Qin et al.

BMC Public Health 2014, 14:948

http://www.biomedcentral.com/1471-2458/14/948

RESEARCH ARTICLE Open Access

Association of dietary pattern and body weight

with blood pressure in Jiangsu Province, China
Yu Qin1, Alida Melse-Boonstra2*, Xiaoqun Pan1, Jinkou Zhao1, Baojun Yuan1, Yue Dai1, Minghao Zhou1,
Johanna M Geleijnse2, Frans J Kok2 and Zumin Shi1,3

Abstract
Background: To identify risk factors, associations between dietary patterns, body mass index (BMI), and
hypertension in a Chinese population.
Methods: Dietary intake was assessed in 2518 adults by a 3-day 24 h recall and a food frequency questionnaire.
Salt and oil intake was assessed by weighing records. Four dietary patterns were identified using principal
component analysis. Overweight and obesity was determined according to the Chinese cut-offs for BMI.
High blood pressure was defined as systolic blood pressure 140 mmHg and/or diastolic blood pressure
90 mmHg. Prevalence ratios (PR) were calculated using Poisson regression.
Results: Of the subjects, 26.7% had high blood pressure. Subjects with overweight and obesity were more
likely to have high blood pressure than those with normal weight (PR, 95% CI: 1.60, 1.40-1.87; 2.45, 2.11-2.85,
respectively). Subjects with a traditional dietary pattern were more likely to have high blood pressure (P for trend = 0.001),
whereas those with a macho or sweet tooth dietary pattern were less likely to have high blood pressure (P for trend =
0.004 and <0.001, respectively). More than half of the population had salt intakes > 9 g/d, and blood pressure increased
with salt intake (P for trend <0.001). Subjects with a traditional dietary pattern had the highest salt intake (12.3 g/d).
Conclusion: A traditional dietary pattern is associated with high blood pressure among the population of Jiangsu
Province, which may be mainly due to high salt intake. Moreover, high BMI is an important determinant of high blood
pressure. Both issues need to be addressed by lifestyle interventions.
Keywords: Dietary pattern, Body weight, Salt, Blood pressure, China

Background poor. According to data from the China National Nutri-

Hypertension has been identified to be the first leading tion and Health Survey of 2002, less than one quarter of
risk factor of mortality and the third leading risk factor the hypertensive population are aware of having hyper-
of the total burden of disease globally [1]. It was esti- tension, and only one quarter is adequately treated and
mated that a quarter of the worlds adults had hyperten- controlled [5].
sion in 2002, and that the proportion will increase to Many studies have indicated that body mass index
29% by 2025 [2]. Hypertension contributes to premature (BMI) is generally positively associated with blood pres-
death and disability from cardiovascular diseases and sure [6], which is also the case in China [7]. Overweight
stroke; peripheral vascular disease; and kidney failure and obesity is an emerging epidemic in China, with al-
[3]. In China, the prevalence of hypertension in the adult most 30% of the adult population being classified as ei-
population has quadrupled from 5% in 1959 to nearly ther overweight or obese [8]. The high prevalence of
19% in 2002, which comprises approximately 200 million hypertension as well as of overweight and obesity in
people [4]. In addition, awareness of hypertension is China can be attributed to the recent economic develop-
ment and urbanization accompanied by unfavorable
changes in diet and lifestyle. The prevalence of hyperten-
* Correspondence: alida.melse@wur.nl
2
Division of Human Nutrition, Wageningen University, P.O. Box 8129, 6700
sion is known to be higher in the north as compared to
EV, Bomenweg 2, Bdg 307, 6703 HD, Wageningen, The Netherlands the south of China, which has been attributed both to
Full list of author information is available at the end of the article

