Correlation between Chinese Visceral Adiposity Index and Nocturnal Hypertension in Young and Middle-aged People

Zhang Qiuyu, Hu Xiaoyong, Tang Rui, Li Hongjian*

Department of Hypertension, the Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China

*Corresponding author: Li Hongjian, Chief physician; E-mail: xydwfygxyk@163.com

Abstract

Background: The Chinese visceral adiposity index (CVAI) is a novel obesity metric that has been proven to correlate closely with prehypertension and hypertension. However, research on the relationship between CVAI and nocturnal hypertension (NH) remains scarce. Objective: To investigate the correlation between CVAI and NH in young and middle-aged adults. Methods: A total of 981 young and middle-aged patients with essential hypertension admitted to the Department of Hypertension at the Fifth Affiliated Hospital of Xinjiang Medical University were consecutively enrolled from February 2023 to September 2023. General data, biochemical indices, and 24-hour ambulatory blood pressure monitoring (ABPM) results were collected, and CVAI was calculated. Patients were divided into a non-nocturnal hypertension (NNH) group (n=95) and an NH group (n=886) based on the presence of NH. Inter-group differences in general characteristics, biochemical indices, 24-hour ABPM parameters, and CVAI were compared. Pearson correlation analysis was used to explore the relationship between CVAI and NH. Multivariate logistic regression analysis was performed to evaluate influencing factors for NH in young and middle-aged adults. Results: The NH group exhibited significantly higher CVAI, 24-hour average systolic and diastolic blood pressure, daytime average systolic and diastolic blood pressure, nocturnal average systolic and diastolic blood pressure, and maximum systolic and diastolic blood pressure compared with the NNH group (all P<0.05). Pearson correlation analysis revealed that CVAI was positively correlated with 24-hour average systolic and diastolic blood pressure, daytime average systolic and diastolic blood pressure, nocturnal average systolic and diastolic blood pressure, and maximum systolic and diastolic blood pressure (r=0.202, 0.183, 0.200, 0.171, 0.168, 0.174, 0.132, 0.157; all P<0.05). Multivariate logistic regression analysis showed that after adjusting for confounders such as sex and age, elevated CVAI was an independent risk factor for NH in young and middle-aged adults (OR=1.009, 95%CI=1.002~1.016, P=0.014). When patients were stratified by CVAI quartiles into Q1 (<103.5243, n=245), Q2 (103.5243~129.7140, n=246), Q3 (129.7140~156.2704, n=245), and Q4 (>156.2704, n=245) groups, the risks of NH in Q2, Q3, and Q4 groups were 1.779-fold (OR=1.779, 95%CI=1.002~3.157), 2.023-fold (OR=2.023, 95%CI=1.061~3.858), and 3.053-fold (OR=3.053, 95%CI=1.383~6.737) higher than in Q1, respectively. Subgroup analysis demonstrated that the association between CVAI and NH was more pronounced in the overweight/obese population (BMI ≥ 24 kg/m²) (P=0.021). Conclusion: CVAI is associated with the risk of NH in young and middle-aged adults, with a stronger association observed in overweight/obese individuals (BMI ≥ 24 kg/m²). CVAI serves as a risk factor for NH in this population.

Keywords: Nocturnal hypertension; Chinese visceral adiposity index; Visceral obesity indicator; Young and middle-aged; Correlation study

Hypertension represents a major modifiable risk factor for cardiovascular disease and all-cause mortality worldwide. Nocturnal hypertension (NH) has garnered increasing clinical attention due to its close associations with asymptomatic cerebrovascular diseases such as arterial stiffness, left ventricular hypertrophy, and cerebral white matter lesions, as well as with asymptomatic target organ damage including microalbuminuria. NH can independently predict cardiovascular and all-cause mortality beyond daytime blood pressure levels. Epidemiological surveys indicate a trend toward younger onset of hypertension, with more pronounced increases in prevalence among young and middle-aged populations compared with elderly groups, yet with lower rates of awareness, treatment, and control. Since 24-hour ambulatory blood pressure monitoring (ABPM) currently represents the sole method for detecting nocturnal blood pressure abnormalities, but is limited by screening awareness and availability, the diagnosis rate of NH remains low. Consequently, identifying simple and readily accessible indicators to recognize individuals at risk for NH is crucial for implementing preventive measures.

