Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

The association between pro-inflammatory diet and incidence of hypertension: a prospective cohort study

Hypertension Research volume 49, pages 1749–1759 (2026)Cite this article

Abstract

Hypertension is a major public health challenge globally and in Iran. Given the role of inflammation in hypertension development, this study aimed to examine the association between the inflammatory potential of diet, quantified using the energy-adjusted Dietary Inflammatory Index (E-DII™), and the incidence of hypertension. The data of the present study were extracted from the Fasa Adult Cohort Study database. In this prospective cohort study, 10,138 participants were recruited at the baseline phase. Participants were contacted by telephone at regular intervals over 7 years. A selected group was also revisited after 5 years. Survival analysis was conducted to investigate the association between E-DII and hypertension incidence over a 7-year follow-up period, using Cox regression. Participants in the highest E-DII tertile (most pro-inflammatory diet) had a significantly higher risk for hypertension incidence during 7 years (HRT3 vs. T1 = 2.24, P value < 0.001). Moreover, the association of E-DII with hypertension incidence after 5 years was examined using logistic regression. Logistic regression revealed a significantly higher hypertension incidence after 5 years among participants in the highest E-DII tertile (ORT3 vs. T1 = 2.62, P value < 0.001). Linear regression showed positive and significant associations between E-DII and change in blood pressure components over 5 years. However, the associations in all models were attenuated and became statistically insignificant after adjustment for body mass index. Our findings indicate that consuming a pro-inflammatory diet was associated with an increased risk of developing hypertension. Moreover, body mass index emerged as a key covariate in this relationship.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on SpringerLink
  • Instant access to the full article PDF.

USD 39.95

Prices may be subject to local taxes which are calculated during checkout

Fig. 1

Similar content being viewed by others

Data availability

The corresponding author will share the article’s data at a reasonable request.

References

  1. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. Lancet. 2021;398:957–80.

  2. Egan BM, Kjeldsen SE, Grassi G, Esler M, Mancia G. The global burden of hypertension exceeds 1.4 billion people: should a systolic blood pressure target below 130 become the universal standard?. J Hypertens. 2019;37:1148–53.

    Article  CAS  PubMed  Google Scholar 

  3. Kjeldsen SE. Hypertension and cardiovascular risk: general aspects. Pharm Res. 2018;129:95–9.

    Article  Google Scholar 

  4. GBD 2019 Stroke Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20:795–820.

  5. Burnier M, Damianaki A. Hypertension as cardiovascular risk factor in chronic kidney disease. Circ Res. 2023;132:1050–63.

    Article  CAS  PubMed  Google Scholar 

  6. GBD 2017 Risk Factor Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392:1923–94.

  7. Global Burden of Metabolic Risk Factors for Chronic Diseases Collaboration. Cardiovascular disease, chronic kidney disease, and diabetes mortality burden of cardiometabolic risk factors from 1980 to 2010: a comparative risk assessment. Lancet Diabetes Endocrinol. 2014;2:634–47.

  8. Wierzejska E, Giernaś B, Lipiak A, Karasiewicz M, Cofta M, Staszewski R. A global perspective on the costs of hypertension: a systematic review. Arch Med Sci. 2020;16:1078–91.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Mancia G, Kreutz R, Brunström M, Burnier M, Grassi G, Januszewicz A, et al. 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). J Hypertens. 2023;41:1874–2071.

    Article  CAS  PubMed  Google Scholar 

  10. Pauletto P, Rattazzi M. Inflammation and hypertension: the search for a link. Nephrol Dial Transpl. 2006;21:850–3.

    Article  Google Scholar 

  11. Madhur MS, Elijovich F, Alexander MR, Pitzer A, Ishimwe J, Van Beusecum JP, et al. Hypertension: Do inflammation and immunity hold the key to solving this epidemic?. Circ Res. 2021;128:908–33.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Zhang Z, Zhao L, Zhou X, Meng X, Zhou X. Role of inflammation, immunity, and oxidative stress in hypertension: new insights and potential therapeutic targets. Front Immunol. 2022;13:1098725.

    Article  CAS  PubMed  Google Scholar 

  13. Patrick DM, Van Beusecum JP, Kirabo A. The role of inflammation in hypertension: novel concepts. Curr Opin Physiol. 2021;19:92–8.

