Abstract
Aims:
Diabetes is associated with significant pregnancy complications, which can be further exacerbated by comorbid hypertension. Racial/ethnic differentials in the burden of comorbid hypertension and diabetes among women of reproductive age has not been described.
Methods:
Using Wave IV of the nationally representative National Longitudinal Study of Adolescent to Adult Health (Add Health), we analyzed survey and biological data from 6,576 non-pregnant women who were aged 24−32 in 2007−2008. Hypertension and diabetes were identified by self-report of diagnosis and biological measurements taken during in-home interviews. We used logistic regression models to predict the presence of comorbid hypertension and diabetes and whether each was diagnosed.
Results:
Over a third (36.0%) of women with diabetes had comorbid hypertension. Compared to non-Hispanic white women, more non-Hispanic black women had comorbid hypertension and diabetes (adjusted odds ratio (aOR) 5.93, 95% CI 3.84−9.16). and, if comorbid, were less likely to have a diabetes diagnosis (aOR 0.03, 95% CI 0.007−0.1) or hypertension diagnosis (aOR 0.22, 95% CI 0.08−0.65 ).
Conclusion:
Comorbid hypertension and diabetes are more common among nonHispanic black women and less likely to be diagnosed, signaling disparities threatening maternal and child health among women with diabetes.
1. Introduction
Both hypertension and diabetes are increasingly prevalent in young adulthood1,2 and each heightens the risks of adverse obstetrical outcomes for women of reproductive age.3–10 When women have diabetes before conception, elevated blood glucose heightens risks of congenital anomalies, perinatal mortality, preeclampsia, and fetal programming in their child for obesity and type 2 diabetes (T2DM) later in life.7–10 Independently, preconception chronic hypertension increases the risk of preterm birth, low birth weight, neonatal unit admission, perinatal mortality, and preeclampsia.11 Preeclampsia, which can be superimposed on chronic hypertension, also increases the risks of fetal growth restriction, preterm birth, and perinatal mortality.12 Another concern is that hypertension is often treated with medications which are contraindicated during pregnancy: approximately 44% of young women with hypertension are treated with angiotensinconverting enzyme inhibitors and 20.4% with angiotensin receptor blockers.1,4,13 Before conception, women with hypertension, diabetes, or both, can engage in preconception care, including pursuit of pregnancy-specific management targets and modification of medication regimens to avoid teratogens, to improve the odds of optimal maternal and child outcomes.14–16
When women have comorbid hypertension and diabetes, the risks during pregnancy appear to be greater when women have either condition alone. In one large cohort study, women with comorbid hypertension and diabetes exhibited higher rates of intrauterine fetal demise, delivery at or before 32 weeks’ gestation, and preterm birth before 37 weeks, but similar or lower rates of preeclampsia, small-for-gestational age infants, and large-for-gestational age infants in comparison to women with either hypertension or diabetes alone.17
Both hypertension and diabetes are more prevalent among racial and ethnic minorities than their non-Hispanic white peers. The age-adjusted prevalence of diabetes was 9.3% for non-Hispanic white adults (95% CI 8.4–10.2), 16.0% for Asian adults (95% CI 13.6–18.9), 16.4% for Hispanic adults (95% CI 14.1–18.9), and 17.7% for non-Hispanic black adults (95% CI 15.8– 19.9) in the 2011−2014 National Health and Nutrition Examination Survey (NHANES).18 Non-Hispanic black and Hispanic adults have exhibited a more rapid increase in diabetes incidence than non-Hispanic white adults.19 Non-Hispanic black and Hispanic/Mexican-American adults with diabetes have higher glycosylated hemoglobin (A1C) than non-Hispanic white adults.20,21 Specifically among young adult women aged 24−32, compared to non-Hispanic white women, non-Hispanic black women have a greater prevalence of diabetes (15.0% vs. 4.8%), and, among those with diabetes, being undiagnosed (75.6% vs. 22.8%) and having A1C above 6.5% (88.2% vs. 26.3%).22 Among women aged 20−44, significantly more non-Hispanic black women have exhibited hypertension (16.6%) than non-Hispanic white women (6.6%).1
Although evidence suggests that comorbid hypertension and diabetes presents a heightened threat of negative obstetrical outcomes and disparities are documented in each condition separately, less is known about the prevalence of the comorbidity, what proportion are diagnosed, and the distribution by race/ethnicity among women of reproductive age. While the age-adjusted prevalence of comorbid diagnosed or undiagnosed hypertension and diabetes in adults over age 20 is 3.1%,23 the estimate includes women who are well beyond their reproductive years. Among women aged 20−44 in a nationally representative sample, 35.2% of women with self-reported diabetes had hypertension, with 3.4 times the adjusted odds of having hypertension compared to women without diabetes.1 While both analyses suggest that the hypertension and diabetes comorbidity is emerging, neither study identifies the rates of diagnoses or differences by race/ethnicity.
