Hypertension is a major risk factor for cardiac events and stroke. Visceral adipose tissue (VAT) is known to increase the risk of incident hypertension in adults. Although adiposity has been linked to markers of inflammation, few studies have examined these markers as potential mediators of the association between visceral adiposity and elevated blood pressure. We evaluated sociodemographic, reproductive, and lifestyle risk factors for elevated blood pressure among midlife Singaporean women. A total of 1189 women, with a mean age of 56.3 ± 6.2 years, from the Integrated Women’s Health Program (IWHP) at National University Hospital, Singapore were studied. Hypothesized risk factors and levels of inflammatory markers were examined in relation to systolic blood pressure (SBP) and diastolic blood pressure (DBP) using multivariable linear regression models. Prehypertension (SBP 120–139 mmHg and/or DBP 80–89 mmHg) and hypertension (SBP ≥140 mmHg and/or DBP ≥90 mmHg) were observed in 518 (43.6%) and 313 (26.3%) women, respectively. Compared to women in the lowest tertiles, women in the middle and upper tertiles of VAT had 7.1 (95% CI, 4.4, 9.8) mmHg and 10.2 (95% CI, 6.7, 13.7) mmHg higher adjusted SBP, respectively. Nulliparous older women with a lower education level and those with no or mild hot flashes also had a significantly higher adjusted SBP. No significant independent risk factors were observed for DBP. Adjustments for IL-6, TNF-α, and hs-CRP did not attenuate the association between VAT and SBP. In summary, we found an independent positive association between VAT and SBP. Elevated levels of inflammatory markers did not mediate the increase in SBP in women with high VAT.
Subscribe to Journal
Get full journal access for 1 year
only $9.92 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Tax calculation will be finalised during checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
Wenger NK, Ferdinand KC, Merz CNB, Walsh MN, Gulati M, Pepine CJ. Women, hypertension, and the systolic blood pressure intervention trial. Am J Med. 2016;129:1030–6.
Gudmundsdottir H, Høieggen A, Stenehjem A, Waldum B, Os IJ. Hypertension in women:latest findings and clinical implications. Ther Adv Chronic Dis. 2012;3:137–46.
Collins P, Rosano G, Casey C, Daly M, Gambacciani M, Hadji P, et al. Management of cardiovascular risk in the peri-menopausal woman: a consensus statement of European cardiologists and gynaecologists. Eur Heart J. 2007;28:2028–40.
Jones HJ, Minarik PA, Gilliss CL, Lee KA. Depressive symptoms associated with physical health problems in midlife women: a longitudinal study. J Affect Disord. 2020;263:301–9.
Ganasarajah S, Poromaa IS, Thu WP, Kramer MS, Logan S, Cauley JA, et al. Objective measures of physical performance associated with depression and/or anxiety in midlife Singaporean women. Menopause. 2019;26:1045–51.
Ahmad A, Oparil S. Hypertension in women: recent advances and lingering questions. Hypertension. 2017;70:19–26.
Stanaway JD, Afshin A, Gakidou E, Lim SS, Abate D, Abate KH, et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392:1923–94.
Harlow SD, Derby CA. Women’s midlife health: why the midlife matters. Womens Midlife Health. 2015;1:5.
United Nations Population Fund U. Population Trends. 2019. https://asiapacific.unfpa.org/en/node/15207. Accessed 18 Mar 2020.
Collaboration NRF. Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19· 1 million participants. Lancet. 2017;389:37.
NCD Risk Factor Collaboration (NCD-RisC). Contributions of mean and shape of blood pressure distribution to worldwide trends and variations in raised blood pressure: a pooled analysis of 1018 population-based measurement studies with 88.6 million participants. Int J Epidemiol. 2018;47:872–83.
Collaboration NRF. Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants. Lancet. 2016;387:1377–96.
Ishikawa Y, Ishikawa J, Ishikawa S, Kayaba K, Nakamura Y, Shimada K, et al. Prevalence and determinants of prehypertension in a Japanese general population: the Jichi Medical School Cohort Study. Hypertens Res. 2008;31:1323–30.
