Mid-life blood pressure levels and the 8-year incidence of type 2 diabetes mellitus: the Rancho Bernardo Study

Impact of different types of hypertensive disorders of pregnancy and their duration on incident post-partum risk of diabetes mellitus: results from the French nationwide study CONCEPTION

AIMS

To evaluate the impact of onset time, duration, and severity of various types of hypertensive disorders of pregnancy (HDP) on the risk of incident DM.

METHODS

We used data from the ongoing French nationwide prospective cohort study CONCEPTION. We included all primiparous women in CONCEPTION who delivered between 2010 and 2018 (n=2,816,793 women). Follow-up spanned from childbirth to 31 December, 2021. HDP and incident DM onset during follow-up were identified using algorithms combining ICD-10 coded diagnoses during hospitalization and/or medication dispensing. We used Cox models to assess the associations between incident DM and preexisting chronic hypertension, gestational hypertension (GH), and various phenotypes of pre-eclampsia.

RESULTS

Pre-eclampsia and GH alone occurred in 2.6% and 4.6% of the population, respectively. During follow-up (mean=4.5 years), 16,670 women had incident DM. The cumulative incidences of DM were 15.8% and 1.8% in women who had pre-eclampsia during pregnancy with and without concomitant gestational diabetes, respectively. The risk of DM was higher after HDP (all types) irrespective of gestational diabetes status during pregnancy. In women without gestational diabetes, compared with those who had no HDP, the risk of incident DM was higher in women who had GH (adjusted hazard ratio, aHR= 1.97 [1.81-2.16]), pre-eclampsia (aHR=2.42 [2.21-2.65]), and preexisting chronic hypertension prior to pregnancy (aHR=3.35 [3.03-3.70]). Pre-eclampsia duration was significantly associated with a higher risk of DM.

CONCLUSION

Women who experienced an HDP had twice the risk of developing DM. Early blood glucose assessment and blood pressure monitoring should be more widely recommended after HDP diagnosis.

Association between triglyceride-glucose index and hypertension: a cohort study based on the China Health and Nutrition Survey (2009-2015)

AIM

Insulin resistance (IR) may participate in the pathogenesis of hypertension by mediating low-grade systemic inflammation. The triglycerides-glucose (TyG) index has recently been suggested as a reliable alternative biochemical marker of IR compared with traditional methods. Herein, we speculated TyG index may also be associated with hypertension.

METHODS

Data of adults were extracted from the China Health and Nutrition Survey (CHNS) in 2009-2015 in this retrospective cohort study. The TyG index was calculated using the formula: TyG = Ln [fasting triglycerides (mg/dL) ×fasting glucose (mg/dL)/2]. Associations between TyG index and hypertension were evaluated by univariate and multivariate logistic regression analyses with odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses of age and gender were also performed. In addition, we assessed the interaction effect between TyG index and body mass index (BMI) on hypertension in participants with different age and gender.

RESULTS

Among 3,413 eligible participants, 1,627 (47.67%) developed hypertension. The average TyG index in hypertension group and non-hypertension group was 8.58 and 8.39 respectively. After adjusting for covariates, we found that compared with participants with TyG index ≤ 8.41 (median value), those who had higher TyG index seemed to have higher odds of hypertension [OR = 1.17, 95%CI: (1.01-1.37)]. Similarly, this association was also discovered in participants who aged ≤ 65 years old [OR = 1.19, 95%CI: (1.01-1.39)] or were female [OR = 1.35, 95%CI: (1.10-1.65)]. Additionally, there was a potential additive interaction effect between obesity and TyG index on hypertension.

CONCLUSION

High TyG index was associated with high odds of hypertension in general population in China, but the causal relationship between them needed further exploration.

Are Overweight and Obesity Risk Factors for Developing Metabolic Syndrome or Hypertension after a Preeclamptic Event?

OBJECTIVE

To identify the determinants and risks associated with developing hypertension and metabolic syndrome in the first year postpartum in women who experienced preeclampsia.

