HYPERTENSIONND 6023

Nutritional Epidemiology

Hypertension is defined as continues rising of systolic blood pressure (SBP) of 140 mmHg or greater and/or diastolic Blood Pressure (DBP) of 90 mmHg or greater (Padwal et., al 2008).

More than 50% of the hypertensive population worldwide are unaware of their condition. (Chockalingam, 2008).

World Health Organization (WHO) estimated that suboptimal blood pressure is the leading factor that leads to death (Campbell et., al 2006).

Hypertension is often called as “silent killer”, because individual with hypertension can be asymptomatic for many years before developing a fatal stroke or heart attack. (MOH, 2002).

Introduction

Programmes and strategies are implemented worldwide - create awareness, to reduce the prevalence and to prevent the hypertension among the population.

World Hypertension Day (WHD) - communicate to the public the importance of hypertension and its serious medical complications, and to provide information on prevention, detection and treatment.

Clinical Practice Guideline (CPG) - to provide a clear and concise approach to all health care providers on the current concepts in the management of hypertension.

Intro cont….

The BP is functioned as the resistance in blood vessels to flow of blood.

Diameter of blood vessel affects the flow of blood. If the diameter is ↓the resistance, it leads to

increase in BP. if the diameter is ↑, the resistance decreases and

lowered the BP BP is regulated by the kidney by controlling

the ECF volume and secreting renin, which then activates the renin-angiotensin system.

Hypertension is developed when the regulatory mechanisms falters

Physiology of Hypertension

CPG for management of hypertension, provides a classification of BP for adults (age 18 and older).

The classification of hypertension

Measured either directly or indirectly. Commonly used to measure BP is by

indirect method.Mercury column sphygmomanometer Aneroid sphygmomanometer Electronic devices Automated ambulatory BP devices

Home BP measurement is also may be used in monitoring control of BP.

The measurement of hypertension

Worldwide epidemiology of hypertension 972 million, 26.4% of the world adult population had

hypertension (Kearney et al. 2005) Based on analysis of National Health and Nutrition

Examination Survey (NHANES) III data, 69% of people with hypertension are aware that they have it.

NHANES III also reported that 66% of adults with prehypertension had one major CVD risk factor; and 29% had CVD, diabetes, or target organ disease.

In Malaysia, based on NHMS I the percentage of adult who were 25 years and above and diagnosed with hypertension were found to be 14%.

NHMS II, the prevalence of hypertension among adults aged 30 years and above was estimated 30 %

Prevalence

Prevalence of hypertension among Malaysians aged 18 years and above in 2006 (NHMS III)

Prevalence of hypertension among Malaysians aged 18 years and above is 32.2%.

Males 33.3% significantly higher than females 31.1%.

Malays 32.9%, Chinese 32.9% and in Indians is 29.4%.

Prevalence of hypertension among Malaysians aged 30 years and above in 2006 (NHMS III)

Prevalence of hypertension for this age group is 42.6%.

prevalence in males is 41.7% and similar with the prevalence of females 43.4%.

Malays 45.4%, Chinese 40.6% and Indian 40.0%.

The disease burden The higher the blood pressure, the greater the chance of target organ damage including: left ventricular hypertrophy congestive heart failure Stroke kidney disease Retinopathy Peripheral vascular disease

Complications of hypertension

Left ventricular hypertrophy

Heart Failure

STRO

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Kidney Disease

Hypertensive Retinopathy

Normal Retinopathy

Economic burden NHMS III reported that, in year 2005

RM215.9 million was spent on antihypertensive medicines alone in Malaysia.

NHMS III also stated that the cost charged for per admission of managing hypertension was RM2, 927 - without comorbidity and complications.

RM4, 716 for hypertension with major comordity and complications.

