Prevalence and characteristics of hypertension in mainland Chinese adults over decades: a systematic review

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Abstract

Hypertension is considered to be the leading risk factor for cardiovascular mortality and accounts for a large proportion of premature deaths in China. An empirical understanding of the pattern of disease burden, such as reliable information about the trend and prevalence of hypertension, is essential in developing effective prevention and control strategies and is also important in the decision-making and planning processes of health. However, there are limited comprehensive reviews or nationwide studies that reveal the current burden of hypertension in China. This review is to systematically evaluate hypertension prevalence and determinants as well as its awareness, treatment and control over decades in China. A systematic search was performed for epidemiological studies on hypertension, published between 1982 and January 2013. MeSH major topic terms ‘hypertension’ and ‘prevalence’ and ‘China’ were used in the search. Data on hypertension prevalence, determinants and awareness, as well as its treatment and control, were extracted and compared. Sixty articles were included for data extraction. The prevalence reported in the studies varied from 7.17 to 51.2%. Awareness, treatment and control rates also varied regionally. Except in the central region of China, where a declining trend in hypertension prevalence was witnessed, a rising trend in hypertension prevalence over time could still be observed in other parts of China. Higher hypertension prevalence was found among men and in the urban population, whereas lower prevalence was found in the southern region. Hypertension awareness and treatment rate varied extensively, with a low control rate, nationwide.

Introduction

Hypertension is a challenging public health problem worldwide and is reported as the leading risk factor for cardiovascular mortality.1 Premature cardiovascular deaths due to hypertension in China accounted for a considerable proportion of all deaths (1.27 million out of 2.33 million total cardiovascular deaths).2 Since 1958, four large-scale national surveys of hypertension prevalence have been conducted—in 1958, 1979–1980, 1991 and 2000, with reported hypertension prevalence rates of 5–11%, 7.7%, 11% and 24–27%, respectively. Although reliable information on the trend and prevalence of hypertension is essential in developing effective prevention and control strategies, at present there is a dearth of studies on hypertension prevalence nationwide; although an estimate of 23.3% for hypertension prevalence was reported in a recent systematic review,3 the searches were limited to the papers published in Chinese journals only. Therefore, an updated and comprehensive assessment of hypertension in China is needed. We conducted this review to systematically evaluate the data available from studies in order to estimate the prevalence trends of hypertension as well as awareness, treatment and control over time in China, and assess the current variation in prevalence determined by demographic or geographic factors such as age, sex, urban or rural residence or geographic region and the like. This review will also provide an evidence base for the rational allocation of heath resources.

Materials and Methods

A standardized review protocol was predefined with a detailed description of search strategy for data source, eligible criteria and data extracting method and tools, as well as for assessment of study quality.

It should be noted that China used a blood pressure value of at least 160/95 mm Hg for hypertension diagnosis and a value of 140/90 mm Hg as diagnostic criteria for normal blood pressure. In the 2005 edition of the Chinese guidelines on prevention and control of hypertension, the diagnostic value for hypertension changed to 140/90 mm Hg and that for normal blood pressure changed to 120/80. Hypertension in this review is defined as systolic blood pressure of at least 140 mm Hg and/or diastolic pressure of at least 90 mm Hg, as diagnostic criteria have changed over time, or self-reported use of antihypertensive medication.

Hypertension awareness is defined as prior diagnosis of hypertension by physicians. Hypertension treatment is defined as using prescription medication because of high blood pressure for more than 2 weeks. Hypertension control is defined as treatment with antihypertensive medication as well as average blood pressure less than 140/90 mm Hg.

Search strategy and selection criteria

Before a systematic search, we did a pilot search for papers and used search terms such as ‘high blood pressure’, ‘hypertens*’ and ‘hypertension’; however, we found that the searched items were similar; in addition, in the Medline database, the MeSH Major topic term ‘hypertension’ also means ‘high blood pressure’. Therefore, a systematic literature search was performed in the Medline database with the MeSH Major topic terms ‘hypertension’, ‘prevalence’ and ‘China’, limited to individuals aged 18. A search was also made in the China National Knowledge Infrastructure digital databases for papers published in Chinese. All searched papers were published from 1982 to January 2013. All the searches were conducted by two independent reviewers (Fang and Song).

Studies were included if the following criteria were met:

  • The study was a population-based cross-sectional study published before January 2013.

  • The study had been carried out on a representative population aged 18 years within mainland China.

  • Hypertension has been clearly defined.

  • The prevalence of hypertension has been reported for both male and female patients.

