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Preventing hypertension: a hopeless dream?
Editorial
Associated Press
Preventing hypertension: a hopeless dream?
See Series pages 591, 601, and 611
In this week’s issue, we publish a clinical Series on hypertension—a disorder that is now so ubiquitous and almost a certainty over a lifetime that the discussions on prevention have become less and less prominent. Although the prevalence in developed countries has remained static at a 90% lifetime risk, the latest US CDC figures show that there might be some improvement in treatment and control. Uncontrolled hypertension in the USA declined from 19% to 12% between 1999 and 2010. The main issues discussed in high-income countries are what the most effective treatment strategies for hypertension are, and how to best treat those with comorbidities, such as diabetes. Two of our Series papers present the latest thinking here. What is most disturbing is the increasing prevalence of hypertension in low and middle income countries and its high prevalence in obese children and teenagers. Mohsen Ibrahim and Albertino Damasceno present in the third paper of our Series a worrying picture of increased lifestyle risk factors, and low awareness and treatment take-up and options in developing
countries. In a study published online on July 23 in Archives of Disease in Childhood, 56% of 255 severely obese children and teenagers had hypertension. With an increasing prevalence of obesity in both developed and developing countries, high consumption of salt, alcohol, and fatty foods, and a more sedentary lifestyle with little physical activity, the hard-won achievements in reducing morbidity and mortality from cardiovascular diseases are likely to be short lived. Optimum treatment, although important once hypertension is established, is not the answer. Preventive efforts are needed at national and international levels. Reducing these risk factors will not only have an effect on hypertension, it will also have wide-reaching beneficial effects for other diseases. South Africa’s Health Minister Aaron Motsoaledi has made remarkable progress in that direction. For example on July 11, he set out the timetable for reducing sodium content of certain foods by law with the aim of reducing the mean population intake of salt from a current level of 8–10 g per day to less than 5 g. Health ministers everywhere take note. The Lancet
Mary Evans Picture Library
Psychological maltreatment of children: everyone’s problem
Rudyard Kipling
For the American Academy of Pediatrics report on psychological maltreatment of children see http://pediatrics. aappublications.org/ content/130/2/372.full For The Lancet Child Maltreatment Series see http:// www.thelancet.com/series/childmaltreatment
538
“If you cross-examine a child of 7 or 8 on his day’s doings (especially when he wants to go to sleep) he will contradict himself very satisfactorily. If each contradiction be set down as a lie and retailed at breakfast, life is not easy. I have known a certain amount of bullying, but this was calculated torture.” Rudyard Kipling’s description of abuse by his supposed caregivers in the 1870s makes for painful reading today. Physical maltreatment also took place; but it was the psychological maltreatment, the sense of rejection and isolation, that he would carry throughout his life, and which might have precipitated the “great darkness” of depression in his later years. Psychological Maltreatment, an American Academy of Pediatrics (AAP) report published on July 30, defines its subject as a pattern of behaviour ”likely to be interpreted by a child that he or she is unloved, unwanted, or serves only instrumental purposes and/or that severely undermines the child’s development and socialization”. Self-report studies suggest that, in the USA and the UK, 8–9% of women, and 4% of men have
experienced severe psychological abuse in childhood; the sequelae might include social difficulties, aggression, mental health problems, self-harm, and attempted suicide. But, as the authors state, “less is known about psychological maltreatment and it has been recognized relatively recently compared with other subtypes of abuse and neglect”. The diagnosis of psychological maltreatment is therefore difficult, and relies on a cautious, sensitive approach by paediatricians and allied health, social care, and teaching professionals. This requires adequately resourced services, and a philosophy of effective assessment and management rather than superficial box-ticking. Moreover, this is not just a problem for professionals to deal with: as the AAP report points out, children who are psychologically maltreated can come from any family, but are often from households experiencing social and health difficulties. Communities as a whole must define and promote good parenting, and address the inequities that lead to unhappy childhoods. The Lancet www.thelancet.com Vol 380 August 11, 2012
Associated Press
Preventing hypertension: a hopeless dream?
