This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.
In recent years, more and more studies have shown that internet-based health management can help patients with hypertension control their blood pressure. However, there is a lack of similar research in China.
We designed this study to clarify the impact of long-term internet-based health management on the control of clinical parameters in patients with hypertension. These results are also expected to identify the relevant factors affecting the control of clinical parameters in hypertension more accurately toward developing more targeted health management strategies.
This was a longitudinal study of internet-based health management in the five provinces of northwest China. The inclusion criteria were aged ≥18 years and no serious cognitive disease or mental disorder. After collecting the physical examination data of 8567 people in the five northwest provinces in 2013, we conducted online health management (including diet, exercise, and behavior) and follow-up. In the physical examination in 2013, 1008 new patients with hypertension were identified, who were divided into a good blood pressure control group and poor blood pressure control group. Physical examination and a questionnaire survey were conducted every 2 years to understand the changes of health management on the subjects’ health-related behaviors. We then analyzed the changes of clinical indicators related to hypertension and the influencing factors related to blood pressure control in patients with hypertension. All statistical analyses were performed using R software (version 4.1.2) and a
A total of 8567 people met the inclusion criteria and underwent health management. Self-comparison showed that after 4 years of health management, the smoking cessation rate and amount of exercise significantly increased (both
Internet-based health management has a significant and long-term effect on blood pressure control in patients with hypertension.
Hypertension is a worldwide health problem with increasing rates of impaired functional status, morbidity, disability, and mortality [
Health management refers to the process of comprehensively managing the health risk factors of individuals or groups. The purpose of health management is to mobilize the enthusiasm of individuals and groups, and effectively use limited resources to achieve the maximum health effect [
Therefore, we designed this study to clarify the impact of long-term internet-based health management on the control of clinical parameters in patients with hypertension. This study is also expected to help identify the most relevant factors affecting the control of clinical parameters in patients with hypertension more accurately toward achieving targeted health management.
This was a prospective, nonrandomized, longitudinal study performed in five provinces of northwest China. The inclusion criteria were aged ≥18 years and no serious cognitive disease or mental disorder. The exclusion criteria were aged <18 years with severe cognitive impairment or mental illness. By 2013, 56,542 people from Shaanxi, Gansu, Ningxia, Inner Mongolia, and Shanxi provinces, including 15 cities and 61 counties (districts, banners), had joined the health management platform, which is for personal use only. This platform includes modules such as exercise management and diet management. Complete relevant data were available for 51,486 people. The included study population participated in an annual medical checkup and completed a questionnaire every 2 years.
After collecting the physical examination data of the study participants in 2013, they received internet-based health management and follow-up. The platform is mainly divided into three modules: “understanding my health,” “improving my health,” and “health improvement effectiveness.” Physical examinations and the questionnaire were administered after 2 years (in 2015) and 4 years (in 2017). Hypertension was based on systolic blood pressure (SBP)≥140 mmHg and/or diastolic blood pressure (DBP)≥90 mmHg on repeated clinical measurements or a previous history of hypertension.
Based on the physical examination in 2013, we divided the newly identified patients with hypertension into two groups according to good and poor BP control. Good BP control was determined according to SBP<140 mmHg and DBP<90 mmHg on repeated clinical measurements; otherwise, the individual was considered to have poor BP control [
The health management platform is for private use only. Anyone can log in to their own account to access health records on the platform according to each physical examination to help users understand their own health status. Relevant experts then formulate an individualized diet, exercise, and other relevant opinions for individuals according to their health status, and carry out health management. After 3 months of health management, the personal health status is further assessed. Health records include individual basic information (eg, age, gender, height, weight) and clinical indicators (eg, BP, blood glucose, blood lipids) from the physical examination in that year, along with family history, diet, and exercise.
The system automatically formulates 12 stages of progressive exercise prescription according to the health status of an individual. Users can choose relevant sports as recommended and manually record the time and date of sports. One week later, the rationality of the recommendations is evaluated by comparing the exercise performed in the previous week with the recommended exercise prescription.
The system platform automatically formulates meal prescriptions for individuals based on the submitted health questionnaire information. Users who want to create personalized recipes according to their personal dietary preferences only need to modify and replace the foods in the expert-recommended recipes. By recording at least 2 days of meal diaries every week, the system can analyze the dietary nutrition status, identify potential problems in meals, and make appropriate recommendations.
