Abstract
In China, there are approximately 250 million adults who have hypertension with low rates of awareness, treatment and control. Changes in lifestyles at a population level have the potential to enhance or deteriorate the prevention and control of hypertension. We used data from a regional hypertension survey to examine the impact of 2/1 mm Hg decreases or increases in population blood pressure on hypertension prevalence, and rates of unawareness of the hypertension diagnosis, treatment, and control. The primary analysis was based on the average blood pressure of respondents from three visits and a diagnostic threshold of 140/90 mm Hg for hypertension. Secondary analyses examined average blood pressure from the first survey visit and also a diagnostic threshold of 130/80 mm Hg for hypertension. The baseline hypertension prevalence was 33.4%, and rates of unawareness of the hypertension diagnosis, treatment, and control were 74.2%, 25.8%, and 9.7%, respectively. Decreases or increases in blood pressure by 10/5 mm Hg resulted in changes in hypertension prevalence (22.1% vs 53.4%) and rates of unawareness of the diagnosis (60.9% vs 83.8%), treatment (39.1% vs 16.2%), and control (21.2% vs 3.6%), respectively. Similar trends were seen in the secondary analyses. Population changes in lifestyle could have a very large impact on the prevalence and control of hypertension in China. The results support implementation of programs to improve population lifestyles while implementing health services policies to enhance the clinical management of hypertension.
Keywords: clinical management of hypertension, diet/nutrition/hypertension, hypertension, prevention, public health
1. INTRODUCTION
In China, there are approximately 250 million people with hypertension1, 2, 3 and the Global Burden of Disease study attributes increased blood pressure to 24% of deaths and 14% of disability‐adjusted life years (DALYs).4 In fact, increased systolic blood pressure is the leading single modifiable risk for death in China.4 Reducing blood pressure by population health interventions (eg, dietary salt reduction) or by enhancing hypertension control clinically on a population scale have been advocated.1, 5
Population reductions in blood pressure can be a cost saving means to prevent and control hypertension. Interventions such as reducing dietary salt have been estimated to have a return on investment of up to $18 for every $1 invested and are considered by the World Health Organization to be a best buy.6 China has initiated efforts to reduce dietary salt and to improve hypertension control clinically.2, 7 Other interventions, such as attaining and maintaining a healthy body weight, regular physical activity, a healthy diet, and low‐risk alcohol consumption, are also effective in reducing blood pressure (Table1).5, 8, 9, 10, 11, 12
Table 1.
Approximate changes in blood pressure with some lifestyle change
| Lifestyle change | Expected change in blood pressure in persons with hypertension |
|---|---|
| Weight loss per 5 kg | 6.3/3.4 mm Hg8 |
| Sodium reduction per 4.4 g salt reduction | 5.4/2.8 mm Hg9 |
| Increase in physical activity | 12.3/6.12 mm Hg10 |
| Reduction in alcohol consumption from 2 or more drinks per day | 5.5/4.0 mm Hg11 |
| DASH type diet | 5.2/2.6 mm Hg5, 12 |
In this study, we examine the potential impact of population interventions to reduce blood pressure on changes in prevalence and control of hypertension using data from a population‐based survey from China. We have examined both increases and decreases in blood pressure within the range expected from various degrees of changes in lifestyles from randomized controlled trials (Table 1). We also examined the impact on the prevalence and hypertension control indicators using both a 140/90 mm Hg threshold and a 130/80 mm Hg threshold.
2. METHOD AND SUBJECTS
This study was approved by the Ethics Committee of the Second Affiliated Hospital. The hypertension survey was conducted in the residents living in three villages of the countryside of Nanchang, Jiangxi, China from March 2017 to May of 2018. The initial survey results have been previously reported.13 There were 2130 adult residents living in the three villages that were surveyed. All of the adults were asked to participate, with 1540 adult residents (72.3%) agreeing and having three BP measurements over 1 week. Therefore, 72.3% of adults in the surveyed villages were included in this study. In the survey, age, diagnosis of hypertension, and use of antihypertensive treatment were collected. The exclusion criteria were acute coronary syndrome, acute stroke, acute heart failure, and atrial fibrillation. Patients with known peripheral artery disease and walking disabilities were also excluded.
