Hypertension techniques

prevalence

in

Asia

and

preventive

medicine

Name:- Omar Sheriff For: - Nadher Ghobi Subject: - Disease Control and Prevention

1.0 Introduction

The first studies related to Hypertension were found inn Bhagwatti (5000 BC), the foods which are bitter, acid, salted and burnt give rise to pain where students were taught in China where furthermore Confucius proposed and propagated an dietary guideline. In Sushrit Samhita (600 BC) BPhas been described Raktachapa, Thus high BPas a clinical problem which was known to the ancient physicians. Then in the 1913 Janeway, found high BPkill people prematurely, while Weises and Ellis in 1930 conducted studies in England where he found people in mid ages have the problem more profoundly. These studies created the pathway for more studies in the future (Sing et.al, 2000) Global Hypertension is alarming, as per the World Health Organisation (WHO) found raised BPis estimated to cause 7.5 million deaths, about 12.8% of the total of all deaths. This accounts for 57 million disability adjusted life years (DALYS) or 3.7% of total DALYS. Raised BPis a major risk factor for coronary heart disease and ischemic as well as hemorrhagic stroke. BPlevels have been shown to be positively and continuously related to the risk for stroke and coronary heart disease. In some age groups, the risk of cardiovascular disease doubles for each increment of 20/10 mmHg of blood pressure, starting as low as 115/75 mmHg. In addition to coronary heart diseases and stroke, complications of raised BPinclude heart failure, peripheral vascular disease, renal impairment, retinal hemorrhage and visual impairment (WHO, 2011). High BPis defined as 140 MM Hg or greater, or an average diastolic BPof 90 mm Hg or greater, when BPis measured twice on each of the three occasions in a person who is not accurately ill and not taking anti Hypertensive medicine (Jekel. Et.al , 2007: Rezvi Sheriff, 2012) Globally, the overall prevalence of raised BP in adults aged 25 and over was around 40% in 2008. The proportion of the worlds population with high blood pressure, or uncontrolled hypertension, fell modestly between 1980 and 2008. However, because of population growth and ageing, the number of people with uncontrolled hypertension rose from 600 million in 1980 to nearly 1 billion in 2008 (WHO, 2011) Initially the article will consider the types of hypertension mainly based on the book Epidemiology, biostatistics and preventive medicine done by Jekel et.al in 2007, then the essay will look at prevalence of hypertension in Asia by summarising key points in the article by sing et.al 2000 on the Hypertension and stroke in Asia: prevalence, control and strategies in developing countries for prevention. Then the essay will move its attention methods of preventive medicine will be discussed both using Jekkel et.al explanations as well as the article from Lindholm et.al Total cardiovascular risk approach to improve efficiency of cardiovascular prevention in resource constrain settings. Since the course instructor requested information on my country Sri Lanka as well to be added, it was initially difficult to find information as most studies corresponded to trials or tests conducted were done in 1988, however Rezvi Sheriff who is the authors father has provided some information he shared at presentation for the Post Graduate Institute of Medicine (PGIM) and will be shared as requested. Finally the Article will be concluded.

2.0 Types of Hypertension As per Jekel et.al show in table 1 below, as BP increases above 120 which is at normal levels and reaches the range between 120-139 Mm Hg with a diastolic BP80-89 shows pre-hypertension and in cases such as this lifestyle changes are proposed, when BP reaches a range of 140-159 MM Hg with diastolic blood pressure, then it is known as stage 1 hypertension, in this case patients are asked to take drugs mainly thiazides for most patients. Patients who reach 160 MM Hg and above are serious and should begin diet and lifestyle changes and be treated with anti-hypertensive medication (Jekkel et.al, 2007) Drug Interpretation treatment normal blood <120 <80 pressure No in some 120-139 80-89 prehypertension cases stage 1140-159 90-99 Hypertension Yes Stage 2 >=160 >=100 Hypertension Yes Table 1: Evaluation of BPand staging of Hypertension, based on average systolic and diastolic blood pressures in persons who are not accurately ill and are not taking antihypertensive medications (Jekkel et.al, 2007) Hypertension is further classified as either essential hypertension, where the cause is unknown due to sensitivity to salt or changes renninangiotestin causes such while the other is non-essential hypertension are treatable causes, such as adrenal medulla or tumours (Jekkel et.al, 2007) 3.0 Hypertension in Asia 3.1 Trends Almost two thirds of the total world population (6 billion) live in Asia, mostly in India and China. There are rapid changes in diet and lifestyle in most Asian countries due to economic development & social transitions in the last 23 decades. With these changes have come the problems of dietrelated chronic diseases which typically occur in middle and later adult life, and counteract the gains in life expectancy attributable to a better food supply. Here are the trends in Asia as per that point: Systolic Hg) BP(MM Diastolic pressure Blood

