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Open Access Full T ext Article
http: //dx.doi.org/10.2147/DMSO.S5132 5Prevalence of hypertension and obesity in patients
with type 2 diabetes mellitus in observational
studies: a systematic literature review
Ann D Colosia1
Roberto Palencia2
Shahnaz Khan1
1RTi Health Solutions, Research
Triangle Park, NC, USA; 2Boehringer
ingelheim GmbH, ingelheim, Germany
Correspondence: Ann D Colosia
RTi Health Solutions, 3040 Cornwallis
Road, Post Office Box 12194, Research
Triangle Park, NC 27709-2194, USA
Tel +1 919 541 6000
Fax +1 919 541 7222
email [anonimizat] gBackground: Hypertension and obesity are known to contribute, directly or indirectly, to the
development of long-term complications of type 2 diabetes mellitus (T2DM). Knowing the
prevalence of these comorbidities is important for determining the size of the population that
may benefit from strategies that reduce blood pressure and weight while controlling blood
glucose.
Methods: In this systematic literature review, electronic searches of PubMed, Embase, and
the Cochrane Library were conducted to identify observational studies of hypertension and/or
obesity prevalence in patients with T2DM throughout the world. The searches were limited to
studies reported in English from January 1, 2001 to February 16, 2012.
Results: From a total of 2,688 studies, 92 observational studies provided prevalence rates
for hypertension and/or obesity specifically in adults with T2DM. Fifteen studies of specific
subtypes of hypertension or subpopulations with T2DM were subsequently excluded, leaving
78 studies (in 77 articles) for inclusion in this article. Of these, 61studies reported hypertension
prevalence, 44 reported obesity prevalence, and 12 reported the prevalence of hypertension with
obesity. Most studies had a low risk of bias regarding diagnosis of T2DM (70/78), hyperten –
sion (59/69), or obesity (45/47). The continental regions with the most observational studies of
hypertension or obesity prevalence were Europe (n = 30) and Asia (n = 26). Hypertension rates
typically were high in all regions; most studies presented rates above 50%, and many presented
rates above 75%. Obesity rates exceeded 30% in 38 of 44 studies and 50% in 14 of 44 studies,
especially those assessing central obesity (based on waist circumference). Among obese adults,
hypertension rates were at or above 70% in Asia and above 80% in Europe; rates were lower
in North and South America but still above 30%.
Conclusion: Around the world, hypertension and obesity, separately or together, are common
comorbidities in adults with T2DM.
Keywords: epidemiology, waist circumference, blood pressure, body mass index, T2DM
Introduction
Hypertension1–6 and obesity7–13 increase the risk of long-term vascular complica –
tions of type 2 diabetes mellitus (T2DM), including stroke, chronic kidney disease,
heart disease, peripheral vascular disease, and death. The relative risk of cardiovas –
cular disease for persons with diabetes is double or more than that of persons without
diabetes,14 although the absolute risk of cardiovascular disease varies around the world.
Hypertension and obesity among patients with T2DM in developing countries are
perhaps even more harmful than in high-income countries, where access to health care
and adequate prevention programs help manage cardiovascular risk factors15 and can
delay complications.16 Blood pressure reduction has been associated with a decreased
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328Colosia et al
risk of T2DM-related complications, including death, stroke,
and the need for retinal photocoagulation.17 Weight loss
helps correct insulin resistance and dyslipidemia found in
patients with T2DM.18 Deaths from cardiovascular disease
and diabetes are highest in low- and middle-income countries
and lowest in high-income countries.19 Within all countries,
the poorest people are affected the most.19 Recent recom –
mendations from the American Diabetes Association and
the European Association for the Study of Diabetes note that
aggressive management of cardiovascular risk factors, which
include high blood pressure and obesity, may be even more
beneficial in patients with T2DM because of their increased
risk of cardiovascular morbidity and mortality.20
Knowing the proportion of the T2DM population at addi –
tional risk of complications from hypertension and obesity
is an important public health measure to determine public
and private resource requirements to reduce these risk fac –
tors or to care for patients after cardiovascular events. Many
epidemiologic reports describe separate prevalence rates
for hypertension, obesity, and diabetes among the general
population19,21–25 or present prevalence rates of hypertension
or obesity in patients with diabetes but often without separat –
ing data for type 1 versus type 2 diabetes.26–28 This systematic
literature review was conducted to determine the rates of
hypertension and/or obesity among patients with T2DM as
reported in observational studies.
Methods
Patient population
Studies included in this systematic literature review were
observational in design and reported hypertension and/or obe –
sity prevalence for adults (aged $18 years) with T2DM.
Data sources and search methods
The computerized literature search included published stud –
ies indexed in PubMed, Embase, the National Health Ser –
vice Economic Evaluation Database (NHS EED) (searched
July 25, 2011), and the Cochrane Library (without NHS EED)
(searched August 2, 2011) dating back to January 1, 2001.
An updated and expanded epidemiology search was con –
ducted on February 16, 2012 for publications dating back to
January 1, 2001. The 10-year period was chosen to capture the
most recent prevalence literature. Given the dynamic nature
of obesity and hypertension over the last several decades,19
recent literature was preferred to allow an understanding of
the current prevalence rates of hypertension and/or obesity
within T2DM populations. This research was not focused on
trends. The search strategies used a combination of medical subject heading (MeSH) terms and title words for the disease
state of interest (“type 2 diabetes mellitus”), the comorbidities
of interest (“hypertension,” “blood pressure,” or “obesity”)
and epidemiology terms (“morbidity,” “incidence,” “preva –
lence,” and the “epidemiology” subheading for the “obesity”
and “hypertension” MeSH terms).
The full search strategies are available in Table s S1
and S2 online at http://www.rtihs.org/supplemental/Colosi
aManuscriptSupplTables_20Aug2013.pd f.
Study selection and data extraction
Two independent reviewers (ADC and one other researcher
at RTI Health Solutions) examined the titles and abstracts
of articles identified in the database searches for potential
relevance. Included studies presented prevalence rates for
hypertension and/or obesity in patients with T2DM evalu –
ated in observational, noninterventional studies. Studies
of hospitalized patients were also included. Studies were
excluded if prevalence rates were not available for patients
with T2DM; if the T2DM population was defined by having
another chronic illness, such as cancer or atrial fibrillation;
or if the study was not reported in English ( Figure 1). The
inclusion criteria did not include preestablished definitions of
hypertension and obesity but instead relied on the identified
articles to define these. For potentially relevant sources, the
full articles were obtained and reviewed to determine whether
prevalence data were specific to patients with T2DM. Study
details were extracted into table s by one reviewer, while the
content of the table s was verified by a second reviewer not
involved in the data extraction. The reviewers discussed each
article to reach consensus regarding the study details.
For each study, the following data were extracted:
author(s); publication year; country of origin; study design;
study population size and description; data-collection period;
and prevalence rates for hypertension, obesity, and hyperten –
sion with obesity. The principal summary measures were the
percentage of patients with T2DM and hypertension, obesity,
or hypertension with obesity. (Data were extracted by ADC
and one other researcher at RTI Health Solutions.)
Risk of misclassification bias was assessed for each
disease state of interest. Involvement of a health care pro –
fessional in determining the presence of a disease state was
considered to confer a low risk of misclassification, whereas
patient self-reporting was considered to confer a high risk.
Risk of bias was unclear when the study did not meet the
definition for low risk of bias but also did not rely exclusively
on self-reporting. (The full criteria for risk of bias and the
individual study assessments are available in Table s S3 and S4
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329Prevalence of hypertension and obesity in type 2 diabetes
online at http://www.rtihs.org/supplemental/ColosiaManusc
riptSupplTables_20Aug2013.pd f).
