Hypertension is an increasingly common public health problem in developed and developing countries. It is also one of the most common causes of death in every region of the world [
Many national and internationally accepted guidelines from Europe and North America offer recommendations for diagnosing and treating hypertension. However, there are differences in these guidelines, and some suggestions are not consistent with clinical practice in Turkey [
The study was carried out in 10 provinces in the Marmara region: Balıkesir, Bilecik, Bursa, Edirne, Istanbul, Kırklareli, Kocaeli, Sakarya, Tekirdağ, and Yalova. Çanakkale Province was not included in the study because the physician in this province is no longer consulted there. A survey about hypertension was completed by adult patients (18 years or older) who had been diagnosed with having hypertension with a SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg (or already using an antihypertensive drug) by Family Health Center physicians between June 01, 2018, and November 30, 2018 in these provinces. The prevalence of hypertension in Turkey has been reported to be 31.8%. Considering this value, for a total population of 66694 registered patients over the age of 18 (combined number of patients registered at all of the Family Health Centers in the region), the necessary sample size for the study was calculated as 7407, with a significance level of 0.05 and an error of
Written consent was obtained from each patient who agreed to participate. The 25-item questionnaire was administered to each participant by their family physician. The doctors read the questions out loud to the patients, and the patients provided a verbal response. The doctors documented the responses digitally, along with a digital copy of the questionnaire. The answers were recorded synchronously on the online web link provided by the Vademecum medication guide company. During the study period, the questionnaire was administered to a total of 2353 people with hypertension. The participants’ BP readings were taken by a standard measurement method with automatic (arm-worn, electronic) BP measurement devices approved by the Turkish Society of Hypertension and Renal Diseases. Patients were asked about the duration and etiology of their hypertension, the medications they had used in the treatment of hypertension, and whether the medication they were using was their first treatment or if it was a modified treatment. Newly developed antihypertensives such as Mineralocorticoid Receptor Antagonists (MRAs), Aldosterone Synthase Inhibitors (ASIs), Aminopeptidase Inhibitors, Angiotensin Receptor-Neprilysin Inhibitors, Natriuretic Peptide Receptor Agonists (NPR-A), and Vasopeptidase Inhibitors were also asked about. The survey included questions about the participants’ sociodemographic characteristics, such as their age, marital status, monthly income, and highest level of education. The survey also asked them to describe their alcohol consumption as “never use,” “social use,” or “continuous (regular) use.” They reported their smoking habits, diet, exercise status, comorbidities, hypertension risk factors, and the presence of conditions related to hypertension, such as retinopathy, nephropathy, and left ventricular hypertrophy. Those patients with organ involvement were also asked to provide retrospective glucose, urea, creatinine, glomerular filtration rate, and lipid parameters.
SPSS 25.0 (IBM Corporation, Armonk, New York, United States) statistical software program was used in all calculations. Quantitative variables are expressed as mean ± SD (standard deviation), median, (minimum/maximum), percentile (25/75), and percentile (5/95), as shown in Tables
Sociodemographic features, body measures, and duration of hypertension of the study participants.
% | ||||||
Balıkesir | 32 | 1.4 | ||||
Bilecik | 24 | 1.0 | ||||
Bursa | 670 | 28.5 | ||||
Edirne | 17 | 0.7 | ||||
İstanbul | 813 | 34.6 | ||||
Kırklareli | 27 | 1.1 | ||||
Kocaeli | 508 | 21.6 | ||||
Sakarya | 68 | 2.9 | ||||
Tekirdağ | 149 | 6.3 | ||||
Yalova | 45 | 1.9 | ||||
Female | 1.449 | 61.6 | ||||
Male | 904 | 38.4 | ||||
Single | 493 | 21.0 | ||||
Married | 1.860 | 79.0 | ||||
Primary school or below | 1.238 | 52.6 | ||||
Secondary school | 503 | 21.4 | ||||
High school | 309 | 13.1 | ||||
University | 303 | 12.9 | ||||
Over 10,000 TL | 43 | 1.8 | ||||
5,000 TL to 10,000 TL | 221 | 9.4 | ||||
Minimum wage or below | 1.074 | 45.6 | ||||
Minimum wage x 2 | 500 | 21.2 | ||||
Minimum wage x 2 to 5,000 TL | 515 | 21.9 | ||||
1 teaspoon | 576 | 24.6 | ||||
1 dessert spoon | 563 | 24.1 | ||||
1 tablespoon | 173 | 7.4 | ||||
No | 1.026 | 43.9 | ||||
Does not use | 2.141 | 91.0 | ||||
Social drinker | 178 | 7.6 | ||||
Continuous use | 34 | 1.4 | ||||
Quit | 407 | 17.3 | ||||
Uses | 331 | 14.1 | ||||
Does not use | 1.615 | 68.6 | ||||
Primary | 1.555 | 73.1 | ||||
Secondary | 572 | 26.9 | ||||
Yes | 1.614 | 68.6 | ||||
No | 739 | 31.4 | ||||
Mean ± SD | Median | (Min/max) | P. (25/75) | P. (5/95) | ||
Height (cm) | 2.305 | 163.00 ± 9.34 | 162.00 | (140/205) | (156/170) | (15/179) |
Weight (kg) | 2.305 | 80.05 ± 14.90 | 79.00 | (40/138) | (70/89) | (58/107) |
BMI (kg/m2) | 2.305 | 30.16 ± 5.31 | 29.65 | (15.57/55.26) | (26.51/33.2) | (22.53/39.67) |
Waist (cm) | 2.303 | 100.71 ± 33.17 | 100.00 | (10/1138) | (91/109) | (79/121) |
Hip (cm) | 2.303 | 112.78 | 108.00 | (50/8893) | (101/116) | (92/130) |
Duration of HT(months) | 2.353 | 15.94 ± 15.53 | 11.00 | (1/49) | (5/21) | (1/49) |
P.: percentile, min: minimum, max: maximum, SD: standard deviation. BMI: body mass index; duration of HT: duration of hypertension.
