Abstract
The prevalence and factors related to hypertension (HTN) treatment and control are well investigated in the Western world but remain poorly understood in the Middle East and in middle‐income countries such as Lebanon. In order to measure the prevalence, awareness, treatment, and control rates of HTN in Lebanon, the authors measured blood pressure (BP) in 1697 adults. The prevalence of optimal BP (<120/80 mm Hg) was 33% and that of pre‐HTN (BP ≥120/80 mm Hg but <140/90 mm Hg) was 30%. The prevalence, awareness, treatment, and control (among treated hypertensive) rates of HTN were 36.9%, 53%, 48.9%, and 54.2%, respectively. Overall, only 27% of patients with HTN had their BP under control. Awareness was the most important predictor of treatment. No predictor of control could be identified. The authors concluded that HTN is prevalent in Lebanon and its overall control is low. Improving awareness is the most important target for intervention.
Hypertension (HTN) is the leading risk factor for cardiovascular disease and mortality worldwide.1, 2 It is present in all countries but its prevalence varies according to genetic background, environmental factors, and level of economic development.3 It is currently estimated that more than 1 billion individuals in the world have HTN and it is the cause of more than 7 million deaths annually.4
Almost three quarters of individuals with HTN live in developing countries with limited health resources and where people have low awareness of HTN and limited access to health care.4, 5 A large proportion of these hypertensive patients are unaware of their blood pressure (BP) level and are consequently not treated. In addition, among treated individuals, more than half do not have their BP under control, even in economically well‐developed countries with excellent healthcare systems.6 Given the importance of this epidemic, the availability of effective medications and the significant reduction in cardiovascular, cerebrovascular, and renal morbidity and mortality with BP lowering, data on HTN prevalence, awareness, treatment, and control in every country are important to obtain.
Lebanon is a developing upper‐middle–income country with a population of 4.42 million (year 2012) living in an area of 10,452 km2.7 Cardiovascular disease is the leading cause of mortality in Lebanon,8 but there have been no national epidemiological studies to date assessing the prevalence and control of risk factors in the Lebanese population. Our study was thus designed to determine the prevalence, awareness, treatment, and control rates of HTN and to assess which factors are associated with its prevalence and control in the adult population.
Material and Methods
Study Population
We conducted a cross‐sectional survey in all six provinces (mohafazats) of Lebanon, focusing on the two provinces located in the center (Beirut and Mount‐Lebanon) where the majority of Lebanese live. Inclusion criteria were Lebanese citizens older than 21 years who gave oral consent to participate. There were no exclusion criteria. The study was approved by the ethics committee of St Joseph University.
Several teams consisting each of at least one physician and one nurse were sent to areas of large public gatherings such as commercial centers, business districts, town halls, and central plazas in villages. People present in these venues were invited to participate in the study.
Data were collected on demographic variables, socioeconomic status, presence of other cardiovascular risk factors, and medication use. Participants were classified as having hyperlipidemia or diabetes if they reported having a blood test that diagnosed the condition or if they were taking lipid‐lowering or antidiabetic medications. They were classified as smokers if they reported smoking more than one cigarette per day or if they smoked a water pipe at least once per week. Body mass index was calculated based on weight and height obtained at the time of the interview. Education and income levels were self‐reported by the participants. Alcohol use was categorized into none or occasional defined as less than one glass of wine (or equivalent) per week, moderate (2–3 glasses per week), or frequent (>3 glasses per week).
In order to determine whether Lebanese citizens are aware of behavior‐related HTN risk factors, participants were specifically asked about the relation of salt intake, Dietary Approaches to Stop Hypertension (DASH) diet, obesity, physical activity, and alcohol use with BP level. Those who were aware that they have HTN were also asked whether they have tried to modify any of these five behavioral factors in order to improve BP control.
