Racial and Ethnic Disparities in Hypertension: Barriers and Opportunities to Improve Blood Pressure Control

Special Considerations Related to Race, Sex, Gender, and Socioeconomic Status in the Preoperative Evaluation: Part 1: Race, History of Incarceration, and Health Literacy

Patients anticipating surgery and anesthesia benefit from preoperative care to lower risks and facilitate services on the day of surgery. Preparing patients often requires extensive evaluation and coordination of care. Vulnerable, marginalized, and disenfranchised populations have special concerns, limitations, and needs. These patients may have unidentified or poorly managed comorbidities. Underrepresented minorities and transgender patients may either avoid or have limited access to health care. Homelessness, limited health literacy, and incarceration hinder perioperative optimization initiatives. Identifying patients who will benefit from additional resource allocation and knowledge of their special challenges is vital to reducing disparities in health and health care.

School neighborhood deprivation is associated with a higher prevalence of hypertension

OBJECTIVES

To examine the association between socioeconomic characteristics of school neighborhoods and the prevalence of hypertension in adolescents.

STUDY DESIGN

We performed a secondary data analysis of over 21,000 adolescents who participated in a school BP surveillance program between 2000 and 2017. BP status was confirmed by BP measurements on up to 3 occasions to diagnose sustained hypertension according to standard pediatric hypertension guidelines. We assessed school neighborhood socioeconomic status (SES) via the area deprivation index (ADI), a composite measure of area-level socioeconomic deprivation and categorized into quartiles. Q1 represented schools in neighborhoods with the least social deprivation while Q4 represented neighborhood with the most socioeconomic deprivation. We performed a cross-sectional analysis using both univariate and multivariable regression analyses.

RESULTS

Of 21,392 children included in our analysis, the prevalence of sustained hypertension was 2.6 %. Hispanics and African Americans were overrepresented in the schools in more deprived neighborhoods. The highest sustained hypertension rate was observed among students attending Q3 (5.5 %) and Q4 (4.2 %) schools compared to Q1 (2.7 %) and Q2 (2.0 %) schools (p < 0.001). Multivariable regression analysis showed that being male, obese, and attending school in a disadvantaged neighborhood were significantly associated with an increased prevalence of hypertension.

CONCLUSIONS

Our findings suggest that school neighborhood deprivation measured by ADI may be a risk factor for hypertension and may contribute to the racial/ ethnic disparities observed in hypertension prevalence in adolescents.

Diabetes and Hypertension at Midlife Predict Increases in Biomarkers of Dementia Among Black Americans

BACKGROUND

Compared to other racial/ethnic groups, Black Americans show accelerated brain aging beginning in midlife and exhibit higher rates and earlier onset of dementia. While these patterns are often viewed as evidence that Black Americans are more vulnerable to Alzheimer's disease, another possibility is that their high risk for chronic vascular pathologies such as high blood pressure and diabetes compromises their brain health. This hypothesis was tested in the present study.

METHODS

Participants included 252 middle-aged Black Americans enrolled in the Family and Community Health Study and living in Iowa or Georgia who had ascertainment of diabetes and hypertension in 2008 and blood drawn in 2008 and 2019. Linear regression models assessed whether hypertension and diabetes were associated with change in neurofilament light chain (NfL), a non-specific biomarker of brain pathology including vascular dementia, and phosphorylated tau181 (p-Tau181), a biomarker of underlying Alzheimer's disease (AD) pathology.

RESULTS

Having a diagnosis of either hypertension or diabetes during middle age was not associated with levels of either p-Tau181 or NfL. However, having a diagnosis of both hypertension and diabetes was robustly associated with higher levels of NfL and increases in NfL over an 11-year period.

CONCLUSIONS

Among Black Americans, comorbid hypertension and diabetes contribute to higher levels of serum NfL, our indicator of neurodegeneration, during late middle age but not with p-Tau181, our indicator of Alzheimer's disease. Rather than being instances of AD, elevated rates of dementia among Black Americans may be largely vascular pathology caused by high rates of diabetes and high blood pressure.

A Latent Class Analysis of Pre-Pregnancy Multimorbidity Patterns in a Delivery Cohort at a Safety-Net Hospital

Background: Multimorbidity affects approximately 1 in 3 adults and is associated with adverse health outcomes. However, there is a paucity of information describing patterns of multimorbidity among the birthing population. The objective of this study was to describe the clustering of pre-pregnancy chronic conditions in the birthing population by age, race and ethnicity, insurance status, and parity using latent class analysis (LCA). Study design: We conducted a retrospective cohort study of deliveries using medical record data between 2015 and 2019. Multimorbidity was defined as having at least two chronic conditions before the start of the index pregnancy, using adapted versions of obstetric comorbidity indices. The final LCA model was selected based on clinical interpretability and statistical fit. We also compared the distribution of sociodemographic factors across classes. Results: Of 6,455 deliveries, 1,870 (29%) deliveries were to patients with multimorbidity. LCA resulted in a 3-class model: Class 1 (45% of individuals with multimorbidity) was characterized by mood/anxiety and substance use disorders; class 2 (39%) was defined by body mass index ≥30 kg/m2 and chronic hypertension; and class 3 (16%) was characterized by reproductive conditions and infertility. Individuals who were <25 years or non-Hispanic White were more frequently in class 1; individuals who were ≥35 years or non-Hispanic Black were disproportionately in class 2. Nulliparas and individuals with private insurance were more frequently in class 3. Conclusion: Multimorbidity is prevalent in pregnancy and distinct chronic condition clusters vary across sociodemographic sub-groups, demonstrating the need for integrative approaches to periconceptional care for birthing individuals with multimorbidity.

Telemedicine Use and Hypertension Control in an Urban Community Health Center Cohort

BACKGROUND

Real-time or synchronous telemedicine can be a valuable adjunctive strategy for chronic disease management, but few studies have assessed its impact on hypertension control among safety-net populations.

OBJECTIVE

To evaluate whether telemedicine is associated with blood pressure (BP) control.

DESIGN

Retrospective cohort study. Mixed-effects logistic regression models clustered by the patient estimated associations between telemedicine and BP control after adjusting for patient factors and neighborhood context.

PARTICIPANTS

Patients seeking care at an urban, multisite community health center with hypertension and ≥1 BP measurement between 2020 and 2022 (3663 patient-year observations across 2086 unique patients).

MAIN MEASURES

The primary outcome was BP control defined as a binary variable. We used the Centers for Medicare & Medicaid Services' Controlling High Blood Pressure quality measure criteria of systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg in the most recent recording in the measurement year.

KEY RESULTS

Among the 2086 patients with hypertension in our sample, there were 1257 (60.3%) Latinx and 425 (20.4%) Black patients. Over 90% lived in a neighborhood of high deprivation as categorized by the social deprivation index. Telemedicine visits, compared to none, were not associated with blood pressure control (1-2 telemedicine visits aOR, 1.05 [95% CI, 0.86-1.28]; ≥3 telemedicine visits aOR, 0.86 [95% CI, 0.68-1.09]). One in-person visit per year, compared to 2-3, was associated with lower odds of BP control (aOR, 0.72 [95% CI, 0.55-0.94]). Black patients, compared to Latinx patients, were less likely of having BP control (aOR, 0.64 [95% CI, 0.48-0.87]).

CONCLUSIONS

In this community health center cohort of patients with hypertension, telemedicine did not compromise blood pressure control. Persistent racial disparities in blood pressure control underscore the need for equity-centered strategies for hypertension management in safety-net primary care settings.

Atherosclerosis: A Comprehensive Review of Molecular Factors and Mechanisms

Atherosclerosis, a condition characterized by the accumulation of lipids and a culprit behind cardiovascular events, has long been studied. However, in recent years, there has been an increase in interest in its initiation, with researchers shifting focus from traditional pathways involving the vascular infiltration of oxidized lipids and towards the novel presence of chronic inflammatory pathways. The accumulation of pro-inflammatory cytokines, in combination with the activation of transcription factors, creates a positive feedback loop that drives the creation and progression of atherosclerosis. From the upregulation of the nod-like receptor protein 3 (NLRP3) inflammasome and the Notch and Wnt pathways to the increased expression of VEGF-A and the downregulation of connexins Cx32, Cx37, and Cx40, these processes contribute further to endothelial dysfunction and plaque formation. Herein, we aim to provide insight into the molecular pathways and mechanisms implicated in the initiation and progression of atherosclerotic plaques, and to review the risk factors associated with their development.

Variation in Hypertension Control by Race and Ethnicity, and Geography in US Veterans

BACKGROUND

Hypertension control and related cardiovascular outcomes among Americans remain suboptimal, and differ by race, ethnicity, and geography. Healthcare access is one of multiple critical factors in hypertension control. Understanding the degree to which healthcare access, versus other factors, produce these outcomes can inform policies and interventions to improve cardiovascular outcomes and reduce disparities. Department of Veterans Affairs Healthcare System data provide a unique opportunity to understand residual racial and ethnic differences in hypertension control after accounting for healthcare access. Our objective was to describe pre-pandemic post-Affordable Care Act implementation hypertension control by geographic sector and race and ethnicity, and assess spatial clustering of hypertension control.

METHODS AND RESULTS

A secondary data analysis of hypertension control among US veterans (n=1 619 414) nationwide and in 4 US territories was conducted using electronic health record data. Age- and sex-adjusted regression models estimated overall and race- and ethnicity-specific rates by geographic sector. We created choropleth maps of hypertension control rates and assessed spatial autocorrelation. Hypertension control rates varied across sectors by race and ethnicity (range, 44.1%-97.5%); Black veterans, followed by American Indian or Alaska Native veterans, had the lowest mean control rates (72.5% and 75.4%, respectively). There was clustering of low hypertension control rates for Black veterans in the Pacific Northwest, Southwest, Missouri, Kansas, and Arkansas, and for American Indian or Alaska Native veterans in the West and Southwest.