Medications used, risk factors, organ involvement, and laboratory findings for patients with hypertension.
% | ||||||
No | 1.238 | 67.3 | ||||
Yes | 602 | 32.7 | ||||
No | 1.459 | 79.3 | ||||
Yes | 381 | 20.7 | ||||
No | 576 | 31.3 | ||||
Yes | 1.264 | 68.7 | ||||
No | 1.318 | 71.6 | ||||
Yes | 522 | 28.4 | ||||
No | 1.839 | 99.9 | ||||
Yes | 1 | 0.1 | ||||
No | 1.321 | 56.1 | ||||
Yes | 1.032 | 43.9 | ||||
No | 1.219 | 51.8 | ||||
Yes | 1.134 | 48.2 | ||||
No | 1.974 | 83.9 | ||||
Yes | 379 | 16.1 | ||||
No | 1.661 | 70.6 | ||||
Yes | 692 | 29.4 | ||||
No | 1.815 | 77.1 | ||||
Yes | 538 | 22.9 | ||||
No | 1.076 | 94.9 | ||||
Yes | 58 | 5.1 | ||||
No | 1.068 | 94.2 | ||||
Yes | 66 | 5.8 | ||||
No | 1.083 | 95.5 | ||||
Yes | 51 | 4.5 | ||||
No | 772 | 68.1 | ||||
Yes | 362 | 31.9 | ||||
No | 510 | 45.0 | ||||
Yes | 624 | 55.0 | ||||
Mean ± SD | Median | (Min/max) | P. (25/75) | P. (5/95) | ||
Triglyceride (mg/dL) | 1.868 | 157.67 ± 98.51 | 138.00 | (1/1651) | (101/188) | (64/310) |
Total chol (mg/dL) | 1.883 | 210.59 ± 48.82 | 208.00 | (12/800) | (179/239) | (137/290) |
HDL chol (mg/dL) | 1.860 | 51.47 ± 15.07 | 49.00 | (4/173) | (42/58) | (32/80) |
LDL chol (mg/dL) | 1.800 | 130.54 ± 39.68 | 128.50 | (12/326) | (104.5/152) | (69.5/199) |
Glucose (mg/dL) | 1.928 | 114.72 ± 39.17 | 103.00 | (11/440) | (93/120) | (82/190) |
Urea (mg/dL) | 2.097 | 38.17 ± 28.61 | 31.00 | (2.14/335.98) | (23/43) | (10/92.02) |
Creatinine (mg/dL) | 1.925 | 1.17 ± 04.26 | 0.81 | (0.14/85) | (0.69/0.97) | (0.55/1.4) |
GFR (ml/dk) | 1.670 | 91.61 ± 38.61 | 90.80 | (0.28/275.7) | (69/110.67) | (30.663/159.48) |
P.: percentile, min: minimum, max: maximum, SD: standard deviation, total chol: total cholesterol, HDL chol: high-density lipoprotein cholesterol, LDL chol: low-density lipoprotein cholesterol, GFR: glomerular filtration rate.
