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Hypertension in the Middle East: current state, human factors, and barriers to control


Hypertension is the leading source of morbidity and death. In the 21st century, there still is a major gap between high and low to middle-income countries in awareness, management, and control; countries in the Middle East represent an example of such disparities. In this review of the literature, light is shed on the prevalence and modifiable risk factors of hypertension specific to the region, as well as regional disparities in diagnosis and management. The crude prevalence rate is estimated to be around 29.5% with wide variability between countries. Various modifiable factors affect the prevalence of hypertension in this region such as excessively high rates of smoking, obesity, a sedentary lifestyle, some gender gap, and a suboptimal healthcare system; socio-economic factors and disparities in education, literacy, and urbanization play a significant role. Patient adherence to treatment is a determining factor of blood pressure control and nonadherence adversely affect outcomes. In addition, physician adherence to international guidelines is poor. Recognizing these barriers to hypertension management, this review serves as a call for increased national and regional efforts to implement favorable healthcare policies and improve clinical outcomes.

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  1. 1.

    Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, et al. Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries. Circulation. 2016;134:441–50. Epub 2016/08/10PubMed PMID: 27502908; PubMed Central PMCID: PMCPMC4979614

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365:217–23. Epub 2005/01/18PubMed PMID: 15652604

    Article  PubMed  Google Scholar 

  3. 3.

    UN. World Economic Situation and Prospects 2020. New York: UN; 2020.

  4. 4.

    Krishnan NLI, Gabriel; Narayan, Ambar; Tiwari, Sailesh; Vishwanath, Tara. 2016. Uneven Odds, Unequal Outcomes: Inequality of Opportunity in the Middle East and North Africa. Directions in Development-Poverty;. Washington, DC: World Bank.

  5. 5.

    Alsheikh-Ali AA, Omar MI, Raal FJ, Rashed W, Hamoui O, Kane A, et al. Cardiovascular risk factor burden in Africa and the Middle East: the Africa Middle East Cardiovascular Epidemiological (ACE) study. PLoS One 2014;9:e102830 Epub 2014/08/05PubMed PMID: 25090638; PubMed Central PMCID: PMCPMC4121128

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Yusufali AM, Khatib R, Islam S, Alhabib KF, Bahonar A, Swidan HM, et al. Prevalence, awareness, treatment and control of hypertension in four Middle East countries. J Hypertens. 2017;35:1457–64. Epub 2017/05/10PubMed PMID: 28486270

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Sarki AM, Nduka CU, Stranges S, Kandala NB, Uthman OA. Prevalence of hypertension in low- and middle-income countries: a systematic review and meta-analysis. Med (Baltim). 2015;94:e1959 Epub 2015/12/20PubMed PMID: 26683910; PubMed Central PMCID: PMCPMC5058882

    Article  Google Scholar 

  8. 8.

    Tailakh A, Evangelista LS, Mentes JC, Pike NA, Phillips LR, Morisky DE. Hypertension prevalence, awareness, and control in Arab countries: a systematic review. Nurs Health Sci. 2014;16:126–30. Epub 2013/10/15PubMed PMID: 24118852; PubMed Central PMCID: PMCPMC4445843

    Article  PubMed  Google Scholar 

  9. 9.

    Motlagh B, O’Donnell M, Yusuf S. Prevalence of cardiovascular risk factors in the Middle East: a systematic review. Eur J Cardiovasc Prev Rehabil. 2009;16:268–80. Epub 2009/04/29PubMed PMID: 19398913

    Article  PubMed  Google Scholar 

  10. 10.

    Tohme RA, Jurjus AR, 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. 2005;19:861–8. Epub 2005/07/22PubMed PMID: 16034449

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Al Riyami AA, Afifi MM. Hypertension in Oman: distribution and correlates. J Egypt Public Health Assoc. 2002;77:383–407. Epub 2007/01/16. PubMed PMID: 17216969

    PubMed  Google Scholar 

  12. 12.

