ESE a — —— x ‘ 4 Publie Perceptions _. i bray ex Pressure P and LeLeritenl U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health ''''a? Public Perceptions of High Blood Pressure and Sodium U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service | National Institutes of Health (v -* )) NIH Publication No. 86-2730 October 1986 ''Preface Although the scientific and medical community has historically related sodium intake and blood pressure levels, some experts are now chal- lenging the role sodium plays in the develop- ment and control of high blood pressure. While not everyone is equally susceptible, sodium restriction is an effective aspect of high blood pressure control for many individuals. Further- more, since there is no apparent potential for . harm from moderate sodium restriction, Dietary C Guidelines for Americans (second edition, 1985, ) Home and Garden Bulletin No. 232), issued by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services, recommends that Americans avoid too much sodium. For further information on the scientific literature on this topic, consult “Nonpharma- cological Approaches to the Control of High Blood Pressure. Final Report of the Subcom- mittee on Nonpharmacological Therapy to the 1984 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure,” Hypertension 8(5):444-467, May 1986. ''Acknowledgments This report was prepared by the National High Blood Pressure Education Program (NHBPEP) and is based on data collected by Market Facts, Inc. The NHBPEP wishes to acknowledge the contributions of the following individuals who assisted with the development of this document. Project Director Edward J. Roccella, Ph.D., M.P.H. Coordinator - National High Blood Pressure Education Program Office of Prevention, Education and Control National Heart, Lung, and Blood Institute Bethesda, Maryland Contributing Writers Elizabeth Keighley Gray, M.H.S. Health Policy Analyst Kappa Systems, Inc. Washington, D.C. Ann Bowler, M.S. Manager, Evaluation and Policy Analysis Kappa Systems, Inc. Washington, D.C. Margaret Ames, Ph.D. Research Associate Kappa Systems, Inc. Washington, D.C. Reviewer Carol M. Haines, M.P.H. Program Data Coordinator Health Education Branch Office of Prevention, Education and Control National Heart, Lung, and Blood Institute Bethesda, Maryland ''733624949 Table of Contents p UBL Page Preface I Acknowledgments Il Introduction 1 Chapter |: Perceptions and Knowledge of High Blood Pressure 6 Chapter Il: Perceptions of the Blood Pressure Measurement Encounter and Prescribed 14 Treatment Chapter III: Public Knowledge and Attitudes About Salt, Sodium, and High Blood Pressure 20 and Professional Advice Received Concerning Sodium Intake Chapter IV: Habits, Skills, and Perceived Barriers Regarding Dietary Sodium Reduction 30 Chapter V: Summary 39 References 41 42 Appendix: Survey Questionnaire ''Index of Tables Table A-1 A-2 A-3 I-14 4 Il-3 Il-4 II-5 Il-6 Il-7 IIl-8 Il-9 Wl-1 Il-2 Il-3 IIl-4 II-5 III-6 Title Calculation of Weights by Age, Race, and Sex Subgroups Reported Characteristics of the 1982 Consumer Food Survey Sample (After Weighting to the 1980 Census Population by Age, Race, and Sex) Comparison of Respondents Identified as Hypertensive in the 1982 Consumer Food Survey and in the 1976-80 National Health and Nutrition Examination Survey (NHANES II) Sample Variability What Is the Term “Hypertension” More Commonly Called? If Someone’s Blood Pressure Is Above a Certain Level, a Doctor Would Say That Person Has High Blood Pressure. Have You Ever Heard What That Level Is? What Is the Level for High Blood Pressure? What Illnesses or Problems Are Caused by High Blood Pressure? If a Person With High Blood Pressure Gets His Pressure Down to Normal, ls He Usually Cured — as One Gets Over a Cold — or Must He Usually Stay on Some Sort of Treatment? What Are Some of the Likely Causes of High Blood Pressure? What Is the Most Important Cause of High Blood Pressure? Is It the Average or Only Unusually Large Consumption of Sodium/Salt That Is Related to High Blood Pressure? Who Can Have High Blood Pressure — Anybody or Just Certain Kinds of People? What Kind of People Can Have High Blood Pressure? Can a Person Tell if Their Blood Pressure Is High? That Is, Are There Any Symptoms? What Symptoms Might People Feel That Would Tell Them Their Blood Pressure Was High? Have You Ever Had Your Blood Pressure Checked? How Long Ago Was Your Blood Pressure Checked? Who Checked Your Blood Pressure the Last Time? Why Did You Have Your Blood Pressure Checked at That Time? Do You Remember What Your Blood Pressure Was the Last Time You Had It Checked? Did Your Doctor Prescribe Any Treatment for You or Tell You What to Do to Lower Your Blood Pressure? What Treatment Did Your Doctor Prescribe? Do You Think That Your Prescribed Treatment Has Helped Lower Your Blood Pressure? How Do You Determine When to Take Your Medicine? Comparison of Characteristics of the Population Reporting They Had Never Been Advised by a Health Professional to Go ona Low-Salt or Low-Sodium Diet to Lower Their Blood Pressure With Characteristics of the Total Survey Population How Do You Feel About Your Sodium or Salt Consumption? Why Do You Believe You Should Reduce Your Consumption of Salt or Sodium? Why Haven't You Tried to Reduce Your Salt or Sodium Consumption? Characteristics of the Population Reporting They Were Advised by a Health Professional to Go on a Low-Salt or Low-Sodium Diet to Lower Their Blood Pressure as Compared With the Total Sample What Have You Been Advised to Do to Keep Your Consumption of Sodium Down? Anything Else? Page NOOO 10 10 11 11 12 14 14 15 15 16 16 17 17 18 20 21 22 23 24 25 '' III-7 Ill-8 Il-9 Il-10 Wl-11 IV-14 IV-2 IV-3 IV-4 IV-5 IV-6 IV-7 IV-8 IV-9 IV-10 IV-11 Do You Have a Specific Limit on How Much Sodium or Salt You Can Consume Per Day or Per Meal? Do You Have a Diet Plan or Instruction Sheet Provided by Your Doctor ? Did Your Doctor or Other Health Professional Give You Any Advice on How to Shop or Cook Differently in Order to Reduce Your Consumption of Sodium? What Advice Did Your Doctor or Other Health Professional Give You on How to Shop or Cook Differently in Order to Reduce Your Consumption of Sodium? Did Your Doctor or Health Professional Give You Any Advice on How to Use Food Labels or Other Sources of Information About the Salt or Sodium Content of Food? What Problems Have You Encountered That Make It Difficult to Reduce Your Consumption of Salt or Sodium? What Do You Find Difficult or Confusing to Understand About the Food Label Information on Sodium? Have You Ever Bought a Low-Sodium or Low-Salt Product? Have You Ever Tried a Low-Sodium Recipe? Factors in the Decision Not to Buy/Try a Low-Sodium Product/Recipe When a Recipe Calls for You to Add Salt, Do You Usually Use the Amount the Recipe Calls For ? Do You Use Any Other Sort of Flavoring Like Herbs or Spices to Replace the Salt in Cooking? When You’re Eating a Meal, Do You Ever Add Salt Before Tasting the Food, or Do You Always Taste the Food First? When You're Eating at Home, How Often Do You Add Salt at the Table? When You're Eating a Meal in a Restaurant, How Often Do You Add Salt? Do You Ever Choose What You Will Order in a Restaurant or What Restaurant to Go to on the Basis of How Much Sodium You Think the Food Will Have? Vi 25 26 26 27 28 30 31 32 32 33 34 35 35 36 36 37 ''Introduction Rationale The United States has sustained a dramatic decline in cardiovascular mortality for more than a decade.’ The decline in stroke mortality has been substantial in all ages and races and in both sexes. While the explanation for this decline remains speculative, the decreases in mortality are both consistent and real. This accelerated decline in stroke mortality coincides with increased efforts by the public to achieve healthier lifestyles. During the past 15 years, the proportion of adults who smoke has declined more than 20 percent; the per capita consumption of foods high in total fats, saturated fats, and cholesterol has decreased 10 to 15 percent; and the proportion of the population exercising regularly has increased by as much as 100 percent.” By 1984, 54 percent of Americans reported that they “try a lot” to avoid eating too much salt or sodium.’ This documented behavior change by the public — giving up present lifestyle practices to prevent future health problems — is particularly notable in light of the fact that health providers have long attested to the difficulty in motivating patients to change behavior patterns that adversely affect their health. In response to the growing public interest in reducing cardiovascular risk and to measure progress in reducing dietary sodium, the Food and Drug Administration (FDA) and the National Heart, Lung, and Blood Institute (NHLBI) spon- sored the 1982 Consumer Food Survey. The specific objectives of the survey were to determine consumer awareness of, use of, and difficulties with the labeling of salt or sodium content of food. Because sodium restriction is frequently used as a nonpharmacologic ap- proach to control high blood pressure, the survey also collected information on consumer knowledge and attitudes about high blood pressure. For interested readers, the results of two similar surveys conducted in 1973 and 1979%*° are available from the High Blood Pressure Information Center. While many questions in the 1982 Consumer Food Survey differ from those in the previous surveys, it still may be useful to compare the results to achieve an overall picture. Survey Methodology and Analysis Four thousand respondents completed tele- phone interviews in October and November of 1982, comprising a 60-percent response rate. Each respondent was a randomly selected adult, age 18 years or older, in a household reached by random-digit dialing using a national probability sampling frame. The inter- views used four versions of the questionnaire, differing in content for approximately the first 10 questions (see appendix for the survey questionnaire). Market Facts, Inc., administered each version of the questionnaire to a sub- sample of 1,000 persons, with each subsample constituting an independent national prob- ability sample. Data analysis staff of the National High Blood Pressure Education Program (NHBPEP) weighted survey results to the 1980 census by age, race, and sex subgroups. The weights, shown in table A-1, were computed by calcu- lating the percentage composition in the 1980 census for each of the 24 age, race, and sex groups (the true percent) and dividing this figure by the percentage composition in the 1982 Consumer Food Survey (the sample percent). One hundred and twenty-eight respondents for which age or race was un- known were excluded, resulting in a total sample size of 3,872. It should be noted that the sum of response percentages for the total sample or for each subgroup may not always equal 100 percent due to rounding procedures. '' TABLE A-1 Calculation of Weights by Age, Race, and Sex Subgroups True Sample Percent Percent Weight* White Males 18-34 17.20 12.82 1.34 35-49 9.31 8.04 1.16 50-64 8.48 6.35 1.34 65 and Over 5.60 4.01 1.40 White Females 18-34 17.07 18.81 0.91 35-49 9.56 13.41 0.71 50-64 9.37 11.93 0.79 65 and Over 8.34 9.69 0.86 Black Males 18-34 2.43 1.73 1.40 35-49 1.06 1.03 1.03 50-64 0.83 0.54 1.54 65 and Over 0.51 0.21 2.43 Black Females 18-34 2.69 2.07 1.30 35-49 1.28 1.40 0.91 50-64 1.02 1.29 0.79 65 and Over 0.75 0.70 1.07 Other Males 18-34 1.29 1.57 0.82 35-49 0.54 0.75 0.72 50-64 0.29 0.18 1.61 65 and Over 0.14 0.16 0.88 Other Females 18-34 AT. 7 0.68 35-49 0.57 0.83 0.69 50-64 0.38 0.60 0.55 65 and Over O17 0.18 0.94 *Weight is calculated as true percent divided by sample percent. The NHBPEP analyzed the weighted results Throughout this report, tables list data for by age, race, sex, education, and presence of selected subgroups where noteworthy dif- high blood pressure, using the second edition ferences in response were found. Conversely, if of the Statistical Program for the Social an expected difference among subgroups was Sciences (SPSS). Open-ended responses were not seen, this type of result is also listed. content-analyzed and assigned to specific response categories by Market Facts, Inc. Table A-2 shows the demographics and reported blood pressure status of the weighted sample. '' TABLE A-2 Reported Characteristics of the 1982 Consumer Food Survey Sample (After Weighting to 1980 Census Population by Age, Race, and Sex) Race White Black Other Sex Male Female Age 18-34 Years 35-49 Years 50-64 Years 65 Years and Over Education Not High School Graduate High School Graduate College Graduate and Over BP Status Reported Hypertensive Reported Normotensive Base: Total sample (n = 3,872). For purposes of analysis, respondents were grouped by reported blood pressure status on the basis of their response to the question, “Have you ever been told by a health profes- sional that your blood pressure was high?” This definition affects the survey analysis in the following ways: e@ Because this report is based on self- reported data, only those respondents who are aware of an elevated blood pressure reading are classified as hypertensive. Therefore, the classification system used excludes the entire subgroup of unaware hypertensives. ® Toconfirm a diagnosis of hypertension Clinically, the average of two or more blood pressure readings on at least two occasions must be elevated.