IJCA-18115; No of Pages 2 International Journal of Cardiology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Recent prevalence of hypertension among Chinese children and adolescents based on 2010 China national blood pressure references Bo Xi a,⁎, Huiwen Li b, Shangshuang Li a, Jie Mi c,⁎ a b c
Department of Epidemiology and Health Statistics, School of Public Health, Shandong University, Jinan, China Grade 2010 of Preventive Medicine, School of Public Health, Shandong University, Jinan, China Department of Epidemiology, Capital Institute of Pediatrics, Beijing, China
a r t i c l e
i n f o
Article history: Received 15 April 2014 Accepted 18 April 2014 Available online xxxx Keywords: Prevalence Hypertension Children and adolescents
Childhood hypertension is a serious public health problem worldwide, especially in China [1,2]. Epidemiological studies have suggested that childhood hypertension could track into adulthood [3]. In addition, hypertension in childhood was strongly associated with increased rates of morbidity and mortality during adulthood [4]. Before 2010, there was no consensus on defining childhood hypertension in China, which impeded the comparisons of hypertension prevalence between different regions of China. In 2010, Mi et al. established the China national blood pressure (BP) references for age and sex using 112,227 children and adolescents aged 3–18 years [5]. Based on this national definition, childhood hypertension was defined as systolic BP (SBP) and/or diastolic BP (DBP) above the 95th percentile for age and gender. In this study, we aimed to perform a systematic review to describe the prevalence of hypertension among children and adolescents in different areas of China using 2010 China national blood pressure references. PubMed and Wanfang databases were searched for eligible literature. Search terms were (“hypertension” or “high blood pressure”) and (“children” or “adolescents” or “students”) and (“China” or “Chinese”). Publications from January 2010 (after the publication of 2010 China national blood pressure references by Mi et al. [5]) to April 2014 were included and the publication languages were limited to English and Chinese. The inclusion criteria were: (1) Chinese children and adolescents aged 3–18 years; (2) used 2010 China national blood pressure references; (3) measured SBP and DBP values at least three times at one occasion; (3) survey was performed since 2008; and ⁎ Corresponding authors. E-mail addresses: [email protected] (B. Xi), [email protected] (J. Mi).
(4) if publication included several surveys in different years, only the most recent survey was included. After literature search, a total of eleven studies (the total number of participants was 444,214) [1,2,6–14] were included in this review. The characteristics of included studies are summarized in Table 1. There was a significant difference in hypertension prevalence across different regions of China (Fig. 1). Children and adolescents in North of China including Beijing City (18.2%) or Shandong Province (23.3%) had higher prevalence of hypertension than those in South of China including Shanghai, Changsha in Hunan, and Rural areas of three cities in Hunan and Hainan provinces (ranging from 3.1% to 11.2%). The higher prevalence of hypertension might be largely attributed to dietary salt intake in North of China. For example, it is estimated that daily intake of salt was about 13 g in adults living in the rural area of Shandong province, twice higher than the recommended salt intake by the World Health Organization (less than 5 g/day) [15]. In addition, obesity is another important risk factor for higher hypertension in North of China. In Shandong province, about 16% of boys and 8% of girls were obese [16] while the corresponding figures were 7% and 3%, respectively, in Changsha city of Hunan province [11]. We also found that the overall prevalence of hypertension was about 14% based on both data from the China Health and Nutrition Survey and the Chinese National Survey on Students' Constitution and Health. Our study has two strengths. First, all included studies followed the same standard that is the China national blood pressure references. Second, all included studies were surveyed during the similar periods, i.e., from 2008 to 2010. Thus, the prevalence was up-to-date and can