Skip to main content
NCBI home page
BMC Cardiovascular Disorders logoLink to BMC Cardiovascular Disorders
. 2025 Aug 2;25:571. doi: 10.1186/s12872-025-05027-6

Revisiting hypertension prevalence and risk factors: prevalence of hypertension and risk of diabetes in China

Qiuting Jia 1, Yanbing Pan 1, Yan Zhang 1, Haiyu Zhang 1, Yanzi Zhang 1, Yongle Wang 1, Yihui Kong 1,✉
PMCID: PMC12317466  PMID: 40753427

Abstract

Background

Hypertension is a common and serious public health issue, with elevated blood pressure significantly increasing the risk of cardiovascular disease and diabetes. In adults, blood pressure values of 130–139 mm Hg/80–89 mm Hg are associated with an increasing relative risk of cardiovascular complications and mortality. According to the American College of Cardiology (ACC) / American Heart Association (AHA) criteria for the diagnosis of hypertension, this study aimed to describe the prevalence and risk factors for stage 1 (systolic blood pressure 130–139 mm Hg or diastolic blood pressure 80–89 mm Hg) and stage 2 (systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg) hypertension. Second, to evaluate the effect of different hypertension grades on the incidence of diabetes.

Methods

Data were obtained from the DATADRYAD database. This study included 32,625 adults from 32 regions in 11 cities in China, enrolled between 2010 and 2016, who were free of diabetes at baseline. Logistic regression was used to assess the risk factors for different grades of hypertension. Cox proportional hazard regression analysis was performed to explore the relationship between stage 1 and stage 2 of hypertension and diabetes. All data were analyzed using the SAS 9.4 software and R software (version 4.2.2).

Results

The study showed that the prevalence of stage 1 and stage 2 hypertension was higher, and the prevalence of stage 1 was higher than stage 2 hypertension. Sex, age, body mass index (BMI), fasting plasma glucose, triglycerides, and alanine aminotransferase (ALT) were the risk factors for stage 1 hypertension, and sex, age, BMI, cholesterol, triglycerides, ALT, and alcohol drinking were risk factors for stage 2 hypertension. In addition, our study demonstrated a significant interaction between age and sex, BMI and sex on the risk of hypertension, respectively. Furthermore, the higher the blood pressure, the higher the risk of developing diabetes.

Conclusions

These findings highlight the importance of paying attention not only to individuals with stage 2 hypertension but also to those with stage 1 hypertension, given the elevated risk of diabetes associated with both.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-025-05027-6.

Keywords: Hypertension, Diabetes, Risk factors, Prevalence

Introduction

Hypertension is not only a risk factor for cardiovascular disease and cerebrovascular disease but also a global public health problem [1]. The American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines have lowered the diagnostic criteria for hypertension to a systolic blood pressure (SBP) ≥ 130 mm Hg or a diastolic blood pressure (DBP) ≥ 80 mm Hg [2]. Hypertension patients are classified according to their blood pressure levels into stage 1 (SBP 130–139 mm Hg or DBP 80–89 mm Hg) and stage 2 (SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg) [2]. With increasingly rapid economic development, urbanization of China, and fast-paced lifestyles, the prevalence of hypertension among young and middle-aged people has been increasing dramatically. National survey data show that 23.2% (244.5 million) of Chinese adults aged 18 and older had an SBP of 130–139 mm Hg and/or a DBP of 80–89 mm Hg, most commonly seen in adults aged 18 to 54 years [3]. Several studies have demonstrated that hypertension is significantly associated with diabetes, cardiovascular events, and cerebrovascular disease [4–7]. However, the awareness rate, treatment rate, and control rate of hypertension patients is still at a lower level [3].

Currently, most studies have focused on the prevalence of blood pressure values of 130–139 mm Hg/80–89 mm and blood pressure values of ≥ 140 mm Hg/≥ 90 mm Hg and their associated risk factors, analyzing factors such as gender, age, low income, smoking, alcohol consumption, body mass index (BMI) and region (urban, rural) [8, 9]. However, few studies have investigated the prevalence of stage 1 hypertension (as defined by the ACC/AHA hypertension guidelines). There are opportunities to prevent the progression of hypertension and reduce cardiovascular disease morbidity and mortality through healthy lifestyles and antihypertensive medication [10–12]. A meta-analysis of people aged 18 and older with no history of cardiovascular disease and SBP 130–139 mm Hg found that lowering SBP by 5 mm Hg reduced the risk of cardiovascular disease by about 10% [13]. Qi Y, Han X et al. showed that 65% of people with SBP 130–139 mm Hg and/or DBP 80–89 mm Hg progressed to BP ≥ 140/90 mm Hg over 15 years [14]. According to the latest international guidelines for pharmacologic antihypertensive treatment, 22.7% (39 million) of adults ≥ 35 years old with SBP 130–139 mmHg and/or DBP 80–89 mmHg need antihypertensive drug therapy in China [15]. Therefore, we urgently need to pay attention to the prevalence of stage 1 hypertension and related risk factors and take early measures to prevent the development of hypertension. In addition, hypertension is also closely associated with the development of diabetes, and patients with a history of hypertension are at a significantly increased risk of developing type 2 diabetes [16]. Advanced stages of diabetes are often associated with multiple complications, which can result in serious physical harm and a diminished quality of life. Patients with hypertension combined with type 2 diabetes have a significantly increased risk of cardiovascular events in comparison with those with hypertension or type 2 diabetes alone [17, 18]. However, the relationship between stage 1 hypertension and diabetes has received little attention.

This study aimed to determine the prevalence of stage 1 and stage 2 hypertension based on the ACC/AHA diagnostic and classification criteria, including overall prevalence as well as subgroup prevalence defined by age, BMI, and sex. In addition, we analyzed the potential risk factors for hypertension among adults from 32 regions across 11 cities in China, and further investigated the association between different grades of hypertension and both the incidence and risk of developing diabetes. This study aimed to provide scientific evidence to support the prevention, management, and improved prognosis of hypertension.

Methods

Data source

The data used in this study were obtained from the public database “DATADRYAD” (10.5061/dryad.ft8750v), with the original dataset provided by Chen et al., which is freely available for download and use [19]. The original study, a retrospective cohort study using data from the Health Screening Program, was approved by the Rich Healthcare Group Review Board, which waived the requirement for informed consent. In compliance with national legislation and institutional regulations, written informed permission to participate was not required for the current study. The original data collected medical records of 211,833 adults without diabetes in 32 regions of 11 Chinese cities (Shanghai, Beijing, Nanjing, Suzhou, Shenzhen, Changzhou, Chengdu, Guangzhou, Hefei, Wuhan, and Nantong) between 2010 and 2016. All participants underwent at least two health examinations between 2010 and 2016. At each visit to the health examination center, participants were required to complete a comprehensive questionnaire to assess their demographic characteristics, lifestyle, medical history, and family history of chronic diseases. Biochemical parameters were determined in blood samples obtained after at least ten hours of fasting, including fasting plasma glucose (FPG), aspartate aminotransferase (AST), cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), blood urea nitrogen (BUN), alanine aminotransferase (ALT), low-density lipoprotein cholesterol (LDL-C), and serum creatinine (Scr). Height, weight, and blood pressure were measured by professional staff. BMI was calculated from weight in kilograms divided by height in meters squared (BMI = weight/height2). The BMI classification was as follows: underweight BMI < 18.5 kg/m2, normal weight BMI 18.5 to < 24.0 kg/m2, overweight BMI 24.0 to < 28.0 kg/m2, and obese BMI ≥ 28.0 kg/m2 [20]. All data were collected under standardized procedures.