Results
From both searches, 2,688 titles and abstracts were identi –
fied from the electronic databases. Of these, 335 full-text
articles were obtained and reviewed, of which 92 studies met
the inclusion criteria. Fifteen studies of patient subpopula –
tions (eg, other medical conditions) or specific subclas –
sifications of hypertension (eg, masked hypertension) were
omitted, leaving 78 studies in 77 articles for inclusion in
this review. The included studies reported the prevalence
of hypertension and/or obesity for patients with T2DM. Of
these, 61studies reported hypertension prevalence, 44 stud-
ies reported obesity prevalence, and 12 studies reported the
prevalence of hypertension with obesity. Europe (n = 30)
and Asia (n = 25) were the continental regions with the
greatest number of observational studies of hypertension
or obesity prevalence. Table S5 (online at http://www.rtihs.
org/supplemental/ColosiaManuscriptSupplTables_20Au
g2013.pd f) gives a more detailed description of each study.
The regions with the largest studies of T2DM populations
were Europe (maximum N = 180,369; median 1,610), North
America (maximum N = 138,336; median, 1,512), and Asia (maximum N = 89,857; median, 669). Smaller studies were
conducted in Oceania (combined N = 5,724 for two studies),
Africa (maximum N = 601; median, 218), and South America
(maximum N = 842; median, 270). Most of the study popula –
tions had a mean age between 50 and 70 years. All regions
except South America also included analyses of populations
with mean ages between 30 and 50 years. Europe also had
studies with mean ages between 70 and 90 years.
Prevalence of hypertension
Among the reviewed studies, hypertension was defined
as blood pressures $140/90, 130/85, and 130/80 mmHg
or the use of antihypertensive medications. Hypertension
prevalence usually increased within a study with decreasing
blood pressure cut points30–36 (eg, dropping the hypertension
definition from $140/90 to $130/80 mmHg). However,
among all of the included studies, there was no clear pat –
tern when the hypertension prevalence rates among patients
with T2DM were compared within a region by differing
hypertension definitions (analysis not shown). Therefore, the
data presented graphically in Figure 2 are not segregated by
hypertension definition. Figure 2 shows the prevalence rates
of hypertension by the regions alphabetically, with countries
within a region ranked by the highest estimate.Search 1:
• PubMed (n = 1,207)
• Embase (n = 905)
• NHS EED (n = 23)
• Cochrane (w/o NHS EED) (n = 168)
• Total number of abstracts retrieved
(n = 2,303)
Inclusions at title/abstract review
(n = 292)
Inclusions after full-text review
(includes 2 reviews)
(n = 123)
From searching bibliographies
(n = 16)
Total included
(n = 139)(Have epidemiology of hypertension and/or
obesity in patients with T2DM or risk analysis)Have epidemiology of hypertension
and/or obesity in patients with T2DMIdentified in electronic databasesSearch 2:
• PubMed (n = 151)
• Embase (n = 223)
• NHS EED (n = 1)
• Cochrane (w/o NHS EED) (n = 10)
• Total number of abstracts retrieved (n = 385)Identified in electronic databasesSearch 1
Search 1n = 245
n = 18
n = 195
n = 3
n = 19
n = 115
n = 35 n = 7n = 1,550Search 2
Search 2Exclusions at title/abstract
review (n = 2,011)
Study population is not
adults with T2DM, or noseparate data for adults with
T2DM
Study population is not
adults with T2DM, or no
separate data for adults with
T2DMNo data of interest on
hypertension and/or obesityin adults with T2DM
a
No data of interest on
hypertension and/or obesity
in adults with T2DMaRelevant data but in
subpopulations characteri-zed by other serious or
chronic medical conditions
b
Not publication type of
interestc
Not publication type ofinterest
c
Total inculded (n = 166)
Studies with risk association data only (n = 74)
Studies with any prevalence data (+/− risk association data) (n = 92 )Total included
(n = 27)From searching bibliographies
(n = 1)Inclusions after full-text review
(n = 26)Inclusions at title/abstract review
(n = 43)
Studies with prevalence data included in this article (n = 77d)Outcomes not reported in
English
Exclusions at full-text
review (n = 169)• •
•
•
•
•
•
•
••n = 8•n = 2•n = 31•n = 5•n = 162n = 144
••
••••
•
•
•
•
•
•
Figure 1 Flow diagram of review and inclusion/exclusion (Preferred Reporting Items for Systematic reviews and Meta-Analyses [PRISMA]).
Notes: aData of interest = incidence or prevalence of hypertension and/or obesity among adults with T2DM (searches one and two) or risk association of hypertension/
obesity with long-term micro- or macrovascular complications of T2DM (search one only); bdoes not exclude patients hospitalized with T2DM complications; cpublication
types excluded were commentaries, case studies, interim reports when end-of-study data were available, and reviews for which primary data were already included; done
article (Thomas and Atkins29) reported on two studies, for a total of 78 studies in 77 articles.
Abbreviations: NHS eeD, National Health Service economic evaluation Database; T2DM, type 2 diabetes mellitus.
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330Colosia et al
Prevalence of obesity
Obesity prevalence was assessed primarily by body mass
index (BMI) and waist circumference, although some
studies also assessed obesity by waist-to-hip ratio.32,34,35,56,85
In all regions, the cut point for defining obesity by BMI was
30 kg/m2, except in a few Asian studies, in which the cut
point was 25 kg/m2,56,86 or 25 kg/m2 for men and 27 kg/m2
for women.53 For waist circumference, obesity was most
commonly defined as measurements of at least 88 cm for
women and at least 102 cm for men (in Africa,41 Asia,33,52,56,87
and Europe32,34,88). (These waist circumference cut points
for increased cardiometabolic risk in women and men were
derived from waist circumferences that correlated with a
BMI $ 30 kg/m2 in a US population. A small minority of the
populations in the US, Europe, Australia, and New Zealand
with BMI below the obese range had waist circumference
values in the obese range).89
Figure 3 shows the prevalence rates of obesity by BMI,
and Figure 4 shows obesity prevalence by waist circumference with regions presented alphabetically, and countries within
a region ranked by the highest estimate. Obesity rates were
well above 30% in 38 of 44 of the studies. There were no data
from observational studies on obesity prevalence by waist
circumference for North America or Oceania. In Europe,
when obesity was defined by at least one of two measures
(elevated BMI or waist-to-hip ratio), obesity was present in
50.9%32 to 98.6%35 of adults with T2DM. In Asia, obesity was
present in 56.1% of adults with T2DM when the criteria were
elevated BMI ( .30 kg/m2) or waist-to-hip ratio, which was
a much higher rate than using BMI alone (6.7%).33 Another
study in Asia reported an obesity prevalence of 69.2% of
adults with T2DM by high waist-to-hip ratio.56
Table 1 shows the prevalence of obesity by BMI class.
The US studies show increases in class 2 and 3 obesity over
time nationally in adults with T2DM96 and in American
Indian and Alaska Native adults with T2DM.100 In the
national population, there was a 58% rise in overall obesity
from 1976 to 2004, with a 140% rise in class 3 obesity.96Zimbabwe37
Cameroon3880
70.1
64.9
85.8
78.4
78.07
76.549.9
42.2
36.4
22.342
40.4
29.357.9
56.495
92.6
87.7
86
86
80
74.1
79.1
78.3
75
6754.3
53.1
66.9
70.9
64.8
51.4
507985
90
65.932.6
75.832.849.954.56567.772.47313.638.5
60.2Israel31
Thailand44
Saudi Arabia45,46
People's Republic of China30,33
Korea47
Jordan48
Malaysia49
Taiwan53,54
Iran55
India36,56–58
Japan1
Sweden59–61,a
Germany7,32
Greece62
Italy63–65
UK9,10,66–68
Belgium69
Finland70,71
Macedonia72
Spain35,73
Ireland74
Romania75
US76,b
Guadeloupe77 North America (n = 3)
Oceania (n = 2)
South America (n = 5)
Multiregion (n = 1)Mexico78
Australia29,c
Brazil79–81
Belgium and Benin84Trinidad and Tobago82,83, dPakistan50,51,52Nigeria39–43
Africa
(n = 7)Asia
(n = 20)Europe
(n = 23)Percentage of patientsHTN, low estimate
HTN, high or single estimate100
90
80
70
60
50
40
30
20
10
0
Figure 2 Hypertension (HTN) prevalence rates among patients with type 2 diabetes mellitus.
