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Primary Prevention of HypertensionClinical and Public Health Advisory Fromthe National High Blood Pressure Education ProgramPaul K. Whelton, MD, MScJiang He, MD, PhDLawrence J. Appel, MD, MPHJeffrey A. Cutler, MD, MPHStephen Havas, MD, MPH, MSTheodore A. Kotchen, MDEdward J. Roccella, PhD, MPHRon Stout, MD, MPHCarlos Vallbona, MDMary C. Winston, EdD, RDJoanne Karimbakas, MS, RDfor the National High Blood PressureEducation Program CoordinatingCommittee

ADIRECT POSITIVE RELATION-ship between blood pres-sure and cardiovascular riskhas long been recognized.This relationship is strong, continu-ous, graded, consistent, independent,predictive, and etiologically signifi-cant for those with and without coro-nary heart disease1,2; it has been iden-tified in both men and women, youngerand older adults, different racial andethnic groups, different countries; andapplies to those with high-normal bloodpressure as well as those with hyper-tension.1,3

Despite progress in prevention,detection, treatment, and control ofhigh blood pressure, hypertensionremains an important public healthproblem. Based on the Third NationalHealth and Nutrition Examination

Survey (NHANES III), approximately43 million noninstitutionalized USadults, 18 years of age or older, metthe criteria for diagnosis of hyperten-sion (systolic blood pressure 140mm Hg or diastolic blood pressure90 mm Hg, or taking antihyperten-sive medication) recommended in The

Sixth Report of the Joint National Com-mittee on Prevention, Detection, Evalua-tion, and Treatment of High Blood Pres-sure (JNC VI).4-6 Almost 13 millionadditional persons had been diag-nosed as having hypertension by ahealth care professional but did notmeet the previously mentioned JNC

Author Affiliations: Department of Epidemiology andMedicine, Tulane University Health Sciences Center(Dr Whelton) and Department of Epidemiology, Schoolof Public Health and Tropical Medicine (Dr He), Tu-lane University, New Orleans, La; Departments of In-ternal Medicine, Epidemiology, and InternationalHealth, Johns Hopkins Medical Institutions, Balti-more, Md (Dr Appel); Division of Epidemiology andClinical Applications (Dr Cutler) and National HighBlood Pressure Education Program, Office of Preven-tion, Education, and Control (Dr Roccella), NationalHeart, Lung, and Blood Institute, National Institutesof Health, Bethesda, Md; Department of Epidemiol-ogy and Preventive Medicine, University of Mary-land School of Medicine, Baltimore (Dr Havas);

Department of Medicine, Division of Endocrinology,Metabolism and Clinical Nutrition, Medical College ofWisconsin, Milwaukee (Dr Kotchen); Health Care Re-search Center, The Procter and Gamble Company, Ma-son, Ohio (Dr Stout); Department of Family and Com-munity Medicine, Baylor College of Medicine, Houston,Tex (Dr Vallbona); American Heart Association, Dal-las, Tex (Dr Winston); and American Institutes forResearch Health Program, Silver Spring, Md (MsKarimbakas).Corresponding Author and Reprints: Edward J. Roc-cella, PhD, MPH, Coordinator, National High Blood Pres-sure Education Program, National Heart, Lung, andBlood Institute/NIH, 31 Center Dr, MSC 2480, Bethesda,MD 20892-2480 (e-mail: roccella@nih.gov).

The National High Blood Pressure Education Program Coordinating Commit-tee published its first statement on the primary prevention of hypertension in1993. This article updates the 1993 report, using new and further evidencefrom the scientific literature. Current recommendations for primary preven-tion of hypertension involve a population-based approach and an intensivetargeted strategy focused on individuals at high risk for hypertension. These2 strategies are complementary and emphasize 6 approaches with proven ef-ficacy for prevention of hypertension: engage in moderate physical activity;maintain normal body weight; limit alcohol consumption; reduce sodium in-take; maintain adequate intake of potassium; and consume a diet rich in fruits,vegetables, and low-fat dairy products and reduced in saturated and total fat.Applying these approaches to the general population as a component of pub-lic health and clinical practice can help prevent blood pressure from increas-ing and can help decrease elevated blood pressure levels for those with highnormal blood pressure or hypertension.JAMA. 2002;288:1882-1888 www.jama.com

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VI criteria.4 Approximately 20 millionof the estimated 43 million personswith hypertension were not beingtreated with antihypertensive medica-tion, and almost 12 million of thenearly 23 million for whom suchmedication was being prescribed hadinadequately controlled hyperten-sion.4 More than 23 million adultshad high-normal blood pressure (130-139 mm Hg systolic or 85-89 mm Hgdiastolic), and almost 38 million hadnormal but above optimal blood pres-sure levels (120-129 mm Hg systolicor 80-84 mm Hg diastolic).

