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Clinical Advances in Diabetes, Obesity, and Hypertension

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Endocrinology & Metabolism".

Deadline for manuscript submissions: 25 October 2026 | Viewed by 20219

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Dr. Piotr Matłosz

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Department of Physical Culture Sciences, Medical College of Rzeszow University, 35-959 Rzeszow, Poland
Interests: health; anthropometry; obesity; physical activity; accelerometry
Special Issues, Collections and Topics in MDPI journals

Dr. Justyna Wyszyńska

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Institute of Health Sciences, Medical College of Rzeszów University, 35-959 Rzeszow, Poland
Interests: accelerometry; body composition; hypertension; obesity; physical activity; risk factors; sleep
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Dear Colleagues,

Obesity is a major risk factor for hypertension, cardiovascular disease, and type 2 diabetes, contributing to increased morbidity and mortality. The prevalence of these conditions varies between populations and is influenced by genetic, dietary, and lifestyle factors. The effective management of these conditions often requires a multidisciplinary approach, including lifestyle modifications, pharmacotherapy, and, in some cases, surgery.

Our aim in launching this Special Issue is to highlight the importance of a comprehensive understanding of the interplay between diabetes, obesity, and hypertension and to provide valuable insights for application in clinical practice by focusing on research advances in the prevalence, prevention, and effective treatment of hypertension, diabetes, and obesity and their complications.

Through this Special Issue, we aim to achieve the following:

Explore the relationships between diabetes, obesity, and hypertension;
Highlight recent clinical advances in the treatment and management of these conditions;
Provide insights into the mechanisms underlying these diseases and their complications;
Discuss the impact of lifestyle modifications, pharmacotherapy, and surgical interventions.

Dr. Piotr Matłosz
Dr. Justyna Wyszyńska
Guest Editors

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Keywords

obesity
hypertension
diabetes
lifestyle
physical activity
risk factors

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16 pages, 678 KB

Open AccessArticle

Exploring Multidimensional Diabetes Self-Management and Health-Related Functioning in Relation to Vascular Complications

by Claudiu Cobuz, Mădălina Ungureanu-Iuga, Iuliana Costescu, Alina Cornea and Maricela Cobuz

J. Clin. Med. 2026, 15(15), 6125; https://doi.org/10.3390/jcm15156125 - 6 Aug 2026

Viewed by 154

Abstract

Background/Objectives: Diabetes mellitus is associated with complex behavioral, psychosocial, and functional challenges that may influence disease burden and complication profiles. This study aimed to identify latent dimensions of diabetes self-management and health-related functioning and to evaluate their association with the type of diabetes-related complications. Methods: A cross-sectional study was conducted in 300 patients with type 2 diabetes, classified into microvascular and macrovascular complication groups. A questionnaire comprising DSMQ (diabetes self-management questionnaire) derived items, SF-36-derived items, and other questions was administered to all participants. Exploratory factor analysis was performed to identify latent dimensions related to self-management, emotional burden, dietary behavior, glycemic control challenges, glucose monitoring, and functional status. Composite scores were calculated for factors with acceptable internal consistency. Between-group comparisons, Spearman correlation analysis, and binary logistic regression models adjusted for age, sex, residence area, marital status, education, diabetes duration, and treatment type were applied. Results: Six latent factors were identified: Emotional Burden, Dietary Self-Management, Functional Limitations, Glycemic Control Challenges, Glucose Monitoring, and General Health Perception. However, only the factors demonstrating acceptable internal consistency were retained for subsequent analyses: Emotional Burden, Functional Limitations, and Glycemic Control Challenges. Functional Limitations showed the strongest association with complication type, with patients with macrovascular complications reporting greater functional impairment. After adjustment for potential confounders and correction for multiple comparisons, higher adherence to the recommended meal plan (DSMQ2) and greater functional limitations remained the principal differences between the complication groups. Functional Limitations Score remained independently associated with complication type in both unadjusted and adjusted logistic regression models. Conclusions: These cross-sectional findings support the integration of functional, psychosocial, and behavioral assessment into comprehensive diabetes care and highlight differences in patient-reported outcomes across complication groups. Full article

(This article belongs to the Special Issue Clinical Advances in Diabetes, Obesity, and Hypertension)

