Sonia Y. Angell

A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future generations: the Lancet Commission on hypertension

Elevated blood pressure is the strongest modifiable risk factor for cardiovascular disease worldwide. Despite extensive knowledge about ways to prevent as well as to treat hypertension, the global incidence and prevalence of hypertension and, more importantly, its cardiovascular complications are not reduced—partly because of inadequacies in prevention, diagnosis, and control of the disorder in an ageing world. The aim of the Lancet Commission on hypertension is to identify key actions to improve the management of blood pressure both at the population and the individual level, and to generate a campaign to adopt the suggested actions at national levels to reduce the impact of elevated blood pressure globally. The first task of the Commission is this report, which briefly reviews the available evidence for prevention, identification, and treatment of elevated blood pressure, hypertension, and its cardiovascular complications. The report focuses on how as-yet unsolved issues might be tackled using approaches with population-wide impact and new methods for patient evaluation and education in the broadest sense (some of which are not always strictly evidence based) to manage blood pressure worldwide. The report is built around the concept of lifetime risk applicable to the entire population from conception. Development of subclinical and sometimes clinical cardiovascular disease results from lifetime exposure to cardiovascular risk factors combined with the susceptibility of individuals to the harmful consequences of these risk factors. The Commission recognises the importance of other cardiovascular risk factors—eg, smoking, obesity, dyslipidaemia, and diabetes mellitus—on antihypertensive treatment. However, as a Commission on hypertension, this report focuses mainly on issues and actions related to elevated blood pressure. Previous action plans for improving management of elevated blood pressure and hypertension have not yet provided adequate results. Therefore, the Commission has identified ten essential and achievable goals and ten accompanying, mutually additive, and synergistic key actions that—if implemented effectively and broadly—will make substantial contributions to the management of blood pressure globally. The Commission deliberately has not listed these complementary key actions by priority because the balance between strength of evidence, feasibility, and potential benefit could differ by country.

