Abstract
Background
The relationship between high sodium intake (HSI) and hypertensive heart disease (HHD) has been confirmed. However, notable regional disparities exist in implementing effective measures to control sodium intake. This study was carried out to estimate the spatiotemporal trends in the burden of HHD attributable to HSI.
Methods
Data obtained from the Global Burden of Disease Study 2021 were analyzed, considering factors such as age, gender, year, and region. Joinpoint regression analysis was applied to investigate the temporal trends in the HHD burden resulting from HSI over the past 32 years.
Results
From 1990 to 2021, the global cases of HHD increased significantly annually. The age-standardized prevalence rates showed a slow gradual increase. However, both the age-standardized death and disability-adjusted life-year (DALY) rates decreased. Specifically, HSI was responsible for 29.2% of total HHD deaths and 30.4% of total DALYs in 1990 but only 22.8% of total HHD deaths and 23.4% of total DALYs in 2021. A greater burden from HSI exposure was observed among men, older adults and people living in middle and low sociodemographic index (SDI) countries and regions. Moreover, over the 32-year period, Guam and Colombia demonstrated the highest reduction in age-standardized death and DALY rates, respectively.
Conclusion
Globally, the age-standardized burden of HHD due to HSI has demonstrated a decline. Although some areas have effectively managed this issue, it remains a challenge in specific areas. Hence, it is crucial to examine and implement the strategies adopted by successful nations to further mitigate this burden.
Introduction
Cardiovascular disease (CVD) remains the leading cause of mortality worldwide and profoundly affects quality of life , . Hypertensive heart disease (HHD) primarily arises from chronic uncontrolled hypertension, leading to functional and structural impairments, chiefly impacting the left ventricle, left atrium, and coronary arteries . This condition constitutes a pivotal mechanism contributing to both the incidence and mortality of CVD. HHD encompasses a spectrum of conditions spanning from uncontrolled hypertension to heart failure. With the projected increase in hypertension prevalence and life expectancy over the next decade, HHD might play a more prominent role in influencing human health . Therefore, it is essential to deepen our understanding of the global burden of HHD.
Risk factors for HHD include older age, obesity, sedentary lifestyle, high sodium intake (HSI), alcohol consumption, and diabetes . Notably, hypertension is the predominant risk factor for the development of HHD , . These factors collectively contribute to heightened hemodynamic pressure on the heart. In response to the related chronic disease, left ventricular hypertrophy serves as a compensatory mechanism, however, it may lead to heart failure over time . Importantly, HSI is consistently associated with hypertension, rendering it a significant dietary risk factor for cardiovascular disease . Sodium is crucial for meeting physiological requirements in humans, while excessive consumption commonly surpasses actual needs , . In recognition of this fact, the World Health Organization in 2013 recommended that all member countries aim to reduce population salt intake by 30% by 2025 to mitigate premature mortality linked to with related diseases . Nonetheless, significant regional disparities exist in implementing strategies to control sodium intake effectively.
A healthy dietary pattern is a global priority for reducing non-communicable diseases, and assessing the impact of HSI on HHD burden is crucial for comprehensive assessment. Currently, there is no direct epidemiological analysis examining the global, regional, and national burden of HHD attributed to HSI. Therefore, we conducted a comprehensive analysis of the disease burden attributable to HSI on a global, regional, and national scale using date from the Global Burden of Disease (GBD) Study 2021. Meanwhile, we investigated the correlation between HHD burden and various factors. The study aimed to estimate the spatiotemporal trends of the HSI-related HHD burden and provide valuable insights for health policy decision-making to mitigate the impact of HHD on the global burden of cardiovascular diseases.
Materials and methods
Data source and definitions
The data concerning the global burden of HHD attributed to HSI is derived from the 2021 GBD study. The primary objective of this study is to furnish dependable and current global, regional, and national findings regarding the prevalence of diseases, injuries, and risk factors , . HHD was identified based on the following International Classification of Diseases (ICD) codes: 402–402.9 (ICD-9) and I11–I11.9 (ICD-10). In accordance with the guidelines provided by the GBD, HSI is quantified in grams per day (g/d), and information pertaining to sodium consumption is obtained from the concentration of sodium in 24-hour urine samples .
Furthermore, the burden of disease was assessed using the disability-adjusted life-year (DALY) rate and the age-standardized death rate (ASDR). The world is divided into 21 regions based on geography. The sociodemographic index (SDI) serves as a composite indicator to evaluate the development status of a location, including low SDI, low-middle SDI, middle SDI, high-middle SDI, and high SDI . Through the Global Health Data Exchange (GHDx) query tool ( http://ghdx.healthdata.org/gbd-results-tool ), detailed information on fatalities, DALYs and corresponding age-standardized Rates (ASRs) attributed to HSI from 1990 to 2021 were obtained. This data was further disaggregated by age, gender, location, year and SDI. The methodologies employed in GBD 2021 and the techniques for estimating disease burden have been explicated in previous research .
Analysis procedures
Initially, an analysis was conducted on the global burden of HHD, focusing on the ASRs of prevalence, mortality, and DALY changes from 1990 to 2021 to determine the trend in the burden of HHD. Subsequently, the global burden of HHD attributable to HSI during the same timeframe was evaluated. Further investigations were conducted to analyze the attributable burdens in detail, considering factors such as year, age, gender, location, and SDI to ascertain the impact of HSI on HHD. To compare data across various populations or within the same population across different time periods, the ASDR and age-standardized DALY were used to eliminate the influences of varying population structure.
