Original Article Nepal Med Coll J December 2023; 25 (4): 277-89

Comorbid Diabetes and Hypertension: Gender differences in

prevalence and risk factors among adults (≥18 years) in an urban
community in Kathmandu district in Nepal
Vinutha Silvanus, Nishchal Dhakal, Niraj Shrestha, Phanindra Prasad Kafle

Department of Community Medicine, Nepal Medical College and Teaching Hospital, Attarkhel, Gokarneshwor-8,
Kathmandu, Nepal

ABSTRACT
Chronic diseases such as diabetes and hypertension are often influenced by biological,
behavioural, environmental and social factors in women and men. This study aimed to identify
the gender differences in prevalence and risk factors of comorbid diabetes and hypertension
(CM) among adults aged 18 years and above in an urban community in Kathmandu, Nepal. A
community-based cross-sectional analytical study was carried out in Gokarneshwor Ward 1, 2
and 3 among adults aged 18 years and above from September 2020- May 2023. Diabetes (DM)
was defined as persons previously diagnosed by a physician and/or on anti-diabetic medication.
Hypertension (HTN) was defined as a systolic blood pressure (SBP) of ≥140 mm Hg or a diastolic
blood pressure (DBP) of ≥90 mm Hg or those who were diagnosed by a physician and/or receiving
antihypertensive medication. Comorbidity (CM) was defined as persons with diabetes and
hypertension. Information regarding socio-demographic data, behavioural and biological risk
factors, anthropometric assessment and morbidity were obtained from adults aged 18 years and
above using a Family study proforma. Multinomial logistic regression analyses with the referent
category being persons with no diabetes or hypertension (NDH) were performed for three
categories HTN vs NDH, DM vs NDH and CM vs NDH. Among 1538 adults with 776 women, overall
prevalence of comorbidity was 5.3% (95% CI: 4.3 – 6.5); among men 6.1% and 5.5% among women.
After adjusting for age, for both women and men, being currently married, alcohol use, family
history of diabetes and generalized obesity were associated with comorbidity. However, these
associations were more robust for men. Moreover, measures of central obesity were associated
with comorbidity for men alone. Though alcohol use was higher among men, the association
with comorbidity was more robust for women. Paradoxically, lower educational status among
women and higher education among men were associated with higher odds of comorbidity. In
conclusion, prevalence of comorbid diabetes and hypertension may differ marginally among
men and women. Though comorbidity rates appear to be lower in Nepal in comparison to
other countries in South Asia, the rising burden emphasizes the need for tailored public health
interventions that address modifiable risk factors among men and women. Further research
may help to elucidate the role of gender on cardiovascular risk and hard outcomes such as
cardiovascular events and mortality among persons with comorbid diabetes and hypertension.

Keywords Corresponding author

Comorbid diabetes and hypertension, gender, Dr. Vinutha Silvanus
prevalence, risk factors, Nepal Associate Professor
Department of Community Medicine
Nepal Medical College and Teaching Hospital
Attarkhel, Gokarneshwor-8, Kathmandu, Nepal
Received on: July 10, 2023 Email: [email protected]
Accepted for publication: October 11, 2023 Orcid No: https://orcid.org/0000-0002-9559-001X
DOI: https://doi.org/10.3126/nmcj.v25i4.60872

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sixth semester posting in the Department
Introduction of Community Medicine. The family study
Chronic diseases such as diabetes and proforma was used to collect socio-demographic
hypertension are often influenced by biological, data including education status, ethnicity,
behavioural as well as environmental and marital status, occupational status, monthly
social factors in women and men.1 Gender can family income and household socioeconomic
be defined as a social construct influenced by status and behavioural and biological risk
behaviour, environment and cultural identity. factors such as smoking, alcohol use, family
Sex (biological) and gender differences can history of diabetes, physical activity levels
play an important role in the pathogenesis, from family members aged 18 years and above
awareness, access to treatment and the sequelae (adults) who were present in the household
of diabetes and hypertension.2,3 Consequently, after obtaining due consent. Among persons
women may experience the same health with diabetes or hypertension information
conditions differently than men.4,5 on age at onset and treatment seeking were
Global estimates suggest that the prevalence also elicited. Anthropometric assessment was
of diabetes is marginally higher among men carried out as follows:
as compared to women (10.8% vs 10.2%). This • Weight: Measured with a weighing scale that
trend is also seen in the South Asian region.6,7 was placed on a flat surface without slippers
Prevalence of diabetes is reportedly higher and reported in kilograms (kg).
among males of SA ethnicity while prediabetes • Height: Measured by placing the person
is more prevalent among the females. However, against a wall and marking the height by a
SA women may be at a higher risk of diabetes ruler. The height was then measured using a
due to their lower socio-economic status.8 non-stretchable measuring tape on the rigid
wall surface and reported in centimetres
The association between diabetes and (cm).12
hypertension has been well documented in
• Waist circumference was measured midway
literature. Persons with diabetes (PWDs) appear
between the lower most margin of the ribs
to have a two-fold higher risk of hypertension
and the top of the iliac crest.
in comparison to those without diabetes. With
the increasing rise in the number of persons • Hip circumference was measured at the
with diabetes, it is estimated that more than maximum circumference of the buttocks,
half of them will have hypertension. Comorbid with the subject standing and the feet placed
diabetes and hypertension may accelerate the together.13
onset of complications such as cardio-vascular The following definitions were used for
disease, stroke and renal disease.9-11 the categorization of study participants:
This study aimed to identify the gender Diabetes was defined as persons previously
differences in prevalence and risk factors of diagnosed by a physician and/or on anti-
co-morbid diabetes and hypertension among diabetic medication.14 Hypertension was
adults aged 18 years and above in an urban defined as a systolic blood pressure (SBP) of
community in Kathmandu, Nepal. ≥140 mm Hg or a diastolic blood pressure (DBP)
of ≥90 mm Hg or those who were diagnosed by
a physician and/or receiving antihypertensive
Materials and Methods medication.15 Generalized obesity was defined
A community-based observational cross- as BMI ≥25 kg/m2 as per Asia-Pacific guidelines.
sectional analytical study was carried out in Overweight was defined as BMI ≥23 kg/m2 as
Gokarneshwor Ward 1, 2 and 3 among adults per Asia-Pacific guidelines. Central obesity was
aged 18 years and above from September 2020- defined as waist circumference ≥90 cm in males
May 2023. Ethical approval was obtained from and ≥80 cm in females and waist to height ratio
NMC-IRC (Ref. No. 033-077/078) for the study. (WtHtR) ≥0.5.16 A family history of DM was
Assuming a baseline prevalence of diabetes of deemed to be present when either one or both
8.4%, a 2% margin of error, a 10% non-response parents were known to have diabetes mellitus.
rate, the minimum sample size was calculated The level of physical activity was assessed as
to be 745 adults. As gender was the primary vigorous, moderate, mild physical based on
variable under consideration, a minimum of occupation and classified as insufficiently
745 women and 745 men were required for the active and sufficiently active categories. Those
study. who have ever consumed alcohol during
their lifetime were classified as ever alcohol
During the study period, 626 households users while those who have smoked in their
were randomly allotted to undergraduate lifetime were classified as ever smokers. For
medical students for family study during their multinomial logistic regression, ethnicity was

