Chronic disease affects 6 in 10 adults in the US, while 4 in 10 adults live with multiple chronic diseases (1). Chronic diseases represent one of the nation’s leading causes of disability and drivers of the nation’s $4.1 trillion in annual health care spending (1). Chronic conditions including heart disease, cancer, stroke, diabetes, and chronic kidney disease dominate the leading causes of death. Furthermore, leading lifestyle risk factors in the US include tobacco use, poor nutrition, physical inactivity, and excessive alcohol use (1). | | Chronic disease prevention and control necessitates a comprehensive strategy to prevent disease (2–4), which is needed now more than ever (5). Information systems innovations are needed to advance health activities and outcomes and to allow decision makers and practitioners to act (4,6–8). Chronic disease data are a foundation that can inform interventions to promote healthy communities, support healthy behaviors and lifestyles, and facilitate effective and coordinated chronic disease prevention and health promotion (5,9). The benefits of an improved chronic disease data landscape include improved management of chronic disease programs, enhanced communication, data exchange, and coordination between federal, state, tribal, local, and territorial health departments and their partners. Additionally, efforts aimed at enhancing chronic disease surveillance practices will better enable a learning health system, precision public health, and improved situational awareness that will ultimately allow people across the US to live longer, healthier lives (10–12).

This article describes a significant decline in emergency department visits for acute life-threatening conditions during the COVID-19 pandemic, suggesting that patients may be delaying or avoiding care or unable to access care during the pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has underscored the need to prevent chronic disease and promote health.1 , 2 More than a million American lives have been lost to COVID-19, and life expectancy decreased between 2018 and 2020.3 , 4 Chronic diseases are major risk factors for COVID-19 morbidity and mortality.5 In addition, COVID-19 morbidity and mortality have been higher among persons from racial and ethnic groups such as those who are African American, Hispanic or Latino, and American Indian or Alaska Native as well as those living at lower SES.6 This has magnified pre-existing health inequities in chronic disease.1 , 2 , 7

Chronic diseases represent 7 of the top 10 causes of death in the United States (1). Six in 10 Americans live with at least 1 chronic condition, such as heart disease, stroke, cancer, or diabetes (2). Chronic diseases are also the leading causes of disability in the US and the leading drivers of the nation’s $3.8 trillion annual health care costs (2,3). | | The COVID-19 pandemic has resulted in enormous personal and societal losses, with more than half a million lives lost (4). COVID-19 is a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that can result in respiratory distress. In addition to the physical toll, the emotional impact has yet to be fully understood. For those with chronic disease, the impact has been particularly profound (5,6). Heart disease, diabetes, cancer, chronic obstructive pulmonary disease, chronic kidney disease, and obesity are all conditions that increase the risk for severe illness from COVID-19 (7). Other factors, including smoking and pregnancy, also increase the risk (7). Finally, in addition to COVID-19–related deaths since February 1, 2020, an increase in deaths has been observed among people with dementia, circulatory diseases, and diabetes among other causes (8). This increase could reflect undercounting COVID-19 deaths or indirect effects of the virus, such as underutilization of, or stresses on, the health care system (8).

Before the coronavirus disease 2019 (COVID-19) pandemic, about 6 in 10 adults in the United States had a chronic condition; 90% of the nation’s health care expenditures were for people with chronic and mental health conditions, and chronic conditions accounted for 7 of the 10 leading causes of death in the United States (1–3).

Implications In this commentary, we describe the evidence-based approach used to identify the primary cause of EVALI and to curb the 2019 outbreak. We also discuss future research opportunities and public health practice considerations to prevent a resurgence of EVALI.

