Burden of High Systolic Blood Pressure in the Eastern Mediterranean Region, 1990 to 2021: Results From the Global Burden of Disease Study 2021

Abstract

Background

High systolic blood pressure (HSBP) is a significant public health issue, increasing the risk of various chronic and acute diseases. This study comprehensively analyzes the HSBP‐attributed burden in the Eastern Mediterranean Region (EMR).

Methods

We extracted and analyzed data on deaths, disability‐adjusted life‐years (DALYs), years of life lost, years lived with disability, and summary exposure values (SEVs) related to HSBP from the Global Burden of Disease (GBD) 2021 study for the EMR countries from 1990 to 2021.

Results

In 2021, HSBP accounted for an estimated age‐standardized death rate of 228.4 (95% UI: 189.6 to 266) and DALYs rate of 4554.9 (3719.7 to 5279.6) per 100,000 population in the EMR. From 1990 to 2021, there was a 12.7% and 14.1% decline in age‐standardized death and DALYs rates linked to HSBP, respectively, with greater reduction among women. During this period, all countries except Pakistan and Libya experienced a decrease in age‐standardized death and DALYs rates, and also countries with higher socio‐demographic index (SDI) reported a lower burden attributable to HSBP in 2021. Despite the overall reduction in burden, age‐standardized SEVs of HSBP increased by 21.3% (12.2% to 31.7%) from 1990 to 2021, with a more significant rise in men than in women.

Conclusion

While the HSBP‐attributed burden has decreased in the EMR from 1990 to 2021, the increasing trend in age‐standardized SEVs indicates a rising exposure. Therefore, implementing effective strategies aimed at further reducing the burden and exposure values of HSBP in this region is essential.

Nonstandard Abbreviations and Acronyms

EMR

Eastern Mediterranean region

GATHER

Guidelines for Accurate and Transparent Health Estimates Reporting

GBD

Global Burden of Disease

HSPB

high systolic blood pressure

SBP

systolic blood pressure

SDI

sociodemographic index

SEV

summary exposure value

UAE

United Arab Emirates

UI

uncertainty interval

WHO

World Health Organization

YLDs

years lived with disability

YLLs

years of life lost

Clinical Perspective.

What Is New?

• The age‐standardized deaths and disability‐adjusted life‐years attributable to high systolic blood pressure (HSBP) in the Eastern Mediterranean region (EMR) were 228.4 (95% uncertainty interval [UI], 189.6–266) and 4554.9 (95% UI, 3719.7–5279.6) per 100 000, respectively.

• During the 1990 to 2021 period, both age‐standardized deaths and disability‐adjusted life‐years decreased in the EMR, which was more prominent in women. The exceptions were Pakistan and Libya, which showed an increase in the burden from HSBP.

• Countries with higher sociodemographic index in the EMR had lower burdens attributable to HSBP.

• The exposure to HSBP measured by summary exposure value revealed that there was an increase in exposure to HSBP in the EMR. This increase was higher in men, compared with women.

What Are the Clinical Implications?

• Despite the decrease in burden attributable to HSBP in the region, the exposure to it increased from 1990 to 2021. The findings of this study could provide healthcare policymakers with the latest update on HSBP in the EMR.

• Since there are significant disparities among EMR countries in terms of economic status and access to health care, healthcare systems should identify high‐risk regions with increased burdens, based on our findings.

• Preventive strategies should be strictly implemented with the aim of reducing the exposure and finally decreasing the burden attributable to HSBP.

High systolic blood pressure (HSBP) is a major global health issue and imposes dramatic pressure on countries' health systems worldwide. ¹ , ² , ³ Currently, it is well known that the repercussions of uncontrolled HSBP are profound and epidemiological findings indicate that the risk of cardiovascular incidents rises in a linear pattern, starting from a systolic blood pressure (SBP) of 120 mm Hg. ⁴ , ⁵ In addition to cardiovascular diseases (CVDs), there are many devastating chronic and acute diseases attributable to or worsened by HSBP such as chronic kidney disease, COVID‐19, stroke, and other metabolic disorders, emphasizing the crucial role of managing SBP to prevent these associated complications. ¹ , ⁵ , ⁶

Previous data from the 2019 GBD (Global Burden of Disease) studies introduced HSBP as the primary risk factor contributing to 10.8 million deaths globally. ³ During the past years, GBD studies have been publishing the temporal trend, associated diseases, and risk factors of the HSBP among different populations around the globe. These populations are categorized based on the World Health Organization's (WHO's) classification of 6 global regions, with the Eastern Mediterranean region (EMR) being one of these regions. ⁷ The EMR includes 22 nations, mainly upper‐ and middle‐income countries and low‐ and middle‐income countries, with a collective population of ≈583 million individuals. ⁷

This study provides an in‐depth analysis of the HSBP temporal trajectory in terms of death and disability‐adjusted life‐years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs) rates in the EMR from 1990 to 2021 by utilizing data sourced from GBD 2021, and delineates the sex discrepancies, age differences, and HSBP pattern in EMR. Also, by utilizing summary exposure values (SEVs) for geographical distribution, age, and sex, we identified the excess risk of HSBP and the level of population exposure to HSBP, contributing to all‐cause mortality, and DALYs from 1990 to 2021. Furthermore, we analyzed the trends in the impact of HSBP on all‐cause mortality and DALYs over the past 2 years from 2019 to 2021 in women and men among different age groups during the time of the COVID‐19 pandemic. The thorough assessment of the regional disease burden of HSBP serves as a critical roadmap for the development and implementation of population‐specific health policies aimed at mitigating HSBP‐related mortality and reducing regional divergences.

METHODS

The data in this article were derived from sources in public domain (Institute for Health Metrics and Evaluation, at http://ghdx.healthdata.org/gbd‐results‐tool).

Overview

In the GBD 2021 project, data on 371 diseases and injuries and 88 risk factors were reported among 204 countries and territories in 21 GBD regions or 7 superregions, with methodological details available in prior literature. ² , ⁸ , ⁹ This study used GBD 2021 data to estimate burden measures attributable to HSBP in the EMR, 1 of the 6 WHO regions comprising 22 countries, including Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates (UAE), and Yemen.

