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Global, regional, and national disease burden attributable to high systolic blood pressure in youth and young adults: 2021 Global Burden of Disease Study analysis

BMC Medicine volume 23, Article number: 74 (2025) Cite this article

Abstract

Background

High systolic blood pressure (HSBP) can cause adverse cardiovascular events and is therefore associated with a heavy global disease burden. However, this disease burden is poorly understood in youth and young adults. We aimed to explore this population to better understand the evolving trends in HSBP-related disease burden, which is crucial for effectively controlling and mitigating harmful effects.

Methods

This systematic analysis used data from the 2021 Global Burden of Disease Study, spanning 1990–2021. Participants were aged 15–39 years from 204 countries/territories. We analysed HSBP-related disease burden by region, sex, age, and temporal trends. The primary outcomes were disability-adjusted life years (DALYs), mortality rates, and estimated annual percentage change.

Results

Globally, the number of HSBP-related deaths among youth and young adults has increased by 36.11% (95% uncertainty interval [95% UI], 20.96–52.37%), whereas the number of DALYs has increased by 37.68% (95% UI, 22.69–53.65%); however, global mortality and DALY rates have remained relatively stable. In 2021, the mortality and DALY rates were 4.29 (95% UI, 3.29–5.28) and 263.37 (95% UI, 201.40–324.46) per 100,000 population, respectively. The overall HSBP-related burden was higher in males than in females, with increasing and decreasing trends for males and females, respectively. Regionally, significant improvements in HSBP-related burden were observed in most high-sociodemographic index (SDI) regions, including high-income Asia Pacific (deaths: percentage change, − 72.65%; DALYs: percentage change, − 69.30%) and Western Europe (deaths: percentage change, − 72.89%; DALYs: percentage change, − 67.48%). In contrast, middle-SDI regions had the highest number of deaths and DALYs in 2021, whereas low-middle-SDI regions had the highest mortality and DALY rates. Furthermore, low-SDI regions experienced the largest increase in the number of deaths and DALYs. The HSBP-related burden increased with age; in addition, the proportion of deaths or DALYs due to ischaemic heart disease and stroke increased with age, reaching > 75% for those > 25 years of age.

Conclusions

The increase in global HSBP-related burden among youth and young adults indicates that current preventative efforts are insufficient. Therefore, targeted measures are needed to counter the trends in HSBP-related diseases and reduce disparities across regions and sexes.

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Background

Hypertension is a major risk factor for cardiovascular events and is significantly associated with the development of diseases such as stroke [1] and kidney disease [2]. It also increases all-cause mortality [3]. Hypertension can be classified into three types based on blood pressure components: systolic blood pressure (SBP) elevation, diastolic blood pressure (DBP) elevation, and simultaneous elevation of SBP and DBP. Of these, an elevated SBP has the greatest impact on adverse cardiovascular outcomes [4]. Currently, more than one billion people worldwide suffer from hypertension [5]. According to the Global Burden of Disease (GBD) Study 2021, approximately 10.9 million people worldwide died from high SBP (HSBP) in 2021, accounting for 226 million disability-adjusted life years (DALYs) [6].

In recent years, global epidemiological trends in HSBP have changed significantly, and the reasons for these changes are multifaceted. Although the prevalence of HSBP has declined in some high-income countries due to effective prevention and treatment measures, it has been increasing in many low- and middle-income countries [7]. This shift reflects substantial differences in healthcare resources, health education, and lifestyles across various socioeconomic regions. However, multiple interacting factors contribute to the development of HSBP. First, changes in dietary habits, particularly high-salt diets and the increased consumption of processed foods, are among the primary causes of the increasing prevalence of HSBP [8]. High salt intake leads to sodium retention and increased blood volume, while excessive intake of saturated fats and refined sugars can cause endothelial dysfunction, both of which lead to HSBP [9]. Long-term high-sugar diets may also contribute to insulin resistance, indirectly promoting hypertension [10]. Low-sodium diets have been shown to decrease the mean arterial pressure in 73.4% of individuals [11], effectively lowering SBP [12]. Moreover, the DASH diet has been shown to reduce SBP more significantly than simply restricting sodium intake to ≤ 2.4 g per day [13]. Second, a lack of physical activity and sedentary lifestyles also significantly increase the risk of HSBP [14]. The resulting obesity leads to hormonal, inflammatory, and endothelial changes that further promote HSBP progression [15]. Third, increased mental stress [16], inadequate sleep [17], and unhealthy lifestyle habits [18], such as smoking and alcohol consumption, are important contributing factors. Lastly, genetic factors and gene variations also play a key role in the development of HSBP [19]. Common related genes include SLC12A3 (encoding the Na-Cl cotransporter), ACE (angiotensin-converting enzyme), AGT (angiotensinogen), FTO (fat mass and obesity-associated gene), and CACNA1C (calcium channel alpha-1C subunit gene). Mutations or polymorphisms in these genes may lead to HSBP by altering processes such as sodium reabsorption, vascular contraction response, lipid metabolism, and abnormal regulation of calcium ion channels [20, 21]. Furthermore, gene-lifestyle interactions, such as poor diet and lack of physical activity, also demonstrate substantial influence in HSBP development [22].