Cholesterol Control Beyond the Clinic: New York City's Trans Fat Restriction

Although blood cholesterol levels in the United States have decreased slightly since the late 1980s (1), consumption of saturated and trans fats remains above recommended maximum levels (2, 3), and only one quarter of U.S. adults with high cholesterol have it under control (4). Some 24 million U.S. adults report taking cholesterol-lowering medications (5). Changing a persons nutrition-related behavior to improve cholesterol control is challenging (6) and a source of frustration for clinicians (7). Public health action can complement health care provider efforts. The New York City Department of Health and Mental Hygiene adopted such a strategy when it restricted the use of artificial trans fat in restaurant food. We describe the rationale and process that led to this New York City Health Code amendment and the Departments experience implementing the rule. Artificial trans fat is an unnecessary ingredient that poses a substantial risk to heart health. Although no randomized, controlled trials have assessed the effect of trans fat consumption on cardiovascular events, evidence from experimental studies, dietary trials, and prospective observational studies (3, 8) demonstrates that consumption of trans fatty acids provides no apparent nutritional benefit and has considerable potential for harm. The Institute of Medicine (3) concluded that a positive linear trend exists between trans fatty acid intake and low-density lipoprotein cholesterol level, which increases the risk for coronary heart disease. Unlike saturated fat, trans fat also decreases high-density lipoprotein cholesterol levels (3, 8, 9). Trans fat intake has a large effect on cardiovascular health: A mere 2% increase in energy intake from trans fat may increase the risk for a coronary event by up to 23% (8). Other potential adverse effects have been noted, such as affecting insulin sensitivity and increasing systemic inflammation, which raises additional public health concerns (8, 10). Each year, 6% to 19% of coronary heart disease events and 30000 or more premature deaths are estimated to occur in the United States because of trans fat consumption (8, 11). The Institute of Medicine, the American Heart Association, the U.S. Department of Agriculture, and other leading health organizations recommend minimizing trans fat intake (3, 1215). To achieve this, health care providers are asked to counsel patients (12). However, such advice is unlikely to be broadly effectivemillions of Americans would need to routinely study package labels on groceries and actively seek information on trans fat in restaurant foods, where a growing proportion of calories are now consumed. Health would be better served by making the use of safer fats the default in food preparation. The Emergence of Artificial Trans Fat and Recognition of Its Risks Trans fats occur naturally in small amounts in some meat and dairy products (3); however, these sources make up only 21% of total trans fat intake (16). The remaining trans fat in the U.S. diet is artificial, produced by partial hydrogenation of vegetable oils and found mostly in processed foodsespecially baked and fried goods and spreads. Partial hydrogenation was patented in 1903. Eight years later, Crisco (J.M. Smucker, Orrville, Ohio) became the first such product widely marketed in the United States (17). These chemically modified oils, like several food ingredients in the 20th century, entered the food supply without a full evaluation of human health effects and were generally recognized as safe on the basis of experience (18). Industrial advantages, such as extended product shelf life and fry oil stability, led to increased use in the 1950s. In the 1970s, margarine made from partially hydrogenated oil was promoted as a healthier alternative to butter (19). However, by the 1990s, studies began to identify trans fat as a health hazard (9). In 2003, the U.S. Food and Drug Administration (FDA) required that all packaged goods display information on trans fat content by 2006 (20). The regulation allows products that contain less than 0.5 grams of trans fat per serving to be labeled zero grams trans fat. This prompted a widespread industry response of reformulating products to declare zero grams trans fat on front-of-package labeling (2123), although such products may still contain trans fat in small amounts, which can add up. The nutrition facts labeling allowed attentive consumers to avoid trans fat in packaged foods; however, restaurantswhich provide one third of daily caloric intake (24)generally do not disclose nutritional information, leaving consumers no practical way to avoid trans fat. At the time of the FDA action, only Denmark limited trans fat in its entire food supply (25). Although local health departments do not commonly regulate packaged goods, inspecting, licensing, and regulating restaurants and retail food outlets are core local public health functions (26). Building on its food safety infrastructure, the Department trained restaurant inspectors in May 2005 to assess the presence of artificial trans fat in products used for frying, baking, or cooking or in spreads by means of food label inspection. Because inspection visits are scheduled each year on the basis of original restaurant licensing date and compliance records, a survey fielded during regularly scheduled inspections approximates a random sample of these establishments. In May and June 2005, inspectors assessed the use of trans fat in oils, shortenings, and spreads used for frying, baking, or cooking or in spreads in 529 restaurants. Of the 478 restaurants that used fats for any of these purposes and for which complete data were collected, trans fat presence could not be determined in one third. Where it could be assessed, 50% of restaurants used artificial trans fat to prepare food. Educational Campaign In August 2005, the Department launched an educational campaign to reduce restaurant artificial trans fat use. Information was sent to the 30000 licensed food outlets in the city, 15000 suppliers and supermarkets, and hundreds of thousands of consumers. Mailings urged restaurants to remove artificial trans fat from food, suppliers to promote 0-grams trans fat products, and patrons to inquire about oils used. Press coverage was extensive (2729). More than 7800 restaurant operators received training on the issue during the mandatory food protection course. Nearly a year later, inspectors surveyed 1021 restaurants in April and May 2006 by following the same methodology as the previous year. Despite the educational campaign, prevalence of artificial trans fat use remained virtually unchanged at 51% in places where it could be assessed. Given survey findings of a wide range of restaurants that cooked without artificial trans fat, successful reformulation of packaged foods, and the Danish experience, the Department concluded that food choice and quality would be unaffected by replacing artificial trans fat and proposed using its regulatory authority to reduce artificial trans fat use (26). Crafting Regulation Department clinical staff, food safety experts, and lawyers considered a range of regulatory options, from disclosure-only requirements to content restrictions. Labeling trans fat would benefit only consumers who were aware of and would act on the dangers of trans fat and would be difficult to enforce. A restriction, however, would benefit all New Yorkers, regardless of language, literacy, level of health awareness, or age. Protecting children, who consume French fries and other quick-service foods that are common sources of artificial trans fat (30), was particularly important. Because artificial trans fat is both harmful and fully replaceable, allowing continued use, even with disclosure, could not be justified. Similarly, restricting trans fat in cooking oils and spreads onlyalthough easier to achievewould be insufficient because baked goods are the largest dietary source of trans fat (16). Given that an estimated one third of calories comes from away-from-home sources, removing most trans fat from restaurants could be expected to reduce trans fatassociated deaths proportionately. The Department drafted a broad proposal to restrict artificial trans fat use in fry oils; spreads; and all other ingredients and products, including baked goods. For the regulation to be clear and enforceable, the Department adopted the FDA threshold used for labeling of up to 0.5 grams of trans fat per serving for products containing any trans fat (20). The regulation would apply to all licensed food establishments, including restaurants, school cafeterias, caterers, senior centers, and street-food vendors. It intentionally did not affect products that contained only natural trans fat. The Department designed enforcement to rely on existing infrastructure. Inspectors check product labels, which restaurants now must maintain, during their regular annual inspections. The rule included a 6-month phase-out period for artificial trans fat in fry oils and spreads and 18 months for all other items, to give restaurants time to identify alternatives and reformulate (31). Fines for violations range from

