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The Journal of Clinical Hypertension logoLink to The Journal of Clinical Hypertension
. 2022 Apr 19;24(5):611–620. doi: 10.1111/jch.14475

Association between changes in facial flushing and hypertension across drinking behavior patterns in South Korean adults

Yu shin Park 1,2, Soo Hyun Kang 1,2, Eun‐Cheol Park 2,3, Suk‐Yong Jang 1,2,✉
PMCID: PMC9106078  PMID: 35437944

Abstract

Heavy alcohol drinking has been reported to be associated with hypertension. Moreover, when drinking alcohol, individuals may experience symptoms such as facial flushing. Therefore, this study aimed to examine the association between changes in facial flushing and hypertension across different drinking behavior patterns in South Korean adults.

Data from the Korea Community Health Survey conducted in 2019 were used, and 118 129 (51 047 men and 67 082 women) participants were included. The participants were divided into five groups based on the change in facial flushing (non‐drinking, non‐flushing to non‐flushing, flushing to flushing, non‐flushing to flushing, flushing to non‐flushing). The risk of hypertension in each facial flushing group was analyzed by multiple logistic regression.

Men in the non‐flushing to flushing group had a significantly higher association with hypertension than other groups (men: odds ratio (OR) 1.42, confidence interval (CI) 1.14–1.76). According to the level of alcohol use disorder, the non‐flushing to flushing group showed a significantly increased odds of hypertension compared to all levels of drinking (men: mild drinking: OR 1.95, CI 1.40–2.71; moderate drinking: OR 2.02, CI 1.41–2.90; women: moderate drinking: OR 1.71, CI 1.16–2.52; heavy drinking: OR 1.90, CI 1.19–3.04).

This study found a significant association between changes in facial flushing and hypertension among adults in South Korea. In particular, individuals who changed from non‐flushing to flushing reactions had an increased association with hypertension than the other groups. Compared to people at the same drinking level, people with non‐flushing to flushing reactions were highly associated with hypertension at moderate drinking level.

Keywords: alcohol use disorder, Asian flushing, facial flushing, hypertension

1. INTRODUCTION

Hypertension is a commonly occurring and leading preventable risk factor for cardiovascular disease and a subject of great interest to researchers. 1 The Global Burden of Disease study found that hypertension is at risk of placing an increasing economic burden on societies globally. 2 , 3 , 4 In South Korea, neoplasms caused 158.2 deaths per 100 000 in 2019. In comparison, diseases of the circulatory system caused 117.8 deaths. These included cardiovascular diseases (60.4 deaths) and cerebrovascular diseases (40.2 deaths). 5 It is well recognized that hypertension is associated with traditional risk factors such as age, body mass index (BMI), smoking, and family history. 6 Additionally, drinking behavior, especially excessive or frequent drinking, is also a risk factor for hypertension. 7 , 8

When drinking alcohol, some people experience facial flushing or palpitations, shortness of breath, headache, and vomiting due to the accumulation of acetaldehyde. 9 In particular, East Asian ethnic groups, such as Korean, Chinese, and Japanese populations, have a higher prevalence of ALDH2 polymorphism than the Western population. 10 , 11 Ethanol is metabolized by alcohol dehydrogenase (ADH) to acetaldehyde, which is eliminated by aldehyde dehydrogenase (ALDH). 12 Alcohol dependence is associated with the isozymes ADH2*2 and ADH3*1, which oxidize alcohol rapidly and produce high amounts of acetaldehyde. 13 Moreover, the ALDH2 polymorphism encodes an inactive subunit, 14 , 15 resulting in high acetaldehyde levels in the blood after alcohol intake. 11 , 16

A previous study suggested a greater association with hypertension in people who have alcohol‐related facial flushing than non‐flushers. 17 Moreover, the risk of hypertension in facial flushers is markedly increased with excessive drinking. 18 More research on specific genotypes associated with alcohol metabolism are necessary because the specific genotypes associated with alcohol metabolism are common in South Korean populations. To the best of our knowledge, no study has examined the association between facial flushing and hypertension changes. Therefore, we examined the association between change in facial flushing and hypertension across different drinking behavior patterns, such as alcohol use disorders, to fill this research gap. We focused both on the presence and absence of facial flushing as well as the occurrence or elimination of facial flushing with time in adults.