The research data were derived from the physical examination data of participants from the five provinces in northwest China and from the questionnaire survey. The health management for participants included dietary guidance; physical exercise guidance; living habits guidance; basic knowledge of hypertension, diabetes, and hyperlipidemia; and other aspects.
Basic characteristics, including age, sex, and family history of hypertension, were collected at the first physical examination. Individual parameters were collected by questionnaire after each physical examination, including health-related behaviors (smoking, drinking, physical activity, sedentary time [hours], sleeping time [hours], quality of sleep [very good, fair, not good, very bad]), dietary intake (cereals and potatoes; fish, livestock, poultry, meat, and eggs; milk and dairy; soybean and nuts; vegetables; fruit). Physical activity was rated according to the International Physical Activity Questionnaire scale [
The clinical measurement results of participants were imported into an epidata database after each physical examination. An automatic sphygmomanometer was used to measure the BP of the left arm (the measurement position was flush with the heart) in a sitting position after the subject rested quietly for at least 5 minutes. The measurement was repeated at intervals of at least 5 minutes and the average of the two readings was recorded. Venous blood samples were collected during fasting, and fasting blood glucose was measured by the glucose oxidase method according to routine operating procedures. Total cholesterol, triglyceride, and other blood lipid indicators were measured on an empty stomach. All the onsite measurements including laboratory tests were validated for internal quality control according to clinical standards.
This study was ethically reviewed and approved by the Biomedical Ethics Committee of Peking University (IRB00001052-0816). All participants in the study provided informed consent. All data were anonymized. No subsidy was provided to the participants.
Descriptive analysis was used to describe the basic characteristics of participants. The raw data were processed using the 99-quantile capping method to remove outliers. Analysis of variance was used to analyze the annual changes in the clinical indices of 8576 subjects and newly identified patients with hypertension. The
The baseline survey included 51,486 individuals, 42,347 (82.25%) of whom were healthy and 9139 (17.75%) of whom had hypertension (new onset+current onset). Among the healthy population, there was a slight majority of men. Among the patients with hypertension, there was a large majority of men (>80%). The average age of the patients with hypertension was higher than that of healthy participants. In addition, the intake of milk, fruits, and vegetables in the population at baseline was deemed to be seriously insufficient (
Basic characteristics of all subjects undergoing a physical examination in 2013.
Characteristics | Total (N=51,486) | Healthy (n=42,347) | Hypertension (n=9139) | ||
|
|||||
|
Age (years), mean (SD) | 36.80 (8.66) | 36.02 (8.22) | 40.4 (9.58) | |
|
|
||||
|
|
Man | 32,408 (62.95) | 25,026 (59.10) | 7382 (80.77) |
|
|
