You are here

Article Text

Article menu

Download PDFPDF

Research report
Prevalence of hypertension subtypes in 2011 and the trends from 1991 to 2011 among Chinese adults
  1. Su-Fen Qi1,
  2. Bing Zhang2,
  3. Hui-Jun Wang2,
  4. Jing Yan3,
  5. Ying-Jun Mi1,
  6. Dian-Wu Liu1,
  7. Qing-Bao Tian1
  1. 1Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Shijiazhuang, Hebei, China
  2. 2National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China
  3. 3Research Center of Electron Microscope, Hebei Medical University, Shijiazhuang, Hebei, China
  1. Correspondence to Dr Qing-Bao Tian, Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang 050000, Hebei, China; tqb1980{at}hebmu.edu.cn

Abstract

Background This study aims to estimate the current prevalence and trends of hypertension subtypes among Chinese adults from 1991 to 2011.

Methods We analysed the measurements of systolic and diastolic blood pressure among adults aged ≥18 years from the China Health and Nutrition Survey (CHNS) 1991–2011. The prevalence was age-adjusted to the 2010 census of Chinese adults.

Results The adjusted prevalence in 2011 was 20.9% (95% CI 20.2% to 21.6%) of hypertension, 3.30% (95% CI 2.99% to 3.62%) of isolated systolic hypertension, 4.44% (95% CI 4.08% to 4.80%) of isolated diastolic hypertension, 4.11% (95% CI 3.76% to 4.46%) of systolic–diastolic hypertension and 9.01% (95% CI 8.51% to 9.51%) of current use of antihypertensive medication, respectively. From 1991 to 2011, the prevalence increased from 15.6% to 20.9% for hypertension (p<0.001) and from 3.04% to 3.30% for isolated systolic hypertension (p<0.001). However, the prevalence decreased from 4.77% to 4.44% for isolated diastolic hypertension (p=0.023) and from 5.27% to 4.11% for systolic–diastolic hypertension (p<0.001). Consistent with these findings, the percentage of current use of antihypertensive medication increased from 2.55% to 9.01%, which accounted for approximately 43.1% of the total number of cases in 2011. Importantly, only 36.9% (equivalent to 17.5% of the total number of hypertensive people) of cases of current use of antihypertensive medication were adequately controlled.

Conclusions Both the prevalence of hypertension and the percentage of current use of antihypertensive medication significantly increased from 1991 to 2011. Currently, about one-fifth of Chinese adults are hypertensive; however, only 17.5% of hypertension is controlled.

  • EPIDEMIOLOGY
  • HYPERTENSION
  • OBESITY

https://doi.org/10.1136/jech-2015-206492

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Introduction

    Cardiovascular disease (CVD) is the leading cause of death worldwide, accounting for 30% of deaths globally.1 In China, the burden of major CVDs has increased from 1990 to 2010,2 and CVD deaths resulted in a 4.79-year life expectancy loss in the Chinese population.3 Hypertension, as a major modifiable risk factor for CVD, accounts for approximately 45% of global CVD morbidity and mortality.4 Globally, the overall prevalence in adults ≥25 years of age was 40% in 2008, with the highest being 46% in Africa.5 ,6 Previous studies in China have suggested that the prevalence of hypertension in adults was from 14.5% in 1991 to 34.0% in 2012.7–10 Since hypertension is associated with wide phenotypic variability, it can be divided into the following subtypes: isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH) and systolic–diastolic hypertension (SDH).11 ,12 These subtypes may provide important information concerning the causation of haemodynamic and/or structural abnormalities that contribute to hypertension.11–16 ISH is associated with increased large artery stiffness,13 ,17 which is more common in the elderly,12 and age, body mass index (BMI) and smoking are significant independent risk factors of ISH.17–19 However, the development of IDH and SDH is associated with increased peripheral vascular resistance,13 ,16 which is more prevalent among young adults,12 and IDH is mainly affected by BMI.20

    On the basis of data obtained from the China Health and Nutrition Survey (CHNS), the prevalence of hypertension has increased from 14.5% in 1991 to 21.4% in 2009.21 However, the prevalence and trends of hypertension subtypes among Chinese adults are still unknown. To further understand these aspects of hypertension in Chinese adults, we present a comprehensive analysis of the trends of the prevalence and proportion of hypertension subtypes among the Chinese population using data obtained from CHNS 1991–2011. In addition, we calculated the crude prevalence of hypertension stratified by age and BMI to estimate the age-specific effect of BMI on hypertension in CHNS 2011.