CONCLUSIONS

Hypertension control rates varied geographically for veteran groups experiencing racial and ethnic disparities. Geographic areas with concentrations of low rates of hypertension control should be a focus for interventions to address racial and ethnic disparities.

Closing the Gap: Digital Innovations to Address Hypertension Disparities

PURPOSE OF REVIEW

Significant inequities persist in hypertension detection and control, with minoritized populations disproportionately experiencing organ damage and premature death due to uncontrolled hypertension. Remote blood pressure monitoring combined with telehealth visits (RBPM) is proving to be an effective strategy for controlling hypertension. Yet there are challenges related to technology adoption, patient engagement and social determinants of health (SDoH), contributing to disparities in patient outcomes. This review summarizes the evidence to date for RBPM, focusing on the potential to advance health equity in blood pressure control and the existing levers for largescale implementation.

RECENT FINDINGS

Several studies demonstrate the promise of RBPM programs to address health disparities through: (1) the use of cellular-enabled blood pressure machines that do not require internet access or smart devices to connect readings into the medical record; (2) emphasis on home blood pressure monitoring to illuminate the daily factors that influence blood pressure control, thereby increasing patient empowerment; (3) adoption of standardized algorithms for hypertension management; and (4) integration of services to address SDoH. Multidisciplinary, non-physician care teams that include nurses, pharmacists, and community health workers are integral to this model. However, most studies have not embraced all aspects of RBPM, and implementation is challenging as current payment models do not support the digital components of RBPM or a diverse workforce of hypertension providers.

CONCLUSION

To address hypertension disparities, RBPM programs need to integrate digital technology that is accessible to all users as well as multidisciplinary care teams that attend to the medical and social needs of populations experiencing health inequities.

Blood Pressure Variability and Cognition in Black and White Older Adults Over 18 Years of Follow-up: A Population-Based Cohort Study

BACKGROUND AND OBJECTIVES

Hypertension is a well-established cardiovascular risk factor for cognitive function. As blood pressure fluctuates because of aging-related changes, we examined the association between visit-to-visit blood pressure variability (BPV) and cognition in older adults.

METHODS

This prospective observational cohort study included 4,770 individuals aged older than 65 years with repeated blood pressure assessment participating in the Chicago Health and Aging Project, a bi-racial population-based study lasting from 1993 to 2012. Blood pressure was measured by research staff every 3 years over 18 of follow-up. Systolic and diastolic BPV was calculated as the sum of the absolute difference in blood pressure between successive measurements, divided by the number (n - 1) of assessments. Cognition was assessed by standardized cognitive tests, and z-scores for the composite cognitive score were computed. Multivariable adjusted linear regression models were used to evaluate the association of systolic and diastolic BPV during the study period with cognition at the last visit.

RESULTS

Of 4,770 individuals, 2,998 (62.9%) were women, 3,146 (66.0%) were Black, and the mean (SD) age at baseline was 71.3 (5.3) years. The mean systolic BPV was 17.7 mm Hg in Black individuals and 16.0 mm Hg in White participants. Higher systolic and diastolic BPV was associated with lower cognitive scores at the end of follow-up. Compared with individuals in the first tertile of systolic BPV (lower BPV), participants with third tertile (higher BPV) had lower cognitive scores by 0.074 standardized units (β -0.074; 95% CI -0.131 to -0.018), corresponding to 1.8 years older in cognitive age. This relationship differed by race, being significant only in older Black adults. Black individuals in the third tertile of systolic BPV had lower cognitive scores by 0.115 standardized units (β -0.115; 95% CI -0.183 to -0.047) compared with those in the first tertile, corresponding to 2.8 years older in cognitive age. Similar findings were observed for diastolic BPV.

DISCUSSION

Elevated BPV, particularly in older Black adults, was associated with a lower cognitive score, suggesting routine assessment for blood pressure to identify and mitigate the adverse role of BPV in cognitive functioning in older adults.

Cost-Effectiveness of a Polypill for Cardiovascular Disease Prevention in an Underserved Population

Importance

The Southern Community Cohort Study (SCCS) Polypill Trial showed that a cardiovascular polypill (a single pill containing a statin and 3 half-standard dose antihypertensive medications) effectively controls cardiovascular disease (CVD) risk factors in a majority Black race and low-income population. The cost-effectiveness of polypill treatment in this population has not been previously studied.

Objective

To determine the cost-effectiveness of the cardiovascular polypill.

Design, Setting, and Participants

A discrete-event simulation version of the well-established CVD policy model simulated clinical and economic outcomes of the SCCS Polypill Trial from a health care sector perspective. A time horizon of 10 years was adopted. Polypill treatment was priced at $463 per year in the base-case analysis. Model input data were derived from the National Health and Nutrition Examination Survey, Medical Expenditure Panel Survey, pooled longitudinal cohort studies, the SCCS Polypill Trial, and published literature. Two cohorts were analyzed: an SCCS Polypill Trial-representative cohort of 100 000 individuals and all trial-eligible non-Hispanic Black US adults. Study parameters and model inputs were varied extensively in 1-way and probabilistic sensitivity analysis.

Exposures

Polypill treatment or usual care.

Main Outcome and Measures

Primary outcomes were direct health care costs (US dollar 2023) and quality-adjusted life-years (QALYs), both discounted 3% annually, and the incremental cost per QALY gained.

Results

In the trial-representative cohort of 100 000 individuals (mean [SD] age, 56.9 [5.9] years; 61 807 female [61.8%]), polypill treatment was projected to yield a mean of 1190 (95% uncertainty interval, 287-2159) additional QALYs compared with usual care, at a cost of approximately $10 152 000. Hence, polypill treatment was estimated to cost $8560 per QALY gained compared with usual care and was high value (<$50 000 per QALY gained) in 99% of simulations. Polypill treatment was estimated to be high value when priced at $559 or less per year and cost saving when priced at $443 or less per year. In almost all sensitivity analyses, polypill treatment remained high value. In a secondary analysis of 3 602 427 trial-eligible non-Hispanic Black US adults (mean [SD] age, 55.4 [7.6] years; 2 006 597 female [55.7%]), polypill treatment was high value, with an estimated cost of $13 400 per QALY gained.

Conclusions and Relevance

Results of this economic evaluation suggest that polypill treatment could be a high value intervention for a low-income, majority Black population with limited access to health care services. It could additionally reduce health disparities.

Predictors of self-reported hypertension among women of reproductive age in North Dakota

BACKGROUND

Understanding the risk factors of hypertension among women of reproductive age (18-44 years) is important for guiding health programs aimed at reducing the burden of hypertensive disorders in this population. Therefore, the objective of this study was to investigate predictors of self-reported hypertension among women of reproductive age in North Dakota.

METHODS

Behavioral Risk Factor Surveillance System data for the years 2017, 2019, and 2021 were obtained from North Dakota Department of Health and Human Services. A conceptual model was used to identify potential predictors of hypertension including sociodemographic characteristics, behavioral factors, chronic health conditions, and healthcare access. A multivariable binary logistic regression model was then used to identify significant predictors of hypertension. The predictive ability of the final model was assessed using a Receiver Operating Characteristic (ROC) curve and area under the curve (AUC).

RESULTS

The odds of hypertension were significantly higher among women of reproductive age who reported frequent mental distress (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.3-3.3), resided in a primary care health professional shortage area (OR = 1.8, 95% CI = 1.2-2.6), were obese (OR = 2.6, 95% CI = 1.7-4.1) and were 35-44 years old (OR = 2.3, 95% CI = 1.6-3.4), relative to their counterparts who did not have frequent mental distress, did not reside in a health professional shortage area, had a normal body mass index, and were 18-34 years old, respectively. Additionally, the odds of hypertension were lower among women who did not have a checkup within the last year compared to those who did have a checkup within the last year (OR = 0.6, 95% CI = 0.4-0.9). The AUC of the final model was 0.68.

CONCLUSIONS

There is evidence that frequent mental distress and disparities in healthcare access or utilization are predictors of hypertension among women of reproductive age in North Dakota. Further research is warranted to determine whether improved mental health can reduce the risk of hypertension in this population. Public health officials may consider promoting hypertension awareness and control programs in areas with limited access to healthcare professionals.

As-Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals

Importance

Asymptomatic blood pressure (BP) elevations in the hospital are commonly treated with as-needed BP medications, including recurring as-needed and 1-time administration. Veterans represent a population at risk of ischemic events from rapid lowering of BP, but the impact of as-needed BP medication use in this population is unknown.

Objective

To assess the risks of acute kidney injury (AKI) and other outcomes from as-needed BP medication administration in a hospitalized veteran cohort.

Design, Setting, and Participants

This retrospective cohort study using target trial emulation and propensity score matching included adult veterans, who were hospitalized 3 or more days in Veterans Administration hospitals between October 1, 2015, and September 30, 2020. Participants must have been hospitalized on a non-intensive care unit medical or surgical floor, must not have undergone surgery, and must have received at least 1 scheduled BP medication in the first 24 hours of admission. Participants also must have had at least 1 systolic BP more than 140 mm Hg during hospitalization. Data in this study were analyzed from April 2023 to August 2024.

Main Outcomes and Measures

The primary outcome was time to first AKI occurrence during hospitalization. Secondary outcomes included greater than 25% reduction in systolic BP within 3 hours of as-needed BP medication administration and the composite outcome of myocardial infarction, stroke, or death during hospitalization.

