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A global brief on Hypertension
Silent killer, global public health crisis
World Health Day 2013
A global brief on hypertension | Foreword
1
© World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel. : +41 22 791 3264 ; fax : +41 22 791 4857 ; e-mail : bookorders@who.int). Requests for permission to reproduce or translate WHO publications - whether for sale or for non-commercial distribution - should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concern- ing the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the infor- mation contained in this publication. However, the published material is being distributed with- out warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Design and layout : MEO design – communication – web, Switzerland Photos : p. 14 : WHO/Jim Holmes ; p. 19 : WHO/C. Black ; p. 20 : WHO/C. Black ; p. 31 : WHO/Harold Ruiz ; p. 33 : WHO ; p.36 : WHO/S. Hollyman Printed by : WHO Document number : WHO/DCO/WHD/2013.2 Any queries regarding this document should be addressed to : communications@who.int
a global brief on hypertension
World Health Day 2013
CONTENTS
5 Foreword
7 Executive summary
8 Section I Why hypertension is a major public health issue
16 Section II Hypertension : the basic facts
22 Section III How public health stakeholders can tackle hypertension
Governments and policy-makers
Health workers
Civil society
Private sector
Families and individuals
World Health Organization
34 Section IV Monitoring the impact of action to tackle hypertension
FOREWORD
We live in a rapidly changing environment. Throughout the world, human health is being shaped
by the same powerful forces : demographic ageing, rapid urbanization, and the globalization of
unhealthy lifestyles. Increasingly, wealthy and resource-constrained countries are facing the same
health issues. One of the most striking examples of this shift is the fact that noncommunicable dis-
eases such as cardiovascular disease, cancer, diabetes and chronic lung diseases have overtaken
infectious diseases as the world’s leading cause of mortality.
One of the key risk factors for cardiovascular disease is hypertension - or raised blood pressure.
Hypertension already affects one billion people worldwide, leading to heart attacks and strokes.
Researchers have estimated that raised blood pressure currently kills nine million people every year.
But this risk does not need to be so high. Hypertension can be prevented. Doing so is far less
costly, and far safer for patients, than interventions like cardiac bypass surgery and dialysis that
may be needed when hypertension is missed and goes untreated.
Global efforts to tackle the challenge of noncommunicable diseases have gained momentum since
the 2011 United Nations Political Declaration on the prevention and control of noncommunicable
diseases. The World Health Organization is developing a Global Plan of Action, for 2013-2020,
to provide a roadmap for country-led action for prevention and control of non-communicable
diseases. WHO’s Member States are reaching consensus on a global monitoring framework to
track progress in preventing and controlling these diseases and their key risk factors. One of the
targets envisaged is a substantial reduction in the number of people with raised blood pressure.
Hypertension is a silent, invisible killer that rarely causes symptoms. Increasing public awareness
is key, as is access to early detection. Raised blood pressure is a serious warning sign that signi‑
ficant lifestyle changes are urgently needed. People need to know why raised blood pressure is
dangerous, and how to take steps to control it. They need to know that raised blood pressure and
other risk factors such as diabetes often appear together. To raise this kind of awareness, countries
need systems and services in place to promote universal health coverage and support healthy
lifestyles : eating a balanced diet, reducing salt intake, avoiding harmful use of alcohol, getting
regular exercise and shunning tobacco. Access to good quality medicines, which are effective and
inexpensive, is also vital, particularly at the primary care level. As with other noncommunicable
diseases, awareness aids early detection while self-care helps ensure regular intake of medication,
healthy behaviours and better control of the condition.
High-income countries have begun to reduce hypertension in their populations through strong
public health policies such as reduction of salt in processed food and widely available diagnosis
and treatment that tackle hypertension and other risk factors together. Many can point to examples
of joint action – across sectors – that is effectively addressing risk factors for raised blood pressure.
In contrast, many developing countries are seeing growing numbers of people who suffer from
heart attacks and strokes due to undiagnosed and uncontrolled risk factors such as hypertension.
This new WHO global brief on hypertension aims to contribute to the efforts of all Member States
to develop and implement policies to reduce death and disability from noncommunicable d iseases.
Prevention and control of raised blood pressure is one of the cornerstones of these efforts.
Dr Margaret Chan
Director-General
World Health Organization
A global brief on hypertension | Foreword
5
executive
summary
Hypertension, also known as high or raised blood pressure,
is a global public health issue.
It contributes to the burden of heart disease, stroke and kidney failure and premature mortality
and disability. It disproportionately affects populations in low- and middle-income countries where
health systems are weak.
Hypertension rarely causes symptoms in the early stages and many people go undiagnosed. Those
who are diagnosed may not have access to treatment and may not be able to successfully control
their illness over the long term.
There are significant health and economic gains attached to early detection, adequate treatment and
good control of hypertension. Treating the complications of hypertension entails costly interven-
tions such as cardiac bypass surgery, carotid artery surgery and dialysis, draining individual and
government budgets.
Addressing behavioural risk factors, e.g. unhealthy diet, harmful use of alcohol and physical inac-
tivity, can prevent hypertension. Tobacco use increases the risk of complications of hypertension. If
no action is taken to reduce exposure to these factors, cardiovascular disease incidence, including
hypertension, will increase.
Salt reduction initiatives can make a major contribution to prevention and control of high
blood pressure. However, vertical programmes focusing on hypertension control alone are
not cost effective.
Integrated noncommunicable disease programmes implemented through a primary health care
approach are an affordable and sustainable way for countries to tackle hypertension.
Prevention and control of hypertension is complex, and demands multi-stakeholder collaboration,
including governments, civil society, academia and the food and beverage industry. In view of the
enormous public health benefits of blood pressure control, now is the time for concerted action.
