Tue, Jan 14, 2025
[Archive]
Volume 9, Issue 3 (Aug 2024)
JNFS 2024, 9(3): 551-560 |
Back to browse issues page
Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Moazen M, Homayounfar R, Kazemi A, Farjam M, Babajafari S. The Association of Dietary Indices, Antioxidant Intake and Bioactive Foods with Hypertension in Diabetic Patients: A Cross-Sectional Analysis regarding Fasa PERSIAN Cohort Study. JNFS 2024; 9 (3) :551-560
URL: http://jnfs.ssu.ac.ir/article-1-906-en.html
URL: http://jnfs.ssu.ac.ir/article-1-906-en.html
National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Full-Text [PDF 703 kb]
(170 Downloads)
| Abstract (HTML) (612 Views)
Introduction
Full-Text: (95 Views)
The Association of Dietary Indices, Antioxidant Intake and Bioactive Foods with Hypertension in Diabetic Patients: A Cross-Sectional Analysis regarding Fasa PERSIAN Cohort Study
Mahsa Moazen; PhD1, Reza Homayounfar; PhD, MPH*2, Asma Kazemi; PhD1, Mojtaba Farjam; MD, PhD3 & Siavash Babajafari; MD, PhD1
Mahsa Moazen; PhD1, Reza Homayounfar; PhD, MPH*2, Asma Kazemi; PhD1, Mojtaba Farjam; MD, PhD3 & Siavash Babajafari; MD, PhD1
1 Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran;
2 National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 3 Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran.
2 National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 3 Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran.
| ARTICLE INFO | ABSTRACT | |
| ORIGINAL ARTICLE | Background: More than half of diabetic patients finally develop hypertension which remarkably increases the risk of multiple complications. This study aims to assess the association between dietary indices, antioxidant intake and bioactive foods, and hypertension in diabetic patients. Methods: This was a cross-sectional population-based study on baseline data of Fasa PERSIAN cohort study which was conducted on adults in Sheshdeh town and its 24 villages, in Iran from 2014 to 2016. This research included 1229 patients with diabetes. A food frequency questionnaire was used to assess three dietary indices (phytochemical index, dietary inflammatory index, and alternative healthy eating index-2010), antioxidant intake, and consumption of bioactive foods. Other lifestyle and demographic factors were also assessed. Multivariable binary logistic regression was performed to assess the associations between independent variables and hypertension. Results: Higher intake of garlic was significantly associated with lower odds of having hypertension after adjusting for potential confounders [adjusted odds ratio (AOR):0.84, 95% confidence interval (CI):0.73-0.97]. Furthermore, female gender [AOR:1.77, 95% CI:1.26-2.49], being older [AOR:1.09, 95% CI:1.08-1.11], having a family history of hypertension [AOR:2.42, 95% CI:1.86-3.16] and higher body mass index (BMI) [AOR:1.1, 95% CI:1.07-1.13] were predictors of having hypertension. Neither dietary indices nor antioxidant intakes were associated with having hypertension in the crude or adjusted models. Conclusion: Garlic consumption is negatively associated with hypertension in diabetic patients. However, female gender, old age, family history of hypertension and higher BMI are positively associated with this condition. Therefore, modifying diet and weight management are recommended for controlling hypertension in this group of patients. Keywords: Antioxidants; Diabetes mellitus; Diet; Garlic; Hypertension |
|
| Article history: Received: 9 Jun 2023 Revised: 21 Feb 2023 Accepted: 31 Jul 2024 |
||
| *Corresponding author: r_homayounfar@yahoo.com kazemiasma66@gmail.com Hafezi Street, Tehran, Iran; and Razi Boulevard, School of Nutrition and Food Sciences, Shiraz, Iran. Postal code: 1981619573 Tel: +98 2122357483 |
Introduction
Diabetes mellitus is a metabolic endocrine disorder characterized by chronic hyperglycemia. It is the consequence of impaired insulin secretion and/or impaired insulin function (Petersmann et al., 2019, Rana et al., 2023). The worldwide prevalence of diabetes was estimated at 10.5% for people aged 20–79 in 2021 (Sun et al., 2022). This high prevalence is alarming because it can increase the number of chronic and acute illnesses around the globe (Harding et al., 2019).
It is noteworthy that more than half of the patients with diabetes finally develop hypertension (Katayama et al., 2018). Presence of hypertension
in diabetic patients complicates therapeutic
strategies, enhances healthcare costs, and remarkably increases the risk of microvascular complications (Tsimihodimos et al., 2018). For instance, the incidence of cardiovascular diseases are reported to be increased by 2-3 fold in hypertensive diabetics (Katayama et al., 2018).
Lifestyle and genetic factors are considered risk factors for developing high blood pressure (Kokubo et al., 2019). Lifestyle interventions including weight reduction, regular physical activity, avoiding smoking (active or passive smoking), restriction of alcohol intake as well as consuming a healthy diet can lead to prevention or management of hypertension (Kokubo et al., 2019, Valenzuela et al., 2021). Adherence to special diets, focus on consumption of the whole grains, fruits, vegetables, legumes, nuts and low-fat dairy products along with reduction in total fat and sodium intake are recommended in the management of hypertension (Castro et al., 2015, Thout et al., 2023).
Inflammation is regarded as a contributing factor to the pathogenesis of hypertension. Elevation of inflammatory markers, such as different cytokines, are reported in hypertensive patients (Xiao and Harrison, 2020). Recently, a dietary scoring system called dietary inflammatory index (DII) has been developed to assess the inflammatory potential of the diet. According to the existing evidence, it is suggested that a more pro-inflammatory diet is related to several diseases such as cardiovascular diseases and certain cancers (Phillips et al., 2019).
Growing evidence has also indicated that oxidative stress plays an important role in progression of hypertension through special mechanisms (Ahmad et al., 2017, Loperena and Harrison, 2017). In the pathophysiological processes of hypertension, oxidative stress has been linked to endothelial dysfunction. However, antioxidant therapy is questionable for preventing the progression of high blood pressure in humans (Ahmad et al., 2017).
Besides, consuming fruits and vegetables has been associated with lower risk of several chronic diseases. These protective effects can be principally attributed to the phytochemicals which are bioactive non-nutrient compounds found in plant foods (Zhang et al., 2015). It has been suggested that consuming phytochemical-rich foods may reduce the prevalence of high blood pressure (Golzarand et al., 2015, Jo and Park, 2022).
There are not many studies (Delshad Aghdam et al., 2021, Farvid et al., 2013, Günther et al., 2009) on the relationship between dietary factors and hypertension in diabetic patients. Besides, to the authors’ knowledge, no study has determined the association between bioactive food consumption and DII, and high blood pressure in the exclusive population of diabetics. Therefore, the present study aims to assess the association of bioactive foods and DII as well as alternative healthy eating index-2010 (AHEI-2010), phytochemical index (PI), antioxidant intake and some other lifestyle or demographic factors with hypertension in the diabetic individuals.
Materials and Methods
Study design and participants
This study was a cross-sectional population-based survey on adults living in the small town of Sheshdeh and its 24 surrounding villages, located in Fasa city in southwest of Iran. This research used the baseline data of Fasa PERSIAN cohort study collected from September 2014 to September 2016. The complete cohort follow-up data are not yet available. The detailed protocol has been published previously (Farjam et al., 2016).
All the eligible habitants were invited to Fasa PERSIAN cohort study. The target population of this study included 11,097 individuals within the age range of 35–70. Of this population, 1229 people were diagnosed with diabetes. The inclusion criteria of this study consisted of all the diabetic patients aged between 35 to 70 who participated in Fasa PERSIAN cohort study. All the other participants (healthy or diagnosed with other diseases) were excluded from the present research.
