Standards for the uniform reporting of hypertension in adults using population survey data: recommendations from the World Hypertension League Expert Committee.

Surveillance and monitoring of cardiovascular risk factors including raised blood pressure are critical to informing efforts to prevent and control cardiovascular disease. Yet, many countries lack the capacity for adequate national surveillance. Furthermore, hypertension indicators are often reported in different ways, which hampers the ability to compare and assess progress. In order to encourage standardized hypertension surveillance reporting, the World Hypertension League assembled an Expert Committee to develop a standard set of core indicators, definitions, and recommended analyses. The recommended core indicators are: (1) blood pressure distribution, (2) prevalence of hypertension, (3) awareness of the condition, (4) antihypertensive drug treatment, and (5) control of hypertension based on drug therapy. Each of these can be reported overall and by age group and sex, with crude and age-standardized changes tracked over time in order to assess the impact of instituted policies and programs for hypertension prevention and control. An expanded list of indicators can also facilitate tracking of hypertension prevention and control efforts. Widespread adoption of these indicators and analyses could benefit all those conducting and analyzing hypertension surveys and will facilitate hypertension surveillance efforts.

Validity of self-reported blood pressure control in people with hypertension attending a primary care center.

OBJECTIVES: The aim of this study was to estimate the validity of self-reported blood pressure control and medication use in people with hypertension, with and without diabetes. METHODS: In a sample of 161 patients with hypertension in a family health team in Ontario, we applied questions from the 2009 Survey on Living with Chronic Disease in Canada Hypertension Component and compared responses against objectively measured and chart-abstracted clinical indicators. Objective blood pressure control was defined as a blood pressure of less than 130/80 mmHg and less than 140/90 mmHg for individuals with and without diabetes, respectively. RESULTS: Self-reported blood pressure control showed reasonable sensitivity (83±11 and 78±10%) but low specificity (30±19 and 58±21%) in people with and those without diabetes, respectively. In the subgroup with diabetes, specificity improved to 88±11% when blood pressure control was defined on the basis of a 140/90 mmHg target. Self-reported and chart-abstracted numbers of prescribed antihypertensive medications showed fair agreement (κ=0.7); 9 and 14% of patients overestimated and underestimated the number of prescribed medications, respectively. CONCLUSION: Although most individuals with controlled hypertension reported having controlled blood pressure, a large proportion of individuals with uncontrolled hypertension also reported that their blood pressure was controlled. This level of misclassification suggests that in a family medicine clinic population and in health survey contexts, a self-reported measure of blood pressure control may not be useful for assessing hypertension control.

Health behaviors for hypertension management in people with and without coexisting diabetes.

Since blood pressure (BP) control is less often achieved by individuals with diabetes, the authors sought to determine whether receipt of and adherence to health behavior advice for hypertension control differs between people with and without diabetes, using data from the 2009 Survey on Living With Chronic Diseases in Canada. Individuals with coexisting diabetes were more likely to report receiving advice to control/lose weight (81% vs 66%), be physically active (79% vs 68%), limit alcohol consumption (78% vs 55%), and modify diet (70% vs 61%) but not limit dietary salt (65% vs 64%) compared with individuals with hypertension alone (n=4.965). People with and without diabetes were equally likely to report following the advice they received, with receipt of advice positively associated with engagement in healthy behaviors. Since receipt of advice appears to influence behavior, health professionals should be encouraged to further promote BP self-management strategies.

Determinants of lifestyle behavior in type 2 diabetes: results of the 2011 cross-sectional survey on living with chronic diseases in Canada.

