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. 2023 Sep 28;18(9):e0292159. doi: 10.1371/journal.pone.0292159

Trends and influence factors in the prevalence, awareness, treatment, and control of hypertension among US adults from 1999 to 2018

Zhixing Fan 1,2,3, Chaojun Yang 1,2,*, Jing Zhang 1,2, Yifan Huang 1,2, Ying Yang 1,2, Ping Zeng 1,2, Wanyin Cai 1,2, Zujin Xiang 1,2, Jingyi Wu 1,2, Jian Yang 1,2,*
Editor: Hean Teik Ong4
PMCID: PMC10538741  PMID: 37768964

Abstract

Objective

We aimed to describe the trends and influence factors in the prevalence, awareness, treatment, and control of hypertension among US Adults from 1999 to 2018.

Methods

We utilized data from the National Health and Nutrition Examination Survey (NHANES) spanning ten survey cycles (n = 53,496). Prevalence, awareness, treatment, and control of hypertension were calculated using survey weights. Joinpoint regression and survey-weighted generalized linear models were used to analyze trends and influence factors, respectively.

Results

The estimated prevalence of hypertension increased significantly from 33.53% to 40.58% (AAPC = 0.896, P = 0.002) during 1999–2018 with dropping rate of newly diagnosed hypertension from 8.62% to 4.82% before 2014 (APC = -4.075, P = 0.001), and then rose to 7.51% in 2018 (APC = 12.302, P = 0.126). Despite modest improvements or stability in the awareness, treatment, and control since 1999, the latter two remained inadequate in 2018 at 59.52% and 51.71%. There was an uptrend in the use of angiotensin-converting enzyme inhibitors (from 24.02% to 45.71%) and angiotensin receptor blockers (from 20.22% to 38.38%), and downtrend in β-blocker (from 12.71% to 4.21%). Men were at higher risk of incidence, un-awareness, un-treatment, and un-control for hypertension. Lower income and education were associated with susceptibility to hypertension, while being married was favorable for treatment and control. Optimal health reduced the incidence of hypertension, and increased the awareness and treatment.

Conclusion

Although the rate of newly diagnosed hypertension has declined slightly since 2010 in the US, the prevalence of hypertension is increasing, and treatment and control rates remain inadequate. To manage hypertension effectively, we need to focus on screening and prevention for high-risk populations, while advocating for optimal health to improve the burden of hypertension.

Introduction

Hypertension is an important risk factor for cardiovascular diseases (CVD), and approximately half of the US adult population meet diagnostic criteria [1]. One study of over 23,000 participants found that half of deaths from coronary heart disease and stroke were among individuals with hypertension [2]. As substantial percentage of patients with un-controlled blood pressure and its strong association with increased CVD risk, especially stroke and heart failure [3, 4], accurately knowing the prevalence, awareness, treatment, and control of hypertension is an important public health issue.

The National Health and Nutrition Examination Survey (NHANES) is a large health and nutritional survey of the civilian noninstitutionalized population of the United States (US) and is extremely useful for monitoring trends in the health status of the population [5]. From NHANES 1999–2000 to 2009–2010, the prevalence of hypertension was stable (from 29.5% to 29.5%), and the rates of awareness and control were improved (from 63.8% to 74.0%; from 27.5% to 46.5%) [6]. From 1999–2000 to 2013–2014, there was a rise in hypertension awareness, treatment, and control [7]. Using the 2015–2016 NHANES survey data, the prevalence of hypertension in the US according to the updated guidelines was 45.4%, corresponding to an estimated 108 million individuals [8]. In NHANES 2017–2018, the prevalence of hypertension was estimated to be 49.64%, and the overall rate of well-controlled hypertension was only 39.64% [9]. Muntner et al [10] found that the prevalence of controlled blood pressure increased from 1999–2000 to 2007–2008, did not significantly change from 2007–2008 through 2013–2014, and then decreased after that. As a result, the prevalence of hypertension is increasing and blood pressure control is inadequate over the years, reflecting an unoptimistic status of hypertension.

The influence factors of hypertension and its control are very important for the reducing the burden of hypertension [11]. The prevalence, awareness, treatment, and control of hypertension were found to differ across racial groups [12]. It is well known that age has a positive correlation with hypertension, while the influence of gender on it is not uniform [13, 14]. Socioeconomic status also plays an important role in hypertension prevalence and its control [15]. The Life’s Simple 7 (LS7) metric incorporates health behaviors (body mass index, diet, smoking, physical activity) and health factors (blood pressure, cholesterol, glucose) to estimate an individual’s level of cardiovascular health [16]. Plante et al [17]. found that each 1-point improvement in LS7 score was associated with a 6% lower risk of incident hypertension. Thus, race, age, gender, socioeconomic status and LS7 are the crucial factors for the management of hypertension prevention and control.

Using data from 10 National Health and Nutrition Examination Surveys (NHANES), we aimed to update the national trend in the prevalence of hypertension (contained newly and previous diagnosed), assess the tendency of awareness, treatment, and control of hypertension, and further explore their influence factors.

Material and methods

Data collection

The NHANES is a nationally representative survey to monitor the health of the US population conducted by the Centers for Disease Control and Prevention, with a complex and multistage sampling design. The NHANES were conducted every 2 years. Participants who were recruited from the US non-institutionalized and civilian population, undergoing 4 stages of selection, including counties, segments, households, and individuals. Data collection was performed through in-home interviews and study visits to a mobile examination center (MEC). The NHANES study protocol was approved by the NCHS Research Ethics Review Board, and written informed consent was obtained from the participants [18]. The additional ethical review was no longer required for the present study due to the usage of publicly available data without identifiable personal information.

Our study included NHANES participants from 1999 to 2018 who who were over 20 years old and were either hypertensive or non-hypertensive (n = 55,043). We excluded pregnant individuals and those with no information on weight variable (n = 1,547). The flow chart of this study was shown in S1 Fig in S1 File.

