You are here

Article Text

Article menu

Download PDFPDF

Epidemiology
Original research
Prevalence of hypertension in Shenzhen, China: a population-based, cross-sectional study
  1. Weicong Cai1,
  2. Yirong Wang1,
  3. Ke Peng2,
  4. Rencheng Zhao3,
  5. Fangjiang Liu1,
  6. Kaihao Lin1,
  7. Fengzhu Xie1,
  8. Lin Lei1,
  9. Ji Peng1
  1. 1Shenzhen Center for Chronic Disease Control, Shenzhen, Guangdong, China
  2. 2National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, Guangdong, China
  3. 3Bao’an District Hospital for Chronic Diseases Prevention and Cure, Shenzhen, Guangdong, China
  1. Correspondence to Dr. Ji Peng; pengji126{at}126.com

Abstract

Objective Hypertension (HTN) is an important public health issue worldwide, associated with the rapid economic development and urbanisation over the last decades. This is especially the case in Shenzhen, which has benefited greatly from the reform and opening-up policies. However, there is limited information on the epidemiology of HTN in this region. This study was designed to investigate the prevalence, awareness, treatment and control of HTN and the associated factors among adult residents in Shenzhen, China.

Design Population-based, cross-sectional study.

Participants Through the multistage stratified random sampling method, a representative sample of 10 043 urban population aged ≥18 years were selected. Three consecutive blood pressure (BP) readings were measured after resting for a 5 min seat by trained staff and HTN was defined as mean systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg and/or self-reported current use of antihypertensive drugs. Participants were interviewed using a structured questionnaire. Anthropometric details, BP, blood and urine samples were also collected.

Primary outcome measure Prevalence of HTN.

Results Overall, the weighted prevalence of HTN among residents in Shenzhen was 19.2% (95% CI 18.5 to 20.0). Among patients with HTN, 55.0% (95% CI 52.9 to 57.1) were aware of their condition and 44.9% (95% CI 42.8 to 47.1) were taking antihypertensive medications, but only 21.7% (95% CI 20.0 to 23.5) achieved BP control. Among those who knew their HTN, 81.7% (95% CI 79.3 to 83.8) were under treatment and 48.3% (95% CI 45.1 to 51.5) were controlled among those with treated HTN. Male, older age, lower educational level, overweight and obesity, family history of HTN, tobacco smoking, alcohol intake, diabetes mellitus, dyslipidaemia and high uric acid were associated with HTN.

Conclusions HTN is a major public health concern in Shenzhen, which has low awareness, treatment and control rates, and is associated with several risk factors. Effective multifaceted implementation strategies are highly needed to combat the emerging burden of HTN.

  • Hypertension
  • PUBLIC HEALTH
  • EPIDEMIOLOGY
  • PREVENTIVE MEDICINE

Data availability statement

Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2022-061606

Statistics from Altmetric.com

    Request Permissions

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

    Strengths and limitations of this study

    • This study from a large representative sample provides new information on the status of prevalence, awareness, treatment, control and risk factors associated with hypertension among the urban adult population in Shenzhen.

    • Some data were self-reported and thus the study is subject to reporting bias and recall bias.

    • The nature of the cross-sectional design prevents us from making causal and temporal inferences between potential risk factors and hypertension.

    • We were unable to compare the effect of monotherapy and combined therapy on optimal blood pressure control, which warrants further study.

    • This study was conducted only in Shenzhen, which may influence the generalisability and representativeness due to regional variations.

    Introduction

    Hypertension (HTN) or raised blood pressure (BP) has become an important global health problem and a huge burden to primary healthcare systems.1 2 It is also the leading modifiable risk factor for cardiovascular disease, premature death and all-cause mortality worldwide.2 3 There has been a dramatic increase in the prevalence of HTN across the world, and earlier work estimated that 31.1% of the global adult population, or 1.39 billion people, had HTN,4 accounting for around 17% of total deaths and 7% of total disability adjusted life years.5 More importantly, HTN disproportionately influences populations in low-income and middle-income countries (LMICs), and not only is HTN more prevalent in LMICs, there are also more people affected living in these countries than in high-income countries (HICs).6 Worse still, HICs experienced a substantial increase in the proportion of HTN awareness, treatment and control, whereas in LMICs these increased slightly or even decreased.4

