While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
How did high blood pressure become one of the most common, dangerous and poorly treated health problems of our time? Two new studies, one that delves into social factors that contribute to hypertension; and one that suggests physicians are mishandling treatment, offer possible solutions and explanations.
“High blood pressure now tops the list of risk factors for death and disability worldwide,” says expert clinician Uchechukwu Sampson, MD, MBA, a cardiologist and a Harold Amos Medical Faculty Development Program alumnus (2009-2013).
“Hypertension is responsible for at least 45 percent of deaths due to heart disease and 51 percent of deaths due to stroke,” according to the World Health Organization report A Global Brief on Hypertension.
What’s Family Got To Do With It?
Persistent and high rates of hypertension also contribute greatly to health care disparities. “Black Americans have the highest rates of high blood pressure [44 percent of Black women and 40 percent of Black men] among all racial and ethnic groups in the United States. They even have higher blood pressure as children,” says Debbie S. Barrington, PhD, MPH, an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program (2005-2007).
As an epidemiologist interested in how social factors shape health, Barrington analyzed 515 Black men who participated in the Howard University Family Study to learn more about the high prevalence of hypertension in that group.
Her study is the first to show that growing up with two parents decreases the likelihood that a Black male child will develop hypertension as an adult.
“We discovered that Black men who lived with both parents had lower blood pressure, in particular lower systolic blood pressure, pulse pressure and mean arterial blood pressure, than men who never lived with both parents,” Barrington explains. “This protective effect was more pronounced for those men who lived with both parents for one to 12 years of their lives—they had a 46 percent lower chance of developing hypertension.”
Determined that her study not be used as yet another indictment of Black single parents, Barrington adds, “this research does not suggest that Black men who were raised by single parents are destined to have high blood pressure. What it does is establish a link between some aspect of early childhood environment and hypertension in Black men. Further research is needed.”
Barrington’s point is underscored by the fact that her study—"Childhood Family Living Arrangements and Blood Pressure in Black Men: The Howard University Family Study,” published in the December 2, 2013, issue of Hypertension—did not uncover a direct cause for the increased risk of high blood pressure in the group.
“I was able to control for education, marital status and the employment status of the Black men,” she adds. “I could not adjust for certain childhood conditions such as parental education and childhood family income, yet these factors may contribute to the association.”
A Growing Health Crisis
To get a better understanding of factors associated with hypertension in the United States, Sampson looked at 69,211 Black and White Americans and concluded: “The prevalence of unreported and uncontrolled hypertension across 12 states in the southeastern United States is high.”
Using the Southern Community Cohort Study, Sampson assessed blood pressure in individuals who had been diagnosed with hypertension and were taking medication to manage the condition, and people who had never received a diagnosis of hypertension.
“We found that among the people who had a hypertension diagnosis and were taking antihypertensive drugs, 58 percent of Blacks and 45 percent of Whites still had high blood pressure,” Sampson says.
Sampson adds: “Although more than 90 percent of these people were on treatment, only 44 percent were taking at least two antihypertensive drugs and only 29 percent were taking diuretics—an affordable and effective recommended first-line treatment. Given the observed high prevalence of uncontrolled high blood pressure, this pattern of medication use suggests suboptimal treatment.”
In addition to the large number of people receiving poor treatment, Sampson discovered that many members of the study group without a history of high blood pressure were unaware that their blood pressure was out of control. “When surveyed, 29 percent of Black study participants and 20 percent of White participants said they did not have hypertension. But when tested, their blood pressure was in the hypertensive range,” Sampson says.
Getting Blood Pressure Under Control
While somewhat surprised by physicians’ seeming lack of attention to unmanaged hypertension, Sampson explains that the problem can be resolved. Here’s his advice to providers and individuals.
▪ For physicians: “Do not assess a person’s blood pressure based only on readings in your office. Ask them to keep a diary of readings over four to six weeks to see if there’s a pattern,” Sampson says, adding, “and don’t hesitate to follow treatment guidelines by using more than two antihypertensive medications, if needed, and don’t negate the use of diuretics.”
▪ For health care consumers: “Invest in a blood pressure monitor and keep track of your blood pressure at home. It’s best to take it upon waking each morning, or when you are relaxed at night, but never after having caffeine or stimulants,” Sampson advises.
The healthy range for blood pressure is 90/60 to 120/80, according to the American Heart Association. “Keeping your weight down, exercising, limiting stress and lowering salt intake will greatly lower your risk,” he adds.
▪ For policy-makers: “We still need more research to help us understand why we are not effectively implementing the treatment guidelines we have at hand,” Sampson says.
“We know a great deal about this disease, its dangerous effect on health and we have the drugs to treat it,” he says. “Now, we need to know why patients are not getting the treatment they need.”
▪ Learn more about the RWJF Health & Society Scholars.
▪ Learn more about the RWJF-supported Harold Amos Medical Faculty Development Program.
▪ For an overview of RWJF scholar and fellow opportunities visit RWJFLeaders.org.
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