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include questions of addictive properties, neurochemical action, long-term sequelae, age-related vulnerability, effectiveness of primary and secondary prevention measures, and ethical issues attendant to behavior change. Each of these issues should be considered not only on its own merit, but also for its lessons for, and commonalities with, the other abusive behaviors. Another example is the theme of 11reproductive health." Family planning, pregnancy and infant health, and sexually transmitted diseases are, of course, all concerned with reproductive health, but elements are also found in the discussions of smoking and health, misuse of alcohol and drugs, nutrition, toxic agent control, occupational safety and health, and immunization. Approaches to ensuring positive results of human reproductive processes compel consideration of issues of sexual attitudes and behavior, understanding of fertility and infertility, decisions about pregnancy, activities and exposures during pregnancy, obstetrical services, and follow-up care of mother and infant. All are important factors in reproduction; central concerns of much of reproductive life. Considering the spectrum of issues in the aggregate, rather than a series of isolated events, has substantial merit. Because such collective themes can be important to the implementation of measures to address the identified objectives, program directors designing such measures and setting priorities should search for the common elements particularly germane to their program needs and resources. Crosscutting Issues A number of issues are common to most or all of the reports: the problem of developing objectives in the face of economic uncertainties, a rapidly changing science base, the needs for more research and data, unpredictable shifts in popular interests and values, trade-offs between health and other societal interests, and ethical considerations in attempts to influence changes in people°s customary habits. Two are discussed below: data requirements and research needs. • Data requirements--The most salient common feature across the 15 areas is the need for better data both to profile current status and to track progress towards the established objectives. Statistical analyses derived from reliable data, continuously reported and coded according to universally accepted definitions and conventions, are the sine qua non for establishing the true nature of the problems preventive measures should address, as well as for charting trends towards achieving the objectives. There is currently great variability in the depth and reliability of data available among the 15 areas. While statistical reports relevant to the problem of smoking are x TLWN 364888

quite complete, virtually no data exist to estimate the problem of unmanaged stress in the population, and its association with mental illness, cardiovascular disease or violent behavior. In some cases, the availability of baseline data and ability to track progress have been relatively more prominent than overall importance to health in shaping the nature of objectives. The paucity of data is particularly handicapping for State and local organizations and agencies seeking to set and track progress toward their own local priorities and objectives for prevention. For the most part, birth and death statistics and local hospital discharge abstract analyses remain their only guides. Results from the continuing National surveys, such as the Health Interview Survey (HIS) and the Realth and Nutrition Examination Surv ey (HANES ), while essential for tracking change in the United States population as a whole, are based on samples too small to r alysis applicable to small areas. Surveillance systems developed to monitor the occurrence of infectious diseases provide models for many of the specific objectives relating to the prevention of other types of diseases and injuries. They depend on systems through which the occurrence of the particular condition or action will be reported within some ascertainable limits of accuracy and completeness. Whatever the source of the necessary data--physicians, hospitals, highway patrols, or insurance claim systems--important issues concerning the quality of the data must be addressed. Using data from surveillance systems which are not based on probability sample designs, or which are based on voluntary reporting, carries risks in making National estimates for tracking objectives. The level of voluntary reporting may differ markedly from one local area to another and fluctuates unpredictably at different points in time. Scientific evaluation of the impact of risk reduction on trends in health status or in reduction of risk factors is difficult methodologically and collection of the data required is expensive. To obtain valid results, test and control populations of considerable size must be followed over considerable periods of time, and a multiplicity of variables must be systematically taken into account. xi TIMN 364889

We anticipate considerable improvements will be made in our data capabilities over the next decade. New methods now being developed will help State health planning agencies, health systems agencies and health departments use existing data more effectively to establish base lines of prevention needs and opportunities. New efforts are underway to target new subjects for National data collection efforts. By 1990 the Nation should have a considerably improved data collection network and therefore be able to assess the progress with greater reliability as well as to establish new priorities based on new knowledge. : Research needs--The development of realistic objectives for risk reduction obviously must take place within the framework of whatever scientific knowledge is currently available. Since for most areas the state of the art is constantly changing, developing objectives for a point in time ten years down the road often means shooting at a moving target. For example, when the initial section on high blood pressure was drafted in June 1979, uncertainty about the efficacy of intervention in cases where blood pressure was only slightly elevated (90 to 104 mm Hg diastolic blood pressure without complications) led the work group to caution that in such cases: "...intervention...is not yet of clearly proven benefit." Ten months later, based on tiae results of aNationai study sponsored by the National Heart, Lung and Blood Institute, the statement was revised to read: "Based on 1979 research results, intervention seems warranted in a large proportion of this population. " If the objectives developed are to be refined and improved, the continuing need for basic biomedical research in most of the 15 subject areas of prevention is clear. Were our understanding of biological processes sufficient to develop vaccines to protect individuals against the most prevalent sexually transmitted diseases, tremendous opportunities for prevention would unfold and the task would become much easier. Similarly, epidemiological and biomedical research to identify major health risks from exposures to toxic agents is fundamentally important. We need new technologies to aid prevention in many areas--the development of acceptable, reversible, male contraceptives, for instance. Many of these issues have beenn addressed inn the process of establishing National research principles, directed by the National Institutes of Heaith. xii TIMN 364890

