Update on Hypertension Epidemiology
Author: Priya Vart 1
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  • 1 Radboud Institute of Health Sciences, Radboud University, The Netherlands

Learning Objectives

  1. Discuss the burden of hypertension based on current epidemiology
  2. Discuss the impact of the 2017 ACC/AHA Blood Pressure Guideline
  3. Discuss updated information on risk factors for hypertension and hypertension control
  4. Discuss updated information on dementia as a complication of hypertension

Burden of Hypertension Globally and in the United States

Hypertension has seen substantial advances since the last issue of the Nephrology Self-Assessment Program on hypertension, particularly in relation to the burden of hypertension, guidelines for hypertension diagnosis and management, and risk factors for hypertension and its complications. In this section, we review the recent reports on the burden of hypertension, consider the impact of recent guidelines, update the risk factors for hypertension, and discuss hypertension-related complications.Hypertension remains the leading risk factor for death and disability worldwide, and the number of deaths and disability due to hypertension and hypertension-related complications continues to rise. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) compiles and analyzes annual data from countries around the world to quantify health loss from hundreds of diseases, injuries, and risk factors. In GBD 2017 (1), data from 195 countries and 82 risk factors were compiled and analyzed. According to this study, high systolic BP accounted for 10.4 million deaths and 218 million disability-adjusted life years (DALYs) in year 2017. This corresponds to a 22.8% increase in the number of deaths and a 20.0% increase in the number of DALYs from year 2007. However, age-standardized rates have declined. In the GBD, the age-standardized death rate decreased by 9.0% and the age-standardized DALYs rate decreased by 8.0% between years 2007 and 2017. An increase in the percentage of older people globally is contributing to an increased number of DALYs and deaths. Among other factors, improvement in hypertension treatment and control is likely responsible for the decline in age-adjusted rates of DALYs and death.

The major complications of hypertension, ischemic heart disease, and stroke are leading causes of death and disability. According to the GDB 2017 report (2), which analyzed 282 causes of death in 195 countries, ischemic heart disease and stroke were the first and third leading causes of death globally. The GBD reported 8.9 million deaths due to ischemic heart disease and 6.2 million deaths due to stroke in 2017, and the number of deaths due to ischemic heart disease and stroke increased by 22.3% and 16.6% between 2007 and 2017. Ischemic heart disease and stroke contributed an estimated 170 million and 132 million DALYs, respectively, and the number of DALYs due to ischemic heart disease and stroke increased by 17.8% and 17.1%, respectively. However, as was observed for hypertension, the age-standardized death rate due to ischemic heart disease and stroke decreased between 2007 and 2017, by 9.7% and 11%, for ischemic heart disease and stroke, respectively. The age-standardized DALYs rate decreased by 9.7% and 13% in the same time period.

Data from the GBD were analyzed to estimate the burden of disease in the United States (US) by age, sex, geography, and year. In the US, high systolic BP was the third leading cause of death in year 2016 (3). Death rates from ischemic heart disease improved from prior years, but death rates from ischemic stroke and hypertensive heart disease worsened. In contrast to the global trend, the number of deaths due to ischemic heart disease in the US declined from 640,900 in year 1990 to 544,800 in year 2016, corresponding to decline of 15.0%. The discrepancy between global and US trends may be attributable to greater improvement in both prevention and treatment of ischemic heart disease, including precipitous declines in cigarette smoking in the US (4).

However, similar to global trends, the number of deaths due to ischemic stroke increased from 84,000 in year 1990 to 113,300 in year 2016, corresponding to an increase of 34.8%. Also, the age-standardized death rate due to ischemic heart disease and ischemic stroke declined between years 1990 and 2016.

Hypertension and Cognition

The brain receives about 20% of the body’s blood supply. There has been a great deal of interest in understanding the link between BP and cognition. Hypertension in the fourth and fifth decades of life has been strongly linked to cognitive impairment 20 to 30 years after the onset of hypertension (5,6). However, studies associating hypertension and late-onset cognitive impairment (i.e., in the eighth, ninth, and tenth decades of life) have been conflicting (79). The failure to assess presence of early or midlife hypertension in prior studies may have contributed to inconsistent associations between BP and cognition. As an example, researchers from the Atherosclerosis Risk in Communities study recently investigated whether early or midlife hypertension influences an association between late-life hypertension and cognition (10). This study enrolled 4761 participants ages 45 to 64 years in years 1987 to 1989 and followed them through years 2016 to 2017. BP was examined over a 24-year period at five in-person visits between 1987 and 1989 and between 2011 and 2013. Detailed neurocognitive evaluations took place in years 2011 to 2013 and years 2016 to 2017, and identified a total of 516 (11%) new dementia cases. Compared with normotensive participants, the risk of dementia was higher in participants with midlife and late-life hypertension (hazard ratio [HR], 1.49; 95% confidence interval [95% CI], 1.06 to 2.08) and participants with midlife hypertension but hypotension in late life (HR, 1.62; 95% CI, 1.11 to 2.37). Evidence was inconclusive for patients with late-life hypotension who had normal BP in midlife (HR, 1.06, 95% CI, 0.84 to 1.33). The risk of mild cognitive impairment was high in participants with midlife hypertension and late-life hypotension, compared with those who were normotensive in midlife and late life (odds ratio [OR], 1.65; 95% CI, 1.01 to 2.69). For the risk of dementia, there was significant interaction by race such that white participants with midlife hypertension and late-life hypotension had a greater risk of incident dementia (HR, 1.77; 95% CI, 1.16 to 2.71) compared with black participants with this same BP pattern (HR, 1.06; 95% CI, 0.45 to 2.48). There was no statistically significant interaction by apolipoprotein-Eε4 status (marker of genetic predisposition to dementia).

