Reduced protein for late-lactation dairy cows

Excess protein in dairy cattle diets unnecessarily increases the cost of production and may contribute to environmental pollution. The objective of this research was to evaluate the effect of feeding dairy cows with two levels of dietary protein on animal performance and manure characteristics. Two experiments were carried out with 24 lactating dairy cows each. Experiment 1 was corn silage based and had a control TMR (HP1) estimated to contain 16.5% CP with SBM and treatment TMR (LP1; 13.5% CP) using DDGS and rumen protected Lys and Met. Experiment 2 was ryegrass haylage based and had a control TMR (HP2) with 15.5% CP with Met and a treatment TMR (LP2) with 13.5% CP with Lys and Met. Experiments were analyzed as a crossover design using the MIXED procedure of SAS with pen as the experimental unit. Experiment 1 had no significant difference between treatments in DMI (21.0 for HP1 and 20.4 kg/cow/d for LP1; P=0.46) and milk yield (20.7 for HP1 and 20.5 kg/cow/d for LP1; P=0.91). Percentage of milk components averaged 4.21, 3.72, 4.54, and 9.15, respectively for fat, protein, lactose, and solids non-fat (P\u3e0.60). Milk urea nitrogen (MUN) decreased (P\u3c0.01) from 17.2 with HP1 to 9.93 mg/dL with LP1. Manure pH was significantly higher for HP1 than LP1 (7.87 and 7.53 respectively, P\u3c0.05). Experiment 2 had no significant difference in cow performance (DMI: 21.4 for HP2 and 20.9 kg/cow/d for LP2; P=0.51; milk yield: 26.4 for HP and 24.4 kg/cow/d for LP2; P=0.19; percentage of milk components averaged 3.48, 3.29 and 4.71, respectively for fat, protein and lactose; P\u3e0.30; MUN decreased (P\u3c0.01) from 9.85 with HP2 to 6.40 mg/dL with LP2). Manure pH was significantly higher for HP2 than LP2 (7.50 for HP and 7.13 for LP, P=0.05). There was no difference in volatilized N between HP2 and LP2. This experiment suggests that performance of late-lactation dairy cows can be maintained with low-protein DDG based diets supplemented with Lys and Met

