Qu et al.

BMC Medicine (2024) 22:245 BMC Medicine

https://doi.org/10.1186/s12916-024-03453-5

RESEARCH ARTICLE Open Access

Trends in cardiovascular risk factor

prevalence, treatment, and control among US
adolescents aged 12 to 19 years, 2001 to March
2020
Qiang Qu1†, Qixin Guo1†, Jinjing Shi1†, Ziqi Chen1, Jinyu Sun1, Iokfai Cheang1, Rongrong Gao1, Yanli Zhou1,
Haifeng Zhang2,3, Shengen Liao1*, Wenming Yao1* and Xinli Li1*

Abstract
Background Early-life cardiovascular risk factors (CVRFs) are known to be associated with target organ damage dur-
ing adolescence and premature cardiovascular morbidity and mortality during adulthood. However, contemporary
data describing whether the prevalence of CVRFs and treatment and control rates have changed are limited. This
study aimed to examine the temporal trends in the prevalence, treatment, and control of CVRFs among US adoles-
cents over the past 2 decades.
Methods This is a serial cross-sectional study using data from nine National Health and Nutrition Examination Survey
cycles (January 2001—March 2020). US adolescents (aged 12 to 19 years) with information regarding CVRFs (includ-
ing hypertension, elevated blood pressure [BP], diabetes, prediabetes, hyperlipidemia, obesity, overweight, cigarette
use, inactive physical activity, and poor diet quality) were included. Age-adjusted trends in CVRF prevalence, treat-
ment, and control were examined. Joinpoint regression analysis was performed to estimate changes in the preva-
lence, treatment, and control over time. The variation by sociodemographic characteristics were also described.
Results A total of 15,155 US adolescents aged 12 to 19 years (representing ≈ 32.4 million people) were included.
From 2001 to March 2020, there was an increase in the prevalence of prediabetes (from 12.5% [95% confidence
interval (CI), 10.2%-14.9%] to 37.6% [95% CI, 29.1%-46.2%]) and overweight/obesity (from 21.1% [95% CI, 19.3%-22.8%]
to 24.8% [95% CI, 21.4%-28.2%]; from 16.0% [95% CI, 14.1%-17.9%] to 20.3% [95% CI, 17.9%-22.7%]; respectively),
no improvement in the prevalence of elevated BP (from 10.4% [95% CI, 8.9%-11.8%] to 11.0% [95% CI, 8.7%-13.4%]),
diabetes (from 0.7% [95% CI, 0.2%-1.2%] to 1.2% [95% CI, 0.3%-2.2%]), and poor diet quality (from 76.1% [95% CI,
74.0%-78.2%] to 71.7% [95% CI, 68.5%-74.9%]), and a decrease in the prevalence of hypertension (from 8.1% [95%
CI, 6.9%-9.4%] to 5.5% [95% CI, 3.7%-7.3%]), hyperlipidemia (from 34.2% [95% CI, 30.9%-37.5%] to 22.8% [95% CI,
18.7%-26.8%]), cigarette use (from 18.0% [95% CI, 15.7%-20.3%] to 3.5% [95% CI, 2.0%-5.0%]), and inactive physical

†
Qiang Qu, Qixin Guo and Jinjing Shi contributed equally.
*Correspondence:
Shengen Liao
[email protected]
Wenming Yao
[email protected]
Xinli Li
[email protected]
Full list of author information is available at the end of the article

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Qu et al. BMC Medicine (2024) 22:245 Page 2 of 16

activity (from 83.0% [95% CI, 80.7%-85.3%] to 9.5% [95% CI, 4.2%-14.8%]). Sex and race/ethnicity affected the evolu-
tion of CVRF prevalence differently. Whilst treatment rates for hypertension and diabetes did not improve significantly
(from 9.6% [95% CI, 3.5%-15.8%] to 6.0% [95% CI, 1.4%-10.6%]; from 51.0% [95% CI, 23.3%-78.7%] to 26.5% [95% CI,
0.0%-54.7%]; respectively), BP control was relatively stable (from 75.7% [95% CI, 56.8%-94.7%] to 73.5% [95% CI, 40.3%-
100.0%]), while glycemic control improved to a certain extent, although it remained suboptimal (from 11.8% [95% CI,
0.0%-31.5%] to 62.7% [95% CI, 62.7%-62.7%]).
Conclusions From 2001 to March 2020, although prediabetes and overweight/obesity increased, hypertension,
hyperlipidemia, cigarette use, and inactive physical activity decreased among US adolescents aged 12 to 19 years,
whereas elevated BP, diabetes, and poor diet quality remained unchanged. There were disparities in CVRF prevalence
and trends across sociodemographic subpopulations. While treatment and control rates for hypertension and diabe-
tes plateaued, BP control were stable, and improved glycemic control was observed.
Keywords Cardiovascular risk factor, Prevalence, Treatment, Control, Pediatrics, NHANES

Background The primary purpose of this study was to determine

Cardiovascular diseases (CVDs) have been the leading how CVRF prevalence changed among US adolescents
cause of deaths and disabilities for several decades [1]. aged 12 to 19 years in the past 2 decades. A secondary
Despite substantial declines in cardiovascular mortality purpose was to determine whether CVRF treatment and
since 1950, CVDs remain the most common source of control rates were improved or deteriorative during this
mortality in the US and accounts for up to 928,741 deaths period, and whether these trends varied across sociode-
in 2020 [2]. CVDs are estimated to result in direct and mographic subgroups. To achieve these goals, data from
indirect costs of over $407.3 billion between 2018 and 9 cycles of the National Health and Nutrition Examina-
2019, constituting a considerable economic and social tion Survey (NHANES) were analyzed.
burden [3].
Recent meta-analyses show that a substantial propor- Methods
tion of boys (6%-39%) and girls (6%-86%) exhibit car- Data collection
diovascular risk factors (CVRFs) [4]. Boys and girls with The NHANES, administered by the National Center
poor health status have 5.7- and 3.6-fold higher CVD for Health Statistics (NCHS) of the Centers for Disease
risks, respectively [4]. Among adolescents, CVRFs are Control and Prevention (CDC), comprises a series of
strongly correlated with early indicators of target organ publicly available, cross-sectional, nationwide surveys of
damage [5–8]. Without appropriate and timely inter- civilian, noninstitutionalized US population [27, 28]. To
vention, conventional CVRFs (including hypertension, obtain nationally representative estimates, the NHANES
elevated blood pressure [BP], diabetes, prediabetes, selects participants aged 1 to 80 years using a complex,
hyperlipidemia, obesity, overweight, cigarette use, inac- multistage, probability sampling design. Most question-
tive physical activity, and poor diet quality) during ado- naire data are collected through in-home interviews,
lescence may persist [9, 10], and are associated with and physical examinations and laboratory testing data
higher mortality and morbidity risks during adulthood are collected through mobile examinations; the data
[11–19]. Thus, mitigating CVRFs in adolescents could are released every 2 years since 1999. Details regarding
potentially result in a reduced number of individuals design, weighting, and methodology have been described
affected by CVDs later in life. The magnitude of CVRF elsewhere [29]. This study included 9 cycles from 2001–
burden in adolescents may have an increasingly pro- 2002 to 2017-March 2020, focusing on participants
found impact on public health as the population ages. aged 12–19 years. Among the adolescent participants,
However, trends in CVRF prevalence, treatment, and unweighted response rates ranged from 54.4% to 88.9%
control in US adolescents are as yet unclear. Moreover, for in-home interviews and 50.7% to 86.4% for mobile
most previous studies do not provide recent estimated examinations (Additional file 1: eTable 1). The NCHS
rates, ignore information on several important subgroups Ethics Review Board approved the study protocol, and
(i.e., sociodemographic status), or have methodological written informed consent was acquired from all indi-
limitations (e.g., unweighted or unadjusted estimates for viduals [30]. The Strengthening the Reporting of Obser-
design variables) [20–24], which are essential for predict- vational Studies in Epidemiology (STROBE) reporting
ing population-level complications and helping develop guideline was followed throughout the study (Additional
effective national public health policies [25, 26]. file 1: eTable 2) [31].
Qu et al. BMC Medicine (2024) 22:245 Page 3 of 16

