Cardiovascular Health Resource Library

Find guidance, case studies, advocacy tools and more for large-scale heart health programs

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Virtual Course: Regulatory Policies to Prevent Obesity and Diet-related Noncommunicable Diseases

Pan American Health Organization

Guideline: sodium intake for adults and children

World Health Organization

WHO global report on sodium intake reduction

World Health Organization

Arm Position and Blood Pressure Readings: The ARMS Crossover Randomized Clinical Trial

Faulty blood pressure readings can put lives at risk. A new randomized clinical trial shows that commonly used arm positions (lap or side) result in substantially higher blood pressure readings which can lead to false diagnoses and over-treatment. To measure blood pressures accurately, the arm should be supported at heart level. The authors call for clinical guidelines to include this new evidence-based knowledge.

Key Points

Question What is the effect of commonly used arm positions on blood pressure (BP) measurements compared to the standard, recommended position?

Findings This crossover randomized clinical trial of 133 adults showed that supporting the arm on the lap overestimated systolic BP by 3.9 mm Hg and diastolic BP by 4.0 mm Hg. An unsupported arm at the side overestimated systolic BP by 6.5 mm Hg and diastolic BP by 4.4 mm Hg, with consistent results across subgroups.

Meaning Commonly used, nonstandard arm positions during BP measurements substantially overestimate BP, highlighting the need for standardized positioning.

Abstract

Importance Guidelines for blood pressure (BP) measurement recommend arm support on a desk with the midcuff positioned at heart level. Still, nonstandard positions are used in clinical practice (eg, with arm resting on the lap or unsupported on the side).

Objective To determine the effect of different arm positions on BP readings.

Design, Setting, and Participants This crossover randomized clinical trial recruited adults between the ages of 18 and 80 years in Baltimore, Maryland, from August 9, 2022, to June 1, 2023.

Intervention Participants were randomly assigned to sets of triplicate BP measurements with the arm positioned in 3 ways: (1) supported on a desk (desk 1; reference), (2) hand supported on lap (lap), and (3) arm unsupported at the side (side). To account for intrinsic BP variability, all participants underwent a fourth set of BP measurements with the arm supported on a desk (desk 2).

Main Outcomes and Measures The primary outcomes were the difference in differences in mean systolic BP (SBP) and diastolic BP (DBP) between the reference BP (desk 1) and the 2 arm support positions (lap and side): (lap or side − desk 1) − (desk 2 − desk 1). Results were also stratified by hypertensive status, age, obesity status, and access to health care within the past year.

Results The trial enrolled 133 participants (mean [SD] age, 57 [17] years; 70 [53%] female); 48 participants (36%) had SBP of 130 mm Hg or higher, and 55 participants (41%) had a body mass index (calculated as weight in kilograms divided by height in meters squared) of 30 or higher. Lap and side positions resulted in statistically significant higher BP readings than desk positions, with the difference in differences as follows: lap, SBP Δ 3.9 (95% CI, 2.5-5.2) mm Hg and DBP Δ 4.0 (95% CI, 3.1-5.0) mm Hg; and side, SBP Δ 6.5 (95% CI, 5.1-7.9) mm Hg and DBP Δ 4.4 (95% CI, 3.4-5.4) mm Hg. The patterns were generally consistent across subgroups.

Conclusion and Relevance This crossover randomized clinical trial showed that commonly used arm positions (lap or side) resulted in substantial overestimation of BP readings and may lead to misdiagnosis and overestimation of hypertension.

Trial Registration ClinicalTrials.gov Identifier: NCT05372328

Guide for Management of Overdue Patients with Hypertension

Resolve to Save Lives

Github page for DHIS2 hypertension and diabetes control package

DHIS2

Factsheet for DHIS2 for Hypertension & Diabetes Programs

Resolve to Save Lives

DHIS2 Tracker is a free, open-source health management data platform developed by DHIS2 and Resolve to Save Lives that program managers can use to monitor large-scale non-communicable disease (NCD) programs. The new version 2.0 integrates hypertension and diabetes care and is optimized for use in busy primary care facilities that manage thousands of patients. DHIS2 is quick and simple enough to record individual patient data during clinical care and records only the data you need to treat patients effectively and monitor outcomes. Not only is DHIS2 a practical, sustainable, ready-to-use solution, but it’s cost-effective and easy-to-train, too.