Research on the HSBP-related disease burden in the youth and young adult population (ages 15–39) carries significant public health and socioeconomic implications. First, a meta-analysis revealed that approximately 23.8% of HSBP-related cardiovascular events occurred in youth and young adults [23], with increasing trends in the incidence of cardiovascular events [24]. Although early intervention in this area is crucial for preventing cardiovascular diseases in middle and later life, the specific disease burden associated with HSBP in this age group remains largely unknown. Second, as this group is in the early and ascending stages of their careers, their health status has profound implications for personal career development and broader socioeconomic progress. The health of youth and young adults is not only vital for individual well-being but also influences their ability to contribute effectively to society’s economic and social development. Currently, studies on HSBP in youth and young adults are relatively scarce, and the existing research primarily focuses on the general population [25] or older adults [26]. The current research gaps include the lack of large-scale, long-term epidemiological studies and the absence of multidimensional studies that comprehensively consider temporal changes, geographic differences, sex, and age. Therefore, this study aimed to assess the disease burden attributed to HSBP among the global population aged 15–39 years, exploring regional, sex, and age-related differences, thereby enhancing our understanding of the dynamic changes in the global HSBP-related burden in this age group, and supporting the achievement of global health goals.

Methods

Data sources

The GBD database employs a systematic approach to assess the burden of diseases, injuries, and risk factors globally and across regions. The methodology includes data collection, integration, modelling, and uncertainty analysis. GBD 2021 integrates information from multiple data sources and uses hierarchical models, spatiotemporal models, and Bayesian inference to adjust and estimate the data [27, 28]. Our analysis utilised data from GBD 2021 [6], which includes information from 204 countries/territories spanning from 1990 to 2021. Data were obtained using the data exchange query tool available at https://vizhub.healthdata.org/gbd-results. Detailed methodological information on the estimation and modelling strategies for HSBP in GBD 2021 can be found on the official website (https://www.healthdata.org/research-analysis/diseases-injuries-risks/factsheets/2021-high-systolic-blood-pressure-level-2-risk). Specific causes of death, DALYs, and 95% uncertainty intervals (UIs) were extracted and stratified based on age, sex, year, and region. This study was conducted in accordance with the principles of the Declaration of Helsinki. The need for ethical approval and informed consent were waived because the GBD database is publicly available and no identifiable information was included in the analyses.

Relevant definitions

Considering the age categories in GBD 2021 and the definitions for youth and young adults in previous research [24], we selected data from the 15–39-year age group for the analysis. GBD 2021 defined HSBP as an SBP of 105–115 mmHg or higher. Regarding risk factors, the GBD approach follows the comparative risk assessment framework, which is based on a causal web of hierarchically organised, potentially combinatory, modifiable risks. For each risk factor, this framework estimates the theoretical minimum risk exposure levels, which represent the risk factor exposure level at which the lowest possible disease burden is observed, indicating the point where risk-related harms are minimised or eliminated [6]. DALYs are a composite measure that quantifies the total disease burden, representing the sum of life years lost due to premature death and years lived with disability. The GBD database includes 21 GBD regions and 204 countries/territories, classified by socio-demographic index (SDI) quintiles. The regional SDI divisions can be obtained from the Institute for Health Metrics and Evaluation (https://ghdx.healthdata.org/search/site/SDI). The five groups are as follows: low-SDI, low-middle-SDI, middle-SDI, high-middle-SDI, and high-SDI regions. These classifications allow for the comparison of disease burden across regions with varying levels of socio-demographic development [29].

