Many studies have suggested that maintaining a healthy lifestyle may prevent most cardiometabolic diseases in the general population, but little is known about how healthy lifestyle is associated with health status in people living with hypertension.

A new study, including 25,820 people with hypertension, has found that maintaining a healthy lifestyle is associated with substantially lower risk for major cardiometabolic diseases, regardless of antihypertensive medication use. Healthy lifestyle was defined as eating a high-quality diet, not smoking, engaging in moderate-to-vigorous physical activity, drinking alcohol moderately, and having a healthy BMI. Findings were published in JAMA Network Open.

Self-Reports Over 30 Years

Researchers, led by Zixin Qiu, MBBS, with the Department of Nutrition, Harvard T.H. Chan School of Public Health in Boston, gathered data from two large prospective cohorts — the Nurses’ Health Study (1986-2014) and Health Professionals Follow-Up Study (1986-2014) with up to 15 repeated measures of self-reported lifestyle factors over 30 years to assess healthy lifestyle practices after hypertension diagnosis as well as changes in lifestyle before and after the diagnosis in relation to incident cardiovascular diseases (CVDs), type 2 diabetes, and life expectancy.

Average age was 60.6 years and the median healthy lifestyle score (HLS) at diagnosis was 3 (on a 0-5 scale where 0 is least healthy). During a median follow-up of 24 years, after adjusting for medication use and other covariates, the adjusted hazard ratio (AHR) for total CVDs when comparing the highest HLS category (5) with the lowest (0 or 1) was 0.49 (95% CI, 0.39-0.61).

The corresponding AHR for type 2 diabetes was 0.21 (95% CI, 0.14-0.30). Participants who improved from lower HLSs (0-3) to higher (4 or 5) after diagnosis of hypertension had lower risk for CVDs (AHR, 0.88; 95% CI, 0.79-0.98) and type 2 diabetes (AHR, 0.56; 95% CI, 0.48-0.65) compared with those who consistently had lower HLSs. Conversely, those whose HLSs declined after diagnosis had higher risk for CVDs (AHR, 1.14; 95%CI, 1.00-1.30) and type 2 diabetes (AHR, 1.75; 95% CI, 1.45-2.10) compared with those who consistently maintained a higher HLS.

Longer Life Expectancy

At age 40, participants who improved their HLS from low to high gained an estimated 0.9 years of life expectancy compared with those who had a consistently low HLS; those whose HLS declined from high to low lost an estimated 0.9 years of life expectancy compared with people who had a consistently high HLS.

The authors estimate that if the entire study population shifted to an ideal set of lifestyle factors after hypertension diagnosis, about 27% of the CVD and about 75% of the type 2 diabetes cases in their sample could be averted.

In an invited commentary, lead editorialist Frank Qian, MD, MPH, with the Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, and colleagues noted the consistent inverse link between more positive lifestyle factors and incident type 2 diabetes is “an observation that is unlikely to be related to BP [blood pressure] control or medication use. Additionally, leveraging the repeated assessment of lifestyle factors, the authors showed that an improved lifestyle score from before to after hypertension diagnosis was also associated with lower incidence of cardiometabolic diseases, and conversely, worsening of lifestyle score was associated with higher risk.”

The editorialists pointed out some limitations of the study, including that use of antihypertensive medications at baseline was low and more often used by people with healthier lifestyles, suggesting potential residual confounding. Also, those in the study were all health professionals, and 90% were White individuals, limiting generalizability.

But this study makes a case for integrating lifestyle modifications with medication, they wrote, particularly as recent trends show a reversal in the progress made in hypertension control and CVD prevention.

Small Changes Can Have Big Payoff

“This is a very robust study,” Casey Mabry, MD, a primary care physician at University of Maryland Baltimore Washington Medical Center, Glen Burnie, Maryland, told Medscape Medical News. She noted that “people who improved their healthy living score to any degree — for example, improving diet, increasing exercise, losing weight, limiting alcohol, and stopping smoking — added approximately 1 year to their life expectancy. The people with the highest score compared to those with the lowest score after diagnosis of high blood pressure had 51% lower risk of cardiovascular disease, 79% lower risk of type 2 diabetes, and increased life expectancy of approximately 8 years.”

However, she also noted that almost all participants in the study were White individuals, “which is unfortunate, as high blood pressure disproportionately affects Black adults in the US — approximately 58% of Black adults in the US have high blood pressure — and is more likely to be severe compared to their White counterparts.”

Even with the limitations of the study, Mabry said, “it does offer some very exciting data that I look forward to sharing with my patients.” Tracking a select few healthy lifestyle interventions with the goal of optimizing a healthy living score as opposed to general ‘be healthy’ advice is likely to be very appealing to the right patient, she said. “Patients often ask me for specific guidance regarding diet and exercise, so I plan on emphasizing the healthy diet guidelines and exercise goals proposed in the study. Perhaps the most encouraging data point is that any improvement in healthy living score positively affects longevity.”

Qiu reported having no relevant financial disclosures. Qian reported receiving a training grant from the T32 Multidisciplinary Training Program in Cardiovascular Epidemiology. Mabry reported having no relevant financial relationships.

Marcia Frellick is an independent healthcare journalist and a regular contributor to Medscape.