In recent years, the Chinese visceral adiposity index (CVAI) has emerged as a novel obesity metric considered closely related to visceral fat content and functional metabolism in Chinese populations, attracting considerable attention in cardiovascular research. Studies have demonstrated that visceral fat, rather than subcutaneous or total fat, correlates with elevated blood pressure. Traditional obesity indices such as body mass index (BMI) and waist circumference (WC) inadequately distinguish body fat content and distribution, particularly in assessing visceral fat. Building upon the visceral adiposity index (VAI), Xia et al. developed CVAI by incorporating BMI, age, high-density lipoprotein cholesterol (HDL-C), triglyceride (TG), and WC, creating an indicator that accurately predicts visceral fat content in Chinese populations, consistent with imaging methods. Research has shown CVAI correlates with various conditions including prehypertension, hypertension, coronary heart disease, and cardiometabolic multimorbidity. However, studies examining its relationship with NH remain limited. Therefore, this investigation explores the correlation between CVAI and NH in young and middle-aged individuals to provide a scientific basis for early identification of high-risk individuals and development of intervention strategies.

1.1 Study Population

This study enrolled 981 young and middle-aged patients with essential hypertension admitted to the Department of Hypertension at the Fifth Affiliated Hospital of Xinjiang Medical University between February 2023 and September 2023. According to NH diagnostic criteria—ABPM indicating nocturnal average systolic blood pressure ≥ 120 mmHg (1 mmHg=0.133 kPa) and/or diastolic blood pressure ≥ 70 mmHg—patients were divided into a non-nocturnal hypertension (NNH) group (n=95) and an NH group (n=886). Inclusion criteria comprised: (1) meeting hypertension diagnostic criteria from the Chinese Guidelines for the Prevention and Treatment of Hypertension (2024 Revision)—office blood pressure ≥ 140/90 mmHg on three separate occasions without antihypertensive medication, or home blood pressure ≥ 135/85 mmHg over 5-7 consecutive days, or 24-hour ambulatory blood pressure ≥ 130/80 mmHg, daytime blood pressure ≥ 135/85 mmHg, and nocturnal blood pressure ≥ 120/70 mmHg; patients with a history of hypertension currently on medication remained diagnosed as hypertensive even if below these thresholds; (2) age 18-64 years per the Chinese Expert Consensus on Hypertension Management in Young and Middle-aged Adults; and (3) complete clinical data. Exclusion criteria included: (1) white-coat hypertension and secondary hypertension; (2) secondary obesity (e.g., Cushing's syndrome, primary hypothyroidism) and medication-induced obesity; and (3) missing clinical indicators. This study was approved by the Ethics Committee of the Fifth Affiliated Hospital of Xinjiang Medical University (Approval No: XYDWFYLSk-2025-25).

1.2 Data Collection

1.2.1 General Data Collection: General information included age, sex, history of coronary heart disease, diabetes, smoking, and alcohol consumption upon admission. Height, weight, and waist circumference were measured, and BMI was calculated. Coronary heart disease was defined as coronary angiography showing ≥50% stenosis in at least one coronary artery, or history of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or old myocardial infarction (OMI). Diabetes was defined as diabetic symptoms plus random blood glucose ≥ 11.1 mmol/L, or fasting blood glucose ≥ 7.0 mmol/L, or 2-hour oral glucose tolerance test ≥ 11.1 mmol/L, or history of diabetes with current use of hypoglycemic agents. Smoking was defined as ≥1 cigarette daily for at least six months. Alcohol consumption was defined as drinking ≥3 times weekly, with >50 g per occasion.

1.2.2 Ambulatory Blood Pressure Monitoring: Calibrated standard ambulatory blood pressure monitors were used. Nocturnal measurements (23:00-08:00) were recorded hourly, and daytime measurements (08:00-23:00) every 20 minutes, ensuring ≥20 valid daytime readings, ≥7 valid nocturnal readings, and at least 70% of expected 24-hour readings. Daytime, nocturnal, 24-hour, and maximum systolic and diastolic blood pressures were collected. NH was diagnosed when ABPM indicated nocturnal average systolic blood pressure ≥ 120 mmHg and/or diastolic blood pressure ≥ 70 mmHg.

