Review of literature

The literature available on the work done so far in India and abroad was
reviewed as per the objective of the present study and has been presented under the
following sections:-

 Prevalence of Hypertension
 Risk factors of Hypertension
 Anthropometry
 Dietary pattern
 Management of Hypertension

Prevalence of Hypertension
The prevalence pattern of Hypertension in developing countries is different
from that in the developed countries. A total of 1609 respondents out of 1662
individuals participated in our cross sectional survey of validated and structured
question nature followed by blood pressure measurement. Results showed pre-
hypertensive levels of blood pressures among 35.8 percent of the participants in
systolic group (120-139 mm of Hg.) and 47.7 percent in diastolic group (80-89 mm
of Hg.). Systolic hypertension (140 mm of Hg.) was present in 40.9 percent and
diastolic hypertension (90 mm Hg.) in 29.3 percent of the participants. Age and
sex-specific prevalence of hypertension showed progressive rise of systolic and
diastolic hypertension in woman when compared to men.(Das SK, et al., 2005).

The overall prevalence of hypertension to be 36.4 per cent in India based

parsi community of Bombay. Out of which 48.5 per cent were unaware of their
condition and 36.4 per cent of those aware of having hypertension were non
compliant with their anti hypertensive drugs. Prevalence of isolated systolic
hypertension (SBP ≥ 160 mm Hg. With DBP< mm Hg.) Was found to be the
dominant from or HTN and mostly prevalent in elderly (≥60 years) people.
Whereas, Shanthirani et al., (2003) found hypertension to be prevalent in 21
percent of two residential area population (>20 years) of Chennai, South India.
(Bharucha and kuruvilla ,2003).

Repoted that recent studies using revised criteria (BP> 140 and / or > 90mm
Hg has shown a high prevalence of hypertension among urban adult (male: female)
i.e. 30.33 per cent in jaipur (1995), 44.45 per cent in Mumbai (1999), 31.36 percent
in Thiruvananthapuram (2000) and 14 per cent in Chennai (2001). Among the
rural population, Hypertension prevalence was 24 (men) and 17 per cent (women)
in Rajasthan (1994) and 4.5 per cent in rural subject in Haryana (1999). Moreover,
the overall prevalence of HBP was reported to be 25 per cent in urban and 10 per
cent in rural population of India, out of which 70 per cent were in stage I HTN
(140-159 systolic and/ or diastolic BP 90-99mm Hg). Borderline HTN and stage
HTN carried a significant cardiovascular risk and thereby necessitated a need of
population based cost effective Hypertension control strategies to be developed.
Gupta (2004).

Further, gupta R from jaipur, through three serial epidemiological studies

(Criteria:>= 140/90 mm of Hg) carried out during 1994, 2001 and 2003
demonstrated rising prevalence of hypertension (30%, 36%, and 51% respectively
among males and 34%,38% and 51% among females).R gupta (1985).

Few studies were carried out comparing different socio economic groups.
The intial study from urban Chennai, Mohan et al62 reported 8.4% prevalence of
hypertension among men and women aged 20 years and above and belonging to
the low socio economic group (based on household income, occupation and dietary
pattern).sililary, in the middle socio economic group had a higher prevalence
(15%) during 1996-97. Misra( 1995).

A study conducted in the urban areas of Chennai during 2000

Ramachandaran et. al., (2002) (age group>=40) reported a higher prevalence of
hypertension (54%) among low income group (monthly income> Rs 30000/annum
and 40% prevalence among high-income group (monthly income > Rs
60000.annum. Reported 12% prevalence of Hypertension in the slums of Delhi.
JR Sharma(2000).

