Abstract:

This study aimed to measure the contribution of selected health behaviors to the prevalence of hypertension control in Brazilian adults 50 years or older, based on data from the ELSI-Brasil study. The study included 4,318 individuals 50 years or older who reported having received a medical diagnosis of hypertension and were taking antihypertensive medication. The selected health behaviors were: physical activity, healthy diet, not consuming excessive alcohol, and never having smoked. The contribution of each health behavior to prevalence of hypertension control was estimated by the attribution method, via adjustment of the binomial additive hazards model, stratified by sex. Prevalence of hypertension control was 50.7% (95%CI: 48.2; 53.1). Overall, health behaviors made a larger contribution to hypertension control in women (66.3%) than in men (36.2%). Moderate alcohol consumption made the largest contribution in both sexes, but particularly in women (52.7% in women versus 19% in men). Physical activity contributed 12.6% in women and 10.7% in men. The other behaviors were more relevant in men: never having smoked (3.4%) and regular consumption of vegetables, legumes, and fruits (3.1%). These results underline the need for measures to promote the adoption of healthy behaviors by hypertensive individuals to reduce blood pressure levels, improve the effectiveness of antihypertensive medication, and decrease their cardiovascular risk.

Keywords:
Hypertension; Healthy Lifestyle; Epidemiology; Sex

Introduction

Hypertension is still a public health problem worldwide due to its high prevalence and difficult control ¹1. Lawes CM, Vander Hoorn S, Rodgers A. International Society of Hypertension. Global burden of blood-pressure-related disease, 2001. Lancet 2008; 371:1513-18.^,22. Cheong AT, Sazlina SG, Tong SF, Azah AS, Salmiah S. Poor blood pressure control and its associated factors among older people with hypertension: a cross-sectional study in six public primary care clinics in Malaysia. Malays Fam Physician 2015; 10:19-25.^,33. Lobo LAC, Canuto R, Dias-da-Costa JS, Pattussi MP. Tendência temporal da prevalência de hipertensão arterial sistêmica no Brasil. Cad Saúde Pública 2017; 33:e00035316.. Prevalence of hypertension is high in the general population (about 30%) and increases sharply with age, reaching some 65% of the elderly ¹1. Lawes CM, Vander Hoorn S, Rodgers A. International Society of Hypertension. Global burden of blood-pressure-related disease, 2001. Lancet 2008; 371:1513-18.^,44. Crim MT, Yoon SSS, Ortiz E, Wall HK, Schober S, Gillespie C, et al. National surveillance definitions for hypertension prevalence and control among adults. Circ Cardiovasc Qual Outcomes 2012; 5:343-51.^,55. Malta DC, Bernal RTI, Andrade SSCDA, Silva MMAD, Velasquez-Melendez G. Prevalência e fatores associados com hipertensão arterial autorreferida em adultos brasileiros. Rev Saúde Pública 2017;51 Supl 1:11s.^,66. Writing Group Members; Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, et al. Executive summary: heart disease and stroke statistics - 2016 update: a report from the American Heart Association. Circulation 2016; 133:447-54.^,77. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507-20.. The importance of hypertension control (systolic pressure < 140mmHg and diastolic pressure < 90mmHg) ⁸8. Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. VII Diretriz Brasileira de Hipertensão Arterial. Arq Bras Card 2016; 107(3 Suppl 3): 1-83.^,99. Sivén SS, Niiranen TJ, Aromaa A, Koskinen S, Jula AM. Social, lifestyle and demographic inequalities in hypertension care. Scand J Public Health 2015; 43:246-53. to reduce cardiovascular morbidity and mortality has been highlighted in various studies ¹⁰10. Gebrezgi MT, Trepka MJ, Kidane EA. Barriers to and facilitators of hypertension management in Asmara, Eritrea: patients' perspectives. J Health Popul Nutr 2017; 36:11.^,1111. Yang F, Qian D, Hu D. Prevalence, awareness, treatment, and control of hypertension in the older population: results from the multiple national studies on ageing. J Am Soc Hypertens 2016; 10:140-8.. In recent decades, even with the development of modern pharmaceutical technologies, blood pressure control is still low, posing a major global public health challenge ²2. Cheong AT, Sazlina SG, Tong SF, Azah AS, Salmiah S. Poor blood pressure control and its associated factors among older people with hypertension: a cross-sectional study in six public primary care clinics in Malaysia. Malays Fam Physician 2015; 10:19-25.^,33. Lobo LAC, Canuto R, Dias-da-Costa JS, Pattussi MP. Tendência temporal da prevalência de hipertensão arterial sistêmica no Brasil. Cad Saúde Pública 2017; 33:e00035316.^,1010. Gebrezgi MT, Trepka MJ, Kidane EA. Barriers to and facilitators of hypertension management in Asmara, Eritrea: patients' perspectives. J Health Popul Nutr 2017; 36:11..

