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Clin Exp Hypertens, Early Online: 1–8

! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/10641963.2013.863321

ORIGINAL PAPER

The prevalence, predictors and associations of hypertension in Sri

Lanka: a cross-sectional population based national survey
Prasad Katulanda1,2, Priyanga Ranasinghe3, Ranil Jayawardena1,4, Godwin R. Constantine1, M. H. Rezvi Sheriff1, and
David R. Matthews2
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1
Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka, 2Oxford Centre for Diabetes,
Endocrinology and Metabolism, University of Oxford, United Kingdom, 3Department of Pharmacology, Faculty of Medicine, University of Colombo,
Sri Lanka, and 4Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia

Abstract Keywords
We studied the community prevalence, patterns and predictors of hypertension in a large sub- Adults, blood pressure, hypertension,
population of South Asian adults with a view of identifying differential risk factors. Data were prevalence, Sri Lanka
collected between years 2005–2006 and 5000 adults were invited for the study. The sample size
was 4485, and about 39.5% were males. Mean systolic and diastolic blood pressures were History
127.1  19.8 mmHg and 75.4  11.3 mmHg, respectively. Age-adjusted prevalence in all adults,
males and females was 23.7%, 23.4% and 23.8%, respectively. Urban adults had a significantly Received 6 June 2013
higher prevalence of hypertension than rural adults. In the binary logistic–regression analysis, Revised 1 August 2013
male gender (OR: 1.2), increasing age, Sri Lankan Moor ethnicity (OR: 1.6), physical inactivity Accepted 19 September 2013
(OR: 1.7), presence of diabetes (OR: 2.2) and central obesity (OR: 2.3) all were significantly Published online 16 January 2014
For personal use only.

associated with hypertension. In conclusion, nearly one-third of the Sri Lankan adult population
is hypertensive. Hence, public health initiatives should encourage healthier lifestyles with
emphasis on preventing obesity and increasing physical activity.

