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Original article

Habitual coffee consumption and 24-h blood pressure control in older adults with hypertension

Esther Lopez-Garcia

^*

, Edilberto Orozco-Arbelaez, Luz María Leon-Mu~noz, Pilar Guallar-Castillon, Auxiliadora Graciani, Jose Ramon Banegas,

Fernando Rodríguez-Artalejo

Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autonoma de Madrid/IdiPAZ, CIBER of Epidemiology and Public Health (CIBERESP), Spain

a r t i c l e i n f o

Article history:

Received 19 June 2015 Accepted 28 March 2016

Keywords:

Coffee

24-h blood pressure BP control

Hypertensive population

s u m m a r y

Background & aims: In normotensive and hypertensive individuals, blood pressure (BP) rises acutely during a few hours following coffee or caffeine consumption. However, the effect of habitual coffee consumption on BP and BP control is uncertain. The aim of this study was to assess the association of habitual coffee consumption on 24-h BP and BP control among older adults with hypertension.

Methods: Data were taken from the Seniors-Study on Nutrition and Cardiovascular Risk in Spain (ENR- ICA), a cross-sectional study conducted in 2012 among 1164 individuals aged63 years. Habitual coffee consumption was assessed with a validated diet history. BP was recorded by 24-h ambulatory monitoring. Ambulatory hypertension was deﬁned as BP 130/80 mm Hg or being under antihypertensive treatment, and uncontrolled BP was deemed as BP 130/80 mm Hg among hypertensives. Analyses were performed with linear and logistic regressions adjusted for the main confounders, including diet, time since diagnosis of hypertension and the number of antihypertensive drugs.

Results: Among the 715 hypertensive participants, those consuming 3 cups of coffee/day showed higher 24-h systolic BP (beta: 3.25 mm Hg, p value ¼ 0.04) and diastolic BP (beta: 2.24 mm Hg, p value¼ 0.02) than non-coffee drinkers. Compared to non-coffee drinkers, the odds ratios (95% conﬁ- dence interval) for uncontrolled BP among those consuming 1, 2, and 3 cups of coffee/day were, respectively: 1.95 (1.15e3.30), 1.41 (0.75e2.68), and 2.55 (1.28e5.09); p for trend ¼ 0.05. The association was similar among individuals who were smokers, had excess weight (body mass index25 kg/m²), low adherence to the Mediterranean diet, or hypercholesterolemia. No association was found between coffee consumption and having a non-dipper BP pattern (<10% nocturnal decline in BP) among hypertensives.

Conclusion: Habitual coffee consumption was associated with uncontrolled BP in a hypertensive older population.

1. Introduction

High blood pressure (BP) is the mean risk factor for global disease burden[1]. In high-income countries, the population rate of hypertension remains high: it reaches 29.0% in the US[2]and 33.3%

in Spain, a European country with a well-developed and free-access healthcare system [3]. Moreover, the control of hypertension among treated patients decreases with age, so that it is only about

45% and 46% among treated hypertensive patients older than 60 years in the US and Spain, respectively.

Clinical guidelines on hypertension management recommend diet therapy to lower BP[4,5], but they do not comment on coffee consumption. This might be due to the fact that the association between coffee consumption and BP has not yet been well char- acterized[6]. In controlled clinical studies, BP rises acutely during a few hours following coffee or caffeine intake in normotensive and hypertensive individuals [7,8]. Also, two meta-analyses of trials with coffee consumption during a few weeks have shown slightly higher BP levels in normotensive and younger age participants [9,10], but not in hypertensive patients [8]. In a recent meta-

* Corresponding author.

E-mail address:esther.lopez@uam.es(E. Lopez-Garcia).

Contents lists available atScienceDirect

Clinical Nutrition

j o u r n a l h o m e p a g e : h t t p : / / w w w . e l s e v i e r . c o m / l o c a t e / c l n u

http://dx.doi.org/10.1016/j.clnu.2016.03.021

Clinical Nutrition 35 (2016) 1457e1463

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analysis including both clinical trials and cohort studies, no sig- niﬁcant effect of coffee consumption on BP or on the risk of hypertension was observed[11]. However, no previous investigation has examined whether habitual coffee consumption may reduce BP control in hypertensive patients[12].