The Coronary Artery Risk Development in Young Adults study examined whether hypertension in the second, third, and fourth decades of life is associated with poorer gait and cognitive impairment in the fifth decade of life (11). This study included 191 participants aged 18 to 30 years who were followed for >30 years. BP was assessed over the entire period, and gait and cognition were assessed at the last study visit. Higher cumulative systolic and diastolic BP was associated with slower walking speed (both P=0.010), smaller step length (P=0.011 and 0.005, respectively), and higher gait variability (P=0.018 and 0.001, respectively). Higher cumulative systolic BP was associated with lower cognitive performance in the executive (P=0.021), memory (P=0.015), and global domains (P=0.010), and higher cumulative diastolic BP was associated with lower cognitive performance in the memory domain (P=0.012). Associations were independent of sociodemographic factors and other conventional vascular risk factors and stroke.

In summary, early or midlife hypertension may have an impact on hypertension-cognition relationship in late life. Failure to accurately assess early or midlife hypertension likely contributed to inconsistent associations observed in earlier published studies. Although the exact pathologic mechanism linking hypertension and poor cognition is not fully understood, it is believed that features of cerebral small vessel disease may underlie the observed link between hypertension and cognitive or mobility decline (12).

Trends in Hypertension Awareness, Treatment, and Control in High-Income Countries

Hypertension awareness and treatment effectively reduce BP and the risk of associated diseases. The US has traditionally had higher rates of hypertension awareness, treatment, and control compared with other high-income countries. Hypertension control rates increased every 2 years in the US from 1999 and 2000 through 2009 and 2010 (32%–53.8%) (13). However, since 2010 the hypertension control rates in the US have plateaued. Hypertension control was only 51.2% in years 2011 and 2012 (13).

A 2019 study reported long-term and recent trends in hypertension awareness, treatment, and control in 12 high-income countries including Australia, Canada, Finland, Germany, Ireland, Italy, Japan, New Zealand, South Korea, Spain, the United Kingdom (UK), and the US (14). This study examined data from 526,336 adults aged 40 to 79 years from 123 national surveys. Between years 1976 and 2017, awareness, treatment, and control of hypertension increased in most countries, although much of the improvement occurred before the mid-2000s, and it has plateaued since. The underlying causes for the plateau are not entirely clear, but they highlight the need to identify and adopt more effective strategies to improve rates of hypertension awareness, treatment, and control.

Awareness and treatment of hypertension among men in Canada and Germany has become comparable or surpassed the US in recent years. As per latest surveys from Canada, Germany, and the US, the prevalence of awareness among men was 84%, 82%, and 79%, and the prevalence of treatment was 81%, 70%, and 70%, respectively. Nationally implemented screening and health checkup programs (e.g., in Canada) (15) may have contributed to improved awareness and treatment in these countries.

In Australia, the rates of awareness and treatment were similar to the US in the 1990s but have fallen behind the US and other countries in recent years, primarily because of lower awareness and treatment of men. In recent years, the prevalence of awareness and treatment of men in Australia was 28%, whereas it was 49% among US men. South Korea and the UK demonstrated relatively low rates of hypertension awareness and treatment in the 1990s, but the UK is now comparable to other countries, and South Korea has outperformed most other countries (Figure 8).

Hypertension control was <25% in most countries in the 1980s and early 1990s and improved over time, reaching 60% to 70% in some countries and some population subgroups. In recent surveys, Finland, Ireland, Japan, and Spain had much lower hypertension control rates compared with most other high-income countries. In these countries, control rates were lower than 30%, whereas Canada, Germany, South Korea, and the US had control rates of ≥50%.

Differences in awareness, treatment, and control across countries may be due to differences in clinical guideline–suggested thresholds for treatment. As an example, Finland had the lowest rate of control and, until recently, a higher treatment threshold (15).

Projected Demographic Changes in Middle-Income Countries and Hypertension Care

Middle-income countries are home to >50% of the world’s population (16). Importantly, the number of older adults (≥60 years) is expected to almost double by 2050, and most of this increase will take place in middle-income countries (16). Such increases in the number of older individuals may affect hypertension care. A recent study examined the potential impact of population aging on hypertension care using nationally representative data from six of the ten largest middle-income countries (17). This study included adults ≥40 years old, and individuals with systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, regardless of treatment status, were classified as hypertensive. The results showed that if the current age-specific prevalence of hypertension remains unchanged until 2050, demographic changes alone will increase the number of adults in need of hypertension care by 319.7 million. The size of the hypertensive population is expected to grow by 151% in Mexico, 108% in India, 105% in South Africa, 101% in Indonesia, 97% in Brazil, and 55% in China. Assuming a reduction in age-specific prevalence of hypertension by 25% by 2050, the number of individuals needing hypertension care will still increase by 145.9 million individuals. Under this scenario Brazil will experience a growth of 48%, China 16%, India 56%, Indonesia 51%, Mexico 88%, and South Africa 54% in individuals needing hypertension care. There will be an even greater increase in the projected number of hypertensive individuals in need of care if countries adopt more stringent BP thresholds for treatment.

Figure 8.
Figure 8.

Prevalence of hypertension and rates of awareness, treatment, and control in women and men aged 40–79 years. Data are from the latest national survey in each country. Results shown are crude (i.e., not age-standardized) to reflect the total burden of hypertension and its awareness, treatment, and control. Age-specific results, and their uncertainty, are available in figures 1 and 3–6, and the appendix (pp 7–9). For each outcome, the color range for cells extends from lowest to highest value. Men and women share the same color scheme. Awareness, treatment, and control are reported as the proportions. *The latest national survey in Ireland had data for people aged 50 to 79 years; data from an earlier survey in 2007 were used for people aged 40 to 49 years. The question on awareness was not asked in 2015 in Japan; awareness data from 2010 were used. The latest national survey in Spain had data for people aged 60 to 79 years; data from an earlier survey in 2009 were used for people aged 40 to 59 years. Reprinted with permission from reference 17 (Sudharsanan N, Geldsetzer P: Impact of coming demographic changes on the number of adults in need of care for hypertension in Brazil, China, India, Indonesia, Mexico, and South Africa. Hypertension 73: 770–776, 2019), which is available under the terms of the Creative Commons Attribution License.

