Public Health Nutrition: Dietary Intervention for Hypertension Prevention

This document discusses the dietary intervention for hypertension prevention in public health nutrition. It covers the DASH diet, sodium restriction, and pilot testing. It also talks about the stakeholders involved and the monitoring strategies. The document includes supporting text, intervention strategy, and causal relationships. It also mentions the importance of pilot testing and stakeholder engagement.

Running head: PUBLIC HEALTH NUTRITION
PUBLIC HEALTH NUTRITION
Name of the Student:
Name of the University:
Author note:

1PUBLIC HEALTH NUTRITION
Question 1
a) For the purpose of reviewing the existing evidence published on the association between
the mentioned dietary recommendations and the prevention of hypertension, an electronic
literature search was conducted. For obtaining relevant studies, databases such as
CINAHL, Medline and PubMed were searched extensively key words such as
‘hypertension’, ‘dietary recommendations’ and ‘prevention’. For conducting an
appropriate search, the approach comprised of inclusion of peer-reviewed, scholarly,
articles, published within the timeframe of 2015 to 2019, and have published articles
relevant to the research question. To maintain usage of studies which were relevant, valid
and significant in their results, randomized controlled trials and systematic review papers
were considered since such research designs are regarded to be the highest level of
evidence (McGowan et al., 2016).
b) The study which was found to be most appropriate to established links between the
mentioned dietary recommendations and the prevention of hypertension, was the
systematic review published by Siervo et al., (2015), which aimed to review the effects of
the Dietary Approach to Stop Hypertention (DASH) on the reduction of cardiovascular
parameters. After extensively reviewing a total of 20 articles consisting of 1917
participants, the authors reported that obtaining results which indicated a significant
decrease both diastolic and systolic blood pressure and levels of HDL as well as total
cholesterol. Considering that this paper utilized a systematic review, the participants
comprised of a variety of ethnic backgrounds. While the study population did not focus
on a single province like Alberta, the results may still display research applicability due

2PUBLIC HEALTH NUTRITION
to consideration of a variety of ethnicities considered. Further, the interventions and
settings were majorly community based and were delivered by a nutritionist – hence
showing similarity and hence applicability to Alberta’s settings. Further, similarities can
be found due to similar dietary interventions used, since the DASH diet advocates ample
consumption of fruits and vegetables, low fat dairy and restrictions in fat and sodium
consumption (Siervo et al., 2015).
Question 2 (As designed by the Author)
Drivers and Influencers:
 Lack of adequate knowledge on the effects of diet on blood pressure
 Lack of adequate knowledge on symptoms of hypertension
 Lack of adequate knowledge on appropriate food selection
 Increased exposure to junk food advertisements
Resultant dietary practices:
 Increased consumption of processed foods high in salt and fat
 Increased consumption of table salt
 Increased usage of salt in cooking
 Increased engagement in sedentary lifestyle
Casual relationships and effects:
 High salt and fat consumption results in oxidative stress
 High salt and fat consumption results in cardiovascular risk factors like hypertension,
high lipid profile
 Sedentary lifestyle results in oxidative stress, obesity and metabolic complications like
hypertension
The above figure demonstrates that a lack of adequate awareness on the need to follow a
balanced diet and the long term, symptoms of hypertension on the future health and wellbeing
will result in poor dietary consumption and resultant hypertensive and cardiovascular
complications. Hence a social and educational based approach must be considered for successful
administration of the proposed public health intervention (Anderson, Young & Long, 2019).