    Once an underdeveloped region, Shenzhen has benefited from the implementation of the reform and opening-up policies in the 1980s, which has led to its extremely significant economic and infrastructural development. At the same time, however, these transitions in Shenzhen have provoked sweeping changes in the lifestyle of the residents, involving increased intake of dietary salt and fat and reduced participation in physical activity (PA), which in turn have undoubtedly contributed to the significant increase in BP and body weight.7 8 Such unhealthy lifestyle changes are affecting numerous young people around the world. This is especially the case in Shenzhen, where the age structure of the population is quite young and the proportion of individuals at least 60 years old is only 5.36%.9 In addition, prior literature indicated that the prevalence of HTN among young people increases more dramatically than among the elderly.10 11

    HTN is a preventable public health concern and is linked with individual unhealthy behaviours such as tobacco smoking, alcohol consumption and physical inactivity.5 Other risk factors have also been found to be associated with HTN, including lower educational level and household income, urban residence, higher body mass index (BMI), higher salt intake and consumption of fatty foods, and insufficient intake of fruits and vegetables.10–16 There are also marked gender and age differences in the prevalence of HTN.10–13

    However, studies about the epidemiological characteristics of HTN in Shenzhen are lacking and evidence between HTN and potential risk factors from Shenzhen’s adult population is scarce. We thereby conducted a cross-sectional study to investigate HTN prevalence, awareness, treatment and control and further identify the risk factors associated with HTN event that could serve for the implementation of effective prevention and intervention strategies.

    Methods

    Study design and participants

    Conducted from September to December 2018, this was the third population-based, cross-sectional study designed to determine the prevalence of chronic non-communicable diseases and their risk factors in Shenzhen, China. In order to obtain enough sample size, the prevalence of diabetes mellitus (DM), which is significantly lower than of HTN and dyslipidaemia, that found in the preinvestigation was used to calculate. The α value, the prevalence of DM, the relative error and the design effect were 0.05, 8.3%, 10% and 2, respectively, with a non-response rate of 15%. This resulted in a final sample size for the present study of 9761.

    Based on feasibility and cost-effectiveness, a multistage stratified sampling method was adopted for the whole sampling process to select communities, households and eligible individuals. First, 10 communities were randomly chosen from 10 administrative districts, respectively. Second, from each selected community, 100 representative households were chosen randomly. Third, from each of the selected household, eligible participants aged ≥18 years old living in Shenzhen for over 6 of the past 12 months were selected on the basis of the Kish selection table. Finally, a sample size of 10 043 participants were enrolled, with 3 excluded due to missing data on covariates and BP measurement.

    Written informed consent was obtained from each participant. The purpose and meaning of the study were explained verbally to consenting participants by trained staff prior to the study.

    Data collection

    Participants were interviewed by trained personnel using a structured questionnaire to collect demographic characteristics, PA involvement, tobacco smoking, alcohol intake and dietary behaviours. Basic details included ethnicity, sex, age, educational level, marital status, health insurance status, and personal and family histories of diseases.

    The Global Physical Activity Questionnaire was used to evaluate participants’ PA levels, and sufficient PA was defined as at least 150 min of moderate-intensity PA or at least 75 min of vigorous-intensity PA per week, or an equivalent combination of moderate-intensity and vigorous-intensity PA.17

    Current smokers were defined as participants who have smoked at least one cigarette per day in the last 6 months and currently smoke any tobacco products, former smokers as participants who have smoked at least one cigarette each day in the past half year but quit smoking for 1 month or above, and never smokers as participants who never smoked. Drinkers were defined as participants who have drunk an average of at least one alcoholic beverage per week and currently consume alcohol.

    Dietary behaviours were also evaluated. (1) Consumption of soft drink was asked based on the number of times in a typical week, with participants classified into ≥6 times/week, 3–5 times/week or ≤2 times/week. (2) Daily salt intake was calculated from the volume of salt consumed per day divided by the number of family members and was classified into ≥5 g/day or <5 g/day. (3) Daily consumption of oil was calculated from the volume of oil consumed per day divided by the number of family members and was classified into <25 g/day, 25–35 g/day or >35 g/day. (4) Daily fruit and vegetable intake was calculated from the number of servings of fruits and vegetables consumed per day in a typical week and was classified into ≥5 servings/day or <5 servings/day.6

