Health and Population Perspectives and Issues 37 (1 & 2), 40-49, 2014

RISK FACTORS FOR HYPERTENSION IN INDIA AND CHINA:

A COMPARATIVE STUDY
FuJun Wang*, V. K. Tiwari** and Hao Wang***

ABSTRACT
To identify the different risk factor for hypertension has differently
impacted in India and China. A systematic review focusing on the
seven independent variables was conducted. All published studies
conducted in India and China with study sample of at least 130
adult population living in urban and rural areas and describing
the prevalence and risk factors (age and sex, unhealthy diet,
overweight and obesity, alcohol, physical inactivity, tobacco) of
hypertension in India and China were included for this review.
A total of 60 relevant articles which were extracted, 36 articles
met the inclusion criteria. Through analyse the risk factors for
hypertension, the review shows China has faced more challenges
than India. This has been found that the per capita salt in-take is
higher than five grams in both the countries as recommended by
the WHO.
Key words: Hypertension, Risk-factors, Prevalence of hypertension,

In 2013, WHO reported that globally cardio-vascular disease accounts for

approximately 17 million deaths a year, nearly one-third of the total deaths for
all deaths from diseases. Of these, complications of hypertension account for 9.4
million deaths worldwide every year. Reports indicate that more than one in three
of the adults (>=25 years old) has hypertension in 2008, and the prevalence show
increase trend in future.
China and India are the two largest developing countries and the most populous
countries in the world. The prevalence of hypertension shows an increasing trend
in both of the countries. Prevention and control of hypertension is a significant
challenge. The numbers of the hypertension population in India and China are
118 million and 160 million in 2000 respectively. If the situation of the risk-factors
*PGDPHM student, E. mail: wangfujunlxd@163.com; **Professor, Department of
Planning and Evaluation; National Institute of Health and Family Welfare, Munirka, New
Delhi-110067. *** Director, Tianjin Population and Family Planning Committee, China.

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for the hypertension is identified in the population, and appropriate action is

taken to reduce the adverse-health life styles; the prevalence of hypertension will
be effectively controlled.
OBJECTIVES
The study was done with the following objectives:

To review the prevalence of hypertension in China and India,

To identify and analyse the risk factors for hypertension in India and China,

To compare the risk-factors influencing hypertension in China and India, and

To suggest strategies for the control and prevention of hypertension in both

the countries.

METHODOLOGY
This is a review study based on published literatures from India and China. All the
published studies conducted in India and China had a study sample of at least
130 young and adult population living in urban and rural areas and describing
the prevalence and risk-factors of hypertension in India and China. The studies
included age and sex, unhealthy diet, overweight and obesity, alcohol, physical
inactivity, tobacco, residence, etc. as risk-factors. A total of 60 relevant articles
were collected and out of those, 18 articles met the criteria for inclusion in the
current comparison. Studies conducted 20 years ago were not included in this
review. The review analysed the influence of the risk-factors for hypertension on
India and China as well as it compares data of both of the countries.
FINDINGS
As we know, the main factors that contribute to the development of high blood
pressure include age, sex, unhealthy diet, tobacco use, physical inactivity, harmful
use of alcohol, obesity, etc., impact of these main risk-factors were taken into
account for the review study.
Age and Sex
In China, a study showed that hypertension was more prevalent among women
than men, and the prevalence rate increased with an increase in age. The study
also found that for the age group 35-44 years, men had a slightly higher rate of
hypertension than women. However, the result was reverse for the population in
the >45 years of age. A cross-section study1 of China demonstrate that the agespecific prevalence of hypertension was 13.0 per cent, 36.7 per cent, and 56.5
per cent among persons in the age-groups of 20-44 years (young people), 4564 years (middle-aged people), and 65 years (elderly people), respectively. The

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observations from the Chinese Registryof Acute Coronary Events describe that
the prevalence of high blood pressure increased with an increase in age. In China,
the population structure has been gradually changing since 1970. Now, China has
more elderly population. China is stepping into an aging population, so preventing
hypertension in the elderly group is a challenge (Figures 1 and 2).
FIGURE 1
AGE-DISTRIBUTION OF HYPERTENSION AMONG CHINESE