In the current study, diabetic patients were divided into two groups of normotensive (n=664) and hypertensive (n=565. Presence of diabetes and hypertension was based on the previous records of participants’ medical history. Blood pressure and blood sugar levels were not considered as the criteria of diagnosis, because most of the patients (91% of the diabetics and 89% of the hypertensive individuals) were under treatment for their diseases.
Data collection
Before registration process, every participant filled out an informed consent from. Interviewers were trained to ask questions from the participants. All the provided questionnaires were in electronic form in order to improve the accuracy and validity of the entered data. This study is comprised of general, medical, and nutritional interviews. Demographic characteristics, family history of diseases, and lifestyle information were asked from every participant. A modified semi-quantitative 125-item food frequency questionnaire (FFQ) was administered to assess the amount of food items consumed in the past year. The FFQ was a modification of Willett format questionnaire (Willett et al., 1985) based on Iranian food items. The validity and reproducibility of this modified questionnaire were assessed, and the results indicated that this FFQ was appropriate for ranking participants based on food group intake (Eghtesad et al.). Energy and nutrient intakes were calculated based on FFQ using Nutritionist IV software (First Data Bank, San Bruno, CA; version 3.5.2). Then, anthropometrics measurements (including weight, height, and waist circumference) were performed, and fasting blood glucose levels were determined for the patients. Blood pressure was measured in both arms, and on each side, the measurement was done twice with a 15-minute interval. Resting heart rate was also assessed in sitting position. In addition, a quality control team monitored all the aspects of data collection and specimen acquisition processes.
Calculating AHEI-2010
Scoring criteria for AHEI-2010 are described in detail by Chiuve (Chiuve et al., 2012). Briefly, the score consisted of 11 components and each component scores from 0 (worst) to 10 (best). Based on the criteria, higher intakes of vegetables, fruits, whole grains, nuts and legumes, long-chain omega-3 fatty acids and polyunsaturated fatty acids received higher scores, whereas higher intakes of sugar-sweetened beverages and fruit juice, red and processed meat, trans fat and sodium received lower scores. Besides, moderate intake of alcohol is supposed to be ideal. All the 11 scores are then summed to obtain the total AHEI-2010, with a higher score indicative of a healthier diet.
Calculating DII
For calculating DII, the method of Shivappa et al. was adopted (Shivappa et al., 2014). The amounts of food parameters (listed in the aforementioned study) intakes were adjusted for each individual’s energy intake. A z-score was derived by subtracting “global daily mean intake” from the adjusted food parameter. It was then divided by its standard deviation (calculated from the world database). To minimize the effect of ‘right skewing’, this value was converted to a percentile score. After that, the resulting number was doubled, ‘1’ was subtracted and multiplied by respective “overall inflammatory effect scores”. Finally, all of the scores were summed to create the overall DII score of each participant. In this study, 32 out of 45 original food parameters were available which could be used to calculate DII. These included energy, fat, carbohydrate, protein, saturated fat, monounsaturated fatty acids, polyunsaturated fatty acids, trans fat, omega-3 fatty acids, omega-6 fatty acids, cholesterol, fiber, zinc, selenium, magnesium, iron, vitamins A, D, E, C, B1, B2, B3, B6, B12, folate, β-carotene, caffeine, garlic, onion, tea, and alcohol.
Calculating PI
Dietary PI was estimated based on the method established by McCarty (McCarty, 2004). The percentage of dietary energy derived from foods rich in phytochemicals was determined to calculate this index. The foods rich in phytochemical included in PI were fruits, vegetables (excluding potatoes), whole grains, nuts, seeds, legumes, fruit and vegetable juices, soy products, beer and olive oil. In the calculation, the authors considered total olive oil consumption instead of extra-olive oil because data for the type of olive oil intake were not available in this study.
Ethical considerations
The cohort study was in agreement with the Helsinki declaration and Iranian national guidelines for ethics in research. The current research was approved by the Ethics Committee of Shiraz University of Medical Sciences (No. IR.SUMS.REC.1399.1096).
Data analyses
Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) software, version 21.0 (IBM Corp., USA). Chi-square test was used for comparing the qualitative data, and independent-samples t-test was applied for comparing the quantitative variables between the groups. Moreover, multivariable binary logistic regression models with enter method was performed to evaluate possible associations between independent variables and having hypertension in diabetic patients. Two models were constructed for controlling potential confounders. Model 1 was adjusted for age, sex, physical activity, family history of hypertension, active smoking and energy intake. Model 2 was adjusted for all variables in model 1 plus diabetes duration, sleep duration, ethnicity, marital status, and body mass index (BMI). P-values <0.05 were considered significant.
Results
General and medical characteristics of the participants are shown in Table 1. Results of this study indicated that most of the population were female (72.1%), married (86.4%) and had a family history of hypertension (58.1%), and the most prevalent ethnic group was Fars (56.6%). Hypertensive diabetics in this research were significantly older (P<0.001), higher duration of diabetes (P=0.008), BMI (P<0.001), waist circumference (P<0.001), systolic and diastolic blood pressure (P<0.001) and pulse rate (P=0.001) compared with normotensive diabetics. On the other hand, physical activity (P<0.001) and sleep duration (P=0.03) were significantly lower in diabetic patients with hypertension. No significant differences were found between the groups regarding fasting blood glucose levels and smoking status (P>0.05).
It is noteworthy that more than half of the patients with diabetes finally develop hypertension (Katayama et al., 2018). Presence of hypertension
in diabetic patients complicates therapeutic
strategies, enhances healthcare costs, and remarkably increases the risk of microvascular complications (Tsimihodimos et al., 2018). For instance, the incidence of cardiovascular diseases are reported to be increased by 2-3 fold in hypertensive diabetics (Katayama et al., 2018).
Lifestyle and genetic factors are considered risk factors for developing high blood pressure (Kokubo et al., 2019). Lifestyle interventions including weight reduction, regular physical activity, avoiding smoking (active or passive smoking), restriction of alcohol intake as well as consuming a healthy diet can lead to prevention or management of hypertension (Kokubo et al., 2019, Valenzuela et al., 2021). Adherence to special diets, focus on consumption of the whole grains, fruits, vegetables, legumes, nuts and low-fat dairy products along with reduction in total fat and sodium intake are recommended in the management of hypertension (Castro et al., 2015, Thout et al., 2023).
Inflammation is regarded as a contributing factor to the pathogenesis of hypertension. Elevation of inflammatory markers, such as different cytokines, are reported in hypertensive patients (Xiao and Harrison, 2020). Recently, a dietary scoring system called dietary inflammatory index (DII) has been developed to assess the inflammatory potential of the diet. According to the existing evidence, it is suggested that a more pro-inflammatory diet is related to several diseases such as cardiovascular diseases and certain cancers (Phillips et al., 2019).
Growing evidence has also indicated that oxidative stress plays an important role in progression of hypertension through special mechanisms (Ahmad et al., 2017, Loperena and Harrison, 2017). In the pathophysiological processes of hypertension, oxidative stress has been linked to endothelial dysfunction. However, antioxidant therapy is questionable for preventing the progression of high blood pressure in humans (Ahmad et al., 2017).
Besides, consuming fruits and vegetables has been associated with lower risk of several chronic diseases. These protective effects can be principally attributed to the phytochemicals which are bioactive non-nutrient compounds found in plant foods (Zhang et al., 2015). It has been suggested that consuming phytochemical-rich foods may reduce the prevalence of high blood pressure (Golzarand et al., 2015, Jo and Park, 2022).
