Journal of the American Society of Hypertension 5(1) (2011) 2130

Research Article

BMI and lifestyle changes as correlates to changes in self-reported

diagnosis of hypertension among older Chinese adults
SangNam Ahn, PhD, MPSAa,*, Hongwei Zhao, ScDb,
Matthew Lee Smith, PhD, MPH, CHES, CPPa, Marcia G. Ory, PhD, MPHa,
and Charles D. Phillips, PhD, MPHc
a

Department of Social and Behavioral Health, School of Rural Public Health, Texas A&M Health Science Center, College Station, Texas;
Department of Epidemiology and Biostatistics, School of Rural Public Health, Texas A&M Health Science Center, College Station, Texas; and
c
Department of Health Policy and Management, School of Rural Public Health, Texas A&M Health Science Center, College Station, Texas
Manuscript received October 12, 2010 and accepted December 8, 2010
b

Abstract
Nutrition transition theory attributes increased prevalence of high blood pressure to excess body weight associated with lifestyle
changes in recent decades. We examined the association of changes in self-reported hypertension diagnoses with changes in
body mass index (BMI), health-related behaviors, health status, and social risk factors among older Chinese adults from
1997 to 2006. Data from the longitudinal China Health and Nutrition Survey (CHNS) were analyzed for adults who were
age 60 years and older, had a BMI exceeding 18.6 kg/m2, and reported no diagnosis of hypertension at baseline (n 1928).
Logistic regression models identified factors contributing to staying nonhypertensive or developing hypertension over time.
Approximately 17.8% (n 324) of study participants developed self-reported hypertension, whereas 83.2% (n 1604)
remained without hypertension. Those who stayed overweight or obese or became overweight or obese were more likely to
report a new hypertension diagnosis. Incident diagnoses were also observed among those who developed acute conditions, sustained memory loss, or increased their income, whereas remaining nonhypertensive was more likely among rural residents and
those who became more physically active and quit drinking alcohol. Study findings provided partial support for the nutrition
transition theory whereby changing demographics and lifestyle factors were associated with increases in incident hypertension.
J Am Soc Hypertens 2011;5(1):2130. 2011 American Society of Hypertension. All rights reserved.
Keywords: Hypertension; obesity; lifestyles; older adults.

Introduction
China is experiencing an obesity epidemic paralleling
rapid increases in obesity seen in other parts of the world.
Grant support: The project described was partially supported
by Grant Number 90OP0001/03 from the Administration on
Aging and Grant Number R01HD047143 from the National Institute of Child Health and Human Development. The content is solely
the responsibility of the authors and does not necessarily represent
the official views of Texas A&M University System Health Science
Center School of Rural Public Health or funding agencies.
Conflict of interest: The authors declare no conflict of interest.
*Corresponding author: SangNam Ahn, PhD, MPSA, School
of Rural Public Health, Texas A&M University Health Science
Center, 1266 TAMU, College Station, TX 77843. Tel: 979-8624941; fax: 979-458-4264.
E-mail: snahn@srph.tamhsc.edu

In 2002, nearly 215 million Chinese were overweight

(body mass index [BMI; kg/m2] 25.029.9) or obese
(BMI  30.0), accounting for 22% of adults.1 Rates are
likely to increase dramatically by 2030 with 810 million
Chinese adults overweight (BMI 25.029.9) or obese
(BMI  30.0): 669 million (59.7%) of these adults will
be overweight and 141 million (12.6%) will be obese.2
Simultaneously, China has a rapidly aging population3 that
may be disproportionately affected by this obesity trend. The
percentage of adults aged 60 years and older is predicted to
double to 24% in 2030 (ie, from 12% in 2010) compared
with the projected world average of 17% in 2030 (ie, from
11% in 2010).4 Previous research found the prevalence of
overweight or obesity was significantly higher among older
Chinese adults than their younger counterparts,5 increasing
their risk of obesity-related comorbidities.68 The combined
effects of the obesity epidemic and aging population are

1933-1711/$ - see front matter 2011 American Society of Hypertension. All rights reserved.
doi:10.1016/j.jash.2010.12.001

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S. Ahn et al. / Journal of the American Society of Hypertension 5(1) (2011) 2130

expected to drastically increase the prevalence of hypertension development in China.911

