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Racial and Ethnic Differences in Blood Pressure Among US Adults, 1999–2018

Originally publishedhttps://doi.org/10.1161/HYPERTENSIONAHA.121.18086Hypertension. 2021;78:1730–1741

Abstract

Racial and 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 to 2002 through 2015 to 2018 (n=51 743) to determine if racial and ethnicity disparities have changed over time. Among US adults not taking antihypertensive medication, the mean age-adjusted SBP (95% CI), mm Hg, in 1999 to 2002 and 2015 to 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 mm Hg (2.7–5.4) higher in 1999 to 2002 and 3.8 mm Hg (2.6–5.0) higher in 2015 to 2018 among non-Hispanic Black adults compared with non-Hispanic White adults, while there was no evidence of a difference between Hispanic adults and non-Hispanic White adults in 1999 to 2002 (−0.2 mm Hg [95% CI, −1.9 to 1.5]) or 2015 to 2018 (−0.8 mm Hg [95% CI, −1.8 to 0.1]). Among US adults taking antihypertensive medication, the mean age-adjusted SBP (95% CI), mm Hg, in 1999 to 2002 and 2015 to 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 to 2002 and 2015 to 2018, mean SBP was 4.8 mm Hg (1.8–7.8) and 6.5 mm Hg (4.5–8.4) higher, respectively, among non-Hispanic Black adults versus White adults, and 2.4 mm Hg (−2.6 to 7.3) and 3.6 mm Hg (0.8 to 6.4) higher, respectively, among Hispanic adults versus non-Hispanic White adults. In the United States, non-Hispanic Black adults continue to have higher SBP levels compared with non-Hispanic White adults.

Introduction

The prevalence of hypertension has been reported to be higher among Black adults compared with White adults in the United States, whereas the prevalence is lower among Asian and Hispanic adults.1,2 According to data from the 2015 to 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 with 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 adults versus White adults.4,5

Racial and 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 race and ethnic disparities in CVD.10 Determining whether BP differences by race and ethnicity 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 race and ethnicity among US adults not taking and taking antihypertensive medication from 1999 to 2000 through 2017 to 2018. In addition, we compared differences in SBP and DBP between racial and ethnic groups in 2015 to 2018 versus 1999 to 2002 to determine if racial and ethnic disparities have been reduced in the past 20 years. To accomplish these goals, data from ten 2-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 noninstitutionalized US population. Since 1999 to 2000, the National Center for Health Statistics has conducted NHANES in 2-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 to 2000 through 2017 to 2018 were analyzed. The National Center for Health Statistics 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=1588) and those who did not have at least one SBP and DBP measurement (n=2772) 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 in the Supplemental Material).

Data Collection

Standardized questionnaires were administered by trained interviewers and used to assess each participant’s age, sex, race and ethnicity, annual household income, health insurance type, health care 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 to 2000 until 2009 to 2010, race and ethnicity was defined as non-Hispanic White, non-Hispanic Black, Hispanic and other, according to the self-reported race and ethnic categories in the publicly available NHANES data sets. Beginning with the 2011 to 2012 cycle, the publicly available NHANES data included non-Hispanic Asian as its own race and ethnicity category.

Body mass index was calculated as weight in kilograms divided by height in meters squared 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, nonfasting 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 was calculated using age, sex, race and ethnicity, serum creatinine and the chronic kidney disease epidemiology collaboration equation.11 Chronic kidney disease was defined as an estimated glomerular filtration rate <60 mL/min per 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 4 mutually exclusive BP categories based on the 2017 American College of Cardiology/American Heart Association BP guideline12: (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 to 2000 and 2017 to 2018 NHANES cycles by race and ethnicity. Due to small sample sizes and unstable estimates, statistics for participants of race and 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 4 BP categories defined by the 2017 American College of Cardiology/American Heart Association BP guideline for US adults by antihypertensive medication use and race and ethnicity in each 2-year period from 1999 to 2000 through 2017 to 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 2-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 and ethnicity for US adults not taking and taking antihypertensive medication, separately, in each 2-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 and 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 2-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 to 2000 and 2001 to 2002 cycles and the 2015 to 2016 and 2017 to 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 and 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 to 2002 and 2015 to 2018, separately, with adjustment for age, sex, body mass index, annual household income, health insurance type, having a health care visit in the past year, diabetes, chronic kidney disease, and a history of clinical CVD. We assessed whether race and 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 to 2002 through 2015 to 2018 using an interaction term between race and ethnicity and survey period (2015–2018 versus 1999–2002). Statistical significance was defined by a 2-sided P<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 and Ethnicity in 1999–2000 and 2017–2018

