Comprehensive Sex/Gender stratified analysis of Blood Pressure and Hypertension in India

Background: Hypertension is a major contributor to cardiovascular diseases, the leading cause of mortality in India. The sex/gender (SG) differences in the prevalence, progression, and treatment of hypertension exist, however there is no SG specific threshold for clinical hypertension detection. Understanding physio- logical and socio-economic correlates stratified by SG can inform the development of targeted, SG-specific prevention and treatment policies for hypertension. Methods: This study utilized data from two successive rounds of the Demo- graphic and Health Survey conducted in India (NFHS-4 and NFHS-5). The surveys incorporated demographic and health metrics, including systolic blood pressure (SBP) and diastolic blood pressure (DBP) measurements. Data from 1.8 million individuals (2019–2021) from NFHS-5 and 0.8 million individuals (2016–2017) from NFHS-4 were analyzed. Results: Our analysis revealed SG disparities in diverse aspects related to blood pressure in India. Men had overall higher levels of SBP and DBP compared to women. Age influenced SBP differently across SGs, with women experiencing a steeper rise starting in their mid-twenties, and no further SBP increase was observed post-menopause. In contrast, body mass index and waist circumference had a similar impact on BP across both SGs. Education demonstrated a marked SG-specific effect, with women possessing higher education levels being nearly twice as likely to maintain normal SBP compared to their uneducated coun- terparts. Furthermore, the risk of non-communicable diseases emerged at lower 1blood pressure thresholds in women than in men. Lastly, an SG-stratified treat- ment cascade analysis highlighted that women, although more likely to be aware of their hypertension, were less adherent to treatment compared to men. Female awareness and adherence saturated at the lower blood pressure threshold. Conclusion: First and foremost, evidence needs to be gathered for SG-specific hypertension threshold. Strong negative association between education and hypertension in women, might suggest preventative strategies should priori- tize education for women as a highly effective intervention. Additionally, while awareness initiatives should focus more on men, adherence support must be pri- oritized for women to enhance treatment outcomes. These findings underscore need for further studies for developing SG-specific guidelines in the prevention and management of hypertension.