FIGURE 2
CHINAs POPULATION PYRAMID 2013

Another research on the trends of hypertension epidemiology in India showed a

similar result. High blood pressure (BP) is a major public health problem in India
and its prevalence is rapidly increasing among both urban and rural populations2.
It has found that the number of cases increased with an increase in age among
165 study subjects. 10 cases (6.06%) comprising 6 males (6.45%) and 4 females
(5.55%) were found in the age group of 21-30 years and 75 cases (45.46%)
comprising 35 males (37.63%) and 40 females (55.56%) were in the age group of
51-60 years.

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FIGURE 3
INDIAs POPULATION PYRAMID 2013

Unhealthy Diet
High blood pressure is the leading risk for mortality, globally. Many researches
show that excess salt intake affects blood pressure. This conclusion is proved by
plenty of scientific experiments and is recognized worldwide.
A case control study2 was conducted in rural township of Tasgaon; Sangli district of
Maharashtra in India during 2001-2002, to study the role of certain modifiable riskfactors in essential hypertension in the 21-60 years age group. Among the dietary
factors, higher salt consumption was also found to be significantly associated with
hypertension (P= 0.0003). Twice the risk of developing hypertension (OR=2.06)
was observed among persons consuming more than 5 grams of salt per day. In
2007, a study assessed the salt-intake of 8.5g/day among urban Chennai adults
using a food frequency questionnaire3. In order to determine the relationship
between dietary sodium and blood pressure in the Chinese population, several
nationwide epidemiological surveys have been conducted to investigate saltintake and the incidence of high blood pressure. The Ministry of Health of China
reported that each Chinese person consumes an average of at least 15 grams of
salt every day in comparison to five grams as recommended by the WHO.
Overweight and Obesity
Overweight and obesity are major risk-factors for a number of chronic diseases
including hypertension, cardio-vascular diseases and cancer. The risk for
hypertension increases with the increase in BMI (Body Mass Index). In 2008,
worldwide 35 per cent of adults aged 20 years and over was overweight, and
11 per cent was obese. Another survey conducted among the rural population
of Bangalore rural district in India in 2009 showed that about 51.96 per cent
was thin with a BMI of <18 while 14.0 per cent was overweight or obese with a
BMI measuring >25 and the rest reported normal. Prevalence of hypertension
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in overweight or obese group was 36 per cent it was 5.8 per cent had a normal
BMI4. A similar research has been conducted in rural area of China in 2004-20065
using a multi-stage cluster sampling method to select a representative sample.
A total of 45,925 adults aged 35 years or older were examined.The prevalence
of overweight and obesity was 16.3 per cent and 1.3 per cent among males
respectively, and 24.4 per cent and 2.7 per cent among females (p value for gender
differences <0.05). According to the World Health Organization classification, the
prevalence rates of overweight and obese were 29.5 per cent and 5.3 per cent
respectively. According to a WHO report6, in 2010, the prevalence rates of BMI
in India with >25 among the population aged >15 years are 20.1 per cent males
and 18.1 per cent females while these figures stood at 45 per cent males and 32
females in China.
Alcohol
A study conducted in India4 showed that alcohol consumption is significantly
associated with hypertension. Among the study population, 14 per cent of them
had the habit of regular alcohol consumption, out of which more than a third
(38.96%) had hypertension. The odds ratio between alcoholics and non-alcoholics
was as high as 21. It means that alcohol consumers had 21 times higher risk of
hypertension in comparison to the non-alcoholics. Alcohol consumption has been
steadily increasing in developing countries like India. At same time, people start
drinking at an earlier age than previously.
Another research7 conducted in northern China shows 9151 people out of 32389
workers developed hypertension during 4 years of follow-up period. At the end
of the follow-up, the cumulative incidence of hypertension in relation to daily
alcoholic intake of none, 124gm, 2549gm, 5099gm, 100149gm and at least
150 gm was 25.03 per cent, 28.82 per cent, 30.10 per cent, 37.07 per cent, 40.14
per cent and 42.49 per cent respectively. According to a WHO report8, a recent
national survey of drinking alcohol in China revealed that China has experienced
dramatic increases in the consumption of alcoholic beverages since the 1990s.
High-risk drinking behaviour has reached epidemic proportions in China.
Physical Inactivity
Many studies that showed the relationship between physical inactivity and
hypertension were conducted in India. One such study2 found a statistically
significant association between hypertension and leisure time physical inactivity
(P=0.009). Odds ratio was found to be 2.51 indicating the absence of leisure
time physical activity which is twice the risk of hypertension when compared
with positive leisure time physical activity. Some researchers have proved that
long-term aerobic exercise regimens have beneficial effects upon systolic blood
pressure.
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A survey9 related to physical activity level was conducted in China. The results
indicate that the proportion of the physically active population in urban China is
low. Additionally, a majority of the physical activity that occurs in China is workrelated, and rates of leisure-time physical activity are low, especially in urban
settings. With the increasing urbanization taking place in China, rates of physical
activity could decline substantially over a relatively short period of time.
Tobacco
India and China are the two most tobacco consumption countries in the world.
Tobacco use is one of the main risk-factors for a number of chronic diseases,
including cardio-vascular, cancer, lungs disease, etc.
A cohort study lasted for 7 years conducted in rural Kerala, India10, with a sample
of 297 individuals aged 1564 years who were free of hypertension at the time
of study enrolment, were followed-up from 2003 to 2010. Nearly one-quarter
(23.6%) of the sample developed hypertension over a mean follow-up period of 7.1
(standard deviation 0.2) years. Current smoking RR value=1.99.The result means
that smoking was significantly associated with the incident of hypertension. An
earlier study using Meta-analysis method has analyzed 24 reviews about tobacco
related with hypertension11. The result showed a significant difference between
them but the link was weak. But some other studies have a different conclusion
with no association between smoking and hypertension among the Mongolian
population12.
Residence
Recent studies13 using revised criteria (BP140/90mmHg) have shown a high
prevalence of hypertension among urban adults with 30 per cent men and 33 per
cent women in Jaipur in 1995, 44 per cent men and 45 per cent women in Mumbai
in 1999, 31 per cent men and 36 per cent women in Thiruvananthapuram in 2000,
14 per cent in Chennai in 2001; and 36 per cent men and 37 per cent women in
Jaipur in 2002. Among the rural populations, hypertension prevalence rates were
found to be 24 per cent in men and 17 per cent in women in Rajasthan in 1994.
Hypertension diagnosed by multiple examinations has been reported among 27
per cent of males and 28 per cent of female executives in Mumbai in 2000, and
4.5 per cent of rural subjects in Haryana in 1999. The gap of prevalence rate for
hypertension between urban and rural area is very clear in India.
According the data from the China National Nutrition and Health Survey 200214, the
prevalence of hypertension was higher in urban compared with rural areas among
men (23% versus 18%;P<0.01) and among women (18% versus 16%;P<0.001).

