J. Lumbini. Med. Coll. Vol 7, No 2, July-Dec 2019 Karki D et al. Prevalence and Associated Risk Factors of Hypertension Among Adults in Palpa District, NepalKarki D et al. Prevalence and Associated Risk Factors of Hypertension Among Adults in Palpa District, Nepal 107 Licensed under CC BY 4.0 International License which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ Submitted: 5 September, 2019 Accepted: 7 December, 2019 Published: 19 January, 2020 a - Lecturer, Department of Community Medicine b - Lumbini Medical College Teaching Hospital, Palpa, Nepal. Corresponding Author: Deelip Kumar Karki e-mail: deelipkarki2039@gmail.com ORCID: https://orcid.org/0000-0002-3838-9993_______________________________________________________ ABSTRACT: Introduction: Hypertension mostly remains asymptomatic when controlled, however there is always an increased risk of heart disease, stroke and renal failure. The higher the blood pressure, the higher the likelihood of harmful consequences to the heart, blood vessels, eyes, brain and kidneys. Methods: A community-based cross-sectional study was conducted in adult population. The blood pressure was measured on left arm, the respondents in sitting posture and arm support at the heart level. Results: The prevalence of hypertension was 22% and higher in people above 60 years of age. Prevalence of hypertension was more in people who had elevated waist to hip ratio (65%) and positive family history (40.8%). The prevalence of hypertension was observed high among diabetics (63.2%) and smokers (33.3%). Conclusion: The prevalence of hypertension was seen positively associated with increasing age, smoking, alcohol sedentary lifestyle, diabetes, stress, central obesity and >25 BMI. Keywords: Hypertension, Prevalence, Risk factors Original Research Articlehttps://doi.org/10.22502/jlmc.v7i2.300 Deelip Kumar Karki,a,b Samata Nepal,a,b Keshav Raj Bhandaria,b Prevalence and Associated Risk Factors of Hypertension Among Adults in Palpa District, Nepal How to cite this article:How to cite this article: Karki DK, Nepal S, Bhandari KR. Prevalence and Associated Risk Factors of Hypertension Among Adults in Palpa District, Nepal. Jour-Jour- nal of Lumbini Medical College. 2019;7(2):107-112. DOI: nal of Lumbini Medical College. 2019;7(2):107-112. DOI: https://doi. org/10.22502/jlmc.v7i2.300. Epub: 2019 January 19.. Epub: 2019 January 19. INTRODUCTION: Globally cardiovascular diseases account for approximately 17 million deaths per year, nearly one-third of the total deaths.[1] Worldwide, nearly one billion people have hypertension; of these, two- thirds are in the middle- and low-income countries. Hypertension is one of the most important causes of premature deaths and the problem is growing. Approximately one-third of the adult population in South East Asia has high blood pressure.[2] Nepal Demographic and Health Survey (2016) showed that 17% of women and 23% of men aged 15 years and above had hypertension.[3] There are a number of behavioral risk factors responsible for hypertension including consumption of food with excessive salt and fat, eating not enough fruits and vegetables, alcohol and tobacco use, physical inactivity, obesity, poor stress management, family history of hypertension, high cholesterol and dyslipidemia. Addressing behavioral risk factors, e.g. unhealthy diet, harmful use of alcohol, smoking and physical inactivity can prevent hypertension. This study aimed to evaluate the prevalence and associated risk factors of hypertension in Palpa district, Nepal. METHODS: This was an observational cross-sectional study conducted in Ribdikot Rural Municipality and Tansen Municipality of Palpa district over a period of two months from May to July, 2019. Ethical approval was taken from Institutional Review Committee of the institute (IRC-LMC 01-C/019) prior to commencement of data collection. The sample size was calculated using the formula: N>Zpq/e2; where, Z= 1.96; prevalence of hypertension (p)=41%[4]; q=1-p and margin of error (e)=5%. The minimum sample size thus calculated was 371.71. A total of 372 participants were taken for the study. Interview schedule was developed and J. Lumbini. Med. Coll. Vol 7, No 2, July-Dec 2019 Karki DK et al. Prevalence and Associated Risk Factors of Hypertension Among Adults in Palpa District, NepalKarki DK et al. Prevalence and Associated Risk Factors of Hypertension Among Adults in Palpa District, Nepal 108 jlmc.edu.np informed consent was taken from the participants. Multi stage sampling method was adopted for the study. The blood pressure was measured on the left arm in sitting quietly on a chair with feet on the floor, legs uncrossed and the arm supported at the heart level. The first reading was taken at least after 15 minutes of rest. The second measurement was obtained after the participant had rest for at least three minutes of the first measurement. If the two readings were different, their mean wasnoted. The systolic blood pressure was recorded at phase I Korotkoff sounds, while the diastolic blood pressure was recorded at phase V Korotkoff sounds. Similarly, systolic blood pressure < 140 mm of Hg and diastolic blood pressure < 90 mm of Hg was considered normal blood pressure. Systolic blood pressure as of 140 mm of Hg or above and/or diastolic pressure 90 mm of Hg or above was considered Hypertension. [5,6] Participants currently on antihypertensive medication were also considered hypertensive. Weight of the participants was measured by weighing machine. To measure height, the participant was made to stand vertically against the wall and just over the head, height was marked on the wall and measured with a measuring tape.Body Mass Index (BMI) was calculated as weight in kilograms divided by square of height in meters (kg/ m2) and classified into four groups as underweight (BMI< 18.5 kg/m2), normal weight (BMI 18.5- 24.9 kg/m2), overweight (BMI 25-29.9 kg/m2) and obese (BMI≥30 kg/m2).[7] Waist circumference was measured over light clothing while breathing out, relaxing and not contracting any abdominal muscles at a level midway between the lower rib margin and the iliac crest in centimeters rounded up to nearest 0.5 cm. Central obesity was defined as increased waist circumference > 88 cm in women and more than >102 cm in men. A waist-to-hip ratio >1.0 for men and >0.8 for women was also considered central obesity.[8] Current smoker was defined as someone who has smoked greater than 100 cigarettes in his life time and smoking every day or some days over the past 6 months. Non-smoker was defined as someone who has not smoked greater than 100 cigarettes in his life time and does not currently smoke.[9] Physical activity was classified as: [10] High: a. Vigorous-intensity activity on at least three days achieving a minimum total physical activity of at least 1500 min/week, or b. seven or more days of any combination of walking, moderate-intensity or vigorous intensity activities achieving a minimum total physical activity of at least 3000 MET-min/week Moderate: a. Three or more days of vigorous-intensity activity of at least 20 min per day, or b. five or more days of moderate-intensity activity and/or walking of at least 30 min per day, or c. five or more days of any combination of walking, moderate-intensity or vigorous intensity activities achieving a minimum total physical activity of at least 600 MET-min/week. Low: a. Low is the lowest level of physical activity. Those individuals who did not meet the criteria for moderate and high were considered low. Total amount of alcohol intake was calculated in number of standard drinks (10 grams of pure ethanol). Any participant who drank alcohol within the last 30 days of data collection was defined as current alcohol user. All the data were collected in a preformed proforma. They were entered to and analyzed using Statistical Package for Social Sciences (SPSSTM) software version 16. Qualitative data were expressed in frequencies and percentages. Chi square test and odds ratio were used to analyze the data. A p-value <0.05 was considered statistically significant. RESULTS: There was a total of 372 participants in the study. Most of the participants were 40-59 years of age group and more than half (52.7%) were female. Most of them (61.6%) were Brahmin or Chhetri. More than one quarter (26.3%) were farmers and 15.3% were illiterate. Table 1 shows the age and gender distribution of normotensive and hypertensive participants. Table 2 shows that 9.5% of the participants in the age group 20-39 years had hypertension whereas 34.8% of those of age 60 years and above had the condition. There was no statistically significant difference in the prevalence of hypertension in terms of sex (p=0.422) and ethnicity (p=0.145). Prevalence of hypertension was found more among illiterate than literate. Prevalence of hypertension was high in those with elevated waist/hip ratio as compared to normal waist/hip ratio (p<0.001, OR= 9). Similarly, 65.3% of those with BMI >25 kg/m2 had hypertension and higher prevalence (40.8%) was found in those with positive family history J. Lumbini. Med. Coll. Vol 7, No 2, July-Dec 2019 Karki DK et al. Prevalence and Associated Risk Factors of Hypertension Among Adults in Palpa District, NepalKarki DK et al. Prevalence and Associated Risk Factors of Hypertension Among Adults in Palpa District, Nepal 109 jlmc.edu.np Table 1. Demographic characteristics of the study population (N=372). Variables Normal BP Stage 1 HTN Stage 2 HTN Under medication Age (years) 20-39 134 (36.0) 4 (1.1) 4 (1.1) 6 (1.6) 40-59 111 (29.8) 18 (4.8) 14 (3.7) 12 (3.2) >60 45 (12.2) 10 (2.8) 4 (1.1) 10 (2.6) Gender Male 134 (36.0) 17 (4.6) 10 (2.6) 15 (4.0) Female 156 (41.9) 15 (4.1) 12 (3.2) 13 (3.6) Table 2. Relation between blood pressure, demographic profile and other variables Variables Categories Number of Respondents Normoten- sion Hyperten- sion Statistics Age (years) 20-39 148 (39.8) 134 (90.5) 14 (9.5) χ2 = 23.7, p<0.00140-59 155 (41.7) 111 (71.6) 44 (28.4) >60 69 (18.5) 45 (65.2) 24 (34.8) Gender Male 176 (47.3) 134 (76.1) 42 (23.9) χ2 = 0.6, p=0.422 Female 196 (52.7) 156 (79.6) 40 (20.4) Ethnicity Dalit 63 (16.9) 55 (87.3) 8 (12.7) χ2 = 3.8, p=0.145 Janajati 80 (21.5) 61 (76.2) 19 (23.8) Brahmin/ Chhetri 229 (61.6) 174 (76.0) 55 (24.0) Education Illiterate 57(15.3) 40 (70.2) 17 (29.8) χ2 = 42.2, p<0.001 Primary 107(28.8) 63 (58.9) 44 (41.1) Secondary 103(27.7) 92 (89.3) 11 (10.7) Intermediate 73 (19.6) 65 (89.0) 8 (11.0) Bachelor and above 32 (8.6) 30 (93.8) 2 (6.2) Waist/ hip ratio Normal 332 (89.2) 276(83.1) 56 (16.9) χ2 = 48.1, p<0.001 OR= 9Elevated 40 (10.8) 14 (35.0) 26 (65.0) BMI <25 323 (86.8) 273 (84.5) 50 (15.5) χ2 = 61.4, p<0.001 OR= 10> 25 49 (13.2) 17 (34.7) 32 (65.3) Family history Yes 98 (26.3) 58 (59.2) 40 (40.8) χ2 = 27.2, p<0.001 No 274 (73.7) 232 (84.7) 42 (15.3) Smoking Yes 69 (18.6) 46 (66.7) 23 (33.3) χ2 = 6.2, p=0.012 No 303 (81.4) 244 (80.5) 59 (19.5) Alcohol consumption Yes 64 (17.2) 35 (54.7) 29 (45.3) χ2 = 24.3, p<0.001No 308 (82.8) 255 (82.8) 53 (17.2) Diabetes Yes 19 (5.1) 7 (36.8) 12 (63.2) χ2 = 19.6, p<0.001No 353 (94.9) 283 (80.2) 70 (19.8) Physical activity Low 180 (48.4) 130 (72.2) 50 (27.8) χ2 = 6.7, p=0.035 Moderate 170 (45.7) 142 (83.5) 28 (16.5) Heavy 22 (5.9) 18 (81.8) 4 (18.2) Stress Yes 40 (10.8) 8 (20.0) 32 (80.0) χ2 = 87.6, p<0.001No 332 (89.2) 282 (84.9) 50 (15.1) J. Lumbini. Med. Coll. Vol 7, No 2, July-Dec 2019 Karki DK et al. Prevalence and Associated Risk Factors of Hypertension Among Adults in Palpa District, NepalKarki DK et al. Prevalence and Associated Risk Factors of Hypertension Among Adults in Palpa District, Nepal 110 jlmc.edu.np of hypertension. Other factors such as smoking (p=0.012), alcohol consumption (p<0.001), diabetes (p<0.001) and sedentary lifestyle (p=0.035) were found statistically significant with hypertension. DISCUSSION: The prevalence of hypertension in this study was 22% which is similar to that of other studies. [11,12,13] This study further showed that the prevalence of hypertension was low (9.5%) in 20-39 years of age group but high (34.8%) among 60 years and above. This signifies the risk of hypertension increases with age. Similar result was obtained in another study.[14] Similarly, NDHS (2016) shows that the prevalence of hypertension increases with age. The lowest prevalence was observed among 30–39 years of age (21.7%) and the highest prevalence was 59.3% among participants above 60 years of age.[3] Arterial and arteriolar stiffness and increased sodium retention are related to rise of blood pressure with age.[15] With increasing age, the aorta and arterial walls are stiffened and this contributes to the higher prevalence of hypertension in older age groups.[16] The prevalence was slightly higher in males (23.9%) than females (20.4%) but the difference observed between them was not statistically significant (p=0.422). There was a statistically significant association between obesity (p<0.001), central obesity (p<0.001) and hypertension. The result was consistent with the findings from other studies conducted in Nepal.[17,18] Similar findings showed that having BMI ≥ 25 (Adjusted OR 2.0) was significantly associated with hypertension.[12] Another study found that obesity is a principal risk factor for development of hypertension.[19] The abdominal adipose tissue results in release of free fatty acids directly in the portal veins and altered lipid levels in the blood.[20] The free fatty acid release also results in endothelial dysfunction that develops hypertension. Obesity and central obesity mean greater fat stores, insulin resistance, increased salt retention, and decreased physical activity all these contribute to rise in blood pressure level.[21] This study found that 40.8% of participants with positive family history had hypertension. There was a significant relation between hypertension and positive family history (OR=3). Similar finding showed that those who had family history of hypertension were nearly six times more likely to be hypertensive when compared to those who did not have (OR 5.7).[12] There is statistically significant relationship between smoking and hypertension (p=0.012). Many studies have proved that cigarette smoking increases the risk of hypertension.[22,23] Alcohol consumption was also associated with hypertension (p<0.001). Different studies in Nepal have observed an association of alcohol consumption to hypertension.[17,18] Another study demonstrated that alcohol intake was positively and significantly associated with risk of hypertension.[24] This study showed association between alcohol, tobacco use and hypertension because it is more prevalent in tobacco users and alcohol users as compared to non-users. Our study depicted that around two-third diabetic patients had hypertension. Another study revealed that the participants who were diabetic were 16 times more likely to be hypertensive than those who were not (AOR=16.322, CI: 2.321-114.771).[25] CONCLUSION: This study evaluated the prevalence and associated risk factors of hypertension. Hypertension was found to be statistically significant with increasing age, smoking, alcohol consumption, sedentary lifestyle, diabetes, central obesity and BMI >25. Screening programs for early detection of hypertension and health education program for prevention and control of hypertension are glaring necessities in the studied region. Conflict of interest: The authors declare that no competing interests exist. Source of funds: No funds were available. J. Lumbini. Med. Coll. Vol 7, No 2, July-Dec 2019 Karki DK et al. Prevalence and Associated Risk Factors of Hypertension Among Adults in Palpa District, NepalKarki DK et al. 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