Published online before print January 26, 2004, doi: 10.1161/01.HYP.0000116302.08484.14
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(Hypertension. 2004;43:578.)
© 2004 American Heart Association, Inc.
Scientific Contributions |
Factors Associated With Hypertension Awareness, Treatment, and Control in a Representative Sample of the Chinese Population
From the Departments of Epidemiology (P.M., P.K.W., J.H.), Tulane University School of Public Health and Tropical Medicine; Department of Medicine (P.M., P.K.W., J.H.) Tulane University School of Medicine, New Orleans, La; Hypertension and Renal Center of Excellence (P.M., P.K.W., J.H.), Tulane University Health Sciences Center; and Chinese Academy of Medical Sciences (D.G., X.W., X.D., G.W.), Beijing, People’s Republic of China.
Correspondence to Paul Muntner, Department of Epidemiology, Tulane University, SPHTM 1430 Tulane Avenue, SL-18 New Orleans, LA 70112 E-mail pmuntner{at}tulane.edu
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Abstract |
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We studied factors associated with awareness, treatment, and control of hypertension (systolic/diastolic blood pressure measurements
140/90 mm Hg, respectively, and/or current drug treatment for hypertension) in a representative sample of the Chinese population (n=15 838). Awareness, treatment, and control were defined by self-report of a hypertension diagnosis, self-report of current antihypertensive medication use, and a systolic and diastolic blood pressure <140/90 mm Hg, respectively. Higher awareness (OR; 95% CI) was noted for persons who were married (1.43; 1.09, 1.88) and had their blood pressure measured in 1 year (47.4; 31.7, 70.4) or 1 to 5 years (11.4; 7.09, 18.2) preceding their study visit; lower awareness was found among men (0.62; 0.52, 0.74) and current smokers (0.79; 0.63, 0.99). Among those aware of their hypertension, treatment was more common (OR; 95% CI) at higher income (1.24 [0.87, 1.75], 1.46 [1.01, 2.12] and 1.58 [1.06, 2.37] for increasing versus the lowest quartile of income) and for participants who had their blood pressure measured during the preceding year (3.87; 1.89, 7.93) and was less common among men (0.76; 0.59, 0.98). Controlled hypertension was more common (OR; 95% CI) among persons whose blood pressure had been measured 1 year (4.93; 1.51, 16.1) and 1 to 5 years (14.8; 3.63, 60.5) prior to their study visit and, among persons aware of their hypertension diagnosis, those who undertook lifestyle modification (1.59; 1.11, 2.27). These data identify potential methods for improving blood pressure control in China through the identification, follow-up, and lifestyle modification of persons with high blood pressure.
Key Words: hypertension, detection and control • cross-sectional studies • population
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Introduction |
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Reduction in infectious disease mortality, changes in lifestyle and diet, and an increase in life expectancy have resulted in a greatly increased burden of chronic diseases in economically developing countries.1 Cardiovascular disease (CVD) is the leading cause of mortality worldwide and is estimated to account for 14.3 million deaths in 1990.2 The majority of these deaths occurred in economically developing countries, with much of this burden occurring in the People’s Republic of China.3
Hypertension is one of the most important modifiable risk factors for CVD in Western and Asian populations.4,5,6 A recent cross-sectional study of China estimated 129 million people aged 35 to 74 years have hypertension.7 This represents the continuance of a trend in which the prevalence and absolute number of persons with hypertension has increased at a steep rate. Specifically, previous estimates found 30 million persons with hypertension in China in 1960, 59 million in 1980, and 94 million in 1990.8
The International Collaborative Study of Cardiovascular Disease in ASIA (InterASIA) was designed to provide current and reliable data on CVD risk factors in the adult population in China. Previous reports from InterASIA indicate that hypertension awareness, treatment, and control are higher in urban versus rural areas and awareness is more common, but control less common, in the north versus the south region of China.9 We took advantage of the large representative sample of the Chinese population studied in InterASIA to examine socioeconomic, behavioral, and treatment factors associated with awareness, treatment, and control of hypertension.
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Methods |
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Study Participants
The InterASIA study has been reported in detail previously.7 In brief, a 4-stage stratified sampling method was used to select a nationally representative sample of the general population aged 35 to 74 years in China during 2000 to 2001 (n=15 540). The overall response rate was 83.3% and was similar among men and women and in urban and rural areas. For the current analysis, we excluded 488 participants with a self-reported history of a doctor-diagnosed heart attack or myocardial infarction, stroke, or congestive heart failure.
