Indian Journal of Experimental Biology

Vol. 52, May 2014, pp. 542-548

Blood pressure variability and pedigree analysis of nocturnal SBP dipping in

Kumbas from rural Chhattisgarh, India
Razia Sultana & Atanu Kumar Pati*
School of Life Sciences, Pt. Ravishankar Shukla University, Raipur 492 010, India
Received 22 April 2013; revised 8 August 2013
Family is the smallest unit of people to share most of the lifestyle, environmental and genetic factors. They are likely to
have similarity in many physiological and behavioural aspects. Therefore, we designed a protocol to test the effect of large
rural Indian families living together (Kumbas), on blood pressure variability. We also investigated the hypothesis that
nocturnal dipping in systolic blood pressure (SBP) is not heritable. Members of two families (1 and 2) consisting of 3-4
generations willingly participated in the study. Both families (natives of Chhattisgarh) belong to reasonably peaceful rural
area and are financially stable. Farming is the main occupation of the members of both families. Few members of the
families had jobs or small business. The null hypothesis regarding heritability of nocturnal dipping trait was accepted based
on data emanating from either of the studied families. Hourly-averaged values depicted less variation in males and females
of family 1 from midnight to early morning at around 06:00, as compared to that in males and females of family 2. The 24 h
averages of BP in family 2 were significantly higher as compared to that in family 1. Further, in family 2 the peaks of SBP,
diastolic blood pressure (DBP) and mean arterial pressure (MAP) occurred significantly earlier as compared to that in family
1. The peak spread of SBP, DBP, heart rate (HR), MAP and pulse pressure (PP) among the members of family 1 was
narrower than that for the members of family 2. Arbitrary cut-off values for classification of dipping, small sample size, and
age dependency of nocturnal dipping might have marred outcome of the pedigree analysis of nocturnal dipping trait in this
study. We have a hunch that the family shares typical temporal ups and downs in 24 h BP and HR. The above hypothesis
needs confirmation based on studies with large data set involving subjective and objective assessment of the effects of
psychosocial factors on BP and HR variability.
Keywords: Circadian, Kumbas - large Indian families, Pedigree analysis inheritance of nocturnal dipping, Variability in BP

Blood pressure is influenced by several factors, such

as stress, emotions, depression, physical work,
temporal physiological changes, food habits, alcohol,
tobacco and genes1,2. As these factors are temporally
superimposed, it is extremely difficult to observe their
effects, in isolation, on BP dynamics. Secondly, these
factors may produce different effects on different
persons. Often, it is practically difficult to group the
subjects in a random population based on the role of
each factor. There are also some factors that produce
universal effects irrespective of traits of the subjects.
The time of the day factor is one among them.
The blood pressure variability along 24 h time
scale has been well studied. Nocturnal dipping is the
most studied characteristic of temporal BP variation.
It has been established that for each 10 mm Hg
increase in night time systolic blood pressure, the

*Correspondent author
Telephone:+91-771-3292885
Fax: +91-771-2262583
E-mail: akpati19@gmail.com

mortality risk increases by 21%3. Nocturnal dipping

between 10 and 20% is accepted as normal; however,
deviations from this cut off is considered as abnormal
and are termed as non-dipping (<10% nocturnal dip in
systolic blood pressure, SBP), extreme dipping
(>20% nocturnal dip in SBP) and rising (elevated
nocturnal SBP than corresponding day time SBP)4,5,6.
Abnormal nocturnal dipping is common in primary
and secondary hypertension and is often associated
with higher prevalence of strokes, cardiovascular
mortality and most importantly poor response to
antihypertensive treatment7,8.
Non-dipping is the most studied abnormality. It is
highly associated with severe cardiovascular damage,
poor vascular prognosis and higher risk for
cardiovascular morbidity9. Non-dipping is particularly
associated with enhanced carotid intima-media
thickening and thereby target organ damage10,
ischemic stroke11 and myocardial infarction12. Poor
long-term survival of non-dipper makes this category
more vulnerable13. In addition, other abnormalities,
such as rising signifies high risk of fatal strokes,

