Vicki L. Burt

Prevalence of Hypertension in the US Adult Population: Results From the Third National Health and Nutrition Examination Survey, 1988-1991

The purpose of this study was to estimate the current prevalence and distribution of hypertension and to determine the status of hypertension awareness, treatment, and control in the US adult population. The study used a cross-sectional survey of the civilian, noninstitutionalized population of the United States, including an in-home interview and a clinic examination, each of which included measurement of blood pressure. Data for 9901 participants 18 years of age and older from phase 1 of the third National Health and Nutrition Examination Survey, collected from 1988 through 1991, were used. Twenty-four percent of the US adult population representing 43,186,000 persons had hypertension. The age-adjusted prevalence in the non-Hispanic black, non-Hispanic white, and Mexican American populations was 32.4%, 23.3%, and 22.6%, respectively. Overall, two thirds of the population with hypertension were aware of their diagnosis (69%), and a majority were taking prescribed medication (53%). Only one third of Mexican Americans with hypertension were being treated (35%), and only 14% achieved control in contrast to 25% and 24% of the non-Hispanic black and non-Hispanic white populations with hypertension, respectively. Almost 13 million adults classified as being normotensive reported being told on one or more occasions that they had hypertension; 51% of this group reported current adherence to lifestyle changes to control their hypertension. Hypertension continues to be a common finding in the general population. Awareness, treatment, and control of hypertension have improved substantially since the 1976-1980 National Health and Nutrition Examination Survey but continue to be suboptimal, especially in Mexican Americans.(ABSTRACT TRUNCATED AT 250 WORDS)

Trends in the Prevalence, Awareness, Treatment, and Control of Hypertension in the Adult US Population: Data From the Health Examination Surveys, 1960 to 1991

The objective of this study was to describe secular trends in the distribution of blood pressure and prevalence of hypertension in US adults and changes in rates of awareness, treatment, and control of hypertension. The study design comprised nationally representative cross-sectional surveys with both an in-person interview and a medical examination that included blood pressure measurement. Between 6530 and 13,645 adults, aged 18 through 74 years, were examined in each of four separate national surveys during 1960-1962, 1971-1974, 1976-1980, and 1988-1991. Protocols for blood pressure measurement varied significantly across the surveys and are presented in detail. Between the first (1971-1974) and second (1976-1980) National Health and Nutrition Examination Surveys (NHANES I and NHANES II, respectively), age-adjusted prevalence of hypertension at > or = 160/95 mm Hg remained stable at approximately 20%. In NHANES III (1988-1991), it was 14.2%. Age-adjusted prevalence at > or = 140/90 mm Hg peaked at 36.3% in NHANES I and declined to 20.4% in NHANES III. Age-specific prevalence rates have decreased for every age-sex-race subgroup except for black men aged 50 and older. Age-adjusted mean systolic pressures declined progressively from 131 mm Hg at the NHANES I examination to 119 mm Hg at the NHANES III examination. The mean systolic and diastolic pressures of every sex-race subgroup declined between NHANES II and III (3 to 6 mm Hg systolic, 6 to 9 mm Hg diastolic). During the interval between NHANES II and III, the threshold for defining hypertension was changed from 160/95 to 140/90 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

The Burden of Adult Hypertension in the United States 1999 to 2000: A Rising Tide

This study aims to estimate the absolute number of persons with hypertension (the hypertension burden) and time trends using data from the National Health and Nutrition Examination Survey of United States resident adults who had hypertension in 1999 to 2000. This information is vitally important for health policy, medical care, and public health strategy and resource allocation. At least 65 million adults had hypertension in 1999 to 2000. The total hypertension prevalence rate was 31.3%. This value represents adults with elevated systolic or diastolic blood pressure, or using antihypertensive medications (rate of 28.4%; standard error [SE], 1.1), and adults who otherwise by medical history were told at least twice by a physician or other health professional that they had high blood pressure (rate of 2.9%; SE, 0.4). The number of adults with hypertension increased by ≈30% for 1999 to 2000 compared with at least 50 million for 1988 to 1994. The 50 million value was based on a rate of 23.4% for adults with elevated blood pressure or using antihypertensive medications and 5.5% for adults classified as hypertensive by medical history alone (28.9% total; P<0.001). The ≈30% increase in the total number of adults with hypertension was almost 4-times greater than the 8.3% increase in total prevalence rate. These trends were associated with increased obesity and an aging and growing population. Approximately 35 million women and 30 million men had hypertension. At least 48 million non-Hispanic white adults, ≈ 9 million non-Hispanic black adults, 3 million Mexican American, and 5 million other adults had hypertension in 1999 to 2000.

