EPIDEMIOLOGY OF HYPERTENSION

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Dr. Muhammedirfan H. Momin Assistant Professor Community Medicine Department Government Medical College, Surat.

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17TH MAY

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HIGH BLOOD PRESSURE ARTERIAL HYPERTENSION

TYPES:

TYPES Over 90–95% of adult hypertension is essential hypertension . [1] The most common cause of secondary hypertension is primary aldosteronism . [2] (January 2000). "Essential hypertension. Part I: definition and etiology" . Circulation 101 (3): 329–35. (June 2009). "Differential diagnosis of primary aldosteronism subtypes". Current Hypertension Reports 11 (3): 217–23.

HISTORY:

HISTORY Image of veins from Harvey's Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus

HISTORY:

HISTORY Some cite the writings of Sushruta in the 6th century BC as being the first mention of symptoms like those of hypertension. Others propose even earlier descriptions dating as far as 2600 years before Christ.

HISTORY:

HISTORY Main treatment for what was called the "hard pulse disease" consisted in reducing the quantity of blood in a subject by the sectioning of veins or the application of leeches . Well known individuals such as The Yellow Emperor of China, Cornelius Celsus , Galen , and Hipocrates advocated such treatments.

HISTORY:

HISTORY Our modern understanding of hypertension began with the work of physician William Harvey (1578–1657), who was the first to describe correctly the systemic circulation of blood being pumped around the body by the heart in his book " De motu cordis ". The basis for measuring blood pressure were established by Stephen Hales in 1733.

HISTORY:

HISTORY Initial descriptions of hypertension as a disease came among others from Thomas Young in 1808 and specially Richard Bright in 1836. The first ever elevated blood pressure in a patient without kidney disease was reported by Frederick Mahomed (1849–1884). It was not until 1904 that sodium restriction was advocated while a rice diet was popularized around 1940.

HISTORY:

HISTORY The Framingham Heart Study added to the epidemiological understanding of hypertension and its relationship with coronary artery disease.

EPIDEMIOLOGY:

EPIDEMIOLOGY In the year 2000 it is estimated that nearly one billion people or ~26% of the adult population have hypertension worldwide. [72] Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J (2005). "Global burden of hypertension: analysis of worldwide data". Lancet 365 (9455): 217–23. doi : 10.1016/S0140-6736(05)17741-1 . PMID 15652604 .

EPIDEMIOLOGY:

EPIDEMIOLOGY It was common in both developed (333 million ) and undeveloped (639 million) countries. [72]

EPIDEMIOLOGY:

EPIDEMIOLOGY However rates vary markedly in different regions with rates as low as 3.4% (men) and 6.8% (women) in rural India, 7% (both) in urban and as high as 68.9% (men) and 72.5% (women) in Poland. [73] (January 2004). "Worldwide prevalence of hypertension: a systematic review". J. Hypertens . 22 (1): 11–9. PMID 15106785 .

EPIDEMIOLOGY:

EPIDEMIOLOGY Pooling of epidemiological studies shows that hypertension is present in 25% urban and 10% rural subjects in India. As rightly commented by Joshi & Parikh , with the current rate of hypertension, India will have the largest number of people with hypertension in the world, with the potential of becoming the 'Hypertension capital of world !‘ Gupta R Trends in hypertension epidemiology in India. J Hum Hypertens . 2004 Feb;18(2):73-8.

EPIDEMIOLOGY:

EPIDEMIOLOGY It is more common in blacks and less in whites and Mexican Americans [1] . (January 2000). "Essential hypertension. Part I: definition and etiology" . Circulation 101 (3): 329–35. PMID 10645931 .

PEDIATRICS:

PEDIATRICS The prevalence of high blood pressure in the young is increasing. [77] (May 2009). "Hypertension in children and adolescents: epidemiology and natural history" . Pediatr . Nephrol . 25 (7): 1219–24.

PEDIATRICS:

PEDIATRICS Most childhood hypertension , particularly in preadolescents, is secondary to an underlying disorder. Kidney disease is the most common (60–70%) cause of hypertension in children. [78] Jamaica Hospital Medical Center (2006). "Hypertension in Children and Adolescents" . Hypertension in Children and Adolescents . American Academy of Family Physician. Retrieved 2007-07-24.

