Abstract
Purpose of Review
Outline recent epidemiologic data regarding hypertension in developing countries, distinguish differences from developed countries, and identify challenges in management and future perspectives.
Recent Findings
Increased sugar intake, air and noise pollution, and low birth weight are emerging hypertension risk factors. The major challenges in management are difficulties in accurate diagnosis of hypertension and adequate blood pressure control.
Summary
In contrast to developed countries, hypertension prevalence rates are on the rise in developing countries with no improvement in awareness or control rates. The increasing burden of hypertension is largely attributable to behavioral factors, urbanization, unhealthy diet, obesity, social stress, and inactivity. Health authorities, medical societies, and drug industry can collaborate to improve hypertension control through education programs, public awareness campaigns, legislation to limit salt intake, encourage generic drugs, development and dissemination of national guidelines, and involving nurses and pharmacists in hypertension management. More epidemiologic data are needed in the future to identify reasons behind increased prevalence and poor blood pressure control and examine trends in prevalence, awareness, treatment, and control. National programs for better hypertension control based on local culture, economic characteristics, and available resources in the population are needed. The role of new tools for hypertension management should be tested in developing world.
Similar content being viewed by others
Explore related subjects
Discover the latest articles, news and stories from top researchers in related subjects.Avoid common mistakes on your manuscript.
Introduction
While trends in hypertension prevalence are on the decline in Western industrial countries with improvement in awareness, treatment, and control rates, high hypertension prevalence rates did not change or on the rise in the developing world. Systolic blood pressure (SBP) falls in high-income countries between 1980 and 2008, and it rose in developing countries [1••]. Reasons for increasing prevalence include aging of the population, since aging is a risk factor for hypertension. Other causes are urbanization with associated changes in lifestyle and dietary habits [2, 3•], increasing prevalence of obesity, diabetes, and metabolic syndrome [4] and lack of physical exercise. The increasing urbanization is one of the main reasons for the rise of prevalence of hypertension. The levels of hypertension in developing countries are higher in urban than in rural settings. People in developing countries are progressively shifting toward a Western style diet with more animal products, refined grains, fat, salt, and sugars and less fibers [5, 6]. Additional hypertension risk factors in some developing countries as a consequence of overcrowding and industrialization are air and noise pollution [7•, 8,9,10,11]. Low birth weight which is associated with future development of hypertension is common in many developing countries [12]. Furthermore, limited financial resources and inadequate health services compounded with medical illiteracy are barriers for improving hypertension prevention and control.
In this review, I will try to outline the following: (1) what is special about hypertension in developing countries; (2) what are the major challenges in its management; and (3) what do we need for the future?
What Is Special About Hypertension in Developing Countries?
High Prevalence and Low Awareness, Treatment, and Control Rates
In a systematic analysis of population-based studies from 135 populations from 968,419 adults in 90 countries, Mills et al. [13•] reported a prevalence rate of hypertension in 2010 of 28.5% in high-income countries and 31.5% in low- and middle-income countries.
The prevalence of hypertension decreased by 2.6% in high-income countries but increased by 7.7% in low- and middle-income countries from 2000 to 2010. The proportions of awareness, treatment, and control of hypertension were much lower in low- and middle-income countries than in high-income countries. Over the past decades, hypertension awareness, treatment, and control increased substantially in high-income countries, whereas there was less improvement in low- and middle-income countries [13•].
In a Prospective Urban Rural Epidemiology (PURE) study [14••] where prevalence, awareness, treatment, and control of hypertension in rural and urban communities were examined in high-, middle-, and low-income countries, the treatment rate was 31.7% in low-income compared with 46.7% in high-income countries. New WHO data for Ghana and South Africa show that less than 10% of people with hypertension had access to effective treatment [15]. The treatment rates in most Western countries was between 50 and 80% [16], while far less in developing countries, e.g., Indonesia 25% [17] and China 22% [18]. The control rates varied from 5.3% in China and 10.1% in India [19].
Hypertension Risk Factors
The current increasing burden of hypertension is largely attributable to behavioral factors such as unhealthy diet (excessive salt and alcohol consumption, low fruit and vegetable consumption), physical inactivity, and obesity. Urbanization which is rapidly increasing worldwide is associated with hypertension because of changes in dietary habits, social stress, and physical inactivity. Insufficient physical activity in adults was reported in 32% of Egyptians and 49% in Iraq (WHO Statistics 2016). Overweight and obesity levels are particularly high among women in Mexico, Egypt, and South Africa [20••]. Siervo et al. [21•] found that meat, animal fat, and milk consumption were directly associated with obesity and hypertension prevalence. Consumption of high sodium content foods is increasing in developing countries [22].
Quiet alarming is the fact that the prevalence of childhood hypertension has been increasing; it currently occurs at a rate of 1–2% in developed countries and at a rate of 5–10% in developing countries [23]. Among a total of 2166 school-aged children in western Turkey, prevalence of hypertension was 15.1% and obesity was 18% [24].
Emerging Hypertension Risk Factors
Sugar and Hypertension
There is now an emerging but inconclusive body of evidence that added sugar, particularly those in soft drinks, may have a direct effect on blood pressure independent of obesity [25]. A recent review of 12 studies with 407,707 participants [26] showed that sugar-sweetened soft drink consumption was associated with increased blood pressure. Brown et al. [27•] reported in a cross-sectional study associations of sugar-sweetened beverages (SSBs), diet beverages, and sugar with blood pressure. Sugars containing fructose may play a major role in the development of hypertension, obesity, and metabolic syndrome [28].
