Greater Risk for Primary Hypertension Shown in Children of Most-Deprived Communities

Children living in the most socioeconomically deprived communities are 60% more likely to be diagnosed with primary hypertension, the leading risk factor of cardiovascular disease (CVD) development later in life, according to study findings published today in JAMA Network Open.

Along with risk of CVD, which is the leading cause of death in the United States, hypertension diagnosis in youth is a predominant cause of target organ damage during childhood. An estimated 4 out of every 100 youth is affected by hypertension, but the disease remains underdiagnosed in 74% of cases. Even when blood pressure (BP) values are consistent with the diagnosis, researchers note that physician recognition of hypertension is poor.

Recent studies have demonstrated a myriad of risk factors associated with primary hypertension development, including prenatal exposures, race, ethnicity, and physical activity. Studies conducted outside the United States additionally suggest the risk posed by socioeconomic factors such as parental education, occupation, employment, and home ownership with hypertension development in youth. However, no current US studies have evaluated the association between area deprivation index (ADI), an index of neighborhood-level socioeconomic factors, and primary hypertension diagnosis.

“The relationship between the level of neighborhood deprivation and primary hypertension in youth has not been well evaluated,” lead study author Carissa Baker-Smith, MD, MPH, FACC, FAHA, FAAP, director of Pediatric Preventive Cardiology, Nemours Children’s Health, Delaware Valley, said in a statement. “Perhaps as a result, strategies for screening and diagnosis of hypertension do not routinely consider a child’s community as a potential risk factor.”

Researchers conducted a cross-sectional analysis of data on Delaware youth aged 8 to 18 years who were covered by Medicaid between 2014 and 2019 to assess the association between ADI and primary hypertension diagnosis. Youth with at least 1 health care visit (inpatient, outpatient, emergency department, long-term care, dental, or home health) and at least 1 month of Medicaid insurance coverage between January 1, 2014, and December 31, 2019, were eligible for inclusion.

Data for ADI were derived from the American Community Survey, in which individuals with ADI greater than or equal to 50 (most deprived) were compared with those with ADI less than 50 (least deprived). Delaware’s median national ADI was reported to be 38 (lower quartile, 25; upper quartile, 52).

The primary outcome investigated was diagnosis of primary hypertension by International Classification of Diseases, Ninth Revision (ICD-9) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes, excluding a secondary hypertension diagnosis. Age, biological sex, race and ethnicity (Hispanic, non-Hispanic Black, and non-Hispanic White), total months receiving Medicaid, national ADI50 (1 = ADI ≥ 50; 0 = ADI < 50), and obesity diagnosis (ICD-9 and ICD-10 codes) were selected to model hypertension diagnosis.

The analysis included 65,452 youths:

• A total of 64,307 (98.3%) were without a hypertension diagnosis (mean [SD] age, 12.5 [3.1] years; 47% female [n = 30,491]; 19% Hispanic [n = 12,500], 40% non-Hispanic Black [n = 25,473], 38% non-Hispanic White [n = 24,565], and 3% other race or ethnicity [n = 1769]; 20% with obesity [n = 13,029]; and 49% with an ADI ≥ 50 [n = 31,548])
• A total of 1145 (1.7%) reported a diagnosis of primary hypertension (mean [SD] age, 13.3 [2.8] years; 41% female [n = 464]; 24% Hispanic [n = 271], 40% non-Hispanic Black [n = 460], 35% non-Hispanic White [n = 396], and 2% other race or ethnicity [n = 18]; 62% with obesity [n = 705]; and 54% with an ADI ≥ 50 [n = 614])
• Mean (SD) duration of full Medicaid benefit coverage was 61 (16) months for those with a diagnosis of primary hypertension and 46.0 (24.3) months for those without

Findings from multivariable logistic regression indicated that residence within communities with ADI greater than or equal to 50 was associated with 60% greater odds of a primary hypertension diagnosis (OR, 1.61; 95% CI, 1.04-2.51; P < .03).

Risk of primary hypertension diagnosis was additionally more than 5 times greater for those with an obesity diagnosis (OR, 5.16; 95% CI, 4.54-5.85; P < .001), with greater risks observed with older age (OR per year, 1.16; 95% CI, 1.14-1.18; P < .001) and longer duration of full Medicaid benefit coverage (OR, 1.03; 95% CI, 1.03-1.04) as well. Prevalence of primary hypertension was highest in those aged 13 to 18.

Conversely, race and ethnicity were not associated with primary hypertension diagnosis, and female sex was associated with lower odds (odds ratio [OR], 0.68; 95% CI, 0.61-0.77). A Medicaid-by-ADI interaction term was further shown to be significant and revealed slightly greater odds of hypertension diagnosis for youths with ADI less than 50 (OR, 1.03; 95% CI, 1.03-1.04) vs ADI greater than or equal to 50 (OR, 1.02; 95% CI, 1.02-1.03), whereas an interaction between ADI50 and obesity was not significant.

“Knowledge of risk factors for hypertension in youth is essential to improve cardiovascular outcomes later in life,” Baker-Smith added. “Our study highlights the importance of considering neighborhood-related factors when diagnosing hypertension.”

Although the sample size was large and diagnoses were available, the lack of BP and body mass index values may have contributed to an underestimation of the true prevalence of hypertension, noted researchers.

“Future studies are needed to further elucidate the association between the 17 components of ADI and hypertension development and diagnosis in youth,” they concluded. “Screening algorithms and national guidelines may consider the importance of ADI when assessing for the presence and prevalence of primary hypertension in youth.”

Reference

Baker-Smith CM, Yang W, McDuffie MJ, et al. Association of area deprivation with primary hypertension diagnosis among youth Medicaid recipients in Delaware. JAMA Netw Open. 2023;6(3):e233012. doi:10.1001/jamanetworkopen.2023.3012