Citation: Nephrology Self-Assessment Program nephsap 19, 1; 10.1681/nsap.2020.19.1.4

In summary, middle-income countries may experience a massive growth in the number of adults needing care for hypertension in the coming decades. Even under the highly idealistic scenario that reduces the age-specific prevalence of hypertension by 25% by 2050, the number of people needing care for hypertension will grow substantially. Consequently, the coming demographic changes in middle-income countries may overpower preventive efforts to reduce the risk of hypertension among older individuals.

Impact of 2017 ACC/AHA Blood Pressure Guideline

The American College of Cardiology/American Heart Association (ACC/AHA) 2017 Guideline for the Prevention, Detection, Evaluation and Management of High BP in Adults provides detailed information on the prevention and treatment of hypertension (18). This is the first comprehensive update since the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High BP (JNC7), which was published in 2003 (19). The 2017 ACC/AHA guideline recommends BP thresholds of 130 mmHg for systolic BP and 80 mmHg for diastolic BP levels to define hypertension (in contrast to JNC7 cutoffs of 140 mmHg for systolic and 90 mmHg for diastolic BP). In addition to individuals recommended for antihypertensive medication by the JNC7 guideline, the 2017 ACC/AHA guideline recommends antihypertensive medication for adults with high cardiovascular disease (CVD) risk (i.e., a history of CVD or 10-year predicted CVD risk ≥10% using the pooled cohort risk equations) and with systolic BP of 130 to 139 mmHg or diastolic BP of 80 to 89 mmHg, and adults ≥65 years old with systolic BP of 130 to 139 mmHg.

The publication of the ACC/AHA 2017 guideline has generated a great deal of interest in understanding its impact. A 2018 study examined data from 9623 adults (≥20 years old) from the 2011 to 2014 National Health and Nutrition Examination Survey (20). Compared with JNC7, the new ACC/AHA guidelines resulted in the following:

  • Hypertension prevalence increased from 31.9% (72.2 million adults) to 45.6% (103.3 million adults), corresponding to an increase of 13.7% (31.1 million adults).
  • Hypertension prevalence more than doubled (increased from 10.5% to 24%) in adults in the age group of 20 to 44 years. Prevalence increased from 63.6% to 75.6% in adults aged 65 to 74 years, and from 75.1% to 82.3% in adults aged ≥75 years.
  • Antihypertensive medication was advised for 36.2% of US adults compared with 34.3% of adults, corresponding to 1.9% (4.2 million) additional adults recommended for antihypertensive medication.

The increase in hypertension prevalence and the number of adults recommended for antihypertension medication was observed across all age, sex, and race/ethnicity subgroups. It is clear from these results that the 2017 ACC/AHA hypertension guideline will result in a substantial increase in the number of US adults defined as having hypertension and a relatively small increase in the percentage of US adults recommended for antihypertensive medication.

Increases in prevalence are also observed outside the US. A recent study from India examined data from the District-Level Household Survey-4 and the Annual Health Survey (21). These surveys were carried out among adults aged ≥18 years between 2012 and 2014 in 27 of the 29 states and five of the seven union territories in India. Hypertension prevalence was weighted to the age structure of India’s population in 2013. Adoption of the 2017 ACC/AHA guideline resulted in an increase in hypertension prevalence from 21.8% (following the JNC7 guideline) to 52.3%, a relative increase of 140%. All sociodemographic groups (age groups, sex, socioeconomic status, rural/urban setting, and regions) experienced increases in hypertension prevalence. The greatest increase in hypertension prevalence was observed in the youngest age group (aged 18–25 years), from 12.5% to 40.2% (i.e., a relative increase of 221%). A study from Nepal reported similar increases in hypertension prevalence. In an analysis of 13,519 adults ≥18 years who participated in the 2016 Nepal Demographic and Health Survey, 44.2% had hypertension according to the 2017 ACC/AHA guideline, and 21.2% had hypertension according to the JNC7 guideline (22). Consequently, adoption of the 2017 ACC/AHA guidelines in Nepal will result in an absolute increase in hypertension prevalence of 23.0%. In the same study, among younger adults (18–29 years), hypertension prevalence almost doubled, increasing from 9.3% per JNC7 guideline to 18.1% per 2017 ACC/AHA. A study from Mexico examined the prevalence of hypertension according to the JNC7 and 2017 ACC/AHA guidelines among 990 adults aged 20 to 64 years from the SALMEX cohort (Salt in Mexico; Mexico City) (23). The new definition increased the prevalence of hypertension from 16.2% to 37.4% in the overall population. In young men (20–44 years) the prevalence increased from 22.5% to 42.2%, and in young women the prevalence increased from 6.8% to 17.1%. In summary, applying the 2017 ACC/AHA guideline, low-income and middle-income countries may result in a nearly a twofold increase in hypertension prevalence, which is likely to put an additional stress on health systems in low-income and middle-income countries where hypertension treatment and control rates are already very low.