An isolated clinical BP measurement may not reﬂect the cumulative effect of coffee intake during several hours, so mean BP obtained in ambulatory blood pressure monitoring (ABPM) over a prolonged period is a better measure of the‘true’ BP[13]. Also, ABPM-derived parameters such as the night-to-day ratio of BP have emerged as important predictors of cardiovascular disease, espe- cially among older individuals[14,15]. Although several studies on coffee and ABPM have been previously published[7], they focused on the effect of high doses over short periods of time; however, evaluation of habitual consumption seems important because long- term coffee intake may lead to partial tolerance to the effects of caffeine on BP. In the only population study that compared values of ABPM across categories of habitual coffee consumption, moderate coffee intake was associated with higher daytime systolic BP[16]. In this study only smoking was considered as a potential confounder in the association.

Accordingly, this study assessed the association of habitual coffee consumption with BP and BP control during a 24-h period in hypertensive participants, considering the effect of potential confounders, including diet, time since diagnosis of hypertension and the number of antihypertensive drugs.

2. Methods

2.1. Study design and participants

We performed a cross-sectional analysis of data obtained in the second wave of the Seniors-Study on Nutrition and Cardiovascular Risk in Spain (ENRICA) cohort. Briefly, the cohort was established in 2008e2010 with 2519 individuals selected through random sam- pling from the population aged 60 years and older in Spain[17]. In 2012, we conducted a second follow-up; specifically, among the 2037 individuals alive and aged63, a phone interview was done to update information on health status, behavioral factors, morbidity and other health-related variables, as well as a home visit to perform a physical exam and to record habitual diet and medication. In addition, in a subsample of 1274 of these participants, 24-h BP was measured. Personnel involved in data collection were trained for the specific study procedures, and study participants gave informed written consent. The study protocol was approved by the Clinical Research Ethics Committee of the‘La Paz’

University Hospital in Madrid.

2.2. Coffee consumption

We used a computerized diet history (DH-E) to assess habitual food consumption in the previous year. This diet history was developed from the one used in the EPIC-Spain cohort study [18,19]. In summary, this new instrument includes a larger number of foods (861) and nutrients, and has been updated with new photographs to estimate portion sizes, new dishes and cooking methods, and the degree of food processing. The DH-E is admin- istered by a trained interviewer, who also collects information about differences in food consumption during the week and on the weekend, as well as seasonal variations. This information is sum- marized into a typical week, by using conversion factors to weigh the weekly frequency of consumption of a food and the number of months in which it is consumed during the year.

Coffee consumption was recorded in detail by asking whether participants consumed caffeinated or decaffeinated coffee and by

asking about the method of preparation: percolated, drip, espresso or instant coffee. Because of the different cup sizes commonly used in each method of preparation, weﬁrst transformed the reported consumption to a standard cup of coffee by calculating the ml of coffee/day consumed from different types of coffee per participant, and then dividing by the standard size of a cup of coffee (75 ml). We considered the following four categories of coffee consumption: no consumption, 1, 2, and3 cups per day. Caffeine was estimated considering the amount provided by each type of coffee (a cup of percolated caffeinated coffee: 80 mg, a cup of drip caffeinated coffee: 115 mg, a cup of espresso caffeinated coffee: 75 mg, and a cup of instant coffee: 65 mg of caffeine). Other nutrients were estimated with standard food composition tables.

2.3. 24-h blood pressure

ABPM was measured with the Microlife^®WatchBP O3 monitor (Microlife Corp, Switzerland), a validated device programmed to register BP at 20-min intervals during the day and 30-min intervals during the night for the 24-h period. Registries were preferably taken on working days, with participants performing their usual activities but advised to keep the arm extended and immobile at the time of cuff inﬂation. The monitor was removed by the study staff the following day.

Registries were considered valid when they fulfill these pre- established criteria: 24-h duration and at least 70% of SBP and DBP successful recordings during the daytime and night-time periods, or at least 20 recordings during the daytime and 7 recordings during the night-time. Ambulatory hypertension was defined as 24-h average BP 130/80 mm Hg or being under antihypertensive treatment, a consensus-based BP threshold for the definition of ABPM-based hypertension in adults, which is equivalent to office BP 140/90 mm Hg[20,21]. Daytime and night-time periods were defined for each patient according to his self-reported time of going-to-bed and getting-up. Night-to-day ratios for systolic BP (SBP) and diastolic BP (DBP) were calculated, and circadian patterns were defined by calculating the percentage decline in SBP during the night, using the formula: ((daytime SBP- night-time SBP)/daytime SBP) * 100. According to this, patients were classified as non- dippers when SBP decline was<10%[20,21].

