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BLOOD PRESSURE PROFILE AND RISK FACTORS FOR HYPERTENSION AMONG YOUNG ADULTS ATTENDING THE OUTPATIENT CLINIC OF OUR LADY OF APOSTLES CATHOLIC HOSPITAL OLUYORO OKE-OFA IBADAN
TABLE OF CONTENTS
Pages
Title page i
Preface and Acknowledgement ii
List of Abbreviations xii
Appendices xiv
CHAPTER ONE
1.0 Summary 1
1.1 Introduction 3
1.2 Statement of the Problem 5
1.3 Aims and Objectives of the Study 6
1.4 Rationale for the Study 7
CHAPTER TWO:
LITERATURE REVIEW 9
2.1 Historical Background 9
2.2 Epidemiology 10
2.3 Classification of Hypertension 12
2.4 Symptoms and Signs 13
2.5 White-Coat Hypertension 14
2.6 Risk Factors 15
2.6.1 Age 15
2.6.2 Sex 16
2.6.3 Obesity . 16
2.6.4 Family History 17
2.6.5 Environmental Factors 18 2.6.6 Concomitant Diseases 21
2.7 Causes of Hypertension 21
2.8 Case Finding 23
2.9 Complications of Hypertension 24
2.9.1 The Renal System 25
2.9.2 The Cardiovascular System 25
2.9.3 The Central Nervous System 26
2.9.4 The Retina 27
2.9.5 Sexual Dysfunction. 27
2.10 Management of Hypertensive Patients 28
2.10.1 The Role of Effective Communication 28
2.10.2 Investigations 30
2.10.3 Treatment 31
2.11 Treatment of Complications 36
2.11.1 Myocardial Infarction 36
2.11.2 Cardiac failure 36
2.11.3 Cerebrovascular Disease 37
2.11.4 Retinopathy 37
2.11.5 Renal Failure 38
2.11.6 Sexual Dysfunction . 38
2.12 Improving and Maintaining Blood Pressure Control 38
2.13 Summary 39
CHAPTER THREE:
METHODOLOGY 40
3.1 Setting. 40
3.2 Study Design 41
3.3 Study Population 41
3.3.1 Inclusion Criteria 42
3.3.2 Exclusion Criteria 42
3.4 Sample Size Estimation 42
3.5 Data Collection. 43
3.6 Instruments of Data Collection 43
3.7 Expected Duration of the study 43
3.8 Funding 44
3.9 Procedure for Data Collection 44
3.10 Follow-up 47
3.11 Statistical Analysis 48
3.12 Ethical Consideration. 49
CHAPTER FOUR
4.1Results 51
4.1.1 General Demographic Characteristics of the Subjects 51
4.1.2 Anthropometric Measurements 54
4.2 Prevalence of Hypertension 56
4.3 Profile of the Hypertensive Subjects 58
4.3.1 Demographic Characteristics of the hypertensive subjects 58
4.4. Risk Factors for Hypertension 62
4.4.1 Medical and Family History 62
4.4.2 Anthropometric Measurements of Hypertensive Subjects 64
4.4.3 Complications of Hypertension 66
4.4.4 Laboratory Results and Follow up 68
CHAPTER FIVE:
DISCUSSION 74
5.1 Discussion 74
5.2 Limitations or Constraints of the Study 80
5.3 Conclusion 80
5.4 Recommendations 81 References 83
LIST OF TABLES Pages
Table 1: Demographic characteristics of the 405 subjects related to blood pressure status 51
Table 2: Demographic characteristics of the hypertensive subjects. 58
Table 3: Identified risk factors for hypertension among the hypertensive Subjects 62
Table 4: Consumed quantity and frequency of food item associated with hypertension 63
Table 5: Clinical signs of complications of hypertension detected in the hypertensive subjects 67
Table 6: Clinically detected target end-organ damage. 68
Table 7: Laboratory results of some hypertensive subjects 69
Table 8: Distribution of abnormal laboratory results among some hypertensive subjects 69
Table 9: Sources of stress named by some subject 70
LIST OF FIGURES Pages
Figure 1: Distribution of BMI of the subjects 55
Figure 2 :Distribution of blood pressure groups among the subjects 57
Figure 3: Blood pressure pattern of the hypertensive subjects according to age group 59