Introduction (DBP) of 5–6 mmHg reduces stroke, coronary disease, and

total vascular deaths by 34%, 19% and 23%, respectively (6).
Hypertension is a major modifiable risk factor for cardiovas-
South Asia, commonly known as the Indian sub-continent,
cular disease (CVD), stroke and end-stage renal failure (1).
is home to almost one-fifth of the world’s population.
High blood pressure (BP) has increased the risk of CVD
Although there are significant cultural differences between
worldwide, and there is evidence showing that the problem is
regional countries, South Asians are an inherently high-risk
only getting worse. More than quarter of the worlds popula-
group for developing abdominal adiposity, diabetes, CVDs
tion is already hypertensive and this number is projected to
and hypertension (7). According to recent World Health
increase to 29% by 2025 (2). This estimation relies especially
Organization (WHO) estimates the highest number of deaths
on a sharp increase in the prevalence of hypertension in
and Disability Adjusted Life Years (DALYs) attributable to
developing countries, which is expected to acccount for nearly
high BP occurred in the WHO Western Pacific and South-
three quarters of the world’s hypertensive population (2,3).
East Asia regions (8). Globally, between 1980 and 2008, SBP
In the year 2000, 7.6 million premature deaths, 54% of
has decreased by 0.8 mmHg per decade in men and 1.0 mmHg
strokes and 47% of CVDs worldwide were attributable to high
per decade in women; however, in the South Asian region,
BP (4). In addition, about 80% of the burden of hypertension
SBP has increased during the same period ranging around
and its complications were observed in low-income and
0.8–1.6 mmHg per decade in men and 1.0–2.7 mmHg per
middle-income countries (4). In 2008, age-standardised mean
decade for women (5). Economic development, industrializa-
systolic BP (SBP) worldwide was 128.1 mmHg in men and
tion, nutrition transition and globalization with rapidly
124.4 mmHg in women (5). Studies have shown that an
changing lifestyles in the region probably account for the
average reduction in SBP of 12–14 mmHg and in diastolic BP
increasing prevalence of hypertension.
Sri Lanka is a developing country in the South Asian
region with a population of 20.9 million (9). In Sri Lanka, a
recent community based survey in four provinces (out of nine)
Correspondence: Prasad Katulanda, MBBS, M.D., D.Phil., Senior reported a hypertension prevalence of 18.8% in men and
Lecturer in Clinical Medicine/Coordinator – Diabetes, Research Unit, 19.3% in women (10). A hospital based study in a single
Department of Clinical Medicine, Faculty of Medicine, University of
Colombo, Sri Lanka. Tel: +94 112679204. Mobile: +94 772920991. province conducted during 1984–1986 reported a prevalence
Fax: +94 112689188. E-mail: prasad.katulanda@yahoo.com of 43.5% (11). To our knowledge, there are no published data
 2 P. Katulanda et al.
regarding the community prevalence of hypertension based
on a national-survey from Sri Lanka or other regional South
Asian countries. The present study aims to describe the
community prevalence, patterns and predictors of hyperten-
sion in a large sub-population of South Asian adults with a
view of identifying differential risk factors, which may lead to
improved preventive measures and care for hypertensive
patients in the South Asia region.
Materials and methods
Study population and sampling
Data were collected as a part of a wider cross-sectional
national study conducted in seven of the nine provinces in
Sri Lanka between August 2005 and September 2006
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(Sri Lanka Diabetes and Cardiovascular Study, SLDCS).
The Northern and Eastern provinces of the country affected
by the war during the study period were not included.
Detailed sampling has been previously reported (12). In brief,
the total sampling frame was approximately 14 million adults
18 years of age living in 12 018 ‘‘village officer’’ units (the
smallest government administrative unit). The total sample
size was 5000 adults. A cluster was defined as 50 households
and the total sample of 5000 adults were recruited from
100 such clusters. The number of clusters for individual
province was determined using a probability-proportional-to-
size (PPS) technique according to the total provincial
For personal use only.
population. In each province, the clusters to be studied were
selected by a computer-generated random number list from
the ‘‘Village Office Units’’ in the particular province.
Subsequently the voters’ registers in each cluster (updated
annually for those aged 18 years) were used to randomly
select the first household and a uniform criterion was used to
select the remaining 49 households in a cluster. The selected
households were visited by the study team and one subject
was randomly selected. Relevant data of 5000 non-institutio-
nalized adults are presented here. Ethical approval was
obtained from the Ethical Review Committee, Faculty of
Medicine, University of Colombo, Sri Lanka.
Definitions, measurements and data collection
Data collection was carried out by a field team of trained
medical graduates and nurses. Seated BP was measured after
a 10-min rest with Omron IA2 digital BP monitors (Omron
Healthcare, Alexandra Technopark, Singapore). Subjects were
considered to have ‘‘diagnosed hypertension’’ if they had
been previously diagnosed at a government hospital or by a
registered medical practitioner or if they were on anti-
hypertensive treatment. New cases (‘‘undiagnosed hyperten-
sion’’) were diagnosed when the average of two resting seated
BP readings, separated by 5 min were 140/90 mmHg. Pre-
hypertension was defined as a SBP of 120–139 mmHg and/or
a DBP of 80–89 mmHg A standard bladder (12–13 cm long
and 35 wide) was used but a larger and a smaller bladder were
available for fat and thin arms, respectively. Diabetes was
diagnosed according to the American Diabetes Association
(13) and WHO criteria (14). Central obesity was defined as
waist circumference 490 cm for males and 480 cm for
females according to Asian cut-off values (15).
Clin Exp Hypertens, Early Online: 1–8
Height was measured using Harpenden pocket stadi-
ometers (Chasmors Ltd, London, UK) to the nearest 0.1 cm
according to standard methods. Body weight was measured
in indoor light clothing to the nearest 0.1 kg using a
SALTER 920 digital weighing scale (Salter Ltd, Tonbridge,
UK). Waist circumference was measured at midway between
iliac crest and lower rib margin at the end of normal
expiration using a plastic flexible tape to the nearest 0.1 cm.
Similarly, the hip circumference was also measured at the
widest part of the buttocks at inter-trochantric level to the
nearest 0.1 cm. Body Mass Index (BMI) was calculated as
weight in kilograms divided by height in meters squared
(kg/m2). An interviewer-administrated questionnaire was
used to obtain socio-demographic details such as age,
gender, area of residence, ethnicity, level of education and
household income. Level of education was classified in to
four categories: no formal education, primary education
(year 1–5), secondary education (year 6–13) and tertiary
education (under-/post-graduate). Similarly for the purpose
of analysis monthly household income in Sri Lankan Rupees
(LKR; 1 US$ ¼ 125 LKR) was classified as follows: LKR
6999, LKR 7000–24 999, LKR 25 000–49 999 and LKR
50 000. Physical activity during the past week was assessed
using, the short version of the International Physical Activity
Questionnaire (IPAQ) administered by an interviewer. Urban
and rural sectors were defined according to the classification
of the Sri Lankan government. Blood samples were
collected from participants for the estimation of overnight
fasting blood glucose, 2-h post prandial blood glucose, total/
LDL/HDL cholesterol and triglycerides. Details of blood
sample collection and biochemical analysis are described
elsewhere (12).
Statistical analyses
All data were double-entered and cross checked for consist-
ency. Data were analysed using SPSS version 14 (SPSS Inc.,
Chicago, IL) and Stata/SE 10.0 (Stata Corporation, College
Station, TX) statistical software packages. The significance
of the differences between proportions (%) and means were
tested using z-test and Student’s t-test or ANOVA, respect-
ively. Direct standardization of prevalence was performed
according to the population data published by the United
Nations population division and for the ‘‘WHO new world
population’’ (16). A binary logistic regression analysis was
performed using the dichotomous variable hypertension
(0 ¼ absent and 1 ¼ present). The independent co-variants
(reference category) included in the binary logistic regres-
sion analysis were the following: gender (‘‘female’’), age
category (‘‘530’’ years), area of residence (‘‘rural’’),
ethnicity (‘‘Sinhalese’’), physical activity (‘‘active’’), pres-
ence of diabetes and central obesity. A stepwise forward
entry method was used to enter the variables. For each
independent variable with more than two categories, dummy
variables were created. The first category was taken as the
reference category. A similar binary logistic regression
analysis with above dependant and independent variables
was also performed separately for both males and females.
In all statistical analyses, p values 50.05 were considered
significant.
 DOI: 10.3109/10641963.2013.863321 Prevalence and predictors of hypertension in Sri Lanka 3

