Hypertension in the United States, 1999 to 2012CLINICAL PERSPECTIVE
Progress Toward Healthy People 2020 Goals
Background—To reduce the cardiovascular disease burden, Healthy People 2020 established US hypertension goals for adults to (1) decrease the prevalence to 26.9% and (2) raise treatment to 69.5% and control to 61.2%, which requires controlling 88.1% on treatment.
Methods and Results—To assess the current status and progress toward these Healthy People 2020 goals, time trends in National Health and Nutrition Examination Surveys 1999 to 2012 data in 2-year blocks were assessed in adults ≥18 years of age age-adjusted to US 2010. From 1999 to 2000 to 2011 to 2012, prevalent hypertension was unchanged (30.1% versus 30.8%, P=0.32). Hypertension treatment (59.8% versus 74.7%, P<0.001) and proportion of treated adults controlled (53.3%–68.9%, P=0.0015) increased. Hypertension control to <140/<90 mm Hg rose every 2 years from 1999 to 2000 to 2009 to 2010 (32.2% versus 53.8%, P<0.001) before declining to 51.2% in 2011 to 2012. Modifiable factor(s) significant in multivariable logistic regression modeling include: (1) increasing body mass index with prevalent hypertension (odds ratio [OR], 1.44); (2) lack of health insurance (OR, 1.68) and <2 healthcare visits per year (OR, 4.24) with untreated hypertension; (3) healthcare insurance (OR, 1.69), ≥2 healthcare visits per year (OR, 3.23), and cholesterol treatment (OR, 1.90) with controlled hypertension.
Conclusions—The National Health and Nutrition Examination Survey 1999 to 2012 analysis suggests that Healthy People 2020 goals for hypertension ( prevalence shows no progress,  treatment was exceeded, and  control) have flattened below target. Findings are consistent with evidence that (1) obesity prevention and treatment could reduce prevalent hypertension, and (2) healthcare insurance, ≥2 healthcare visits per year, and guideline-based cholesterol treatment could improve hypertension control.
Hypertension is a major contributor to death and disability from heart and vascular diseases. The estimated number of years of life lost to hypertension-related diseases in 2010 included: ischemic heart disease, 7.2 million; stroke, 1.9 million; and chronic kidney disease, other cardiovascular and circulatory, and hypertensive heart disease, 2.2 million combined.1 The treatment and control of hypertension reduce fatal and nonfatal cardiovascular events, especially when combined with effective hypercholesterolemia management.2 Million Hearts estimated that 1 000 000 cardiovascular events could be prevented in the United States in a 5-year period from 2013 to 2017, with hypertension control a featured component of the success plan.3
Editorial see p 1674
Clinical Perspective on p 1699
US Healthy People provides evidence-based, 10-year national objectives for pursuing its vision of a society in which all people live long, healthy lives.4 Healthy People 2010 aimed to reduce prevalent hypertension in adults to 16% and raise control to 50%.4 The 2010 control goal was met in 2007 to 2008 with an estimated 50.1% of all adults with hypertension attaining blood pressure <140/<90.5 However, the goal of reducing prevalent hypertension to 16% was not attained, because 29.5% of adults in 2009 to 2010 either reported taking medication to lower blood pressure or had blood pressure ≥140/≥90 mm Hg.6
Healthy People 2020 established goals for: (1) decreasing prevalent hypertension to 26.9%, based on a 10% relative decrease from 29.9% in 2005 to 2008; (2) treating 69.5% of all adults with hypertension, which reflects a 10% improvement from 63.2% in 2005 to 2008; and (3) controlling 61.2% of all adults with hypertension based on projected trends.7 The goals of treating 69.5% and controlling 61.2% of all adults with hypertension will require that 88% of treated adults attain control. Although Kaiser Permanente in Northern California, a large managed healthcare system, controlled 87.1% of treated adults with hypertension in 2011,8 attaining this level of success in all adults could prove challenging. Many clinical settings (eg, federally qualified health centers and rural clinics) have fewer resources and supports for quality improvement and provide care for a larger proportions of adults, including the uninsured, who typically have less favorable outcomes than Kaiser.9,10
This analysis of National Health and Nutrition Examination Survey 1999 to 2012 data was conducted to better understand trends and key variables impacting Healthy People 2020 goals for hypertension prevalence, treatment, and control. More specifically, current status and trends in hypertension awareness, treatment, and control were assessed, and modifiable factors that could facilitate progress toward Healthy People 2020 goals were identified.