2014 Qin et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. 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.
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dietary factors [9], and to the higher prevalence of over- hypertension. In total, 2518 subjects with 1146 males and
weight and obesity in northern China [10]. 1372 females were included in the data analysis. Written
Multiple dietary factors affect blood pressure. A large- consents were obtained from all the participants. The
scale intervention study on Dietary Approaches to Stop study was approved by the Human Investigation Review
Hypertension (DASH) revealed that a dietary pattern Committee at the National Institute for Nutrition and
rich in fruits and vegetables, rich in low-fat dairy prod- Food Safety, Chinese Center for Disease Control and
ucts, and reduced in saturated fat and cholesterol re- Prevention.
duces the risk of hypertension [11]. Furthermore, dietary
sodium reduction, regular aerobic physical activity, and Dietary intake measurement
moderation of alcohol consumption will help to main- Trained interviewers from the local Center for Disease
tain normal blood pressure [12]. Hypertension has been Control and Prevention visited subjects in their homes
reported in relation to some western and South-East to collect information on food intake using a 24-h diet-
Asian dietary patterns [13-15]. Data from the Shanghai ary recall method on three consecutive days, including
Mens Health Study showed that a dietary pattern con- two weekdays and one weekend day. Energy and nutri-
sisting mainly of fruit and milk was inversely associated ent intake was calculated by SAS Software using the
with blood pressure among middle-aged and elderly dietary recall data in conjunction with the China Food
men [16]. Wang et al. [10] found that a typical trad- Composition Tables published in 2002 [21].
itional southern Chinese dietary pattern, characterized Salt, oil, and condiments which contributed to salt in-
by high intakes of fruit, pork, poultry, rice, vegetables, take, such as soy sauce, vinegar, and monosodium glu-
aquatic products and nuts, was inversely related with tamate, were weighed at the 1st 24-h recall, and again at
hypertension independent of BMI [10]. the 2nd recall 24 h later. The household salt and oil con-
Jiangsu Province, located at the mid-east coast of sumption was calculated as the difference between the
China, is an economically booming area with a popula- two weighings. Individual salt and oil intake was esti-
tion of 73.6 million. Dietary and lifestyle habits have mated based on the proportion of each household mem-
changed dramatically in this Province over the past two bers food consumption, and categorized into quartiles.
decades [17]. The current age-standardized prevalence
of the metabolic syndrome has been estimated to be Dietary patterns
30.5%, with high blood pressure as the leading compo- A validated food frequency questionnaire (FFQ) was used
nent (45.2%) among its population [18]. However, the to collect dietary information over the past year [22].
etiology of hypertension in this Province is so far unex- The FFQ included a series of detailed questions regarding
plained. Therefore, we aimed to investigate the associa- the usual frequency and quantity of intake of thirty-three
tions between dietary patterns, BMI, and hypertension foods and beverages. This was further merged into twenty-
in a representative sample of the population of Jiangsu five food items in the analysis because of the low intake of
Province. some food items. Portion size for each food was estab-
lished by using food models. Subjects were asked to recall
Methods the frequency of consumption of individual food items
Subjects (number of times per day, per week, per month, per year)
The study was conducted in Jiangsu Province using a and the estimated portion size, using local weight units
multistage cluster sampling method, as described previ- (1 liang =50 g) or natural units (cups). Intakes of foods
ously [19,20], which was part of the 2002 National repre- were converted into g/week for data analysis. Use of vita-
sentative cross-sectional survey in nutrition and health. min and mineral supplements was included in the ques-
Six counties and two prefectures represented a geograph- tionnaire, but because these were very seldomly used in
ically and economically diverse population for Jiangsu the area, they were not included in this analysis.
Province. From each of the six areas, three streets/towns Dietary patterns were identified by factor analysis, using
were randomly selected. In each street/town, two villages/ standard principal component analysis as described before
neighbourhoods were further randomly selected. In each for this population [19]. Four different patterns were de-
village/neighbourhood, thirty households were randomly fined: 1) the traditional pattern (characterized primarily
selected. All members in the households were invited to by consumption of rice and freshly cooked vegetables, sec-
take part in the study, and adults aged 20 years and above ondary of pork and fish, and lastly of root vegetable and
were included in our study. Those already diagnosed with wheat flour); 2) the macho pattern (characterized primar-
hypertension, diabetes, dyslipidemia, stroke and cardio- ily by consumption of animal foods and alcohol, and sec-
vascular diseases were excluded from the study, because ondary of eggs, fish, nuts, and fruits); 3) the sweet tooth
they may have changed their dietary habits. Among 2832 pattern (characterized primarily by consumption of cake,
subjects, 311 (11%) had already been diagnosed with milk, yoghurt and drinks, secondary of animal foods, nuts
