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Journal of Atherosclerosis and Thrombosis logoLink to Journal of Atherosclerosis and Thrombosis
. 2017 May 1;24(5):518–529. doi: 10.5551/jat.36178

Fifty-year Time Trends in Blood Pressures, Body Mass Index and their Relations in a Japanese Community: The Circulatory Risk in Communities Study (CIRCS)

Miyuki Hori 1, Akihiko Kitamura 2,3, Masahiko Kiyama 3, Hironori Imano 1,3, Kazumasa Yamagishi 3,4, Renzhe Cui 1, Mitsumasa Umesawa 4,5, Isao Muraki 3, Takeo Okada 3, Tomoko Sankai 4, Tetsuya Ohira 6, Isao Saito 7, Takeshi Tanigawa 8, Hiroyasu Iso 1,✉; for the CIRCS Investigators
PMCID: PMC5429167  PMID: 27667328

Abstract

Aim: Data for long-term trends in blood pressures, body mass index (BMI), and their relations are needed to set future intervention priorities for prevention of cardiovascular disease. The objective of this study was to investigate these trends revealed by repeated cross-sectional surveys conducted from 1963 to 2013 in a Japanese community.

Methods: Men and women aged 40–79 years who participated in annual cardiovascular checkups were enrolled, and the number of participants ranged between 1,776 and 2,366 with consistently high participation rates for both sexes aged 60–69 years. Sex- and age-specific mean systolic and diastolic blood pressures were calculated using mixed effects modeling for repeated measurement, and the prevalence of hypertension with and without obesity (BMI ≥ 25 kg/m2) were also calculated.

Results: Sex- and age-specific mean systolic and diastolic blood pressures declined irrespective of antihypertensive medication use in both men and women from 1963–1966 to 2009–2013, while mean BMI increased among men of all ages and women of ages 60–69 and 70–79 years. For both sexes aged 60–69 years, the prevalence of hypertension with obesity increased, but the prevalence of hypertension without obesity was still higher that with obesity.

Conclusions: Despite the transition to increased BMI levels, targeting non to obese hypertension remains important in addition to targeting obese hypertension for cardiovascular disease prevention.

Keywords: Blood pressure, Body mass index, Hypertension, Obesity, Long-term trends

Introduction

The overall worldwide prevalence of hypertension in individuals aged ≥ 25 years was approximately 40% in 20081). The number of hypertensive people in the growing and aging global population rose from 600 million in 1980 to nearly 1 billion in 20082). Since elevated blood pressure, a major risk factor for stroke and coronary heart disease, is highly prevalent3–5), the population attributable fraction (PAF) of hypertension for cardiovascular disease is as high as 60% in Asian countries6). Similarly, body mass index (BMI) levels have increased worldwide7). In 2008, the prevalence of obesity (BMI ≥ 25 kg/m2) was 34% for men and 35% for women aged > 20 years in the world7). Overweight or obesity is a major risk factor for hypertension and coronary heart disease8, 9). Increased BMI leads to increased cardiac output and peripheral vascular resistance, insulin resistance, substances released from adipocytes, increased sympathetic nervous system response, and obstructive type of sleep apnea10–14).

Worldwide, the increasing trend in BMI may have had an impact on trends in blood pressure levels and on the prevalence of hypertension. However, in Japan, where the prevalence of obesity has been low7), the impact has not been well elucidated. Data on long-term trends in blood pressures, BMI, and their relations are useful to build future intervention priorities for the prevention of cardiovascular disease in Japan and other countries where the prevalence of obesity is low.

Aim

The objectives of this study were to investigate the longer-term trends for blood pressure, BMI, and their relations revealed by repeated cross-sectional surveys conducted from 1963 to 2013 in a Japanese community.

Methods

Study Population

The Circulatory Risk in Community Study (CIRCS) is an ongoing dynamic cohort study that was started in Ikawa in 1963. Ikawa is a rural community of Akita prefecture, 550 km northeast of Tokyo. It covers an area of 48 km2, and its total census population was 7,030 in 1965 and 5,493 in 2010.

Non-institutionalized residents aged > 40 years in Ikawa were invited to undergo annual cardiovascular surveys and follow-up surveillance for the development of cardiovascular disease and stroke events. Details of the study methods have been previously reported15–17). Participation rates for the annual checkups are displayed in Table 1. Participants aged 40–79 years were enrolled to investigate the long-term trends for BMI and blood pressure levels.

Table 1. Sex- and age-specific number of residents, participants and participation rates from 1963–66 to 2009–13.

1963–66 1972–75 1976–79 1980–83 1984–87 1988–91 1992–95 1996–99 2000–03 2004–08 2009–13
Men
40–49
     Residents (n)* 362 479 461 443 403 467 496 458 420 331 304
     Participants (n) 286 356 334 283 299 255 208 192 135 97 89
     Participation rates (%) 79.0 74.3 72.5 63.9 74.2 54.6 41.9 41.9 32.1 29.3 29.3
50–59
     Residents (n)* 335 314 356 398 456 440 406 432 458 501 425
     Participants (n) 279 249 265 324 361 321 265 202 221 225 167
     Participation rates (%) 83.3 79.3 74.4 81.4 79.2 73.0 65.3 46.8 48.3 44.9 39.3
60–69
     Residents (n)* 215 270 265 259 278 361 423 420 416 359 421
     Participants (n) 199 222 199 216 240 257 278 326 294 264 295
     Participation rates (%) 92.6 82.2 75.2 83.4 86.3 71.2 65.7 77.7 70.7 73.5 70.1
70–79
     Residents (n)* 80 144 150 155 185 204 219 244 268 332 330
     Participants (n) 53 91 82 107 126 137 135 150 189 201 199
     Participation rates (%) 66.3 63.2 54.8 69.0 68.1 67.2 61.6 61.6 70.5 60.5 60.3
 
Women
40–49
     Residents (n)* 456 497 487 477 453 483 494 459 423 352 298
     Participants (n) 399 471 381 365 395 309 272 272 210 152 128
     Participation rates (%) 87.5 94.8 78.2 76.5 87.2 64.0 55.1 59.3 49.6 43.2 43.0
50–59
     Residents (n)* 354 419 446 472 484 483 445 460.5 476 485 410
     Participants (n) 325 363 345 404 451 403 363 342 345 314 264
     Participation rates (%) 91.8 86.6 77.4 85.6 93.2 83.4 81.6 74.3 72.5 64.7 64.4
60–69
     Residents (n)* 244 312 330 348 378 442 476 476.5 477 434 465
     Participants (n) 229 260 261 302 336 367 382 416 383 355 357
     Participation rates (%) 93.9 83.3 79.1 86.8 88.9 83.0 80.3 87.3 80.3 81.8 76.8
70–79
     Residents (n)* 101 188 191 193 247 293 347 389 431 466 448
     Participants (n) 76 89 109 143 158 145 180 223 259 281 277
     Participation rates (%) 75.2 47.3 57.2 74.1 64.0 49.5 51.9 57.3 60.1 60.3 61.8
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*

Census populations in 1965, 1975, 1980, 1985, 1990, 1995, 2000, 2005, and 2010, respectively.

