ABSTRACT:

Objective:

To analyze the behavior of the prevalence of hypertension in the city of São Paulo and its associated factors.

Methods:

The present study used data from the Health Survey in the Municipality of São Paulo (ISA Capital), a population-based cross-sectional study conducted in São Paulo. Data from 1,667 and 3,184 individuals were analyzed in 2003 and 2015, respectively, aged 20 years and over. Descriptive analyzes of the prevalence of hypertension were performed with 95% confidence intervals. Simple and multiple analyzes were performed to analyze the possible associations with socioeconomic, demographic and lifestyle variables by Poisson regression.

Results:

The prevalence of hypertension increased from 17.2% in 2003 to 23.2% in 2015. The associated variables with hypertension were: gender (females); age (60 years old and over); marital status (married, separated and widowed); having a religion; low education level; being born in the state of São Paulo (except capital); nutritional status (low weight, overweight and obesity); former smokers.

Conclusion:

The prevalence of self-reported hypertension increased significantly in the study period. Considering this disease’s impact on society, knowing its current prevalence and identifying its main associated factors, the need to intensify the efforts to prevent it disease is evident in order to mitigate damage to individuals and impact on public expenditure.

Keywords:
Epidemiology; Hypertension; Risk factors; Self-report

INTRODUCTION

Arterial hypertension is a chronic multifactorial condition characterized by sustained elevation of blood pressure levels, with systolic pressure ≥ 140 mmHg and/or diastolic pressure ≥ 90 mmHg. It constitutes one of the most important known and controllable risk factors for the development of cardiovascular diseases, such as infarction, chronic renal failure and stroke¹1. Sociedade Brasileira de Cardiologia. 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol 2016; 107(Supl. 3): 1-83.. Cardiovascular diseases are the leading cause of death in the world, accounting for 30% of all deaths, with an increasing burden in developing countries²2. Lee DE, Cooper RS. Recommendations for global hypertension monitoring and prevention. Curr Hypertens Rep 2009; 11(6): 444-9. https://doi.org/10.1007/s11906-009-0075-9
https://doi.org/https://doi.org/10.1007/... . Hypertension is the cause of at least 45% of deaths from heart disease and 51% of deaths from stroke worldwide³3. World Health Organization. Causes of Death 2008. Genebra: World Health Organization; 2011..

Because of the high morbidity and mortality and of the chronic condition profile related to hypertension, and because it remains asymptomatic for many years, the issue becomes a permanent challenge for health systems worldwide, justifying efforts for its early detection and adequate control, which aim to reduce its cardiac, cerebrovascular, renal and peripheral arterial complications⁴4. Ramos ACMF, Seixas TC, Rocha CRM, Ávila RT. O programa de controle da hipertensão arterial no sistema público de saúde no município do Rio de Janeiro. Rev SOCERJ 2003; 16(2): 141-5.^,55. Sorlie PD, Allison MA, Avilés-Santa ML, Cai J, Daviglus ML, Howard AG, et al. Prevalence of hypertension, awareness, treatment and control in Hispanic community health study / study of Latinos. Am J Hypertens 2014; 27(6): 793-800. https://doi.org/10.1093/ajh/hpu003
https://doi.org/https://doi.org/10.1093/... .

According to the World Health Organization (WHO), hypertension affects 20 to 40% of the adult population⁶6. World Health Organization. Pan American Health Organization. Hypertension [Internet]. Pan American Health Organization; 2018 [acessado em 22 jan. 2018]. Disponível em: Disponível em: https://www.paho.org/hq/index.php?option=com_topics&view=article&id=221&Itemid=40878&lang=en
https://www.paho.org/hq/index.php?option... , with the highest prevalence among men and in middle and low-income countries⁷7. Danaei G, Finucane MM, Lin JK, Singh GM, Paciorek CJ, Cowan MJ, et al. National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 746 country-years and 5,4 million participants. Lancet 2011; 377(9765): 568-77. https://doi.org/10.1016/S0140-6736(10)62036-3
https://doi.org/https://doi.org/10.1016/... .

In Brazil, according to data from the National Health Survey (Pesquisa Nacional de Saúde - PNS), the prevalence of hypertension in 2013 was 21.4%, with 24.2% among women and 18.3% among men. This prevalence was higher according to age: 20.6% among adults aged 30 to 59 years, 44.4% among elderly people aged 60 to 64 years and 52.7% among those aged 65 to 74 years⁸8. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Pesquisa Nacional de Saúde 2013. Módulo de Doenças Crônicas. Hipertensão [Internet]. Brasil: Ministério da Saúde; 2017 [acessado em 17 dez. 2017]. Disponível em: Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?pns/pnsqb.def
http://tabnet.datasus.gov.br/cgi/tabcgi.... . The prevalence of hypertension was also higher in people with low education levels, living in urban areas and in southeastern Brazil⁹9. Andrade SSA, Stopa SR, Brito AS, Chueri PS, Szwarcwald CL, Malta DC. Prevalência de hipertensão arterial autorreferida na população brasileira: análise da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2015; 24(2): 297-304. http://dx.doi.org/10.5123/S1679-49742015000200012
https://doi.org/http://dx.doi.org/10.512... .