The National Health and Nutrition Examination Surveys (NHANES) assess health and nutritional status of the US civilian noninstitutionalized population. Participants are selected by using a multistage, probability sampling design. All adults provided written consent approved by the National Center for Health Statistics.
Participants included adults ≥18 years of age in NHANES 1999 to 2012 with at least 1 recorded blood pressure (BP).
Race/ethnicity was determined by self-report and separated into non-Hispanic white (white), non-Hispanic black (black), Hispanic ethnicity, and other.
BP was measured by trained professionals using sphygmomanometry and appropriately sized arm cuffs in volunteers after 5 minutes of seated rest. The first BP was excluded in estimating mean systolic and diastolic values for individuals with >1 value as recommended in NHANES physician examination procedures manuals.11–17
Hypertension was defined by systolic BP ≥140 and diastolic BP ≥90 mm Hg or a positive response to “Are you currently taking prescribed medication to lower your BP?”
Awareness of hypertension was defined by the percentage of adults with prevalent hypertension reporting that a physician told them they had hypertension.
The treatment of hypertension was defined by the percentage of adults with prevalent hypertension reporting that they were taking prescription medication to lower BP.
The percentage of treated hypertension controlled was calculated as the number of adults on BP medications with values of <140/<90 mm Hg divided by the number of treated adults.
Hypertension control was defined as BP <140/<90 mm Hg in all adults with hypertension including those with diabetes mellitus and chronic kidney disease.18
Diabetes mellitus included19: (1) diagnosed diabetes mellitus defined by positive response(s) to ≥1 questions, “Have you ever been told by a doctor that you have diabetes?” or “Are you now taking insulin?” or “Are you now taking diabetic pills to lower your blood sugar?” and (2) undiagnosed diabetes mellitus defined by a fasting glucose of ≥126 mg/dL or glycosylated hemoglobin ≥6.5%.
Hypercholesterolemia was defined by non–high-density lipoprotein cholesterol relative to the Framingham 10-year coronary heart disease risk as previously described.2 Non–high-density lipoprotein cholesterol was used, because low-density lipoprotein cholesterol values were missing on more than half of subjects, and participants with and without values were different.
Hypercholesterolemia treatment was determined by adults answering affirmatively to “Are you taking prescribed medication to lower your cholesterol?”
Chronic kidney disease was defined as estimated glomerular filtration rate of <60 mL–1·1.73 m–2·min–1 or urine albumin:creatinine ≥300 mg/g (ie, values previously selected to define a lower BP target than <140/<90 mm Hg).20 Serum creatinine values were adjusted to account for methodological differences across surveys.21
Cardiovascular disease included the following. (1) Coronary heart disease (CHD) was defined by a positive response to 3 questions listed previously.18 (2) Stroke was defined by the endorsement of “Has a doctor ever told you that you had a stroke?”22 (3) Congestive heart failure was defined by an affirmative response to “Has a doctor ever told you that you had congestive heart failure?”
