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Prevalence of Hypertension and Controlled Hypertension — United States, 2007–2010

Cathleen D. Gillespie, MS1

Kimberly A. Hurvitz, MHS2

1National Center for Chronic Disease Prevention and Health Promotion, CDC

2National Center for Health Statistics, CDC


Corresponding author: Cathleen D. Gillespie, MS, Division for Heart Disease and Stroke Prevention, National Center for Health Statistics, CDC. Telephone: 770-488-5855; E-mail: ckg2@cdc.gov.

Introduction

Hypertension is a major risk factor for heart disease and stroke. As the first and fourth leading causes of death in the United States, heart disease and stroke occur in approximately 30% of adults aged ≥18 years in the United States (1). Disparities in the prevalence of hypertension among racial/ethnic groups have persisted at least since 1960, with the prevalence remaining highest among non-Hispanic black adults (1–4). Blood pressure control among those with hypertension can reduce the risk of subsequent cardiovascular diseases (5). Among adults with hypertension, Mexican-American persons born outside the United States, and persons without health insurance had lower rates of blood pressure control in 2005–2008 (3). Not only do non-Hispanic black adults have higher rates of hypertension, but among those with hypertension they also have lower rates of blood pressure control than non-Hispanic white adults (2,3).

Healthy People 2020 includes objectives to reduce the prevalence of hypertension among adults to 26.9% (objective HDS-5.1) and to increase the prevalence of blood pressure control among adults with hypertension to 61.2% (objective HDS-12) (6). Further, in 2011, the U.S. Department of Health and Human Services launched the Million Hearts initiative, which is intended to bring together communities, health systems, nonprofit organizations, federal agencies, and private-sector partners from across the country to prevent 1 million heart attacks and strokes over the course of 5 years (available at http://millionhearts.hhs.gov/index.html). Blood pressure control is a part of the initiative in the prevention of these adverse events. Therefore, hypertension prevalence and blood pressure control among those with hypertension are important indicators to monitor over time to identify improvements or persistent challenges in vulnerable segments of the U.S. population.

This analysis of hypertension and the discussion that follows are part of the second CDC Health Disparities and Inequalities Report (2013 CHDIR) (3).The 2011 CHDIR was the first CDC report to assess disparities across a wide range of diseases, behavioral risk factors, environmental exposures, social determinants, and health-care access. The topic presented in this report is based on criteria that are described in the 2013 CHDIR Introduction (7). This report provides more current information on the prevalence of hypertension and blood pressure control among adults aged ≥18 years. The purposes of this report on hypertension and controlled hypertension are to discuss and raise awareness of differences in the characteristics of persons with hypertension and controlled hypertension, and to prompt actions to reduce disparities.

Methods

To estimate the age-adjusted prevalence of hypertension and blood pressure control among adults aged ≥18 years by selected demographic and health characteristics, CDC analyzed data from the National Health and Nutrition Examination Survey (NHANES) aggregated from two survey cycles: 2007–2008 and 2009–2010. NHANES is a national survey representative of the U.S. civilian noninstitutionalized population. Details of the NHANES survey methodology are available at http://www.cdc.gov/nchs/nhanes/about_nhanes.htm. During 2007–2010, the response rate among persons screened was 76.3%. Data were analyzed for 11,782 participants who had adequate data from the interview and examination components of the survey necessary to determine hypertension status. Blood pressure was determined by an average of up to three measurements taken during a single examination. Hypertension was defined as an average systolic blood pressure (SBP) ≥140 mmHg, an average diastolic blood pressure (DBP) ≥90 mmHg, or if the participant reported the current use of blood pressure lowering medication. Blood pressure control was defined as an average SBP <140 mmHg and an average DBP <90 mmHg among persons with hypertension. Pregnant women were excluded.

