumption Survey: Continuing Survey of Food Intakes by Individuals, women 19-50 years and their children 1-5 years, 4 days. Hyattsville, Maryland: US Department of Agriculture, 1988; USDA report no. 86-3. 10. US Department of Agriculture. Nationwide Food Consumption Survey: Continuing Survey of Food Intakes by Individuals, men 19-50 years 1-day, 1985. Hyattsville, Maryland: US Department of Agriculture, 1986. (NFCS, CSF II report no. 85-3). 11. National Heart, Lung, and Blood Institute. The 1988 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1988;148:1023-38. 12. Horan M, Roccella E. Nonpharmacologic treatment of hypertension: does it work? Eur Heart J 1987;8(suppl B):77-86. 13. Farquhar J, Fortman S, Flora J, et al. Effects of communitywide education on cardiovascular risk factors. JAMA 1990;264:359-65.

• When originally written, this objective used 160/95 mm Hg as

the standard for control; in 1984, the standard was revised to 140/90 mm Hg.

** When originally written, this objective incorrectly referred to "daily sodium ingestion." Three to six g of salt is equivalent to 1.2-2.4 g of sodium.

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