Division of Endocrinology and Metabolism, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, 2

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1 Originl Article Epidemiology pissn eissn DIABETES & METABOLISM JOURNAL Higher Prevlence nd Awreness, but Lower Control Rte of Hypertension in Ptients with Dibetes thn Generl Popultion: The Fifth Koren Ntionl Helth nd Nutrition Exmintion Survey in 211 Seung-Hyun Ko 1, Hyuk-Sng Kwon 1, De Jung Kim 2, Je Hyeon Kim 3, Nn Hee Kim 4, Chul Sik Kim 5, Kee-Ho Song 6, Jong Chul Won 7, Soo Lim 8, Sung Hee Choi 8, Kyungdo Hn 9, Yong-Moon Prk 1,11, Bong-Yun Ch 1, on behlf of the Tskforce Tem of Dibetes Fct Sheet of the Koren Dibetes Assocition 1 Division of Endocrinology nd Metbolism, Deprtment of Internl Medicine, The Ctholic University of Kore College of Medicine, Seoul, 2 Deprtment of Endocrinology nd Metbolism, Ajou University School of Medicine, Suwon, 3 Division of Endocrinology nd Metbolism, Deprtment of Medicine, Smsung Medicl Center, Sungkyunkwn University School of Medicine, Seoul, 4 Division of Endocrinology nd Metbolism, Deprtment of Internl Medicine, Kore University College of Medicine, Seoul, 5 Division of Endocrinology nd Metbolism, Deprtment of Internl Medicine, Hllym University Scred Hert Hospitl, Hllym University College of Medicine, Anyng, 6 Deprtment of Internl Medicine, Konkuk University School of Medicine, Seoul, 7 Deprtment of Internl Medicine, Mitochondril Reserch Group, Inje University Snggye Pik Hospitl, Inje University College of Medicine, Seoul, 8 Deprtment of Internl Medicine, Seoul Ntionl University Bundng Hospitl, Seoul Ntionl University College of Medicine, Seongnm, 9 Deprtments of Biosttistics, 1 Preventive Medicine, The Ctholic University of Kore College of Medicine, Seoul, Kore; 11 Deprtment of Epidemiology nd Biosttistics, Arnold School of Public Helth, University of South Crolin, Columbi, SC, USA Bckground: We investigted the prevlence, wreness, tretment, nd control rte of hypertension in Koren dults with dibetes using ntionlly representtive dt. Methods: Using dt of 5,15 dults from the fifth Kore Ntionl Helth nd Nutrition Exmintion Survey in 211 (4,389 nondibetes mellitus [non-dm]), 242 newly dignosed with DM (new-dm), nd 474 previously dignosed with DM (known-dm), we nlyzed the prevlence of hypertension (men systolic blood pressure 14 mm Hg, distolic blood pressure 9 mm Hg, or use of ntihypertensive mediction) nd control rte of hypertension (blood pressure [BP] <13/8 mm Hg). Results: The prevlence of hypertension in dibetic dults ws 54.6% (44.4% in new-dm nd 62.6% in known-dm, P<.1 nd P<.1, respectively) compred with non-dm dults (26.2%). Compred to non-dm, wreness (85.7%, P<.1) nd tretment (97.%, P=.2) rtes were higher in known-dm, wheres no differences were found between new-dm nd non-dm. Control rte mong ll hypertensive subjects ws lower in new-dm (14.9%), compred to non-dm (35.1%, P<.1) nd known-dm (33.3%, P=.4). Control rte mong treted subjects ws lso lower in new-dm (.2%), compred to non-dm (68.4%, P<.1) nd known-dm (39.9%, P<.1). Conclusion: Higher prevlence nd low control rte of hypertension in dults with dibetes suggest tht stringent efforts re needed to control BP in ptients with dibetes, prticulrly in newly dignosed dibetic ptients. Keywords: Blood pressure; Dibetes mellitus; Hypertension; Kore Ntionl Helth nd Nutrition Exmintion Survey Corresponding uthors: Yong-Moon Prk Deprtment of Preventive Medicine, The Ctholic University of Kore College of Medicine, 222 Bnpo-dero, Seocho-gu, Seoul , Kore; Deprtment of Epidemiology nd Biosttistics, Arnold School of Public Helth, University