Demographic comparison

To assess the representativeness of our findings, we compared Wisconsin-based prevalence estimates with global and U.S. benchmarks reported in recent analyses. Globally, hypertension affects 1 in 3 adults, and the number of people living with hypertension doubled between 1990 and 2019, reaching approximately 1.3 billion in 2019. In the United States, data from the 2021–2023 National Health and Nutrition Examination Survey (NHANES) indicate that 47.7% of adults had hypertension, with prevalence higher in men (50.8%) than women (44.6%).^{(17,Reference Fryar, Kit, Carroll and Afful18)} Within Wisconsin, our inpatient sample demonstrated an overall prevalence of 6.0%, a lower estimate that corresponds to the clinical setting rather than population-based surveillance. Nonetheless, the demographic gradients observed locally are consistent with national patterns. Female patients in Wisconsin exhibited a prevalence of 4.96%, markedly lower than the global estimate for women. At the same time, adults aged 65 years and older accounted for more than half of all cases, with a prevalence of 16.2%. These comparisons highlight both the methodological differences between datasets and the importance of situating state-level findings within a broader global context.

Cultural and ethnic dietary patterns

Particularly noteworthy was the identification of a distinct pattern wherein Hispanic patients in central Milwaukee County exhibited significantly lower hypertension rates despite socioeconomic disadvantages comparable to other low-income populations. This finding extends the established ‘Hispanic paradox’ in cardiovascular mortality documented by previous researchers,^{(Reference Zhou, Perel, Mensah and Ezzati1,Reference Leng, Jin, Li, Chen and Jin3)} who demonstrated lower cardiovascular mortality rates among Hispanics despite higher prevalence of cardiovascular risk factors and lower socioeconomic status.

The protective pattern observed in our study population may be related to traditional Mexican dietary practices, which are characterised by higher consumption of specific foods previously reported to be associated with favourable cardiovascular outcomes. Recent phytochemical analyses of traditional Mexican foods have identified substantial concentrations of bioactive compounds with reported associations to cardiovascular benefits.^{(Reference Villaverde, Rivera-Paredez, Argoty-Pantoja, Velázquez Cruz and Salmerón19)} A comprehensive analysis by Alatorre-Cruz et al.^{(Reference Alatorre-Cruz, Carreño-López, Alatorre-Cruz, Paredes-Esquivel, Santiago-Saenz and Nieva-Vázquez20)} documented significant concentrations of phenolic compounds in traditional Mexican diets, confirming their potent antioxidant and anti-inflammatory properties. These compounds have been associated with modulating multiple pathophysiological pathways implicated in hypertension development, including endothelial dysfunction, oxidative stress, and vascular inflammation.^{(Reference Martin-Ikpe, Were and Okoror13,Reference Chaturvedi, Zhu, Gadela, Prabhakaran and Jafar16)}

Traditional Mexican diets, which include staple foods such as beans, corn, chili peppers, and a variety of indigenous plant products, have been widely associated with beneficial cardiovascular profiles and lower blood pressure.^{(Reference Acciai, Deweese, Yedidia, Lloyd, Tulloch and Delia21,Reference Needham, Strugnell, Allender and Orellana22)} These dietary associations extend beyond individual food items, as preparation methods such as nixtamalization, fermentation, and other traditional cooking practices may contribute to the availability and use of nutrient-rich components.^{(Reference Vadiveloo, Sotos-Prieto, Parker, Yao and Thorndike23–Reference Torres-Fuentes, Suárez, Aragonès, Mulero, Ávila-Román and Arola-Arnal25)}

More broadly, the predominance of plant-based proteins, dietary fibre, and complex carbohydrates within these diets, alongside relatively lower consumption of ultra-processed foods, aligns with nutritional patterns that have been consistently linked to lower hypertension prevalence in observational and intervention studies.^{(Reference Kris-Etherton, Petersen, Velarde, Barnard, Miller and Ros26)} This dietary composition aligns with nutritional factors previously associated with lower hypertension prevalence, including adequate potassium intake, moderate sodium consumption, and abundant antioxidant compounds.