There are not many studies (Delshad Aghdam et al., 2021, Farvid et al., 2013, Günther et al., 2009) on the relationship between dietary factors and hypertension in diabetic patients. Besides, to the authors’ knowledge, no study has determined the association between bioactive food consumption and DII, and high blood pressure in the exclusive population of diabetics. Therefore, the present study aims to assess the association of bioactive foods and DII as well as alternative healthy eating index-2010 (AHEI-2010), phytochemical index (PI), antioxidant intake and some other lifestyle or demographic factors with hypertension in the diabetic individuals.
Materials and Methods
Study design and participants
This study was a cross-sectional population-based survey on adults living in the small town of Sheshdeh and its 24 surrounding villages, located in Fasa city in southwest of Iran. This research used the baseline data of Fasa PERSIAN cohort study collected from September 2014 to September 2016. The complete cohort follow-up data are not yet available. The detailed protocol has been published previously (Farjam et al., 2016).
All the eligible habitants were invited to Fasa PERSIAN cohort study. The target population of this study included 11,097 individuals within the age range of 35–70. Of this population, 1229 people were diagnosed with diabetes. The inclusion criteria of this study consisted of all the diabetic patients aged between 35 to 70 who participated in Fasa PERSIAN cohort study. All the other participants (healthy or diagnosed with other diseases) were excluded from the present research.
In the current study, diabetic patients were divided into two groups of normotensive (n=664) and hypertensive (n=565. Presence of diabetes and hypertension was based on the previous records of participants’ medical history. Blood pressure and blood sugar levels were not considered as the criteria of diagnosis, because most of the patients (91% of the diabetics and 89% of the hypertensive individuals) were under treatment for their diseases.
Data collection
Before registration process, every participant filled out an informed consent from. Interviewers were trained to ask questions from the participants. All the provided questionnaires were in electronic form in order to improve the accuracy and validity of the entered data. This study is comprised of general, medical, and nutritional interviews. Demographic characteristics, family history of diseases, and lifestyle information were asked from every participant. A modified semi-quantitative 125-item food frequency questionnaire (FFQ) was administered to assess the amount of food items consumed in the past year. The FFQ was a modification of Willett format questionnaire (Willett et al., 1985) based on Iranian food items. The validity and reproducibility of this modified questionnaire were assessed, and the results indicated that this FFQ was appropriate for ranking participants based on food group intake (Eghtesad et al.). Energy and nutrient intakes were calculated based on FFQ using Nutritionist IV software (First Data Bank, San Bruno, CA; version 3.5.2). Then, anthropometrics measurements (including weight, height, and waist circumference) were performed, and fasting blood glucose levels were determined for the patients. Blood pressure was measured in both arms, and on each side, the measurement was done twice with a 15-minute interval. Resting heart rate was also assessed in sitting position. In addition, a quality control team monitored all the aspects of data collection and specimen acquisition processes.
Calculating AHEI-2010
Scoring criteria for AHEI-2010 are described in detail by Chiuve (Chiuve et al., 2012). Briefly, the score consisted of 11 components and each component scores from 0 (worst) to 10 (best). Based on the criteria, higher intakes of vegetables, fruits, whole grains, nuts and legumes, long-chain omega-3 fatty acids and polyunsaturated fatty acids received higher scores, whereas higher intakes of sugar-sweetened beverages and fruit juice, red and processed meat, trans fat and sodium received lower scores. Besides, moderate intake of alcohol is supposed to be ideal. All the 11 scores are then summed to obtain the total AHEI-2010, with a higher score indicative of a healthier diet.
Calculating DII
For calculating DII, the method of Shivappa et al. was adopted (Shivappa et al., 2014). The amounts of food parameters (listed in the aforementioned study) intakes were adjusted for each individual’s energy intake. A z-score was derived by subtracting “global daily mean intake” from the adjusted food parameter. It was then divided by its standard deviation (calculated from the world database). To minimize the effect of ‘right skewing’, this value was converted to a percentile score. After that, the resulting number was doubled, ‘1’ was subtracted and multiplied by respective “overall inflammatory effect scores”. Finally, all of the scores were summed to create the overall DII score of each participant. In this study, 32 out of 45 original food parameters were available which could be used to calculate DII. These included energy, fat, carbohydrate, protein, saturated fat, monounsaturated fatty acids, polyunsaturated fatty acids, trans fat, omega-3 fatty acids, omega-6 fatty acids, cholesterol, fiber, zinc, selenium, magnesium, iron, vitamins A, D, E, C, B1, B2, B3, B6, B12, folate, β-carotene, caffeine, garlic, onion, tea, and alcohol.
Calculating PI
Dietary PI was estimated based on the method established by McCarty (McCarty, 2004). The percentage of dietary energy derived from foods rich in phytochemicals was determined to calculate this index. The foods rich in phytochemical included in PI were fruits, vegetables (excluding potatoes), whole grains, nuts, seeds, legumes, fruit and vegetable juices, soy products, beer and olive oil. In the calculation, the authors considered total olive oil consumption instead of extra-olive oil because data for the type of olive oil intake were not available in this study.
Ethical considerations
The cohort study was in agreement with the Helsinki declaration and Iranian national guidelines for ethics in research. The current research was approved by the Ethics Committee of Shiraz University of Medical Sciences (No. IR.SUMS.REC.1399.1096).
Data analyses
Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) software, version 21.0 (IBM Corp., USA). Chi-square test was used for comparing the qualitative data, and independent-samples t-test was applied for comparing the quantitative variables between the groups. Moreover, multivariable binary logistic regression models with enter method was performed to evaluate possible associations between independent variables and having hypertension in diabetic patients. Two models were constructed for controlling potential confounders. Model 1 was adjusted for age, sex, physical activity, family history of hypertension, active smoking and energy intake. Model 2 was adjusted for all variables in model 1 plus diabetes duration, sleep duration, ethnicity, marital status, and body mass index (BMI). P-values <0.05 were considered significant.
Results
General and medical characteristics of the participants are shown in Table 1. Results of this study indicated that most of the population were female (72.1%), married (86.4%) and had a family history of hypertension (58.1%), and the most prevalent ethnic group was Fars (56.6%). Hypertensive diabetics in this research were significantly older (P<0.001), higher duration of diabetes (P=0.008), BMI (P<0.001), waist circumference (P<0.001), systolic and diastolic blood pressure (P<0.001) and pulse rate (P=0.001) compared with normotensive diabetics. On the other hand, physical activity (P<0.001) and sleep duration (P=0.03) were significantly lower in diabetic patients with hypertension. No significant differences were found between the groups regarding fasting blood glucose levels and smoking status (P>0.05).