Primary prevention of hyperten-sion provides an opportunity to inter-rupt and prevent the continuing costlycycle of managing hypertension and itscomplications.7 The purpose of this ar-ticle is to update the 1993 National HighBlood Pressure Education Program Work-ing Group Report on Primary Preven-tion of Hypertension7 and to address thepublic health challenges of hyperten-sion described in the JNC VI report.6

METHOD OF GUIDELINEDEVELOPMENTThe National High Blood Pressure Edu-cation Program (NHBPEP) Coordinat-ing Committee consists of representa-tives from 38 national professional,public, and voluntary health organiza-tions and 7 federal agencies. As part ofthe mission to translate research re-sults into practice, the NHBPEP Com-mittee develops guidelines, adviso-ries, and statements for the clinical andpublic health communities. Since thefirst statement on the primary preven-tion of hypertension was published in1993,7 new and further evidence sup-porting those recommendations hasemerged.

The National Heart, Lung, and BloodInstitute (NHLBI) staff identified re-search suggesting the need to update theNHBPEP 1993 report. The chair of theCoordinating Committee appointed co-chairs and additional members to serveas a working group on behalf of the Co-ordinating Committee. To assist the co-chairs, NHLBI staff conducted aMEDLINE search of the English-

language, peer-reviewed scientific lit-erature from 1993 through 2001 usingkey Medical Subject Headings (MeSH)terms hypertension, blood pressure, pri-mary prevention, exercise, weight loss, al-cohol drinking, diet sodium-restricted, di-etary potassium, and diet.

The co-cha i r s rev iewed theMEDLINE search results, identified newareas to be addressed, and, with the as-sistance of NHLBI staff, developed anoutline and subsequently assembled aworking draft of the document. Thedraft document was distributed to themembers of the working group for ad-ditions and modifications. Thereafter,the additions and modifications weretabulated and discussed via teleconfer-encing and electronic mail. This pro-cess continued among members of theworking group, NHLBI staff, and co-chairs in a reiterative fashion. The co-chairs adjudicated differences of opin-ions. The assembled document wasmailed to the working group mem-bers for their final comments. The co-chairs then revised the document andforwarded it to the entire Coordinat-ing Committee for review and com-ment. A working group member pre-sented the report to the entire NHBPEPCoordinating Committee at its Febru-ary 2002 meeting, and they providedoral and written comments to be in-cluded in the document. Two meet-ings of NHLBI staff and the co-chairswere held to address and incorporatethe Coordinating Committee com-ments. Thereafter, the penultimate draftof the report was prepared and sent tothe Coordinating Committee whounanimously voted to approve it.

The development of this report wasfunded entirely by the NHLBI. Themembers of the working group, Coor-dinating Committee, and reviewersserved as volunteers.

Evidence ClassificationThe studies that provided evidence sup-porting the recommendations of this re-port were classified and reviewed by thestaff, co-chairs, and working groupmembers. The scheme used for classi-fication of the evidence is adapted from

Last and Abramson8 and has been usedpreviously.6 (See boxed note before Ref-erence List for the classification scheme.)