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recategorized as Brahmin and Chhetris (0) Men Women
and others (1). Marital status was recoded as

100
married (2) or single (1). The latter category
included unmarried, divorced and widowed
persons. By occupation, the participants were

80
grouped as employed outside home or studying

Age (years)
(0), and those at home including homemakers,

60
retired or unemployed (1).
Statistical analysis: The collected data was

40
entered in MS Excel spreadsheet and licensed
Stata 15 software was used for analysis. The

20
significance level (α) was set at 5% for all Mean Age Age at onset (HTN)
statistical analyses. Bivariate analysis was used Age at onset (DM)
to assess differences among men and women
in relation to socio-demographic, biological Fig. 1: Boxplot depicting age distribution and age
and behavioural risk factors. Chi-square test at onset of hypertension and diabetes among men
was used to examine significant differences. (n=762) and women (n=776)
Overall and gender specific prevalence rates of
hypertension, diabetes and comorbidity were
reported within 95% confidence limits. Men Women

200
For further analyses, the study population was
divided into four groups: the normal group
without either diabetes or hypertension (NDH),
150

the hypertension group with hypertension

alone and no diabetes (HTN), diabetes group
with diabetes alone and no hypertension (DM),
and the comorbidity group with both diabetes
100

and hypertension (CM).

Independent associations between morbidity
50

groups (NDH, HTN, DM, CM) and socio- Normal HTN DM CM Normal HTN DM CM

demographic, behavioural and biological risk SBP (mmHg) DBP (mmHg)

factors was assessed by multinomial logistic Graphs by Sex

regression analyses with the NDH group being Fig. 2: Boxplot depicting systolic and diastolic
the referent category. Crude and age-adjusted blood pressure distribution in relation to morbidity
Odds Ratios for HTN vs NDH, DM vs NDH and outcomes among men (n=762) and women (n=776)
CM vs NDH with 95% confidence intervals were
calculated. An OR >1 indicated that the odds of
the outcome falling in the comparison group level and lower) and physical activity levels
relative to the odds of the outcome falling in in comparison to men. Moreover, rates of
the referent group was increased. An OR <1 generalized (BMI ≥ 25 kg/m2) and central obesity
indicated that the odds of the outcome falling (increased waist circumference and WtHtR)
in the comparison group relative to the odds of were higher among women. Behavioural risk
the outcome falling in the referent group was factors such as smoking and alcohol use was
decreased.   higher among men (Table 1).

Using the post-estimation command in STATA, Median age was 42 years (IQR 30-54 years)
marginal effects plots were generated to among men and 40 years (IQR 30.5-52 years)
depict the probability (adjusted predictions) among women (P=0.36). Likewise, there was no
of hypertension, diabetes and comorbidity significant difference in median age at onset for
outcomes at different values of age among men hypertension (50 years vs 52 years, P=0.07) and
and women. diabetes (50 years vs 51 years, P=0.50) between
the sexes (Fig. 1). The distribution of systolic
and diastolic blood pressure (mmHg) across
Results morbidity outcomes is shown by the boxplot in
Fig. 2.
Altogether, 1538 adults were included in the
study, amongst whom 776 (50.5%) were women. Within 95% confidence limits, the overall
Looking at socio-demographic characteristics, prevalence of hypertension ranged from
women had lower educational status (primary 21.9% to 26.3% and diabetes ranged

