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Senanayake, Sameera Jayan, Ruwanpathirana, Thilanga, & Gunawar-

dena, Nalika
(2019)
Hypertension in a rural community in Sri Lanka: Prevalence, associated
factors and its effect on the renal profile.
Journal of Hypertension, 37 (9), pp. 1805-1812.

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https://doi.org/10.1097/HJH.0000000000002107
Hypertension in a rural community in Sri Lanka: Prevalence, associated
factors and its effect on the renal profile

Short title : Hypertension in a CKDu hit population

Sameera SENANAYAKE *1,2 , Thilanga RUWANPATHIRANA 1, Nalika GUNAWARDANA 3

[1] Epidemiology Unit, Ministry of Health, Sri Lanka; [2] Queensland University of
Technology, Australia; [3] World Health Organization, Country Office, Sri Lanka

Source of funding
National Science Foundation of Sri Lanka (RPHS/2016/CKDu 07), Ministry of Health,
Nutrition and Indigenous Medicine and Worlds Health Organization Country Office Sri
Lanka.

Conflict of interest
The authors of this manuscript have no conflicts of interest to disclose.

*Address for correspondence

Sameera Senanayake
Australian Centre for Health Services Innovation
Institute of Health and Biomedical Innovation
Queensland University of Technology
60 Musk Ave, Kelvin Grove, QLD 4059
Australia

E-mail: [email protected]
Tel : +61450865361

Word count : 3921

Number of tables : 06

Number of figures : 00
Abstract

Introduction
Chronic kidney disease (CKD) in which the etiology cannot be attributed to any known
etiology, is named CKD of uncertain etiology (CKDu). The main aims of this analysis were to
estimate the prevalence of hypertension and to identify the associated factors in a rural
community vulnerable to CKDu and to identify the effect of hypertension on the renal
profile among this community.

Methods
We conducted a cross-sectional representative population survey in five study areas in
Anuradhapura district, a rural district in Sri Lanka. Blood pressure, blood glucose, bio-
impedance measurements and renal profile were measured using standard instruments and
protocols.

Results
A total of 4803 participants (88.7%) took part in the study. The overall prevalence of
hypertension in the study population was 26.3% (95%CI 25.0 – 27.5). Among those who
were previously diagnosed, only 17.3% had normal blood pressure. Increasing age, family
history of hypertension, presence of diabetes mellitus, eGFR less than 60 ml/min/1.7m2 and
increasing body mass index were independently associated with having hypertension. High
prevalence of hypertension was observed among those who had glomerular filtration rate
(eGFR) less than 60 ml/min/1.7m2. Hypertension was significantly associated with having
eGFR less than 60 ml/min/1.7m2 (aOR 2.931).

Conclusion
One in four individuals in the rural district of Anuradhapura is a hypertensive. Hypertension
poses a significant burden to CKD even in populations affected by CKDu. Hence, public
health initiatives should be implemented parallelly to control both CKDu and hypertension
in these rural communities.

Key words : Hypertension; Chronic kidney disease of uncertain etiology; Sri Lanka
Introduction
The prevalence of hypertension, a major modifiable risk factor of non-communicable
diseases (NCDs), is increasing globally. It is projected to affect 29% or approximately 1.56
billion of the adult world’s population by 2025 and this will be a 60% increase from the
corresponding figure in the year 2000 (1). World over, hypertension is responsible for
around 45% deaths related to ischaemic heart disease and 51% deaths due to stroke (2). Of
the global attributable burden of hypertension, 80% is said to occur in low-income and
middle-income countries (3). However, less is known about the magnitude, distribution and
determinants of hypertension in these parts of the world.

During the World Health Assembly in 2013, the countries set a target to reduce the
prevalence of hypertension by a quarter of its 2010 level, by 2025 (4). Furthermore, 2030
Agenda for Sustainable Development targets to reduce premature mortality from NCDs by
one third by 2030 with a focus on universal health coverage, reaching all (5). Thus, it is
imperative that low-income and middle-income countries generate epidemiological
evidence on magnitude, distribution and determinants of hypertension among the
population groups that are likely to be more vulnerable for NCDs which will enable them
design and implement evidence based targeted interventions (6).

Research confirm that the prevalence and the determinants of hypertension vary
significantly according to the place or residence even with in a country (7-9). According to
two studies done by Al Kibria et al (2018)(10) in Bangladesh and Wang et al (2018)(9) in China,
a significant differences in the prevalence was noted between urban and rural populations.