During the in-home interviews, information regarding Cardiology/American Heart Association guidelines [33,
age, sex, race/ethnicity, educational level, income to pov- 34], age-, sex-, and height-specific BP percentiles and
erty ratio (IPR), insurance status, and medical conditions 130/80 mmHg were used to define high BP in adoles-
(including medical history and medication use) was col- cents aged < 18 and 18–19 years, respectively (Additional
lected. Race/ethnicity categories included non-Hispanic file 1: eTable 3). Hypertension was defined as stage 1 or
White, non-Hispanic Black, Mexican American, and 2 levels and/or current use of antihypertensive medica-
other races/ethnicities (including other Hispanic and tions (Additional file 1: eMethod 1), whereas elevated BP
other/multiple races or ethnicities). Medical history and was defined as an elevated level. Diabetes was defined
medication use were self-reported. Medication use was as a H ­ bA1c of ≥ 6.5%, FPG of ≥ 126 mg/dL, self-report
determined by the responses to questions about taking of previous diagnosis, and/or current use of antidia-
prescription drugs. Participants who answered ‘yes’ were betic medications, whereas prediabetes was defined as
asked to show all drug containers; when not available, a ­HbA1c of 5.7%-6.4% and/or FPG of 100–125 mg/dL
participants were asked to verbally list all drug names. [35]. Hyperlipidemia was defined as a TC of ≥ 200 mg/
Participants were asked whether they had ever smoked dL, HDL-C of < 40 mg/dL, non-HDL-C of ≥ 145 mg/dL,
cigarettes, how old they were when they first smoked, LDL-C of ≥ 130 mg/dL, triglycerides of ≥ 130 mg/dL,
and whether they smoked during the past month to and/or current use of antihyperlipidemic medications
determine smoking status. Participants were also asked [36, 37]. Obesity and overweight were defined based
to report the frequency and duration of moderate- and, on BMI using the Lambda Mu Sigma method [38]. In
separately, vigorous-intensity physical activity (includ- accordance with CDC’s standard [39, 40], cigarette use
ing work- and transportation-related and leisure-time was defined as smoking cigarettes within the previous
domains) during a typical week. Weekly exercise time 30 days. Based on the 2018 Physical Activities Guidelines
was calculated as the minutes of moderate-intensity for Americans [41], inactive physical activity was defined
physical activity plus twice the minutes of vigorous- as a weekly exercise time of < 420 and < 150 min/wk in
intensity physical activity per week. Dietary informa- adolescents aged < 18 and 18–19 years, respectively. Diet
tion was obtained from 24-h recall interviews during the quality was broadly classified according to HEI-2015, and
mobile examinations. The simple Healthy Eating Index- a score of < 51 points was considered as poor diet quality
2015 (HEI-2015) scoring algorithm (per day), based on [42]. Consistent definitions were applied for the CVRFs
13 dietary components (including total fruit, whole fruit, throughout the study.
total vegetables, greens or beans, whole grains, dairy, CVRF treatment and control rates were also assessed
total protein foods, seafood or plant protein, fatty acids, in adolescents aged 12–19 years. Hypertension treat-
refined grains, sodium, added sugars, and saturated fat), ment was defined as current use of antihypertensive
was used to indicate overall diet quality [32]. Anthro- medications. Hypertension was considered controlled
pometry parameters including weight, height, and BP if (1) BP was reduced to < 90th percentile in adolescents
were measured using standard protocols. Body mass aged < 13 years, (2) BP was reduced to < 90th percentile
index (BMI) was calculated by dividing weight by height and < 130/80 mmHg in adolescents aged 13–17 years,
squared. Systolic and diastolic BP were calculated as the or (3) BP was reduced to < 130/80 mmHg in adoles-
mean of 3 (sometimes 4) BP determinations. cents aged 18–19 years [33, 34]. Diabetes treatment was
Non-fasting laboratory testing was used to measure defined as current use of antidiabetic medications. Dia-
serum levels of hemoglobin A ­ 1c ­(HbA1c), total cholesterol betes was considered controlled if ­HbA1c was reduced
(TC) and high-density lipoprotein cholesterol (HDL- to < 7% [43, 44]. Hyperlipidemia treatment and control
C). The non-high-density lipoprotein cholesterol (non- rates were not analyzed because the updated guidelines
HDL-C) was calculated by subtracting HDL-C from TC. no longer recommended lipid-level targets for treatment
Approximately half of the participants were sampled and the number of adolescents receiving lipid-lowering
to attend a morning examination, during which fasting medications was small [36, 37].
plasma glucose (FPG), low-density lipoprotein choles-
terol (LDL-C), and triglycerides levels were measured Statistical analysis
after fasting for 8.5 to less than 24 h. To ensure that the estimates accurately represented the
noninstitutionalized US population, weights for the inter-
Assessment of CVRF prevalence, treatment, and control view sample, examination sample, fasting subsample, and
The prevalence of CVRFs was evaluated through the dietary sample were appropriately used for all analyses.
above parameters derived from in-home interviews and Baseline characteristics of adolescents aged 12–19 years
mobile examinations. According to the 2017 American were presented as means or proportions with 95% con-
Academy of Pediatrics and 2017 American College of fidence intervals (CIs). A linear trend in the weighted
Qu et al. BMC Medicine (2024) 22:245 Page 4 of 16

means and proportions over time was tested using F test White, 14.4% non-Hispanic Black, 13.3% Mexican Amer-
based on weighted linear regression or Wald test based ican, and 14.9% from other races/ethnicities; over time,
on logistic regression, with time treated as a continuous the proportions of Mexican Americans and other races/
variable. Estimates for the prevalence, treatment, and ethnicities increased significantly (P for trend = 0.02
control of CVRF were age-adjusted to the 2000 Census and < 0.001, respectively), whereas the proportion of
population, using the age groups of 12 to 14, 15 to 17, and non-Hispanic Whites decreased (P for trend < 0.001). The
18 to 19 years. We calculated relative % change per 4-year proportions of individuals who were born outside the US
cycle and P for trend using a joinpoint regression model varied from 7.3% to 10.1%, and those who lived in poverty
with heteroscedastic and uncorrected errors, as previ- from 28.5% to 32.3%. The proportions of individuals with
ously described [26, 45]. The default maximum number health insurance increased from 85.5% in 2001–2004 to
of joinpoints (0 joinpoints, corresponding to a straight 91.8% in 2017-March 2020 (P for trend < 0.001).
line) was allowed to avoid possible overfitting. The opti- Compared with earlier years, individuals in the recent
mal fitting model was chosen by performing 4499 permu- survey cycles were more likely to have normal diastolic
tation tests based on the Monte Carlo method, adjusting BP, improved lipid profiles (including TC, HDL-C, non-
for multiple tests. Parameters were estimated using HDL-C, LDL-C, and triglycerides), more exercise time,
weighted least squares, with weights proportional to the and an increased HEI-2015 score, but were prone to a
inverse of the variance of ln-transformed age-standard- higher BMI, increased H ­ bA1c level, and impaired fasting
ized prevalence rate at each 4-year cycle. Furthermore, glucose. Age-adjusted trends in mean BP, H ­ bA1c, FPG,
logistic regression analyses were conducted, adjusting for TC, HDL-C, non-HDL-C, LDL-C, triglycerides levels,
age, sex, and race/ethnicity, to identify factors associated BMI, weekly exercise time, and HEI-2015 for all individu-
with the prevalence, treatment, and control of CVRFs. als and pivotal subgroups (age and race/ethnicity) are dis-
To assess clinical implications of the updated guide- played in Additional file 1: eFigures 2–4 and eTable 4.
lines for high BP on the prevalence, treatment, and con-
trol of high BP among adolescents, we also performed a CVRF prevalence rates
sensitivity analysis by defining hypertension and elevated The prevalence rates of CVRFs among adolescents aged
BP following the 2003 National Institutes of Health’s 12–19 years are summarized for age-adjusted analy-
National Heart, Lung, and Blood Institute (NIH/NHLBI) sis in Table 2 and for demographics-adjusted analysis in
and 2004 NIH/NHLBI guidelines (Additional file 1: eTa- Table 3, and the secular trends are summarized in Addi-
ble 3) [46, 47]. The definition of hypertension treatment tional file 1: eTable 4.
was identical to that used in the main analysis. Hyper- The age-adjusted prevalence of hypertension among
tension was considered controlled if (1) BP was reduced adolescents aged 12–19 years significantly decreased from
to < 95th percentile in adolescents aged < 18 years or (2) 8.1% (95% CI, 6.9%-9.4%) in 2001–2004 to 5.5% (95% CI,
BP was reduced to < 140/90 mmHg in adolescents aged 3.7%-7.3%) in 2017-March 2020 (Fig. 1A), with a -15.3%
18–19 years [46, 47]. relative decrease (95% CI, -26.8% to -1.9%) per 4-year
All analyses were performed using R software 4.2.3 cycle (P for trend = 0.04). The age-adjusted prevalence of
(R Foundation) and Joinpoint Regression Program 5.0.2 elevated BP and diabetes did not change over this period
(National Cancer Institute). A two-sided P-value of less (P for trend = 0.73 and 0.27, respectively) (Figs. 1B-C). The
than 0.05 was considered statistically significant. age-adjusted prevalence of prediabetes was numerically
higher in 2017-March 2020 than in 2001–2004 (37.6%
Results [95% CI, 29.1%-46.2%] versus 12.5% [95% CI, 10.2%-
Baseline characteristics 14.9%], Fig. 1D), although the difference did not reach sig-
There were 97,657 individuals initially identified from nificance (P for trend = 0.08). The age-adjusted prevalence
2001-March 2020 NHANES. After exclusions for age < 12 of hyperlipidemia was lower in 2017-March 2020 (22.8%
or ≥ 20 years (n = 81,980), unavailable information on [95% CI, 18.7%-26.8%]) than in 2001–2004 (34.2% [95% CI,
all CVRF components (n = 369), or pregnancy at the 30.9%-37.5%]) (Fig. 1E), with a -9.8% relative decrease (95%
time of examination (n = 153), 15,155 adolescents aged CI, -15.2% to -4.0%) per 4-year cycle (P for trend = 0.01).
12–19 years were finally included, representing approxi- The age-adjusted prevalence of obesity significantly
mately 32.4 million noninstitutionalized and nonpreg- increased from 16.0% (95% CI, 14.1%-17.9%) in 2001–
nant US population (Additional file 1: eFigure 1). 2004 to 20.3% (95% CI, 17.9%-22.7%) in 2017-March
Table 1 presents the descriptive characteristics of the 2020 (Fig. 1F), with a 6.4% relative increase (95% CI,
individuals stratified by survey periods. The mean age 4.2%-8.6%) per 4-year cycle (P for trend = 0.002); as did
was 15.4 years, and 51.3% were boys. The racial and overweight (from 21.1% [95% CI, 19.3%-22.8%] in 2001–
ethnic distribution was as follows: 57.4% non-Hispanic 2004 to 24.8% [95% CI, 21.4%-28.2%] in 2017-March
Qu et al. BMC Medicine (2024) 22:245 Page 5 of 16

