Child Maltreatment and Inflammatory Response to Mental Stress Among Adults Who Have Survived a Myocardial Infarction.

OBJECTIVE: Experiences of child maltreatment are associated with cardiovascular risk and disease in adulthood; however, the mechanisms underlying these associations are poorly understood. METHODS: We examined associations between retrospectively self-reported exposure to child maltreatment (Early Trauma Inventory Self-Report Short Form) and inflammatory responses to mental stress among adults (mean age = 50 years) who recently had a myocardial infarction ( n = 227). Inflammation was assessed as blood interleukin-6 (IL-6), matrix metalloproteinase-9 (MMP-9), and monocyte chemoattractant protein-1 concentrations, measured before and after a standardized public speaking stress task. We used mixed linear regression models adjusting for cardiovascular disease severity, medication usage, and psychosocial, demographic, and life-style factors. RESULTS: In women, increases in IL-6 levels and MMP-9 levels with stress were smaller in those exposed to sexual abuse, relative to those unexposed (IL-6 geometric mean increases = 1.6 [95% confidence interval {CI} = 1.4-1.9] pg/ml versus 2.1 [95% CI = 1.8-2.4] pg/ml; MMP-9 geometric mean increases = 1.0 [95% CI = 0.9-1.2] ng/ml versus 1.2 [95% CI = 1.1-1.4] ng/ml). No differences were noted for emotional or physical abuse. By contrast in men, individuals exposed to sexual abuse had larger IL-6 responses than those not exposed to abuse. CONCLUSIONS: These findings suggest sex differences in stress response among survivors of a myocardial infarction exposed to abuse early in life. They also underscore the importance of examining sex as an effect modifier of relationships between exposure to early life adversity and inflammatory responses to mental stressors in midlife.

Does This Adult Patient Have Hypertension?: The Rational Clinical Examination Systematic Review.

Importance: Office blood pressure (BP) measurements are not the most accurate method to diagnose hypertension. Home BP monitoring (HBPM) and 24-hour ambulatory BP monitoring (ABPM) are out-of-office alternatives, and ABPM is considered the reference standard for BP assessment. Objective: To systematically review the accuracy of oscillometric office and home BP measurement methods for correctly classifying adults as having hypertension, defined using ABPM. Data Sources: PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and DARE databases and the American Heart Association website (from inception to April 2021) were searched, along with reference lists from retrieved articles. Data Extraction and Synthesis: Two authors independently abstracted raw data and assessed methodological quality. A third author resolved disputes as needed. Main Outcomes and Measures: Random effects summary sensitivity, specificity, and likelihood ratios (LRs) were calculated for BP measurement methods for the diagnosis of hypertension. ABPM (24-hour mean BP ≥130/80 mm Hg or mean BP while awake ≥135/85 mm Hg) was considered the reference standard. Results: A total of 12 cross-sectional studies (n = 6877) that compared conventional oscillometric office BP measurements to mean BP during 24-hour ABPM and 6 studies (n = 2049) that compared mean BP on HBPM to mean BP during 24-hour ABPM were included (range, 117-2209 participants per analysis); 2 of these studies (n = 3040) used consecutive samples. The overall prevalence of hypertension identified by 24-hour ABPM was 49% (95% CI, 39%-60%) in the pooled studies that evaluated office measures and 54% (95% CI, 39%-69%) in studies that evaluated HBPM. All included studies assessed sensitivity and specificity at the office BP threshold of 140/90 mm Hg and the home BP threshold of 135/85 mm Hg. Conventional office oscillometric measurement (1-5 measurements in a single visit with BP ≥140/90 mm Hg) had a sensitivity of 51% (95% CI, 36%-67%), specificity of 88% (95% CI, 80%-96%), positive LR of 4.2 (95% CI, 2.5-6.0), and negative LR of 0.56 (95% CI, 0.42-0.69). Mean BP with HBPM (with BP ≥135/85 mm Hg) had a sensitivity of 75% (95% CI, 65%-86%), specificity of 76% (95% CI, 65%-86%), positive LR of 3.1 (95% CI, 2.2-4.0), and negative LR of 0.33 (95% CI, 0.20-0.47). Two studies (1 with a consecutive sample) that compared unattended automated mean office BP (with BP ≥135/85 mm Hg) with 24-hour ABPM had sensitivity ranging from 48% to 51% and specificity ranging from 80% to 91%. One study that compared attended automated mean office BP (with BP ≥140/90 mm Hg) with 24-hour ABPM had a sensitivity of 87.6% (95% CI, 83%-92%) and specificity of 24.1% (95% CI, 16%-32%). Conclusions and Relevance: Office measurements of BP may not be accurate enough to rule in or rule out hypertension; HBPM may be helpful to confirm a diagnosis. When there is uncertainty around threshold values or when office and HBPM are not in agreement, 24-hour ABPM should be considered to establish the diagnosis.