Data from the Surveillance of Risk and Protection Factors for Chronic Diseases by Telephone Survey (Vigitel) in 2016 showed that the prevalence of hypertension in Brazil was 25.7%, varying between 16.9 and 31.7%. The prevalence was higher among women (27.5%) than among men (23.6%)¹⁰10. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde. VIGITEL Brasil 2016 - Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica e fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e Distrito Federal em 2016. Brasília: Ministério da Saúde; 2017..

The main factors associated with hypertension are: advanced age, being female, overweight, salt intake, excessive alcohol consumption, smoking, physical inactivity, low income and genetic factors¹1. Sociedade Brasileira de Cardiologia. 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol 2016; 107(Supl. 3): 1-83..

The identification of the current prevalence of hypertension in the city of São Paulo and its associated factors, raised through household surveys, is important to assist in targeting interventions for the prevention and control of this disease, as it raises detailed information about the characteristics of the population.

In this sense, the Municipal Department of Health of São Paulo, in partnership with the Schools of Public Health and Medicine of Universidade de São Paulo (USP), Universidade Estadual de Campinas (Unicamp) and the Health Institute of the State Department of Health of the Government of São Paulo, held three editions of the Health Survey in the Municipality of São Paulo (ISA Capital), in 2003, 2008 and 2015. This survey was designed to learn about aspects of public health in the city that are not contained in routine information systems of the Unified Health System (SUS).

The present study aimed to analyze the evolution of the prevalence of arterial hypertension between 2003 and 2015 and the associated factors in 2015 among adults and the elderly in the capital of São Paulo.

METHODS

This study used data collected by ISA Capital. A total of 1,667 individuals in 2003 and 3,184 in 2015, all aged 20 years or over and residing in the city of São Paulo, were interviewed.

ISA Capital is a cross-sectional population-based study with probabilistic samples stratified by conglomerates in two stages, carried out in three periods. In the 2003 survey, the strata were built by grouping the census sectors into three groups, defined by the percentage of heads of households with a university degree, and eight domains grouped by gender and age were also identified. In the 2015 survey, to obtain data on regional health coordinators in the city of São Paulo, a division into five strata (Midwest, East, North, Southeast and South) and four domains by gender and age was used.

The information was obtained through questionnaires applied by interviewers visiting the households and answered directly by the drawn residents or by their mother or guardian, if the selected individual had any limitations or disabilities. The questionnaire was organized into thematic blocks, with most of the questions being closed and with predefined alternatives.

The dependent variable (outcome) was the prevalence of self-reported hypertension, through the question: Has any doctor already informed you that you have hypertension or high blood pressure? The independent variables related to socioeconomic and demographic information were: gender, age group (20 to 59 years, 60 years and over), skin color (white, black, brown, other), marital status (single, married, separated, widowed), religion (yes, no), education (higher education, secondary education, intermediate education, primary education, no schooling) and place of birth (city of São Paulo, state of São Paulo, another state, another country).

In the marital status variable, the married category included individuals who reported that they lived with their partner and were in a stable relationship. The separated category involved the separated and the divorced individuals.

To assess physical activity, individuals who performed 150 minutes or more of physical activity per week were considered physically active.

The variables related to lifestyle were: physical activity (yes, no), nutritional status (eutrophy, underweight, overweight, obesity) and smoking (never smoked, smoker, ex-smoker). Nutritional status was classified by body mass index (BMI), which in turn was obtained by dividing weight (kg) by height (m) squared. For adults (20-59 years), the following cutoff points were adopted: low weight (BMI < 18.5 kg/m²), eutrophy (BMI between 18.5 and 24.9 kg/m²), overweight (BMI between 25 and 29.9 kg/m²) and obesity (BMI ≥ 30 kg/m²). For the elderly (aged 60 and over), the cutoff points were: low weight (BMI < 23 kg/m²), eutrophy (BMI between 23 and 27.9 kg/m²), overweight (BMI between 28 and 29.9 kg/m²) and obesity (BMI ≥ 30 kg/m²).

The data was encoded directly in the questionnaires and typed in an Epi Info mask in 2003. In 2015, the data was entered directly into tablets and the coding was done in the final bank in Excel.

For data analysis, descriptive analyzes were performed, calculating the estimates of prevalence for hypertension and 95% confidence intervals (95%CI). Then, associations with socioeconomic, demographic and lifestyle characteristics were verified using the confidence interval, considering the 5% significance level and complex sample design. Simple Poisson regression was performed, taking into account hypertension as a dependent variable and socioeconomic, demographic and lifestyle variables as independent variables. The variables that presented a significance level of p < 0.20 were subjected to the Poisson multiple regression analysis, and only variables with p < 0.05 remaining in the final model. The measure of association used was the prevalence ratio (PR).

In order to verify the behavior of the prevalence of arterial hypertension in the analyzed period, the survey banks were joined and Poisson regression techniques were used, with the disease being the dependent variable and the years the independent variables, in addition to 2003 being the reference year, and having been adjusted by gender and age group. All analyzes were carried out using the survey mode of the Stata 13 software, given the complex sample design.