Definition of hypertension and its awareness, treatment, and control

Blood pressure determinations were taken at the MEC by a trained physician and measured in the right arm unless specific conditions prohibited the use of the right arm. Three consecutive blood pressures readings were obtained after 5 minutes of quiet rest in a seated position. A fourth attempt may be made if a blood pressure measurement was incomplete or interrupted. The average blood pressure was calculated by the NHANES analytic notes [19], with the following rules: 1) the diastolic reading with zero was not used to calculate the diastolic average; 2) if all diastolic readings were zero, then the average would be zero; 3) if only one blood pressure reading was obtained, that reading was the average; 4) if there was more than one blood pressure reading, the first reading was always excluded from the average. The diagnostic criteria of hypertension [20] was average blood pressure ≥ 140/90 mmHg as well as self-reporting of “ever told you had high blood pressure” or “taking prescription for hypertension”. Previous diagnosed hypertension was defined as self-reporting of “ever told you had high blood pressure” or “taking prescription for hypertension” regardless of the current average blood pressure. Newly diagnosed hypertension was defined as average blood pressure ≥ 140/90 mmHg without self-report of hypertension history and drug use.

Awareness of hypertension was defined as a positive reply to the history of hypertension [7]. Treatment of hypertension was defined as an affirmative response to the question of “Are you now taking prescribed medicine for high blood pressure?” [7]. Controlled hypertension was defined as systolic blood pressure < 140 mm Hg and diastolic blood pressure < 90 mm Hg in participants with hypertension [7]. The classification of antihypertensive drugs was obtained during the household interview. If participants answered affirmatively to the question “if you had taken any prescription medications in the past 30 days”, they should show the medication containers of all the products used or report the name of the medication to the interviewer. When the interviewer entered the medication name into the computer, the name was automatically identified as either an exact match or a similar text matches. Using drug-classification codes, we determined the classification of antihypertensive medication, including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), calcium channel blocker (CCB), β-blocker and diuretic (S1 Table in S1 File).

Social demography and LS7

The sociodemographic factors consisted of age, sex (male and female) and race (non-Hispanic white, non-Hispanic black, Mexican American, non-Hispanic Asian and other race), marital status (yes and no), education level (less than high school, high school graduate, some college, and college graduate or above), insurance status (uninsured and any insurance), income-to-poverty ratio (PIR). PIR was divided into three categories: PIR <1, low income; PIR 1–1.8, middle income; PIR≥1.8, high income.

LS7 scores were calculated by 7 components of individual health behaviors or factors, including average blood pressure, total cholesterol, HbA1c/diabetes, smoking status, body mass index (BMI), physical activity, healthy eating index (HEI). Each individual component was scored as 0 points (poor), 1 point (intermediate), or 2 points (ideal) (S2 Table in S1 File). A total score was calculated as the sum of the points from all LS7 components, ranging from 0 to 14. Participants were categorized into three LS7 health categories [17]: scores ≤4 points indicated inadequate health, 5 to 9 indicated average health, and 10 to 14 indicated optimal health.

Statistical analysis

NHANES data was extracted and preprocessed by “nhanesR package”. NHANES provided weights to ensure a representative and unbiased estimation of the total civilian non-institutionalized US population. The prevalence was weighted by 2-year weights from 1999 to 2018. While we combined 20-year weights to calculate the total prevalence and analyze the influence factors.

The estimation of weighted prevalence and proportion were both conducted by “survey package” that was specially handled complex sample design surveys, summarized as mean and 95% confidence interval (CI). Joinpoint regressions was used to determine trends in log-transformed prevalence, awareness, treatment, and control of hypertension, allowing 1 joinpoint. The Monte Carlo method was used for selecting the best-fitting model and identifying point of change in trends (joinpoint) [21]. Annual percent change (APC) was used to evaluate the internal trend of each independent interval before and after inflection. If there was no turning point, average annual percent change (AAPC) and its 95% CI were calculated to express the trend in the prevalence, awareness, treatment, and control of hypertension.

AAPC=eΣwiβi/Σwi−1×100

Where wi is the interval span width of each piece-wise function (i.e., the number of years included in the interval), βi is the regression coefficient. When the AAPC and its 95% CI were both greater than 0, the rate indicated an uptrend; on the contrary, when the AAPC and its 95% CI were both less than 0, the rate indicated a downtrend; any AAPC with a 95% CI overlapping with zero was considered stable trend.

Survey-weighted generalized linear models were performed to evaluate odds ratio (OR) and 95% CI by “survey package” (family = quasibinomial), estimating the factors associated with the prevalence of hypertension, and the factors for the awareness, treatment, and control of hypertension.

Statistical analysis was performed using R version 4.1.1 software and Joinpoint regressions Program 4.9.0.0. Statistical significance was < 0.05.

Result

Trends in the prevalence of hypertension

To analyze the trend in the prevalence of hypertension, 53,496 participants were included, representing an estimated 214,087,600 US adults aged 20 or older. A total of 22,947 patients satisfied the diagnostic criteria for hypertension, with a prevalence of 37.56%. The estimated prevalence of hypertension increased significantly from 33.53% to 40.58% from 1999 to 2018, with AAPC of 0.896 (P = 0.002 for trend) (Fig 1 and Table 1). A significant increase in the estimated prevalence of hypertension was observed in the following population over the study period (Table 1): male (from 32.45% to 42.55%; P<0.001 for trend), non-Hispanic white (from 33.56% to 41.87%; P = 0.008 for trend), non-Hispanic black (from 40.21% to 49.37%; P<0.001 for trend), Mexican American (from 25.01% to 27.49%; P = 0.015 for trend), other Hispanic (from 29.39% to 34.94%; P = 0.029 for trend), married (from 36.10% to 42.85%; P = 0.044 for trend) or not (from 31.40% to 37.99%; P = 0.003 for trend), high school graduate (from 37.60% to 43.44%; P = 0.008 for trend), some college (from 30.59% to 42.83%; P<0.001 for trend), college graduate or above (from 25.87% to 34.24%; P = 0.027 for trend), low income (from 34.56% to 41.33%; P = 0.005 for trend), high income (from 32.00% to 40.42%; P = 0.018 for trend), insured adults (from 36.66% to 42.42%; P = 0.009 for trend) or not (from 20.19% to 29.27%; P = 0.003 for trend), inadequate health (from 68.70% to 80.17%; P<0.001 for trend), and average health (from 37.87% to 49.23%; P = 0.005 for trend). The inflection point, the annual rate of change before or after inflection, and AAPC in the prevalence of hypertension were shown in S3 Table in S1 File.

Fig 1. Trends in the prevalence of hypertension among US adults from 1999 to 2018.

Fig 1

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Table 1. Prevalence of hypertension among US adults from 1999 to 2018.