Hypertension prevalence and control estimates were analyzed by selected demographic and health characteristics: sex, age group (18–44, 45–64, and ≥65 years), race and ethnicity, marital status, educational attainment, country of birth, family income to federal poverty threshold, health insurance status (for persons aged 18–64 years), veteran status, diagnosed diabetes status, obesity status, and disability. Race was defined as white, black, and Mexican American. Ethnicity was defined as Hispanic or non-Hispanic. Educational attainment among adults aged ≥25 years was defined as follows: less than high school, high school graduate or equivalent, some college or Associate of Arts (AA) degree, and college graduate or above. Household income was defined as family income to federal poverty threshold, as defined by the Department of Health and Human Services poverty guidelines (8), specific to family size and appropriate year and state. Health insurance status was defined as having either private or public insurance, or being uninsured. Obesity among adults aged ≥20 years is defined as a body mass index ≥30 kg/m2 based on measured weight and height. Veteran status, diagnosed diabetes,* and disability status were self-reported (Table).

Disparities were measured as the deviations from a "referent" category prevalence. The referent group was the group that had the most favorable estimate for the variables used to assess disparities during the period reported. Absolute difference was measured as the simple difference between a population subgroup estimate and the estimate for its respective reference group. The relative difference, a percentage, was calculated by dividing the absolute difference by the value in the referent category and multiplying by 100.

Statistical analyses were weighted to account for the complex survey design. Prevalence estimates, except those by age group, were age adjusted to the 2000 U.S. standard population using the direct method. Estimates of hypertension control that are age-adjusted to the 2000 U.S. standard population tend to be lower than those adjusted to the population with hypertension because of the difference between the age distribution of the general population and that of the population with hypertension (9).

Results

During 2007–2010, the overall age-adjusted prevalence of hypertension among persons aged ≥18 years was 29.6% (Table). Among persons aged ≥18 years with hypertension, the overall age-adjusted prevalence of blood pressure control was 48.0%. Substantial differences (relative difference >10%) in the prevalence of hypertension were indicated by age group, race/ethnicity, educational attainment, country of birth, family income, health insurance, diabetes, obesity, and disability status. The highest rates of hypertension were observed among those aged ≥65 years (71.6%), adults with diabetes (59.4%), and non-Hispanic black adults (41.3%). Although the difference in hypertension prevalence by sex was statistically significant, the difference was not substantial. Hypertension prevalence increased with age and decreased with increasing income level, but no significant trend was observed by educational attainment. Non-Hispanic blacks had a higher rate of hypertension (41.3%) than non-Hispanic whites (28.6%) and Hispanics (27.7%). Adults born in the United States had a higher rate of hypertension (30.6%) than non-U.S.-born adults (25.7%). Adults aged <65 years with public insurance had a higher rate of hypertension (28.3%) than those with private insurance (20.0%) and those with no insurance (20.4%). Persons with diabetes had a significantly higher rate of hypertension than those without diabetes (59.4% versus 27.7%), as did those who were obese compared with those who were not (40.5% versus 25.0%) and those with a disability compared with those with no disability (40.2% versus 29.0%).

Substantial differences in the prevalence of blood pressure control were observed among all population groups except veteran status. Among persons aged ≥18 years with hypertension, rates of blood pressure control were lowest among those without health insurance (27.9%), Mexican-Americans (30.3%), those who were never married (34.9%), and those born outside the United States (38.9%). Men, adults aged 18–44 years, Hispanics, Non-Hispanic blacks, those who were never married, non-U.S.-born, persons without health insurance had a lower prevalence of hypertension control than their counterparts. Men had a lower rate of hypertension control than women (42.7%). Adults aged 18–44 years had a lower rate of hypertension control (40.9%) than adults aged 45–64 years (53.3%) and 64 years and over (51.4%). The rate of controlled blood pressure was lower among Hispanics (34.4%) and non-Hispanic blacks (42.5%) than non-Hispanic whites (52.6%). Non-U.S.-born adults had a lower rate of hypertension control (38.9%) than U.S.-born adults (49.3%). Adults aged <65 years with no insurance had a lower rate of hypertension control (27.9%) than those with public insurance (60.2%) or private insurance (50.6%). Controlled hypertension was also lower among those classified as not obese compared with those who were obese (41.4% versus 54.0%), persons without diabetes compared with those with diabetes (45.4% versus 63.6%), and persons with no disability compared with those with a disability (45.0% versus 59.3%). Controlled hypertension was not linearly associated with age, educational attainment, or income level.

