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Diabetes, Hypertension, and the Mediating Role of Lifestyle: A Cross-Sectional Analysis in a Large Cohort of Adults

      Introduction

      Whether diabetes is associated with hypertension risk remains controversial, potentially owing to the confounding effect of lifestyle. This study aims to analyze the association between diabetes and hypertension in adults and the mediating impacts of lifestyle.

      Methods

      A cohort of Spanish workers (aged 18–64 years) insured by an occupational risk prevention company participated in this nationwide cross-sectional study between 2012 and 2016 (data analysis was performed in 2021). Participants’ lifestyle‒related factors—BMI, sleeping hours, alcohol, smoking, and physical activity—were assessed, and the prevalence of hypertension and diabetes was registered.

      Results

      A total of 451,157 participants (33.1% women, aged 44.5 [SD=9.2] years, 3.2% with diabetes, and 29.3% with hypertension) with complete data for all variables were assessed. Having diabetes was associated with a higher prevalence of hypertension even after adjusting for all lifestyle-related factors (OR=1.44, 95% CI=1.43, 1.48), and people with diabetes and hypertension had a higher prevalence of mild kidney function impairment than people with diabetes alone (OR=1.06, 95% CI=1.01, 1.13). However, people with diabetes and an optimal lifestyle—normal weight and sleeping hours, absent-to-little alcohol drinking, nonsmoking, and regular physical activity—presented a prevalence of hypertension comparable with that of those without diabetes (OR=1.00, 95% CI=0.71, 1.32). In separate analyses among people with diabetes, an optimal lifestyle was associated with a lower prevalence of hypertension than the worse—opposite—lifestyle (OR=0.29, 95% CI=0.18, 0.53). The lifestyle-related factors showing the strongest inverse association with adjusted risk of hypertension were normal weight (OR=0.49, 95% CI=0.42, 0.53 versus overweight/obesity) and regular physical activity (OR=0.79, 95% CI=0.74, 0.82 versus inactivity).

      Conclusions

      Diabetes is positively and largely independently associated with hypertension risk. Yet, a healthy lifestyle can attenuate this association.
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      REFERENCES

