Associations between age, cohort, and urbanization with SBP and DBP in China: a population-based study across 18 years

Association of urbanization with psychological well-being in Chinese adults aged 50 years and older: a population-based study

OBJECTIVE

To examine the association between urbanization and psychological well-being (PWB) in China.

METHODS

Data were obtained from the 2015 China Health and Nutrition Survey (CHNS) and included 3,071 men and 3,385 women aged 50 years or older who lived in 288 communities across 12 provinces and municipalities. The urbanization index, which summarizes 12 urbanization dimensions at community level, was categorized into tertiles representing low, medium, and high levels of urbanization. PWB was assessed by scoring three self-reported questions. Gender-stratified multilevel analyses were used to estimate the association between urbanization and PWB.

RESULTS

After controlling for individual-level factors, the urbanization index was associated positively with PWB. More specifically, an increase of one SD in the score of community population density, economic activity, housing, education, sanitation, or diversity was associated significantly with PWB in both genders. In addition, increases in the score of community communications, social services, transportation, or modern markets were associated significantly with PWB in women, but not in men.

CONCLUSION

Urbanization has, on average, had an independent and positive effect on PWB in middle-aged and older Chinese populations, with many components of urbanization being separately and positively associated with PWB, especially in women.

Association between napping and 24-hour blood pressure variability among university students: A pilot study

Background

Blood pressure variability (BPV) has been reported to be a predictor of cardiovascular and some cognitive diseases. However, the association between napping and BPV remains unknown. This study aimed to explore the association between napping and BPV.

Materials and methods

A cross-sectional study including 105 university students was conducted. Participants' 24 h ambulatory blood pressure monitoring (24 h ABPM) were measured, and napping behaviors were investigated. BPV were measured by the 24 h ABPM, included standard deviation (SD), coefficient of variation (CV), and average real variability (ARV).

Results

Among the participants, 61.9% reported daytime napping. We found that nap duration was significantly associated with daytime CV of diastolic blood pressure (DBP) (r = 0.250, P = 0.010), nighttime CV of systolic blood pressure (SBP) (r = 0.217, P = 0.026), 24 h WCV of DBP (r = 0.238, P = 0.014), 24 h ARV of SBP (r = 0.246, P = 0.011) and 24 h ARV of DBP (r = 0.291, P = 0.003). Compared with the no napping group, 24 h WCV of DBP, daytime CV of DBP, and daytime SD of DBP were significantly higher in participants with napping duration >60 min. With multiple regression analysis we found that nap duration was an independent predictor for 24 h ARV of SBP (β = 0.859, 95% CI, 0.101-1.616, P = 0.027) and 24 h ARV of DBP (β = 0.674, 95% CI, 0.173-1.175, P = 0.009).

Conclusions

Napping durations are associated with BPV among university students. Especially those with napping durations >60 min had a significantly higher BPV than those non-nappers.

Gender differences in association of urbanization with psychological stress in Chinese adults: A population-based study

Objective

To investigate the gender-specific associations between exposure to urbanization and psychological stress in China experiencing rapid urbanization.

Methods

Data were obtained from the 2015 China Health and Nutrition Survey. A total of 4,388 men and 5,098 women aged at least 18 years were obtained from 288 communities across 12 provinces and municipalities. Tertiles of the urbanization index, summarizing 12 urbanization dimensions at the community level, were used to define low, medium, and high levels of urbanization. The psychological stress was measured based on the 10-item Perceived Stress Scale. The gender-stratified multilevel analysis (Level-1: Individuals, Level-2: Communities, and Level-3: provinces/municipalities) was used to estimate the association between exposure to urbanization and psychological stress.

Results

After controlling for age, education status, marital status, work status, household income per capita, current smoking, alcohol drinking, sleep duration, BMI, and chronic conditions, the urbanization index was negatively associated with psychological stress in women (P _trend = 0.017) but not men (P _trend = 0.476). More specifically, a one-standard deviation increase in the score of community population density (β = -0.329, P = 0.329), modern markets (β = -0.247, P = 0.044), education (β = -0.448, P = 0.002), and housing (β = -0.380, P = 0.005) was negatively associated with psychological stress only in women, separately.

Conclusion

Our data revealed that living in the most urbanized communities is associated with lower levels of psychological stress for women but not men. Thus, this study can help empower decision-makers to accurately target vulnerable communities and plan effective strategies to address psychological outcomes.

Multistate Markov model application for blood pressure transition among the Chinese elderly population: a quantitative longitudinal study

OBJECTIVE

To explore the transitions of different blood pressure states based on a multistate Markov model among the Chinese elderly population.

SETTING

A community health centre in Xiamen, China.

PARTICIPANTS

1833 elderly Chinese people.

METHODS

A multistate Markov model was built based on 5001 blood pressure measurements from 2015 to 2020. Research was conducted to explore the process of hypertension progression, providing information on the transition probability, HR and the mean sojourn time in three blood pressure states, namely normal state, elevated state and hypertensive state.