    Methods

    Study design

    The CHNS is an international collaborative project between the National Institute for Nutrition and Food Safety, the Chinese Center for Disease Control and Prevention, and the University of North Carolina at Chapel Hill and is currently the only large-scale longitudinal, household-based survey in China.22 The first round of CHNS was conducted in 1989, and was subsequently performed in 1991, 1993, 1997, 2000, 2004, 2006, 2009 and 2011 (http://www.cpc.unc.edu/projects/china). The CHNS began with eight provinces and a ninth, Heilongjiang, was added in 1997, with three of the largest municipalities including Beijing, Shanghai and Chongqing in 2011. These provinces account for approximately 56% of China's population, varying substantially in geography, economic development, public resources and health indicators.23 A detailed description of the survey design and procedures has been published elsewhere.22 ,24 ,25

    Study participants

    Analysis was based on data obtained from the CHNS conducted in 1991, 1993, 1997, 2000, 2004, 2006, 2009 and 2011, because the data were not collected for all age groups in the 1989 survey. This study focused on adults aged 18 years or older in each survey year and the data provided information on age, gender, the use of antihypertensive medications and detailed physical examinations, including systolic blood pressure (SBP), diastolic blood pressure (DBP), height and weight. To limit biases caused by pre-existing factors, participants who had been diagnosed with pregnancy or lactation and participants with missing information on SBP or DBP or extreme or implausible blood pressure (BP) values (SBP–DBP <10 mm Hg) were excluded. In addition, to calculate the age-specific effect of BMI on the prevalence of hypertension in CHNS 2011, participants with missing information on height, weight, extreme or implausible height (<120.0 cm) or BMI (BMI <15.0 or >40.0 kg/m2) values were excluded.

    Anthropometric methods and definitions of hypertension

    BP was based on the mean of three measurements collected after 10 min of seated rest and a 30 s interval between cuff inflations by experienced physicians using standard mercury sphygmomanometers.26 In this process, regularly calibrated mercury sphygmomanometers with appropriate-sized cuffs were employed. SBP was measured at the first appearance of a pulse sound (Korotkoff phase I), and DBP at the disappearance of the pulse sound (Korotkoff phase V).27 Three measurements of SBP or DBP were averaged as the corresponding BP values to reduce the effect of measurement errors. BMI was calculated as participants’ weight in kilograms divided by their height in metres squared (kg/m2).

    Consistent with the WHO conventions (1999) and the seventh Joint National Commission guidelines (JNC7),26 hypertension was defined as SBP/DBP ≥140/90 mm Hg or current use of antihypertensive medication. The following hypertension subtypes were included in the analysis: (1) ISH, defined as SBP ≥140 mm Hg and DBP <90 mm Hg; (2) IDH, defined as SBP <140 mm Hg and DBP ≥90 mm Hg; (3) SDH, defined as SBP ≥140 mm Hg and DBP ≥90 mm Hg and (4) current use of antihypertensive medication. However, we were unable to distinguish between ISH, IDH or SDH in hypertension cases of current use of antihypertensive medication because their original BP values were unknown.26

    Statistical methods

    Analyses were stratified by gender, age and BMI. On the basis of the patients’ age at the interview during 1991–2011, the participants were stratified into the following age groups: 18–39, 40–59 and ≥60 years and/or into the following BMI groups: <20, 20–21, 22–23, 24–25, 26–27 and ≥28 kg/m2. Taking into account unequal probabilities of selection, the values of hypertension and subtypes were adjusted by the direct method to the 2010 census of the Chinese adults using the corresponding age groups. The age-adjusted prevalence estimates of ISH, IDH and SDH, together with the use of antihypertensive medication from the most recent data (the CHNS of 2011), were compared using the χ2 test between males and females as well as a comparison of different age groups. Trends in the age-adjusted prevalence of hypertension and subtypes among participants and trends of the proportion of hypertension subtypes from 1991 to 2011 were assessed by using linear-by-linear trend testing.