Current burden of hypertension in Sri Lanka and its geographical distributions is poorly
understood. This is in the context where a contrasting difference is observed in the socio-
economic context between urban and rural communities and many health-related
indicators show urban rural disparities with rural populations showing relatively poorer
outcomes(11). Lack of recent population based epidemiological studies, variations of
definitions used to define hypertension and failing to present disaggregated estimates of
geographical distributions are some of the reasons.
According to a national survey conducted in 2005 by Katulanda et al., the prevalence of
hypertension was 27.4% (95% CI 26.1 – 28.7) among adults of more than 18 years (n=4485)
(12)
. The study included both the ‘diagnosed hypertension’ (previously diagnosed at a
government hospital or by a registered medical practitioner or if they were on
antihypertensive treatment) and ‘undiagnosed hypertension’ (the average of two resting
seated BP readings, separated by 5 min were above or equal to 140/90 mmHg) in its
estimation of hypertension prevalence. The prevalence of hypertension among urban and
rural populations were 26.5% (95% CI 25.7 – 27.7) and 22.9% (95% CI 21.5 – 24.3),
respectively confirming the vulnerability of the rural populations. The latest source of
evidence on prevalence of hypertension from a population-based survey in Sri Lanka is from
the Word Health Organization’s STEPS survey conducted in 2015. It included a nationally
representative sample of 5188 adults aged 18-69 years and reported a prevalence of raised
blood pressure of 26.1% (95% CI 24.4-27.7) accounted by those on medication for
hypertension and those who had raised blood pressure at the time of survey (the average of
two resting seated BP readings, separated by 5 min were systolic > 140 mmHg and or
diastolic > 90 mmHg) (13). It does not present the disaggregated estimates for urban and
rural populations.

Hypertension is a well-known risk factor of chronic kidney disease (CKD) (14, 15). Triggered by
an exponential increase noted in the number of CKD cases in the rural populations of the
North Central Province (NCP) in Sri Lanka in early 1990s, the rising burden of CKD in Sri
Lanka has drawn the attention of national and international medical communities (16). CKD
in which the etiology cannot be attributed to any known etiology, like hypertension, is
named CKD of uncertain etiology (CKDu) and the rise in CKD burden in rural populations of
NCP is attributed to cases of CKDu. However, while all the attention is drawn to the
‘unknown’ CKD (CKDu), burden of CKD due to known causes such as hypertension is poorly
understood in communities affected by CKDu.

In this milieu, the main aims of this analysis is to fill two knowledge gaps. First was to
estimate the prevalence of hypertension and to identify the associated factors in a rural
community in NCP vulnerable to CKDu and the second was to identify the effect of
hypertension on the renal profile among this community. The evidence generated from this
analysis will help to better understand the burden of hypertension and design targeted
interventions in rural CKDu affected communities in Sri Lanka.

Methods
Study design and study setting
This was a community-based cross-sectional household survey designed primarily to estimate
the magnitude of impaired kidney function in the district of Anuradhapura, Sri Lanka (17). The
study was conducted in three of 23 Divisional Secretariat areas of the Anuradhapura district,
from March to May 2017. Anuradhapura district is a rural agricultural district and the most
CKDu affected district in Sri Lanka. Within the three Divisional Secretariat areas, five
geographically demarcated settings comprising 2- 4 villages located adjacent to each other
were selected as the study areas. The basis for the geographical demarcation was to include
approximately 1000 potentially eligible adult residents.

Study participants
All adults above the age of 18 years, whose main place of residence (defined as living in the
setting for at least for 5 days of the week for the past 6 months) was in the study area, were
invited to take part. Exclusion criteria were: (i) pregnancy; and (ii) patients undergoing
treatment for cancer.

Sample size and sampling technique

This paper presents an analysis of data collected to determine the population prevalence of
impaired kidney function in the Anuradhapura district. The required sample size was
(18)
estimated as 1000 from each of the five study areas with 5000 from all areas. We
confirmed that this sample size also allows accurate estimation of the prevalence of
hypertension with sufficient statistical power for comparisons between population
subgroups. As indicated above, the study areas were selected to ensure an approximate 1000
potentially eligible adult residents from each of the five areas, and this was done using the
official updated voter’s lists of local administrative officers. Using the voter’s lists as the base,
all of the households in the defined study area were visited and all eligible adults were invited
to take part. Study information was provided, and those granting informed written consent
were recruited to the study. A team of ten graduates from a University located in the district
were trained to collect data.

Data collection
Upon recruitment, history related to previous diagnosis of hypertension and treatment were
collected in the home using an interviewer-administered questionnaire by the trained
interviewers. The medical and treatment records were photographed and were used to cross
check the accuracy of the self-reported information at the stage of analysis. Information on
other existing NCDs, socio-demographic and life style characteristics were also collected using
the interviewer administered questionnaires. Upon completion of the questionnaire, study
participants were provided with a container and an instruction sheet on collecting the early
morning urine sample and were requested to visit the ‘clinic’ on the following day before
work for the anthropometry measurements and biological sample collection. Revisits the
houses were done to recruit any eligible study participants who were not available in the
house at the time of the first visit. The ‘clinics’ were set up within the study areas in locations
that were acceptable and accessible to all the villagers and about 100 were invited to each
clinic.

