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. 2024 Oct 26;14:25503. doi: 10.1038/s41598-024-76869-x

Trends in prevalence of hypertension and high-normal blood pressure among US adults, 1999–2018

Ting Wang 1, Huizhen Liu 1, Xiaoqin Zhou 1, Changxi Wang 2,3,✉
PMCID: PMC11513990  PMID: 39462089

Abstract

Hypertension and high-normal blood pressure (BP) increase the risk for cardiovascular diseases. Examining trends in hypertension and high-normal BP among US adults is crucial. Participants aged 20 years or older from the 1999–2018 National Health and Nutrition Examination Surveys, were included. Trend analyses were performed to assess temporal changes in prevalence of hypertension and high-normal BP among US adults. Among the 48,580 participants included in this analysis, the mean (SD) age was 47.2 years (18 years) and 50.9% were women. Age-adjusted prevalence of hypertension was stable from 1999 to 2000 (29.5% [95% CI 26.6–32.3%]) through 2017–2018 (31.9%, [95% CI 29.0–34.7%]) (P = 0.265 for linear trend). Age-adjusted prevalence of high-normal BP decreased from 10.9% (95% CI 9.4–12.5%) in 1999–2000 to 8.0% (95% CI 7.1–9.0%) in 2007–2008, then increased to 9.8% (95% CI 8.3–11.3%) in 2017–2018 (P = 0.002 for nonlinear trend). Compared with men, hypertension and high-normal BP was less likely among women (multivariable-adjusted prevalence ratio, 0.90 [95% CI 0.84–0.97]; 0.68 [95% CI 0.52–0.88], respectively). Compared with non-Hispanic Black, high-normal BP was less likely among Mexican American, non-Hispanic White, and other race (multivariable-adjusted prevalence ratio, 0.59 [95% CI 0.44–0.79]; 0.53 [95% CI 0.41–0.69]; 0.56 [95% CI 0.74 − 0.71], respectively). The same held for hypertension.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-024-76869-x.

Subject terms: Hypertension, Public health, Epidemiology

Introduction

Hypertension is the most prevalent cardiovascular disorder in the US and the world. According to the World Health Organization (WHO), approximately one in four adults have hypertension and by 2025, hypertension is projected to affect more than 1.5 billion people worldwide1. In the US, the overall age-adjusted prevalence of hypertension decreased from 47.0% in 1999–2000 to 41.7% in 2013–2014. However, it then increased to 45.4% in 2017–20182.

Hypertension is an important contributor to the global burden of disease. In 2019, the leading risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10.8 million deaths (19.2% of all deaths in 2019)3. In the US, hypertension accounted for more cardiovascular disease (CVD) deaths than any other modifiable cardiovascular risk factor and was second only to cigarette smoking as a preventable cause of death for any reason4.

More than that, people with high levels of blood pressure, although not meeting the diagnostic criteria of hypertension are as well under risk of cerebral, cardiovascular, and kidney events. A meta-analysis including more than 1 million individuals showed that death from both stroke and ischemic heart disease increased progressively and linearly from levels as low as 75 mmHg diastolic blood pressure (DBP) upward and 115 mmHg systolic blood pressure (SBP)5. For each 20 mmHg increase of office SBP or 10 mmHg increase of office DBP, the risk for fatal stroke or CVD doubled. Therefore, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) introduced a concept named “prehypertension”, to find those people who may benefit from early intervention6. The term “prehypertension” was subsequently called “elevated blood pressure” in the American College of Cardiology/American Heart Association (ACC/AHA) guideline and “high-normal blood pressure” in the 2020 International Society of Hypertension (ISH) guideline and the 2023 European Society of Hypertension (ESH) guideline7–9. The term “high-normal blood pressure (BP)” is used in this study.

High-normal BP is proven to be associated with adverse health outcomes. Evidence shows that participants with high-normal BP have a worse cardiovascular risk profile compared with subjects with a normal BP, with significantly higher serum lipid, glucose, and uric acid levels, as well as a higher prevalence of metabolic syndrome, type 2 diabetes mellitus and obesity10–12. High-normal BP, particularly high-range, is associated with increased risk of total CVD, coronary heart disease, myocardial infarction, and stroke13. Effective control of high-normal BP could prevent more than 10% of CVD cases.

Current literature on the temporal changes in the prevalence of hypertension in the US is vast2,14–16. However, there have been limited research on the trend in the prevalence of high-normal BP in the US.

In the current study, we aim to investigate trends in the prevalence of high-normal BP and hypertension among US adults aged 20 years or older, overall, and across age, sex, and race/ethnicity subgroups, from the 1999–2018 National Health and Nutrition Examination Survey (NHANES). Also, because there is an opportunity to prevent the transition to hypertension and reduce CVD morbidity and mortality through lifestyle intervention and antihypertensive drug use among adults with high-normal BP, temporal changes in risk factors for incident hypertension, CVD, and hypertension-mediated organ damage (HMOD) were studied among this population17.

Methods

Study participants

NHANES is a series of nationally representative, cross-sectional studies. It is designed to assess the health and nutritional status of the US population and is conducted by the National Center for Health Statistics within the US Centers for Disease Control and Prevention. Participants are selected from the U.S. noninstitutionalized, civilian population with the use of a stratified, multistage probability sampling method18. Since 1999–2000, the survey has been conducted in 2-year cycles. For the current analysis, 10 cycles conducted from 1999 to 2000 through 2017–2018 were used. Each cycle is independent with different participants recruited and with protocols approved by the institutional review board of the National Center for Health Statistics, Centers for Disease Control and Prevention. Written informed consent was obtained from each participant. The institutional review board of the University of Alabama at Birmingham considered the analysis of anonymous data to be exempt research. All methods were carried out in accordance with relevant guidelines and regulations.

Data collection

In each 2-year cycle, participants completed in-home interviews and visited a mobile examination center, where they responded to additional questionnaires and underwent a physical examination and blood sample collection. Among participants selected for NHANES from 1999 to 2018, the unweighted response rate ranged from 52 to 84% for the household interview and 49–80% for the medical examination (Table S1)19. A standardized questionnaire was used to collect information on sociodemographics, dietary data, health-related behaviors, medical condition, and use of antihypertensive medication.

NHANES also collected biological specimens for laboratory analysis in the mobile examination center. A subset of participants was randomly selected to attend the morning session after an overnight fast. Laboratory samples undergo quality control measures to identify trends, shifts, and uncertainties in the collected data18.