The rise in comorbid hypertension and diabetes has also been documented among pregnant women. In the National Inpatient Sample, the prevalence of chronic hypertension per 1,000 deliveries rose from 15.8 to 23.6 (p < 0.001), and pre-existing diabetes from 8.6 to 10.3 (p < 0.001) between 2005 and 2014.24 Analysis of the health discharge data for all deliveries during 2001–2007 in California revealed that 18.1% of pregnancies with preconception diabetes also had hypertensive disease; women with preconception diabetes had 3.33 times the odds of having preconception chronic hypertension compared to women with gestational diabetes.25 The proportion of pregnancies in women with preconception diabetes who also had preconception hypertension increased from 7.4% in 2000 to 14.1% in 2010 in an analysis of the State Inpatient Database, which includes 97% of community hospital discharges.26
Describing emerging trends in chronic illness among women of reproductive age is critical for directing efforts to support these women to optimize maternal health through preconception care.14,27,28 Therefore, the objectives of this study were to 1) estimate the prevalence of the comorbid hypertension and diabetes among women of reproductive age and 2) test the hypotheses that comorbidity prevalence and lack of diagnoses differ by race and ethnicity.
2. Methods and Materials
2.1. Subjects
We utilized data from the National Longitudinal Study of Adolescent to Adult Health (Add Health). This stratified, school-based cluster sample was representative of students in grades seven through twelve in the 1994–1995 school year in the United States, when the first wave of data was collected.29 Participants were recruited from high schools and feeder middle schools while in the seventh through twelfth grades during the 1994–1995 school year (Wave I). In-home interviews were conducted in 1996 (Wave II), 2001–2002 (Wave III), and 2007–2008 (Wave IV). Biological specimens were also collected in Wave IV, when participants were aged 24−32. Study design and informed consent procedures are described in detail elsewhere 30 We applied sample weights to adjust for unequal probability of selection and school-level clustering. Estimates are, thus, nationally representative of students who were in grades seven through twelve in the 1994–1995 school year in the United States.
2.2. Primary Outcome
Our primary outcome was comorbid hypertension and diabetes. We categorized women as having diabetes based on self-reported diagnosis or glycosylated hemoglobin (A1C) ≥ 6.5%. A1C was determined from capillary whole blood collected from a finger prick, which has been determined to be a valid and reliable test.31,32 A1C represents average blood glucose over the preceding two to three months, and A1C ≥ 6.5% is both the current threshold for diabetes diagnosis and the value at which the American Diabetes Association (ADA) warns that women may be at elevated risk of adverse obstetrical outcomes upon becoming pregnant.14 Participants were deemed diagnosed if they answered “yes” to the question “Has a doctor, nurse or other health care provider ever told you that you have or had: high blood sugar or diabetes {if female, add “when you were not pregnant”}?” Based on the ADA criteria, women with A1C ≥ 6.5% or a diagnosis were categorized as having diabetes, and women with A1C between 5.7−6.5% without a diagnosis were categorized as having prediabetes. Finally, women with an A1C < 5.7% without a diagnosis were categorized as having normoglycemia (neither prediabetes or diabetes).
