Abstract
Racial/ethnic differences in blood pressure (BP), regardless of antihypertensive medication use, contribute to cardiovascular disease disparities. We analyzed systolic BP (SBP) data from US adults in the National Health and Nutrition Examination Survey from 1999–2002 through 2015–2018 (n=51,743) to determine if racial/ethnicity disparities have changed over time. Among US adults not taking antihypertensive medication, the mean age-adjusted SBP (95%CI), mmHg, in 1999–2002 and 2015–2018 was 119.6 (118.7,120.5) and 119.4 (118.7,120.1) for non-Hispanic White adults, 124.7 (123.7,125.7) and 124.9 (123.8,125.9) for non-Hispanic Black adults and 120.4 (118.6,122.2) and 120.4 (119.7,121.2) for Hispanic adults. The mean multivariable-adjusted SBP was 4.1 mmHg (2.7,5.4) higher in 1999–2002 and 3.8 mmHg (2.6,5.0) higher in 2015–2018 among non-Hispanic Black adults compared to non-Hispanic White adults, while there was no evidence of a difference between Hispanic adults and non-Hispanic White adults in 1999–2002 (−0.2 mmHg; 95%CI −1.9,1.5) or 2015–2018 (−0.8 mmHg; 95%CI −1.8,0.1). Among US adults taking antihypertensive medication, the mean age-adjusted SBP (95%CI), mmHg, in 1999–2002 and 2015–2018 was 129.6 (126.7,132.4) and 127.1 (125.6,128.6) for non-Hispanic White adults, 136.9 (133.8,140.0) and 135.3 (132.5,138.1) for non-Hispanic Black adults and 133.9 (128.0,139.7) and 131.8 (127.6,136.0) for Hispanic adults. After multivariable adjustment, in 1999–2002 and 2015–2018, mean SBP was 4.8 mmHg (1.8,7.8) and 6.5 mmHg (4.5,8.4) higher, respectively, among non-Hispanic Black adults versus White adults, and 2.4 mmHg (−2.6,7.3) and 3.6 mmHg (0.8,6.4) higher, respectively, among Hispanic adults versus non-Hispanic White adults. In the US, non-Hispanic Black adults continue to have higher SBP levels compared with non-Hispanic White adults.
Keywords: blood pressure, race/ethnic disparities, trends, hypertension, antihypertensive medication
The prevalence of hypertension has been reported to be higher among Black compared with White adults in the US, while the prevalence is lower among Asian and Hispanic adults.1, 2 According to data from the 2015–2018 National Health and Nutrition Examination Survey (NHANES), non-Hispanic Black and Asian adults with hypertension taking antihypertensive medication are less likely to have controlled blood pressure (BP) compared to non-Hispanic White adults.3 Differences in the prevalence of hypertension and BP control have been estimated to be the single largest contributor to the excess risk for cardiovascular disease (CVD) among Black versus White adults.4, 5
Racial/ethnic differences in BP levels in the US extend below the threshold used to define hypertension.6–9 There is a graded increase in CVD risk with higher systolic BP (SBP) beginning at levels above 100 mm Hg, emphasizing the importance of achieving equity in BP even below levels used to define hypertension for preventing racial and ethnicity disparities in CVD.10 Determining whether BP differences by race have attenuated over time could identify the need for additional public health interventions to reduce disparities in CVD risk. The purpose of the current analysis was to estimate changes in SBP and diastolic BP (DBP) levels by racial/ethnicity among US adults not taking and taking antihypertensive medication from 1999–2000 through 2017–2018. In addition, we compared differences in SBP and DBP between racial/ethnic groups in 2015–2018 versus 1999–2002 to determine if racial/ethnic disparities have been reduced in the past 20 years. To accomplish these goals, data from ten two-year cycles of the US NHANES were analyzed.
METHODS
Anonymized NHANES data and materials can be accessed at https://wwwn.cdc.gov/nchs/nhanes/Default.aspx. The NHANES was designed to assess the health and nutritional status of the non-institutionalized US population. Since 1999–2000, the National Center for Health Statistics (NCHS) has conducted NHANES in two-year cycles using a multistage probability sampling design to provide nationally representative estimates. For the current analysis, publicly available data files for the ten NHANES cycles conducted from 1999–2000 through 2017–2018 were analyzed. The NCHS Institutional Review Board approved the study protocol for each NHANES cycle. Written informed consent was obtained from each participant.
We restricted the current analysis to adults ≥18 years of age who completed the NHANES interview and physical examination (n=56,367). We excluded participants who were pregnant (n=1,588) and those who did not have at least one SBP and DBP measurement (n=2,772) or who were missing information on antihypertensive medication use (n=264). After these exclusions, a total of 51,743 participants were included in the analysis (Figure S1).
Data collection
Standardized questionnaires were administered by trained interviewers and used to assess each participant’s age, sex, race/ethnicity, annual household income, health insurance type, healthcare utilization, prior diagnoses of diabetes and clinical CVD including heart attack, coronary heart disease, stroke, or heart failure, and use of antihypertensive medication, oral glucose lowering medication and insulin. From 1999–2000 until 2009–2010, race/ethnicity was defined as non-Hispanic White, non-Hispanic Black, Hispanic and other, according to the self-reported race/ethnic categories in the publicly available NHANES data sets. Beginning with the 2011–2012 cycle, the publicly available NHANES data included non-Hispanic Asian as its own race/ethnicity category.