Definitions

HSBP, defined in GBD 2021 as a theoretical minimum‐risk exposure level of ≥105 to 115 mm Hg, represents the threshold minimizing population‐level risk. The GBD 2021 framework organizes risk factors hierarchically across 4 levels. Level 1 categorizes risks as environmental, occupational, behavioral, or metabolic. Level 2 includes 20 specific risks or clusters, while level 3 expands 9 of these into 42 detailed risks, alongside 11 unchanged factors. Level 4 further details 5 level 3 risks into 22 specific factors while maintaining 11 level 2 and 37 level 3 risks unchanged. In the GBD 2021 context, HSBP is classified as a level 2 metabolic risk. ² , ⁸

The sociodemographic index (SDI) measures socioeconomic development using lag‐distributed income per capita, average years of education, and fertility rates among women younger than 25 years. ¹⁰ Countries are grouped into 5 SDI quintiles: low, low‐middle, middle, high‐middle, and high SDI. ⁸ Afghanistan, Somalia, and Yemen are in the low SDI group; Djibouti, Pakistan, Sudan, Morocco, and Egypt are in the low‐middle group; Syria, Palestine, Iraq, Tunisia, and Iran are in the middle group; Jordan, Libya, Lebanon, Bahrain, and Oman are in the high‐middle group; and Saudi Arabia, Qatar, Kuwait, and the UAE are in the high SDI group. Age is classified into 17 groups: 5‐year increments from 15 to 19 years to 90 to 94 years, and 95 years and older.

Data Sources, Processing, and Modeling Strategy

The GBD 2021 data sources, methodologies, and HSBP‐related risk assessments are detailed in prior research. ³ , ⁹ Mean SBP and related risk factors were assessed using data from the literature and household surveys such as STEPS and the National Health and Nutrition Examination Survey, focusing on population‐based studies with direct SBP measurements. While no systematic review was conducted, GBD 2019 data were updated. The study primarily used the Behavioral Risk Factors Surveillance System for self‐reported hypertension diagnoses, adjusted for bias, and categorized by demographics.

For modeling mean SBP, a spatiotemporal Gaussian process regression framework was implemented, allowing for demographic variations. In brief, this method is a 3‐stage modeling approach used within the GBD studies. ¹¹ It draws strength across time and geography to produce full‐time series estimates with uncertainty intervals (UIs) from data that are often unevenly distributed across space and time. The first stage of this model fits a linear regression to the data with fixed effects on specified covariates. Then, the residuals between the regression fit and the data across time and geography are smoothed in order to generate a nonlinear trend that better follows available data in a location, region, and superregion. Finally, this trend is used as a mean function in a Gaussian process regression to account for input data variance and to generate uncertainty in the final estimates. ¹² Covariates were carefully chosen based on causal relationships and predictive validity testing. The final predictions for mean SBP were derived from an ensemble of the top 50 models, while SD estimates were calculated through linear regression using demographic data. Adjustments for within‐person variability were incorporated using correction factors from longitudinal surveys, ultimately leading to a comprehensive global SBP distribution for each sex, aimed at delivering accurate and varied SBP estimates across populations. ² , ⁸

Given that the GBD relies on deidentified collective data, informed consent forms were not required for this study. Findings are accessible via the GBD Compare website (https://vizhub.healthdata.org/gbd‐compare) and input data through the Global Health Data Exchange (http://ghdx.healthdata.org/gbd‐results‐tool). This study adhered to the GATHER (Guidelines for Accurate and Transparent Health Estimates Reporting). ¹³

Statistical Analysis

The estimation methods for this study are detailed in previous works. ² , ⁸ , ⁹ Deaths and DALYs attributable to HSBP were calculated by multiplying expected deaths or DALYs for each country, stratified by age, sex, and year. Deaths were defined using the Cause of Death Ensemble model. YLDs were calculated with disability weights, and YLLs by multiplying age‐specific deaths by life expectancy from the GBD standard life table. Total burden was expressed as DALYs, combining YLLs and YLDs. SEVs were reported as age‐standardized rates (0–100). Temporal changes from 1990 to 2021 were analyzed as percentage shifts. Burden estimates were presented as raw counts and age‐standardized rates per 100 000 (extrapolated to a hypothetical population with a standardized age structure) based on 500 simulations with 95% UIs calculated using the GBD standard‐population structure to compare the estimates made in different populations with a variety of age structures. The standard population was calculated with the nonweighted mean of the age‐specific population proportional distributions for all national locations with populations >5 million. ⁹ , ¹⁴ Analyses were performed using Python 3.10.4, Stata version 13.1 (StataCorp LLC), and R version 4.2.1 (R Foundation for Statistical Computing).

RESULTS

Overview

In 2021, there were 826.4 thousand deaths (95% UI, 677.8–960.7) attributable to HSBP in the region, resulting in an age‐standardized death rate of 228.4 (95% UI, 189.6–266) per 100 000 individuals (Table1). By sex, there were 393.7 (95% UI, 321.0–457.9) thousand deaths in women, corresponding to an age‐standardized death rate of 234.5 (95% UI, 193.2–272) per 100 000. However, among men, there were 432.7 (95% UI, 354.8–508.7) thousand deaths, with an age‐standardized death rate of 222.7 (95% UI, 182.7–262.4) per 100 000 (Table 1). From 1990 to 2021, there was a decline of 12.7% (95% UI, −20.4% to −3.3%) in terms of age‐standardized death rate attributable to HSBP. Notably, the decrease in HSBP‐attributable deaths was higher in women, with a reduction of 19.5% (95% UI, −27.6 to −9.5), compared with a decrease of 5.3% (95% UI, −14.6 to 7.7) in men (Table 1).

Table 1.