The global consumption of sugar and animal products has increased steadily in the last five decades and highly populated, emerging economies have assumed a key role [29]. India, East Asia, and Latin America continue to drive growth in world sugar consumption [29]. The WHO has recommended limiting the consumption of added sugar to less than 10% of total energy intake [30]. The American Heart Association has further lowered the upper limit of added sugar intake to around 6% [31].
Air Pollution
Air pollution, both outdoor and indoor, is considered a major health problem in developing countries. Rapid urbanization associated with unplanned growth of cities in many developing countries is accompanied by environmental risks as a result of overcrowding and industrial development, both leading to air pollution. Sustained exposure to ambient and household air pollution has deleterious effects on cardiovascular systems and associated with hypertension [7•].
East Asian countries, due to their rapidly developing economies and dense pollution, are exposed to very high levels of air pollution. Dong et al. [9] found an association between long-term air pollution and increased blood pressure and hypertension in Chinese; however, the association was only statistically significant in men. In a cross-sectional survey of both oil-/gas-polluted and non-polluted communities in the Niger Delta region of Nigeria, Ezejimofor et al. [8] found that participants living in oil-polluted areas were almost five times as likely to have developed hypertension.
An association was found between exposure to indoor air pollution during pregnancy and low birth weight [7•].
Noise Pollution
Another byproduct of overcrowding, urbanization, and industrialization in developing countries is the increased levels of noise exposure. Noise exposure is independently associated with hypertension. In a cross-sectional study conducted in Brazil, DeSouza et al. [11] found an association between occupational noise exposure and hypertension, among petrochemical workers at Rio de Janeiro. Cumulative noise exposure was found to be associated with hypertension among steel workers in China [10]. Elevated risk of hypertension was shown in subjects exposed to high levels of noise for longer duration and with cumulative noise exposure of 85 dB and above [11].
Low Birth Weight
In developing countries, infant weight is lower than in developed countries. The highest proportion of low birth weight babies in the world is in South Asia [32]. The percentage of low birth weight among new born according to WHO statistics was 32 in Pakistan, 32.3 in Sudan, and 45 in Yemen [33]. There is an increased relationship of birth weight and adult hypertension [34]. Low birth weight has a tendency to cause adult high blood pressure in South Asian region [12].
Inadequate Health Services
At least half of the world population still lacks access to essential health services. In many developing countries, medical health insurance is non-existent. Low- and middle-income countries face many competing priorities for investment and end up committing less financial resources to health. The USA spends US $ 8362 per capita on health, whereas Eritrea spends 12 US $ [35]. In poorer countries, most health care costs must be paid by patients out of pocket according to recent WHO statistics 2016 [33]. The out-of-pocket expenditure as percentage of total health expenditure was 63% in Afghanistan, 75.5% in Sudan, 56.3% in Pakistan, and 55.7% in Egypt. The health workforce was quite limited in developing countries. The number of physicians per 10,000 population was 2.1 in Djibouti, 2.7 in Afghanistan, 3.0 in Yemen, and 8.4 in Egypt [33].
Major Challenges in Management of Hypertension
Accurate Diagnosis of Hypertension
There have been widespread and well-documented difficulties in the ability to take an accurate and reproducible blood pressure measurement. A major contributing factor to the rising tide of hypertension in African countries is the lack of a simple, reliable, and accurate device for measuring blood pressure [36].
The British Hypertension Society Guidelines—NICE [37]—recommend that a diagnosis of hypertension should be confirmed using 24 h ABPM as a gold standard rather than be based solely on measurements of blood pressure taken in the clinic. The recent Australian Guidelines [38••] recommend ambulatory and/or home monitoring should be offered to confirm the blood pressure level if clinic blood pressure is ≥ 140/90 mmHg, or hypertension is suspected. The Canadian Guidelines (2017) recommended automated office blood pressure measurement for hypertension diagnosis [39•].
The WHL and WHO have advocated the use of automated blood pressure devices especially in low-resource settings as a partial solution to improve the accuracy of blood pressure assessment [40, 41].
Improving Blood Pressure Control
Prevalence of uncontrolled hypertension is high and increasing in low- and middle-income countries. Current control rates are very low, as low as 2% in Africa [42].
Barriers to treatment and control of hypertension among hypertensive patients were examined in a community-based cross-sectional study in Nepal [43]. Reasons for poor adherence to drugs include the silent nature of hypertension, long duration of therapy, complicated drug regimen, too many tablets, frequent dosing, drug cost, feeling of no immediate benefit with lack of motivation and drug side effects, and fear of potential harm. Avoiding or reducing the dose of medications deliberately was observed among Dutch, British, American, Brazilian, and Thai [44]. In Malaysia, patients are reluctant to visit physicians for the second time because of their denial of their condition [45]. Attaei et al. analyzed the availability, costs, and affordability of blood pressure-lowering medicines with data recorded in 20 countries participating in the PURE study [46••]. A large proportion of communities in low- and middle-income countries do not have access to more than one blood pressure-lowering medicine and, when available, they are often not affordable.
Measures to Improve Hypertension Control
Patients, physicians, health authorities, and medical societies should collaborate to improve blood pressure control.
