Hypertension and obesity among paralytic poliomyelitis survivors in Nigeria

Hong Kong Physiotherapy Journal (2015) 33, 21e27

Available online at www.sciencedirect.com

ScienceDirect journal homepage: www.hkpj-online.com

RESEARCH REPORT

Hypertension and obesity among paralytic poliomyelitis survivors in Nigeria Abiola A. Atowoju, MSc a,*, Babatunde O.A. Adegoke, PhD a, Joseph F. Babalola, PhD b a b

Department of Physiotherapy, College of Medicine, University of Ibadan, Ibadan, Nigeria Department of Human Kinetics and Health Education, Institute of Education, University of Ibadan, Ibadan, Nigeria

KEYWORDS cardiovascular health; hypertension; obesity; polio survivors

Abstract Background: Hypertension and obesity have been reported as prevalent cardiovascular risk indicators among poliomyelitis (polio) survivors in developed countries, but findings from developed countries may not be directly extrapolated to Nigeria because of racial and environmental differences. Objective: This cross-sectional survey aimed at providing reference data on the prevalence of hypertension and obesity among polio survivors in Nigeria. Methods: Resting blood pressure (RBP) and body mass index (BMI) in consecutively recruited participants were categorized using the British Hypertension Society Classification and the World Health Organization BMI Scale, respectively. Results: A total of 252 (119 males, 133 females) participants were included in the study; mean age was 34.0  9.1 years (range, 21e52 years) and polio was contracted at a mean age of 3.2  2.2 years. Approximately 25% and 48% of the participants had hypertension and prehypertension, respectively. Overweight/obesity was present in about 41% of the participants. Prevalence of hypertension and obesity from this study were lower than values previously reported for populations in developed countries, probably due to the relatively younger age of participants. Prevalence of hypertension was, however, higher than the national average for the non-physically challenged adult Nigerians. Conclusion: Cardiovascular health promotion should be emphasized among polio survivors in Nigeria. Copyright ª 2014, Hong Kong Physiotherapy Association Ltd. Published by Elsevier (Singapore) Pte Ltd. All rights reserved.

* Corresponding author. Department of Physiotherapy, Faculty of Clinical Sciences, University of Ibadan, P.M.B. 5017, G.P.O, Dugbe, Ibadan, Nigeria. E-mail address: [email protected] (A.A. Atowoju). http://dx.doi.org/10.1016/j.hkpj.2014.10.002 1013-7025/Copyright ª 2014, Hong Kong Physiotherapy Association Ltd. Published by Elsevier (Singapore) Pte Ltd. All rights reserved.

22

Introduction It is projected that over the next 2 decades there will be a rise in cardiovascular disease mortality rates in developing countries, due to demographic changes and progressive urbanization [1], while by 2025 about 75% of the world hypertensive population will be in developing countries [2]. These developing countries account for 75% of the world’s people living with disability, with the World Health Organization estimates putting the number of Nigerians with disability at 19 million, or approximately 20% of the country’s population [3]. Poliomyelitis (polio) survivors constitute one of the largest groups of people with disabilities in the world [4]. Physical inactivity, one of the factors which contributes directly to the incidence of hypertension and also indirectly through its association with risk factors like obesity [5], has been reported among people with disabilities [6,7]. This is attributed to various factors including their primary motor disability and physical barriers to exercise and mobility [7]. The low physical activity reported among these individuals raises serious concern regarding their health and wellbeing, particularly when they enter their later years when the effects of the natural aging process are compounded by years of sedentary living and severe deconditioning [7e9]. It is crucial, therefore, to regularly assess the health profile of this high-risk population and proffer timely solutions. Though the prevalence of cardiovascular diseases is generally under-investigated among persons with disability [10], few available studies have identified cardiovascular disease or its risk factors among polio survivors. A significantly higher prevalence of hypertension was reported among Chinese patients with paralytic polio [11], while a high prevalence of cardiac risk factors was reported among polio survivors in the United States [12]. Polio was recently identified as a significant risk factor for stroke, independent of hypertension, diabetes mellitus, hyperlipidemia, and cardiac diseases among a sample of Taiwanese people [13]. In another cohort of Taiwanese polio population, a higher prevalence of obesity and significant increase in total and regional fat mass were demonstrated when compared with age- and sex-matched able-bodied controls [14]. Epidemiologic studies showed that people with physical disabilities have a 1.2e3.9-fold increase in obesity prevalence than the general population [15]. Pathophysiological changes of body composition and energy metabolism, physical inactivity, and muscle atrophy, all favour the development of obesity in this population [15]. It is opined, however, that there is a substantial variation in the prevalence of obesity between nations [16], with an increasing number of overweight and obese individuals reportedly in developing countries [17]. Studies have similarly identified racial variations in the incidence and prevalence of hypertension, with blacks having a higher prevalence in studies conducted among nonphysically challenged individuals [18,19]. Considering the mobility challenge and consequent reduced physical functioning and activity level faced by people with physical disabilities in a developing country like Nigeria, and the accompanying known black ethnicity risk factor for hypertension, it is essential to assess the prevalence of hypertension and obesity among this high-risk population. This will go a long way at addressing the cardiovascular health

