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The prevalence of hypertension and its association with other cardiovascular disease risk factors in a representative sample of the Lebanese population

Abstract

Hypertension is a well-known major risk factor for cardiovascular diseases. This study has been designed to assess the prevalence of hypertension, its co-occurrence with other cardiovascular risk factors and its association with cardiovascular diseases in a representative sample of Lebanese population. A pretested questionnaire was administered to 2125 adults aged equal or above 30 years old from all regions in Lebanon and proportionate with the respective population density. Data revealed that 23.1% of the respondents admitted being hypertensive, with no statistically significant difference between male and female patients. Prevalence of hypertension increased with age (P<0.01) and hypertension tended to occur more in the less educated and the unemployed (P<0.01). Only 45.7% of hypertensive patients followed a low fat diet while 14.7% exercised daily. The prevalence of hypertension increased significantly with an increase in body mass index particularly in female patients. Among the hypertensive respondents, 23.9% were diabetic, 38.1% were hyperlipidaemic and 9.1% were both diabetic and hyperlipidaemic. Co-occurrence of hypertension with diabetes, hyperlipidaemia or both was more common in female patients compared to male patients. In addition, stroke, myocardial infarction (MI) and atherothrombosis occurred in hypertensive respondents at rates of 2.4, 4.3 and 9.5%, respectively. Hypertensive female patients reported more stroke and atherothrombotic episodes compared to male patients, whereas hypertensive male patients had more MIs. Based on these results it is very important to address the issue of lifestyle modification for the prevention and treatment of hypertension and awareness campaigns should stress the fact that cardiovascular diseases are not only restricted to men.

Introduction

High blood pressure (BP) is the number one attributable risk for death throughout the World.1, 2, 3 Worldwide prevalence estimates for hypertension may be as much as one billion individuals, and approximately 7.1 million deaths per year may be due to hypertension.1 According to the World Health Organization (WHO),1 62% of cerebrovascular diseases and 49% of ischaemic heart disease are due to a suboptimal BP. Elevated BP is associated with a two to three times higher risk of developing congestive heart failure4, 5, 6 and substantially increases the risk of stroke.7, 8, 9 Although the age-adjusted death rate for coronary heart disease has decreased, reflecting multiple improvements in treatment, the age-adjusted death rate attributable to hypertension as a primary or contributing cause of death actually rose by 36.4% over the past decade in the United States (US)10 and the impact of hypertension is increasing worldwide.

Hypertension is well known to be a major risk factor for cardiovascular diseases (CVD).1, 10, 11 CVD affect developed and wealthy countries and documented evidence reveals that more than 4.5 million deaths due to coronary artery disease (CAD) occur in the developing world. It is also projected that CAD mortality rates will double from 1990 to 2020, with approximately 82% of the increase attributable to the developing world.12 There is currently an increased awareness that most developing countries are experiencing an ‘epidemiologic transition’ in which causes of death are shifting from primarily infectious causes to noncommunicable diseases.13, 14, 15

Cohort studies and population-based mortality data in the Arab region are largely lacking. In Lebanon, national statistics and census are nonexistent to date. A ‘Population and Housing’ survey conducted by the Ministry of Social Affairs (MOSA) in 1996 estimated the crude death rate as 7.4 per 1000 population, while CVD and cancer accounted for around 31 and 10% of death, respectively, as reported in the year before the survey.16 Another study conducted in Beirut17 between 1983 and 1993 followed up 1786 men and women 50 years old and above, in order to quantify noncommunicable disease mortality rates, showed that noncommunicable diseases, mainly CVD and cancer, were the leading cause of death accounting for 60 and 15% of deaths, respectively. This same study revealed increased levels of chronic disease morbidity, in particular, hypertension 25% and diabetes 13%.

Since hypertension is well known as a major contributor to CVD, several countries have tried to determine its prevalence at the national or community level. In Lebanon, hypertension was not studied separately, however, its approximate prevalence was detected along with epidemiological data collected for the study of either CVD17, 18, 19 or diabetes.20 Most of these studies targeted either the capital, Beirut, or focused on a special region of Lebanon.17, 18, 20

This present study is a cross-sectional study which aims to assess the prevalence of hypertension and its co-occurrence with other well-known CVD risk factors such as diabetes, hyperlipidaemia, obesity, sedentary lifestyle and diet in Lebanese adults. In addition, this study depicts the association between hypertension and certain CVD such as myocardial infarction (MI), strokes and atherothrombotic episodes in Lebanese men and women.

