Healthy lifestyles such as regular physical activity, frequent consumption of fruits and vegetables, weight control/weight loss and limited alcohol consumption are effective and recommended in hypertension control. Using data collected from a total of 131 788 female participants (aged 18 years) of the 2003 Behavioral Risk Factor Surveillance System, we examined the racial/ethnic disparities in hypertension-related lifestyle behaviours in 36 770 US women with self-reported hypertension from five races/ethnicities (non-Hispanic white (29 237), non-Hispanic black (4288), Asian (445), American Indian/Alaska native (553) and Hispanic (2247)). The prevalence of hypertension varied by race/ethnicity, with the highest seen in non-Hispanic black population (36.9 versus 20.2–26.8% in other racial/ethnic groups). Of all hypertensive women, using non-Hispanic white women as the referent, we found that non-Hispanic black (adjusted odds ratio (AOR): 0.65; 95% confidence interval (CI): 0.55–0.77), American Indian/Alaska native (AOR: 0.72; 95% CI: 0.52–1.00) and Hispanic women (AOR: 0.70; 95% CI: 0.57–0.86) were significantly less likely to engage in physical activity at recommended levels; non-Hispanic black women were more likely to consume8 servings per day of fruits and vegetables (AOR: 1.70; 95% CI: 1.24–2.34), and less likely to report losing weight (AOR: 0.61; 95% CI: 0.53–0.71). In addition, Hispanic hypertensive women were significantly more likely than non-Hispanic white women to receive weight-loss advice (AOR: 1.97; 95% CI: 1.60–2.44). In contrast, non-Hispanic white women were significantly more likely than those from other races/ethnicities to consume alcoholic beverages or engage in binge drinking. Our results demonstrate that race/ethnicity is an independent predictor of lifestyle behaviours related to hypertension control among American women with hypertension.
High blood pressure or hypertension remains an important risk factor for cerebrovascular, cardiovascular and renal diseases including stroke, coronary heart disease, heart failure and kidney failure.1, 2, 3 The prevalence of hypertension in US adults aged 20 years appears to be increasing and about 72 million individuals (or 29.6%) had hypertension during 2003–2004.4, 5, 6 In addition, the death rate attributable to hypertension increased by 25% from 1994 to 2004.5, 6
Adoption of healthy lifestyles has been shown to be an effective approach for the prevention and management of high blood pressure,7, 8, 9, 10, 11 and to enhance the efficacy of antihypertensive medications.7 The American Heart Association (AHA) and the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommend that overweight/obese individuals should lose weight to attain a body mass index (BMI) <25 kg m−2 ideally, and that non-overweight persons maintain a normal body weight.8, 12 Furthermore, people with hypertension are advised to consume a diet rich in fruits and vegetables (8–10 servings per day), rich in low-fat dairy products and reduced in saturated fat and cholesterol, engage in regular aerobic physical activity (at least 30 min per day on most days of the week) and limit alcohol consumption to no more than two drinks per day in men and to no more than one drink per day in women and lighter weight persons.8, 12 In addition, reducing dietary salt intake and increasing potassium intake is also associated with reduced blood pressure levels.7, 8
Significant racial/ethnic disparities in hypertension prevalence, treatment and control exist in US adults.6, 13, 14, 15, 16, 17 Evidence has shown that non-Hispanic black population had the highest prevalence of hypertension6, 13 and a higher death rate attributable to hypertension than white population.5 Among those treated with antihypertensive medicine, black and Mexican-American patients were less likely to achieve blood pressure control, and Mexican-American patients had lower rates of hypertension awareness and treatment than white patients.14 Similar ethnic variation in hypertension was also reported among women.18
The purpose of the present study was to assess the influence of race/ethnicity on the likelihood of adopting lifestyle behaviours to control hypertension, which may account for some of the disparities in hypertension prevalence and blood pressure control, using a large, nationally representative population-based sample of US women with self-reported hypertension.
Data for this analysis came from the 2003 Behavioral Risk Factor Surveillance System (BRFSS), a population-based telephone survey of health-related behaviours regarding the leading causes of death among non-institutionalized US adults aged 18 years. The BRFSS data have consistently been found to provide valid and reliable estimates of population prevalence when compared to national household surveys in the US.19, 20, 21 In 2003, a total of 160 284 female participants were interviewed. The median cooperation rate (the percentage of eligible persons contacted who completed the interview) was 74.8%.