Measures to improve BP control |
---|
Patients |
• Home: BP measurement and self BP monitoring |
• Education: improving adherence to treatment and lifestyle |
Physicians |
• Patients education and motivation |
• Drug prescription: |
• Affordable drugs: generic, off-patent |
• Minimize frequency of dosing and number of tables |
• Single-pill combination: enabling once-daily dosing |
• Encourage more frequent office visits |
Health authorities |
• Health insurance |
• Provide list of essential drugs |
• Promote generic policies |
• Salt legislations: food industry and restaurants |
• Sponsor education programs jointly with medical societies |
• Provide opportunistic BP screening |
• Hypertension clinics |
• Involve nurses and pharmacists in patient management |
Medical societies |
• Develop and disseminate national hypertension guidelines |
• Physician, nurse, and pharmacist education |
• Specialized hypertension clinics |
• Public and patient awareness programs through the internet, social media, and telemedicine |
• Establish blood pressure checking stations in malls, metro stations, etc. |
Role of Patients
Self-blood pressure monitoring and home blood pressure measurement together with patient education proved effective in improving hypertension control. Meta-analyses of randomized trials have demonstrated improved hypertension control and lower mean diastolic and systolic blood pressure with home monitor use [47•, 48]. Recent guidelines recommend home blood pressure monitoring. Home blood pressure management significantly lowers blood pressure when compared to usual care in high-income countries [49]. A clinical trial in Mexico and Honduras documented that individuals using a blood pressure monitoring combined with automated interactive voice response messages had SBP levels lower on average than that of control groups [50].
Among patients with hypertension at high risk of cardiovascular disease, self-monitoring with self-titration antihypertensive medications compared with usual care resulted in lower SBP at 12 months [51•].
Role of Physicians
Physicians play a central role in improving patients’ adherence to medication through patients’ education and motivation, prescription of affordable drugs, minimizing frequency of dosing, and number of tablets. Single-pill combination and once-daily dosing proved effective in improving compliance to drug therapy. Blood pressure monitoring through more frequent office visits may help to maintain patient enthusiasm and adherence to medication.
Physicians should prescribe generic medicines, if possible, rather than more expensive brand-name medications [52].
Role of Health Authorities
Health authorities in developing countries have the responsibility of providing nationwide health insurance which is lacking in the majority of poor countries, to develop a list of essential drugs, promote generic policies, establish legislation to limit salt content in processed foods and restaurants, sponsor education programs for physicians and nurses, encourage opportunistic blood pressure screening, and help establishment of specialized hypertension clinics. Health authorities can share in multicomponent intervention programs. Low-income patients in Argentina with uncontrolled hypertension who participated in a community health worker-led multicomponent intervention experienced a greater decrease in systolic and diastolic blood pressure than did patients who received usual care [53]. Health authorities should ensure access to affordable blood pressure-lowering medicines.
Role of Nurses and Pharmacists
In developing countries, as the numbers of people with hypertension increase, the role of nurses continues to expand. They help measuring and monitoring blood pressure and patient education and paying reminder phone calls for drug intake and office appointments. Nurses lead blood pressure service in community, worksite, school, and other settings. Nurse-led hypertension management has been demonstrated to result in greater rates of blood pressure control than those achieved with standard care [54•].
Nurse-led clinics proved effective for hypertension care in rural and urban sub-Saharan Africa [55]. Patients followed by nurses were more likely to be prescribed blood pressure-lowering treatment and adhere to such medications. In Mexico, home-delivered health promotion by nurses on top of usual care was associated with lowering of blood pressure in the intervention group compared with the control groups [56].
Santschi et al. [57] reviewed the impact of pharmacist care on the management of cardiovascular disease risk factors among outpatients. Pharmacist care was associated with significant reduction in systolic/diastolic blood pressure.
A key feature of the most effective hypertension care models is a multi-disciplinary team that collaborates in delivering hypertension care services. RCTs of team-based hypertension care involving nurse or pharmacist intervention demonstrated reduction in SBP and DBP and greater achievement of blood pressure goals when compared with usual care [58].
Adherence Improving Interventions
Non-adherence to antihypertensive medication is common in developing countries [59•]. Approximately half of the patients start treatment for hypertension abandon treatment [60••, 61]. Educating the patient was found to be a key component of a cost-effective approach to improve adherence [62]. Reducing the number of daily doses appears to be effective in increasing adherence to blood pressure-lowering medication and should be tried as a first-line therapy [63].
Ensuring access and supply of inexpensive medicines is crucial since drug costs account for two thirds of the estimated resource needs. Promoting local manufacturing of generic products and price regulations to ensure availability of inexpensive medicines is required [64].
Generic drugs have helped to improve accessibility and affordability of antihypertensive therapy in developing countries [65•]. Developing countries should adopt laws permitting generic substitution, requiring the pharmacist to substitute a generic for a brand-name medication except when prescriber indicates “brand only.” The use of generic medications influence adherence. Policies that promote generic medicines can generate large savings. In France, implementation of a general generic substitutions strategy saved nearly US $ 2 billion in 2008 alone [66].
Terline et al. performed a quality assessment of five commonly used antihypertensive generic drugs in ten Sub-Saharan African countries [65•] using standardized methods. In this study, one quarter of the available generic antihypertensive drugs was found to be of poor quality. In Rwanda, 20% of hypertensive medicines on the market were of substandard content and 70% were of insufficient stability [67].
The adoption of an essential medicine list into public policy could lead to lower medication costs and could serve as a starting point for the development of a national drug coverage system [68]. Each country is encouraged to prepare their own list of essential medicines.
Salt Reduction
Worldwide salt intakes are above recommendations [69•]. Strategies to reduce intake are required. Given the current food environment, educational efforts such as clinician counseling are useful, but a comprehensive public health approach is necessary to achieve meaningful reductions in sodium intake. Three-gram per day should become the long-term target for population salt intake.
