Skip to main content

The prevalence of hypertension among Malaysian adults and its associated risk factors: data from Malaysian Community Salt Study (MyCoSS)

Abstract

Background

Hypertension is one of the most common risk factors for cardiovascular disease and leading cause of mortality globally. The aims of this study were to assess the prevalence of hypertension and its associated risk factors among Malaysian population using data from the Malaysian Community Salt Study (MyCoSS).

Methods

This study was a cross-sectional study using multi-stage stratified sampling method. Data collection was carried out via face-to-face interview at the respondent’s home from October 2017 until March 2018. A total of 1047 respondents aged 18 years and above completed the questionnaires and blood pressure measurement. A person who reported diagnosis of hypertension by a physician and had systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg on three readings was categorised as hypertensive. Risk factors of hypertension were analysed using multiple logistic regression.

Results

The prevalence of hypertension in the present study was 49.39% (95% CI 44.27–54.51). There was no statistically significant difference in gender. Age, household income, BMI, and diabetes were significantly associated with hypertension. Hypertension found had inverse association with the level of education. Age was the strongest predictor of hypertension (35–44 years old; OR=2.39, 95% CI=1.39–4.09, 45–54 years old; OR=5.50, 95% CI=3.23–9.38, 55–64 years old OR=13.56, 95% CI=7.77–23.64 and 65 years old and above; OR=25.28, 95% CI=13.33–48.66). Those who had higher BMI more likely to be hypertensive as compared to respondents with normal weight (overweight, OR=1.84; 95% CI=1.18–2.86; obese, OR=4.29% CI=2.56–7.29).

Conclusion

The findings showed that hypertension is prevalent among adults in Malaysia. Those with older age, higher BMI, and diabetes are more likely to have hypertension. Efforts regarding lifestyle modification and education could be important in hypertension management and prevention.

Background

Cardiovascular disease (CVD) is the largest cause of non-communicable disease (NCD) deaths with an estimated 17.6 million people died worldwide in 2012 [1]. Hypertension is well established as an important risk factor for CVD and was diagnosed as systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥90 mmHg [2, 3]. Besides hypertension, CVD risk factors also include abdominal obesity, dyslipidemia, and insulin resistance also known as “metabolic syndrome” [3].

Hypertension has become more prevalent over the past decades worldwide including in developing countries due to various factors, including economic development and population ageing [4]. Data from the National Health and Nutrition Examination Survey (NHANES) found that rates of hypertension among US adults increased from 23.9% in 1988–1994 to 29.0% in 2007–2008 [5]. Prevalence of hypertension was about 27% in Southeast Asian region [6]. In 2010, it is estimated that 325 million Chinese adult aged 18 years or older were diagnosed with hypertension [7]. In Thailand, one out of four Thais had hypertension and almost half of them were not aware that they had high blood pressure [8]. The national prevalence of hypertension among Malaysian adults was 30.3% with rates increasing with age as reported by National Health and Morbidity Survey (NHMS) in 2015 [9].

Many epidemiological studies have established the risk factors for hypertension. These included age, gender, weight, body mass index (BMI), waist circumference (WC), sedentary lifestyle, smoking and alcohol intake [10,11,12]. Others have implicated lipid disorders, diabetes, salt intake and family history of high blood pressure [13]. More recently, attention has been drawn to excess intake of salt and its major role in the pathogenesis of higher blood pressure [14]. Although local studies on lifestyle risk factors and hypertension were available, the relationship between hypertension and dietary sodium intake are limited. Therefore, this study aims to determine the prevalence and associated risk factors of hypertension including dietary sodium intake among Malaysian adult population using data from the Malaysian Community Salt Study (MyCoSS).

Methodology

Study design

MyCoSS is a cross-sectional study which used a multi-stage stratified sample design to obtain a nationally representative sample. One eligible adult aged 18 to 59 years old was selected from each household using Kish table to participate in the survey. A total of 1047 respondents were giving consents to take part in this study. Face-to-face interviewed at respondents’ homes were done using mobile devices during the data collection period between October 2017 and March 2018.

