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Hypertension in East Asia
AJH
1995; 8:111S-114S
Hypertension in East Asia Daniel W. Jones
Asians comprise the largest single ethnic group in the world and the fastest growing minority ethnic group within the United States. The prevalence of hypertension in most Asian groups is similar to that of non-Asians. The associations with hypertension are similar to those seen in Western populations. Body mass index is a surprisingly strong predictor of blood pressure, even in very lean Asian populations. Studies in Asian groups suggest that the prevalence of target organ disease as
related to hypertension are dependent on other cardiovascular disease risk factors. Stroke is more common than heart disease in Asia. Hypertension treatment data in East Asia is sparse, and treatment methods vary widely. Hypertension control among the world's largest ethnic group remains a challenge. Am J Hypertens 1995;8:111S-114S
ypertension is an increasingly important cause of morbidity and mortality around the world, including East Asia. This review of hypertension in East Asia will focus on the four countries of the People's Republic of China, Japan, South Korea, and North Korea. Asians comprise approximately one-half of the world's population and probably represent onefourth to one-third of the world's hypertensives. Additionally, Asians are the fastest growing minority group within the United States.
Because survey methods vary, comparison of data among countries must be done with caution. Among East Asian nations, prevalence rates are highest in Japan. In all countries reported, prevalence of hypertension rises with age, particularly in Japan and China. Prevalence rates for Japan are similar to Western industrialized nations. Prevalence rates appear to be rising in all East Asian countries. 1'2
H
PREVALENCE OF HYPERTENSION Only in the last several years have population-based random surveys been performed in East Asian countries to allow determination of hypertension prevalence rates. Figure 1 shows the prevalence rates by age for Japan,1 China,2 and South Korea.3 Prevalence rates are not currently available from North Korea (personal communication with Dr. Jang Gwan Hak). Address correspondence and reprint requests to Daniel W. Jones, MD, Director, Division of Hypertension, The University of Mississippi Medical Center, 2500 North State Street, Jackson, MS
39216-4505.
From the Division of Hypertension, Department of Medicine, The University of Mississippi Medical Center, Jackson, Mississippi,
© 1995 by the American Journal ot Hypertension. Ltd
KEY WORDS: Asians, ethnicity, race, hypertension.
A s s o c i a t i o n s With H y p e r t e n s i o n Because East Asian nations differ culturally from Western countries, it may be somewhat of a surprise that the associations with hypertension in East Asia are essentially the same as reported for most Western countries. Table 1 shows the associations for a recent survey performed in South Korea. 3 Associations reported for Japan 1 and China 2 are similar. It is important to note that the association of hypertension and obesity is strong in each survey done in East Asia. 1-3 Also, body mass index and blood pressure are related as continuous variables when evaluated by multiple logistic regression analysis. Figure 2 shows the relationship between body m a s s index and diastolic blood pressure in the Korean survey. 4 When adjusted for all other measured variables, body mass index remains strongly associated with blood pressure with statistical significance in extremely thin subjects down to a body mass index of 0895-7061/95/$9.50 0895-7061(95)00310-0
112S
A]H-DECEMBER 1995-VOL. 8, NO. 12, PART 2
JONES
70 ~
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FIGURE 1. Hypertension prevalence rates by age for Japan, China and South Korea (Hypertension = blood pressure ~ 140/90 mm Hg or on medication). <17. Similar results were found in a survey of Yi farmers in China. 5 Target Organ Damage The differences in hypertensive target organ damage in East Asia compared to Western countries can be appreciated in mortality data from these countries. Figure 3 shows that overall cardiovascular disease mortality is similar for Western Pacific region countries that report to the World Health Organization (WHO). 6 Because Australia is included, this reporting group offers a convenient contrast with a Western culture. Figure 4 shows that among the countries reported, only Australia has a high mortality rate from ischemic heart disease. 