In the study, all participants had three visits where BP was measured within a week. Blood pressure (BP) was measured in the primary health center by doctors. The subjects were advised to avoid cigarette smoking and consumption of coffee, tea, and alcohol for at least 30 minutes before the BP measurement. In each visit, the BP of the right arm was measured using an oscillometric BP monitor (Omron HEM‐7430) after a 5‐minute rest period. Measurements were taken three times at 1‐minute intervals, and the averages were recorded as the visit BP value.
Hypertension was defined as ≥140/90 mm Hg based on the definition used by many hypertension guidelines.14, 15, 16 Hypertension was also defined as ≥130/80 mm Hg as recommended in the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) High Blood Pressure Guideline17
Respondents were defined as having hypertension if their blood pressure met or exceeded the blood pressure threshold (140/90 or 130/ 80 mm Hg in different analyses) or they reported taking antihypertensive drugs within the last 2 weeks. Respondents were defined as having undiagnosed hypertension if they had blood pressure readings meeting the definition of hypertension but no history of a hypertension diagnosis and reported they were not taking antihypertensive drugs. Respondents were assessed as being treated for hypertension if they reported taking antihypertensive drugs within the last 2 weeks. Respondents were classified as having controlled hypertension if they reported taking antihypertensive medications within 2 weeks or had been diagnosed with hypertension and they had both systolic and diastolic blood pressure less than the respective threshold for defining hypertension.18
For the epidemiological definition, hypertension was based on the average of the first day BP values while the clinical definition of hypertension was based on the average of three visit BP readings.15 The hypertension prevalence based on the epidemiological or the clinical criteria was calculated and expressed as a percent of the total surveyed population.
The percent of the survey respondents with hypertension were assessed at the threshold for hypertension of 140/90 and 130/ 80 mm Hg. The blood pressure of respondents was increased and decreased by 2/1 mm Hg to a change of 10/5 mm Hg, and the percent with hypertension as well as the rates of not being aware of having hypertension, treatment, and control were assessed. All data were recorded on an Excel 2003 spreadsheet. Statistical analysis was performed using the Statistical Package for Social Science software 23.0 (SPSS). Data are expressed as means and standard deviations. Dichotomous variables expressed as numbers and percentages, the rates of the trends over the changes in BP, were analyzed with the chi‐square test; furthermore, Bonferroni method was used for pairwise comparison of the difference between the given changes BP and the BP threshold. A P value of <.05 was considered statistically.
3. RESULTS
One thousand, five hundred forty adult residents (21‐94 years, 62.8 ± 13.7 years) including 779 males and 761 females were included. There were 312 smokers, 8.6% were taking antihypertensive medications, and the mean blood pressure was 131.8/74.4 mm Hg. The characteristics of the respondents are in Table 2.
Table 2.
Characteristics of the survey respondents
| Respondent characteristics | Number ± SD (%) |
|---|---|
| Total | 1540 (100) |
| Men | 779（50.6） |
| Women | 761（49.4） |
| Age (average) | 62.8 ± 13.7 y |
| Body mass index (BMI) | 22.7 ± 3.4 kg/m2 |
| Smoker (%) | 312（20.3） |
| Antihypertensive drug treatment | 133 (8.6%) |
| Mean SBP (mm Hg) | 131.8 ± 74.4 |
| Mean DBP (mm Hg) | 74.4 ± 9.9 |
3.1. 140/90 mm Hg hypertension threshold
Overall, the prevalence of hypertension using the clinical definition was 33.4% while the rates of not being aware of having hypertension were 74.2%, antihypertensive drug treatment was 25.8%, and control was 9.7% (Table 3).
Table 3.