Over 70 countries rely on DHIS2 to manage health programs for TB, malaria, Covid-19, MCH, vaccinations, and more, and Nigeria now uses it to manage their large-scale NCD program. Your country can be next.

This factsheet offers key features and a use-case from Nigeria.

Learn more about true user-centered care and the Digital team at Resolve to Save Lives.

Demo site for DHIS2 hypertension and diabetes control package

DHIS2

7.5 million lives saved and counting

Resolve to Save Lives

5-year progress report on global trans fat elimination

World Health Organization

New World Health Organization progress report, supported by RTSL.

Since initial call to action in 2018 for all countries to eliminate toxic trans fat and protect their people from this risk factor for heart attack and strokes, 43 more countries have banned trans fat protecting an additional 2.8 billion people, or 46% of the world—as compared to just 6% 5 years ago. The REPLACE technical package provides guidance on best-practice policies that governments can implement today to protect the remaining 54% of the world from this harmful but easily replaceable food additive.

Guide to Developing Nutrition Standards

Resolve to Save Lives

Nutrition standards guide developed by Resolve to Save Lives that governments can use to ensure food and beverages purchased, served and/or sold in government settings such as schools, public hospitals, childcare or child development facilities, correctional facilities and government workplaces are healthy and low in sodium.

Lower sodium, longer lives

Resolve to Save Lives

Designing an optimal digital tool for hypertension and other long-term treatment programs

Resolve to Save Lives

Healthy Public Food Procurement and Service Policies Fact Sheet

RESOLVE TO SAVE LIVES

Monitoring foods and beverages provided and sold in public sector settings

INFORMAS Public Sector Policies and Actions – The Healthy Food Environment Policy Index (Food-EPI)

INFORMAS

Healthy food procurement policies and their impact

NIEBYLSKI ML ET AL. INT J ENVIRON RES PUBLIC HEALTH. 2014.

Trans fat elimination communications toolkit

World Health Organization, Resolve to Save Lives

Global report on hypertension: The race against a silent killer

World Health Organization

Implementation of Global Hearts Hypertension Control Programs in 32 Low- and Middle-Income Countries

Andrew E. Moran, ET AL.

Our formula for effective hypertension care

Resolve to Save Lives

Sodium Reduction Framework

Resolve to Save Lives

Implementing and enforcing trans fat elimination policies: Case studies

Resolve to Save Lives

Developing and Implementing a Trans Fat Elimination Policy: A 7-Step Guide for Policymakers

Resolve to Save Lives

Integrating hypertension and HIV management: Toolkit

Resolve to Save Lives

DHIS2 Package for Hypertension & Diabetes Control Programs

Resolve to Save Lives

A hypertension and diabetes control package for the District Health Information System 2 (DHIS2)—a free, open-source health management data platform.

Not only is DHIS2 a practical, sustainable, ready-to-use solution, but it’s cost-effective and easy-to-train, too.

Developed by the Federal Ministry of Health in Nigeria in collaboration with WHO-Nigeria and the University of Oslo, the newly updated DHIS2 hypertension/diabetes program (v2) and DHIS2 Android app (v3.0) are now available, meaning DHIS2 is optimized for use in busy primary care facilities managing thousands of patients with hypertension and diabetes, is quick and simple enough to record individual patient data during clinical care, and records only the data you need to treat patients effectively and monitor outcomes. Program managers can use the HEARTS360 dashboard to monitor WHO HEARTS indicators for large-scale non-communicable disease (NCD) programs. The DHIS2 package is now available to any country in the world.

Quick-Start Guide to Implementing a National Hypertension Control Program

Resolve to Save Lives

Trans fat elimination: Reasons for policy action now

Resolve to Save Lives

Under Pressure: Strategies to improve access to medicines to treat high blood pressure

Resolve to Save Lives and Médecins Sans Frontières

Our report, developed in collaboration with the Médecins Sans Frontières Access project, identifies barriers to affordable blood pressure medication in LMICs and underscores the need for a transformation of the global blood pressure medicines market to make life-saving medicines more affordable and available.

WHO 5 keys to a healthy diet

World Health Organization

A framework to monitor and evaluate implementation of the WHO global strategy on diet, physical activity and health (2008)

WHO

This paper sets out an approach to measure the implementation of the WHO Global Strategy on Diet, Physical Activity and Health (DPAS) at country level and proposes a framework and indicators for this purpose. The indicators provided in this document should be seen as examples to be used, as appropriate, after adjusting to the country reality. The proposed framework and indicators are intended to provide a simple and reliable tool for Member States. The indicators are also intended to be flexible and adaptable to national circumstances and to take into account existing as well as planned activities in surveillance and monitoring.