A global brief on hypertension | Executive summary
7
SECTION I
Why hypertension
is a major public
health issue
8 I | Why hypertension is a major public health issue | A global brief on hypertension
Globally cardiovascular disease accounts for approximately 17 million deaths a year, near-
ly one third of the total (1). Of these, complications of hypertension account for 9.4 million
deaths worldwide every year (2). Hypertension is responsible for at least 45% of deaths due to
heart disease (total ischemic heart disease mortality is shown in Fig. 1), and 51% of deaths due to
stroke (total stroke mortality is shown in Fig. 2). (1)
Figure 01
ischemic heart
disease mortality
rates
(age standardized, per 100 000)
Source :
Causes of death 2008,
World Health Organization,
Geneva
12-74
75-108
109-151
152-405
Data not available
Figure 02
cerebrovascular
disease
mortality rates
(age standardized, per 100 000)
Source :
Causes of death 2008,
World Health Organization,
Geneva
11-49
50-88
89-131
132-240
Data not available
A global brief on hypertension | Why hypertension is a major public health issue | I
9
In 2008, worldwide, approximately 40% of of adults aged 25 and above, while the lowest
adults aged 25 and above had been diagnosed prevalence at 35% is found in the Americas
with hypertension ; the number of people with (Fig. 3). Overall, high-income countries have a
the condition rose from 600 million in 1980 to lower prevalence of hypertension - 35% - than
1 billion in 2008 (3).The prevalence of hyper other groups at 40% (3, 4).
tension is highest in the African Region at 46%
Figure 03
AGE-standARDIZED
70
PREVALENCE OF
RAISED BLOOD
PRESSURE IN ADULTS 60
AGED 25+ YEARS
by WHO Region and World
Bank income group, comparable 50
estimates, 2008
Source :
40
Global status report on
noncommunicable diseases
2010, Geneva,World Health 30
Organization, 2011
20
Men
Women
10
Both sexes
AFR : Africa Region
AMR : Region of the Americas 0
EMR : Eastern Mediterranean Region AFR AMR EMR EUR SEAR WPR Lower- Lower- Upper- High-
EUR : European Region income middle- middle- income
SEAR : South-East Asia Region
WPR : Western Pacific Region income income
Men Women Both sexes
Not only is hypertension more prevalent in tems, the number of people with hypertension
low- and middle-income countries, there are who are undiagnosed, untreated and uncon-
also more people affected because more peo- trolled are also higher in low- and middle-
ple live in those countries than in high-income income countries compared to high-income
countries. Further, because of weak health sys- countries.
10 I | Why hypertension is a major public health issue | A global brief on hypertensionThe increasing prevalence of hypertension is has nearly doubled since 1980. The global prev-
attributed to population growth, ageing and alence of high cholesterol was 39% and prev-
behavioural risk factors, such as unhealthy alence of diabetes was 10% in adults over 25
diet, harmful use of alcohol, lack of physical years (3). Tobacco use, unhealthy diet, harmful
activity, excess weight and exposure to per- use of alcohol and physical inactivity are also
sistent stress. the main behavioural risk factors of all major
noncommunicable diseases, i.e. cardiovascular
The adverse health consequences of hyper
disease, diabetes, chronic respiratory disease
tension are compounded because many peo-
and cancer (5-9).
ple affected also have other health risk fac-
tors that increase the odds of heart attack, If appropriate action is not taken, deaths due
stroke and kidney failure. These risk factors to cardiovascular disease are projected to rise
include tobacco use, obesity, high cholesterol further (Fig. 4).
and d iabetes mellitus. Tobacco use increases
the risk of complications among those with
hypertension. In 2008, 1 billion people were
smokers and the global prevalence of obesity
Cardiovascular diseases Perinatal conditions Tuberculosis
Figure 04
Cancer Maternal conditions Malaria the projected
Diabetes Chronic respiratory diseases HiV / Aids mortality trend
from 2008 to 2030
24% for major
noncommunicable
22%
diseases and
20% communicable
18% diseases
Deaths by cause (%)
16%
Source :
14% The Global Burden of Disease,
12% 2004 update. Geneva, World
Health Organization, 2008.
10%
8%
6%
4%
2%
0%
2008 2015 2030
A global brief on hypertension | Why hypertension is a major public health issue | I
11Populations around the world are rapidly ageing (Fig. 5) and prevalence of hypertension i ncreases
with age (6).
Figure 05
upper middle-income 2000 pyramid upper middle-income 2010 pyramid
Comparison of
the average age 80+ 0.7% 1.5% 80+ 1.1% 2.0%
75–79 1.0% 1.6% 75–79 1.2% 1.8%
pyramids in 2000 80+
70–74
0.7%
1.8%
1.5%
2.5%
80+
70–74
1.1%
1.9%
2.0%
2.6%
75–79 1.0% 1.6% 75–79 1.2% 1.8%
with 2010, 65–69 2.3% 2.8% 65–69 2.2% 2.6%
70–74 1.8% 2.5% 70–74 1.9% 2.6%
upper 60–64
65–69
3.0%
2.3%
3.5%
2.8%
60–64
65–69
3.2%
2.2%
3.6%
2.6%
middle-income 55–59
60–64
3.1%
3.0%
3.3%
3.5%
55–59
60–64
4.4%
3.2%
4.8%
3.6%
category
category
50–54 4.2% 4.4% 50–54 5.3% 5.6%
and high-income 55–59
45–49 5.5%
3.1% 3.3%
5.5%
55–59
45–49
4.4%
6.2%
4.8%
6.3%
category
category
50–54 4.2% 4.4% 50–54 5.3% 5.6%
countries 40–44 6.4% 6.4% 40–44 6.5% 6.5%
45–49 5.5% 5.5% 45–49 6.2% 6.3%
35–39 7.1% 7.1% 35–39 7.2% 7.1%
AgeAge
AgeAge
40–44 6.4% 6.4% 40–44 6.5% 6.5%
Source : 30–34
35–39
7.5%
7.1%
7.4%
7.1%
30–34
35–39
8.1%
7.2%
7.8%
7.1%
25–29 8.3% 8.1% 25–29 9.0% 8.7%
World population prospects : 30–34 7.5% 7.4% 30–34 8.1% 7.8%
20–24 9.3% 8.9% 20–24 9.4% 8.9%
The 2010 revision, CDROM 25–29
15–19
8.3%
10.2%
8.1%
9.6%
25–29
15–19
9.0%
8.8%
8.7%
8.2%
Edition, Department of 20–24
10–14
9.3%
10.5%
8.9%
9.8%
20–24
10–14
9.4%
8.4%
8.9%
7.8%
15–19 10.2% 9.6% 15–19 8.8% 8.2%
Economic and Social 5–9 9.8% 9.1% 5–9 8.5% 7.8%
10–14 10.5% 9.8% 10–14 8.4% 7.8%
Affairs, Population 0–4 9.5% 8.7% 0–4 8.6% 9.9%
5–9 9.8% 9.1% 5–9 8.5% 7.8%
Division, New York, 0–4 20% 15% 9.5%
10% 5% 0% 5% 10%
8.7% 15% 20% 0–4 20% 15% 8.6%
10% 5% 0% 5% 10%
9.9% 15% 20%
United Nations, 2011.