BACKGROUND: Since August, 2019, US public health officials have been investigating a national outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). A spectrum of histological patterns consistent with acute to subacute lung injury has been seen in biopsies; however, autopsy findings have not been systematically characterised. We describe the pathological findings in autopsy and biopsy tissues submitted to the US Centers for Disease Control and Prevention (CDC) for the evaluation of suspected EVALI. METHODS: Between Aug 1, 2019, and Nov 30, 2019, we examined lung biopsy (n=10 individuals) and autopsy (n=13 individuals) tissue samples received by the CDC, submitted by 16 US states, from individuals with: a history of e-cigarette, or vaping, product use; respiratory, gastrointestinal, or constitutional symptoms; and either pulmonary infiltrates or opacities on chest imaging, or sudden death from an undetermined cause. We also reviewed medical records, evaluated histopathology, and performed infectious disease testing when indicated by histopathology and clinical history. FINDINGS: 21 cases met surveillance case definitions for EVALI, with a further two cases of clinically suspected EVALI evaluated. All ten lung biopsies showed histological evidence of acute to subacute lung injury, including diffuse alveolar damage or organising pneumonia. These patterns were also seen in nine of 13 (69%) autopsy cases, most frequently diffuse alveolar damage (eight autopsies), but also acute and organising fibrinous pneumonia (one autopsy). Additional pulmonary pathology not necessarily consistent with EVALI was seen in the remaining autopsies, including bronchopneumonia, bronchoaspiration, and chronic interstitial lung disease. Three of the five autopsy cases with no evidence of, or a plausible alternative cause for acute lung injury, had been classified as confirmed or probable EVALI according to surveillance case definitions. INTERPRETATION: Acute to subacute lung injury patterns were seen in all ten biopsies and most autopsy lung tissues from individuals with suspected EVALI. Acute to subacute lung injury can have numerous causes; however, if it is identified in an individual with a history of e-cigarette, or vaping, product use, and no alternative cause is apparent, a diagnosis of EVALI should be strongly considered. A review of autopsy tissue pathology in suspected EVALI deaths can also identify alternative diagnoses, which can enhance the specificity of public health surveillance efforts. FUNDING: US Centers for Disease Control and Prevention.

On March 13, 2020, the United States declared a national emergency in response to the coronavirus disease 2019 (COVID-19) pandemic. Subsequently, states enacted stay-at-home orders to slow the spread of SARS-CoV-2, the virus that causes COVID-19, and reduce the burden on the U.S. health care system. CDC* and the Centers for Medicare & Medicaid Services (CMS)(dagger) recommended that health care systems prioritize urgent visits and delay elective care to mitigate the spread of COVID-19 in health care settings. By May 2020, national syndromic surveillance data found that emergency department (ED) visits had declined 42% during the early months of the pandemic (1). This report describes trends in ED visits for three acute life-threatening health conditions (myocardial infarction [MI, also known as heart attack], stroke, and hyperglycemic crisis), immediately before and after declaration of the COVID-19 pandemic as a national emergency. These conditions represent acute events that always necessitate immediate emergency care, even during a public health emergency such as the COVID-19 pandemic. In the 10 weeks following the emergency declaration (March 15-May 23, 2020), ED visits declined 23% for MI, 20% for stroke, and 10% for hyperglycemic crisis, compared with the preceding 10-week period (January 5-March 14, 2020). EDs play a critical role in diagnosing and treating life-threatening conditions that might result in serious disability or death. Persons experiencing signs or symptoms of serious illness, such as severe chest pain, sudden or partial loss of motor function, altered mental state, signs of extreme hyperglycemia, or other life-threatening issues, should seek immediate emergency care, regardless of the pandemic. Clear, frequent, highly visible communication from public health and health care professionals is needed to reinforce the importance of timely care for medical emergencies and to assure the public that EDs are implementing infection prevention and control guidelines that help ensure the safety of their patients and health care personnel.

Since entering the U.S. marketplace in 2007, e-cigarette, or vaping, products have evolved into a diverse class of inhaled aerosol devices. Earlier generations of these products were disposable, resembled conventional cigarettes in shape, and were designed to deliver nicotine to the user. Newer generations are rechargeable, don’t resemble conventional cigarettes, and can be used to deliver various substances, including nicotine and tetrahydrocannabinol (THC, the psychoactive ingredient in marijuana).1 The U.S. markets for both nicotine- and THC-containing vaping products have dramatically expanded. Recently, there has been an unprecedented increase in the use of nicotine-containing products by young people (see graph).2 Simultaneously, an increasing number of U.S. states have legalized marijuana use, a shift that coincided with changes in the public perception of risk, the availability of a wide variety of products containing THC or cannabidiol (CBD, a nonpsychoactive ingredient in marijuana), and increases in marijuana use among adults, especially young adults.3