See Series pages 591, 601, and 611
In this week’s issue, we publish a clinical Series on hypertension—a disorder that is now so ubiquitous and almost a certainty over a lifetime that the discussions on prevention have become less and less prominent. Although the prevalence in developed countries has remained static at a 90% lifetime risk, the latest US CDC figures show that there might be some improvement in treatment and control. Uncontrolled hypertension in the USA declined from 19% to 12% between 1999 and 2010. The main issues discussed in high-income countries are what the most effective treatment strategies for hypertension are, and how to best treat those with comorbidities, such as diabetes. Two of our Series papers present the latest thinking here. What is most disturbing is the increasing prevalence of hypertension in low and middle income countries and its high prevalence in obese children and teenagers. Mohsen Ibrahim and Albertino Damasceno present in the third paper of our Series a worrying picture of increased lifestyle risk factors, and low awareness and treatment take-up and options in developing
countries. In a study published online on July 23 in Archives of Disease in Childhood, 56% of 255 severely obese children and teenagers had hypertension. With an increasing prevalence of obesity in both developed and developing countries, high consumption of salt, alcohol, and fatty foods, and a more sedentary lifestyle with little physical activity, the hard-won achievements in reducing morbidity and mortality from cardiovascular diseases are likely to be short lived. Optimum treatment, although important once hypertension is established, is not the answer. Preventive efforts are needed at national and international levels. Reducing these risk factors will not only have an effect on hypertension, it will also have wide-reaching beneficial effects for other diseases. South Africa’s Health Minister Aaron Motsoaledi has made remarkable progress in that direction. For example on July 11, he set out the timetable for reducing sodium content of certain foods by law with the aim of reducing the mean population intake of salt from a current level of 8–10 g per day to less than 5 g. Health ministers everywhere take note. The Lancet
Mary Evans Picture Library
Psychological maltreatment of children: everyone’s problem
Rudyard Kipling
For the American Academy of Pediatrics report on psychological maltreatment of children see http://pediatrics. aappublications.org/ content/130/2/372.full For The Lancet Child Maltreatment Series see http:// www.thelancet.com/series/childmaltreatment
538
“If you cross-examine a child of 7 or 8 on his day’s doings (especially when he wants to go to sleep) he will contradict himself very satisfactorily. If each contradiction be set down as a lie and retailed at breakfast, life is not easy. I have known a certain amount of bullying, but this was calculated torture.” Rudyard Kipling’s description of abuse by his supposed caregivers in the 1870s makes for painful reading today. Physical maltreatment also took place; but it was the psychological maltreatment, the sense of rejection and isolation, that he would carry throughout his life, and which might have precipitated the “great darkness” of depression in his later years. Psychological Maltreatment, an American Academy of Pediatrics (AAP) report published on July 30, defines its subject as a pattern of behaviour ”likely to be interpreted by a child that he or she is unloved, unwanted, or serves only instrumental purposes and/or that severely undermines the child’s development and socialization”. Self-report studies suggest that, in the USA and the UK, 8–9% of women, and 4% of men have
experienced severe psychological abuse in childhood; the sequelae might include social difficulties, aggression, mental health problems, self-harm, and attempted suicide. But, as the authors state, “less is known about psychological maltreatment and it has been recognized relatively recently compared with other subtypes of abuse and neglect”. The diagnosis of psychological maltreatment is therefore difficult, and relies on a cautious, sensitive approach by paediatricians and allied health, social care, and teaching professionals. This requires adequately resourced services, and a philosophy of effective assessment and management rather than superficial box-ticking. Moreover, this is not just a problem for professionals to deal with: as the AAP report points out, children who are psychologically maltreated can come from any family, but are often from households experiencing social and health difficulties. Communities as a whole must define and promote good parenting, and address the inequities that lead to unhappy childhoods. The Lancet www.thelancet.com Vol 380 August 11, 2012