Table 1 Baseline Characteristics of US Adolescents Aged 12 to 19 Years, 2001 to March 2­ 020a

Characteristics 2001–2004 2005–2008 2009–2012 2013–2016 2017-March 2020 P for ­trendc
(n = 4591)b (n = 3404)b (n = 2563)b (n = 2693)b (n = 1904)b

Age, mean, y 15.4 (15.3–15.5) 15.5 (15.3–15.6) 15.4 (15.3–15.5) 15.4 (15.2–15.5) 15.4 (15.3–15.5) .83
Age group, y
12–14 39.7 (37.2–42.1) 37.0 (34.2–39.7) 38.7 (36.3–41.0) 38.9 (36.1–41.7) 39.3 (37.2–41.4) .77
15–17 37.0 (34.4–39.6) 39.5 (37.2–41.9) 38.5 (36.0–41.0) 39.2 (37.4–40.9) 37.4 (34.9–39.9) .84
18–19 23.3 (20.7–26.0) 23.5 (21.3–25.6) 22.8 (20.0–25.7) 22.0 (20.1–23.8) 23.3 (21.3–25.3) .60
Sex
Female 48.6 (46.9–50.3) 48.5 (46.4–50.7) 48.5 (46.1–50.9) 48.8 (46.8–50.9) 49.1 (44.8–53.4) .80
Male 51.4 (49.7–53.1) 51.5 (49.3–53.6) 51.5 (49.1–53.9) 51.2 (49.1–53.2) 50.9 (46.6–55.2) .80
Race/ethnicityd
Non-Hispanic White 63.1 (57.7–68.6) 61.9 (56.9–66.9) 56.7 (50.8–62.6) 53.3 (46.1–60.6) 50.8 (44.7–56.9) < .001
Non-Hispanic Black 14.2 (11.1–17.3) 15.1 (11.6–18.6) 14.8 (11.0–18.6) 14.3 (10.5–18.2) 13.4 (9.3–17.5) .71
Mexican American 10.9 (8.0–13.7) 11.5 (9.0–13.9) 13.8 (10.2–17.3) 15.1 (10.7–19.5) 15.8 (11.4–20.2) .02
Other 11.8 (8.6–15.0) 11.6 (8.7–14.5) 14.7 (12.1–17.3) 17.3 (14.9–19.7) 20.0 (17.0–22.9) < .001
Birth country (n = 4591) (n = 3403) (n = 2560) (n = 2692) (n = 1904)
US born 91.0 (89.2–92.8) 91.7 (89.8–93.5) 89.9 (87.9–91.9) 92.7 (91.2–94.2) 92.1 (89.8–94.3) .31
Non-US born 9.0 (7.2–10.8) 8.3 (6.5–10.2) 10.1 (8.1–12.1) 7.3 (5.8–8.8) 7.9 (5.7–10.2) .31
Income to poverty (n = 4318) (n = 3186) (n = 2316) (n = 2450) (n = 1680)
ratio, %
   < 130 31.1 (27.9–34.3) 28.5 (24.9–32.0) 32.3 (26.9–37.6) 31.0 (26.3–35.8) 29.2 (25.8–32.7) .92
130–349 36.4 (34.1–38.6) 35.8 (32.5–39.2) 36.4 (31.9–40.9) 39.2 (35.1–43.2) 37.4 (34.0–40.7) .25
  ≥ 350 32.5 (29.1–35.9) 35.7 (31.1–40.4) 31.3 (26.0–36.6) 29.8 (24.9–34.7) 33.4 (29.3–37.5) .43
Insurance status (n = 4514) (n = 3377) (n = 2548) (n = 2683) (n = 1894)
Uninsured 14.5 (12.1–16.9) 14.5 (12.4–16.7) 12.2 (9.6–14.8) 10.2 (8.5–11.9) 8.2 (6.3–10.2) < .001
Insured 85.5 (83.1–87.9) 85.5 (83.3–87.6) 87.8 (85.2–90.4) 89.8 (88.1–91.5) 91.8 (89.8–93.7) < .001
Body mass index, 23.3 (23.0–23.7) 23.4 (23.1–23.8) 23.8 (23.4–24.2) 24.1 (23.7–24.6) 24.4 (23.9–24.8) < .001
mean, kg/m2e
Weight ­statusf (n = 4464) (n = 3331) (n = 2507) (n = 2627) (n = 1832)
Normal 63.0 (60.3–65.8) 61.9 (59.4–64.4) 60.6 (57.9–63.3) 57.6 (54.7–60.5) 55.1 (51.2–59.0) < .001
Overweight 21.0 (19.3–22.8) 21.8 (20.2–23.3) 22.1 (20.2–24.1) 23.7 (21.8–25.5) 24.8 (21.5–28.2) .02
Obesity 15.9 (14.0–17.8) 16.3 (13.8–18.8) 17.3 (15.1–19.5) 18.7 (16.0–21.4) 20.1 (17.7–22.5) .004
Blood ­pressureg
Systolic (n = 4371) (n = 3211) (n = 2438) (n = 2554) (n = 1653)
  Normal 85.1 (83.4–86.8) 83.6 (80.4–86.7) 85.6 (83.6–87.5) 87.1 (85.7–88.6) 85.3 (82.1–88.4) .26
  Elevated 11.2 (10.1–12.3) 11.6 (9.4–13.7) 10.7 (8.8–12.6) 10.2 (8.9–11.6) 12.2 (9.8–14.6) .93
  Stage 1 3.4 (2.5–4.2) 4.3 (3.0–5.6) 3.1 (2.2–4.0) 2.2 (1.5–2.9) 2.5 (1.2–3.8) .02
  Stage 2 0.3 (0.1–0.6) 0.5 (0.3–0.8) 0.6 (0.2–1.1) 0.4 (0.2–0.7) 0.1 (0.0–0.1) .10
Diastolic (n = 4349) (n = 3202) (n = 2423) (n = 2539) (n = 1653)
  Normal 95.2 (94.0–96.3) 96.9 (96.0–97.7) 97.9 (96.9–98.8) 98.6 (98.1–99.1) 97.0 (96.0–97.9) < .001
  Elevated 0.5 (0.2–0.8) 0.2 (0.0–0.4) 0.4 (0.0–0.8) 0.0 (0.0–0.1) 0.1 (0.0–0.2) .01
  Stage 1 3.9 (3.0–4.8) 2.7 (1.9–3.5) 1.5 (0.8–2.2) 1.2 (0.8–1.7) 2.6 (1.7–3.5) .002
  Stage 2 0.5 (0.2–0.7) 0.3 (0.0–0.5) 0.3 (0.0–0.6) 0.1 (0.0–0.2) 0.4 (0.0–1.0) .56
Hemoglobin ­A1c, % (n = 4209) (n = 3015) (n = 2303) (n = 2375) (n = 1656)
   < 5.7 97.0 (96.4–97.6) 95.9 (94.8–97.0) 93.2 (92.0–94.5) 94.0 (92.8–95.2) 93.2 (91.2–95.2) < .001
5.7–6.4 2.4 (1.7–3.0) 3.6 (2.7–4.6) 6.3 (5.1–7.4) 5.7 (4.5–6.9) 6.2 (4.4–8.1) < .001
   ≥ 6.5 0.6 (0.3–0.9) 0.5 (0.2–0.8) 0.5 (0.1–0.9) 0.3 (0.0–0.7) 0.6 (0.0–1.2) .75
FPG, mg/dLh (n = 2037) (n = 1425) (n = 1161) (n = 1118) (n = 740)
   < 100 88.2 (85.8–90.5) 76.2 (72.6–79.9) 83.8 (80.7–86.9) 75.0 (70.6–79.4) 65.4 (57.6–73.2) < .001
100–125 11.3 (8.9–13.8) 23.0 (19.3–26.7) 16.0 (12.9–19.1) 24.2 (19.7–28.7) 34.2 (26.4–42.0) < .001
   ≥ 126 0.5 (0.0–0.9) 0.8 (0.2–1.3) 0.2 (0.0–0.4) 0.8 (0.0–1.6) 0.4 (0.0–0.8) .89
Qu et al. BMC Medicine (2024) 22:245 Page 6 of 16

Table 1 (continued)
Characteristics 2001–2004 2005–2008 2009–2012 2013–2016 2017-March 2020 P for ­trendc
(n = 4591)b (n = 3404)b (n = 2563)b (n = 2693)b (n = 1904)b

TC (n = 4130) (n = 2989) (n = 2264) (n = 2331) (n = 1593)