® Because the hyper- tensive classification used here may be Percent 85 11 5 48 52 42 22 20 16 18 61 21 24 76 based on only one occasion, respondents who had an isolated elevated reading may be mistakenly defined as hypertensive in this report. The above biases in the data have opposing effects, the first resulting in overrepresentation of hypertensives and the second in under- representation. To estimate the validity of the data, table A-3 demographically compares the respondents classified as hypertensives in this report with aware hypertensives from the 1976- 80 National Health and Nutrition Examination Survey (NHANES II). In both surveys, respon- dents were asked if they had ever been told by a health professional that their blood pressure was high. A positive response was used to classify respondents as self-reported hyper- tensives for this report. In NHANES Il, classi- fication of aware hypertensives was based on having been told by a physician that the '' respondent had high blood pressure in addition to an elevated blood pressure reading or reported taking of antihypertensive medication. These data indicate that the 1982 Consumer Food Survey somewhat underrepresents black hypertensives and the age group of 65 years and over. However, demographic trends are similar in both surveys; blacks have a higher prevalence of hypertension than do whites, and the rate of hypertension increases with age. In NHANES II, although the hypertensive preva- lence rate is higher among men than women, the rate of awareness among hypertensives is higher in women than in men. The 1982 survey data present similar trends. TABLE A-3 Comparison of Respondents Identified as Hypertensive in the 1982 Consumer Food Survey and in the 1976-80 National Health and Nutrition Examination Survey (NHANES II) 1982 Survey NHANES Il Reported Rate of Aware Hypertensives Hypertensives (%) (%) TOTAL 24 23 Race White 24 22 Black 27 33 Sex Male 22 21 Female 26 26 Age 18-34 13 11 35-49 21 23 50-64 38 36 65 and Over 40 46 Education Not High School Graduate 32 not available High School Graduate 23 not available College Graduate and Over 20 not available '' The NHBPEP calculated standard errors for the total sample and each subsample used in the analysis to estimate the reliability of generalizing the results to the U.S. population. Table A-4 lists the confidence intervals, which were calculated based on these sampling variability figures. Results based on the total sample (n = 3,872) have a maximum 95-percent confidence interval of + 1.6 percent. This means that 95 times out of 100 the true proportion for the U.S. population falls within + 1.6 percent of the reported percent. This variability is larger for questions based ona subsample of the total population, and readers are encouraged to use the confidence intervals listed in table A-4 to judge the reliability of findings for specific questions in the following pages. The results of the survey are discussed in the following chapters. Chapter | presents the public’s general knowledge of high blood pressure including: synonymity between “hypertension” and “high blood pressure,” the likely causes and sequelae of the disease, and the levels at which it is diagnosed. Chapter II provides a more focused assessment of blood pressure screening and treatment experiences: when it was last checked, by whom and for what reason, recollected blood pressure level, treatments prescribed, perceived effectiveness of the recommended treatment, and reported determinants of medication usage. Chapter III discusses public knowledge and attitudes about salt, sodium, and high blood pressure, as well as professional advice received to en- courage dietary sodium reduction. Chapter IV addresses factors perceived as barriers to reducing sodium intake as well as habits and skills concerning sodium usage. Chapter V summarizes the findings and implications of the survey. TABLE A-4 Sample Variability Subsample TOTAL Race White Black Sex Male Female Age 18-34 Years 35-49 Years 50-64 Years 65 Years and Over Education Not High School Graduate High School Graduate College Graduate and Over BP Status Reported Hypertensive Reported Normotensive No. in 95% Confidence Sample Interval* 3,872 S16 3,291 77. 426 4.7 1,859 +23 2,013 2:2 1,626 +2:4 852 +3.4 774 +3.5 620 +3.9 697 +3:7 2,362 +2.0 813 +3.4 929 £32 2,943 +1.8 *Using the maximum response variance (50%-50%). ''Chapter | Perceptions and Knowledge of High Blood Pressure This chapter presents data on public knowl- education level, and more women than men edge of high blood pressure in 1982. The were aware of this relationship (61 percent vs. respondents to each question (the “base”) are 47 percent, respectively). Interestingly, 35 described below each table. percent of the respondents who reported that Fifty-five percent of the survey population they had been told their blood pressure was was aware that hypertension is more commonly high were not aware of the more common name called high blood pressure (table I-1). Knowl- of the disease. edge of this relationship was directly related to TABLE I-1 What Is the Term “Hypertension”? More Commonly Called?* High Blood Pressure Other/Don’t Know (%) (%) TOTAL 55 45 Sex Male 47 53 Female 61 39 Education Not High School Graduate 35 65 High School Graduate 56 44 College Graduate and Over 71 29 BP Status Reported Hypertensive 65 35 Reported Normotensive 52 48 Base: Total sample for one of four versions of the questionnaire (n = 949). *Open-ended response. '' The majority of the general public does not (table I-3). Because the 1980 Report of the know the blood pressure level above which a Joint National Committee on Detection, Evalua- doctor would diagnose a person as hyper- tion, and Treatment of High Blood Pressure had tensive (table I-2). Moreover, only 50 percent of recommended that persons with diastolic pres- those reporting being diagnosed hypertensive sures between 90 and 95 mm Hg be referred had heard what that threshold is. for confirmation of hypertension, responses When the respondents who stated that they within this range were deemed acceptable. had heard the threshold for hypertension were Similarly, responses in the range of 140 to 160 asked to name that level, small percentages mm Hg systolic pressure were considered gave answers within the acceptable ranges correct in this analysis. TABLE 1-2 If Someone’s Blood Pressure Is Above a Certain Level, a Doctor Would Say That Person Has High Blood Pressure. Have You Ever Heard What That Level Is? Yes No Don’t Know (%) (%) (%) TOTAL 38 54 8 Race White 39 53 8 Black 29 64 6 Education Not High School Graduate 27 67 1 High School Graduate 36 56 8 College Graduate and Over 5S 38 9 BP Status Reported Hypertensive 50 42 8 Reported Normotensive 34 58 8 Base: Total sample (n = 3,872). TABLE I-3 What Is the Level for High Blood Pressure?* Both Systolic and Diastolic Ranges Systolic Range Diastolic Range 140 to 160 mm Hg 140 to 160 mm Hg 90 to 95 mm Hg and 90 to 95 mm Hg (%) (%) (%) TOTAL 17 13 7. Base: Respondents who reported having heard the level for high blood pressure (n = 1,054). *Open-ended response. '' The majority of the public was aware that high blood pressure causes cardiovascular problems (table I-4). Although a larger percent of respondents related high blood pressure to heart problems (71 percent) than to stroke (59 percent), most respondents correctly identified both of these major sequelae. Only 8 percent of respondents correctly identified kidney prob- lems resulting from high blood pressure. More- over, less than 5 percent of respondents indicated a mistaken belief that high blood pressure Causes nervousness, physical deterio- ration, dizziness, or headaches. The general public is aware that high blood pressure is a chronic disease and cannot be cured. When respondents were asked whether persons with high blood pressure could be cured or if they must stay on treatment, 93 percent stated that they must stay on treat- ment. This awareness of high blood pressure as a chronic problem was fairly evenly distributed across all subgroups, as shown for educational level in table I-5. TABLE 1-4 What Ilinesses or Problems Are Caused by High Blood Pressure?* Responses Heart Attacks, Heart Trouble Stroke Kidney Problems Hardening of Arteries Death Nervousness, Irritability General Physical Deterioration Dizziness, Vertigo Headaches Other Don’t Know Base: Total sample (n = 3,87 2). *Open-ended response. Percent of Respondents** a 59 ONNWWAADO **Total exceeds 100 percent due to multiple responses. TABLE 1-5 If a Person With High Blood Pressure Gets His Pressure Down to Normal, Is He Usually Cured — as One Gets Over a Cold — Or Must He Usually Stay on Some Sort of Treatment? Stay on Treatment (%) TOTAL 93 Education Not High School Graduate 89 High School Graduate 93 College Graduate and Over 93 Base: Total sample (n = 3,872). Usually Don’t Cured Know (%) (%) 4 3 5 6 4 3 4 3 '' When respondents were asked to specify respondents who mentioned multiple causes of causes of high blood pressure, more than 30 high blood pressure believed emotional pres- different answers were given. Salt and sodium sure, worry, or anxiety to be the most likely were mentioned by one-third of these cause. These respondents also mentioned respondents, ranking second only to stress overweight, improper diet, and too much salt as (table 1-6). very likely causes of high blood pressure (table More than one-fourth (28 percent) of the I-7). TABLE I-6 What Are Some of the Likely Causes of High Blood Pressure?* Percent of Likely Causes Respondents** Stress 52 Salt or Sodium 35 Improper Diet 33 Overweight 26 Fatty Food/Cholesterol 17 Heredity 15 Alcohol 10 Overexertion, Overwork 7 Smoking 7 Lack of Exercise 4 Other 11 Not Sure 10 Base: Total sample (n = 3,872). *Open-ended response. **Total exceeds 100 percent due to multiple responses. TABLE I-7 What Is the Most Important Cause of High Blood Pressure? Percent of Most Important Cause Respondents Stress 28 Overweight 16 Improper Diet 15 Salt or Sodium 15 Fatty Foods/Cholesterol 6 Heredity 5 Alcohol 3 Overexertion, Overwork 2 Smoking 1 Lack of Exercise 1 Other 5 Not Sure 3 Base: Respondents who reported knowing more than one cause of high blood pressure (n = 2,643). '' Almost one-half of the respondents in the aware of this relationship at the average subsample who knew of the relationship sodium intake level. between salt, sodium, and high blood pressure For the most part, the general public was (table I-6) were aware that an average con- aware that high blood pressure is not restricted sumption of salt or sodium is related to high to certain kinds of people, with 93 percent of blood pressure (table I-8). This knowledge the sample indicating this response. Demo- increased with education level and decreased graphic variables did not substantially affect with age; relatively small percentages of the respondents’ awareness that anyone can have elderly (36 percent) and those not completing high blood pressure, as shown in table I-9 for high school (29 percent) indicated that they are race and education levels. TABLE I-8 Is It the Average or Only Unusually Large Consumption of Sodium/Salt That Is Related to High Blood Pressure? Unusually Large Don’t Know/ Average Amount Amount No Answer (%) (%) (%) TOTAL 47 50 3 Age 18-34 51 47 2 35-49 49 49 2 50-64 41 55 4 65 and Over 36 56 8 Education Not High School Graduate 29 66 § High School Graduate 47 50 3 College Graduate and Over 59 39 2 Base: Respondents who reported that an average consumption of salt or sodium is related to high blood pressure (n = 1,283). TABLE I-9 Who Can Have High Blood Pressure — Anybody or Just Certain Kinds of People? Just Certain Anybody Kinds of People Not Sure (%) (%) (%) TOTAL 93 S 2 Race White 94 4 2 Black 90 8 3 Education Not High School Graduate 89 7 4 High School Graduate 94 5 2 College Graduate and Over 94 5 1 Base: Total sample (n = 3,872). 10 '' Of the small number who responded that only certain people could have high blood pressure (5 percent of the total), almost one-half (49 percent) identified overweight people as the type to have high blood pressure. It is of interest that the next most frequently men- tioned response was tense/nervous people (39 percent). This indicates that the previously documented misconception associating hyper- tension and tension still exists in this small proportion of the population. Other types of people mentioned include the elderly, blacks, and those with poor diets (table I-10). Almost two-thirds of the survey population indicated that they believe people can tell if their blood pressure is high (i.e., that high blood pressure has symptoms). This misconception was more common in blacks (72 percent) than in whites (58 percent) and reported more frequently by those who were not high school graduates (table I-11). It is of interest that reported hypertensives maintain this belief to the same extent as do normotensives (60 percent each). TABLE I-10 What Kind of People Can Have High Blood Pressure?* Response Overweight People Tense/Nervous People Old People Black People People With Poor Diets Women Men Other Don’t Know Percent of Respondents** 49 39 18 15 9 3 3 26 1 Base: Respondents who reported that only certain kinds of people can have high blood pressure (n= 191). *Open-ended response. **Total is greater than 100 percent due to multiple responses. TABLE I-11 Can a Person Tell if Their Blood Pressure Is High? That Is, Are There Any Symptoms? Yes (%) TOTAL 60 Race White 58 Black 72 Education Not High School Graduate 67 High School Graduate 60 College Graduate and Over 55 BP Status Reported Hypertensive 60 Reported Normotensive 60 Base: Total sample (n = 3,872). 11 No Not Sure (%) (%) 32 8 34 8 22 5 25 8 32 8 38 r 37 4 31 7 '' The most frequently mentioned symptoms of exhaustion (14 percent). Comparing the high blood pressure, as shown in table I-12, responses from tables I-12 and I-4 suggests were dizziness (52 percent) and headaches (34 that respondents differentiated between percent). Many other symptoms were also symptoms associated with pressure elevations mentioned, including getting flushed (18 and those associated with chronic illnesses percent), nervousness (15 percent), and that are complications of high blood pressure. TABLE I-12 What Symptoms Might People Feel That Would Tell Them Their Blood Pressure Was High?* Percent of Response Respondents** Dizziness 52 Headaches 34 Get Flushed, Red 18 Feel Tense/Nervous/Stress 15 Feel Tired/Weak, Exhaustion 14 Feel “Full,” Internal Pressure Shortness of Breath/Hyperventilating Faster Pulse/Heartbeat/Heart Palpitation Poor Eyesight, Blurred Vision, Spots Blackouts, Fainting Nosebleeds Sweating, Perspiring Ringing in Ears Feel Lightheaded Pain Other Than Headache Rise in Temperature Feel Irritable, Angry, Aggressive Swelling of Feet, Hands, Extremities Nausea, Upset Stomach, Sick Stroke Numbness Dry Mouth/Bad Breath Red, Bloodshot Eyes Blindness Other elnbol lt ee ® e o Base: Respondents who reported that people can tell if their blood prespressure is high (n = 2,369). *Open-ended response. **Total exceeds 100 percent due to multiple responses. — Less than 0.5 percent. 