RESULTS

Probabilities of moving from the normal state to the hypertensive state in the first year were 16.97% (female) and 21.73% (male); they increased dramatically to 47.31% (female) and 51.70% (male) within a 3-year follow-up period. The sojourn time in the normal state was 1.5±0.08 years. Elderly women in the normal state had a 16.97%, 33.30% and 47.31% chance of progressing to hypertension within 1, 2 and 3 years, respectively. The corresponding probabilities for elderly men were 21.73%, 38.56% and 51.70%, respectively. For elderly women starting in the elevated state, the probabilities of developing hypertension were 25.07%, 43.03% and 56.32% in the next 1, 2 and 3 years, respectively; while the corresponding changes for elderly men were 20.96%, 37.65% and 50.86%. Increasing age, body mass index (BMI) and glucose were associated with the probability of developing hypertension from the normal state or elevated state.

CONCLUSIONS

Preventive actions against progression to hypertension should be conducted at an early stage. More awareness should be paid to elderly women with elevated state and elderly men with normal state. Increasing age, BMI and glucose were critical risk factors for developing hypertension. The derived transition probabilities and sojourn time can serve as a significant reference for making targeted interventions for hypertension progression among the Chinese elderly population.

Sociodemographic, lifestyle, behavioral, and parental factors associated with sugar-sweetened beverage consumption in children in China

Objective

Evidence shows sugar-sweetened beverage (SSB) consumption is a risk factor for obesity and non-communicable diseases (NCDs) in children. Investigating the influential profiles, which have been examined insufficiently, will help to inform the reduction of SSB consumption. The present research examines the current trend in SSB consumption and associated factors among children in China, in order to inform policy development.

Methods

Secondary data was extracted from China’s Health and Nutrition Survey (CHNS; 2004, 2006, 2009, and 2011), a repeated cross-sectional research, and a Chi-squared test was applied to compare SSB consumption in the last year, queried by social demographical, `environmental, behavioral, and parental factors. Multilevel mixed-effects logistic regression was employed to examine the trend and effects of the multiple factors.

Results

A total of 6015 Chinese children aged 6–17 years were investigated. From 2004 to 2011, the percentage of SSB consumption in children increased from 72.6% to 90.3%. The prevalence in urban areas was higher than the prevalence in rural areas, higher in high schools than primary and middle schools, higher in east coast affluent provinces than other provinces, and higher in high-income households than low-income households. Other associated factors include children’s fast food and salty snacks preference, level of physical activity, sedentariness, and parental education. The strongest association with SSB consumption in children was the mother’s SSB consumption (adjusted odds ratio: 5.54, 95% CI: 3.17–9.67).

Conclusion

Children’s SSB consumption has increased significantly in China, and is associated with socio-economic, demographic, level of physical activity, food preference, and parental factors. Future strategies aimed at reducing SSB consumption among children need to consider these factors.

Circulating ERBB3 levels are inversely associated with the risk of overweight-related hypertension: a cross-sectional study

BACKGROUND

Hypertension and overweight are independent risk factors for cardiovascular disease, and overweight increase the risk of developing high blood pressure. ERBB3( also known as HER3) plays a considerable role in the development of cardiovascular diseases. However, the effect of ERBB3 levels in hypertensive overweight patients is unknown. The aim of this study was to assess the association between ERBB3 levels and hypertension in overweight Chinese patients.

METHODS

We evaluated the height,weight, blood pressure, biochemical indicators, and ERBB3 levels in 128 Chinese adults aged 33-79 years. Plasma ERBB3 levels were assessed by the enzyme-linked immunosorbent assay, and body mass index(BMI) was calculated as body weight divided by height squared. Participants were allocated into three groups according to blood pressure and BMI: healthy control (CNT, n = 31; normotensive and non-overweight), hypertension (HT, n = 33; hypertension and non-overweight), and hypertension with overweight (HTO, n = 64; hypertension and overweight). Statistical significance was defined as a two-tailed P < 0.05.

RESULTS

There was no significant difference in mean ERBB3 levels among the three groups, although a linear decrease from CNT (1.13 ± 0.36), HT (1.03 ± 0.36), to HTO (0.84 ± 0.26 ng/mL) was observed in men (P = 0.007). Among the drinking population, the ERBB3 level was significantly reduced in the HTO group as compared with those of the CNT and HT groups (0.76 ± 0.23 versus 1.18 ± 0.37 and 1.20 ± 0.30, respectively). ERBB3 levels were negatively correlated with diastolic blood pressure in men (r= - 0.293, P = 0.012), smoking (r= - 0.47, P = 0.004), and drinking (r = - 0.387, P = 0.008). BMI in men and among drinkers, and uric acid among drinkers were negatively correlated with ERBB3 levels. Multivariate conditional logistic regression showed that plasma ERBB3 levels were associated with a reduced risk of HTO in men [odds ratio (OR) 0.054; 95 % confidence interval (CI): 0.007-0.412) and drinkers (OR 0.002; 95 % CI: 0.000-0.101).

CONCLUSIONS

ERBB3 may contribute to the pathogenesis of hypertension in overweight patients, with BMI, gender, and drinking all potentially modulating the process.