A.A. Atowoju et al. needs of people with physical disabilities in Nigeria. Findings from available studies in developed countries may not be directly extrapolatable to Nigeria, considering the racial differences and dissimilarities in environment, nutrition, level of development, and sociocultural factors between such developed countries and Nigeria. There is a need to fill this knowledge gap. The purpose of this study was therefore to document the prevalence of hypertension and obesity among paralytic polio survivors in Nigeria.

Methods This descriptive cross-sectional survey involved 252 (119 males and 133 females) consecutively recruited adult polio survivors. The study was approved by the Ethics Committee of the University of Ibadan/University College Hospital, Ibadan, Nigeria, while permission to involve participants in the study was obtained from the requisite authority. All experiments were done in accordance with the Declaration of Helsinki. Participants were recruited from 19 local government centres in Oyo State, Nigeria, where physically challenged individuals congregate for weekly or fortnightly meetings of their association and from five institutions for the physically challenged individuals in the state. Informed consent was obtained from each participant after explanation of the study’s goals and procedures. Relevant information on participants’ demographic profile and socioeconomic status was obtained using an appropriately designed background information sheet. Indices of obesity and hypertension were delimited to body mass index (BMI; estimated from the height and weight measurements of participants) and resting blood pressure (RBP), respectively.

Measurements Each participant’s supine length (proxy for standing height) [20] was measured using a non-elastic tape measure and marker. Participants who had bilateral lower limb contractures and whose lower limbs could hence not be fully extended for the purpose of height measurement were excluded from the study. Body weight was measured with participants in light clothing and bare feet, while assuming a crook sitting posture on an outsized weighing scale (Zhongshan Camry Manufacturer and Trading Co. Ltd., Zhongshan, Guangdong, China). The RBP was measured on the left arm with an Omron MX2 basic digital automatic BP and heart rate monitor (Omron Healthcare Company Limited, Kyoto, Japan), after a 10-minute rest in sitting. Following the American Heart Association recommendations [21], two BP readings were taken, with a 1 minute interval between readings. The average of the measurements was recorded as the participant’s BP. Additional readings were taken if the difference between the first two readings was >5 mm Hg and the average calculated and recorded. The values were confirmed on two other occasions at about the same time of the day. Self-report of a medical diagnosis of hypertension and/or history of usage of antihypertensive medication was also obtained for reference purposes. BMI was calculated as the ratio of the weight in kg to the square of the height in metres [22]. The British Hypertension Society Classification [23] and the World Health

23 Organization BMI Scale [24] were used to categorize participants’ RBP and BMI, respectively.

Statistical analysis Statistical analysis was performed with SPSS version 17.0 (SPSS Inc., Chicago, IL, USA). Frequency counts were used to summarize participants’ nonparametric physical and sociodemographic characteristics, while means and standard deviation were computed for the parametric physical and health variables. Independent t test was used to compare the continuous data of male and female participants, while Chi-square test was used to compare the categorical data. The level of significance for both tests was 5% (p < 0.05). The distribution of participants in the various BP and BMI classifications were presented using percentages and pie charts.

systolic BP (p Z 004) than female participants, whereas the female participants had significantly higher BMI (p < 0.001) than male participants. Using the British Hypertension Society’s classification which is similar to those of the European Society of Hypertension and the World Health Organization [23], 25.8% of the participants had high-normal BP (systolic BP of 130e139 mmHg and diastolic BP of 85e89 mmHg), while 25.1% fell under the hypertension category (systolic BP > 140 mmHg and diastolic BP > 90 mmHg; Fig. 1). Based on the classification in the report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [25], however, 48.0% of the participants had their BP values in the prehypertension category, while 25.1% fell in the hypertension category. More than half of the participants did not meet the World Health Organization recommended BMI values with 44 (17.5%) being underweight, 102 (40.5%) being either overweight or obese, and 106 (42.1%) within the recommended BMI range (Fig. 2).