Materials and methods

Study population

The study population included 2125 adults, aged equal or above 30 years old. The sample size was calculated based on the latest national demographic survey carried out in 1996.16 The respondents were divided between different regions based on the respective population distribution reported in the 1996 survey: Beirut 13.1%; Mount Lebanon 36.7%; South Lebanon 16.7%; North Lebanon 21.6% and Bekaa 12.9%. To reach this representative sample of the population, a two-stage cluster sampling was followed whereby self-weighing is ensured through the choice of all regions in which clusters were selected in proportion to the respective density of the population per region. In the first stage, the governorate was used as an administrative section. In the second stage, regions were selected in each governorate and were divided into areas. The regions were relatively nonoverlapping to a great extent and all regions were included with a balance between urban and rural areas. Clusters of 25 respondents were selected per area. Each region had enough areas to reflect the respective percentage of the registered population. The clusters were distributed as follows: Beirut 11 clusters (275); Mount Lebanon 30 clusters (750); North Lebanon 20 clusters (500); South Lebanon and Bekaa 12 clusters (300) each, making a total of 2125 individuals.

Data collection

Face-to-face interviews were conducted from December 20, 2003 to February 20, 2004 all over Lebanon by trained field workers. A systematic random sampling of households was selected for interviewing. The sampling strategy consisted of the following: random selection of the areas, listing of all households within the selected areas and consequent random selection of the households from the list, finally interviewing of all eligible individual within a household.

Area selection: A census enumeration of districts showed the population size in each area. Areas were relatively uniform in size and were classified by region.

Household selection: The interviewees started from the central square of the selected area and randomly selected households from the list.

Individual selection: All persons aged 30 years and above living in the house were listed and included in the study. Interviewees were instructed to make at least two visits at two different times of the day before dropping any interviewee living in the household.

Measurement

A pretested questionnaire in Arabic using medical terms understood by all people was administered by trained and experienced interviewers to collect the necessary data. The instrument consisted of three main sections.

Section 1: It included information on sociodemographic data regarding location, age, gender, educational level and type of work.

Section 2: It covered the health seeking behaviour of the respondents, questions were worded as follows: ‘when was the last time you visited a physician? (Or had your BP or blood sugar or blood lipid measured?)’ The following response choices were provided: ‘less than a week’, ‘a month ago’, ‘3 months ago’, ‘a year ago’, ‘more than a year ago’ or ‘never’. Respondents were then asked if they suffer from and/or are being treated for hypertension, diabetes or hyperlipidaemia with the following questions:

‘Do you suffer from --------?’ answer choices were: ‘yes’, ‘no’ or ‘don’t know’‘Do you take any medications for --------?’ answer choices: ‘yes’ or ‘no’‘Have you ever stopped taking your medications and why?’

Respondents were also asked if they are following or have ever followed any low fat diet. A self-report of height and weight were collected and answers were used to calculate the body mass index (BMI) of each individual as weight (in kilograms) divided by height (in meters) squared, the BMI was then converted into ranges as follows: normal: BMI <25 kg/m2, overweight: 25BMI<30 kg/m2 and obese: BMI30 kg/m2.

Physical activity was assessed by the following question: ‘Do you exercise for more than 30 min?’ and the following response choices were provided: ‘daily’, ‘every week’, ‘sometimes’ or ‘never’.

Section 3: It addressed directly the status of the respondents regarding stroke, MI and atherothrombosis. Questions were formulated as follows: ‘have you ever suffered from ------? And the following response choices were listed: ‘yes’, ‘no’ or ‘don’t remember’. Those who did not remember were included with the persons who answered ‘no’ for the data analysis.

Data analysis

A total of 2010 questionnaires covering all regions were collected. The remaining 115 persons were household members who could not be reached for the interview after three visits. None of the randomly selected and reachable households or individuals refused to enroll in the study, and all participants were aware of the objectives behind this questionnaire. Collected data were entered and analysed into the Statistical Package for Social Sciences (SPSS) v.12. The Chi-square (χ2) test was used to determine the existence of associations between hypertension and sociodemographic, Cardiovascular disease risk factors and CVD Fisher's exact test was used when expected cell frequencies were less than 5 and a P-value <0.05 was considered to be statistically significant.

Results

Table 1 shows the characteristics of the study population. The mean age of the 2010 respondents was 49.32±12.97 years and the respondents were almost equally divided between genders. The regional distribution of respondents was relatively consistent with the 1996 National Household Survey.16

Table 1 Characteristics of the study population

Concerning the respondents’ health-seeking behaviour, data showed that 85% (1707) reported having a medical check up within less than a year while only 12.5% (252) visited a physician several years ago, and 2.5% (51) admitted never visiting a physician. In addition, 81.6% (1639) reported to have their BP measured during the past year, and only 12.1% (243) had their BP measured several years ago, while 6.4% (128) reported never having their BP measured. In addition, about 70% had their blood glucose and lipid levels measured during the past year while 13% never had them measured and 29.9% (601) followed a low-fat diet. As for physical activity, 20.4% (411) reported exercising daily for 30 min; however, 40.3% (811) admitted never engaging in any physical activity. The mean BMI of respondents was 26.2±4.64 kg/m2 with the following distribution: 40.3% (811) BMI of <25 kg/m2, 45% (905) 25BMI<30 kg/m2, 13.5% (272) BMI30 kg/m2, only 1.1% (23) did not report their height and weight.

