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Maturitas xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Maturitas
journal homepage: www.elsevier.com/locate/maturitas

1 Prevalence and risk factors of hypertension among pre- and

2 post-menopausal women: A cross-sectional study in a rural area
3 of northeast China
4 Q1 Ying Zhou a , Xinghu Zhou a , Xiaofan Guo a , Guozhe Sun a , Zhao Li a , Liqiang Zheng b ,
5 Hongmei Yang a , Shasha Yu a , Wenna Li a , Lu Zhou a , Yingxian Sun a,∗
a
6 Department of Cardiology, The First Hospital of China Medical University, Shenyang, Liaoning, China
b
7 Department of Clinical Epidemiology, Library, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
8

9
23 a r t i c l e i n f o a b s t r a c t
10
11 Article history: Objectives: The aim of this study was to assess the prevalence and risk factors of hypertension in pre-
12 Received 8 July 2014 menopausal women (Pre-MW) and post-menopausal women (Post-MW) and determine whether years
13 Received in revised form 3 November 2014 since menopause (YSM) is associated with hypertension.
14 Accepted 5 December 2014
Methods: A cross-sectional study was conducted with 6324 women over 35 years of age (2616 Pre-MW
15 Available online xxx
and 3708 Post-MW). Questionnaires, measurements and blood biochemical indexes were collected.
16
Results: The overall prevalence of hypertension among women in rural northeast China was 48.8%, and
17 Keywords:
it increased with age. Post-MW had a higher prevalence of hypertension than Pre-MW (62.4% vs. 29.7%,
18 Hypertension
19 Risk factors
P < 0.01). After controlling for confounding variables, overweight (OR = 1.97, 95% CI: 1.72–2.25), obe-
20 Pre-menopausal women sity (OR = 2.97, 95% CI: 2.30–3.84), diabetes mellitus (OR = 2.13, 95% CI: 1.73–2.62), high triglycerides
21 Post-menopausal women (OR = 1.41, 95% CI: 1.20–1.65), and history of cardiovascular diseases in first-degree relatives (OR = 1.60,
22 Years since menopause 95% CI: 1.42–1.81) were associated with hypertension in all participants. However, abdominal obesity
(OR = 1.29, 95% CI: 1.05–1.58) was associated with higher odds among Post-MW only. Hypertension
was associated with being postmenopausal (OR = 1.22; 95% CI: 1.03–1.46), and the risk of hypertension
reached a peak level in the <5-year group (OR = 1.29; 95% CI, 1.07–1.57).
Conclusions: Postmenopausal status was an independent risk factor for hypertension. The risk of hyper-
tension was highest in Post-MW with ≤5 YSM and then decreased. Other risk factors of hypertension were
body mass index (BMI), abdominal obesity, a family history of cardiovascular disease among first-degree
relatives, a personal history of diabetes, and high TG.
© 2014 Published by Elsevier Ireland Ltd.

24 1. Introduction and 54 years of age; and after 55 years of age, the prevalence 33

Q2 is higher in women [5]. However, given the effects of aging and 34

25 Cardiovascular disease (CVD), including both heart and cere- other significant risk factors such as body weight and cholesterol 35

26 brovascular disease, is the leading cause of death in China [1] and level on the cardiovascular system, results of studies on the rela- 36

27 hypertension has been identified as the major risk factor for CVD tionship between menopausal status and hypertension are not 37

28 [2]. Post-menopausal women (Post-MW) are at increased risk of consistent. 38

29 CVD [3] and the prevalence of hypertension in women increases The observations of cross-sectional and longitudinal studies 39

30 when they reach menopause [4]. Indeed, until 45 years of age, have been variable. Some cross-sectional studies suggested Post- 40

31 the prevalence of hypertension tends to be lower in women than MW were at greater risk of being hypertensive than premenopausal 41

32 in men. The rates are similar in men and women between 45 women (Pre-MW) independent of age and body mass index (BMI) 42

[6,7], but other studies found no significant association between 43

hypertension and menopausal status after adjusting for age [8,9]. 44

However, although the prevalence of hypertension in rural Chinese 45

∗ Corresponding author at: Department of Cardiology, The First Hospital of China
women is high, awareness and control are low [10], and study of 46
Medical University, 155 Nanjing North Street, Heping District, Shenyang 110001,
China. Tel.: +86 24 83282688; fax: +86 24 83282346. the relationship between menopausal status and hypertension has 47

E-mail address: yxsun@mail.cmu.edu.cn (Y. Sun). been limited. Because hypertension is one of the most important 48

http://dx.doi.org/10.1016/j.maturitas.2014.12.001
0378-5122/© 2014 Published by Elsevier Ireland Ltd.