Analysis indicated that the prevalence of hypertension in the Marmara region was 31.8%. Of the 2353 hypertensive patients who took part in the study, 1449 were women (61.6%) and 904 were men (38.4%). Among the respondents, 1555 (73.1%) had primary etiology and 572 (26.9) had secondary etiology. Regarding exercise, 1614 patients (68.6%) reported not exercising at all and 739 patients (31.4%) reported exercising regularly. Regarding diet, 1026 patients (43.9%) had not restricted their salt intake (Table
The drug most commonly used by patients in this study to treat hypertension was an angiotensin converting enzyme (ACE) inhibitor (1264 patients, 32.7%). In contrast, only one patient was using a newly developed drug (0.1%). In terms of risk factors, 1032 (43.9%) of the patients were in the risky age group and 1134 (48.2%) had a family history of hypertension. There were 379 patients (16.1%) who self-reported as smokers. Diabetes mellitus was present in 692 patients (29.4%), hyperlipidemia in 538 patients (22.9%), retinopathy in 58 patients (5.1%), nephropathy in 66 patients (5.8%), and left ventricular hypertrophy in 51 patients (4.5%) (Table
In 2003, the PatenT study, a nationwide field survey of 4910 people, was conducted to determine the prevalence of hypertension in Turkey (PatenT: Prevalence, awareness, and treatment of hypertension in Turkey). The study results indicated the prevalence to be 31.8% of the adult population [
Our study was a similar cross-sectional field scan, and we found the prevalence of hypertension in the Marmara region to be 31.8%. Although this rate is considered high, it does indicate that hypertension prevalence has not increased since 2003. The practice of family medicine, which began in the last 10 years in Turkey, and the role of family physicians may have contributed to keeping the rate from increasing. Their success in curbing increasing rates of hypertension to the point where the rate has stabilized speaks to the effectiveness of the individual protection, diagnosis, treatment regulation, and strict follow-ups provided by the family physicians.
Another recent study reported the overall prevalence of hypertension as 32.96% [
The majority of the participants with hypertension in this study did not exercise at all, and nearly half of them (43.9%) did not restrict their dietary intake of salt. These results emphasize the need for family physicians to apply a holistic approach to treating their patients who have hypertension. Physicians must work with these patients to increase their awareness of their condition and encourage them to make simple yet life-saving lifestyle changes to improve their health and reduce hypertension.
There are several different types or groups of antihypertensive medications that can effectively reduce BP. The Joint National Committee (JNC6) and (JNC7) recommend diuretics and beta blockers as the first choice in the treatment of uncomplicated hypertension [
A study in China showed that five risk factors—increased age, male gender, city center work, cardiopulmonary insufficiency, and being overweight—were related to a higher prevalence of hypertension [
A 2017 retrospective cohort study reported the incidence rate of target organ damage in hypertensive patients as 40.3%. The most common target organ damage was heart failure (11.6%), followed by ischemic heart disease (8.3%). The least common types of target organ damage were retinopathy (0.9%), atrial fibrillation (0.9%), and sexual dysfunction (0.67%) [
A study conducted in Canada reported that 67% of hypertension cases treated by family physicians in a 10-year period were well controlled through the physicians’ care. The authors of the study suggest that a family physician may be the best suited clinician for detecting, evaluating, managing, and controlling hypertension. They also suggest that the family physician can be duly supported in providing care with help from secondary- and tertiary-care counselors, laymen, and the Ministry of Health in that country [
We were unable to attain the required sample size, in the current study. Since our study period was limited to six months and the working physician’s resources were restricted, limited data could be collected. Since the selection of samples was randomized, even if only one-third of the required samples were collected, we believe that the sample size was large enough to not seriously affect the reliability of the results. Another limitation of this study was that the patients’ examined lifestyle habits did not include their regular consumption of caffeinated beverages, particularly coffee or tea. It has been suggested that the consumption of caffeine correlates to BP and blood lipid levels. Future studies should include coffee and tea consumption as potential factors affecting BP. Another limitation is that the results are based on self-report survey responses rather than clinically measured data. There is always a risk of self-reported information lacking accuracy, either because participants are not entirely truthful or they may lack knowledge about some of the information requested. Therefore, even though many of our results are consistent with those from other studies in similar populations, they may not be entirely accurate. Additionally, it was not clear in our survey if the sodium intake reported by the patients refers only to the quantity they add to their food in cooking or at the table or if it represents their actual total sodium intake, including sodium naturally occurring in foods or added by manufacturers as a seasoning or as a preservative. Future studies addressing these issues may further clarify the relationship between these factors and the effective treatment of hypertension.
Our study results show that the prevalence of hypertension in Turkey’s Marmara region is high, and, similar to the country in general, hypertension in Marmara is affected by different factors. However, although Marmara is the most crowded and industrialized region of the country, the prevalence of hypertension in that region is not higher than that for the country nationwide, suggesting that family medicine, put into practice in recent years in Turkey, has been successfully established. Individuals are benefitting from being closely monitored and cared for by their family physicians. Health policies that support family medicine and other clinicians should be developed to promote awareness of hypertension, its risk factors, and the severe complications that may arise. Further support for family medicine practitioners may positively affect public health.
The data used to support the findings of this study are available from the corresponding author upon request.
The study was performed after receiving the approval of the Clinical Ethics Committee of Bursa Uludağ University (reference number: 2018-8/17, dated: 24.04.2018) and in accordance with the Declaration of Helsinki. In addition to the ethical approval, a written letter of permission (reference number. 49654233-604.02 dated: 20.07.2018) from The Republic of Turkey Ministry of Health, Ankara, was obtained.
The authors report no conflicts of interest.
The authors would like to thank Editage Vademecum (