At the clinics, the trained data collectors performed the of blood pressure measurements.

All data collectors successfully completed training sessions on the use of the blood pressure
measurement protocol. The training included preparation of study participants for blood
pressure measurement, selection of an appropriate cuff size and standard blood pressure
measurement techniques. Blood pressure was measured using calibrated automated
“Omron HEM-7270 Intelisense Automatic Electronic Blood Pressure Monitor”. Three
measurements were done on each study unit in sitting position ensuring five minutes resting
in between each measurement. Other than the blood pressure measurements samples of 5ml
of blood were drawn for measurements of serum creatinine and samples of overnight urine
were collected for measurement of urine proteins Capillary random plasma glucose was
measured using a glucometer, height using stadiometer, bio-impedance outputs of body fat
percentage, body mass index and total body water percentage using a TANITA SC-240MA
Body composition analyzer.
Serum creatinine and urine protein: creatinine ratio was tested in the laboratory of the
Anuradhapura Teaching Hospital. Serum creatinine was measured using assays calibrated
utilizing quality controls traceable to isotope dilution mass spectrometry (IDMS) standards.
eGFR value was calculated using the CKD-EPI equation, which needed the serum creatinine
value, age, sex and race (black or other).

Institutional ethics committee approval was obtained from the Ethics Review Committee of
the Faculty of Medicine, University of Colombo (EC-17-031). All the study units were informed
regarding their clinical and laboratory findings. Those needed medical referral were referred
to the Anuradhapura Teaching Hospital for appropriate care.

Data analysis
In estimating the prevalence of hypertension, a study unit was classified as having
‘hypertension’, if he/she had any of the following criteria;
• previously diagnosed of hypertension with evidence of medical records
• being on anti-hypertension drugs
• the average of two resting seated BP readings of systolic blood pressure > 140
mmHg and or diastolic blood pressure > 90 mmHg at the time of the survey

Prevalence of hypertension was estimated for the total population and for subgroups of
population disaggregated by age, sex and area.

The mean values of clinical and biochemical parameters namely, body mass index, body fat
percentage, eGFR value, urine Albumin-Creatinine ratio (ACR), and random blood glucose of
those classified as hypertension were compared with those without. Non-parametric tests
were used as all the above variables were non-normally distributed indicating a skewed
distribution.
Mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) were calculated
dividing the cumulative SBP and DBP by the total number of study units. Distribution of the
mean SBP and mean DBP of the total study population and males and females by socio-
demographic, life style and biological characteristics, presence of diabetes and renal
function were evaluated for significant differences.

Furthermore, the study units previously diagnosed as hypertensives and who were
identified as having hypertension at the survey were categorized into five groups in line
with the American Heart Association guidelines (19) .
• Normal: Less than 120/80 mm Hg
• Elevated: Systolic between 120-129 mm Hg and diastolic less than 80 mm Hg
• Stage 1: Systolic between 130-139 mm Hg or diastolic between 80-89 mm Hg
• Stage 2: Systolic at least 140 mm Hg or diastolic at least 90 mm Hg
• Hypertensive crisis: Systolic over 180 mm Hg and/or diastolic over 120 mm Hg

Association of socio-demographic, life style and biological characteristics and presence of

diabetes with hypertension were identified by conducting bivariate as well as multiple
logistic regression analyses. In classifying a study unit as a diabetic, he/she was considered a
diabetic if he/she either self-reported being a diabetic (with evidence of medical records) or
being on treatment for diabetes or capillary random plasma glucose more than 200 mg/dL
at the time of survey.

To assess the independent association between renal effect and hypertension, two separate
logistic regression models were developed, keeping eGFR level (eGFR less than 60
ml/min/1.7m2 and eGFR more than or equal to 60 ml/min/1.7m2) and urine Albumin-
Creatinine ratio (ACR less than or equal to 30mg/g and ACR more than 30 mg/g) as
dependent variables. The other factors controlled in the models were age, sex, number of
years of education, current smoking status, current alcohol consumption status, daily water
intake, body fat percentage, body water percentage, body mass index, diabetes mellitus,
family history of chronic kidney disease, use of agrochemicals and ever occupied in farming.

A ‘p’ value of<0.05 was considered statistically significant.

Results
Characteristics of the study participants
The total study included 4803 participants with an overall response rate of 88.7%. Nearly
half of the study participants were in the age category of 31-50 years. Of the study
population, a majority were females (68.2%). Nearly 50% of the participants (46.6%) were
engaged in full time farming and 28.7% in part-time farming.