Body mass index (BMI) was calculated as weight divided by height and categorized as normal (<25 kg/m2), overweight (25–29 kg/m2) and obese (≥30 kg/m2). Diabetes was defined by fasting serum glucose ≥126 mg/dL, non-fasting serum glucose ≥200 mg/dL, glycated hemoglobin ≥6.5%, or self-reported diabetes with the use of oral glucose lowering medication or insulin. Estimated glomerular filtration rate (eGFR) was calculated using age, sex, race/ethnicity, serum creatinine and the Chronic Kidney Disease (CKD) Epidemiology Collaboration equation.11 CKD was defined as an eGFR <60 ml/min/1.73m2 or an albumin-to-creatinine ratio ≥30 mg/g.
BP measurement
BP was measured during the examination using the same standardized protocol for each NHANES cycle. Using a mercury sphygmomanometer, a trained physician measured SBP and DBP up to three times at 30 second intervals. The mean of all available measurements was used to define SBP and DBP for each participant.
Definitions of BP categories
Participants were grouped into four mutually exclusive BP categories based on the 2017 American College of Cardiology/American Heart Association (ACC/AHA) BP guideline:12 (1) SBP <120 mm Hg and DBP <80 mm Hg (2) SBP between 120 and 129 mm Hg and DBP <80 mm Hg (3) SBP between 130 and 139 mm Hg with DBP < 90 mm Hg or DBP between 80 and 89 mm Hg with SBP < 140 mm Hg and (4) SBP ≥140 mm Hg or DBP ≥90 mm Hg.
Statistical analysis
Summary statistics for characteristics of US adults not taking and taking antihypertensive medication, separately, were calculated for the 1999–2000 and 2017–2018 NHANES cycles by race/ethnicity. Due to small sample sizes and unstable estimates, statistics for participants of race/ethnicity other than non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic are not reported. We estimated the mean age-adjusted SBP and DBP and the age-adjusted prevalence of the four BP categories defined by the 2017 ACC/AHA BP guideline for US adults by antihypertensive medication use and race/ethnicity in each two-year period from 1999–2000 to 2017–2018.
Differences in mean SBP and DBP between non-Hispanic Black, non-Hispanic Asian, and Hispanic adults versus non-Hispanic White adults were estimated using linear regression for US adults not taking and taking antihypertensive medication, separately, in each two-year period. Poisson regression with robust variance was used to estimate prevalence ratios (PRs) for SBP ≥140 mm Hg or DBP ≥90 mm Hg associated with race/ethnicity for US adults not taking and taking antihypertensive medication, separately, in each two-year period. In a secondary analysis, we calculated the age-adjusted prevalence and PRs for SBP ≥130 mm Hg or DBP ≥80 mm Hg associated with race/ethnicity. Joinpoint statistical software was used to estimate trend lines for the mean age-adjusted difference in SBP and DBP and PR for SBP ≥140 mm Hg or DBP ≥90 mm Hg and SBP ≥130 mm Hg or DBP ≥80 mm Hg, among US adults not taking and taking antihypertensive medication, separately.13 The above analyses were done with ten two-year periods to maximize the number of time points to evaluate trends using Joinpoint statistical software (National Cancer Institute, Rockville MD).13
After pooling data from the NHANES 1999–2000 and 2001–2002 cycles and the 2015–2016 and 2017–2018 cycles into 4-year groups, we calculated the mean age-adjusted SBP and DBP and the age-adjusted prevalence of SBP ≥140 mm Hg or DBP ≥90 mm Hg for each race/ethnicity group. Two-year NHANES cycles were pooled into 4-year groups to provide more stable estimates and a larger sample size for conducting analyses with multivariable adjustment. Differences in mean SBP and DBP and PRs for SBP ≥140 mm Hg or DBP ≥90 mm Hg and SBP ≥130 mm Hg or DBP ≥80 mm Hg between non-Hispanic Black, non-Hispanic Asian, and Hispanic adults versus non-Hispanic White adults were estimated using linear and Poisson regression models in 1999–2002 and 2015–2018, separately, with adjustment for age, sex, BMI, annual household income, health insurance type, having a healthcare visit in the past year, diabetes, CKD, and a history of clinical CVD. We assessed whether race/ethnicity differences in mean SBP and DBP and the prevalence of SBP ≥140 mm Hg or DBP ≥90 mm Hg and SBP ≥130 mm Hg or DBP ≥80 mm Hg changed from 1999–2002 to 2015–2018 using an interaction term between race/ethnicity and survey period (2015–2018 versus 1999–2002). Statistical significance was defined by a 2-sided P value <0.05.
NHANES sampling weights were used in all calculations to obtain US nationally representative estimates. Age adjustment was performed using direct standardization with the standard population being all US adults not taking and taking antihypertensive medication across the study period from 1999 to 2018 (see footnotes in Tables 1 and 2 for standard population). Data management was conducted in SAS version 9.4 (SAS Institute, Cary, NC). Data analysis was conducted using R version 4.0.1 (Vienna, Austria).
Table 1.