Information on sociodemographic characteristics including gender, age, education level, marital status and household income were collected. Lifestyle behaviours, such as current smoking status and physical activity status, were also assessed. To assess physical activity, a validated Short-International Physical Activity Questionnaire (Short-IPAQ) in Malay version was used [15]. Respondents were asked whether they currently smoked cigarettes to assess current smoking status. Diabetes was diagnosed as random blood sugar ≥11.1 mmol/l or self-report of previous diagnosis of diabetes by doctors [16]. Assessment of dietary sodium intake using food frequency questionnaire (FFQ) from a previous study comprises 104 food items [17].

Blood pressure measurements

Blood pressure measurements were measured with a digital blood pressure monitor (Omron HBP-1300). Measurement of blood pressure was taken three times in a stable condition with 1- to 2-min interval between each measurement. The average of last two measurement of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were used to determine high blood pressure. The Malaysia Guideline on the Management of Hypertension, 4th Edition, 2013, was used to defined hypertension [18]. A person who reported diagnosis of hypertension previously by a physician and had SBP ≥140 mmHg and/or DBP ≥90 mmHg was diagnosed as hypertensive. Respondents within normal or pre-hypertensive range were categorised into the normal group (normotensive).

Anthropometry variables

Body weight and height was measured using digital weighing scale (TANITA HD-319) and SECA 213 portable stadiometer with an accuracy of 0.1 kg/0.1 cm, respectively. SECA measuring tape (SECA, Germany) used to measured waist circumference. All measurements were done using validated and calibrated instruments and following standardised protocols. Body mass index (BMI) was computed as weight to the square of height (kg/m2) and categorised according to WHO 1998 guidelines [19].

Statistical analysis

All categorical variables were presented as frequency and percentages while continuous variable was presented as mean with 95% confidence interval (CI). Differences in proportions between categorical variables were analysed using chi-square. Univariate and multiple logistic regression was performed to explore the effects of age, gender, marital status, education level, household income, smoking, physical activity status, diabetes, BMI, and waist circumference as the risk factors for hypertension. The adjusted odds ratios were presented with 95% confidence interval (CI) with p value <0.05 was accepted as statistically significant. Data analyses were done using SPSS version 21.0.

Results

A total of 1047 respondents with mean age of 48.80 years (95% CI 47.03–50.61). The characteristics related with normotensive and hypertensive state among respondents are shown in Table 1. The prevalence of hypertension in present study was 49.39% (95% CI 44.27–54.51) with no significant difference in gender. Prevalence of hypertension was higher among married group (79.96%; 95% CI 74.70–84.36) and those in low household income group (50.83%; 95% CI 43.92–57.70). Higher prevalence of hypertension was shown among those with primary education level (33.77%; 95% CI 27.40–40.78) and secondary education level (48.02%; 95% CI 43.16–52.92) as compared to those with tertiary education (18.20%; 95% CI 12.37–25.96). Individuals with hypertension had significantly greater mean BMI (27.65 kg/m2, 95% CI 26.99–28.30, vs 25.68 kg/m2, 95% CI 25.08–26.28) and waist circumference index (93.88 cm, 95% CI 92.43–95.32, vs 86.63 cm, 95% CI 85.20–88.06) than those with normal blood pressure.

Table 1 Baseline characteristic of respondents with normotensive and hypertension

Table 2 shows various risk factors associated with hypertension. Univariate analysis showed that age, academic level, household income, marital status, BMI, waist circumference, current smoking, diabetes and total sodium intake were independently associated with increased odds for hypertension. Hypertension shown had negatively associated with the level of education. After controlling for other covariates, age was the strongest predictor of hypertension (35–44 years old; OR=2.39, 95% CI=1.39–4.09, 45–54 years old; OR=5.50, 95% CI=3.23–9.38, 55–64 years old OR=13.56, 95% CI=7.77–23.64 and 65 years old and above; OR=25.28, 95% CI=13.33–48.66). Overweight or obese respondents were more likely to be hypertensive compared to normal weight (overweight, OR=1.84; 95% CI=1.18–2.86; obese, OR=4.29; 95% CI=2.56–7.29).

Table 2 Factors associated with hypertension from univariate and multivariate logistic regression model

Discussion

The prevalence of hypertension in our study was 49.4%, which is higher than the nationally representative data set of 19,936 Malaysian adults in 2015 (35.3%) [20]. However, the result was comparable with Abdul-Razak et al. who found 47.9% of Malaysian adults aged more than 30 years were diagnosed with hypertension [21]. The rising of hypertension and other non-communicable disease (NCD) was correlated with modernisation and an increasing economy status with most Malaysians adopted sedentary lifestyles and high consumption of high calorie, salty and fatty food [22].