Data on respondents' race/ethnicity were categorized as: (1) non-Hispanic white, (2) non-Hispanic black, (3) Asian, (4) American Indian/Alaska native, (5) Hispanic, (6) native Hawaiian or other pacific islander, (7) multiracial and (8) other races. All respondents who reported they were of Hispanic/Latino origin (a person, of any racial background and of any religion, who has at least one ancestor from the people of Spain or Spanish-speaking Latin American) were coded as Hispanic, and about 64% of nation's Hispanic population are of Mexican or Mexican-American ancestry. We excluded the last three categories because there were few women in these races/ethnicities. Hypertension was assessed by asking respondents whether they had ever been told by doctors, nurses or other health professionals that they had had high blood pressure. For those who responded with a ‘yes’ to the question, they were further asked whether they were taking medicine for their high blood pressure. The general hypertension-related lifestyle behaviours examined in the study were respondents' physical activity status, fruit and vegetable consumption, weight loss status, receipt of doctors' advice on weight loss and alcohol consumption. Physical activity was assessed by asking respondents how often and how long in a usual week they engaged in moderate physical activities (such as brisk walking, bicycling, vacuuming or anything else that causes small increases in breathing or heart rate) or vigorous physical activities (such as running, aerobics, heavy yard work or anything else that causes large increases in breathing or heart rate). Respondents were then categorized as: (1) meet recommendations for physical activity (performing moderate physical activities for 30 min per day on 5 days per week and/or vigorous physical activities for 20 min per day on 3 days per week) and (2) do not meet physical activity recommendations (insufficient quantity to achieve either moderate or vigorous physical activity recommendations, or no physical activity), following the recommendations made by the Centers for Disease Control and Prevention and the American College of Sports Medicine as well as the US Surgeon General.22, 23 Fruit and vegetable consumption was assessed by asking respondents how many times per day (or per week, per month, per year) they drank fruit juices or ate fruit, green salad, potatoes (excluding french fries, fried potatoes and potato chips), carrots or any other vegetables. Respondents were categorized as: (1) consumption of fruits and vegetables 5 or 8 servings per day and (2) consumption of fruits or vegetables <5 or <8 servings per day, following the Healthy People 2010 objectives on food and nutrient consumption,24 the Dietary Guidelines for Americans,25 and the lifestyle modification recommendations made by the AHA and the JNC for patients with hypertension.8, 12 Weight loss was assessed by asking respondents whether they were currently losing weight. The receipt of doctors' advice on weight loss was assessed by asking respondents whether in the past 12 months doctors, nurses or other health professionals had given them advice about their weight. Their responses were (1) yes, lose weight; (2) yes, gain weight; (3) yes, maintain current weight; (4) no advice and (5) don't know/not sure. We treated the first category as ‘receipt of weight-loss advice’ and combined the rest four categories into ‘receipt of no advice on weight loss’. Alcohol consumption was assessed by asking respondents how many days per week or per month they had had at least one drink of any alcoholic beverages during the past 30 days (a drink of alcohol was defined as an equivalent of one shot of liquor), and how many drinks they had on average on the days when they drank. Respondents were categorized as: (1) no alcohol use, (2) having alcohol but 1 drink per day on average, (3) having an average of >1 drink per day. Binge drinking was defined as having 5 drinks consumed on one or more occasion.
In addition to race/ethnicity, other demographic variables in our analyses included respondents' age, BMI, education levels (<high school diploma, high school graduate, some college/technical school and college graduate), marital status (married, divorced, never married and others) and employment (employed, unemployed and retired). Current smokers were defined as participants who had smoked 100 cigarettes during their lifetime and were still smoking. Current non-smokers were those participants who had smoked <100 cigarettes during their lifetime or those who had smoked 100 cigarettes in their entire life but had stopped.
