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Determinants of hypertension among diabetic patients in southern Ethiopia: a case-control study

Abstract

Background

Hypertension, among diabetic patients, is a worldwide public-health challenge and a number one modifiable risk factor for other cardiovascular diseases and death. The prevalence of hypertension among the diabetic population is nearly twice of nondiabetic patients. Screening and prevention of risk factors for hypertension based on evidence from local studies is required to minimize the burden of hypertension among diabetic patients. This study is aimed at assessing the determinants of hypertension among diabetic patients in Wolaita Sodo University Comprehensive Specialized Hospital, Southern Ethiopia, 2022.

Methods

Facility-based unmatched case-control study design was conducted from March 15 to April 15, 2022, at the outpatient diabetic clinic, Wolaita Sodo University Comprehensive Specialized Hospital. A total of 345 diabetic patients were selected using systematic random sampling techniques. Data were collected using a structured questionnaire by interviewing and extracting from the medical chart of patients. Bivariate logistic regression followed by multiple logistic analysis was used to identify the determinants of hypertension among diabetic patients. A p-value less than 0.05 is considered to be statistically significant.

Results

The significant determinants of hypertension among diabetes patients were being overweight [AOR = 2.06, 95% CI (1.1, 3.89), P = 0.025], being obese [AOR = 2.64, 95% CI (1.22, 5.70), P = 0.013], lack of Moderate intensity exercise [AOR = 2.41, 95% CI (1.36,4.24), P = 0.002], age [AOR = 1.03, 95% CI (1.01, 1.06), P = 0.011], Type 2 diabetes mellitus [AOR = 5.05, 95% CI (1.28, 19.88), P = 0.021], duration of diabetes mellitus ≥ 6 years [AOR = 7.47, 95% CI (2.02, 27.57), P = 0.003], diabetic nephropathy [AOR = 3.87, 95% CI (1.13, 13.29), P = 0.032], and urban residence [AOR = 2.11, 95% CI (1.04,4.29), P = 0.04].

Conclusion

Being overweight and obese, lack of moderate-intensity exercise, age, type 2 diabetes mellitus, duration of Diabetes ≥ 6 years, presence of diabetic nephropathy, and being urban residents were significant determinants of hypertension among diabetic patients. These risk factors can be targeted by health professionals for prevention and earlier detection of hypertension among diabetic patients.

Peer Review reports

Background

Hypertension, defined as a sustained systolic and diastolic blood pressure greater than 140/90 Millimeters of mercury (mmHg), is common among both type 1 and type 2 diabetes [1]. This definition is predicated on unambiguous data that levels above this threshold are strongly related to mortality and morbidity due to Atherosclerotic Cardiovascular Disease (ASCVD), and microvascular complications as well as antihypertensive treatment in populations with baseline systolic and diastolic blood pressure above this range reduces the occurrence of ASCVD events and microvascular complications. The “sustained” aspect of the hypertension definition is vital, as blood pressure measurements have a considerable normal variation [2].

Atherosclerotic Cardiovascular Disease (ASCVD) is defined as an acute coronary syndrome, myocardial infarction (MI), angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease presumed to be of atherosclerotic origin is the number one cause for morbidity and mortality of people with diabetes and is that the largest contributor to the direct and indirect costs of diabetes. Microvascular complications include diabetic nephropathy, retinopathy, and neuropathy [3, 4].

Diabetes mellitus is a chronic medical condition that is characterized by raised blood glucose levels as a result of very little or no insulin hormone production or insulin resistance in the body. There are three main types of diabetes namely type 1, type 2, and gestational diabetes mellitus. Type 1 diabetes mostly causes diabetes in children but can occur at any age. Type 2 diabetes accounts for the majority which is around 90% of diabetes worldwide. Gestational diabetes mellitus is a type of diabetes where the diagnosis is first made during pregnancy [5].

Hypertension (HTN) is common among patients with diabetes, with the prevalence differing with type and duration of diabetes, age, sex, race/ethnicity, body mass index, history of glycemic control, and the presence or absence of a renal problem, among other factors [6,7,8]. In addition, Hypertension among diabetic patients remains a strong modifiable risk factor for atherosclerotic diseases, and microvascular complications. Hence, Blood pressure should be measured at every routine clinical care visit for diabetic patients and risk factors for increased blood pressure should be prevented and controlled accordingly [9].

Hypertension and diabetes mellitus have become major public health problems globally, and both are significant risk factors for Atherosclerotic Cardiovascular Disease (ASCVD). Globally, nearly one billion people have HTN; of these, 76% are in developing countries and it is predicted that by 2025, up to 1.56 billion adults worldwide will be hypertensive [10]. Hypertension causes approximately 7.5 million mortality annually, accounting for 57 million disability-adjusted life years, and for about 6% of mortality worldwide [11, 12]. Additionally, diabetes mellitus (DM) is growing at the fastest proportion globally, with the number of adult diabetes population increased more than three times over the past 20 years. The global estimate of the adult diabetes population was 151 million in 2000. By 2009 it had increased by 88% to 285 million. In 2019, International Diabetes Federation calculated that 9.3% of adults aged 20–79 years which is around 463 million people are living with diabetes. Ethiopia is one of the four African countries with the highest number of diabetes (1.7 million) in adults 20–79 years of age [5].

Hypertension, among diabetic patients, is a worldwide public health problem [13]. The diabetic population is nearly twice more affected by hypertension as non-diabetic patients [14]. Compared with other cardiovascular disorders, HTN is the leading comorbid disease in diabetic patients and its effects are devastating if not controlled [15, 16]. Different studies in Africa have shown a high prevalence of Hypertension among diabetic patients. A study conducted in Kenya reported that 50% of diabetic patients had HTN [17]. Another study in Nigeria reported that 54.2% of diabetic individuals had HTN [18]. Similarly, According to the studies conducted in Ethiopia, the prevalence of hypertension among diabetic patients was 59.5% (Debre Tabor) [19], 56.3% (Adama) [20], and 46.5%(Jimma) [21].