Proportion
20% 15% of
10%total
5%males
0% (%)
5%and10%
females
15% (%)
20% Proportion of total
20% 15% 10% 5%males
0% (%)
5%and10%
females
15% (%)
20%
Proportion of total males (%) and females (%) Proportion of total males (%) and females (%)
Men
High-income 2000 pyramid High-income 2010 pyramid
Women 80+ 2.1% 4.3% 80+ 3.0% 5.6%
75–79 2.3% 3.5% 75–79 2.6% 3.5%
80+ 2.1% 4.3% 80+ 3.0% 5.6%
70–74 3.3% 4.1% 70–74 3.5% 4.1%
75–79 2.3% 3.5% 75–79 2.6% 3.5%
65–69 4.0% 4.4% 65–69 4.2% 4.6%
70–74 3.3% 4.1% 70–74 3.5% 4.1%
60–64 4.6% 4.9% 60–64 5.6% 5.8%
65–69 4.0% 4.4% 65–69 4.2% 4.6%
55–59 5.2% 5.3% 55–59 6.2% 6.3%
60–64 4.6% 4.9% 60–64 5.6% 5.8%
category
category
50–54 6.6% 6.4% 50–54 6.9% 6.8%
55–59 5.2% 5.3% 55–59 6.2% 6.3%
45–49
category
7.0% 6.8% 45–49 7.4% 7.1%
category
50–54 6.6% 6.4% 50–54 6.9% 6.8%
40–44 7.6% 7.2% 40–44 7.4% 7.0%
45–49 7.0% 6.8% 45–49 7.4% 7.1%
35–39 8.0% 7.5% 35–39 7.5% 6.9%
AgeAge
AgeAge
40–44 7.6% 7.2% 40–44 7.4% 7.0%
30–34 9.8% 7.3% 30–34 7.3% 6.7%
35–39 8.0% 7.5% 35–39 7.5% 6.9%
25–29 7.6% 7.0% 25–29 7.3% 6.6%
30–34 9.8% 7.3% 30–34 7.3% 6.7%
20–24 7.1% 6.6% 20–24 6.8% 6.3%
25–29 7.6% 7.0% 25–29 7.3% 6.6%
15–19 7.0% 6.5% 15–19 6.4% 6.0%
20–24 7.1% 6.6% 20–24 6.8% 6.3%
10–14 6.8% 6.3% 10–14 5.9% 5.5%
15–19 7.0% 6.5% 15–19 6.4% 6.0%
5–9 6.7% 6.1% 5–9 5.9% 5.5%
10–14 6.8% 6.3% 10–14 5.9% 5.5%
0–4 6.3% 5.8% 0–4 6.1% 5.7%
5–9 6.7% 6.1% 5–9 5.9% 5.5%
0–4 20% 15% 10%
6.3% 5% 0% 5% 5.8%
10% 15% 20% 20% 15%
0–4 10% 6.1%
5% 0% 5% 10%
5.7% 15% 20%
Proportion of total
20% 15% 10% 5%males
0% (%)
5%and10%
females
15% (%)
20% Proportion
20% 15% 10%of total
5% males
0% (%)
5% and
10%females (%)
15% 20%
Proportion of total males (%) and females (%) Proportion of total males (%) and females (%)
12 I | Why hypertension is a major public health issue | A global brief on hypertensionNot addressing hypertension in a timely fashion will have
significant economic and social impact.
Nearly 80% of deaths due to cardiovascular of ill health. Current age standardized mor-
disease occur in low- and middle-income tality rates of low-income countries are higher
countries. They are the countries that can least than those of developed countries (Fig. 6) (1,3).
afford the social and economic consequences
Figure 06
Equatorial Guinea mortality rates of
Oman cardiovascular
Saudi Arabia
diseases in
Slovakia
Estonia
high-income
Hungary and low-income
Trinidad and Tobago countries
Croatia (age standardized, 2008)
Poland
Czech Republic
Source :
Afghanistan
Kuwait
Kyrgyzstan Causes of death 2008,
United Arab Emirates
Somalia [Online Database]. Geneva,
Bahrain
Tajikistan World Health Organization.
Brunei Darussalam
Malawi
Bahamas
Guinea-Bissau Low-income countries
Greece
Zambia
San Marino High-income countries
Guinea
Barbados
Mozambique
Cyprus
Ethiopia
Germany
Central African Republic
Malta
Chad
Slovenia
Democratic Republic of the Congo
Finland
Uganda
United States of America
Burundi
Austria
Lao People's Democratic Republic
Luxembourg
Benin
Sweden
Burkina Faso
Portugal
Bangladesh
Qatar
Liberia
Ireland
United Republic of Tanzania
Denmark
Comoros
United Kingdom
Sierra Leone
New Zealand
Mauritania
Singapore
Ghana
Belgium
Rwanda
Norway
Gambia
Italy
Togo
Iceland
Cambodia
Republic of Korea
Myanmar
Switzerland
Haiti
Netherlands
Mali
Andorra
Eritrea
Canada
Madagascar
Australia
Niger
Spain
Nepal
Monaco
Solomon Islands
France
Kenya
Israel
Zimbabwe
Japan
Democratic People's Republic of Korea
0 100 200 300 400 500 600 700
Cardiovascular disease death rate, age standardized (per 100 000)
A global brief on hypertension | Why hypertension is a major public health issue | I
13Early detection and treatment of hyper Premature death, disability, personal and
tension and other risk factors, as well as pub- family disruption, loss of income, and health-
lic health policies that reduce exposure to care expenditure due to hypertension, take a
behavioural risk factors, have contributed to toll on families, communities and national
the gradual decline in mortality due to heart finances. In low- and middle-income coun-
disease and stroke in high-income countries tries many people do not seek treatment
over the last three decades. For example, in for hypertension because it is prohibitively
1972, comprehensive preventive interven- expensive. Households often then spend a
tions were initiated in a community project substantial share of their income on hospi-
in North Karelia, in Finland. At that time talization and care following complications
Finland had an extremely high mortality rate of hyper tension, including heart attack,
from heart disease. Within five years, many stroke and kidney failure. Families face cata-
positive changes were already observed in strophic health expenditure and spending on
the form of dietary changes, improved hyper health care, which is often long term in the
tension control, and smoking reduction. Ac- case of hypertension complications, pushing
cordingly a decision was made to expand the tens of millions of people into poverty (11).