Katsuya T, Ishikawa K, Sugimoto K, Rakugi H, Ogihara T. Salt sensitivity of Japanese from the viewpoint of gene polymorphism. Hypertens Res. 2003;26:521–5.
Seow LSE, Subramaniam M, Abdin E, Vaingankar JA, Chong SA. Hypertension and its associated risks among Singapore elderly residential population. J Clin Gerontol Geriatr. 2015;6:125–32.
Lin YA, Chen YJ, Tsao YC, Yeh WC, Li WC, Tzeng IS, et al. Relationship between obesity indices and hypertension among middle-aged and elderly populations in Taiwan: a community-based, cross-sectional study. BMJ Open. 2019;9:e031660.
Otani K, Haruyama R, Gilmour S. Prevalence and correlates of hypertension among Japanese adults, 1975 to 2010. Int J Environ Res Public Health. 2018;15:1645.
Park JB, Kario K, Wang J-G. Systolic hypertension: an increasing clinical challenge in Asia. Hypertens Res. 2015;38:227–36.
Bonafini S, Giontella A, Tagetti A, Montagnana M, Benati M, Danese E, et al. Markers of subclinical vascular damages associate with indices of adiposity and blood pressure in obese children. Hypertens Res. 2019;42:400–10.
Malhotra R, Bautista MAC, Müller AM, Aw S, Koh GC, Theng YL, et al. The aging of a young nation: population aging in Singapore. Gerontologist. 2019;59:401–10.
Dimitriadis K, Tsioufis C, Mazaraki A, Liatakis I, Koutra E, Kordalis A, et al. Waist circumference compared with other obesity parameters as determinants of coronary artery disease in essential hypertension: a 6-year follow-up study. Hypertens Res. 2016;39:475–9.
Haraguchi N, Koyama T, Kuriyama N, Ozaki E, Matsui D, Watanabe I, et al. Assessment of anthropometric indices other than BMI to evaluate arterial stiffness. Hypertens Res. 2019;42:1599–605.
Després J-P, Lemieux I. Abdominal obesity and metabolic syndrome. Nature. 2006;444:881.
Choi J, Joseph L, Pilote LJ. Obesity and C‐reactive protein in various populations: a systematic review and meta‐analysis. Obes Rev. 2013;14:232–44.
Kershaw EE, Flier JS. Adipose tissue as an endocrine organ. J Clin Endocrinol Metab. 2004;89:2548–56.
Jayedi A, Rahimi K, Bautista LE, Nazarzadeh M, Zargar MS, Shab-Bidar S. Inflammation markers and risk of developing hypertension: a meta-analysis of cohort studies. Heart. 2019;105:686–92.
Buford TW. Hypertension and aging. Ageing Res Rev. 2016;26:96–111.
Hall JE, do Carmo JM, da Silva AA, Wang Z, Hall ME. Obesity-induced hypertension: interaction of neurohumoral and renal mechanisms. Circ Res. 2015;116:991–1006.
Lyon CJ, Law RE, Hsueh WA. Minireview: adiposity, inflammation, and atherogenesis. Endocrinology. 2003;144:2195–200.
Thu WPP, Logan SJS, Lim CW, Wang YL, Cauley JA, Yong EL. Cohort profile: the Integrated Women’s Health Programme (IWHP): a study of key health issues of midlife Singaporean women. Int J Epidemiol. 2018;47:389–90.
Topouchian J, Agnoletti D, Blacher J, Youssef A, Ibanez I, Khabouth J, et al. Validation of four automatic devices for self-measurement of blood pressure according to the international protocol of the European Society of Hypertension. Vasc Health Risk Manag. 2011;7:709.
Price AJ, Crampin AC, Amberbir A, Kayuni-Chihana N, Musicha C, Tafatatha T, et al. Prevalence of obesity, hypertension, and diabetes, and cascade of care in sub-Saharan Africa: a cross-sectional, population-based study in rural and urban Malawi. Lancet Diabetes Endocrinol. 2018;6:208–22.
Ong HL, Abdin E, Seow E, Pang S, Sagayadevan V, Chang S, et al. Prevalence and associative factors of orthostatic hypotension in older adults: Results from the Well-being of the Singapore Elderly (WiSE) study. Arch Gerontol Geriatr. 2017;72:146–52.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560–71.