Results was significantly higher than the mean SBP and DBP of
Sinhalese and Tamils when considering all adults and
The original sample size was 5000, of which 4485 adults
females; however, this difference was not significant in
consented to take part in the study (response rate – 89.7%),
males (Tables 1 and 2). When considering the level of
39.5% (n ¼ 1772) were males. Mean age was 46.1  15.1
education, the highest and the lowest mean SBP in all adults
years. Socio-demographic data of the study population is
and females was observed in those with no formal education
described elsewhere (12). In summary, 21.3% (n ¼ 955) were
and tertiary education, respectively (Table 1). However,
urban residents, 86.4% (n ¼ 3877) were Sinhalese by ethni-
such a distinct pattern was not observed between the mean
city, while 6.7% (n ¼ 299) were Tamils and 6.6% (n ¼ 298)
SBP and level of education in males. The mean DBP did not
were Moors. Data from 4450 subjects aged 18 years were
demonstrate a significant variation with the level of education
used for prevalence estimations, and 35 subjects in whom
(Table 2). The relationship between mean SBP and DBP with
BP readings were not available were excluded. Mean SBP
monthly household income did not demonstrate a distinct
in all adults was 127.1  19.8 mmHg and the mean
pattern in all adults, males and female (Tables 1 and 2).
DBP was 75.4  11.3 mmHg. The mean SBP of males
The mean SBP/DBP of those who were physically active
(129.0  19.4 mmHg) was significantly higher than in females
(125.1  18.2/74.6  11.0) was significantly lower than those
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(125.9  19.9) (p50.001). However, there was no significant

who were inactive (132.2  22.3/77.0  12.0) (p50.001).
gender difference in the mean DBP (males –
This was observed independently in both males and females
75.2  11.6 mmHg; females – 75.4  11.1 mmHg).
irrespective of age (data not shown). Furthermore, in all
Tables 1 and 2 describe the relationship between mean
adults, the total MET minutes of physical activity showed a
SBP and DBP with socio-demographic characteristics. In all
significant correlation with both SBP (r ¼ 0.12) and DBP
adults, males and females, the mean DBP was significantly
(r ¼ 0.10). Similar results were observed in males and
higher among urban adults than the rural counterparts;
females independently (data not shown). Both SBP and DBP
however, this difference was not observed for mean SBP
showed significant correlations with BMI, waist circumfer-
(Tables 1 and 2). Mean SBP significantly increased with age
ence, hip circumference and waist–hip ratio in all adults,
in all adults, males and females (Table 1). The mean DBP also
males and females (Table 3). Similarly, a significant correl-
increased significantly from age category of 530 years up to
ation was observed between SBP/DBP and fasting blood
age category 40–49 years; thereafter, although mean DBP
glucose, 2-h post prandial blood glucose, total/LDL choles-
increased in the other age categories no statistically signifi-
For personal use only.

terol and triglycerides (Table 3).

cant relationship was observed (Table 2). Both SBP and DBP
In all adults, the crude prevalence of hypertension was
showed a significant correlation with age in all adults: males
27.4% (95% CI: 26.1–28.7), of which 579 (47.5%) adults were
and females (Table 3). In the different ethnicities, the highest
previously diagnosed with hypertension, while the remaining
mean SBP and DBP was observed in Sri Lankan Moors, and it
640 adults were newly diagnosed (52.5%). The age-adjusted

Table 1. Mean SBP and socio-demographic characteristics in all adults, males and females.