12 '' Summary This chapter contains data from the 1982 Consumer Food Survey on public knowledge of high blood pressure. Major findings presented in this chapter are: e@ Although many people know that high blood pressure is also called hypertension, knowl- edge of the thresholds for diagnosing this condition is relatively low. Thirty-eight per- cent had heard what the level for high blood pressure is, but of this subgroup, only 16 percent could correctly identify it. Blacks tended to lag behind whites in this knowl- edge area. @ More people relate high blood pressure to heart problems (71 percent) than to stroke (59 percent). @ One-half of the respondents who knew of the relationship between salt and high blood pressure incorrectly stated that only the consumption of unusually large amounts of sodium/salt is related to the development of high blood pressure. 13 e Asmall percentage of the population mis- takenly believed that only certain types of people (e.g., overweight, nervous, old, or black) can have high blood pressure. The belief that people can tell when their pressure is high is still prevalent (60 percent of respondents). Interestingly, this percep- tion is found as frequently in reported hypertensives as in reported normotensives. Respondents identified dizziness, head- aches, getting flushed, stress, and weakness as symptoms that signal elevated blood pressure. ''Chapter Il Perceptions of the Blood Pressure Measurement Encounter and Prescribed Treatment This chapter presents 1982 data on the public’s most recent blood pressure measurement encounter and prescribed treatment, including how long ago pressure was measured, who measured it, what the reading was, and the types of treatment prescribed if blood pressure was found to be elevated. The survey results suggest that almost all adults in the United States have had their blood pressure checked at some time in their life (table II-1). This finding was consistent among all age, sex, and educational segments of the Survey population. Eighty percent of respondents reported hav- ing had their blood pressure checked in the past year, with 28 percent reporting checks in the previous month, 45 percent in the past 1 to 6 months, and 7 percent in the past 7 to 12 months (table II-2). Large percentages of reported hypertensives, the elderly, and blacks indicated that they had been checked within the past year (90 percent, 87 percent, and 84 percent, respectively). TABLE II-1 Have You Ever Had Your Blood Pressure Checked? Yes No (%) (%) TOTAL 99 1 Race White 99 1 Black 99 1 Base: Total sample (n = 3,872). TABLE II-2 How Long Ago Was Your Blood Pressure Checked?* (a) (b) (c) (a+b+c) (d) ()) Within 1-6 7-12 Within 1-2 More Than Past Months Months Past Years 2 Years Month Ago Ago Year Ago Ago (%) (%) (%) (%) (%) (%) TOTAL 28 45 7 80 14 7 Race White 27. 45 7 79 14 T Black 32 45 8 84 13 3 Age 18-34 22 47 8 77 16 7 35-49 24 45 9 tT 16 7 50-64 33 44 5 81 12 t 65 and Over 42 40 5 87 8 5 BP Status Reported Hypertensive 42 44 4 90 8 2 Reported Normotensive 23 45 8 76 16 8 Base: Respondents who reported ever having had their blood pressure checked (n = 3,832). *Open-ended response. 14 '' According to the 1982 survey results pre- sented in table II-3, the vast majority of most recent blood pressure measurements were performed by either a doctor or a nurse (46 percent and 45 percent, respectively). Reported hypertensives indicated a higher percentage of most recent measurements being performed by doctors (56 percent) than did reported normo- tensives (43 percent). Measurement occurred as part of a general physical examination for the majority of respondents (54 percent) who reported having their blood pressure checked (table II-4). As would be expected, larger percentages of age 50 indicated prior knowledge or suspicion of high blood pressure, while the percentage indicating other illnesses as the reason for their most recent blood pressure check was fairly consistent through all groups (10 to 13 per- cent). Almost one-third of the aware hyper- tensives (31 percent) had their blood pressure last taken because of a known or suspected blood pressure problem, compared to only 2 percent of the normotensives. Almost one-third of those age 65 and over (31 percent) reported that their most recent blood pressure measurement was due to either a potential or known blood pressure problem or because they reported hypertensives and individuals over had another disease. TABLE II-3 Who Checked Your Blood Pressure the Last Time? BP Status Response Total Normotensive Hypertensive (%) (%) (%) Doctor 46 43 56 Nurse 45 48 36 Coin-Operated Automated Machine 5 5 3 Self/Family Member at Home 4 4 5 Other 1 1 1 Base: Respondents who reported ever having had their blood pressure checked (n = 3,832). TABLE I1-4 Why Did You Have Your Blood Pressure Checked at That Time? Part of Knew/ More No Suspected Had General Special Had BP Another Physical Reason Problem Disease Exam Other (%) (%) (%) (%) (%) TOTAL 15 9 11 54 10 Age 18-34 15 4 10 57 15 35-49 16 8 10 Sr 9 50-64 16 16 12 50 6 65 and Over 15 18 13 48 5 BP Status Reported Hypertensive 9 31 10 43 i Reported Normotensive 17 2 11 58 12 Base: Respondents who reported ever having had their blood pressure checked (n = 3,832). 15 '' Table II-5 shows that almost as many respondents experiencing high or low readings respondents remembered their most recent are more likely to remember the actual reading. measurement as did not (35 percent vs. 39 Seventy-four percent of respondents who percent, respectively). The frequency of re- reported being told their blood pressure was membering directly increased with both educa- high said their doctor prescribed treatment to tion level and age. Response to this open- lower their pressure. Again, the positive ended question suggests that persons who response increased with age, and a consider- experience normal readings often simply ably higher percentage of women reported remember that their last blood pressure prescribed treatment than did men (table II-6). reading was normal. On the other hand, TABLE II-5 Do You Remember What Your Blood Pressure Was the Last Time You Had It Checked?* Just Just Just Remember Remember Remember Yes ItWas O.K. ItWas High It Was Low No (%) (%) (%) (%) (%) TOTAL 35 23 2 1 39 Age 18-34 28 23 2 1 45 35-49 36 21 2 1 39 50-64 40 22 3 1 34 65 and Over 43 24 2 _ 31 Education Not High School Graduate 25 26 3 1 45 High School Graduate 33 23 2 1 41 College Graduate and Over 47 19 2 1 31 BP Status Reported Hypertensive 50 13 5 ~~ 32 Reported Normotensive 30 26 1 1 42 Base: Respondents who reported ever having had their blood pressure checked (n = 3,832). *Open-ended response. — Less than 0.5 percent. TABLE II-6 Did Your Doctor Prescribe Any Treatment for You or Tell You What to Do to Lower Your Blood Pressure? Yes No (%) (%) TOTAL 74 25 Race White 74 24 Black 16 23 Sex Male 69 29 Female 77 ot Age 18-34 52 48 35-49 68 29 50-64 82 Le 65 and Over 85 12 Base: Respondents who reported ever having been told that their blood pressure was high (n = 927). 16 '' Medication and sodium reduction were the two treatments most frequently mentioned by respondents who reported treatment pre- scribed. While an equal proportion of blacks and whites were prescribed treatment (table II- 6), the types of treatment reported were different (table II-7). Blacks represented a higher percentage of responses for almost all types of treatments (excluding exercise) than did whites. This suggests that doctors may combine therapy approaches more frequently when treating black hypertensives as an inten- sive effort to lower the high stroke mortality in the black population. As age increased, the percentage who reported being told to take medicine more than doubled from 45 percent to 96 percent, while younger respondents, ages 18-34 (where hypertension tends to be in the milder range), were told more frequently to reduce their sodium intake. In general, respondents found prescribed treatments to be helpful. The exception to this was the advice to cut down or stop smoking, which only one-half of those so advised con- sidered to help lower blood pressure (table II-8). This lower percentage undoubtedly reflects the fact that almost one-third of respondents (30 percent) who were told to cut down or stop smoking did not follow this advice. It should also be noted that the National High Blood Pressure Education Program does not consider smoking cessation to be definitive therapy for high blood pressure. However, individuals who smoke increase their cardiovascular risk, and, therefore, practitioners often encourage hyper- tensive patients to stop smoking. TABLE II-7 What Treatment Did Your Doctor Prescribe? Reduce Cut Sodium Watch Down Get Take or Salt or Lose Avoid or Stop More Medicine Intake Weight Stress Smoking Exercise (%) (%) (%) (%) (%) (%) TOTAL 81 78 64 61 29 47 Race White 80 78 63 61 28 48 Black 87 79 78 66 41 42 Age 18-34 45 83 62 61 31 44 35-49 t2 76 69 53 38 40 50-64 89 77 68 66 31 53 65 and Over 96 76 58 61 22 46 Base: Respondents who reported having been told that their blood pressure was high and who were prescribed treatment (n = 683). TABLE II-8 Do You Think That Your Prescribed Treatment Has Helped Lower Your Blood Pressure? Did Not Not Helped Help Followed Not Sure (%) (%) (%) (%) Take Medicine (n = 553) 89 4 2 4 Reduce Sodium or Salt Intake (n = 530) 84 5 3 8 Avoid Stress (n = 418) 81 8 6 6 Watch/Lose Weight (n = 439) 80 7 6 8 Get More Exercise (n = 322) 78 5 z 10 Cut Down/Stop Smoking (n = 201) 51 11 30 9 Base: Respondents who reported that their doctor had prescribed each of the above specific treatments to lower their blood pressure. 17 '' Most respondents (87 percent of those who more likely to adhere to medication regimens were prescribed medication) took their blood than were blacks, as were those age 50 and pressure medication on a regular schedule or older compared to those under age 50 (table II- as recommended by their doctor. Whites were 9). TABLE II-9 How Do You Determine When to Take Your Medicine?* Take When Take on Blood Pressure Regular Schedule Feels High/ or When Told When Remember/ by Doctor Other (%) (%) TOTAL 87 13 Race White 88 12 Black 80 20 Age 18-34 76 24 35-49 78 22 50-64 89 11 65 and Over 91 9 Base: Respondents who reported having been prescribed medicine for their blood pressure (n = 5583). *Open-ended response. 18 '' Summary Chapter II presents data concerning the public’s most recent blood pressure measure- ment encounter and information on prescribed treatment and reported adherence to medica- tion. Major findings include: @ Blood pressure measurement is a routine health care procedure experienced by vir- tually the entire U.S. population some time in their lifetime. @ The large majority of the population experi- ence annual or 6-month blood pressure checks (80 percent of respondents report checks within the past year and 72 percent within the past 6 months). @ Hypertensives tended to have had their blood pressure measured within the past 6 months. @ Doctors and nurses perform most of the blood pressure checks and do so at about the same frequency. @ Blood pressure measurements are per- formed as part of a general physical exami- nation more frequently than for any other reason. @ Most people do not remember their last blood pressure reading (65 percent). How- ever, the ability to do so increases markedly with both education level and age. @ Hypertensives who are age 50 or older are much more likely to be prescribed treatment than those under age 50, and women report a higher percentage of treatment prescrip- tions than do men. @ The following treatments were prescribed to the majority of hypertensives: medication (81 percent), sodium reduction (78 percent), weight loss (64 percent), and stress avoid- ance (61 percent). Sodium reduction was prescribed almost twice as frequently as medication for hypertensives ages 18 to 34, and all therapy approaches, excluding exer- cise, were prescribed for blacks more fre- quently than for whites. 19 @ Hypertensives generally found the pre- scribed treatment helpful with the exception of the advice to cut down or stop smoking, which 30 percent admitted they did not follow. @ The majority of hypertensives who were prescribed medication reported taking it on a regular schedule or according to their doctor's instructions. Blacks were somewhat less adherent to medication regimens than were whites, and older hypertensives re- ported adhering to a regular medication- taking schedule more frequently than did younger hypertensives. ''Chapter III Public Knowledge and Attitudes About Salt, Sodium, and High Blood Pressure and Professional Advice Received Concerning Sodium Intake Public Knowledge and Attitudes About Salt, Sodium, and High Blood Pressure This section presents attitudes concerning ship of salt or sodium to health problems. sodium consumption among those respondents Reported characteristics of this sample are who have not specifically been advised by a similar to those of the total sample with the health professional to reduce their sodium exception of a somewhat lower percentage of intake (88 percent of the total, n = 3,407). The persons reporting being told their blood pres- data reflect the respondents’ views on the sure was high (table III-1). relationship of salt to sodium and the relation- TABLE III-1 Comparison of Characteristics of the Population Reporting That They Never Had Been Advised by a Health Professional to Go on a Low-Salt or Low-Sodium Diet With the Characteristics of the Total Survey Population Distribution of Those Distribution of Not on a Low-Sodium Diet Total Sample (n = 3,407) (n = 3,842) (%) (%) Race White 85 85 Black 10 11 Other 5 5 Sex Male 49 48 Female 51 52 Age 18-34 45 42 35-49 23 22 50-64 19 20 65 and Over 13 16 Education Not High School Graduate 17 18 High School Graduate 62 61 College Graduate and Over 21 21 BP Status Reported Hypertensive 18 24 Reported Normotensive 82 76 20 '' Even though respondents reported never having been advised to lower salt consumption, more than one-half (55 percent) indicated concern about sodium intake, and 29 percent report actually reducing sodium consumption quite a bit (table III-2). Although reported hypertensives were more concerned about sodium than were normotensives, almost one- third did not worry about their sodium intake. When the subgroup expressing concern about their sodium consumption were ques- tioned about reasons for such concern, one- third (34 percent) of this group mentioned high blood pressure. Blacks (43 percent) and men (38 percent) were somewhat more concerned about sodium and high blood pressure than were whites (33 percent) and women (32 percent). However, the percentages of respon- dents who mentioned the development of subsequent cardiovascular problems as a reason for reducing salt consumption were low; as shown in table IIl-3, responses include heart attacks (9 percent), stroke (2 percent), and arteriosclerosis (2 percent). Of the respondents who said they probably should reduce their sodium consumption but hadn't tried to do so, only 13 percent indicated a taste preference for salt as the reason for not reducing sodium intake (table III-4). The large majority (69 percent) of respondents gave no reason for not reducing sodium; they just were not that worried. TABLE III-2 How Do You Feel About Your Sodium or Salt Consumption? Race BP Status Reported Reported Total White Black Hypertensive Normotensive (%) (%) (%) (%) (%) | Don’t Think | Personally 42 43 38 31 45 Have Any Need to Worry About My Sodium Intake | Think | Probably Should 18 17 21 20 18 Reduce It But | Haven’t Really Tried | Have Been Trying to 8 7 9 9 7 Reduce It But Not Very Successfully | Have Reduced My 29 30 28 36 28 Sodium Consumption Quite a Bit Not Sure a 3 5 4 3 Base: Respondents who reported that they have never been told by a doctor or other health professional to lower salt consumption (n = 3,407). 