Characteristics Total (n = 53496) 1999–2000 (n = 4582) 2001–2002 (n = 5078) 2003–2004 (n = 4802) 2005–2006 (n = 4641) 2007–2008 (n = 5877) 2009–2010 (n = 6148) 2011–2012 (n = 5503) 2013–2014 (n = 5704) 2015–2016 (n = 5648) 2017–2018 (n = 5513) AAPC P
Total 37.56(36.01,39.10) 33.53(30.41,36.65) 34.00(31.41,36.58) 37.67(35.38,39.97) 36.83(34.41,39.25) 36.72(34.65,38.79) 35.72(32.84,38.60) 38.05(35.37,40.74) 40.33(38.25,42.42) 38.75(36.10,41.40) 40.58(37.34,43.81) 0.896(0.42,1.375) 0.002
Age (years) 20–49 14.94(14.13,15.76) 13.21(9.53,16.89) 15.20(13.13,17.26) 15.62(12.85,18.40) 13.84(10.62,17.06) 13.85(12.18,15.53) 13.31(11.43,15.18) 14.41(12.53,16.30) 17.06(14.75,19.36) 15.14(12.76,17.53) 17.28(14.19,20.38) 0.728(-0.52,1.991) 0.216
40–59 38.51(37.29,39.73) 36.87(30.90,42.84) 34.01(30.46,37.57) 39.60(35.60,43.59) 38.96(34.75,43.18) 38.54(36.01,41.07) 34.82(31.19,38.45) 39.96(37.12,42.80) 41.30(38.26,44.34) 39.56(35.96,43.16) 41.01(35.63,46.39) 0.749(-0.023,1.526) 0.056
60–85 68.80(67.69,69.91) 67.21(64.13,70.29) 69.74(66.19,73.30) 70.68(67.77,73.59) 69.15(66.57,71.73) 69.14(66.55,71.74) 69.74(66.17,73.30) 67.45(63.93,70.97) 69.41(66.70,72.13) 67.30(62.70,71.90) 68.15(64.24,72.05) -0.05(-0.288,0.188) 0.639
Sex Female 37.61(36.68,38.55) 34.57(31.43,37.70) 35.91(33.11,38.71) 38.26(35.13,41.39) 36.97(33.99,39.95) 36.92(34.33,39.51) 35.25(32.70,37.80) 37.31(34.68,39.94) 40.55(37.40,43.71) 38.03(34.84,41.22) 38.70(35.38,42.02) 0.503(-0.011,1.019) 0.054
Male 37.50(36.48,38.51) 32.45(28.35,36.55) 31.99(28.72,35.26) 37.06(34.35,39.77) 36.69(33.89,39.48) 36.51(33.86,39.16) 36.21(32.42,40.00) 38.85(35.39,42.30) 40.09(38.06,42.13) 39.51(36.76,42.26) 42.55(38.48,46.63) 1.231(0.738,1.726) <0.001
Race Non-Hispanic white 38.62(37.58,39.66) 33.56(29.81,37.31) 34.89(32.14,37.64) 39.16(36.35,41.97) 37.87(34.83,40.91) 38.13(35.16,41.10) 36.70(32.94,40.46) 39.06(35.42,42.70) 42.70(39.84,45.55) 39.34(36.17,42.51) 41.87(37.53,46.21) 0.972(0.336,1.611) 0.008
Non-Hispanic black 46.13(44.99,47.27) 40.21(37.70,42.72) 44.31(39.32,49.30) 43.65(40.35,46.95) 45.68(42.91,48.45) 44.48(40.61,48.35) 45.15(41.43,48.87) 47.96(44.62,51.30) 48.85(45.55,52.16) 46.82(43.02,50.61) 49.37(45.46,53.28) 1.003(0.618,1.39) <0.001
Mexican American 25.88(24.34,27.42) 25.01(21.71,28.31) 19.11(16.79,21.42) 23.82(16.60,31.03) 23.13(19.45,26.81) 24.15(20.57,27.74) 25.61(22.04,29.18) 27.11(21.19,33.03) 27.46(23.07,31.86) 31.55(25.51,37.59) 27.49(23.38,31.60) 1.683(0.415,2.968) 0.015
Other Hispanic 30.09(28.01,32.16) 29.39(21.59,37.18) 27.24(21.28,33.20) 29.22(13.99,44.45) 22.65(14.80,30.51) 29.38(24.61,34.16) 27.08(23.75,30.41) 31.18(24.89,37.48) 29.23(25.28,33.18) 32.18(27.20,37.17) 34.94(29.70,40.18) 1.31(0.173,2.46) 0.029
Other race 32.90(30.83,34.97) 36.63(24.23,49.04) 26.59(18.30,34.89) 30.52(25.01,36.03) 32.60(26.40,38.80) 28.92(21.61,36.24) 29.38(23.65,35.11) 31.48(27.98,34.97) 31.27(26.51,36.03) 36.19(30.00,42.38) 37.98(32.12,43.84) 1.124(-0.116,2.379) 0.07
Marital status No 36.05(34.97,37.13) 31.40(28.15,34.65) 34.21(30.75,37.67) 34.68(30.88,38.47) 35.87(32.18,39.56) 34.23(31.25,37.20) 32.96(29.75,36.17) 36.49(33.42,39.56) 38.70(35.34,42.06) 39.02(35.23,42.80) 37.99(34.73,41.26) 0.984(0.442,1.529) 0.003
Yes 38.87(37.91,39.82) 36.10(32.26,39.94) 33.86(30.44,37.27) 39.92(37.74,42.11) 37.45(34.73,40.18) 38.65(36.67,40.64) 37.83(34.50,41.16) 39.46(36.05,42.87) 41.64(39.30,43.97) 38.53(35.60,41.45) 42.85(39.14,46.57) 0.685(0.022,1.352) 0.044
Education level Less than high school 43.65(42.33,44.96) 39.42(36.24,42.60) 43.34(38.39,48.30) 45.06(39.87,50.26) 43.35(39.74,46.96) 42.70(38.62,46.79) 42.29(38.15,46.43) 46.86(43.89,49.82) 43.66(39.79,47.53) 43.70(39.34,48.06) 44.52(38.66,50.37) 0.578(-0.039,1.2) 0.063
High school graduate 40.92(39.63,42.20) 37.60(32.81,42.38) 35.31(30.70,39.92) 41.27(38.44,44.10) 39.07(35.06,43.07) 38.96(35.83,42.09) 39.40(35.80,43.00) 41.11(35.69,46.53) 45.73(42.71,48.75) 44.72(40.83,48.60) 43.44(38.80,48.09) 1.084(0.368,1.806) 0.008
Some college 37.13(35.95,38.32) 30.59(26.96,34.23) 31.45(29.21,33.68) 35.08(32.03,38.13) 34.01(30.69,37.34) 35.24(31.94,38.54) 36.19(33.18,39.20) 37.56(32.23,42.88) 41.93(37.91,45.95) 40.53(37.21,43.85) 42.83(38.29,47.38) 1.838(1.422,2.256) <0.001
College graduate or above 31.17(29.74,32.61) 25.87(22.16,29.58) 28.62(24.04,33.21) 31.02(26.60,35.44) 33.44(28.29,38.58) 31.33(27.77,34.90) 27.54(22.30,32.78) 31.79(27.58,36.00) 33.00(30.22,35.79) 30.85(26.46,35.24) 34.24(28.67,39.82) 0.995(0.147,1.849) 0.027
PIR Low income 36.07(34.45,37.69) 34.56(28.79,40.32) 34.09(29.06,39.12) 33.00(28.98,37.02) 33.46(28.20,38.72) 34.63(30.54,38.72) 33.47(30.65,36.30) 33.63(27.45,39.80) 38.91(36.15,41.67) 40.00(34.30,45.69) 41.33(35.56,47.09) 1.286(0.499,2.078) 0.005
Middle income 41.05(39.77,42.33) 37.59(33.28,41.90) 37.31(33.24,41.38) 40.07(34.68,45.47) 42.89(39.20,46.57) 39.71(36.58,42.83) 40.52(36.04,45.00) 42.29(37.54,47.04) 44.58(41.30,47.86) 41.94(38.61,45.27) 39.80(35.79,43.80) 0.567(-0.109,1.248) 0.089
High income 36.87(35.90,37.85) 32.00(28.49,35.51) 33.10(30.16,36.05) 37.99(35.32,40.67) 35.80(33.10,38.50) 36.36(34.12,38.60) 35.28(31.71,38.85) 38.09(34.97,41.21) 39.41(36.46,42.35) 37.14(34.40,39.89) 40.42(36.32,44.52) 0.827(0.187,1.47) 0.018
Health insurance No 24.77(23.55,25.98) 20.19(16.35,24.02) 20.71(16.03,25.38) 24.84(21.40,28.28) 24.92(20.59,29.25) 24.71(22.58,26.84) 23.09(19.60,26.58) 25.73(22.33,29.13) 26.20(23.49,28.91) 27.16(22.59,31.72) 29.27(23.94,34.60) 1.45(0.674,2.232) 0.003
Yes 40.32(39.39,41.25) 36.66(32.91,40.41) 36.93(34.25,39.61) 40.58(38.09,43.06) 39.53(36.98,42.07) 39.61(37.21,42.02) 39.07(36.23,41.91) 41.11(37.82,44.40) 43.42(40.89,45.94) 40.47(37.27,43.67) 42.42(39.01,45.82) 0.718(0.235,1.203) 0.009
Life’s simple 7 Inadequate health 71.54(69.92,73.16) 68.70(61.14,76.25) 63.35(56.47,70.24) 67.84(63.95,71.72) 64.80(58.75,70.86) 70.81(65.03,76.59) 71.44(67.20,75.69) 71.49(67.30,75.68) 72.86(69.00,76.73) 81.56(78.52,84.59) 80.17(76.02,84.32) 1.368(0.805,1.934) <0.001
Average health 43.20(42.30,44.10) 37.87(35.36,40.39) 38.60(35.85,41.36) 41.21(38.11,44.31) 42.12(39.57,44.67) 43.61(41.52,45.70) 43.75(40.70,46.80) 47.03(44.26,49.79) 39.84(37.12,42.57) 46.46(43.77,49.15) 49.23(45.81,52.65) 1.168(0.457,1.883) 0.005
Optimal health 11.22(10.38,12.06) 7.13(4.78,9.49) 8.65(6.42,10.88) 13.11(10.41,15.80) 12.16(9.76,14.55) 12.62(10.43,14.81) 10.91(8.33,13.49) 12.70(10.50,14.89) 6.41(4.02,8.81) 11.58(9.06,14.11) 12.26(8.81,15.70) 0.877(-2.097,3.941) 0.52
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PIR: income-to-poverty ratio; AAPC: average annual percent change