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Total Employees 1493 (100%) Total Hypertensive 455 (30.5%) Known Hypertensive 197 (13.2%) RULE OF HALVES Employees on regular Treatment 139 (9.3%) Employees having controlled Hypertension 71 (4.7%)

TRACKING OF BLOOD PRESSURE:

TRACKING OF BLOOD PRESSURE

Classification:

Classification Blood pressure is usually classified based on the systolic and diastolic blood pressures. Systolic blood pressure is the blood pressure in vessels during a heart beat. Diastolic blood pressure is the pressure between heartbeats.

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The variation in pressure in the left ventricle (blue line) and the aorta (red line) over two cardiac cycles ("heart beats"), showing the definitions of systolic and diastolic pressure The variation in pressure in the left ventricle (blue line) and the aorta (red line) over two cardiac cycles ("heart beats"), showing the definitions of systolic and diastolic pressure

Classification:

Classification A systolic or the diastolic blood pressure measurement higher than the accepted normal values for the age of the individual is classified as prehypertension or hypertension.

Classification:

Classification Hypertension has several sub-classifications including, hypertension stage I, hypertension stage II, and isolated systolic hypertension . Isolated systolic hypertension refers to elevated systolic pressure with normal diastolic pressure and is common in the elderly. These classifications are made after averaging a patient's resting blood pressure readings taken on two or more office visits

Classification:

Classification Hypertension is also classified as resistant if medications do not reduce blood pressure to normal levels. Exercise hypertension is an excessively high elevation in blood pressure during exercise . The range considered normal for systolic values during exercise is between 200 and 230 mm Hg. [ 9] Exercise hypertension may indicate that an individual is. at risk for developing hypertension at rest

ERRORS:

ERRORS OBSERVER INSTRUMENTAL SUBJECTIVE

Diagnosis:

Diagnosis Hypertension is generally diagnosed on the basis of a persistently high blood pressure. Three separate sphygmomanometer measurements at least one week apart . Initial assessment of the hypertensive patient should include a complete history and physical examination . Exceptionally, if the elevation is extreme , or if symptoms of organ damage are present then the diagnosis may be given and treatment started immediately.

Classification:

Classification The 7 th report of the joint national committee ON Prevention , Detection, Evaluation and Treatment Of High Blood Pressure ( JNC VII ) provides a classification of Blood pressure for adults aged 18 years or older . The classification is based on the mean of 2 or more properly measured seated BP readings on each of 2 or more office visits . The 7 th report of the joint national committee (JNC VII). U.S. Department of health and human services. NIH publication No. 04-5230. August 2004

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Category SBP (mm Hg) DBP (mmHg) Normal <120 <80 Pre- hypertension 120 – 139 or 80-89 Stage1 Hypertension 140 – 159 or 90 - 99 Stage2 Hypertension > 160 or > 100 CLASSIFICATION OF BLOOD PRESSURE JNC VII 9

Classification:

Classification Prehypertension is not a disease category ->a designation chosen to identify individuals at high risk of developing hypertension, ->alerted to this risk and encouraged to intervene and prevent or delay the disease from developing. Individuals who are Prehypertensive are not candidates for drug therapy based on their level of BP and should be firmly and unambiguously advised to practice lifestyle modification in order to reduce their risk of developing hypertension in the future.

CLASSIFICATION OF BLOOD PRESSURE (WHO/ISH):

CLASSIFICATION OF BLOOD PRESSURE (WHO/ISH) Category Systolic Diastolic Optimal Normal High Normal < 120 <130 130-139 <80 <85 85-89 Grade 1 (mild hypertension ) Subgroup: borderline 140-159 140-149 90-99 90-94 Grade 2 (moderate hypertension ) 160-179 100-109 Grade 3 (severe hypertension) ≥ 180 ≥ 110 Isolated Systolic Hypertension (ISH) Subgroup (borderline) ≥ 140 140-149 <90 <90

SIGNS AND SYMPTOMS:

SIGNS AND SYMPTOMS Mild to moderate essential hypertension is usually asymptomatic . headache , drowsiness , confusion , vision disorders , nausea , and vomiting

RISK FACTORS:

RISK FACTORS NONMODIFIABLE MODIFIABLE

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POLYGENIC 3% AND 45%

ETHNICITY:

ETHNICITY

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High alcohol intake, defined as 75 gm or more per day.

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LACK OF SLEEP

MECHANISM:

MECHANISM Carbon Monoxide induces atherogenesis Nicotine stimulates adrenergic dive raising blood pressure and myocardial oxygen demand Affects lipid metabolism with fall in protective HDL. Risk of death from CHD declines quite substantially within one year of stopping smoking and after 10-20 years it is the same as that of non-smokers. For those who had MI, the risk of a fatal recurrence reduced by 50% after giving up smoking.