Sociodemographic variables

Participants reported age, sex, race and ethnicity, education, household income, health insurance status, and access to health care. Age was categorized as 20–39, 40–59, or ≥ 60 years. Sex was categorized as male or female. Self-reported race data includes 6 groups (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Mexican American, other Hispanic, and other race). Race and ethnicity was not consistently reported in the NHANES (e.g., Hispanic participants were oversampled after 2007 and non-Hispanic Asian participants were not classified until 2011). For consistency over time, we categorized participants as self-reported Mexican American, non-Hispanic Black, non-Hispanic White, or other race and ethnicity (e.g., non-Hispanic Asian, other Hispanic, and other race). Education was categorized as high school or less, some college, or college graduate. Household income was measured by the income-to-poverty ratio (annual family income divided by the poverty threshold adjusted for family size and inflation), and classified as < 130%, 130–349%, or 350% and over20.

Blood pressure

An identical protocol was used to measure blood pressure levels between 1999 and 2018. Blood pressures were measured by trained physician examiners using a mercury sphygmomanometer. After resting quietly in a seated position for 5 min, three consecutive blood pressure measurements were obtained at 30-second intervals. Quality control included quarterly recertification of physicians with retraining as needed, annually retraining of all physicians and monitoring/repairing equipment. Certification required video test recognition of Korotkoff sounds and performing measurements on volunteers. The mean of all available measurements was used to calculate SBP and DBP. According to the 2020 ISH Global Hypertension Practice Guidelines8, hypertension was defined as SBP level of 140 mmHg or higher, DBP level of 90 mmHg or higher, or self-reported use of antihypertensive medication. High-normal BP was defined as SBP level of 130 to 139 mmHg, and/or DBP level of 85 to 89 mmHg.

Lifestyle risk factors

Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared. Body weight and height were measured using a digital weight scale and a fixed stadiometer respectively and following standard procedures. BMI was categorized into 4 levels: <18.5, 18.5 to < 25.0, 25.0 to < 30.0, and 30.0 or higher21. Current cigarette smoking was defined by self-reporting smoking at least 100 cigarettes in lifetime and currently smoking or having quit less than 1 year ago22. Information about alcohol consumption was obtained from questions on drinking frequency (days per week, month, or year) and drinking quantity (drinks per day) in the past year. Weekly alcohol consumption was defined as none, moderate (men: 1–14 drinks; women: 1–7 drinks), or heavy (men: >14 drinks; women: >7 drinks)22–24. For physical activity, the questionnaire changed from a specific Physical Activity and Physical Fitness Questionnaire (1999–2000 to 2005–2006 cycle) to the Global Physical Activity Questionnaire (2007–2008 cycle and thereafter). Both questionnaires included questions related to daily activities, leisure time activities, and sedentary activities. They assessed the duration of the physical activities in 3 domains: household/work-related physical activities, transportation-related physical activities, and leisure time physical activities. In brief, the former assessed minutes of physical activities during the past 30 days; the latter assessed minutes of physical activities in a typical week. Physical activities were measured by calculating minutes per week. We followed the similar methods described by Zhao et al.25 to calculate minutes of physical activities per week for 2005–2006 cycle and before, and Du et al.26 and the WHO analysis guide27 for 2007–2008 cycle and after. Briefly, the total minutes of physical activities per week were calculated based on participants’ self-reported information on the duration, frequency, and level of exertion. Household-, work- and transportation related physical activities were defined as moderate activity according to the NHANES guidelines26. The minutes of vigorous activity was twice the minutes of moderate activity24,25. Total amount of physical activity was calculated as the minutes of equivalent moderate physical activity per week of all domains. According to the 2018 Physical Activity Guidelines for Americans28, three levels of physical activities were created: (1) physically active if participants reported at least 150 min of moderate physical activities per week; (2) insufficiently active if they reported 0 to < 150 min of moderate physical activities per week; (3) inactive if they reported no moderate physical activity. Details of the measurements of the above lifestyle factors can be found elsewhere29.

Metabolic risk factors

Estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI (chronic kidney disease epidemiology collaboration) equation with calibrated serum creatinine30,31. Chronic kidney disease (CKD) was defined by eGFR < 60 mL/min/1.73m2 or urinary albumin to creatinine ratio (UACR) ≥ 30 mg/g32. Diagnosed diabetes was defined as self-report of diabetes diagnosis by a physician or other health professional, or taking hypoglycemic medication. Undiagnosed diabetes was defined as having a fasting plasma glucose level of 126 mg/dL or more or glycated hemoglobin levels (HbA1c) level of 6.5% or more among individuals without diagnosed diabetes. Diabetes included both diagnosed and undiagnosed diabetes33. Hyperuricemia was defined as a serum urate level > 7.0 mg/dL among men and a serum urate level > 6.0 mg/dL among women34. Total cholesterol was categorized as normal (< 200 mg/dL), or elevated (≥ 200 mg/dL).35 Low levels of high-density lipoprotein cholesterol were defined as < 40 mg/dL36. We calculated non–high-density lipoprotein (non-HDL) cholesterol as total measured cholesterol minus HDL cholesterol. We defined lipid control as a non-HDL cholesterol level of less than 130 mg/dL37.

Statistical analysis

The age-adjusted prevalence of high-normal BP and hypertension were calculated for all US adults, by age group, sex, and across racial and ethnicity subgroups, for each 2-year NHANES survey cycle from 1999 to 2000 to 2017–2018. Age adjustment was performed with direct standardization using the 2000 US census population as a reference, with ages 20 through 39 years, 40 through 59 years, 60 years and over as the reference population38.

Survey-weighted logistic regression was used for age-adjusted prevalence of high-normal BP, and hypertension to test the significance of linear or nonlinear trends. A quadratic term for year was added to assess the linearity of secular trend. If the age-adjusted prevalence had no statistically significant association with the quadratic term, linear models were used. If the age-adjusted prevalence had statistically significant association with the quadratic term, the final trend model was a regression model with both a linear time term and a quadratic term. In addition, Jointpoint trend analysis was applied to assess the statistical significance of changes in regression slopes between 2 or more time periods. Jointpoint statistical software was used to estimate the number and location of jointpoints for the nonlinear trend. The homogeneity of secular trends among age, sex and race/ethnicity subgroups was tested using an interaction term of time by subgroup in the regression models, and the statistical significance was assessed using the likelihood ratio test.

Multivariable adjusted prevalence ratios for high-normal BP and hypertension associated with NHANES cycles were calculated as well, using Poisson regression with robust variance estimates. The initial model was adjusted for age, race/ethnicity, and sex, and then further adjusted for sociodemographic variables, and then all the risk factors in 2 subsequent regression models.