The prevalence of previously diagnosed hypertension and newly diagnosed hypertension were 31.04% and 6.48%, respectively. The previous diagnosed hypertension (from 24.84% to 33.03%) was increasing significantly with 1.544% relative increase per 2-cycle, from 1999–2000 to 2017–2018 (S4 and S5 Tables in S1 File and Fig 1); while, the incidence of newly diagnosed hypertension was significantly dropped from 8.62% to 4.82% during 1999–2014 (APC = -4.075, P = 0.001), and then rose to 7.51% in 2018 (APC = 12.302, P = 0.126) (S6 and S7 Tables in S1 File and Fig 1). In addition to the participants of college graduate or above and optimal health, the other subpopulations were all significantly raised in the trend of previous diagnosed hypertension prevalence from 1999 to 2018 (all P<0.05 for trend).

Analysis of influence factors for hypertension

Establishing survey-weighted generalized linear models, the association between prevalence of hypertension and sociodemographic and LS7 was estimated (Table 2). The prevalence of hypertension was higher associated with 40–59 years old (OR = 2.924; 95%CI: 2.697, 3.170), 60–85 years old (OR = 9.147; 95%CI: 8.380, 9.983), male (OR = 1.090; 95%CI: 1.030, 1.154), non-Hispanic black (OR = 1.521; 95%CI: 1.420, 1.629), and insured (OR = 1.455; 95%CI: 1.342, 1.577). While, Mexican American (OR = 0.782; 95%CI: 0.708, 0.863), other Hispanic (OR = 0.882; 95%CI: 0.782, 0.995), college graduate or above (OR = 0.863; 95%CI: 0.789, 0.944), high income (OR = 0.912; 95%CI: 0.845, 0.984), average health (OR = 0.355; 95%CI: 0.322, 0.391), and optimal health (OR = 0.081; 95%CI: 0.072, 0.092) decreased the risk of hypertension. The factors associated with the prevalence of previously diagnosed hypertension was basically in line with total hypertension. The older and non-Hispanic black were associated with a higher risk of both previously and newly diagnosed hypertension; while, average health and optimal health both showed inverse associations with them.