In relation to ethical aspects, the interview took place only after the individuals selected were made aware of the Informed Consent and after having signed the document, in case of agreement.

This work was approved by the Research Ethics Committee of the School of Medicine of Universidade de São Paulo on November 4, 2015, under protocol number 437/15.

RESULTS

The prevalence levels of self-reported arterial hypertension in the city of São Paulo were: 17.2% (95%CI 14.8 - 19.9) in 2003 and 23.2% (95%CI 21.5 - 25.0) in 2015. This increase was statistically significant when comparing the values of 2003 and 2015. There was a 30% increase in the prevalence of hypertension in the municipality (PR = 1.3; 95%CI 1.1 - 1.5), considering the year of 2003 as a reference (adjusted for gender and age group) (Table 1).

Considering 2015, the prevalence of arterial hypertension was higher among women (26.5%; 95%CI 24.2 - 28.9) than among men (19.5%; 95%CI 17.3 - 21.8) and higher among individuals aged 60 years or older (54.9%; 95%CI 51.0 - 58.6). The prevalence of hypertension was higher among widowers (56.2%; 95%CI 50.9 - 61.2), individuals that have a religion (24.6%; 95%CI 22.7 - 26.6), without education (47.2%; 95%CI 37.0 - 57.7) and migrants from the state of São Paulo (33.6%; 95%CI 27.4 - 40.4) (Table 2).

Regarding lifestyle characteristics, the prevalence of hypertension was higher among individuals who did not practice enough physical activities (30.9%; 95%CI 27.0 - 35.2), obese individuals (39.5%; 95%CI 35.3 - 43.8) and ex-smokers (33.9%; 95%CI 29.6 - 38.5) (Table 2).

After adjusting the variables, the individuals who were most likely to report hypertension were women (PR = 1.2; 95%CI 1.0 - 1.4), the elderly (PR = 2.6; 95%CI 2.2 - 3.1) and those who had a religion (PR = 1.3; 95%CI 1.0 - 1.7). Individuals who were married (PR = 1.5; 95%CI 1.2 - 2.2), separated (PR = 2.0; 95%CI 1.5 - 2.8) and widowers (PR = 1.6; 95%CI 1.2 - 2.2), had a higher chance when compared to singles, as well as those with lower levels of education, such as people who had up to intermediate education (PR = 1.3; 95%CI 1.0 - 1, 7), primary education (PR = 1.6; 95%CI 1.3 - 2.0) and those who didn’t study (PR = 1.4; 95%CI 1.0 - 2.0), when compared to those with higher education.

Regarding the place of birth, individuals who migrated from other municipalities in the state of São Paulo had higher chances (PR = 1.2; 95%CI 1.0 - 1.5) when compared to those who were born in the capital. People with low weight (PR = 1.3; 95%CI 1.0 - 1.5), overweight (PR = 1.7; 95%CI 1.4 - 2.0) and obesity (PR = 2.5; 95%CI % 2.1 - 2.9) were more likely to have hypertension in relation to eutrophic individuals, and ex-smokers (PR = 1.2; 95%CI 1.0 - 1.4) had a 20% higher prevalence than those who have never smoked (Table 2).

This study also pointed out a significant increase in obesity in the city of São Paulo, going from 11.4% (95%CI 9.0 - 14.3) in 2003 to 20.7 (95%CI 19.1 - 22.3) in 2015 (Table 3).

DISCUSSION

The results showed a progressive increase in the prevalence of self-reported arterial hypertension in the city of São Paulo. This value is similar to that found in Vigitel 2016, which indicated a prevalence of 25.9% (95%CI 23.8 - 29.1) in the capital of São Paulo State⁹9. Andrade SSA, Stopa SR, Brito AS, Chueri PS, Szwarcwald CL, Malta DC. Prevalência de hipertensão arterial autorreferida na população brasileira: análise da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2015; 24(2): 297-304. http://dx.doi.org/10.5123/S1679-49742015000200012
https://doi.org/http://dx.doi.org/10.512... .

A possible explanation for this increase can be attributed to the expansion of the diagnosis of the disease due to the greater access to health services by the population through the teams of the Family Health Strategy (Estratégia Saúde da Família - ESF)¹¹11. Pierin AMG, Marroni SN, Taveira LAF, Benseñor IJM. Controle de hipertensão arterial e fatores associados na atenção primária em Unidades Básicas de Saúde localizadas na região Oeste da cidade de São Paulo. Ciên Saúde Colet 2011; 16(Supl. 1): 1389-400. http://dx.doi.org/10.1590/S1413-81232011000700074
https://doi.org/http://dx.doi.org/10.159... . It can also be considered that the increase in the prevalence of hypertension in this population is related to the increase in overweight and obesity in the population of the city of São Paulo¹²12. Malta DC, Bernal RTI, Andrade SSCA, Silva MMA, Velasquez-Melendez G. Prevalência e fatores associados com hipertensão arterial autorreferida em adultos brasileiros. Rev Saúde Pública 2017; 51(Supl. 1): 1-11. http://dx.doi.org/10.1590/s1518-8787.2017051000006
https://doi.org/http://dx.doi.org/10.159... .