Characteristics of US adults by race/ethnicity in 1999–2000 and 2017–2018.
| NHANES Cycle | ||||||||
|---|---|---|---|---|---|---|---|---|
| 1999–2000 (n=4,427) | 2017–2018 (n=5,173) | |||||||
| Characteristics | Non-Hispanic White | Non-Hispanic Black | Non-Hispanic Asian† | Hispanic | Non-Hispanic White | Non-Hispanic Black | Non-Hispanic Asian | Hispanic |
| Not taking antihypertensive medication | ||||||||
| Unweighted No. of participants | 1,465 | 634 | - | 1,308 | 1,253 | 749 | 556 | 920 |
| Weighted proportion‡ | 70.1% | 9.8% | - | 15.3% | 62.0% | 10.2% | 5.8% | 17.2% |
| Age, years | ||||||||
| 18 to 44 | 60.4% | 74.6% | - | 72.0% | 51.4% | 68.2% | 61.4% | 67.4% |
| 45 to 64 | 28.3% | 20.6% | - | 22.7% | 33.2% | 25.8% | 31.4% | 27.8% |
| 65 to 74 | 6.9% | 3.1% | - | 3.4% | 10.5% | 3.8% | 3.9% | 3.7% |
| ≥ 75 | 4.4% | 1.8% | - | 1.8% | 4.9% | 2.2% | 3.3% | 1.0% |
| Women | 49.8% | 50.4% | - | 50.4% | 51.1% | 51.8% | 51.6% | 50.6% |
| Body mass index‖ | ||||||||
| Normal | 42.6% | 38.0% | - | 31.6% | 34.0% | 30.3% | 51.0% | 19.3% |
| Overweight | 33.6% | 28.1% | - | 41.1% | 28.7% | 25.8% | 35.5% | 37.5% |
| Obese | 23.8% | 33.9% | - | 27.4% | 37.2% | 43.9% | 13.6% | 43.2% |
| Income | ||||||||
| < $20,000 | 17.9% | 29.2% | - | 27.6% | 10.2% | 20.6% | 8.0% | 18.6% |
| $20,000 to $44,999 | 27.5% | 39.1% | - | 42.8% | 21.2% | 31.7% | 17.2% | 30.0% |
| $45,000 to $74,999 | 27.4% | 17.1% | - | 18.0% | 18.2% | 19.4% | 19.6% | 23.0% |
| ≥ $75,000 | 27.2% | 14.5% | - | 11.6% | 50.4% | 28.4% | 55.1% | 28.4% |
| Health insurance | ||||||||
| Private | 74.7% | 61.9% | - | 50.5% | 67.2% | 40.5% | 64.8% | 46.4% |
| Medicare | 5.5% | 3.7% | - | 4.9% | 7.5% | 5.7% | 4.7% | 3.3% |
| Medicaid | 1.6% | 4.1% | - | 5.2% | 8.4% | 19.0% | 12.8% | 13.6% |
| Other government | 1.2% | 0.7% | - | 0.6% | 5.4% | 10.2% | 7.6% | 7.2% |
| Uninsured | 16.9% | 29.5% | - | 38.7% | 11.5% | 24.7% | 10.1% | 29.5% |
| Health care visit in the last year | 81.0% | 78.6% | - | 72.3% | 83.9% | 74.6% | 79.7% | 71.0% |
| Diabetes§ | 4.1% | 5.4% | - | 6.0% | 5.6% | 7.4% | 10.8% | 8.8% |
| Chronic kidney disease¶ | 13.0% | 14.9% | - | 14.0% | 13.4% | 17.9% | 16.1% | 11.3% |
| History of clinical CVD# | 4.6% | 2.7% | - | 1.2% | 4.5% | 3.2% | 1.4% | 1.6% |
| Taking antihypertensive medication | ||||||||
| Unweighted No. of participants | 418 | 230 | - | 230 | 541 | 455 | 176 | 246 |
| Weighted proportion‡ | 74.1% | 13.5% | - | 9.6% | 64.5% | 14.8% | 5.4% | 10.3% |
| Age, years | ||||||||
| 18 to 44 | 13.4% | 19.9% | - | 13.8% | 6.3% | 14.3% | 10.3% | 14.7% |
| 45 to 64 | 42.9% | 50.1% | - | 51.2% | 41.4% | 50.1% | 50.6% | 49.9% |
| 65 to 74 | 23.9% | 18.6% | - | 22.9% | 28.1% | 18.8% | 23.5% | 24.1% |
| ≥ 75 | 19.8% | 11.4% | - | 12.2% | 24.1% | 16.8% | 15.6% | 11.3% |
| Women | 51.0% | 63.8% | - | 67.7% | 50.2% | 61.5% | 56.5% | 46.1% |
| Body mass index‖ | ||||||||
| Normal | 18.6% | 14.4% | - | 5.8% | 12.2% | 15.7% | 28.4% | 10.4% |
| Overweight | 33.9% | 29.9% | - | 49.3% | 29.3% | 24.5% | 48.7% | 34.9% |
| Obese | 47.5% | 55.8% | - | 45.0% | 58.5% | 59.9% | 22.9% | 54.7% |
| Income | ||||||||
| < $20,000 | 27.5% | 43.0% | - | 57.0% | 11.0% | 22.8% | 14.5% | 20.9% |
| $20,000 to $44,999 | 31.8% | 32.3% | - | 19.0% | 25.1% | 27.9% | 12.1% | 34.4% |
| $45,000 to $74,999 | 21.0% | 9.9% | - | 17.4% | 20.7% | 19.3% | 22.8% | 12.4% |
| ≥ $75,000 | 19.7% | 14.8% | - | 6.7% | 43.1% | 29.9% | 50.7% | 32.3% |
| Health insurance | ||||||||
| Private | 75.0% | 64.2% | - | 38.6% | 70.0% | 49.0% | 54.8% | 39.6% |
| Medicare | 18.7% | 20.5% | - | 30.2% | 15.9% | 23.7% | 26.3% | 24.9% |
| Medicaid | 2.4% | 2.7% | - | 11.8% | 4.1% | 8.7% | 4.1% | 15.6% |
| Other government | 1.3% | 2.2% | - | 1.1% | 4.9% | 8.4% | 8.7% | 9.6% |
| Uninsured | 2.6% | 10.4% | - | 18.3% | 5.0% | 10.2% | 6.2% | 10.3% |
| Health care visit in the last year | 99.3% | 96.5% | - | 99.2% | 99.3% | 98.8% | 93.7% | 97.5% |
| Diabetes§ | 17.1% | 34.4% | - | 29.6% | 32.3% | 35.0% | 32.5% | 36.2% |
| Chronic kidney disease¶ | 33.7% | 45.1% | - | 38.0% | 39.4% | 40.1% | 40.2% | 30.0% |
| History of clinical CVD# | 20.1% | 12.2% | - | 12.5% | 22.1% | 17.5% | 11.9% | 16.4% |
NHANES: National Health and Nutrition Examination Survey, CVD: cardiovascular disease
Information on non-Hispanic Asian adults is not available in the NHANES 1999–2002 public use data files.