Results

Of the 133 760 veterans eligible for analysis (mean [SD] age, 71.2 [11.6] years), 96% were male. The mean (SD) baseline estimated glomerular filtration rate was 75.7 (22.7) mL/min/1.73m2. A total of 28 526 patients (21%) received as-needed BP medication. As-needed BP medication use was associated with an increased AKI risk (adjusted hazard ratio, 1.23 [95% CI, 1.18-1.29]) compared to nonusers. Subgroup analyses showed higher AKI risk with intravenous as-needed BP medication use (compared to oral or combined oral and intravenous routes). Secondary analyses indicated as-needed BP medication users had a 1.5-fold greater risk of rapid BP reduction (95% CI, 1.39-1.62) and 1.69-fold higher rate of the composite outcome (95% CI, 1.49-1.92) compared to nonusers.

Conclusions and Relevance

The results of this retrospective cohort study showed that as-needed BP medication use among veterans is associated with increased AKI risk. The risks and benefits of this type of BP medication use would best be determined through a prospective trial, and these data suggest that there is the necessary equipoise to conduct such a trial.

Regional and socioeconomic disparities in calcium scans

INTRODUCTION

Disparities in cardiovascular care are well recognized, with socioeconomic status being one of the strongest determinants of cardiovascular disease outcomes. This study evaluates whether these disparities translate to coronary artery calcium (CAC) scan utilization. Specifically, we aim to describe regional variation and socioeconomic variables that impact CAC utilization across the United States relative to the prevalence of coronary artery disease (CAD) and related comorbidities.

METHODS

This cross-sectional study integrates county-level CAC utilization with CAD prevalence and publicly available socioeconomic variables including self-identified ethnicity, education, and adjusted gross income. CAC utilization rates were sourced from 2022 hospital commercial claims, outpatient Medicare service claims, and independent imaging center claims. Heart disease prevalence and socioeconomic variables were extracted from the Centers for Disease Control and Prevention and the National Center for Chronic Disease Prevention and Health Promotion. Adjusted gross income per capita was gathered from Internal Revenue Service data.

RESULTS

CAC utilization was evaluated across 808 counties within the United States, representing 600,379 claims. Median utilization was 1.62 scans per 1,000 persons with a range of 0.03 to 104.39. The West had the highest CAC scan utilization rate (median 3.09 scans per 1,000 persons) with a CAD prevalence of 548 per 100,000 persons. In contrast, the Midwest had the lowest utilization rate (median 1.24 scans per 1,000 persons) with a CAD prevalence of 635 per 100,000 persons. Socioeconomic factors that favor higher CAC utilization include a larger density of White/Caucasian ethnicity (p = 0.007) and a higher adjusted gross income per capita (p = 0.006). Counties with the lowest rates of CAC utilization have a higher population of African Americans (p <0.001) and a higher proportion of females (p <0.001).

CONCLUSION

This analysis highlights regional and socioeconomic differences in CAC utilization in the United States. Under-represented ethnicities such as African Americans have among the lowest rates of CAC utilization despite having a higher burden and mortality from heart disease. Discordance between CAC utilization, heart disease prevalence and socioeconomic status reveals a need for targeted interventions and policies aimed at mitigating structural barriers that perpetuate health inequities.

Prevalence, trends, and associated factors of isolated systolic, diastolic, and systolic-diastolic hypertension in Peru: A nine-year analysis of the Demographic and Family Health Survey

INTRODUCTION

While HTN is widely seen as a primary threat to cardiovascular conditions worldwide, it is essential to recognize that not all HTN is identical.

OBJECTIVE

To determine the prevalence, trend, and factors associated with each type of HTN: isolated systolic (ISH), isolated diastolic (IDH), and systolic-diastolic (SDH).

METHODS

A secondary analysis of data from the Demographic and Family Health Survey from 2014 to 2022 was conducted. For the analysis of associated factors, a Poisson regression model with robust variance was implemented to calculate adjusted prevalence ratios (aPR) along with their 95% confidence intervals.

RESULTS

The prevalence was 7.02%, 1.55%, and 3.28% for ISH, IDH, and SDH, respectively. ISH showed a decline in 2022, unlike the other two types, which seem to be on the rise. A statistically significant association was found in men and an increased risk with age for ISH and SDH, unlike IDH, where age acts as a protective factor. Additional factors identified include smoking and excessive alcohol consumption, while a high intake of fruits/vegetables offers a protective effect. Obesity and diabetes were associated with a higher risk, and significant variations by region and altitude, as well as among ethnic groups, were observed.

CONCLUSIONS

Significant differences in the prevalence of HTN subtypes have been found, underscoring the heterogeneity of this chronic condition, both in related factors and in trends over the years.

Hypertension: A Continuing Public Healthcare Issue

Hypertension is a cardiovascular disease defined by an elevated systemic blood pressure. This devastating disease afflicts 30-40% of the adult population worldwide. The disease burden for hypertension is great, and it greatly increases the risk of cardiovascular morbidity and mortality. Unfortunately, there are a myriad of factors that result in an elevated blood pressure. These include genetic factors, a sedentary lifestyle, obesity, salt intake, aging, and stress. Although lifestyle modifications have had limited success, anti-hypertensive drugs have been moderately effective in lowering blood pressure. New approaches to control and treat hypertension include digital health tools and compounds that activate the angiotensin receptor type 2 (AT2), which can promote cardiovascular health. Nonetheless, research on hypertension and its management is vital for lessening the significant health and economic burden of this condition.

A study of impulsivity and adverse childhood experiences in a population health setting

As complex mental health traits and life histories are often poorly captured in hospital systems, the utility of using the Barratt Impulsivity Scale (BIS) and Adverse Childhood Experiences (ACEs) for assessing adult disease risks is unknown. Here, we use participants from the Healthy Nevada Project (HNP) to determine if two standard self-assessments could predict the incidence and onset of disease. We conducted a retrospective cohort study involving adult participants who completed the Behavioral and Mental Health Self-Assessment (HDSA) between September 2018 and March 2024. Impulsivity levels were measured using the BIS-15, and retrospective self-reports of ACEs were collected through a standardized questionnaire. In total, 17,482 HNP participants completed the HDSA. Our findings indicate that ACEs were significantly associated with impulsivity. Disease associations with impulsivity and ACEs were evaluated using a phenome-wide association study, identifying 230 significant associations with impulsivity. Among these, 44 were related to mental health diagnoses, including major depressive disorder (MDD). Kaplan-Meier survival estimates characterized the differences in the lifetime predicted probability between high and low impulsivity for major depressive disorder and essential hypertension. This analysis showed that having both high ACEs and high impulsivity confer substantial risk of MDD diagnosis (hazard ratios 2.81, 2.17, respectively). Additionally, lifetime predicted probability of MDD was approximately 40% higher for high ACEs and high impulsivity compared to no ACEs and low impulsivity. Essential hypertension demonstrated similar trends, with an approximate 20% increase in predicted lifetime probability of diagnosis. These results demonstrate that high ACES and elevated impulsivity scores are associated with a range of negative health outcomes and a simple self-assessment of complex traits and life history may significantly impact clinical risk assessments.

The Memphis SOUND Project: The Development of a Community-Based Research Project to Address Hearing Health Disparities Among Black Adults Who Qualify for Cochlear Implants

OBJECTIVE

The objective of this article is to introduce the concept of community-based participatory research as a means to understand barriers to cochlear implant access racially minoritized populations.

BACKGROUND

Black adults living in the United States experience unique barriers to cochlear implantation. Community-based research approaches can be used to understand and address these barriers.

APPLICATION

The Memphis SOUND Project is a community-based research initiative that seeks to address hearing health disparities by examining utilization of hearing healthcare among Black adults. Preliminary findings introduce motivators and barriers related to CI intervention in this population.

CONCLUSION

This Memphis SOUND Project provides valuable insights to the benefits of community-based research in understanding and addressing CI utilization disparities.

Variations in antihypertensive medication treatment and blood pressure control among Veterans with HIV and existing hypertension

BACKGROUND

Hypertension is a leading risk factor for cardiovascular disease among patients living with HIV (PLWH). Understanding the predictors and patterns of antihypertensive medication prescription and blood pressure (BP) control among PLWH with hypertension (HTN) is important to improve the primary prevention efforts for this high-risk population. We sought to assess important patient-level correlates (eg, race) and inter-facility variations in antihypertension medication prescriptions and BP control among Veterans living with HIV (VLWH) and HTN.

METHODS

We studied VLWH with a diagnosis of HTN who received care in the Veterans Health Administration (VHA) from January 2018 to December 2019. We evaluated HTN treatment and blood pressure control across demographic variables, including race, and by medical comorbidities. Data were also compared among VHA facilities. Predictors of HTN treatment and control were assessed in 2-level hierarchical multivariate logistic regression models to estimate odds ratios (ORs). The VHA facility random-effects parameters from the hierarchical models were used to calculate the median odds ratios to characterize the variation across the different VHA facilities.

RESULTS

A total of 17,468 VLWH with HTN (mean age 61 years, 97% male, 54% Black, 40% White) who received care within the VHA facilities in 2018-2019 were included. 73% were prescribed antihypertension medications with higher prescription rates among Black vs White patients (75% vs 71%) and higher prescription rates among patients with a history of cardiovascular disease, diabetes, and kidney disease (>80%), and those receiving antiretroviral therapy and with controlled HIV viral load (∼75%). Only 27% of VLWH with HTN had optimal BP control of systolic BP <130 mmHg and diastolic BP <80 mmHg, with a lower rate of control among Black vs White patients (24% v. 31%). In multivariate regression, Black patients had a higher likelihood of HTN medication prescription (OR 1.32, 95% CI: 1.22-1.42) but were less likely to have optimal BP control (OR 0.82; 0.76-0.88). Important positive correlates of antihypertensive prescription and optimal BP control included: number of outpatient visits in prior year, and histories of diabetes, coronary artery disease, and heart failure. There was about 10% variability in both antihypertensive prescription and BP control patterns between VHA facilities for patients with similar characteristics. There was increased inter-facility variation in antihypertensive prescription among those with a history of heart failure and those not receiving antiretroviral therapy.