Ideal (< 170 mg/dL) 62.1 (59.6–64.5) 64.5 (61.9–67.1) 69.1 (66.6–71.6) 69.3 (67.1–71.4) 71.8 (68.3–75.3) < .001
Intermediate 25.9 (23.5–28.2) 25.3 (23.2–27.5) 22.2 (20.1–24.4) 21.6 (19.8–23.3) 22.1 (18.8–25.4) .01
(170–199 mg/dL)
Poor (≥ 200 mg/dL) 12.1 (10.1–14.1) 10.2 (8.7–11.6) 8.6 (6.7–10.5) 9.2 (7.8–10.6) 6.1 (4.8–7.5) < .001
HDL-C (n = 4133) (n = 3001) (n = 2276) (n = 2339) (n = 1606)
Ideal (≥ 45 mg/dL) 66.0 (64.1–68.0) 68.7 (66.5–70.9) 71.4 (69.0–73.9) 71.4 (68.6–74.2) 69.4 (65.4–73.4) .03
Intermediate (40–44 16.3 (15.2–17.4) 16.4 (14.6–18.2) 13.1 (11.4–14.9) 13.0 (11.3–14.8) 16.5 (13.7–19.3) .24
mg/dL)
Poor (< 40 mg/dL) 17.6 (16.0–19.3) 14.9 (13.5–16.4) 15.4 (13.6–17.2) 15.6 (13.0–18.2) 14.1 (11.8–16.4) .06
Non-HDL-Ci (n = 4125) (n = 2989) (n = 2263) (n = 2330) (n = 1591)
Ideal (< 120 mg/dL) 62.7 (60.8–64.7) 66.5 (63.5–69.6) 71.9 (69.2–74.6) 72.4 (70.1–74.7) 75.3 (71.7–79.0) < .001
Intermediate 23.2 (21.3–25.1) 21.1 (18.5–23.7) 17.8 (15.8–19.7) 17.6 (15.7–19.4) 16.8 (13.6–19.9) < .001
(120–144 mg/dL)
Poor (≥ 145 mg/dL) 14.1 (12.3–15.9) 12.4 (10.6–14.1) 10.3 (8.0–12.7) 10.0 (8.5–11.6) 7.9 (6.1–9.7) < .001
LDL-Ch (n = 1904) (n = 1402) (n = 1143) (n = 1061) (n = 715)
Ideal (< 110 mg/dL) 75.9 (73.0–78.8) 80.0 (77.0–83.0) 80.7 (78.6–82.8) 83.7 (80.6–86.8) 83.7 (79.1–88.2) .001
Intermediate 16.2 (13.8–18.6) 13.3 (10.7–15.8) 12.0 (10.2–13.9) 10.7 (8.0–13.5) 11.5 (7.4–15.7) .02
(110–129 mg/dL)
Poor (≥ 130 mg/dL) 7.9 (6.0–9.8) 6.7 (5.0–8.5) 7.2 (5.3–9.2) 5.6 (3.7–7.4) 4.8 (2.9–6.7) .02
Triglyceridesh (n = 2003) (n = 1406) (n = 1146) (n = 1062) (n = 716)
Ideal (< 90 mg/dL) 62.0 (57.9–66.0) 64.7 (61.3–68.2) 71.8 (68.3–75.2) 78.6 (74.6–82.5) 77.9 (72.1–83.6) < .001
Intermediate 20.8 (17.6–23.9) 21.1 (18.1–24.0) 17.3 (14.1–20.5) 11.7 (8.6–14.7) 15.4 (10.4–20.4) .002
(90–129 mg/dL)
Poor (≥ 130 mg/dL) 17.3 (14.2–20.3) 14.2 (10.8–17.6) 10.9 (9.1–12.7) 9.8 (7.0–12.6) 6.7 (4.8–8.6) < .001
Weekly exercise time, 185.6 (159.3–212.0) 836.3 (763.4–909.2) 993.0 (906.7–1079.4) 1044.4 (974.3–1114.6) 1617.5 (1439.2–1795.8) < .001
mean, min/wkj
HEI-2015, mean, ­pointsk 43.5 (42.9–44.2) 43.8 (43.0–44.6) 45.9 (45.0–46.8) 46.0 (45.2–46.8) 43.7 (42.6–44.8) .03
Diet ­qualityl (n = 4357) (n = 3228) (n = 2417) (n = 2492) (n = 1740)
Ideal 0.0 (0.0–0.1) 0.2 (0.0–0.4) 0.1 (0.0–0.3) 0.8 (0.3–1.3) 0.7 (0.1–1.3) .03
Intermediate 23.9 (21.8–25.9) 26.4 (23.3–29.4) 32.0 (28.4–35.7) 31.7 (28.8–34.6) 27.6 (24.5–30.8) .002
Poor 76.1 (74.0–78.1) 73.5 (70.4–76.5) 67.8 (64.1–71.5) 67.5 (64.5–70.5) 71.7 (68.6–74.9) < .001
SI conversions: to convert glucose to mmol/L, multiply by 0.0555; TC, HDL-C, non-HDL-C, and LDL-C to mmol/L, multiply by 0.0259; triglycerides to mmol/L, multiply
by 0.0113
Abbreviations: CI Confidence interval, FPG Fasting plasma glucose, HDL-C High-density lipoprotein cholesterol, HEI-2015 Healthy Eating Index-2015, LDL-C Low-density
lipoprotein cholesterol, NHANES National Health and Nutrition Examination Survey, non-HDL-C Non-high-density lipoprotein cholesterol, TC Total cholesterol
a
Nationally representative estimates of US adolescents aged 12–19 years from the 2001-March 2020 NHANES. The sample size for each 4-year interval was
unweighted, whereas all other numbers were weighted means or percentages with 95% CIs
b
Unweighted sample size
c
F test based on weighted linear regression or Wald test based on logistic regression
d
Race/ethnicity was based on self-report. The non-Hispanic Asian category was not available before 2011 due to the survey design, and thus estimates could not be
presented separately. All other racial/ethnic groups were grouped as ‘Other’
e
Body mass index was missing for 394 (2.6%) participants among 15,155 included from the examination sample
f
Weight status (normal, overweight, and obesity) was based on Ref [38]
g
Blood pressure (normal, elevated, stage 1, and stage 2) were based on Ref [33, 34]
h
FPG, LDL-C, and triglycerides were based on fasting laboratory testing
i
Non-HDL-C was calculated as the difference between serum TC and HDL-C
j
Weekly exercise time was calculated as the minutes of moderate-intensity physical activity plus twice the minutes of vigorous-intensity physical activity per week.
During 2001–2006, physical activity levels were underestimated due to a lack of data on home/yard tasks for adolescents aged 12–15 years and a lack of time data on
muscle-strengthening activities across the age spectrum; data on weekly exercise time for participants aged 12–17 years were not available during 2017-March 2020,
and thus estimates only represented those aged 18–19 years throughout this period. Weekly exercise time was missing for 5050 (33.3%) participants among 15,155
included from the examination sample
k
HEI-2015 was missing for 292 (2.0%) participants among 14,526 included from the dietary day one sample
l
Diet quality (ideal, intermediate, and poor) was based on Ref [42]
Table 2 Age-Adjusted Prevalence of Cardiovascular Risk Factors by Subgroups Among US Adolescents Aged 12 to 19 Years, 2001 to March 2­ 020a
Characteristics Adolescents with cardiovascular risk factors, % (95% CIs)b

Hypertensionc Elevated ­BPc Diabetesd Prediabetesd Hyperlipidemiae Obesityf Overweightf Cigarette ­useg Inactive physical Poor diet q
­ ualityi
­activityh

Cases/No.j 901/14247 1518/14247 84/6461 1504/6461 1708/6192 2815/14761 3358/14761 1553/13865 5579/10105 10,262/14234
Age group, y
Qu et al. BMC Medicine

12–14 3.4 (2.7–4.1) 7.3 (6.2–8.3) 0.9 (0.3–1.4) 28.0 (25.1–30.9) 24.3 (21.9–26.7) 16.1 (14.7–17.6) 23.7 (22.2–25.3) 2.2 (1.7–2.8) 59.8 (57.3–62.3) 70.0 (67.7–72.3)
15–17 6.7 (5.8–7.6) 11.4 (10.3–12.5) 0.8 (0.4–1.2) 21.7 (19.1–24.4) 25.4 (23.1–27.7) 17.8 (16.4–19.2) 21.5 (20.0–22.9) 13.1 (11.9–14.4) 52.9 (50.4–55.4) 72.1 (70.3–73.9)
18–19 9.4 (8.0–10.8) 14.1 (12.1–16.1) 1.4 (0.7–2.1) 22.3 (19.1–25.4) 35.1 (31.5–38.8) 19.8 (17.7–21.9) 22.7 (20.7–24.7) 24.4 (22.3–26.5) 24.7 (22.5–27.0) 71.9 (69.1–74.7)
Sex
Female 4.0 (3.3–4.7) 5.5 (4.7–6.2) 0.9 (0.4–1.3) 16.8 (14.6–19.0) 24.0 (21.5–26.5) 18.2 (16.8–19.6) 21.8 (20.5–23.1) 10.6 (9.7–11.5) 54.8 (52.5–57.0) 69.5 (67.7–71.3)
(2024) 22:245