METHODS

A cohort study was conducted, involving women who had experienced preeclampsia (PE) recently. The control group was women with the same characteristics but a healthy pregnancy. The variables analyzed were somatometry, disease history, pre-pregnancy body mass index (Pre-BMI), and Third Adult Treatment Panel updated (ATP III) metabolic syndrome (MS) data (blood pressure, obesity, triglycerides, high-density lipoproteins, and fasting glucose). These variables were measured at 3, 6, and 12 months postpartum.

RESULTS

Women with a history of PE exhibited higher systolic and diastolic blood pressure than women without PE. The risk of developing isolated diastolic arterial hypertension at 3 and 12 months of follow-up was two to eight times greater in women with a history of PE. Factors associated with having higher blood pressure levels were preeclampsia, insulin resistance, age, and BMI. Neither the pre-BMI index nor gestational weight gain (GWG) had any effect on blood pressure in any of the three assessments. Women with preeclampsia had a 5- to 8-fold increased risk of developing MS (which could be explained not only by the history of preeclampsia but also by the history of pre-pregnancy obesity). However, PE was not identified as a risk factor at the six-month evaluation and was only explained by pre-pregnancy obesity and overweight.

CONCLUSIONS

Obesity and overweight, as well as preeclampsia, were strongly associated with the development of hypertension and metabolic syndrome during the first year following childbirth.

Associations of Midlife and Late-Life Blood Pressure Status With Late-Life Retinal OCT Measures

Purpose

To explore the relationship of long-term blood pressure (BP) patterns with late-life optical coherence tomography (OCT) structural measures reflecting optic nerve health.

Methods

Participants in this community-based cohort study of black and white individuals were part of the Atherosclerosis Risk in Communities study and the nested Eye Determinants of Cognition (EyeDOC) study. Participants had BP measured six times from 1987 to 2017 and were categorized into five BP patterns: sustained normotension; midlife normotension, late-life hypertension (systolic BP [SBP] >140 mmHg or diastolic BP [DBP] >90 mmHg or antihypertensive medication use); sustained hypertension; midlife normotension, late-life hypotension (SBP <90 mmHg or DBP <60 mmHg); and midlife hypertension, late-life hypotension. Multivariable linear regression modeling was used to evaluate associations between BP patterns and late-life OCT ganglion cell complex (GCC) and peripapillary retinal nerve fiber layer (RNFL) thickness.

Results

In total, 931 eyes of 931 participants (mean age at EyeDOC visit = 80 years; 63% female; 45% black) were included. Mean GCC and RNFL thicknesses in the sustained normotension pattern were 90.8 ± 10.3 µm and 89.9 ± 11.2 µm versus 89.4 ± 11.9 µm and 90.1 ± 12.2 µm in the sustained hypertension pattern (P > 0.05). Compared to the sustained normotension pattern, no significant differences in GCC or RNFL thickness were found for any anomalous BP pattern.

Conclusions

Assessment of long-term BP status showed no significant associations with late-life OCT structural measures.

Translational Relevance

OCT imaging results in our population-based sample suggest that neither hypertension, even when present in midlife, nor late-life hypotension are significant risk factors for late-life optic nerve damage.

Insulin Resistance the Hinge Between Hypertension and Type 2 Diabetes

Epidemiological studies have documented a high incidence of diabetes in hypertensive patients.Insulin resistance is defined as a less than expected biologic response to a given concentration of the hormone and plays a pivotal role in the pathogenesis of diabetes. However, over the last decades, it became evident that insulin resistance is not merely a metabolic abnormality, but is a complex and multifaceted syndrome that can also affect blood pressure homeostasis. The dysregulation of neuro-humoral and neuro-immune systems is involved in the pathophysiology of both insulin resistance and hypertension. These mechanisms induce a chronic low grade of inflammation that interferes with insulin signalling transduction. Molecular abnormalities associated with insulin resistance include the defects of insulin receptor structure, number, binding affinity, and/or signalling capacity. For instance, hyperglycaemia impairs insulin signalling through the generation of reactive oxygen species, which abrogate insulin-induced tyrosine autophosphorylation of the insulin receptor. Additional mechanisms have been described as responsible for the inhibition of insulin signalling, including proteasome-mediated degradation of insulin receptor substrate 1/2, phosphatase-mediated dephosphorylation and kinase-mediated serine/threonine phosphorylation of both insulin receptor and insulin receptor substrates. Insulin resistance plays a key role also in the pathogenesis and progression of hypertension-induced target organ damage, like left ventricular hypertrophy, atherosclerosis and chronic kidney disease. Altogether these abnormalities significantly contribute to the increase the risk of developing type 2 diabetes.