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23 pages, 2419 KB

Open AccessArticle

Bidirectional Associations Between Blood Glucose and Blood Pressure: A Data-Driven Causal Analysis Using Structural Equation Modelling and Granger Causality on NHANES Longitudinal Data

by Irina Naskinova, Mikhail Kolev, Mariyan Milev, Hristo Kalinov, Meglena Lazarova, Stanislava Stoilova and Iveta Nikolova

J. Clin. Med. 2026, 15(10), 3751; https://doi.org/10.3390/jcm15103751 - 13 May 2026

Viewed by 488

Abstract

Background and Objectives: Whether hyperglycaemia causes hypertension, hypertension worsens glycaemic control, or both conditions arise from shared metabolic drivers remains clinically consequential yet unresolved. This study applies a triangulated causal inference framework to large-scale population data to quantify the direction, magnitude, and robustness of the glucose–blood pressure relationship. The primary objective is to test for bidirectional causal effects between glycaemic status and blood pressure; secondary objectives include quantifying effect magnitudes by multiple complementary methods and assessing robustness to unmeasured confounding. Materials and Methods: We analysed 55,386 adults from the National Health and Nutrition Examination Survey (NHANES, 1999–2023). Multiple causal inference techniques were integrated: directed acyclic graph (DAG) testing, structural equation modelling (SEM) with latent constructs, propensity score matching (PSM), inverse probability weighting (IPW), doubly robust augmented IPW (AIPW), and E-value/Rosenbaum Γ sensitivity analyses, with external replication in the Framingham Heart Study data (n = 4240). Results: All of the methods used confirmed the bidirectional effects. PSM showed that hyperglycaemia increased systolic BP by 1.76 mmHg (95% CI: 0.58–2.96, p = 0.005), and hypertension increased fasting glucose by 6.55 mg/dL (95% CI: 4.61–8.58, p < 0.001), revealing a marked asymmetry favouring the BP → glucose direction. AIPW confirmed both effects (3.51 mmHg and 6.15 mg/dL, both p < 0.001). SEM identified significant bidirectional structural paths between latent glycaemic and blood-pressure constructs, with the Glycaemic → BPState path showing a negative coefficient (β = −0.15, p = 0.043), a sign reversal attributable to conditioning on the shared latent metabolic-syndrome factor. Sensitivity analyses indicated that an unmeasured confounder would need associations of RR ≥ 1.40–1.64 with both exposure and outcome to nullify these estimates, representing moderate robustness. Conclusions: The BP → glucose pathway is the dominant causal direction, suggesting that prioritisation of hypertension control may yield underappreciated benefits for glycaemic regulation. These findings support integrated cardiometabolic management strategies. Full article

(This article belongs to the Special Issue Clinical Advances in Diabetes, Obesity, and Hypertension)

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12 pages, 588 KB

Open AccessArticle

Clinical Outcomes of Insulin Glargine U300 on Glycemic Control and Hypoglycemia: A Retrospective Observational Study

by Gökçen Güngör Semiz, Mehmet Çağrı Ünal, İsmail Selimoğlu, Sıla Kalender, Ege Erbay, Mehmet Emin Arayici, Abdurrahman Çömlekçi, Serkan Yener and Tevfik Demir

J. Clin. Med. 2026, 15(9), 3529; https://doi.org/10.3390/jcm15093529 - 5 May 2026

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Abstract

Background/Objectives: Insulin glargine U300 (IGlarU300) is a second-generation, long-acting insulin analog designed to provide a more stable pharmacokinetic profile compared to insulin glargine U100. However, long-term real-world data reflecting its long-term impact on glycemic control and hypoglycemia across diverse populations remain limited. This study evaluated the 24-month clinical outcomes of transitioning to IGlarU300 in a real-world setting. Methods: This retrospective, single-center, observational study enrolled patients with type 1 (T1DM) or type 2 diabetes mellitus (T2DM) who transitioned to IGlarU300 between 2017 and 2021. HbA1c levels, body weight, insulin doses, and hypoglycemia rates were evaluated at baseline and up to 24 months. Results: A total of 242 patients (T1DM: n = 68, T2DM: n = 174) were analyzed. HbA1c levels significantly declined at all follow-up points compared to baseline (mean change at 12 months: −0.85% [95% CI: −1.24 to −0.47%]; p < 0.001]). No significant change in total insulin dose was observed over the one-year follow-up; however, improved glycemic control led to a significant reduction in oral antidiabetic medication use, reflecting successful treatment simplification and a decrease in polypharmacy burden (mean change: -0.50 [95% CI: −0.70 to −0.30]; p < 0.001). Notably, both severe and mild hypoglycemia episodes showed significant reductions (p = 0.010 and p = 0.019, respectively). Switching to IGlarU300 was associated with sustained improvements in glycemic control and a reduction in hypoglycemia rates. Conclusions: These findings suggest that IGlarU300 may be an effective clinical option for optimizing metabolic outcomes, though further controlled studies are warranted to confirm these observational results. Full article