Statistical analysis
The ASR served as an indicator designed to mitigate the influence of variations in population age distributions . It was calculated as the aggregate of products derived from specific age-specific rates per 100,000 population. All cases and their corresponding ASRs per 100 000 people were recorded with 95% uncertainty intervals (UIs) . The 95% UIs for all estimates in the GBD study were applied using the DisMod-MR 2.1 tool. DALYs were the sum of years lived with disability (YLDs) and years of life lost (YLL), with each DALY representing one year of healthy life lost . YLL were equal to deaths multiplied by the standard life expectancy at each age, while YLDs were derived from the prevalence multiplied by disability weights for mutually exclusive sequelae of diseases and injuries. Additionally, the annual percentage change (APC) was used to estimate the rate of change over a specific time period . This study utilized Joinpoint to evaluate the temporal trend of age-standardized DALY and death rates. The increase and decrease trends of the rates can be expressed through changes in the slope of the curve over time. Joinpoint regression analysis was conducted employing Joinpoint software (version 4.7.0). All analyses were performed with R software (version 3.5.2) by the R Core Team, located in Vienna, Austria. Data are reported with values accompanied by 95% confidence intervals (CIs) or 95% uncertainty intervals (UIs). Furthermore, Pearson correlation tests were conducted to assess the association between the burden of HHD due to HSI and the SDI to determine the influence of sociodemographic variables on this burden.
Results
1990–2021 Global HHD disease burden trends
The global disease burden of HHD increased considerably from 1990 to 2021 ( Fig. 1 and Supplementary Table S1 ). The age-standardized prevalence rate rose from 125.4 (95% UI: 99.0-158.0) per 100,000 people in 1990 to 148.3 (95% UI: 117.3-186.3) per 100,000 people in 2021. Similarly, the prevalence increased from 4.6 million (95% UI: 3.7-5.8) in 1990 to 12.5 million (95% UI: 9.9-15.8) in 2021. In contrast, the ASDR decreased from 20.9 (95% UI: 17.1-23.2) per 100,000 people to 16.3 (95% UI: 13.8-18.0) per 100,000 people during the same period. Nevertheless, the number of global HHD deaths increased from 0.7 million (95% UI: 0.6-0.8) in 1990 to 1.3 million (95% UI: 1.1-1.5) in 2021, an 85.7% increase. Moreover, while the rate of age-standardized DALY decreased from 406.5/100 000 people to 301.6 /100 000 people, the number of DALYs increased from 15.5 million (95% UI: 12.3-17.3) in 1990 to 25.5 million (95% UI: 21.5-28.0) in 2021. In terms of the prevalence, deaths and DALYs, all shown a substantial yearly increase from 1990 to 2021. The age-standardized prevalence rate has gradually risen, with the lowest prevalence recorded in 1990 and the highest in 2021. Conversely, the ASDR and age-standardized DALY rate generally exhibit a decreasing trend.
Global burden of HHD attributable to HSI in 2021
Except for a few regions, there were increases in the global and regional burdens of HHD attributable to HSI from 1990 to 2021, details of which are provided in Supplementary Table S2 . Specifically, in 2021, HSI contributed to 6.0 million (95% UI: 1.5-12.3) DALYs and 304.0 thousand (95% UI: 63.8-641.1) deaths worldwide due to HHD. In 1990, HSI was responsible for 29.2% of all total deaths and 30.4% of total DALYs caused by HHD, compared to 22.8% of total deaths and 23.4% of total DALYs in 2021. A reduction was observed in the proportion of deaths and DALYs of HHD resulting from HSI.
Temporal trends in the HHD burden attributable to HSI
Since 1990, there has been a significant reduction in age-standardized deaths and DALY rates attributed to HSI exposure in HHD. However, the age-standardized death and DALY rates caused by this risk factor exhibited different trends. Fig. 2 indicated that the age-standardized DALY rate dropped markedly with varying APCs since 1990 ( P < 0.001), resulting in a notable overall burden reduction of 42.4% by 2021. The most significant decline occurred between 1992 and 1998 (APC=3.18%, P < 0.001). Additionally, while there has been a general downward trajectory, the ASDR increased with a 0.05% APC ( P = 0.072) between 2006 and 2017. In other time periods, the HSI-attributable ASDR for HHD decreased with varying APCs, with the most notable reduction occurring once again between 1992 and 1998 (APC=3.01%, P < 0.001).
Age- and sex-specific HHD burden attributable to HSI
As depicted in Supplementary Fig. S1 , HSI contributed the most to the burden of HHD among people aged 50-74 years. The HHD burden related to HSI this age group exhibited a “V-shaped” trend, with the lowest burden recorded in 2006. From 1990 to 2021, the HSI-attributable ASDR of HHD remained stable among people aged <49 years, while DALYs presented slight fluctuations in this population. Besides, the burden associated with HSI for the older people showed slight fluctuated from 1990 to 2006, but there was a significant upward trend between 2006 and 2021.
In the subgroup analysis by gender, the overall burden of HHD attributable to HSI was higher in males compared to females, except the population over 95 years old. Significant disparities existed between females and males in different age groups in terms of DALYs and deaths attributable to HSI ( Fig. 3 ). The DALY and death rates of HHD caused by HSI increase with age in both genders, with the highest rate observed in people aged over 95 years old. Overall, the increase in DALY and death rates tends to be more pronounced among females compared to males, except in the specific age group.
Regional and national HHD burdens attributable to HSI
Regionally, Eastern Sub-Saharan Africa exhibited the highest age-standardized DALY and death rates attributable to HSI in both 1990 and 2021 ( Fig. 4 A and B ). In contrast, Australia recorded the lowest rates during the same period. Notably, High-income North America experienced the most rapid growth in age-standardized DALY and death rates from 1990 to 2021, with percentages increasing by 190% and 170% respectively. Meanwhile, the most considerable reduction in both age-standardized DALY and death rates were observed in High-income Asia Pacific, with a decrease of 70%.
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