Please cite this article in press as: Zhou Y, et al. Prevalence and risk factors of hypertension among pre- and post-menopausal women:
A cross-sectional study in a rural area of northeast China. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.12.001
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2 Y. Zhou et al. / Maturitas xxx (2014) xxx–xxx

49 preventable contributors to disease and death [11], a better under- annual income. Smoking and alcohol status were divided into cur- 109

50 standing of its epidemiology and risk during menopause is crucial rent smokers/drinkers and nonsmokers/drinkers. Sleep duration, 110

51 for improving therapeutic strategies, survival and quality of life. including hours of both nocturnal sleep and naps, was self-reported 111

52 This multistage, stratified study used random-cluster samp- on the questionnaires. The responses were reported as ≤7, 7–8, 8–9, 112

53 ling to recruit 6324 women across rural China. The study was and >9 h/day. 113

54 designed to estimate the prevalence and characterize risk fac- Blood pressure (BP) was measured three times at 2 min inter- 114

55 tors of hypertension among Pre-MW and Post-MW in a rural area vals after a rest period of least 5 min following an American Heart 115

56 of northeast China, especially to clarify the association between Association protocol. An automatic electronic sphygmomanometer 116

57 menopausal status and hypertension independent of confounding (HEM-907; Omron), previously validated according to the British 117

58 variables. Another objective was to determine whether years since Hypertension Society protocol [12], was used. Weight and height 118

59 menopause (YSM) was associated with hypertension. were measured to the nearest 0.5 kg and 0.1 cm. Waist circumfer- 119

ence (WC) was measured to the nearest 0.1 cm at the midpoint 120

between the lower rib and upper margin of the iliac crest using a 121
60 2. Methods
nonelastic tape and with the participants standing at the end of a 122

normal expiration. 123

61 2.1. Study population
Blood samples were collected from the antecubital vein in the 124

morning after at least a 12 h fast. Vacutainer tubes containing EDTA 125

62 From January 2012 to August 2013, a representative sample of
were used. Fasting plasma glucose (FPG), total cholesterol (TC), 126
63 women ≥35 years of age was recruited in rural areas of Liaoning
low-density lipoprotein cholesterol (LDL-C), high-density lipopro- 127
64 Province in northeast China with the aim describing the prevalence,
tein cholesterol (HDL-C), triglycerides (TG) and other routine blood 128
65 incidence, and natural history of cardiovascular risk factors. This
biochemical indexes were assayed enzymatically with an autoana- 129
66 multistage study used random-cluster sampling of different pop-
lyzer. All laboratory equipment was calibrated, and tests were run 130
67 ulation strata. In the first stage, three counties (Dawa, Zhangwu,
in duplicate in a blinded fashion. 131
68 and Liaoyang) in the eastern, southern, and northern regions of
69 Liaoning province were selected. In the second stage, one town was
2.3. Definitions 132
70 randomly selected from each county (a total of three towns). In the
71 third stage, 8–10 rural villages were randomly selected from each
Following JNC-7 report guidelines [13], hypertension was 133
72 town (a total of 26 rural villages).
defined as a systolic blood pressure (SBP) ≥140 mmHg, and/or 134
73 Women who were pregnant, had malignant tumors, or mental
diastolic blood pressure (DBP) ≥90 mmHg, and/or use of antihyper- 135
74 disorders were excluded from the study. All the eligible perma-
tensive medications. Participants were divided into three groups 136
75 nent residents of each village who were ≥35 years of age were
by normal BMI (<25 kg/m2 ), overweight (25 ≤ BMI <30 kg/m2 ), 137
76 invited to participate (a total of 14,016 participants). Of those,
and obese (BMI ≥ 30 kg/m2 ), according to the World Health Orga- 138
77 11,956 (85.3%) agreed and completed the study. The Ethics Com-
nization (WHO) criteria [14]. Abdominal obesity was defined 139
78 mittee of China Medical University (Shenyang, China) approved the
as a WC ≥ 88 cm [15]. Dyslipidemia was defined according to 140
79 study, and all procedures were performed in accordance with eth-
the National Cholesterol Education Program Third Adult Treat- 141
80 ical standards. Written consent was obtained from all participants
ment Panel (ATP III) criteria [16]. High TC was defined as 142
81 after they had been informed of the objectives, benefits, medi-
≥6.21 mmol/L (240 mg/dL). High TG was defined as ≥2.26 mmol/L 143
82 cal content, and confidentiality of personal information. Informed
(200 mg/dL). Diabetes mellitus was diagnosed by the WHO cri- 144
83 consent was obtained from proxies of illiterate residents. A final
teria, i.e., FPG ≥ 7 mmol/L (126 mg/dL) and/or being on treatment 145
84 sample of 6324 women with a complete set of baseline data for the
for diabetes [17]. A woman was considered postmenopausal if 146
85 variables analyzed in the study were evaluated.
she reported menses had ceased for 1 year or more, and age at 147

