India’s Hypertension diagnosis rates improve but still among the lowest in the World
Sai Krishna Muthyanolla
August 30, 2021
The WHO funded first comprehensive global analysis of trends in hypertension prevalence, detection, treatment, and control was recently published. As per the data, while the diagnosis & treatment rates in India have improved in the last 30 years, they are still among the lowest in the World.
Hypertension or elevated blood pressure is a medical condition wherein the force exerted by circulating blood against the walls of the arteries in the human body is too high. Unhealthy diets, obesity, physical inactivity, and a family history of hypertension are some of the risk factors for the condition, which can cause serious damage to the heart, kidneys, and other organs. It is one of the top causes of death and disease throughout the world. More than a billion adults globally are estimated to have hypertension. However, despite the condition being easy to detect, about half the persons who have hypertension are unaware that they have the condition. Lack of diagnosis results in low rates of treatment of hypertension, though it can be controlled with low-cost treatment.
First comprehensive global analysis of trends in Hypertension published recently
Recently, the first comprehensive global analysis of trends in hypertension prevalence, detection, treatment, and control was published in the peer-reviewed journal, The Lancet. The study was led by Imperial College London and the World Health Organization (WHO). A global network of physicians and researchers was involved in the study, including scientists from the Indian Council of Medical Research (ICMR). Information from 1201 different studies carried out between 1990 and 2019 with data on 104 million participants in the age group of 30 to 79 years, across 184 countries covering 99% of the global population, has been used for the study. The study presents consistent national, regional, and global estimates of trends in hypertension prevalence, detection, treatment, and control from 1990 to 2019 for 200 countries and territories.
Hypertension has been defined in the study as having systolic blood pressure of ≥ 140 millimetres of mercury (mm Hg), diastolic blood pressure ≥ of 90 mm Hg, and/or taking medication for hypertension. The study applied a ‘Bayesian hierarchical model’ to estimate the prevalence of hypertension, the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control).
Over 1.28 billion people globally had Hypertension in 2019
According to the report, the number of adults aged between 30 to 79 years with hypertension has almost doubled from 650 million in 1990 to over 1.28 billion in 2019. The number of men with hypertension has increased from 317 million to 652 million while the number of women with hypertension has gone up from 331 million to 626 million, in these three decades. During this period, the number of men with hypertension has overtaken the number of women with hypertension in the mentioned age group. As per the report, more than 1 billion persons with hypertension, accounting for 82% of all the persons with hypertension in the world in 2019, lived in low-income and middle-income regions. The reason behind the increase in number as compared to 1990 is because prevalence remained unchanged or slightly increased while the population grew and became older.
50% or more Men in the 30 to 79 years age group had Hypertension in 10 countries
The prevalence of hypertension in 2019 was the highest in Paraguay where 51% of women and 62% of men had hypertension in the 30 to 79 years age group. The prevalence was 50% and above among women in three countries (Paraguay, Tuvalu, and Dominica) and in ten countries among men including Paraguay, Hungary, Poland, Argentina, Lithuania, Romania, Belarus, Croatia, Tajikistan, and Serbia. On the other hand, Switzerland recorded the least prevalence among women (17%) and Eritrea recorded the least prevalence among men (22%).  Switzerland, Peru, and Canada recorded 20% and lower prevalence among women. A total of 16 countries recorded prevalence below 25% among women whereas that among men was recorded in 6 countries including Eritrea, Peru, Bangladesh, Canada, Ethiopia, and the Solomon Islands.
31% of the population in India had Hypertension
India is ranked 156 and 164 globally in terms of hypertension prevalence among men and women respectively, in 2019. The prevalence was 31.6% among men and 30.5% among women, in 2019. Nearly 31% of those in the 30 to 79 age group have hypertension in India, as of 2019.
Prevalence in India, along with the US and China has gone up
To understand India’s position vis-à-vis other nations, we compare the prevalence of hypertension among BRICS nations and other developed countries like the USA, UK, Australia, Canada, Switzerland, Spain, and Japan which are part of G20 countries. Canada and Switzerland are among the countries with low prevalence.
In 1990, the prevalence among men in the 30 to 79 age group was about 28% in India. Among these 12 countries, India had the second-lowest prevalence, after China. On the other hand, Russia had a prevalence of nearly 51% followed by Japan, the UK, Brazil, and Switzerland which had a prevalence of more than 40%. However, after 30 years, the prevalence has gone up in South Africa, the USA, India, China, and Brazil. In 2019, the prevalence among men was 47.9% in Brazil and 43.7% in South Africa.
Among women, the prevalence was 53.1% in Russia in 1990. Brazil, UK, Australia, Japan, and South Africa had a prevalence of more than 30% and were ahead of India. However, in 2019, like the case with men, the prevalence has increased in the same five countries- the USA, South Africa, India, Brazil, and China. The prevalence in Russia, South Africa, and Brazil continues to be above 40%.
