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 pressure
was 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
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www.jhealth.info
Journal of Research in
Public Health
An International
Scientific Research Journal
Authors:
Pauline Suganthy
Vijayabarathy and
Pushparani D.



Institution:
Associate Professor in
Applied 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 Pushparani D.
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 Health
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An International Scientific Research Journal
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 cardiovascular
morbidity 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 an
unrelated 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 of
studies 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 identify
the 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
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 blood
pressure 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) / stature
2
(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 71.3
3 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 21.7
50-59 486 30.7 164 23.9 109 23.4 55 24.9
>59 240 15.2 233 34.0 146 31.4 87 39.4
TOTAL 1583 100 686 100 465 100 221 100
Pearson Chi-Square : 13.997; df:4; significance 0.007; p.value<0.05;0% have expected count less than 5


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 years
Male Female
HT cases Percentage % HT cases Percentage %
20-29 17 6.8 21 4.8
30-39 38 15.3 77 17.6
40-49 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/Hg
Male Female Total
No Percentage% No Percentage % No Percentage %
Pre hypertension (81-89) 32 12.9 38 8.7 70 10.2
Mild hypertension (90-99) 132 53.0 225 51.5 357 52.0
Moderate hypertension (100-109) 56 22.5 112 25.6 168 24.5
Severe hypertension (>=110) 26 10.4 55 12.6 81 11.8
Isolated systolic hypertension
(Diastolic<80 Systolic >140)
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
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 male
hypertensive 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.
Among the hypertensive cases, (Table-6) 60.2%
had higher waist hip ratio. High proportions of female
respondents with a higher waist hip ratio (80.3%) were
recorded in this study. Similar observations were
Pauline and Pushparani, 2012
Journal of Research in Public Health (2012) 1(2): 037-046 041
BMI Values
Male Female
No: of cases Percentage %
No Percentage % No Percentage %
< 18.5 - Under weight 18 7.2 29 6.6 47 6.9
18.5-22.9 - Normal 98 39.4 113 25.9 211 30.7
23-24.9-At risk obesity 45 18.1 70 16.0 115 16.8
25-29.9 -Grade I obesity 71 28.5 167 38.2 238 34.7
30 - Grade II obesity 17 6.8 58 13.3 75 10.9
Total 249 100 437 100 686 100
Test of Significance: Pearson Chi square=19.842; df:4; Sig:0.001; p value>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
<0.91 187 75.1 <0.81 86 19.7 273 39.8
Total 249 100 Total 437 100 686 100
Table: 6 Waist hip Ratio of Hypertensive cases


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 physical
activity, 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
Hindu
Christian
Muslim

499
79
108

72.6
11.5
15.7

1133
158
292

71.6
10.0
18.4
2 Type of family
Nuclear
Joint

570
116

83.1
16.9

1446
137

91.3
8.7
3 Nature of work
Sedentary
Moderate
Heavy


463
97
126

67.5
14.1
18.4

209
1088
286

13.2
68.7
18.1
4 BMI
<18.5
18.5-22.9
23-24.9
>=25-29.9

47
211
115
313

6.9
30.7
16.8
45.6


195
642
365
381


12.3
40.5
23.1
24.1
5 Tobacco
Yes
No

449
237

65.5
34.5

117
1466

7.4
92.6
6 Alcohol
Yes
No

152
534

22.2
77.8

55
1528

3.5
96.5
7 Family history
Yes
No
No idea

202
380
104

29.4
55.4
15.2

66
1471
46

4.2
92.9
2.9
8 Salt intake
High
Moderate
Low

251
391
44

36.6
57.0
6.4

71
1346
166

4.5
85.0
10.5
Table: 7 - A comparative study on life style factors between the hypertensive and the
Normal cases of the study population
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 study
conducted 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% of
hypertensive 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* 1.057
3 Height 1.392 2.917 0.228 1 0.633 4.023
4 Weight -0.044 0.034 1.600 1 0.206 0.957
5 BMI 0.143 0.086 2.745 1 0.098 1.154
6 Religion 0.025 0.113 0.047 1 0.827 1.025
7 Physacti -1.031 0.121 72.633 1 0.000* 0.357
8 Tobacco -3.186 0.192 275.104 1 0.000* 0.041
9 Alcohol -3.362 0.299 126.401 1 0.000* 0.035
10 Pain_Kil -3.129 0.187 280.395 1 0.000* 0.044
11 Famihist -0.793 0.190 17.380 1 0.000* 0.453
12 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


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, frequent
intake 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 terms
of 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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