Studies were included only when the prevalence of MH was reported, office
blood pressure in detail. All data were extracted independently by two readers with
a standardized protocol and data- collection from the prevalence of MH averaged
16.8% (95% confidence interval 13.0-20.5%) the MH prevalence was 7% for
children and 19% for adults. MH prevalence did not differ significantly when
determined with self or ambulatory BP measurement (21.1% vs 16.8%; P=0.42).
subjects with MH had significantly higher left ventricular mass index (LVMI)
values than normotensives (110 vs. 98 g /m; P<0.01) but similar values as
sustained hypertension (109 g/m ). In addition, patients with MH were more often
smokers than normotensives (mean difference 18%; P<0.03).Willem J (2008).

The prevalence of population wide hypertension,obesity and dyslipidemia has not

been well studied 2251 pasture area of xinjiang. The present epidemiological study
was performed to determine the prevalence of hypertension area of xinjiang. The
present epidemiological study was performed to determine the prevalence of
hypertension , obesity and dyslipidemia in minority populations from the porential
risk factors for hypertension. Frommlet F and Znal L (2010).

A total of 482 individuals (212 males and 270 females) were interviewed in
the measurements was taken. Overall prevalence of hypertension was 47% (n-
226)with equel sex ratio; 109 (21.6%) had stage –I hypertension, 45 (9.34%) had
stage11 hypertension and 72 were prehypertensives. Only 81 (16.8%) hypertensive
patients were aware of their disease. Among the parameters such as dietary habits,
physical activity, educational standards, salt intake, and diabetes mellitus, only
high salt diet (P=0.03) and diabetes mellitus (P=0.004) had a significant
association with hypertensive state. Vimala, and anji (2009).

Cross-sectional surveys were conducted in six-twenty urban streets in

different cities from five different corners of India. there were 3212 randomly
selected women from Moradabad (n=902), Trivandrum (n=760), Calcutta (n=365),
Nagpur (n=405) and Bombay (n=780),aged 25-64 years, the prevalence of
hypertension (>140/90 mm Hg ) was significantly (P<0.01) high in Trivandrum,
south India (30.7%) and Bombay, west India (28.0%), Compared to Morabad ,
which is in northern India (22.6%), Nagpur in central India (24.2%) and Culcutta,
in east India (19.1%) mean systolic and diastolic hypertension east the most
common form of hypertension (50.5%,n=1506 ) in the five Indian cities.
According to old criteria, the overall prevalence of hypertension (>160.95 MM
Hg ) was 14.8% (n=481). Multivariate logistic regression analysis on pooled data
from the five cities, after adjustment for age, showed that age (odds ratio
1.16),body mass index (1.68) and obesity were strongly associated with
hypertension. A sedentary lifestyle and salt intake were weakly associated and
alcohol intake was not a factor with these women. Ryanp (2007).
 The study was undertaken in three selected villages of chiraigaon
community. This study was primarily directed towards estimating the magnitude.
Kumar S and Mishra (2008).

Risk factors of Hypertension

A cross-sectional study was designed. In this study, multiple logistic

regression and receiver operating characteristic analysis were performed on order
to obtain the precise relevance of each anthropometric measurement as a blood
pressure marker. Nine hundred and thirteen men, 36±8years-old, were submitted to
a standardized questionnaire of demographic and risk factors, Knowledge,
anthropometric and conventional blood pressure measurements were taken, and
blood sample evaluations of glucose, total cholesterol, LDL cholesterol and
triglycerides were performed. Overweightness or obesity was identified 64, 11.1%
were smokers and hypertension was detected in 29.2% of the participants. A linear
correlation was significant (p<0.001) between both the systolic pressure and waist-
to-hip ratio. Waist circumference (WC) was the only independent anthropometric
measurement related to hypertension. Hypertensive patients presented all
anthropometric measurement larger than normotensives. S.L.Cassani (2008).

Compute red the differences between dietary and non dietary factory in
Hypertension and normal blood pressure (BP) of Chinese urban people (2068
subject aged 35-64 years). Age, BMI, overweight and family history of
Hypertension were found to be positively associated to high BP. Moreover, the
whole population reported high na intake and low consumption Na-K levels.
Education level in women and physical activity in men were found inversely
associated with the high BP Condition. Hu and tian (2001).

Age

Reported that systolic blood pressure (≥140 mm Hg) increased from 4 per cent (18-
29 year age group) to 36 per cent among persons 60 years of age of age or older
and revealed that age was independently associated with higher prevalence of
Hypertension. Shah et.al., (2001).
Conducted a cross sectional survey of 314 middle aged subjects (163 men; aged
40-60 years) in urban population of thiruvanathapuram, Kerala and found over half
of all middle aged individuals to be hypertensive and older age was reported to be
associated with an increased prevalence of Hypertension. Zachariah et. al., (2003)

Genetic factors

Compared US born and African born health professionals in a cross sectional

survey with respect to genetic and psychological predictors of hypertension.
Among three genetic loci reported to be associated with increased Hypertension
risk, the AGT-235 Homozygous T genotype was found more frequent among
African born participants than US born African and conclude that US born African
American have different genotype distribution that increases their risk of
Hypertension. Poston et al., (2001)

Socio-economic status

Conducted a cross sectional study to examine the association between socio-

economic status (SES) and Hypertension (SBP≥140 / DBP≥ 90 mm Hg) in 2082
adults in Jamaica. The income distribution of BP and Hypertension were non
linear and moreover, the Hypertension was found to be the highest in wealthiest
women, in men with same high school education, income was positively associated
with BP and therefore suggested the need to identify behavioral and environmental
factors for effective Hypertension management strategies. Mendez et al ;( 2003)

Evaluated the economic and education related inequalities in blood

association of SBP with increasing income and education in women, whereas, on
consistent association was found between education or income and BP in men.
Guilford et al; (2004)

SMOKING

Reported that smoking has been associated with increasing risk of

Hypertension, diabetes, hyperlipidema and cardiac diseases. Modifiable
independent determinant of stocke. especially current-smoking was found to be
crucial and extremely modifiable independent determinant of stroke. Boden-
Albala and sacco (2000)
Alcohol consumption

Evaluated the relationship between alcohol consumption and blood pressure

(BP) in healthy normotensive men with daily consumption of red wine,
dealcoholized red wine or beer. The results of the study showed that both red wine
and beer significantly (P>0.05)increased awake systolic BP i.e. 2.9 and 1.9 mm Hg
and asleep heart rate (5.0 and 4.4 bpm) respectively, therefore concluded that red
wine polyphenolics do not have a significant role in mitigating the blood pressure
elevating effects of alcohol in men. Zilken et. al., (2005)

STRESS

Assessed the association between job strain and blood procure in our
population samples of age 25to 54 years from northern Italy. Among men there
was a 3mm Hg increase of systolic blood pressure (p<0.001) moving from low to
high strain job categories whereas, no revant difference were found among job
strain categories in women and for diastolic blood pressure in both gender group.
Cesena et al., (2003)

Anthropometry
Studied the effectiveness of WHtR for assessing central fat distribution
among Japanese people (6141 men and 2137 women). The correlation coefficient
was found between WHtR and the morbidity index for coronary risk factors
including Hypertension. Nearly all overweigh men and women (BMI ≥ 25) had
WHtR ≥0.5 (98.5% for men and 97.5% for women and therefore. Concluded
WHtR as the best one, simple and practical anthropometric index to identify higher
metabolic risks in normal and overweigh population. Healthy subjects 20 females
and 101 males { age 47 +9 yr. B.M.I29.+5, Umbilical circumference 994 mm +
116, hip circumference 1002+ 74 mm, WHR 0.94+0.07, Systolic Blood pressure
=142+7 mm Hg, Diastolic Blood pressure=86+5 mm Hg.) Hsieh et al., (2003)

.
 Reported WHtR as a valuable obesity index for predicting diabetes
Hypertension and lipidemia based on the study conducted on a large cluster
sampling of 16,818 rural inhabitants in Dhaka (aged> 20 years). The mean (SD)
values of BMI,WHR, and WHtR were significantly high and highest for WHtR.
Sayeed et al; (2003

Studied the relationship of anthropometric measurements to the blood

pressure in 230 elderly i.e. 83 men and 110 women over 65 and 60 years,
respectively. The weight, waist and hip circumferences were measured and WHR
and BMI were calculated. 75 per cent of the people were considered to be obese or
overweight according to BMI. Moreover,75 per cent of the people belonged to risk
group according to WHR and also had Hypertension (>140>90mm Hg). Rurik et
al., (2004)

Studied the association of short stature in adult population (age>18 and < 60
yrs) with arterial Hypertension and obesity. The systolic (>140 mm Hg ) and
diastolicartial Hypertension (90 mm Hg ) reading were found significantly higher
in women in the 1st quartile(Q) than in those in 4th Q of height distribution.
Hypertension was found to be more prevalent in women (50 %) who were obese
and short than in those who were obese but not short. Moreover, found that stature
to be negatively correlated with Hypertension and overweight in women.
Florencio et al., (2004)

Evaluated three commonest obesity measurements (BMI,WC and WHR) to

examine the relationship between 24 hour ambulatory boold pressure monitoring
(ABPM) in 370 essential hypertensive patients aged 18-86 years (56.76% women
and 75.86% men).The finding of the study indicated that the prevalence of
Hypertension was high in obese patients and WHR offered additional beyond BMI
and WC to predict the Hypertension risk according to the ABPM. Feldstein et at.,
(2005)

Dietary pattern
The objectives of this study were to identify the dietary patteners associated
with hypertension among Korean males. Data from the 2001 Korean. National
Health and Nutrition survey of 1,869 men aged 20-65 years were used for the
analysis. As an initial analysis, a factor analysis was applied. As a result of the
initial analysis, three major dietary patterns were identified. Dietary pattern 1
(traditional ) was heavily loaded with vegetables, Fish and cereal. Dietray pattern 2
(Western) was loaded with fast foods, bread, meats and dairy products. Dietary
pattern 3 (Drinker ) was loaded With mostly pork, beer and soju (Korean liquor).
From the second stage of the analysis, there was a tendency of positive association
between traditional Patterns and hypertension risk. However, the rendency did not
meet statistical significance level(p<0.05). In summary, Unlikely findings.
However, the full explanation of the finding remained to be answered with further
investigation since none of the dietary patterns identified showed any statistical
significance. conducted a population based health survey in subjects aged 30 to 79
years and revealed that the subjects with elevated serum calcium levels than those
with normal PTH. Moreover, the systolic and diastolic blood pressures were found
to be significantly higher in females with elevated serum PTH. Jorde et al., (2000)

Compared the differences of dietary and non dietary factors of hypertension

and normal blood pressure (BP) in Chinese Urban people (2068 subjects aged 35-
64yrs). The whole population had a high sodium and low potassium consumption
levels and moreover, hypertensive subjects had significantly higher daily dietary
sodium intake (P>0.05) and higher dietary Na and K ratio (P<0.01) than the
subjects with the normal BP. Hu and tian (2001)

Conducted a dietary survey to study the prevalence of essential

hypertension in relation to diet and salt among different communities of Mumbai
(india). The findings revealed a high incidence of HTN among communities of
with high salt intake (Marwaris, 15.25%, Kannadigas 20.75%), however, the
Punjabi group had the lowest salt significant (P<0.01)correlation of calories, fat
and salt intake was found with the blood pressure of the subjects. Mathur (2004)

Lifestyle modifications
Discussed the role of lifestyle factors like nutritional factors, alcohol,
physical activity, smoking and obesity in the prevention and treatment of
hypertension and thereby concluded that physicians should be motivated to provide
guidance to the population relative to lifestyle practices that can help prevent and
control hypertension. Campbell et al., (1999) also reported the recommendations
on lifestyle modification i.e. maintain a healthy BMI, limit alcohol intake (2 or
fewer standard drinks/day), Exercise regularly, restrict sodium intake and
individualize behavior modification to reduce the negative effects of stress to
maintain or reduce the risk of Hypertension for Canadians. Disky and janick
(2001)

Determined the effect of aerobic exercise on blood pressure in participants

whose intervention and control groups differed only in aerobic exercise. Aerobic
exercise was found to be associated with a significant reduction in mean systolic
(03.84 mm Hg) and diastolic blood pressure (-2.58 mm Hg) in all participants. The
study concluded that an increase in aerobic physical activity should be considered
as an important component of lifestyle modification for prevention and treatment
of high blood pressure. Wheaton et al., (2002)

Reported exercise to be associated with reduction in blood pressure (SBP 3.5

mm Hg and DBP 2.0 mm Hg ) weight loss of 8 kg in overweight hypertensive
patients resulted in reduction of 8.5 (DBP) and 6.5 mm Hg (DBP). Moreover, a
combined exercise and weight loss intervention has been shown to decrease SBP
and DBP by 12.5 and 7.9 mm Hg, respectively and reported the positive role of
behavioral intervention in the management of high BP. Bacon et al. (2004)

Conducted a study to find out whether regular physical activity can reduce
the risk of Hypertension in both men and women and in subjects with or without
overweight. Multivariate adjusted hazard ratios of Hypertension associated with
light , moderate and high physical activity were 1.00,0.63 and 0.59 in men
(P<0.001) and 0.71 in women (P<0.001), respectively. The study indicated that
regular physical activity and weight control can reduce the risk of Hypertension
and its protective effect was observed in both sexes regardless of the severity of
obesity. Hu et. al., (2004)

Conducted a study in Japanese male office workers (aged 35 to 59 years)

who were without Hypertension and had no history of cardiovascular diseases.
Daily energy expenditure was estimated by a one day activity record during an
ordinary weekday over 7 successive years. Mean SBP and DBP in each follow up
year decreased as daily energy expenditure and increased. The risk of hypertension
was found to inversely related to daily energy expenditure are thereby daily
activity as an effective for prevention of Hypertension. Nakanish and Suzuki
(2005)

MATERIALS AND METHODS

An appropriate selection and application of scientific methodology adds to clarity
of research design. This chapter therefore elucidates in details the methodological
steps used for present investigation distinctively described under the following
headings:-

1. Domain of the study.

2. Sampling procedure.
3. Development/ construction of questionnaires and collection of data.

1. Domain of the studies:-

The present study was undertaken in the G.V.Home Sc. Women P.G.
Collage Sangaria

2. Sampling Procedure :-
The present study was conducted on a total of 70 patients
hypertensive subjects of age 30 years and above, selected randomly from
Hanumangarh city.

3. Development/ construction of questionnaires and collection.

Firstly a preliminary survey of few subjects was conducted to

investigate their dietary habits and other baseline information for further
investigation .

3.3.1Questunnaire/ interview schedule-:

A well structured and exhaustive questionnaire was formulated after

consulting literature collect the relevant information specifically keeping in
mind the objectives if the study. For the pre-testing of questionnaire, 10
questionnaires were got filled up by hypertensive patients other than the
selected subjects and then evaluated for responses of the subjects. On the
basis of collected information and difficulties faced, necessary
improvements/ modifications were incorporated to make it more functional
and the finalized questionnaire (Appendix-1) was used for final data
collection.

3.3.2 Collection of data:-

Data was collected through personal interview method. An effort was made
to develop a rapport with the subjects to extract correct information as for as
possible. Cross checking and indirect quthenticity of the study, the data was
collected through a well structured questionnaire cum interview schedule
which was divided in various selection viz.