1.2.3 Laboratory Examinations: After ≥8 hours of fasting, venous blood samples were collected in the morning and sent to the laboratory for measurement of TG, total cholesterol (TC), HDL-C, low-density lipoprotein cholesterol (LDL-C), blood urea nitrogen (BUN), serum creatinine (SCr), red blood cells, and hemoglobin.

1.2.4 CVAI Calculation: The CVAI was calculated using the following formulas:
- Males: CVAI = -267.93 + 0.68 × age (years) + 0.03 × BMI (kg/m²) + 4.00 × WC (cm) + 22.00 × log₁₀TG (mmol/L) - 16.32 × HDL-C (mmol/L)
- Females: CVAI = -187.32 + 1.71 × age (years) + 4.23 × BMI (kg/m²) + 1.12 × WC (cm) + 39.76 × log₁₀TG (mmol/L) - 11.66 × HDL-C (mmol/L)

1.3 Statistical Analysis

Statistical analysis was performed using SPSS 27.0. Normally distributed continuous variables were expressed as mean ± standard deviation (x̄ ± s) and compared between groups using independent samples t-tests. Non-normally distributed continuous variables were presented as median (P₂₅, P₇₅) and compared using Mann-Whitney U tests. Categorical variables were expressed as percentages and compared using χ² tests. Pearson or Spearman correlation analyses were employed to explore relationships between CVAI and other variables. Multivariate logistic regression analysis was used to assess influencing factors for NH in young and middle-aged adults. Statistical significance was defined as P<0.05.

2.1 Comparison of General Characteristics Between Groups

This study included 981 young and middle-aged hypertensive patients (627 males [63.9%] and 354 females [36.1%]), with a mean age of 50.5 ± 9.4 years and mean CVAI of 131.14 ± 41.75. The NH group comprised 886 cases, while the NNH group included 95 cases. The NH group showed significantly higher proportions of males, smoking history, alcohol consumption, BMI, WC, TG, CVAI, SCr, 24-hour average systolic and diastolic blood pressure, daytime average systolic and diastolic blood pressure, nocturnal average systolic and diastolic blood pressure, maximum systolic and diastolic blood pressure, red blood cells, and hemoglobin, along with lower age, compared with the NNH group (all P<0.05). No significant differences were observed between groups in HDL-C, TC, LDL-C, BUN, history of coronary heart disease, or diabetes history (all P>0.05) [TABLE:1].

2.2 Correlation Analysis Between CVAI and Variables

Pearson correlation analysis revealed that CVAI was positively correlated with 24-hour average systolic and diastolic blood pressure, daytime average systolic and diastolic blood pressure, nocturnal average systolic and diastolic blood pressure, maximum systolic and diastolic blood pressure, BMI, and WC (r=0.202, 0.183, 0.200, 0.171, 0.168, 0.174, 0.132, 0.157, 0.760, 0.922; all P<0.001), and negatively correlated with age (r=-0.067, P<0.05). Spearman correlation analysis showed that CVAI was positively correlated with smoking, alcohol consumption, TG, BUN, SCr, red blood cells, hemoglobin, and diabetes (rs=0.307, 0.313, 0.331, 0.116, 0.309, 0.285, 0.387, 0.094; all P<0.001), and negatively correlated with sex and HDL-C (rs=-0.490, -0.396; all P<0.001) [TABLE:2].

