Approximately 11.9% of Chinese adults are affected by diabetes, and this number is steadily increasing. However, in China, only 38.0% of diabetes cases are properly recognized, with 34.1% receiving treatment and 33.1% having their blood glucose levels effectively controlled (1). Hyperglycemia is recognized for triggering various vascular complications and increasing oxidative stress through multiple pathways (2). Atherosclerosis, a leading cause of mortality in diabetes patients, is primarily associated with natural and modified lipids (3–5). Furthermore, obesity, characterized by an excessive proportion of body fat, is closely linked to the risk of diabetes (6, 7). Research conducted about 20 years ago underscored body mass index (BMI) as an independent predictor of diabetes (8). Bariatric surgery has been identified as a promising method for achieving diabetes remission (9). In conclusion, obesity not only poses a significant risk for diabetes and cardiovascular disease but also contributes to premature mortality and disability in the population at large (10–12).

To accurately assess the complexity of obesity, there is a pressing need for more precise indicators. Although the BMI is widely utilized and easily accessible, its simplicity hinders its ability to capture the multifaceted nature of obesity. BMI relies solely on height and weight measurements, failing to differentiate between fat and muscle mass or account for the distribution of body fat. Recognizing the limitations of BMI, recent findings have challenged its effectiveness in predicting health risks, such as diabetes (13, 14). Research by Lu et al., involving 5860 Chinese participants, revealed that increased BMI alone, without abdominal obesity, did not significantly correlate with the risk of type 2 diabetes. Conversely, individuals with abdominal obesity experienced a 55% increase in the incidence of type 2 diabetes (15). Such limitations have prompted the exploration of alternative obesity indicators. Given the crucial role of fat accumulation in the pathogenesis of diabetes, it is imperative to explore a new fat index. Notably, body fat percentage (BFP) has demonstrated greater accuracy than BMI in measuring obesity, particularly central obesity, and has shown improved predictive capabilities for certain diseases (16, 17).

Previous studies have explored the relationship between BFP and diabetes risk under different backgrounds (18, 19). However, whether the relationship between them in patients with hypertension is the same as that of other populations is still rarely explored. Given the significant differences in BFP levels between men and women due to variations in sex hormones and body fat distribution, the association between BFP and diabetes has seldom been investigated across different genders. Therefore, we conducted a cross-sectional study to explore the association between BFP and diabetes risk and the gender differences in hypertensive population.

This extensive cross-sectional study, encompassing a substantial sample size of 14,228 participants from the hypertensive population in southern China, revealed there is a positive association between BFP and diabetes. Even after adjusting for potential confounding variables, the association remained statistically significant. Notably, in men, this positive association was more pronounced. Additionally, the positive association between BFP and diabetes was consistent across all subgroups of women, and there is a more significant positive association between the two in men with LDL-C<2.6mmol/L.

There have been numerous speculations and reports on the pathogenesis of obesity and diabetes. As early as 2001, researchers discovered that adipocytes secrete resistin, which initially shed light on the link between obesity and insulin resistance (21). This discovery has since catalyzed the emergence of various research directions and disciplines, delving into mechanisms that lead to adipose tissue inflammation. These investigations include examining the role of adaptive immune cells and the activation and phenotype transformation of macrophages, all of which may contribute to insulin resistance (22).

The accumulation of fat is an important link in the physical damage caused by obesity. BFP has been preliminarily explored as an emerging indicator for evaluating body fat. Previous studies have investigated the connection between BFP and diabetes in various populations. Chen et al.’s study on 3367 Chinese subjects demonstrated a positive association between BFP and diabetes, highlighting BFP as an independent risk factor and a valuable diagnostic indicator for type 2 diabetes (23). Similarly, Peña J et al. found in a study involving 1920 Mexican participants that BFP is a key risk factor for type 2 diabetes, surpassing BMI in predictive value (24). Moreover, a prospective study with 1532 participants revealed a significant positive association between male trunk fat percentage and diabetes incidence, while the association with female trunk fat percentage, although positive, was not statistically significant (25). But as is well known that hypertension is an independent risk factor for diabetes often co-existing with the condition (26), is linked to insulin resistance in hypertensive individuals and serves as a confounding variable associated with overweight and obesity (27–29). High blood pressure can increase the risk of vascular complications in diabetic patients that emphasizing the importance of identifying high-risk hypertensive individuals with diabetes for prevention and management (30, 31). While previous studies have explored various other anthropometric indices for predicting diabetes in hypertensive populations (32), but our study uniquely focuses on the relationship between BFP and diabetes among hypertensive patients and the gender differences within it.