After excluding from the analytical sample participants who refused to answer, had missing responses to any questions or responded ‘don't know/not sure’ to any questions (except for the question on receiving weight-loss advice), a total of 131 788 participants were included in our analyses. Prevalence estimates by race/ethnicity for self-reported hypertension, taking antihypertensive medicine and adoption of individual lifestyle behaviours or clusters of healthy lifestyle behaviours (evaluated as meeting physical activity recommendations, consuming 8 servings per day of fruits and vegetables, currently losing weight, receipt of weight-loss advice and limiting alcohol consumption to 1 drink per day) were age-standardized to the 2000 US population. The prevalence estimates were reported only if the relative standard error of an estimate (the standard error of an estimate divided by the estimate itself) was 30%. Logistic regression analyses were conducted to assess the odds ratios for adoption of the defined lifestyle behaviours among women with hypertension by race/ethnicity using non-Hispanic white women as the referent. We used SAS (version 9.1, SAS Institute Inc., Cary, NC, USA) and SUDAAN software (release 9.0, Research Triangle Institute, Research Triangle Park, NC, USA) to account for the multi-stage, disproportionate stratified sampling design.
Among the 131 788 female participants included in our analyses, 36 770 reported having hypertension and 30 269 took antihypertensive medicine. The age-standardized prevalence of hypertension varied by race/ethnicity (Figure 1a): non-Hispanic black women had the highest prevalence of hypertension (36.9%, 95% confidence interval (CI): 35.6–38.4%, P<0.001) among all racial/ethnic groups. Non-Hispanic white and Asian women tended to have a lower prevalence of hypertension compared to American Indian/Alaska native and Hispanic women.
Of all women with hypertension, 62.1% (95% CI: 60.8–63.8%) of women were on antihypertensive medication. The percentage of hypertensive women who were on antihypertensive medication was significantly higher in non-Hispanic black population than in non-Hispanic white and Hispanic populations (P<0.001, Figure 1b). In addition, significant differences by race/ethnicity were present for age, education, employment, marital status, BMI and smoking status (Table 1, P<0.001 for all). Notably, the percentage of older women (70 years old) with hypertension was significantly higher in non-Hispanic white population (36%) than in other four racial/ethnic groups (ranged from 17 to 21%). More than a half (54%) of Asian hypertensive women had education of college graduate level or above, and more than a half (55%) of non-Hispanic black women with hypertension were obese; in contrast, 56% of Asian women with hypertension had BMI levels <25 kg m−2. In addition, 38% of American Indian/Alaska native women with hypertension were smoking, which was significantly higher than that in other racial/ethnic groups.
Overall, 38.9% (95% CI: 37.5–40.4%) of hypertensive women met physical activity recommendations; 25.2% (95% CI: 24.0–26.5%) or 5.1% (95% CI: 4.4–6.0%) consumed fruits and vegetables at 5 or 8 servings per day, respectively; 58.5% (95% CI: 57.1–60.0%) were currently losing weight and 30.7% (95% CI: 29.4–32.2%) received weight-loss advice. In addition, 36.8% (95% CI: 35.4–38.3%) of hypertensive women reported consuming alcohol but at 1 drink per day; 5.6% (95% CI: 4.8–6.6%) had alcohol consumption of >1 drink per day; and 8.1% (95% CI: 7.2–9.2%) were binge drinkers.
The age-adjusted percentage of women with hypertension who met physical activity recommendations was significantly higher in non-Hispanic white population than in non-Hispanic black and Hispanic populations (Table 2, P0.001). The fruit and vegetable consumption at 5 servings per day did not differ significantly by race/ethnicity; however, Asian women with hypertension tended to have a higher rate than other races of consuming fruits and vegetables at this level. In addition, the percentage of women with hypertension who consumed 8 servings per day of fruits and vegetables was significantly higher in non-Hispanic black women than in white women (P<0.05). For weight control status, the prevalence of obesity in non-Hispanic black women with hypertension (56.6%, 95% CI: 53.3–59.8%) was significantly higher than in non-Hispanic white (38.6%, 95% CI: 36.9–40.4%, P<0.005), Asian (10.9%, 95 CI: 5.9–19.0%, P<0.001) and Hispanic women (45.1%, 95% CI: 40.2–50.0%, P<0.001). The prevalence of overweight plus obesity in non-Hispanic black women (81.9%, 95% CI: 79.3–84.3%) was also significantly higher than in non-Hispanic white (69.0%, 95% CI: 67.2–70.7%, P<0.005) and Asian women (46.3%, 95% CI: 32.4–60.8%, P<0.001). However, the percentage of women with hypertension who were currently losing weight was significantly lower in non-Hispanic black population than in Hispanic population, and was the lowest in Asian population (P<0.05 for all). The percentage of women with hypertension who received weight-loss advice was significantly higher in non-Hispanic black and Hispanic populations than in non-Hispanic white and Asian populations (P<0.01 for all, Table 2). Stratification analyses by BMI showed that, among those who were overweight and/or obese, the percentages of hypertensive women who reported losing weight or receiving weight-loss advice tended to be higher in Asian and Hispanic populations than in other racial/ethnic groups (data not shown). In addition, the percentages of hypertensive women who consumed alcohol or engaged in binge drinking were significantly higher in non-Hispanic white population than in non-Hispanic black and Hispanic populations (P<0.001 for all).