Data were adjusted for sampling weights to represent noninstitutionalized, civilian, non-Hispanic White, non-Hispanic Black, non-Hispanic Asian and Hispanic US adults. The numbers do not add to 100% as the proportion of other race/ethnicities is not presented.
Normal weight was defined as a body mass index < 25 kg/m2, overweight was defined as a body mass index 25–29 kg/m2 and obese was defined as a body mass index ≥ 30 kg/m2.
Diabetes was defined by fasting serum glucose ≥ 126 mg/dL, non-fasting glucose ≥ 200 mg/dL, glycated hemoglobin (HbA1c) ≥ 6.5%, or self-reported use of insulin or oral glucose lowering medication.
Chronic kidney disease was defined by an estimated glomerular filtration rate < 60 ml/min/1.73m2 or an albumin-to-creatinine ratio ≥ 30 mg/dL.
Clinical cardiovascular disease was defined by a self-report of a previous heart attack, coronary heart disease, stroke, or heart failure.
Table 2.
Age-adjusted mean and multivariable-adjusted difference in systolic and diastolic blood pressure for non-Hispanic Black, non-Hispanic Asian and Hispanic adults compared with non-Hispanic White US adults not taking (top panel) and taking (bottom panel) antihypertensive medication in 1999–2002 and 2015–2018.
| Systolic blood pressure, mm Hg | Diastolic blood pressure, mm Hg | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1999–2002 | 2015–2018 | 1999–2002 | 2015–2018 | |||||||
| Race-ethnicity | Age-adjusted Mean (95% CI) | Mean Difference* (95% CI) | Age-adjusted Mean (95% CI) | Mean Difference* (95% CI) | P-value† | Age-adjusted Mean (95% CI) | Mean Difference* (95% CI) | Age-adjusted Mean (95% CI) | Mean Difference* (95% CI) | P-value† |
| US adults not taking antihypertensive medication | ||||||||||
| NH White | 119.6 (118.7, 120.5) | 0 (ref) | 119.4 (118.7, 120.1) | 0 (ref) | ref | 72.4 (71.6, 73.1) | 0 (ref) | 71.3 (70.4, 72.2) | 0 (ref) | ref |
| NH Black | 124.7 (123.7, 125.7) | 4.1 (2.7, 5.4) | 124.9 (123.8, 125.9) | 3.8 (2.6, 5.0) | 0.72 | 73.8 (72.9, 74.7) | 1.3 (−0.2, 2.9) | 72.3 (71.3, 73.2) | 0.8 (−0.3, 1.9) | 0.60 |
| NH Asian | -‡ | - | 118.9 (117.8, 119.9) | 0.7 (−0.5, 1.8) | - | - | - | 73.1 (72.3, 73.8) | 2.7 (1.7, 3.7) | - |
| Hispanic | 120.4 (118.6, 122.2) | −0.2 (−1.9, 1.5) | 120.4 (119.7, 121.2) | −0.8 (−1.8, 0.1) | 0.54 | 71.6 (70.8, 72.4) | −1.0 (−2.1, 0.2) | 70.7 (69.8, 71.5) | −0.9 (−1.9, 0.1) | 0.97 |
| US adults taking antihypertensive medication | ||||||||||
| NH White | 129.6 (126.7, 132.4) | 0 (ref) | 127.1 (125.6, 128.6) | 0 (ref) | ref | 77.8 (75.7, 80.0) | 0 (ref) | 77.0 (75.3, 78.8) | 0 (ref) | ref |
| NH Black | 136.9 (133.8, 140.0) | 4.8 (1.8, 7.8) | 135.3 (132.5, 138.1) | 6.5 (4.5, 8.4) | 0.37 | 80.8 (78.5, 83.0) | 4.2 (2.0, 6.4) | 79.0 (76.7, 81.2) | 2.4 (0.6, 4.1) | 0.23 |
| NH Asian | - | - | 131.4 (127.1, 135.7) | 3.9 (1.0, 6.8) | - | - | - | 77.8 (75.6, 79.9) | 1.3 (−0.5, 3.0) | - |
| Hispanic | 133.9 (128.0, 139.7) | 2.4 (−2.6, 7.3) | 131.8 (127.6, 136.0) | 3.6 (0.8, 6.4) | 0.68 | 75.9 (71.5, 80.4) | 1.9 (−0.6, 4.5) | 77.7 (74.8, 80.6) | 0.1 (−1.7, 1.8) | 0.26 |
CI: confidence interval; NH: non-Hispanic
Adjusted for age, sex, body mass index, income, insurance, healthcare visit in the past year, diabetes, chronic kidney disease, and prior cardiovascular disease.