Consent was implied by the participation in health checkups under a community-based program for stroke prevention and was approved by the municipal government and local physicians' association15). The study was also approved by the ethics committees of the Osaka Centre for Cancer and Cardiovascular Disease Prevention, the University of Tsukuba, and Osaka University.

Bp Status at Baseline and at Follow-Up

Systolic and fifth-phase diastolic pressures in the right arm were measured by trained physicians using standard mercury sphygmomanometers with 14× 51-cm cuffs according to the standard epidemiological method. Participants were seated and had rested for 5 min before the measurement. From 1963 to 1980, the blood pressure measurement was repeated after five deep breaths when systolic blood pressure ≥ 160 mmHg or diastolic blood pressure ≥ 95 mmHg; from 1981 to 2007, when systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg; and from 2008 to 2013, when systolic blood pressure ≥ 130 mmHg or diastolic blood pressure ≥ 85 mmHg. To standardize the conditions, we used the first reading for the analyses. We defined hypertension as those with systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg and/or taking antihypertensive medication. Controlled hypertension were persons under antihypertensive medication with systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg. BMI was calculated by dividing weight in kilograms by height in meters squared, and BMI ≥ 25 kg/m2 was considered obese.

The health checkups were performed every year and offered free of charge to all residents aged ≥ 40 years. From 1963, we conducted face-to-face interviews based on the CIRCS questionnaire related to participants' health conditions and dietary habits3). From 1975, we asked about smoking habits and usual daily alcohol intake (g/day).

Statistical Analysis

Sex-specific and age-adjusted mean systolic and diastolic blood pressure levels were calculated according to 11 periods (4–5 years for each period). We also calculated mean systolic and diastolic blood pressure levels according to antihypertensive medication use or not. When persons participated in annual cardiovascular risk surveys twice or more in each period, data in the earliest year were used. The significance of trends for blood pressure and BMI variables was examined using mixed effects modeling for repeated measurement adjusting for age, with the 11 periods represented as median year18). The repeated analysis was conducted because approximately 80% of the participants appeared in the next survey period.

All statistical analyses were performed using SAS for Windows version 9.4 (SAS Institute, Inc., Cary, NC, USA) for the analyses. All probability values for statistical tests were two-tailed, and values < 0.05 were regarded as statistically significant.

Results

The number of men and women aged 40–79 years who participated in health checkups were 1,846 in 1963–1966, 2,101 in 1972–1975, 1,976 in 1976–1979, 2,144 in 1980–1983, 2,366 in 1984–1987, 2,194 in 1988–1991, 2,083 in 1992–95, 2,123 in 1996–1999, 2,036 in 2000–2003, 1,889 in 2004–2008 and 1,776 in 2009–2013 (Table 1). Participation rates were consistently high (≥ 60%) for men aged 60–69 and 70–79 years and for women aged 50–59 and 60–69 years. Therefore, the results for men and women aged 60–69 years were regarded as the primary finding for long-term trends.

Downward trends of mean systolic and diastolic blood pressure levels were observed for men and women of all age groups, except for men aged 70–79 years in diastolic blood pressure from 1963–1966 to 2009–2013 (Table 2 and Fig. 1). These blood pressure declines were observed for persons without antihypertensive medication use as well as those with it (Table 2). The prevalence of antihypertensive medication use increased from 8.5% in 1963–1966 to 47.2% in 1976–1979 for men and from 8.7% to 42.2% for women, and thereafter along with downward trends for blood pressure levels, it declined to 38.0% for men and to 31.7% for women in 2009–2013. The proportion of hypertension controlled under antihypertensive medication among hypertensive persons increased from 5.9% in 1963–1966 to 56.3% in 2009–2013 for men and from 5.0% to 60.2% for women. The prevalence of hypertension declined from 76.9% in 1963–1966 to 60.0% in 2009–2013 for men and from 67.7% to 53.8% for women.

Table 2. Sex- and age-specific means and prevalence or proportions of cardiovascular risk characteristics from 1963–66 to 2009–13.