    Height and weight of participants were uniformly measured without shoes and heavy clothing, following common standard protocols. BMI was defined as weight divided by height squared (kg/m2) and was further classified into four categories: underweight (<18.5 kg/m2), normal (18.5–23.9 kg/m2), overweight (24.0–27.9 kg/m2) and obesity (≥28.0 kg/m2).18

    The subjects themselves took at least 30 mL morning mid-urine and sealed and handed it to the staff investigators for test. Overnight fasting blood samples were drawn after a 15 min rest, in the sitting position, by venipuncture to measure blood glucose, serum total cholesterol, total triglycerides, low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol. Blood and urine specimens were kept at 2°C–8°C and sent within 2 hours to the Shenzhen laboratory of Guangzhou KingMed Diagnostics Center, where the specimens were processed and stored frozen at −80°C until laboratory assays could be performed. Based on the Guidelines for the Prevention and Treatment of Dyslipidemia in Adults in China (2016 Revised Version), participants who met one of the following criteria were considered to have dyslipidaemia: total triglycerides ≥2.3 mmol/L, serum total cholesterol ≥6.2 mmol/L, LDL cholesterol ≥4.1 mmol/L, HDL cholesterol <1.04 mmol/L19 and a diagnosis of dyslipidaemia. Participants were defined to have high uric acid if their uric acid was >420 µmol/L20 and DM if fasting plasma glucose was ≥7.0 mmol/L, self-reported current use of insulin or oral hypoglycaemic drugs or a history of diagnosis of diabetes.21 22

    The subjects were told not to smoke, exercise, and drink coffee, alcohol or tea at least 30 min before examination. Measurement of BP was performed before blood draw and three consecutive readings of BP were measured using a validated and standardised mercury sphygmomanometer (HEM-7124, OMRON) on the same arm after a 5 min seated rest, with 1 min between each measurement. The average of the three readings was considered as each participant’s BP. Consistent with the US Eighth Joint National Committee standards1 and Chinese guidelines,23 HTN was defined as an average systolic BP of ≥140 mm Hg and/or an average diastolic BP of ≥90 mm Hg and/or self-reported current use of antihypertensive drugs. Awareness of HTN was defined as self-report of any prior diagnosis of HTN by a doctor among participants identified as hypertensive, treatment as the use of prescribed antihypertensive medication within 2 weeks at the time of the interview, and control as an average systolic BP of <140 mm Hg and an average diastolic BP of <90 mm Hg; patients not meeting these criteria were considered unaware, untreated and uncontrolled, respectively.

    Patient and public involvement

    No patients were involved.

    Quality control

    To ensure the quality of the survey and physical measurements, staff investigators were trained uniformly in accordance with the study protocol to be familiar with the specific methodologies and tools employed. Height, weight and BP were measured and obtained repeatedly from 5% of participants by quality control staff. Also, the staff validated the members from 5% of the selected family and reinterviewed 10% of the subjects by telephone based on the abbreviated version of the main questionnaire.

    Statistical analysis

    Categorical variables were presented as number (percentage) and tested for between-group differences using χ2 test. HTN prevalence, awareness, treatment and control were expressed as percentage with 95% CI and weights were calculated according to the 2010 Chinese census. All significant variables (including ethnicity, sex, age, educational level, marital status, BMI, health insurance status, family history of HTN, family history of cancer, smoking status, alcohol consumption, soft drinks intake, cancer, chronic obstructive pulmonary disease, DM, dyslipidaemia and high uric acid) tested by χ2 test were included in the multivariable logistic regression model to explore the potential risk factors associated with HTN, where OR and the corresponding 95% CI of significant variables were calculated, using forward conditional manner and selection criteria of αin=0.05 and αout=0.10. SPSS V.26.0 was used for statistical analyses and a two-tailed P value <0.05 was considered statistically significant.

    Results

    Overall, 10 043 participants were aged 18–95 years old, with a mean age of 43.4 years (SD=12.64). More participants were Han, female, married, had normal weight, well educated with a high school degree or higher, and had various types of health insurance. Majority of the participants did not have a family history of any chronic diseases, including HTN, coronary heart disease, cerebrovascular disease, DM and cancer. Of the whole sample, the crude and weighted prevalence of HTN were 21.3% (n=2143, 95% CI 20.5 to 22.2) and 19.2% (95% CI 18.5 to 20.0), respectively. Ethnicity, sex, age, educational level, marital status, BMI, health insurance status, and family history of HTN and cancer were significantly associated with HTN (table 1).

