RELATED LITERATURE

Hypertension, also known as high or raised blood pressure, is a condition in which the

blood vessels have persistently raised pressure. Blood is carried from the heart to all parts of the

body in the vessels. Each time the heart beats, it pumps blood into the vessels. Blood pressure is

created by the force of blood pushing against the walls of blood vessels (arteries) as it is pumped

by the heart. The higher the pressure the harder the heart has to pump. (1).

It is one of the strongest risk factors for almost all different cardiovascular diseases

acquired during life, including coronary disease, left ventricular hypertrophy and valvular heart

diseases, cardiac arrhythmias including atrial fibrillation, cerebral stroke and renal failure. (1.6)

According to the American College of Cardiology, the American Heart Association from

the “2017 guideline for the prevention, detection, evaluation and management of high blood

pressure in adults”, for years, hypertension was classified as a blood pressure (BP) reading of

140/90 mm Hg or higher, but the updated guideline classifies hypertension as a BP reading of

130/80 mm Hg or higher. The updated guideline also provides new treatment recommendations,

which include lifestyle changes as well as BP-lowering medications(1.3), however, the Philippines

still follows the 2003 high blood pressure guideline (JNC 7) – at 140/90 mmHg instead of the new

130/80 mmHg set. “The ACC/AHA guideline was based on a study conducted mostly by

Caucasians Americans (98%). Only 2% was of Asian ethnicity”, said Dr. Jorge Sison, president

of the Philippine Heart Association (PHA). (1.4)

The Joint National Committee on Detection, Evaluation, and Treatment of High Blood

Pressure (JNC) issued 7 described three stages of high blood pressure associated with increasing

risk of cardiovascular and renal diseases. It used cut-off points of 120-139 mmHg (systolic) and

80-89 mmHg (diastolic) to define Stage prehypertension, 140-159 (systolic) and 90-99 (diastolic)

for Stage 1 and ≥ 160 (systolic) and ≥100 (diastolic) to consider Stage 2 hypertension. (1.5).

Normal adult blood pressure is defined as a blood pressure of <120 mm Hg1 when the heart

beats (systolic) and a blood pressure of <80 mm Hg when the heart relaxes (diastolic). When

systolic blood pressure is equal to or above 140 mm Hg and/or a diastolic blood pressure equal to

or above 90 mm Hg the blood pressure is considered to be raised or high. (1)

 Most people with hypertension have no symptoms at all; this is why it is known as the

“silent killer”. Sometimes hypertension causes symptoms such as headache, shortness of breath,

dizziness, chest pain, palpitations of the heart and nose bleeds, but not always. (1)

In recent years, studies have assessed intrapersonal factors such as age, sex, waist

circumference, body mass index, triglycerides, and cholesterol levels as risk profiles for

hypertension in adults (Agyemang & Owusu-Dabo, 2008; Ferguson et al., 2008; Njelekela et al.,

2009). Furthermore, extrapersonal factors such as smoking, alcohol consumption, physical

inactivity, and high sodium diets are also attributed to increased risk profiles (BeLue, et al., 2009;

Njelekela, et al., 2009) (1.1). Behavior and lifestyle-related factors can put people at a higher risk

for developing high blood pressure . In some cases, Genetic factors may play a role and a close

relative may have a history of high blood pressure and combined with unhealthy lifestyle

choices.(1.2).
 RISK FACTORS FOR HYPERTENSION

Cigarette smoking

Tobacco kills more than 7 million people each year. More than 6 million of those deaths

are the result of direct tobacco use while around 890 000 are the result of non-smokers being

exposed to second-hand smoke. (1.7). Globally, tobacco use and exposure to secondhand smoke

contribute to approximately 12 percent of all heart disease deaths, as data from WHO showed (2.2)

For the past decades, it has been clear that smoking is an important (and modifiable) risk

factor for Cardiovascular diseases (CVD); according to World Health Organization data. Kjeldsen

(2018) smoking cessation is the single most effective lifestyle measure for the prevention of a large

number of CVD. (1.6). Cigarette smoking acutely exerts an hypertensive effect, mainly through

the stimulation of the sympathetic nervous system. However, mechanisms linking smoking to

blood pressure are poorly understood. Available data do not put clearly in evidence a direct causal

relationship between these cardiovascular risk factors, a concept supported by the evidence that no

lower blood pressure values have been observed after chronic smoking cessation.(1.8)

Thuy et al. (2010) examined the association between smoking and hypertension in a

population-based sample of Vietnamese men (n=910). The researcher found out that there were

significant trends of increasing prevalence of hypertension with increasing years (P = 0.05) and

pack-years (P = 0.03) of smoking(2).