1963–66 1972–75 1976–79 1980–83 1984–87 1988–91 1992–95 1996–99 2000–03 2004–08 2009–13 p for trend
Men
40–49
    Systolic blood pressure, mmHg 142 139*** 134*** 132*** 133*** 134*** 133*** 131*** 132*** 130*** 126*** < 0.001
        With antihypertensive medication use 178 154*** 149*** 147*** 150*** 145*** 148*** 152*** 146*** 128*** 130*** < 0.001
        Without antihypertensive medication use 140 138* 133*** 131*** 132*** 133*** 132*** 130*** 131*** 129*** 127*** < 0.001
    Diastolic blood pressure, mmHg 85 86 85 84 86 84 85 85 87* 85 85 0.65
        With antihypertensive medication use 105 94** 92** 94** 95 92** 94* 96 94* 90** 90** 0.07
        Without antihypertensive medication use 84 86* 84 83 85 84 85 85 87** 85 85 0.30
    Antihypertensive medication usea, % 3.9 9.0 9.3 13.4*** 9.0 9.0** 6.7 7.8 10.4 8.3 12.4* 0.05
    Controlled hypertension under medicationb, c, % 0.0 15.6 19.4 26.3* 25.9 30.4 7.1 20.0 28.6 62.5*** 54.6*** 0.002
    Hypertensiond, % 51.8 50.0 45.2 42.8** 42.5** 38.8** 35.6** 44.3 49.6 44.3 46.1 0.05
    Body mass index, kg/m2 22.8 23.1 23.5*** 23.4*** 23.3** 23.6*** 23.6*** 23.9*** 24.3*** 24.6*** 24.7*** < 0.001
    Obesity (BMI ≥ 25)a, % 12.5 18.5 21.3** 27.6*** 28.4*** 28.2*** 32.2*** 33.3*** 28.9*** 38.1*** 42.7*** < 0.001
50–59
    Systolic blood pressure, mmHg 150 145** 141*** 138*** 139*** 138*** 138*** 135*** 138*** 130*** 129*** < 0.001
        With antihypertensive medication use 168 157* 156** 145*** 147*** 146*** 149*** 148*** 145*** 138*** 134*** < 0.001
        Without antihypertensive medication use 148 143** 137*** 137*** 138*** 138*** 136*** 133*** 138*** 129*** 128*** < 0.001
    Diastolic blood pressure, mmHg 88 87 87 85*** 86** 85*** 85*** 87 89 83*** 83*** < 0.001
        With antihypertensive medication use 100 90*** 94* 89*** 92** 89*** 90*** 92** 93* 87*** 87*** < 0.001
        Without antihypertensive medication use 87 87 85* 84*** 85* 84*** 84*** 86 88 82*** 83*** < 0.001
    Antihypertensive medication usea, % 8.2 21.7*** 25.3*** 25.9*** 18.3*** 17.1*** 18.9** 17.3** 16.3** 23.1*** 28.1*** < 0.001
    Controlled hypertension under medicationb, c, % 13.0 13.0 7.5 36.9* 36.4* 32.7 24.0 34.3 22.2 40.4** 51.1*** < 0.001
    Hypertensiond, % 63.1 65.1 55.5* 56.8 51.3* 50.2* 50.6* 47.5** 57.0 48.9** 53.3 0.003
    Body mass index, kg/m2 22.4 22.8* 23.1*** 23.0*** 23.1*** 23.4*** 23.4*** 23.8*** 24.0*** 24.1*** 24.2*** < 0.001
    Obesity (BMI ≥ 25)a, % 16.7 17.7 18.1 19.5 18.6* 27.1* 26.4*** 38.6*** 37.1*** 36.9*** 38.3*** < 0.001
60–69
    Systolic blood pressure, mmHg 160 156* 149*** 143*** 141*** 145*** 140*** 139*** 139*** 134*** 132*** < 0.001
        With antihypertensive medication use 179 163** 157*** 150*** 146*** 152*** 144*** 147*** 145*** 138*** 136*** < 0.001
        Without antihypertensive medication use 158 153** 145*** 141*** 139*** 143*** 139*** 137*** 137*** 133*** 130*** < 0.001
    Diastolic blood pressure, mmHg 89 87 85*** 84*** 83*** 84*** 83*** 84*** 85*** 80*** 80*** < 0.001
        With antihypertensive medication use 97 90* 88** 87*** 85*** 87*** 83*** 87*** 86*** 80*** 81*** < 0.001
        Without antihypertensive medication use 88 85** 83*** 82*** 82*** 83*** 84*** 83*** 85** 80*** 80*** < 0.001
    Antihypertensive medication usea, % 8.5 36.0*** 47.2*** 41.2*** 33.8*** 36.6*** 32.4*** 32.8*** 32.7*** 35.2*** 38.0*** < 0.001
    Controlled hypertension under medicationb, c, % 5.9 8.8 17.0 27.0 34.6* 27.7 41.1** 34.6* 35.4* 55.9*** 56.3*** < 0.001
    Hypertensiond, % 76.9 79.3 76.9 67.6** 61.7*** 66.9** 64.0*** 58.6*** 64.3** 58.0*** 60.0*** < 0.001
    Body mass index, kg/m2 22.2 22.2 22.6* 22.4 22.4 22.8** 22.7*** 23.3*** 23.7*** 23.7*** 24.0*** < 0.001
    Obesity (BMI ≥ 25)a, % 10.6 12.2 20.2** 16.7 17.9* 22.2** 19.9** 24.2*** 34.0*** 29.6*** 36.6*** < 0.001
70–79
    Systolic blood pressure, mmHg 168 161*** 156*** 150*** 146*** 148*** 143*** 144*** 142*** 138*** 133*** < 0.001
        With antihypertensive medication use 183 168 162 154* 149* 152* 149* 147* 146* 143** 137** < 0.001
        Without antihypertensive medication use 167 152*** 152*** 145*** 143*** 145*** 138*** 140*** 138*** 134*** 129*** < 0.001
    Diastolic blood pressure, mmHg 87 84 85 82** 80*** 82** 81*** 82** 81*** 78*** 77*** < 0.001
        With antihypertensive medication use 97 88 88 84 80* 82 82* 81* 82* 79* 77** < 0.001
        Without antihypertensive medication use 87 80*** 82* 80*** 79*** 81*** 80*** 82** 81*** 77*** 77*** < 0.001
    Antihypertensive medication usea, % 3.8 50.6*** 56.1*** 54.2*** 50.0*** 46.0*** 48.9*** 40.7*** 45.0*** 46.3*** 51.3*** 0.007
    Controlled hypertension under medicationb, c, % 0.0 6.5 17.4 22.4 33.3 30.2 39.4 31.2 34.1 37.6 52.9 < 0.001
    Hypertensiond, % 88.7 86.8 87.8 81.3 77.0 75.2 66.7** 70.7** 64.6*** 63.2*** 65.8** < 0.001
    Body mass index, kg/m2 21.8 22.0 22.4 21.8 21.9 22.2 22.3 22.9** 23.2*** 23.1*** 23.3*** < 0.001
    Obesity (BMI ≥ 25)a, % 13.3 13.3 17.3 16.0 13.5 20.4** 19.3* 24.0** 19.6** 26.4** 25.1* 0.02