Study population

Our exposure factors of interest were age, sex, BMI, FPG, HDL-C, LDL-C, TC, TG, ALT, Scr, smoking status, alcohol drinking status, and family history of diabetes. Therefore, the following group participants with the incomplete records had been excluded: (1) 24 participants had no record of blood pressure; (2) 4854 participants had no record of TC; (3) 34 participants had no record of TG; (4) 89,673 participants had no record of HDL-C; (5) 192 participants had no record of LDL-C; (6) 410 participants had no record of ALT; (7) 1257 participants had no record of Scr; and (8) 82,764 participants had no record of smoking status. Ultimately, the total of 32,625 participants entered the final analysis, including 27,000 normotensive participants, 4251 stage 1 hypertensive participants, and 1374 stage 2 hypertensive participants (Fig. 1). Supplementary Table 1 presents the baseline characteristics of the included and excluded participants.

Fig. 1.

Fig. 1

Open in a new tab

The flowchart of study. Abbreviations: HDL-C high-density lipoprotein cholesterol, LDL-C low-density lipoprotein cholesterol, ALT alanine aminotransferase, Scr serum creatinine

Definitions and measurements

Blood pressure was measured according to the standard protocol recommended by the American Heart Association [21]. In a quiet environment, after participants rested for 3–5 min, medical workers measured office blood pressure using standard mercury sphygmomanometers and recorded them. Participants were advised to avoid alcohol, smoking, exercise, tea and coffee for at least 30 min prior to the blood pressure measurements. Blood pressure was measured three times with a standard mercury sphygmomanometer and the average of the three blood pressures was recorded with least 30 s between the measurements. According to the ACC/AHA hypertension guidelines, hypertension was defined as an SBP ≥ 130 mm Hg or a DBP ≥ 80 mm Hg, and normotension was defined as SBP < 130 mm Hg and DBP < 80 mm Hg [2]. Stage 1 hypertension was defined as an SBP 130–139 mm Hg or a DBP 80–89 mm Hg, and stage 2 as ≥ 140 mm Hg or ≥ 90 mm Hg [2]. After 10 h of fasting, venous blood samples were collected and immediately sent to the laboratory for determination of fasting glucose on an automated analyzer (Beckman 5800) using the glucose oxidase method. The diagnostic criteria for diabetes were fasting plasma glucose ≥ 7.00 mmol/L and/or self-reported diabetes during follow-up. Participants were reviewed at the time of diagnosis of diabetes or at the time of last visit, whichever came first. All methods were performed in accordance with the relevant guidelines and regulations.

Statistical analyses

According to the central limit theorem, when the sample size is sufficiently large, the distribution of the sample mean approximates normality. Continuous data were expressed as mean ± standard deviation (SD), and categorical variables were expressed as frequencies and percentages. One-way ANOVA was used to compare quantitative variables between the groups, and the chi-square test or Fisher’s exact test was performed for categorical variables. The Bonferroni correction test was used for multiple comparisons. Univariate and multivariable logistic regressions were used to analyze the significant risk factors for stage 1 and stage 2 hypertension. In the multivariable logistic regression analysis, all candidate variables were simultaneously included in the model to evaluate their independent associations with hypertension. The results of the analysis were presented by the odds ratio (OR) with corresponding 95% confidence interval (CI). The interaction between risk factors for hypertension was assessed by interaction analysis. Kaplan-Meier curves were used to analyze the incidence of new-onset diabetes during follow-up in individuals with different blood pressure grades. In addition, Cox hazard regression analysis was constructed to calculate the hazard ratio (HR) for the development of diabetes in different blood pressure grades. A two-sided test with p < 0.05 was considered as statistically significant difference, and SAS 9.4 software and R software (version 4.2.2) were used for statistical analysis.

Results

Prevalence of stage 1 and stage 2 hypertension

Baseline characteristics of participants stratified by blood pressure grade are shown in Table 1. A total of 32,625 participants, aged 20–93 years, finally participated in the statistical analysis, including 21,210 males (65.01%) and 11,415 females (34.99%). Based on baseline blood pressure levels, participants were divided into three groups. 27,000 individuals had normal blood pressure, 4251 had stage 1 hypertension, and 1374 had stage 2 hypertension. The prevalence of stage 1 hypertension was 13.03% (15.24% in males and 8.93% in females, respectively), and stage 2 hypertension was 4.21% (4.96% in males and 2.82% in females, respectively) in all participants. The prevalence of stage 1 hypertension was significantly higher than stage 2 hypertension. The prevalence of both stage 1 and stage 2 hypertension was higher in males than in females. Participants with different blood pressure grades had significant differences in age, BMI, TC, TG, HDL-C, and ALT (p < 0.05). Compared with normotension, the other two groups of hypertensive patients had significantly increased in age, BMI, TC, TG, ALT, FPG, LDL-C, and Scr, and significantly decreased in HDL-C. In addition, current smoking and current drinking rates were higher among patients with stage 1 and stage 2 hypertension compared to those with normotension.

Table 1.

Characteristics of participants categorized by blood pressure levels

Characteristics NMT (n = 27000) Stage 1 (n = 4251) Stage 2 (n = 1374) p value p* value p& value pΔ value
Gender,% < 0.001 < 0.001 < 0.001 1.000
 Female 10,074 (37.31) 1019 (23.97) 322 (23.44)
 Male 16,926 (62.69) 3232 (76.03) 1052 (76.56)
Age, years 41.77 ± 11.88 48.90 ± 14.00 52.94 ± 12.88 < 0.001 < 0.001 < 0.001 < 0.001
BMI, kg/m2 23.20 ± 3.19 25.03 ± 3.27 25.99 ± 3.29 < 0.001 < 0.001 < 0.001 < 0.001
FPG, mmol/L 4.94 ± 0.60 5.12 ± 0.64 5.17 ± 0.67 < 0.001 < 0.001 < 0.001 0.127
Cholesterol, mmol/L 4.72 ± 0.88 5.02 ± 0.91 5.09 ± 0.89 < 0.001 < 0.001 < 0.001 0.030
Triglycerides, mmol/L 1.37 ± 1.04 1.76 ± 1.15 2.00 ± 1.51 < 0.001 < 0.001 < 0.001 < 0.001
HDL-C, mmol/L 1.34 ± 0.31 1.31 ± 0.30 1.29 ± 0.30 < 0.001 < 0.001 < 0.001 0.231
LDL-C, mmol/L 2.71 ± 0.68 2.90 ± 0.71 2.90 ± 0.70 < 0.001 < 0.001 < 0.001 1.000
ALT, U/L 24.45 ± 20.84 29.58 ± 22.28 31.56 ± 22.90 < 0.001 < 0.001 < 0.001 0.008
Scr, µmol/L 71.73 ± 15.25 74.48 ± 14.50 75.56 ± 15.99 < 0.001 < 0.001 < 0.001 0.406
Smoking status,% < 0.001 < 0.001 < 0.001 0.035
 Current smoker 5238 (19.40) 1024 (24.09) 386 (28.09)
 Ever smoker 1071 (3.97) 195 (4.59) 58 (4.22)
 Non-smoker 20,691 (76.63) 3032 (71.32) 930 (67.69)
Drinking status,% < 0.001 < 0.001 < 0.001 0.002
 Current drinker 614 (2.27) 170 (4.00) 87 (6.33)
 Ever drinker 4503 (16.68) 785 (18.47) 225 (16.38)
 Never drinker 21,883 (81.05) 3296 (77.53) 1062 (77.29)
Family history of diabetes, % 0.008 0.248 0.023 0.345
Yes 1564 (5.79) 218 (5.13) 56 (4.08)
 No 25,436 (94.21) 4033 (94.87) 1318 (95.92)
Open in a new tab