Strategies for salt reduction are outlined by Cobb et al. [70] and these include: public education, mass media education campaigns coupled with voluntarily efforts by industry, and warning labels on high-salt packaged foods. National legislation reducing the addition of salt to food is a cost-effective policy. The International Society of Hypertension and the World Hypertension League have developed a policy statement calling for reducing dietary salt [71].
Hypertension Guidelines
The absence of specific national hypertension treatment guidelines based on country-specific circumstances adds to the challenges in hypertension management. What is prescribed in developed countries may not be applicable in developing countries. Many developing countries with limited resources cannot treat everyone with a blood pressure beyond the defined thresholds (≥ 140/90 mmHg). As resources for managing hypertension are limited, it is important that interventions are guided by cost-effectiveness and guidelines should include drug affordability as main management component.
The threshold of cardiovascular risk for deciding the start of drug treatment can be adjusted to suit the country context. Cost-effectiveness of an intervention depends on the gross domestic product per head for the country. WHO proposed different 10-year total cardiovascular risk threshold for intensive interventions based on countries resource level [72•]. The development of the Egyptian hypertension guidelines by the Egyptian Hypertension Society could serve as an example for developing countries [73]. Egyptian guidelines tried to adopt evidence-based recommendations to local economic, cultural, and lifestyle circumstances. The real threshold of hypertension must be considered as flexible, being higher or lower based on the total cardiovascular risk of each individual [74]. The WHO suggests performing cardiovascular risk stratification according to WHO/ISH risk prediction charts using a limited panel of data [75].
What Do We Need for the Future?
More Epidemiologic Data
A substantial proportion of countries have little usable data on the hypertension prevalence, awareness, treatment, and control rates and determinants of hypertension and have weak surveillance systems. Improving country-level surveillance and monitoring must be a top priority in the fight against hypertension.
Little is currently known about how socioeconomic factors may influence the distribution of blood pressure and hypertension in these societies. The role of emerging dietary risk factors, e.g., sugar and fat intake and environmental pollution needs to be clarified in epidemiologic studies.
We need data about the cost-effectiveness of aggressive management of hypertension in developing countries and approaches to improve detection and adherence to treatment.
Development of National Programs
There are several hypertension strategies that hypertension organizations can use as templates [76, 77]. All strategies require adaptation to the national or regional circumstances based on cultures, values, health literacy, health care systems, and available resources.
Health authorities and drug industry in collaboration with national hypertension societies should develop national programs for hypertension control which include the following activities:
-
(1)
Development and dissemination of national country- or region-specific hypertension guidelines and translating guidelines into clinical practice.
-
(2)
Plan, sponsor, and execute public awareness programs through social media, internet, press, and T.V.
-
(3)
Salt reduction campaign. Make healthy low-salt foods readily available and affordable.
-
(4)
Prepare list of essential drugs and promote generic prescription.
-
(5)
Specialized hypertension clinics providing free service for screening, diagnosis investigating, and monitoring hypertensive patients. Routine and opportunistic screening should be encouraged, with establishing blood pressure checking stations in malls and public places.
A successful blood pressure screening program [78] should include (1) training to accurately measure blood pressure; (2) use of accurate equipment (blood pressure devices)—semi-automated devices are recommended; (3) appropriate interpretations of blood pressure readings: e.g., blood pressure of 140–170/90–95 mmHg will require follow-up within a few weeks, if more than 180 mmHg, follow-up as soon as possible by a medical doctor; (4) follow-up instructions can be provided at blood pressure checking stations as posters or other forms of printed material. Routine opportunistic screening for hypertension in formal medical setting can significantly increase hypertension awareness in developing countries [79].
New Management Tools
The efficacy and cost-effectiveness of new hypertension management tools needs to be tested in developing countries. Examples of these new tools are the electronic health records, automated office blood pressure (AOBP) measurement, and telemedicine and home blood pressure tele-monitoring.
Although the introduction of a fully electronic health record system may seem far off in many countries, they are being introduced rapidly in others. In many developing countries, costs, available technology, lack of technical expertise, and computer skills of staff are limitations to the widespread use of electronic documentation.
Electronic medical records (EMR) improve the quality of care as a result of having health information immediately available at all times.
There is now sufficient evidence to consider replacing manual office blood pressure with AOBP in routine clinical practice [80]. AOBP has a greater accuracy and consistency than manual blood pressure. Recent hypertension guidelines recommend, when feasible, AOBP [40, 81] as the preferred electronic sphygmomanometer and should replace the manual blood pressure measurement.
Telemedicine and in particular home blood pressure tele-monitoring (HBPT) represent a promising tool for improving blood pressure control. HBPT consists of automated blood pressure data transmission from the patient’s home to the doctor’s office or to a clinic [82•]. It is generally based on the use of electronic-automated upper arm or wrist blood pressure monitors storing blood pressure values obtained at patient’s home. When data are received at the central telemedicine server, they are sorted and automatically analyzed. HBPT showed a clear benefit in terms of greater blood pressure reductions, but the overall costs were significantly high [83].
Expanding Financial Coverage for Health Care
This should have a priority on the agenda of health authorities in order to improve hypertension control in the coming years. Governments in low-resource settings should adopt new strategies to manage the increasing financial burden of hypertension and NCDs. Health care insurance or publically provided health care can improve hypertension control specially among the poor who cannot afford cost of drugs and medical care. Health insurance coverage was associated with improved outcomes of hypertension care in US settings [84•] and correlated with improvement in hypertension control in Taiwan [85].