CONCLUSION

In a retrospective analysis of large VHA data, we found that VLWH with HTN have suboptimal antihypertensive medication prescription and BP control. Black VLWH had higher HTN medication prescription rates but lower optimal BP control.

Culturally Tailored Lifestyle Modification Strategies for Hypertension Management: A Narrative Review

Hypertension (HTN) is a significant global health challenge affecting billions of individuals worldwide. The prevalence of HTN varies considerably across the globe due to diverse factors, such as lifestyle influenced by culture, genetics, health care access, and socioeconomic conditions. Lifestyle modification has a substantial impact on blood pressure management; however, some cultural practices and behaviors affect recommended lifestyle modification strategies for HTN management. The purpose of this review was to explore lifestyle modification strategies for HTN management from a cultural perspective. Lifestyle modification, including physical activity, stress reduction, changes in dietary patterns (adopting a low-sodium diet and intake of fruit and vegetables), and weight management, provide an effective non-pharmacologic intervention for the management of hypertension. Individual's cultural practices have the potential to determine their diet, physical activity levels, knowledge, and perception about HTN, adherence to treatment and medications, and the use of local herbal preparations for HTN management. Culture focuses on individuals' belief, practices and how these beliefs and practices influence their lifestyle behaviors for HTN management. It is important to consider patients' cultural beliefs before recommending lifestyle behaviors for HTN management.

Harnessing Wearables and Digital Technologies to Decode the Cardiovascular Exposome

The cardiovascular exposome encompasses the array of external and internal factors affecting cardiovascular health throughout life, inviting comprehensive monitoring and analysis to enhance prevention, diagnosis, and treatment strategies. Wearable and digital technologies have emerged as promising tools in this domain, offering longitudinal, real-time data on physiological parameters such as heart rate, heart rhythm, physical activity, and sleep patterns. This review explores the advancements in wearable sensor technology, the methodologies for data collection and analysis, and the integration of these technologies into clinical practice and research. Primary findings indicate significant improvements in device accuracy and functionality, facilitated by enhanced sensor technology, artificial intelligence, and data connectivity. These advancements enable precise monitoring, early detection of cardiovascular anomalies, and personalized healthcare interventions. Ultimately, wearables and digital health technologies have the potential to facilitate a deeper understanding of cardiovascular disease and behavior and bridge gaps in traditional healthcare models to help usher in more efficient, personalized, patient-centered care.

Zip Code Health Disparities: Mapping Cardiovascular Inequities at the Neighborhood Level

This review examines the multifaceted impact of neighborhood-level social determinants of health (SDOH) on cardiovascular disease (CVD) and outlines strategic interventions for mitigating cardiovascular health inequities. Research highlights that environmental and socioeconomic factors within a neighborhood-including education, unemployment, healthcare access, racial segregation, systemic inequities, air quality, housing quality, and other SDOH-influence CVD outcomes. Addressing CVD disparities necessitates a comprehensive strategy that integrates policy reform, enhanced community infrastructure, improved healthcare access, and community empowerment and leverages innovative technology to create equitable health outcomes across diverse populations.

EXpanding Technology-Enabled, Nurse-Delivered Chronic Disease Care (EXTEND): Protocol and Baseline Data for a Randomized Trial

BACKGROUND

Approximately 10-15 % of individuals with type 2 diabetes have persistently poorly-controlled diabetes mellitus (PPDM) despite receiving available care, and frequently have comorbid hypertension. Mobile monitoring-enabled telehealth has the potential to improve outcomes in treatment-resistant chronic disease by supporting self-management and facilitating patient-clinician contact but must be designed in a manner amenable to real-world use.

METHODS

Expanding Technology-Enabled, Nurse-Delivered Chronic Disease Care (EXTEND) is an ongoing randomized trial comparing two 12-month interventions for comorbid PPDM and hypertension: 1) EXTEND, a mobile monitoring-enabled self-management intervention; and 2) EXTEND Plus, a comprehensive, nurse-delivered telehealth program incorporating mobile monitoring, self-management support, and pharmacist-supported medication management. Both arms leverage a novel platform that uses existing technological infrastructure to enable transmission of patient-generated health data into the electronic health record. The primary study outcome is difference in HbA1c change from baseline to 12 months. Secondary outcomes include blood pressure, weight, implementation barriers/facilitators, and costs.

RESULTS

Enrollment concluded in June 2023 following randomization of 220 patients. Baseline characteristics are similar between arms; mean age is 54.5 years, and the cohort is predominantly female (63.6 %) and Black (68.2 %), with a baseline HbA1c of 9.81 %.

CONCLUSION

The EXTEND trial is evaluating two mobile monitoring-enabled telehealth approaches that seek to improve outcomes for patients with PPDM and hypertension. Critically, these approaches are designed around existing infrastructure, so may be amenable to implementation and scaling. This study will promote real-world use of telehealth to maximize benefits for those with high-risk chronic disease.

Effects of polygenic risk score and sodium and potassium intake on hypertension in Asians: A nationwide prospective cohort study

Genetic factors, lifestyle, and diet have been shown to play important roles in the development of hypertension. Increased salt intake is an important risk factor for hypertension. However, research on the involvement of genetic factors in the relationship between salt intake and hypertension in Asians is lacking. We aimed to investigate the risk of hypertension in relation to sodium and potassium intake and the effects of genetic factors on their interactions. We used Korean Genome and Epidemiology Study data and calculated the polygenic risk score (PRS) for the effect of systolic and diastolic blood pressure (SBP and DBP). We also conducted multivariable logistic modeling to evaluate associations among incident hypertension, PRSSBP, PRSDBP, and sodium and potassium intake. In total, 41,351 subjects were included in the test set. The top 10% PRSSBP group was the youngest of the three groups (bottom 10%, middle, top 10%), had the highest proportion of women, and had the highest body mass index, baseline BP, red meat intake, and alcohol consumption. The multivariable logistic regression model revealed the risk of hypertension was significantly associated with higher PRSSBP, higher sodium intake, and lower potassium intake. There was significant interaction between sodium intake and PRSSBP for incident hypertension especially in sodium intake ≥2.0 g/day and PRSSBP top 10% group (OR 1.27 (1.07-1.51), P = 0.007). Among patients at a high risk of incident hypertension due to sodium intake, lifestyle modifications and sodium restriction were especially important to prevent hypertension.

Predictive Models for Sustained, Uncontrolled Hypertension and Hypertensive Crisis Based on Electronic Health Record Data: Algorithm Development and Validation

Background

Assessing disease progression among patients with uncontrolled hypertension is important for identifying opportunities for intervention.

Objective

We aim to develop and validate 2 models, one to predict sustained, uncontrolled hypertension (≥2 blood pressure [BP] readings ≥140/90 mm Hg or ≥1 BP reading ≥180/120 mm Hg) and one to predict hypertensive crisis (≥1 BP reading ≥180/120 mm Hg) within 1 year of an index visit (outpatient or ambulatory encounter in which an uncontrolled BP reading was recorded).

Methods

Data from 142,897 patients with uncontrolled hypertension within Atrium Health Greater Charlotte in 2018 were used. Electronic health record-based predictors were based on the 1-year period before a patient's index visit. The dataset was randomly split (80:20) into a training set and a validation set. In total, 4 machine learning frameworks were considered: L2-regularized logistic regression, multilayer perceptron, gradient boosting machines, and random forest. Model selection was performed with 10-fold cross-validation. The final models were assessed on discrimination (C-statistic), calibration (eg, integrated calibration index), and net benefit (with decision curve analysis). Additionally, internal-external cross-validation was performed at the county level to assess performance with new populations and summarized using random-effect meta-analyses.

Results

In internal validation, the C-statistic and integrated calibration index were 0.72 (95% CI 0.71-0.72) and 0.015 (95% CI 0.012-0.020) for the sustained, uncontrolled hypertension model, and 0.81 (95% CI 0.79-0.82) and 0.009 (95% CI 0.007-0.011) for the hypertensive crisis model. The models had higher net benefit than the default policies (ie, treat-all and treat-none) across different decision thresholds. In internal-external cross-validation, the pooled performance was consistent with internal validation results; in particular, the pooled C-statistics were 0.70 (95% CI 0.69-0.71) and 0.79 (95% CI 0.78-0.81) for the sustained, uncontrolled hypertension model and hypertensive crisis model, respectively.

Conclusions

An electronic health record-based model predicted hypertensive crisis reasonably well in internal and internal-external validations. The model can potentially be used to support population health surveillance and hypertension management. Further studies are needed to improve the ability to predict sustained, uncontrolled hypertension.

Association between platelet to high-density lipoprotein cholesterol ratio (PHR) and hypertension: evidence from NHANES 2005-2018

BACKGROUND

The Platelet to High-Density Lipoprotein cholesterol Ratio (PHR) is a novel indicator of inflammatory response and metabolic disorders, linked to various chronic diseases. This study aims to investigate the relationship between PHR and hypertension.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES), collected across seven consecutive cycles from 2005 to 2018, were analyzed. The dataset included participants' hypertension status as reported by a doctor, their use of antihypertensive medications, and the average of three blood pressure measurements to identify hypertensive adults, along with complete information for PHR calculation. PHR was calculated based on Platelet (PLT) count and High-Density Lipoprotein cholesterol (HDL-C) using the following formula: PHR = [PLT (1000 cells/µL) / HDL-C (mmol/L)]. A multivariable logistic regression model was employed to assess the association between PHR and hypertension, and subgroup analyses were conducted to explore potential influencing factors. Additionally, Restricted Cubic Spline (RCS) curves were applied for threshold effect analysis to describe nonlinear relationships.