Nutrition guidelines and standards for school meals: A report from 33 low and middle-income countries (2019)

Food and Agriculture Organization, United Nations

NOURISHING Framework

World Cancer Research Fund International

Food Service Guidelines Organizational Policy Template

Adapted from the Centers for Disease Control & Prevention

Eating Well in Government Venues website

ChangeLab Solutions, United States

Action framework for developing and implementing public food procurement and service policies for a healthy diet

WORLD HEALTH ORGANIZATION

Provides an overview of how to develop, implement, assess compliance with, and evaluate the effectiveness of a healthy public food procurement and service policy. It is intended for government policy makers or program managers working on public food procurement or service, at either a national or a subnational level, including at regional, provincial and city levels.

Replacing Trans Fat the Healthiest Way

Resolve to Save Lives

REPLACE Technical Package

World Health Organization

Rapid Assessment of Trans Fat in Fats and Oils (English)

Infographic: Trans Fat Country Score Card

World Health Organization

Annotated bibliography: Trans fat elimination

Resolve to Save Lives

WHO global sodium benchmarks for different food categories, 2nd ed

World Health Organization

What’s in Our Food? A guide to introducing effective front-of-package nutrient labels

Vital Strategies

Priority actions to advance population sodium reduction

Nicole Ide et al

Global sodium reduction strategies course

Johns Hopkins School of Public Health

Building momentum: Lessons on implementing a robust front-of-pack food label

World Cancer Research Fund International

Action framework for developing and implementing public food procurement and service policies for a healthy diet

World Health Organization

Preventing cardiovascular disease through salt reduction: Strategies for success

Resolve to Save Lives

The SHAKE Technical Package for Salt Reduction

World Health Organization

Annotated bibliography: sodium reduction

Resolve to Save Lives

Managing Large-Scale Hypertension Control Programs: A Six-Step Guide

Resolve to Save Lives

Our guide for program managers starting up national or subnational hypertension control programs, broken down into six steps and and supported by practical tools from our hypertension control resource library and the WHO HEARTS technical package and adaptable to the local program and setting.

Lives Saved Calculator for Cardiovascular Health Interventions

Resolve to Save Lives

HEARTS technical package

World Health Organization

Tools for the Assessment of the Public Food Procurement and Policy Landscape

Resolve to Save Lives

This tool provides example surveys for capturing key aspects of the food procurement and policy landscape. Example surveys include: 1) Overview of Government Institutions’ Food Procurement Processes; 2) Key Informant Interview Tool; 3) Detailed Assessment of the Food Environment in Government Settings

Effectiveness and safety of using standardized treatment protocols for hypertension

Andrew E. Moran, et.al

This new systematic review demonstrates that standardized and simplified hypertension treatment protocols significantly reduce high blood pressure compared with usual hypertension care. Simple hypertension management protocols streamline treatment steps, improving outcomes for patients and making medications more available and affordable.

ABSTRACT

Large gaps persist in the diagnosis, awareness, treatment, and control of hypertension globally. Standardized treatment protocols (STPs) have been widely proposed to guide hypertension treatment, particularly in primary healthcare settings. However, there has been no review that quantifies the effects of hypertension STPs on blood pressure (BP) reduction and control. We conducted a systematic review of randomized clinical trials (RCTs) among adults with hypertension, comparing hypertension STPs (intervention) with usual care (comparator) for effects on BP. Relevant RCTs were identified by searching multiple electronic databases. Random-effects meta-analyses were conducted to evaluate between-group differences in systolic BP reduction (primary outcome), diastolic BP reduction, BP control, and adverse events (AEs). Sixteen RCTs involving 59,945 participants (baseline mean BP: 149/91 mmHg) were included. Reductions in systolic and diastolic BP with STPs compared to usual care were 6.7 (95% CI 3.7–9.8) mmHg and 2.6 (1.2–4.1) mmHg, respectively (p < 0.001 for both). BP control achieved was 57% in the STP group compared to 24% in the usual care group (p < 0.001). The overall incidence of any AEs was 14.5% versus 13.5% (RR 1.27 [0.88–1.82]) with STPs and usual care, respectively. In summary, interventions involving hypertension STPs significantly reduce systolic and diastolic BP and improve BP control compared to usual care. STPs can, therefore, be an efficient strategy to implement evidence-based treatments and upscale treatment coverage, given the large untreated and uncontrolled hypertension burdens globally.