of South Crolin, 8 Sumter St, Columbi, SC 2928, USA E-mil: mrkymprk@gmil.com Bong-Yun Ch Division of Endocrinology nd Metbolism, Deprtment of Internl Medicine, Seoul St. Mry s Hospitl, The Ctholic University of Kore College of Medicine, 222 Bnpo-dero, Seocho-gu, Seoul , Kore E-mil: bych@ctholic.c.kr Received: Nov. 23, 213; Accepted: Dec. 22, 213 This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution Non-Commercil License ( which permits unrestricted non-commercil use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. Copyright 214 Koren Dibetes Assocition

2 Ko SH, et l. INTRODUCTION The tretment of hypertension nd chievement of trget blood pressure (BP) in type 2 dibetes is importnt in crdiovsculr outcomes nd mortlity [1]. According to the United Kingdom Prospective Dibetes Study (UKPDS), liner reltionship exists between men systolic blood pressure (SBP) nd the risk of mcrovsculr nd microvsculr complictions [1,2]. Conversely, severl epidemiologicl studies nd clinicl trils hve lso demonstrted tht control of hypertension cn significntly reduce mortlity nd microvsculr or mcrovsculr complictions in ptients with type 2 dibetes [3-5]. Bsed on these results, the current tretment guideline nd expert opinions hve consistently stted the trget BP levlel s <13/8 mm Hg in ptients with type 2 dibetes. The Seventh Report of the Joint Ntionl Committee on the Detection, Evlution, nd Tretment of High Blood Pressure (JNC-7), the Americn Dibetes Assocition (ADA), the Interntionl Dibetes Federtion (IDF), nd the Koren Dibetes Assocition (KDA) tretment guidelines recommend tht BP in type 2 dibetes should be mintined below 13/8 mm Hg [6-9]. However, severl epidemiologicl studies of chieved BP in hypertension trils hve suggested no benefits ssocited with n chieved lower SBP [1-12]. One observtionl subgroup nlysis of 6,4 ptients with dibetes nd 22,576 prticipnts with coronry rtery disese (CAD) in the Interntionl Verpmil SR-Trndolpril Study showed tht tight control of SBP (<13 mm Hg) mong ptients with dibetes nd CAD ws not ssocited with improved crdiovsculr outcomes compred with norml controls (chieved SBP 13 to 14 mm Hg) [12]. Bsed on these results, ADA hs recommended in 213 tht people with dibetes nd hypertension should be treted to chieve SBP of <14 mm Hg nd distolic blood pressure (DBP) <8 mm Hg [11]. Bsed on recent lrge epidemiologicl nlyses, rndomized clinicl trils, nd clinicl recommendtions of other countries, KDA dopted lso in 213 the tretment gol of BP <14/8 mm Hg in type 2 dibetes (unpublished dt). Optiml BP control is essentil in ptients with type 2 dibetes; however, the clinicl benefits of trget BP gol of <14/8 mm Hg rther thn <13/8 mm Hg for the Asin popultion with type 2 dibetes requires further investigtion becuse Asins re t much greter risk of stroke thn the risk of myocrdil infrction [13]. In this study we investigted the prevlence of hypertension nd BP control mong ptients with dibetes from ntionlly representtive smples. We nlyzed the BP levels in Koren dults, using dt from the fifth Kore Ntionl Helth nd Nutrition Exmintion Survey (KNHANES-V) in 211 to explore the prevlence, wreness, nd control rte of hypertension. METHODS Study design This study used the dt from the fifth KNHANES-V conducted by the Koren Ministry of Helth nd Welfre. This survey ws ntionlly representtive study of noninstitutionlized civilins using strtified, multistge probbility smpling design. Smpling units were defined bsed on the dt of household registries, including geogrphicl re, gender, nd ge groups. The KNHANES ws composed of helth interview survey, helth exmintion survey nd nutrition