NHMS III has listed two broad approaches to prevent hypertension.

whole population approach

the ‘at-risk’ group

Disease prevention

encourage people to change their lifestyle to lower their blood pressureReducing the average intake of salt as

recommended Increase the intake of potassium by

increasing the intake of fruits and vegetables to at least five portions a day

Overweight and obese people have control their weight to achieve 10% weight loss

Increasing the amount of physical activity

The whole population approach

Concentrate more on people with high risk of developing hypertension.

Individual who are at the risk of cardiovascular risk factors.

Overweight and obese people.

Those with family history of hypertension.

The ‘at-risk’ individual group approach

Factors of Hypertension

1) Dietary intake2) Obesity3) Smoking4) Physical inactive5) Emotional factors6) Aging7) Ethnicity8) Genetic9) Education10) Socia-economic11) Diseases

complication

Factors of hypertension

High sodium diet causes body to retain fluid, thus increase the blood pressure (Cheung et al. 2000).

Potassium helps in balance the amount of sodium in body cell.

Reduced sodium intake but increased potassium intake could prevent of getting hypertension(Geleijnse et al. 2003).

Dietary intake

Over alcohol consumption will raise blood pressure by stimulate body to release hormones to increase blood flow and heart rate.

Alcohol intake may increase blood pressure to a much greater extent, even among moderate drinkers (Chen et al. 2008).

Dietary intake

NHANES data in year 1999-2000 reported approximately 60% of overweight individuals and 75.5% of obese individuals had hypertension, whereas the prevalence was only 47% in the non-overweight group.

Higher volume of blood circulated through blood vessels, thus raising the pressure on the artery walls.

Obese children and adolescents are at greater risk for high blood pressure when they reach adulthood.

Obesity

Teo and Idris (1996) study in elderly Chinese in Malaysia reported hypertension was significantly more common in smokers than non-smokers.

Average elevation in systolic pressure of 20 mmHg after the first cigarette (Groppelli et al. 1992).

Smoking

Higher heart rate in inactive individuals will increase heart contraction, lead to hypertension.

Aerobic exercise decreases blood pressure through a reduction of vascular resistance (Cornelissen & Fagard 2005).

Recreational activity in early pregnancy reduces the risk of hypertensive disorders of pregnancy (Fortner et al. 2011).

Physical inactive

Depression and anxiety increase the risk of hypertension (Silla et al. 2010).

Scalco et al. (2005) suggested that hyper reactivity of the sympathetic nervous system raising the blood pressure.

Emotional

The NHANES data in year 1999-2000 showed rate of hypertension increased from 40% to 88% among people aged 18-39 years, 8% to 65% among those 60 years and older (Wang & Wang 2004).

There was a significant rise in the prevalence of hypertension with age (Teo &

Idris 1996).

Aging

Source: Data from the 1999-2000 National Health and Nutrition Examination Survey. Fields, L. E. et.al (2004)

Asia Pacific Cohort Studies Collaboration (2003) showed similar association in men and women in the prevalence of hypertension, risk of stroke and risk of heart disease.

NHMS III report similar prevalence with 41.7% in males 43.4% in females.

A prospective longitudinal cohort study by Vasan et al. (2002) also reported lifetime risk for hypertension was similar for men and women.

Gender

Blacks had the highest rate, whereas Mexican Americans had the lowest rate hypertension according to NHANES III.

NHMS III reported Malay female (48.4%)had significant higher prevalence than Chinese female (38.7%) and Indian female (39.5%).

Ethnicity

Hypertension follow a significantly increasing trend inversely proportional to the level of education (NHMS III 2006; NHANES III 2000).

Higher educated individuals will be more aware of risk of disease and maintain body health as compared to low educated individuals.

Education

Hypertension was increasing trend inversely proportional to the level of household income (NHMS III 2006; Teo & Idris 1996).

However it is weak determinant of blood pressure as compared to factors of age and body mass index (Grotto et al. 2007).