RESULTS

Higher PHR was associated with an increased prevalence of hypertension. After adjusting for various covariates, including race, education level, Family Poverty Income Ratio (PIR), smoking, alcohol consumption, sleep disturbances, waist circumference, diabetes, coronary heart disease, angina, heart attack, and stroke, the results remained significant (OR = 1.36; 95% CI, 1.32, 1.41, P < 0.001). Participants with the highest PHR levels had a 104% higher risk of hypertension compared to those with the lowest PHR levels (OR = 2.04; 95% CI, 1.89, 2.21, P < 0.001).

CONCLUSION

Elevated PHR levels are strongly associated with an increased risk of hypertension. Specifically, when PHR is below 280, the risk of hypertension increases in proportion to PHR. This suggests that regular monitoring of PHR may help identify patients at risk of hypertension early, allowing for timely interventions to slow disease progression. Larger cohort studies are necessary to confirm these findings.

Trends and Patterns in Hypertension-Related Deaths: A Comprehensive Analysis Using Center for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) Data

Hypertension (HTN) is a leading cause of cardiovascular morbidity and mortality worldwide. Despite advances in treatment, including the development and use of vasodilator-β-blocker combination and treatment with antihypertensive agents, HTN-related deaths have shown concerning trends. As such, the objective of this study is to examine the trends, disparities, and demographic variations in HTN-related mortality over a decade and to identify key factors contributing to these patterns, including genetics, dietary habits, structural discrimination in access to healthcare, lifestyle choices, and secondary hypertension, which is due to underlying conditions like kidney disease, hormonal disorders, or certain medications. To attain this objective, this retrospective study has utilized data from the Center for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database to assess HTN-related mortality rates from 2010 to 2020. Age-adjusted mortality rates were calculated, and subgroup analyses were conducted by gender, race/ethnicity, and age groups. Temporal trends were analyzed to identify significant changes in mortality rates over time. Moreover, IBM SPSS Statistics, version 29 (IBM Corp., Armonk, NY) was used in the analysis, while 95% confidence intervals (CIs), were calculated to demonstrate the temporary trend of mortality rates overall and by age, sex, ethnicity, and region. Therefore, the mortality data from 2010 to 2020 show significant trends and variations across demographic groups. Overall, HTN-related mortality rate in the United States increased from 5.1 per 100,000 in 2010 to 6.4 in 2020, reflecting a general upward trend. For males, the rate rose from 4.8 to 6.6 per 100,000 during the same period. Racial disparities are notable, with Black or African American individuals having the highest mortality rates, increasing from 9.6 to 11.2 per 100,000. Age-specific data reveal that mortality in the 65-74 age group more than doubled, from 10.3 to 16.2 per 100,000, while in the 75-84 age group, it rose from 32.1 to 35.7. The 85+ age group had the highest rates, increasing from 144.0 to 155.0 per 100,000. States with the highest age-adjusted rates include Mississippi, Georgia, West Virginia, California, and Alabama. The study findings highlight the growing burden of HTN-related mortality in the United States, particularly among males, racial minorities, and older adults. This situation underscores the need for targeted public health interventions, which include creation of hypertension awareness in minority groups and enhancing medication adherence especially among Blacks, and addressing the social determinants of health contributing to higher HTN rates and poorer outcomes, including disadvantaged neighborhoods, structural discrimination and racism, and limited access to healthcare. The study found that African Americans are likely to be diagnosed with HTN earlier in life with higher HTN-related mortality than Whites, and with 50% increased risk of cardiovascular disease mortality. Continuous efforts are required to aptly address such disparities contributing to ongoing HTN treatment and care inequalities.

Bridging the Gap: Tackling Racial and Ethnic Disparities in Hypertension Management

Hypertension is a prevalent health concern with significant implications for cardiovascular disease risk, affecting diverse populations worldwide and imposing substantial health system burdens. This review article explores racial and ethnic disparities in hypertension prevalence, treatment, and management, highlighting the disproportionate impact on minority populations. Certain racial and ethnic groups in the United States exhibit higher prevalence rates of hypertension and related complications due to a confluence of genetic, social, and economic factors. Despite comparable treatment rates, blood pressure control is often less effective among these groups, partly due to less intensive treatment and systemic barriers to care. Different populations encounter unique challenges, with prevalence and control rates influenced by dietary habits, socioeconomic status, and healthcare disparities. This review summarizes current management practices and highlights the necessity for tailored approaches that consider ethnic-specific treatment responses. It underscores the importance of addressing socioeconomic and cultural barriers while incorporating both pharmacological and nonpharmacological treatments. Future research should focus on developing culturally relevant assessment tools, enhancing data collection, and evaluating interventions designed to mitigate these disparities. To promote health equity and optimize the management of hypertension in a variety of populations, it is imperative to address these inequities using individualized, evidence-based strategies.

Trends and disparities in prevalence of diagnosed hypertension among U.S. Adults from 2019 to 2022

BACKGROUND

Hypertension (HTN) stands as a significant risk factor for cardiovascular diseases. Identifying trends and disparities in HTN prevalence is vital for developing public health policies.

OBJECTIVE

Investigate the trends and disparities in HTN prevalence among U.S. adults from 2019 to 2022.

METHODS

Data from the CDC's National Health Interview Survey were utilized, with regression analysis including Joinpoint and ARIMA models performed by ChatGPT-4 to predict future trends.

RESULTS

The study observed fluctuations in the overall prevalence of diagnosed HTN starting at 27.0 % (95 % CI: 26.4-27.7, 2019), and reaching 27.2 % (95 % CI: 26.5-27.8, 2022). Males consistently showed higher HTN rates than females throughout the study period, with male prevalence increasing from 27.2 % (95 % CI: 26.3-28.1, 2019) to 27.9 % (95 % CI: 27.0-28.8, 2022), while females experienced decline from 26.9 % (95 % CI: 26.1-27.8, 2019) to 26.5 % (95 % CI: 25.7-27.3, 2022). Southern U.S. exhibited the highest prevalence at 30.1 % (95 % CI: 29.1-31.2, 2022), compared to the lowest in the West at 22.5 % (95 % CI: 21.4-23.8). Black adults showed a higher prevalence of 34.4 % (95 % CI: 32.4-36.4, 2022) compared to White adults at 27.4 % (95 % CI: 26.7-28.2), and significantly lower rates were observed in Asian adults at 14.5 % (95 % CI: 7.4-24.5).

CONCLUSION

This study highlights stable trends in HTN prevalence among U.S. adults from 2019 to 2022, with significant disparities by gender, region, and race, underscoring the need for targeted public health interventions to address these inequalities.

Community-Based Physical Activity Programs for Blood Pressure Management in African Americans: A Scoping Review

BACKGROUND

Hypertension is a significant risk factor for cardiovascular disease, with a higher prevalence among African Americans (AA) than other racial groups. The impact of community-based interventions on managing blood pressure (BP) in AA communities is not fully understood. The purpose of this review was to synthesize literature on community-based physical activity (PA) programs designed to manage BP in AA populations.

METHODS

We conducted a scoping review by searching 4 databases (PubMed, CINAHL, MEDLINE, and APA PsycInfo) and reference lists of studies. Search terms included community PA, community-based, hypertension, high BP, AA, Black Americans, PA, and exercise. Inclusion criteria were studies (1) conducted in the United States and (2) published in English language from January 2013 to September 2023, with community-based interventions that included PA for BP management among AA aged ≥18 years.

RESULTS

Search results yielded 260 studies, of which 11 met the inclusion criteria. BP decreased over time in studies that incorporated PA, faith-based therapeutic lifestyle changes with nutritional education. The duration of the PA interventions varied, with moderate to vigorous PAs implemented for 12 weeks or longer having a greater impact on BP management.

CONCLUSIONS

Evidence suggests that community-based PA programs can potentially reduce BP among AA. PA programs incorporating faith-based therapeutic lifestyle change with nutritional education appear to reduce BP. Practitioners should consider multicomponent community-based PA initiatives to improve BP outcomes in AA communities.

Role of Clinical Pharmacology in Diversity and Inclusion in Global Drug Development: Current Practices and Industry Perspectives: White Paper

The 2022 United States Food and Drug Administration (US FDA) draft guidance on diversity plan (DP), which will be implemented through the Diversity Action Plans by December 2025, under the 21st Century Cures Act, marks a pivotal effort by the FDA to ensure that registrational studies adequately reflect the target patient populations based on diversity in demographics and baseline characteristics. This white paper represents the culminated efforts of the International Consortium of Quality and Innovation (IQ) Diversity and Inclusion (D&I) Working Group (WG) to assess the implementation of the draft FDA guidance by members of the IQ consortium in the discipline of clinical pharmacology (CP). This article describes current practices in the industry and emphasizes the tools and techniques of quantitative pharmacology that can be applied to support the inclusion of a diverse population during global drug development, to support diversity and inclusion of underrepresented patient populations, in multiregional clinical trials (MRCTs). It outlines strategic and technical recommendations to integrate demographics, including age, sex/gender, race/ethnicity, and comorbidities, in multiregional phase III registrational studies, through the application of quantitative pharmacology. Finally, this article discusses the challenges faced during global drug development, which may otherwise limit the enrollment of a broader, potentially diverse population in registrational trials. Based on the outcomes of the IQ survey that provided the current awareness of diversity planning, it is envisioned that in the future, industry efforts in the inclusion of previously underrepresented populations during global drug development will culminate in drug labels that apply to the intended patient populations at the time of new drug application or biologics license application rather than through post-marketing requirements.

Examining the Hypertension Control Cascade in Adults With Uncontrolled Hypertension in the US

Importance

Uncontrolled hypertension is a major contributor to cardiovascular disease (CVD) in the US.

Objective

To determine the prevalence of hypertension control cascade outcomes (hypertension awareness, treatment recommendations, and medication use) among individuals with uncontrolled hypertension to inform action across cascade levels.