In addition to the Hispanic paradox, our analysis also revealed relatively low hypertension prevalence among Asian and Native American patients in Milwaukee County. For Asian populations, this observation is consistent with recent evidence showing that adherence to dietary patterns emphasising fruits, vegetables, and whole grains has been associated with lower risk of incident hypertension, with South Asian Americans experiencing a 67% reduction when closely following a DASH-style diet.^{(Reference Hussain, Deierlein, Kanaya, Talegawkar, O’Connor and Gadgil27)} Such a protective association may partly reflect broader dietary traditions rich in plant-based proteins, legumes, and soy, which have been consistently associated with lower blood pressure in both observational studies and dietary intervention trials.^{(Reference Tomé-Carneiro and Visioli28)} At the same time, scholars caution against treating Asian American populations as a single group; dietary practices are highly diverse and shaped by cultural, social, and structural factors,^{(Reference Chan, Laynor, Ali and Yi29)} suggesting that the relatively low prevalence observed locally should be interpreted with attention to subgroup variation.

Native American patients also showed comparatively lower prevalence in our cohort, a result that appears consistent with emerging evidence on culturally tailored dietary practices. Recent community-based interventions that provided tribally administered healthy food boxes reported associations with lower blood pressure and improved diet quality among Native American adults.^{(Reference Henderson, Rosenman, Fyfe-Johnson, Taniguchi, Standridge and Shackleford30,Reference Taniguchi, Williams-Nguyen, Muller, Fyfe-Johnson, Henderson and Umans31)} A protocol currently underway, the Native Opportunities to Stop Hypertension (NOSH) trial, similarly integrates a culturally adapted DASH diet to support cardiovascular health among American Indian and Alaska Native adults.^{(Reference Sinclair, Nguyen, Wetherill, Nelson, Jackson and Taniguchi32)} These findings support protective associations between culturally responsive dietary strategies and hypertension prevalence, even in the face of broader socioeconomic disadvantages.

Income

Income level is an important factor associated with hypertension prevalence, with higher-income groups consistently exhibiting lower rates. In neighbourhoods with median and high incomes, access to a greater quantity and variety of food resources is associated with lower hypertension prevalence.^{(Reference Schutte, Srinivasapura Venkateshmurthy, Mohan and Prabhakaran33–Reference Johnson, Montgomery and Ewell35)} These communities’ benefit from increased purchasing power, which not only allows residents to prioritise healthier food choices and adopt nutritious dietary behaviours, ^{(Reference Johnson, Montgomery and Ewell35,Reference Penne and Goedemé36)} but also is associated with greater access to medical resources and treatments.^{(Reference O’Donnell, Hankey, Rangarajan, Chin, Rao-Melacini and Ferguson37)} This advantage is associated with early diagnosis and timely medical intervention, which is further associated with improved cardiovascular health outcomes.

In contrast, low-income neighbourhoods face compounding challenges that are associated with a higher prevalence of hypertension. Economic constraints can limit individuals’ ability to access healthy food options, even in areas with adequate food resources. Although food deserts are traditionally associated with rural settings, they are also prevalent in urban environments, disproportionately affecting low-income communities. The patterns observed in West Milwaukee County align with existing research,^{(Reference Needham, Strugnell, Allender and Orellana22)} which reports that urban food deserts often overlap with neighbourhoods characterised by elevated rates of chronic disease and health inequities.^{(Reference Kelli, Hammadah, Ahmed, Ko, Topel and Samman-Tahhan6)} While these areas may have enough food outlets, lower-than-average household incomes hinder residents’ ability to access fresh and nutritious food options. This economic barrier is often associated with reliance on less healthy, calorie-dense, and processed foods, which are associated with higher hypertension prevalence.^{(Reference Penne and Goedemé36)}

Healthcare access beyond insurance coverage

In our insurance analysis, we revealed only modest associations. Medicaid coverage showed a positive and statistically significant association (EE = 1.071, 95% CI: 1.039–1.105, p < 0.001), while private insurance demonstrated a negative and significant association (EE = 0.944, 95% CI: 0.921–0.967, p < 0.001). Other forms of coverage, including Medicare, self-pay, and ‘other’, did not reach significance. This uneven pattern may indicate that insurance type alone does not fully capture the barriers patients face, and it may reflect that additional dimensions of healthcare access must be considered.

