Although high blood pressure, or hypertension, is one of the most serious and common diseases of modern times, it does not receive significant attention at individual, societal and government levels. High blood pressure is serious because it has no symptoms. A person might have high blood pressure for years without suffering any health problems. However, if left untreated or controlled, it can lead to grave consequences such as heart attack, stroke and kidney failure. Given its importance, WHO is highlighting high blood pressure for this year’s World Health Day in an effort to draw attention to its dangers.

What is high blood pressure?

Understanding blood pressure requires an understanding of the blood cycle. The cycle starts with a contraction of the heart muscle, which pumps its load of oxygen- and nutrient-rich blood to all cells of the body. With each contraction the blood moves from the heart into the aorta, which is the largest artery in the human body. The aorta carries the blood and distributes it to all other arteries of the body. The heart muscle then relaxes to allow new blood into the heart and the cycle begins again.

The force with which the heart pumps blood into the arteries and vessels is called blood pressure. Generally, the level of blood pressure is measured by the quantity of blood pumped by the heart and the resistance the blood flow receives in arteries and veins.

How do we measure blood pressure?

Normal blood pressure in adults is measured by millimetres of mercury (mmHg) and is recorded in two numbers. The first is the systolic blood pressure (the highest pressure in blood vessels), which is the pressure when the heart contracts. It ideally ranges between 115 and 120 mmHg. The second is the diastolic blood pressure (the lowest pressure in blood vessels), which is the pressure while the heart relaxes and dilates. It ideally ranges between 75 and 80 mmHg. Blood pressure is considered high if the systolic measurement is 140 mmHg or more and/or the diastolic measurement is 90 mmHg or more.

Why is high blood pressure dangerous?

It is important to keep your blood pressure within normal limits so that your body’s key organs, e.g. heart, brain and kidney, can work efficiently to maintain your health. Continued high blood pressure can exhaust and damage the heart muscle, which then has to make greater effort to pump blood into the rest of the body. This can affect its efficiency over the long term. Blood pressure that is higher than normal limits also weakens blood vessels, which can lead to stroke, heart attack, infertility, kidney failure, blindness and internal bleeding.

How prevalent is high blood pressure?

One out of every three adults worldwide has high blood pressure. The older people become, the higher the prevalence rises. It starts at one in every ten persons aged in their 20s and 30s, and reaches five out of every ten persons in their 50s. Worldwide, the number of people with high blood pressure grew from 600 million in 1980 to a billion persons in 2008.

Heart disease and stroke are the leading causes of death in most countries; one third of annual deaths worldwide (17.3 million persons) are attributed to cardiovascular diseases. The consequences of high blood pressure account for 8.4 million deaths every year, and high blood pressure is a direct cause of 13% of global deaths. It is also the leading cause of 45% of cardiovascular deaths and 51% of stroke deaths and hence is a global public health threat.

The highest prevalence of hypertension is seen in some low-income African countries, where it is estimated that 40% of adults have high blood pressure.

In the WHO Eastern Mediterranean Region, indicators show that two out of every five people, or more than a quarter of the adult population, have high blood pressure. Incidence rates range between 27.5% (United Arab Emirates) and 42.6% (Libya) and are almost equal between men and women.

Why do we get high blood pressure?

High blood pressure is a noncommunicable disease, with no specific causes. It can strike anyone. However, there are factors that increase the probability of incidence, or the risks if the person is already hypertensive. Some of these factors are related to ageing and others to people’s lifestyle and behaviour. They include the following.

• Unhealthy nutritional habits, which are the leading cause of hypertension, e.g. high intake of salt, fatty foods or alcohol or low intake of vegetables and fruits.
• Low physical activity and lack of exercise. Some people lead sedentary lifestyles and do not exert physical activity or practice sports, thereby increasing their risk of becoming hypertensive.
• Obesity and overweight. The higher a person’s body mass index, the higher the risk for high blood pressure.
• Smoking and tobacco use. The chemical contents of tobacco also cause arterial stenosis, leading to hypertension.
• Constant fatigue, psychological stress, diabetes, raised blood cholesterol and high fat or alcohol intake, which are all factors that increase the risks of high blood pressure.
• Age. Risks increase with age. Women are more likely to have high blood pressure upon reaching menopause, and pregnant women can experience temporary high blood pressure, which returns to normal after delivery. People can also be hypertensive for genetic reasons.