    View this table:
    Table 1

    Comparison of baseline characteristics of study participants with and without hypertension

    As presented in table 2, significant differences in individual lifestyle variables between participants with and without HTN included smoking status, alcohol consumption and soft drinks intake. Moreover, whether participants had any chronic diseases including cancer, chronic obstructive pulmonary disease, DM and dyslipidaemia or high uric acid were significantly linked with HTN (table 2).

    View this table:
    Table 2

    Comparison of individual behavioural and clinical factors in study participants with and without hypertension

    Based on the significant variables tested by χ2 test, a multivariate logistic regression analysis was performed to estimate their ORs for HTN and the results are displayed in table 3. Male, older age, lower educational level, overweight or obesity, family history of HTN, DM, dyslipidaemia and high uric acid were positively associated with HTN. In addition, participants who were smokers or alcohol drinkers had higher odds of HTN.

    View this table:
    Table 3

    Multivariable logistic regression to estimate potential risk factors for hypertension

    Among those with HTN, 55.0% (n=1179, 95% CI 52.9 to 57.1) were aware of their status and 44.9% (n=963, 95% CI 42.8 to 47.1) were taking antihypertensive medications, but only 21.7% (n=465, 95% CI 20.0 to 23.5) achieved BP control. Among those who knew their HTN, 81.7% (95% CI 79.3 to 83.8) were under treatment to lower their BP and 48.3% (95% CI 45.1 to 51.5) were controlled among those with treated HTN. There were significant differences in awareness, treatment and control rates among participants of various sexes, ages and educational levels (table 4).

    View this table:
    Table 4

    Awareness, treatment and control among adults with hypertension in Shenzhen

    Discussion

    This survey from a large representative sample provides new information on the status of prevalence, awareness, treatment, control and risk factors associated with HTN among the urban adult population in Shenzhen. Overall, the prevalence of HTN in Shenzhen was lower than the national level and urban residents in the top developed provinces in China, but higher than in Hunan, Hainan and Guangxi.10 With the rapid economic growth over the past decades, ageing, urbanisation and associated unhealthy lifestyle and diet may explain the dramatic increase in the prevalence of HTN.12 24 25 Also, residents in developed areas tend to suffer from higher psychosocial stress, coupled with individual unhealthy lifestyle, contributing to the development of HTN.26 27 This is especially the case in Shenzhen, which has turned from a small fishing village to a prosperous modern metropolis in the last four decades.

    In line with other research,10 12 28 29 our study revealed that there was a significant between-gender difference and male residents were at higher risk of HTN than female residents. Several possibilities might contribute to this gender disparity. First, individual unhealthy behaviours such as tobacco smoking, physical inactivity and alcohol consumption are associated with HTN, which could be found more frequently in men than in women.6 30 31 This is supported partly by the present study—tobacco smoking and alcohol intake could increase the risk of HTN. Second, an increase in body weight has been identified as another contributing factor for elevated BP and previous study indicated that the prevalence of obesity and overweight among men was higher than among women.6 16 31 32 In this study, overweight and obesity increased the odds of HTN, which was aligned with other studies.10 12 16 Third, people in developed areas often live a stressful life and men were more likely to be exposed to higher relationship and occupational stress than their counterparts, resulting in the rapid increase in the prevalence of HTN.27 33 Collectively, there is an urgent call for effective sex-specific interventions to address this discrepancy, and long-established lifestyle modification programmes are highly required to help residents adopt healthy behaviours to prevent the development of HTN and its complications.

    Consistent with previous findings,10 12 this study found that age was positively associated with HTN and the likelihood increased dramatically with age. More importantly, however, the younger population experienced a more rapid growth in the prevalence of HTN in comparison with the elderly.10 11 This means that more attention should be paid to changes in the prevalence of HTN in Shenzhen because the age structure of its residents is quite young. Aligned with other results,34 35 our study also revealed that lower educational level could increase the odds of developing HTN. In addition, family history of HTN is a significant independent risk factor for HTN.12 This could be observed in the present study. Therefore, it is of great significance for these key populations to seek early BP monitoring because HTN is a silent killer without symptoms mostly during the early stages.