6 This is typical of all Western industrialized nations with high prevalence rates for hypertension. In contrast, stroke is much more common in East Asian countries. 6 Figure 5 shows mortality rates for cerebrovascular disease. Over the last several decades, as infectious diseases have come under control in East Asian countries, cardiovascular disease has become the leading cause of death in all of these countries. As opposed to Western countries where ischemic heart disease predominates, in all four of these East Asian countries, stroke was the leading cause of death, and ischemic heart disease remains relatively uncommon. Reasons for this can be seen in the differences in other risk factors for cardiovascular disease. Other Risk Factors for Cardiovascular DiseaseOther risk factors for cardiovascular disease differ substantially from W e s t e r n n a t i o n s . Total cholesterol
Body Mass Index
FIGURE 2. Mean diastolic blood pressure (mm Hg) by body mass index category (kg/m2). Reproduced from Jones DW et al4 with permission. values are 10% to 25% less than in Western countries, and diabetes mellitus is less common. 7"8 Cigarette smoking is more common among men compared to Western countries, but less common among women. 2"3 Smoking rates for men for these four countries are in the 70% range. Reported smoking rates for women are still <20% in most of these countries. Population-based surveys of prevalence of left ventricular hypertrophy are not available for any of these countries. However, data from a large hypertension clinic in Korea suggests that electrocardiographic left ventricular h y p e r t r o p h y may be more c o m m o n among mild-to-moderate hypertensives than in the United States. Figure 6 compares subjects in this Korean hypertension clinic with data from the US Hypertension Detection and Follow-up Program (HDFP) for whites and blacks. 9 HYPERTENSION TREATMENT Treatment methods for hypertension vary significantly among countries within East Asia. Japan has a very strong organized health care system that is similar to Western industrialized countries. Health screening is a major part of the health care program, and hypertension control programs have been organized for a good number of years. 1° Though traditional methods of treatment are available within Ja3500 • • • •
3000
TABLE 1. ASSOCIATIONS WITH HYPERTENSION IN KOREA Variable
P
Odds Ratio
.0001 .0001 .0001 .0001 .0001 .0010
2.2 1.9 1.4 1.3 1.2 0.9
2500
..... ........ ........ ....
• • • •
Korea China Japan Australia
.t
/.
S.~,,
2000 1500
Family history Age Alcohol Urban location Body mass index Smoking
From Kim ]Set al3 with permission.
.'~I
.,.~':~
1ooo D
500
...-'""
A
-=' --'"- ."- - - ' " ~ " ' : * "-" .... "r 35-44 45-54
, 55-64
65-74
Age FIGURE
3.
Cardiovascular disease mortality by age.
AJH-DECEMBER 1995-VOL. 8, NO. 12, PART 2
HYPERTENSION IN EASTASIA 113S
20
1400 • • • *
1200 1000
..... ........ ........ ....
• • • *
Korea China Japan Australia
•
/
18
/
/
16 14
./ /
8OO
~ t2
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i
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600
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0
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,
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pan, most patients are treated with Western medicines by established international standards. 1° South Korea also has an organized health care system, though less developed than the one in Japan and with fewer resources available. The major focus of hypertension treatment is the use of Western medicines, though traditional therapy is available and covered by the national health insurance. The two treatment approaches are usually not combined, however. 11 In contrast, in China and in North Korea, treatment approaches include integration of Western medication and traditional approaches, including herbal medicines and acupuncture. 2"11 One health care provider often will use both approaches on a given patient. In North Korea, innovative treatment methods are being tried, including hypobaric therapy (personal communication with Dr. Jang Gwan Hak). HYPERTENSION AWARENESS, T R E A T M E N T , AND CONTROL RATES Figure 7 shows the hypertension awareness, treatment, and control rates for the three countries for which these data were available. 1,12,13 Rates for Japan are similar to those of Western countries.14 Rates for China and South Korea are somewhat lower. DISCUSSION AND CONCLUSIONS
HDFP Black
I I~(q'W~V(ll
Group
Age
FIGURE 4. Ischemic heart disease mortality by age.