2. METHODS

We used data from the Korea Community Health Survey (KCHS) conducted by the Korea Center for Disease Control and Prevention (KCDC) in 2019. The KCHS is a cross‐sectional, nationally representative survey that has been conducted regularly since 2008 to gather regional data for planning, monitoring, and evaluating community health services. The data for providing country‐level health indicators is made using a large population‐based National Census Registry and a systematic, stratified, and multistage cluster sampling method. The weights allocated to each participant's data were calculated based on geographic and demographic distributions to generalize the entire population of Korea.

2.1. Participants

The 2019 survey included 229 099 individuals, and the analysis excluded individuals who were younger than 19 years of age (n = 2200) and pregnant (n = 641). In addition, we excluded individuals who had been undergoing anti‐hypertensive drug treatment were excluded (n = 62 286). Some anti‐hypertensive drugs cause facial flushing. 19 , 20 Finally, after excluding those with missing data (n = 45 843), 118 129 healthy participants were included in this study.

Our study did not require approval from the Institutional Review Board or informed consent because the KCHS is a secondary dataset available in the public domain and does not contain private information.

2.2. Variables

The dependent variable of this study was the risk of hypertension. Blood pressure was measured thrice with intervals of 1 minute for stabilization, and the final blood pressure was the average of the three measurements. Hypertension was classified as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg. 21 We classified those who met the hypertension criteria and those who did not meet the hypertension criteria when measuring blood pressure, except for taking anti‐hypertensive drugs.

Facial flushing reaction was the primary independent variable of interest. The following question assessed past facial flushing reaction: “In the past year or two, did you experience a quick facial flushing reaction when drinking a small glass of beer?” A current facial flushing reaction was assessed by asking the following question: “Do you currently experience a facial flushing reaction when drinking a small amount of beer?” The data on past and present facial flushing reactions were self‐reported.

We divided the study population into five categories: people who have never drunk alcohol (ND, non‐drinking); people who never had facial flushing reaction (NN, non‐flushing→ non‐flushing); people who had facial flushing reaction in the past and present (FF, flushing→ flushing); people who had facial flushing reaction in the past but not in the present (FN, flushing→ non‐flushing); and people who did not have facial flushing reaction in the past but did in the present (NF, non‐flushing→ flushing). Furthermore, we analyzed each group stratified by variables such as alcohol use.

We controlled for covariates such as sociodemographic and socioeconomic factors, health behaviors, and health conditions of the participants. The sociodemographic factors were age (19–29, 30–39, 40–49, 50–59, and ≥60 years) and sex (men and women). The socioeconomic factors were education level (below middle school, high school, and college or higher), region (city and rural areas), marital status (yes and no), occupation (white‐collar, pink collar, blue‐collar, and unemployed), and household income (high, middle high, middle‐low, and low). Health behavior factors included smoking status (non‐smoker, past smoker, and current smoker), BMI (non‐obese and obese), diagnosis of diabetes (yes and no), and physical activity assessed to walking practice rate (yes and no). In the female group, menopause status was added (yes and no). Additionally, we used the Alcohol Use Disorder Identification Test Score (AUDIT‐C) to assess the pattern of alcohol use. Cut‐off scores of AUDIT‐C for heavy alcohol drinking were 7 for men and 6 for women, and mild alcohol drinking were 3 for both men and women. 22

2.3. Statistical analysis

Independent variables were compared using the chi‐squared test to identify the association between changes in facial flushing and hypertension. After adjusting for sociodemographic, economic, and health‐related variables, we used a multiple logistic regression analysis to evaluate the association between the change of facial flushing and hypertension. The results were reported using odds ratios (ORs) and confidence intervals (CIs). Moreover, we performed a subgroup analysis stratified by sex and multiple logistic regression analysis was used to examine the associations with change in facial flushing in persons with hypertension according to the level of alcohol use disorder. Differences were considered significant at P‐values of <.05 as well as at P‐values for trends <.05. Data were analyzed using SAS 9.4 (SAS Institute Inc; Cary, North Carolina, USA) and a P value <.05 was considered to be statistically significant.