Male 8.2 (7.3–9.1) 15.4 (14.0–16.7) 1.1 (0.6–1.6) 31.3 (28.5–34.1) 30.7 (28.2–33.1) 17.3 (16.0–18.5) 23.3 (22.0–24.7) 13.0 (11.8–14.3) 42.7 (40.6–44.8) 73.1 (71.3–74.8)
Race/ethnicityk
Non-Hispanic White 6.2 (5.2–7.1) 10.3 (9.1–11.5) 0.8 (0.3–1.2) 21.9 (18.5–25.3) 28.8 (26.2–31.4) 15.5 (13.9–17.1) 22.0 (20.6–23.5) 14.3 (12.9–15.7) 46.7 (44.1–49.3) 72.9 (70.7–75.2)
Non-Hispanic Black 8.6 (7.5–9.8) 13.6 (12.5–14.7) 1.4 (0.7–2.2) 25.1 (22.0–28.2) 21.4 (19.0–23.8) 22.6 (21.0–24.3) 22.1 (20.8–23.5) 7.0 (6.1–7.9) 51.6 (48.4–54.7) 75.2 (73.1–77.3)
Mexican American 4.9 (4.0–5.8) 10.3 (8.7–11.9) 1.9 (0.8–2.9) 30.6 (26.4–34.7) 28.2 (25.3–31.1) 22.9 (21.0–24.9) 26.8 (25.3–28.3) 9.4 (8.1–10.6) 52.3 (49.7–54.9) 64.9 (62.4–67.4)
Other 4.9 (3.8–6.0) 8.6 (7.2–10.1) 0.5 (0.1–1.0) 26.0 (22.6–29.5) 27.2 (23.6–30.7) 16.6 (14.7–18.5) 21.7 (19.6–23.8) 9.4 (7.7–11.1) 47.8 (44.7–51.0) 66.7 (63.7–69.7)
Birth country
US born 6.4 (5.7–7.1) 10.7 (9.8–11.5) 1.0 (0.7–1.4) 23.8 (21.5–26.0) 27.7 (26.0–29.4) 18.3 (17.1–19.4) 23.0 (21.9–24.0) 12.2 (11.3–13.1) 47.8 (46.1–49.5) 72.3 (70.9–73.8)
Non-US born 3.9 (2.9–4.9) 9.5 (7.0–12.0) 0.4 (0.0–0.8) 29.0 (24.0–33.9) 26.1 (21.9–30.2) 12.0 (9.8–14.2) 19.0 (16.9–21.2) 9.2 (7.3–11.1) 55.3 (51.4–59.3) 59.9 (55.7–64.1)
Income to poverty ratio, %
   < 130 6.7 (5.9–7.5) 10.3 (9.1–11.4) 1.3 (0.6–1.9) 26.2 (23.7–28.7) 29.7 (27.2–32.2) 21.5 (19.9–23.0) 24.1 (22.5–25.7) 14.9 (13.4–16.4) 49.7 (47.5–51.9) 72.9 (70.7–75.0)
130–349 6.4 (5.4–7.5) 11.3 (9.9–12.6) 0.9 (0.4–1.4) 24.7 (21.7–27.8) 28.2 (25.4–31.1) 19.1 (17.4–20.8) 23.4 (21.8–25.0) 11.8 (10.3–13.3) 48.7 (46.2–51.3) 72.8 (71.1–74.6)
≥ 350 5.0 (4.0–6.1) 9.9 (8.3–11.4) 0.8 (0.1–1.5) 20.5 (16.2–24.8) 24.9 (21.1–28.7) 12.4 (10.9–14.0) 20.5 (18.6–22.4) 9.9 (8.4–11.4) 47.2 (43.7–50.6) 69.6 (66.5–72.7)
Insurance status
Uninsured 5.9 (4.5–7.3) 11.1 (9.0–13.2) 1.0 (0.0–2.5) 26.3 (22.0–30.7) 31.4 (26.9–35.9) 20.3 (17.5–23.1) 23.5 (21.2–25.8) 16.4 (14.2–18.5) 52.6 (48.4–56.9) 67.4 (63.9–70.9)
Insured 6.1 (5.5–6.8) 10.3 (9.5–11.2) 1.0 (0.7–1.4) 23.6 (21.4–25.8) 26.9 (25.1–28.8) 17.3 (16.2–18.4) 22.5 (21.4–23.6) 11.0 (10.2–11.8) 47.7 (45.9–49.6) 71.7 (70.2–73.2)

Abbreviations: BP Blood pressure, CI Confidence interval

a
Nationally representative estimates of US adolescents aged 12–19 years from the 2001-March 2020 National Health and Nutrition Examination Survey
b
All estimates were age-standardized to the 2000 Census population using the age groups of 12 to 14, 15 to 17, and 18 to 19 years
c
Hypertension was defined as stage 1 or 2 levels and/or current use of antihypertensive medications, whereas elevated BP was defined as an elevated level (see Ref. [33, 34])
d
Diabetes was defined as a hemoglobin A ­ 1c of
­ 1c of ≥ 6.5%, fasting plasma glucose of ≥ 126 mg/dL, self-report of previous diagnosis, and/or current use of antidiabetic medications, whereas prediabetes was defined as a hemoglobin A
5.7%-6.4%
e
Hyperlipidemia was defined as a total cholesterol of ≥ 200 mg/dL, high-density lipoprotein cholesterol of < 40 mg/dL, non-high-density lipoprotein cholesterol of ≥ 145 mg/dL, low-density lipoprotein cholesterol of ≥ 130 mg/dL,
triglycerides of ≥ 130 mg/dL, and/or current use of antihyperlipidemic medications
f
Obesity and overweight were defined based on body mass index using the Lambda Mu Sigma method (see Ref [38])
g
Cigarette use was defined as smoking cigarettes within the previous 30 days
h
Inactive physical activity was defined as a weekly exercise time of < 420 and < 150 min/wk in adolescents aged < 18 and 18–19 years, respectively. Weekly exercise time was calculated as the minutes of moderate-intensity physical
activity plus twice the minutes of vigorous-intensity physical activity per week. During 2001–2006, physical activity levels were underestimated due to a lack of data on home/yard tasks for adolescents aged 12–15 years and a lack of time
data on muscle-strengthening activities across the age spectrum; data on weekly exercise time for participants aged 12–17 years were not available during 2017-March 2020, and thus estimates only represented those aged 18–19 years
throughout this period
i
Poor diet quality was defined as a Healthy Eating Index-2015 score of < 51 points
j
Unweighted number of cases and sample size
k
Race/ethnicity was based on self-report. The non-Hispanic Asian category was not available before 2011 due to the survey design, and thus estimates could not be presented separately. All other racial/ethnic groups were grouped
as ‘Other’
Page 7 of 16
Table 3 Adjusted ORs for Cardiovascular Risk Factors by Subgroups Among US Adolescents Aged 12 to 19 Years, 2001 to March 2­ 020a
Characteristics Adolescents with cardiovascular risk factors, adjusted ORs (95% CIs)

Hypertensionb Elevated ­BPb Diabetesc Prediabetesc Hyperlipidemiad Obesitye Overweighte Cigarette ­usef Inactive physical Poor diet q
­ ualityh
­activityg

Cases/No.i 901/14247 1518/14247 84/6461 1504/6461 1708/6192 2815/14761 3358/14761 1553/13865 5579/10105 10,262/14234
Age group, y
Qu et al. BMC Medicine

12–14 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
15–17 2.03 (1.61, 2.56) 1.67 (1.39, 2.00) 0.96 (0.41, 2.25) 0.73 (0.61, 0.86) 1.06 (0.88, 1.28) 1.14 (1.00, 1.31) 0.88 (0.78, 1.00) 6.56 (5.04, 8.54) 0.76 (0.67, 0.86) 1.10 (0.96, 1.27)
18–19 2.90 (2.24, 3.75) 2.08 (1.66, 2.59) 1.64 (0.69, 3.89) 0.71 (0.58, 0.88) 1.67 (1.38, 2.02) 1.29 (1.11, 1.51) 0.94 (0.81, 1.09) 14.20 (10.65, 18.94) 0.22 (0.19, 0.26) 1.09 (0.92, 1.29)
Sex
Female 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
(2024) 22:245

Male 2.12 (1.70, 2.63) 3.18 (2.72, 3.73) 1.27 (0.64, 2.53) 2.28 (1.94, 2.69) 1.40 (1.16, 1.70) 0.94 (0.84, 1.06) 1.08 (0.97, 1.20) 1.26 (1.08, 1.47) 0.59 (0.52, 0.67) 1.20 (1.07, 1.34)
Race/ethnicityj
Non-Hispanic White 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
Non-Hispanic Black 1.46 (1.16, 1.84) 1.40 (1.22, 1.62) 1.90 (0.88, 4.12) 1.21 (0.90, 1.62) 0.67 (0.55, 0.82) 1.60 (1.36, 1.88) 1.01 (0.91, 1.13) 0.42 (0.35, 0.51) 1.23 (1.01, 1.49) 1.13 (0.96, 1.33)
Mexican American 0.77 (0.61, 0.99) 0.99 (0.81, 1.22) 2.54 (1.12, 5.74) 1.58 (1.20, 2.09) 0.97 (0.81, 1.17) 1.63 (1.40, 1.90) 1.29 (1.16, 1.44) 0.59 (0.49, 0.73) 1.28 (1.08, 1.51) 0.69 (0.59, 0.80)
Other 0.78 (0.58, 1.05) 0.83 (0.67, 1.04) 0.70 (0.24, 2.03) 1.25 (0.94, 1.64) 0.93 (0.74, 1.17) 1.10 (0.91, 1.32) 0.98 (0.84, 1.15) 0.60 (0.46, 0.78) 1.04 (0.88, 1.23) 0.75 (0.61, 0.92)
Birth country
US born 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
Non-US born 0.68 (0.50, 0.92) 0.92 (0.65, 1.28) 0.37 (0.13, 1.06) 1.15 (0.86, 1.53) 0.85 (0.67, 1.08) 0.51 (0.41, 0.64) 0.72 (0.62, 0.84) 0.87 (0.66, 1.14) 1.36 (1.12, 1.64) 0.66 (0.53, 0.81)
Income to poverty ratio, %
< 130 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
130–349 0.92 (0.75, 1.14) 1.12 (0.94, 1.33) 0.76 (0.38, 1.53) 0.95 (0.78, 1.16) 0.88 (0.73, 1.05) 0.91 (0.80, 1.03) 0.97 (0.85, 1.11) 0.65 (0.52, 0.80) 1.02 (0.90, 1.15) 0.96 (0.83, 1.10)
≥ 350 0.71 (0.56, 0.91) 0.93 (0.75, 1.15) 0.74 (0.27, 2.04) 0.76 (0.58, 1.00) 0.68 (0.53, 0.87) 0.57 (0.49, 0.67) 0.83 (0.72, 0.96) 0.44 (0.34, 0.55) 1.01 (0.83, 1.23) 0.77 (0.63, 0.93)
Insurance status
Uninsured 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
Insured 0.93 (0.70, 1.23) 0.90 (0.71, 1.14) 1.48 (0.42, 5.22) 0.85 (0.67, 1.07) 0.81 (0.63, 1.04) 0.90 (0.75, 1.08) 1.00 (0.87, 1.16) 0.51 (0.42, 0.61) 0.84 (0.68, 1.03) 1.10 (0.93, 1.31)

