George A. Mensah, MD, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Mailstop K-40, 4770 Buford Highway NE, Atlanta, GA 30341-3717 E-mail: email@example.com
High blood pressure (BP) is the most important preventable risk factor for death, disability, and complications from stroke and heart disease.1 In addition, it is the leading risk factor for death from all causes, and it ranks second as a cause of disability.1 The World Health Organization and the Global Burden of Disease Project estimated that in 2001, high BP caused 7.6 million deaths, or 13.5% of global mortality, and an additional 91.5 million disability-adjusted life-years worldwide.1,2
High BP is also common. An estimated 1 billion persons live with high BP today, a number projected to increase to 1.56 billion by 2025.3 The proportion of the population with high BP varies by country. One recent study found the lowest values in rural India (3.4% in men and 6.8% in women) and the highest in Poland (68.9% in men and 72.5% in women).4 Sadly, high BP is universally marked by poor control at the population level. Despite increased awareness and the availability of safe, effective medications, control of this problem ranges from just 5.4% in Korea to 58% in Barbados. In Europe, the most recent data suggest that high BP is not controlled in nearly two-thirds of patients, and despite a large recent increase in antihypertensive drug use, no significant improvement in control rates have occurred since the 1990s.5
THE PROBLEM OF HIGH BP IN THE UNITED STATES
Even though the prevention and control of high BP has been a public health priority in the United States for nearly 4 decades, it remains a major clinical and public health problem.6 As of 2004, the age-adjusted prevalence of high BP in adults had not declined from the 1988–1994 baseline and remained significantly higher than the Healthy People 2010 (HP 2010) national goal (29.6% vs the goal of 16%).7 The proportion of adults whose high BP was controlled also fell short of the national goal (33.1% vs 50%).7 Control rates (among those with high BP) were suboptimal in all sex and racial/ethnic groups, with rates lowest in Mexican American women (24.6%) and non-Hispanic black men (26.8%).7 In fact, the HP 2010 midcourse review8 reported that none of the 4 specific objectives for high BP had met their 2010 targets; objective 12–12 (on BP monitoring) had had no change at all from baseline, and objective 12–9 (high BP prevalence) had actually moved away from the target (Figure).
The adverse finding about prevalence is not surprising. In children, adolescents, and older adults, prevalence has actually increased, a phenomenon attributed to the continuing epidemic of obesity and overweight and the aging of the population. Currently, an estimated 65 million Americans live with high BP, about half of whom are treated, and about 1 in 3 have their high BP controlled.9 Unfortunately, control remains suboptimal even in such high-risk patients as those with diabetes or chronic kidney disease.10 High BP still remains the leading cause of ambulatory visits to physicians for chronic conditions, with associated direct plus indirect costs estimated at $63.5 billion for 2006.11 There are some recent statistics that may suggest an improvement in awareness of the risk of hypertension, the number of hypertensive patients on treatment, and the percentage who report that their BP is controlled to goal levels of <140/90 mm Hg.12,13
Although patient-related factors play a role in suboptimal treatment and control, physician-related factors, such as therapeutic inertia, contribute to the problem. As reported by Berlowitz and colleagues,14 40% of patients had BP values >160/90 mm Hg despite averaging 6 clinic visits annually; even so, increases in therapy occurred in only 7% of visits. The recent survey suggests that >30% of people with elevated BP did not have therapy changed.13
The burgeoning burden of persons with prehypertension is an additional concern. In adults aged 20 years or older, an estimated 41.9 million men and 27.8 million women have prehypertension,15 defined as BP levels of >120/80 mm Hg to <140/90 mm Hg, a condition also seen in children and adolescents, with a prevalence of 9.5% among those aged 11 to 17 years.16 In fact, approximately 20% of adolescents with elevated BP are at risk for hypertension.16 Prehypertension begets hypertension, and thus the rising tide of hypertension cannot be stemmed without addressing prehypertension.
THE HIGH BP PROBLEM IS SOLUBLE
In spite of the disappointing national and global performance in controlling high BP, we have enough evidence to suggest that the problem is soluble. Reaching a solution, however, will require actions from many stakeholders, including patients and their families, the general public, employers, health care providers, payers, and policy makers. Patients, their families, and the general public must have the proper tools, skills, and access to resources for taking effective action; supportive environments are also necessary.