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DISCUSSION
Data from Inter ASIA, the most recent Chinese national study, estimated that
129824000 Chinese persons aged 3574 years had hypertension. The prevalence
of hypertension in China was 26.0 per cent15. As per the World Health Statistics
2010 report16, 33.20 per cent of men and 31.70 per cent of women above 25
years suffer from hypertension in India.However, different levels of risk-factors
of hypertension have an impact on the population of India and China. The data
in this review provide some information about the risk-factors of hypertension in
terms of age and sex, unhealthy diet, overweight and obesity, alcohol, physical
inactivity, tobacco. At same time, different regions have different prevalence rates.
All the studies conducted in both the countries indicate the prevalence of
hypertension an ascending trend with an increase in age. The results are consistent
with studies conducted in other countries. However, India and China will confront
different situations on the age factor. In China, population structure is facing a
rapid aging because of implementation of family planning policy. Demographic
dividend period is gradually disappearing. There is a huge proportion of older
population in future of China. This means China will have a large number of elderly
patients including hypertension patients. In India, the population structure is
completely different from China. China will face more challenges than India in
terms of age-specific prevalence rates of hypertension.
Excess salt in-take significantly affects blood pressure. Too much sodium in
your diet can cause your body to retain fluid, which increases blood pressure.
Many scientific experiments have proved it. India and China are facing the same
problem in this field. Both the countries have a high-salt food culture. According a
research, an average per capita salt consumption in India is 13.8 gm/day. Similarly,
each Chinese person consumes an average of at least 15 grams of salt every day.
At the same time, different regions have different salt in-take among people in
both the countries. However, the per capita salt in-take is higher than five grams
in both the countries as recommended by the WHO.
The Framingham Heart Study, a famous study for 44 years, estimated that excess
body weight including overweight and obesity accounted for approximately
26 per cent and 28 per cent of cases of hypertension among men and women
respectively. According to a WHO report17, the prevalence rates of obesity among
females and males in India are 3.7 per cent and 1.7 per cent respectively. But
the rates of obesity were 10.6 per cent, 7.2 per cent, 6.4 per cent, 4.3 per cent,
6.0 per cent and 2.7 per cent respectively for large city, middle-and-small city,
class 1 rural, class 2 rural, class 3 rural and class 4 rural areas in China18. Obesity
prevalence rates are in alarming proportion in India than China.
There is a strong link between alcohol and non-communicable diseases such as
hypertension. Hypertension and other cardio-vascular disorders such as cardiac
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arrhythmias or heart failure are adversely effected by alcohol. According to the

