|Year : 2020 | Volume
| Issue : 3 | Page : 232-235
The impact of body mass index and number of antihypertensive medications on clinical management of hypertension in primary health care
Hatouf H Sukkarieh1, Rami T Bustami2, Hadeel Al-Khaneen3, Abdulkarim Saeed4
1 College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
2 College of Business, Alfaisal University, Riyadh, Saudi Arabia
3 Department of Family Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
4 College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||03-Jul-2020|
|Date of Decision||22-Jul-2020|
|Date of Acceptance||30-Jul-2020|
|Date of Web Publication||07-Nov-2020|
Hatouf H Sukkarieh
College of Medicine, Alfaisal University, P.O. Box 50927, Riyadh 11533, Kingdom of Saudi Arabia.
Source of Support: None, Conflict of Interest: None
Introduction: Hypertension (HTN) is an extremely common disease and its prevalence is increasing globally. The association between obesity and HTN is not yet fully understood, insulin resistance and renal dysfunction are said to be the main causes of obesity-related HTN. This study explored the effect of obesity and different number of medications on blood pressure (BP) control in patients with HTN. Methods: This was a retrospective study conducted in the outpatient primary care clinic at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Results: A total of 286 patients were included in the study with an average weight of 80.6 kg and an average body mass index (BMI) of 32.2. Only 63% of the participants had controlled BP. There was a trend toward better controlled BP levels among male participants (67.1%) compared with females (57.7%) and among those with higher BMI levels, P = 0.099 and 0.094, respectively. Patients receiving two antihypertensive medications were more likely to have their BP controlled compared to those receiving four medications (odds ratio [95% confidence interval] =2.62 [1.32, 5.20]; P = 0.006). Conclusion: Uncontrolled BP was not associated with BMI. Taking two antihypertensive medications was associated with more BP control than monotherapy or combination of therapy with three drugs or more.
Keywords: Body mass index, hypertension, obesity, polypharmacy, primary health care
|How to cite this article:|
Sukkarieh HH, Bustami RT, Al-Khaneen H, Saeed A. The impact of body mass index and number of antihypertensive medications on clinical management of hypertension in primary health care. Saudi J Health Sci 2020;9:232-5
|How to cite this URL:|
Sukkarieh HH, Bustami RT, Al-Khaneen H, Saeed A. The impact of body mass index and number of antihypertensive medications on clinical management of hypertension in primary health care. Saudi J Health Sci [serial online] 2020 [cited 2021 Jan 20];9:232-5. Available from: https://www.saudijhealthsci.org/text.asp?2020/9/3/232/300289
| Introduction|| |
Hypertension (HTN) is an extremely common disease and its prevalence is increasing globally. HTN affects over one billion people around the world and is likely to reach over 1.5 billion people by 2025. It has been labeled as a “silent killer” due to its association with cardiovascular diseases such as ischemic heart disease, heart failure, and stroke. Moreover, HTN is considered as the most important cause of premature death. Up to 13.5% of premature deaths are caused by HTN alone. In the context of the growing cardiovascular disease burden, the importance of modifiable risk factors such as HTN should not be underestimated. HTN is one of the most important preventable risk factors causing these conditions and preventing it may reduce mortality rates.
The dramatic increase in HTN prevalence may be linked to the higher rates of obesity worldwide., Although the association between obesity and HTN is not yet fully understood, insulin resistance and renal dysfunction are said to be the main causes of obesity-related HTN. The abnormal kidney function in relation to obesity and HTN can be explained by the activation of the renin–angiotensin–aldosterone system and increased sympathetic nervous system activity by fat-derived adipokines such as leptin and adiponectin. Excess weight gain can increase the risk of developing essential HTN by 65%–75%. Previous studies suggested that having a high blood pressure (BP) with other risk factors such as increased body weight, smoking, and high cholesterol levels can lead to 70%–75% of stroke and 80%–90% of ischemic heart disease globally. Several studies explored the relation between different body mass index (BMI) levels and HTN., One study carried out in Italy suggested that obesity had a direct effect on BP. They found a gradient of increasing BP levels with higher classes of BMI. Another study done in Saudi Arabia found a significant association between BMI and risk of developing HTN. Moreover, many clinical studies suggested that weight loss can reduce BP levels in hypertensive patient and maintaining a BMI <25 kg/m2 is effective in primary prevention of HTN. Furthermore, treating HTN with monotherapy or polytherapy plays a critical role in the maintenance and control of BP. Decisions regarding the best pharmacological treatment for hypertensive patients will have major morbidity and mortality consequences, as well as significant implications for the cost of medical care. A number of studies linking the effect of BMI group and number of medications in association with BP control are scarce. Therefore, the present study was undertaken to provide a better insight into the effect of obesity and different number of medications on BP control in patients with HTN.
| Methods|| |
This retrospective study was conducted for a random sample of patients in the outpatient primary care clinic in King Abdulaziz Medical City (KAMC) in Riyadh from 2016 to 2017. Patients were included if they had records of three consecutive BP readings at least 1 month apart. In addition to BP, data on several patient demographics and medication-related data were collected including age, gender, weight, height, BMI, comorbidities, and antihypertensive medications including thiazide-type diuretics, calcium channel blocker, angiotensin-converting enzyme inhibitors, or angiotensin receptor blocker. Lack of BP control was defined as having a BP measure of ≥140/90 on at least two consecutive readings.
