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Blood pressure studies in the adult population of Agra, India
Blood Pressure Population
Studies in the Adult of Agra, India*
KRISHNA MATHUR, M.D., PREM N. WAHI, M.D. and DEVENDRA GAHLAUT, M.D. Agra, India
munities of Hindus, Moslems, Christians and Sikhs and represented in a good measure the cross section of the population. The study covered professionals, business executives and senior government servants, clerks, school teachers and shopkeepers, and skilled, manual and agricultural workers. Socioeconomic classification was based on the consideration given to income, profession and social status.8 Of these 1,634 persons, 352 (282 men and 70 women) belonged to a “high” socioeconomic group, 553 (464 men and 89 women) to a “middle” and 729 (662 men and 67 women) to a “low” group. In the last category of men were included 295 skilled workers, 234 manual workers and 133 agricultural workers. A dietary survey of this population9 has shown a very low consumption of animal proteins. Most of the persons are vegetarians and even those who are nonvegetarians take meat, fish, eggs or fowl infrequently. Intake of calories of fat is in a low range compared to American or English standards, varying from 15 f 8 per cent in the “low” socioeconomic group to 34 f 10 per cent in the “high” group. The sodium chloride intake is 6 to 10 gm. per day. The average diet is just over 2,000 calories per day. The majority of the persons were at work, but they were all made to rest for about 30 minutes before the examination began. A clinical history was taken and physical examination completed. All blood pressure measurements were made in the right arm, in the sitting position, in a quiet room by one of us with a blood pressure cuff 14 cm. wide. The lowest read-
T
FE M’OR~D Health Organization’s Expert Committee on Cardiovascular Diseases and Hypertension,’ which met in Geneva in October 1958 to discuss the public health problems created by cardiovascular diseases, recommended that studies be done throughout the world to determine the distribution of possible differences in blood pressure in many populations. Such studies, it is presumed, would not only define the limits of normal blood pressure in groups of people of different races and nationalities but would also serve to reveal the incidence of hypertension a well as the influence of geographic, cultural and other environmental factors on the height of systolic and diastolic pressure. There are very few reports on blood pressure studies from India. Padmavati and Gupta2 have reported on the blood pressure studies in rural and urban groups in Delhi. Many of the other reports on blood pressure range in normal Indians have been made on highly selective groups, like the villagers of North Bihar by Shreenivas,3 industrial workers of Kanpur by Dubey,4 policemen of Calcutta by Dotto, liquor permit holders and teetotalers of Bombay by Shah and KunjannamG and patients attending the outpatient department of J. J. Hospital of Bombay by Sathe.’ This paper records our observations on blood pressure levels among the adult population at Agra, an important town in Northern India. MATERIALS
AND
ing of three blood pressure determinations made at 4 Systolic pressure minute intervals was recorded. was taken at the appearance of the first sound
METHODS
when the cuff was deflated slowly and the diastolic pressure at the point of the disappearance of the sound. Blood pressure levels of 160/95 mm. Hg and above were accepted as the hypertensive range in accordance with the criteria of hypertension laid down by the W.H.O. Expert Committee.’ Detailed investigations for etiological factors were made in all suspected cases.
For this study, 1,634 persons, including 1,408 men and 226 women above the age of 20 years, were selected. They were drawn from different sectors into which the city of Agra had been divided and their representative populations examined. Two adjoining groups of villages were surveyed for agricultural workers. These persons from rural and urban areas belonged to all the major religious com* From the Department of Medicine, Sarojini from the Indian Council of Medical Research. JANUARY
1963
Naidu Medical
61
College, Agra, India.
This study was aided by grants
Mathur,
62
Wahi and Gahlaut TABLE I
Variations
_~Mco---_-~~~~~~ ~~7 Mean Blood Pressure _---(mm. Hg)-m ~--Diastolic Systolic
_____ Cases (no. 1
4gt? (yr.)
.._
__
of Blood Pressure
with Age and Sex _~
~
-\I’omen Mean Blood -.--(mm. Systolic
Cases (no.)
__. ~_ Pressure Hg)-mmDiastolic
~~ ~
21-30
625
117.9
(11.0)”
76 2
(8.4)
40
116.9
(10.1)
76.2
(6.2)
31-40
312
119.6
(13.9)
78 6
(10.2)
60
123.2
(11 .8)
77.9
(7.5)
41-50
250
125 2
(18.8)
81 9
(15.5)
65
131.4
(18.2)
81.9
(3.3)
51-60
152
130.2
(21 .61
83 9
(14.2)
25
137.3
(26.0)
83.3
(14.9)
6lm-70
54
133.1
(22.5)
79.4
(11.8)
31
153.3
(23.6!