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Table 1: Gender differences in socio-demographic, biological and behavioural risk factors

among study participants (n=1538)
Variable Men n (%) Women n (%) Overall n (%) P value*
Number 762 (49.5) 776 (50.5) 1,538
Age (years)
18-29 179 (23.5) 167 (21.5) 346 (22.5) 0.07
30-49 316 (41.5) 367 (47.3) 683 (44.4)
≥ 50 267 (35.0) 242 (31.2) 509 (33.1)
Marital status
Single/Widowed 154 (20.2) 154 (20.0) 308 (20.1) 0.92
Currently married 608 (79.8) 615 (80.0) 1,223 (79.9)
Ethnicity
Bahun and Chhetri 399 392 791 0.97
Adibasi-Janajati and others 377 369 746
Educational attainment
Secondary and above 438 (57.6) 308 (39.7) 746 (48.5) <0.0001***
Primary and lower 323 (42.4) 468 (60.3) 791 (51.5)
Occupational status
Working outside home 541 207 748 <0.0001***
Student 74 46 120
Homemaker/Retired/
147 522 669
Unemployed
SES
Upper & Middle 608 (79.8) 621 (80.0) 1,229 (79.9) 0.90
Lower 154 (20.2) 155 (20.0) 309 (20.1)
Smoking status
Never smoker 597 (78.4) 730 (94.1) 1,327 (86.3) <0.0001***
Ever smoker 165 (21.6) 46 (5.9) 211 (13.7)
Alcohol use
Never user 494 (64.8) 664 (85.7) 1,158 (75.3) <0.0001***
Ever user 268 (35.2) 111 (14.3) 379 (24.7)
BMI status (kg/m2)
Normal weight (18.5-22.9) 251 (32.9) 217 (27.9) 468 (30.4) 0.002**
Overweight (23-24.9) 175 (23.0) 148 (19.1) 323 (21.0)
Obese (≥ 25) 336 (44.1) 411 (52.9) 747 (48.6)
Family h/o diabetes
No 728 (95.5) 741 (95.5) 1469 0.96
Yes 34 (4.5) 35 (4.5) 69
Physical activity level
Sufficiently active 118 (15.5) 52 (6.7) 170 (11.1) <0.0001***
Insufficiently active 644 (84.5) 724 (93.3) 1,368 (88.9)
Central obesity measures
WC (cm)
Normal 301 (47.6) 147 (22.5) 448 (34.8) <0.0001***
Increased (M ≥ 90/ F ≥ 80) 332 (52.4) 507 (77.52) 839 (65.2)
Waist to height ratio
Normal 167 (21.9) 110 (14.2) 277 (18.0) <0.0001***
Increased (> 0.5) (8.1) 666 (5.8) 1,261 (82.0)
*Chi-square test

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Table 2: Overall and gender-specific prevalence of hypertension, diabetes and

comorbidity among the study population (n=1,538)
Chi-square
Morbidity status Overall n (%) 95% CL Men n (%) Women n (%)
P value
Number 1,538 762 776
Hypertension 0.035
No 1,168 (75.9) 73.7 -78.1 561 (73.6) 607 (78.2)
Yes 370 (24.1) 21.9 -26.3 201 (26.4) 169 (21.8)
Diabetes 0.53
No 1,376 (89.5) 87.8 – 90.9 678 (88.9) 698 (89.9)
Yes 162 (10.5) 9.1 -12.2 84 (11.1) 78 (10.1)
Comorbidity 0.18
No 1,457 (94.7) 93.5 – 95.7 716 (93.9) 741 (95.5)
Yes 81 (5.3) 4.3 – 6.5 46 (6.1) 35 (5.5)
(CL- confidence limits)

Table 3: Association between hypertension and diabetes in the study population (n=1538)
Morbidity Diabetes P valuea OR (95% CI) Gender-specific OR
Hypertension NO YES <0.0001 3.76 (2.69-5.25) Men: 4.03 (95% CI: 2.56-6.50)
NO 1087 (79.0) 81 (50.0) Women: 3.42 (95% CI: 2.11 - 5.56)
YES 289 (21.0) 81 (50.0)
Total 1376 162
(a Compared using Pearson’s Chi-squared test, OR – Odd’s ratio, CI – Confidence interval)

from 9.1% to 12.2%. Overall prevalence of for persons with diabetes were 3.76 (OR 95%
comorbidity ranged from 4.3% to 6.5% in the CI: 2.6 to 5.2) in comparison to those without
study population. On disaggregating by sex, diabetes. On stratifying for gender, odds of
prevalence of hypertension, diabetes and comorbidity among men were 4.03 (95% CI:
comorbidity among men was 26.4.3% (95% CL: 2.56 to 6.50), and among women 3.42 (95% CI:
23.4% to 29.6%), 11.1% (95% CL: 8.9% to 13.4%) 2.11 to 5.56), respectively (Table 3).
and 6.1% (95% CL: 4.6% to 7.9%), respectively.
Among women it was 21.8% (95% CL: 19.0% For further analysis, the study population
to 24.8%), 10.1% (95% CL: 8.1% to 12.3%) and was grouped into four outcome categories:
the referent category were persons without
5.5% (95% CL: 3.3% to 6.2%).
hypertension and diabetes (NHD) comprising of
Hypertension prevalence was found to be 1087 persons, among whom 564 (51.9%) were
significantly higher among men (Chi-square women. The second category comprised of 289
value 4.45, P=0.03). However, diabetes (Chi- persons with HTN, with 134 (46.4%) women.
square value 0.38, P=0.53) and comorbidity The third category comprised of 81 persons
prevalence did not differ significantly between with DM among whom 43 (53.1%) were women.
men and women (Chi-square value 1.79, P=0.18) The final category comprised of persons with
as shown in Table 2. CM; there were 81 persons with comorbidity
among whom 35 (43.2%) were women (Table
Amongst persons with hypertension (n=370), 3). As shown in Table 4, among men, there was
about one fifth (21.8%) were found to have a significant association between morbidity
diabetes; and amongst persons with diabetes pattern and age, ethnicity, educational
(n=162), one half (50.0%) were found to have attainment, marital status, occupational
hypertension. The overall odds of hypertension status, smoking status, alcohol use (P<0.0001),