BP was measured after at least 10 minutes of rest in the sitting position using an automatic sphygmomanometer and a tailored sized cuff, with the arm at the heart level. The average of two measurements taken 5 minutes apart was used. In cases where the two measurements differed by more than 20 mm Hg for systolic BP (SBP) or more than 10 mm Hg for diastolic BP (DBP), a third measurement was taken after at least five additional minutes and the average of the last two measurements was used for the study. The automatic sphygmomanometer used was the PiC Solution Classic Check (Grandate, Italy), which was validated for self‐measurement of BP and was approved for this indication by the European Society of Hypertension.9
Definitions
Prevalent HTN was defined by an SBP ≥140 mm Hg and/or a DBP ≥90 mm Hg or by individuals who were currently taking antihypertensive medications irrespective of their BP at the time of the examination. Pre‐HTN was defined by individuals who did not meet the definition of HTN but who had an SBP ≥120 mm Hg and <140 mm Hg and/or a DBP ≥80 mm Hg and <90 mm Hg. Normotensive individuals were those who did not meet the definition of HTN and who had an SBP <120 mm Hg and a DBP <80 mm Hg at the time of the examination.
Awareness of HTN was defined by persons with HTN who answered “yes” to the question “Have you ever been told by a doctor or a healthcare professional that you have high BP” and/or by a person who was taking antihypertensive medications. Treatment of HTN was defined by the current use of antihypertensive medications. Recent guidelines do not support reduction of BP to a target lower than 140/90 mm Hg even in high‐risk patients.10 Based on this, control of HTN was defined by an SBP <140 mm Hg and a DBP <90 mm Hg in all categories of hypertensive patients.
Statistical Analysis
Participants’ characteristics were summarized using counts or percentages with 95% confidence intervals (CIs) or mean±standard deviation. Mean BP levels between groups were compared using Student t test. The proportions of persons with HTN, aware of their condition, receiving treatment, or with controlled BP were determined for select sociodemographic and lifestyle and risk factors and compared using chi‐square test. Because many of these risk factors and sociodemographic characteristics may be interdependent, they were entered into a logistic regression analysis in order to determine the independent predictors of HTN presence, awareness, treatment, and control. Given that the distribution of our study population in terms of age groups and sex ratio may be different from the general Lebanese population, the prevalence rate of HTN was age‐ and sex‐adjusted based on the most recent statistical bulletin issued by the Ministry of Health.11 Analyses were conducted using Stata version 12 (StataCorp, College Station, TX). A P value <.05 was considered statistically significant.
Results
Prevalence, Awareness, Treatment, and Control Rates
From December 2012 to August 2013, a total of 1697 participants were enrolled in the study. Their mean age was 42.9±15.8 years and 56% were men. They were recruited from all six provinces (mohafazats) of Lebanon. Table 1 lists the distribution of the study population according to age, area of residence, and sex, and compares the results with the national statistics issued by the Ministry of Health.11 The most important difference between the study sample and the Lebanese population was that of sex (56.2% vs 49.4% men). In term of age groups, the most important difference was in people older than 65 years (10.4% in our sample vs 14.6% in the population). We intentionally inflated the number of participants living in Beirut (24.4% vs 9.6% in the official statistics) because the number given by the Ministry of Health in that regard reflects the number of “voters” in Beirut and not the true number of Beirut's residents (people who live in Beirut but vote in other provinces).
Table 1.
Distribution of the Study Population According to Age, Area of Residence, and Sex and Comparison With the National Statistics Issued by the Ministry of Health
| National Statistics, % | Study Population, % | |
|---|---|---|
| Age group, ya | P<.001 | |
| 21–34 | 38.5 | 35.6 |
| 35–49 | 28.2 | 30.3 |
| 50–65 | 18.7 | 23.7 |
| ≥65 | 14.6 | 10.4 |
| Province of residence | P<.001 | |
| Mount Lebanon | 38.1 | 40.2 |
| North | 20.6 | 12.6 |
| Beqaa | 13.5 | 9.3 |
| South | 11.3 | 8.5 |
| Beirut | 9.6 | 24.4 |
| Nabatieh | 7 | 5 |
| Sex | P<.001 | |
| Male | 49.4 | 56.2 |
| Female | 50.6 | 43.8 |
Percentage is calculated in Lebanese citizens aged 21 years and older. P values are for comparison between national statistics and study population.
