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General Medicine: Open Access Aziz, Gen Med (Los Angeles) 2017, 5:5
DOI: 10.4172/2327-5146.1000297

Research Article OMICS International

Association of Serum Lipids with High Blood Pressure and Hypertension

among Diabetic Patients. Mathematical Regression Models to Predict
Blood Pressure from Lipids. An Experience from 12-year Follow Up of
more than 9000 Patients' Cohort
Kamran Mahmood Ahmed Aziz*
Consultant Diabetologist, Honorary Professor and Research Scientist (Endocrinology, Diabetes and Metabolism), Aseer Diabetes Center of Aseer Central Hospital,
Ministry of Health, Saudi Arabia
*Corresponding author: Aziz KMA, Diabetology Clinic, Aseer Diabetes Center, Aseer Central Hospital, Ministry of Health, P.O.Box 34, Abha, Saudi Arabia, Tel:
00966-568361040; E-mail: drkamran9999@yahoo.com
Rec date: July 25, 2017; Acc date: September 18, 2017; Pub date: September 21, 2017
Copyright: © 2017 Aziz KMA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Dyslipidemia and hypertension alone predispose to the risk of coronary artery disease, especially if the patient is
diabetic. This risk is increased and multiplied when both dyslipidemia and hypertension coexists. There is a lack of
studies and significant data for the correlation or association of blood pressure with serum lipids. The studies
conducted in the past showed the conflicting results with poor associations. Furthermore, these studies were not
conducted on diabetic subjects and lack regression models or mathematical linear equations. Hence, we conducted
a prospective, observational cohort study on 9340 diabetic subjects for the duration of 12 year (2005-2017), with the
aim to find significant associations, correlations between serum lipids (total cholesterol, triglycerides, LDL-C, HDL-C
and Non-HDL-C) and blood pressure (systolic and diastolic). Our data has demonstrated that total cholesterol,
triglycerides, and LDL-C were significantly correlated with systolic and diastolic BP, and raised among hypertensive
patients as compared to non-hypertensive ( p<0.001 for all lipids). The highest correlations were found between
Non-HDL-C with systolic and diastolic blood pressures (r=0.414 and r=0.415, respectively with p<0.001). However,
HDL-C was inversely correlated with systolic and diastolic BP and was raised among non-hypertensive patients.
Regression models and mathematical linear equations were developed to estimate increasing blood pressure by the
given serum lipid levels. All regression models were significant (p<0.0001). We concluded and developed regression
models, for the first time in medical research that high lipid levels contribute to the development of increase systolic
and diastolic blood pressures. With triglycerides, total-cholesterol, and HDL-C, Non-DHL-C levels should also be
calculated in diabetology clinics and general practice. Screening should be done for diabetic patients to detect high
blood pressure (or HTN) and elevated serum lipids, and early initiation of management to prevent diabetes
complications.