Figure 4: Distribution of the BMI of the subjects based on their BP status 65 LIST OF ABBREVIAT1ONS
ACE-I: Angiotensin Converting Enzyme Inhibitor
AIDS: Acquired Immune Deficiency Syndrome
ANOVA: Analysis of Variance
ARB: Angiotensin-Receptor Blocker
BMI: Body Mass Index
BP: Blood Pressure
CCB: Calcium-Channel Blockers
CHF: Congestive Heart Failure
COAD: Chronic Obstructive Airway Disease
CVD: Cardiovascular Diseases
DASH Trial: Dietary Approach to Stop Hypertension Trial
DOT: Directly Observed Treatment
ECG: Electrocardiogram
GFR: Glomerular Filtration Rate
HC: Hip Circumference
HTN: Hypertension
| ISH: | The International Society of Hypertension |
| JNC7: | The Seventh Report of the Joint National Committee on Prevention,Detection |
| Evaluation and Treatment of High Blood pressure. | |
| LSM: | Life Style Modification |
| LVH: | Left Ventricular Hypertrophy |
| MI | Myocardial Infarction |
| NH1S: | National Health Insurance Scheme |
| PCV: | Packed Cell Volume |
| PEPFAR: | Presidential Emergency Plan for AIDS Reduction |
| SPSS: | Statistical Package for the Social Sciences |
| TUI: | Time urgency/Impatience |
| WC: | Waist circumference |
| WHO: | The World Health Organization |
| WHR: | Waist-to-hip Ratio |
| APPENDICES | Pages |
| Appendix I: JNC 7 Classification of blood pressure for adults 18 years and older | 12 |
| Appendix II: The Keith-Wagener classification of hypertensive retinopathy | 27 |
| Appendix III: The JNC 7 Lifestyle modification guideline to manage Hypertension | 33 |
| Appendix IV: Compelling indications for antihypertensive drug therapy | 34 |
| Appendix V: Cardiovascular Risk Stratification | 35 |
| Appendix VI : Informed Consent | 96 |
Appendix VII: Questionnaire 98
Appendix VIII: Algorithm for Treatment of Hypertension 108
SUMMARY
Objectives: This study was carried out to investigate the Blood Pressure Profile among young adult male and non-pregnant female patients ( aged18 – 50 years) attending an outpatient clinic in Ibadan, Oyo State so as to establish whether routine blood pressure checks in this age group is essential. It also sought to determine risk factors present in those found to be hypertensive and to detect complications of hypertension if present.
The study was a descriptive cross-sectional study, based at the Out-Patient Clinic of the Catholic Hospital Oluyoro Oke-Ofa, Ibadan. The study population was consecutive young adult male and non-pregnant female patients aged 18 – 50 years who attended the hospital for the first time between January and March 2011, and met the inclusion criteria and consented to participate in the study. Semi-structured questionnaire was administered and physical examination was carried out. Laboratory analysis of blood and urine was done for the subjects with confirmed hypertension.
A total of 405 adults participated in the study out of which154 were males and 251 were females. The mean age of the participants was 31.6 years. Their mean BMI was 23.7 kg/m2 and the mean BP was 129.5/85.7mmHg. One hundred and twenty-four (30.6%) were found to be hypertensive. The male hypertensives were 51 and the females 73 giving a ratio of almost 1:1.4.
The mean BMI of these hypertensives was 24.7kg/m2while their mean BP was
154.8/101.5mmHg. Sixty-six of the hypertensives had stage 1 hypertension while 58 had stage 2 hypertension.