P-value for the change in the difference in systolic blood pressure and diastolic blood pressure between non-Hispanic Black adults and Hispanic adults versus non-Hispanic White adults in 2015–2018 versus 1999–2002.
Information on non-Hispanic Asian adults was not available in the NHANES 1999–2002 public use data files.
RESULTS
In both 1999–2000 and 2017–2018, non-Hispanic Black and Hispanic adults not taking antihypertensive medication were more likely to be 18–44 years of age, obese, have an income <$20,000, and be uninsured compared to non-Hispanic White adults (Table 1). Among adults taking antihypertensive medication, in both 1999–2000 and 2017–2018, non-Hispanic Black and Hispanic adults were more likely to be 45 to 64 years of age, have an income <$20,000 and to be uninsured compared to non-Hispanic White adults. Non-Hispanic Black adults taking antihypertensive medication were also more likely to obese and have diabetes in 1999–2000 compared to non-Hispanic White adults.
Trends in BP from 1999–2000 to 2017–2018
From 1999–2000 to 2009–2010, the mean age-adjusted SBP declined by 2.0 mm Hg among non-Hispanic White adults not taking antihypertensive medication and then increased 1.8 mm Hg by 2017–2018 (Figure 1, Table S1). Between 1999–2000 and 2011–2012, the mean age-adjusted SBP among non-Hispanic Black and Hispanic adults not taking antihypertensive medication, declined by 2.6 and 3.5 mm Hg, respectively, and then increased 3.1 and 1.6 mm Hg, respectively, by 2017–2018, respectively. Among non-Hispanic White adults not taking antihypertensive medication, the mean age-adjusted DBP decreased by 2.2 mm Hg, from 1999–2000 to 2005–2006 and then increased 1.6 mm Hg by 2017–2018. From 1999–2000 to 2013–2014, the mean age-adjusted DBP among non-Hispanic Black and Hispanic adults not taking antihypertensive medication, decreased by 3.7 and 3.1 mm Hg, respectively, and then increased 3.5, and 3.0 mm Hg, respectively, by 2017–2018, respectively.
Figure 1:
Trends in the mean age-adjusted systolic and diastolic blood pressure overall and by race/ethnicity among US adults not taking antihypertensive medication, 1999–2000 to 2017–2018
Panel A. Systolic blood pressure
Panel B. Diastolic blood pressure
The line segments were generated using Joinpoint (National Cancer Institute). Age adjustment was performed using direct standardization. Among participants not taking antihypertensive medication, the standard population age distribution was 59.0%, 31.0%, 6.2% and 3.8% for those age 18 to 44 years, 45 to 64 years, 65 to 74 years and 75 years or older, respectively. Among participants taking antihypertensive medication, the standard population age distribution was 11.0%, 45.8%, 24.3% and 18.9% for those age 18 to 44 years, 45 to 64 years, 65 to 74 years and 75 years or older, respectively.
Among US adults taking antihypertensive medication, from 1999–2000 to 2009–2010, the mean age-adjusted SBP declined by 9.1 and 10.1 mm Hg among non-Hispanic White and non-Hispanic Black adults, respectively, and then increased 3.4 and 7.0 mm Hg by 2017–2018, respectively (Figure 2, Table S1). Among Hispanic adults, the mean age-adjusted SBP declined by 9.9 mm Hg between 1999–2000 and 2013–2014 and then increased 4.1 mm Hg by 2017–2018. The mean age-adjusted DBP declined by 4.8 mm Hg among non-Hispanic White adults between 1999–2000 and 2009–2010 and then increased 5.0 mm Hg by 2017–2018. From 1999–2000 to 2013–2014, the mean age-adjusted DBP declined by 3.7 and 7.3 mm Hg among non-Hispanic Black and Hispanic adults, respectively, and then increased by 4.2 among non-Hispanic Black and 5.2 mm Hg among Hispanic adults by 2017–2018. Trends in the mean age-adjusted difference in SBP and DBP for non-Hispanic Black and Hispanic adults compared to non-Hispanic White US adults not taking and taking antihypertensive medication from 1999–2000 through 2017–2018 are shown in Figure S2 and Table S2.
Figure 2:
Trends in the mean age-adjusted systolic and diastolic blood pressure overall and by race/ethnicity among US adults taking antihypertensive medication, 1999–2000 to 2017–2018
Panel A. Systolic blood pressure
Panel B. Diastolic blood pressure
The line segments were generated using Joinpoint (National Cancer Institute). Age adjustment was performed using direct standardization. Among participants not taking antihypertensive medication, the standard population age distribution was 59.0%, 31.0%, 6.2% and 3.8% for those age 18 to 44 years, 45 to 64 years, 65 to 74 years and 75 years or older, respectively. Among participants taking antihypertensive medication, the standard population age distribution was 11.0%, 45.8%, 24.3% and 18.9% for those age 18 to 44 years, 45 to 64 years, 65 to 74 years and 75 years or older, respectively.