Association of the Geriatric Nutritional Risk Index with incident hypertension in the older Chinese population: a 6-year cohort study

Background

We examined the association of the Geriatric Nutritional Risk Index (GNRI) with the incidence of hypertension.

Methods

We used data of the China Health and Nutrition Survey in this study. Participants aged ≥60 years were eligible. The GNRI was defined as follows: GNRI = [1.489 × albumin (ALB; g/L)] + [41.7 × (actual weight/ideal weight)]. Participants with systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or use of antihypertensive medication were defined as having hypertension.

Results

This study included 4853 participants, comprising 3612 control participants and 1241 participants with hypertension. The GNRI, ALB, and body mass index (BMI) were significantly associated with higher incidence of hypertension (HR: 1.030, 1.026, and 1.088; 95% CI: 1.020–1.041, 1.008–1.044, and 1.069–1.107, respectively). The GNRI, ALB, and BMI were associated with an earlier age of hypertension onset (β = −0.403, −0.613, and −0.321; 95% CI: −0.493 to −0.314, −0.767 to −0.459, and −0.484 to −0.159, respectively).

Conclusions

A higher GNRI was associated with increased incidence of hypertension. An elevated GNRI was associated with earlier age of hypertension onset.

Defining pathways to healthy sustainable urban development

Goals and pathways to achieve sustainable urban development have multiple interlinkages with human health and wellbeing. However, these interlinkages have not been examined in depth in recent discussions on urban sustainability and global urban science. This paper fills that gap by elaborating in detail the multiple links between urban sustainability and human health and by mapping research gaps at the interface of health and urban sustainability sciences. As researchers from a broad range of disciplines, we aimed to: 1) define the process of urbanization, highlighting distinctions from related concepts to support improved conceptual rigour in health research; 2) review the evidence linking health with urbanization, urbanicity, and cities and identify cross-cutting issues; and 3) highlight new research approaches needed to study complex urban systems and their links with health. This novel, comprehensive knowledge synthesis addresses issue of interest across multiple disciplines. Our review of concepts of urban development should be of particular value to researchers and practitioners in the health sciences, while our review of the links between urban environments and health should be of particular interest to those outside of public health. We identify specific actions to promote health through sustainable urban development that leaves no one behind, including: integrated planning; evidence-informed policy-making; and monitoring the implementation of policies. We also highlight the critical role of effective governance and equity-driven planning in progress towards sustainable, healthy, and just urban development.

Association of a Province-Wide Intervention With Salt Intake and Hypertension in Shandong Province, China, 2011-2016

IMPORTANCE

High salt intake is associated with hypertension, which is a leading modifiable risk factor for cardiovascular disease.

OBJECTIVE

To assess the association of a government-led, multisectoral, and population-based intervention with reduced salt intake and blood pressure in Shandong Province, China.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the Shandong-Ministry of Health Action on Salt and Hypertension (SMASH) program, a 5-year intervention to reduce sodium consumption in Shandong Province, China. Two representative samples of adults (aged 18-69 years) were surveyed in 2011 (15 350 preintervention participants) and 2016 (16 490 postintervention participants) to examine changes in blood pressure, and knowledge, attitudes, and behaviors related to sodium intake. Urine samples were collected from random subsamples (2024 preintervention participants and 1675 postintervention participants) for measuring sodium and potassium excretion. Data were analyzed from January 20, 2017, to April 9, 2019.

INTERVENTIONS

Media campaigns, distribution of scaled salt spoons, promotion of low-sodium products in markets and restaurants, and activities to support household sodium reduction and school-based sodium reduction education.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in urinary sodium excretion. Secondary outcomes were changes in potassium excretion, blood pressure, and knowledge, attitudes, and behaviors. Outcomes were adjusted for likely confounders. Means (95% CIs) and percentages were weighted.

RESULTS

Among 15 350 participants in 2011, 7683 (50.4%) were men and the mean age was 40.7 years (95% CI, 40.2-41.2 years); among 16 490 participants in 2016, 8077 (50.7%) were men and the mean age was 42.8 years (95% CI, 42.5-43.1 years). Among participants with 24-hour urine samples, 1060 (51.8%) were men and the mean age was 40.9 years (95% CI, 40.5-41.3 years) in 2011 and 836 (50.7%) were men and the mean age was 40.7 years (95% CI, 40.1-41.4 years) in 2016. The 24-hour urinary sodium excretion decreased 25% from 5338 mg per day (95% CI, 5065-5612 mg per day) in 2011 to 4013 mg per day (95% CI, 3837-4190 mg per day) in 2016 (P < .001), and potassium excretion increased 15% from 1607 mg per day (95% CI, 1511-1704 mg per day) to 1850 mg per day (95% CI, 1771-1929 mg per day) (P < .001). Adjusted mean systolic blood pressure among all participants decreased from 131.8 mm Hg (95% CI, 129.8-133.8 mm Hg) to 130.0 mm Hg (95% CI, 127.7-132.4 mm Hg) (P = .04), and diastolic blood pressure decreased from 83.9 mm Hg (95% CI, 82.6-85.1 mm Hg) to 80.8 mm Hg (95% CI, 79.4-82.1 mm Hg) (P < .001). Knowledge, attitudes, and behaviors associated with dietary sodium reduction and hypertension improved significantly.