Women
40–49
    Systolic blood pressure, mmHg 133 131** 126*** 126*** 127*** 129*** 126*** 126*** 123*** 121*** 120*** < 0.001
        With antihypertensive medication use 172 160 145*** 147*** 149** 157* 150** 146*** 142*** 139*** 133*** < 0.001
        Without antihypertensive medication use 132 129** 126*** 125*** 126*** 128*** 125*** 125*** 127*** 121*** 119*** < 0.001
    Diastolic blood pressure, mmHg 80 80 78** 77*** 79 79 79 79 81 76*** 76*** 0.01
        With antihypertensive medication use 95 94 86* 89 91 95 96 88 91 85* 87 0.23
        Without antihypertensive medication use 79 79 77** 77*** 79 78 79 79 80 76*** 75*** 0.02
    Antihypertensive medication usea, % 2.8 5.3 7.6* 9.3*** 5.6 5.8 4.8 6.3 4.3 5.9 6.3 0.17
    Controlled hypertension under medicationb, c, % 18.2 8.0 41.4 32.4 36.4 16.7 7.7 23.5 33.3 44.4 62.5* 0.127
    Hypertensiond, % 33.6 28.0* 26.0*** 23.3*** 25.6*** 30.7 25.4* 25.4** 23.8* 21.1** 19.5*** 0.001
    Body mass index, kg/m2 23.1 23.5** 24.0*** 23.6** 23.7*** 23.5* 23.6** 23.5* 23.3 23.2 22.9 0.95
    Obesity (BMI ≥ 25)a, % 19.8 30.8*** 31.8*** 28.2** 31.4*** 27.8** 28.3* 26.5* 28.1 27.6* 24.2 0.52
    50–59
    Systolic blood pressure, mmHg 143 140 134*** 135*** 135*** 135*** 133*** 133*** 135*** 128*** 125*** < 0.001
        With antihypertensive medication use 159 151 147** 145*** 145*** 146*** 145*** 147*** 149** 139*** 135*** < 0.001
        Without antihypertensive medication use 142 139* 132*** 133*** 134*** 134*** 131*** 132*** 133*** 127*** 124*** < 0.001
    Diastolic blood pressure, mmHg 84 84 81*** 81*** 82* 81** 82* 82 84 78*** 77*** < 0.001
        With antihypertensive medication use 95 94 86* 89 91 95 96 88 91 85* 87 0.02
        Without antihypertensive medication use 83 84 80*** 80*** 81* 81** 81* 82 83 78*** 77*** < 0.001
    Antihypertensive medication usea, % 6.5 14.3* 22.6*** 24.0*** 17.3*** 16.4*** 14.6** 12.6* 15.4*** 15.6*** 13.3* 0.13
    Controlled hypertension under medicationb, c, % 23.8 19.2 29.5 38.1 39.7 36.4 24.5 23.3 17.0 44.9* 65.7*** 0.01
    Hypertensiond, % 52.0 52.6 45.8** 47.0 47.0 45.2 39.9*** 39.2*** 42.6*** 36.9*** 29.2*** < .0001
    Body mass index, kg/m2 23.0 23.7*** 24.4*** 24.1*** 24.1*** 24.4*** 24.2*** 24.3*** 24.3*** 24.1*** 23.8** 0.005
    Obesity (BMI ≥ 25)a, % 23.6 34.2*** 37.7*** 38.9*** 38.8*** 40.3*** 34.4*** 38.0*** 32.5** 32.8** 31.4* 0.17
    60–69
    Systolic blood pressure, mmHg 155 151* 143*** 142*** 142*** 142*** 138*** 139*** 140*** 135*** 132*** < 0.001
        With antihypertensive medication use 177 167* 154*** 148*** 147*** 147*** 145*** 147*** 147*** 139*** 135*** < 0.001
        Without antihypertensive medication use 153 145*** 139*** 139*** 140*** 140*** 135*** 136*** 138*** 133*** 132*** < 0.001
    Diastolic blood pressure, mmHg 86 85 83*** 81*** 82*** 81*** 81*** 82*** 83*** 78*** 78*** < 0.001
        With antihypertensive medication use 93 89 86** 87*** 87*** 85*** 87*** 89*** 92*** 84*** 82*** < 0.001
        Without antihypertensive medication use 86 83** 80*** 80*** 81*** 79*** 79*** 81*** 83*** 77*** 78*** < 0.001
    Antihypertensive medication usea, % 8.7 34.6*** 42.2*** 35.4*** 29.8*** 32.4*** 35.1*** 31.7*** 32.9*** 29.3*** 31.7*** < 0.001
    Controlled hypertension under medicationb, c, % 5.0 7.8 21.8 43.0*** 35.0** 37.8** 38.8** 27.3* 34.1** 51.9*** 60.2*** < 0.001
    Hypertensiond, % 67.7 68.1 64.8 61.6* 61.3 60.0* 56.8*** 57.0** 61.1* 52.7*** 53.8*** < 0.001
    Body mass index, kg/m2 23.1 23.7** 24.1*** 23.9*** 24.0*** 24.3*** 24.1*** 24.8*** 25.0*** 24.6*** 24.5*** < 0.001
    Obesity (BMI ≥ 25)a, % 23.5 31.7 41.9*** 37.9* 37.6** 40.9*** 36.2** 46.9*** 45.2*** 35.8** 35.1** 0.001
70–79
    Systolic blood pressure, mmHg 165 157** 152*** 148*** 145*** 148*** 143*** 141*** 141*** 141*** 138*** < 0.001
        With antihypertensive medication use 176 161* 158** 155** 149*** 149*** 147*** 145*** 147*** 143*** 139*** < 0.001
        Without antihypertensive medication use 163 154* 145*** 140*** 141*** 146*** 140*** 138*** 137*** 139*** 137*** < 0.001
    Diastolic blood pressure, mmHg 88 83** 82*** 80*** 80*** 78*** 78*** 78*** 79*** 75*** 75*** < 0.001
        With antihypertensive medication use 86 87 84 82 81 78* 79 78* 80 76** 75** < 0.001
        Without antihypertensive medication use 88 81** 79*** 78*** 78*** 78*** 77*** 78*** 79*** 76*** 75*** < 0.001
    Antihypertensive medication usea, % 11.8 49.4*** 69.7*** 55.9*** 53.2*** 43.5*** 41.7*** 47.1*** 47.1*** 55.5*** 52.0*** 0.003
    Controlled hypertension under medicationb, c, % 22.2 9.1 18.4 25.0 32.1 34.9 40.0*** 41.0 34.4 39.7 51.4 < 0.001
    Hypertensiond, % 80.3 88.8 86.2 75.5 76.0 78.6 65.6* 68.2* 67.2* 74.7 72.6 0.002
    Body mass index, kg/m2 23.3 23.3 23.6 23.6 23.6 24.3* 23.9 24.4** 24.5** 24.4* 24.2 0.003
    Obesity (BMI ≥ 25)a, % 22.0 34.8 33.3 33.8 33.5 42.1* 38.9 40.1* 40.9** 42.0** 38.8** 0.001
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Test of differences from the 1963–66 values:

*

p < 0.05,

**

p < 0.01,

***

p < 0.001

a

Prevalence: the denominator is the participants of each sex- and age-specific group,

b

Proportion: the denominator is the hyperteinsive persons of each sex- and age-specific group,

c

The proportion of controlled hypertension under medication among hypertensive persons aged 40–49 and 50–59 years fluctuated because of the small number of persons who took antihypertensive medication,

d

Systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg and/or antihypertensive medication use

Fig. 1.

Fig. 1.

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Mean systolic and diastolic blood pressure levels for men and women aged 60–69 years between 1963–1966 and 2009–2013

The I bars indicate 95% confidence intervals.

Age-adjusted mean values of BMI and prevalence of obesity increased for men and women of all age groups, except for women aged 40–49 years (Table 2). Mean BMI increased from 22.2 kg/m2 in 1963–1966 to 24.0 kg/m2 in 2009–2013 for men aged 60–69 and from 23.1 kg/m2 in 1963–1966 to 25.0 kg/m2 in 2000–2003 for women aged 60–69, and thereafter, declined to 24.5 kg/m2 for women in 2009–2013 (Table 2 and Fig. 2). When adjusted for BMI as well as age, the declining trend for mean diastolic blood pressure was somewhat enhanced for men aged 40–49 years, but otherwise, no substantial changes were observed (data not shown).

Fig. 2.

Fig. 2.

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Mean body mass index for men and women aged 60–69 years between 1963–1966 and 2009–2013

The I bars indicate 95% confidence intervals.

Table 3 and Fig. 3 show the sex- and age-specific prevalence of hypertension with and without obesity for men and women from 1963–1966 to 2009–2013. The prevalence of hypertension with obesity increased from 10.5% in 1963–1966 to 23.1% in 2009–2013 for men aged 60–69 years and from 18.8% to 25.0% for women aged 60–69 years. The corresponding prevalence of hypertension without obesity for ages 60–69 years decreased from 65.3% to 37.3% for men and from 47.3% to 28.7% for women, but it was mostly higher than that of hypertension with obesity over time.

Table 3. Sex and age-specific prevalence of hypertension with and without obesity from 1963–66 to 2009–13.

1963–66 1972–75 1976–79 1980–83 1984–87 1988–91 1992–95 1996–99 2000–03 2004–08 2009–13 P for trend
Men
40–49
    Hypertension with obesity, % 5.3 11.0* 13.8*** 14.8*** 17.1*** 12.9*** 16.4*** 19.8*** 17.8*** 17.5*** 27.0 < 0.001
    Hypertension without obesity, % 42.9 39.0* 31.4*** 27.9*** 25.4*** 25.9*** 19.2*** 24.5*** 31.9*** 26.8*** 19.1*** < 0.001
50–59
    Hypertension with obesity, % 12.3 12.5 11.7 13.3 13.3* 17.5*** 15.5** 23.3*** 26.2*** 21.8*** 24.6*** < 0.001
    Hypertension without obesity, % 49.3 52.6 43..6 43.5 38.0* 32.7*** 35.1** 24.3*** 30.8*** 27.1*** 28.7*** < 0.001
60–69
    Hypertension with obesity, % 10.5 10.8 18.6* 11.6 13.8* 16.3* 13.3 17.8*** 25.5*** 21.6*** 23.1*** < 0.001
    Hypertension without obesity, % 65.3 68.5 57.7* 56.0 48.3* 50.6* 50.7 40.8*** 38.8*** 36.4*** 37.3*** < 0.001
70–79
    Hypertension with obesity, % 8.7 13.3 13.3 14.2 11.9 17.5* 14.8* 18.7** 14.3*** 19.9*** 21.1*** < 0.001
    Hypertension without obesity, % 78.3 73.3 73.3 67.0 65.1 57.7* 51.9* 52.0** 50.3*** 43.3*** 44.7*** < 0.001
 
Women
40–49
    Hypertension with obesity, % 7.9 13.0*** 11.8*** 11.0** 11.7** 12.3 12.1* 12.5** 10.0* 10.5** 10.9* 0.02
    Hypertension without obesity, % 22.8 15.1*** 14.2*** 12.3** 13.9** 18.5 13.2* 12.9** 13.8* 11.2** 8.6* 0.02
50–59
    Hypertension with obesity, % 14.2 24.8*** 23.0*** 23.5*** 22.4*** 20.9*** 17.9** 23.1*** 20.6*** 19.4*** 13.6*** 0.001
    Hypertension without obesity, % 36.4 27.8*** 22.5*** 23.5*** 24.6*** 24.1*** 22.0** 16.1*** 22.0*** 17.5*** 15.5*** 0.001
60–69
    Hypertension with obesity, % 18.8 24.7 33.3*** 29.5** 29.0** 28.6*** 24.7** 29.8*** 30.8*** 25.1*** 25.0** < 0.001
    Hypertension without obesity, % 47.3 43.2 29.7*** 32.1** 32.2** 31.3*** 32.0** 27.2*** 30.3*** 27.6*** 28.7** < 0.001
70–79
    Hypertension with obesity, % 15.6 32.6 31.9 26.8* 28.5 37.2*** 29.4** 30.6** 31.7** 34.9** 32.3** 0.003
    Hypertension without obesity, % 60.9 56.2 52.1 48.6* 47.5 41.4*** 36.1** 37.4** 35.5** 39.9** 40.2** 0.003
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* Test of differences from the 1963–66 values:

*

p < 0.05,

**

p < 0.01,

***

p < 0.001

Fig. 3.

Fig. 3.

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Trends in the prevalence of hypertension with and without obesity for men and women aged 60–69 years between 1963–1966 and 2009–2013

Hypertension is shown as colored, and non-hypertension is shown as dotted.

Discussion

The present study showed a substantial and consistent decline in systolic blood pressure levels, while BMI levels increased and correspondingly prevalence of hypertension with obesity increased over the past 50 years for both men and women in a Japanese rural community. The prevalence of hypertension with obesity increased for both sexes of all age groups, but the prevalence of hypertension without obesity still overwhelmed that with obesity for men and women aged 60–69 years and other age groups except for ages of 40–49 years in 2009–2013. The previous study using Japanese national data showed that the prevalence of obesity increased in men and remained stable in women, and the odd ratio of hypertension associated with obesity increased from 1.94 in 1980 to 2.82 in 2010 for men and from 2.37 to 3.48 for women19). In that study population aged 30–79 years, the PAF increased from 14.6% in 1980 to 39.3% in 2010 for men, and from 23.9% to 34.8% for women. The PAF estimated in the present study population aged 40–79 years was 12.6% in 1980–1983 and 24.4% in 2009–2013 for men, and 36.7% and 40.1% for women20). Although hypertension attributable to obesity increased overtime, there remained a large fraction of hypertension attributable to non-obesity.