The 2015 Philippines’ Global Adult Tobacco Survey (GATS) reported that currently only 15.9

Filipino adults currently smoked tobacco products – 40.3 among men and 5.1 % among women. Smoking

among women declined by close to 50% - also a sign that measures to counteract smoking among women

are working. (2.1). Moreover, the Philippine Statistics Authority lists five other non-communicable

diseases linked to smoking as top causes of deaths and diseases among Filipinos namely, cancers,

stroke, hypertension, diabetes mellitus, other heart diseases. These are known to be strongly linked

to four risk factors, one of which is tobacco use.(2.2)

Alcohol

21 September 2018 – Geneva. More than 3 million people died as a result of harmful use of alcohol

in 2016, according a report released by the World Health Organization (WHO) today. This

represents 1 in 20 deaths. More than three quarters of these deaths were among men. Overall, the

harmful use of alcohol causes more than 5% of the global disease burden(3). An estimated 2.3

billion people are current drinkers. Alcohol is consumed by more than half of the population in

three WHO regions – the Americas, Europe and the Western Pacific (3.2)

The relationship between alcohol consumption an cardiovascular diseases is complex. Habitual

light to moderate alcohol intake (up to 1 drink per day for women and 1 or 2 drinks per day for

men) is associated with decreased risks for total mortality, coronary artery disease, diabetes

mellitus, congestive heart failure, and stroke. However, higher levels of alcohol consumption are

associated with increased cardiovascular risk (3.3). Moreover, alcohol consumption has

detrimental effects on hypertension, atrial fibrillation and hemorrhagic stroke, regardless of the

drinking pattern (Roerecke and Rehm 2012)(3.1).

Epidemiological, preclinical and clinical studies established the association between high alcohol

consumption and hypertension. Several possible mechanisms have been proposed such as an

imbalance of the central nervous system, increased cortisol levels, increased vascular reactivity,

and stimulation of the renin-angiotensin-aldosterone system is the major contributors of the

alcohol-induced hypertension (3.4).

(Briasoulis et al 2012) A total of 16 prospective studies (33,904 men and 193,752 women) were

included in the analysis. Compared with nondrinkers, men with alcohol consumption with <10g/d

and 11 to 20 g/d had a trend toward increased risk of hypertension, whereas a significantly

increased risk of hypertension was found with heavy alcohol consumption of 31 to 40 g/d. Among

women, the meta‐analysis indicated protective effects at <10 g/d, and a trend toward decreased

risk of hypertension with alcohol consumption 11 to 20 g/d, whereas a significantly increased risk

of hypertension was indicated with heavy alcohol consumption of 21 to 30. (3.5).

Diet

Unhealthy diet and physical inactivity contribute to around 30% of preventable morbidity and

mortality from non-communicable diseases, including morbidity and mortality due to

hypertension. Excessive intake of saturated fatty acids and trans fatty acids, along with higher

consumption of salt and sugar, are risk factors for cardiovascular diseases including hypertension.

(3.6)

The prevalence of risk factors for cardiovascular diseases is high in most countries of the Eastern

Mediterranean Region. Two out of five adults in the Eastern Mediterranean Region are affected

by high blood pressure. Levels of overweight and obesity are very high in Bahrain, Egypt, Jordan,

Kuwait, Saudi Arabia and the United Arab Emirates, with the prevalence of overweight and

obesity ranging from 74% to 86% among women and 69% to 77% among men. Estimates of

sodium intake indicate that the amount of salt in diets in most countries in the Region is higher

than the recommended level. Total fat intake has increased in most countries of the Region,

contributing between 35.9% and 38.9% of the total energy intake. This percentage is higher than

the maximum value of 30% recommended by WHO. There is also a trend towards increased

consumption of fat from animal products, which are high in saturated fatty acids.(3.6)

