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Abstract—Overall hypertension prevalence has not changed in the United States in recent decades although awareness,
treatment, and control improved. However, hypertension epidemiology and its temporal trends may differ in younger adults
compared with older adults. Our study included 41 331 participants ≥18 years of age from 8 National Health and Nutrition
Examination Surveys (1999–2014) and estimated temporal trends of hypertension, awareness, treatment, and control
among young adults (age, 18–39 years) compared with middle-age (age, 40–59 years) and older adults (age, ≥60 years).
In 2013 to 2014, 7.3% of the US young adults had hypertension. During 1999 to 2014, young adults saw larger increases
in hypertension awareness, treatment, and control than did older adults. However, all of these components of hypertension
control were lower among young adults compared with middle-aged or older adults (74.7% younger versus 81.9% middle
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versus 88.4% older for awareness; 50.0% versus 70.3% versus 83.0% for treatment; and 40.2% versus 56.7% versus 54.4%
for control). Worse hypertension awareness, treatment, and control in young adults overall were mostly driven by worse
measures in young adult men compared with young adult women. More frequent healthcare visits by young adult women
explained ≈28% of the sex-related difference in awareness, 60% of the difference in treatment, and 52% of the difference in
control. These findings suggest that improved access to and engagement in medical care might improve hypertension control
in young adults, particularly young adult men, and reduce life-time cardiovascular risk. (Hypertension. 2017;70:00-00.
•
DOI: 10.1161/HYPERTENSIONAHA.117.09801.) Online Data Supplement
Key Words: blood pressure ■ body mass index ■ cardiovascular diseases ■ hypertension ■ young adult
Received May 30, 2017; first decision June 16, 2017; revision accepted July 12, 2017.
From the Division of General Medicine, Columbia University, New York, NY.
The online-only Data Supplement is available with this article at http://hyper.ahajournals.org/lookup/suppl/doi:10.1161/HYPERTENSIONAHA.
117.09801/-/DC1.
Correspondence to Andrew E. Moran, Division of General Medicine, Columbia University Medical Center, Presbyterian Hospital, 9th Floor E, Room
105, 622 W, 168th St, New York, NY 10032. E-mail aem35@cumc.columbia.edu
© 2017 American Heart Association, Inc.
Hypertension is available at http://hyper.ahajournals.org DOI: 10.1161/HYPERTENSIONAHA.117.09801
1
2 Hypertension October 2017
When further stratified by sex, temporal trends in hyper- young adult men (68.4% versus 86.0% for awareness; 43.7%
tension prevalence, awareness, treatment, and control in men versus 61.3% for treatment; and 33.7% versus 51.8% for
and women were similar to those observed in the overall pop- control, respectively, in 2013–2014). Young adult women
ulation (Figure 3). However, young adult men had a substan- reported on average more healthcare visits than men (Figure
tially higher prevalence of pre-hypertension compared with S3). More frequent healthcare visits in women explained
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young adult women (33.6% versus 12.8% in 2013–2014). ≈28% of the sex-related difference in awareness, 60% of the
Awareness, treatment, and control were also much lower in difference in treatment, and 52% of the difference in control in
Figure 2. Age-standardized weighted prevalence (95% confidence interval) of hypertension, pre-hypertension, awareness, treatment, and
control by age.
4 Hypertension October 2017
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Figure 3. Age-standardized weighted prevalence (95% confidence interval) of hypertension, pre-hypertension, awareness, treatment, and
control by age and sex.
2013 to 2014 (Figure S4). In contrast, health insurance status obese among those with hypertension was 2.87 (95% confi-
explained little of the differences in hypertension awareness dence interval, 1.82–4.51) comparing young adults to those
(5%), treatment (8%), and control (8%) between young adult aged ≥40 years, adjusting for sex and race/ethnicity.
men and women.