The mortality rate for stroke had been on the decline since the mid 1960s in the developed countries of Asia, such as Australia, New Zealand, and Japan, with some improvement in Singapore, Taiwan and Hong Kong, some areas of China and Malaysia about 15 years

(sing

India, China, Phillippines, Thailand, Sri Lanka, Iran, Pakistan, Nepal, there has been a rapid increase in stroke mortality and prevalence of hypertension. The prevalence of hypertension according to new criteria (.140/90 mm Hg) varies between 1535% in urban adult populations of Asia. In rural populations, the prevalence is two to three times lower than in urban subjects. Hypertension and stroke occur at a relatively younger age in Asians and the risk of hypertension increases at lower levels of body mass index of 2325 kg/m2. Overweight, sedentary behaviour, alcohol, higher social class, salt intake, diabetes mellitus and smoking are risk factors for hypertension in most of the countries of Asia. In Australia, New Zealand and Japan, lower social class is a risk factor for hypertension and stroke. et.al 2000)

3.2 Prevalence in Asia The prevalence of hypertension in countries of Asia was as low as 2% in rural areas to 24% in urban areas. According to new criteria of the WHOISH subcommittee (.140/90 mm Hg), the prevalence appears to be 535% in different countries of Asia (figure 1 and 2).

Figure 1: Population studies on prevalence of hypertention (Sing et.al 2000)

Figure 2: Comparable studies on Urban population (Sing et.al 2000)

Figure 3: comparable studies of rural populations (Sing et.al 2000) Most Studies published from 1958 which used WHO criteria for diagnosis of hypertension have shown a steadily increasing trend in the prevalence of hypertension (figures 1-3). Studies from the cities of Ludhiana, Bombay, Jaipur and Moradabad showed a prevalence of more than 10%. Statistical analysis of this trend in comparable surveys showed a significant increase demonstrated by non-parametric analysis (MantelHaenzel x2 +/- 6.11 P , alpha 0.01). The prevalence of Hypertension by WHO/ISH criteria also showed a steep increase from 6.2% in 1959 to 25.6% in 1998 (figure 2). According to old WHO guidelines, the prevalence of hypertension in rural

populations also showed an increase (Table 6). Shah in Mumbai reported a prevalence of 0.52 and +/- 0.1% and Gupta in Haryana reported a prevalence of 3.6 +/- 0.4%. However, in north India, recent studies have reported a high prevalence of 7.08 +/- 0.5% in Rajasthan and 4.3 +/- 0.4% in Uttar Pradesh.18 In south India, Kerala 67 the prevalence was as high as 17.8 +/- 1.1% in a suburban village. It seems that there is a significant increase in the prevalence of hypertension in the last few decades in India (MantelHaenzel x2 +/- 5.93, P , alpha 0.01). There was also a substantial increase in mean blood pressures from the 1960s to 1998 (figure 4) (sing et.al 2000) .

Figure 4: Mens blood pressure between 40-49 years (sing et.al 2000)

Since hypertension is the major cause of CAD and stroke, it is clear that one of the biggest challenges facing public health authorities and medical practioners is the control of hypertension, both in individual patients and at the population level. It affects 50 million people. Americans contribute to more (sing et.al 2000) 3.1.1 Sri Lanka Since the instructor requested the author to conduct some studies in relation to my home country in Sri Lanka was briefly discussed. However only few studies have been conducted in relation to this topic as the best study done was in 1988, therefore presentations done by the authors father who is Dean of the Postgraduate Institute of medicine have been taken in to consideration. Here are some key insights from that presentation: As per Sri Lanka Health Association Hypertension is classified as shown below in figure 5

Figure 5 : SLMA guidelines (Rezvi Sheriff 2012) 90% of whose BP was normal (<140/90) at 55 years ultimately developed hypertension in their life time.

Risk of CVS disease in Sri Lanka increased progressively from 115/75 with doubling of the incidence of both coronary heart disease and stroke for every 20mmHg systolic / 10mmHg diastolic increment of blood pressure Hypertension is the commonest risk factor for the commonest death in adults. In 1990 5.8% In 2000 7.2% increasing worldwide By 2020 Hypertension will be the most common risk factor for death and disability globally National Prevalence Survey o o o WB / MOH 2000 studied WP/NCP/SP/Uva Age Group 30 65 Years. Height , Weight, Waist, BP Wijewardene, Mohideen et al 2005 in 4 provinces on 6047 individuals o Showed a prevalence of Males 19.4% Females 20.6%

(Rezvi Sheriff, 2012)

Figure 6: Mortality major risk factors in Sri Lanka (Rezvi Sheriff, 2012) o Figure 6 depicts the major risk factors in mortality from hypertension it was shown that high blood pressure, smoking, high collestral were the top 3 contributors to mortality

Figure 7: forecasted increases in diabeties, hypertension and IHD (Rezvi Sheriff 2012)

o Figure 7 shows the projected increase in Hypertension forecasted,

while this has been projected based on figure 8 which shows the prevailence of Hypertension in males and females and it was found males had more prevailence.