Keywords: Lipids; Blood pressure; Coronary artery disease; Diabetes Untreated hypertension has various adverse effects on the human
body, including end organ damage. Both high blood pressure and
Introduction elevated serum lipids are major risk factors for the development of
ischemic heart disease (IHD) or CAD, and their progression is
Currently hypertension is defined as the blood pressure (BP) values accelerated among diabetics. Furthermore, these metabolic
of ≥ 140/90 mmHg. Atherosclerotic cardiovascular disease (ASCVD) is abnormalities are also associated with macrovascular and
one of the leading causes of morbidity and mortality among diabetic microvascular complications of type 2 diabetes and risk factors for
patients and also general population with high economic cost and atherosclerosis in children and young adults [7-10].Current research
burden [1-3]. Essential hypertension is the silent killer because it is literature has shown that diabetes mellitus is a cardio-vascular risk
usually asymptomatic and undetected. Uncontrolled hypertension can equivalent and has been further confirmed by Framingham study and
cause damage to all organs of body. Dyslipidaemia and hypertension other landmark studies [11,12]. Diabetic dyslipidemia is defined as
are the commonest risk factors for coronary artery disease (CAD). elevated triglyceride, elevated low-density lipoprotein cholesterol
Hypertension and hypercholesterolemia (or dyslipidemia) each (LDL-C) and low high density lipoprotein cholesterol (HDL-C) levels
predisposes to CAD and their combined effects are demonstrated to be [13]. Furthermore, new guidelines have recommended targeting non-
multiplicative. There is also pronounced influence of blood pressure on HDL cholesterol for reducing cardiovascular morbidity and mortality.
the rate of atheroma formation in human subjects. Isolated systolic Although in 1963 Albrink demonstrated that triglyceride was an
hypertension, commonly seen in elderly subjects, can be attributed to important atherosclerotic risk in diabetes, however, recent trials have
atherosclerosis induced stiffening of aorta and major arteries. proved that by lowering triglyceride levels, primary end point of major
Atherosclerosis is more extensive and severe in hypertensive patients coronary events was not reduced significantly. This evidence was
than in normotensive; this was the conclusion after the autopsy studies further supported by Fenofibrate Intervention and Event Lowering in
conducted on human coronary arteries and aortas collected from Diabetes (FIELD) study. Hence, it was demonstrated high density
various parts of the world [4-6]. lipoprotein (HDL-C) is a strong inverse co-variate of triglyceride and

Gen Med (Los Angeles), an open access journal Volume 5 • Issue 5 • 1000297
ISSN:2327-5146
Citation: Aziz KMA (2017) Association of Serum Lipids with High Blood Pressure and Hypertension among Diabetic Patients. Mathematical
Regression Models to Predict Blood Pressure from Lipids. An Experience from 12-year Follow Up of more than 9000 Patients' Cohort.
Gen Med (Los Angeles) 5: 297. doi:10.4172/2327-5146.1000297