This study also pointed out an increase in the prevalence of obesity in the municipality from 2003 to 2015, and both overweight and obesity are known risk factors for hypertension¹³13. Whelton PK. Epidemiology of hypertension. Lancet 1994; 344(8915): 101-6. https://doi.org/10.1016/S0140-6736(94)91285-8
https://doi.org/https://doi.org/10.1016/... .

Another factor to be considered is that populations around the world are aging. This demographic change could also explain the increase in hypertension in São Paulo¹⁴14. Beard JR, Bloom D. Towards a comprehensive public health response to population ageing. Lancet 2015; 385(9968): 658-61. https://doi.org/10.1016/S0140-6736(14)61461-6
https://doi.org/https://doi.org/10.1016/... . Arterial hypertension in this municipality was more prevalent among women, a result that corroborates the findings of several studies conducted in Brazil with self-reported data¹¹11. Pierin AMG, Marroni SN, Taveira LAF, Benseñor IJM. Controle de hipertensão arterial e fatores associados na atenção primária em Unidades Básicas de Saúde localizadas na região Oeste da cidade de São Paulo. Ciên Saúde Colet 2011; 16(Supl. 1): 1389-400. http://dx.doi.org/10.1590/S1413-81232011000700074
https://doi.org/http://dx.doi.org/10.159... ^,1515. Schmidt MI, Duncan BB, Hoffmann JF, Moura L, Malta DC, Carvalho RMSV. Prevalência de diabetes e hipertensão no Brasil baseada em inquérito de morbidade autorreferida, Brasil, 2006. Rev Saúde Pública 2009; 43(Supl. 2): 74-82. http://dx.doi.org/10.1590/S0034-89102009000900010
https://doi.org/http://dx.doi.org/10.159... ^,1616. Andrade SSCA, Malta DC, Iser BM, Sampaio DC, Moura L. Prevalência de hipertensão autorreferida nas capitais brasileiras em 2011 e análise de sua tendência no período de 2006 a 2011. Rev Bras Epidemiol 2014; 17(Supl. 1): 215-26. http://dx.doi.org/10.1590/1809-4503201400050017
https://doi.org/http://dx.doi.org/10.159... . On the other hand, the literature shows that the prevalence of hypertension is higher among men when blood pressure is measured, as shown by data from PNS¹⁷17. Malta DC, Santos NB, Perillo RD, Szwarcwald CL. Prevalence of high blood pressure measured in the Brazilian population, National Health Survey, 2013. São Paulo Med J 2016; 134(2): 163-70. http://dx.doi.org/10.1590/1516-3180.2015.02090911
https://doi.org/http://dx.doi.org/10.159... .

In a study conducted with the Brazilian population, an association was found between hypertension and gender at the limit of significance in the adjusted model¹¹11. Pierin AMG, Marroni SN, Taveira LAF, Benseñor IJM. Controle de hipertensão arterial e fatores associados na atenção primária em Unidades Básicas de Saúde localizadas na região Oeste da cidade de São Paulo. Ciên Saúde Colet 2011; 16(Supl. 1): 1389-400. http://dx.doi.org/10.1590/S1413-81232011000700074
https://doi.org/http://dx.doi.org/10.159... , and in a study with the elderly population in the state of São Paulo, the association between women was present only in the crude analysis¹⁸18. Zaitune MPA, Barros MBA, César CLG, Carandina L, Goldbaum M. Hipertensão arterial em idosos: prevalência, fatores associados e práticas de controle no município de Campinas, São Paulo Brasil. Cad Saúde Pública 2006; 22(2): 285-94. http://dx.doi.org/10.1590/S0102-311X2006000200006
https://doi.org/http://dx.doi.org/10.159... . In this study, women were 20% more likely to have hypertension. A possible explanation for this is that women are generally more aware of illnesses, seek more medical assistance and have greater adherence to health care¹⁹19. Pinheiro RS, Viacava F, Travassos C, Brito AS. Gênero, morbidade, acesso e utilização de serviços de saúde no Brasil. Ciênc Saúde Colet 2002; 7(4): 687-707. http://dx.doi.org/10.1590/S1413-81232002000400007
https://doi.org/http://dx.doi.org/10.159... ^,2020. Levorato CD, Mello LM, Silva AS, Nunes AA. Fatores associados à procura por serviços de saúde numa perspectiva relacional ao gênero. Ciênc Saúde Coletiva 2014; 19(4): 1263-74. http://dx.doi.org/10.1590/1413-81232014194.01242013
https://doi.org/http://dx.doi.org/10.159... .