84.6
(11 ,7)
>71
15
141.2
(23.5)
80 2
112.2)
5
120.0
(10.9)
68.8
(8.91
* Figures
in parenthrsis
indicatr
standard
deviations. ‘r4HLb. 11
Variations -m-~-
-
Cases (no.)
Group
of Blood Prrssurc
_._. -Men~__ Mean Blood Pressure --(mm. Hg)-m -Diastolic Systolic ~__.._ ~
with Socioeconomic -pm.
Group
~~~~ --
Chsrs (no.)
\Vomen -----Mean Blood Pressure _--- --(mm. Hg)---_ Diastolic Systolic
_
High
282
128.5
(17.7)*
83.5
(7.2)
70
136.0
(21.9)
84.1
(12.4)
Middfr
464
122.3
(28.1)
79.2
(7.9)
89
128.8
(21.5)
77.8
(10.7)
Low
67
108.8
(18.2)
68.1
(13.4)
662
118.9
(14.1)
75.9
(10.2)
Skilled
295
116.9
(13.Rj
76.3
(9.7)
Manual
234
120.8
(15.0)
75.8
(8.9)
Agricultural
133
119.7
(12.61
75.4
(9.7)
* Figures For square
in parrnthcsis
statistical evaluation trst was used. KOR~IAL
BLOOD
indicatr of
standard the
PRESSURE
dwiations.
data,
the
chi-
RANGE
The material was analyzed according to age, sex, socioeconomic status, weight and height. T’ariations With dg~ and SPX: Men showed a consistent rise of systolic blood pressure with age from 117.9 f 11.0 mm. Hg in the third decade to 141.2 f 23.5 mm. Hg in the eighth decade (Table I). On comparing the mean blood pressures in the two sexes, it was found that women had a lower mean systolic pressure than men in the third decade, but showed a steeper rise after the age of 40 years. The differences in the diastolic blood pressures between men and women were not appreciable. Systolic as well as diastolic blood pressures showed a definite increase with age in both sexes up to the sixth decade after which the results were not uniform (Table I).
The associations of increased systolic and diastolic blood pressures with age were statistically significant (p <0.05). Ihriations With Socioeconomic Status: Highest mean systolic as well as diastolic blood pressures were observed in the “high” socioeconomic group and the lowest in the “low” socioeconomic group, in both men and women (Table II). No appreciable d i fferences were observed either in systolic or diastolic blood pressures among the subgroups of the “low” socioeconomic group in men. Statistical analysis revealed a significant relation (p <0.05) between socioeconomic status and the systolic and diastolic blood pressures. Variations with Body Weight: In males the minimal and maximal mean values of systolic and diastolic blood pressures were observed in the lowest and highest weight groups, respectively (Table III). The intervening figures THE
AMERICAN
JOURNAL
OF
CARDIOLOGY
Blood Pressure
in Agra
63
TABLE III Variations of Blood Pressure with Body Weight
Weight (Ibs.) -90 91-100 101-110 111-120 121-130 131-140 141-150 151-160 161-170 171-180 181+
CZiXS
(no.) 73 145 280 258 223 144 95 67 53 31 31
Men Mean Blood Pressure -----(mm. Hg)----Systolic Diastolic 115.9 120.8 118.2 119.7 120.9 123.8 125.4 130.8 130.7 127.5 141.9
(12.8)* (10.6) (9.5) (16.8) (13.2) (12.4) (11.4) (12.6) (14.1) (13.4) (16.8)
73.4 75.8 75.8 77.1 78.5 80.1 82.0 89.1 83.4 82.7 92.8
(8.3) (7.7) (10.3) (6.9) (10.1) (9.0) (8.2) (7.6) (9.4) (8.8) (11.3)
Cases (no.) 60 40 23 39 21 15 18
Women Mean Blood Pressure -----(mm. Hg)-----. Systolic Diastolic 123.0 126.8 132.7 134.5 135.6 137.5 130.2
(11.6) (13.5) (14.8) (11.9) (10.8) (14.3) (11.8)
77.0 78.0 80.0 80.0 82.6 86.0 81.9
(8.8) (10.2) (10.6) (9.8) (7.9) (11.4) (10.5)
* The figures in parenthesis indicate standard deviation.