CONCLUSIONS AND RELEVANCE

The findings suggest that a government-led and population-based intervention in Shandong, China, was associated with significant decreases in dietary sodium intake and a modest reduction in blood pressure. The results of SMASH may have implications for sodium reduction and blood pressure control in other regions of China and worldwide.

Dietary Potassium Intake Remains Low and Sodium Intake Remains High, and Most Sodium is Derived from Home Food Preparation for Chinese Adults, 1991-2015 Trends

BACKGROUND

Intervention strategies to reduce sodium intake and increase potassium intake may decrease blood pressure; however, most are focused on reducing sodium in processed food globally.

OBJECTIVES

We attempt to fill important gaps in understanding the dynamics of these dietary determinants of hypertension in China.

METHODS

We used data on 29,926 adults aged ≥20 y between 1991 and 2015 from an ongoing cohort, the China Health and Nutrition Survey. We collected detailed diet data with use of weighing methods with 3 consecutive 24-h recalls. With panel data random-effects models, we analyzed factors associated with sodium and potassium intakes and sodium to potassium (Na/K) ratios.

RESULTS

Sodium intake decreased from 6.3 g/d in 1991 to 4.1 g/d in 2015, still twice the tolerable upper intake recommended by the WHO. Potassium intake was 1.7 g/d in 1991 and 1.5 g/d in 2015, below half that recommended by the WHO. The Na/K ratio decreased from 4.1 (ratios in g) in 1991 to 3.1 in 2015, 5 times the recommendation of the WHO. More than two-thirds (67%) of sodium intake was from salt added during food preparation, with 8.8% from processed foods in 2015, up from 5.0% in 1991. The most at-risk populations lived in China's central region and rural areas, were middle aged, had lower educations, or were farmers.

CONCLUSIONS

Sodium intake is very high across all regions in China. As part of sodium reduction efforts, China should target people living in the central region and adults aged above 60 whose sodium intakes are much higher. Strategies to decrease sodium intake and increase potassium intake should be different from those applied in the Western world where the major source is processed food. Reduced sodium higher potassium salts should become a major policy initiative in China.

BMI modified the association of current smoking with the incidence of hypertension in Chinese population: a 22-year cohort study

Background

There was little known on how the interaction effect between obesity and current smoking affected the incidence of hypertension. The aim of this study was to investigate how body mass index (BMI) modified the effect of current smoking on the incidence of hypertension.

Methods

Data were obtained from the China Health and Nutrition Survey (CHNS). According to the WHO recommendations for Chinese people, the normal weight, overweight, and obesity were defined using the BMI cutoff values 18.5 kg/m², 23.0 kg/m², and 27.5 kg/m, respectively. Current smokers were defined as having smoked at least 100 cigarettes or electronic cigarettes, 20 cigars, or 20 tobacco pipes and other type of tobacco in the last 30 days preceding the survey. Hypertension was defined as systolic blood pressure (SBP)/ diastolic blood pressure (DBP) ≥ 140/90 mmHg, use of anti-hypertensive medications, or a self-reported diagnosis.

Results

This study included 12,900 subjects. There were interaction effects between obesity and current smoking in females (P = 0.030) and the 50–59 years group (P = 0.049). Current smoking was a significant predictor of incident hypertension only in the total and female populations with normal weight (HR: 1.119 and 1.274; HR 95% CI: 1.013–1.236 and 1.143–1.415; and P = 0.027 and 0.040, respectively). Stratified by age, current smoking affected the development of hypertension only in the 50–59 years subjects with the normal weight (HR: 1.356; HR 95% CI: 1.084–1.697; and P = 0.008).

Conclusions

Current smoking was a significant predictor of incident hypertension only in the female and middle-age populations with normal weight but not in the overweight and obesity as well as the younger and elder populations.

Association of exposure to Chinese famine in early life with the incidence of hypertension in adulthood: A 22-year cohort study

BACKGROUND AND AIMS

Undernutrition in early life may have a lifelong effect on adult health. The conclusions on the association of exposure to famine with the risk of hypertension were inconsistent. The aim of this study was to examine the association of exposure to the Chinese famine with incident hypertension.

METHODS AND RESULTS

Data were obtained from the China Health and Nutrition Survey. All included participants were divided into five birth cohorts: no exposure, born in or after 1962 (N = 2 088); fetal exposure, between 1959 and 1961 (N = 880); early childhood exposure, between 1956 and 1958 (N = 1 214); mid-childhood exposure, between 1953 and 1955 (N = 1 287); and late childhood exposure, between 1949 and 1952 (N = 1 445). Hypertension was defined as SBP/DBP ≥140/90 mmHg, use of hypertensive medications, or a self-reported diagnosis. A total of 6 914 participants were included. The exposure to famine decreased the incidence of hypertension (P = 0.0018, 0.0001, <0.0001, and <0.0001; HR: 0.715, 0.686, 0.622, and 0.527, respectively) in males. Similarly, the exposure to famine might also decrease incident hypertension in the rural areas (P = 0.0013, <0.0001, <0.0001, and <0.0001; HR: 0.735, 0.706, 0.679, and 0.539, respectively). There were interaction effects between famine severity and exposure to famine in early (P = 0.024) and late childhood (P = 0.009).

