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Self-Reported Hypertension and Use of Antihypertensive Medication Among Adults — United States, 2005–2009

	MMWR Weekly Volume 62, No. 13 April 5, 2013

Self-Reported Hypertension and Use of Antihypertensive Medication Among Adults — United States, 2005–2009

Weekly

April 5, 2013 / 62(13);237-244

Hypertension affects one third of adults in the United States (1) and is a major risk factor for heart disease and stroke (2). A previous report found differences in the prevalence of hypertension among racial/ethnic populations in the United States; blacks had a higher prevalence of hypertension, and Hispanics had the lowest use of antihypertensive medication (3). Recent variations in geographic differences in hypertension prevalence in the United States are less well known (4). To assess state-level trends in self-reported hypertension and treatment among U.S. adults, CDC analyzed 2005–2009 data from the Behavioral Risk Factor Surveillance System (BRFSS). The results indicated wide variation among states in the prevalence of self-reported diagnosed hypertension and use of antihypertensive medications. In 2009, the age-adjusted prevalence of self-reported hypertension ranged from 20.9% in Minnesota to 35.9% in Mississippi. The proportion reporting use of antihypertensive medications among those who reported hypertension ranged from 52.3% in California to 74.1% in Tennessee. From 2005 to 2009, nearly all states had an increased prevalence of self-reported hypertension, with percentage-point increases ranging from 0.2 for Virginia (from 26.9% to 27.1%) to 7.0 for Kentucky (from 27.5% to 34.5%). Overall, from 2005 to 2009, the prevalence of self-reported hypertension among U.S. adults increased from 25.8% to 28.3%. Among those reporting hypertension, the proportion using antihypertensive medications increased from 61.1% to 62.6%. Increased knowledge of the differences in self-reported prevalence of hypertension and use of antihypertensive medications by state can help in guiding programs to prevent heart disease, stroke, and other complications of uncontrolled hypertension, including those conducted by state and local public health agencies and health-care providers.
BRFSS is a state-based telephone survey of health behaviors among adults aged ≥18 years.* The survey has been conducted by state health departments, with assistance from CDC, since 1984. Questions on hypertension are asked in odd-numbered years. Since 2005, two questions about hypertension have been included in BRFSS. The first question is, "Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?" Respondents who answer "yes" to the first question are then asked, "Are you currently taking medicine for your high blood pressure?" These questions were used to assess prevalence of self-reported hypertension and proportion reporting antihypertensive medication use among those with reported hypertension in 2005, 2007, and 2009. Estimates were calculated for the United States overall and for the 50 states and the District of Columbia. In addition to analysis by state, estimates were analyzed by age group, sex, race/ethnicity,† and level of education. Age-adjusted estimates were calculated using the 2000 U.S. standard population. Linear trends were assessed using orthogonal polynomial coefficients, and results were considered significant at p<0 .05.="" p=""> Median state response rates for BRFSS were 51.1% (range: 34.6%–67.4%) in 2005, 50.6% (range: 26.9%–65.4%) in 2007, and 52.5% (range: 37.9%–66.9%) in 2009. Total respondents were 356,112 in 2005, 430,912 in 2007, and 432,617 in 2009. State sample sizes ranged from 2,432 in 2009 (Alaska) to 39,549 in 2007 (Florida).