interventions nationally. Now, some 35 years Moreover, the loss of family income from
later, the annual cardiovascular disease mor- death or disability can be devastating. In
tality rate among the working- age popu- certain low- and middle-income countries,
lation in Finland is 85% lower compared to current health expenditure on cardiovascu-
the rates in 1977. Observed reductions in pop- lar diseases alone accounts for 20% of total
ulation risk factors (serum cholesterol, blood health expenditure.
pressure and smoking) have been shown to
Over the period 2011-2025, the cumulative
explain most of the decline in cardiovascular
lost output in low- and middle-income coun-
mortality. Concurrent improvements in early
tries associated with noncommunicable dis-
detection and treatment of risk factors have
eases is projected to be US$ 7.28 trillion (Ta-
also contributed to the decline in cardiovas-
ble 1) (12). The annual loss of approximately
cular disease mortality.
US$ 500 billion due to major noncommuni-
cable diseases amounts to approximately 4%
of gross domestic product for low- and mid-
dle-income countries. Cardiovascular disease
including hyper tension accounts for nearly
half of the cost (Fig. 7) (13).
table 01 Economic burden of noncommunicable diseases, 2011-2025 (US$ trillion in 2008).
Country Cardiovascular Respiratory
Diabetes Cancer Total
income group diseases diseases
Upper middle 0.31 2.52 1.09 1.20 5.12
Lower middle 0.09 1.07 0.44 0.26 1.85
Low 0.02 0.17 0.06 0.05 0.31
Total of low and middle 0.42 3.76 1.59 1.51 7.28
14 I | Why hypertension is a major public health issue | A global brief on hypertensionThe increasing incidence of noncommunicable by the United Nations General Assembly in
diseases will lead to greater dependency and September 2011, acknowledges the rapidly
mounting costs of care for patients and their growing burden of noncommunicable dis-
families unless public health efforts to prevent eases and its devastating impact on health,
these conditions are intensified. The Political socioeconomic development and poverty al-
Declaration of the High-level Meeting of the leviation. The Political Declaration commits
General Assembly on the Prevention and Con- governments to a series of concrete actions (8).
trol of Non-communicable Diseases, adopted
Figure 07
Lost output
Lost
2011-2025,
output 2011-2025,
by disease
bytype
disease type Lost output
Lost
2011-2025,
output 2011-2025,
by income
bycategory
income category
THE COST of
noncommunicable
diseases for all
Respiratory
RespiratoryCancer Cancer low and middle-
Lower Lower
diseases diseases 21% 21%
middle-income
middle-income
income countries,
22% 22%
26% 26% by disease and
DiabetesDiabetes income level
6% 6%
Low-income
Low-income Upper Upper Source :
4% 4% middle-income
middle-income
Cardiovascular
Cardiovascular Based on the Global
70% 70%
diseases diseases Economic Burden of
51% 51% Non-communicable Diseases,
Prepared by the World
Economic Forum and the
Harvard School of Public
Health, 2011.
If no action is taken to tackle hypertension and other noncommunicable diseases, the economic
losses are projected to outstrip public spending on health (Fig. 8).
Losses from NCDs, 2011-2025
Projected public spending on health, 2011-2025 (assuring spending remains at 2009 level) Figure 08
8 comparing
losses from FOuR
7 noncommunicable
disease conditions
6 to public health
spending, 2011-2025
Trillions of 2008 US$
5 Source :
Based on the Global
4 Economic Burden of
Noncommunicable Diseases,
3 Prepared by the World
Economic Forum and the
Harvard School of Public
2
Health, 2011.
1 Losses from NCDs
2011-2025
0
Total, low and middle (84%) Low (12%) Lower middle (36%) Upper middle (36%) Projected public
spending on health,
(assuming spending
INCOME GROUP
Income (%(%
group ofof
world
worldpopulation)
population) remains at 2009 level)
A global brief on hypertension | Why hypertension is a major public health issue | I
15SECTION 2
Hypertension :
the basic facts
16 II | Hypertension : the basic facts | A global brief on hypertensionBlood is carried from the heart to all parts of the body in blood
vessels. Each time the heart beats, it pumps blood into the vessels.
Blood pressure is created by the force of blood pushing against the
walls of blood vessels (arteries) as it is pumped by the heart.
Hypertension, also known as high or raised blood pressure, is
a condition in which the blood vessels have persistently raised
pressure.
The higher the pressure in blood vessels the harder the heart has to
work in order to pump blood. If left uncontrolled, hypertension can
lead to a heart attack, an enlargement of the heart and eventually
heart failure. Blood vessels may develop bulges (aneurysms) and
weak spots due to high pressure, making them more likely to clog
and burst. The pressure in the blood vessels can also cause blood to
leak out into the brain. This can cause a stroke. Hypertension can
also lead to kidney failure, blindness, rupture of blood vessels and
cognitive impairment.