The crude prevalence of HTN in our study was 36.9% (Figure, Table 2). The prevalence of HTN was higher in men compared with women and increased with increasing age groups. Almost three quarters of Lebanese aged 65 years and older had HTN. In addition, HTN was more prevalent in patients who smoked, patients with diabetes, patients with hyperlipidemia, patients with higher BMI, and those who were married, divorced, or widowed compared with singles. HTN tended to be more prevalent in persons with higher income levels (P=.05). In multivariate analysis, higher age group, male sex, higher BMI, and presence of diabetes and hyperlipidemia were independent predictors of HTN (Table 3). When adjustment was made according to the distribution of age and to sex ratio in the Lebanese population, the prevalence of HTN was 35.9% (95% CI, 30%–41.7%).
Figure 1.
Hypertension prevalence, awareness, treatment, and control among men and women.
Table 2.
Hypertension Prevalence, Awareness, Treatment, and Control by Demographic and Baseline Characteristics
| No. | Prevalence, % | Awareness, % | Treatment, % | Control in Treated, % | |
|---|---|---|---|---|---|
| All | 1697 | 36.9 | 53 | 48.9 | 54.2 |
| Age, y | P<.001 | P<.001 | P<.001 | P=ns | |
| 21–34 | 600 | 14.8 | 23.2 | 13.8 | 53.8 |
| 35–49 | 510 | 34.1 | 41.3 | 37.8 | 58.2 |
| 50–64 | 399 | 57.6 | 59.1 | 55.8 | 53 |
| ≥65 | 176 | 73.3 | 78.8 | 76.1 | 52.5 |
| Sex | P<.001 | P=.067 | P=.057 | P=.021 | |
| Female | 742 | 29.5 | 57.9 | 54 | 62.3 |
| Male | 952 | 42.7 | 50.4 | 46.1 | 48.9 |
| Education | P=.09 | P=ns | P=ns | P=ns | |
| <High school | 249 | 30.5 | 50.5 | 46.2 | 54 |
| High school | 78 | 35.9 | 53.6 | 50 | 64.3 |
| College | 344 | 39.8 | 58.6 | 55.4 | 54.5 |
| >College | 1020 | 37.5 | 50.9 | 46.8 | 53.3 |
| Income level | P=.05 | P=.028 | P=.022 | P=.098 | |
| Poor | 603 | 33.3 | 45.9 | 41 | 43.5 |
| Lower middle | 569 | 37.8 | 51.1 | 47.2 | 59.2 |
| Upper middle | 148 | 37.8 | 63.8 | 61.4 | 62.8 |
| Affluent | 114 | 44.8 | 63.5 | 56.9 | 48.3 |
| Marital status | P<.001 | P<.001 | P<.001 | P=ns | |
| Single | 565 | 21.8 | 28 | 25 | 64.5 |
| Married | 1052 | 43.6 | 59.4 | 55.2 | 52.5 |
| Divorced | 38 | 47.4 | 42.1 | 31.6 | 83.3 |
| Widowed | 40 | 62.5 | 64 | 60 | 46.7 |
| Province of residence | P=ns | P=.053 | P=.011 | P=ns | |
| Beirut | 410 | 39.8 | 58.8 | 55.8 | 59.4 |
| Mount Lebanon | 675 | 35.4 | 46 | 40.6 | 48.5 |
| North | 211 | 33.2 | 52.9 | 51.4 | 58.3 |
| South | 142 | 38.7 | 54.5 | 54.5 | 56.7 |
| Bekaa | 157 | 39.5 | 65.1 | 59.7 | 51.3 |
| Nabatieh | 84 | 33.3 | 51.6 | 40 | 41.7 |
| Current smoking | P=.007 | P=.009 | P=.004 | P=ns | |
| Yes | 180 | 47.2 | 66.3 | 63.5 | 55.6 |
| No | 1513 | 35.6 | 51.2 | 46.8 | 53.9 |
| Body mass index | P<.001 | P=ns | P=ns | P=ns | |
| <25 | 731 | 22.3 | 54.4 | 49.7 | 59.5 |
| 25–29 | 579 | 45.6 | 51.7 | 46.8 | 51.6 |
| ≥30 | 289 | 53.3 | 57.7 | 54.8 | 55.3 |
| Diabetes mellitusa | P<.001 | P<.001 | P<.001 | P=ns | |
| Yes | 155 | 73.5 | 76.7 | 73.9 | 54.1 |
| No | 1530 | 33.2 | 48 | 43.5 | 54 |
| Hyperlipidemiaa | P<.001 | P<.001 | P<.001 | P=ns | |
| Yes | 431 | 55.4 | 68.8 | 64.6 | 56.7 |
| No | 1246 | 30.4 | 43.7 | 39.5 | 51.6 |
| Alcohol intake | P=ns | P=ns | P=.036 | P=ns | |
| ≤1 drink per wk | 240 | 35.4 | 48.9 | 39.3 | 45.7 |
| 2–3 drinks per wk | 181 | 33.7 | 43.6 | 40.3 | 60 |
| >3 drinks per wk | 1276 | 37.6 | 55 | 51.7 | 54.8 |
Self‐reported.
