Nearly 9 million US adults aged 35-64 years with stage 1 systolic hypertension would be recommended nonpharmacological therapy by the 2017 ACC/AHA BP guideline because of younger age and lower CVD risk. We projected that controlling SBP to <130 mmHg could prevent over 26,000 CVD events compared with the status quo. Universal adoption of the DASH diet was projected to prevent 28,000 CVD events over 10 years. Sustained weight loss, sodium reduction, and increased fruit and vegetable intake could also offer significant population benefits. Finally, relying solely on behavioral counseling at healthcare encounters might fail to reach the half of men and one-quarter of women with stage 1 systolic hypertension at low CVD risk who do not regularly engage with the healthcare system.

As the JNC7 BP guideline explicitly stated prehypertension was not a disease category¹, the lower BP threshold to define hypertension in the 2017 ACC/AHA BP guideline is an example of medicalization that effectively created a new medical diagnosis for those previously considered disease-free ³⁸. A new diagnosis of hypertension may change incentives in physician-patient interactions. However, many providers have limited training in in effective health counseling, let alone in tailoring recommendations for diverse patient populations ³⁹. A common critique of medicalization is that racial and ethnic minorities and people of lower socioeconomic status (SES) face more barriers that prevent them from fulfilling these ‘prescribed’ health behavior changes. Furthermore, the population most in need of nonpharmacological BP control is often uninsured, and does not regularly access healthcare for counseling opportunities to occur⁴⁰.

Policies that improve the food system and neighborhood conditions may facilitate recommended behavior changes irrespective of whether a person regularly interacts with a healthcare provider. Though salt alternatives can provide a more favorable ratio of dietary potassium to sodium among those who cook at home⁴¹ population benefits may be minimal among groups reliant on processed foods without commitment from stakeholders in restaurant and food manufacturing industries⁴². The US Food and Drug Administration has recently announced voluntary sodium reduction guidelines for commercially produced and packaged foods, involving gradually reducing maximum sodium content to allow consumer tastes to adapt and focusing on per-package versus per-serving sodium content⁴³. Similar industry-oriented policies in the United Kingdom were associated with modest annual reductions in sodium levels detected in population-representative urine samples between 2003 and 2007⁴⁴.

Community members are more likely to be more physically active if they reside in economically invested areas that are well-connected by sidewalks, with adequate street lighting and lower levels of crime^45,46. Amenities within walking distance that have been associated with lower prevalence of physical inactivity and obesity include destinations for errands, green spaces such as parks, outdoor features such as beaches and trails, and a public transit system that is proximate to employment^47,48. Racial and ethnic minorities as well as low socioeconomic status people are concentrated in areas with more barriers to walking, fewer free physical activity facilities, and limited available healthy food choices^46,49. Marginalized people also often report having less time and resources to engage in recommended health behaviors⁵⁰. Multilevel public health strategies that restructure the disadvantaged environmental context for vulnerable groups are vital to redress CVD disparities. These public health approaches can synergistically achieve a broader population reach than the individual behavior change interventions that provided inputs for our analysis. Quantifying the cost of such population-level interventions would enable estimation of cost-effectiveness.