3. RESULTS

Table 1 shows the general characteristics of the participants. There were 51 047 men and 67 082 women in this study, and 11 234 (22%) men and 10 406 (15.5%) women had a risk of hypertension. Participants were grouped into five categories based on the change in facial flushing reaction. Of the men, 5798 (11.4%) reported they have never drunk alcohol, 29 044 (56.9%) reported non‐flushing to alcohol, 11 592 (22.7%) reported flushing in the past and present, 3711 (7.3%) reported facial flushing reaction in the past but not in the present, and 902 (1.8%) reported facial flushing reaction in the present but not in the past. Of the women, 18 060 (26.9%) reported they have never drunk alcohol, 32 616 (48.6%) reported non‐flushing to alcohol, 11 476 (17.1%) reported flushing in the past and present, 3958 (5.9%) reported facial flushing reaction in the past but not in the present, and 972 (1.4%) reported facial flushing reaction in the present but not in the past.

TABLE 1.

General characteristics of the study population

Hypertension
Men Women
TOTAL Yes No TOTAL Yes No
Variables No. % No. % No. % P No. % No. % No. % P
Total 118 129 51,047 100.0 11 234 22.0 39 813 78.0 67 082 100.0 10 406 15.5 56 676 84.5
Facial flushing change
 non‐drinking 5798 11.4 1142 19.7 4656 80.3 <.0001 18 060 26.9 3789 21.0 14 271 79.0 <.0001
 non‐flushing →non‐flushing 29 044 56.9 6530 22.5 22 514 77.5 32 616 48.6 4271 13.1 28 345 86.9
 flushing →flushing 11 592 22.7 2414 20.8 9178 79.2 11 476 17.1 1560 13.6 9916 86.4
 non‐flushing →flushing 902 1.8 255 28.3 647 71.7 972 1.4 201 20.7 771 79.3
 flushing →non‐flushing 3711 7.3 893 24.1 2818 75.9 3958 5.9 585 14.8 3373 85.2
Age (years)
 19‐29 8467 16.6 816 9.6 7651 90.4 <.0001 8966 13.4 242 2.7 8724 97.3 <.0001
 30‐39 9619 18.8 1818 18.9 7801 81.1 10 200 15.2 714 7.0 9486 93.0
 40‐49 10 865 21.3 2699 24.8 8166 75.2 13 644 20.3 1683 12.3 11 961 87.7
 50‐59 9859 19.3 2560 26.0 7299 74.0 14 468 21.6 2513 17.4 11 955 82.6
 ≥60 12 237 24.0 3341 27.3 8896 72.7 19 804 29.5 5254 26.5 14 550 73.5
Marital Status
 Living w/ spouse 33 383 65.4 7703 23.1 25 680 76.9 <.0001 44 096 65.7 6883 15.6 37 213 84.4 .3433
 Living w/o spouse 17 664 34.6 3531 20.0 14 133 80.0 22 986 34.3 3523 15.3 19 463 84.7
Region
 City 16 621 32.6 3565 21.4 13056 78.6 0.035 22 173 33.1 3047 13.7 19 126 86.3 <.0001
 Rural 34 426 67.4 7669 22.3 26757 77.7 44 909 66.9 7359 16.4 37 550 83.6
Educational level
 Middle school or less 7795 15.3 2147 27.5 5648 72.5 <.0001 18 886 28.2 5098 27.0 13 788 73.0 <.0001
 High school 15 344 30.1 3830 25.0 11514 75.0 20 188 30.1 3155 15.6 17 033 84.4
 College or over 27 908 54.7 5257 22651 28 008 41.8 2153 25 855
Household Income
 Low 8740 17.1 2225 25.5 6515 74.5 <.0001 15 401 23.0 3760 24.4 11 641 75.6 <.0001
 Mid‐low 8574 16.8 2083 24.3 6491 75.7 11 184 16.7 1918 17.1 9266 82.9
 Mid‐high 15 395 30.2 3407 11 988 18 056 26.9 2405 15 651
 High 18 338 35.9 3519 19.2 14819 80.8 22 441 33.5 2323 10.4 20 118 89.6
Occupational categories a
 White 14 534 28.5 2932 20.2 11 602 79.8 <.0001 15 564 23.2 1270 8.2 14 294 91.8 <.0001
 Pink 6192 12.1 1270 20.5 4922 79.5 12 044 18.0 1775 14.7 10 269 85.3
 Blue 20 477 40.1 4929 24.1 15 548 12 620 18.8 2730 21.6 9890
 Inoccupation 9844 19.3 2103 21.4 7741 78.6 26 854 40.0 4631 17.2 22 223 82.8
Smoking
 Non smoker 15 180 29.7 2666 17.6 12 514 82.4 <.0001 63 027 94.0 9673 15.3 53 354 84.7 <.0001
 past smoker 17 362 34.0 4218 24.3 13 144 75.7 1998 3.0 331 16.6 1667 83.4
 smoker 18 505 36.3 4350 23.5 14 155 76.5 2057 3.1 402 19.5 1655 80.5
BMI
 Non‐obesity 48 115 94.3 10 145 21.1 37 970 78.9 <.0001 64 865 96.7 9725 15.0 55 140 85.0 <.0001
 Obesity 2932 5.7 1089 37.1 1843 62.9 2217 3.3 681 30.7 1536 69.3
Diagnose of diabetes
 Yes 3152 6.2 794 25.2 2358 74.8 <.0001 3323 5.0 749 22.5 2574 77.5 <.0001
 No 47 895 93.8 10 440 21.8 37 455 78.2 63 759 95.0 9657 15.1 54 102 84.9
Physical activity‐walk
 Yes 28 240 55.3 6226 22.0 2 2014 78.0 0.810 40 054 59.7 6323 15.8 33 731 84.2 0.017
 No 22 807 44.7 5008 22.0 17 799 78.0 27 028 40.3 4083 15.1 22 945 84.9
Menopausal status
 Yes 32 882 49.0 7576 23.0 25 306 77.0 <.0001
 No 34 200 51.0 2830 8.3 31 370 91.7
Alcohol use disorder
 Mild drinking & Non‐drinking 16 560 32.4 3153 19.0 13 407 81.0 44 918 67.0 7512 16.7 37 406 83.3
 Moderate drinking 15 746 30.8 3174 20.2 12 572 79.8 <.0001 12 595 18.8 1497 11.9 11 098 88.1 <.0001
 Heavy drinking 18 741 36.7 4907 26.2 13 834 73.8 9569 14.3 1397 14.6 8172 85.4
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a