3PUBLIC HEALTH NUTRITION
Question 3
A. Supporting Text
A key causative factor underlying hypertension is the lack of awareness on the
importance of consuming a diet which is balanced nutritionally and on the harmful effects on
health if not managed timely. Hence, a dietary intervention will be undertaken since a diet which
is high in sodium and fat will result in symptoms of hypertension. A DASH diet along with
restriction in sodium consumption have been implicated to result in improved blood pressure and
reduction in obesity - a key risk factor in hypertension (Soltani et al., 2016). Hence a public
health intervention, consisting of educating citizens on the need to restrict salt, cholesterol and
saturated fat intake and consume adequate quantities of fruits, vegetables and low fat dairy is
expected to result in outcomes like alleviation of hypertension and obesity and maintenance of
healthy levels of blood pressure (Rai et al., 2017).
B. Intervention Strategy (As designed by the Author)
Goals: To reduce rates of Hypertension
Dietary Principles:
 Consumption of a diet low in sodium, saturated fat and cholesterol.
 Consumption of a diet high in fruits, vegetables and low fat dairy products
Causal relationships: A diet high in table salt, processed foods and high fat foods results in
increased obesity and metabolic complications such as hypertension.
Dietary Intervention: Dietary Approaches to Stop Hypertension (DASH) diet along with
restriction in sodium consumption (table salt usage)
 Elements of the Intervention:
 Adequate consumption of fruits, vegetables and low fat dairy
 Restricted consumption of red meat and saturated fats

4PUBLIC HEALTH NUTRITION
 Restricted usage of table salt consumption and usage in cooking
 Avoidance of consumption of processed, packaged and junk foods.
Expected Outcome/Change:
 Reduction of hypertensive symptoms
 Maintenance of healthy levels of blood pressure
 Increased public health literacy on the effects of hypertension
 Increased public health literacy on strategies of balanced diet consumption
Question 4
The nutritional intervention of a DASH diet coupled with restrictions in sodium
consumption has been known to be beneficial in the prevention and reduction of rates of
hypertension among the population. The Dietary Approach to Stop Hypertension (DASH)
encompasses that for the prevention, reduction and management of hypertension, the diet must
comprise of plenty of fruits and vegetables, low fat or skimmed dairy products and restrictions in
the consumption of foods rich in cholesterol and saturated fats (Peairs et al., 2017). The scientific
evidence which discusses extensively on the benefits of DASH diet nutritional interventions on
population hypertension, was the randomized controlled trial Juraschek et al., (2017). The
authors, in a randomized study consisting of 412 participants, compared the effects of a low
sodium vas a high sodium, a DASH vs. a non-DASH diet, and a low sodium DASH vs. a high
sodium DASH diet on blood pressure. The study findings reported that a DASH diet coupled
with low sodium intake resulted in the highest rates of reduction of blood pressure hence
validating the beneficial effects of this dietary intervention in hypertension prevention. This
study settings can be considered to be similar to Alberta since both health interventions in
Alberta as well that employed in the chosen evidence focus on dietary strategies to prevent and
manage hypertension. Likewise, for both Alberta as well as the chosen evidence, the intervention

5PUBLIC HEALTH NUTRITION
has been aimed at the general population without any specific inclusion of hypertensive patients
taking anti-hypertensive medications hence indicating similarity (Juraschek et al., 2017).
Question 5
The concept of opportunity cost implies the loss or sacrifice of one alternative due to the
result of prioritizing a specific alternative. To further elaborate, an opportunity cost implies the
situation of a trade off which implies giving up of additional or alternative benefits or profits for
the purpose of achieving a chosen alternative (Rujis et al., 2017).
Since public health strategies require consideration and often prioritization of several
alternative health interventions and approaches due to the presence of limitations in terms of
cost and funding available for implementation of the overall public health framework.
Considering that hypertension is a key harmful component of the metabolic syndrome which is
caused due to a number of factors, it is not surprising that the public health intervention against
hypertension in Alberta will consist of several trade-offs and opportunity costs (Masters et al.,
2017). In addition to dietary interventions, interventions consisting of exercise as well as anti-
hypertensive medication administration also prove to be beneficial in the prevention, control and
management of hypertension. Hence, in the chosen public health intervention to control
population rates of hypertension in Alberta, prioritizing dietary interventions will result in a
trade-off where limited cost will remain for implementation of exercise and pharmacological
interventions hence resulting in the removal of considering such alternative interventions
(Cookson et al., 2017).
However, since no single intervention may be beneficial and the importance of a
multidisciplinary holistic approach must be considered due to the multifaceted symptomatic