Table 3.
Multivariate Predictors of Hypertension Prevalence and Awareness
| Category | Prevalence | Awareness |
|---|---|---|
| Odds Ratio (95% Confidence Interval) | Odds Ratio (95% Confidence Interval) | |
| Age (reference, 21–34), y | ||
| 35–49 | 2.7 (1.8–4)a | 0.9 (0.4–1.8) |
| 50–64 | 6.2 (4.1–9.4)a | 2.2 (1.1–4.3)b |
| ≥65 | 9.4 (5.3–16.5)a | 6.1 (2.6–14.2)a |
| Sex (reference, female) | 1.6 (1.2–2.2)c | 0.6 (0.4–0.9)b |
| Body mass index (reference, <25) | ||
| 25–29 | 2.1 (1.5–2.8)a | |
| ≥30 | 2.7 (1.9–3.8)a | |
| Income level (reference, poor) | ||
| Lower middle | 1.3 (0.8–2.0) | |
| Upper middle | 2.5 (1.3–5.0)c | |
| Affluent | 2.8 (1.3–5.7)c | |
| Marital status (reference, single) | ||
| Married | 2.1 (1.2–3.8)b | |
| Divorced | 0.9 (0.3–3.2) | |
| Widowed | 1.0 (0.3–3.3) | |
| Known diabetes (reference, absent) | 2.4 (1.5–3.9)a | 1.8 (1.02–3.1)b |
| Known hyperlipidemia (reference, absent) | 1.3 (1–1.8)b | 2.0 (1.3–3.0)c |
a P<.001, b P<.05, and c P<.01.
HTN awareness was 53% (Figure, Table 2). It increased with increasing age and income level groups, and was higher in patients who smoked, patients with diabetes, and patients with hyperlipidemia as well as those who were married, widowed, or divorced compared with singles. In multivariate analysis, all these factors remained independent predictors of awareness except for smoking. In addition, female sex was an independent predictor of HTN awareness compared with male sex (Table 3).
About 49% of patients with HTN were receiving treatment (Figure). Treatment rates were higher in older individuals, in those with higher income, in people who were married, in patients who smoked, in patients with diabetes mellitus and hyperlipidemia, and in those who reported drinking more than three drinks per week. Treatment rates were lower in the two provinces of Mont‐Lebanon and Nabatieh compared with the four other provinces (Table 2). However, awareness in HTN was the most important determinant of treatment. Among “aware” participants, 93% were taking BP‐lowering therapy. When adjusted for awareness, treatment rates did not vary according to the participants’ sociodemographic or clinical characteristics or risk factors, and were consistently close or superior to 90% except in three categories: younger individuals (age group 21–34 years) where the rate was 62%, participants who reported no or occasional alcohol consumption (≤1 drink per week) where the rate was 81%, and in one province of residence (Nabatieh) where it was 80%. In multivariate analysis, however, age group was the only predictor of treatment among aware individuals. Compared with the age group 21 to 34 years, the three other groups of 35–49, 50–64, and ≥65 years had odds ratios (95% CI) of 15 (2–106), 28 (4–181) and 34 (4–293), respectively (P=.003).
Among treated participants, 54% had their BP under control during the examination (Figure, Table 2). This translates into an overall 27% control rate when all hypertensive patients were considered (treated and not treated). Overall, men had a lower control rate than women (48.9% vs 62.3%; P=.021) in the monovariate analysis; however, in the multivariate analysis, this difference was no longer statistically significant (odds ratio men vs women: 0.55, 95% CI, 0.3–1.05; P=.07). Our survey did not identify any other characteristics associated with control among treated individuals.