CharacteristicsNHANES cycle
1999–2000 (n=4427)2017–2018 (n=5173)
Non-Hispanic WhiteNon-Hispanic BlackNon-Hispanic Asian*HispanicNon-Hispanic WhiteNon-Hispanic BlackNon-Hispanic AsianHispanic
Not taking antihypertensive medication
 Unweighted no. of participants146563413081253749556920
 Weighted proportion70.1%9.8%15.3%62.0%10.2%5.8%17.2%
 Age, y
  18–4460.4%74.6%72.0%51.4%68.2%61.4%67.4%
  45–6428.3%20.6%22.7%33.2%25.8%31.4%27.8%
  65–746.9%3.1%3.4%10.5%3.8%3.9%3.7%
  ≥754.4%1.8%1.8%4.9%2.2%3.3%1.0%
 Women49.8%50.4%50.4%51.1%51.8%51.6%50.6%
 Body mass index
  Normal42.6%38.0%31.6%34.0%30.3%51.0%19.3%
  Overweight33.6%28.1%41.1%28.7%25.8%35.5%37.5%
  Obese23.8%33.9%27.4%37.2%43.9%13.6%43.2%
 Income
  <$20 00017.9%29.2%27.6%10.2%20.6%8.0%18.6%
  $20 000–$44 99927.5%39.1%42.8%21.2%31.7%17.2%30.0%
  $45 000–$74 99927.4%17.1%18.0%18.2%19.4%19.6%23.0%
  ≥$75 00027.2%14.5%11.6%50.4%28.4%55.1%28.4%
 Health insurance
  Private74.7%61.9%50.5%67.2%40.5%64.8%46.4%
  Medicare5.5%3.7%4.9%7.5%5.7%4.7%3.3%
  Medicaid1.6%4.1%5.2%8.4%19.0%12.8%13.6%
  Other government1.2%0.7%0.6%5.4%10.2%7.6%7.2%
  Uninsured16.9%29.5%38.7%11.5%24.7%10.1%29.5%
 Health care visit in the last year81.0%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 disease13.0%14.9%14.0%13.4%17.9%16.1%11.3%
 History of clinical CVD4.6%2.7%1.2%4.5%3.2%1.4%1.6%
Taking antihypertensive medication
 Unweighted no. of participants418230230541455176246
 Weighted proportion74.1%13.5%9.6%64.5%14.8%5.4%10.3%
 Age, y
  18–4413.4%19.9%13.8%6.3%14.3%10.3%14.7%
  45–6442.9%50.1%51.2%41.4%50.1%50.6%49.9%
  65–7423.9%18.6%22.9%28.1%18.8%23.5%24.1%
  ≥7519.8%11.4%12.2%24.1%16.8%15.6%11.3%
 Women51.0%63.8%67.7%50.2%61.5%56.5%46.1%
 Body mass index
  Normal18.6%14.4%5.8%12.2%15.7%28.4%10.4%
  Overweight33.9%29.9%49.3%29.3%24.5%48.7%34.9%
  Obese47.5%55.8%45.0%58.5%59.9%22.9%54.7%
 Income
  <$20 00027.5%43.0%57.0%11.0%22.8%14.5%20.9%
  $20 000–$44 99931.8%32.3%19.0%25.1%27.9%12.1%34.4%
  $45 000–$74 99921.0%9.9%17.4%20.7%19.3%22.8%12.4%
  ≥$75 00019.7%14.8%6.7%43.1%29.9%50.7%32.3%
 Health insurance
  Private75.0%64.2%38.6%70.0%49.0%54.8%39.6%
  Medicare18.7%20.5%30.2%15.9%23.7%26.3%24.9%
  Medicaid2.4%2.7%11.8%4.1%8.7%4.1%15.6%
  Other government1.3%2.2%1.1%4.9%8.4%8.7%9.6%
  Uninsured2.6%10.4%18.3%5.0%10.2%6.2%10.3%
 Health care visit in the last year99.3%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 disease33.7%45.1%38.0%39.4%40.1%40.2%30.0%
 History of clinical CVD20.1%12.2%12.5%22.1%17.5%11.9%16.4%

CVD indicates cardiovascular disease; and NHANES, National Health and Nutrition Examination Survey.

