Elsevier

The Lancet

Volume 377, Issue 9765, 12–18 February 2011, Pages 568-577
The Lancet

Articles
National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5·4 million participants

https://doi.org/10.1016/S0140-6736(10)62036-3Get rights and content

Summary

Background

Data for trends in blood pressure are needed to understand the effects of its dietary, lifestyle, and pharmacological determinants; set intervention priorities; and evaluate national programmes. However, few worldwide analyses of trends in blood pressure have been done. We estimated worldwide trends in population mean systolic blood pressure (SBP).

Methods

We estimated trends and their uncertainties in mean SBP for adults 25 years and older in 199 countries and territories. We obtained data from published and unpublished health examination surveys and epidemiological studies (786 country-years and 5·4 million participants). For each sex, we used a Bayesian hierarchical model to estimate mean SBP by age, country, and year, accounting for whether a study was nationally representative.

Findings

In 2008, age-standardised mean SBP worldwide was 128·1 mm Hg (95% uncertainty interval 126·7–129·4) in men and 124·4 mm Hg (123·0–125·9) in women. Globally, between 1980 and 2008, SBP decreased by 0·8 mm Hg per decade (−0·4 to 2·2, posterior probability of being a true decline=0·90) in men and 1·0 mm Hg per decade (−0·3 to 2·3, posterior probability=0·93) in women. Female SBP decreased by 3·5 mm Hg or more per decade in western Europe and Australasia (posterior probabilities ≥0·999). Male SBP fell most in high-income North America, by 2·8 mm Hg per decade (1·3–4·5, posterior probability >0·999), followed by Australasia and western Europe where it decreased by more than 2·0 mm Hg per decade (posterior probabilities >0·98). SBP rose in Oceania, east Africa, and south and southeast Asia for both sexes, and in west Africa for women, with the increases ranging 0·8–1·6 mm Hg per decade in men (posterior probabilities 0·72–0·91) and 1·0–2·7 mm Hg per decade for women (posterior probabilities 0·75–0·98). Female SBP was highest in some east and west African countries, with means of 135 mm Hg or greater. Male SBP was highest in Baltic and east and west African countries, where mean SBP reached 138 mm Hg or more. Men and women in western Europe had the highest SBP in high-income regions.

Interpretation

On average, global population SBP decreased slightly since 1980, but trends varied significantly across regions and countries. SBP is currently highest in low-income and middle-income countries. Effective population-based and personal interventions should be targeted towards low-income and middle-income countries.

Funding

Funding Bill & Melinda Gates Foundation and WHO.

Introduction

High blood pressure is the leading risk factor for cardiovascular disease mortality, causing more than 7 million deaths every year worldwide.1, 2, 3 Multicountry studies4, 5, 6, 7 have shown large differences in mean population blood pressure, associated with variations in adiposity and dietary salt. Studies in a few countries and communities with repeated data show that change in population blood pressure can range from remaining almost unchanged to 10 mm Hg per decade.4, 8, 9, 10, 11, 12, 13, 14, 15

Reliable information about trends in blood pressure is needed to understand its dietary, lifestyle, and pharmacological determinants within populations; set intervention priorities; and evaluate national programmes. Despite decades of research on health consequences of high blood pressure and benefits of interventions, our knowledge of trends, with few exceptions,10, 11, 12, 16, 17, 18 is based on cohort and community studies, mainly from high-income countries.4, 8, 13, 19, 20, 21, 22, 23 Previous analyses reviewed published studies to estimate mean blood pressure or hypertension prevalence worldwide.24, 25 These studies advanced our knowledge of worldwide levels, but were based on only a few dozen studies, did not assess time trends, did not explicitly address missing data for entire countries or for older ages, combined data from nationally representative surveys with subnational and community studies without distinguishing them, and did not account for all sources of uncertainty including missing and older country data. Many health examination surveys have measured blood pressure, providing an opportunity to systematically and comprehensively assess regional and national trends.

We reviewed and accessed unpublished and published studies to collate comprehensive data for blood pressure. We developed and applied statistical methods to systematically address measurement comparability, missing data, non-linear trends, age patterns, and national versus subnational and community representativeness. With these data and methods, we estimated blood pressure trends and their uncertainties by country.

Section snippets

Study design

We estimated 1980–2008 trends in mean systolic blood pressure (SBP) and their uncertainties, by sex, for 199 countries and territories in 21 subregions of the Global Burden of Diseases, Injuries, and Risk Factors study, which are grouped into seven merged regions (webappendix p 21). We estimated trends in SBP, rather than diastolic blood pressure (DBP), because prospective studies1, 26 strongly suggest that SBP is a better predictor of cardiovascular disease risk, especially in older adults

Results

Our analysis included 786 country-years with 5·4 million participants (figure 1). 406 country-years were from 28 high-income countries and 380 from 107 low-income and middle-income countries. High-income subregions of east Asia, North America, and western Europe had the most data per country (webappendix pp 67–69). National surveys provided 20% of all data, subnational studies 15%, and community studies the remainder (webappendix pp 70–71). Japan had the most national data with 28 years,

Discussion

We systematically analysed health examination surveys and epidemiological studies, and estimated worldwide trends in SBP, the leading cardiovascular risk factor. We noted that, after standardising for population age structure, mean SBP decreased by about 1 mm Hg per decade for men and women between 1980 and 2008. The estimated trends changed the age-standardised prevalence of uncontrolled hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg) from 33% (95% CI 28–39) in 1980 to 29% (27–31) in 2008 in

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