Table 2. Influencing factors of hypertension among US adults from 1999 to 2018.

Characteristics Diagnosis of hypertension Previous diagnosis of hypertension Newly diagnosed hypertension
OR (95% CI) P OR (95% CI) P OR (95% CI) P
Age (years) 20–49 1 (reference) 1 (reference) 1 (reference)
40–59 2.924(2.697,3.170) <0.0001 3.143(2.881, 3.428) <0.0001 2.183(1.893,2.518) <0.0001
60–85 9.147(8.380,9.983) <0.0001 9.823(8.977,10.749) <0.0001 6.544(5.579,7.675) <0.0001
Sex Female 1 (reference) 1 (reference) 1 (reference)
Male 1.090(1.030,1.154) 0.003 1.012(0.951, 1.077) 0.703 1.330(1.192,1.485) <0.0001
Race Non-Hispanic white 1 (reference) 1 (reference) 1 (reference)
Non-Hispanic black 1.521(1.420,1.629) <0.0001 1.568(1.460, 1.684) <0.0001 1.324(1.145,1.532) <0.001
Mexican American 0.782(0.708,0.863) <0.0001 0.731(0.658, 0.812) <0.0001 0.985(0.838,1.157) 0.850
Other Hispanic 0.882(0.782,0.995) 0.041 0.870(0.763, 0.992) 0.038 0.925(0.708,1.207) 0.562
Other race 1.030(0.924,1.149) 0.592 0.999(0.890, 1.120) 0.980 1.136(0.928,1.392) 0.215
Marital status No 1 (reference) 1 (reference) 1 (reference)
Yes 0.976(0.914,1.041) 0.456 0.987(0.921, 1.058) 0.712 0.915(0.813,1.030) 0.140
Education level Less than high school 1 (reference) 1 (reference) 1 (reference)
High school graduate 1.018(0.939,1.104) 0.662 1.020(0.935, 1.113) 0.648 1.053(0.922,1.203) 0.445
Some college 1.023(0.938,1.114) 0.608 1.035(0.944, 1.134) 0.465 0.957(0.824,1.112) 0.565
College graduate or above 0.863(0.789,0.944) 0.001 0.836(0.759, 0.921) <0.001 0.981(0.825,1.166) 0.823
Health insurance No 1 (reference) 1 (reference) 1 (reference)
Yes 1.455(1.342,1.577) <0.0001 1.563(1.427, 1.713) <0.0001 1.101(0.949,1.279) 0.202
PIR Low income 1 (reference) 1 (reference) 1 (reference)
Middle income 1.020(0.932,1.117) 0.662 1.001(0.918, 1.092) 0.975 1.078(0.894,1.300) 0.427
High income 0.912(0.845,0.984) 0.019 0.863(0.795, 0.936) <0.001 1.109(0.946,1.300) 0.200
Life’s simple 7 Inadequate health 1 (reference) 1 (reference) 1 (reference)
Average health 0.355(0.322,0.391) <0.0001 0.372(0.334, 0.414) <0.0001 0.322(0.286,0.362) <0.0001
Optimal health 0.081(0.072,0.092) <0.0001 0.095(0.083, 0.108) <0.0001 0.041(0.032,0.053) <0.0001
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PIR: income-to-poverty ratio

Trends in the prevalence of awareness, treatment, and control among hypertension

Among hypertension, the prevalence of awareness, treatment, and control were 81.97%, 60.00%, and 52.46%, respectively. The prevalence of awareness increased from 73.22% to 87.52% through 1999–2014 (APC = 1.1272, P = 0.003), and then decreased to 81.16% in 2018 (APC = -2.101, P = 0.276) (S8 and S9 Tables in S1 File and Fig 2). The rates of treatment and control were both increased from 51.16% to 67.47% (APC = 3.053, P = 0.001) and from 41.20% to 60.05% (APC = 3.690, P = 0.001) before 2009, then undulate down to 59.52% (APC = -1.242, P = 0.058) and 51.71% (APC = -1.753, P = 0.084) in 2018 after that (S10-S13 Tables in S1 File and Fig 2). The increased trends in the awareness of hypertension were mainly in the subpopulation of 20–49 years old, 60–85 years old, both female and male, non-Hispanic white, married or not, less than high school, some college, all PIR, insured or not, inadequate health and average health (S8 and S9 Tables in S1 File). The trend in the prevalence of treatment among hypertension raised in 20–49 years old, non-Hispanic black, Mexican American, no marital and Some college (S10 and S11 Tables in S1 File). The prevalence of control among hypertension were increased in the population of 60–85 years old, male, non-Hispanic white, married or not, middle income, insured and average health (S12 and S13 Tables in S1 File).

Fig 2. Trends in the awareness, treatment, and control of hypertension among US adults from 1999 to 2018.

Fig 2

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We further estimated the trends in the prevalence of five antihypertensive agent during study interval. Of those who were now taking prescribed medicine for hypertension, only 3,295 participants reported or showed the specific medicine. The use of ACEI, ARB, CCB, β-blocker and diuretic were 35.36%, 33.21%, 16.32%, 39.80%, 8.78%, and 84.97%, respectively. There was an uptrend in the use of ACEI (from 24.02% to 45.71%, AAPC = 3.368, P = 0.001) and ARB (from 20.22% to 38.38%, AAPC = 2.746, P = 0.004), and a downtrend in the use of β-blocker (from 12.71% to 4.21%, AAPC = -6.463, P = 0.009) from 1999 to 2018 (S14 and S15 Tables in S1 File and Fig 3). Before 2005, the use of CCB and diuretics increased from 6.46% to 23.70 (APC = 24.884, P = 0.093) and decreased from 93.54% to 81.18% (APC = -3.208, P = 0.081), respectively, and then decreased to 9.05% (APC = -6.665, P = 0.021) and increased to 91.89% (APC = 1.231, P = 0.022) in 2018 after that.

Fig 3. Prevalence of antihypertensive use among US hypertension adults from 1999 to 2018.