Risk of developing pre-diabetes or diabetes over time in a cohort of Mexican health workers

Aim

To determine the association between known risk factors (e.g., obesity, metabolic syndrome and its components) and the development of pre-diabetes or diabetes over time in a cohort of Mexican health workers.

Methods

Participants in the Mexican Health Worker Cohort Study with complete information at two waves of data collection, 2004–2006 (W1) and 2011–2013 (W2), were included in the analysis (n = 1,174). Multivariable binary and multinomial logistic regression were used to examine the cross-sectional associations between specific risk factors and diabetes status (diabetes, pre-diabetes, or neither) at W1 and the longitudinal associations between changes in risk factors and progression of diabetes status from W1 to W2, respectively.

Results

Mean time between waves was 7.0 years (SD 1.1). Prevalence of pre-diabetes and diabetes was 16% and 10% at W1 and increased to 30% and 16% at W2, respectively. The cross-sectional prevalence of pre-diabetes and diabetes was significantly higher among men, participants over the age of 45 years, and individuals who were overweight or obese or had metabolic syndrome (MS), three or more components of the MS, elevated alanine aminotransferase (ALT) levels, or elevated uric acid. In longitudinal analyses, remaining obese or gaining weight between waves was associated with an increased risk of developing pre-diabetes. A greater risk of developing pre-diabetes or diabetes was also observed among individuals who either maintained or acquired MS, elevated ALT, or elevated uric acid (only for diabetes) from W1 to W2.

Conclusions

Weight gain and acquiring or maintaining MS, elevated ALT levels, or elevated uric acid were associated with a significant risk of developing pre-diabetes or diabetes. Our findings, especially in the context of the obesity epidemic in Mexico, point towards an urgent need for initiatives to help reduce excess weight in order to avert future cases of pre-diabetes and diabetes.

Contribution and interaction of the low-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio and triglyceride to diabetes in hypertensive patients: A cross-sectional study

AIMS/INTRODUCTION

Hypertension is one of the most significant risk factors for diabetes. The present study aimed to investigate the associations of lipid profiles, including the ratio of low-density lipoprotein cholesterol (LDL-C)-to-high-density lipoprotein cholesterol (HDL-C) and triglyceride (TG) levels, as well as their interactions, with type 2 diabetes in hypertensive patients.

MATERIALS AND METHODS

Hypertensive patients without a history of diabetes and hypolipidemic agents were enrolled continuously at the Hypertension Clinic, Zhongshan Hospital, Fudan University (Shanghai, China) from 2014 to 2016. General clinical data, including body mass index, blood pressure, fasting glucose and 2-h post-load glucose levels, and lipid profiles, were collected. The LDL-C/HDL-C ratio, TG/HDL-C ratio and TC/HDL-C ratio were separately calculated. Statistical analyses were carried out by using SPSS software (version 13.0).

RESULTS

In total, 935 hypertensive patients were included, of which 114 patients (12.2%) were diagnosed with diabetes. After multivariate adjustments, the LDL-C/HDL-C ratio and TG levels had the most significant and independent associations with diabetes. In the multivariate logistic regression, the LDL-C/HDL-C ratio and TG were independently associated with diabetes. After the interaction variable was included, the LDL-C/HDL-C ratio remained independently associated with diabetes, but TG was replaced by TG*LDL-C/HDL-C.

CONCLUSIONS

In conclusion, elevated LDL-C/HDL-C ratios and TG levels were associated with diabetes in patients with hypertension, with an interactive effect of the LDL-C/HDL-C ratio and TG on diabetes in the hypertensive population.

