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Screening for hypertension in the selected rural areas of Tirunelveli

District and a study on their Lifestyle related risk factors

Keywords:

Hypertension, Pre-hypertension, Isolated hypertension.

ABSTRACT:

Background:The aim of this study was to identify the lifestyle related risk factors for hypertension in

selected rural areas of Tirunelveli District.

Materials and Methods: A door-to-door survey was conducted amongst all the residents of the

selected villages. Based on availability and willingness, all the residents both normotensive cases and

hypertensive cases above 20 years of age, were interviewed and data relating to the demographics

of the individuals, BMI, dietary habits, alcohol consumption, tobacco use, psychosocial stress, past

medical history and drug history. Blood pressure (BP) and anthropometric data was recorded. Binary

logistic regression analysis was used to determine the association between variables.

Results: Out of 2269 cases surveyed, 686 were hypertensive cases and the rest were normotensive

cases. Increasing age was an independent predictor of hypertension in both sexes. 11.8% percent of

the hypertensive cases were found to have severe hypertension. Only 1.5% percent had isolated

hypertension wherein the diastolic hypertension was found to be normal and the systolic pressurewas higher than 140 mmHg. Among men the percentage of obesity was 35.3% whereas that of

females was 51.5%. Among the tobacco users the percentage of hypertensive cases was 65.5%

compared to 7.4% among normal cases. Similar trend was observed among alcohol (22.2%) and the

extra salt (36.6%) consumers. The occurrence of hypertension was also high among the persons who

had hypertensive family history (29.4%). The variables such as age and sex, physical activity, frequent

consumption of tobacco, alcohol, pain killers, dietary factor like high salt intake, and health

conditions like family history were significantly associated with hypertension.

Conclusions:Through this study, different risk factors were identified indicating that the adoption of

westernized lifestyle, exposure to stress of acculturation and modernization might be the reasons for

such a phenomenon among the rural population. With the exception of age, all the risk factors

identified were potentially modifiable.

037-046 | JRPH | 2012 | Vol 1 | No 2

This article is governed by the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which gives permission for unrestricted use, non-commercial, distribution andreproduction in all medium, provided the original work is properly cited.

www.jhealth.info

Journal of Research in

Public HealthAn International

Scientific Research Journal

Authors:

Pauline Suganthy

Vijayabarathy and

PushparaniD.

Institution:

Associate Professor inApplied Nutrition and

Public Health,Sadakathullah Appa College,

Tirunelvei- 627011.

Corresponding author:

Pauline Suganthy

Vijayabarathy

Email:

paulinepeterma@yahoo.com

Phone No:+919443971916.

Web Address:http://jhealth.info/

documents/PH0012.pdf.

Dates:Received: 10 Oct 2012 Accepted: 17 Oct 2012 Published: 26 Oct 2012

Article Citation:

Pauline Suganthy Vijayabarathy and PushparaniD.

Screening for hypertension in the selected rural areas of Tirunelveli District and a

study on their Lifestyle related risk factors.

Journal of Research in Public Health (2012) 1(2): 037-046

Original Research

Journal of Research in Public ealth

Jour

nalofRes

earch

inP

ublicHealth

An International Scientific Research Journal

mailto:paulinepeterma@yahoo.commailto:paulinepeterma@yahoo.commailto:paulinepeterma@yahoo.com

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INTRODUCTION:

Hypertension is an increasingly important

medical and public health issue worldwide. It remains a

major global public health challenge that has been

identified as the leading risk factor for cardiovascularmorbidity and mortality. It is often called silent killer

because people with hypertension can be asymptomatic

for years and then have a fatal stroke or heart

attack. Worldwide hypertension is estimated to cause

7.1 million premature deaths and 4.5% of the disease

burden *Whitworth,2003+. As per WHOs The World

health statistics 2012 report, one in three has raised

blood pressure. The prevalence of hypertension

in India is reported as ranging from 10 to 30.9%

(Padmavathy, 2002). The average prevalence of

hypertension in India is 25% in urban and 10% in rural

inhabitants (Gupta, 2004). Primary (essential)

hypertension is the most common form of

hypertension, accounting for 90-95% of all cases of

hypertension.In almost all contemporary societies,

blood pressure rises with age and the risk of becoming

hypertensive in later life, is considerable (Vasan et al.,

2002). Hypertension is also referred to as Blood

Pressure. It is the force applied against the walls of the

arteries as the heart pumps blood through the body.

The pressure is determined by the force and amount of

blood pumped and the size and flexibility of the arteries.

