Hypertension – or high blood pressure – is a serious medical condition that significantly increases the risk of heart, brain, kidney and other diseases. It is one of the major causes leading to heart attacks, heart failure, stroke, collectively known as cardiovascular diseases (CVD), and chronic kidney damage. Controlling hypertension is important to prevent lifelong complications and acute cardiovascular events. Hypertension is known to be the single most important leading cause of early deaths due to cardiovascular diseases.
Hypertension is defined as having systolic blood pressure (SPB) ≥140 mmHg or diastolic blood pressure (DPB) ≥90 mmHg. Many factors contribute to the age-related increased blood pressure; however, the main contributors seem to be lifestyle related behavioural risk factors such as poor-quality diet high in sodium and low in potassium, overweight and obesity, consumption of alcohol, use of tobacco and physical inactivity.
Keeping high blood pressure under control requires early diagnosis, early and effective treatment alongside lifestyle modifications to address behavioural risk factors. Hypertension is considered ‘controlled’ when the systolic blood pressure (BP) is maintained below 140 mmHg and diastolic BP below 90 mmHg, with medications and lifestyle modifications.
Blood pressure is read as two numbers, systolic (upper value) and diastolic (lower value). The normal average Blood Pressure of an adult is 120 / 80 mm Hg. Values above 140/90 are considered as high blood pressure or hypertension.
Global situation of hypertension.
WHO Global Report on Hypertension in 2023 estimated that the number of hypertensive adults almost doubled globally during the last three decades, from 650 million in 1990 to 1.3 billion adults by 2019. The health impact of increasing trends of high blood pressure translated to 10.8 million avoidable deaths annually and 235 million years of life lost or lived with disability.
Globally, almost every 1 in 3 adults is hypertensive, with male prevalence slightly higher than females under 50 years age group. Beyond the age of 50, the prevalence reaches nearly 49%, or every 1 out of 2 individuals, with nearly equal prevalence among both men and women.
While early diagnosis and timely treatment is important, nearly 46% of individuals were never diagnosed. Of those diagnosed, only 42% were on treatment, with nearly half among these having their blood pressure controlled. Hence in most of the countries, there are significant gaps in diagnosis and treatment coverage, with low-income countries facing the major brunt of illness.
WHO has been working with Member States to improve global and national response to tackle NCDs and their risk factors since 2013. The Member States agreed on "Global action plan for the prevention and control of NCDs 2013-2020", that was subsequently extended to 2030 synchronizing with the Sustainable Development Goals (SDG), which includes SDG target 3.4 of reducing premature mortality due to noncommunicable diseases by a third against a baseline of 2015. The global implementation roadmap 2023-2030 under this plan aims to achieve this reduction by achieving nine voluntary global targets. Reducing prevalence of hypertension by 25% is one of the targets under the global roadmap.
Hypertension status and coverage in the WHO South-East Asia Region.
Hypertension poses a significant health challenge in the countries of WHO South-East Asia Region affecting an estimated 294 million individuals aged 30 and above. The condition was responsible for 2.4 million annual deaths in 2019, accounting for nearly half of all deaths due to cardiovascular diseases. Half among those with high blood pressure were unaware of their condition and only less than half of those on treatment had their condition under control.
In the South-East Asia Region, The Seventy-sixth Regional Committee in 2022 endorsed the initiative "SEAHEARTS: Accelerating Prevention and Control of Cardiovascular Diseases in the South-East Asia Region (SEA/RC76/R5). The Call to Action asks for developing interim milestones for risk factor reduction and improved treatment cascade in broader context of NCD prevention and control.
Current situation of hypertension diagnosis and management in Sri Lanka
Sri Lanka is experiencing continually a rise in prevalence of hypertension, due to effects of changing demographics towards aging population, urbanization and continued prevalence of behavioural risk factors. The estimates from the 2021 Sri Lanka NCD risk factor survey (STEPS), showed that every 1 in 3 adults (34.8%) had raised blood pressure, an almost 25% increase in prevalence from that of 2015 STEPS survey. Importantly, more than half (54%) with raised blood pressure were unaware of their hypertensive status. Even among those being aware, at least 20% among them were not on any medication, whereas only 40% had their blood pressure under control while on treatment.
The behavioural risk factors contributing to hypertension have also been on the rise. STEPS survey revealed that one in three adults are physically inactive. Nearly 70% of individuals had inadequate intake of vegetables and fruits, while prevalence of blood cholesterol levels (defined as total cholesterol ≥ 5.0 mmol/l or 190mg/dl) was found to be high in nearly half of adults (48%), almost doubling since 2015, showing increasing trend of overweight and obesity in the population. The salt intake was estimated at 8.5 gms per day among adults, much higher than the WHO recommended salt intake of less than 5 gms/day for adults.
Over the last few years, Sri Lanka adopted key population based and health systems measures to tackle risk factors and improve detection, diagnosis and management of hypertension. The National Multisectoral Strategic Action Plan for noncommunicable diseases was initiated in 2016 with target to reduce hypertension by 25% in line with global recommendations; the plan has been updated to 2027 and has targets in place to tackle risk factors and improve treatment coverage. Sri Lanka initiated targeted programmes through establishing healthy lifestyle centres to improve screening of adults and developed a simple hypertension treatment protocol based on recommendations of the 2021 WHO Guidelines for the pharmacological treatment of hypertension in adults. Pilot projects in selected provinces have shown success of improved case detection and improved control among individuals put on medications. Sri Lanka is among the first countries to introduce mandatory front-of-pack traffic-light labelling regulations (concentration based colour coding for Sugar, Salt and Fat) for pre-packaged solid and semi-solid processed foods (Regulations 2019-No 2119/3 (86). National guidelines to improve physical activity among all age groups and in work settings have been developed and promoted.
Despite these efforts in place, the trends of rising prevalence, and gaps in screening and treatment reflect persistent challenges. The WHO SEARO estimated that of the 4.3 million hypertensive adults in Sri Lanka, just over 1.5 million are on treatment. There is a need to expand the case detection through screening and improve treatment coverage, as well as compliance to treatment for improving blood pressure control rates.
The WHO Sri Lanka is collaborating with the Directorate of Noncommunicable Diseases, Ministry of Health to implement SEAHEARTS to improve coverage for hypertension in Sri Lanka. This will include protocol-based treatment to cater nearly a million additional individuals within the next three years and enhanced engagement of health workforce for case finding and compliance to treatment. Multisectoral advocacy will be supported to promote healthy lifestyles and implement national guidelines on healthy diets and physical activity, as well as expanding active screening for improved case detection. WHO will work with in-country partners to address the service delivery gaps, allocate resources effectively, and increase treatment compliance for individuals affected with hypertension in Sri Lanka, to achieve national milestone of achieving treatment coverage by 50% by 2025.
2021 STEPS Country Report Sri Lanka.https://www.who.int/publications/m/item/2021-steps-country-report-sri-lanka
SEAHEARTS: Accelerating prevention and control of cardiovascular diseases in the South-East Asia Region -https://www.who.int/southeastasia/publications-detail/SEA-RC76-R5
WHO Global report on hypertension: the race against a silent killer. 2023.Global report on hypertension: the race against a silent killer (who.int)
WHO Guideline for the pharmacological treatment of hypertension in adults.20219789240033986-eng.pdf (who.int)
WHO SEAHEARTS for accelerating CVD Control website: https://www.who.int/southeastasia/activities/seahearts-for-accelerating-cvd-control