Various studies in different populations have focused on assessing the prevalence of blood pressure control in hypertensive individuals. A study in China consisting of 1,738,886 adults 35 to 75 years of age showed that fewer than 30% of the study population had their blood pressure controlled ¹²12. Lu J, Lu Y, Wang X, Li X, Linderman GC, Wu C, et al. Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project). Lancet 2017; 390:2549-58.. A multicenter study of Ghanaian migrant men living in Amsterdam, London, and Berlin showed low hypertension control, with prevalence ranging from 20 to 36% ¹³13. Agyemang C, Nyaaba G, Beune E, Meeks K, Owusu-Dabo E, Addo J, et al. Variations in hypertension awareness, treatment, and control among Ghanaian migrants living in Amsterdam, Berlin, London, and nonmigrant Ghanaians living in rural and urban Ghana - the RODAM study. J Hypertens 2018; 36:169-77.. The same result was observed in Mozambique, where prevalence of control was 33% ¹⁴14. Damasceno A, Azevedo A, Silva-Matos C, Prista A, Diogo D, Lunet N. Hypertension prevalence, awareness, treatment, and control in mozambique. Hypertens 2009; 54:77-83.. In the United States, in 1999-2000, according to a report from the National Health and Nutrition Examination Survey (NHANES), prevalence of hypertension control was 31.6%, increasing to 53.1% from 2009 to 2010 and remaining stable until 2016, when prevalence of hypertension control dropped to 48.3% ¹⁵15. Bloch MJ. Recent data from National Health and Nutrition Examination Survey (NHANES) demonstrates no improvement in US blood pressure control rates. J Am Soc Hypertens 2018; 12:3-4.. In Canada, prevalence of control increased from 12% to 66% from 1990 to 2006 ¹⁶16. Leenen FH, Dumais J, McInnis NH, Turton P, Stratychuk L, Nemeth K, et al. Lum-Kwong MM & Fodor G. Results of the Ontario survey on the prevalence and control of hypertension. CMAJ 2008; 178:1441-9..

In Brazil, to our knowledge, only one study examined the prevalence of hypertension control from 1997 to 2008 in community-living elderly 70 years or older, showing a decrease in prevalence of this control from 44.6% to 40.1% ¹⁷17. Firmo JOA, Peixoto SV, Loyola Filho AID, Uchôa E, Lima-Costa MF. Birth cohort differences in hypertension control in a Brazilian population of older elderly: the Bambuí cohort study of aging (1997 and 2008). Cad Saúde Pública 2011; 27 Suppl 3:S427-34..

Although antihypertensive medication has precise indications, the adoption of a healthy lifestyle is strongly recommended for the control of this condition ⁹9. Sivén SS, Niiranen TJ, Aromaa A, Koskinen S, Jula AM. Social, lifestyle and demographic inequalities in hypertension care. Scand J Public Health 2015; 43:246-53., featuring regular physical activity, healthy eating, smoking cessation, and moderate alcohol consumption ¹¹11. Yang F, Qian D, Hu D. Prevalence, awareness, treatment, and control of hypertension in the older population: results from the multiple national studies on ageing. J Am Soc Hypertens 2016; 10:140-8.^,1818. Castro I, Waclawovsky G, Marcadenti A. Nutrition and Physical activity on hypertension: implication of current evidence and guidelines. Curr Hypertens Rev 2015; 11:91-9.^,1919. Nogueira IC, Santos ZMDSA, Mont DGB, Martins ABT, Araújo Magalhães CB. Efeitos do exercício físico no controle da hipertensão arterial em idosos: uma revisão sistemática. Rev Bras Geriatr Gerontol 2012; 15:587-601.. This indication is based on evidence that these behaviors can reduce blood pressure levels, improve the effect of antihypertensive drugs, and decrease the cardiovascular risk, and that this effect is enhanced when two or more of these practices are combined ²⁰20. Guo J, Zhu YC, Chen YP, Hu Y, Tang XW, Zhang B. The dynamics of hypertension prevalence, awareness, treatment, control and associated factors in Chinese adults: results from CHNS 1991-2011. J Hypertens 2015; 33:1688-96.. However, unhealthy behaviors are persist even after a diagnosis of hypertension, which can contribute to the lack of blood pressure control in these individuals ⁸8. Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. VII Diretriz Brasileira de Hipertensão Arterial. Arq Bras Card 2016; 107(3 Suppl 3): 1-83..