menopause was self-reported. 148

86 2.2. Data collection and measurements Occupational physical activity was divided into three categories: 149

low (participants reported a low level of activity); moderate (partic- 150

87 Data were collected by cardiologists and trained nurses using ipants reported a moderate level of activity); and high (participants 151

88 a standard questionnaire in a face-to-face interview during a sin- reported a high level of activity). 152

89 gle clinic visit. Study staff attended training sessions, and only those
90 who achieved a perfect score on a subsequent evaluation were 2.4. Statistical analysis 153

91 accepted. Investigators received ongoing instruction and support

92 during the data collection period. Descriptive statistics were calculated, with continuous variables 154

93 Data collected by the questionnaire included demographic char- reported as mean ± standard deviation (SD) and categorical vari- 155

94 acteristics and lifestyle habits. The former consisted of age, gender, ables as numbers and percentages. Differences between Pre-MW 156

95 race, family history of disease, financial status, educational level, and Post-MW were evaluated using Student’s t-test or the 2 test 157

96 and marital status. Participants were asked whether they had expe- as appropriate. Multivariate logistic regression was used to iden- 158

97 rienced menopause and those who answered “yes” were asked to tify the association between hypertension and related risk factors 159

98 give the age at which it began. None of the participants received using odds ratios (ORs) and 95% confidence intervals (CIs). All sta- 160

99 hormone replacement therapy within 2 weeks of, or during the tistical analyses were performed using SPSS version 19.0 software 161

100 survey. Lifestyle questions collected data on smoking status, alco- (IBM Corp., Armonk, NY, USA), and P values less than 0.05 were 162

101 hol consumption, intensity of occupational activity, and sleep-time considered to be statistically significant. 163

102 per night. Questionnaires were monitored by a central steering

103 committee with a subcommittee for quality control. 3. Results 164

104 Family history included diseases in first-degree relatives includ-

105 ing parents, offspring and siblings. Educational level was recorded The total study population comprised 6324 female participants 165

106 as primary school or below, middle school, and high school or with a mean age of 53.4 ± 10.3 years. A total of 3708 women (58.6%) 166

107 above. Financial status was divided into three levels, less than 5000, had experienced menopause at a median age of 48.9 ± 4.1 years. 167

108 5000 to 20,000, and more than 20,000 Chinese yuan (CNY) local Age-specific prevalence rates for hypertension are shown in Fig. 1. 168

Please cite this article in press as: Zhou Y, et al. Prevalence and risk factors of hypertension among pre- and post-menopausal women:
A cross-sectional study in a rural area of northeast China. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.12.001
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Fig. 2. ORs of hypertension by years since menopause adjusted for all variables.
Error bars represent the 95% CI. *P < 0.05. The reference group was pre-menopausal
Fig. 1. The prevalence of hypertension by age for pre- and post-menopausal women. women.