The prevalence of hypertension among Chinese adults
age 18 years and older increased from 11.9% in 1993 to
15.8% in 1998, and to 26.2% in 2003.8 In the older population, increases in hypertension prevalence were even
more pronounced.8,12 A survey among Chinese showed
dramatically higher prevalence rates of hypertension among
adults aged 60 years and older (ie, the prevalence of hypertension: 50% for men compared with 52% for women) than
among their younger counterparts (ie, 12% for men
compared with 6% for women aged 1844 years; 28%
for men compared with 29% for women aged 4559
years).13 Hypertension is responsible for 7.6 million premature deaths and 92 million disability-adjusted life years
(DALYs) worldwide.14 In a cross-sectional study, hypertension was the leading preventable risk factor for death
among Chinese adults age 40 years and older, claiming
11.7% of the total mortality.15
Obesity fosters poorer health outcomes among older adults
with hypertension through a variety of biological and clinical
pathways. For example, older adults commonly have low
fitness levels or functional limitations.16 Obesity itself may
result in reduced physical activity, which may exert additional, independent effects to raise blood pressure.10 Physiologically, angiotensinogen mRNA expression is increased in
visceral fat, which partly explains the relationship between
hypertension and obesity in the metabolic syndrome.17
However, controversy remains concerning whether (1) BMI
has the predictive power to affect obesity-related health
consequences1821; (2) BMI is predictive of developing
hypertension22,23; and (3) behavioral interventions are effective in reducing the risks of high blood pressure.23,24 These
debates may be partially attributed to limited information
about how changes in lifestyle and body composition covary
with changes in hypertension status among older Chinese
adults.
According to the nutrition transition theory, large shifts
in dietary habits and physical activity patterns have
occurred in recent decades of the 20th century.25 Using
a conceptual framework guided by this theory, our study
investigated whether changes in BMI, health-related behaviors, health status, and social risk factors were associated
with changes in self-reported hypertension diagnoses.
Within this framework, this study compared the changes
in self-reported diagnoses of hypertension among older
Chinese adults with changes in covariates of interest across
study waves ranging from 1997 to 2006. The purposes of
this study were to (1) identify changes in BMI, healthrelated behaviors, health status, and social risk factors
among older Chinese adults over the past 10 years; (2)
examine factors associated with self-reported diagnosis of
hypertension; and (3) discuss health policies that might
slow the unfavorable shifts in nutritional and health status
trends.

Methods
Study Population
Data for this study were from the China Health and Nutrition Survey (CHNS). The CHNS is an ongoing longitudinal
survey established in the late 1980s in 9 China provinces and
conducted jointly by the Chinese Academy of Preventive
Medicine and the University of North Carolina at Chapel
Hill.26 As the first nationwide longitudinal study in China,
the CHNS aimed to examine how social and economic
transformation in these provinces affects the health and
nutritional status of Chinese residents.7 The survey used
a multistage, random cluster process to draw a sample
from each province that varied substantially in geography,
economic development, public resources, and health indicators.7 The sample represented approximately 50% of the
Chinese population.27 We used data from participants in
1997, 2000, 2004, and 2006 and included adults who were
aged 60 years and older at baseline, responded to at least 2
survey waves, had a BMI greater than 18.6 kg/m2 at baseline, and reported no diagnosis of hypertension at baseline.
For the purposes of the study, we excluded those who reported having hypertension at baseline (n 375). In this
study, analysis periods ranged by participant; with time 1
being the first survey wave in which the respondent participated and time 2 being the final survey wave in which that
same respondent participated. For this reason, we controlled
for the duration of the respondents participation in the final
model. The final analytic sample size was 1928.

Dependent Variables
Changes in Self-reported Diagnosis of Hypertension.
Participants were asked if they were diagnosed with hypertension in the 12 months preceding each survey period. We
created a variable reflecting change in hypertensive status:
scored 0 if the participants reported no hypertension in the
later survey; 1 if they developed hypertension in the later
survey period. Previous research supports that self-reported
hypertension is a relatively valid tool to assess the hypertensive status of study participants.28,29

Independent Variables
Nutritional Factor
BMI was calculated by dividing weight in kilograms by the
square of height in meters and rounding to the nearest tenth.30
Participants BMI scores were categorized using the World
Health Organization criteria: normal (BMI 18.5 to 24.9
kg/m2), overweight (BMI 25.0 to 29.9 kg/m2), and obese
(BMI  30.0 kg/m2), which led to the development of a binary
variable (ie, normal versus overweight/obese) for the
purposes of this study.31 BMI status was further categorized

S. Ahn et al. / Journal of the American Society of Hypertension 5(1) (2011) 2130

into staying normal (scored 0), becoming overweight/obese

(scored 1), becoming normal (scored 2), and staying overweight/obese (scored 3) in the later survey period.