The occurrence of both hypertension (HTN) and diabetes mellitus (DM) significantly increases the risk of developing macrovascular complications, leading to a higher incidence of coronary heart disease, heart failure, peripheral arterial disease, and stroke, and also increases the risk of microvascular complications, such as nephropathy or retinopathy [22].In addition, the development of HTN in diabetic individuals complicates the treatment plan and increases the costs associated with health care [23].

Up to 80% of people with diabetes will die of cardiovascular disease, especially HTN and stroke [24, 25]. The presence of both hypertension and DM contributes to the risk of death and cardiovascular events by 44% and 41%, respectively, as compared to 7% and 9% of these risks in people with diabetes alone [26].

The United Kingdom Prospective Diabetes Study demonstrated that blood pressure control results in the prevention of cardiovascular complications in patients with diabetes. Each 10 mmHg decrease in mean systolic blood pressure brings about a 12% reduction of any complication related to diabetes and a 15% reduction in mortality related to diabetes [27]. Older age, overweight/obesity, unhealthy diet, lack of physical exercise, smoking, family history of hypertension, and being an urban resident are major risk factors for HTN [28,29,30,31].

The coexistence of hypertension and diabetes has not been given adequate attention in many low-resource setting countries like Ethiopia. In some parts, this is mainly due to health care being stretched by other priorities like Human Immune deficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), tuberculosis, and malaria. However, the urbanization of the country has created a change within the lifestyles of the population related to nutrition, physical activities, and behaviors like smoking, alcohol, and drug use among urban dwellers, which increases the likelihood of developing non-communicable diseases (NCDs) like hypertension and diabetes. Therefore, it’s time to deal with NCDs particularly the coexistence of hypertension and diabetes.

Moreover, Hypertension is the most important modifiable risk factor for coronary heart disease, stroke, congestive heart failure, end-stage renal disease, and peripheral vascular disease. These risks are more prevalent and serious in diabetic patients. Many Sub-Saharan African countries, including Ethiopia, lack detailed basic data on the determinants of hypertension among diabetic patients [32]. There are few studies on the prevalence of hypertension among diabetes patients, however, published information on determinants of hypertension among diabetes patients is sparse. To date, there is a lack of published evidence regarding the determinants of hypertension among diabetic patients in the Wolaita Zone. Hence, this study aimed at assessing the determinants of hypertension among diabetic patients in Wolaita Sodo University Comprehensive Specialized Hospital, southern Ethiopia.

Methods

Study setting and period

The study was conducted from March 15 to April 15, 2022, at Wolaita Sodo University Comprehensive Specialized Hospital which is located in Sodo town, Wolaita Zone, Southern Ethiopia, 329 km from Addis Ababa, the capital city of Ethiopia [33].

Study design

Facility-based Unmatched case-control study design was conducted.

Study population

All diabetic patients who were attending the diabetic clinic at Wolaita Sodo University Comprehensive Specialized Hospital for follow-up during the study period were involved in this study. The cases are all diabetic patients diagnosed with hypertension and the controls are all diabetic patients without hypertension who meet the eligibility criteria.

Eligibility criteria

Inclusion criteria

All diabetic patients aged ≥ 18 years and who had been following up at a diabetic clinic during the study period were included in the study.

Exclusion criteria

Patients who were severely ill, pregnant women, not able to communicate, and developed hypertension before diabetes were excluded from the study.

Sample size determination

The sample size was calculated by using EPI Info software version 7.2.3.1 with the following Parameters: significance = 95%; power = 80%; Adjusted odds ratio (AOR) = 3.9. The Case to control ratio is taken to be 1:2 and The proportion of controls with exposure was 4%. The odds ratio was taken from a study conducted in Debre tabor, Northwest Ethiopia, taking current smoking status as a risk factor for hypertension resulting in the maximum sample size of 311 [19]. Assuming a non-response rate of 10%, the sample size for cases and controls was found to be 115 and 230, respectively, which gave us a total sample of 345.

Sampling procedure and technique

A systematic random sampling technique was used to select the study subjects. There were 40 patients on average will be seen daily in the diabetic clinic which gives a total of 880 diabetic patients in one-month duration. Two sampling intervals (Ks), one for cases and one for controls, were calculated by dividing the number of cases (250) and controls (630) of the population (N) by their respective number of cases (115) and controls (230) of the sample (n). So, the sampling interval (K) became 2. Therefore, the subjects were selected for every K interval (K = 2) of cases and controls, and the first study subjects were selected by lottery method.

Study variables

Dependent variables: The presence or absence of hypertension among diabetic patients is the dependent variable.

Independent variables: The independent variables were socio-demographic factors (sex, age, education status, residence, marital status, occupation, ethnicity, and religion), behavioral risk factors (cigarette smoking, alcohol drinking, and chat chewing), health profiles (type and duration of DM, Diabetic self-care practice and family history of HTN and others), and nutritional risk factors (heavy salt consumption, overweight and obesity).

Data collection tools and procedures

Data was collected by interviewing the study participants and extracting from the medical chart of patients using a structured questionnaire after getting verbal informed consent from the participants. Questionnaires were developed by reviewing different relevant literature. A review of the diabetic patients’ records was conducted to identify cases and controls. Cases and controls were recorded by identification number. Before data collection, the study subjects were identified as cases and controls based on the identification number by the supervisor. The data collectors were blinded to the status of the respondent and they were unable to identify the study subject as case and control.