The study found that age, occupation, body mass index, waist circumference and hip circumference were significantly associated with high blood pressure. Evidence of target endorgan damage seen include hypertensive heart disease in 23(18.5%) of the 124, retinopathy in
5(4.0%), congestive cardiac failure in 3(2.4%). nephropathy in 3(2.4%) and encephalopathy in 1(0.8%). There was also laboratory evidence of target end—organ damage.
Conclusion: Undetected cases of hypertension, with complications and target end-organ damage, exist in young adults in Ibadan, Oyo state and family physicians, on the front line of disease prevention, should pay attention to case finding for hypertension in this age group.
CHAPTER ONE
1.1 Introduction
Hypertension is a chronic illness that is known to occur in people of all age groups worldwide and at the same time cuts across all socio-economic classes. It is said to exist when the value of the systolic blood pressure is equal to or greater than 140mmHg and the diastolic blood pressure is equal to or greater than 90mmHg based on the average of at least two readings taken with the patient comfortable and at rest.1
About 95% of cases of hypertension have no known attributable causes and this is referred to as essential or primary hypertension. In about 5% of cases, there are identifiable
causes and such cases are referred to as secondary hypertension2
Despite the fact that hypertension affects all age groups, the possibility of the presence of hypertension is seldom considered by most attending physicians when seeing paediatric, adolescent and young adult patients. This may be due to the widely held belief that hypertension is a disease that comes naturally with increase in age and therefore should be seen only in the elderly.
Case finding is the process of searching for asymptomatic disease or risk factors for a disease among patients who are consulting a physician in a hospital setting. It is a process of opportunistic screening which involves using the time when a patient is in contact with the medical services to measure aspects of his health, as opposed to population screening which involves setting up services specifically aimed at identifying problems. Case finding is the method used in family practice and is an aspect of screening.3
Some risk factors which predispose individuals to the development of hypertension have been identified. These risk factors include cigarette smoking, obesity (BMI > 30kg/m), physical inactivity, dyslipidaemia, diabetes mellitus, sleep apnoea, microalbuminuria, age (>55 years for men, >65 years for women), family history of cardiovascular disease, the black race and those of African American (black) ancestry. Others are the use of oral contraceptive pills/hormones, stress, excessive alcohol consumption, excessive dietary salt intake, insufficient intake of potassium, long term steroid use (oral or topical) for treatment of ailments like asthma and eczema, muscle building or skin depigmentation4.
Some of these risk factors are modifiable, while others are not. Modifiable risk factors are mainly behavioral and include alcohol consumption, cigarette smoking, physical inactivity, dietary alterations. Risk factors that cannot be modified include age, race and a positive family
history of hypertension.5
For individuals who have been diagnosed to be hypertensive, several approaches to treatment, both orthodox and unorthodox have been adopted by both patients and physicians. Orthodox means of treatment include, lifestyle modification which encompasses dietary modification, weight reduction, regular exercise and the use of anti-hypertensives, while alternative means of treatment include spirituality and the use of native herbs and concoctions; foods such as garlic, onions, olive oil, lime and ginger.6
Today, the African continent is in a phase of epidemiological transition. Urbanization and modern urban lifestyle are amongst the leading factors contributing to increase in the prevalence
of hypertension and cardiovascular diseases (CVD). 7
1.2 Statement of the Problem
Most of the previous studies describe hypertension in older adults and the elderly but there is a paucity of data on hypertension in young adults because they are deemed to be at lower risk of developing the disease. With the problem of hypertension worldwide, there is increasing concern that hypertension in young adults may also be on the rise, and that cases are not being detected because of inadequate screening of this age group,8,9 hence the need for this study. The outcome of the study is expected to provide baseline data and greater insight into the prevalence of hypertension among young adults in Ibadan, Oyo State, Nigeria.