169 The prevalence of hypertension increased with age, and was sig-
170 nificantly higher in Post-MW than in Pre-MW (62.4% vs. 29.7%, relatives were significantly associated with an increased risk for 185

171 P < 0.01). hypertension. Current smoking was associated with a lower risk of 186

172 The baseline data in Table 1 indicate that Post-MW were older hypertension. No significant relationships emerged between edu- 187

173 and were more likely to be shorter, heavier, and have a larger WC cational or marital status, alcohol drinking, annual income, activity 188

174 than Pre-MW. However, BMI (P = 0.245) and the prevalence of obe- intensity and risk of hypertension. The age-adjusted OR (1.30, 95% 189

175 sity (P = 0.357) of the two groups were not significantly different. CI: 1.11–1.53) and multiple-adjusted OR (1.22, 95% CI: 1.03–1.46) 190

176 Post-MW had higher SBP, DBP, LDL-C, TG, TC and FPG than Pre-MW. for hypertension were significantly higher in Post-MW than in Pre- 191

177 Smoking prevalence was significantly higher in Post-MW than in MW. 192

178 Pre-MW, but there was no significant difference in the prevalence Post-MW were stratified by YSM (<5, 5–9, 10–14, and ≥15 years) 193

179 of alcohol drinking in the two groups. Awareness, treatment, and to investigate the risk of hypertension associated with YSM. When 194

180 control rates of hypertension were very low in both groups, but the multivariate analysis was adjusted for confounding variables, 195

181 were higher in Post-MW. the risk for hypertension in Post-MW decreased with YSM, with a 196

182 Regression analysis (Table 2) found that the ORs for hyperten- peak occurring in the <5-year group (OR = 1.29, 95% CI: 1.07–1.57), 197

183 sion increased with age and BMI. A personal history of diabetes, no statistical significance was found for women who were >5 YSM 198

184 high TG, and a history of cardiovascular diseases in first-degree (Fig. 2). 199

Table 1
Characteristics of female participants according to menopausal status (n = 6324).

Characteristics Total Pre-menopausal Post-menopausal P valuea

N 6324 2616 3708

Mean ± SD
Age (years) 53.4 ± 10.3 44.1 ± 4.8 60.0 ± 7.8 <0.001
Height (cm) 155.6 ± 6.1 157.2 ± 5.8 154.4 ± 6.0 <0.001
Weight (cm) 60.3 ± 10.1 61.7 ± 9.8 59.3 ± 10.3 <0.001
Body mass index (kg/m2 ) 24.9 ± 3.8 24.9 ± 3.8 24.8 ± 3.9 0.245
Waist circumference (cm) 81.3 ± 9.8 80.0 ± 9.1 82.3 ± 10.1 <0.001
Waist-to-hip ratio 0.9 ± 0.1 0.8 ± 0.1 0.9 ± 0.1 <0.001
Systolic blood pressure (mmHg) 140.2 ± 24.1 130.9 ± 19.1 146.9 ± 25.0 <0.001
Diastolic blood pressure (mmHg) 80.6 ± 11.5 78.9 ± 10.9 81.8 ± 11.9 <0.001
Low-density lipoprotein cholesterol (mmol/L) 3.0 ± 0.8 2.7 ± 0.7 3.2 ± 0.9 <0.001
High-density lipoprotein cholesterol (mmol/L) 1.4 ± 0.3 1.4 ± 0.3 1.4 ± 0.4 0.007
Triglyceride (mmol/L) 1.6 ± 1.3 1.3 ± 1.1 1.8 ± 1.5 <0.001
Total cholesterol (mmol/L) 5.3 ± 1.1 4.8 ± 1.0 5.6 ± 1.1 <0.001
Fasting plasma glucose (mmol/L) 5.9 ± 1.6 5.5 ± 1.2 6.1 ± 1.8 <0.001
(%)
Race (Han) (%) 94.8 93.8 95.4 0.005
Current smoking (%) 16.3 10.8 20.1 <0.001
Alcohol consumption (%) 2.9 2.7 3.0 0.513
Educational status (%) <0.001
Primary school or below 57.0 34.5 72.8
Middle school 35.2 55.0 21.3
High school or above 7.8 10.4 5.9
Obesity (%) 8.9 8.5 9.2 0.357
Abdominal obesity (%) 25.0 19.6 28.8 <0.001
Hypertension (%)
Prevalence rate 48.8 29.7 62.4 <0.001
Awareness rate 24.4 12.0 33.1 <0.001
Treatment rate 18.3 8.2 25.4 <0.001
Control rate 3.6 2.3 4.5 <0.001
a
Compared between pre-menopausal and post-menopausal women.