    Excess weight has been accepted as a primary determinant of HTN.6 16 32 Earlier research indicated that it is possible that obesity is correlated independently with HTN but may be mediated by physical inactivity and unhealthy diet.36 However, unlike other results,6 14 15 we did not find an association between HTN and intake of fruits and vegetables, salt intake and insufficient PA in the present study. Such an association needs to be studied further. Moreover, other metabolic risk factors including DM and dyslipidaemia were also associated with HTN,6 which was confirmed in this study. These findings reflect the complexity of the risk factors linked with HTN, and bespoke intervention strategies for specific population subgroups will be better choices to effectively control HTN and its consequences.

    High or elevated BP, as a large global health burden, is closely and strongly related with cardiovascular disease and kidney disease.28 HTN is a silent and invisible killer that rarely shows symptoms, so increasing public awareness about knowing their BP level is key, as is access to early detection.6 However, awareness, treatment and control of HTN are unacceptably low across the world, particularly in LMICs.16 28 In this study, we found that awareness, treatment and control rates among individuals with HTN exceeded the national levels10 11 and were higher than other regional results in China.12 29 This may be partially attributed to the healthcare reform and comprehensive strategies at the community level initiated by the Shenzhen government in the past decade, resulting in significant improvement in healthcare access and affordability. Moreover, we found that the rate of treatment and control was markedly higher among those who knew their condition. This might suggest that higher level of awareness and knowledge of HTN is of great help to improve patient adherence to antihypertensive medications, acting as a significant facilitator of HTN control. Ultimately, large-scale, community-based BP screening and education programmes could be a cost-effective approach to improve individual awareness, with parallel efforts to deliver multifaceted interventions to enforce patient compliance with medications and physician compliance with recommended clinical guidelines, translating into better HTN treatment and control. Nonetheless, it is worthwhile noting that the awareness, treatment and control rates in this study remain lower than in HICs,4 28 where strong and effective public health policies and interventions have begun to launch to address HTN and its complications and to modify other risk determinants.28 This highlights the need to deepen the primary healthcare reform, and innovative integrated strategies for HTN prevention and control are urgently required to illuminate impediments at the patient, provider, system and community levels. Also, consistent with other findings,10–12 significant differences in the awareness, treatment and control rates among participants of different sexes, ages and educational levels were observed in our study. It is thus essential to quickly identify effective ways to address these gaps in an affordable and sustainable manner, and the enormous benefits of BP control to public health make a compelling case for action.37

    This study provides up-to-date information on the epidemiology of HTN in an immigrant and ‘young people’ city. However, several potential limitations need to be considered. First, except for blood and urine chemistry, anthropometric and BP measurements, other information was self-reported, resulting in recall bias and reporting bias. It is possible that participants might over-report or under-report their individual lifestyles, especially for socially desirable behaviours such as PA involvement and fruit and vegetable intake, which may limit us from further exploring their association with HTN. Second, the nature of cross-sectional design prevents us from making causal and temporal inferences between potential risk factors and HTN. Third, earlier literature indicated that combined therapy might be more effective than monotherapy to achieve optimal BP control,11 but we were unable to compare them due to the absence of medication data. Fourth, this study was conducted only in Shenzhen, which may influence the study’s representativeness and generalisability due to regional variations. Future study should take these limitations into consideration.

    Conclusions

    With a crude and weighted prevalence of 21.3% and 19.2%, respectively, and with low awareness, treatment and control rates, HTN is a major public health problem among adult residents in Shenzhen. Several risk factors for HTN were identified, including male, older age, lower educational level, overweight and obesity, family history of HTN, tobacco smoking, alcohol intake, DM, dyslipidaemia and high uric acid. These findings provide insights into the importance of HTN prevention and control, and effective multifaceted implementation strategies need to be developed to prevent individuals from developing HTN and reduce the burden of this condition.

    Data availability statement

    Data are available upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by the Ethics Committee of the Shenzhen Center for Chronic Disease Control (no: SZCCC-2018-019-02-PJ). Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    We thank all participants for their participation in this study.