Three groups(White, Pink, Blue) based on International Standard Classification Occupations codes. Inoccupation group includes housewife

Table 2 reports the findings of logistic regression analysis for the association between change in facial flushing and hypertension stratified by sex. Men in the NF group had a higher OR of hypertension than other groups (men: OR 1.42, CI 1.14–1.76); among women, there was no statistically significant relationship between change in facial flushing and hypertension. Additionally, participants who drink moderately (men: OR 1.20, CI 1.11–1.30, women: OR 1.16, CI 1.07–1.27) and heavily (men: OR 1.83, CI 1.69–1.98, women: OR 1.93, CI 1.76–2.13) were strongly associated with an increased risk for hypertension.

TABLE 2.

Results of factors associated with hypertension

Hypertension
Men Women
Variables OR 95% CI OR 95% CI
Facial flushing change
 Non‐drinking 1.00 1.00
 non‐flushing →non‐flushing 1.11 (0.99 ‐ 1.25) 0.93 (0.86 ‐ 1.01)
 flushing →flushing 1.09 (0.97 ‐ 1.22) 1.03 (0.94 ‐ 1.13)
 non‐flushing →flushing 1.42 (1.14 ‐ 1.76) 1.11 (0.90 ‐ 1.37)
 flushing →non‐flushing 1.08 (0.93 ‐ 1.24) 0.93 (0.81 ‐ 1.06)
Age (years)
 19‐29 1.00 1.00
 30‐39 2.48 (2.22 ‐ 2.77) 2.98 (2.50 ‐ 3.56)
 40‐49 3.79 (3.38 ‐ 4.24) 5.71 (4.82 ‐ 6.77)
 50‐59 4.35 (3.87 ‐ 4.90) 6.98 (5.68 ‐ 8.57)
 ≥60 5.21 (4.57 ‐ 5.94) 9.28 (7.47 ‐ 11.54)
Marital Status
 Living wtih spouse 1.00 1.00
 Living without spouse 1.32 (1.23 ‐ 1.42) 1.09 (1.01 ‐ 1.16)
Region
 City 1.00 1.00
 Rural 0.99 (0.94 ‐ 1.05) 1.01 (0.96 ‐ 1.08)
Occupational categories a
 White 1.00 1.00
 Pink 0.95 (0.86 ‐ 1.04) 1.06 (0.95 ‐ 1.17)
 Blue 1.04 (0.97 ‐ 1.12) 1.12 (1.00 ‐ 1.25)
 Inoccupation 1.05 (0.95 ‐ 1.15) 1.11 (1.01 ‐ 1.22)
Educational level
 Middle shool or less 1.33 (1.20 ‐ 1.47) 1.72 (1.54 ‐ 1.92)
 High school 1.22 (1.14 ‐ 1.30) 1.31 (1.20 ‐ 1.42)
 College or over 1.00 1.00
Household income
 Low 1.12 (1.02 ‐ 1.22) 1.25 (1.14 ‐ 1.37)
 Mid‐low 1.17 (1.08 ‐ 1.28) 1.20 (1.10 ‐ 1.32)
 Mid‐high 1.11 (1.04 ‐ 1.19) 1.13 (1.05 ‐ 1.23)
 High 1.00 1.00
Smoking
 Non smoker 1.00 1.00
 Past smoker 1.06 (0.98 ‐ 1.14) 1.36 (1.16 ‐ 1.61)
 smoker 1.04 (0.97 ‐ 1.12) 1.28 (1.10 ‐ 1.48)
BMI
 Non‐obesity 1.00 1.00
 Obesity 3.25 (2.94 ‐ 3.59) 3.57 (3.08 ‐ 4.14)
Diagnose of diabetes
 Yes 1.00 1.00
 No 1.17 (1.05 ‐ 1.31) 1.06 (0.94 ‐ 1.20)
Physical activity‐walk
 Yes 1.00 1.00
 No 0.91 (0.87 ‐ 0.97) 0.96 (0.90 ‐ 1.01)
Menopausal status
 Yes 1.17 (1.03 ‐ 1.34)
 No 1.00
Alcohol use disorder
 mild drinking & non‐drinking 1.00 1.00
 moderate drinking 1.20 (1.11 ‐ 1.30) 1.16 (1.07 ‐ 1.27)
 heavy drinking 1.83 (1.69 ‐ 1.98) 1.93 (1.76 ‐ 2.13)
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a