The questionnaire had three parts: part I, social demographic data and health profile data; part II, Risk factors like behavioral and nutritional factors; and part III, Physical measurement, laboratory tests, and diabetic complications. Laboratory tests were analysed for blood glucose, total cholesterol and HDL cholesterol using CardioCheck PA Analyser and for Triglycerides levels using Cobas Integra 400 Plus (Roche Diagnostics GmbH, Mannheim, Germany) clinical chemistry analyser. The variables that were taken from the medical chart of patients include duration with diabetes since diagnosis, type of diabetes, the presence of complications, and fasting blood sugar during the first diagnosis of diabetic patients of both cases and controls.

Operational definitions

Hypertension - the average of casual systolic blood pressure readings ≥ 140 mmHg and/or diastolic pressure readings ≥ 90 mmHg [1].

Body Mass Index (BMI) - Underweight: BMI < 18.5 kg/m2; Normal weight: 18.5 ≤ BMI < 25; Overweight: 25 ≤ BMI < 30; obesity BMI ≥ 30 [34].

Waist Circumference: High risk ≥ 94 cm in men and 80 cm in women; substantially high risk > 102 cm in men and > 88 cm in women [35].

Waist to Hip ratio (WHR): Substantially high ≥ 0.90 cm in men and ≥ 0.86 cm in women [35].

Waist-to-height ratio (WHtR): Values for both sexes: low risk 0.40–0.49, high risk 0.50–0.59, and substantially high risk ≥ 0.60 [36].

Glycemic control: Glycemic status was considered as good glycemic control if an average of four consecutive fasting blood glucose measurements 80–130 mg/dL and poor glycemic control if an average of blood glucose values on four consecutive visits were > 130 or < 80 mg/dL [37].

Diabetes Self-care practice: It is a daily activity that the individual patients were performed to manage diabetes on their behalf (dietary practice, exercise, medication, daily foot care, monitoring blood glucose). Diabetes self-care practice was assessed by participants’ responses to the 15-item Summary of Diabetes Self-Care Activities (SDSCA) in the last 7 days. Response choices for each question were range from 0 to 7 based on the number of days on which the indicated behavior was performed. The overall mean score was estimated by the summation of each item of the scale and divided by the total number of questions. Therefore, after calculating the overall mean score, participants who scored equal to or greater than the mean score were classified as having good diabetes self-care practice and those who scored below the mean were considered as having poor self-care practice [38].

Regular exercise: defined in this study as moderate-intensity aerobic physical activity(walking and running) for at least 30 min at least 5 days a week or at least 150 min/per week [39].

Excess salt consumption: people who reported every use of top-added salt on a plate [40].

Heavy Alcohol Consumption - Refers to the average consumption of more than 5 standard alcoholic drinks per day for men (≈ 50gm of alcohol) or > 4 alcoholic drinks (or 40gm of alcohol) for women. A standard alcoholic drink is the equivalent of one glass/can/bottle (330ml) of regular beer (with 3% ethanol), one glass (100ml) of wine (10% ethanol), or one glass or measure (40ml) of distilled spirit, each of which adds up to about 10 g of ethanol per drink [41].

Current Smokers: A person who smokes any quantity of cigarettes in the last 12 months was labeled as a current smoker [42].

Khat chewing: Khat chewer was defined as khat chewing at least once a week while occasional use was defined as khat chewing less than once a week [43].

Data quality management

The questionnaire was initially prepared in English, and it was translated into Amharic. This questionnaire, prepared in Amharic, was translated back to English to ensure consistency. Data were collected by three nurses (B.Sc.) and two supervisors (B.Sc. /M.Sc.). The training was given to data collectors by the principal investigator and supervisors.

The questionnaire was pre-tested on 5% of the total sample size a week before the actual data collection in Dubo Hospital which is located in Areka town, Wolaita Zone, Southern Ethiopia. Furthermore, the principal investigator and supervisors gave feedback and corrections on daily basis to the data collectors. Completion, accuracy, consistency, and clarity of the collected data were checked regularly.

Weight (in kilograms) was measured in light clothing and without shoes using calibrated standard beam balance that is used for weight measurement in the medical setup. The scale pointer was checked at zero before taking every measurement. The weight of the study participant was measured to the nearest 0.1 kg using a standing beam balance. Height was measured using Stadiometer in centimeters (cm) in an erect position in which the back of the head, shoulder blades, buttocks, and heels make contact with the backboard at a precision. The measurement was recorded to the nearest 0.1 cm. Body mass index was calculated as weight in kilograms divided by the square of height in meters (kg/m2) [44].

Waist and hip circumferences were measured using a non-stretch tape meter with 0.1 cm precision. Waist circumference was measured by placing a tape measure around the bare abdomen at the midpoint between the lower margin of the last palpable rib and the top of the iliac crest of the hip bone. Hip circumference was measured by placing a tape measure around the hip at the maximum circumference over the buttocks or around the greater trochanter of the femoral bone. The waist-to-hip ratio (WHR) and Waist to height ratio (WHtR) were calculated using measurements of waist, hip circumferences, and height [45].

Data processing and analysis

The collected data were entered into Epi data version 4.6.0.2 and analyzed using Statistical Package for Social Science (SPSS) version 25. Percentages and frequencies were used to summarize categorical variables. The results were presented by tables and graphs based on the nature of the variable. The distribution of the continuous variables was checked for normality distribution. Mean with standard deviation and median with interquartile range were used to summarize normally and non-normally distributed continuous variables respectively.

Analysis using a bivariate logistic regression model was used to see the association between the explanatory variables and the outcome variable. This was followed by multivariable logistic regression analysis using those variables with a P-value of 0.2 or less in the bivariable analysis. To check the goodness of fit of the statistical model, the Hosmer-Lemeshow test was used. Multicollinearity was assessed by the Tolerance test and variance inflation factor. The Odds ratio with 95% CI was used to measure the strength between the dependent and the independent variables. A p-value less than 0.05 was used to determine the level of statistical significance.