(This article belongs to the Special Issue Clinical Advances in Diabetes, Obesity, and Hypertension)

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13 pages, 962 KB

Open AccessArticle

Diagnostic Performance of HbA1c for Detecting OGTT-Diagnosed Diabetes in Obese Individuals with Suspected Prediabetes

by Abdullah Budak, Ihsan Solmaz, Ömer Faruk Alakuş and Bilgin Bahadır Başgöz

J. Clin. Med. 2026, 15(1), 374; https://doi.org/10.3390/jcm15010374 - 4 Jan 2026

Cited by 1 | Viewed by 1174

Abstract

Background: We aimed to investigate the diagnostic performance between the oral glucose tolerance test (OGTT) and HbA1c in diagnosing prediabetes and diabetes among obese individuals, and to evaluate the diagnostic performance of HbA1c for detecting OGTT-defined diabetes in obese individuals referred for evaluation of suspected prediabetes. Methods: Individuals with prediabetes were included between 1 January 2020 and 31 December 2022. Participants were categorized as mildly, moderately, morbidly, or super obese based on body mass index (BMI). According to the 75 g OGTT results, patients were classified into three groups: isolated impaired fasting glucose (IFG), combined IFG + impaired glucose tolerance (IGT), and overt type 2 diabetes mellitus (T2DM). The threshold HbA1c value for T2DM diagnosis in obese patients was determined based on OGTT outcomes. Results: Of the 139 prediabetic obese patients included, 115 (82.7%) were female, with a mean age of 45.18 ± 11.74 years. Based on BMI, 34 patients (24.5%) were mildly obese, 41 (29.5%) moderately obese, 49 (35.3%) morbidly obese, and 15 (10.8%) super obese. According to the 75 g OGTT results, 37.4% (n = 52) had isolated IFG, 45.3% (n = 63) had combined IFG + IGT, and 17.3% (n = 24) had overt T2DM. A weak–moderate positive correlation was observed between HbA1c and fasting blood glucose (Spearman’s rho = 0.263, p = 0.002). ROC–AUC analysis showed that HbA1c had significant discriminatory power in detecting T2DM diagnosed by the 75 g OGTT (AUC = 0.881, 95% CI: 0.816–0.946, p < 0.001). The optimal HbA1c cut-off was 6.15%, with 83.3% sensitivity and 80% specificity. The positive predictive value was 46.1%, and the negative predictive value was 95.8%. Conclusions: An HbA1c threshold of 6.15% demonstrated optimal performance for detecting OGTT-defined diabetes in obese individuals with suspected prediabetes. This value should not be interpreted as a population-wide diagnostic threshold. These findings indicate that HbA1c may serve as a useful screening tool to identify obese individuals who warrant confirmatory OGTT testing, rather than as a stand-alone diagnostic criterion. Further large-scale studies are warranted to confirm these results and support future clinical guidelines. Full article

(This article belongs to the Special Issue Clinical Advances in Diabetes, Obesity, and Hypertension)

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12 pages, 481 KB

Open AccessArticle

The Impact of Glucagon-like Peptide-1 Receptor Agonists on Cardiovascular–Kidney–Metabolic Health in Romanian Patients with Type 2 Diabetes: A Retrospective Study

by Niculina Lixandru, Laura Gaita, Simona Popescu, Andreea Herascu, Bogdan Timar and Romulus Timar