Mean systolic blood pressure, mmHg (SD)

All Males Females
Area of residence
Urban 127.0 (19.8) 129.0 (19.8) 125.7 (19.8)
Rural 127.6 (19.5) 129.1 (17.7) 126.7 (20.5)
Age category
530 years 117.5a (12.0) 121.7a (11.6) 114.5a (11.4)
30–39 years 120.9a (12.0) 122.7b (13.2) 119.8a (14.4)
40–49 years 125.6a (16.8) 126.6a,b (16.4) 125.0a (17.0)
50–59 years 130.6a (20.9) 130.6a,b (19.4) 130.7a (21.9)
60–69 years 137.9a (23.4) 140.4a,b (23.8) 136.3a (22.9)
470 years 143.2a (25.3) 144.9a,b (26.4) 141.8a (24.4)
Ethnicity
Sinhalese 127.1a (19.5) 129.0 (19.0) 125.8a (19.8)
Tamil 125.2b (21.5) 127.4 (23.0) 123.4b (20.2)
Muslim 129.6a,b (21.0) 130.6 (20.2) 129.0a,b (21.5)
Level of education
No formal education 131.2a (23.2) 128.3a (23.3) 131.9a (23.2)
Primary education 129.8b (22.6) 131.2a (22.6) 128.9b (22.5)
Secondary education 126.2a,b (18.8) 128.6 (18.6) 124.6a,b (18.7)
Tertiary education 124.9a,b (15.3) 127.2 (13.9) 121.7a,b (16.7)
Monthly household income
LKR 6999 127.5 (21.4) 129.5 (22.1) 126.4 (20.9)
LKR 7000–24 999 126.6 (17.7) 128.5 (16.8) 125.1 (18.3)
LKR 25 000–49 999 126.5 (17.0) 128.4 (14.1) 124.7 (19.4)
LKR 50 000 129.1 (13.7) 130.5 (15.4) 127.6 (12.0)

LKR, Sri Lankan Rupees.

a,b,c
Mean SBP values with same superscripts in a column within the same group are significantly different (p 5 0.05).
 4 P. Katulanda et al. Clin Exp Hypertens, Early Online: 1–8

Table 2. Mean DBP and socio-demographic characteristics in all adults, males and females.

Mean systolic blood pressure, mmHg (SD)

All Males Females
Area of residence
Urban 75.0a (11.2) 75.0a (11.2) 75.1a (10.9)
Rural 76.6a (11.4) 76.4a (11.4) 76.6a (11.5)
Age category
530 years 70.3a,b (8.8) 70.3a,b (8.8) 70.7a,b (8.9)
30–39 years 73.9a,b (9.9) 73.2a,b (10.0) 74.3a,b (9.8)
40–49 years 76.4a,c (11.2) 76.2a,c (11.7) 76.6a (10.9)
50–59 years 77.7b (12.1) 77.9b (12.3) 77.6b (12.0)
60–69 years 77.9c (12.2) 79.0c (12.4) 77.1 (12.0)
470 years 76.6 (11.9) 77.2 (12.3) 76.1 (11.6)
Ethnicity
Sinhalese 75.2a (11.2) 75.1 (11.4) 75.2a (11.0)
Tamil 75.3b (11.9) 75.5 (12.7) 75.1b (11.2)
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Muslim 77.3a,b (11.9) 76.6 (12.3) 77.8a,b (11.6)

Level of education
No formal education 75.9 (11.1) 73.5 (11.9) 76.5 (10.9)
Primary education 75.6 (11.8) 75.9 (12.5) 75.4 (11.4)
Secondary education 75.3 (11.2) 75.2 (11.4) 75.4 (11.0)
Tertiary education 74.8 (10.2) 74.9 (9.8) 74.6 (10.9)
Monthly household income
LKR 6999 75.0a,b (11.4) 74.9 (12.2) 75.0a (11.0)
LKR 7000–24 999 75.9a (11.1) 75.6 (11.0) 76.1a (11.1)
LKR 25 000–49 999 75.2 (11.0) 75.3 (10.3) 75.1 (11.6)
LKR 50 000 78.5b (9.4) 77.8 (9.5) 79.2 (9.4)

LKR, Sri Lankan Rupees.

a,b,c
Mean DBP values with same superscripts in a column within the same group are significantly different (p50.05).
For personal use only.

Table 3. Correlation of systolic/diastolic blood pressures and age, anthropometric and biochemical parameters in all adults, males and females.