Conclusion
Management of hypertension remains a major challenge for developing countries. Prevalence rates are on the rise, while treatment and control rates are not improving or even declining. Improvement is required in the following areas: (1) technique to measure blood pressure and reach accurate diagnosis of hypertension, (2) analysis of patients compliance and follow-up, (3) development and implementation of treatment guidelines, (4) continued physician, pharmacist, nurse, and patient education, (5) involvement of health authorities, medical societies, and drug industry, (6) salt reduction programs.
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
•• Danaei G, Finucane MM, Lin JK, Singh GM, Paciorek CJ, Cowan MJ, et al. National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5·4 million participants. Lancet. 2011;377(9765):568–77. Data for trends in blood pressure in 199 countries and territories from health surveys and epidemiologic studies. Authors estimated worldwide trends in population mean systolic blood pressure.
Agyemang C, Bruijnzeels MA, Owusu-Dabo E. Factors associated with hypertension awareness, treatment, and control in Ghana, West Africa. J Hum Hypertens. 2005;20(1):67–71.
• Bernabé-Ortiz A, Carrillo-Larco RM, Gilman RH, Checkley W, Smeeth L, Miranda JJ, et al. Impact of urbanisation and altitude on the incidence of, and risk factors for hypertension. Heart. 2017;103(11):827–33. Data from the CRONICAS cohort study. Urbanization can negatively affect population health.
Godfrey R, Julien M. Urbanisation and health. Clin Med (Lond) 2005; 5(2):137–141.
Danaei G, Singh GM, Paciorek CJ, Lin JK, Cowan MJ, Finucane MM, et al. The global cardiovascular risk transition: associations of four metabolic risk factors with national income, urbanization, and Western diet in 1980 and 2008. Circulation. 2013;127:1493–502.
Zeba AN, Yaméogo MT, Tougouma SJ, Kassié D, Fournet F. Can urbanization, social and spatial disparities help to understand the rise of cardiometabolic risk factors in Bobo-Dioulasso? A study in a secondary city of Burkina Faso, West Africa. Int J Environ Res Public Health. 2017;14(4):378.
• Mannucci PM, Franchini M. Health effects of ambient air pollution in developing countries. Int J Environ Res Public Health. 2017;14(9):1048–56. Review of the deleterious effects of ambient air pollution in financially deprived population. Both outdoor and indoor air pollutions pose a threat to human health.
Ezejimofor MC, Uthman OA, Maduka O, Ezeabasili AC, Onwuchekwa AC, Ezejimofor BC, et al. The burden of hypertension in an oil- and gas-polluted environment: a comparative cross-sectional study. Am J Hypertens. 2016 Aug;29(8):925–33.
Dong GH, Qian ZM, Xaverius PK, Trevathan E, Maalouf S, Parker J, et al. Association between long-term air pollution and increased blood pressure and hypertension in China. Hypertension. 2013 Mar;61(3):578–84.
Shrestha A, Shiqi M. Occupational noise exposure in relation to hypertension: a cross-sectional study in the steel factory. Occup Med Health Aff. 2017;5:306–16.
de Souza TC, Périssé AR, Moura M. Noise exposure and hypertension: investigation of a silent relationship. BMC Public Health. 2015;15:328.
Ediriweera DS, Dilina N, Perera U, Flores F, Samita S. Risk of low birth weight on adulthood hypertension—evidence from a tertiary care hospital in a South Asian country, Sri Lanka: a retrospective cohort study. BMC Public Health. 2017;17(1):358.
• Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, et al. Global disparities of hypertension prevalence and control a systematic analysis of population-based studies from 90 countries. Circulation. 2016;134:441–50. This is an analysis of population-based studies from 90 countries showing that global disparities are large and increasing.
•• Chow CK, Teo KK, Rangarajan S, Islam S, Gupta R, Avezum A, et al. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA. 2013;310(9):959–68. A cross-sectional study of 153996 adults from 628 communities in high, middle, and low-income countries. There were differences in hypertension awareness, treatment, and control rates between high- and low-income countries.
Lloyd-Sherlock P, Ebrahim S, Grosskurth H. Is hypertension the new HIV epidemic? Int J Epidemiol. 2014;43(1):8–10.
Joffres M, Falaschetti E, Gillespie C, Robitaille C, Loustalot F, Poulter N, et al. Hypertension prevalence, awareness, treatment and control in national surveys from England, the USA and Canada, and correlation with stroke and ischaemic heart disease mortality: a cross-sectional study. BMJ Open. 2013;3(8):e003423.
Hussain MA, Al Mamun A, Peters SA, Woodward M, Huxley RR. The burden of cardiovascular disease attributable to major modifiable risk factors in Indonesia. J Epidemiol. 2016;26(10):515–21.
Wang J, Zhang L, Wang F, Liu L, Wang H, China National Survey of Chronic Kidney Disease Working Group. Prevalence, awareness, treatment, and control of hypertension in China: results from a national survey. Am J Hypertens. 2014;27(11):1355–61.
Irazola VE, Gutierrez L, Bloomfield GS, Carrillo-Larco RM, Prabhakaran D, Gaziano T, et al. Hypertension prevalence, awareness, treatment, and control in selected communities of nine low- and middle income countries: results from the NHLBI/UHG network of centers of excellence for chronic diseases. Glob Heart. 2016;11(1):47–59.
•• Popkin BM. Global nutrition dynamics: the world is shifting rapidly toward a diet linked with noncommunicable diseases. Am J Clin Nutr. 2006;84:289–98. Author discusses the nutrition transition, obesity prevalence, and trends in higher and lower income countries. There are higher intakes of animal and partially hydrogenated fats and lower intakes of fibers and reduced energy expenditure.
