The Age Associations of Blood Pressure, Cholesterol, and Glucose

Analysis of Health Examination Surveys From International Populations

Gitanjali M. Singh, PhD*; Goodarz Danaei, MD, DSc*; Pamela M. Pelizzari, MPH; John K. Lin, AB;
Melanie J. Cowan, MPH; Gretchen A. Stevens, DSc; Farshad Farzadfar, MD, DSc;
Young-Ho Khang, MD, PhD; Yuan Lu, MSc; Leanne M. Riley, MSc;
Stephen S. Lim, PhD; Majid Ezzati, PhD

Background—The age association of cardiovascular disease may be in part because its metabolic risk factors tend to rise
with age. Few studies have analyzed age associations of multiple metabolic risks in the same population, especially in
nationally representative samples. We examined worldwide variations in the age associations of systolic blood pressure
(SBP), total cholesterol (TC), and fasting plasma glucose (FPG).
Methods and Results—We used individual records from 83 nationally or subnationally representative health examination
surveys in 52 countries to fit a linear model to risk factor data between ages 30 and 64 years for SBP and FPG, and
Downloaded from http://circ.ahajournals.org/ by guest on January 14, 2018

between 30 and 54 years for TC. We report the cross-country variation of the slope and intercept of this relationship.
We also assessed nonlinear associations in older ages. Between 30 and 64 years of age, SBP increased by 1.7 to
11.6 mm Hg per 10 years of age, and FPG increased by 0.8 to 20.4 mg/dL per 10 years of age in different countries and
in the 2 sexes. Between 30 and 54 years of age, TC increased by 0.2 to 22.4 mg/dL per 10 years of age in different
surveys and in the 2 sexes. For all risk factors and in most countries, risk factor levels rose more steeply among women
than among men, especially for TC. On average, there was a flattening of age-SBP relationship in older ages; TC and
FPG age associations reversed in older ages, leading to lower levels in older ages than in middle ages.
Conclusions—The rise with age of major metabolic cardiovascular disease risk factors varied substantially across
populations, especially for FPG and TC. TC rose more steeply in high-income countries and FPG in the Oceania
countries, the Middle East, and the United States. The SBP age association had no specific income or geographical
pattern. (Circulation. 2012;125:2204-2211.)
Key Words: aging 䡲 blood pressure 䡲 cholesterol 䡲 glucose

C ardiovascular disease (CVD) rates tend to rise with age

in most populations, although the age association of
CVD varies across countries and has changed over time.1–3 It
is believed that this association is partly because major CVD
risk factors including blood pressure, cholesterol, and diabe-
tes rise with age, and possibly because risk factor effects
accumulate over life course.1 Despite this commonly held
view, some studies have found that populations with low
CVD risk, eg, some rural populations in developing countries,
have attenuated age gradients of blood pressure and choles-
terol in comparison with urban and industrialized popula-
tions, attributed in part to lower consumption of salt and
animal products and lower body mass index.4 –11 Most previ-
ous studies focused on a single risk factor and, with the
notable exception of the Intersalt study, were in 1 or a small
number of populations. To our knowledge, there is no
quantitative analysis of the age association of multiple CVD
risk factors across nationally representative samples from
countries in different regions and at different stages of
economic development.
Clinical Perspective on p 2211
We used health examination surveys in populations world-
wide to conduct consistent cross-population analyses of the

Received August 10, 2011; accepted March 20, 2012.

From the Harvard School of Public Health, Boston, MA (G.M.S., G.D., J.K.L., Y.L.); Johns Hopkins Bloomberg School of Public Health, Baltimore,
MD (P.M.P.); World Health Organization, Geneva, Switzerland (M.J.C., G.A.S., L.M.R.); Tehran University of Medical Sciences, Tehran, Iran (F.F.);
University of Ulsan College of Medicine, Seoul, Korea (Y-H.K.); University of Washington, Seattle, WA (S.S.L.); and School of Public Health, Imperial
College London, London, United Kingdom (M.E.).
Guest Editor for this article was Vera Bittner, MD, MSPH.
*Drs Singh and Danaei contributed equally to this work.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.111.058834/-/
DC1.
Correspondence to Majid Ezzati, MRC-HPA Centre for Environment and Health, Department of Epidemiology and Biostatistics, Imperial College
London, Norfolk Place, London W2 1PG, United Kingdom. E-mail majid.ezzati@imperial.ac.uk
© 2012 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.111.058834

2204
 Singh et al
Downloaded from http://circ.ahajournals.org/ by guest on January 14, 2018
age associations of blood pressure, cholesterol, and glucose.
We examined the age associations in young to middle ages,
and how age association changes in older ages. Following the
analyses of Intersalt data,10 we also examined whether the age
association slopes are correlated with average population risk
factor levels. Finally, we examined whether all risk factors
rise more or less steeply in the same populations, and whether
the slopes are associated with national income.
Methods
Our analysis was on systolic blood pressure (SBP), serum total
cholesterol (TC), and fasting plasma glucose (FPG), because these
factors were measured in a larger number of surveys than other
markers of risk such as low-density lipoprotein cholesterol or
postprandial glucose.
Data Sources
The data for this analysis were deidentified individual records in 83
health examination surveys in 52 countries that all covered ages 30
to 64 with measured SBP, TC, and FPG. The details of the surveys
included in the analysis are provided in online-only Data Supplement
Table I. All surveys had data on men and women. Fifty-four surveys
were national, and the other 29 covered large subnational regions
(eg, 9 provinces in China). Of the latter group, 16 were from England
and Scotland and were designed with all the features of a national
survey; these surveys are labeled as subnational in online-only Data
Supplement Table I because we considered United Kingdom as the
parent country. We excluded 6 other surveys for reasons detailed in
online-only Data Supplement Table I. All surveys had data on SBP,
32 on TC, and 22 on FPG. Fifty-two surveys were from low- and
middle-income countries, and 31 were from high-income countries.
Statistical Analysis
We dropped 0.7% of participants for SBP, 0.3% for TC, and 0.6%
for FPG, because they did not have information on age. When SBP
was measured more than once (all but 1 survey), we dropped the first
SBP measurement because it was significantly higher than subse-
quent ones, and we used the average of the other measurements as
each participant’s SBP. All analyses were done separately for men
and women.
For each survey and risk factor, we estimated the slope and
intercept of the linear relationship between risk factor and age by
Age Association of Metabolic Risk Factors 2205
Figure 1. Distributions of age associa-
tion (A) slopes and (B) intercepts of SBP,
TC, and FPG. Each box plot shows dis-
tributions for all analyzed surveys. SBP
indicates systolic blood pressure; TC,
total cholesterol; FPG, fasting plasma
glucose; F, female; M, male.
fitting a linear regression model to individual records of participants
who were between 30 and 64 years of age for SBP and FPG, and
between 30 and 54 years of age for TC. All analyses used survey
sample weights when available. Hereafter, we refer to the coefficient
of age in this linear regression as “slope” and to the regression
constant as “intercept.” We used 30 years as the start age because
some surveys did not have measurement below this age, and there
was indication that there may also be nonlinearity at ⬍30 years,
making earlier ages incomparable across surveys. We restricted the
analysis to 64 and 54 years because the slope may significantly
change in older ages, making the linear model inappropriate;
exploratory analyses showed that slopes changed at a younger age
for TC than for SBP and FPG. We examined the distributions of the
slopes and intercepts across populations and report their descriptive
statistics (Figure 1).
In each survey, we also calculated mean risk factor levels in 5-year
age groups, ie, 30 to 34, 35 to 39, …, 85⫹ years and used these mean
levels to calculate an age-standardized mean for men and women in
each survey for ages 30 to 64 for SBP and FPG and 30 to 54 for TC;
we used the world population in 2000 as the standard population.
Thus, we created, separately by sex, a data set in which each
observation was 1 survey, and the variables were the slope and the
intercept of the age association and the age-standardized mean for
the same age range. We fitted a simple linear regression, separately
for each sex, with the slope as the dependent variable and the
age-standardized mean as the independent variable. The dependent
variable in this regression is a measure of how steep/shallow the age
association is; the independent variable measures how low/high the
risk factor level is in the population across ages. A previous analysis
of Intersalt had used sample median risk factor level instead of the
age-standardized mean.10 We did not use sample median because the
survey populations had different age distributions, which could
affect the comparability of the median. We also considered regres-
sion models that included whether a country was high versus low and
middle income, but did not include that variable in the final model
because its coefficients were not statistically significant at the 0.05
level. We conducted a similar analysis with the intercept (at age 30
years) as the dependant variable. Both regressions included a
country-level random intercept to account for repeated surveys in the
same countries.
Because there is a simple linear relationship between the intercept
and slope of age association and the age-standardized mean, at a
constant age-standardized mean any change in the coefficient of
slope is accompanied by a change in the opposite direction in the
coefficient of intercept and vice versa. At the extreme, if change in
 2206 Circulation May 8, 2012