  • The blood pressure testing protocol has been stated.

Studies were excluded under the following terms:

  • They addressed an occupational group, an ethnic minority group, pregnant women, a specific gender and so on.

  • Only a subtype of hypertension has been studied.

  • The size of the study population was smaller than the size of the city’s.

  • There was no report on overall population prevalence of hypertension or no report of hypertension prevalence for male and female patients.

  • The study contained data that may have been published in more than one paper.

  • Response rate was lower than 80%.

  • The year of study was not stated.

Screening and data extraction

After the search results were saved, two independent reviewers (Ma and Zhang) assessed the searched publications. The first stage was to perform a quick scan of the title and abstract and exclude those that were explicitly irrelevant to hypertension prevalence data. Then the remaining manuscripts were assessed and further screened for full-text reading. In case of disagreement, a third reviewer appraised the paper until interactive consensus was reached for inclusion criteria (Jing or Chen).

A standardized data extraction form using Microsoft Office Excel was designed according to the ‘Strengthening the Reporting of Observational Studies in Epidemiology’ Statement checklist.4

Assessment of study quality and risk of bias

An assessment tool for study quality and risk bias appraisal was developed by referring to the ‘Strengthening the Reporting of Observational Studies in Epidemiology’ guidelines. When the same source of data was used to publish different papers, we carefully assessed the manuscripts to retain the high-quality ones and extracted the required information. The assessment of study quality and risk of bias was undertaken by two independent reviewers (Fang and Song). Discrepancies were resolved through a consensus process (Jing or Chen).

Data analysis

The trend of hypertension prevalence by age group was displayed in line graphs; the difference in hypertension prevalence by gender was illustrated in a scatter graph. Comparisons of trends in geographic variations were tested by the Mantel–Haenzel χ2-test using SAS 9.1 software.

Results

Search result

The initial search of the database identified 3000 potential articles, including 407 from the Medline database and 2593 from the China National Knowledge Infrastructure database. After scanning the titles and abstracts, 632 articles were considered for full-text review. Papers whose data were from the same source were compared for their consistency. After checking the papers using the same source data, we found that the third hypertension prevalence in Zhejiang5 published in 2004 and Xu's study6 published in 2005 were in fact derived from the same survey. The former study reported hypertension prevalence by age, but did not report the rate of awareness, treatment and control of hypertension, whereas the latter study reported the rate of awareness, treatment and control of hypertension; therefore, the reported data from these two articles were collated. Finally, 60 articles were included for data extraction (Figure 1). The articles excluded and the reasons for exclusion are listed in the supplementary data.

Figure 1
figure1

Flowchart of selected studies in the review.

Characteristics of included studies

The main characteristics of the selected studies are displayed in Table 1. Among the 60 selected articles, 58 were single cross-sectional studies, whereas two were cross-sectional studies comparing the trend of hypertension prevalence in different periods;7, 8 all the data reported were extracted, as they met the eligible criteria. Therefore, the year of study dated from 1959 to 2010, with a sample size ranging from 985 to 950 356.

Table 1 Prevalence (%) and trends in prevalence of hypertension in China

Studies were mainly from published journal articles, whereas one was from a dissertation thesis.9 Of these, three studies were epidemiological surveys performed at the national level, and the rest were regional studies performed at least at the city level. Although not all studies mentioned the hypertension diagnostic criteria, and diagnostic criteria varied among studies. Specifically, studies that used a value of blood pressure of at least 160/95 mm Hg for hypertension also reported hypertension prevalence by a cutoff value of 140/90 mm Hg; therefore, to maintain consistency, we extracted only data reported at a cutoff value of 140/90 mm Hg, and thus all included studies used a blood pressure cutoff value of 140/90 mm Hg for hypertension.

Prevalence of hypertension

Hypertension prevalence varied between studies. For the three nation-level studies,10, 11, 12 the reported hypertension prevalence was 13.6% in 1991, 27.2% in 2001 and 18.0% in 2002. As differences in population age range, Jiang’s investigation11 conducted in 2001 showed a lower prevalence of hypertension than Yang’s investigation12 in 2002.

The lowest overall hypertension prevalence reported was 7.17% in Heilongjiang Province7 conducted in 1959, whereas the highest prevalence was 51.2% in Lhasa, Tibet,13 conducted in 2010. Fu’s study7 reported that hypertension prevalence in the Heilongjiang province had escalated from 7.17% in 1959 to 18.2% in 1999.