From 2005 to 2009, overall age-adjusted prevalence of self-reported hypertension in the United States increased from 25.8% to 28.3% (Table 1). Self-reported hypertension ranged from 21.1% (Colorado) to 33.5% (Mississippi) in 2005, and from 20.9% (Minnesota) to 35.9% (Mississippi) in 2009. From 2005 to 2009, nearly all states had an increased prevalence of self-reported hypertension, with percentage-point increases ranging from 0.2 for Virginia (from 26.9% to 27.1%) to 7.0 for Kentucky (from 27.5% to 34.5%). In 2009, the prevalence of self-reported hypertension was, in general, higher in southern states and lower in western states (Figure).
Among those with self-reported hypertension, the estimated number of participants reporting use of antihypertensive medications was 45,023,301 in 2005, 50,191,337 in 2007, and 53,602,447 in 2009; the proportion increased from 61.1% (2005) to 62.6% (2009). In 2009, among those with self-reported hypertension, the proportion reporting current use of antihypertensive medication was highest in Tennessee (74.1%) and lowest in California (52.3%); however, Tennessee showed no significant change in reported antihypertensive medication use from 2005 to 2009, whereas California had a significant increase, from 48.0% to 52.3%. As with self-reported hypertension, the proportion of participants reporting use of antihypertensive medication generally was higher in southern states and lower in western states (Figure). States that showed significant increases in use of antihypertensive medications included California, Iowa, and Michigan, whereas Kentucky, Nebraska, and Rhode Island had significant decreases.
By selected characteristics, self-reported hypertension prevalence in 2009 was significantly higher among persons aged ≥65 years (59.6%) compared with persons aged 18–44 years (13.3%) and 45–64 years (37.1%); among men (30.3%) compared with women (26.2%); among blacks (39.6%) compared with American Indian/Alaska Natives (32.0%), Hispanics (27.6%), whites (27.1%), and Asian/Pacific Islanders (24.0%); and among those with less than a high school education (33.6%) compared with those with a high school education (31.4%), those with some college (29.2%), and those with a college degree or higher (23.8%). From 2005 to 2009, the prevalence of self-reported hypertension increased for all sociodemographic subgroups, although the linear trends were not significant for Hispanics, Asian/Pacific Islanders, and American Indian/Alaska Natives (Table 1).
Among persons reporting hypertension in 2009, the proportion reporting antihypertensive medication use was significantly higher among persons aged ≥65 years (94.1%) compared with those aged 18–44 years (45.1%) and 45–64 years (82.3%); among women (66.9%) compared with men (59.9%); and among blacks (71.6%) compared with Hispanics (55.2%) (Table 2). From 2005 to 2009, significant increases in self-reported use of antihypertensive medication among those reporting hypertension were observed among blacks (from 67.0% to 71.6%) and Hispanics (from 51.2% to 55.2%).