Woman | 19,078 (37.05) | 17,321 (40.90) | 1757 (19.23) |
|
|
||||
|
|
Yes | 6367 (12.37) | 4694 (11.08) | 1673 (18.31) |
|
|
No | 45,119 (87.63) | 37,653 (88.92) | 7466 (81.69) |
|
|
||||
|
|
Yes | 6611 (12.84) | 4849 (11.45) | 1762 (19.28) |
|
|
No | 44,875 (87.16) | 37,498 (88.55) | 7377 (80.72) |
|
|||||
|
|
||||
|
|
Nonsmoking | 32,628 (63.37) | 28,142 (66.46) | 4487 (49.10) |
|
|
Current smoking | 17,287 (33.59) | 13,135 (31.02) | 4152 (45.43) |
|
|
Quit smoking | 1570 (3.04) | 1070 (2.52) | 500 (5.47) |
|
|
||||
|
|
No alcoholic beverages | 34,013 (66.06) | 28,878 (68.19) | 5135 (56.19) |
|
|
Drinking | 17,473 (33.94) | 13,469 (31.81) | 4004 (43.81) |
|
|
||||
|
|
Low | 15,256 (29.63) | 12,612 (29.78) | 2644 (28.93) |
|
|
Medium | 23,722 (46.07) | 19,623 (46.34) | 4099 (44.85) |
|
|
High | 12,508 (24.30) | 10,112 (23.88) | 2396 (26.22) |
|
Sedentary time (hours), mean (SD) | 5.23 (2.75) | 5.27 (2.76) | 5.04 (2.74) | |
|
|
||||
|
|
Below the recommended intake | 21,631 (42.01) | 18,134 (42.82) | 3497 (38.26) |
|
|
Moderate to recommended intake | 15,381 (29.87) | 12,686 (29.96) | 2695 (29.49) |
|
|
Higher than recommended intake | 14,474 (28.12) | 11,527 (27.22) | 2947 (32.25) |
|
|
||||
|
|
Below the recommended intake | 26,009 (50.52) | 21,543 (50.87) | 4466 (48.87) |
|
|
Moderate to recommended intake | 12,747 (24.76) | 10,466 (24.71) | 2281 (24.96) |
|
|
Higher than recommended intake | 12,730 (24.72) | 10,338 (24.42) | 2392 (26.17) |
|
|
||||
|
|
Below the recommended intake | 45,585 (88.54) | 37,420 (88.37) | 8165 (89.34) |
|
|
Moderate to recommended intake | 5901 (11.46) | 4927 (11.63) | 974 (10.66) |
|
|
||||
|
|
Below the recommended intake | 33,943 (65.92) | 27,883 (65.84) | 6060 (66.31) |
|
|
Moderate to recommended intake | 2864 (5.56) | 2351 (5.55) | 513 (5.61) |
|
|
Higher than recommended intake | 14,679 (28.52) | 12,113 (28.61) | 2566 (28.08) |
|
|
||||
|
|
Below the recommended intake | 38,980 (75.71) | 32,166 (75.96) | 6814 (74.56) |
|
|
Moderate to recommended intake | 8545 (16.60) | 6967 (16.45) | 1578 (17.27) |
|
|
Higher than recommended intake | 3961 (7.69) | 3214 (7.59) | 747 (8.17) |
|
|
||||
|
|
Below the recommended intake | 44,682 (86.78) | 36,567 (86.35) | 8115 (88.80) |
|
|
Moderate to recommended intake | 5038 (9.79) | 4276 (10.10) | 762 (8.34) |
|
|
Higher than recommended intake | 1766 (3.43) | 1504 (3.55) | 262 (2.86) |
|
|||||
|
|
||||
|
|
Very good | 11,442 (22.22) | 9483 (22.39) | 1959 (21.44) |
|
|
Fair | 31,761 (61.69) | 26,208 (61.89) | 5553 (60.76) |
|
|
Not good | 6840 (13.29) | 5498 (12.98) | 1342 (14.68) |
|
|
Very bad | 1443 (2.80) | 1158 (2.74) | 285 (3.12) |
|
Sleeping time (hours), mean (SD) | 7.23 (1.16) | 7.25 (1.14) | 7.18 (1.21) | |
|
Psychological scoreb, mean (SD) | 17.77 (5.05) | 17.72 (5.04) | 17.98 (5.05) |
aIPAQ: International Physical Activity Questionnaire.
bA higher score indicates a worse psychological state.
Of all subjects screened, a total of 8567 individuals screened in 2013, 2015, and 2017 were deemed to be eligible for inclusion in the study. After 4 years of health management, the smoking cessation rate increased significantly (
Changes of self-management and clinical parameters of eligible participants (N=8567).