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and fruits, and lastly of pickled vegetables and alcohol); Alcohol use and socio-economic status
and finally 4) the healthy pattern (characterized primarily Alcohol use was assessed by asking the participants about
by consumption of whole grains, fruits, pickled vegetables, the frequency and amount of alcohol/beer intake, and cate-
and secondary by fresh vegetables, milk, eggs and fish). gorized into three categories, namely <0, 09, and 10 g/
The four factors explained 30.5% of the total variance in d. Low socio-economic status (SES) was defined as an in-
intake (10.6%, 8.6%, 5.9% and 5.4% for traditional, macho, come of less than 1999 Yuan,medium as 20004999 Yuan
sweet tooth, and healthy patterns, respectively). Scores and high as more than 5000 Yuan.
for each pattern were calculated as the sum of the prod-
ucts of the factor loading coefficient and the standardized Statistical analysis
weekly intake of each food associated with that pattern. The food intakes followed normal distribution. Variables
Only foods with factor loadings of more than 0.20 and less were presented as percentage or mean standard devi-
than 0.20 were included in calculation of pattern scores ation (SD). Students t-test, ANOVA and chi-square test
because these items represent the foods most strongly re- was used to determine subgroup differences for continu-
lated to the identified factor. Factor scores were divided ous and qualitative variables, respectively. Poisson analysis
into quartiles. The scores (intakes) increased from quartile was performed using SAS 9.2 to analyze associations be-
1 (Q1) to quartile 4 (Q4). tween BMI, salt intake, dietary pattern and high blood
pressure with household, age, gender and other known
Anthropometric measurement risk factors including SES, salt and potassium intake,
Weight was measured in light indoor clothing without physical activity and alcohol use as confounders. All other
shoes to the nearest 10th of a kilogram. Height was mea- analyses were performed using SPSS 19.0 (IBM SPSS Inc.,
sured without shoes to the nearest 10th of a centimeter USA). Statistical significance was set at = 0.05.
with a stadiometer. Waist circumference was measured
at 1 cm above the navel at minimal respiration. All mea- Results
surements were performed twice during the visit by The mean age of the subjects was 47.0 14.5 years old,
trained observers using a standard protocol and tech- and 26.7% had high blood pressure. Older subjects
niques [23]. Body mass index (BMI) was calculated as had a higher prevalence of high blood pressure than
weight in kilograms divided by height in squared meters. younger subjects (P for trend <0.001). The prevalence
Subjects were classified into BMI categories as underweight reduced in subjects with more active commuting activities
(BMI < 18.5), normal weight (BMI > 18.5 < 24), overweight (P for trend <0.001), and increased with more leisure time
(BMI 24 < 28) and obese (BMI 28) according to Chinese activities (P for trend <0.001). Compared with never
standards [24]. drinkers, alcohol drinkers had a higher prevalence of
high blood pressure (P for trend <0.001). The prevalence of
Blood pressure measurement hypertension increased with salt intake (P for trend <0.001)
Blood pressure was measured twice on the right arm by and over BMI categories (P for trend <0.001). No dif-
trained investigators with the participants in a seated ferences were found for gender, SES and potassium
position after 5 minutes of rest, using a standard mer- intake (Table 1).
cury sphygmomanometer and appropriate-sized cuff ac- The prevalence of overweight and obesity was 28.8%
cording to a standard protocol [25]. The mean of those and 10.6% among subjects, respectively. Subjects with
two measurements was used for analyses, with a coeffi- overweight and obesity were more likely to have high
cient of variation of 1.28% and 1.78% for systolic and blood pressure than those with normal weight (PR: 1.60,
diastolic blood pressure, respectively. High blood pres- 95% CI: 1.40-1.87; PR: 2.45, 95% CI: 2.11-2.85, respect-
sure was defined as systolic blood pressure 140 mmHg ively), after adjustment for household, age, gender, SES,
and/or diastolic blood pressure 90 mmHg. salt and potassium intake, physical activity and alcohol
use (Table 2).
Physical activity The average salt intake was 11.4 9.6 g/d, and there
Information on physical activity was collected using a was a positive association between salt intake and high
validated physical activity questionnaire covering a time blood pressure (P for trend < 0.01), independent of house-
period of one year [26]. Questions on daily commuting hold, age, gender, SES, potassium intake, physical activ-
to and from work were categorized into three categories: ity, BMI and alcohol use (Table 3).
(1) using motorized transportation or not (0 min of Salt intake increased over quartiles of the traditional
walking or cycling); (2) walking or bicycling 129 min; pattern, and decreased over quartiles of the sweet tooth
(3) walking or bicycling for >30 min. Daily leisure-time pattern. Fresh vegetable intake was highest in the highest
physical activity including boxing, running, walking, etc., quartile of the traditional pattern. Potassium and energy
was classified into 0; 129; 30 min. intake increased over quartiles of the traditional, Macho
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Table 1 Subject characteristics by blood pressure status1 Table 2 Prevalence ratios (95% CI) of high blood pressure
Blood pressure2 P among BMI categories
Normal High BMI Model 1 Model 2 Model 3
N 1845 673 Underweight 0.74 (0.48-1.15) 0.68 (0.44-1.03) 0.71 (0.46-1.08)