also indicated a trend of rising systolic and diastolic blood pressures with increase in body although the rise was not smooth weight, through all the weight groups. In women also both systolic and diastolic pressures increased with increasing body weight up to 140 pounds, after which a slight fall was observed (Table III). The association between body weight and the and diastolic blood pressures was systolic statistically significant (p <0.05) in both sexes. I’ariations With Height: Variations of blood pressure were studied in relation to height. Statistical analysis showed that neither systolic nor diastolic blood pressure is affected by height in either sex (p >0.05). INCIDENCE OF HYPERTENSION Seventy-one of 1,634 persons examined during the present study had blood pressure levels of 160/95 mm. Hg and above giving an over-all incidence of hypertension of 4.3 per cent. The highest incidence (9.4 per cent) was observed in the “high” socioeconomic group and the lowest (1.9 per cent) in the “low” group (Table IV). The effect of socioeconomic status on the was statistically of hypertension incidence significant (p <0.05). The incidence of hypertension rose progressively among men from 1 per cent in the third decade to 8.4 per cent in the seventh decade (Table v). In women the incidence of hyperJANUARY1963
tension was very low in the third and fourth decades but showed a steeper rise, compared to males, after the age of 40 years. The relation of age to the incidence of hypertension in both sexes was statistically significant (p <0.05). DISCUSSION High blood pressure is as widespread in India today as in many countries of the West, for hypertension is the second most common cause of heart disease,‘O and cerebrovascular accidents are frequently associated with hypertension. Blood pressure levels which constitute high blood pressure at various ages have not been accurately worked out. In the present study, mean systolic pressures for each decade are lower than those reported by Master et al.” Both systolic and diastolic pressures among men and women showed a statistically significant increase with age, with a steady rise from the TABLE Incidence
Group
IV
of Hypertension in Different Socioeconomic Groups
Cases (no. 1
,-Hypertension---, Blood Pressure 160/95 mm. Hg (no.)
Pcrcentage
High
352
33
9.4
Middle
553
24
4.3
Low
729
14
1.9
Mathur,
64
Wahi and Gahlaut TABLE v
Incidence of Hypertension
_____ _____~~
Group (yr.)
- _-.
~
Men---_
,.With No.
cases (no.1
in Different Age Groups _
Hypertension--Percentage
_~._~
Cases (no.1
_ Women ____ -With Hypertension--. No. Percentage
21-30
625
6
1 .o
40
0
31-40
312
14
4.5
60
1
1.6
41-40
250
18
7.2
65
7
10.7
51-60
152
12
7.9
25
3
12.2
69
6
8.4
36
4
11 .l
56
4.0
15
6.6
>61 ~_._._______ Totals
~~-
1408
-~~~
third to the sixth decade, the females showing a In the steeper rise after the age of 40 years. subsequent decades the increase in systolic pressure was more uniform while the diastolic levels tended to be lower. Compared to the largest series of 15,706 persons in the United States reported by Master et al.,” who also found a significant correlation between age and the height of systolic and diastolic pressures, the mean systolic pressures in the present study are lower for men in each decade, but the differences in the diastolic readings are not significant. The differences become still less marked in women. Similar are the observations when our figures are compared with the average blood pressure readings by age and sex among Japanese, reported by Schroeder.” The mean systolic as well as diastolic blood pressures of Formosan Chinesen are, however, lower than our figures for the third and fourth decades, after which the differences are less marked, but the relationship with age is similar. Padmavati and Gupta’ observed only a very small rise with age among men at Delhi, but among the women a steep and steady rise with age similar to ours. On the other hand, Moore and BehI in aboriginal Miall and ethnic groups in West China, 01dhami4 in South Wales and Kaminer and Lutz’s in bushmen of the Kalahari Desert of South Africa did not find any relation of blood pressure to age. Plattlr considers that there are two types of blood pressure population, one in which significantly rises in middle age and another population in which the blood pressure rises only little, if at all, with increasing years. Any sample of blood pressure in the general population, according to him, will show a rise with age
.._. .~~______
226
_---__
0.0