be comparable. However, several limitations should be noted. First, all studies provided hypertension prevalence at only one occasion except for the study by Meng et al. [6] which provided variations of prevalence at three different times. Thus, the prevalence reported in our present review would have overestimated the true prevalence of hypertension in Chinese children and adolescents. Meng et al. [6] demonstrated that the prevalence of hypertension among children and adolescents aged 3–18 years in Beijing of China was 18.2%, 5.1%, and 3.1%, at the first, second, and third visits, respectively. Second, we did not demonstrate the data on the reasons why the prevalence was different between different regions of China although we cited several references on prevalence of obesity and consumption of salt intake in limited areas of China. Third, we only provided prevalence in several regions of China and further researches are required to comprehensively examine prevalence of
http://dx.doi.org/10.1016/j.ijcard.2014.04.214 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Xi B, et al, Recent prevalence of hypertension among Chinese children and adolescents based on 2010 China national blood pressure references, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.214
2
B. Xi et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Table 1 Characteristics of included studies examining the prevalence of hypertension in Chinese children based on the China national blood pressure references. Study
Survey year
No. of participants
Meng et al. [6] Zhang et al. [7] Cao et al. [8] Lu et al. [9] Lu et al. [10] Cao et al. [11] Yang et al. [12] Zhang et al. [13] Xu et al. [14]
2010 2010 2010 2008–2009 2009 2010 2011 2009 2010
Xi et al. [1]
2009
878
Dong et al. [2]
2010
197,191
25
Prevalence (%)
20
6692 38,860 11,571 4935 78,114 88,974 1750 5456 9793
Province/city/region
Age range (years)
Beijing Shandong Jiaozuo in Henan Yangtze River Delta region (Jiangsu, Zhejiang, Shanghai) Shanghai Changsha in Hunan Rural areas of Huaihua, Jishou, and Zhangjiajie in Hunan Hainan Eastern China (Harbin, Beijing, Jinan, Shanghai, Chongqing, Guangzhou) Nine provinces (Liaoning, Heilongjiang, Jiangsu, Shandong, Henan, Hubei, Hunan, Guangxi and Guizhou) 30 provinces of China except for Tibet
Prevalence (%) Total
Boys
Girls
3–18 7–17 6–18 6–18 7–20 12–17 7–15 7–18 6–13
18.2 23.3 7.3 17.9 11.2 3.1 6.5 3.3 10.8
19.3 26.2 7.6 20.3 – 4.7 – 3.5 9.7
17.1 20.3 6.9 15.3 – 1.5 – 3.1 11.9
6–17
13.8
12.6
15.2
7–17
14.5
16.1
12.9
23.3 18.2
17.9 13.8
15 11.2
10
14.5
10.8
7.3
6.5
5
3.1
3.3
0 Beijing
Shandong
Jiaozuo in Yangtze Henan River Delta region
Shanghai Changsha in Rural areas Hunan of three cities in Hunan
Hainan
Eastern China
9 provinces 30 provinces
Region Fig. 1. Prevalence of hypertension among children and adolescents across different regions in China.
hypertension in other areas of China. Fourth, we only reported the prevalence of hypertension in Han Chinese children but not in other minorities. China is a multiracial country with about 56 nationalities, but Han nationality accounts for about 92% of total Chinese population. The present study suggested that it is important to investigate the regional distribution of hypertension prevalence in children and adolescents and to establish the regionally specific intervention strategies to combat hypertension epidemics. Primary measures should be recommended to control weight and reduce salt intake, especially in North of China, in order to reduce the prevalence of childhood hypertension according to different regions of China. References [1] Xi B, Liang Y, Mi J. Hypertension trends in Chinese children in the national surveys, 1993 to 2009. Int J Cardiol 2013;165:577–9. [2] Dong B, Wang HJ, Wang Z, Liu JS, Ma J. Trends in blood pressure and body mass index among Chinese children and adolescents from 2005 to 2010. Am J Hypertens 2013;26:997–1004. [3] Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation 2008;117:3171–80. [4] Franks PW, Hanson RL, Knowler WC, Sievers ML, Bennett PH, Looker HC. Childhood obesity, other cardiovascular risk factors, and premature death. N Engl J Med 2010;362:485–93. [5] Mi J, Wang TY, Meng LH, et al. Development of blood pressure reference standards for Chinese children and adolescents. Chin J Evid Based Pediatr 2010;5:4–14 [in Chinese].