BP Categories and Levels
Prevalence of the three BP categories (optimal, pre‐HTN, and HTN) is summarized in Table 4 and is categorized according to sex and age group. Overall, only one third of the Lebanese have an optimal BP defined as <120/80 mm Hg. Optimal BP was more prevalent in women compared with men in all age groups, while pre‐HTN and HTN were overall more prevalent in men, but the difference was mainly observed in younger patients and disappeared in elderly patients (older than 65 years).
Table 4.
BP Categories by Sex and Age Group Among Lebanese Participants
| Category | Age Group, y | No. | Optimal BP, % | Pre‐HTN, % | HTN, % |
|---|---|---|---|---|---|
| Men | 21–34 | 324 | 34 (29–39)a | 46 (41–51)a | 20 (15–24)a |
| 35–49 | 287 | 24 (19–29)a | 34 (28–39) | 42 (36–48)a | |
| 50–64 | 220 | 10 (6–14)a | 29 (23–35)b | 60 (54–67) | |
| ≥65 | 117 | 8 (3–12)b | 16 (10–23) | 76 (68–84) | |
| Overall | 948 | 22 (20–25)a | 35 (32–38)a | 43 (40–46)a | |
| Women | 21–34 | 274 | 69 (63–74) | 22 (17–27) | 9 (6–13) |
| 35–49 | 223 | 46 (40–53) | 30 (24–36) | 24 (19–30) | |
| 50–64 | 178 | 26 (19–32) | 20 (14–26) | 54 (47–62) | |
| ≥65 | 59 | 19 (9–29) | 14 (5–22) | 68 (56–80) | |
| Overall | 734 | 48 (44–51) | 23 (20–26) | 30 (26–33) | |
| Both sexes | 21–34 | 600 | 50 (46–54) | 35 (31–39) | 15 (12–18) |
| 35–49 | 510 | 34 (30–38) | 32 (28–36) | 34 (30–38) | |
| 50–64 | 399 | 18 (14–21) | 25 (21–29) | 58 (53–62) | |
| ≥65 | 176 | 11 (7–16) | 15 (10–21) | 73 (67–80) | |
| Overall | 1685 | 33 (31–36) | 30 (27–32) | 37 (35–39) |
Abbreviation: HTN, hypertension. Values are expressed prevalence (95% confidence interval).a P<.001 and b P<.05 (for men vs women in the same blood pressure [BP] classification and age category).
Mean BP levels stratified by sex, age group, and HTN categories (no HTN, untreated HTN, and treated HTN) are summarized in Table 5. Mean SBP increased with age in individuals with or without HTN. In the category of participants without HTN, women had statistically lower SBP and DBP levels than men in all age groups (except for DBP in patients older than 65). However, when HTN was present but not treated, mean SBP and DBP levels in women were similar to those observed in men. In participants with treated HTN, SBP was not statistically different between men and women, but DBP was overall lower in women (Table 5). Treatment of HTN was associated with an average 9.4 mm Hg and 10.5 mm Hg lower SBP and DBP, respectively, compared with untreated individuals (P<.001 for both).
Table 5.