since it will be in fact a mean of the two populations. Highly significant association between socioeconomic status and blood pressure in both sexes, with highest values of systolic and diastolic blood pressures in the “high” socioeconomic group and lowest values in the ‘Llow” socioeconomic group, has been observed by us. Miall and Oldham, I4 in a survey of arterial blood pressure in an urban and rural population in South Wales, observed that persons in the high socioeconomic group had high blood pressure compared to those engaged in manual labor. Padmavati and Gupta2 also noticed that in every decade the systolic and diastolic blood pressures were higher in the high socioeconomic group than in the “low;” they explained this on the basis of steady weight gain with age in the case of upper classes that was almost absent among the rural and industrial workers in their series. Our observations of a significant positive correlation between body weight and blood pressure and a steady increase in systolic and diastolic pressure with weight lend support to this observation. Master et al.” also observed an increase of systolic and diastolic blood pressures with increasing weight, particularly after the age of 40 years. The theory of differences in mental attitude and diet advanced by Lowenstein’G to explain the difference in blood pressure between Chinese and Westerners is not borne out by the studies of Schroeder.i2 He compared systolic blood pressure of Japanese from the records of insurance companies before the war (1927-29), when there was a period of prosperity and growth, to the records during the postwar depression in 1947 and subsequently in 1953 when Japan showed partial recovery. THE AMERICANJOURNAL OF CARDIOLOGY
Blood Pressure In common with the experience of other workers,” no correlation could be established between the levels of blood pressure and height. Although the hypertensive levels accepted by different authors have not been uniform and the results cannot be strictly comparable, the incidence of hypertension in our population is lower for every decade compared to American figures and higher than those reported from Delhi.* Our observations (1) that the highest incidence of hypertension was in the high socioeconomic group and the lowest in the low group, (2) that the incidence rose with each decade and (3) the higher incidence was found in women compared to men after the fourth decade are in conformity with the findings of Master et al.,” Padmavati and Gupta2 and others. All cases of hypertension in the present series were without evident cause. No attempt has been made to speculate about the etiologic and environmental factors in the pathogenesis of these cases. Detailed analysis of diet made during our survey9 has convinced us that dietary sodium chloride, proteins, fat and total calories are not related to the incidence of hypertension. SUMMARY
The normal blood pressure range of 1,634 apparently healthy persons over 20 years of age in the general population of Agra (India) is presented and analyzed according to age, sex, socioeconomic status, weight and height. There was a steady rise of systolic and diastolic blood presstires with age in both sexes up to the sixth decade, the women showing a steeper rise after the age of 40 years. Highest values of systolic and diastolic blood pressures were observed in the “high” socioeconomic group and lowest values in the “low” Statistically significant increase in the group. blood pressures was also observed when correlated with increase in body weight. No correlation could be established with body height. The over-all incidence of hypertension, with
JANUARY 1963
in Agra
65
160/95 mm. Hg and over the measure of hypertensive levels, was 4.3 per cent. It was 9.4 per cent in the high socioeconomic group and only 1.9 per cent in the low group. The incidence rose progressively with age. The women showed a higher incidence than men after the age of 40 years. REFERENCES 1. World Health Organization Technical Report, series No. 168. W.H.O. Geneva, 1959. 2. PADMAVATI, S. and GUPTA, S. Blood pressure studies in rural and urban groups in Delhi. Circulation, 19: 395, 1959. 3. SHREENIVAS. Blood pressure range. Indian Heart J., 3: 22, 1951. 4. DUBEY, V. D. A study of blood pressure amongst industrial workers of Kanpur. J. Indian M. A., 23: 495, 1954. 5. DOTTO, B. B. Studies on blood pressure, height and weight and abdominal measurement of 2,500 members of Calcutta police with short notes on their medical impairments. Indian M. Cm., 84: 239, 1949. 6. SHAH, V. V. and KUNJANNAM,P. V. The incidence of hypertension in liquor permit holders and teetotalers. J. A. Physicians India, 7: 243, 1959. 7. SATHE, R. V. Incidence and etiology of hypertension. J. A. Physicians India, 7: 99, 1959. 8. MATHUR, K. S. Environmental factors in coronary heart disease. An epidemiological study at Agra f India). Circulation. 21: 684. 1960. 9. MATH&, K. S., W~HI, P:N., SRIVASTAVA,S. K. and GAHLAUT, D. S. Diet in western Uttar Pradesh. J. Indian M. A., 37: 58, 1961. 10. MATHUR, K. S. Problem of heart disease in India. Am. J. Cardiol., 21: 60, 1960. 11. MASTER, A. M., DUBLIN, L. I. and MARKS, H. H. The normal blood pressure range and its clinical implications. J.A.M.A., 143: 1464, 1950. 12. SCHROEDER,H. A. Degenerative cardiovascular disease in the Orient. J. Chron. Dis., 8: 287, 1958. 13. MOORE, W. R. and BEH, Y. T. Blood pressure amongst aboriginal ethnic groups of Szechwan Province, West China. Lam& 1: 966, 1937. 14. MIALL, W. E. and OLDHAM,P. D. Factors influencing arterial blood pressure in general population. Clin. SC., 17: 409, 1958. 15. KAMINER, B. and LUTZ, W. P. Blood pressure in bushmen of the Kalahari Desert. Circulation, 22: 289, 1960. 16. LOWENSTEIN, F. W. Some epidemiological apects of blood pressure and its relation to diet and constitution with particular consideration of the Chinese. Am. Heart J., 47: 874, 1954. Essential hypertension. Incidence, 17. PLATT, R. course and heredity. Ann. Znt. Med., 55: 1, 1961.