On August 1, 2019, the first cases of electronic cigarette (e-cigarette), or vaping, product use–associated lung injury (EVALI) were reported to the Centers for Disease Control and Prevention (CDC).1 The cluster was an initial signal of an outbreak that by December 17, 2019, had resulted in 2506 cases involving hospitalized patients being reported to the CDC. Most patients with EVALI have been men and adolescent boys (67%), have been younger than 35 years of age (78%), and have reported using e-cigarette products containing tetrahydrocannabinol (THC) (80%).2

The United States is experiencing an unprecedented outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) (1). All EVALI patients have used e-cigarette, or vaping, products, and most (>/=85%) have reported using products containing tetrahydrocannabinol (THC) (2,3), the principal psychoactive component of cannabis. To examine whether e-cigarette, or vaping, product use behaviors differed between adult EVALI patients and adults who use these products but have not developed lung injury, the Illinois Department of Public Health (IDPH) conducted an online public survey during September-October 2019 targeting e-cigarette, or vaping, product users in Illinois. Among 4,631 survey respondents, 94% reported using any nicotine-containing e-cigarette, or vaping, products in the past 3 months; 21% used any THC-containing products; and 11% used both THC-containing products and nicotine-containing products. Prevalence of THC-containing product use was highest among survey respondents aged 18-24 years (36%) and decreased with increasing age. E-cigarette, or vaping, product use behaviors of 66 EVALI patients aged 18-44 years who were interviewed as part of the ongoing outbreak investigation were compared with a subset of 519 survey respondents aged 18-44 years who reported use of THC-containing e-cigarette, or vaping, products. Compared with these survey respondents, EVALI patients had higher odds of reporting exclusive use of THC-containing products (adjusted odds ratio [aOR] = 2.0, 95% confidence interval [CI] = 1.1-3.6); frequent use (more than five times per day) of these products (aOR = 3.1, 95% CI = 1.6-6.0), and obtaining these products from informal sources, such as a dealer, off the street, or from a friend (aOR = 9.2, 95% CI = 2.2-39.4). The odds of using Dank Vapes, a class of largely counterfeit THC-containing products, was also higher among EVALI patients (aOR = 8.5, 95% CI = 3.8-19.0). These findings reinforce current recommendations not to use e-cigarette, or vaping, products that contain THC and not to use any e-cigarette, or vaping, products obtained from informal sources. In addition, because the specific compound or ingredient causing lung injury is not yet known, CDC continues to recommend that persons consider refraining from use of all e-cigarette, or vaping, products while the outbreak investigation continues (1).

CDC, the Food and Drug Administration, state and local health departments, and other public health and clinical stakeholders are investigating a national outbreak of electronic-cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) (1). As of October 22, 2019, 49 states, the District of Columbia (DC), and the U.S. Virgin Islands have reported 1,604 cases of EVALI to CDC, including 34 (2.1%) EVALI-associated deaths in 24 states. Based on data collected as of October 15, 2019, this report updates data on patient characteristics and substances used in e-cigarette, or vaping, products (2) and describes characteristics of EVALI-associated deaths. The median age of EVALI patients who survived was 23 years, and the median age of EVALI patients who died was 45 years. Among 867 (54%) EVALI patients with available data on use of specific e-cigarette, or vaping, products in the 3 months preceding symptom onset, 86% reported any use of tetrahydrocannabinol (THC)-containing products, 64% reported any use of nicotine-containing products, and 52% reported use of both. Exclusive use of THC-containing products was reported by 34% of patients and exclusive use of nicotine-containing products by 11%, and for 2% of patients, no use of either THC- or nicotine-containing products was reported. Among 19 EVALI patients who died and for whom substance use data were available, 84% reported any use of THC-containing products, including 63% who reported exclusive use of THC-containing products; 37% reported any use of nicotine-containing products, including 16% who reported exclusive use of nicotine-containing products. To date, no single compound or ingredient used in e-cigarette, or vaping, products has emerged as the cause of EVALI, and there might be more than one cause. Because most patients reported using THC-containing products before symptom onset, CDC recommends that persons should not use e-cigarette, or vaping, products that contain THC. In addition, because the specific compound or ingredient causing lung injury is not yet known, and while the investigation continues, persons should consider refraining from the use of all e-cigarette, or vaping, products.