01 HOW
hypertension is defined
Blood pressure is measured in millimetres of However, the cardiovascular benefits of nor-
mercury (mm Hg) and is recorded as two num- mal blood pressure extend to lower systo
bers usually written one above the other. The lic (105 mm Hg) and lower diastolic blood
upper number is the systolic blood pressure - pressure levels (60 mm Hg). Hypertension is
the highest pressure in blood vessels and hap- defined as a systolic blood pressure equal to
pens when the heart contracts, or beats. The or above 140 mm Hg and/or diastolic blood
lower number is the diastolic blood pressure - pressure equal to or above 90 mm Hg. Nor-
the lowest pressure in blood vessels in between mal levels of both systolic and diastolic blood
heartbeats when the heart muscle relaxes. Nor- pressure are particularly important for the
mal adult blood pressure is defined as a systolic efficient function of vital organs such as the
blood pressure of 120 mm Hg and a diastolic heart, brain and kidneys and for overall health
blood pressure of 80 mm Hg. and wellbeing.
A global brief on hypertension | Hypertension : the basic facts | II
1702 CAUSES
of hypertension
Behavioural risk factors
There are many behavioural risk factors for the
development of hypertension (Fig. 9) including :
• consumption of food containing too much salt and fat, and not eating enough
fruit and vegetables
• harmful levels of alcohol use
• physical inactivity and lack of exercise
• poor stress management.
These behavioural risk factors are highly influenced by people’s working and
living conditions.
In addition, there are several metabolic factors that increase the risk of heart disease, stroke, kid-
ney failure and other complications of hypertension, including diabetes, high cholesterol and
being overwight or obese. Tobacco and hypertension interact to further raise the likelihood of
cardiovascular disease.
Figure 09
Main factors that
contribute to
the development
of high blood
pressure and its
complications Behavioural risk factors Cardiovascular disease
Globalization Unhealthy diet High blood pressure Heart attacks
Urbanization Tobacco use Obesity Strokes
Ageing Physical inactivity Diabetes Heart failure
Income Harmful use of alcohol Raised blood lipids
Education Kidney disease
Housing Metabolic risk factors
Social determinants
and drivers
18 II | Hypertension : the basic facts | A global brief on hypertensionSocioeconomic factors
Social determinants of health, e.g. income, Rapid unplanned urbanization also tends
education and housing, have an adverse to promote the development of hyper
impact on behavioural risk factors and tension as a result of unhealthy environ-
in this way influence the development of ments that encourage consumption of fast
hypertension. For example, unemployment food, sedentary behavior, tobacco use and
or fear of unemployment may have an im- the harmful use of alcohol. Finally, the risk
pact on stress levels that in turn influences of hypertension increases with age due to
high blood pressure. Living and working stiffening of blood vessels, although a geing
conditions can also delay timely detection of blood vessels can be slowed through
and treatment due to lack of access to dia healthy living, including healthy eating and
gnostics and treatment and may also im- reducing the salt intake in the diet.
pede prevention of complications.
Other factors
In some cases there is no known specific Occasionally, when blood pressure is mea-
cause for hypertension. Genetic factors may sured it may be higher than it usually
play a role, and when hypertension devel- is. For some people, the anxiety of visit-
ops in people below the age of 40 years it ing a doctor may temporarily raise their
is important to exclude a secondary cause blood pressure (“white coat syndrome”).
such as kidney disease, endocrine disease Measuring blood pressure at home instead,
and malformations of blood vessels. using a machine to measure blood pressure
several times a day or taking several mea-
Preeclampsia is hyper tension that oc-
surements at the doctor’s office, can reveal
curs in some women during pregnancy. It
if this is the case.
usually resolves after the birth but it can
sometimes linger, and women who experi-
ence preeclampsia are more likely to have
hypertension in later life.
A global brief on hypertension | Hypertension : the basic facts | II
1903 THE SYMPTOMS
of high blood pressure
Most hypertensive people have no symp- be dangerous to ignore such symptoms,
toms at all. There is a common misconcep- but neither can they be relied upon to sig-
tion that people with hypertension always nify hypertension. Hypertension is a seri-
experience symptoms, but the reality is ous warning sign that significant lifestyle
that most hypertensive people have no changes are required. The condition can be
symptoms at all. Sometimes hypertension a silent killer and it is important for every-
causes symptoms such as headache, short- body to know their blood pressure reading.
ness of breath, dizziness, chest pain, palpi-
tations of the heart and nose bleeds. It can
04 Hypertension
and life-threatening diseases
It is dangerous to ignore high blood pres- nation with other risk factors e.g., tobacco
sure, because this increases the chances of use, physical inactivity, unhealthy diet,
life-threatening complications. The higher obesity, diabetes, high cholesterol, low so-
the blood pressure, the higher the likeli- cioeconomic status and family history of
hood of harmful consequences to the heart hypertension (Fig. 9). Low socioeconomic
and blood vessels in major organs such as status and poor access to health services
the brain and kidneys. This is known as and medications also increase the vulner-
cardiovascular risk, and can also be high in ability of developing major cardiovascular
people with mild hypertension in combi- events due to uncontrolled hypertension.
20 II | Hypertension : the basic facts | A global brief on hypertension05 DIAGNOSING
hypertension
There are electronic, mercury and aneroid de- six months and users should be trained and as-
vices that are used to measure blood pressure sessed in measuring blood pressure using such
(14). WHO recommends the use of affordable devices.
and reliable electronic devices that have the
Blood pressure measurements need to be
option to select manual readings (14, 15).
recorded for several days before a diagnosis
Semi-automatic devices enable manual read-
of hypertension can be made. Blood pressure
ings to be taken when batteries run down,
is recorded twice daily, ideally in the morning
a not uncommon problem in resource-con-
and evening. Two consecutive measurements
strained settings. Given that mercury is toxic,
are taken, at least a minute apart and with the
it is recommended that mercury devices be
person seated. Measurements taken on the
phased out in favour of electronic devices (14).
first day are discarded and the average value
Aneroid devices such as sphygmomanometers
of all the remaining measurements is taken to
should be used only if they are calibrated every
confirm a diagnosis of hypertension.
Early detection, treatment and self-care of hypertension
has significant benefits
If hypertension is detected early it is possi- Self-monitoring of blood pressure is recom-
ble to minimize the risk of heart attack, heart mended for the management of hypertension
failure, stroke and kidney failure. All adults in patients where measurement devices are
should check their blood pressure and know affordable. As with other noncommunicable
their blood pressure levels. Digital blood pres- diseases, self-care can facilitate early detection
sure measurement machines enable this to be of hypertension, adherence to medication and
done outside clinic settings. If hyper tension healthy behaviours, better control and aware-
is detected people should seek the advice of a ness of the importance of seeking medical
health worker. For some people, lifestyle chang- advice when necessary. Self-care is important
es are not sufficient for controlling blood pres- for all, but it is particularly so for people who
sure and prescription medication is needed. have limited access to health services due to
geographic, physical or economic reasons.