2.3 Multivariate Logistic Analysis of Influencing Factors for NH in Young and Middle-aged Adults

Using the presence of NH in young and middle-aged hypertensive patients (no NH=0, NH=1) as the dependent variable and CVAI (actual measured value) as the independent variable, multivariate logistic regression analysis was performed after adjusting for confounders including sex (male=1, female=2), smoking history (no=0, yes=1), alcohol consumption history (no=0, yes=1), age, TG, SCr, red blood cells, and hemoglobin. The results demonstrated that elevated CVAI was an independent risk factor for NH in young and middle-aged adults (OR=1.009, 95%CI=1.002~1.016, P=0.014). When patients were stratified by CVAI quartiles into Q1 (<103.5243, n=245), Q2 (103.5243~129.7140, n=246), Q3 (129.7140~156.2704, n=245), and Q4 (>156.2704, n=245) groups, with Q1 as the reference, the risks of NH in Q2, Q3, and Q4 groups were 1.779-fold (OR=1.779, 95%CI=1.002~3.157), 2.023-fold (OR=2.023, 95%CI=1.061~3.858), and 3.053-fold (OR=3.053, 95%CI=1.383~6.737) higher, respectively [TABLE:3].

2.4 Subgroup Analysis of Influencing Factors for NH in Young and Middle-aged Adults

Further multivariate logistic regression analysis by sex subgroups showed no significant association between CVAI and NH in either males (OR=1.008, 95%CI=0.999~1.016, P=0.084) or females (OR=1.011, 95%CI=0.999~1.024, P=0.068). However, when stratified by BMI into <24 kg/m² and ≥24 kg/m² subgroups, CVAI was significantly associated with NH in the BMI ≥24 kg/m² subgroup (OR=1.012, 95%CI=1.002~1.021, P=0.021) [TABLE:4].

Nocturnal hypertension represents a risk factor for target organ damage involving the heart, brain, kidneys, and blood vessels, as well as for cardiovascular events, independent of office blood pressure levels. Therefore, early diagnosis and intervention for NH are crucial for reducing cardiovascular risk. This study marks the first systematic analysis of the association between CVAI and NH in young and middle-aged populations. After adjusting for relevant confounders, elevated CVAI level emerged as a risk factor for NH incidence (OR=1.009, 95%CI=1.002~1.016, P=0.014). When analyzed as a categorical variable, Q2, Q3, and Q4 groups showed 1.779-fold, 2.023-fold, and 3.053-fold higher risks of NH compared with Q1, respectively. These findings suggest that visceral fat accumulation may be a driving factor underlying nocturnal blood pressure abnormalities in young and middle-aged individuals. Subgroup analyses further indicated that the relationship between CVAI and NH was more pronounced in overweight/obese individuals (BMI ≥24 kg/m²).

Research indicates that NH prevalence is high among young and middle-aged hypertensive populations in China, a conclusion supported by our study showing NH prevalence reaching 90.3%. A cohort study of 59,124 participants followed for 9.7 years demonstrated that nocturnal systolic blood pressure remained closely associated with all-cause and cardiovascular mortality even after adjusting for daytime systolic blood pressure. Similarly, Boggia et al. found that nocturnal blood pressure was an important predictor of total, cardiovascular, and non-cardiovascular mortality after adjusting for confounders. A Japanese study revealed that nocturnal systolic blood pressure was significantly associated with atherosclerotic cardiovascular disease (ASCVD) and heart failure risk in individuals with at least one cardiovascular risk factor. Research in 305 elderly individuals aged ≥65 years showed significantly higher nocturnal systolic blood pressure in the cognitive impairment group, with more patients exhibiting elevated nocturnal blood pressure. Presta et al. identified NH as an independent risk factor for stroke occurrence. A study of 319 newly diagnosed hypertensive patients found that NH patients had significantly increased pulse wave velocity (PWV), carotid intima-media thickness, and left ventricular mass index (LVMI) compared with those with normal nocturnal blood pressure. Cross-sectional research demonstrated that NH was significantly associated with left ventricular hypertrophy (OR=11.1, 95%CI=3.0~40.1), whereas non-dipping hypertension was not (OR=1.4, 95%CI=0.4~5.5). A cross-sectional study of 2,386 non-dialysis chronic kidney disease (CKD) patients revealed that compared with those without morning or nocturnal hypertension, individuals with combined morning and nocturnal hypertension had higher risks of left ventricular hypertrophy (OR=2.87, 95%CI=2.01~4.09), increased carotid intima-media thickness (OR=2.01, 95%CI=1.47~2.75), low glomerular filtration rate (OR=3.18, 95%CI=2.23~4.54), and proteinuria (OR=1.79, 95%CI=1.33~2.40), with high cardiovascular and renal risks also observed in the isolated nocturnal hypertension group. Collectively, these findings underscore the close relationship between NH and cardiovascular disease with hypertensive target organ damage, highlighting the importance of nocturnal blood pressure control in reducing these risks. Our study demonstrates a positive correlation between CVAI level and NH risk, particularly significant in individuals with BMI ≥24 kg/m², suggesting that CVAI may serve as a simple and reliable indicator for identifying high-risk populations.

