The n e w e ng l a n d j o u r na l of
Special Article
From the Centers for Disease Control and
Prevention, Atlanta. Address reprint re-
quests to Dr. Frieden at the Centers for
Disease Control and Prevention, 1600 Clif-
ton Rd., Atlanta, GA 30333, or at tfrieden@
cdc.gov.
N Engl J Med 2015;373:1748-54.
DOI: 10.1056/NEJMsa1511248
Copyright 2015 Massachusetts Medical Society.
1748
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m e dic i n e
Shattuck Lecture
The Future of Public Health
ThomasR. Frieden, M.D., M.P.H.
T
he field of public health aims to improve the health of as many
people as possible as rapidly as possible. Since 1900, the average life span
in the United States has increased by more than 30 years; 25 years of this
gain have been attributed to public health advances.1,2 Globally, life expectancy
doubled during the 20th century,3 largely as a result of reductions in child mortal-
ity attributable to expanded immunization coverage, clean water, sanitation, and
other child-survival programs.4
Public health focuses on denominators what proportion of all people who
can benefit from an intervention actually benefit. Maximizing health requires
contributions from many sectors of society, including broad social, economic,
environmental, transportation, and other policies in which government plays key
roles; involvement of civil society; innovation by the public and private sectors; and
health care and public health action. Although there has sometimes been distrust
and disrespect between the health care and public health fields,5 they are inevita-
bly and increasingly interdependent; maximizing potential health gains is a defin-
ing challenge for both fields.
Buil ding a Publ ic He a lth Py r a mid
To maximize impact, public health works at five levels (Fig.1). At the first level
the base of the pyramid are socioeconomic factors such as income, educa-
tion, housing, and race. Although these factors are not diseases, both public
health efforts and health care can have some effect on them for example,
through health insurance coverage that reduces poverty or through prevention of
teen pregnancy to reduce the perpetuation of poverty. Immediately above the so-
cioeconomic factors are traditional public health interventions that change the
context to make default decisions the healthy choices (e.g., by providing clean
drinking water). At the next level are long-lasting protective interventions, such as
immunizations, that require only intermittent action by the health care system.
Next are clinical interventions requiring long-term, daily care, such as blood-
pressure control. The last level includes counseling and education, such as exhort-
ing people to eat healthy food and be physically active. Each level is important, but
interventions at the pyramids base generally improve health for more people, at
lower unit cost, than those at the top.6
To increase the impact of clinical care on population health, improvements in
the third and fourth levels need to be implemented more effectively. Blood-pres-
sure control, which can save more lives than any other clinical intervention,7 is
successful in only about half of Americans; nearly 90% of patients with uncon-
trolled hypertension have both health insurance and a regular source of care, and
more than 80% have multiple contacts with the health system each year.8
To maximize health overall, both communicable and noncommunicable dis-
n engl j med 373;18nejm.org October 29, 2015
The New England Journal of Medicine
Copyright 2015 Massachusetts Medical Society. All rights reserved.
 Shat tuck Lecture
ease threats need to be addressed in the United
States and globally. There are important connec-
tions between infectious and noninfectious dis-
eases: most cases of cervical cancer and many
cases of liver cancer can now be prevented
through vaccination; diabetes, obesity, and to-
bacco and alcohol use increase risks of both
cancer and infections. U.S. and global health are
also inextricably connected, as outbreaks of Ebola
virus disease and the Middle East respiratory
syndrome (MERS) and the spread of drug resis-
tance make clear. Nevertheless, it is useful to
give separate consideration to ways of address-
ing infectious and noninfectious conditions.
Infec t ious Dise a se s
in the Uni ted S tate s
Despite progress over the past century, the
United States continues to face substantial infec-
tious disease challenges. Human immunodefi-
ciency virus (HIV) infection, hepatitis C virus
infection, drug-resistant bacteria, health care
associated infections, and preventable influenza
and pneumonia continue to kill more than
100,000 people in the United States each year.9-11
The increase in drug resistance, higher preva-
lence of risk factors such as diabetes and obesity,
aging of the population, and greater complexity
of medical interventions make infectious-disease
control increasingly important and challenging.
Addressing these challenges requires a combina-
tion of technological advances, more effective
clinical and administrative systems, and political
commitment to invest in prevention and control.
From a public health perspective, an effective
clinical system has five essential characteristics:
consistency, patient-centeredness, team-based
care, registry-based information systems, and
continuous improvement in treatments and de-
livery. These core features can help clinical sys-
tems address infectious-disease threats through
standardization of care, interventions that in-
crease patient adherence, team-based approaches
to care (including hospital stewardship pro-
grams),12 rigorous monitoring of outcomes, and
continuous improvement in detection, treatment,
and prevention. Standardization and team-based
care can increase vaccination rates and reduce
prescription of unnecessary or overly broad-