Statistical analysis

To assess the disease burden attributable to HSBP in youth and young adults, we analysed the number and rates of HSBP-related deaths and DALYs from 1990 to 2021; the estimates used in this study are publicly available via the GBD results tool (http://ghdx.healthdata.org/gbd-results-tool). Linear regression was employed to determine the estimated annual percentage change (EAPC) and its 95% confidence interval (95% CI), providing a description of the temporal trends. The detailed calculation method is documented elsewhere [30]. The age-standardised rates for the study population were calculated with direct standardisation using the global age distribution [31]. To analyse the global distribution and regional differences in the burden of HSBP, we quantified the temporal trends in HSBP-related disease burden by sex and in 5-year intervals. Additionally, we generated maps for the 204 countries/territories, showing HSBP-related mortality and DALY rates and the percentage changes in HSBP-related deaths and DALYs. Furthermore, regional comparative analyses were conducted. The data were aggregated by geographical regions as defined by the GBD study, and maps were created using the “ggplot2” and “sf” R packages to visualise the distribution of disease burden. In addition, we calculated the Spearman correlation coefficient between the 2021 SDI and mortality and DALY rates and their EAPCs. Gaussian process regression was utilised to describe the relationship between the SDI (1990–2021) and HSBP-related mortality and DALY rates, as well as their EAPCs in the included regions. All calculations were conducted using R, version 4.3.2 (The R Foundation for Statistical Computing, Vienna, Austria), with a P-value < 0.05 indicating statistical significance.

Patient and public involvement

Patients and the public were not involved in this study.

Results

Overall HSBP-related burden in youth and young adults

Globally, the number of HSBP-related deaths and DALYs among youth and young adults has gradually increased. The number of deaths increased from 93,664 (95% UI: 69,114–118,062) in 1990 to 127,488 (95% UI: 97,749–156,979) in 2021, reflecting a 36.11% increase (95% UI: 20.96–52.37%) (Table 1; Fig. 1a; Additional file 1, Table S1).

Table 1 Deaths, mortality rates, and EAPC of youths and young adults with HSBP (1990–2021)
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Fig. 1
figure 1

Temporal trends in global disease burden attributable to high systolic blood pressure among youth and young adults by SDI quintiles and sex from 1990–2021. a Death cases. b DALYs. c Mortality rates. d DALY rates. DALY, disability-adjusted life year; SDI, sociodemographic index

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The number of DALYs increased from 5,690,434 (95% UI: 4,199,113–7,205,650) in 1990 to 7,834,791 (95% UI: 5,991,320–9,652,176) in 2021, an increase of 37.68% (95% UI: 22.69–53.65%) (Table 2; Fig. 1b; Additional file 1, Table S2). Despite this increase, the global overall mortality and DALY rates have remained relatively stable from 1990 to 2021. During this period, the mortality rate changed from 4.27 per 100,000 population (95% UI: 3.15–5.39) to 4.29 per 100,000 population (95% UI: 3.29–5.28), and the DALY rate changed from 259.62 per 100,000 population (95% UI: 191.58–328.76) to 263.37 per 100,000 population (95% UI: 201.40–324.46). In contrast, the age-standardised mortality and DALY rates showed a slight decrease (Tables 1 and 2; Fig. 1c, d).

Table 2 DALYs, DALY rates, and EAPC of youths and young adults with HSBP (1990–2021)
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HSBP-related burden in youth and young adults by GBD region

From 1990 to 2021, the number of HSBP-related deaths and DALYs among youth and young adults increased in most GBD regions; however, no increase was observed in Australasia, Central Europe, high-income Asia Pacific, Eastern Europe, Southern Latin America, Tropical Latin America, and Western Europe (Tables 1 and 2). Although the UIs of the percentage changes in mortality and DALY rates for Central Asia, East Asia, Southern Sub-Saharan Africa, and Southern Latin America spanned zero, a comparison of the estimates for 1990 and 2021 indicated that the disease burden increased in the first three regions, whereas Southern Latin America saw a reduction in burden. In 2021, South Asia had the highest number of HSBP-related deaths and DALYs, while Australasia had the lowest (Tables 1 and 2). Additionally, from 1990 to 2021, HSBP-related mortality and DALY rates either remained stable or increased in most regions, except for declines in Australasia, Central Asia, Central Europe, Central Sub-Saharan Africa, Eastern Europe, Eastern Sub-Saharan Africa, high-income Asia Pacific, North Africa, the Middle East, Southern Latin America, Southern Sub-Saharan Africa, Tropical Latin America, and Western Europe. The largest decrease was observed in Western Europe, whereas the largest increase was recorded in the Caribbean (Tables 1 and 2). In 2021, Southeast Asia had the highest HSBP-related mortality and DALY rates, and Australasia had the lowest (Tables 1 and 2; Additional file 1, Fig. S1).

HSBP-related burden in youth and young adults by countries/territories

In 2021, among the 204 countries/territories analysed in the GBD study, India had the highest number of HSBP-related deaths and DALYs among youth and young adults, followed by China and Indonesia (Additional file 1, Tables S3 and S4). The highest mortality and DALY rates due to HSBP were found in Nauru, followed by Palau and Vanuatu. Sweden had the lowest mortality and DALY rates (Fig. 2; Additional file 1, Tables S3 and S4). The Republic of Korea showed the greatest reduction in the percentage change in deaths and DALYs, whereas Cameroon exhibited the largest increase (Fig. 2; Additional file 1, Tables S3 and S4). Additionally, from 1990 to 2021, Zimbabwe had the largest increase in mortality and DALY rates. In contrast, the Republic of Korea experienced the most significant decrease in EAPC for mortality, while Luxembourg had the greatest reduction in EAPC for DALY rates (Additional file 1, Table S5).