Socia-economic

Health condition or diseases lead to high blood pressure (Mahendran 2009):

kidney failure aortic stenosis renal artery stenosis Cushing’s Syndrome Phaeochromocytoma consuming medicines like steroids and

contraceptive pills

Diseases

Intervention in Malaysiao Hypertension screening programme. o Individuals with BP ≥140/90 mmHg were sent to clinics for treatment.

Source: Clinical Practice Guideline: Management of hypertension. 2008

Source: Clinical Practice Guideline: Management of hypertension (2008)

Management of hypertension

Antihypertensive drugs in patients with concomitant conditions

The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice+/- Use with care- Contraindicated* Only non-dihydropyridine CCB# Metoprolol, bisoprolol, carvedilol – dose needs to be gradually titrated@ Current evidence available for amlodipine and felodipine only$ Contraindicated in bilateral renal artery stenosis

Weight reduction for individuals who are more than 10% overweight, with 5% target weight loss.

Restriction of sodium intake with consuming of less than 6g sodium chloride.

Consume diet rich in fruits, vegetables and dairy products.

Reduced saturated and total fat intake.

Lifestyle changes

Medical Nutrition Therapy Guidelines for Hypertension (2002), potassium, calcium and magnesium supplement are not recommended for treatment of hypertension.

It recommended :≥ 60 mmol potassium/day< 2 cups of coffee containing caffeine

Dietary intake

Increase physical activity, practice exercise especially aerobic exercise.

Cardiovascular patient is advised to practice milder intensity exercise, such as brisk walking for 30 – 60 minutes at least 3 times a week.

At least six months of exercise, blood pressure reduction is very modest amongst hypertension patients

Physical activity

It operates through > 45 partner organizations, the Coordinating Committee, state and local health departments, and hypertension coalitions.

It develop education, screening programs and activities in NGO, public, events and work places.

National High Blood Pressure Education Program (NHBPEP) in America

Source: Chobanian et al. (2003); Ostchega Y. et al. (2008)

Control blood pressure was defined as <140/90 mmHg and expressed as a % of all hypertensives

The guidelines were developed in partnership with the British Hypertension Society and have 65 recommendations, 36 of which are new with 12 listed as key priorities.

United Kingdom National Institute for Health and Clinical Excellence (NICE) guideline

Source: Protocol for management of hypertension in adults (2007)

The prevalence of hypertension is increasing in alarm rate even though many guidelines and programs have been carried out.

This increase has been related to an increasing sedentary lifestyle with less physical activities as well as changing dietary habits and stress.

The populations, for example Malaysian is facing huge disease and economic burden due to hypertension.

Thus, various intervention programmes, prevention and management of hypertension with the collaboration of healthy lifestyle should be practice in order to reduce the prevalence and hypertension risk.

CONCLUSION

Asia Pacific Cohort Studies Collaboration. 2003. Blood pressure and cardiovascular disease in the Asia Pacific region. Journal of Hypertension. 21 (4): 707-716.

Chen, L., Davey, S. G., Harbord, R. M., Lewis, S. J. 2008. Alcohol intake and blood pressure: a systematic review implementing a Mendelian randomization approach. PLos Medicine. 5(3): e52. doi=10.1371/journal.pmed.0050052.

Cheung, B. M. Y., Ho, S. P. C., Cheung, A. H. K. & Lau, C.P. 2000. Diastolic blood pressure is related to urinary sodium excretion in hypertensive Chinese patients. QJM: An International Journal of Medicine. 93(3): 163-168.

Cornelissen, V. A. & Fagard, R. H. 2005. Effects of endurance training on blood pressure, blood pressure-regulating mechanisms, and cardiovascular risk factors. Hypertension. 46(4): 667-675.

Fortner, R. T., Pekow, P. S., Whitcomb, B. W., Sievert, L. L., Markenson, G. & Chasen-Taber, L. 2011. Physical activity and hypertensive disorders of pregnancy among Hispanic women. Medicine and Science in Sports and Exercise. 43 (4): 639-646.