Prevalence of hypertension in the population

The overall prevalence of hypertension in the study population was 26.3% (95% CI 25.0 –
27.5) (n=1262). Of those classified as having hypertension, 58.0% (n=733) were previously
diagnosed with evidence of medical records or were on anti-hypertension drugs, while
41.9% (n=529) were not, but found to have average blood pressures of systolic blood
pressure > 140 mmHg and/ or diastolic blood pressure > 90 mmHg>140/90 at the time of
the survey (Table 1). There was no significant difference in the prevalence of hypertension
between males 27.9% (95% CI 25.7 – 30.2) and female 25.4% (95% CI 23.9 – 26.9) (p=0.065).
In both sexes the prevalence of hypertension significantly increased with increasing age
(p<0.05).

Evaluating the treatment history of the 733 who had records of previously been diagnosed
with hypertension, 396 (54.0%) were found not to be on any medications in spite of having
been prescribed drugs. A total of 167 (22.8%) were on one drug, 99 (13.7%) were on two
drugs and 71 (9.7%) were on more than two drugs, at the time of survey.

The table 2 describes the mean values of clinical and biochemical parameters according to
the hypertension status. Body mass index, body fat percentage, eGFR value, urine Albumin-
Creatinine ratio (ACR), and random blood glucose (RBS) value were significantly (p<0.001)
higher in those who had hypertension.

Distribution of SPB and DPB according to different characteristics

The mean systolic blood pressure and the mean diastolic blood pressure in the study sample
were 121.2 (SD + 15.5) and 74.4 (SD + 13.2), respectively (Table 3). Both mean SBP and DBP
were significantly (p<0.05) higher in males compared to females. In both males and
females, the lowest SBP was observed in the youngest age category (age 18 – 30 years),
while the highest was among the oldest age category (age more than 70 years). Those who
were not occupied in farming recorded the lowest SBP and DPB and this was seen in both
males and females. As expected, the participants who had a family history of hypertension,
had the highest SBP and DBP. Interestingly, consumption of alcohol and smoking were not
significantly associated with both SBP and DBP in both sexes. Among those who had
records of previously been diagnosed with hypertension, those who were not on any anti-
hypertensive drugs recorded the highest mean SBP and DBP between both sexes. Study
participants who had either diabetes mellitus or eGFR less than 60 ml/min/1.7m2 had
significantly higher SBP and DBP compared to those who did not.

Distribution of the study units previously diagnosed as hypertensives and who were
identified as having hypertension at the survey according to the American Heart Association
guidelines is presented in Table 4. Among those who were previously diagnosed, only
17.3% had normal blood pressure. The category that reflects the poorest blood pressure
control, the ‘hypertensive crisis’ recorded 2.1% of those who were previously diagnosed as
well as 3.6% of those who were identified as having hypertension at the survey.

Factors associated with hypertension

Multiple logistic regression analysis was performed to evaluate the factors independently
associated with hypertension (Table 5). Increasing age (aOR 1.068), family history of
hypertension (aOR 1.736), presence of diabetes mellitus (aOR 2.594), eGFR less than 60
ml/min/1.7m2 (aOR 2.772) and increasing Body mass index (aOR 1.051) were found to be
significantly associated with having hypertension. Being a female (aOR 0.598) and increase
body water percentage (aOR 0.957) were significant protective factors of having
hypertension.

Independent effect of hypertension on the renal profile

High prevalence of hypertension was observed among those who had eGFR less than 60
ml/min/1.7m2 (61.7% (95% CI 57.8 - 65.6)) compared to those who had more than or equal
to 60 ml/min/1.7m2 (21.1% (95% CI 19.8 - 22.3). Furthermore, the prevalence of
hypertension among those who had the urine Albumin-Creatinine ratio more than 30 mg/g
(49.1%; 95% CI 44.4 – 53.7) was significantly higher compared to those who had ACR less
than 30 mg/g (23.9%; 95% CI 22.6 – 25.2).

To assess the independent association between renal effect and hypertension, multiple
logistic regression analysis was performed. Two separate logistic regression models were
run, keeping eGFR level (eGFR less than 60 ml/min/1.7m2 and eGFR more than or equal to
60 ml/min/1.7m2) and urine Albumin-Creatinine ratio (ACR less than or equal to 30mg/g and
ACR more than 30 mg/g). The other factors controlled in the models were age, sex, number
of years of education, current smoking status, current alcohol consumption status, daily
water intake, body fat percentage, body water percentage, body mass index, diabetes
mellitus, family history of chronic kidney disease, use of agrochemicals and ever occupied in
farming. The results indicate that hypertension is significantly associated with having eGFR
less than 60 ml/min/1.7m2 (aOR 2.931) and ACR more than 30mg/g (aOR 2.168) (Table 6).