6PUBLIC HEALTH NUTRITION
causative background underlying hypertension. Hence, for the purpose of strategic prioritization,
instead of simultaneous implementation, alternative interventions for hypertension management
can be considered one at a time (Fortuna et al., 2015). Hence, after a phase of dietary
intervention implementation, the public health authorities can consider a second phase consisting
of exercise intervention and a third phase consisting of pharmacological interventions. Such
categorization during different time periods will allow enough time to collect funds and hence
prevent emergence of opportunity costs (Ho et al., 2016).
Question 6
The dietary components of the intervention, especially restriction on the consumption of
sodium and incorporation of a DASH diet, will be required to undergo a pilot test before
implementation throughout the province of Alberta. It must be remembered that Alberta is a
huge province and records the fourth highest population in the nation of Canada. It is also
worthwhile to mention that the population of Alberta has a vast ethnic diversity and is composed
of several ethnic groups – each with its own set of dietary and cultural principles of practice
(Ezekowitz et al. 2018). Diet and eating patterns are largely a component of personal beliefs,
family traditions, religious practices and ethnicities. Hence, it is highly likely that the DASH diet
and the dietary practice of salt restriction may not be accepted whole heartedly by every
population group residing in Alberta. Hence, to assess the feasibility, acceptability and
compliance to the proposed dietary interventions in the management of hypertension, a pilot test
must be conducted prior to implementation on a provincial scale (Morton, 2018).
As discusses previously, a public health intervention, prior to its implementation on a
larger scale, must comprise of pilot testing components. Hence, public health officials must

7PUBLIC HEALTH NUTRITION
considered pilot testing DASH diet and sodium restriction dietary interventions over a small
sample in each province of Alberta. In case of success, public health authorities in each province
can proceed to generate the intervention by conducting educational camps or community diet
programs in each various hospitals, health centers or community centers of the province for the
purpose of exerting widespread impact (Purnell et al., 2016). Diet programs encompassing
voluntary participation with suitable rewards and exemptions on public health assessments can
be conducted further to assert greater reach and dissemination of the intervention. Taking aid
from the federal government in terms of funding, municipalities in each province can consider
dissemination of pamphlets and brochures containing details of an anti-hypertensive diet or even
arrange of mass media advertisements disseminating information on the same (Lu et al., 2015).
Question 7
For the successful implementation of the public health intervention, key stakeholders who
need to be involved include: nutritionists, nurses, doctors or physicians, pharmacists, fitness
experts and media houses. Nutritionists will aim to educate the public on the anti-hypersensitive
diet plan to be followed, fitness experts will be responsible for educating in exercise principles,
nurses and doctors will aid in public health assessments and screening while pharmacists will aid
in the procurement of medical equipment and medications (Shaoli et al., 2017).
To persuade or enlighten such stakeholders on the benefits of dietary, exercise and
pharmacological interventions in the management of hypertension, results and findings acquired
from scholarly, peer reviewed scientific articles will be discussed extensively. To initiate
stakeholder engagement, strategies of timely and interpersonal communication will be used
where each stakeholder will be contacted prior to the implementation of the process followed by