age-standardized mean is only due to a change in intercept (ie, Table 1. Mean (SD) Slopes and Intercepts by National Income
shifting the whole line up/down), then the coefficient of regression of
slope on mean would on average be 0, and the coefficient of Low and Middle
regression of intercept on mean would be 1.0. On the other hand, if Income High Income
the change in age-standardized mean is only due to a shift in slope
(rotating the regression line around the same intercept), the coeffi- Male Female Male Female
cient of regression of the intercept on mean would be 0 and that of Slope of risk factor
slope would be 1/[0.5⫻(65⫺30)] or ⬇0.06 for SBP and FPG. age association
To analyze risk factor patterns in older ages, we used surveys that (per decade of age)
had data ⬎65 years of age: 38 surveys for SBP, 17 for TC, and 8 for
FPG (online-only Data Supplement Table I). We divided the surveys SBP (mmHg) 4.8 (1.6) 8.0 (1.6) 4.8 (1.0) 8.1 (1.0)
into tertiles of slope for SBP and to those below and above median TC (mg/dL) 5.7 (3.8) 12.0 (3.7) 9.6 (4.9) 16.3 (4.9)
slope for TC and FPG. In each tertile or median group, we estimated FPG (mg/dL) 8.6 (5.3) 11.6 (6.0) 5.4 (1.8) 5.5 (2.4)
mean risk factor level for 5-year age groups across all surveys,
adjusting for differences across surveys using a fixed-effects regres- Intercept at age 30
sion model. of risk factor age
All analyses were done using STATA 10 (StataCorp, College association
Station, TX). SBP (mmHg) 121.7 (6.0) 113.6 (5.4) 123.9 (4.5) 112.7 (4.7)
TC (mg/dL) 186.4 (14.4) 180.6 (10.7) 202.9 (9.1) 186.2 (9.4)
Results
FPG (mg/dL) 100.5 (15.3) 94.7 (13.7) 93.9 (2.8) 89.7 (1.6)
Age Associations of SBP, TC, and FPG SBP indicates systolic blood pressure; TC, total cholesterol; and FPG, fasting
Downloaded from http://circ.ahajournals.org/ by guest on January 14, 2018