The overall prevalence of hypertension as reported by the respondents was 23.1% (464) and only 4.2% (85) did not know their status. The great majority of hypertensive patients, 89.4% (415) were on medications while 2.7% (55) stopped medication intake for several reasons mainly: forgetting, the cost of medications, the physician's recommendation, by personal choice, or due to side effects. There was no statistically significant difference between male and female patients with 47.6% (221) hypertensive female patients and 52.4% (243) male patients. As shown in Table 2, the prevalence of cardiovascular disease risk factors increased with age and their association with ageing was statistically significant. As depicted in Table 3, the lowest percentage of hypertension was found in the capital, Beirut, whereas the South had the highest. In addition, a statistically significant association was found between the presence of hypertension and both absence of education and unemployment.

Table 2 Prevalence of cardiovascular disease risk factors by age
Table 3 Prevalence of hypertension by region, educational level and type of work

Data on the co-occurrence of hypertension and other CVD risk factors is shown in Table 4. Moreover, healthy lifestyle and lifestyle modification were also assessed in hypertensive respondents. Data revealed that only 45.7% (212) of hypertensive patients followed a low-fat diet, 14.7% (68) exercised daily for 30 min while more than half, 56% (260) of hypertensive respondents did not exercise at all. A statistically significant association was found between hypertension and lack of low-fat diet and daily physical exercise, respectively (P<0.001). In addition, the percentage of obesity increased in the presence of hypertension reaching 19.8% (92). Hypertensive female patients tended to be more overweight and obese than hypertensive male patients with 30.7% (96) of overweight female patients being hypertensive compared to 24.4% (143) of overweight male patients, on one hand. On the other hand, 47.5% (56) of obese female patients and 23.4% (36) of obese male patients were hypertensive. There was a statistically significant correlation in female patients between hypertension and overweight (P<0.01).

Table 4 Co-occurrence of major CVD risk factors in hypertensive respondents

Association of hypertension with CVD

As depicted in Table 5, the percentage of hypertensive female patients who had a stroke and atherothrombosis was higher than male patients, whereas hypertensive male patients reported having had a MI more frequently than female patients. Further analysis revealed that hypertensive respondents were more likely to have had suffered from a stroke (OR=2.11; 95% CI: 1.15–5.47; P=0.02) or MI (OR=2.95; 95% CI: 1.61–5.42; P=0.0003) or an atherothrombotic episode (OR=3.62; 95% CI: 2.34–5.6; P<0.0001) than nonhypertensive participants.

Table 5 Association of hypertension with CVD by gender

Other cardiovascular disease risk factors

Diabetes was reported in 13.8% (278) of the 2010 respondents, with 13.6% (123) of female patients and 14.1% (155) of male patients being diabetic. Moreover, the overall prevalence of hyperlipidaemia was 20.7% (416) whereby, 19.5% (177) female patients and 21.7% (239) male patients were hyperlipidaemic.

Discussion

The target population of our study was 2125 Lebanese citizens aged 30 years and above distributed among all regions. A total of 2010 respondents participated reflecting a response rate of 95%. The distribution of participants within different age groups, regions and gender were approximately similar to National Distribution Tables.16 Relatively a good percentage of the population had a good health-seeking behaviour, however the majority did not have a healthy lifestyle as almost half did not exercise, two-thirds did not follow a healthy diet and the population average BMI was in the overweight range.

The overall prevalence of hypertension in this representative sample of the Lebanese population was 23.1%. In a study conducted by Sibai et al17 to determine cardiovascular disease-related mortality in 1786 men and women above 50 years, living in Beirut, between 1983 and 1993, hypertension was found in 25% of the sample. In our study, the calculated prevalence of hypertension among respondents living in Beirut and older than 50 years, was 27.86% (34/122), which reflects the increase in the prevalence of hypertension over the years. Another study conducted in a specific community in Beirut18 found that 31% of men and 18% of women to be hypertensive. In our study, percentages between men and women did not differ significantly even in Beirut, this could be explained by the fact that our study included several areas in Beirut while the former study targeted a specific community. Another study conducted by Salti et al20 in three different communities detected an overall prevalence of systolic BP165 mmHg and diastolic B.P95 mmHg in 10.2% of male and 11.3% of female patients. The differences in the prevalence of hypertension between these studies reflect the fact that hypertension prevalence differs between regions and between populations selected for the different studies. This was actually confirmed by our study which revealed differences in the distribution of hypertensive patients in different regions of Lebanon. Compared to neighbouring and other Mediterranean countries, Lebanon has a lower prevalence of hypertension.21, 22, 23, 24 However, compared to other countries,25, 26 Lebanon still has a high prevalence of hypertension and requires urgent interventions for prevention, treatment and control.