Electronic cigarettes (e-cigarettes), also called vapes, e-hookas, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS), are electronic devices that produce an aerosol by heating a liquid typically containing nicotine, flavorings, and other additives; users inhale this aerosol into their lungs (1). E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis (1). Use of e-cigarettes is commonly called vaping. Lung injury associated with e-cigarette use, or vaping, has recently been reported in most states (2-4). CDC, the Food and Drug Administration (FDA), state and local health departments, and others are investigating this outbreak. This report provides data on patterns of the outbreak and characteristics of patients, including sex, age, and selected substances used in e-cigarette, or vaping, products reported to CDC as part of this ongoing multistate investigation. As of September 24, 2019, 46 state health departments and one territorial health department had reported 805 patients with cases of lung injury associated with use of e-cigarette, or vaping, products to CDC. Sixty-nine percent of patients were males, and the median age was 23 years (range = 13-72 years). To date, 12 deaths have been confirmed in 10 states. Among 514 patients with information on substances used in e-cigarettes, or vaping products, in the 30 days preceding symptom onset, 76.9% reported using THC-containing products, and 56.8% reported using nicotine-containing products; 36.0% reported exclusive use of THC-containing products, and 16.0% reported exclusive use of nicotine-containing products. The specific chemical exposure(s) causing the outbreak is currently unknown. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. CDC will continue to work in collaboration with FDA and state and local partners to investigate cases and advise and alert the public on the investigation as additional information becomes available.

On September 6, 2019, this report was posted as an MMWR Early Release on the MMWR website (https://www.cdc.gov/mmwr). As of August 27, 2019, 215 possible cases of severe pulmonary disease associated with the use of electronic cigarette (e-cigarette) products (e.g., devices, liquids, refill pods, and cartridges) had been reported to CDC by 25 state health departments. E-cigarettes are devices that produce an aerosol by heating a liquid containing various chemicals, including nicotine, flavorings, and other additives (e.g., propellants, solvents, and oils). Users inhale the aerosol, including any additives, into their lungs. Aerosols produced by e-cigarettes can contain harmful or potentially harmful substances, including heavy metals such as lead, volatile organic compounds, ultrafine particles, cancer-causing chemicals, or other agents such as chemicals used for cleaning the device (1). E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis, or other drugs; for example, "dabbing" involves superheating substances that contain high concentrations of THC and other plant compounds (e.g., cannabidiol) with the intent of inhaling the aerosol. E-cigarette users could potentially add other substances to the devices. This report summarizes available information and provides interim case definitions and guidance for reporting possible cases of severe pulmonary disease. The guidance in this report reflects data available as of September 6, 2019; guidance will be updated as additional information becomes available.

BACKGROUND: Meta-analyses of observational studies have shown that women with a shorter interpregnancy interval (the time from delivery to start of a subsequent pregnancy) are more likely to experience adverse pregnancy outcomes, such as preterm delivery or small for gestational age birth, than women who space their births further apart. However, the studies used to inform these estimates have methodological shortcomings. METHODS: In this commentary, we summarise the discussions of an expert workgroup describing good practices for the design, analysis, and interpretation of observational studies of interpregnancy interval and adverse perinatal health outcomes. RESULTS: We argue that inferences drawn from research in this field will be improved by careful attention to elements such as: (a) refining the research question to clarify whether the goal is to estimate a causal effect vs describe patterns of association; (b) using directed acyclic graphs to represent potential causal networks and guide the analytic plan of studies seeking to estimate causal effects; (c) assessing how miscarriages and pregnancy terminations may have influenced interpregnancy interval classifications; (d) specifying how key factors such as previous pregnancy loss, pregnancy intention, and maternal socio-economic position will be considered; and (e) examining if the association between interpregnancy interval and perinatal outcome differs by factors such as maternal age. CONCLUSION: This commentary outlines the discussions of this recent expert workgroup, and describes several suggested principles for study design and analysis that could mitigate many potential sources of bias.

