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Burden and determinants of hypertension in rural Pondicherry, India.


Globally, hypertension has been acknowledged as a significant public health concern to the population in socioeconomic and epidemiological transition, and is also the most prevalent risk factor of cardiovascular diseases [1]. In-fact, recent estimates show that hypertension affects more than a third of adults aged 25 and above, accounting for about a billion people worldwide and contributes to nearly 9.4 million deaths from cardiovascular diseases each year [2]. Furthermore, it has been estimated that by the year 2030, 23 million cardiovascular deaths are projected to be due to hypertension, of which about 85% cases will be from low-resource settings and developing nations [2]. A high and increasing prevalence of hypertension in both rural and urban areas of India has been reported in recent studies [3,4]. An analysis of nationally-representative survey data revealed that almost 22% of the men and 26% of women had hypertension [3]. In addition, findings of studies performed in different settings have revealed a conclusive evidence between high blood pressure and early onset/precipitation of other disorders (viz. coronary heart disease, stroke, heart failure and impaired renal function) [3,4].

Prevention of hypertension is possible. Early detection and appropriate/effective control of blood pressure is a critical element to reduce the risk of hypertension-induced-organ damage and other serious complications [3,5]. In addition, creating awareness among the members of the community regarding the potential risk factors that eventually determine the occurrence of hypertension is essential for combating the rising trends of hypertension in the community [5]. Thus implementation of effective primary and secondary prevention measures should be the most important goals in the planning of health policy measures [5]. There is a scarcity of literature on hypertension from rural India, which constitutes 70% of the total population. We followed a cohort of adults in rural Pondicherry, India over three years to study the incidence of T2DM. The research data were analyzed to explore the prevalence of hypertension and its risk factors [6].

Materials and Methods

Study setting

A population based study was undertaken in two of the villages (viz. Ramanathapuram and Pillaiyarkuppam), under the jurisdiction of Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry from 2012 to 2014.

Sample size

The sample size was estimated by employing a freely available open source software, Open Epi Version 2.3.10 [6]. The sampling frame comprised individuals aged above 25 years (n=2608). Single stage cluster random sampling was carried out. Using streets as the primary sampling unit, four streets in Ramanathapuram and six streets in Pillaiyarkuppam were chosen by lot method.

Inclusion and exclusion criteria

From the houses of the selected streets, all participants aged more than 25 years were invited to take part in the study. Subjects not willing to participate (n=33) and those with missing forms [7] were excluded.

Study tool and variables

Subjects were interviewed with the help of a pre-tested structured questionnaire. Information pertaining to socio-demographic parameters (viz. age, sex, education, occupation, per capita income), family history, level of physical activity, tobacco and alcohol use were obtained using the questionnaire. In addition, each of the study subjects was subjected to anthropometric measurements (viz. height, weight and waist circumference).


All the study participants were interviewed face-to-face using the pre-tested structured questionnaire after obtaining their informed consent. Blood pressure was checked with digital blood pressure monitor (OMRON SEM-1, Japan) in the right upper limb with subjects in sitting posture. Two readings were taken, the mean of two was considered as an individual's blood pressure measurement. As per JNC-8 classification, hypertension was defined as SBP of [greater than or equal to] 140 mm of Hg or/and DBP of [greater than or equal to] 90 mm of Hg or those taking antihypertensive medication.

Ethical consideration

Ethical clearance was obtained from the Institutional Ethics Committee prior to the start of the study. Written informed consent was obtained from the study participants before obtaining any information from them. Utmost care was taken to maintain privacy and confidentiality.

Statistical analysis

Data were analyzed using the SPSS statistical package version 16.0. The associations were assessed using Chi-square test and Unpaired T test for the categorical (%) and continuous (mean [+ or -] SD) variables respectively. Variables with p < 0.05 in univariate analysis were included in the multivariate logistic regression using Backward method.