i
FIGURE 6. Left ventricular hypertrophy (L VH) rates for blacks and whites in the Hypertension Detection and Follow-Up Program (HDFP) and Korean subjects in a hypertension clinic in Korea. All subjects with an untreated diastolic blood pressure 90 to 114 mm Hg. to Western countries, there are significant differences in target organ damage. Stroke is much more common in East Asia than in other parts of the world, and ischemic heart disease is still quite uncommon. Conventional wisdom suggests that lower intake of saturated fat in East Asia leads to lower heart disease rates. Because East Asians are much thinner than Western populations, interesting insights into the relationship between body mass and blood pressure are derived from this population. It is somewhat surprising that the relationship is so strong in these thin populations. This finding could have implications in our understanding of the mechanism of the relationship between body mass and blood pressure. Among East Asian nations, Japan has the highest hypertension prevalence rates, but the lowest ageadjusted stroke rates. This paradox can best be explained by the difference in hypertension control rates and adds to the strong evidence that hypertension treatment is effective in stroke prevention. The diversity of treatment approaches used in East Asia should be fertile ground for innovative research
Information from East Asia on hypertension provides useful insights. Though prevalence rates are similar 2000
1500
oo
• • • *
..... ........ ........ ....
• • • *
i
Korea China Japan Australia
~,,/,:"
~J--6;n
// /." /,/ /°/ /%°
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L
//
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.,..°. ..o~...~" o• ~'~.•
.• •
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Treated
Controlled
65-74
FIGURE 7. Hypertension awareness, treatment, and control
FIGURE 5. Cerebrovascular disease mortality by age.
rates for three countries (Hypertension = blood pressure ~- 160/ 95 or on medication). Reproduced from Jones DW et al4 with permission.
35-44
45-54
55-64
Age
114S
JONES
AJH-DECEMBER 1995-VOL. 8, NO. 12, PART 2
into culturally appropriate treatment m e t h o d s of hypertension. Well-designed studies to c o m p a r e treatm e n t a p p r o a c h e s are n e e d e d . K n o w l e d g e of h y p e r t e n s i o n in East Asia should be useful not only in m a n a g e m e n t of patients in that region, but also in providing useful insight into hypertension mechanisms, as well as treatment methods, that might be applied in other areas of the world.
ACKNOWLEDGMENTS The author is grateful for assistance through personal visits or personal communication with: China--Dr. Zhou Beifan, Chinese Academy of Medical Sciences, Beijing; Japan--Dr. Teruo Omae, National Cardiovascular Center, Osaka; South Korea--Dr. Joung Soon Kim, Seoul National University, Seoul; and North Korea--Dr. Jang Gwan Hak, Central Committee, Medical Scholars Association, Pyongyang. Commonly accepted designations, rather than the full names of the four countries, are used for convenience.
REFERENCES 1. Ueda K, Omae T: Control of hypertension in a Japanese community, in Bullpit CJ (ed): Handbook of Hypertension, Vol 6: Epidemiology of Hypertension. Elsevier Science Publishers, New York, 1985. 2. Lisheng L: Hypertension studies in China. Clin Exp Hypertens [A] 1993;15(6):1015--1024. 3.
Kim JS, Jones DW, KJm SJ, Hong YP: Korean national blood pressure survey. Am J Prey Med 1994;10:200204. 4. Jones DW, Kim JS, Andrew ME, et al: Body mass index and blood pressure in Korean men and women. J Hypertens 1994;12:1433-1437. 5. He J, Klag MJ, Whelton PK, et al: Body mass and
6. 7.
8.
9.
10.
11.
12.
13.