BACKGROUND: The World Health Organization (WHO) recommends that women wait at least 24 months after a livebirth before attempting a subsequent pregnancy to reduce the risk of adverse maternal, perinatal, and infant health outcomes. However, the applicability of the WHO recommendations for women in the United States is unclear, as breast feeding, nutrition, maternal age at first birth, and total fertility rate differs substantially between the United States and the low- and middle-resource countries upon which most of the evidence is based. METHODS: To inform guideline development for birth spacing specific to women in the United States, the Office of Population Affairs (OPA) convened an expert work group meeting in Washington, DC, on 14-15 September 2017 among reproductive, perinatal, paediatric, social, and public health epidemiologists; obstetrician-gynaecologists; biostatisticians; and experts in evidence synthesis related to women's health. RESULTS: Presentations and discussion topics included the methodological quality of existing studies, evaluation of the evidence for causal effects of short interpregnancy intervals on adverse perinatal and maternal health outcomes, good practices for future research, and identification of research gaps and priorities for future work. CONCLUSIONS: This report provides an overview of the presentations, discussions, and conclusions from the expert work group meeting.

Four decades ago, U.S. life expectancy was within the same range as other high-income peer countries. However, during the past decades, the United States has fared worse in many key health domains resulting in shorter life expectancy and poorer health-a health disadvantage. The National Heart, Lung, and Blood Institute convened a panel of national and international health experts and stakeholders for a Think Tank meeting to explore the U.S. health disadvantage and to seek specific recommendations for implementation research opportunities for heart, lung, blood, and sleep disorders. Recommendations for National Heart, Lung, and Blood Institute consideration were made in several areas including understanding the drivers of the disadvantage, identifying potential solutions, creating strategic partnerships with common goals, and finally enhancing and fostering a research workforce for implementation research. Key recommendations included exploring why the United States is doing better for health indicators in a few areas compared with peer countries; targeting populations across the entire socioeconomic spectrum with interventions at all levels in order to prevent missing a substantial proportion of the disadvantage; assuring partnership have high-level goals that can create systemic change through collective impact; and finally, increasing opportunities for implementation research training to meet the current needs. Connecting with the research community at large and building on ongoing research efforts will be an important strategy. Broad partnerships and collaboration across the social, political, economic, and private sectors and all civil society will be critical-not only for implementation research but also for implementing the findings to have the desired population impact. Developing the relevant knowledge to tackle the U.S. health disadvantage is the necessary first step to improve U.S. health outcomes.

The increasing prevalence of persons with multimorbidity in many countries has sparked strong growth in research on the epidemiology of multimorbidity, in part to help improve approaches to preventing and managing chronic conditions ( 1–6 ). In this issue of the Journal , Garin and colleagues have made a major contribution to this field of research by examining nationally representative data from studies of noninstitutionalized, predominantly older adults in nine countries that represent the socioeconomic spectrum, and by using a common set of 12 chronic conditions to characterize epidemiologic patterns of multimorbidity among older adults in those countries ( 7 ). | Particularly noteworthy are their results for the relation between multimorbidity and sociodemographic factors (age, sex, education, marital status, wealth, and place of residence), as well as the most prevalent comorbid conditions (hypertension, arthritis, and cataract). In addition, their analysis identified selected multimorbidity combinations for each country and across countries, the most common of which are “cardio-respiratory” and “metabolic” patterns.

In this issue of Preventing Chronic Disease, Kristal et al (1) report on analyses of several standardized questions about health behaviors related to sugar-sweetened beverage consumption and other aspects of diet and physical activity in a Bronx population served by several federally qualified health centers. These analyses are part of a larger project that links clinical and community approaches to measuring and improving diet and physical activity behaviors. Other components of the larger project included electronic health record (EHR)–based referrals to community diabetes prevention resources and enhanced community access to more healthful foods. The larger project illustrates several innovative approaches that health care and community organizations might use for advancing population health through improved delivery of high-quality health care and better links between clinical and community resources. | The study by Kristal et al highlights the importance of measuring and acting on health-risk behaviors in both clinical and community settings. In the United States, just 4 modifiable risk behaviors (tobacco use, poor nutrition, physical inactivity, and unhealthy alcohol use) account for about 40% of mortality (2). In their study, Kristal et al programmed questions for assessing selected risk behaviors into the EHR. These questions, derived from the state-based Behavioral Risk Factor Surveillance System, also are used in the New York City Community Health Survey. The use of similar questions at several population levels (ie, clinic, community, and state) increases the ability of health care and community health providers and decision makers to use comparable data on risk factors and health outcomes in populations in different settings and at local, state, and national levels for diverse purposes — detecting problems, monitoring trends, targeting and triggering interventions, and comparing the results achieved in various health care and community contexts.