Abbreviations: ALT alanine aminotransferase, BMI body mass index, FPG fasting plasma glucose, HDL-C high-density lipoprotein cholesterol, LDL-C low-density lipoprotein cholesterol, NMT normotension, Scr serum creatinine

Data are presented as mean (SD), or number (%)

p < 0.05 was considered statistically significant

*Comparison between Stage 1 hypertension and normotension;

&Comparison between Stage 2 hypertension and normotension;

ΔComparison between Stage 1 hypertension and Stage 2 hypertension

Prevalence of stage 1 and stage 2 of hypertension stratified by sex and age

Interaction analysis revealed a significant interaction between sex and age on the risk of stage 1 and stage 2 hypertension (pinteraction < 0.001). Therefore, the prevalence of stage 1 and stage 2 hypertension was calculated in subgroups stratified by age and sex, as shown in Table 2. The prevalence of stage 1 hypertension was 15.24% in males and 8.93% in females. The prevalence of stage 2 hypertension was 4.96% in males and 2.82% in females. The prevalence of stage 1 hypertension and stage 2 hypertension was significantly higher in males than in females. The prevalence of hypertension showed a gradual upward trend with increasing age in the overall population, as well as in both male and female groups (p for trend < 0.001). Subgroup analysis showed that the prevalence of stage 1 hypertension was higher than stage 2 hypertension in both males and females in the same age group, but only the 45–54 age group was statistically significant (p = 0.017). In addition, in the 55–93 age group, no difference was observed in the prevalence of different blood pressure grades in different gender subgroups (p > 0.05).

Table 2.

Prevalence of stage 1 and stage 2 of hypertension stratified by sex and age

Age (year) Total (32625) Female (11415) Male (21210) p value pa value pb value pc value
N NMT Stage 1 Stage 2 N NMT Stage 1 Stage 2 N NMT Stage 1 Stage 2
Overall 32,625 82.76 13.03 4.21 11,415 88.25 8.93 2.82 21,210 79.80 15.24 4.96 < 0.001 < 0.001 < 0.001 0.686
20 ~ 34 8278 90.78 8.05 1.17 3006 96.81 2.73 0.47 5272 87.35 11.08 1.57 < 0.001 < 0.001 < 0.001 0.557
35 ~ 44 11,063 88.16 9.55 2.30 3876 95.20 4.00 0.80 7187 84.36 12.54 3.10 < 0.001 < 0.001 < 0.001 0.311
45 ~ 54 6461 80.54 14.01 5.45 2314 85.52 11.15 3.33 4147 77.77 15.60 6.63 < 0.001 < 0.001 < 0.001 0.017
55 ~ 64 4113 69.75 21.27 8.97 1332 70.65 21.92 7.43 2781 69.33 20.96 9.71 0.055 0.752 0.021 0.023
65 ~ 93 2710 61.22 27.64 11.14 887 62.46 26.16 11.39 1823 60.61 28.36 11.03 0.484 0.241 0.987 0.436
p for trend < 0.001 < 0.001 < 0.001
Open in a new tab

Abbreviations: NMT normotension

Values are percentages

p < 0.05 was considered statistically significant

aComparison between Stage 1 hypertension and normotension in different genders

bComparison between Stage 2 hypertension and normotension in different genders

cComparison between Stage 1 hypertension and Stage 2 hypertension in different genders

Prevalence of stage 1 and stage 2 of hypertension stratified by sex and BMI

The analysis revealed that the interaction between BMI and sex also had a significant effect on stage 1 and stage 2 risk of hypertension (pinteraction < 0.001). Therefore, the prevalence of different blood pressure grades was calculated by stratified BMI and sex, as presented in Table 3. There was a linear trend in the prevalence of stage 1 and stage 2 hypertension with BMI in the total population and different gender groups, with the prevalence of both stage 1 and stage 2 hypertension increasing as BMI levels increased (p for trend < 0.001). Even those with a low BMI were at risk for hypertension (BMI < 18.5 kg/m2, 4.57% in Stage 1 and 0.81% in Stage 2, respectively). Subgroup analysis revealed that the prevalence of stage 1 hypertension was higher than stage 2 hypertension in both males and females under different BMI strata, but with no statistical difference (p > 0.05). In addition, no difference was observed in the prevalence of different blood pressure grades in the different gender subgroups for obese and overweight individuals (p > 0.05).

Table 3.

Prevalence of stage 1 and stage 2 of hypertension stratified by sex and BMI

BMI (kg/m2) Total (32625) Female (11415) Male (21210) p value pa value pb value pc value
N NMT Stage 1 Stage 2 N NMT Stage 1 Stage 2 N NMT Stage 1 Stage 2
overall 32,625 82.76 13.03 4.21 11,415 88.25 8.93 2.82 21,210 79.80 15.24 4.96 < 0.001 < 0.001 < 0.001 0.686
Underweight 1489 94.63 4.57 0.81 931 95.92 3.54 0.54 558 92.47 6.27 1.25 0.015 0.013 0.139 0.661
Normal 17,003 88.75 9.18 2.07 7697 91.87 6.63 1.51 9306 86.17 11.29 2.54 < 0.001 < 0.001 < 0.001 0.919
Overweight 11,045 76.99 17.17 5.84 2257 78.29 15.99 5.72 8788 76.66 17.47 5.87 0.228 0.090 0.638 0.594
Obesity 3088 64.67 23.51 11.82 530 64.72 21.70 13.58 2558 64.66 23.89 11.45 0.275 0.410 0.239 0.108
p for trend < 0.0001 < 0.0001 < 0.0001
Open in a new tab

Abbreviations: BMI body mass index, NMT normotension

Values are percentages

p < 0.05 was considered statistically significant

aComparison between Stage 1 hypertension and normotension in different genders

bComparison between Stage 2 hypertension and normotension in different genders

cComparison between Stage 1 hypertension and Stage 2 hypertension in different genders

Associations of blood pressure levels with new-onset diabetes

Analysis using Kaplan-Meier curves revealed that the incidence of new-onset diabetes gradually increased over the follow-up period for individuals with higher blood pressure grades (Fig. 2). During a median of 3.0-year follow-up, 693 of the 32,625 participants developed diabetes. The prevalence of diabetes was 1.73%, 3.48%, and 5.75% for normotension, stage 1 hypertension, and stage 2 hypertension, respectively, and the prevalence of diabetes was positively correlated with blood pressure grade (p for trend < 0.001). When analyzed using the Cox proportional hazards model, blood pressure levels were significantly associated with the risk of developing diabetes in both the crude model and the model adjusted for age and sex, with higher hypertension grades associated with an increased risk of diabetes (p for trend < 0.001). However, after multivariable adjustment, this trend association between hypertension and diabetes was no longer statistically significant (p for trend = 0.219). The results are presented in Table 4.

Fig. 2.

Fig. 2

Open in a new tab

Elevated Blood Pressure Grades and Risk of New-Onset Diabetes.Abbreviations: NMT normotension

Table 4.