| Table 1. General and medical characteristics of diabetic patients with and without hypertension. | |||
| Variables | Normotensive(n=664) | Hypertensive(n=565) | P-valuea |
| Gender Male Female |
223 (33.6)b 441 (66.4) |
120 (21.2) 445 (78.8) |
<0.001 |
| Ethnicity Fars Turkish speaking nomads Arabic speaking nomads Others |
363 (54.7) 193 (29.1) 31 (4.7) 77 (11.5) |
332 (58.7) 175 (31.0) 17 (3.0) 41(7.3) |
0.024 |
| Marital status Married Single Widow/widower Divorced |
593 (89.3) 16 (2.4) 49 (7.4) 6 (0.9) |
469 (83.0) 6 (1.1) 86 (15.2) 4 (0.7) |
<0.001 |
| Family history of hypertension (yes)d | 336 (50.6) | 378 (66.9) | <0.001 |
| Active smoking (yes)e | 132 (19.9) | 91 (16.1) | 0.087 |
| Passive smoking (at home or workplace) (yes) | 385 (58.2) | 304 (54.0) | 0.135 |
| Age (y) | 51.13±8.92 | 56.57±7.74 | <0.001 |
| Diabetes duration (y) | 3.65±4.40c | 4.36±4.91 | 0.008 |
| Body mass index (kg/m2) | 26.48±4.43 | 28.11±4.66 | <0.001 |
| Physical activity (MET.h/day) | 40.00±9.44 | 37.73±7.85 | <0.001 |
| Waist circumference (cm) | 95.98±10.91 | 100.76±10.86 | <0.001 |
| Sleep duration (h/day) | 7.73±1.78 | 7.50±1.96 | 0.03 |
| Systolic blood pressure (mmHg) | 110.22±15.26 | 126.08±21.15 | <0.001 |
| Diastolic blood pressure (mmHg) | 74.57±10.93 | 80.38±12.60 | <0.001 |
| Pulse rate (bpm) | 75.38±10.61 | 77.48±10.82 | 0.001 |
| Fasting blood glucose (mg/dl) | 182.28±62.72 | 134.75±59.55 | 0.069 |
| a: Independent-samples t-test was used for comparing the continuous variables, and chi-square test was applied for comparing the qualitative data; b: n (%); c: Mean±SD; d: e: Smoked at least 100 cigarettes in the life; Family history in first degree relatives; MET: metabolic equivalent. |
|||
Results of the multivariable logistic regression models showed that female gender [adjusted odds ratio (AOR): 1.77, 95% confidence interval (CI): 1.26-2.49], being older [AOR: 1.09, 95% CI: 1.08-1.11], having a family history of hypertension [AOR: 2.42, 95% CI: 1.86-3.16], and higher BMI [AOR: 1.1, 95% CI: 1.07-1.13] were predictors of having hypertension after adjusting for all the potential confounders (Table 2). Data were also stratified by menopausal status in women, and the association between gender and hypertension remained significant in this regard [AOR: 1.92, 95% CI: 1.16-3.17 for pre-menopausal women versus men; AOR: 1.84, 95% CI: 1.28-2.65 for post-menopausal women versus men] (Data not shown).
| Table 2. Logistic regression models for the association between general characteristics and presence of hypertension in diabetic patients. | ||||||
| Variables | Crude OR (95% CI) |
P-value | Model 1 Adjusted OR (95% CI) |
P-value | Model 2 Adjusted OR (95% CI) |
P-value |
| Gender Male Female |
1 (Reference) 1.88 (1.45-2.43) |
<0.001 |
1 (Reference) 1.90 (1.38-2.63) |
<0.001 |
1 (Reference) 1.77 (1.26-2.49) |
0.001 |
| Age (y) | 1.08 (1.06-1.1) | <0.001 | 1.09 (1.07-1.11) | <0.001 | 1.09 (1.08-1.11) | <0.001 |
| Ethnicity Fars Turkish speaking nomads Arabic speaking nomads Others |
1 (Reference) 0.99 (0.77-1.28) 0.60 (0.33-1.10) 0.58 (0.39-0.88) |
0.007 |
1 (Reference) 1.12 (0.85-1.48) 0.65 (0.33-1.27) 0.69 (0.44-1.08) |
0.126 |
1 (Reference) 1.18 (0.89-1.58) 0.68 (0.34-1.34) 0.68 (0.43-1.06) |
0.128 |
| Marital status Married Single Widow/widower Divorced |
1 (Reference) 0.47(0.188-1.22) 2.22 (1.53-3.22) 0.84 (0.24-3.00) |
<0.001 |
1 (Reference) 0.44 (0.16-1.22) 1.07 (0.71-1.62) 0.64 (0.17-2.40) |
0.825 |
1 (Reference) 0.50 (0.17-1.45) 1.11 (.725-1.688) 0.65 (0.17-2.49) |
0.861 |
| Family history of hypertension (yes) | 1.97 (1.57-2.49) |
<0.001 |
2.40 (1.86-3.09) |
<0.001 |
2.42 (1.86-3.16) |
<0.001 |
| Physical activity (MET.h/day) | 0.97 (0.96-0.98) |
<0.001 |
0.98 (0.97-0.99) |
0.015 |
0.99 (0.97-1.00) |
0.103 |
| Active smoking () (yes) | 0.77 (0.58-1.04) | 0.088 | 0.96 (0.66-1.39) | 0.824 | 0.96 (0.66-1.41) | 0.844 |
| Diabetes duration (y) | 1.03 (1.01-1.06) | 0.009 | 0.99 (0.97-1.03) | 0.967 | 1.01 (0.98-1.04) | 0.585 |
| Body mass index (kg/m2) | 1.08 (1.06-1.11) | <0.001 | 1.10 (1.07-1.13) | <0.001 | 1.10 (1.07-1.13) | <0.001 |
| Sleep duration (h/day) | 0.93 (0.88-0.99) | 0.027 | 0.97 (0.91-1.04) | 0.440 | 0.98 (0.91-1.05) | 0.599 |
| Model 1 is adjusted for age, sex, physical activity, family history of hypertension, and active smoking; Model 2 is adjusted for all the variables in model 1 plus diabetes duration, sleep duration, ethnicity, marital status and body mass index; CI: confidence interval; OR: odds ratio; MET: metabolic equivalent; P-values provided for ethnicity and marital status are P for trend. |
||||||
In terms of dietary indices, none of the AHEI-2010, DII and PI were significantly associated with having hypertension in crude or adjusted models (P>0.05, Table 3). Additionally, energy intake, percentage of energy derived from macronutrients (carbohydrate, protein and fat), fiber intake, and antioxidant intakes (vitamin A, vitamin E, vitamin C, selenium and zinc) were not predictors of having hypertension (P>0.05. Table 3).
| Table 3. Logistic regression models for the association between dietary indices, macronutrient and antioxidant intakes and selected bioactive foods, and presence of hypertension in diabetic patients. | ||||||
| Variables | Crude OR (95% CI) |
P-value | Model 1: Adjusted OR (95% CI) |
P-value | Model 2: Adjusted OR (95% CI) |
P-value |
| AHEI-2010 | 1.01 (0.99-1.03) | 0.125 | 1.02 (0.99-1.03) | 0.061 | 1.02 (0.99-1.03) | 0.074 |
| DII | 0.96 (0.92-1.01) | 0.108 | 0.98 (0.93-1.04) | 0.474 | 1.01 (0.95-1.07) | 0.762 |
| PI | 1.00 (0.99-1.01) | 0.377 | 1.00 (0.99-1.01) | 0.370 | 1.01 (0.99-1.01) | 0.081 |
| Energy (kcal/day) | 0.99 (0.99-0.99) | <0.001 | 0.99 (0.99-1.00) | 0.164 | 0.99 (0.99-1.00) | 0.176 |
| Carbohydrate(% energy) | 1.00 (0.98-1.02) | 0.819 | 1.01 (0.98-1.03) | 0.671 | 1.01 (0.99-1.03) | 0.372 |
| Protein (% energy) | 1.04 (0.97-1.12) | 0.228 | 1.01 (0.94-1.09) | 0.812 | 0.99 (0.92-1.07) | 0.869 |
| Fat (% energy) | 1.00 (0.98-1.02) | 0.999 | 0.99 (0.98-1.02) | 0.739 | 0.99 (0.97-1.01) | 0.429 |
| Fiber (g/day) | 0.98 (0.98-0.99) | 0.016 | 1.01 (0.99-1.02) | 0.193 | 1.01 (0.99-1.02) | 0.441 |
| Vitamin A (μg/day) | 1.00 (0.99-1.00) | 0.939 | 1.00 (0.99-1.00) | 0.057 | 1.00 (0.99-1.00) | 0.096 |
| Vitamin E(mg/day) | 0.96 (0.93-0.99) | 0.004 | 1.01 (0.97-1.05) | 0.769 | 0.99 (0.95-1.03) | 0.573 |
| Vitamin C (mg/day) | 0.99 (0.99-1.00) | 0.123 | 1.00 (0.99-1.00) | 0.538 | 1.00 (0.99-1.00) | 0.939 |
| Selenium (μg/day) | 0.98 (0.98-0.99) | <0.001 | 0.99 (0.99-1.00) | 0.409 | 0.99 (0.98-1.00) | 0.077 |
| Zinc (mg/day) | 0.92 (0.89-0.96) | <0.001 | 1.02 (0.97-1.08) | 0.403 | 0.99 (0.94-1.05) | 0.795 |
| Garlic (g/day) | 0.88 (0.78-0.99) | 0.037 | 0.87 (0.75-0.99) | 0.042 | 0.84 (0.73-0.97) | 0.014 |
| Onion (g/day) | 0.99 (0.99-1.00) | 0.128 | 1.00 (0.99-1.00) | 0.731 | 0.99 (0.99-1.00) | 0.446 |
| Cruciferous vegetables (g/day) | 0.99 (0.98-1.00) | 0.186 | 0.99 (0.98-1.00) | 0.168 | 0.99 (0.98-1.00) | 0.067 |
| Olive (g/day) | 0.97 (0.93-1.01) | 0.164 | 0.98 (0.93-1.02) | 0.324 | 0.96 (0.92-1.01) | 0.130 |
| Fish (g/day) | 0.99 (0.98-1.01) | 0.930 | 1.01 (0.99-1.03) | 0.113 | 1.01 (0.99-1.02) | 0.386 |
| Soybean and soy protein (g/day) | 0.97 (0.95-1.00) | 0.072 | 0.99 (0.96-1.02) | 0.428 | 0.99 (0.96-1.02) | 0.672 |
| black tea (cup/day) | 0.99 (0.95-1.03) | 0.658 | 1.02 (0.97-1.06) | 0.452 | 1.02 (0.98-1.07) | 0.351 |