Age and gender

Twenty-eight studies reported hypertension prevalence in different age groups (4 in an urban setting, 8 in a rural setting and 16 in both urban and rural settings). Hypertension prevalence in China rose rapidly with age both in the urban setting and in the rural setting (Figures 2 and 3). The same trend was observed between the urban and rural settings as well (Supplementary Figure 1). Although two studies,14, 15 both from Ningxia Province, Northwest China, showed that hypertension prevalence in those over 75 years was lower than that in individuals in the age groups 55–65 and 65–75, Mantel–Haenzel χ2-testing in the two studies showed that hypertension prevalence increases with age (P<0.001). The lower hypertension prevalence in those over 75 years may be because of the relatively smaller size of that population compared with other age groups.

Figure 2
figure2

Hypertension prevalence by age group in the rural setting.

Figure 3
figure3

Hypertension prevalence by age group in the urban setting.

Of the studies that have reported hypertension prevalence by gender, hypertension prevalence between male and female patients varied over setting and time, with a prevalence ranging from 6.54%7 to 56.0%13 for male and from 6.39%7 to 48%13 for female patients. Over the past two decades, despite three studies16, 17, 18 reporting higher hypertension prevalence rates among females compared with males, it was still apparent that males generally had higher hypertension prevalence compared with females in the remaining 56 studies (Supplementary Figure 2).

Geographic variations

Over the past decade, hypertension prevalence in the southern region has remained relatively steady over time, with a lower rate than in other regions nationwide (the lowest prevalence reported is 15.1%19). There have been only three studies14, 15, 20 from the northwest region in 2009 with a reported prevalence of about 21.7%; however, in the past 10 years, there has been a declining trend in hypertension prevalence in the central region (P<0.0001), whereas a rising trend has been seen in the other regions (P<0.0001), which is more obvious in the southwest region (P<0.0001). The highest prevalence reported is 51.2% in Lhasa, Tibet.13

Urban–rural disparity

Studies in three different settings (both urban and rural settings, n=42; urban setting, n=8; rural setting, n=10) were included in this review. Among those conducted in both urban and rural settings, 25 reported hypertension prevalence for urban and rural settings separately. Five of 25 studies reported higher hypertension prevalence in the rural compared with the urban population; among these five studies,21, 22, 23, 24, 25 statistical comparisons showed that hypertension prevalence in the urban population was significantly higher than that in the rural population in four studies, whereas no statistically significant difference in hypertension prevalence between rural and urban populations was found in the fifth study.25 For the remaining 20 studies that reported higher hypertension prevalence in urban than in rural populations, there existed statistical difference between urban and rural populations, except in the case of five studies,26, 27, 28, 29, 30 which did not conduct statistical comparisons. Although higher hypertension prevalence in urban than in rural populations was reported in Li’s study,16 the study also indicated that significant differences in hypertension between urban and rural populations were only seen after the age of 35 years.

Awareness, treatment and control of hypertension in China

Thirty-one studies reported the rate of awareness, treatment and control of hypertension: one national-level report and 30 regional reports, as shown in Table 2. The rates of awareness, treatment and control of hypertension at the national level reported in 2001 were 44.7%, 28.2% and 8.1%, respectively.11 The highest rate of awareness reported was 85.5% in Shanghai in 2008,31 whereas the highest rates for treatment and control were 94.17% and 42.29%, respectively, in Chengdu in 2008.22 A slightly rising trend in the rate of awareness, treatment and control can be seen over the past 10 years; however, the overall control rate is still low nationwide and the treatment rate in Lhasa, Tibet, was only 24.2% in 2010.13

Table 2 Rate of awareness, treatment and control (%) of hypertension in China

Discussion

Although this review was unable to compute an overall estimate of hypertension prevalence in China in recent years, given the high heterogeneity among studies, we have tried to highlight the changing trends in terms of age group and geographic regions. Owing to extensive variations in the geographic regions examined among studies we did not conduct a meta-analysis to generate a pooled prevalence rate. The main changing trend was similar to that in other synthesized research32 that has shown increased hypertension prevalence in China over the last few decades, and a very recent study is also consistent with this trend.33

Although nationwide data for hypertension prevalence since 2002 were not available for this review, we did notice that the Fourth National Health Service Survey reported hypertension prevalence of 9.39% in 2008 among the surveyed population aged 35 years in the survey area;34 the relatively lower reported rate may be partially attributed to the confirmation of hypertension strictly by physicians only. The reported hypertension prevalence rate in the China Health Statistical Yearbook in 2008 was, however, 5.49%.35 These two reported data sources were not included in this review, as the research method could not be ascertained or the study did not meet the eligible criteria.