LIFETIME BURDEN OFELEVATED BLOOD PRESSUREAge-related increase in blood pressureis a typical occurrence in most but notall populations. Accordingly, the preva-lence of hypertension increases withincreasing age, such that more than 1 ofevery 2 adults older than 60 years of agehas hypertension.4 Experience in theFramingham Heart Study suggests thatthe residual lifetime risk for hyperten-sion is90%,andtheprobabilityof receiv-ing antihypertensive medication is 60%for middle-aged and elderly individu-als.9 High blood pressure increases mor-bidity and mortality from coronary heartdisease, stroke, congestive heart fail-ure, and end-stage renal disease.1,10,11

There is no convincing evidence of aJ-shaped relationship or a thresholdbelow which the relationship betweenlevel of blood pressure and risk of car-diovascular and renal disease is notobserved.12 The association of systolicblood pressure with risk of cardiovas-cular and renal disease is stronger thanthe corresponding relationship for dias-tolic blood pressure.13 In light of suchknowledge, this advisory is primarilyfocused on systolic blood pressure.

High blood pressure is only one ofseveral proven major modifiable riskfactors for cardiovascular disease. Incombination, these factors provide apowerful basis for predicting risk andpreventing cardiovascular complica-tions in the general population. Arecent reportof largecohort studies con-ducted in 366559 young and middle-aged men and women indicated thatpersons with a low cardiovascular dis-ease-riskprofile (serumcholesterol level200 mg/dL [5.18 mmol/L], bloodpressure 120/80 mm Hg, and no cur-rent cigarette smoking) have a 72% to85% lower mortality from cardiovas-cular disease and a 40% to 58% lowermortality from all causes compared withpersons who have 1 or more of 3 modi-fiable cardiovascular risk factors.14 Theestimated greater life expectancy for the

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low-risk group ranged from 5.8 to 9.5years. Computer programs and risk-calculating charts are available to as-sist clinicians and public health work-ers in determining risk (http://www.nhlbi.nih.gov).15

RECOMMENDATIONSApproaches to Primary Preventionof Hypertension

Hypertension can be prevented bycomplementary application of strate-gies that target the general populationand individuals and groups at higher riskfor high blood pressure. Lifestyle inter-ventions are more likely to be success-ful, and the absolute reductions in riskof hypertension are likely to be greaterwhen targeted in persons who are olderand those who have a higher risk of de-veloping hypertension compared withtheir counterparts who are younger orhave a lower risk. However, preven-tion strategies applied early in life pro-vide the greatest long-term potential foravoiding the precursors that lead to hy-pertension and elevated blood pres-sure levels and for reducing the overallburden of blood pressurerelated com-plications in the community.

Population-Based StrategyA population-based approach aimed atachieving a downward shift in the dis-tribution of blood pressure in the gen-eral population is an important compo-nent for any comprehensive plan toprevent hypertension. As shown in theFIGURE, a small decrement in the dis-

tribution of systolic blood pressure islikely to result in a substantial reduc-tion in the burden of blood pressurerelated illness.16 In an analysis based onFramingham Heart Study experience,Cook et al17 reported that a 2-mm Hg re-duction in the population average of di-astolic blood pressure for white US resi-dents 35 to 64 years of age would resultin a 17% decrease in the prevalence ofhypertension, a 14% reduction in therisk of stroke and transient ischemic at-tacks, and a 6% reduction in the risk ofcoronary heart disease. Public health ap-proaches, such as lowering sodium con-tent or caloric density in the food sup-ply, and providing attractive, safe, andconvenient opportunities for exercise areideal population-based approaches forreduction of average blood pressure inthe community. Enhancing access to ap-propriate facilities (parks, walking trails,bike paths) and to effective behaviorchange models is a useful strategy for in-creasing physical activity in the gen-eral population.18

Intensive Targeted StrategyMore intensive targeted approaches,aimed at achieving a greater reductionin blood pressure in those who are mostlikely to develop hypertension, comple-ment the previously mentioned popu-lation-based strategies for prevention ofhypertension. Groups at high risk forhypertension include those with high-normal blood pressure, a family his-tory of hypertension, African Ameri-can (black) ancestry, overweight or obe-sity, a sedentary lifestyle, excess intakeof dietary sodium, insufficient intake ofpotassium, or excess consumption ofalcohol. Contexts in which intensivetargeted interventions can be con-ducted to prevent hypertension in Af-rican Americans and older Americansinclude health care settings as well assenior centers and faith-based organi-zations that have blood pressure screen-ing and referral programs.