Women were categorized as being hypertensive if they had systolic blood pressure (SBP) of 140 or above, diastolic blood pressure (DBP) of 90 or above, or self-reported a diagnosis. Participants were further categorized as diagnosed if they answered “yes” to the question “Has a doctor, nurse or other health care provider ever told you that you have or had: high blood pressure or hypertension {if female, add “when you were not pregnant”}?” Blood pressure was taken according to study protocols. Participants were categorized as prehypertensive if they had SBP 120−139 or DBP 80−89 without a diagnosis. Women were categorized as normotensive if their SBP was less than 120 and DBP was less than 80, without a diagnosis. Although the ADA has used 130/80mmHg as a standard target in the past for most adults with diabetes, currently the ADA recommends that most adults with diabetes should be treated to < 140/90mmHg (these targets change to 120−160/80−105 once women become pregnant).14
Women were categorized as having comorbid hypertension and diabetes if, by the criteria described above, they exhibited both hypertension and diabetes.
2.3. Predictors
We used the following demographic characteristics as predictors: race/ethnicity, educational attainment, health insurance type, and report of limited access to healthcare in the prior 12 months. We chose to use educational attainment as a proxy for socioeconomic position because the links between education and health status are often more stable than income at this age.33
We included self-identified non-pregnant female respondents in the analysis. From the 7,785 non-pregnant women in the sample, respondents were excluded for missing values, refusals, or uncertain responses for demographic characteristics or biological data. The final unweighted analytic sample contained 6,576 women.
2.4. Statistical Analysis
We used STATA version 14.1 (StataCorp LP) to conduct the analysis. To account for stratification, clustering, and unequal probability of selection, we applied survey weights and performed an unconditional subclass analysis using the SVY and SUBPOP commands.34 We produced unbiased weighted population estimates of prevalence and computed design-based standard errors using Taylor Series Linearization. Associations were tested using the second order Rao-Scott design-adjusted F test, with the null hypotheses of independence.
A logistic regression was used to model race/ethnicity as a predictor for having comorbid hypertension and diabetes and adjusted for educational attainment, type of health insurance, and access to care. Within the subpopulation of women with comorbid hypertension and diabetes, we modeled race/ethnicity as a predictor of having each disease diagnosed. The overall significance of each predictor was examined with an adjusted Wald test. All tests were two-tailed, with a 0.05 significance level. Institutional review board approval was obtained from the University of North Carolina at Chapel Hill.
3. Results
We estimate that 1.9% of American women aged 24–32 had comorbid hypertension and diabetes (Table 1). Race/ethnicity, education, insurance, and access to care all had significant bivariate associations with having comorbid hypertension and diabetes.
Table 1.
Comorbid hypertension and diabetes among U.S women aged 24–32, Add Health, 2007–2008 (N=6,576).