SATURATED FAT  is fat that consists of  TRIGLYSERIDES `LDL:

SATURATED FAT is fat that consists of TRIGLYSERIDES `LDL

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LDL leads to accumulation of cholesterol in tissue cells particularly the smooth muscle cells of the vascular system, and thus involved in arteriosclerotic process. In contrast HDL functions in the removal of cholesterol from cells. Low HDL/LDL ratio favours the development of atheroma .

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progesterone

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% PERCENTAGE MANAGER OFFICER CASHIER CLERK CLASS IV APPRENTICE Socio Economic Status. NORMAL HYPERTENSIVE

OTHER RISK FACTORS:

OTHER RISK FACTORS potassium deficiency ( hypokalemia ), [1 8 ] vitamin D deficiency . [2 3 ] [ 2 4 ] An elevation of renin [2 8 ] sympathetic nervous system overactivity . [2 9 ] Insulin resistance [2 8 ] [ 3 0 ] low birth weight [ 3 1 ]

SECONDARY HT:

SECONDARY HT Cushing's syndrome , [ 3 2 ] metabolic disorder , pre- eclampsia

PREVENTION:

PREVENTION PRIMARY POPULATION STRATEGY HIGH RISK STRATEGY SECONDARY

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GOOSEBERRY GARLIC

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Olive (JETUN) Leaf Extract Lower Cholesterol

CHINESE TEA:

CHINESE TEA

DASH:

DASH "DASH" stands for "Dietary Approaches to Stop Hypertension," It emphasizes fruits, vegetables, and lowfat dairy foods and is low in saturated fat, total fat, and cholesterol. The DASH eating plan includes whole grains, poultry, fish, and nuts and has reduced amounts of fats, red meats, sweets, and sugared beverages.

DASH:

DASH The DASH eating plan shown below is based on 2,000 calories a day . The number of daily servings in a food group may vary from those listed depending on your caloric needs. This diet has been shown to be effective based on research sponsored by the National Heart, Lung, and Blood Institute (part of the NIH , a United States government organization)

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Food Group Daily Servings (except as noted) Serving Sizes Grains & grain products 7-8 1 slice bread 1 cup ready-to-eat cereal* ½ cup cooked rice, pasta, or cereal *Serving sizes vary between  ½ to 1 ¼ cups. Check the product's nutrition label

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Vegetables 4-5 1 cup raw leafy vegetable 1/2 cup cooked vegetable 6 ounces vegetable juice Fruits 4-5 1 medium fruit 1/4 cup dried fruit 1/2 cup fresh, frozen, or canned fruit 6 ounces fruit juice

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Lowfat or fat free dairy foods 2-3 8 ounces milk 1 cup yogurt 1 & 1/2 ounces cheese Lean meats, poultry, and fish 2 or less 3 ounces cooked lean meats, skinless poultry, or fish

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Nuts, seeds, and dry beans 4-5 per week 1/3 cup or 1 &1/2 ounces nuts 1 tablespoon or 1/2 ounce seeds 1/2 cup cooked dry beans Sweets 5 per week 1 tablespoon sugar 1 tablespoon jelly or jam 1/2 ounce jelly beans 8 ounces lemonade

** Fat content changes serving counts for fats and oils: For example, 1 tablespoon of regular salad dressing equals 1 serving; 1 tablespoon of a lowfat dressing equals   serving; 1 tablespoon of a fat free dressing equals 0 servings:

Fats & oils** 2-3 1 teaspoon soft margarine 1 tablespoon lowfat mayonnaise 2 tablespoons light salad dressing 1 teaspoon vegetable oil ** Fat content changes serving counts for fats and oils: For example, 1 tablespoon of regular salad dressing equals 1 serving; 1 tablespoon of a lowfat dressing equals   serving; 1 tablespoon of a fat free dressing equals 0 servings

DASH Sodium :

DASH Sodium The biggest blood pressure-lowering benefits were for those eating the DASH eating plan at the lowest sodium level ( < 1,500 milligrams per day) .