Body mass index, abdominal adiposity, weight gain and risk of developing hypertension: a systematic review and dose-response meta-analysis of more than 2.3 million participants

OBJECTIVE

This study aimed to test the association between anthropometric measures and risk of developing hypertension.

METHODS

We did a systematic search using PubMed and Scopus, from inception up to January 2017. Prospective cohort studies reporting the risk estimates of hypertension for three or more quantitative categories of indices of general and abdominal adiposity were included. Summary relative risks were calculated using random-effects models.

RESULTS

Fifty-seven prospective cohort studies were included. Summary relative risks were 1.49 (95% confidence interval [CI]: 1.41, 1.58; I²  = 97.4%, n = 50) for a five-unit increment in body mass index, 1.27 (95%CI: 1.15, 1.39; I²  = 95.0%, n = 14) for a 10-cm increment in waist circumference, 1.16 (95%CI: 1.09, 1.23; I²  = 77.8%, n = 5) for weight gain equal to a one-unit increment in BMI, and 1.37 (95%CI: 1.24, 1.51; I²  = 76.4%, n = 8) and 1.74 (95%CI: 1.35, 2.13; I²  = 58.9%, n = 4) for a 0.1-unit increment in waist-to-hip ratio and waist-to-height ratio, respectively. The risk of hypertension increased continuously with increasing all anthropometric measures, and also along with weight gain.

CONCLUSION

Being as lean as possible within the normal body mass index range may be the best suggestion in relation to primary prevention of hypertension.

Different Combinations of Glucose Tolerance and Blood Pressure Status and Incident Diabetes, Hypertension, and Chronic Kidney Disease

Background

The impact of different combinations of glucose tolerance and blood pressure status on the development of type 2 diabetes mellitus (T2DM), hypertension (HTN), and chronic kidney disease (CKD) still needs to be investigated.

Methods and Results

A total of 12 808 Iranian adults aged ≥20 years were included in 3 separate analyses to investigate incidence of T2DM, HTN, and CKD. Multivariate Cox proportional hazard models were used to calculate hazard ratios (95% CI). During a median follow‐up of >10 years, the overall incidence rate for T2DM, HTN, and CKD was 12.2, 29.8, and 24.8 per 1000 person‐years. For incident T2DM, considering normal glucose tolerance/normal blood pressure as reference, prediabetes (PreDM)/HTN had the highest risk (hazard ratio: 7.22 [5.71–9.12]) while PreDM/normal blood pressure also showed a significant risk (5.58 [4.41–7.05]). Furthermore, risk of PreDM/HTN was higher than PreDM/normal blood pressure (P<0.05). For incident HTN, normal glucose tolerance/prehypertension was a strong predictor (3.28 [2.91–3.69]); however, addition of PreDM or T2DM did not increase the risk. For incident CKD, every category that included HTN and/or T2DM showed significant risk; this risk was marginally significant for the PreDM/HTN group (1.19 [0.98–1.43], P=0.06). In addition, PreDM/ normal blood pressure was a marginally significant risk factor for incident HTN while normal glucose tolerance/prehypertension was a significant predictor of T2DM.

Conclusions

Presence of HTN was associated with increased risk of T2DM among the PreDM population; however, dysglycemia did not increase the risk of HTN among individuals with prehypertension. For incident CKD, intensive management of HTN and T2DM, rather than their predisease states, should be considered.

Revisiting the prehypertension debate: increasing evidence for treatment yet randomized clinical trials are lacking

In 2009, Blood Pressure featured a debate about whether to treat patients with prehypertension (Kiely et al., Blood Press. 2009;18:300-303; McInnes GT, Blood Press. 2009;18:304-307). Our group supported pharmacotherapy for this condition at that time. Since then, additional evidence linking prehypertension with associated morbidities has emerged. These studies are detailed below and provide further evidence for the treatment of prehypertension.

Higher maternal body mass index is associated with an increased risk for later type 2 diabetes in offspring

OBJECTIVES

To investigate whether the body mass index (BMI) of a child's mother is associated with an increased future risk of type 2 diabetes, independent of genetic risk or childhood metabolic, behavioral, and environmental factors.