Data Collection
The selection of variables for the current analysis was hypothesis driven based on previous literature on blood pressure awareness, treatment, and control.10,11,12 Information on demographics (age, gender, and residential area), socioeconomic status (education level achieved, marital status, and annual household income), cigarette smoking, alcohol consumption, and physical activity was collected. Participants who reported having smoked 100 cigarettes during their lifetime were classified as current smokers if they currently smoked and former smokers if they did not. Consumption of alcohol included questions about the number of liangs (
50 g) of rice wine, wine, beer, or liquor consumed during the preceding 12 months. Heavy alcohol consumption was categorized as more than 2 drinks per day, with one drink equaling 355 g of beer, 100 g of rice wine or wine, or 25 g of liquor. Participants were also asked about the number of hours in a typical day that they were not active, watched television, participated in other sedentary activities, and participated in light, moderate, and vigorous physical activity. Metabolic equivalents (METS) were calculated by multiplying the number of hours spent participating in vigorous activities by 8.0, moderate activities by 4.0, light activities by 1.0, watching television or sedentary activities by 1.0, and not active by 0.5.13 Using the total number of METS per day, participants were classified into quartile of physical activity. Finally, information related to time since a participant had last received a blood pressure (BP) measurement was categorized as being within the preceding year, 1 to 5 years, or 5 years or more.
During the clinic visit, height and weight were measured using a standardized protocol and body mass index was calculated in kilograms per meter squared. Normal weight, overweight, and obesity were defined as a body mass index <25, 25 to 30, and 30 kg/m2, respectively. Three seated BP measurements were obtained, after 5 minutes rest, from each participant by a trained and certified observer according to a standard protocol adapted from procedures recommended by the American Heart Association.7,14
Hypertension was defined as an average systolic BP (SBP) 140 mm Hg and/or an average diastolic BP (DBP) 90 mm Hg, and/or self-reported pharmacological treatment for hypertension within the 2 weeks prior to the interview. Awareness of hypertension was defined as a self-report of any prior diagnosis of hypertension by a health care professional. Treatment of hypertension was defined as a self-reported use of pharmacological medication for the management of high BP within the 2 weeks preceding the participant’s interview. Control of hypertension was defined as having an average SBP <140 mm Hg and an average DBP <90 mm Hg in the context of pharmacological treatment of hypertension.
The Institutional Review Board at the Tulane University Health Sciences Center approved the InterASIA study. In addition, ethics committees and other relevant regulatory bodies in China approved the study. Written informed consent was obtained from each participant before data were collected. Participants with untreated conditions identified during the examination were referred to their usual primary health care provider.
Statistical Methods
Overall and age-specific mean levels of SBP and DBP were determined for all participants with and without hypertension and among participants with hypertension who were aware of their diagnosis, were receiving treatment for their hypertension, and those whose hypertension was controlled. The proportion of the study population with hypertension who were aware of their diagnosis, were receiving treatment, and whose BP was controlled was determined by age group, gender, education level, marital status, cigarette smoking, body mass index, quartile of household income, heavy alcohol consumption, level of daily physical activity, and time since a participant’s last BP measurement. The proportion of the population aware of their hypertension was restricted to those with hypertension and the proportion on treatment to those aware of their diagnosis. Hypertension control was assessed among all participants with hypertension and among those participants who were treated for their hypertension. Crude differences in these proportions across participant characteristics (eg, men versus women) were determined using 
2 tests. The odds ratios and 95% confidence intervals of hypertension awareness, treatment, and control associated with participant characteristics was determined after adjustment for age, gender, and geographic region (North/South and Urban/Rural) using multivariate logistic regression models.
The percentage of participants aware of their hypertension diagnosis who were undertaking lifestyle modification to control their BP was calculated. Lifestyle modification was defined as self-reported attempts of weight loss, reduced dietary salt or alcohol consumption, increased exercise, use of complementary/alternative medication, and any other method specifically undertaken by participants to lower their BP because of a diagnosis of hypertension. The odds ratios of hypertension control associated with lifestyle modification were determined among persons aware of their hypertension diagnosis using logistic regression models after initial adjustment for age, gender, and geographic region (North versus South and urban versus rural) and subsequent additional adjustment for marital status, cigarette smoking, overweight/obesity, heavy alcohol consumption, physical activity, and time since the participant’s last measurement of BP.