This study found no significant difference in prevalence of hypertension by gender. This finding was in contrast with findings from other studies that showed a higher prevalence of hypertension was detected in men than in women [21]. Limited sample size may have influenced to the differing results in rate of hypertension among men and women. Consistent with other studies, hypertension prevalence was lowest among those with higher income status and higher academic level among the Malaysian population, similar to other countries in the region [23, 24].

Multivariate analysis showed that age, higher academic level, moderate household income, BMI and diabetes were significantly associated with hypertension. This study found that the prevalence of hypertension increased with age in both men and women. Similar results were seen among adults in India and Taiwan [11, 25]. Academic level was shown as a protective factor and the result was similar with a study in China [13]. Better knowledge on healthy lifestyle and being well informed about blood pressure management may contribute to lower risk of hypertension among those with higher education level [26].

Our findings confirmed the finding from previous studies that BMI and diabetes were associated with high risk of hypertension [7, 27]. A study conducted by Papathanasiou et al. suggest greater BMI was significantly and directly related with increased resting blood pressure in both gender [28]. However, waist circumference did not show an association with hypertension in this study. Feng et al. suggested that waist circumference is strongly independently associated with diabetes because the measurement reflects an accumulation of intra-abdominal fat that could lead to insulin resistance. Meanwhile, BMI is associated with hypertension due to increase in body weight (BMI) which may increase body fluid volume, peripheral resistance and cardiac output [25].

Excess consumption of dietary sodium has a main role in the pathogenesis of elevated blood pressure. A study by Zhang et al. showed that high sodium intake was positively related with systolic blood pressure [26]. Our result indicated that in multivariable analysis, no significantly different between sodium intake and hypertension. The results may be due to limitations of cross-sectional study design and the dietary data that was collected using food frequency questionnaire. Compared with 24-h sodium excretion, estimation participants’ usual sodium intake from food frequency questionnaire in this study may under or overestimate actual intake. Other possible reason was that respondents may already be aware about risk of high salt diet with hypertension. Study by Abdul-Razak et al. found that awareness of hypertension among Malaysian adult more than 30 years of age was 53.2 % [21].

There are several strengths in our study: first, the random selection of the respondents, sample size, and high participation rate, and second, examination of the relationship between BP and anthropometry, lifestyle risk factors, and dietary sodium intake added the strength of this study. The main limitation in this study was that the sampling framework is not the total population representative, and therefore, caution is needed in extrapolating the information. The limitation of sampling size may have overestimated the prevalence of hypertension as compared with national prevalence. Nevertheless, associated risk factors of hypertension indicated in this study were in line with other studies except for gender.

Conclusion

Current finding revealed that hypertension is prevalent among adult in Malaysia and it found that age, BMI, those with middle household income and diabetes were predictors of hypertension. These results further underline the need for routine blood pressure check-up to identify subjects with high-risk of hypertension. Strategies to strengthen the monitoring of modifiable risk factors including optimal weight control should be advocate for better hypertension control in Malaysia.

Availability of data and materials

The dataset of this article belongs to the MyCoSS project. At present, the data are not publicly available but can be obtained from the authors upon reasonable request and with the permission from the Director General of Health, Malaysia.

Abbreviations

MyCoSS:

Malaysian Community Salt Study

NHMS:

National Health and Morbidity Survey

CVD:

Cardiovascular disease

NCD:

Non-communicable disease

BMI:

Body mass index

SBP:

Systolic blood pressure

DBP:

Diastolic blood pressure

SD:

Standard deviation

CI:

Confidence interval

References

  1. 1.

    McAloon CJ, Boylan LM, Hamborg T, Stallard N, Osman F, Lim PB, et al. The changing face of cardiovascular disease 2000-2012: an analysis of the world health organisation global health estimates data. Int J Cardiol. 2016;224:256–64.

    Article  Google Scholar 

  2. 2.

    World Health Organisation. A global brief on hypertension: silent killer, global public health crisis. Geneva: WHO Press WHO; 2013.

    Google Scholar 

  3. 3.

    National Institute for Health (NIH). The seventh report of the joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure (JNC7): National Institute for Health (NIH); 2004.

  4. 4.