    Tazi MA, Abir-Khalil S, Chaouki N, Cherqaoui S, Lahmouz F, Srairi JE, et al. Prevalence of the main cardiovascular risk factors in Morocco: results of a National Survey, 2000. J Hypertens. 2003;21:897–903. Epub 2003/04/26PubMed PMID: 12714863

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Matar D, Frangieh AH, Abouassi S, Bteich F, Saleh A, Salame E, et al. Prevalence, awareness, treatment, and control of hypertension in Lebanon. J Clin Hypertens (Greenwich). 2015;17:381–8. Epub 2015/01/27PubMed PMID: 25619545

    Article  Google Scholar 

  14. 14.

    Esteghamati A, Meysamie A, Khalilzadeh O, Rashidi A, Haghazali M, Asgari F, et al. Third national Surveillance of Risk Factors of Non-Communicable Diseases (SuRFNCD-2007) in Iran: methods and results on prevalence of diabetes, hypertension, obesity, central obesity, and dyslipidemia. BMC Public Health. 2009;9:167 Epub 2009/06/02PubMed PMID: 19480675; PubMed Central PMCID: PMCPMC2697989

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    El-Reshaid K, Al-Owaish R, Diab A. Hypertension in kuwait: the past, present and future. Saudi J Kidney Dis Transpl. 1999;10:357–64. Epub 2008/01/24PubMed PMID: 18212446

    CAS  PubMed  Google Scholar 

  16. 16.

    Ashour Z, Ibrahim MM, Appel LJ, Ibrahim AS, Whelton PK. The Egyptian National Hypertension Project (NHP). Design and rationale. The NHP Investigative Team. Hypertension. 1995;26:880–5. Epub 1995/12/01PubMed PMID: 7490143

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    El-Shahat YI, Bakir SZ, Farjou N, Hashim T, Bohaliga A, Al-Hossani H, et al. Hypertension in UAE Citizens - Preliminary Results of a Prospective Study. Saudi J Kidney Dis Transpl. 1999;10:376–81. Epub 2008/01/24PubMed PMID: 18212449

    CAS  PubMed  Google Scholar 

  18. 18.

    Al-Noumani H, Wu JR, Barksdale D, Alkhasawneh E, Knafl G, Sherwood G. Relationship between medication adherence and health beliefs among patients with hypertension in Oman: pilot study. Sultan Qaboos Univ Med J. 2017;17:e329–e33. Epub 2017/10/25PubMed PMID: 29062557; PubMed Central PMCID: PMCPMC5642364

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Mathers C, Stevens G, Hogan D, Mahanani WR, Ho J. Global and regional causes of death: patterns and trends, 2000-15. In: Jamison DT, Gelband H, Horton S, Jha P, Laxminarayan R, et al., editors. Disease control priorities: improving health and reducing poverty. 3rd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2017.

  20. 20.

    Ibrahim MM. Epidemiology of hypertension in egypt. Saudi J Kidney Dis Transpl. 1999;10:352–6. Epub 2008/01/24. PubMed PMID: 18212445

    CAS  PubMed  Google Scholar 

  21. 21.

    Al-Nozha M, Al-Khadra A, Arafah MR, Al-Maatouq MA, Khalil MZ, Khan NB, et al. Metabolic syndrome in Saudi Arabia. Saudi Med J. 2005;26:1918–25.

  22. 22.

    Khader A, Farajallah L, Shahin Y, Hababeh M, Abu-Zayed I, Zachariah R, et al. Hypertension and treatment outcomes in Palestine refugees in United Nations Relief and Works Agency primary health care clinics in Jordan. Trop Med Int Health. 2014;19:1276–83. Epub 2014/07/22PubMed PMID: 25039838

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Arnaout MS, Almahmeed W, Ibrahim M, Ker J, Khalil MT, Van Wyk CT, et al. Hypertension and its management in countries in Africa and the Middle East, with special reference to the place of beta-blockade. Curr Med Res Opin. 2011;27:1223–36. Epub 2011/04/21PubMed PMID: 21504302

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    World health statistics 2020: monitoring health for the SDGs, sustainable development goals. Geneva: World Health Organization; 2020.

  25. 25.

    Health and well-being profile of the Eastern Mediterranean Region: an overview of the health situation in the Region and its countries in 2019. Cairo: WHO Regional Office for the Eastern Mediterranean; 2020.

  26. 26.