• Siervo M, Montagnese C, Mathers JC, Soroka KR, Stephan BC, Wells JC. Sugar consumption and global prevalence of obesity and hypertension: an ecological analysis. Public Health Nutr. 2014;17(3):587–96. Information from 72 countries. Consumption of sugar and animal products were directly associated with GDP and urbanization rates. Prevalence of overweight and consumption of cereals were significantly predictors of hypertension.
Noubiap JJ, Bigna JJ, Nansseu JR. Low sodium and high potassium intake for cardiovascular prevention: evidence revisited with emphasis on challenges in sub-Saharan Africa. J Clin Hypertens (Greenwich). 2015;17(1):81–3.
Luma GB, Spiotta RT. Hypertension in children and adolescents. Am Fam Physician. 2006;73:1558–68.
Önsüz FM, Demir F. Prevalence of hypertension and its association with obesity among school children aged 6-15 living in Sakarya Province in Turkey. Turk J Med Sci. 2015;45(4):907–12.
Te Morenga LA, Howatson AJ, Jones RM, Mann J. Dietary sugars and cardiometabolic risk: systematic review and meta-analyses of randomized controlled trials of the effects on blood pressure and lipids. Am J Clin Nutr. 2014;100(1):65–79.
Malik AH, Akram Y, Shetty S, Malik SS, Yanchou Njike V. Impact of sugar-sweetened beverages on blood pressure. Am J Cardiol. 2014;113(9):1574–80.
• Brown IJ, Stamler J, Van Horn L, et al. Sugar-sweetened beverage, sugar intake of individuals and their blood pressure: INTERMAP Study. Hypertension. 2011;57(4):695–701. Authors report cross-sectional associations of sugar-sweetened beverages, diet beverages, and sugars with blood pressure in an international study. There were significant sugar-sodium interactions.
Johnson RJ, Segal MS, Sautin Y, Nakagawa T, Feig DI, Kang DH, et al. Potential role of sugar (fructose) in the epidemic of hypertension, obesity and the metabolic syndrome, diabetes, kidney disease, and cardiovascular disease. Am J Clin Nutr. 2007;86(4):899–906.
Schmidhuber J, Shetty P. The nutrition transition to 2030. Why developing countries are likely to bear the major burden. Acta Agric Scand Sect C Food Econ. 2005;2(3–4):150–66.
Ruxton CH, Gardner EJ, McNulty HM. Is sugar consumption detrimental to health? A review of the evidence 1995–2006. Crit Rev Food Sci Nutr. 2010;50(1):1–19.
Johnson RK, Appel LJ, Brands M, Howard BV, Lefevre M, Lustig RH, et al. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation. 2009;120(11):1011–20.
Lee AC, Katz J, Blencowe H, Cousens S, Kozuki N, Vogel JP, et al. National and regional estimates of term and preterm babies born small for gestational age in 138 low-income and middle-income countries in 2010. Lancet Glob Health. 2013;1(1):e26–36.
WHO Statistics. East Mediterranean Region 2016. http://apps.who.int/iris/bitstream/10665/112738/1/9789240692671_eng.pdf.
Law CM, Egger P, Dada O, Delgado H, Kylberg E, Lavin P, et al. Body size at birth and blood pressure among children in developing countries. Int J Epidemiol. 2001;30(1):52–7.
World Health Organization Spending on Health. A global overview. Fact Sheet no. 319. April 2012. http://www.who.int/mediacentre/factsheets/fs319/en/.
Sliwa K, Stewart S. A low-cost solar-powered blood-pressure device. Lancet. 2011;378(9792):647–8.
Krause T, Lovibond K, Caulfield M, McCormack T, Williams B, Guideline Development Group. Management of hypertension: summary of NICE guidance. BMJ. 2011;343:d4891.
•• Gabb GM, Mangoni AA, Anderson CS, Cowley D, Dowden JS, Golledge J, et al. Guideline for the diagnosis and management of hypertension in adults—2016. Med J Aust. 2016;25(2):85–9. Update of the Australian guidelines for the management of hypertension. There are changes in management as a result of guidelines which include ambulatory and/or home blood pressure monitoring and lower blood pressure target for high risk patients.
• Leung AA, Daskalopoulou SS, Dasgupta K, McBrien K, Butalia S, Zarnke KB, et al. Hypertens Canada’s 2017 GUIDELINES for diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Can J Cardiol. 2017;33(5):557–76. The Canadian guidelines are updated every year. The most recent 2017 guidelines recommend automated office blood pressure for hypertension diagnosis and combination drug therapy as initial step in pharmacologic management.
Campbell NR, Berbari AE, Cloutier L, Gelfer M, Kenerson JG, Khalsa TK, et al. Policy statement of the world hypertension league on noninvasive blood pressure measurement devices and blood pressure measurement in the clinical or community setting. J Clin Hypertens (Greenwich). 2014;16(5):320–2.
World Health Organization. Affordable technology, blood pressure measuring devices for low resource settings. Report 1-26. Geneva: World Health Organization; 2005.
Adeloye D, Basquill C. Estimating the prevalence and awareness rates of hypertension in Africa: a systematic analysis. Schnabel RB, ed. PLoS One. 2014;9(8):e104300.
Devkota S, Dhungana RR, Pandey AR, Bista B, Panthi S, Thakur KK, et al. Barriers to treatment and control of hypertension among hypertensive participants: a community-based cross-sectional mixed method study in municipalities of Kathmandu, Nepal. Front Cardiovasc Med. 2016;3:26. https://doi.org/10.3389/fcvm.2016.00026.
Marshall IJ, Wolfe CD, McKevitt C. Lay perspectives on hypertension and drug adherence: systematic review of qualitative research. BMJ. 2012;344:e3953.
