Hypertension Research (2010) 33, 878–879 & 2010 The Japanese Society of Hypertension All rights reserved 0916-9636/10 $32.00 www.nature.com/hr
COMMENTARY
You reap what you sow: the long-term benefits of your investment Farouk Mookadam and Susan Wilansky Hypertension Research (2010) 33, 878–879; doi:10.1038/hr.2010.124; published online 22 July 2010
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n a very important and elegant study described in this issue, Fernandes and Zanesco highlight the epidemiologic data regarding the prevalence of type 2 diabetes mellitus and concomitant arterial hypertension.1 The authors examine an adult cohort in a retrospective study of four cities in an industrialized state in Brazil wherein the estimated prevalence of hypertension was 36% and that of type 2 diabetes mellitus 29%. The authors confirm the high prevalence of arterial hypertension in patients with type 2 diabetes mellitus. In this study, 1436 adults were analyzed; 61% were women and the age range was broad, ranging from 18 to 94 years, with one in five participants (20.2%) being older than 65. Self-reported physical activity was documented through interviews. Body mass index (BMI) was calculated from self-reported body anthropometrics. The Baecke Questionnaire2 was used to identify the level of physical activity. Of note, both leisure time physical activities as well as regular aerobic-type exercise were recorded. Physical activity was recorded in youth, childhood, adolescence and adulthood. Specific questions were asked regarding physical activity after school. The results of the study showed that, in general, men were more physically active than women in this Brazilian population. Subjects with a higher formal education who were younger also had greater levels of physical activity. Obese and overweight patients had lower levels of physical activity. Approximately 9% of patients self-reported diabetes mellitus, and 26% selfreported hypertension, with a male preponderance for the diagnosis of high blood
Dr F Mookadam and S Wilansky are at the Department of Cardiology, Mayo Clinic Arizona, 8822 E Diamond Rim Dr, Scottsdale 85259, AZ, USA. E-mail:
[email protected]
pressure. Further, the study shows that the prevalence of arterial hypertension and type 2 diabetes mellitus increases with advancing age and is positively associated with BMI. Higher levels of formal education were associated with lower incidences of diabetes or hypertension. In addition, overweight and obese adults were less likely to participate in regular exercise activity as adults and were also less likely to have exercised in youth compared with subjects with a normal BMI (less than 25 kg m2). The odds ratio for current engagement in physical activity was 2.38 (95% confidence interval (CI) 1.73–3.28; P¼0.001). The authors point out that any physical activity was associated with a lower occurrence of arterial hypertension and type 2 diabetes mellitus. However, current physical activity was not associated with either disease. The odds ratio was 0.44 (95% CI 0.3–0.64) for arterial hypertension and 0.32 (95% CI 0.17–0.61) for type 2 diabetes in adults who had regularly engaged in sport activities in childhood and adolescence. IMPAIRED GLUCOSE METABOLISM Individuals with impaired glucose metabolism have an increased risk of developing type 2 diabetes mellitus and the consequences of cardiovascular disease.3 Based on the 2005–2006 National Health and Nutrition Examination Survey, 1402 patients older than 20 years of age without a history of diabetes were reviewed in 2009. This survey showed that approximately 30% of the US adult population had pre-diabetes in 2005 and 2006, but only 7.3% (95% CI 5.5–9.2%) were aware that they had it. Only 50% of patients with pre-diabetes reported reducing their caloric intake or exercising regularly during the previous year, and approximately one-third sought advice from a formal health-care provider regarding
behavior modification to reduce the risk of developing diabetes or to improve glycemic control.4 It is estimated that 33–65% of individuals with glucose intolerance or impaired fasting glucose may go on to develop type 2 diabetes mellitus within 6 years compared with less than 5% of individuals with normal blood glucose.5 Clinical trials provide robust evidence that type 2 diabetes mellitus can be prevented or delayed in high-risk adults with dysglycemia. This would entail lifestyle modification, which includes dietary change and introduction of aerobic-type exercise coupled with weight loss. The optimal method of lifestyle change has not yet been clearly delineated. The constituents of the metabolic syndrome, which are similar to those of the study reported by Fernandes and Zanesco (this issue), would suggest that their cohort likely had a concomitant diagnosis of metabolic syndrome. Certainly, the prevalence of hypertension in association with dysglycemia and higher BMI would confirm that diagnosis.6,7 In conclusion, the study by Fernandes and Zanesco1 is not surprising; however, the message needs to be reiterated that exercise in early childhood, adolescence and as young adults will impact the prevalence and incidence of pre-diabetes, diabetes and hypertension in older age. Risk factor modification to reduce the incidence of obesity, diabetes and hypertension should begin in childhood. Incorporating aerobic exercise and dietary health education into the school curriculum starting at the earliest grade level, coupled with a reduction in dietary salt and an improvement in BMI with maintenance of ideal body weight and caloric restriction, would result in long-term health benefits that will likely abrogate the modern epidemics of obesity, hypertension, diabetes
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and the constellation of the metabolic syndrome. A directed public awareness campaign would reap benefits in the future. Cultivating good habits as a child will have health benefits in adulthood.
1 Fernandes RA, Zanesco A. Early physical activity promotes lower prevalence of chronic diseases in adulthood. Hypertens Res 2010; 33: 926–931.
2 Baecke JA, Burema J, Frijters JE. A short questionnaire for the measurement of habitual physical activity in epidemiological studies. Am J Clin Nutr 1982; 36: 936–942. 3 Coutinho M, Gerstein HC, Wang Y, Yusuf S. The relationship between glucose and incident cardiovascular events. A metaregression analysis of published data from 20 studies of 95,783 individuals followed for 12.4 years. Diabetes Care 1999; 22: 233–240. 4 Geiss LS, James C, Gregg EW, Albright A, Williamson DF, Cowie CC. Diabetes risk reduction behaviors among U.S. adults with prediabetes. Am J Prev Med 2010; 38: 403–409. 5 de Vegt F, Dekker JM, Jager A, Hienkens E, Kostense PJ, Stehouwer CD, Nijpels G, Bouter LM, Heine RJ. Relation
of impaired fasting and postload glucose with incident type 2 diabetes in a Dutch population: The Hoorn Study. JAMA 2001; 285: 2109–2113. 6 Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 344: 1343–1350. 7 Jiamsripong P, Mookadam M, Alharthi MS, Khandheria BK, Mookadam F. The metabolic syndrome and cardiovascular disease: part 2. Prev Cardiol 2008; 11: 223–229.
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