Lifestyle Factors
Physical activity was based on nonleisure physical activity
levels: having no physical activity, or engaging in very light,
light, moderate, heavy, and very heavy physical activity. We
categorized these responses as staying with no physical
activity (scored 0), becoming more active (scored 1),
becoming less active (scored 2), continuing light activity
(scored 3), and continuing moderate or more activity
(scored 4) in the later survey period. Although there are no
previous studies to test reliability or validity on this variable,
several published studies have found it to be significant
predictor of weight.3234 The smoking variable was dichotomized to reflect smoker or nonsmoker status. We categorized
this variable into remaining a nonsmoker (scored 0),
becoming a smoker (scored 1), quitting smoking (scored 2),
and continuing to smoke (scored 3) in the later survey period.
Alcohol followed a similar coding scheme: consuming
alcohol and not consuming alcohol consumption in the past
12 months. We categorized this variable into remaining a nonalcohol drinker (scored 0), becoming an alcohol drinker
(scored 1), quitting alcohol drinking (scored 2), and
continuing to drink alcohol (scored 3) in the later survey
period.

Health-related Factors
Participants were asked to report if they had had any
of the following acute symptoms during the preceding
4 weeks: (1) fever, sore throat, cough; (2) diarrhea, stomachache; (3) headache, dizziness; (4) joint pain, muscle
pain; (5) rash, dermatitis; (6) eye/ear disease; (7) any other
infectious disease; and (8) other noncommunicable
diseases,35 which led to a binary variable (yes or no) for
distribution characteristics. We categorized this variable
into staying with no acute conditions (scored 0), developing
new acute conditions (scored 1), reporting the conditions at
baseline but avoiding acute conditions in the later survey
period (scored 2), and continuing to have acute conditions
(scored 3) in the later survey. Previous research suggests
that limitations in cognitive functioning are associated
with an increased risk of high blood pressure.36,37 In the
present study, cognitive functioning was measured by
a single self-reported question that inquired about memory
status.35,38 Those who responded bad or very bad were
considered to have a possible cognitive impairment.35 For
the analysis, we categorized this variable into remaining
the same (scored 0), deteriorating (scored 1), improving
(scored 2), and remaining deteriorated (scored 3) in the
later survey period.

23

Social Risk Factors

Marital status was recorded as never married, married,
divorced, widowed, and separated, coded into 2 categories
of living with a spouse (value 0) or living without a spouse
(value 1). We categorized this variable into staying married
(scored 0), becoming single (scored 1), becoming married
(scored 2), and staying single (scored 3) in the later survey.
The household income was computed as the sum of all sources of income in the household, inflated to a 2006 price index,
and divided by household size.35 The current study examined
tertiles of per capita income based on the distribution of the
continuous form of this variable in the selected study
sample.35 We categorized this variable into staying at low
income (scored 0), increasing income (scored 1), decreasing
income (scored 2), staying at medium income (scored 3), and
staying at high income (scored 4) in the later survey. Other
demographic variables were treated as time-stationary variables. For example, the education level of each older person
was coded into none (value 0), primary (value 1), or
moderate or more education (value 2) based on their
completed years of education.35 Participants also reported
their residential sites (ie, urban or rural) and gender (ie,
male or female).

Statistical Analyses
Analyses were conducted with the Stata (version 10)
statistical package (Stata Corp, College Station, TX). Participant characteristics were described first. We next conducted
bivariate analyses using Pearson c2 test or t test to examine
the bivariate relationship between changes in self-reported
diagnosis of hypertension and each change of nutritional,
health-related, lifestyle, and social risk factors. Finally,
a logistic regression model was tested to examine the independent influence of changes in BMI, health-related behaviors, and social risk factors on changes in self-reported
diagnosis of hypertension. Odds ratio estimates and their
95% confidence intervals for regression coefficients are
displayed.