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Table 4: Hypertension, diabetes and comorbidity outcomes across socio-demographic,
behavioural and biological risk factors among men (n=762)
Variables Men P valuea
NHD HTN DM CM
Number (n) 523 155 38 46
Age groups (years)
18-29 173 (33.1) 6 (3.9) 0 0
30-49 228 (43.6) 61 (39.4) 19 (50.0) 8 (17.4) <0.0001***
≥ 50 122 (23.3) 88 (56.7) 19 (50.0) 38 (82.6)
Marital status
Single/Widowed 136 (26.0) 12 (7.7) 4 (10.5) 2 (4.4)
<0.0001***
Currently married 387 (74.0) 143 (92.3) 34 (89.5) 44 (95.6)
Ethnicity
Bahun and Chhetri 554 (50.9) 139 (48.1) 53 (65.4) 45 (55.6)
533
0.04*
Adibasi-Janajati and others (49.0) 51.90 150 (51.9) 28 (34.6) 36 (44.4)
34.57 44.44
Educational attainment
Secondary and above 317 (60.7) 68 (43.9) 22 (57.9) 31 (67.4)
0.001**
Primary and lower 205 (39.3) 87 (56.1) 16 (42.1) 15 (32.6)
Occupational status
Working/Studying 445 (85.1) 119 (76.7) 21 (55.3) 30 (65.2)
<0.0001***
Homemaker/Retired/Unemployed 78 (14.9) 36 (23.2) 17 (44.7) 16 (34.7)
SES
Upper and middle 415 (79.4) 121 (78.1) 33 (86.8) 39 (84.8)
0.581
Lower 108 (20.7) 34 (21.9) 5 (13.2) 7 (15.2)
Smoking status
Never smoker 438 (83.7) 100 (64.5) 26 (68.4) 33 (71.7)
<0.0001***
Ever smoker 85 (16.3) 55 (35.5) 12 (31.6) 13 (28.3)
Alcohol use
Never user 362 (69.2) 83 (53.5) 24 (63.2) 25 (54.4)
0.002**
Ever user 161 (30.8) 72 (46.5) 14 (36.8) 21 (45.6)
BMI status (kg/m2)
Normal weight (18.5-22.9) 187 (35.8) 40 (25.8) 13 (34.2) 11 (23.9)
Overweight (23-24.9) 130 (24.9) 27 (17.4) 10 (21.1) 8 (21.7) 0.009**
Obese (≥ 25) 206 (39.4) 88 (56.7) 17 (44.7) 25 (54.3)
Family h/o diabetes
No 505 (96.6) 150 (96.8) 34 (89.5) 39 (84.8)
0.002**
Yes 18 (3.4) 5 (3.2) 4 (10.5) 7 (15.2)
Physical activity level
Sufficiently active 88 (16.8) 19 (12.3) 6 (15.8) 5 (10.9)
0.42
Insufficiently active 435 (83.2) 136 (87.7) 32 (84.2) 41 (89.1)
Central Obesity measures
WC (cm)
Normal 239 (57.0) 40 (28.9) 14 (40.0) 8 (19.5)
<0.0001***
Increased (M ≥ 90/ F ≥ 80) 180 (42.9) 98 (71.0) 21 (60.0) 33 (80.5)
Waist to height ratio
Normal 139 (26.6) 16 (10.3) 9 (23.7) 3 (6.5) <0.0001***
Increased (> 0.5) 384 (73.4) 139 (89.7) 29 (76.3) 43 (93.5)
a Compared using Pearson’s Chi-squared test
*Significant P value < 0.05 **Highly significant P value < 0.01 ***Very highly significant P value < 0.0001

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Adjusted Predictions age, educational attainment, occupational status,

1 smoking status, alcohol use, BMI (P <0.0001)
family history of diabetes(P=0.002) and central
.8

obesity measures (increased WC: P=0.003 and

WtHtR P=0.02) as shown in Table 5.
Probability
.6

The results of multinomial logistic regression

.4

for morbidity outcomes among men is shown

in Table 6. Overall, odds for HTN increased
.2

significantly by a factor of 1.06 (95% CI: 1.05–

0

20 30 40 50 60 70 80 1.07) for a one-year increase in age. For diabetes,

Age (years)
No HTN&DM HTN
odds increased significantly by a factor of 1.06
DM HTN&DM (95% CI: 1.04–1.08) for a one-year increase in
age. For comorbid diabetes and hypertension;
Fig. 3: Marginsplot depicting the overall probability of the odds increased significantly by a factor of
hypertension, diabetes and comorbidity in relation to 1.11 (95% CI: 1.09–1.14) for a one-year increase
age among the study population (n=1538) in age.
Among adult men, in crude analyses, there was
Adjusted Predictions
a significant association between comorbidity
1