All Ages and Age‐Standardized Rates of DALYs, Deaths, YLDs, and YLLs of HSBP by Sex in 1990 and 2021 and Overall Percent Change During 1990 to 2021 in the EMR

Measure	Age, metric	Year						Percent change (1990–2021)
		1990			2021
		Both	Women	Men	Both	Women	Men	Both	Women	Men
DALYs	Age‐standardized	5302 (4378.1–6121.7)	5606.8 (4728–6499.5)	5035.1 (4093.9–5946.9)	4554.9 (3719.7–5279.6)	4429.2 (3602.7–5149.1)	4665.2 (3832.9–5464.1)	−14.1 (−22.1 to −3.9)	−21 (−29.5 to −10)	−7.3 (−16.9 to 5.9)
	All ages	9 175 408.6 (7 514 526.8–10 648 212.1)	4 422 148.7 (3 675 220.9–5 113 825.5)	4 753 259.9 (3 837 149.4–5 636 372.7)	19 876 213.2 (16 071 843.1–23 207 563.9)	8 927 822.5 (7 193 991.5–10 466 097.6)	10 948 390.7 (8 900 297.7–1 285 1443.4)	116.6 (95.2–144.5)	101.9 (78.7–132.1)	130.3 (104.8–163.4)
Deaths	Age‐standardized	261.8 (217.1–303)	291.4 (245.8–337.7)	235.1 (190.5–278.2)	228.4 (189.6–266)	234.5 (193.2–272)	222.7 (182.7–262.4)	−12.7 (−20.4 to −3.3)	−19.5 (−27.6 to −9.5)	−5.3 (−14.6 to 7.7)
	All ages	384 456.3 (319 793.2–443 853.1)	194 246.4 (164 833.7–225 872.5)	190 209.9 (154 164.2–224 796.8)	826 483.8 (677 842.1–960 737.2)	393 711.9 (321 057.2–457 952.1)	432 771.9 (354 860.1–508 719)	115 (95.1–140.5)	102.7 (80.6–131)	127.5 (103.9–160.4)
YLDs	Age‐standardized	151.8 (105.3–201.2)	152.2 (107.9–201)	151.3 (104.7–199.9)	163.8 (116.5–213.3)	153.4 (109.9–202.4)	173.6 (123.2–227.7)	7.9 (3.7–13)	0.8 (−4.3 to 5.9)	14.7 (9.4–21.8)
	All ages	278 759.1 (192 142–370 447.1)	132 975.9 (92 686.2–175 764.3)	145 783.2 (100 622.2–193 239.1)	778 489.8 (547 479.6–1 026 912.7)	353 185.8 (249 520.3–468 152.9)	425 304 (299 095.3–561 262.1)	179.3 (168–192.6)	165.6 (151.3–181.1)	191.7 (178.2–209.6)
YLLs	Age‐standardized	5150.2 (4256.6–5952.1)	5454.6 (4595.6–6341.1)	4883.8 (3969.2–5779.1)	4391.1 (3587.8–5114.9)	4275.8 (3482.8–4989.8)	4491.7 (3682.7–5275.6)	−14.7 (−22.9 to −4.3)	−21.6 (−30.3 to −10.4)	−8 (−17.9 to 5.5)
	All ages	8 896 649.5 (7 282 351.8–10 361 902)	4 289 172.8 (3 562 482.1–4 975 915)	4 607 476.7 (3 719 780.9–5 480 746)	19 097 723.4 (15 392 600.5–22 356 496)	8 574 636.7 (6 917 690.5–10 058 974.1)	10 523 086.7 (8 504 963.4–12 404 126.6)	114.7 (92.9–143.4)	99.9 (76.4–131.1)	128.4 (102.1–162.2)

DALY indicates disability‐adjusted life‐year; EMR, Eastern Mediterranean region; HSBP, high systolic blood pressure; YLD, years lived with disability; and YLL, years of life lost.

Furthermore, in 2021, HSBP was responsible for an estimated 19.8 million DALYs (95% UI, 16.0–23.2), including 8.9 (95% UI, 7.1–10.4) million DALYs in women and 10.9 (95% UI, 8.9–12.8) million DALYs in men (Table 1). This corresponds to an age‐standardized DALYs rate of 4554.9 (95% UI, 3719.7–5279.6) per 100 000 individuals, with rates of 4429.2 (95% UI, 3602.7–5149.1) in women and 4665.2 (95% UI, 3832.9–5464.1) in men. Between 1990 and 2021, the age‐standardized DALYs rate attributed to HSBP decreased by 14.1% (95% UI, −22.1% to −3.9%), with a greater decrease in women (−21% [95% UI, −29.5% to −10%]), compared with men (−7.3% [95% UI, −16.9% to 5.9%]) (Table 1, Figure 1). Similarly, the age‐standardized YLLs rate associated with HSBP decreased by 14.7% (95% UI, −22.9% to −4.3%) during the same period; with a greater decline in women (−21.6% [95% UI, −30.3% to −10.4%]) than in men (−8% [95% UI, −17.9% to 5.5%]) (Table 1, Figure 1). Conversely, the age‐standardized YLDs rate associated with HSBP increased by 7.9% (95% UI, 3.7–13) between 1990 and 2021; with a greater increase in men (14.7% [95% UI, 9.4%–21.8%]) compared with women (0.8% [95% UI, −4.3% to 5.9%]) (Table 1, Figure 1). Overall, the time trend of age‐standardized death rates, DALYs, and YLLs from 1990 to 2021 was decreasing, while the time trend of age‐standardized YLDs showed an increase in both sexes, reaching a plateau in the early 2000s (Figure 1, Table S1).

Figure 1. Time trends of age‐standardized rates of DALYs, deaths, YLDs, and YLLs attributed to high systolic blood pressure in the Eastern Mediterranean region from 1990 to 2021 stratified by sex.

Shaded areas represent 95% uncertainty intervals. There was a decrease in DALYs, deaths, and YLLs. Also, men had lower DALYs and YLLs before 2005 to 2006 while higher than women from 2006. DALY indicates disability‐adjusted life‐year; YLD, years lived with disability; and YLL, years of life lost.