Discussion

The prevalence of hypertension has remained consistent over the past 10 years, at an overall rate of approximately 30% (1,13). During 2007–2010, the prevalence of hypertension by the analyzed demographic characteristics was highest among those aged ≥65 years (71.6%) and among non-Hispanic blacks (41.3%), two population groups known to be disproportionately affected (1,3,12). Although the overall prevalence of blood pressure control has improved over the past 10 years, non-Hispanic blacks and Hispanics continue to have lower prevalence of control than their non-Hispanic white counterparts (8,12). Also consistent with other research, the prevalence of hypertension was higher among those with diagnosed diabetes, obese persons, and persons with disabilities (3). However, all three of these groups had higher rates of blood pressure control than their counterparts in 2007–2010 (63.6%, 54.0%, and 59.3%, respectively, versus 45.4%, 41.4%, and 45.0% among those without diagnosed diabetes, obesity, and disabilities, respectively). This difference is likely because of higher rates of treatment with medication among these groups (5,14). In contrast, although the prevalence of hypertension was lowest among those aged 18–44 years (9.8%), the prevalence of blood pressure control was significantly lower among this group than their older counterparts. This is most likely because of lower rates of hypertension awareness and treatment with medication among younger adults (13,15).

Limitations

The findings in this report are subject to at least four limitations. First, NHANES data are restricted to the civilian noninstitutionalized population; thus, results from this study are not generalizable to persons who live in nursing homes, long-term care facilities, or prisons, or to military personnel. Second, reliable data were not available for persons of certain racial/ethnic groups or sexual orientation/gender identity. Only non-Hispanic blacks and Hispanics were oversampled; consequently, estimates cannot be calculated for other racial/ethnic populations (e.g., American Indians/Alaska Natives, Asians/Pacific Islanders). Third, the cross-sectional study design provides a one-time only assessment of blood pressure, although blood pressure can be measured multiple times during one visit. This one-time assessment can overestimate or underestimate hypertension prevalence. However, the standardized measurement of blood pressure in a mobile examination center makes NHANES the best source of national data on hypertension. Finally, this report does not examine time trends in disparities to assess progress toward eliminating disparities. Although other studies included time trends, only a limited number of demographic characteristics such as race/ethnicity, age, and sex were examined (10).

Conclusion

Consistent with the 2011 CHDIR and other studies, no change has occurred in the prevalence of hypertension over the last decade, although the rate of hypertension control continues to improve (2,3,10). Disparities in hypertension prevalence and control persist among most population groups assessed similar to what has been published elsewhere. Although rates of control have continued to show improvement (2,10), more time is needed to determine whether the population will meet Healthy People 2020 target of 61.2%. Certain subgroups of persons with hypertension exhibit even lower rates of blood pressure control, indicating a need for interventions that span the population and focus on vulnerable subgroups. The United States Preventive Services Task Force (USPSTF) recommends blood pressure screening for all adults aged ≥18 years, and as a result of provisions in the Patient Protection and Affordable Care Act (ACA), Medicare now covers certain adult clinical preventive services recommended by the USPSTF without patient cost sharing (§4103) (11,12). The law also requires that "nongradfathered" private health plans include these same services without cost sharing (§1001). In addition, the ACA ensures certain preventive and wellness services without cost-sharing for Medicare recipients (§4103), a group most in need of hypertension management. The national Million Hearts initiative endeavors to increase the number of persons in the United States whose hypertension is under control by 10 million, as part of its goal to prevent 1 million heart attacks and strokes by the year 2017. The Guide to Community Preventive Services Task Force recommends system interventions to improve blood pressure control, including clinical decision support systems, reducing out-of-pocket costs for CVD preventive services for patients with hypertension, and team-based care. Because the rate of blood pressure control is lowest among persons without health insurance, compared to those with insurance coverage, it will be important to monitor this and other vulnerable population groups in the future.