    Bromfield S, Muntner P. High blood pressure: the leading global burden of disease risk factor and the need for worldwide prevention programs. Curr Hypertens Rep. 2013;15(3):134–6.

    Article  Google Scholar 

  5. 5.

    Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA. 2010;303(20):2043–50.

  6. 6.

    Neupane D, McLachlan CS, Sharma R, Gyawali B, Khanal V, Mishra SR, et al. Prevalence of hypertension in member countries of south Asian Association for Regional Cooperation (SAARC): systematic review and meta-analysis. Med. 2014;93(13):1–10.

  7. 7.

    Wang J, Zhang L, Wang F, Liu L, Wang H. Prevalence, awareness, treatment, and control of hypertension in China: results from a national survey. Am J Hypertens. 2014;27(11):1355–61.

    CAS  Article  Google Scholar 

  8. 8.

    Sakboonyarat B, Mungthin M. Prevalence and associated factors of uncontrolled hypertension among Thai patients with hypertension: a nationwide cross-sectional survey. Rev Épidémiol Santé Publique. 2018;66:S310–1.

    Google Scholar 

  9. 9.

    Institute For Public Health. National Health and Morbidity Survey. Vol II: Non communicable disease, risk factors and other health. In: Problem; 2015.

    Google Scholar 

  10. 10.

    Park J, Lee J-S, Kim J. Relationship between dietary sodium, potassium, and calcium, anthropometric indexes, and blood pressure in young and middle aged Korean adults. Nutr Res Pract. 2010;4(2):155–62.

    CAS  Article  Google Scholar 

  11. 11.

    SIngh RB, Fedacko J, Pella D, Macejova Z, Ghosh S, De AK, et al. Prevalence and risk factors for prehypertension and hypertension in five Indian cities. Acta Cardiol. 2011;66(1):29–37.

    Article  Google Scholar 

  12. 12.

    Li G, Wang H, Wang K, Wang W, Dong F, Qian Y, et al. Prevalence, awareness, treatment, control and risk factors related to hypertension among urban adults in Inner Mongolia 2014: differences between Mongolian and Han populations. BMC Public Health. 2016;16(1):294.

    Article  Google Scholar 

  13. 13.

    Sun Z, Zheng L, Wei Y, Li J, Zhang X, Zhang X, et al. Prevalence and risk factors of the rural adult people prehypertension status in Liaoning Province of China. Circ J. 2007;71(4):550–3.

    Article  Google Scholar 

  14. 14.

    Appel LJ, Frohlich ED, Hall JE, Pearson TA, Sacco RL, Seals DR, et al. The importance of population-wide sodium reduction as a means to prevent cardiovascular disease and stroke: a call to action from the American Heart Association. Circulation. 2011;123(10):1138–43.

    Article  Google Scholar 

  15. 15.

    Teh C, Lim K, Chan Y, Lim K, Azahadi O, Akmar AH, et al. The prevalence of physical activity and its associated factors among Malaysian adults: findings from the National Health and morbidity survey 2011. Public Health. 2014;128(5):416–23.

    CAS  Article  Google Scholar 

  16. 16.

    Ministry of Health. Clinical practice guidelines: Management of Tye 2 diabetes mellitus. 5th edition. Putrajaya: Ministry of Health Malaysia; 2015.

  17. 17.

    Institute for Public Health. Determination of dietary sodium intake among the Ministry of Health staff (MySalt 2015): National Institutes of Health, Ministry of Health Malaysia; 2015.

  18. 18.

    Ministry of Health. Clinical practice guidelines: Management of Hypertension 5th edition. Putrajaya: Ministry of Health Malaysia; 2018.

  19. 19.

    World Health Organization. Obesity: Preve nting and managing the global epidemic. Report of a WHO consultation on obesity. Geneva: World Health Organization; 1998.

  20. 20.

    Ab Majid NL, Omar MA, Khoo YY, Mahadir Naidu B, Ling Miaw Yn J, Rodzlan Hasani WS, et al. Prevalence, awareness, treatment and control of hypertension in the Malaysian population: findings from the National Health and morbidity survey 2006-2015. J H Hypertens. 2018;32(8-9):617–24.

    Article  Google Scholar 

  21. 21.

    Abdul-Razak S, Daher AM, Ramli AS, Ariffin F, Mazapuspavina MY, Ambigga KS, et al. Prevalence, awareness, treatment, control and socio demographic determinants of hypertension in Malaysian adults. BMC Public Health. 2016;16:351.