2.4. Potential confounders

Study participants reported their age, educational level, smoking status, and quality of sleep. Weight and height were measured in each subject under standardized conditions. Body mass index (BMI) was calculated as weight in kg divided by squared height in m. Physical activity during leisure time was measured with a questionnaire developed for the EPIC-Spain cohort, and was expressed in METs h/week[22]. Accordance with the Mediterra- nean diet was evaluated with the Mediterranean Diet Adherence Screener (MEDAS), derived from the information obtained with the diet history[23]. The MEDAS presents 12 items related to targets for food consumption and 2 items related to targets for food intake habits; participants obtain one point for each target achieved. In our study, the scale ranged from 0 to 13 because we did not use the target for alcohol consumption, included in the models as an independent variable. Other diet-related confounders were intake of total energy, alcohol and sodium. Information about physician- diagnosed myocardial infarction, stroke and heart failure, diabetes, hypercholesterolemia or hypertension was also recorded.

Finally, persons with hypertension were asked to report the year of their diagnosis and the number of antihypertensive drugs.

E. Lopez-Garcia et al. / Clinical Nutrition 35 (2016) 1457e1463 1458

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2.5. Statistical analysis

Of the 1274 individuals with measurement of 24-h BP, 1164 provided complete information on the study variables and com- plied with pre-established quality criteria in the ABPM; the 715 persons who had ABPM-based hypertension formed the analytical sample.

We used linear regression to analyze the cross-sectional association between categories of coffee consumption and 24-h, daytime, night-time, and nocturnal decline in SBP and DBP. The main results were expressed as beta coefﬁcients for the SBP and DBP across categories of coffee consumption. The analyses were adjusted for the potential confounders described above. All variables were modeled as categorical by using dummy terms. We additionally modeled coffee consumption as a continuous variable to test for doseeresponse associations.

We used adjusted logistic regression models to calculate odds ratios (ORs) for the association between coffee consumption and uncontrolled 24-h hypertension, considering‘uncontrolled’ to be 24-h BP 130/80 mm Hg[20,21]. Because the US guidelines from the NIH-Institute of Heart, Lung and Blood and the American Heart Association recently proposed a clinical goal for BP control of150/

90 mm Hg for older people[24], we also ran an additional model approximating this goal to its 24-h BP equivalent as140/90 mm Hg, based on Head et al.[25]To identify possible differences among subgroups, we conducted stratiﬁed analyses by categories of sex, smoking status, BMI, leisure-time physical activity, MEDAS score, sodium intake, having diabetes or hypercholesterolemia, and by number of antihypertensive drugs. We tested the interaction between our exposure and the categories of the stratiﬁcation variables with uncontrolled hypertension by using likelihood-ratio tests, which compared models with and without cross-product interaction terms. Similarly, we calculated ORs for having a non- dipper BP pattern by categories of coffee consumption. We examined the association of types of coffee, including caffeinated and

decaffeinated, and caffeine intake with uncontrolled 24-h BP and having a non-dipper pattern. Finally, we examined whether the association between coffee consumption and BP was different for the group of non-hypertensive participants in the cohort.

The analyses were performed with SAS (version 9.2, SAS Insti- tute Inc., Cary, NC) statistical software.

3. Results

Among the study participants, 85% were coffee drinkers. The 24- h, daytime, and night-time SBP means (SD) were: 127.3 (11.6), 129.9 (12.0), and 121.6 (13.2) mm Hg, and the nocturnal decline in BP was 6.4 (6.4) %. The correspondingﬁgures for DBP were: 70.9 (7.5), 73.2 (8.0), 66.0 (8.1) mm Hg, and 9.6 (8.1) %. In addition, 322 participants (45.0%) had uncontrolled BP and 512 (71.6%) had a non-dipper BP pattern.

The characteristics of the study population by categories of coffee consumption are shown in Table 1. Compared to non- drinkers of coffee, those with the highest consumption had a higher prevalence of smoking and a higher BMI, and they also consumed a diet with larger amounts of total energy, alcohol and sodium intake. In addition, the hypertensive participants with higher coffee consumption were diagnosed on average more recently than non-drinkers and were less likely to use antihypertensive drugs.