    Article  CAS  PubMed  Google Scholar 

  14. Drummond GR, Vinh A, Guzik TJ, Sobey CG. Immune mechanisms of hypertension. Nat Rev Immunol. 2019;19:517–32.

    Article  CAS  PubMed  Google Scholar 

  15. Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension. 2020;75:1334–57.

    Article  CAS  PubMed  Google Scholar 

  16. Filippou CD, Tsioufis CP, Thomopoulos CG, Mihas CC, Dimitriadis KS, Sotiropoulou LI, et al. Dietary Approaches to Stop Hypertension (DASH) diet and blood pressure reduction in adults with and without hypertension: a systematic review and meta-analysis of randomized controlled trials. Adv Nutr. 2020;11:1150–60.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Filippou CD, Thomopoulos CG, Kouremeti MM, Sotiropoulou LI, Nihoyannopoulos PI, Tousoulis DM, et al. Mediterranean diet and blood pressure reduction in adults with and without hypertension: a systematic review and meta-analysis of randomized controlled trials. Clin Nutr. 2021;40:3191–200.

    Article  PubMed  Google Scholar 

  18. Galland L. Diet and inflammation. Nutr Clin Pract. 2010;25:634–40.

    Article  PubMed  Google Scholar 

  19. Koelman L, Egea Rodrigues C, Aleksandrova K. Effects of dietary patterns on biomarkers of inflammation and immune responses: a systematic review and meta-analysis of randomized controlled trials. Adv Nutr. 2022;13:101–15.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Hart MJ, Torres SJ, McNaughton SA, Milte CM. Dietary patterns and associations with biomarkers of inflammation in adults: a systematic review of observational studies. Nutr J. 2021;20:24.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Christ A, Lauterbach M, Latz E. Western diet and the immune system: an inflammatory connection. Immunity. 2019;51:794–811.

    Article  CAS  PubMed  Google Scholar 

  22. Shivappa N, Steck SE, Hurley TG, Hussey JR, Hébert JR. Designing and developing a literature-derived, population-based dietary inflammatory index. Public Health Nutr. 2014;17:1689–96.

    Article  PubMed  Google Scholar 

  23. Hébert JR, Shivappa N, Wirth MD, Hussey JR, Hurley TG. Perspective: The Dietary Inflammatory Index (DII)—lessons learned, improvements made, and future directions. Adv Nutr. 2019;10:185–95.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Liu FH, Liu C, Gong TT, Gao S, Sun H, Jiang YT, et al. Dietary Inflammatory Index and Health Outcomes: an umbrella review of systematic review and meta-analyses of observational studies. Front Nutr. 2021;8:647122.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Sepehrinia M, Khanmohammadi S, Rezaei N, Kuchay MS. Dietary inflammatory potential and metabolic (dysfunction)-associated steatotic liver disease and its complications: a comprehensive review. Clin Nutr ESPEN. 2025;65:162–71.

    Article  PubMed  Google Scholar 

  26. Sepehrinia M, Pourmontaseri H, Naghizadeh MM, Vahid F, Hebert JR, Homayounfar R, et al. The association between energy-adjusted Dietary Inflammatory Index and 10-year cardiovascular risk: Fasa Adult Cohort Study. Food Sci Nutr. 2024;12:5530–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Pourmontaseri H, Sepehrinia M, Kuchay MS, Farjam M, Vahid F, Dehghan A, et al. The association between energy-adjusted Dietary Inflammatory Index and metabolic syndrome and its mediatory role for cardiometabolic diseases: a prospective cohort study. Front Nutr. 2024;11:1429883.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Farhangi MA, Nikniaz L, Nikniaz Z, Dehghan P. Dietary inflammatory index potentially increases blood pressure and markers of glucose homeostasis among adults: findings from an updated systematic review and meta-analysis. Public Health Nutr. 2020;23:1362–80.

    Article  PubMed  Google Scholar 

  29. Canto-Osorio F, Denova-Gutierrez E, Sánchez-Romero LM, Salmerón J, Barrientos-Gutierrez T. Dietary Inflammatory Index and metabolic syndrome in Mexican adult population. Am J Clin Nutr. 2020;112:373–80.