Although some studies have assessed factors associated with blood pressure control in hypertensive individuals ²2. Cheong AT, Sazlina SG, Tong SF, Azah AS, Salmiah S. Poor blood pressure control and its associated factors among older people with hypertension: a cross-sectional study in six public primary care clinics in Malaysia. Malays Fam Physician 2015; 10:19-25.^,2020. Guo J, Zhu YC, Chen YP, Hu Y, Tang XW, Zhang B. The dynamics of hypertension prevalence, awareness, treatment, control and associated factors in Chinese adults: results from CHNS 1991-2011. J Hypertens 2015; 33:1688-96., to our knowledge there are no population-based studies that have measured the contribution of health behaviors to this control. The current study thus aimed to quantify the contribution of selected health behaviors (physical activity, diet, and drinking and smoking habits) to blood pressure control in a representative national sample of the Brazilian population 50 years or older.

Methods

Study scenario and population

The Brazilian Longitudinal Study of Aging (ELSI-Brasil) is a household-based study that aims to examine the dynamics of aging in the Brazilian population and its determinants, as well as this population’s demand on the social and health systems. The sample was designed to represent the Brazilian population 50 years and older, and the baseline consisted of all the residents from this age bracket in the sampled households. For the sample calculation, municipalities were allocated in four strata according to their population size. The first three strata consisted of municipalities with up to 750 thousand inhabitants, and the sample was selected in three stages (municipality, census tract, and household). In the fourth stratum, consisting of large municipalities, selection was in two stages (census tract and household). The final sample consisted of 10 thousand individuals (9,412 participated) living in households located in 70 municipalities in different regions of Brazil. Data were collected using a questionnaire at the participant’s home, where physical examination was performed and samples were collected for laboratory tests. All the personnel involved in this process were trained and certified by the project’s coordinators. Further details on ELSI are available on the research project’s homepage (http://elsi.cpqrr.fiocruz.br/) and in another publication ²¹21. Lima-Costa MF, Andrade FB, Souza Jr, Neri AL, Duarte YAO, Castro-Costa E, et al. The Brazilian Longitudinal Study of Aging (ELSI-Brasil): objectives and design. Am J Epidemiol 2018; 187:1345-53..

The eligible population for the current study consists of participants who responded affirmatively to the following questions: (a) “Has a doctor ever told you that you have hypertension (high blood pressure)?” and (b) “Are you taking medication for hypertension (high blood pressure)?”.

Study variable

The study’s dependent variable is hypertension control, defined as systolic pressure < 140mmHg and diastolic pressure < 90mmHg ⁸8. Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. VII Diretriz Brasileira de Hipertensão Arterial. Arq Bras Card 2016; 107(3 Suppl 3): 1-83.^,99. Sivén SS, Niiranen TJ, Aromaa A, Koskinen S, Jula AM. Social, lifestyle and demographic inequalities in hypertension care. Scand J Public Health 2015; 43:246-53.. To measure blood pressure, participants remained sitting and resting for at least five minutes. Three measurements were taken, and the final measurement was recorded as the mean of the second and third measurement.

The target health behaviors were regular physical activity, weekly consumption of vegetables, legumes, and fruits, moderate alcohol consumption, and never having smoked. Physical activity included walking and moderate activities, considering only activities performed for at least 10 straight minutes each time. Individuals reported the frequency (days per week) and duration (time per day) of the activities in the week prior to the interview, converted into total time of physical activity in that week. Regular physical activity was defined as at least 150 minutes a week, according to recommendations by the World Health Organization ²²22. World Health Organization. Global recommendations on physical activity for health. http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/ (acessado em 28/Nov/2017).
http://www.who.int/dietphysicalactivity/... and the 7^th Brazilian Guidelines on Hypertension ⁹9. Sivén SS, Niiranen TJ, Aromaa A, Koskinen S, Jula AM. Social, lifestyle and demographic inequalities in hypertension care. Scand J Public Health 2015; 43:246-53..