Additionally, behavioral research is needed to learn the basis for such addictions as smoking, overeating, and dependence on alcohol and drugs. Research at the interface between biomedical and behavioral methodologies is required to advance our knowledge of the effects of stress on health, and of how to control them. Social science research is needed to find more effective ways to communicate to vulnerable and inaccessible populations, such prevention techniques as lifestyle change measures to reduce their percentage of low birth weight, high risk infants. Health services research is required to learn how to maintain adherence to health promotion measures over long time periods, such as high blood pressure control regimens and maintaining a balance between energy input from food and output from exercise. Cost effectiveness studies, too, could identify preferred measures in some areas of prevention, despite the difficulties already noted in defining the associated costs and benefits that limit the applicability of such analysis to many prevention activities. Finally, legal and public policy research is called many areas of prevention, so that questions of individual and collective rights and responsibilities, and of trade-offs between economic and health values, and of short run versus long run benefits can be systematically introduced into public debate. I m pl.ementation Implementation of the objectives for each of the 15 areas requires a pluralistic process involving public and private participants from many sectors and backgrounds. Health officials and health providers must be joined by employers, labor unions, community leaders, school teachers, communications executives, architects and engineers, and many others in efforts to prevent disease and promote health. It is important to emphasize that, while the Federal Government must bear responsibility for leading, catalyzing and providing strategic support for these activities, the effort must be collective and it must have locall roots. Accordingly, the objectives contained in this volume must be viewed dynamically. They. ought not to be considered rigid obligations, but as useful National guideposts--to be altered to fit local conditions, or as our level of understanding of the problems at hand changes. There will be controversy. Issues often raised in connection with the advocacy and adoption of prevention measures include: the appropriate role of government in fostering personal behavior change; the pv" 364891

philosophy and psychology of throwing responsibility for serious health problems back to the victi.m ; the role of business and industrial processes in health and disease; the preferential treatment of certain categories of people for insurance purposes; the role of government in regulating health protection measures. Despite such questions, the objectives presented in Promoting fiealthlPreventing Disease represent an important component of a focused National prevention strategy. Substantial- gains to the health of Americans can be attained if we have the will to apply what we know. From the Federal perspective, work is already under way to apply the capabilities of Federally sponsored programs to the agenda set forth. If similar efforts are undertaken at the State and local levels to design measures for implementing locally-based objectives, progress can be greatly facilitated. To draw upon the last line of Healthy People, "If the commitment is made at every level, we ought to attain the goals established in this report, and Americans who might otherwise have suffered disease and disability will instead be healthy people." T.IUN 364892

HIGH BLOOD PRESSURE CONTROL 1. Nature and Extent of the Problem High blood pressure is perhaps the most potent of the risk factors for coronary heart disease and stroke--and contributes as well to diseases of the kidney and eyes. Because it is asymptomatic, a large number of people are unaware of their condition. High blood pressure is, however, only one of several risk factors for heart disease and stroke. Other prominent factors for heart disease include cigarette smoking, elevated blood cholesterol levels, diabetes and obesity. It is essential to recognize the multiple nature of these risks and their proved or suspected interaction. Correspondingly, both health professionals and the public need to know more about approaches for dealing comprehensively with these multiple risk factors and how to act on the basis of this knowledge. Control of high blood pressure requires patients to adhere to regimens over their lifetime. These may include various combinations of pharmaceutical interventions and changes in diet, exercise and stress management practices. (See Smoking and Health, Nutrition, Physical Fitness and Exercise, and Control of Stress and Violent Behav%or. ) a. Health implications s Heart disease, the leading cause of death in the U.S. population, was responsible for over 700,000 deaths in 1977; stroke led to 183,000 deaths in that year. Survivors are often severely handicapped. s About 60 million people have elevated blood pressures (above 140/90) and are at increased risk for death and illness. s©f these, about 35 million people (15 percent of the U.S. population) have high blood pressure at, or above 160/95, which is the World Health Organization definite determination of hypertension. These people face excess risk of death or illness from heart attack, heart failure, stroke, and kidney failure, and are the primary targets for control efforts. s Much of this excess risk is attributable to mild high blood pressure (90 to 104 mm Hg diastolic blood pressure without complications) . Based on 1979 research results, intervention seems warranted in a large proportion of this population. a Other important risk groups are: persons with diastolic blood pressure over 104 (for whom drugs have been proven beneficial); populations having a high prevalence (e.g., blacks and el.d.erly ); persons with limited access to, or use of, medical care such as young men and the poor. I TINIlN 364893