SULTANA & PATI: BP VARIABILITY & NOCTURNAL SYSTOLIC BP DIPPING

intracranial hemorrhage, target organ damage and

cardiovascular mortality5,11,14 and extreme dipping is
associated with lacunar stroke, silent myocardial
ischemia, silent cerebrovascular lesion14,15 and
ischemic stroke5. Study on inheritance pattern of
such an import BP characteristic (nocturnal dipping)
is meager.
Thus, 24 h BP measurement has prognostic and
diagnostic significance. However, the ambulatory BP
recordings in free living conditions are likely to be
influenced by environmental and lifestyle factors that
may mislead the investigators. Approximately two
decades before Spitzer et al.16 found that BP is the
lowest when person is with family as compared to
when he is with friends, professionals or strangers.
However, a solitary study on effect of family size
on hypertension by Bani17 documented higher
prevalence of hypertension in large families.
Investigations of this nature have not yet been carried
out for 24 h BP variations.
Therefore, we designed a study protocol to check
the hypothesis that the members of the large families
(Kumbas) living together, sharing most of the
environmental and life style factors will exhibit
similar pattern in 24 h BP variability. We also tested
the hypothesis that nocturnal dipping is not
heritable. We selected two large rural families in our
studies to test the above hypotheses.
Material and Methods
Selection of subjects and situationTwo
families living in a small semi-rural place, Kasdol
[Latitude: 21 37' 05" N. Longitude: 82 26' 49" E],
114 km away from State headquarters Raipur, were
chosen (Fig. 1). The area is calm, pollution free,
surrounded by forest and many tourist places. Locals
are basically farmers, but internet, television, mobile
phones, and other electronic gadgets are available and
are being used by some affluent villagers. Most
people, except older ones, are literate. Daily routine is
quite undisturbed, relatively less demanding and
nights are silent enough supporting a good sleep.
Overall the environment is favourable for studying
inheritability of nocturnal dipping in free living
conditions. The prevalence of hypothyroidism and
diabetes in the selected families is very low. We did
not exclude one or two members from the studied
population, who are suffering from metabolic
disorders, as our basic interest was to see 24 h
variability in BP.

543

Details of family 1 (Jagat family)This family

consists of 4 generations. Most of the members live
together. The food habits, time of food intake and
timings of sleep-wake schedule are similar for almost
all the members of the family. The eating habits are
traditional consisting of moderately low fats, more
seasonal vegetables, and fruits, and unpolished rice.
Most of the members in the family, including women,
youngsters and teens, are farmers. Most of the
members are literate and some of them occupied
government job. The socio-economic status of the
family is moderately strong. One of the members was
Surpanch of the place. Although the family belongs
to scheduled tribe, no economic backwardness was
observed. Overall life style was found to be healthy
and socially peaceful.
Details of family 2 (Banjare family)This family
consists of 3 generations. Most of the members live
together. The food habits, time of food intake and
timings of sleep-wake schedule are similar for almost
all the members of the family. They follow traditional
methods of cooking involving seasonal vegetables.
They consume fruits and appear healthy. The most of
the members are well-educated. The members are
traditionally farmers but few of them also work in
government offices and run petty business. Their
socio-economic status seems to be strong.
The average sleep and wake times of both
the families are similar; they go to bed at around
22:00 hrs and wake up at 06:00 hrs. Their lunch
and dinner times are also comparable and
were recorded between 12:00 to 13:00 hrs, and
20:00 hrs, respectively.
Objective and subjective recordingsThe subjects
were provided with Ambulatory Blood Pressure
Monitor (ABPM). The BP and HR were monitored
continuously for at least over two consecutive days.
The recording was automated at every 15 min during
the waking period and at every half hour during sleep
period. The data were downloaded to a personal
computer for further statistical analysis. Biographical
information on each subject was gathered and
tabulated (Table 1). Derived variables, such as mean
arterial pressure (MAP), double product (DP) and
pulse pressure (PP) were computed.
The ABPM recordings were made between June
and August for the members of the family 1
and between April and May for the family 2. All
members of family 2 were studied during the