14.
blood pressure in a lean population in southwestern China. Am J Epidemiol 1994;139:380-389. World Health Organization 1991 Statistical Annual. World Health Organization, Geneva, 1991. USA-PRC Collaborative Study of Cardiovascular and Cardiopulmonary Epidemiology Group. Date of Preview-Baseline Serum Lipids. US Department of Health and Human Services, Public Health Service, National Institutes of Health, Washington, DC, April, 1990. Jones DW, Sands CD: Effects of doxazosin and hydrochlorothiazide on lipid levels in Korean patients with essential hypertension. J Cardiovasc Pharmacol 1993;22(3):431-437. ]ones DW: Dietary sodium and electrocardiographic left ventricular hypertrophy. Korean J Epidemiol (in press). Omae T: The changing pattern of cardiovascular disease in the Japanese population in relation to hypertension control programs. J Cardiovasc Pharmacol 1990;16(suppl 7):$81-$82. ]ones DW, Chei UT, Sands CD: High blood pressure: knowledge and behavior in Asia. Korean Circ J 1992;22(6):1009-1016. Tao Shou-chi, Wu Xi-jui, Duan Xiu-fang, et al: Hypertension Prevalence and the Status of Awareness, Treatment and Control in the People's Republic of China: A Nationwide Survey in 1991. (in press). Jones DW, Kim JS, Kim SJ, Hong YP: Hypertension awareness, treatment, and control rates in an Asian population: results of a national survey in Korea. Ethnicity and Health (in press). Baba S, Pan WH, Ueshima H, et al: Comparison of blood pressure levels and body mass index in Japanese and US national surveys. J Hypertens 1986; 4(suppl 6):$24-$26.
1995; 8:111S-114S
Hypertension in East Asia Daniel W. Jones
Asians comprise the largest single ethnic group in the world and the fastest growing minority ethnic group within the United States. The prevalence of hypertension in most Asian groups is similar to that of non-Asians. The associations with hypertension are similar to those seen in Western populations. Body mass index is a surprisingly strong predictor of blood pressure, even in very lean Asian populations. Studies in Asian groups suggest that the prevalence of target organ disease as
related to hypertension are dependent on other cardiovascular disease risk factors. Stroke is more common than heart disease in Asia. Hypertension treatment data in East Asia is sparse, and treatment methods vary widely. Hypertension control among the world's largest ethnic group remains a challenge. Am J Hypertens 1995;8:111S-114S
ypertension is an increasingly important cause of morbidity and mortality around the world, including East Asia. This review of hypertension in East Asia will focus on the four countries of the People's Republic of China, Japan, South Korea, and North Korea. Asians comprise approximately one-half of the world's population and probably represent onefourth to one-third of the world's hypertensives. Additionally, Asians are the fastest growing minority group within the United States.
Because survey methods vary, comparison of data among countries must be done with caution. Among East Asian nations, prevalence rates are highest in Japan. In all countries reported, prevalence of hypertension rises with age, particularly in Japan and China. Prevalence rates for Japan are similar to Western industrialized nations. Prevalence rates appear to be rising in all East Asian countries. 1'2
H
PREVALENCE OF HYPERTENSION Only in the last several years have population-based random surveys been performed in East Asian countries to allow determination of hypertension prevalence rates. Figure 1 shows the prevalence rates by age for Japan,1 China,2 and South Korea.3 Prevalence rates are not currently available from North Korea (personal communication with Dr. Jang Gwan Hak). Address correspondence and reprint requests to Daniel W. Jones, MD, Director, Division of Hypertension, The University of Mississippi Medical Center, 2500 North State Street, Jackson, MS
39216-4505.
From the Division of Hypertension, Department of Medicine, The University of Mississippi Medical Center, Jackson, Mississippi,
© 1995 by the American Journal ot Hypertension. Ltd
KEY WORDS: Asians, ethnicity, race, hypertension.