Increased Prevalence of Hypertension among Men than Women since 2008
Between 1990 and 2019, the prevalence has gone up from 28.1% in 1990 to 31.6% among men and from 29.4% to 30.5% among women, in India. It is seen that until 2008, the prevalence was more among women as compared to men. However, in 2008 the prevalence among men overtook that among women, like the global trend. This trend continues to date with prevalence among men more than the prevalence among women.
Globally, 41% of women and 51% of men were unaware of their condition
Significant gaps in the diagnosis and treatment of hypertension exist, as noted in the study. An estimated 46% of adults or about 580 million persons with hypertension were unaware that they have the condition. 41% of women and 51% of men were unaware of their condition because they were never diagnosed.  In 1990, about 30.2% of the men with hypertension were diagnosed which has increased to 49% in 2019. During the same period, the proportion of women with hypertension who were diagnosed has gone up from 42.8% to 58.9%.
In 2019, the proportion of men with hypertension who were diagnosed was the highest in Iceland where 82.9% of men were diagnosed. Kazakhstan and Canada too had more than 80% diagnosis. USA, Switzerland, Germany, Costa Rica, and Croatia had more than 70% diagnosis. Rwanda had the lowest proportion of men diagnosed with only 17.7%. Meanwhile, among women, Kazakhstan led the list with over 86.4% diagnosed followed by the USA and Iceland which had more than 82% women diagnosed. Costa Rica, El Salvador, and Russia are the other countries with more than 80% diagnosis among women. Rwanda was at the bottom of the list with 28.6% women diagnosed.
India is ranked 182 for women and 170 for men in terms of Hypertension diagnosis
Of the 200 countries, India was ranked 182 for women and 170 for men in terms of a hypertension diagnosis in 2019. India’s rate of diagnosis is among the lowest in the world. Among women, 41.7% of those with hypertension were diagnosed whereas, among the men, the same was 31.7%, in 2019.
Comparison with the 12 other countries as seen earlier reveals that India had the least diagnosis rates, both in 1990 and 2019 among men and women. China and South Africa have recorded an improvement in diagnosis among men from less than 24% in 1990 to above 40% in 2019. The USA which had the highest diagnosis rate among men in 1990 was overtaken by Canada which has more than 80% diagnosis in 2019.
Among women, the proportion of diagnosis continues to be the highest in the USA where 74.5% were diagnosed in 1990, which has increased to 82.8% in 2019. UK and China had diagnosis rates below 40% in 1990 but have significantly improved their diagnosis rates to over 55% in 2019.
Diagnosis has improved in India but remains low
In India, there has been a steady increase in the diagnosis rate over the years. The diagnosis among women increased from 18.8% in 1990 to 41.7% in 2019. During this period, the diagnosis among men increased from 12.2% to 31.7%. Though the diagnosis rate has improved, it remains one of the lowest in the world.  As a result of the poor diagnosis rates, the rate of treatment is poor in India. India’s hypertension treatment rate was only 35% in women and 25% in men.
AP, Telangana, and Kerala have a high prevalence of Hypertension
The NFHS -5 survey has reported data on hypertension in India based on 3 criteria.
According to the Phase-I findings covering 22 states and UTs in 2019-20, 25% of the male population on average is estimated to be having elevated blood pressure or taking medication to control it while 22.5 % of the women population have Hypertension. Sikkim has a comparatively higher proportion of the population having moderate-severe levels of elevated blood pressure among smaller states and Kerala, Telangana, and Andhra Pradesh top the list among larger states. Bihar had a lower proportion of the population suffering from hypertension.
WHO has released new guidelines for Hypertension treatment
Taking note of the rising cases, the WHO recently released the ‘WHO Guideline for the pharmacological treatment of hypertension in adults’, which provides new recommendations to help countries improve the management of hypertension. The recommendations give guidance on blood pressure levels for diagnosis, medication, the target blood pressure level, and how often to have follow-up checks on blood pressure.
Source: Guideline for the pharmacological treatment of hypertension in adults (WHO)
What are the Government of India’s programs for control and diagnosis of Hypertension?
In India, the government implements the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) since 2010 up to the district level under the National Health Mission. NPCDCS focuses on strengthening infrastructure, human resource development, health promotion & awareness generation for prevention, early diagnosis, management, and referral to an appropriate level of the healthcare facility for treatment of the given Non-Communicable Diseases (NCDs) including Hypertension. Another population-based initiative for prevention, control, and screening for common NCDs including Hypertension has been rolled out under NHM Ayushman Bharat – Health and Wellness Centres (AB-HWC). Under this initiative, persons aged more than 30 years are screened for common NCDs including Hypertension. As per National Action Plan and Monitoring framework for prevention and control of Noncommunicable Diseases (NCDs), a target was set to reduce the prevalence of raised blood pressure by 10% by the year 2020, and by 25% by 2025. However, the target has clearly not been achieved by 2020.
Going by the numbers, India still has a long way to go both in diagnosis and treatment particularly in the case of men.