Results
Table 1 shows that approximately 17.8% (n 324) of
study participants developed self-reported hypertension
during the study period, whereas 83.2% (n 1604) did not
report hypertension at any point in the study period. Approximately 7.4% (n 142) of study participants became overweight or obese, 5.9% (n 114) reported moving from
overweight or obese to normal weight, and 19.4% (n
372) stayed overweight or obese. Participants who became
less physically active, became a cigarette smoker, became
an alcohol drinker, developed acute conditions, and reported
a deteriorated memory status were 27.6% (n 531), 5.7%
(n 109), 8.3% (n 159), 28.9% (n 559), and 27.4%
(n 527) participants, respectively. The average duration

24

S. Ahn et al. / Journal of the American Society of Hypertension 5(1) (2011) 2130

Table 1
Characteristics of the study participants (n 1,928) in the China Health and Nutrition Survey*
Hypertension change
BMI change

Physical activity changey

Smoking change

Alcohol change

Acute condition change

Memory status change

Gender
Residence
Education

Marital status change

Income change

Duration of study participation (years)z

Variables

n (%) or Mean (SD)

Staying without hypertension

Developing hypertension
Staying normal weight
Becoming overweight/obese
Becoming normal weight
Staying overweight/obese
Staying not active
Becoming more active
Becoming less active
Continuing light active
Continuing  moderate active
Remaining a nonsmoker
Becoming a smoker
Quitting smoking
Continuing to smoke
Remaining a nonalcohol drinker
Becoming an alcohol drinker
Quitting alcohol drinking
Continuing to drink alcohol
Staying at no acute conditions
Developing new acute conditions
Avoiding acute conditions
Continuing to have acute conditions
Remaining same or improved
Deteriorating
Improving
Remaining deteriorated
Male
Female
Urban
Rural
No school
Primary
Intermediate
Staying married
Becoming single
Becoming married
Staying single
Staying at low income
Increasing income
Decreasing income
Staying at medium income
Staying at high income

1604
324
1289
142
114
372
648
241
531
124
380
1269
109
206
344
1173
159
264
332
1104
559
138
127
612
527
275
512
916
1012
704
1224
786
618
350
1275
198
47
408
333
626
370
239
360
5.6

(83.2)
(17.8)
(67.2)
(7.4)
(5.9)
(19.4)
(33.7)
(12.5)
(27.6)
(6.4)
(19.8)
(65.8)
(5.7)
(10.7)
(17.8)
(60.8)
(8.3)
(13.7)
(17.2)
(573)
(28.9)
(7.2)
(6.6)
(31.8)
(27.4)
(14.3)
(26.6)
(47.5)
(52.5)
(36.5)
(63.5)
(44.8)
(35.2)
(19.9)
(66.1)
(10.3)
(2.4)
(21.2)
(17.3)
(32.5)
(19.2)
(12.4)
(18.7)
(2.9)

BMI, body mass index.

* Data presented are numbers (percentages) or mean values  standard deviation (SD), as appropriate for the variable.
y
Nonleisure physical activity.
z
Study duration ranged from 2 to 9 years.

of study enrollment (ie, from baseline to follow-up study

wave) was 5.6 years, ranging from 2.0 to 9.0 years.
Table 2 shows that BMI change was associated with
remaining without hypertension versus developing hypertension. Changes in health-related behaviors showed significant bivariate associations with developing self-reported

diagnosis of hypertension. Staying with no hypertension

during the survey period was more likely among those
who became more physically active, quit smoking, and
quit drinking alcohol during the survey period. Longer
participation in the study was associated with developing
hypertension.

S. Ahn et al. / Journal of the American Society of Hypertension 5(1) (2011) 2130

25

Table 2
Bivariate association between changes in self-reported diagnosis of hypertension and variables of interest (n 1928)

BMI change

Physical activity changey

Smoking change

Alcohol change

Acute condition change

Memory status change

Gender
Residence
Education

Marital status change

Income change

Variables

Staying Without Hypertension

n (%) or Mean (SD)

Developing Hypertension
n (%) or Mean (SD)

P Trend*

Staying normal weight

Becoming overweight/obese
Becoming normal weight
Staying overweight/obese
Staying not active
Becoming more active
Becoming less active
Continuing light active
Continuing  moderate active
Remaining a non-smoker
Becoming a smoker
Quitting smoking
Continuing to smoke
Remaining a non-alcohol drinker
Becoming an alcohol drinker
Quitting alcohol drinking
Continuing to drink alcohol
Staying at no acute conditions
Developing new acute conditions
Avoiding acute conditions
Continuing to have acute conditions
Remaining same or improved
Deteriorating
Improving
Remaining deteriorated
Male
Female
Urban
Rural
No school
Primary
Intermediate
Staying married
Becoming single
Becoming married
Staying single
Staying at low income
Increasing income
Decreasing income
Staying at medium income
Staying at high income

