1-190
Behavioral Aspects of Intervention Strategies
to Reduce Dietary Sodium
Shiriki Kumanyika
Downloaded from http://hyper.ahajournals.org/ by guest on July 12, 2017
This article addresses general and specific aspects of dietary sodium interventions from the
perspective of behavioral change. Changing dietary behavior requires relearning a range of
habitual behaviors involved in day-to-day eating situations in the context of a diverse and
complex food supply and in consideration of numerous factors, other than health concerns, that
influence habitual eating patterns. Potential obstacles to dietary sodium reduction relate to the
wide distribution of sodium in foods, the strong cultural values for salt, and the difficulty of
assessing success in sodium reduction. A review of sodium interventions reported in the
literature suggests that state-of-the-art behavioral change strategies can be effective in
achieving reductions in sodium intake to around 3,000 mg/day but that this level is achieved
only with highly motivated individuals and when a high level of intervention (i.e., intensive and
multifaceted) is provided. Thus, in regard to sodium reduction in the general population, either
the goal will have to be modest or the food supply will have to change so that substantial
decreases in sodium intake can be accomplished with less intensive and less costly interventions. (Hypertension 1991;17[suppl I]:I-190-I-195)
A ttempts to demonstrate the usefulness of di/ \
etary sodium reduction in hypertension pre•i- A . vention and control assume that sodium
reduction is sufficiently feasible to be worth pursuing
as a public health intervention strategy. However,
dietary modifications such as sodium reduction are
difficult. Caution is warranted in making judgments
about the feasibility of long-term sodium reduction
on a populationwide basis.
This article addresses general problems encountered
in dietary change interventions and highlights issues of
special relevance to sodium reduction. Differences in
the effectiveness of various programs in achieving longterm changes in sodium intake of free-living individuals
can probably be attributed to differences in the amount
and type of intervention strategies used.
Dietary Behavior Change
Changing Habits
All dietary interventions must equip individuals to
master the complex process of changing established
behavior related to food selection and consumption
in a variety of situations.1 Purchasing food within
certain nutrient content restrictions requires the
time, ability, and willingness to make careful choices
From the Nutrition Department, College of Health and Human
Development, Pennsylvania State University, University Park, Pa.
Address for reprints: Shiriki Kumanyika, PhD, Associate Professor, Nutrition Department, S-126 Henderson, Pennsylvania
State University, University Park, PA 16802.
from a large, diverse, and ever-changing array of food
items available in supermarkets.2 A person must be
able to read and interpret food labels and to differentiate among brands or forms of processed food
items that may be similar in many respects but
markedly different in others (e.g., in sodium or fat
content). Changes in cooking practices require a new
set of decisions about what to include in recipes and
about procedures before (e.g., draining, rinsing, and
marinating) and during food preparation, including
what flavorings to add or avoid. Controlling qualitative aspects of food intake when eating away from
home involves decisions about where or what to eat,
as well as the social skills needed to find out how food
was prepared or to request changes in how food will
be prepared or served.
The burden of day-to-day eating decisions in our
complex food environment is manageable precisely
because many of these decisions are made without
thinking. However, the habitual nature of eating
poses a major obstacle to long-term dietary change,
and strategies to build skills in habit change are now
considered essential for state-of-the-art dietary interventions.1-3 Dietary change requires that habitual
eating responses be set aside in favor of reasoned
actions that ultimately become the basis for new
habits. Habits are conditioned responses that are
performed in response to certain cues (antecedents)
and perpetuated by frequent, positive reinforcements
(consequences) as perceived by the individual in
question. Changes in habits require altering either
Kumanyika Behavioral Aspects of Sodium Reduction
Downloaded from http://hyper.ahajournals.org/ by guest on July 12, 2017
cues (i.e., reasons for eating), consequences (responses to eating), or both, in a direction favoring
relinquishment of old patterns and adoption of new
ones.
The process of dietary behavioral change is, therefore, more than a matter of simply knowing what
needs to be done and having "will power." Changing
diet requires that numerous situational problems
posed by familiar eating situations be identified and
resolved and that the behavioral "scripts" for responding to these situations be rewritten.1 To succeed, the
individual needs skill in diagnosing problems, considering alternatives, setting goals, and taking relevant
actions as well as appropriate motivation and coping
resources. For example, the social climate of eating
includes family interactions that may have to be
renegotiated in order for different foods to be made
available in the home. Other factors related to eating
motivations and to the potential for dietary behavioral change include knowledge, beliefs, and selfregulatory skills. Relevant material and logistical factors include the ability or resources to afford, acquire,
and prepare different foods.