When stratified by race/ethnicity, non-Hispanic blacks had Discussion
a higher prevalence of hypertension compared with non-His- In a representative sample of noninstitutionalized US adults,
panic whites or Mexican-Americans across the years (Figure hypertension prevalence remained unchanged from 1999 to
S5). Among adults ≥40 years of age, awareness and treatment 2014, whereas there was a decrease in pre-hypertension and
were higher in non-Hispanic blacks, but the prevalence of an increase in the awareness, treatment, and control of hyper-
controlled hypertension was lower compared with non-His- tension. Despite these improvements, awareness, treatment,
panic whites. Hypertension awareness, treatment, and control and control were worse among young adults 18 to 39 years
stratified by race/ethnicity could not be reliably compared for of age compared with those ≥40 years. Worse hypertension
participants aged 18 to 39 years because of small numbers. awareness, treatment, and control in young adults were mostly
Among those with hypertension, obesity prevalence driven by lower prevalence of awareness, treatment, and con-
increased over time and was particularly high among young trol in young adult men compared with young adult women
adults (Figure 4). The age-standardized prevalence of obesity and were partly explained by fewer healthcare visits in young
increased from 65% in 1999 to 2000 to 73% in 2013 to 2014 adult men. These findings suggest that public health and medi-
among those aged 18 to 39 years, from 51% to 57% among cal care outreach efforts on young adults, particularly young
those aged 40 to 59 years, and from 35% to 42% among those adult men, could prevent hypertension and, potentially, later
aged ≥60 years. In 2013 to 2014, the odds ratio for being life cardiovascular disease.
Zhang and Moran Trends in Hypertension Among US Young Adults 5
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Figure 4. Age-standardized weighted prevalence of overweight and obesity among participants with hypertension.
Our study showed that the prevalence of hypertension control. We did observe that although the overall control
remained unchanged from 1999–2000 to 2013–2014 in all rate of hypertension was lower among young adults com-
age groups, consistent with previous findings.3,4 In addition, pared with middle-aged or older adults, when treated, young
we found that the prevalence of pre-hypertension decreased and middle-aged adults were more likely to achieve blood
from 31.1% to 24.0% in the same period, with the largest pressure control compared with older adults. This might be
reduction seen among young adults 18 to 39 years of age. explained by a higher proportion of stage 2 hypertension and
This decline in pre-hypertension was consistent with another higher prevalence of comorbidities limiting pharmacological
recent NHANES report.23 The exact reason for this decline is treatment among older adults.27,28
unclear; however, we observed a decrease in current smok- We also observed sex-related differences in pre-hyperten-
ing in our study with the largest reduction seen among young sion, awareness, and management among young adults, with
adults (data not shown), suggesting that decrease in smok- young adult men having substantially higher prevalence of
ing may partly explain the decrease in pre-hypertension.24 pre-hypertension and lower awareness, treatment, and control
Dietary patterns (eg, sodium and potassium intakes) may have compared with young adult women. Sex-related differences
changed as well during this period, but these changes were not were diminished in those ≥40 years of age. This awareness
reliably measurable in NHANES. Further research is needed and treatment gap between younger and older adult men is not
