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Malaysian Society of Hypertension 11 th Annual Scientific Meeting

Malaysian Society of Hypertension 11 th Annual Scientific Meeting. Symposium I Reality Check: Burden of Hypertension and Current Scenario. Lecture Hypertension in the Philippines. DANTE D. MORALES, M.D., FPCP, FPCC, FACP, FACC Immediate Past President, Philippine Society of Hypertension

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Malaysian Society of Hypertension 11 th Annual Scientific Meeting

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  1. Malaysian Society of Hypertension11th Annual Scientific Meeting Symposium I Reality Check: Burden of Hypertension and Current Scenario Lecture Hypertension in the Philippines DANTE D. MORALES,M.D., FPCP, FPCC, FACP, FACC Immediate Past President, Philippine Society of Hypertension Associate Clinical Professor, U.P. College of Medicine Senior Vice-President for Medical Affairs, Manila Doctors Hospital Jan. 17, 2014 Shangri-la Hotel, Kuala Lumpur, Malaysia

  2. Agenda Background: Population, Morbidity and Mortality in the Philippines National Nutrition Survey (NNS) & National Nutrition & Health Survey(NNHeS) • Scope, coverage, sampling design • Components and organization Prevalence of hypertension (HPN) • Prevalence, population means • HPN & modifiable risk factors in MI & Stroke • Factors for uncontrolled HPN Initiatives

  3. Philippine Population 89.468,680 97.976,600 92.937,852 84,619,980 Republic of Philippines OFFICIAL Statistics, Census Years, National Statistics Office. 

  4. Deaths by cause, all ages, per 100,000 population, Philippines, 2009

  5. Ten Leading Causes of Mortality Philippines, 2009 Source: Philippine Health Statistics, 2009

  6. Ten Leading Causes of Morbidity Philippines, 2009 Source: Philippine Health Statistics, 2009

  7. National Nutrition Survey Presidential Executive Orders: 1987 - mandated FNRI to define the citizenry’s nutritional status particularly on malnutrition’s causes and effects, and identify alternative solutions 1996 - designated FNRI to: Generate clinical data for decision making of the government & private sector Conduct National Nutrition Survey (NNS) every 5 years at the national & regional levels Medical specialty organizations collaborated & contributed to the surveys of 1998, 2003, 2008 & 2013

  8. 7th National Nutrition Survey (NNS): Philippines, 2008- most recent survey done - started in May 2008 and ended in Dec 2008 - 8th NNS started in June 2013 to end 1st quarter of 2014

  9. LUZON VISAYAS MINDANAO Scope & Coverage • All 17 Regions • 79 Provinces & NCR • 3,377 Enumeration Areas • 36,633 Households • 191,351 Individuals Total Population 20 years and above: 45M Eligible subjects representing 45M: 7700

  10. National Nutrition and Health Survey 2008 Sampling Design NNHeS Adopted NSO’s 2008 Labor Force Survey (LFS) Sample (4 replicates) ALL REG/PROV 17 Regions 79 Provinces incl Batanes One bgy or contiguous bgys w/ at least 500 households (HHs) PRIMARY SAMPLING UNIT 1st Stage Contiguous area in a bgy w/ 150-200 HHs ENUMERATION AREAS (EAs) 2nd Stage Sample households for all members of each sample HH 3rd Stage

  11. National Nutrition and Health Survey 2008 8 Components of the 7th NNS NNHeS Anthropometric Biochemical Clinical and Health D ietary Economic Food Insecurity Government program participation Health 7th National Nutrition Survey: Philippines, 2008

  12. National Nutrition and Health Survey 2008 8 Components of the 7th NNS NNHeS Anthropometric Biochemical Clinical and Health D ietary Economic Food Insecurity Government program participation Health 7th National Nutrition Survey: Philippines, 2008

  13. National Nutrition and Health Survey 2008 NNHeS 7th NNS : Philippines, 2008 – Clinical and Health Component or National Nutrition and Health Survey II (NNHeS II) : 2008 The Whole Philippines