gender Normal 1 1 1

Male 831 (45.0) 315 (46.8) 0.43 Overweight 1.73 (1.49-2.01) 1.60 (1.38-1.85) 1.60 (1.40-1.87)

Female 1014 (55.0) 358 (53.2) Obesity 2.98 (2.56-3.46) 2.46 (2.12-2.85) 2.45 (2.11-2.85)

Age P for trend <0.001 <0.001 <0.001

20-29 270 (14.6) 10 (1.5) < 0.001 Model 1 crude model.

Model 2 adjusted by household, age and gender.
30-39 459 (24.9) 51 (7.6) Model 3 additionally adjusted by SES, salt intake, potassium intake, alcohol use
and physical activity.
40-49 423 (22.9) 124 (18.4)
50-59 292 (15.8) 191 (28.4)
and healthy patterns, and decreased over the sweet tooth
60+ 401 (21.7) 297 (44.1) pattern (Table 4).
SES Table 5 shows that the prevalence of high blood pres-
Low 570 (31.2) 216 (32.3) 0.31 sure increased over quartiles of the traditional dietary pat-
Middle 583 (31.9) 225 (33.6) tern (P for linear trend = 0.006), and decreased over quartiles
of the Macho dietary pattern (P for linear trend = 0.02) and
High 672 (36.8) 228 (34.1)
the sweet tooth dietary pattern (P for linear trend <0.001).
Active commuting
There was no trend in the prevalence over quartiles of the
None 628 (34.0) 325 (48.3) < 0.001 healthy dietary pattern. The trends remained similar after
1-30 min/d 966 (52.4) 268 (39.8) adjustment for household, age, gender, SES, physical activ-
>30 min/d 251 (13.6) 80 (11.9) ity, BMI and energy intake.
Leisure time activity
Discussion
None 1704 (92.4) 577 (85.7) < 0.001
We found that the traditional dietary pattern was posi-
1-30 min/d 70 (3.8) 43 (6.4)
tively associated with hypertension, whereas the two
>30 min/d 71 (3.8) 53 (7.9) more westernized dietary patterns showed a negative as-
Alcohol drinking sociation. BMI and salt intake both were strong determi-
Never 1590 (86.2) 552 (82.0) 0.005 nants of hypertension, but also age, and alcohol intake
Low 142 (7.7) 61 (9.1) were associated with high blood pressure, whereas phys-
ical activity.
High 113 (6.1) 60 (8.9)
A main strength of the study is that the sampling is
Salt intake
based on a representative population including different
<6 474 (25.7) 154 (22.9) < 0.003 sociodemography and geography. We used dietary weigh-
6-9 428 (23.2) 140 (20.8) ing in combination with a 3-day 24-h recall in the study
9-14 523 (28.3) 178 (26.4) which provided a relatively accurate estimation of salt in-
14 420 (22.8) 201 (29.9) take. As a cross-sectional study, the main limitation is that
we cannot establish a causal relationship between dietary
Potassium intake
patterns and high blood pressure. However, we excluded
< 1.28 478 (25.9) 162 (24.1) 0.57
1.28-1.56 463 (25.1) 163 (24.2) Table 3 Prevalence ratios (95% CI) of high blood pressure
1.56-1.94 437 (23.7) 189 (28.1) among salt intake categories
1.94 467 (25.3) 159 (23.6) Salt intake (g/d) Model 1 Model 2 Model 3
BMI <6 1 1 1
<18.5 110 (6.0) 18 (2.7) <0.001 6-9 1.00 (0.82-1.23) 1.01 (0.84-1.22) 0.98 (0.81-1.17)
18.5-24 1134 (61.5) 266 (39.5) 9-14 1.03 (0.86-1.25) 1.06 (0.89-1.27) 1.00 (0.84-1.18)
24-28 485 (26.3) 238 (35.4) 14 1.32 (1.10-1.58) 1.32 (1.10-1.56) 1.21 (1.02-1.43)
28 116 (6.3) 151 (22.4) P for trend 0.003 0.003 0.01
1
Data are presented as N (%). Differences between groups were analyzed by Model 1 crude model.
chi-square test. 2High blood pressure is defined as SBP 140 mmHg and/or Model 2 adjusted by household, age and gender.
DBP 90 mmHg. Model 3 additional adjusted by SES, BMI, potassium intake, alcohol use and
physical activity.
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Table 4 Food and nutrient intakes related to high blood pressure in the lowest and highest quartiles of dietary patterns
Traditional Macho Sweet tooth Healthy
Q1 Q4 Q1 Q4 Q1 Q4 Q1 Q4
Salt (g/d) 11.4 8.9 12.3 11.9* 11.2 9.2 11.3 9.1 13.7 11.8 9.4 6.6* 10.9 9.1 11.5 9.5
Meat (g/d) 42.9 57.9 113.7 89.2* 54.0 62.8 119.9 93.0* 74.9 86.5 110.3 81.9* 103.1 79.4 85.1 87.2*
Fresh 256.5 173.6 326.7 144.5* 288.4 177.2 282.8 158.7 302.9 167.3 251.4 127.6* 285.1 142.5 285.9 169.6
vegetable (g/d)
Oil (g/d) 44.7 29.1 43.7 28.5* 40.7 28.7 42.5 27.5 48.2 30.4 38.2 23.2* 37.6 27.1 44.8 28.7*
K (g/d) 1.8 0.6 1.8 0.7* 1.6 0.6 1.7 0.6* 1.8 0.6 1.6 0.5* 1.6 0.6 1.8 0.7*
Energy (KJ/d) 2510.2 734.9 2505.7 669.6* 2306.0 675.0 2476.8 718.1* 2677.3 688.5 2111.7 599.1* 2273.5 654.5 2465.8 731.5*
*P < 0.05 over quartiles analyzed by ANOVA.