| Model 1 is adjusted for energy intake, age, sex, physical activity, family history of hypertension, and active smoking; Model 2 is adjusted for all the variables in model 1 plus diabetes duration, sleep duration, ethnicity, marital status and body mass index; CI: confidence interval; OR: odds ratio; AHEI: alternative healthy eating index; DII: dietary inflammatory index; PI: phytochemical index.. | ||||||
Results of the analysis of bioactive foods revealed that higher intake of garlic was significantly associated with lower odds of hypertension in both crude and adjusted models (AOR: 0.84, 95% CI: 0.73-0.97 for model 2). However, the associations were not significant (P>0.05) for other food intakes (onion, cruciferous vegetables, olive, fish, soya, and tea) (Table 3).
Discussion
Results of the present study indicated that female gender, being older, positive family history of hypertension, and higher BMI were significantly associated with having hypertension in diabetic patients. Findings from a cross-sectional study which was carried out in adults in Isfahan, Iran, indicated that hypertensive patients were significantly older, had higher BMI, and had a higher family history of hypertension compared with normotensive participants. However, male gender was more prevalent in hypertensive subjects (Eghbali et al., 2018). Moreover, results of a cross-sectional study in urban population of Varanasi, India, demonstrated that factors such as male gender, the eldest age group, and overweight or obese had higher odds for hypertension (Singh et al., 2017).
The incidence of hypertension is rising greatly among the elderly population. Increased inflammation and oxidative stress that play a role in aging process can contribute to the development of hypertension (Buford, 2016).
The effect of gender on hypertension is poorly elucidated. Various studies have described gender differences as a cardiovascular risk factor. But, their findings are sometimes contradictory (Doumas et al., 2013). It has been reported that some biological factors protect women against hypertension before menopause (Everett and Zajacova, 2015). For instance, high estrogen concentration in premenopausal women decreases aortic stiffness. However, abrupt decrease in estrogen level after menopause results in an elevated cardiovascular risk (Doumas et al., 2013). The contrary result obtained from the present study should be more extensively investigated in the population of diabetic patients with hypertension.
Family history is frequently used as an alternative indicator to investigate the relationship between genetic factors and diseases. As mentioned earlier, both genetic and environmental factors lead to an increased risk of hypertension (Peng et al., 2019).
There is also a great body of evidence that suggests excess weight gain is a main contributor to high blood pressure. Physical compression of the kidneys with fat, activation of the renin-angiotensin-aldosterone system, and elevated activation of sympathetic nervous system are some of the proposed mechanisms for obesity-induced hypertension (Hall et al., 2015).
Bioactive foods are substances with strong anti-oxidative, anti-inflammatory, antithrombotic, antihypertensive and immune-modulating properties (Mozaffari-Khosravi et al., 2009, Parihar and Parihar, 2019). In the current study, higher intake of garlic was significantly associated with lower odds of hypertension in the diabetic population. Similar to the findings of this study, treatment with raw crushed garlic in patients with metabolic syndrome significantly decreased blood pressure (Choudhary et al., 2018). In addition, a cross-sectional study of Chinese adults without hypertension reported that a more frequent raw garlic consumption was negatively associated with prehypertension (Zhang et al., 2020).
Possible mechanisms of garlic consumption on reduction of blood pressure include inhibiting angiotensin-converting enzyme, increasing the concentration of nitric oxide, and producing hydrogen sulfide by erythrocytes (Rohner et al., 2015, Xiong et al., 2015). It has been reported that hydrogen sulfide induces dilatation of blood vessels in smooth muscle cells (Rohner et al., 2015). Allicin is the primary and most biologically active ingredient in garlic, responsible for its pharmacological functions (Savairam et al., 2023, Xiong et al., 2015).
None of the dietary indices (i.e. AHEI-2010, DII and PI) in the present study were significantly associated with high blood pressure in diabetic patients. In agreement with this finding, in a cross-sectional study performed on adults without chronic diseases, DII score was not associated with blood pressure of the participants (Muhammad et al., 2019). In another study on normotensive subjects, the prospective association between dietary PI and the risk of hypertension were assessed. However, in this study the odds of hypertension were significantly lower for higher quartiles of dietary PI after controlling for confounders (Golzarand et al., 2015). Furthermore, in a previous study, the association between adherence to Dietary Approaches to Stop Hypertension (DASH) diet and high blood pressure was investigated in youth with diabetes. The findings demonstrated that a higher DASH score was inversely associated with hypertension in type 1 diabetic patients, whereas no associations were found in type 2 diabetic individuals (Günther et al., 2009). Failure to obtain significant results in dietary indices in the current study may be explained by cross-sectional design of the research as well as the lack of information concerning the type of diabetes of the individuals.
Results of the present study regarding dietary antioxidant intakes showed that these nutrients were not predictors of having hypertension in diabetic individuals. Findings of a former cross-sectional study on type 2 diabetic patients showed that the total antioxidant capacity of the patient’s diet was inversely associated with hypertension (Farvid et al., 2013). A further study that assessed the associations between serum antioxidant vitamins and blood pressure reported that levels of vitamin C, α-carotene, and β-carotene were negatively related to blood pressure, while levels of vitamins A and E directly related to blood pressure (Chen et al., 2002). Although oxidative stress is discovered to be involved in the pathophysiology of high blood pressure (Ahmad et al., 2017), not all hypertensions are linked to oxidative stress (Baradaran et al., 2014). Furthermore, if an antioxidant is not restored after scavenging the free radicals, it will start to be a pro-oxidant (Baradaran et al., 2014).
Discussion
Results of the present study indicated that female gender, being older, positive family history of hypertension, and higher BMI were significantly associated with having hypertension in diabetic patients. Findings from a cross-sectional study which was carried out in adults in Isfahan, Iran, indicated that hypertensive patients were significantly older, had higher BMI, and had a higher family history of hypertension compared with normotensive participants. However, male gender was more prevalent in hypertensive subjects (Eghbali et al., 2018). Moreover, results of a cross-sectional study in urban population of Varanasi, India, demonstrated that factors such as male gender, the eldest age group, and overweight or obese had higher odds for hypertension (Singh et al., 2017).