ENERGY AND PROTEIN EFFICIENCY OF LACTATING DAIRY COWS FED GROUND PEAS, CANOLA MEAL AND RUMEN-PROTECTED AMINO ACIDS

Forages as conserved silage or grass cannot supply enough nutrients and energy as required by lactating dairy cows. As a result, supplementation with grains is needed to provide animals with enough nutrients to be healthy and produce milk being profitable (NRC, 2001). High producing cows need protein supplementation from sources other than forages in order to maximize milk protein production, with emphasis on replenishing requirements for specific amino acids. Excessive protein in the diet or deficiency of an essential amino acid can reduce productivity and increase excretion of N to the environment, causing pollution. Research must be conducted to help dairy farmers make informed decisions about the use of alternative protein supplements as a way to improve farm profitability, optimize protein and energy utilization and increase knowledge about environmental pollution. Therefore, strategies to reduce feed costs through sourcing lower-cost, yet high nutritional value feed ingredients, may optimize milk production enhancing the economic and social sustainability of dairy farming in the Northeast U.S. Therefore, the 2 research areas identified as the main focuses of this dissertation were: 1) development of a proof of concept technique to determine dry matter intake (DMI) for animals on pasture, and 2) improvement of economic and nutrient use efficiencies when feeding ground field peas (GFP), an alternative feedstuff, in order to decrease costs of dairy rations. In the first step, a proof of concept technique was developed to estimate energy requirements and DMI of lactating Holstein cows in a tie stall. The objective of this technique was to create a methodology to use spot short-term measurements of CH4 (QCH4) and CO2 (QCO2) integrated with backward dietary energy partition calculations to estimate DMI. Twelve multiparous cows averaging 173 ± 37 days in milk and 4 primiparous cows averaging 179 ± 27 days in milk were blocked by days in milk, parity, and DMI (as a percentage of body weight) and, within each block, randomly assigned to 1 of 2 treatments: ad libitum intake (AL) or restricted intake (RI = 90% DMI) according to a crossover design. Each experimental period lasted 22 d with 14 d for treatments adaptation and 8 d for data and sample collection. Diets contained (DM basis): 40% corn silage, 12% grass-legume haylage, and 48% concentrate. Spot short-term gas measurements were taken in 5-min sampling periods from 15 cows (1 cow refused sampling) using a portable automated open circuit gas quantification system (GreenFeed, C-Lock Inc., Rapid City, SD) with intervals of 12 h between the 2 daily samples. Sampling points were advanced 2 h from a day to the next to yield 16 gas samples/cow over 8 d to account for diurnal variation in QCH4 and QCO2. The following equations were used sequentially to estimate DMI: 1) Heat production (HP) (MJ/d) = (4.96 + 16.07 ÷ respiratory quotient) × QCO2; respiratory quotient = 0.95; 2) Metabolizable energy intake (MJ/d) = (heat production + milk-energy) ± tissue energy balance; 3) Digestible energy (DE) intake (MJ/d) = metabolizable energy + CH4-energy + urinary-energy; 4) Gross energy (GE) intake (MJ/d) = DE + [(DE ÷ in vitro true dry matter digestibility) – DE]; and 5) DMI (kg/d) = GE intake estimated ÷ diet GE concentration. Data were analyzed using the MIXED procedure of SAS and Fit Model procedure in JMP (α = 0.05). Cows significantly differed in measured DMI (23.8 vs. 22.4 kg/d for AL and RI, respectively; P \u3c 0.01). Dry matter intake estimated using QCH4 and QCO2 coupled with dietary backward energy partition calculations (equations 1 to 5 above) was highest in cows fed for AL (22.5 vs. 20.2 kg/d). The resulting R2 were 0.28 between measured DMI and estimated by gaseous measurements and 0.36 between measured and DMI predicted by the NRC (2001). Results showed that spot short-term measurements of QCH4 and QCO2 coupled with dietary backward estimations of energy partitions underestimated DMI by 7.8%. However, the approach proposed herein was able to significantly discriminate differences in DMI between cows fed for AL or RI. The second focus of this dissertation was aimed to decrease feed costs while improving nutrient efficiency in dairy cows. Ground field peas are an adequate source of energy and protein compared to corn meal and soybean meal (SBM) that could be used as an alternative feedstuff in order to decrease feeding costs. Field peas are available for feed in the northern regions of the United States and Canada. Previous studies showed that diets with more than 25% GFP, DM basis) resulted in reduced milk and milk protein yield in dairy cows. Decreased yields may be caused by limited supplies of MP-Lys and MP-Met due to extensive degradation of GFP RDP in the rumen and we hypothesize that cows fed with GFP supplemented with RP Lys and RP Met will maintain performance when compared to a diet with corn meal and soybean meal supplemented with RP Lys