A s s o c i a t i o n s With H y p e r t e n s i o n Because East Asian nations differ culturally from Western countries, it may be somewhat of a surprise that the associations with hypertension in East Asia are essentially the same as reported for most Western countries. Table 1 shows the associations for a recent survey performed in South Korea. 3 Associations reported for Japan 1 and China 2 are similar. It is important to note that the association of hypertension and obesity is strong in each survey done in East Asia. 1-3 Also, body mass index and blood pressure are related as continuous variables when evaluated by multiple logistic regression analysis. Figure 2 shows the relationship between body m a s s index and diastolic blood pressure in the Korean survey. 4 When adjusted for all other measured variables, body mass index remains strongly associated with blood pressure with statistical significance in extremely thin subjects down to a body mass index of 0895-7061/95/$9.50 0895-7061(95)00310-0
112S
A]H-DECEMBER 1995-VOL. 8, NO. 12, PART 2
JONES
70 ~
50
"
_j _ - .
88
~
40
_~
30 + 7
~
~
22~j~
~
~
84
*J.6,,.
~
82
~China
~
80
*Ko,',,=
o
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~
74
a
0 30-39
40-49
50-59
60-69
>70
72
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i
J
i
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~
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i
i
L
i
i
i
i
i
i
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16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
FIGURE 1. Hypertension prevalence rates by age for Japan, China and South Korea (Hypertension = blood pressure ~ 140/90 mm Hg or on medication). <17. Similar results were found in a survey of Yi farmers in China. 5 Target Organ Damage The differences in hypertensive target organ damage in East Asia compared to Western countries can be appreciated in mortality data from these countries. Figure 3 shows that overall cardiovascular disease mortality is similar for Western Pacific region countries that report to the World Health Organization (WHO). 6 Because Australia is included, this reporting group offers a convenient contrast with a Western culture. Figure 4 shows that among the countries reported, only Australia has a high mortality rate from ischemic heart disease. 6 This is typical of all Western industrialized nations with high prevalence rates for hypertension. In contrast, stroke is much more common in East Asian countries. 6 Figure 5 shows mortality rates for cerebrovascular disease. Over the last several decades, as infectious diseases have come under control in East Asian countries, cardiovascular disease has become the leading cause of death in all of these countries. As opposed to Western countries where ischemic heart disease predominates, in all four of these East Asian countries, stroke was the leading cause of death, and ischemic heart disease remains relatively uncommon. Reasons for this can be seen in the differences in other risk factors for cardiovascular disease. Other Risk Factors for Cardiovascular DiseaseOther risk factors for cardiovascular disease differ substantially from W e s t e r n n a t i o n s . Total cholesterol
Body Mass Index
FIGURE 2. Mean diastolic blood pressure (mm Hg) by body mass index category (kg/m2). Reproduced from Jones DW et al4 with permission. values are 10% to 25% less than in Western countries, and diabetes mellitus is less common. 7"8 Cigarette smoking is more common among men compared to Western countries, but less common among women. 2"3 Smoking rates for men for these four countries are in the 70% range. Reported smoking rates for women are still <20% in most of these countries. Population-based surveys of prevalence of left ventricular hypertrophy are not available for any of these countries. However, data from a large hypertension clinic in Korea suggests that electrocardiographic left ventricular h y p e r t r o p h y may be more c o m m o n among mild-to-moderate hypertensives than in the United States. Figure 6 compares subjects in this Korean hypertension clinic with data from the US Hypertension Detection and Follow-up Program (HDFP) for whites and blacks. 9 HYPERTENSION TREATMENT Treatment methods for hypertension vary significantly among countries within East Asia. Japan has a very strong organized health care system that is similar to Western industrialized countries. Health screening is a major part of the health care program, and hypertension control programs have been organized for a good number of years. 1° Though traditional methods of treatment are available within Ja3500 • • • •
3000
TABLE 1. ASSOCIATIONS WITH HYPERTENSION IN KOREA Variable
P
Odds Ratio
.0001 .0001 .0001 .0001 .0001 .0010
2.2 1.9 1.4 1.3 1.2 0.9
2500
..... ........ ........ ....