The good news is that most Americans with high BP are aware of it, and most are trying to control it. Long-term changes in lifestyle and behavior are critical; these include addressing physical inactivity, obesity, poor nutrition, and excessive intake of sodium and alcohol.17 The continuing epidemic of obesity and overweight is a major concern; indeed, the Framingham Heart Study has shown that 65% and 78% of the risk of high BP in women and men, respectively, may be related to obesity and that excess adiposity may represent the most preventable and controllable antecedent factor. Not surprisingly, sustained weight loss, even a modest decrease, significantly reduces the long-term risk of high BP in overweight adults. Similarly, moderate levels of physical activity on most days of the week coupled with weight control is effective in reducing the risk of high BP in obese men and women.18
Although the failure of patients to adhere to their physician's advice, especially about lifestyle changes and use of pharmacotherapy, is often discussed, the practices of providers are at issue as well. In addition to therapeutic inertia, there is often widespread failure to follow established guidelines. Using a team of nurse practitioners, community health workers, and physicians has been found effective in improving BP control.19 In a recent international call to action,20 we identified 5 core actions that should be rigorously implemented by practitioners and targeted by health systems worldwide: (1) detect and prevent high BP, (2) assess total cardiovascular risk, (3) actively partner with the patient, (4) treat hypertension to goal, and (5) create a supportive environment.
CALL FOR ACTION
Over the past decade, many urgent calls for action to control high BP have gone unheeded.20–25 This is unfortunate, because a careful review suggests that significant progress could have been made by addressing 3 principal pillars of these calls for action: providers, patients, and policies. It is not too late, however, to refocus the agenda on achieving at least 3 of the 4 HP 2010 objectives.
First, we must recognize the crucial role that health care providers—physicians, nurses, pharmacists, and other allied health professionals—play and the many challenges they face. Appropriate incentives should be provided to facilitate the adoption of the 5 core actions and the attainment of goals for control in all practices. In essence, BP control should be adopted as a quality measure, using nationally accepted metrics such as those in HP 2010. Adherence to established guidelines in all clinical practices will essentially abolish therapeutic inertia. Providers should continue to nurture partnerships with community resources, such as fire stations, work sites, pharmacies, and religious organizations to promote awareness, prevention, and control of high BP. Treating physicians will need support from their health care organizations in the form of systems improvements, information technology, appointment reminder and follow-up systems, and infrastructure for delivering culturally and linguistically appropriate services.
Second, we must continue to increase the proportion of people who are taking actions to control their BP and provide them with the tools and skills they need. Programs initiated by the National High Blood Pressure Education Program (NHBPEP) have been successful and deserve continued support. State and local health departments that focus on low-income and indigent patients with high BP have demonstrated some success and should be supported. In particular, programs that serve Mexican Americans, American Indians, and African Americans who have low control rates deserve emphasis. Programs in the community that help patients and their families increase physical activity, improve nutrition, and prevent and control obesity from childhood onward will be essential.
Third, many of these actions will not be feasible or sustainable without environmental and policy change. For example, patients who restrict consumption of table salt as their strategy against high BP are unlikely to succeed if they have high intakes of processed food. Clearly, they are more likely to succeed if policies exist to reduce the sodium content of such foods.25 Similarly, appropriate policies in the built environment, at work sites, in schools, and in the food and beverage industry can play crucial roles in facilitating long-term lifestyle and behavioral change.17 Providing incentives to improve the quality of care for high BP requires appropriate policies in the health care setting.
But all is not lost. Recent surveys suggest that >50% of persons with high BP have implemented lifestyle changes and that 70% to 90% are taking medication. We should also not forget that, although control rates have not been ideal over the past 30 to 40 years, stroke, congestive heart failure, progression of less severe to more severe hypertension, and myocardial infarction have been dramatically reduced by treatment of high BP.
A REASON TO BE HOPEFUL
Yes, there are many reasons for optimism. Efforts to raise awareness of high BP and the importance of treatment and control, especially in high-risk persons, have been successful.26 This is a major accomplishment that reflects the work of the NHBPEP,27 the American Society of Hypertension, the International Society on Hypertension in Blacks, the American Heart Association, and other organizations and federal agencies.7 We have compelling evidence from clinical trials that the national goals can be achieved. Many safe medications in both brand and generic formulations have demonstrated effectiveness, especially in combinations of 2 or more. Most important, we have the science- and evidence-based knowledge we need. Knowing is not enough, however; we must also act. The scientific evidence and public health infrastructure exist to inform policy development and ensure effective actions for progress in controlling high BP. What we now need is an additional will to act.
Acknowledgments and disclosure:
Dedicated to the memory of Sir Peter Medawar (1915–1987), Nobel laureate and a stroke patient, on the 40th and 35th anniversaries of the publication of his works The Art of the Soluble (1967) and The Hope of Progress (1972), which influenced the title of this editorial. I am grateful to Peter L. Taylor for technical and editorial assistance. The findings and conclusions in this editorial are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.