to better understand how changes in these factors or others a phenomenon unique to the United States: it has also been
may explain the decline in pre-hypertension in young adults. observed in China, South Korea, and Germany.29–31 Young
Hypertension awareness, treatment, and control increased women may be more likely to have their blood pressure
from 1999–2000 to 2013–2014, with the largest percentage checked than young men (eg, during regular gynecological
point improvements among young adults. Despite this prog- care or pregnancy).32 Accordingly, when we adjusted for num-
ress, only 53.9% of the hypertensive adults had their blood ber of healthcare visits in the past year as a surrogate marker
pressure controlled in 2013 to 2014, which was substantially of healthcare use, higher number of visits in women explained
lower than the Healthy People 2020 goal of 62.1%.25 some of the sex-related differences. These results were con-
Young adults 18 to 39 years have significantly lower sistent with previous NHANES reports,33,34 as well as with
awareness, treatment, and control of hypertension compared results from a cross-sectional study of young adults aged 24 to
with adults aged ≥40 years. Lower prevalence of treatment 32 years from the National Longitudinal Study of Adolescent
among young adults might be due, in part, to healthcare pro- Health, which found that hypertension awareness was ≈2-fold
viders’ uncertainty and concern about long-term benefits and higher in young adults who had seen a provider for routine
adverse effects of early pharmacological intervention in this healthcare in the past 2 years.35 Taken together, these findings
age group. As a case in point, the 2014 National Hypertension suggest that efforts to improve blood pressure control among
Guidelines strongly recommended treating raised DBP in young adults, particularly men, should focus on raising aware-
adults aged ≥30 years but only weakly recommended treat- ness, improving screening strategy, and advancing follow-up
ment in those aged 18 to 29 years.26 The best tolerated and and subsequent linkage to care.4,35 With implementation of the
safest approach to controlling blood pressure in young adults Affordable Care Act, the rate of insurance in US adults aged
may be lifestyle modifications, such as reduced sodium 19 to 25 years old increased by >10% since 2010, represent-
intake, weight loss, and physical activity. We were not able to ing an increase of ≈6.1 million young adults with access to
examine young adult uptake of these behaviors in the present a regular source of medical care, and potentially, prevention
analysis or how increased uptake might affect hypertension programs.36 In our analysis, health insurance coverage alone
6 Hypertension October 2017
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Medicine, Presbyterian Hospital, 9th Fl. East, Rm. 105, 622 West 168th St., New York, NY
1
Table S1. Age-standardized weighted prevalence (standard error) of hypertension, and awareness, treatment, and control of
hypertension per 100 adults in the US general population
Overall By NHANES survey cycle
Age 1999- 2001- 2003- 2005- 2007- 2009- 2011- 2013-
groups Total 2000 2002 2004 2006 2008 2010 2012 2014
Cases P-trend
N (n = (n = (n = (n = (n = (n = (n = (n =
4,487) 4,945) 4,668) 4,693) 5,615) 5,988) 5,294) 5,641)
Hypertension
All 41,331 14,229 28.7 (1.4) 28.0 (0.9) 29.7 (1.1) 29.0 (1.0) 29.6 (0.7) 28.5 (0.9) 28.7 (0.7) 29.4 (0.9)
Age
(years)
18-39 15,669 1,053 7.6 (1.6) 6.4 (0.5) 6.8 (0.8) 7.2 (1.0) 7.8 (0.9) 6.8 (0.7) 7.3 (0.6) 7.3 (0.5) 0.80
40-59 12,490 4,174 30.2 (2.0) 29.3 (1.9) 33.1 (2.2) 31.2 (1.8) 32.2 (1.3) 30.4 (2.0) 31.8 (1.4) 32.7 (1.4) 0.61
≥60 13,172 9,002 66.1 (1.9) 66.9 (1.8) 67.2 (1.7) 66.5 (1.6) 66.5 (1.8) 66.7 (1.8) 64.4 (1.8) 65.6 (1.9) 0.64