Cigarette smoker was defined if a patient answered “every day” or “some days” to “Do you now smoke cigarettes?”2
SAS version 9.4 (Cary, NC) survey procedures were used for within survey analyses, and appropriate weights accounting for unequal probabilities of selection, oversampling, and nonresponse were used. NHANES reporting guidelines were followed. The clinical epidemiology of hypertension was age-adjusted to the US 2010 Census. In 2010, the proportion of adults aged 18 to 44 years, 45 to 64 years, and ≥65 years was 0.481, 0.348, and 0.171.23 For age-adjusting hypertension awareness, treatment, and control across time, additional weights were calculated, because prevalent hypertension varies by age group. The proportion of adults in each age group that were hypertensive was multiplied by their respective year 2010 weight for all adults. Weights were then calculated by dividing the product for each age group by the sum of products for all 3 age groups in each survey.5 P values of <0.05 were accepted as statistically significant. Multiple comparisons with Bonferroni adjustment (pairwise significance level=0.05/3) were applied to assess within- and between-group differences. PROC SURVEYLOGISTIC was used to assess the association between clinical variables and BP control. For within-survey, between-group comparisons at each of the 3 NHANES time periods, Rao-Scott χ2 tests were used to assess differences in distributions of categorical variables and Wald F tests for differences in continuous variables. Pairwise comparisons between the 3 NHANES periods were conducted with t tests of weighted means. Odds ratios and 95% confidence intervals were calculated, and statistical significance was assumed when 95% confidence intervals did not cross the line of identity (1.0).
The process for identifying 12 262 adults with hypertension in NHANES 1999 to 2012 is depicted in Figure 1. Across time, adults with hypertension did not differ significantly by age, sex, race, healthcare insurance, or prevalent hypercholesterolemia, cardiovascular disease, chronic kidney disease, or 10-year CHD risk <10% (Table 1). The percentage of adults with infrequent health care (0–1 visits/y) declined between 1999 to 2004 and 2009 to 2012. Body mass index and prevalent obesity were greater in 2005 to 2008 and 2009 to 2012, than in 1999 to 2004. Systolic BP declined with time; diastolic BP was lower in 2005 to 2008 and 2009 to 2012 than in 1999 to 2004. Prevalent diabetes mellitus and 10-year CHD risk-equivalent status (>20%) were greater in 2009 to 2012 than in 1999 to 2004.
With age adjusted to the US 2010 census, prevalent hypertension (Figure 2) did not change over time (P=0.32), whereas awareness, treatment, and control increased (all P<0.001) as did controlled/treated hypertension (P=0.0015). Prevalent hypertension did not change significantly in any of the 6 groups by age and race/ethnicity, whereas awareness, treatment, proportion of treated adults controlled, and control increased over time in all groups except for adults <45 years (Figure 3). The other exception was in Hispanics, where the proportion of treated adults with hypertension controlled did not increase over time (P=0.09). Prevalent hypertension rose with increasing age; awareness and treatment were higher in the 2 older groups than in adults <45 years. The proportion of treated adults controlled was higher at ages <45 and 45 to 64 than at ages ≥65 years. Hypertension control was greater among adults 45 to 64 than among adults 18 to 44 years of age.
Prevalent hypertension was higher in black than in white and Hispanic adults (Figure 3). Hypertension awareness and treatment were higher in black than in Hispanic adults. The proportion of treated adults controlled was higher in whites than in blacks. Hypertension control did not differ significantly between the 3 race/ethnicity groups, although 95% confidence intervals were relatively wide, especially in Hispanic adults.
Data for the clinical epidemiology of hypertension in Figure 2 are provided in Table I in the online-only Data Supplement. Descriptive data for the 3 age groups shown in Figure 3 are provided in Table II in the online-only Data Supplement. P values for between-group within time period and within-group between time periods are provided in Tables IIa and IIb in the online-only Data Supplement, respectively. Descriptive data for the white, black, and Hispanic groups in Figure 3 are provided in Table III in the online-only Data Supplement. P values for within- and between-group comparisons are provided in Tables IIIa and IIIb in the online-only Data Supplement. Of note, in 2004 to 2008 and 2009 to 2012, blacks were less likely to be treated for hypercholesterolemia than whites (P<0.001), despite higher 10-year CHD risk (P<0.001).