The distributions of slopes and intercepts for SBP, TC, and
FPG are shown in Figure 1. Slopes varied across surveys,
with TC and FPG having larger interquartile ratios than SBP
(Figure 1A). The intercepts at age 30 varied less than the
slopes, with intercept interquartile ratios ranging from 30% of
that of slope for male TC to 86% for female SBP (Figure 1B).
The median slope for SBP was 4.7 and 8.1 mm Hg per 10
years of age for men and women, respectively (Figure 1). At
the low end, SBP increased 1.7 to 2.1 mm Hg per 10 years of
age for men in surveys such as Cape Verde 2007, Tonga
2001, Tokelau 2005, and India 2007. At the high end, the
slope was ⬎11 mm Hg per 10 years of age for women in
Nauru 2004 and Sao Tome et Principe 2009 (online-only
Data Supplement Table II). The lowest slope in our analysis
(1.7 mm Hg per 10 years) was ⬇2 to 3 times as large as the
lowest Intersalt slopes, and the highest slope in our analysis
was ⬇10% lower than the highest Intersalt slope.10 Median
intercept at age 30 for men was 123.1mm Hg, ranging from
⬍115 mm Hg to ⬎131 mm Hg in Sao Tome et Principe 2009,
South Africa Study on Global Ageing and Adult Health 2009,
and Cape Verde 2007 (online-only Data Supplement Table
II). Women had a lower median intercept at 30 years of age
(113.1 mm Hg), ranging from ⬍105 mm Hg in a number of
countries in Asia and the Pacific to ⬎125 mm Hg in Niger
2007 (online-only Data Supplement Table II). SBP slopes and
intercepts in high-income and low- and middle-income coun-
tries were generally similar (Table 1, Figure 2).
Median FPG slope was slightly higher among women than
men (7.7 versus 6.1 mg/dL per 10 years of age); however,
men had higher median intercept at age 30 than women (95.2
versus 89.8 mg/dL) (Table 1, Figure 2). Men and women in
a number of surveys had relatively shallow rise in FPG, ⬍3
mg/dL per 10 years of age in Algeria 2003, Colombia
National Health Survey 2007, England Health Survey for
England 2003, Korea National Health and Nutrition Exami-
nation Survey (NHANES) 2001, Thailand National Health
Examination Survey I 1991, and US NHANES II 1976 to
1980 (online-only Data Supplement Table II). The steepest
rises in FPG per 10 years of age, those ⬎15 mg/dL (and as
high as 20.4 mg/dL), were in men and women in Kuwait
2006, American Samoa 2004, Tokelau 2005, and Nauru
plasma glucose.
2004. Aside from populations in Oceania, the next largest
FPG slopes were in later US surveys of NHANES 2005 to
2006 for women (9.2 mg/dL per 10 years) and NHANES
2003 to 2004 for men (8.0 mg/dL per 10 years). Intercepts
ranged from ⬍86 mg/dL for both men and women in
Colombia 2007 and Nauru 2004 to ⬎110 mm Hg for men and
women in Kiribati 2004, Tokelau 2005, and American Samoa
2004. FPG slopes and intercepts were higher in low- and
middle-income countries than in high-income ones (Table 1,
online-only Data Supplement Table II); the differences were
not statistically significant, possibly because of the relatively
small number of surveys with FPG data.
The age associations for TC had 2 salient features. First,
the TC slopes were markedly higher in women than in men
(Figure 1A), with medians being 15.1 mg/dL and 7.8 mg/dL
per 10 years of age, respectively. In contrast, median intercept
at age 30 of 185.9 mg/dL in women was lower than the 198.6
mg/dL median among men. Second, TC generally was higher
at age 30 and rose more steeply with age in high-income
populations than in low- and middle-income countries (Fig-
ure 2, Table 1). Despite this general pattern, some recent
surveys in high-income countries also had relatively low
slope. The steepest slopes were 15.2 to 17.4 mg/dL per 10
years of age for men in England Health Survey for England
1993 and Ireland Survey of Lifestyle, Attitudes and Nutrition
1998 and 21.7 to 22.4 mg/dL for women in England Health
Survey for England 1993 and US NHANES II. Men in
Kuwait 2006, Nauru 2004, and Korea NHANES 1998, 2001,
and 2005 had relatively little rise in TC with age. The
smallest intercepts at age 30 for men and women were in
Samoa (⬍155 mg/dL), whereas the largest, ⬎200 mg/dL for
women and ⬎215 mg/dL for men were in Germany Bundes-
Gesundheits survey 1998. TC slope and intercept were
correlated with per capita availability of animal fats in the
food supply (with use of data from the food balance sheets of
the Food and Agriculture Organization of the United Na-
tions), with correlation coefficients ranging 0.47 to 0.74 for
intercept and slope in the 2 sexes.
 Singh et al
Downloaded from http://circ.ahajournals.org/ by guest on January 14, 2018
Figure 2. Age association slopes and intercepts of SBP, TC, and FPG for males versus females. Each data point represents an ana-
lyzed survey. The outliers and extremes are identified. See online-only Data Supplement Table II for numeric information for all surveys.
SBP indicates systolic blood pressure; TC, total cholesterol; and FPG, fasting plasma glucose.
Although risk factor slopes and intercepts differed between
men and women, they were moderately correlated across
countries, with correlation coefficients ranging from 0.29 for
SBP to 0.91 for FPG for slopes and from 0.79 for SBP to 0.95
for FPG for intercepts (Figure 2). There was little correlation
among the slopes and intercepts across different risk factors
(pairwise correlations ranged from ⫺0.26 to 0.36), ie, at least
some of the determinants of each risk factor vary across
populations independently of those of other risk factors.
An important finding in some of the countries with
multiple survey rounds over long periods was that age
associations of risk factors have changed over time. For
example, the age associations of SBP and TC became
shallower over multiple rounds of US NHANES and England
Health Survey for England,12 whereas that of FPG became
substantially steeper over multiple NHANES rounds (online-
only Data Supplement Table II).
Figure 3 shows that on average there was a flattening of
age-SBP relationship around age 70 years, especially among
men. FPG and TC age associations reversed in older ages
(⬇55– 60 for TC and 60 – 65 for FPG), leading to lower levels
in older ages than in middle ages. The FPG reversal was more
modest for those surveys with below-median slope. In sec-
ondary analyses, we tested this flattening or reversal of age
association at older ages in individual surveys by fitting a
series of 2-peice linear regressions to those surveys that had
data ⬎65 years. This analysis showed that SBP continued to
Age Association of Metabolic Risk Factors 2207
rise with age beyond 65 years in some surveys, whereas the
rise became more attenuated or stopped in others. TC and
FPG either increased at a slower rate or began to decline in
older ages in most surveys.
Relationship Between Slope and Average Risk
Factor Level in the Population
The strongest relationship between slope and age-
standardized mean was seen for FPG with the regression
coefficient being 0.21 for each decade of life (95% CI 0.12,
0.29) for men and 0.28 (95% CI 0.17, 0.39) for women (Table
2). In other words, populations that had 10 mg/dL higher
age-standardized mean FPG were those in which FPG rose by
an additional 2.1 and 2.8 mg/dL for each decade of age for
men and women, respectively. Mirroring this, the coefficients
of the regression of intercept at 30 on age-standardized mean
FPG were 0.72 (95% CI 0.60, 0.83) for men and 0.64 (95%
CI 0.49, 0.80) for women, which was smaller than those of
SBP and TC (Table 2). Together, these results indicate that
differences in slope account for about one-third to one-half of
the variations in age-standardized mean FPG across popula-
tions. For example, a population with an age-standardized
mean FPG of ⬇150 mg/dL (about the same level as American
Samoa in 2004) versus one that had average FPG of 95 mg/dL
(about the same level as England in 2003) would have an
additional 1.2 to 1.5 mg/dL rise in FPG for each year of age,
or 42 to 53 mg/dL over 35 years. Because intercept is also
 2208 Circulation May 8, 2012
Downloaded from http://circ.ahajournals.org/ by guest on January 14, 2018
higher, by age 65, the Samoans would have a mean FPG that
is higher by 80 to 88 mg/dL. SBP slope had the weakest
association with age-standardized mean SBP, with a regression
coefficient of 0.09 (95% CI 0.04, 0.15) for each decade of life for
men and 0.09 (0.04, 0.14) for women. Consequently, SBP
intercept had the largest association with its age-standardized
mean among the 3 risk factors, with regression coefficients being
0.86 for women and men (Table 2).10
Discussion
Our analysis of health examination surveys found that the age
association of 3 major CVD risk factors, characterized by
their intercept at age 30 years and slope in the subsequent
decades of life, varied substantially among different popula-
tions. SBP had the smallest variation in slope relative to that
of its intercept at age 30 years, and FPG had the opposite
pattern. In other words, more of the cross-population differ-
ences in SBP occurred by age 30 in comparison with those of
FPG which occurred mostly in adult life. We also found that
Figure 3. Average risk factor level by
age in groups of surveys. Survey groups
were formed based on whether slope
between 30 and 64 years for SBP and
FPG (30 –54 years for TC) was in the
lowest, middle, or highest tertile (SBP) or
below/above median (TC and FPG). SBP
indicates systolic blood pressure; TC,
total cholesterol; and FPG, fasting
plasma glucose.
the rise in SBP, TC, and FPG with age generally became
attenuated or even reversed in older ages, as hypothesized in
previous studies using more limited data.13–15 The age at
which change in slope occurred was smallest for TC
(⬇55– 60 years) and largest for SBP (⬇65–70 years). The
reasons for flattening or reversal in older ages requires further
investigation and may include selective early mortality
among those with high risk factor levels, increased use of
medication in older ages,16,17 or possibly cohort effects.
Previous studies, using samples from specific communities
and cohorts, found that some communities had flat or shallow
age associations for these 3 risk factors.4 –11 However, some
of these communities were selected specifically because they
had low CVD risk or diets that were low in salt or animal
products, and thus, by design, were not representative of
national populations. None of the populations in our data had
flat SBP age curves, possibly because national populations
(versus smaller individual communities) are all affected by
major determinants of SBP, especially salt intake. Some
 Singh et al
Table 2. Coefficients of the Regression of the Risk Factor
Age Association Slope/Intercept on Age-Standardized Means
Male Female
Coefficient Coefficient
(95% CI) P (95% CI)
Slope (per decade
of life) of risk
factor age
association
SBP (mmHg) 0.09 (0.04, 0.15) 0.002 0.09 (0.04, 0.14)
TC (mg/dL) 0.10 (0.01, 0.20) 0.048 0.19 (0.06, 0.32)
FPG (mg/dL) 0.21 (0.12, 0.29) ⬍0.001 0.28 (0.17, 0.39) ⬍0.001
Intercept at age 30
of risk factor age
association
SBP (mmHg) 0.86 (0.78, 0.94) ⬍0.001 0.86 (0.79, 0.93) ⬍0.001
TC (mg/dL) 0.85 (0.74, 0.95) ⬍0.001 0.75 (0.59, 0.90) ⬍0.001
Downloaded from http://circ.ahajournals.org/ by guest on January 14, 2018
FPG (mg/dL) 0.72 (0.60, 0.83) ⬍0.001 0.64 (0.49, 0.80) ⬍0.001
SBP indicates systolic blood pressure; TC, total cholesterol; and FPG, fasting
plasma glucose.
populations in our analysis had shallow age associations for
FPG in both sexes and for TC in men.
Western high-income countries had higher slopes and
intercepts for TC, especially in surveys before 2000, possibly
because TC slope is affected by intake of animal fats, often
associated with higher income.18,19 However ,TC slope de-
clined in later surveys in high-income countries, possibly
because of changes in diet or an increase in the use of statins
in middle-aged and older people. There was no association
between national income and the slopes of SBP and FPG.
This may be because salt intake, a major determinant of SBP
in populations,11,20,21 is determined more by cultural and
geographical factors than by national income. Furthermore,
high-income countries may have higher coverage of blood
pressure screening and antihypertensive drug use which
would help attenuate the age association of SBP. There may
also be an independent effect of aging on SBP, eg, because of
vascular stiffness, which would lead to some similarities
across populations.22 This does not explain the nearly flat age
association in some previous studies such as Intersalt.4,6,10 We
found the largest FPG slopes in countries in the Middle East
and Oceania, which also have some of the highest body mass
index levels in the world.23 The age gradients of blood