Notes: Superscript numbers correspond to reference numbers. For countries with more than one reference citation, the citations are provided in the following order:
study presenting the low estimate; study presenting the high estimate; and, if applicable, study or studies presenting mid-range value(s). Mid-range values are not shown in
the figure. aMean ages in the study by Hassing et al59 were 83.1–84.0 years; bSuh et al76 provided both low and high estimates; cThomas and Atkins29 provided both low and
high estimates (two studies in one report); dthe low estimate in South America used an atypical definition of hypertension (the proportion of patients with systolic blood
pressure .144 mmHg).82
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331Prevalence of hypertension and obesity in type 2 diabetes
Prevalence of hypertension with obesity
Five studies reported the rate of both hypertension and obesity
among patients with T2DM.7,43,82,88,99 In Africa (Nigeria43), the
presence of both hypertension and obesity defined by BMI was
found in 44.9% of patients with T2DM. In Europe, two studies found similar rates of coexistence of these comorbidities when
obesity was defined by BMI (50.7% in Germany7) or waist
circumference (52% in Italy88). In South America, two studies
of the same population found higher rates of coexistence with
hypertension (systolic blood pressure .144 mmHg or dia -Africa
(n = 4)Asia
(n = 10)Europe
(n = 9)Percentage of patientsBMI, low estimate
BMI, high or single estimate100
90
80
70
60
50
40
30
20
10
0
Zimbabwe37
Israel31Qatar90Saudi Arabia46
People's Republic of China33
Croatia95Jordan48
Taiwan53,54Iran87
India56
Japan86
Sweden94Germany7
France93Italy63UK9,10,91,92
US76,96
Guadeloupe77
North
America
(n = 5)
Oceania (n = 2)South
America
(n = 5)Mexico78,97
Australia29,a
Brazil81Trinidad and Tobago82 Nigeria39,43,85
42.5
85.5
83.45
58.6
53.8
51.6
38
40.6
37.3
33.9
6.7
22.1
64.1
49.8
39.2
37.5
36.9
32.7
62.4
64.2
38
39.2
26.8
46
51
30.5
34.23211.9
Figure 3 Prevalence of obesity defined by body mass index (BMI) among patients with type 2 diabetes mellitus.
Notes: Superscript numbers correspond to reference numbers. For countries with more than one reference citation, the citations are provided in the following order: study
presenting the low estimate; study presenting the high estimate; and, if applicable, study or studies presenting mid-range value(s). Mid-range values are not shown in the figure.
aThomas and Atkins29 provided both low and high estimates (two studies in one report).
Africa
(n = 2)Asia
(n = 6)Europe
(n = 6)Percentage of patientsWC, low estimate
WC, high or single estimate100
90
80
70
60
50
40
30
20
10
0
Iran87India56,98Pakistan52People's
Republic
of China33Korea47UK9Italy34 Trinidad
and
Tobago83,99Macedonia72,bSpain35,73Germany32,a
South
America
(n = 2)Nigeria41,8547.7
54.6
81.5
6729.0
61.5
20.1
54.8
37.2
96.9
72.9
92
70.7
77.3
37.9
75.5
56.8
55.3
80.6
Figure 4 Prevalence of obesity defined by waist circumference (WC) among patients with type 2 diabetes mellitus.
Notes: Superscript numbers correspond to reference numbers. For countries with more than one reference citation, the citations are provided in the following order:
study presenting the low estimate; study presenting the high estimate. aKoehler et al32 provided both low and high estimates; bBosevski et al72 provided both low and high
estimates.
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332Colosia et al
stolic blood pressure .83 mmHg) when obesity was defined
by waist circumference (18.2% and 29.5%, respectively) than
by BMI (11.3% and 19.2%, respectively).82,99
Eight studies reported the presence of one comorbidity
in patients with the other comorbidity.2,9,31,48,82,94,97,101 Studies
in Asia (Israel31 and Jordan48) and Europe (Sweden94 and the
UK9) found a high prevalence ( $70%) of hypertension among
obese patients ( Figure 5). The rates were lower in single stud –
ies in North America (Mexico97) and South America (Trinidad and Tobago82) but still above 30% ( Figure 5). In the two
studies that reported the rate of obesity among hypertensive
patients, the rates were 43% in a European (Italian) study101
and 10.7% in an Asian (Saudi Arabian) study.2
Risk of bias
Most of the studies had a low risk of bias regarding diag –
nosis of T2DM, hypertension, or obesity. Only five of the
78 studies relied on self-reporting of T2DM (n = 4),54,62,76,96
Asia
(n = 2)BP ≥ 130/80 BP ≥ 130/85 BP ≥ 140/90 BP ≥ 130/80
or AHD useBP ≥ 140/90
or AHD useBP > 130/85
DBP > 83 SBP > 144Hypertension
not definedPercentage of patients100
93.3
84.5
69.776.687.5
80.4
33.0 33.053.590
80
70
60
50
40
30
20
10
0
Jordan48 Sweden94UK9Trinidad
and Tobago99Trinidad
and Tobago99Mexico97
South
America
(n = 1)North
America
(n = 1)Europe
(n = 2)Israel31 Israel31Israel31
Figure 5 Prevalence of hypertension among obese adults with type 2 diabetes mellitus.
Abbreviations: AHD, antihypertensive drug; BP, blood pressure; DBP, diastolic blood pressure; SBP, systolic blood pressure.Table 1 Prevelence (%) of body mass index (BMI) classes of obesity
Region/Country Prevalence by BMI Class
Africa
Nigeria85BMi Classes 1 and 2:a 14.3
BMi Class 3:b 4.3
Europe
UK91BMi Class 1:c 20.9
BMi Classes 2 and 3:d 9.6
UK9BMi Class 1:e 29
BMi Class 2:f 21.3
BMi Class 3:b 13.8
North America
US (Alaskan Natives and American Indians)100BMi Class 1:e 30.9 (in 1995); 28.9 (in 2004)
BMi Class 2:f 16.7 (in 1995); 20.4 (in 2004); P , 0.001
BMi Class 3:b 11.5 (in 1995); 20.3 (in 2004); P , 0.001
US (national population sample)96BMi Class 3:b 8.6 (in NHANES II); 20.7 (in NHANES 2005–2006); P , 0.0001
Asia
Taiwan54BMi Class 1:g 33.5
BMi Class 2:h 7.1
Notes: aBMI 30–39.9 kg/m2; bBMi $ 40 kg/m2; cBMi 30–34 kg/m2; dBMi $ 35 kg/m2; eBMI 30–34.9 kg/m2; fBMI 35–39.9 kg/m2; gBMI 25–29.9 kg/m2; hBMi $ 30 kg/m2.
Abbreviations: NHANeS, National Health and Nutrition examination Survey; UK, United Kingdom; US, United States.
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333Prevalence of hypertension and obesity in type 2 diabetes
hypertension (n = 2),54,93 or obesity (n = 1).54 Two of the stud –
ies were European – one from France93 and the other from
Greece62 – and one study was from Asia (Taiwan54). Four
studies had unclear diagnostic criteria for T2DM in patients
not attending diabetes clinics or hospitals – one from Asia,33
two from Europe,70,71 and one from North America.78 Seven
studies had unclear assessments of hypertension – one from
Africa40 and six from Europe.10,65,66,68,70,71 None of the studies
had unclear assessments of obesity.