Page 2 of 7

HDL-C with Non-HDL-C must also be considered while managing Data were summarized as percentages with mean ± SD and 95%CI for
dyslipidemia [14,15]. the variables.
In the past, some research trials were conducted and attempts were Normal distribution of variables was confirmed via SPSS by
made to show a positive relation between serum total cholesterol and observing skewness and kurtosis values between -1 and +1 with no
blood pressure [16-24]; however, their results were inconsistent and potential/influential outliers before further proceedings. Hence, this
these trials concluded that these associations were insignificant. Some required no data transformations. For this purpose, normality tests
studies have shown positive correlations [25,26], but these studies were were also performed with Q-Q plots, hence confirming their normal
not conducted on diabetic subjects, and have not developed statistical distribution. Independent t-test was performed to test the significant
regression models for serum lipids and blood pressure. Under this difference between groups of variables. Pearson's correlation analysis
overview, the aim of the current study was to find associations and was used to test the correlation between variables.
significant correlations between serum lipids (total cholesterol, LDL-C,
Predictive regression models were used to develop relationship of
HDL-C, Non-HDL-C and triglycerides) and to develop statistical
serum lipids and blood pressures, and it was then estimated by
regressions models and linear equations by which systolic and diastolic
mathematical linear equations to confirm that how serum lipids
blood pressure elevations can be predicted or calculated by increasing
contribute to the development of high or increased blood pressure.
serum lipids among diabetic patients.
This study was designed to have a statistical power of 90% to detect
significant changes. All p-values were two-sided, and p-values less than
Methods 0.05 were considered statistically significant. This study was reviewed
This is a prospective, cross-sectional observational cohort study and approved by the research committee of Aseer Diabetes Center;
conducted at the diabetology clinic of Aseer Diabetes Center, Aseer consent was taken from the participating patients and all
Central Hospital. Total study duration was 12 years, from August 2005 methodologies on subjects reported in current study were in
until July 2017, with total number of patients 9340, who, were routinely accordance with Helsinki Declaration of 1975 (revised in 2008).
followed up in the diabetes clinic. We selected all type-1 and type-2
diabetic subjects who, were in regular follow up in the diabetes center. Results
However, Children (age<13 years), pregnant diabetic women, and
Demographic data is presented in Table 1, while descriptive
patients on end stage renal disease (ESRD) or on dialysis and with
statistics is demonstrated in Table 2. It was found that 42% of patients
active hepatic disease were excluded from the study. Detail history and
were hypertensive and 61% demonstrated dyslipidemia.
physical examination was done. Blood pressure was measured by
standardized methodology. Blood pressure of ≥ 140/90 was labelled as Parameters Description with N (%) ; Total=9340
"hypertension". All blood samples were collected in fasting state of not
less than 12 hours, early in the morning. Low-density lipoprotein Gender Male Female
cholesterol, LDL (mg/dl) was measured directly in plasma by
59% 41%
Automated Low-Density Lipoprotein (ALDL) method for the
Dimension® clinical chemistry system and analyzer (Siemens Type of Diabetes Type-1 Type-2
healthcare diagnostics Inc. Newark, DE 19714, U.S.A), in vitro
diagnostic test intended for quantitative determination of LDL-C. 16% 84%
HDL-C (mg/dl) was measured directly in plasma by Automated High Hypertension status Hypertensive Non-Hypertensive
Density Lipoprotein (AHDL) method by the Dimension® clinical
chemistry system and analyzer (Siemens healthcare diagnostics Inc. 42% 58%
Newark, DE 19714, U.S.A), in vitro diagnostic test intended for
Dyslipidemia status Abnormal Lipids Normal Lipids
quantitative determination of HDL-C. Similarly, total cholesterol (T.
cholesterol) was measured directly by CHOL method (based on 61% 39%
enzymatic procedures), a quantitative determination by the
Dimension® clinical chemistry system and analyzer. Non-HDL-C was Table 1: Demographic data of diabetic patients.
calculated as total cholesterol – HDL-C. Serum triglyceride (mg/dl)
was measured by an enzymatic procedure; the sample is incubated Serum lipid values with or without hypertension status (with Mean
with lipoprotein lipase (LPL) enzyme reagent that converts ± SD; 95% CI and p-values) is presented in Table 3. It was found that
triglycerides to free glycerol and fatty acids. These are further oxidized serum lipid values were higher among hypertensive patients (p-
to dihyhroxyacetone phosphate and hydrogen peroxide (H2O2) which value<0.001 for all serum lipids). However, HDL-C was lower in
is again converted to quinoneimine, absorbance of which is directly hypertensives (p-value<0.001).
proportional to the total amount of glycerol. Absorbance is measured
by bichromatic (510,700 nm) endpoint technique. Collectively, patients Tables 4 and 5, present the correlation between serum lipids and
with LDL ≥ 100 mg/dl, triglycerides ≥ 150 mg/dl and HDL ≤ 40 mg/dl blood pressure (systolic and diastolic, respectively). It is evident from
were labeled as "dyslipidemia". All laboratory sample requests were the tables that correlations and p-values were positively significant.
entered in a computer software and results retrieved by Natcom However, HDL-C was found to be negatively significant with systolic
Hospital Information System (NATCOM HIS; National Computer and diastolic blood pressures. Regression models and linear equations
System Co. Ltd [27]. Patients' data were analyzed by IBM® SPSS® for the serum lipids with systolic and diastolic blood pressures are
statistics, version 20, for Microsoft Windows. All statistical tests were presented in Tables 6 and 7, respectively. The linear mathematical
applied according to the available standard medical statistical methods. equations are constructed in these tables by which systolic or diastolic
BP can be calculated by the given lipid levels. All the models were
found to be significant (p<0.0001).