  14. National Nutrition and Health Survey 2008 7th NNS-NNHeS II The National Nutrition and Health Survey II:2008 or NNHeS II:2008 Steering Committee (7): Chair: Dante D. Morales, M.D. Co-Chair: RodySy, M.D. Members: FNRI - Mario Capanzana, M.D. DOH - Precy Cuevas PHA - Teresa Abola, M.D. PLAS - Nelson Abelardo, M.D. PSH - Abdias Aquino, M.D. Technical Committee (4): Chair: Antonio L. Dans, M.D. Co-Chair: Felix Eduardo Punzalan, M.D. Members: CharmaineDuante Ma. Vanessa V. Sulit

  15. Participating & Contributing Medical Organizations

  16. PREVALENCE OF HYPERTENSION IN THE PHILIPPINES -ADULT POPULATION 20 YEARS & ABOVE National Nutrition and Health Survey 2008 The National Nutrition and Health Survey II:2008 or NNHeS II:2008 NNHeS

  17. Prevalence of Atherosclerosis-Related Risk Factors and Diseases in the Philippines Rody G. Sy1, Dante D. Morales1, Antonio L. Dans2, Elizabeth Paz-Pacheco3, Felix Eduardo R. Punzalan1, Nelson S. Abelardo1, and Charmaine A. Duante4 1Section of Cardiology, Department of Medicine, College of Medicine, University of the Philippines (UP) System, Manila, Philippines 2Section of Adult Medicine, Department of Medicine, College of Medicine, UP System, Manila, Philippines 3Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, College of Medicine, UP System, Manila, Philippines 4Food and Nutrition Research Institute, Department of Science and Technology, Taguig, Philippines Sy RG, Morales DD, et al; Prevalence of Atherosclerosis-Related Risk Factors and Diseases in the Philippines. Journal of Epidemiology 2012; 22 (5):440-447.

  18. Profile of Responders and Nonrespondersin NNHeS 2008

  19. BP Classification and Criteria Based on The Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC VII)

  20. Prevalence (%) of Hypertension by Sex (Philippines 2003 and 2008) Age-adjusted Unadjusted Sy RG, Morales DD, et al; Prevalence of Atherosclerosis-Related Risk Factors and Diseases in the Philippines. Journal of Epidemiology 2012; 22 (5):440-447.

  21. Trends in the Prevalence of Hypertension among Adults in the Philippines: 1998, 2003 and 2008 Unadjusted for Age 25.3 25.7 22.5 21 17.1 17.4 Sy RG, Morales DD, et al; Prevalence of Atherosclerosis-Related Risk Factors and Diseases in the Philippines. Journal of Epidemiology 2012; 22 (5):440-447.

  22. Trends in the Prevalence of Hypertension among Adults in the Philippines: 2003 and 2008 Adjusted for Age 24.6 21.6 20.6 16.4 Sy RG, Morales DD, et al; Prevalence of Atherosclerosis-Related Risk Factors and Diseases in the Philippines. Journal of Epidemiology 2012; 22 (5):440-447.

  23. Population Means for Hypertension by Sex (Philippines 2003 and 2008) Unadjusted Age-adjusted Sy RG, Morales DD, et al; Prevalence of Atherosclerosis-Related Risk Factors and Diseases in the Philippines. Journal of Epidemiology 2012; 22 (5):440-447.

  24. Mean systolic BP and diastolic BP (mm Hg) among adults based on a single visit BP, by age, Philippines – NNHeS II: 2008

  25. Treatment Gap Prevalence, Awareness and Treatment of Hypertension by Sex Males Females Total Unpublished NNHeS 2003 Estimated Prevalence, Awareness and Treatment of Hypertension in Adults 20 years or more

  26. PRESYON 3 Report of the Council on Hypertension. Phil Heart Assn. Results:Prevalence of Hypertension in Adults - 28%(F: 50%, M: 50%)* % 28 25.3 22 22.5 21 11 Nationwide Registry PRESYON 1 NHES PRESYON 2 NHES PRESYON 3

  27. Li H, et al. J Hypertens2010;28:432-8. Sharma AK, et al. Indian Heart J 2006;58:21-7. 7. Wu Y, et al. J Hypertens2009;27:190-7 Lee HS, et al. Clin Exp Hypertens 2010;32:166-78. 8. Basic Health Researches, 2008. Indonesian Health Korean National Health and Nutrition Examination Survey Department (c/o Dr Arieska Ann Soenarta). (KNHANES) 2008 [Korean]. Available at: http://knhanes.cdc.go.kr. Institute of Public Health (IPH) 2008. The Third National Health and Morbidity Survey 2006 Vol. 2. Ministry of Health Malaysia pp 199-316 ISBN 978-983-3887-30-9. Dans AL et al. Unpublished NNHeS 2003 Estimated Prevalence, Awareness and Treatment of Hypertension in Adults 20 years or more