Schneider H, Behre H. Contemporary evaluation of climacteric complaints: its impact on quality of life. In: Schneider HPG, editor. Hormone replacement therapy and quality of life. London, New York, Washington, Boca Raton: The Parthenon Publishing Group; 2002. p. 45–61.
Bull FC, Maslin TS, Armstrong T. Global physical activity questionnaire (GPAQ): nine country reliability and validity study. J Phys Act Health. 2009;6:790–804.
WHO, Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363:157.
Bazzocchi A, Ponti F, Albisinni U, Battista G, Guglielmi G. DXA: Technical aspects and application. Eur J Radiol. 2016;85:1481–92.
Schoeller DA, Tylavsky FA, Baer DJ, Chumlea WC, Earthman CP, Fuerst T, et al. QDR 4500A dual-energy X-ray absorptiometer underestimates fat mass in comparison with criterion methods in adults. Am J Clin Nutr. 2005;81:1018–25.
Abizanda P, Navarro JL, García-Tomás MI, López-Jiménez E, Martínez-Sánchez E, Paterna G. Validity and usefulness of hand-held dynamometry for measuring muscle strength in community-dwelling older persons. Arch Gerontol Geriatr. 2012;54:21–7.
Chen L-K, Woo J, Assantachai P, Auyeung TW, Chou MY, Iijima K, et al. Asian Working Group for Sarcopenia: 2019 consensus update on sarcopenia diagnosis and treatment. J Am Med Dir Assoc. 2020;21:300–7.e2.
Simonsick EM, Newman AB, Nevitt MC, Kritchevsky SB, Ferrucci L, Guralnik JM, et al. Measuring higher level physical function in well-functioning older adults: expanding familiar approaches in the Health ABC study. J Gerontol Ser A Biol Sci Med Sci. 2001;56:M644–9.
Chandra A, Neeland IJ, Berry JD, Ayers CR, Rohatgi A, Das SR, et al. The relationship of body mass and fat distribution with incident hypertension: observations from the Dallas Heart Study. J Am Coll Cardiol. 2014;64:997–1002.
Park S-Y, Karki S, Saggese SM, Zuriaga MA, Carmine B, Hess D, et al. Angiotensin II-mediated vasoconstriction of the visceral adipose tissue vasculature is linked to systemic hypertension in obesity. FASEB J. 2017;31:684.6.
Elffers TW, de Mutsert R, Lamb HJ, De Roos A, Van Dijk JK, Rosendaal FR, et al. Body fat distribution, in particular visceral fat, is associated with cardiometabolic risk factors in obese women. PloS ONE. 2017;12:e0185403.
Oikonomou EK, Antoniades C. The role of adipose tissue in cardiovascular health and disease. Nat Rev Cardiol. 2019;16:83–99.
Kunutsor SK, Laukkanen JA. Should inflammatory pathways be targeted for the prevention and treatment of hypertension? Heart. 2019;105:665–7.
Chei C-L, Loh JK, Soh A, Yuan J-M, Koh W-P. Coffee, tea, caffeine, and risk of hypertension: The Singapore Chinese Health Study. Eur J Nutr. 2018;57:1333–42.
Zheng C-J, Dong Y-h, Zou Z-y, Lv Y, Wang ZH, Yang ZG, et al. Sex difference in the mediation roles of an inflammatory factor (hsCRP) and adipokines on the relationship between adiposity and blood pressure. Hypertens Res. 2019;42:903.
Skinner AC, Steiner MJ, Henderson FW, Perrin EM. Multiple markers of inflammation and weight status: cross-sectional analyses throughout childhood. Pediatrics. 2010;125:e801–9.
Brown DE, Mautz WJ, Warrington M, Allen L, Tefft HA, Gotshalk L, et al. Relation between C‐reactive protein levels and body composition in a multiethnic sample of school children in Hawaii. Am J Hum Biol. 2010;22:675–9.
Ouchi N, Parker JL, Lugus JJ, Walsh K. Adipokines in inflammation and metabolic disease. Nat Rev Immunol. 2011;11:85.