    Article  PubMed  Google Scholar 

  30. MacDonald CJ, Laouali N, Madika AL, Mancini FR, Boutron-Ruault MC. Dietary inflammatory index, risk of incident hypertension, and effect modification from BMI. Nutr J. 2020;19:62.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Vissers LET, Waller M, van der Schouw YT, Hébert JR, Shivappa N, Schoenaker D, et al. A pro-inflammatory diet is associated with increased risk of developing hypertension among middle-aged women. Nutr Metab Cardiovasc Dis. 2017;27:564–70.

    Article  CAS  PubMed  Google Scholar 

  32. Zhou N, Xie ZP, Liu Q, Xu Y, Dai SC, Lu J, et al. The dietary inflammatory index and its association with the prevalence of hypertension: a cross-sectional study. Front Immunol. 2022;13:1097228.

    Article  CAS  PubMed  Google Scholar 

  33. Ramallal R, Toledo E, Martínez-González MA, Hernández-Hernández A, García-Arellano A, Shivappa N, et al. Dietary Inflammatory Index and Incidence of Cardiovascular Disease in the SUN Cohort. PLoS ONE. 2015;10:e0135221.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Khan I, Kwon M, Shivappa N, Hébert JR, Kim MK. Proinflammatory dietary intake is associated with increased risk of metabolic syndrome and its components: results from the population-based prospective study. Nutrients. 2020;12:1196.

  35. Jam SA, Rezaeian S, Najafi F, Hamzeh B, Shakiba E, Moradinazar M, et al. Association of a pro-inflammatory diet with type 2 diabetes and hypertension: results from the Ravansar non-communicable diseases cohort study. Arch Public Health. 2022;80:102.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Shivappa N, Bonaccio M, Hebert JR, Di Castelnuovo A, Costanzo S, Ruggiero E, et al. Association of proinflammatory diet with low-grade inflammation: results from the Moli-sani study. Nutrition. 2018;54:182–8.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Kim HY, Lee J, Kim J. Association between dietary inflammatory index and metabolic syndrome in the general Korean population. Nutrients. 2018;10:648.

  38. Homayounfar R, Farjam M, Bahramali E, Sharafi M, Poustchi H, Malekzadeh R, et al. Cohort Profile: the Fasa Adults Cohort Study (FACS): a prospective study of non-communicable diseases risks. Int J Epidemiol. 2023;52:e172–8.

    Article  PubMed  Google Scholar 

  39. Poustchi H, Eghtesad S, Kamangar F, Etemadi A, Keshtkar AA, Hekmatdoost A, et al. Prospective epidemiological research studies in Iran (the PERSIAN Cohort Study): rationale, objectives, and design. Am J Epidemiol. 2018;187:647–55.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Farjam M, Bahrami H, Bahramali E, Jamshidi J, Askari A, Zakeri H, et al. A cohort study protocol to analyze the predisposing factors to common chronic non-communicable diseases in rural areas: Fasa Cohort Study. BMC Public Health. 2016;16:1–8.

    Article  Google Scholar 

  41. Eghtesad S, Hekmatdoost A, Faramarzi E, Homayounfar R, Sharafkhah M, Hakimi H, et al. Validity and reproducibility of a Food Frequency Questionnaire assessing food group intake in the PERSIAN Cohort Study. Front Nutr. 2023;10:1059870.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Eghtesad S, Masoudi S, Sharafkhah M, Rashidkhani B, Esmaeili-Nadimi A, Najafi F, et al. Validity and reproducibility of the PERSIAN Cohort Food Frequency Questionnaire: assessment of major dietary patterns. Nutr J. 2024;23:35.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Bazmi S, Sepehrinia M, Pourmontaseri H, Bazyar H, Vahid F, Farjam M, et al. Androgenic alopecia is associated with higher dietary inflammatory index and lower antioxidant index scores. Front Nutr. 2024;11:1433962.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Ho FK, Wirth MD, Parra-Soto S, Boonpor J, Zhou Z, Petermann-Rocha F, et al. Dose-response associations of dietary inflammatory potential with health outcomes: a prospective cohort study of 198,265 UK Biobank participants. Curr Probl Cardiol. 2023;48:101774.