glucose and diabetes are influenced by body weight and body
composition, although an independent age effect has also
been observed.24 –30 Similarly, between late-1970s and mid-
2000s, when mean body mass index in the United States
increased, FPG age association shifted from one of the
shallowest to one of the steepest worldwide.
Men and women in the same populations were generally on
the low or high side of the distribution of slopes, but slopes
tended to be higher among women than men, especially for
TC, with the opposite pattern for intercepts. Because the data
for men and women are from the same surveys, differences in
measurement methods are unlikely to account for this finding.
We hypothesize 2 potential explanations for the differences in
Age Association of Metabolic Risk Factors 2209
male-female intercept and slope for SBP, TC, and FPG. First,
these differences may be a consequence of differences in
dietary and environmental factors between men and women
in the same country.31–33 Second, the higher slope among
women may be due to real physiological differences, eg,
P
those associated with menopause.34 It is well known that
before menopause women have lower CVD rates and this sex
difference narrows after menopause,35,36 but the evidence for
the role of hormonal factors on postmenopausal increase in
CVD risk factors remains limited and equivocal.37– 41 Under-
0.001
standing the role of dietary, environmental, and reproductive
0.005
factors in male-female blood pressure, cholesterol, and glu-
cose differences at various ages requires individual level
follow-up data or at least surveys with consistent and com-
parable data on such determinants including time since
menopause.
The strengths and innovations of this analysis include the
inclusion of 3 major CVD risk factors; a relatively large
number of surveys from high-income and low- and middle-
income countries, as well; and estimation of slope and
intercept by use of individual records. The limitations of our
analysis include the fact that fewer surveys had measured TC
and FPG than SBP; some regions of the world were underrep-
resented in the data, eg, Latin America; it was not possible to
investigate age associations before age 30; and there were
few countries with repeated surveys over a few decades. The
lack of repeated surveys in most countries restricted our
ability to examine cohort effects, which may be an important
determinant of cross-sectional age patterns. For example, data
from multiple rounds of NHANES, the only survey that
covered ⬎25 years, show that SBP, TC, and FPG had both
age and cohort effects in the United States. Specifically, at
any given age, SBP and TC were generally lower in later birth
cohorts than in earlier ones; FPG was generally higher in later
birth cohorts. A previous analysis used an age and cohort
model on NHANES data and found a continuous decline in
SBP levels and age slope in subsequent birth cohorts in the
United States.12 Median SBP decreased by 2.4 mmHg per
decade of birth year which was still smaller than the age
effect. The SBP decrease by birth cohort was larger in women
than men. Results for TC were similar with median TC
declining by 0.12 mmol/L per decade of birth year.42
It is well established that for individuals and populations,
CVD risk factors are affected by interactions of genetic
factors, diet and adiposity, behavioral and psychosocial fac-
tors, and treatment access and utilization. On the basis of our
findings, an important research need is to use individual
records from longitudinal studies to examine how these risk
factors change over life course,43 especially in relation to
dietary, behavioral, psychosocial, and healthcare determi-
nants. For example, a recent analysis of data from multiple
cohorts in the United Kingdom found that blood pressure rose
through late adulthood, with declining slopes; some of the
rise and the levels in younger ages were associated with body
mass index.44 Furthermore, repeated population health sur-
veys with measurements of CVD risk factors would help
examine how changes in factors like salt and animal fat
intake, adiposity, and the use of antihypertensive drugs and
 2210 Circulation May 8, 2012
statins influence the levels and age patterns of risk factors at
the population level.
Sources of Funding
Dr Ezzati is supported by a strategic award from the UK Medical
Research Council (MRC) and by the National Institute for Health
Research Comprehensive Biomedical Research Centre at Imperial
College London and Imperial College Healthcare NHS Trust. The
analysis of metabolic risk factors was undertaken as a part of the
Global Burden of Diseases, Injuries, and Risk Factors Study. A grant
from the Bill and Melinda Gates Foundation supported the Study’s
core activities and partially supported the analyses in this article. The
results in this article are prepared independently of the final estimates
of the Global Burden of Diseases, Injuries, and Risk Factors Study.
Partial support for the analysis was provided by the Program on the
Global Demography of Aging. The sponsors of the study had no role
in study design, data collection, data analysis, data interpretation,
writing of the report, or decision to submit manuscript.
Disclosures
Gretchen Stevens, Melanie Cowan, and Leanne Riley are staff
Downloaded from http://circ.ahajournals.org/ by guest on January 14, 2018
members of the World Health Organization. The authors alone are
responsible for the views expressed in this publication and they do
not necessarily represent the decisions, policy, or views of the World
Health Organization.
References
1. Sniderman AD, Furberg CD. Age as a modifiable risk factor for cardio-
vascular disease. Lancet. 2008;371:1547–1549.
2. Jemal A, Ward E, Hao Y, Thun M. Trends in the leading causes of death
in the United States, 1970 –2002. JAMA. 2005;294:1255–1259.
3. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and
regional burden of disease and risk factors, 2001: systematic analysis of
population health data. Lancet. 2006;367:1747–1757.
4. Carvalho JJ, Baruzzi RG, Howard PF, Poulter N, Alpers MP, Franco LJ,
Marcopito LF, Spooner VJ, Dyer AR, Elliott P, Stamler J, Stamler R.
Blood pressure in four remote populations in the INTERSALT Study.
Hypertension. 1989;14:238 –246.
5. Connor WE, Cerqueira MT, Connor RW, Wallace RB, Malinow MR,
Casdorph HR. The plasma lipids, lipoproteins, and diet of the Tarahumara
indians of Mexico. Am J Clin Nutr. 1978;31:1131–1142.
6. He J, Klag MJ, Whelton PK, Chen JY, Mo JP, Qian MC, Mo PS, He GQ.
Migration, blood pressure pattern, and hypertension: the Yi Migrant
Study. Am J Epidemiol. 1991;134:1085–1101.
7. Beaglehole R, Foulkes MA, Prior IA, Eyles EF. Cholesterol and mortality
in New Zealand Maoris. BMJ. 1980;280:285–287.
8. Pauletto P, Caroli M, Pessina AC, Dal Palu C. Hypertension prevalence
and age-related changes of blood-pressure in semi-nomadic and urban
Oromos of Ethiopia. Eur J Epidemiol. 1994;10:159 –164.
9. Poulter N, Khaw KT, Hopwood BE, Mugambi M, Peart WS, Rose G,
Sever PS. Blood pressure and associated factors in a rural Kenyan com-
munity. Hypertension. 1984;6:810 – 813.
10. Rodriguez BL, Labarthe DR, Huang B, Lopez-Gomez J. Rise of blood
pressure with age. New evidence of population differences. Hypertension.
1994;24:779 –785.
11. Elliott P, Marmot M, Dyer A, Joossens J, Kesteloot H, Stamler R, Stamler
J, Rose G. The INTERSALT study: main results, conclusions and some
implications. Clin Exp Hypertens A. 1989;11:1025–1034.
12. Goff DC, Howard G, Russell GB, Labarthe DR. Birth cohort evidence of
population influences on blood pressure in the United States, 1887–1994.
Ann Epidemiol. 2001;11:271–279.
13. Lawes CM, Vander Hoorn S, Law M, Elliot P, MacMahon S, Rodgers A.
High blood pressure. In: Ezzati M, Lopez A, Rodgers A, Murray CJM,
eds. Comparative Quantification of Health Risks:Global and Regional
Burden of Disease Attributable to Selected Major Risk Factors. Vol 1.
Geneva, Switzerland: World Health Organization; 2004:281–358.
14. Lawes CM, Vander Hoorn S, Law M, Elliot P, MacMahon S, Rodgers A.
High cholesterol. In: Ezzati M, Lopez A, Rodgers A, Murray CJM, eds.
Comparative Quantification of Health Risks:Global and Regional Burden
of Disease Attributable to Selected Major Risk Factors. Vol 1. Geneva,
Switzerland: World Health Organization; 2004:391– 496.
15. Danaei G, Lawes CM, Vander Hoorn S, Murray CJ, Ezzati M. Global and
regional mortality from ischaemic heart disease and stroke attributable to
higher-than-optimum blood glucose concentration: comparative risk
assessment. Lancet. 2006;368:1651–1659.
16. Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness,
treatment, and control of hypertension, 1988 –2008. JAMA. 2011;303:
2043–2050.
17. Mann D, Reynolds K, Smith D, Muntner P. Trends in statin use and
low-density lipoprotein cholesterol levels among US adults: impact of the
2001 National Cholesterol Education Program guidelines. Ann Pharma-
cother. 2008;42:1208 –1215.
18. Law M. Dietary fat and adult diseases and the implications for childhood
nutrition: an epidemiologic approach. Am J Clin Nutr. 2000;72:
1291S–1296S.
19. Ezzati M, Vander Hoorn S, Lawes CM, Leach R, James WP, Lopez AD,
Rodgers A, Murray CJ. Rethinking the “diseases of affluence” paradigm:
global patterns of nutritional risks in relation to economic development.
PLoS Med. 2005;2:e133.
20. Law MR, Frost CD, Wald NJ. By how much does dietary salt reduction
lower blood pressure? I. Analysis of observational data among popu-
lations. BMJ. 1991;302:811– 815.
21. Elliott P, Stamler J, Nichols R, Dyer AR, Stamler R, Kesteloot H, Marmot
M. Intersalt revisited: further analyses of 24 hour sodium excretion and
blood pressure within and across populations. Intersalt Cooperative
Research Group. BMJ. 1996;312:1249 –1253.
22. Steppan J, Barodka V, Berkowitz DE, Nyhan D. Vascular stiffness and
increased pulse pressure in the aging cardiovascular system. Cardiol Res
Pract. 2011;2011:263585.
23. Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek CJ,
Singh GM, Gutierrez HR, Lu Y, Bahalim AN, Farzadfar F, Riley LM,
Ezzati M. National, regional, and global trends in body-mass index since
1980: systematic analysis of health examination surveys and epidemio-
logical studies with 960 country-years and 9.1 million participants.
Lancet. 2011;377:557–567.
24. Imbeault P, Prins JB, Stolic M, Russell AW, O’Moore-Sullivan T,
Despres JP, Bouchard C, Tremblay A. Aging per se does not influence
glucose homeostasis: in vivo and in vitro evidence. Diabetes Care.
2003;26:480 – 484.
25. Ferrannini E, Vichi S, Beck-Nielsen H, Laakso M, Paolisso G, Smith U.
Insulin action and age. European Group for the Study of Insulin
Resistance (EGIR). Diabetes. 1996;45:947–953.
26. Yang YC, Lu FH, Wu JS, Chang CJ. Age and sex effects on HbA1c. A
study in a healthy Chinese population. Diabetes Care. 1997;20:988 –991.
27. Maneatis T, Condie R, Reaven G. Effect of age on plasma glucose and
insulin responses to a test mixed meal. J Am Geriatr Soc. 1982;30:
178 –182.
28. Meneilly GS, Elahi D, Minaker KL, Sclater AL, Rowe JW. Impairment
of noninsulin-mediated glucose disposal in the elderly. J Clin Endocrinol
Metab. 1989;68:566 –571.
29. Hashimoto Y, Futamura A, Ikushima M. Effect of aging on HbA1c in a
working male Japanese population. Diabetes Care. 1995;18:1337–1340.
30. Iozzo P, Beck-Nielsen H, Laakso M, Smith U, Yki-Jarvinen H, Ferrannini
E. Independent influence of age on basal insulin secretion in nondiabetic
humans. European Group for the Study of Insulin Resistance. J Clin
Endocrinol Metab. 1999;84:863– 868.
31. Lawlor DA, Ebrahim S, Davey Smith G. Sex matters: secular and geo-
graphical trends in sex differences in coronary heart disease mortality.
BMJ. 2001;323:541–545.
32. Lawlor DA, Ebrahim S, Davey Smith G. Role of endogenous oestrogen
in aetiology of coronary heart disease: analysis of age related trends in
coronary heart disease and breast cancer in England and Wales and Japan.
BMJ. 2002;325:311–312.
33. Nikiforov SV, Mamaev VB. The development of sex differences in
cardiovascular disease mortality: a historical perspective. Am J Public
Health. 1998;88:1348 –1353.
34. Matthews KA, Crawford SL, Chae CU, Everson-Rose SA, Sowers MF,
Sternfeld B, Sutton-Tyrrell K. Are changes in cardiovascular disease risk
factors in midlife women due to chronological aging or to the menopausal
transition? J Am Coll Cardiol. 2009;54:2366 –2373.
35. Kannel WB, Hjortland MC, McNamara PM, Gordon T. Menopause and
risk of cardiovascular disease: the Framingham study. Ann Intern Med.
1976;85:447– 452.
36. Kannel WB, Levy D. Menopause, hormones, and cardiovascular vulner-
ability in women. Arch Intern Med. 2004;164:479 – 481.
 Singh et al Age Association of Metabolic Risk Factors 2211