and age (P<0.0001), marital status (P=0.005),

occupational status, smoking status, alcohol
.8

use, family history of diabetes, BMI status

Probability

(P=0.002) and central obesity measures

.6

(P<0.0001). After adjusting for age, among

.4

men being currently married (adjOR=5.8 [1.24-

26.96], P value =0.025), alcohol ever use (adjOR
.2

=2.44 [1.25-4.74], P value =0.008), a family

0

20 30 40 50 60 70 80 history of diabetes (adjOR 9.09 (3.72-25.66), P

Age (years)
value <0.0001), generalized obesity (BMI ≥25 kg/
No HTN&DM HTN
DM HTN&DM m2) (adjOR =1.18 [1.15-5.8], P value =0.021) and
increased waist circumference (adjOR =4.68
Fig. 4: Marginsplot depicting adjusted predictions for [2.01-10.88], P value <0.0001 ) and increased
probability of hypertension (HTN), diabetes (DM) and waist to height ratio (adjOR =4.53 [1.31-15.62], P
comorbidity (CM) for men aged 20 to 80 years (n=762) value =0.017) remained significantly associated
with increased odds for comorbid diabetes and
hypertension. After adjusting for age, odds
Adjusted Predictions of comorbidity among those with primary or
lower level of education decreased by a factor
1

of 0.23 (adjOR [0.11-0.50], P value <0.0001) in

.8

comparison to those with secondary or higher

level of education.
Probability
.6

Among adult women, in crude analyses,

.4

there was a significant association between

.2

comorbidity and age, marital status,

occupational status, smoking status, alcohol
0

20 30 40 50
Age (years)
60 70 80 use, family history of diabetes, BMI status and
No HTN&DM HTN
central obesity measures. After adjusting for
DM HTN&DM age, being currently married, (adjOR =4.11
[1.43-11.74], P value =0.008), alcohol ever use
Fig. 5: Marginsplot depicting adjusted predictions (adjOR =4.15 [1.83-9.42], P value =0.001), a
for probability of hypertension (HTN), diabetes (DM) family history of diabetes (adjOR =7.95 [2.76-
and comorbidity (CM) for women aged 20 to 80 years 22.85], P value <0.0001) and generalized obesity
(n=776) (BMI ≥25 kg/m2) (adjOR =5.13 [1.70-15.48], P
value =0.003) remained significantly associated
family history of diabetes (P=0.002), BMI status with increased odds for comorbid diabetes and
(P=0.009) and central obesity measures (P < hypertension (Table 7).
0.0001).
The marginsplot showed that overall
Among women, there was a significant probability (adjusted predictions) of HTN, DM
association between morbidity outcomes and and comorbidity outcomes at age 80 years

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Table 5: Hypertension, diabetes and comorbidity outcomes across socio-demographic, behavioral
and biological risk factors among women (n=776)
Variables Women P valuea
NHD HTN DM CM
Number (n) 564 134 43 35
Age (years)
18-29 165 (29.3) 1 1 0 <0.0001***
30-49 295 (52.3) 46 (34.3) 16 (37.2) 10 (28.6)
≥ 50 104 (18.4) 87 (64.9) 26 (60.5) 25 (71.4)
Marital status
Single/Widowed 110 (19.7) 34 (25.4) 3 (6.9) 7 (20.0) 0.058
Currently married 447 (80.3) 100 (74.6) 40 (93.1) 28 (80.0)
Ethnicity
Bahun and Chhetri 291 (51.6) 66 (49.3) 25 (58.1) 17 (48.6) 0.765
Adibasi-Janajati and others 273 (48.4) 68 (50.7) 18 (41.8) 18 (51.4)
Educational attainment
Secondary and above 271 (48.1) 21 (15.7) 10 (23.3) 6 (17.1) <0.0001***
Primary and lower 293 (51.9) 113 (84.3) 33 (76.7) 29 (82.9)
Occupational status
Employed/Studying 215 (38.1) 26 (19.5) 6 (13.9) 6 (17.1) <0.0001***
Homemaker/Retired/Unemployed 349 (61.9) 107 (80.5) 37 (86.1) 29 (82.9)
SES
Upper and middle 454 (30.8) 106 (79.1) 31 (72.1) 30 (85.7) 0.471
Lower 110 (19.5) 28 (21.9) 12 (27.9) 5 (14.3)
Smoking status
Never smoker 541 (95.9) 124 (92.5) 36 (83.7) 29 (82.9) <0.0001***
Ever smoker 23 (4.1) 10 (7.5) 7 (16.3) 6 (17.1)
Alcohol use
Never user 508 (90.2) 97 (72.4) 36 (83.7) 23 (65.7) <0.0001***
Ever user 55 (9.8) 37 (27.6) 7 (16.3) 12 (34.2)
BMI status (kg/m2)
Normal weight (18.5-22.9) 182 (32.3) 19 (14.2) 11 (25.6) 5 (14.3) <0.001***
Overweight (23-24.9) 113 (20.0) 20 (14.9) 9 (20.9) 6 (17.4)
Obese (≥ 25) 269 (47.7) 95 (70.9) 23 (53.5) 24 (68.6)
Family h/o diabetes
No 548 (97.2) 130 (97.0) 36 (83.7) 27 (77.1) 0.002***
Yes 16 (2.8) 4 (3.0) 7 (16.3) 8 (22.9)
Physical activity level
Sufficiently active 40 (7.1) 9 (6.7) 3 (6.9) 0 0.470
Insufficiently active 524 (92.9) 125 (93.3) 40 (93.1) 35 (100.0)
Central Obesity measures
WC (cm)
Normal 121 (26.3) 14 (11.9) 8 (19.1) 4 (11.7) 0.003**
Increased (M ≥ 90/ F ≥ 80) 340 (73.7) 103 (88.1) 34 (80.9) 30 (88.3)
Waist to height ratio
Normal 93 (16.5) 10 (7.5) 3 (6.9) 4 (11.4) 0.02**
Increased (> 0.5) 471 (83.5) 124 (92.5) 40 (93.1) 31 (88.6)