spectrum antibiotics. Registry-based approaches
have the potential to increase the proportion of
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Increasing population Increasing individual
impact effort needed
Counseling
and education
Clinical interventions
Long-lasting protective interventions
Changing the context to make individuals default
decisions healthy
Socioeconomic factors
Figure 1. The Health Impact Pyramid.
Public health focuses on denominators what proportion of all people who
can benefit from an intervention actually benefit. Improvements at the base
of the pyramid generally improve health for more people, at lower unit cost,
than those at the top. Adapted with permission from Frieden.6
patients with HIV infection who are effectively
treated from the current rate of 40% or less in the
United States.13 Coordination among health care
facilities and public health departments can sub-
stantially reduce the spread of drug resistance.14
Technological advances present new opportu-
nities for infectious-disease control. These in-
clude large-scale, real-time whole-genome se-
quencing, which can improve identification of
organisms, resistance, and infection clusters and
elucidate the effects of the microbiome on health.
New technologies complement and enhance but
do not replace core epidemiologic functions.
Infec t ious Dise a se s a round
the Wor l d
Recent decades have seen substantial progress
in addressing some infectious diseases globally.
Rates of death from the acquired immunodefi-
ciency syndrome (AIDS),15 tuberculosis,16 and
malaria17 have decreased substantially. Tropical
diseases such as filariasis are being controlled.18
Polio and guinea worm disease are nearly eradi-
cated.19,20 Vaccination programs prevent more
than 2 million deaths each year among children
1749
 The n e w e ng l a n d j o u r na l
under 5 years of age, although at least another
1.5 million deaths could be averted if current
programs were expanded and new vaccines de-
veloped.21
The Ebola epidemic that began in West Africa
in 2014 revealed once again how a weak link in
disease detection and control anywhere can be a
vulnerability everywhere. In theory, control of
Ebola is simple. Programs must find, isolate, and
safely care for infected people, track contacts,
and safely bury patients who die. The challenge
in West Africa has been to undertake these tasks
in communities with no electricity or running
water, no Internet or cell-phone coverage, large
segments of society that are nonliterate and
trust neither the government nor modern med-
icine, and a near complete lack of core public
health infrastructure.
The Ebola outbreak offers three essential les-
sons. First, every country must have the core
public health functionality to identify a threat
when it emerges, stop it promptly, and prevent it
wherever possible. The goal of the Global Health
Security Agenda is to strengthen every countrys
capacity, including trained epidemiologists, high-
quality laboratories, timely and accurate disease-
surveillance systems, and rapid response teams.22,23
Second, when national capacity is over-
whelmed, the world must be able to move imme-
diately and decisively. Epidemics are global prob-
lems. The World Health Organization (WHO) and
its Global Outbreak Alert and Response Network
need to strengthen global response capacity in
epidemiology, laboratory science, clinical care,
logistics, anthropology, and other disciplines
essential for disease control. The responses in
individual countries can be quicker, more efficient,
and more cost-effective than a global effort but
only if systems in daily use can be rapidly scaled
up in emergencies.
Third, the lack of effective infection preven-
tion and control in hospitals and other health
care facilities is a key vulnerability. Because Ebola
infections, MERS, and the severe acute respira-
tory syndrome (SARS) usually result in severe
illness or death within weeks after exposure, the
presence and spread of these infections are read-
ily apparent. But tuberculosis,24,25 diseases caused
by drug-resistant organisms,26 Clostridium difficile
infection,27 measles,28 and many other conditions
are routinely spread in health care facilities. Every
country needs a strong system to support, coor-
dinate, and monitor infection control in health
1750 n engl j med 373;18nejm.org October 29, 2015
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of m e dic i n e
facilities. Such facilities need full-time staff
dedicated to monitoring and improving infec-
tion control, and facility leadership needs to
fully support these staff.
Chronic Dise a se s in
the Uni ted S tate s
Tobacco use is still the leading underlying cause
of death in the United States and worldwide.
Smoking prevalence in the United States is de-
clining, albeit slowly. Smoking-cessation coun-
seling and treatment are effective clinical inter-
ventions, but public health interventions, including
raising tobacco taxes, expanding smoke-free
public places, running hard-hitting antitobacco
advertising campaigns, reducing images of smok-
ing in movies and television, and increasing the
purchase age to 21 years, can reduce smoking
rates much more. In its first 3 years, the Tips
from Former Smokers advertising campaign
from the Centers for Disease Control and Pre-
vention helped at least 300,000 smokers quit and
saved at least 50,000 lives, at a cost of less than
$500 per smoker who quit, less than $400 per
year of life saved, and less than $3,000 per life
saved.29 Regulation of the toxicity and addictive-
ness of combustible tobacco holds promise for
reducing the harms of tobacco but faces certain
opposition from the tobacco industry.
Improved cardiovascular care, particularly bet-
ter blood-pressure control, can save far more
lives than any other clinical intervention but will
require substantial improvement at the fourth