SBP and DBP According to Sex, Age, and Hypertension Status
| Age, y | No Hypertension | Hypertension Untreated | Treated Hypertension | |||
|---|---|---|---|---|---|---|
| SBP | DBP | SBP | DBP | SBP | DBP | |
| Men | ||||||
| 21–34 | 119.78 (10.76)a | 74.10 (8.52)a | 141.39 (11.38) | 90.93 (9.24)b | 136.62 (15.49) | 82.05 (11.99) |
| 35–49 | 119.20 (9.71)a | 76.63 (7.75)c | 142.41 (12.94) | 94.09 (8.72) | 134.11 (16.88) | 88.51 (11.57) |
| 50–64 | 123.00 (10.04)c | 78.78 (7.44)a | 148.68 (13.96) | 93.30 (9.99) | 142.20 (25.01) | 87.79 (16.18)c |
| ≥65 | 123.89 (11.86)b | 73.10 (9.60) | 156.93 (17.83) | 91.07 (11.87) | 136.44 (15.42) | 78.93 (10.65) |
| Overall | 120.39 (10.48)a | 75.61 (8.35)a | 145.45 (14.23) | 92.78 (9.59) | 138.13 (20.02) | 84.48 (13.89)a |
| Women | ||||||
| 21–34 | 109.92 (10.78) | 70.70 (8.58) | 139.41 (10.69) | 97.62 (9.45) | 126.17 (17.96) | 83.64 (13.60) |
| 35–49 | 113.57 (12.46) | 73.54 (8.63) | 146.63 (13.17) | 95.73 (9.74) | 128.65 (22.95) | 82.49 (16.64) |
| 50–64 | 116.42 (12.38) | 73.69 (8.86) | 149.12 (17.05) | 92.32 (12.84) | 135.80 (21.18) | 79.69 (12.52) |
| ≥65 | 116.28 (13.21) | 70.37 (9.23) | 151.79 (15.68) | 85.48 (12.33) | 135.95 (17.81) | 74.95 (9.36) |
| Overall | 112.36 (11.89) | 72.07 (8.75) | 147.13 (15.05) | 93.61 (11.62) | 133.84 (20.41) | 79.15 (12.85) |
| Total | ||||||
| 21–34 | 114.95 (11.82) | 72.45 (8.69) | 141.02 (11.19) | 92.20 (9.57) | 131.79 (16.85) | 82.78 (12.24) |
| 35–49 | 116.37 (11.51) | 75.08 (8.34) | 143.54 (13.07) | 94.53 (8.98) | 132.15 (19.28) | 86.34 (13.79) |
| 50–64 | 119.78 (11.65) | 76.32 (8.50) | 148.85 (15.10) | 92.94 (11.08) | 139.46 (23.57) | 84.33 (15.21) |
| ≥65 | 120.82 (12.85) | 72.00 (9.45) | 155.60 (17.16) | 89.62 (12.01) | 136.28 (16.13) | 77.66 (10.37) |
| Overall | 116.45 (11.88) | 73.88 (8.71) | 145.93 (14.46) | 93.02 (10.20) | 136.49 (20.24) | 82.45 (13.73) |
Abbreviations: DBP, diastolic blood pressure; SBP, systolic blood pressure. Values are expressed as mean (standard deviation).a P≤.001, b P<.05, and c P<.01 (for men vs women in the same blood pressure classification and age category).
Compliance With Lifestyle Measures in Patients With HTN
The majority of participants enrolled in the study were aware of behavioral risk factors associated with HTN, except for the DASH diet. The percentage of participants aware of each risk factor was the following: sodium intake 88%, DASH diet 8%, alcohol consumption 63%, excessive weight 84%, and physical activity 56%. However, the prevalence of HTN did not vary according to the level of awareness. A total of 1399 participants (82.4%) knew about the association of three or more of these five risk factors with BP level and had an HTN prevalence of 38.2%, 234 (13.8%) were aware of one or two risk factors and had an HTN prevalence of 30.3%, and only 64 individuals (3.7%) were not aware of any risk factor and had an HTN prevalence of 32.8% (P=.16 for HTN prevalence comparison).
Among patients who were aware of HTN, 70% answered “yes” to the question “Have you tried to decrease your salt intake,” 40% answered “yes” to the question “Have you tried to decrease your weight,” 20% said “yes” to “Did you try to engage in more physical activity,” 11% answered “yes” to “Have you decreased your alcohol consumption,” and 9% said “yes” to “Did you consume more DASH‐type nutriments.” These proportions did not vary among aware, treated, and controlled (in treated) hypertensive participants and in a logistic regression analysis, a “yes” answer to any of these lifestyle measure questions was not associated with a higher likelihood of BP control.
Classes of Medications Used in the Treatment of HTN
Among a subgroup of 282 participants who were able to report the name of medications they were using for HTN, 46% were taking monotherapy, 45% bi‐therapy, and 9% three or more drugs. Angiotensin receptor blockers (ARBs) were the most commonly used drugs (used by 39% of patients), followed by β‐blockers (37%), diuretics (28%), calcium channel blockers (CCBs) (24%), angiotensin enzyme‐converting enzyme (ACE) inhibitors (16%), and potassium‐sparing diuretics (2%). Three percent of responders were taking drugs from other families (total percentage higher than 100 because a patient may be using one or more drug).