The data that formed the basis of the 2017 ACC/AHA guideline were mainly derived from middle-aged and elderly adults, but applying the guideline cutoffs almost doubled the hypertension prevalence in young adults. This raised concern whether young adults newly labeled as hypertensive were at increased risk of CVD. A recent study in adults (aged 20–39 years) compared the incidence of ≥2 days of hospitalization or death due to CVD across categories of systolic and diastolic BP as defined by the new guidelines (24). This study followed 2,488,101 participants in the Korean National Health Insurance Service for a median duration of 10 years. During follow-up, a total of 44,813 CVD events occurred. The incidence of CVD was 164 per 100,000 person-years in men with normal BP (systolic BP <120 mmHg, diastolic BP <80 mmHg) and 215 per 100,000 person-years in men with stage 1 hypertension (systolic BP 130–139 mmHg, diastolic BP 80–89 mmHg). In adjusted analysis, the risk of CVD was 25% higher in men with stage 1 hypertension versus normal BP (95% CI, 1.21 to 1.28). The CVD risk was also higher among women with stage 1 hypertension (91 per 100,000 person years among normotensive women and 131 per 100,000 among those with stage 1 hypertension. In adjusted analysis, the risk of CVD was 27% higher in women with stage 1 hypertension versus normal BP (HR, 1.27; 95% CI, 1.21 to 1.34). The incidence and risk of coronary heart disease and stroke were also higher in men and women with stage 1 hypertension compared with those with normal BP. These results suggest that the new hypertension guidelines also identify young adults at increased risk of CVD.

  • The number of deaths and disability due to hypertension continue to rise worldwide though age-standardized rates have declined.
  • Awareness and treatment reduce blood pressure and the risk of associated diseases.
  • The 2017 ACC/AHA guidelines will result in a large increase in the number of US adults defined as having hypertension but a relatively small increase in the percentage of US adults recommended for anti-hypertensive medication.

Prevalence in Children and Young People

In a recent systematic review and meta-analysis of 47 studies published between years 1994 and 2018, the global estimated prevalence of hypertension among children 19 years and younger was 4.0% (95% CI, 3.3% to 4.8%) (25). The prevalence of childhood hypertension did not differ significantly by sex, urban or rural setting, or region based on geographic locations or per-capita income. When examined across time periods, the prevalence was the highest in the 2010s (6.02%; 95% CI, 4.38% to 7.91%) compared with the 2000s (3.30%; 95% CI, 2.69% to 3.97%) or the 1990s (1.26%; 95% CI, 0.79% to 1.84%). The highest prevalence was in the obese group (15.27%; 95% CI, 7.31% to 25.38%) followed by overweight (4.99%; 95% CI, 2.18% to 8.81%) and normal weight (1.90%; 95% CI, 1.06% to 2.97%) children. Across age, hypertension prevalence increased from 4.32% (95% CI, 2.79% to 6.63%) among children aged 6 years to 7.89% (95% CI, 5.75% to 10.75%) among those aged 14 years, and then decreased to 3.28% (95% CI, 2.25% to 4.77%) among children aged 19 years in year 2015. In the time period between years 2000 and 2015, the whole age range (6–19 years) experienced increasing rates of hypertension prevalence. The pooled hypertension prevalence in this systematic review and meta-analysis was lower than previously reported (4.00%–11.2%) (26). The disparity might be explained mainly by the difference in numbers of visits for BP measurements. In the present systematic review and meta-analysis, only studies that repeated BP measurements on at least three separate occasions (as recommended by the fourth report from the National High Blood Pressure Education Program Working Group (27) [Fourth Report]), were included, whereas in previous systematic review and meta-analysis studies, BPs measured on one or two occasions were also eligible. The increase in prevalence of childhood obesity may be responsible for an observed upward trend in the prevalence of childhood hypertension over the past two decades (28).

There were fewer studies from Africa. However, a systematic review and meta-analysis based on studies from Africa did not demonstrate an upward trend in the prevalence of childhood hypertension in recent years (29). Nonetheless, in the near future we can expect an increase in childhood hypertension globally, given the upcoming wave of childhood obesity in middle-income and low-income countries. Across age groups, hypertension prevalence peaked around puberty, which may be explained by hormone changes and rapid growth spurts.

In 2017, the American Academy of Pediatrics (AAP) updated its clinical practice guideline for screening and management of high BP in children and adolescents (30). For children aged <13 years, the definitions of normal and elevated BP and hypertension were similar to Fourth Report. However, the specific percentile cutoffs were at least 3 mmHg lower in the AAP guideline compared with Fourth Report. For adolescents aged ≥13 years, the APP guideline proposed static BP cutoffs to define elevated BP (120/<80 to 129/<80 mmHg), stage 1 hypertension (130/80 to 139/89 mmHg) and stage 2 hypertension (≥140/≥90 mmHg). A study performed in 15,647 generally healthy children aged 5 to 18 years from National Health and Nutrition Examination Surveys compared the AAP and the Fourth Report definitions for prevalence of pediatric hypertension (31). That study reported that adoption of the AAP guideline resulted in a prevalence of elevated BP of 9.3%, whereas adoption of Fourth Report guideline resulted in a prevalence of only 10%. Compared with the Fourth Report guideline, the AAP guideline resulted in an increase in stage 1 hypertension prevalence from 2.7%% to 5.3% and in stage 2 hypertension prevalence from 0.07% to 0.41%. In the study, 5.8% of the children were reclassified to either elevated BP or a more severe clinical stage of hypertension, and only 0.5% moved to either normal BP or elevated BP from higher categories.

The results from another study that examined data of 47,200 children and adolescents aged 6 to 17 years from six countries (China, India, Iran, Korea, Poland, and Tunisia) were similar (32). In this study, according to the AAP guideline, the prevalence of elevated BP was 8.6%, the prevalence of stage 1 hypertension was 14.5%, and the prevalence of stage 2 hypertension was 1.7%. According to the Fourth Report guideline, the prevalence of elevated BP was 14.9%, the prevalence of stage 1 hypertension was 6.6%, and the prevalence of stage 2 hypertension was 0.4%.

