Dietary sodium reduction: a public health approach to decreasing hypertension.

In the years between 1960 and 1991, the prevalence of hypertension in the United States decreased from 29.7% to 20.4%. The recognition of hypertension as the Bsilent killer[ and the work of the National High Blood Pressure Education Program contributed to this public health success. In recent years, however, hypertension has reemerged as a major public health problem. The prevalence of hypertension in US adults has steadily increased and now hovers between 29% and 30%. This increase is due in part to aging demographics as well as the epidemic of overweight and obesity. It is now estimated that nearly 75 million or 1 in every 3 adults has hypertension. Hypertension constitutes a significant risk factor for myocardial infarction, stroke, heart failure, and renal failure. Cardiovascular clinicians have an enormous armamentarium of pharmacological agents that, particularly when used in combination, have the potential to control most cases of hypertension; indeed, control rates have risen over time, according to an article published inThe Journal of the American Medical Association in May 2010. In an accompanying editorial, Aram Chobanian, Boston University Medical Center, and first author of the Joint National Committee on the Prevention Detection and Treatment of Hypertension (JNC 7) guidelines, commented that although the progress in treatment is encouraging, rates of high blood pressure will continue to rise as the population ages unless steps are taken to change some of its underlying causes. Ford and colleagues, in a recent article, calculated the percentage of Americans considered Blow risk[ for CVD. The trend from the period 1999 to 2004 was unfavorable, demonstrating that only 7.5% (down from 10.5% in the period 1988Y1994) would be considered low risk. One factor contributing to this negative trend was the decrease in the percentage of normotensive patients. Recently, the Institute of Medicine (IOM), in its report entitled BA Population-Based Policy and Systems Change Approach to PreventandControlHypertension,[ published in February 2010, declared high blood pressure a Bneglected disease.[ In its report, the IOM called for population-based strategies designed to impact large numbers of people and improve population health status. The IOM further championed behavioral and lifestyle interventions that target risk factors that contribute to hypertension, identifying the following: unhealthy diets, excess salt consumption and low dietary potassium intake, overweight/obesity, and sedentary lifestyles. In April 2010, the IOM released a second report related to the hypertension document, BStrategies to Reduce Sodium Intake in the United States,[ focusing on a population approach to dietary sodium reduction. In 2008, Congress actually petitioned the IOM for recommendations on strategies to reduce dietary sodium intake. The average intake of sodium for American adults is approximately 3400 mg daily, fully 50% more than the current upper limit recommendation of no more than 2300 mg daily. (Actually, for at least 70% of adults in the United StatesVthose with hypertension, African Americans, and those older than 40 yearsVthe daily consumption of sodium should not exceed 1500 mg.) Typically, when clinicians open a dialogue with hypertensive or heart failure patients regarding reducing dietary sodium intake, patients often reply that Bthe salt shaker is not even on the table,[ unaware that only about 6% of dietary sodium comes from salt added at the table. Approximately 75% of dietary sodium comes from processed food. Voluntary efforts to reduce sodium intake have been unsuccessful. The