The burden of hypertension has shifted from high to low- and middle-income countries

The burden of hypertension has shifted from high to low- and middle-income countries

Mary-Anne Land – PHAA


The number of adults aged 30–79 years with hypertension has increased from 650 million to 1.28 billion in the last thirty years, according to the first comprehensive global analysis of trends in hypertension prevalence, detection, treatment and control, led by Imperial College London and the World Health Organization (WHO), and published today in The Lancet. Nearly half these people did not know they had hypertension.

The study, covered the period 1990–2019. It used blood pressure measurement and treatment data from over 100 million people aged 30–79 years in 184 countries, together covering 99% of the global population.

Researchers found that there was little change in the overall rate of hypertension in the world from 1990 to 2019, but the burden has shifted from wealthy nations to low- and middle-income countries. The rate of hypertension has decreased in wealthy countries – which now typically have some of the lowest rates – but has increased in many low- or middle-income countries.

As a result, Canada, Peru and Switzerland had among the lowest prevalence of hypertension in the world in 2019, while some of the highest rates were seen in the Dominican Republic, Jamaica and Paraguay for women and Hungary, Paraguay and Poland for men.

In Australia, the estimated age-standardised prevalence of hypertension was 26.3% in women and 32.3% in men.

Despite the fact that the global percent of people who have hypertension has changed little since 1990, the number of people with hypertension doubled to 1.28 billion. This was primarily due to population growth and ageing. In 2019, over one billion people with hypertension (82% of all people with hypertension in the world) lived in low- and middle-income countries.

Although it is straightforward to diagnose hypertension and relatively easy to treat the condition with low-cost drugs, the study revealed significant gaps in diagnosis and treatment. About 580 million people with hypertension (41% of women and 51% of men) were unaware of their condition because they were never diagnosed.

The study also indicated that more than half of people (53% of women and 62% of men) with hypertension, or a total 720 million people, were not receiving the treatment that they need. Blood pressure was controlled, in fewer than 1 in 4 women and 1 in 5 men with hypertension.

Professor Majid Ezzati, senior author of the study and Professor of Global Environmental Health at the School of Public Health at Imperial College London, said: “Nearly half a century after we started treating hypertension, which is easy to diagnose and treat with low-cost medicines, it is a public health failure that so many of the people with high blood pressure in the world are still not getting the treatment they need.”

Men and women in Canada, Iceland and the Republic of Korea were most likely to receive medication to effectively treat and control their hypertension, with more than 70% of those with hypertension receiving treatment in 2019. Comparatively, men and women in sub-Saharan Africa, central, south and south-east Asia, and Pacific Island nations are the least likely to be receiving medication. Treatment rates were below 25% for women, and 20% for men, in a number of countries in these regions, creating a massive global inequity in treatment.

Encouragingly, some middle-income countries have successfully scaled up treatment, and are now achieving better treatment and control rates than most high-income nations. For example, Costa Rica and Kazakhstan now have higher treatment rates than most higher-income countries.

Dr Bin Zhou, a research fellow at the School of Public Health at Imperial College London, who led the analysis, said: “Although hypertension treatment and control rates have improved in most countries since 1990, there has been little change in much of sub-Saharan Africa and Pacific Island nations.”

The ‘World Health Organization Guideline for the pharmacological treatment of hypertension in adults’, also released today, provides new recommendations to help countries improve the management of hypertension.

Dr Taskeen Khan, of WHO’s Department of Noncommunicable Diseases, who led the guideline development, said: “The new global guideline on the treatment of hypertension, the first in 20 years, provides the most current and relevant evidence-based guidance on the initiation of medicines for hypertension in adults.”

While the guideline does not address modifiable risk factors for hypertension such as unhealthy
diet, physical inactivity, consumption of tobacco and alcohol, and being overweight or obese, a
comprehensive treatment plan for hypertension must include addressing these risk factors through lifestyle modifications and other interventions.

A key nonpharmacological approach to treatment or prevention of hypertension is reducing sodium intake.

There is unequivocal evidence that excess sodium intake leads to hypertension. It is projected that lowering sodium intake from the estimated global average of 3950mg/day to the WHO recommended maximum of 2000mg/day would avert at least three million premature deaths each year and possibly many more.

In 2015, about 21% of the hypertension burden in Australia was due to a diet high in sodium.

The current Australian approach to reducing population sodium intake is based upon a voluntary food supply reformation – however, the most cost-effective action that should be undertaken immediately, with expected accelerated results in cases of hypertension prevented and health care costs avoided is mandatory reformulation of manufactured, ultra-processed foods.  Setting maximum limits for sodium in processed food categorise promotes industry reformulation, creates a level playing field across the food processing sector – increasing cooperation, and ensures healthier products without requiring consumer action.


This blog is based on the World Health Organization and Imperial College London joint press release.

Photo credit: NICE GUYS from Pexels

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