To examine how sociodemographic variables and risk factors moderated adjusted prevalence of hypertension, we fit a survey-weighted Poisson regression with robust variance estimates to estimate the prevalence ratio by examining 6-year survey periods (2007–2012, and 2013–2018). Survey cycles were polled to provide more stable estimated. Cycles 2005–2006 and before were excluded due to the change in the physical activity questionnaire since the 2007–2008 cycle. The model was first adjusted for age, sex, and race/ethnicity, then further adjusted for all sociodemographic variables, and finally all the metabolic risk factors and modifiable lifestyle risk factors. Analyses were repeated to calculate the age-adjusted prevalence of high-normal BP among adults without hypertension (i.e., among adults with normal BP and high-normal BP). Participants with missing data were imputed using multiple imputation in multivariate analysis. A complete case analysis was as well performed for sensitivity analysis.

The age-adjusted proportion/mean of the metabolic and modifiable lifestyle risk factors were calculated as well. The statistical significance of trends in the change in risk factors over NHANES cycles was calculated using linear regression or logistic regression, as appropriate.

In the sensitivity analysis, the age-adjusted proportion of adults with hypertension and high-normal BP was calculated using thresholds in the 2017 ACC/AHA BP guideline39. Hypertension was defined as SBP level of 130 mmHg or higher, DBP level of 80 mmHg or higher, or antihypertensive medication use. High-normal BP, named as elevated BP in the 2017 ACC/AHA guideline, was defined as SBP of 120 to 129 mmHg, and DBP of < 80 mmHg.

For all analyses, confidence intervals were calculated using Taylor series linearization. NHANES survey weights, which account for the complex, cluster-stratified design of NHANES, were used to calculate nationally representative estimates.

All analyses were performed with R version 4.3.2 (The R Foundation for Statistical Computing, Vienna, Austria), and Jointpoint Regression Program, Version 5.0.2 (Statistical Research and Applications Branch, Surveillance Research Program, National Cancer Institute). Two-sided P < 0.05 was considered statistically significant. Adjustment for multiple comparisons was not performed, and the results should be interpreted as exploratory due to the potential for type I error. Statistical analyses were conducted from November 2023 to May 2024.

Results

We included participants in NHANES from 1999 to 2018 who aged 20 years or older and completed a study interview and examination (n = 52398). Participants who were pregnant (n = 1469) and those who did not have at least 1 SBP and DBP measurement (n = 2349) were excluded. The final study included 48,580 participants, of which 52.3% were with normal BP, 9.8% with high-normal BP, and 37.9% with hypertension (Fig. S1). Of the final analysis sample, the mean (SD) age was 47.2 years (18 years) and 50.9% were women; 68.6% were non-Hispanic White adults; 11.0%, non-Hispanic Black adults; 8.0%, Mexican American adults; and 12.4%, other race.

The weighted proportion of participants aged 20 to 39 years ranged from 35.0 to 42.8%, and the weighted proportion of women from 50.5 to 51.5% in the surveys (Table 1). The weighted proportion of non-Hispanic White decreased from 71.0% in 1999–2000 to 62.8% in 2017–2018, while the proportions of other three categories all increased. The weighted proportions of persons with < = high school education decreased from 50.2% in 1999–2000 to 38.2% in 2017–2018, while those who were college graduates or higher increased from 22.2 to 31.0% during the same period. The weighted proportions of persons with family income-to-poverty ratio ≤ 130% varied from 23.3 to 19.8%, those who did not have health insurance from 18.8 to 13.6%, and those who did not have regular health care access from 17.1 to 18.1%.

Table 1.

Characteristics of study participants in the National Health and Nutrition Examination Surveys (NHANES), 1999–2018.

Characteristics 1999–2000 2001–2002 2003–2004 2005–2006 2007–2008 2009–2010 2011–2012 2013–2014 2015–2016 2017–2018
Total No. of participantsa 4041 4486 4198 4210 5377 5718 5021 5333 5248 4948
Age group, No. (%) b
20–39 1266 (42.8) 1450 (39.3) 1351 (38.1) 1427 (36.6) 1684 (36.6) 1849 (35.8) 1734 (35.2) 1768 (35.7) 1727 (35.0) 1449 (35.3)
40–59 1219 (34.8) 1485 (39.8) 1244 (39.1) 1374 (40.1) 1735 (39.2) 1940 (39.0) 1662 (38.4) 1852 (37.3) 1747 (36.4) 1576 (35.1)
60 and over 1556 (22.3) 1551 (20.9) 1603 (22.8) 1409 (23.4) 1958 (24.2) 1929 (25.2) 1625 (26.4) 1713 (27.0) 1774 (28.6) 1923 (29.7)
Sex, No. (%)
Men 2024 (49.5) 2277 (49.2) 2141 (49.5) 2170 (49.3) 2667 (48.5) 2817 (49.1) 2530 (49.0) 2590 (48.8) 2561 (48.8) 2428 (49.0)
Women 2017 (50.5) 2209 (50.8) 2057 (50.5) 2040 (50.7) 2710 (51.5) 2901 (50.9) 2491 (51.0) 2743 (51.2) 2687 (51.2) 2520 (51.0)
Race and ethnicity, No. (%)
Non-Hispanic Black 770 (10.4) 852 (10.4) 829 (10.9) 958 (10.9) 1109 (11.2) 1012 (11.1) 1329 (11.4) 1090 (11.3) 1107 (11.2) 1165 (11.3)
Mexican American 1093 (6.3) 920 (6.8) 830 (7.5) 819 (7.7) 916 (8.3) 1048 (8.6) 489 (7.6) 713 (9.1) 914 (8.8) 651 (8.7)
Non-Hispanic White 1803 (71.0) 2393 (72.9) 2239 (72.9) 2143 (72.7) 2548 (69.9) 2778 (68.7) 1854 (66.8) 2297 (66.0) 1743 (64.5) 1720 (62.8)
Other race 375 (12.3) 321 (9.9) 300 (8.7) 290 (8.6) 804 (10.6) 880 (11.6) 1349 (14.1) 1233 (13.6) 1484 (15.5) 1412 (17.2)
Education, No. (%) n = 4027 n = 4480 n = 4191 n = 4206 n = 5373 n = 5704 n = 5019 n = 5328 n = 5246 n = 4940
≤ High school 2501 (50.2) 2412 (44.5) 2303 (45.5) 2170 (42.6) 2990 (45.6) 2940 (41.8) 2237 (36.8) 2334 (36.7) 2388 (35.3) 2145 (38.2)
Some college 900 (27.6) 1169 (29.6) 1149 (31.5) 1199 (31.3) 1383 (29.1) 1598 (30.5) 1512 (32.1) 1640 (32.7) 1558 (32.6) 1602 (30.8)
College graduate 626 (22.2) 899 (25.9) 739 (23.0) 837 (26.1) 1000 (25.3) 1166 (27.7) 1270 (31.1) 1354 (30.6) 1300 (32.2) 1193 (31.0)
Family income-to-poverty ratio, No. (%) n = 3468 n = 4171 n = 3954 n = 4014 n = 4898 n = 5180 n = 4618 n = 4926 n = 4715 n = 4322
≤130% 1061 (23.3) 1094 (20.7) 1140 (20.3) 1025 (16.9) 1489 (20.4) 1712 (21.3) 1643 (24.4) 1675 (24.2) 1519 (20.9) 1212 (19.8)
130-349% 1331 (35.8) 1626 (35.3) 1588 (38.3) 1581 (37.5) 1914 (35.0) 1964 (36.7) 1579 (34.6) 1703 (34.6) 1875 (36.7) 1793 (36.3)
≥ 350% 1076 (40.9) 1451 (44.0) 1226 (41.4) 1408 (45.7) 1495 (44.5) 1504 (41.9) 1396 (41.0) 1548 (41.2) 1321 (42.4) 1317 (44.0)
Covered by health insurance, No. (%) n = 3984 n = 4418 n = 4158 n = 4207 n = 5372 n = 5715 n = 5016 n = 5327 n = 5238 n = 4934
Yes 3145 (81.2) 3594 (83.1) 3340 (82.1) 3268 (81.1) 4100 (80.8) 4263 (79.4) 3820 (80.0) 4202 (82.0) 4332 (86.7) 4204 (86.4)
No 839 (18.8) 824 (16.9) 818 (17.9) 939 (18.9) 1272 (19.2) 1452 (20.6) 1196 (20.0) 1125 (18.0) 906 (13.3) 730 (13.6)
Access to health care, No. (%) n = 4038 n = 4486 n = 4198 n = 4210 n = 5377 n = 5718 n = 5021 n = 5333 n = 5248 n = 4947
≥ 1 Health care facility 3357 (82.9) 3803 (85.5) 3619 (85.6) 3553 (85.0) 4582 (86.0) 4818 (86.2) 4243 (85.3) 4478 (84.1) 4330 (83.3) 4047 (81.9)
None 681 (17.1) 683 (14.5) 579 (14.4) 657 (15.0) 795 (14.0) 900 (13.8) 778 (14.7) 855 (15.9) 918 (16.7) 900 (18.1)
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aNumbers were unadjusted for survey weights