(White, Pink, Blue) based on International Standard Classification Occupations codes. Inoccupation group includes housewife

Figure 1 shows the results of stratified analyses of the association of the changes in facial flushing on hypertension according to alcohol consumption. Overall, taking the non‐drinking group as the reference category, the OR of the NF was high in mild and moderate drinking levels among men. (mild drinking: OR 1.95, CI 1.40–2.71; moderate drinking: OR 2.02 CI, 1.41–2.90). Also, the OR of the NF was high in moderate and heavy drinking levels among women. (moderate drinking: OR 1.71, CI 1.16–2.52; heavy drinking: OR 1.90 CI, 1.19–3.04)

FIGURE 1.

FIGURE 1

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Stratified analysis of the changes in facial flushing with respect to hypertension by alcohol consumption

Finally, Table 3 reports the subgroup analysis stratified by independent variables. Men diagnosed with diabetes had an increased association with hypertension in the NF group (OR 2.24, CI 1.22–4.11). Additionally, men who did not exercise had an increased risk of hypertension in the NF group (OR 1.68, CI 1.26–2.25).

TABLE 3.

The results of subgroup analysis stratified by independent variables

Variables Hypertension
Facial flushing change
No‐drinking non‐flushing → non‐flushing flushing → flushing non‐flushing → flushing flushing → non‐flushing
OR OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Men
Age
 19‐29 1.00 1.17 (0.77 ‐ 1.77) 1.11 (0.72 ‐ 1.72) 1.16 (0.49 ‐ 2.75) 1.11 (0.64 ‐ 1.91)
 30‐39 1.00 1.16 (0.83 ‐ 1.63) 0.95 (0.67 ‐ 1.34) 1.52 (0.84 ‐ 2.76) 1.05 (0.69 ‐ 1.58)
 40‐49 1.00 1.29 (0.98 ‐ 1.71) 1.22 (0.93 ‐ 1.62) 1.61 (1.00 ‐ 2.60) 1.17 (0.85 ‐ 1.61)
 50‐59 1.00 0.96 (0.74 ‐ 1.24) 1.10 (0.85 ‐ 1.42) 1.40 (0.86 ‐ 2.28) 1.00 (0.74 ‐ 1.36)
 ≥60 1.00 1.04 (0.88 ‐ 1.24) 1.14 (0.97 ‐ 1.35) 1.39 (1.00 ‐ 1.94) 1.13 (0.90 ‐ 1.43)
Diagnose of diabetes
 Yes 1.00 0.97 (0.67 ‐ 1.40) 0.97 (0.66 ‐ 1.43) 2.24 (1.22 ‐ 4.11) 0.68 (0.42 ‐ 1.13)
 No 1.00 1.13 (1.01 ‐ 1.28) 1.11 (0.98 ‐ 1.25) 1.35 (1.07 ‐ 1.70) 1.12 (0.96 ‐ 1.29)
BMI
 non‐obesity 1.00 1.13 (1.01 ‐ 1.27) 1.10 (0.98 ‐ 1.24) 1.40 (1.11 ‐ 1.76) 1.10 (0.95 ‐ 1.28)
 Obesity 1.00 0.91 (0.62 ‐ 1.35) 1.00 (0.68 ‐ 1.48) 1.58 (0.73 ‐ 3.41) 0.80 (0.48 ‐ 1.34)
Physical activity
 Yes 1.00 1.01 (0.86 ‐ 1.20) 0.97 (0.82 ‐ 1.14) 1.18 (0.85 ‐ 1.63) 0.91 (0.73 ‐ 1.13)
 No 1.00 1.21 (1.03 ‐ 1.42) 1.22 (1.04 ‐ 1.42) 1.68 (1.26 ‐ 2.25) 1.25 (1.04 ‐ 1.52)
Women
Age