However, not all studies reported increases in stage 1 and stage 2 hypertension prevalence with the use of the AAP guideline. A study performed in 22,224 students aged 10 to 17 years in the US compared the AAP and the Fourth Report definitions for prevalence of pediatric hypertension (33). In this study, applying the AAP guideline resulted in an increase in the prevalence of elevated BP from 14.8% to 16.3%. However, stage 1 hypertension prevalence decreased from 12.3% to 10.6%, and stage 2 prevalence was similar using both guidelines (i.e., 2.3% and 2.4%). The discrepancy in findings could be the result of differences in the age ranges of the study populations compared with prior studies. Indeed, in this study (33), students <13 years constituted only one third of the study population. Increases in both elevated BP and hypertension with the AAP guideline was observed when students <13 years were analyzed separately. More importantly, children who were reclassified upward had worse cardiometabolic profiles in relation to weight, waist circumference, body mass index, lipid levels, and hemoglobin A1c levels. In the Bogalusa Heart Study with 36-year follow-up since childhood (34), children reclassified to upward BP levels demonstrated increased risk of adult hypertension (OR 2.12; 95% CI, 1.48 to 3.04), metabolic syndrome (OR 1.43; 95% CI, 1.01 to 2.19) and left ventricular hypertrophy (OR 2.05; 95% CI, 1.12 to 3.75) compared with normotensive children.

In summary, about 4% to 5% of children experience hypertension. Hypertension prevalence may be higher in studies in which BP was measured on fewer than the recommended three separate occasions. Hypertension in children seems to have increased in the past two decades, potentially owing to increasing rates of obesity in children. The newly proposed AAP guideline for hypertension diagnosis in children will likely increase the number of children labeled as having hypertension, representing a substantial increase in disease burden for the healthcare system. Importantly, newly diagnosed individuals demonstrate worse cardiometabolic profiles and are at increased risk of hypertension-related complications.

Risk Factors for Hypertension

Well-recognized risk factors for hypertension include increasing age, black race, obesity, family history, physical inactivity, alcohol intake, and male sex. We discuss recent studies of previously known and more recently identified risk factors.

Socioeconomic Status and Hypertension

A recent scientific statement from the American Heart Association called for improved awareness and understanding of social determinants of risk and outcomes for CVD (35). This statement indicated that consideration of the role of social determinants is essential if we are to achieve the goals set for improvement in cardiovascular health and reduce the consequences from cardiovascular disorders.

Socioeconomic status, assessed by income, education, and/or occupation, is a major determinant of hypertension. Socioeconomic status is believed to affect chronic stress, lifestyles and behavior patterns, and access to health care, which influence the risk for hypertension (36,37). In high-income countries (including the US), individuals with low socioeconomic status generally exhibit a high prevalence of hypertension (38,39). However, the same association is not observed across all world economic regions. A recent study examined the association between socioeconomic status and risk of hypertension and CVD using data from 154,169 participants from 20 low-income, middle-income, and high-income countries (40). In this study, in high-income countries, the prevalence of hypertension was 34.8% among individuals with trade school, college, or university background and 57.5% among individuals who had no formal education or only primary education. By contrast, in low-income countries, the prevalence of hypertension was 39.2% in the high-education group but only 28.6% in the low-education group. Observed differences in the distribution of hypertension prevalence across socioeconomic status between low-income and high-income countries is at least partially attributed to the lower prevalence of obesity and physical inactivity among individuals of higher socioeconomic status in high-income countries and the higher prevalence of obesity and physical inactivity among individuals of higher socioeconomic status in low-income countries. Of note, the lower hypertension prevalence in low socioeconomic status groups in low-income counties does not mean lower risk for CVD. Indeed, in this study, the risk of major cardiovascular events was greater among those with low levels of education in all types of country studied (adjusted HR in those with no or only primary education ranged from 1.50 in high-income countries to 2.23 in low-income countries). The higher risk of CVD may be a consequence of inadequate access to primary and secondary prevention and of access to medical care among people with the lowest levels of education in low-income countries (41).

In middle-income countries, the association between socioeconomic status and hypertension has been mixed. Data from China, a middle-income country, suggest that hypertension prevalence is greater in low-education groups compared with high-education groups (42). By contrast, data from India, another middle-income country, suggest that hypertension prevalence is greater in high-education groups compared with low-education groups (43). It is worth noting that the socioeconomic gradient in hypertension prevalence in middle-income countries is generally less steep than in low-income and high-income countries. Middle-income countries are undergoing “epidemiologic transition,” and the social gradient in behavioral risk factors generally changes over the course of the epidemiologic transition. This may be reflected in the nature of associations between observed socioeconomic status and hypertension in middle-income countries.

Socioeconomic status also seems to be related to BP control. The Multination EIGHT Study (Evaluation of Hypertension in Sub-Saharan Africa) investigated the relationship between individual wealth and hypertension control in 12 countries from sub-Saharan Africa (44). In an analysis of 2198 hypertensive adults, the proportion of uncontrolled hypertension was 72.8% in the high-wealth group, 79.3% in the middle-wealth group, and 81.8% in the low-wealth group (P for trend, <0.01). This trend was particularly evident in low-income countries, in which the odds of uncontrolled hypertension increased 1.37-fold (OR 1.37; 95% CI, 0.99 to 1.90) and 1.88-fold (OR 1.88; 95% CI, 1.10 to 3.21) in patients with middle and low individual wealth, compared with those with high individual wealth. In the US, a group of investigators examined changes in mean systolic BP by socioeconomic status between 1999 and 2014 (45). Socioeconomic status was assessed from the level of poverty income ratio, a measure of inflation-adjusted income relative to poverty threshold. From 1999 to 2014, there was little evidence of a change in the mean systolic BP for adults with incomes at or below the federal poverty level (127.6 mmHg to 126.8 mmHg; P=0.44), but there was a decrease in the mean systolic BP for adults in the middle-income (128.0 mmHg to 124.8 mmHg; P<0.001) and high-income groups (126.0 mmHg to 122.3 mmHg; P<.001). Limited hypertension awareness and limited ability to afford medication in the low-income group may be responsible for the observed trend (42).