Design, Setting, and Participants

This weighted cross-sectional study used January 2017 to March 2020 National Health and Nutrition Examination Survey (NHANES) data from noninstitutionalized adults aged 18 years or older in the US with uncontrolled hypertension. Data analysis occurred from January to February 2024.

Exposure

Calendar year of response to the NHANES survey.

Main Outcomes and Measures

Mean blood pressure (BP) was computed using up to 3 measurements. Uncontrolled hypertension was defined as systolic BP of 130 mm Hg or greater or diastolic BP of 80 mm Hg or greater, regardless of medication use. Outcomes included patient awareness of hypertension, treatment recommendations, and medication use. To estimate population totals by subgroup, the age-standardized proportion of each outcome was multiplied by the estimated number of adults with uncontrolled hypertension.

Results

The study included 3129 US adults with uncontrolled hypertension (1675 male [weighted percentage, 52.3%]; 775 aged 18 to 44 years [weighted percentage, 29.4%]; 1306 aged 45 to 64 years [weighted percentage, 41.4%]; 1048 aged 65 years or older [weighted percentage, 29.2%]), resulting in a population estimate of 100.4 million adults (weighted percentage, 83.7%) with uncontrolled hypertension. More than one-half of study participants (57.8 million adults [weighted percentage, 57.6%]) were unaware that they had hypertension, and of the 35.0 million who were aware and met criteria for antihypertensive medication, 24.8 million (weighted percentage, 70.8%) took the medication but had hypertension that remained uncontrolled. These negative outcomes in the hypertension control cascade occurred across demographic groups, with notably high prevalence among younger adults and individuals engaged in health care. Among an estimated 30.1 million adults aged 18 to 44 years with hypertension, 10.4 of 11.3 million females (weighted percentage, 91.8%) and 17.7 million of 18.8 million males (weighted percentage, 94.3%) had uncontrolled hypertension. Of the 10.4 million females, 7.2 million (weighted percentage, 68.8%) were unaware of their hypertension status, and of the 17.7 million males, 12.0 million (weighted percentage, 68.1%) were unaware. Additionally, 9.9 of 13.0 million adults with uncontrolled hypertension (weighted percentage, 75.7%) reported no health care visits in the past year and were unaware. Conversely, among 70.6 million adults with uncontrolled hypertension reporting 2 or more health care visits, approximately one-half (36.6 million [weighted percentage, 51.8%]) were unaware.

Conclusions and Relevance

In this cross-sectional study, more than 50% of adults with uncontrolled hypertension in the US were unaware of their hypertension and were untreated, and 70.8% of those who were treated had hypertension that remained uncontrolled. These findings have serious implications for the nation's overall health given the association of hypertension with increased risk for CVD.

Digital Innovation to Grow Quality Care Through an Interprofessional Care Team (DIG IT) Among Underserved Patients With Hypertension

PURPOSE

The impact of digital health on medically underserved patients is unclear. This study aimed to determine the early impact of a digital innovation to grow quality care through an interprofessional care team (DIG IT) on the blood pressure (BP) and 10-year atherosclerotic cardiovascular disease (ASCVD) risk score of medically underserved patients.

METHODS

This was a 3-month, prospective intervention study that included patients aged 40 years or more with BP of 140/90 mmHg or higher who received care from DIG IT from August through December 2021. Sociodemographic and clinical outcomes of DIG IT were compared with historical controls (controls) whose data were randomly extracted by the University of California Data Warehouse and matched 1:1 based on age, ethnicity, and baseline BP of the DIG IT arm. Multiple linear regression was performed to adjust for potential confounding factors.

RESULTS

A total of 140 patients (70 DIG IT, 70 controls) were included. Both arms were similar with an average age (SD) of 62.8 (9.7) years. The population was dominated by Latinx (79.3%) persons, with baseline mean BP of 163/81 mmHg, and mean ASCVD risk score of 23.9%. The mean (SD) reduction in systolic BP at 3 months in the DIG IT arm was twice that of the controls (30.8 [17.3] mmHg vs 15.2 [21.2] mmHg; P <.001). The mean (SD) ASCVD risk score reduction in the DIG IT arm was also twice that of the controls (6.4% [7.4%] vs 3.1% [5.1%]; P = .003).

CONCLUSIONS

The DIG IT was more effective than controls (receiving usual care). Twofold improvement in the BP readings and ASCVD scores in medically underserved patients were achieved with DIG IT.

Addressing Hypertension Disparities via Systems Dynamics: Insights From Community Health Connections

Background and objective Hypertension remains a major public health challenge in the United States, disproportionately affecting various demographic groups. Significant disparities persist in hypertension prevalence and control due to interactions between socioeconomic factors, healthcare access, and systemic inequities. In this study, we aimed to determine the impact of socioeconomic and healthcare factors on hypertension control among patients at Community Health Connections (CHC), a Federally Qualified Health Center serving 36 communities in North Central Massachusetts, and identify effective interventions using systems dynamics modeling to promote health equity. Materials and methods This was a retrospective observational study using data from 2023 CHC patients, and the National Health and Nutrition Examination Survey (NHANES) 2011-2014. Systems dynamics modeling was employed to visualize interactions among factors influencing hypertension outcomes. The study included 4,870 CHC patients. Participants were selected based on clinical records and comprised 3,690 White participants (76%), 464 Black/African American participants (10%), 108 Asian participants (2%), and 608 classified as Other/Non-reported (12%). The cohort included 2,490 males (51%) and 2,380 females (49%). Socioeconomic factors (e.g., race, age, insurance status) and healthcare access were the study variables. The primary outcome was hypertension control, defined as a blood pressure reading of <140/90 mmHg. The study measured control rates across different demographic groups and assessed the impact of socioeconomic and healthcare factors on these rates. Results Among the 4,870 CHC patients, 3,007 (62%) achieved hypertension control. The overall hypertension control rate varied significantly by race: White: 68.6%, Black/African American: 61.6%, Asian: 63.2%, and Other/Non-reported: 65.6%. Insured patients had a control rate of 67.7%, compared to 37.5% for uninsured patients (p<0.001). Systems dynamics models illustrated how socioeconomic disparities and healthcare access issues amplify health inequities. Key interventions identified include, but are not limited to, multidisciplinary care teams, community health worker programs, and telehealth services. Conclusions Addressing hypertension disparities among CHC patients requires a systemic approach integrating socioeconomic, healthcare, and policy-related interventions. Systems dynamics modeling provides a framework for designing and implementing targeted interventions, enhancing health equity, and improving hypertension control outcomes in underserved populations. Further research is needed to test the effectiveness of these interventions before their broad implementation.

Reducing Cardiovascular Disparities in Kentucky: The Design, Implementation, and Evaluation of the Cardiovascular Assessment Risk Reduction and Education Self-Measured Blood Pressure (CARE SMBP) Monitoring Program

Hypertension is a leading risk factor in cardiovascular disease (CVD) with the highest national rates in southeastern and Appalachian counties. To reduce hypertension health disparities and CVD risk, the Kentucky Department for Public Health Heart Disease and Stroke Program (KHDSP) designed, implemented, and continuously evaluated the Cardiovascular Assessment Risk Reduction and Education Self-Measured Blood Pressure (CARE SMBP) program in rural and Appalachian Kentucky. Ten health care systems and two local health departments implemented CARE SMBP. CARE SMBP patients improved their blood pressure and engaged in lifestyle behavior changes that lead to improved long-term health. Health care researchers and potential SMBP implementors can reference the CARE SMBP framework and evaluation results to design their own clinically supported SMBP programs with educational support to reduce CVD risk.

Risk factors of undiagnosed and uncontrolled hypertension in primary care patients with hypertension: a cross-sectional study

BACKGROUND

Hypertension is a common heart condition in the United States (US) and severely impacts racial and ethnic minority populations. While the understanding of hypertension has grown considerably, there remain gaps in US healthcare research. Specifically, there is a lack of focus on undiagnosed and uncontrolled hypertension in primary care settings.

AIM

The present study investigates factors associated with undiagnosed and uncontrolled hypertension in primary care patients with hypertension. The study also examines whether Black/African Americans are at higher odds of undiagnosed and uncontrolled hypertension compared to White patients.

METHODS

A cross-sectional study was conducted using electronic health records (EHR) data from the University of Utah primary care health system. The study included for analysis 24,915 patients with hypertension who had a primary care visit from January 2020 to December 2020. Multivariate logistic regression assessed the odds of undiagnosed and uncontrolled hypertension.

RESULTS

Among 24,915 patients with hypertension, 28.6% (n = 7,124) were undiagnosed and 37.4% (n = 9,319) were uncontrolled. Factors associated with higher odds of undiagnosed hypertension included age 18-44 (2.05 [1.90-2.21]), Hispanic/Latino ethnicity (1.13 [1.03-1.23]),  Medicaid (1.43 [1.29-1.58]) or self-pay  (1.32 [1.13-1.53]) insurance, CCI 1-2 (1.79 [1.67-1.92]), and LDL-c ≥ 190 mg/dl (3.05 [1.41-6.59]). For uncontrolled hypertension, risk factors included age 65+ (1.11 [1.08-1.34]), male (1.24 [1.17-1.31]), Native-Hawaiian/Pacific Islander (1.32 [1.05-1.62])  or Black/African American race (1.24 [1.11-1.57]) , and self-pay insurance (1.11 [1.03-1.22]).

CONCLUSION

The results of this study suggest that undiagnosed and uncontrolled hypertension is prevalent in primary care. Critical risk factors for undiagnosed hypertension include younger age, Hispanic/Latino ethnicity, very high LDL-c, low comorbidity scores, and self-pay or medicaid insurance. For uncontrolled hypertension, geriatric populations, males, Native Hawaiian/Pacific Islanders, and Black/African Americans, continue to experience greater burdens than their counterparts. Substantial efforts are needed to strengthen hypertension diagnosis and to develop tailored hypertension management programs in primary care, focusing on these populations.