level of the pyramid. Better implementation of
the ABCS daily aspirin use for people at
high risk, blood-pressure control, cholesterol man-
agement, and smoking cessation could save
100,000 lives yearly in the United States if rates
of clinical service utilization increase to those
achieved by high-performing systems.7 Every
10% increase in the number of people effectively
treated for hypertension would lead to preven-
tion of an additional 14,000 deaths a greater
impact than that of any other intervention stud-
ied.7 Nationally, just over half of adults with hy-
pertension have it under control, up from slight-
ly over 40% 15 years ago.30,31 But health systems
such as Kaiser Permanente Northern California32
and communities such as MinneapolisSt. Paul33
have increased control rates to 70 to 80%.
Some of the highest-performing U.S. health
systems Geisinger,34 North Shore,35 and oth-
 Shat tuck Lecture
ers examined data from electronic health re-
cords and found that nearly a third of people
with multiple elevated readings were never told
that they had high blood pressure, much less
had it treated. Investigators identified and treat-
ed patients with elevated blood-pressure read-
ings and created automated reminders to find
and treat patients who would not otherwise be
included in the denominator for clinical quality
measures.36
High sodium intake is a leading contributor
to hypertension, and Americans consume an
average of 3500 mg of sodium per day, far more
than recommended. Reducing average sodium
intake by a third could save up to half a million
lives and nearly $100 billion in health care costs
over the next 10 years.37,38 Because the sodium
content of most processed and restaurant foods
puts reducing intake beyond personal or clinical
reach,39 action is needed at the societal level,
such as working with food manufacturers and
restaurants to steadily reduce sodium content.
In the United Kingdom, industry initially re-
sisted government calls to voluntarily reduce
sodium content but then reduced sodium levels
in many food categories by 14 to 36% in 2 to
3years achieving a 20% reduction in bread
between 2001 and 2011 and a 57% reduction in
breakfast cereals between 2004 and 2011.40 Aver-
age British sodium intake fell by 15% between
2003 and 2011, and there was a substantial re-
duction in average blood pressure, a 40% drop
in the number of deaths from heart attacks, and
a 42% decrease in deaths from stroke, with re-
duced sodium intake estimated to account for a
quarter to a third of the mortality reduction.41
Although the rapid increases seen in obesity
since the 1970s appear to have leveled off, obe-
sity and overweight continue to be serious prob-
lems in the United States.42 Increasing physical
activity and improving nutrition are keys to obe-
sity prevention and control, and policies that
change the environment to make healthful eat-
ing and regular physical activity easier, safer, and
more attractive are likely to be most effective.43
Chronic Dise a se s a round
the Wor l d
Even in low-income countries, chronic diseases
and injuries now kill twice as many people as
infectious diseases, and rates are higher than
those in high-income countries. The only excep-
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Copyright 2015 Massachusetts Medical Society. All rights reserved.
tion is sub-Saharan Africa, although chronic
diseases are increasing there as well. Healthier
populations will increase economic stability and
growth, and effective collaboration to imple-
ment programs that address these diseases can
provide important lessons on how to tackle the
leading causes of preventable disability and pre-
mature death.
Tobacco use kills more than 6 million people
per year more deaths than HIV, tuberculosis,
and malaria combined, and nearly 80% of these
deaths occur in low- and middle-income coun-
tries.44 Without urgent action, tobacco use will
kill more than 1 billion people in this century.
Bloomberg Philanthropies, joined by the Bill and
Melinda Gates Foundation and supporting WHO
and individual countries, have expanded the
WHO-recommended MPOWER strategy in recent
years (Table1). These efforts are expected to
prevent more than 7 million deaths in the 41
countries that fully implemented at least one
MPOWER policy between 2007 and 2010, and
that impact is expected to increase dramatically
in the future.45 Nevertheless, much more must
be done to reduce tobacco use.
Hypertension is the only condition that kills
more people globally than tobacco use more
than 9 million per year.46 Blood pressure does
not necessarily increase with age if sodium in-
take, physical activity, and other factors remain
in the healthy range.47 However, even with effec-
tive community-wide interventions, there will be
substantial need for treatment of hypertension.
Currently, only about one in seven people with
hypertension has it under control. Improved
functioning at the fourth level of the pyramid,
including through standardized protocols that
simplify availability, delivery, and use of core
blood-pressure medications and allow tasks to
be delegated to nursing and nonmedical staff,
could save a million or more lives worldwide
each year; a reduction of sodium intake in con-
junction with treatment could save even more.46
In much of the world, motor vehicle crashes
are now the leading cause of death among peo-
ple 15 to 29 years of age. Public health interven-
tions at the lower levels of the pyramid are effec-
tive, inexpensive, and highly cost-effective. Such
interventions include lowering allowable blood
alcohol levels for drivers and implementing ran-
dom traffic stops to reduce drunk driving; in-
creasing the use of seat belts, child restraints,
and helmets; promoting increased taxation of
1751
 The n e w e ng l a n d j o u r na l of m e dic i n e

