Epidemiology and Control of Hypertension and Diabetes in Costa Rica

Abstract

Costa Rica is one of the countries that make up Central America, neighboring Nicaragua and Panama. Costa Rica shares with its neighbors the social and economic problems characteristic of developing countries; however, one difference is that Costa Rica can derive a great part of its budget and expense to health and education, as it had abolished the army in 1948. It is for this reason that Costa Rica shares diseases characteristic of their region like the Dengue, yet at the same time have a true explosion in the fields of hypertension (HTA), diabetes (DM), and cardiovascular disease.

The health system of Costa Rica has nearly universal coverage, reaching 98% of the population with primary and secondary diverse levels of attention that give appropriate and satisfactory treatment to all hypertensive and diabetic patients.

The HTA and the DM are true public health problems; however, before 2004, there weren't appropriate data on their prevalence and management. Small studies showed an increase in the prevalence of HTA from 9 to 24%, though no data on the prevalence of DM were available. In 2004, the Multinational Survey of Diabetes and Hypertension and Other Factors of Risk carried out in San José, Costa Rica, determined a prevalence of HTA of 25% and of DM of 8%. Likewise, the methodology of the survey allowed an evaluation of the quality of the attention of the HTA (Tracer of Arterial Hypertension) and, consequently, appropriate control of hypertensive patients in Costa Rica; through it, it was determined that greater effort was required for earlier detection and resource optimization to better handle hypertensive and diabetic patients and thus reduce cardiovascular morbidity-mortality and chronic renal disease.

Keywords:

• Costa Rica
• hypertension
• diabetes
• prevalence
• cardiovascular
• risk
• control

Costa Rica is one of the smallest countries in Latin America with a surface of 51,100 square kilometers and a population of 4,255,000. By gender, the distribution is 50.8% men and 49.2% women. Adults older than 15 constitute the 70% of the population. The index of human development of Costa Rica is 0.834, based on longevity, education, and purchasing power, and occupies 45^th place in the world scale, making it one of the best from Latin America. The infantile mortality is 9.24 (per 1000 live births), and the life expectancy is 80.65 years for women and 76.24 years for men.[1] Costa Rica has more economic and social development than most other countries in the region, and it is recognized that their health system is one of the best in Latin America.

This economic and social profile, as well as the solidity of their health system and their population's longevity, makes Costa Rica's health problems very peculiar for the area: they are similar to those of more developed countries, where the main causes of mortality are cardiovascular disease and cancer. This panorama has forced Costa Rica to develop epidemic studies in the field of cardiovascular disease and evaluate the quality of the country's attention and health system.

HEALTH SYSTEM OF COSTA RICA

Costa Rica invests 6% of its gross internal product in health, an approximate total of $1.14 trillion American dollars.[2]

The public health system of Costa Rica has almost universal coverage, reaching 98% of the population, and it consists of a primary level of 893 Basic Teams for the integral attention, one for 4,000 people. These units comprise a general practitioner, a nurse, and a technician in health. The secondary level is made up of 178 clinics and 20 regional hospitals, and the tertiary level constitutes nine national hospitals.[3] The patients have free access to the system as well as complete rights to the treatment, and the handling of hypertension and diabetes is carried out in sequential form in the three levels according to complexity and complications.

CARDIOVASCULAR DISEASE IN COSTA RICA

Cardiovascular disease has represented the primary cause of mortality in Costa Rica since 1970. In men and women, 48% of cardiovascular deaths are due to the coronary heart disease; however, cerebrovascular disease has shown a decline of 29% in the last 30 years due to a better attention of people with HTA for the services of health.[4]

Hypertension represents the second most common cause of attention in the external consultation of the Costa Rican Public Health Services. In 2003, this problem generated more than 500,000 consultations and is the main reason of external consultation in 45-year-old and older women (28%) and men (25%).[5] In Costa Rica, two previous studies of the prevalence of HTA were identified in small communities. One was in the canton of Desamparados, an urban area south of the capital in 1989; hypertensive people were categorized as having a diastolic blood pressure >90 mmHg or those that took anti-hypertensive treatment. Prevalence in 15-year-olds was found to be 15.3%.[6] A rural study in 1988 measured a 20–65-year-old population's representative sample; hypertensive people were those with a diastolic pressure > 95 mmHg or those that took treatment, and prevalence was determined to be 14%.[7] In 1989, in a sample of 934 children and adolescents of 6–16 years in an urban area reported a prevalence of HTA of 5.1% according to the 95^th percentile, fitting for age and gender.[8]

MULTINATIONAL SURVEY ON DIABETES AND HYPERTENSION

The general objective of this study was to determine the prevalence of diabetes mellitus, hypertension, and other cardiovascular risk factors such as dislipidemia, obesity, sedentary lifestyle, feeding, and the consumption of alcohol and tobacco, in the mature population of the metropolitan area of San José.[9] Regarding the population and design, the survey was carried out in 2,400 people aged 20 years or older, with multistage sampling stratified by age groups. The field work occurred from September to December of 2004, and information was collection via home visits carried out by three specialized teams.