Figure 8: trends in mortality due males/females (rezvi sheriff 2012)

to

Cerebrovascular

disease

in

3.2 The non-communicable element- nutritional and endemic factors After reviewing descriptive epidemiological studies from many developed and developing countries, concluded that there is usually a sequence in the emergence of chronic diseases as the diet of the developing country becomes more westernised (Figure 1). Overweight, central obesity and hyperinsulinemia come first, then appendicitis, diabetes and hypertension tend to occur early, followed after several decades by coronary heart disease, insulin resistance syndrome and gall stones, then cancer of the large bowel and finally various chronic disorders of the gastrointestinal tract and bone and joint diseases and renal diseases. Such changes have occurred more obviously in countries or population where cultural change has occurred (sing et.al 2000). Furthermore he goes on to state The dietary staple in southern China, southern India and in most Asian countries has been rice for many centuries. In north India and north China, Pakistan, Afganistan, Iran, Nepal, the main staple is wheat or corn. Traditionally fat and sugar consumption have been low and animal protein consumption especially low (sing et.al 2000). The salt consumption in China and Japan was 1020 g/day and in India it varied between 520 g/day. However the diet is rapidly changing in the cities to resemble that of the more affluent countries, which has been associated with marked increase in overweight, hypertension, diabetes and CAD. Such trends have been reported in most of the countries of Asia. The global availability of inexpensive vegetable fat has resulted in greatly increased fat consumption among low income countries such as India, China, Thailand, Philippines as well as in newly industrialised countries such as Taiwan, Hong Kong, Singapore, Korea etc(sing et.al 2000). The transition has occurred at lower levels of gross national product than previously and is further accelerated by rapid urbanisation and industrialisation. In China, the proportion of upper income persons who were consuming a relatively high fat diet (.30% en/day) rose from 22.8% to 66.6% between 1989 and 1993(sing et.al 2000).

The lower and middle income classes also showed a rise from 19% to 36.4% in the former and 19.1% to 51.0% in the latter. In India, in a recent study, the intake of fruits and vegetables showed no significant difference in higher and lower social classes but the consumption of visible fat was three-fold greater in social classes 1 and 2 than social classes 35 . Higher social classes also have higher risk of CVD. In Japan, there is a three-fold increase in dietary fat from 1955 when Japanese were supposed to have undernutrition. Undernutrition was fully controlled by 1965 in Japan without any increase in CAD, although dietary fat intake (14.8%) was doubled from 1955 (sing et.al, 2000) To prove this further as per the world Development Report of there has been a marked increase salt, fat, Tobacco and sedentary behaviour has been on the increase in this region (One world, 2000). 4.0 Prevention and cure of Hypertension in Asia As per Jekell et.al 2007, Hypertension is further classified as either essential hypertension, where the cause is unknown due to sensitivity to salt or changes rennin-angiotestin causes such while the other is nonessential hypertension are treatable causes, such as adrenal medulla or tumours (Jekkel et.al, 2007). Preventive medicine can take the form life style modification required for mainly patients in the Pre-hypertension up to stage 2 hypertension which includes anti-hypertensive drugs plus the following modifications: 1. Weight reduction 2. increased physical activity 3. institution of a healthy diet (increase in potassium, calcium and magnesium) 4. reduced alcohol intake 5. Reduced smoking (Jekkel et.al 2007) However the problem has As per Sing et.al Asia has been the education of the disease was poor, as per his study it was found that Awareness of hypertension among hypertensives has not been studied in the majority of the studies. Only 46 (11%) of men and 44 (16%) of women hypertensive were aware of their condition in a study by Gupta et al from Rajasthan, India. The Five City Study showed that the awareness was significantly less at Moradabad and Nagpur compared to Calcutta (12% and 14% vs 22%, P , 0.05) where it was comparable with Bombay (24%) and Trivandrum (26%).In another study among 7630 employees in a town, the prevalence of hypertension was 33.2% of 2535 hypertensives, only 559 (22.0%) were aware of their hypertension. The aware hypertensives were predominantly symptomatic, overweight and had higher age and BP than the unaware hypertensives. In Pakistan 70% of the hypertensives were not aware of their hypertension (sing et.al 2000) Hypertension in Asian countries in relatively younger populations appears to be due to interaction of genes and environment and to nutritional inadequacies in early age. Therefore, the dynamics of the prevention effort may vary compared to those witnessed in the developed countries. Programmes for CVD prevention in developed countries started when the epidemic of CVD was close to its peak and the community had become