| Total | Comorbid | Not comorbid | Rao-Scott F Test | |
|---|---|---|---|---|
| Total | 6,576 | 159 (1.9%) | 6,417 (98.1%) | |
| Race/ethnicity | p < 0.001 | |||
| Non-Hispanic white | 3,641 | 45 (1.0%) | 3,596 (99.0%) | |
| Non-Hispanic black | 1,505 | 82 (6.5%) | 1,423 (93.5%) | |
| Hispanic | 1,005 | 20 (0.9%) | 985 (99.1%) | |
| Native American | 49 | - | - | |
| Asian | 376 | 8 (0.6%) | 368 (99.4%) | |
| Education | p = 0.002 | |||
| College graduate or more | 2,267 | 28 (1.0%) | 2,239 (99.0%) | |
| Some college or vocational school | 2,968 | 73 (1.9%) | 2,895 (98.1%) | |
| High school graduate | 908 | 39 (3.3%) | 869 (96.7%) | |
| Less than high school | 433 | 19 (3.2%) | 414 (96.8%) | |
| Insurance | p < 0.001 | |||
| Private insurance | 4,667 | 88 (1.3%) | 4,579 (98.7%) | |
| Medicaid | 703 | 32 (3.6%) | 671 (96.4%) | |
| No insurance | 1,206 | 39 (3.0%) | 1,167 (97.0%) | |
| Access to Care | p = 0.008 | |||
| Had access | 4,913 | 103 (1.6%) | 4,810 (98.4%) | |
| Lacked access | 1,663 | 56 (2.9%) | 1,607 (97.1%) |
Only 35.4% of women aged 24–32 were both normotensive and normoglycemic (Table 2). Overall, 18.8% of this population had hypertension, 5.3% had diabetes, and 1.9% had comorbid hypertension and diabetes. Of the women with diabetes, 36.0% had prehypertension and 36.0% had hypertension (Table 2). We also noted that 9.2% had comorbid prehypertension and prediabetes. There was a significant bivariate association between hypertension and diabetes when tested with a second order Rao-Scott design-adjusted F test (p < 0.001).
Table 2.
Population estimates of prevalence of hypertension, diabetes, and comorbid hypertension and diabetes among U.S women aged 24–32, Add Health, 2007–2008 (N=6,576).
| No Hypertension (n = 3,004) | Prehypertension (n = 2,361) | Hypertension (n = 1,211) | Total | |
| Normoglycemia | 2,282 (49.0%) | 1,589 (35.0%) | 695 (16.1%) | 4,566 (100%) |
| Prediabetes | 606 (35.2%) | 621 (41.2%) | 357 (23.7%) | 1,584 (100%) |
| Diabetes | 116 (28.0%) | 151 (36.0%) | 159 (36.0%) | 426 (100%) |
Unweighted n with weighted row percentages.
Among the women with comorbid hypertension and diabetes, almost one in five had neither diagnosed (19.7%). We estimate that 30.8% had not received a diagnosis of hypertension and 48.5% had not received a diagnosis of diabetes, while only 40.4% had a diagnosis for both (Table 3). There was no significant bivariate association between diagnosis status of hypertension and a diabetes when tested with a second order Rao-Scott design-adjusted F test (p = 0.065).
Table 3.
Diagnosis status of comorbid hypertension and diabetes among U.S women aged 24–32, Add Health, 2007–2008 (N=159).
| Undiagnosed hypertension | Diagnosed hypertension | |
| Undiagnosed diabetes | 31 (19.7%) | 39 (28.8%) |
| Diagnosed diabetes | 23 (11.1%) | 66 (40.4%) |
Unweighted n with weighted row percentages.
In the adjusted logistic regression model (Table 4), race/ethnicity was a significant predictor of comorbid hypertension and diabetes. Non-Hispanic black women had almost six times the odds of comorbidity than non-Hispanic white women (aOR 5.93, 95% CI 3.84−9.16). Access to care, insurance, and education were not significant in the model.
Table 4.
Odds of having comorbid hypertension and diabetes among U.S women aged 24–32 in Add Health, 2007–2008 (n=6,576).