    Vialle-Valentin CE, Serumaga B, Wagner AK, Ross-Degnan D. Evidence on access to medicines for chronic diseases from household surveys in five low- and middle-income countries. Health Policy Plan. 2015;30:1044–52. Epub 2014/09/27PubMed PMID: 25255920; PubMed Central PMCID: PMCPMC4654757

    Article  PubMed  Google Scholar 

  27. 27.

    Abukhdeir HF, Caplan LS, Reese L, Alema-Mensah E. Factors affecting the prevalence of chronic diseases in Palestinian people: an analysis of data from the Palestinian Central Bureau of Statistics. East Mediterr Health J. 2013;19:307–13. Epub 2013/07/26. PubMed PMID: 23882954; PubMed Central PMCID: PMCPMC4143143

    CAS  Article  Google Scholar 

  28. 28.

    Virdis A, Giannarelli C, Neves MF, Taddei S, Ghiadoni L. Cigarette smoking and hypertension. Curr Pharm Des. 2010;16:2518–25. Epub 2010/06/17PubMed PMID: 20550499

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Khattab A, Javaid A, Iraqi G, Alzaabi A, Ben Kheder A, Koniski ML, et al. Smoking habits in the Middle East and North Africa: results of the BREATHE study. Respir Med. 2012;106:S16–24. Suppl 2Epub 2013/02/08PubMed PMID: 23290700

    Article  PubMed  Google Scholar 

  30. 30.

    Abdulle AM, Nagelkerke NJ, Abouchacra S, Pathan JY, Adem A, Obineche EN. Under- treatment and under diagnosis of hypertension: a serious problem in the United Arab Emirates. BMC Cardiovasc Disord. 2006;6:24 Epub 2006/06/07PubMed PMID: 16753071; PubMed Central PMCID: PMCPMC1501045

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Qasim H, Alarabi AB, Alzoubi KH, Karim ZA, Alshbool FZ, Khasawneh FT. The effects of hookah/waterpipe smoking on general health and the cardiovascular system. Environ Health Prev Med. 2019;24:58 Epub 2019/09/16PubMed PMID: 31521105; PubMed Central PMCID: PMCPMC6745078

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure. Am J Prev Med. 2009;37:518–23. Epub 2009/12/01PubMed PMID: 19944918; PubMed Central PMCID: PMCPMC2805076

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Rezk-Hanna M, Doering L, Robbins W, Sarna L, Elashoff RM, Victor RG. Acute effect of hookah smoking on arterial stiffness and wave reflections in adults aged 18 to 34 years of age. Am J Cardiol. 2018;122:905–9. Epub 2018/07/31PubMed PMID: 30057235

    Article  PubMed  Google Scholar 

  34. 34.

    Azar RR, Frangieh AH, Mroue J, Bassila L, Kasty M, Hage G, et al. Acute effects of waterpipe smoking on blood pressure and heart rate: a real-life trial. Inhal Toxicol. 2016;28:339–42. Epub 2016/04/26PubMed PMID: 27109645

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Garrison RJ, Kannel WB, Stokes J 3rd, Castelli WP. Incidence and precursors of hypertension in young adults: the Framingham Offspring Study. Prev Med. 1987;16:235–51. Epub 1987/03/01PubMed PMID: 3588564

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Susic D, Varagic J. Obesity: a perspective from hypertension. Med Clin North Am. 2017;101:139–57. Epub 2016/11/26PubMed PMID: 27884225

    Article  PubMed  Google Scholar 

  37. 37.

    Channanath AM, Farran B, Behbehani K, Thanaraj TA. Association between body mass index and onset of hypertension in men and women with and without diabetes: a cross-sectional study using national health data from the State of Kuwait in the Arabian Peninsula. BMJ Open. 2015;5:e007043 Epub 2015/06/06PubMed PMID: 26044759; PubMed Central PMCID: PMCPMC4466600

    Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Dalacoura K. Women and Gender in the Middle East and North Africa: Mapping the Field and Addressing Policy Dilemmas at the Post-2011 Juncture.MENARA Final Reports, 3. 2019.

  39. 39.