        • Chen V
        • Ning H
        • Allen N
        • et al.
        Lifetime risks for hypertension by contemporary guidelines in African American and White men and women.
        JAMA Cardiol. 2019; 4: 455-459https://doi.org/10.1001/jamacardio.2019.0529
        • Virani SS
        • Alonso A
        • Benjamin EJ
        • et al.
        Heart disease and stroke statistics-2020 update: a report from the American Heart Association.
        Circulation. 2020; 141: e139-e596https://doi.org/10.1161/CIR.0000000000000757
        • Molinero A
        • Calvo E
        • Beaney T
        • et al.
        May Measurement Month 2019: an analysis of blood pressure screening results from Spain.
        Eur Heart J Suppl. 2021; 23: B138-B140https://doi.org/10.1093/eurheartj/suab060
        • Ko GT
        • Cockram CS
        • Chow CC
        • et al.
        Effects of body mass index, plasma glucose and cholesterol levels on isolated systolic hypertension.
        Int J Cardiol. 2005; 101: 429-433https://doi.org/10.1016/j.ijcard.2004.03.059
        • Sprafka JM
        • Bender AP
        • Jagger HG.
        Prevalence of hypertension and associated risk factors among diabetic individuals. The three-city study.
        Diabetes Care. 1988; 11: 17-22https://doi.org/10.2337/diacare.11.1.17
        • Lastra G
        • Syed S
        • Kurukulasuriya LR
        • Manrique C
        • Sowers JR.
        Type 2 diabetes mellitus and hypertension: an update.
        Endocrinol Metab Clin North Am. 2014; 43: 103-122https://doi.org/10.1016/j.ecl.2013.09.005
        • Sowers JR
        • Epstein M
        • Frohlich ED.
        Diabetes, hypertension, and cardiovascular disease: an update [published correction appears in Hypertension. 2001;37(5):1350].
        Hypertension. 2001; 37: 1053-1059https://doi.org/10.1161/01.hyp.37.4.1053
        • de Boer IH
        • Bangalore S
        • Benetos A
        • et al.
        Diabetes and hypertension: a position statement by the American Diabetes Association.
        Diabetes Care. 2017; 40: 1273-1284https://doi.org/10.2337/dci17-0026
        • Sasaki N
        • Ozono R
        • Higashi Y
        • Maeda R
        • Kihara Y.
        Association of insulin resistance, plasma glucose level, and serum insulin level with hypertension in a population with different stages of impaired glucose metabolism.
        J Am Heart Assoc. 2020; 9e015546https://doi.org/10.1161/JAHA.119.015546
        • Sun D
        • Zhou T
        • Heianza Y
        • et al.
        Type 2 diabetes and hypertension.
        Circ Res. 2019; 124: 930-937https://doi.org/10.1161/CIRCRESAHA.118.314487
        • da Silva AA
        • do Carmo JM
        • Li X
        • Wang Z
        • Mouton AJ
        • Hall JE.
        Role of hyperinsulinemia and insulin resistance in hypertension: metabolic syndrome revisited.
        Can J Cardiol. 2020; 36: 671-682https://doi.org/10.1016/j.cjca.2020.02.066
        • Valenzuela PL
        • Carrera-Bastos P
        • Gálvez BG
        • et al.
        Lifestyle interventions for the prevention and treatment of hypertension.
        Nat Rev Cardiol. 2021; 18: 251-275https://doi.org/10.1038/s41569-020-00437-9
        • Arshi B
        • Tohidi M
        • Derakhshan A
        • Asgari S
        • Azizi F
        • Hadaegh F.
        Sex-specific relations between fasting insulin, insulin resistance and incident hypertension: 8.9 years follow-up in a Middle-Eastern population.
        J Hum Hypertens. 2015; 29: 260-267https://doi.org/10.1038/jhh.2014.70
        • Fernández-Navarro P
        • Sanz-Anquela JM
        • Sánchez Pinilla A
        • Arenas Mayorga R
        • Salido-Campos C
        • López-Abente G
        Detection of spatial aggregation of cases of cancer from data on patients and health centres contained in the Minimum Basic Data Set.
        Geospat Health. 2018; 13: 616https://doi.org/10.4081/gh.2018.616
        • Williams B
        • Mancia G
        • Spiering W
        • et al.
        2018 ESC/ESH Guidelines for the management of arterial hypertension [published correction appears in Eur Heart J. 2019;40(5):475].
        Eur Heart J. 2018; 39: 3021-3104https://doi.org/10.1093/eurheartj/ehy339
        • Association American Diabetes
        Diagnosis and classification of diabetes mellitus [published correction appears in Diabetes Care. 2010;33(4):e57].
        Diabetes Care. 2010; 33: S62-S69https://doi.org/10.2337/dc10-S062
        • Levey AS
        • Stevens LA
        • Schmid CH
        • et al.
        A new equation to estimate glomerular filtration rate [published correction appears in Ann Intern Med. 2011;155(6):408].
        Ann Intern Med. 2009; 150: 604-612https://doi.org/10.7326/0003-4819-150-9-200905050-00006
        • Valenzuela PL
        • Santos-Lozano A
        • Barrán AT
        • et al.
        Joint association of physical activity and body mass index with cardiovascular risk: a nationwide population-based cross-sectional study [published correction appears in Eur J Prev Cardiol. 2021;28(14):1620–1621].
        Eur J Prev Cardiol. January 26, 2021; (In press. Online)https://doi.org/10.1093/eurjpc/zwaa151
        • Bull FC
        • Al-Ansari SS
        • Biddle S
        • et al.
        World Health Organization 2020 guidelines on physical activity and sedentary behaviour.
        Br J Sports Med. 2020; 54: 1451-1462https://doi.org/10.1136/bjsports-2020-102955
        • Salgado C
        • Azevedo C
        • Proença H
        • Vieira S.
        Missing data.
        Secondary Analysis of Electronic Health Records. 1st ed. Springer, Cham, Switzerland2016: 143-162
        • Whelton PK
        • Carey RM
        • Aronow WS
        • et al.
        2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Hypertension. 2018;71(6):e140–e144].
        Hypertension. 2018; 71: e13-e115https://doi.org/10.1161/HYP.0000000000000065
        • Lai TS
        • Curhan GC
        • Forman JP.