Short-term Versus Long-term Motivations
Health concerns are only one aspect of motivations for eating, and regardless of what health
workers would like to believe, they are not usually
the most important ones.4-8 Knowledge of human
behavior strongly suggests that except in life-threatening situations such as extreme hunger or when
adverse reactions are anticipated, health-related
considerations will be subordinate to sensory, social, emotional, and pragmatic determinants of food
consumption. Thus, even when consumers are fully
informed about the potential health risks associated
with a given dietary behavior, the key determinants
of the ability to change the behavior may be the
extent to which other, competing motivations for
the behavior can be brought into alignment with the
desired change. These factors include flavor, familiarity, cultural norms, emotional connotations of
food, and pragmatic variables such as perceived
cost, ease of acquisition and preparation, and the
availability of alternatives. On a day-to-day basis,
these other, short-term motivations are more likely
than long-range health concerns to define the positive or negative reinforcements associated with an
altered eating pattern.
Issues of Dietary Behavioral Change Relevant to
Sodium Reduction
Within the general framework that is common to
all behavioral interventions, the nature of the challenges encountered and the strategies needed to
address these challenges are shaped by factors specific to the food constituents involved, for example,
which and how many foods are important dietary
sources, the functional and social roles of these foods
in the dietary pattern in question, and the ease or
difficulty of keeping track of how much is consumed.
1-191
The food and eating decisions encountered in lowering dietary sodium are different in many respects
from those encountered in increasing dietary fiber or
reducing dietary fat, for example. Many of the foods
that are major contributors to sodium, fat, and fiber
in the US diet are different,9-11 and the number of
different food items contributing to sodium intake is
greater than for fat or fiber. The sensory effects of
removing salt from food are qualitatively different
from those that result from removing fat or adding
fiber. Pietinen et al12 and Puska et al13 reported that,
in a randomized study comparing success at reducing
dietary fat and dietary sodium, sodium reduction was
associated with a higher level of perceived difficulty
than fat reduction. Some reasons why sodium reduction may pose more difficulty for the average consumer than some other aspects of dietary change are
summarized below.
Flavor and Familiarity
Because no true substitute for the salty flavor is
likely to be found,14 some deprivation of accustomed
flavors is an inevitable concomitant of sodium reduction. Unlike cuisines that rely heavily on spices such
as curry or chili for strong flavor, American cuisine
relies primarily on salt to provide or enhance flavor.
Even where salt is added to foods for reasons other
than flavoring (e.g., for functional purposes), the
salty flavor becomes an aspect of the characteristic
taste of food at whatever level of salt is added.
Experimental studies suggest that the perceived saltiness of a given concentration of salt increases with
prolonged sodium restriction and that high concentrations of salt may become somewhat aversive after
adaptation to a reduced sodium diet.14 Such adaptations favor the success of dietary sodium interventions because the sense of being deprived of the salty
flavor may decrease with time. However, given the
difficulty of avoiding inadvertent consumption of
highly salted foods on a sustained basis, even by those
who prefer to follow low sodium dietary practices,
the environment promotes readaptation to a higher
salt preference.
Strategies to counteract negative reactions to the
loss of salty flavor include judicious use of small
amounts of salt or generous use of other flavors. As
discussed elsewhere in these proceedings,14 a small
amount of salt added at the table may greatly improve the palatability of a food cooked without salt,
with little overall increase in the amount of sodium
consumed. Processed foods containing small
amounts of salt may be more acceptable to consumers than foods that are entirely salt free.15 Herbs and
spices, used in sufficient quantities and according to
principles that have been well established in other
cultures, can also result in very flavorful foods. However, the unfamiliarity of these flavors may limit the
sociocultural or emotional value of these foods. In
addition to being palatable, alternatives to high salt
1-192
Supplement I Hypertension Vol 17, No 1, January 1991
foods must be culturally, socially, and emotionally
acceptable.
Downloaded from http://hyper.ahajournals.org/ by guest on July 12, 2017
Cultural Values
The sociocultural and emotional values for salt or
certain high salt foods may overwhelm even the most
well-established health motivations for reducing sodium intake. Salted food may have religious uses
(e.g., kosher meats)16 or be strongly tied to ethnic or
regional identity (e.g., certain typical Asian, Caribbean, or Southern or Southern-black foods).17 Many
highly salted foods have well-established social uses
and connotations that may be linked to their salty
flavor (e.g., potato chips, corn chips, snack crackers,
salted peanuts and popcorn, pickles, and other party
or buffet foods).