Risk of incident diabetes according to blood pressure levels

N = 32,625 Blood pressure grades
NMT Stage 1 Stage 2 p for trend p value
Absolute risk of developing diabetes
Number of events (%) 466 (1.73) 148 (3.48) 79 (5.75) < 0.001 < 0.001
Hazard ratio (95% confidence interval)
Crude Ref. 2.065 (1.717–2.485) 3.335 (2.627–4.234) < 0.001
Age and sex-adjusted Ref. 1.203 (0.995–1.455) 1.624 (1.272–2.073) < 0.001
Multivariable-adjusteda Ref. 1.004 (0.829–1.215) 1.209 (0.945–1.548) 0.219
Open in a new tab

Abbreviations: NMT normotension

aAdjusted for age, sex, body mass index, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, cholesterol, triglycerides, alanine aminotransferase, serum creatinine, smoking status, drinking status, and family history of diabetes

Risk factors associated with stage 1 and stage 2 of hypertension

A univariate logistic regression analysis was used to assess the significant determinants of stage 1 hypertension (vs. normotension), stage 2 hypertension (vs. normotension), and stage 2 hypertension (vs. stage 1 hypertension). The results are presented in Table 5. Males, elder age, BMI, FPG, TC, TG, HDL-C, LDL-C, ALT, and Scr were significantly associated with stage 1 and stage 2 hypertension (p < 0.001). Among the above factors, HDL-C was a protective factor (OR = 0.674 and 0.556, respectively) and the other factors were risk factors. In addition, the risk of stage 1 and stage 2 hypertension increased with increasing age and BMI grade. The prevalence of stage 2 hypertension was significantly increased in those who were overweight or obese (24 ≤ BMI < 28, OR = 3.251; BMI ≥ 28, OR = 7.836). A similar trend was observed for stage 1 hypertension (OR = 2.155 and 3.514, respectively). Otherwise, a BMI < 18.5 seemed to exert a protective effect against stage 1 and stage 2 hypertension (OR = 0.467 and 0.365, respectively). Compared to non-smokers, current smokers had a higher risk of developing stage 1 and stage 2 hypertension (OR = 1.334 and 1.640, respectively), and ever smokers had an increased risk of developing stage 1 hypertension (OR = 1.243), but ever smokers were not significantly associated with stage 2 hypertension (p = 0.180). A similar pattern was observed for drinking status, whereby current drinking was associated with a higher prevalence of stage 1 and stage 2 hypertension compared to the never drinking population (OR = 1.838 and 2.920, respectively). Ever drinking was not significantly associated with stage 2 hypertension compared to the never drinking population (p = 0.698) but was found to be positively associated with stage 1 hypertension. Interestingly, a family history of diabetes was more highly correlated with stage 2 hypertension (p = 0.008), but not significantly correlated with stage 1 hypertension (p = 0.083). Using stage 1 hypertension as a reference, rising age, overweight or obesity, FPG, TC, TG, ALT, and Scr were still significantly associated with stage 2 hypertension. Current smoking and current drinking were risk factors compared with non-smoking and never drinking, and the differences in other risk factors were not statistically significant (all p > 0.05).

Table 5.

Risk factors associated stage 1 and stage 2 of hypertension by univariate logistic regression analysis

Characteristics Stage1/NMT Stage2/NMT Stage2/Stage1
OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value
Gender
 Female Ref. Ref. Ref.
 Male 1.888 (1.752–2.034) < 0.001 1.944 (1.712–2.208) < 0.001 1.030 (0.892–1.189) 0.687
Age group 1.547 (1.508–1.587) < 0.001 1.960 (1.877–2.046) < 0.001 1.253 (1.196–1.314) < 0.001
BMI (kg/m2)
Normal Ref. Ref. Ref.
Underweight 0.467 (0.364–0.598) < 0.001 0.365 (0.205–0.651) < 0.001 0.783 (0.419–1.461) 0.442
Overweight 2.155 (2.005–2.316) < 0.001 3.251(2.848–3.712) < 0.001 1.509 (1.304–1.746) < 0.001
Obesity 3.514 (3.181–3.883) < 0.001 7.836 (6.720–9.137) < 0.001 2.230 (1.879–2.645) < 0.001
FPG (mmol/L) 1.615 (1.532–1.704) < 0.001 1.841 (1.686–2.010) < 0.001 1.126 (1.025–1.237) 0.013
Cholesterol (mmol/L) 1.418 (1.369–1.468) < 0.001 1.512 (1.432–1.598) < 0.001 1.090 (1.020–1.165) 0.011
Triglycerides (mmol/L) 1.312 (1.278–1.347) < 0.001 1.358 (1.313–1.405) < 0.001 1.145 (1.094–1.198) < 0.001
HDL-C (mmol/L) 0.674 (0.605–0.751) < 0.001 0.556 (0.462–0.668) < 0.001 0.825 (0.671–1.014) 0.068
LDL-C (mmol/L) 1.479 (1.414–1.547) < 0.001 1.474 (1.369–1.587) < 0.001 1.000 (0.918–1.090) 0.993
ALT(U/L) 1.009 (1.008–1.010) < 0.001 1.009 (1.008–1.011) < 0.001 1.004 (1.001–1.006) 0.005
Scr(µmol/L) 1.012 (1.010–1.014) < 0.001 1.016 (1.012–1.019) < 0.001 1.005 (1.001–1.009) 0.020
Smoking status
 Non-smoker Ref. Ref. Ref.
 Current smoker 1.334 (1.235–1.441) < 0.001 1.640 (1.451–1.853) < 0.001 1.229 (1.070–1.411) 0.004
 Ever smoker 1.243 (1.062–1.454) 0.007 1.205 (0.918–1.582) 0.180 0.970 (0.717–1.312) 0.842
Drinking status
 Never drinker Ref. Ref. Ref.
 Current drinker 1.838 (1.545–2.187) < 0.001 2.920 (2.313–3.685) < 0.001 1.589 (1.216–2.076) 0.001
 Ever drinker 1.157 (1.064–1.259) 0.001 1.030 (0.889–1.193) 0.698 0.890 (0.755–1.048) 0.161
Family history of diabetes
 No Ref. Ref. Ref.
 Yes 0.879 (0.760–1.017) 0.083 0.691 (0.526–0.907) 0.008 0.786 (0.582–1.061) 0.116
Open in a new tab

Abbreviations: ALT alanine aminotransferase, BMI body mass index, CI Confidence interval, FPG fasting plasma glucose, HDL-C high-density lipoprotein cholesterol, LDL-C low-density lipoprotein cholesterol, NMT normotension, OR Odds ratio, Scr serum creatinine

Age group (20 ~ 34,35 ~ 44,45 ~ 54,55 ~ 64,65 ~ 93)

As presented in Table 6, multivariable logistic regression analysis showed that males had a higher risk of developing stage 1 and stage 2 hypertension than females (OR = 1.754 in stage 1, and 1.292 in stage 2, respectively). With increasing age and BMI grade, individuals were at higher risk of developing stage 1 and stage 2 hypertension. BMI < 18.5 exerted a protective impact on stage 1 hypertension (OR = 0.676) but was not significantly associated with stage 2 hypertension (p = 0.053). FPG, TG, ALT, and Scr were significantly associated with stage 1 hypertension. Elevated TC, TG, and ALT were positively associated with stage 2 hypertension. A striking observation was that current smokers had a significantly lower risk of developing stage 1 hypertension compared to non-smokers (OR = 0.777) but was not significantly associated with stage 2 hypertension (p = 0.166). Current and ever drinkers were not significantly associated with stage 1 hypertension compared to never drinkers (p > 0.05), but current drinkers were found to have a significantly increased risk of stage 2 hypertension (OR = 1.719). In addition, the prevalence of stage 1 and stage 2 hypertension was not associated with the family history of diabetes (p > 0.05). Refer to stage 1 hypertension group, stage 2 hypertension was significantly associated with elder age, overweight or obesity, LDL-C, ALT, and Scr, and current drinkers were more likely to have stage 2 hypertension compared to never drinkers, with no statistically difference in other risk factors (all p > 0.05).

