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Beyond behaviors: do biological intermediates improve lifestyle scoring for blood pressure?

G. Aljuraiban,Sara Al-Musharaf,Fatima A Almadani,Tagreed A. Mazi,M. Abulmeaty,Madhawi M. Aldhwayan

Published 2026 in Frontiers in Cardiovascular Medicine

ABSTRACT

Background Hypertension prevalence is high in Saudi Arabia. Both lifestyle behaviors and biological intermediates influence blood pressure (BP); however, there is limited evidence from the Middle East on whether composite lifestyle scores that integrate both domains would capture BP variation better than behavioral metrics alone. This study aimed to examine associations of an overall lifestyle risk score (behavioral + biological) and a behavioral-only score with BP outcomes. Methods In a cross-sectional study of Saudi adults (n = 1,041), we constructed (i) an overall lifestyle score (BioBeh score), including waist circumference, total cholesterol, fasting glucose, smoking, sleep, physical activity, perceived stress, and diet quality, and (ii) a behavioral-only score (Beh score), including smoking, sleep, physical activity, perceived stress, and diet. We examined the association with BP [systolic/diastolic BP (SBP/DBP)], elevated BP, and hypertension using multivariable linear and logistic regression, adjusted for various confounders. Results Each 1-point higher BioBeh score was associated with lower SBP (−1.68 mmHg; 95% CI: −2.58, −0.79), lower DBP (−1.67 mmHg; 95% CI: −2.66, −0.68), and reduced odds of hypertension (OR 0.73; 95% CI: 0.63, 0.85), but not with elevated BP. No associations were found with the Beh score. Waist circumference was the strongest individual component [SBP −3.80 (−4.70, −2.91); DBP −3.31 (−4.30, −2.32) mmHg; hypertension OR 0.57; 95% CI: 0.49, 0.66]. Conclusions In Saudi adults, a biologically enriched lifestyle score captures BP variation and hypertension risk more robustly than behavior-only metrics. These findings support risk stratification and prevention strategies that emphasize central adiposity alongside basic lipid and glucose profiles.

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