Much has been written about the historical importance of salt in trade, about wars fought over salt,
about codification of cultural values for salt in words
such as "salutary" and "salary," or in expressions like
"salt of the earth."18 This strong cultural value may
limit the extent to which sodium is viewed as a hazard
worthy of rigid avoidance behaviors compared with
potentially carcinogenic food additives or food constituents, such as cholesterol, that do not have any
particular cultural connotation.
Convenience, Availability, and Cost
The natural distribution of sodium in foods is
superseded by the pattern of its addition to a wide
variety of foods for functional purposes (e.g., as a
preservative or leavening agent) and its addition as a
flavoring agent.19 Processed versions of naturally low
sodium foods such as grains and cereals or fruits and
vegetables actually make major contributions to dietary sodium intake.9 In industrialized societies, in
which consumers rely heavily on processed foods, the
contribution of consumer-added salt (cooking salt
and table salt) is only about 15%.20
Two behavioral change approaches can be used to
work around the problem of sodium in processed
foods, although unfortunately, neither is ideal. One
strategy is to use fewer processed foods. However,
processed foods are convenient, and the preparation
of alternatives requires more effort, time, and skill. In
addition, since the consumer has no control over the
use of processed foods in restaurants, this approach
also requires limiting the number of meals eaten out.
The other strategy is to use low or reduced sodium
versions of processed foods. Such products may be
more available now than in the past, but their availability on supermarket shelves is still difficult to
predict, and they may be unavailable in smaller food
stores or low income neighborhoods. Further, even
when sodium-modified products are priced to compete with regular versions, they are not likely to be
the best bargain available.
Behavioral Feedback
There are usually no observable biological effects of
increases or decreases in sodium intake, because ho-
meostatic mechanisms lead to compensatory changes in
sodium excretion in urine and other body fluids. The
lack of visible effects of high sodium intake reinforces
the idea that it is not harmful on a day-to-day basis. In
addition, it is difficult for a person to know whether
attempts to reduce sodium intake have been successful.
Dietary sodium can be estimated from a food intake
diary. However, not only does the food diary method
require the patience and skill to accurately list everything eaten, but the use of diaries to monitor sodium
intake is also limited by the difficulty of estimating the
amounts of sodium added to a wide spectrum of
processed and restaurant foods and by the probability
that food records kept by "sodium-conscious" individuals underestimate the amounts of sodium actually
consumed.21-22 Sodium intake can be estimated more
objectively from sodium excretion determined by laboratory analysis of one or, preferably, several 24-hour
urine collections or from short-cut urinafysis methods
such as overnight urine collections or chloride titrator
strips, which approximate 24-hour urinary sodium values.23'24 The greater difficulty and expense of using
urine samples for behavioral feedback can be compared with the relative ease and economy of obtaining
body weight as a measure of success at weight loss.
Amount of Sodium Reduction Associated With
Different Levels of Intervention
Although potentially effective counseling and intervention techniques addressing various aspects of
the dietary change process can be identified, these
techniques are not easy to implement and are usually
labor and time intensive.1-25 Further, even when
dietary change interventions are initially successful, it
is difficult to prevent relapses to former habit patterns without continuing or repeated interventions.
Several studies12-21-26 indicate that interventions of
limited intensity are inadequate for achieving meaningful reductions in dietary sodium intake even
among hypertensive patients who may be highly
motivated by the potential for reducing or avoiding
medications. The low level intervention in these
studies consisted of a limited number or frequency of
patient education sessions. Community-wide programs that provide for minimal or no individual
counseling are also associated with limited success.
For example, Pietinen et al12 reported that in the
North Karelia Salt Project, a community-based education program using mass media information, verbal
and written information for individuals with hypertension, training programs for health workers, and
efforts to increase the production of low sodium
foods was not associated with decreased sodium
excretion in the population over a 3-year period, with
the exception of a 7% decrease in 24-hour sodium
excretion (from an average of 170 to 158 mmol)
among normotensive women. A small but statistically
significant increase in sodium excretion among the
men surveyed was noted.