Regular consumption of vegetables, legumes, and fruits was defined as the consumption of five or more portions of these foods distributed across at least five days a week ²²22. World Health Organization. Global recommendations on physical activity for health. http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/ (acessado em 28/Nov/2017).
http://www.who.int/dietphysicalactivity/... .

Moderate alcohol consumption was defined as mean consumption of up to two daily doses of alcoholic beverages for men and up to one daily dose for women. One dose contains about 14g of ethanol and is the equivalent of 350mL of beer, 150mL of wine, and 45mL of distilled liquor ²³23. O'Keefe JH, Bhatti SK, Bajwa A, DiNicolantonio JJ, Lavie CJ. Alcohol and cardiovascular health: the dose makes the poison...or the remedy. Mayo Clin Proc 2014; 89:382-93..

Data analysis

We estimated the prevalence rates for hypertension control and the health behaviors in the sample, stratified by sex. Comparison of the prevalence rates between the sexes used Pearson’s chi-square test, considering the sampling parameters and individuals’ weights.

The attribution method is used to quantify the contribution of a set of explanatory variables to the prevalence of a target outcome in cross-sectional studies ²⁴24. Nusselder WJ, Looman CW. Decomposition of differences in health expectancy by cause. Demography 2004; 4:315-34.. It was used in the current study to quantify each health behavior’s contribution to the prevalence of hypertension control. The method allows estimating each variable’s contribution based on cross-sectional data, combining the health behavior’s prevalence in the sample and the effect (impact) of each behavior on hypertension control, the latter estimated by the binomial additive hazards model.

Using this method, the prevalence of hypertension control is divided into the different health behaviors, recalling that individuals may adopt more than one healthy behavior and that individuals who do not practice any healthy behavior may still have their blood pressure under control. The prevalence of hypertension control not explained by the variables considered in the model is called “background”. Hypertension control of individuals who do not adopt any of the healthy behaviors is thus attributed entirely to background. For individuals who report only or more healthy behaviors, the contribution is divided between these behaviors and the background.

Estimation of the contribution pertaining to each health behavior to the prevalence of hypertension control can be summarized in the following stages:

(1) Calculation of the likelihood of hypertension control according to cause: prevalence of hypertension control by each health behavior is obtained by calculating the predicted probability of hypertension control for each individual, defined as the sum of the probabilities of hypertension control due to the various health behaviors and the control due to background;

(2) Total number of individuals with hypertension controlled by cause: sum of the probabilities from each health behavior and background estimated in item (1);

(3) Contribution of each health behavior to hypertension control: division of the estimated number of individuals with hypertension control according to cause (item 2) by the total number of individuals in the sample.

This process results in each health behavior’s relative contribution, and that of the background, to the prevalence of hypertension control in the study sample (which was the study’s objective).

Further details on the method and its applications can be found in other studies ²⁵25. Nusselder WJ, Looman CW, Mackenbach JP, Huisman M, van Oyen H, Deboosere P, et al. The contribution of specific diseases to educational disparities in disability-free life expectancy. Am J Public Health 2005; 95:2035-41. (Yokota RTDC, Looman CW, Nusselder WJ. Addhaz: binomial and multinomial additive harzard models. R package version 0.4. https://rdrr.io/cran/addhaz/).

The analysis was done for the total sample and stratified by sex, and the results were presented as the regression model’s coefficients and respective 95% confidence intervals (95%CI), along with each health behavior’s relative contribution to hypertension control. A bubble graph was used to illustrate the results. The data were analyzed with the R software, version 3.4.1 (http://www.r-project.org). Analysis of the attribution method used the “addhaz” package, version 0.5, to adjust the binomial additive hazards model and calculate the relative contribution (Yokota RTDC, Looman CW, Nusseler WJ, Van Oyen H. addhaz: binomila and multinomial additive hazard models. R package version 0.5. https://cran.r-project.org/web/packages/addhaz/index.html), considering the individuals’ weights.