Among patients who were receiving two‐drug combination, ARBs or ACE inhibitors were by large the most commonly used and were associated with a diuretic or a CCB or a β‐blocker in 43%, 22%, and 19% of cases, respectively. Other combinations were β‐blockers and diuretics (8%), β‐blockers and CCBs (7%), and CCBs and diuretics (1%).
In a univariate logistic regression analysis comparing different drug families in the monotherapy subgroup, none of the family was statistically associated with better HTN control. In a similar analysis, bi‐therapy and therapy with three or more drugs were not associated with better HTN control compared with monotherapy.
Discussion
This study evaluated prevalence, awareness, treatment, and control rates of HTN in Lebanon. It highlights the extent of the epidemic: 35.9% of the study participants were hypertensive, 30% had pre‐HTN, and only one third had optimal BP level. The awareness rate was 53% and the overall treatment rate was 48.9% but treatment rate was extremely high (93%) in persons who were aware. BP control was observed in 54% of those who were treated, resulting in an overall 27% control rate when all hypertensive patients were considered. HTN prevalence increased with increasing age and BMI, and was higher in men, married people, and in patients with diabetes and hyperlipidemia. HTN awareness was lower in men compared with women, but was higher in patients who were older, married, had a higher income, or who were diagnosed with diabetes or hyperlipidemia. Treatment was mainly determined by awareness and to a lesser degree by age.
We could not identify any predictor of HTN control in treated individuals. It is possible to hypothesize that the inadequate control level may be related to both behavioral risk factors and medical therapy. Sixty to more than 90% of participants with HTN did not try to decrease their weight, engage in more physical activity, reduce alcohol consumption, or adapt to the DASH diet. Participants who reported compliance with these behavioral factors did not, however, have a better control rate. This may result from inadequate compliance or from higher BP levels at baseline.
The class of antihypertensive medications was not associated with BP control. This is consistent with large randomized clinical trials showing that all classes are similar in terms of BP reduction.12 Half of treated participants, however, were taking monotherapy. This is different from randomized clinical trials, where more than three quarters of patients needed at least two classes of drugs for the control of HTN.13, 14 Our finding that bi‐therapy or a combination with three or more drugs were not superior to monotherapy is similar to what was reported in prior surveys, and most likely reflects the use of these combinations in patients with more severe disease at baseline.15, 16 It is possible that more frequent use of combination therapy could have resulted in a better BP control rate. Another hypothesis for the high prevalence of HTN and the inadequate control may be the unstable political situation and the various conflicts that occurred within recent years. Several studies have demonstrated the importance of exposure to stress (war and terror) on BP level and on HTN control.17
Our study is the first to evaluate the prevalence of HTN in Lebanon by measuring BP in a large sample of Lebanese citizens during a face‐to‐face interview. An older study performed in 2003 on 2125 adults aged 30 years or older and living in different regions of the country found an HTN prevalence of 23.1%, with equal rates between men and women.18 Contrary to our survey, that study was based on a questionnaire only, and the diagnosis of HTN was self‐reported. BP was not measured. Given the significant number of patients unaware of their condition, the reported prevalence in that older study underestimates the true prevalence of HTN in Lebanon. Our study is also the first to measure the prevalence of normal BP and of pre‐HTN and to evaluate HTN awareness, treatment, and control rates.
Comparison With Other Countries
HTN prevalence, awareness, treatment, and control rates depend on several demographic and socioeconomic factors, making comparisons of populations of different countries difficult to interpret. A recent survey on the global prevalence and control of HTN6 reported an age‐ and sex‐adjusted prevalence of 36.4% in high‐income countries, and 45.2% in upper‐middle–income countries. Awareness, treatment, and overall control rates were 48.3%, 45.6%, and 17.6% in the former and 52.1%, 46.1%, and 15.8% in the latter, respectively. Lebanon is classified as an upper‐middle–income7 country and compares favorably with these numbers with a prevalence close to that of high‐income countries (35.9%) and better awareness, treatment, and controls rates.