Please cite this article in press as: Zhou Y, et al. Prevalence and risk factors of hypertension among pre- and post-menopausal women:
A cross-sectional study in a rural area of northeast China. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.12.001
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Table 2
Age-adjusted and multiple-adjusted ORs of hypertension.

Pa OR (95% CI)a Pb OR (95% CI)b

Age (years)
35–44 (Ref) 1.00 1.00
45–54 <0.001 2.70 (2.32–3.13) <0.001 2.09 (1.75–2.50)
55–64 <0.001 5.81 (4.99–6.76) <0.001 3.61 (2.83–4.59)
≥65 <0.001 10.86 (8.91–13.22) <0.001 6.43 (4.80–8.63)
Race
Han (Ref) 1.00 1.00
Non-Han 0.016 0.74 (0.59–0.95) 0.030 0.75 (0.58–0.97)
Educational status, %
Primary school or below 1.00 1.00
Middle school 0.654 0.97 (0.86–1.10) 0.783 0.98 (0.86–1.12)
High school or above 0.189 0.87 (0.70–1.07) 0.473 0.92 (0.73–1.16)
Family income
≤5000 yuan (Ref) 1.00 1.00
5000–20,000 yuan 0.745 0.97 (0.81–1.17) 0.794 0.97 (0.80–1.18)
>20,000 yuan 0.013 0.78 (0.64–0.95) 0.063 0.82 (0.66–1.00)
Marital status
Single (Ref) 1.00 1.00
Married 0.424 0.64 (0.21–1.93) 0.337 0.56 (0.17–1.83)
Re-married 0.425 0.60 (0.17–2.12) 0.182 0.40 (0.11–1.54)
Divorced 0.172 0.38 (0.09–1.53) 0.274 0.44 (0.10–1.91)
Widowed 0.461 0.65 (0.21–2.03) 0.409 0.60 (0.18–2.00)
2
BMI (kg/m )
<25 (Ref) 1.00 1.00
25–30 <0.001 2.33 (2.07–2.63) <0.001 1.97 (1.72–2.25)
≥30 <0.001 4.20 (3.42–5.17) <0.001 2.97 (2.30–3.84)
Abdominal obesity
No (Ref) 1.00 1.00
Yes <0.001 2.37 (2.09–2.70) 0.024 1.21 (1.03–1.42)
Current smoking
No (Ref) 1.00 1.00
Yes <0.001 0.75 (0.65–0.87) 0.009 0.81 (0.70–0.95)
Current alcohol drinking
No (Ref) 1.00 1.00
Yes 0.422 1.14 (0.83–1.58) 0.132 1.30 (0.92–1.82)
Intensity of activity
1 (light) (Ref) 1.00 1.00
2 (middle) 0.700 1.03 (0.89–1.20) 0.668 1.04 (0.88–1.22)
3 (heavy) 0.539 0.96 (0.85–1.09) 0.524 0.96 (0.84–1.10)
Sleep time per night
7–8 h (Ref) 1.00 1.00
≤7 h 0.669 0.97 (0.86–1.11) 0.838 0.99 (0.86–1.13)
8–9 h 0.253 1.11 (0.93–1.34) 0.542 1.06 (0.87–1.29)
>9 h 0.111 1.20 (0.96–1.51) 0.315 1.13 (0.89–1.44)
Diabetes
No (Ref) 1.00 1.00
Yes <0.001 2.89 (2.38–3.51) <0.001 2.13 (1.73–2.62)
Hypercholesterolemia
No (Ref) 1.00 1.00
Yes <0.001 1.33 (1.15–1.53) 0.119 1.13 (0.97–1.32)
High triglycerides
No (Ref) 1.00 1.00
Yes <0.001 2.04 (1.76–2.36) <0.001 1.41 (1.20–1.65)
A history of cardiovascular diseases in first-degree relatives
No (Ref) 1.00 1.00
Yes <0.001 1.75 (1.56–1.96) <0.001 1.60 (1.42–1.81)
Menopausal status
Pre-menopause (Ref) 1.00 1.00
Post-menopause 0.002 1.30 (1.11–1.53) 0.024 1.22 (1.03–1.46)
Years since menopausec
Pre-menopause (Ref) 1.00 1.00
YSM < 5 years 0.001 1.37 (1.14–1.64) 0.009 1.29 (1.07–1.57)
5 years ≤ YSM ≤ 9 years 0.127 1.18 (0.95–1.45) 0.436 1.09 (0.87–1.37)
10 years ≤ YSM ≤ 14 years 0.764 1.04 (0.81–1.32) 0.884 0.98 (0.76–1.27)
YSM ≥ 15 year 0.926 1.01 (0.76–1.36) 0.614 0.92 (0.68–1.26)
a
Adjusted for age.
b
Adjusted for age, BMI, race, educational status, family income, marital status, abdominal obesity, current smoking, current alcohol drinking, intensity of activity, sleep
time per night, diabetes, hypercholesterolemia, high triglycerides, family history of cardiovascular diseases in the first degree relatives, menopausal status.
c
Menopausal status was not adjusted in corresponding models.