In the elderly population, a distinct gender-specific pattern in BFP distribution is observed. Younger male individuals tend to exhibit higher BFP values, whereas older female individuals demonstrate an opposite trend. This phenomenon can be attributed to age-related hormonal changes: in aging males, declining testosterone levels contribute to alterations in fat distribution patterns and progressive loss of muscle mass, consequently leading to reduced body fat percentage. Conversely, postmenopausal women experience significant estrogen depletion, which promotes visceral fat accumulation in abdominal regions, ultimately resulting in increased BFP. Our research also indicates a stronger positive association between BFP and diabetes in men compared to women. This disparity may stem from differences in male and female hormones or variations in fat distribution (33). Men are more prone to abdominal obesity and higher levels of visceral fat, while women typically accumulate fat in the buttocks and thighs, with a greater proportion of subcutaneous fat (34). Consequently, weight gain in men often results from increased visceral fat, which may significantly elevate the risk of diabetes. Research has found that fat in gluteus–femoral area in overweight and obese women has a protective effect on glucose and lipid related cardiac metabolic risks. Compared with subjects with widespread distribution of visceral fat, hip and thigh fat are associated with a beneficial fat factor profile and fewer pro-inflammatory molecules (35, 36). This distribution may offer protective effects against glucose and fat-related cardiac metabolic diseases (37). The study also confirmed that people with type 2 diabetes respond less to obesity treatment than those without type 2 diabetes, especially males. Women respond better to treatment than men (38). This could explain the heightened association between BFP and diabetes in men. Our findings also suggest that in men with lower LDL-C levels, the positive association between BFP and diabetes is more pronounced. Traditional treatments often involve lowering LDL-C to less than 2.6 mmol/L, or even lower, particularly for patients with known cardiovascular diseases or at high risk (39). However, intensive statin therapy may elevate the risk of developing diabetes (40, 41). Studies propose that patients with lower LDL-C levels may become complacent, adopt poorer lifestyles, gain weight, and subsequently develop diabetes. Additionally, impaired insulin secretion and intensified insulin resistance may contribute to this phenomenon (42).

This cross-sectional study, offers insights into the gender differences within the association between BFP and diabetes among hypertensive patients that less-explored. The study’s emphasis on a homogeneous population of hypertensive patients enhances result reliability, and detailed subgroup analyses contribute to result stability. However, this article also has certain limitations. Dual energy X-ray absorption or bioelectrical impedance analysis is considered the gold standard for measuring BFP (43). The formula we use to calculate BFP has been applied in multiple articles and is easier to obtain in clinical practice. But it still cannot achieve the same status as the gold standard (44). And the hypertensive participants enrolled in our study were not stratified according to the etiology of hypertension, including both primary and secondary hypertension cases. Secondly, this study is a cross-sectional study, which means that the results could not establish a causal relationship between BFP and diabetes. Despite performing multivariate corrections, it remains challenging to eliminate potential confounding factors. And we did not gather more detailed information about subjects, such as dietary structure. As a result, we cannot ascertain whether these factors have a regulatory effect on the association between BFP and the risk of diabetes. Lastly, this study focuses solely on the hypertensive population in southern China, raising uncertainties about the generalizability of the conclusions to other populations.

BFP shows a positive association with the risk of diabetes among hypertensive patients in southern China. This association is notably stronger in men compared to women. It is recommended that men should pay more attention to changes in BFP than women. Further longitudinal studies are required to unveil the underlying mechanisms and establish a causal relationship between the two variables.