bEstimated proportion was adjusted for survey weights.

Trends in normal blood pressure, high-normal blood pressure, and hypertension

Age-adjusted prevalence of hypertension increased slightly from 29.5% (95% CI 26.6–32.3%) in 1999–2000 to 31.9% (95% CI 29.0–34.7%) in 2017–2018 in the study population (Fig. 1A; Table S2). However, the change had no statistical significance (P = 0.265 for linear trend). Age-adjusted prevalence of high-normal blood pressure decreased from 10.9% (95% CI 9.4–12.5%) in 1999–2000 to 8.0% (95% CI 7.1–9.0%) in 2007–2008, then increased to 9.8% (95% CI 8.3–11.3%) in 2017–2018 (P = 0.002 for nonlinear trend) (Fig. 1A; Table S3). The joint trend was significant (P < 0.001) for changes in slopes between the 2 time periods (Table S6). Age-adjusted prevalence of normal blood pressure was stable from 1999 to 2000 (59.6% [95% CI 56.6-62.6%]) to 2017–2018 (58.3% [95% CI 55.6–61.1%]) (P = 0.062 for linear trend) (Fig. 1A; Table S4). The number of US adults with normal BP and hypertension increased from 1999 to 2000 to 2017–2018, whereas the number of US adults with high-normal BP remained stable (Fig. 1B; Table S2).

Fig. 1.

Fig. 1

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Trends in estimated prevalence and weighted number of hypertension, high-normal BP, normal BP in US adults, 1999–2018. a P  = 0.265 for linear trend in hypertension. b P  = 0.002 for nonlinear trend in high-normal BP. c P  = 0.856 for linear trend in normal BP. d Error bars indicate 95% CIs.

Secular trends by age group

The prevalence of hypertension was stable in age groups of 20–39 (P = 0.448 for linear trend) and 60 and over (P = 0.129 for linear trend) (Fig. 2; Table S2). In age group of 40–59, the prevalence of hypertension increased from 30.1% (95% CI 26.1–34.0%) in 1999–2000 to 36.3% (95% CI 30.2–42.3%) in 2017–2018 (P = 0.044 for linear trend). The results showed that the risk of hypertension increased with age.

Fig. 2.

Fig. 2

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Trends in Hypertension and High-normal Blood Pressure, by Age, Sex, and Race/Ethnicity in US adults, 1999–2018. A P = 0.044 for linear trend in hypertension among adults aged 40–59. B P = 0.015 for linear trend in hypertension in men. C P = 0.001 for nonlinear trend in hypertension in other race. D P = 0.007 for nonlinear trend in high-normal BP among adults aged 40–59, and p = 0.009 for linear trend in high-normal BP among adults aged 60 and over. E P = 0.003 for nonlinear trend in high-normal BP in men. F P = 0.013 for nonlinear trend in high-normal BP in non-Hispanic Black, p = 0.005 for non-linear trend in Mexican American, and p = 0.03 for non-linear trend in other race. G Error bars indicate 95% CIs. Only p-values < 0.05 are described in notes.

The prevalence of high-normal BP was stable in age group of 20–39 (P = 0.765 for linear trend) (Fig. 2; Table S3). In age group of 40–59, the prevalence of high-normal BP decreased from 13.3% (95% CI 10.9–15.7%) to 9.2% (95% CI 7.6–10.8%) in 2009–2010, and then increased to 11.9% (95% CI 9.2–14.5%) in 2017–2018 (P = 0.007 for nonlinear trend). The prevalence of high-normal BP decreased from 12.3% (95% CI 10.4–14.2%) in 1999–2000 to 8.7% (95% CI 6.7–10.7%) in age group of 60 and over (P = 0.009 for linear trend). The prevalence of high-normal BP was highest in age group of 40–59.