Results

Socio-demographic characteristics of the respondents

A total of 115 diabetic patients who had hypertension (cases) and 230 DM patients who had no hypertension (controls) were included with a response rate of 100%. The mean (± SD) age was 55.1 (± 11.9) years for cases and 44.3 (± 13.8) years for controls. Forty-eight cases (41.7%) and 85 (37.0%) controls were female participants. Most of the cases (85.2%) and controls (61.3%) were living in urban areas. Most of the cases (62%) and controls (70%) attended only secondary education or less. In addition, most of the cases (98.3%) and controls (87%) were married. While 30% (30.4%) of the cases were housewives then followed by government employees and private work, only 24% (24.3%) of the control were in private work then followed by government employees and housewives (Table 1).

Table 1 Socio-demographic characteristics of people with diabetes on follow-up at Wolaita Sodo University Comprehensive Specialized Hospital, Southern Ethiopia, 2022

Health profile of the respondents

The median (IQR) reported duration of DM from the diagnosis was 8 [5, 14] years in cases and 5 [2, 10] years in controls. 15% of the cases and 5.2% of the controls reported a family history of HTN. The majority of the cases (97.4%) and controls (72.2%) were having type two DM. Of the study participants, 44.3% of the cases and 48.7% of the controls reported using insulin. The majority of cases (41.7%) but only a few of the control (23%) were overweight and a higher percentage of cases (27.8) as compared to controls (13%) were obese (Table 2).

Table 2 Health profile of people with diabetes on follow-up at Wolaita Sodo University Comprehensive Specialized Hospital, Southern Ethiopia, 2022

Metabolic risk factors of hypertension

The median SBP (Q1, Q3) of the cases were 146 (136,155) mmHg in cases and 126 (121,134) mmHg in controls. Then, the median DBP (Q1, Q3) of the cases was 85 (79, 92) mmHg in cases and 79 (73, 85) mmHg in controls (Table 3).

Table 3 Metabolic factors of people with diabetes on follow-up at Wolaita Sodo University Comprehensive Specialized Hospital, Southern Ethiopia, 2022

Determinants of hypertension among Diabetic patients

The bivariate logistic regression model was used to see the association between the explanatory variables and the outcome variable. Then, eleven variables were selected for the multivariable logistic regression analysis using the P value less than 0.2 from the bivariate logistic regression. These included Age, Place of residence, type of DM, duration of DM, family history of Hypertension, family history of DM, smoking history, moderate-intensity exercise, BMI, diabetic nephropathy, and diabetic retinopathy. The crude and adjusted odds ratios along with their 95% confidence interval were determined. Then, a P-value less than or equal to 0.05 was considered to be statistically significant.

Multiple logistic regression analysis results identified no significant difference among cases and control for the variables including a family history of hypertension, family history of DM, ever-smoked tobacco products, and diabetic retinopathy in this study.

Based on the result of the multivariable logistic regression analysis, the following variables were found to be independent determinants of hypertension among diabetic individuals at a P value less than 0.05: Age, place of residence, type of DM, Duration of DM, Moderate intensity exercise, BMI, diabetic nephropathy and diabetic retinopathy (Table 4). The model fitness was checked by Hosmer and Lemeshow test (chi-square = 8.843) with P-value = 0.356, and overall 82.7% of variables were correctly classified.

Being overweight and obese were significantly associated with hypertension among diabetic patients. The odds of hypertension were 2.06 times higher among overweight diabetic individuals than those with normal weight [AOR = 2.06, 95% CI (1.1, 3.89), P = 0.025]. Similarly, obese individuals with diabetes had about 2.64 times higher odds of developing hypertension when compared with normal weight [AOR = 2.64, 95% CI (1.22, 5.70), P = 0.013].

Moderate-intensity exercise was significantly associated with lower odds of hypertension among diabetic individuals. Diabetic individuals with a lack of moderate-intensity exercise had about 2.4 times higher odds to develop hypertension [AOR = 2.41, 95% CI (1.36, 4.24), P = 0.002].

Age was another significant independent determinant of hypertension among diabetic patients. For each one-year increase in age, there was a 3% increased odds of developing hypertension among diabetic patients [AOR = 1.03, 95% CI (1.01, 1.06), P = 0.011].

The type and duration of diabetes was also significant determinant of hypertension among the diabetes population. Type 2 DM patients had 5 times higher odds of developing hypertension when compared to type 1 DM patients [AOR = 5.05, 95% CI (1.28, 19.88), P = 0.021]. Similarly, the odds of hypertension were 7 times higher when the duration of DM is longer than 5 years since diagnosis [AOR = 7.47, 95% CI (2.02, 27.57), P = 0.003].

The presence of diabetic nephropathy was another independent risk factor for the development of hypertension in diabetic patients. The odds of hypertension were around four times higher among diabetic nephropathy patients when compared to individuals without diabetic nephropathy [AOR = 3.87, 95% CI (1.13, 13.29), P = 0.032].

Finally, being an urban resident had been found as an independent risk factor for the development of hypertension among diabetic patients. The odds of hypertension among urban residents were two times higher than the rural residents in this study [AOR = 2.11, 95% CI (1.04, 4.29), P = 0.04] (Table 4).

Table 4 Multivariable logistic regression analysis results of determinants of hypertension among diabetic people on follow-up at Wolaita Sodo University Comprehensive Specialized Hospital, Southern Ethiopia, 2022

Discussion

This study identified Overweight, Moderate intensity exercise, Age, Type and duration of DM, diabetic nephropathy, and urban dwellers as independent determinants of hypertension among diabetic individuals in Wolaita Sodo University Comprehensive Specialized Hospital, Southern Ethiopia,2022.