21 '' TABLE III-3 Why Do You Believe You Should Reduce Your Consumption of Salt or Sodium?* Race Sex BP Status Reported Reported Total White Black Male Female Hypertensive Normotensive (%) (%) (%) (%) (%) (%) (%) Hypertension/ 34 33 43 38 32 40 33 High Blood Pressure Causes Health 22 22 22 23 21 18 23 Problems/Not Good for You Water Retention/ 13 13 12 8 17 13 13 Puffiness Heart Attack/ 9 9 5 10 8 7 9 Coronary/ Cardiovascular Disease Eat Too Much 8 9 6 8 9 5 9 Salt/Body Doesn't Need Amount Other 8 8 8 i 8 11 7 Stroke/Bursting of 2 3 1 2 3 2 2 Blood Vessels Arteriosclerosis/ 2 2 1 2 2 1 2 Hardening of the Arteries Don’t Know/ 2 2 4 2 2 2 2 No Answer Base: Respondents who reported that they think they should reduce their salt or sodium consumption, although they reported that a health professional had never recommended that they do so (n = 1,937). *Open-ended response. 22 '' TABLE III-4 Why Haven’t You Tried to Reduce Your Salt or Sodium Consumption? Is It That You Aren’t Really Worried About It or Are There Other Reasons?* Race BP Status Reported Reported Total White Black Hypertensive Normotensive (%) (%) (%) (%) (%) No Reason/ 69 68 75 56 72 Not That Worried Like Taste of Salt/Don’t 13 15 3 7 12 Like Taste Without Salt Other 3 9 9 14 8 Don’t Have Current 5 5 8 F 5 Problems From Salt Don’t Use Much 3 2 2 3 3 Salt Anyway Can’t/Someone Else 1 1 a 4 _ Controls Salt and Food Base: Respondents who reported that they believed that they should reduce their sodium, but who reported that they hadn't really tried (n = 641). *Open-ended response. — Less than 0.5 percent. 23 '' Professional Advice Received Concerning Sodium Intake Table III-5 shows the characteristics of the Compared to the total survey sample, this small sample of respondents who reported group is overrepresentative of hypertensives, being advised to go on a low-salt or low-sodium females, and persons 50 years of age and older. diet (12 percent of the total; n = 458). TABLE III-5 Characteristics of the Population Reporting They Were Advised by a Health Professional to Go on a Low-Salt or Low-Sodium Diet as Compared With the Total Sample Respondents on Total Low-Salt Diet Sample (n = 458) (n = 3,872) (%) (%) Race White 84 85 Black and Other 16 16 Sex Male 37 48 Female 63 52 Age 18-34 16 42 35-49 15 22 50-64 35 20 65 and Over 35 16 Education Not High School Graduate 25 18 High School Graduate 57 61 College Graduate and Over 18 21 BP Status Reported Hypertensive 70 24 Reported Normotensive 30 76 24 '' By far, the most frequently reported advice to lower sodium consumption consisted of not adding salt to food (table III-6). Of the respon- dents advised to cut down on their salt or sodium, 76 percent received this advice, fol- lowed in frequency by instructions to avoid or to eat certain types of food (35 percent and 14 percent, respectively). Respondents reported receiving specific instructions on the use of labeling information less often; of those who did, responses included use of food labels (11 percent), ingredient lists (5 percent), and nutri- tion labels (3 percent). Only 8 percent of respondents advised to cut down on salt reported being given quantitative limits to the amount of sodium or salt they could consume per day or per meal. As shown in table III-7, blacks received this information more frequently than did whites. TABLE III-6 What Have You Been Advised to Do to Keep Your Consumption of Sodium Down? Anything Else?* Don’t Add Salt Avoid Certain Types of Food Eat Certain Types of Food Look for Food Labeled Low-Sodium/Salt-Free Look for Salt on the Ingredient List Look for Sodium on the Nutrition Label Use Salt Substitute Avoid Salt (No Specifics) Eat Balanced Diet Go on a Reduced-Calorie Diet Follow Prescribed Diet Plan Use Low-Sodium Recipes All Other Don’t Know Race Total** White Black (%) (%) (%) 76 76 68 35 34 36 14 14 ce 11 11 12 5 5 T 3 4 1 4 4 4 3 2 4 1 1 3 1 1 1 2 1 1 1 1 4 1 1 — Base: Respondents who reported that they have been advised by a health professional togoona low- salt or low-sodium diet (n = 458). *Open-ended response. **Total exceeds 100 percent due to multiple responses. — Less than 0.5 percent. TABLE III-7 Do You Have a Specific Limit on How Much Sodium or Salt You Can Consume Per Day or Per Meal? Yes (%) TOTAL 8 Race White 7 Black 13 Not Sure/ No No Answer (%) (%) 87 5 88 5 85 2 Base: Respondents who reported that they have been advised by a health professional togoona low-salt or low-sodium diet (n = 458). '' When the 8 percent who had received advice on specific limits were asked to identify these limits, the responses were random in nature (results not shown), suggesting the public’s poor understanding of quantitative information on sodium intake. However, these same respondents did indi- cate that health professionals provided written instructions or diet plans to almost one-half (46 percent) of the patients advised to restrict their salt (table III-8). As education level increased, the percent of respondents who reported receiving this type of material tended to decrease. Blacks reported receiving written instructions more often than did whites (74 percent vs. 41 percent). Blacks also reported receiving advice more frequently from their health professionals on ways to shop or cook to reduce sodium than did whites (table III-9). Overall, however, respon- dents reported receiving this type of advice less frequently than they received diet plans (34 percent in table III-9 vs. 46 percent in table IIl-8). TABLE III-8 Do You Have a Diet Plan or Instruction Sheet Provided by Your Doctor? TOTAL Race White Black Education Not High School Graduate High School Graduate College Graduate and Over Yes No (%) (%) 46 54 41 59 74 26 §2 48 44 56 42 58 Base: Respondents who reported that they have been advised by a health professional togoona low- salt or low-sodium diet (n = 458). TABLE III-9 Did Your Doctor or Other Health Professional Give You Any Advice on How to Shop or Cook Differently in Order to Reduce Your Consumption of Sodium? Yes (%) TOTAL 34 Race White 30 Black oT No Not Sure (%) (%) 65 1 69 1 43 — Base: Respondents who reported that they have been advised by a health professional to goona low- salt or low-sodium diet (n = 458). — Less than 0.5 percent. '' When respondents who reported receiving use of sodium labeling was an infrequent shopping or cooking advice were asked what response. Of interest is that 21 percent of that advice was, the most frequent responses blacks reported receiving advice to substitute were to refrain from adding salt, specific foods herbs or other spices for salt in their cooking as to eat or drink or avoid, and to cook foods ina compared to only 9 percent of whites. certain way (table III-10). Again, information on TABLE III-10 What Advice Did Your Doctor or Other Health Professional Give You on How to Shop or Cook Differently in Order to Reduce Your Consumption of Sodium?* Race Total White Black (%) (%) (%) Told Not to Add Salt 25 21 30 Told What Foods to Eat/Drink 24 26 18 Told What Foods Not to Eat/Drink 23 23 21 Told How Foods Should Be Cooked 18 17 23 Told to Use Herbs/Spices to Replace Salt 11 9 21 Told to Use Food Label to 10 11 6 Check Salt/Sodium Content Told How Foods Should Not Be Cooked 9 10 8 Don’t Know/No Answer 8 9 5 Other 16 16 TT Base: Respondents who reported being on a recommended low-sodium diet and who were given advice by a health professional (n = 154). *Open-ended response. 27 '' When respondents who were advised to restrict dietary sodium were specifically asked about food labeling advice, only one-fifth (20 percent) reported receiving such advice (table Ill-11). In contrast to table III-8, where educa- tion level correlated indirectly with the fre- quency of diet plans provided, table II|-11 indicates that those with high school and college educations were given sodium labeling advice almost twice as frequently (23 percent) as were those with less than a high school education (13 percent). These results suggest that health professionals may be tailoring their advice to the education level of the patient. TABLE III-11 Did Your Doctor or Health Professional Give You Any Advice on How to Use Food Labels or Other Sources of Information About the Salt or Sodium Content of Food? Yes (%) TOTAL 20 Sex Male ee Female 21 Education Not High School Graduate 13 High School Graduate 22 College Graduate and Over 23 Not Sure/ Don’t Know/ No No Answer (%) (%) 73 7 75 8 72 7 78 9 73 3 66 9 Base: Respondents who reported that they have been advised by a health professional to goona low- salt or low-sodium diet (n = 458). 28 '' Summary A substantial percentage of people who have not been advised to reduce their sodium intake appear to be concerned with their sodium consumption. Information on the attitudes of this population includes: @ Even though these respondents had not been advised to reduce their sodium, almost one-third stated that they had. An additional 25 percent expressed concern about their dietary salt intake. @ The most frequently mentioned reason for believing they should reduce sodium intake was high blood pressure. Potential subse- quent cardiovascular events — such as heart attack, stroke, and arteriosclerosis — re- ceived little mention. @ The large majority of those who were con- cerned about their sodium consumption but had not tried to reduce it gave no specific reasons besides lack of motivation. Advice offered by health professionals to assist patients in reducing their sodium intake appears to be somewhat simplistic and non- specific. For example: @ The most frequently reported professional advice offered to lower sodium consumption was to refrain from adding salt to food. 29 @ Only 8 percent of those on low-sodium diets reported receiving specific limits on the daily consumption of sodium. Virtually none of the respondents could specify the recommend- ed sodium limit. @ Awritten diet plan was the most frequently received assistance provided by health professionals. Advice on how to shop or cook differently to reduce dietary sodium was provided less often. @ Of those respondents who did receive sodium reduction advice, general messages consisting of not to add salt and which foods to eat or avoid were reported about 25 percent of the time. @ Only 20 percent of those on low-sodium diets received specific information on how to use food labels to reduce sodium con- sumption. ''Chapter IV Habits, Skills, and Perceived Barriers Regarding Dietary Sodium Reduction This chapter examines public behavior con- cerning dietary sodium intake. Included is information on problems encountered in reduc- ing salt while cooking, at the table, and when dining in restaurants. Table IV-1 presents the characteristics of, and types of problems reported by, respondents who are trying to reduce sodium in their diets. For analysis purposes, the problems are divided into two categories: internal problems, which people have the potential to solve, and external problems, which people usually feel powerless to change. Interestingly, a large percentage of respondents (42 percent) re- ported no problems in reducing sodium; how- ever, this response markedly decreased among those with college educations and in younger individuals. It is not known whether or to what extent respondents actually did reduce their sodium. The internal problems included in the survey were liking the taste of salt (81 percent) and difficulty in changing the salt habit (4 percent). These problems were reported less frequently by hypertensives than by normotensives, who may have less motivation to reduce salt. Younger respondents also more frequently reported liking the taste of salt. The percentage of respondents reporting sodium in processed food as a problem in- creased with education level but decreased with age. Whites found this external problem a barrier more often than did blacks (table IV-1). TABLE IV-1 What Problems Have You Encountered That Make It Difficult to Reduce Your Consumption of Salt or Sodium?* External Problem Internal Problem Like Sait in Manufacturers My Food/ Habit/No Put Salt In Restaurant Like the Wilipower/ All Foods/No FoodsHave Must Cook Taste of Hardto Foods Without TooMuch for Others None/No Don’t Know/ Salt Change Salt Salt/Sodium With Salt Problems Other NoAnswer (%) (%) (%) (%) (%) (%) (%) (%) TOTAL 31 4 12 4 1 42 4 1 Race White 31 4 13 § 1 41 4 1 Black 30 3 5 2 2 53 5 1 Age 18-34 36 4 16 § 2 32 6 1 35-49 32 5 12 4 1 42 4 _ 50-64 25 3 9 4 1 52 5 1 65 and Over 26 4 5 4 _ 60 3 _ Education Not High School Graduate 28 3 4 2 1 57 3 2 High School Graduate 32 4 11 3 1 43 4 1 College Graduate and Over 31 5 18 9 2 30 5 _- BP Status Reported Hypertensive 25 3 12 4 1 49 5 _- Reported Normotensive 34 4 12 4 2 40 4 1 Base: Respondents who reported trying to reduce the sodium in their diets (n = 2,320). *Open-ended response. — Less than 0.5 percent. 