Abbreviations: BP Blood pressure, CI Confidence interval, OR Odds ratio

a
Nationally representative estimates of US adolescents aged 12–19 years from the 2001-March 2020 National Health and Nutrition Examination Survey. Adjusted ORs with 95% CIs were adjusted for age, sex, and race/ethnicity groups
b
Hypertension was defined as stage 1 or 2 levels and/or current use of antihypertensive medications, whereas elevated BP was defined as an elevated level (see Ref [33, 34])
c
Diabetes was defined as a hemoglobin A ­ 1c of
­ 1c of ≥ 6.5%, fasting plasma glucose of ≥ 126 mg/dL, self-report of previous diagnosis, and/or current use of antidiabetic medications, whereas prediabetes was defined as a hemoglobin A
5.7%-6.4%
d
Hyperlipidemia was defined as a total cholesterol of ≥ 200 mg/dL, high-density lipoprotein cholesterol of < 40 mg/dL, non-high-density lipoprotein cholesterol of ≥ 145 mg/dL, low-density lipoprotein cholesterol of ≥ 130 mg/dL,
triglycerides of ≥ 130 mg/dL, and/or current use of antihyperlipidemic medications
e
Obesity and overweight were defined based on body mass index using the Lambda Mu Sigma method (see Ref [38])
f
Cigarette use was defined as smoking cigarettes within the previous 30 days
g
Inactive physical activity was defined as a weekly exercise time of < 420 and < 150 min/wk in adolescents aged < 18 and 18–19 years, respectively. Weekly exercise time was calculated as the minutes of moderate-intensity physical
activity plus twice the minutes of vigorous-intensity physical activity per week. During 2001–2006, physical activity levels were underestimated due to a lack of data on home/yard tasks for adolescents aged 12–15 years and a lack of time
data on muscle-strengthening activities across the age spectrum; data on weekly exercise time for participants aged 12–17 years were not available during 2017-March 2020, and thus estimates only represented those aged 18–19 years
throughout this period
h
Poor diet quality was defined as a Healthy Eating Index-2015 score of < 51 points
i
Unweighted number of cases and sample size
j
Race/ethnicity was based on self-report. The non-Hispanic Asian category was not available before 2011 due to the survey design, and thus estimates could not be presented separately. All other racial/ethnic groups were grouped as ‘Other’
Page 8 of 16
Qu et al. BMC Medicine (2024) 22:245 Page 9 of 16

2020) (Fig. 1G), with a 3.9% relative increase (95% CI, coming from middle- or high-income families, and hav-
2.3%-5.5%) per 4-year cycle (P for trend = 0.004). The ing health insurance. Inactive physical activity was more
age-adjusted prevalence of cigarette use was numeri- likely among non-Hispanic Blacks or Mexican Americans
cally lower in 2017-March 2020 than in 2001–2004 (3.5% and non-US-born individuals, and was less likely among
[95% CI, 2.0%-5.0%] versus 18.0% [95% CI, 15.7%-20.3%], older individuals and boys. The adjusted prevalence of
Fig. 1H), although the difference was not statistically sig- poor diet quality was higher among boys, while it was
nificant (P for trend = 0.07). The age-adjusted prevalence lower among individuals who were Mexican American or
of inactive physical activity was lower in 2017-March the other racial/ethnic group, who were born outside the
2020 (9.5% [95% CI, 4.2%-14.8%]) than in 2001–2004 US, or who were from high-income families.
(83.0% [95% CI, 80.7%-85.3%]) (Fig. 1I), with a -29.0% Age-adjusted trends in CVRF prevalence rates were
relative decrease (95% CI, -41.0% to -14.7%) per 4-year generally similar between boys and girls, whereas there
cycle (P for trend = 0.01). There was no significant change were some disparities across races/ethnicities (Additional
in the age-adjusted prevalence of poor diet quality (P for file 1: eFigures 5–6). Non-Hispanic Whites experienced a
trend = 0.13) (Fig. 1J). significant decrease in hyperlipidemia (2001–2004: 36.6%
The adjusted prevalence of hypertension or elevated [95% CI, 31.9%-41.4%]; 2017-March 2020: 21.3% [95% CI,
BP was higher among older individuals, boys, and non- 13.7%-28.8%]; P for trend = 0.02), whereas an increase
Hispanic Blacks; individuals who were Mexican Ameri- in diabetes was observed among non-Hispanic Blacks
can, who were born outside the US, or who were from (2001–2004: 0.6% [95% CI, 0.0%-1.3%]; 2017-March
high-income families were less likely to have hyperten- 2020: 3.6% [95% CI, 0.8%-6.4%]; P for trend = 0.005).
sion. Mexican Americans were more likely to have both Mexican Americans experienced a significant decrease
diabetes and prediabetes; the adjusted prevalence of in hyperlipidemia (2001–2004: 32.4% [95% CI, 29.1%-
prediabetes was also higher among boys, while being 35.6%]; 2017-March 2020: 25.7% [95% CI, 17.9%-33.5%];
lower among older individuals. Hyperlipidemia was P for trend < 0.001), but also an increase in obesity (2001–
more likely among older individuals and boys, and was 2004: 16.7% [95% CI, 14.3%-19.0%]; 2017-March 2020:
less likely among non-Hispanic Blacks and affluent indi- 29.4% [95% CI, 22.6%-36.1%]; P for trend = 0.009) and
viduals. Obesity and overweight were more common overweight (2001–2004: 24.0% [95% CI, 21.6%-26.5%];
among Mexican Americans, while being less common 2017-March 2020: 28.8% [95% CI, 24.5%-33.2%]; P for
among non-US-born or affluent individuals; older indi- trend = 0.04), whereas a decrease in hypertension was
viduals and non-Hispanic Blacks were also more likely observed in the other racial/ethnic group (2001–2004:
to have obesity. The adjusted prevalence of cigarette use 6.3% [95% CI, 2.9%-9.7%]; 2017-March 2020: 3.6% [95%
correlated positively with being older and male, while it CI, 1.7%-5.4%]; P for trend = 0.03). Trends in the preva-
correlated negatively with being non-Hispanic Black, lence of elevated BP, prediabetes, cigarette use, inactive
Mexican American, or the other racial/ethnic group, physical activity, and poor diet quality were generally

(See figure on next page.)

Fig. 1 Age-Adjusted Trends in the Prevalence of Hypertension, Elevated BP, Diabetes, Prediabetes, Hyperlipidemia, Obesity, Overweight,
Cigarette Use, Inactive Physical Activity, and Poor Diet Quality Among US Adolescents Aged 12 to 19 Years, 2001 to March ­2020a−i. Abbreviations:
BP Blood pressure, CI Confidence interval.a Nationally representative estimates of US adolescents aged 12–19 years from the 2001-March 2020
National Health and Nutrition Examination Survey. Whiskers indicate 95% CIs. P for trend was calculated by the Joinpoint Regression Program:
P = .04 for hypertension in panel A; P = .73 for elevated BP in panel B; P = .46 for diabetes in panel C; P = .08 for prediabetes in panel D; P = .01
for hyperlipidemia in panel E; P = .002 for obesity in panel F; P = .004 for overweight in panel G; P = .07 for cigarette use in panel H; P = .01
for inactive physical activity in panel I; and P = .13 for poor diet quality in panel J. Specific estimates are presented in Additional file 1: eTable 4. b
All estimates were age-standardized to the 2000 Census population using the age groups of 12 to 14, 15 to 17, and 18 to 19 years. c Hypertension
was defined as stage 1 or 2 levels and/or current use of antihypertensive medications, whereas elevated BP was defined as an elevated level (see
Ref [33, 34]). d Diabetes was defined as a hemoglobin ­A1c of ≥ 6.5%, fasting plasma glucose of ≥ 126 mg/dL, self-report of previous diagnosis, and/
or current use of antidiabetic medications, whereas prediabetes was defined as a hemoglobin A ­ 1c of 5.7%-6.4%.e Hyperlipidemia was defined
as a total cholesterol of ≥ 200 mg/dL, high-density lipoprotein cholesterol of < 40 mg/dL, non-high-density lipoprotein cholesterol of ≥ 145 mg/
dL, low-density lipoprotein cholesterol of ≥ 130 mg/dL, triglycerides of ≥ 130 mg/dL, and/or current use of antihyperlipidemic medications. f
Obesity and overweight were defined based on body mass index using the Lambda Mu Sigma method (see Ref. [38]). g Cigarette use was defined
as smoking cigarettes within the previous 30 days. h Inactive physical activity was defined as a weekly exercise time of < 420 and < 150 min/wk
in adolescents aged < 18 and 18–19 years, respectively. Weekly exercise time was calculated as the minutes of moderate-intensity physical activity
plus twice the minutes of vigorous-intensity physical activity per week. During 2001–2006, physical activity levels were underestimated due
to a lack of data on home/yard tasks for adolescents aged 12–15 years and a lack of time data on muscle-strengthening activities across the age
spectrum; data on weekly exercise time for participants aged 12–17 years were not available during 2017-March 2020, and thus estimates
only represented those aged 18–19 years throughout this period. i Poor diet quality was defined as a Healthy Eating Index-2015 score of < 51 points
Qu et al. BMC Medicine (2024) 22:245 Page 10 of 16

Fig. 1 (See legend on previous page.)