References

  1. CDC. Vital signs: prevalence, treatment, and control of hypertension—United States, 1999–2002 and 2005–2008. MMWR 2011;60:103–8.
  2. CDC. National Center for Health Statistics. Health, United States, 2012: with special feature on emergency care. Hyattsville, MD: US Department of Health and Human Services; 2013.
  3. CDC. Prevalence of hypertension and controlled hypertension—United States, 2005–2008. MMWR 2011:60;94–97. In: CDC. CDC health disparities and inequalities report—United States, 2011. MMWR 2011, 60(Suppl; January 14, 2011).
  4. Burt VL, Cutler JA, Higgins M, et al. Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population. Data from the health examination surveys, 1960 to 1991. Hypertension 1995;26:60–9
  5. National Heart, Lung, and Blood Institute. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206–52.
  6. US Department of Health and Human Services. Healthy people 2020. Available at http://www.healthypeople.gov/2020/default.aspx.
  7. CDC. Introduction: In: CDC Health disparities and inequalities report—United States, 2011. MMWR 2011;60(Suppl; January 14, 2011).
  8. US Department of Health and Human Services. Poverty Guidelines, Research, and Measurement. Available at http://aspe.hhs.gov/poverty/index.cfm.
  9. Crim MT, Yoon SS, Ortiz E, et al. National surveillance definitions for hypertension prevalence and control among adults. Circ Cardiovasc Qual Outcomes 2012;5:343–51.
  10. Yoon S, Burt V, Louis T, Carroll MD. Hypertension among adults in the United States, 2009–2010. NCHS data brief, no 107. Hyattsville, MD: National Center for Health Statistics; 2012.
  11. Agency for Healthcare Research and Quality: Screening for high blood pressure. Available at http://www.uspreventiveservicestaskforce.org/uspstf07/hbp/hbprs.htm.
  12. Patient Protection and Affordable Care Act. Public. Law. 111-148 111th Congress, March 23, 2010. Government Printing Office, 2010. Available at http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf.
  13. Yoon S, Ostchega Y, Louis T. Recent trends in the prevalence of high blood pressure and its treatment and control, 1999-2008. NCHS data brief, no 48. Hyattsville, MD: National Center for Health Statistics; 2010.
  14. Bertoia ML, Waring ME, Gupta PS, et al. Implications of new hypertension guidelines in the United States. Hypertension 2012;60:639–44.
  15. Egan BM, Zhoa Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA 2010;303:2043–50.

* Persons with diagnosed diabetes are defined as those who have ever been told by a health-care professional that they have diabetes. Persons without diabetes are defined as those who have never been told by a health-care professional that they have diabetes or have never been told that they have borderline diabetes.

Persons classified as having a disability provided the answer 'Yes' to any of four questions:

• Unable to work at a job or business because of a physical, mental, or emotional problem

• Limited because of difficulty remembering or because of periods of confusion

• Limited in any activity because of a physical, mental or emotional problem

• Uses special equipment, such as a cane, a wheelchair a special bed, or a special telephone.


TABLE. Age-adjusted* prevalence of hypertension and blood pressure control among adults aged ≥18 years, by selected demographic and health characteristics — National Health and Nutrition Examination Survey, United States, 2007–2010

Characteristic

Hypertension§

Blood pressure control

Sample Size

%

(95% CI)

Absolute
difference
(percentage
points)

Relative
difference
(%)

%

(95% CI)

Absolute
difference
(percentage
points)

Relative
difference
(%)

Total

11,782

29.6

(28.6–30.7)

48.0

(44.6–51.4)

Sex

Male

5,854

30.5

(29.0–31.9)

1.9**

6.6

42.7

(38.3–47.2)

-12.8**

-23.1

Female

5,928

28.6

(27.4–29.7)

Ref.

Ref.

55.5

(51.8–59.3)

Ref.

Ref.

Age group (yrs), unadjusted††

18–44

5,051

9.8

(8.9–10.7)

Ref.

Ref.