Fig 3

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ACEI: angiotensin-converting enzyme inhibitors; ARB: angiotensin receptor blockers; CCB: calcium channel blocker.

Analysis of influence factors for awareness, treatment, and control of hypertension

The influence factors of awareness, treatment, and control of hypertension were displayed in Table 3. The 40–59 years old (OR = 1.388; 95%CI: 1.197,1.608), 60–85 years old (OR = 1.415; 95%CI: 1.216, 1.647), non-Hispanic black (OR = 1.220; 95%CI: 1.063, 1.400), insured (OR = 1.428; 95%CI: 1.213, 1.680), and optimal health (OR = 2.100; 95%CI: 1.623, 2.717) increased the risk of hypertension awareness; while, male (OR = 0.789; 95%CI: 0.704, 0.883), Mexican American (OR = 0.753; 95%CI: 0.653, 0.868) and high income (OR = 0.788; 95%CI: 0.674, 0.921) decreased it. The treatment for hypertension was raised mainly in the population of 40–59 years old (OR = 4.249; 95%CI: 3.692, 4.891), 60–85 years old (OR = 8.661; 95%CI: 7.518, 9.978), non-Hispanic black (OR = 1.537; 95%CI: 1.378, 1.714), married (OR = 1.192; 95%CI: 1.086, 1.309) and insured (OR = 2.313; 95%CI: 2.019, 2.649), and declined with male (OR = 0.767; 95%CI: 0.707, 0.833) and Mexican American (OR = 0.832; 95%CI: 0.725, 0.955). The un-control of blood pressure among hypertension was associated with 40–59 years old (OR = 0.907; 95%CI: 0.802, 1.027)), 60–85 years old (OR = 0.655; 95%CI: 0.579, 0.740), male (OR = 0.891; 95%CI: 0.822, 0.966), non-Hispanic black (OR = 0.810; 95%CI: 0.736, 0.891), Mexican American, (OR = 0.846; 95%CI: 0.738, 0.971); and inversely associated with married (OR = 1.095; 95%CI: 1.008, 1.189), insured (OR = 1.364; 95%CI: 1.195, 1.557), average health (OR = 2.035; 95%CI: 1.834,2.258) and optimal health (OR = 6.669; 95%CI: 5.522,8.055). Subsequently, we explored the influence factors for the control of blood pressure in hypertension with prescription medicine. The control of blood pressure worsened in participants of 60–85 years old (OR = 1.915; 95%CI: 1.495, 2.454), non-Hispanic black (OR = 1.436; 95%CI: 1.299,1.587), and better in insured (OR = 0.769; 95%CI: 0.627, 0.945), average health (OR = 0.479; 95%CI: 0.423, 0.542), and optimal health (OR = 0.124; 95%CI: 0.091, 0.169).

Table 3. Influencing factors of awareness, treatment, and control among US hypertension adults from 1999 to 2018.

Characteristics Awareness Treatment Control Un-control of blood pressure in persons with antihypertensive drugs
OR (95% CI) P OR (95% CI) P OR (95% CI) P OR (95% CI) P
Age (years) 20–49 1 (reference) 1 (reference) 1 (reference) 1 (reference)
40–59 1.388(1.197,1.608) <0.0001 4.249(3.692,4.891) <0.0001 0.907(0.802,1.027) 0.122 1.091(0.849,1.403) 0.493
60–85 1.415(1.216,1.647) <0.0001 8.661(7.518,9.978) <0.0001 0.655(0.579,0.740) <0.0001 1.915(1.495,2.454) <0.0001
Sex Female 1 (reference) 1 (reference) 1 (reference) 1 (reference)
Male 0.789(0.704,0.883) <0.0001 0.767(0.707,0.833) <0.0001 0.891(0.822,0.966) 0.006 0.914(0.829,1.008) 0.072
Race Non-Hispanic white 1 (reference) 1 (reference) 1 (reference) 1 (reference)
Non-Hispanic black 1.220(1.063,1.400) 0.005 1.537(1.378,1.714) <0.0001 0.810(0.736,0.891) <0.0001 1.436(1.299,1.587) <0.0001
Mexican American 0.753(0.653,0.868) <0.001 0.832(0.725,0.955) 0.009 0.846(0.738,0.971) 0.017 1.150(0.985,1.342) 0.076
Other Hispanic 0.926(0.699,1.227) 0.590 0.836(0.680,1.027) 0.088 0.881(0.723,1.073) 0.207 1.214(0.984,1.497) 0.070
Other race 0.895(0.737,1.086) 0.258 0.921(0.777,1.092) 0.343 0.821(0.706,0.954) 0.010 1.245(1.018,1.524) 0.033
Marital status No 1 (reference) 1 (reference) 1 (reference) 1 (reference)
Yes 1.064(0.958,1.181) 0.243 1.192(1.086,1.309) <0.001 1.095(1.008,1.189) 0.032 0.925(0.817,1.047) 0.217
Education level Less than high school 1 (reference) 1 (reference) 1 (reference) 1 (reference)
High school graduate 0.990(0.864,1.134) 0.881 0.982(0.868,1.111) 0.770 1.023(0.926,1.130) 0.653 0.984(0.862,1.124) 0.815
Some college 1.139(0.983,1.320) 0.083 1.002(0.878,1.143) 0.977 1.059(0.946,1.186) 0.316 1.008(0.877,1.159) 0.908
College graduate or above 0.906(0.765,1.073) 0.250 0.885(0.758,1.032) 0.119 1.013(0.896,1.145) 0.837 0.914(0.777,1.075) 0.276
Health insurance No 1 (reference) 1 (reference) 1 (reference) 1 (reference)
Yes 1.428(1.213,1.680) <0.0001 2.313(2.019,2.649) <0.0001 1.364(1.195,1.557) <0.0001 0.769(0.627,0.945) 0.013
PIR Low income 1 (reference) 1 (reference) 1 (reference) 1 (reference)
Middle income 0.914(0.781,1.070) 0.261 1.030(0.900,1.178) 0.669 0.895(0.799,1.002) 0.054 0.981(0.829,1.161) 0.823
High income 0.788(0.674,0.921) 0.003 0.946(0.830,1.077) 0.397 0.891(0.787,1.008) 0.067 0.921(0.782,1.084) 0.318
Life’s simple 7 Inadequate health 1 (reference) 1 (reference) 1 (reference) 1 (reference)
Average health 1.111(0.981,1.258) 0.096 0.943(0.842,1.055) 0.303 2.035(1.834,2.258) <0.0001 0.479(0.423,0.542) <0.0001
Optimal health 2.100(1.623,2.717) <0.0001 0.834(0.666,1.044) 0.112 6.669(5.522,8.055) <0.0001 0.124(0.091,0.169) <0.0001
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PIR: income-to-poverty ratio