The impact of increases and decreases in population blood pressure BP (at intervals of 2/1 mm Hg) on hypertension prevalence, and rates of “unawareness” of hypertension diagnosis, antihypertensive drug treatment, and control using a hypertension threshold of 140/90 mm Hg or greater from a population blood pressure survey (n = 1540)
| BP change (mm Hg) | Epidemiologicala | Clinicala | ||||||
|---|---|---|---|---|---|---|---|---|
| Prevalence n (%) | Unawarenessb n (%) | Treated n (%) | Control n (%) | Prevalence n (%) | Unawarenessb n (%) | Treated n (%) | Control n (%) | |
| −10/5 |
390c (25.3) |
257c (65.9) |
133c (34.1) |
67c (17.2) |
340c (22.1) |
207c (60.9) |
133c (39.1) |
72c (21.2) |
| −8/4 |
431c (28.0) |
298 (69.1) |
133 (30.9) |
65c (15.1) |
368c (23.9) |
235 (63.9) |
133 (36.1) |
68c (18.5) |
| −6/3 |
461c (29.9) |
328 (71.1) |
133 (28.9) |
54c (11.7) |
399c (25.9) |
266 (66.7) |
133 (33.3) |
63 (15.8) |
| −4/2 |
509c (33.1) |
376 (73.9) |
133 (26.1) |
51 (10.0) |
433 (28.1) |
300 (69.3) |
133 (30.7) |
57 (13.2) |
| −2/1 |
555 (36.0) |
422 (76.0) |
133 (24.0) |
50 (9.0) |
466 (30.0) |
333 (71.5) |
133 (28.5) |
54 (11.6) |
| 0 |
611/1540 (39.7) |
478/611 (78.2) |
133/611 (21.8) |
43/611 (7.0) |
515/1540 (33.4) |
382/515 (74.2) |
133/515 (25.8) |
50/515 (9.7) |
| 2/1 |
679 (44.1) |
546 (80.4) |
133 (19.6) |
36 (5.3) |
574 (37.3) |
441 (76.8) |
133 (23.2) |
43 (7.5) |
| 4/2 |
743c (48.2) |
610 (82.1) |
133 (17.9) |
35 (4.7) |
637c (41.4) |
504 (79.1) |
133 (20.9) |
43 (6.8) |
| 6/3 |
817c (53.1) |
684 (83.7) |
133 (16.3) |
32 (3.9) |
688c (44.7) |
555 (80.7) |
133 (19.3) |
41 (6.0) |
| 8/4 |
865c (56.2) |
732 (84.6) |
133 (15.4) |
31 (3.6) |
770c (50.0) |
637c (82.7) |
133c (17.3) |
34c (4.4) |
| 10/5 |
917c (59.5) |
784c (85.5) |
133c (14.5) |
26c (2.8) |
823c (53.4) |
690c (83.8) |
133c (16.2) |
30c (3.6) |
| P‐valued | <.001 | <.001 | <.001 | <.001 | <.001 | <.001 | <.001 | <.001 |
The epidemiological data are based on the average of three readings at a single visit. The clinical data are based on the average of three visits.
Unawareness is defined as having high blood pressure but not having been diagnosed before the survey and not taking antihypertensive medication.
P < .05, compared with the 140/90 mm Hg
P value for trend in column.
The impact of interventions that would increase population blood pressure at 2/1 mm Hg intervals to 10/5 mm Hg are shown in Table 2. An increase in population blood pressure of 10/5 mm Hg would increase the prevalence of hypertension from 33.4% to 53.4% while reducing the hypertension control rate almost 2/3rds from 9.7% to 3.6%. The percent of those with hypertension treatment with a 10/5 mm Hg increase would be reduced from 25.8% to 16.2%.
Decreases in population blood pressure would have the opposite effect on hypertension indicators (Table 3). The reduction in population blood pressure by 10/5 mm Hg would reduce the prevalence of hypertension by 1/3rd to 22.1% while the hypertension control rate would increase to 21.2% and the treatment rate to 39.1%.