Discussion
It is known that hypertension and obesity are common among
patients with T2DM. This systematic review has captured
data from observational studies from 36 countries around the
world, demonstrating that the high prevalence of both obesity
and hypertension is a worldwide issue. In this review, most
of the studies reported hypertension rates above 60%, with
rates even exceeding 75% in many of the studies. India,36,56–58
Japan,1 and Iran55 were no table for having even their highest
prevalence estimates below 50%, whereas Mexico,78 Romania,75
and Taiwan13,54 had single or highest estimates just above 50%
(Figure 2). Even for the countries with relatively low prevalence
rates of hypertension in this review, the rates were consistent
with higher hypertension rates among adults with diabetes102
when compared with reports of general populations or adults
without diabetes. In India, although the overall hypertension rate
among patients with T2DM in the study by Tharkar et al58 was
39%, the urban prevalence was 63.2% and the rural prevalence
was 36.8%. Hypertension prevalence among adults from the
general population in urban India ranges from 20% to 40% and
in rural areas from 12% to 17%.103 Therefore, the by-locality
hypertension rates reported by Tharkar et al58 are consistent with
the expectation of hypertension rates that are 1.5 to 3.0 times
higher in persons with T2DM than in those without diabetes.102
Similarly, the hypertension rates among patients with T2DM
were higher than rates reported for the general population in
Iran,19,55 Japan,1,19 Mexico,78,104 and Romania.75,105
Of the studies evaluating obesity prevalence in patients
with T2DM, over one-quarter of the 32 rates based on BMI
were above 50%, whereas over four-fifths of the rates esti –
mated by waist circumference ( Figure 4) were above 50%.
The high prevalence of central obesity (high waist circum –
ference) in most regions was observed despite the fact that
only seven studies used waist circumference cut points as
low as32,47,72,83,98 or lower than47,98 those recommended by
the International Diabetes Federation (IDF) ( $80 cm for
women and $94 cm for men from Europe, Sub-Saharan
Africa, Eastern Mediterranean, and Middle East; $80 cm for women and $90 cm for men from South Asia, South and
Central America, People’ s Republic of China, and Japan).106
Therefore, the prevalence rates for central obesity are likely
underestimates for many of the studies in this review.
The need for measuring both BMI and waist circumfer –
ence in clinical practice is debated. Although waist circumfer –
ence is a strong predictor of cardiometabolic risk, multiple
expert organizations have agreed that adding this measure in
the USA is unlikely to alter the management of obesity already
defined by the gold-standard BMI.89 They did note the value of
assessing waist circumference changes in monitoring weight
loss.89 However, guidelines in India give BMI ( .25 kg/m2) and
waist circumference ( .90 cm for men; .80 cm for women)
equal importance in determining cardiometabolic risk and
recommend that both should be measured.107
In this review, the ranges of prevalence rates for hyper –
tension and obesity were broad for many of the regions and
also globally. The variations may be due to patient selection
methods and to sample sizes. For example, for hyperten –
sion prevalence, the particularly low estimate of 13.6% was
found in a Saudi Arabian study in which the patients with
T2DM were identified in a national screening program.45
This contrasted with the 78.07% prevalence rate in another
Saudi Arabian study that recruited patients from hospitals or
clinics.46 Further, the data in this review are the minimum
and maximum prevalence rates reported by the studies, with
no age or sample size adjustments.
Strengths and limitations
of this literature review
Risk of disease misclassification is a concern with studies
that investigate prevalence rates. Although the verification of
the disease states by a health care professional was not part
of the inclusion criteria for this review, most of the studies
in this review had this verification for T2DM, hypertension,
and obesity. Very few of the observational studies in this
review relied on patient self-report of T2DM, hypertension,
or obesity.
This literature review study included only observational
studies. In clinical trials, physicians may be biased to enroll
patients in greater need of medical management – possibly
increasing enrollment of patients with hypertension compared
with the general population of patients with T2DM. Further,
clinical studies involve alterations in treatment and new inter –
ventions; therefore, the potential or perceived increased risk
may limit the study to a subset of patients with T2DM.
Studies in this literature review were grouped geo –
graphically by country and continent. No study meeting the
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334Colosia et al
inclusion criteria (see “Methods”) was excluded based on
the country in which it was conducted. Prevalence data were
obtained for all six of the well-populated continents. How –
ever, the interpretation of the findings in this review is limited
by the lack of representation for some sizable populations.
None of the studies identified was conducted in Russia, some
of the highly populated regions in Southeast Asia, Canada,
or most of the countries in South America and Africa. Some
of the highest diabetes prevalence rates, ranging from 16.4%
in Vanuatu to 25.7% in Kiribati, have been found in Pacific
Island nations108 not represented in this article. Russia has
a high prevalence of diabetes (10.0% of the population, or
12.6 million persons),108 hypertension (34.4% with blood
pressure $140/90 mmHg or on antihypertensive medica –
tions),109 and obesity (24.9% with BMI $ 30 kg/m2).110 Few
studies were identified for the People’ s Republic of China,
although it is the country with the largest number of patients
with diabetes (90 million).108
This literature review focused on studies presenting
separate prevalence data for patients with T2DM, apart
from diabetes as a whole. This focus may explain some of
the gaps in regional data because information on comor –
bidities is often gathered for patients with diabetes without
regard to type. Another possible explanation for the gaps
is that studies reporting the prevalence of hypertension or
obesity incidental to non-epidemiologic research questions
would not have been identified, because the search terms
in this review identified studies indexed as having the
epidemiology of hypertension or obesity as a major focus.
In addition, this review included only studies reported in
English. Although an update of the systematic literature
review reported here is beyond the scope of the current
article, an informal search of the electronic databases was
conducted on August 2, 2013. This search identified poten –
tially useful studies from countries already represented in
the systematic review, including the People’ s Republic of
China,111–113 and from four additional countries (Bangla –
desh,114 the Congo,115 Ghana,116 and Morocco117) but still
no studies from Russia or Canada.
Unmet need
The unmet need for controlling hypertension and obesity
among adults with T2DM is great. In the USA, over 40%
of those with diabetes and hypertension have uncontrolled
hypertension26 even though the expenditure to treat diabetes
in this country is the highest in the world.118 Controlling
obesity in persons with T2DM is especially challenging
because obesity has been increasing over the last several decades among all persons in all regions of the world, with
most regions seeing dramatic increases.19 The same factors
increasing obesity among all persons are faced by the
patients with T2DM as they try to reduce weight. The pos –
sible environmental factors include the increased availability
of cheap, energy-dense, and highly pala table foods; better
food distribution systems; and pervasive food marketing
strategies – all coupled with decreased physical activity due
in part to changes in work activity and transportation.119 The
challenge of controlling weight among persons with T2DM
is likely to only continue because the rise in obesity is driv –
ing an increase in T2DM.21,120 The number of persons with
T2DM is expected to reach 552 million in 2030, owing to
increasing prevalence in every country.108
Many of the strategies for control of hypertension and
obesity can be used for persons with or without diabetes and
regardless of type of diabetes, although a preference exists
for including angiotensin-converting enzyme inhibitors in the
treatment of persons with diabetes.18,121 Treatment choices for
T2DM are numerous20 and have differing effects on weight
and blood pressure.122 Although long-term data that confirm
the benefit of small reductions in weight or blood pressure are
often lacking, antidiabetic therapies should – to the greatest
possible extent, given patient needs – at least not worsen hyper –
tension and obesity. However, the literature review presented
in this article focused on prevalence only and does not support
recommendations about specific weight-reducing or blood
pressure-reducing therapies. Outcomes of prospective trials of
antidiabetic agents that lead to weight and/or blood pressure
reduction should help clarify the benefits of these effects.
Conclusion
The prevalence rates of hypertension and obesity in patients
with T2DM are high throughout the world. There is evidence
of no table differences in these rates among countries/regions.