aware and alarmed by its impact. Counselling for lifestyle modification to decrease the risk of disease is more readily accepted by such populations. However, developing Asian countries suffer from the double burden of pretransitional and post-transitional diseases and community awareness of the dangers of CVD is not high.The transition towards becoming an industrial market is unleashing consumer aspirations that impatiently seek an affluent and indulgent lifestyle. There are new five star hospitals developing in every developing country of Asia with no clinical epidemiology department or health promotion department (sing et.al 2000) As per Jekkel et.al for type 1 and 2 hypertension in controlled via the use of drugs and anti-hypertensive medicines. He further states that medicine has found diuretics, beta blockers, angiotensin converting enzyme (ACE) inhibitors, angiotestin blockers, calcium channel blockers, alpha blockers can be used with the help of a suitable treatment plan can also be customized as per the condition of the patient. In clinical trials, Thiazide dueretics and beta blockers have been shown to reducing CVD as blood pressure, so there is an argument for starting treatment of hypertension with the use of Thiazide Diuretics are good for the young but bad with the senior population. Beta blockers are good for patients with conduction abnormalities and caution has to be put forth in chronic obstructive pulmonary disease but is mainly used for patients with myocardial infarction or angina pectoris (with no condition of abnormalities). While ACE inhibitators were found to be useful with myocardial infarction and stroke can reduce overall mortality in high risk CVD patients (Jekkel et.al 2000)

,
figure 10: Various images for beta blockers, ACE inhibitors, Calcium blockers and Alpha blockers It has to be remembered that most countries in Asia are resource constrained even in the more affluent countries such as China and India, there are severe shortages of basic medical facilities let alone sophisticated expensive equipment for prevention of CVD. Therefore shanty et.al conducts a study where Using World Health Organization (WHO) and the International Society of Hypertension risk prediction charts, cardiovascular risk was categorized in a cross-sectional study of 8,625 randomly selected people aged 40 to 80 years (mean age, 54.6 years) from defined geographic regions of Nigeria, Iran, China, Pakistan, Georgia, Nepal, Cuba, and Sri Lanka. Cost estimates for drug therapy were calculated for three countries. She finds that a large fraction (90.0 -98.9%) of the study population has a 10-year cardiovascular risk <20%. Only 0.24.8% are in the high-risk categories (_30%). Adopting a total risk approach and WHO guidelines recommendations would restrict unnecessary drug treatment and reduce the drug costs significantly. Adopting a total cardiovascular risk approach instead of a single risk factor approach reduces health care expenditure by reducing drug costs. Therefore, limited resources can be more efficiently used to target high-risk people who will benefit the most. This strategy needs to be complemented with population-wide measures to shift the cardiovascular risk distribution of the whole population (Shanti et.al 2000)

figure 11: Proposed matrix chart to measure heart disease by WHO (Shanti et.al 2011) 5.0Conclusion The articles clearly show that Hypertension is slowly but surely increasing the global scale and especially Asia, the changing demographics coupled with economic and social transformation is allowing the disease to deepen in to global society. Therefore the article provides useful insights on how to administer or prevent such disease taking in to consideration the economic dynamic affecting society.

6.0 References Jekkel,FJ.Katz, Elmore, G.J and Wild M.G.D, (2007), Epidemiology, Biostatistics and preventive medicine, Saunders Elsevier, USA WHO, 2011, Raised blood pressure, http://www.who.int/gho/ncd/risk_factors/blood_pressure_prevalence_text/e n/index.html accessed 22/11/2012

Singh, R B; Suh, I L; Singh, V P; Chaithiraphan, S; Laothavorn, P; et al., Hypertension and stroke in Asia: prevalence, control and strategies in developing countries for prevention Journal of Human Hypertension 14. 10/11 (Oct 2000): 749-63.

Mendis, Shanthi; Lindholm, Lars H. ; Anderson, Simon G.; Alwan, Ala; Koju, Rajendra; et al, Total cardiovascular risk approach to improve efficiency of cardiovascular prevention in resource constrain settings, Journal of Clinical Epidemiology 64. 12 (Dec 2011): 1451-1462. One world, 2000, World Development report 2000/2001, One world publishing, UK Sheriff, R., Hypertension, Power point slides, Post graduate Institute of Medicine Sri Lanka,