37. Janssen I, Powell LH, Crawford S, Lasley B, Sutton-Tyrrell K.
Menopause and the metabolic syndrome: the Study of Women’s Health
Across the Nation. Arch Intern Med. 2008;168:1568 –1575.
38. Barton M, Meyer MR. Postmenopausal hypertension: mechanisms and
therapy. Hypertension. 2009;54:11–18.
39. Willeit J, Kiechl S, Egger G, Oberhollenzer M, Oberhollenzer F, Muggeo
M, Poewe W, Bonora E. The role of insulin in age-related sex differences
of cardiovascular risk profile and morbidity. Atherosclerosis. 1997;130:
183–189.
40. Cifkova R, Pitha J, Lejskova M, Lanska V, Zecova S. Blood pressure
around the menopause: a population study. J Hypertens. 2008;26:
1976 –1982.
41. Casiglia E, Tikhonoff V, Caffi S, Bascelli A, Schiavon L, Guidotti F,
Saugo M, Giacomazzo M, Martini B, Mazza A, D’Este D, Pessina AC.
Menopause does not affect blood pressure and risk profile, and meno-
pausal women do not become similar to men. J Hypertens. 2008;26:
1983–1992.
42. Goff DC J, Labarthe DR, Howard G, Russell GB. Primary prevention of
high blood cholesterol concentrations in the United States. Arch Intern
Med. 2002;162:913–919.
43. Tate RB, Manfreda J, Cuddy TE. The effect of age on risk factors for
ischemic heart disease: the Manitoba Follow-Up Study, 1948 –1993. Ann
Epidemiol. 1998;8:415– 421.
44. Wills AK, Lawlor DA, Matthews FE, Aihie Sayer A, Bakra E, Ben-Shlomo Y,
Benzeval M, Brunner E, Cooper R, Kivimaki M, Kuh D, Muniz-Terrera G,
Hardy R. Life course trajectories of systolic blood pressure using longitudinal
data from eight UK cohorts. PLoS Med. 2011;8:e1000440.