Trends in Blood Pressure Control Among US Adults With Hypertension, 1999-2000 to 2017-2018.

Importance: Controlling blood pressure (BP) reduces the risk for cardiovascular disease. Objective: To determine whether BP control among US adults with hypertension changed from 1999-2000 through 2017-2018. Design, Setting, and Participants: Serial cross-sectional analysis of National Health and Nutrition Examination Survey data, weighted to be representative of US adults, between 1999-2000 and 2017-2018 (10 cycles), including 18 262 US adults aged 18 years or older with hypertension defined as systolic BP level of 140 mm Hg or higher, diastolic BP level of 90 mm Hg or higher, or use of antihypertensive medication. The date of final data collection was 2018. Exposures: Calendar year. Main Outcomes and Measures: Mean BP was computed using 3 measurements. The primary outcome of BP control was defined as systolic BP level lower than 140 mm Hg and diastolic BP level lower than 90 mm Hg. Results: Among the 51 761 participants included in this analysis, the mean (SD) age was 48 (19) years and 25 939 (50.1%) were women; 43.2% were non-Hispanic White adults; 21.6%, non-Hispanic Black adults; 5.3%, non-Hispanic Asian adults; and 26.1%, Hispanic adults. Among the 18 262 adults with hypertension, the age-adjusted estimated proportion with controlled BP increased from 31.8% (95% CI, 26.9%-36.7%) in 1999-2000 to 48.5% (95% CI, 45.5%-51.5%) in 2007-2008 (P < .001 for trend), remained stable and was 53.8% (95% CI, 48.7%-59.0%) in 2013-2014 (P = .14 for trend), and then declined to 43.7% (95% CI, 40.2%-47.2%) in 2017-2018 (P = .003 for trend). Compared with adults who were aged 18 years to 44 years, it was estimated that controlled BP was more likely among those aged 45 years to 64 years (49.7% vs 36.7%; multivariable-adjusted prevalence ratio, 1.18 [95% CI, 1.02-1.37]) and less likely among those aged 75 years or older (37.3% vs 36.7%; multivariable-adjusted prevalence ratio, 0.81 [95% CI, 0.65-0.97]). It was estimated that controlled BP was less likely among non-Hispanic Black adults vs non-Hispanic White adults (41.5% vs 48.2%, respectively; multivariable-adjusted prevalence ratio, 0.88; 95% CI, 0.81-0.96). Controlled BP was more likely among those with private insurance (48.2%), Medicare (53.4%), or government health insurance other than Medicare or Medicaid (43.2%) vs among those without health insurance (24.2%) (multivariable-adjusted prevalence ratio, 1.40 [95% CI, 1.08-1.80], 1.47 [95% CI, 1.15-1.89], and 1.36 [95% CI, 1.04-1.76], respectively). Controlled BP was more likely among those with vs those without a usual health care facility (48.4% vs 26.5%, respectively; multivariable-adjusted prevalence ratio, 1.48 [95% CI, 1.13-1.94]) and among those who had vs those who had not had a health care visit in the past year (49.1% vs 8.0%; multivariable-adjusted prevalence ratio, 5.23 [95% CI, 2.88-9.49]). Conclusions and Relevance: In a series of cross-sectional surveys weighted to be representative of the adult US population, the prevalence of controlled BP increased between 1999-2000 and 2007-2008, did not significantly change from 2007-2008 through 2013-2014, and then decreased after 2013-2014.

Trends in All-Cause, Cardiovascular, and Noncardiovascular Mortality Among US Adults With Hypertension.