8PUBLIC HEALTH NUTRITION
interpersonal, one-to-one conversations with the same (Payne & Calton, 2017). Further, a
collaborative, person centered and transactional approach will be undertaken where key
stakeholders will be allowed to bring forth their ideas to the table and hence, result in
consideration of opinions from everyone for the final development of the intervention strategy.
To continue engagement with these stakeholders, benefits such as discounts or voucher plans can
be consider (Herremans, Nazari & Mahmoudian, 2016). Hence for example, citizens showing
active compliance to the voluntary public health programs for hypertension management will be
given a discount voucher highlighting significant cost exemption for attending clinical services
provided by nursing or clinician stakeholders hence resulting in a win-win situation and long
term public as well as stakeholder engagement. To further ensure engagement, stakeholders will
be encouraged that they will also receive a fair share of the profits incurred (Andriof &
Waddock, 2017).
Question 8
a) To ensure working of the strategy, public health campaigns will be undertaken for
monitoring the blood pressures of citizens on a community level, especially those who
participated in the voluntary community programs. Further, feedback surveys can be
conducted by the public health authorities in each province after implementation of the
strategy to obtain insight on the opinions of the public (Potthoff & Vonend, 2017).
b) Qualitative methods like interviews or online platforms allowing the public to provide
their feedback will be beneficial to explore aspects of public acceptability and
compliance to the intervention (Oh et al., 2019).

9PUBLIC HEALTH NUTRITION
c) For measuring the aspects of changes of blood pressure as well as public engagement in
interventions, quantitative values like blood pressure recordings and records of
participants can be collected by public health authorities or community centers in each
province implementing the intervention. Calculating the number of brochures sold and
results of an online public multiple choice based survey on public levels of awareness
after implementation will also be useful quantitative data (Rehman et al., 2017).
d) Formative studies in the form of randomized controlled trials which have evaluated the
associations between diet and hypertension, may be required to be collected and
evaluated. Likewise, primary data can also be useful in the form of pilot testing
conductance as discussed below (Gay et al., 2016).
e) Before finalizing strategy implementation, pilot studies researching on effects of a anti-
hypertensive diet on blood pressure will prove to be useful where quantitative data on
blood pressure values and qualitative data via participant feedback interviews can be
collected (Conn et al., 2015).
f) A key indicator would be the expected outcome of reduction in blood pressure
considering the beneficial effects of a DASH diet with sodium restriction on hypertension
prevention. This can be measured in hospitals or community centers implementing this
intervention by using blood pressure measuring devices like a sphygmomanometer
(Cuevas, Williams & Albert, 2017).
g) To asses dietary intake in the province, public health officials and authority in each of the
municipalities can conduct dietary recall surveys or evaluate the follow up diets of those
citizens who had participated in voluntary community intervention programs mentioned
previously (Hornik, 2018).

10PUBLIC HEALTH NUTRITION
Question 9
a) The characteristic dietary changes promoted by the by intervention include consumption
of fruits, vegetables, low fat dairy and restricted consumption of saturated fat, cholesterol
and sodium. Excessive consumption of processed or salty foods may hinder adequate
adoption of proposed dietary principles (Steinberg, Bennett & Svetkey, 2017).
b) Cultural barriers can be expected where ethnically diverse groups may not comply to the
dietary interventions. Hence, culturally competent diet strategies will be provided to
mitigate the same. The opposition can come in the form of skepticism from these
communities which can be overcome by conducting empathetic, patient and culturally
competent interpersonal communication with such communities (Mackenbach et al.,
2017).
Question 10
A scenario which will reflect high public participation and compliance to the intervention
despite unchanged hypertension rates, will be seen as successful by stakeholders. Such a
situation can arise if instead of linking with achievement of outcomes, the generation of profits is
associated with merely public participation and factors like inadequately financial arrangements
can contribute to the same (Forsythe et al., 2016). To reduce the likelihood, the financial
agreements between stakeholders must be designed adequately where a part of profit generation
must be associated with public’s achievement of outcomes and hence, is estimated to further
motivate stakeholder engagement instead of restricting it only till public participation (Tomkiv et
al., 2017).