There is a direct relationship between age and arterial hypertension, according to widely publicized studies¹¹11. Pierin AMG, Marroni SN, Taveira LAF, Benseñor IJM. Controle de hipertensão arterial e fatores associados na atenção primária em Unidades Básicas de Saúde localizadas na região Oeste da cidade de São Paulo. Ciên Saúde Colet 2011; 16(Supl. 1): 1389-400. http://dx.doi.org/10.1590/S1413-81232011000700074
https://doi.org/http://dx.doi.org/10.159... ^,1616. Andrade SSCA, Malta DC, Iser BM, Sampaio DC, Moura L. Prevalência de hipertensão autorreferida nas capitais brasileiras em 2011 e análise de sua tendência no período de 2006 a 2011. Rev Bras Epidemiol 2014; 17(Supl. 1): 215-26. http://dx.doi.org/10.1590/1809-4503201400050017
https://doi.org/http://dx.doi.org/10.159... ^,2121. Miall WE, Chinn S. Blood pressure and ageing; results of a 15-17 year follow up study in South Wales. Clin Sci Mol Med 1973; 45(Supl. 1): S23-33. https://doi.org/10.1042/cs045023s
https://doi.org/https://doi.org/10.1042/... ^,2222. Ferreira SRG, Moura EC, Malta DC, Sarno F. Frequência de hipertensão arterial e fatores associados. Brasil, 2006. Rev Saúde Pública 2009; 43(Supl. 2): 98-106. http://dx.doi.org/10.1590/S0034-89102009000900013
https://doi.org/http://dx.doi.org/10.159... . Thus, in this study, the prevalence of hypertension was higher among the elderly (60 years and over). The PR was about three times that of adults aged 20 to 59 years, similarly to that found in other studies¹¹11. Pierin AMG, Marroni SN, Taveira LAF, Benseñor IJM. Controle de hipertensão arterial e fatores associados na atenção primária em Unidades Básicas de Saúde localizadas na região Oeste da cidade de São Paulo. Ciên Saúde Colet 2011; 16(Supl. 1): 1389-400. http://dx.doi.org/10.1590/S1413-81232011000700074
https://doi.org/http://dx.doi.org/10.159... ^,2323. Nakashima L, Trevisol FS, Sebold FJG, Della Júnior AP, Pereira MR, Trevisol DJ. Prevalência de hipertensão arterial sistêmica em adultos do município de Tubarão (SC). Rev AMRIGS 2015; 59(1): 4-9.. A fact that may explain this association is that, with advancing age, the arteries tend to become more rigid, which may be related to the increase in blood pressure in these people²⁴24. Rourke MFO. Arterial ageing: principles and implications for monitoring and therapy. Rev Bras Hipertens 2007; 14(2): 79-82.^,2525. Bortolotto LA, Macêdo TA. Alterações vasculares da hipertensão arterial. Rev Soc Cardiol Estado de São Paulo 2008; 18(2): 150-61.. Another factor for the higher prevalence of hypertension among the elderly may be the demographic transition itself, due to the accelerated aging of the population²⁶26. Vasconcelos AMN, Gomes MMF. Transição demográfica: a experiência brasileira. Epidemiol Serv Saúde 2012; 21(4): 539-48. http://dx.doi.org/10.5123/S1679-49742012000400003
https://doi.org/http://dx.doi.org/10.512... .

In the municipality of São Paulo, when considering the marital status of individuals, those who were separated were twice as likely to have hypertension. Additionally, a positive association was found between married and widowed individuals compared to singles. The same was observed by Belon et al., who also found a higher chance of hypertension among married people, suggesting that living with someone could be related to greater access to health services, impacting on a greater chance of detecting hypertension in this group²⁷27. Belon AP, Francisco PMSB, Barros MBA, Cesar CLG, Carandina L, Goldbaum M, et al. Diabetes em idosos: perfil sociodemográfico e uso de serviços de saúde. In: XVI Encontro Nacional de Estudos Populacionais. Cascambu; 2008..

Some authors suggest that the quality of marriage may play a more important role in health than the marital situation itself²⁸28. Liu H, Waite L. Bad marriage, broken heart? Age and gender differences in the link between marital quality and cardiovascular risks among older adults. J Health Soc Behav 2014; 55(4): 403-23. https://doi.org/10.1177/0022146514556893
https://doi.org/https://doi.org/10.1177/... and that the quality of the relationship moderates the effect of stress. It has been reported that when the marital relationship has a negative quality, there may be an increase in blood pressure, as stress can affect the vascular system²⁹29. Birditt KS, Newton NJ, Cranford JA, Ryan LH. Stress and relationship quality among older couples: implications for blood pressure. J Gerontol B Psychol Sci Soc Sci 2016; 71(5): 775-85. https://doi.org/10.1093/geronb/gbv023
https://doi.org/https://doi.org/10.1093/... .