Discussion

In this study, we analyzed NHANES and found that the rate of newly diagnosed hypertension in the US has slightly declined since 2010, while the prevalence of hypertension is on the rise. Although antihypertension strategy was becoming more standardized with an uptrend in the use of ACEI and ARB, and downtrend in β-blocker, the control and treatment of hypertension are still inadequate. The trends and influences in prevalence, awareness, treatment, and control of hypertension varied with age, gender, race, education, income, and LS7. Therefore, in the management of hypertension, the focus population should be screened out and stratified by age, sex and race for precise prevention and control. Meanwhile, optimal health should be advocated to improve the burden of hypertension.

The estimated prevalence of newly diagnosed hypertension decreased from 8.62% to 7.51% during 1999–2018, while the whole prevalence of hypertension increased significantly from 33.53% to 40.58%, and the treatment and control in hypertension remained at 59.52% and 51.71% in 2018, respectively. It shows that although the hypertension prevention and control measures taken in the past have achieved a certain effect, the burden of hypertension is still relatively heavy. In terms of medication for hypertension, there was an uptrend in the use of ACEI (from 24.02% to 45.71%) and ARB (from 20.22% to 38.38%), and downtrend in the use of β-blocker (from 12.71% to 4.21%), which is consistent with recommendations in the guidelines for the treatment of adult hypertension drugs [22]. While, we also found that the trend in the prevalence of CCB and diuretic remained stable. In fact, a growing body of clinical evidence suggests that diuretics and CCB are essential for effective blood pressure control in older adults [23, 24]. With the increasing degree of population aging, the clinical use of diuretics and CCB needs more attention.

Our results showed that from the age distribution, the prevalence of hypertension in the group of ≥40 years old presented an increasing trend from 1999 to 2018, and the prevalence of hypertension in adults in each survey year increased with the increase of age. Many studies have found that aging is a risk factor for hypertension, indicating that the elderly is still the key monitoring group for hypertension [25]. From the gender distribution, the crude prevalence of hypertension in male adults showed an increasing trend from 1999 to 2018. While, there was no statistical significance in the variation trend of female. In addition, the gender of male has been confirmed as an influencing factor of hypertension among US adults in this study. This may be related to unhealthy eating habits, high mental pressure and reduced physical labor of men [26]. However, women are more likely to accept the concept of healthy life and perform better than men in hypertension prevention behaviors (such as blood pressure monitoring and weight control, etc.), resulting in a higher prevalence of hypertension in men [27]. Therefore, health education related to hypertension should be strengthened among men. In addition, non-Hispanic black was the shared factors that increased the rate of incidence, awareness, treatment, and un-control for hypertension. The relationship between race and hypertension has received increasing attention [28]. There have been many reports on the relationship between race and hypertension, but the relationship between race and hypertension has not been fully clarified. Genetics and lifestyle differences are probably the most important factors [29].

In our study, we also found that lower income and education were positively associated with the occurrence of hypertension. In general, low-income hypertensive patients have relatively low purchasing power for fruits and vegetables and other food, unreasonable diet structure, and relatively little time and facilities for physical exercise, so they have poor ability to control blood pressure [30, 31]. Secondly, low-income patients are generally not well educated, often lack knowledge of health care and hypertension-related diseases, and lack of attention to their own health, unable to do scientific and regular exercise and diet, and cannot detect disease risk factors, so hypertension progresses quickly and the condition is serious [32]. Interestingly, we found that health insurance was an influencing factor of awareness, treatment, and control among US hypertension adults. This may be owing to people with insurance tend to have higher incomes and greater financial ability to value physical health [33]. A healthy lifestyle is also essential for blood pressure control. Generally, a healthy lifestyle includes eating right, exercising moderately, quitting smoking, abstaining from alcohol, and maintaining mental balance [3]. In this study, optimal health has been confirmed to be an advocated approach to improve the burden of hypertension.

Our study had several strengths. First, the complex sampling design of NHANES and survey weighted analysis of our study permitted the accurately calculation of prevalence estimates for the US population. The large sample size of NHANES facilitated subgroup analyses for the burden of hypertension. Second, we updated the tendency in the prevalence, awareness, treatment, and control of hypertension nationally represented US adults from 1999 to 2018, as well as in the subgroup of social demography and LS7. Third, based on the epidemiological characteristics of hypertension, we explored the influencing factors of its prevalence, awareness, treatment, and control to provide theoretical basis for the health policy.

This study has several limitations. Firstly, there are non-response bias and recall bias during the whole survey period in NHANES. For non-responders, we don’t know the prevalence and management of hypertension. Meanwhile, the inaccurately reporting that they did not remember whether their doctor had told them they had hypertension and misreported the status of anti-hypertensive medication, may lead biased estimation. Secondly, for the analysis of influencing factors, residual confounding and reverse causation may existed since this is a cross-sectional study. Thirdly, due to a lower number of participants who reported or showed the specific hypertension drugs, the research about the prevalence and influence of antihypertensive strategy was insufficient.

Conclusion

The rate of newly diagnosed hypertension in US has slightly declined since 2010, but the prevalence of hypertension is on the rise, and the control and treatment of hypertension are still inadequate. To manage hypertension effectively, we need to focus on screening and prevention for high-risk populations, while advocating for optimal health to improve the burden of hypertension.

Supporting information

S1 File. Contents of supplement.

(DOCX)

Click here for additional data file. (411.4KB, docx)

Acknowledgments

The authors expressed gratitude to NHANES for data collection and quality control.