survey conducted by trined investigtors. Additionl detils regrding the study design nd methods re provided elsewhere [14, 15]. A totl of 8,55 out of 1,589 subjects (76.1%) prticipted in ll three surveys in 211. After excluding subjects younger thn 3 yers of ge, pregnnt women nd subjects with missing BP dt, 5,15 dibetic dults were eligible for the present nlysis (4,389 nondibetes mellitus [non-dm], 242 newly dignosed DM; new-dm nd 474 previously dignosed DM; known-dm). This study ws pproved by the Institutionl Review Bord of The Ctholic University of Kore. Definition of dibetes nd hypertension Subjects previously dignosed with dibetes by physicin or those tking insulin or orl hypoglycemic gents were clssified s known-dm. New-DM ws defined s individuls with fsting plsm glucose 126 mg/dl nd/or hemoglobin A1c (HbA1c) 6.5% in the bsence of previous dignosis of dibetes [16]. Hypertension ws defined s SBP 14 mm Hg, DBP 9 mm Hg, or self-reported current use of ntihypertensive medictions [15,17,18]. Prticipnts with hypertension who were told tht they hd hypertension were clssified s hving positive wreness of their disese. Ptients were considered to be under tretment if they hd hypertension nd simultneously reported currently tking ntihypertensive medictions [15,17,18]. Subjects were considered to hve controlled hypertension if they hd n verge SBP <13 mm Hg nd n verge DBP <8 mm Hg, s recommended by the JNC-7, ADA, IDF, nd the KDA [6-9]. Although the recent trget BP gol hs 52

3 Hypertension in ptients with dibetes in Kore been chnged from BP <13/8 mm Hg to <14/9 mm Hg [11], we used the previous trget BP gol (BP <13/8 mm Hg) in this nlysis for comprison with previously published dt. Mesurements Anthropometric mesurements of the prticipnts were performed by specilly trined exminers. BP ws mesured three times in subjects seted for t lest 5 minutes using mercury sphygmomnometer on the right rm (Bumnometer; Bum, Copigue, NY, USA). The men vlue of three seprte BP redings ws used for dt nlysis. Wist circumference ws mesured to the nerest.1 cm in horizontl plne t the midpoint between the ilic crest nd the costl mrgin t the end of norml expirtion. The body mss index ws clculted s the individul s weight in kilogrms divided by the squre of the individul s height in meters. Blood smples were obtined fter minimum fsting time of 8 hours. HbA1c vlues were mesured using high-performnce liquid chromtogrphy 723 G7 (Tosoh, Tokyo, Jpn). The serum fsting glucose levels, totl cholesterol, high density lipoprotein cholesterol, triglycerides, nd cretinine were mesured enzymticlly in centrl lbortory using n utomtic nlyzer 76 (Hitchi, Tokyo, Jpn). Lifestyle-relted or other chrcteristics, including durtion nd tretment of dibetes nd subjects comorbidities were investigted using structured questionnire. Sttisticl nlysis The dt were nlyzed using the pproprite smple weights provided by the Kore Centers for Disese Control nd Prevention. All dt were presented s the men±stndrd error (SE) for continuous vribles nd s frequency percentge (SE) for ctegoricl vribles. Sttisticl nlyses were performed using the SAS version 9.2 (SAS Institute, Cry, NC, USA) survey procedure to ccount for the complex smpling design nd to provide ntionlly representtive prevlence estimte. Prevlence, wreness, tretment, nd control rte of hypertension were compred between non-dm nd new-dm or known-dm, using Bonferroni correction. A P vlue less thn.5 ws considered sttisticlly significnt. RESULTS Prevlence The men ge of the subjects showed significnt differences between groups (48.9±.4 yers in non-dm, 54.9±.9 yers in new-dm, nd 61.2±.8 yers