    Statistical analysis was performed using SPSS software for Windows V.13.0. The statistical significance was determined as a two-tailed p<0.05.

    Results

    After excluding ineligible participants, a total of 74 887 participants aged ≥18 years at baseline were included. The selection procedure of the participants in this study is summarised in figure 1.

    Figure 1
    Figure 1

    Flow chart illustrating the sample selection procedure (CHNS, China Health and Nutrition Survey).

    The anthropometric characteristics of all of the participants in eight waves of the CHNS 1991–2011 are displayed in table 1. The mean age of the participants increased from 41.2 (95% CI 40.9 to 41.6) years in 1991 to 46.9 (95% CI 46.5 to 47.2) years in 2011. The percentage of SBP ≥140 mm Hg among all participants increased from 9.26% in 1991 to 17.5% in 2011. A similar significant trend was observed in DBP ≥90 mm Hg.

    View this table:
    Table 1

    Characteristics of the participants aged 18 years and older: CHNS 1991–2011

    Age-adjusted prevalence of hypertension and subtypes in CHNS 2011

    According to CHNS 2011, 20.9% of the Chinese adults were hypertensive (table 2). The subtype-specific prevalence of hypertension was 3.30% (95% CI 2.99% to 3.62%) of ISH, 4.44% (95% CI 4.08% to 4.80%) of IDH, 4.11% (95% CI 3.76% to 4.46%) of SDH and 9.01% (95% CI 8.51% to 9.51%) of the current use of antihypertensive medication.

    View this table:
    Table 2

    Trends in the prevalence of hypertension and subtypes among Chinese adults aged 18 years or older: the CHNS 1991–2009 (% (95% CI))*

    The prevalence was significantly greater for males compared to females (23.4% vs 18.7%; χ2=40.7, p<0.001; table 2). Similar significant differences were observed in the prevalence of IDH (6.23% vs 2.92%; χ2=310, p<0.001) and SDH (5.26% vs 3.09%; χ2=310, p<0.001) according to gender. However, there was no significant difference between males and females for the prevalence of ISH (3.44% vs 3.21%; χ2=1.19, p=0.275). In contrast, the prevalence of the use of antihypertensive medication was significantly greater for females compared to males (8.49% vs 9.52%, χ2=59.2, p<0.001).

    The prevalence of hypertension in 2011 increased with age, with the highest prevalence being 47.8% (95% CI 45.4% to 50.1%) and 50.4% (95% CI 48.1% to 52.6%) in the age group of ≥60 years in males and females, respectively (see online supplementary table S1). Similar increasing trends were observed in the ISH and the use of antihypertensive medications. However, the highest prevalence of IDH was 8.42% (95% CI 7.38% to 9.45%) and 4.45% (95% CI 3.72% to 5.18%) in the age group of 40–59 years in males and females, respectively. Interestingly, the highest prevalence of SDH was 10.4% (95% CI 9.24% to 11.5%) in males aged 40–59 years and 5.84% (95% CI 4.79% to 6.88%) in females in the age group of ≥60 years.

    Trend of age-adjusted prevalence of hypertension and subtypes

    Secular changes in the age-adjusted prevalence of hypertension and subtypes among Chinese adults from 1991 to 2011 are presented in table 2. From 1991 to 2011, the prevalence increased from 15.6% to 20.9% for hypertension (p<0.001) and from 3.04% to 3.30% for isolated systolic hypertension; however, the prevalence was decreased from 4.77% to 4.44% for IDH; and from 5.27% to 4.11% for SDH. Consistent with these findings, the prevalence of the current use of antihypertensive medication increased from 2.55% to 9.01% (p<0.001). Details of age-specific and gender-specific prevalence of hypertension and subtypes are shown in online supplementary table S1.