Blood pressure drugs work in several ways,
such as removing excess salt and fluid from
the body, slowing the heartbeat or relaxing and
widening the blood vessels.
A global brief on hypertension | Hypertension : the basic facts | II
21SECTION 3
How public health
stakeholders
can tackle
hypertension
22 III | How public health stakeholders can tackle hypertension | A global brief on hypertensionThe prevention and control of hypertension requires
political will on the part of governments and policy-
makers. Health workers, the academic research community,
civil society, the private sector and families and individuals
all have a role to play. Only this concerted effort can
harness the testing technology and treatments available
to prevent and control hypertension and thereby delay or
prevent its life-threatening complications.
01 GOVERNMENTS
and policy-makers
Public health policy must address hyper services. Preventing complications of hyper
tension because it is a major cause of disease tension is a critical element of containing
burden. Interventions must be affordable, sus- health-care costs. All countries can do more
tainable and effective. As such, vertical pro- to improve health outcomes of patients with
grammes that focus solely on hypertension are hypertension by strengthening prevention,
not recommended. Programmes that address increasing coverage of health services, and by
total cardiovascular risk need to be an integral reducing the suffering associated with high
part of the national strategy for prevention and levels of out-of-pocket payment for health ser-
control of noncommunicable diseases. vices (16-18).
Health systems that have proven to be most Hyper tension can only be effectively
effective in improving health and equity or- addressed in the context of systems strength-
ganize their services around the principle ening across all components of the health
of universal health coverage. They promote system : governance, financing, information,
actions at the primary care level that target human resources, service delivery and access
the entire spectrum of social determinants of to inexpensive good quality generic medicines
health ; they balance prevention and health and basic technologies. Governments must
promotion with curative interventions ; and ensure that all people have equitable access
they emphasize the first level of care with ap- to the preventive, curative and rehabilitative
propriate coordination mechanisms. health services they need to prevent them de-
veloping hypertension and its complications.
Even in countries where health services are
(17, 18).
accessible and affordable, governments are
finding it increasingly difficult to respond to
the ever-growing health needs of their pop-
ulations and the increasing costs of health
A global brief on hypertension | How public health stakeholders can tackle hypertension | III
23There are six important components of any country
initiative to address hypertension
1 |an integrated primary care programme 4|reduction of risk factors in the population
2|the cost of implementing the programme 5|workplace-based wellness programmes
3|basic diagnostics and medicines 6|monitoring of progress.
1 | The features of an integrated primary care programme
Integrated programmes must be established WHO tools such as the WHO/Internation-
at the primary care level for control of hyper al Society of Hyper tension (ISH) risk pre-
tension. In most countries this is the weakest diction charts (Fig. 10) (18) are designed to
level of the health system. Very effective treat- aid risk assessment. WHO/ISH charts are
ment is available to control hypertension to available for all World Health Organization
prevent complications. Treatment should be subregions. Evidence-based guidance is also
targeted particularly at people at m edium or available on management of patients with
high risk of developing heart attack, stroke or hypertension through integrated programmes
kidney damage. For this to happen, patients even in resource-constrained settings (19-22).
presenting with hypertension should have a WHO tools also provide evidence-based guid-
cardiovascular risk assessment, including tests ance on the appropriate use of medicines, so that
for diabetes mellitus and other risk factors. unnecessary costs related to drug therapy can be
Hypertension and diabetes are closely linked, avoided to ensure sustainability of programmes.
and one cannot be properly managed without At least 30 low- and middle-income countries are
attention to the other. The objective of an inte- now using these tools to address hypertension in
grated programme is to reduce total cardiovas- an affordable and sustainable manner.
cular risk to prevent heart attack, stroke, kid-
Although cost-effective interventions are
ney failure and other complications of diabetes
available for addressing hypertension, there
and hypertension. Adopting this comprehen-
are major gaps in application, particularly
sive approach ensures that drug treatment is
in resource-constrained settings. It is essential
provided to those at medium and high risk. It
to quickly identify ways to address these gaps
also prevents unnecessary drug treatment of
including through operational research ; the
people with borderline hypertension and low
enormous benefits of blood pressure control
cardiovascular risk. Inappropriate drug treat-
for public health make a compelling case for
ment exposes people to unwarranted harmful
action. (23).
effects and increases the cost of health care ;
both need to be avoided. Further, there are
inexpensive, very effective medicines avail-
able for control of hypertension which have a
very good safety margin. They should be used
whenever possible. WHO protocols are avail-
able to provide the required guidance.
24 III | How public health stakeholders can tackle hypertension | A global brief on hypertensionFigure 10
world health organization and international
Source :
society of hypertension risk prediction chart
10-year risk of a fatal or non-fatal cardiovascular event by gender, age, smoking
Prevention of cardiovascular disease :
status, systolic blood pressure, blood cholesterol, and presence or absence Guidelines for assessment and management
of diabetes. Different charts are available for all World Health Organization of cardiovascular risk.
subregions. Geneva, World Health Organization, 2012
Risk Level2 | The cost of implementing an integrated primary care
programme
The cumulative cost of implementing an in- iagnostics and medicines. The cumulative cost
d
tegrated primary care programme to prevent of scaling up very cost-effective interventions
heart attack, stroke and kidney failure, using that address cardiovascular disease and cervical
blood pressure as an entry point, is shown in cancer in all low- and middle-income countries
Fig. 11. Estimated costs cover primary care is estimated to be US$ 9.4 billion a year (21).
outpatient visits for consultation, counselling,
Figure 11
TOTal estimated
cost of scaling
up individual-
based best buy
intervention for
noncommunicable 14
diseases
in all low- and 12
middle-income
countries
10
Source :
Scaling up action against 8
Cost (US$ billion)
noncommunicable diseases :
how much will it cost ? 6
Geneva, World Health
Organization, 2011
4
Noncommunicable disease 2
programme managment
Prevention of cervical cancer 0
via screening and lesion removal
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025
Aspirin for people
with an acute heart attack
Multi-drug therapy
for individuals
> 30% Cardiovascular disease risk
Screening for cardiovascular
disease risk (persons > 40 years)
A WHO costing tool to estimate the cost of establishing such a
programme in any country (21) takes into account :
• the need to gradually increase coverage of the whole • the availability and appropriate use of essential medi-
population in an affordable manner to advance the uni- cines to prevent complications in people with moderate
versal health coverage agenda ; to high cardiovascular risk ;
• availability of basic technologies to manage people • the links between different levels of the health system
with hypertension ; so that people can be managed appropriately based on
their level of risk.