Geleijnse, J. M. Kok, F. J. & Grobbee, D. E. 2003. Blood pressure response to changes in sodium and potassium intake: a metaregression analysis of randomised trials. Journal of Human Hypertension. 17: 471-480.

Grotto, I., Huerta, M., Grossman, E. & Sharabi, Y. 2007. Reative impact of socioeconomic status on blood pressure lessons from a large-scale survey of young adults.American Journal of Hypertension. 20(11): 1140-1145.

REFERENCES

Groppelli, A., Giorgi, D. M. & Omboni, S. 1992. Persistent blood pressure increase induced by heavy smoking. Journal of Hypertension. 10: 495-499.

Malaysian Dieticians’ Association & Ministry of Health (MOH). 2002. Medical Nutrition Therapy Guidelines for Hypertension. Kuala Lumpur: Malaysian Dieticians’ Association.

Mahendran, R. 2009. Hypertension. http://www.pantai.com.my/docs-writeup/hypertension/ [18 December 2011].

Ministry of Health, Academy of Medicine of Malaysia & Malaysian Society of Hypertension. 2008. Clinical Practice Guideline: Management of hypertension. Ed ke-3. Putrajaya: Ministry of Health.

Scalco, A. Z., Scalco, M .Z., Azul, J. B. S. & Lotufo, N. F. 2005. Hypertension and depression. Clinics. 60 (3): 241-250.

Silla, M. C., Cedric, L., Bernard, R., Stephane, L., Pierre-Francois, P. & Richard, D. L. 2010. Differences in emotion processing in patients with essential and secondary hypertension. American Journal of Hypertension. 23 (5): 515-521.

Teo, G. S., Idris, M. N. 1996. Prevalence of hypertension among Chinese elderly and its relationship to behavioural and nutritional factors. Medical Journal of Malaysia. 51(1): 33-40.

Vasan, R. S., Beiser, A., Seshadri, S., Larson, M. G., Kannel, W. B., D’Agostino, R. B. & Levy, D. 2002. Residual lifetime risk for developing hypertension in middle-aged women and men- the Framingham Heart Study. Journal of the American Medical Association. 287(8): 1003-1010.

Wang, Y. & Wang, Q.J. 2004. The prevalence of prehypertension and hypertension among US adults according to the New Joint National Committee Guidelines. Archives of Internal Medicine.164: 2126-2134.

Padwal, R.S., Hemmelgarn, B.R., Nadia, A.K., Grover, S., McAlister, F.A., McKay, D.W.,Wilson. T., Penner, B., Burgess, E., Bolli, P., Hill, M.D., Mahon, J., Martin G Myers, M.G., Abbott. C., Schiffrin, E.L., Honos, G., Mann, K., Tremblay. G., Milo, A., Cloutier, L., Chockalingam, A., Rabkin, S., Dawes, M., , Touyz, R.M, Bell, C., Burns, K.D., Ruzicka, M., Campbell, N.R.., Lebel, M,. Tobe. S.W. 2008. The 2008 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 1 – blood pressure measurement,diagnosis and assessment of risk. Can J Cardiol 24 (6): 455-463.

Campbell, N.R., Petrella, R., Kaczorowski., J. Public education on hypertension: A new initiative to improve the prevention, treatment and control of hypertension in Canada. Can J Cardiol. 22 (7): 599-603.

Chockalingam, A. 2008. World Hypertension Day and global awareness. Can J Cardiol 24 (6): 441-444.

National Health and Nutrition Examination Survey. 1999-2000 Fields, L. E. et.al. Hypertension.2004.44:398-404

Chobanian AV et al. JAMA. 2003. 289: 2560-2572: Ong, K.L. et al. Hypertension. 2007. 49: 69-75:Ostchega Y. et al. NCHS data Brief. 2008. 3: 1-8

National Health and Nutrition Examination Survey. 1999-2000 Fields, L. E. et.al. Hypertension.2004.44:398-404.

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