Interventions WithDocumented EfficacyThe 1993 recommendations7 in-cluded weight loss, reduced intake of

dietary sodium, moderation in alco-hol consumption, and increased physi-cal activity as the best proven interven-tions for prevention of hypertension.Since then, further evidence in sup-port of these recommendations hasemerged. In addition, potassiumsupplementation and modification ofeating patterns has been shown to bebeneficial in prevention of hyperten-sion. Brief descriptions of the 6 recom-mended lifestyles with proven effi-cacy for prevention of hypertension arepresented in the BOX. A summary of se-lected intervention efficacy experi-ence published since 1993 is pre-sented in the following sections.

Weight Loss. A comprehensive re-view of the evidence supporting the valueof modest reductions in body weight isprovided in the Clinical Guidelines for theIdentification, Evaluation, and Treat-mentofOverweightandObesity inAdults.19

He et al20 reported on the experience of181 normotensive persons who had par-ticipated in phase I of the Trials of Hy-pertension Prevention. During their ini-tial 18 months of active intervention,those assigned to the weight loss groupreduced their body weight by 7.7 lb (3.5kg) and their systolic and diastolic bloodpressures by 5.8 and 3.2 mm Hg, respec-tively. After 7 years of follow-up, the in-cidence of hypertension was 18.9% in theweight loss group and 40.5% in the con-trol group. These findings suggest thatweight loss interventions produce ben-efits that persist long after the cessationof the active intervention. In phase II ofthe Trials of Hypertension Prevention,the 595 participants assigned to a weightloss counseling intervention experi-enced a 21% reduction in hypertensionincidence compared with 596 counter-parts assigned to usual care.21 Weight lossparticipants who were able to lose 9.7 lb(4.4 kg) or more and to sustain thisweight loss through the 36-month pe-riod of follow-up experienced average re-duction in systolic and diastolic bloodpressure of 5.0 and 7.0 mm Hg, respec-tively.22

Dietary Sodium Reduction. Atleast 3 meta-analyses23-25 of the efficacyof reduced sodium intake in lowering

Figure. Systolic Blood Pressure Distributions

Before Intervention

After Intervention

Reduction in BP

Reduction in BP,mm Hg

% Reduction in MortalityStroke CHD Total

235

6 8

14

4 5 9

3 4 7

Pre

vale

nce,

%

Blood Pressure, mm Hg

BP indicates blood pressure; CHD, coronary heart dis-ease. Adapted from Arch Intern Med,7 with addi-tional data from Stamler.16

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blood pressure have been publishedsince 1993. In all 3 reports, sodiumreduction was associated with a smallbut significant reduction in systolicblood pressure in normotensive per-sons. In a meta-analysis of 12 random-ized controlled trials conducted in1689 normotensive participants, Cut-ler et al23 estimated that an averagereduction of 77 mmol/d in dietaryintake of sodium resulted in a 1.9-mm Hg (95% confidence interval [CI],1.2-2.6 mm Hg) decrement in systolicblood pressure and a 1.1-mm Hg (95%CI, 0.6-1.6 mm Hg) decline in dias-tolic blood pressure.

In a randomized controlled trial (theDietary Approaches to Stop Hyperten-sion [DASH]-Sodium Trial) con-ducted in 412 persons with an averagesystolic blood pressure of 120 to 159mm Hg and an average diastolic bloodpressure of 80 to 95 mm Hg, a reduc-tion in sodium intake from a high level(mean urinary sodium excretion, 142mmol/d) to an intermediate level (meanurinary sodium excretion, 107 mmol/d)reduced systolic blood pressure by 2.1mm Hg (P

Moderation of Alcohol Consump-tion. In a meta-analysis of 15 random-ized controlled trials, Xin et al32

reported that decreased consumptionof alcohol (the median reduction inself-reported consumption of alcoholwas 76%, with a range from 16%-100%) was associated with a reductionin blood pressure, and that the rela-tionship between reduction in meanpercentage of alcohol and decline inblood pressure was dose-dependent.32

Pooling of the experience of 269 nor-motensive participants enrolled in 6randomized controlled trials identifieda reduced consumption of alcohol asbeing associated with a 3.56-mm Hg(95% CI, 2.51-4.61 mm Hg) lowerlevel of systolic blood pressure and a1.80-mm Hg (95% CI, 0.58-3.03mm Hg) lower level of diastolic bloodpressure.32 Therefore, it is recom-mended that alcohol consumption belimited to no more than 1 oz (30 mL)of ethanol (eg, 24 oz [720 mL] of beer,10 oz [300 mL] of wine, or 2 oz [60mL] of 100-proof whiskey) per day inmost men and to no more than 0.5 oz(15 mL) of ethanol per day in womenand lighter-weight persons.