All calculations were conducted using Stata software, taking into account the complex survey design of InterASIA.15 Survey weights were also applied to obtain population level estimates for China.
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Results |
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Blood Pressure Levels
SBP was higher at older age among participants with and without hypertension (Table 1). In contrast, DBP was lower at older age among persons with hypertension and was not substantially different across age groups among normotensives. Age-specific SBP and DBP levels were similar among all participants with hypertension, those who were aware of their diagnosis, and treated hypertensives. In contrast, mean SBP and DBP levels among persons who had controlled their hypertension were substantially lower compared with all participants with hypertension. However, on average, SBP was 9 mm Hg higher (125 versus 116 mm Hg) and DBP was 3 mm Hg higher (78 versus 75 mm Hg) among persons with controlled hypertension compared with persons without hypertension.
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Awareness, Treatment, and Control
Overall, 26.4% (n=4066) of the population without a history of CVD met the definition for hypertension. Of this group, 43.0% (n=1909) were aware of their diagnosis. Of those aware of their hypertension diagnosis, 61.5% were receiving treatment (n=1216), and 7.7% (n=351) of all participants with hypertension, 29.1% of those receiving treatment, had an SBP/DBP <140/90 mm Hg at their InterASIA study visit. Hypertension awareness was more common among participants 50 years old and older and among women (Table 2). Additionally, participants who were former smokers, were overweight or obese, had a higher income, or had their BP measured within the 5 years preceding their InterASIA study visit were more likely to be aware of their diagnosis of hypertension. In contrast, current smokers, participants who consumed 2 servings of alcohol per day, and those who were less active were less likely to be aware of their hypertension. Among those who were aware of their hypertension, participants who were older, women, former smokers, and overweight or obese and those who had their BP measured during the preceding 12 months were more likely to be receiving medications for their hypertension; current smokers, those who consumed 2 drinks per day, and those who were more physically active were less likely to be receiving medications for their hypertension.
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Among all participants with hypertension, BP control was more common in women, former smokers, participants who were overweight or obese, and those who had their BP measured within the previous year or within 1 to 5 years of their InterASIA study visit. In contrast, current smokers, participants who consumed 2 alcoholic beverages per day and were more physically active were less likely to have controlled hypertension. Among persons receiving treatment for their hypertension, those who were 50 to 64 years old and obese were less likely and participants who had their BP measured within the previous year or within 1 to 5 years of their study visit were more likely to have controlled hypertension.
After adjustment for age, sex, and geographical region (North/South and urban/rural), the odds of hypertension awareness were higher among participants 50 years old, those who had a higher level of education, were married, were former versus never smokers, were overweight or obese, had a higher income, or whose BP had been measured during the year, or 1 to 5 years, preceding their InterASIA study visit (Table 3). In contrast, men, current smokers, and participants who were more physically active were less likely to be aware of their diagnosis of hypertension. Among those aware of having hypertension, participants who were older than 50 years old, were former smokers, were overweight or obese, had a higher income, and those whose BP had been measured during the year preceding their InterASIA study visit were more likely to be receiving pharmacological treatment for their hypertension. In contrast, men, participants who consumed 2 drinks of alcohol and were more physically active were significantly less likely to be receiving antihypertensive medication.
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Among all participants with hypertension, the odds ratio (95% CI) of hypertension control was 2.75 (1.67, 4.53) for those who were former versus never smokers, 0.70 (0.46, 1.06), 0.68 (0.44, 1.05), and 0.34 (0.20, 0.58) for persons in the three increasingly higher quartiles of physical activity, respectively, compared with their counterparts in the lowest quartile (ie, most sedentary) of physical activity, and 115 (41.8, 316) and 60.0 (18.7, 193) for persons who last had their BP measured within 1 and 1 to 5 years prior to their study visit, respectively, versus more than 5 years preceding the InterASIA study visit. Among persons receiving treatment for their hypertension, older age was associated with a lower odds of hypertension control. In contrast, among persons receiving drug treatment for their hypertension, the odds ratios of hypertension control was 2.28 (1.26, 4.14) for former versus never smokers and 14.8 (3.63, 60.5) and 4.93 (1.51, 16.1) among persons whose last BP measurement was within 1 to 5 years and within 1 year of their InterASIA study visit, respectively, versus more than 5 years ago.