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Table 6: Crude and Age adjusted Odds Ratios from multinomial logistic regression for hypertension,
diabetes and comorbidity outcomes among men (n=762)
Characteristic HTN vs NDH DM vs NDH CM vs NDH
Crude OR Adjusted ORa Crude OR Adjusted ORa Crude OR Adjusted ORa
1.06 (1.05 - 1.06 (1.04- 1.11 (1.09- -
Age (years) - -
1.07) *** 1.08) *** 1.14) ***
Marital status
Single/Widowed Ref Ref Ref Ref Ref Ref
4.18 (2.25- 2.43 (1.23-4.8) 2.98 (1.04- 7.73 (1.84- 5.8 (1.24-26.96)
Currently married 1.73 (0.58-5.16)
7.7) *** ** 8.57) * 32.32) ** *
Ethnicity
Bahun and Chhetri Ref Ref Ref Ref Ref Ref
.36 0.007
Adibasi-Janajati and 1.14 (.79- 0.45 (0.21-0.97) .65 (.35 -
1.47 (0.99-2.17) (.17 - .76) 0.94 (0.49-1.83)
others 1.63) * 1.20)
**
Educational attainment
Secondary and above Ref Ref Ref Ref Ref Ref
1.98 (1.38- 1.12 (.58- 0.23 (0.11-0.50)
Primary and lower 1.09 (0.72-1.63) 0.57 (0.27-1.2) .75 (.39-1.42)
2.84) *** 2.19) ***
Occupational status
Working/Studying Ref Ref Ref Ref Ref Ref
Homemaker/Retired/ 1.72 (1.10- 4.61 (2.3- 2.25 (1.01- 3.04 (1.50-
.59 (0.34-1.01) 0.65(0.29-1.44)
Unemployed 2.68) * 9.14) *** 5.02)* 5.80) **
Smoking status
Never smoker Ref Ref Ref Ref Ref Ref
2.83 (1.89- 2.3 (1.49-3.53) 2.38 (1.15- 2.03 (1.03-
Ever smoker 1.93 (0.92-4.05) 1.5 (0.72-3.11)
4.24) *** *** 4.89) * 4.02) *
Alcohol use
Never user Ref Ref Ref Ref Ref Ref
1.95 (1.35- 2.10 (1.4-3.12) 1.31 (0.66- 1.88 (1.02- 2.44 (1.25-4.74)
Ever user 1.39 (0.69-2.82)
2.81) *** *** 2.6) 3.47) * **
BMI status (kg/m2)
Normal weight (18.5-
Ref Ref Ref Ref Ref Ref
22.9)
1.69 (0.86- 1.31 (0.52- 1.93 (0.57-
Overweight (23-24.9) 1.06 (0.60-1.89) 0.95 (0.37-2.4) 1.93 (0.57-6.48)
3.31) 3.27) 6.48)
3.38 (1.02- 2.01 (1.27-3.19) 1.41 (0.67- 3.24 (1.21-
Obese (≥ 25) 0.93 (0.73-5.05) 1.18 (1.15-5.8) *
3.47) *** ** 2.97) 8.66) *
Family h/o diabetes
No Ref Ref Ref Ref Ref Ref
0.93 (0.34- 3.3 (1.05- 4.05 (1.26- 5.03 (1.98- 9.09 (3.72-
Yes 1.14 (0.40-3.23)
2.56) 10.29) * 13.19) * 12.76) ** 25.66) ***
Central obesity measures (n = 633)
WC (cm)
Normal Ref Ref Ref Ref Ref Ref
Increased (M ≥ 90/ F 3.25 (2.14- 2.68 (1.73-4.16) 1.99 (0.98- 5.47 (2.47- 4.68 (2.01-
1.64 (0.80-3.37)
≥ 80) 4.92) *** *** 4.02) 12.14) *** 10.88) ***
Waist to height ratio
Normal Ref Ref Ref Ref Ref Ref
3.14 (1.80- 2.6 (1.45-4.68) 1.16 (0.53- 5.18 (1.58- 4.53 (1.31-
Increased (> 0.5) 0.96 (0.43-2.14)
5.46) *** ** 2.52) 16.99) ** 15.62) **
*Significant P value < 0.05 **Highly significant P value < 0.01 ***Very highly significant P value < 0.0001,
Ref: Reference group; For multinomial logistic regression, referent category is persons without hypertension
or diabetes [ NHD (n= 564)]. Each category of morbidity hypertension alone [HTN (n=134)], diabetes alone
[DM (n=43)] and comorbidity [CM (n=35)] was compared to the referent group.

