Mediation Effect of Obesity on the Association of Socioeconomic Status with Blood Pressure in the Elderly Hypertensive Population

Abstract

Background: Socioeconomic status (SES) plays a crucial role in blood pressure (BP) control. SES may influence BP control through obesity indices, such as body mass index (BMI) and waist circumference (WC). This study aimed to understand the relationships between SES and BP control in the elderly hypertensive population, and to determine whether BMI and WC mediate the relationship between SES and BP control.

Methods: The study was conducted in Jia County, Henan Province, China, from 1 July to 31 August 2023. The 18,963 hypertensive people over 65 years old who were included in the National Basic Public Health Service Program were investigated. The study utilized questionnaire surveys to collect data on participants' demographic characteristics, disease history, lifestyle behaviors, antihypertensive medication, and measured height, weight, and blood pressure. SES was indexed by participants' self-reported educational level, family income, and occupation, and categorized into low, medium, and high groups by using latent category analysis (LCA). Logistic regression models were used to analyze the associations between SES and BP control. Obesity indicators, represented by BMI and WC, were included in mediation models to examine the indirect effects of BMI/WC on the association between SES and BP control.

Results: The mean age of 17,234 participants was 73.4 years and 9888 (57.4%) of the participants were female. The LCA results indicated the number of participants in low SES, middle SES, and high SES groups were 7760, 8347, and 1127, respectively. Compared with the low SES group, the odds ratios (ORs) and 95% confidence intervals (CIs) for the association of BP control with middle SES and high SES were 1.101 (1.031, 1.175), and 1.492 (1.312, 1.696). This association was similarly found in the subsequent subgroup analyses (p < 0.05). Compared with low SES, our findings further suggested that BMI (indirect effects: 95% CIs: -0.004--0.001; p < 0.001) and WC (indirect effects: 95% CIs: -0.003--0.001; p = 0.020) play a suppressing role in the association between high SES and BP control.

Conclusions: Our study indicated that the elderly hypertensive population with high SES may have a better result for BP control. However, we found that BMI/WC plays a suppressing role in this association. This indicated that despite the better BP control observed in elderly hypertensive populations with high SES, BMI and WC might undermine this beneficial relationship. Therefore, implementing strategies for obesity prevention is an efficient way to maintain this beneficial association between high SES and BP control.

Keywords: blood pressure; elderly hypertensive population; mediation effect; obesity; socioeconomic status.

Figure 1

Adjusted odds ratio (OR) of blood pressure control associated with socioeconomic status according to the subpopulation (low SES is the reference group). In addition to adjustment for gender, age, antihypertensive medication-use situation, numbers of antihypertensive medications, hypertension duration, the covariates of marital status, drinking status, smoking status, physical activity, BMI, and WC, were mutually adjusted in the analysis. Small green squares are ORs, and their horizontal lines indicate the corresponding 95% CI. SES: socioeconomic status. BP: blood pressure. BMI: body mass index. WC: waist circumference.

Figure 2

Heatmaps of the associations between education, income, occupation, and blood pressure. Data are OR (95% CI). All models were adjusted for age, gender, marital status, drinking status, smoking status, healthy physical activity, the use of antihypertensive medication, number of antihypertensive medications, duration of hypertension, BMI, and WC. The colors are presented in a gradient, with a darker color shade indicating a stronger association. * p < 0.05.