Correlation co-efficient (r)

Systolic blood pressure Diastolic blood pressure
All Males Females All Males Females
Age 0.39* 0.37* 0.40* 0.20* 0.24* 0.17*
Anthropometric parameters
Body Mass Index 0.24* 0.23* 0.26* 0.32* 0.28* 0.35*
Waist circumference 0.24* 0.23* 0.28* 0.33* 0.33* 0.34*
Hip circumference 0.24* 0.17* 0.21* 0.28* 0.24* 0.30*
Waist–hip ratio 0.27* 0.17* 0.24* 0.24* 0.30* 0.22*
Biochemical parameters
Fasting blood glucose 0.17* 0.13* 0.18* 0.16* 0.16* 0.16*
2-h PPBS 0.19* 0.17* 0.22* 0.18* 0.16* 0.20*
Total cholesterol 0.22* 0.20* 0.24* 0.22* 0.24* 0.21*
LDL cholesterol 0.18* 0.14* 0.22* 0.17* 0.16* 0.18*
HDL cholesterol 0.02 0.08 0.06 0.01 0.10 0.07
Triglycerides 0.21* 0.15* 0.25* 0.24* 0.22* 0.26*

PPBS, post prandial blood sugar; LDL, low-density lipoprotein; HDL, high-density lipoprotein.
*Significant correlations (p50.05).

prevalence of hypertension in all adults was 23.7% (95% CI:
22.4–25.0). The age-adjusted prevalence in males and females
were 23.4% (95% CI: 21.4–25.4) and 23.8% (95% CI: 22.2–
25.4), respectively, and while there was no significant
difference between genders. Urban adults had a significantly
higher prevalence of hypertension than their rural counter-
parts and this was also observed independently in both males
and females (Table 4). The mean age of those with
hypertension (56.0  13.5 years) was significantly higher
than those without hypertension (42.4  14.0 years)
(p50.001). The prevalence of hypertension increased with
increasing age in all adults, males and females (Table 4). In
the different ethnic groups, the highest prevalence of
hypertension was observed in Sri Lankan Moors, followed
by Sinhalese and Tamils (Table 4). A similar pattern was also
observed in both males and females (Table 4). In all adults,
the highest prevalence of hypertension was observed in those
with the highest level of education (‘‘tertiary education’’), this
was also observed independently in males, but not in females
(Table 4). Pre-hypertension was present in 12% of males and
11.4% of females.
Those with hypertension had a significantly higher weight,
BMI, waist circumference, hip circumference, waist–hip ratio,
SBP and diastolic BP, fasting blood glucose, 2-h post prandial
blood glucose, total and LDL cholesterol and triglycerides
(Table 5). This was observed in both males and females
 DOI: 10.3109/10641963.2013.863321 Prevalence and predictors of hypertension in Sri Lanka 5
Table 4. Age-standardized prevalence of hypertension in all adults, males and females.

Prevalence (95% confidence interval)

All Males Females p Value*
Area of residence
Urban 26.5 (25.7–27.7)a 26.8 (24.2–29.2)a 26.5 (24.9–28.2)a NS
Rural 22.9 (21.5–24.3)a 22.6 (21.4–23.9)a 23.2 (22.4–24.1)a NS
Age category
530 years 5.4 (4.0–7.2) 6.8 (4.2–10.1) 4.4 (2.7–6.9) NS
30–39 years 12.0 (9.9–14.3) 11.8 (8.5–15.8) 12.0 (9.4–15.1) NS
40–49 years 23.3 (20.8–25.9) 21.7 (17.8–26.0) 24.2 (21.0–27.6) NS
50–59 years 38.0 (34.8–41.3) 36.7 (31.6–42.0) 38.9 (34.8–43.1) NS
60–69 years 50.3 (45.0–54.6) 52.8 (45.9–59.7) 48.6 (43.1–54.2) NS
470 years 64.6 (59.2–69.7) 59.7 (51.4–67.7) 68.5 (61.2–75.1) NS
Ethnicity
Sinhalese 23.1 (21.8–24.5)a 22.8 (21.7–24.0)a 23.4 (21.7–25.2)a NS
Tamil 24.1 (22.3–26.4)b 23.4 (20.6–26.2)b 24.7 (22.5–26.9)b NS
Clin Exp Hypertens Downloaded from informahealthcare.com by QUT Queensland University of Tech on 05/27/14

