EPIDEMIOLOGIC AND SOCIOMEDICAL ASPECTS OF HYPERTENSION

Cardiovascular diseases are a major determinant of overall and premature mortality in advanced and in rapidly developing societies. In view of their importance it is mandatory to identify underlying risk factors and to guide preventive and therapeutic actions accordingly. Hypertension is one of the most prevalent and well-established cardiovascular risk factors. This paper briefly summarizes some major determinants of high blood pressure from an epidemiologic and sociomedical point of view. Determinants include age, overweight, physical inactivity, salt and alcohol intake, family history of hypertension, race and socio-economic status. The complexity of these influences is discussed by pointing to interactions between genetic and socio-environmental influences, e.g. in the case of age, bodyweight and salt intake. Based on experimental animal research there is now solid evidence on direct links between psychosocial stress, patterns of neuroendocrine activation and elevation of blood pressure, Four theoretical concepts are described which identify conditions of chronic psychosocial vulnerability or protection in man, and their role in explaining the prevalence of hypertension in epidemiologic studies is discussed. The four concepts are labelled ''socioemotional support'', ''lifestyle incongruity'', ''job strain' and ''effort-reward-imbalance at work''. Special emphasis is given to the two latter concepts in view of the potential role of occupational life in triggering high blood pressure during middle adulthood. For instance, Table 1 indicates that high job strain, i.e. high demands in combination with tow control at work, is associated with a relative risk of 3 of being hypertensive, after adjusting for important con founders. Similarly, men who suffer from chronic stress at work in terms of high effort and low reward (especially low job security, forced occupational mobility) are at risk of being hypertensive (see Table 2). These results have practical implications at three levels. First, socio-epidemiologic findings point to the ongoing need of identifying undetected and untreated risk groups in the general population. Community and work site prevention programs are particularly important in this respect. Second, physicians need to intensify their assessment of hypertensive risk including collection and evaluation of psychosocial information. Third, programs offered by behavioral medicine should be integrated into conventional therapy, and primary prevention should include structural as well as personal measures to protect people against hypertensive risks.