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The United Nations High Level Meeting Addresses Noncommunicable Diseases, But Where Is Hypertension?

2011; Wiley; Volume: 13; Issue: 11 Linguagem: Inglês

10.1111/j.1751-7176.2011.00535.x

1751-7176

George A. Mensah, George L. Bakris,

Nutritional Studies and Diet

In September 2011, the United Nations' General Assembly will hold a high-level meeting (UN HLM) of heads of state and government and representatives of states and governments to address the prevention and control of noncommunicable diseases (NCDs).1,2 This high-level meeting, to be held in New York City, is expected to be a watershed event in the prevention and control of NCDs. It will provide a unique opportunity to prioritize NCDs as a global health challenge of enormous proportions with significant societal, economic, and developmental implications.1,2 The UN HLM should bring much needed attention and resources to the prevention and control of NCDs, especially in low- and middle-income countries where nearly 80% of global NCD mortality occurs.3,4 Successful implementation of priority actions in the anticipated "Outcomes Document"4 could lead to a sustained global movement against preventable death, disease, and disability from NCDs, especially cardiovascular diseases, cancer, diabetes, and chronic respiratory disease.5,6 Accordingly, the World Health Organization (WHO) and several health professional associations have called for a strategy addressing these four NCDs and four related behavioral risk factors including tobacco use, poor diet, physical inactivity, and harmful use of alcohol.6–9 In this perspective, we praise the work that the WHO, civil society leadership, and many health professional organizations have done in bringing attention to these major NCDs and risk factors. Considering how common hypertension is, and the magnitude of associated preventable morbidity, mortality, and economic costs, we also highlight hypertension as an important chronic disorder and a major risk factor for NCDs. Nearly 1 billion people today live with hypertension, compared with 600 million 3 decades ago.10 This number is projected to increase to nearly 1.6 billion by 2025.11 Overall, the global prevalence of hypertension in adults 25 years and older was estimated at 40% in 2008.3 As shown in Figure 1, the prevalence in adult men and women combined exceeds 33% in all parts of the world defined by income level or WHO region, with the highest prevalence (46%) seen in the WHO Africa Region.3 Hypertension prevalence and trends are most worrisome in developing countries and those with economies in transition. For example, a recent analysis by Danei and colleagues10 showed that globally, between 1980 and 2008, systolic blood pressure (BP) decreased in both women and men in Western Europe, Australasia, and high-income North America; however, systolic BP rose in Oceania, East Africa, and South and Southeast Asia for both sexes and in West Africa for women.10 In fact, systolic BP in women was highest in some East and West African countries, with means of ≥135 mm Hg, while systolic BP in men was highest in Baltic and East and West African countries, where mean systolic BP reached ≥138 mm Hg.10 In these countries, hypertension is invariably the major cause of stroke and a leading cause of morbidity and mortality.10,12 Age-standardized prevalence of raised blood pressure in adults 25 years and older by the World Health Organization WHO Region and World Bank income group, comparable estimates, 2008. AFR indicates Africa; AMR, America; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South-East Asia Region; WPR, Western Pacific Region. Reproduced with permission from the WHO.3 Worldwide, hypertension causes an estimated 7.5 million deaths per year, about 13% of the total of all annual deaths.13 It is therefore the leading global risk factor for mortality in the world (Figure 2), followed by tobacco use, high blood glucose, physical inactivity, and overweight and obesity, which cause 9%, 6%, 6%, and 5% of annual deaths, respectively.13 The corresponding burden of disease is estimated at 57 million disability-adjusted life-years (DALYs) or 3.7% of total DALYs.13 Thus, not only is hypertension common and associated with significant morbidity and reduced quality of life, it is also deadly, especially in developing countries, and exerts most of its toll in the prime of life.14,15 Deaths attributed to 19 leading risk factors, by country income level, 2004. Reproduced with permission from the World Health Organization.13 Hypertension is also important as a cause of chronic NCD beyond its impact on cardiovascular disease. It ranks next to diabetes as the 2nd leading cause of chronic kidney disease (CKD) in the Western world. Patients with hypertension who have uncontrolled BP and a family history of kidney disease are at highest risk for progressing to end-stage renal disease (ESRD) requiring dialysis, a major health care expenditure. Data of more than 10,000 men followed for 16 years clearly demonstrate a close relationship between the magnitude of BP control and progression to ESRD.16 Epidemiological data clearly indicate increasing trends of ESRD related to both diabetes and hypertension, an observation true not only in the United States but throughout the Western world. The growing prevalence of CKD and its implications for global public health, therefore, clearly has a major impact on the economic burdens shared by different societies around the world.17 In many low- and middle-income countries, the presence of hypertension in the setting of poverty and diabetes are considered major drivers of the burden of CKD18 and a growing public health and economic burden.17 The UN HLM provides a unique opportunity to highlight the value of effective population-based and personal interventions targeted towards low-income and middle-income countries.10 Nugent and colleagues19 have called attention to the rapid rise of hypertension and other risk factors such as diabetes and obesity, especially among the poor, that will result in profound burden of NCDs that developing countries are ill-equipped to address. Suboptimal BP is responsible for a large and an increasing economic and health burden, especially in developing countries.20 Gaziano and associates recently examined the health care costs attributable to suboptimal BP for adults 30 years and older and showed that worldwide, suboptimal BP cost US$3.7 billion in 2001, representing about 10% of the world's overall health care expenditures.20 In the Eastern Europe and Central Asia region, high BP consumed an estimated 25% of all health expenditures.20 The authors estimated that if current BP levels persist, hypertension may cost nearly US$1 trillion over a 10-year period globally in