subjects with diagnosed hypertension and related diseases occurred, although we used a validated food frequency
to avoid possible dietary change following clinicians sug- questionnaire in the survey. The salt intake is estimated
gestions and thereby maintaining a natural association based on household salt use, which may underestimate
between dietary intake and blood pressure in the study real intake. Measuring 24 urine sodium excretion would
population. Misclassification of food intake may have be a better choice, however, it would be a challenge to ob-
tain complete 24 hour urine collections from a large
population and it would still be hard to quantify habitual
Table 5 Prevalence ratios (PRs) of high blood pressure intake because of day-to-day variation [27]. In our study
among dietary patterns we used 24-h recall combination with dietary weighing,
Dietary pattern % Model 1 Model 2 Model 3 which is better than FFQ only.
Traditional Our study shows that the prevalence of high blood
Q1 21.1 1 1 1 pressure was positively associated with the traditional
Q2 28.2 1.34 (1.09-1.65) 1.37 (1.10-1.71) 1.30 (1.05-1.61) dietary pattern. This is counterintuitive, since the trad-
itional dietary pattern, with its abundant amount of
Q3 28.0 1.33 (1.09-1.62) 1.37 (1.10-1.71) 1.51 (1.21-1.88)
fresh vegetables, is more in line with the DASH diet
Q4 28.7 1.36 (1.11-1.66) 1.39 (1.12-1.71) 1.47 (1.18-1.82)
than any of the other dietary patterns in our population.
P for trend 0.006 0.007 0.001 Effective prevention and treatment of hypertension has
Macho been shown for the Mediterranean Diet, as a model of
Q1 29.9 1 1 1 DASH, with abundant amounts of fresh vegetable intake
Q2 27.0 0.90 (0.76-1.08) 0.90 (0.76-1.07) 0.92 (0.77-1.09) usually in the form of salads without cooking [13]. How-
ever, eating raw vegetables is not common in many other
Q3 25.8 0.86 (0.72-1.03) 0.85 (0.71-1.02) 0.82 (0.69-0.98)
parts of the world. For example, in Korea, subjects with
Q4 24.1 0.81 (0.67-0.97) 0.80 (0.66-0.96) 0.78 (0.65-0.94)
a traditional dietary pattern mostly consumed salted veg-
P for trend 0.02 0.02 0.004 etables resulting in high sodium intake [15]. Moreover,
Sweet tooth Chinese vegetarian diets contain large amounts of salt
Q1 31.8 1 since these are predominantly based on soy products with
Q2 27.5 0.86 (0.73-1.02) 0.84 (0.71-1.00) 0.86 (0.73-1.02) little taste, which differs from western vegetarian diets.
Therefore, Chinese vegetarian diets tend to have high so-
Q3 24.0 0.76 (0.63-0.91) 0.72 (0.60-0.86) 0.75 (0.62-0.90)
dium content, which may predispose to hypertension [28].
Q4 23.4 0.74 (0.61-0.89) 0.67 (0.55-0.82) 0.71 (0.58-0.86)
In Jiangsu Province, vegetables are traditionally cooked
P for trend 0.0004 < 0.0001 0.0001 and then stir-fried with a large amount of oil and salt,
Healthy which may contribute to high energy and sodium intake.
Q1 26.5 1 1 1 We also found a clear association between salt intake and
Q2 26.1 0.98 (0.82-1.18) 0.99 (0.82-1.19) 0.92 (0.77-1.10) hypertension, and salt intake was highest in subjects with
a traditional dietary pattern. Therefore, our results may
Q3 25.7 0.97 (0.80-1.17) 0.97 (0.81-1.17) 0.88 (0.74-1.06)
be explained by food preparation habits related to the
Q4 28.6 1.08 (0.90-1.29) 1.09 (0.91-1.30) 0.89 (0.74-1.07)
traditional dietary pattern. Our findings are consistent
P for trend 0.45 0.19 0.19 with several other studies in Asian populations that
Q1 is the lowest quartile, Q4 is the highest quartile. found a positive association between a traditional dietary
Model 1 crude model.
Model 2 adjusted by household, age and gender.
pattern rich in vegetables and hypertension [10,15,16].
Model 3 additionally adjusted by SES, BMI, physical activity and energy intake. However, the opposite has also been reported with a
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negative association between a traditional dietary pattern of China this has begun earlier. Analysis of follow up
and hypertension in southern China, which included fruit, data will throw more light on this.
poultry, pork, aquatic product, soybean product and vege- The Macho pattern with a high intake of meat also
tables [10], suggesting that factors other than vegetable in- showed negative association with blood pressure, which
take play an important role. is inconsistent with some other reports [41-43]. A cross-
Salt intake has been acknowledged as a direct risk fac- sectional study showed that meat eaters had a higher
tor for hypertension [29]. Salt (sodium chloride) is dis- prevalence of hypertension than non-meat eaters, espe-
tributed predominantly to the extracellular space. The cially vegans [41]. An international collaborative cross-
rise in extracellular volume by excess amounts of salt in- sectional study found that a high intake of red meat with
take results in increased cardiac output and rising blood 103 g/d resulted in both higher systolic and diastolic
pressure [30]. A meta-analysis of 17 randomized trials blood pressure [42]. A 10-year follow-up study indicated
showed that modest and long-term reduction of salt in- that red meat intake, but not poultry, was positively as-
take lowers blood pressure in both hypertensive and sociated with the risk of hypertension, compared to
normotensive individuals [31]. In addition, dietary so- those who consumed no red meat [43]. Meat products,
dium reduction is related to decreased blood pressure particularly red meat, are a major source of saturated
[32,33] and reduces the risk of cardiovascular outcomes fat, animal protein, and cholesterol, which may contrib-
by 25-30% [34]. WHO recommends a salt intake of no ute to the development of hypertension [44]. However,
more than 5 g per day [35], however, the majority of our other studies reported that a higher intake of meat
study population consumed salt at amounts much higher lowers blood pressure [45,46]. The effect of animal meat
than this recommendation. The inverse association be- therefore remains uncertain [47].
tween sweet tooth pattern and hypertension that we
found may be due to the relatively low intake of salt in Conclusion
combination with low vegetable and oil intake. In conclusion, we found that a traditional dietary pat-
In our study, overweight and obese subjects were more tern is associated with high blood pressure in Jiangsu
likely to have high blood pressure. Maintaining a normal Province, which may mainly be due to a higher intake of
body weight (BMI 18.5-24.9 kg/m2) is recommended for salt. Overweight and obesity were also directly associated
prevention and management of hypertension [12]. Two with blood pressure in the population. Our results suggest
meta-analyses of randomized controlled trials showed that decreasing the use of salt and other salt-containing
that weight loss contributed to a reduction in both sys- condiments in food preparation should be included in the
tolic and diastolic blood pressure [6,36]. It has been esti- dietary recommendations for the prevention of high blood
mated that weight loss of 10 kg can reduce 520 mmHg pressure. Our findings may be generalized to other parts
of systolic blood pressure [12]. Obesity is associated with of China and other Asian countries with similar cooking
hyperleptinemia via secreting several immunomodula- habits, although dietary patterns may differ. Public health
tors and bioactive molecules by adipose tissue [37,38]. measures including mass education campaigns with diet-
Leptin, which helps blood volume and pressure homeo- ary recommendations should be conducted to promote
stasis in normal conditions, increases blood pressure healthy lifestyles including weight management and re-
through activation of the sympathetic nervous system duction of salt use in China. Further studies should be
during chronic hyperleptinemia [38,39]. conducted to examine the association between blood pres-
We found a negative association between the more sure and salt intake in this population more closely.
westernized sweet tooth dietary pattern and the preva-
Abbreviations
lence of hypertension in Jiangsu Province. In contrast, a BMI: Body mass index; DASH: Dietary Approaches to Stop Hypertension;
clear positive association between a western dietary pat- FFQ: Food frequency questionnaire; PR: Prevalence ratios; SES: Socio-economic
tern and hypertension was found on the national level in status; SD: Standard deviation.
China [10]. As compared to the western dietary pattern Competing interests
in the national study, we found that subjects with a pre- The author(s) declare that they have no competing interests.
dominant sweet tooth dietary pattern had lower salt in-
Authors contributions
take than for example those with a traditional dietary YQ contributed to the field work, data collection, quality control, analysis,
pattern, which may partly explain our findings. More- and manuscript writing. AMB and ZS contributed to the writing suggestions,
over, we previously found a negative association between statistical advice and critical English review. XP, BY, YD, and MZ contributed
to the implementation in the field, quality control, and data collection. JZ,
the sweet tooth dietary pattern and central obesity [40]. JMG and FJK gave advice on the manuscript writing. All authors have read
It may be that the nutrition and epidemiologic transition and approved the final manuscript.
at the time of the study had only just begun in Jiangsu
Acknowledgements
Province thereby not yet showing an association between We are extremely grateful to all the families who took part in this study. We
exposure and disease outcomes, whereas in other parts thank the participating Regional Centers for Disease Control and Prevention
Qin et al. BMC Public Health 2014, 14:948 Page 7 of 8
http://www.biomedcentral.com/1471-2458/14/948