Qu et al. BMC Medicine (2024) 22:245 Page 11 of 16

Fig. 2 Age-Adjusted Trends in the Rates of Hypertension and Diabetes Treatment and Control Among US Adolescents Aged 12 to 19 Years,
2001 to March ­2020a−d. Abbreviations: BP Blood pressure, CI Confidence interval. a Nationally representative estimates of US adolescents aged
12–19 years from the 2001-March 2020 National Health and Nutrition Examination Survey. Whiskers indicate 95% CIs. P for trend was calculated
by the Joinpoint Regression Program: P = .79 for hypertension treatment and P = .60 for diabetes treatment in panel A; P = .66 for BP control
and P value was not applicable for glycemic control in panel B. Specific estimates are presented in Additional file 1: eTable 4. b All estimates
were age-standardized to the 2000 Census population using the age groups of 12 to 14, 15 to 17, and 18 to 19 years. c Hypertension treatment
was defined as current use of antihypertensive medications and was evaluated among adolescents with hypertension (n = 901). Diabetes treatment
was defined as current use of antidiabetic medications and was evaluated among adolescents with diabetes (n = 84). d Control was evaluated
among adolescents receiving treatment (n = 68 for hypertension and n = 40 for diabetes). Hypertension was considered controlled if (1) BP
was reduced to < 90th percentile in adolescents aged < 13 years, (2) BP was reduced to < 90th percentile and < 130/80 mmHg in adolescents aged
13–17 years, or (3) BP was reduced to < 130/80 mmHg in adolescents aged 18–19 years. Diabetes was considered controlled if hemoglobin A ­ 1c
was reduced to < 7%

comparable across racial/ethnic groups over the study attain significance (P value was not applicable). No sig-
period. nificant difference was seen in diabetes treatment across
different sociodemographic subpopulations after adjust-
CVRF treatment and control rates ing for other factors (Additional file 1: eTables 5–6).
Among adolescents aged 12–19 years with hyperten- Compared with younger individuals, older individuals
sion, the use of any antihypertensive medication did not were more likely to achieve individualized ­HbA1c targets.
change significantly, from 9.6% (95% CI, 3.5%-15.8%) in Treatment and control rates for hypertension and dia-
2001–2004 to 6.0% (95% CI, 1.4%-10.6%) in 2017-March betes by age and race/ethnicity were not evaluated due to
2020 (P for trend = 0.79) (Fig. 2A and Additional file 1: limited sample size.
eTable 4). Among those receiving pharmacologic ther-
apy, there was also no significant change in age-adjusted Sensitivity analysis
hypertension control rates, from 75.7% (95% CI, 56.8%- When using the 2003 NIH/NHLBI and 2004 NIH/
94.7%) in 2001–2004 to 73.5% (95% CI, 40.3%-100.0%) NHLBI guidelines, the age-adjusted prevalence of hyper-
in 2017-March 2020 (P for trend = 0.66). Hypertension tension decreased (2001–2004: 4.8% [95% CI, 3.8%-
treatment was generally more likely among older indi- 5.7%]; 2017-March 2020: 3.0% [95% CI, 1.8%-4.1%]; P
viduals, and was less likely among boys (Additional file 1: for trend = 0.04), whereas the age-adjusted prevalence
eTables 5–6). There was no significant difference in BP of elevated BP increased (2001–2004: 14.8% [95% CI,
control across different sociodemographic subpopula- 13.1%-16.6%]; 2017-March 2020: 14.6% [95% CI, 11.7%-
tions after adjusting for other factors. 17.5%]; P for trend = 0.27), although trends over time
Among adolescents with diabetes, the use of any anti- were similar (Additional file 1: eFigure 7 and eTable 4).
diabetic medication did not change significantly, from The use of any antihypertensive medication was sub-
51.0% (95% CI, 23.3%-78.7%) in 2001–2004 to 26.5% (95% stantially higher among adolescents with hypertension
CI, 0.0%-54.7%) in 2017-March 2020 (P for trend = 0.60) based on older guidelines (2001–2004: 19.3% [95% CI,
(Fig. 2B and Additional File 1: eTable 4). Among those 10.3%-28.4%]; 2017-March 2020: 28.3% [95% CI, 21.4%-
receiving pharmacologic therapy, higher age-adjusted 35.1%]; P for trend = 0.17), as was hypertension control
diabetes control rates were observed in 2017-March 2020 rates (2001–2004: 90.5% [95% CI, 75.9%-100.0%]; 2017-
(62.7% [95% CI, 62.7%-62.7%]) than in 2001–2004 (11.8% March 2020: 82.8% [95% CI, 57.1%-100.0%]; P value was
[95% CI, 0.0%-31.5%]), although the difference did not not applicable).
Qu et al. BMC Medicine (2024) 22:245 Page 12 of 16

Discussion a sensitivity analysis using the older guidelines (from

Between 2001 and March 2020, prediabetes and over- 4.8% to 3.0%). This decrease was consistent with that
weight/obesity increased among US adolescents aged seen previous reports [65, 66]. Actually, obesity appears
12–19 years, while hypertension, hyperlipidemia, ciga- to be more relevant to wide pulse pressure rather than
rette use, and inactive physical activity decreased, and mean arterial pressure [67]. The contrary trends may
elevated BP, diabetes, and poor diet quality did not be partly explained by reduced lead exposure acting on
change markedly. Boys experienced a higher prevalence small resistance arteries, improved screening programs,
of hypertension, elevated BP, prediabetes, hyperlipidemia, and earlier pharmacologic or lifestyle interventions such
cigarette use, and poor diet quality, and a lower preva- as increased physical activity, smoking cessation, and
lence of inactive physical activity than girls. Furthermore, sodium restriction [68–72]. The prevalence of inactive
among racial/ethnic groups, non-Hispanic Whites had a physical activity significantly decreased from 83.0% to
significant decrease in hyperlipidemia, while an increase 9.5%, as did the prevalence of cigarette use (from 18.0%
in diabetes was seen among non-Hispanic Blacks. Mexi- to 3.5%, although the difference was not statistically sig-
can Americans had a significant decrease in hyperlipi- nificant). Hyperlipidemia also showed a relative decrease
demia, but also an increase in overweight/obesity, while of -33.3% over the past two decades, possibly due to
a decrease in hypertension was seen in the other racial/ reduced levels of trans-fatty acids in the food supply and
ethnic group. Trends in the prevalence of elevated BP, a decline in smoking prevalence [73, 74]. These findings
prediabetes, cigarette use, inactive physical activity, and suggest that interventions targeting hypertension, hyper-
poor diet quality were generally similar across racial/ lipidemia, cigarette use, and physical activity have been
ethnic groups. Whilst treatment rates for hypertension more effective in comparison to interventions targeting
and diabetes did not show improvement over time, BP overweight/obesity, prediabetes/diabetes, and diet qual-
control remained relatively stable, and there were some ity. In light of the strong association between CVRFs and
improvements in glycemic control, although it remained target organ damage during adolescence, as well as pre-
suboptimal. mature cardiovascular morbidity and mortality during
The increase in overweight/obesity prevalence (to adulthood, our data support the need for strengthening
24.8% and 20.3%, respectively) among adolescents was public health planning and individualized clinical inter-
consistent with that previously observed [48–51]. This ventions [5, 11–19].
rise in overweight/obesity rates may have a negative Considerable disparities exist regarding the prevalence
impact on public health and healthcare budgets because rates and trends of CVRFs across different sex and racial/
obesity is strongly correlated with other CVRFs such as ethnic groups. On the one hand, boys were consistently
hypertension, diabetes, and hyperlipidemia, which could at higher risk for hypertension, elevated BP, prediabe-
result in premature CVDs and cardiovascular death tes, hyperlipidemia, cigarette use, and poor diet quality;
during adulthood [13, 16, 52–54]. Several factors may however, on the other hand, boys were at lower risk for
contribute to the increase in overweight/obesity preva- inactive physical activity. Men presented a similar risk for
lence, including larger food portion sizes, consumption the aforementioned CVRFs compared to women as boys
of energy-dense, nutrient-poor foods, changing modes were to girls, and were more likely to experience severe
of transportation, and sedentary behaviors [55–58]. The adverse events (e.g., myocardial infarction, stroke, heart
prevalence of prediabetes increased from 12.5% to 37.6% failure, and cardiovascular death) [75–77]. The exact
during this period, although the difference did not reach mechanisms underlying such inequalities are not fully
significance, whereas there was no noticeable change understood, but are likely influenced by differences in
over time in the prevalence of diabetes. Additionally, the inherent physiology, anti-inflammatory immune profiles,
prevalence of poor diet quality decreased from 76.1% to sex steroid hormone levels, and lifestyles (e.g., sodium
67.8% from 2001–2004 to 2009–2012 but then increased intake) [78, 79]. Thus, it is necessary to adopt more effec-
to 71.7% in 2017-March 2020. Multicomponent behav- tive strategies that consider sex differences in the man-
ior-changing interventions (e.g., increased physical activ- agement of CVRFs.
ity [regardless of light or moderate-to-vigorous intensity], Unlike other races/ethnicities, non-Hispanic Blacks
reduced sedentary behavior, adequate sleep, and high- experienced a significant increase in diabetes, which may
quality diets) [59–63], in combination with improved partly be attributed to early-life exposures, education,
parent support behaviors [64], could help ease the bur- availability of services, and other factors potentially related
den of overweight/obesity for this population. to structural racism [80]. Planning future efforts to address
Despite the increased overweight/obesity prevalence, and mitigate these inequalities across racial/ethnic groups
there was a gradual decrease in the prevalence of hyper- should be prioritized in the management of CVRFs among
tension, from 8.1% to 5.5%, with similar results seen in US adolescents. Besides, a clinically relevant increase in
Qu et al. BMC Medicine (2024) 22:245 Page 13 of 16