    References

    1. ↵
      1. James PA,
      2. Oparil S,
      3. Carter BL
      . 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the eighth joint National Committee (JNC 8). JAMA 2014;311:507–20.doi:10.1001/jama.2013.284427pmid:http://www.ncbi.nlm.nih.gov/pubmed/24352797
      OpenUrlCrossRefPubMedWeb of Science
    2. ↵
      1. GBD 2017 Causes of Death Collaborators
      . Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the global burden of disease study 2017. Lancet 2018;392:1736–88.doi:10.1016/S0140-6736(18)32203-7pmid:http://www.ncbi.nlm.nih.gov/pubmed/30496103
      OpenUrlCrossRefPubMed
    3. ↵
      1. GBD 2017 Risk Factor Collaborators
      . Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the global burden of disease study 2017. Lancet 2018;392:1923–94.doi:10.1016/S0140-6736(18)32225-6pmid:http://www.ncbi.nlm.nih.gov/pubmed/30496105
      OpenUrlCrossRefPubMed
    4. ↵
      1. Mills KT,
      2. Bundy JD,
      3. Kelly TN, et al
      . Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries. Circulation 2016;134:441–50.doi:10.1161/CIRCULATIONAHA.115.018912pmid:http://www.ncbi.nlm.nih.gov/pubmed/27502908
      OpenUrlAbstract/FREE Full Text
    5. ↵
      1. World Health Organization
      . Global status report on noncommunicable diseases 2014. Geneva: World Health Organization, 2014.
    6. ↵
      1. World Health Organization
      . A global brief on hypertension: silent killer, global public health crisis. Geneva: World Health Organization, 2013.
    7. ↵
      1. Zhai FY,
      2. Du SF,
      3. Wang ZH, et al
      . Dynamics of the Chinese diet and the role of urbanicity, 1991-2011. Obes Rev 2014;15 Suppl 1:16–26.doi:10.1111/obr.12124pmid:http://www.ncbi.nlm.nih.gov/pubmed/24341755
      OpenUrlPubMed
    8. ↵
      1. Ng SW,
      2. Howard A-G,
      3. Wang HJ, et al
      . The physical activity transition among adults in China: 1991-2011. Obes Rev 2014;15 Suppl 1:27–36.doi:10.1111/obr.12127pmid:http://www.ncbi.nlm.nih.gov/pubmed/24341756
      OpenUrlPubMed
    9. ↵
      Shenzhen statistics bureau. Available: http://tjj.sz.gov.cn/zwgk/zfxxgkml/tjsj/tjgb/content/post_8772048.html [Accessed 30 Jun 2021].
    10. ↵
      1. Wang Z,
      2. Chen Z,
      3. Zhang L, et al
      . Status of hypertension in China: results from the China hypertension survey, 2012-2015. Circulation 2018;137:2344–56.doi:10.1161/CIRCULATIONAHA.117.032380pmid:http://www.ncbi.nlm.nih.gov/pubmed/29449338
      OpenUrlAbstract/FREE Full Text
    11. ↵
      1. Lu J,
      2. Lu Y,
      3. Wang X, et al
      . Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China peace million persons project). Lancet 2017;390:2549–58.doi:10.1016/S0140-6736(17)32478-9pmid:http://www.ncbi.nlm.nih.gov/pubmed/29102084
      OpenUrlCrossRefPubMed
    12. ↵
      1. Huang X-B,
      2. Zhang Y,
      3. Wang T-D, et al
      . Prevalence, awareness, treatment, and control of hypertension in southwestern China. Sci Rep 2019;9:19098.doi:10.1038/s41598-019-55438-7pmid:http://www.ncbi.nlm.nih.gov/pubmed/31836764
      OpenUrlPubMed
    13. ↵
      1. Soubeiga JK,
      2. Millogo T,
      3. Bicaba BW, et al
      . Prevalence and factors associated with hypertension in Burkina Faso: a countrywide cross-sectional study. BMC Public Health 2017;17:64.doi:10.1186/s12889-016-3926-8pmid:http://www.ncbi.nlm.nih.gov/pubmed/28077112
      OpenUrlPubMed
    14. ↵
      1. Li B,
      2. Li F,
      3. Wang L, et al
      . Fruit and vegetables consumption and risk of hypertension: a meta-analysis. J Clin Hypertens 2016;18:468–76.doi:10.1111/jch.12777pmid:http://www.ncbi.nlm.nih.gov/pubmed/26826021
      OpenUrlPubMed
    15. ↵
      1. He FJ,
      2. Li J,
      3. Macgregor GA