WHO Global Status Report on Alcohol 2004, per capita pure alcohol consumption
rates amongst 15+ years were 0.82 litres and 4.45 litres in India and China,
respectively19. Hence, China should pay more attention to control alcohol-related
hypertension than India. Globally, around 31 per cent of adults aged 15 years
and above were insufficiently active in 2008 that included 28 per cent men and
34 per cent women. Approximately, 3.2 million deaths each year are attributed
to insufficient physical activity. Sedentary activities were significantly associated
with hypertension. Many studies have reported that physical inactivity has a great
impact on the prevalence of hypertension. It has been observed that physical
activity of Indian and Chinese population is insufficient.
There is no consensus on the effect of tobacco use on hypertension. Some
researches describe that tobacco use has a light impact on hypertension while
others showed no affect of tobacco on hypertension. Yet, according to a WHO
report, tobacco use is a risk-factor for hypertension. China and India are the
largest two countries on consuming tobacco. In 2012, an estimated 28.1 per cent
of adults in China (52.9% of men and 2.4% of women) were current smokers20.
Even though a large chunk of the Chinese population uses tobacco, China doesnt
have a tobacco control policy. If the high smoking prevalence rate among Chinese
adults persists, China will suffer from a heavy disease burden and incur serious
socio-economic losses in the 21st century. The prevalence rates of hypertension
were different in rural and urban areas. The population of hypertension in urban
is more than in rural areas in both the countries. With the increasing of economic
activities, the number of population with high blood pressure shows a rising trend
in rural areas as well making the gap between rural and urban population with
high BP closer.
CONCLUSION
Hypertension is significantly affecting India and China. The prevalence rates of
hypertension are all at high level and show an ascending trend in China and
India. The authors conclude that the socio-demographic and lifestyle factors
are accelerating the hypertension epidemic currently in both the countries. All
the risk-factors of hypertension in China and India are more or less similar. They
impact the prevalence rate of high blood pressure. Accordingly, China will face
more difficult situation to prevent hypertension due to a high rate of alcohol
consumption. China has entered the aging society. Hence, the country will face
the burden of an increasing elderly population. Because of traditional culture,
Chinese people consume more alcohol than Indians. So, restricting alcohol
consumption is more necessary in China. But obesity is a challenge for both India
and China. The prevalence rates of obesity and overweight are increasing among
the population in both the Asian giants. The affect of tobacco use is also pretty
important for both the countries. With the increasing urbanization, the disparity

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of hypertension in different regions is gradually narrowed. Meanwhile, others

risk-factors also influence the prevalence of high blood pressure in both of the
countries.
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