Descriptive statistical analyses were performed for the study sample. Continuous variables were summarized using mean, standard deviation (SD), median, and interquartile range. Proportions were used for categorical variables. Management of HTN (BP control status) was assessed and compared by demographic and clinical factors. Categorical data were analyzed using the Chi-square test. For continuous variables with normal distribution, t-test was used for comparisons. If there was evidence against normality, the nonparametric Mann–Whitney U-test was utilized. A logistic regression analysis was used to determine the effect of BMI on BP control. Adjustments were made for several demographic and clinical factors including age, gender, weight, height, comorbidities, and antihypertensive medications. Statistical significance was considered at P < 0.05. All statistical analyses were performed using the Statistical Package for the IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.).
| Results|| |
A total of 286 subjects were included with an average age of 65.7 (SD = 10.8) years. Gender distribution was almost similar (52% males). The average weight for the participants was 80.6 (SD = 20.3) kg and the average BMI was 32.2 (SD = 18.8). Fifty-nine percent of patients had three or more comorbidities and about 53% of patients were taking three or more antihypertensive medications. [Table 1] shows the descriptive statistics for the participants. Only 63% of the participants had controlled BP. The results from comparing BP control by several patient demographic and clinical characteristics are provided in [Table 2]. The average height for participants with controlled HTN compared with uncontrolled HTN was statically significant, P = 0.014 (average ± SD; 161.0 ± 9.2, 157.6 ± 14.1, respectively). There was a trend toward better controlled BP levels among male participants (67.1%) compared with females (57.7%) and among those with higher BMI levels; P = 0.099 and 0.094, respectively. The results from logistic regression analysis [Table 3] and [Figure 1] showed that patients receiving 2 BP medications were more likely to have their BP controlled compared to those receiving four medications (odds ratio [OR] 95% confidence interval [CI] = 2.62 [1.32, 5.20]; P = 0.006). Higher likelihood of BP control was associated with increased height (OR [95% CI], per 10 cm increase = 1.44 [1.11, 1.87]; P = 0.006). Age, gender, weight, or number of comorbidities were not related to BP control.
|Table 2: Management of hypertension (hypertension control status) by demographic and clinical factors|
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|Table 3: Multivariate logistic regression model for blood pressure control|
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|Figure 1: Odds ratio for blood pressure control by number of antihypertensive medications|
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| Discussion|| |
The results of this study which was done in KAMC in Riyadh, one of the largest medical cities in Saudi Arabia, showed that most of our patients are obese, 40% of them had 4 comorbidities or more, and the taller they get, the higher the chance of getting their BP under control. In this study, males were found to have their HTN controlled more than females. This finding is consistent with that of Aldiab et al. who found that females were more hypertensive and prehypertensive than males in univariate and multivariate analyses. This could be explained by the fact that females have a steeper increase in their BP after menopause, giving the fact that the mean age of our sample is 65.8, and the mean age for menopause in Saudi population is 48.3, reported by Aldughaither et al. The present study found that 63% of our patients had their BP under control. This is encouraging since the national survey done by the Ministry of Health of Saudi Arabia in 2013 reported that 45% of hypertensive patients had their BP under control. As discussed previously in the literature, obesity is considered well-recognized risk factor for HTN. It contributes to both to the high prevalence of HTN and poor control of BP. The higher production of inflammatory cytokines and reduced nitric oxide activity among obese patients are suggested to trigger the elevation in BP. In contrast to the earlier findings, this study showed no evidence correlating the HTN control and obesity in both linear and group analyses. Moreover, the exact number of medications differed from different guidelines among countries. The differences between physicians' prescription habits and adherences to newer HTN guidelines may explain the differences in using combination therapy over monotherapy worldwide for treating HTN. A combination of therapy is used much more frequently in the United States than China. A population-based screening study with a sample size over 1.7 million adults has been done in China and they found that 81% of uncontrolled HTN patients were on monotherapy. This could be explained by the uncommon use of multidrug therapy in China. Hence, the use of combination of therapy is much more promising in the control of HTN. The results from this study seem to be constant with what has been mentioned. More control of BP was seen with the usage of combination therapy of two drugs than the usage of monotherapy. Moreover, an increased number of medications, more than 2 drugs, were linked with poor BP control. It seems constant with different HTN guidelines where three-drug combination therapy is not recommended as initial therapy. This study found that more control of BP was linked with two-medication regimen with P = 0.006 when they compared with more than two medications. One study found that starting antihypertensive medication with two-drug combination is associated with discontinuation. As a result, single-pill combination therapy was favored by the European Society of Hypertension/European Society of Cardiology and other societies. This was also supported by multiple researches that assessed the compliance of medications using various methods, and these studies unambiguously found an inverse relationship between the compliance and the number of pills. The strength of this study is its methodological contribution and reinforcement of the previously demonstrated relationship between some known patient factors and the likelihood of BP control through detailed analyses a set of hypothesized factors related to that disease. However, our finding on the impact of BMI on BP control was not consistent with previous results on the literature for other country other than Saudi Arabia like China, Italy, and Iran. This study has a number of limitations. All participants in the present study were restricted to middle-aged and older patients, potentially reducing the generalizability of the study findings. Although we had adjusted for some potential confounders, the observed association between number of medications and BP control might be confounded by other factors that were not measured in our study, such as adherent to medications. This is a relatively small study, and a future investigation is needed including a larger and more representative sample.
| Conclusion|| |
Poor BP control was not associated with BMI groups. Considering two-medication regimen for treating HTN was significantly associated with much better BP control than monotherapy or combination of therapy with three drugs or more. Further studies are warranted to confirm these findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]