Do you know your numbers? Check your blood pressure regularly for hypertension prevention and control

WORLD HYPERTENSION DAY "May 17"

"May 17" marks World Hypertension Day (an initiative of the World Hypertension League), which is observed in conjunction with May Measure Month (MMM), an initiative launched by the International Society of Hypertension in 2017, lasting from May 1 to July 31, 2024. These observances emphasize the need to prevent, detect, and treat high blood pressure. The theme for World Hypertension Day in 2024 is "Measure Your Blood Pressure Accurately, Control It and Live Longer," focusing on combatting low awareness rates globally, especially in Low- and Middle-Income Countries(LMICs), regarding accurate blood pressure measurement. In addition, Salt Awareness Week is also celebrated from 13 to 19 May 2024; reducing salt intake is a quick and easy way to reduce blood pressure and improve health.

What is Hypertension?

Hypertension (HTN) is a growing global issue, particularly affecting LMICs in South and East Asia and sub-Saharan Africa. The World Health Organization (WHO) defines hypertension as 140/90 mmHg or higher blood pressure. To be diagnosed with hypertension, a person's systolic blood pressure must be ≥140 mmHg, and diastolic blood pressure must be ≥90 mmHg on two occasions. Although high blood pressure is common, it can be dangerous if left untreated. Globally, it is estimated that 1.28 billion adults have hypertension, with two-thirds of them residing in LMICs. The WHO reports that one in four men and one in five women have HTN. High blood pressure (BP) is the primary modifiable risk factor for global cardiovascular mortality, accounting for over 11 million deaths annually. Hypertension is a significant contributor to heart disease and stroke, accounting for 45% and 51% of deaths. In 2019, this condition was responsible for 10.8 million deaths and 9.3% of global disability-adjusted life years (DALYs).

The primary difficulties in managing high blood pressure involve raising awareness about the condition, providing effective treatment, and achieving optimal control. Despite numerous clinical guidelines for hypertension management and evidence demonstrating the clear benefits of maintaining optimal blood pressure, achieving this goal remains challenging. Furthermore, disparities persist between racial and income groups, even in high-income countries, resulting in disadvantaged subgroups having far more difficulty in controlling their blood pressure, which in turn leads to higher rates of cardiovascular mortality. Approximately 46% of adults with hypertension are unaware of their condition, leading to numerous complications. The primary challenge is the diagnosis and treatment of hypertension, as only 42% of people are diagnosed on time, and only 21% (i.e., one in five cases) are being treated among the diagnosed cases.   Additionally, there is a significant challenge in controlling hypertension even after diagnosis, with more than 50% (1.4 billion individuals) of patients diagnosed with hypertension having uncontrolled blood pressure in both high-income countries (HICs) and low-middle-income countries (LMICs). 

Hypertension is typically asymptomatic; thus, regular blood pressure monitoring is essential. Initiatives such as May Measurement Month are celebrated to ensure that hypertension (HTN) cases are detected early and managed effectively by raising awareness of the importance of checking one's blood pressure.

Risk Factors for Hypertension

Factors that contribute to hypertension can generally be divided into two categories: modifiable and non-modifiable. Modifiable risk factors are those that can be changed or managed, such as unhealthy diet (consuming too much salt, high intake of saturated and trans fats, and low consumption of fruits and vegetables), lack of physical activity, smoking, excessive alcohol consumption, and being overweight or obese. Non-modifiable risk factors, on the other hand, are those that cannot be changed or managed, such as a family history of hypertension, age greater than 65 years, and coexisting diseases such as diabetes or kidney disease. Some studies have suggested that racial and ethnic differences may be risk factors for hypertension.

Physical inactivity is a significant risk factor for cardiovascular diseases, as it increases the risk of high blood pressure by 30-50%. Physical inactivity is less than 150 min of moderate-intensity activity per week or equivalent. In addition, increased BMI is a critical risk factor for hypertension, with evidence of an increased risk in children and of all age groups. The development of hypertension with high BMI has been well established. Unplanned urbanization patterns have contributed to lifestyle changes, including sedentary habits and consumption of high-fat, salt, and sugary products, leading to increased obesity.

Dietary factors play a crucial role in the development of hypertension, with approximately 27 dietary factors reported to be either protective or adverse risk factors. High salt intake is a significant risk factor for sodium retention, expanding the extracellular volume and increasing cardiac output. This leads to increased peripheral resistance through the activation of autoregulatory vasoconstriction. Potassium, fruit, vegetable, and alcohol intake are also directly related to hypertension. The interaction between cardiovascular disease and alcohol is complex, with the harmful effects of alcohol evident in the form of binge or cumulative lifetime consumption. However, determining the strength of this correlation is complicated by the association of heavy drinking with other hypertension risk factors, including sedentary lifestyle, smoking, and dietary habits, including salty food. Similarly, a high cholesterol level is a crucial risk factor for cardiovascular disease and can also increase the risk of high blood pressure.