•Among special issues are the growing proportion of elderly in the population, their high prevalence of high blood pressure, uncertainty about the benefit of treating isolated systolic blood pressure and the sometimes unpredictable side effects of drugs used to control high blood pressure in older people. • Children present an opportunity, since precursors of high blood pressure may be identified in them, but also present a dilemma as the benefit of early intervention i.nn this population is not known and a firm consensus on defining high blood pressure in youngsters has not yet been reached. Changes in habitual diet may prove useful in prevention. nd tren : Although blood pressure can be controlled, the specific cause of 90 to 95 percent of high blood pressure is not known. Thus, while short-term emphasis must be placed on control, increased understanding of the causes of hypertension must be pursued to enable prevention of high blood pressure in the long run. # High salt intake is associated with high blood pressure in susceptible people; reduced salt intake is one measure for reducing high blood pressure. ~Many successful approaches to detection and control (e.g., use of allied health personnel, wori:site care, patient tracking systems) are not yet widely adopted or integrated into mainstream care. • Aithough prevalence data indicate a problem of great magnitude, incidence data for high blood pressure and its complications do not exist to aid improved planning of intervention strategies for both primary and secondary prevention. • Men are only half as likely as women to have their high blood pressure controlled. • Rural (non-SMSA) areas and urban inner city areas have made less progress in high blood pressure control in recent years than have metropolitan areas. 9 Many health professionals are - inattentive to regimen adherence kills to deal with adherence. t School health education rarely addresses risk factor control and lifestyle impact on health in a satisfactory way. TVAN 364894

• The proportion of the population with high blood pressure who are aware of their condition and are successfully controlling it appears to have doubled in the last 5 years, while the proportion of this population who are unaware of their condition has sharply decreased. However, the proportion who are aware of their condition, but whose high blood pressure remains untreated or ' uncontrolled, appears to have stayed constant. - PreventionJPromotion Measures a. Potential measures *Education and information measures include: continuing current efforts to heighten professional and public awareness of possibilities for blood pressure control, with messages targeted to groups at special risk, such as black males, the elderly and users of oral contraceptives; informing the public that daily intake of over 5 grams total salt (2 grams sodium) is not essential for good health and may contribute to the development of high blood pressure in some people; -- developing and distributing palatable recipes for low sodium diets ; -- raising public awareness that overweight predisposes to high blood pressure and weight control often assists blood pressure control; avoidance of juvenile obesity is especially important; encouraging increased physical activity and understanding that maintaining an appropriate balance between the energy individuals expend in their daily physical activity and the amount of energy they consume through the food they eat determines their success in controlling weight; increasing public awareness of the fact that stress reduction and exercise may be useful adjuncts for some persons to provide a healthy lifestyle and lessen the risk of hypertension; increasing public awareness of multiple risk factors and the interaction of risk factors; alerting physicians on value of monitoring the children of hypertensives with attention to weight control and low salt intake; 3 TIMN 364895

-- increasing professional school training in behavioralJmotivatian skills; -- involving specialists in behavioral medicine in teaching programs and assisting in patient adherence to regimens; -- encouraging introduction/inclusion of health-related content into the curricula of public/private institutions which train food preparationJprocessing personnel; -- more active nutrition education in school health and lunch programs for school children and for the elderly; -- influencing industry to take active steps to promote high blood pressure controllprevention among its employees and throughout the Nation by changes in both products (primarily reduced sodium content of processed foods) and marketing approaches; awareness by employers and the public of the potential for insurance premium cost savings associated with blood pressure control, not smoking and weight control among individual and group policy purchasers. s Service measures include: -- providing blood pressure checks routinely at contact with health providers (e, g. , physicians, dentists, nurse practitioners) and through programs staffed by suitably trained non-professionals (e, g . , firemen ) ; -- providing high blood pressure detection and treatment services at the worksite with a systematic program for fallotiv-up; -- giving health providers instruction in techniques to improve patient adherence to blood pressure control regimens. s Technologic measures include: increasing use of systems/policy analysis methods in program planning at all levels; reducing fat content (caloric density) and sodium content of snack and highly processed foods; -- developing practical means to supply low sodium content water to populations living in "hard" water areas. TIMN 364896

• Legislative and regulatory measures include: promoting consumer choice through labeling of foods for sodium and caloric content; seeking uniform National guidelines and Federal agency (National Institutes of Health, Department of Agriculture, and Food and Drug Administration) policies for nutrition (e, g. , sodium consumption, total dietary fat content); modifying State practice acts to provide for expanded roles of allied health professionals in the management/control of high blood pressure. • Economic measures include: providing free or low cost access to blood pressure checks during intervals between physician examinations; reducing economic barriers (e.g., costs) to use of allied health personnel; providing industry with tax incentives to encourage development of lower calorie, fat, sodium-containing foodstuffs ; -- reducing economic barriers to control through reimbursement for antihypertension prescription drugs. b. Relative strength of the measures • Education and information measures: -- established impact; low technology implementation possible; wide acceptance of this approach now exists; excellent costleffective potential. • Service measures; -- effective with potential for significant impact. • Technologic measures: use of syst_ems analysis approach to planning to facilitate more comprehensive/objective problem analysis resulting in. more effective plans; food content changes to allow greater consumer choice; may influence a major source of calorie self-abuse, and could be especially relevant to school children among whom adverse eating patterns have lasting effects. 5 TIMN 364897