Table 6.

Risk factors associated stage 1 and stage 2 of hypertension by multivariable logistic regression analysis

Characteristics Stage1/NMT Stage2/NMT Stage2/Stage1
OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value
Gender
 Female Ref. Ref. Ref.
 Male 1.754 (1.566–1.964) < 0.001 1.292 (1.071–1.559) 0.008 0.851 (0.691–1.048) 0.130
Age group 1.471 (1.431–1.513) < 0.001 1.862 (1.774–1.953) < 0.001 1.265 (1.201–1.333) < 0.001
BMI (kg/m2)
Normal Ref. Ref. Ref.
Underweight 0.676 (0.525–0.871) 0.002 0.564 (0.315–1.012) 0.053 0.962 (0.510–1.815) 0.905
Overweight 1.552 (1.435–1.679) < 0.001 2.180 (1.891–2.514) < 0.001 1.400 (1.201–1.632) < 0.001
Obesity 2.415 (2.163–2.697) < 0.001 5.028 (4.238–5.964) < 0.001 2.101 (1.745–2.530) < 0.001
FPG (mmol/L) 1.146 (1.084–1.211) < 0.001 1.083 (0.990–1.186) 0.083 0.979 (0.887–1.079) 0.665
Cholesterol (mmol/L) 1.058 (0.964–1.162) 0.233 1.178 (1.019–1.362) 0.027 1.139 (0.961–1.350) 0.133
Triglycerides (mmol/L) 1.088 (1.050–1.128) < 0.001 1.100 (1.045–1.159) < 0.001 1.053 (0.989–1.121) 0.104
HDL-C (mmol/L) 1.066 (0.935–1.215) 0.341 1.042 (0.840–1.292) 0.711 0.989 (0.770–1.271) 0.930
LDL-C (mmol/L) 1.099 (0.985–1.226) 0.092 0.882 (0.743–1.048) 0.155 0.805 (0.659–0.982) 0.033
ALT(U/L) 1.004 (1.002–1.005) < 0.001 1.006 (1.004–1.008) < 0.001 1.003 (1.000-1.006) 0.041
Scr(µmol/L) 0.996 (0.993–0.999) 0.004 1.002 (0.997–1.006) 0.520 1.006 (1.001–1.011) 0.023
Smoking status
 Non-smoker Ref. Ref. Ref.
 Current smoker 0.777 (0.712–0.848) < 0.001 0.906 (0.787–1.042) 0.166 1.114 (0.954-1.300) 0.172
 Ever smoker 0.887 (0.751–1.048) 0.158 0.859 (0.642–1.148) 0.305 0.947 (0.691–1.298) 0.735
Drinking status
 Never drinker Ref. Ref. Ref.
 Current drinker 1.174 (0.977–1.412) 0.087 1.719 (1.335–2.214) < 0.001 1.379 (1.041–1.826) 0.025
 Ever drinker 0.983 (0.898–1.077) 0.715 0.899 (0.767–1.055) 0.193 0.918 (0.770–1.093) 0.335
Family history of diabetes
 No Ref. Ref. Ref.
 Yes 0.961 (0.826–1.117) 0.605 0.758 (0.572–1.006) 0.055 0.824 (0.606–1.120) 0.217
Open in a new tab

Abbreviations: ALT alanine aminotransferase, BMI body mass index, CI Confidence interval, FPG fasting plasma glucose, HDL-C high-density lipoprotein cholesterol, LDL-C low-density lipoprotein cholesterol, NMT normotension, OR Odds ratio, Scr serum creatinine

Age group (20 ~ 34,35 ~ 44,45 ~ 54,55 ~ 64,65 ~ 93)

Discussion

Hypertension is a common cardiovascular risk factor with a significant cardiometabolic risk burden. It could be associated with cardiac and vascular injury and could lead to adverse cardiovascular events. However, there are different criteria in diagnosing hypertension. According to the European Society of Cardiology, hypertension is defined as SBP ≥ 140 mm Hg and/or DBP ≥ 90 mm Hg [22]. In comparison, the ACC/AHA considers SBP ≥ 130 mm Hg or DBP ≥ 80 mm Hg as hypertension [2]. The prevalence of hypertension is different depending on the diagnostic criteria and method of diagnosis, and varies greatly among countries and regions. When hypertension is defined as systolic blood pressure ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg, the global prevalence of hypertension in 2010 is 31% (1.4 billion people) [23]. The hypertension prevalence in the United States is similar to the global prevalence at 31.9% (approximately 72.2 million people) [24], and the prevalence of hypertension among adults in China is 23.2% (244.5 million) [3], slightly lower than the global prevalence of hypertension. The prevalence of hypertension in the United States is expected to increase to 45.6% (approximately 103.3 million) when the diagnostic criterion for hypertension is SBP ≥ 130 mm Hg or DBP ≥ 80 mm Hg [24]. Epidemiologic data indicate that the prevalence of hypertension (SBP ≥ 130 mm Hg or DBP ≥ 80 mm Hg) in China is expected to increase by 23.2%, a higher increase than in the United States [3]. Lowering the diagnostic criteria for hypertension will result in a significant increase in the prevalence of hypertension in China and greatly increase the burden of hypertensive disease and the cost of treatment. Based on the ACC/AHA diagnostic criteria for hypertension, this study found an overall hypertension prevalence of 17.24%, with 13.03% for stage 1 hypertension and 4.21% for stage 2 hypertension. The prevalence of stage 1 hypertension was significantly higher than that of stage 2, but lower than the epidemiological estimates of hypertension prevalence. This may be because the 11 cities are primarily located in more economically developed regions, where residents tend to be better educated, more health-conscious, and more focused on primary prevention and lifestyle interventions for hypertension.

The prevalence of diabetes was 1.73%, 3.48%, and 5.75% for normotension, stage 1 hypertension, and stage 2 hypertension, respectively, and the prevalence of diabetes was positively correlated with blood pressure grades, which were consistent with the results of other studies [16]. When using the Cox proportional hazards model to analyze the risk of developing diabetes among individuals with hypertension, the results showed that higher grades of hypertension were associated with an increased risk of diabetes in both the crude model and the model adjusted only for age and sex (p for trend < 0.001). However, after further adjustment for potential confounders, including BMI, lipid levels, liver function, smoking, and alcohol consumption, this trend association was no longer statistically significant (p for trend = 0.219). These findings suggest that the relationship between hypertension and diabetes may not reflect an independent causal association but may instead be influenced by factors such as obesity, metabolic disturbances, and unhealthy lifestyle behaviors. These factors likely contribute to the development of both hypertension and diabetes through shared pathophysiologic mechanisms (e.g., insulin resistance, dyslipidemia) [25–27], thereby attenuating the independent effect of hypertension on diabetes risk in statistical models. Furthermore, interactions among these confounders may further increase the complexity of disease mechanisms. Future studies should further investigate the interaction mechanisms among these coexisting risk factors to achieve a more comprehensive understanding of the complex relationship between hypertension and diabetes. For a long time, the public and researchers have focused more on the risk of diabetes and health problems among individuals with SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg, while relatively little attention has been given to those with blood pressure in the range of 130–139/80–89 mmHg (stage 1 hypertension). This study found that the prevalence of diabetes among individuals with stage 1 hypertension reached 3.48%, indicating that this population may also be at increased metabolic risk and should receive greater attention. Hypertension combined with diabetes can significantly increase the risk of microvascular complications (such as diabetic nephropathy and retinopathy) and macrovascular events (such as myocardial infarction and stroke), leading to serious health damage and reduced quality of life [28, 29]. Therefore, the prevention and treatment of hypertension should begin as early as possible to delay its progression and prevent complications through lifestyle modifications and pharmacological interventions.