Controlling hypertension and reducing obesity in these
patients is important to limit the morbidity and costs for the
health care systems derived from diabetic complications.
Knowing the prevalence of these comorbidities is important
for determining the size of the population that may benefit
from strategies to reduce blood pressure and weight in addi –
tion to adequately controlling blood glucose.
Acknowledgments
The authors thank Dr Manel Pladevall-Vila, Ms Catherine
Copley-Merriman, and Mr Bastian Hass for reviewing the
manuscript. We also thank Maureen Kurtz for reviewing
titles/abstracts and articles and for data extraction.
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335Prevalence of hypertension and obesity in type 2 diabetes
Disclosure
This project was funded under a contract with Boehringer
Ingelheim GmbH. Ann D Colosia and Shahnaz Khan are
employees of RTI Health Solutions and have provided
consulting services to Boehringer Ingelheim GmbH. Roberto
Palencia is an employee of Boehringer Ingelheim GmbH.
Boehringer Ingelheim markets and develops compounds for
the treatment of T2DM.
References
1. Nakano S, Ito T, Furuya K, et al. Ambulatory blood pressure level rather
than dipper/nondipper status predicts vascular events in type 2 diabetic
subjects. Hypertens Res . 2004;27(9):647–656.
2. Salman RA, Al-Rubeaan KA. Incidence and risk factors of hyperten –
sion among Saudi type 2 diabetes adult patients: an 11-year prospective
randomized study. J Diabetes Complications . 2009;23(2):95–101.
3. Stratton IM, Cull CA, Adler AI, Matthews DR, Neil HA, Holman RR.
Additive effects of glycaemia and blood pressure exposure on risk of
complications in type 2 diabetes: a prospective observational study
(UKPDS 75). Diabetologia . 2006;49(8):1761–1769.
4. Anderson RJ, Bahn GD, Moritz TE, et al; V ADT Study Group. Blood
pressure and cardiovascular disease risk in the Veterans Affairs Diabetes
Trial. Diabetes Care . 2011;34(1):34–38.
5. Gaede P , Lund-Andersen H, Parving HH, Pedersen O. Effect of a
multifactorial intervention on mortality in type 2 diabetes. N Engl J
Med. 2008;358(6):580–591.
6. Bakris GL, Weir MR, Shanifar S, et al; RENAAL Study Group. Effects of
blood pressure level on progression of diabetic nephropathy: results from
the RENAAL study. Arch Intern Med . 2003;163(13):1555–1565.
7. Hanefeld M, Koehler C, Gallo S, Benke I, Ott P . Impact of the individual
components of the metabolic syndrome and their different combina –
tions on the prevalence of atherosclerotic vascular disease in type 2
diabetes: the Diabetes in Germany (DIG) study. Cardiovasc Diabetol .
2007;6:13.
8. Eeg-Olofsson K, Cederholm J, Nilsson PM, et al. Risk of cardiovascular
disease and mortality in overweight and obese patients with type 2
diabetes: an observational study in 13,087 patients. Diabetologia .
2009;52(1):65–73.
9. Song SH, Hardisty CA. Type 2 diabetes mellitus: a high-risk condition
for cardiovascular disease irrespective of the different degrees of
obesity. QJM . 2008;101(11):875–879.
10. Mulnier HE, Seaman HE, Raleigh VS, et al. Risk of stroke in people
with type 2 diabetes in the UK: a study using the General Practice
Research Database. Diabetologia . 2006;49(12):2859–2865.
11. Kim SK, Kim HJ, Ahn CW , et al. Hyperleptinemia as a robust risk
factor of coronary artery disease and metabolic syndrome in type 2
diabetic patients. Endocr J . 2008;55(6):1085–1092.
12. Scott R, O’Brien R, Fulcher G, et al; Fenofibrate Intervention and Event
Lowering in Diabetes (FIELD) Study Investigators. Effects of fenofi –
brate treatment on cardiovascular disease risk in 9,795 individuals with
type 2 diabetes and various components of the metabolic syndrome:
the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD)
study. Diabetes Care . 2009;32(3):493–498.
13. Tseng CH, Chong CK, Tseng CP , Shau WY , Tai TY . Hypertension is the
most important component of metabolic syndrome in the association
with ischemic heart disease in Taiwanese type 2 diabetic patients. Circ J .
2008;72(9):1419–1424.
14. Kannel WB, McGee DL. Diabetes and cardiovascular risk factors: the
Framingham study. Circulation . 1979;59(1):8–13.
15. World Health Organization (WHO). Cardiovascular diseases (CVDs)
[web page on the Internet]. Fact sheet no 317. Geneva: WHO; 2012
[updated September]. Available from: http://www.who.int/mediacentre/
factsheets/fs317/en/index.htm l. Accessed January 23, 2013. 16. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular
diseases: part I: general considerations, the epidemiologic transition,
risk factors, and impact of urbanization. Circulation . 2001;104(22):
2746–2753.
17. 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):703–713.
18. American Diabetes Association. Standards of medical care in
diabetes – 2013. Diabetes Care . 2013;36 Suppl 1:S11–S66.
19. WHO. World Health Statistics 2012 . Geneva: WHO; 2012. Available
from: http://www.who.int/gho/publications/world_health_statistics/
EN_WHS2012_Full.pd f. Accessed January 23, 2013.
20. Inzucchi SE, Bergenstal RM, Buse JB, et al; American Diabetes
Association (ADA); European Association for the Study of Diabetes
(EASD). Management of hyperglycemia in type 2 diabetes: a patient-
centered approach: position statement of the American Diabetes
Association (ADA) and the European Association for the Study of
Diabetes (EASD). Diabetes Care . 2012;35(6):1364–1379. Erratum in:
Diabetes Care . 2013;36(2):490.
21. Health and Environment Alliance (HEAL). Figures on Obesity and
Diabetes in the European Union . Brussels: HEAL; nd. Available from:
http://www.env-health.org/IMG/pdf/Obesity_and_diabetes_in_the_
European_Union_to_partners_2_.pd f. Accessed February 14, 2013.
22. Romero CX, Romero TE, Shlay JC, Ogden LG, Dabelea D. Changing
trends in the prevalence and disparities of obesity and other cardiovas –
cular disease risk factors in three racial/ethnic groups of USA adults.
Adv Prev Med . 2012;2012:172423.
23. Cook-Huynh M, Ansong D, Steckelberg RC, et al. Prevalence of
hypertension and diabetes mellitus in adults from a rural community
in Ghana. Ethn Dis . 2012;22(3):347–352.
24. Ford ES, Mokdad AH, Giles WH, Galuska DA, Serdula MK.
Geographic variation in the prevalence of obesity, diabetes, and obesity-
related behaviors. Obes Res . 2005;13(1):118–122.
25. Shen J, Goyal A, Sperling L. The emerging epidemic of obesity,
diabetes, and the metabolic syndrome in China. Cardiol Res Pract .
2012;2012:178675.
26. Keenan NL, Rosendorf KA; Centers for Disease Control and Prevention
(CDC). Prevalence of hypertension and controlled hypertension –
United States, 2005–2008. MMWR Surveill Summ . 2011;60 Suppl:
94–97.
27. CDC. Prevalence of overweight and obesity among adults with diag –
nosed diabetes – United States, 1988–1994 and 1999–2002. MMWR
Morb Mortal Wkly Rep . 2004;53(45):1066–1068.
28. Tiptaradol S, Aekplakorn W . Prevalence, awareness, treatment and
control of coexistence of diabetes and hypertension in thai population.
Int J Hypertens . 2012;2012:386453.
29. Thomas MC, Atkins R. Assessment and management of hypertension
in patients with type 2 diabetes. Intern Med J . 2009;39(3):143–149.