    Crude prevalence of hypertension stratified by age and BMI in 2011

    To further clarify the effects of BMI on age-specific prevalence of hypertension, we calculated crude prevalence to estimate the age-specific effect of BMI in CHNS 2011 (figure 2). The BMI-specific prevalence increased sharply when BMI ≥24 kg/m2 in groups of those aged 18–39 and ≥60, indicating that body weight has a strong effect on hypertension and optimal BMI should be lower than 24 in these two age groups. In contrast, the BMI-specific prevalence of hypertension increased gradually without platforms in the group of those aged 40–59. Interestingly, the prevalence in the group of those aged 18–39 and having a BMI of 26–27 (13.1%, 95% CI 9.39% to 16.9%) was similar to that in the group of those aged 40–59 years and having a BMI of 20–21 (12.9%, 95% CI 10.7% to 15.1%) (figure 2), suggesting that the effect of increasing 6 kg/m2 on the risk of hypertension was equivalent to that of increasing age by 20 years. A similar pattern was observed in the group of those aged 40–59 years and having a BMI of 26–27 (33.5%, 95% CI 30.5% to 36.5%) and in the group of those aged ≥60 years and having a BMI <20 (30.6%, 95% CI 26.3% to 34.9%). Taken together, our findings suggest that the effect of increasing 6–8 kg/m2 on the risk of hypertension could be equivalent to that of increasing age by 20 years.

    Figure 2
    Figure 2

    Crude prevalence of hypertension stratified by age and body mass index (BMI, kg/m2) in 2011. The prevalence of hypertension and 95% CIs (p value, 95% CI) of hypertension are shown. The bars indicate 95% CI.

    Trend of the proportion of hypertension subtypes from 1991 to 2011

    In CHNS 2011, a total of 3501 individuals had hypertension. Among these cases, 593 (16.9%), 573 (16.4%), 667 (19.1%) and 1668 (47.6%) patients had ISH, IDH, SDH and currently used antihypertensive medication, respectively (figure 3). In individuals who currently used antihypertensive medication, 1053 (63.1%) patients were uncontrolled, including 394 (23.6%) with ISH, 137 (8.20%) with IDH and 522 (31.4%) with SDH. In contrast, only 615 (36.9%) patients (equivalent to 17.5% of the total number of hypertensive people) taking medication were adequately controlled.

    Figure 3
    Figure 3

    Prevalence cases of hypertension and subtypes among Chinese aged ≥18 years in CHNS 2011. Prevalence cases of hypertension in the total (A), number of males (C), and females (E); cases were controlled into systolic blood pressure ≤140 mm Hg and diastolic blood pressure ≤90 mm Hg among people taking antihypertensive medication in the total (B), number of males (D) and females (F). CHNS, China Health and Nutrition Survey; ISH, isolated systolic hypertension; IDH, isolated diastolic hypertension; SDH, systolic–diastolic hypertension; MED, currently taking antihypertensive medication; Controlled, hypertension was controlled into systolic blood pressure ≤140 mm Hg and diastolic blood pressure ≤90 mm Hg among people taking antihypertensive medication.

    The trend of the proportion of hypertension subtypes from 1991 to 2011 is observed in figure 3. The proportion of individuals taking antihypertensive medication among hypertension cases was increased from 16.1% in 1991 to 47.6% in 2011 (p<0.001) (figure 3A). Consistent with these findings, the proportion of ISH, IDH and SDH decreased (p<0.001). Similarly, the proportion of individuals who were controlled into SBP ≤140 mm Hg and DBP ≤90 mm Hg among people who used antihypertensive medication increased from 18.5% in 1991 to 36.9% in 2011 (p<0.001) (figure 3B). The same increasing trend was observed in the proportion of ISH (p<0.001), where the trend of the proportion of IDH showed no significant change (p=0.117). Accordingly, the proportion of SDH among people who used antihypertensive medication decreased from 54.5% to 31.3% (p<0.001).