Studies continue to assess the impact of the 2008 economic recession on cardiovascular health. The economic recession of 2008 affected >70% of Americans aged ≥40 years (46). A large number of people lost their jobs and homes. Previously, home foreclosures were found to be associated with an increase in systolic BP (47). Recently, investigators from the Multi-Ethnic Study of Atherosclerosis (MESA) provided direct evidence of the impact of the 2008 economic recession on BP (48). This study generated five waves of longitudinal data, four of which were held before the economic recession between 2000 and 2007 and one of which was held in 2010 to 2011 after the economic recession was examined. For each study participant, investigators calculated the difference in mean systolic BP between actually observed mean systolic BP at the fifth wave and projected mean systolic BP at wave five derived from four previous waves. Among those on medication after the recession, systolic BP increased by 12.7 mmHg in those <65 years old and 7.9 mmHg in those ≥65 years old. Among those not on medication after the recession, systolic BP increased by 4.5 mmHg in those <65 years old and 2.9 mmHg in those ≥65 years old. Moreover, the onset of the recession was accompanied by a substantial decline in medication use and treatment intensity for control of BP.

These findings highlight the importance of socioeconomic factors as determinants of hypertension and hypertension control. Traditionally we focused on certain physiologic, lifestyle, and genetic risk factors. It is time we broaden the focus to incorporate social determinants of health as another arm of risk. Failure to demonstrate awareness of the socioeconomic dynamic may result in a growing burden of hypertension, especially in already disadvantaged groups.

Early Cognitive Function and Hypertension

Higher cognitive function at a young age may be associated with a lower risk of developing hypertension (49). Cognitive impairment in early life is believed to influence educational attainment, income, and health behaviors, which may underlie the increased risk for hypertension in later life (50). Recent evidence suggests that the relationship between cognitive function and hypertension may be contributing to sex disparities in hypertension development (51). Investigators from the National Longitudinal Study of Youth 1979 investigated interaction of sex with cognitive function for relationship with hypertension. Cognitive function was assessed when participants (n = 5251) were 14 and 21 years old, and participants were followed prospectively (until 2014) for hypertension diagnosis. One standard deviation of higher cognitive function at a young age was associated with a reduced risk of hypertension (acceleration factor: ĉ = 0.97; 95% CI, 0.96 to 0.99, P=0.001). There was a significant interaction between sex and cognitive function (ĉ = 0.97; 95% CI, 0.96 to 0.99, P=0.001), such that the association between cognitive function and hypertension was stronger in women than men. Therefore, compared with men with high cognitive function in young age, women with high cognitive function in young age were less likely to be diagnosed with hypertension later in life. The addition of sex and income interaction to the model attenuated the association of sex and cognitive function interaction with hypertension. These data suggest that income differences between sexes could underlie the greater benefit conferred by higher cognitive function among women than men. An explanation that has been proposed to explain these findings is that women with high cognitive function do not progress as far as men in the workplace and may be thus protected from the risks of highly paid but stressful occupations. By contrast, men with high cognitive function tend to work more and prioritize their job over other activities (52).

Alcohol Intake and Hypertension

The relationship between light to moderate alcohol intake and incident hypertension has been controversial. Some epidemiologic studies revealed a J-shaped or U-shaped association between alcohol intake and incidence of hypertension, suggesting that light to moderate amount of alcohol intake is associated with decreased hypertension risk compared with both abstainers and heavy drinkers (5355). However, these data have been questioned because of inadequate assessment of alcohol intake and because of residual confounding due to the known association between type, quantity, and pattern of drinking with socioeconomic factors and other lifestyle behaviors.

A recent study including data from 512,715 Chinese adults used genetic variants to classify people by alcohol intake and compared this classification with that determined by self-reporting (56). This study predicted alcohol intake from two genetic variants (ALDH2-rs671 and ADH1B-rs1229984) that are known to be causally linked to amount of alcohol intake. Because genes are determined at birth, the predicted alcohol intake is deemed unlikely to be influenced by reporting bias, socioeconomic factors, and/or other lifestyle behaviors. In this study, genetic variant–predicted alcohol intake was positively associated with systolic BP, along with high-density lipoprotein and γ-glutamyl transferase (a marker for alcohol use). This association was particularly strong among men (Figure 9).

Figure 9.
Figure 9.

Associations of physiologic factors with drinking patterns and with genotypic determinants of mean alcohol intake, in men. Conventional epidemiological analyses (A–C) relate self-reported drinking patterns at baseline to mean systolic blood pressure (A), HDL cholesterol (B), and γ-glutamyl transferase (C). Results are adjusted for age, area, education, income, and smoking. The means for current drinkers are plotted against usual alcohol intake, with a fitted line giving the slope (95% CI) per 280 g alcohol per week. Genetic epidemiological analyses (D–F) ignore individual drinking patterns, and for all men relate mean alcohol intake in six categories of genotype and study area to genotypic effects on mean systolic blood pressure (D), HDL cholesterol (E), and γ-glutamyl transferase (F). Results are adjusted for age and area. The slope of the fitted line is the inverse-variance-weighted mean of the slopes of the fitted lines in each study area. The area of each square in A–F is inversely proportional to the variance of the result. Error bars show 95% CIs. Reprinted with permission from reference 56 (Millwood IY, Walters RG, Mei XW, Guo Y, Yang L, Bian Z, et al.; China Kadoorie Biobank Collaborative Group: Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China. Lancet 393: 1831–1842, 2019), which is available under the terms of the Creative Commons Attribution License.