Gen Med (Los Angeles), an open access journal Volume 5 • Issue 5 • 1000297
ISSN:2327-5146
Citation: Aziz KMA (2017) Association of Serum Lipids with High Blood Pressure and Hypertension among Diabetic Patients. Mathematical
Regression Models to Predict Blood Pressure from Lipids. An Experience from 12-year Follow Up of more than 9000 Patients' Cohort.
Gen Med (Los Angeles) 5: 297. doi:10.4172/2327-5146.1000297

Page 3 of 7

Variables Mean ± SD

Age 53 ± 15

Diabetes duration 16 ± 9.8

Triglycerides (mg/dl) 154 ± 97.9

Total cholesterol (mg/dl) 190 ± 48.8

LDL-C (mg/dl) 119 ± 49.5

HDL-C (mg/dl) 42 ± 18

Non-HDL-C (mg/dl) 151 ± 48

Systolic blood pressure (mmHg) 128.7 ± 16.3

Diastolic blood pressure (mmHg) 79.2 ± 9

Table 2: Variables with descriptive statistics (mean ± SD).

Serum lipids Hypertension status with serum lipids P-value

(in mg/dl)
Yes No

Total cholesterol 194 ± 50; 95% CI 190 to 197 185 ± 46 ; 95% CI 182 to189 <0.001

Triglycerides 162 ± 94 ; 95% CI 156 to 169 152 ± 89 ; 95% CI 146 to159 <0.001

LDL-C 123 ± 55; 95% CI 119 to 127 115 ± 43; 95% CI 95 to 105 <0.001

HDL-C 40 ± 13; 95% CI 41 to 39 43 ± 23; 95% CI 42 to 45 <0.001

Non-HDL-C 153 ± 49 ; 95% CI 148 to 155 147 ± 45 ; 95% CI 142 to149 <0.001

Table 3: Serum lipids levels with hypertension state (Mean ± SD; 95% CI).

Variables tested for Pearson's correlation P-value Variables tested for Pearson's Correlation P-value
correlations coefficient correlations Coefficient

Systolic BP and triglycerides 0.391 < 0.0001 Diastolic BP and triglycerides 0.428 <0.0001

Systolic BP and total Cholesterol 0.385 < 0.001 Diastolic BP and T cholesterol 0.383 <0.001

Systolic BP and LDL-C 0.358 <0.01 Diastolic BP and LDL-C 0.349 <0.01

Systolic BP and HDL-C -0.36 <0.01 Diastolic BP and HDL-C -0.371 <0.01

Systolic BP and Non-HDL-C 0.414 <0.0001 Diastolic BP and Non-HDL-C 0.415 <0.0001

Table 4: Correlation of lipids and systolic BP. Table 5: Correlation of lipids and diastolic BP.

Variables F-value T-value P-value Regression/Linear equations y=a+bx

Serum Triglyceride and systolic BP 13.3 162.8 <0.0001 Sys BP = 126.3+(0.015 × triglycerides)

Serum cholesterol and systolic BP 11.65 74.95 <0.0001 Sys BP = 123.3+(0.029 × total cholesterol)

Serum LDL-C and systolic BP 4.9 112.2 <0.0001 Sys BP = 126+(0.019 × LDL)

Serum HDL-C and Systolic BP 5.36 126 <0.0001 Sys BP = 130.6+(-0.052 × HDL)

Serum Non-HDL-C and systolic BP 19.4 89.9 <0.0001 Sys BP = 105+(0.343 × Non-HDL-C)

Table 6: Regression models for systolic blood pressure and serum lipids.