How can we detect high blood pressure?

There is a common misconception that people with high blood pressure always have symptoms. The fact is that they rarely have symptoms. This is why hypertension is described as the ‘silent killer’. Many people are unaware of their condition and remain undiagnosed, only to discover it too late, after dangerous consequences such as heart attack take place. When symptoms do occur, the most common are headache, shortness of breath, dizziness, chest pain, heart palpitations or nose bleeds.

The best way to detect high blood pressure is to measure it, either at adoctor’s office or at home with a digital blood pressure meter. The normal blood pressure range is between 115/75 and 120/80 mmHg.

There are three levels of high blood pressure.

Prehypertension

The systolic blood pressure ranges between 120 and 139 mmHg or the diastolic blood pressure is between 80 and 89 mmHg.

First stage

The systolic blood pressure ranges between 140 and 159 mmHg or the diastolic blood pressure is between 90 and 99 mmHg.

Second stage

The systolic blood pressure is 160 mmHg or higher, or the diastolic blood pressure is 100 mmHg or higher.

How do people control their high blood pressure?

People must play a more effective role in maintaining their health. Knowledge of blood pressure level helps people to monitor their health. The earlier hypertension is detected, the less risk there is of possible consequences such as heart attack, stroke, kidney failure or blindness.

If an individual detects high blood pressure, s/he should:

• Immediately see a doctor, follow the doctor’s instructions and adhere to prescribed medications;
• Monitor levels of blood sugar and cholesterol and urine albumin in order to ensure the kidneys are healthy and evaluate risks to the heart and blood vessels;
• Change dietary habits by reducing daily salt intake to less than 5 grams, eating fruits and vegetables on a daily basis and reducing intake of saturated and trans fatty acids;
• Lose weight, if overweight: every 5 kilograms lost reduces systolic blood pressure by 2–10 mmHg;
• Avoid tobacco and alcohol use and manage tension and stress through healthy relaxation methods;
• Monitor blood pressure regularly through blood pressure meters, which are available at affordable prices.

Self-care, quitting unhealthy habits, consulting a doctor and adhering to medications are all very important. Self-care is even more important for people who have limited access to health services.

Reduction of salt to prevent high blood pressure

The daily amount of salt consumed by people is a major contributor to hypertension. Daily salt intake in most countries ranges between 9 and 12 grams. However, WHO recommends that daily salt intake should not exceed 5 grams.

Scientific and medical studies have showed that reducing daily salt consumption is one of the most effective means of lowering blood pressure, and therefore reducing the risk of heart disease and stroke.

Food producers can play an effective role in maintaining people’s health if they gradually and steadily reduce the salt added to processed food. In addition, media campaigns are needed to encourage everyone to reduce the amount of salt in their food.

Several countries have implemented successful programmes to reduce food salt and raise public awareness about salt-related dangers to health. In the early 1970s, Finland, in collaboration with the media, implemented a systematic plan to encourage people to reduce their salt intake. The plan included public media campaigns and collaboration with food producers. The resulting decrease in salt intake has reduced systolic and diastolic blood pressure by 10 mmHg as well as deaths from heart disease and stroke in Finland since that period.

The United Kingdom, United States of America and other high-income countries have also implemented successful salt reduction initiatives, in collaboration with food producers. Recently, several developing countries have launched national initiates to reduce salt intake. Salt reduction among a population requires concerted efforts at all levels and contributions from the government, food producers, nongovernmental organizations, health care experts and the public at large.

