THE BIOSOCIAL PROFILE AND HEALTH RELATED QUALITY OF LIFE AMONGST HYPERTENSIVE WITH OVERWEIGHT AND OBESITY IN PLATEAU STATE SPECIALIST HOSPITAL, JOS.

SUMMARY

Overweight and obesity have emerged as a problem in developing countries causing morbidity and affecting the quality of life of the individuals affected. They are also noticed to be more prevalent among those who have non-communicable diseases like hypertension.

This study was aimed to assess the biosocial profile and health related quality of life among overweight and obese hypertensive adult patients attending the General and Medical outpatient clinic of the Plateau State Specialist hospital Jos, Nigeria.

Methods

A cross- sectional study of two hundred and ten (210) adults aged eighteen years and above, attending the General and Medical outpatient clinic of the Plateau State Specialist Hospital, Jos was carried out between February and April 2011. The subjects were administered questionnaires (semi-structured and WHOQOL-Bref) which sought information on socio-demographic characteristics, presence or absence of overweight/obesity and biosocial factors for

overweight/obesity as well as health related quality of life.

The result was analyzed using Epi info statistical software version 3.5.1. The mean age of the subjects was 56.8 ± 12.8 years. There were 78 males and 132 females in ratio 1:1.7. The overall prevalence of overweight/obesity was 61.0%. Statistically significant biosocial factors were age group (X²= 4.3716, p= 0.0185), gender (X²=7.8041, p= 0.003), marital status (X²=3.3075, p=0.037), educational level (X²=8.0621, p=0.0447), occupation (X²=14.3466, p=0.0008), number of children (X²=2.7502, p=0.049) and consumption of refined diets (X²=59.6676, p=0.00001). However place of residence (X²=1.8819, p=0.09), consumption of alcohol (X²=0.1107, p=0.3768), cigarette smoking (Fisher’s exact test=0.1513) and regular exercise (Fisher’s exact test=0.5367) were not statistically significant. With logistic regression analysis of statistically significant biosocial factors, age group < 50 (OR=1.9228, 95% CI= 0.2805-0.9642 p= 0.0379), female gender

(OR=2.2556, 95% CI=0.2493-0.7883, p=0.0056), Primary education (OR=2.9286, 95% CI=1.3396-6.4024, p=0.0071), unskilled occupation(OR=3.4409, 95% CI=1.773-6.6788, p=0.0002), skilled occupation (OR=2.3656; 95% CI=0.2014-0.8873; p=0.0228), occasional consumption of refined diet (OR=9.3759; 95% CI=0.0291-0.8296; p=0.0004), daily consumption of refined diet (OR=40.667; 95% CI=0.0031-0.1936, p=0.00001) retained their statistical significance.

Subjects who were overweight or obese in this study did not show significant impairment in the overall quality of life (X²=0.9289, p=0.1676), general health satisfaction (X²=2.161, p=0.07083), physical health (X²=1.967, p=0.08044), psychological health (X²=1.50, p=0.111), social relationship (X²=1.764, p=0.09219) and environmental health (X²=0.47, p=0.25) domains of health related quality of life when compared with hypertensive who were not overweight or obese. Conclusion

The prevalence of overweight and obesity among hypertensive was 61.0%. Biosocial factors for overweight and obesity in this study were age group, gender, marital status, educational level, having more than three children, having unskilled and skilled occupation and consumption of refined diet. With logistic regression analysis independent factors for overweight and obesity identified in this study were age group < 50, female gender, primary education, having unskilled and skilled occupation, and consumption of refined diet.

Health education on diet, increased physical activity and exercise should be encouraged among these subjects. Co morbid diseases in hypertension should be sought for because it can affect their health related quality of life

TABLE OF CONTENTS

Title page……………………………………………………………………………………i

Declaration………………………………………………………….……………………….ii

Certification….………………………………………………………………………………iii Dedication….…………………………………………….………………………………….iv

Acknowledgement….……………………………………..…………………………….…v

Table of contents…………………………………………………………………….…….vi List of figures…………………….………………………………………………………….x