Table 1 reflects the socio-demographic profile of study subjects in accordance with their blood pressure status. The age distribution of the study participants varied from 25 years to 98 years with a mean of 45.6 ([+ or -] 13.7). The overall prevalence of hypertension was 24.7% (258/1043), with higher prevalence among male (28.7%) than among females (21.0%). The prevalence of diabetes in the community was 12.2%. Also, it was seen that 27.5% of hypertensive subjects were diabetic and 55.9% of the diabetics were hypertensive. Univariate analysis of the risk factors for hypertension revealed a statistically significant association was observed between hypertension and reduced physical activity/week, higher pack year of smoking, more consumption of alcohol, obesity, higher waist circumference, raised total cholesterol and triglycerides level, low HDL and excessive consumption of oil/salt. In addition, a positive family history of hypertension and co-existence of diabetes also accounted for the higher prevalence of hypertension among the study subjects. Normotensive and hypertensive individuals did not differ significantly with regard to the educational status, occupation status, per capita income and calorie intake per day.

Multivariate analysis showed that with each year increase in age, the risk of hypertension rose by 2.9% (Table 2). Also, those with a family history of hypertension and coexisting diabetes had 1.8 and 2.0 times higher chances of having hypertension. Of the modifiable risk factors, addiction in any form predisposed to high blood pressure i.e. a unit increase in pack year of smoking and gm/day of alcohol poses an additional risk of 11.9% and 1.1% respectively. Besides higher amount of body fat as measured by BMI and abdominal obesity independently predicted risk of hypertension. Among the dietary factors, salt intake was significantly linked to hypertension with consumption of each additional gram of salt per day mounted 4.7% extra risk of hypertension. Dyslipidemia in the form of elevated triglyceride determined higher chance of raised blood pressure.


The prevalence of obesity among the study participants was 24.7% (258/1043), which was much similar to a community-based cross-sectional study performed in the South India (21.1%) [7]. However, the findings of a baseline epidemiological study done among South Asian adults revealed that the prevalence of hypertension ranged from 30.7% (India), 33.5% (Pakistan) and 39.3% (Bangladesh) [8]. The present study revealed higher prevalence among men (28.7%) than among women (21.0%). In contrast, reverse trend was observed in a study conducted by the World Health Organization in India [3]. The reasons for such variability may be the high prevalence of smoking (25.3%) and alcohol use (50.3%) amongst the men while none of the females used these substances in the study area. Also, more men were diabetic than females (14.5% Vs. 9.9%, p < 0.05).

In the present study, a directly proportional relationship between increase in age and prevalence of hypertension was observed. Similar results were reported in a cross-sectional study [4]. This is probably because of the independent factor of age and adoption of range of harmful lifestyle habits--physical inactivity, smoking/alcohol addiction, faulty dietary practices, and full-blown appearance of other co-morbidities, as the age progresses.

Furthermore, a statistically significant relationship was seen between hypertension and lack of physical activity, addiction to smoking/alcohol, higher body mass index, raised serum cholesterol and higher caloric intake. Studies from different settings have revealed similar results [4,8,9]. This reflects the constellation of multiple lifestyle habits in the causation of the hypertension. In addition, a definite risk of hypertension was observed if the subjects had a positive family history of hypertension in our study. Family history of hypertension has been shown to be a strong predictor of development of hypertension [9,10]. Besides, simultaneous presence of diabetes augmented the chances of having hypertension by 1.8 times. Similar findings were revealed in a systematic review assessing the epidemiology of hypertension in India [11,12]. These finding reiterates the importance of common risk factors and highlights the need for comprehensive screening for other cardiometabolic risk factors among the individuals presenting with any single risk factor [13].

The current study depicted that with every unit increase in pack year of smoking and gm/day of alcohol, an additional risk of 11.9% and 1.1% respectively was posed on the development of hypertension. Addiction of tobacco was found to be a significant parameter in augmenting the risk of hypertension in the community [14]. These findings provide enough evidence to enhance the efforts of health sector in creating awareness about the consequences of smoking/alcohol consumption, and enforce legal provisions in a stringent manner.

Owing to the exploration of most of the socio-demographic and lifestyle attributes, the findings of the study can be definitely utilized by the policy makers to address the identified risk factors. Limitation of the study was single contact data of diet by recall method and family level aggregate information was obtained on vegetable, oil and salt intake. In addition, as the research was from a nonrandom sample of villages of southern India, the generalization of the findings needs caution.