Trends in Antihypertensive Medication Use and Blood Pressure Control Among United States Adults With Hypertension The National Health and Nutrition Examination Survey, 2001 to 2010

Background— The monitoring of national trends in hypertension treatment and control can provide important insight into the effectiveness of primary prevention efforts for cardiovascular disease. The objective of this study was to examine recent trends in antihypertensive medication use and its impact on blood pressure control among US adults with hypertension. Methods and Results— A total of 9320 hypertensive people aged ≥18 years from the National Health and Nutrition Examination Survey 2001 to 2010 were included in this study. The prevalence of antihypertensive medication use increased from 63.5% in 2001 to 2002 to 77.3% in 2009 to 2010 (Ptrend<0.01). Most notably, there was a large increase in the use of multiple antihypertensive agents (from 36.8% to 47.7%, Ptrend<0.01). Overall, the use of thiazide diuretics, &bgr;-blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers increased by 23%, 57%, 31%, and 100%, respectively. In comparison with monotherapy, single-pill combinations and multiple-pill combinations were associated with 55% and 26% increased likelihoods of blood pressure control, respectively. By the 2009 to 2010 time period, 47% of all hypertensive people and 60% of treated hypertensive people had blood pressure controlled. However, higher treated but uncontrolled hypertension rates continued to persist among older Americans, non-Hispanic blacks, diabetic people, and those with chronic kidney disease. Also, Mexican Americans with hypertension were still less likely to take antihypertensive medication than non-Hispanic whites with hypertension. Conclusions— Antihypertensive medication use and blood pressure control among US adults with hypertension significantly increased over the past 10 years. Combination therapy regimens can facilitate achievement of blood pressure goals.Background— The monitoring of national trends in hypertension treatment and control can provide important insight into the effectiveness of primary prevention efforts for cardiovascular disease. The objective of this study was to examine recent trends in antihypertensive medication use and its impact on blood pressure control among US adults with hypertension. Methods and Results— A total of 9320 hypertensive people aged ≥18 years from the National Health and Nutrition Examination Survey 2001 to 2010 were included in this study. The prevalence of antihypertensive medication use increased from 63.5% in 2001 to 2002 to 77.3% in 2009 to 2010 ( P trend<0.01). Most notably, there was a large increase in the use of multiple antihypertensive agents (from 36.8% to 47.7%, P trend<0.01). Overall, the use of thiazide diuretics, β-blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers increased by 23%, 57%, 31%, and 100%, respectively. In comparison with monotherapy, single-pill combinations and multiple-pill combinations were associated with 55% and 26% increased likelihoods of blood pressure control, respectively. By the 2009 to 2010 time period, 47% of all hypertensive people and 60% of treated hypertensive people had blood pressure controlled. However, higher treated but uncontrolled hypertension rates continued to persist among older Americans, non-Hispanic blacks, diabetic people, and those with chronic kidney disease. Also, Mexican Americans with hypertension were still less likely to take antihypertensive medication than non-Hispanic whites with hypertension. Conclusions— Antihypertensive medication use and blood pressure control among US adults with hypertension significantly increased over the past 10 years. Combination therapy regimens can facilitate achievement of blood pressure goals. # Clinical Perspective {#article-title-35}

Total folate and folic acid intake from foods and dietary supplements in the United States: 2003–2006

