More than 1 in 5 US adults with hypertension now has both diabetes and high cholesterol. Yet only about 1 in 4 has all three conditions under control, according to an analysis published in the Journal of the American College of Cardiology (JACC).

Using National Health and Nutrition Examination Survey data from 1999 to 2023, researchers found that treatment and control of cardiometabolic conditions improved early in the 2000s but plateaued after about 2010. These findings came even as the prevalence of diabetes and obesity continued to rise.

Among patients with hypertension, diabetes, and hyperlipidemia, only 26.3% achieved control of all three conditions from 2021 to 2023 — a figure that has not improved significantly in more than a decade (P = .769).

Experts say the findings reflect a broader shift in cardiovascular disease driven by metabolic risk. For example, another study published in December 2025 showed that obesity and diabetes have become highly prevalent among those with heart failure.

“These findings underscore a rapidly evolving shift from ischemic to metabolic drivers of heart failure,” John Ostrominski, MD, a fellow in Cardiovascular Medicine and Obesity Medicine at Brigham and Women’s Hospital in Boston, wrote in an editorial accompanying that study.

Rising obesity and dysglycemia are reshaping cardiovascular risk profiles nationwide, he added.

Hyeok-Hee Lee, MD, PhD, lead author of the recent JACC analysis and an advanced hypertension and vascular medicine research fellow at Beth Israel Deaconess Medical Center in Boston, said clinicians must first recognize how often cardiometabolic risk factors such as diabetes, hyperlipidemia, and obesity cluster around hypertension.

“Only with this awareness can physicians be more vigilant when seeing patients with hypertension and proactively screen for the full spectrum of cardiometabolic disorders,” Lee told Medscape Medical News.

Growing Burden of Metabolic Disease

Among adults with hypertension, diabetes prevalence increased from 17.2% in 1999-2000 to 27.8% in 2021-2023 (P < .001).

In the most recent survey period, 73.1% of adults with hypertension had hyperlipidemia, despite a small overall decline over time (P = .008).

The share of adults with hypertension who had both diabetes and high cholesterol nearly doubled, from 12.5% in 1999-2000 to 21.3% in 2021-2023 (P < .001).

Obesity increased from 43.7% to 52.4% during the study period (P < .001). High-risk alcohol use also increased modestly (P = .024), but smoking rates remained stable (P = .789).

“These comorbidities in isolation are significant drivers of premature cardiovascular events and are additive when present together,” Lee said.

Cardiologists say delayed diagnosis remains a major barrier to improving outcomes. 

“Unfortunately, we see that a lot,” said Nishant Shah, MD, preventive cardiologist and associate professor of medicine at Duke University Hospital, Durham, North Carolina, who was not involved in the study. “Oftentimes, these conditions aren’t even diagnosed.”

He added that many patients do not recognize symptoms early.

“In most cases, you don’t feel those conditions,” Shah said. “If patients haven’t been formally diagnosed, they often won’t know that they have them.”

Access to care is also a barrier for many patients, according to Marwa Sabe, MD, associate director in the section of Advanced Heart Failure and Transplant Cardiology at Beth Israel Deaconess Medical Center. Sabe was not involved in the study. 

“This may stem from a combination of financial constraints, lack of reliable transportation, and significant delays in establishing care with primary care physicians and specialists,” Sabe said.

Why Progress Has Stalled

Treatment rates for cardiometabolic disease rose through the late 2000s but stopped improving afterward, the study found.

Eric A. Secemsky, MD, director of vascular intervention in the Cardiovascular Institute at Beth Israel Deaconess Medical Center and co-author of the study, said growing patient complexity has outpaced traditional care models.

“Most of the past efforts for cardiometabolic risk control have focused on individual risk factors in isolation,” Secemsky said. “But patients are now more complex, often living with multiple cardiometabolic conditions at the same time, living longer, and having a higher risk of obesity and inactivity.”

As a result, older treatment approaches may no longer be sufficient.

“Hypertension should no longer be considered or managed in isolation but rather as part of an interconnected cardiometabolic milieu that requires comprehensive management,” he added.

Among patients with both hypertension and diabetes, the proportion of those receiving treatment for both conditions increased from the beginning of the study period but plateaued at 71.6% in 2021-2023. However, only 31.2% achieved control of both blood pressure and glucose levels in 2021-2023, with no significant improvement after 2007-2008 (P = .216).

Among patients with hypertension and high cholesterol, 50.4% received treatment for both conditions in recent years, but only 32.3% achieved control of both (P = .109).

Patients with all three conditions fared worst. Although 62.1% received treatment for hypertension, diabetes, and high cholesterol in recent years, only 26.3% achieved control of all three.

Lee said that medication burden likely contributes to poor adherence.

“Treatment adherence becomes a major challenge when patients are dealing with multiple risk factors,” he said. “Strategies that simplify regimens, such as polypills or device-based therapies, may help reduce pill burden and hence improve adherence.”

Blood pressure control showed a similar pattern. Treatment increased from 2009 to 2010 but plateaued at 75.5% in 2021-2023. Only about half of the patients achieved blood pressure below 140/90 mm Hg.

Mean systolic blood pressure declined early in the study period but stabilized afterward. In 2021-2023, the average systolic blood pressure measured 136 mm Hg.

Underuse of Newer Therapies

Younger adults, women, and uninsured people were less likely to receive treatment for all three cardiometabolic conditions, according to the study. Control rates were also lower among women, patients with lower income, and those without health insurance.

The authors said these gaps highlight the need for a broader approach to cardiovascular risk management.

Although use of newer therapies — such as GLP-1 receptor agonists, SGLT2 inhibitors, and statins — increased over time, the population-level impact on overall risk control remains limited.

“Clinicians need to be more proactive about using these therapies,” Lee said. “Uptake of GLP-1 receptor agonists remains surprisingly low, despite strong evidence of its health benefits.”

Shah said system-level coordination will be critical to improving outcomes.

“We’re a team,” he said. “Whoever sees the patient first should feel empowered to make changes toward their care.”

Sabe agreed, saying that “the best medicine includes prevention and early intervention.”

“Patient education and early screening are probably the most important steps providers can take to prevent poor outcomes in the long term,” said Sabe.

Sabe reported having consulted for Novo Nordisk. Lee, Secemsky, and Ostrominski reported having no relevant disclosures.

Lara Salahi is a health journalist based in Boston.