Reported by

Jing Fang, MD, Carma Ayala, PhD, Fleetwood Loustalot, PhD, Shifan Dai, MD, PhD, Div for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: Jing Fang, jfang@cdc.gov, 770-488-0259.

Editorial Note

The findings in this report, using BRFSS data, indicate that from 2005 to 2009, a small but significant increase in the prevalence of self-reported hypertension was observed among U.S. adults. Among those with self-reported hypertension, the proportion who reported use of antihypertensive medication also increased significantly.
In 2011, a report based on results from the National Health and Nutrition Examination Survey (NHANES) showed that among adults aged ≥18 years, the prevalence of measured hypertension did not increase significantly from 1999–2002 to 2005–2008; however, the use of antihypertensive medication and control of hypertension showed significant increases (1). The prevalence of measured hypertension in NHANES did not increase during 1999–2008 (1); therefore, the increase in self-reported hypertension described in the current report likely is related to an increase in the awareness of hypertension. Measured blood pressure is not available with BRFSS surveys; therefore, hypertension control could not be assessed in the current report. The findings in this report show that among persons with hypertension, the proportion reporting antihypertensive medication use increased overall from 2005 to 2009; however, only a few states showed significant increases or decreases in the proportion reporting antihypertensive medication use.
Substantial differences among states were observed for self-reported hypertension prevalence, in general, the prevalence was higher in southern states than in other regions. Use of antihypertensive medication varied by state, but overall BRFSS estimates generally were consistent with other national estimates (5–7). The recent REasons for Geographic and Racial Differences in Stroke (REGARDS) study found that, compared with whites, black participants were more aware of hypertension and more likely to be treated. However, among those treated, blacks were less likely than whites to have their blood pressure controlled (5). The high prevalence of hypertension in the southern states found in this study is in the "stroke belt," a geographically identified region of high stroke morbidity and mortality, and likely is contributing to the disparate burden of disease in the region (8). The findings by sex were similar to results from NHANES 2005–2008, which found that anti­hypertensive treatment was lower among men than women (7).
The findings in this report are subject to at least three limitations. First, data were self-reported, and hypertension and use of antihypertensive medications were not verified independently. Second, BRFSS surveys only noninstitutionalized persons with landline telephones; in 2009, 24.5% of U.S. households only had cellular telephone service (9). Finally, median state response rates for BRFSS were low; however, BRFSS provides the only available state-specific estimates of hypertension prevalence and antihypertensive medication use.
Hypertension is a major modifiable risk factor for cardiovascular disease, and improving awareness of hypertension is an important first step to treating and controlling hypertension and preventing heart disease and stroke. Clinical guidelines for hypertension management emphasize the control of hypertension through participation in healthy lifestyle behaviors, and using appropriate and specific antihypertensives medications with integrated clinical systems to support sustained adherence (2). A CDC goal is to increase public health interventions in clinical and community settings to reduce the deleterious effects of hypertension by increasing awareness and control of high blood pressure.§ One effective intervention is the Community Preventive Services Task Force recommendation for use of team-based care to improve blood pressure control.¶ Currently, 41 states receive CDC funding to develop and implement heart disease and stroke prevention programs.** CDC's National Heart Disease and Stroke Prevention Program works to increase prevention and control of high blood pressure through sodium reduction, health system strategies such as collection and use of quality measures, promotion of team-based care, and community-clinical linkages.
In addition, the Million Hearts initiative, a public and private partnership co-led by CDC and the Centers for Medicare and Medicare Services, targets blood pressure control and seeks to align and coordinate resources across community and clinical settings (10). Increasing awareness of hypertension, improving hypertension control, and encouraging adherence to evidence-based practices addressing hypertension are needed, especially in those states with higher prevalence of hypertension and lower proportion of use of antihypertensive medications.

References

1. CDC. Vital signs: prevalence, treatment, and control of hypertension—United States, 1999–2002 and 2005–2008. MMWR 2011;60:103–8.
2. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) express. JAMA 2003;289:2560–71.
3. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation 2012;125:e2–220.
4. CDC. Cardiovascular disease risk factors and preventive practices among adults—United States, 1994: a behavioral risk factor atlas. MMWR 1998;47(No. SS-5):35–69.
5. Howard G, Prineas R, Moy C, et al. Racial and geographic differences in awareness, treatment, and control of hypertension: the REasons for Geographic and Racial Differences in Stroke study. Stroke 2006;37:1171–8.
6. Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988–2008. JAMA 2010;303:2043–50.
7. CDC. Control of hypertension among adults—National Health and Nutrition Examination Survey, United States, 2005–2008. In: Use of selected clinical preventive services among adults—United States, 2007–2010. MMWR 2012;61(Suppl 2):19–25.
8. Howard VJ, Woolson RF, Egan BM, et al. Prevalence of hypertension by duration and age at exposure to the stroke belt. J Am Soc Hypertens 2010;4:32–41.
9. Blumberg SJ, Luke JV. Wireless substitution: early release of estimates from the National Health Interview Survey, July–December 2009. Hyattsville, MD: US Department of Health and Human Services, CDC; 2010. Available at http://www.cdc.gov/nchs/nhis.htm.
10. CDC. Million Hearts: strategies to reduce the prevalence of leading cardiovascular disease risk factors—United States, 2011. MMWR 2011;60:1248–51.

* Details on BRFSS methodology, sampling procedures, design, and quality are available at http:/www.cdc.gov/brfss.

† In this report, persons identified as Hispanic might be of any race. Persons identified as black, white, Asian/Pacific Islander, or American Indian/Alaska Native are non-Hispanic. The five racial/ethnic categories are mutually exclusive.

§ Available at http://www.cdc.gov/dhdsp/programs/nhdsp_program/goals.htm.

¶ Available at http://www.thecommunityguide.org/cvd/teambasedcare.html.

** Information available at http://www.cdc.gov/dhdsp/programs/nhdsp_program/index.htm.