With regard to separated individuals, a higher prevalence of sleep complaints was found among the newly separated, which increases the risk of arterial hypertension in the future³⁰30. Kriestch KN, Mason AE, Sbarra DA. Sleep complaints predict increases in resting blood pressure following marital separations. Health Psychol 2014; 33(10): 1204-13. https://doi.org/10.1037/hea0000089
https://doi.org/https://doi.org/10.1037/... . Among widowers, it has been seen in the literature that women had a higher risk of hypertension as soon as they lost their husbands, but those who have been widows for a long time have not had such an association, since the mourning period, which corresponds to a moment of great emotional stress, has passed³¹31. Perkins JM, Lee HY, James KS, Oh S, Krishna A, Heo J, et al. Marital status, widowhood duration, gender and health outcomes: a cross-sectional study among older adults in India. BMC Public Health 2016; 16(1): 1032-43. https://doi.org/10.1186/s12889-016-3682-9
https://doi.org/https://doi.org/10.1186/... . Thus, people who experience situations of prolonged emotional tension may become hypertensive, especially when there is a genetic disposition for such a disease³²32. Mac Fadden MAJ, Ribeiro AV. Aspectos psicológicos e hipertensão essencial. Rev Assoc Med Bras 1998; 44(1): 4-10. http://dx.doi.org/10.1590/S0104-42301998000100002
https://doi.org/http://dx.doi.org/10.159... , strengthening, however, the different prevalence rates found in this study.

Some studies were carried out with the purpose of raising questions about people’s religiosity and spirituality and their association with the prevalence of arterial hypertension. In a survey conducted in the United States, a lower prevalence of hypertension was found in individuals who practiced religious activities³³33. Gillum FR, Ingram DD. Frequency of attendance at religious services, hypertension, and blood pressure: the third National Health and Nutrition Examination Survey. Psychosom Med 2006; 68(3): 382-5. https://doi.org/10.1097/01.psy.0000221253.90559.dd
https://doi.org/https://doi.org/10.1097/... . Another American study found that practitioners of religious activities were 40% less likely to have hypertension³⁴34. Koenig HG, George LK, Hays JC, Larson DB, Cohen HJ, Blazer DG. The relationship between religious activities and blood pressure in older adults. Int J Psychiatric Med 1998; 28(2): 189-213. https://doi.org/10.2190/75JM-J234-5JKN-4DQD
https://doi.org/https://doi.org/10.2190/... . Although religious people tend to have lower rates of hypertension³⁵35. Levin J, Schiller P. Is there a religious factor in health? J Relig Health 1987; 26(1): 9-36., since they theoretically follow guidelines that value health care, people in the city of São Paulo who have religion were more likely to have hypertension than people without a religion. As this is a cross-sectional study, it is not possible to point out the temporality of this information; that is, it is not known whether people became religious before or after the diagnosis of hypertension. However, people tend to seek a religion in situations of stress, in search of greater well-being³⁶36. Koenig HG. Religião, espiritualidade e psiquiatria: uma nova era na atenção à saúde mental. Rev Psiq Clin 2007; 34(Supl. 1): 5-7. http://dx.doi.org/10.1590/S0101-60832007000700002
https://doi.org/http://dx.doi.org/10.159... .

Studies show that lower levels of education are associated with risk factors for hypertension¹¹11. Pierin AMG, Marroni SN, Taveira LAF, Benseñor IJM. Controle de hipertensão arterial e fatores associados na atenção primária em Unidades Básicas de Saúde localizadas na região Oeste da cidade de São Paulo. Ciên Saúde Colet 2011; 16(Supl. 1): 1389-400. http://dx.doi.org/10.1590/S1413-81232011000700074
https://doi.org/http://dx.doi.org/10.159... ^,3737. Barros MBA, Francisco PMSB, Zancheta LM, Cesar CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003 - 2008. Ciênc Saúde Colet 2011; 16(9): 3755-68. http://dx.doi.org/10.1590/S1413-81232011001000012
https://doi.org/http://dx.doi.org/10.159... , as observed in the city investigated. Individuals who studied up to primary and intermediate school and those who never studied were more likely to have hypertension, compared to those with higher education. This may be because people with higher education levels are more aware of health care and behaviors related to disease prevention³⁸38. Hayes DK, Greenlund KJ, Denny CH, Neyer JR, Croft JB, Keenan NL. Racial ethnic and socioeconomic disparities in health-related quality of life among people with coronary heart disease, 2007. Prev Chronic Dis 2011; 8(4): 1-12.. In addition, it is also necessary to consider possible inequalities in access, since more educated people have less difficulty in accessing health services³⁹39. Almeida APSC, Nunes BP, Duro SMS, Facchini LA. Determinantes socioeconômicos do acesso a serviços de saúde em idosos: revisão sistemática. Rev Saúde Pública 2017; 51(1): 1-15. http://dx.doi.org/10.1590/s1518-8787.2017051006661
https://doi.org/http://dx.doi.org/10.159... .

The birthplace of São Paulo residents was associated with hypertension, since the PR observed among individuals who were born in other municipalities in the state of São Paulo and migrated to the capital was higher when compared to those born in the capital. A study carried out with elderly people in the interior of the state found a higher PR among those born in other states than among those born in the same state where the research was carried out¹⁸18. Zaitune MPA, Barros MBA, César CLG, Carandina L, Goldbaum M. Hipertensão arterial em idosos: prevalência, fatores associados e práticas de controle no município de Campinas, São Paulo Brasil. Cad Saúde Pública 2006; 22(2): 285-94. http://dx.doi.org/10.1590/S0102-311X2006000200006
https://doi.org/http://dx.doi.org/10.159... . One factor that can explain what happened is the stress to which migrants are exposed due to the process of adapting to changes in habits and culture⁴⁰40. Mooteri SN, Petersen F, Dagubati R, Pai RG. Duration of residence in the United States as a new factor for coronary artery disease (The Konkani Heart Study). Am J Cardiol 2004; 93(3): 359-61. https://doi.org/10.1016/j.amjcard.2003.09.044
https://doi.org/https://doi.org/10.1016/... .