Ethical aspects

ELSI-Brasil was approved by the Institutional Review Board of the René Rachou Research Institute, Oswaldo Cruz Foundation, Minas Gerais (CAAE: 34649814.3.0000.5091). All those who agreed to participate in the study signed a free and informed consent form, specific for each procedure performed.

Results

Among the 9,412 participants from the ELSI-Brasil baseline, 4,451 reported having a medical diagnosis of hypertension and were using antihypertensive medication and were included in this analysis. Of these, 4,310 (96.8%) had complete information for all the variables in the analysis and were included in the study. Prevalence of adequate control of hypertension was 50.2% (95%CI: 47.7; 52.6). Mean age of participants was 64.7 years (standard deviation = 9.9), 59.9% were women, and 37% had less than four years of schooling, while median monthly per capital income was BRL 799.00.

Among 4,451 participants of the ELSI study that reported having received a medical diagnosis of hypertension and using antihypertensive medication, 4,318 (97%) had information for all the variables and were included in the study.

Table 1 shows the prevalence rates for hypertension control and health behaviors in the older adults, according to sex. Among the participants, 50.7% presented controlled blood pressure levels, with no significant differences between women (51.4%) and men (49.6%). As for health behaviors, 58.9% of the women reported never having smoked, a higher proportion than men (33.7%); 98.7% of the women reported moderate alcohol consumption (compared to 94.3% of the men); and 18.9% of the women consumed vegetables, legumes, and fruits regularly, a higher proportion than in men (13.4%). Regular physical activity was similar in women and men (62.5% and 61.7%, respectively).

Table 2 shows the prevalence of hypertension control among participants according to the adoption of healthy behaviors, for the total sample and stratified by sex. Among women, hypertension control was more frequent in those reporting regular physical activity (54.1%), while in men, the highest prevalence of blood pressure control was in those reporting regular consumption of vegetables, legumes, and fruits (56.6%).

Table 3 shows the health behaviors’ impact and relative contribution to hypertension control, separately for men and women. In women, moderate alcohol consumption (β = 0.39) and physical activity (β = 0.15) had a significant impact on blood pressure control. In men, the only significant impact was from physical activity (β = 0.15). For the sample as a whole, physical activity (β = 0.14) and moderate alcohol consumption (β = 0.21) showed a significant impact on blood pressure control.

The relative contribution of health behaviors to prevalence of hypertension control depends on both the model’s estimated impact and the behavior’s prevalence in the sample. Both in the total population and the sex strata, moderate alcohol consumption and regular physical activity were the health behaviors that contributed most to blood pressure control. The contribution of moderate alcohol consumption was greater in women (52.68%) than in men (19.02%). For regular physical activity, the contributions were more similar (12.64% for women and 10.74% for men). Table 3 provides detailed information on the contribution by the other health behaviors in the total study population and among women and men.

Figure 1 illustrates the size of the contributions by health behaviors to blood pressure control, as a function of its two dimensions: prevalence of the behavior in the sample and its impact on the outcome. An analysis of the bubble’s diameter, which is proportional to the contribution by each health behavior, shows the consistency of the key contribution by moderate alcohol consumption (more intensely by women), followed by regular physical activity (in women and men).

Discussion

The current study showed that only half (50.7%) of older Brazilian adults who reported taking antihypertensive medication had their blood pressure under control. It was also possible to estimate the contribution of selected health behaviors to the prevalence of hypertension control, generally evidencing a larger contribution by these behaviors in women. The behaviors that were investigated featured moderate alcohol consumption and regular physical activity.