and Met. The objective of this study was to compare a source of non-protein N (i.e. urea) vs. a source of soluble true protein (i.e. GFP) and evaluate diets with 25% of GFP supplemented with rumen-protected (RP) Lys (AjiPro-L, Ajinomoto, Japan) and Met (Smartamine-M, Adisseo, France) as a substitute for corn meal and SBM on animal performance and energy balance. Twelve multiparous and 4 primiparous lactating Holstein cows were blocked by days in milk, milk yield and parity, and randomly assigned to 1 of 4 diets in a replicated 4 × 4 Latin square design. Diets were 35.5% corn silage, 15.5% grass-legume haylage, 5.9% roasted soybean, and: (1) 36% corn meal and 1.3% urea (3.59:1 MP-Lys:MP-Met ratio; negative control (U), (2) 29.7% corn meal, 9.8% SBM, and RP-Lys RP-Met (3.07:1 MP-Lys:MP-Met ratio (CSAA), (3) 25% GFP, 12.3% corn meal, and 2.4% SBM (3.88:1 MP-Lys:MP-Met ratio; FP), and (4) 25% GFP, 12.2% corn meal, 2.4% SBM, and RP-Lys RP-Met (3.13:1 MP-Lys:MP-Met ratio; FPAA). Data were analyzed using the MIXED procedure of SAS with orthogonal contrasts for pairwise comparisons between treatments (α = 0.05). Dietary treatments had 15.4%, 15.1%, 14.9% and 15.0% CP, respectively for U, CSAA, FP and FPAA. As expected, cows fed U had decreased DMI (23.3 kg vs. 24.6 kg/d, P \u3c 0.01), milk protein yield (1.15 kg vs. 1.21 kg/d, P \u3c 0.001), total concentration of ruminal VFA (103 mM vs. 112 mM, P \u3c 0.001), HP (129 MJ/d vs. 141 MJ/d, P \u3c 0.001), NDF digestibility (30.2% vs. 46.0%, P \u3c 0.01), ADF digestibility (37.6% 50.4%, P \u3c 0.02), total purines derivatives (343 mmol/d vs 414 mmol/d, P \u3c 0.01), and highest excretion of MUN (9.85 mg/dL vs. 9.09 mg/dL, P \u3c 0.01) when compared to cows fed FP. Cows fed FP had decreased plasma concentration of Met (19.6 mM). Feeding cows CSAA and FPAA mitigated these negative responses. Cows fed FPAA had positive tissue energy balance, higher HP and consequently higher metabolizable energy intake when compared to CSAA diet. In addition, increased milk yield was correlated to a decrease in HP (R2 = 0.329, n = 16 observations). Results showed that feeding FPAA increased HP and milk protein yield to levels compared to cows fed CSAA. Results suggest that feeding diets with 25% GFP and RP-Lys and RP-Met will improve animal performance and energy efficiency. When cows were fed FPAA, a decrease in plasma His concentration was found compared to CSAA. Cows fed FPAA could, then, be limiting in His, which could have caused a decrease in milk protein production. Results from the literature show that feeding RP-Met can cause a decrease in the plasma concentration of EAA for reasons that still need to be studied. Canola meal is a good alternative to SBM that has potential to mitigate the effect on AA concentration in plasma. Previous studies reported increased plasma concentrations of most EAA when feeding CAM, mostly due to an increase in DMI, but research feeding GFP and CAM with RP Met have never been performed. The hypothesis of this study was that cows fed GFP with CAM and RP Met would have higher milk protein percentage and yield when compared to cows fed 25% GFP, SBM and RP Met due to an increase in DMI and consequent increase in plasma AA concentration. The objectives of this study were to compare lactating production responses of cows fed diets with (DM basis) 35.0% Corn silage, 14.0% grass-legume silage, 25% GFP, 1.5% citrus pulp, and corn meal, flaked corn and dry distillers grains in variable amounts with 1) SBM (11%) as the major source of supplemental protein, (FPSB diet), 2) CAM (13.5%) as the major source of supplemental protein (FPCM diet). For each experimental diet, RP Met was top dressed to half of the cows (27 g/d) to result in a total of 4 treatments: 1) FPSB diet with no RP Met supplemented, 2) FPSB diet with supplementation of RP Met, 3) FPCM diet with no RP Met supplemented and 4) FPCM diet with supplementation of RP Met. Twelve multiparous and 4 primiparous lactating Holstein cows were blocked by DIM, milk yield and parity, and randomly assigned to 1 of 4 diets in a replicated 4 × 4 Latin square design. Data were analyzed using the MIXED procedure of SAS and pairwise tests for protein source and supplementation or not of RP Met was performed (α = 0.05). Cows fed FPCM had higher DMI and milk yield when compared to cows fed FPSB. No effect on DMI and milk yield was observed for supplementation of RP Met. Cows produced milk with higher concentration of protein when supplemented with RP Met, but RP Met had no effect on milk protein yield. On the other hand, cows fed FPCM had higher yield of milk protein when compared to cows fed FPSB. No difference was found for milk fat and lactose concentrations between diets and addition of RP Met. Milk true N efficiency (Milk true N ÷ N intake) was higher and MUN was lower for cows fed FPCM compared to cows fed FPSB, showing that overall N efficiency of cows fed FPCM was better. Results show that CAM will increase N efficiency and increase milk and milk protein yield when fed to diets with 25% GFP, as a result of higher DMI