Abbreviations…………………….…………………………………………………………xii

Summary…………………………..………………………………………………………1-2

CHAPTER ONE

1.0 Introduction………………..……………………………………………………………3

1.1Background………………………………………………………………………………3

1.2.0 Concept of quality of life……………………………………………………………..4

1.2.1 Definition……………………………………………………………………………..4

1.3 Hypertension definition and classification……………………………………………..5

1.4.0 Obesity definition and indices………………………………………………………..5

1.4.1 Obesity indices………………………………………………………………………..5

1.5 The burden of hypertension and obesity………………………………………………..7

1.6 Problem Statement………………………………………………………………………8

1.7 Justification of the study in family medicine……………………………………………9

1.8 Aim of the study…………………………………………………………………………9

1.9 Objectives of the study………………………………………………………………….9 CHAPTER TWO

2.0 Literature review…………………………………………………………………………10

2.1 Preamble………………………………………………………………………………….10

2.2.0 WHOQOL instruments………………………………………………….……………….10

2.2.1 Rationale for the development of the WHOQOL……………………………………..12

2.2.2 Uses of WHOQOL instruments……………………………………………………….12

2.3.0 Overview of hypertension……………………………………………………………..14

2.3.1 Epidemiology of hypertension…………………………………………………………14

2.3.2 Risk factors of hypertension…………………………………………………………..15

2.4.0 Overview of obesity…………………………………………………………………..17

2.4.1 Epidemiology of obesity………………………………………………………………17

2.4.2 Risk factors of obesity…………………………………………………………………21

2.4.3 Outcome of obesity……………………………………………………………………23

2.5 Obese-hypertension syndrome…………………………………………………………..24

2.6 Cardiometabolic syndrome………………………………………………………………28

2.7 Evaluation and outcome of patients with hypertension………………………………….30

2.8 Hypertension treatment and control………………………………………………………31

2.9 Obesity prevention……………………………………………………………………….35

2.10 Health related quality of life in overweight and obese hypertensives…………………41

CHAPTER THREE

3.0 Material and methods…………………………………………………………………….44

3.1 Study area…………………………………………………………………………………44

3.1.1 Study site……………………………………………………………………………….44

3.2 Study population………………………………………………………………….………45

3.2.1 Inclusion Criteria……………………………………………………………………….45

3.2.2 Exclusion Criteria…………………………………………………………..…………..45 3.3 Study design………………………………………………………………………………45

3.3.1 Sample size……………………………………………………………………………..45

3.3.2 Sampling Method………………………………………………………………………46

3.4 Ethical clearance………………………………………………………………………….46

3.5 Study materials……………………………………………………………………………46

3.5.1 Method of data collection………………………………………………………………47

3.6 Method of data analysis…………………………………………………………………..49

CHAPTER FOUR

4.0 Results……………………………………………………………………………………50

4.1 Characteristics of Patients Enrolled………………………………………………………50

4.1.1 Demographic characteristics……………………………………………………………50

4.1.2 Social characteristics of study subjects…………………………………………………55

4.1.3 Information on illness…………………………………………………………………..57

4.1.4 Physical examination information of the study subjects………………………….……60

4.2 Prevalence of overweight/obesity………………………………………………………..65

4.3 Biosocial profile associated with overweight/obesity…………………………………….66

4.4 Health related quality of life of overweight/obese hypertensive…………………………77

CHAPTER FIVE

5.0 Discussion…………………………………………………………..….….…………….80

5.1 Prevalence of overweight/obesity amongst hypertensive…………….…….……………81

5.2 Biosocial profile of overweight/obese subjects………………………….….…………..…82

5.3 Quality of life among overweight/obese hypertensive.……………………….……….…..88

5.4 Conclusion.………………………………………….…….…………………….…………89

5.5 Recommendations……………………………………………………………….………….91

References………………………………………………………………………….…………..93

CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND

Whitehead in the World Health Organization (WHO) document; “The concepts and principles of equity and health” states that “equity in health implies that ideally everyone should have a fair opportunity to attain their full potential and, more pragmatically that no one should be disadvantaged from achieving this potential, if it can be avoided” and “equity is therefore concerned with creating equal opportunities for health and with bringing health differentials down to the lowest level possible”.¹ Other researchers agreed that equity in health should minimize the avoidable differences in health and its determinants.¹ The inequality could be in terms of systematic and potential disadvantage across social groups, such as those defined by gender, geography, socioeconomics, race, ethnicity, religion and age.¹

Even though the concept of Quality of Life (QOL) has been in literature since the time of Aristotle,² it was first popularized by WHO. In the 1948 constitution, the WHO defined health as “a state of complete physical mental and social well-being and not merely the absence of disease or infirmity.”^3,4 It is a state of wholeness in which the individual is able to play his role in the community.

It follows that measurement of health must not only include estimates of the frequency and severity of diseases, but also well-being and QOL.³

Although hypertension is thought to be asymptomatic, cognitive changes, mood alterations, and general symptoms such as dizziness and headache attributable to hypertension have been described.⁵ Some symptoms are unique to antihypertensive medications, but overlap with symptoms described or attributed to the disease of hypertension as well as the general symptoms are seen in a primary care population.⁵

Overweight and obesity are known co morbid conditions and risk factors for developing hypertension.⁶ Obesity is considered as a disease by itself and a major risk factor for several

important diseases.^{6 – 10}

Symptoms, whether disease or treatment induced, may impair the health-related quality of life (HRQOL) of patients.⁵ HRQOL refers to the physical, emotional, and social impact of disease and treatments and is distinct from physiologic measures of disease.⁵ HRQOL measure may reflect disease or treatment characteristic that are not captured by clinical symptom measures and also may be an efficient way to represent the impact of disease and treatment from the patient’s perspective.⁵