Long-term blood pressure trends were reported from Japanese, Finnish, and US studies. According to the National Health and Nutrition Survey in Japan21, 22), mean systolic and diastolic blood pressures for men and women aged 60–69 years declined between 1961 and 2010. Mean BMI increased from 22.0 kg/m2 in 1976–1980 to 23.7 kg/m2 in 2011 for men aged 60–69 years, whereas for women, it did not change: 23.0 kg/m2 and 22.9 kg/m2 for 1976–1980 and 2011, respectively23). As shown in Supplementary Fig. 1, the prevalence of obesity increased from 16.0% in 1976–1980 to 31.0 % in 2011 for men aged 60–69 years, but it decreased from 27.2% to 24.0% for women.

Supplementary Fig. 1.

Supplementary Fig. 1.

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Trends in age-adjusted prevalence of obesity (BMI ≥ 25 kg/m2) among US, Finnish, and Japanese men and women

Finland: Data from the North Karelia province project for men and women aged 30–59 years in 1972, 1977, 1982, 1987, 1992, 1997, 2002, and 20071).

United States: Data from NHANES I (1971–74), NHANES II (1976–80), NHANES III (1988–94), NHANES (1999–2002), NHANES (2003–06), and NHANES (2009–12) for men and women aged 20–74 years2).

Rural Japan: Data from the present study for men and women aged 60–69 years in 1972–1975, 1976–1979, 1980–1983, 1984–1987, 1992–1995, 1996–1999, 2000–2003, and 2004–2008.

Japan: Data from the National Health and Nutrition Survey in Japan in 1976–1980, 1981–1985, 1986–1990, 1991–1995, 1996, 2001, and 20113).

A 35-year population survey in the province of North Karelia in Finland showed that both mean systolic and diastolic blood pressure levels for men and women aged 30–59 years declined between 1972 and 2002, but plateaued between 2002 and 200724). For men, mean BMI continuously increased from 26.0 kg/m2 in 1972 to 27.1 kg/m2 in 2002 and to 27.4 kg/m2 in 2007, whereas for women, it did not change: 26.8, 26.8, and 26.6 kg/m2 for 1972, 2002, and 2007, respectively25). As shown in Supplementary Fig. 1, the corresponding prevalence of obesity was 57%, 68%, and 70% for men, and 61%, 54%, and 54% for women.

The National Health and Nutrition Examination Survey (NHANES) in the United States26, 27) indicated that mean systolic and diastolic blood pressure for individuals aged 18–74 years decreased between 1960–1962 and 2001–2008 (age ≥ 18 in 2001–2008) for men and women. As shown in Supplementary Fig. 1, the prevalence of obesity increased from 50% in 1960–1962 to 61% in 1988–1994 and to 73% in 2009–2012 for men, and from 40% to 51% and to 65%, respectively, for women28).

The declining trend in systolic blood pressure levels were commonly observed among men and women of Japanese, Finnish, and US samples. The improvement of hypertension treatment and the reduction of salt consumption may have favored the change in blood pressure in these countries. Other dietary factors which contributed to the systolic blood pressure decline29) for Japanese may include increased intakes of fresh fruits, vegetables, and dairy products30). The prevalence of obesity was much lower in Japanese than in Finnish and Americans (Supplementary Fig. 1). Globally, people in countries of east, southeast, and south Asia and central Africa are less obese31) and have high risk of mortality from stroke32). Lean hypertensives had the greater risk of mortality from cardiovascular disease than obese hypertensives33, 34). Therefore, the prevention and control for hypertension may be also important in countries with less obese populations.

The strengths of this study are its investigation of long-term time trends and the high response rates among men and women aged 60–69 years in addition to among men aged 70–79 years and women aged 50–59 years. To the best of our knowledge, no other population-based study has been conducted to investigate long-term trends for the relations between blood pressures and BMI.

The limitations of the study warrant discussion. First, we did not have individual information on salt intake, which is a major determinant of blood pressure levels. According to our nutrition survey of a subsample of the present study3), mean salt intake decreased from 20 g/day in the 1960s to 14 g/day in the 1980s for men aged 40–59 years. The large decline in the prevalence of hypertension without obesity may be partly explained by this reduction in salt intake, although this was not directly shown here because of the subsample nutrition survey. Second, this study was performed in one rural community in Japan, and the participation rates were not high enough for men aged 40–59 years, nor for women aged 40–49 years in the 1990's and thereafter. Therefore, caution should be taken in applying our findings to other Japanese populations. However, comparing our results with Japanese national survey (National Health and Nutrition Survey), we found similar trends in blood pressure levels in the general Japanese population, although the prevalence of obesity among women was higher by 5 to 23 point in the present study than in the national sample21, 22). Third, because we used the first reading of blood pressure measurement to analyze the data consistently through 50 years, blood pressure levels may be overestimated compared with usual values. However, when we used the second reading, if the first reading was high, the prevalence of hypertension did not change materially: the difference = −0.3% to 0.0%. Lastly, hypertensive persons can move from non-obese in one survey to obese in another or vice versa. However, the percentage for the shift to the other category between one to the next periods was small (approximately 5%).

In conclusion, we found a substantial decline in blood pressure levels over the past 50 years for both men and women aged 40–79 years in a Japanese rural community. The prevalence of hypertension without obesity declined and that with obesity increased along with increased BMI levels. In spite of the transition for increased BMI levels, the targeting for non-obese hypertension remained important in addition to the targeting for obese hypertension in order to control of hypertension. Our findings may be applicable to other countries where the prevalence of hypertension is high and that of obesity is low.

Acknowledgments

The authors thank professors emeriti Yoshio Komachi and Takashi Shimamoto, of the University of Tsukuba, and Professor David R. Jacobs Jr. of the University of Minnesota for their valuable comments on this study. We also thank Ms Flaminia Miyamasu, University of Tsukuba, for editorial assistance. The full list of CIRCS investigators is presented in reference17).

