Hypertension in the 21st Century
The Tide Is Rising; Our Daze Must End
Epidemiologists can sometimes mesmerize with numbers that, while important, seem inanimate, distant, and impersonal. Not this time. Dr Larry Fields et al have brought the growing hypertension epidemic to life in this issue of Hypertension.1 The clarion call has been sounded; the tide is rising. Whereas the US population grew 13.2% from 1990 to 2000, the estimated number of hypertensives rose 30%, which is more than twice the rate of population growth. As the authors note, factors contributing to the disproportionately faster growth of hypertension include an aging population with an expanding girth. Improvements in medical care for hypertensive patients leading to longer survival also appear to increase the opportunity for an individual to become hypertensive.
Of equal or greater importance, the authors provide information that is vital for determining the societal impact of hypertension and for guiding efforts directed at its prevention, treatment, and control and for directing the allocation of resources required to achieve key goals. Their demographic analyses identified groups by age, gender, and ethnicity that have the greatest absolute burden of hypertension. Of interest, the greatest number of men with hypertension (mode) occurs in the age band of 45 to 54 years, whereas for women the mode is present at age above 75 years. White Americans account for more than 70% of hypertensives, which is proportional to the general population; a fact which may be underappreciated. As expected, black Americans are over-represented in the hypertensive compared with the general population, whereas Hispanic Americans are under-represented in the hypertensive compared with general population. The demography of hypertension has important implications for prevention and management strategies and the resources required to produce a positive impact.
The Tide Is Rising! A Bad Situation With the Potential to Get Worse Presents Great Opportunity
The US population is aging and projected to add ≈30 million individuals aged 60 years and older in the next 20 years. The obesity epidemic shows no signs of slowing. If these trends continue, the prevalence of hypertension, along with diabetes, dyslipidemia, heart and renal disease, and stroke will continue to grow disproportionately more than the population along with an escalating health and economic burden.
There is also an opportunity to stabilize or reverse the trend. Obesity, sedentary lifestyles, and the cardiovascular risk factor cluster including hypertension are not inevitable consequences of aging. As the authors note, blood pressures decline with weight loss, healthy diets, and exercise. The potential contributions of public health strategies and lifestyle changes are under-appreciated.2 Coronary heart disease mortality in the United States declined ≈30% from 1968 to 1976, with more than half of the decline attributable to lifestyle change. Cardiovascular outcomes were reduced >50% in the Oslo Diet and Smoking Study in men randomized to education on healthy diets and smoking cessation compared with men in a time-control group.
The overwhelming numbers on the prevalence of hypertension and its health consequences and economic costs also heighten the importance of cost-effective prevention, treatment, and control strategies. The report by Fields et al provides a foundation for additional work in this broad arena.
The tide is rising. The alert has been issued. The daze must end. Sixty-five million Americans have hypertension. Sixty-nine percent or >40 000 000 hypertensive patients were not controlled in National Health and Nutrition Examination Surveys 1999 to 2000 and more than 40% or nearly 25 000 000 were untreated. This is the time to develop a comprehensive, integrated, and cost-effective approach to the prevention, treatment, and control of hypertension.
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.