Being overweight and obese were significantly associated with hypertension among diabetic patients. The odds of hypertension were 2.06 times higher among overweight diabetic individuals than those with normal weight. Similarly, obese individuals with diabetes had about 2.64 times higher odds of developing hypertension when compared with normal weight. This is consistent with previous studies conducted in Nigeria [46], Iraq [47], and Ethiopia [48, 49]. Several mechanisms relate obesity to hypertension including dietary factors, vascular injury, renal dysfunction, sympathetic over-activation, inappropriate RAAS activation, structural and functional abnormalities in the kidney and heart, insulin resistance, and Immune dysfunction [50].

Moderate-intensity exercise was significantly associated with lower odds of hypertension among diabetic individuals. Diabetic individuals with a lack of moderate-intensity exercise had about 2.4 times higher odds to develop hypertension. This result is consistent with previous studies done in different countries [51,52,53,54]. Different epidemiological studies have shown decrement in both systolic and diastolic pressure in the general population with moderate-level intensity exercisers. Moderate-intensity exercise is beneficial and recommended for both the prevention and treatment of hypertension [55]. The proposed mechanisms by which moderate-intensity exercise reduces blood pressure include increased insulin sensitivity, beneficial changes in autonomic nervous system function, and vasoconstriction regulations [51].

Age was another significant independent determinant of hypertension among diabetic patients. For each one-year increase in age, there was a 3% increased odds of developing hypertension among diabetic patients. This finding is similar with studies done in Netherland [56] ,Morocco [57], United Arab Emirates [58], Libya [59] and Ethiopia [60, 61]. When their age increases, individuals will adopt a sedentary lifestyle and gain weight which predisposes them to hypertension. Age is one of the non-modifiable risk factors of hypertension increasing peripheral vascular resistance associated with atherosclerotic changes in the vessels [55].

The type and duration of diabetes were other significant determinant of hypertension among the diabetes population. Type 2 DM patients had 5 times higher odds of developing hypertension when compared to type 1 DM patients. Similarly, the odds of hypertension were 7 times higher when the duration of DM is longer than 6 years since diagnosis. This finding is similar to studies done in different countries [6,7,8, 30]. Although there is a higher prevalence of hypertension and other cardiovascular diseases among Type 2 DM, Type 1 DM patients are still at higher risk, particularly with a longer duration of DM. This is explained partly by the obesity epidemic, glycemic control, pathology in the arterial wall, abnormal inflammation cascade, and atherosclerosis [6].

The presence of diabetic nephropathy was another independent risk factor for the development of hypertension in diabetic patients. The odds of hypertension were around four times higher among patients with diabetic nephropathy when compared to individuals without diabetic nephropathy. Hypertension is one of the leading comorbidity of patients with CKD. This result is consistent with different studies conducted in different countries [62,63,64]. The prevalence of hypertension among CKD patients increases with a progressive decline in renal function [65]. Hypertension may develop as a result of kidney disease and the presence of hypertension also worsens further decline of renal function [55]. The mechanism of hypertension in kidney disease is related to decreased capacity of the kidney to excrete sodium, hypersecretion of renin, and increased activation of the sympathetic nervous system [66].

Finally, being an urban resident had been found as an independent risk factor for the development of hypertension among diabetic patients. The odds of hypertension among urban resident was two times higher than the rural residents in this study. This finding is similar to studies done in India [67], Ghana [68], and Ethiopia [19, 31]. urbanization has created a change in the lifestyles of the population related to nutrition, physical activities, and behaviors like smoking, alcohol, and drug use among urban dwellers, which increases the likelihood of developing hypertension [69, 70]. The development of hypertension is influenced by various environmental factors associated with urbanization including dietary factors, physical activity, and alcohol intake [22].

Strength and limitation of the study

The design of the study used a case-control study to evaluate the determinant of hypertension is one of the strengths of the study. The other strength of the study is the recruitment of the large sample size in the study. The study also included multiple potential risk factors to determine their association with the development of hypertension. The study also utilized different data collection methods including interviews, medical chart review, and measurements.

The limitation of the study includes the fact that arises from the very nature of case-control design which is difficult to determine the temporal association between the outcome and risk factors. It is also a single facility-based study. Random and systemic measurement errors may also affect the result in variables reported by the individual.

Conclusions

Hypertension, among diabetic patients, is a worldwide public-health challenge and a number one modifiable risk factor for other cardiovascular diseases and death. The prevalence of hypertension among the diabetic population is nearly twice of nondiabetic patients. Hence, Screening and prevention of risk factors for hypertension based on evidence from local studies is required to minimize the burden of hypertension among diabetic patients.

This study has identified Overweight and obesity, Moderate intensity exercise, Age and type and duration of DM, diabetic nephropathy, and urban residence as independent determinants of hypertension among diabetes patients. These risk factors can be targeted for effective screening and prevention of hypertension in diabetic patients.

These research findings suggest screening and prevention of hypertension can be intensified among type two diabetic Patients and diabetic patients with a longer duration of the disease. Moderate-intensity exercise for at least thirty minutes per day for at least five days per week can be prescribed for all diabetic patients. Overweight and obese patients can also be enrolled in weight reduction interventions and given close follow-up to prevent hypertension in these high-risk groups.

Moderate-intensity exercise and prevention of overweight and obesity are also important modifiable risk factors that can be applied on large scale to prevent hypertension in diabetic patients. Large-scale screening and detection programs can be implemented in these high-risk groups to tackle this problem at the community level. Healthcare professionals, public health professionals, and nutrition professionals can expand this recommendation to a large scale to produce a significant result in the prevention and management of hypertension in diabetic patients.