Difference in SBP and DBP by race/ethnicity in 1999–2002 and 2015–2018
Among US adults not taking antihypertensive medication and after multivariable adjustment, mean SBP was 4.1 (95% CI 2.7, 5.4) and 3.8 mm Hg (95% CI 2.6, 5.0) higher among non-Hispanic Black compared to non-Hispanic White adults, in 1999–2002 and 2015–2018, respectively (Table 2; top panel). There was no evidence of a difference in mean SBP between Hispanic and non-Hispanic White adults in 1999–2002 or 2015–2018. After multivariable adjustment, mean DBP was 2.7 mm Hg (95% CI 1.7, 3.7) higher among non-Hispanic Asian compared to non-Hispanic White adults not taking antihypertensive medication in 2015–2018.
Among US adults taking antihypertensive medication and after multivariable adjustment, the mean SBP was 4.8 (95% CI 1.8, 7.8) and 6.5 mm Hg (95% CI 4.5, 8.4) higher among non-Hispanic Black compared to non-Hispanic White adults, in 1999–2002 and 2015–2018, respectively, and 3.9 mm Hg (95% CI 1.0, 6.8) higher among non-Hispanic Asian compared non-Hispanic White adults in 2015–2018 (Table 2; bottom panel). The mean multivariable-adjusted DBP was 4.2 (95% CI 2.0, 6.4) and 2.4 mm Hg (95% CI 0.6, 4.1) higher among non-Hispanic Black compared to non-Hispanic White adults taking antihypertensive medication in 1999–2000 and 2015–2018, respectively.
Trends in age-adjusted BP categories
The age-adjusted proportion of non-Hispanic White and Hispanic adults not taking antihypertensive medication with SBP ≥140 mm Hg or DBP ≥90 mm Hg decreased from 1999–2000 to 2013–2014 and increased by 2017–2018 (Figure 3, Table S3). The age-adjusted proportion of non-Hispanic Black adults not taking antihypertensive medication with SBP ≥140 mm Hg or DBP ≥90 mm Hg decreased from 1999–2000 to 2011–2012 and then increased by 2017–2018. Among non-Hispanic White and non-Hispanic Black adults taking antihypertensive medication, the age-adjusted proportion with SBP ≥140 mm Hg or DBP ≥90 mm Hg decreased from 1999–2000 to 2011–2012, and then increased by 2017–2018. The proportion of Hispanic adults taking antihypertensive medication with SBP ≥140 mm Hg or DBP ≥90 mm Hg decreased from 1999–2000 to 2017–2018. Trends in the age-adjusted prevalence of SBP ≥130 mm Hg or DBP ≥80 mm Hg are shown in Table S4. The PRs of SBP ≥140 mm Hg or DBP ≥90 mm Hg and SBP ≥130 mm Hg or DBP ≥80 mm Hg for non-Hispanic Black and Hispanic adults compared to non-Hispanic White US adults not taking and taking antihypertensive medication from 1999–2000 to 2017–2018 are shown in Figure S3 and Table S5.
Figure 3:
Trends in the percentage of US adults not taking and taking antihypertensive medication with systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg overall and by race/ethnicity, 1999–2000 to 2017–2018
Panel A. Adults not taking antihypertensive medication
Panel B. Taking antihypertensive medication
The line segments were generated using Joinpoint (National Cancer Institute). Age adjustment was performed using direct standardization. Among participants not taking antihypertensive medication, the standard population age distribution was 59.0%, 31.0%, 6.2% and 3.8% for those age 18 to 44 years, 45 to 64 years, 65 to 74 years and 75 years or older, respectively. Among participants taking antihypertensive medication, the standard population age distribution was 11.0%, 45.8%, 24.3% and 18.9% for those age 18 to 44 years, 45 to 64 years, 65 to 74 years and 75 years or older, respectively.
PRs for BP categories by race/ethnicity in 1999–2002 and 2015–2018
After multivariable adjustment and among US adults not taking antihypertensive medication, non-Hispanic Black adults in 1999–2000 and 2015–2018 were more likely to have SBP ≥140 mm Hg or DBP ≥90 mm Hg and SBP ≥130 mm Hg or DBP ≥80 mm Hg compared to non-Hispanic White adults (Table 3; top panel). In 2015–2018, non-Hispanic Asian adults were more likely than non-Hispanic White adults to have SBP ≥140 mm Hg or DBP ≥90 mm Hg and SBP ≥130 mm Hg or DBP ≥80 mm Hg. Among US adults taking antihypertensive medication in 1999–2002 and 2015–2018, non-Hispanic Black adults were more likely to have SBP ≥140 mm Hg or DBP ≥90 mm Hg and SBP ≥130 mm Hg or DBP ≥80 mm Hg compared to non-Hispanic White adults after multivariable adjustment (Table 3; bottom panel). Among those taking antihypertensive medication in 2015–2018, non-Hispanic Asian adults were more likely than non-Hispanic White adults to have SBP ≥140 mm Hg or DBP ≥90 mm Hg and SBP ≥130 mm Hg or DBP ≥80 mm Hg.