One critical dimension is geographic accessibility. Prior studies have demonstrated that patients living closer to primary care providers have been observed to show higher awareness of their hypertension and higher rates of control, while those in underserved or segregated areas have been observed with lower rates of awareness and control.^{(Reference Luo, Kibriya, Zakin, Craver, Connellan and Tasmin38,Reference Lind, Wong, Frochen, Yuan and Washington39)} These findings imply that insurance coverage may be insufficient when the spatial distribution of healthcare providers restricts the ability of patients to engage with care.

However, Geographic access cannot be separated from system capacity and appointment availability. Even where providers are physically present, long delays before specialty or follow-up appointments remain common, with some patients waiting several months.^{(Reference Basch, Hillyer and Basch40)} Evidence also suggests that shorter waiting times are associated with greater engagement and adherence, indicating that timeliness is associated with more effective chronic disease management.^{(Reference Thornton, Tsai, Santana, Penz, Flemons and Fraser41)} Thus, the benefits of insurance are contingent not only on the presence of providers but also on the system’s ability to accommodate patients in a timely manner.

A further consideration is continuity of care. Hypertension outcomes have been associated with patients maintaining regular follow-up visits.^{(Reference Mahmood, Jalal, Hadi and Shah42)} Experiences during the COVID-19 pandemic showed that continuity maintained through telemedicine was associated with better blood pressure control.^{(Reference Taylor, Berg, Thompson, Dean, Yuan and Nallamshetty43)} These observations indicate that the stability of patient-provider relationships has been associated with more consistent hypertension management, while fragmented or episodic care may be associated with less effective management of hypertension despite insurance coverage.

Food resource and access

Access to sufficient and diverse food resources is an important factor associated with hypertension prevalence. This study demonstrates a consistent negative association between food resource availability and hypertension prevalence across Milwaukee County and Wisconsin as a whole. Regardless of the type of food resources, whether convenience stores, supermarkets, fast-food outlets, or full-service restaurants, greater accessibility was associated with lower prevalence rates of hypertension (Table 2). These findings underscore the association between food accessibility and chronic disease patterns, particularly hypertension, through its association with dietary diversity and healthier eating practices.^{(Reference Suarez, Isakova, Anderson, Boulware, Wolf and Scialla44,Reference Little, Rosa, Heasley, Asif, Dodd and Richter45)}

Food deserts, defined as areas with a limited number of food resources regardless of type, were predominantly identified in neighbourhoods with high hypertension prevalence rates.^{(Reference Kelli, Kim, Tahhan, Liu, Ko and Hammadah5,Reference Kelli, Hammadah, Ahmed, Ko, Topel and Samman-Tahhan6,Reference Testa, Jackson, Semenza and Vaughn46)} These areas often lack sufficient food outlets, such as supermarkets or grocery stores, which corresponds with the limited residents’ ability to access fresh and nutritious food options.^{(Reference Kelli, Kim, Tahhan, Liu, Ko and Hammadah5,Reference Vadiveloo, Sotos-Prieto, Parker, Yao and Thorndike23,Reference Kris-Etherton, Petersen, Velarde, Barnard, Miller and Ros26)} Conversely, regions with a concentration of highly processed and calorie-dense food sources, such as convenience stores and fast-food outlets, may be associated with poor dietary habits and increased hypertension prevalence.^{(Reference Atanasova, Kusuma, Pineda, Frost, Sassi and Miraldo24,Reference Kris-Etherton, Petersen, Velarde, Barnard, Miller and Ros26)}

The heatmaps (Figure 4) visually depict these contrasting patterns across Milwaukee County. In the northwest region, despite having an adequate number of convenience stores and fast-food outlets, the lack of supermarkets and grocery stores corresponds with limited access to fresh fruits and vegetables and is associated with higher hypertension prevalence rates.^{(Reference Acciai, Deweese, Yedidia, Lloyd, Tulloch and Delia21,Reference Needham, Strugnell, Allender and Orellana22)} This imbalance in food resource types highlights the association of food quality and diversity in shaping dietary health outcomes. On the other hand, the southern parts of Milwaukee County, which have fewer food resources overall, also exhibit high hypertension prevalence rates. This emphasises the importance of total food resource density in relation to health outcomes, irrespective of food type.^{(Reference Little, Rosa, Heasley, Asif, Dodd and Richter45,Reference Liu and Eicher-Miller47,Reference Glickman, Clark and Freedman48)}