Fig. 2
figure 2

Global HSBP-related burden in youths and young adults in 204 countries/territories. a Mortality rate in 2021. b Change in the number of deaths attributable to HSBP between 1990–2021. c DALY rate in 2021. d Change in the number of DALYs attributable to HSBP between 1990–2021. DALY, disability-adjusted life year; HSBP, high systolic blood pressure

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Association of HSBP-related burden with SDI

An analysis of regions stratified by SDI levels showed that from 1990 to 2021, the number of deaths and DALYs decreased in the high- and high-middle-SDI regions, whereas they increased in other regions (Tables 1 and 2; Fig. 1a, b). The largest reduction in HSBP-related mortality and DALY rates was observed in the high-SDI regions, whereas the greatest increase was observed in the low-middle-SDI regions. Notably, the mortality and DALY rates in the high-, high-middle-, and low-SDI regions showed a fluctuating downward trend, whereas those in the low-middle- and middle-SDI regions exhibited a fluctuating upward trend (Tables 1 and 2; Fig. 1c, d).

In 2021, middle-SDI regions had the highest number of deaths and DALYs, followed by low-middle-SDI regions, and the lowest number was found in high-SDI regions (Tables 1 and 2). The highest HSBP-related mortality and DALY rates were observed in the low-middle-SDI regions, whereas the lowest was observed in the high-SDI regions (Tables 1 and 2; Fig. 1). Overall, HSBP-related mortality and DALY rates were negatively correlated with SDI (r = − 0.456, P < 0.001; r = − 0.441, P < 0.001) (Fig. 3). Additionally, the EAPC of both deaths and DALYs showed a significant negative correlation with SDI (r = − 0.479, P < 0.001) (Fig. 3).

Fig. 3
figure 3

Correlations between HSBP-related mortality and DALY rates and SDI and EAPC. a, c Correlations between mortality (a) or DALY (c) rates and SDI in 2021. b, d Correlation between EAPC of mortality rate (b) or DALY rate (d) and SDI in 2021. e, f Association between the rates of HSBP-related deaths or DALY and SDI (1990–2021) across 21 regions. For each region, the points from left to right depict the estimates for each year. The solid blue line represents expected values across the SDI spectrum. e Mortality rate. f DALY rate. DALY, disability-adjusted life year; EAPC, estimated annual percentage change; HSBP, high systolic blood pressure; SDI, sociodemographic index

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When analysing the correlation between SDI, mortality, and DALY rates using Gaussian process regression, we observed that higher SDI levels were associated with decreased HSBP-related mortality and DALY rates among youth and young adults globally. However, in Central Asia and Eastern Europe, the relationship between SDI and these rates formed an asymmetric inverted V-shape, peaking at SDI levels of around 0.55 and 0.70, respectively (Fig. 3). Additionally, mortality rates in Eastern Europe have been consistently higher than expected since 1990. In Eastern Europe and Central Asia, mortality rates initially surged and then declined sharply, whereas in Andean and Central Latin America, rates first declined and then rose with increasing SDI levels. Central Europe showed a linear downward trend (Fig. 3e). Furthermore, three of the four highest SDI regions, namely Australasia, high-income Asia Pacific, and Western Europe, experienced a significant decline in HSBP-related mortality rates, whereas high-income North America reported fluctuating stable or even rising mortality rates (Fig. 3e). The pattern of DALY rates mirrored mortality rates (Fig. 3f).

HSBP-related burden by sex group

Globally, from 1990 to 2021, the number of HSBP-related deaths among youth and young adults increased by 45.83% (95% UI: 27.25–67.26%) for males and 16.66% (95% UI: − 2.24–39.89%) for females (Fig. 1a; Additional file 1, Table S1). Similarly, the number of DALYs increased by 46.85% (95% UI: 28.79–68.36%) for males and 20.25% (95% UI: 1.78–42.59%) for females (Fig. 1b; Additional file 1, Table S2). In 2021, the total number of deaths and DALYs among males was higher than that among females (Additional file 1, Tables S1 and S2). HSBP-related mortality and DALY incidence rates in young males were approximately 1.9–2.4 times higher than those in females of the same age (Additional file 1, Tables S1 and S2). The sex differences in mortality and DALY rates in 2021 were statistically significant (P < 0.001). Since 1990, the mortality and DALY rates for females have decreased by 13.74% and 11.09%, respectively, whereas those for males have increased by 7.08% and 7.82%, respectively (Additional file 1, Tables S1 and S2).