Table 1. MPOWER Strategy for Tobacco Control.*

Policy Strategy Target

Monitor tobacco use and Obtain data from surveys of nationally representative samples of adults and young peo-
prevention policies ple, conducted within the past 5 yr and collected at least every 5 yr
Protect people from tobacco Ensure that all public places (health facilities, schools and universities, government facili-
smoke ties, indoor offices and workplaces, restaurants, bars and cafes, public transport) are
completely smoke-free or that at least 90% of the population is covered by complete
subnational (local or regional) smoke-free legislation
Offer help to quit tobacco Establish national toll-free quit line and full coverage of both nicotine-replacement ther
use apy and at least some cessation services provided by health clinics or other primary
care facilities, hospitals, health professionals, or community organizations
Warn about the dangers of Ensure that warning labels cover at least 50% of the front and back of individual pack
tobacco ages of tobacco products and appear on any outside packaging and labeling used in
retail sale that include pictures or pictograms and that such labels include specific
health warnings; describe specific harmful effects of tobacco use on health; are large,
clear, visible, and legible; rotate periodically; and are written in the principal language
or languages of the country
Promote advertising campaigns to be aired on television, radio, or both as part of a com-
prehensive tobacco-control program and including research on target audiences;
pretesting of campaign messages and communications materials; purchase of radio
and TV airtime, print and billboard advertising, and other placement using a thor-
ough media-planning process that effectively and efficiently reaches the target audi-
ence; working with journalists to gain publicity or news coverage for the campaign;
and evaluations of campaign implementation effectiveness and impact
Enforce bans on tobacco Promote a ban on all forms of direct and indirect advertising of tobacco products, includ-
advertising, promotion, ing advertising on national television and radio, in local magazines and newspapers,
and sponsorship on billboards and outdoor advertising, and at the point of sale; on free distribution of
tobacco products in the mail or through other means; on promotional discounts; on
nontobacco goods and services identified with tobacco brand names (brand stretch-
ing); on brand names of nontobacco products used for tobacco products (brand
sharing); on product placement in television or films; and ban sponsorship by the
tobacco industry
Raise taxes on tobacco Revise tax laws so that more than 75% of the retail price of tobacco products is tax
products