11PUBLIC HEALTH NUTRITION
References
Anderson, J., Young, L., & Long, E. (2019). Diet and hypertension. Food and nutrition series.
Health; no. 9.318.
Andriof, J., & Waddock, S. (2017). Unfolding stakeholder engagement. In Unfolding stakeholder
thinking (pp. 19-42). Routledge.
Conn, V. S., Ruppar, T. M., Chase, J. A. D., Enriquez, M., & Cooper, P. S. (2015). Interventions
to improve medication adherence in hypertensive patients: systematic review and meta-
analysis. Current hypertension reports, 17(12), 94.
Cookson, R., Mirelman, A. J., Griffin, S., Asaria, M., Dawkins, B., Norheim, O. F., ... & Culyer,
A. J. (2017). Using cost-effectiveness analysis to address health equity concerns. Value in
Health, 20(2), 206-212.
Cuevas, A. G., Williams, D. R., & Albert, M. A. (2017). Psychosocial factors and hypertension:
a review of the literature. Cardiology clinics, 35(2), 223-230.
Ezekowitz, J. A., McAlister, F. A., Howlett, J., Alemayehu, W., Paterson, I., Belenkie, I., ... &
Alberta HEART Investigators. (2018). A prospective evaluation of the established criteria
for heart failure with preserved ejection fraction using the Alberta HEART cohort. ESC
heart failure, 5(1), 19-26.
Forsythe, L. P., Ellis, L. E., Edmundson, L., Sabharwal, R., Rein, A., Konopka, K., & Frank, L.
(2016). Patient and stakeholder engagement in the PCORI pilot projects: description and
lessons learned. Journal of general internal medicine, 31(1), 13-21.

12PUBLIC HEALTH NUTRITION
Fortuna, R. J., Nagel, A. K., Rose, E., McCann, R., Teeters, J. C., Quigley, D. D., ... & Rocco, T.
A. (2015). Effectiveness of a multidisciplinary intervention to improve hypertension
control in an urban underserved practice. Journal of the American Society of
Hypertension, 9(12), 966-974.
Gay, H. C., Rao, S. G., Vaccarino, V., & Ali, M. K. (2016). Effects of different dietary
interventions on blood pressure: systematic review and meta-analysis of randomized
controlled trials. Hypertension, 67(4), 733-739.
Herremans, I. M., Nazari, J. A., & Mahmoudian, F. (2016). Stakeholder relationships,
engagement, and sustainability reporting. Journal of Business Ethics, 138(3), 417-435.
Ho, A. K., Bartels, C. M., Thorpe, C. T., Pandhi, N., Smith, M. A., & Johnson, H. M. (2016).
Achieving weight loss and hypertension control among obese adults: a US
multidisciplinary group practice observational study. American journal of
hypertension, 29(8), 984-991.
Hornik, R. (2018). Public health education and communication as policy instruments for
bringing about changes in behavior. In Social marketing (pp. 45-58). Psychology Press.
Juraschek, S. P., Gelber, A. C., Choi, H. K., Appel, L. J., & Miller III, E. R. (2016). Effects of
the Dietary Approaches to Stop Hypertension (DASH) diet and sodium intake on serum
uric acid. Arthritis & Rheumatology, 68(12), 3002-3009.
Lu, C. H., Tang, S. T., Lei, Y. X., Zhang, M. Q., Lin, W. Q., Ding, S. H., & Wang, P. X. (2015).
Community-based interventions in hypertensive patients: a comparison of three health
education strategies. BMC public health, 15(1), 33.