Funding Sources

This work was supported by a grant-in-aid for scientific research A [no. 22249022, 2010–2013] and B [no. 22390123, 2010–2014] from the Japan Society for the Promotion of Science and sciences research grant [Research on Cardiovascular Diseases H24-018, 2012] from the Ministry of Health, Labour and Welfare of Japan.

Conflict of Interest

None declared.

References

  • 1). World Health Organization: Global status report on noncommunicable diseases 2010. World health Organization; Geneva; 2011 [Google Scholar]
  • 2). Danaei G, Finucane MM, Lin JK, Singh GM, Paciorek CJ, Cowan MJ, Farzadfar F, Stevens GA, Lim SS, Riley LM, Ezzati M, Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Blood Pressure) : National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5·4 million participants. Lancet, 2011; 377: 568-577 [DOI] [PubMed] [Google Scholar]
  • 3). Shimamoto T, Komachi Y, Inada H, Doi M, Iso H, Sato S, Kitamura A, Iida M, Konishi M, Nakanishi N, Terao A, Naito Y, Kojima S: Trends for coronary heart disease and stroke and their risk factors in Japan. Circulation, 1989; 79: 503-515 [DOI] [PubMed] [Google Scholar]
  • 4). Kannel WB, Wolf PA, Verter J, McNamara PM: Epidemiologic assessment of the role of blood pressure in stroke: the Framingham Study. 1970. JAMA, 1996; 276: 1269-1278 [PubMed] [Google Scholar]
  • 5). Lawes CM, Bennett DA, Lewington S, Rodgers A: Blood pressure and coronary heart disease: a review of the evidence. Semin Vasc Med, 2002; 2: 355-368 [DOI] [PubMed] [Google Scholar]
  • 6). Martiniuk AL, Lee CM, Lawes CM, Ueshima H, Suh I, Lam TH, Gu D, Feigin V, Jamrozik K, Ohkubo T, Woodward M, Asia-Pacific Cohort Studies Collaboration : Hypertension: its prevalence and population-attributable fraction for mortality from cardiovascular disease in the Asia-Pacific region. J Hypertens, 2007; 25: 73-79 [DOI] [PubMed] [Google Scholar]
  • 7). Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek CJ, Singh GM, Gutierrez HR, Lu Y, Bahalim AN, Farzadfar F, Riley LM, Ezzati M, Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Body Mass Index) : National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9·1 million participants. Lancet, 2011; 377: 557-567 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8). Ni Mhurchu C, Rodgers A, Pan WH, Gu DF, Woodward M, Asia Pacific Cohort Studies Collaboration : Body mass index and cardiovascular disease in the Asia-Pacific Region: an overview of 33 cohorts involving 310 000 participants. Int J Epidemiol, 2004; 33: 751-758 [DOI] [PubMed] [Google Scholar]
  • 9). Prospective Studies Collaboration: Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet, 2009; 373: 1083-1096 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10). Rahmouni K: Obesity-Associated Hypertension: Recent Progress in Deciphering the Pathogenesis. Hypertension, 2014; 64: 215-221 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11). Poirier P, Lemieux I, Mauriège P, Dewailly E, Blanchet C, Bergeron J, Després JP: Impact of waist circumference on the relationship between blood pressure and insulin: the Quebec Health Survey. Hypertension, 2005; 45: 363-367 [DOI] [PubMed] [Google Scholar]
  • 12). Kim DH, Kim C, Ding EL, Townsend MK, Lipsitz LA: Adiponectin levels and the risk of hypertension: a systematic review and meta-analysis. Hypertension, 2013; 62: 27-32 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13). Bjorntorp P: Obesity and adipose tissue distribution as risk factors for the development of disease: a review. Infusionstherapie, 1990; 17: 24-27 [DOI] [PubMed] [Google Scholar]
  • 14). Tishler PV, Larkin EK, Schluchter MD, Redline S: Incidence of sleep-disordered breathing in an urban adult population: the relative importance of risk factors in the development of sleep-disordered breathing. JAMA, 2003; 289: 2230-2237 [DOI] [PubMed] [Google Scholar]
  • 15). Iso H, Shimamoto T, Naito Y, Sato S, Kitamura A, Iida M, Konishi M, Jacobs DR, Jr, Komachi Y: Effects of a long-term hypertension control program on stroke incidence and prevalence in a rural community in northeastern Japan. Stroke, 1998; 29: 1510-1518 [DOI] [PubMed] [Google Scholar]
  • 16). Kitamura A, Sato S, Kiyama M, Imano H, Iso H, Okada T, Ohira T, Tanigawa T, Yamagishi K, Nakamura M, Konishi M, Shimamoto T, Iida M, Komachi Y: Trends in the incidence of coronary heart disease and stroke and their risk factors in Japan, 1964 to 2003: the Akita-Osaka study. J Am Coll Cardiol, 2008; 52: 71-79 [DOI] [PubMed] [Google Scholar]
  • 17). Imano H, Iso H, Kiyama M, Yamagishi K, Ohira T, Sato S, Noda H, Maeda K, Okada T, Tanigawa T, Kitamura A, CIRCS Investigators : Non-fasting blood glucose and risk of incident coronary heart disease in middle-aged general population: the Circulatory Risk in Communities Study (CIRCS). Prev Med, 2012; 55: 603-607 [DOI] [PubMed] [Google Scholar]
  • 18). Jacobs DR, Jr., Hannan PJ, Wallace D, Liu K, Williams OD, Lewis CE: Interpreting age, period and cohort effects in plasma lipids and serum insulin using repeated measures regression analysis: the CARDIA Study. Stat Med, 1999; 18: 655-679 [DOI] [PubMed] [Google Scholar]
  • 19). Nagai M, Ohkubo T, Murakami Y, Takashima N, Kadota A, Miyagawa N, Saito Y, Nishi N, Okuda N, Kiyohara Y, Nakagawa H, Nakamura Y, Fujiyoshi A, Abbott RD, Okamura T, Okayama A, Ueshima H, Miura K, NIPPON DATA80/90/2010 Research Group : Secular trends of the impact of overweight and obesity on hypertension in Japan, 1980-2010. Hypertens Res, 2015; 38: 790-795 [DOI] [PubMed] [Google Scholar]