CONCLUSION

Exposure to the Chinese famine decreased the incidence of hypertension, especially in males and in the rural areas. Furthermore, the exposure postponed the age at the onset of hypertension.

Isolated systolic hypertension in the young: a position paper endorsed by the European Society of Hypertension

: Whether isolated systolic hypertension in the young (ISHY) implies a worse outcome and needs antihypertensive treatment is still a matter for dispute. ISHY is thought to have different mechanisms than systolic hypertension in the elderly. However, findings from previous studies have provided inconsistent results. From the analysis of the literature, two main lines of research and conceptualization have emerged. Simultaneous assessment of peripheral and central blood pressure led to the identification of a condition called pseudo or spurious hypertension, which was considered an innocent condition. However, an increase in pulse wave velocity has been found by some authors in about 20% of the individuals with ISHY. In addition, obesity and metabolic disturbances have often been documented to be associated with ISHY both in children and young adults. The first aspect to consider whenever evaluating a person with ISHY is the possible presence of white-coat hypertension, which has been frequently found in this condition. In addition, assessment of central blood pressure is useful for identifying ISHY patients whose central blood pressure is normal. ISHY is infrequently mentioned in the guidelines on diagnosis and treatment of hypertension. According to the 2013 European Guidelines on the management of hypertension, people with ISHY should be followed carefully, modifying risk factors by lifestyle changes and avoiding antihypertensive drugs. Only future clinical trials will elucidate if a benefit can be achieved with pharmacological treatment in some subgroups of ISHY patients with associated risk factors and/or high central blood pressure.

Generational differences in longitudinal blood pressure trajectories by geographic region during socioeconomic transitions in China

OBJECTIVES

To examine generational differences in longitudinal blood pressure trajectories by region following socioeconomic transitions, which is important for establishing the population risk of cardiovascular diseases (CVDs).

METHODS

With data from the China Health and Nutrition Survey (1991-2011), we used multilevel growth-curve models to estimate systolic/diastolic blood pressure (SBP/DBP) levels at the mean age and rates of change by cohort (born between 1931 and 1980), region, and sex.

RESULTS

Younger cohorts generally had higher SBP/DBP levels at 44.5 years but lower growth rates in SBP/DBP than older cohorts. They became prehypertensive (SBP ≥ 120 mm Hg or DBP ≥ 80 mm Hg) at an earlier age. The upward shift of SBP/DBP trajectories across cohorts was more pronounced in the Coastal and Southern Mountainous Regions than the Northeastern and Inland Regions, and for males versus females.

CONCLUSIONS

Younger cohorts have a longer lifetime duration of being susceptible to CVDs, posing warnings for an increased burden of CVDs. Generational differences in BP trajectories and geographic and sex variations in the cohort trends highlight the need for tailored interventions to tackle the generation, region, and sex-based risk of CVDs.

Urban-rural-specific trend in prevalence of general and central obesity, and association with hypertension in Chinese adults, aged 18-65 years

BACKGROUND

China has the largest obese population in the world, and the prevalence of central obesity is increasing dramatically in China. Moreover, the rapid economic growth of China in recent decades has led to rapid urbanization in rural China. However, studies comparing the prevalence trends of different types of obesity and the association of obesity with hypertension between urban and rural areas in China are very scarce, and most studies have focused only on the difference in the prevalence of overweight and general obesity or hypertension among rural and urban populations. Therefore, the focus of this study was to examine the shifts in the overall distribution of the prevalence of different types of obesity and to estimate the risk of hypertension in different types of obesity among urban and rural adults aged 18-65 years.

METHODS

Seven iterations of the China Health and Nutrition Survey (CHNS), conducted in 1993, 1997, 2000, 2004, 2006, 2009 and 2011, were used in this study. A total of 53,636 participants aged 18-65 years were included. Obesity was classified into three types based on body mass index (BMI) and waist circumference (WC). A log-binomial model was constructed to estimate the prevalence ratio (PR) of hypertension with three types of obesity.

RESULTS

The age-standardized prevalence of central obesity only, general obesity only, and both central and general obesity increased from 15.8, 0.2 and 2.9% in 1993 to 30.3, 0.9 and 10.3% in 2011, respectively. The prevalence of central obesity only (urban vs. rural: 20.8% vs. 13.4% in 1993, 29.6% vs. 30.6% in 2011) and both central and general obesity (urban vs. rural: 3.5% vs. 2.5% in 1993, 10.0% vs. 10.6% in 2011) in rural adults exceeded that in urban adults in 2011. Participants with both central and general obesity had the highest risk for incident hypertension compared with those with normal body measurements (adjusted PR, urban: 2.30 (95% CI, 2.01-2.63), rural: 2.50 (95% CI, 2.25-2.77)).