BACKGROUND: Lifestyle behavior modification is an essential component of self-management of type 2 diabetes. We evaluated the prevalence of engagement in lifestyle behaviors for management of the disease, as well as the impact of healthcare professional support on these behaviors. METHODS: Self-reported data were available from 2682 adult respondents, age 20 years or older, to the 2011 Survey on Living with Chronic Diseases in Canada's diabetes component. Associations with never engaging in and not sustaining self-management behaviors (of dietary change, weight control, exercise, and smoking cessation) were evaluated using binomial regression models. RESULTS: The prevalence of reported dietary change, weight control/loss, increased exercise and smoking cessation (among those who smoked since being diagnosed) were 89.7%, 72.1%, 69.5%, and 30.6%, respectively. Those who reported not receiving health professional advice in the previous 12 months were more likely to report never engaging in dietary change (RR = 2.7, 95% CI 1.8 - 4.2), exercise (RR = 1.7, 95% CI 1.3 - 2.1), or weight control/loss (RR = 2.2, 95% CI 1.3 - 3.6), but not smoking cessation (RR = 1.0; 95% CI: 0.7 - 1.5). Also, living with diabetes for more than six years was associated with not sustaining dietary change, weight loss and smoking cessation. CONCLUSION: Health professional advice for lifestyle behaviors for type 2 diabetes self-management may support individual actions. Patients living with the disease for more than 6 years may require additional support in sustaining recommended behaviors.

Antihypertensive medication use, adherence, stops, and starts in Canadians with hypertension.

BACKGROUND: Some of the greatest barriers to achieving blood pressure control are perceived to be failure to prescribe antihypertensive medication and lack of adherence to medication prescriptions. METHODS: Self-reported data from 6017 Canadians with diagnosed hypertension who responded to the 2008 Canadian Community Health Survey and the 2009 Survey on Living with Chronic Diseases in Canada were examined. RESULTS: The majority (82%) of individuals with diagnosed hypertension reported using antihypertensive medications. The main reasons for not taking medications were either that they were not prescribed (42%) or that blood pressure had been controlled without medications (45%). Of those not taking antihypertensive medications in 2008 (n = 963), 18% had started antihypertensive medications by 2009, and of those initially taking medications (n = 5058), 5% had stopped. Of those taking medications in 2009, 89% indicated they took the medication as prescribed, and 10% indicated they occasionally missed a dose. Participants who were recently diagnosed, not measuring blood pressure at home, not having a plan to control blood pressure, or not receiving instructions on how to take medications were less likely to be taking antihypertensive medications; similar factors tended to be associated with stopping antihypertensive medication use. CONCLUSIONS: Compatible with high rates of hypertension control, most Canadians diagnosed with hypertension take antihypertensive medications and report adherence. Widespread implementation of self-management strategies for blood pressure control and standardized instructions on antihypertensive medication may further optimize drug treatment.

Factors associated with lack of awareness and uncontrolled high blood pressure among Canadian adults with hypertension.

BACKGROUND: Approximately 17% of Canadians with high blood pressure were unaware of their condition, and of Canadians aware of having the condition, approximately 1 in 5 have uncontrolled high blood pressure despite high rates of pharmacotherapy. The objectives of the current study are to estimate the prevalence of resistant hypertension and examine factors associated with (1) lack of awareness and (2) uncontrolled hypertension despite pharmacotherapy. METHODS: Using the 2007-2009 Canadian Health Measures Survey (N = 3473, aged 20-79 years) and logistic regression, we quantified relationships between characteristics and (1) presence of hypertension, (2) lack of awareness (among those with hypertension), and (3) uncontrolled high blood pressure (among those treated for hypertension). RESULTS: Older age, lowest income, and less than high school education were associated with presence of hypertension. Men (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.2) and adults < 60 years (OR, 1.7; 95% CI, 1.1-2.6) were more likely than others to be unaware. Among those aged 60+ years, women were more likely than men to have uncontrolled high blood pressure (OR, 2.4; 95% CI, 1.1-5.2) despite treatment. Elevated systolic blood pressure was the issue in over 90% of women and 80% of men with uncontrolled hypertension. Depending on the definition employed, 4.4% (95% CI, 2.4-6.4) to 7.8% (95% CI, 6.0-9.6) of the population with hypertension had resistant hypertension. CONCLUSIONS: Messaging or interventions encouraging screening may be helpful for all younger Canadian adults and men; programs encouraging blood pressure control may help older women.

Prevalence, awareness, treatment, and control of hypertension among Canadian adults with diabetes, 2007 to 2009.