in known-dm; P<.1). Men durtion of dibetes in the known-dm group ws 8 yers. The prevlence of hypertension in dibetic dults ws 54.6% (44.4% in new-dm nd 62.6% in known-dm; P<.1 nd P<.1, respectively) compred with non-dm dults (26.2%), indicting the prevlence of hypertension ws significntly higher in subjects with dibetes (Tble 1). Additionlly, 44.4% of ptients who were dignosed with dibetes for the first time hd hypertension simultneously. Men SBP level ws lso significntly higher in ptients with dibetes (118.1±.4 mm Hg in non-dm, 126.1±1.5 mm Hg in new-dm, nd 127.7± 12.1 mm Hg in known-dm; P<.1). However, men DBP Tble 1. Clinicl chrcteristics ccording to dibetes sttus Chrcteristic Non-DM New-DM Known- DM No. 4, P vlue Age, yr 48.9± ± ±.8 <.1 Gender, % femle 48 (.7) 6.3 (3.6) 55.6 (2.8).4 Body mss index, 23.7± ± ±.2 <.1 kg/m 2 Wist circumference, cm 81.5±.2 9.± ±.6 <.1 Dibetes durtion, yr NA ± 8.1±.4 <.1 Current smoker, % 23.4 (.8) 3 (4) 26.3 (2.6).1267 Hevy drinker, % 11.1 (.7) 13.4 (2.9) 1 (1.9).613 Men SBP, mm Hg 118.1± ± ±1.1 <.1 Men DBP, mm Hg 77.± ±.8.6±.6.6 Hypertension, yes 26.2 (.8) 44.4 (4.2) 62.6 (2.9) <.1 Dibetes tretment, yes Lbortory dt NA NA 89.6 (1.5) Glucose, mg/dl 92.7± ± ±2.6 <.1 Cretinine, mg/dl.84±..87±.1.91±.1 <.1 egfr, 92.6± ± ±1.1 <.1 ml/min/1.73 m 2 Totl cholesterol, mg/dl Triglycerides, mg/dl 192.5± ± ±2.2 < ± ± ±7.1 <.1 HbA1c, % 5.5± 7.2±.1 7.4±.1 <.1 Vlues re presented s men±stndrd error or percentge (stndrd error). DM, dibetes mellitus; NA, not vilble; SBP, systolic blood pressure; DBP, distolic blood pressure; egfr, estimted glomerulr filtrtion rte; HbA1c, hemoglobin A1c. 53

4 Ko SH, et l. level ws highest in the new-dm group (P=.6). Men HbA1c levels of new-dm nd known-dm were 7.2%±.1% nd 7.4%±.1%, respectively. Awreness, tretment, nd control rte of hypertension The wreness of hypertension ws significntly different between non-dm nd known-dm group (Fig. 1). Compred to non-dm, wreness (85.7%, P<.1) nd tretment (97.%, P=.2) rtes were higher in known-dm, wheres no differences were found between new-dm nd non-dm groups. Control rte mong ll hypertensive subjects ws lower in new- DM (14.9%), compred to non-dm (35.1%, P<.1) nd known-dm (33.3%, P=.4). Control rte mong treted subjects ws lso lower in new-dm (.2%), compred to non- DM (68.4%, P<.1) nd known-dm (39.9%, P<.1). The prevlence of hypertension showed n incresed tendency ccording to the increse in ge (ll P for liner trend <.5). In ddition, compred to ptients with dibetes, the prevlence of hypertension ws lower in the non-dm popultion cross ll ge ctegories (ll P<.5) (Fig. 2). We lso nlyzed the tretment nd control rtes between non-dm nd DM (new-dm nd known-dm) groups. Tretment rte ws not significntly different between the two groups cross ll ge ctegories (Fig. 3A). However, control rte of hypertension mong treted prticipnts ws significntly lower in the younger-ged popultion. Compred to the control rte Non-DM New-DM Known-DM b b Awreness Tretment Control rte mong prevlence Control rte mong tretment Fig. 1. Awreness, tretment nd control of hypertension ccording to dibetes sttus. P<.5 vs. nondibetes mellitus (non- DM), b P<.5 vs. known-dm. Non-DM New-DM Known-DM Fig. 2. Comprison of hypertension prevlence ccording to dibetes sttus by ge group (ll P for liner trend <.5). 54