Individuals consuming3 cups of coffee/day showed higher 24- h SBP (beta: 3.25 mm Hg, p value¼ 0.04) and DBP (beta: 2.24 mm Hg, p value¼ 0.02) than non-coffee drinkers. These differences were observed for both, daytime and night-time SBP. However, no differences were found in the percentage of nocturnal decline in BP (Table 2). In addition, compared to non-coffee drinkers, the ORs (95% conﬁdence interval) for uncontrolled BP among those hypertensives consuming 1, 2, and3 cups of coffee/day were respectively: 1.95 (1.15e3.30), 1.41 (0.75e2.68), and 2.55 (1.28e5.09); p for trend¼ 0.05. The corresponding ORs (95% conﬁdence interval)

Table 1

Characteristics of hypertensive^aolder adults according to categories of total coffee consumption.^bN¼ 715.

Total coffee consumption, cups/d

0 1 2 3 P value^c

Participants, n 110 395 120 90

Men, % 45.4 52.1 51.7 54.4 0.57

Age, y 73.2 (5.8) 72.9 (6.6) 71.6 (6.5) 71.3 (5.7) 0.001

Education, primary or less, % 53.6 58.5 55.0 42.2 0.20

Current smoker, % 5.4 5.0 10.0 14.4 0.001

BMI, kg/m² 28.2 (4.0) 29.4 (4.6) 28.5 (4.1) 29.8 (5.0) 0.03

Leisure-time physical activity, METs h/wk 24.2 (19.5) 21.2 (14.4) 22.1 (14.6) 20.5 (14.5) 0.73

Poor sleep quality, % 9.1 5.0 5.8 2.2 0.19

Dietary variables

Mediterranean diet score^d 7.6 (1.5) 7.3 (1.5) 6.9 (1.5) 7.1 (1.6) 0.03

Energy intake, kcal/d 1999 (492) 1992 (412) 2121 (568) 2146 (507) <0.001

Alcohol intake, g/d 6.7 (13.1) 8.5 (12.5) 10.6 (16.3) 10.8 (13.3) 0.006

Sodium intake, mg/d 2655 (1090) 2645 (923) 2804 (1205) 2798 (993) 0.001

Caffeine intake, mg/d 20 (38) 37 (48) 117 (106) 262 (219) <0.001

Cardiovascular disease^e, % 9.1 7.8 6.7 6.7 0.89

Diabetes, % 21.8 26.8 17.5 21.1 0.15

Hypercholesterolemia, % 56.4 48.3 50.0 60.0 0.15

Duration of hypertension, y 8.4 (9.0) 8.1 (8.8) 7.0 (8.3) 5.8 (8.3) 0.007

Number of antihypertensive drugs 1.4 (1.0) 1.4 (0.9) 1.3 (1.0) 1.1 (0.9) 0.008

0, % 2.7 16.5 20.8 31.1 0.01

1, % 31.8 39.5 36.7 35.6 0.50

2, % 30.0 29.1 28.3 24.4 0.83

3, % 15.5 14.9 14.2 8.9 0.49

a24-h BP 130/80 mm Hg or antihypertensive treatment.

b Values are means± SD or n (%).

c Obtained from ANOVA for continuous variables and from chi-square test for categorical variables.

d Mediterranean Diet Adherence Screener.

e Including coronary heart disease, stroke and congestive heart failure.

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when we deﬁned uncontrolled hypertension as 24-h BP 140/90 were 2.37 (1.14e4.94), 1.59 (0.67e3.80), and 3.09 (1.25e7.61); p for trend¼ 0.09. The association was similar among men and women, former or current smokers, those with excess weight, low adherence to the Mediterranean diet, higher sodium intake or with diabetes or hypercholesterolemia (Table 3). No association was found between coffee consumption and having a non-dipper BP pattern among hypertensives (Table 4).

