Journal of Hypertension:
Original papers: Epidemiology
High blood pressure prevalence and control in a middle-aged French population and their associated factors: the MONA LISA study
Wagner, Alinea; Sadoun, Abdelghania; Dallongeville, Jeanb; Ferrières, Jeanc; Amouyel, Philippeb; Ruidavets, Jean-Bernardc; Arveiler, Dominiquea
aLaboratoire d'épidémiologie et de santé publique, EA 3430, Université de Strasbourg, Strasbourg, France
bINSERM, U 744, Institut Pasteur de Lille, Université Lille2, Lille, France
cINSERM, U 558, Département d'épidémiologie, Université Paul Sabatier, Toulouse, France
Received 7 April, 2010
Revised 16 August, 2010
Accepted 18 August, 2010
Correspondence to Aline Wagner, Laboratoire d'épidémiologie et de santé publique, EA 3430, Faculté de médecine 67085 Strasbourg Cedex, France Tel: +33 3 68 85 31 95; fax: +33 3 68 85 31 89; e-mail: firstname.lastname@example.org
Aims: This work aims to assess high blood pressure (BP) prevalence and control and their associated factors in a population-based study conducted in three French areas: the Urban Community of Lille and the districts of Bas-Rhin and Haute-Garonne, between 2005 and 2007.
Methods: Participants were randomly recruited from electoral rolls after stratification on sex, 10-year age group (35–74 years) and town size. BP was measured by trained medical staff following standardized procedures. High BP was defined as BP at least 140/90 mmHg and/or taking antihypertensive drugs or following a specific diet. BP below 140/90 mmHg among treated individuals was considered adequately controlled (<130/80 mmHg among diabetics).
Results: Four thousand eight hundred and twenty-five participants were recruited (mean age 55.5 ± 11.3 years). The prevalence of high BP was greater in men (47%) than in women (35%). Antihypertensive treatment concerned 80% of the hypertensive individuals with most often a combination therapy. Control rates concerned only 38% of women and 22% of men and decreased with age. Metabolic risk factors and aging were independently associated with high BP prevalence as were low educational level and alcohol consumption. Diabetes and high cardiovascular risk were strong independent predictors of uncontrolled BP. The use of multiple drug treatment did not predict a better control.
Conclusions: Hypertension is frequent in France, particularly in the age group 55–74 years. Control rates remain low, particularly in high-risk, older and diabetic individuals. Intensified efforts are required to improve lifestyle, awareness of the condition, and use of appropriate and well tolerated combination therapy.
Abbreviation BP: blood pressure.
Cardiovascular diseases contribute largely to the public health burden in France as in other developed countries. Hypertension is one of the most prevalent modifiable risk factors for coronary heart disease, stroke, congestive heart failure and renal insufficiency, and clinical trials have demonstrated the efficacy of lowering blood pressure (BP) to decrease cardiovascular morbidity and mortality . Precise guidelines concerning its management have been prescribed by various societies these last decades. These guidelines have been recently updated in France  and in Europe  based on new scientific evidence. Data on hypertension prevalence and management are scarce in France and need to be appraised at the population level. Improving screening and management of high BP requires some good knowledge of the risk profiles in the underlying population.
From 2005 to 2007, the French MONICA centres have carried out the MONA LISA survey in the general population to assess the current prevalence of classical risk factors for cardiovascular diseases.
The aims of this study were:
1. to determine high BP prevalence, awareness, treatment and control in a survey representative of the French population in three regions and
2. to assess which factors are associated with hypertension prevalence and control. In particular, we hypothesized that hypertension control varied according to the number of cardiovascular risk factors of the indiviual.
Material and methods
The MONA LISA study is an epidemiological multicentre cross-sectional population-based study conducted in the three French centres that had previously participated in the WHO-MONICA surveys designed to monitor cardiovascular risk factors [4,5]. Inhabitants aged 35–74 years of the Lille Urban Community in northern France, the Bas-Rhin county in eastern France and the Haute-Garonne county in southern France were randomly sampled from electoral rolls after stratification by town size, sex and 10-year age groups. Each area includes about 500 000 inhabitants. The Lille Urban Community area is essentially urban, whereas the Bas Rhin and Haute-Garonne counties are mixed rural and urban areas. The cities/towns/villages were randomly selected by town size to be representative of the background population distribution. The goal was to obtain 200 participants for each centre, sex and age group. The protocol was approved by the appropriate independent ethics committee. Informed consent to participate was signed by all the participants. Participation rates were 50% in men and 51% in women.