5 Hypertension in ptients with dibetes in Kore of hypertension in the yers nd older ge group, the rte ws less thn hlf in the 3 to 49 yers ge group in ptients with dibetes (Fig. 3C). Non-DM DM Non-DM Non-DM 35.8 DM DM Fig. 3. Comprison of (A) tretment rte, (B) control rte mong prevlence, nd (C) control rte mong tretment ccording to presence of dibetes by ge group. P<.5 between nondibetes mellitus (non-dm) nd DM popultion. A B C We clssified BP into four stges ccording to severity in ptients with dibetes. The proportion of dibetic ptients with stge 1 nd 2 hypertension, s defined by the JNC-7 criteri (SBP 14 mm Hg or DBP 9 mm Hg), ws significntly higher in the new-dm popultion (P<.1). However, the proportion of subjects with n SBP <13 mm Hg nd DBP <8 mm Hg ws significntly higher in known-dm subjects (P<.1) (Fig. 3). DISCUSSION According to 211 KNHANES, the prevlence of hypertension in ptients with dibetes ws 54.6%, which ws pproximtely 2-fold higher thn nondibetic dults (26.2%) in Kore. In spite of higher prevlence, wreness, nd tretment rtes, control rte of hypertension in ptients with dibetes remins unstisfctory compred to the nondibetic popultion. The control rte ws more significnt, especilly in newly dignosed subjects with dibetes. The pproprite tretment of hypertension, especilly in ptients with dibetes is importnt cliniclly becuse of its effects on clinicl outcomes nd helth burden. Among dults with dibetes enrolled in the UKPDS, ech 1-mm Hg decrese in SBP ws ssocited with decrese of 12% in dibetes-relted complictions, 15% in deths relted to dibetes, 11% in myocrdil infrctions, nd 13% in microvsculr complictions [1]. Similr to other countries, except for mlignncy, crdiovsculr disese is the leding cuse of deth in Kore [19]. Crdiovsculr disese hs been mjor cuse of deth for ptients with dibetes nd in the generl popultion. Therefore, dequte control of hypertension in subjects with hypertension is n importnt helth concern. After the Interntionl Expert Committee recommended the use of the HbA1c with threshold 6.5% to dignose dibetes in 29, ADA hs dopted this recommendtion [2]. In 211, Committee of Clinicl Prctice Guideline of KDA lso dopted HbA1c s dignostic criteri for dibetes [8]. HbA1c hs been mesured in ll prticipnts ged 1 yers since 211, the second yer of the 5th KNHANES, regrdless of fsting glucose level or presence of dignosed dibetes. Therefore, HbA1c ws vilble s dignostic criteri for dibetes in Kore using KNHANES-V since 211. When HbA1c 6.5% ws dded to the dignostic mesurement, the prevlence of dibetes ws incresed from 1.5% to 12.4% (mle, 23.8%; femle, 1.4%) in KNHANES-V 211 nlysis [16]. According to 55

6 Ko SH, et l. this chnge in prevlence of dibetes, the prevlence of hypertension in dibetic subjects ws lso incresed from 51.7% in 28 (KNHANES-IV) to 54.6% in 211. Generlly, the prevlence of hypertension is higher in the dibetic popultion compred to generl popultion. Hypertension is up to three times more common in ptients with type 2 dibetes thn in nondibetic subjects nd is frequent in type 1 dibetic subjects [21]. From 1988 to 1994, 71% of the United Sttes dult popultion with dibetes hd elevted BP. The wreness nd tretment of elevted BP were higher mong people with dibetes thn mong United Sttes dult popultion (82% vs. 69% for wreness nd 71% vs. 53% for tretment, respectively) [3]. However, high wreness nd tretment rte of hypertension did not reflect pproprite control of hypertension. In our nlysis, we found tht less thn hlf of the popultion tht treted hypertension ttined trget BP gols both in the new-dm nd known-dm groups. Compred to control rte of hypertension in the nondibetic popultion, the rtes in new-dm nd known-dm subjects were remrkbly low. Previous studies lso found tht only 12% to 35% of dibetic ptients with hypertension controlled their BP below 13/8 mm Hg [22]. The reson why prevlence of hypertension is higher in people with dibetes thn in nondibetic subjects remins