Citation: Nephrology Self-Assessment Program nephsap 19, 1; 10.1681/nsap.2020.19.1.4

Because alcohol intake was minimal among women, the findings in men were probably driven mainly by alcohol exposure rather than other physiologic effects of studied genetic variants. Minimal alcohol intake among women (likely because of cultural reasons) was also a limitation of the study because the association of alcohol intake with BP could not be established in women. This was particularly relevant, given that the J-shaped or U-shaped association in prior epidemiologic studies was mainly observed among women.

Long Working Hours and Hypertension

Long working hours are fairly common. According to a 2010 US population-based survey, about 19% of Americans regularly worked 48+ hours/week (57). Similarly, the sixth European Working Conditions Survey 2015 estimated that about 15% of Europeans regularly work 48+ hours/week (58). Long working hours are linked to increased risk of stroke and coronary heart disease (59). However, an association between long working hours and hypertension has been mixed, partially because of differences in instruments and methods used to measure BP. Recently a study reported an association of long working hours with the prevalence of masked and sustained hypertension (60). This study analyzed data from 3547 white-collar workers who held a wide range of positions, ranging from senior managers to office workers. Workers’ activities involved planning and providing insurance services. Workers self-reported their working hours. Workplace clinic BP was measured the times in resting position, and ambulatory BP was recorded every 15 minutes during daytime working hours (8:00–16:00). Compared with working <35 hours per week, working >48 hours was associated with increased risk of masked hypertension (prevalence ratio 1.42; 95% CI, 1.09 to 2.64) and sustained hypertension (prevalence ratio 1.66; 95% CI, 1.15 to 2.50). These associations were independent of sociodemographics, lifestyle-related risk factors, diabetes mellitus, family history of CVD, and job-related stress. These results are particularly interesting. Psychologic stress and exposure to high-risk behaviors such as smoking and high alcohol intake are believed to be the main factors that could link long working hours to hypertension. However, results in this study were independent of job stress and of smoking and alcohol intake. It is possible that the study did not adequately capture job stress and health behaviors, but there are likely other factors at play that link long working hours to hypertension and are yet to be identified and understood. Nonetheless, these findings may encourage health policies and workplace initiatives to reduce long working hours for the primary prevention of hypertension.

Oral Health and Blood Pressure Control

Several observational studies support a relationship between periodontitis, a chronic inflammatory disorder of tissues surrounding the teeth, and hypertension. A recent meta-analysis of 40 studies reported increased prevalence of hypertension among individuals with moderate to severe periodontitis (pooled OR 1.22; 95% CI, 1.10 to 135) and in those with severe periodontitis (pooled OR 1.49; 95% CI, 1.09 to 2.05) (61). The weighted mean difference in systolic and diastolic BP between patients with and without periodontitis was 4.49 mmHg (95% CI, 2.88 to 6.11) and 2.03 mmHg (95% CI, 1.25 to 2.81), respectively. However, only five out of 12 interventional studies confirmed a reduction in BP following periodontal therapy. Therefore, whether or not periodontitis is causally linked to hypertension remained unclear. A recent study including approximately 750,000 participants from the UK-Biobank/International Consortium of Blood Pressure-Genome-Wide Association Studies found periodontitis-linked single nucleotide polymorphisms to be associated with systolic BP (P=0.001) and diastolic BP (P=0.013) (62). This study also investigated effects of treatment of periodontitis on BP in a randomized intervention trial. For this, 50 hypertensive patients with moderate to severe periodontitis were randomly allocated to intensive periodontal treatment and 51 patients to control periodontal treatment. At 2 months, there was a reduction of 11.1 mmHg (95% CI, 6.5 to 15.8) in mean systolic BP and 8.3 mmHg (95% CI, 3.98 to 12.6) in mean diastolic BP among individuals assigned to intensive periodontal treatment compared with control periodontal treatment. Patients with higher baseline systolic BP experienced greater reduction in BP (Figure 10).

Figure 10.
Figure 10.

Effects of conventional periodontal treatment and intensive periodontal treatment on BP. Changes of 24-h average systolic (A) and diastolic (B) BP between baseline and 2 months following control periodontal treatment or intensive periodontal treatment are reported as mean ± 95% confidence interval (95% CI). Subsequently, difference in change was calculated between randomization groups. (C) Relationship between baseline systolic BP and the effect of intensive periodontal treatment on BP reduction. Patients were divided in tertiles of baseline ambulatory 24-h BP monitoring measured systolic BP and change of systolic BP between baseline and follow-up (delta systolic BP) was analyzed and presented as mean with 95% CI. Ambulatory 24-h BP monitoring Tertile 1: <130 mmHg; Tertile 2: 131–138 mmHg; and Tertile 3 >138 mmHg. Reprinted with permission from reference 62 (Czesnikiewicz-Guzik M, Osmenda G, Siedlinski M, Nosalski R, Pelka P, Nowakowski D, et al.: Causal association between periodontitis and hypertension: evidence from Mendelian randomization and a randomized controlled trial of non-surgical periodontal therapy. Eur Heart J 40: 3459–3470, 2019), which is available under the terms of the Creative Commons Attribution License.