A physical examination was performed by a trained medical staff following standardized methods. SBP and DBP were measured after the individual had been sitting for at least 10 min with an automatic sphygmomanometer (OMRON 705IT) and a tailored sized cuff, with the arm at heart level. The average of two measurements achieved 30 min apart was used for analysis. Standardized anthropometric measurements (weight, height) were obtained on individuals in light clothing without shoes. Waist circumference was recorded using a tape measure at midpoint between the superior border of the iliac crest and the lower border of the rib cage. Body mass index was calculated as body weight divided by height squared (kg/m2).
Participants filled out a questionnaire during a face-to-face interview. Information was collected on demographic variables, socioeconomic status, smoking and alcohol consumptions, personal medical history and medication use, parental history of hypertension.
Individuals were classified as hypertensive if they had a SBP at least 140 mmHg or a DBP at least 90 mmHg or currently followed an antihypertensive diet or used an antihypertensive medication.
Participants were considered to be aware of their hypertension if they answered ‘yes’ to the question ‘have you ever been told by a doctor or health professional that you had hypertension?’. Treatment of high BP was defined by use of antihypertensive agents during the last 15 days. Hypertension was considered to be controlled among treated individuals when SBP was less than 140 mmHg (130 mmHg) and DBP was less than 90 mmHg (80 mmHg), values in brackets concerning diabetic individuals. As the lower BP goal (<130/80 mmHg) among diabetic patients has been recently challenged , prevalence of BP control was also assessed using the cut-off value of 140/90 in all participants.
Participants were considered to have diabetes if they were treated with hypoglycaemic medications (insulin or oral diabetes medications) or if their fasting blood glucose levels reached 7 mmol/l (1.26 g/l) or more. Dyslipidaemia was defined with a low-density lipoprotein (LDL) cholesterol at least 1.60 g/l or a high-density lipoprotein (HDL) cholesterol below 0.40 g/l (0.50 g/l in women) or triglycerides at least 2 g/l or taking lipid-lowering drugs. A high level of creatininaemia was considered beyond the highest decile cut-off (≥12.5 mg/l in men, ≥10.3 mg/l in women). High-risk waist girth was set up at 102 cm in men and 88 cm in women. Total alcohol consumption was inferred from the sum of millilitres of alcohol intake per week from wine, beer, cider and spirits and participants were classified as abstinent, low consumers and high consumers (≥20 g/l in women, ≥40 g/l in men). Participants reporting at least one cigarette per day were classified as current smokers. Regular physical activity outside work was considered in participants reporting at least 20 min of intense physical activity, once a week or more. Participants were classified as: low (no or primary or secondary school), medium (secondary school graduation), or high educational level (college/university graduation). Parental history of hypertension was reported as no, uncertain or yes.
All samples were analysed in the same laboratory at the Pasteur Institute of Lille. Total cholesterol and triglycerides were measured with enzyme assays (Olympus). HDL cholesterol was measured after sodium phosphotungstate/magnesium chloride precipitation (Olympus). LDL was calculated with the Friedewald equation when triglycerides levels were lower than 4.56 mmol/l. Glucose was measured using the standard glucose hexokinase method (DuPont Dimension, Brussels, Belgium).
Age-adjusted prevalence was calculated using, as standard population, the age structure of the underlying population in the three areas in 2006, derived from the latest French national census. Standard errors of the percentages were estimated taking into account the sample weights and sample design by using Taylor series linearization. Differences between age groups, centres and sex were estimated with chi-squared test for categorical variables and ANOVA for continuous variables. A significant trend of the various prevalences with aging was computed with the Armitage test. Multiple logistic regression was used to assess the independent associations of potential factors with high BP prevalence and lack of BP control. All potential factors with a ‘P’ of 0.30 or less in univariate analysis were entered in the multivariate model.
Hypertension control among treated individuals was also compared according to the number of cardiovascular risk factors. Cardiovascular risk factors considered were smoking and metabolic factors belonging to the modified Adult Treatment Panel III definition  of the metabolic syndrome (high waist girth, impaired fasting glucose, high plasma triglycerides and low HDL-cholesterol). Because very few participants had all five risk factors considered, those with four or five risk factors were grouped together. All analyses were conducted with the SAS statistical software (version 9.1; SAS Institute Inc., Cary, North Carolina, USA).
Four thousand eight hundred and twenty-five participants were recruited (1601 in the North, 1598 in the East and 1626 in the South) with, as expected, similar sizes by sex and 10-year age group.