Parameter | 2013 | 2015 | 2017 | ||
|
|||||
|
Quit smokinga, n (%) | 249 (7.90) | 357 (10.80) | 391 (11.48) | <.001 |
|
Sufficient exercise, n (%) | 5324 (62.15) | 5512 (64.34) | 5604 (65.41) | <.001 |
|
Sufficient cereal and potato intake, n (%) | 4789 (55.90) | 4851 (56.62) | 4861 (56.74) | .49 |
|
Sufficient fish, eggs, poultry, and livestock meat intake, n (%) | 4418 (51.57) | 4475 (52.24) | 4524 (52.81) | .27 |
|
Sufficient milk and dairy intake, n (%) | 1106 (12.91) | 1112 (12.98) | 1125 (13.13) | .91 |
|
Sufficient soybean and nut intake, n (%) | 4537 (52.96) | 4519 (52.75) | 4541 (53.01) | .94 |
|
Sufficient vegetable intake, n (%) | 1986 (23.18) | 1961 (22.89) | 1979 (23.10) | .90 |
|
Sufficient fruit intake, n (%) | 874 (10.20) | 898 (10.48) | 902 (10.53) | .75 |
|
Times of drinking per week, mean (SD) | 0.916 (1.716) | 0.927 (1.693) | 0.937 (1.680) | .73 |
|
|||||
|
SBPb (mmHg) | 116.08 (12.89) | 116.41 (12.91) | 116.41 (13.20) | .32 |
|
DBPc (mmHg) | 76.87 (10.38) | 76.90 (10.33) | 76.71 (10.48) | .39 |
|
FPGd (mmol/L) | 5.42 (2.99) | 5.38 (2.79) | 5.35 (2.64) | .38 |
|
TCe (mmol/L) | 5.14 (4.49) | 5.06 (4.30) | 4.96 (3.94) | .09 |
|
TGf (mmol/L) | 2.11 (2.29) | 2.08 (0.22) | 2.13 (2.19) | .36 |
|
LDL-Cg (mmol/L) | 1.85 (1.41) | 1.91 (1.36) | 1.92 (1.34) | .005 |
|
HDL-Ch (mmol/L) | 2.05 (1.89) | 1.99 (1.82) | 1.96 (1.69) | .007 |
|
BMI (kg/m2) | 23.09 (4.05) | 23.10 (3.75) | 23.16 (3.73) | .21 |
aThe smoking cessation rate was calculated as smoking in the year/total number of smokers in that year.
bSBP: systolic blood pressure.
cDBP: diastolic blood pressure.
dFPG: fasting plasma glucose.
eTC: total cholesterol.
fTG: triglyceride.
gLDL-C: low-density lipoprotein cholesterol.
hHDL-C: high-density lipoprotein cholesterol.
In the physical examination of 2013, 1008 new patients with hypertension were found. After 4 years of health management, their smoking cessation rate increased significantly (
Changes of health-related behaviors and clinical parameters in patients with new-onset hypertension (N=1008).
Parameter | 2013 | 2015 | 2017 | ||
|
|||||
|
Quit smokinga, n (%) | 32 (5.27) | 85 (8.34) | 94 (9.18) | .03 |
|
Sufficient physical activity (IPAQb), n (%) | 631 (62.60) | 665 (65.97) | 678 (67.26) | .08 |
|
Sufficient cereal and potato intake, n (%) | 551 (54.66) | 546 (54.17) | 553 (54.86) | .95 |
|
Sufficient fish, eggs, poultry, and livestock intake, n (%) | 503 (49.90) | 516 (51.19) | 522 (51.79) | .69 |
|
Sufficient milk and dairy intake | 145 (14.38) | 137 (13.59) | 150 (14.88) | .71 |
|
Sufficient soybean and nut intake, n (%) | 530 (52.58) | 517 (51.29) | 522 (51.79) | .84 |
|
Sufficient vegetable intake, n (%) | 237 (23.51) | 228 (22.62) | 224 (22.22) | .78 |
|
Sufficient fruit intake, n (%) | 110 (10.91) | 117 (11.61) | 111 (11.01) | .87 |
|
Times of drinking per week, mean (SD) | 1.09 (2.23) | 1.09 (2.20) | 1.08 (2.15) | >.99 |
|
|||||
|
SBPc (mmHg) | 127.54 (16.45) | 127.11 (16.15) | 126.10 (16.24) | .13 |
|
DBPd (mmHg) | 91.96 (8.77) | 89.68 (9.98) | 88.55 (10.70) | <.001 |
|
FPGe (mmol/L) | 6.01 (3.79) | 5.94 (3.70) | 5.89 (3.57) | .75 |
|
TCf (mmol/L) | 5.88 (5.88) | 5.73 (5.71) | 5.60 (5.58) | .54 |
|
TGg (mmol/L) | 2.75 (2.99) | 2.63 (2.82) | 2.63 (2.75) | .56 |
|
LDL-Ch (mmol/L) | 2.04 (1.75) | 2.06 (1.67) | 2.06 (1.65) | .94 |
|
HDL-Ci (mmol/L) | 2.34 (2.38) | 2.26 (2.31) | 2.20 (2.24) | .43 |
|
BMI (kg/m2) | 24.69 (5.33) | 24.60 (5.09) | 24.58 (4.92) | .87 |
aThe smoking cessation rate was smoking in the year/total number of smokers in that year.
bIPAQ: International Physical Activity Questionnaire.
cSBP: systolic blood pressure.
dDBP: diastolic blood pressure.
eFPG: fasting plasma glucose.
fTC: total cholesterol.
gTG: triglyceride.
hLDL-C: low-density lipoprotein cholesterol.
iHDL-C: high-density lipoprotein cholesterol.