Abbreviations

CVD

cardiovascular diseases

NHANES

National Health and Nutrition Examination Survey

US

United States

LS7

Life’s Simple 7

MEC

mobile examination center

ACEI

angiotensin-converting enzyme inhibitors

ARB

angiotensin receptor blockers

CCB

calcium channel blocker

PIR

income-to-poverty ratio

BMI

body mass index

HEI

healthy eating index

CI

confidence interval

AAPC

average annual percent change

Data Availability

All data are available from NHANES (https://www.cdc.gov/nchs/nhanes/index.htm)

Funding Statement

This research was supported by the National Natural Science Foundation of China (No. 82371597, 81800258, 82271618), supported by the Natural Science Foundation of Hubei Province (2023AFB609) and supported by Health Commission of Hubei Province (WJ2023M150).

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Decision Letter 0

Hean Teik Ong

24 Aug 2023

PONE-D-23-23791Trends and Influence Factors in the Prevalence, Awareness, Treatment, and Control of Hypertension among US Adults from 1999 to 2018PLOS ONE

Dear Dr. Yang,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please address comments and revisions requested by reviewers. Please submit your revised manuscript by Oct 08 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 

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Academic Editor

PLOS ONE

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Additional Editor Comments:

Please address comments and revisions requested by reviewers.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Regarding this statement in page 4

However, there is no estimation of the trends in the prevalence, awareness, treatment, and control of hypertension over a 20-years period in the US, and few studies have explored the factors influencing hypertension incidence, awareness, treatment, and control simultaneously.

There are 2 other articles that cover the same population over an almost similar period of time

1) Trends in the Prevalence, Awareness, Treatment, and Control of Hypertension among Young Adults in the United States, 1999–2014

Yiyi Zhang, and Andrew E Moran, MD. Hypertension. 2017 Oct; 70(4): 736–742.

2)Trends in Blood Pressure Control Among US Adults With Hypertension, 1999-2000 to 2017-2018

Paul Muntner, Shakia T Hardy, Lawrence J Fine , Byron C Jaeger, Gregory Wozniak, Emily B Levitan , Lisandro D Colantonio. JAMA 2020 Sep 22;324(12)

Suggest to review that statement.

Reviewer #2: This is a well researched article that needs minor revision to make it more useful and easier reading for readers.

1. All abbreviations in the Abstract, Text and Legends should be preceded by full spelling. To make it easier for readers, a list of abbreviations should be added before the Introduction of the main text.

2. In calculating the average annual percent change (AAPC), the author assumes that the trend is consistent over the period studied, with a statistical calculation used to give the average rate. However as can be seen from Figure 1, there is no consistent trend over the period studied. For example, for newly diagnosed hypertension, the incidence dropped from 1999-2014, and then rose from 2014-2018. Authors therefore need to rewrite the section on "Trends in the prevalence of awareness, treatment, and control among hypertension", to apply AAPC selectively over specific periods or not to use it for certain parameters. It is very important not to over, under or incorrectly estimate consistencies in the trend.

3. Figure 1 is most important, and graphically represents what the whole article is about. It should be presented as 3 separate Figures.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Hean Teik Ong

**********

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PLoS One. 2023 Sep 28;18(9):e0292159. doi: 10.1371/journal.pone.0292159.r002

Author response to Decision Letter 0

30 Aug 2023

Reviewer #1:

Regarding this statement in page 4

However, there is no estimation of the trends in the prevalence, awareness, treatment, and control of hypertension over a 20-years period in the US, and few studies have explored the factors influencing hypertension incidence, awareness, treatment, and control simultaneously.

There are 2 other articles that cover the same population over an almost similar period of time

1) Trends in the Prevalence, Awareness, Treatment, and Control of Hypertension among Young Adults in the United States, 1999–2014

Yiyi Zhang, and Andrew E Moran, MD. Hypertension. 2017 Oct; 70(4): 736–742.

2)Trends in Blood Pressure Control Among US Adults With Hypertension, 1999-2000 to 2017-2018

Paul Muntner, Shakia T Hardy, Lawrence J Fine , Byron C Jaeger, Gregory Wozniak, Emily B Levitan , Lisandro D Colantonio. JAMA 2020 Sep 22;324(12)

Suggest to review that statement.

Response : We have revised this statement and cited the two reference in the introduction section.

Reviewer #2:

This is a well researched article that needs minor revision to make it more useful and easier reading for readers.

1. All abbreviations in the Abstract, Text and Legends should be preceded by full spelling. To make it easier for readers, a list of abbreviations should be added before the Introduction of the main text.

Response 1: We have added full spelling about the abbreviations in the Abstract, Text and Legends. A list of abbreviations was added before the Introduction of the main text.

2. In calculating the average annual percent change (AAPC), the author assumes that the trend is consistent over the period studied, with a statistical calculation used to give the average rate. However as can be seen from Figure 1, there is no consistent trend over the period studied. For example, for newly diagnosed hypertension, the incidence dropped from 1999-2014, and then rose from 2014-2018. Authors therefore need to rewrite the section on "Trends in the prevalence of awareness, treatment, and control among hypertension", to apply AAPC selectively over specific periods or not to use it for certain parameters. It is very important not to over, under or incorrectly estimate consistencies in the trend.

Response 2: We used annual percent change (APC) to evaluate the internal trend of each independent interval before and after inflection (Line 166-178), and rewrite the section on "Trends in the prevalence of awareness, treatment, and control among hypertension"(Line 208-211, 233-239, 252-259).

3. Figure 1 is most important, and graphically represents what the whole article is about. It should be presented as 3 separate Figures.

Response 3: We have separated into 3 Figures.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (17.8KB, docx)

Decision Letter 1

Hean Teik Ong

14 Sep 2023

Trends and Influence Factors in the Prevalence, Awareness, Treatment, and Control of Hypertension among US Adults from 1999 to 2018

PONE-D-23-23791R1

Dear Dr. Chaojun Yang,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Hean Teik Ong

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a well written article. The trends and factors influencing prevalence, awareness, treatment

and control of hypertension were well analysed.

Reviewer #2: This is a revised manuscript, that is well written, with initial comments posing 2 questions asking for minor revisions. The reviewer comments have been adequately addressed and necessary revisions have been done. The article can be accepted.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Liew Yew Fong

Reviewer #2: Yes: Hean Teik Ong

**********

Acceptance letter

Hean Teik Ong

19 Sep 2023

PONE-D-23-23791R1

Trends and Influence Factors in the Prevalence, Awareness, Treatment, and Control of Hypertension among US Adults from 1999 to 2018

Dear Dr. Yang:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Hean Teik Ong

Academic Editor

PLOS ONE

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