The research revealed a high prevalence of hypertension in the rural adults of Pondicherry. The need of the hour is to develop comprehensive and flexible measures to promote adoption of a healthy diet, physical activity and de-addiction in the general population. 10.4172/0974-8369.1000238


[1.] World Health Organization (2013) Cardiovascular diseases - Fact sheet No. 317, USA.

[2.] World Health Organization (2013) World Health Day 2013: calls for intensified efforts to prevent and control hypertension, USA.

[3.] Moser KA, Agrawal S, Davey Smith G, Ebrahim S (2014) Socio-demographic inequalities in the prevalence, diagnosis and management of hypertension in India: analysis of nationally-representative survey data. PLoS One 9:e86043.

[4.] Kokiwar PR, Gupta SS, Durge PM (2012) Prevalence of hypertension in a rural community of central India. J Assoc Physicians India 60:26-29.

[5.] Shrivastava SR, Shrivastava PS, Ramasamy J (2014) The determinants and scope of public health interventions to tackle the global problem of hypertension. Int J Prev Med 5:807-812.

[6.] Majgi SM, Soudarssanane BM, Roy G, Das AK (2012) Risk factors of diabetes mellitus in rural Puducherry. Online J Health Allied Scs 11:4.

[7.] Shanthirani CS, Pradeepa R, Deepa R, Premalatha G, Saroja R, et al. (2003) Prevalence and risk factors of hypertension in a selected South Indian population--the Chennai Urban Population Study. J Assoc Physicians India 51:20-27.

[8.] Chow CK, Teo KK, Rangarajan S, Islam S, Gupta R, et al. (2013) Prevalence, awareness, treatment and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA 310:959-968.

[9.] Kaur P, Rao SR, Radhakrishnan E, Rajasekar D, Gupte MD (2012) Prevalence, awareness, treatment, control and risk factors for hypertension in a rural population in South India. Int J Public Health 57:87-94.

[10.] Basu S, Millett C (2013) Social epidemiology of hypertension in middle- income countries: determinants of prevalence, diagnosis, treatment, and control in the WHO SAGE study. Hypertension 62:18-26.

[11.] Gupta R, Gipta N (2013) Hypertension epidemiology in the 21 century India. J Prev Cardiol 2:350-5.

[12.] Min H, Chang J, Balkrishnan R (2010) Sociodemographic risk factors of diabetes and hypertension prevalence in republic of Korea. Int J Hypertens 410794.

[13.] Gupta R, Yusuf S (2014) Towards better hypertension management in India. Indian J Med Res 139:657-660.

[14.] Dogan N, Toprak D, Demir S (2012) Hypertension prevalence and risk factors among adult population in Afyonkarahisar region: a cross-sectional research. Anadolu Kardiyol Derg 12:47-52.

Saurabh Ram Bihari Lal Shrivastava (1) *, Arun Gangadhar Ghorpade (2) and Prateek Saurabh Shrivastava (1)

(1) Shri Sathya Sai Medical College and Research Institute, Kancheepuram, Tamil Nadu, India

(2) Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

* Corresponding author: Dr. Saurabh Ram Bihari Lal Shrivastava, Department of Community Medicine, 3rd floor, Shri Sathya Sai Medical College and Research Institute, Ammapettai village, Thiruporur - Guduvancherry Main Road, Sembakkam Post, Kancheepuram-603108, Tamil Nadu, India, Tel: +919884227224; E-mail:

Received April 16, 2015; Accepted May 30, 2015; Published June 06, 2015
Table 1: Socio-demographic profile normotensive and hypertensive

Variables *                           Normal n (%)