In addition, further Multicenter studies can be studied to investigate risk factors across large sample sizes and different study settings to determine the risk factors for the determinant of hypertension among the diabetic population. This can increase the knowledge of risk factors as well as possible intervention strategies from large-scale studies in different study settings which can be extrapolated to the population level.

Data Availability

The datasets used and analysed during the current study are available from the corresponding author upon reasonable request. The questionnaire used in this study is included in the Supplementary file.

Abbreviations

AOR:

Adjusted Odds Ratio

ASCVD:

Atherosclerotic Cardiovascular Disease

BMI:

Body Mass Index

CI:

Confidence Interval

COR:

Crude Odds Ratio

DM:

Diabetes mellitus

HIV/AIDS:

Human Immune deficiency Virus/Acquired Immune Deficiency Syndrome

HTN:

Hypertension

mmHg:

Millimeters of Mercury

MI:

Myocardial Infarction

NCDs:

Non-Communicable Diseases

SD:

Standard deviation

SPSS:

Statistical Package for Social Science

WHO:

World Health Organization

References

  1. American Diabetes A. 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2021. Diabetes care. 2021;44(Suppl 1):S125-S50.

  2. de Boer IH, Bangalore S, Benetos A, Davis AM, Michos ED, Muntner P, et al. Diabetes and hypertension: a position Statement by the american Diabetes Association. Diabetes Care. 2017;40(9):1273–84.

    Article  PubMed  Google Scholar 

  3. Brunström M, Carlberg B. Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses. BMJ. 2016;352.

  4. Ettehad D, Emdin CA, Kiran A, Anderson SG, Callender T, Emberson J, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. The Lancet. 2016;387(10022):957–67.

    Article  Google Scholar 

  5. International Diabetes F. International Diabetes Federation. IDF Diabetes Atlas. 9th ed. Brussels, Belgium: International Diabetes Federation; 2019.

    Google Scholar 

  6. De Ferranti SD, De Boer IH, Fonseca V, Fox CS, Golden SH, Lavie CJ, et al. Type 1 diabetes mellitus and cardiovascular disease: a scientific statement from the American Heart Association and American Diabetes Association. Circulation. 2014;130(13):1110–30.

    Article  PubMed  Google Scholar 

  7. Fox C, Golden S, Anderson C, Bray G, Burke L, De Boer I, American Heart Association Diabetes Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Clinical Cardiology, Council on Cardiovascular and Stroke Nursing, Council on Cardiovascular Surgery and Anesthesia, Council on Quality of Care and Outcomes Research; American Diabetes Association, et al. Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence: a scientific statement from the American Heart Association and the american Diabetes Association. Diabetes Care. 2015;38(9):1777–803.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Arauz-Pacheco C, Parrott MA, Raskin P. Treatment of hypertension in adults with diabetes. Diabetes Care. 2003;26:80.

    Article  Google Scholar 

  9. Gæde P, Oellgaard J, Carstensen B, Rossing P, Lund-Andersen H, Parving H-H, et al. Years of life gained by multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: 21 years follow-up on the Steno-2 randomised trial. Diabetologia. 2016;59(11):2298–307.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. The Lancet. 2005;365(9455):217–23.

    Article  Google Scholar 

  11. Kotchen TA. Hypertension control: trends, approaches, and goals. Am Heart Assoc; 2007.

  12. Organization WH. Global health risks: mortality and burden of disease attributable to selected major risks. World Health Organization; 2009.

  13. Lopez-Jaramillo P, Lopez-Lopez J, Lopez-Lopez C, Rodriguez-Alvarez MI. The goal of blood pressure in the hypertensive patient with diabetes is defined: now the challenge is go from recommendations to practice. Diabetol Metab Syndr. 2014;6(1):1–10.

    Article  Google Scholar 

  14. Paul B, Sapra B, Maheshwari S, Goyal R. Role of losartan therapy in the management of diabetic hypertension. J Assoc Phys India. 2000;48(5):514–8.

    CAS  Google Scholar 

  15. Mendis S. Cardiovascular risk assessment and management in developing countries. Vasc Health Risk Manag. 2005;1(1):15.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Harman E, Dolek D, Tütüncüoğlu A, Emren S, Levent F, Korkmaz G, et al. Rate of blood pressure control and antihypertensive treatment approaches in diabetic patients with hypertension. Turk Kardiyoloji Dernegi Arsivi: Turk Kardiyoloji Derneginin Yayin Organidir. 2014;42(8):733–40.

    Article  PubMed  Google Scholar 

  17. Otieno C, Vaghela V, Mwendwa F, Kayima J, Ogola E. Cardiovascular risk factors in patients with type 2 diabetes mellitus in Kenya: levels of control attained at the Outpatient Diabetic Clinic of Kenyatta National Hospital, Nairobi. East Afr Med J. 2005;82(12).

  18. Unadike B, Eregie A, Ohwovoriole A. Prevalence of hypertension amongst persons with diabetes mellitus in Benin City. Nigeria Nigerian journal of clinical practice. 2011;14(3):300–2.

    Article  CAS  PubMed  Google Scholar 

  19. Akalu Y, Belsti Y. Hypertension and its Associated factors among type 2 diabetes Mellitus patients at Debre Tabor General Hospital, Northwest Ethiopia. Diabetes Metab Syndr Obes. 2020;13:1621–31.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Dedefo A, Galgalo A, Jarso G, Mohammed A. Prevalence of hypertension and its management pattern among type 2 diabetic patients attending, Adama Hospital Medical College, Adama. J Diabetes Metab. 2018;9(10):1–8.

    Article  Google Scholar 

  21. Tamiru S, Alemseged F. Risk factors for cardiovascular diseases among diabetic patients in southwest Ethiopia. Ethiop J Health Sci. 2010;20(2).