Lifestyle Modification and Hypertension Control
More than half (50.2%) of persons aware of their hypertension diagnosis had made lifestyle modifications in an attempt to control their BP (Table 4). After adjustment for age, gender, and geographic region (North/South and urban/rural), among the population aware of their hypertension diagnosis, the odds ratio (95% CI) of controlled hypertension associated with any form of lifestyle modification was 1.56 (1.12, 2.18). Further adjustment for education level, marital status, former and current smoking, overweight, obesity, income, alcohol consumption, physical activity, and time since blood pressure was last measured did not substantially alter this association. Losing weight, reducing salt, increasing exercise, or reducing alcohol because of a diagnosis of hypertension were each associated with hypertension control.
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Adjusted Odds Ratios (95% CI) of Hypertension Control Associated With Lifestyle Modification Among the Chinese Population Aware of Their Hypertension Diagnosis
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Discussion |
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This study presents several important findings regarding awareness, treatment, and control of hypertension in the People’s Republic of China. Overall, the proportion of hypertensives aware, treated, and controlled was low. Persons who had a higher education, were former smokers, were married, were overweight or obese, were less physically active, had a higher income, and had their BP measured within the previous year or within 1 to 5 years were more likely to be aware of their diagnosis of hypertension. Additionally, among participants receiving treatment to lower their blood pressure, former smokers and participants who had their BP measured within the preceding 5 years were more likely to have their hypertension controlled at their InterASIA study visit. Finally, even after adjustment for several potential confounders, participants aware of their hypertension who undertook lifestyle modification were more likely to have systolic and diastolic BP less than 140 and 90 mm Hg, respectively.
The finding of better BP control among persons aware of their hypertension and undertaking lifestyle modification is important but not surprising. Several large randomized trials and meta-analyses of trials have identified the benefits of salt reduction, increased physical activity, potassium supplementation, and moderation in alcohol consumption in the prevention and treatment of high BP.16,17,18,19,20 The results of the current study are reassuring because they suggest these lifestyle modifications are effective in controlling hypertension when applied in settings outside the controlled environment of a randomized trial. Complications from lifestyle modification are minimal and may enfranchise patients to take control of their health.21
The InterASIA study results indicate that hypertension is undertreated in China. Among the population without a history of cardiovascular disease, only 26.5% of InterASIA participants with hypertension were receiving pharmacological treatment. This is substantially lower than the corresponding percentage (52.2%) for the US population of similar age between 1988 and 1994. Furthermore, in InterASIA, SBP and DBP levels were similar among treated and untreated hypertensives. Although this may be the result of BP-lowering medication usage being restricted to the most severe hypertensives, a different pattern has been reported for the US population. Specifically, in the US, SBP and DBP are markedly lower among treated versus untreated persons with hypertension (Table 5). BP levels among the Chinese population with hypertension reflect those of patients with hypertension in the US 25 years ago as reported in Second National Health and Nutrition Examination Survey (NHANES II).22 Current levels of hypertension treatment and control in China from the InterASIA were similar to those seen in the United States 25 years ago and awareness was substantially lower. These rates have improved markedly over the past 25 years in the United States.23,24 Additionally, a high proportion of the Chinese population with hypertension, 32.5%, had not had their BP measured within the preceding 5 years compared with only 3.4% of their counterparts with hypertension in the US population. This may partially explain the substantially lower rates of hypertension awareness in China compared with the United States. The improvements seen during the past 25 years in the United States may be the result of the dedicated effort of the National Heart, Lung, and Blood Institute’s National High Blood Pressure Education Program.
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Like other economically developing countries, the health care system in China faces a financial challenge. Although national guidelines require blood pressure to be measured during all outpatient visits, it is still very common that no blood pressure check-up is performed, especially in rural China. In addition, community-based blood pressure screening and education programs are uncommon in China. Furthermore, clinicians are still used to treating only patients with blood pressure 160/95 mm Hg in China. Our findings highlight the need for developing a national high blood pressure education program to coordinate the effort of detection, prevention, and treatment of hypertension in China.