Studies in the Adult of Agra, India*
KRISHNA MATHUR, M.D., PREM N. WAHI, M.D. and DEVENDRA GAHLAUT, M.D. Agra, India
munities of Hindus, Moslems, Christians and Sikhs and represented in a good measure the cross section of the population. The study covered professionals, business executives and senior government servants, clerks, school teachers and shopkeepers, and skilled, manual and agricultural workers. Socioeconomic classification was based on the consideration given to income, profession and social status.8 Of these 1,634 persons, 352 (282 men and 70 women) belonged to a “high” socioeconomic group, 553 (464 men and 89 women) to a “middle” and 729 (662 men and 67 women) to a “low” group. In the last category of men were included 295 skilled workers, 234 manual workers and 133 agricultural workers. A dietary survey of this population9 has shown a very low consumption of animal proteins. Most of the persons are vegetarians and even those who are nonvegetarians take meat, fish, eggs or fowl infrequently. Intake of calories of fat is in a low range compared to American or English standards, varying from 15 f 8 per cent in the “low” socioeconomic group to 34 f 10 per cent in the “high” group. The sodium chloride intake is 6 to 10 gm. per day. The average diet is just over 2,000 calories per day. The majority of the persons were at work, but they were all made to rest for about 30 minutes before the examination began. A clinical history was taken and physical examination completed. All blood pressure measurements were made in the right arm, in the sitting position, in a quiet room by one of us with a blood pressure cuff 14 cm. wide. The lowest read-
T
FE M’OR~D Health Organization’s Expert Committee on Cardiovascular Diseases and Hypertension,’ which met in Geneva in October 1958 to discuss the public health problems created by cardiovascular diseases, recommended that studies be done throughout the world to determine the distribution of possible differences in blood pressure in many populations. Such studies, it is presumed, would not only define the limits of normal blood pressure in groups of people of different races and nationalities but would also serve to reveal the incidence of hypertension a well as the influence of geographic, cultural and other environmental factors on the height of systolic and diastolic pressure. There are very few reports on blood pressure studies from India. Padmavati and Gupta2 have reported on the blood pressure studies in rural and urban groups in Delhi. Many of the other reports on blood pressure range in normal Indians have been made on highly selective groups, like the villagers of North Bihar by Shreenivas,3 industrial workers of Kanpur by Dubey,4 policemen of Calcutta by Dotto, liquor permit holders and teetotalers of Bombay by Shah and KunjannamG and patients attending the outpatient department of J. J. Hospital of Bombay by Sathe.’ This paper records our observations on blood pressure levels among the adult population at Agra, an important town in Northern India. MATERIALS
AND
ing of three blood pressure determinations made at 4 Systolic pressure minute intervals was recorded. was taken at the appearance of the first sound
METHODS
when the cuff was deflated slowly and the diastolic pressure at the point of the disappearance of the sound. Blood pressure levels of 160/95 mm. Hg and above were accepted as the hypertensive range in accordance with the criteria of hypertension laid down by the W.H.O. Expert Committee.’ Detailed investigations for etiological factors were made in all suspected cases.
For this study, 1,634 persons, including 1,408 men and 226 women above the age of 20 years, were selected. They were drawn from different sectors into which the city of Agra had been divided and their representative populations examined. Two adjoining groups of villages were surveyed for agricultural workers. These persons from rural and urban areas belonged to all the major religious com* From the Department of Medicine, Sarojini from the Indian Council of Medical Research. JANUARY
1963
Naidu Medical
61
College, Agra, India.
This study was aided by grants
Mathur,
62
Wahi and Gahlaut TABLE I
Variations
_~Mco---_-~~~~~~ ~~7 Mean Blood Pressure _---(mm. Hg)-m ~--Diastolic Systolic
_____ Cases (no. 1
4gt? (yr.)
.._
__
of Blood Pressure
with Age and Sex _~
~
-\I’omen Mean Blood -.--(mm. Systolic
Cases (no.)
__. ~_ Pressure Hg)-mmDiastolic
~~ ~
21-30
625
117.9
(11.0)”
76 2
(8.4)
40
116.9
(10.1)
76.2
(6.2)
31-40
312
119.6
(13.9)
78 6
(10.2)
60
123.2
(11 .8)
77.9
(7.5)
41-50
250
125 2
(18.8)
81 9
(15.5)
65
131.4
(18.2)
81.9
(3.3)
51-60
152
130.2
(21 .61
83 9
(14.2)
25
137.3
(26.0)
83.3
(14.9)
6lm-70
54
133.1
(22.5)
79.4
(11.8)
31
153.3
(23.6!