* 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 and 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, nonfasting 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 per 1.73 m2 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) and Taking (Bottom) Antihypertensive Medication in 1999–2002 and 2015–2018

Race-ethnicitySystolic blood pressure, mm HgDiastolic blood pressure, mm Hg
1999–20022015–20181999–20022015–2018
Age-adjusted mean (95% CI)Mean difference* (95% CI)Age-adjusted mean (95% CI)Mean difference* (95% CI)P valueAge-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 White119.6 (118.7 to 120.5)0 (Ref)119.4 (118.7 to 120.1)0 (Ref)Ref72.4 (71.6 to 73.1)0 (Ref)71.3 (70.4 to 72.2)0 (Ref)Ref
 NH Black124.7 (123.7 to 125.7)4.1 (2.7 to 5.4)124.9 (123.8 to 125.9)3.8 (2.6 to 5.0)0.7273.8 (72.9 to 74.7)1.3 (−0.2 to 2.9)72.3 (71.3 to 73.2)0.8 (−0.3 to 1.9)0.60
 NH Asian118.9 (117.8 to 119.9)0.7 (−0.5 to 1.8)73.1 (72.3 to 73.8)2.7 (1.7 to 3.7)
 Hispanic120.4 (118.6 to 122.2)−0.2 (−1.9 to 1.5)120.4 (119.7 to 121.2)−0.8 (−1.8 to 0.1)0.5471.6 (70.8 to 72.4)−1.0 (−2.1 to 0.2)70.7 (69.8 to 71.5)−0.9 (−1.9 to 0.1)0.97
US adults taking antihypertensive medication
 NH White129.6 (126.7 to 132.4)0 (Ref)127.1 (125.6 to 128.6)0 (Ref)Ref77.8 (75.7 to 80.0)0 (Ref)77.0 (75.3 to 78.8)0 (Ref)Ref
 NH Black136.9 (133.8 to 140.0)4.8 (1.8 to 7.8)135.3 (132.5 to 138.1)6.5 (4.5 to 8.4)0.3780.8 (78.5 to 83.0)4.2 (2.0 to 6.4)79.0 (76.7 to 81.2)2.4 (0.6 to 4.1)0.23
 NH Asian131.4 (127.1 to 135.7)3.9 (1.0 to 6.8)77.8 (75.6 to 79.9)1.3 (−0.5 to 3.0)
 Hispanic133.9 (128.0 to 139.7)2.4 (−2.6 to 7.3)131.8 (127.6 to 136.0)3.6 (0.8 to 6.4)0.6875.9 (71.5 to 80.4)1.9 (−0.6 to 4.5)77.7 (74.8 to 80.6)0.1 (−1.7 to 1.8)0.26

NH indicates non-Hispanic; and NHANES, National Health and Nutrition Examination Survey.

* Adjusted for age, sex, body mass index, income, insurance, health care 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 vs non-Hispanic White adults in 2015–2018 vs 1999–2002.

‡ Information on non-Hispanic Asian adults was not available in the NHANES 1999–2002 public use data files.

Results

In both 1999 to 2000 and 2017 to 2018, non-Hispanic Black and Hispanic adults not taking antihypertensive medication were more likely to be 18 to 44 years of age, obese, have an income <$20 000 and be uninsured compared with non-Hispanic White adults (Table 1). Among adults taking antihypertensive medication, in both 1999 to 2000 and 2017 to 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 with non-Hispanic White adults. Non-Hispanic Black adults taking antihypertensive medication were also more likely to obese and have diabetes in 1999 to 2000 compared with non-Hispanic White adults.

Trends in BP From 1999 to 2000 Through 2017 to 2018

From 1999 to 2000 through 2009 to 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 to 2018 (Figure 1, Table S1). Between 1999 to 2000 and 2011 to 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 to 2018, respectively. Among non-Hispanic White adults not taking antihypertensive medication, the mean age-adjusted DBP decreased by 2.2 mm Hg, from 1999 to 2000 through 2005 to 2006 and then increased 1.6 mm Hg by 2017 to 2018. From 1999 to 2000 through 2013 to 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 to 2018, respectively.

Figure 1.

Figure 1. Trends in the mean age-adjusted systolic and diastolic blood pressure overall and by race and ethnicity among US adults not taking antihypertensive medication, 1999–2000 to 2017–2018.A, Systolic blood pressure. 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 18–44 y, 45–64 y, 65–74 y, and 75 y 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 18–44 y, 45–64 y, 65–74 y, and 75 y or older, respectively.