Discussion
This study was done to assess the burden of hypertension and its effect on the renal profile
in a rural CKDu affected community in Sri Lanka. To the best of the authors’ knowledge, this
is the first in-depth analysis of the burden of hypertension in a rural community severely
affected by CKDu.

The overall prevalence of hypertension in the study population was 26.3% (95% CI 25.0 –
27.5). There was no significant difference in the prevalence of hypertension between males
27.9% (95% CI 25.7 – 30.2) and female 25.4% (95% CI 23.9 – 26.9). The current study
defined ‘hypertension’, as previously diagnosed with evidence of medical records or being
on anti-hypertension drugs or the average of two resting seated blood pressure readings of
systolic blood pressure > 140 mmHg and or diastolic blood pressure > 90 mmHg at the time
of the survey. This was in keeping with the two national surveys conducted in Sri Lanka,
STEPS survey (2015) (13) and the study by Katulanda et al (2014) (12) which allowed
comparisons across the studies. Katulanda et al. reported a prevalence of hypertension of
22.9% (95% CI 21.5–24.3) among a rural community, with a similar age and sex distribution
to the present study, which was significantly lower than the prevalence of hypertension
among the rural population of the present study. The data of Katulanda et al. was collected
in 2005 and this significant increase of prevalence can attributed to the time lapse.
However, possibilities of higher vulnerability of the CKDu affected communities included in
the present study to hypertension needs to be further explored. Though more recent, the
STEPs survey in 2015 did not stratify the prevalence according the rural and urban areas,
precluding direct comparison with the results of the present study. Comparable prevalence
of hypertension in rural parts of other regional countries were evident in the literature.
According to a study done in a rural communities in India(20) the prevalence was found be
27.0% (95% CI 26.3 - 27.7).

In the present study 11.0% (n=529) were found to have average blood pressures of systolic
blood pressure > 140 mmHg and/ or diastolic blood pressure > 90 mmHg and were classified
as hypertensive at the time of the survey. Furthermore, 3.6% among them were in
hypertensive crisis (>180/120 mmHg) at the time of detection. The problem of undiagnosed
hypertensive patients were evident in Argentina (35.9%)(21), India (22.2%)(22) and China
(15.5%)(23), indicating that it is a public health problem that needs greater attention.

Among those who were already diagnosed as having hypertension 23.2% were on two or
more anti-hypertension medications. This value is slightly lower compared to a multi-
country study done by Jafar et al (2018), which included Sri Lanka, where 31% of the already
diagnosed hypertensive patients were on two or more drugs (24). Evidence indicate that it
takes two-three antihypertensive drugs to achieve optimal blood pressure control (25). In
United States, the use of multiple classes of antihypertensive drugs increased from 37% in
2001 to 48% in 2009. Furthermore, the overall hypertension control rate increased from
29% to 47% during the same time period (26).

The American College of Cardiology and the American Heart Association (ACC/AHA) latest
guidelines recommend target blood pressure levels below 130/80mmHg, irrespective of the
comorbid conditions or age (27). In the current study, among those who were previously
diagnosed, 68.8% a had their blood pressure more than 130/80mmHg. The fact that those
with an existing diagnosis of hypertension showed poor blood pressure control, together
with the fact that the proportion of diagnosed hypertensive patients taking two or more
drugs was comparatively low in the study population, could indicate lack of effective
titration of number of antihypertensive medications among this rural community, which
could have contributed to the poor blood pressure control.

Poor control of blood pressure among those who are already diagnosed in rural
communities is a common finding Evidence indicate that poor compliance is the main
reason for unsatisfactory blood pressure control (28). Two studies done in two resource poor
settings in Nigeria and Pakistan, found that the compliance could be as low as 32%-48% (29,
30)
. Poor knowledge of the importance of the compliance (31)and lack of affordability of drugs
due to high out-of-pocket expenditure (32) were found to be associated with poor
compliance.

Multiple logistic regression analysis revealed that increasing age, male sex, family history of
hypertension, presence of diabetes mellitus, eGFR less than 60 ml/min/1.7m2 and increasing
body mass index to be significantly associated with having hypertension. Old age and
increased body mass index are consistently been found to be associated with increased risk
of hypertension (33, 34). Evidence concerning the gender has been inconsistent in the
literature. According to a meta-analysis by Neupane et al. (2014), male sex was a
significantly risk factor of hypertension (OR 1.19; 95% CI 1.02 - 1.37)(33) and similar finding
was found in couple of other studies as well (35, 36). However, contrasting results have been
evident in couple of studies done in several Asian countries (10, 37, 38).