Designing Front-of-Package Labels to Inform Consumers and Encourage Healthier Food Choices in Bangladesh: A Qualitative Study

Lindsay S. Taillie, et al.

New study co-authored by the RTSL nutrition team uses focus groups of consumers in Bangladesh to better understand purchasing decisions and effectiveness of nutrition labels. Chief food purchase concerns include that a food has sufficient beneficial nutrients, is free from germs or toxins, and does not contain high levels of nutrients of concern. Results suggest that front-of-package labels would help consumers more easily identify unhealthy foods and that warning labels were perceived as more effective than color-coded labels.

Abstract:

Background/Objectives: Front-of-package labeling (FOPL) policies are a useful strategy to inform consumers about foods high in nutrients of concern, but little is known about what type of label works best in Bangladesh, a country with increasing levels of unhealthy food intake and diet-related diseases. Methods: We conducted 10 focus groups with men and women in rural and urban Bangladesh (n = 76). Using a semi-structured discussion guide, we asked consumers for their perceptions of the healthfulness of nutrients and foods, two common FOPLs (a color-coded guideline daily allowance [GDA] label and a warning label), and different visual elements of the warning label (e.g., shape, icon, text). Results: Participants understood the health harms of sugar and salt consumption but were less clear on saturated fat. Both FOPLs were perceived as helpful for identifying unhealthy foods, but the warning labels were perceived as easier to understand and more likely to influence behaviors than the GDA. Regarding the design of warning labels, participants perceived warning devices, holding straps, and octagonal shapes as effective but had mixed reactions to which icons or textual statements were most effective. Conclusions: FOPLs are likely to facilitate Bangladeshi consumers’ ability to identify unhealthy products. Further research is needed to understand the impact on food choices as well as the most effective design in this population.

Trends in hypertension prevalence, awareness, treatment, and control in the Thai population, 2004 to 2020

A new study in BMC conducted and funded by RTSL’s partners in Thailand analyzes trends in hypertension prevalence, awareness, treatment, and control in Thailand over the past 15 years. Despite significant strides such as the adoption of universal health coverage, hypertension awareness and blood pressure control remain a challenge throughout Thailand. An urgent and concerted public health response is needed to improve diagnosis and control of hypertension to prevent premature deaths from this leading killer.

Resolve to Save Lives works closely with governments to improve heart health and save lives from high blood pressure, the world’s leading killer. Learn more here.

Global overview of government-endorsed nutrition labeling policies of packaged foods: a document review

Ummay Afroza, et al.

Clear and accurate nutrition labeling on food products is an important way for consumers to understand what’s in the foods they buy. This new comprehensive review in Frontiers led by partners at the National Heart Foundation of Bangladesh and co-authored by Resolve to Save Lives shows that governments are scaling up action to help consumers make informed food choices especially through front-of-package labels (FOPL). Research in the field shows that the most effective FOPL is mandatory; uses a black and white warning label design to flag products high in sodium, sugar, and saturated fat; and is developed free from any conflicts of interest.

Learn more about RTSL’s work to create healthier food environments here, or browse our library of key resources.

Vital Strategies; Guidelines for Media Planning 

Vital Strategies

Singapore Case Study: Reducing Singaporeans’ High Sodium Intake

Resolve to Save Lives

Getting Fiscal Policies Right: Lessons and recommendations across NCD risk factors

NCD Alliance

Food taxes for healthy eating

Imperial College Business School

Fiscal policies to promote healthy diets: WHO guideline

World Health Organization

Policies to protect children from the harmful impact of food marketing: WHO guideline

World Health Organization

Protecting children from the harmful impact of food marketing: policy brief

World Health Organization

Selling a sick future: countering harmful marketing to children and young people across risk factors for NCDs

NCD Alliance

WHO South-East Asia Region Sodium Benchmarks for Packaged Foods

World Health Organization South-East Asia Regional Office

RTSL-UW Lives Saved Calculator 

University of Washington, Resolve to Save Lives

FOPWL regulations around the globe

Global Health Advocacy Incubator

PAHO: Protocol for Population Level Sodium Determination in 24‐hour Urine Samples