From the perspective of different SDI levels, from 1990 to 2021, HSBP-related deaths and DALYs decreased in both males and females in high- and high-middle-SDI regions, whereas the overall numbers increased in other regions for both sexes (Additional file 1, Tables S1 and S2, Figs. S1 and S2). In 2021, the middle-SDI regions recorded the highest numbers of HSBP-related deaths and DALYs, while the high-SDI regions had the lowest. The differences in mortality and DALY rates across SDI regions were statistically significant (P < 0.001). Across all SDI regions, the number of deaths and DALYs was higher in males than in females (Additional file 1, Tables S1 and S2).

In terms of mortality trends, the rates have fluctuated downward for females in all SDI regions since 1990. For males, the mortality rates fluctuated downward only in the high- and high-middle-SDI regions, whereas in other regions, they fluctuated upward (Fig. 1; Additional file 1, Table S1). The trends in DALY rates were almost identical to those in mortality rates.

HSBP-related burden by age group

In 2021, the number of HSBP-related deaths and DALYs among youth and young adults increased significantly with age, peaking in the 35–39-year age group (Additional file 1, Table S6 and S7). Notably, the cause distribution changed with age; for those aged < 25 years, the primary cause of death or DALY was hypertensive heart disease. As age increased, the proportion of deaths or DALYs due to ischaemic heart disease and stroke increased, reaching over 75% for those > 25 years of age (Additional file 1, Fig. S2).

Discussion

Using the latest data released in GBD 2021, this analysis comprehensively and systematically assessed HSBP-related disease burden in youth and young adults. Although the HSBP-related mortality and DALY incidence rates in youth and young adults did not change significantly between 1990 and 2021, the number of deaths and DALYs increased by over one third. Notable differences were observed by sex and region, along with variations in the distribution of causes of disease burden across different age groups. Additionally, the burden of HSBP among youth and young adults increased in the middle/low-SDI regions, whereas it decreased in the high-SDI regions. The asymmetric inverted V-shaped relationship of SDI with mortality and DALY rates indicates that the disease burden may be relatively high in middle-SDI regions. Despite the reduction in the disease burden in regions with a high SDI, the significant imbalance in the current regional epidemiology suggests that alleviating the global burden of HSBP remains a significant challenge. Therefore, strategies aimed at addressing the health needs of the young and middle-aged populations are urgently required.

The burden of an SBP of 105–115 mmHg or more

The burden of blood pressure-related diseases among youth and young adults may be associated with unhealthy lifestyles, obesity, and lack of exercise [32]. Our analysis found that an SBP of 105–115 mmHg or more is an increasingly serious health problem for individuals aged 15–39 years. Although most HSBP-related research considers SBP ≥ 140 mmHg as the SBP cutoff, the SPRINT trial confirmed that intensive blood pressure lowering (target SBP < 120 mmHg) significantly reduces the incidence of cardiovascular events compared with standard blood pressure lowering (target SBP < 140 mmHg) [3]. However, although the average SBP among youth and young adults is generally lower, few definitive trials have suggested that 110–120 mmHg or even < 105 mmHg is the optimal SBP level for this group [33]. Therefore, the benefits of controlling HSBP to ≤ 105 mmHg in youth and young adults remain inconclusive and warrant further research. Considering that excessive blood pressure lowering may increase the risk of adverse events, including hypotension, syncope, and renal function decline, and that individual differences may exist in blood pressure response and tolerance [34], intensive blood pressure treatment in youth and young adults should be approached with caution.

When comparing our findings with those reported from other cohorts or databases, significant regional and national differences emerge in the epidemiological status of hypertension among youth and young adults. Even within the same population, the prevalence rates vary considerably depending on the diagnostic criteria applied [35]. For instance, a national registry study in Poland reported a hypertension prevalence of 35.2% among adults, whereas the prevalence among children under 18 years was approximately 0.5% [36]. In the Arab world, the estimated prevalence of hypertension among adolescents is 12.6% [37], whereas in China, the prevalence is approximately 4% among adolescents aged 6–17 years [38] and 4.3% among university students aged 18–22 years [39]. In Malaysia, the prevalence of hypertension in the 18–39-years age group is 17.7% [40], and in Zimbabwe, the prevalence among 18–24-year-olds is approximately 7.4% [41]. However, few previous studies have conducted a global, cross-sectional comparison of the mortality and DALY rates and disease burden associated with HSBP.

