Unhealthy behavior and risk of uncontrolled hypertension in treated individuals - the CONSTANCES population-based study (2024)

Basic characteristics of the study population

Bord1presents the basic characteristics of the studied participants, which were compared between subjects with controlled and uncontrolled hypertension. The mean ± standard deviation (SD) age of the population was 59.8 ± 8.6. Unhealthy behavior was prominent; the majority of participants (91.3%) did not follow dietary recommendations to a high degree, more than two-thirds (70%) were obese (body mass index ≥25), 15% drank heavy alcohol, and 10.2% were sedentary.

Of the 10,710 hypertensive-treated participants, 6003 had uncontrolled hypertension, achieving a prevalence of poor blood pressure control of 56.1%. Uncontrolled hypertension was more common in men than in women (62.9% versus 47.9%, respectively, p < 0.001) and with increasing age categories with the highest prevalence observed in people over 65 years of age (63.1%). After adjustment for age and gender, uncontrolled hypertension was more common in participants with lower education (46.8% vs. 41.3%, p < 0.001), who were in a relationship (78% vs. 73.8%, p < 0.001), with diabetes (17.4)% vs. 13.1%, p < 0.001) or with dyslipidemia (62.2% vs. 57%, p < 0.001). It was less common in those with previous CVD (11.8% vs. 14.7, p < 0.001). Regarding lifestyle factors, those who are overweight or obese and those with heavy alcohol consumption have a significantly higher prevalence of uncontrolled hypertension (p < 0.001 for both variables), while high dietary adherence is associated with a lower frequency. Interestingly, inverse associations were seen with physical activity and smoking status: those with high levels of physical activity (p = 0.008) were more likely to have uncontrolled hypertension, while current smokers appear to be more likely to have controlled hypertension (p < 0.001). Globally, 56.3% of subjects received one antihypertensive drug, while 34.3% received dual therapy and 9.4% received three or more medications; those with uncontrolled hypertension were less likely to receive monotherapy and more likely to receive dual or triple (or more) therapy (p = 0.001).

Characteristics and unhealthy behavior

Figure1illustrates the frequency of unhealthy behaviors in participants with and without uncontrolled hypertension. Also tables2In​in 33presents the characteristics of men and women respectively, depending on the number of unhealthy behaviors. Globally, unhealthy behaviors were more common among men, with 22.7% reporting three or more unhealthy behaviors, compared to 11% of women (p < 0.001). Among participants with uncontrolled hypertension, 2.0%, 24.5%, 54.0%, and 19.5% exhibited 0, 1, 2, or ≥3 unhealthy behaviors, respectively. Minimal differences were seen between genders in the associations studied; An age-adjusted analysis shows that an increasing number of unhealthy behaviors is associated with lower monthly household income (p < 0.001), lower education (p < 0.001), the presence of dyslipidemia or diabetes (p trend < 0.001) and current smoking status (p) < 0.001).

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Figure 1

Proportion of subjects based on the number of unhealthy behaviors, stratified by gender.

Uncontrolled blood pressure and unhealthy behavior

The association between uncontrolled high blood pressure and diet, physical activity, body mass index (BMI), alcohol consumption and number of unhealthy behaviors is described in Table4for men and in an additional table for women. In men, there was no major difference between the associations found after adjustment for age, monthly income and education level (model 1) and after further adjustment for diabetes and dyslipidemia (model 2). In other words, the associations found significant in model 1 remained significant in model 2. However, in women, the association between individual unhealthy lifestyle factors and uncontrolled hypertension did not reach statistical significance and is available in the Supplementary Table.1.