in Jiangsu Province, including the Nanjing, Xuzhou, Jiangyin, Taicang, 17. Wang CN, Liang Z, Wei P, Liu P, Yu JX, Zhang DM, Ma FL: Changes in
Suining, Jurong, Sihong, and Haimen Centers for their support for the data dietary patterns and certain nutrition-related diseases in urban and rural
collection. The Project was supported by Jiangsu Provincial Health Bureau. residents of Jiangsu Province, China, during the 1990s. Biomed Environ Sci
Yu Qin is supported by an INREF fellowship from Wageningen University, 2002, 15(4):271276.
The Netherlands. 18. Zuo H, Shi Z, Hu X, Wu M, Guo Z, Hussain A: Prevalence of metabolic
syndrome and factors associated with its components in Chinese adults.
Author details Metabolism 2009, 58(8):11021108.
1
Department of Non-communicable Chronic Disease Control, Jiangsu 19. Shi Z, Hu X, Yuan B, Pan X, Dai Y, Holmboe-Ottesen G: Association between
Provincial Center for Disease Control and Prevention, Nanjing, P. R. China. dietary patterns and anaemia in adults from Jiangsu Province in Eastern
2
Division of Human Nutrition, Wageningen University, P.O. Box 8129, 6700 China. Br J Nutr 2006, 96(5):906912.
EV, Bomenweg 2, Bdg 307, 6703 HD, Wageningen, The Netherlands. 20. Qin Y, Melse-Boonstra A, Shi ZM, Pan XQ, Yuan BJ, Dai Y, Zhao JK, Zimmerman
3
Discipline of Medicine, University of Adelaide, Adelaide, Australia. MB, Kok FJ, Zhou MH: Dietary intake of zinc in the population of Jiangsu
Province, China. Asia Pac J Clin Nutr 2009, 18(2):193199.
Received: 27 January 2014 Accepted: 5 September 2014 21. Yang Y, Wang G, Pan X: China Food Composition Table 2002. Beijing: Beijing
Published: 12 September 2014 Medical University Publishing House; 2002.
22. Zhao W, Hasegawa K, Chen J: The use of food-frequency questionnaires
for various purposes in China. Public Health Nutr 2002, 5(6A):829833.
References
23. World Health Organization: Physical status: the use and interpretation of
1. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ: Selected major
anthropometry. Report of a WHO Expert Committee. World Health Organ
risk factors and global and regional burden of disease. Lancet 2002,
Tech Rep Ser 1995, 854:1452.
360(9343):13471360.
24. Zhou BF, the Cooperative Meta-analysis Group of Working Group on Obesity
2. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J: Global
in China: Predictive values of body mass index and waist circumference for
burden of hypertension: analysis of worldwide data. Lancet 2005,
risk factors of certain related diseases in Chinese adults: study on optimal
365(9455):217223.
cut-off points of body mass index and waist circumference in Chinese
3. Deaton C, Froelicher ES, Wu LH, Ho C, Shishani K, Jaarsma T: The global
adults. Asia Pac J Clin Nutr 2002, 11(Suppl 8):S685S693.
burden of cardiovascular disease. Eur J Cardiovasc Nurs 2011,
25. 1999 World Health Organization-International Society of Hypertension
10(Suppl 2):S5S13.
Guidelines for the Management of Hypertension. Guidelines Subcommittee.
4. Wang LD: Nutrition and Health Status in Chinese People. Beijing, China:
J Hypertens 1999, 17(2):151183.
Peoples Publishing House; 2005.
5. Wu Y, Huxley R, Li L, Anna V, Xie G, Yao C, Woodward M, Li X, Chalmers J, 26. Ma GS, Luan DC, Liu AL, Li YP, Cui ZH, Hu XQ: Analysis and evaluation of a
Gao R, Kong L, Yang X: Prevalence, awareness, treatment, and control physical activity questionnaire of professionals in China. Acta Nutr Sinica
of hypertension in China: data from the China National Nutrition and 2007, 3:217221.
Health Survey 2002. Circulation 2008, 118(25):26792686. 27. Elliott P, Stamler J, Nichols R, Dyer AR, Stamler R, Kesteloot H, Marmot M:
6. Neter JE, Stam BE, Kok FJ, Grobbee DE, Geleijnse JM: Influence of weight Intersalt revisited: further analyses of 24 hour sodium excretion and
reduction on blood pressure: a meta-analysis of randomized controlled blood pressure within and across populations. Intersalt Cooperative
trials. Hypertension 2003, 42(5):878884. Research Group. BMJ 1996, 312(7041):12491253.
7. Zheng L, Zhang Z, Sun Z, Li J, Zhang X, Xu C, Hu D, Sun Y: The association 28. Kwok TC, Chan TY, Woo J: Relationship of urinary sodium/potassium
between body mass index and incident hypertension in rural women in excretion and calcium intake to blood pressure and prevalence of