• • • •
Korea China Japan Australia
.t
/.
S.~,,
2000 1500
Family history Age Alcohol Urban location Body mass index Smoking
From Kim ]Set al3 with permission.
.'~I
.,.~':~
1ooo D
500
...-'""
A
-=' --'"- ."- - - ' " ~ " ' : * "-" .... "r 35-44 45-54
, 55-64
65-74
Age FIGURE
3.
Cardiovascular disease mortality by age.
AJH-DECEMBER 1995-VOL. 8, NO. 12, PART 2
HYPERTENSION IN EASTASIA 113S
20
1400 • • • *
1200 1000
..... ........ ........ ....
• • • *
Korea China Japan Australia
•
/
18
/
/
16 14
./ /
8OO
~ t2
/
i
g_ lO
/ /
600
8 6 4
/ 4O0 .*- s ' d ' *
200
II . . . .
0
35-44
~1~
}
ij|lzl
"
I
Iii "w'l°ll
_'7_~. . . . . _a~ . ~ ; ' - - ' ; ' " : ' - - " ! . . . . . . . 45-54
~.
55-64
I
,
2 HDFP White
65-74
pan, most patients are treated with Western medicines by established international standards. 1° South Korea also has an organized health care system, though less developed than the one in Japan and with fewer resources available. The major focus of hypertension treatment is the use of Western medicines, though traditional therapy is available and covered by the national health insurance. The two treatment approaches are usually not combined, however. 11 In contrast, in China and in North Korea, treatment approaches include integration of Western medication and traditional approaches, including herbal medicines and acupuncture. 2"11 One health care provider often will use both approaches on a given patient. In North Korea, innovative treatment methods are being tried, including hypobaric therapy (personal communication with Dr. Jang Gwan Hak). HYPERTENSION AWARENESS, T R E A T M E N T , AND CONTROL RATES Figure 7 shows the hypertension awareness, treatment, and control rates for the three countries for which these data were available. 1,12,13 Rates for Japan are similar to those of Western countries.14 Rates for China and South Korea are somewhat lower. DISCUSSION AND CONCLUSIONS
HDFP Black
I I~(q'W~V(ll
Group
Age
FIGURE 4. Ischemic heart disease mortality by age.
i
FIGURE 6. Left ventricular hypertrophy (L VH) rates for blacks and whites in the Hypertension Detection and Follow-Up Program (HDFP) and Korean subjects in a hypertension clinic in Korea. All subjects with an untreated diastolic blood pressure 90 to 114 mm Hg. to Western countries, there are significant differences in target organ damage. Stroke is much more common in East Asia than in other parts of the world, and ischemic heart disease is still quite uncommon. Conventional wisdom suggests that lower intake of saturated fat in East Asia leads to lower heart disease rates. Because East Asians are much thinner than Western populations, interesting insights into the relationship between body mass and blood pressure are derived from this population. It is somewhat surprising that the relationship is so strong in these thin populations. This finding could have implications in our understanding of the mechanism of the relationship between body mass and blood pressure. Among East Asian nations, Japan has the highest hypertension prevalence rates, but the lowest ageadjusted stroke rates. This paradox can best be explained by the difference in hypertension control rates and adds to the strong evidence that hypertension treatment is effective in stroke prevention. The diversity of treatment approaches used in East Asia should be fertile ground for innovative research
Information from East Asia on hypertension provides useful insights. Though prevalence rates are similar 2000
1500
oo
• • • *
..... ........ ........ ....