  • 20). Rockhill B, Newman B, Weinberg C: Use and misuse of population attributable fractions. Am J Public Health, 1998; 88: 15-19 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21). Ikeda N, Gakidou E, Hasegawa T, Murray CJ: Understanding the decline of mean systolic blood pressure in Japan: an analysis of pooled data from the National Nutrition Survey, 1986-2002. Bull World Health Organ, 2008; 86: 978-988 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22). Miura K, Nagai M, Ohkubo T: Epidemiology of hypertension in Japan: where are we now? Circ J, 2013; 77: 2226-2231 [DOI] [PubMed] [Google Scholar]
  • 23). Yoshiike N, Seino F, Tajima S, Arai Y, Kawano M, Furuhata T, Inoue S: Twenty-year changes in the prevalence of overweight in Japanese adults: the National Nutrition Survey 1976-95. Obes Rev, 2002; 3: 183-190 [DOI] [PubMed] [Google Scholar]
  • 24). Vartiainen E, Laatikainen T, Peltonen M, Juolevi A, Männistö S, Sundvall J, Jousilahti P, Salomaa V, Valsta L, Puska P: Thirty-five-year trends in cardiovascular risk factors in Finland. Int J Epidemiol, 2010; 39: 504-518 [DOI] [PubMed] [Google Scholar]
  • 25). Puska P, Vartiainen E, Laatikainen T, Jousilahti P, Paavola M, editors: The North Karelia Project: from North Karelia to national action. Helsinki: Helsinki University Printing House; 2009 [Google Scholar]
  • 26). Burt VL, Cutler JA, Higgins M, Horan MJ, Labarthe D, Whelton P, Brown C, Roccella EJ: Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population: Data from the health examination surveys, 1960 to 1991. Hypertension, 1995; 26: 60-69 [DOI] [PubMed] [Google Scholar]
  • 27). Wright JD, Hughes JP, Ostchega Y, Yoon SS, Nwankwo T: Mean systolic and diastolic blood pressure in adults aged 18 and over in the United States, 2001-2008. Natl Health Stat Report, 2011; 35: 1-22 [PubMed] [Google Scholar]
  • 28). National Center for Health Statistics: Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD: 2014 [PubMed] [Google Scholar]
  • 29). Chan Q, Stamler J, Griep LM, Daviglus ML, Horn LV, Elliott P: An Update on Nutrients and Blood Pressure. J Atheroscler Thromb, 2016; 23: 276-289 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30). Ministry of Health, Labour and Welfare: National Health and Nutrition survey in Japan. Internet: http://www.mhlw.go.jp/bunya/kenkou/kenkou_eiyou_chousa.html. (in Japanese, accessed 9 August 2016)
  • 31). Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, Mullany EC, Biryukov S, Abbafati C, Abera SF, Abraham JP, Abu-Rmeileh NM, Achoki T, AlBuhairan FS, Alemu ZA, Alfonso R, Ali MK, Ali R, Guzman NA, Ammar W, Anwari P, Banerjee A, Barquera S, Basu S, Bennett DA, Bhutta Z, Blore J, Cabral N, Nonato IC, Chang JC, Chowdhury R, Courville KJ, Criqui MH, Cundiff DK, Dabhadkar KC, Dandona L, Davis A, Dayama A, Dharmaratne SD, Ding EL, Durrani AM, Esteghamati A, Farzadfar F, Fay DF, Feigin VL, Flaxman A, Forouzanfar MH, Goto A, Green MA, Gupta R, Hafezi-Nejad N, Hankey GJ, Harewood HC, Havmoeller R, Hay S, Hernandez L, Husseini A, Idrisov BT, Ikeda N, Islami F, Jahangir E, Jassal SK, Jee SH, Jeffreys M, Jonas JB, Kabagambe EK, Khalifa SE, Kengne AP, Khader YS, Khang YH, Kim D, Kimokoti RW, Kinge JM, Kokubo Y, Kosen S, Kwan G, Lai T, Leinsalu M, Li Y, Liang X, Liu S, Logroscino G, Lotufo PA, Lu Y, Ma J, Mainoo NK, Mensah GA, Merriman TR, Mokdad AH, Moschandreas J, Naghavi M, Naheed A, Nand D, Narayan KM, Nelson EL, Neuhouser ML, Nisar MI, Ohkubo T, Oti SO, Pedroza A, Prabhakaran D, Roy N, Sampson U, Seo H, Sepanlou SG, Shibuya K, Shiri R, Shiue I, Singh GM, Singh JA, Skirbekk V, Stapelberg NJ, Sturua L, Sykes BL, Tobias M, Tran BX, Trasande L, Toyoshima H, van de Vijver S, Vasankari TJ, Veerman JL, Velasquez-Melendez G, Vlassov VV, Vollset SE, Vos T, Wang C, Wang X, Weiderpass E, Werdecker A, Wright JL, Yang YC, Yatsuya H, Yoon J, Yoon SJ, Zhao Y, Zhou M, Zhu S, Lopez AD, Murray CJ, Gakidou E: Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet, 2014; 384: 766-781 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32). Kim AS, Johnston SC: Global variation in the relative burden of stroke and ischemic heart disease. Circulation, 2011; 124: 314-323 [DOI] [PubMed] [Google Scholar]
  • 33). Carman WJ, Barrett-Connor E, Sowers M, Khaw KT: Higher risk of cardiovascular mortality among lean hypertensive individuals in Tecumseh, Michigan. Circulation, 1994; 89: 703-711 [DOI] [PubMed] [Google Scholar]
  • 34). Irie F, Iso H, Noda H, Sairenchi T, Otaka E, Yamagishi K, Doi M, Izumi Y, Ota H: Associations between metabolic syndrome and mortality from cardiovascular disease in Japanese general population, findings on overweight and non-overweight individuals. Ibaraki Prefectural Health Study. Circ J, 2009; 73: 1635-1642 [DOI] [PubMed] [Google Scholar]

Supplementary References

  • 1). Vartiainen E, Laatikainen T, Peltonen M, Juolevi A, Männistö S, Sundvall J, Jousilahti P, Salomaa V, Valsta L, Puska P: Thirty-five-year trends in cardiovascular risk factors in Finland. Int J Epidemiol, 2010; 39: 504-518 [DOI] [PubMed] [Google Scholar]
  • 2). National Center for Health Statistics: Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD: 2014 [PubMed] [Google Scholar]
  • 3). Yoshiike N, Seino F, Tajima S, Arai Y, Kawano M, Furuhata T, Inoue S: Twenty-year changes in the prevalence of overweight in Japanese adults: the National Nutrition Survey 1976-95. Obes Rev, 2002; 3: 183-190 [DOI] [PubMed] [Google Scholar]

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