Diabetes was defined as glycemia in fasting adults of 125 mg/dL or greater and posprandial of 200 mg/dL. The diabetes prevalence was of 8% (diabetes prevalence) and 17.8% (abnormal glycemia prevalence), with fasting abnormal glycemia defined as between 100–125.9 mg/dL or postprandial among 130–199 mg/dL (see Figure 1). One interesting fact is that 24% of the patient's diabetics had no awareness of their disease.

Figure 1 Diabetes: fast glycemia 126 mg/dL and PTG>200mg/dL. Abnormal glycemia: fast glycemia 100–125.9 mg/dL(fast) and PTG 140–199.9 mg/dL.

The prevalence of hypertension in the general population was 25.2% and of pre-hypertension was 25.4%. It was defined as a systolic blood pressure >140 mm/Hg and diastolic blood pressure >90 mm/Hg; a systolic blood pressure between 120–139 mm/Hg and a diastolic blood pressure between 80–89 mm/Hg defined pre-hypertension. A very interesting fact was the prevalence of 61% after 65 years (see Figure 2).

Figure 2 Pre-hypertension: systolic 120–139 mmHg, diastolic 80–89 mmHg. Hypertension: systolic > 140 mmHg, diastolic > 90 mmHg.

CONTROL OF HYPERTENSION

In 2005, the results became available of a study to evaluate the control of the HTA in Costa Rica.[10] This study was carried out in the whole country among 2007 patients (64% women and 36% men) between September and December 2004. A total of 2007 clinical files were generated, and interviews were carried out with each patient. Study cases were managed at different levels of attention and were handled by family doctors, internists, and two nephrologists. Some of the more important results showed that 54% of the patients took two or more anti-hypertensive drugs, and 46% took one anti-hypertensive drug. The control of HTA was defined as treatment blood pressure values less than 140/90 mmHg; only 44% of the men and 48% of the women reached this goal (see Figure 3). For the diabetics and hypertensive patients, the achievement of the treatment blood pressure arterial values less than 130/80 mmHg were obtained only in 20% of the men and 24% of the women.

Figure 3 Percentage of hypertensive patients that reach the principal goal of the treatment (<140/90 mmHg), according to sex. Costa Rica 2004.

COMMENT

Hypertension as well as diabetes are very important public health problems and the main cardiovascular risk factors in Costa Rica. Studies of the prevalence of HTA and DM carried out in the 1990s did not establish a defined prevalence of these two entities; however, based on evidence of a more recent reviews, the prevalence of HTA was 25.4% and of DM was 8%. Such a prevalence is near values from United States, Canada, and Latin America, but far from European values.[11]

According to the literature it is considered that a third of the world population's is hypertensive and Costa Rica is about the stocking of these values.

The prevalence of HTA remained relatively stable in the last decade in economically developed countries but had increased in the developing countries; in Costa Rica, the prevalence rose from 15% to 25%, near the estimated world prevalence of HTA of about 30%.[12]

On the other hand, although the levels of knowledge, treatment, and control in HTA vary among the different countries, the values observed in Costa Rica with an average of 46% suggested insufficient and inadequate handling and control of our hypertensive patients. This weakness must be improved upon.

Given the importance of cardiovascular disease on the causes of death in Costa Rica, the recent information and surveys reinforce the significance of HTA and DM. They force future political and health efforts to focus on the field of primary prevention to reduce the prevalence of HTA and DM. It is necessary to implement programs that modify and intervene in the population's lifestyle in such aspects as weight loss, sodium reduction, moderation in the consumption of alcohol, physical activity increase, and changes in dietary habits. Future studies will also investigate the presence in these patients of renal disease risk factors, such as microalbuminuria.

The handling of these medical problems implies the combined and coordinated participation of patients, physicians, government and private health institutions, and the pharmaceutical industry.

ACKNOWLEDGMENTS

The author is grateful to Dr. Jaime Tortos, a member of the Cardiology Service, San Juan de Dios Hospital, San Jose, Costa Rica, for providing important data.