STUDY DESIGN

The analyses were based on the Cardiovascular Risk in Young Finns Study including 1835 individuals aged 3-18 years at baseline with data on maternal BMI, childhood metabolic factors, as well as 34 newly identified type 2 diabetes susceptibility alleles. These subjects were then followed-up over 21-27 years.

RESULTS

Maternal BMI (OR for 1-SD increase 1.54 [95% CI 1.12-2.11], P = .008) and child's systolic blood pressure (1.54 [1.01-2.35], P = .04) were significantly associated with increased odds for later type 2 diabetes, in a multivariable analysis adjusted for age, sex, type 2 diabetes genetic risk score, childhood BMI, insulin, lipids, dietary factors, socioeconomic status, and mother's age, and history of type 2 diabetes. A risk prediction model, which included maternal BMI status outperformed one which utilized only child's BMI data (area under the receiver operating characteristic curve 0.720 vs 0.623, P = .02). The inclusion of genetic risk score and other baseline risk variables did not additionally improve prediction (area under the receiver operating characteristic curve 0.720 vs 0.745, P = .40).

CONCLUSIONS

Maternal BMI is a useful variable in determining offspring risk of developing type 2 diabetes.

High-normal blood pressure and long-term risk of type 2 diabetes: 35-year prospective population based cohort study of men

BACKGROUND

The link between type 2 diabetes and hypertension is well established and the conditions often coexist. High normal blood pressure, defined by WHO-ISH as systolic blood pressure (SBP) 130-139 mm Hg or diastolic blood pressure (DBP) 85-89 mm Hg, has been found to be an independent predictor for type 2 diabetes in studies, although with relatively limited follow-up periods of approximately 10 years. The aim of this study was to investigate whether hypertension, including mildly elevated blood pressure within the normal range, predicted subsequent development of type 2 diabetes in men over an extended follow-up of 35 years.

METHODS

Data were derived from the Gothenburg Primary Prevention Study where a random sample of 7 494 men aged 47-55 years underwent a baseline screening investigation in the period 1970-1973. A total of 7 333 men were free from previous history of diabetes at baseline. During a 35-year follow-up diabetes was identified through the Swedish hospital discharge and death registries. The cumulative risk of diabetes adjusted for age and competing risk of death was calculated. Using Cox proportional hazard models we calculated the multiple adjusted hazard ratios (HR) (95% confidence interval (CI)) for diabetes at different blood pressure levels.

RESULTS

During a 35-year follow-up, 956 men (13%) were identified with diabetes. The 35-year cumulative risk of diabetes after adjusting for age and competing risk of death in men with SBP levels <130 mm Hg, 130-139 mm Hg, 140-159 mm Hg and ≥160 mm Hg were 19%, 30%, 31% and 49%, respectively. The HR for diabetes adjusted for age, body mass index (BMI), cholesterol, antihypertensive treatment, smoking, physical activity and occupation were 1.43 (95% CI 1.12-1.84), 1.43 (95% CI 1.14-1.79) and 1.95 (95% CI 1.55-2.46) for men with SBP 130-139 mm Hg, 140-159 mm Hg, and ≥ 160 mm Hg, respectively (reference; SBP<130 mm Hg).

CONCLUSION

In this population, at mid-life, even high-normal SBP levels were shown to be a significant predictor of type 2 diabetes, independently of BMI and other conventional type 2 diabetes risk factors over an extended follow-up.

Evaluation of the National Kidney Foundation of Hawai'i's Kidney Early Detection Screening program

PURPOSE

Discussion of the formative program evaluation results of the National Kidney Foundation of Hawai'i (NKFH) Kidney Early Detection Screening (KEDS) program for Chronic Kidney Disease (CKD). The formative program evaluation had 921 participants who enrolled in the NKFH KEDS screening program between 2006-2009. The evaluation included 14 KEDS sites in Honolulu, Maui, and Hawai'i counties.

