1) National, Regional, and Global Trends in Systolic Blood Pressure Since 1980: Systematic Analysis of Health Examination Surveys and Epidemiological Studies With 786 Country-Years and 5.4 Million Participants 2) National, Regional, and Global Trends in Serum Total Cholesterol Since 1980: Systematic Analysis of Health Examination Surveys and Epidemiological Studies With 321 Country-Years and 3.0 Million Participants 3) National, Regional, and Global Trends in Body-Mass Index Since 1980: Systematic Analysis of Health Examination Surveys and Epidemiological Studies With 960 Country-Years and 9.1 Million Participants

Study Questions:

What has been the worldwide trend in data for blood pressure (BP), cholesterol, and body mass index (BMI); how does each relate to changes in dietary, lifestyle, and pharmacological determinants; and to what degree do national and regional programs differ?


The trends in mean systolic BP (SBP), cholesterol, and BMI for adults were assessed in 199 countries and territories from cohorts varying from 3 million to 9 million participants. Data were obtained from published and unpublished health examination surveys. A Bayesian hierarchical model was used by gender to estimate mean SBP, cholesterol, and BMI by age, country, and year, accounting for whether a study was nationally representative.


In 2008, age-standardized mean SBP worldwide was 128 mm Hg in men and 124 mm Hg in women—a decrease of about 1 mm Hg over 2 decades. BP was greater in high-income countries and rose in Africa and Southern Asia. SBP was highest in Baltic and East and West African countries, with average above 135 mm Hg. The percentage of the world’s population with high BP, or uncontrolled hypertension, fell modestly between 1980 and 2008. However, because of population growth and aging, the actual number of people with uncontrolled hypertension rose from 600 million in 1980 to nearly 1 billion in 2008.

In 2008, age-standardized mean total cholesterol worldwide was 179 mg/dl in men and 184 mg/dl in women. Globally, cholesterol decreased by 2% per decade in men and women. Total cholesterol fell in the high-income regions by about 3.5% per decade, but increased in East and Southeast Asia and the Pacific. Despite improvements, serum total cholesterol in 2008 was highest in the high income regions (203 mg/dl in men and women) and lowest in sub-Saharan Africa (men 186 mg/dl and women 165 mg/dl).

In 2008, an estimated 1.46 billion adults worldwide had a BMI of 25 kg/m2 or greater; of these, about 205 million men and 297 million women were obese. Between 1980 and 2008, mean BMI worldwide increased by 0.4 kg/m2 per decade in men and 0.5 kg/m2 per decade in women. In 2008, about 10% of men and 14% of women in the world were obese (BMI above 30 kg/m2), compared with 5% for men and 8% for women in 1980. Pacific island nations have the highest average BMI in the world, reaching 34-35 kg/m2, up to 70% higher than some countries in Southeast Asia and sub-Saharan Africa.

The main determinants of BP trends are likely to be patterns of consumption of salt and fruits and vegetables, overweight and obesity, and use of antihypertensive drugs. High BP is the leading risk factor for cardiovascular disease mortality, and causes more than 7 million deaths worldwide annually.


The authors concluded that overweight and obesity, high BP, and high cholesterol are no longer Western problems or problems of wealthy nations. Their presence has shifted toward low- and middle-income countries, making them global problems. Population-based and personal interventions should be targeted toward low- and middle-income countries.


The three studies published in The Lancet provide the scientific bases for increasing a worldwide effort to increase prevention, which would impact cardiovascular disease, cancer, and diabetes. BMI increased by an average of 1 kg/m2 per decade in the United States, where women have the highest mean BMI of high-income countries. In advanced and higher income countries, the BP and cholesterol are decreasing despite a fattening (doubling obesity) of the populations. One could conclude that this reflects improvement in screening and treatment, which should lead to decrease in cardiovascular event rates. However, the long-term consequences of increasing weight will be associated with increasing diabetes and its consequences. The worldwide incremental health care cost attributable to available and affordable high salt-high fat-high glycemic index fast foods is enormous, and will continue for decades. Would it be the realist or pessimist that concludes there is little likelihood the average person will decide to embrace healthy foods and increase physical activity, particularly if the ‘risk factors’ are controllable with pharmacologic interventions?

Clinical Topics: Dyslipidemia, Prevention, Lipid Metabolism, Nonstatins, Hypertension

Keywords: Overweight, Blood Pressure, Glycemic Index, Cholesterol, Body Mass Index, Developed Countries, Epidemiologic Studies, Motor Activity, Obesity, Hypertension, United States, Diabetes Mellitus

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