84.6
(11 ,7)
>71
15
141.2
(23.5)
80 2
112.2)
5
120.0
(10.9)
68.8
(8.91
* Figures
in parenthrsis
indicatr
standard
deviations. ‘r4HLb. 11
Variations -m-~-
-
Cases (no.)
Group
of Blood Prrssurc
_._. -Men~__ Mean Blood Pressure --(mm. Hg)-m -Diastolic Systolic ~__.._ ~
with Socioeconomic -pm.
Group
~~~~ --
Chsrs (no.)
\Vomen -----Mean Blood Pressure _--- --(mm. Hg)---_ Diastolic Systolic
_
High
282
128.5
(17.7)*
83.5
(7.2)
70
136.0
(21.9)
84.1
(12.4)
Middfr
464
122.3
(28.1)
79.2
(7.9)
89
128.8
(21.5)
77.8
(10.7)
Low
67
108.8
(18.2)
68.1
(13.4)
662
118.9
(14.1)
75.9
(10.2)
Skilled
295
116.9
(13.Rj
76.3
(9.7)
Manual
234
120.8
(15.0)
75.8
(8.9)
Agricultural
133
119.7
(12.61
75.4
(9.7)
* Figures For square
in parrnthcsis
statistical evaluation trst was used. KOR~IAL
BLOOD
indicatr of
standard the
PRESSURE
dwiations.
data,
the
chi-
RANGE
The material was analyzed according to age, sex, socioeconomic status, weight and height. T’ariations With dg~ and SPX: Men showed a consistent rise of systolic blood pressure with age from 117.9 f 11.0 mm. Hg in the third decade to 141.2 f 23.5 mm. Hg in the eighth decade (Table I). On comparing the mean blood pressures in the two sexes, it was found that women had a lower mean systolic pressure than men in the third decade, but showed a steeper rise after the age of 40 years. The differences in the diastolic blood pressures between men and women were not appreciable. Systolic as well as diastolic blood pressures showed a definite increase with age in both sexes up to the sixth decade after which the results were not uniform (Table I).
The associations of increased systolic and diastolic blood pressures with age were statistically significant (p <0.05). Ihriations With Socioeconomic Status: Highest mean systolic as well as diastolic blood pressures were observed in the “high” socioeconomic group and the lowest in the “low” socioeconomic group, in both men and women (Table II). No appreciable d i fferences were observed either in systolic or diastolic blood pressures among the subgroups of the “low” socioeconomic group in men. Statistical analysis revealed a significant relation (p <0.05) between socioeconomic status and the systolic and diastolic blood pressures. Variations with Body Weight: In males the minimal and maximal mean values of systolic and diastolic blood pressures were observed in the lowest and highest weight groups, respectively (Table III). The intervening figures THE
AMERICAN
JOURNAL
OF
CARDIOLOGY
Blood Pressure
in Agra
63
TABLE III Variations of Blood Pressure with Body Weight
Weight (Ibs.) -90 91-100 101-110 111-120 121-130 131-140 141-150 151-160 161-170 171-180 181+
CZiXS
(no.) 73 145 280 258 223 144 95 67 53 31 31
Men Mean Blood Pressure -----(mm. Hg)----Systolic Diastolic 115.9 120.8 118.2 119.7 120.9 123.8 125.4 130.8 130.7 127.5 141.9
(12.8)* (10.6) (9.5) (16.8) (13.2) (12.4) (11.4) (12.6) (14.1) (13.4) (16.8)
73.4 75.8 75.8 77.1 78.5 80.1 82.0 89.1 83.4 82.7 92.8
(8.3) (7.7) (10.3) (6.9) (10.1) (9.0) (8.2) (7.6) (9.4) (8.8) (11.3)
Cases (no.) 60 40 23 39 21 15 18
Women Mean Blood Pressure -----(mm. Hg)-----. Systolic Diastolic 123.0 126.8 132.7 134.5 135.6 137.5 130.2
(11.6) (13.5) (14.8) (11.9) (10.8) (14.3) (11.8)
77.0 78.0 80.0 80.0 82.6 86.0 81.9
(8.8) (10.2) (10.6) (9.8) (7.9) (11.4) (10.5)
* The figures in parenthesis indicate standard deviation.