The geographical distribution of age‐standardized death shows higher DALYs, YLLs, and YLDs rates in countries located in the eastern areas of the region in 1990 and 2021 for both sexes (Figure 2). A similar geographical distribution pattern of these measures was observed in the region in 1990 and 2021 for women (Figure S1) and men (Figure S2).

Figure 2. Geographical distribution of age‐standardized rates for DALYs, deaths, YLDs, and YLLs attributed to high systolic blood pressure in the Eastern Mediterranean region in 1990 and 2021 for both sexes.

The maps illustrate regional disparities, with countries showing varying levels of disease burden. Shaded regions indicate high and low rates, with specific values displayed for each metric. Imagery reproduced from the GEBCO_2022 Grid, GEBCO Compilation Group (2022) GEBCO 2022 Grid (doi:10.5285/e0f0bb80‐ab44‐2739‐e053‐6c86abc0289c). DALY indicates disability‐adjusted life‐year; YLD, years lived with disability; and YLL, years of life lost.

Burden of HSBP Among Countries in the Region

In 2021, the countries with the highest age‐standardized death rates attributable to HSBP were Egypt (370.5 [95% UI, 299.1–449.3]), Afghanistan (328 [95% UI, 249.8–408.1]), and Iraq (315 [95% UI, 248.2–385.9]). In contrast, the lowest rates were observed in Lebanon (94.1 [95% UI, 75–115.5]), Kuwait (99.8 [95% UI, 77.8–122.4]), and Qatar (131.1 [95% UI, 99.6–163.4]) (Figure 3 and Table S2). From 1990 to 2021, all countries experienced a reduction in the age‐standardized death rate attributed to HSBP, with the exception of Pakistan, Libya, and Iraq, which showed an increase of 19% (95% UI, 0.1%–48.5%), 13.3% (95% UI, −13.9% to 47.9%), and 0.9% (95% UI, −20.9% to 24.8%), respectively (Table S2). Moreover, Qatar (−62.3% [95% UI, −70.8% to −52.3%]), Lebanon (−58.8% [95% UI, −67.6% to −47.8%]), and Bahrain (−50.7% [95% UI, −58.6% to −41.4%]) had the 3 highest decreases in age‐standardized death rates associated with HSBP, while Djibouti (−0.3% [95% UI, −25.5% to 36.4%]), Egypt (−7.3% [95% UI, −22.7% to 12.6%]), and Somalia (−9% [95% UI, −29.7% to 20.8%]) had the 3 lowest decreases, from 1990 to 2021 (Table S2).

Figure 3. Ranking of age‐standardized rates of DALYs, deaths, YLDs, and YLLs attributed to high systolic blood pressure in the Eastern Mediterranean region in 1990 and 2021.

The figure shows how the burden of high systolic blood pressure has shifted across countries over time, highlighting regional differences in disease burden and changes between 1990 and 2021. DALY indicates disability‐adjusted life‐year; index; YLD, years lived with disability; and YLL, years of life lost.

By sex, Egypt recorded the highest age‐standardized death rates for women at 540.5 (95% UI, 427.9–647.5), while Kuwait had the lowest at 63.6 [95% UI, 47.3–77.1] (Figures S3, Table S2). Between 1990 and 2021, Kuwait (−65.8% [95% UI, −71% to −59.7%]), and Pakistan (−1.3% [95% UI, −22.8% to 32.2%]) had the highest and lowest decrease in age‐standardized death rates attributable to HSBP among women, respectively (Table S2). For men, Iraq had the highest age‐standardized death rate (372 [95% UI, 283.1–455.3]), while the UAE had the lowest one (116.1 [95% UI, 86–145.6]) (Figures S4, Table S2). During the same period, Qatar (−62.3% [95% UI, −71.6% to −50.4%]) and Oman (−3.3% [95% UI, −31.2% to 40.2%]) reported the highest and lowest decrease in age‐standardized death rates attributable to HSBP for men, respectively (Table S2).

In 2021, the 3 countries with the highest age‐standardized DALYs rates per 100 000 population were Egypt (7093.8 [95% UI, 5672.3–8616]), Afghanistan (6780.5 [95% UI, 4901.6–8685.9]), and Iraq (5999 [95% UI, 4676–7387.5]). On the other hand, the 3 lowest rates were observed in Lebanon (1818.7 [95% UI, 1454.2–2222]), Kuwait (1917.4 [95% UI, 1509.7–2362.1]), and Qatar (2259.6 [95% UI, 1746–2861.6]) (Figure 3, Table S2). From 1990 to 2021, The age‐standardized DALYs rates decreased among all countries in the region, with the exception of Pakistan and Libya, which experienced increases of 20.5% (95% UI, −0.8% to 51.4%) and 14.9% (95% UI, −13.5% to 53.3%), respectively (Table S2). Notably, the highest decrease in age‐standardized DALYs rates during this period occurred in Qatar (−63.6% [95% UI, −71.9% to −53.2%]), Lebanon (−60.3% [95% UI, −68.7% to −50%]), and Bahrain (−54.5% [95% UI, −61.8% to −45.7%]), while the lowest were recorded in Egypt (−2.7% [95% UI, −19% to 18.7%]), Djibouti (−3.3% [95% UI, −29.4% to 32.9%]), and Iraq (−11.4% [95% UI, −32.5% to 11.2%]) (Table S2). Sex disparities were evident, with Egypt exhibiting the highest age‐standardized DALYs rates for women (8572.4 [95% UI, 6945–10 342.3]), while Iraq had the highest rates for men (7221.5 [95% UI, 5411.7–8877.2]). Kuwait and the UAE recorded the lowest rates for women (1118.7 [95% UI, 884.3–1325.7]), and men (2147.6 [95% UI, 1639.7–2702.1]), respectively (Figures S3 and S4 and Table S2). Moreover, between 1990 and 2021, Kuwait (−68.7% [95% UI, −73.4% to −63.2%]) and Pakistan (−0.5% [95% UI, −22.4% to 33.8%]) had the highest and lowest decrease in age‐standardized death rates attributable to HSBP among women, respectively (Table S2). For men, the UAE showed the highest decline in age‐standardized death rates attributable to HSBP (−65.2% [95% UI, −71.6% to −58.4%]), whereas Iraq exhibited the lowest decrease (−5.3% [95% UI, −30.4% to 22.2%]) during the same period (Table S2).