Muslim 31.3 (27.2–35.5)a,b 33.5 (28.8–38.8)a,b 30.2 (28.6–31.6)a,b NS

Level of education
No formal education 20.6 (15.8–25.9) 11.2 (4.2–22.6) 23.0 (17.4–29.3) NS
Primary education 21.3 (18.6–24.4) 21.6 (17.0–26.5) 20.9 (17.4–24.7) NS
Secondary education 24.1 (22.6–25.6) 23.9 (21.6–26.3) 24.2 (22.3–26.2) NS
Tertiary education 25.1 (17.5–33.3) 28.6 (18.5–40.0) 18.5 (8.4–30.9) NS
Monthly household income
LKR 6999 21.2 (19.6–22.9)a 20.7 (18.0–23.6) 21.5 (19.5–23.6)a NS
LKR 7000–24 999 26.8 (24.7–29.0)a 25.5 (22.4–28.7) 30.0 (27.1–33.1)a NS
LKR 25 000–49 999 22.3 (16.9–28.8) 22.6 (14.7–31.6) 25.6 (17.4–35.1) NS
LKR 50 000 25.0 (13.9–40.4) 20.6 (7.1–42.2) 17.6 (5.0–38.8) NS

*p Values – males versus females; NS, not significant; LKR, Sri Lankan Rupees.
a,b
Mean prevalence values with same superscripts in a column within the same group are significantly different (p50.05).
For personal use only.

Table 5. Mean values of clinical and biochemical parameters in those with and without hypertension.

Mean (SD)
Hypertensive Non-hypertensive p
Weight (kg) 55.5 (12.5) 52.3 (11.1) 50.001
Body mass index (kg m2) 23.1 (4.5) 21.2 (4.0) 50.001
Waist circumference (cm) 81.8 (11.8) 75.6 (11.3) 50.001
Hip circumference (cm) 91.1 (9.4) 88.2 (8.7) NS
Waist–hip ratio 0.9 (0.1) 0.8 (0.1) 50.001
Fasting blood glucose (mg/dl) 99.0 (33.2) 88.4 (24.9) 50.001
2-h post prandial blood glucose (mg/dl) 127.8 (62.6) 104.9 (46.3) 50.001
Total cholesterol (mg/dl) 220.2 (43.7) 201.7 (42.4) 50.001
LDL cholesterol (mg/dl) 144.6 (38.1) 132.0 (36.9) 50.001
HDL cholesterol (mg/dl) 46.8 (10.9) 46.8 (10.0) NS
Triglycerides (mg/dl) 143.5 (74.6) 113.6 (61.9) 50.001

independently (data not shown). The mean weekly total MET
minutes of those with hypertension (3626.7 min/week) was
significantly lower than those without hypertension
(5107.1 min/week). A similar pattern was observed in both
males and females separately (data not shown). The preva-
lence of hypertension in the different physical activity
categories of the IPAQ was as follows: ‘‘inactive’’ – 41.3%
(95% CI: 37.0–45.8), ‘‘moderately active’’ – 31.9% (95% CI:
29.4–34.6) and ‘‘active’’ – 22.7% (95% CI: 21.1–24.4). In
patients with diabetes, the prevalence of hypertension was
55.4% (95% CI: 51.0–59.6), which was significantly higher
than in those without diabetes (23.6%, 95% CI: 22.3–24.9)
(p50.001). Hypertension was present in 40.1% (95% CI:
37.5–42.8) of participants with central obesity, while only
21.8% (95% CI: 20.4–23.3) adults without central obesity
were hypertensive (p50.001).
The results of the binary logistic regression analysis in all
adults using the dichotomous variable ‘‘hypertension’’ (0 ¼
absent and 1 ¼ present) as the dependant factor and other
independent variables are shown in Table 6. The overall
model was statistically significant as determined by the
likelihood ratio test (2 ¼ 957.99, p50.001). The Cox &
Snell R-Square and Nagelkerke R Square values were 0.194
and 0.280, respectively. The results indicate that male gender
(OR: 1.2), increasing age, Sri Lankan Moor ethnicity (OR:
1.6), physical inactivity (OR: 1.7), presence of diabetes (OR:
2.2) and central obesity (OR: 2.3) all were associated
with significantly increased risk of developing hypertension
(Table 6). Similar results were seen independently in males
and females (Table 6).
Discussion
In this first community-based national survey on hypertension
from Sri Lanka, the age-adjusted prevalence in all adults
was 23.7% (males – 23.4%; females – 23.8%), while
 6 P. Katulanda et al. Clin Exp Hypertens, Early Online: 1–8

Table 6. Binary logistic regression analysis in all adults, males and females.