Physical inactivity is considered an independent risk factor associated with hypertension⁴¹41. Beunza JJ, Martínez-González MA, Ebrahim S, Bes-Rastrollo M, Núñez J, Martínez JA, et al. Sedentary behaviors and the risk of incident hypertension. The SUN Cohort. Am J Hypertens 2007; 20(11): 1156-62. https://doi.org/10.1016/j.amjhyper.2007.06.007
https://doi.org/https://doi.org/10.1016/... , but in the city of São Paulo, individuals in this condition were 40% more prone to hypertension than those who were physically active, which was not maintained in the final model but only in the simple analysis. A possible explanation for what happened is that people who do not exercise tend to be obese and to eat in an unhealthy way, which are already known risk factors for hypertension⁴²42. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis (DCNT) no Brasil 2011-2022. Brasília: Ministério da Saúde ; 2011.^,4343. Bertrais S, Beyeme-Ondoua JP, Czernichow S, Galan P, Hercberg S, Oppert JM. Sedentary behaviors, physical activity, and metabolic syndrome in middle-aged French subjects. Obes Res 2005; 13(5): 936-44. https://doi.org/10.1038/oby.2005.108
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In the municipality analyzed, a positive association was found between hypertension and overweight and obesity. Overweight individuals had a 70% greater chance of having hypertension in relation to eutrophic individuals, and obese individuals had more than twice the chance. Studies show that obesity is directly associated with hypertension⁴⁴44. Garrison RJ, Kannel WB, Stokes III J, Castelli WP. Incidence and precursors of hypertension in young adults: The Framingham Offspring Study. Prev Med 1987; 16(2): 235-51. https://doi.org/10.1016/0091-7435(87)90087-9
https://doi.org/https://doi.org/10.1016/... ^,4545. Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 2013; 309(1): 71-82. https://doi.org/10.1001/jama.2012.113905
https://doi.org/https://doi.org/10.1001/... . On the other hand, they also show that small reductions in body weight result in a significant drop in arterial hypertension and improve the associated metabolic changes⁴⁶46. Reisin E, Frohlich ED, Messerli FH, Dreslinski GR, Dunn FG, Jones MM, et al. Cardiovascular changes after weight reduction in obesity hypertension. Ann Intern Med 1983; 98(3): 315-9. https://doi.org/10.7326/0003-4819-98-3-315
https://doi.org/https://doi.org/10.7326/... ^,4747. Langford HG, Blaufox MD, Oberman A, Hawkins CM, Curb JD, Cutter GR, et al. Dietary therapy slows the return of hypertension after stopping prolonged medication. JAMA 1985; 253(5): 657-64.^,4848. Gordon NF, Scott CB, Levine BD. Comparison of single versus multiple lifestyle interventions: are the antihypertensive effects of exercise training and diet induced weight loss additive? Am J Cardiol 1997; 79(6): 763-7. https://doi.org/10.1016/s0002-9149(96)00864-8
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Smoking is a recognized risk factor for hypertension, as the components of cigarettes induce vasoconstriction and affect the elasticity of the arteries, since the presence of nicotine and carbon monoxide constitutes aggressions to the vascular endothelium, causing an inflammatory response and accelerating the atherosclerosis process⁴⁹49. Silva MAMRT. Efeitos do tabagismo sobre o sistema cardiovascular: hemodinâmica e propriedades elásticas arteriais [tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2005.^,5050. Nunes SOB, Castro MRP, Castro MAS. Tabagismo, comorbidades e danos à saúde. In: Nunes SOB, Castro MRP, editores. Tabagismo: abordagem, prevenção e tratamento. Londrina: Eduel; 2011.^,5151. Mitchel RN. Vasos sanguíneos. In: Kumar V, Abbas AK, Aster JC, editores. Robbins & Cotran Patologia - Bases patológicas das doenças. 9ª ed. Rio de Janeiro: Elsevier; 2013. p. 881-948.. In the municipality of São Paulo, ex-smokers were 20% more likely to report hypertension than individuals who had never smoked. A similar result was found in other studies¹¹11. Pierin AMG, Marroni SN, Taveira LAF, Benseñor IJM. Controle de hipertensão arterial e fatores associados na atenção primária em Unidades Básicas de Saúde localizadas na região Oeste da cidade de São Paulo. Ciên Saúde Colet 2011; 16(Supl. 1): 1389-400. http://dx.doi.org/10.1590/S1413-81232011000700074
https://doi.org/http://dx.doi.org/10.159... ^,5252. Green MS, Jucha E, Luz Y. Blood pressure in smokers: epidemiologic findings. Am Heart J 1986; 111(5): 932-40. https://doi.org/10.1016/0002-8703(86)90645-9
https://doi.org/https://doi.org/10.1016/... . One possible explanation for this is that quitting can trigger withdrawal symptoms, such as increased appetite with consequent weight gain¹¹11. Pierin AMG, Marroni SN, Taveira LAF, Benseñor IJM. Controle de hipertensão arterial e fatores associados na atenção primária em Unidades Básicas de Saúde localizadas na região Oeste da cidade de São Paulo. Ciên Saúde Colet 2011; 16(Supl. 1): 1389-400. http://dx.doi.org/10.1590/S1413-81232011000700074
https://doi.org/http://dx.doi.org/10.159... ^,5353. Balbani APS, Montovani JC. Método para abandono de tabagismo e tratamento da dependência da nicotina. Rev Bras Otorrinolaringol 2005; 71(6): 820-7. http://dx.doi.org/10.1590/S0034-72992005000600021
https://doi.org/http://dx.doi.org/10.159... ^,5454. Krukowski RA, Bursac Z, Little MA, Klesges RC. The relationship between body mass index and post-cessation weight gain in the year after quitting smoking; a cross-sectional study. PloS One 2016; 11(3): 1-12.. In addition, it is from the age of 45 that people usually seek treatment to stop smoking, that is, after a long period of exposure to tobacco, which is when the first chronic effects of the substances begin to appear⁵⁵55. Castro MRP, Matsuo T, Nunes SOB. Características clínicas e qualidade de vida de fumantes em um centro de referência de abordagem e tratamento do tabagismo. J Bras Pneumol 2010; 36(1): 67-74. http://dx.doi.org/10.1590/S1806-37132010000100012
https://doi.org/http://dx.doi.org/10.159... . In any case, it is worth mentioning that, because of the study design, individuals could have stopped smoking after the diagnosis of hypertension, since smoking cessation is highly recommended as soon as possible, regardless of the time of use, depending on the harm caused by smoking and its possible complications⁵⁶56. Gao K, Shi X, Wang W. The life-course impact of smoking on hypertension, myocardial infartion and respiratory diseases. Sci Rep 2017; 7(1): 4330. https://doi.org/10.1038/s41598-017-04552-5
https://doi.org/https://doi.org/10.1038/... .