The incidence of hypertension is rising greatly among the elderly population. Increased inflammation and oxidative stress that play a role in aging process can contribute to the development of hypertension (Buford, 2016).
The effect of gender on hypertension is poorly elucidated. Various studies have described gender differences as a cardiovascular risk factor. But, their findings are sometimes contradictory (Doumas et al., 2013). It has been reported that some biological factors protect women against hypertension before menopause (Everett and Zajacova, 2015). For instance, high estrogen concentration in premenopausal women decreases aortic stiffness. However, abrupt decrease in estrogen level after menopause results in an elevated cardiovascular risk (Doumas et al., 2013). The contrary result obtained from the present study should be more extensively investigated in the population of diabetic patients with hypertension.
Family history is frequently used as an alternative indicator to investigate the relationship between genetic factors and diseases. As mentioned earlier, both genetic and environmental factors lead to an increased risk of hypertension (Peng et al., 2019).
There is also a great body of evidence that suggests excess weight gain is a main contributor to high blood pressure. Physical compression of the kidneys with fat, activation of the renin-angiotensin-aldosterone system, and elevated activation of sympathetic nervous system are some of the proposed mechanisms for obesity-induced hypertension (Hall et al., 2015).
Bioactive foods are substances with strong anti-oxidative, anti-inflammatory, antithrombotic, antihypertensive and immune-modulating properties (Mozaffari-Khosravi et al., 2009, Parihar and Parihar, 2019). In the current study, higher intake of garlic was significantly associated with lower odds of hypertension in the diabetic population. Similar to the findings of this study, treatment with raw crushed garlic in patients with metabolic syndrome significantly decreased blood pressure (Choudhary et al., 2018). In addition, a cross-sectional study of Chinese adults without hypertension reported that a more frequent raw garlic consumption was negatively associated with prehypertension (Zhang et al., 2020).
Possible mechanisms of garlic consumption on reduction of blood pressure include inhibiting angiotensin-converting enzyme, increasing the concentration of nitric oxide, and producing hydrogen sulfide by erythrocytes (Rohner et al., 2015, Xiong et al., 2015). It has been reported that hydrogen sulfide induces dilatation of blood vessels in smooth muscle cells (Rohner et al., 2015). Allicin is the primary and most biologically active ingredient in garlic, responsible for its pharmacological functions (Savairam et al., 2023, Xiong et al., 2015).
None of the dietary indices (i.e. AHEI-2010, DII and PI) in the present study were significantly associated with high blood pressure in diabetic patients. In agreement with this finding, in a cross-sectional study performed on adults without chronic diseases, DII score was not associated with blood pressure of the participants (Muhammad et al., 2019). In another study on normotensive subjects, the prospective association between dietary PI and the risk of hypertension were assessed. However, in this study the odds of hypertension were significantly lower for higher quartiles of dietary PI after controlling for confounders (Golzarand et al., 2015). Furthermore, in a previous study, the association between adherence to Dietary Approaches to Stop Hypertension (DASH) diet and high blood pressure was investigated in youth with diabetes. The findings demonstrated that a higher DASH score was inversely associated with hypertension in type 1 diabetic patients, whereas no associations were found in type 2 diabetic individuals (Günther et al., 2009). Failure to obtain significant results in dietary indices in the current study may be explained by cross-sectional design of the research as well as the lack of information concerning the type of diabetes of the individuals.
Results of the present study regarding dietary antioxidant intakes showed that these nutrients were not predictors of having hypertension in diabetic individuals. Findings of a former cross-sectional study on type 2 diabetic patients showed that the total antioxidant capacity of the patient’s diet was inversely associated with hypertension (Farvid et al., 2013). A further study that assessed the associations between serum antioxidant vitamins and blood pressure reported that levels of vitamin C, α-carotene, and β-carotene were negatively related to blood pressure, while levels of vitamins A and E directly related to blood pressure (Chen et al., 2002). Although oxidative stress is discovered to be involved in the pathophysiology of high blood pressure (Ahmad et al., 2017), not all hypertensions are linked to oxidative stress (Baradaran et al., 2014). Furthermore, if an antioxidant is not restored after scavenging the free radicals, it will start to be a pro-oxidant (Baradaran et al., 2014).
The population-based design of this study,
its relatively large sample size, providing questionnaires in electronic form (for improving the accuracy and validity of the entered data), as well as controlling for potential confounders were the strengths of the present work. Besides, this study was notable due to exploring the relationships between various dietary factors and hypertension in the population of diabetics. This study had also certain limitations. The principal limitation was the cross-sectional nature of the research that precluded definite causal inferences which may also be a source of recall bias. Furthermore, in the data collection forms no information was available regarding the type of diabetes regarding the participants. Therefore, the researchers could not interpret the results separately for each type of diabetes. Finally, the patients were not newly diagnosed, and nutritional recommendations were not given to them.
Conclusion
In conclusion, it seems that higher garlic consumption is inversely associated with having hypertension in diabetic patients. However, being female and older, having a family history of hypertension, and higher BMI are positively associated with this health problem. Therefore, modifying diet and weight management under the supervision of an experienced dietitian are recommended for controlling hypertension in this group of patients. Further studies with prospective or interventional designs are required to confirm these results.
Acknowledgments
The authors would like to thank Shiraz University of Medical Sciences for approving and funding this research.
Authors’ contributions
Homayounfar, R. and Farjam, M. designed and conducted the research. Moazen, M. and Kazemi, A. analyzed and interpreted data, wrote the article, and had the primary responsibility for final content. Babajafari, S. designed the study, interpreted the data and revised the manuscript. All authors read and approved the final manuscript.
Conflict of Interest
The authors declared no conflict of interests.
Funding
Shiraz University of Medical Sciences funded this study.
References
Ahmad KA, et al. 2017. Antioxidant therapy for management of oxidative stress induced hypertension. Free radical research. 51 (4): 428-438.
Baradaran A, Nasri H & Rafieian-Kopaei M 2014. Oxidative stress and hypertension: Possibility of hypertension therapy with antioxidants. Journal of research in medical sciences. 19 (4): 358.
Buford TW 2016. Hypertension and Aging. Ageing research reviews. 26: 96.
Castro I, Waclawovsky G & Marcadenti A 2015. Nutrition and physical activity on hypertension: implication of current evidence and guidelines. Current hypertension reports. 11 (2): 91-99.
Chen J, He J, Hamm L, Batuman V & Whelton PK 2002. Serum antioxidant vitamins and blood pressure in the United States population. Hypertension. 40 (6): 810-816.
Chiuve SE, et al. 2012. Alternative dietary indices both strongly predict risk of chronic disease. Journal of nutrition. 142 (6): 1009-1018.
Choudhary PR, Jani RD & Sharma MS 2018. Effect of Raw Crushed Garlic (Allium sativum L.) on Components of Metabolic Syndrome. Journal of dietary supplements. 15 (4): 499-506.
Delshad Aghdam S, et al. 2021. Dietary phytochemical index associated with cardiovascular risk factor in patients with type 1 diabetes mellitus. BMC cardiovascular disorders. 21 (1): 293.
Doumas M, Papademetriou V, Faselis C & Kokkinos P 2013. Gender differences in hypertension: myths and reality. Current hypertension reports. 15 (4): 321-330.
Eghbali M, et al. 2018. Prevalence, awareness, treatment, control, and risk factors of hypertension among adults: a cross-sectional study in Iran. Epidemiology and health. 40.
Eghtesad S, et al. Validity and reproducibility of a food frequency questionnaire assessing food group intake in the PERSIAN Cohort Study. Frontiers in nutrition. 10: 1059870.