J. Clin. Med. 2026, 15(1), 152; https://doi.org/10.3390/jcm15010152 - 25 Dec 2025

Viewed by 1334

Abstract

Background/objectives: Chronic degenerative complications of diabetes, such as atherosclerotic cardiovascular disease and chronic kidney disease, contribute to an increased morbimortality in patients with type 2 diabetes (T2D), and thus, a multifactorial approach becomes essential. Among the classes of antihyperglycemic agents with beneficial pleiotropic cardiorenal effects, the glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have proven to reduce the risk of major adverse cardiovascular (CV) and renal events. This study aims to assess the impact of treatment with GLP-1 RA on CV risk factors, insulin sensitivity, and renal function in Romanian patients with T2D. Methods: In an observational retrospective study, 150 patients with T2D were evaluated at the start of therapy with a GLP-1 RA and then after 6 and 12 months. Results: After 12 months of treatment, 59.3% of patients succeeded in achieving weight loss of over 5% of their initial weight, and 24.7% of patients achieved weight loss of over 10% of their initial weight, with the most significant decrease being measured in the first 6 months. HbA1c has shown a similar profile, with a significant reduction in the first 6 months of treatment, continued at a slower rate in the following 6 months. Additionally, the lipid profile, blood pressure values, and uric acid values, alongside the triglyceride/high-density lipoprotein cholesterol (TG/HDLc) ratio and the triglyceride–glucose (TyG) index have improved in these T2D patients treated with GLP-1 RA, while their eGFR decrease was slower than the one expected for similar populations without such a pharmacologic agent in their regimen. Conclusions: Treatment with GLP-1 RA in patients with T2D is associated with an improved cardiovascular–kidney–metabolic risk profile, ameliorated glycemic control, reduced weight, lower insulin resistance, and slower kidney disease progression. Full article

(This article belongs to the Special Issue Clinical Advances in Diabetes, Obesity, and Hypertension)

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13 pages, 757 KB

Open AccessArticle

Blood Pressure Levels and Triglyceride–Glucose Index: A Cross-Sectional Study from a Nationwide Screening in Mongolia

by Byambasuren Dagvajantsan, Oyunsuren Enebish, Khangai Enkhtugs, Bayarbold Dangaa, Munkhtulga Gantulga, Mijidsuren Ganbat, Narantuya Davaakhuu, Tumur-Ochir Tsedev-Ochir, Batzorig Bayartsogt, Enkhtur Yadamsuren, Altantuya Shirchinjav and Oyuntugs Byambasukh

J. Clin. Med. 2025, 14(19), 6890; https://doi.org/10.3390/jcm14196890 - 29 Sep 2025

Cited by 2 | Viewed by 1854

Abstract

Background: The triglyceride–glucose (TyG) index has emerged as a reliable surrogate marker of insulin resistance. This study aimed to investigate the association between blood pressure (BP) levels and the TyG index and to assess whether even modest elevations in BP were associated with higher TyG index values. Methods: A cross-sectional analysis was conducted using data from 120,264 participants who underwent nationwide health screening in Mongolia between 2023 and 2024. BP was categorized into five stages. The TyG index was calculated based on fasting triglyceride and glucose levels. Results: The mean TyG index increased progressively with advancing hypertension stages (p for trend <0.001). Multivariate analysis showed that even elevated BP was independently associated with a higher TyG index (adjusted OR 1.108, 95% CI 1.039–1.183; p = 0.002), with the association strengthening across hypertension stage 1 (adjusted OR 1.238, 95% CI 1.200–1.277), stage 2 (adjusted OR 1.516, 95% CI 1.463–1.572), and hypertensive crisis (adjusted OR 1.575, 95% CI 1.350–1.836) (all p < 0.001). Central obesity further amplified the association between hypertension stage and TyG index levels. Among participants without central obesity, the TyG index increased from 8.086 (95% CI: 8.079–8.093) in the normal BP group to 8.449 (8.362–8.536) in the hypertensive crisis group. Similarly, among those with central obesity, the TyG index rose from 8.345 (8.336–8.354) in the normal group to 8.732 (8.685–8.778) in the hypertensive crisis group. Conclusions: This study demonstrates that the TyG index rises consistently with increasing BP stages, even at early elevations, suggesting that insulin resistance may begin at modest blood pressure increases. Full article

(This article belongs to the Special Issue Clinical Advances in Diabetes, Obesity, and Hypertension)