30 '' Of the respondents who found some of the quantitative information supplied were reported labeling information difficult to understand (n = by 30 percent of the respondents and in- 477), one-half stated that the major difficulty creased with education level. Overall, re- was the general clarity of the labeling informa- sponses appear to indicate a need for stan- tion (table IV-2). Specific complaints about the dardized quantitative terminology in labeling. TABLE IV-2 What Do You Find Difficult or Confusing to Understand About the Food Label Information on Sodium?* Education Not High High College School School Graduate Total** Graduate Graduate and Over (%) (%) (%) (%) General 50 63 49 45 Language, Terminology Can't Find Label Information Easily Specific 30 19 29 3f Don’t Know What Grams, Milligrams Are, Nonstandardization of Salt Terms Don’t Know How Many Grams Are Needed per Day Manufacturers Disguise Salt in Names Actual Quantity of Salt 22 15 22 26 is Not Given Other 16 15 17 413 Don’t Know 4 f 3 2 Base: Respondents who reported that they were concerned about sodium in their diet, but find label information confusing (n = 477). *Open-ended response. **Total exceeds 100 percent due to multiple responses. 31 '' Use of low-sodium or low-salt products and a product of this kind (table IV-3). However, only recipes is examined in tables IV-3 and IV-4. one-third (32 percent) of the smaller sample of Women and hypertensives were more likely to respondents who prepared meals at home and use these low-sodium measures than were men who had seen a low-sodium recipe in print and normotensives. In 1982, one-half of the stated that they had tried such a recipe (table respondents who had seen low-sodium prod- IV-4). ucts in their grocery store reported purchasing TABLE IV-3 Have You Ever Bought a Low-Sodium or Low-Salt Product? Other Yes No Response (%) (%) (%) TOTAL 50 47 3 Sex Male 45 51 4 Female 54 44 2 Education Not High School Graduate 48 49 3 High School Graduate 50 47 3 College Graduate and Over 53 44 3 BP Status Reported Hypertensive 63 33 4 Reported Normotensive 46 49 3 Base: Respondents who reported having seen a low-sodium or low-salt product in their grocery store (n = 3,404). TABLE IV-4 Have You Ever Tried a Low-Sodium Recipe? Yes No (%) (%) TOTAL 32 68 Sex Male 25 1 Female 36 64 BP Status Reported Hypertensive 44 OF, Reported Normotensive 28 72 Base: Respondents who reported doing at least some meal preparations and have seen a low- sodium recipe (n = 1,867). 32 '' In an attempt to identify barriers to the use of low-sodium products and recipes, the survey asked why respondents who thought about these techniques did not try them (table IV-5). The most frequent reasons given for not buying low-sodium products were a lack of motivation (17 percent) and a belief that such products would be inferior in taste (16 percent). Because finding and preparing a low-sodium recipe can require extra effort, it was not surprising that the reasons given by almost one-half of the respondents were that it took too much time to prepare or that they never got around to it. TABLE IV-5 Factors in the Decision Not to Buy/Try a Low-Sodium Product/Recipe* Product Factors Recipe Factors (n = 345) (n = 344) (%) (%) Didn’t See Need for It 17 4 Thought Would Have No/ 16 10 Bad/Poor Taste Didn't Get Around to It 13 26 Too Hard/Too Much Work/ _ 21 Don’t Have Time Cost/Too Expensive ie 3 Couldn't Find the Product 9 - Wanted/Not Available Other Family Members Use/ 3 4 Like Salt Someone Else Does Most of the 2 4 Cooking/Shopping Other 16 19 Don’t Know/No Answer 13 12 Base: Respondents who reported having thought about buying/trying a low-sodium product/recipe, but didn’t. *Open-ended response. — Not applicable. 33 '' Forty-eight percent of the respondents who whites. Encouraging numbers of reported prepare foods reported using less salt than hypertensives (65 percent) and those age 50 recipes call for (table IV-6). Men consistently and over (62 to 68 percent) reported never reported adding more salt than did women, and using or using less salt in cooking. blacks cut the amount less frequently than TABLE IV-6 When a Recipe Calls for You to Add Salt, Do You Usually Use the Amount the Recipe Calls For? Use About Never Use Use Use What Recipe Salt in Other More Less Says Cooking Responses (%) (%) (%) (%) (%) TOTAL § 48 3S 7. 5 Race White 5 49 34 7 5 Black 6 39 38 7 10 Sex Male T 40 38 6 9 Female 3 53 32 8 4 Age 18-34 7 45 39 5 4 35-49 2s 44 41 4 6 50-64 3 51 29 11 6 65 and Over 1 54 22 14 9 BP Status Reported Hypertensive 2 53 20 +2 8 Reported Normotensive 5 49 38 > 3 Base: Respondents who reported preparing food (n = 3,310). 34 '' It has been reported that methods of food reducing salt than were men and normo- preparation that make food flavorful without tensives, and use of herbs or spices to replace added salt enhance the ability to maintain a salt increased with education level. low-sodium diet.’ When respondents who pre- The majority of respondents reported using pare food were asked if they used herbs and salt discriminately, both at home and at restau- spices to replace salt in cooking, almost one- rants (table IV-8). Approximately 75 percent of half of the respondents (45 percent) said that respondents stated that they always taste the ‘ they did (table IV-7). Again, women and hyper- food before salting. Whites and men were more tensives were more likely to use this method of likely to add salt without tasting the food first. TABLE IV-7 Do You Use Any Other Sort of Flavoring Like Herbs or Spices to Replace the Salt in Cooking? , Yes No (%) (%) TOTAL 45 55 Sex Male 38 62 Female 50 50 Education Not High School Graduate 34 66 High School Graduate 46 54 College Graduate and Over 51 49 BP Status Reported Hypertensive 51 49 Reported Normotensive 43 $5 Base: Respondents who reported preparing food (n = 3,310). TABLE IV-8 . When You’re Eating a Meal, Do You Ever Add Salt Before Tasting the Food, or Do You Always Taste the Food First? In a Restaurant At the Table at Home Sometimes Always Sometimes Always Add Without Taste Add Without Taste Tasting First Tasting First , (%) (%) (%) (%) TOTAL 24 76 26 74 Race White 25 74 27 73 Black 17 82 18 81 Sex Male 30 69 29 70 Female AT 83 22 78 Base: Total sample (n = 3,87 2). 35 '' Data on the frequency of adding salt at the Trends for adding salt at restaurants were table at home indicate that consumers were similar to previously reported trends at home aware of the potentially unhealthy effects of (table IV-10). Again, more than half of the total this habit (table IV-9). The majority of all survey population (57 percent) stated that they respondents (58 percent) reported that they rarely or never added salt at restaurants. Salt almost never add salt at the table at home. The usage in restaurants declined with increasing trend of salt usage decreasing with age is age. Although hypertensives had a higher repeated here. More than 70 percent of hyper- frequency of rarely or never adding salt, the tensives stated that they rarely or never added majority of normotensives (54 percent) also salt at the table. reported this practice. TABLE IV-9 When You’re Eating at Home, How Often Do You Add Salt at the Table? Almost Always or Rarely or Never Sometimes Add Salt Add Salt (%) (%) TOTAL 41 58 Age 18-34 51 49 35-49 45 54 50-64 33 66 65 and Over 21 78 BP Status Reported Hypertensive 28 11 Reported Normotensive 46 54 Base: Total sample (n = 3,872). TABLE IV-10 When You’re Eating a Meal in a Restaurant, How Often Do You Add Salt? Almost Always Rarely Never Eat or Sometimes or Never Out (%) (%) (%) TOTAL 40 57 2 Race White 39 59 2 Black 47 48 5 Age 18-34 47 52 1 35-49 47 52 1 50-64 oo 62 3 65 and Over 19 73 9 BP Status Reported Hypertensive 28 67 6 Reported Normotensive 44 54 2 Base: Total sample (n = 3,872). 36 '' The choice of restaurant and foods to order may reflect the general concern and ability to moderate sodium consumption consistently. Only 13 percent of respondents who go to restaurants reported that they either chose a particular restaurant or ordered their food on the basis of the levels of salt or sodium they thought the food would contain. However, a higher percentage of reported hypertensives (24 percent) reported that they chose their food or restaurant on this basis than did normo- tensives (10 percent). Blacks, women, and those age 50 and over stated more frequently than did whites, men, and those under age 50 that sodium content was a consideration when they ordered their food or chose a restaurant (table IV-11). Overall, however, the percentages of respondents indicating this type of behavior were under 25 percent for all groups reported. TABLE IV-11 Do You Ever Choose What You Will Order in a Restaurant or What Restaurant to Go to on the Basis of How Much Sodium You Think the Food Will Have? Choose Food Choose Restaurant on This Basis on This Basis (%) (%) TOTAL 13 13 Race White 12 12 Black 20 18 Sex Female 15 14 Age 18-49 9 10 50 and Over 20 17 RP Status Reported Hypertensive 24 19 Reported Normotensive 10 11 Base: Respondents who reported going to restaurants (n = 3,782). 37 '' Summary This chapter presents survey results of the reported status of consumer habits, skills, and perceived barriers related to sodium consump- tion. It should be kept in mind while interpreting the data that these results may represent desired rather than actual behavior. To better understand the issue, problems mentioned when trying to reduce sodium intake were grouped into two categories. Internal problems calling for behavior change by the individual (e.g., liking the taste of salt) were mentioned almost twice as frequently as were external problems (e.g., sodium content of processed foods and restaurant food), which people felt powerless to change. Comprehending and using food label informa- tion was found to be a specific problem for 20 oercent of the respondents who were con- cerned about sodium intake. Approximately one-third of the group experiencing this prob- lem mentioned specific gaps in the information available on labels (i.e., standardization of salt terms and units of measure). ~The National Academy of Sciences has estimated that the average adult adds from 3.4 to 6.0 grams of salt per day to their food during cooking or at the table. It has been suggested that Americans would reach a healthier level of sodium consumption if this added salt could be reduced substantially or eliminated entirely. This chapter investigates both the habits of adding salt at the table and using salt or salt replacements in cooking. Survey findings include: @ Adding salt to food appears to be a habit in approximately one-fourth of the population. ®@ Salt-adding behavior is fairly consistent, whether eating at home or eating ina restaurant. ®@ Certain groups consistently use less salt. For example, adding salt in all environments decreased with age. @ More than one-half of the respondents who do some food preparation reported using either no salt or less than the recipe called for when preparing a dish. 38 @ Women, who traditionally have been more concerned with diet and nutrition than have men, reported less use of salt in cooking and a greater use of such salt substitutes as herbs and spices. Women also reported tasting food before adding salt more fre- quently than did men. The primary barriers to buying low-sodium products or using low-sodium recipes were similar. @ The most frequently reported reason for not trying either low-sodium products or low- sodium recipes centered around a lack of motivation. Another commonly mentioned barrier to trying low-sodium recipes was the amount of extra work involved. e@ A reason frequently stated for not buying low-sodium products was the expectation of lack of taste. @ Reported purchase of low-sodium products was more prevalent than reported use of low-sodium recipes. Women and hyper- tensives reported using these methods to avoid high-sodium foods more often than did men and normotensives. The public does not appear to be changing restaurant choices because some restaurant foods may be high in sodium. Relatively few respondents stated that they ordered their food in a restaurant or avoided certain restaurants based on the perceived sodium content of the food. ''Chapter V Summary Knowledge of High Blood Pressure The majority of the general public knows that hypertension means high blood pressure, that it can happen to anyone, and that it is a condition that can be controlled but not cured. Most consumers are able to name correctly both heart problems and strokes as sequelae to hypertension; however, few know of the rela- tionship between high blood pressure and kidney disease. Although high blood pressure does not have reliable symptoms, 60 percent of the public believe they can tell if their blood pressure is high, with dizziness being the symptom most often specified. In general, the public associates the known risk factors for high blood pressure — such as obesity, sodium consumption, heredity, and alcohol — with the development of hypertension. A very small minority of the public knows the blood pressure threshold above which hypertension is diag- nosed. The Hypertensive Profile In this survey, hypertensives were defined as those individuals who reported that a doctor or other health professional had told them that their blood pressure was high. Comparison with other survey data indicates that this subpopu- lation has similar demographic characteristics to hypertensives who are aware of their disease. Of the reported hypertensives in the survey population, 75 percent were prescribed some type of treatment, the most common being medication. Nonpharmacologic ap- proaches to therapy, also mentioned by a majority of hypertensives, included reducing dietary sodium or salt, controlling weight, and avoiding stress. For the most part, the pre- scribed treatments were perceived as helping to lower the blood pressure. Smoking cessation was the behavior change adhered to least often. Most of the hypertensives reported taking their medicine as prescribed; those who did not were more often young or black. 