Organizations responsible for fighting high blood pressure

Governments, health care professionals, the private sector, families and individuals have a crucial role in the prevention and treatment of high blood pressure, and therefore in preventing its dangerous consequences.

Role of civil society

The whole of society, including nongovernmental organizations, academia, professional associations and the private sector, has a key role in combating noncommunicable diseases in general and hypertension in particular by addressing the major common risk factors such as tobacco use, unhealthy diet, low physical activity and harmful use of alcohol. Partnerships between nongovernmental organizations and academia offer opportunities for the exchange of expertise and resources required for building capacities and developing the skills of individuals, families and communities.

Economic and social costs of hypertension and the role of government

Hypertension, heart attacks, cardiac arrests, strokes and kidney failure are a huge burden on the health care budget in all countries. Expenditure on cardiovascular diseases ranges between 8% and 22% of total health expenditure in most countries.

The consequences of high blood pressure result in serious social costs including depletion of family resources on treatment, early death and disability and loss of the family’s breadwinner. Dealing with these consequences also puts a huge economic burden on the budgets of governments and states.

Some countries have managed to control the prevalence of hypertension through targeted prevention strategies. Controlling high blood pressure and related risk factors is possible and affordable. It also results in huge savings for the country over the long term.

Several countries have also managed, thanks to early detection programmes for high blood pressure, to gradually reduce deaths from cardiac disease and stroke over the past three decades.

A package of interventions and policies should be adopted by governments to reduce the prevalence of high blood pressure and mitigate its consequences:

• Evaluating cardiovascular health and measuring blood pressure during a patient’s first contact with primary health care providers;
• Integrating treatment for high blood pressure within primary health care as an integral part of the national strategy for noncommunicable disease prevention and control;
• Developing integrated policies to reduce people’s exposure to behavioural risk factors, .e.g. unhealthy diet and lack of exercise, and establishing a population-based strategy for salt reduction;
• Ensuring the availability of technology and essential medicines for the treatment of patients and the necessary coordination and integration between different levels of the health system for appropriate treatment;
• Ensuring universal access to the necessary services to prevent high blood pressure and its consequences.

Role of doctors and health care providers

Most hypertension cases can be treated at primary health care level. Doctors and other trained health care officials play a vital role in the detection and treatment of high blood pressure. WHO has developed guidelines and several tools to assist health care providers in offering affordable treatment of high blood pressure at the primary care level.

World Health Day campaign objectives

The World Health Day 2013 campaign, which is held under the theme: “Control your pressure, control your life”, aims at the following:

• Reducing rates of heart attack and stroke
• Promoting awareness and healthy behaviour, improving detection methods and developing protective settings
• Raising awareness about the causes, consequences and prevention of hypertension
• Encouraging adults to check their blood pressure regularly and follow the advice of doctors and health care providers
• Promoting self-care to prevent hypertension and control its effects
• Providing universal access to blood pressure measurement devices
• Urging national and local authorities to develop settings that facilitate healthy behaviour.

Why do we need legislation for a health issue?

Worldwide, high blood pressure is estimated to cause 7.5 million deaths yearly, making it the world’s leading cause of death, followed by tobacco use.

Fortunately, we know what works: a comprehensive set of actions that, if supported by legislation and implemented by countries, can help to reduce the prevalence of high blood pressure.

1. Promoting a balanced diet
2. Reducing salt intake
3. Discouraging tobacco use
4. Discouraging harmful use of alcohol
5. Promoting regular physical activity

Each of these items has a set of legal measures that, once adopted, can significantly reduce the death toll associated with high blood pressure, help those affected by it and prevent future morbidity and mortality.

World Health Day 2013, with its focus on high blood pressure, can provide new impetus for the development and implementation of effective laws at national level. Such laws will help people to improve their quality of life and oblige the food industry, together with national authorities, to implement certain measures and take actions proven to work.

Legislation is at the heart of effective control of different health risks, including high blood pressure. Legislation institutionalizes a country’s commitment, creates a focus of activity and controls private conduct in ways that informal measures cannot. It is therefore very important.