Studies from several countries have investigated factors associated with hypertension awareness, treatment, and control.25,11,26,27,28 Many of these investigations reported demographic and geographic associations with hypertension awareness, treatment, and control. Many obstacles to hypertension control exist, including social and economic factors.29 Our study findings are consistent with several previous reports.25,11,10 Specifically, these studies found that former smokers and overweight participants with hypertension are more likely to have controlled their blood pressure. Compared with patients who continue to smoke, patients who quit smoking may be more health conscious and visit the physician more often after a diagnosis of hypertension. Physicians may pay more attention to patients with hypertension who are overweight/obese because they are at greater risk of cardiovascular disease. Studies conducted in developing countries have consistently indicated that compared with their counterparts with a lower income, persons with a higher income have better access to health care and higher rates of awareness, treatment, and control of hypertension.
In a previous publication using the InterASIA dataset, rates of lifestyle modification were reported to be similar among persons with SBP/DBP <140/90 mm Hg and their counterparts with a SBP/DBP 140/90 mm Hg. One goal of that analysis was to report the percentage of the population who were taking measures to control their blood pressure. Therefore, the previous analysis provided rates of lifestyle modification among all persons who reported a diagnosis of hypertension. In contrast, in the current manuscript, we sought to determine whether lifestyle modification was associated with blood pressure control. As such, we limited our analysis to participants meeting the definition of hypertension of a SBP/DBP 140/90 mm Hg or currently taking blood pressure medication. The current results support the role of lifestyle modification as a therapy, either alone or in conjunction with pharmacological treatment, in lowering blood pressure.
Findings in the current investigation must be considered within the context of the study’s limitations. Specifically, BP was measured 3 times following a standard protocol during only a single visit. According to both World Health Organization and National Institute of Health guidelines, hypertension should be defined based on the average of at least 2 or more BP readings taken at 2 or more visits after an initial screening.21,30 Another limitation of the current study was the cross-sectional study design of InterASIA. Finally, the study was confined to adults who were 35 to 74 years old.
Important strengths of the current study include the large, nationally representative nature of the InterASIA study population. As such, the results of the current study can be extrapolated to the general population with hypertension in China and perhaps to other Asian populations. Additional strengths include use of a standardized protocol with stringent quality control procedures for measurement of BP and collection of a wide array of socioeconomic, behavioral, and demographic characteristics. Such extensive data collection permitted conduct of a comprehensive analysis of factors associated with increased blood pressure awareness, treatment, and control in the general population of China.
Our findings have important public health implications. First, hypertension awareness is related to several cardiovascular disease risk factors, including overweight and smoking. It appears that the identification of persons with hypertension in China is limited to those with additional comorbid conditions. Second, control of hypertension was greater among former smokers and lower among persons who consume 2 drinks of alcohol per day. Smoking cessation and reduced alcohol consumption may not be the sole reason for controlled hypertension among these patients but may occur concurrently with other lifestyle modifications that benefit persons making these changes. Therefore, the health benefits of multifaceted lifestyle modification, including smoking cessation and consuming <2 drinks per day, should be communicated to patients with hypertension. Third, factors related to the awareness of hypertension are markedly similar in China and the United States. Finally, persons who had their BP measured more recently were more likely to be aware of their diagnosis of hypertension, to be treated for this diagnosis, and to have their systolic and diastolic BP controlled to less than 140/90 mm Hg. Given the escalating burden of hypertension in China, a broad population-based approach for detection, treatment, and control of hypertension is an essential prerequisite for preventing morbidity and mortality from BP-related disease.
Perspectives
Once a patient develops hypertension, controlling it is a function of awareness and treatment (pharmacological and lifestyle). Increasing awareness and treatment of blood pressure elevations is a central focus of the BP education program in the United States. A similar initiative has been proposed for enhancing awareness and control of the burden of hypertension in China. Given the continuing increase in the burden of hypertension in China and the success of the National High Blood Pressure Education Program in the United States, a similar program implemented in China may have a tremendous positive impact in reducing the burden of cardiovascular disease.
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Acknowledgments |
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The InterASIA study was funded by a contractual agreement between Tulane University, La, and Pfizer Inc., NY. Several researchers employed by Pfizer Inc. were members of the Study Steering Committee that designed the study. However, the study was conducted, analyzed, and interpreted by the investigators independently of the sponsor. Dr. Muntner also received partial support for this work from a Scientist Development Award from the American Heart Association (0235134N). This publication was also made possible by National Institutes of Health Grant Number P20 RR17659–01 from the Center of Biological Research Excellence Program of the National Center for Research Resources.
Received November 6, 2003; first decision November 10, 2003; accepted December 29, 2003.
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