In the last three years, the COVID-19 vaccine has generated a lot of public interest as a possible risk factor for blood clot formation, resulting in sudden cardiac arrest. However, a proven, bigger, and preventable risk factor for heart attack and brain stroke, i.e., hypertension, rarely gets due public attention. Let us dive deep into high blood pressure and its public health relevance.
In 2023, the World Health Organization (WHO) released a report, the first ever on hypertension, titled “Global report on hypertension: the race against a silent killer”. Hypertension was considered a silent killer as people often are not aware about high blood pressure till they develop complications. High blood pressure is the singlemost important risk factor for early deaths, leading to an estimated 10.8 million preventable deaths every year, globally. High blood pressure causes more deaths than other leading risk factors, such as tobacco use and high blood sugar. The number of adults with hypertension nearly doubled in the last three decades (since 1990) to reach 1.3 billion. Globally, an estimated 46% of adults with hypertension are unaware that they have the condition, and less than half (42%) with hypertension are diagnosed and treated. Only one in five adults (21%) with hypertension has it under control.
The Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study has estimated that in India, 311 million people (or one in every three adults) have hypertension. In the country, adults with hypertension are threefold of the estimated 101 million people living with diabetes.
Cut the salt
Excess dietary salt intake (five grams or more per day), one of the key risk factors to hypertension, contributed to two million cardiovascular disease deaths in 2019. Research studies have shown that by reducing salt, cardiovascular disease risks can be reduced by 30% and mortality by 20%. Indian adults consume on average eight to 11 grams of salt per day, which is approximately twice that of the WHO recommended daily salt intake. High salt intake is responsible for an estimated 1,75,000 deaths in India.
Hypertension is not an issue for any one socio-economic group. A Delhi-based non-governmental organisation, Foundation for People-centric Health Systems, conducted 50 health camps in five localities of Delhi and Gurugram, from October 2023 to March 2024, and screened and treated around 12,000 people. Most of the people were women, migrant workers, and rickshaw and taxi drivers, nearly all from low income groups. A large number of them were found to have diabetes and hypertension, a majority of cases detected for the first time in these camps, indicating the gaps in terms of awareness, detection and treatment.
In India, the government has set a target of putting 75 million people with hypertension and/or diabetes on standard care by 2025. The India Hypertension Control Initiative (IHCI), a collaborative project of the ICMR, Ministry of Health and Family Welfare/Directorate General of Health Services, WHO India and other partners, was initiated in November 2017 in 25 districts in five States of India.
Simple and scalable
The IHCI follows five simple and scalable strategies, implemented through primary health care. The IHCI rolled out simplified drug and dose-specific treatment protocols for primary-care settings. It also focused on strengthening the drug supply chain by including protocol-based drugs in the State essential drug list; the forecasting of drugs based on morbidity, and ensuring adequate budget allocation in annual plans to purchase hypertension medication. The IHCI has also followed team-based and decentralised care. In addition, components to make health services patient-centric by measures such as the dispensing of 30 days of medicine in every patient visit are part of the initiative. It has also used information systems for programme monitoring.
Nearly six years of IHCI implementation has resulted in two major programmatic learnings. First, the development of simple treatment protocols with fewer drugs, ensuring reliable drug supply, linking patients to facilities closer to home for follow-up and engaging teams increases access and utilisation of health services from government facilities, by bringing people to health services. Second, simplified programme monitoring makes programme performance assessment both quantifiable and actionable. The IHCI won the ‘2022 UN Interagency Task Force, and WHO Special Programme on Primary Health Care Award’. The IHCI was expanded to 140-plus districts of India, in 2023.
Seventy-six million cardiovascular deaths and 450 million disability adjusted life years (DALYs) would be avoided, if countries, with proven interventions, mobilise to achieve the goal of 50% population hypertension control by 2050. An estimated 4.6 million deaths can be prevented in India by 2040 if half the hypertensive population has its blood pressure under control. This will help countries achieving the targets under their National Health Policy along with global targets and commitments such as universal health coverage.
What should be done? First, raise awareness about the risk of and long-term adverse impact of untreated hypertension. High blood pressure can affect the entire vascular system (multiple organs including the heart, kidneys, brain and eyes).
Second, scale up evidence-based public health interventions such as the IHCI. Strategies and lessons from such experiences should be used to design and implement interventions to prevent and control other lifestyle diseases such as diabetes mellitus and chronic kidney diseases.
Third, the interventions in health programmes are often targeted on modifiable risk factors. However, there are non-modifiable risk factors such as family history, an age of over 65 years and pre-existing comorbidities such as diabetes and/or kidney disease, all of which make a person at higher risk of hypertension. India already has a high burden of each of these non-modifiable risk factors: high burden of hypertension (a family risk factor for future generation); high burden of comorbidities and a rapidly rising elderly population. Therefore, hypertension control initiatives in India need to focus on the healthy adults as well, who may have known non-modifiable risk factors.
Fourth, intensify efforts to reduce dietary salt consumption using strategies such as ‘SHAKE the salt habit’ under the WHO’s HEARTS strategy. Under SHAKE, there are five approaches: of Surveillance to measure and monitor salt use; Harness industry to promote and reformulate foods and meals that contain less salt; A adopt to standard labelling and marketing; Knowledge, educate and communicate to empower individuals to eat less salt; Environment — support settings that promote healthy eating.
Fifth, lifestyle diseases demand multi-sectoral actions. In 2017, India developed and approved a multi-sectoral plan for the prevention and the control of non-communicable diseases. These plans must be revisited and more concrete actions done by key sectors. We need to leapfrog to this as soon as possible.
Sixth, having informed citizens is the key to control hypertension at the population level. Raise awareness about salt in food. There is invisible salt in the form of pickles, breads, namkeen and papad. Food packages need to have better labelling of items/packets in terms of low, medium and high salt content. People also need to be sensitised to read food package labels and make informed decisions.
Seventh, stronger enforcement of food regulation in India has the potential to prevent many diseases and reduce the burden on health services. There needs to be higher taxation on high salt (and also high sugar, high fat) food and other packaged products.
Regular BP checks
Take Control. Regular checking of one’s blood pressure should become an integral part of lifestyle. Access to BP apparatus needs to be increased in public places such as malls, shops and pharmacies, where people can have their BP measured either free or at nominal and affordable charges. Every office and workplace needs to have a functional BP apparatus and employees should be encouraged to check their BP regularly. Every single visit to health-care providers should be used to measure one’s BP. Physicians should advise/sensitise people to measure and monitor their BP.
Dr. Chandrakant Lahariya, a medical doctor, was formerly with the World Health Organization. He is a consultant physician at the Centre for Health and Wellness, a primary health-care initiative based out of New Delhi. Dr. Balram Bhargava, a medical doctor and cardiologist, is the former Director General of the Indian Council of Medical Research, New Delhi, and, currently, President of the National Academy of Sciences, India