INDIAN J EXP BIOL, MAY 2014

544

pre-monsoon period; while in the family 1, in

21 subjects [out of 44] recordings were made before
onset of monsoon. Therefore, we divided subjects of
family 1 into two groups, i.e., pre-monsoon group
and monsoon group and compared averages,
amplitudes and acrophases of rhythms in all variables
of both groups to ascertain if monsoon alters BP and
heart rate (HR) variability.
Data analysisThe data were retrieved by A&D
software. Cosinor rhythmometry18,19 was employed to
evaluate the parameters of circadian rhythm (=24 h)
in systolic blood pressure (SBP), diastolic blood
pressure (DBP) and HR. Other statistical techniques,
namely ANOVA followed by Duncans multiple
range test were used whenever pertinent. The data
were further analyzed via PC based statistical software
like, Excel ToolPak, and SPSS (Version - 10.0).
The pedigree charts were made for two families.
All the subjects were classified on the basis of
nocturnal dipping of SBP. The patterns of inheritance
dipping were observed for each family.
Result
Distribution in the pattern of BP variability
Family 1: Out of 44 family members, 23 were
dippers, 12 were non-dippers, 7 were extreme dippers
and 2 were risers (Table 1). Rhythm detection ratio
for SBP, DBP and HR was lower among non-dippers
and risers (Table 2).
Family 2: Out of 11 family members, 5 were
dippers, 4 were extreme dippers and 2 were risers.
Rhythm detection ratio for SBP, DBP and HR was
higher among dippers and extreme dippers of the
family. Out of two risers in the family, one displayed
insignificant rhythm in DBP and HR (Table 2).
Table 1Biographical summary of family 1 and family 2

Age (y)
Age Median (y)
BSA (Unit)
BMI (Unit)
D
ND
ED
R

Family 1

Family 2

28.37 2.98

26.54 4.31

Pedigree analysisThe visual analysis of pedigree

charts showed no inheritance pattern for the trait Nocturnal
dipping in either of the studied families (Fig. 1).
24 h BP and HR variation
Males of family 1 and 2: Data on BP and HR in
males of each family were pooled separately and
plotted against clock hour. A more smoothness in
SBP, DBP and HR variability was observed in males
of family 1 as compared to that in males of family 2.
The night-time period between 00:00 and 06:00-08:00
hrs was also very composed in males of family 1 as
compared to that in males of family 2. A prominent
afternoon dip at around 1500 to 1600 hrs in BP and
HR were observed in males of both the families (Fig. 2).
Females of family 1 and 2: Data on BP and HR in
females of each were pooled separately and plotted
against clock hour. A more smoothness in SBP, DBP
and HR were observed in females of family 1 as
compared to that in females of family 2. The night
time period between 00.00 and 06.00-08.00 hrs was
also very composed in females of family 1 as compared
to that in females of family 2. The afternoon dip in
females of both the families was not as prominent as of
their respective male counterparts (Fig. 2).
Table 2Rhythm detection ratio of family 1 and family 2
Subject group
Family 1

Family 2

Nocturnal
SBP (%)
Dipping Status

DBP (%)

HR (%)

0.82

0.78

0.91

ND

0.43

0.50

0.71

ED

1.00

0.71

0.71

0.00

0.50

0.50

1.00

0.60

0.80

ED

1.00

1.00

1.00

1.00

0.50

0.50

D=Dipper; ND=Non-dipper; ED=Extreme dipper; R=Riser

1.40 0.05
1.48 0.13
21.25 0.67
23.73 1.45
Nocturnal Dipping Status
23
12
7
2

5
4
2
0

BSA=Body surface area; BMI=Body mass index; D=Dipper;

ND=Non-dipper; ED=Extreme dipper; R=Riser

Fig. 1Pedigree chart of family 1 and 2 illustrates nocturnal

dipping of SBP in four generations. Circles represent female
members of the family and squares represent male members of the
family. Crossed circles and squares represent dead members of the
family. Green, yellow, red and purple colors represent dippers,
extreme dippers, non-dippers and risers, respectively.

SULTANA & PATI: BP VARIABILITY & NOCTURNAL SYSTOLIC BP DIPPING

MesorThe factor family produced a significant

effect on 24 h averages of SBP, DBP, MAP, DP and
PP. The 24 h averages of SBP, DBP, MAP, DP and
PP in family 2 were significantly higher as compared
to that in family 1 (Fig. 3). No significant effect of the
factor family was documented for HR.

545

AmplitudeNo significant change was documented

in amplitudes of any of the studied variables as
function of family (Fig. 4).
Peak occurrence and peak spreadThe factor
family produced significant effects on peaks of SBP,
DBP and MAP (Fig. 5). In family 2, the peaks

Fig. 224 h circadian variation of SBP, DBP and HR in males and females of family 1 and 2. The shaded area indicates period of sleep.