Pan American Health Organization

The WHO/PAHO Protocol for Population Level Sodium Determination in 24-hour Urine Samples guides countries in conducting surveys to estimate dietary salt intake, offering support for planning, staff training, data collection, and result dissemination to advance salt reduction initiatives

Countering Industry Interference: Industry Watch Resources

Global Health Advocacy Incubator

Reducing Demand for Unhealthy Food: Resources

Global Health Advocacy Incubator

Advocacy Action Guide Four Phases to Health Policy Success

Global health Advocacy Incubator

NOURISHING Database

World Cancer Research Fund

Tackling NCDs: best buys and other recommended interventions for the prevention and control of noncommunicable diseases, 2nd ed

World Health Organization

RTSL Global Nutrition Database  for Packaged Foods

Resolve to Save Lives

Improving hypertension care among private sector providers in India

Andrew E. Moran, et al.

A recent analysis authored by RTSL and our partners in India shows a lack of awareness among private sector providers in India that high blood pressure is a critical health threat. Providing prescriptions to patients is the first step in increasing medication availability and affordability. To encourage evidence-based hypertension care, the government and NGOs could implement strategies such as tailored incentives, financial rewards, tax benefits, accreditation, and recognition for private healthcare providers who prioritize controlling high blood pressure. Professional bodies in the private sector should establish programs emphasizing quality assurance and certifications in this area. Future research should focus on designing and testing new models for private sector hypertension service delivery.

Phone Calls to Overdue Patients with Hypertension – factsheet

Resolve to Save Lives

Leading a Good Data Review Meeting – factsheet

Resolve to Save Lives

Leading a Good Data Review Meeting

Resolve to Save Lives

Change Package: Overdue Patient Management

Resolve to Save Lives

Decentralizing hypertension care in Punjab and Maharashtra States

BioMed Central Ltd

By bringing care delivery closer to communities, we can provide more people with access to quality care, improve hypertension control and save more lives. Our experts in India documented the decentralization process and its impact on patient outcomes in nine districts from 2018–2022.

Patient retention to hypertension treatment: A mixed-method study from North India

The Journal of Clinical Hypertension

Improving hypertension control requires patient retention to hypertension treatment, which requires ready access to care. This study highlights the need for improved primary care services and patient-centered services, including extended clinic hours and diagnostic facilities.

Experts from Resolve to Save Lives India analyzed patient retention rates in hypertension treatment using a mixed-method concurrent design in a North Indian district, considering socio-demographic characteristics and patient follow-up rates along with focus group discussions and in-depth interviews with health care providers and patients. Patient retention and blood pressure control were better at Health and Wellness Centers (HWCs) levels; barriers such as medication side effects, pill burden, and limited health care access hindered patient retention and medication adherence, compromising hypertension control at higher-level facilities, notably among females.

“The decentralization process involved training, treatment protocol provision, supervision, and monitoring. Among 394,038 individuals registered with hypertension from 2018–2021, 69% were under care in 2022. Nearly half of those under care (129,720/273,355) received treatment from HWCs in 2022. Care of hypertensive individuals from district hospitals (14%), community health centres (20%), and primary health centres (24%) were decentralized to HWCs. Overall BP control rose from 20% (4,004/20,347) in 2019 to 58% (157,595/273,355) in 2022, while missed visits decreased from 61% (12,394/20,347) in 2019 to 26% (70,894/273,355) in 2022. This trend was consistent in both states. HWCs exhibited the highest BP control and the lowest missed visits throughout the study period compared to other facility types.”

Read the full study here.

Authors: Nidhi Jaswal PhD, Sonu Goel PhD, Kritika Upadhyay MPH, Anupam Khungar Pathni MBBS, Om Prakash Bera MPH, MBA, Vandana Shah LLM

Living Longer and Healthier: Integrating HIV and Hypertension Services for People Living with HIV in India

Resolve to Save Lives

Lower Sodium, Longer Lives in India

Resolve to Save LIves

Addressing Unhealthy Diets in India

Resolve to Save Lives: India Country Profile

Resolve to Save Lives

Blood pressure poster study

RESOLVE TO SAVE LIVES

A qualitative study conducted by Resolve to Save Lives determined this poster to be the most impactful for encouraging patients to take their blood pressure medications daily. Forty patients from five different places said they prefer this poster because it shows someone actually taking their medication, which made clear what they needed to do.