Among US adults taking antihypertensive medication, from 1999 to 2000 through 2009 to 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 to 2018, respectively (Figure 2, Table S1). Among Hispanic adults, the mean age-adjusted SBP declined by 9.9 mm Hg between 1999 to 2000 and 2013 to 2014 and then increased 4.1 mm Hg by 2017 to 2018. The mean age-adjusted DBP declined by 4.8 mm Hg among non-Hispanic White adults between 1999 to 2000 and 2009 to 2010 and then increased 5.0 mm Hg by 2017 to 2018. From 1999 to 2000 through 2013 to 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 to 2018. Trends in the mean age-adjusted difference in SBP and DBP for non-Hispanic Black and Hispanic adults compared with non-Hispanic White US adults not taking and taking antihypertensive medication from 1999 to 2000 through 2017 to 2018 are shown in Figure S2 and Table S2.

Figure 2.

Figure 2. Trends in the mean age-adjusted systolic and diastolic blood pressure overall and by race and ethnicity among US adults taking antihypertensive medication, 1999–2000 to 2017–2018.A, Systolic blood pressure. 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 18–44 y, 45–64 y, 65–74 y, and 75 y 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 18–44 y, 45–64 y, 65–74 y, and 75 y or older, respectively.

Difference in SBP and DBP by Race and Ethnicity in 1999 to 2002 and 2015 to 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 with non-Hispanic White adults, in 1999 to 2002 and 2015 to 2018, respectively (Table 2, top). There was no evidence of a difference in mean SBP between Hispanic and non-Hispanic White adults in 1999 to 2002 or 2015 to 2018. After multivariable adjustment, mean DBP was 2.7 mm Hg (95% CI, 1.7–3.7) higher among non-Hispanic Asian compared with non-Hispanic White adults not taking antihypertensive medication in 2015 to 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 with non-Hispanic White adults, in 1999 to 2002 and 2015 to 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 to 2018 (Table 2, bottom). 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 with non-Hispanic White adults taking antihypertensive medication in 1999 to 2000 and 2015 to 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 to 2000 through 2013 to 2014 and increased by 2017 to 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 to 2000 through 2011 to 2012 and then increased by 2017 to 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 to 2000 through 2011 to 2012, and then increased by 2017 to 2018. The proportion of Hispanic adults taking antihypertensive medication with SBP ≥140 mm Hg or DBP ≥90 mm Hg decreased from 1999 to 2000 through 2017 to 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 with non-Hispanic White US adults not taking and taking antihypertensive medication from 1999 to 2000 through 2017 to 2018 are shown in Figure S3 and Table S5.

Figure 3.

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 and ethnicity, 1999–2000 to 2017–2018.A, Adults not taking antihypertensive medication. 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 18–44 y, 45–64 y, 65–74 y, and 75 y 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 18–44 y, 45–64 y, 65–74 y, and 75 y or older, respectively.

PRs for BP Categories by Race and Ethnicity in 1999 to 2002 and 2015 to 2018

After multivariable adjustment and among US adults not taking antihypertensive medication, non-Hispanic Black adults in 1999 to 2000 and 2015 to 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 with non-Hispanic White adults (Table 3, top). In 2015 to 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 to 2002 and 2015 to 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 with non-Hispanic White adults after multivariable adjustment (Table 3, bottom). Among those taking antihypertensive medication in 2015 to 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) and Taking (Bottom) Antihypertensive Medication in 1999–2002 and 2015–2018

Race-ethnicitySBP ≥140 mm Hg or DBP ≥90 mm Hg*SBP ≥130 mm Hg or DBP ≥80 mm Hg*
1999–20022015–20181999–20022015–2018
Age-adjusted prevalence (95% CI)Prevalence ratio (95% CI)Age-adjusted prevalence (95% CI)Prevalence ratio (95% CI)P valueAge-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 White12.6% (10.8–14.4)1 (Ref)10.6% (8.7–12.6)1 (Ref)Ref34.6% (32.0–37.3)1 (Ref)29.0% (26.3–31.6)1 (Ref)Ref
 NH Black19.4% (16.7–22.1)1.43 (1.15–1.79)18.5% (16.2–20.7)1.54 (1.21–1.97)0.6645.4% (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 Asian12.3% (10.2–14.3)1.31 (1.02–1.67)33.7% (30.0–37.3)1.35 (1.17–1.56)
 Hispanic14.8% (11.5–18.1)1.05 (0.79–1.39)11.5% (10.2–12.8)0.88 (0.71–1.10)0.3732.2% (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 White41.3% (37.8–44.7)1 (Ref)31.0% (27.8–34.2)1 (Ref)Ref68.2% (64.9–71.5)1 (Ref)55.5% (51.1–59.9)1 (Ref)Ref
 NH Black52.1% (48.9–55.4)1.22 (1.07–1.40)44.8% (41.1–48.5)1.37 (1.23–1.52)0.2176.0% (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 Asian40.0% (33.3–46.7)1.25 (0.99–1.58)67.7% (63.4–72.0)1.19 (1.06–1.34)
 Hispanic47.9% (39.5–56.3)1.03 (0.80–1.33)39.3% (34.2–44.3)1.16 (0.95–1.42)0.4773.9% (66.8–81.0)1.06 (0.95–1.19)62.7% (57.5–67.9)1.09 (0.97–1.23)0.77

DBP indicates diastolic blood pressure; NH, non-Hispanic; NHANES, National Health and Nutrition Examination Survey; and SBP, systolic blood pressure.