    Article  PubMed  Google Scholar 

  45. Mazidi M, Shivappa N, Wirth MD, Hebert JR, Mikhailidis DP, Kengne AP, et al. Dietary inflammatory index and cardiometabolic risk in US adults. Atherosclerosis. 2018;276:23–7.

    Article  CAS  PubMed  Google Scholar 

  46. Zhang X, Guo Y, Yao N, Wang L, Sun M, Xu X, et al. Association between dietary inflammatory index and metabolic syndrome: analysis of the NHANES 2005-2016. Front Nutr. 2022;9:991907.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Aslani Z, Sadeghi O, Heidari-Beni M, Zahedi H, Baygi F, Shivappa N, et al. Association of dietary inflammatory potential with cardiometabolic risk factors and diseases: a systematic review and dose-response meta-analysis of observational studies. Diabetol Metab Syndr. 2020;12:86.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Yi Q, Li X, He Y, Xia W, Shao J, Ye Z, et al. Associations of dietary inflammatory index with metabolic syndrome and its components: a systematic review and meta-analysis. Public Health Nutr. 2021;24:5463–70.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Vitale M, Calabrese I, Massimino E, Shivappa N, Hebert JR, Auciello S, et al. Dietary inflammatory index score, glucose control and cardiovascular risk factors profile in people with type 2 diabetes. Int J Food Sci Nutr. 2021;72:529–36.

    Article  CAS  PubMed  Google Scholar 

  50. Wang Y, Armijos RX, Xun P, Weigel MM. Dietary Inflammatory Index and cardiometabolic risk in Ecuadorian women. Nutrients. 2021;13:2640.

  51. Ferreira M, Cronjé HT, van Zyl T, Bondonno N, Pieters M. The association between an energy-adjusted Dietary Inflammatory Index and inflammation in rural and urban Black South Africans. Public Health Nutr. 2021;25:1–13.

    PubMed  PubMed Central  Google Scholar 

  52. Todendi PF, Salla R, Shivappa N, Hebert JR, Ritter J, Cureau FV, et al. Association between dietary inflammatory index and cardiometabolic risk factors among Brazilian adolescents: results from a national cross-sectional study. Br J Nutr. 2022;128:744–52.

    Article  CAS  PubMed  Google Scholar 

  53. Pauletto P, Rattazzi M. Inflammation and hypertension: the search for a link. Nephrol Dial Transplant. 2006;21:850–3.

    Article  PubMed  Google Scholar 

  54. Kirabo A. A new paradigm of sodium regulation in inflammation and hypertension. Am J Physiol Regul Integr Comp Physiol. 2017;313:R706–R10.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Dandona P, Dhindsa S, Ghanim H, Chaudhuri A. Angiotensin II and inflammation: the effect of angiotensin-converting enzyme inhibition and angiotensin II receptor blockade. J Hum Hypertens. 2007;21:20–7.

    Article  CAS  PubMed  Google Scholar 

  56. Forrester SJ, Booz GW, Sigmund CD, Coffman TM, Kawai T, Rizzo V, et al. Angiotensin II Signal Transduction: an update on mechanisms of physiology and pathophysiology. Physiol Rev. 2018;98:1627–738.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. Crowley SD. The cooperative roles of inflammation and oxidative stress in the pathogenesis of hypertension. Antioxid Redox Signal. 2014;20:102–20.

    Article  CAS  PubMed  Google Scholar 

  58. Ahluwalia N, Andreeva VA, Kesse-Guyot E, Hercberg S. Dietary patterns, inflammation and the metabolic syndrome. Diabetes Metab. 2013;39:99–110.

    Article  CAS  PubMed  Google Scholar 

  59. Cicero AFG, Veronesi M, Fogacci F. Dietary intervention to improve blood pressure control: beyond salt restriction. High Blood Press Cardiovasc Prev. 2021;28:547–53.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  60. Zhou B, Bennett JE, Wickham AP, Singleton RK, Mishra A, Carrillo-Larco RM, et al. General and abdominal adiposity and hypertension in eight world regions: a pooled analysis of 837 population-based studies with 7·5 million participants. Lancet. 2024;404:851–63.