200 Association between hypertension and related risk factors relatives were all associated with increased risk of hyperten- 204

201 for Pre-MW and Post-MW. evaluated in the study population sion. However, the detrimental effect of abdominal obesity and 205

202 are shown in Table 3. Age, BMI, personal history of diabetes, protective effect of current smoking were significant only in 206

203 high TG, and a history of cardiovascular diseases in first-degree Post-MW. 207

Please cite this article in press as: Zhou Y, et al. Prevalence and risk factors of hypertension among pre- and post-menopausal women:
A cross-sectional study in a rural area of northeast China. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.12.001
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Table 3
Association between hypertension and related risk factors for Pre-MW and Post-MW.

Pre-menopause Post-menopause

Risk factors Pa OR (95% CI)a Pa OR (95% CI)a

Age (years) <0.001 1.10 (1.08–1.12) <0.001 1.07 (1.06–1.09)

BMI (kg/m2 )
<25 (Ref) 1.00 1.00
25–30 <0.001 2.41 (1.96–2.96) <0.001 1.67 (1.41–1.98)
≥30 <0.001 3.62 (2.48–5.28) <0.001 2.50 (1.77–3.53)
Smoking status
Never (Ref) 1.00 1.00
Current 0.141 1.23 (0.93–1.63) <0.001 0.70 (0.58–0.83)
Abdominal obesity
No (Ref) 1.00 1.00
Yes 0.289 1.15 (0.89–1.50) 0.016 1.29 (1.05–1.58)
Diabetes
No (Ref) 1.00 1.00
Yes <0.001 2.32 (1.57–3.44) <0.001 2.07 (1.63–2.62)
High triglycerides
No (Ref) 1.00 1.00
Yes 0.045 1.35 (1.01–1.80) <0.001 1.48 (1.22–1.79)
A history of cardiovascular diseases in first-degree relatives
No (Ref) 1.00 1.00
Yes <0.001 1.67 (1.39–2.01) <0.001 1.56 (1.33–1.82)
Race
Han (Ref) 1.00 1.00
Non-Han 0.161 0.77 (0.54–1.11) 0.135 0.76 (0.53–1.09)
a
Adjusted for age, BMI, race, family income, abdominal obesity, current smoking, diabetes, high triglycerides, family history of cardiovascular diseases in the first degree
relatives.