Though there is lack of evidence regarding the population attributable risk of hypertension
on CKD(39), hypertension is an established risk factor of chronic kidney disease (40). In our
study, the prevalence of hypertension was significantly higher among those who had eGFR
less than 60 ml/min/1.7m2 (61.7%) and those who had ACR more than 30 mg/g (49.1%).
However, interestingly both these proportions are much low when compared with the
current literature from other countries. According to the United States Renal Data System
(2013), prevalence of hypertension among those who has eGFR less than 60 ml/min/1.7m2 is
around 84% and among those who had ACR more than 30 mg/g is around 69% (41). CKDu in
Anuradhapura is characterized by eGFR less than 60 ml/min/1.7m2 and/or ACR more than
30 mg/g, with no known risk factors of CKD, such as hypertension and diabetes. Thus,
comparatively low proportions of those with hypertension among those with poor renal
profile could be reflects the situation of CKDu in the study area.

Our study had couple of limitations. Though, longitudinal measurement of blood pressure is
needed to confirm the diagnosis of hypertension, those with the average of two high resting
BP readings at the time of the survey were considered as having hypertension. Similarly,
blood glucose measurements and eGFR values were also measured only once, thus
misclassification is a possibility.

In conclusion, one in four individuals in the rural district of Anuradhapura is a hypertensive.