CLINICAL PERSPECTIVE
Cardiovascular disease (CVD) risk factors, such as systolic blood pressure, total cholesterol, and fasting plasma glucose,
tend to increase with age and these age trends are generally believed to be inevitable. However, it is unclear how much
of these age trends are truly physiological and not due to environment or lifestyle factors. Studies on a few rural populations
in developing countries have reported very little elevation in CVD risk factors with age, suggesting that lifestyle and
Downloaded from http://circ.ahajournals.org/ by guest on January 14, 2018

environmental factors may play an important part in creating age trends. However, there are no comparative multicountry
studies that cover all or large parts of national populations and address multiple risk factors simultaneously. The present
analysis uses data from 83 national and subnational surveys from high- and low/middle-income countries to consistently
estimate the age trends of 3 major CVD risk factors. The results showed that age trends in total cholesterol, fasting plasma
glucose, and systolic blood pressure varied substantially across populations. Total cholesterol increased more rapidly with
age in Western high-income countries, especially before 2000, possibly because total cholesterol slope is affected by
animal fat intake. The largest fasting plasma glucose slopes were in Oceania, the Middle East, and, more recently, the
United States, which also have high body mass index levels. Age trends in systolic blood pressure had no specific income
or geographical pattern, possibly because salt intake is determined more by cultural factors. These cross-population
variations indicate that environmental and lifestyle factors play a large role in determining age trends in metabolic risk
factors of CVD and emphasize the importance of life-long prevention to attenuate and delay the age-related increases in
CVD risk.
 The Age Associations of Blood Pressure, Cholesterol, and Glucose: Analysis of Health
Examination Surveys From International Populations
Gitanjali M. Singh, Goodarz Danaei, Pamela M. Pelizzari, John K. Lin, Melanie J. Cowan,
Gretchen A. Stevens, Farshad Farzadfar, Young-Ho Khang, Yuan Lu, Leanne M. Riley, Stephen
S. Lim and Majid Ezzati
Downloaded from http://circ.ahajournals.org/ by guest on January 14, 2018

Circulation. 2012;125:2204-2211; originally published online April 4, 2012;

doi: 10.1161/CIRCULATIONAHA.111.058834
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2012 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539

The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circ.ahajournals.org/content/125/18/2204

Data Supplement (unedited) at:

http://circ.ahajournals.org/content/suppl/2012/04/04/CIRCULATIONAHA.111.058834.DC1

Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published
in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial
Office. Once the online version of the published article for which permission is being requested is located,
click Request Permissions in the middle column of the Web page under Services. Further information about
this process is available in the Permissions and Rights Question and Answer document.