POTASSIUM:

POTASSIUM In addition, an increase in dietary potassium , which offsets the effect of sodium has been shown to be highly effective in reducing blood pressure. [46]

TOBACCO USE AND ALCOHOL CONSUMPTION :

TOBACCO USE AND ALCOHOL CONSUMPTION Discontinuing tobacco use and alcohol consumption has been shown to lower blood pressure. The exact mechanisms are not fully understood, but blood pressure (especially systolic) always transiently increases following alcohol or nicotine consumption.

DEFINITION:

DEFINITION An abnormal growth of the adipose tissue due to an enlargement of fat cell size ( hypertrophic obesity) or an increase in fat cell number ( hyperplastic obesity) or combination of both.

OBESITY:

OBESITY The distribution of fat induced by the weight gain affects the risk associated with obesity and the kind of disease that results.

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Fat Distribution ANDROID GYNOID

ASSESSMENT OF OBESITY:

ASSESSMENT OF OBESITY Body volume index Waist-hip ratio Sagittal Abdominal Diameter (SAD) Body fat percentage Body water Allometric law Ponderal index Rohrer's index Skin fold thickness

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The body mass index ( BMI ), or Quetelet index , is measure of body weight based on a person's weight and height. Though it does not actually measure the percentage of body fat , it is used to estimate a healthy body weight based on a person's height. Due to its ease of measurement and calculation, it is the most widely used diagnostic tool to identify weight problems within a population, usually whether individuals are underweight , overweight or obese .

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It was invented between 1830 and 1850 by the Belgian polymath Adolphe Quetelet during the course of developing "social physics". [1] Body mass index is defined as the individual's body weight divided by the square of his or her height. The formulae universally used in medicine produce a unit of measure of kg/m 2 . BMI = WEIGHT (kg) HEIGHT 2 (m)

ASSESSMENT OF OBESITY:

ASSESSMENT OF OBESITY BMI can also be determined using a BMI chart, [2] which displays BMI as a function of weight (horizontal axis) and height (vertical axis) using contour lines for different values of BMI or colors for different BMI categories.

WHO & Indo US health summit / mohfw:

WHO & Indo US health summit / mohfw BMI WORLD INDIA Severely Underweight ≤ 16.4 ≤ 16.4 Underweight ≤18.4 ≤18.4 Normal 18.5 - 24.9 18.5 - 22.9 Overweight 25.0 - 29.9 23.0 - 24.9 G1 30.0 - 34.9 25.0 - 26.9 G2 35.0 - 39.9 27.0 - 28.9 G3  40.0 29-31.9 Morbid obesity --  32 .0

PREVALENCE:

PREVALENCE It is extremely difficult to assess the size of the problem and compare the prevalence rate in different countries as no exact figures are available and also because definitions of obesity not standardized. However it has been estimated to affect 20-40 % of the adults 10-20 % of children and adolescents in developed countries.

PREVALENCE:

PREVALENCE Obesity has reached epidemic proportions in India in the 21st century, with morbid obesity affecting 5% of the country's population. [1] SOURCE "India facing obesity epidemic: experts" . The Hindu . 2007-10-12.

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States Males (%) Males rank Females (%) Females rank Punjab 30.3 1 37.5 1 Goa 20.8 3 27 3 Tamil Nadu 19.8 4 24.4 4 Andhra Pradesh 17.6 5 22.7 5 Kerala 24.3 2 34 2 Sikkim 17.3 6 21 8 Mizoram 16.9 7 20.3 17 Himachal Pradesh 16 8 19.5 12 Maharashtra 15.9 9 18.1 13 Gujarat 15.4 10 17.7 7 Haryana 14.4 11 17.6 6 Karnataka 14 12 17.3 9 Manipur 13.4 13 17.1 11

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Uttarakhand 11.4 15 14.8 14 Arunachal Pradesh 10.6 16 12.5 19 Uttar Pradesh 9.9 17 12 18 Jammu and Kashmir 8.7 18 11.1 20 Rajasthan 8.4 20 9 21 Meghalaya 8.2 22 8.9 26 Orissa 6.9 23 8.6 25 Assam 6.7 24 7.8 22 Chattisgarh 6.5 25 7.6 27 West Bengal 6.1 26 7.1 16 Madhya Pradesh 5.4 27 6.7 23 Jharkhand 5.3 28 5.9 28 Tripura 5.2 29 5.3 24 Third National Family Health Survey . Mumbai: International Institute for Population Sciences. 2006.

