Articles 568 www.thelancet.com Vol 377 February 12, 2011 Lancet 2011; 377: 568–77 Published Online February 4, 2011 DOI:10.1016/S0140- 6736(10)62036-3 See Editorial page 527 See Comment page 529 *These authors contributed equally to the research and manuscript and are listed in alphabetical order †Members listed at end of paper Department of Epidemiology (G Danaei MD), Department of Biostatistics (M M Finucane AM, C J Paciorek PhD), Department of Global Health and Population (J K Lin AB, G M Singh PhD, F Farzadfar MD, Prof M Ezzati PhD), and Department of Environmental Health (Prof M Ezzati), Harvard School of Public Health, Boston, MA, USA; Department of Statistics, University of California, Berkeley, CA, USA (C J Paciorek); Department of Chronic Diseases and Health Promotion (M J Cowan MPH, L M Riley MSc) and Department of Health Statistics and Informatics (G A Stevens DSc), World Health Organization, Geneva, Switzerland; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA (S S Lim PhD); Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK (Prof M Ezzati); and MRC-HPA Centre for Environment and Health, Imperial College, London, UK (Prof M Ezzati) Correspondence to: Prof Majid Ezzati, MRC-HPA Centre for Environment and Health, Department of Epidemiology and Biostatistics,School of Public 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 Goodarz Danaei*, Mariel M Finucane*, John K Lin*, Gitanjali M Singh*, Christopher J Paciorek, Melanie J Cowan, Farshad Farzadfar, Gretchen A Stevens, Stephen S Lim, Leanne M Riley, Majid Ezzati, on behalf of the Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Blood Pressure)† Summary Background Data for trends in blood pressure are needed to understand the effects of its dietary, lifestyle, and pharmacological determinants; set intervention priorities; and evaluate national programmes. However, few worldwide analyses of trends in blood pressure have been done. We estimated worldwide trends in population mean systolic blood pressure (SBP). Methods We estimated trends and their uncertainties in mean SBP for adults 25 years and older in 199 countries and territories. We obtained data from published and unpublished health examination surveys and epidemiological studies (786 country-years and 5·4 million participants). For each sex, we used a Bayesian hierarchical model to estimate mean SBP by age, country, and year, accounting for whether a study was nationally representative. Findings In 2008, age-standardised mean SBP worldwide was 128·1 mm Hg (95% uncertainty interval 126·7–129·4) in men and 124·4 mm Hg (123·0–125·9) in women. Globally, between 1980 and 2008, SBP decreased by 0·8 mm Hg per decade (–0·4 to 2·2, posterior probability of being a true decline=0·90) in men and 1·0 mm Hg per decade (–0·3 to 2·3, posterior probability=0·93) in women. Female SBP decreased by 3·5 mm Hg or more per decade in western Europe and Australasia (posterior probabilities ≥0·999). Male SBP fell most in high-income North America, by 2·8 mm Hg per decade (1·3–4·5, posterior probability >0·999), followed by Australasia and western Europe where it decreased by more than 2·0 mm Hg per decade (posterior probabilities >0·98). SBP rose in Oceania, east Africa, and south and southeast Asia for both sexes, and in west Africa for women, with the increases ranging 0·8–1·6 mm Hg per decade in men (posterior probabilities 0·72–0·91) and 1·0–2·7 mm Hg per decade for women (posterior probabilities 0·75–0·98). Female SBP was highest in some east and west African countries, with means of 135 mm Hg or greater. Male SBP was highest in Baltic and east and west African countries, where mean SBP reached 138 mm Hg or more. Men and women in western Europe had the highest SBP in high-income regions. Interpretation On average, global population SBP decreased slightly since 1980, but trends varied significantly across regions and countries. SBP is currently highest in low-income and middle-income countries. Effective population- based and personal interventions should be targeted towards low-income and middle-income countries. Funding Bill & Melinda Gates Foundation and WHO. Introduction High blood pressure is the leading risk factor for cardiovascular disease mortality, causing more than 7 million deaths every year worldwide. 1–3 Multicountry studies 4–7 have shown large differences in mean population blood pressure, associated with variations in adiposity and dietary salt. Studies in a few countries and communities with repeated data show that change in population blood pressure can range from remaining almost unchanged to 10 mm Hg per decade. 4,8–15 Reliable information about trends in blood pressure is needed to understand its dietary, lifestyle, and pharma- cological determinants within populations; set inter- vention priorities; and evaluate national programmes. Despite decades of research on health consequences of high blood pressure and benefits of interventions, our knowledge of trends, with few exceptions, 10–12,16–18 is based on cohort and community studies, mainly from high- income countries. 4,8,13,19–23 Previous analyses reviewed published studies to estimate mean blood pressure or hypertension prevalence worldwide. 24,25 These studies advanced our knowledge of worldwide levels, but were based on only a few dozen studies, did not assess time trends, did not explicitly address missing data for entire countries or for older ages, combined data from nationally representative surveys with subnational and community studies without distinguishing them, and did not account for all sources of uncertainty including missing and older country data. Many health examination surveys have measured blood pressure, providing an opportunity to