Blood pressure levels
A north-to-south gradient of BP levels was observed with higher levels in the northern and eastern parts of France than in the South, in both sexes (Fig. 1). In men BP was higher than in women whatever the age group or the centre. SBP increased regularly from 128.0 and 115.7 mmHg in participants aged 35–44 years to 150.0 and 145.6 mmHg in participants aged 65–74 years, in men and women, respectively. DBP increased in the first two age groups and then stabilized or even decreased.
Table 1 provides the prevalence of BP categories according to the 2003 ESH/ESC classification  by sex and age groups. An optimal BP was observed among only 15.6% of men and 36.8% of women, with a decreasing trend with aging. Conversely, all grades of hypertension increased strongly with increasing age in both sexes.
Hypertension prevalence, awareness, treatment and control
The age-adjusted prevalence of hypertension was 47% in men and 35% in women aged 35–74 years (Table 2). Age-specific prevalence rates gradually increased, being higher in men than in women in all age groups, although differences reduced in the oldest one. Hypertension awareness was more prevalent in women (66%) compared with men (54%) and increased with increasing age groups. About 80% of the hypertensives aware of their condition were under antihypertensive drug treatment, women more frequently than men. Antihypertensive medication greatly varied with age, concerning 50% of the youngest and 90% of the oldest individuals. Among treated participants only 22% of men and 38% of women had controlled hypertension corresponding to 10.6 and 22.1% of all participants with hypertension. These former values slightly improved and reached 24% of men and 39% of women when the BP goal among diabetics was set at less than 140/90 mmHg. Hypertension control rates declined with age from 31 or 69% among the youngest to 19 or 27% among the oldest, in men and women, respectively.
Among the 1135 individuals receiving an antihypertensive treatment, 46.6% had a monotherapy, 34.3% two different classes of drug and 19.1% at least three different classes of drug without difference by sex or centre.
Factors associated with high blood pressure prevalence and control
Concerning predictors of hypertension we found no evidence of interaction with sex, thus results are presented in the whole sample (Table 3). Whatever the cardiovascular risk factor considered, hypertension prevalence was higher in affected individuals. In multivariate models, being older, living in the North or East of France, obesity, diabetes, dyslipidaemia and high creatininaemia were independent predictors of hypertension. A low educational level, parental history of high BP, and alcohol consumption were also more prevalent among hypertensive individuals.
Table 4 illustrates crude and adjusted odds ratios (ORs) of hypertension control. Because of several sex × predictor interactions, data are presented separately for men and women. In men diabetes, dyslipidaemia and high alcohol consumption were independently associated with lack of BP control. In women, the youngest ones and those living in the south were more likely to have their BP controlled, whereas diabetes and a single or a multitherapy with three or more classes were predictors of not being at BP goal.
Hypertension control according to the number of cardiovascular risk factors
We assessed the association between the number of cardiovascular risk factors (among five risk factors) and the lack of BP control in treated participants. BP control among treated participants declined with the number of risk factors from 36% in the absence of risk factors to 17% in the presence of four or five of those risk factors (Fig. 2). After adjusting for sex, age, centre, educational level and number of drugs, each additional cardiovascular risk factor from 0 to 4 or 5 increased the risk of not being at BP goal by 22% (OR 1.09–1.38, P < 10−3). Similar results were observed in both sexes.
The population-based study allows an update of hypertension prevalence and management in France by age and sex. It confirms the high prevalence of this risk factor, with mean SBP levels beyond the accepted 140 mmHg value among 55–74-year-old men and 65–74-year-old women, and a north-to-south gradient, with higher prevalence in the north and east of France compared to the South. It also highlights a low overall hypertension control rate particularly in older and high-risk individuals.
Comparing prevalence between various populations requires an adapted methodology taking into account the age structure of the underlying populations. Age-standardized hypertension prevalence in the 35–64-age group (34.8%) was similar to those reported in some European countries at the end of the nineties. The rates reached 41.8% in men and 27.4% in women as compared to 44.8 and 30.6% in Italy, and 44.8 and 32.0% in Sweden [8,9]. They were much lower than those reported in Germany (55.3%) or Finland (48.7%) but higher than that of North America (27.6%).
Hypertension control rates at the 140/90 mmHg level in the 35–64-age range are in the average of those obtained in five European countries in men (24% in France for values ranging from 14.3% in Spain to 39.7% in England); they are rather higher in French women (45%) than values ranging from 19.5% in Sweden to 40.5% in England . However, they appeared really low compared with those found in the US: 45.8% in men and 61.2% in women. Modest results were also noticed in the French study EPIMIL concerning younger military men (20–58 years), with only 42% of the treated hypertensive achieving the 140/90 mmHg BP goals , and were even poorer (12.5% in men, 33.2% in women) in a French working population at the end of the nineties .