Age Groups Effect on the Burden of HSBP in the EMR

In 1990, the deaths, DALYs, YLLs, and YLDs attributable to HSBP increased with advancing age, with the highest rates observed in the 95+ year age group for both sexes. This trend was consistent in 2021, where the deaths, DALYs, YLLs, and YLDs attributable to HSBP continued to rise with age, reaching their peak in the 95+ year age group for both sexes. In addition, women had higher rates of deaths, DALYs, and YLLs than men in age groups ranging from 65 to 69 years to 95+ years in 1990. In 2021, women in age groups from 70 to 74 years to 95+ years exhibited higher rates of deaths, DALYs, and YLLs compared with men. Nevertheless, before the age of 65 to 69 years in 1990 and 70 to 74 years in 2021, women had lower rates of death, DALYs, and YLLs compared with men. In terms of YLDs, women had lower rates among ages 65 to 69 years to 95+ years compared with men in 1990. However, in 2021, women showed lower YLD rates among all age groups compared with men (Figure 4, Table S3).

Figure 4. Rates of DALYs, deaths, YLDs, and YLLs attributed to high systolic blood pressure in the Eastern Mediterranean region in 1990 and 2021, stratified by sex and age group.

The figure shows the differential burden of high systolic blood pressure among different age groups and sexes, highlighting trends in both men and women during the 3 decades. DALY indicates disability‐adjusted life‐year; YLD, years lived with disability; and YLL, years of life lost.

SDI Effect on the Burden of HSBP in the EMR

In addition, countries classified as high and high‐middle SDI had a lower burden attributable to HSBP (including deaths, DALYs, YLLs, and YLDs) compared with those in the low and low‐middle SDI quintiles in 2021 (Figures 5 and 6, Table S4).

Figure 5. Age‐standardized rates of DALYs, deaths, and YLLs attributed to high systolic blood pressure in countries of the Eastern Mediterranean region in 2021, categorized by SDI quintiles for both sexes.

The figure highlights the association between SDI and the burden of high systolic blood pressure, showing that lower SDI countries generally have higher rates of disease burden. DALY indicates disability‐adjusted life‐year; SDI, sociodemographic index; and YLL, years of life lost.

Figure 6. Age‐standardized rates of DALYs, YLDs, and YLLs attributed to high systolic blood pressure in countries of the Eastern Mediterranean region in 2021, categorized by SDI quintiles for both sexes.

The figure illustrates the association between SDI levels and the burden of high systolic blood pressure, with countries in lower SDI quintiles generally experiencing higher rates of DALYs and YLDs. DALY indicates disability‐adjusted life‐year; SDI, sociodemographic index; YLD, years lived with disability and YLL, years of life lost.

SEVs of HSBP in the EMR

The geographical distribution of the age‐standardized rate of SEVs of HSBP exhibited higher rates in eastern countries of the region in 1990, which subsequently shifted to western countries of the region by 2021 for both sexes (Figure 7). The geographical distribution patterns of these measures were consistent among the region for both women and men in 1990 and 2021 (Figure 7).

Figure 7. Geographical distribution of the age‐standardized rates of summary exposure value for high systolic blood pressure in countries of the Eastern Mediterranean region in 1990 and 2021, stratified by sex.

The figure illustrates the regional variation in exposure to high systolic blood pressure, with distinct patterns across countries and over time. Shaded regions indicate high and low rates, with specific values displayed for each metric. Imagery reproduced from the GEBCO_2022 Grid, GEBCO Compilation Group (2022) GEBCO 2022 Grid (doi:10.5285/e0f0bb80‐ab44‐2739‐e053‐6c86abc0289c).

As of 2021, the age‐standardized SEVs of HSBP was 40.8 per 100 000 population (95% UI, 30.0–53.3), with a value of 39.8 (95% UI, 29.0–51.9) for women and 41.7 (95% UI, 30.2–55.1) for men. The highest age‐standardized SEVs of HSBP were reported in Libya (55.8 [95% UI, 40.5–70.5]), Sudan (50.9 [95% UI, 36.4–66.6]), and Iraq (49.0 [95% UI, 36.4–64.2]), while the lowest rates were found in Palestine (28.6 [95% UI, 18.7–40.5]), Saudi Arabia (30.4 [95% UI, 24.1–51.2]), and Kuwait (30.9 [95% UI, 21.0–42.0]) (Figure S5 and Table S5). In addition, for women, the highest and lowest age‐standardized values of HSBP were recorded in Sudan (51.1 [95% UI, 35.6–68.1]) and Qatar (22.0 [95% UI, 14.5–31.8]), respectively. For men, these values were highest in Libya (61.4 [95% UI, 43.6–77.5]) and lowest in Yemen (28.7 [95% UI, 18.5–41.9]) (Figure S5 and Table S5). From 1990 to 2021, the age‐standardized SEVs of HSBP demonstrated an increasing trend, with an overall rise of 21.3% (95% UI, 12.2%–31.7%). This increase was higher among men (32.4% [95% UI, 20.1%–47.9%]), compared with women (10.5% [95% UI, −3.1% to 25.2%]). The age‐standardized rates of SEVs of HSBP increased in all countries, with the exceptions of Kuwait, Morocco, Palestine, Qatar, Saudi Arabia, and the UAE, during 1990 to 2021. The highest increase was observed in Oman (101.7% [95% UI, 52.7%–190.6%]), while the largest decrease occurred in the UAE (−28.1% [95% UI, −42.6% to 6.3%]) (Figure S6, Table S5). Among women, the age‐standardized rates of HSBP SEVs increased in all countries except Jordan, Kuwait, Morocco, Palestine, Qatar, Saudi Arabia, and the UAE during the same period (Figure S7). The highest increase was again noted in Oman (124.1% [95% UI, 36.1%–279.5%]), while the greatest decrease occurred in Saudi Arabia (−34.4% [95% UI, −56.2% to −3%]) (Tables S5 and S6). Conversely, among men, the age‐standardized rates of SEVs of HSBP showed an increasing trend in all countries except Morocco, Palestine, Saudi Arabia, and the UAE from 1990 to 2021 (Figure S8). Notably, the highest increase for men was in Oman (92% [95% UI, 33.6%–199.2%]) and the largest decrease was in the UAE (−29.3% [95% UI, −46.8 to −10.2]) during this period (Tables S5 and S6).