Secular trends by sex

Age-adjusted prevalence of hypertension was stable in men (P = 0.015 for linear trend) and women (P = 0.291 for linear trend) participants, although men had an upward trend (Fig. 2; Table S2).

Age-adjusted prevalence of high-normal BP in men followed the same pattern as the whole population. It decreased from 14.2% (95% CI 11.7–16.6%) to 9.9% (95% CI 8.5–11.2%) in 2007–2008, and then increased to 12.7% (95% CI 10.2–15.3%) in 2017–2018 (P = 0.003 for nonlinear trend) (Fig. 2; Table S3). Age-adjusted prevalence of high-normal BP was stable in women (P = 0.938 for linear trend).

Secular trends by race and ethnicity

Age-adjusted prevalence of hypertension was stable in non-Hispanic Black (P = 0.090 for linear trend), Mexican American (P = 0.052 for linear trend) and non-Hispanic White (P = 0.249 for linear trend) participants (Fig. 2; Table S2). Age-adjusted prevalence of hypertension in other race decreased from 27.5% (95% CI 20.3–34.8%) in 1999–2000 to 22.0% (95% CI 19.3–24.8%) in 2013–2014, and then increased to 29.6% (95% CI 25.9–33.2%) in 2017–2018 (P = 0.001 for nonlinear trend). Figure 2 revealed that age-adjusted prevalence of hypertension was higher in Non-Hispanic Black compared with other racial and ethnic groups.

Age-adjusted prevalence of high-normal BP in non-Hispanic Black, Mexican American, and other race followed the same pattern as the whole population, where the prevalence first decreased and then increased (Non-Hispanic Black: P = 0.013 for nonlinear trend; Mexican American: P = 0.005 for nonlinear trend; Other race: P = 0.030 for nonlinear trend) (Fig. 2; Table S3). Age-adjusted prevalence of high-normal BP was stable in non-Hispanic White (P = 0.070 for linear trend).

Secular trends in lifestyle and metabolic risk factors

Age-adjusted prevalence of participants with BMI < 18.5 decreased from 2.1% (95% CI 1.6–2.7%) in 1999–2000 to 1.6% (95% CI 1.1–2.1%) in 2017–2018 (P = 0.032 for linear trend) (Fig. S2; Table S7). The same pattern was observed in participants with BMI of 18.5–<25.0 (P < 0.001 for linear trend), and with BMI of 25.0–<30.0 (P = 0.001 for linear trend). Age-adjusted prevalence of participants with obesity (BMI ≥ 30.0) increased from 30.0% (95% CI 26.9–33.1%) in 1999–2000 to 42.6% (95% CI 38.8–46.4%) in 2017–2018 (P < 0.001 for linear trend). Age-adjusted prevalence of current smoking decreased from 26.5% (95% CI 23.6–29.4%) in 1999–2000 to 20.5% (95% CI 18.1–22.9%) (P < 0.001 for linear trend). Age-adjusted prevalence of moderate alcohol consumption increased from 70.7% (95% CI 68.3-73.0%) in 1999–2000 to 75.6% (95% CI 73.3-77.9%) in 2017–2018 (P < 0.001 for linear trend). Age-adjusted prevalence of heavy alcohol consumption was stable through 1999–2000 to 2017–2018 (P = 0.138 for linear trend). Age-adjusted prevalence of insufficiently active physical activity decreased from 24.1% (95% CI 21.9-26.2%) in 1999–2000 to 10.7% (95% CI 9.4-12.0%) in 2017–2018 (P < 0.001 for linear trend). Age-adjusted prevalence of active physical activity increased from 56.7% (95% CI 52.8–60.5%) in 1999–2000 to 69.2% (95% CI 67.4–-71.0%) in 2017–2018 (P < 0.001 for linear trend).

Age-adjusted prevalence of diabetes mellitus increased from 8.7% (95% CI 6.8-10.6%) in 1999–2000 to 15.2% (95% CI 13.3-17.0%) in 2017–2018 (P < 0.001 for linear trend). Age-adjusted prevalence of elevated total cholesterol decreased from 51.4% (95% CI 49.4-53.4%) in 1999–2000 to 36.6% (95% CI 33.1-40.1%) in 2017–2018 (P < 0.001 for linear trend). Age-adjusted prevalence of low high-density lipoprotein cholesterol decreased from 25.0% (95% CI 22.1-27.8%) in 1999–2000 to 16.4% (95% CI 14.0-18.8%) in 2017–2018 (P < 0.001 for linear trend). Age-adjusted prevalence of lipid control increased from 29.0% (95% CI 26.1-32.0%) in 1999–2000 to 47.7% (95% CI 44.2-51.3%) in 2017–2018 (P < 0.001) for linear trend). Age-adjusted prevalence of hyperuricemia and CKD was stable from 1999 to 2000 to 2017–2018 (hyperuricemia: P = 0.646 for linear trend; CKD: P = 0.902 for linear trend).

Multivariable adjusted prevalence ratio of hypertension and high-normal BP

After further adjusted for sociodemographic variables and risk factors, secular trend of adjusted prevalence ratio of hypertension was consistent of that of age-adjusted prevalence of hypertension, which remained stable (Table 2). The results held true for adjusted prevalence ratio of high-normal BP among the whole population. The adjusted prevalence ratio first decreased, then increased.

Table 2.

Multivariate adjusted prevalence ratio for hypertension and high-normal blood pressure in US adults, 1999–2018.

Modela 1999–2000 2001–2002 2003–2004 2005–2006 2007–2008 2009–2010 2011–2012 2013–2014 2015–2016 2017–2018 P for linear trend P for non-linear trend
Hypertension
Model 1b 1 [Reference] 1.05 (0.95,1.17) 1.05 (0.93,1.19) 0.99 (0.88,1.11) 1.03 (0.92,1.15) 1.00 (0.87,1.14) 1.07 (0.95,1.20) 1.08 (0.96,1.21) 1.01 (0.89,1.14) 1.09 (0.96,1.24) 0.326
Model 2c 1 [Reference] 1.06 (0.95,1.17) 1.06 (0.95,1.19) 1.00 (0.89,1.12) 1.04 (0.94,1.15) 1.02 (0.90,1.16) 1.10 (0.98,1.23) 1.12 (1.01,1.24) 1.05 (0.94,1.17) 1.13 (1.01,1.27) 0.037
Model 3d 1 [Reference] 1.04 (0.95,1.13) 1.05 (0.95,1.16) 0.95 (0.87,1.05) 0.98 (0.90,1.07) 0.95 (0.85,1.07) 1.03 (0.92,1.15) 1.04 (0.95,1.14) 0.96 (0.87,1.07) 1.04 (0.94,1.16) 0.883
High-normal blood pressure
Model 1b 1 [Reference] 1.18 (0.95,1.47) 0.92 (0.72,1.18) 0.96 (0.74,1.25) 0.62 (0.47,0.81) 0.71 (0.54,0.93) 0.81 (0.61,1.08) 0.74 (0.57,0.96) 0.91 (0.71,1.17) 0.86 (0.67,1.10) 0.001
Model 2c 1 [Reference] 1.19 (0.95,1.48) 0.92 (0.71,1.18) 0.96 (0.73,1.25) 0.62 (0.47,0.82) 0.72 (0.55,0.94) 0.82 (0.61,1.10) 0.76 (0.58,0.98) 0.92 (0.71,1.18) 0.86 (0.67,1.11) 0.002
Model 3d 1 [Reference] 1.20 (0.96,1.50) 0.93 (0.72,1.20) 0.97 (0.73,1.29) 0.64 (0.48,0.85) 0.73 (0.55,0.95) 0.83 (0.61,1.12) 0.78 (0.59,1.02) 0.94 (0.73,1.21) 0.88 (0.68,1.14) 0.003
Open in a new tab