Kumanyika Behavioral Aspects of Sodium Reduction
1-193
TABLE 1. Strategies Included in Different Levels of Sodium Interventions
Intervention strategies
Low
Knowledge about sodium reduction
Mass media information in community
Individuals given instruction face to face
Family members given instruction face to face
Facilitating acquisition of low sodium foods
Individuals helped to identify sources of low sodium foods
Retailers encouraged to make low sodium foods available
Individuals given low sodium foods
Behavioral counseling and social support
Opportunities to taste low sodium foods
Feedback on urinary sodium excretion
Level of intervention
Medium
High
+
+
±
+
+
+, Strategy included; ±, strategy possibly included; - , strategy not included.
Downloaded from http://hyper.ahajournals.org/ by guest on July 12, 2017
At the other extreme, studies in which an intensive, multicomponent intervention was delivered for
an extended period of time (generally to individuals
preselected for a high adherence potential) report
substantial success in lowering sodium intake levels.22-24-27-31 Lang et al27 reported reductions of sodium intake of about 50% at 3 months in a small
study of men and women who received detailed
instructions in their homes, supplemented by prompt
telephone feedback on the sodium content of weekly
24-hour urine collections. The Hypertension Intervention Trial reported a 47% decrease in sodium
intake maintained at 1 year,28 as a result of an
intervention program that included an extended period of dietary instruction and behavioral counseling,
involvement of family members, food-tasting experiences, and periodic feedback on 24-hour urinary
sodium excretion (V. Lasser, oral communication,
February 1990). Nugent et al29 report a 50% decrease
in sodium excretion in patients receiving behavioral
counseling that included feedback on 24-hour urinary sodium excretion, compared with a 30% drop
among those receiving an intensive counseling program but without the behavioral components and
urine feedback. Other intervention studies22*24-30"31 in
which intensive and relatively comprehensive counseling was provided with support continued over an
extended time period have reported sodium reductions in the range of 20-40% after periods of 1-5
years.
Based on the impressions from these studies and
on the theoretical perspective previously described,1
the level of sodium reduction that might be expected
to result from intervention programs that are more or
less inclusive of various behavioral change strategies
can be estimated (Table 1). Low, medium, and high
interventions can be differentiated according to activities that are included (+), possibly included (±),
or not included ( - ) in the intervention design. Considering the behavioral outcome as a function of the
"dose" of intervention might help to clarify why some
studies suggest that sodium reduction is not feasible
and others demonstrate that it is highly feasible.
According to the classification scheme in Table 1,
the lowest level of intervention potentially associated
with at least minimum success would include community education strategies (e.g., information in the
mass media), either as a specific aspect of the intervention design or as an opportunistic aspect (i.e., one
that takes advantage of ongoing health promotion
campaigns), along with supplementary individually
oriented informational strategies such as oral presentations or printed information and would also include
attempts to increase the availability of low sodium
foods. This would be similar to the community-based
program described in the North Karelia Salt Project12
and, at best, might yield a 10% reduction in average
daily sodium intake. Results of programs using most
or all of the strategies listed in Table 1 suggest that in
a general population this highest level of intervention
might yield sodium intake reductions of 20-40%.
Intermediate between these extremes would be interventions providing for face-to-face contacts with
individuals and family members and including appropriate informational and motivational content along
with one or more of the other strategies listed. This
level of intervention can be expected to have moderate but not optimal success. For example, in the
North Karelia Salt Project,12 a 2-year substudy involving 200 persons with mild hypertension evaluated
the effect of more extensive individual and group
counseling in addition to the community-based program and demonstrated a sodium reduction of 16%
in men and 20% in women.
Based on an initial sodium intake level of about
4,000 mg (175 meq) per day these low, medium, and
high levels of intervention would reduce sodium
intake, respectively, to about 3,600 mg (158 meq),
3,200 mg (140 meq), and 2,400 mg (105 meq) per
day. However, Table 1 is an oversimplification in that
there is overlap among these components and in that
other variables, such as the intensity and skill of the
intervention, also affect success. In addition, the
success of dietary sodium interventions may vary
according to whether sodium alone is the focus or
1-194
Supplement I
Hypertension
Vol 17, No 1, January 1991
Downloaded from http://hyper.ahajournals.org/ by guest on July 12, 2017
whether sodium reduction is integrated with other
areas of nutrition or health counseling. Theoretically,
including sodium reduction as part of a broader
health improvement effort provides an opportunity to
link motivations for sodium reduction to other, perhaps more intrinsically rewarding, changes such as
weight reduction.32
In conclusion, the relevance of this discussion of
behavioral aspects of sodium interventions relates to
the feasibility of dietary sodium interventions in high
salt, industrialized societies where people rely on
processed or restaurant foods for logistical reasons,
whether or not they prefer them, where the food
supply is extremely large and diverse, where the
existence of current generations can be tied to historical roles of salted foods in survival, and, furthermore, where it is difficult for individuals to really
determine how much sodium they are consuming on
a day-to-day basis. Advocates of dietary sodium
reduction who attempt to minimize the associated
problems may be doing a disservice to their cause.