The impact on hypertension prevalence and control indicators using an epidemiological definition of hypertension rather than a clinical definition is similar but the hypertension prevalence and rate of being unaware of the diagnosis is higher and hypertension treatment and control rates lower with the epidemiological definition (Table 3).
3.2. 130/80 mm Hg hypertension threshold
Overall, the prevalence of hypertension using the clinical definition was 56.2% while the rate of not being aware of having hypertension was 84.6%, antihypertensive drug treatment 15.4%, and control 3.2% (Table 4).
Table 4.
The impact of increases and decreases in population blood pressure BP (at intervals of 2/1 mm Hg) on hypertension prevalence, and rates of “unawareness” of hypertension diagnosis, antihypertensive drug treatment, and control using a hypertension threshold of 130/80 mm Hg or greater from a population blood pressure survey (n = 1540)
| BP change (mm Hg) | Epidemiologicala | Clinicala | ||||||
|---|---|---|---|---|---|---|---|---|
| Prevalence (%) | Unawarenessb (%) | Treated (%) | Control (%) | Prevalence (%) | Unawarenessb (%) | Treated (%) | Control (%) | |
| −10/5 |
670c (43.5) |
537c (80.1) |
133c (19.9) |
41c (6.1) |
561c (36.4) |
428c (76.3) |
133c (23.7) |
44c (7.8) |
| −8/4 |
736c (47.8) |
603 (81.9) |
133 (18.1) |
34 (4.6) |
632c (41.0) |
499 (79.0) |
133 (21.0) |
40 (6.3) |
| −6/3 |
801c (52.0) |
668 (83.4) |
133 (16.6) |
33 (4.1) |
686c (44.5) |
553 (80.6) |
133 (19.4) |
40 (5.8) |
| −4/2 |
867c (56.3) |
734 (84.7) |
133 (15.3) |
32 (3.7) |
743c (48.2) |
610 (82.1) |
133 (17.9) |
38 (5.1) |
| −2/1 |
913 (59.3) |
780 (85.4) |
133 (14.6) |
30 (3.3) |
820 (53.2) |
687 (83.8) |
133 (16.2) |
30 (3.7) |
| 0 |
979 (63.6) |
846 (86.4) |
133/979 (13.6) |
25/979 (2.6) |
866 (56.2) |
733 (84.6) |
133/866 (15.4) |
28/866 (3.2) |
| 2/1 |
1037 (67.3) |
904 (87.2) |
133 (12.8) |
22 (2.1) |
954 (61.9) |
821 (86.1) |
133 (13.9) |
22 (2.3) |
| 4/2 |
1079 (70.1) |
946 (87.7) |
133 (12.3) |
18 (1.7) |
10 163 (66.0) |
883 (86.9) |
133 (13.1) |
17 (1.7) |
| 6/3 |
11 213 (72.8) |
988 (88.1) |
133 (11.9) |
9 (0.8) |
10 733 (69.7) |
940 (87.6) |
133 (12.4) |
13 (1.2) |
| 8/4 |
11 803 (76.6) |
1047 (88.7) |
133 (11.3) |
7c (0.6) |
11 293 (73.3) |
996 (88.2) |
133 (11.8) |
11c (1.0) |
| 10/5 |
12 263 (79.6) |
1093 (89.2) |
133 (10.8) |
6c (0.5) |
11 833 (76.8) |
1050 (88.8) |
133 (11.2) |
9c (0.8) |
| P‐valued | <.001 | <.001 | <.001 | <.001 | <.001 | <.001 | <.001 | <.001 |
The epidemiological data are based on the average of three readings at a single visit. The clinical data are based on the average reading from three visits over 1 wk.
Unawareness is defined as having high blood pressure but not having been diagnosed before the survey and not taking antihypertensive medication.
P < .05, compared with the 140/90 mm Hg
P value for trend in column.
