Policy Tag: Hypertension

Adopted by the 71st WMA General Assembly (online), Cordoba, Spain, October 2020

 

PREAMBLE

Hypertension is the single most important risk factor for cardiovascular death globally. It accounts for more deaths from cardiovascular disease than any other modifiable risk factor. More than half of people who die from coronary heart disease and stroke had hypertension. “As populations age, adopt more sedentary lifestyles, and increase their body weight, the prevalence of hypertension worldwide will continue to rise.

Uncontrolled hypertension is a major cause of stroke and other co-morbid, chronic conditions, such as heart failure, kidney disease, vision loss, or mild cognitive impairment. Because hypertension can be asymptomatic, it may often go undiagnosed.

In 2010, hypertension emerged as the leading risk factor for disease burden in every region of the world. Moreover, elevated systolic blood pressure (SBP) is a leading global health risk. The WHO Global Plan of Action for the prevention of non-communicable diseases calls for a 25% reduction in the prevalence of elevated blood pressure by 2025.

Prevalence

Worldwide prevalence of hypertension has grown significantly over the past four decades, and most with hypertension are not achieving optimal control.

Of concern is an increasing disparity in hypertension prevalence between high-income and low/middle–income countries. Almost three times as many people with hypertension live in low/middle–income countries than in high-income countries. Low-income countries in south Asia, sub-Saharan Africa, and central and eastern Europe, are particularly impacted. Moreover, the prevalence of elevated blood pressure was highest in certain regions of Africa in both sexes.

Risk Factors

Hypertension risk factors are attributes that increase the likelihood of developing the disease. Risk factors include the following:

  • Lifestyle/Diet: Unavailability of healthy food choices, lack of access to safe neighborhoods for exercising, and unhealthy lifestyle habits can raise the risk of hypertension. Unhealthy lifestyle habits include unhealthy eating patterns such as eating too much sodium and highly processed food, drinking too much alcohol, smoking, and being physically inactive.
  • Age: Blood pressure (BP) tends to increase with age. However, the risk of hypertension is increasing for children and teens, possibly due to the rise in the number of children and teens who are overweight or obese.
  • Socioeconomic Status: In high-income countries, the greatest absolute burden of hypertension disease is in age groups 60 years and older, whereas in low/middle-income countries, the greatest absolute burden is in the middle-aged groups, such as 40 to 59 years. The age-standardized prevalence of hypertension is higher in low/middle-income countries than in high-income countries.
  • Sex: Before age 55, men are more likely than women to develop hypertension. After age 55, women are more likely than men to develop it.
  • Genetics/Family History: Research has identified many gene variations associated with small increases in the risk of developing hypertension. Some people are genetically predisposed to dietary sodium sensitivity.

Accurate blood pressure measurement

The accurate measurement of BP—both within the clinical setting and at home—is essential for the diagnosis and management of hypertension. In many countries, national clinical guidelines recommend how to achieve an accurate BP measurement and offer best practice recommendations.

Policy implications

Policies and actions at the global, national, and local levels are necessary to recognize and combat hypertension. Much effort is needed worldwide to improve awareness, treatment, and control for all populations. Current guidelines to diagnose and treat hypertension, and evidence-based guidance on the importance of proper BP measurement, offer anchors for national policies on BP measurement and control. Implementation can make significant progress towards lowering global hypertension prevalence and improving patient outcomes. To address the risk factors for hypertension, policies should also focus on addressing socioeconomic, lifestyle and dietary factors which contribute to the development of the disease.

 

RECOMMENDATIONS

  1. The World Medical Association recommends that national governments:
  • Recognize hypertension as the single most important risk factor for cardiovascular disease and death.
  • Declare hypertension control a national health priority.
  • Support campaigns to raise public awareness of hypertension, including recognition of its widespread and asymptomatic nature, and its risk of contributing to development of other serious diseases.
  • Deploy adequate resources to improve hypertension awareness, diagnosis, measurement, and management.
  • Develop country-specific strategies which address the risk factors for hypertension and advocate for improvements in awareness, diagnosis, measurement and management.
  • Promote the recommendations adopted by the WMA as stated in the Statement on Reducing Dietary Sodium Intake.
  1. The World Medical Association recommends that its constituent members:
  • Advocate at the international, national, and local levels to promote hypertension awareness, healthy lifestyles, and patient access to hypertension diagnosis and treatment including medications. This includes supporting the concept that social determinants of health are part of hypertension disease prevention.
  • Recognize and support national guidelines and strategies for measuring BP accurately.
  • Support the exchange of hypertension research, information, tools, and other resources amongst healthcare teams and patients.
  • Support the development of medical curricula that respond to societal hypertension needs with a focus on community-based primary care training and BP measurement and management skills.
  • Promote research on the causes, mechanisms and effective treatments of hypertension.
  • Advocate for sustained availability antihypertensive medications.
  1. The World Medical Association recommends that physicians:
  • Emphasize the risk factors for hypertension and ways to mitigate them, paying special attention to prevention and treatment in high-risk populations.
  • Emphasize team-based care to help prevent and, where it has been diagnosed by a physician, to treat hypertension.
  • Implement BP measurement best practices and techniques, including training and retraining of all healthcare team members.
  • Promote patient hypertension treatment adherence by facilitating ongoing patient BP self-management and involvement in the patient’s own care.

 

Adopted by the 59th WMA General Assembly, Seoul, Korea, October 2008
and revised by the 70th WMA General Assembly, Tbilisi, Georgia, October 2019

 

PREAMBLE

Dietary table salt is an ionic compound comprising of sodium chloride, which is 40% sodium (Na+) and 60% chloride (Cl-). There is overwhelming evidence that excessive sodium intake is a risk factor for the development, or worsening of hypertension, which is one of the main cardiovascular risk factors. Hypertension may also be an independent risk factor for cardiovascular diseases as well as all-cause mortality. The effect of dietary sodium on blood pressure is influenced by various demographic factors such as age and ethnicity.