 19‐29 1.00 1.25 (0.68 ‐ 2.29) 1.28 (0.66 ‐ 2.46) 0.45 (0.09 ‐ 2.14) 0.69 (0.29 ‐ 1.63)
 30‐39 1.00 1.03 (0.71 ‐ 1.51) 0.93 (0.61 ‐ 1.41) 0.65 (0.28 ‐ 1.48) 1.23 (0.75 ‐ 2.04)
 40‐49 1.00 1.39 (1.10 ‐ 1.76) 1.56 (1.21 ‐ 2.01) 0.97 (0.56 ‐ 1.69) 1.28 (0.94 ‐ 1.75)
 50‐59 1.00 0.96 (0.82 ‐ 1.12) 1.14 (0.96 ‐ 1.35) 1.79 (1.26 ‐ 2.56) 1.00 (0.78 ‐ 1.28)
 ≥60 1.00 0.82 (0.73 ‐ 0.91) 0.92 (0.80 ‐ 1.07) 1.13 (0.79 ‐ 1.62) 0.89 (0.71 ‐ 1.11)
Diagnose of diabetes
 Yes 1.00 1.07 (0.82 ‐ 1.39) 1.11 (0.79 ‐ 1.56) 0.69 (0.35 ‐ 1.38) 0.76 (0.44 ‐ 1.33)
 No 1.00 0.93 (0.86 ‐ 1.01) 1.02 (0.93 ‐ 1.12) 1.14 (0.92 ‐ 1.42) 0.93 (0.81 ‐ 1.07)
BMI
 Non‐obesity 1.00 0.91 (0.84 ‐ 0.99) 1.01 (0.92 ‐ 1.12) 1.12 (0.88 ‐ 1.43) 0.93 (0.81 ‐ 1.07)
 Obesity 1.00 1.47 (1.02 ‐ 2.12) 1.43 (0.96 ‐ 2.13) 1.17 (0.53 ‐ 2.58) 1.08 (0.56 ‐ 2.08)
Physical activity
 Yes 1.00 0.92 (0.82 ‐ 1.04) 1.03 (0.90 ‐ 1.19) 1.15 (0.82 ‐ 1.61) 0.87 (0.71 ‐ 1.06)
No 1.00 0.94 (0.85 ‐ 1.04) 1.03 (0.91 ‐ 1.16) 1.07 (0.82 ‐ 1.40) 0.99 (0.83 ‐ 1.18)
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*

Adjusted for other covariates

4. DISCUSSION

We found that change in facial flushing reaction was associated with a higher risk of hypertension. Especially, individuals with facial flushing reaction in the present but not in the past increased the likelihood of hypertension, and we also examined individuals who consumed similar alcohol levels. The association between flushing changes and hypertension was different for each alcohol consumption level. Among those who drink mild or moderate, men who did not have facial flushing reaction in the past but did in the present were the highest likelihood of hypertension. And women who did not have facial flushing reaction in the past but did in the present were the highest likelihood of hypertension among moderate drinking group.

Some studies link hypertension and alcohol‐induced facial flushing. 17 , 23 The likelihood of hypertension was higher in people with facial flushing than in those without facial flushing in previous study. In the result of our study, the difference between the two group was not significant. Since previous studies considered only current facial flushing, different results may have been derived from our study. While polymorphisms partly explained the association in alcohol metabolism genes, 24 these studies did not find any evidence that facial flushing reaction is associated with the risk of hypertension. 25 , 26 Therefore, further studies are necessary.