After 4 years of health management in the patients with new-onset hypertension (N=1008), 195 (19.35%) patients had good BP control and 813 (80.65%) patients had poor BP control. Statistical analysis showed that younger patients had better control than older patients (
Factors related to blood pressure control in patients with new-onset hypertension.
Factors | Total (N=1008) | Well- controlled (<140/90 mmHg) (n=195) | Poorly controlled (≥140/90 mmHg) (n=813) | |||
|
||||||
|
Age (years), mean (SD) | 37.23 (8.43) | 36.15 (7.89) | 37.48 (8.54) | .05 | |
|
|
.03 | ||||
|
|
Male | 791 (78.5) | 141 (17.8) | 650 (82.2) |
|
|
|
Female | 217 (21.5) | 54 (24.9) | 163 (75.1) |
|
|
|
.77 | ||||
|
|
Yes | 149 (14.8) | 27 (18.1) | 122 (81.9) |
|
|
|
No | 859 (85.2) | 168 (19.6) | 691 (80.4) |
|
|
|
.27 | ||||
|
|
Yes | 143 (14.2) | 33 (23.1) | 110 (76.9) |
|
|
|
No | 865 (85.8) | 162 (18.7) | 703 (81.3) |
|
|
||||||
|
|
.13 | ||||
|
|
Yes | 637 (63.2) | 133 (20.9) | 504 (79.1) |
|
|
|
No | 371 (36.8) | 62 (16.7) | 309 (83.3) |
|
|
|
.83 | ||||
|
|
Yes | 673 (66.8) | 132 (19.6) | 541 (80.4) |
|
|
|
No | 335 (33.2) | 63 (18.8) | 272 (81.2) |
|
|
|
<.001 | ||||
|
|
Yes | 343 (34.0) | 87 (25.4) | 256 (74.6) |
|
|
|
No | 665 (66.0) | 108 (16.2) | 557 (83.8) |
|
|
|
<.001 | ||||
|
|
Yes | 364 (36.1) | 99 (27.2) | 265 (72.8) |
|
|
|
No | 644 (63.9) | 96 (14.9) | 548 (85.1) |
|
|
|
<.001 | ||||
|
|
Yes | 114 (11.3) | 36 (31.6) | 78 (68.4) |
|
|
|
No | 894 (88.7) | 159 (17.8) | 735 (82.2) |
|
|
|
.07 | ||||
|
|
Yes | 184 (18.3) | 45 (24.5) | 139 (75.5) |
|
|
|
No | 824 (81.7) | 150 (18.2) | 674 (81.8) |
|
|
|
.94 | ||||
|
|
Yes | 677 (67.2) | 130 (19.2) | 547 (80.8) |
|
|
|
No | 331 (32.8) | 65 (19.6) | 266 (80.4) |
|
|
|
<.001 | ||||
|
|
Yes | 166 (16.5) | 51 (30.7) | 115 (69.3) |
|
|
|
No | 842 (83.5) | 144 (17.1) | 698 (82.9) |
|
|
|
<.001 | ||||
|
|
Yes | 500 (49.6) | 120 (24.0) | 380 (76.0) |
|
|
|
No | 508 (50.4) | 75 (14.8) | 433 (85.2) |
|
|
|
.01 | ||||
|
|
Yes | 112 (11.1) | 32 (28.6) | 80 (71.4) |
|
|
|
No | 896 (88.9) | 163 (18.2) | 733 (81.8) |
|
|
|
.77 | ||||
|
|
Yes | 791 (78.5) | 151 (19.1) | 640 (80.9) |
|
|
|
No | 217 (21.5) | 44 (20.3) | 173 (79.7) |
|
|
|
.09 | ||||
|
|
Yes | 797 (79.1) | 145 (18.2) | 652 (81.8) |
|
|
|
No | 211 (20.9) | 50 (23.7) | 161 (76.3) |
|
|
|
.004 | ||||
|
|
Yes | 426 (42.3) | 101 (23.7) | 325 (76.3) |
|
|
|
No | 582 (57.7) | 94 (16.2) | 488 (83.8) |
|
aIPAQ: International Physical Activity Questionnaire.