With regard to dieting, men who reported low or moderate adherence to the diet had a 1.26-fold (adjusted odds ratio (ORa) 1.26, 95% confidence interval (CI) 1.04-1.53 ) and 1.41-fold (ORa 1.41, 95% CI 1.17.) increase in the odds of uncontrolled hypertension compared to people with high diet adherence. Similarly, the odds of uncontrolled hypertension increased 1.25 times (1.09–1.43) and 1.57 times (1.35–1.83) in overweight and obese men, respectively, compared with normal BMI . Furthermore, there was a significant association between alcohol consumption and uncontrolled hypertension (p = 0.003); Men who consumed heavy alcohol had a 1.34-fold increase in the odds of uncontrolled hypertension compared with light/never drinkers (ORa 1.34, 95% CI 1.10–1.63). The association remained significant when dichotomizing the variable and comparing heavy drinking with moderate/light drinking (ORa 1.35, 95% CI 1.09–1.44; p = 0.01). Furthermore, in both sexes there was a significant increase in age-adjusted mean systolic blood pressure with light, moderate and heavy alcohol consumption: in women, mean systolic blood pressure was ± SD in the categories 134.6 ± 4.8, 135.5 ± 4 , 2 and ±2 , 136.1 ± 4, < 0.001), and in men this was 134.9 ± 4.6, 135.7 ± 4.0 and 136.4 ± 3.6, respectively (p < 0.001). Regarding physical activity, there was an unexpected inverse association between sedentary physical activity and uncontrolled hypertension. Furthermore, the prevalence of uncontrolled hypertension increased with the number of unhealthy lifestyle factors only in men (p < 0.001). Those who reported three or more unhealthy behaviors had a 1.67-fold (1.09-2.53) increase in the odds of uncontrolled hypertension.

Study design and study population

Details on objectives and study design for the CONSTANCES cohort (http://www.constances.fr/index_EN.php) has been previously published^15,32. Briefly, CONSTANCES is a prospective epidemiological cohort composed of randomly selected adult participants aged 18–69 years at baseline, linked to the French National Health Insurance Fund (CNAM) database; General scheme covering 85% of the general French population ) following a stratified sampling scheme. across age, gender, socio-economic status and region in France.

Volunteers who agreed to participate in the study were required to complete self-administered questionnaires and were invited to participate in one of 22 selected health screening centers (HSCs) to benefit from a comprehensive health screening. They were also linked through French administrative and national social databases in the health field. Social, demographic, health, behavioral, occupational, biological, and anthropometric data were collected through these various sources. All participants in the CONSTANCES cohort signed an informed consent form. This study follows the principles of the Declaration of Helsinki and was approved by the National Data Protection Authority (National Commission for Information Technology and Freedoms; CNIL) en de Institutional Review Board van het National Institute for Medical Research en het Local Committee for Personal Protection (Committee for the Protection of Human Beings).

Studying participants

The current study is a cross-sectional analysis of participants who were known to have hypertension, registered by the physician or measured during the medical examination at the HSC, and who were receiving antihypertensive medications. Of a total of 87,808 voluntary participants recruited between February 2012 and January 2018 and for whom data were available through linkage to the health insurance administrative database, 10,764 subjects met the above definition and were eligible for inclusion in the current analysis. We excluded 54 participants with a BMI <18 kg/m2²and therefore we analyzed 10,710 hypertensive-treated participants.

Uncontrolled blood pressure

Blood pressure measurements were performed based on Standard Operating Procedures (SOPs)³³during the clinical research at HSC. Systolic and diastolic blood pressure were measured using an automated oscillometric blood pressure monitor in each arm at 2-minute intervals and after 5 minutes of rest. The arm yielding the highest systolic blood pressure was considered the reference arm and after 1 minute of rest, a third blood pressure measurement was taken, taking into account the average of these 2 measurements. Uncontrolled blood pressure was defined as mean systolic blood pressure ≥140 mm Hg and/or mean diastolic blood pressure ≥90 mm Hg³⁴.

Definitions of behavioral risk factors

Lifestyle factors were assessed using validated self-administered questionnaires. They were described and classified based on a previous study that evaluated the link between unhealthy behaviors and the risk of high blood pressure²⁴. Similarly, unhealthy behavior was defined as in the original study²⁴. The lifestyle factors are also presented here.

Alcohol usewas determined taking into account the amount and type of alcoholic beverages consumed in the previous week³⁵. We defined subsequent alcohol consumption as never/light (0–3 drinks/week (0–30 g/week) for men and 0–2 (0–20 g/week) for women), moderate (4–21 (40–20 g/week) ) 210 g/week) drinks/week for men and 3-14 (30-140 g/week) for women) and heavy drinkers (>21 drinks/week (>210 g/week) for men and > 14 (>140 g) /week) for women)³⁶. Heavy drinking was considered unhealthy behavior.