BACKGROUND The term total folate intake is used to represent folate that occurs naturally in food as well as folic acid from fortified foods and dietary supplements. Folic acid has been referred to as a double-edged sword because of its beneficial role in the prevention of neural tube defects and yet possible deleterious effects on certain cancers and cognitive function. Previous monitoring efforts did not include folic acid from dietary supplements and are therefore not complete. OBJECTIVE Our objective was to combine data on dietary folate (as measured by two 24-h recalls) and folic acid from dietary supplements (collected with a 30-d frequency questionnaire) with the use of the bias-corrected best power method to adjust for within-person variability. DESIGN The National Health and Nutrition Examination Survey (NHANES) is a nationally representative, cross-sectional survey. Linear contrasts were constructed to determine differences in dietary and total folate intake for age and racial-ethnic groups by sex; prevalence of inadequate and excessive intakes is presented. RESULTS In 2003-2006, 53% of the US population used dietary supplements; 34.5% used dietary supplements that contained folic acid. Total folate intake (in dietary folate equivalents) was higher for men (813 +/- 14) than for women (724 +/- 16) and higher for non-Hispanic whites (827 +/- 19) than for Mexican Americans (615 +/- 11) and non-Hispanic blacks (597 +/- 12); 29% of non-Hispanic black women had inadequate intakes. Total folate and folic acid intakes are highest for those aged > or =50 y, and 5% exceed the Tolerable Upper Intake Level. CONCLUSIONS Improved total folate intake is warranted in targeted subgroups, which include women of childbearing age and non-Hispanic black women, whereas other population groups are at risk of excessive intake.

Cardiorespiratory Fitness Levels Among US Adults 20–49 Years of Age: Findings From the 1999–2004 National Health and Nutrition Examination Survey

Data from the 1999-2004 National Health and Nutrition Examination Survey were used to describe the distribution of cardiorespiratory fitness and its association with obesity and leisure-time physical activity (LTPA) for adults 20-49 years of age without physical limitations or indications of cardiovascular disease. A sample of 7,437 adults aged 20-49 years were examined at a mobile examination center. Of 4,860 eligible for a submaximal treadmill test, 3,250 completed the test and were included in the analysis. The mean maximal oxygen uptake ( max) was estimated as 44.5, 42.8, and 42.2 mL/kg/minute for men 20-29, 30-39, and 40-49 years of age, respectively. For women, it was 36.5, 35.4, and 34.4 mL/kg/minute for the corresponding age groups. Non-Hispanic black women had lower fitness levels than did non-Hispanic white and Mexican-American women. Regardless of gender or race/ethnicity, people who were obese had a significantly lower estimated maximal oxygen uptake than did nonobese adults. Furthermore, a positive association between fitness level and LTPA participation was observed for both men and women. These results can be used to track future population assessments and to evaluate interventions. The differences in fitness status among population subgroups and by obesity status or LTPA can also be used to develop health policies and targeted educational campaigns.

Gender Differences in Hypertension Treatment, Drug Utilization Patterns, and Blood Pressure Control Among US Adults With Hypertension: Data From the National Health and Nutrition Examination Survey 1999–2004

BACKGROUND National guidelines recommend the same approach for treating hypertensive men and women. It is not known, however, whether current US antihypertensive medication utilization patterns and the resulting degrees of blood pressure (BP) control are similar or different among hypertensive women and men. METHODS The study was a cross-sectional, nationally representative survey of the noninstitutionalized civilian US population. Persons aged > or =18 years from the National Health and Nutrition Examination Survey (NHANES) 1999-2004 were classified as hypertensive based on a BP > or =140/90 mm Hg, currently taking antihypertensive medication, or having been diagnosed by a physician. RESULTS Among hypertensives, the prevalence of antihypertensive medication use was significantly higher among women than men (61.4% vs. 56.8%), especially among middle-aged persons (40-49 years, 53.1% vs. 42.7%) and among non-Hispanic blacks (65.5% vs. 54.6%). Also, treated women were more likely than men to use diuretics (31.6% vs. 22.3%) and angiotensin receptor blockers (11.3% vs. 8.7%). Among treated hypertensives, the proportion taking three or more antihypertensive drugs was lower among women than men, especially among older persons (60-69 years: 12.3% vs. 19.8%, 70-79 years: 18.6% vs. 21.2%, and > or =80 years: 18.8% vs. 22.8%). Only 44.8% of treated women achieved BP control vs. 51.1% of treated men. CONCLUSIONS Hypertensive women are significantly more likely to be treated than men, but less likely to have achieved BP control. Additional efforts may be needed to achieve therapeutic goals for the US hypertensive population, especially for hypertensive women.

High blood pressure and cardiovascular disease mortality risk among U.S. adults: the third National Health and Nutrition Examination Survey mortality follow-up study.