Hypertension is rarely accompanied by any

symptom and its identification is usually

through screening, or when seeking healthcare for anunrelated problem. A proportion of people with high

blood pressure reports headaches (particularly at

the back of the head and in the morning), as well

as lightheadedness,vertigo, tinnitus (buzzing or hissing

in the ears), altered vision or fainting episodes (Fisher

and Williams, 2005).

Untreated hypertension leads to

many degenerative diseases including heart failure, end

stage renal disease and peripheral vascular disease.

Annually, it causes 7.1 million (one third) global

preventable premature deaths (Kearney et al., 2004).

Although hypertension was considered primarily an

urban phenomenon (Gupta et al., 1996) a number ofstudies conducted in rural areas have revealed that it is

a problem in rural areas as well (Baldwa et al., 1984).

Hypertension which was found to be more common

among urban community has become an important

public health challenge among people living in the rural

community also particularly among low income group,

with evidence of considerable lack of awareness,

under-diagnosis, treatment, and control. Although no

cure is available, hypertension is easily detected and

usually controllable (Paul et al.,2011). The emphasis on

lifestyle modifications has given diet a prominent role in

prevention and management of hypertension

(Krause, 2008)

Information on the burden of disease from

hypertension is essential in developing effective

prevention and control strategies. An up-to-date and

comprehensive assessment of the evidence concerning

hypertension in rural areas is lacking. Essential

hypertension, a grossly underestimated condition in

rural communities is likely to be an important public

health problem. There is an urgent need to develop

strategies to prevent, detect, treat, and control

hypertension effectively in the rural areas. Preventive

activities can be initiated on the basis of lifestyle-related

risk factors. The purpose of this survey was to identifythe hypertensive patients in the selected rural areas of

Tirunelveli district, and the life style related risk factors,

which may help to optimize their health and treatment

needs.

Pauline and Pushparani,2012

038 Journal of Research in Public Health (2012) 1(2): 037-046

http://en.wikipedia.org/wiki/Screening_(medicine)http://en.wikipedia.org/wiki/Occiputhttp://en.wikipedia.org/wiki/Lightheadednesshttp://en.wikipedia.org/wiki/Lightheadednesshttp://en.wikipedia.org/wiki/Occiputhttp://en.wikipedia.org/wiki/Screening_(medicine)

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MATERIALS AND METHODS:The study was carried out in nine village

Panchayats namely Seevalaperi, Naduvakurichi,

Maruthur, Udaiyarkulam, Kansapuram, Keelapaatam,

Melapattam, Notchikulam and Thirumalai

kozhundhupuram from Palayamkottai union in

Tirunelveli district. The findings of the pilot study done

during a medical camp was the basis for selecting these

villages. All the houses in these villages were included

for the survey based on the willingness and availability

of the subjects for the study. All the willing individuals

of age 20 years and above were screened by measuring

the blood pressure with sphygmomanometer

(Diamond Co., Industrial Electronics and Allied Products,

Electronics Cooperative Estate, Pune, Maharashtra).

The individual was made comfortable and after five

minutes of rest the blood pressure of participants was

measured. Hypertension was defined as either systolic

blood pressure above 139 mmHg and/or a diastolic

blood pressure above 89 mmHg and/or treatment with

anti-hypertensive medications (WHO, 2010). Subjects

with more than 139 mmHg systolic blood pressure and

85 mmHg diastolic blood pressure were selected as

respondents for the study as hypertensive cases. Blood

Pressure of each study subject was classified and graded

as per WHO/ISH definitions and classification of bloodpressure level (WHO, 1999).

Weight and height were measured using a

portable weighing machine and steel measuring tape.

Height was measured using the tape mounted on the

wall with the subject in standing position, without foot

wear and with the head positioned against the wall.

Body weight was measured (to the nearest of 0.5 kg)

with the participant in standing position on weighing

scale, feet about 15 cm apart and equally distributing

weight on both lower limbs with minimum clothes and

no footwear.

The weight for height ratio is a simple and

widely accepted method which estimates total body

mass. The most commonly used ratio is the Quetelets

Index or Body Mass Index (BMI). Body mass index is

used as an indicator of an individuals health. It is usually

compared with table values that has ideal or desirable

weight ranges for specific height. An individual can be

categorized as healthy, underweight, overweight

or obese (Kuczmarski and Mariefanelli, 2001).