Table 3.
Age-adjusted prevalence and multivariable-adjusted prevalence ratios for SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg (left column) and SBP ≥ 130 mm Hg or DBP ≥ 80 mm Hg (right column) among non-Hispanic Black, non-Hispanic Asian and Hispanic compared with non-Hispanic White US adults not taking (top panel) and taking (bottom panel) antihypertensive medication in 1999–2002 and 2015–2018.
| SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg* | SBP ≥ 130 mm Hg or DBP ≥ 80 mm Hg* | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1999–2002 | 2015–2018 | 1999–2002 | 2015–2018 | |||||||
| Race-ethnicity | Age-adjusted Prevalence (95% CI) | Prevalence Ratio (95% CI) | Age-adjusted Prevalence (95% CI) | Prevalence Ratio (95% CI) | P-value† | Age-adjusted Prevalence (95% CI) | Prevalence Ratio (95% CI) | Age-adjusted Prevalence (95% CI) | Prevalence Ratio (95% CI) | P-value† |
| US adults not taking antihypertensive medication | ||||||||||
| NH White | 12.6% (10.8, 14.4) | 1 (ref) | 10.6% (8.7, 12.6) | 1 (ref) | ref | 34.6% (32.0, 37.3) | 1 (ref) | 29.0% (26.3, 31.6) | 1 (ref) | ref |
| NH Black | 19.4% (16.7, 22.1) | 1.43 (1.15, 1.79) | 18.5% (16.2, 20.7) | 1.54 (1.21, 1.97) | 0.66 | 45.4% (41.3, 49.4) | 1.27 (1.11, 1.45) | 39.5% (37.3, 41.8) | 1.27 (1.14, 1.42) | 0.97 |
| NH Asian | -‡ | - | 12.3% (10.2, 14.3) | 1.31 (1.02, 1.67) | - | - | - | 33.7% (30.0, 37.3) | 1.35 (1.17, 1.56) | - |
| Hispanic | 14.8% (11.5, 18.1) | 1.05 (0.79, 1.39) | 11.5% (10.2, 12.8) | 0.88 (0.71, 1.10) | 0.37 | 32.2% (28.8, 35.5) | 0.85 (0.74, 0.99) | 30.5% (28.6, 32.4) | 0.92 (0.82, 1.02) | 0.44 |
| US adults taking antihypertensive medication | ||||||||||
| NH White | 41.3% (37.8, 44.7) | 1 (ref) | 31.0% (27.8, 34.2) | 1 (ref) | ref | 68.2% (64.9, 71.5) | 1 (ref) | 55.5% (51.1, 59.9) | 1 (ref) | ref |
| NH Black | 52.1% (48.9, 55.4) | 1.22 (1.07, 1.40) | 44.8% (41.1, 48.5) | 1.37 (1.23, 1.52) | 0.21 | 76.0% (71.6, 80.4) | 1.13 (1.02, 1.24) | 66.1% (62.7, 69.5) | 1.17 (1.06, 1.28) | 0.63 |
| NH Asian | - | - | 40.0% (33.3, 46.7) | 1.25 (0.99, 1.58) | - | - | - | 67.7% (63.4, 72.0) | 1.19 (1.06, 1.34) | - |
| Hispanic | 47.9% (39.5, 56.3) | 1.03 (0.80, 1.33) | 39.3% (34.2, 44.3) | 1.16 (0.95, 1.42) | 0.47 | 73.9% (66.8, 81.0) | 1.06 (0.95, 1.19) | 62.7% (57.5, 67.9) | 1.09 (0.97, 1.23) | 0.77 |
CI: confidence interval, DBP: diastolic blood pressure, NH: non-Hispanic, SBP: systolic blood pressure
Adjusted for age, sex, body mass index, income, insurance, healthcare visit in the past year, diabetes, chronic kidney disease, and prior cardiovascular disease.
P-value for the change in the prevalence ratios for systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg and systolic blood pressure ≥ 130 mm Hg or diastolic blood pressure ≥ 80 mm Hg between non-Hispanic Black adults and Hispanic adults versus non-Hispanic White adults in 2015–2018 versus 1999–2002.
Information on non-Hispanic Asian adults is not available in the NHANES 1999–2002 public use data files.
Discussion
Among non-Hispanic White, non-Hispanic Black, and Hispanic US adults not taking and taking antihypertensive medication, mean age-adjusted SBP and DBP declined and then increased between 1999–2000 and 2017–2018. Among US adults not taking antihypertensive medication, the mean SBP and DBP in 2015–2018 were within 1–2 mm Hg of values in 1999–2002 for each race/ethnicity group. There was no evidence that the higher mean SBP and the higher proportion with SBP ≥140 mm Hg or DBP ≥90 mm Hg among non-Hispanic Black compared to non-Hispanic White US adults that were present in 1999–2002 were attenuated by 2015–2018.