CONCLUSIONS

Both WC and BMI should be considered measures of obesity and targeted in hypertension prevention. More attention should be paid to the incidence of central obesity in adults in rural China.

Effect of BMI and Its Optimal Cut-Off Value in Identifying Hypertension in Uyghur and Han Chinese: A Biethnic Study from the China National Health Survey (CNHS)

Objective

The effect of adiposity on hypertension among Uyghur Chinese is not clear. This study aimed to compare the effect of BMI and its optimal cut-off value in identifying hypertension in Uyghur and Han adults in China.

Methods

By using a multistage stratified sampling method, 3072 Uyghur and 3195 Han adults underwent questionnaire interview, physical examination, and biochemical tests. Age- and sex-standardized prevalence of hypertension was calculated. Adjusted odds ratios for adiposity associated with hypertension were estimated. ROC analyses were used for assessing the ethnic and sex specific optimal BMI cut-off values in identifying hypertension.

Results

Both in Uyghur and Han, increased BMI was consistent with the elevated systolic and diastolic blood pressure. Although more Uyghur were overweight/obese, their standardized prevalence of hypertension (17.87%) was lower than that of Han (20.28%). Han adults had 1.42 times odds than Uyghur of hypertension. The adjusted ORs of overweight and obesity were 2.67 and 6.04 in Uyghur and 2.74 and 7.58 in Han. In male, the optimal cut-off values of BMI identifying hypertension in Uyghur and Han were 24.6 kg/m² and 24.9 kg/m² , respectively, but the correspond values in Uyghur and Han females were 27.2 kg/m² and 25.0 kg/m².

Conclusions

Adiposity had strong effect on hypertension, but this effect was less strong in Uyghur female than in Han female.

Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data.

METHODS

We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting.

FINDINGS

Globally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1-4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0-8·4) while the total sum of global YLDs increased from 562 million (421-723) to 853 million (642-1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6-9·2) for males and 6·5% (5·4-7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782-3252] per 100 000 in males vs s1400 [1279-1524] per 100 000 in females), transport injuries (3322 [3082-3583] vs 2336 [2154-2535]), and self-harm and interpersonal violence (3265 [2943-3630] vs 5643 [5057-6302]).

INTERPRETATION

Global all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data.

METHODS

We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting.

FINDINGS

Globally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1-4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0-8·4) while the total sum of global YLDs increased from 562 million (421-723) to 853 million (642-1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6-9·2) for males and 6·5% (5·4-7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782-3252] per 100 000 in males vs s1400 [1279-1524] per 100 000 in females), transport injuries (3322 [3082-3583] vs 2336 [2154-2535]), and self-harm and interpersonal violence (3265 [2943-3630] vs 5643 [5057-6302]).

INTERPRETATION

Global all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury.

FUNDING

Bill & Melinda Gates Foundation.

Prediction of transfer among multiple states of blood pressure based on Markov model: an 18-year cohort study

OBJECTIVE

This study aimed to identify the rules of transition between normotension, prehypertension and hypertension states and to establish a prediction model for the incidence of prehypertension and hypertension.

METHODS

Data from the China Health and Nutrition Survey from 1991 to 2009 were used as training data to develop the model. Data of the year 2011 were used for model validation. The multistate Markov model was developed using the msm package in R software.

RESULTS

A total of 5265 participants were included at baseline, with an average follow-up of 8.05 ± 5.27 years and 17 640 observations. The ratio of men to women was 1 : 1.17, and the mean age was 37.54 ± 13.80 years. Within 10 years, in men, from normotension, the average probability to prehypertension and hypertension are 34.5 and 35.25%, respectively; from prehypertension, the average probability of recovering to normotension and developing to hypertension are 17.78 and 43.85%, respectively. In women, the average probabilities are 27.49, 28.09, 29.11 and 39.05%. Fat consumption increasing was found to be a protective factor, with 4.5% lower rate of transferring from normotension to prehypertension for a quarter percentage increasing. The model showed a very good prediction ability within 10 years and provided good prediction of blood pressure in the 2011 cohort (χ = 0.781, P = 0.676).

CONCLUSION

The multistate Markov model can be a useful tool to identify the rules of transition among multiple states of blood pressure and predict well prevalence of the normotension, prehypertension and hypertension in cohort populations.

Association of Body Fat Mass and Fat Distribution With the Incidence of Hypertension in a Population-Based Chinese Cohort: A 22-Year Follow-Up

BACKGROUND

There have been few studies on the association between the incidence of hypertension and the presence and distribution of body fat. The aim of this article was to evaluate this association.