Body Mass Index (BMI) was calculated from the

expression: BMI = weight (kg) / stature2 (m

2) and

categorized according to the cut-off points established

by the World Health Organization (WHO). Abdominal

Pauline and Pushparani, 2012

Journal of Research in Public Health (2012) 1(2): 037-046 039

S.No Particulars Male Percentage% Female Percentage % Total Percentage %

1 Hypertensive Cases 249 36.3 437 63.7 686 28.7

2 Normal Cases 666 39.1 1037 60.9 1583 71.33 Total screened 915 38.3 1474 61.7 2269 100

Table: 1 Characteristics of cases under study

Table : 2 Age wise distribution of the Normal, New and old hypertensive cases

Age Normal cases Percentage %

Total HT cases New Cases Old Cases

No Percentage % No Percentage % No Percentage %

20-29 166 10.5 38 5.5 32 6.9 6 2.7

30-39 276 17.4 115 16.8 90 19.4 25 11.3

40-49 415 26.2 136 19.8 88 18.9 48 21.750-59 486 30.7 164 23.9 109 23.4 55 24.9

>59 240 15.2 233 34.0 146 31.4 87 39.4TOTAL 1583 100 686 100 465 100 221 100

Pearson Chi-Square : 13.997; df:4; significance 0.007; p.value

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obesity was diagnosed using the criteria proposed by

WHO (1995). From the recorded height and weight of

each patient, the BMI values were computed and were

grouped according to the following classification given

by (Robert and Weisell, 2002)

Waist Hip ratio is a simple, accurate method for

determining body fat pattern and current health status.

The predominant distribution of fat in obese person in

the upper part or lower part of the body may determine

disease pattern. Abdominal density is often measured as

waist to hip ratio (Hopkin, 2001). Waist circumference

was measured in centimetres (cm) at the level of

umbilicus to the nearest 0.1 cm. Hip circumference was

measured at the trochanteric level in centimeters to the

nearest 0.1 cm. Abdominal obesity was defined using

the revised criteria for Asian Indians (abdominal obesity:

waist circumference >=90 cm for men and >=80 cm for

women) (WHO, 2000). The waist to hip circumference

ratio (WHR) was calculated from the expression:

WHR = WC / HC and categorized according to WHO

recommendation (WHO, 1995). The cut-off used for

WHR were >0.9 for males and >0.8 for females

(Webb, 2002)

Around 2269 members participated in the study.

Out of 2269 participants 686 were hypertensive cases

and the rest were normal cases. An interview schedule

was used for all those who participated in the study

to assess the life style risk factors. The first part

of the schedule had questions pertaining to the

socio-demographic profile such as age, sex, level of

education and per-capita income, occupation, religion,

lifestyle habits such as smoking, consumption of alcohol

etc.,. Current smoker/tobacco user was defined as

someone who at the time of the survey smoked/used

tobacco in any form either daily or occasionally.

The group of non-smokers comprised individuals who

had never smoked (those who have never smoked at all)

and ex-smokers. Regarding consumption of alcohol,

a current drinker was defined as one who consumed

one or more drinks of any type of alcohol in the year

preceding the survey. Frequent use of pain killers was

defined as one who consumed pain killers for simple

Pauline and Pushparani, 2012

Table: 3 Age and sex wise distribution of hypertensive Cases

Age in yearsMale Female

HT cases Percentage % HT cases Percentage %

20-29 17 6.8 21 4.8

30-39 38 15.3 77 17.640-49 40 16.1 96 22.0

50-59 64 25.7 100 22.9>59 90 36.1 143 32.7

Total 249 100 437 100

040 Journal of Research in Public Health (2012) 1(2): 037-046

Diastolic Pressure in mm/HgMale Female Total

No Percentage% No Percentage % No Percentage %

Pre hypertension (81-89) 32 12.9 38 8.7 70 10.2Mild hypertension (90-99) 132 53.0 225 51.5 357 52.0

Moderate hypertension (100-109) 56 22.5 112 25.6 168 24.5Severe hypertension (>=110) 26 10.4 55 12.6 81 11.8

Isolated systolic hypertension

(Diastolic140)

3 1.2 7 1.6 10 1.5

Total 249 100 437 100 686 100

Test of significance Chi square=4.183; df:4 Sig:0.382; p value>0.05;10% have expected count less than 5.

Table: 4 Sex wise classification of Hypertension

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aches and pains without consulting physicians. Family

history and past history of hypertension, were also

included.

Collected data were analyzed to find out the

association between attributes using Pearson

chi-square and Binary Logistic regression analysis using

SPSS software version 11.

RESULTS:

Total sample of the study population who

volunteered for the study (Table-1) was 2269. Out of

which 71.3% were Normal cases and the rest 28.7%

were hypertensive cases. It was found that the number

of female hypertensive cases were more (63.7%)

compared to the male counter part (36.3%).

The percentage of hypertension in adults from

30 to 39 years of age in the study area was 16.8%. It was

least (5.5%) in the age group of 20-29 years and

maximum (34%) in subjects 60 years of age (Table-2).