aMultiple imputation was performed.

bIncludes adjustment for age groups, sex, and race/ethnicity.

cIncludes adjustment for age groups, sex, race/ethnicity, education, family income-to-poverty ratio, health insurance, and access to health care.

dIncludes simultaneous adjustment for all characteristics.

Comparison of hypertension and high-normal BP among adults without hypertension by age group, sex, race and ethnicity and other factors

In 2007–2012, compared with participants age 20–39 years, it was estimated that hypertension was more likely among participants aged 40–59 years (Model 3: prevalence ratio, 3.67 [95% CI 3.05–4.42]) and most likely among those aged 60 years and over (Model 3: prevalence ratio, 6.36 [95% CI 5.20–7.77]) (Table 3). Compared with male, it was estimated that hypertension was less likely among female (Model 3: prevalence ratio, 0.92 [95% CI 0.86–0.98]). Compared with non-Hispanic Black, it was estimated hypertension was less likely among Mexican American, non-Hispanic White and other race (Model 3: prevalence ratio, 0.60 [95% CI 0.51–0.70], 0.78 [95% CI 0.72–0.85], and 0.72 [95% CI 0.65–0.80], respectively). Similar patterns were noted in 2013–2018 (Table 3). Model 1 and 2 obtained consistent conclusions, although magnitudes were different for some categories.

Table 3.

Association of age, sex, race/ethnicity with hypertension and high-normal blood pressure among adults without hypertension in 2007–2012 and 2013–2018.

Characteristic Prevalence ratio (95% CI) (2007–2012)a Prevalence ratio (95% CI) (2013–2018)a
Model 1b Model 2c Model 3d Model 1b Model 2c Model 3d
Hypertension
Age group
20–39 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
40–59 4.24 (3.54,5.08) 4.11 (3.42,4.93) 3.67 (3.05,4.42) 4.23 (3.50,5.12) 3.96 (3.28,4.78) 3.59 (2.94,4.38)
60 and over 8.76 (7.31,10.51) 7.96 (6.57,9.65) 6.36 (5.20,7.77) 8.07 (6.74,9.67) 7.03 (5.78,8.54) 5.94 (4.86,7.25)
Sex
Male 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
Female 0.93 (0.87,0.99) 0.90 (0.85,0.96) 0.92 (0.86,0.98) 0.92 (0.86,1.00) 0.88 (0.82,0.95) 0.90 (0.84,0.97)
Race/ethnicity
Non-Hispanic Black 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
Mexican American 0.57 (0.48,0.68) 0.59 (0.49,0.71) 0.60 (0.51,0.70) 0.59 (0.50,0.70) 0.59 (0.50,0.71) 0.61 (0.51,0.72)
Other race 0.63 (0.55,0.70) 0.65 (0.58,0.74) 0.72 (0.65,0.80) 0.70 (0.62,0.78) 0.74 (0.66,0.83) 0.84 (0.74,0.94)
Non-Hispanic White 0.67 (0.60,0.74) 0.70 (0.64,0.77) 0.78 (0.72,0.85) 0.69 (0.62,0.76) 0.73 (0.66,0.80) 0.79 (0.71,0.88)
High-normal blood pressure among US adults without hypertension
Age group
20–39 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
40–59 2.02 (1.48,2.77) 2.08 (1.51,2.88) 1.94 (1.37,2.74) 2.21 (1.69,2.88) 2.27 (1.72,3.00) 2.04 (1.55,2.67)
60 and over 3.96 (3.00,5.22) 3.96 (2.94,5.34) 3.60 (2.60,5.00) 3.06 (2.32,4.02) 3.10 (2.30,4.18) 2.86 (2.12,3.88)
Sex
Male 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
Female 0.69 (0.56,0.84) 0.68 (0.56,0.83) 0.72 (0.58,0.89) 0.65 (0.51,0.83) 0.66 (0.52,0.85) 0.68 (0.52,0.88)
Race/ethnicity
Non-Hispanic Black 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
Mexican American 0.60 (0.46,0.78) 0.59 (0.45,0.78) 0.54 (0.41,0.72) 0.64 (0.49,0.82) 0.62 (0.48,0.81) 0.59 (0.44,0.79)
Other race 0.62 (0.46,0.84) 0.65 (0.47,0.89) 0.66 (0.48,0.91) 0.50 (0.39,0.64) 0.52 (0.41,0.65) 0.56 (0.44,0.71)
Non-Hispanic White 0.60 (0.46,0.77) 0.65 (0.50,0.83) 0.66 (0.52,0.85) 0.49 (0.39,0.62) 0.51 (0.41,0.64) 0.53 (0.41,0.69)
Open in a new tab

aMultiple imputation was performed.

bIncludes adjustment for age groups, sex, and race/ethnicity.

cIncludes adjustment for age groups, sex, race/ethnicity, education, family income-to-poverty ratio, health insurance, and access to health care. Full tables refer to Supplementary Tables S14 and S15.

dIncludes simultaneous adjustment for all characteristics. Full tables refer to Supplementary Tables S14 and S15.

Moreover, hypertension was more prevalent in participants with lower education, no access to health care, diabetes, hyperuricemia, and chronic kidney disease. The details appeared in Table S8.