1127
114
85
269
510
213
434
101
342
1033
91
180
300
951
137
233
283
970
400
125
109
520
436
237
411
774
830
547
1057
660
519
286
1067
159
36
342
294
506
308
212
284
5.51

162
28
29
103
138
28
97
23
38
236
18
26
44
222
22
31
49
134
159
13
18
92
91
38
101
142
182
157
167
126
99
64
208
39
11
66
39
120
62
27
76
6.12

<.001

Duration of study
participation (years)

(70.7)
(7.2)
(5.3)
(16.9)
(31.9)
(13.3)
(27.1)
(6.3)
(21.4)
(64.4)
(5.7)
(11.2)
(18.7)
(59.3)
(8.5)
(14.5)
(17.6)
(60.5)
(24.9)
(7.8)
(6.8)
(32.4)
(27.2)
(14.8)
(25.6)
(48.3)
(51.8)
(34.1)
(65.9)
(45.1)
(35.4)
(19.5)
(66.5)
(9.9)
(2.2)
(21.3)
(18.3)
(31.6)
(19.2)
(13.2)
(17.7)
(2.87)

(50.3)
(8.7)
(9.0)
(31.9)
(42.6)
(8.6)
(29.9)
(7.1)
(11.7)
(72.8)
(5.6)
(8.0)
(13.6)
(68.5)
(6.8)
(9.6)
(15.1)
(41.4)
(49.1)
(4.0)
(5.6)
(28.6)
(28.3)
(11.8)
(31.4)
(43.8)
(56.2)
(48.5)
(51.5)
(43.6)
(34.3)
(22.2)
(64.2)
(12.0)
(3.4)
(20.4)
(12.0)
(37.0)
(19.1)
(8.3)
(23.5)
(2.79)

<.001

.024

.014

<.001

.096

.146
<.001
.595

.394

.001

.001

BMI, body mass index.

* Bold numbers are statistically significant; P trends are based on the modified Pearson chi-square statistics (for categorical variables) or
t-statistics (for continuous variables).
y
Nonleisure physical activity.

Those who became overweight or obese (odds ratio

[OR] 1.73), stayed overweight or obese (OR 2.51), or
became normal weight (OR 2.66) in the later survey
period were more likely to develop self-reported diagnosis
of hypertension (Table 3). Developing self-reported

diagnosis of hypertension in the later survey period was

more common among those who developed acute conditions
(OR 2.64), sustained deteriorated memory status (OR
1.54), had an increased income (OR 1.56), stayed at
high income (OR 1.73), and participated in the study

26

S. Ahn et al. / Journal of the American Society of Hypertension 5(1) (2011) 2130

Table 3
Logistic regression reporting the effects of changes in status on the development of hypertension among older Chinese adults (n 1738)
Variables

BMI change

Physical activity changey

Smoking change

Alcohol change

Acute condition change

Memory status change

Gender
Residence
Education

Marital status change

Income change

Staying normal weight

Becoming overweight/obese
Becoming normal weight
Staying overweight/obese
Staying not active
Becoming more active
Becoming less active
Continuing light active
Continuing  moderate active
Remaining a non-smoker
Becoming a smoker
Quitting smoking
Continuing to smoke
Remaining a non-alcohol drinker
Becoming an alcohol drinker
Quitting alcohol drinking
Continuing to drink alcohol
Staying at no acute conditions
Developing new acute conditions
Avoiding acute conditions
Continuing to have acute
conditions
Remaining same or improved
Deteriorating
Improving
Remaining deteriorated
Male
Female
Urban
Rural
No school
Primary
Intermediate
Staying married
Becoming single
Becoming married
Staying single
Staying at low income
Increasing income
Decreasing income
Staying at medium income
Staying at high income

Duration of study
participation (years)

Staying Without Hypertension vs. Developing Hypertension

Odds Ratio

Robust SE

P Trend*

95% CI

1
1.73
2.66
2.51
1
0.57
0.88
1.03
0.77
1
1.13
0.73
0.87
1
0.70
0.54
0.82
1
2.64
0.65
1.30