39 Perceptions of the Blood Pressure Measurement Encounter Survey results indicate that almost every per- son 18 years of age and over in the United States recalls having their blood pressure measured at some time in his or her life. In addition, the large majority reports having had it checked within the past year. Nurses measure blood pressures as frequently as doctors do, and together they constitute the primary source of measurement. Blood pressure is most often measured as part of a more general physical exam, although this varies with age and hyper- tension status. Only one-third of respondents can specify their last blood pressure reading, while another one-third simply remember being told if it was high, low, or O.K. The remaining one-third do not remember their last blood pressure reading. Knowledge and Attitudes Regarding Salt Consumption About half of the general public know that the average consumption level of sodium or salt in the United States is related to high blood pressure. Due to the survey design, questions regarding personal feelings and attitudes about consumption of dietary sodium were asked only of those who were not on low-sodium diets recommended by professionals. Almost one- half of this group felt that they had no need to worry about their sodium intake, although this response was given less frequently by blacks. About one-third of the individuals reported that they had already reduced their sodium intake, while the remaining respondents wanted to reduce their sodium consumption but either hadn't really tried or hadn’t been successful. The reason mentioned most frequently by this last group was the possibility of developing high blood pressure. '' Reported Health Professional Advice for Reducing Dietary Sodium According to those on a low-sodium diet, the most common advice given by a health profes- sional as a method of reducing dietary sodium is not to add salt to food. The next most common advice, as reported by about one-third of those on a low-sodium diet, is to avoid particular foods. Very few of those on sodium- restricted diets mentioned a health profes- sional recommending a specific daily sodium “limit,” similar to a limit on calories per day, and none of these people could specify what their recommended sodium limit was. Health professionals handed out diets or instruction sheets more commonly than they gave this information verbally; almost one-half of those on low-sodium diets reported receiving written advice. Advice on food shopping or preparation was rarely reported, and advice on the use of food labels was reported even less frequently. Respondents who did recall receiv- ing this type of advice reported that recom- mendations appeared very simplistic in nature, i.e., to “check the label” and to “not add salt.” Perceived Barriers to Reducing Sodium Consumption Liking the taste of salt is the most common problem reported by those who are trying to reduce their sodium consumption. The percep- tion that food manufacturers add salt to every- thing was also mentioned as a concern by these consumers. The confusing language and terminology used on food labels is also a barrier to those concerned about the sodium in their diet, although this problem decreased with increasing education. Reasons for not buying a low-sodium product varied and included such factors as not seeing a real need for it, not getting around to it, or the expectation of poor taste. Use of low-sodium recipes was primarily hindered by the amount of time or work needed to acquire and use the recipe. 40 Reported Sodium Reduction Skills Only five percent of those who are on low- sodium diets have been advised to use the list of ingredients on food labels to help keep track of salt or sodium in their food. Advice on the use of the nutrition label is even less common, with only 3 percent of the respondents report- ing using this source of information. Of those who have seen low-sodium products in the grocery store, one-half have purchased these types of products. However, of those who have seen low-sodium recipes, less than one-third have tried any. Consumers generally showed less concern about sodium in the food served when dining outside of the home; only about one out of ten choose either the restaurant or the food at a restaurant on the basis of perceived sodium content in the food. The majority of consumers in the United States who do some cooking say they either use less salt than recipes call for or use no salt in their cooking. Instead, almost one-half of the food preparers use herbs or spices in the place of salt. Six out of ten adults say they rarely or never add salt at the table, either at home or in restaurants. Of those who do add some salt, three-fourths say they always taste the food first. ''References 1. Kannel, W.B. and Thom, T.D. “Declining Cardiovascular Mortality,” Circulation 70(3):331-336, September 1984. 2. Kannel, W.B. “Meaning of the Downward Trend in Cardiovascular Mortality,” Journal of the American Medical Association 247(6):87 7-880, February 12, 1982. 3. The Prevention Index ’85: A Report Card on the Nation’s Health. Rodale Press, Inc., Emmaus, Pennsylvania, 1985. 4. The Public and High Blood Pressure: A Survey. U.S. Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, National High Blood Pressure Education Program, Bethesda, Maryland, DHEW Publication No. (NIH) 77-356, June 1973. 5. The Public and High Blood Pressure: Six-Year Followup Survey of Public Knowledge and Reported Behavior. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, Bethesda, Maryland, NIH Publication No. 81-2118, September 1981. 6. 1984 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, National High Blood Pressure Education Program, Bethesda, Maryland, NIH Publication No. 84-1088, June 1984. Published originally in Archives of Internal Medicine, Vol. 144, May 1984, and in Journal of the American Osteopathic Association, Vol. 83, No. 9, May 1984. 7. Report of the Working Group on Critical Patient Behaviors in the Dietary Management of High Blood Pressure. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, National High Blood Pressure Education Program, Bethesda, Maryland, NIH Publication No. 83-2269, December 1982. 41 ''''SURVEY QUESTIONNAIRE MARKET FACTS INC., 676 NORTH ST. CLAIR, CHICAGO, ILLINOIS 60611 Card 1 Qu. No. (1-4) INTERVIEWER: 5 8 FIELD STATION: 9;}/3/1]0]0] 01/183 DATE: TIME BEGAN: AM/PM_~ TIME ENDED: AM/PM CONSUMER FOOD SURVEY SCREENER Hello, I’m calling for Market Facts, a consumer opinion company in Chicago. We're doing a study for the Food and Drug Administration — the FDA — and we would like to include someone in your household in this important study. Participation in this survey is completely voluntary, but | hope you will cooperate. May | please speak to a member of your household who is eighteen years of age or older? (IF A NEW PERSON COMES TO TELEPHONE, REINTRODUCE YOURSELF AND CONTINUE.) 1. First, can you tell me how many persons in your household, including yourself, are 18 years of age or older? 1 2 3 4 5 6 7 8 or more (14) 2. Starting with the o/dest of these adults in your household, can you tell me their names? PERSON NUMBER NAME DOINIOIaAS;ASWOI NM] — (15) FIND THE TOTAL NUMBER OF ADULTS IN THE TOP ROW OF THE TABLE BELOW. THE NUMBER DIRECTLY BELOW INDICATES THE PERSON WHOIS SELECTED FOR THE INTERVIEW. UNDER THE COLUMN ABOVE LABELED “PERSON NUMBER,” CIRCLE THE NUMBER INDICATING THE PERSON CHOSEN. 16] 0} 2/17 TOTAL NUMBER OF ADULTS 1}/2/3]4)]5/6 SELECT RESPONDENT NUMBER 1};2/2/3 ASK TO SPEAK WITH THE SELECTED RESPONDENT. 3. Is (NAME OF QUALIFIED RESPONDENT) at home now? Yes... 1———>-_ (ASK TO SPEAK TO THAT PERSON, CONTINUE ON QUESTIONNAIRE WITH QUALIFIED RESPONDENT) No....2 43 ''4.When will it be most convenient for me to call back to speak with (NAME OF QUALIFIED RESPONDENT)? Day Time | would like to verify that | reached you by dialing Is that correct? Yes... 1 No. ... 2—a—(ASK FOR CORRECT PHONE NO. AND RECORD BELOW) TELEPHONE NUMBER 5. Aside from prices, please tell me about any particular problems, difficulties, or concerns you have with food these days. (Probe: Do you have any other prob- 19 20 lems of any kind relating to food? LIST INORDER OF MENTION) 20 22 23 24 25 26 None/no problem... 97 6. Many food packages and cans have a list of ingredients that tells what things are in the product. Do you ever pay attention to this information? YOS. occ eee eee 1 Ne 2 3 (SKIP TO QU. 10) (27) Never noticed it...3 Not sure.......... 8 7.Do you ever use this information to avoid using a particular ingredient or to avoid using too much of a particular ingredient? YeS........ 1 No ........ 2 I 3 (SKIP TO QU. 10) (28) Not sure.. al 8. What types of ingredients do you try to avoid? (PROBE) Any others? 29 30 QU. 8 QU. 9 eu a INGREDIENT AVOIDED Completely Too Much 1 2 (37) 33 34 1 2 (38) 35 36 1 2 (39) 1 2 (40) 9. FOR EACH INGREDIENT NAMED IN QU. 8, ASK: Do you try to avoid__——SCSCSCSCSsCSSsS (READ INGREDIENT) Completely, or do you just try to avoid getting too much? (RECORD ABOVE) 10. Many food packages and cans have a nutrition label that tells you how many calories are in each serving of the product and also what vitamins and other nutrients it has. Do you ever pay attention to any of this information? Never noticed it...3 44 (41) ''11.I’m going to name six kinds of nutrition information besides calories, and I’d like you to tell which one of them is most valuable to you. The six kinds of information are: (READ LIST STARTING AT “X”). Let me read it once more: (READ AGAIN, SAME ORDER). Which one of those kinds of informaton is most valuable to you? (PUTA“1” INTHE APPROPRIATE SPACE. IF RESPONDENT CANNOT CHOOSE, ENTER SIX “9s” AND SKIP TO STATEMENT BEFORE QU. 45, PAGE 3.) RANK (_ ) a. Protein aoe, (FE) (_ ) b. Cholesterol —_____ (43) ( )c. Fat —_____ (44) ( )d. Vitamins and minerals —_____ (45) ( )e.Sodium (SKIP TO QU. 32) (20) Did not mention caffeine ...2 INTERVIEWER: ASK EVERYONE EXCEPT RESPONDENTS WHO MENTION CAFFEINE IN QU. 29 OR 30. IF MENTION CAFFEINE, SKIP TO QU. 32. 31.Have you read or heard anything about the dangers to pregnant women of drinking coffee or other things that contain caffeine? Yes, have read/heard...... 1 (21) No, haven't read/heard.... 2 32. What things besides coffee might contain caffeine? (DO NOT READ CHOICES. RECORD FIRST MENTION UNDER “FIRST ANSWER,” ETC.) First Second Third Answer Answer Answer 1 -)- 1 1 1 Colas/Soft drinks/Coke/Pepsi, etc......... 2 2 2 Anti-drowsiness pills (No—Doz, etc.) ....... 3 3 3 Combination headache remedies (Anacin, @tc.)...... 00... cece eee eee eee 4 4 4 Other medications ..............0..0e ee eee 5 5 5 Other (SPECIFY) (22) (23) (24) 48 ''35. Which of these statements best describes your own feelings about the amount of fat you eat? (READ LIST. CIRCLE ONLY ONE.) | don’t think | personally have any need to worry about the amount of fat | Cat... ccc cece eee 1—_———___—3- (SKIP TO QU. 42) | think | probably should reduce it but | haven't really tried............. 2 | have been trying to reduce it but not very successfully............... | | have reduced my fat consumption quite a bit ..................0000 ee (DO NOT READ) Not sure ............. 8 ———-(SKIP TO QU. 42) 36. Why are you concerned about fat? (PROBE) Any other reasons? (DO NOT READ CHOICES. RECORD FIRST MENTION UNDER “FIRST ANSWER,” SECOND MENTION UNDER “SECOND ANSWER,” ETC.) First Second Third Fourth Answer Answer Answer Answer High in calories/ Trying to lose weight .......... 1 1 1 1 May cause heart/ cardiovascular problems ...... 2 2 2 2 May cause cancer............... 3 3 3 3 Other (SPECIFY)____s—CSsé«(2@C*+): (27) (28) (29) 37.Didadoctor or other health professional tell you to reduce the amount of fat you eat, or did you decide on your own? Ordered by doctor/professional... 1 Decided on own ...............05 2 38. Are you following definite instructions — like from a doctor or a diet book — that tell you what you can and cannot eat, or are you doing it without help? Following instructions .................5. 1 Doing it without help .................... 2 Not really doing anything to reduce fat...3 39. Have you read or heard anything about different kinds of fats, like saturated fats and polyunsaturated fats? No/Not sure... 2 (SKIP TO QU. 42) 40. What have you read or heard? (PROBE) Can you tell me anything else about saturated and polyunsatured fats? 41.Are you concerned about both saturated and polyunsaturated fats, or only about one of them? Saturated only.......... 2 Polyunsaturated only... 3 42. Another substances that many people think about when they think about fats is cholesterol. Are you personally at all concerned with the amount of cholesterol you consume? Would you say you’re: (READ LIST) Not at all concerned ................. 1 ——— (SKIP TO QU. 45) A little concerned.................005 2 Very concerned about cholesterol....3 (DO NOT READ) Not sure............ 8 —————3_ (SKIP TO QU. 45) 49 (25) (30) (31) (32) 33 34 (35) (36) ''43. Are you making any particular effort to limit or reduce the amount of cholesterol you consume? YeS......... 1 No........-. 21 yw (SKIP TO QU. 45) Not sure....8| 44.Did a doctor or other health professional tell you to reduce the amount of cholesterol you consume, or did you decide on your own? Ordered by doctor/professional... 1 Decided On Own............000 eee 2 We would like to find out what people have heard about some common health problems. The one | want to ask you about is high blood pressure. 45. If someone’s blood pressure is above a certain level, a doctor would say that person has high blood pressure. Have you ever heard what that level is? No.......05 2 (SKIP TO QU. 47) Not sure....8 46. What do you think that level is that would be considered to show high blood pressure? over ___ Ss (RECORD NUMBERS) (40-42) (43-45) Other form of response: 47.Who can have high blood pressure — anybody or just certain kinds of people? Anybody ............. 1 3—(SKIP TO QU. 49) Just certain people... 