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12 pages, 1754 KB

Open AccessArticle

Long-Term Cardiorenal Benefits of Sodium-Glucose Cotransporter-2 Inhibitors in Patients with Type 2 Diabetes Mellitus: A Real-World Single-Center Experience

by Adnan Agha, Bachar Afandi, Saeed AlKaabi, Naser Abdulla Naser Salem Alshkeili, Mohammed Ali Alsharoon Alshemeili, Mohammed Mohammed Al Ghaithi, Mohammad Mohammed Hareb Alsaadi and Juma Alkaabi

J. Clin. Med. 2025, 14(18), 6365; https://doi.org/10.3390/jcm14186365 - 9 Sep 2025

Viewed by 1376

Abstract

Background: The United Arab Emirates (UAE) faces a high burden of type 2 diabetes mellitus (T2DM) and its complications. While sodium-glucose cotransporter-2 inhibitors (SGLT2i) have demonstrated cardiorenal benefits in clinical trials, real-world evidence on their association with calculated cardiovascular risk in Middle Eastern populations remains limited. This study evaluated the long-term real-world outcomes associated with SGLT2i use in Emirati patients with T2DM. Methods: We conducted a retrospective observational study of patients with T2DM initiated on SGLT2i (empagliflozin, dapagliflozin, or canagliflozin) at Tawam Hospital, UAE, between 1 January 2018 and 31 December 2018. Patients were followed for up to 5 years. Primary outcomes included changes in glycated hemoglobin (HbA1c), estimated glomerular filtration rate (eGFR), and body mass index (BMI). A key secondary outcome was the change in 10-year atherosclerotic cardiovascular disease (ASCVD) risk, calculated using the ACC/AHA Pooled Cohort Equations. Results: We included 185 patients (mean age 57 ± 12 years, 56.2% female), with 107 (57.8%) receiving empagliflozin, 54 (29.2%) dapagliflozin, 11 (5.9%) canagliflozin, and 13 (7.0%) who switched between agents. Significant improvements were observed in HbA1c (8.7 ± 1.8% to 8.2 ± 1.9%, p < 0.001), while eGFR showed preservation of renal function with an annual decline of 1.1 mL/min/1.73 m². Among 120 patients eligible for ASCVD risk assessment (excluding 65 with established cardiovascular disease), the mean 10-year ASCVD risk decreased from 22.3 ± 5.3% at baseline to 19.3 ± 4.9% at 5 years (absolute reduction −3.0%, 95% CI −2.4 to −3.6%, p < 0.001). Serious adverse events were rare, including acute kidney injury (1.1%) and fractures (1.6%). No episodes of diabetic ketoacidosis or severe hypoglycemia were observed. Conclusions: In this real-world cohort from the UAE, SGLT2 inhibitor use was associated with sustained glycemic control, preserved renal function, and lower calculated 10-year cardiovascular risk over 5 years. These observational findings, noted in the context of comprehensive risk factor management, support the potential benefits of SGLT2i in high-risk Middle Eastern patients with T2DM, though prospective controlled studies are needed to confirm causality. Full article

(This article belongs to the Special Issue Clinical Advances in Diabetes, Obesity, and Hypertension)

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13 pages, 537 KB

Open AccessArticle

High Prevalence of Metabolic-Associated Fatty Liver Disease (MAFLD) in Children and Adolescents with Severe Obesity

by Magdalena Mierzwa, Żaneta Malczyk, Mirosław Bik-Multanowski, Stephanie Brandt-Heunemann, Bertram Flehmig, Ewa Małecka-Tendera, Artur Mazur, Elżbieta Petriczko, Michael B. Ranke, Martin Wabitsch, Małgorzata Wójcik, Agata Domżol and Agnieszka Zachurzok