30. Chen XY , Thomas GN, Chen YK, Chan JC, Wong KS. Atherosclerotic
vascular disease rather than metabolic syndrome predicts ischemic
stroke in diabetic patients. Cerebrovasc Dis . 2010;30(4):374–379.
31. Kabakov E, Norymberg C, Osher E, et al. Prevalence of hypertension in
type 2 diabetes mellitus: impact of the tightening definition of high blood
pressure and association with confounding risk factors. J Cardiometab
Syndr . 2006;1(2):95–101.
32. Koehler C, Ott P , Benke I, Hanefeld M; DIG Study Group. Comparison
of the prevalence of the metabolic syndrome by WHO, AHA/NHLBI,
and IDF definitions in a German population with type 2 diabetes: the
Diabetes in Germany (DIG) Study. Horm Metab Res . 2007;39(9):
632–635.
33. Lu B, Y ang Y , Song X, et al. An evaluation of the International Diabetes
Federation definition of metabolic syndrome in Chinese patients older
than 30 years and diagnosed with type 2 diabetes mellitus. Metabolism .
2006;55(8):1088–1096.
34. Marchesini G, Forlani G, Cerrelli F , et al. WHO and ATPIII proposals
for the definition of the metabolic syndrome in patients with Type 2
diabetes. Diabet Med . 2004;21(4):383–387.
Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy downloaded from https://www.dovepress.com/ by 46.148.112.27 on 29-Jul-2018
For personal use only.
Powered by TCPDF (www.tcpdf.org)
1 / 1

Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2013:6submit your manuscript | www.dovepress.co m
Dove press Dove press
336Colosia et al
35. Relimpio F , Martinez-Brocca MA, Leal-Cerro A, et al. Variability in
the presence of the metabolic syndrome in Type 2 diabetic patients
attending a diabetes clinic. Influences of age and gender. Diabetes Res
Clin Pract . 2004;65(2):135–142.
36. Viswanathan V , Snehalatha C, Kumutha R, Nair BM, Ramachandran A.
Impact of Joint National Committee VII recommendations on diabetic
microvascular complications. J Assoc Physicians India . 2004;52:
873–876.
37. Makuyana D, Gomo Z, Munyombwe T, Matenga JA, Hakim JG.
Metabolic syndrome disorders in urban black Zimbabweans with type 2
Diabetes mellitus. Cent Afr J Med . 2004;50(3–4):24–29.
38. Choukem SP , Kengne AP , Dehayem YM, Simo NL, Mbanya JC.
Hypertension in people with diabetes in sub-Saharan Africa: revealing
the hidden face of the iceberg. Diabetes Res Clin Pract . 2007;77(2):
293–299.
39. Alebiosu CO, Odusan BO. Metabolic syndrome in subjects with type-2
diabetes mellitus. J Natl Med Assoc . 2004;96(6):817–821.
40. Puepet FH, Agaba EI, Chuhwak EK. Some metabolic abnormalities
in type 2 diabetic patients in Jos, north central Nigeria. Niger J Med .
2003;12(4):193–197.
41. Ogbera AO, Azenabor AO. Hyperuricaemia and the metabolic syndrome
in type 2 DM. Diabetol Metab Syndr . 2010;2:24.
42. Ikem RT, Akinola NO, Balogun MO, Ohwovoriole AE, Akinsola A.
What does the presence of hypertension portend in the Nigerian with
non insulin dependent diabetes mellitus. West Afr J Med . 2001;20(2):
127–130.
43. Isezuo SA, Ezunu E. Demographic and clinical correlates of metabolic
syndrome in Native African type-2 diabetic patients. J Natl Med Assoc .
2005;97(4):557–563.
44. Bunnag P , Plengvidhya N, Deerochanawong C, et al. Thailand diabetes
registry project: prevalence of hypertension, treatment and control of
blood pressure in hypertensive adults with type 2 diabetes. J Med Assoc
Thai. 2006;89 Suppl 1:S72–S77.
45. El-Hazmi MA, Warsy AS. Association of hypertension and non-insulin-
dependent diabetes mellitus in the Saudi population. Ann Saudi Med .
2001;21(1–2):5–8.
46. Alwakeel JS, Sulimani R, Al-Asaad H, et al. Diabetes complications in
1952 type 2 diabetes mellitus patients managed in a single institution
in Saudi Arabia. Ann Saudi Med . 2008;28(4):260–266.
47. Kim WY , Kim JE, Choi YJ, Huh KB. Nutritional risk and metabolic
syndrome in Korean type 2 diabetes mellitus. Asia Pac J Clin Nutr .
2008;17 Suppl 1:47–51.
48. Mubarak FM, Froelicher ES, Jaddou HY , Ajlouni KM. Hypertension
among 1000 patients with type 2 diabetes attending a national diabetes
center in Jordan. Ann Saudi Med . 2008;28(5):346–351.
49. Chan GC. Type 2 diabetes mellitus with hypertension at primary
healthcare level in Malaysia: are they managed according to guidelines?
Singapore Med J . 2005;46(3):127–131.
50. Khuwaja AK, Rafique G, White F, Azam SI. Macrovascular
complications and their associated factors among persons with type 2
diabetes in Karachi, Pakistan – a multi-center study. J Pak Med Assoc .
2004;54(2):60–66.
51. Shera AS, Jawad F, Maqsood A, Jamal S, Azfar M, Ahmed U.
Prevalence of chronic complications and associated factors in type 2
diabetes. J Pak Med Assoc . 2004;54(2):54–59.
52. Tariq M, Hadi A, Rahman SU. Metabolic syndrome in type-2
diabetics: an update on the silent epidemic. Rawal Medical Journal .
2010;35(2):201–204.
53. Tzeng TF , Hsiao PJ, Hsieh MC, Shin SJ. Association of nephropathy
and retinopathy, blood pressure, age in newly diagnosed type 2 diabetes
mellitus. Kaohsiung J Med Sci . 2001;17(6):294–301.
54. Tseng CH. Body mass index and blood pressure in adult type 2 diabetic
patients in Taiwan. Circ J . 2007;71(11):1749–1754.
55. Janghorbani M, Amini M. Metabolic syndrome in type 2 diabetes
mellitus in Isfahan, Iran: prevalence and risk factors. Metab Syndr Relat
Disord . 2007;5(3):243–254. 56. Vikram NK, Misra A, Pandey RM, et al. Anthropometry and body
composition in northern Asian Indian patients with type 2 diabetes:
receiver operating characteristics (ROC) curve analysis of body mass
index with percentage body fat as standard. Diabetes Nutr Metab .
2003;16(1):32–40.
57. Dhobi GN, Majid A, Masoodi SR, Bashir MI, Wani AI, Zargar AH.
Prevalence of hypertension in patients with new onset type 2 diabetes
mellitus. J Indian Med Assoc . 2008;106(2):92, 94–98.
58. Tharkar S, Satyavani K, Viswanathan V . Cost of medical care among
type 2 diabetic patients with a co-morbid condition – hypertension in
India. Diabetes Res Clin Pract . 2009;83(2):263–267.
59. Hassing LB, Hofer SM, Nilsson SE, et al. Comorbid type 2 diabetes
mellitus and hypertension exacerbates cognitive decline: evidence from
a longitudinal study. Age Ageing . 2004;33(4):355–361.
60. Torffvit O, Tencer J, Rippe B. The response to antihypertensive therapy
is dependent on renal structural changes. A 5-year prospective study of
renal biopsy in type 2 diabetic patients with micro-macroalbuminuria.
J Diabetes Complications . 2010;24(6):361–367.
61. Nilsson PM, Cederholm J, Zethelius BR, Eliasson BR, Eeg-Olofsson K,
Gudbj Rnsdottir S. Trends in blood pressure control in patients with
type 2 diabetes: data from the Swedish National Diabetes Register
(NDR). Blood Press . 2011;20(6):348–354.