In sensitivity analyses, we examined the independent association of each type of coffee and caffeine intake with the risk of uncontrolled 24-h BP. No differences could be observed for the types of coffee, but a signiﬁcant direct trend could be seen across

quartiles of caffeine intake [ORs and 95% CI: 1.0, 1.16 (0.72e1.87), 1.60 (0.99e2.59), 1.61 (0.97e2.69); p for trend ¼ 0.03]. In addition, no differences were observed for types of coffee and risk of having a non-dipper pattern, and no association appeared between caffeine intake and this pattern. No association was found between coffee and the ABPM-derived parameters among non-hypertensive participants (Supplemental Table 1).

4. Discussion

In this study, consumption of 3 or more cups of coffee/day was associated with higher levels of 24-h BP and with uncontrolled BP.

Table 2

Beta regression coefﬁcients (p values)^afor the association between coffee consumption and blood pressure (BP) and % nocturnal decline in BP among the 715 hypertensive participants.

0 1 2 3 p value for trend^b

N 110 395 120 90

Systolic BP

24-h, mm Hg Ref. 1.87 (0.12) 1.26 (0.39) 3.25 (0.04) 0.10

Daytime, mm Hg Ref. 2.29 (0.07) 1.11 (0.47) 3.25 (0.05) 0.14

Night-time, mm Hg Ref. 1.51 (0.28) 1.33 (0.44) 3.63 (0.05) 0.04

Nocturnal decline in BP^c, % Ref. 0.49 (0.48) 0.12 (0.88) 0.33 (0.71) 0.26

Diastolic BP

24-h, mm Hg Ref. 0.79 (0.28) 0.21 (0.82) 2.24 (0.02) 0.08

Daytime, mm Hg Ref. 0.53 (0.50) 0.36 (0.71) 2.26 (0.03) 0.08

Night-time, mm Hg Ref. 0.56 (0.50) 0.20 (0.84) 1.77 (0.11) 0.18

Nocturnal decline in BP, % Ref. 0.26 (0.76) 0.66 (0.53) 0.29 (0.80) 0.78

aLinear regression models adjusted for age (<70, 70e79, 80 y), sex, educational level (primary or less, secondary, university), smoking status (never smoker, past, current), BMI (<25, 25-<30, 30 kg/m²), physical activity during leisure time (tertiles), poor sleep quality (yes, no), Mediterranean Diet Adherence Screener (tertiles), and energy, alcohol and sodium intake (tertiles), cardiovascular disease, diabetes, hypercholesterolemia, duration of hypertension (<1, 1 and < 5, 5 and < 10, 10 y) and number of antihypertensive drugs used (none, 1, 2,3).

bp value from the models in which coffee consumption was modeled as a continuous variable.

c ((Daytime BPe night-time BP)/daytime BP)*100.

Table 3

Odds ratios (95% conﬁdence interval)^afor uncontrolled 24-h blood pressure according to categories of coffee consumption among the 715 hypertensive participants.

0 1 2 3 p value

for trend^b

p value for interaction

N 110 395 120 90

Uncontrolled 24-h hypertension^c 1.0 1.95 (1.15e3.30) 1.41 (0.75e2.68) 2.55 (1.28e5.09) 0.05

Men (n¼ 367) 1.0 3.54 (1.55e8.08) 2.30 (0.88e6.03) 5.20 (1.82e14.8) 0.05

Women (n¼ 348) 1.0 1.19 (0.57e2.51) 0.90 (0.36e2.29) 1.88 (0.66e5.34) 0.35 0.34

Never smoker (n¼ 418) 1.0 1.64 (0.85e3.30) 1.62 (0.70e3.80) 2.31 (0.83e6.51) 0.27 0.76

Past or current smoker (n¼ 297) 1.0 2.72 (1.10e7.01) 1.52 (0.53e4.45) 3.42 (1.20e10.2) 0.11

BMI< 25 (n ¼ 126) 1.0 1.80 (0.40e8.03) 0.87 (0.11e6.75) 0.75 (0.07e7.65) 0.87 0.20

BMI 25 (n ¼ 589) 1.0 1.98 (1.10e3.55) 1.66 (0.81e3.38) 2.74 (1.28e5.86) 0.03

Leisure-time physical activity< median (n¼ 285)

1.0 2.04 (0.87e4.80) 0.76 (0.26e2.23) 2.05 (0.68e6.14) 0.58 0.70

Leisure-time physical activity median (n¼ 430)