PURPOSE We sought to examine whether prehypertension is associated with increased cardiovascular disease (CVD) mortality risk and whether the association of blood pressure with CVD outcome is modified by social demographics or hypertension treatment and control. METHODS Data from the Third National Health and Nutrition Examination Survey and mortality follow-up through 2000 were used to estimate the relative risk of death from CVD associated with hypertension and prehypertension, after adjusting for confounding and modifying factors. RESULTS Compared with normotension, the relative risks of CVD mortality were 1.23 (95% confidence interval [95% CI] 0.85-1.79, p=0.26) for prehypertension, 1.64 (95% CI 1.11-2.41, p=0.01) for hypertension, 1.74 (95% CI 1.28-2.49, p=0.007) for uncontrolled hypertension, and 1.15 (95% CI 0.79-1.80, p=0.53) for controlled hypertension. Hypertensive adults <65 years and non-Hispanic blacks had a 3.86-fold and a 4.65-fold increased CVD mortality risk respectively. Age, gender, and race/ethnicity stratified analyses showed no associations between prehypertension and CVD mortality. However, blood pressure at a high range of prehypertension (130-139/84-89 mmHg) was associated with increased risk of CVD mortality (hazard ratio 1.41, p<0.05) relative to blood pressure less than 120/80 mmHg. CONCLUSIONS This study supports a strong, significant, and independent association of elevated blood pressure with CVD mortality risk. Hypertension continued to greatly increase CVD morality risk, particularly among persons <65 years and non-Hispanic blacks. Treatment and control of hypertension eliminated the excess CVD mortality risk observed among the hypertension population.

Antihypertensive Medication Use Among US Adults With Hypertension

BACKGROUND High blood pressure can be controlled through existing antihypertensive drug therapy. This study examined trends in prescribed antihypertensive medication use among US adults with hypertension and compared drug utilization patterns with recommendations of the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. METHODS AND RESULTS Persons aged > or =18 years from the National Health and Nutrition Examination Surveys were identified as hypertensive on the basis of either a blood pressure > or =140/90 mm Hg or self-reported current treatment for hypertension with a prescription medication. In 1999-2002, 62.9% of US hypertensive adults took a prescription antihypertensive medication compared with 57.3% during 1988-1994 (P<0.01). Men had the greatest increase in antihypertensive medication use (47.5%, 1988-1994 versus 57.9%, 1999-2002 [P<0.001]). In both surveys, antihypertensive medication use increased with age, was lower among men than among women, and was lower among Mexican Americans than among non-Hispanic whites and blacks. Multiple antihypertensive drug use increased from 29.1% to 35.8% (P<0.001). Polytherapy with a calcium channel blocker, beta-blocker, or angiotensin-converting enzyme inhibitor significantly increased by 30%, 42%, and 68%, respectively, whereas monotherapy with a diuretic or beta-blocker significantly decreased. For hypertensives with diabetes, congestive heart failure, or a prior heart attack, the utilization patterns closely followed the Sixth Joint National Committee guideline recommendations. CONCLUSIONS Antihypertensive medication use and multiple antihypertensive medication use among US hypertensive adults increased over the past 10 years, but disparities by sociodemographic factors continue to exist.

Trends in Blood Pressure Among Adults With Hypertension: United States, 2003 to 2012

The aim of this study is to describe trends in the awareness, treatment, and control of hypertension; mean blood pressure; and the classification of blood pressure among US adults 2003 to 2012. Using data from the National Health and Nutrition Examination Survey 2003 to 2012, a total of 9255 adult participants aged ≥18 years were identified as having hypertension, defined as measured blood pressure ≥140/90 mm Hg or taking prescription medication for hypertension. Awareness and treatment among hypertensive adults were ascertained via an interviewer administered questionnaire. Controlled hypertension among hypertensive adults was defined as systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg. Blood pressure was categorized as optimal blood pressure, prehypertension, and stage I and stage II hypertension. Between 2003 and 2012, the percentage of adults with controlled hypertension increased (P-trend <0.01). Hypertensive adults with optimal blood pressure and with prehypertension increased from 13% to 19% and 27% to 33%, respectively (P-trend <0.01 for both groups). Among hypertensive adults who were taking antihypertensive medication, uncontrolled hypertension decreased from 38% to 30% (P-trend <0.01). Similarly, a decrease in mean systolic blood pressure was observed (P-trend <0.01); however, mean diastolic blood pressure remained unchanged. The trend in the control of blood pressure has improved among hypertensive adults resulting in a higher percentage with blood pressure at the optimal or prehypertension level and a lower percentage in stage I and stage II hypertension. Overall, mean systolic blood pressure decreased as did the prevalence of uncontrolled hypertension among the treated hypertensive population.