[6] Meng L, Liang Y, Liu J, Hu Y, Yan Y, Mi J. Prevalence and risk factors of hypertension based on repeated measurements in Chinese children and adolescents. Blood Press 2013;22:59–64. [7] Zhang Y, Sun G, Zhao J, Lin M, Chu Z. Monitoring of blood pressure among children and adolescents in a coastal province in China: results of a 2010 survey. Asia Pac J Public Health May 1 2012 [Epub ahead of print]. [8] Cao J, Hu Y, Xu F. Distribution of blood pressure and related influencing factors in 11571 school aged children. Guide China Med 2011;9:290–2 [in Chinese]. [9] Lu L, Wan Y, Dai Y, Xu R, Fang Q. The comparison of diagnostic criteria for hypertension in 4935 school children in Yangtze River Delta region. Chin J Clin Pediatr 2011;10:948–51 [in Chinese]. [10] Lu X, Shi P, Luo CY, et al. Prevalence of hypertension in overweight and obese children from a large school-based population in Shanghai, China. BMC Public Health 2013;13:24. [11] Cao ZQ, Zhu L, Zhang T, Wu L, Wang Y. Blood pressure and obesity among adolescents: a school-based population study in China. Am J Hypertens 2012;25:576–82. [12] Yang X, Song W, Yang Q, Gao Q, Pu Q, Shu S. BMI, blood pressure and their association among children of 7–15 years old in rural areas of Xiangxi. Prog Mod Biomed 2012;16:3167–9 [in Chinese]. [13] Zhang CX, Shi JD, Huang HY, Feng LM, Ma J. Nutritional status and its relationship with blood pressure among children and adolescents in South China. Eur J Pediatr 2012;171:1073–9. [14] Xu H, Hu X, Liu A, et al. Prevalence of high blood pressure among children aged 6– 13 years from six cities of China. Chin J Sch Health 2012;33:1409–11 [in Chinese]. [15] Chu J, Ma J, Guo X, Lu Z, Dong J, Zhang J. Study on intervention effect of salt measuring spoons and scaled oil pots for rural residents in Shandong province. Chin Prev Med 2010;11:1104–7 [in Chinese]. [16] Zhang YX, Zhao JS, Sun GZ, Lin M, Chu ZH. Prevalent trends in relatively high blood pressure among children and adolescents in Shandong, China. Ann Hum Biol 2012;39:259–63.
Please cite this article as: Xi B, et al, Recent prevalence of hypertension among Chinese children and adolescents based on 2010 China national blood pressure references, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.214
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Recent prevalence of hypertension among Chinese children and adolescents based on 2010 China national blood pressure references Bo Xi a,⁎, Huiwen Li b, Shangshuang Li a, Jie Mi c,⁎ a b c
Department of Epidemiology and Health Statistics, School of Public Health, Shandong University, Jinan, China Grade 2010 of Preventive Medicine, School of Public Health, Shandong University, Jinan, China Department of Epidemiology, Capital Institute of Pediatrics, Beijing, China
a r t i c l e
i n f o
Article history: Received 15 April 2014 Accepted 18 April 2014 Available online xxxx Keywords: Prevalence Hypertension Children and adolescents
Childhood hypertension is a serious public health problem worldwide, especially in China [1,2]. Epidemiological studies have suggested that childhood hypertension could track into adulthood [3]. In addition, hypertension in childhood was strongly associated with increased rates of morbidity and mortality during adulthood [4]. Before 2010, there was no consensus on defining childhood hypertension in China, which impeded the comparisons of hypertension prevalence between different regions of China. In 2010, Mi et al. established the China national blood pressure (BP) references for age and sex using 112,227 children and adolescents aged 3–18 years [5]. Based on this national definition, childhood hypertension was defined as systolic BP (SBP) and/or diastolic BP (DBP) above the 95th percentile for age and gender. In this study, we aimed to perform a systematic review to describe the prevalence of hypertension among children and adolescents in different areas of China using 2010 China national blood pressure references. PubMed and Wanfang databases were searched for eligible literature. Search terms were (“hypertension” or “high blood pressure”) and (“children” or “adolescents” or “students”) and (“China” or “Chinese”). Publications from January 2010 (after the publication of 2010 China national blood pressure references by Mi et al. [5]) to April 2014 were included and the publication languages were limited to English and Chinese. The inclusion criteria were: (1) Chinese children and adolescents aged 3–18 years; (2) used 2010 China national blood pressure references; (3) measured SBP and DBP values at least three times at one occasion; (3) survey was performed since 2008; and ⁎ Corresponding authors. E-mail addresses: [email protected] (B. Xi), [email protected] (J. Mi).