Poor blood pressure control and treatment compliance among majority of those who had
been previously diagnosed as hypertension is a great concern. Couple of modifiable risk
factors were identified during the study and targeted primary preventive interventions are
recommended. Poor renal profiles in the absence of any known causes of CKD confirmed
the vulnerability of the study population to CKDu.
Table 1: Prevalence of hypertension by age category, study area and sex
Prevalence (95% Confidence Interval)
All (N = 4803) Male (N = 1529) Female (N = 3274)
No 95% CI No 95% CI No 95% CI
Total population 1262 26.3 (25.0 – 27.5) 428 27.9 (25.7 – 30.2) 834 25.4 (23.9 – 26.9)
Age categories
18 – 30 (N=774) 39 5.0 (3.4 - 6.5) 21 11.4 (6.8 - 16.1) 18 3.0 (1.6 - 4.4)
31 – 50 (N = 2225) 385 17.2 (15.2 - 18.8) 113 16.5 (13.7 - 19.3) 272 17.6 (15.7 - 19.5)
51 – 70 (N = 1573) 694 44.0 (41.5 - 46.4) 239 41.7 (37.6 - 45.7) 455 45.3 (42.2 - 48.4)
> 70 (N = 231) 144 61.8 (55.4 - 68.2) 55 56.5 (46.2 - 66.8) 89 65.4 (57.3 - 73.5)
Study area
Area 1 (N = 908) 238 26.2 (23.3 – 29.1) 89 30.7 (25.3 – 36.0) 149 24.1 (20.7 – 27.5)
Area 2 (N = 1008) 264 26.2 (23.5 – 28.9) 88 25.8 (21.2 – 30.5) 176 26.3 (23.0 – 29.7)
Area 3 (N = 926) 243 26.2 (23.4 – 29.1) 79 25.2 (20.4 – 30.8) 164 26.7 (23.2 – 30.3)
Area 4 (N = 1000) 299 29.9 (27.1 – 32.7) 101 33.6 (28.3 – 39.0) 198 28.3 (24.9 – 28.3)
Area 5 (N = 961) 218 22.7 (20.3 – 25.3) 71 24.8 (19.8 – 29.9) 147 21.8 (18.7 – 24.9)
Table 2: Comparison of clinical and biochemical parameters according to the hypertension
status
clinical and biochemical parameters Hypertensive Non-Hypertensive Significance#
Mean (SD) Mean (SD)
Body mass index (kg/m2) 24.3 (5.2) 22.8 (4.6) <0.001
Body fat percentage 31.0 (9.3) 28.7 (9.4) <0.001
Body water percentage 49.5 (5.9) 50.0 (5.3) 0.005
eGFR (60 ml/min/1.7m2) 71.4 (27.9) 93.3 (23.6 <0.001
Urine Albumin-Creatinine ratio (mg/g) 78.2 (325.4) 24.5 (209.0) <0.001
Random Blood Glucose value (mg/dl) 139.8 (62.1) 118.3 (42.7) <0.001
#
Mann-Whitney U test
Table 3 : Mean SBP and DBP and socio-demographic characteristics in all adults, males and females
Number (%) Mean systolic Diastolic Blood Pressure, mmHg (SD)
All (N=4803) Male (N=1529) Female (N=3274)
Systolic Diastolic Systolic Diastolic Systolic Diastolic
Mean (SD) Sig Mean (SD) Sig Mean (SD) Sig Mean (SD) Sig Mean (SD) Sig Mean (SD) Sig
Total population 4803 (100.0) 121.2 (15.5) 74.4 (13.2) 123.3 (18.2) 75.4 (13.1) 120.3 (18.5) 73.9 (13.2)
Age categories
18 – 30 774 (16.1) 110.6 (12.7) Sig# 67.9 (8.5) Sig# 117.7 (13.6) Sig# 67.8 (9.6) Sig# 108.3(11.6) Sig# 67.9 (8.1) Sig#
31 – 50 2225 (46.3) 118.7 (16.0) 74.6 (14.9) 120.0 (16.2) 74.7 (14.2) 118.1 (15.9) 74.5 (15.2)
51 – 70 1573 (32.8) 128.3 (16.0) 77.3 (11.8) 127.5 (20.0) 78.7 (11.9) 128.5 (20.1) 76.4 (11.6)
> 70 231 (4.8) 133.3 (20.7) 75.4 (10.3) 131.7 (19.7) 75.4 (11.3) 134.1 (21.3) 75.4 (9.7)
Number of years of
education in schools and in
higher education institutes
No schooling 238 (5.0) 128.8 (20.4) Sig# 76.1 (10.3) Sig# 126.3 (21.2) NS# 77.3 (10.2) NS# 127.0 (20.3) Sig# 75.8 (10.3) Sig#
< 10 1650 (34.4) 124.8 (20.1) 75.8 (11.8) 123.5 (19.4) 75.7 (11.7) 125.5 (20.5) 75.9 (11.8)
≥ 10 2915 (60.6) 118.8 (16.8) 73.5 (14.9) 122.9 (17.2) 75.1 (14.2) 116.8 (16.4) 72.7 (14.0)
Ever occupied in farming
No 1188 (24.7) 115.2 (15.9) Sig# 71.4 (11.8) Sig# 118.3 (14.9) Sig# 70.9 (18.3) Sig# 114.5 (16.1) Sig# 71.5 (9.7) Sig#
Part time farming 1377 (28.7) 124.3 (19.0) 75.5 (12.3) 123.8 (18.1) 76.0 (11.6) 124.5 (19.8) 75.0 (12.9)
Full time farming 2238 (46.6) 122.6 (18.7) 75.4 (14.2) 124.3 (19.1) 76.4 (12.3) 121.9 (18.5) 74.9 (14.9)
Family history of
hypertension
Present 1582 (33.0) 123.2 (18.1) Sig$ 75.8 (15.6) Sig$ 124.3 (17.0) Sig$ 76.0 (12.0) 122.7 (18.5) Sig$ 75.7 (16.8) Sig$
Absent 3221 (67.0) 120.3 (18.6) 73.3 (11.9) 122.8 (18.6) 75.1 (13.6) 119.0 (18.4) 73.0 (10.9)
Current use of Alcohol
Present 831 (17.3) 122.9 (17.6) Sig$ 76.1 (14.1) Sig$ 122.9 (17.6) NS$ 76.0 (14.2) NS$ 122.9 (18.7) NS$ 77.4 (11.2) NS$
Absent 3972 (82.6) 120.8 (18.6) 74.1 (13.0) 123.6 (18.9) 74.7 (11.8) 120.2 (18.5) 73.9 (13.2)
Current smoking
Present 416 (8.6) 121.8 (18.1) NS$ 75.3 (12.0) NS$ 121.6 (18.1) Sig$ 75.3 (12.1) NS$ 126.3 (17.4) NS$ 77.9 (8.6) NS$
 Absent 4387 (91.4) 121.1 (18.5) 74.3 (13.3) 123.8 (18.2) 75.4 (13.5) 120.2 (18.5) 73.9 (13.2)
Daily water intake
Less than 3 L 2737 (57.0) 120.8 (18.8) Sig$ 73.7 (11.1) Sig$ 123.1 (18.9) NS$ 74.8 (12.0) NS$ 120.1 (18.6) NS$ 73.4 (10.8) Sig$
>= 3 L 2066 (43.0) 121.8 (18.1) 75.4 (15.5) 123.3 (17.7) 75.8 (13.9) 120.5 (18.2) 74.9 (16.8)
Number of anti-hypertensive
drugs# (N=733)
Not on drugs 396 (54.0) 138.1 (19.9) Sig# 81.6 (12.4) Sig# 139.1 (20.9) Sig# 84.2 (14.1) Sig# 139.9 (19.6) Sig# 80.5 (11.5) NS#
One drug 167 (22.8) 130.9 (18.8) 77.6 (10.0) 128.3 (20.5) 77.0 (11.1) 132.0 (18.0) 77.9 (9.6)
Two drugs 99 (13.5) 138.3 (19.6) 80.3 (11.7) 132.5 (18.7) 81.5 (12.5) 137.6 (19.5) 80.0 (11.5)
More than two drugs 71 (9.7) 134.7 (26.0) 79.1 (17.2) 134.5 (19.0) 81.5 (19.3) 134.7 (27.5) 78.5 (16.8)
Diabetes Mellitus
Present 470 (9.8) 130.2 (19.2) Sig$ 77.9 (13.0) Sig$ 129.5 (18.3) Sig$ 77.4 (11.5) Sig$ 130.3 (19.6) Sig$ 78.2 (13.7) Sig$
Absent 4333 (90.2) 120.3 (18.1) 74.0 (13.1) 122.6 (18.1) 75.2 (13.3) 119.1 (18.0) 73.4 (13.0)
eGFR level
<60 600 (12.5) 130.1 (21.9) Sig$ 77.3 (11.8) Sig$ 128.7 (21.2) Sig$ 78.7 (12.4) Sig$ 131.2 (22.5) Sig$ 75.9 (11.1) Sig$
>= 60 4203 (87.5) 120.0 (17.6) 74.0 (13.3) 121.9 (17.2) 74.6 (13.2) 119.1 (17.7) 73.7 (13.4)
# Among those who are already diagnosed as hypertensive
Sig# - Significant difference at 0.05 level using Kruskal Wallis Test; NS# - Significant difference at 0.05 level using Kruskal Wallis Test
Sig$ - Significant difference at 0.05 level using Mann-Whitney U Test; NS# - Significant difference at 0.05 level using Mann-Whitney U Test
Table 4 : Distribution of the study units identified as having hypertension according to the
American Heart Association guidelines
American Heart Association category Previously diagnosed as Identified as having
having hypertension hypertension at the survey
No. (%) No. (%)
Normal 127 (17.3) 0 (0.0)
Elevated 102 (13.9) 0 (0.0)
Stage – 1 193 (26.3) 0 (0.0)
Stage – 2 296 (40.4) 510 (96.4)
Hypertensive crisis 15 (2.1) 19 (3.6)
Total 733 (100.0) 529 (100.0)

