Beyond behaviors: do biological intermediates improve lifestyle scoring for blood pressure?

Background: Hypertension prevalence is high in Saudi Arabia. Both lifestyle behaviors and biological intermediates influence blood pressure (BP); however, there is limited evidence from the Middle East on whether composite lifestyle scores that integrate both domains would capture BP variation better than behavioral metrics alone. This study aimed to examine associations of an overall lifestyle risk score (behavioral + biological) and a behavioral-only score with BP outcomes. Methods: = 1,041), we constructed (i) an overall lifestyle score (BioBeh score), including waist circumference, total cholesterol, fasting glucose, smoking, sleep, physical activity, perceived stress, and diet quality, and (ii) a behavioral-only score (Beh score), including smoking, sleep, physical activity, perceived stress, and diet. We examined the association with BP [systolic/diastolic BP (SBP/DBP)], elevated BP, and hypertension using multivariable linear and logistic regression, adjusted for various confounders. Results: Each 1-point higher BioBeh score was associated with lower SBP (-1.68 mmHg; 95% CI: -2.58, -0.79), lower DBP (-1.67 mmHg; 95% CI: -2.66, -0.68), and reduced odds of hypertension (OR 0.73; 95% CI: 0.63, 0.85), but not with elevated BP. No associations were found with the Beh score. Waist circumference was the strongest individual component [SBP -3.80 (-4.70, -2.91); DBP -3.31 (-4.30, -2.32) mmHg; hypertension OR 0.57; 95% CI: 0.49, 0.66]. Conclusions: In Saudi adults, a biologically enriched lifestyle score captures BP variation and hypertension risk more robustly than behavior-only metrics. These findings support risk stratification and prevention strategies that emphasize central adiposity alongside basic lipid and glucose profiles.