(4) if publication included several surveys in different years, only the most recent survey was included. After literature search, a total of eleven studies (the total number of participants was 444,214) [1,2,6–14] were included in this review. The characteristics of included studies are summarized in Table 1. There was a significant difference in hypertension prevalence across different regions of China (Fig. 1). Children and adolescents in North of China including Beijing City (18.2%) or Shandong Province (23.3%) had higher prevalence of hypertension than those in South of China including Shanghai, Changsha in Hunan, and Rural areas of three cities in Hunan and Hainan provinces (ranging from 3.1% to 11.2%). The higher prevalence of hypertension might be largely attributed to dietary salt intake in North of China. For example, it is estimated that daily intake of salt was about 13 g in adults living in the rural area of Shandong province, twice higher than the recommended salt intake by the World Health Organization (less than 5 g/day) [15]. In addition, obesity is another important risk factor for higher hypertension in North of China. In Shandong province, about 16% of boys and 8% of girls were obese [16] while the corresponding figures were 7% and 3%, respectively, in Changsha city of Hunan province [11]. We also found that the overall prevalence of hypertension was about 14% based on both data from the China Health and Nutrition Survey and the Chinese National Survey on Students' Constitution and Health. Our study has two strengths. First, all included studies followed the same standard that is the China national blood pressure references. Second, all included studies were surveyed during the similar periods, i.e., from 2008 to 2010. Thus, the prevalence was up-to-date and can be comparable. However, several limitations should be noted. First, all studies provided hypertension prevalence at only one occasion except for the study by Meng et al. [6] which provided variations of prevalence at three different times. Thus, the prevalence reported in our present review would have overestimated the true prevalence of hypertension in Chinese children and adolescents. Meng et al. [6] demonstrated that the prevalence of hypertension among children and adolescents aged 3–18 years in Beijing of China was 18.2%, 5.1%, and 3.1%, at the first, second, and third visits, respectively. Second, we did not demonstrate the data on the reasons why the prevalence was different between different regions of China although we cited several references on prevalence of obesity and consumption of salt intake in limited areas of China. Third, we only provided prevalence in several regions of China and further researches are required to comprehensively examine prevalence of
http://dx.doi.org/10.1016/j.ijcard.2014.04.214 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Xi B, et al, Recent prevalence of hypertension among Chinese children and adolescents based on 2010 China national blood pressure references, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.214
2
B. Xi et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Table 1 Characteristics of included studies examining the prevalence of hypertension in Chinese children based on the China national blood pressure references. Study
Survey year
No. of participants
Meng et al. [6] Zhang et al. [7] Cao et al. [8] Lu et al. [9] Lu et al. [10] Cao et al. [11] Yang et al. [12] Zhang et al. [13] Xu et al. [14]
2010 2010 2010 2008–2009 2009 2010 2011 2009 2010
Xi et al. [1]
2009
878
Dong et al. [2]
2010
197,191
25
Prevalence (%)
20
6692 38,860 11,571 4935 78,114 88,974 1750 5456 9793
Province/city/region
Age range (years)
Beijing Shandong Jiaozuo in Henan Yangtze River Delta region (Jiangsu, Zhejiang, Shanghai) Shanghai Changsha in Hunan Rural areas of Huaihua, Jishou, and Zhangjiajie in Hunan Hainan Eastern China (Harbin, Beijing, Jinan, Shanghai, Chongqing, Guangzhou) Nine provinces (Liaoning, Heilongjiang, Jiangsu, Shandong, Henan, Hubei, Hunan, Guangxi and Guizhou) 30 provinces of China except for Tibet
Prevalence (%) Total
Boys
Girls
3–18 7–17 6–18 6–18 7–20 12–17 7–15 7–18 6–13
18.2 23.3 7.3 17.9 11.2 3.1 6.5 3.3 10.8
19.3 26.2 7.6 20.3 – 4.7 – 3.5 9.7
17.1 20.3 6.9 15.3 – 1.5 – 3.1 11.9
6–17
13.8
12.6
15.2
7–17
14.5
16.1
12.9
23.3 18.2
17.9 13.8
15 11.2
10
14.5
10.8
7.3
6.5
5
3.1
3.3
0 Beijing
Shandong
Jiaozuo in Yangtze Henan River Delta region
Shanghai Changsha in Rural areas Hunan of three cities in Hunan
Hainan
Eastern China
9 provinces 30 provinces
Region Fig. 1. Prevalence of hypertension among children and adolescents across different regions in China.