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Table 7: Crude and Age adjusted Odds Ratios from multinomial logistic regression for
hypertension, diabetes, and comorbidity outcomes among women (n=776)
Characteristic HTN vs NDH DM vs NDH CM vs NDH
Adjusted Adjusted Adjusted
Crude OR Crude OR Crude OR
ORa ORa ORa
1.09 (1.07 - 1.07 (1.05- 1.11 (1.08-
Age (years) - - -
1.10) *** 1.09) *** 1.14) ***
Marital status
Single/Widowed Ref Ref Ref Ref Ref Ref
0.72 (.46- 1.44 (.93- 3.28 (.99- 1.73 (.58- .98 (.41- 5.8 (1.24-
Currently married
1.12) 2.21) 10.8) 5.16) 2.31) 26.96) *
Ethnicity
Bahun and Chhetri Ref Ref Ref Ref Ref Ref
Adibasi-Janajati and 1.44 (.93- .76 (.40 .96 (0.50- 1.12 (.57 - 1.57 (.72-
1.09 (.75- 1.6)
Others 2.73) -1.43) 1.84) 2.23) 3.27)
Educational attainment
Secondary and above Ref Ref Ref Ref Ref Ref
4.97 (3.03- 1.54 (0.87- 3.05 (1.47- 1.14 (0.49- 4.47 (1.82- 0.74 (0.25-
Primary and lower
8.15) *** 2.73) 6.31) ** 2.64) 10.93) ** 2.22)
Occupational status
Working/Studying Ref Ref Ref Ref Ref Ref
Homemaker/Retired/ 2.53 (1.59- 1.12 (0.34- 3.79 (1.57- 2.08 (0.83- 2.97 (1.21- 0.99 (0.84-
Unemployed 4.02) *** 1.01) 9.15) ** 5.21) 7.28) * 1.17)
Smoking status
Never smoker Ref Ref Ref Ref Ref Ref
1.89 (.88- .86 (.36- 4.57 (1.83- 2.35 (0.89- 4.86 (1.83- 1.97 (0.37-
Ever smoker
4.08) 2.02) 11.37) ** 6.17) 12.87) ** 2.64)
Alcohol use
Never user Ref Ref Ref Ref Ref Ref
3.52 (2.20- 3.05 (1.79- 1.79 (0.76- 1.56 (0.65- 4.81 (2.27- 4.15 (1.83-
Ever user
5.63) *** 5.20) *** 4.22) 3.78) 10.21) *** 9.42) **
BMI status (kg/m2)
Normal weight (18.5-
Ref Ref Ref Ref Ref Ref
22.9)
1.69 (0.86- 2.7 (0.99- 1.31 (0.52- 1.45 (.55- 1.93 (0.57- 3.07 (0.81-
Overweight (23-24.9)
3.31) 4.72) 3.27) 3.80) ** 6.48) 8.95)
3.38 (1.99- 4.11 (2.19- 1.41 (0.67- 1.44 (.65- 3.24 (1.21- 5.13 (1.70-
Obese (≥ 25)
5.73) *** 7.73) ** 2.97) 3.18) ** 8.66) * 15.48) **
Family h/o diabetes
No Ref Ref Ref Ref Ref Ref
1.05 (0.34- .80 (0.24- 6.65 (2.5- 5.15 (1.89- 10.14 (3.99- 7.95 (2.76-
Yes
3.20) 2.62) 17.2) *** 14.03) ** 25.78) *** 22.85) ***
Central Obesity measures n = 654
WC (cm)
Normal Ref Ref Ref Ref Ref Ref
Increased (M ≥ 90/ F 2.61 (1.40- 2.39 (1.22- 1.51 (.68- 1.31 (0.57- 2.66 (.92- 2.81 (.88-
≥ 80) 4.74) ** 4.69) ** 3.35) 3.02) 7.73) 8.95)
Waist to height ratio
Normal Ref Ref Ref Ref Ref Ref
2.44 (1.23- 2.04 (0.94- 2.63 (0.79- 2.14 (0.62- 1.53 (.52- 1.37 (.42-
Increased (> 0.5)
4.84) *** 4.46) 8.68) 7.35) 4.43) 4.41)
*Significant P value < 0.05 **Highly significant P value < 0.01 ***Very highly significant P value < 0.0001,
Ref: Ref group