    Article  Google Scholar 

  22. 22.

    Khor G-L. Food availability and the rising obesity prevalence in Malaysia. IeJSM. 2012;6(suppl 1):S61–8.

    Google Scholar 

  23. 23.

    Naing C, Yeoh PN, Wai VN, Win NN, Kuan LP, Aung K. Hypertension in Malaysia: an analysis of trends from the national surveys 1996 to 2011. Med. 2016;95(2):e2417.

    Article  Google Scholar 

  24. 24.

    Do HT, Geleijnse JM, Le MB, Kok FJ, Feskens EJ. National prevalence and associated risk factors of hypertension and prehypertension among Vietnamese adults. Am J Hypertens. 2015;28(1):89–97.

    Article  Google Scholar 

  25. 25.

    Lin SJ, Lee KT, Lin KC, Cheng KH, Tsai WC, Sheu SH, et al. Prevalence of prehypertension and associated risk factors in a rural Taiwanese adult population. Int J Cardiol. 2010;144(2):269–73.

    Article  Google Scholar 

  26. 26.

    Li X, Ning N, Hao Y, Sun H, Gao L, Jiao M, et al. Health literacy in rural areas of China: hypertension knowledge survey. Int J Environ Res Public Health. 2013;10(3):1125.

    Article  Google Scholar 

  27. 27.

    Meng XJ, Dong GH, Wang D, Liu MM, Liu YQ, Zhao Y, et al. Epidemiology of prehypertension and associated risk factors in urban adults from 33 communities in China--the CHPSNE study. Circ J. 2012;76(4):900–6.

    Article  Google Scholar 

  28. 28.

    Papathanasiou G, Zerva E, Zacharis I, Papandreou M, Papageorgiou E, Tzima C, et al. Association of high blood pressure with body mass index, smoking and physical activity in healthy young adults. Open Cardiovasc Med J. 2015;9:5–17.

    Article  Google Scholar 

Download references

Acknowledgements

The authors would like to thank the Director General of Health Malaysia for permission to publish this paper. Appreciation goes to the Department of Statistics, Malaysia, in the sampling process. Acknowledgement also goes to the Ministry of Health Malaysia, namely Nutrition Division, Non-Communicable Disease Section, State Health Departments, Liaison Officers and scouts in the preparation and during the data collection. Our sincere appreciation also goes to all data collectors and participants.

About this supplement

This article has been published as part of Journal of Health, Population and Nutrition Volume 40 Supplement 1, 2021: Malaysian Community Salt Survey 2017-2018 (MyCoSS). The full contents of the supplement are available online at https://jhpn.biomedcentral.com/articles/supplements/volume-40-supplement-1.

Funding

Publication costs are funded by the Newton-Ungku Omar Fund: UK – Malaysia Bilateral Health Research Collaboration for Non-Communicable Diseases with the grant number of MR/P012590/1 (joint funding from the Academy of Sciences Malaysia, Malaysian Industry-Government Group for High Technology, and the Medical Research Council, UK). The funders had no role in the study design, data collection, data analysis, data interpretation or writing of the article.

Author information

Affiliations

Authors

Contributions

RA, FO, CSM, MFAM, FJH, GMG and AB conceived for the concept and project development. RA and FO helped supervise the project’s progress. NAMZ, FO, LP and NIW analysed the data and wrote the draft manuscript. All authors provided critical feedback and helped shape the research, analysis and approved the final manuscript.

Corresponding author

Correspondence to Nor Azian Mohd Zaki.

Ethics declarations

Ethics approval and consent to participate

Ethical approvals of the study were obtained from the Medical Research Ethics Committee (MREC), Ministry of Health Malaysia (NMRR-17-423-34969) and Queen Mary (University of London) Research Ethics Committee (MR/P012590/1) prior to conducting the study. Informed written consent was obtained from all respondents before the start of study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Zaki, N.A.M., Ambak, R., Othman, F. et al. The prevalence of hypertension among Malaysian adults and its associated risk factors: data from Malaysian Community Salt Study (MyCoSS). J Health Popul Nutr 40, 8 (2021). https://doi.org/10.1186/s41043-021-00237-y

Download citation

Keywords

  • Malaysian community salt study (MyCoSS)
  • Hypertension
  • Blood pressure
  • Cardiovascular disease