This study aimed to determine the prevalence, morbidity and mortality of hypertension over the last three decades in Saudi Arabia. Our findings indicate that the prevalence, deaths and DALYs attributable to hypertension has steadily increased during this period in Saudi Arabia. The increase in hypertension prevalence is comparable to those reported from GBD studies conducted in several other countries. [9, 10] The prevalence, deaths and DALYs due to hypertension was almost double in women than men in Saudi Arabia. This might be due to socio-economic factors and gender disparities in education, literacy, employment and women empowerment. [3] Therefore, there is a need to increase population level programs for improving hypertension prevention and management targeting women in Saudi Arabia.
This rising trend in hypertension can be attributed to the impact of the recent modernization of Saudi society, the adoption of a western lifestyle, and moving away from traditional practices. These changes may have given rise to the unhealthy triad of a poor dietary habits, sedentary lifestyles, and overweight and obesity in Saudi people. [11] Behavioural and cardiometabolic risk factors such as unhealthy dietary patterns, insufficient physical activity, smoking and obesity can increase the risk of many chronic conditions, including hypertension. [12] Data suggest that there is a high rate of obesity in the Eastern region of Saudi Arabia, which can exacerbate the risk of hypertension. [6, 13] Previous studies reported that hypertension increases with urbanization. [14] However, the high prevalence of hypertension in rural areas in the Middle-East, including Saudi Arabia might have been attributable to reduced awareness levels of hypertension and its risk factors. [15] Furthermore, patient adherence to treatment and physician adherence to international hypertension guidelines have been reported to be poor in this region. [3]
Hypertension is a leading source of morbidity and mortality in many countries globally. A previous Saudi cross-sectional study showed that almost one in four adults in Saudi Arabia had hypertension in 2017. [16] The high prevalence of hypertension in Saudi Arabia is comparable with other countries in the Middle East where almost one in three people had hypertension. We found that females had had a higher prevalence of hypertension than males in the last 30 years. The Saudi Health Information Survey (SIHS) reported a more than half participants with undiagnosed and uncontrolled hypertension, with a larger proportion of them being female. [17] This is consistent with the findings of the Prospective Urban Rural Epidemiology (PURE) study, which recruited patients from four Middle-East countries including Saudi Arabia and showed higher prevalence of hypertension in Saudi women than men (33% vs 29%).[15] Another study in the Alkharj region of Saudi Arabia, showed more females had hypertension than males (55% vs 48%). [4] A systematic review that included 85,000 participants from the Middle East, reported that hypertension was higher in women compared to men (23% vs 20%). [18]
The high prevalence of hypertension in Saudi women can be attributed to many factors, including the high prevalence of obesity in this population group and higher sedentary lifestyles. [3,19−21] Another likely contributing factor is the traditional gender inequality in education, resulting in relatively low awareness about health issues among women.[20] These gaps in education and health awareness persists despite fundamental approaches that have been introduced in recent years towards equity in education and health to provide women with more rights in these fields. Additionally, other socio-cultural factors, such as females being confined to domestic duties, might limit their physical and recreational activities, and limited access to healthcare, thereby making them more susceptible. [15,22−24] Moreover, certain female-specific factors, such as gestational hypertension, and pre-eclampsia and women in menopausal status with no estrogen may increase the incidence of hypertension. [25]
The DALYs attributable to hypertension in Saudi Arabia steadily decreased during the last three decades. This might be due to availability of modern treatments and advancements in technologies for hypertension management including interventional approach for renal stenosis. [26–28] The decrease in burden of hypertension may also be attributed to the impact of the educational campaigns carried out by the local healthcare authorities to raise awareness among Saudis and enhance their compliance with the different management approaches. Furthermore, DALYs and mortality were higher in older age groups in the study. This may be due to older patients are vulnerable to hypertension-related complications and associated morbidity and mortality. Besides, the compliance to medical treatment is lower in these age groups, with less frequent practices of healthcare seeking behaviour and routine check-ups. Moreover, the effect of other comorbidities can also be a significant factor in older patients, contributing to the worsened prognosis and mortality. [29–33]
There are a few limitations in our study. First, our study estimated the prevalence and associated morbidity and mortality of hypertension based on limited population-based studies in Saudi Arabia and other countries which might not reflect the actual burden. Second, we did not evaluate the use of medication, and medication adherence which influences hypertension. Finally, the GBD defined hypertension as high systolic blood pressure of 110–115 mm Hg, which is much lower than the cut off suggested by the World Health Organization [34]and other professional bodies such as the American College of Cardiology/American Heart Association and the European Society of Cardiology/European Society of Hypertension. [35] Moreover, the definition was applied to the whole population and might not reflect hypertension in younger and older aged people. Therefore, the results should be interpreted with caution. On the other hand, our study used standardized GBD tools and analysis which can be compared with other GBD studies. Beside age-standardized analysis, we also stratified these burden indicators based on sex and age groups to clarify the potential differences between different subgroups.
Our findings might help healthcare authorities to target the populations at high risk with proper interventions to increase the quality of care aimed at reducing the burden of hypertension in Saudi Arabia. Future research using GBD data with standarised definition of hypertension in different age groups might be useful. Also, the recent COVID-19 pandemic have caused many countries to redirect their health priorities and resources towards a pandemic response, compromising access to and availability of primary care services for hypertension management. [36] Our findings underscore the urgent need to strengthen primary care services for hypertension detection, awareness and management using innovative approaches like text messaging and digital health approaches which have shown to improve hypertension. [37–39]