Results of the multivariable logistic regression analysis to identify variables associated with hypertension awareness, treatment, and control are shown in Table 2. Among modifiable variables, prevalent hypertension was greater with increasing body mass index, with more frequent health care, and in adults reporting treatment for cholesterol. Adults unaware of hypertension were less likely to have more frequent health care and higher body mass indices, and to affirm treatment for hypercholesterolemia. Adults with untreated hypertension were less likely to have more frequent health care, to be obese, to be insured, and to affirm treatment for hypercholesterolemia. The ratio of treated patients controlled was higher in adults with more frequent health care, with healthcare insurance, and with treatment reported for hypercholesterolemia in the previous month. Hypertension control was greater in subjects with more frequent care, higher body mass indices, healthcare insurance, and hypercholesterolemia treatment in the previous month reported.
The main objective of this NHANES 1999 to 2012 analysis was to assess the current status and trends in the clinical epidemiology of hypertension relative to Healthy People 2020 goals.7 Prevalent hypertension varied within a narrow range of 30.1% to 30.8% between 1999 to 2000 and 2011 to 2012 (Figure 2). Given that prevalent hypertension stabilized at absolute levels 3% to 4% above the 2020 goal of 26.9%, new strategies or novel approaches are required.
A secondary goal of this NHANES 1999 to 2012 analysis was to identify modifiable factors that could facilitate progress toward Healthy People 2020 goals for hypertension prevalence, treatment, and control. Reducing prevalent hypertension is definition dependent. Healthy People 2020 defined prevalent hypertension as treatment for hypertension or BP ≥140/≥90 mm Hg.7 Thus, in addition to decreasing incident hypertension, prevalent hypertension can be reduced by lifestyle changes that (1) decrease BP to <140/<90 mm Hg in untreated adults and (2) decrease control BP to <140/<90 mm Hg without medications in previously treated adults.
Prospective observational and interventional studies document that body mass index and changes in body mass index are strongly related to incident and prevalent hypertension across the adult age span24–27; and this was the only modifiable, lifestyle-related factor included in our analysis. Higher levels of physical activity, lower levels of sodium intake, a Dietary Approaches to Stop Hypertension concordant diet, and less analgesic use are other modifiable factors associated with reduced likelihood of incident hypertension.25 Although efficacious, the percentage of the US population is small whose lifestyle patterns are consistent with a low risk for prevalent and incident hypertension.25,26,28 New strategies to improve lifestyle patterns in the population are required to reduce prevalent hypertension to the Healthy People 2020 goal of 26.9%. A complementary strategy includes antihypertensive medication, which reduces incident hypertension in adults with prehypertension.29
The Healthy People 2020 goal of controlling hypertension in 61.2% of all adults is challenging given control at 51.2% in NHANES 2011 to 2012 (Figure 2). Hypertension control begins with awareness. Age-adjusted awareness of hypertension rose from 69.6% (66.0%–73.2%) in 1999 to 2000 to 81.2% (79.1%–83.3%) in 2007 to 2008, but remained flat in 2009 to 2012 (Figure 2). Hypertension awareness is lower in adults who are male and infrequently use health care (Table 2). Although health insurance was not independently related to awareness, insurance increases healthcare use and risk factor awareness.30,31 Growth of accountable care organizations should also raise hypertension screening and awareness.32
Healthy People 2020 aim to treat 69.5% of all adults with hypertension, which was exceeded in 2007 to 2012. Modifiable variables strongly associated with untreated hypertension are frequency of health care and insurance. Efforts to provide healthcare insurance to more adults and growth of organizations accountable for care outcomes including hypertension control should further increase the proportion of adults with hypertension on treatment.31–34
The Healthy People 2020 goal of controlling 88.1% of treated patients is likely the most challenging because levels have stabilized since 2007 to 2008 at <70%. By increasing the percentage of patients who are aware and treated, the proportion of treated adults who must be controlled to attain the BP control goal of 61.2% declines and becomes more feasible. Although 87.1% of adults with hypertension were controlled during 2011 in a large insured, managed-care organization,8 this substantially exceeds the levels observed among treated patients in the United States (Figure 2). Less evident is that higher control rates require BP control on a greater percentage of visits, which necessitates mean systolic and diastolic BP and intervisit BP variability below current levels.35
The main analysis for this report centered on hypertension control at <140/<90 mm Hg for all adults irrespective of age and comorbid health conditions.2,8 The evidence-based treatment goal for adults ≥60 years was recently established as <150/<90 mm Hg by the Committee appointed to Eighth Joint National Committee,35 which would increase the percentage of treated patients controlled and overall control.18 However this recommendation is at variance with other guidelines and expert opinion,36 which continue to recommend a BP goal of <140/<90 mm Hg, with the exception of adults ≥80 years of age for whom the BP goal of <150/<90 mm Hg is recommended.