40.9

(34.4–47.5)

-12.4**

-23.3

45–64

3,854

40.4

(37.9–43.0)

30.6**

312.2

53.3

(49.8–56.8)

Ref.

Ref.

≥65

2,877

71.6

(68.4–74.7)

61.8**

630.6

51.4

(48.2–54.6)

-1.9

-3.6

Race/Ethnicity

White, non-Hispanic

5,559

28.6

(27.1–30.2)

0.9

3.2

52.6

(48.8–56.5)

Ref.

Ref.

Black, non-Hispanic

2,305

41.3

(39.1–43.5)

13.6**

49.1

42.5

(37.6–47.5)

-10.1**

-19.2

Hispanic§§

3,372

27.7

(26.4–29.1)

Ref.

Ref.

34.4

(30.7–38.2)

-18.2**

-34.6

Mexican American

2,121

27.5

(25.8–29.2)

NA

NA

30.3

(26.1–34.5)

-22.3**

-42.4

Marital status (persons aged ≥20 years)

Never married

1,885

31.8

(29.4–34.3)

1.7

5.6

34.9

(29.1–40.6)

-15.7**

-31.0

Married or living with partner

6,678

30.1

(28.6–31.6)

Ref.

Ref.

50.6

(46.8–54.5)

Ref.

Ref.

Divorced/separated or widowed

2,656

31.1

(29.2–33.1)

1.0

3.3

50.4

(42.3–58.4)

-0.2

-0.4

Educational attainment (persons aged ≥25 years)††

Less than high school

3,127

36.9

(34.5–39.4)

8.9**

31.8

41.8

(33.9–49.6)

-10.8

-20.5

High school graduate or equivalent

2,422

36.3

(34.2–38.4)

8.3**

29.6

51.6

(45.6–57.7)

-1.0

-1.9

Some college or AA degree

2,677

34.5

(32.7–36.4)

6.5**

23.2

49.3

(44.3–54.2)

-3.3

-6.3

College graduate or higher

2,096

28.0

(25.3–30.6)

Ref.

Ref.

52.6

(46.0–59.2)

Ref.

Ref.

Country of birth

United States

8,784

30.6

(29.5–31.7)

4.9**

19.1

49.3

(45.7–52.9)

Ref.

Ref.

Outside of the United States

2,993

25.7

(24.2–27.1)

Ref.

Ref.

38.9

(32.4–45.5)

-10.4**

-21.1

Family income to federal poverty threshold††,¶¶ (%)

<100

2,359

32.8

(30.6–34.9)

5.2

18.8

46.2

(38.0–54.3)

-6.9

-13.0

100–199

2,940

32.5

(30.9–34.1)

4.9**

17.8

42.0

(34.7–49.4)

-11.1

-20.9

200–399

2,777

30.6

(28.8–32.5)

3.0

10.9

53.1

(47.1–59.2)

Ref.

Ref.

400–499

840

28.0

(25.0–31.0)

0.4

1.4

45.7

(35.2–56.3)

-7.4

-13.9

≥500

1,773

27.6

(25.1, 30.1)

Ref.

Ref.

51.4

(46.6–56.2)

-1.7

-3.2

Health insurance status*** (persons aged 18–64 years)

Private

4,555

20.0

(18.4–21.5)

Ref.

Ref.

50.6

(46.3–54.9)

-9.6**

-15.9

Public

1,489

28.3

(25.6–30.9)

8.3

41.5

60.2

(51.8–68.6)

Ref.

Ref.

Uninsured

2,829

20.4

(18.2–22.6)

0.4

2.0

27.9

(21.7–34.2)

-32.3**

-53.7


TABLE. (Continued) Age-adjusted* prevalence of hypertension and blood pressure control among adults aged ≥18 years, by selected demographic and health characteristics — National Health and Nutrition Examination Survey, United States, 2007–2010

Characteristic

Hypertension§

Blood pressure control

Sample Size

(%)

(95% CI)

Absolute difference (percentage points)

Relative difference (%)

(%)

(95% CI)

Absolute difference (percentage points)

Relative difference (%)

Veteran status

Yes

1,473

30.8

(26.9–34.8)

1.1

3.7

52.5

(44.4–60.5)

Ref.