also indicated a trend of rising systolic and diastolic blood pressures with increase in body although the rise was not smooth weight, through all the weight groups. In women also both systolic and diastolic pressures increased with increasing body weight up to 140 pounds, after which a slight fall was observed (Table III). The association between body weight and the and diastolic blood pressures was systolic statistically significant (p <0.05) in both sexes. I’ariations With Height: Variations of blood pressure were studied in relation to height. Statistical analysis showed that neither systolic nor diastolic blood pressure is affected by height in either sex (p >0.05). INCIDENCE OF HYPERTENSION Seventy-one of 1,634 persons examined during the present study had blood pressure levels of 160/95 mm. Hg and above giving an over-all incidence of hypertension of 4.3 per cent. The highest incidence (9.4 per cent) was observed in the “high” socioeconomic group and the lowest (1.9 per cent) in the “low” group (Table IV). The effect of socioeconomic status on the was statistically of hypertension incidence significant (p <0.05). The incidence of hypertension rose progressively among men from 1 per cent in the third decade to 8.4 per cent in the seventh decade (Table v). In women the incidence of hyperJANUARY1963
tension was very low in the third and fourth decades but showed a steeper rise, compared to males, after the age of 40 years. The relation of age to the incidence of hypertension in both sexes was statistically significant (p <0.05). DISCUSSION High blood pressure is as widespread in India today as in many countries of the West, for hypertension is the second most common cause of heart disease,‘O and cerebrovascular accidents are frequently associated with hypertension. Blood pressure levels which constitute high blood pressure at various ages have not been accurately worked out. In the present study, mean systolic pressures for each decade are lower than those reported by Master et al.” Both systolic and diastolic pressures among men and women showed a statistically significant increase with age, with a steady rise from the TABLE Incidence
Group
IV
of Hypertension in Different Socioeconomic Groups
Cases (no. 1
,-Hypertension---, Blood Pressure 160/95 mm. Hg (no.)
Pcrcentage
High
352
33
9.4
Middle
553
24
4.3
Low
729
14
1.9
Mathur,
64
Wahi and Gahlaut TABLE v
Incidence of Hypertension
_____ _____~~
Group (yr.)
- _-.
~
Men---_
,.With No.
cases (no.1
in Different Age Groups _
Hypertension--Percentage
_~._~
Cases (no.1
_ Women ____ -With Hypertension--. No. Percentage
21-30
625
6
1 .o
40
0
31-40
312
14
4.5
60
1
1.6
41-40
250
18
7.2
65
7
10.7
51-60
152
12
7.9
25
3
12.2
69
6
8.4
36
4
11 .l
56
4.0
15
6.6
>61 ~_._._______ Totals
~~-
1408
-~~~
third to the sixth decade, the females showing a In the steeper rise after the age of 40 years. subsequent decades the increase in systolic pressure was more uniform while the diastolic levels tended to be lower. Compared to the largest series of 15,706 persons in the United States reported by Master et al.,” who also found a significant correlation between age and the height of systolic and diastolic pressures, the mean systolic pressures in the present study are lower for men in each decade, but the differences in the diastolic readings are not significant. The differences become still less marked in women. Similar are the observations when our figures are compared with the average blood pressure readings by age and sex among Japanese, reported by Schroeder.” The mean systolic as well as diastolic blood pressures of Formosan Chinesen are, however, lower than our figures for the third and fourth decades, after which the differences are less marked, but the relationship with age is similar. Padmavati and Gupta’ observed only a very small rise with age among men at Delhi, but among the women a steep and steady rise with age similar to ours. On the other hand, Moore and BehI in aboriginal Miall and ethnic groups in West China, 01dhami4 in South Wales and Kaminer and Lutz’s in bushmen of the Kalahari Desert of South Africa did not find any relation of blood pressure to age. Plattlr considers that there are two types of blood pressure population, one in which significantly rises in middle age and another population in which the blood pressure rises only little, if at all, with increasing years. Any sample of blood pressure in the general population, according to him, will show a rise with age
.._. .~~______
226
_---__
0.0