BACKGROUND: Death certificate data indicate that hypertension may have increased as a contributing cause of death among US adults. Hypertension is not commonly recorded on death certificates although it contributes to a substantial proportion of cardiovascular disease (CVD) deaths. METHODS: We estimated changes in all-cause, CVD, and non-CVD mortality over 5 years of follow-up among 4 cohorts of US adults with hypertension using mortality follow-up data from National Health and Nutrition Examination Survey III in 1988 to 1994, and National Health and Nutrition Examination Survey cycles from 1999 to 2000 through 2015 to 2016 (n=20 927). Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or antihypertensive medication use. Participants were grouped according to the date of their National Health and Nutrition Examination Survey study visit (1988-1994, 1999-2004, 2005-2010, 2011-2016). RESULTS: There were 2646, 1048, and 1598 all-cause, CVD, and non-CVD deaths, respectively. After age, gender, and race/ethnicity adjustment and compared with the 1988 to 1994 cohort, the hazard ratio of all-cause mortality was 0.88 (95% CI, 0.76-1.01) for the 1999 to 2004 cohort, 0.82 (95% CI, 0.70-0.95) for the 2005 to 2010 cohort, and 0.89 (95% CI, 0.75-1.05) for the 2011 to 2016 cohort (P trend=0.123). The age, gender, and race/ethnicity-adjusted hazard ratios for CVD mortality compared with the 1988 to 1994 cohort were 0.74 (95% CI, 0.60-0.90) for the 1999 to 2004 cohort, 0.61 (95% CI, 0.50-0.74) for the 2005 to 2010 cohort, and 0.57 (95% CI, 0.44-0.74) for the 2011 to 2016 cohort (P trend <0.001). There was no evidence of a change in CVD mortality between the 2005 to 2010 and 2011 to 2016 cohorts (P=0.661). Noncardiovascular mortality did not decline over the study period (P trend=0.145). CONCLUSIONS: The decline in CVD mortality among US adults with hypertension stalled after 2005 to 2010.

Social Determinants of Health and Incident Apparent Treatment-Resistant Hypertension Among White and Black US Adults: The REGARDS Study.

BACKGROUND: We examined the association of multilevel social determinants of health with incident apparent treatment-resistant hypertension (aTRH). METHODS AND RESULTS: We analyzed data from 2774 White and 2257 Black US adults from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study taking antihypertensive medication without aTRH at baseline to estimate the association of social determinants of health with incident aTRH. Selection of social determinants of health was guided by the Healthy People 2030 domains of education, economic stability, social context, neighborhood environment, and health care access. Blood pressure (BP) was measured during study visits, and antihypertensive medication classes were identified through a pill bottle review. Incident aTRH was defined as (1) systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg, or systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg for those with diabetes or chronic kidney disease while taking ≥3 classes of antihypertensive medication or (2) taking ≥4 classes of antihypertensive medication regardless of BP level, at the follow-up visit. Over a median 9.5 years of follow-up, 15.9% of White and 24.0% of Black adults developed aTRH. A percent of the excess aTRH risk among Black versus White adults was mediated by low education (14.2%), low income (16.0%), not seeing a friend or relative in the past month (8.1%), not having someone to care for them if ill or disabled (7.6%), lack of health insurance (10.6%), living in a disadvantaged neighborhood (18.0%), and living in states with poor public health infrastructure (6.0%). CONCLUSIONS: Part of the association between race and incident aTRH risk was mediated by social determinants of health.

Race differences in ambulatory blood pressure monitoring parameters.

BACKGROUND: Mean systolic and diastolic blood pressure (SBP and DBP) on ambulatory blood pressure (BP) monitoring (ABPM) are higher among Black compared with White adults. With 48 to 72 BP measurements obtained over 24 h, ABPM can generate parameters other than mean BP that are associated with increased risk for cardiovascular events. There are few data on race differences in ABPM parameters other than mean BP. METHODS: To estimate differences between White and Black participants in ABPM parameters, we used pooled data from five US-based studies in which participants completed ABPM (n = 2580). We calculated measures of SBP and DBP level, including mean, load, peak, and measures of SBP and DBP variability, including average real variability (ARV) and peak increase. RESULTS: There were 1513 (58.6%) Black and 1067 (41.4%) White participants with mean ages of 56.1 and 49.0 years, respectively. After multivariable adjustment, asleep SBP and DBP load were 5.7% (95% CI: 3.5-7.9%) and 2.7% (95% CI: 1.1-4.3%) higher, respectively, among Black compared with White participants. Black compared with White participants also had higher awake DBP ARV (0.3 [95%CI: 0.0-0.6] mmHg) and peak increase in DBP (0.4 [95% CI: 0.0-0.8] mmHg). There was no evidence of Black:White differences in awake measures of SBP level, asleep peak SBP or DBP, awake and asleep measures of SBP variability or asleep measures of DBP variability after multivariable adjustment. CONCLUSION: Asleep SBP load, awake DBP ARV and peak increase in awake DBP were higher in Black compared to White participants, independent of mean BP on ABPM.

Trends in the Prevalence of Multiple Chronic Conditions Among US Adults With Hypertension From 1999-2000 Through 2017-2020.