Rather, what would seem to be needed is a complete
understanding of the factors involved in dietary sodium reduction and of what level of sodium reduction is probable when only a limited program is
mounted. Facing the reality then that, based on the
examples above, reduction of sodium intake to an
average of less than 3,000 mg (130 meq) per day will
require cost- and labor-intensive individualized counseling programs and will only be suitable for individuals likely to actively engage in such counseling, the
alternatives for public health interventions are sharpened: either the targeted level of sodium reduction
will have to be at a level that can be achieved with
less costly campaigns or the task of sodium reduction
will have to be made easier for the average individual. The first alternative suggests a need for research
to better specify the dose-response relation of population blood pressure change to specific levels of
population sodium reduction. The second suggests a
need for drastic changes in the food supply. Some
combination of these two alternatives may be ideal.
References
1. Ewart CK: Changing dietary behavior A social action theory
approach. Clin Nutr 1989;8:9-16
2. Wadden TA, Brownell KD: The development and modification of dietary practices in individuals, large groups, and
populations, in Matarazzo JD, Weiss SM, Herd JA, Miller NE,
Weiss SM (eds): Behavioral Health. New York, John Wiley &
Sons, Inc, 1984, pp 608-631
3. Weinsier RL, Wadden TA, Ritenbaugh C, Harrison G,
Johnson FS, Wilmore JH: Recommended therapeutic guidelines for professional weight control programs. Am J Clin Nutr
1984;40:865-872
4. Reaburn JA, Krondl M, Lau D: Social determinants in food
selection. J Am DietAssoc 1979;74:637-641
5. Sanjur D: Social and Cultural Perspectives in Nutrition. New
Jersey, Prentice-Hall, Inc, 1982, pp 285-316
6. Rozin P: The acquisition of food habits and preferences, in
Matarazzo JD, Weiss SM, Herd JA, Miller NE, Weiss SM
(eds): Behavioral Health. New York, John Wiley & Sons, Inc,
1984, pp 590-607
7. Axelson ML: The impact of culture on food-related behavior.
Annu Rev Nutr 1986;6:345-363
8. Murcott A: Soriologkal and social anthropological approaches
to food and eating. World Rev Nutr Diet 1988^5:1-40
9. Block G, Dresser CM, Hartman AM, Carroll MD: Nutrient
sources in the American diet: Quantitative data from the
NHANES II survey: I. Vitamins and minerals. Am J Epidemiol
1985;122:13-26
10. Block G, Dresser CM, Hartman AM, Carroll MD: Nutrient
sources in the American diet: Quantitative data from the
NHANES II survey: II. Macronutrients and fats. Am J Epidemiol 1985;122:27-40
11. Block G, Lanza E: Dietary fiber sources in the United States
by demographic group. / Natl Cancer Inst 1987;83-91
12. Pietinen P, Tanskanen A, Nissinen A, Tuomilehto J, Puska P:
Changes in dietary habits and knowledge concerning salt
during a community-based prevention programme for hypertension. Ann Clin Res 1984;16(suppl 16):15O-155
13. Puska P, Iacono JM, Nissinen A, Korhonen HJ, Vartiainen E,
Pietinen P, Dougherty R, Leino U, Mutanen M, Moisio S,
Huttunen J: Controlled randomized trial of the effect of
dietary fat on blood pressure. Lancet 1983;l:l-5
14. Beauchamp GK, Engelman K: High salt intake: Sensory and
behavioral factors. Hypertension 1991;17(suppl I):I-173-I-175
15. Thaler BI, Paulin JM, Phelan EL, Simpson FO: A pilot study
to test the feasibility of salt restriction in a community. N Z
Afcd/1982;95:839-842
16. Burns ER, Neubort PH: Sodium content of koshered meat
(letter). JAMA 1984;252:2960
17. Kumanyika S, Helitzer DL: Nutritional status and dietary
pattern of racial minorities in the United States, in Report of
the Secretary's Task Force on Black and Minority Health,
Volume II: Cmsscutting Issues in Minority Health. US Department of Health and Human Services. Washington, DC, US