Risso-Gill I, Balabanova D, Majid F, Ng KK, Yusoff K, Mustapha F, et al. Understanding the modifiable health systems barriers to hypertension management in Malaysia: a multi-method health systems appraisal approach. BMC Health Serv Res. 2015;15:254.
•• Attaei MW, Khatib R, McKee M, Lear S, Dagenais G, Igumbor EU, et al. Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet Public Health. 2017;2(9):e411–9. Authors analyzed the availability, costs, and affordability of blood pressure-lowering medicines and blood pressure control in 20 countries participating in the PURE study. A large proportion of communities in low-income and middle-income countries do not have access to affordable therapy.
• Agarwal R, Bills JE, Hecht TJ, Light RP. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension. 2011;57(1):29–38. Blood pressure improved with home-based blood pressure monitoring and to more frequent antihypertensive medication reductions. An important study supporting home blood pressure monitoring for management of hypertension.
Angell S, Guthartz S, Dalal M, Foster V, Pogue V, Wei A, et al. Integrating self blood pressure monitoring into the routine management of uncontrolled hypertension: translating evidence to practice. J Clin Hypertens. 2013;15:180–5.
Anderson C, Dadabhai S, Damasceno A, Dzudie A, Islam SMS, Kamath D, et al. Home blood pressure management intervention in low- to middle-income countries: protocol for a mixed methods study. JMIR Res Protoc. 2017;6(10):e188.
Piette JD, Datwani H, Gaudioso S, Foster SM, Westphal J, Perry W, et al. Hypertension management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries. Telemed J E Health. 2012;18(8):613–20.
• McManus RJ, Mant J, Haque MS, Bray EP, Bryan S, Greenfield SM, et al. Effect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial. JAMA. 2014;312(8):799–808. Authors study the effects of self-monitoring with self-titration of antihypertensive medication in high-risk hypertensive patients. This approach resulted in lower systolic blood pressure at 12 months.
Choudhry NK, Denberg TD, Qaseem A. Improving adherence to therapy and clinical outcomes while containing costs: opportunities from the greater use of generic medications: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2016;164:41–9.
HE J, Irazola V, Mills KT, Poggio R, et al. Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: a randomized clinical trial. JAMA. 2017;318:1016–25.
• Himmelfarb CR, Commodore-Mensah Y, Hill MN. Expanding the role of nurses to improve hypertension care and control globally. Ann Glob Health. 2016;82(2):243–53. This is a state-of-the-art review outlining the role of nurses in hypertension management involving all aspects of care. Multi-disciplinary team improves care processes and control rates.
Kengne AP, Awah PK, Fezeu LL, Sobngwi E, Mbanya JC. Primary health care for hypertension by nurses in rural and urban sub-Saharan Africa. J Clin Hypertens (Greenwich). 2009;11(10):564–72.
Garcia-Peña C, Thorogood M, Armstrong B, Reyes-Frausto S, Muñoz O. Pragmatic randomized trial of home visits by a nurse to elderly people with hypertension in Mexico. Int J Epidemiol. 2001;30(6):1485–91.
Santschi V, Chiolero A, Burnand B, Colosimo AL, Paradis G. Impact of pharmacist care in the management of cardiovascular disease risk factors: a systematic review and meta-analysis of randomized trials. Arch Intern Med. 2011;171:1441–53.
Carter BL, Bosworth HB, Green BB. The hypertension team: the role of the pharmacist, nurse, and teamwork in hypertension therapy. J Clin Hypertens (Greenwich). 2012;14(1):51–65.
• Nielsen JØ, Shrestha AD, Neupane D, Kallestrup P. Non-adherence to anti-hypertensive medication in low- and middle-income countries: a systematic review and meta-analysis of 92443 subjects. J Hum Hypertens. 2017;31(1):14–21. This is a review of 22 studies using medical adherence scale. There is considerable variation of non-adherence to antihypertensive medication in low- and middle-income countries depending upon the methods used to estimate non-adherence.
•• Burnier M, Wuerzner G, Struijker-Boudier H, Urquhart J. Measuring, analyzing, and managing drug adherence in resistant hypertension. Hypertension. 2013;62:218–25. The review discusses diagnosis and how to improve drug adherence. Electronic monitoring methods of assessing adherence provide a unique description of the temporal patterns of drug intake and behavior in the population. Approximately half of the patients abandon treatment during the first year of treatment.
Vrijens B, Vincze G, Kristanto P, Urquhart J, Burnier M. Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories. BMJ. 2008;336(7653):1114–7.
Chapman RH, Kowal SL, Cherry SB, Ferrufino CP, Roberts CS, Chen L. The modeled lifetime cost-effectiveness of published adherence-improving interventions for antihypertensive and lipid-lowering medications. Value Health. 2010;13:685–94.
Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database Syst Rev. 2004;2:CD004804.
Hogerzeil HV, Liberman J, Wirtz VJ, Kishore SP, Selvaraj S, Kiddell-Monroe R, et al. Promotion of access to essential medicines for non-communicable diseases: practical implications of the UN political declaration. Lancet. 2013;381(9867):680–9.
• Macquart de Terline D, Diop BI, Bernard M, Do B, Ikama MS, N’guetta R, Balde DM, Tchabi Y, Sidi Aly A, Ali Toure I, Zabsonre P, Damorou JF, Takombe JL, Narayanan K, Fernandez C, Tafflet M, Plouin PF, Empana JP, Marijon E, Jouven X, Antignac M. Substandard drugs among five common antihypertensive generic medications: an analysis from 10 African countries. J Hypertens. 2017;36(2):395–401. A study in ten sub-Saharan African countries. Nearly one quarter of the available generic antihypertensive drugs were found to be of poor quality. The study stresses the limitations of generic antihypertensive drugs in developing countries.