Our findings showed a better management of hypertension in women which is a commonly observed result either in Europe [12–16] or in the US  or elsewhere in the world [18,19]. Awareness and antihypertensive medication use were greater among hypertensive women than men. Women were also more likely to achieve BP control, a finding in general agreement with previous studies although not all [20,21]. Possible explanations for the better BP control observed in women could be a higher compliance, greater health concern, and also lower pretreatment BP for the youngest age groups.
As expected, hypertensives had a greater prevalence of metabolic disturbances such as obesity and particularly central obesity, diabetes, dyslipidaemia, high level of creatininaemia, all factors encountered in the metabolic syndrome. Alcohol intake was associated with hypertension in men only, possibly because of a threshold effect as suggested by the results of a longitudinal study highlighting a hypertension risk that appears at four drinks per day in women compared to one drink per day in men .
As reported in other studies in France [11,23] and elsewhere [17,24–27], BP control became poorer with increasing age with a statistically significant effect in women. This may be due to higher BP levels in older individuals making it more difficult to achieve BP goals, and thus requiring more intensive treatment with associated issues of tolerability and adherence. The difficulty in treatment of arterial stiffness, a disease of the elderly known to be associated with worse response to therapy, may also be evoked. Such assumptions are in agreement with the results of a recent prospective study demonstrating a lack of control at follow-up in older individuals and those with higher baseline systolic levels . Achieving BP control appeared also less frequent among diabetics even when the BP goal was set to less than 140/90 mmHg. Such findings have been previously noticed  but the reasons for inadequate BP control in diabetics are currently unknown. Uncontrolled BP was independently associated with the number of classes of drugs in women. Whereas two different classes were favourable to BP control compared to only one, taking three or more classes did not demonstrate better control. This already reported result [29,30] might reflect the severity of the disease and the difficulties in obtaining adequate control despite more aggressive treatment. The present study indicates that the higher the number of cardiovascular risk factors, the lower the percentage of participants with controlled hypertension. These results are worrying given the important morbidity–mortality issues in high-risk individuals in whom BP is not decreased to target levels.
Some weaknesses of the study must be underlined apart from its cross-sectional design that prevents any causality inference. BP measurements were taken twice after at least a 10-min rest but on the same occasion, which does not correspond to the recommendations of hypertension diagnostic requiring two BP measurements recorded on three separate occasions . This may have overestimated the prevalence of hypertension and underestimated the level of BP control. Also, some data in the 35–44-year age group, such as hypertension control rate, derived from a reduced number of individuals and must therefore be interpreted with caution. A biased selection of the study sample cannot be ruled out given the relatively low response rate and this might also affect the generalizability of the study. However, several checks have been made that are quite reassuring. The geographical representativeness of the sample was found to be good due to the adequate town size stratification. The socioeconomic structure of the sample, compared to that of the background population as obtained from the 2006 census data, showed very little difference concerning occupational categories and a slight overrepresentation of highly educated people that would, if anything, tend to underestimate the prevalence of hypertension. Finally, as sodium excretion in the urine was not assessed in the study population, salt intake, an important determinant of BP prevalence and control, could not be considered in the models.
The strengths of this study include the large representative sample of the general population in three areas distributed from north to south of France in regions at contrasted cardiovascular risk, the collection of various lifestyle factors, medical data and BP measurements by trained staff according to standardized protocols, the adequate standardization of prevalence and survey design adaptation allowing comparisons between countries.
In conclusion, hypertension prevalence is important in France, particularly in the 55–74-year age group, in men and in the north and east of the country. Rates of hypertension control remain disappointingly low despite frequent use of combination therapy. More attention is needed to obtain BP control especially among diabetic and high-risk individuals. Such target requires intensified efforts to improve lifestyle, but also awareness of the condition, and use of appropriate and well tolerated combination therapy.
We would like to thank nurses, physicians, dieticians, computer scientists and secretaries of Lille, Strasbourg and Toulouse and the Centre de Médecine Préventive de Lille, the Laboratoire d'Analyses Génomiques and the Service de Biologie Spécialisée de l'Institut Pasteur de Lille, the Centre de Santé de la MGEN de Strasbourg, the Unité de Coordination de la Biologie des Essais Cliniques des Hôpitaux Universitaires de Strasbourg and the Departments of Cardiology of the Toulouse University Hospital. The MONA LISA Study was made possible by an unrestricted grant of Pfizer and by a grant from ANR (ANR-05-PNRA-018).
There are no conflicts of interest.
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