The prevalence of controlled blood pressure levels in older adults diagnosed with hypertension and taking antihypertensive medication was lower than in Canada (66%) ¹⁶16. Leenen FH, Dumais J, McInnis NH, Turton P, Stratychuk L, Nemeth K, et al. Lum-Kwong MM & Fodor G. Results of the Ontario survey on the prevalence and control of hypertension. CMAJ 2008; 178:1441-9., but higher than in the United States (48%) ¹⁵15. Bloch MJ. Recent data from National Health and Nutrition Examination Survey (NHANES) demonstrates no improvement in US blood pressure control rates. J Am Soc Hypertens 2018; 12:3-4. and in other developing countries (20 to 36%) ¹³13. Agyemang C, Nyaaba G, Beune E, Meeks K, Owusu-Dabo E, Addo J, et al. Variations in hypertension awareness, treatment, and control among Ghanaian migrants living in Amsterdam, Berlin, London, and nonmigrant Ghanaians living in rural and urban Ghana - the RODAM study. J Hypertens 2018; 36:169-77.^,1414. Damasceno A, Azevedo A, Silva-Matos C, Prista A, Diogo D, Lunet N. Hypertension prevalence, awareness, treatment, and control in mozambique. Hypertens 2009; 54:77-83.. Our results did not show a significant difference in the prevalence of hypertension control between women and men, although such differences between the sexes (even though not entirely understood) have been identified in other studies, possibly reflecting women’s greater concern for the own health ²⁶26. Choi HM, Kim HC, Kang DR. Sex differences in hypertension prevalence and control: analysis of the 2010-2014 Korea National Health and Nutrition Examination Survey. PLoS One 2017; 12:e0178334.^,2727. Assumpção D, Domene SMA, Fisberg RM, Canesqui AM, Barros MBA. Diferenças entre homens e mulheres na qualidade da dieta: estudo de base populacional em Campinas, São Paulo. Ciênc Saúde Colet 2017; 22:347-58.^,2828. Dorner TE, Stronegger WJ, Hoffmann K, Stein KV, Niederkrotenthaler T. Socio-economic determinants of health behaviours across age groups: results of a cross-sectional survey. Wien Klin Wochenschr 2013; 125:261-9.. The differences observed between the sexes and between populations may be partly explained by the combination of factors determining hypertension control, especially adequate treatment and the adoption of healthy habits ²⁶26. Choi HM, Kim HC, Kang DR. Sex differences in hypertension prevalence and control: analysis of the 2010-2014 Korea National Health and Nutrition Examination Survey. PLoS One 2017; 12:e0178334.^,2727. Assumpção D, Domene SMA, Fisberg RM, Canesqui AM, Barros MBA. Diferenças entre homens e mulheres na qualidade da dieta: estudo de base populacional em Campinas, São Paulo. Ciênc Saúde Colet 2017; 22:347-58.^,2828. Dorner TE, Stronegger WJ, Hoffmann K, Stein KV, Niederkrotenthaler T. Socio-economic determinants of health behaviours across age groups: results of a cross-sectional survey. Wien Klin Wochenschr 2013; 125:261-9.. Understanding these combinations is thus important, because although the literature confirms a possible behavior change resulting from the impact of the diagnosis of hypertension (leading the individual to adhere to healthier habits) ⁸8. Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. VII Diretriz Brasileira de Hipertensão Arterial. Arq Bras Card 2016; 107(3 Suppl 3): 1-83., it is still possible to observe persistent unhealthy behaviors among hypertensive individuals ²⁹29. Costa MFF L, Peixoto SV, César CC, Malta DC, Moura ECD. Comportamentos em saúde entre idosos hipertensos, Brasil, 2006. Rev Saúde Pública 2009; 43 Suppl 2:18-26..

In general, our results indicate that health behaviors can help improve hypertension control, as an adjuvant to medication. The adoption of such behaviors thus has positive repercussions on quality of life and mortality rates in hypertensive individuals, as already demonstrated in the literature ²2. Cheong AT, Sazlina SG, Tong SF, Azah AS, Salmiah S. Poor blood pressure control and its associated factors among older people with hypertension: a cross-sectional study in six public primary care clinics in Malaysia. Malays Fam Physician 2015; 10:19-25.^,1111. Yang F, Qian D, Hu D. Prevalence, awareness, treatment, and control of hypertension in the older population: results from the multiple national studies on ageing. J Am Soc Hypertens 2016; 10:140-8.^,1818. Castro I, Waclawovsky G, Marcadenti A. Nutrition and Physical activity on hypertension: implication of current evidence and guidelines. Curr Hypertens Rev 2015; 11:91-9..

The contribution of health behaviors to hypertension control, as described in this study, depends on the behaviors’ prevalence and their impact on this control ²⁵25. Nusselder WJ, Looman CW, Mackenbach JP, Huisman M, van Oyen H, Deboosere P, et al. The contribution of specific diseases to educational disparities in disability-free life expectancy. Am J Public Health 2005; 95:2035-41.. Larger contributions are not necessarily observed between the most prevalent behaviors or between those with the greatest impact on hypertension control, since such contributions result from the combination of these factors. In men, for example, the greatest estimated impact was from regular consumption of vegetables, legumes, and fruits (β = 0.17), but since this behavior was less prevalent (13.4%), its contribution was exceeded by that of regular physical activity, which has a smaller impact (β = 0.12), butt which is a more prevalent behavior (61.7%) in this group.