BACKGROUND: The prevalence of many chronic conditions has increased among US adults. Many adults with hypertension have other chronic conditions. METHODS: We estimated changes in the age-adjusted prevalence of multiple (≥3) chronic conditions, not including hypertension, using data from the National Health and Nutrition Examination Survey, from 1999-2000 to 2017-2020, among US adults with (n = 24,851) and without (n = 24,337 hypertension. Hypertension included systolic blood pressure (BP) ≥130 mm Hg, diastolic BP ≥80 mm Hg, or antihypertensive medication use. We studied 14 chronic conditions: arthritis, asthma, cancer, coronary heart disease, chronic kidney disease, depression, diabetes, dyslipidemia, hepatitis B, hepatitis C, heart failure, lung disease, obesity, and stroke. RESULTS: From 1999-2000 to 2017-2020, the age-adjusted mean number of chronic conditions increased more among US adults with vs. without hypertension (2.2 to 2.8 vs. 1.7 to 2.0; P-interaction <0.001). Also, the age-adjusted prevalence of multiple chronic conditions increased from 39.0% to 52.0% among US adults with hypertension and from 26.0% to 30.0% among US adults without hypertension (P-interaction = 0.022). In 2017-2020, after age, gender, and race/ethnicity adjustment, US adults with hypertension were 1.94 (95% confidence interval: 1.72-2.18) times as likely to have multiple chronic conditions compared to those without hypertension. In 2017-2020, dyslipidemia, obesity, and arthritis were the most common 3 co-occurring chronic conditions among US adults with and without hypertension (age-adjusted prevalence 16.5% and 3.1%, respectively). CONCLUSIONS: In 2017-2020, more than half of US adults with hypertension had ≥3 additional chronic conditions, a substantial increase from 20 years ago.

Maintenance of Normal Blood Pressure From Middle to Older Age: Results From the Atherosclerosis Risk in Communities Study.

BACKGROUND: It is unknown whether maintaining normal blood pressure (BP) from middle to older age is associated with improved health outcomes. METHODS: We estimated the proportion of Atherosclerosis Risk in Communities study participants who maintained normal BP from 1987 to 1989 (visit 1) through 1996 to 1998 and 2011 to 2013 (over 4 and 5 visits, respectively). Normal BP was defined as systolic BP <120 mm Hg and diastolic BP <80 mm Hg, without antihypertensive medication. We estimated the risk of cardiovascular disease, dementia, and poor physical functioning after visit 5. In exploratory analyses, we examined participant characteristics associated with maintaining normal BP. RESULTS: Among 2699 participants with normal BP at baseline (mean age 51.3 years), 47.1% and 15.0% maintained normal BP through visits 4 and 5, respectively. The hazard ratios comparing participants who maintained normal BP through visit 4 but not visit 5 and through visit 5 versus those who did not maintain normal BP through visit 4 were 0.80 (95% CI, 0.63-1.03) and 0.60 (95% CI, 0.42-0.86), respectively, for cardiovascular disease, and 0.85 (95% CI, 0.71-1.01) and 0.69 (95% CI, 0.54-0.90), respectively, for poor physical functioning. Maintaining normal BP through visit 5 was more common among participants with normal body mass index versus obesity at visit 1, those with normal body mass index at visits 1 and 5, and those with overweight at visit 1 and overweight or normal body mass index at visit 5, compared with those with obesity at visits 1 and 5. CONCLUSIONS: Maintaining normal BP was associated with a lower risk of cardiovascular disease and poor physical functioning.

Design of the Equity in Prevention and Progression of Hypertension by Addressing Barriers to Nutrition and Physical Activity Study: A Cluster Randomized Trial.

BACKGROUND: High rates of hypertension and poverty in the rural south contribute to health disparities with Black adults experiencing higher rates of cardiovascular disease than White adults, underscoring the need to identify prevention strategies. METHODS: The equity in prevention and progression of hypertension by addressing barriers to nutrition and physical activity (EPIPHANY) study is a cluster randomized controlled trial testing a multilevel intervention to reduce barriers to a healthy lifestyle to lower blood pressure (BP) among rural, Black adults. Health education fairs offered to 20 churches in the Alabama Black Belt are being used to screen and enroll adults with elevated BP or stage 1 hypertension (systolic BP 120-139 mmHg and diastolic BP < 90 mmHg) who are not recommended for antihypertensive medication, according to the 2017 American College of Cardiology/American Heart Association BP guideline. Participants (n = 240) in churches randomized to the control condition are offered access to online resources including cooking and exercise classes. Participants (n = 240) in churches randomized to the intervention are receiving access to online resources; telephone-based peer support for lifestyle modification; funding for churches to develop programs to address food access and/or barriers to physical activity; and training of church members to serve as church champions to deliver training for church members on lifestyle modification. We will employ a Type 1 hybrid implementation-effectiveness design to assess effectiveness and implementation. CONCLUSIONS: The EPIPHANY study is designed to prevent hypertension among rural, Black adults by addressing structural and individual barriers to lifestyle modification through peer support.