Burden Attributable to HSBP in the EMR During 2019 to 2021

Between 2019 and 2021, the age‐standardized rates of death, DALYs, and YLLs exhibited slight decreases of −1.6% (95% UI, −7.3% to 4.2%), −1.7% (95% UI, −8.2% to 5.0%), and −1.8% (95% UI, −8.5% to 5.2%), respectively, with a more pronounced decline observed among women compared with men. In contrast, the age‐standardized rate of YLD showed no notable change during this period (Table S7). Furthermore, all countries in the region displayed a decreasing trend in the age‐standardized rates of death and DALYs attributable to HSBP, except for Bahrain, Iraq, Jordan, Kuwait, Palestine, Qatar, and Yemen between 2019 and 2021. The largest reductions in the age‐standardized rates of DALYs and deaths attributable to HSBP were observed in the UAE (−30.7% [95% UI, −41.8% to −19.4%] for DALYs; −32.2% [95% UI, −43.4% to −21.2%] for death), followed by Oman (−10.2% [95% UI, −16.8% to −4.2%] for DALYs; −8.0% [95% UI, −14.3% to −1.9%] for death), and Iran (−6.7% [95% UI, −9.8% to −3.1%] for DALYs; −6.5% [95% UI, −9.8% to −3.1%] for death). On the other hand, the highest increases in the age‐standardized rates of DALYs and deaths attributable to HSBP were recorded in Qatar (4.8% [95% UI, −2.6% to 11.9%] for DALYs; 13.0% [95% UI, 5.5%–19.9%] for death), Iraq (6.9% [95% UI, −0.7% to 14.2%] for DALYs; 10.3% [95% UI, 0.6%–17.4%] for death), and Jordan (2.5% [95% UI, −4.2% to 9.7%] for DALYs; 3.5% [95% UI, −3.3% to 10.2%] for death) (Table S7).

DISCUSSION

In this study, we comprehensively investigated the temporal trend of HSBP in the EMR from 1990 to 2021. There was a 12.7% and a 14.1% decline in terms of age‐standardized mortality and DALYs, respectively, attributable to HSBP. During 1990 to 2021, all countries experienced a reduction in the age‐standardized death rates attributed to HSBP, with the exception of Pakistan, Libya, and Iraq. This reduction in HSBP‐related mortality is mostly owed to prolonged efforts to manage SBP by increasing public awareness and preventive care quality. ¹⁵ , ¹⁶

Furthermore, from 1990 to 2021, the age‐standardized SEVs of HSBP demonstrated an increasing trend, with an overall rise of 21.3%. This increase was higher among men (32.4%), compared with women (10.5%). These findings indicate that the population at risk of exposure to HSBP has been increasing over recent decades, likely due to rising life expectancy and a growing elderly population in both sexes, which are more susceptible to HSBP. ⁹ , ¹⁷ In this way, according to the GBD 2021 report, global life expectancy increased by 22.7 years between 1950 and 2021. ¹⁸ Regarding the sex difference in the increasing rate of SEVs, it may be related to the higher prevalence of prehypertensive conditions among men (45%) compared with women (27%). ¹⁹ , ²⁰ Behavioral factors, such as higher smoking rates, greater stress exposure, and poorer dietary habits among men, may contribute to this trend. Biological factors, including hormonal differences that may confer some protective effects in premenopausal women, also play a role. These gender‐specific risks likely interact with disparities in healthcare access and management strategies, where men may delay seeking care or lack adherence to treatment. Exploring these interactions within the broader public health framework can inform tailored interventions to address the distinct needs of men and women in hypertension prevention and management.

Countries classified as having a high and high‐middle SDI had a lower attributable burden from HSBP (including death and DALY rates) compared with those in the low and low‐middle SDI quintiles in 2021. A high SDI is often indicative of better access to healthcare facilities, higher‐quality medical care, advanced medical technologies, well‐trained healthcare professionals, comprehensive healthcare infrastructure, and greater capacity for research and innovation in health care. Public health initiatives, such as national screening programs and improved health insurance coverage, also contribute to this disparity. ²¹ , ²²

In this regard, high SDI countries such as Saudi Arabia, the UAE, and Qatar have designed policies to address the issue of HSBP in their countries. Saudi Arabia has a significant investment in the improvement of healthcare facilities and coverage, supporting the Saudi Vision 2030 program, which includes transformation in the healthcare sector with noncommunicable diseases at a higher priority. ²³ , ²⁴ Salt intake >5 g/day, as suggested by WHO, is another reported risk factor for hypertension in Saudi Arabia as well as other EMR countries. ²⁵ Salt reduction initiatives are included in Saudi Vision 2030. ²⁴ In UAE, the UAE's national noncommunicable diseases action plan was designed to align with WHO 2025 targets and sustainable development goals for 2030. ²⁶ This plan included a 25% relative reduction in the prevalence of HSBP. Similar salt reduction strategies by the government have been planned as well, such as the reformulation of products in the food industry to reduce salt and trans‐fatty acids, as well as media campaigns, social media activities, and labeling foods for their salt levels. ²⁷ Finally, Qatar, as another example of a high SDI country with a relatively lower burden from HSBP, designed the Qatar National Health Strategy (2018–2022) with the aim of reducing the burden of CVDs with a focus on primary healthcare service as the main point of contact. ²⁸ Moreover, the Ministry of Public Health in Qatar regularly updates the clinical practice guidelines on the management of hypertension including diagnosis confirmation, target blood pressure (BP), and HSBP treatments. ²⁹ It seems that these strategies have provided the country's healthcare system with better rates in terms of burden compared with other EMR countries.