Odds ratio (95% CI)

Co-variants (reference category) All Male Female
Male gender 1.2 (1.1–1.4)#
Age category (530 years)
30–39 years 1.9 (1.3–2.8)* 1.4 (0.8–2.6) 2.4 (1.4–4.0)*
40–49 years 4.0 (2.8–5.7)* 3.0 (1.8–5.1)* 5.1 (3.1–8.3)*
50–59 years 8.2 (5.8–11.7)* 6.1 (3.7–10.2)* 10.5 (6.4–17.3)*
60–69 years 13.7 (9.5–19.9)* 12.5 (7.3–21.1)* 15.5 (9.2–26.1)*
470 years 25.6 (17.1–38.2)* 15.2 (8.6–26.9)* 39.4 (22.3–69.5)*
Urban residence 1.0 (0.9–1.1) 0.9 (0.6–1.2) 0.8 (0.7–1.1)
Ethnicity (Sinhalese)
Tamil 0.9 (0.8–1.1) 0.9 (0.7–1.1) 0.8 (0.5–1.2)
Sri Lankan Moor 1.6 (1.3–1.9)# 1.5 (1.2–1.8)# 1.4 (1.2–1.6)#
Physical inactivity 1.7 (1.4–1.9)# 1.4 (1.2–1.6)* 1.5 (1.2–1.8)#
Diabetes 2.2 (1.8–2.7)* 2.2 (1.5–3.1)* 2.2 (1.7–2.9)*
Clin Exp Hypertens Downloaded from informahealthcare.com by QUT Queensland University of Tech on 05/27/14

Central obesity 2.3 (2.0–2.8)* 2.3 (1.7–3.2)* 2.4 (1.9–2.9)*

*p50.001; #p50.01.

pre-hypertension was present in 12% of males and 11.4% of
females. The World Health Organization (WHO) STEPS
survey conducted in 5 of the 21 districts of Sri Lanka during
the same time period as the present study reported a
prevalence of 21.8% in all adults (17). A community based
survey in year 2000–2001 conducted in four out of nine
provinces of Sri Lanka reported a hypertension prevalence of
18.8% in men and 19.3% in women. Hence, there has been a
24% increase in the prevalence over a period of 5–6 years.
For personal use only.
We also observed a very high prevalence of previously
undiagnosed hypertension; of the 1219 adults with hyperten-
sion, 640 were newly diagnosed (52.5%) at the time of study,
which is a considerably higher proportion compared to data
from other countries. A large population based study in India
reported that 22.2% of those with hypertension were previ-
ously undiagnosed (21). In Mexico 40% of hypertensive men
and 23% of women were undiagnosed and untreated, and in
China, it was 15.5% (22,23). However, in developed countries