    Period effect on prevalence of hypertension and subtypes during 1991–2011

    To further clarify the period (1991–2011) effect on hypertension, the age-specific (40, 50 and 60 years) prevalence in different periods (1991–2000, 2000–2011 and 1991–2011) was analysed (figure 4). The prevalence of hypertension increased from 9.84% in 1991 to 36.6% in 2011 in males aged 50 years, which reflected the period effect on the age-specific prevalence of hypertension over the period of 1991–2011. However, we could not find a period effect in other age groups (figure 4A). A similar period effect was found in the prevalence of ISH (figure 4B), which increased over the period of 1991–2011 in males aged 50 and 60 years. There was no period effect on the age-specific prevalence of IDH even when stratified by gender (figure 4C). The prevalence of SDH decreased from 17.4% to 9.33% in males and from 13.8% to 5.97% in females aged 60 years over the period of 1991–2011 (figure 4D). In contrast, the prevalence of using antihypertensive medication increased from 6.52% to 18.7% in males and from 6.90% to 20.9% in females aged 60 years over the same period (figure 4E).

    Figure 4
    Figure 4

    Age-adjusted prevalence of hypertension and subtypes in males and females in the age group of 40, 50 and 60 years over the periods of 1991–2000, 2000–2011 and 1991–2011 in China (ISH, isolated systolic hypertension; IDH, isolated diastolic hypertension; SDH, systolic–diastolic hypertension; MED, currently taking antihypertensive medication).

    Discussion

    This study reported the recent prevalence and trends of hypertension subtypes as well as the use of antihypertensive medications among Chinese adults aged 18 years or older, based on the CHNS from 1991 to 2011. Compared with 1991, the prevalence increased from 15.6% to 20.9% for hypertension and from 3.04% to 3.30% for ISH; however, the prevalence decreased from 4.77% to 4.44% for IDH and from 5.27% to 4.11% for SDH. Consistent with these findings, the percentage of current use of antihypertensive medication increased from 2.55% to 9.01%, which accounted for approximately 43.1% of the number of cases in 2011. Importantly, only 36.9% (equivalent to 17.5% of the total number of hypertensive people) of cases taking medication were adequately controlled.

    The present data showed a striking increase in the prevalence of hypertension from 1246 (15.6%) to 3501 (20.9%) in Chinese adults based on the CHNS 1991–2011, which is equivalent to 222 million individuals. A similar trend was observed in studies based on data obtained from the national survey data in China during 1991–20027 ,28 and CHNS 1991–2009.21 The data taken together showed that the prevalence of hypertension in China has been increasing over the past 20 years.

    The prevalence of hypertension was 22.9% in CHNS 2009 and 20.9% in CHNS 2011 in our study, which were lower than the values reported by recent studies.10 ,29 These discrepant findings resulted from the differential age of the participants. For example, we used one database of CHNS aged ≥18 years, whereas Li et al10 used integrated data obtained from 48 independent studies with participants aged 20–79 years. However, this discrepancy could have resulted from a different population used for calculating the age-adjusted prevalence. For example, we used the 2010 census data with 22.9% in CHNS 2009, whereas Xi et al21 used the 2000 census of Chinese adults adjusting with 21.4% in CHNS 2009.

    The percentage of the current use of antihypertensive medications was 9.01% in 2011, which accounted for approximately 43.1% among the total hypertensive people in 2011. Importantly, only 36.9% (equivalent to 17.5% among the total number of hypertensive people) of cases among patients taking medication were adequately controlled in our study, which was equivalent to 35.3 million individuals who were under control among the 95.7 million individuals using antihypertensive medication in CHNS 2011. These percentages of treatment and control of hypertension were higher compared to previous studies, in which treatment and control of the total number of the total hypertensive people, and control among patients taking medication were 34.1%, 9.3% and 27.4%, respectively, in 2009,29 and 35.2%, 11.2% and 31.8%, respectively, in 2010.10 In a previous study in CHNS 2009, the treatment and control of hypertension in the total number of hypertensive people and of patients taking medication were 22.8%, 6.1% and 33.1%, respectively, in 2009.21 These inconsistent data indicated the percentage of hypertension control in all hypertensive people and increased more rapidly in patients taking medication.

