Diabetes Drives Cardiovascular Risk in the Metabolic Triad: An Eight-Year Occupational Cohort Study of Ten Thousand Workers

Background: Cardiovascular diseases remain the leading cause of death and maintain a high burden in Latin America. Obesity, hypertension, and type 2 diabetes are independent risk factors, but their coexistence could amplify cardiovascular damage beyond their individual sum. The aim of our study was to determine, in a Peruvian occupational cohort followed for 8 years, how the coexistence of obesity, hypertension, and diabetes is associated with the incidence of major cardiovascular events and to identify which combinations confer the highest risk. Methods: This was a retrospective observational cohort study of Peruvian workers without cardiovascular history, followed for 8 years. Obesity, hypertension, and diabetes were evaluated in eight mutually exclusive categories. The outcome was cardiovascular disease. Adjusted risk ratios were estimated using Cox regression, adjusted for age, sex, cholesterol, and triglycerides. Results: A progressive risk increase pattern was observed where the group without components had an incidence of 1.30 per 1,000 person-years, while the triad reached 34.94 per 1,000 person-years with adjusted hazard ratio (aHR) = 10.87 (2.81 - 42.06). Among isolated components, diabetes showed the highest risk (aHR = 4.24; 1.36 - 13.35) compared to obesity (1.45; 0.68 - 3.10) and hypertension (1.17; 0.32 - 4.24). In combinations, obesity + diabetes (aHR = 6.34; 1.73 - 23.27) and diabetes + hypertension (5.86; 1.47 - 23.39) concentrated the highest risks, above obesity + hypertension (2.01; 0.71 - 5.72). Conclusions: In the working population, the coexistence of obesity, hypertension, and diabetes progressively increases CVD risk, with diabetes as the main axis and the triad identifying a very high-risk subgroup. These findings support periodic screening and intensive multifactorial management in the occupational setting, prioritizing those presenting diabetes alone or in combination.