    Article  Google Scholar 

  61. Neter JE, Stam BE, Kok FJ, Grobbee DE, Geleijnse JM. Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension. 2003;42:878–84.

    Article  CAS  PubMed  Google Scholar 

  62. DeMarco VG, Aroor AR, Sowers JR. The pathophysiology of hypertension in patients with obesity. Nat Rev Endocrinol. 2014;10:364–76.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  63. Kawai T, Autieri MV, Scalia R. Adipose tissue inflammation and metabolic dysfunction in obesity. Am J Physiol Cell Physiol. 2021;320:C375–91.

    Article  CAS  PubMed  Google Scholar 

  64. Scarpellini E, Tack J. Obesity and metabolic syndrome: an inflammatory condition. Dig Dis. 2012;30:148–53.

    Article  CAS  PubMed  Google Scholar 

  65. Pourmontaseri H, Khanmohammadi S. Demographic risk factors of pro-inflammatory diet: a narrative review. Front Nutr. 2024;11:1448806.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran

    Abbas Nikpour & Hossein Pourmontaseri

  2. National Nutrition and Food Technology Research Institute (WHO Collaborating Center), Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Matin Sepehrinia & Reza Homayounfar

  3. Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran

    Matin Sepehrinia, Mojtaba Farjam & Azizallah Dehghan

  4. Nutrition and Health Research Group, Department of Precision Health, Luxembourg Institute of Health, Strassen, Luxembourg

    Farhad Vahid

  5. South Carolina Statewide Cancer Prevention and Control Program and Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA

    James R. Hébert

  6. Department of Nutrition, Connecting Health Innovations LLC (CHI), Columbia, SC, USA

    James R. Hébert

Authors
  1. Abbas Nikpour
    View author publications

    Search author on:PubMed Google Scholar

  2. Hossein Pourmontaseri
    View author publications

    Search author on:PubMed Google Scholar

  3. Matin Sepehrinia
    View author publications

    Search author on:PubMed Google Scholar

  4. Farhad Vahid
    View author publications

    Search author on:PubMed Google Scholar

  5. Mojtaba Farjam
    View author publications

    Search author on:PubMed Google Scholar

  6. James R. Hébert
    View author publications

    Search author on:PubMed Google Scholar

  7. Reza Homayounfar
    View author publications

    Search author on:PubMed Google Scholar

  8. Azizallah Dehghan
    View author publications

    Search author on:PubMed Google Scholar

Contributions

Conceptualization: HP, MS, and AN; methodology: HP and AD; software: HP; validation: RH, MF, and AD; formal analysis: HP and AD; investigation: AD, MF, and RH; resources: AD, MF, and RH; data curation: AD; writing—original draft preparation: HP, AN, and MS; writing—review and editing: FV, MF, RH, and JRH; visualization: HP and AN; supervision: FV and RH; project administration: AD and RH. All authors have read and agreed to the published version of the manuscript.

Corresponding authors

Correspondence to Reza Homayounfar or Azizallah Dehghan.

Ethics declarations

Conflict of interest

All authors except JRH disclose no conflict of interest. JRH discloses that he owns a controlling interest in Connecting Health Innovations LLC (CHI), a company that has licensed the right to his invention of the dietary inflammatory index (DII®) from the University of South Carolina to develop computer and smartphone applications for patient counseling and dietary intervention in clinical settings. CHI owns the exclusive right to the E-DII™.

Ethics

All steps of this cohort study followed the Helsinki Declaration and were confirmed by the Ethics Committee of Fasa University of Medical Sciences (IR.FUMS.REC.1402.108). All participants of FACS provided written informed consent and were aware of the study’s aim.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nikpour, A., Pourmontaseri, H., Sepehrinia, M. et al. The association between pro-inflammatory diet and incidence of hypertension: a prospective cohort study. Hypertens Res 49, 1749–1759 (2026). https://doi.org/10.1038/s41440-026-02585-w

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Version of record:

  • Issue date:

  • DOI: https://doi.org/10.1038/s41440-026-02585-w

Keywords

Search

Advanced search

Quick links