* Adapted from the World Health Organization.44

alcohol; and reducing and enforcing speed lim- tecting adulterated food, prohibiting alcohol-
its. Better-engineered roads and vehicles also impaired driving, and protecting workers and
increase safety and reduce crash injuries and the public from second-hand smoke. Legal and
deaths. Policies require effective enforcement, policy changes in this area often both reflect
which is lacking in many parts of the world. and accelerate changes in social norms. The
third is to implement societal interventions
when individuals cannot efficiently or effectively
The Rol e of G ov er nmen t
protect their own health through such policies
A responsive government can maintain that peo- as vaccination mandates, clean air regulations,
ple are responsible for their own health while water fluoridation, micronutrient fortification of
also taking public health action that changes food, and elimination of lead in paint and gaso-
default choices to make it easier for people to line interventions that have all greatly im-
stay healthy.48 Key public health actions do one proved the health of Americans.1,49
of three things, all of which are now well ac-
cepted but were initially controversial. The first The F u t ur e
is to promote free and open information such
as truth-in-advertising laws and nutrition-facts In the future, clinical medicine could see costs
panels. The second is to protect people from increase without substantial improvement in
harm caused by others for example, by de- health outcomes.50 Alternatively, new delivery

1752 n engl j med 373;18nejm.org October 29, 2015

The New England Journal of Medicine

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Copyright 2015 Massachusetts Medical Society. All rights reserved.
 Shat tuck Lecture

models and technology could substantially in-
crease healthy life expectancy. The public health
field, for its part, may not be able to keep pace
with changing risks and increased opposition to
core public health actions that promote healthy
living or it could expand its past successes to
further reduce tobacco and alcohol use, control
persistent infectious diseases, increase physical
activity, improve nutrition, and reduce harms
from injuries and other environmental risks.
By working more closely together, clinical
medicine and public health can help each other
improve health maximally and emphasize
societys responsibility to promote both healthy
environments and consistent, high-quality care.
Public health organizations can publicize infor-
mation on health outcomes and risks that clari-
fies the need for, or achievement of, substantial
progress. Clinical experts can identify and vali-
date preventable harms and effective interven-
tions to protect patients.
The involvement of many parts of society,
including government agencies, health organiza-
tions, nongovernmental organizations, clinicians,
the private sector, and communities, is increas-
ingly important for success. Everyone benefits
when people are healthier.
Accountability for outcomes is essential
public healths obsession with denominators can
reduce the number of people missed by interven-
tions that improve health and save lives. Work-
ing together, clinical medicine and public health
can ensure that people live active and productive
lives far longer than was ever thought possible.
Presented as the 125th Shattuck Lecture at the annual meet-
ing of the Massachusetts Medical Society, Boston, May 1, 2015.
Disclosure forms provided by the author are available with the
full text of this article at NEJM.org.
I thank the Massachusetts Medical Society for the honor of
presenting the 2015 Shattuck Lecture; Richard Garfield, R.N.,
Ph.D., Sherri Berger, M.S.P.H., Michael Iademarco, M.D., M.P.H.,
and Debra Houry, M.D., M.P.H., for critical review of the manu-
script; and Kathryn Foti and Drew Blakeman for additional re-
search and assistance in the preparation of the manuscript.