Contributions of mean and shape of blood pressure distribution to worldwide trends and variations in raised blood pressure: A pooled analysis of 1018 population-based measurement studies with 88.6 million participants

© The Author(s) 2018. Background: Change in the prevalence of raised blood pressure could be due to both shifts in the entire distribution of blood pressure (representing the combined effects of public health interventions and secular trends) and changes in its high-blood-pressure tail (representing successful clinical interventions to control blood pressure in the hypertensive population). Our aim was to quantify the contributions of these two phenomena to the worldwide trends in the prevalence of raised blood pressure. Methods: We pooled 1018 population-based studies with blood pressure measurements on 88.6 million participants from 1985 to 2016. We first calculated mean systolic blood pressure (SBP), mean diastolic blood pressure (DBP) and prevalence of raised blood pressure by sex and 10-year age group from 20-29 years to 70-79 years in each study, taking into account complex survey design and survey sample weights, where relevant. We used a linear mixed effect model to quantify the association between (probittransformed) prevalence of raised blood pressure and age-group- and sex-specific mean blood pressure. We calculated the contributions of change in mean SBP and DBP, and of change in the prevalence-mean association, to the change in prevalence of raised blood pressure. Results: In 2005-16, at the same level of population mean SBP and DBP, men and women in South Asia and in Central Asia, the Middle East and North Africa would have the highest prevalence of raised blood pressure, and men and women in the highincome Asia Pacific and high-income Western regions would have the lowest. In most region-sex-age groups where the prevalence of raised blood pressure declined, one half or more of the decline was due to the decline in mean blood pressure. Where prevalence of raised blood pressure has increased, the change was entirely driven by increasing mean blood pressure, offset partly by the change in the prevalence-mean association. Conclusions: Change in mean blood pressure is the main driver of the worldwide change in the prevalence of raised blood pressure, but change in the high-blood-pressure tail of the distribution has also contributed to the change in prevalence, especially in older age groups

Height and body-mass index trajectories of school-aged children and adolescents from 1985 to 2019 in 200 countries and territories: a pooled analysis of 2181 population-based studies with 65 million participants