Gen Med (Los Angeles), an open access journal Volume 5 • Issue 5 • 1000297
ISSN:2327-5146
Citation: Aziz KMA (2017) Association of Serum Lipids with High Blood Pressure and Hypertension among Diabetic Patients. Mathematical
Regression Models to Predict Blood Pressure from Lipids. An Experience from 12-year Follow Up of more than 9000 Patients' Cohort.
Gen Med (Los Angeles) 5: 297. doi:10.4172/2327-5146.1000297

Page 4 of 7

Variables F-Value T-Value P-Value Regression/Linear Equations y=a+bx

Serum Triglyceride and diastolic BP 26.76 181.5 <0.0001 Dias BP = 77.27+(0.012 × triglycerides)

Serum cholesterol and diastolic BP 11.2 84.3 <0.0001 Dias BP = 76.2+(0.015 × total cholesterol)

Serum LDL-C and diastolic BP 3.5 126.6 <0.0001 Dias BP = 78+(0.009 × LDL)

Serum HDL-C and diastolic BP 7.4 141.3 <0.0001 Dias BP = 80.6+(-0.034 × HDL)

Serum Non-HDL-C and diastolic BP 19.6 101.1 <0.0001 Dias BP = 76+(0.21 × Non-HDL-C)

Table 7: Regression models for diastolic blood pressure and serum lipids.

Discussion respectively. However, if serum triglyceride value is 300, for example,

then according to the given linear equation, it can raise systolic BP up
Management of dyslipidemia is an essential part of managing to 131 mmHg. Similarly, LDL-C levels of 180 mg/dl can lead to BP
diabetes as a whole. In general clinical practice, physicians target LDL- elevations up to approximately 129.5 mm Hg. Hence, by this technique
C as a primary target. However, recently to target non-HDL-C is also physicians can know that chronic exposures of high serum lipids can
recommended. Non-HDL-C can be derived simply by abstracting lead to significant elevations in the near future. Additionally, and
HDL-C from total cholesterol which will give a better index of overall according to our statistical analysis, HDL-C levels should be raised as
bad or harmful total cholesterol, a risk for CAD. According to recent they are associated with reduced systolic and diastolic BP. Dylipidemia
evidence and recommendations from National Cholesterol Education and high non-HDL-C cholesterol is also associated with
Program (NCEP), target of LDL-C is to be <100 mg/dl in patients with hypothyroidism among diabetic patients, and requires screening with
diabetes, followed by non-HDL-C cholesterol of <130 mg/dl as a regular follow up. Additionally, it has been demonstrated in research
secondary target if triglyceride level remains elevated (>200 mg/dl). trials that dyslipidemia is associated with the development of
American Diabetes Association (ADA) has recommended similar nephropathy and early detection of dyslipidemia with nephropathy is
management guidelines. This evidence indicates the importance of recommended in primary care clinics [34-36].
non-HDL-C as a potential marker of dyslipidemia [28-32]. It is
essential to screen diabetic patients for dyslipidemia at initial and Hypertension or elevated blood pressure is associated with CAD,
follow up visits as serum lipids contribute to the elevation of the blood cerebrovascular disease (CVA) and other diabetes related
pressure and poses CAD risk. Current study has demonstrated complications as well. Diabetic patients are at risk of cardiovascular
prevalence of diabetic dyslipidemia and hypertension to be 61% and and atherosclerotic disease development and progression. Efforts
42% respectively, which is alarming. Furthermore, the data has should be made to reduce elevated blood pressure among diabetics
demonstrated that hypertension state was associated with elevated with available medications, as tight blood pressure control have shown
serum lipids (p<0.001). reductions in morbidity and mortality and diabetes related
complications [37-53]. Additionally, diabetic patients should be
Although there are studies which have shown that elevated serum screened for dyslipidemia as well, as this pathological state leads to
lipids are associated with high blood pressure or hypertension CAD or IHD with high morbidity and mortality rates. Dylipidemia
[16-24,33], however, they demonstrated conflicting results and their and high triglycerides are associated with insulin resistance. Free fatty
exact correlations with regression models were not developed in the acid-induced insulin resistance is associated with activation of protein
past to predict BP elevation contributed by elevated serum lipids. No kinase C-theta (C-ɵ) and alterations in the insulin signaling cascade.
study has found correlation between non-HDL-C and blood pressure Aggressive treatment should be initiated if dyslipidemia is detected
or HTN. Furthermore, these previous studies were not conducted in with statins [54-62]. Furthermore, during management of diabetes in
diabetic patients. This was achieved for the first time in the medical diabetology clinics, diabetologist should consider options for the
research history in our study. Between lipids and blood pressure, the management of type-1 and type-2 diabetic patients. For type-1, basal
highest correlations were found between non-HDL-C with systolic and bolus insulin is the best strategy. For type-2 diabetics, oral agents
diastolic blood pressures (r=0.414 and r=0.415, respectively, with (sulfonylurea or oral hypoglycemic agents, Metformin, DPP-4
p<0.001 for both); after non-HDL, the correlations for triglycerides inhibitors, SGLT-2 inhibitors, thiazolidinediones) can be used alone or
were significant with systolic and diastolic blood pressures (r=0.391 in combination with insulin; these treatments can be shifted to insulin
and r=0.428, respectively with p<0.0001 for both). HDL-C, a good with metformin if they remain uncontrolled on oral agents. Metformin
cholesterol, was inversely related with systolic and diastolic blood should be prescribed to type-2 diabetic patients (if not
pressures. Non-HDL-C (i.e., non-HDL-C=total cholesterol–HDL-C), contraindicated) because metformin has cardiovascular protective
gives the value for overall harmful cholesterol. Our data has effects, reduces insulin resistance, increases insulin sensitivity, and
demonstrated that correlations for non-HDL-C with blood pressures decreases the serum lipids while elevates HDL-C as has been
were the most significant, and this cholesterol or lipid is contributing demonstrated by research studies [63-70]. It is recommended following
most for the elevated BP or HTN. Although in general practice it is best available guidelines for the management of diabetes and its
ignored, however, non-HDL-C must be considered in tertiary care complications [71,72].
diabetes centers to reduce cardio-metabolic risk among diabetics. The
linear equations (y=a+bx) can be used to predict blood pressures by Our research, for the first time in medical history has demonstrated
given lipid values. For example, if given triglyceride value is 200 mg/dl, significant correlations, associations and regression models/linear
the systolic and diastolic BP will be 129 mmHg and 80 mmHg, mathematical equations between serum lipids (including non-HDL-C)