13PUBLIC HEALTH NUTRITION
Mackenbach, J. D., Burgoine, T., Lakerveld, J., Forouhi, N. G., Griffin, S. J., Wareham, N. J., &
Monsivais, P. (2017). Accessibility and affordability of supermarkets: associations with
the DASH diet. American journal of preventive medicine, 53(1), 55-62.
Masters, R., Anwar, E., Collins, B., Cookson, R., & Capewell, S. (2017). Return on investment
of public health interventions: a systematic review. J Epidemiol Community
Health, 71(8), 827-834.
McGowan, J., Sampson, M., Salzwedel, D. M., Cogo, E., Foerster, V., & Lefebvre, C. (2016).
PRESS peer review of electronic search strategies: 2015 guideline statement. Journal of
clinical epidemiology, 75, 40-46.
Morton, J. A. (2018). Cultural Influences of Herbal Supplementation in Hypertension
Management Among the United States Virgin Islander.
Oh, D. K., Song, J. M., Park, D. W., Oh, S. Y., Ryu, J. S., Lee, J., ... & Lee, J. S. (2019). The
effect of a multidisciplinary team on the implementation rates of major diagnostic and
therapeutic procedures of chronic thromboembolic pulmonary hypertension. Heart &
Lung, 48(1), 28-33.
Payne, S. L., & Calton, J. M. (2017). Towards a managerial practice of stakeholder engagement:
Developing multi-stakeholder learning dialogues. In Unfolding stakeholder thinking (pp.
121-135). Routledge.
Peairs, A. D., Shah, A. S., Summer, S., Hess, M., & Couch, S. C. (2017). Effects of the dietary
approaches to stop hypertension (DASH) diet on glucose variability in youth with Type 1
diabetes. Diabetes management (London, England), 7(5), 383.

14PUBLIC HEALTH NUTRITION
Potthoff, S. A., & Vonend, O. (2017). Multidisciplinary approach in the treatment of resistant
hypertension. Current hypertension reports, 19(1), 9.
Purnell, T. S., Calhoun, E. A., Golden, S. H., Halladay, J. R., Krok-Schoen, J. L., Appelhans, B.
M., & Cooper, L. A. (2016). Achieving health equity: closing the gaps in health care
disparities, interventions, and research. Health Affairs, 35(8), 1410-1415.
Rai, S. K., Fung, T. T., Lu, N., Keller, S. F., Curhan, G. C., & Choi, H. K. (2017). The Dietary
Approaches to Stop Hypertension (DASH) diet, Western diet, and risk of gout in men:
prospective cohort study. bmj, 357, j1794.
Rehman, H., Kamal, A. K., Morris, P. B., Sayani, S., Merchant, A. T., & Virani, S. S. (2017).
Mobile health (mHealth) technology for the management of hypertension and
hyperlipidemia: slow start but loads of potential. Current atherosclerosis reports, 19(3),
12.
Ruijs, A., Kortelainen, M., Wossink, A., Schulp, C. J. E., & Alkemade, R. (2017). Opportunity
cost estimation of ecosystem services. Environmental and resource economics, 66(4),
717-747.
Shaoli, W. U., Xie, M., Jiang, M., Shuzhen, H. E., Xie, J., Tong, Y., & Yanfen, Y. E. (2017).
Effect of multidisciplinary collaborations in control of peritoneal dialysis patients with
hypertension. Chinese Journal of Practical Nursing, 33(9), 641-646.
Siervo, M., Lara, J., Chowdhury, S., Ashor, A., Oggioni, C., & Mathers, J. C. (2015). Effects of
the Dietary Approach to Stop Hypertension (DASH) diet on cardiovascular risk factors: a
systematic review and meta-analysis. British Journal of Nutrition, 113(1), 1-15.

15PUBLIC HEALTH NUTRITION
Soltani, S., Shirani, F., Chitsazi, M. J., & Salehi‐Abargouei, A. (2016). The effect of dietary
approaches to stop hypertension (DASH) diet on weight and body composition in adults:
a systematic review and meta‐analysis of randomized controlled clinical trials. Obesity
reviews, 17(5), 442-454.
Steinberg, D., Bennett, G. G., & Svetkey, L. (2017). The DASH diet, 20 years
later. Jama, 317(15), 1529-1530.
Tomkiv, Y., Liland, A., Oughton, D. H., & Wynne, B. (2017). Assessing Quality of Stakeholder
Engagement: From Bureaucracy to Democracy. Bulletin of Science, Technology &
Society, 37(3), 167-178.