Government Printing Office, 1985, pp 118-190
18. Bloch MR: The social influence of salt. SciAm 1963;209:88-98
19. Crocco SC: The role of sodium in food processing. J Am Diet
Assoc 1982;80:36-39
20. James WP, Ralph A, Sanchez Castillo CP: The dominance of
salt in manufactured food in the sodium intake of affluent
societies. Lancet 1987;l:426-429
21. Buccicone J, McAllister RG: Failure of single session dietary
counseling to reduce salt intake in hypertensive patients. South
Med J 1977;70:1436-1441
22. Wassertheil-Smoller S, Langford HG, Blaufox MD, Oberman
A, Hawkins M, Levine B, Cameron M, Babcock C, Pressel S,
Caggiula A, Cutter G, Curb D, Wing R: Effective dietary
intervention in hypertensives: Sodium restriction and weight
reduction. J Am Diet Assoc 1985;85:423-430
23. Luft FC, Sloan RS, Lang CL, Cohen SJ, Finebery NS, Miller
JZ, Weinberger MH: Influence of home monitoring on compliance with a reduced sodium diet. Arch Intern Med 1984;144:
1963-1965
24. Hypertension Prevention Trial Research Group: The Hypertension Prevention Trial: Three-year effects of dietary changes
on blood pressure. Arch Intern Med 1990;150:153-162
25. Green LW, Wilson AL, Lovato CY: What changes can health
promotion achieve and how long do these changes last? The
trade-offs between expediency and durability. Prev Med 1986;
15:508-521
26. Evers SE, Bass M, Dormer A, McWhinney IR: Lack of impact
of salt restriction advice on hypertensive patients. Prev Med
1987;16:213-220
27. Lang CL, Weinberger MH, Miller JZ: Dietary counseling
results in effective dietary sodium restriction. J Am DietAssoc
1985;85:477-479
28. Lasser NL, Batey DM, Hymowitz N, Lasser VM, Kanders BS,
Lehrer PM: The hypertension intervention trial, in Strasser T,
Ganten D (eds): Mild Hypertension: From Drug Treatment to
Practice. New York, Raven Press, Publishers, 1987, pp 203-212
29. Nugent CA, Carnahan JE, Sheehan ET, Myers C: Salt restriction in hypertensive patients: Comparison of advice, educa-
Kumanyika
tion, and group management. Arch Intern Med 1984;144:
1415-1417
30. Stamler R, Stamler J, Gosch FC, Civinelli J, Fishman J, MeKeever P, McDonald A, Dyer AR: Primary prevention of
hypertension by nutritional-hygienic means. JAMA 1989-,262:
1801-1807
31. Jeffery RW, Tonascia S, Bjornson-Benson W, Schlundt DG,
Sugars C, for the Hypertension Prevention Trial Research
Behavioral Aspects of Sodium Reduction
1-195
Group: Treatment in the Hypertension Prevention Trial.
Controlled Clin Trials 1989;10:65S-83S
32. Kumanyika S: Designing sodium reduction strategies: Problems and solutions. Clin Nutr 1989;8:17-24
KEY WORDS • sodium • blood pressure • sodium intake •
diet
Downloaded from http://hyper.ahajournals.org/ by guest on July 12, 2017
Behavioral aspects of intervention strategies to reduce dietary sodium.
S Kumanyika
Hypertension. 1991;17:I190
doi: 10.1161/01.HYP.17.1_Suppl.I190
Downloaded from http://hyper.ahajournals.org/ by guest on July 12, 2017
Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1991 American Heart Association, Inc. All rights reserved.
Print ISSN: 0194-911X. Online ISSN: 1524-4563
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://hyper.ahajournals.org/content/17/1_Suppl/I190
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in
Hypertension can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial
Office. Once the online version of the published article for which permission is being requested is located, click
Request Permissions in the middle column of the Web page under Services. Further information about this
process is available in the Permissions and Rights Question and Answer document.
Reprints: Information about reprints can be found online at:
http://www.lww.com/reprints
Subscriptions: Information about subscribing to Hypertension is online at:
http://hyper.ahajournals.org//subscriptions/