- Records from the case notes of adult patients (18-50 years) attending Catholic Hospital, Oluyoro, Oke-ofa, Ibadan reveal that they do have their blood pressure checked routinely before consultation with a doctor irrespective of their ailment. Often, if the patient does not present with symptoms suggestive of hypertension, minimal attention is paid to the recorded blood pressure. They may not also have thorough physical examination or laboratory investigations that may reveal the risk factors of hypertension. Hypertension is believed to be unusual in young adults since it is assumed that it is a disease that comes with age. However, hypertension can occur to appreciable level in these young adults with some progressing to complications. Besides, cardiovascular disease is said to be increasingly affecting the developing country populations in their productive years.7 However, the risk of developing severe degrees of high blood pressure has decreased in the past 25 years due partly to improved treatment.10 There are also suggestions that the situation of high undetected hypertension is changing as a result of more attention to case
finding by Family Physicians.11
- Records of the case notes of adult patients attending Catholic Hospital, Oluyoro, Oke-ofa,
Ibadan, Oyo State show that a total of nine thousand, seven hundred and twenty-five (9725)patients attended the hospital between June and December 2010 which is on the average about one thousand six hundred and twenty (1620) patients in a month. Out of this number six thousand, three hundred and twenty-one (6321) {65%} were males and non-pregnant females between the ages of 18 and 50 years attending the hospital for the first time. Of this number, a total of one thousand, eight hundred and one (1801) {28.5%} have their blood pressure reading above 140/90 mmHg. This means that about 28.5% of these young adults may be hypertensive.12 A study done by Akinkugbe on hypertension in Nigeria stated that less than a third of those with high blood pressure are aware of the fact that they are hypertensive and that less than a third of those who are aware that they have the disease are under any form of treatment.10 Also a Canadian health report stated that almost 50% of hypertensive patients are either unaware or aware that they have the disease but are untreated.8 At the Catholic Hospital, Oluyoro, Oke-ofa, Ibadan, this researcher had occasionally seen new young adult patients with evidence of target end-organ damage from undetected hypertension. Such cases also serve as pointers to the fact that the prevalence of hypertension in this age group could be significant, and that the subject is worthy of study.
1.3 Aim and Objectives of the Study
a) The Aim (General Objective)
The general objective of this study is to define the blood pressure profile as well as the risk factors for hypertension among young adults attending the Outpatient Clinic of Catholic Hospital, Oluyoro, Oke-ofa, Ibadan.
b) The Specific Objectives
- To determine the prevalence of hypertension among young adult patients attending the
Outpatient Clinic of Catholic Hospital, Oluyoro, Oke-ofa, Ibadan, Nigeria.
- To assess the risk factors for hypertension in them.
- To detect the presence, if any of complications of hypertension in those with
1.4 Rationale for the Study
The outcome of the study is expected to provide baseline data and greater insight into the prevalence of hypertension among young adults in Ibadan. Specifically, it would afford scholars, physicians and other healthcare workers the opportunity of having documented information about cases of hypertension reported in young adults attending a general hospital in Ibadan.
It has always been the case that attention is focused on the older patients and pregnant women when it comes to issues bordering on hypertension screening, prevention and control. This has almost always excluded young adults (that actually constitute the most active and dynamic, yet vulnerable group of the population) from hypertension studies and intervention.
A major relevance of this study will be the opportunity for the subjects taking part in the study to know their blood pressure status following the screening. They are also expected to gain relevant knowledge about hypertension generally. Such enlightenment constitutes a major benefit in case finding as a method of disease prevention and control.
Finally, the study will be of major relevance to family physicians in performing their roles as frontline doctors, as they are responsible for the identification of a disease or abnormality in an individual, its investigation and its treatment and follow-up as related to hypertension.11 The study will further emphasize the need for family physicians to pay more attention to case finding for asymptomatic diseases, especially hypertension.
BLOOD PRESSURE PROFILE AND RISK FACTORS FOR HYPERTENSION AMONG YOUNG ADULTS ATTENDING THE OUTPATIENT CLINIC OF OUR LADY OF APOSTLES CATHOLIC HOSPITAL OLUYORO OKE-OFA IBADAN