In this study, we assessed the association between the presence of facial flushing and alcohol consumption. The reasons for the change in facial flushing can be explained as follows. Facial flushing is a well‐known symptom of acetaldehyde accumulation and intolerance to alcohol. 9 Some studies showed that the genotype of ADH and ALDH was associated with liver disease. 27 , 28 , 29 , 30 Chronic alcoholics have a higher tolerance to alcohol than others because of the metabolic adaptation of the central nervous system and increased ethanol elimination rate. 31 Increased ethanol elimination increases both blood and tissue acetaldehyde levels in chronic alcoholics. 32 People with liver injury experience decreasing activities of ADH and proportionally low‐K ALDH (ALDH2). 33 It is speculated that the decrease in ADH could be due to centrilobular cell necrosis. 33 , 34 Thus, decrease in liver function may be associated with a decrease in the activity of the enzyme that metabolizes alcohol. This, in turn, leads to the accumulation of alcohol and acetaldehyde in the body and induces symptoms such as facial flushing. 9 Therefore, people who have liver disease with non‐facial flushing in the past may develop a facial flushing reaction later.

In our study, people who did not have a facial flushing reaction in the past but did in the present were significantly associated with the risk of hypertension among those who were diagnosed with diabetes or did not exercise. Although the mechanism causing flushing is unknown, it is clear that this is not a good indication or reaction in the body. Research findings have indicated that ALDH2 polymorphism that causes facial flushing is related to cancer risk incidence according to alcohol intake. It is noteworthy that these studies mainly focused on upper oral pharyngeal and laryngeal cancer and esophageal squamous cell carcinoma. 35 , 36 , 37 Thus, if people have never had facial flushing to alcohol before but experience facial flushing now, people need to exercise caution with their alcohol intake. However, as there are no studies in the literature supporting this result, it is difficult to determine an absolute judgment.

This study has some limitations. First, this study was based on data from a cross‐sectional survey. Therefore, although the association could be confirmed, the causality could not be evaluated. Second, our data were self‐reported; thus, it is subject to recall bias and underreporting of drinking habits or experience of facial flushing. Therefore, the association of facial flushing with drinking may not be accurate. Moreover, we do not know how long it has been since changes in facial flushing were observed by participants. Third, although the cut‐off points used for facial flushing are in accordance with KCHS, it may be difficult to compare our findings in different settings or populations. 38 Fourth, residual confounding factors may exit because taking some medication like steroid that cause facial flushing have not been identified due to data limitation. These factors should be considered in future studies. Finally, due to lack of similar studies, it is difficult to explain all the findings in this study. Therefore, it is necessary to perform precise measurements of facial flushing in further studies.

Despite these limitations, this study has several strengths. We used the most recent nationally representative database to determine the association between facial flushing and hypertension. Therefore, the results obtained are highly representative of adults in South Korea. Furthermore, in our analysis, we adjusted for several social factors that are known potential confounders for facial flushing pattern or hypertension, including sex, socioeconomic status, and health behaviors, to appropriately estimate the associations across different drinking behavior patterns.

In conclusion, this study found a significant association between change in facial flushing and hypertension among adults in South Korea. In particular, individuals who changed from non‐flushing to flushing reactions had an increased association with hypertension than those in the other groups. Compared to people at the same drinking level, people with non‐flushing to flushing reactions were highly associated with hypertension at moderate drinking level.

CONFLICT OF INTEREST

None declared.

AUTHOR CONTRIBUTIONS

Soo Hyun Kang conceived of the presented idea. Yu Shin Park and Soo Hyun Kang developed the theory and performed the computations. Yu Shin Park and Soo Hyun Kang verified the analytical methods. Eun Cheol Park and Suk Yong Jang encouraged Yu Shin Park to investigate facial flushing mechanism and supervised the findings of this work. All authors discussed the results and contributed to the final manuscript.

Supporting information

SUPPORTING INFORMATION

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ACKNOWLEDGEMENTS

The authors would like to thank our colleagues from the Department of Public Health, Graduate School of Yonsei University for their advice on this manuscript.

Park Y, Kang SH, Park E‐C, Jang S‐Y. Association between changes in facial flushing and hypertension across drinking behavior patterns in South Korean adults. J Clin Hypertens 2022;24:611–620. 10.1111/jch.14475

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