References
1. Ten great public health achievements
United States, 19001999. MMWR
Morb Mortal Wkly Rep 1999;48:241-3.
2. Bunker JP, Frazier HS, Mosteller F.
Improving health: measuring effects of
medical care. Milbank Q 1994;72:225-58.
3. Riley JC. Estimates of regional and
global life expectancy, 18002001. Popul
Dev Rev 2005;31:537-43.
4. Riley JC. Rising life expectancy:
a global history. Cambridge, United King-
dom:Cambridge University Press, 2001.
5. Fee E, Brown TM. The unfulfilled
promise of public health: dj vu all over
again. Health Aff (Millwood) 2002; 21:
31-43.
6. Frieden TR. A framework for public
health action: the health impact pyramid.
Am J Public Health 2010;100:590-5.
7. Farley TA, Dalal MA, Mostashari F,
Frieden TR. Deaths preventable in the
U.S. by improvements in use of clinical
preventive services. Am J Prev Med 2010;
38:600-9.
8. Vital signs: awareness and treatment
of uncontrolled hypertension among adults
United States, 20032010. MMWR
Morb Mortal Wkly Rep 2012;61:703-9.
9. CDC National Health Report: leading
causes of morbidity and mortality and as-
sociated behavioral risk and protective fac-
tors United States, 20052013. MMWR
Surveill Summ 2014;63:Suppl 4:3-27.
10. Murphy SL, Kochanek KD, Xu J, Heron
M. Deaths:final data for 2012. National
Vital Statistics Reports. Vol. 63. No. 9. Hy-
attsville, MD:Department of Health and
Human Services, Centers for Disease
Control and Prevention, National Center
for Health Statistics, 2015.
11. Antibiotic resistance threats in the
United States, 2013. Atlanta:Centers for
Disease Control and Prevention, 2013.
12. Core elements of hospital antibiotic
stewardship programs. Atlanta:Centers
for Disease Control and Prevention, 2015
(www.cdc.gov/getsmart/healthcare/ countries through global health security.
implementation/core-elements.html).
13. Vital signs: HIV diagnosis, care, and
treatment among persons living with HIV
United States, 2011. MMWR Morb
Mortal Wkly Rep 2014;63:1113-7.
14. Vital signs: estimated effects of a co-
ordinated approach for action to reduce
antibiotic-resistant infections in health
care facilities United States. MMWR
Morb Mortal Wkly Rep 2015;64:826-31.
15. Global update on the health sector
response to HIV, 2014. Geneva:World
Health Organization, 2014.
16. Global tuberculosis report 2014. Ge-
neva:World Health Organization, 2014.
17. Achieving the malaria MDG target:
reversing the incidence of malaria 2000-
2015. Geneva:World Health Organization
and United Nations Childrens Fund,
2015.
18. Neglected tropical diseases: becom-
ing less neglected. Lancet 2014;383:1269.
19. Progress towards polio eradication
worldwide, 2014-2015. Wkly Epidemiol
Rec 2015;90:253-9.
20. Progress toward global eradication of
dracunculiasis January 2013June
2014. MMWR Morb Mortal Wkly Rep 2014;
63:1050-4.
21. Global vaccine action plan 2011-2020.
Geneva:World Health Organization, 2013.
22. Global health global health secu-
rity agenda. Atlanta:Centers for Disease
Control and Prevention;2015 (www.cdc
.gov/globalhealth/security).
23. Frieden TR, Tappero JW, Dowell SF,
Hien NT, Guillaume FD, Aceng JR. Safer
Lancet 2014;383:764-6.
24. Frieden TR, Woodley CL, Crawford JT,
Lew D, Dooley SM. The molecular epide-
miology of tuberculosis in New York City:
the importance of nosocomial transmis-
sion and laboratory error. Tuber Lung Dis
1996;77:407-13.
25. Frieden TR, Brudney KF, Harries AD.
Global tuberculosis: perspectives, pros-
pects, and priorities. JAMA 2014; 312:
1393-4.
26. Laxminarayan R, Duse A, Wattal C,
et al. Antibiotic resistance-the need for
global solutions. Lancet Infect Dis 2013;
13:1057-98.
27. Banaei N, Anikst V, Schroeder LF.
Burden of Clostridium difficile infection in
the United States. N Engl J Med 2015;372:
2368-9.
28. Maltezou HC, Wicker S. Measles in
health-care settings. Am J Infect Control
2013;41:661-3.
29. Xu X, Alexander RL Jr, Simpson SA,
et al. A cost-effectiveness analysis of the
first federally funded antismoking cam-
paign. Am J Prev Med 2015;48:318-25.
30. Guo F, He D, Zhang W, Walton RG.
Trends in prevalence, awareness, manage-
ment, and control of hypertension among

n engl j med 373;18nejm.org October 29, 2015 1753

The New England Journal of Medicine
Downloaded from nejm.org on August 28, 2017. For personal use only. No other uses without permission.
Copyright 2015 Massachusetts Medical Society. All rights reserved.
 Shattuck Lecture