62. Skliros E, Sotiropoulos A, Vasibossis A, et al. Poor hypertension control
in Greek patients with diabetes in rural areas. The V ANK study in
primary care. Rural Remote Health . 2007;7(3):583.
63. Comaschi M, Coscelli C, Cucinotta D, Malini P, Manzato E,
Nicolucci A; SFIDA Study Group – Italian Association of Diabetolo –
gists (AMD). Cardiovascular risk factors and metabolic control in type 2
diabetic subjects attending outpatient clinics in Italy: the SFIDA (survey
of risk factors in Italian diabetic subjects by AMD) study. Nutr Metab
Cardiovasc Dis . 2005;15(3):204–211.
64. Bacci S, Rizza S, Prudente S, et al. The ENPP1 Q121 variant predicts
major cardiovascular events in high-risk individuals: evidence for
interaction with obesity in diabetic patients. Diabetes . 2011;60(3):
1000–1007.
65. Zoppini G, Verlato G, Leuzinger C, et al. Body mass index and the risk
of mortality in type II diabetic patients from Verona. Int J Obes Relat
Metab Disord . 2003;27(2):281–285.
66. Echouffo-Tcheugui JB, Sargeant LA, Prevost AT, et al. How much might
cardiovascular disease risk be reduced by intensive therapy in people
with screen-detected diabetes? Diabet Med . 2008;25(12):1433–1439.
67. Higgins GT, Khan J, Pearce IA. Glycaemic control and control of risk
factors in diabetes patients in an ophthalmology clinic: what lessons
have we learned from the UKPDS and DCCT studies? Acta Ophthalmol
Scand . 2007;85(7):772–776.
68. Song SH, Hardisty CA. Early onset type 2 diabetes mellitus: a harbinger
for complications in later years – clinical observation from a secondary
care cohort. QJM . 2009;102(11):799–806.
69. Dehout F , Haumont S, Gaham N, Amoussou-Guenou K, Hermans MP .
Metabolic syndrome in Bantu subjects with type 2 diabetes from
sub- Saharan extraction: prevalence, gender differences and HOMA
hyperbolic product. Diabetes Metab Syndr Clin Res Rev . 2008;2(1):
5–11.
70. Hu G, Sarti C, Jousilahti P , et al. The impact of history of hypertension
and type 2 diabetes at baseline on the incidence of stroke and stroke
mortality. Stroke . 2005;36(12):2538–2543.
71. Hu G, Jousilahti P , Tuomilehto J. Joint effects of history of hypertension
at baseline and type 2 diabetes at baseline and during follow-up on the
risk of coronary heart disease. Eur Heart J . 2007;28(24):3059–3066.
72. Bosevski M, Pemovska G, Bosevska G, Georgievska-Ismail L. Clinical
role of estimation metabolic syndrome’ s components in type 2 diabetic
population with symptomatic coronary artery disease – a comparison
of two criteria. Med Arh . 2010;64(3):144–146.
73. del Cañizo-Gómez FJ, Moreira-Andrés MN. Cardiovascular risk factors
in patients with type 2 diabetes. Do we follow the guidelines? Diabetes
Res Clin Pract . 2004;65(2):125–133.
Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy downloaded from https://www.dovepress.com/ by 46.148.112.27 on 29-Jul-2018
For personal use only.
Powered by TCPDF (www.tcpdf.org)
1 / 1

Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2013:6submit your manuscript | www.dovepress.co m
Dove press Dove press
337Prevalence of hypertension and obesity in type 2 diabetes
74. Agha A, Dillon D, Corbett M, Sreenan S. Target blood pressure for
patients with type 2 diabetes is difficult to achieve in the setting of a
busy diabetes clinic. Ir J Med Sci . 2003;172(4):168–170.
75. Babe EB, Babe V , Ofrim D, Toadere A. Prevalence and prognostic
significance of silent myocardial ischemia in diabetic patients with and
without hypertension. Arch Balk Med Union . 2009;44(3):210–214.
76. Suh DC, Kim CM, Choi IS, Plauschinat CA, Barone JA. Trends in
blood pressure control and treatment among type 2 diabetes with
comorbid hypertension in the United States: 1988–2004. J Hypertens .
2009;27(9):1908–1916.
77. Foucan L, Deloumeaux J, Donnet JP , et al. Metabolic syndrome
components in Indian migrants with type 2 diabetes. A matched
comparative study. Diabetes Metab . 2006;32(4):337–342.
78. Jiménez-Corona A, Rojas R, Gómez-Pérez FJ, Aguilar-Salinas CA.
Early-onset type 2 diabetes in a Mexican survey: results from the
National Health and Nutrition Survey 2006. Salud Publica Mex . 2010;
52 Suppl 1:S27–S35.
79. Leitão CB, Canani LH, Kramer CK, et al. Blood pressure means rather
than nocturnal dipping pattern are related to complications in Type 2
diabetic patients. Diabet Med . 2008;25(3):308–313.
80. Moehlecke M, Leitão CB, Kramer CK, et al. Effect of metabolic syn –
drome and of its individual components on renal function of patients
with type 2 diabetes mellitus. Braz J Med Biol Res . 2010;43(7):
687–693.
81. Wobeto VP , Pinho Pda C, Souza JR, Zaccariotto TR, Zonati Mde F .
Haptoglobin genotypes and refractory hypertension in type 2 diabetes
mellitus patients. Arq Bras Cardiol . 2011;97(4):338–345. English and
Portuguese.
82. Ezenwaka CE, Offiah NV . Cardiovascular risk in obese and nonobese
patients with type 2 diabetes in the West Indies. J Biomed Sci . 2001;8(4):
314–320.
83. Ezenwaka CE, Nwagbara E, Seales D, et al. A comparative study of
the prevalence of the metabolic syndrome and its components in type 2
diabetic patients in two Caribbean islands using the new International
Diabetes Federation definition. Arch Physiol Biochem . 2007;113(4–5):
202–210.
84. Hermans MP, Amoussou-Guenou KD, Ahn SA, Rousseau MF.
Impact of metabolic syndrome and its severity on microvascular
complications in type 2 diabetes. Diabetes Metab Syndr Clin Res Rev .
2010;4(3):150–154.
85. Fasanmade OA, Okubadejo NU. Magnitude and gender distribution
of obesity and abdominal adiposity in Nigerians with type 2 diabetes
mellitus. Niger J Clin Pract . 2007;10(1):52–57.
86. Ogawa K, Ueda K, Sasaki H, et al. History of obesity as a risk factor
for both carotid atherosclerosis and microangiopathy. Diabetes Res
Clin Pract . 2004;66 Suppl 1:S165–S168.
87. Marjani A. Prevalence of obesity among type 2 diabetes mellitus in Gorgan
(South East of Caspian Sea), Iran. J Chin Clin Med . 2011;6(2):85–92.
88. Bianchi C, Penno G, Malloggi L, et al. Non-traditional markers of
atherosclerosis potentiate the risk of coronary heart disease in patients
with type 2 diabetes and metabolic syndrome. Nutr Metab Cardiovasc
Dis. 2008;18(1):31–38.
89. Klein S, Allison DB, Heymsfield SB, et al; Association for Weight
Management and Obesity Prevention; NAASO, The Obesity Society;
American Society for Nutrition; American Diabetes Association. Waist
circumference and cardiometabolic risk: a consensus statement from
Shaping America’ s Health: Association for Weight Management and
Obesity Prevention; NAASO, The Obesity Society; the American
Society for Nutrition; and the ADA. Am J Clin Nutr . 2007;85(5):
1197–1202.
90. Bener A, Zirie M, Al-Rikabi A. Genetics, obesity, and environmental
risk factors associated with type 2 diabetes. Croat Med J . 2005;46(2):
302–307.