METHODS AND RESULTS

Data were obtained from the China Health Nutrition Survey, a 22-year cohort study of 12 907 participants. Body mass index and triceps skinfold thickness were used as markers of body fat, whereas waist circumference (WC) was used as a marker of fat distribution. Cox regression was used to examine the association of body mass index, WC, and skinfold thickness with the incidence of hypertension. The interval between the baseline and hypertension diagnosis was the time variable, and hypertension was the end event. The mean age and proportion of men and women were 38.29 and 38.03 years and 45.63% and 54.37%, respectively. Compared with normal WC, abdominal obesity was associated with hypertension (P<0.001; crude hazard ratio, 2.11; 95% confidence interval, 1.89-2.37). Similarly, overweight (crude hazard ratio, 1.75; 95% confidence interval, 1.64-1.87) and obesity (crude hazard ratio, 3.19; 95% confidence interval, 2.80-3.63) were risk factors for hypertension (all P<0.001). When stratified by sex, the results confirmed that WC and body mass index predicted the development of hypertension in both men and women but not skinfold thickness in women.

CONCLUSIONS

Body mass index and WC were independent risk factors for hypertension, but skinfold thickness was a poor marker of body fat and could not be used to predict hypertension.

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of risk factor exposure and attributable burden of disease. By providing estimates over a long time series, this study can monitor risk exposure trends critical to health surveillance and inform policy debates on the importance of addressing risks in context.

METHODS

We used the comparative risk assessment framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2016. This study included 481 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk (RR) and exposure estimates from 22 717 randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources, according to the GBD 2016 source counting methods. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. Finally, we explored four drivers of trends in attributable burden: population growth, population ageing, trends in risk exposure, and all other factors combined.

FINDINGS

Since 1990, exposure increased significantly for 30 risks, did not change significantly for four risks, and decreased significantly for 31 risks. Among risks that are leading causes of burden of disease, child growth failure and household air pollution showed the most significant declines, while metabolic risks, such as body-mass index and high fasting plasma glucose, showed significant increases. In 2016, at Level 3 of the hierarchy, the three leading risk factors in terms of attributable DALYs at the global level for men were smoking (124·1 million DALYs [95% UI 111·2 million to 137·0 million]), high systolic blood pressure (122·2 million DALYs [110·3 million to 133·3 million], and low birthweight and short gestation (83·0 million DALYs [78·3 million to 87·7 million]), and for women, were high systolic blood pressure (89·9 million DALYs [80·9 million to 98·2 million]), high body-mass index (64·8 million DALYs [44·4 million to 87·6 million]), and high fasting plasma glucose (63·8 million DALYs [53·2 million to 76·3 million]). In 2016 in 113 countries, the leading risk factor in terms of attributable DALYs was a metabolic risk factor. Smoking remained among the leading five risk factors for DALYs for 109 countries, while low birthweight and short gestation was the leading risk factor for DALYs in 38 countries, particularly in sub-Saharan Africa and South Asia. In terms of important drivers of change in trends of burden attributable to risk factors, between 2006 and 2016 exposure to risks explains an 9·3% (6·9-11·6) decline in deaths and a 10·8% (8·3-13·1) decrease in DALYs at the global level, while population ageing accounts for 14·9% (12·7-17·5) of deaths and 6·2% (3·9-8·7) of DALYs, and population growth for 12·4% (10·1-14·9) of deaths and 12·4% (10·1-14·9) of DALYs. The largest contribution of trends in risk exposure to disease burden is seen between ages 1 year and 4 years, where a decline of 27·3% (24·9-29·7) of the change in DALYs between 2006 and 2016 can be attributed to declines in exposure to risks.

INTERPRETATION

Increasingly detailed understanding of the trends in risk exposure and the RRs for each risk-outcome pair provide insights into both the magnitude of health loss attributable to risks and how modification of risk exposure has contributed to health trends. Metabolic risks warrant particular policy attention, due to their large contribution to global disease burden, increasing trends, and variable patterns across countries at the same level of development. GBD 2016 findings show that, while it has huge potential to improve health, risk modification has played a relatively small part in the past decade.

FUNDING

The Bill & Melinda Gates Foundation, Bloomberg Philanthropies.

A population-based national estimate of the prevalence and risk factors associated with hypertension in Rwanda: implications for prevention and control

BACKGROUND

Hypertension is a leading cause of cardiovascular diseases and a growing public health problem in many developed and developing countries. However, population-based data to inform policy development are scarce in Rwanda. This nationally representative study aimed to determine population-based estimates of the prevalence and risk factors associated with hypertension in Rwanda.

METHODS

We conducted secondary epidemiological analysis of data collected from a cross-sectional population-based study to assess the risk factors for NCDs using the WHO STEPwise approach to Surveillance of non-communicable diseases (STEPS). Adjusted odds ratios at 95% confidence interval were used to establish association between hypertension, socio-demographic characteristics and health risk behaviors.