A Large-Scale Genome-Wide Study of Gene-Sleep Duration Interactions for Blood Pressure in 811,405 Individuals from Diverse Populations

Although both short and long sleep duration are associated with elevated hypertension risk, our understanding of their interplay with biological pathways governing blood pressure remains limited. To address this, we carried out genome-wide cross-population gene-by-short-sleep and long-sleep duration interaction analyses for three blood pressure traits (systolic, diastolic, and pulse pressure) in 811,405 individuals from diverse population groups. We discover 22 novel gene-sleep duration interaction loci for blood pressure, mapped to 23 genes. Investigating these genes' functional implications shed light on neurological, thyroidal, bone metabolism, and hematopoietic pathways that necessitate future investigation for blood pressure management that caters to sleep health lifestyle. Non-overlap between short sleep (12) and long sleep (10) interactions underscores the plausible nature of distinct influences of both sleep duration extremes in cardiovascular health. Several of our loci are specific towards a particular population background or sex, emphasizing the importance of addressing heterogeneity entangled in gene-environment interactions, when considering precision medicine design approaches for blood pressure management.

Predicting chronic responses to calcium channel blockade with a virtual population of African Americans with hypertensive chronic kidney disease

Chronic kidney disease (CKD) is associated with the progressive loss of functional nephrons and hypertension (HTN). Clinical studies demonstrate calcium channel blocker (CCB) therapy mitigates the decline in renal function in humans with essential HTN. However, there are few long-term clinical studies that determine the impact of CCBs in patients with hypertensive CKD. African Americans (AA) have a higher prevalence of CKD and a faster progression to total kidney failure as compared to the white population but the mechanisms are poorly understood. Both clinical evidence (the African American Study of Kidney Disease and Hypertension, or AASK trial) and experimental studies have demonstrated that CCB may expose glomerular capillaries to high systemic pressures and exacerbate CKD progression. Therefore, using a large physiological model, we set out to replicate the AASK trial findings, predict renal hemodynamic responses and the role of the renin-angiotensin system during CCB antihypertensive therapy in a virtual population, and hypothesize mechanisms underlying those findings. Our current mathematical model, HumMod, is comprised of integrated systems that play an integral role in long-term blood pressure (BP) control such as neural, endocrine, circulatory, and renal systems. Parameters (n=341) that control these systems were randomly varied and resulted in 1400 unique models that we define as a virtual population. We calibrated these models to individual patient level data from the AASK trial: BP and glomerular filtration rate (GFR) before and after 3 years of amlodipine (10 mg/day). After calibration, the new virtual population (n=165) was associated with statistically similar BP and GFR before and after CCB. Baseline factors such as elevated single nephron GFR and low tubuloglomerular feedback were correlated with greater declines in renal function and increased glomerulosclerosis after 3 years of CCB. Blocking the renin-angiotensin system (RAS) in the virtual population decreased glomerular pressure, limited glomerular damage, and further decreased BP (-14 ± 8 mmHg) as compared to CCB alone (-11 ± 9 mmHg). Our simulations echo the potential risk of CCB monotherapy in AA CKD patients and support blockade of the renin angiotensin system as a valuable tool in renal disease treatment when combined with CCB therapy.

Racial and Ethnic Disparities Within Social Determinants of Health Amongst Patients With Systemic Lupus Erythematosus

Introduction This study aims to identify the influence of social determinants of health (SDoH) on patients with systemic lupus erythematosus (SLE), emphasizing racial and ethnic disparities in healthcare. Methods A cross-sectional study used the National Institute of Health's (NIH) All of Us Research Program (AoU). From 727,000 patients, SLE patients were categorized by race, ethnicity, and responses to the Social Determinants of Health survey from May 2018 until March 2023. Survey questions addressed transportation access, neighborhood safety, provider biases, and food insecurity. JMP Pro 16.0 and R 4.2.2 were used for statistical analysis. Results Significant racial disparities were evident amongst SLE patients for transportation access, neighborhood safety, food security, and respect from healthcare providers (p-value < 0.001). African Americans, Asians, and White participants showed different perceptions regarding neighborhood crime, healthcare provider courtesy, and feeling unheard by providers, with respective p-values of 0.001, 0.010, and 0.023. Hispanic participants perceived higher neighborhood crime rates, felt unsafe during nighttime walks, felt unheard by healthcare providers, and reported worrying about food security compared to non-Hispanic participants, with respective p-values of 0.003, 0.003, 0.009, and <0.001.  Discussion SLE is affected by access to care, treatments, stress, and lifestyle habits. Therefore, identifying SDoH for SLE patients is critical as it impacts disease progression, leading to delays in diagnosis, improper management, and worsening morbidity.  Conclusion Targeted social and community-based interventions may improve access to care, identify implicit biases among providers, and alleviate food insecurity.

Sociodemographic predictors of hypertensive crisis in the hospitalized population in the United States

INTRODUCTION

Hypertensive crisis (HC) encompasses hypertensive emergencies (HE) and urgencies (HU).

METHODS

A retrospective analysis of the 2016-2020 National Inpatient Sample was conducted, and all hospitalizations for HC were identified with their ICD-10 codes. A probability estimation of outcomes was calculated by performing multivariable logistic regression analysis, which took confounders into account. Our primary outcomes were SDs of HC. Secondary outcomes were myocardial infarction (MI), stroke, acute kidney injury (AKI), and transient ischemic attack (TIA).

RESULTS

The minority populations were more likely than the Whites to be diagnosed with HCs: Black 2.7 (2.6-2.9), Hispanic 1.2 (1.2-1.3), and Asian population 1.4 (1.3-1.5), (p < 0.0001, all). Furthermore, being male 1.1 (1.09-1.2, p < 0.0001), those with 'self-pay' insurance 1.02 (1.01-1.03, p < 0.0001), and those in the <25th percentile of median household income 1.3 (1.2-1.3, p < 0.0001), were more likely to be diagnosed with HCs. The Black population had the highest likelihood of end-organ damage: MI 2.7 (2.6-2.9), Stroke 3.2 (3.1-3.4), AKI 2.4 (2.2-2.5), and TIA 2.8 (2.7-3.0), (p < 0.0001, all), compared to their Caucasian counterpart.

CONCLUSIONS

Being of a minority population, male sex, low-income status, and uninsured were associated with a higher likelihood of hypertensive crisis. The black population was the youngest and had the highest risk of hypertensive emergencies. Targeted interventions and healthcare policies should be implemented to address these disparities and enhance patient outcomes.

Hypertension Prevalence and Related Risk Factors Among Mexican American Adults Are Increasing: National Health and Nutrition Examination Survey 1999 to 2018

BACKGROUND

Acculturation affects hypertension prevalence among Hispanic people, but there have been no recent analyses specifically focused on Mexican American (MA) people. We sought to determine age-adjusted hypertension prevalence, abdominal obesity, and acculturation trends among MA adults and non-Hispanic White adults.

METHODS AND RESULTS

Data from the NHANES (National Health and Nutrition Examination Survey) were analyzed in 2-year increments to observe trends in hypertension and risk factors (age, sex, body mass index, smoking status, abdominal obesity, waist-to-height ratio (WHtR), education, and income). Acculturation was based on three commonly used measures. The sample included 30 920 adults. Age-adjusted hypertension prevalence is higher in MA adults (52.7%) than White adults (48.3%). Hypertension risk factors-age, obesity prevalence, WHtR, acculturation-all significantly increased among MA adults, while smoking declined. Higher acculturation scores increased hypertension likelihood (odds ratio [OR], 1.44 [95% CI, 0.91-1.97]) for MA adults compared with those with lower acculturation scores. White adults with elevated WHtR >0.5 had a 40% higher risk of hypertension than those with WHtR <0.5, but among MA adults, elevated WHtR did not increase risk for hypertension. There was a significant increase in hypertension prevalence among MA adults from 2003 to 2018 at an average biennial rate of 2.23%. There was no change in hypertension prevalence among White adults from 1999 to 2018.

CONCLUSIONS

Over 20 years of NHANES, more highly acculturated MA adults were at greater risk for hypertension, despite declines in smoking and controlling for age, sex, obesity status, education, and income. Finding ways to promote more traditional lifestyle and eating habits for MA adults could be a beneficial approach to reducing hypertension risk factors in this population.

U.S. Filipino Adults Have Elevated Prevalence of Hypertension Across the Adult Lifespan: Findings From a Cross-Sectional Electronic Health Record Study

Introduction

The prevalence of hypertension increases with age and differs by race and ethnicity. Among U.S. Asian adults, prevalence is higher for Filipino adults than for other major Asian subgroups, but whether this disparity exists across the adult lifespan is unknown. This study examined hypertension prevalence by age decade, comparing Filipino adults with South Asian, Chinese, Black, Hispanic, and White adults.

Methods

This cross-sectional study used 2015-2016 electronic health record data from a Northern California integrated healthcare delivery system for 1,839,603 adults aged 30-79 years, including 128,124 Filipino adults. Hypertension was defined by diagnosis codes. Sex-specific prevalence was calculated by race and ethnicity overall and by 10-year age decade from ages 30-39 years to 70-79 years. The prevalence of hypertension among 5 racial and ethnic groups was compared within each decade (with Filipino as the reference), adjusting for age, English language, diabetes, smoking, and weight category.

Results

Decade-specific prevalence of hypertension among Filipino men and women, respectively, was 9.7% and 8.5% for ages 30-39 years, 26.0% and 23.9% for ages 40-49 years, 45.9% and 44.4% for ages 50-59 years, 65.4% and 63.9% for ages 60-69 years, and 82.1% and 82.9% for ages 70-79 years. Across all age decades, hypertension prevalence among Filipino adults largely tracked with Black adults and was much higher than among South Asian, Chinese, White, and Hispanic adults. This pattern remained after adjusting for covariates, with the largest differences observed for adults aged <60 years.