  28. Worldwide Prevalence of HTN is High* Germany7 Finland7 Spain7 England7 Sweden7 Italy7 Japan8 Egypt9 South Korea9 † United States7 Canada7 Taiwan9 Philippines10 0 10 20 30 40 50 60 70 • *Defined as systolic/diastolic blood pressure ≥140/90, (≥160/95 for Taiwan) or receiving treatment. • †South Korea is defined as men, aged 30-59. • 7. Wolf-Maier et al. JAMA 2003;289:2363-2369; 8. Data on file, Pfizer, Inc, New York, NY; • 9. WHO Collaborating Center on Surveillance of Cardiovascular Disease Web site. Available at www.cvdinfobase.ca. Accessed Feb. 22, 2005 • 10. National Nutrition & Health Survey (NNHeS:2003-2004). Dans, AL, Morales DD et al. Phil J Int Med, May-June 2005 • 10. Sy RG, Morales DD, et al; Prevalence of Atherosclerosis-Related Risk Factors and Diseases in the Philippines. Journal of Epidemiology 2012; 22 (5):440-447.

  29. Global Prevalence of Hypertension by WHO Regions, 2008 Prevalence of High Blood Pressure in Adults ≥25 Years Old Prevalence, % WHO=World Health Organization World Health Organization. World Health Statistics. 2012.

  30. NNHeS I & II: 2003 & 2008 : Prevalence of Atherosclerosis- Related Risk Factors & Diseases- Age Adjusted 2003 – Dans A, MoralesD, et al. Phil J Intern Med 2005;43:103-115. 2008 – SyR, MoralesD, et al. for publication - Journal of Epidemiology 2012

  31. NNHeS I & II: 2003 & 2008 : Prevalence of Atherosclerosis- Related Risk Factors & Diseases- Age Adjusted 2003 – Dans A, MoralesD, et al. Phil J Intern Med 2005;43:103-115. 2008 – SyR, MoralesD, et al. for publication - Journal of Epidemiology 2012

  32. ESTIMATED NO. OF DEATHS FROM Coronary Artery Disease (CAD) & STROKE (CVD) FOR ALL RISK FACTORS Adapted from Sy RG, Morales DD, et al; Prevalence of Atherosclerosis-Related Risk Factors and Diseases in the Philippines. Journal of Epidemiology 2012; 22 (5):440-447.

  33. Modifiable Risk Factors Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Salim Yusuf, Steven Hawken, Stephanie Ôunpuu, Tony Dans, et alon behalf of the INTERHEART Study Investigators. Lancet 2004; 364: 937–52 Risk factors for ischaemic and intracerebralhaemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Martin J O’Donnell MD, Dennis Xavier MD, Lisheng Liu, MD, PremPais, MD, Antonio Dans, MD, Salim Yusuf on behalf of the INTERSTROKE Investigators. Lancet Vol 376, Issue 9735, pp112-123, 10 Jul 2010

  34. Factors for Uncontrolled Hypertension among Hypertensive Patients Managed by Physicians Practicing in Metro Manila, Philippines Research Question: Among Filipinos, what are the factors for uncontrolled hypertension among patients managed by physicians practicing in Metro Manila? • Philippine Heart Association - Council on Hypertension and Committee on Research. Eugene Reyes. Noemi Pestano et al: Factors for Uncontrolled Hypertension Among Hypertensive Patients Managed by Physicians Practicing in Metro Manila, Philippines. Research Paper Presentation. May 25, 2011

  35. Objectives: • To present the prevalence of uncontrolled hypertension in the Philippines. • To discuss the risks associated with poor blood pressure control. • To enumerate the factors that affect blood pressure control. • To provide strategies that may improve blood pressure control. Research Design and Methodology: • Research design: Cross-sectional analytical design • Personal face-to-face interview, aided by a validated structured questionnaire (trained research field personnel) • Philippine Heart Association - Council on Hypertension and Committee on Research. Eugene Reyes. Noemi Pestano et al: Factors for Uncontrolled Hypertension Among Hypertensive Patients Managed by Physicians Practicing in Metro Manila, Philippines. Research Paper Presentation. May 25, 2011