Moderate alcohol consumption (up to two doses a day for men and up to one dose a day for women) was the health behavior that contributed the most to blood pressure control in this population. Evidence indicates that decreasing alcohol consumption significantly reduces blood pressure levels (systolic and diastolic), with a dose-response effect. A decrease in alcohol consumption is even recommended for the prevention and treatment of hypertension among individuals who drink excessively ⁹9. Sivén SS, Niiranen TJ, Aromaa A, Koskinen S, Jula AM. Social, lifestyle and demographic inequalities in hypertension care. Scand J Public Health 2015; 43:246-53.^,3030. Rysz J, Franczyk B, Banach M, Gluba-Brzozka A. Hypertension-current natural strategies to lower blood pressure. Curr Pharm Des 2017; 23:2453-61.^,3131. Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2001; 38:1112-7.. The effect of alcohol intake on blood pressure is more striking in the elderly than in the younger population ³²32. Wakabayashi I. Influence of gender on the association of alcohol drinking with blood pressure. Am J Hypertens 2008; 21:1310-7.. This may partly explain the large contribution by moderate alcohol consumption to blood pressure control in this population, which consists of individuals 50 years or older. In our study, the contribution of moderate alcohol consumption to blood pressure control was larger in women. This was due to the larger impact of this behavior in women, since the prevalence rates were similar between the sexes. Our results are consistent with findings from a study in Japanese adults, in which alcohol intake increased blood pressure levels more in men than in women ³²32. Wakabayashi I. Influence of gender on the association of alcohol drinking with blood pressure. Am J Hypertens 2008; 21:1310-7..

Next to moderate alcohol consumption, regular physical activity was the health behavior that most contributed to hypertension control, both in the total sample and in men and women. Various studies have evidenced the positive association between physical activity and blood pressure control ¹⁰10. Gebrezgi MT, Trepka MJ, Kidane EA. Barriers to and facilitators of hypertension management in Asmara, Eritrea: patients' perspectives. J Health Popul Nutr 2017; 36:11.^,1818. Castro I, Waclawovsky G, Marcadenti A. Nutrition and Physical activity on hypertension: implication of current evidence and guidelines. Curr Hypertens Rev 2015; 11:91-9.^,1919. Nogueira IC, Santos ZMDSA, Mont DGB, Martins ABT, Araújo Magalhães CB. Efeitos do exercício físico no controle da hipertensão arterial em idosos: uma revisão sistemática. Rev Bras Geriatr Gerontol 2012; 15:587-601.^,3333. Archilla AT, González JP, Ramírez AS, Sánchez EF, Ruiz JRG, Barrilao RG. Efecto de un programa lúdico de actividad física general de corta duración y moderada intensidad sobre las cifras de presión arterial y otros factores de riesgo cardiovascular en hipertensos mayores de 50 años. Aten Primária 2017; 49:473-83.. The current study corroborates these results, quantifying the contribution of physical activity to hypertension control and highlighting the importance of maintaining physical activity at recommended levels among hypertensive individuals, as an important adjuvant to medication. Despite its importance, regular physical activity is still not a common habit in the population, and especially among the elderly there has been an increase in physical inactivity ¹⁸18. Castro I, Waclawovsky G, Marcadenti A. Nutrition and Physical activity on hypertension: implication of current evidence and guidelines. Curr Hypertens Rev 2015; 11:91-9.^,2020. Guo J, Zhu YC, Chen YP, Hu Y, Tang XW, Zhang B. The dynamics of hypertension prevalence, awareness, treatment, control and associated factors in Chinese adults: results from CHNS 1991-2011. J Hypertens 2015; 33:1688-96..