Change in Trans Fatty Acid Content of Fast-Food Purchases Associated With New York City's Restaurant Regulation: A Pre–Post Study

200 to

Prevalence, Awareness, Treatment, and Predictors of Control of Hypertension in New York City

2000. From Concept to Action The regulation was proposed as an amendment to the citys Health Code, approvable by the Board of Health. Nearly 2300 public comments were received, with supporters outnumbering opponents 31 to 1. Local, regional, and national organizations and professional medical associations made statements of support. Opposition came primarily from industry associations, including the National Restaurant Association and its state affiliate and the Grocery Manufacturers Association (32). The restaurant industry, which often opposes regulation on principle, alleged that the elimination of artificial trans fat would result in more expensive and less flavorful food and also claimed that the supply of alternative oils was insufficient and the regulatory timeline unre

Sodium Content of Lunchtime Fast Food Purchases at Major US Chains

BACKGROUND Dietary trans fat increases risk for coronary heart disease. In 2006, New York City (NYC) passed the first regulation in the United States restricting trans fat use in restaurants. OBJECTIVE To assess the effect of the NYC regulation on the trans and saturated fat content of fast-food purchases. DESIGN Cross-sectional study that included purchase receipts matched to available nutritional information and brief surveys of adult lunchtime restaurant customers conducted in 2007 and 2009, before and after implementation of the regulation. SETTING 168 randomly selected NYC restaurant locations of 11 fast-food chains. PARTICIPANTS Adult restaurant customers interviewed in 2007 and 2009. MEASUREMENTS Change in mean grams of trans fat, saturated fat, trans plus saturated fat, and trans fat per 1000 kcal per purchase, overall and by chain type. RESULTS The final sample included 6969 purchases in 2007 and 7885 purchases in 2009. Overall, mean trans fat per purchase decreased by 2.4 g (95% CI, -2.8 to -2.0 g; P < 0.001), whereas saturated fat showed a slight increase of 0.55 g (CI, 0.1 to 1.0 g; P = 0.011). Mean trans plus saturated fat content decreased by 1.9 g overall (CI, -2.5 to -1.2 g; P < 0.001). Mean trans fat per 1000 kcal decreased by 2.7 g per 1000 kcal (CI, -3.1 to -2.3 g per 1000 kcal; P < 0.001). Purchases with zero grams of trans fat increased from 32% to 59%. In a multivariate analysis, the poverty rate of the neighborhood in which the restaurant was located was not associated with changes. LIMITATION Fast-food restaurants that were included may not be representative of all NYC restaurants. CONCLUSION The introduction of a local restaurant regulation was associated with a substantial and statistically significant decrease in the trans fat content of purchases at fast-food chains, without a commensurate increase in saturated fat. Restaurant patrons from high- and low-poverty neighborhoods benefited equally. However, federal regulation will be necessary to fully eliminate population exposure to industrial trans fat sources. PRIMARY FUNDING SOURCE City of New York and the Robert Wood Johnson Foundation Healthy Eating Research program.

Sodium Intake in a Cross-Sectional, Representative Sample of New York City Adults