26 III | How public health stakeholders can tackle hypertension | A global brief on hypertension3 | Basic diagnostics and medicines
The basic diagnostic technologies required The cost of implementing such a programme is
for addressing hyper tension include accu- low, at less than US$ 1 per head in low-income
rate blood pressure measurement devices, countries, less than US$ 1.50 per head in lower
weighing scales, urine albumin strips, fasting middle-income countries and US$ 2.50 in up-
blood sugar tests and blood cholesterol tests. per middle-income countries. Expressed as a
proportion of current health spending, the cost
Not all patients diagnosed with hypertension
of implementing such a package amounts to
require medication, but those at medium to
4% in low-income countries, 2% in lower mid-
high risk will need one or more of eight essen-
dle-income countries and less than 1% in up-
tial medicines to lower their cardiovascular risk
per middle-income countries (22).
(a thiazide diuretic, an angiotensin converting
enzyme inhibitor, a long-acting calcium chan-
nel blocker, a beta blocker, metformin, insulin,
a statin and aspirin).
4 | Reduction of risk factors in the population
The likelihood of cardiovascular disease in- volve general changes in behaviour. In the pop-
creases continuously as the level of a risk fac- ulation-based approach, interventions target
tor such as blood pressure increases, without the
population, community, worksites and
any natural threshold limit. Most cardiovascu- schools, aiming at modifying social and envi-
lar disease in the population occurs in people ronmental determinants.
with an average risk level, because they consti-
Therefore, in addition to strengthening health
tute the largest proportion of the population.
systems, a cost-effective programme must in-
Although a very high risk factor level increases
clude population-wide approaches to shift the
the chances of developing cardiovascular dis-
blood pressure distribution of the whole pop-
ease in an individual, the number of cases from
ulation to a healthy pattern. Population-wide
this risk group is relatively low because of the
approaches to reduce high blood pressure are
relatively low proportion of people in this
similar to those that address other major non-
population segment. The population-based
communicable diseases. They require public
approach is thus based on the observation that
policies to reduce the exposure of the whole
effective reduction of cardiovascular disease
population to risk factors such as an unhealthy
rates in the population usually calls for com-
diet, physical inactivity, harmful use of alcohol
munity-wide changes in unhealthy behav-
and tobacco use (24-27) with a special focus on
iors or reduction in mean risk factor levels.
children, adolescents and youth.
Hence, these interventions predominantly in-
table 02 The following evidence-based policy interventions are very cost effective
• Excise tax increases
• Smoke-free indoor workplaces and public places
Tobacco use • Health information and warnings about tobacco
• Bans on advertising and promotion
• Excise tax increases on alcoholic beverages
Harmful
• Comprehensive restrictions and bans on alcohol marketing
alcohol use • Restrictions on the availability of retailed alcohol
Unhealthy • Salt reduction through mass-media campaigns and reduced salt con-
diet and tent in processed foods
physical • Replacement of trans-fats with polyunsaturated fats
inactivity • Public awareness programme about diet and physical activity
A global brief on hypertension | How public health stakeholders can tackle hypertension | III
27SALT reduction
Dietary salt intake is a contributing factor for hypertension.
In most countries average per-person salt Reducing population salt intake requires
intake is too high and is between 9 grams (g) action at all levels, including the government,
and 12 g/day (28). Scientific studies have the food industry, nongovernmental organi-
consistently demonstrated that a modest re- zations, health professionals and the pub-
duction in salt intake lowers blood pressure lic. A modest reduction in salt intake can be
in people with hypertension and people with achieved by voluntary reduction or by regu-
normal blood pressure, in all age groups, and lating the salt content of prepackaged foods
in all ethnic groups, although there are vari- and condiments. The food industry can make
ations in the magnitude of reduction. Several a major contribution to population health if
studies have shown that a reduction in salt a gradual and sustained decrease is achieved
intake is one of the most cost-effective inter- in the amount of salt that is added to pre-
ventions to reduce heart disease and stroke packaged foods. In addition, sustained mass-
worldwide at the population level. media campaigns are required to encourage
reduction in salt consumption in households
WHO recommends that adults should con-
and communities.
sume less than 2000 milligrams of sodium, or
5 g of salt per day (27, 29). Sodium content is Several countries have successfully carried
high in processed foods, such as bread (ap- out salt reduction programmes as a result
proximately 250 mg/100 g), processed meats of which salt intake has fallen. For example,
like bacon (approximately 1500 mg/100 g), Finland initiated a systematic approach to
snack foods such as pretzels, cheese puffs and reduce salt intake in the late 1970s through
popcorn (approximately 1500 mg/100 g), as mass-media campaigns, cooperation with the
well as in condiments such as soy sauce (ap- food industry, and implementation of salt la-
proximately 7000 mg/100 g), and bouillon or beling legislation. The reduction in salt intake
stock cubes (approximately 20 000 mg/100 g). was accompanied by a decline in both systolic
and diastolic blood pressure of 10 mm Hg or
Potassium-rich food helps to reduce blood
more. A reduction in salt intake contributed to
pressure (30). WHO recommends that adults
the reduction of mortality from heart disease
should consume at least 3,510 mg of potassium
and stroke in Finland during this period. The
/day. Potassium-rich foods include : beans and
United Kingdom of Great Britain and North-
peas (approximately 1,300 mg of potassium
ern Ireland, the United States of America and
per 100 g), nuts (approximately 600 mg/100 g),
several other high-income countries have also
vegetables such as spinach, cabbage and par
successfully developed programmes of volun-
sley (approximately 550 mg/100 g) and fruit
tary salt reduction in collaboration with the
such as bananas, papayas and dates (approxi-
food industry. More recently, several develop-
mately 300 mg/100 g). Processing reduces the
ing countries have also launched national salt
amount of potassium in many food products.
reduction initiatives.