(Lelong et, al 2015) Cross-sectional analyses were performed using data from 8,670 volunteers

from the NutriNet-Santé Study, an ongoing French web-based cohort study. Dietary intakes were

assessed using three 24-hour records. Salt intake was positively associated with SBP in men but

not in women. The negative relationship between consumption of fruits and vegetables and SBP

was significant in both sexes. (3.7). (cite by Sung Kyu Ha , 2014) INTERSALT study was one of

the first large international epidemiologic studies on sodium intake and hypertension using a

standardized method for measuring 24-hour urinary sodium. In an initial analysis of 48 of the 52

centers, no significant association between sodium intake and median BP was found. However,

after inclusion of the remaining 4 centers, in which the average sodium consumption was 0.2-

50mmol/day, they found a significant association between salt intake and the increase in BP with

age (3.8).
Age

Hypertension is a highly prevalent condition that dramatically rises in incidence with

increasing age. Several key mechanisms – including inflammation, oxidative stress, and

endothelial dysfunction – are common to biologic aging and hypertension development and

appear to have key mechanistic roles in the development of the cardiovascular and collateral

risks of late-life hypertension (4). Higher prevalence among the elderly is largely due to

physiological changes in artery structure and function that come with aging. (4.1)

Hypertension increased over time in individuals aged 40 to 59 years and 60 years or older, and

it was greater among individuals aged 60 years or older and 40 to 59 years than for those 18 to

39 years and was more common in those 60 years or older than for 40 to 59 years (Egan et al

2010) (4.2).

Notably, older adults account for the bulk of hypertension-related morbidity and mortality –

due largely to dramatically greater prevalence among the elderly (Mozaffarian et al., 2015). In

fact, recent data from the National Health and Nutrition Examination Survey indicate that 70%

of older adults have hypertension, compared to only 32% for adults aged 40-59 years (Figure

1) (Mozaffarian et al., 2015). (4.3)

The data was collected from The Statewide Planning and Research Cooperative System

(SPARCS) in New York State. SPARCS discharges are collected from inpatients from

2000 to 2012. The method is cross-sectional analysis. The prevalence of hypertension

consistently increases with age going from 6.49% hypertension for the 18 - 39 age group to

66.15% hypertension prevalence for the 80 + age group (Alamoudi, 2014). (4.4)

Within 3 integrated healthcare systems in the Cardiovascular Research Network, they studied

152,561 patients with incident hypertension, 55.6% were women. Compared to men, women

were older, had more kidney disease and more blood pressure measures during follow-up. A

significant gender by age interaction was found with men aged 18–49 having 17% lower odds

of hypertension control and men aged ≥ 65 having 12% higher odds of hypertension control

compared to women of similar ages (p<0.001). In this incident hypertension cohort, younger

men and older women had lower rates of hypertension control compared to similarly aged

peers. (4.5)
Physical Inactivity

Globally, around 23% of adults aged 18 and over were not active enough in 2010 (men 20%

and women 27%). Insufficient physical activity is a key risk factor for noncommunicable

diseases (NCDs) such as cardiovascular diseases, cancer and diabetes. (5.3)

Physical inactivity among the adult population constitutes a real problem in the Eastern

Mediterranean Region. Low levels of physical activity have a direct link with weight gain,

which in turn increases the risk of raised blood pressure. In some countries of the Region, the

prevalence of physical inactivity can reach 70% of the adult population. (5)

In this cross-sectional study, adult United States residents were included from the Medical

Expenditure Panel Survey (MEPS) for 2002. Hypertensive patients who were physically active

accounted for 46 % and the risk of hypertension was higher in physically inactive individuals

than in those who were physically active (Odds ratio, 1.1; 95 % Confidence interval, 1.07 to

1.12, p < 0.0001). (5.1)

Published literature reports controversial results about the association of physical activity (PA)

with risk of hypertension. PubMed and Embase databases were searched to identify all related

prospective cohort studies. Thirteen prospective cohort studies were identified, including

136 846 persons who were initially free of hypertension, and 15 607 persons developed

hypertension during follow-up. The results of this meta-analysis suggested that there was an

inverse dose–response association between levels of recreational PA and risk of hypertension,

whereas there was no significant association between occupational PA and hypertension. (5.2)
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