Social Determinants of Health and Uncontrolled Blood Pressure in a National Cohort of Black and White US Adults: the REGARDS Study.

BACKGROUND: Determining the contribution of social determinants of health (SDOH) to the higher proportion of Black adults with uncontrolled blood pressure (BP) could inform interventions to improve BP control and reduce cardiovascular disease. METHODS: We analyzed data from 7306 White and 7497 Black US adults taking antihypertensive medication from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study (2003-2007). SDOH were defined using the Healthy People 2030 domains of education, economic stability, social context, neighborhood environment, and health care access. Uncontrolled BP was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg. RESULTS: Among participants taking antihypertensive medication, 25.4% of White and 33.7% of Black participants had uncontrolled BP. The SDOH included in the current analysis mediated the Black-White difference in uncontrolled BP by 33.0% (95% CI, 22.1%-46.8%). SDOH that contributed to excess uncontrolled BP among Black compared with White adults included low annual household income (percent-mediated 15.8% [95% CI, 10.8%-22.8%]), low education (10.5% [5.6%-15.4%]), living in a health professional shortage area (10.4% [6.5%-14.7%]), disadvantaged neighborhood (11.0% [4.4%-18.0%]), and high-poverty zip code (9.7% [3.8%-15.5%]). Together, the neighborhood-domain accounted for 14.1% (95% CI, 5.9%-22.9%), the health care domain accounted for 12.7% (95% CI, 8.4%-17.3%), and the social-context-domain accounted for 3.8% (95% CI, 1.2%-6.6%) of the excess likelihood of uncontrolled BP among Black compared with White adults, respectively. CONCLUSIONS: SDOH including low education, low income, living in a health professional shortage area, disadvantaged neighborhood, and high-poverty zip code contributed to the excess likelihood of uncontrolled BP among Black compared with White adults.

Race- and Sex-Specific Factors Associated With Age-Related Slopes in Systolic Blood Pressure: Findings From the CARDIA Study.

BACKGROUND: Although blood pressure (BP) increases throughout young adulthood for most individuals, the age-related slope is not uniform. This study aimed to assess associations of demographic, clinical, behavioral, psychosocial, and neighborhood characteristics with age-related BP slope among 4 race-sex groups who participated in the Coronary Artery Risk Development in Young Adults study. METHODS: Individuals (n=3554) aged 18 to 30 years were included in this analysis if they had normal BP at baseline and ≥2 BP measurements during the years 1985/1986 to 2015/2016. Associations of exposure variables with systolic BP slope were assessed using multivariate linear models. RESULTS: Over a mean follow-up of ~30 years, greater decade increases in systolic BP were estimated among Black than White participants (mean difference between Black females and White females: 3.0 mm Hg/decade; between Black males and White males: 4.7 mm Hg/decade). The exposure risk factors associated with greater increases in systolic BP throughout adulthood varied by race and sex. None of these factors were associated with increases in systolic BP in all race-sex groups. Parent history of high BP was associated with a steeper positive slope among Black females (effect size per decade: 1.1 [95% CI, 0.6-1.6]; P<0.01), Black males (0.6 [95% CI, 0.02-1.2]; P<0.05), and White females (0.6 [95% CI, 0.2-1.0]; P<0.01). Other risk factors were associated with greater age-related yearly increases in systolic BP among 1 or 2 of the 4 race-sex groups or were not statistically significant. CONCLUSIONS: Culturally tailored BP reduction approach should be considered in conjunction with primordial prevention, to moderate increases in BP throughout adulthood.

Hypertension Statistics for US Adults: An Open-Source Web Application for Analysis and Visualization of National Health and Nutrition Examination Survey Data.