J. Clin. Med. 2025, 14(10), 3565; https://doi.org/10.3390/jcm14103565 - 20 May 2025

Cited by 5 | Viewed by 3094

Abstract

Background: Severe obesity in children and adolescents presents a particular health burden due to high prevalence of complications and comorbidities, including metabolic-associated fatty liver disease (MAFLD). The aim of this study was to assess the prevalence of MAFLD in Polish children and adolescents with severe obesity, and assess its relation to anthropometric profiles and metabolic risk factors. Patients and Methods: In 212 children and adolescents with severe obesity (aged 3–18 years), physical examination, body composition, liver ultrasound (US), and biochemical assessment were performed. MAFLD was diagnosed based on the presence of steatosis in US and/or persistently elevated alanine aminotransferase concentration. Results: MAFLD was present in 125 (59.0%) patients. Metabolic Syndrome (MetS) was diagnosed among 57.5% of patients without MAFLD, and in 66.5% of patients with MAFLD (p > 0.05). Impaired fasting glucose, impaired glucose tolerance, and high HOMA-IR occurred more frequently in MAFLD than in non-MAFLD patients (p < 0.05). In the MAFLD group, a higher number of patients with ≥4 components of MetS were observed than in the non-MAFLD group (33.6% vs. 12.6%, p = 0.0004). Conclusions: The prevalence of MAFLD among children and adolescents with severe obesity was 59%. These patients are characterised by more pronounced insulin resistance and higher number of MetS components. Full article

(This article belongs to the Special Issue Clinical Advances in Diabetes, Obesity, and Hypertension)

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10 pages, 512 KB

Open AccessArticle

A New Score for Metabolic Age in Type 2 Diabetes Mellitus: Physical Rating Score

by Hasan Esat Yücel, Tufan Ulcay, Özkan Görgülü, Ruken Öncü, Emre Uğuz and Erkan Dulkadiroğlu

J. Clin. Med. 2025, 14(9), 2868; https://doi.org/10.3390/jcm14092868 - 22 Apr 2025

Cited by 2 | Viewed by 1853

Abstract

Background: Metabolic age (met-age), a risk marker, may vary within the same chronological age group. Its association with chronological age, waist/height ratio, obesity degree, body mass index (BMI), and physical rating score (PRS)—risk factors for type 2 diabetes—remains unexplored. Methods: A total of 122 type 2 diabetes patients (50 males, 72 females) were analyzed. Bioimpedance measurements were taken using the Tanita MC-780MA, alongside anthropometric data. Variables were compared, and correlations with met-age were assessed. Results: The met-age–chronological age difference was higher in females with type 2 diabetes (p < 0.001). Females also had higher BMI, obesity degree, fat mass, and waist/height ratio (p < 0.05), but lower waist/hip ratio (p < 0.001). Males showed higher PRS, muscle mass, and fat-free mass (p < 0.001). Met-age positively correlated with chronological age and negatively with PRS in both sexes (p < 0.05). According to the linear regression model, in females, the met-age was influenced positively by chronological age and waist/height ratio and negatively by PRS (R² = 0.983). In males, it was positively influenced by chronological age, obesity grade, and BMI, but negatively by PRS (R² = 0.974). Conclusions: Met-age correlates with chronological age and PRS in type 2 diabetes patients. It increases with advancing age and lower PRS, with waist/height ratio impacting females and BMI/obesity degree affecting males. Full article

(This article belongs to the Special Issue Clinical Advances in Diabetes, Obesity, and Hypertension)

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22 pages, 952 KB

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The Impact of Ramadan Fasting on Endothelial Function, Cardiovascular Risk Factors, and Cardiovascular Disease

by Musaab Ahmed, Mohamed H. Ahmed and Nisha Shantakumari

J. Clin. Med. 2025, 14(17), 6191; https://doi.org/10.3390/jcm14176191 - 2 Sep 2025

Viewed by 7169

Abstract

Endothelial dysfunction, marked by reduced nitric oxide bioavailability, is a known factor in cardiovascular disorders. Prior studies have shown that dietary changes affect endothelial function and alter risk factors. Research studies have examined the possible impacts of Ramadan fasting on endothelial dysfunction. This narrative review aimed to assess the impacts of Ramadan fasting on endothelial function. We conducted a search of the PubMed and SCOPUS databases with various search terms. The review focused on research papers published in English language from 2000 to 2024. This review included sixty-six studies. Ramadan fasting elevated the levels and bioavailability of nitric oxide and improved some indicators of endothelial dysfunction. Ramadan fasting may enhance endothelial dysfunction and modify its risk factors, by promoting weight reduction and improving insulin resistance. Moreover, Ramadan fasting induced alterations in the structure, composition, abundance, and overexpression of gut microbiota. Further research is necessary to evaluate the safety, efficacy, and importance of Ramadan fasting on endothelial function and cardiovascular health. Full article

(This article belongs to the Special Issue Clinical Advances in Diabetes, Obesity, and Hypertension)

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