China. Eur J Clin Nutr 2010, 64(8):769775. hypertension among older Chinese vegetarians. Eur J Clin Nutr 2003,
8. Shen J, Goyal A, Sperling L: The emerging epidemic of obesity, diabetes, 57(2):299304.
and the metabolic syndrome in china. Cardiol Res Pract 2012, 29. Brown IJ, Tzoulaki I, Candeias V, Elliott P: Salt intakes around the world:
2012:178675. implications for public health. Int J Epidemiol 2009, 38(3):791813.
9. Zhao L, Stamler J, Yan LL, Zhou B, Wu Y, Liu K, Daviglus ML, Dennis BH, 30. Freis ED: Salt, volume and the prevention of hypertension. Circulation 1976,
Elliott P, Ueshima H, Yang J, Zhu L, Guo D: Blood pressure differences 53(4):589595.
between northern and southern Chinese: role of dietary factors: 31. He FJ, MacGregor GA: Effect of modest salt reduction on blood pressure:
the international study on macronutrients and blood pressure. a meta-analysis of randomized trials. Implications for public health.
Hypertension 2004, 43(6):13321337. J Hum Hypertens 2002, 16(11):761770.
10. Wang D, He Y, Li Y, Luan D, Yang X, Zhai F, Ma G: Dietary patterns and 32. Dumler F: Dietary sodium intake and arterial blood pressure. J Ren Nutr
hypertension among Chinese adults: a nationally representative 2009, 19(1):5760.
cross-sectional study. BMC Public Health 2011, 11(1):925. 33. Midgley JP, Matthew AG, Greenwood CM, Logan AG: Effect of reduced
11. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray dietary sodium on blood pressure: a meta-analysis of randomized
GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH, Karanja N: A clinical trial controlled trials. JAMA 1996, 275(20):15901597.
of the effects of dietary patterns on blood pressure. DASH Collaborative 34. Cook NR, Cutler JA, Obarzanek E, Buring JE, Rexrode KM, Kumanyika SK,
Research Group. New England J Med 1997, 336(16):11171124. Appel LJ, Whelton PK: Long term effects of dietary sodium reduction on
12. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones cardiovascular disease outcomes: observational follow-up of the trials of
DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ, Joint National hypertension prevention (TOHP). BMJ 2007, 334(7599):885888.
Committee on Prevention, Detection Evaluation Treatment of High Blood 35. WHO: Reducing Salt Intake in Populations. Report of a WHO Forum and Technical
Pressure. National Heart, Lung Blood, Institute National High Blood Pressure Meeting 57 October 2006, Paris, France. Geneva: World Health Organization; 2007.
Education Program Coordinating, Committee: Seventh report of the Joint 36. Staessen J, Fagard R, Amery A: The relationship between body weight and
National Committee on Prevention, Detection, Evaluation, and blood pressure. J Hum Hypertens 1988, 2(4):207217.
Treatment of High Blood Pressure. Hypertension 2003, 42(6):12061252. 37. Caro JF, Kolaczynski JW, Nyce MR, Ohannesian JP, Opentanova I, Goldman
13. Kokkinos P, Panagiotakos DB, Polychronopoulos E: Dietary influences on WH, Lynn RB, Zhang PL, Sinha MK, Considine RV: Decreased
blood pressure: the effect of the Mediterranean diet on the prevalence cerebrospinal-fluid/serum leptin ratio in obesity: a possible mechanism
of hypertension. J Clin Hypertens 2005, 7(3):165170. quiz 171162. for leptin resistance. Lancet 1996, 348(9021):159161.
14. Schulze MB, Hu FB: Dietary patterns and risk of hypertension, type 2 38. Kshatriya S, Liu K, Salah A, Szombathy T, Freeman RH, Reams GP, Spear RM,
diabetes mellitus, and coronary heart disease. Curr Atheroscler Rep 2002, Villarreal D: Obesity hypertension: the regulatory role of leptin. Int J
4(6):462467. Hypertens 2011, 2011:270624.
15. Kim YO: Dietary patterns associated with hypertension among Korean 39. Rahmouni K, Correia ML, Haynes WG, Mark AL: Obesity-associated hypertension:
males. Nutr Res Pract 2009, 3(2):162166. new insights into mechanisms. Hypertension 2005, 45(1):914.
16. Lee SA, Cai H, Yang G, Xu WH, Zheng W, Li H, Gao YT, Xiang YB, Shu XO: 40. Shi Z, Hu X, Yuan B, Hu G, Pan X, Dai Y, Byles JE, Holmboe-Ottesen G:
Dietary patterns and blood pressure among middle-aged and elderly Vegetable-rich food pattern is related to obesity in China. Int J Obesity
Chinese men in Shanghai. Br J Nutr 2010, 104(2):265275. (Lond) 2008, 32(6):975984.
Qin et al. BMC Public Health 2014, 14:948 Page 8 of 8
http://www.biomedcentral.com/1471-2458/14/948