Regular consumption of vegetables, legumes, and fruits and never having smoked make a larger contribution to blood pressure control in men than in women (for whom the contribution by these two behaviors was practically nil). This is because the impact of these factors on hypertension control in this population is very low. Women in the current study displayed healthier habits than men, with the largest differences in the prevalence rates of regular consumption of vegetables and fruits and never having smoked. A study in the Austrian adult population (≥ 20 years) ²⁸28. Dorner TE, Stronegger WJ, Hoffmann K, Stein KV, Niederkrotenthaler T. Socio-economic determinants of health behaviours across age groups: results of a cross-sectional survey. Wien Klin Wochenschr 2013; 125:261-9. found evidence of women’s greater propensity to adopt healthy habits, especially quality diet. Another study showed that among females 10 years or older in Campinas, São Paulo, adherence to healthy life habits is not due to the adoption of single health behaviors. In this study, among women with healthier diet, the proportions of physical exercise and absence of smoking were also higher ²⁷27. Assumpção D, Domene SMA, Fisberg RM, Canesqui AM, Barros MBA. Diferenças entre homens e mulheres na qualidade da dieta: estudo de base populacional em Campinas, São Paulo. Ciênc Saúde Colet 2017; 22:347-58.. These results suggest a more comprehensive adoption of healthy behaviors by women, occurring homogeneously in the two groups assessed (both with controlled and uncontrolled hypertension) and attenuating the impact of these behaviors on prevalence of blood pressure control.

Special attention should be given to the control of hypertension attributed to background, indicating that among both women (33.7%) and men (63.7%), hypertension control is attributed to other factors, such as schooling, socioeconomic status, obesity, and others, which are widely described in the literature as associated with hypertension control ²2. Cheong AT, Sazlina SG, Tong SF, Azah AS, Salmiah S. Poor blood pressure control and its associated factors among older people with hypertension: a cross-sectional study in six public primary care clinics in Malaysia. Malays Fam Physician 2015; 10:19-25.^,1010. Gebrezgi MT, Trepka MJ, Kidane EA. Barriers to and facilitators of hypertension management in Asmara, Eritrea: patients' perspectives. J Health Popul Nutr 2017; 36:11.^,2020. Guo J, Zhu YC, Chen YP, Hu Y, Tang XW, Zhang B. The dynamics of hypertension prevalence, awareness, treatment, control and associated factors in Chinese adults: results from CHNS 1991-2011. J Hypertens 2015; 33:1688-96.^,2828. Dorner TE, Stronegger WJ, Hoffmann K, Stein KV, Niederkrotenthaler T. Socio-economic determinants of health behaviours across age groups: results of a cross-sectional survey. Wien Klin Wochenschr 2013; 125:261-9., but which were not the focus of the current study. In addition, the drug treatment variable used in ELSI-Brasil was based on the participant’s self-report and does not mean that the reported treatment was followed according to the medical prescription. A qualitative study in Bambuí, Minas Gerais, Brazil, showed that elderly individuals’ understanding of the use of antihypertensive medication does not necessarily coincide with the medical prescription ³⁴34. Firmo JOA, Lima-Costa MF, Uchôa E. Projeto Bambuí: maneiras de pensar e agir de idosos hipertensos. Cad Saúde Pública 2004; 20:1029-40.. These findings suggest that in addition to the other factors mentioned above, part of the prevalence attributed to background may be due to the inability to determine whether the drug prescription was followed correctly.

The current study’s potential limitations include the cross-sectional design, which does not allow establishing a temporal relationship between the variables. The study was not exploratory, nor did it aim to identify the determinants of hypertension control, so that the discussion only pointed to possible hypotheses for the prevalence attributed to background and for the observed differences between the sexes. Importantly, these results cannot be extrapolated to the individual level or to other populations, since they depend on the behavior’s prevalence in the respective population. Despite the above, the study was conducted in a representative sample of Brazil’s older adult population, using standardized data collection procedures, as the first study to quantify the contribution of health behaviors to blood pressure control.

In short, the study’s results showed that only half of the hypertensive individuals had their blood pressure under control. The study also identified an important contribution by moderate alcohol consumption and physical activity to blood pressure control. These data reinforce the need for measures that promote and encourage improvements in health behaviors in the population.

Acknowledgments

The authors wish to acknowledge the funding from the Brazilian Ministry of Health (DECIT/SCTIE - Department of Science and Technology, Division of Science, Technology, and Strategic Inputs; case 404965/2012-1); Section on Health of the Elderly, Department of Strategic Planning Actions, Healthcare Division (COSAPI/DAPES/SAS - cases 20836, 22566, and 23700); and the Ministry of Science, Technology, Innovation, and Communication.

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