In 2007–2012, compared with participants age 20–39 years, it was estimated that high-normal BP was more likely among participants aged 40–59 years, and 60 years and over (Model 3: prevalence ratio, 1.94 [95% CI 1.37–2.74], and 3.60 [95% CI 2.60-5.00], respectively) (Table 3). Compared with male, it was estimated that hypertension was less likely among female (Model 3: prevalence ratio, 0.72 [95% CI 0.58–0.89]). Compared with non-Hispanic Black, it was estimated hypertension was less likely among Mexican American, non-Hispanic White and other race (Model 3: prevalence ratio, 0.54 [95% CI 0.41–0.72], 0.66 [95% CI 0.52–0.85], and 0.66 [95% CI 0.48–0.91], respectively). Similar patterns were noted in 2013–2018. Model 1 and 2 obtained consistent conclusions, although magnitudes differed.

However, the other sociodemographic variables and risk factors did not have a significant effect on high-normal BP. The details appeared in Table S9.

The results were similar in the sensitivity analysis using a complete case approach (Table S15 and S16).

Sensitivity analysis

Using the 2017 ACC/AHA BP guideline definition, age-adjusted prevalence of hypertension decreased from 48.3% (95% CI 45.5-51.0%) in 1999–2000 to 43.1% (95% CI 41.5–44.8%) in 2013–2014, and then increased to 47.1% (95% CI 44.3–49.9%) in 2017–2018 (P = 0.003 for nonlinear trend) (Fig. S3, Table S10). Age-adjusted prevalence of high-normal BP was stable through 1999–2018 (P = 0.625 for linear trend) (Table S11). Age-adjusted prevalence of normal BP increased from 39.2% (95% CI 36.0–42.3%) in 1999–2000 to 45.3% (95% CI 43.5–47.0%) in 2013–2014, and then decreased to 40.6% (95% CI 37.9–43.2%) in 2017–2018 (P = 0.010 for nonlinear trend) (Fig. S2, Table S12).

Age-adjusted prevalence of hypertension was higher among participants who were older, men, and non-Hispanic Black (Fig. S4, Table S10). Although age-adjusted prevalence of high-normal BP was higher in men participants, it was lowest among participants aged 20–39 years and who were non-Hispanic Black (Table S11). Age-adjusted prevalence of normal BP was lower among participants who were older, men, and non-Hispanic Black (Table S12).

Multivariable adjusted prevalence ratio of hypertension and high-normal BP followed the same pattern (Table S14). Results showed that the secular trends of hypertension, high-normal BP, and normal BP changed when the definition changed.

Discussion

From the 1999–2000 to the 2017–2018 cycles, the age-adjusted prevalence of hypertension and normal BP remained stable. The age-adjusted prevalence of high-normal BP decreased from 1999 to 2000 through 2013–2014, and then increased from 2013 to 2014 through 2017–2018. Difference in prevalence of hypertension and high-normal BP persisted among age, sex, and race/ethnicity subgroups.

Temporal changes in prevalence of hypertension among US adults have been studied widely. Our result was consistent with previous trend analyses2,40. Studies on prevalence of high-normal BP among US adults are limited. Booth et al.22 investigated the prevalence of prehypertension from 1999 to 2012 and found that it had decreased. Our research built on and extended Booth et al.’s study by assessing trends in prevalence of hypertension and high-normal BP over a 20-year period (1999–2018). Although the prevalence of high-normal BP did decrease from 1999 to 2000 through 2013–2014, it subsequently increased from 2013 to 2014 through 2017–2018.

As described above, the prevalence of high-normal BP decreased significantly between 1999 and 2014 while the prevalence of hypertension was stable. Although effective management of high-normal BP could defer or prevent the transition to hypertension, trends in blood pressure control in adults with high-normal BP was not clear. It was possible that the proportion of adults with high-normal BP decreased, whereas the proportion of adults transited from high-normal BP to hypertension remained unchanged or increased. Therefore, the proportion of adults with hypertension was stable throughout the period. Further research was needed to explore the transition from normal BP to high-normal BP, and high-normal BP to hypertension. Another possible reason was that the number of US adults with high-normal BP remained stable, whereas the number with normal BP and hypertension increased during this time period because of population growth. Because of population growth and ageing, the number of adults with hypertension could be expected to increase. Moreover, as reported in the 2016 Lancet Commission, hypertension is a largely preventable condition caused by lifestyles increasingly characterized by reduced physical activity, unhealthy diet, overweight, and obesity1. Our results agreed with that and showed that ageing and BMI were more influential risk factors. US adults with obesity increased dramatically throughout the period, thus it was not surprising that the number of adults with hypertension increased.

Our results showed that the prevalence of hypertension increased with age. US adults aged 60 years and over were under the greatest risk of hypertension. It is well-documented that chronological age is a strong risk factor for hypertension41–43. As age increases, peripheral vascular resistance and large artery stiffness increase, which in turn leads to rise in SBP and DBP43. As for high-normal BP, participants aged 40–59 had the highest prevalence, and those aged 60 and over came next. The reason may be that prevalence of hypertension was greatest at age 60 and over. This is consistent with previous studies22,44. It implies that intervention of high-normal BP among adults aged 40–59 is of crucial need.

Temporal changes in prevalence of hypertension between men and women were different. Prevalence of hypertension in men increased all the time while that in women stayed stable. Prevalence in men surpassed women in 2013–2014. Recent studies as well showed gender difference in the prevalence of hypertension2,45. The prevalence of high-normal BP was higher in men than that in women from 1999 to 2000 through 2017–2018, which was in line with previous studies46,47. The cause of difference was not investigated in our study. However, the difference was associated with risk factors such as age, change of vascular structure, diabetes mellitus, vascular disease, BMI, and so on, as previous research showed45,46.

Racial and ethnic differences in the prevalence of hypertension have been well documented before2,16,22,48. Age-adjusted prevalence was highest in non-Hispanic Black. After multivariate adjustment, non-Hispanic Black persons still have higher risk compared with individuals in other racial and ethnic groups. It has been shown that body mass index, SBP, and HbA1c were persistently higher in the Black population from 1999 to 2018, which may contribute to the higher prevalence of hypertension48. Other factors that play an important role in racial and ethnic differences include social determinants like diet pattern, family income, chronic stress, and access to health care48,49. Although age-adjusted prevalence of high-normal BP were close in racial and ethnic subgroups, the risk of high-normal BP was still highest in Non-Hispanic Black after multivariate adjustment, as other studies reported46,47.