The Healthy People 2020 goal of controlling hypertension in 61.2% of all adults requires that the product of the proportion of adults with hypertension treated and the proportion of treated adults controlled reach the stated level. If 78% of adults are treated, moderately above levels in 2007 to 2012, then the proportion of treated adults with hypertension controlled to attain 61.2% control in the US adult population declines from 88.1% to 78.5%, which is in the range obtained by a growing number of practice settings.37 In multivariable analysis, modifiable factors independently associated with hypertension control in treated adults included health insurance, ≥2 annual healthcare visits, and hypercholesterolemia treatment.
Previous reports document that health insurance is associated with hypertension control among adults treated for hypertension.30–32 The link between hypercholesterolemia treatment, mainly statins, and hypertension control is largely indirect. In a meta-analysis of 40 randomized placebo-controlled studies, patients randomly assigned to statins had a 2.6 mm Hg reduction in systolic BP in comparison with the placebo group.38 In the Anglo-Scandinavian Cardiac Outcomes Trials (ASCOT), hypertensive patients randomly assigned to atorvastatin had a significantly lower risk of treatment-resistant hypertension than patients randomly assigned to placebo.39 These studies were not designed to assess statin effects on BP or treatment resistance and do not constitute compelling evidence to recommend statins for BP reduction. However, if statins lower BP and reduce treatment-resistant hypertension as suggested by randomized, placebo-controlled trials,38,39 then implementing the 2013 Cholesterol Guidelines, which increase the number of hypertensive adults eligible for statin therapy by a net of ≈7 million,40 could improve hypertension control.
Race/ethnicity disparities in hypertension control persist when controlling for confounding factors (Table 2). Hypertension control was lower in black than in white adults with hypertension, although blacks were more likely to be aware of and treated for hypertension than whites. Thus, the primary factor contributing to less hypertension control in black than white adults is the lower proportion of treated individuals attaining target BP (Table 2). Greater attention in black adults to modifiable factors independently associated with the proportion of treated adults controlled including ≥2 healthcare visits per year and health insurance could improve equity in hypertension control. Moreover, in 1999 to 2012, blacks were less likely to report cholesterol treatment than whites, despite greater 10-year CHD risk (Tables III, IIIa in the online-only Data Supplement). Thus, implementing current guideline-based statin therapy may improve equity in hypertension control.
Hypertension control was also lower in Hispanic than white adults when accounting for potential confounders (Table 2). Hispanic adults were less likely than white adults to receive treatment for hypertension and less likely to be controlled when treated. Variables independently associated with both untreated hypertension and the proportion of treated adults controlled included infrequent health care and lack of health insurance. With regard to the importance of health insurance, in a previous NHANES report of adults with multiple risk factors, Hispanics <65 years of age were ≈3 times more likely to be uninsured than whites in the age group (41% versus 13%).41 In particular, Hispanics <65 years were less likely to be treated for hypertension and less likely to be controlled when treated, which is consistent with the current report. Disparities in multiple risk factor control between whites and Hispanics <65 years of age were not evident at ≥65 years of age. Although this analysis did not focus on age by race/ethnicity subgroups, greater attention to these modifiable variables, especially in Hispanic adults <65 years of age, could improve equity in hypertension control.