Fig. 324 h average of SBP (mm Hg), DBP (mm Hg), HR

(beat/min), MAP (mm Hg), DP and PP (mm Hg) as function of
family. [Factor family df1,55 (identical to all variables): F = 8.92,
P <0.01; F = 10.04, P<0.01; F = 6.61, P <0.05; F = 10.45,
P <0.01; F = 18.40, P <0.001 and F = 2.28, P = 0.14, respectively,
from ANOVA. Means bearing an asterisk significantly differ from
the corresponding mean of the other family].

Fig. 4A (% M) of SBP (mm Hg), DBP (mm Hg), HR (beat/min),

MAP (mm Hg), DP and PP (mm Hg) as function of family: [Factor
family df1,55 (identical to all variables): F = 2.71, P = 0.10; F =
0.79, P = 0.38; F = 0.53, P = 0.47; F = 1.39, P = 0.24; F = 0.48, P =
0.49 and F = 0.05, P = 0.83, respectively, from ANOVA. Means
bearing similar letters are not statistically significantly different
from each other (based on Duncans multiple-range test)].

546

INDIAN J EXP BIOL, MAY 2014

of SBP, DBP and MAP were detected at around

1130 hrs. The peaks occurred significantly earlier as
compared to that in family 1 observed in late
afternoon; at around 1400 hrs. The peak spread of
SBP, DBP, HR, MAP and PP, except DP, among the
members of family 1 was significantly narrower than
that among the members of family 2. The highest
peak spread was noticed in HR (19.97 h) of family 2,
and the lowest was noticed in SBP (0.62 h), PP (1.14 h)
and MAP (1.93 h) of family 1.
Monsoon and BP variabilityThe ABPM
recordings in the family 2 was conducted prior to
the onset of monsoon. Comparison of averages
(Mesors), amplitudes and acrophases of rhythms in
all variables between pre-monsoon and monsoon
groups of family 1 revealed a significant decline
in the average of PP and an increase in the amplitude
of HR in the latter (Fig. 6). The peak in the
SBP rhythm occurred earlier in the monsoon group as
compared with that of the pre-monsoon group
(Fig. 6). Apart from the above no changes were
noticed in other studied variables.

Fig. 5Peak of SBP (mm Hg), DBP (mm Hg), HR (beat/min),

MAP (mm Hg), DP and PP (mm Hg) as function of family.
[Factor family df1,55 (identical to all variables): F = 7.04,
P <0.05; F = 9.48, P <0.01; F = 1.22, P = 0.27; F = 8.50, P<0.01;
F =1.48, P= 0.23 and F = 1.18, P= 0.28, respectively, from
ANOVA. Means bearing an asterisk significantly differ from the
corresponding mean of the other family].

Discussion
Hypertension is growing faster among urban
dwellers due to stressful, sedentary and fast lifestyle.
On the other hand the rural dwellers are no longer
untouched from this health problem. However, rate of
increase in hypertensive cases is comparatively
slower in rural population. Among rural population
the causes of hypertension differ and are attributed to
poor socio-economic conditions, under nutrition and
illiteracy. Indian families, especially in rural areas are
traditional. With reference to their food habits, rituals,
festivals and other important daily activities, they
follow their traditions, without knowing the exact
reason for such practices. For example, in rural
Chhattisgarh area most of the villagers are farmers.
They wake up early and go to bed early. Nevertheless,
they are relatively less stressed. In addition, junk food
habits are less common among the youngsters. It was
that the lifestyle and environmental factors as well as
the previously studied causal factors of hypertension
for rural dwellers (mentioned above) are much less in
farmer families of rural Chhattisgarh. Therefore, these
types of population were selected for studying BP
variability and heritability of nocturnal dipping trait.
Fava et al.20 found partial recessive inheritance in
nocturnal dipping. In the present study, the visual
assessment of pedigree charts revealed no pattern of
inheritance (Autosomal or Sex-linked inheritance) in
the studied families. Therefore, the inheritance of
nocturnal dipping of SBP could not be confirmed in
either of the studied families. Arbitrary cut-off values,
small sample size and age dependency of nocturnal
dipping could possibly interfere with the human
pedigree analysis of nocturnal dipping pattern.
Thus, it is difficult to assess the inheritance of
nocturnal dipping pattern from overt rhythms in
ambulatory conditions.
Secondly, along with the genetic factors, nongenetic factors are reported to produce blood pressure
variations21. Previous reports on Victorian family

Fig. 624 h average of SBP (mm Hg), amplitude of HR and peak of SBP as function of monsoon. [Factor Monsoon df1, 44 (identical to
all variables): F = 6.62, P<0.05; F = 4.73, P<0.05; F = 5.82, P<0.05. Means bearing an asterisk significantly differ from the corresponding
mean of the other group].