Food assistance paradox

Contrary to anticipated associations, individuals receiving food stamps consistently exhibited higher hypertension prevalence compared to demographically similar individuals without such assistance (EE = 1.179, 95% CI: 1.114–1.248 for those below the poverty line with food stamps versus EE = 0.949, 95% CI: 0.899–1.002 for those below the poverty line without assistance). Although these programmes are designed to alleviate food insecurity, our findings suggest they may not adequately address nutritional quality. This gap may lead to increased reliance on energy-dense, nutrient-poor foods, potentially contributing to the higher observed prevalence of hypertension among participants. This observation aligns with research by Zhang et al.^{(Reference Zhang, Chen, Diawara and Wang49)} documenting associations between food stamp participation and suboptimal dietary patterns among low-income women.

Among low-income populations, food stamp recipients represent a distinct subgroup facing unique challenges in accessing and utilising nutritious food options. Economic constraints further compound these challenges, as affordability often takes precedence over nutritional value. This economic trade-off has associated with continued reliance on less nutritious foods, which in turn has been associated with elevated hypertension prevalence rates.^{(Reference Atanasova, Kusuma, Pineda, Frost, Sassi and Miraldo24,Reference Bhat, Coyle, Trieu, Neal, Mozaffarian and Marklund50)}

These dietary patterns among food stamp recipients have been reported in relation to adverse health outcomes, particularly hypertension. The over-reliance on processed, calorie-dense foods and the insufficient intake of fruits, vegetables, and nutrient-rich alternatives have been associated with increased chronic disease risk.^{(Reference Wang, Du, Huang and Xu12)} Poor nutritional intake is associated with higher prevalence of hypertension risk factors over time, highlighting potential areas for improving nutritional considerations within food assistance programmes. Policy reforms prioritising access to affordable, nutrient-dense foods, coupled with public health initiatives promoting balanced diets, may have relevance for reducing the health disparities experienced by food stamp recipients.^{(Reference Zhang, Chen, Diawara and Wang49)}

Urban change and gentrification

Beyond programmatic barriers, neighbour-level changes may be associated with changes in access in complex ways. Urban redevelopment may be associated with greater physical proximity to food outlets and other amenities, yet at the same time, it may be associated with lower affordability and accessibility for long-standing residents. Evidence indicates that such improvements are not consistently associated with healthier diets. A natural experiment in a public housing community showed that proximity to a newly opened supermarket was not associated with better dietary outcomes among children, except for those who lacked reliable transportation, highlighting that mobility is associated with differences in access.^{(Reference Miller, Shier, Wong and Datar51)} Similarly, recent analyses caution that some neighbourhoods contain supermarkets or other outlets that are physically nearby but remain economically inaccessible. These areas can be understood as a variant of food deserts, sometimes described in the literature as ‘food mirages’, where healthier choices remain out of reach for many households.^{(Reference Firestine and Murrell52)} Our findings are consistent with this pattern, indicating that purchasing power may be associated with whether environmental interventions align with reduced hypertension prevalence.

When viewed through the lens of gentrification, these dynamics become even more pronounced. Redevelopment may be associated with changes in the retail mix and neighbourhood amenities, while also being associated with higher costs and reduced access for long-standing residents. Systematic reviews describe how gentrification has been associated with variants of food deserts, with healthier retailers introduced but at price points that exclude lower-income households.^{(Reference Delong53)} Large-scale analyses across U.S. cities have reported associations between gentrification, which may also coincide with worsening social deprivation and reduced life expectancy among Black and Hispanic residents, despite some improvements in health care availability.^{(Reference Acolin, Crowder, Decter-Frain, Hajat, Hall and Homandberg54)} Similar findings have been noted with green gentrification, where new parks and walkable spaces are used more often by newcomers than by long-term residents, indicating associations with continued patterns of exclusion.^{(Reference Jelks, Jennings and Rigolon55)} These observations indicate that associations between urban change and health outcomes may relate less to the simple presence of new infrastructure and more to whether those resources remain affordable and accessible to the communities they are meant to serve.