P-value <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
Prehypertension
All 41,331 10,717 31.1 (1.0) 29.8 (0.9) 28.2 (0.9) 28.2 (1.2) 27.0 (1.0) 25.9 (1.0) 28.1 (1.1) 24.0 (0.7)
Age
(years)
18-39 15,669 4,286 32.2 (1.2) 30.6 (1.8) 27.0 (1.3) 29.0 (1.8) 27.1 (1.7) 27.6 (1.4) 27.6 (1.6) 23.4 (1.4) <0.001
40-59 12,490 3,894 34.7 (1.6) 34.0 (1.2) 34.9 (1.6) 33.7 (1.9) 30.9 (1.2) 29.2 (1.5) 33.9 (1.7) 27.1 (1.3) <0.001
≥60 13,172 2,537 23.1 (1.5) 21.2 (1.5) 19.9 (1.3) 17.7 (0.7) 20.4 (1.4) 17.5 (1.0) 19.9 (1.8) 20.3 (1.5) <0.001
P-value <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
Awareness (among participants with hypertension)
All 14,229 11,142 69.5 (2.0) 70.5 (1.5) 75.1 (1.7) 77.9 (1.5) 79.7 (1.1) 81.5 (1.5) 82.1 (1.8) 84.4 (1.3)
Age
(years)
18-39 1,053 602 52.1 (7.2) 48.6 (3.1) 53.7 (6.3) 51.8 (4.6) 64.7 (7.9) 58.7 (5.6) 61.5 (4.7) 74.7 (3.4) <0.001
40-59 4,174 3,274 73.0 (3.0) 72.1 (2.7) 75.1 (2.7) 79.2 (2.2) 79.1 (2.4) 84.1 (1.8) 82.5 (2.6) 81.9 (2.8) <0.001
≥60 9,002 7,266 70.0 (1.9) 73.4 (1.3) 79.3 (1.9) 81.9 (1.6) 83.2 (1.4) 84.0 (1.6) 85.8 (1.6) 88.4 (1.1) <0.001
2
P-value 0.03 <0.001 <0.001 <0.001 0.01 <0.001 <0.001 <0.001
Treatment (among participants with hypertension)
All 14,229 9,949 59.1 (2.7) 60.2 (1.7) 64.7 (2.2) 67.8 (1.6) 71.6 (1.2) 75.8 (1.7) 74.5 (1.9) 74.7 (2.2)
Age
(years)
18-39 1,053 418 27.7 (5.7) 35.9 (3.0) 39.3 (7.6) 29.3 (4.3) 49.1 (5.9) 46.0 (5.4) 44.0 (5.7) 50.0 (4.2) 0.001
40-59 4,174 2,784 62.1 (3.3) 58.8 (2.3) 61.4 (4.0) 66.1 (2.5) 67.7 (2.7) 77.0 (2.6) 72.9 (2.7) 70.3 (4.0) <0.001
≥60 9,002 6,747 62.8 (3.2) 66.1 (2.1) 72.2 (2.0) 76.6 (1.8) 79.1 (1.4) 80.6 (1.6) 81.7 (1.8) 83.0 (1.5) <0.001
P-value <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
Controlled (among participants treated for hypertension)
All 9,949 6,121 53.1 (2.5) 58.9 (1.2) 62.4 (2.3) 65.8 (1.8) 68.3 (1.4) 70.1 (1.2) 70.3 (1.9) 73.0 (1.5)
Age
(years)
50.9
18-39 418 301 80.0 (6.4) 77.3 (5.9) 81.5 (6.4) 82.7 (5.3) 71.2 (5.7) 78.1 (5.4) 80.4 (5.1) 0.13
(10.9)
40-59 2,784 1,942 65.6 (3.5) 63.0 (2.6) 66.9 (3.2) 71.6 (3.2) 73.8 (1.8) 72.4 (2.4) 79.1 (3.1) 80.7 (2.6) <0.001
≥60 6,747 3,878 43.5 (2.4) 51.6 (1.3) 55.9 (2.6) 58.2 (2.2) 61.3 (2.0) 68.1 (1.4) 61.9 (2.7) 65.5 (1.8) <0.001
P-value <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
Controlled (among all participants with hypertension)
All 14,229 6,121 31.4 (2.4) 34.8 (1.5) 39.7 (2.2) 43.7 (1.5) 48.3 (1.6) 53.1 (1.7) 51.8 (2.4) 53.9 (2.6)
Age
(years)
18-39 1,053 301 14.1 (2.9) 28.7 (3.9) 30.4 (7.3) 23.9 (4.3) 40.6 (6.0) 32.8 (5.0) 34.4 (5.5) 40.2 (3.9) <0.001
40-59 4,174 1,942 40.8 (3.4) 37.1 (2.6) 41.1 (3.7) 47.4 (2.4) 49.9 (2.4) 55.7 (2.4) 57.7 (3.9) 56.7 (4.7) <0.001
≥60 9,002 3,878 27.4 (2.3) 34.1 (1.4) 40.4 (1.9) 44.6 (2.3) 48.4 (2.0) 54.9 (2.0) 50.6 (2.5) 54.4 (1.9) <0.001
P-value <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
3
Figure S1. Age-standardized weighted prevalence of health insurance and healthcare
visits among participants with hypertension, by age group.
4
Figure S2. Unadjusted and adjusted prevalence of hypertension, and awareness,
treatment, and control of hypertension by age.
5
Figure S3. Age-standardized weighted prevalence of health insurance and healthcare
visits among participants with hypertension, by age and sex.
6
Figure S4. Unadjusted and adjusted prevalence of hypertension awareness, treatment,
and control by sex among young adults 18-39 years of age.
7
Figure S5. Age-standardized weighted prevalence (95% CI) of hypertension,
prehypertension, awareness, treatment, and control by age and race.
Estimates with relative standard error > 30% were not shown in the plot.
8
Figure S6. Age-standardized weighted mean systolic and diastolic blood pressure
among the overall population and those treated for hypertension.