Reprints: Information about reprints can be found online at:

http://www.lww.com/reprints

Subscriptions: Information about subscribing to Circulation is online at:

http://circ.ahajournals.org//subscriptions/
SUPPLEMENTAL MATERIAL
Supplemental Tables

Table S1: Surveys included in the analysis and their characteristics

 Data SBP TC FPG
Survey population (national / sub-
Region Country (Survey) Year above 65 Sample size Sample size Sample size
national)*
years
Female Male Female Male Female Male
High income
E t Asia
East Ai S th Korea
South K (K NHANES)
(K-NHANES) 1998 Y N ti l with
National ith sample
l weights
i ht 5257 4514 5257 4514 5257 4514
East Asia South Korea (K-NHANES) 2001 Y National with sample weights 4051 3269 4313 3552 4295 3487
East Asia South Korea (K-NHANES) 2005 Y National with sample weights 3630 2863 3585 2827 3559 2804
Australasia Australia (AUSDIAB) 2001 Y National with sample weights 4530 3645 3480 2759 4575 3687
Australasia Australia (RFPS) 1989 N sub-national 3483 3360 2662 2577 -- --
Western Europe Germany (BGS) 1998 Y National with sample weights 2318 2145 1679 1625 -- --
Western Europe Ireland (SLAN) 1998 Y National without sample weights 225 79 170 58 -- --
Western Europe Ireland (SLAN) 2002 Y National without sample weights 142 107 117 76 -- --
Western Europe Scotland (Scottish Health Survey) 1995 N sub-national† 2850 2318 -- -- -- --
Western Europe Scotland (Scottish Health Survey) 1998 N sub-national† 2669 2201 1676 1385 -- --
Western Europe Scotland (Scottish Health Survey) 2003 Y sub-national† 1908 1465 1041 841 -- --
Western Europe England (HSE) 1991-1992 Y sub-national† 1629 1672 1180 1122 -- --
Western Europe England (HSE) 1993 Y sub-national† 3846 4031 2864 2723 -- --
Western Europe England (HSE) 1994 Y sub-national† 3644 3684 2657 2509 -- --
Western Europe England (HSE) 1995 Y sub-national† 4243 3780 -- -- -- --
Western Europe England (HSE) 1996 Y sub-national† 2128 4432 -- -- -- --
Western Europe England (HSE) 1997 Y sub-national† 2371 2128 -- -- -- --
Western Europe England (HSE) 1998 Y sub-national† 3889 3704 2705 2454 -- --
Western Europe
Weste u ope England
g a d (HSE)
( S ) 2001
00 Y sub-national
sub at o a † 2133
33 1249
9 -- -- -- --
Western Europe England (HSE) 2002 Y sub-national† 1085 554 -- -- -- --
Western Europe England (HSE) 2003 Y sub-national† 1949 1173 2070 1803 351 283
Western Europe England (HSE) 2005 Y sub-national† 940 591 -- -- -- --
Western Europe England (HSE) 2006 Y sub-national† 1733 1118 1873 1528 --
Western Europe England (HSE) 2007 Y sub-national† 819 522 -- -- -- --
Middle East Kuwait (STEP) 2006 N National with sample weights 1052 696 866 545 962 629
Middle East Qatar (GCC) 2006 N National with sample weights 1427 1406 -- -- -- --
North America Canada (Heart Health Survey) 1989 N National with sample weights 5882 5671 -- -- -- --
North America US (NHANES II) 1976-1980 N National with sample weights 3438 3118 2153 1915 1218 1057
North America US (NHANES III) 1998-1994 Y National with sample weights 4597 4024 3549 2974 4634 4000
 Data SBP TC FPG
Survey population (national / sub-
Region Country (Survey) Year above 65 Sample size Sample size Sample size
national)*
years
Female Male Female Male Female Male
North America US (NHANES) 1999-2002 Y National with sample weights 2368 2225 1950 1767 1288 1210
N th A
North i
America US (NHANES) 2003 2004
2003-2004 Y N ti l with
National ith sample
l weights
i ht 1067 990 868 920 615 538
North America US (NHANES) 2005-2006 Y National with sample weights 1150 1098 972 928 616 594
Low or middle income
Central Asia Mongolia (STEP) 2005 N National with sample weights 1213 1154 -- -- -- --
East Asia China (CHNS) 1991 Y sub-national 2362 2432 -- -- -- --
East Asia China (CHNS) 1993 Y sub-national 2435 2460 -- -- -- --
East Asia China (CHNS) 1997 Y sub-national 2943 2643 -- -- -- --
East Asia China (CHNS) 2000 Y sub-national 3372 3071 -- -- -- --
East Asia China (SAGE) 2009 N National without sample weights 1685 1558 -- -- -- --
South Asia India (SAGE) 2007 N National with sample weights 4376 2715 -- -- -- --
Southeast Asia Indonesia (FLS 3) 2000 Y sub-national 6752 5954 -- -- -- --
Southeast Asia Sri Lanka (STEP) 2006 N National without sample weights 4409 4331 -- -- -- --
Southeast Asia Thailand (NHES 1) 1992 Y National with sample weights 4945 3606 3496 2688 4359 3360
Southeast Asia Thailand (NHES 2) 1997 Y National without sample weights 2154 1437 1011 598 -- --
Southeast Asia Thailand (NHES 3) 2004 Y National with sample weights 11931 10505 7282 6188 11321 9948
Southeast Asia Vietnam (NHS) 2002 Y National with sample weights 30664 26079 -- -- -- --
Eastern Europe Russia (LMS) 1993 Y National without sample weights 2847 4033 -- -- -- --
Eastern Europe Russia (LMS) 1994 Y National without sample weights 3590 2847 -- -- -- --
Eastern
aste Europe
u ope Russia
uss a ((LMS)
S) 1992-1993
99 993 Y National
Nat o a wwithout
t out sample
sa p e weights
we g ts 3760 2995
995 -- -- -- --
Latin America and Caribbean Colombia (National Health Survey) 2007 N National with sample weights 4813 3332 4018 2688 4811 3283
Latin America and Caribbean Dominica (STEP) 2007 N National with sample weights 407 330 -- -- -- --
Latin America and Caribbean Mexico (ENSA) 2000 Y National with sample weights 6388 15413 -- -- -- --
Latin America and Caribbean Mexico (ENSANUT) 2006 Y National with sample weights 13214 8625 -- -- -- --
Latin America and Caribbean St. Kitts (STEP) 2007 N sub-national 688 396 -- -- -- --
Middle East Algeria (STEP) 2003 N sub-national 1998 1357 1436 933 1693 1131
Middle East Iran (NCDS) 2005 N National with sample weights 27622 27879 15979 14480 22263 20750
Middle East Turkey (PatenT) 2003 Y National without sample weights 1186 1820 -- -- -- --
Oceania American Samoa (STEP) 2004 N National without sample weights 937 824 -- -- 894 783
Oceania Cook Islands (STEP) 2003 N National without sample weights 858 845 -- -- -- --
 Data SBP TC FPG
Survey population (national / sub-
Region Country (Survey) Year above 65 Sample size Sample size Sample size
national)*
years
Female Male Female Male Female Male
Oceania Fiji (STEP) 2002 N National without sample weights 2572 1732 -- -- -- --
O i
Oceania Ki ib ti (STEP)
Kiribati 2004 N N ti l without
National ith t sample
l weights
i ht 664 521 -- -- 537 431
Oceania Marshall Islands (STEP) 2002 N National without sample weights 638 418 -- -- -- --
Oceania Micronesia (STEP) 2003 N sub-national 836 548 -- -- -- --
Oceania Nauru (STEP) 2004 N National with sample weights 753 681 692 615 697 628
Oceania Samoa (STEP) 2002 N National without sample weights 1161 967 858 705 1106 923
Oceania Solomon Islands (STEP) 2005 N sub-national 794 551 -- --
Oceania Tokelau (STEP) 2005 N National without sample weights 208 169 125 113 206 168
Oceania Tonga (STEP) 2004 N National without sample weights 447 309 -- --
Oceania Vanuatu (STEP) 2005 N sub-national 415 315 -- -- -- --
Sub-Saharan Africa Benin (STEP) 2008 N National without sample weights 2818 2813 -- -- -- --
Sub-Saharan Africa Botswana (STEP) 2007 N National with sample weights 2000 896 -- -- -- --
Sub-Saharan Africa Cameroon (STEP) 2003 N sub-national 2714 1753 -- -- -- --
Sub-Saharan Africa Cape Verde (STEP) 2007 N National with sample weights 963 542 -- -- -- --
Sub-Saharan Africa Eritrea (STEP) 2004 N National without sample weights 784 787 -- -- -- --
Sub-Saharan Africa Ethiopia (STEP) 2006 N sub-national 1971 1277 -- -- -- --
Sub-Saharan Africa Gabon (STEP) 2009 N sub-national 924 719 -- -- -- --
Sub-Saharan Africa Ghana (SAGE) 2009 N National with sample weights 1254 1605 -- -- -- --
Sub-Saharan Africa Madagascar (STEP) 2005 N sub-national 2208 2148 -- -- -- --
Sub-Saharan
Sub Sa a a Africa
ca Mozambique
o a b que (S
(STEP)) 2005
005 N National
Nat o a wwithout
t out sample
sa p e weights
we g ts 1380
380 1015
0 5 -- -- -- --
Sub-Saharan Africa Niger (STEP) 2007 N National without sample weights 768 1057 -- -- -- --
Sub-Saharan Africa Sao Tome et Principe (STEP) 2009 N National without sample weights 1063 760 -- -- -- --
Sub-Saharan Africa Seychelles (STEP) 2004 N National with sample weights 617 513 428 350 606 494
Sub-Saharan Africa South Africa (DHS) 1998 Y National with sample weights 4008 2635 -- -- -- --
Sub-Saharan Africa South Africa (SAGE) 2009 N National with sample weights 1699 1301 -- -- -- --
*
Sub-national refers to surveys that cover multiple communities or regions within a country.