To clarify the influencing factors of hypertension control, we performed regression analysis. Binary logistic regression analysis showed a significant correlation between health-related behavior and the ability to achieve BP control in patients with hypertension. Achieving BP control was more difficult for patients who did not follow the guidance of health management to change fish, livestock, poultry, meat, and egg intake; fruit intake; increase physical activity; and improve their psychological state. The area under the ROC curve was 0.6787 (
Binary logistics model of factors related to blood pressure control after health management in patients with hypertension.
Variable | Estimate (B) | aORa (95% CI) | ||
Intercept | –1.6612 | N/Ab | <.001 | |
Female gender (male=reference) | –0.3079 | 0.73 (0.50-1.09) | .12 | |
Age (years) | 0.0155 | 1.02 (1.00-1.04) | .14 | |
|
||||
|
BMI | 0.299 | 1.35 (0.97-1.89) | .08 |
|
Cereal and potato intake | 0.333 | 1.40 (0.99-1.95) | .05 |
|
Fish, eggs, poultry, and livestock intake | 0.5328 | 1.70 (1.21-2.39) | .002 |
|
Fruit intake | 0.4829 | 1.62 (1.08-2.41) | .02 |
|
Physical activity (IPAQc) | 0.4776 | 1.61 (1.16-2.26) | .005 |
|
Psychological state | 0.3783 | 1.46 (1.05-2.02) | .02 |
aaOR: adjusted odds ratio.
bN/A: not applicable.
cIPAQ: International Physical Activity Questionnaire.
Long-term internet-based health management has a good effect on the BP control of patients with hypertension, especially on regulating SBP. Moreover, this control effect is long-lasting and not easy to rebound. In addition, this study found that being young; female; more likely to follow the guidance of health management to control BMI within a reasonable range; adjust intake levels of cereals and potatoes, fish, eggs, poultry, livestock, milk, and fruit; and appropriately increase physical activity have a significant effect on the control of BP in patients with hypertension.
After 4 years of health management, 195 (19.35%) of the 1008 patients with hypertension had achieved good BP control. In 2018, the BP control rate of Chinese patients with hypertension (age≥18 years) was reported to be much lower at only 11.0% [
This study found that changing dietary intake, appropriately increasing physical activity, adjusting the mental state, and controlling BMI according to health management guidance can effectively increase the control rate of BP in patients with hypertension. In addition, the rate of BP control was higher in female patients and in younger patients. Atik et al [
Strengths of our study include the consistency of the findings in this study and other cohort studies, together with the fact that internet-based health management has strong universality. Moreover, we combined logistic regression to analyze the related factors of BP control in patients with hypertension and also analyzed dietary components in more detail than in previous studies.
However, some limitations should be noted. To date, this research has been carried out over a relatively short time and therefore the longer-term effects are unknown; however, our research will continue to clarify the effect of internet-based health management on BP control in patients with hypertension. In addition, our study population was only recruited from five provinces in northwest China, which is still small compared with the whole country. However, the incidence rate of hypertension in these provinces represents the medium level for nationwide statistics [
Our findings confirm that internet-based health management has a significant effect on BP control in patients with hypertension, which can be maintained over the long-term. However, at present, the attention to internet-based health management remains insufficient, and there is still a long way to go to comprehensively popularize this management strategy.
blood pressure
diastolic blood pressure
General Health Questionnaire
receiver operating characteristic
systolic blood pressure
The data sets generated during and analyzed during the current study are not publicly available due to data confidentiality requirements but are available from the corresponding author on reasonable request.
BC and DM conceived and designed the study, performed the analyses, interpreted the data, and wrote the manuscript. YD and XY acquired, analyzed, and interpreted the data. All authors critically reviewed the manuscript for important intellectual content. All authors have read and approved the final manuscript.
None declared.