  22. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C 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. Journal of the American College of Cardiology. 2018;71(19):e127-e248.

  23. Aroda VR, Knowler WC, Crandall JP, Perreault L, Edelstein SL, Jeffries SL, et al. Metformin for diabetes prevention: insights gained from the diabetes prevention program/diabetes prevention program outcomes study. Diabetologia. 2017;60(9):1601–11.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Katon WJ, Rutter C, Simon G, Lin EH, Ludman E, Ciechanowski P, et al. The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care. 2005;28(11):2668–72.

    Article  PubMed  Google Scholar 

  25. WHO W. A global brief on hypertension: Silent killer, global public health crisis. 2013.

  26. Emdin CA, Rahimi K, Neal B, Callender T, Perkovic V, Patel A. Blood pressure lowering in type 2 diabetes: a systematic review and meta-analysis. JAMA. 2015;313(6):603–15.

    Article  PubMed  Google Scholar 

  27. Tight blood pressure control. And risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK prospective diabetes Study Group. BMJ. 1998;317(7160):703–13.

    Article  Google Scholar 

  28. Alwan A. Global status report on noncommunicable diseases 2010. World Health Organization; 2011.

  29. Koly KN, Biswas T, Islam A. Increasing prevalence of hypertension in Bangladesh: a review. Cardiovasc J. 2015;8(1):59–64.

    Article  Google Scholar 

  30. Belew MA, Abate TW, Berhie AY, Abeje ED, Ayele DA, Abate MD, et al. Determinants of hypertension among diabetes patients attending selected comprehensive specialized hospitals of the Amhara Region, Ethiopia: an unmatched case-control study. PLoS ONE. 2022;17(12):e0279245.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Haile TG, Mariye T, Tadesse DB, Gebremeskel GG, Asefa GG, Getachew T. Prevalence of hypertension among type 2 diabetes mellitus patients in Ethiopia: a systematic review and meta-analysis. Int Health. 2022.

  32. Hendriks ME, Wit FW, Roos MT, Brewster LM, Akande TM, de Beer IH, et al. Hypertension in sub-saharan Africa: cross-sectional surveys in four rural and urban communities. PLoS ONE. 2012;7(3):e32638.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Woliata Sodo University Teaching and Referral Hospital. (2021) HMIS report. 2021.

  34. World Health Organization. Body Mass Index (BMI). Situation and trends. [cited 2021 August 8]. Available from: https://www.who.int/gho/ncd/risk_factors/bmi_text/en/.

  35. World Health Organization. Waist circumference and waist-hip ratio: report of a WHO expert consultation. Geneva 2008. Available from: https://www.who.int/nutrition/publications/obesity/WHO_report_waistcircumference_and_waisthip_ratio/en/.

  36. World Health O. Definition, diagnosis and classification of diabetes mellitus and its complications: report of a WHO consultation. Part 1, diagnosis and classification of diabetes mellitus. Geneva: World Health Organization; 1999.

    Google Scholar 

  37. American Diabetes A. 6. Glycemic Targets: Standards of Medical Care in Diabetes-2021. Diabetes care. 2021;44(Suppl 1):S73-S84.

  38. Toobert DJ, Hampson SE, Glasgow RE. The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care. 2000;23(7):943–50.

    Article  CAS  PubMed  Google Scholar 

  39. Who W. global recommendations on physical activity for health. geneva World Heal Organ. 2010;60.

  40. Helelo TP, Gelaw YA, Adane AA. Prevalence and Associated factors of hypertension among adults in Durame Town, Southern Ethiopia. PLoS ONE. 2014;9(11):e112790.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Organization WH. WHO STEPS surveillance manual: the WHO STEPwise approach to chronic disease risk factor surveillance. World Health Organization; 2005. p. 9241593830.

  42. Yusuf S, Hawken S, Ôunpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. The lancet. 2004;364(9438):937–52.

    Article  Google Scholar 

  43. Gebrehanna E, Berhane Y, Worku A. Khat chewing among Ethiopian University Students- a growing concern. BMC Public Health. 2014;14(1):1198.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Statistics NCfH. Anthropometry Procedures Manual—National Health and Nutrition Examination Survey (NHANES). Hyattsville, MD: NCHS; 2013.

    Google Scholar 

  45. Institute EPH. Ethiopia STEPS report on risk factors for non-communicable diseases and prevalence of selected NCDs. 2016.

  46. Unadike BC, Eregie A, Ohwovoriole AE. Prevalence of hypertension amongst persons with diabetes mellitus in Benin City. Nigeria Nigerian journal of clinical practice. 2011;14(3):300–2.

    Article  CAS  PubMed  Google Scholar 

  47. Mansour AA. Prevalence and control of hypertension in iraqi diabetic patients: a prospective cohort study. open Cardiovasc Med J. 2012;6:68.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Abdissa D, Kene K. Prevalence and determinants of Hypertension among Diabetic Patients in Jimma University Medical Center, Southwest Ethiopia, 2019. Diabetes Metab Syndr Obes. 2020;13:2317–25.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Migora B, Geleso MG, Girum T, Bireda M, Gebru M, Dessu S. Survival Time to Development of Hypertension and its predictors among a Cohort of Diabetic Patients in Health Facilities of Gurage Zone: a Retrospective Follow-Up study. Vasc Health Risk Manag. 2021;17:259–66.

    Article  PubMed  PubMed Central  Google Scholar 

  50. DeMarco VG, Aroor AR, Sowers JR. The pathophysiology of hypertension in patients with obesity. Nat reviews Endocrinol. 2014;10(6):364–76.

    Article  CAS  Google Scholar 

  51. Diaz KM, Shimbo D. Physical activity and the prevention of hypertension. Curr Hypertens Rep. 2013;15(6):659–68.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Jackson C, Herber-Gast G-C, Brown W. Joint effects of physical activity and BMI on risk of hypertension in women: a longitudinal study. J Obes. 2014;2014.