Iran, as a country in the middle SDI group, set the Iranian Non‐communicable Diseases Committee, which included 13 targets, 4 of which were directly or indirectly related to hypertension. ³⁰ On the other hand, a country such as Egypt, classified as low‐middle SDI, had the highest DALYs in the EMR. This might stem from inconsistent approaches by physicians in BP measurement, treatment inadequacy, lower awareness, lower treatment, lower control, and lack of registries for CVD risk factors. ³¹ , ³² , ³³ This shortage of epidemiologic studies to identify national patterns regarding HSBP has led to the adaptation of evidence‐based guidelines in Western countries with some modifications. ³⁴ The high burden attributed to HSBP in Egypt clearly shows the need for high‐quality data at the national level regarding HSBP control among the EMR countries. However, countries such as Pakistan, Libya, and Iraq, despite their higher SDI classification in some cases, exhibit an increased HSBP burden. This deviation may be influenced by sociopolitical instability, economic challenges, or inequities in healthcare access within these countries. Furthermore, variations in lifestyle risk factors, the quality of preventive care, and the prioritization of noncommunicable diseases in health policies could explain these anomalies. A detailed understanding of how SDI impacts healthcare access and public health measures within the EMR could provide deeper insights into these trends. For low SDI countries, feasible interventions include implementing cost‐effective community‐based programs such as mobile health clinics, hypertension awareness campaigns, and task‐shifting strategies to train nonphysician healthcare workers for early detection and management. ³⁵ Integrating HSBP prevention into existing primary care frameworks and leveraging international collaborations to improve access to essential antihypertensive medications could also be impactful. ³⁶ Comparative data from other regions, such as sub‐Saharan Africa and Southeast Asia, reveal the effectiveness of interventions such as subsidized BP monitoring and national salt reduction strategies. ³⁷ , ³⁸ A detailed understanding of how SDI impacts healthcare access and public health measures within the EMR, alongside lessons from other regions, can inform targeted and sustainable strategies to reduce the HSBP burden.

Considering the HSBP‐related burden in the context of aging, from 1990 to 2021, there was a decreasing trend of HSBP‐attributable death and DALY rates in both sexes. Moreover, in both 1990 and 2021, the death and DALYs attributable to HSBP escalated with advancing age documented in the 95 and older age bracket for both sexes. Our findings align with earlier GBD investigations concerning the burden of HSBP in the EMR and various other areas. ¹ , ⁷ , ³⁹ Arterial aging, arterial stiffness, and impaired vasoconstriction that are associated with aging contribute to the adverse outcomes of HSBP and subsequent CVDs as individuals age. ⁴⁰ , ⁴¹ In addition, from the public health point of view, the difference in age‐related awareness, treatment, and control of hypertension stands as another possible factor that helps younger people with HSBP have better prognoses compared with their older peers. Undoubtedly, heightened awareness, timely identification, and effective treatment from a younger age can substantially enhance the prevalence and outcomes of HSBP. ⁴²

The 2017 guideline set out by the American College of Cardiology/American Heart Association introduced lower BP thresholds for diagnosing hypertension, reducing them by 10 mm Hg. This adjustment categorizes elevated BP as SBP ranging from 120 to 129 mm Hg, while stage I hypertension is acknowledged as SBP between 130 and 139 mm Hg. ⁶ , ⁴³ However, there remain the potential differences between the sexes. It is widely recognized that in healthy individuals, BP levels in women during adulthood tend to be lower on average compared with men. ⁴⁴ In addition, there appears to be a correlation between SBP and mortality from CVDs that differs by sex, indicating a heightened risk of CVD mortality at lower SBP levels among women when compared with men. ⁴⁵ , ⁴⁶ , ⁴⁷ In a study by Niiranen et al., ⁴⁵ cardiovascular incidence consistently increased with SBP elevation starting at a lower range of SBP in women compared with men. They showed that for women, having an SBP between 100 and 109 mm Hg was linked to the occurrence of CVDs, unlike in men where the risk was observed at SBP levels of 130 to 139 mm Hg. ⁴⁵ In our research, concerning sex variances among age groups, women aged older than 65 to 69 years in 1990 and 70 to 74 years in 2021 displayed significantly higher rates of mortality and DALYs in comparison to men. Nevertheless, before the age of 65 years in 1990 and 70 years in 2021, women had slightly lower rates of death and DALY rates compared with men. Furthermore, a study reported that the incidence of hypertension is higher in men up to the age of 45 years, with similar rates for both genders between 46 and 64 years. After age 65 years, this pattern reverses, with women exhibiting a higher prevalence. ¹⁹ Notably, it has been reported that women are more aware of their hypertensive condition (74.3% versus 52.5%) and are more likely to seek medical care for it (62.1% versus 36.1%). ⁴⁸ This could explain the lower burden of hypertension‐related health issues among women compared with men.