BACKGROUND: Data from the US National Health and Nutrition Examination Survey are freely available and can be analyzed to produce hypertension statistics for the noninstitutionalized US population. The analysis of these data requires statistical programming expertise and knowledge of National Health and Nutrition Examination Survey methodology. METHODS: We developed a web-based application that provides hypertension statistics for US adults using 10 cycles of National Health and Nutrition Examination Survey data, 1999 to 2000 through 2017 to 2020. We validated the application by reproducing results from prior publications. The application's interface allows users to estimate crude and age-adjusted means, quantiles, and proportions. Population counts can also be estimated. To demonstrate the application's capabilities, we estimated hypertension statistics for noninstitutionalized US adults. RESULTS: The estimated mean systolic blood pressure (BP) declined from 123 mm Hg in 1999 to 2000 to 120 mm Hg in 2009 to 2010 and increased to 123 mm Hg in 2017 to 2020. The age-adjusted prevalence of hypertension (ie, systolic BP≥130 mm Hg, diastolic BP≥80 mm Hg or self-reported antihypertensive medication use) was 47.9% in 1999 to 2000, 43.0% in 2009 to 2010, and 44.7% in 2017 to 2020. In 2017 to 2020, an estimated 115.3 million US adults had hypertension. The age-adjusted prevalence of controlled BP, defined by the 2017 American College of Cardiology/American Heart Association BP guideline, among nonpregnant US adults with hypertension was 9.7% in 1999 to 2000, 25.0% in 2013 to 2014, and 21.9% in 2017 to 2020. After age adjustment and among nonpregnant US adults who self-reported taking antihypertensive medication, 27.5%, 48.5%, and 43.0% had controlled BP in 1999 to 2000, 2013 to 2014, and 2017 to 2020, respectively. CONCLUSIONS: The application developed in the current study is publicly available at https://bcjaeger.shinyapps.io/nhanesShinyBP/ and produced valid, transparent and reproducible results.

BMI and blood pressure control among United States adults with hypertension.

OBJECTIVES: Less than half of United States adults with hypertension have controlled blood pressure (BP). Higher BMI is associated with an increased risk for hypertension but the association between BMI and BP control is not well characterized. We examined hypertension awareness, antihypertensive medication use, and BP control, by BMI category. METHODS: Data for 3568 United States adults aged at least 18 years with hypertension (BP at least 140/90 mmHg or taking antihypertensive medication) from the 2015 to 2018 National Health and Nutrition Examination Survey were analyzed. BMI was categorized as normal (<25 kg/m2), overweight (25 to <30 kg/m2), class 1 obesity (30 to <35 kg/m2), or class 2 or 3 obesity (≥35 kg/m2). Hypertension awareness and antihypertensive medication use were self-reported. BP control was defined as BP less than 140/90 mmHg using the average of up to three measurements. RESULTS: Among United States adults with hypertension, 15.6% had normal BMI, 31.3% had overweight, 26.2% had class 1 obesity, and 26.8% had class 2 or 3 obesity. Among those with normal BMI, overweight, class 1 obesity, and class 2 or 3 obesity: 67.9, 76.8, 84.0, and 87.8% were aware they had hypertension, respectively; 88.1, 88.1, 90.9, and 90.2% of those aware were taking antihypertensive medication, respectively; 63.5, 65.9, 71.1, and 64.1% of those taking antihypertensive medication had controlled BP, respectively; and 37.1, 44.3, 53.8, and 50.8% of those with hypertension had controlled BP, respectively. CONCLUSION: United States adults with hypertension and normal BMI were less likely to be aware they had hypertension and have controlled BP compared with those with overweight or obesity.

Evaluating novel approaches for estimating awake and sleep blood pressure: design of the Better BP Study - a randomised, crossover trial.

INTRODUCTION: For many people, blood pressure (BP) levels differ when measured in a medical office versus outside of the office setting. Out-of-office BP has a stronger association with cardiovascular disease (CVD) events compared with BP measured in the office. Many BP guidelines recommend measuring BP outside of the office to confirm the levels obtained in the office. Ambulatory BP monitoring (ABPM) can assess out-of-office BP but is not available in many US practices and some individuals find it uncomfortable. The aims of the Better BP Study are to (1) test if unattended office BP is closer to awake BP on ABPM compared with attended office BP, (2) assess if sleep BP assessed by home BP monitoring (HBPM) agrees with sleep BP from a full night of ABPM and (3) compare the strengths of associations of unattended versus attended office BP, unattended office BP versus awake BP on ABPM and sleep BP on HBPM versus ABPM with markers of end-organ damage. METHODS AND ANALYSIS: We are recruiting 630 adults not taking antihypertensive medication in Birmingham, Alabama, and New York, New York. Participants are having their office BP measured with (attended) and without (unattended) a technician present, in random order, using an automated oscillometric office BP device during each of two visits within one week. Following these visits, participants complete 24 hours of ABPM and one night of HBPM, in random order. Psychosocial factors, anthropometrics, left ventricular mass index and albumin-to-creatinine ratio are also being assessed. ETHICS AND DISSEMINATION: This study was approved by the University of Alabama at Birmingham and the Columbia University Medical Center Institutional Review Boards. The study results will be disseminated at scientific conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04307004.