Huby A-C, Otvos L Jr, Belin de Chantemèle EJ. Leptin induces hypertension and endothelial dysfunction via aldosterone-dependent mechanisms in obese female mice. Hypertension. 2016;67:1020–8.
Kim DH, Kim C, Ding EL, Townsend MK, Lipsitz LA. Adiponectin levels and the risk of hypertension: a systematic review and meta-analysis. Hypertension. 2013;62:27–32.
Haug EB, Horn J, Markovitz AR, Fraser A, Macdonald-Wallis C, Tilling K, et al. The impact of parity on life course blood pressure trajectories: the HUNT study in Norway. Eur J Epidemiol. 2018;33:751–61.
Jang M, Lee Y, Choi J, Kim B, Kang J, Kim Y, et al. Association between parity and blood pressure in Korean Women: Korean National Health and Nutrition Examination Survey, 2010–2012. Korean J Fam Med. 2015;36:341–8.
Li W, Ruan W, Lu Z, Wang D. Parity and risk of maternal cardiovascular disease: A dose–response meta-analysis of cohort studies. Eur J Prev Cardiol. 2018;26:592–602.
Brummett BH, Babyak MA, Jiang R, Huffman KM, Kraus WE, Singh A, et al. Systolic blood pressure and socioeconomic status in a large multi-study population. SSM Popul Health. 2019;9:100498.
Vathesatogkit P, Woodward M, Tanomsup S, Hengprasith B, Aekplakorn W, Yamwong S, et al. Long-term effects of socioeconomic status on incident hypertension and progression of blood pressure. J Hypertens. 2012;30:1347–53.
Leng B, Jin Y, Li G, Chen L, Jin N. Socioeconomic status and hypertension: a meta-analysis. J Hypertens. 2015;33:221–9.
Jackson EA, El Khoudary SR, Crawford SL, Matthews K, Joffe H, Chae C, et al. Hot flash frequency and blood pressure: data from the Study of Women’s Health Across the Nation. J Womens Health. 2016;25:1204–9.
Brown DE, Sievert LL, Morrison LA, Rahberg N, Reza A. The relation between hot flashes and ambulatory blood pressure: the Hilo Women’s Health Study. Psychosom Med. 2011;73:166.
Fitchett G, Powell LH. Daily spiritual experiences, systolic blood pressure, and hypertension among midlife women in SWAN. Ann Behav Med. 2009;37:257–67.
Rosenblad A. A comparison of blood pressure indices as predictors of all-cause mortality among middle-aged men and women during 701,707 person-years of follow-up. J Hum Hypertens. 2018;32:660–7.
Gottesman RF, Schneider AL, Albert M, Alonso A, Bandeen-Roche K, Coker L, et al. Midlife hypertension and 20-year cognitive change: the atherosclerosis risk in communities neurocognitive study. JAMA Neurol. 2014;71:1218–27.
Gersh FL, Lavie CJ. Menopause and hormone replacement therapy in the 21st century. Heart. 2020;106:479–81.
Wu Y, Tai ES, Heng D, Tan CE, Low LP, Lee J. Risk factors associated with hypertension awareness, treatment, and control in a multi-ethnic Asian population. J Hypertens. 2009;27:190–7.
Ok Ham K, Jeong Kim B. Evaluation of a cardiovascular health promotion programme offered to low‐income women in Korea. J Clin Nurs. 2011;20:1245–54.
The authors thank the study participants and study coordinators of IWHP. They are also grateful to Ms Tan Sze Yee from the Department of Orthopedic Surgery for conducting whole body DXA scans and to Dr Li Jun for grant management and the procurement of study materials.
This study was partially funded by a Singapore National Medical Research Council Grant (Number: NMRC/CSA-SI/0010/2017) provided to ELY.
Conflict of interest
The authors declare that they have no conflict of interest.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Thu, W.P.P., Sundström-Poromaa, I., Logan, S. et al. Blood pressure and adiposity in midlife Singaporean women. Hypertens Res 44, 561–570 (2021). https://doi.org/10.1038/s41440-020-00600-2
- Blood pressure