| Adjusted odds of comorbidity versusnone | Adjusted Wald Test | |
|---|---|---|
| Race/ethnicity | p < 0.001 | |
| Non-Hispanic white | Referent | |
| Non-Hispanic black | 5.93 (3.84−9.15)*** | |
| Hispanic | 0.80 (0.36−1.77) | |
| Native American | - | |
| Asian | 0.64 (0.19−2.15) | |
| Education | p = 0.22 | |
| College graduate or more | Referent | |
| Some college or vocational school | 1.33 (0.73–2.45) | |
| High school graduate | 2.13 (0.98–4.64) | |
| Less than high school | 1.82 (0.85–3.94) | |
| Insurance | p = 0.20 | |
| Private insurance | Referent | |
| Medicaid | 1.54 (0.80–2.97) | |
| No insurance | 1.65 (0.89–3.05) | |
| Access to Care | p = 0.13 | |
| Had access | Referent | |
| Lacked access | 1.48 (0.91–2.41) |
When we examined the subpopulation of women with the comorbidity (Table 5), we found that race/ethnicity was the only significant predictor of having a hypertension diagnosis or a diabetes diagnosis. Non-Hispanic black women had significantly lower odds than non-Hispanic white women of having their hypertension diagnosed (aOR 0.22, 95% CI 0.08−0.65) or diabetes diagnosed (aOR 0.03, 95% CI 0.01−0.10). Asian women also had lower odds of having their hypertension diagnosed (aOR 0.10, 95% 0.02−0.45), as did women without a high school diploma (aOR 10.1, 95% CI 1.11–91.90).
Table 5.
Odds of diagnoses among women with comorbid hypertension and diabetes among U.S women aged 24–32 in Add Health, 2007–2008 (n=159).
| Adjusted odds of diagnosed vs. undiagnosed diabetes | Adjusted Wald Test | Adjusted odds of diagnosed vs. undiagnosed hypertension | Adjusted Wald Test | |
|---|---|---|---|---|
| Race/ethnicity | p < 0.001 | p = 0.001 | ||
| Non-Hispanic white | Referent | Referent | ||
| Non-Hispanic black | 0.03 (0.01−0.10)*** | 0.22 (0.08−0.65)** | ||
| Hispanic | 0.26 (0.04−1.89) | 0.52 (0.06−4.57) | ||
| Native American | - | - | ||
| Asian | 4.89 (0.43−55.17) | 0.10 (0.02−0.45)** | ||
| Education | p = 0.92 | p = 0.18 | ||
| College graduate or more | Referent | Referent | ||
| Some college or vocational school | 0.67 (0.20−2.25) | 3.15 (0.80–12.46) | ||
| High school graduate | 0.69 (0.16−2.97) | 2.76 (0.48–15.99) | ||
| Less than high school | 0.80 (0.11−5.71) | 10.09 (1.11–91.89)* | ||
| Insurance | p = 0.53 | p = 0.81 | ||
| Private insurance | Referent | Referent | ||
| Medicaid | 1.53 (0.40−5.79) | 0.82 (0.15–4.31) | ||
| No insurance | 0.79 (0.21−3.05) | 1.71 (0.41–7.12) | ||
| Access to Care | p = 0.39 | p = 0.23 | ||
| Had access | Referent | Referent | ||
| Lacked access | 1.74 (0.48−6.35) | 2.02 (0.64–6.44) |
4. Discussion
We estimated that 36.0% of women in the U.S. aged 24–32 with diabetes also have hypertension, such that 1.9% of American women aged 24–32 have comorbid hypertension and diabetes. Less than half of comorbid women reported that both their hypertension and diabetes were diagnosed. Comorbid hypertension and diabetes were both more common among nonHispanic black women and less likely to be diagnosed, signaling an important health disparity that must be addressed to improve population maternal and child health.
To our knowledge, this is the first study to estimate the prevalence and describe racial/ethnic disparities related to comorbid hypertension and diabetes using A1C-based identification of disease among women in this US population-based sample. The Add Health sample of young adults is large enough for comparison of non-Hispanic black, non-Hispanic white, Hispanic, and Asian women (cell counts for the Native American women were too small to be reported, per Add Health guidelines). In contrast, the number of women of reproductive age sampled by NHANES limits the estimations that can be made.37 Since Add Health has a larger sample of women in this age range, we were able to determine that non-Hispanic black women are disproportionately burdened by the comorbid hypertension and diabetes and also disproportionately lack diagnoses for both illnesses. Our findings are consistent with the trends of the past 30 years about inequity in the hypertension and diabetes burdens.20,36,38,39 By focusing on women of reproductive age, we highlight the implications not only for cardiovascular disease but also for reproductive health and the prevention of adverse obstetrical outcomes.