Discrepancies across high-SDI regions

In 2021, the disease burden of HSBP among youth and young adults showed significant disparities across the different SDI regions and countries. In relatively high-SDI regions such as Australasia, central Europe, high-income Asia Pacific, and Western Europe, the HSBP-related burden among youth and young adults has significantly improved since 1990. This phenomenon may be attributed to higher health literacy among residents in regions with a high SDI, which enables them to better understand and implement healthy lifestyles, such as a balanced diet, regular exercise, and moderation in smoking and alcohol consumption [25]. Moreover, comprehensive chronic disease management programs, including regular blood pressure monitoring, patient education, and constructive guidelines, are commonly implemented in high-SDI regions [42]. Notably, over the past 30 years, some high-SDI regions, such as Eastern Europe, still exhibit relatively high HSBP-related mortality and DALY rates, despite showing some improvements. This may be related to high salt intake, which significantly contributes to the hypertension burden in regions with a high SDI, particularly in Eastern Europe [43]. Additionally, high alcohol and tobacco consumption and low fruit and vegetable intake in Eastern European countries significantly contribute to the burden of hypertension-related diseases [43]. This indicates that even in high-SDI regions, measures should be taken to optimise existing health policies.

The relationship between SDI and HSBP-related burden

Mortality and DALY data for youth and young adults indicate that middle-, low-middle-, and low-SDI regions bear a heavy HSBP-related burden. Although the percent change UIs/CIs for the high-middle- and middle-SDI regions spanned zero, indicating uncertainty in the changes in mortality and DALY rates, a comparison of the specific values for 1990 and 2021 suggests a general trend of decreasing disease burden in the high-middle-SDI regions and an increasing burden in the middle-SDI regions.

Currently, the middle-SDI regions are experiencing rapid development, with resident lifestyles gradually shifting from traditional low-fat and low-salt diets to high-fat, high-salt, and high-sugar diets [44]. These regions also face challenges such as insufficient financial investment in healthcare [45], internal socioeconomic inequality [46], increased environmental pollution, and adverse occupational exposure due to industrialisation and urbanisation [47]. These factors may contribute to the severe burden of HSBP in these regions. In contrast, high-SDI regions have already undergone these transitions, whereas low-SDI regions have yet to encounter these issues. However, as the main driving force of SDI development, middle- and low-SDI regions should focus on alleviating the disease burden in the young adult population.

Furthermore, the interaction between HSBP and non-communicable diseases, including obesity and diabetes, has significant implications for public health. These conditions often co-occur [48], creating a vicious cycle that exacerbates the burden of chronic diseases and leads to more severe comorbidities, such as cardiovascular diseases and kidney disorders. In regions with low and middle SDI where health resources are limited, the issue of disease comorbidity is particularly acute, and greater attention should be given to screening for such comorbidities.

Discrepancies across different countries

The national differences observed in this study align with previous research on older populations, indicating that most HSBP-related deaths occur in low- and middle-income countries. However, the driving metabolic or behavioural risk factors for changes in the HSBP-related burden have yet to be quantified [26]. With their large population bases, India, China, and Indonesia experience higher numbers of HSBP-related deaths and DALYs among youth and young adults. Other contributing factors include urbanisation, dietary habits (high-salt and high-fat diets), and lifestyle changes, such as a lack of physical activity [8]. Furthermore, these countries may have shortcomings in early hypertension screening and management, leading to delayed or inadequate interventions [49]. In contrast, countries like Cameroon and Zimbabwe are witnessing a continuous rise in HSBP-related burden in younger populations, primarily due to economic underdevelopment and scarce healthcare resources [50]. Similarly, despite having smaller populations and limited public health resources, small island nations like Nauru, Palau, and Vanuatu also exhibit high HSBP-related mortality and DALY rates. This is partly due to insufficient consumption of fruits and vegetables and high sugar intake [51]. In contrast, Sweden benefits from a world-leading healthcare system and efficient public health policies, including early screening, promotion of healthy diets, and physical activity advocacy, which ensure timely and effective management of HSBP [52]. In recent years, South Korea has significantly reduced its hypertension-related mortality and DALY rates, owing to its robust healthcare system, improvements in public health policies, and widespread hypertension management [53]. In summary, the differences in the HSBP-related burden among youth and young adults across various countries and regions reflect a combination of factors, including public health policies, resident lifestyles, regional economic and social development levels, the prevalence of health education and preventive measures, and environmental and cultural influences [43, 47, 54]. Understanding these differences can assist in formulating more targeted public health strategies and interventions to effectively reduce HSBP-related disease burden.