Behavioural confounders

Behavioural factors also form a crucial part of the broader risk landscape, and their association with hypertension is equally important as geographic, socioeconomic, and environmental determinants. Hypertension is associated not only with the neighbourhoods where individuals live but also with the routines and practices embedded in daily life. Evidence from randomised clinical trials shows that lifestyle modifications, including weight reduction, regular exercise, and reduced alcohol intake, can significantly lower blood pressure.^{(Reference van Oort, Beulens, van Ballegooijen, Grobbee and Larsson56)} These findings indicate the importance of considering behavioural risk factors and structural exposures as interdependent rather than separate domains.

Physical activity provides one of the clearest examples of this connection. Population-based analyses have shown that higher-intensity activity is associated with reduced risk of hypertension, even after accounting for overall energy expenditure.^{(Reference Gribble, Hershey, López-Gil, Lan, Kales and Martínez-González57)} Yet activity patterns are not evenly distributed; they are often associated with work demands, neighbourhood safety, and access to recreational spaces, indicating that community context may be associated with individual behaviour. Stress adds another dimension. Large-scale studies using both survey data and biological markers demonstrate that individuals experiencing sustained occupational stress have a higher prevalence of hypertension.^{(Reference Wang, Zhu, Song, Zhou, Chan and Li58)} Stress exposures have also been observed more often in communities facing economic instability, which are associated with heightened risks created by poverty and residential disadvantages.

Tobacco use further illustrates how individual practices intersect with social patterning. Experimental studies report associations with short-term blood pressure elevations after smoking, and longitudinal evidence confirms elevated long-term risk among chronic smokers.^{(Reference Jareebi59)} Finally, alcohol consumption has been associated with a largely linear relationship with blood pressure, with no clear safe threshold.^{(Reference Cecchini, Filippini, Whelton, Iamandii, Di Federico and Boriani60)} Because drinking patterns vary across income and racial groups in the United States, alcohol use may be associated with reinforcing or widening the disparities observed in our Wisconsin population, due to the state’s long-standing brewing industry and cultural emphasis on alcohol availability.

From food deserts to food environment synergy

Recent studies have worked on characterising neighbourhood food environments through binary classifications of ‘food deserts’ or ‘food secure’ areas.^{(Reference Kelli, Kim, Tahhan, Liu, Ko and Hammadah5,Reference Kelli, Hammadah, Ahmed, Ko, Topel and Samman-Tahhan6)} The Food Environment Policy Index^{(Reference Swinburn, Vandevijvere, Kraak, Sacks, Snowdon and Hawkes61)} and the exposome concept^{(Reference Daher62)} have provided valuable frameworks for examining how physical food access is associated with health outcomes. However, these approaches have significant limitations. They often examine environmental factors in isolation, focusing primarily on the physical presence or absence of food resources without adequately addressing the economic and cultural dimensions that are associated with food choices. They do not capture the complex, synergistic interactions between multiple environmental factors that collectively are associated with cardiovascular health outcomes.

In this project, we propose a novel conceptual framework – the ‘Food Environment Synergy Model’ that better captures these complex interactions. Unlike traditional models, our framework integrates three critical dimensions that are often studied separately: food resource distribution (physical access), economic accessibility (affordability), and cultural dietary patterns (nutritional knowledge and practices). By combining these factors, our approach reveals how their interactions shape unique patterns of risk and resilience within communities.

For instance, neighbourhoods with high physical access to food resources but limited economic accessibility demonstrate different risk patterns than those with both physical and economic barriers. Similarly, areas with strong cultural dietary traditions, such as those maintaining traditional Mexican dietary practices, exhibit unique resilience patterns that may be associated with variations in the expected socioeconomic health gradient. These patterns illustrate how social determinants rarely operate independently but combine in ways that are associated with layered profiles of risk and resilience. Recent scholarship supports this view, showing that affordability, availability, and cultural norms intersect to be associated with dietary behaviours in low-income contexts,^{(Reference Sawyer, van Lenthe, Kamphuis, Terragni, Roos and Poelman63)} that structural inequities combine with cultural practices to be associated with food choices,^{(Reference Odoms-Young, Brown, Agurs-Collins and Food Insecurity64)} and that nutrition disparities are best understood through frameworks capturing multi-level interrelationships.^{(Reference Agurs-Collins, Alvidrez, ElShourbagy Ferreira, Evans, Gibbs and Kowtha65)} Together with work by Kebede et al.^{(Reference Kebede, Nicholls, Clarke, Savin and Harrison66)} which emphasises food systems as complex socioecological systems, these perspectives are consistent with the Food Environment Synergy Model’s premise that physical, economic, and cultural determinants must be considered jointly to capture the complexity of community health environments.