Background—Hypertension-related risk in urban areas may vary from national estimates; however, objective data on prevalence and treatment in local areas are scarce. We assessed hypertension prevalence, awareness, treatment, and control among New York City (NYC) adults. Methods and Results—The NYC Health And Nutrition Examination Survey (HANES), modeled on the national HANES, was conducted in 2004 with a representative sample of noninstitutionalized NYC residents ≥20 years of age. Hypertension outcomes were examined with interview and examination data (n=1975). Multiple logistic regression was used to assess factors associated with control among adults with hypertension. We found that 25.6% of NYC adults had hypertension. Blacks had a higher prevalence than whites (32.8% versus 21.1%, P<0.001), as did Hispanics (26.5% versus 21.1%, P<0.05). Foreign-born residents who had lived in the United States for <10 years had lower rates than those who had lived in the United States longer (20.0% versus 27.5%, P<0.05). Among adults with hypertension, 83.0% were diagnosed, 72.7% were treated, and 47.1% had hypertension controlled. Of those treated, 64.8% had hypertension controlled. After adjustment for sociodemographic variables among all adults with treated hypertension, lack of a routine place of medical care was most strongly associated with poor control levels (adjusted odds ratio 0.21, 95% confidence interval 0.07 to 0.66). Among nonelderly adults with treated hypertension, blacks had 4-fold lower odds than whites of having hypertension controlled (adjusted odds ratio 0.24, 95% confidence interval 0.06 to 0.92). Conclusions—In NYC, hypertension is common and frequently uncontrolled. Low levels of control are associated with poor access to care. Racial disparities in prevalence and control are evident among nonelderly adults.

Progress toward sodium reduction in the United States

C ardiovascular disease is the leading cause of death in the United States, and high blood pressure is a leading risk factor. An extensive body of research describes a direct association between sodium intake and blood pressure. Current US recommendations advise adults to limit sodium intake to less than 2300 mg/d, and several demographic groups (blacks, middle-aged and older adults, and people with hypertension), which together compose 69% of US adults, to limit daily intake to 1500 mg. Despite these suggestions, adults consume an average of approximately 3500 mg of sodium per day. Individual efforts to reduce sodium intake have limited effect, likely because more than 75% of dietary sodium comes from packaged and restaurant foods. The American Medical Association has called on industry to reduce the sodium content of processed and restaurant foods by 50%. A reduction by this amount would save tens of thousands of lives each year, and this reduction could save almost

US Food Industry Progress During the National Salt Reduction Initiative: 2009–2014

20 billion in health care costs annually. There are limited published data on the relationship between restaurant food and sodium intake. Using data from a large cross-sectional survey of patrons exiting fast food chain restaurants in New York City (NYC), we assessed the amount of sodium in meal purchases by fast food chain and by chain category.

Self-Blood Pressure Monitoring in an Urban, Ethnically Diverse Population A Randomized Clinical Trial Utilizing the Electronic Health Record

OBJECTIVES We estimated sodium intake, which is associated with elevated blood pressure, a major risk factor for cardiovascular disease, and assessed its association with related variables among New York City adults. METHODS In 2010 we conducted a cross-sectional, population-based survey of 1656 adults, the Heart Follow-Up Study, that collected self-reported health information, measured blood pressure, and obtained sodium, potassium, and creatinine values from 24-hour urine collections. RESULTS Mean daily sodium intake was 3239 milligrams per day; 81% of participants exceeded their recommended limit. Sodium intake was higher in non-Hispanic Blacks (3477 mg/d) and Hispanics (3395 mg/d) than in non-Hispanic Whites (3066 mg/d; both P < .05). Higher sodium intake was associated with higher blood pressure in adjusted models, and this association varied by race/ethnicity. CONCLUSIONS Higher sodium intake among non-Hispanic Blacks and Hispanics than among Whites was not previously documented in population surveys relying on self-report. These results demonstrate the feasibility of 24-hour urine collection for the purposes of research, surveillance, and program evaluation.

Highlighting the ratio of sodium to potassium in population-level dietary assessments: cross-sectional data from New York City, USA.

The average adult in the United States of America consumes well above the recommended daily limit of sodium. Average sodium intake is about 3 463 mg/day, as compared to the 2010 dietary guidelines for Americans recommendation of < 2 300 mg/day. A further reduction to 1 500 mg/day is advised for people 51 years or older; African Americans; and people with high blood pressure, diabetes, or chronic kidney disease. In the United States of America, the problem of excess sodium intake is related to the food supply. Most sodium consumed comes from packaged, processed, and restaurant foods and therefore is in the product at the time of purchase. This paper describes sodium reduction policies and programs in the United States at the federal, state, and local levels; efforts to monitor the health impact of sodium reduction; ways to assess consumer knowledge, attitudes, and behavior; and how these activities depend on and inform global efforts to reduce sodium intake. Reducing excess sodium intake is a public health opportunity that can save lives and health care dollars in the United States and globally. Future efforts, including sharing successes achieved and barriers identified in the United States and globally, may quicken and enhance progress.