MAIN FINDINGS

Based on the results of the formative evaluation, process changes were made to program recruitment, training, and procedure. A majority of participants were women, between 46 and 75 years old. The ethnic groups represented were: White, Japanese, Hawaiian/Part Hawaiian, Filipino, Chinese, Hispanic, and Other. The three most common risk factors identified were: (1) blood relative with diabetes, (2) blood relative with cardiovascular disease, and (3) self-reported high blood pressure. Participants in Hawai'i County had the highest mean for total risk factors. Ethnicity, gender, and age were significantly associated with selected vital signs, physiological measures, and lab tests. Fourteen percent of KEDS participants had an abnormal albumin:creatinine (A:C) ratio and 12% had an abnormal glomerular filtration rate (GFR), requiring follow-up by a health care professional.

PRINCIPAL CONCLUSIONS

The KEDS formative program evaluation findings improved program planning and implementation. Summative program evaluation and implications for conducting research studies in this area will be the next step in the evaluation process.

Body mass index in a large cohort of patients assigned to age decades between <20 and ≥80 years: relationship with cardiovascular morbidity and medication

OBJECTIVE

There is an ongoing debate about the relationship between obesity and morbidity in the elderly, the clinical relevance of overweight and obesity in older patients and the need or harms of treatment. The main purpose of our study was to investigate whether a higher BMI is associated with a worse cardiovascular risk in all age groups, especially in the older ones.

SUBJECTS AND DESIGN

We performed a retrospective evaluation of clinical data from 3926 patients who visited a medical outdoor center for diagnostic and/or therapeutic interventions in the period from January 1995 to July 2010. Patients were assigned to eight age groups of one decade from <20 years to ≥80 years.

RESULTS

The Body Mass Index (BMI) of our patients showed a continuous increase with increasing age with peak values in the age decade 61-70 years (26.29 ±4.42 kg/m2). This was paralleled by an increase in cardiovascular events and need for continuous medication, demonstrating peak values in the age decade 61-70 years (22.3% in the female and 24.7% in the male group). In all age decades up to 80 years the BMI values were higher in patients with events compared to those without it. multivariable linear regression analysis - including confounding variables (blood pressure, fasting glucose, HDL-cholesterol, triglycerides, physical activity, smoking) - revealed for all age groups a strong positive relation of BMI and a negative relation of fat free mass (FFM) to the probability for a cardiovascular event and need for medication.

CONCLUSION

In all age groups, the percentage of cardiovascular events was directly correlated with the BMI. Having in mind the transition to an aging society, therapeutic and preventive strategies should, therefore, include weight management strategies also for the elderly.

Accuracy of anthropometric indexes of obesity to predict diabetes mellitus type 2 among men and women with hypertension

BACKGROUND

Anthropometric measurements and indexes that assess excess of adiposity are associated with cardiovascular risk factors, and predict diabetes mellitus.

METHODS

This cross-sectional study reported the performance of adiposity indexes to detect or turn diabetes unlikely in patients with hypertension. Patients with hypertension (blood pressure (BP) ≥140/90 mm Hg or antihypertensive drug use) aged 18-80 years, being 150 men and 332 women, had weight, height, waist circumference (WC), hip circumference, body mass index (BMI), waist-hip ratio (WHR), waist-to-height ratio (WHtR), and waist-to-square height ratio (WHt(2)R) calculated. Diabetes was diagnosed by fasting blood glucose ≥126 mg/dl or antidiabetic drug use (23% of the sample).

RESULTS

All anthropometric indexes were associated with diabetes in a modified Poisson regression, adjusting for age, smoking, and physical activity, in women, but not in men. In men, only the area under the receiver-operating characteristic curve (AUC) for WHR was statistically associated with diabetes (0.67, 95% confidence interval (CI) 0.57-0.77). A cutoff of ≥0.95 had sensitivity of 84.6% (73.3-95.9) and negative post-test probability of 12.8% (3.2-22.4). Among women, WC >88 cm, WHR ≥0.85, and WHtR > 0.54 had sensitivity >93% and negative post-test probability <7.5%.

CONCLUSIONS

WHR ≥0.85, WC >88.0 cm, and WHtR >0.54 for women and WHR ≥0.95 for men are highly suggestive of diabetes among this population of hypertensive patients. Indexes below these cutoffs turn diabetes unlikely in this context. The investigation of reproducibility of this performance in other outpatient clinics is warranted.