    The results of the age-specific effect of BMI on the prevalence of hypertension indicated that body weight had a strong effect on hypertension and optimal BMI, which was lower than 24 in the group of those aged 18–39 and ≥60 years; however, the BMI-specific prevalence of hypertension increased gradually without platforms in the group of those aged 40–59 years in CHNS 2011. These above results suggested that overweight and obesity are associated with the prevalence of hypertension in Chinese adults.

    Both the prevalence of hypertension and the percentage of the current use of antihypertensive medication increased significantly from 1991 to 2011. Currently, about one-fifth of Chinese adults are hypertensive; however, the overall treatment and control of hypertension (in hypertensive individuals) increased over time, but are still unacceptably low. Taken together, our results suggest an urgent need for controlling modifiable risk factors (particularly in those maintaining a BMI <24 kg/m2 for life, which is important to control hypertension) and a national hypertension education programme to improve the prevention, detection, treatment and control of hypertension in China, with the ultimate goal of lowering hypertension-related morbidity and mortality.

    Study limitations

    Some limitations should be considered when interpreting our data. First, this study is limited due to its cross-sectional nature; thus, cause and effect could not be established. Second, other social and environmental variables such as physical activity and diet as well as geographic regions, which may have an impact on hypertension, were not considered. Third, although three BP measurements were obtained to estimate the average, all of them were obtained on a single visit, which may result in an overestimation of uncontrolled hypertension. However, this effect should be minimised for the within-sample comparison.21 Despite these limitations, we had a large sample size and all BP measurements were performed at the study subjects’ homes, which would minimise the white-coat hypertension effect. Finally, since the CHNS population is not a representative sample, caution should be taken when generalising these results to the whole national population.

    Conclusions and perspectives

    Both the prevalence of hypertension and the percentage of the current use of antihypertensive medication increased significantly from 1991 to 2011. Currently, about one-fifth of Chinese adults are hypertensive; however, only 17.5% of hypertension is controlled. Taking into account the high prevalence of hypertension and low hypertension treatment and control rates, these data underscore the critical need to determine an effective way for hypertension prevention and control in China.

    What is already known on this subject

    • The prevalence of hypertension has increased in the previous study. However, the prevalence and trends of hypertension subtypes among Chinese adults are still unknown. This study aims to estimate the current prevalence and trends of hypertension subtypes among Chinese adults from 1991 to 2011.

    What this study adds

    • This study showed the trends of hypertension subtypes among Chinese adults from 1991 to 2011.

