Adherence to Healthy Lifestyle and Risk of Cardiometabolic Diseases in Individuals With Hypertension

Importance Hypertension significantly increases the risk of cardiovascular diseases (CVDs) and related cardiometabolic conditions, yet the role of healthy lifestyle in modifying these risks remains underexplored. Objective To investigate associations of adherence to healthy lifestyle before and after a hypertension diagnosis with the risk of developing CVDs and type 2 diabetes (T2D). Design, Setting, and Participants This prospective, population-based cohort study included US individuals participating in the Nurses’ Health Study (1986-2014) and Health Professionals Follow-Up Study (1986-2014) with incident hypertension diagnosed during each study’s follow-up period. Follow-up for incident CVDs continued through June 30, 2020, in NHS or June 30, 2016, in HPFS. For incident T2D, follow-up ended December 31, 2019, in both cohorts. Data were analyzed from November 2024 to April 2025. Exposure A healthy lifestyle, defined as eating a high-quality diet, not smoking, engaging in moderate-to-vigorous-intensity physical activity, no more than moderate alcohol consumption, and having a healthy body mass index. Lifestyle factors were reassessed every 2 to 4 years, and each criterion that was met contributed 1 point to a participant’s total healthy lifestyle score (HLS; score range, 0 least healthy to 5 most healthy). Main Outcomes and Measures Incident CVDs and/or T2D and multivariable-adjusted hazard ratios (AHRs) for their associations with time-varying lifestyle scores. Results A total of 25 820 individuals were included (mean SD age, 60.6 0.1 years; 18 742 females 72.6%). The median HLS at diagnosis was 3 (IQR, 2-4). During a median follow-up period of 24 years (IQR, 23-25 years), 3300 incident CVDs and 2529 T2D cases were identified. After adjustment for medication use and other relevant covariates, the 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), and the corresponding AHR for T2D was 0.21 (95% CI, 0.14-0.30). Participants who improved from lower HLS (0-3) to higher (4 or 5) after hypertension diagnosis had lower risk of CVDs (AHR, 0.88; 95% CI, 0.79-0.98) and T2D (AHR, 0.56; 95% CI, 0.48-0.65) compared with those who consistently had lower HLS. Conversely, those whose HLS declined after diagnosis had higher risk of CVDs (AHR, 1.14; 95% CI, 1.00-1.30) and T2D (AHR, 1.75; 95% CI, 1.45-2.10) compared with those who consistently maintained a higher HLS. In joint analyses, higher HLS was associated with a lower risk of cardiometabolic diseases irrespective of antihypertensive medication use. Compared with participants with an HLS of 0 to 2 and no antihypertensive medication use, those with the highest HLS (5) had lower risk of incident CVDs and T2D among both nonusers and users: for CVDs, the AHR was 0.62 (95% CI, 0.42-0.93) among nonusers and 0.63 (95% CI, 0.50-0.80) among users; for T2D, the AHR was 0.32 (95% CI, 0.13-0.78) among nonusers and 0.44 (95% CI, 0.30-0.67) among users. Conclusions and Relevance In this cohort study of individuals living with hypertension, maintaining a healthy lifestyle was associated with lower risk of major cardiometabolic diseases independent of antihypertensive medication use, underscoring the value of adopting multiple healthy lifestyle behaviors.