Total                                      785
Age in years                      44.4 ([+ or -] 13.3)
Women                                  422 (79.0)
Men                                    363 (71.3)
Educational status
No schooling                           243 (76.9)
Attended school                        542 (74.6)
Occupational status
Non-workers                            234 (73.4)
Worker                                 551 (76.1)
PCI in Rs/month                   1363 ([+ or -] 1122)
Physical activity (Mets/wk)       8383 ([+ or -] 5454)
Smoking pack year                  0.1 ([+ or -] 0.9)
Alcohol (gm/day)                   5.6 ([+ or -] 19.5)
Body mass index (kg/[m.sup.2])     22.2 ([+ or -] 4.4)
Waist circumference (cm)          79.8 ([+ or -] 11.3)
Total cholesterol                 173.0 ([+ or -] 33.5)
Triglyceride                      112.3 ([+ or -] 62.9)
LDL                               107.7 ([+ or -] 28.4)
HDL                               42.5 ([+ or -] 10.1)
Calorie (kcal/day)               1986.6 ([+ or -] 789.2)
Protein (gm/day)                  48.9 ([+ or -] 20.9)
Oil consumption (L/month)         0.74 ([+ or -] 0.33)
Salt intake (gm/day)               16.4 ([+ or -] 5.9)
Family history of hypertension
Absent                                 683 (77.3)
Present                                102 (63.8)
Absent                                 729 (79.6)
Present                                 56 (44.1)

Variables *                        Hypertension n (%)      p value (#)

Total                                      258                 --
Age in years                      49.5 ([+ or -] 14.2)       <0.001
Gender                                                        0.004
Women                                  112 (21.0)
Men                                    146 (28.7)
Educational status                                            0.420
No schooling                            73 (23.1)
Attended school                        185 (25.4)
Occupational status                                           0.343
Non-workers                             85 (26.6)
Worker                                 133 (23.9)
PCI in Rs/month                   1523 ([+ or -] 1296)        0.056
Physical activity (Mets/wk)       6649 ([+ or -] 5294)        0.001
Smoking pack year                  0.7 ([+ or -] 3.9)        <0.001
Alcohol (gm/day)                  10.7 ([+ or -] 28.3)        0.001
Body mass index (kg/[m.sup.2])     23.9 ([+ or -] 4.0)       <0.001
Waist circumference (cm)          85.9 ([+ or -] 11.5)       <0.001
Total cholesterol                 186.3 ([+ or -] 42.0)      <0.001
Triglyceride                      142.3 ([+ or -] 87.4)      <0.001
LDL                               112.0 ([+ or -] 35.0)       0.062
HDL                               46.0 ([+ or -] 11.9)       <0.001
Calorie (kcal/day)               2000.4 ([+ or -] 773.6)      0.667
Protein (gm/day)                  49.4 ([+ or -] 20.4)        0.707
Oil consumption (L/month)         0.79 ([+ or -] 0.35)        0.092
Salt intake (gm/day)               18.0 ([+ or -] 6.6)        0.003
Family history of hypertension                               <0.001
Absent                                 200 (22.7)
Present                                 58 (36.3)
Diabetes                                                     <0.001
Absent                                 187 (20.4)
Present                                 71 (55.9)

(#) p value of Unpaired T test and Chi square test for continuous and
categorical variables PCI: Per capita income, BMI: Body mass index

Table 2: Backward logistic regression for the risk of hypertension.

Variables                           AOR (95% CI)       p value

Age in years                     1.029 (1.016-1.042)   <0.001
Smoking pack year                1.119 (1.006-1.245)    0.038
Alcohol (gm/day)                 1.011 (1.004-1.018)    0.001
Body mass index                  1.053 (1.000-1.109)    0.051
Waist circumference              1.020 (1.000-1.039)    0.050
Total cholesterol                1.004 (1.000-1.009)    0.072
Triglyceride                     1.003 (1.000-1.005)    0.019
Salt intake (gm/day)             1.047 (1.019-1.075)    0.001
Family history of hypertension
Absent                                    1
Present                          1.758 (1.150-2.689)    0.009
Absent                                    1
Present                          2.047 (1.306-3.209)    0.001

Factors with p value <0.05 were included
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Title Annotation:Research Article
Author:Shrivastava, Saurabh Ram Bihari Lal; Ghorpade, Arun Gangadhar; Shrivastava, Prateek Saurabh
Publication:Biology and Medicine
Article Type:Report
Date:Jul 1, 2015
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