    References

    1. ↵
      1. Hong Y
      . Burden of cardiovascular disease in Asia: big challenges and ample opportunities for action and making a difference. Clin Chem 2009;55:1450–2. doi:10.1373/clinchem.2009.125369
      OpenUrlFREE Full Text
    2. ↵
      1. Yang G,
      2. Wang Y,
      3. Zeng Y, et al
      . Rapid health transition in China, 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet 2013;381:1987–2015. doi:10.1016/S0140-6736(13)61097-1
      OpenUrlCrossRefPubMedWeb of Science
    3. ↵
      1. Fan J,
      2. Li GQ,
      3. Liu J, et al
      . Impact of cardiovascular disease deaths on life expectancy in Chinese population. Biomed Environ Sci 2014;27:162–8. doi:10.3967/bes2014.037
      OpenUrlPubMed
    4. ↵
      1. Ezzati M,
      2. Vander Hoorn S,
      3. Lawes CM, et al
      . Rethinking the “diseases of affluence” paradigm: global patterns of nutritional risks in relation to economic development. PLoS Med 2005;2:e133. doi:10.1371/journal.pmed.0020133
      OpenUrlCrossRefPubMed
    5. ↵
      World Health Organization. World health statistics 2014. 2014:121.
    6. ↵
      1. Alwan A,
      2. Armstrong T,
      3. Bettcher D, et al
      . Global status report on noncommunicable diseases. 2010:21–2.
    7. ↵
      1. Wu X,
      2. Duan X,
      3. Gu D, et al
      . Prevalence of hypertension and its trends in Chinese populations. Int J Cardiol 1995;52:39–44. doi:10.1016/0167-5273(95)02443-Z
      OpenUrlCrossRefPubMedWeb of Science
    8. ↵
      1. Gao Y,
      2. Chen G,
      3. Tian H, et al
      . Prevalence of hypertension in china: a cross-sectional study. PLoS ONE 2013;8:e65938. doi:10.1371/journal.pone.0065938
      OpenUrlCrossRefPubMed
    9. ↵
      1. Ke L,
      2. Ho J,
      3. Feng J, et al
      . Prevalence, awareness, treatment and control of hypertension in Macau: results from a cross-sectional epidemiological study in Macau, China. Am J Hypertens 2015;28:159–65. doi:10.1093/ajh/hpu121
      OpenUrlAbstract/FREE Full Text
    10. ↵
      1. Li D,
      2. Lv J,
      3. Liu F, et al
      . Hypertension burden and control in mainland China: analysis of nationwide data 2003–2012. Int J Cardiol 2015;184:637–44. doi:10.1016/j.ijcard.2015.03.045
      OpenUrlCrossRefPubMed
    11. ↵
      1. Franklin SS,
      2. Pio JR,
      3. Wong ND, et al
      . Predictors of new-onset diastolic and systolic hypertension: the Framingham Heart Study. Circulation 2005;111:1121–7. doi:10.1161/01.CIR.0000157159.39889.EC
      OpenUrlAbstract/FREE Full Text
    12. ↵
      1. Franklin SS,
      2. Jacobs MJ,
      3. Wong ND, et al
      . Predominance of isolated systolic hypertension among middle-aged and elderly US hypertensives: analysis based on National Health and Nutrition Examination Survey (NHANES) III. Hypertension 2001;37:869–74. doi:10.1161/01.HYP.37.3.869
      OpenUrlCrossRef
    13. ↵
      1. Franklin SS,
      2. Gustin W IV.,
      3. Wong ND, et al
      . Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation 1997;96:308–15. doi:10.1161/01.CIR.96.1.308
      OpenUrlAbstract/FREE Full Text
    14. ↵
      1. Verdecchia P,
      2. Angeli F
      . Natural history of hypertension subtypes. Circulation 2005;111:1094–6. doi:10.1161/01.CIR.0000158690.78503.5F
      OpenUrlFREE Full Text
    15. ↵
      1. Saladini F,
      2. Dorigatti F,
      3. Santonastaso M, et al
      . Natural history of hypertension subtypes in young and middle-age adults. Am J Hypertens 2009;22:531–7. doi:10.1038/ajh.2009.21
      OpenUrlAbstract/FREE Full Text
    16. ↵
      1. Franklin SS
      . Arterial stiffness and hypertension: a two-way street? Hypertension 2005;45:349–51. doi:10.1161/01.HYP.0000157819.31611.87
      OpenUrlCrossRef
    17. ↵
      1. Wilking SV,
      2. Belanger A,
      3. Kannel WB, et al
      . Determinants of isolated systolic hypertension. JAMA 1988;260:3451–5. doi:10.1001/jama.1988.03410230069030
      OpenUrlCrossRefPubMedWeb of Science
    18. ↵
      1. Midha T,
      2. Idris M,
      3. Saran R, et al
      . Isolated systolic hypertension and its determinants—a cross-sectional study in the adult population of Lucknow district in North India. Indian J Community Med 2010;35:89–93. doi:10.4103/0970-0218.62579
      OpenUrlCrossRefPubMed
    19. ↵
      1. Grebla RC,
      2. Rodriguez CJ,
      3. Borrell LN, et al
