Age at Diagnosis of Hypertension by Race and Ethnicity in the US From 2011 to 2020

Abstract

This cross-sectional study assesses differences in the age at which adults in the US are diagnosed with hypertension based on race and ethnicity.

Hypertension affects nearly half of US adults and contributes to cardiovascular disease (CVD) burden.¹ Hypertension prevalence is disproportionately higher among non-Hispanic Black adults vs non-Hispanic White adults (hereafter, Black and White adults) and may develop at younger ages.² Earlier age at hypertension onset may mean greater cumulative exposure to high blood pressure (BP) across the life course, which is associated with increased risk of CVD,^3,4 and may contribute to racial disparities in hypertension-related outcomes. We aimed to identify racial and ethnic differences in age at hypertension onset using a contemporary, nationally representative sample.

Methods

This cross-sectional study used data from the National Health and Nutrition Examination Surveys (NHANES) 2011 to 2020, which were analyzed January to April 2022. We included adults (aged ≥20 years) with self-reported diagnosis of hypertension (ie, clinician told them they had hypertension) and data on age at onset. Mean (SD) age at hypertension diagnosis was calculated overall and for each self-reported race and ethnicity group. We pooled data across cycles because no significant trends were observed. We also calculated the proportion of adults diagnosed at age 50 years or younger, 40 years or younger, and 30 years or younger. Multivariate regression models adjusted for sex, educational level, and household income were used to assess the association between race and ethnicity and age at hypertension diagnosis. In addition, we estimated the age-adjusted proportion of participants unaware of hypertension with objectively measured high BP of 140/90 mm Hg or greater and separately 130/80 mm Hg or greater. All analyses accounted for the NHANES complex sampling design. The Northwestern University Institutional Review Board approved the study and waived the informed consent requirement because only publicly available, deidentified data were used. We followed the STROBE reporting guideline. Statistical analyses were conducted using Stata, version 17. Two-sided P < .05 was considered statistically significant.

Results

A total of 9627 participants reported a diagnosis of hypertension, which represents approximately 75 million adults. Participants’ races and ethnicities included Asian, Black, Hispanic, and White (Table 1). Overall, the mean (SD) age at hypertension diagnosis was 46 (15) years (Table 2), with significantly younger age at diagnosis among Black (age 42 [14] years) and Hispanic (age 43 [15] years) adults vs White adults (age 47 [15] years; P < .01). No difference in age at hypertension diagnosis was observed between Asian and White adults. A higher proportion of Black adults (25%) and Hispanic adults (23%) reported hypertension diagnosis at age 30 years or younger vs White adults (17%; P < .01). Among participants who did not report a hypertension diagnosis, a higher proportion of Asian (24%; P < .01), Black (28%; P < .01), and Hispanic (21%; P = .01) adults were unaware of hypertension (BP ≥140/90 mm Hg) vs White adults (16%), with similar patterns for adults with BP of 130/80 mm Hg or greater (Table 2).

Table 1. Demographic Characteristics of Adults With Self-report of Hypertension in the Overall Population and by Race and Ethnicity^a.

Characteristic	%
	Overall	Hispanic	Asian	Black	White
Unweighted total, No.	9517	1880	811	2850	3631
Weighted total, No.	74 966 635	8 371 593	3 063 120	10 592 405	50 194 591
Age, mean (SD), y	58 (15)	53 (15)	58 (14)	55 (15)	59 (15)
Sex
Female	52	51	51	58	50
Male	48	49	49	42	50
Educational level
> High school diploma	16	38	21	20	11
High school diploma	26	24	17	29	26
Some college	34	26	19	32	35
≥ College degree	25	12	43	19	28
Household income
≤ $44 999	45	58	37	57	40
$45 000-$99 999	34	33	37	32	34
≥ $100 000	22	9	26	11	26

^a Data are from National Health and Nutrition Examination Surveys 2011 to 2020. All statistics are weighted to be representative of the US noninstitutionalized population.

Table 2. Distribution of Age at Hypertension Diagnosis by Race and Ethnicity^a.

	%
	Overall	Hispanic	Asian	Black	White
Distribution of age at diagnosis, mean (SD), y	46 (15)	43 (15)	48 (14)	42 (14)	47 (15)
Adjusted P valueb	NA	<.01	.86	<.01	Reference
Proportion of adults with hypertension
Diagnosed ≤50 y	64	70	59	73	61
Adjusted P valuec	NA	<.01	.96	<.01	Reference
Diagnosed ≤40 y	37	44	29	48	35
Adjusted P valuec	NA	<.01	.23	<.01	Reference
Diagnosed ≤30 y	19	23	12	25	17
Adjusted P valuec	NA	<.01	.42	<.01	Reference
Proportion of adults unaware of hypertensiond
BP ≥140/90 mm Hg	18	21	24	28	16
P value for difference	NA	.01	<.01	<.01	Reference
BP ≥130/80 mm Hg	38	42	44	51	36
P value for difference	NA	.01	<.01	<.01	Reference

Abbreviations: BP, blood pressure; NA, not applicable.

^a Data are from National Health and Nutrition Examination Surveys 2011 to 2020. All statistics are weighted to be representative of the US noninstitutionalized population.

^b From multivariable linear regression adjusted for sex, educational level, and household income.

^c From multivariable logistic regression adjusted for sex, educational level, and household income.

^d Defined as proportion of adults who were unaware they had hypertension with objectively measured high BP (140/90 mm Hg or greater) with overall weighted total N = 156 156 766.

Discussion

Mean age of hypertension diagnosis was 4 to 5 years earlier among Black and Hispanic adults vs White adults in the US between 2011 and 2020. Among Black and Hispanic adults with hypertension, 1 in 4 reported diagnosis at age 30 years or younger. Limitations of this study include reliance on self-report, recall bias, and lack of information on when antihypertensive medications were initiated. Aggregation of Asian and Hispanic subgroups may obscure differences. However, NHANES is a representative sample of US adults, which enhances the generalizability of these findings. Lower hypertension awareness among racial and ethnic minoritized groups suggests potential for underestimating differences in age at onset.

Earlier hypertension onset in Black and Hispanic adults may contribute to racial and ethnic CVD disparities. Greater cumulative exposure of high BP is associated with subclinical and clinical CVD. Potential factors associated with earlier hypertension onset include dietary quality, sedentary behavior, and upstream structural and systemic factors (eg, racism, weathering, and other environmental exposures).^5,6 These findings emphasize the importance of hypertension prevention and screening in young adulthood and adolescence.