WHO. Health systems financing: the path to universal coverage. www.who.int/whr/2010/en/.
Twagirumukiza M, Cosijns A, Pringels E, Remon JP, Vervaet C, Van Bortel L. Influence of tropical climate conditions on the quality of antihypertensive drugs from Rwandan pharmacies. Am J Trop Med Hyg. 2009;81(5):776–81.
Cameron A, Ewen M, Ross-Degnan D, Ball D, Laing R. Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis. Lancet. 2009;373(9659):240–9.
Newson RS, Lion R, Meijer GW, Neufingerl N, van Zweden R, Feunekes GIJ, et al. Barriers for progress in salt reduction in the general population. An international study. Appetite. 2013;71(1):22–3. This is an international study conducted to drive knowledge on salt intake and associated behaviors in the general population. One third of participants were not interested in salt reduction. People were unaware of the main dietary sources of salt.
Cobb LK, Appel LJ, Anderson CAM. Strategies to reduce dietary sodium intake. Curr Treat Options Cardiovasc Med. 2012;14(4):425–34.
Campbell NR, Lackland DT, Chockalingam A, Lisheng L, Harrap SB, Touyz RM, et al. The International Society of Hypertension and World Hypertension League call on governments, nongovernmental organizations and the food industry to work to reduce dietary sodium. J Hypertens. 2014;32(2):446–7.
• Modesti PA, Agostoni P, Agyemang C, Basu S, Benetos A, Cappuccio FP, et al. Cardiovascular risk assessment in low-resource settings: a consensus document of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk in Low Resource Settings. J Hypertens. 2014;32(5):951–60. This is a consensus document by the ESH working group on hypertension and cardiovascular risk in low-resource settings. The threshold of cardiovascular risk for deciding the start of drug treatment can be adjusted to suit the country context. Cost-effectiveness of an intervention depends on the gross domestic product per head for the country.
Ibrahim MM. The Egyptian hypertension society: Egyptian hypertension guidelines. Egypt Heart J. 2014;66:79–132.
López-Jaramillo P, Coca A, Sánchez R, Zanchetti A, Latin American Society of Hypertension. Hypertension guidelines: is it time to reappraise blood pressure thresholds and targets? Position statement of the Latin American Society of Hypertension. Hypertension. 2016;68(2):257–62.
Mendis S, Lindholm LH, Mancia G, Whitworth J, Alderman M, Lim S, et al. World Health Organization (WHO) and International Society of Hypertension (ISH) risk prediction charts: assessment of cardiovascular risk for prevention and control of cardiovascular disease in low and middle-income countries. J Hypertens. 2007;25(8):1578–82.
Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262–9.
Go AS, Bauman MA, Coleman King SM, Fonarow GC, Lawrence W, Williams KA, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. J Am Coll Cardiol. 2014;63(12):1230–8.
Mangat BK, Campbell N, Mohan S, Niebylski ML, Khalsa TK, Berbari AE, et al. Resources for blood pressure screening programs in low resource settings: a guide from the world hypertension league. J Clin Hypertens (Greenwich). 2015;17:418–20.
Maurer J, Ramos A. One-year routine opportunistic screening for hypertension in formal medical settings and potential improvements in hypertension awareness among older persons in developing countries: evidence from the Study on Global Ageing and Adult Health (SAGE). Am J Epidemiol. 2015 Feb 1;181(3):180–4.
MG1 M. Replacing manual sphygmomanometers with automated blood pressure measurement in routine clinical practice. Clin Exp Pharmacol Physiol. 2014;41(1):46–53.
Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31(7):1281–357.
• Mboni S, Ferrari R. The role of telemedicine in hypertension management: focus on blood pressure telemonitoring. Curr Hypertens Rep. 2015;17(4):535. This review updates and critically assesses the role of telemedicine and home blood pressure monitoring in the management of hypertensive patients. The review outlines the advantages and benefits of telemedicine in hypertension management. There was a clear benefit in terms of greater blood pressure reductions.
Omboni S, Gazzola T, Carabelli G, Parati G. Clinical usefulness and cost effectiveness of home blood pressure telemonitoring: meta-analysis of randomized controlled studies. J Hypertens. 2013;31:455–68.
• Maimaris W, Paty J, Perel P, Legido-Quigley H, Balabanova D, Nieuwlaat R, et al. The influence of health systems on hypertension awareness, treatment, and control: a systematic literature review. PLoS Med. 2013;10(7):e1001490. This is a systematic review of the influence of national or regional health systems on hypertension awareness, treatment, and control. It supports the minimization of medication co-payments in health insurance plans.
Su TC, Bai CH, Chang HY, You SL, Chien KL, Chen MF, et al. Evidence for improved control of hypertension in Taiwan: 1993–2002. J Hypertens. 2008;26(3):600–6.
Acknowledgments
I thank my secretaries Mrs. Rehab M El-Ashkar and Mrs. Nesma M El-Ashkar for their excellent secretarial work and their help in the preparation of the manuscript.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The author declares no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Blood Pressure Monitoring and Management
Rights and permissions
About this article
Cite this article
Mohsen Ibrahim, M. Hypertension in Developing Countries: A Major Challenge for the Future. Curr Hypertens Rep 20, 38 (2018). https://doi.org/10.1007/s11906-018-0839-1
Published:
DOI: https://doi.org/10.1007/s11906-018-0839-1