Age and sex differences

Even among youth and young adults, the burden of HSBP increases with age, and specific causes tend to shift from hypertensive heart disease to ischaemic heart disease and stroke. This may be caused by vascular remodelling during the ageing process [55] and changes in cardiac structure and function [56]. Additionally, ageing is accompanied by chronic low-grade inflammation and changes in immune system functions, which may be contributing factors for the age-related differences observed in this study [57]. Our analysis of the differences between age groups revealed significant disparities in disease burden, even within smaller age intervals (15–39 years). Notably, individuals aged 20–39 years exhibited HSBP-related mortality and DALY rates that were 40 and 32 times higher, respectively, than those in the 15–19-years age group. Similarly, the absolute numbers of HSBP-related deaths and DALYs in the 20–39-years age group were more than 100 times higher than those in the 15–19-years age group. This highlights the fact that, even within younger populations, the increasing burden of HSBP due to ageing should not be overlooked. It also emphasises the need for age-specific screening frequencies to address HSBP more effectively across different age groups.

Although HSBP-related mortality and DALY rates has increased in youth and young adults over the past decades, the relatively low rates in this population may be due to the limited directly fatal impact of HSBP in this age group. Additionally, this phenomenon may reflect the pathological characteristics of HSBP, whereby the long-term effects of HSBP, such as changes in heart structure and function, may not yet be fully evident in younger populations, and the fatal consequences of the disease tend to manifest more gradually with age.

Sex differences in the trends over time are intriguing. From 1990 to 2021, both mortality and DALY rates improved among females across all SDI regions. However, among males, improvements were observed only in the high- and high-middle-SDI regions. The higher burden of HSBP in males may be attributed to factors such as increased vascular tension due to higher testosterone levels, which accelerates the progression of hypertension [58, 59]. Young males are also more likely to engage in unhealthy lifestyles [60] and are more susceptible to the genetic influences of familial hypertension [41]. Moreover, males often face greater social and psychological stressors in both work and life, which can accelerate hypertension by affecting their autonomic nervous and endocrine systems [41, 61].

Implications for public health

Our study has profound policy implications. First, analysing the trends in HSBP-related burden provides a scientific basis for planning and implementing effective health interventions aimed at reducing the burden of HSBP among youth and young adults. Second, this study offers critical sex-specific health insights for working-age populations in various countries and regions, emphasising the importance of optimising healthcare resource allocation to enhance the responsiveness and efficiency of healthcare systems. Third, given the significant disparities between countries and regions, targeted policies that consider each country’s unique backgrounds and circumstances are essential. This approach ensures fairness and effectiveness of health interventions, thereby promoting health equity across various populations.

To this end, we propose the following specific policy recommendations. Strategies to reduce the burden of HSBP in youth and young adults should focus on prevention, early screening, and multi-level interventions. First, health education and behaviour changes are fundamental, aiming to raise the awareness of hypertension among young people; promote the benefits of healthy diets, exercise, and stress management; and encourage regular health check-ups. Second, policies such as limiting salt and sugar intake and regulating nutrition labels, along with improving cooking habits, should be implemented. Successful strategies from high-SDI regions may provide valuable insights and be adjusted to apply to low-SDI regions. For example, although the DASH and low-sodium diets have shown significant effectiveness in preventing and managing hypertension in young adults [62], their global implementation may face challenges related to cultural adaptation and practical execution. Dietary habits, economic conditions, availability of food, and culinary cultures may limit the acceptability and effectiveness of these dietary patterns in middle- and low-SDI regions. Moreover, the conflict between traditional and modern dietary habits, as well as poor acceptance of low-sodium foods, may affect the success of these dietary interventions. Therefore, tailoring dietary interventions to local cultural and socio-economic contexts will be crucial to achieve hypertension control targets. Cross-national cooperation and experience-sharing will help develop health intervention plans that align with the cultural and economic backgrounds of different regions. Lastly, strengthening resource allocation is essential to reduce the HSBP-related burden gap across regions with different economic levels. Increased investment in public health, especially primary healthcare facilities in rural areas of middle- and low-SDI regions, is necessary to provide affordable screening and treatment services.

Limitations

This study has several limitations that should be acknowledged. First, GBD 2021 relies on global data, which can be influenced by various factors, such as differences in data collection methods and the quality of data sources. Disparities in these aspects could affect the overall quality and reliability of the data used in our analysis. Second, the GBD 2021 database updated its data sources and analytical strategies, including adjusting the theoretical minimum risk exposure level for blood pressure changes from 110–115 to 105–115 mmHg, setting 105–115 mmHg as the starting point for assessing risk. This definition helps identify early potential health risks within the ‘normal’ blood pressure range, particularly in long-term health burden assessments. However, incorporating this range into hypertension-related risk standards may lead to overestimation, especially among low-risk individuals, and does not entirely align with the traditional clinical definition of hypertension. Consequently, we suggest that the study results be viewed as an early warning for health risks. Third, HSBP may not only be caused by primary hypertension; it may also be secondary to renal-related diseases (e.g. chronic kidney disease and renovascular disease), endocrine disorders (e.g. pheochromocytoma, Cushing’s syndrome, adrenal diseases, and hyperthyroidism), metabolic disorders (e.g. obesity and overweight [15]), and even aortic coarctation and drug-induced hypertension (e.g. induced by oral contraceptives [63]). However, since the GBD database cannot link HSBP with these underlying causes, further research is required to explore the associations and specific causes of HSBP burden, which is also of growing public interest. Lastly, DBP and pulse pressure may independently impact outcomes such as mortality [61], and blood pressure components have synergistic effects on prognosis [64]. Although SBP is a crucial component in hypertension management, DBP is more reflective of the cardiovascular health status and future disease risk among young individuals [65]. However, the GBD 2021 database does not include DBP or pulse pressure measurements, limiting the comprehensive assessment of these parameters.