• • • *
i
Korea China Japan Australia
~,,/,:"
~J--6;n
// /." /,/ /°/ /%°
1000
;• Korea I i
L
//
. . . I m//" 500
j,.s* ..o.• j* ..°* . ~ •" °o.°O
.,..°. ..o~...~" o• ~'~.•
.• •
Aware
Treated
Controlled
65-74
FIGURE 7. Hypertension awareness, treatment, and control
FIGURE 5. Cerebrovascular disease mortality by age.
rates for three countries (Hypertension = blood pressure ~- 160/ 95 or on medication). Reproduced from Jones DW et al4 with permission.
35-44
45-54
55-64
Age
114S
JONES
AJH-DECEMBER 1995-VOL. 8, NO. 12, PART 2
into culturally appropriate treatment m e t h o d s of hypertension. Well-designed studies to c o m p a r e treatm e n t a p p r o a c h e s are n e e d e d . K n o w l e d g e of h y p e r t e n s i o n in East Asia should be useful not only in m a n a g e m e n t of patients in that region, but also in providing useful insight into hypertension mechanisms, as well as treatment methods, that might be applied in other areas of the world.
ACKNOWLEDGMENTS The author is grateful for assistance through personal visits or personal communication with: China--Dr. Zhou Beifan, Chinese Academy of Medical Sciences, Beijing; Japan--Dr. Teruo Omae, National Cardiovascular Center, Osaka; South Korea--Dr. Joung Soon Kim, Seoul National University, Seoul; and North Korea--Dr. Jang Gwan Hak, Central Committee, Medical Scholars Association, Pyongyang. Commonly accepted designations, rather than the full names of the four countries, are used for convenience.
REFERENCES 1. Ueda K, Omae T: Control of hypertension in a Japanese community, in Bullpit CJ (ed): Handbook of Hypertension, Vol 6: Epidemiology of Hypertension. Elsevier Science Publishers, New York, 1985. 2. Lisheng L: Hypertension studies in China. Clin Exp Hypertens [A] 1993;15(6):1015--1024. 3.
Kim JS, Jones DW, KJm SJ, Hong YP: Korean national blood pressure survey. Am J Prey Med 1994;10:200204. 4. Jones DW, Kim JS, Andrew ME, et al: Body mass index and blood pressure in Korean men and women. J Hypertens 1994;12:1433-1437. 5. He J, Klag MJ, Whelton PK, et al: Body mass and
6. 7.
8.
9.
10.
11.
12.
13.
14.
blood pressure in a lean population in southwestern China. Am J Epidemiol 1994;139:380-389. World Health Organization 1991 Statistical Annual. World Health Organization, Geneva, 1991. USA-PRC Collaborative Study of Cardiovascular and Cardiopulmonary Epidemiology Group. Date of Preview-Baseline Serum Lipids. US Department of Health and Human Services, Public Health Service, National Institutes of Health, Washington, DC, April, 1990. Jones DW, Sands CD: Effects of doxazosin and hydrochlorothiazide on lipid levels in Korean patients with essential hypertension. J Cardiovasc Pharmacol 1993;22(3):431-437. ]ones DW: Dietary sodium and electrocardiographic left ventricular hypertrophy. Korean J Epidemiol (in press). Omae T: The changing pattern of cardiovascular disease in the Japanese population in relation to hypertension control programs. J Cardiovasc Pharmacol 1990;16(suppl 7):$81-$82. ]ones DW, Chei UT, Sands CD: High blood pressure: knowledge and behavior in Asia. Korean Circ J 1992;22(6):1009-1016. Tao Shou-chi, Wu Xi-jui, Duan Xiu-fang, et al: Hypertension Prevalence and the Status of Awareness, Treatment and Control in the People's Republic of China: A Nationwide Survey in 1991. (in press). Jones DW, Kim JS, Kim SJ, Hong YP: Hypertension awareness, treatment, and control rates in an Asian population: results of a national survey in Korea. Ethnicity and Health (in press). Baba S, Pan WH, Ueshima H, et al: Comparison of blood pressure levels and body mass index in Japanese and US national surveys. J Hypertens 1986; 4(suppl 6):$24-$26.