28 III | How public health stakeholders can tackle hypertension | A global brief on hypertension5 | Workplace wellness programmes
and high blood pressure control
WHO considers workplace health pro- sures, including, where appropriate, through
grammes to be one of the most cost-effective good corporate practices, workplace wellness
ways to prevent and control noncommunica- programmes and health insurance plans.”
ble diseases including hypertension (31).
Workplace wellness programmes should focus
The United Nations high-level meeting on on promoting worker health through the re-
noncommunicable disease prevention and duction of individual risk-related behaviours,
control in 2011 called on the private sector to e.g. tobacco use, unhealthy diet, harmful use
“promote and create an enabling environment of alcohol, physical inactivity and other health
for healthy behaviours among workers, includ- risk behaviours. They have the potential to
ing by establishing tobacco-free workplaces, reach a significant proportion of employed
and safe and healthy working environments adults for early detection of hypertension and
through occupational safety and health mea- other illnesses.
6 | Monitoring of progress
Please see section 4 : Monitoring the impact of action to tackle hypertension (p.34).
02 Health
workers
Skilled and trained health workers at all physician health workers can play a very im-
levels of care are essential for the success of portant role in detection and management of
hypertension control programmes. Health hypertension. WHO has developed guidelines
workers can raise the awareness of hyper and several tools to assist health workers in
tension in different population groups. managing hypertension cost effectively in pri-
Activities can range from blood pressure mary care. More information on how health
measurement campaigns to health education workers should manage people with high
programmes in the workplace to information blood pressure is available online, including
dialogue with policy makers on how living how to measure blood pressure, which blood
conditions and unhealthy behavior influence pressure devices to use, how to counsel on life-
blood pressure levels. style change and when to prescribe medicines
(14-16, 19-21).
Training of health workers should be institu-
tionalized within medical, nursing and allied http ://www.who.int/nmh/publications/phc2012/en/index.html)
health worker curricula. The majority of cas-
es of hypertension can be managed effective-
ly at the primary health care level. Primary
health-care physicians as well as trained non-
A global brief on hypertension | How public health stakeholders can tackle hypertension | III
2903 CIVIL
society
Civil society institutions, in particular non- Civil society action is particularly important
governmental organizations (NGOs), aca- in addressing the common risk factors of to-
demia and professional associations, have bacco use, unhealthy diet, physical inactivity
a major part to play in addressing hyper and the harmful use of alcohol where complex
tension and in the overall prevention and commercial, trade, political and social factors
control of noncommunicable diseases at both are at play. Partnerships between NGOs and
country and global levels. academia can bring together the expertise and
resources needed to build both workforce ca-
Civil society institutions have several roles
pacity and the skills of individuals, families
that they are uniquely placed to fulfil. They
and communities. The International Society of
help strengthen capacity to address prevention
Hyper tension, World Hyper tension League,
of noncommunicable diseases at the national
World Heart Federation and the World Stroke
level. They are well-placed to garner political
Association have a long history of collabora-
support and mobilize society for wide support
tion with WHO and working specifically in
of activities to address hypertension and other
the area of hypertension and cardiovascular
noncommunicable diseases. In some countries,
disease (32-35).
civil society institutions are significant provid-
ers of prevention and health-care services and
often fill gaps in services and training provid-
ed to the public and private sectors.
04 PRIVATE
sector
The private sector - excluding the tobacco in- the collaboration of the private sector to put in
dustry - can make a significant contribution place the means necessary to reduce the impact
to hypertension control in several ways. of cross-border marketing of foods high in satu-
rated fats, trans-fatty acids, sugar, or salt.
In addition to contributing to worksite well-
ness programmes, it can actively participate in In addition, the private sector has potential to
the implementation of the set of recommenda- contribute to prevention and control of hyper
tions on the marketing of foods and non-alcohol- tension and other noncommunicable diseases
ic beverages to children which was endorsed through the development of cutting-edge health
by the Sixty-third World Health Assembly technologies and applications, and manufactur-
in May 2010 (36). Evidence shows that expo- ing affordable health commodities.
sure to advertising influences children’s food
Other ways in which the private sector can con-
preferences, purchase requests and consump-
tribute to prevention and control of hypertension
tion patterns. Advertising and other forms of
are outlined in the draft Global Noncommunica-
food marketing to children are widespread
ble Diseases Action Plan 2013-2020 (9).
across the world. Most of this marketing is for
foods with a high content of salt, fat and sugar.
At country level the recommendations require
30 III | How public health stakeholders can tackle hypertension | A global brief on hypertension05 FAMILIES
and individuals
While some people develop hypertension as they get older, this is
not a sign of healthy ageing. All adults should know their blood
pressure level and should also find out if a close relative had or
has hypertension as this could place them at increased risk.
The odds of developing high blood pres- Individuals who already have hyper
sure and its adverse consequences can be tension can actively participate in manag-
minimized by : ing their condition by :
| Healthy diet • adopting the healthy behaviours listed
above
• promoting a healthy lifestyle with
emphasis on proper nutrition for infants • monitoring blood pressure at home if
and young people feasible
• reducing salt intake to less than 5 g of • checking blood sugar, blood cholesterol
salt per day and urine albumin
• eating five servings of fruit and • knowing how to assess cardiovascular
vegetables a day risk using a risk assessment tool
• reducing saturated and total fat intake. • following medical advice
| Alcohol • regularly taking any prescribed
medications for lowering blood
• avoiding harmful use of alcohol.
pressure.
| Physical activity
• regular physical activity, and promotion
of physical activity for children and
young people. WHO recommends
physical activity for at least 30 minutes a
day five times a week.
• maintaining a normal body weight.
| Tobacco
• stopping tobacco use and exposure to
tobacco products
| Stress
• proper management of stress
A global brief on hypertension | How public health stakeholders can tackle hypertension | III
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