2 Not sure.............. 8 Se (SKIP TO QU. 49) 48. What kinds of people can have high blood pressure? (PROBE) Any others? (DO NOT READ CHOICES. RECORD FIRST MENTION UNDER “FIRST ANSWER,” ETC.) First Second Third Answer Answer Answer Old people..............00 ccc eee 1 1 1 Overweight people...............0.:-ee eee 2 2 2 MGR uo cee mce mee new ne mes HEM TM SEM ER ERTS 3 3 3 WOMEN cas cicnseie wiwoesieoseewiwewee news 4 4 4 Tense/Nervous people.................05. 5 5 5 Other (SPECIFY) (47) (48) (49) 49. Canaperson tell if their blood pressure is high? That is, are there any symptoms? No.........- 2 3 (SKIP TO QU. 51) Not sure....3 50 (37) (38) (39) (46) (50) ''50. What symptoms might people feel that would tell them their blood pressure is high? (PROBE) Any others? (DO NOT READ CHOICES. RECORD FIRST MEN- TION UNDER “FIRST ANSWER,” ETC.) First Second Third Answer Answer Answer DizZin€SS.... 0... cee eee cee eee cence 01 01 01 Headaches ........... 0... c cece eee ee eee 02 02 02 Feel tense/nervous ............... cece eee 03 03 03 Feel tired/weak............ 0... cece eee eee 04 04 04 Get flushed/red.......... 0.0... cece eee eee 05 05 05 Feel “full’/internal pressure............... 06 06 06 Other (SPECIFY) (51-52) (53-54) (55-56) 51.As you understand it, what are some of the likely causes of high blood pressure? (PROBE) Any others? (DO NOT READ CHOICES. RECORD FIRST MENTION UNDER “FIRST ANSWER,” ETC.) QU.51 ~First Second Third Fourth Answer Answer Answer Answer QU. 52 SOGIUM: wecascwieseniws 01 01 01 01 01 Salt...............0000. 02 02 02 02 02 Emotional pressure/ Worry/Stress/ ANXICNY occa msmaceniws 03 03 03 03 03 Fatty foods/ Cholesterol.......... 04 04 04 04 04 Alcohol/Excessive drinking ............. 05 05 05 05 05 Improper diet (other than fats, cholesterol, alcohol, salt, sodium).............. 06 06 06 06 06 Being overweight...... 07 07 07 07 07 Overexertion/ Overwork............ 08 08 08 08 08 Heredity............... 09 09 09 09 09g Smoking............... 10 10 10 10 10 Not sure............... 98 —2 (SKIP TO QU. 54) Other (SPECIFY) (57-58) (59-60) (61-62) (63-64) (65-66) 52.(ASK ONLY THOSE WHO NAME MORE THAN ONE CAUSE IN QU. 51) Which one do you feel is the most important cause of high blood pressure? (INTER- VIEWER: CIRCLE RESPONSE ABOVE) 53.(ASK ONLY THOSE WHO NAME SODIUM OR SALT IN QU. 51) You mentioned (sodium/salt) a second ago as being related to high blood pressure. Could this be consumption of amounts that most Americans consume, or only consump- tion of unusually large amounts? Average amounts........... 1 Unusually large amounts... 2 51 (67) ''54. I'd like to read you some possible treatments other people we have interviewed have mentioned. For each one, would you please tell me if you feel it is a treatment that would definitely help control high blood pressure, might help control high blood pressure, or would not help control high blood pressure? (READ LIST STARTING AT “X”) Definitely Might Would Not Help Help Help Control Control Control ( ) a. Dieting to lose weight.... 1 2 3 (68) ( )b. Taking medicine......... 1 2 3 (69) ( )c. Regular exercise......... 1 2 3 (70) ( )d. Low-salt diet ............ 1 2 3 (71) ( )e. Psychotherapy — that is, seeing a psychiatrist or psychologist............. 1 2 3 (72) ( )f. Restingalot ............. 1 2 3 (73) ( )g. Vitamin Bacicc ccc. cc eens 1 2 3 (74) ( )h. Low-fat diet ............. 1 2 3 (75) ( )i. Stopping smoking........ 1 2 3 (76) ( )j. Reducing stress.......... 1 2 3 (77) 55. From what you know or have heard, if a person with high blood pressure gets his pressure down to normal, is he usually cured — as one gets over a cold — or must he usually stay on some type of treatment? Usually cured....... 1 (78) Stay on treatment... 2 (79 open) 80 Card 3 Dup 1-4 56. Why are doctors concerned about high blood pressure? That is, what problems might be caused by high blood pressure? (PROBE) Any other problems? (DO NOT READ CHOICES. RECORD FIRST MENTION UNDER “FIRST ANSWER,” ETC.) First Second Third Answer Answer Answer StKOK6 «ccccciwasraiees moeaiw news a wee woe mee 01 01 01 Heart attacks/Heart trouble............... 02 02 02 Kidney problems..............0e cece eee eee 03 03 03 Dizziness/Vertigo............. eee eee eee eee 04 04 04 Headaches .......... 0. cece eee eee eee 05 05 05 Nosebleeds........... 0.000 cece cece eee nee 06 06 06 Hardening of the arteries/ Atherosclerosis ..............:0e eee eee eee 07 07 07 Diabetes. ......... 0... ccc eee e eee eens 08 08 08 57. Have you ever had your blood pressure checked? That’s the test where they wrap a cuff around your upper arm and pump it up soit squeezes your arm. Have you ever had this done? VOSS. .icusess 1 No.......05- 2] 3 (SKIP TO QU. 62) (11) Not sure... 8| 58. How long ago was the /ast time you had this done? (DO NOT READ) Within past month ...... 1 1-6 months ago......... 2 7-12 months ago....... 3 (12) 1-2 years ago........... 4 Morethan2yearsago...5 52 ''59. Do you remember who did the test? Was it a doctor, or a nurse, or did you do it yourself at home, or on a “test yourself” machine or at a “test your blood pres- sure” van, or what? (DO NOT READ) | DY ole) 0) 1 NUIS@.... cc ce eee eee ee teen ee eaes 2 Self/family member athome ............... 3 MAGCHING siciccisscaiemenswow wiwea min win ow we 4 “Test your blood pressure” van or station... 5 Other (SPECIFY) 60. Why did you have your blood pressure checked at that time? Was it: (READ LIST) Just curiosity for no special reason .......... 6. cc eee eee ee 1 When you were donating blood ............. eee eee ee eee 2 Because you already knew or suspected you might have a blood pressure problem ............ 000 cece eens 3 When you had another diseaSe.............. cece eee eee 4 Part of a more general physical exam...............000005 5 Some other reason (SPECIFY) 61.Do you happen to remember what your blood pressure was? (DO NOT READ) Yes... 1——— (Record: over __) (16-18) (19-21) Just remember it was O.K.... 2 Just remember it was high... 3 No/Not Sure..............005 4 Other response (SPECIFY) 62. Have you ever been told by a doctor or other health professional that your blood pressure is high? VOS occ ccc cece cece cence eeees —— (SKIP TO QU. 64) Yes, in a special circumstance... 23=(SPECIFY CIRCUMSTANCE): NO... ccc ccc ce cece eee eens 3 Not Sure ...... ccc cee eee ee 8 63. Have you ever been warned that your blood pressure is going up or cautioned to do anything about it? VOSs sia wiw es 1 we (SKIP TO QU. 65) No.......... 2 Not sure... 3 3e— (SKIP TO QU. 71) 64. Have you been told more than once that your blood pressure is high, or did this happen only one time? Only one time..... 1 More than once... 2 65. Did your doctor prescribe any treatment for you or tell you what to do to lower your blood pressure? Not sure....8 (13) (14) (15) (22) (23 open) (24) (25) (26) ''66. Which of these things were you told you should do? (READ LIST) QU. 66 QU. 67 QU. 68 Did Not Not Not} Still No Yes|Followed Helped Help Sure|Doing Stopped a. Taking medicine? |2 1 1 2 3 8PP 1 2(27-29) b. Reducing your sodium or salt intake? 2 11> #1 2 3 811 2(30-32) c. Watching your weight or losing weight? 2 m= 1 2 3 z= 1 2 (83-35) d. Avoiding stress or slow down and relax? | 2 i= 861 2 3 8) 1 2 (36-38) e. Cutting down or stopping smoking? 2 Ir 1 2 3 8 1 2 (39-41) f. Getting more exercise? 2 11> 1 2 3 8 1 2 (42-44) g. Doing anything else? (45-50 open) (IF ALL RESPONSES ARE “NO” OR “NOT SURE,” SKIP TO QU. 71) 67.(FOR EACH “YES” IN QU. 66, ASK) Do you think that______ (READ _ ITEM) has helped lower your blood pressure? (IF RESPONDENT VOLUNTEERS THAT HE DID NOT FOLLOW THE PRESCRIPTION, RECORD.) (RECORD ABOVE) 68.(FOR EACH “YES” IN QU. 66 EVER FOLLOWED, ASK) Are you still _ CCC (READ) ITEM) or haves you Stopped? (RECORD ABOVE) IF NOT TAKING MEDICINE (“NO” TO QU. 66a), SKIP TO QU. 71 69. (ASK ONLYTO THOSE TOLD TO TAKE MEDICINE IN QU. 66; OTHERS SKIP TO QU. 71.) How do/did you decide when to take the medicine? (DO NOT READ) Take on regular schedule .............. cee ec eee eee eeeee 1 Take when blood pressure feels high/when feel symptoms ... 2 (51) Take when remember............0 cee cee eee eee ee eee eee 3 Other (SPECIFY) 54 ''70. (ASK ONLY TO THOSE WHO HAVE STOPPED TAKING MEDICINE IN QU. 68; OTHERS SKIP TO QU. 71) Why did you stop taking the medicine? (PROBE) Any other reasons? (DO NOT READ CHOICES. RECORD FIRST MENTION UNDER “FIRST ANSWER” AND SECOND MENTION UNDER “SECOND ANSWER.”) First Second Doctor told me to stop because: Answer Answer | didn’t need it anymore.............. 0c. cece eee eee 01 01 Bad side effects .............. 0. c ccc cece e cece ee ees 02 02 Other reason (SPECIFY) Decided to stop on my own because: | didn’t think | needed it anymore ................... 10 10 Bad side effects ..........0 0... ccc cece cece eee eee ee 11 11 Cost to0 MUCH........ 00. cece eee cece ecnceeeeees 12 12 Other reason (SPECIFY) NO reaSONn GiVEN.......... eee eee eee enna ees 97 97 (52-53) (54-55) Other response (SPECIFY) 71.1s there anyone else in your household who has high blood pressure? Yes... 1 No....2 72. I'd like to ask you very briefly about other health conditions that might affect the way you or other members of your household eat. Do you or anyone in your household have any kind of kidney problem? (IF YES, IDENTIFY WHETHER IS RESPONDENT OR OTHER PERSON) No.......... 1 Yes, self..... 2 Yes, other...3 Yes, both....4 73.Do you or anyone in your household have diabetes or a pre-diabetic con- dition? No.......... 1 Yes, self..... 2 Yes, other...3 Yes, both....4 74. Are you or anyone in your household seriously overweight? No.......... 1 Yes, self..... 2 Yes, other...3 Yes, both....4 75. Are you or anyone in your household pregnant? NGO sie es eae aes 1 Yes, self..... 2 Yes, other...3 Yes, both....4 55 (56) (57) (58) (59) (60) ''76. Have you or anyone in your household ever had a heart attack? No.......... 1 Yes, self..... 2 Yes, other...3 Yes, both....4 77. Have you or anyone in your household ever had a stroke? No.......... 1 Yes, self..... 2 Yes, other...3 Yes, both....4 78. Are you or anyone in your household on a low-salt or low-sodium diet recom- mended by a doctor or other health professional? No........8. 1 Yes, self..... 2 —— (SKIP TO QU. 83) Yes, other...3 Yes, both....4 e~(SKIP TO QU. 83) Not sure..... 8 79.Which of these statements would best describe your own feelings about sodium or salt consumption? (READ LIST) | don’t think | personally have any need to worry about my sodium con- SUMPTION.......... 0. cece eee eee 1 —————-_ (SKIP TO QU. 1 | think | probably should reduce it but | haven’t really tried............. | have been trying to reduce it but not very successfully...............000e (SKIP TO QU. 81) | have reduced my sodium consumption quite a bit.......... 4 (DO NOT READ) Not sure........ 8 ———»-_ (SKIP TO QU. 106) 80. Why haven't you tried to reduce your salt or sodium consumption? Is it that you aren't really all that worried about it or are there other reasons? No other reasons...6 81.What problems have you encountered that make it difficult to reduce your consumption of salt or sodium? (PROBE) Any other problems? | like salt in my food/I like the taste of salt..... 1 None/No problems.............-0. ee eee eee eee 6 82.Why do you believe you should reduce your consumption of salt or sodium? (PROBE FOR SPECIFIC GOALS BEYOND “Would be better for me” TYPE ANSWERS) SKIP TO QU. 92 56 (61) (62) (63) (64) 65 66 67 68 69 70 71 72 73 ''83. Do you have a specific limit on how much sodium you can consume per day or per meal? YeS......... 1 No.......... 2k 3a (SKIP TO QU. 85) Not sure... 8| 84. What is your sodium limit? milligrams per milliequivalents per Other responses (SPECIFY) 85. What have you been advised to do to keep your consumption of sodium down? (PROBE) Anything else? (DO NOT READ CHOICES. RECORD FIRST MENTION UNDER “FIRST ANSWER,” ETC.) First Second Third Fourth Answer Answer Answer Answer Don’t add salt ................... 01 01 01 01 Avoid certain types of foods ..... 02 02 02 02 Eat certain types of foods ....... 03 03 03 03 Look for foods labeled “low sodium” or “salt free,” etc. ..... 04 04 04 04 Look for salt on the ingredient TS) 05 05 05 05 Look for sodium on the nutrition label................. 06 06 06 06 Other (SPECIFY) Nothing/Wasn’t given any AdVICE. . 1... eee ee eee 97 97 97 97 (9-10) (11-12) (13-14) (15-16) 86.What problems have you encountered that make it difficult to reduce your consumption of salt or sodium? (PROBE) Any other problems? | like salt in my food/I like the taste of salt No problems 87.Do you have a diet plan or instruction sheet provided by your doctor or other health professional? Yes... 1 No....2 88. Did your doctor or other health professional give you any advice on howto shop or cook differently in order to reduce your consumption of sodium? i? eee 2| =~ (SKIP TO QU. 90) 57 (74) (75-79 open) [3] 80 Card 4 Dup 1-4 (5-8) 17 18 19 (20) (21) ''89. What did he tell you? (PROBE) Anything else? 22 23 90.(ASK ONLY TO THOSE WHO DID NOT MENTION RECEIVING ADVICE ON USING FOOD LABELS IN QU. 89) Did your doctor or other health professional give you any advice on how to use food labels or other sources of information about the salt or sodium content of food? YeS......... 1 No........0. 2] 3 (SKIP TO QU. 92) Not sure... 8| 91.What did he tell you? (PROBE) Anything else? 24 (25) 26 27 92. Howcould you keep track of how much salt or sodium isin different foods? What sources of information cou/d you use, whether or not you actually do use them? (PROBE) Any others? (DO NOT READ CHOICES. RECORD FIRST MENTION UNDER “FIRST ANSWER,” SECOND MENTION UNDER “SECOND ANSWER,” 28 ETC.) First Second’ Third Fourth Answer Answer Answer Answer Ingredient list (the list of what things are in the food)....... 01 01 01 01 Nutrition label (the part that lists calories, ——S- vitamins, etc.)........ 02 02 02 02 Label statement of sodium per serving..... 03 03 03 03 Label claims (e.g., “no salt,” “reduced sodium”)... 04 04 04 04 Store posters/ Shelf displays.... 05 05 05 05 Information provided by doctor ..... 06 06 06 06 Information from newspapers, 07 O07 07 07 magazines... Low-sodium 08 08 08 08 recipes .... (29-30) (31-32) (33-34) (35-36) Other (SPECIFY) (IF ALL FOUR CIRCLED, SKIP TO QU. 95, OTHERWISE CONTINUE) 58 ''93. Do you know of any information on food /abels [other than (ALL FIRST FOUR CHOICES CIRCLED IN QU. 92)] that might help you keep track of how much Salt or sodium is in your food? YOR. ivivwiws 1 NG. win reeiws 2} 3 (SKIP TO QU. 95) Not sure... 8 94.What information is that? (PROBE) Any other information? (DO NOT READ CHOICES. RECORD FIRST MENTION UNDER “FIRST ANSWER,” ETC.) First Second Third Answer Answer Answer Ingredient liSts iiss cccaiwasaiwrasawnewid mew 1 1 1 Nutrition label .................. cece eee ee 2 2 2 Label statement of sodium per serving.... 