Asian hypertensive women had a significantly higher percentage of adopting only one healthy lifestyle behaviour than those from American Indian/Alaska native and Hispanic populations, and had the lowest percentage of adopting three healthy lifestyle behaviours among all racial/ethnic groups (P<0.05, Figure 2a); the similar pattern was also observed among women without hypertension (Figure 2b). In addition, American Indian/Alaska native women with hypertension had the lowest percentage of adopting 4–5 healthy lifestyle behaviours (P<0.05 for all), which was not observed among women without hypertension. The cumulative frequency of having 1–5 healthy lifestyle behaviours did not differ significantly by race/ethnicity or by hypertension status.
The odds of meeting physical activity recommendations among non-Hispanic black, American Indian/Alaska native and Hispanic women with hypertension was 35, 28 and 30% lower, respectively, than non-Hispanic white women (P<0.05 for all; Table 3). Non-Hispanic black women were 70% more likely to consume fruits and vegetables at 8 servings per day and 39% less likely to lose weight than non-Hispanic white women (P<0.05 for both); however, non-Hispanic black women were only slightly more likely to receive weight-loss advice compared to the white women (P<0.1). Hispanic women were 97% more likely to receive weight-loss advice than non-Hispanic white women (P<0.01). In addition, the adjusted odds ratios for alcohol consumption (at the levels of 1 drink per day and >1 drink per day) and for binge drinking in four minority racial/ethnic groups were significantly lower than in non-Hispanic white women (P<0.01 for all, Table 3).
Although multiple lifestyle modifications have been recommended for patients with hypertension,7, 8, 12 our results, at the national level, demonstrate the general deficiencies in adopting healthy lifestyle behaviours among hypertensive women of all races/ethnicities. Overall, only a little more than one-third of hypertensive women met public health recommendations for physical activity and a very small proportion of them (<7%) achieved the 8 servings per day of fruit and vegetable consumption. Although overweight/obesity is highly prevalent among women with hypertension, only 59% of them tried to control their weight, and 31% received weight-loss advice. Therefore, a wide gap exists even with increasing scientific attention to the beneficial effects of healthy lifestyle behaviours on hypertension.
Our results further demonstrate that significant racial/ethnic variation exists in hypertension prevalence and the hypertension-related lifestyle behaviours among American women with hypertension even after multivariate adjustment for socio-demographic variables. Our findings that non-Hispanic black women had the highest prevalence of self-reported hypertension and antihypertensive treatment among all racial/ethnic groups agree with the findings from several other studies.6, 16, 18 However, at present, limited information is available about lifestyle behaviours with respect to hypertension control among hypertensive women of different races/ethnicities. In a community-based survey that included 438 participants with hypertension, only 11% reported consuming 5 servings per day of fruits and vegetables, 18% reported participating in physical activity 5 times per week26 and significantly lower rates for these behaviours were seen in African-American women.26 With ample statistical power, our study further demonstrated that non-Hispanic black, American Indian/Alaska native and Hispanic hypertensive women were less likely to meet public health recommendations for physical activity than white women. In addition, our study showed that non-Hispanic black women were 70% more likely than white women to consume fruits and vegetables at 8 servings per day, a level recommended by AHA (a scientific statement);8 however, only about 7% of them achieved this level of fruit and vegetable consumption in the present study. Therefore, more efforts are needed to further enhance the adherence to dietary guidelines in hypertensive women including black women.