since it will be in fact a mean of the two populations. Highly significant association between socioeconomic status and blood pressure in both sexes, with highest values of systolic and diastolic blood pressures in the “high” socioeconomic group and lowest values in the ‘Llow” socioeconomic group, has been observed by us. Miall and Oldham, I4 in a survey of arterial blood pressure in an urban and rural population in South Wales, observed that persons in the high socioeconomic group had high blood pressure compared to those engaged in manual labor. Padmavati and Gupta2 also noticed that in every decade the systolic and diastolic blood pressures were higher in the high socioeconomic group than in the “low;” they explained this on the basis of steady weight gain with age in the case of upper classes that was almost absent among the rural and industrial workers in their series. Our observations of a significant positive correlation between body weight and blood pressure and a steady increase in systolic and diastolic pressure with weight lend support to this observation. Master et al.” also observed an increase of systolic and diastolic blood pressures with increasing weight, particularly after the age of 40 years. The theory of differences in mental attitude and diet advanced by Lowenstein’G to explain the difference in blood pressure between Chinese and Westerners is not borne out by the studies of Schroeder.i2 He compared systolic blood pressure of Japanese from the records of insurance companies before the war (1927-29), when there was a period of prosperity and growth, to the records during the postwar depression in 1947 and subsequently in 1953 when Japan showed partial recovery. THE AMERICANJOURNAL OF CARDIOLOGY
Blood Pressure In common with the experience of other workers,” no correlation could be established between the levels of blood pressure and height. Although the hypertensive levels accepted by different authors have not been uniform and the results cannot be strictly comparable, the incidence of hypertension in our population is lower for every decade compared to American figures and higher than those reported from Delhi.* Our observations (1) that the highest incidence of hypertension was in the high socioeconomic group and the lowest in the low group, (2) that the incidence rose with each decade and (3) the higher incidence was found in women compared to men after the fourth decade are in conformity with the findings of Master et al.,” Padmavati and Gupta2 and others. All cases of hypertension in the present series were without evident cause. No attempt has been made to speculate about the etiologic and environmental factors in the pathogenesis of these cases. Detailed analysis of diet made during our survey9 has convinced us that dietary sodium chloride, proteins, fat and total calories are not related to the incidence of hypertension. SUMMARY
The normal blood pressure range of 1,634 apparently healthy persons over 20 years of age in the general population of Agra (India) is presented and analyzed according to age, sex, socioeconomic status, weight and height. There was a steady rise of systolic and diastolic blood presstires with age in both sexes up to the sixth decade, the women showing a steeper rise after the age of 40 years. Highest values of systolic and diastolic blood pressures were observed in the “high” socioeconomic group and lowest values in the “low” Statistically significant increase in the group. blood pressures was also observed when correlated with increase in body weight. No correlation could be established with body height. The over-all incidence of hypertension, with
JANUARY 1963
in Agra
65
160/95 mm. Hg and over the measure of hypertensive levels, was 4.3 per cent. It was 9.4 per cent in the high socioeconomic group and only 1.9 per cent in the low group. The incidence rose progressively with age. The women showed a higher incidence than men after the age of 40 years. REFERENCES 1. World Health Organization Technical Report, series No. 168. W.H.O. Geneva, 1959. 2. PADMAVATI, S. and GUPTA, S. Blood pressure studies in rural and urban groups in Delhi. Circulation, 19: 395, 1959. 3. SHREENIVAS. Blood pressure range. Indian Heart J., 3: 22, 1951. 4. DUBEY, V. D. A study of blood pressure amongst industrial workers of Kanpur. J. Indian M. A., 23: 495, 1954. 5. DOTTO, B. B. Studies on blood pressure, height and weight and abdominal measurement of 2,500 members of Calcutta police with short notes on their medical impairments. Indian M. Cm., 84: 239, 1949. 6. SHAH, V. V. and KUNJANNAM,P. V. The incidence of hypertension in liquor permit holders and teetotalers. J. A. Physicians India, 7: 243, 1959. 7. SATHE, R. V. Incidence and etiology of hypertension. J. A. Physicians India, 7: 99, 1959. 8. MATHUR, K. S. Environmental factors in coronary heart disease. An epidemiological study at Agra f India). Circulation. 21: 684. 1960. 9. MATH&, K. S., W~HI, P:N., SRIVASTAVA,S. K. and GAHLAUT, D. S. Diet in western Uttar Pradesh. J. Indian M. A., 37: 58, 1961. 10. MATHUR, K. S. Problem of heart disease in India. Am. J. Cardiol., 21: 60, 1960. 11. MASTER, A. M., DUBLIN, L. I. and MARKS, H. H. The normal blood pressure range and its clinical implications. J.A.M.A., 143: 1464, 1950. 12. SCHROEDER,H. A. Degenerative cardiovascular disease in the Orient. J. Chron. Dis., 8: 287, 1958. 13. MOORE, W. R. and BEH, Y. T. Blood pressure amongst aboriginal ethnic groups of Szechwan Province, West China. Lam& 1: 966, 1937. 14. MIALL, W. E. and OLDHAM,P. D. Factors influencing arterial blood pressure in general population. Clin. SC., 17: 409, 1958. 15. KAMINER, B. and LUTZ, W. P. Blood pressure in bushmen of the Kalahari Desert. Circulation, 22: 289, 1960. 16. LOWENSTEIN, F. W. Some epidemiological apects of blood pressure and its relation to diet and constitution with particular consideration of the Chinese. Am. Heart J., 47: 874, 1954. Essential hypertension. Incidence, 17. PLATT, R. course and heredity. Ann. Znt. Med., 55: 1, 1961.