The results of this study showed that the mean (SD) age of normotensive, stage 1 and stage 2 patients were 41.77 (11.88), 48.90 (14.00) and 52.94 (12.88) years, respectively. According to the previous diagnostic criteria (SBP ≥ 140 mm Hg and/or DBP ≥ 90 mm Hg), the median (interquartile range) age of hypertensive patients was 66 (57–74) years in southern China [30] and 58.8 (50.0–69.0) years in central China [31]. With the the ACC/AHA hypertension diagnostic criteria, the population suffering from hypertension is getting younger and younger, which may be caused by the young and middle-aged population facing long-term tremendous work pressure, unbalanced diet and lack of exercise. With the increasing of age, the prevalence of stage 1 and stage 2 hypertension may be related to changes in the physiological function of blood vessels. As we get older, the elasticity of the arterial wall decreases and large artery stiffness increases, leading to higher blood pressure [32]. Overall, the prevalence of stage 1 and stage 2 hypertension was significantly more frequent in males than in females. The cause of this difference may be linked to hormonal changes in males and females. Estrogen activates vascular smooth muscle cells and endothelial cells, causing vasodilation, reducing vascular remodeling and exerting a protective effect on blood vessels [33, 34], and the specific mechanism of action can be further studied and analyzed.

The improving of living standard and dietary conditions has led to an increasing number of overweight and obese people. According to the China Nutrition and Health Survey, the prevalence of overweight in adults has been reported to be 17.7% and the prevalence of obesity in adults is 5.6% [35]. Several studies have shown that hypertension is associated with BMI [36, 37]. Overweight and obesity could lead to significant insulin resistance, which results in secondary hyperinsulinemia, enhanced renal reabsorption of water and sodium, activation of the sympathetic nervous system, and decreased arterial elasticity, and could eventually result in increasing blood pressure [25]. This study showed that the prevalence of both stage 1 and stage 2 hypertension was increased in overweight and obese people, and the higher the BMI the greater the risk of developing hypertension. Therefore, weight control, lifestyle changes, and a balanced diet structure can effectively prevent and stop the development of hypertension.

The results of multivariable logistic regression showed that risk factors for stage 1 hypertension included sex, age, overweight or obesity, FPG, TG, and ALT, while stage 2 risk factors included sex, age, overweight or obesity, TC, TG, ALT, and current drinking. Studies have shown that dyslipidemia (high TG, high TC, high LDL-C, and low HDL-C) and high FPG are traditional risk factors for hypertension [38–40]. Dyslipidemia can impair endothelial cell function and activate the renin-angiotensin-aldosterone system, causing a decrease in nitric oxide, an increase in angiotensin, and oxidative stress, resulting in vasoconstriction and diastolic dysfunction and thus increasing blood pressure [41–44]. In our study, HDL-C and LDL-C were not significantly associated with hypertension, which may be influenced by extreme values. Surprisingly, current smoking was a protective factor for stage 1 hypertension, with a significantly lower risk of developing stage 1 hypertension (OR = 0.777), which was not significantly associated with stage 2 hypertension. This was inconsistent with the results of other partial studies [45, 46]. There is no consensus on the association between smoking and blood pressure. Studies have suggested that smoking is a risk factor for hypertension, as it impacts the hemodynamics of small and large arteries, damages endothelial cells and causes hypertension [47, 48]. However, a cross-sectional study of men in Inner Mongolia, China, found that current smokers had lower blood pressure compared to non-smokers and former smokers [49]. Another cohort study of the relationship between smoking habits and blood pressure in Japanese men reached similar conclusions: Smoking is a protective factor for hypertension, and the factor is possibly influenced by age, BMI, alcohol consumption, and physical activity [50]. There may be an interaction among age, BMI, alcohol consumption, and physical activity. It has been suggested that smokers have lower body weight and that those with low body weight have a reduced risk of developing hypertension or elevated blood pressure [51]. Another study mentioned that lower blood pressure in the smoking population may be due to a complex neuro-hormonal-stressor “down-regulation” or “desensitization” [52].The exact mechanism of which needs to be further explored in future studies. Alcohol consumption activates the sympathetic nervous system and renin-angiotensin system activity, promotes the release of norepinephrine, and causes oxidative stress, ultimately resulting in increased blood pressure [53]. Several studies have shown that ALT and AST as markers of liver impairment are associated with the development of hypertension [54, 55]. Higher ALT is strongly associated with insulin resistance, oxidative stress, and inflammatory response, which in turn can contribute to the development of hypertension [56]. Our study came to a similar conclusion that the higher the ALT the greater the risk for the development of stage 1 and stage 2 hypertension.

In addition, our study demonstrated a significant interaction between age and sex, BMI and sex on the risk of hypertension, respectively. Interaction means the mutual influence of two or more pathogenic factors on the mechanisms of disease pathogenesis. In conclusion, the development of hypertension is due to a combination of genetic, environmental (unhealthy diet, mental stress, and smoking), and social determinants. Therefore, we can prevent the occurrence of hypertension and stop its further progression by reducing weight, decreasing sodium and fat intake, supplementing potassium, increasing exercise, reducing mental stress, quitting smoking, and limiting drinking.

Conclusion

The present study suggests that the prevalence of stage 1 and stage 2 hypertension was high and that hypertensive patients were getting younger in a population of 32 regions in 11 cities in China. Both stage 1 and stage 2 hypertension were significantly associated with an increased risk of developing diabetes, which may indicate an increased risk of cardiovascular complications among individuals with hypertension. Most of the risk factors for stage 1 and stage 2 hypertension can be prevented or effectively controlled through lifestyle changes. However, the awareness, treatment, and control rates of hypertension in the Chinese population are at a low level. Therefore, blood pressure screening and continuous health screening should be carried out as early as possible, and community-based health education on hypertension should be conducted to raise people’s awareness of hypertension and provide scientific and comprehensive interventions for hypertensive patients.

Strengths and limitations of the study

The present study has several strengths. First, this study is a large sample study with participants from 32 regions in 11 cities in China, who are well representation of the Chinese population. Second, we used the ACC/AHA hypertension diagnostic criteria, which have received less attention from other researchers.

The current study also has some limitations. First, when exploring risk factors for hypertension, all data were baseline information, which has some degree of limitation in explaining causality, therefore a cohort approach is needed for future longitudinal studies. Second, for the diagnosis of diabetes, we used only fasting glucose and did not make 2-hour oral glucose tolerance tests or measurement of glycated hemoglobin levels, which may lead to some errors. Third, the initial study design excluded patients who developed diabetes within 2 years. Therefore, when analyzing the prevalence of diabetes at different blood pressure grades, it may be possible to underestimate the prevalence of diabetes. Moreover, although the participants were from 32 regions across 11 cities in China, the original data did not include specific geographic information, making it impossible to perform region-based stratification or multilevel analysis. Finally, the original data collection lacked detailed information on medication history, cardiovascular disease history, or other chronic conditions, which may have led to an underestimation of the prevalence of hypertension and affected the accuracy of the results. Future studies should actively improve this deficiency.