We also noted that 9.2% of the women aged 24–32 had both prehypertension and prediabetes (41.2% of women with prediabetes also have prehypertension), representing women who are at heightened risk of progressing to hypertension, diabetes, or both within their reproductive years. Data from NHANES also suggests that the prevalence of comorbid prehypertension and prediabetes is increasing.40
Diabetes management for women of reproductive age needs to include care that anticipates the possibility of pregnancy and supports women to achieve their reproductive goals. The ADA recommends that women strive to optimize diabetes management before pregnancy.14 In a systematic review and meta-analysis, Wahabi et al. (2010) estimated that preconception care for all women with preconception diabetes can reduce the relative risks of preterm birth by 0.70, birth defects by 0.25, and perinatal mortality by 0.35.15,41 Based on Wahabi et al.’s findings, Peterson et al. estimated that universal preconception care could save 5.5 billion dollars in annual preventable U.S. health costs attributed to adverse birth outcomes associated with preconception diabetes.42 However, a Cochrane review suggested that more research is needed to identify the optimal preconception care protocol.16 We recommend that innovations in diabetes management address the coordination of care for management of hypertension as well as reproductive health.
We note several limitations of our analyses. There was no validated method to distinguish type 1 diabetes (T1DM) or T2DM in the surveys, which would be valuable for tracking disparate trends in these two patient groups. In an Australian cohort study, significantly less preconception hypertension was observed among pregnant women with T1DM than T2DM.43 Nonetheless, our findings are still valuable because women with T1DM and T2DM share the same risks associated with elevated blood glucose during pregnancy.14 Given that blood pressure is routinely measured in healthcare encounters, we were surprised that women who had received a diabetes diagnosis could have had undiagnosed hypertension. While Add Health protocols for measuring blood pressure and A1C are well-validated and based on diagnostic criteria, these measurements do not constitute diagnoses by a medical professional.32,44 Additionally, as with any self-reported personal information, the inquiry about diagnosis is vulnerable to recall bias. Despite these limitations, we determined that Add Health was the optimal dataset for our research question because diabetes was determined by biomarkers, and the study offers a population-based sample with a large number of women of reproductive age.
5. Conclusion
Hypertension and diabetes increasingly affect women’s health throughout the lifespan and often go undiagnosed. The growing prevalence of chronic illness during women’s reproductive years, particularly among non-Hispanic black women, has serious implications for goals of excellence and equity in maternal and child health. Women with diabetes, hypertension, or both will need coordinated family planning, preconception, prenatal, birthing, and postpartum care from skilled providers to have safe, healthy pregnancies.
Comorbid Hypertension and Diabetes among U.S. Women of Reproductive Age: Prevalence and Disparities.
Among women aged 24–32 with diabetes, 36.0% had comorbid hypertension.
Non-Hispanic black women had greater odds of having comorbid hypertension and diabetes than non-Hispanic white women.
Non-Hispanic black women had greater odds of having their comorbid hypertension and diabetes be undiagnosed than non-Hispanic white women.
Acknowledgments:
This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill and funded by grant P01HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. Special acknowledgment is due to Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Information on how to obtain the Add Health data files is available on the Add Health website (http://www.cpc.unc.edu/addhealth). No direct support was received from grant P01HD31921 for this analysis.
Funding: Research reported in this publication was supported by the National Institute Of Nursing Research of the National Institutes of Health under Award Number F31NR017320. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. While producing this manuscript, Ms. Britton has been supported as a Hillman Scholar in Nursing Innovation and a Jonas Nurse Leader Scholar. Funders had no role in the conduct of the research or preparation of the manuscript.
Footnotes
Declarations of interest: none
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