Ref.

No (referent)

10,307

29.7

(28.7–30.7)

Ref.

Ref.

47.4

(43.4–51.5)

-5.1

-9.7

Diagnosed diabetes status††† 

Yes

1,421

59.4

(54.1–64.7)

31.7

114.4

63.6

(56.2–71.1)

Ref.

Ref.

No (referent)

10,352

27.7

(26.6–28.8)

Ref.

Ref.

45.4

(41.7–49.0)

-18.2**

-28.6

Obesity status§§§ (persons aged ≥20 years)

Yes

4,197

40.5

(39.0–41.9)

15.5

62.0

54.0

(50.2–57.8)

Ref.

Ref.

No (referent)

6,890

25.0

(23.5–26.4)

Ref.

Ref.

41.4

(36.5–46.3)

-12.6**

-23.3

Disability¶¶¶

Yes

2,612

40.2

(37.6–42.9)

11.2

38.6

59.3

(53.2–65.3)

Ref.

Ref.

No (referent)

8,613

29.0

(27.8–30.1)

Ref.

Ref.

45.0

(41.2–48.8)

-14.3**

-24.1

Abbreviations: 95% CI = 95% confidence interval; Ref. = referent; NA = not applicable.

* Age adjusted to the 2000 U.S. standard population. Age specific data are not age adjusted. Hypertension prevalence data (except those by education status, health insurance coverage, diabetes status, and age group) are age adjusted to the following seven age groups: 18–29, 30–39, 40–49, 50–59, 60–69, 70–79, and ≥80 years. Data by health insurance status are age adjusted using the age groups 18–29, 30–39, 40–49, 50–59, and 60–64 years. Data by diabetes status are age adjusted using the age groups 18–49, 50–59, 60–69, 70–79, and ≥80 years. Blood pressure control data (except those by education status, health insurance coverage, and age group) are age adjusted to the following five age groups: 18–49, 50–59, 60–69, 70–79, and ≥80 years. Data by education status are age adjusted using the age groups 25–49, 50–59, 60–69, 70–79, and ≥80 years. Data by health insurance status are age adjusted using the age groups 18–49, 50–59, and 60–64 years.

Pregnant women were excluded.

§ Hypertension among adults is defined as an average systolic blood pressure ≥140 mmHg, an average diastolic blood pressure ≥90 mmHg, or self-reported current use of blood pressure lowering medication.

Blood pressure control is defined as an average systolic blood pressure <140 mmHg and an average diastolic blood pressure <90 mmHg among adults with hypertension.

** p<0.05 for absolute difference compared with referent group, with Bonferroni adjustment for demographic variables with more than two categories.

†† p<0.05, test of trend for hypertension prevalence by income and age using weighted least squares regression on the categorical variable; not significant by education or for controlled hypertension.

§§ Persons of Hispanic ethnicity might be of any race or combination of races.

¶¶ Family income: income of all persons within a household who are related to each other by blood, marriage, or adoption. Family income to federal poverty threshold: the ratio of family income to the federal poverty threshold as defined by the Department of Health and Human Services' (HHS) poverty guidelines, specific to family size, as well as the appropriate year and state.

*** Private health insurance: private health insurance or Medigap insurance. Public health insurance: Medicare, Medicaid, State Children's Health Insurance Program, military health care, state-sponsored health plan, or other government insurance.

††† Persons with diagnosed diabetes: those who have ever been told by a health-care professional that they have diabetes. Persons without diabetes: those who have never been told by a health-care professional that they have diabetes or have never been told that they have borderline diabetes.

§§§ Obesity: body mass index ≥30 kg/m2 based on measured weight and height.

¶¶¶ Disability: inability to work at a job or business because of a physical, mental, or emotional problem; limitation caused by difficulty remembering or periods of confusion; limitation in any activity because of a physical, mental, or emotional problem; or use of special equipment (e.g., a cane, wheelchair, special bed, or special telephone).



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