Supplementary Information

Supplementary Material 1. (15.2KB, docx)

Acknowledgements

Many thanks to the Wu Jieping Medical Foundation for its support of this study and project. The authors also sincerely thank Chen Ying et al. for their contributions to the original study. In addition, we thank all the field investigators and participants for their valuable contributions.

Conflict of interest

None.

Clinical trial number

Not applicable.

Authors’ contributions

Qiuting Jia: Conceptualization, Methodology, Validation, Formal analysis, Resources, Data Curation, Writing - original draft, Writing-Review & Editing, Visualization. Yanbing Pan: Methodology, Formal analysis, Investigation, Writing-Review & Editing. Yan Zhang: Validation, Investigation, Writing-Review & Editing. Haiyu Zhang: Methodology, Software, Writing-Review & Editing. Yanzi Zhang: Data Curation, Writing-Review & Editing. Yongle Wang: Data Curation, Writing-Review & Editing. Yihui Kong: Conceptualization, Resources, Writing-Review & Editing, Supervision, Project Administration, Funding Acquisition.

Funding

This study was supported by Wu Jieping Medical Foundation (NO.320.6750.2020-06-77, NO.320.6750.2020-06-78).

Data availability

The study data are available in the DATADRYAD database (10.5061/dryad.ft8750v).

Declarations

Ethics approval and consent to participate

The original study, a retrospective cohort study using data from the Health Screening Program, was approved by the Rich Healthcare Group Review Board, which waived the requirement for informed consent. In compliance with national legislation and institutional regulations, written informed permission to participate was not required for the current study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