Socioeconomic factors, like education level and access to health care, are important social determinants of hypertension. The REGARDS study revealed that low education was associated with a higher risk of developing hypertension50. People with higher education are more likely to have a better knowledge of hypertension, and subsequently live a healthier lifestyle51. Those with limited healthcare access are more likely to have worse hypertension awareness and management52. No significant association were found between socioeconomic factors and high-normal BP, although several studies showed that adults with a low socioeconomic status were at risk of elevated blood pressure53. The reason that the association was not detected in our study may be the limited sample size or unstudied confounding variables.

Lifestyles intervention is an important approach to prevent the onset of hypertension9. Our study revealed that those with obesity were at a higher risk of hypertension. Weight loss makes an important contribution to the treatment of hypertension54. Both the 2017 ACC/AHA and the 2023 ESC/ESH guideline recommend other lifestyle intervention like engaging in regular physical activities, a moderation of alcohol consumption, and smoking cessation, although no significant association were observed between the above factors and hypertension/high-normal BP in our study.

Temporal changes in risk factors of hypertension and high-normal BP were investigated as well. Our studies observed that the prevalence of obesity and diabetes mellitus increased from 1999 to 2000 to 2017–2018, which may increase the risk of hypertension and high-normal BP. On the other hand, the prevalence of current smoking is decreasing and the prevalence of active physical activities and lipid control is increasing, which may help prevent the incidence of hypertension and high-normal BP. Further research is needed to study how the risk factors change by sex, race/ethnicity, and socioeconomic factors for development of health policies for targeted interventions.

In the sensitivity analysis, results showed that different definitions of hypertension and high-normal BP led to different prevalence rate, and thus different secular trends. In fact, the definition of hypertension and high-normal BP was arbitrary. They were defined to simplify the decision on hypertension management (lifestyle intervention or drug treatment). Both the ACC/AHA and the ESC/ESH guidelines recommend treatment initiation with antihypertensive agents at thresholds of SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg7,9. For patients who have BP ≥ 130/80 mm Hg, whether treatment should be started depend on whether CVD is established. As Whelton et al.55 discussed, the ACC/AHA classification is simpler and captures more of the CVD risk. However, it leads to a greater challenge for health care professionals because (1) it results in a higher percentage of adults with hypertension and (2) there is need to assess atherosclerotic CVD risk for treatment options, especially in adults with ACC/AHA stage 1 hypertension (DBP of 80–89 mm Hg or SBP of 130–139 mmHg). Although the ESC/ESH guideline has more BP categories, it provides a detailed instruction for the administration of antihypertensive drug therapy.

As discussed previously, Muntner et al.14 and Fan et al.16 have explored NHANES regarding the prevalence of hypertension. The purpose of Muntner et al.’s study was to analyze the trends in blood pressure control among US adults with hypertension. It focused on US adults with hypertension while our study included all the US adults with valid blood pressure measurements. We aimed to determine not only the trends in prevalence of hypertension, but also the trends in prevalence of high-normal blood pressure. The contents of Fan et al.’s study has some overlaps with ours. We both investigated the trends in prevalence of hypertension and its influence factors. However, we also described the temporal changes in the influence factors to explore how hypertension could be prevented. What’s more, we investigated the trends in prevalence of high-normal blood pressure and its influence factors, which is the most important contribution of our study. Our study broadened the current literature on prevalence of hypertension, especially on prevalence of high-normal BP, since studies on prevalence on high-normal BP are limited. By employing the complex sampling design of NHANES, we were able to obtain the accurate prevalence estimates for the US adults population. We also explored the temporal changes of influencing factors of hypertension and high-normal BP, so as to provide some hints for the health policy.

Limitation

This study has several limitations. First, fasting plasma glucose were available for only a subsample of participants. Therefore, the sample size was limited when conducting the multivariate analysis. Second, the physical activity questionnaire changed in cycle 2007–2008. An abrupt change was observed at the same time, so direct comparison among survey cycles were not feasible. Third, each participant completed only a single visit. However, it is recommended by the guidelines that mean should be obtained by using multiple BP measurements during 2 or more visits7,9. Fourth, participants in NHANES were not followed longitudinally, so within-person changes cannot be assessed. Fifth, this study is a cross-sectional observational study, so causal relationship cannot be established between hypertension, high-normal BP, and risk factors.

Conclusion

In this serial cross-sectional surveys weighted to be representative of US adults aged 20 years or older, the prevalence of hypertension stayed stable from 1999 to 2000 to 2017–2018. The age-adjusted prevalence of high-normal BP decreased from 1999 to 2000 through 2013–2014, and then increased from 2013 to 2014 through 2017–2018.

Temporal changes in risk factors for incident hypertension and CVD were also investigated. Age-adjusted prevalence of participants with obesity, diabetes mellitus, active physical activity, and lipid control increased from 1999 to 2000 to 2017–2018, while age-adjusted prevalence of current smokers decreased. Age-adjusted prevalence of participants with heavy alcohol consumption, hyperuricemia and chronic kidney disease was stable.

Perspectives

The prevalence of high-normal BP has not been examined to date. Our study showed that the prevalence of high-normal BP has increased after 2007–2008. Attention needs to be paid to those with high-normal BP to prevent transition to hypertension.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1 (1.6MB, pdf)

Acknowledgements

We thank the NHANES research and field team and every respondent in the study for their contributions.

Abbreviations

ACC

American College of Cardiology

AHA

American Heart Association

BMI

Body mass index

BP

Blood pressure

CKD

Chronic kidney disease

CVD

Cardiovascular disease

DBP

Diastolic blood pressure

ESC

European Society of Cardiology

ESH

European Society of Hypertension

HMOD

Hypertension-mediated organ damage

NHANES

National Health and Nutrition Examination Survey

SBP

Systolic blood pressure

WHO

World Health Organization

Author contributions

Study conception: T.W.; Data analysis: T.W.; Writing: T.W., H.L; Checking: X.Z.; Supervision: C.W. All authors have read and approved the final manuscript.

Funding

National Natural Science Foundation of China, Grant/Award Number: 12201441; Sichuan Science and Technology Program (2023NSFSC1597); Med-X for informatics, Sichuan University (YGJC006).

Data availability

Data is publicly available. See: https://www.cdc.gov/nchs/nhanes/index.htm.

Declarations

Ethics approval and consent to participate

Protocols of NHANES were approved by the institutional review board of the National Center for Health Statistics, Centers for Disease Control and Prevention. Written informed consent was obtained from each participant. The institutional review board of the University of Alabama at Birmingham considered the analysis of anonymous data to be exempt research.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material 1 (1.6MB, pdf)

Data Availability Statement

Data is publicly available. See: https://www.cdc.gov/nchs/nhanes/index.htm.

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