In the current study, the mean age-adjusted SBP and DBP were similar in 1999–2000 and 2017–2018 among US adults not taking antihypertensive medication for each race/ethnicity group. While decreases in SBP and DBP among adults not taking antihypertensive medication occurred as recently as 2013–2014, increases in SBP and DBP through 2017–2018 reversed previous improvements. Non-pharmacologic lifestyle modification including weight loss, regular physical activity, adherence to Dietary Approaches to Stop Hypertension dietary pattern, and reduction in alcohol intake have been shown to lower BP among adults with and without hypertension.14, 15 However, the proportion of US adults who are obesity is increasing and the prevalence is higher among Black women compared to White women. Also, adherence to physical activity and dietary sodium intake recommendations are low, emphasizing the need for approaches aimed at lifestyle modifications to reduce BP.16, 17 A population-wide 1 to 2 mm Hg decrease in BP, achievable through lifestyle changes, has been estimated to substantially reduce population-wide CVD risk.18
The race/ethnic disparities in mean SBP and prevalence of SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg and SBP ≥ 130 mm Hg or DBP ≥ 80 mm Hg, with higher levels among non-Hispanic Black compared to non-Hispanic White adults in 1999–2002 were not reduced in 2015–2018. Achieving equity by eliminating these differences could have a large impact on racial disparities in CVD mortality.19, 20 Previous studies have estimated that up to 60% of all health disparities are attributable to negative social determinants of health (SDOH),21, 22 including lack of education on health behaviors, low socioeconomic status, lack of transportation and limited access to heart healthy foods and physical activity spaces, and that SDOH contribute to inequalities in BP between Black and White populations.8, 23–25 In 2020, both the US Surgeon General and the AHA published Calls to Action that advocate for addressing social determinants of health and racism within evidence-based interventions to increase equity in BP control and cardiovascular health.23, 26 27–30 Achieving equity in BP among those taking and not taking antihypertensive medication may require multilevel interventions, including economic and social remedies, equitable education, equal access to health care, and community context.23
The lower proportion of Black versus White US adults taking antihypertensive medication that achieve controlled BP has been documented for several decades.3, 31 In the current study, among US adults taking antihypertensive medication, Black adults had higher mean SBP and DBP levels and were more likely to have SBP≥140 mm Hg or DBP ≥90 mm Hg compared to White adults. There are a number of potential reasons for these findings. The 2017 ACC/AHA BP guideline endorsed the use of two or more antihypertensive medications to achieve BP control among adults with stage 2 hypertension, particularly for Black adults.32 However, the majority of patients who initiate antihypertensive medication do so with monotherapy which is associated with a lower likelihood of achieving BP control than combination therapy.33–35 Although prior studies have shown that Black compared to White adults are more likely to initiate antihypertensive medication with combination therapy and be prescribed a higher number of antihypertensive medications, Black adults are less likely to achieve BP control.3, 36, 37 Black adults on average are more likely to have obesity, diabetes, and CKD, each of which has been associated with pharmacological treatment resistance, than their white counterparts and may require more intensive drug therapy.38 Overcoming therapeutic inertia and increasing the intensity of antihypertensive medication including combination therapy should aid in reducing disparities in BP control between Black and White adults.
This study has several limitations. We relied on BP measurements from a single visit and the 2017 ACC/AHA BP guideline recommends averaging BP measurements from two or more visits and confirmation of office hypertension by out-of-office BP measurement,12 which are not done in NHANES. Data on non-Hispanic Asian adults were not available prior to 2011–2012 which restricted the description of trends for this group to 8 years, 2011–2012 through 2017–2018. The response rate for NHANES has declined from 1999–2000 through 2017–2018. However, any potential bias from the differential response rate across sub-groups was reduced by weighting adjustment.39
Perspectives
In conclusion, the mean age-adjusted SBP and DBP in 2017–2018 was within 1 mm Hg of levels 20 years earlier in 1999–2000 among non-Hispanic White and non-Hispanic Black adults and within 2 mm Hg among Hispanic adults not taking antihypertensive medication. Among US adults not taking and taking antihypertensive medication, disparities in SBP and the prevalence of SBP ≥140 mm Hg or DBP ≥90 mm Hg and SBP ≥130 mm Hg or DBP ≥80 mm Hg, with higher levels among non-Hispanic Black compared to non-Hispanic White adults, in 1999–2002 remained present in 2015–2018. These data emphasize the importance of population-wide efforts to improve BP control and equity in BP levels between race/ethnic populations in the US.
Supplementary Material
Novelty and Significance.
What Is New?
Determining whether blood pressure (BP) differences by race have attenuated over time could identify the need for additional public health interventions to reduce disparities in cardiovascular risk.
What Is Relevant?
Among US adults not taking antihypertensive medication, the mean multivariable-adjusted systolic BP (SBP) was 4.1 mmHg higher in 1999–2002 and 3.8 mmHg higher in 2015–2018 among non-Hispanic Black compared to non-Hispanic White adults. Among US adults taking antihypertensive medication in 1999–2002 and 2015–2018, mean multivariable-adjusted SBP was 4.8 and 6.5 mmHg higher, respectively, among non-Hispanic Black adults versus White adults, and 2.4 and 3.6 mmHg higher, respectively, among Hispanic adults versus non-Hispanic White adults.
Summary
In the US, non-Hispanic Black adults continue to have higher SBP levels compared with non-Hispanic White adults.
Acknowledgements
Sources of funding: Drs. Hardy and Muntner receive support through R01HL139716 from the National Heart Lung Blood Institute (NHLBI). Dr. Foti is supported by T32 HL007024 from the NHLBI.
Footnotes
Disclosures: Paul Muntner receives grant funding and consulting fees from Amgen Inc. unrelated to topic in the current manuscript.
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