208 4. Discussion for changes in the risk of hypertension with YSM warrant further 245

study. 246

209 The prevalence of hypertension in women 35 years of age or It is widely recognized that as body weight increases, BP can rise 247

210 older was higher in this rural region of northwest China than that [24]. However, some studies have suggested that this relationship 248

211 reported for women in other regions of China [18,19]. One reason differs in Pre- and Post-MW [25,26]. In this study, we found that 249

212 may be that the participants in this study were older than those in overweight and obesity were associated with a 1.97-fold and 2.97- 250

213 other studies. Differences in lifestyle and diet might also account for fold increased risk for hypertension, but that the ORs in Pre- and 251

214 the increased prevalence of hypertension observed in these rural Post-MW were not significantly different. In contrast with a pre- 252

215 Chinese women. vious study, we found a relationship between abdominal obesity 253

216 Postmenopausal status may remain a significant cardiovascular and hypertension [27], however, the OR for abdominal obesity was 254

217 risk factor after controlling for age and BMI [9,20]. However, the observed to be lower than that for a BMI ≥ 30 (1.21 vs. 2.97). 255

218 results of studies on changes in BP with menopause are conflicting. Smoking and drinking alcohol have been found to be risk fac- 256

219 This study found that postmenopausal status was associated with tors of hypertension [18], but a relatively small number of studies 257

220 a 1.22-fold increased risk for hypertension even after adjusting for [7,22], including this one, did not reach a similar conclusion. The 258

221 confounding variables such as age and BMI. That result is con- effect of smoking on BP can be transient, thus during periods of 259

222 sistent with other studies [7,21,22]. It is somewhat lower than abstention, smokers may have BP similar to or lower than non- 260

223 an estimate reported for women in Korea (3.19-fold) [6], simi- smokers. Under-reporting of alcohol consumption and smoking 261

224 lar to the risk reported for women in Italy (1.22 vs. 1.14–1.60) status, especially among those who recently stopped smoking or 262

225 [7,22] and Taiwan [21]. In the study conducted in Taiwan [21], drinking, may partially account for a lack of association with high 263

226 the crude OR for hypertension was 2.4. Discrepancies might result BP in epidemiological studies. 264

227 from differences in the definition of hypertension and differ- This study has some limitations. First, because it was a cross- 265

228 ences in the distribution of YSM within the study populations, sectional study, the findings cannot provide sufficient evidence 266

229 which might increase the risk of hypertension. It is interesting of causality. Second, prevalence of hypertension may have been 267

Q3 that Geum et al. [6] reported the highest risk of hypertension

230 under- or overestimated because it was assessed by measurements 268

231 in women who were 5–9 YSM, and that the risk of hyperten- made on a single day. Third, age at menopause was self-reported 269

232 sion was not significantly increased in women with 15 YSM. As and may be subject to recall bias. The reliability of self-reported 270

233 in this study, Hidalgo et al. [23] reported an increased risk of age at menopause has been reported to range from 71% to 82% 271

234 hypertension at 5 years post-menopause. As shown in Fig. 1, the [28,29]. Therefore, in order to reduce such bias, only women who 272

235 prevalence of hypertension significantly increased with age. How- were able to provide consistent reports without hesitancy were 273

236 ever, given that the number of years of menopause should have included. Fourth, women with a history of hysterectomy were not 274

237 a somewhat linear correlation with age, it is odd that the OR for excluded, but in China the surgical menopause rate is only 3.6–4.0% 275

238 hypertension decreased with YSM as shown in Fig. 2. However, [30,31]. We thus believe that surgical menopause affected a small 276

239 this may have been caused by other risk factors of hyperten- percentage of the study population and had little effect on the 277

240 sion. The effects of menopause are mitigated as YSM increases, results. Finally, some study participants received annual health 278

241 while obesity, abdominal obesity, diabetes, and triglyceride lev- examinations, which may have led to differences in some base- 279

242 els continue to add to the risk of hypertension. The relationship line characteristics compared with those who do not have access 280

243 between YSM and hypertension might depend on the duration of to medical services. Few participants were older than 70 years of 281

244 the hormonal changes related to the menopause, the mechanism age, which may have contributed to a healthy survivorship bias. 282

Please cite this article in press as: Zhou Y, et al. Prevalence and risk factors of hypertension among pre- and post-menopausal women:
A cross-sectional study in a rural area of northeast China. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.12.001
 G Model
MAT 6296 1–6 ARTICLE IN PRESS
6 Y. Zhou et al. / Maturitas xxx (2014) xxx–xxx

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Please cite this article in press as: Zhou Y, et al. Prevalence and risk factors of hypertension among pre- and post-menopausal women:
A cross-sectional study in a rural area of northeast China. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.12.001