The impact of interventions that would increase population blood pressure at 2/1 mm Hg intervals to 10/5 mm Hg are shown in Table 4. An increase in population blood pressure of 10/5 mm Hg would increase the prevalence of hypertension from 56.2% to 76.8% while reducing the hypertension control rate about 3/4ths from 3.2% to 0.8%. The percent of those with hypertension treated with a 10/5 mm Hg increase would be reduced from 15.4% to 11.2%.
Decreases in population blood pressure would have the opposite effect on hypertension indicators (Table 4). The reduction in population blood pressure by 10/5 mm Hg would reduce the prevalence of hypertension by 1/3rd to 36.4% while the hypertension control rate would more than double to 7.8% and the treatment rate increase almost 2/3rd to 23.7%.
The impact on hypertension prevalence and control indicators using an epidemiological definition of hypertension rather than a clinical definition is similar but the hypertension prevalence and rate of being unaware of the diagnosis is higher and hypertension treatment and control rates lower with the epidemiological definition (Table 4).
4. DISCUSSION
Changes in population blood pressure, in the range expected from substantive alterations in lifestyles that impact blood pressure, could have a major impact on the prevalence, awareness, treatment, and control rate of hypertension in China. The prevalence of hypertension, defined by a threshold of 140/90 mm Hg, varied from its current 33.4%‐53.4% with a population increase in blood pressure of 10/5 mm Hg and was reduced to 22.1% with a population reduction in blood pressure of 10/5 mm Hg. Similarly, the hypertension control rate was reduced from 9.7% to 3.6% by a population blood pressure increase of 10/5 mm Hg and improved to 21.2% by a reduction in population blood pressure of 10/5 mm Hg. Consistent changes were seen when an epidemiological vs a clinical definition of hypertension was considered or if the hypertension threshold was 130/80 mm Hg.
Previously, Cook et al previously modeled the impact of a 2 mm Hg reduction in population blood pressure on hypertension and cardiovascular disease rates in United States. The impact on cardiovascular disease rate of the 2 mm Hg population reduction in diastolic blood pressure was greater than that expected from antihypertensive treatment of all people with a diastolic blood pressure of ≥95 mm Hg, and diastolic hypertension prevalence (diastolic blood pressure ≥ 90 mm Hg) was reduced by 17%.19 Joffres et al20 found that a population reduction in blood pressure of 5.06/2.7 mm Hg related to salt reduction in Canada would reduce the prevalence of hypertension by about 30% and almost double the hypertension control rate. In our analysis, a 4/2 mm Hg reduction in population blood pressure (using a similar epidemiological definition as Cook) was 16.6%. Differences in the “true” population distribution of blood pressure (hypertension prevalence 39.7% in our study vs 19.4% in Joffres) and different methodologies for assessing blood pressure are likely to explain the differences in our results vs those of Joffres et al Increases in blood pressure of 20/10 mm Hg have a linear doubling impact on cardiovascular disease; hence, changes in population blood pressure in the magnitude examined in this study would be expected to have a major impact on cardiovascular disease rates in China.19, 20, 21 To our knowledge, ours is the only study to report the impact of increases in population BP on major hypertension indicators and to examine a multitude of blood pressure changes that are within the realm to those expected by major public health interventions.