United States adults, 1999 to 2010. J Am
Coll Cardiol 2012;60:599-606.
31. Nwankwo T, Yoon SS, Burt V, Gu Q.
Hypertension among adults in the US:
National Health and Nutrition Examina-
tion Survey, 2011-2012. NCHS Data Brief.
No. 133. Hyattsville, MD:Department of
Health and Human Services, Centers for
Disease Control and Prevention, National
Center for Health Statistics, 2013.
32. Jaffe MG, Lee GA, Young JD, Sidney S,
Go AS. Improved blood pressure control
associated with a large-scale hyperten-
sion program. JAMA 2013;310:699-705.
33. Luepker RV, Steffen LM, Jacobs DR Jr,
Zhou X, Blackburn H. Trends in blood
pressure and hypertension detection, treat-
ment, and control 1980 to 2009: the Min-
nesota Heart Survey. Circulation 2012;126:
1852-7.
34. Shah NR. Identifying hypertension in
electronic health records:a comparison
of various approaches. Presented at the
AHRQ Comparative Effectiveness Research
Methods Symposium, Rockville, MD,
June 12, 2009.
35. Rakotz MK, Ewigman BG, Sarav M,
et al. A technology-based quality innova-
tion to identify undiagnosed hypertension
among active primary care patients. Ann
Fam Med 2014;12:352-8.
36. Wall HK, Hannan JA, Wright JS. Pa-
tients with undiagnosed hypertension:
hiding in plain sight. JAMA 2014; 312:
1973-4.
37. Coxson PG, Cook NR, Joffres M, et al.
Mortality benefits from US population-
wide reduction in sodium consumption:
projections from 3 modeling approaches.
Hypertension 2013;61:564-70.
38. Bibbins-Domingo K, Chertow GM,
Coxson PG, et al. Projected effect of dietary
salt reductions on future cardiovascular
disease. N Engl J Med 2010;362:590-9.
39. Adler AJ, Taylor F, Martin N, Gottlieb
S, Taylor RS, Ebrahim S. Reduced dietary
salt for the prevention of cardiovascular
disease. Cochrane Database Syst Rev 2014;
12:CD009217.
40. He FJ, Brinsden HC, MacGregor GA.
Salt reduction in the United Kingdom:
a successful experiment in public health.
J Hum Hypertens 2014;28:345-52.
41. He FJ, Pombo-Rodrigues S, Macgregor
GA. Salt reduction in England from 2003
to 2011: its relationship to blood pres-
sure, stroke and ischaemic heart disease
mortality. BMJ Open 2014;4(4):e004549.
42. Ogden CL, Carroll MD, Kit BK, Flegal
KM. Prevalence of childhood and adult
obesity in the United States, 2011-2012.
JAMA 2014;311:806-14.
43. Frieden TR, Dietz W, Collins J. Reduc-
ing childhood obesity through policy
change: acting now to prevent obesity.
Health Aff (Millwood) 2010;29:357-63.
44. WHO report on the global tobacco
epidemic, 2015:raising taxes on tobacco.
Geneva:World Health Organization,
2015.
45. Levy DT, Ellis JA, Mays D, Huang AT.
Smoking-related deaths averted due to
three years of policy progress. Bull World
Health Organ 2013;91:509-18.
46. Angell SY, De Cock KM, Frieden TR.
A public health approach to global man-
agement of hypertension. Lancet 2015;
385:825-7.
47. Intersalt Cooperative Research Group.
Intersalt: an international study of electro-
lyte excretion and blood pressure: results
for 24 hour urinary sodium and potassium
excretion. BMJ 1988;297:319-28.
48. Frieden TR. Governments role in pro-
tecting health and safety. N Engl J Med
2013;368:1857-9.
49. Ten great public health achievements
United States, 20012010. MMWR
Morb Mortal Wkly Rep 2011;60:619-23.
50. Bayer R, Galea S. Public health in the
precision-medicine era. N Engl J Med 2015;
373:499-501.
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