      . Effect of longer term modest salt reduction on blood pressure: cochrane systematic review and meta-analysis of randomised trials. BMJ 2013;346:f1325.doi:10.1136/bmj.f1325pmid:http://www.ncbi.nlm.nih.gov/pubmed/23558162
      OpenUrlAbstract/FREE Full Text
    16. ↵
      1. Chow CK,
      2. Teo KK,
      3. Rangarajan S, et al
      . Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA 2013;310:959–68.doi:10.1001/jama.2013.184182pmid:http://www.ncbi.nlm.nih.gov/pubmed/24002282
      OpenUrlCrossRefPubMedWeb of Science
    17. ↵
      1. World Health Organization
      . Chronic diseases and health promotion. global physical activity surveillance. Available: http://www.who.int/chp/steps/GPAQ_CH.pdf?ua=1 [Accessed 12 Aug 2021].
    18. ↵
      1. Zhou B-F
      . Effect of body mass index on all-cause mortality and incidence of cardiovascular diseases--report for meta-analysis of prospective studies open optimal cut-off points of body mass index in Chinese adults. Biomed Environ Sci 2002;15:245–52.pmid:http://www.ncbi.nlm.nih.gov/pubmed/12500665
      OpenUrlPubMedWeb of Science
    19. ↵
      1. Joint Committee for the Revision of Chinese Adult Dyslipidemia Prevention Guidelines
      . Chinese Adult Dyslipidemia Prevention Guidelines (2016 Revised Edition)[Chinese]. Chin J Circulation 2016;31:937–53.
      OpenUrl
    20. ↵
      1. Endocrinology Branch of Chinese Medical Association
      . Guidelines for the diagnosis and treatment of hyperuricemia and gout in China (2019)[Chinese]. Chin J Endocrin Metabolism 2020;36:1–13.
      OpenUrl
    21. ↵
      1. Diabetes Branch of Chinese Medical Association
      . Guidelines for Prevention and Treatment of Type 2 Diabetes in China (2017 Edition)[Chinese]. Chin J Practical Intern Med 2018;38:292–344.
      OpenUrl
    22. ↵
      1. NCD Risk Factor Collaboration (NCD-RisC)
      . Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4.4 million participants. Lancet 2016;387:1513–30.doi:10.1016/S0140-6736(16)00618-8pmid:http://www.ncbi.nlm.nih.gov/pubmed/27061677
      OpenUrlCrossRefPubMed
    23. ↵
      1. Liu LS
      . Writing Group of Chinese Guidelines for the Management of Hypertension. 2010 Chinese guidelines for the management of hypertension [Chinese]. Zhonghua Xin Xue Guan Bing Za Zhi 2011;39:579–615.
      OpenUrlPubMed
    24. ↵
      1. Jiang H,
      2. Room R,
      3. Hao W
      . Alcohol and related health issues in China: action needed. Lancet Glob Health 2015;3:e190–1.doi:10.1016/S2214-109X(15)70017-3pmid:http://www.ncbi.nlm.nih.gov/pubmed/25794669
      OpenUrlPubMed
    25. ↵
      1. Huang C,
      2. Yu H,
      3. Koplan JP
      . Can China diminish its burden of non-communicable diseases and injuries by promoting health in its policies, practices, and incentives? Lancet 2014;384:783–92.doi:10.1016/S0140-6736(14)61214-9pmid:http://www.ncbi.nlm.nih.gov/pubmed/25176549
      OpenUrlCrossRefPubMed
    26. ↵
      1. Spruill TM
      . Chronic psychosocial stress and hypertension. Curr Hypertens Rep 2010;12:10–16.doi:10.1007/s11906-009-0084-8pmid:http://www.ncbi.nlm.nih.gov/pubmed/20425153
      OpenUrlCrossRefPubMed
    27. ↵
      1. Liu M-Y,
      2. Li N,
      3. Li WA, et al
      . Association between psychosocial stress and hypertension: a systematic review and meta-analysis. Neurol Res 2017;39:573–80.doi:10.1080/01616412.2017.1317904pmid:http://www.ncbi.nlm.nih.gov/pubmed/28415916
      OpenUrlCrossRefPubMed
    28. ↵
      1. Mills KT,
      2. Stefanescu A,
      3. He J
      . The global epidemiology of hypertension. Nat Rev Nephrol 2020;16:223–37.doi:10.1038/s41581-019-0244-2pmid:http://www.ncbi.nlm.nih.gov/pubmed/32024986
      OpenUrlPubMed
    29. ↵
      1. Li H,
      2. Meng Q,
      3. Sun X, et al