91. Mulnier HE, Seaman HE, Raleigh VS, Soedamah-Muthu SS,
Colhoun HM, Lawrenson RA. Mortality in people with type 2 diabetes
in the UK. Diabet Med . 2006;23(5):516–521. 92. Daousi C, Casson IF , Gill GV , MacFarlane IA, Wilding JP , Pinkney JH.
Prevalence of obesity in type 2 diabetes in secondary care: associa –
tion with cardiovascular risk factors. Postgrad Med J . 2006;82(966):
280–284.
93. Hillier TA, Fosse S, Balkau B, Simon D, Eschwège E, Fagot-
Campagna A. Weight, the metabolic syndrome, and coronary heart
disease in type 2 diabetes: associations among a national French
sample of adults with diabetes-the ENTRED study. J Cardiometab
Syndr . 2006;1(5):318–325.
94. Ridderstråle M, Gudbjörnsdottir S, Eliasson B, Nilsson PM,
Cederholm J; Steering Committee of the Swedish National Diabetes
Register (NDR). Obesity and cardiovascular risk factors in type 2
diabetes: results from the Swedish National Diabetes Register. J Intern
Med. 2006;259(3):314–322.
95. Poljicanin T, Pavlic ´-Renar I, Metelko Z. Obesity in type 2 diabetes:
prevalence, treatment trends and dilemmas. Coll Antropol . 2011;35(3):
829–834.
96. Kramer H, Cao G, Dugas L, Luke A, Cooper R, Durazo-Arvizu R.
Increasing BMI and waist circumference and prevalence of obesity
among adults with Type 2 diabetes: the National Health and Nutri –
tion Examination Surveys. J Diabetes Complications . 2010;24(6):
368–374.
97. Aguilar-Salinas CA, Rojas R, Gómez-Pérez FJ, et al. Prevalence and
characteristics of early-onset type 2 diabetes in Mexico. Am J Med .
2002;113(7):569–574.
98. Taruni N, Romeo K, Romola P , Brojendro O, David L. Prevalence
study of metabolic syndrome in newly detected diabetes patients in
RIMS. J Med Soc . 2010;24(1):2–4.
99. Ezenwaka CE, Offiah NV . Abdominal obesity in type 2 diabetic
patients visiting primary healthcare clinics in Trinidad, West Indies.
Scand J Prim Health Care . 2002;20(3):177–182.
100. Wilson C, Gilliland S, Moore K, Acton K. The epidemic of extreme
obesity among American Indian and Alaska Native adults with
diabetes. Prev Chronic Dis . 2007;4(1):A06.
101. Ravera M, Noberasco G, Re M, et al. Chronic kidney disease and
cardiovascular risk in hypertensive type 2 diabetics: a primary care
perspective. Nephrol Dial Transplant . 2009;24(5):1528–1533.
102. Hypertension in Diabetes Study (HDS): I. Prevalence of hypertension
in newly presenting type 2 diabetic patients and the association with
risk factors for cardiovascular and diabetic complications. J Hypertens .
1993;11(3):309–317.
103. Reddy KS. Regional case studies – India. Nestle Nutr Workshop Ser
Pediatr Program . 2009;63:15–24; discussion 41–46, 259–268.
104. Barquera S, Durazo-Arvizu RA, Luke A, Cao G, Cooper RS.
Hypertension in Mexico and among Mexican Americans: prevalence
and treatment patterns. J Hum Hypertens . 2008;22(9):617–626.
105. Dorobantu M, Darabont RO, Badila E, Ghiorghe S. Prevalence, Aware –
ness, Treatment, and Control of Hypertension in Romania: Results of
the SEPHAR Study. Int J Hypertens . 2010;2010:970694.
106. International Diabetes Federation (IDF). The IDF Worldwide
Consensus Definition of the Metabolic Syndrome . Brussels: IDF;
2006. Available from: http://www.idf.org/webdata/docs/IDF_Meta_
def_final.pd f. Accessed February 14, 2013.
107. Misra A, Chowbey P , Makkar BM, et al; Consensus Group. Consensus
statement for diagnosis of obesity, abdominal obesity and the metabolic
syndrome for Asian Indians and recommendations for physical
activity, medical and surgical management. J Assoc Physicians India .
2009;57:163–170.
108. IDF . The global burden [web page on the Internet]. In: IDF Diabetes
Atlas . 5th ed. Brussels: IDF; nd. Available from: http://www.idf.org/
diabetesatlas/5e/the-global-burde n. Accessed February 14, 2013.
109. WHO Global Health Observatory Data Repository. Blood pressure:
raised blood pressure (SBP $ 140 or DBP $ 90) [database on the
Internet]. Geneva: WHO; nd. Available from: http://apps.who.
int/gho/data/?theme =main&node =A875 #. Accessed February 14,
2013.
Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy downloaded from https://www.dovepress.com/ by 46.148.112.27 on 29-Jul-2018
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338Colosia et al
110. WHO Global Health Observatory Data Repository. Overweight/
Obesity: obesity (body mass index $30) by country [database on the
Internet]. Geneva: WHO; nd. Available from: http://apps.who.int/gho/
data/?them e=main&node =A900#. Accessed February 14, 2013.
111. Cheng XB, Hsieh YT, Tu ST, Hsieh MC. Obesity and low target
attainment rates in Chinese with type 2 diabetes. Eur J Intern Med .
2012;23(4):e101–e105.
112. DiBonaventura MD, Liu GG, Stankus A. The prevalence and burden
of comorbid hypertension and obesity among patients with type 2
diabetes in Urban China. V alue Health . 2012;15(7):A664.
113. Feng RN, Zhao C, Wang C, Niu YC, Li K, Guo FC, et al. BMI is
strongly associated with hypertension, and waist circumference is
strongly associated with type 2 diabetes and dyslipidemia, in northern
Chinese adults. J Epidemiol . 2012;22(4):317–323.
114. Hossain MS, Rahaman MZ, Banik S, Sarwar MS, Yokota K.
Prevalence of the metabolic syndrome in diabetic patients living
in a coastal region of Bangladesh. Int J Pharm Sci Res . 2012;3(8):
2633–2638.
115. Katchunga P , Masumbuko B, Belma M, Kashongwe Munogolo Z,
Hermans MP , M’buyamba-Kabangu JR. Age and living in an urban
environment are major determinants of diabetes among South Kivu
Congolese adults. Diabetes Metab . 2012;38(4):324–231.
116. Frank LK, Heraclides A, Danquah I, Bedu-Addo G, Mock –
enhaupt FP , Schulze MB. Measures of general and central obesity and
risk of type 2 diabetes in a Ghanaian population. Trop Med Int Health .
2013;18(2):141–151. 117. Berraho M, El Achhab Y, Benslimane A, El Rhazi K, Chikri M,
Nejjari C. Hypertension and type 2 diabetes: a cross-sectional study
in Morocco (EPIDIAM Study). Pan Afr Med J . 2012;11:52.
118. Zhang P , Zhang X, Brown J, et al. Global healthcare expenditure on
diabetes for 2010 and 2030. Diabetes Res Clin Pract . 2010;87(3):
293–301.
119. Swinburn BA, Sacks G, Hall KD, et al. The global obesity
pandemic: shaped by global drivers and local environments. Lancet .
2011;378(9793):804–814.
120. Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V ,
Chisholm D. Tackling of unhealthy diets, physical inactivity, and
obesity: health effects and cost-effectiveness. Lancet . 2010;376(9754):
1775–1784.
121. Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure. The Seventh Report of the
Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure . Washington DC: US Department of
Health and Human Services; 2004. Available from: http://www.nhlbi.
nih.gov/guidelines/hypertension/jnc7full.pd f. Accessed February 10,
2013.
122. White J. Efficacy and safety of incretin based therapies: clinical trial
data. J Am Pharm Assoc (2003) . 2009;49 Suppl 1:S30–S40.
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