Everett B & Zajacova A 2015. Gender Differences in Hypertension and Hypertension Awareness Among Young Adults. Biodemography and social biology. 61 (1): 1.
Farjam M, et al. 2016. A cohort study protocol to analyze the predisposing factors to common chronic non-communicable diseases in rural areas: Fasa Cohort Study. BMC public health. 16 (1): 1090.
Farvid M, et al. 2013. The associations between oxygen radical absorbance capacity of dietary intake and hypertension in type 2 diabetic patients. Journal of human hypertension. 27 (3): 164-168.
Golzarand M, Bahadoran Z, Mirmiran P, Sadeghian-Sharif S & Azizi F 2015. Dietary phytochemical index is inversely associated with the occurrence of hypertension in adults: a 3-year follow-up (the Tehran Lipid and Glucose Study). European journal of clinical nutrition. 69 (3): 392-398.
Günther AL, et al. 2009. Association between the dietary approaches to hypertension diet and hypertension in youth with diabetes mellitus. Hypertension. 53 (1): 6-12.
Hall JE, do Carmo JM, da Silva AA, Wang Z & Hall ME 2015. Obesity-induced hypertension: interaction of neurohumoral and renal mechanisms. Circulation research. 116 (6): 991-1006.
Harding JL, Pavkov ME, Magliano DJ, Shaw JE & Gregg EW 2019. Global trends in diabetes complications: a review of current evidence. Diabetologia. 62 (1): 3-16.
Jo U & Park K 2022. Phytochemical index and hypertension in Korean adults using data from the Korea National Health and Nutrition Examination Survey in 2008-2019. European journal of clinical nutrition. 76 (11): 1594-1599.
Katayama S, Hatano M & Issiki M 2018. Clinical features and therapeutic perspectives on hypertension in diabetics. Hypertension research. 41 (4): 213-229.
Kokubo Y, Padmanabhan S, Iwashima Y, Yamagishi K & Goto A 2019. Gene and environmental interactions according to the components of lifestyle modifications in hypertension guidelines. Environmental health preventive medicine. 24: 1-11.
Loperena R & Harrison DG 2017. Oxidative Stress and Hypertensive Diseases. Medical clinics of North America. 101 (1): 169-193.
McCarty MF 2004. Proposal for a dietary “phytochemical index”. Medical hypotheses. 63 (5): 813-817.
Mozaffari-Khosravi H, Jalali-Khanabadi B-A, Afkhami-Ardekani M, Fatehi F & Noori-Shadkam M 2009. The effects of sour tea (Hibiscus sabdariffa) on hypertension in patients with type II diabetes. Journal of human hypertension. 23 (1): 48-54.
Muhammad HFL, et al. 2019. Dietary inflammatory index score and its association with body weight, blood pressure, lipid profile, and leptin in indonesian adults. Nutrients. 11 (1): 148.
Parihar A & Parihar MS 2019. Bioactive Food Components in the Prevention of Cardiovascular Diseases. In Bioactive Molecules in Food (ed. J.-M. Mérillon and K. G. Ramawat), pp. 137-157. Springer International Publishing: Cham.
Peng Q, Shao Y-Q, Fang X & Zhang Y-Y 2019. The effect of body mass index and its interaction with family history on hypertension: a case-control study. Clinical hypertension. 25: 6.
Petersmann A, et al. 2019. Definition, Classification and Diagnosis of Diabetes Mellitus. Experimental clinical endocrinology diabetes. 127 (S 01): S1-S7.
Phillips CM, et al. 2019. Dietary Inflammatory Index and Non-Communicable Disease Risk: A Narrative Review. Nutrients. 11 (8): 1873.
Rana SK, Sharma P, Gupta J & Singh N 2023. Literature Review on Evaluation of Ulcerative Disorder in Patient Suffering from Diabetes Mellitus. World journal of pharmaceutical research. 12 (6): 419-444.
Rohner A, Ried K, Sobenin IA, Bucher HC & Nordmann A 2015. A systematic review and metaanalysis on the effects of garlic preparations on blood pressure in individuals with hypertension. American journal of hypertension. 28 (3): 414-423.
Savairam VD, Patil NA, Borate SR, Ghaisas MM & Shete RV 2023. Allicin: A review of its important pharmacological activities. Pharmacological research-modern chinese medicine. 8: 100283.
Shivappa N, Steck SE, Hurley TG, Hussey JR & Hébert JR 2014. Designing and developing a literature-derived, population-based dietary inflammatory index. Public health nutrition. 17 (8): 1689-1696.
Singh S, Shankar R & Singh GP 2017. Prevalence and Associated Risk Factors of Hypertension: A Cross-Sectional Study in Urban Varanasi. International journal of hypertension. 2017 (1): 5491838.
Sun H, et al. 2022. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes research and clinical practice. 183: 109119.
Thout SR, Yu J, Santos JA, Hameed M & Coyle DH 2023. Dietary intakes of hypertensive patients in rural India: Secondary outcomes of a randomised, double-blind, controlled trial. Dialogues in health. 2: 100109.
Tsimihodimos V, Gonzalez-Villalpando C, Meigs JB & Ferrannini E 2018. Hypertension and Diabetes Mellitus: Coprediction and Time Trajectories. Hypertension. 71 (3): 422-428.
Valenzuela PL, et al. 2021. Lifestyle interventions for the prevention and treatment of hypertension. Nature reviews cardiology. 18 (4): 251-275.
Willett WC, et al. 1985. Reproducibility and validity of a semiquantitative food frequency questionnaire. American journal of epidemiology. 122 (1): 51-65.
Xiao L & Harrison DG 2020. Inflammation in Hypertension. Canadian journal of cardiology. 36 (5): 635-647.
Xiong X, et al. 2015. Garlic for hypertension: A systematic review and meta-analysis of randomized controlled trials. Phytomedicine. 22 (3): 352-361.
Zhang S, et al. 2020. Raw garlic consumption is inversely associated with prehypertension in a large-scale adult population. Journal of human hypertension. 34 (1): 59-67.
Zhang YJ, et al. 2015. Antioxidant Phytochemicals for the Prevention and Treatment of Chronic Diseases. Molecules (Basel, Switzerland). 20 (12): 21138-21156.
In conclusion, it seems that higher garlic consumption is inversely associated with having hypertension in diabetic patients. However, being female and older, having a family history of hypertension, and higher BMI are positively associated with this health problem. Therefore, modifying diet and weight management under the supervision of an experienced dietitian are recommended for controlling hypertension in this group of patients. Further studies with prospective or interventional designs are required to confirm these results.
Acknowledgments
The authors would like to thank Shiraz University of Medical Sciences for approving and funding this research.
Authors’ contributions
Homayounfar, R. and Farjam, M. designed and conducted the research. Moazen, M. and Kazemi, A. analyzed and interpreted data, wrote the article, and had the primary responsibility for final content. Babajafari, S. designed the study, interpreted the data and revised the manuscript. All authors read and approved the final manuscript.
Conflict of Interest
The authors declared no conflict of interests.
Funding
Shiraz University of Medical Sciences funded this study.
References
Ahmad KA, et al. 2017. Antioxidant therapy for management of oxidative stress induced hypertension. Free radical research. 51 (4): 428-438.
Baradaran A, Nasri H & Rafieian-Kopaei M 2014. Oxidative stress and hypertension: Possibility of hypertension therapy with antioxidants. Journal of research in medical sciences. 19 (4): 358.
Buford TW 2016. Hypertension and Aging. Ageing research reviews. 26: 96.
Castro I, Waclawovsky G & Marcadenti A 2015. Nutrition and physical activity on hypertension: implication of current evidence and guidelines. Current hypertension reports. 11 (2): 91-99.