The distribution of the study population by age

and sex is presented in Table-3 and it showed that the

number of hypertensive cases was highest (36.1%) in

the age group of 60 or more among the malehypertensive cases and it was (32.7%) among the

females. In both males and females hypertensive cases,

the occurrence of hypertension increased with

increasing age. High prevalence of hypertension was

also reported in many developed countries where it was

found that at any given time almost half of the

individuals had high BP. (Kearney et al.,2005).

Table-4 shows that nearly 10.2% of the total

cases were identified as pre-hypertensive cases and

11.8% of the hypertensive cases were found to have

severe hypertension. Only 1.5% had Isolated

hypertension wherein the diastolic hyper tension was

found to be normal and the systolic pressure was higher

than 140mm/Hg.

Table-5 shows that among the hypertensive

cases 6.9% were under weight and 16.8% were at risk

for obesity. Nearly 45.6% were obese with BMI greater

than 24.9. Among men the percentage of obesity was

35.3% whereas that of females was 51.5%. The effects

of obesity and hypertension are cumulative and several

studies have documented that the coexistence of these

factors increases the cardiovascular diseases risk

(Sundquist et al.,2001) Pearson chi-square test reveals

that there is association between sex and BMI the

p value being 0.05; 0% have expected count less than 5.

Table: 5 Sex wise Classification of Body Mass Index (BMI)

WHR Male HT cases Percentage % WHR Female HT cases Percentage % Total HT cases Percentage %

>0.9 62 24.9 >0.8 351 80.3 413 60.2

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reported in a study conducted in rural Wardha

(Deshmukh et al.,2006).

Table-7 shows that most of the study population

including hypertensive cases and normal cases

comprised of nuclear family (83.1% and 91.3%), hindu(72.6%; 71.6%), christian (11.5%; 10%), and muslim

(15.7%; 18.4%) by religion. 45.6% hypertensive cases

and 24.1% normal cases had BMI (Body Mass Index)

greater than 24.9. Among the tobacco users the

percentage of hypertensive cases was 65.5% compared

to 7.4% among normal cases. Similar trend was

observed in alcohol consumption (22.2%) and the extra

salt (36.6%) intake among hypertensive cases.

The occurrence of hypertension was also high among

the persons who had the family history of hypertension

(29.4%).

Association of study variables with hypertension

was analyzed by binary logistic regression and reflected

in table-8. The variables such as age and sex physicalactivity, frequent consumption of tobacco, alcohol, pain

killers, dietary factor, like high salt intake and health

condition like family history were significantly

associated with hypertension. Anthropometric index like

height, weight and BMI, along with religious background

were also analyzed but they were not significantly

associated. Among the risk factors of hypertension

considered for this study 76.6% could be explained by

binary logistic regression analysis.

Pauline and Pushparani, 2012

042 Journal of Research in Public Health (2012) 1(2): 037-046

S.NO Characteristics HT cases (n=686) Percentage % Normal cases (n=1583) Percentage %

1 Religion

HinduChristian

Muslim

49979

108

72.611.5

15.7

1133158

292

71.610.0

18.4

2 Type of family

NuclearJoint

570116

83.116.9

1446137

91.38.7

3 Nature of workSedentaryModerate

Heavy

46397

126

67.514.1

18.4

2091088

286

13.268.7

18.1

4 BMI

=25-29.9

47211

115313

6.930.7

16.845.6

195642

365381

12.340.5

23.124.1

5 Tobacco

YesNo

449237

65.534.5

1171466

7.492.6

6 AlcoholYes

No152534

22.277.8

551528

3.596.5

7 Family history

YesNo

No idea

202380

104

29.455.4

15.2

661471

46

4.292.9

2.98 Salt intake

HighModerate

Low

251391

44

36.657.0

6.4

711346

166

4.585.0

10.5

Table: 7 - A comparative study on life style factors between the hypertensive and the

Normal cases of the study population

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DISCUSSION:

Among the samples who volunteered for the

study, 71.3% were Normal cases and the rest 28.7%

were hypertensive cases. Among the hypertensive cases

36.3% were males and 63.7% were females. A studyconducted by Kokiwar prashant reveals the occurrence

of more hypertensive cases in females (23.4%)

compared to males (14.4%) and this difference was

statistically significant (Kokiwar et al.,2011). A study by

Bourne et al.,(2011) found that 2.5 times more females

than males were affected by hypertension (Paul et al.,

2011). Significantly higher prevalence of hypertension

among the females was observed by Sharma and Singh,

(1997). The study also revealed that with advancing age

the magnitude of hypertension increased. Similar

finding was reported by Gupta et al.,(2002). The Pearson

Chi square test also revealed that there was association

between age and the occurrence of old and new cases

of hypertension, with p value < 0.05. More than 10% of

the cases were in pre hypertensive stage.Specifically, it

has been reported that individuals with blood pressure

values of 130-139/85-89 mmHg were significantly at

higher risk of developing cardiovascular diseases

compared to subjects with lower blood pressure

values (Vasan et al., 2001). Hence intervention at

pre-hypertensive stage to reverse the condition is one

of the specific protection against cardiovascular

diseases. The Pearson chi-square test has a value of

4.183 revealing no association between sex and grades

of hypertension.