1.2 CONCEPT OF QUALITY OF LIFE

QOL is a familiar statement because of its frequent usage. It has application in education, health and sociology.^{11, 12} The concept of QOL is based on;

1. The notion that individuals have their own unique perspective on QOL, which depends on present lifestyle, past experience, hopes for the future, dreams and ambitions.¹³
2. QOL is generally conceptualized as a multidimensional construct encompassing several domains. These domains as put forward by WHO include “the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.¹³
3. QOL can include both objective and subjective perspectives in each of these domains. The objective assessment of QOL focuses on what the individual can do. The subjective

assessment include the individuals perception or appraisal of QOL.¹³

1.2.1 DEFINITION

 WHO defines QOL as the individuals perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.⁴ It is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, personal belief and their

relationship to salient features of their environment.^4,14

1.3 HYPERTENSION DEFINITION AND CLASSIFICATION

Hypertension is defined as blood pressure (BP) equal or greater than 140/90mmHg with or without

antihypertensive medication.^{8, 15 – 20} Hypertension can either be primary or secondary. Primary or essential hypertension is defined as that without an identifiable cause, while secondary hypertension has an identifiable cause.²¹ In general, it is said that about 95% of patients who have hypertension have no obvious underlying cause and as such are classified as having essential

hypertension.²¹

The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), classified hypertension into normal BP, pre-

hypertension, stage 1 and stage 2  hypertension.²²

Normal BP is regarded as systolic blood pressure (SBP) less than (<) 120 and the diastolic blood pressure (DBP) < 80mmHg.²² Pre-hypertension is when SBP is between 120 – 139mmHg or DBP is between 80 – 89mmHg. Stage 1 hypertension is when SBP is between 140-159 or DBP is between 90-99.²² Stage 2 hypertension is SBP greater or equal to 160mmHg and DBP greater or equal to 100mmHg.²²

1.4 OBESITY DEFINITION AND INDICES

Obesity is a term used to indicate excessive deposition of fat in the body.^{7,16,23,24,25} It is the most common nutritional disorder in developed countries, and is becoming significant in the developing

countries.6,23,26,27

1.4.1 Obesity Indices: The body mass index (BMI), commonly used to determine desirable body weight was invented by a Belgian Polymath, Adolphe Quelet, between 1830 and 1850.⁷ BMI is a measure of weight in relation to height and is calculated as weight (kg) divided by height (m²)

squared.^{6,7,15,16,28,29} People with a BMI of 18.5 to 24.9 are normal, while those with BMI of 25.0

to 29.9 are considered overweight and those with BMI of 30 and above are obese.^{6,8,15,16,28,30} Furthermore, while those with BMI of 25.0 to 29.9 are classified as overweight grade I, those with

BMI of 30 -39.99 and 40 and above are classified as overweight grade II and overweight grade III

(Morbid obesity) respectively.¹⁷

BMI is the most cited index for obesity because it approximates adiposity and fat distribution in adults.³⁰ It has been identified by WHO as the most useful epidemiological measure of obesity.²⁴ It is simple, inexpensive, more closely associated with BP than with the other obesity indices and it is considered a predictor of cardiovascular risk.³⁰ It is nevertheless a crude index that does not take into account the distribution of body fat, resulting in variability in different individuals and populations.²⁴

In the assessment of obesity,  the central distribution of body fat cannot be overlooked, hence, the use of other anthropometric indices such as waist circumference (WC) and waist to hip ratio (WHR), as measures of adiposity.²⁴ The waist to hip ratio can be obtained by measuring the smallest part of the waist and dividing the waist measured by the hip measure which is the widest part of the buttocks.^7,29 Men with a WC of < 94, 94 – 101.9 and greater or equal to 102cm are classified as normal weight, overweight and obese respectively, while women with WC < 80, 80 – 87.9 and 88 are normal, overweight and Obese respectively.³¹ Men with WHR < 0.90, 0.90 -0.99 and greater or equal to 1.0 are classified as normal weight, overweight and obese respectively, while women are classified in the same categories on the basis of WHR of < 0.80, 0.80 – 0.84 and

greater or equal to 0.85 according to WHO recommendation.³¹

WC has been recommended as a simple and practical measure for identifying overweight and obese patients.²⁴ It is particularly useful for individuals and population groups with different body builds.²⁴ There is however, no consensus as to the importance of the different measurements of body fat.³²