      . Prevalence and determinants of isolated systolic hypertension among young adults: the 1999–2004 US National Health And Nutrition Examination Survey. J Hypertens 2010;28:15–23. doi:10.1097/HJH.0b013e328331b7ff
      OpenUrlCrossRefPubMedWeb of Science
    20. ↵
      1. Yeh CJ,
      2. Pan WH,
      3. Jong YS, et al
      . Incidence and predictors of isolated systolic hypertension and isolated diastolic hypertension in Taiwan. J Formos Med Assoc 2001;100:668–75.
      OpenUrlPubMed
    21. ↵
      1. Xi B,
      2. Liang Y,
      3. Reilly KH, et al
      . Trends in prevalence, awareness, treatment, and control of hypertension among Chinese adults 1991–2009. Int J Cardiol 2012;158:326–9. doi:10.1016/j.ijcard.2012.04.140
      OpenUrlCrossRefPubMed
    22. ↵
      1. Popkin BM,
      2. Du S,
      3. Zhai F, et al
      . Cohort Profile: the China Health and Nutrition Survey—monitoring and understanding socio-economic and health change in China, 1989–2011. Int J Epidemiol 2010;39:1435–40. doi:10.1093/ije/dyp322
      OpenUrlFREE Full Text
    23. ↵
      1. Du T,
      2. Sun X,
      3. Yin P, et al
      . Increasing trends in central obesity among Chinese adults with normal body mass index, 1993–2009. BMC Public Health 2013;13:327. doi:10.1186/1471-2458-13-327
      OpenUrlCrossRefPubMed
    24. ↵
      1. Popkin BM,
      2. Paeratakul S,
      3. Zhai F, et al
      . Dietary and environmental correlates of obesity in a population study in China. Obes Res 1995;3(Suppl 2):135s–43s. doi:10.1002/j.1550-8528.1995.tb00456.x
      OpenUrl
    25. ↵
      1. Zhang B,
      2. Zhai FY,
      3. Du SF, et al
      . The China Health and Nutrition Survey, 1989–2011. Obes Rev 2014;15(Suppl 1):2–7. doi:10.1111/obr.12119
      OpenUrl
    26. ↵
      1. Lenfant C,
      2. Chobanian AV,
      3. Jones DW, et al
      ., Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7): resetting the hypertension sails. Hypertension 2003;41:1178–9. doi:10.1161/01.HYP.0000075790.33892.AE
      OpenUrlCrossRef
    27. ↵
      1. Nguyen TT,
      2. Adair LS,
      3. He K, et al
      . Optimal cutoff values for overweight: using body mass index to predict incidence of hypertension in 18- to 65-year-old Chinese adults. J Nutr 2008;138:1377–82.
      OpenUrlAbstract/FREE Full Text
    28. ↵
      1. Wu Y,
      2. Huxley R,
      3. Li L, et al
      . Prevalence, awareness, treatment, and control of hypertension in China: data from the China National Nutrition and Health Survey 2002. Circulation 2008;118:2679–86. doi:10.1161/CIRCULATIONAHA.108.788166
      OpenUrlAbstract/FREE Full Text
    29. ↵
      1. Wang J,
      2. Zhang L,
      3. Wang F, et al
      . Prevalence, awareness, treatment, and control of hypertension in China: results from a national survey. Am J Hypertens 2014;27:1355–61. doi:10.1093/ajh/hpu053
      OpenUrlAbstract/FREE Full Text
    View Abstract

    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • S-FQ and BZ contributed equally and share first authorship.

    • Contributors Q-BT contributed to all aspects of the research and writing process and takes final responsibility for the paper. S-FQ contributed to the analysis and interpretation of the data as well as drafting of the article. BZ and H-JW contributed to the collection and analysis of the data. JY and Y-JM assisted in the analysis, review and final approval of the article. D-WL contributed to the revision and final approval of the article.

    • Funding This study was funded by the National Natural Science Foundation of China (81 172 666), Institute of Nutrition and Health, Chinese Center for Disease Control and Prevention, China; Caroline Population Center, University of North Carolina at Chapel Hill, the NIH (R01-HD30880, DK056350, R24HD050924 and R01-HD38700) and Fogarty International Center, NIH.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Ethics approval Ethics permission was obtained from the Institute for Nutrition and Food Safety, the China Center for Disease Control (China CDC).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The first round of CHNS was conducted in 1989, and was subsequently performed in 1991, 1993, 1997, 2000, 2004, 2006, 2009 and 2011 (http://www.cpc.unc.edu/projects/china). The data can be downloaded from: http://www.cpc.unc.edu/projects/china/data/datasets/data-downloads-registration.