  36. Factors Affecting Poor BP Control • Socioeconomic Factors • Type of Drug Used • Social Class of Patient • Class of Drug Used • Behavioral Factors • Adherence to Medication • Smoking • Alcohol Intake • Patient Factors • Presence of co-morbid conditions (e.g. DM, MI) • Education of Patient • Increasing no. of current medication • Duration of HPN • Gender of Patient • Age of Patient • Physician Factors • Knowledge of Guidelines • Type of Drug Used • MD- type of practice • Class of Drug Used • MD- duration of practice

  37. Results 9.0 8.5 8.0 6.5 7.5 7.0 9.5 6.0 2.5 5.5 5.0 4.0 4.5 0.0 0.5 1.5 3.5 1.0 2.0 3.0 5.50 0.55 0.69 0.49 1.36 Multivariate Analysis 0.69 0.99 1.22 0.94 0.56 1.16 *Type of Drug Used: Branded vs Generic **Class of Drug Used: ARB vs Non ARB 1.57 1.04 0.86 1.37 0.84 Factors for Uncontrolled Hypertension Among Hypertensive Patients Managed by Physicians Practicing in Metro Manila, Research Paper Presentation. May 25, 2011

  38. Factors Affecting BP Control • Factors Associated With Poor BP Control • Presence of diabetes mellitus • Increasing number of medications taken (2 or more) • Factors Associated With Good BP Control • Type of drug used by patients (Branded only) • Class of drug used (ARB) • Good adherence • Philippine Heart Association - Council on Hypertension and Committee on Research. Factors for Uncontrolled Hypertension Among Hypertensive Patients Managed by Physicians Practicing in Metro Manila, Philippines. Research Paper Presentation. May 25, 2011

  39. Globalization Urbanization Aging Group Poverty Low Educ Stress Diabetes HPN Dyslipidemia Obesity Abnormal Lung Fn Heart Disease Stroke Cancer Chronic Lung Disease Smoking Poor Diet Inactivity GUAPLES Intermediate Risk Factors Behavioral Risk Factors Predisposing Environment Chronic NCD The Rise of Chronic Non-communicable Diseases in Southeast Asia: Time for Action. Dans, A., Ng, N., Bonita, R. et al. The Lancet, 377:9766 pp 680-689.

  40. Initiatives • Emphasize on preventive interventions with low cost but high health impact • Increase compliance with low cost medicines • Implement population interventions: salt reduction, food labeling, tobacco control & multi-drug treatment • Integrate non-communicable disease prevention and control programs • Establish coalition of medical associations • Public Private Partnership: DOH, FNRI-DOST and other governmental agencies

  41. Thank you & See you on..

  42. Thank you!

  43. Control Rate in Philippines & Metro ManilaBP Control Rate (Adults ≥ 18 years) Philippines1 Metro Manila2 *94/ 469 = 20% *240/ 1000 = 24% Sison et al. PRESYON 2 Presented at the PHA Annual Convention, May 2007 1 • Factors for Uncontrolled Hypertension Among Hypertensive Patients Managed by Physicians Practicing in Metro Manila, Philippines. Research Paper Presentation. May 25, 2011, in press 2

  44. HypertensionAwareness, Treatment, and Control US and Europe Age-Adjusted Hypertension Awareness, Treatment, and Control in the Population Aged 35–64 Years at the 140/90 mm Hg Threshold 80 70 60 50 % of the population 40 30 20 10 CANADA USA ITALY SWEDEN UK SPAIN GERMANY Katharina Wolf-Maier; Richard S. Cooper; Holly Kramer et al, Hypertension , 2004; 43:10

  45. NNHeS I & II: 2003 & 2008 : Prevalence of Atherosclerosis- Related Risk Factors & Diseases- Age Adjusted 2003 – Dans A, MoralesD, et al. Phil J Intern Med 2005;43:103-115. 2008 – SyR, MoralesD, et al. for publication - Journal of Epidemiology 2012

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