overweight/obesity prevalence was observed in Mexican were underestimated due to a lack of data on home/yard
Americans during the study period, which was generally tasks for adolescents aged 12–15 years and a lack of time
consistent with previous reports [48, 49]. While disparities data on muscle-strengthening activities across the age
in overweight/obesity between Mexican Americans and spectrum. Additionally, because data on weekly exercise
non-Hispanic Whites used to be specific to US-born Mex- time for participants aged 12–17 years were not avail-
ican Americans, the disparities have expanded to non-US- able during 2017-March 2020, estimates only represented
born Mexican Americans over recent years [81]. Possible those aged 18–19 years throughout this period, poten-
reasons include the recent and rapid nutrition transition, tially underestimating the prevalence of inactive physi-
changing selection migration dynamics, and longer time to cal inactivity. Fifth, the response rates for the NHANES
live in the US [82–84]. However, in contrast to the increase have declined over time. Sixth, although the combination
in obesity, Mexican Americans, together with non-His- of two continuous NHANES cycles improved the reli-
panic Whites, had a significant decrease in hyperlipidemia. ability of prevalence estimates, the study may not have
Further studies are needed to explore the contributing fac- had sufficient statistical power to detect small changes in
tors for the fluctuation. population subgroups with limited sample sizes. Finally,
Throughout the survey period, hypertension treat- a proportion of nonpregnant participants (n = 368) were
ment rate remained low (< 15%), albeit this may be excluded because of insufficient clinical information. As
partly explained by earlier lifestyle modifications. In the sample differed slightly from the included population
a retrospective study including 15,422 children (aged and between survey years in terms of baseline character-
3–17 years) with BP equal to or greater than 95th percen- istics, this study may not have been completely free of
tile, 14,841 (96.2%) children sought lifestyle counseling, selection bias (Additional file 1: eTables 7–8). However,
whereas 831 (5.4%) children received antihypertensive the proportion of missing data was low (≈ 2.4%); there-
medications, and 848 (5.5%) children received BP-related fore, exclusion of the sample were not expected to signifi-
referrals [85]. Approximately 75% of adolescents receiv- cantly affect the results.
ing antihypertensive medications achieved BP targets at
both the start and end of study period. When using the
older guidelines, the proportions of adolescents who Conclusions
received antihypertensive medications or who achieved Over the past 2 decades, despite an increase in pre-
BP targets were substantially higher (varying between diabetes and overweight/obesity, hypertension, hyper-
8.0%-28.3% and 79.9%-100.0%, respectively). Meanwhile, lipidemia, cigarette use, and inactive physical activity
diabetes treatment rates ranged from 26.5% to 72.1%, decreased among US adolescents aged 12 to 19 years,
with no significant difference found during the study while elevated BP, diabetes, and poor diet quality
period. There was an upward trend in glycemic control remained unchanged. There were disparities in the prev-
rates (from 11.8% to 62.7%), although the difference was alence of and trends in CVRFs across sociodemographic
not statistically significant. A consistent screening, treat- subpopulations. While treatment rates for hyperten-
ment, and monitoring program for adolescents is curial sion and diabetes did not improve over time, BP con-
to ensure that they are receiving the best care available. trol remained relatively stable, and there were numerical
improvements in glycemic control.

Limitations Abbreviations
BMI Body mass index
This study has several limitations. First, misclassification BP Blood pressure
of elevated BP/hypertension, prediabetes/diabetes, and CDC Centers for Disease Control and Prevention
hyperlipidemia may have existed due to the use of self- CI Confidence interval
CVD Cardiovascular disease
reported diagnoses and dependence on single-occasion CVRF Cardiovascular risk factor
physical examination or laboratory testing, possibly lead- FPG Fasting plasma glucose
ing to an overestimation of CVRF prevalence among HbA1c Hemoglobin ­A1c
HDL-C High-density lipoprotein cholesterol
adolescents. Second, recommendations for the definition HEI-2015 Healthy Eating Index-2015
of hypertension and target BP levels have changed over IPR Income to poverty ratio
the entire study period, resulting in a higher prevalence LDL-C Low-density lipoprotein cholesterol
NCHS National Center for Health Statistics
of hypertension and lower treatment and control rates. NHANES National Health and Nutrition Examination Survey
Third, we assessed risk factor treatment and control rely- NIH/NHLBI National Institutes of Health’s National Heart, Lung, and Blood
ing only on medication use, without considering lifestyle Institute
non-HDL-C Non-high-density lipoprotein cholesterol
modifications such as salt-reduced diets and aerobic exer- STROBE  Strengthening the Reporting of Observational Studies in
cise, which are usually taken prior to pharmacologic ther- Epidemiology
apy. Fourth, during 2001–2006, physical activity levels TC Total cholesterol
Qu et al. BMC Medicine (2024) 22:245 Page 14 of 16

Supplementary Information Laboratory for Innovation and Transformation of Luobing Theory, General
Program of National Natural Science Foundation of China (81970339 and
The online version contains supplementary material available at https://​doi.​
82370389), and National Key R&D Program of China (2017YFC1700505). XL
org/​10.​1186/​s12916-​024-​03453-5.
and HZ reported serving as Associate Fellows at the Collaborative Innovation
Center for Cardiovascular Disease Translational Medicine. IC reported serving
Additional file 1: eMethod 1. Therapeutic Drug Classes Used to Define as Post-doctorate Follow at Nanjing Medical University.
Any Use of Antihypertensive and Antidiabetic Medications. eFigure 1.
Inclusion Diagram for US Adolescents Aged 12 to 19 Years, 2001 to March Availability of data and materials
2020. eFigure 2. Age-Adjusted Trends in Mean BP, Hemoglobin ­A1c, FPG, All raw data included in this study are publicly available at https://​wwwn.​cdc.​
TC, HDL-C, Non-HDL-C, LDL-C, Triglycerides Levels, Body Mass Index, gov/​nchs/​nhanes/.
Weekly Exercise Time, and HEI-2015 for US Adolescents Aged 12 to 19
Years, 2001 to March 2020. eFigure 3. Age-Adjusted Trends in Mean BP,
Hemoglobin ­A1c, FPG, TC, HDL-C, Non-HDL-C, LDL-C, Triglycerides Levels, Declarations
Body Mass Index, Weekly Exercise Time, and HEI-2015 for US Adolescents
Aged 12 to 19 Years by Sex, 2001 to March 2020. eFigure 4. Age-Adjusted Ethics approval and consent to participate
Trends in Mean BP, Hemoglobin A ­ 1c, FPG, TC, HDL-C, Non-HDL-C, LDL-C, The NCHS Ethics Review Board approved the study protocol, and written
Triglycerides Levels, Body Mass Index, Weekly Exercise Time, and HEI-2015 informed consent was acquired from all individuals.
for US Adolescents Aged 12 to 19 Years by Race/Ethnicity, 2001 to March
2020. eFigure 5. Age-Adjusted Trends in the Prevalence of Hypertension, Consent for publication
Elevated BP, Diabetes, Prediabetes, Hyperlipidemia, Obesity, Overweight, Not applicable.
Cigarette Use, Inactive Physical Activity, and Poor Diet Quality Among US
Adolescents Aged 12 to 19 Years by Sex, 2001 to March 2020. eFigure 6. Competing interests
Age-Adjusted Trends in the Prevalence of Hypertension, Elevated BP, The authors declare that they have no competing interests.
Diabetes, Prediabetes, Hyperlipidemia, Obesity, Overweight, Cigarette Use,
Inactive Physical Activity, and Poor Diet Quality Among US Adolescents Author details
1
Aged 12 to 19 Years by Race/Ethnicity, 2001 to March 2020. Years by Race/ Present Address: State Key Laboratory for Innovation and Transformation
Ethnicity, 2001 to March 2020. eFigure 7. Age-Adjusted Trends in the of Luobing Theory, Department of Cardiology, The First Affiliated Hospital
Prevalence of High BP and Hypertension Treatment and Control Rates of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
2
Among US Adolescents Aged 12 to 19 Years According to the 2003 NIH/ Department of Cardiology, Gusu School, The Affiliated Suzhou Hospital
NHLBI and 2004 NIH/NHLBI Guidelines, 2001 to March 2020. eTable 1. of Nanjing Medical University, Suzhou Municipal Hospital, Nanjing Medical
Unweighted Response Rates for the NHANES In-Home Interviews and University, 26 Daoqian Street, Suzhou 215002, China. 3 Department of Cardiol-
Mobile Examinations Among US Adolescents Aged 12 to 19 Years by Age ogy, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing 210029, China.
and Sex Groups, 2001 to March 2020. eTable 2. Strengthening the Report-
ing of Observational Studies in Epidemiology (STROBE) Reporting Guide- Received: 2 January 2024 Accepted: 28 May 2024
line for Reporting Cross-sectional Studies Checklist. eTable 3. Classification
of BP by the 2003 NIH/NHLBI, 2004 NIH/NHLBI, 2017 AAP, and 2017 ACC/
AHA Guidelines. eTable 4. Trends in Age-Adjusted Means or % (95% CIs) of
Cardiovascular Parameters, Cardiovascular Risk Factors, and Hypertension
and Diabetes Treatment and Control Among US Adolescents Aged 12 to References
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