Cigarette smoking significantly increases the risk of hypertension by stimulating the sympathetic nervous system. This stimulation causes inflammation and metabolic changes, which are the major risk factors for hypertension.

Additionally, other factors, such as stress, lack of sleep, and anxiety, have also been linked to increased blood pressure. Moreover, air pollution is a significant risk factor for noncommunicable diseases, including hypertension.

Sign and symptoms

Patients with high blood pressure are often asymptomatic, and regular blood pressure checks are crucial for early diagnosis and management. Symptoms of high blood pressure include severe headaches, chest pain, dizziness, difficulty breathing, nausea, vomiting, blurred vision, anxiety, confusion, ringing in the ears, nosebleeds, and abnormal heart rhythms.

Prevention and Control of Hypertension

Effective strategies for managing blood pressure include lifestyle changes and pharmacological treatments. Recommended lifestyle changes include reducing salt intake, consuming a diet high in fruits and vegetables, maintaining a healthy weight, engaging in regular physical activity, quitting smoking, and limiting alcohol consumption. While some patients with low or borderline hypertension may only require lifestyle modifications, most will need drug treatment in addition to lifestyle management.

These include:

Eating a healthy diet: Healthy eating habits are essential for managing hypertension. The Dietary Approaches to Stop Hypertension (DASH) trial recommends balanced calorie intake, emphasizing fruits, vegetables, low-salt, fat, cholesterol, and sugar products. The 2020 ISH guidelines advise reducing salt intake and avoiding or limiting processed foods with high salt content. To manage blood pressure, the ESH/ESC guidelines recommend a daily sodium intake of 2g (5g salt) for general and hypertensive patients. The World Health Organization (WHO) has established a voluntary target for its member states to achieve a 30% reduction in the average salt intake of the population by 2025 as a strategy for controlling noncommunicable diseases (NCDs) and hypertension. A balanced diet, including fruits, vegetables, low-fat dairy products, whole grains, fish, and a low intake of red meat and saturated fats, is recommended for patients with hypertension to manage their blood pressure.

Weight loss and physical activity: Besides dietary changes, physical activity and weight loss are essential for effective hypertension management. A meta-analysis of randomized controlled trials of aerobic endurance training found that regular aerobic physical activity can reduce systolic and diastolic blood pressure by 3.5/2.5 mmHg in the general population, with more effectiveness (8.3/5.2 mmHg) observed among participants with hypertension. Patients with hypertension are advised to engage in at least 30 minutes of moderate-intensity aerobic exercise, such as walking, jogging, cycling, or swimming, for 5-7 days per week.

Quitting/ reducing smoking and alcohol consumption are recommended lifestyle interventions for hypertension management. Furthermore, reducing air pollution is a crucial global, regional, and national strategy to prevent NCDs.

Pharmacological treatment: After diagnosis, the doctor may recommend medication for high blood pressure based on the patient's overall health. The aim is to lower blood pressure to 130/80 mmHg or less if the patient has certain conditions, such as cardiovascular disease, diabetes, chronic kidney disease, or a high risk of heart disease. There is strong evidence supporting the use of antihypertensive medications in treating and managing hypertension. It is crucial to use these medications regularly to prevent complications and reduce the risk of adverse events. By lowering blood pressure with antihypertensive medication, patients can reduce their risk of stroke by 35%, coronary events by 20%, heart failure by 40%, and all-cause mortality by 10-15%. Therefore, patients with hypertension need to take their prescribed antihypertensive medication regularly, as directed by their healthcare provider.

Conclusion: In conclusion, an effective intervention is urgently needed to combat hypertension and its associated mortality and morbidity. The WHO has recommended targeted interventions for high-risk groups, but the healthcare system may need to be equipped to handle this burden. Primary healthcare workers and volunteers could be vital in preventing and controlling cardiovascular diseases, including hypertension. Using advanced technology, such as mobile technology, to raise awareness and disseminate information could be helpful. Operational research utilizing advanced technology could be an essential investment for low- and middle-income countries to effectively manage and control high blood pressure. Cost-effective interventions should be implemented to increase awareness of hypertension and its complications.

Author information: Dr Buna Bhandari is a public health academic and researcher who spent more than a decade researching and advocating for the prevention, treatment, and control of high blood pressure, especially for high-risk, vulnerable, and marginalized groups. She is a Lown Scholar for the Cardiovascular Health Program at the Harvard T.H. Chan School of Public Health, USA, and an active member of the Women in Hypertension Research "Development and Training Committee" at the International Society of Hypertension. She is a Chair of AuthorAID stewards and an INASP associate as well. Contact : X: @bunabh; Linkedin: Buna Bhandari

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Thumbnail image: Image generated in Freepik AI, May 16, 2024

First image: Photo by Mufid Majnun on Unsplash

Second image: Photo by Jacopo Maia on Unsplash