SULTANA & PATI: BP VARIABILITY & NOCTURNAL SYSTOLIC BP DIPPING

heart study indicate that along with the genetic factors

familial environment is associated with cardiovascular
risk factors22,23. Although in the present study both
families displayed a significant circadian variation for
all the studied parameters, the raw data plotting
suggests less variation in males and females of family 1
from mid-night to early morning at around 0600 h, as
compared to that in males and females of family 2.
Blood pressure and heart rate of family 2 seemed to
be disturbed especially during sleep time. This
signifies that disruption of pattern in circadian blood
pressure could be initiated by social interactions.
Circadian clocks were evolved in response to
environmental conditions. Apart from physical
standards of time (mainly sunlight), social interactions
also play as zeitgeber for entrainment of biological
clocks, especially for social animals like humans.
Social rhythm stability hypothesis put forth by
Ehler et al.24 suggests that the disruptive social events
either major ones like death and break-ups or minor
ones like disturbance in normal routine of person or of
those around him can affect a persons circadian
rhythm. Human beings are psychologically and
emotionally attached to their families. They become
insecure and are prone to diseases when their family
passes through some sorts of turmoil25.
Two possibilities arise from the above discussion.
Firstly, the 24 h variations documented in families
could be genetic. Secondly, typical familial situation
produces positive or negative modulation of 24 h
blood pressure variations. Bani17 reported that large
family size contributes to hypertension; however, it
needs further confirmation.
Therefore, for studying the impact of lifestyle
factors on blood pressure, subjects of a family may be
more suitable than randomly selected subjects with
special reference to investigation of the pattern of 24
h blood pressure profile. The observed disorganized
fluctuations in blood pressure within the family could
be ascribed to psychosocial or any other familial
factor. At this moment it is difficult to ascertain the
exact cause of impaired pattern in BP and HR.
There are number of reports that have documented
seasonal variation in blood pressure26-29. The cardiac
disease-related mortality has been reported to be more
among elderly subjects in winter as compared to
summer26. These reports prompted us to compare the
pattern of blood pressure variability between
pre-monsoon and monsoon groups belonging only to
the family 1, as all members of the family 2 were

547

monitored prior to the onset of monsoon. The effects

of monsoon did not produce any wide spread effect on
the pattern of blood pressure variability at least at the
group level. The average of PP decreased and
amplitude of HR increased in the monsoon group as
compared with that of the pre-monsoon group. No
peer studies are available for comparison especially
regarding changes observed in PP, amplitude of HR
and advancement in the occurrence of peak in SBP.
However, the averages of SBP, DBP and HR
remained unchanged as function of timing of ABPM
recordings pre- and post-onset of monsoon. The
present findings neither contradict nor support earlier
reports26-29 that have highlighted seasonal variation in
BP, especially since, unlike this study that spanned
over a period of three months only, earlier studies
were conducted along longitudinal time scale
covering 12 or more consecutive months. There are
also contradictory reports regarding seasonal variation
in BP. Fine30 did not find any seasonal variation in
blood pressures of patients on hemodialysis.
Conclusion
Arbitrary cut-off values for classification of
dipping, small sample size, and age dependency of
nocturnal dipping might have marred pedigree
analysis of nocturnal dipping trait. The social or
familial influence documented on the characteristics
of circadian blood pressure rhythm may provide more
insights to 24 h BP and HR as members of the large joint
families share most of the lifestyle, environmental,
psychosocial and genetic factors. We have a hunch that
the family shares typical temporal ups and downs in 24 h
BP & HR. This hypothesis needs confirmation based
on studies with large data set involving subjective and
objective assessment of the effects of psychosocial
factors on BP & HR variability.
Acknowledgement
Thanks are due to the University Grants
Commission (UGC), New Delhi, for support through
its sDRS-SAP Scheme sanctioned to the School of
Life Sciences, Pt. Ravishankar Shukla University,
Raipur, in the thrust area, Chronobiology, and the
Department of Science and Technology (DST), New
Delhi, for supporting School of Life Sciences through
its DST-FIST program.
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