3 3 3 Label claims like “no salt” or “lOW SOdIUM”. .. 0... eee eee eee eee 4 4 4 (38) (39) (40) Other (SPECIFY) IF RESPONDENT DOES NOT IDENTIFY AT LEAST ONE LABEL SOURCE OF INFORMATION (codes 1-4), SKIP TO QU. 97 95. Is any of this information confusing or difficult to understand? No/Not sure..... 2 3 (SKIP TO QU. 97) 96. What do you find confusing or difficult to understand? (PROBE) Anything else? 97. Most food packages have a list of ingredients that tells what is in the food. Do you yourself use information on the list of ingredients to help keep track of salt or sodium? YeS......... 1 NOwasicenewes 2 Not sure... “a 3 (SKIP TO QU. 99) 98. What specifically do you look for in the list of ingredients? (PROBE) Anything else? (DO NOT READ CHOICES. RECORD FIRST MENTION UNDER “FIRST ANSWER,” ETC.) First Second Third Answer Answer Answer 1 Respondent mentions that where appear 2 3 Word “sodium” (in chemical names) ....... 4 list is important ...................0 0008. 5 2 3 4 5 (46) (47) (48) Other (SPECIFY) 59 (37) (41) 42 43 44 (45) ''99. Many packages also have a nutrition label that gives the calorie content, vita- mins, protein, and so on, and sometimes sodium. Do you yourself use the information about sodium in the nutrition label to help keep track of salt or sodium? VOSS. cc eimscaivewaieie 1 NO... cece eee eee 2 “When it is there” ...3 100. How often have you seen food packages that have a statement like, “sodium content — so many milligrams per serving?” Would you say you have: (READ LIST) Never seen this ............... 0s eee ee 1 Seen it only afewtimes............... 2 Seen it quite often .................0.. 3 Seen it on almost all food products....4 101. Is this kind of statement, “so many milligrams of sodium per serving,” useful to you? Would you say: (READ LIST) It's very useful and understandable..................... 1 It would be more useful if you understood it better...... 2 It would not be very useful in any case ................. 3 102. Some foods are labeled “low sodium” or “salt free” or “no added salt” or things like that. I’m going to read a list of a few of the different terms; please tell me which of these words you have actually seen on food labels. Have you seen the words: (READ LIST) QU. 102 QU. 104 Not Seen or No, Have Not Yes, Do Not Seen Sure Keep Keep a. Salt free 1 2 (52) 1 2 (60) b. No salt added 1 2 1 2 c. Without added salt 1 2 1 2 d. Unsalted 1 2 1 2 e. Low sodium 1 2 1 2 f. Moderately low sodium 1 2 1 2 g. Reduced sodium 1 2 1 2 h. Sodium free 1 2 (59) 1 2 (67) 103. Which of these statements comes closest to your point of view: | think it’s useful to have all of these terms because they mean somewhat different things.................. 4] ———_———-_ (SKIP TO QU. 105) | think there are too many different terms and only some of them should be USO oie opps ere mie pase were me eee eae wie ce one aos ed Wad DUR RM RLERIS SS BR RE 2 | don’t think this kind of information would be useful in any case ..............5. 3 SKIP TO QU. 105) (DO NOT READ) Not sure......... 8 104. Which one or more terms do you think should be kept? I'll read the list again and you tell me whether you would like each term to be kept. (READ ENTIRE LIST IN QU. 102, AND RECORD ABOVE) 60 (49) (50) (51) (68) ''105. What could the Government or food manufacturers or grocery stores do to help people who are trying to reduce their consumption of saltorsodium,orwhoare 69 70 trying to keep track of it? (PROBE) Anything else? 71 72 73 74 75 76 Nothing... 97 106. How much of the food shopping do you do for your household? Would you say you do: (READ LIST) All of the food shopping... 1 (77) Most of it.................. 2 (78-79 open) About half of it ............ 3 [4]80 Only a little of it........... 4 Card 5 NONn6 Of it esses sows eauewen 5 —S ———_—— i (SKIP TO Qu. 110) Dup 1-4 107. There are some products specially made to have less sodium; they’re often labeled “low sodium” or “salt free” or something like that. Have you ever seen any of these products advertised on TV or in a magazine or anywhere? VYeS wo... eee 1 No/Not sure....2 (5) 108. Does your grocery store carry any of these products? YeS......... 1 No.......... 2] (6) Not sure....8} Se (SKIP TO QU. 110) 109. Does the store have all of these products together at one place, or are they mixed in with the regular foods? All one place.............. 1 Mixed with other foods....2 110. Have you ever bought any of these foods? YeS, | have ...... ccc cece eee eee eee eens 1 SKIP TO QU. 113) | haven’t, but other household shopper has ... 2 YeS......... 1 No.......... 2 3p (SKIP TO QU. 114) Not sure.... 8| 112.Why did you decide not to buy? (PROBE) Any other reasons? SKIP TO QU. 114 113.(Do you) (Does he/she) buy “low-salt” or “low-sodium” foods regularly, only sometimes, or hardly ever? (DO NOT READ) Regularly .......... 1 Only sometimes. ... 2 Hardly ever........ 3 Only once.......... 4 61 (7) (8) (12) ''114. Other than buying foods labeled “low salt” or “low sodium,” do you make any particular effort to choose foods with less salt or sodium than others? YO@S.aseasnie 1 NOecarnaewes 2 3 (SKIP TO QU. 118) Not sure... .8| 115.In general, how do you do this? (PROBE) Any other methods? (DO NOT READ CHOICES. RECORD FIRST MENTION UNDER “FIRST ANSWER,” ETC.) First Second Third Answer Answer Answer By avoiding types of food | know are salty or high in Sodium .................0ee eee By buying types of food that | know don’t have much salt or Sodium............... 2 2 By looking for salt or sodium on the ingredient list................. cee eee eee 3 3 By looking for sodium on the nutrition NF 0 -) 4 4 5 5 —- 1 1 By looking for separate declarations of SOCIUM GONTONE i ac cia ce sis wee ae cee oe wes (14) (15) (16) Other methods (SPECIFY) SKIP TO QU. 118 116. Does the person who does the shopping ever buy foods labeled “low salt” or “low sodium” or anything like that? VOS oo. ccc eee eens 1 So 2 (SKIP TO QU. 118) Not SUre.... cece cee ee eee 8 No one in household shops ....3 117. Does he/she buy “low-salt” or “low-sodium” foods regularly, only sometimes, or hardly ever? (DO NOT READ) Regularly .......... 1 Only sometimes. ... 2 Hardly ever........ 3 Only once.......... 4 118. How often do you prepare meals for your household? Would you say you do: (READ LIST) All of the meal preparations... 1 Most of it.............00. ee eee 2 About half of it................ 3 Only a little of it............... 4 None of it.................0005 5 ———JI (SKIP TO QU. 128) 119. Have you ever seen any recipes — maybe in a cookbook, magazine, or news- paper — that are written for people who want to avoid salt or sodium? VOS Loc ccc cee eect e eee eee 1 No, but other household food preparer uses them.............0 ccc eee eee eee 2 ———_ (SKIP TO QU. 123) No/Not Sure.......... 0... c cece eee eee 3—— (SKIP TO QU. 124) 62 (13) (17) (18) (19) (20) ''120. Have you ever tried any of these recipes? Yes....1 3p (SKIP TO QU. 123) No..... 2 121. Have you ever thought about trying one of these recipes? YeS......... 1 No.......... 2] Not sure.... 8} (SKIP TO QU. 124) 122. Why did you decide not to try it? SKIP TO QU. 124 123. (Do you) (Does he/she) use low-salt recipes regularly, only sometimes, or hardly ever? (DO NOT READ) Regularly .......... 1 Only sometimes. ... 2 Hardly ever........ 3 Only once.......... 4 124. O.K., I’d like to ask you about regular recipes — not special low-salt ones. When a recipe Calls for you to add salt, do you usually use the amount the recipe says, or do you often use more or less? MOre ....... ccc eee eee e eens 1 LESS... eee cc eee eee ane 2 About what recipe says ............. 3 “| never use any Salt in cooking” ....4 “| never/rarely use recipes”......... 5 Not Sure............. ccc cee ee eee ee 8 125. Do you use any other sort of flavoring like herbs or spices to replace salt in cooking? YeS .........05. 1 No/Not sure....2 3 (SKIP TO QU. 127) 126. What do you use? (PROBE) Anything else? (RECORD FIRST MENTION UNDER “FIRST ANSWER,” ETC.) First Second Third Answer Answer Answer ed =) ©) ©] =) 01 01 01 1 0) 9 02 02 02 GAP IG ss co wie is seme s 05 Sed Tom akin renew cee ne 03 03 03 OreGanO....... cee eee eee eee eee 04 04 04 (28-29) (30-31) (32-33) Other (SPECIFY) 63 (21) (22) 23 24 (25) (26) (27) ''127. How about when you’re making something like noodles or frozen vegetables, where the directions on the package often tell you to add salt to the water. Do you usually add the amount suggested, or more, or less, or don’t you usually add any? (DO NOT READ) NY 0) = 1 AS:SUQQGOSIOG 6 iis cccsn vixen ces owsewnw men ney 2 LOSS... ccc ccc cece cnet e eee e eee 3 Don’t add any............ ccc cece eee e eee ee 4 Add salt for noodles, not for vegetables..... 5 Do not make these products ............... 6 Other reSponses........... cc cece eee 7 128. Would you say that the person who does most of the cooking generally: (READ LIST) Uses a lot of salt in cooking..................04. 1 Uses about an average amount ................. 2 Uses only a very little salt, or.................00. 3 Never use Salt...... 0.0... ccc eee eee eee eee 4 (DO NOT READ) No one in household cooks ....6 (DO NOT READ) Not Sure................000 eee 8 129. Nowlet’s talk about salt you might add at the table. When you're eating at home, do you: (READ LIST) Almost always add Salt................ 1 Sometimes add salt................... 2 Rarely add Salt............ 0.0.0 e eee 3 Never add Salt ............... cess eee 4 (SKIP TO QU. 131) (DO NOT READ) Never eat at home....6 (DO NOT READ) Not sure ............. 8 130. Do you ever add salt before tasting the food, or do you a/ways taste the food first? Sometimes add without tasting... 1 Always taste first ................. 2 131.How about when you’re eating a meal in a restaurant? Do you: (READ LIST) Almost always add salt ........... 1 Sometimes add salt .............. 2 Rarely add salt................... 3 Never add salt..................0. 4 —_————(SKIP TO QU. 133) (DO NOT READ) Never eat out. ... 6—>(SK IP. TO QU. 139) (DO NOT READ) Not sure......... 8 132. Do you ever add salt before tasting the food, or do you always taste the food first? Sometimes add without tasting... 1 Always taste first ................. 2 133. Do you ever choose what you will order in a restaurant on the basis of how much sodium you think the food will have? Yes...1 No....2 134. Do you ever avoid going to a particular type of restaurant because you think the food will have too much sodium? V OS ie: nee are om 1 No.......00. 2] (SKIP TO QU. 136) Not sure... .8| 64 (34) (35) (36) (37) (38) (39) (40) (41) ''135. What types of restaurants do you avoid? (RECORD FIRST MENTION UNDER “FIRST ANSWER,” ETC.) First Second Answer Answer Chinese/Oriental........... 0... ccc cece cee ee ees 1 1 Fast food (i.e., MacDonalds).................00eee eee 2 2 (42) (43) Other (SPECIFY) 136. Have you ever noticed statements of the sodium contents of restaurant foods listed on the menu or posted or anything? Yes... 1 No....2 137. Some restaurants have special meals for people on low-calorie diets. Have you ever seen a special listed for people on low-sodium diets? Yes...1 No....2 138. Have you ever asked to have your food specially prepared without salt in a restaurant? Yes...1 NOs «ae 2 Now I'd like to ask you a few more questions to help us group the answers of the people we talk to. 139. What is your date of birth? month day year (47-48) (49-50) (51-52) 140. What was the last grade of school you completed? Sth Grade OF OSS. ui cscwissw new iw siew mews weer er 1 Oth-11th grade........ eee eee 2 12th grade/High school graduate.............. 3 Trade or technical training after high school....4 1-3 years of college ............ cece eee eee eee 5 4-year college graduate...................008. 6 PostQraduat@sss seasccewircae visewaiesemew new ams 7 141.Do you live: (READ LIST) IN City... cece ec ewwes 1 In the suburbs....... 2 Inasmalltown...... 3 Inthe country....... 4 142. /ncluding yourself, how many people live in your household? —_—_ (ENTER NUMBER) (55-56) 65 (44) (45) (46) (53) (54) ''143.We need to know your approximate household income for 1981, including salaries, pensions, investments, and so on. Please stop me when | read the right amount. Was it: (READ LIST) Less than $5,000................. 1 Between $5,000 and $10,000....2 Between $10,000 and $15,000...3 Between $15,000 and $20,000...4 Between $20,000 and $25,000...5 Between $25,000 and $35,000...6 Between $35,000 and $50,000...7 More than $50,000............... 8 144. Finally, to which racial or ethnic group do you belong? Do you consider yourself: (READ LIST) American Indian or Alaskan Native....... 1 Asian (Oriental) or Pacific Islander....... 2 Black but not Hispanic................... 3 White but not Hispanic .................. 4 Hispanic (Mexican, Cuban, Puerto Rican, Central or South American) ............ 5 Thank you very much for your cooperation. 145.(DO NOT ASK) Respondent is: 146. (DO NOT ASK) State Code: (code) (61-62) (RECORD FROM SAMPLE LABEL) 66 (57-58) (59) (60) (63-79 open) 80 '' DISCRIMINATION PROHIBITED: Under provisions of applicable public laws enacted by Congress since 1964, no person in the United States shall, on the grounds of race, color, national origin, handicap, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity (or, on the basis of sex, with respect to any education program or activity) receiving Federal financial assistance. In addition, Executive Order 11141 prohibits discrimination on the basis of age by contractors and subcontractors in the performance of Federal contracts, and Executive Order 11246 states that no federally funded contractor may discriminate against any employee or applicant for employment because of race, color, religion, sex, or national origin. Therefore, the National Heart, Lung, and Blood Institute must be operated in compliance with these laws and Executive Orders. '' NIH Publication No. 86-2730 October 1986 ''