Potassium Supplementation. Clini-cal trials and meta-analyses indicate thatpotassium supplementation lowersblood pressure in both hypertensive andnormotensive persons. In a meta-analysis of the results from 12 trials with1049 normotensive participants,Whelton et al33 reported that potas-sium supplementation (median, 75mmol/d) lowered systolic blood pres-sure by 1.8 mm Hg (95% CI, 0.6-2.9)and diastolic blood pressure by 1.0mm Hg (95% CI, 0.0-2.1). The effectsof potassium supplementation ap-peared greater in those with higherlevels of sodium intake.

Modification of Whole Diets. TheDASH and DASH-Sodium trials useddietary interventions that incorporatedseveralnutritional recommendations forlowering blood pressure.26,34 In the8-week DASH trial, study participantswithasystolicbloodpressureof less than160 mm Hg and a diastolic blood pres-sure between 80 and 95 mm Hg were

randomly assigned to one of the follow-ing dietary groups: (1) a control diet thatwas low in fruits, vegetables, and dairyproducts,witha fat content typicalof theaverage diet in the United States, (2) asimilar diet that was rich in fruits andvegetables, or (3) a DASH diet that wasrich in fruits, vegetables, and low-fatdairy products but reduced in satu-rated and total fat.35 Among the 326 nor-motensive DASH participants (bloodpressure 140/90 mm Hg), the DASHdiet reduced systolic blood pressure by3.5 mm Hg (P

levels early in life are more likely todevelop hypertension later in life.Efforts to prevent blood pressure lev-els from increasing in childhood areprudent and best accomplished byapplication of the same lifestyle ap-proaches used to prevent and treat hy-pertension in adults.44

Accordingly, school administratorsare encouraged to examine their lunchmenus and promote the use of heart-healthy foods. Parents are encouragedto read food labels and make wisechoices for lunches prepared at home.In addition, school curricula should in-clude health education programs thatpromote increased physical activity andother healthy lifestyles aimed at pre-vention of cardiovascular and otherchronic diseases.

ADDITIONAL RESEARCHFurther strengthening of the sciencethat underpins strategies for imple-mentation and maintenance of hyper-tension prevention strategies is war-ranted. Some of the most pressingneeds include (1) attaining a betterunderstanding of physical and behav-ioral factors that influence blood pres-sure during growth and development,(2) gaining additional knowledge ofthe efficacy and effectiveness of spe-cific dietary interventions, such asincreased dietary protein or dietaryfiber intake, and other modificationsof whole diets in the prevention ofhypertension, (3) testing alternativestrategies for implementation of non-pharmacologic interventions, includ-ing nutrition education, in clinicaland community settings, (4) enhanc-ing the capacity to change generalenvironmental exposures to diet andexercise in a favorable manner byworking with the food industry andplanning agencies, (5) identifying andtesting culturally specific approachesfor hypertension prevention, (6)maintaining a strong program ofbehaviorally focused research tostrengthen the empirical base of edu-cational interventions, and (7) charac-terizing phenotypic and genetic pre-dictors of response to interventions

for prevention of hypertension in anindividual and/or group.

BARRIERS TO IMPROVEMENTCultural norms, insufficient attentionto health education and lack of refer-ral to registered dietitians, economicdisincentives to healthier lifestyles, lackof reimbursement for hypertension pre-vention counseling services by third-party payers, and other barriers to pre-vention of hypertension continue toimpede progress. For example, eco-nomic disincentives to healthier lif-estyles include higher prices for low-sodium products and lower unit pricingfor larger portions. To overcome thisbarrier, professional associations andpolicy developers should work withthe food industry to increase availabil-ity of lower-sodium food productsand to provide educational programsfor consumers regarding portion sizeand heart-healthy food choices. Inaddition, insufficient attention tohealth education, including nutritioneducation, by health care providers,school systems, and public health andvoluntary associations is an impedi-ment to progress.