0.449
0.705
0.429

0.153
0.155
0.287
0.178

0.365
0.195
0.191

0.194
0.132
0.183

0.393
0.224
0.374

.036
<.001
<.001

.036
.473
.907
.249

.709
.244
.521

.202
.012
.385

<.001
.214
.367

1.036
1.583
1.799

0.336
0.625
0.599
0.485

0.598
0.437
0.564

0.410
0.336
0.534

1.974
0334
0.737

2.876
4.472
3.512

0.963
1.244
1.781
1.206

2.129
1.234
1.337

1.207
0.873
1.274

3.538
1.278
2.283

1
1.16
0.96
1.54
1
0.87
1
0.59
1
1.06
0.94
1
0.88
0.69
1.05
1
1.56
1.44
0.71
1.73
1.06

0.216
0.225
0.284

0.156

0.090

0.185
0.213

0.196
0.340
0.194

0.349
0.346
0.227
0.452
0.028

.434
.855
.018

.444

.001

.758
.777

.576
.451
.773

.047
.134
.288
.035
.036

0.803
0.605
1.077

0.615

0.438

0.749
0.601

0.572
0.263
0.736

1.007
0.894
0.381
1.040
1.004

1.668
1.517
2.214

1.238

0.797

1.488
1.463

1.364
1.810
1.512

2.419
2.303
1.331
2.888
1.114

BMI, body mass index; CI, confidence interval.

* Bold numbers are statistically significant.
y
Nonleisure physical activity.

longer (OR 1.06). Conversely, remaining with no selfreported diagnosis of hypertension during the survey period
was more common among those who lived in rural areas
(OR 0.59), became more physically active (OR 0.57),
and quit drinking alcohol (OR 0.54) in the later survey.

Discussion
Study findings provide partial evidence to support nutrition transition theory among these older Chinese adults.
Developing hypertension during the survey period was

S. Ahn et al. / Journal of the American Society of Hypertension 5(1) (2011) 2130

closely associated with changes in having excess body fat,

worsening health status (ie, deteriorated memory status,
developing acute conditions), and having a longer followup period in which to develop hypertension. Conversely,
remaining free of hypertension was related to becoming
more physically active, quitting drinking alcohol, and
residing in rural areas. These reported correlates are similar
to those reported for American adults.39,40
In recent decades, China rapidly generated and sustained
economic growth, which was followed by unprecedented
increases in income and living standards.41 Meanwhile,
healthy lifestyles have been compromised with the
increased42 use of motorized transportation43; consumption
of calorie-dense fast food,44 salt,45 and fat46; and television
viewing.47,48 These factors have been documented as
contributors to increased obesity prevalence and cardiovascular comorbidities.7,49
The significant and positive associations between changes
in body composition and hypertensive status in older Chinese
adults found in this study have also been reported in previous
studies.8,50,51 We found that developing hypertension was
more common among those who became overweight or
obese (ie, 7.4%) or stayed overweight or obese (ie, 19.4%)
during the study period. Until recently, increases in obesity
were considered problems in high-income or affluent countries; however, recent evidence reveals that the most dramatic
increases in obesity are found in developing countries,
including China.52
The current study findings indicate that developing hypertension might be associated with the mixed or independent
factors of aging and excess body weight. Participants age
60 years and older were likely to develop hypertension as
they stayed longer in the study and had excess body weight.
The findings can be explained by using molecular pathways
of vascular aging and hypertension, which are considered to
be mediated by p66shc and endothelin-1.53 Obesity can be
a contributor to hypertension through multiple mechanisms
including elevated circulating volume, vasoconstriction,
enhanced cardiac output, and activation of the reninangiotensin system.17,54
Given the increasing proportion of aging and overweight/
obese older adults in China, public health interventions to
reduce excess body weight can improve burden of cardiovascular diseases (especially hypertension) by improving
individual health outcomes and subsequently reducing
health care costs associated with chronic diseases.55 We
found that 12.5% of study participants became more physically active and another 13.7% quit drinking alcohol in the
later survey period. These participants were less likely to
develop hypertension during the study period. Previous
studies support that the risk of developing hypertension
can be attenuated by attending more physical activity39,56,57
and reducing alcohol consumption.40,58,59
To appropriately interpret these study findings, physical
activity and drinking alcohol must be contextualized in