41. Appleby PN, Davey GK, Key TJ: Hypertension and blood pressure among
meat eaters, fish eaters, vegetarians and vegans in EPIC-Oxford.
Public Health Nutr 2002, 5(5):645654.
42. Tzoulaki I, Brown IJ, Chan Q, Van Horn L, Ueshima H, Zhao L, Stamler J,
Elliott P: Relation of iron and red meat intake to blood pressure: cross
sectional epidemiological study. BMJ 2008, 337:a258.
43. Wang L, Manson JE, Buring JE, Sesso HD: Meat intake and the risk of
hypertension in middle-aged and older women. J Hypertens 2008,
26(2):215222.
44. Stamler J, Liu K, Ruth KJ, Pryer J, Greenland P: Eight-year blood pressure
change in middle-aged men: relationship to multiple nutrients.
Hypertension 2002, 39(5):10001006.
45. Hodgson JM, Burke V, Beilin LJ, Puddey IB: Partial substitution of
carbohydrate intake with protein intake from lean red meat lowers
blood pressure in hypertensive persons. Am J Clin Nutr 2006,
83(4):780787.
46. Nowson CA, Wattanapenpaiboon N, Pachett A: Low-Sodium Dietary
Approaches to Stop Hypertension-Type Diet Including Lean red Meat
Lowers Blood Pressure in Postmenopausal Women. Nutr Res 2009,
29(1):818.
47. Appel LJ, Giles TD, Black HR, Izzo JL Jr, Materson BJ, Oparil S, Weber MA:
ASH position paper: dietary approaches to lower blood pressure. J Am
Soc Hypertens 2010, 4(2):7989.

doi:10.1186/1471-2458-14-948
Cite this article as: Qin et al.: Association of dietary pattern and body
weight with blood pressure in Jiangsu Province, China. BMC Public
Health 2014 14:948.

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