      . Prevalence, awareness, treatment, and control of hypertension in rural China: results from Shandong Province. J Hypertens 2010;28:432–8.doi:10.1097/HJH.0b013e328334b39epmid:http://www.ncbi.nlm.nih.gov/pubmed/20087215
      OpenUrlCrossRefPubMedWeb of Science
    30. ↵
      1. Halanych JH,
      2. Safford MM,
      3. Kertesz SG, et al
      . Alcohol consumption in young adults and incident hypertension: 20-year follow-up from the coronary artery risk development in young adults study. Am J Epidemiol 2010;171:532–9.doi:10.1093/aje/kwp417pmid:http://www.ncbi.nlm.nih.gov/pubmed/20118194
      OpenUrlCrossRefPubMed
    31. ↵
      1. Samadian F,
      2. Dalili N,
      3. Jamalian A
      . Lifestyle modifications to prevent and control hypertension. Iran J Kidney Dis 2016;10:237–63.pmid:http://www.ncbi.nlm.nih.gov/pubmed/27721223
      OpenUrlPubMed
    32. ↵
      1. Global Burden of Metabolic Risk Factors for Chronic Diseases Collaboration (BMI Mediated Effects),
      2. Lu Y,
      3. Hajifathalian K, et al
      . Metabolic mediators of the effects of body-mass index, overweight, and obesity on coronary heart disease and stroke: a pooled analysis of 97 prospective cohorts with 1·8 million participants. Lancet 2014;383:970–83.doi:10.1016/S0140-6736(13)61836-Xpmid:http://www.ncbi.nlm.nih.gov/pubmed/24269108
      OpenUrlCrossRefPubMedWeb of Science
    33. ↵
      1. Manohar S,
      2. Thongprayoon C,
      3. Cheungpasitporn W, et al
      . Associations of rotational shift work and night shift status with hypertension: a systematic review and meta-analysis. J Hypertens 2017;35:1929–37.doi:10.1097/HJH.0000000000001442pmid:http://www.ncbi.nlm.nih.gov/pubmed/28650914
      OpenUrlPubMed
    34. ↵
      1. Leng B,
      2. Jin Y,
      3. Li G, et al
      . Socioeconomic status and hypertension: a meta-analysis. J Hypertens 2015;33:221–9.doi:10.1097/HJH.0000000000000428pmid:http://www.ncbi.nlm.nih.gov/pubmed/25479029
      OpenUrlCrossRefPubMed
    35. ↵
      1. Pengpid S,
      2. Peltzer K
      . Prevalence, awareness, treatment and control of hypertension among adults in Kenya: cross-sectional national population-based survey. East Mediterr Health J 2020;26:923–32.doi:10.26719/emhj.20.063pmid:http://www.ncbi.nlm.nih.gov/pubmed/32896887
      OpenUrlPubMed
    36. ↵
      1. Esteghamati A,
      2. Abbasi M,
      3. Alikhani S, et al
      . Prevalence, awareness, treatment, and risk factors associated with hypertension in the Iranian population: the National survey of risk factors for noncommunicable diseases of Iran. Am J Hypertens 2008;21:620–6.doi:10.1038/ajh.2008.154pmid:http://www.ncbi.nlm.nih.gov/pubmed/18451810
      OpenUrlCrossRefPubMed
    37. ↵
      1. World Health Organization
      . A prioritized research agenda for prevention and control of noncommunicable diseases. Geneva: World Health Organization, 2011.

    Footnotes

    • Contributors Guarantor: JP. Conceptualisation: LL and JP. Methodology: LL and JP. Software: WC. Validation: WC and JP. Formal analysis: WC, YW and KP. Investigation: YW, KP, RZ, FL, KL and FX. Data curation: WC. Writing - original draft preparation: WC. Writing - review and editing: WC and JP. Supervision: LL and JP. Project administration: JP. Funding acquisition: KP and JP. All authors have read and agreed to the published version of the manuscript.

    • Funding This study was funded by the Sanming Project of Medicine in Shenzhen (no: SZSM201911015) and the Young Talent Program of the Academician Fund, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen (no: YS-2020-006). The funding body had no role in the design of the study, collection, analysis and interpretation of data, writing the manuscript, and decision to submit the paper for publication.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

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