COMMENTARY

Can Blood Pressure Set National Social Agenda? Can Genes Determine Therapy?

Linda Brookes, MSc

Disclosures

March 21, 2008

In This Article

Content

This month, prominent researchers ask which should be used to set national policy -- the measure of gross domestic product, "happiness" measures, or blood pressure control rates? New analyses this month find that the prevalence of hypertension in the United Kingdom is diminishing and control is improving -- but for whom? Similar statistics are also noted in primary care practices in the United States, but with curious differences in who gets the best results. Another study looks at which doctors intensify antihypertension treatment -- what's wrong with cardiologists? Finally, in other news, a pharmacogenetic substudy of ALLHAT, FDA approval of the direct-renin inhibitor, and results with dietary low-fat dairy products.

National Policy Makers Urged to Take Note of Reported Levels of Hypertension

Several news stories recently have reported studies of national "happiness" levels in the populations of an assortment of (mostly European) societies. The methodologies for measuring "happiness," however, were based on various surrogate indices, and now David G. Blanchflower, PhD (Dartmouth College, Hanover, New Hampshire) and Andrew J. Oswald, DPhil (University of Warwick, Coventry, UK) have suggested that instead, governments should be taking more notice of the prevalence of hypertension in their countries when assessing the state of their citizens' happiness and mental health. The 2 economists have examined the relation between subjective measures of happiness and comparatively objective readings of blood pressure and found an inverse relation between the 2, ie, happy countries seem to have fewer blood-pressure problems. These data are the kind of information that policy-makers need in designing new economic and social policies, the researchers believe. The report of their study is published online in the Journal of Health Economics.[1]

Dr. Blanchflower and Prof. Oswald are interested in how countries evaluate the happiness and mental health of their citizens. They believe that rather than the simple, straightforward measures, such as real gross domestic product (GDP), already used as the basis for forming economic policy, a national well-being index should be incorporated. "However, to make progress on the construction of a national well-being index, a better empirical justification for the use of subjective life satisfaction and happiness statistics is needed," they point out. The key point for their idea is that individuals know whether a doctor has informed them that they suffer from blood-pressure problems, and such knowledge has the advantage that it is relatively free of the cultural and language problems that bedevil questionnaire-based evidence about happiness."

Their study used mainly data from Eurobarometer 56.1. The Eurobarometer surveys of social and political attitudes and trends are conducted among representative population samples in countries of the European Union on behalf of the European Commission. Eurobarometer 56.1 collected information in September-October 2001 from approximately 15,000 randomly sampled individuals in 16 countries (Austria, Belgium, Denmark, East Germany, Finland, France, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden, the United Kingdom, and West Germany).

Among the questions on this survey was: "Would you say that you have had problems of high blood pressure?"

Possible answers were: Not at all / No more than usual / Rather more than usual / Much more than usual. (It was presumed that anyone who replied that they had hypertension must have obtained that information from their physicians.)

Overall, 69% of participants reported they had no high blood pressure problems and 21% reported no more than usual. When controlled for variables such as life experiences before age 18 (such as whether they grew up in a single parent home), marital status, job status, and gender, people in Portugal, East Germany, and West Germany reported the highest levels of blood-pressure problems, with the lowest levels reported in Sweden, Denmark, and the UK. The data also showed an association between fewer reported problems with hypertension and a higher level of education.

The question about well-being in the survey was simple: "Would you say you are very satisfied, fairly satisfied, not very satisfied, or not at all satisfied with the life you lead?"

In country-by-country rankings, as recently reported in other surveys, Denmark emerged as the happiest country and Greece, Italy, Portugal, and East Germany ranked lowest.

When correlated with measures of well-being and happiness from 3 different surveys,[2,3,4,5] the researchers found that an inverse relation was borne out: overall those who reported few or no blood pressure problems reported that they were most satisfied with their lives, with the 69% who reported no blood pressure problems and the 21% who reported no more problems than usual also answering that they were fairly or very satisfied with their lives.

Plotting the measure of hypertension problems against a measure of "happiness" for each nation based on 2002 and 2004 data from the biennial European Social Survey (measured as Extremely unhappy to Extremely happy on a scale of 0-10),[4,5] the lowest blood-pressure countries, Sweden (lowest), Denmark (next lowest), and the United Kingdom (third lowest) were ranked #3, #1, and #8, respectively, in happiness; conversely, the 3 highest blood-pressure countries, West Germany (#14), East Germany (#15), and Portugal (#16), were ranked between #12 and #14 in the happiness league table.

Grouping the 16 nations by blood-pressure quartiles showed that in the lowest blood pressure quartile (Ireland, Denmark, The Netherlands, and Sweden), 48.5% of individuals said they were very satisfied with life. Among the countries in the highest blood-pressure quartile (East Germany, West Germany, Portugal, and Finland), only 22.5% of citizens gave that satisfaction rating.

To address suggestions that their results might be related to different degrees of information and health resources in different countries, Dr. Blanchflower and Prof. Oswald compared the numbers of physicians per head in the countries with lowest and highest reported levels of blood pressure. The mean number of physicians per 100,000 in these countries was almost identical, with 333 in 3 low blood-pressure nations (Sweden, The Netherlands, and Denmark) and 332 in 3 high blood-pressure nations (East Germany, Portugal, and Finland). "This seems encouraging and suggests that the hypertension patterns are not the result merely of different diagnosis levels," the researchers comment.

Further checks indicated that the results did not differ by age or gender of the participants. Another suggestion was that "the paper's correlation is illusory and a product of the fact that an inherently cheery nation will be optimistic about everything." They admit that this is an important potential concern, but believe that "it is not easy to believe that someone told by their doctor that they have a condition of high blood pressure has an incentive to conceal or misreport that." They call for more work to collect information on measures of hypertension and measures of well-being and predict that "the construction of a national well-being index, to replace the simple GDP goals adopted by governments in the 20th century, might one day draw upon both happiness and blood-pressure data."

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