Chen J, He J, Hamm L, Batuman V & Whelton PK 2002. Serum antioxidant vitamins and blood pressure in the United States population. Hypertension. 40 (6): 810-816.
Chiuve SE, et al. 2012. Alternative dietary indices both strongly predict risk of chronic disease. Journal of nutrition. 142 (6): 1009-1018.
Choudhary PR, Jani RD & Sharma MS 2018. Effect of Raw Crushed Garlic (Allium sativum L.) on Components of Metabolic Syndrome. Journal of dietary supplements. 15 (4): 499-506.
Delshad Aghdam S, et al. 2021. Dietary phytochemical index associated with cardiovascular risk factor in patients with type 1 diabetes mellitus. BMC cardiovascular disorders. 21 (1): 293.
Doumas M, Papademetriou V, Faselis C & Kokkinos P 2013. Gender differences in hypertension: myths and reality. Current hypertension reports. 15 (4): 321-330.
Eghbali M, et al. 2018. Prevalence, awareness, treatment, control, and risk factors of hypertension among adults: a cross-sectional study in Iran. Epidemiology and health. 40.
Eghtesad S, et al. Validity and reproducibility of a food frequency questionnaire assessing food group intake in the PERSIAN Cohort Study. Frontiers in nutrition. 10: 1059870.
Everett B & Zajacova A 2015. Gender Differences in Hypertension and Hypertension Awareness Among Young Adults. Biodemography and social biology. 61 (1): 1.
Farjam M, et al. 2016. A cohort study protocol to analyze the predisposing factors to common chronic non-communicable diseases in rural areas: Fasa Cohort Study. BMC public health. 16 (1): 1090.
Farvid M, et al. 2013. The associations between oxygen radical absorbance capacity of dietary intake and hypertension in type 2 diabetic patients. Journal of human hypertension. 27 (3): 164-168.
Golzarand M, Bahadoran Z, Mirmiran P, Sadeghian-Sharif S & Azizi F 2015. Dietary phytochemical index is inversely associated with the occurrence of hypertension in adults: a 3-year follow-up (the Tehran Lipid and Glucose Study). European journal of clinical nutrition. 69 (3): 392-398.
Günther AL, et al. 2009. Association between the dietary approaches to hypertension diet and hypertension in youth with diabetes mellitus. Hypertension. 53 (1): 6-12.
Hall JE, do Carmo JM, da Silva AA, Wang Z & Hall ME 2015. Obesity-induced hypertension: interaction of neurohumoral and renal mechanisms. Circulation research. 116 (6): 991-1006.
Harding JL, Pavkov ME, Magliano DJ, Shaw JE & Gregg EW 2019. Global trends in diabetes complications: a review of current evidence. Diabetologia. 62 (1): 3-16.
Jo U & Park K 2022. Phytochemical index and hypertension in Korean adults using data from the Korea National Health and Nutrition Examination Survey in 2008-2019. European journal of clinical nutrition. 76 (11): 1594-1599.
Katayama S, Hatano M & Issiki M 2018. Clinical features and therapeutic perspectives on hypertension in diabetics. Hypertension research. 41 (4): 213-229.
Kokubo Y, Padmanabhan S, Iwashima Y, Yamagishi K & Goto A 2019. Gene and environmental interactions according to the components of lifestyle modifications in hypertension guidelines. Environmental health preventive medicine. 24: 1-11.
Loperena R & Harrison DG 2017. Oxidative Stress and Hypertensive Diseases. Medical clinics of North America. 101 (1): 169-193.
McCarty MF 2004. Proposal for a dietary “phytochemical index”. Medical hypotheses. 63 (5): 813-817.
Mozaffari-Khosravi H, Jalali-Khanabadi B-A, Afkhami-Ardekani M, Fatehi F & Noori-Shadkam M 2009. The effects of sour tea (Hibiscus sabdariffa) on hypertension in patients with type II diabetes. Journal of human hypertension. 23 (1): 48-54.
Muhammad HFL, et al. 2019. Dietary inflammatory index score and its association with body weight, blood pressure, lipid profile, and leptin in indonesian adults. Nutrients. 11 (1): 148.
Parihar A & Parihar MS 2019. Bioactive Food Components in the Prevention of Cardiovascular Diseases. In Bioactive Molecules in Food (ed. J.-M. Mérillon and K. G. Ramawat), pp. 137-157. Springer International Publishing: Cham.
Peng Q, Shao Y-Q, Fang X & Zhang Y-Y 2019. The effect of body mass index and its interaction with family history on hypertension: a case-control study. Clinical hypertension. 25: 6.
Petersmann A, et al. 2019. Definition, Classification and Diagnosis of Diabetes Mellitus. Experimental clinical endocrinology diabetes. 127 (S 01): S1-S7.
Phillips CM, et al. 2019. Dietary Inflammatory Index and Non-Communicable Disease Risk: A Narrative Review. Nutrients. 11 (8): 1873.
Rana SK, Sharma P, Gupta J & Singh N 2023. Literature Review on Evaluation of Ulcerative Disorder in Patient Suffering from Diabetes Mellitus. World journal of pharmaceutical research. 12 (6): 419-444.
Rohner A, Ried K, Sobenin IA, Bucher HC & Nordmann A 2015. A systematic review and metaanalysis on the effects of garlic preparations on blood pressure in individuals with hypertension. American journal of hypertension. 28 (3): 414-423.
Savairam VD, Patil NA, Borate SR, Ghaisas MM & Shete RV 2023. Allicin: A review of its important pharmacological activities. Pharmacological research-modern chinese medicine. 8: 100283.
Shivappa N, Steck SE, Hurley TG, Hussey JR & Hébert JR 2014. Designing and developing a literature-derived, population-based dietary inflammatory index. Public health nutrition. 17 (8): 1689-1696.
Singh S, Shankar R & Singh GP 2017. Prevalence and Associated Risk Factors of Hypertension: A Cross-Sectional Study in Urban Varanasi. International journal of hypertension. 2017 (1): 5491838.
Sun H, et al. 2022. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes research and clinical practice. 183: 109119.
Thout SR, Yu J, Santos JA, Hameed M & Coyle DH 2023. Dietary intakes of hypertensive patients in rural India: Secondary outcomes of a randomised, double-blind, controlled trial. Dialogues in health. 2: 100109.
Tsimihodimos V, Gonzalez-Villalpando C, Meigs JB & Ferrannini E 2018. Hypertension and Diabetes Mellitus: Coprediction and Time Trajectories. Hypertension. 71 (3): 422-428.
Valenzuela PL, et al. 2021. Lifestyle interventions for the prevention and treatment of hypertension. Nature reviews cardiology. 18 (4): 251-275.
Willett WC, et al. 1985. Reproducibility and validity of a semiquantitative food frequency questionnaire. American journal of epidemiology. 122 (1): 51-65.
Xiao L & Harrison DG 2020. Inflammation in Hypertension. Canadian journal of cardiology. 36 (5): 635-647.
Xiong X, et al. 2015. Garlic for hypertension: A systematic review and meta-analysis of randomized controlled trials. Phytomedicine. 22 (3): 352-361.
Zhang S, et al. 2020. Raw garlic consumption is inversely associated with prehypertension in a large-scale adult population. Journal of human hypertension. 34 (1): 59-67.
Zhang YJ, et al. 2015. Antioxidant Phytochemicals for the Prevention and Treatment of Chronic Diseases. Molecules (Basel, Switzerland). 20 (12): 21138-21156.
Type of article: orginal article |
Subject:
public specific
Received: 2023/06/9 | Published: 2024/08/20 | ePublished: 2024/08/20
Received: 2023/06/9 | Published: 2024/08/20 | ePublished: 2024/08/20
Send email to the article author
| Rights and permissions | |
 |
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