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was about 50%, 6% and 22%, respectively in (OR 1.8, 95% CI 1.2-2.8) higher among women
comparison to 2%, 1% and 0% at age 20 years in comparison to men. Higher education,
(Fig. 3). On disaggregation for sex, among men urban residence and increased BMI were
the probability (adjusted predictions) of HTN, associated with comorbidity.19 In comparison,
DM and comorbidity at age 40 years was about the screening for the twin epidemic (SITE)
18%, 5% and 4% and at 80 years increased to study (n =15,662) in India reported a much
42%, 6% and 22%, respectively in comparison higher prevalence of comorbidity among adults
to 4%, 1% and 0% at age 20 years (Fig. 4). Among at about 21%. The prevalence of hypertension
women the probability (adjusted predictions) among PWDs was also higher at almost 60%.
of HTN, DM and comorbidity at age 40 years However, gender specific rates for comorbidity
was about 12%, 5% and 2% and at age 80 years were not reported. 20
was about 58%, 12% and 22% respectively in
comparison to 2%, 1% and 0% at age 20 years In the present study, among the biological
among women (Fig. 5). risk factors, age was a robust predictor for
comorbidity with a one-year increase associated
with 11% increase in odds for comorbidity. Age
Discussion was a significant effect modifier among both
men and women as the robustness of odds
Overall, the study findings reveal that the ratios for most characteristics decreased when
prevalence of hypertension was significantly age was held constant. It is pertinent to note
higher among men (23% to about 30%) in that family history of diabetes and alcohol use
comparison to women (22% to 25%). However, were the only characteristics that became more
prevalence rate of diabetes at 9% to 13% robust when age was held constant.
among men was like that among women at 8%
to 12%. Comorbid diabetes and hypertension The margins plot showed that the probability
prevalence was marginally higher among men of comorbid hypertension and diabetes
(5% to 8%) in comparison to women (3% to 6%) would exceed that of diabetes at age 50
though this difference did not reach statistical years among men and at about 65 years for
significance. Notably, one-half of all persons women. However, by the age of 80 years the
with diabetes (n =162) in the study population probability of comorbidity was similar among
were found to have hypertension. Men with men and women. Though men with diabetes
diabetes were found to have 300% increased had higher odds of hypertension, there was no
odds (OR 4.3, 95% CI: 2.56 -6.50) while women significant gender difference in the prevalence
with diabetes had 240% increased odds of of comorbidity in the study population.
hypertension. Hence, association between
diabetes and hypertension appeared to be Other biological risk factors that were robustly
more robust among men. associated with comorbid diabetes and
hypertension and common to both men and
Looking at previous studies in Nepal, in 2015, women were family history of diabetes and
a large cross-sectional community-based study obesity (BMI >=25 kg/m2). However, measures
among 4200 adults aged between 15 to 69 years, of central obesity such as increased waist
reported a lower prevalence of comorbidity of circumference and increased waist to height
2% that ranged from 1.5% to 2.7%. Comorbidity ratio were associated with increased relative
prevalence was reported to be higher among risk of comorbidity among men alone.
males (2.5% vs 1.6%), in urban areas (2.8%
Among behavioural risk factors, though alcohol
vs 1.8%). However, gender-specific risk for
use was higher among men, its association
comorbidity was not significant (F 1.15, 0.74- with comorbidity was more robust among
1.80).17 Looking at other countries in the SA women (300% vs 144% increased odds).
region, rates of hypertension and diabetes that Among sociodemographic risk factors, being
were similar to Nepal were reported in Bhutan, currently married was associated with higher
among 2,800 adults aged between 25 to 74 years. odds for comorbidity for both women and
The prevalence of diabetes and hypertension men. However, higher level of education was
was 8.6% and 28.3% among men and 7.7% and associated with increased odds of comorbidity
20.9% among women. Over one-half of persons among men; while the reverse was observed
(54.1%) with diabetes had hypertension.18 among women. However, after adjusting for
age, the association with educational status
However, in Bangladesh, a nationally
remained significant for men alone.
representative survey (n = 7521) among adults
aged 35 years and above, reported higher There have been regional variations in
prevalence of co-morbidity among women the association of risk factors as seen from
(5.7% vs 3.2%). The risk of co-morbidity was 80% national level surveillance studies for non-

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communicable diseases across South Asia and levels was not assessed. Lived experiences of
Asia-Pacific region. The cardiometabolic risk women and men with diabetes, hypertension
reduction in South Asia (CARRS) study reported and comorbidity were not considered in this
that among PWDs, the odds of hypertension study.
were higher among women 1.64 (95% CI 1.2-
2.3) in comparison to men 1.2 (95% CI 0.97- In conclusion, the study findings suggest that
1.6).21 in an urban community in Nepal, prevalence
of comorbid diabetes and hypertension was
Looking from the lens of hypertension, in the marginally higher among men. Though this
present study about one-fifth of persons with difference did not reach statistical significance,
hypertension (n =370) had diabetes. However, the odds of comorbidity were higher for men.
about one third of persons with hypertension (n Older age, being currently married, alcohol
=2426) aged 40 years and above were found to use, family history of diabetes, and obesity
have diabetes with higher rates among women were associated with comorbidity for both
in Bangladesh, Pakistan and Sri Lanka. 21 men and women. Most of these associations
were more robust for men, however, alcohol
A more recent analysis of data from Korea use and obesity were more robust for women.
National Health and Nutrition Examination Central obesity measures were associated
survey (2008-11) reported that comorbid with comorbidity among men. A paradoxical
diabetes and hypertension was more robustly relationship was seen for educational level with
associated with fat and lean mass than diabetes lower educational status associated with higher
and hypertension. The association between risk among women and higher education with
comorbidity and body fat variables was more higher risk for men.
robust in women than in men aged fifty years
and above.22 Though comorbidity rates appear to be lower
in comparison to other countries in South
In China, comorbid diabetes and hypertension Asia, the rising burden of non-communicable
were found to be higher among older persons, diseases with about 70% proportionate
women, those with higher education, single mortality rate in Nepal emphasize the need
and increased waist circumference. More for tailored public health interventions that
importantly, comorbidity was significantly address modifiable risk factors among men and
associated with higher risk of cardiovascular women. Further research may help to identify
disease due to a synergistic and additive the role of biological, behavioural and socio-
effect.23 Hence, there is consistent evidence demographic risk factors on cardiovascular
in literature that persons with comorbidity risk and hard outcomes such as cardiovascular
were older, had higher education, were more events and mortality among men and women
sedentary, had raised BMI and increased waist with comorbid diabetes and hypertension in
circumference.24 Nepal.
Comorbid diabetes and hypertension are known Conflict of interest: None
to be associated with raised triglyceride levels,
cardiovascular and chronic renal disease. Source of research fund: None
However, evidence from systematic reviews
suggests that diabetes and comorbidity may be
more severe for women with a 50% excess risk
of mortality due to cardiovascular disease.25,26
But, it is argued that this may be an artifact
due to better life expectancy among women
without diabetes in comparison to men without
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