1.0 2.17 (1.05e4.47) 1.86 (0.80e4.35) 2.66 (1.00e7.08) 0.08

Mediterranean diet score<8 (n ¼ 403) 1.0 2.93 (1.32e6.54) 1.86 (0.74e4.68) 3.55 (1.33e9.48) 0.10 0.36 Mediterranean diet score8 (n ¼ 312) 1.0 1.24 (0.59e2.61) 1.22 (0.47e3.19) 1.94 (0.64e5.82) 0.29

Sodium intake< median (n ¼ 357) 1.0 1.49 (0.71e3.13) 1.14 (0.45e2.87) 1.53 (0.53e4.43) 0.31 0.33 Sodium intake median (n ¼ 358) 1.0 3.25 (1.36e7.77) 2.70 (1.01e7.23) 4.91 (1.71e14.1) 0.07

Without diabetes (n¼ 545) 1.0 1.66 (0.88e3.11) 1.86 (0.89e3.89) 2.47 (1.10e5.55) 0.03 0.28

With diabetes (n¼ 170) 1.0 3.98 (1.22e13.0) 0.63 (0.13e3.13) 3.16 (0.62e16.0) 0.67

Without hypercholesterolemia (n¼ 348) 1.0 1.90 (0.82e4.40) 1.07 (0.39e2.98) 2.12 (0.66e6.23) 0.56 0.32 With hypercholesterolemia (n¼ 367) 1.0 1.88 (0.92e3.83) 1.77 (0.74e4.27) 3.06 (1.25e7.47) 0.03

0e1 antihypertensive drug (n ¼ 410) 1.0 1.10 (0.58e2.07) 0.88 (0.41e1.91) 2.07 (0.91e4.74) 0.06 0.83

2 antihypertensive drugs (n ¼ 305) 1.0 2.25 (0.99e5.11) 1.92 (0.72e5.13) 2.68 (0.86e8.28) 0.15

aLogistic regression models adjusted for age (<70, 70e79, 80 y), sex, educational level (primary or less, secondary, university), smoking status (never smoker, past, current), BMI (<25, 25-<30, 30 kg/m²), physical activity during leisure time (tertiles), poor sleep quality (yes, no), Mediterranean Diet Adherence Screener (tertiles), energy, alcohol, and sodium intake (tertiles), cardiovascular disease, diabetes and hypercholesterolemia, duration of hypertension (<1, 1 and < 5, 5 and < 10, 10 y) and number of antihypertensive drugs used (none, 1, 2,3), except for the stratiﬁcation variable.

bp value from the models in which coffee consumption was modeled as a continuous variable.

c 24-h BP 130/80 mm Hg.

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These results contribute to our understanding of the effect of habitual coffee consumption in the older population. They may also help to guide clinical advice for hypertensive patients.

The HARVEST Study [16] assessed whether smoking and habitual coffee consumption had a joint effect on 24-h BP in 887 young patients with mild hypertension. They found that daytime SBP in male smokers who drank4 cups/day of coffee was 6.0 mm Hg higher, compared to non-smokers who abstained from coffee;

among women, the association did not reach statistical signiﬁ- cance. Our results extend these previousﬁndings because we were able to estimate differences in 24-h BP across categories of coffee more precisely by considering the effect of important factors that also affect BP values. In addition, our results provide useful information for clinical practice by estimating the probability of having uncontrolled 24-h BP and having a non-dipper BP pattern among coffee consumers.

Because uncontrolled hypertension is the main risk factor for cerebrovascular disease, our results showing a higher probability of uncontrolled BP among hypertensives with high coffee consumption might translate into a higher stroke risk among coffee consumers. However, the evidence on the association between coffee intake and cardiovascular disease in hypertensive patients is inconclusive[8]. Among the few studies available, three found no association of coffee with cerebrovascular disease [26e28], one observed an increased risk of thromboembolic stroke among coffee consumers[29], two found an inverse association between coffee consumption and heart disease mortality[30,31], and one reported a lower risk of cerebral infarction associated with higher coffee consumption[32]. Of note is that the study that found an increased risk had the smallest number of events (n¼ 76)[29] while the study that observed a decreased risk had the highest number of cases (n¼ 1729)[32]. A possible reason for the lack of association between coffee consumption and stroke in most studies might be that the risk of stroke was not calculated separately in patients with controlled and uncontrolled BP. In addition, 24-h BP is a better

measure than a one-time measurement because it assesses daylong BP during activities of daily living. Thus, it would be of interest to include ABPM in future longitudinal studies of coffee and cerebrovascular disease.