Although the lower average SBP in women compared with men is well‐documented, particularly before menopause, SBP trajectories differ between sexes over time. Contrary to the belief that significant vascular disease processes in women develop later than in men by 10 to 20 years, studies focusing on sex‐specific analyses have revealed that BP measurements progress more swiftly in women than in men, starting early in life. ⁴⁷ Furthermore, women typically exhibit sharper increases in SBP starting as early as their third decade of life, and these trends persist across their lifespan. ⁴⁶ , ⁴⁷ The sexual dimorphism in age‐related elevation of BP could be attributed to various factors, including variances in hormonal and chromosomal factors, as well as sex‐biased nonchromosomal gene expression. Research on genome regulation suggests that the effects of estrogen play a considerable role in the sex‐based differences observed in the genetic architecture of BP. Estrogen's functions in the cardiovascular system include the regulation of endothelium‐mediated relaxation and BP and the estrogen decrease in postmenopausal women has been linked to an increased CVD risk. However, hormone replacement therapy has not been found to alleviate this observed CVD risk, underscoring the intricate nature of estrogen's impact on clinical CVD risk. ⁴⁹ Also, it has been suggested that common conditions in women such as autoimmune diseases, obesity, and preeclampsia might exacerbate cardiovascular complications when combined with hypertension. ⁵⁰ Building on that, women generally have smaller coronary artery size and aortic root dimensions than men, even when adjusting for body size, potentially leading to elevated CVD risk in a sex‐specific manner. ⁴⁵ , ⁵¹ These hormonal and anatomical distinctions may play a role in the sex‐specific relationship between SBP and CVDs. In light of this, and in line with previous research, the outcomes hint at a potential necessity for a lower sex‐specific definition of optimal SBP for women. Confirmatory studies are essential, involving diverse cohorts without preexisting CVDs, repeated SBP measurements, and extended follow‐up periods. Although evidence suggests that women tend to develop high HSBP‐associated CVDs at lower SBP thresholds, our findings showed a more significant decrease in deaths and DALYs attributed to HSBP in women compared with men between 1990 and 2021. It is noteworthy that men are more exposed to social and environmental hazards such as smoking, alcohol consumption, and unhealthy dietary patterns, potentially contributing to sex‐specific variations in the impact of HSBP. Notably, men demonstrate lower levels of hypertension awareness and receive antihypertensive treatment at lower rates than women. ¹ Therefore, effective management of BP and associated risk factors through lifestyle modifications and enhanced health education among men is crucial for reducing overall mortality among individuals with HSBP.

The effect of lifestyle factors should also be considered when comparing men and women. It has been shown that a higher‐risk lifestyle has a more detrimental effect on middle‐aged adults than older adults, especially in men. ⁵² This highlights the need for lifestyle risk reduction among middle‐aged men. On the other hand, it has been shown that high body mass index, low physical activity, and alcohol intake are individual risk factors for hypertension in both sexes. ⁵³ , ⁵⁴ , ⁵⁵ Regarding awareness factors, a study in Iran, one of the EMR countries, showed that awareness was higher among women and increased with age. ⁵⁶ This could be due to lower access to healthcare systems and less attention to health among men. ⁵⁷ , ⁵⁸

In the current study, we also investigated the HSBP temporal trend between 2019 and 2021, during the COVID‐19 pandemic, and established that there was a continued decrease in age‐standardized death rates and DALYs, with a slightly stronger drop observed among women compared with men in the EMR. This prompts questions about the reasons behind this ongoing decline despite healthcare disruptions caused by the pandemic, including delayed screenings, missed patient’ appointments, and patients avoiding hospitals for fear of contracting the virus. Nevertheless, this downward trend persisted despite the challenges posed by the pandemic, possibly attributable to factors such as the implementation of virtual/digital healthcare services, efficient vaccination campaigns against COVID‐19, and enhanced medical care delivery methods.

Our research employed the GBD 2021 data to evaluate the trajectory of HSBP burden in terms of deaths, DALYs, YLLs, and YLDs rates among different age, sex, and countries, and it is expected to be informative for regional and national healthcare policies in the EMR. Considering the rising mortality rates of CVDs, there is a pressing need to strengthen population‐wide primary prevention approaches for HSBP as a primary risk factor for CVDs. ⁵⁹ Consequently, it is imperative to advocate for the development and implementation of regionally sensitive and relevant strategies across EMR countries, with a particular focus on low‐ and middle‐income nations. These findings can facilitate more tailored recommendations for the precise prevention and effective management of HSBP in at‐risk regions and populations.

Regarding its strengths, this study offers the most thorough and up‐to‐date insights into the current situation and trends of the burden attributable to HSBP based on data from GBD 2021 in the EMR during the years 1990 to 2021. Also, this study reported the effects of the COVID‐19 pandemic on the attributable burden of HSBP and provided the latest information regarding the health burden associated with HSBP during the pandemic. However, similar to other GBD studies, its primary limitations stem from the GBD methodologies in collecting data and the use of complex modeling strategies, so it is not manipulatable. In addition, the availability and quality of foundational primary data, particularly in regions where countries exhibit high rates of data source incompleteness, is a major limitation. This is more prominent in countries with a low SDI where there is an inherent limitation in primary data availability in these regions, and data sparsity or lower quality of data might impact the modeling. Moreover, data gaps could influence the SEV trend estimates and their implications for interpreting trends over time. GBD studies try to minimize this by calculating and reporting 95% UIs. In instances where data are lacking, the outcomes hinge on the out‐of‐sample predictive validity of the modeling efforts. While enhancements in data processing and modeling techniques may lead to incremental advances in GBD estimate precision, substantial improvements require more and enhanced primary data collection. It should be noted that GBD methodologies, while robust, do not routinely provide explicit sensitivity analyses or alternative scenarios to account for the impact of data sparsity on SEV estimates. The lack of such analyses prevents a deeper understanding of how limitations in the underlying data might influence global and regional SEV trends. Policymakers using these estimates should interpret results with caution, especially in regions where data collection remains a challenge. Future studies addressing these gaps through sensitivity analyses or scenario testing would improve the reliability of SEV trends and their applicability to public health interventions.

CONCLUSIONS

Based on GBD 2021 findings, there was a 12.7% and a 14.1% decline in terms of age‐standardized death and DALYs attributed to HSBP, respectively, during 1990 to 2021 in the EMR, and both are conversely related to SDI. In addition, the trend of decreasing age‐standardized death and DALYs attributed to HSBP continued throughout the COVID‐19 pandemic, from 2019 to 2021. However, the age‐standardized SEVs of HSBP demonstrated an increasing trend, with an overall rise of 21.3%. Considering the complexities in healthcare systems of the EMR and adverse health effects of HSBP, policymakers should design necessary interventions to reduce the burden of HSBP.

Sources of Funding

None.

Disclosures

The authors declare that they have no known competing financial interests or personal relationships that could have influenced the work reported in this paper.

Supporting information

Tables S1–S7

Figures S1–S8