Overweight and obesity are established risk factors for hypertension, with research indicating that regional fat distribution is more important than total body fat. Excess visceral fat-induced obesity has been confirmed to correlate with hypertension. CVAI has become a direct and reliable indicator for assessing visceral fat in Chinese individuals. A cross-sectional study by Gui et al. involving 9,488 middle-aged and elderly individuals over 45 years showed that non-hypertensive participants had lower CVAI levels compared with hypertensive individuals, with each unit increase in CVAI associated with a 1.01-fold increase in hypertension risk in Model 3. Among 13 obesity-related indices, CVAI showed the strongest association with hypertension in middle-aged and elderly Chinese populations. Another study of 3,884 individuals aged ≥60 years similarly reported higher CVAI levels in hypertensive versus non-hypertensive populations, with the highest CVAI quartile showing increased hypertension risk compared with the lowest quartile. Subgroup analyses by sex, BMI, abdominal obesity, and diabetes demonstrated that CVAI correlated with hypertension across all subgroups, with a stronger association observed in elderly women. Previous research indicates that young and middle-aged individuals with BMI >23.6 kg/m² are more prone to blood pressure abnormalities, while our study found that young and middle-aged hypertensive patients with BMI ≥24 kg/m² are more susceptible to NH. Using ABPM as the diagnostic standard for NH avoids the white-coat effect of office blood pressure and biases associated with home self-monitoring. By focusing on young and middle-aged populations, our study elucidates the relationship between visceral fat and nocturnal blood pressure in this demographic.

Potential mechanisms linking visceral fat to hypertension include: (1) visceral fat secretion of adipocytokines involved in blood pressure elevation; (2) production of free fatty acids via the portal vein leading to insulin resistance, which is implicated in hypertension pathogenesis; (3) higher cardiac sympathetic activity in visceral versus subcutaneous obesity, suggesting a link between blood pressure and visceral fat; (4) activation of the renin-angiotensin-aldosterone system associated with visceral fat and obesity-related hypertension, with nocturnal supine position increasing venous return and potentially elevating nocturnal blood pressure; and (5) abdominal obesity as a risk factor for obstructive sleep apnea syndrome (OSAS), particularly through visceral fat accumulation, with nocturnal hypoxemia in OSAS patients causing sympathetic activation and nocturnal blood pressure elevation.

This study has several limitations. First, its cross-sectional design precludes establishing causality between CVAI and NH. Second, although some confounders were adjusted for, factors such as sleep quality and OSAS history were not. Third, the study was limited to young and middle-aged populations and may not be generalizable to other age groups. Finally, the substantial disparity in sample sizes between groups may affect statistical stability.

In conclusion, CVAI correlates with NH risk in young and middle-aged adults, with a more pronounced association in overweight/obese individuals (BMI ≥24 kg/m²). For young and middle-aged hypertensive patients, particularly those with BMI ≥24 kg/m², body composition analysis should be performed to measure visceral fat levels, enabling targeted interventions to reduce visceral fat through enhanced physical activity and ultimately decrease the risk of NH and its complications.

Author Contributions: Zhang Qiuyu conceived and designed the study, conducted the research, wrote the manuscript, and takes responsibility for the article; Zhang Qiuyu and Hu Xiaoyong collected and organized data and performed statistical analysis; Tang Rui revised the manuscript; Li Hongjian supervised quality control and review. The authors declare no conflicts of interest.

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(Received: May 28, 2025; Revised: July 10, 2025)
(Editor: Li Weixia)