A possible limitation of this study is related to the fact that all information is self-reported, including the diagnosis of hypertension. This information helps to identify people who received the diagnosis, but does not identify individuals who are unaware of such a condition. However, self-reported hypertension has been used in population-based surveys and has proved to be a safe tool in the absence of blood pressure measurement⁵⁷57. Lima-Costa MF, Peixoto SV, Firmo JOA. Validade da hipertensão arterial autoreferida e seus determinantes (Projeto Bambuí). Rev Saúde Pública 2004; 38(5): 637-42. http://dx.doi.org/10.1590/S0034-89102004000500004
https://doi.org/http://dx.doi.org/10.159... ^,5858. Selem SSAC, Castro MA, César CLG, Marchioni DML, Fisberg RM. Validade da hipertensão autorreferida associa-se inversamente com escolaridade em brasileiros. Arq Bras Cardiol 2013; 100(1): 52-9. http://dx.doi.org/10.1590/S0066-782X2012005000119
https://doi.org/http://dx.doi.org/10.159... ^,5959. Chrestani MAP, Santos IS, Matijasevich AM. Hipertensão arterial sistêmica autorreferida: validação diagnóstica em estudo de base populacional. Cad Saúde Pública 2009; 25(11): 2395-406. http://dx.doi.org/10.1590/S0102-311X2009001100010
https://doi.org/http://dx.doi.org/10.159... . In addition, it is important to consider that, due to the cross-sectional design of the study, exposure and effect are measured at the same time, which does not allow the establishment of causal relationships⁶⁰60. Bastos JLD, Duquia RP. Um dos delineamentos mais empregados em epidemiologia: estudo transversal. Scientia Medica 2007; 17(4): 229-32..

CONCLUSION

The prevalence of hypertension increased significantly between 2003 and 2015 in the city of São Paulo, and the factors positively associated were: being female, age (60 years or more), marital status (married, separated, widowed), having a religion, education (intermediate education, primary education, no education), nutritional status (underweight, overweight, obesity) and smoking (ex-smokers).

The periodic repetition of this type of survey helps to provide important data to monitor and follow up on the behavior of diseases, as well as to identify their associated factors, highlighting the need to reassess ongoing actions and strategies and to intensify those that contribute to prevention and control, mitigating the damage to individuals as well as reducing public spending.

ACKNOWLEDGEMENTS

I would like to sincerely thank Professor Moisés Goldbaum, Professor Chester Luiz Galvão Cesar, Professor Maria Regina Alves Cardoso and Doctor Kátia Cristina Bassichetto for the teachings, support and understanding; and the School of Medicine and School of Public Health at USP for the welcome. I am grateful to the coordinators and interviewers of the research, who have always endeavored to do quality work. I would also like to thank the interviewees who were willing to collaborate with the research. I am grateful to the Coordination for the Improvement of Higher Education Personnel (Capes) for funding this study.

References

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