  53. Beunza JJ, Martínez-González M, Ebrahim S, Bes-Rastrollo M, Núñez J, Martínez JA, et al. Sedentary behaviors and the risk of Incident Hypertension*: the SUN Cohort. Am J Hypertens. 2007;20(11):1156–62.

    PubMed  Google Scholar 

  54. Non-Communicable O. National strategic action plan (nsap) for prevention & control of non-communicable diseases in Ethiopia. Google Scholar; 2016.

  55. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). Eur Heart J. 2018;39(33):3021–104.

    Article  PubMed  Google Scholar 

  56. Blom J, De Ruijter W, Witteman J, Assendelft W, Breteler M, Hofman A, et al. Changing prediction of mortality by systolic blood pressure with increasing age: the Rotterdam study. Age. 2013;35(2):431–8.

    Article  CAS  PubMed  Google Scholar 

  57. Berraho M, El Achhab Y, Benslimane A, Rhazi KE, Chikri M, Nejjari C. Hypertension and type 2 diabetes: a cross-sectional study in Morocco (EPIDIAM Study). Pan African Medical Journal. 2012;11(1).

  58. Mussa BM, Abduallah Y, Abusnana S. Prevalence of hypertension and obesity among emirati patients with type 2 diabetes. J Diabetes Metab. 2016;7(1):1–5.

    Google Scholar 

  59. Nouh F, Omar M, Younis M. Prevalence of hypertension among diabetic patients in Benghazi: a study of associated factors. Asian J Med Health. 2017;6(4):1–11.

    Article  Google Scholar 

  60. Kotiso K, Mekebo N, Wolde D, Gebremariam B. Prevalence and Predictors of Hypertension-Type 2 Diabetes Mellitus Comorbidity among Patients in Wachemo University Nigest Elleni Mohammed Memorial Referral Hospital, Southern Ethiopia. 2020.

  61. Kassa A, Woldesemayat EM. Hypertension and diabetes mellitus among patients at Hawassa University comprehensive specialized hospital, Hawassa, Southern Ethiopia. International journal of chronic diseases. 2019;2019.

  62. Wagnew F, Eshetie S, Kibret GD, Zegeye A, Dessie G, Mulugeta H, et al. Diabetic nephropathy and hypertension in diabetes patients of sub-saharan countries: a systematic review and meta-analysis. BMC Res Notes. 2018;11(1):565.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Wu B, Bell K, Stanford A, Kern DM, Tunceli O, Vupputuri S, et al. Understanding CKD among patients with T2DM: prevalence, temporal trends, and treatment patterns—NHANES 2007–2012. BMJ Open Diabetes Research and Care. 2016;4(1):e000154.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Tomino Y, Gohda T. The prevalence and management of diabetic nephropathy in Asia. Kidney Dis. 2015;1(1):52–60.

    Article  Google Scholar 

  65. Muntner P, Anderson A, Charleston J, Chen Z, Ford V, Makos G, et al. Hypertension awareness, treatment, and control in adults with CKD: results from the chronic renal insufficiency cohort (CRIC) study. Am J Kidney Dis. 2010;55(3):441–51.

    Article  CAS  PubMed  Google Scholar 

  66. Kotchen* TA. Hypertension. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson JL, editors. Harrison’s principles of Internal Medicine 21e. New York, NY: McGraw-Hill Education; 2022.

    Google Scholar 

  67. Chauhan S, Gupte SS, Kumar S, Patel R. Urban-rural differential in diabetes and hypertension among elderly in India: a study of prevalence, factors, and treatment-seeking. Diabetes & metabolic syndrome. 2021;15(4):102201.

    Article  CAS  Google Scholar 

  68. Agyemang C. Rural and urban differences in blood pressure and hypertension in Ghana, West Africa. Public Health. 2006;120(6):525–33.

    Article  PubMed  Google Scholar 

  69. Savica V, Bellinghieri G, Kopple JD. The effect of nutrition on blood pressure. Annu Rev Nutr. 2010;30:365–401.

    Article  CAS  PubMed  Google Scholar 

  70. Chan Q, Stamler J, Griep LMO, Daviglus ML, Horn LV, Elliott P. An Update on Nutrients and Blood Pressure: Summary of INTERMAP Study Findings. J Atheroscler Thromb. 2016;23(3):276-89.

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Contributions

EAA, SBW, ZGT, BZW ,and EAB; conception, design of the study ,and data analysis. EAA, SBW: analyzed the data and interpreted the findings. EAA: conducted and supervised data collection and management. All authors read and approved the final manuscript.

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Correspondence to Eyosiyas Abreham Anjajo.

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Ethical clearance was obtained from Wolaita Sodo University Ethical review board with reference number CRCSOO8/02/14, according to the standardized principle and procedure, which is in line with national and WHO guidelines. All methods in this research were carried out in accordance with relevant national and international ethical guidelines and regulations. Information sheets and consent forms were delivered along with each questionnaire and all the subjects were asked if they are willing to participate before conducting the interview and informed consent was obtained from each participant. Informed consent for all illiterate participants was obtained from their parents and/or their legal guardian(s). Data was kept confidential and anonymous throughout the study. The personal identifier was not used in the study.

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The authors would like to thank the study participants, data collectors, and supervisors.

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Supplementary Material 1 The questionnaire used for data collection in this study is included in the supplementary file.

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Anjajo, E.A., Workie, S.B., Tema, Z.G. et al. Determinants of hypertension among diabetic patients in southern Ethiopia: a case-control study. BMC Cardiovasc Disord 23, 233 (2023). https://doi.org/10.1186/s12872-023-03245-4

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