hypertension in other areas of China. Fourth, we only reported the prevalence of hypertension in Han Chinese children but not in other minorities. China is a multiracial country with about 56 nationalities, but Han nationality accounts for about 92% of total Chinese population. The present study suggested that it is important to investigate the regional distribution of hypertension prevalence in children and adolescents and to establish the regionally specific intervention strategies to combat hypertension epidemics. Primary measures should be recommended to control weight and reduce salt intake, especially in North of China, in order to reduce the prevalence of childhood hypertension according to different regions of China. References [1] Xi B, Liang Y, Mi J. Hypertension trends in Chinese children in the national surveys, 1993 to 2009. Int J Cardiol 2013;165:577–9. [2] Dong B, Wang HJ, Wang Z, Liu JS, Ma J. Trends in blood pressure and body mass index among Chinese children and adolescents from 2005 to 2010. Am J Hypertens 2013;26:997–1004. [3] Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation 2008;117:3171–80. [4] Franks PW, Hanson RL, Knowler WC, Sievers ML, Bennett PH, Looker HC. Childhood obesity, other cardiovascular risk factors, and premature death. N Engl J Med 2010;362:485–93. [5] Mi J, Wang TY, Meng LH, et al. Development of blood pressure reference standards for Chinese children and adolescents. Chin J Evid Based Pediatr 2010;5:4–14 [in Chinese].
[6] Meng L, Liang Y, Liu J, Hu Y, Yan Y, Mi J. Prevalence and risk factors of hypertension based on repeated measurements in Chinese children and adolescents. Blood Press 2013;22:59–64. [7] Zhang Y, Sun G, Zhao J, Lin M, Chu Z. Monitoring of blood pressure among children and adolescents in a coastal province in China: results of a 2010 survey. Asia Pac J Public Health May 1 2012 [Epub ahead of print]. [8] Cao J, Hu Y, Xu F. Distribution of blood pressure and related influencing factors in 11571 school aged children. Guide China Med 2011;9:290–2 [in Chinese]. [9] Lu L, Wan Y, Dai Y, Xu R, Fang Q. The comparison of diagnostic criteria for hypertension in 4935 school children in Yangtze River Delta region. Chin J Clin Pediatr 2011;10:948–51 [in Chinese]. [10] Lu X, Shi P, Luo CY, et al. Prevalence of hypertension in overweight and obese children from a large school-based population in Shanghai, China. BMC Public Health 2013;13:24. [11] Cao ZQ, Zhu L, Zhang T, Wu L, Wang Y. Blood pressure and obesity among adolescents: a school-based population study in China. Am J Hypertens 2012;25:576–82. [12] Yang X, Song W, Yang Q, Gao Q, Pu Q, Shu S. BMI, blood pressure and their association among children of 7–15 years old in rural areas of Xiangxi. Prog Mod Biomed 2012;16:3167–9 [in Chinese]. [13] Zhang CX, Shi JD, Huang HY, Feng LM, Ma J. Nutritional status and its relationship with blood pressure among children and adolescents in South China. Eur J Pediatr 2012;171:1073–9. [14] Xu H, Hu X, Liu A, et al. Prevalence of high blood pressure among children aged 6– 13 years from six cities of China. Chin J Sch Health 2012;33:1409–11 [in Chinese]. [15] Chu J, Ma J, Guo X, Lu Z, Dong J, Zhang J. Study on intervention effect of salt measuring spoons and scaled oil pots for rural residents in Shandong province. Chin Prev Med 2010;11:1104–7 [in Chinese]. [16] Zhang YX, Zhao JS, Sun GZ, Lin M, Chu ZH. Prevalent trends in relatively high blood pressure among children and adolescents in Shandong, China. Ann Hum Biol 2012;39:259–63.
Please cite this article as: Xi B, et al, Recent prevalence of hypertension among Chinese children and adolescents based on 2010 China national blood pressure references, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.214