What are the legal measures needed?

For each of the actions above, there are certain measures that if implemented by the government will help to reduce the prevalence of high blood pressure at national level. Table 1 provides examples of suggested measures to be included in legislation to help reduce the prevalence of high blood pressure.

Table 1. Suggested measures to be included in legislation to help reduce prevalence of high blood pressure.

What is needed for the development of effective legislation?

A national lead agency should be identified to initiate the process. Since the measures needed to address high blood pressure cut across many sectors, it is unlikely that all necessary legislative action can be incorporated into one law. It is therefore crucial to have a lead agency coordinating the development of various laws to ensure all necessary technical measures are incorporated.

The lead agency along with many other partners at national level will follow the country’s normal procedures for revising or initiating legislation.

The technical lead agency must have control of the process and access to the concerned authorities at all stages of the process. Otherwise changes can be made to the proposed actions that are not based on evidence and that may reduce the effectiveness of the new legislation.

Once the idea of legislation is proposed, the items that will go into the legislation must be identified. This should be the responsibility of the specialized technical team established by the lead agency. It should not be left to the legal departments to draft the legislation and to decide on what measures to include.

The different phases of the legislative development process are expected to be as follows.

What are the potential obstacles?

Technical recommendations ignored during legal drafting. It is very important for the lead agency to have access to all partners during all phases in order to make sure the relevant technical recommendations are incorporated into the legislation.

No social or media support. Awareness campaigns should be initiated for all partners, the public and the media at the beginning of the process in order to ensure support for the new legislation.

Weak implementation and enforcement of legislation. It is vital to identify an enforcement authority within the legislation, as without one there is a high risk of weak enforcement. Sometimes, the lead agency is assigned this task in the legislation. It is also very important to have a strong monitoring system; nongovernmental organizations and civil society groups can be excellent partners in this area. The selection of the right enforcement authority, the right mix of penalties and the right enforcement procedures is critical for effective enforcement.

Regular physical activity [1] is one of the first treatments recommended to lower blood pressure and improve cardiovascular health, among both the general population and those people with hypertension.

What is the link between high blood pressure and physical activity?

Exercising on a regular basis has many health benefits and protects people against high blood pressure and cardiovascular diseases. Studies show that by reducing systolic blood pressure by 5 mmHg, deaths from strokes can be reduced by 14% and deaths from coronary heart disease can be decreased by 9%[2]. Regular exercise is key to preventing and treating hypertension.

What is the prevalence of physical inactivity in the Region?

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.

The situation among adolescents is not encouraging. Data on the combined risk factors of overweight and lack of physical activity show that adolescents do not exercise sufficiently.

What is the recommended amount of exercise?

Physical activity refers to any bodily movement which uses energy and is performed as part of daily activities, such as household chores, walking, certain work and leisure-time activities, games, sports or planned exercise.

For every age bracket, WHO recommends levels of physical activity for the prevention of chronic diseases such as cardiovascular diseases, stroke and hypertension.

Children and youth aged 5–17 years

• Children should accumulate at least 60 minutes of moderate-to-vigorous intensity physical activity daily.
• Amounts of physical activity greater than 60 minutes provide additional health benefits.
• Most of the daily physical activity should be aerobic. Vigorous intensity activities should be incorporated, including those that strengthen muscle and bone, at least 3 times per week.

Adults aged 18–64 years

• Adults should accumulate at least 150 minutes of moderate intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous intensity aerobic physical activity throughout the week
• For additional health benefits, adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous intensity aerobic physical activity per week, or an equivalent combination of moderate and vigorous intensity activity.
• Muscle-strengthening activities should be carried out on 2 or more days a week.