Both increases and decreases in population blood pressure can occur with population changes in the major determinants of blood pressure (eg, diet, physical activity, obesity). Randomized controlled trials have confirmed lifestyle changes can significantly impact blood pressure (Table 1). In addition, several countries that have introduced substantive public health policy changes have subsequently observed significant changes in population blood pressure. For example, in Finland there were reductions in population diastolic blood pressure of over 8 mm Hg during the implementation of programs to reduce dietary salt, improve nutrition and physical activity, and enhance the clinical management of cardiovascular risks.22 A salt reduction program in the United Kingdom also had a significant impact on salt consumption, blood pressure, and cardiovascular disease.23 Major social change can also impact population blood pressure. Social upheaval in former Soviet Union countries following the breakup of the Soviet Union were marked by increases in blood pressure and cardiovascular disease with some countries subsequently improving and others continuing to have some of the world's highest rates of cardiovascular risks and disease.24
Our study has several limitations. The analyses assume instantaneous changes in population blood pressure with no changes in clinical management of hypertension. In addition, the analyses using a 130/80 mm Hg threshold may also have limited face validity for clinicians in China given the national guidance is to use 140/90 mm Hg as the diagnostic threshold. Hence, the findings need to be viewed from a theoretical perspective rather than the likely results that could occur with the implementation of major public policies that would occur over years and be likely to impact clinical practice. The survey was also conducted in a single region of China and is not directly generalizable to all of China. The prevalence of hypertension in provinces of China ranges from 18% to 37%, while the prevalence of hypertension was 39.7% in our study.1 Hypertension indicators (rates of awareness, treatment and control) also have regional variations within China.1 The ability to generalize the findings may also be limited when applying the analysis to other countries. Nevertheless, many countries will have similar blood pressure distributions, and most low‐/middle‐income countries have similar rates of hypertension prevalence, awareness, treatment, and control and will have relatively similar impacts of shifts in population distribution of blood pressure.25, 26, 27 The study findings are also impacted by the number of visits used to assess blood pressure. Hence, in this analysis we examined the impact of using average blood pressures from a single visit or three visits to define hypertension. Nearly all population surveys assess blood pressure at a single visit which inflates the prevalence of hypertension compared to the average blood pressure of three visits (Table 3). The data using the epidemiological definition therefore will be more representative of results from blood pressure surveys that assess single visit blood pressure following an intervention that changes population blood pressure. The average of three visits used for the clinical definition in this study will be more representative of the usual basil blood pressure of the population, and therefore, the true impact of interventions that change population blood pressure. We also used both an older and more conventional threshold for defining hypertension (140/90 mm Hg) and the newer threshold (130/80 mm Hg) for hypertension to allow interpretation of the data with both thresholds.
Large changes in the prevalence of hypertension and its clinical indicators can be seen with changes in lifestyles that could be attained with public health policies. Many of the policies are outlined by the World Health Organization and are either highly cost‐effective or cost saving.6 Policies to reduce dietary salt have a return on investment of 13‐19$ for every dollar invested and are particularly relevant in China where the salt intake is very high.28, 29, 30 Policies to reduce population blood pressure do not compete with health services policies to clinically improve blood pressure treatment and control but as our study indicates reducing population blood pressure will significantly enhance the awareness, treatment, and control rates reducing the clinical burden of disease.31, 32 Although our data are from China, the concepts are broadly applicable to other countries and especially those with a high prevalence rate and low rates of treatment and control. Our analysis of the impact of increases in blood pressure should concern policy makers in countries where there is a lack of political will to prevent deterioration in population diet, activity, obesity, and alcohol consumption and support policy change where there is political will to introduce healthy public policies.
CONFLICT OF INTEREST
NRCC was a paid consultant to the Novartis Foundation (2016‐2017) to support their program to improve hypertension control in low‐ to middle‐income countries which includes travel support for site visits and a contract to develop a survey. NRCC has provided paid consultative advice on accurate blood pressure assessment to Midway Corporation (2017) and is an unpaid member of World Action on Salt and Health (WASH). The other authors have no conflicts of interest to declare.
AUTHOR CONTRIBUTIONS
Wei‐guo Fan, Feng Xie, and Yi‐rong Wan: Conducted the survey and data analysis, reviewed and approved the final manuscript. Norm RC Campbell: Developed the concept, drafted and revised the manuscript and approved the final version. Hai Su: Oversaw the survey and data analysis, assisted in the analysis design and writing of the manuscript and approved the final version.
Fan W‐G, Xie F, Wan Y‐R, Campbell NRC, Su H. The impact of changes in population blood pressure on hypertension prevalence and control in China. J Clin Hypertens. 2020;22:150–156. 10.1111/jch.13820
Contributor Information
Norm R. C. Campbell, Email: ncampbel@ucalgary.ca.
Hai Su, Email: suyihappy@sohu.com.
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