As has been mentioned in the Methods section, a diagnostic blood pressure value of 140/90 mm Hg was used to evaluate normal blood pressure, although later in 2005 this value was used as the diagnostic value for hypertension. Therefore, we extracted data from those studies that reported blood pressure at a cutoff value of 140/90 mm Hg. Inclusion of studies that defined hypertension before 2005 may lead to bias as self-reported use of blood pressure medicine is a criterion for diagnosing hypertension and blood pressure medicine was less likely to be used when the diagnosis of high blood blood pressure was 160/95 in comparison with 140/90 mm Hg. Furthermore, differences in sampling as well as possible regional and age differences in different studies may also result in potential bias when reporting hypertension prevalence.

This review also showed that hypertension prevalence increased with age, indicating higher demand for health in the ageing population. Generally, male patients tend to have higher hypertension prevalence compared with female patients. Possible explanations may be difference in physiological structure, or the fact that there is a larger rate of smoking and drinking among males than among females in China.36 However, no statistical difference was found in those three studies16, 17, 18 that reported higher hypertension prevalence among females than among males. Possible reasons discussed in one study17 were changes in female patients’ endocrine metabolic regulation and diet after pregnancy; a common characteristic among those three studies was that the population size in the group aged 35–45 years was relatively larger than that of other age groups compared with other studies in this review.

Similar to a previous study,37 in this review hypertension prevalence in the south region is lower than that in other regions. However, the highest hypertension prevalence was reported in the southwest region in 2010, almost triple that of the lowest reported in the east region during the same time period. Higher hypertension prevalence was found in the urban population than in the rural population, suggesting that the differences may be from urbanization, as increasing evidence showed that development in economics and urbanization are related to the changes in behavioral lifestyle.38 A pooled estimate of hypertension prevalence of 21.5% in the city population was reported in another meta study in 2010,39 which was lower than that reported in Zhang’s study (41.76%),40 which was also conducted in 2010 in the urban population only in East China and was selected in this review. Yet, the difference further indicated that regional differences cannot be ignored when performing such reviews.

As for the other factors associated with hypertension, the most commonly mentioned in this review are body mass index (BMI), family history and income. Almost all the studies that involved BMI reported that higher BMI is associated with higher risk of developing hypertension. Although salt intake was generally considered to highly correlate with hypertension,41 only six studies reported this trend. This review reveals that hypertension prevalence in the southern region was lower than that in the northern region, which is consistent with northerners having higher salt intake compared with southerners.42, 43

The rates of awareness, treatment and control of hypertension are important parameters for prevention and control of hypertension. Although there has been a slight increase in the rate of awareness, treatment and control of hypertension in the past few years, situations vary extensively nationwide. In Shanghai, one of the most developed cities in China, the awareness rate reached 85.5% and treatment rate 74.2% in 2008, whereas the control rate was only 31.5%.31

In this review, the entire prevalence rate reported is a crude rate, as some studies did not adjust the standardized prevalence rate, and, among those that did adjust, the selected standard population for adjustment varied (summarized in the Supplementary Table 1). The absence of data on the current level of hypertension prevalence worldwide indicates that a nationwide survey is needed to illustrate the present burden of hypertension to health services, and regional health allocation should give due attention to the southwest region. Even so, this review can still be used as an aid in planning health policies.

Conclusions

To date, this review is the longest systematic review on hypertension prevalence in the Chinese population in terms of study period. Although hypertension prevalence in the central region of China is declining, a rising trend can still be observed in other parts of China over decades, more obvious in Southwest China. Southerners tend to have a lower hypertension prevalence compared with people from other parts. Hypertension prevalence increased with age, and there is higher hypertension prevalence in the urban population than in the rural population. Given the variation in the awareness and treatment rates, and the low control rate nationwide, China has still a long way to go in its fight against hypertension.

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Acknowledgements

We thank Professor Yonghua Hu, Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, for his kind and valuable suggestions in the review.

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Correspondence to D Chen.

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The authors declare no conflict of interest.

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Supplementary Information accompanies this paper on the Journal of Human Hypertension website

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Fang, L., Song, J., Ma, Z. et al. Prevalence and characteristics of hypertension in mainland Chinese adults over decades: a systematic review. J Hum Hypertens 28, 649–656 (2014) doi:10.1038/jhh.2014.5

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Keywords

  • prevalence
  • China
  • high blood pressure

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