Blood Pressure Control Among US Adults, 2009 to 2012 Through 2017 to 2020.

BACKGROUND: The National Health and Nutrition Examination Survey data indicate that the proportion of US adults with hypertension that had controlled blood pressure (BP) declined from 2013 to 2014 through 2017 to 2018. We analyzed data from National Health and Nutrition Examination Survey 2009 to 2012, 2013 to 2016, and 2017 to 2020 to confirm this finding. METHODS: Hypertension was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg or antihypertensive medication use. BP control among those with hypertension was defined as systolic BP <140 mm Hg and diastolic BP <90 mm Hg. RESULTS: The age-adjusted prevalence of hypertension was 31.5% (95% CI, 30.3%-32.8%), 32.0% (95% CI, 30.6%-33.3%), and 32.9% (95% CI, 31.0%-34.7%) in 2009 to 2012, 2013 to 2016, and 2017 to 2020, respectively (P trend=0.218). The age-adjusted prevalence of hypertension increased among non-Hispanic Asian adults from 27.0% in 2011 to 2012 to 33.5% in 2017 to 2020 (P trend=0.003). Among Hispanic adults, the age-adjusted prevalence of hypertension increased from 29.4% in 2009 to 2012 to 33.2% in 2017 to 2020 (P trend=0.029). In 2009 to 2012, 2013 to 2016, and 2017 to 2020, 52.8% (95% CI, 50.0%-55.7%), 51.3% (95% CI, 47.9%-54.6%), and 48.2% (95% CI, 45.7%-50.8%) of US adults with hypertension had controlled BP (P trend=0.034). Among US adults taking antihypertensive medication, 69.9% (95% CI, 67.8%-72.0%), 69.3% (95% CI, 66.6%-71.9%), and 67.7% (95% CI, 65.2%-70.3%) had controlled BP in 2009 to 2012, 2013 to 2016, and 2017 to 2020, respectively (P trend=0.189). Among all US adults with hypertension and those taking antihypertensive medication, a decline in BP control between 2009 to 2012 and 2017 to 2020 occurred among those ≥75 years, women, and non-Hispanic black adults. CONCLUSIONS: These data confirm that the proportion of US adults with hypertension who have controlled BP has declined.

Changes in the Incidence of Childhood Obesity.

OBJECTIVES: Examine childhood obesity incidence across recent cohorts. METHODS: We examined obesity incidence and prevalence across 2 cohorts of children in the United States 12 years apart using the Early Childhood Longitudinal Studies, parallel data sets following the kindergarten cohorts of 1998 and 2010 with direct anthropometric measurements at multiple time points through fifth grade in 2004 and 2016, respectively. We investigated annualized incidence rate and cumulative incidence proportion of obesity (BMI z-score ≥95th percentile based on Centers for Disease Control and Prevention weight-for-age z-scores). RESULTS: Among children who did not have obesity at kindergarten entry, there was a 4.5% relative increase in cumulative incidence of new obesity cases by end of fifth grade across cohorts (15.5% [14.1%-16.9%] vs 16.2% [15.0%-17.3%]), though annual incidence did not change substantially. The risk of incident obesity for children who had normal BMI at kindergarten entry stayed the same, but the risk of incident obesity among overweight kindergartners increased slightly. Social disparities in obesity incidence expanded: incidence of new cases during primary school among non-Hispanic Black children increased by 29% (95% confidence interval, 25%-34%), whereas risk for other race-ethnic groups plateaued or decreased. Children from the most socioeconomically disadvantaged households experienced 15% higher cumulative incidence across primary school in 2010 than 1998. CONCLUSIONS: Incidence of childhood obesity was higher, occurred at younger ages, and was more severe than 12 years previous; thus, more youths may now be at risk for health consequences associated with early onset of obesity.

Predicted cardiovascular risk for United States adults with diabetes, chronic kidney disease, and at least 65 years of age.