27

terms of Chinese culture and society. Occupational physical

activity among Chinese adults, especially in the agricultural
sector, has declined,45 and modes of transportation among
the Chinese people have dramatically shifted from walking
or bicycling to motorcycles or automobiles.43 Another
factor contributing to changes in weight among the Chinese
may be alcohol consumption, which is an energy-dense
nutrient. Similar to social drinking in the United
States,60 the Chinese people often consume more food
while drinking.61 Considering the changes in these behavioral factors in China, the current study findings suggest
that lifestyle behavioral interventions for physical activity
and alcohol consumption may help to lessen hypertension
and other cardiovascular disorders, especially if they are
socially and culturally tailored.
Unlike these fairly straightforward findings, developing
hypertension was observed among those who increased
their incomes and became normal weight. First, those
who increased their income (ie, 32.5%) and stayed at
high income (ie, 18.7%) were more likely to develop
self-reported hypertension diagnoses. Although there is
a general socioeconomic-hypertension gradient in developed countries,62,63 the underlying mechanisms between
income and hypertension incidence may be different in
developing countries including China. Given Chinas rapid
economic development and individuals increasing
income, people may use their purchasing power to obtain
fattier and saltier foods. Previous research demonstrated
that energy intake from animal sources has increased,64
and the average energy intake from dietary fat among
urban Chinese has been increasing, well exceeding the
World Health Organizations recommendation.46 Moreover, Chinese dietary habits have become more Westernized.65 For example, a cross-sectional study showed that
a significant number of study participants reported having
eaten at McDonalds.66 There are well-known relationships
between fast food intake and increased obesity and cardiovascular diseases.67 Nevertheless, the association between
income and hypertension incidents should be validated in
future research studies.
Those who lost weight during the study period (ie, from
overweight or obese to normal) (ie, 5.9%) were more
likely to develop hypertension. In an attempt to find plausible explanations, we performed additional analyses by
comparing these older adults with the other participants
in terms of gender, age, and number of comorbidities;
however, no significant differences were observed. It
may be that those who once were overweight or obese,
but did not develop hypertension at baseline, were subsequently diagnosed with hypertension associated with their
BMI status. This diagnosis could trigger physician recommendations to lose weight by improving dietary and physical activity patterns. As a consequence, these older adults
may have lost weight but were still diagnosed with
hypertension.

28

S. Ahn et al. / Journal of the American Society of Hypertension 5(1) (2011) 2130

This study has limitations that must be acknowledged.

First, this study is based on only 2 of 4 study waves for
each participant (ie, the baseline and the latest survey
sequence). By including only 2 waves of the survey for
each participant, we may have lost information associated
with the middle survey waves. Nevertheless, identifying
the changing nature of the study variables was consistent
with the primary purposes of this study. For example, we
were able to see the independent contribution of the changing
BMI status to hypertensive changes among study participants. Next, the nonleisure physical activity variable available in the current study was limited and did not capture
how often the study participants engaged in physical activity
in everyday routines. As economic growth permits more
leisure activity, it will be important to also document this
type of physical activity among older Chinese adults. The
CHNS dataset did not include information about dietary
salt intake, which is known to increase the risk of both hypertension and obesity.68 Thus, our studys findings should be
cautiously interpreted given the possible misspecification
generated by this missing information.
Moreover, there might be an underreporting issue related
to the inherent limitation of self-reported diagnosis of hypertension.69 However, despite these limitations, self-reported
hypertension is often viewed as a valid measurement in the
United States.70,71 Further, the self-reported diagnosis of
hypertension using the CHNS has also been used to identify
prevalence of hypertension in China.72,73 Current studies
indicate that the validity of self-reported hypertension is
fair to high in face-to-face home interview among Chinese
individuals.73 Although there are acknowledged limitations,
one advantage is that self-reported physician-diagnosed
hypertension may partially eliminate false positives.73 As
we only recently learned that blood pressure measurements
were available in this dataset (ie, systolic and diastolic blood
pressure), the primary purpose of this study was to identify
factors related to self-reported hypertension diagnosis.
Future studies will include clinical measures of hypertension
to examine discordance between self-reported hypertension
diagnosis and clinically measured hypertension.

Conclusions
To our knowledge, this is the first study to assess the
associations of changes in body composition, healthrelated behaviors, health status, and social risk factors
with changes in hypertensive status in older Chinese adults.
This study found evidence that promoting lifestyle factors
(improved body composition, more active physical activity,
and reduced/eliminated alcohol consumption) can be
important factors in reducing the risk of developing hypertension. Vast opportunities exist for public health interventions to ameliorate these risk factors and foster a healthier
population of aging Chinese.

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