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Table 5 : Factors associated with hypertension among study participants
Covariates Bivariate analysis Multivariate analysis
Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI)
OR 95% CI Sig. aOR 95% CI Sig.
Age in years 1.073 1.067 1.079 <0.001 1.068 1.060 1.076 <0.001
Sex
Male 1 1
Female 0.879 0.767 1.008 0.065 0.598 0.443 0.807 0.001
Number of years of education 0.905 0.887 0.922 <0.001 0.996 0.980 1.011 0.580
Ever occupied in farming
No 1 1
Part time farming 2.565 2.119 3.102 <0.001 1.057 0.835 1.338 0.645
Full time farming 3.332 2.726 4.073 <0.001 1.121 0.868 1.447 0.381
Family history of hypertension
Present 1.605 1.404 1.835 <0.001 1.736 1.472 2.046 <0.001
Absent 1 1
Current use of Alcohol
Present 0.820 0.687 0.977 0.027 0.834 0.63 1.105 0.206
Absent 1 1
Current smoking
Present 0.969 0.770 1.218 0.778 1.024 0.746 1.405 0.884
Absent 1 1
Daily water intake
Less than 3 L 1 1
>= 3 L 1.005 0.883 1.114 0.939 1.082 0.917 1.277 0.352
Diabetes Mellitus
Present 5.029 4.128 6.127 <0.001 2.594 2.051 3.281 <0.001
Absent 1 1
eGFR level
<60 6.074 5.069 7.276 <0.001 2.772 2.203 3.49 <0.001
>= 60 1 1
Body mass index (kg/m2) 1.065 1.050 1.080 <0.001 1.051 1.021 1.083 0.001
Body fat percentage 1.027 1.020 1.034 <0.001 1.014 0.991 1.038 0.247
Body water percentage 0.983 0.971 0.994 0.004 0.957 0.931 0.983 0.001

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Table 6: Independent effect of hypertension on the renal profile among study participants
Renal parameter (Dependent Hypertension status (As an Adjusted OR of being a p value
#
variable in the Multiple independent variable) hypertensive (95% CI)
Logistic regression model) aOR 95% CI
eGFR level < 60 Hypertensive 2.931 2.321 3.698 <0.001
Non-Hypertensive 1
Urine Albumin-Creatinine Hypertensive 2.168 1.711 2.748 <0.001
ratio > 30 mg/g Non-Hypertensive 1
#
Other independent variables controlled in the model: Age, Sex, Number of years of education, Current
smoking, Current alcohol consumption, Daily water intake, Body fat percentage, Body water percentage, Body
Mass Index, Diabetes Mellitus, Family history of chronic kidney disease, Use of agrochemicals, Ever occupied in
farming

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