The projected prevalence of hypertension in Sri Lanka adults
in year 2015 and 2020 based on the projected changes in
population size (UN population forecasts) and estimated
changes in incidence of hypertension (based on above data)
was 30.2% and 34.1%, respectively. The WHO STEPS
surveys conducted in regional countries have reported on
the prevalence of hypertension; Bangladesh – 17.9% (year
2009–2010), Bhutan – 17.1% (year 2007), India – 14.5% (year
2007–2008) and Nepal – 9.3% (year 2007–2008) (17). The
National Health Survey of Pakistan conducted in 2005–2006
estimated that hypertension affects 18% of all adults (18).
Hence, the national prevalence of hypertension in Sri Lanka is
higher than in regional countries with populations sharing
similar genetic backgrounds and life styles, a finding that
requires further evaluation. However, it is also important to
note that the Sri Lankan prevalence of hypertension is much
lower than the estimated global prevalence in 2008, which
according to the WHO is around 40% (19).
The prevalence of hypertension has been shown to differ in
different countries and across geographical regions. The
reasons for such differences are still a matter of debate, the
relative contributions given by environmental and genetic
factors being still poorly defined (20). A study conducted in
Italy concluded that genetic factors involved in the expression
of BP traits account for only 30% of the phenotypic variance,
but seem to play a larger role in men; co-morbidities and
environmental factors remain of predominant importance in
determining BP (20). These findings on the differential
contribution of environmental and genetic factors on the
prevalence of hypertension need to be replicated in South
Asian populations. Such understating will have implication for
planning public health interventions aimed at reducing the
disease burden.
such as USA, the presence of undiagnosed hypertension is
only 8% (24). Undiagnosed hypertension is an important
public health problem as it is associated with target organ
damage, cardiovascular risk and increased mortality.
Korhonen et al. (25) demonstrated that one in five patients
with undiagnosed hypertension had evidence of subclinical
target organ damage, and three in four patients may be
regarded as having high cardiovascular risk. The only way to
know whether a person has high BP is to have it measured,
since majority of those with elevated BPs are asymptomatic.
The reasons for the presence of such high level of undiag-
nosed disease could be multi-factorial. Lack of awareness,
poor access to health-care facilities, language-barriers in
health care and therapeutic inertia are all probable reasons
(26). However, Sri Lanka has achieved a unique status in the
world with health indicators that are comparable with those of
developed countries and its population has a very literacy
level (490%) (27). Hence, there is a need to further explore
other factors that are contributory to such high levels of non-
diagnosis.
In the logistic regression analysis, male gender, physical
inactivity and Moor (Muslim) ethnicity were all significantly
associated with hypertension. Previously we have demon-
strated that the prevalence of Metabolic Syndrome and
diabetes is higher amongst the people of Moor ethnicity
from Sri Lanka (28,29). This could be due to differential
cultural beliefs in healthy seeking behavior, dietary habits and
physical activity patterns among the different ethnicities.
Indeed, those of Moor ethnicity from Sri Lanka are known to
have lower levels of physical activity than other ethnicities
(30). Hence, it is important to consider ethnic differences
when instituting screening programmes and preventive meas-
ures. Physical activity is another important determinant of BP,
 DOI: 10.3109/10641963.2013.863321
and lifestyle modifications, such as physical activity, are
recommended first-line/adjunctive therapies for hypertension.
Regular physical activity is also known to reduce mortality in
patients with high BP (31). Hence, numerous governing
bodies including the US Preventative Services Task force
(USPSTF) recommends counseling by health-care providers
to promote regular physical activity. However, very few
patients receive exercise counseling from health-care pro-
viders to help lower BP and improve health outcomes (32).
In the present study, diabetes and central obesity were also
significantly associated with hypertension. Based on popula-
tion studies, risk estimates indicate that at least two-thirds of
the prevalence of hypertension can be directly attributed to
obesity (33). Furthermore, abdominal adiposity has also been
implicated in the pathogenesis of coronary artery disease,
Clin Exp Hypertens Downloaded from informahealthcare.com by QUT Queensland University of Tech on 05/27/14
sleep apnoea, stroke and congestive heart failure (34). In
overweight and obese subjects, the cardiovascular risk is not
significantly increased unless hypertension is present (35).
Hence, hypertension could be one of the mediators through
which obesity causes CVD. While obese subjects are prone to
hypertension, the Framingham and Tecumseh studies showed
that hypertensive subjects are also appear to be prone to
weight gain (36). In hypertensive diabetic patients, lowering
BP to less than 130/80 mmHg is a primary goal in manage-
ment. Both hypertension and diabetes mellitus affect the same
major target organs. The combined presence of hypertension
and diabetes concomitantly accelerates the decrease in renal
For personal use only.
function, the development of diabetic retinopathy and the
development of cerebral disease (37). Hence, aggressive
control of body weight, BP and glucose levels should be
attempted in patients with concomitant obesity, diabetes and
hypertension in order to reduce the cardiovascular risk, target
organ damage and mortality.
The strengths of the present study are its national
representativeness, being community based, random selection
of subjects out of a well-defined and homogenous target
population and the very high response rate. However, several
limitations need to be kept in mind prior to drawing
conclusions from our results. The inability to include subjects
from the Northern and Eastern provinces of the country due to
the war is a limitation, since majority of the Tamils in
Sri Lanka reside in these two provinces, while the Tamils
included in the present study were mainly plantation workers
of Indian origin and Tamils living in Colombo. Furthermore,
the cross-sectional design of our study limits the inference of
causality for the risk factors identified. In addition, although
dietary salt intake has a direct effect on BP, we were unable to
evaluate dietary factors in the present survey, due to the lack
of a validated dietary assessments tool and a nutrition
composition database on local mixed dishes. We also did
not evaluate the degree of control, awareness about disease
and compliance in those already diagnosed with hypertension.
In conclusion, nearly one-third of the Sri Lankan adult
population is hypertensive, with a large proportion of non-
diagnosed hypertension. It is important to introduce health
education measures that will promote prevention and early
detection of hypertension. The reasons for non-diagnosis must
be investigated to enable implementation of appropriate
measures to improve early detection and reduce the risk of
developing complications. There is a need to encourage
Prevalence and predictors of hypertension in Sri Lanka 7
healthier lifestyles with emphasis on preventing obesity and
increasing level of activity.
Acknowledgements
The National Science Foundation of Sri Lanka was the
primary source of funding for the study. The additional
support provided from the Oxford Centre for Diabetes
Endocrinology and Metabolism, UK, and the NIHR
Biomedical Research Centre Programme is gratefully
acknowledged.
Declaration of interest
The authors report no conflicts of interest. The
authors alone are responsible for the content and writing of
the paper.
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