Citation: Nephrology Self-Assessment Program nephsap 19, 1; 10.1681/nsap.2020.19.1.4

Another study investigated the impact of periodontitis on BP control (63). An analysis of 3626 hypertensive subjects ≥30 years old showed that periodontal disease was significantly associated with 2.3 to 3 mmHg higher systolic BP and with higher odds of unsuccessful antihypertensive treatment. Interestingly, achieved systolic BP in treated adults with periodontitis was similar to that in untreated adults with good oral health, suggesting that antihypertensive treatment in the presence of periodontitis might not be as effective as in the absence of the disease. In summary, periodontitis is likely causally linked to hypertension and may reveal the likelihood of BP control in hypertensive subjects.

Health Behaviors, Genes, and Blood Pressure

Efforts to prevent development of hypertension are critical in lowering disease burden. The general belief is that favorable health behaviors such as healthy diet, not smoking, and physical activity lower the risk of hypertension (64). Recent evidence suggests that even people who are genetically predisposed to hypertension and CVD may benefit from favorable health behaviors (65). Investigators from UK biobank, a national long-term cohort in the UK, investigated the extent to which lifestyle factors could offset the effect of an adverse BP genetic profile on BP and CVD risk. An analysis of data from 277,005 individuals aged 40 to 69 years demonstrated a difference in systolic BP between bottom-tertile and top-tertile lifestyle scores of 4.9, 4.3, and 4.1 mmHg in low, middle, and high genetic risk groups, respectively. Similarly, the risk of CVD in top-tertile lifestyle score compared with bottom-tertile lifestyle score was 30%, 33%, and 31% lower in low, middle, and high genetic risk groups, respectively. It was also worth noting that compared with individuals with low genetic risk score and favorable lifestyle score, the hazard ratio for cardiovascular disease was 1.43 (1.30–1.58) in individuals with low genetic risk score and unfavorable lifestyle score and 1.21 (1.09–1.35) in individuals with high genetic risk score and favorable lifestyle score. These findings suggest that a favorable lifestyle may offset risk—at least part of the risk—associated with genetic susceptibility. In addition, people with no genetic susceptibility could lose their inherent protection if they have an unhealthy lifestyle. There findings are particularly relevant, given that it is possible to modify lifestyle but currently it is not possible to alter the genetic makeup. Whether individuals with high genetic susceptibility should be targeted for lifestyle modification will require careful consideration because of the sensitivity of genetic information.

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    Prevalence of hypertension and rates of awareness, treatment, and control in women and men aged 40–79 years. Data are from the latest national survey in each country. Results shown are crude (i.e., not age-standardized) to reflect the total burden of hypertension and its awareness, treatment, and control. Age-specific results, and their uncertainty, are available in figures 1 and 3–6, and the appendix (pp 7–9). For each outcome, the color range for cells extends from lowest to highest value. Men and women share the same color scheme. Awareness, treatment, and control are reported as the proportions. *The latest national survey in Ireland had data for people aged 50 to 79 years; data from an earlier survey in 2007 were used for people aged 40 to 49 years. The question on awareness was not asked in 2015 in Japan; awareness data from 2010 were used. The latest national survey in Spain had data for people aged 60 to 79 years; data from an earlier survey in 2009 were used for people aged 40 to 59 years. Reprinted with permission from reference 17 (Sudharsanan N, Geldsetzer P: Impact of coming demographic changes on the number of adults in need of care for hypertension in Brazil, China, India, Indonesia, Mexico, and South Africa. Hypertension 73: 770–776, 2019), which is available under the terms of the Creative Commons Attribution License.

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    Associations of physiologic factors with drinking patterns and with genotypic determinants of mean alcohol intake, in men. Conventional epidemiological analyses (A–C) relate self-reported drinking patterns at baseline to mean systolic blood pressure (A), HDL cholesterol (B), and γ-glutamyl transferase (C). Results are adjusted for age, area, education, income, and smoking. The means for current drinkers are plotted against usual alcohol intake, with a fitted line giving the slope (95% CI) per 280 g alcohol per week. Genetic epidemiological analyses (D–F) ignore individual drinking patterns, and for all men relate mean alcohol intake in six categories of genotype and study area to genotypic effects on mean systolic blood pressure (D), HDL cholesterol (E), and γ-glutamyl transferase (F). Results are adjusted for age and area. The slope of the fitted line is the inverse-variance-weighted mean of the slopes of the fitted lines in each study area. The area of each square in A–F is inversely proportional to the variance of the result. Error bars show 95% CIs. Reprinted with permission from reference 56 (Millwood IY, Walters RG, Mei XW, Guo Y, Yang L, Bian Z, et al.; China Kadoorie Biobank Collaborative Group: Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China. Lancet 393: 1831–1842, 2019), which is available under the terms of the Creative Commons Attribution License.

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    Effects of conventional periodontal treatment and intensive periodontal treatment on BP. Changes of 24-h average systolic (A) and diastolic (B) BP between baseline and 2 months following control periodontal treatment or intensive periodontal treatment are reported as mean ± 95% confidence interval (95% CI). Subsequently, difference in change was calculated between randomization groups. (C) Relationship between baseline systolic BP and the effect of intensive periodontal treatment on BP reduction. Patients were divided in tertiles of baseline ambulatory 24-h BP monitoring measured systolic BP and change of systolic BP between baseline and follow-up (delta systolic BP) was analyzed and presented as mean with 95% CI. Ambulatory 24-h BP monitoring Tertile 1: <130 mmHg; Tertile 2: 131–138 mmHg; and Tertile 3 >138 mmHg. Reprinted with permission from reference 62 (Czesnikiewicz-Guzik M, Osmenda G, Siedlinski M, Nosalski R, Pelka P, Nowakowski D, et al.: Causal association between periodontitis and hypertension: evidence from Mendelian randomization and a randomized controlled trial of non-surgical periodontal therapy. Eur Heart J 40: 3459–3470, 2019), which is available under the terms of the Creative Commons Attribution License.

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