Weight loss is associated with a greater reduction in blood pressure.27, 28, 29 A meta-analysis showed that an average weight loss of 5.1 kg, achieved by energy restriction and/or increasing physical activity, reduced systolic blood pressure by 4.4 mm Hg and diastolic blood pressure by 3.6 mm Hg.10 In the present study, substantial racial/ethnic variations existed in the percentages of women who were currently losing weight. Compared to non-Hispanic white women with hypertension, non-Hispanic black women were less likely to report losing weight (even in those who were overweight and/or obese), although more black women with hypertension were obese than white women (57 versus 39%). This is consistent with a lower physical activity participation rate seen in non-Hispanic black women. Xu and Regain30 reported that physicians were more likely to recommend lifestyle modifications for obese patients. However, our study showed that, although non-Hispanic black women with hypertension had the highest prevalence of obesity among all races/ethnicities, they were only slightly more likely (but not significantly) than white women to receive doctors' advice on weight loss. In addition, our results indicated that Asian and Hispanic hypertensive women who were overweight and/or obese tended to have higher rates of receiving weight-loss counselling, which agree with the finding from a previous study that Asian and Hispanic women were more likely than white women to undergo any lifestyle counselling.31 However, these women were not found to be more likely to lose weight as recommended in the present study. Taken together, these data suggest that more effective and aggressive approaches should be taken by physicians to enhance adherence to the weight loss recommendations among hypertensive women.
A meta-analysis has shown that alcohol reduction among heavy drinkers significantly reduces systolic and diastolic blood pressure.32 However, most studies included in this meta-analysis were conducted in men with either normal or high blood pressure with or without antihypertensive medication.32 Among women, the association between alcohol intake and risk of hypertension follows a J-shaped curve even after adjustment for potential confounding factors.33, 34 The AHA dietary guidelines recommend limiting alcohol consumption to no more than one drink per day for women.8 Thus, hypertensive women whose alcohol consumption exceeds one drink per day should consider reducing their intake. Our results showed that non-Hispanic white women with hypertension were significantly more likely to consume alcoholic beverages and to engage in binge drinking than other races. Given the limited information about the effects of alcohol reduction on blood pressure control among hypertensive women, future studies may be directed to this area, especially in hypertensive women from diverse ethnic groups.
Our study is subject to several limitations. First, self-reported measures of all responses were used, thus subject to recall bias. For example, we used self-reported hypertension in our analyses. There may be some people who did not know they had hypertension, so we may have excluded people with undiagnosed hypertension. However, Vargas et al.35 reported that self-reported hypertension was a valid measure for surveillance of hypertension in the National Health and Nutrition Examination Survey in the absence of measured blood pressure. Second, information on the severity of hypertension or the degree of hypertension control was not collected so we were unable to analyse data stratified by these variables. Third, although we have included a total of 36 770 hypertensive women in our analyses (one of the largest studies), there were relatively small numbers of women in the minority ethnic groups such as Asian and American Indian/Alaska native. Therefore, the findings of the minority ethnic groups should be interpreted with caution. Fourth, although we have evaluated weight loss and physicians' advice on weight loss in our analyses, information on the degree of weight loss, or physicians' counselling on other lifestyle behaviours (such as physical activity) remained unknown. Several studies have reported that the rates for nutrition and exercise counselling were low (about 35 and 26% of all visits, respectively) in patients with hypertension,31 and only about 21.4% of physicians provided routine advice on lifestyle changing to their hypertensive patients.36 In addition, significant difference in counselling rate exists with respect to age, race, comorbidity and survey cohort.31 Finally, we were unable to evaluate dietary sodium reduction, an important lifestyle modification for hypertension control,8, 12 due to lack of information on it in the present study.
In summary, among US women with hypertension, adoption of healthy lifestyle behaviours related to hypertension control remains suboptimal, and race/ethnicity is an independent predictor of adopting healthy lifestyles or adhering to lifestyle modification recommendations. Given the rapid expansion of minority populations, future hypertension interventions may focus on culturally appropriate educational programs or techniques to improve hypertension control in high-risk ethnic groups and to reduce disparities ultimately.
The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
About this article
Diabetes and Associated Cardiovascular Complications in American Indians/Alaskan Natives: A Review of Risks and Prevention Strategies
Journal of Diabetes Research (2018)