BACKGROUND: Prior national surveys suggested that treatment and control of hypertension were poor in individuals with diabetes. Using measured blood pressures, we estimated prevalence, awareness, treatment, and control of hypertension between 2007 and 2009 among Canadians with diabetes and sought to determine whether a treatment gap still exists for individuals with diabetes. METHODS: Using data from cycle 1 of the Canadian Health Measures Survey, estimates of hypertension prevalence, awareness, treatment, and control were described and compared between individuals with and without self-reported diabetes. RESULTS: Three-quarters of individuals reporting diabetes also had hypertension; of these, 89% (95% confidence interval [CI], 80%-98%) were aware, 88% (95% CI, 81%-94%) were treated, and 56% (95% CI, 45%-66%) were controlled to < 130/80 mm Hg. Among those treated with pharmacotherapy, 39% (95% CI, 31%-48%) were using monotherapy, 29% (95% CI, 18%-40%) were taking 2 medications, and 31% (95% CI, 22%-39%) were taking 3 or more medications; control to < 130/80 mm Hg was achieved by 63% (95% CI, 53%-74%). Among those treated, individuals with diabetes were significantly less likely to be treated to their recommended target (< 130/80 mm Hg) compared with individuals without diabetes (< 140/90 mm Hg; odds ratio(adjusted) 0.3; 95% CI, 0.2-0.6). CONCLUSIONS: Hypertension treatment and control among people with diabetes have improved in Canada during the past 2 decades. Nonetheless, nearly half of people with diabetes are above the treatment target. Health care professionals should continue to increase their efforts in supporting patients with diabetes in achieving blood pressure control, with emphasis on lifestyle management and pharmacotherapy.

Prevalence of, and barriers to, preventive lifestyle behaviors in hypertension (from a national survey of Canadians with hypertension).

Patients with hypertension are advised to lower their blood pressure to <140/90 mm Hg through sustained lifestyle modification and/or pharmacotherapy. To describe the use of lifestyle changes for blood pressure control and to identify the barriers to these behaviors, the data from 6,142 Canadians with hypertension who responded to the 2009 Survey on Living With Chronic Diseases in Canada were analyzed. Most Canadians with diagnosed hypertension reported limiting salt consumption (89%), having changed the types of food they eat (89%), engaging in physical activity (80%), trying to control or lose weight if overweight (77%), quitting smoking if currently smoking (78%), and reducing alcohol intake if currently drinking more than the recommended levels (57%) at least some of the time to control their blood pressure. Men, those aged 20 to 44 years, and those with lower educational attainment and lower income were, in general, less likely to report engaging in lifestyle behaviors for blood pressure control. A low desire, interest, or awareness were commonly reported barriers to salt restriction, changes in diet, weight loss, smoking cessation, and alcohol reduction. In contrast, the most common barrier to engaging in physical activity to regulate blood pressure was the self-reported challenge of managing a coexisting physical condition or time constraints. In conclusion, programs and interventions to improve the adherence to lifestyle changes to treat hypertension may need to consider the identified barriers to lifestyle behaviors in their design.

Health behaviour advice from health professionals to Canadian adults with hypertension: results from a national survey.

BACKGROUND: Health professionals play an important role in providing health information to patients. The objectives of this study were to examine the type of advice that Canadians with hypertension recall receiving from health professionals to manage their condition, and to assess if there is an association between health behaviour advice provided by health professionals and self-reported engagement in health behaviour modification. METHODS: Respondents of the 2009 Survey on Living with Chronic Diseases in Canada (N = 6142) were asked about sociodemographic characteristics, health care utilization, and health behaviour modification to control hypertension. Association between receipt of advice from health professional and ever engaging, continuing to engage, and not engaging in health behaviour modification was quantified by prevalence rate ratios. RESULTS: Most participants (90.9%; 95% confidence interval [CI], 89.6-92.2) reported that the health professional most responsible for treating their high blood pressure was their general practitioner. Approximately 9% reported that they had not received or do not recall receiving any advice for blood pressure control. The most commonly reported advice received from a health professional was to participate in physical activity or exercise (70.0%). Respondents who had received advice on health behaviour change to manage their high blood pressure were more likely to report engaging in the behaviour compared with those who did not receive such advice. CONCLUSIONS: Many Canadians with hypertension receive health behaviour change advice from their health professionals. Receiving this advice was associated with a greater likelihood of attempting health behaviour change and attempting to sustain that change.