Although clinical measures are considered acceptable in the diagnosis of true central obesity, better imaging techniques such as dual – energy X-ray absorptiometry (DEXA), Magnetic radio imaging (MRI) or an abdominal computerized tomography probably are required for accurate

description.^25,29,32,33 Skin fold thickness, densitometry may also be used for description of central

obesity.^25,32 These are however not practicable for everyday clinical use.²⁵

1.5 THE BURDEN OF HYPERTENSION AND OBESITY

The shift in the pattern of non-communicable diseases (NCD) like hypertension, diabetes and obesity in developing countries is occurring at a faster rate than it did in the industrialized regions of the world half a century ago.²⁷

In the World Health Report (1999), it was stated that in 1998, 78% of the burden of noncommunicable and 85% of the CVD arose from the developing low and middle-income countries.²⁷ According to estimates by the Global Burden of Disease (GBD) study, death due to NCD in developing countries will be four times that due to communicable diseases by 2020.⁶ Such NCD include hypertension, diabetes, coronary heart disease, stroke and metabolic syndrome.⁶

Commonly, these diseases have obesity as a common denominator.^6,34

CVD is already the leading cause of mortality in many developing countries.^6,27,35 Between 1990 and 2020, mortality from CVD in developing countries is expected to increase by 120% for women and 137% for men, which is expected to be substantially greater than from developed countries

(29 and 48% respectively).²⁷ A near tripling CVD mortality in Latin America, the middle east, and Sub-Saharan Africa is expected to occur in the next two decades.²⁷

These NCD are associated with tremendous financial and public health impact^36,37 and as such would require fundamental social and political intervention.³⁴

Disability, decreased quality of life, greater use of health care facilities, and increased absenteeism have been reported with obesity.²⁷ A strong relationship between BMI and decreased physical functioning with a reduction in overall productivity has been seen.²⁷ A six year study demonstrated that an obese person experiences a 50% increase in lost productivity and visits a doctor more often than a healthy person.²⁷ All these factors increase health care expenditure leading to slowing of economic growth and development and reduction in Gross domestic product.²⁷

In Nigeria, chronic diseases were projected to account for 24% of all the death in the year 2005 (WHO 2005) and that if there is a 2% annual reduction in chronic disease death rate in Nigeria, it would result in an economic gain of 500 million dollars for the country over the next 10 years.⁷

1.6 PROBLEM STATEMENT

Systemic hypertension is the “silent killer” of our times throughout the world. It is also strongly associated with overweight and obesity.¹⁶ Globally, there is a disturbing trend towards adiposity.²¹ The prevalence of obesity among patients with hypertension is much higher than the population prevalence of obesity.^16,38 As obesity is independently associated with hypertension, there is a

strong need to address the problem among hypertensive patients.¹⁶

In the first two weeks of June 2010, BMI of 54 consecutive hypertensive patients at the MOPD of PSSH was measured. It revealed that 17 of them had normal BMI, 17 were overweight, while 20

of them were obese, and that about 68.5% of patients seen were either overweight or obese.

Non-communicable diseases have become the leading cause of disability and death in many developing countries including Nigeria. These countries affected cannot afford the financial cost presently borne by the developed world in managing the conditions and mostly do not have the kind of health care system that  can effectively handle the disease burden.⁶ Hence, detection, treatment and control of these conditions are poor.

Health professionals frequently make quality of life judgments when making decisions about the care of disabled patients. However patients with chronic, or life threatening disease who live without the expectation of cure have conditions that are likely to have an impact on their physical, psychological and social well-being. This is especially important given that HRQOL can be a risk

factor for subsequent cardiovascular events or complications.³⁹

1.7 JUSTIFICATION OF THE STUDY IN FAMILY MEDICINE

1. It will help the physician to address and give health education to the patient on the modifiable factors that can result to decreased morbidity and decreased quality of life.
2. It will help the physician to plan therapeutic interventions that will ensure good control of BP and desirable HRQOL.
3. It will help the physician to intensify health education and counseling so as to achieve primary prevention of hypertension and its associated co morbidity.
4. It will help in providing reasonable evidence for evaluating the quality of care given to these patients at the outpatient department.

1.8 AIM OF THE STUDY: To determine the biosocial profile and quality of life of hypertensives with overweight/obesity in Plateau State Specialist Hospital.

1.9 OBJECTIVES OF THE STUDY

1. To determine the prevalence of overweight and obesity among those diagnosed with hypertension attending the General outpatient and Medical Outpatient department of

PSSH.

2. To determine the biosocial profile of those who are overweight and obese among these

hypertensive patients.

3. To assess the Quality of Life of overweight – obese hypertensive patients.

THE BIOSOCIAL PROFILE AND HEALTH RELATED QUALITY OF LIFE AMONGST HYPERTENSIVE WITH OVERWEIGHT AND OBESITY IN PLATEAU STATE SPECIALIST HOSPITAL, JOS.