We found no association between coffee consumption and a non-dipping BP pattern. The non-dipping profile is frequently accompanied by high nocturnal BP, which has been shown to predict both all-cause and cardiovascular morbidity and mortality [14,33]. Some possible explanations are that BP during sleep is more closely related to basal BP because it does not reflect the variability produced by physical and mental activities, and that night-time BP may be influenced by sleep apnea, which is associated with worse prognosis[34]. Because the non-dipping pattern is associated with excess mortality rather than cardiovascular morbidity, it is possible that this pattern is also a marker of pre- existing disease[14]. Although we found no association between coffee and the non-dipping pattern, the higher levels of night-time BP found among coffee consumers, compared to non-consumers, suggest that the effect of coffee might last during the night.

Coffee has a complex chemical composition[35]. Although most available evidence suggests that caffeine is the main culprit for the BP-raising effect[7,36,37], it is unclear whether other substances in coffee may also have an effect on BP, mediated by different path- ways[38]. In addition, some clinical trials have shown that a type of coffee with reduced amounts of hydroxyhydroquinone and higher amounts of chlorogenic acid than the regular type was able to reduce BP after 4e12 weeks of consumption[39e41]. Thus, the net impact of coffee on BP would be the result of the effect of all its components.

As suggested by our results, it is unclear whether moderate coffee drinkers (1e2 cups/day) have a lower risk of uncontrolled BP than heavy coffee drinkers. In a recent meta-analysis that found a U-shaped association between coffee and cardiovascular disease [42], the authors suggested that the beneﬁcial effects of coffee may be greater than the adverse effects among moderate consumers, Table 4

Odds ratios (95% conﬁdence interval)^afor non-dipper blood pressure pattern according to categories of coffee consumption among the 715 hypertensive participants.

0 1 2 3 p value

for trend^b

p value for interaction

N 110 395 120 90

Non-dipper^c 1.0 0.88 (0.53e1.45) 1.27 (0.67e2.39) 1.20 (0.61e2.36) 0.45

Men (n¼ 367) 1.0 0.83 (0.40e1.73) 1.65 (0.65e4.16) 1.51 (0.57e3.98) 0.16

Women (n¼ 348) 1.0 1.12 (0.52e2.40) 1.09 (0.43e2.76) 1.25 (0.45e3.44) 0.86 0.21

Never smoker (n¼ 418) 1.0 0.98 (0.50e1.90) 1.32 (0.56e3.15) 1.57 (0.56e4.66) 0.78 0.90

Past or current smoker (n¼ 297) 1.0 0.54 (0.21e1.29) 1.06 (0.36e3.06) 0.84 (0.29e2.35) 0.45

BMI<25 (n ¼ 126) 1.0 2.51 (0.51e12.3) 1.37 (0.24e7.82) 4.00 (0.43e36.8) 0.71 0.97

BMI25 (n ¼ 589) 1.0 0.80 (0.45e1.44) 1.48 (0.70e3.15) 1.04 (0.49e2.23) 0.46

Leisure-time physical activity< median (n¼ 285)

1.0 0.45 (0.16e1.32) 0.39 (0.11e1.34) 1.95 (0.46e8.23) 0.39 0.70

Leisure-time physical activity median (n¼ 430)

1.0 1.17 (0.63e2.16) 2.10 (0.96e4.61) 0.86 (0.37e1.99) 0.87

Mediterranean diet score<8 (n ¼ 403) 1.0 0.68 (0.32e1.46) 0.83 (0.35e2.00) 1.29 (0.49e3.36) 0.37 0.75 Mediterranean diet score8 (n ¼ 312) 1.0 1.22 (0.58e2.58) 2.72 (0.95e7.75) 1.31 (0.44e3.91) 0.47

Sodium intake< median (n ¼ 357) 1.0 1.49 (0.74e3.00) 2.01 (0.83e4.83) 1.73 (0.65e4.62) 0.63 0.40 Sodium intake median (n ¼ 358) 1.0 0.50 (0.22e1.17) 0.87 (0.32e2.40) 0.84 (0.30e2.26) 0.40

Without diabetes (n¼ 545) 1.0 0.70 (0.39e1.28) 1.31 (0.62e2.74) 0.91 (0.42e1.96) 0.55 0.38