Adults aged 65 years and older

• Older adults should accumulate at least 150 minutes of moderate intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous intensity aerobic physical activity throughout the week.
• Aerobic activity should be performed in sessions of around 10-minutes duration.
• For additional health benefits, older adults should increase their moderate intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous intensity aerobic physical activity per week.
• Older adults with poor mobility should perform physical activity to enhance balance and prevent falls on 3 or more days per week.
• Muscle-strengthening activities, involving major muscle groups, should be done on 2 or more days a week.

[1] Physical activity is any bodily movement produced by the skeletal muscles that uses energy. (WHO)

[2] San Francisco burden of disease and injury study. Determinants of health, high blood pressure: what can be done?

The prevention and control of high blood pressure, also known as hypertension, requires political will on the part of governments and policy-makers along with the efforts of health workers, the academic research community, civil society, the private sector and families and individuals. Everyone has a role to play.

Governments and policy-makers

• Implement public health policies and interventions that are affordable, sustainable and cost-effective.
• Integrate hypertension control programmes that address total cardiovascular risk as an integral part of national strategies for the prevention and control of noncommunicable diseases.
• Set up a surveillance and monitoring system to track the prevalence of hypertension and other noncommunicable diseases.
• Ensure equitable access to preventive, curative and rehabilitative health services.
• Promote actions at the primary health care level that target prevention and health promotion.
• Ensure the availability of essential medicines for the control of hypertension.
• Strengthen all components of the health system: governance, financing, information, human resources, service delivery and access to quality generic medicines and basic technologies.
• Mobilize population-wide approaches to reduce the exposure of the whole population to risk factors such as unhealthy diet, physical inactivity, harmful use of alcohol and tobacco use.

Health workers

• Raise awareness on hypertension among different population groups through blood pressure measurement campaigns and health education programmes in the workplace.
• Follow WHO guidelines and tools to manage hypertension cost-effectively in primary health care settings.
• Follow WHO guidance on the appropriate use of medicines in an affordable and sustainable manner.

Academia and professional associations

• Build the capacity of primary health care physicians and non-physician health workers in the detection and management of hypertension.
• Institutionalize training on the detection and management of hypertension within the educational curricula for physicians, nurses and allied health workers.
• Generate and disseminate scientific evidence to inform implementation of appropriate cost-effective measures for prevention and control of hypertension.

Civil societies and nongovernmental organizations

• Partner with academia to build both workforce capacity and the skills of individuals, families and communities.
• Advocate with policy-makers about the influence of living conditions and behaviour on blood pressure levels.
• Mobilize political and social awareness to address hypertension and other noncommunicable diseases.
• Provide prevention and health care services that fill gaps in the public and private sectors.
• Improve access to parks and playgrounds and create safe neighbourhoods for physical activity.

The private sector, excluding the tobacco industry

• Practice and ensure responsible marketing of foods and non-alcoholic beverages, particularly to children.
• Ensure correct labelling of food products to enable consumers to make healthy choices.
• Contribute to the development of cutting-edge health technologies and applications for the detection of high blood pressure.
• Promote workplace-based wellness programmes by establishing tobacco-free workplaces, implementing occupational health and safety measures and health insurance plans and creating environments for walking, cycling, sports and other physical activities.
• Work towards making essential medicines more affordable and accessible.

Individuals

• Have your blood pressure checked regularly. High blood pressure has no symptoms in most people.
• Maintain a healthy lifestyle (eat a healthy diet, maintain a healthy weight, get regular exercise, stop smoking).
• If you are diagnosed with high blood pressure, participate actively in managing the condition.
• Adopt healthy behaviours
• Monitor blood pressure regularly
• Check blood sugar, blood cholesterol and urine albumin
• Check cardiovascular risk using a risk assessment tool
• Follow medical advice and comply with medication.

World Health Organization

• Provide evidence-based guidance and implementation tools to assist countries in addressing hypertension through a combination of interventions focused on individuals and the whole population.
• Coordinate the development of a global action plan for the prevention and control of noncommunicable diseases and a global monitoring framework.
• Monitor the impact of action to address hypertension and other noncommunicable diseases.