uncler. The suggested pthogenesis of hypertension in dibetic subjects includes genetic fctors, combined bdominl obesity, insulin resistnce, utonomic dysfunction, premture rteril stiffness, nd endothelil dysfunction [23]. Notbly, ptients with dibetes hve more isolted systolic hypertension, higher bsl hert rtes, enhnced vribility in BP, nd hypertension more resistnt to tretment compred to ptients without dibetes [24-27]. Moreover, their trget BP level is lower thn the generl popultion nd more ttention is needed for hypertensive ptients with dibetes. In this study, pproximtely 45% of the new-dm subjects hd hypertension, which ws equivlent to pproximtely twice the nondibetic popultion. In ddition, new-dm ptients were more unwre of hving hypertension nd hd significntly lower control rte of hypertension compred to known-dm subjects. When we divided the subjects bsed on ge ctegories, the prevlence of hypertension ws significntly higher ccording to incresed ge both in nondibetic nd dibetic dults. The younger ged group (3 to 49 yers) showed significntly lower control rtes mong ll ge ctegories both in the nondibetic nd dibetic popultion. Therefore, urgent ctions re needed to improve the control rte in ptients with dibetes, especilly in the younger-ged popultion. In conclusion, pproximtely hlf of Koren dults dignosed with dibetes hd hypertension, nd dibetic ptients with hypertension re not dequtely controlled. The considerbly low control rte of hypertension suggests tht intensive interventions nd incresed clinicl ttention should be urgently initited to rech trget BP levels in ptients with dibetes, especilly in newly dignosed subjects with dibetes. Active dpttion of the guidelines, incresed eduction nd implementtion support should be strted to improve the mngement of hypertension. In ddition, to improve BP control, strict dherence to ntihypertensive mediction, lifestyle modifictions such s weight loss, reduction in sodium intke, incresed physicl ctivity nd voidnce of smoking should be emphsized for dibetic individuls. CONFLICTS OF INTEREST No potentil conflict of interest relevnt to this rticle ws reported. REFERENCES 1. Adler AI, Strtton IM, Neil HA, Yudkin JS, Mtthews DR, Cull CA, Wright AD, Turner RC, Holmn RR. Assocition of systolic blood pressure with mcrovsculr nd microvsculr complictions of type 2 dibetes (UKPDS 36): prospective observtionl study. BMJ 2;321: Stmler J, Vccro O, Neton JD, Wentworth D. Dibetes, other risk fctors, nd 12-yr crdiovsculr mortlity for men screened in the Multiple Risk Fctor Intervention Tril. Dibetes Cre 1993;16: Geiss LS, Rolk DB, Engelgu MM. Elevted blood pressure mong U.S. dults with dibetes, Am J Prev Med 22;22: Hnsson L, Znchetti A, Crruthers SG, Dhlof B, Elmfeldt D, Julius S, Menrd J, Rhn KH, Wedel H, Westerling S. Effects of intensive blood-pressure lowering nd low-dose spirin in ptients with hypertension: principl results of the Hypertension Optiml Tretment (HOT) rndomised tril. HOT Study Group. Lncet 1998;351: Hert Outcomes Prevention Evlution Study Investigtors. Effects of rmipril on crdiovsculr nd microvsculr out- 56