SUMMARYA combination of increased physical ac-tivity, moderation in alcohol intake, andconsumption of a diet that is lower insodium content and higher in fruits, veg-etables, and low-fat dairy products thanthe average American diet represents thebest approach for preventing high bloodpressure in the general population andin high-risk groups. The demonstratedreductions in blood pressure using life-style changes can be as large as thoseseen in drug studies, can occur in vir-tually all subgroups of the population,and can be sustained over a long pe-riod of time (more than 3 years).

Additional education of health careprofessionals and the general public, en-hanced means of support for those at-tempting to change their lifestyles, andpolicies aimed at reducing the burdenin complying with the recommenda-tions for nonpharmacologic reduc-tions in blood pressure are essential el-

ements for any national program aimedat prevention of hypertension. Giventhat sodium added during processingof foods accounts for approximatelythree quarters of an individuals totalsodium intake, any meaningful reduc-tion in sodium intake is predicated ona decrease in dietary sodium from foodsources.45 This could be achieved bygradually reducing the amount of so-dium added during processing and bygreater availability and promotion offoods with a lower sodium content. Re-duction in discretionary salt intake atthe table and during cooking is desir-able but unlikely to have a major im-pact on dietary sodium intake in mostpersons.

Despite the acknowledged chal-lenges to implementing these recom-mendations, the potential for healthbenefits makes continued efforts toachieve prevention of hypertension animportant national objective.

Funding/Support: This work was funded entirely bythe National Heart, Lung, and Blood Institute. The au-thors and Coordinating Committee representativesserved as volunteers without remuneration.The NHBPEP Coordinating Committee Includes Rep-resentatives From the Following Member Organiza-tions: American Academy of Family Physicians; Ameri-can Academy of Insurance Medicine; AmericanAcademy of Neurology; American Academy of Oph-thalmology; American Academy of Physician Assis-tants; American Association of Occupational HealthNurses; American College of Cardiology; American Col-lege of Chest Physicians; American College of Occu-pational and Environmental Medicine; American Col-lege of Physicians-American Society of InternalMedicine; American College of Preventive Medicine;American Dental Association; American Diabetes As-sociation; American Dietetic Association; AmericanHeart Association; American Hospital Association;American Medical Association; American Nurses As-sociation; American Optometric Association; Ameri-can Osteopathic Association; American Pharmaceu-tical Association; American Podiatric MedicalAssociation; American Public Health Association;American Red Cross; American Society of Health-System Pharmacists; American Society of Hyperten-sion; Association of Black Cardiologists; Citizens forPublic Action on High Blood Pressure and Choles-terol, Inc; International Society on Hypertension inBlacks; National Black Nurses Association, Inc; Na-tional Hypertension Association, Inc; National Kid-ney Foundation, Inc; National Medical Association; Na-tional Optometric Association; National StrokeAssociation; NHLBI Ad Hoc Committee on MinorityPopulations; Society of Geriatric Cardiology; Societyfor Nutrition Education. Federal Agencies: Agency forHealthcare Research and Quality; Department of Vet-erans Affairs; Centers for Medicare and Medicaid Ser-vices; Health Resources and Services Administration;National Center for Health Statistics, Centers for Dis-ease Control and Prevention; National Heart, Lung,and Blood Institute; National Institute of Diabetes andDigestive and Kidney Diseases.

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Scheme Used forClassification of the EvidenceM Meta-analysis; use of statisticalmethods to combine the results fromclinical trials

Ra Randomized controlled trials; alsoknown as experimental studies

Re Retrospective analyses; alsoknown as case-control studies

F Prospective study; also known ascohort studies, including historicalor prospective follow-up studies.

X Cross-sectional survey; also knownas prevalence studies

Pr Previous review or position state-ments

C Clinical interventions (nonran-domized)

To provide information on the evi-dence category for articles in this re-port, these symbols are appended tothe citations in the reference list.

PRIMARY PREVENTION OF HYPERTENSION

1888 JAMA, October 16, 2002Vol 288, No. 15 (Reprinted) 2002 American Medical Association. All rights reserved.

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