Fysical activitywas assessed using three questions related to the frequency of exercise, leisure activities and sports³⁷. We assigned 0, 1, or 2 points to each question based on increasing frequency of activity. A score of 0–6 was then calculated and physical activity level was classified as sedentary (0–2), moderately active (3–4). ), and very active (5-6). Sedentary level was considered unhealthy behavior³⁷.

Diet assessmentwas done using a validated 52-item food frequency questionnaire (FFQ), from which a DASH score was constructed based on 8 food groups or nutrients for which consumption should be increased (fruits, vegetables, nuts and legumes, low-fat dairy products, whole grains) or reduced (sodium, sweetened drinks, red and processed meat)³⁸. Consumption of each dietary component was divided into quintiles and participants' intakes were assigned 1–5 points according to a gender-specific intake ranking.^38,39. Component scores were summed and a total DASH score of 8–40 was calculated. The DASH score was then divided into tertiles for analysis; a higher tertile indicates higher diet quality, compliance with dietary recommendations was then divided into low, medium and high. We considered a low/medium diet as unhealthy behavior.

BMI(BMI, kg/m2²) was calculated by HSC and then divided into three classes: normal (≤25 kg/m²), overweight (25 kg/m²2), and obese (≥30 kg/m²). We took overweight/obesity into account (BMI >25 kg/m2).²) an unhealthy behavior.

Accordingly, participants could engage in 0 (none), 1, 2, 3, or 4 unhealthy behaviors.

Covariate

Covariates were defined and classified as the original analysis²⁴and they include the following. Education level was collected according to the International Standard Classification of Education (ISCED)⁴⁰and were then classified into three levels: high school diploma or less (≤13 years of education), bachelor's degree (14–16 years of education), and postgraduate degree (≥17 years of education). Marital status was divided into married or single (including widowed or divorced/divorced). Household monthly income was divided into: <1000; 1000-2099; 2100-4199; ≥ 4200 euros per month.

Blood sugar, triglycerides and total cholesterol were measured by taking fasting blood samples at HSC. Diabetes mellitus status was based on the use of antidiabetic drugs or a fasting blood glucose concentration greater than or equal to 7 mmol/l. Dyslipidemia was defined as a fasting total cholesterol or triglyceride level of ≥6.61 mmol/L (255 mg/dL) or >1.7 mmol/L (150 mg/dL), respectively. History of CV disease was considered as any self-reported previous diagnosis of angina pectoris, myocardial infarction, cerebrovascular accident or peripheral artery disease¹⁴. Chronic kidney disease was defined as known proteinuria or impaired renal function (creatinine clearance <60 ml/min calculated by the co*ckroft-Gault equation) for more than 3 months.⁴¹or chronic kidney disease, diagnosed by biopsy or ultrasound of the kidneys and confirmed by a nephrologist.

Statistical analysis

Descriptive analysis was performed using counts and percentages or mean ± SD. Each characteristic was compared between subjects with controlled and uncontrolled hypertension using logistic regressions adjusted for age and sex. In addition, we compared characteristics of subjects based on the number of unhealthy behaviors using logistic regressions adjusted for age and stratified by gender. We also use logistic models to estimate the association between uncontrolled high blood pressure and unhealthy behavior. In a first step, the models were adjusted for age, education and monthly income (model 1). In a second step, the models were further adjusted for diabetes and dyslipidemia (model 2). Initially, we ran separate models for each unhealthy behavior using categorical and binary variables. We next examined the association between uncontrolled hypertension and the number of unhealthy behaviors (0 ≥ 3) independently associated with hypertension control. A general linear model was used to study age-adjusted mean systolic blood pressure across an increasing number of unhealthy factors. Adjusted odds ratios (ORa) were presented along with a 95% confidence interval (CI), all statistical analyzes were performed using SAS 9.4 (SAS Institute) and p ≤ 0.05 was considered significant.

Editor's NoteSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

These authors contributed equally: Michelle Cherfan and Alexandre Vallée.

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