Salt intake is also a risk factor for gastric cancer [1].

The World Health Organization (WHO) recommends that average daily sodium consumption in adults (≥16 years of age) should be less than 2000 mg (5 g salt). For children (2–15 years of age), the adult intake limit of 2 g/day sodium should be adjusted downward based on the energy requirements of children relative to those of adults [2].

The majority of the world’s population consumes too much sodium – 3.95 (3.89–4.01) g/day, equivalent to table salt level of 10.06 (9.88–10.21) g/day. These consumption levels are far above the recommended limit [3].

The main source of sodium is dietary consumption, 90% of it in the form of salt [4], as added salt during cooking or eating, or in processed foods such as canned soups, condiments, commercial meals, baking soda, processed meats (such as ham, bacon, bologna), cheese, snacks, and instant noodles, among others. In higher-income countries sodium added during food processing can be as high as 75%-80% of total salt intake [5].

The Global Action Plan for the Prevention and Control of Non-Communicable Disease (NCDs) 2013-2020 is made up of 9 global targets, including a 30 % relative reduction in mean population intake of sodium. The WHO has created the S.H.A.K.E technical package to assist Member States with the development, implementation and monitoring of salt reduction strategies.

The WHO recognises that while salt reduction is recommended globally, there is concern that iodine deficiency disorders (IDD) may re-emerge as iodized salt is the main vehicle for dietary iodine intake through fortification. Therefore the WHO, in recognition of the importance of both sodium reduction and iodine fortification, urges that efforts of the two programs be coordinated [6].

Substantial overall benefits can result from even small reductions in the population’s blood pressure. Population-wide efforts to reduce dietary sodium intake are a cost-effective way to reduce overall hypertension levels and subsequent cardiovascular disease. Evidence shows that keeping sodium consumption within the reference level could prevent an estimated premature 2.5 million deaths each year globally [7].

 

RECOMMENDATIONS

1. WMA and its Constituent Members should:

a. Urge governments to recognise that salt consumption is a serious public health problem and prioritise prevention as an equitable, cost effective and lifesaving population-wide approach to address high sodium intake and the associated high burden of cardiovascular diseases.

b. Work in cooperation with national and international health organisations to educate consumers from childhood about the effects of excessive sodium intake on hypertension and cardiovascular disease, the benefits of long-term reductions in sodium intake, and about the dietary sources of salt/sodium and how these can be reduced.

c. Urge the governments and other stakeholders work together to achieve the targets set in the Global Action Plan for the Prevention and Control of NCDs 2013-2020.

d. Recognise the critical role of the food processing and food services industry in reducing dietary sodium, and support regulatory efforts involving mandatory targets in food processing, sodium content of foodstuffs, and clear labelling. Food reformulation efforts must target food products that are most commonly consumed in the population.

2. Constituent members of WMA should:

a. Encourage their governments strictly to enforce laws regulating the sodium content in processed foods.

b. Embrace a multi stakeholder approach in working towards reducing the consumption of excessive sodium by the population, including active promotion of physician awareness regarding the effects of excessive dietary sodium.

c. Recognise that sodium reduction and salt iodization programmes need to be compatible and support sodium reduction strategies that do not compromise dietary iodine content, or increase or worsen iodine deficiency disorders, especially in low income settings.

d. Contribute to making the public aware of the potential consequences of low iodine levels as a result of restricted iodized salt intake.

e. Encourage their members to contribute to scientific research on sodium reduction strategies.

f. Encourage the initiation of food labeling, media campaigns and population-wide policies such as mandatory reformulation to achieve larger reductions in population-wide salt consumption than individually focused interventions.

3. Individual physicians should:

Counsel patients about the major sources of sodium in their diets and how to reduce sodium intake, including reducing the amount of salt used in cooking at home, use of salt substitutes, and addressing any relevant local practices and beliefs that contribute to high sodium intake.

 

References:

[1] World Cancer Research Fund / American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 2007.

[2] Guideline: Sodium intake for adults and children. Geneva, World Health Organization (WHO), 2012.

[3] Mozaffarian, Dariush, Fahimi, Saman, Singh, Gitanjali M., Micha, Renata, Khatibzadeh, Shahab, Engell, Rebecca E., Lim, Stephen, Danaei, Goodarz, Ezzati, Majid and Powles, John (2014) Global sodium consumption and death from cardiovascular causes. New England Journal of Medicine, 371 7: 624-634. doi:10.1056/NEJMoa1304127.

[4] J. He, N.R.C. Campbell, G.A. MacGregor. Reducing salt intake to prevent hypertension and cardiovascular disease. Rev. Panam. Salud Publica, 32 (4) (2012), pp. 293-300.

[5] World Health Organization Regional Office for Europe Mapping salt reduction initiatives in the WHO European Region (Web. 10 May 2014.) http://www.euro.who.int/__data/assets/pdf_file/0009/186462/Mapping-salt-reduction-initiatives-in-the-WHO-European-Region.pdf (2013).

[6] Salt reduction and iodine fortification strategies in public health. 2014. http://www.who.int/nutrition/publications/publichealth_saltreduc_iodine_fortification/en/.

[7] McLaren L, Sumar N, Barberio AM, Trieu K, Lorenzetti DL, Tarasuk V, Webster J, Campbell NRC.Population-level interventions in government jurisdictions for dietary sodium reduction. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD010166. doi: 10.1002/14651858.CD010166.pub2.