Summary Background Comparable global data on health and nutrition of school-aged children and adolescents are scarce. We aimed to estimate age trajectories and time trends in mean height and mean body-mass index (BMI), which measures weight gain beyond what is expected from height gain, for school-aged children and adolescents. Methods For this pooled analysis, we used a database of cardiometabolic risk factors collated by the Non-Communicable Disease Risk Factor Collaboration. We applied a Bayesian hierarchical model to estimate trends from 1985 to 2019 in mean height and mean BMI in 1-year age groups for ages 5–19 years. The model allowed for non-linear changes over time in mean height and mean BMI and for non-linear changes with age of children and adolescents, including periods of rapid growth during adolescence. Findings We pooled data from 2181 population-based studies, with measurements of height and weight in 65 million participants in 200 countries and territories. In 2019, we estimated a difference of 20 cm or higher in mean height of 19-year-old adolescents between countries with the tallest populations (the Netherlands, Montenegro, Estonia, and Bosnia and Herzegovina for boys; and the Netherlands, Montenegro, Denmark, and Iceland for girls) and those with the shortest populations (Timor-Leste, Laos, Solomon Islands, and Papua New Guinea for boys; and Guatemala, Bangladesh, Nepal, and Timor-Leste for girls). In the same year, the difference between the highest mean BMI (in Pacific island countries, Kuwait, Bahrain, The Bahamas, Chile, the USA, and New Zealand for both boys and girls and in South Africa for girls) and lowest mean BMI (in India, Bangladesh, Timor-Leste, Ethiopia, and Chad for boys and girls; and in Japan and Romania for girls) was approximately 9–10 kg/m2. In some countries, children aged 5 years started with healthier height or BMI than the global median and, in some cases, as healthy as the best performing countries, but they became progressively less healthy compared with their comparators as they grew older by not growing as tall (eg, boys in Austria and Barbados, and girls in Belgium and Puerto Rico) or gaining too much weight for their height (eg, girls and boys in Kuwait, Bahrain, Fiji, Jamaica, and Mexico; and girls in South Africa and New Zealand). In other countries, growing children overtook the height of their comparators (eg, Latvia, Czech Republic, Morocco, and Iran) or curbed their weight gain (eg, Italy, France, and Croatia) in late childhood and adolescence. When changes in both height and BMI were considered, girls in South Korea, Vietnam, Saudi Arabia, Turkey, and some central Asian countries (eg, Armenia and Azerbaijan), and boys in central and western Europe (eg, Portugal, Denmark, Poland, and Montenegro) had the healthiest changes in anthropometric status over the past 3·5 decades because, compared with children and adolescents in other countries, they had a much larger gain in height than they did in BMI. The unhealthiest changes—gaining too little height, too much weight for their height compared with children in other countries, or both—occurred in many countries in sub-Saharan Africa, New Zealand, and the USA for boys and girls; in Malaysia and some Pacific island nations for boys; and in Mexico for girls. Interpretation The height and BMI trajectories over age and time of school-aged children and adolescents are highly variable across countries, which indicates heterogeneous nutritional quality and lifelong health advantages and risks

Rising rural body-mass index is the main driver of the global obesity epidemic in adults

Body-mass index (BMI) has increased steadily in most countries in parallel with a rise in the proportion of the population who live in cities(.)(1,2) This has led to a widely reported view that urbanization is one of the most important drivers of the global rise in obesity(3-6). Here we use 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017. We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017-and more than 80% in some low- and middle-income regions-was due to increases in BMI in rural areas. This large contribution stems from the fact that, with the exception of women in sub-Saharan Africa, BMI is increasing at the same rate or faster in rural areas than in cities in low- and middle-income regions. These trends have in turn resulted in a closing-and in some countries reversal-of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women. There is an urgent need for an integrated approach to rural nutrition that enhances financial and physical access to healthy foods, to avoid replacing the rural undernutrition disadvantage in poor countries with a more general malnutrition disadvantage that entails excessive consumption of low-quality calories.Peer reviewe

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants.

BACKGROUND: Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories. METHODS: We used data from 1990 to 2019 on people aged 30-79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age. FINDINGS: The number of people aged 30-79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306-359) million women and 317 (292-344) million men in 1990 to 626 (584-668) million women and 652 (604-698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55-62) of women and 49% (46-52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43-51) of women and 38% (35-41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20-27) for women and 18% (16-21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran. INTERPRETATION: Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings. FUNDING: WHO

Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants

Background Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories. Methods We used data from 1990 to 2019 on people aged 30-79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age. Findings The number of people aged 30-79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306-359) million women and 317 (292-344) million men in 1990 to 626 (584-668) million women and 652 (604-698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55-62) of women and 49% (46-52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43-51) of women and 38% (35-41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20-27) for women and 18% (16-21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran. Interpretation Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings. Copyright (C) 2021 World Health Organization; licensee Elsevier