In this report, adults <45 years were less likely to be aware of and treated for hypertension than older adults, but more likely to be controlled when treated. Our previous NHANES analyses indicate that infrequent health care, especially among men <45 years of age, is a major contributor to undiagnosed and untreated hypertension in this age group.42
Limitations include relatively small cross-sectional samples of the US population. Confidence intervals are often wide, which limits power for detecting clinically significant differences in the epidemiology of hypertension. BP was measured by trained professionals using a standardized protocol. Yet, hypertension status among untreated adults and control among treated adults were based on a single evaluation. Moreover, significant associations between independent and dependent variables in multivariable logistic regression analyses do not establish causal relationships.
In summary, our analysis shows that age-adjusted prevalent hypertension has remained at ≈30% of adults from 1999 to 2012, which is above the Healthy People 2020 goal of 26.9%. Awareness, treatment, proportion of treated adults controlled, and control of hypertension improved from 1999 to 2000 to 2011 to 2012. Yet, these key variables did not change significantly between 2007 to 2008 and 2011 to 2012. Specifically, the proportion of treated adults with controlled hypertension has flattened at levels substantially below values required to attain the Healthy People 2020 control goal of 61.2%. To foster progress, our analysis is consistent with previous data that obesity prevention and treatment could reduce incident and prevalent hypertension. Also in agreement with earlier reports, increasing the proportion of adults with health insurance and increasing healthcare use are 2 modifiable variables independently linked with hypertension treatment and control. The new cholesterol guideline, which, if implemented, would lead to a greater proportion of adults with hypertension on statins,40 may also raise hypertension control. Ongoing efforts to reduce the proportion of uninsured adults, growth of accountable care organizations, and dissemination and implementation of best practices emerge as potentially useful solutions to reducing these critical gaps and attaining the Healthy People 2020 hypertension control goal.
Sources of Funding
This work was supported in part by National Institutes of Health grant HL105880; United States Army, W81XWH-10-2-0057, Centers for Disease Control, Atlanta, GA (Community Transformation Grant thru the South Carolina Department of Health and Environmental Control [SC DHEC]), and the State of South Carolina, Columbia, SC.
Dr Egan has received income as a consultant to Blue Cross Blue Shield South Carolina, Daiichi-Sankyo, Medtronic, Novartis, and research support from Daiichi-Sankyo, Medtronic, Novartis, and Takeda. The other authors report no conflicts.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/10.1161/CIRCULATIONAHA.114.010676/-/DC1.
- Received April 17, 2014.
- Accepted August 18, 2014.
- © 2014 American Heart Association, Inc.
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Cardiovascular disease imposes a substantial and growing health and economic burden in the United States. Hypertension, which is highly prevalent and suboptimally controlled, contributes substantially to the burden of cardiovascular disease. To mitigate the cardiovascular disease burden, Healthy People 2020 set goals that included the following: (1) reducing prevalent hypertension to 26.9%, (2) treating 69.5%, and (3) controlling 61.2% of adults with hypertension, which implies that 88% of treated adults attain control. To assess current status and progress toward 2020 goals, National Health and Nutrition Examination Surveys 1999 to 2012 on adults were analyzed. Prevalent hypertension, defined as on treatment or blood pressure ≥140/≥90 mm Hg, did not change from 1999 to 2000 to 2011 to 2012, averaging ≈30.5%. Hypertension treatment at 74.7% in 2011 to 2012 exceeded the Healthy People 2020 goal. However, the proportions of treated adults controlled (68.9%) and the controlled (51.2%) in 2011 to 2012 were unchanged since 2007 to 2008 and substantially below 2020 targets. Our analyses confirmed reports that obesity contributes to prevalent hypertension. Healthcare insurance and ≥2 healthcare visits per year were associated with higher rates of hypertension treatment and control. Cholesterol treatment was linked to higher proportions of treated adults controlled and overall control. Clinicians have opportunities to reduce prevalent hypertension by promoting healthy nutrition and physical activity patterns that can also reduce obesity. Clinicians can improve hypertension treatment and control by getting at-risk adults in for care at least twice annually to assess and appropriately manage blood pressure. The 2013 Cholesterol Guideline, which increases the numbers of statin-eligible adults, may also improve hypertension control.