245from collaborative and comparative studies in Southeast Asia and Africa [ 57 ] show
that much or most of the poor detection and treatment may rise from lack of under-
standing of hypertension’s chronicity made worse by the asymptomatic presenta-
tion of the disease, as well as underdeveloped societal conditions including the high
cost of often poor-quality health care, the difficulty of finding proper treatment
expertise and materials, and unequal access to often inefficient health services.
However, some of the risk factors for the development and for worse outcomes
of hypertension appear to be both overnutrition and undernutrition. The complexi-
ties of many developing societies undergoing urban transitions are that both of these
two forms of malnutrition will coexist within the same population.
One result of the convoluted nature of rapidly urbanizing societies in the devel-
oping world is that both forms of malnutrition can be found side-by-side in a
population.
An ineluctable first step in the treatment of hypertension anywhere is to under-
stand its epidemiology as well as its natural history; these are often underdescribed
in poorer nations, especially in sub-Saharan Africa. Where systematic monitoring of
hypertension is in its initial stages, it must be remembered that alongside greater
incidence, early estimates may be exaggerated due to greater awareness among the
population, facilitating detection, as well as better methods of control, allowing a
greater number of people to survive with high BP [ 58 ]. A lessened intake of salt
directly decreases hypertension [ 52 ] and, like obesity, is a rare reversible cause of
high blood pressure. As such, it is key in the struggle with hypertension [ 59 ].
Additionally, salt intake may be restricted at the individual level through counseling
as well as among the population at large through policies limiting the salt found in
processed foods like bread [ 59 , 60 ]. These policies work in the long run because an
individual’s taste buds can grow accustomed to differing levels of salt content in
food. Unfortunately, it is much harder to grow accustomed to a lower salt content
than to a higher one, so reducing salt intake will remain a serious challenge for
health-care providers and officials [ 52 ]. Reducing salt taste thresholds can be done,
however, as we know that high salt-content food typically loses its appeal within
4–6 weeks of switching to a diet low in salt [ 52 ]. This is why salt reduction at the
population level has proved, to date, more cost-effective than clinical interventions
[ 52 ]. The Global Burden of Disease Study from the World Health Organization
(WHO) indicates that lowering the amount of salt in processed foods through action
at the level of societies could preserve 21 million or more disability-adjusted life
years worldwide – every year [ 61 ]. Beneficial effects on blood pressure have been
shown to derive from fruit and vegetable fiber, magnesium, and potassium, as well
as calcium from low-fat dairy [ 52 , 62 ]. Obesity is a major cause of hypertension and
the efforts increasing physical activity among the population beginning at young
ages and decreasing caloric intake may lessen the prevelance of the obesity in the
general population.
There have been many success stories in developed countries regarding decreased
CVD risk stemming from reduced consumption at the population level of energy-
dense and high-fat diets but few parallel examples in developing ones. One excep-
tion is Iran, which introduced a program based on the high-risk factor and population
15 Public Health Efforts for Earlier Resistant Hypertension Diagnosis...