With diabetes (n¼ 170) 1.0 2.48 (0.75e8.19) 0.82 (0.18e3.73) 6.16 (1.03e36.8) 0.75

Without hypercholesterolemia (n¼ 348) 1.0 0.77 (0.34e1.72) 0.88 (0.33e2.37) 0.51 (0.18e1.47) 0.75 0.04 With hypercholesterolemia (n¼ 367) 1.0 0.94 (0.47e1.89) 1.62 (0.67e3.95) 2.12 (0.83e5.42) 0.27

0e1 antihypertensive drug (n ¼ 410) 1.0 0.84 (0.43e1.67) 1.56 (0.66e3.71) 1.08 (0.45e2.58) 0.57 0.66

2 antihypertensive drugs (n ¼ 305) 1.0 0.90 (0.40e2.03) 1.16 (0.43e3.16) 1.64 (0.47e5.72) 0.47

aLogistic regression models adjusted for age (<70, 70e79, 80 y), sex, educational level (primary or less, secondary, university), smoking status (never smoker, past, current), BMI (<25, 25-<30, 30 kg/m²), physical activity during leisure time (tertiles), poor sleep quality (yes, no), Mediterranean Diet Adherence Screener (tertiles), energy, alcohol, and sodium intake (tertiles), cardiovascular disease, diabetes and hypercholesterolemia, duration of hypertension (<1, 1 and < 5, 5 and < 10, 10 y) and number of antihypertensive drugs used (none, 1, 2,3), except for the stratiﬁcation variable.

b p value from the models in which coffee consumption was modeled as a continuous variable.

c Non-dipper: nocturnal SBP fall<10% of daytime value.

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whereas the opposite would occur for heavy consumers. It is also known that habitual coffee users develop partial tolerance to caffeine, compared to occasional coffee drinkers. Moreover, most of the acute effects of coffee on BP have been observed in clinical trials that used high doses of coffee [12]. Although habitual coffee drinkers tend to distribute their consumption throughout the day, the cumulative dose ingested may still be lower than those tested in the trials. Finally, whether genetic polymorphisms may modulate the individual BP response to coffee remains a subject of research [43,44].

One strength of this study was that coffee intake was measured using a diet history that registered the different types of coffee consumed, as well as cup size. Another one was that the results were adjusted for well-measured potential confounders, such as smoking, BMI and the amount of sodium in the diet, as well as for antihypertensive drug treatments. Also, the results were robust in population subgroups with a higher prevalence of a non-dipping pattern, including diabetic and obese individuals[45,46].

The main limitation of this study was the cross-sectional design, which did not allow for causal inferences. However, because the diet history may accurately reﬂect habitual consumption during 1 year, a cross-sectional study still seems appropriate, although we cannot rule out the possibility that individuals with a long-term diagnosis of hypertension and a history of uncontrolled BP ten- ded to consume less coffee. Another limitation was that we could not differentiate between habitual coffee drinkers during the previous year and during a longer time. Since tolerance to caffeine is a usual explanation for the lack of association between prolonged coffee consumption and BP, we cannot exclude the possibility that the higher levels of 24-h BP observed among individuals with high coffee intake was due to the fact that tolerance was not fully reached. In addition, although we adjusted our results for the number of antihypertensive drugs used, we could not control for the appropriateness of this medication. Finally, as in any observa- tional study, some residual confounding may persist.

In conclusion, habitual coffee consumption of at least 3 cups/day was associated with uncontrolled BP in a hypertensive older population. Our results suggest that it is prudent for physicians and other health professionals to ask hypertensive patients, in partic- ular those with uncontrolled BP, about habitual coffee consumption; moderating coffee intake may be a simple strategy to improve BP control among the elderly.

Conﬂict of interest None.

Acknowledgments

Baseline data collection was funded by grants from the State Secretary for RþD of Spain and FEDER (FIS 09/1626 and 12/1166) and by the‘Catedra de Epidemiología y Control del Riesgo Cardio- vascular’. Speciﬁc funding for this analysis has been obtained from FIS grants 09/0104, 12/2321, and 13/0288.

Appendix A. Supplementary data

Supplementary data related to this article can be found athttp://

dx.doi.org/10.1016/j.clnu.2016.03.021.

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