health spending, with indirect costs projected to be as high as US$3.6 trillion.20 The UN HLM has the unique opportunity to highlight hypertension as a leading developmental hurdle in addition to the large morbidity and mortality it causes. It is understandable that the WHO has chosen to highlight only 4 NCDs and 4 risk factors. This is not a time to attempt to boil the ocean; so parsimony is not only prudent, but the practical choice. However, addressing physical inactivity and poor diet (with special emphasis on excess dietary sodium intake), although a necessary first step in hypertension prevention and can play an important role in treatment and control, will not be enough to control the majority of patients with hypertension.21 Safe and effective treatments are available,22 and protocols have been published on evidence-based treatment and control, especially using cost-effective generic drugs in low-resource settings.23 The UN HLM has the opportunity to promote affordable approaches and rational resource allocation within the context of primary health care. BP control rates are the highest in the United States, at 51%, largely because of successful public-private interventions as seen in the efforts of the American Society of Hypertension, American Heart Association, the National Kidney Foundation, the Centers for Disease Control and Prevention, and the National Heart, Lung, and Blood Institute of the National Institute of Health. While these efforts have resulted in higher control rates relative to the rest of the world, it has taken more than a decade over what was projected by the Healthy People 2000 initiative.24 In order to accelerate global control of hypertension, increased public-private partnerships underpinned by a "whole-of-government" approach and the establishment of national plans for NCD prevention and control that also addresses hypertension are needed. This is a great opportunity for the WHO to partner with groups around the world as well as governmental authorities to ensure that this major cardiovascular risk is prevented or better controlled. As a first step, a much higher priority must be given to hypertension on the global health and development agendas. This would mandate increases in funding for hypertension surveillance, detection, evaluation, treatment, and control and investment in low-cost priority actions. Among these actions should be dietary sodium reduction strategies, which have been identified as a best buy.3 Additionally, a centralized effort is essential for this to be implemented properly, thus, government partnership calling for a response through national plans for NCD prevention and control must be established. This calls for governmental agency partnerships with industry and health care organizations for health promotion and the prevention of NCDs and risk factors. Examples of such efforts would include funding for preventive care, incentives for physical activities, promoting physical fitness programs in public schools, and providing incentives for increased consumption of fruits and vegetables, which are naturally low in sodium and high in potassium and contribute to the prevention and control of hypertension.25 The collaboration with health care professionals would mean supporting health care systems so that primary care providers would have financial support to screen patients during preventive care examinations, have dieticians available for consultation for proper balanced diets, and other ancillary support. The current environment does not reinforce any of these efforts to any major extent. An international working group convened to identify activities that health care professionals should undertake to reduce development and properly identify hypertension early. These 5 core objectives include: (1) detect and prevent high BP; (2) assess total cardiovascular risk; (3) form an active partnership with the patient; (4) treat hypertension to guideline goals; and (5) create a supportive environment.9,26 In addition, the NCD alliance has proposed 5 overarching priority actions for the response to the crisis (leadership, prevention, treatment, international cooperation, and monitoring and accountability) and the delivery of 5 priority interventions (tobacco control, salt reduction, improved diets and physical activity, reduction in harmful alcohol intake, and essential drugs and technologies). The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility.5 Universities and academic health centers have already started aiding in the effort to reduce NCDs by providing medical support for indigent care clinics, helping identify patients at risk, and providing education on proper dietary management.27,28 Unfortunately, much of what has been done is limited in that patients armed with this information cannot afford or have access to the nutritious foods and physical activity that can help decrease NCD risk.27,28 This is an area where public-private partnerships can have significant impact. To be most effective, public-private partnerships involving governmental agencies and clinics, hospitals, health care providers, and the pharmaceutical industry must be strengthened. Importantly, however, these partnerships must be broadened to include other entities in the private sector, such as the food and beverage industry. Several food companies have independently and voluntarily taken steps to reformulate their products including substantial reductions in the amount of sodium in processed foods.29 ConAgra Foods, Kraft Foods, and PepsiCo have all made commitments in sodium reduction. For example, PepsiCo30 announced in March 2010 that it will reduce by 25% the average amount of sodium per serving in key global food brands by 2015. Together with commitments to increase the amount of whole grains, fruits, vegetables, nuts, and seeds in their portfolio as well as expand options for managing calories, the food and beverage industry can be an important private sector ally in the prevention and control of hypertension. To ensure sustainable prevention and control of hypertension, the UN HLM must also call for increased collaboration and coordination of research efforts in capacity-building for implementation of science and research. The model provided by the Global Alliance for Chronic Diseases in its seminal approach for hypertension research in centers of excellence across the globe can be very instructive.31 These collaborations can help avoid wasteful duplication of research efforts and facilitate implementation of evidence-based approaches for the prevention and control of NCDs. Disclosure: Statements made and opinions expressed in this manuscript are those of the authors and should not be construed as necessarily representing an official position of University of Chicago or PepsiCo, Inc.