The present study has recorded 30.7% ofhypertensive cases within normal range of BMI which is

contrary to the findings of many studies on obesity and

hypertension, which state that BMI more than or equal

to 25 was found to be significantly associated with

hypertension. Similar findings were observed by a cross

sectional study conducted among laborers in Madhya

Pradesh. (Kapoor et al., 2010). Gender difference in

Waist Hip Ratio was observed in the present study

which revealed that 80.3% of the female hypertensive

cases and 24.9% of male hypertensive cases had higher

waist hip ratio. Central obesity indicated by increased

waist-hip ratio has been positively correlated with high

blood pressure in several populations. (WHO, 1996).

Women have substantially more total adipose tissue

than men, and these wholebody sex differences

are complemented by major differences in tissue

distribution. Men have greater arm muscle mass, larger

and stronger bones, less limb fat and a relatively

greater central distribution of fat. Women have a

more peripheral distribution of fat in early adulthood

(Derby et al.,2006).

Pauline and Pushparani, 2012

Journal of Research in Public Health (2012) 1(2): 037-046 043

S.NO Particulars B S.E. WALD df Sig Exp(B)

1 Sex 0.678 0.224 9.170 1 0.002* 1.971

2 Age 0.055 0.008 51.211 1 0.000* 1.0573 Height 1.392 2.917 0.228 1 0.633 4.0234 Weight -0.044 0.034 1.600 1 0.206 0.957

5 BMI 0.143 0.086 2.745 1 0.098 1.1546 Religion 0.025 0.113 0.047 1 0.827 1.025

7 Physacti -1.031 0.121 72.633 1 0.000* 0.3578 Tobacco -3.186 0.192 275.104 1 0.000* 0.041

9 Alcohol -3.362 0.299 126.401 1 0.000* 0.03510 Pain_Kil -3.129 0.187 280.395 1 0.000* 0.044

11 Famihist -0.793 0.190 17.380 1 0.000* 0.45312 Salt_Int -1.675 0.185 82.310 1 0.000* 0.187

Constant 15.829 4.682 11.431 1 0.001* 7492285.108

Table: 8 - Association between Hypertension and risk factors by Binary Logistic regression analysis

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In this study an attempt has been made to find

out the association between different risk factors of

hypertension by binary logistic regression analysis.

A significant relationship was observed between

hypertension and consumption of extra salt, frequentintake of pain killers (NSAID- non steroidal anti

inflammatory drug), alcohol and tobacco. Similar to our

study additional salt intake was identified as a risk factor

of hypertension in a study conducted in Singur block of

Hooghly district of West Bengal (Sadhukhan and Dan,

2005). On the contrary, in rural Tamil Nadu no

significant association between hypertension and salt

intake among adults was observed. (Gilberts et al.,

1994).

All non-steroidal anti-inflammatory drugs

(NSAIDs) in doses adequate to reduce inflammation and

pain can increase blood pressure in both normotensive

and hypertensive individuals [Warner and Mitchell,

2008]. A significant association of smoking and

hypertension was revealed by Jajoo et al., (1993) in

rural Sevagram. Contrary to the findings of various

studies no significant association was found in the

present study. A strong correlation of BMI with blood

pressure was also reported in different studies

(Goel and Kaur, 1996). Risk factors identified were not

the same in all the studies conducted in different places

and hence there is a need for identification of risk

factors in the specific area for better prevention and

control of hypertension and its complications.

CONCLUSION:

As India continues to undergo economic growth

and demographic transition, the burden of hypertension

is likely to increase. Identifying and controlling

hypertension may be one of the most important and

least expensive ways in which India can help to control

its disease burden in the coming decades.

The hypertension epidemic has been clearly highlighted

as an important public health problem. To effectively

combat this reality, a multifaceted approach is needed

aiming at reduction of life style risk factors and creating

awareness on prevention and effective control in termsof diet, medication and relaxation. Health planners

should develop strategies for the prevention and control

of the increasing trend of hypertension considering

these findings.

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