With non-communicable conditions accounting for nearly two-thirds of deaths worldwide, the emergence of chronic diseases as the predominant challenge to global health is undisputed. In the USA, chronic diseases are the main causes of poor health, disability, and death, and account for most of health-care expenditures. The chronic disease burden in the USA largely results from a short list of risk factors-including tobacco use, poor diet and physical inactivity (both strongly associated with obesity), excessive alcohol consumption, uncontrolled high blood pressure, and hyperlipidaemia-that can be effectively addressed for individuals and populations. Increases in the burden of chronic diseases are attributable to incidence and prevalence of leading chronic conditions and risk factors (which occur individually and in combination), and population demographics, including ageing and health disparities. To effectively and equitably address the chronic disease burden, public health and health-care systems need to deploy integrated approaches that bundle strategies and interventions, address many risk factors and conditions simultaneously, create population-wide changes, help the population subgroups most affected, and rely on implementation by many sectors, including public-private partnerships and involvement from all stakeholders. To help to meet the chronic disease burden, the US Centers for Disease Control and Prevention (CDC) uses four cross-cutting strategies: (1) epidemiology and surveillance to monitor trends and inform programmes; (2) environmental approaches that promote health and support healthy behaviours; (3) health system interventions to improve the effective use of clinical and other preventive services; and (4) community resources linked to clinical services that sustain improved management of chronic conditions. Establishment of community conditions to support healthy behaviours and promote effective management of chronic conditions will deliver healthier students to schools, healthier workers to employers and businesses, and a healthier population to the health-care system. Collectively, these four strategies will prevent the occurrence of chronic diseases, foster early detection and slow disease progression in people with chronic conditions, reduce complications, support an improved quality of life, and reduce demand on the health-care system. Of crucial importance, with strengthened collaboration between the public health and health-care sectors, the health-care system better uses prevention and early detection services, and population health is improved and sustained by solidifying collaborations between communities and health-care providers. This collaborative approach will improve health equity by building communities that promote health rather than disease, have more accessible and direct care, and focus the health-care system on improving population health.

More than 2 million heart attacks and strokes occur each year, resulting in > 800 000 cardiovascular deaths. Despite declining trends in mortality, cardiovascular disease is still the leading cause of death in the United States, and the prevalence of hypertension, dyslipidemia, and tobacco use can still be greatly improved.1 Of US adults aged ≥18 years, 31% have hypertension, and this prevalence has shown little improvement in the past decade. Of these adults, 70% receive pharmacological treatment, but only 46% are controlled.2 We see similar trends in hypercholesterolemia.3 Although there has been a long-term trend toward declining cardiovascular disease mortality because of both improvements in risk factors and treatments,4 much additional progress is needed in both clinics and communities.

Learning lessons from previous pandemics is not merely an academic exercise. Our experiences from 1918 and other 20th-century pandemics helped us prepare for and respond to the 2009 H1N1 pandemic. In addition to better understanding these earlier pandemics, we must continue to learn and apply lessons from our experience with the current H1N1 pandemic to improve our ability to respond to future pandemics. Any reflection on the first pandemics of the 20th and 21st centuries must begin with gratitude for the fruits of science and technology, many of which were unimaginable in 1918. We can now detect, prevent, and treat disease; clarify the dynamic circumstances of pandemics; and save lives.

Most Americans consume far more salt than is healthy; the average sodium intake has increased over the past 30 years from already high levels to more than double the recommended amount (1, 2). Excess sodium consumption increases blood pressure (3); each 20–mm Hg increase in systolic blood pressure above 115 mm Hg doubles the risk for heart attack and stroke (4), which are the first and third leading causes of death in the United States, respectively (5). These effects of increased blood pressure on heart attack and stroke begin to occur at blood pressures that are well below levels at which drug treatment of hypertension is recommended currently (6). | Worldwide, cardiovascular disease is the leading cause of death among people aged 60 years or older and second among those aged 15 to 59 years; half or more of all strokes and heart attacks are attributable to high blood pressure (7). In the United States, approximately 100 000 deaths each year have been attributed to excess sodium intake (8). Because about one third of U.S. adults have hypertension and another 28% have levels above the desirable range (9), and because sodium consumption contributes to the increase in blood pressure observed with increasing age (9), reductions in salt intake will lead to substantial population-wide improvements in health.