† Surveys designed to be representative of all of England or Scotland, similar to a national survey. Their classification as subnational here is simply
because they do not cover all of UK
**Of surveys that met eligibility criteria (subnational or national survey, covering at least some decades of middle-age and older adult ages), we excluded the
following surveys for reasons stated:
RLMS 1992 – First round of survey, documentation cited issues in data collection.
England HSE 1999 – Oversampled minorities and not representative when individual records used for estimating intercept and slope.
England HSE 2004 – Oversampled minorities and not representative when individual records used for estimating intercept and slope.
Mexico ENSA 2000 – How sample was selected for lab measurement was unknown at the time of analysis; excluded from FPG and TC analysis.
Thailand NHES2 – Fasting level of full sample was known; excluded from FPG analysis.
Jordan BRFSS 2004 and 2007 – How sample was selected for physical and lab measurement was unknown at the time of analysis.

 
Table S2: Age association slope and intercept for surveys used in the analysis
 SBP (mmHg) TC (mg/dL) FPG (mg/dL) SBP (mmHg) TC (mg/dL) FPG (mg/dL)
Slope per decade of age Slope per decade of age Slope per decade of age Intercept at age 30 Intercept at age 30 Intercept at age 30
Region Country (Survey) Year Female Male Female Male Female Male Female Male Female Male Female Male
High income
East Asia South Korea (K-NHANES) 1998 8.09 4.29 12.95 1.45 6.25 4.65 110.81 121.26 170.79 189.09 91.79 96.01
East Asia South Korea (K-NHANES) 2001 8.26 4.57 14.69 2.30 3.32 2.40 106.12 118.87 182.60 207.55 92.15 95.96
East Asia South Korea(K-NHANES) 2005 8.39 5.05 12.37 1.30 4.24 5.02 102.56 114.63 166.82 185.71 86.69 91.22
Australasia Australia (AUSDIAB) 2001 7.61 5.12 14.28 9.64 4.14 5.41 108.92 119.84 192.03 207.47 90.76 94.44
Australasia Australia (RFPS) 1989 9.46 6.32 16.38 11.75 107.18 118.39 187.53 204.25
Western Europe Germany (BGS) 1998 10.60 6.40 17.51 14.55 115.95 126.37 204.75 219.48
Western Europe Ireland (SLAN) 1998 10.61 7.09 21.01 17.42 107.65 122.84 177.01 193.22
Western Europe Ireland (SLAN) 2002 6.44 7.03 21.01 17.42 118.84 124.09 177.01 193.22
Western Europe Scotland (Scottish Health Survey) 1995 8.46 4.46 113.86 126.62
Western Europe Scotland (Scottish Health Survey) 1998 8.30 4.83 18.75 11.81 114.18 125.74 185.70 204.14
Western Europe Scotland (Scottish Health Survey) 2003 7.44 3.53 19.34 11.19 112.26 125.51 190.56 208.00
Western Europe England (HSE) 1991-1992 8.80 5.04 20.66 12.68 119.08 130.02 192.81 212.94
Western Europe England (HSE) 1993 8.14 5.04 21.70 12.77 118.90 130.23 191.40 214.64
Western Europe England (HSE) 1994 8.18 4.93 20.29 15.20 117.51 128.45 195.04 213.80
Western Europe England (HSE) 1995 7.78 4.70 118.45 129.27
Western Europe England (HSE) 1996 8.36 4.79 117.86 129.10
Western Europe England (HSE) 1997 7.71 4.39 117.73 129.04
Western Europe England (HSE) 1998 7.68 4.34 16.68 9.91 116.70 128.14 187.59 203.72
Western Europe England (HSE) 2001 7.25 4.50 118.29 128.04
Western Europe England (HSE) 2002 7.41 4.42 117.55 127.23
Western Europe England (HSE) 2003 6.94 3.69 17.75 9.52 0.93 4.06 112.55 125.62 190.25 211.77 88.08 86.40
Western Europe England (HSE) 2005 6.22 3.12 112.89 126.16
Western Europe England (HSE) 2006 6.45 3.53 17.42 9.18 112.33 125.50 185.87 204.79
Western Europe England (HSE) 2007 6.73 3.32 111.99 124.54
Middle East Kuwait (STEP) 2006 7.65 5.25 8.64 0.19 20.42 18.38 111.13 116.84 187.35 202.86 82.93 91.40
Middle East Qatar (GCC) 2006 8.15 4.46 114.39 123.14
North America Canada (Heart Health Survey) 1989 8.15 6.12 108.64 119.66
North America US (NHANES II) 1978 8.79 4.69 22.44 11.68 3.36 2.90 111.10 122.57 186.45 202.76 88.03 92.29
North America US (NHANES III) 1991 8.70 5.67 16.81 7.96 7.77 6.06 109.10 118.24 182.57 198.73 89.77 94.53
North America US (NHANES) 2000 8.62 4.27 8.48 7.32 7.22 7.08 107.23 116.92 193.04 198.04 89.55 95.25
North America US (NHANES) 2004 8.63 4.41 5.01 7.76 7.67 7.97 107.46 116.42 196.76 198.52 89.73 95.88
North America US (NHANES) 2006 8.57 3.96 3.75 5.73 9.23 7.78 106.05 117.76 196.37 196.31 90.35 95.74
Low or middle income
Central Asia Mongolia (STEP) 2005 8.72 6.78 -- -- -- -- 116.90 124.66 -- -- -- --
East Asia China (CHNS) 1991 6.47 5.33 -- -- -- -- 104.03 109.15 -- -- -- --
East Asia China (CHNS) 1993 6.48 4.42 -- -- -- -- 104.16 110.55 -- -- -- --
East Asia China (CHNS) 1997 6.64 4.35 -- -- -- -- 107.15 113.38 -- -- -- --
East Asia China (CHNS) 2000 6.65 4.51 -- -- -- -- 107.21 113.96 -- -- -- --
East Asia China (SAGE) 2009 7.91 5.33 -- -- -- -- 115.52 123.37 -- -- -- --
South Asia India (SAGE) 2007 4.22 2.06 -- -- -- -- 110.83 113.91 -- -- -- --
Southeast Asia Indonesia (FLS 3) 2000 9.77 6.66 -- -- -- -- 114.25 119.16 -- -- -- --
Southeast Asia Sri Lanka (STEP) 2006 6.95 4.43 -- -- -- -- 114.35 121.89 -- -- -- --
Southeast Asia Thailand (NHES 1) 1992 5.91 3.54 10.92 5.68 4.32 2.79 108.24 112.33 177.34 179.12 91.82 91.57
Southeast Asia Thailand (NHES 2) 1997 7.90 6.24 16.07 5.21 108.58 115.85 188.23 190.57 -- --
Southeast Asia Thailand (NHES 3) 2004 7.03 5.19 14.86 5.02 7.36 4.16 108.43 114.48 185.67 195.33 86.03 93.15
 SBP (mmHg) TC (mg/dL) FPG (mg/dL) SBP (mmHg) TC (mg/dL) FPG (mg/dL)
Slope per decade of age Slope per decade of age Slope per decade of age Intercept at age 30 Intercept at age 30 Intercept at age 30
Region Country (Survey) Year Female Male Female Male Female Male Female Male Female Male Female Male
Southeast Asia Vietnam (NHS) 2002 7.59 5.33 -- -- -- -- 107.98 115.04 -- -- -- --
Eastern Europe Russia (LMS) 1993 8.91 4.37 -- -- -- -- 112.36 121.44 -- -- -- --
Eastern Europe Russia (LMS) 1994 8.89 4.40 -- -- -- -- 112.24 121.47 -- -- -- --
Eastern Europe Russia (LMS) 1992-1993 9.07 5.19 -- -- -- -- 113.86 122.03 -- -- -- --
Latin America and Caribbean Colombia (National Health Survey) 2007 9.82 5.96 15.00 6.90 4.53 2.50 111.28 122.54 164.63 175.79 80.61 85.58
Latin America and Caribbean Dominica (STEP) 2007 10.52 5.71 -- -- -- -- 117.91 127.27 -- -- -- --
Latin America and Caribbean Mexico (ENSA) 2000 6.56 3.77 -- -- -- -- 113.65 119.93 -- -- -- --
Latin America and Caribbean Mexico (ENSANUT) 2006 6.57 3.86 -- -- -- -- 112.39 119.08 -- -- -- --
Latin America and Caribbean St. Kitts (STEP) 2007 9.22 5.77 -- -- -- -- 116.53 128.48 -- -- -- --
Middle East Algeria (STEP) 2003 8.37 6.09 4.04 3.28 2.63 0.83 119.46 119.44 182.74 177.15 87.43 89.28
Middle East Iran (NCDS) 2005 9.16 6.09 15.12 6.94 8.11 4.57 110.62 115.79 184.70 188.99 97.78 100.45
Middle East Turkey (PatenT) 2003 5.65 10.65 -- -- -- -- 118.95 118.01 -- -- -- --
Oceania American Samoa (STEP) 2004 8.79 5.09 -- -- 16.05 12.33 117.10 129.21 -- -- 122.13 129.59
Oceania Cook Islands (STEP) 2003 8.06 5.64 -- -- -- -- 115.65 127.38 -- -- -- --
Oceania Fiji (STEP) 2002 8.81 3.40 -- -- -- -- 114.07 122.41 -- -- -- --
Oceania Kiribati (STEP) 2004 4.31 3.08 -- -- 11.18 13.91 111.55 121.91 -- -- 111.86 113.21
Oceania Marshall Islands (STEP) 2002 10.35 4.67 -- -- -- -- 101.62 114.91 -- -- -- --
Oceania Micronesia (STEP) 2003 7.58 4.47 -- -- -- -- 109.97 123.52 -- -- -- --
Oceania Nauru (STEP) 2004 11.27 6.56 13.88 2.99 19.59 12.71 111.21 124.88 175.22 180.09 75.96 79.94
Oceania Samoa (STEP) 2002 8.61 3.69 11.21 10.40 14.69 10.82 111.20 125.40 152.87 154.95 101.76 106.00
Oceania Solomon Islands (STEP) 2005 7.63 2.93 -- -- -- -- 106.99 114.01 -- -- -- --
Oceania Tokelau (STEP) 2005 10.71 2.04 8.52 15.41 18.28 11.61 103.28 122.43 184.40 174.44 110.24 127.60
Oceania Tonga (STEP) 2004 6.47 2.04 -- -- -- -- 114.90 126.37 -- -- -- --
Oceania Vanuatu (STEP) 2005 8.88 2.79 -- -- -- -- 123.42 130.51 -- -- -- --
Sub-Saharan Africa Benin (STEP) 2008 8.48 4.09 -- -- -- -- 115.61 125.07 -- -- -- --
Sub-Saharan Africa Botswana (STEP) 2007 8.80 3.99 -- -- -- -- 120.24 125.65 -- -- -- --
Sub-Saharan Africa Cameroon (STEP) 2003 9.12 5.90 -- -- -- -- 112.33 120.44 -- -- -- --
Sub-Saharan Africa Cape Verde (STEP) 2007 9.37 1.71 -- -- -- -- 120.53 136.49 -- -- -- --
Sub-Saharan Africa Eritrea (STEP) 2004 8.11 4.10 -- -- -- -- 107.30 116.01 -- -- -- --
Sub-Saharan Africa Ethiopia (STEP) 2006 8.38 8.34 -- -- -- -- 115.93 119.77 -- -- -- --
Sub-Saharan Africa Gabon (STEP) 2009 6.67 4.92 -- -- -- -- 117.39 123.65 -- -- -- --
Sub-Saharan Africa Ghana (SAGE) 2009 5.52 3.04 -- -- -- -- 119.43 124.77 -- -- -- --
Sub-Saharan Africa Madagascar (STEP) 2005 7.83 5.09 -- -- -- -- 119.09 123.44 -- -- -- --
Sub-Saharan Africa Mozambique (STEP) 2005 10.60 6.60 -- -- -- -- 120.48 126.87 -- -- -- --
Sub-Saharan Africa Niger (STEP) 2007 7.63 5.81 -- -- -- -- 125.84 130.04 -- -- -- --
Sub-Saharan Africa Sao Tome et Principe (STEP) 2009 11.63 5.16 -- -- -- -- 120.52 132.25 -- -- -- --
Sub-Saharan Africa Seychelles (STEP) 2004 8.82 6.49 16.26 3.05 12.23 9.18 113.08 123.92 187.96 207.56 88.00 97.68
Sub-Saharan Africa South Africa (DHS) 1998 7.52 5.14 -- -- -- -- 110.34 117.92 -- -- -- --
Sub-Saharan Africa South Africa (SAGE) 2009 6.73 3.74 -- -- -- -- 123.51 132.74 -- -- -- --