Moreover, Table 2 shows that all CVD risk factors (hypertension, diabetes, hyperlipidaemia and obesity) tend to increase with age in both genders. Such findings had actually been confirmed by other studies.10, 20, 21, 22 In this study, the percentage of CVD risk factors tended to increase by 3–4 times in the 41–50 years age group compared to the 30–40 years age group. Therefore, it is very important to address the issue of prevention early in life because the precursors of the disease are present long before clinically acceptable levels of hypertension are recognized.27, 28 Furthermore, as shown in Table 3, hypertension seems to cluster more among the less educated and among those who are unemployed. In addition, stress due to a low or absent income could also be a contributing factor to the development of high BP either directly or indirectly by causing depression and anxiety. Based on our results, a very small percentage of patients adopted lifestyle modifications, which are the first step in any management of high BP.10 The proven benefit of weight loss, special diets29 and physical activity30 strongly suggests that lifestyle modification should be the first choice to prevent, delay or control hypertension. The prevalence of overweight and obesity in our sample was actually high. Even higher percentages were reported in a recent study carried out on 2104 individuals, 3 years and older.31 This is actually quite close to the prevalence of obesity reported in the US.32

Results revealed a significant association between hypertension and other CVD risk factors in the Lebanese (Table 4). The co-occurrence of all these diseases is pernicious and places affected individuals at a higher risk of CVD, stroke, progression of renal disease and diabetic nephropathy than the sum of these risk factors occurring alone.33, 34, 35 Therefore, aggressive BP control36, 37 is needed in this case to prevent further complications from hypertension and other CVD risk factors. In addition, the Lebanese population does not seem to differ from its Western counterparts10 since results revealed a significant association between hypertension and CVD in the Lebanese population.

A surprising and new finding was that hypertensive Lebanese women are at a much higher risk than hypertensive men. Compared to men, hypertensive women had a higher prevalence of diabetes, hyperlipidaemia, stroke and atherothrombotic episodes. Similar results were reported in other studies.38 Moreover, Lebanese women were more predisposed to obesity at older age groups compared to men which might place them at a higher risk for CVD. Therefore, prevention has to target both male and female patients equally with a special stress on female patients as the majority still considers itself not at risk for CVD, which is considered ‘a men's disease’.

Our study could be considered as the first to date study depicting the prevalence of hypertension and other CVD risk factors in a representative sample of the Lebanese population. Most data were derived from key-informants interview surveys. However, there are several limitations to this study. First, the rates are no doubt substantial underestimates especially when considering overweight and obesity. In fact, validation studies of self-reported weight and height revealed that overweight and obese participants tend to underestimate their weight and all participants overestimated their height.39, 40 Another limitation is that undiagnosed hypertension and other risk factors were not accounted for, since 6.4% of respondents admitted never having their BP measured. A major drawback to our study is the absence of any clinical measurement for the documentation of hypertension; however, several studies carried out both nationally41 and internationally42, 43, 44, 45, 46 to assess the validity of self-reported chronic diseases including hypertension revealed a moderate to substantial agreement between questionnaire data and either clinical examinations42, 43 or medical records.44, 45, 46 A study carried out in Beirut41 to assess the agreement between self-reported morbidity and physical examination, revealed that heart disease had the highest agreement followed by hypertension and concluded that the health interview survey was reasonably accurate for data collection of chronic conditions, which are clearly defined for the population. Hence, interview surveys are valid and have many advantages over population-based studies that use medical examination to gather morbidity data such as a higher response rate and the lower cost of nonmedical interviewers.

Most studies have shown that the best approach to decrease CVD mortality is by risk factor modification.47, 48, 49, 50 However, preventive health receives only sporadic attention in the context of office visits for acute and chronic medical problems in Lebanon. Based on this study, it is important to stress the need for prevention and health education for all age groups and both genders. In addition, a special importance should be addressed to lifestyle modifications among the Lebanese in order to prevent and control the projected increase in cardiovascular disease burden and mortality.

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Tohme, R., Jurjus, A. & Estephan, A. The prevalence of hypertension and its association with other cardiovascular disease risk factors in a representative sample of the Lebanese population. J Hum Hypertens 19, 861–868 (2005). https://doi.org/10.1038/sj.jhh.1001909

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Keywords

  • risk factors
  • prevalence
  • cardiovascular diseases

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