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BMI MALE FEMALE TOTAL n % n % n % ≤18.4 98 8.3 51 16.1 149 9.9 18.5 - 24.9 626 53.1 129 40.8 755 50.5 25.0 - 29.9 384 32.6 94 29.7 478 32.0 30.0 - 34.9 62 5.2 31 9.8 93 6.2 35.0 - 39.9 7 0.5 8 2.5 15 1.0  40.0 0 0 3 0.9 3 0.2 TOTAL 1177 100.0 316 100.0 1493 100.0

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Praween Kumar Agrawal (2002-05-23). "Emerging Obesity in Northern Indian States: A Serious threat for Health" (PDF). IUSSP Conference, Bankik , June 10–12 2002 . Go to PDF file

WAIST HIP RATIO:

WAIST HIP RATIO WHO WHR MALE <= 1.0 WHR FEMALE <= 0.85

INDO-US HEALTH SUMMIT:

INDO-US HEALTH SUMMIT SUMMIT JNC Waist size M < 35 inches < 40 inches Waist size F < 31 inches < 35 inches BP <130/80 <120/70 in DM or HF <140/90 <130/80 Blood Sugar <100 mg/dl <100mg/dl Exercise 45-120 min/day 30 min/day

Lipid profile target for Indians:

Lipid profile target for Indians Normal: S. cholesterol <200 mg% S. LDL <100 mg% S. TG <150 mg% S. HDL <45 mg%

Lipid profile target for Indians:

Lipid profile target for Indians Pateints with heart disease, DM, HT or Risk factors: S. cholesterol <150 mg% S. LDL <70 mg% S. TG <120 mg% S. HDL <50mg%

Lipid profile target for Indians:

Lipid profile target for Indians For secondary prevention, 50% reduction in LDL is essential. For Primary prevention, 30% reduction in LDL is essential.

Daily dietary requirements in Indian:

Daily dietary requirements in Indian Dietary Sources Requirement Wheat, Rice, Dal , Juar , Bajra , maiz and any variety of dalpulses and vegetables 400-500 gm/day Fresh Fruits 300-500 Low fat diet 30-50gd Lean meat, poultry, chicken, fish 30-50 gm/day

SOURCE:

SOURCE Simple and essential requirement to control hypertension- the silent killer non drug treatment of hypertension . Indian J Med Sci 1999; 53(10):444-46.

Exercise:

Exercise DEFINITION Exercise is physical activity that is planned, structured, and repetitive for the purpose of conditioning the body. Exercise 'makes you feel full ‘ Washington, Aug 25 (ANI): Brazilian researchers have discovered that exercise not only helps you shed kilos by burning calories but also makes you feel full by triggering neurons in the brain .

Exercise:

Exercise Researchers at the University of Campinas Exercise say that exercise restores the sensitivity of neurons involved in the control of satiety (feeling full), which in turn contributes to reduced food intake and consequently weight loss. It is postulated that excessive consumption of fat creates failures in the signal transmitted by neurons controlling satiety in the hypothalamus . These failures can lead to uncontrollable food intake and, consequently, obesity.

Exercise:

Exercise Physical activity contributes to the prevention and treatment of obesity, not only by increasing energy expenditure but also by modulating the signals of satiety and reducing food intake . SOURCE: Brazilian researchers at the University of Campinas Exercise-Jose Barreto C. Carvalheira , The study will be published next week in the online, open access journal PLoS Biology.

Exercise:

Exercise Regular exercise improves blood flow and helps to reduce the resting heart rate and blood pressure

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massage

GOAL:

GOAL

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World Heart Day 2010 Workplace Wellness Take Responsibility for your own heart health 26 September 2010

BLOOD PRESSURE MEASUREMENT:

BLOOD PRESSURE MEASUREMENT Regular blood pressure measurement is very crucial and in case of normotensive it can be at 3-6 months interval in this high hypertension risk group and in case of hypertension it will be as per treatment protocol.

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MODIFICATIONS RECOMMENDATION APPROXIMATE SBP REDUCTION Weight reduction Maintain normal body weight (body mass index 18.5–24.9 kg/m2). 5–20 mmHg per 10kg 144,145 Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and low fat dairy products with a reduced content of saturated and total fat. 8–14 mmHg 124,125

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Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). 2–8 mmHg Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week). 4–9 mmHg Moderation of alcohol consumption Limit consumption to no more than 2 drinks (e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in male, and to no more than 1 drink per day in female and lighter weight persons. 2–4mmHg

THANKS:

THANKS drmhmomin@yahoo.co.in Mobile: +91-9426845307