7 Hypertension in ptients with dibetes in Kore comes in people with dibetes mellitus: results of the HOPE study nd MICRO-HOPE substudy. Lncet 2;355: Americn Dibetes Assocition. Stndrds of medicl cre in dibetes: 27. Dibetes Cre 27;3 Suppl 1:S Chobnin AV, Bkris GL, Blck HR, Cushmn WC, Green LA, Izzo JL Jr, Jones DW, Mterson BJ, Opril S, Wright JT Jr, Roccell EJ; Joint Ntionl Committee on Prevention, Detection, Evlution, nd Tretment of High Blood Pressure, Ntionl Hert, Lung, nd Blood Institute; Ntionl High Blood Pressure Eduction Progrm Coordinting Committee. Seventh report of the Joint Ntionl Committee on Prevention, Detection, Evlution, nd Tretment of High Blood Pressure. Hypertension 23;42: Ko SH, Kim SR, Kim DJ, Oh SJ, Lee HJ, Shim KH, Woo MH, Kim JY, Kim NH, Kim JT, Kim CH, Kim HJ, Jeong IK, Hong EK, Cho JH, Mok JO, Yoon KH; Committee of Clinicl Prctice Guidelines, Koren Dibetes Assocition. 211 Clinicl prctice guidelines for type 2 dibetes in Kore. Dibetes Metb J 211;35: Interntionl Dibetes Federtion 25: Globl guideline for type 2 dibetes. Avilble from: (updted 213 Nov 21). 1. Nilsson PM, Cederholm J. Dibetes, hypertension, nd outcome studies: overview 21. Dibetes Cre 211;34 Suppl 2:S Americn Dibetes Assocition. Stndrds of medicl cre in dibetes: 213. Dibetes Cre 213;36 Suppl 1:S Cooper-DeHoff RM, Gong Y, Hndberg EM, Bvry AA, Denrdo SJ, Bkris GL, Pepine CJ. Tight blood pressure control nd crdiovsculr outcomes mong hypertensive ptients with dibetes nd coronry rtery disese. JAMA 21;34: Gunrthne A, Ptel JV, Gmmon B, Gill PS, Hughes EA, Lip GY. Ischemic stroke in South Asins: review of the epidemiology, pthophysiology, nd ethnicity-relted clinicl fetures. Stroke 29;4:e Kore Centers for Disese Control nd Prevention (KCDC): Kore Ntionl Helth nd Nutrition Exmintion Survey. Avilble from: (updted 213 Nov 21). 15. Ko SH, Kwon HS, Song KH, Ahn YB, Yoon KH, Yim HW, Lee WC, Prk YM. Long-term chnges of the prevlence nd control rte of hypertension mong Koren dults with dignosed dibetes: Koren Ntionl Helth nd Nutrition Exmintion Survey. Dibetes Res Clin Prct 212;97: Jeon JY, Ko SH, Kwon HS, Kim NH, Kim JH, Kim CS, Song KH, Won JC, Lim S, Choi SH, Jng MJ, Kim Y, Oh K, Kim DJ, Ch BY; Tskforce Tem of Dibetes Fct Sheet of the Koren Dibetes Assocition. Prevlence of dibetes nd predibetes ccording to fsting plsm glucose nd HbA1c. Dibetes Metb J 213;37: McAlister FA, Wilkins K, Joffres M, Leenen FH, Fodor G, Gee M, Trembly MS, Wlker R, Johnsen H, Cmpbell N. Chnges in the rtes of wreness, tretment nd control of hypertension in Cnd over the pst two decdes. CMAJ 211;183: Wng J, Geiss LS, Cheng YJ, Impertore G, Sydh SH, Jmes C, Gregg EW. Long-term nd recent progress in blood pressure levels mong U.S. dults with dignosed dibetes, Dibetes Cre 211;34: The Sttistics Kore. Avilble from: (updted 213 Nov 21). 2. Americn Dibetes Assocition. Dignosis nd clssifiction of dibetes mellitus. Dibetes Cre 21;33 Suppl 1:S Mhs DM, Kinney GL, Wdw P, Snell-Bergeon JK, Dbele D, Hoknson J, Ehrlich J, Grg S, Eckel RH, Rewers MJ. Hypertension prevlence, wreness, tretment, nd control in n dult type 1 dibetes popultion nd comprble generl popultion. Dibetes Cre 25;28: Suh DC, Kim CM, Choi IS, Pluschint CA, Brone JA. Trends in blood pressure control nd tretment mong type 2 dibetes with comorbid hypertension in the United Sttes: J Hypertens 29;27: Cmpbell NR, Gilbert RE, Leiter LA, Lrochelle P, Tobe S, Chocklingm A, Wrd R, Morris D, Tsuyuki RT, Hrris SB. Hypertension in people with type 2 dibetes: updte on phrmcologic mngement. Cn Fm Physicin 211;57: Brown MJ, Cstigne A, de Leeuw PW, Mnci G, Plmer CR, Rosenthl T, Ruilope LM. Influence of dibetes nd type of hypertension on response to ntihypertensive tretment. Hypertension 2;35: Pop-Busui R. Crdic utonomic neuropthy in dibetes: clinicl perspective. Dibetes Cre 21;33: Ozw M, Tmur K, Iwtsubo K, Mtsushit K, Ski M, Tsurumi-Ikey Y, Azum K, Shigeng A, Okno Y, Msud S, Wkui H, Ishigmi T, Umemur S. Ambultory blood pressure vribility is incresed in dibetic hypertensives. Clin Exp Hypertens 28;3: Grossmn E, Messerli FH. Mngement of blood pressure in ptients with dibetes. Am J Hypertens 211;24: