|Year : 2020 | Volume
| Issue : 9 | Page : 4705-4711
Association of obesity and pulse pressure with hypertension in an Iranian urban population
Mohammad Shojaei, Abdolreza Sotoodeh Jahromi, Rahmanian Karamatollah
Research Center for Noncommunicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran
|Date of Submission||28-Apr-2020|
|Date of Decision||11-Jun-2020|
|Date of Acceptance||21-Jul-2020|
|Date of Web Publication||30-Sep-2020|
Prof. Rahmanian Karamatollah
Research Center for Non.communicable Diseases, Jahrom University of Medical Sciences, Jahrom
Source of Support: None, Conflict of Interest: None
Objective: Nowadays, obesity is an important health problem and pulse pressure (PP) is a good predictor of cardiovascular events. The aim of study was to determine the association of obesity and PP with hypertension (HTN) in individuals aged 30 years or older in the urban population of Jahrom, Iran. Materials and Methods: In this study, we used a multistage stratified sampling method to select participants among the urban population aged 30 years or older. Height, weight, and blood pressure were obtained by a trained physician. Obesity was defined according to the World Health Organization classification. Angina was assessed with reliable and validate Rose questionnaire. Data were record by SPSS-16. Categorical and continues variables analyzed by Chi-squared, independent t-test, and one-way ANOVA test. Binary logistic regression analysis method was used for the association of PP and obesity with HTN and Rose angina that adjusted for age, gender, education class, marital status, smoking, total cholesterol, triglyceride, low-density lipoprotein, and high-density lipoprotein. A P < 0.05 was considered as statistical significance. Results: The prevalence of obesity was 18.1% that was greater in women (24.8% vs. 9.9%, P < 0.001). The prevalence of Rose angina and HTN in obese individuals were more than in normal weight individuals (24.8% vs. 16.4%, P = 0.027) and (42.0% vs. 31.1%, P < 0.001), respectively. Furthermore, patients in higher PP groups were older, were more possible to had HTN and had greater diastolic blood pressure (DBP), systolic blood pressure (SBP), and mean arterial pressure (MAP) in compared to individuals in the lower PP group. The individuals with HTN had greater DBP, SBP, MAP, PP, and body mass index (BMI) than individuals without HTN. However, individuals who had Rose angina, only had higher PP and BMI in compared to ones without Rose angina. The obese individuals had 1.97 (1.22–3.17, P = 0.005) fold for HTN risk than individuals with normal weight. In addition, PP weakly increased the risk of HTN about 1.09 fold (1.07–1.10, P < 0.001). However, Rose angina was associated only to overweight status (odds ratio = 1.51, confidence interval 95%: 1.03–2.20), P = 0.035) than individuals in normal weight group. Conclusion: Obesity and PP were higher in hypertensive individuals and overweight in individuals with Rose angina. It is time to pay more attention to abnormal BMI.
Keywords: Hypertension, mean arterial pressure, obesity, pulse pressure, rose angina
|How to cite this article:|
Shojaei M, Jahromi AS, Karamatollah R. Association of obesity and pulse pressure with hypertension in an Iranian urban population. J Family Med Prim Care 2020;9:4705-11
|How to cite this URL:|
Shojaei M, Jahromi AS, Karamatollah R. Association of obesity and pulse pressure with hypertension in an Iranian urban population. J Family Med Prim Care [serial online] 2020 [cited 2021 Sep 26];9:4705-11. Available from: https://www.jfmpc.com/text.asp?2020/9/9/4705/296330
| Introduction|| |
Obesity is considered as dangerous health problems, because of its association with morbidity, disability, and mortality. The prevalence of overweight and obesity is increasing in developed and developing countries. The World Health Organization (WHO) estimated that in 2005 about 1.6 billion and at least 400 million adults (aged > 15 years) were overweight and obese, respectively. In studies conducted in general population in Iran, the prevalence of obesity was 10.8–38.0%.
Overweight and obesity associated with high risk for health problems including; type two diabetes mellitus, prediabetes, hypertension (HTN), metabolic syndrome, and hyperlipidemia. Investigators found that blood pressure rose as body mass index (BMI) increased.,
Higher pulse pressure (PP) increases cardiovascular (CV) and cerebrovascular accidents and is an indicator of large artery stiffness. Investigators documented that morbidity and mortality following CV insults, including myocardial infarction (MI) was independently associated with PP., In addition, Weiss et al. found that PP was associated with all-cause mortality (hazard ratio = 1.69, 95% confidence interval [CI] = 1.19 − 2.38, P = 0.003) in elderly patients admitted to an acute geriatric ward. Bangalore et al. found that PP, as well as systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP), are independent and strong predictors of adverse outcomes. However, SBP, DBP, and MAP are relatively stronger predictors of CV events than PP. Higher PP had potent stress on arteries that caused higher fracture rate in elastic constituents. Intima of vasculatures becomes vulnerable to threat, thus the risk of atherosclerosis and thrombosis greater than before. In addition, increased PP caused more stress on the heart, which be able to result in cardiac disease. The prevalence of HTN and Rose angina, respectively, was 35.4% and 21.1% among individuals aged 30 years or over, in Jahrom, a south city in Fars province, Iran.,
Thus, in the present study, we determined the association of obesity and PP with HTN and Rose angina.
| Methods|| |
This investigation was based on a cross-sectional survey that adopted a cluster stratified systematic random sampling in urban area of Jahrom, a south city in Iran. Participants aged 30 years or older were selected from all urban health centers (10 centers) according to sex, age, and proportion of population in each health center. All called individuals interviewed face-to-face at internal clinic of Peymanie hospital and completed a demographic and a detailed medical questionnaire by trained interviewers. Pregnant and lactating women, people with chronic disease and mental disorders, and persons who were unable to walk, were not included in the study.
Eight hundred and ninety-one individuals participated in study. The procedures followed were in accordance with Ethical Committee on human experimentation of Jahrom University of Medical Sciences (ethics code: JUMS.REC.1378.51.7). Of all participants were obtained a written informed consent.
Height was measured, to the nearest 0.5 cm, without shoes. The weight was measured to the nearest 100 g (Seca700, Germany), with light cloths and without shoes. BMI was calculated as weight (in kilograms) divided by height (in meters) squared. The definition proposed by the WHO for three groups of BMI was used in this study. Individuals with BMI of less than 25 kg/m2 were classified as normal weight, those with BMI of 25 to <30 kg/m2 were classified as overweight and those with BMI ≥30 kg/m2 were classified as obesity. We also stratified the subjects by smoking status. Then, smoker was defined as subjects who used smoking material at least 1 day/week.
Blood pressure was measured after at least 5 min' rest, using a mercuric sphygmomanometer (Richter, Germany) by trained physician. The subject's right arm was placed at the heart level. Two measurements were taken with 5 min' interval. SBP and DBP were defined as the average of the two SBP and DBP readings. HTN was defined as an average SBP ≥140 mmHg, an average DBP ≥90 mmHg, according to JNC7. PP was calculated as subtracting DBP from SBP, and the individuals were categorized into three PP groups, by one-third; PP1: PP <40 mmHg, n = 315 (35.4%); PP2: PP 40–50 mmHg, n = 298 (33.4%); and PP3: PP >50 mmHg, n = 278 (31.2%). MAP was calculated as (2DBP + SBP)/3.
Angina was assessed by validate and reliable of Persian version of Rose questionnaire. Definite angina was defined according to standard criteria as chest pain or discomforts which: 1-was brought on by exertion, 2-was situated in the central or left anterior chest, 3-forced the subject to slow down or stop, 4-was relieved if the subject did so, and 5-was relieved within 10 min. Possible angina was defined as chest pain brought on by exertion, but not fulfilling all of the four additional criteria for definite angina. Totally, we use sum of definite and possible angina as Rose angina.
Continuous variables were presented as mean values and standard deviation (SD). Categorical variables were presented as frequencies. Associations between categorical variables were tested by the use of contingency tables and the Chi squared test. Comparisons between continuous variables between groups were performed by analysis of independent t-test or one-way ANOVA test. Binary logistic regression test was used for determining of PP and BMI groups with HTN and angina. The other entered variables in model were age, gender, education, marital status, smoking, total cholesterol, triglyceride, high-density lipoprotein, and low-density lipoprotein. The result is presented as odds ratios (ORs) with 95% CI. The statistical analysis was performed using SPSS software, version 16 (SPSS Inc., Chicago, IL, USA). Values of P < 0.05 were considered to indicate statistical significance.
| Results|| |
In total, of 891 participants, 45.3% were men and 89.5% were married. The most of participants (28.9%) belong to aged 40–49 years and then to 30–39 years (25.7%), 50–59 years (23.4%) and 60 years or older (22%), respectively. One hundred and forty (15.7%) of participants had academic level of, 39.8% ≥9 years of, and 25.6% primary of education. Also, 18.9% of individuals were illiterate.
As shown in [Table 1], the prevalence of obesity was 18.1% among participants that was higher in female (24.8% vs. 9.9%, P < 0.001) and in subjects with primary education (P = 0.023). Contrariwise, participants aged ≥60 years had lower prevalence of obesity (P = 0.021), and marital status had not effect on obesity percentage. Obese individuals had greater prevalence of HTN (P = 0.045) and Rose angina (P = 0.027) than individuals with normal weight. Also, individuals in the obese group had higher blood pressure components of DBP, SBP, and MAP than those in the normal weight group.
|Table 1: The prevalence of obesity according to age group, sex, education, and marital status|
Click here to view
Individuals in higher PP groups were older, were more possible to had HTN and had greater DBP, SBP, and MAP in compared to individuals in the lower PP group. Although there are higher proportions of individuals who reported Rose angina in the high PP group, statistically was not significant [Table 2].
The individuals with HTN had greater DBP, SBP, MAP, PP, and BMI than individuals without HTN [Table 3]. However, individuals who had Rose angina, only had higher PP and BMI in compared to ones without Rose angina.
|Table 3: Blood pressure components and body mass index according to hypertension and Rose angina|
Click here to view
In binary logistic regression analysis, the obese individuals had 1.97 (1.22–3.17, P = 0.005) fold for HTN risk than individuals with normal weight. In addition, PP weakly increased the risk of HTN about 1.09-fold (1.07–1.10, P < 0.001). However, Rose angina was associated only to overweight status (OR = 1.51, CI 95%: 1.03–2.20), P = 0.035) than individuals in normal weight group [Table 4].
|Table 4: Binary logistic regression method of the association between hypertension and Rose angina with body mass index groups and pulse pressure|
Click here to view
| Discussion|| |
In the present study, the prevalence of obesity was 18.1% that was more frequent in female. Also, obese individuals had greater proportion of HTN and Rose angina. We found that individuals with higher PP were older and hypertensive and had higher DBP, SBP, and MAP in compared to individuals in lower PP group. In the other hand, PP and obesity were associated to HTN and overweight to Rose angina.
The prevalence of obesity in our study was consistent to the result of found in Jamaica 19.7%, but was more than China 2%, Japan 2.9%, Ghana 10.4%, and Switzerland 14.3%.
Our study showed the higher prevalence of obesity in women than in men, similar to results of Ghana and Switzerland. Adversely, the same prevalence of obesity among men and women was suggested by Lee et al., but was more in men than in women by Borges et al. in Brazil, and Wu in Taiwan.
The differences in lifestyles, physical activity, and sex hormones, additionally, other genetic or behavioral factors and also, the age of participants and the defining of obesity may explain the observed differences in the prevalence of obesity. The major contributors for obesity are low physical activity and high consumption of fat. Other factors are urbanization, advancing age, high socioeconomic level, dietary habits, and life styles.
Obese and overweight individuals were more hypertensive than individuals with normal weight. Similar to our finding, results of a study in Peru confirmed the higher prevalence of HTN in obese than in normal weight individuals. Furthermore, Nurdiantami et al. found that the prevalence of HTN was positively related with increasing BMI. Also, Kawamoto et al. found that increasing BMI category were positively associated to HTN. In study carried out in Nigeria, hypertensive individuals were more obese than ones without HTN. In an analysis of the overall sample, each increasing in BMI unit was associated with a 10% increase the odds ratio of HTN (OR = 1.1, 95% CI: 1.1–1.2, P < 0.0001).
Our finding suggested the greater frequency of Rose angina in obese individuals. This finding was suggested by Robinson et al. that showed the higher prevalence of obesity in patients with atherosclerosis than without one. A prospective study showed a positive association of BMI with risk of coronary artery disease which each 2 kg/m2 raise in usual BMI, increased 12% (95% CI 6%–19%, P = 0.0001) of ischemic heart disease mortality. However, by Frohlich and Dobiasova suggested the opposite finding.
This study also assessed the relationship between blood pressure indexes (SBP, DBP, MAP, and PP), HTN, and angina. Our results confirmed the greater level of blood pressure indexes in HTN and PP in Rose angina which these were higher in subjects with hypertensive and Rose angina individuals. SBP, DBP, and MAP have confirmed that were relatively stronger predictors of CV events than PP in elderly patients with coronary artery disease and HTN. In another study in women with coronary disease, increased levels of PP were associated with coronary disease progression following 3.2 years of follow-up.
With binary logistic regression model, HTN was associated to obesity and PP and Rose angina to overweight. It found that the relation between PP and coronary heart disease is nonlinear in patients with type 2 diabetes and HTN. So that, patients with PP < 45 mmHg and PP more than 55 mmHg had increased risk of future event of coronary heart disease, compared with those with PP between 45 and 55 mmHg. In agreed to our results, certain studies have shown that PP is a stronger predictor of CV events than SBP and/or DBP, while other studies have shown that SBP and/or DBP is a more potent predictor of CV events than PP. A study by Ghanbarian et al. showed that SBP, DBP, and PP were not significant difference in subjects with myocardial ischemic finding on electrocardiogram than individuals without myocardial ischemic. Also, in Framingham Heart Study, confirmed the association of PP with coronary heart disease in middle-aged and elderly patients.
This is study about the association of obesity and PP with HTN and Rose angina in the Iranian urban population.
This study showed that the prevalence of HTN in society is high and higher BMI is one of the major risk factors in patients. Therefore, paying attention to measuring blood pressure in clients (especially people with high BMI) to health-care centers is very important to identify hypertensive patients.
As for the limitations of current study, this is a cross-sectional study in general population, without control on affecting other factors on relation of HTN, BMI, and angina. In our study, the diagnosis of CV disease was done by Rose questionnaire but in other studies was done by angiography.
| Conclusion|| |
We found that obesity and PP had a positive effect on HTN but overweight on the angina. Thus, attention to abnormal BMI is essential.
The authors would like to thank the Research Deputy of Jahrom University of Medical Sciences. We also appreciate all those who participated in this research project or otherwise helped us conduct this study. This study was funded by the Jahrom University of Medical Sciences.
Financial support and sponsorship
This research work has been financed by Jahrom University of Medical Sciences, Jahrom, Iran.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bastien M, Poirier P, Lemieux I, Després JP. Overview of epidemiology and contribution of obesity to cardiovascular disease. Prog Cardiovasc Dis 2014;56:369-81.
Gupta AK, Johnson WD. Prediabetes and prehypertension in disease free obese adults correlate with an exacerbated systemic proinflammatory milieu. J Inflamm 2010;7:36-40.
Pang W, Sun Z, Zheng L, Li J, Zhang X, Liu S, et al
. Body mass index and the prevalence of prehypertension and hypertension in a Chinese rural population. Intern Med 2008;47:893-7.
Kelishadi R, Alikhani S, Delavari A, Alaedini F, Safaie A, Hojatzadeh E. Obesity and associated lifestyle behaviours in Iran: Findings from the first national non-communicable disease risk factor surveillance survey. Public Health Nutr 2008;11:246-51.
Rahmanian K, Shojaei M, Sotoodeh-Jahromi AR, Abdolhossein Madani A. The association between pre-diabetes with body mass index and marital status in an Iranian Urban population. Global J Health Sci 2016;8:95-101.
Verma M, Rajput M, Kishore K, Kathirvel S. Asian BMI criteria are better than WHO criteria in predicting Hypertension: A cross-sectional study from rural India. J Fam Med Prim Care 2019;8:2095-100.
Goswami B, Bhattacharjya H, Sengupta S, Bhattacharjee B. Associations of obesity and serum leptin level with elevated blood pressure among urban secondary school students of a northeastern city of India: A baseline observation. J Family Med Prim Care 2020;9:1442-7. [Full text]
Accetto R, Korenčan S, Radenković S, Milenković J. Treatment of patients with risk factors&58; Compliance and adherence. Acta Facultatis Med Naissensis 2017;34:5-11.
Hojs R, Fabjan T. Renal dysfunction and ischemic stroke. Acta Facultatis Med Naissensis 2013;30:185-91.
Weiss A, Boaz M, Beloosesky Y, Kornowski R, Grossman E. Pulse pressure predicts mortality in elderly patients. J Gen Intern Med 2009;24:893-6.
Winston GJ, Palmas W, Lima J, Polak JF, Bertoni AG, Burke G, et al
. Pulse pressure and subclinical cardiovascular disease in the multi-ethnic study of atherosclerosis. Am J Hypertens 2013;26:636-42.
Rahmanian K, Shojaie M. The prevalence of pre-hypertension and its association to established cardiovascular risk factors in South of Iran. BMC Res Notes 2012;5:386.
Shojaei M, Jahromi AS, Rahmanian K, Madani AH. Gender differences in the prevalence of cardiovascular risk factors in an Iranian urban population. OnLine J Biol Sci 2015;15:178-84.
The WHO Fact Sheets No 311: Obesity and Overweight. Geneva: World Health Organization; 2006.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA. 2001;285:2486-97.
Najafi-Ghezeljeh T, Kassaye TM, Yadavar-Nikravesh M, Ekman I, Emami A. The Iranian version of Angina Pectoris characteristics questionnaire: Reliability assessment. J Clin Nurs 2009;18:694-9.
Ferguson TS, Younger NO, Tulloch-Reid MK, Wright MBL, Ward EM, Ashley DE, et al
. Prevalence of prehypertension and its relationship to risk factors for cardiovascular disease in Jamaica: Analysis from a cross-sectional survey. BMC Cardiovascular Dis 2008;8:2-9.
Lee JS, Kawakubo K, Mori K, Akabayashi A. BMI specific waist circumference for detecting clusters of cardiovascular risk factors in a Japanese population. J Atheroscler Thromb 2010;17:468-75.
Agyemang C, Owusu-Dabo E, de. Jonge A, Martins D, Ogedegbe G, Stronks K. Overweight and obesity among Ghanaian residents in the Netherlands: How do they weigh against their urban and rural counterparts in Ghana? Public Health Nutrition 2008;12:909-16.
Doll S, Paccaud F, Bovet P, Burnier M, Wietlisbach V. Body mass index, abdominal adiposity and blood pressure: Consistency of their association across developing and developed countries. Int J Obes Relat Metab Disord 2002;26:48-57.
Borges HP, Cruz. Ndo C, Moura EC. Association between hypertension and overweight in adults in Belem, state of Para (Brazil), 2005. Arq Bras Cardiol 2008;91:99-106.
Wu DM, Pai L, Chu NF, Sung PK, Lee MS, Tsai JT, et al
. Prevalence and clustering of cardiovascular risk factors among healthy adults in a Chinese population: The MJ Health Screening Center Study in Taiwan. Int J Obesity 2001;25:1189-95.
Carrillo-Larco RM, Bernabe-Ortiz M, Sacksteder KA, Diez-Canseco F. Association between sleep difficulties as well as duration and hypertension: Is BMI a mediator? Global Health Epidemiol Genomics 2017;2:1-8.
Nurdiantami Y, Watanabe K, Tanaka E, Pradono J, Anme T. Association of general and central obesity with hypertension. Clin Nutrition 2018;37:1259-63.
Kawamoto R, Kohara K, Tabara Y, Miki T. High prevalence of prehypertension is associated with the increased body mass index in community-dwelling Japanese. Tohoku J Exp Med 2008;216:353-61.
Ononamadu CJ, Ihegboro GO, Ezekwesili CN, Onyeukwu OF, Umeoguaju UF, Ezeigwe OC, et al
. Comparative analysis of anthropometric indices of obesity as correlates and potential predictors of risk for hypertension and prehypertension in a population in Nigeria. Cardiovascular J Afr 2017;28:92-9.
Njelekela MA, Mpembeni R, Muhihi A, Mligiliche NL, Spiegelman D, Hertzmark E, et al
. Gender-related differences in the prevalence of cardiovascular disease risk factors and their correlates in urban Tanzania. BMC Cardiovasc Disord 2009;9:30.
Robinson JG, Fox KM, Bullano MF, Grandy S, SHIELD Study Group. Atherosclerosis profile and incidence of cardiovascular events: A population-based survey. BMC Cardiovasc Disord 2009;9:46.
Chen Z, Yang G, Zhou M, Smith M, Offer A, Ma J, et al
. Body mass index and mortality from ischaemic heart disease in a lean population: 10 year prospective study of 220 000 adult men. Int J Epidemiol 2006;35:141-50.
Frohlich J, Dobiásová M. Fractional esterification rate of cholesterol and ratio of triglycerides to HDL-cholesterol are powerful predictors of positive findings on coronary angiography. Clin Chem 2003;49:1873-80.
Bangalore S, Messerli FH, Franklin SS, Mancia G, Champion A, Pepine CJ. Pulse pressure and risk of cardiovascular outcomes in patients with hypertension and coronary artery disease: An INternational VErapamil SR-trandolapril STudy (INVEST) analysis. Eur Heart J 2009;30:1395-401.
Nair GV, Waters D, Rogers W, Kowalchuk GJ, Stuckey TD, Herrington DM. Pulse pressure and coronary atherosclerosis progression in postmenopausal women. Hypertension 2005;45:53-7.
Nargesi AA, Esteghamati S, Heidari B, Hafezi-Nejad N, Sheikhbahaei S, Pajouhi A, et al
. Nonlinear relation between pulse pressure and coronary heart disease in patients with type 2 diabetes or hypertension. J Hypertension 2016;34:974-80.
Franklin SS, Khan SA, Wong ND, Larson MG, Levy D. Is pulse pressure useful in predicting risk for coronary heart Disease? The Framingham heart study. Circulation 1999;100:354-60.
Davidson KW, Haas DC, Shimbo D, Pickering TG, Jonas BS. Standardizing the comparison of systolic blood pressure vs. pulse pressure for predicting coronary heart disease. J Clin Hypertens 2006;8:411-3.
Ghanbarian A, Rezaei-Ghaleh NA, Habibi Moeeni AS, Shafiei G, Kalhor Y, Haj Sheykh Alslami F. et al
. Blood pressure measures and ECG-defined myocardial infarction in an Iranian population: Tehran Lipid and Glucose Study. Iran J Endocrinol Metabolism 2004;6:63-9.
[Table 1], [Table 2], [Table 3], [Table 4]