The Food Environment Synergy Model helps frame the seemingly paradoxical findings in our study, such as the protective associations observed in Hispanic populations despite economic disadvantages, and the higher hypertension rates among food stamp recipients compared to similarly impoverished non-recipients. By moving beyond unidimensional classifications of food environments, this model provides a more nuanced understanding of how environmental factors collectively are associated with cardiovascular health outcomes and points toward more targeted intervention approaches.^{(Reference Swinburn, Vandevijvere, Kraak, Sacks, Snowdon and Hawkes61)} Our model supports recent calls for integrated assessment approaches that consider multiple interacting factors in food environment research.^{(Reference von Philipsborn, Geffert, Klinger, Hebestreit, Stratil and Rehfuess67)}

In operational terms, the Food Environment Synergy Model may indicate the relevance of interventions that address multiple dimensions of access simultaneously. At the policy level, this may include subsidies for fresh produce in underserved neighbourhoods, incentives for culturally relevant food retailers, and adjustments to programmes such as SNAP to better support healthy purchasing. At the community level, strategies could combine nutritional education with financial support like vouchers and partnerships with cultural organisations that reinforce protective dietary traditions. Together, these approaches provide examples of how the model can be translated into practice, and they highlight a pathway for public health planning that moves beyond single-dimensional solutions toward more integrated and context-sensitive strategies.^{(Reference Garrity, Krzyzanowski Guerra, Hart, Al-Muhanna, Kunkler and Braun68)}

Limitations

Several methodological limitations warrant acknowledgment. First, our cross-sectional design precludes definitive causal interpretations regarding the temporal relationships between social determinants and hypertension development. Second, while our spatial mapping methodology provides valuable insights into geographic distributions of risk factors, it potentially masks individual-level heterogeneity within ZIP code boundaries. Third, our utilisation of hospitalisation data introduces potential selection bias by capturing only individuals who accessed hospital services, potentially underrepresenting those with undiagnosed hypertension or limited healthcare access. Fourth, while we identified cultural dietary patterns as potentially protective among Hispanic populations, we lack detailed nutritional intake data to quantitatively characterise the specific dietary components that may be related to the observed cardioprotective associations. Finally, it should be noted that food environments are dynamic and can change rapidly over time, whereas our data captures a single time point, limiting the extent to which findings capture longitudinal changes in food access and availability.

Strengths and future research directions

Despite these limitations, our study offers several methodological strengths. The substantial sample size (387,047 patients) and extensive geographic coverage (597 ZIP codes) provide robust statistical power and ecological validity. Additionally, our approach to distinguishing between food deserts and food swamps offers a more nuanced characterisation of food environment association with hypertension prevalence than conventionally employed literature. The integrated socioecological analytical framework enabled simultaneous examination of multiple environmental and socioeconomic determinants at both individual and community levels, highlighting interaction patterns that may not be evident in narrower analyses.

Future research should pursue several promising trajectories based on our findings. Longitudinal studies tracking changes in neighbourhood food environments, transportation patterns, and hypertension outcomes could strengthen causal inferences and identify critical intervention windows. Detailed nutritional analyses employing metabolomic and phytochemical methodologies could isolate specific bioactive compounds in traditional Mexican diets that confer cardiovascular protection, potentially identifying novel nutraceutical compounds for targeted hypertension prevention. Implementation research could evaluate the feasibility and effectiveness of incorporating cultural dietary knowledge into clinical and community-based hypertension prevention programmes. Additionally, economic analyses of food assistance programme modifications prioritising nutritional quality could quantify potential healthcare cost savings from reduced hypertension prevalence.