        Insulin resistance and risk of incident hypertension among men.
        J Clin Hypertens (Greenwich). 2009; 11: 483-490https://doi.org/10.1111/j.1751-7176.2009.00160.x
        • Goff Jr, DC
        • Zaccaro DJ
        • Haffner SM
        • Saad MF
        Insulin Resistance Atherosclerosis Study. Insulin sensitivity and the risk of incident hypertension: insights from the insulin Resistance Atherosclerosis Study.
        Diabetes Care. 2003; 26: 805-809https://doi.org/10.2337/diacare.26.3.805
        • Niemann B
        • Rohrbach S
        • Miller MR
        • Newby DE
        • Fuster V
        • Kovacic JC.
        Oxidative stress and cardiovascular risk: obesity, diabetes, smoking, and pollution: part 3 of a 3-Part Series.
        J Am Coll Cardiol. 2017; 70: 230-251https://doi.org/10.1016/j.jacc.2017.05.043
        • Kayama Y
        • Raaz U
        • Jagger A
        • et al.
        Diabetic cardiovascular disease induced by oxidative stress.
        Int J Mol Sci. 2015; 16: 25234-25263https://doi.org/10.3390/ijms161025234
        • Cohen RA
        • Tong X.
        Vascular oxidative stress: the common link in hypertensive and diabetic vascular disease.
        J Cardiovasc Pharmacol. 2010; 55: 308-316https://doi.org/10.1097/fjc.0b013e3181d89670
        • Xu M
        • Huang Y
        • Xie L
        • et al.
        Diabetes and risk of arterial stiffness: a Mendelian randomization analysis.
        Diabetes. 2016; 65: 1731-1740https://doi.org/10.2337/db15-1533
        • Zhu Z
        • Zheng Z
        • Zhang F
        • et al.
        Causal associations between risk factors and common diseases inferred from GWAS summary data.
        Nat Commun. 2018; 9: 224https://doi.org/10.1038/s41467-017-02317-2
        • Aikens RC
        • Zhao W
        • Saleheen D
        • et al.
        Systolic blood pressure and risk of type 2 diabetes: a Mendelian randomization study.
        Diabetes. 2017; 66: 543-550https://doi.org/10.2337/db16-0868
        • Mbanya JC
        • Thomas TH
        • Wilkinson R
        • Alberti KG
        • Taylor R.
        Hypertension and hyperinsulinaemia: a relation in diabetes but not essential hypertension.
        Lancet. 1988; 1: 733-734https://doi.org/10.1016/S0140-6736(88)91538-3
        • Cosentino F
        • Grant PJ
        • Aboyans V
        • et al.
        2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD [published correction appears in Eur Heart J. 2020;41(45):4317].
        Eur Heart J. 2020; 41: 255-323https://doi.org/10.1093/eurheartj/ehz486
        • Liu X
        • Zhang D
        • Liu Y
        • et al.
        Dose–response association between physical activity and incident hypertension: a systematic review and meta-analysis of cohort studies.
        Hypertension. 2017; 69: 813-820https://doi.org/10.1161/HYPERTENSIONAHA.116.08994
        • Poorolajal J
        • Hooshmand E
        • Bahrami M
        • Ameri P.
        How much excess weight loss can reduce the risk of hypertension?.
        J Public Health (Oxf). 2017; 39: e95-e102https://doi.org/10.1093/pubmed/fdw077
        • Santos-Lozano A
        • Barrán AT
        • Fernández-Navarro P
        • et al.
        Association between physical activity and cardiovascular risk factors: dose and sex matter.
        J Sport Health Sci. 2021; 10: 604-606https://doi.org/10.1016/j.jshs.2021.03.002
        • Chandra A
        • Neeland IJ
        • Berry JD
        • et al.
        The relationship of body mass and fat distribution with incident hypertension: observations from the Dallas Heart Study.
        J Am Coll Cardiol. 2014; 64: 997-1002https://doi.org/10.1016/j.jacc.2014.05.057
        • Astuti A
        • Karwiky G
        • Tiksnadi B
        • et al.
        Waist circumference has a stronger correlation with hypertension compare to body mass index in rural coast area.
        J Hypertens. 2015; 33: e18https://doi.org/10.1097/01.hjh.0000469780.63844.0f
        • Ashwell M
        • Gunn P
        • Gibson S.
        Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: systematic review and meta-analysis.
        Obes Rev. 2012; 13: 275-286https://doi.org/10.1111/j.1467-789X.2011.00952.x
        • Itani O
        • Jike M
        • Watanabe N
        • Kaneita Y.
        Short sleep duration and health outcomes: a systematic review, meta-analysis, and meta-regression.
        Sleep Med. 2017; 32: 246-256https://doi.org/10.1016/j.sleep.2016.08.006
        • Roerecke M
        • Tobe SW
        • Kaczorowski J
        • et al.
        Sex-specific associations between alcohol consumption and incidence of hypertension: a systematic review and meta-analysis of cohort studies.
        J Am Heart Assoc. 2018; 7e008202https://doi.org/10.1161/JAHA.117.008202
        • Panagiotakos DB
        • Kourlaba G
        • Zeimbekis A
        • Toutouzas P
        • Polychronopoulos E.
        The J-shape association of alcohol consumption on blood pressure levels, in elderly people from Mediterranean Islands (MEDIS epidemiological study).
        J Hum Hypertens. 2007; 21: 585-587https://doi.org/10.1038/sj.jhh.1002187
        • Gillman MW
        • Cook NR
        • Evans DA
        • Rosner B
        • Hennekens CH.
        Relationship of alcohol intake with blood pressure in young adults.
        Hypertension. 1995; 25: 1106-1110https://doi.org/10.1161/01.hyp.25.5.1106
        • Costanzo S
        • Di Castelnuovo A
        • Donati MB
        • Iacoviello L
        • de Gaetano G.
        Wine, beer or spirit drinking in relation to fatal and non-fatal cardiovascular events: a meta-analysis.
        Eur J Epidemiol. 2011; 26: 833-850https://doi.org/10.1007/s10654-011-9631-0
        • Linneberg A
        • Jacobsen RK
        • Skaaby T
        • et al.
        Effect of smoking on blood pressure and resting heart rate: a Mendelian randomization meta-analysis in the CARTA Consortium.
        Circ Cardiovasc Genet. 2015; 8: 832-841https://doi.org/10.1161/CIRCGENETICS.115.001225