Conclusions

Similar to Black adults, Filipino adults have persistently higher hypertension prevalence than South Asian, Chinese, Hispanic, and White adults across the adult lifespan. These findings underscore the importance of surveillance and prevention efforts for this high-risk Asian group beginning in early adulthood.

Toward an "Equitable" Assimilation of Artificial Intelligence and Machine Learning into Our Health Care System

Enthusiasm about the promise of artificial intelligence and machine learning in health care must be accompanied by oversight and remediation of any potential adverse effects on health equity goals that these technologies may create. We describe five equity imperatives for the use of AI/ML in health care that require attention from health care professionals, developers, and policymakers.

Prevalence of Metabolic Syndrome Among Emerging Adult Cannabis Users by Race/Ethnicity: Analysis of the 2009-2018 National Health and Nutrition Examination Surveys

Background

Association between cannabis use and metabolic syndrome (MetS) has been documented; yet variation by race/ethnicity is understudied. We examined cannabis use and MetS by race/ethnicity among emerging adults (18-25 years old), the age group with the highest prevalence of cannabis use.

Methods

Data from 18- to 25-year-olds who completed the National Health and Nutrition Examination Survey (2009-2018) were analyzed. Current cannabis use was defined as ≥1 day of use in the last 30 days. MetS was defined using standardized guidelines as ≥3 of the following: elevated fasting glucose, triglycerides, systolic (SBP) and/or diastolic blood pressure (DPB), waist circumference, and/or low high-density lipoprotein (HDL) cholesterol. Logistic regression was used to examine the association between current cannabis use (CCU) and MetS, adjusting for covariates.

Results

Of 3974 respondents, 48.8% were female, mean age 21.1 years (SD = 2.4), 56.7% non-Hispanic white, 20.4% Hispanic, and 14.0% non-Hispanic black (NHB). Hispanics had the highest MetS prevalence (7.9%) and lowest CCU prevalence (23.5%). NHB had highest CCU prevalence (33.4%, P < .0001) and lowest MetS prevalence (4.8%, P = .2543). CCUs had a higher mean SBP (P = .020) and Hispanics (P = .002) than never users. Conversely, NHB CCUs exhibited lower mean SBP than NHB never users (P = .008). CCUs had 42% reduced odds of MetS than never users (AOR: 0.58, 95% CI: 0.35-0.95). Among NHB, CCUs had 78% lower likelihood of having MetS than never users (AOR: 0.22, 95% CI: 0.06-0.81).

Conclusions

Cannabis use impacts MetS and blood pressure differently by race/ethnicity. Current cannabis use was associated with lower odds of MetS overall and among NHB. Further research is warranted to investigate how administration routes, dosages, and usage duration affect MetS.

Clinicians' perspectives on race-specific guidelines for hypertensive treatment

Despite the general consensus that there is no biological basis to race, racial categorization is still used by clinicians to guide diagnosis and treatment plans for certain diseases. In medicine, race is commonly used as a rough proxy for unmeasured social, environmental, and genetic factors. The American College of Cardiology's Eighth Joint National Committee's (JNC 8) guidelines for the treatment of hypertension provide race-specific medication recommendations for Black versus non-Black patients, without strong evidence for race-specific physiological differences in drug response. Clinicians practicing family or geriatric medicine (n = 21) were shown a video of a mock hypertensive patient with genetic ancestry test results that could be viewed as discordant with their phenotype and self-identified race. After viewing the videos, we conducted in-depth interviews to examine how clinicians value and prioritize different cues about race -- namely genetic ancestry data, phenotypic appearance, and self-identified racial classifications - when making treatment decisions in the context of race-specific guidelines, particularly in situations when patients claim mixed-race or complex racial identities. Results indicate that clinicians inconsistently follow the race-specific guidelines for patients whose genetic ancestry test results do not match neatly with their self-identified race or phenotypic features. However, many clinicians also emphasized the importance of clinical experience, side effects, and other factors in their decision making. Clinicians' definitions of race, categorization of the patient's race, and prioritization of racial cues greatly varied. The existence of the race-specific guidelines clearly influences treatment decisions, even as clinicians' express uncertainty about how to incorporate consideration of a patient's genetic ancestry. In light of widespread debate about removal of race from medical diagnostics, researchers should revisit the clinical justification for maintaining these race-specific guidelines. Based on our findings and prior studies indicating a lack of convincing evidence for biological differences by race in medication response, we suggest removing race from the JNC 8 guidelines to avoid risk of perpetuating or exacerbating health disparities in hypertension.

Food resources and kitchen skills plus aerobic training (FoRKS+) for black adults with hypertension: A pilot trial protocol

BACKGROUND

Midlife hypertension is associated with cognitive decline and Alzheimer's disease and related dementia (ADRD), suggesting that blood pressure control may be a therapeutic target for dementia prevention. Given excess hypertension in non-Hispanic Black (NHB) adults, blood pressure control may also reduce ADRD disparities. We describe a pilot randomized controlled trial (RCT) to evaluate the feasibility and preliminary efficacy of a multicomponent lifestyle-based intervention versus enhanced usual care on cognition among middle-aged NHB adults.

METHODS AND STUDY DESIGN

The Food Resources and Kitchen Skills plus Aerobic Training (FoRKS+) study is a 2-arm, single-blinded trial that compares those receiving the FoRKS+ program (target N = 64) versus those receiving enhanced usual care (target N = 64) in local federally-qualified health centers. Key eligibility criteria include self-identified NHB adults between ages 35-75 with a mean systolic blood pressure ≥ 130 mm/Hg obtained from 24-h ambulatory blood pressure monitoring. The FoRKS+ program includes 5 weeks of hypertension self-management courses, 11 weeks of nutrition courses, and 12 weeks of aerobic training in dietitian and health coach-led virtual groups. We will collect data on primary cognitive outcomes, feasibility, hypothesized intervention mediators and moderators, and demographic and health covariates at baseline, near intervention weeks 16-, and 28 (primary outcome assessment), and week 52 follow-up. We will use mixed-effects modeling to examine intervention effects on cognition.

DISCUSSION

This pilot RCT will examine the feasibility and preliminary effects of a multicomponent lifestyle intervention on cognitive function in NHB adults, which may have implications for reducing health disparities in ADRD.

Treating Hypertension: Important for Heart Health, Fundamental for Brain Health

The Brain Health crisis stands as one of humankind's most pressing threats, with age-related noncommunicable brain diseases, particularly stroke, and dementia, affecting hundreds of millions annually and jeopardizing the economic well-being of populations worldwide. Epidemiological studies indicate that ≈40% of dementia and 60% of stroke cases are attributable to modifiable risk factors. In this Comments and Opinions article, we underscore the pivotal role of blood pressure (BP) control in reducing suffering, enhancing economic well-being, and promoting healthy longevity for populations worldwide. Emphasizing that BP control is crucial for both brain and heart health, it advocates for heightened awareness, positioning hypertension as a primary focus for preventing dementia and stroke with potential global impact. Despite its significance, BP control encounters global challenges, with proportions of the population maintaining adequately controlled hypertension ranging from 23% to 90%. The World Health Organization estimated that 46% of the 1.28 billion people with hypertension are unaware of their elevated BP. Given the notable disparities in BP management, addressing BP management also contributes to combating significant health inequalities. The next time you are faced with a patient anxious about the prospect of experiencing a fate similar to a parent with dementia or a sister with a stroke, we suggest a straightforward answer for health care providers: start ensuring BP control. BP is a matter of brain health, and it is a matter of our economic future.

Race/Ethnicity and Other Predictors of Early-Onset Type 2 Diabetes Mellitus in the US Population

OBJECTIVES

Among US adults aged 20 + years in the USA with previously diagnosed type 2 diabetes mellitus (T2DM), we aimed to estimate the prevalence of early-onset T2DM (onset at age < 50.5 years) and to test associations between early-onset T2DM and race/ethnicity, and other hypothesized predictors.

METHODS

We pooled data from the annual National Health and Nutrition Examination Surveys (NHANES) over the years 2001 through 2018. We tested hypotheses of association and identified predictors using stepwise logistic regression analysis, and 11 supervised machine learning classification algorithms.

RESULTS

After appropriate weighting, we estimated that among adults in the USA aged 20 + years with previously diagnosed T2DM, the prevalence of early-onset was 52.9% (95% confidence intervals, 49.6 to 56.2%). Among Non-Hispanic Whites (NHW) the prevalence was 48.6% (95% CI, 44.6 to 52.6%), among Non-Hispanic Blacks: 56.9% (95% CI, 51.8 to 62.0%), among Hispanics: 62.7% (95% CI, 53.2 to 72.3%). In the final multivariable logistic regression model, the top-3 markers predicting early-onset T2DM in males were NHB ethnicity (OR = 2.97; 95% CI: 2.24-3.95) > tobacco smoking (OR = 2.79; 95% CI: 2.18-3.58) > high education level (OR = 1.65; 95% CI: 1.27-2.14) in males. In females, the ranking was tobacco smoking (OR = 2.59; 95% CI: 1.90-3.53) > Hispanic ethnicity (OR = 1.49; 95% CI: 1.08-2.05) > obesity (OR = 1.30; 95% CI: 0.91-1.86) in females. The acculturation score emerged from the machine learning approach as the dominant marker explaining the race disparity in early-onset T2DM.

CONCLUSIONS

The prevalence of early-onset T2DM was higher among NHB and Hispanic people, than among NHW people. Independently of race/ethnicity, acculturation, tobacco smoking, education level, marital status, obesity, and hypertension were also predictive.