  • 1.Dzau VJ, Hodgkinson CP, Precision Hypertension. Hypertension. 2024. 10.1161/HYPERTENSIONAHA.123.21710. [DOI] [PubMed] [Google Scholar]
  • 2.Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018;138:e484-594. [DOI] [PubMed] [Google Scholar]
  • 3.Wang Z, Chen Z, Zhang L, Wang X, Hao G, Zhang Z, et al. Status of hypertension in China. Circulation. 2018. 10.1161/CIRCULATIONAHA.117.032380. [Google Scholar]
  • 4.Przezak A, Bielka W, Pawlik A. Hypertension and type 2 Diabetes—The novel treatment possibilities. Int J Mol Sci. 2022;23:6500. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Isordia-Salas I, Santiago-Germán D, Jiménez-Alvarado RM, Leaños-Miranda A. Genetic variants associated with high susceptibility of premature ischemic stroke. J Renin-Angiotensin-Aldosterone Syst. 2023;2023:9002021. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Wang Z, Ma L, Liu M, Fan J, Hu S, Writing committee of the report on cardiovascular health and diseases in china. Summary of the 2022 report on cardiovascular health and diseases in China. Chin Med J (Engl). 2023;136:2899–908.38018129 [Google Scholar]
  • 7.Webb AJ, Werring DJ. New insights into cerebrovascular pathophysiology and hypertension. Stroke. 2022;53:1054. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Booth JN, Li J, Zhang L, Chen L, Muntner P, Egan B. Trends in prehypertension and hypertension risk factors in US adults. Hypertension. 2017;70:1999–2012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Shen Y, Chang C, Zhang J, Jiang Y, Ni B, Wang Y. Prevalence and risk factors associated with hypertension and prehypertension in a working population at high altitude in China: a cross-sectional study. Environ Health Prev Med. 2017;22:19. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Q L, Y Z, T G, K Y, K G, X M, et al. Association of Lifestyle Factors and Antihypertensive Medication Use With Risk of All-Cause and Cause-Specific Mortality Among Adults With Hypertension in China. JAMA network open. 2022;5. [DOI] [PMC free article] [PubMed]
  • 11.Q Y, A C, Md R, F L. Antihypertensive Medication Adherence and Risk of Cardiovascular Disease Among Older Adults: A Population-Based Cohort Study. Journal of the American Heart Association. 2017;6. [DOI] [PMC free article] [PubMed]
  • 12.Jia Q, Yang Y, Liu L, Zhang H, Chen Y, Wang Y, et al. Relationship between life’s essential 8, vitamin D, and cardiometabolic outcomes. Diabetes Res Clin Pract. 2025;222: 112057. [DOI] [PubMed] [Google Scholar]
  • 13.Collaboration TBPLTT. Pharmacological blood pressure Lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis. Lancet (London England). 2021;397:1625. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Qi Y, Han X, Zhao D, Wang W, Wang M, Sun J, et al. Long-term cardiovascular risk associated with stage 1 hypertension defined by the 2017 ACC/AHA hypertension guideline. J Am Coll Cardiol. 2018;72:1201–10. [DOI] [PubMed] [Google Scholar]
  • 15.Wang Z, Hao G, Wang X, Chen Z, Zhang L, Zhang Z, et al. Clinical outcomes and economic impact of the 2017 ACC/AHA guidelines on hypertension in China. J Clin Hypertens (Greenwich). 2019;21:1212–20. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Emdin CA, Anderson SG, Woodward M, Rahimi K. Usual blood pressure and risk of New-Onset diabetes: evidence from 4.1 million adults and a Meta-Analysis of prospective studies. J Am Coll Cardiol. 2015;66:1552. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Climie RE, van Sloten TT, Bruno R-M, Taddei S, Empana J-P, Stehouwer CDA, et al. Macrovasculature and microvasculature at the crossroads between type 2 diabetes mellitus and hypertension. Hypertension. 2019;73:1138–49. [DOI] [PubMed] [Google Scholar]
  • 18.Chen G, McAlister FA, Walker RL, Hemmelgarn BR, Campbell NRC. Cardiovascular outcomes in Framingham participants with diabetes: the importance of blood pressure. Hypertension. 2011;57:891–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Chen Y, Zhang X-P, Yuan J, Cai B, Wang X-L, Wu X-L, et al. Association of body mass index and age with incident diabetes in Chinese adults: a population-based cohort study. BMJ Open. 2018;8:e021768. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Zhou B-F. Effect of body mass index on all-cause mortality and incidence of cardiovascular diseases–report for meta-analysis of prospective studies open optimal cut-off points of body mass index in Chinese adults. Biomed Environ Sci. 2002;15:245–52. [PubMed] [Google Scholar]
  • 21.Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al. Recommendations for blood pressure measurement in humans and experimental animals. Hypertension. 2005. 10.1161/01.HYP.0000150859.47929.8e. [DOI] [PubMed] [Google Scholar]
  • 22.Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018;39:3021–104. [DOI] [PubMed] [Google Scholar]
  • 23.Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, et al. Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries. Circulation. 2016;134:441–50. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.P M, Rm C, S G, Dw J, Sj T, Jt W, et al. Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline. Circulation. 2018;137. [DOI] [PMC free article] [PubMed]
  • 25.McGill JB, Haffner S, Rees TJ, Sowers JR, Tershakovec AM, Weber M. Progress and controversies: treating obesity and insulin resistance in the context of hypertension. J Clin Hypertens (Greenwich). 2009;11:36–41. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Lee S-H, Park S-Y, Choi CS. Insulin resistance: from mechanisms to therapeutic strategies. Diabetes Metab J. 2022;46:15–37. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Petrie JR, Guzik TJ, Touyz RM. Diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms. Can J Cardiol. 2018;34:575–84. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Pavlou DI, Paschou SA, Anagnostis P, Spartalis M, Spartalis E, Vryonidou A, et al. Hypertension in patients with type 2 diabetes mellitus: targets and management. Maturitas. 2018;112:71–7. [DOI] [PubMed] [Google Scholar]
  • 29.Yamazaki D, Hitomi H, Nishiyama A. Hypertension with diabetes mellitus complications. Hypertens Res. 2018;41:147–56. [DOI] [PubMed] [Google Scholar]
  • 30.Hu L, Huang X, You C, Li J, Hong K, Li P, et al. Prevalence and risk factors of prehypertension and hypertension in southern China. PLoS One. 2017;12:e0170238. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Chen C, Yuan Z. Prevalence and risk factors for prehypertension and hypertension among adults in central China from 2000–2011. Clin Exp Hypertens. 2018;40:734–43. [DOI] [PubMed] [Google Scholar]
  • 32.Franklin SS, Gustin W, Wong ND, Larson MG, Weber MA, Kannel WB, et al. Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation. 1997;96:308–15. [DOI] [PubMed] [Google Scholar]
  • 33.Khalil RA. Estrogen, vascular estrogen receptor and hormone therapy in postmenopausal vascular disease. Biochem Pharmacol. 2013;86:1627–42. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Özdemir Kumral ZN, Kolgazi M, Üstünova S, Kasımay Çakır Ö, Çevik ÖD, Şener G, et al. Estrogen receptor agonists alleviate cardiac and renal oxidative injury in rats with renovascular hypertension. Clin Exp Hypertens. 2016;38:500–9. [DOI] [PubMed] [Google Scholar]
  • 35.Li L, Rao K, Kong L, Yao C, Xiang H, Zhai F, et al. [A description on the Chinese National nutrition and health survey in 2002]. Zhonghua Liu Xing Bing Xue Za Zhi. 2005;26:478–84. [PubMed] [Google Scholar]
  • 36.Tang N, Ma J, Tao R, Chen Z, Yang Y, He Q, et al. The effects of the interaction between BMI and dyslipidemia on hypertension in adults. Sci Rep. 2022;12:927. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Guo B, Shi Z, Zhang W, Zhao H, He K, Hu X, et al. Trajectories of body mass index (BMI) and hypertension risk among middle-aged and elderly Chinese people. J Hum Hypertens. 2021;35:537–45. [DOI] [PubMed] [Google Scholar]
  • 38.Lin Y-H, Liu Y-H, Wu D-W, Su H-M, Chen S-C. Dyslipidemia increases the risk of incident hypertension in a large Taiwanese population follow-up study. Nutrients. 2022;14:3277. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Yi Q, Hu H, Zeng Q. Association of triglycerides to high density lipoprotein cholesterol ratio with hypertension in Chinese adults: a cross-sectional study. Clin Exp Hypertens. 2023;45:2195996. [DOI] [PubMed] [Google Scholar]
  • 40.Tian X, Feng J, Chen S, Zhang Y, Zhang X, Xu Q, et al. Baseline and longitudinal cardiovascular health using life’s essential 8 metrics with the risk of incident hypertension. Clin Exp Hypertens. 2023;45:2271190. [DOI] [PubMed] [Google Scholar]
  • 41.Hurtubise J, McLellan K, Durr K, Onasanya O, Nwabuko D, Ndisang JF. The different facets of dyslipidemia and hypertension in atherosclerosis. Curr Atheroscler Rep. 2016;18:82. [DOI] [PubMed] [Google Scholar]
  • 42.Cahill PA, Redmond EM. Vascular endothelium– gatekeeper of vessel health. Atherosclerosis. 2016;248:97–109. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Konukoglu D, Uzun H. Endothelial dysfunction and hypertension. Adv Exp Med Biol. 2017;956:511–40. [DOI] [PubMed] [Google Scholar]
  • 44.Ahmad H, Khan H, Haque S, Ahmad S, Srivastava N, Khan A. Angiotensin-Converting enzyme and hypertension: A systemic analysis of various ACE inhibitors, their side effects, and bioactive peptides as a putative therapy for hypertension. J Renin Angiotensin Aldosterone Syst. 2023;2023:7890188. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Mohammed Nawi A, Mohammad Z, Jetly K, Abd Razak MA, Ramli NS, Wan Ibadullah WAH, et al. The prevalence and risk factors of hypertension among the urban population in Southeast Asian countries: A systematic review and Meta-Analysis. Int J Hypertens. 2021;2021:6657003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Qiu L, Wang W, Sa R, Liu F. Prevalence and risk factors of hypertension, diabetes, and dyslipidemia among adults in Northwest China. Int J Hypertens. 2021;2021:5528007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Ambrose JA, Barua RS. The pathophysiology of cigarette smoking and cardiovascular disease: an update. J Am Coll Cardiol. 2004;43:1731–7. [DOI] [PubMed] [Google Scholar]
  • 48.Berlin I, Cournot A, Renout P, Duchier J, Safar M. Peripheral haemodynamic effects of smoking in habitual smokers. A methodological study. Eur J Clin Pharmacol. 1990;38:57–60. [DOI] [PubMed] [Google Scholar]
  • 49.Li G, Wang H, Wang K, Wang W, Dong F, Qian Y, et al. The association between smoking and blood pressure in men: a cross-sectional study. BMC Public Health. 2017;17:797. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Okubo Y, Suwazono Y, Kobayashi E, Nogawa K. An association between smoking habits and blood pressure in normotensive Japanese men: a 5-year follow-up study. Drug Alcohol Depend. 2004;73:167–74. [DOI] [PubMed] [Google Scholar]
  • 51.Bowman TS, Gaziano JM, Buring JE, Sesso HD. A prospective study of cigarette smoking and risk of incident hypertension in women. J Am Coll Cardiol. 2007;50:2085–92. [DOI] [PubMed] [Google Scholar]
  • 52.Alomari MA, Al-Sheyab NA. Cigarette smoking lowers blood pressure in adolescents: the Irbid-TRY. Inhal Toxicol. 2016;28:140–4. [DOI] [PubMed] [Google Scholar]
  • 53.Okubo Y, Sairenchi T, Irie F, Yamagishi K, Iso H, Watanabe H, et al. Association of alcohol consumption with incident hypertension among middle-aged and older Japanese population: the Ibarakai prefectural health study (IPHS). Hypertension. 2014;63:41–7. [DOI] [PubMed] [Google Scholar]
  • 54.Jia J, Yang Y, Liu F, Zhang M, Xu Q, Guo T, et al. The association between serum alanine aminotransferase and hypertension: a national based cross-sectional analysis among over 21 million Chinese adults. BMC Cardiovasc Disord. 2021;21:145. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Liang X, Zhong H, Xiao L. The effect of community hypertension management on blood pressure control and its determinants in Southwest China. Int Health. 2020;12:203–12. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Kerner A, Avizohar O, Sella R, Bartha P, Zinder O, Markiewicz W, et al. Association between elevated liver enzymes and C-reactive protein: possible hepatic contribution to systemic inflammation in the metabolic syndrome. Arterioscler Thromb Vasc Biol. 2005;25:193–7. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material 1. (15.2KB, docx)

Data Availability Statement

The study data are available in the DATADRYAD database (10.5061/dryad.ft8750v).

Articles from BMC Cardiovascular Disorders are provided here courtesy of BMC

RESOURCES