Conclusions

As of 2021, despite no significant changes in the global HSBP-related age-standardised mortality and DALY rates among youth and young adults, the overall burden has markedly increased. This increase was particularly pronounced in the middle-SDI regions. The degree of HSBP-related burden varied significantly between different regions, sexes, and age groups. This study underscores the need for further in-depth research to explore the reasons for these disparities. This is crucial for narrowing regional differences and further reducing the burden of HSBP among youth and young adults.

Data availability

Data used in this study were obtained from the Global Health Data Exchange Global Burden of Disease Results Tool (https://ghdx.healthdata.org/gbd-results-tool), accessed on 12 June 2024.

Abbreviations

CI:

Confidence interval

DALY:

Disability-adjusted life year

DBP:

Diastolic blood pressure

EAPC:

Estimated annual percentage change

GBD:

Global Burden of Disease

HSBP:

High systolic blood pressure

SBP:

Systolic blood pressure

SDI:

Sociodemographic index

UI:

Uncertainty interval

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Acknowledgements

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Funding

This study was supported by the Department of Education of Liaoning Province (JYTQN2023022). The funding agencies had no role in the study design, collection, analysis, and interpretation of the data; in the writing of the report; or in the decision to submit the article for publication.

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  1. Chuan He, Saien Lu, and Haijie Yu contributed equally to the study.

Authors and Affiliations

  1. Department of Laboratory Medicine, First Hospital of China Medical University, Shenyang, Liaoning Province, China

    Chuan He

  2. National Clinical Research Center for Laboratory Medicine, First Hospital of China Medical University, Shenyang, Liaoning Province, China

    Chuan He

  3. Department of Cardiology, First Hospital of China Medical University, Shenyang, Liaoning Province, China

    Saien Lu, Haijie Yu, Yingxian Sun & Xueyao Zhang

  4. Department of Epidemiology, School of Public Health, China Medical University, Shenyang, Liaoning Province, China

    Xueyao Zhang

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Contributions

CH, SL, and HY contributed to the conception and design of the work. YS and XZ contributed to the acquisition, analysis, and interpretation of the data. CH, SL, HY, and XZ drafted the manuscript. YS critically revised the manuscript. All authors agreed to be accountable for all aspects of the work, ensuring its integrity and accuracy. CH, SL, and HY contributed equally to this work. YS and XZ were the guarantors of this study. All authors read and approved the final manuscript.

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This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval and informed consent were waived because the GBD is publicly available and no identifiable information was included in the analyses.

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Supplementary Information

12916_2025_3918_MOESM1_ESM.docx

Additional file 1: Table S1. Changes in HSBP-related deaths and death rates in the youth and young adults by sex and SDI region, 1990-2021. Table S2. Changes in HSBP-related DALYs and DALY rates in the youth and young adults by sex and SDI region, 1990-2021. Table S3. Ranks of HSBP-related deaths, death rates, and changes in the youth and young adults in 204 countries/territories, 1990-2021. Table S4. Ranks of HSBP-related DALYs, DALY rates, and the changes in the youth and young adults of 204 countries/territories, 1990-2021. Table S5. EAPC ranks of HSBP-related death and DALY rates in the youth and young adults of 204 countries/territories, 1990-2021. Table S6. Deaths, mortality rates, DALYs, and DALY rates of youth and young adults with HSBP (1990–2021) by different age groups. Table S7. Deaths, mortality rates, DALYs, and DALY rates of youth and young adults with HSBP (1990–2021) by 2 age groups. Fig. S1. Comparison of HSBP-related mortality (a) and DALY rates (b) in the 21 regions in 1990 and 2021. Fig. S2. Proportion of HSBP-related disease burden by different age groups.

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He, C., Lu, S., Yu, H. et al. Global, regional, and national disease burden attributable to high systolic blood pressure in youth and young adults: 2021 Global Burden of Disease Study analysis. BMC Med 23, 74 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12916-025-03918-1

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