* Adjusted for age, sex, body mass index, income, insurance, health care visit in the past year, diabetes, chronic kidney disease, and prior cardiovascular disease.

P value for the change in the prevalence ratios for SBP ≥140 mm Hg or DBP ≥90 mm Hg and SBP ≥130 mm Hg or DBP ≥80 mm Hg between non-Hispanic Black adults and Hispanic adults vs non-Hispanic White adults in 2015–2018 vs 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 to 2000 and 2017 to 2018. Among US adults not taking antihypertensive medication, the mean SBP and DBP in 2015 to 2018 were within 1 to 2 mm Hg of values in 1999 to 2002 for each race and 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 with non-Hispanic White US adults that were present in 1999 to 2002 were attenuated by 2015 to 2018.

In the current study, the mean age-adjusted SBP and DBP were similar in 1999 to 2000 and 2017 to 2018 among US adults not taking antihypertensive medication for each race and ethnicity group. While decreases in SBP and DBP among adults not taking antihypertensive medication occurred as recently as 2013 to 2014, increases in SBP and DBP through 2017 to 2018 reversed previous improvements. Nonpharmacological 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 with obesity is increasing and the prevalence is higher among Black women compared with 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 racial and 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 with non-Hispanic White adults in 1999 to 2002 were not reduced in 2015 to 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,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 social determinants of health contribute to inequalities in BP between Black and White populations.8,23–25 In 2020, both the US Surgeon General and the American Heart Association 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.23,26–30 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 with White adults. There are several potential reasons for these findings. The 2017 American College of Cardiology/American Heart Association BP guideline endorsed the use of 2 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 with 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 chronic kidney disease, 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 American College of Cardiology/American Heart Association BP guideline recommends averaging BP measurements from 2 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 before 2011 to 2012 which restricted the description of trends for this group to 8 years, 2011 to 2012 through 2017 to 2018. The response rate for NHANES has declined from 1999 to 2000 through 2017 to 2018. However, any potential bias from the differential response rate across subgroups was reduced by weighting adjustment.39

Perspectives

In conclusion, the mean age-adjusted SBP and DBP in 2017 to 2018 was within 1 mm Hg of levels 20 years earlier in 1999 to 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 with non-Hispanic White adults, in 1999 to 2002 remained present in 2015 to 2018. These data emphasize the importance of population-wide efforts to improve BP control and equity in BP levels between race and ethnic populations in the United States.

Article Information

Nonstandard Abbreviations and Acronyms

BP

blood pressure

CVD

cardiovascular disease

DBP

diastolic blood pressure

NHANES

National Health and Nutrition Examination Survey

PRs

prevalence ratios

SBP

systolic blood pressure

Footnotes

*The content in this manuscript is solely the responsibility of the author and does not necessarily represent the official views of the American Medical Association.

The Supplemental Material is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/HYPERTENSIONAHA.121.18086.

For Sources of Funding and Disclosures, see page 1740.

Correspondence to: Shakia T. Hardy, PhD, MPH, Department of Epidemiology, University of Alabama at Birmingham, 1665 University Blvd, Birmingham, AL 35233. Email

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Novelty and Significance

What Is New?

  • Determining whether blood pressure differences by race and ethnicity 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 blood pressure was 4.1 mm Hg higher in 1999 to 2002 and 3.8 mm Hg higher in 2015 to 2018 among non-Hispanic Black compared with non-Hispanic White adults. Among US adults taking antihypertensive medication in 1999 to 2002 and 2015 to 2018, mean multivariable-adjusted systolic blood pressure was 4.8 and 6.5 mm Hg higher, respectively, among non-Hispanic Black adults versus White adults, and 2.4 and 3.6 mm Hg higher, respectively, among Hispanic adults versus non-Hispanic White adults.

Summary

In the United States, non-Hispanic Black adults continue to have higher systolic blood pressure levels compared with non-Hispanic White adults.