Gen Med (Los Angeles), an open access journal Volume 5 • Issue 5 • 1000297
ISSN:2327-5146
Citation: Aziz KMA (2017) Association of Serum Lipids with High Blood Pressure and Hypertension among Diabetic Patients. Mathematical
Regression Models to Predict Blood Pressure from Lipids. An Experience from 12-year Follow Up of more than 9000 Patients' Cohort.
Gen Med (Los Angeles) 5: 297. doi:10.4172/2327-5146.1000297

Page 5 of 7

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Med 80: 23-32.
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Gen Med (Los Angeles), an open access journal Volume 5 • Issue 5 • 1000297
ISSN:2327-5146
Citation: Aziz KMA (2017) Association of Serum Lipids with High Blood Pressure and Hypertension among Diabetic Patients. Mathematical
Regression Models to Predict Blood Pressure from Lipids. An Experience from 12-year Follow Up of more than 9000 Patients' Cohort.
Gen Med (Los Angeles) 5: 297. doi:10.4172/2327-5146.1000297

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Gen Med (Los Angeles), an open access journal Volume 5 • Issue 5 • 1000297
ISSN:2327-5146
Citation: Aziz KMA (2017) Association of Serum Lipids with High Blood Pressure and Hypertension among Diabetic Patients. Mathematical
Regression Models to Predict Blood Pressure from Lipids. An Experience from 12-year Follow Up of more than 9000 Patients' Cohort.
Gen Med (Los Angeles) 5: 297. doi:10.4172/2327-5146.1000297

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ISSN:2327-5146