    Donnelly TT, Al-Thani ABM, Benjamin K, Al-Khater AH, Fung TS, Ahmedna M, et al. Arab female and male perceptions of factors facilitating and inhibiting their physical activity: Findings from a qualitative study in the Middle East. PLoS One. 2018;13:e0199336 Epub 2018/07/17PubMed PMID: 30011280; PubMed Central PMCID: PMCPMC6047779

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Modesti PA, Bamoshmoosh M, Rapi S, Massetti L, Al-Hidabi D, Al, et al. Epidemiology of hypertension in Yemen: effects of urbanization and geographical area. Hypertens Res. 2013;36:711–7. Epub 2013/03/15PubMed PMID: 23486167; PubMed Central PMCID: PMCPMC3734526

    Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Mowafi H. Conflict, displacement and health in the Middle East. Glob Public Health. 2011;6:472–87. Epub 2011/05/19PubMed PMID: 21590557

    Article  PubMed  Google Scholar 

  42. 42.

    Rosenthal T. Immigration and acculturation: impact on health and well-being of immigrants. Curr Hypertens Rep. 2018;20:70 Epub 2018/07/05PubMed PMID: 29971699

    Article  PubMed  Google Scholar 

  43. 43.

    Geldsetzer P, Manne-Goehler J, Marcus ME, Ebert C, Zhumadilov Z, Wesseh CS, et al. The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1.1 million adults. Lancet. 2019;394:652–62. Epub 2019/07/23PubMed PMID: 31327566

    Article  PubMed  Google Scholar 

  44. 44.

    Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension. 2020;75:1334–57. Epub 2020/05/07PubMed PMID: 32370572

    CAS  Article  PubMed  Google Scholar 

  45. 45.

    Lotfaliany M, Akbarpour S, Mozafary A, Boloukat RR, Azizi F, Hadaegh F. Hypertension phenotypes and incident cardiovascular disease and mortality events in a decade follow-up of a Middle East cohort. J Hypertens. 2015;33:1153–61. Epub 2015/02/24PubMed PMID: 25699976

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Khdour MR, Hallak HO, Shaeen M, Jarab AS, Al-Shahed QN. Prevalence, awareness, treatment and control of hypertension in the Palestinian population. J Hum Hypertens. 2013;27:623–8. Epub 2013/04/12PubMed PMID: 23575447

    CAS  Article  PubMed  Google Scholar 

  47. 47.

    Gupta P, Patel P, Strauch B, Lai FY, Akbarov A, Maresova V, et al. Risk factors for nonadherence to antihypertensive treatment. Hypertension. 2017;69:1113–20. Epub 2017/05/04PubMed PMID: 28461599

    CAS  Article  PubMed  Google Scholar 

  48. 48.

    Alhaddad IA, Hamoui O, Hammoudeh A, Mallat S. Blood pressure control in treated hypertensive Middle Eastern patients: a post hoc analysis based on JNC8 definitions. Vasc Health Risk Manag. 2019;15:35–46. Epub 2019/03/19PubMed PMID: 30881006; PubMed Central PMCID: PMCPMC6410753

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Whelton PK, Carey RM, Aronow WS, Casey DE Jr., Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:1269–324. Epub 2017/11/15PubMed PMID: 29133354

    CAS  Article  PubMed  Google Scholar 

  50. 50.

    zaei S, Mahmoudi Z, Sheidaei A, Aryan Z, Mahmoudi N, Gohari K, et al. Salt intake among Iranian population: the first national report on salt intake in Iran. J Hypertens. 2018;36:2380–9. Epub 2018/07/14PubMed PMID: 30005027

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    Nasreddine L, Akl C, Al-Shaar L, Almedawar MM, Isma’eel H. Consumer knowledge, attitudes and salt-related behavior in the Middle-East: the case of Lebanon. Nutrients. 2014;6:5079–102. Epub 2014/11/18PubMed PMID: 25401502; PubMed Central PMCID: PMCPMC4245581

    Article  PubMed  PubMed Central  Google Scholar 

  52. 52.

    Nair SC, Satish KP, Sreedharan J, Ibrahim H. Assessing health literacy in the eastern and middle-eastern cultures. BMC Public Health. 2016;16:831 Epub 2016/08/20PubMed PMID: 27538529; PubMed Central PMCID: PMCPMC4991078

    Article  PubMed  PubMed Central  Google Scholar 

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Correspondence to Sabine Karam.

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Abboud, M., Karam, S. Hypertension in the Middle East: current state, human factors, and barriers to control. J Hum Hypertens (2021).

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