Unveiling the twin epidemics of hypertension and diabetes: a cross-sectional analysis of sex-specific prevalence, risk, and hotspots in India's epidemiological transition zones

Background India is experiencing a rising prevalence of hypertension and diabetes, which often coexist and significantly contribute to non-communicable diseases (NCDs) burden. This study examines the sex-stratified prevalence, coexistence, and bidirectional risks of hypertension and diabetes across states with varying epidemiological transition levels (ETL) and identifies the high-burden hotspots. Methods This study analysed data from the fifth round of the National Family Health Survey, covering 614,426 women and 556,199 men aged 30 and above, with biomarker information on both diabetes and hypertension. Age-standardized prevalence was estimated, and adjusted risk ratios (ARR) were obtained on multivariate logit scale. Spatial autocorrelation and hotspot analyses were conducted using ArcGIS Pro to identify geographic clusters of twin epidemics. Results Hypertension prevalence was 30.3% (95%CI:30.14–30.48) among men and 28.6% (95%CI: 28.47–28.79) among women, whereas diabetes prevalence was at 19.7% (95%CI: 19.58–19.88) in men and 17.4% (95%CI 17.22–17.50) in women. Among individuals with diabetes, 43.1% (95%CI:42.67–43.53) of men and 43.9% (95%CI:43.48–44.36) of women had hypertension, while 28.1% (95%CI:27.75–28.37) of hypertensive men and 26.6% (95%CI: 26.33–26.93) of hypertensive women were diabetic. Hotspots for the twin epidemic of hypertension and diabetes were identified in coastal regions, including the southern states with high ETLs, as well as the northern states with high-ETLs and the northeastern region of the country. ARR estimates revealed that the risk of hypertension among individuals with diabetes was 39% higher (95% CI: 1.38–1.40) in men and 41% higher (95% CI: 1.39–1.42) in women as compared to individuals without diabetes. Similarly, the risk of diabetes among individuals with hypertension was 51% higher (95% CI: 1.49–1.52) in men and 55% higher (95% CI: 1.53–1.57) in women as compared to individuals without hypertension. Conclusion Our findings indicate that the presence of one condition significantly heightens the risk of developing the other, posing a major public health challenge in India, with marked geographic disparities. Achieving SDG target 3.4—reducing premature NCD mortality by one-third—requires addressing these intersecting epidemics as a unified entity for effective management. Targeted interventions should prioritise high-burden hotspots for integrated care strategies to mitigate the twin epidemics of diabetes and hypertension.