RESULTS

Of the 7116 study participants, 62.8% were females and 38.2% were males. The mean age of study participants was 35.3 years (SD 12.5). The overall prevalence of hypertension was 15.3% (16.4% for males and 14.4% for females). Twenty two percent of hypertensive participants were previously diagnosed. A logistic regression model revealed that age (AOR: 8.02, 95% CI: 5.63-11.42, p < 0.001), living in semi-urban area (AOR: 1.30, 95% CI: 1.01-1.67, p = 0.040) alcohol consumption (AOR: 1.24, 95% CI: 1.05-1.44, p = 0.009) and, raised BMI (AOR: 3.93, 95% CI: 2.54-6.08, p < 0.001) were significantly associated with hypertension. The risk of having hypertension was 2 times higher among obese respondents (AOR: 3.93, 95% CI: 2.54-6.08, p-value < 0.001) compared to those with normal BMI (AOR: 1.74, 95% CI: 1.30-2.32, p-value < 0.001). Females (AOR: 0.75, 95% CI: 0.63-0.88, p < 0.001) and students (AOR: 0.45, 95% CI: 0.25-0.80, p = 0.007) were less likely to be hypertensive.

CONCLUSION

The findings of this study indicate that the prevalence of hypertension is high in Rwanda, suggesting the need for prevention and control interventions aimed at decreasing the incidence taking into consideration the risk factors documented in this and other similar studies.

Life-course and Cohort Trajectories of Chronic Non-communicable Diseases Risk Factors in China

BACKGROUND

NCDs are the leading disease burdens in China and the NCDs risk factors shifts have accelerated at an unprecedented scale over the past 30 years. The aim of this study was to analysis the natural trajectories of NCDs risk factors over the life course.

METHODS

The large-scale longitudinal data from the CHNS includes nine rounds of surveys between 1989 and 2011. Overall, 145913 observations (29719 individuals) at multiple exams have been followed up over a 23-year period. The mixed-effects models with random intercepts were used to the characterize shifts in the distribution of these risk factors across the whole life course.

RESULTS

During about 23 years observational period across all age bands, the mean AMC, UAC, TSF, BMI, WC, DBP, SD, DD, and PA trajectory all increased until a certain age. Then decreased in both gender, whereas SBP strictly increased across lifespan; and the secular trend in AMC and WC, SBP, DBP was greater in women than in men; younger generations had higher AMC, UAC, TSF, BMI, WC, WHR, WHtR, SBP, DBP levels across adulthood, whereas younger birth cohorts had lower SD, DD, and PA levels.

CONCLUSION

We observed in a large and comprehensive longitudinal dataset that provided strong evidence of population-wide secular shifts from childhood onwards, which suggests that promoting healthier lifestyles, body weight, blood pressure and enhancing the primary practitioner's capability should be required to reduce the burden of NCDs in China.

Cardiovascular Risk Factors in Parents of Food-Allergic Children

Previous studies suggest that chronic stress may induce immune system malfunction and a broad range of adverse health outcomes; however, the underlying pathways for this relationship are unclear. Our study aimed to elucidate this question by examining the relationship between parental cardiovascular risk factors including systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI), and waist-to-hip ratio (WHR) and maternal psychological stress score (MPSS) relative to the severity of the child's food allergy (FA) and number of affected children. SBP, DBP, BMI, and WHR were measured and calculated at the time of recruitment by trained nurses. MPSS was obtained based on self-report questionnaires covering lifestyle adjustments, perceived chronic stress, and quality of life. General linear models examined whether caregiver chronic stress was associated with FA. For mothers with children under age 5 years, SBP, DBP and number of affected children had strong and graded relationships with severity of the child's FA. MPSS was also significantly and positively associated with child FA severity (P < 0.001). However, no relationships were found between FA severity, BMI, or WHR for either parent. This was also the case for paternal SBP, DBP, and number of affected children of any age. There is a strong and graded link between cardiovascular risk and perceived stress in mothers of food-allergic children under age 5. Findings may have important implications for family-centered care of FA, may generalize to caregivers of children with chronic conditions, and extend the literature on allostatic load.

QUANTILE REGRESSION FOR MIXED MODELS WITH AN APPLICATION TO EXAMINE BLOOD PRESSURE TRENDS IN CHINA

Cardiometabolic diseases have substantially increased in China in the past 20 years and blood pressure is a primary modifiable risk factor. Using data from the China Health and Nutrition Survey we examine blood pressure trends in China from 1991 to 2009, with a concentration on age cohorts and urbanicity. Very large values of blood pressure are of interest, so we model the conditional quantile functions of systolic and diastolic blood pressure. This allows the covariate effects in the middle of the distribution to vary from those in the upper tail, the focal point of our analysis. We join the distributions of systolic and diastolic blood pressure using a copula, which permits the relationships between the covariates and the two responses to share information and enables probabilistic statements about systolic and diastolic blood pressure jointly. Our copula maintains the marginal distributions of the group quantile effects while accounting for within-subject dependence, enabling inference at the population and subject levels. Our population level regression effects change across quantile level, year, and blood pressure type, providing a rich environment for inference. To our knowledge, this is the first quantile function model to explicitly model within-subject autocorrelation and is the first quantile function approach that simultaneously models multivariate conditional response. We find that the association between high blood pressure and living in an urban area has evolved from positive to negative, with the strongest changes occurring in the upper tail. The increase in urbanization over the last twenty years coupled with the transition from the positive association between urbanization and blood pressure in earlier years to a more uniform association with urbanization suggests increasing blood pressure over time throughout China, even in less urbanized areas. Our methods are available in the R package BSquare.