BACKGROUND: The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends using 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk to guide decisions to initiate antihypertensive medication. METHODS: We included adults aged 40-79 years from the National Health and Nutrition Examination Survey 2013-2018 (n = 8803). We computed 10-year predicted ASCVD risk using the Pooled Cohort risk equations. Clinical CVD was self-reported. Analyses were conducted overall and among those with stage 1 hypertension, defined by a mean SBP of 130-139 mmHg or DBP of 80-89 mmHg. In subgroups defined by diabetes, chronic kidney disease (CKD), and age at least 65 years, we estimated the proportion of United States adults with high ASCVD risk (i.e. 10-year predicted ASCVD risk ≥10% or clinical CVD) and estimated age-adjusted probability of having high ASCVD risk. RESULTS: Among United States adults, an estimated 72.3, 64.5, and 83.9 of those with diabetes, CKD, and age at least 65 years had high ASCVD risk, respectively. Among United States adults with stage 1 hypertension, an estimated 55, 36.7, and 72.6% of those with diabetes, CKD, and age at least 65 years had high ASCVD risk, respectively. The probability of having high ASCVD risk increased with age and exceeded 50% for United States adults with diabetes and CKD at ages 52 and 57 years, respectively. For those with stage 1 hypertension, these ages were 55 and 64 years, respectively. CONCLUSION: Most United States adults with diabetes, CKD, or age at least 65 years had high ASCVD risk. However, many with stage 1 hypertension did not.

Factors Associated With Not Having a Healthcare Visit in the Past Year Among US Adults With Hypertension: Data From NHANES 2013-2018.

BACKGROUND: Not having a healthcare visit in the past year has been associated with a higher likelihood of uncontrolled blood pressure (BP) among individuals with hypertension. METHODS: We examined factors associated with not having a healthcare visit in the past year among US adults with hypertension using data from the US National Health and Nutrition Examination Survey 2013-2018 (n = 5,985). Hypertension was defined as systolic BP (SBP) ≥140 mm Hg, diastolic BP (DBP) ≥90 mm Hg, or antihypertensive medication use. Having a healthcare visit in the past year was self-reported. RESULTS: Overall, 7.0% of US adults with hypertension reported not having a healthcare visit in the past year. Those without vs. with a healthcare visit in the past year were less likely to be aware they had hypertension (45.0% vs. 83.9%), to be taking antihypertensive medication (36.7% vs. 91.4%, among those who were aware they had hypertension), and to have controlled BP (SBP/DBP <140/90 mm Hg; 9.1% vs. 51.7%). After multivariable adjustment, not having a healthcare visit in the past year was more common among US adults without health insurance (prevalence ratio [PR]: 2.22; 95% confidence interval [CI] 1.68-2.95), without a usual source of healthcare (PR: 5.65; 95% CI 4.16-7.67), who smoked cigarettes (PR: 1.34; 95% CI 1.02-1.77), and with heavy vs. no alcohol consumption (PR: 1.55; 95% CI 1.16-2.08). Also, not having a healthcare visit in the past year was more common among those without diabetes or a history of atherosclerotic cardiovascular disease, and those not taking a statin. CONCLUSIONS: Interventions should be considered to ensure all adults with hypertension have annual healthcare visits.

Age-Specific Prevalence and Factors Associated With Normal Blood Pressure Among US Adults.

BACKGROUND: The mean systolic blood pressure (SBP) for US adults increases with age. Determining characteristics of US adults ≥65 years with normal blood pressure (BP) may inform approaches to prevent this increase. METHODS: We analyzed US National Health and Nutrition Examination Survey 2011-2018 data (n = 21,581). BP was measured up to 3 times and averaged. Normal BP was defined as SBP <120 mm Hg and diastolic BP (DBP) <80 mm Hg among participants not taking antihypertensive medication. Those with SBP ≥120 mm Hg, DBP ≥80 mm Hg, self-reporting having hypertension or taking antihypertensive medication were categorized as having elevated BP or hypertension. RESULTS: The prevalence of normal BP was 57.8%, 25.3%, 11.2%, and 5.0% among US adults who were 18-44, 45-64, 65-74, and ≥75 years, respectively. After multivariable adjustment, in US adults ≥65 years of age, normal BP vs. elevated BP/hypertension was more common among those with moderate and no vs. heavy alcohol consumption (prevalence ratio [PR] 3.03; 95% confidence interval [CI] 1.25-7.36 and 2.53; 95% CI 0.96-6.65, respectively), ≥150 vs. <150 minutes of physical activity per week (PR = 1.44; 95% CI 1.01-2.05), overweight and normal weight vs. obesity (PR = 1.88; 95% CI 1.22-2.90 and 2.94; 95% CI 1.89-4.59, respectively), and a high Dietary Approaches to Stop Hypertension score (PR = 1.43; 95% CI 1.00-2.05). US adults ≥65 years with normal BP vs. elevated BP/hypertension were less likely to have good or fair/poor vs. excellent/very good self-rated health, diabetes, albuminuria, atherosclerotic cardiovascular disease, and heart failure. CONCLUSIONS: Among US adults ≥65 years, normal BP was associated with healthy lifestyle factors and a lower prevalence of adverse health conditions.