When compared with adjacent countries, such as Turkey,19 Egypt,20 and Palestine,21 Lebanon had a higher prevalence of HTN (35.9% vs 26.3%–31.8% for these three countries), better awareness (53% vs 37.5%–51%), higher treatment rate (48.9% vs 23.9%–40%), and much higher overall control (27% vs 8%–9%). These differences may be explained by several factors, such as older age of the Lebanese population, higher level of socioeconomic development, and higher ratio of physicians to the general population.22 Lebanon, however, remains far behind countries such as the United States, where HTN awareness, treatment, and overall control rates were 81%, 72.5%, and 50%, respectively, in 2007–2008.23
Public Health Implications
Weak surveillance and lack of reliable data in several Middle Eastern and North African (MENA) countries make it hard for public health agencies to track prevalence and control rates of HTN and to respond appropriately. This study provides well‐needed data on the importance of the HTN epidemic in Lebanon. Generalization of its findings to other MENA countries may be debatable because the genetic background and susceptibility for cardiovascular disease may not be the same. However, the sociocultural norms such as a high‐fat and ‐sodium diet, no regular exercise, and high rates of smoking and the lack of governmental public health measures such as inexistent or ineffective regulations on food labeling (eg, amount of salt and calories) and the low budgets spent on health care are comparable. This contributes to the low awareness and control rates seen in neighboring countries.19, 20, 21 Public health implications of this study are thus not only relevant to Lebanon but also to similar upper‐middle–income countries and to other countries in the MENA regions.
Our results confirm the importance of the HTN epidemic in Lebanon: only one third of Lebanese have optimal BP levels and the remaining two thirds are either hypertensive or prehypertensive. Men in particular are severely affected by the disease: 43% and 35% have either HTN or pre‐HTN. Their awareness, treatment, and overall control rates are lower than those of women. Men are also at high cardiovascular risk, not only because of HTN but also because hypertensive patients are more likely to be older in age, to have a higher BMI, and/or to have diabetes or hyperlipidemia.
The results of our study should encourage the development of national programs in Lebanon and in similar countries of the MENA region to improve public awareness of HTN and to train public health providers for better screening and treatment of this disease. Several studies have shown that public awareness and healthcare provider performance in the treatment of HTN can be significantly improved through awareness campaigns and standardized treatment approaches.24, 25 Awareness is a key determinant for treatment. In our study, unawareness was the most important reason for lack of BP control. On the other hand, more than 90% of aware individuals received treatment with average reductions in SBP and DBP by 9.4 mm Hg and 10 mm Hg, respectively. This alone has tremendous public health implication as it can lead to a 25% reduction in the risk of myocardial infarction and to a 40% reduction in the risk of stroke if sustained over 5 years.26 In countries where national health programs were implemented, significant improvement in awareness, treatment, and control rates of HTN were achieved.23
Strengths and Limitations of the Study
The strengths of this study include the large representative sample that was recruited from all the provinces of Lebanon, the collection of various lifestyle factors and medical data, and the measurement of BP by a medical doctor. BP was measured in a “relaxed” setting while patients were doing their usual daily activity, which has the potential of reducing the phenomena of white‐coat HTN. In addition, HTN prevalence, awareness, treatment, and control rates were stratified according to several social, demographic, and risk factors.
Nevertheless, the study has some limitations that should be reported. First, the proportion of individuals recruited from the capital Beirut was much higher than the proportion of citizens living in it according to statistics from the Ministry of Health. These official numbers, however, represent the percentage of individuals who are registered to vote in Beirut during national elections and do not represent the true percentage of people living in Beirut. In addition, the results obtained in Beirut were very close to the national average. Thus, it is unlikely that a possible “overrepresentation” of Beirut in our study could have affected the results to a significant degree. Second, BP was measured twice over a 5‐minute interval. The usual diagnostic criteria for HTN require BP measurement at two or more subsequent visits after an initial screen. This is, however, impossible to perform in large population surveys. It is thus possible that the prevalence of HTN might have been overestimated. However, all other studies on HTN prevalence and control have followed a similar design.
Conclusions
HTN is widely prevalent in Lebanon and it affects one third of the population. Awareness, treatment, and control rates are better than neighboring countries but remain low and should be substantially improved.
Acknowledgment and Disclosures
This study was supported by a grant from the St Joseph University Council of Research. There are no conflicts of interest and no disclosures to declare.
J Clin Hypertens (Greenwich). 2015;17:381–388. DOI: 10.1111/jch.12485. © 2015 Wiley Periodicals, Inc.
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