Results Participants’ mean age was 34.0  9.1 years (range Z 21e52 years). They contracted polio at the mean age of 3.2  2.1 years and the majority (133 or 52.8%) were females. There was an almost equal distribution between bilateral (126 or 50.0%) and unilateral (123 or 48.8%) lower limb affectation. Most of the participants (185 or 73.3%) depended on assistive devices or a wheelchair for ambulation. The majority (196 or 77.8%) was employed. Only a few (9.5 or 1.6%) were taking alcoholic drinks or taking both alcoholic drinks and smoking (4 or 1.6%; Tables 1 and 2). Significantly higher proportions of male polio survivors had means of transportation (p Z 0.029) and consumed alcohol/smoked (p < 0.001) than their female counterparts. Table 3 shows that male participants were significantly taller (p Z 0.001) and had significantly higher Table 1

Discussion Our results showed that the prevalence of hypertension was 25.1%, with another 47.8% in the prehypertension category. Twenty-one point four percent were overweight and 19.1% were obese. There are no previous studies on the prevalence of obesity or hypertension among polio survivors in Nigeria. However, in a systematic review of articles published on the prevalence of obesity among non-physically challenged adults in Nigeria from January 2001 to September 2012 [17], the prevalence of overweight ranged from 20.3% to 35.1%, while the prevalence of obesity ranged from 8.1% to 22.2%. The lowest prevalence of obesity was observed in Maiduguri (8.1%), while the highest

Physical characteristics of participants

Parts affected One LL Both LLs Both LLs and 1 UL All extremities Mode of ambulation Hand-to-knee gait Walking stick Elbow crutches Axillary crutches Wheelchair Shuffles/crawls Calipers Do not use calipers Calipers on one LL Calipers on both LLs Reason for not using calipers Cannot afford it Feel discomfort with use of calipers LL Z lower limb; UL Z upper limb. a Only among those not wearing calipers.

Male

Female

Total

n Z 119

n Z 133

n Z 252

Chi-square test (c2)

p

59 59 1 0

64 67 1 1

123 126 2 1

0.936

0.817

26 20 8 28 25 12

21 28 10 28 38 8

47 48 18 56 63 20

4.807

0.440

95 17 7

103 20 7

198 37 17

0.319

0.853

57a 30a

69a 42a

126a 72a

0.227

0.634

24 Table 2

A.A. Atowoju et al. Sociodemographic characteristics of participants

Marital status Single Married Divorced Widowed Education Uneducated Primary school Secondary school OND/NCE HND/1st degree PGD Accommodation 1-room apartment 2-room apartment 1 room and parlour apartment 2 rooms and parlour apartment >3 rooms Means of transportation None Motorcycle Saloon car Religion Christianity Islam Social habits Not taking alcohol/smoking Taking alcohol Taking alcohol and smoking Occupation Schooling Unemployed Self employed Paid employment

Male

Female

Total

n Z 119

n Z 133

n Z 252

Chi-square test (c2)

p

54 61 4 0

51 71 8 3

105 132 12 3

4.412

0.220

23 24 33 20 15 4

32 33 38 18 11 1

55 57 71 38 26 5

5.004

0.415

66 4 26 12 11

87 3 21 10 12

153 7 47 22 23

3.014

0.555

106 3 10

129 0 4

235 3 14

7.067

0.029*

56 63

71 62

127 125

1.005

0.316

95 20 4

129 4 0

224 24 4

19.109

<0.001*

8 13 60 38

12 23 64 34

20 36 124 72

3.158

0.368

* Significant difference between male and female participants at a Z 0.05. HND Z Higher National Diploma; NCE Z National Certificate in Education; OND Z Ordinary National Diploma; PGD Z Post-Graduate Diploma.

Table 3 Selected physical and health characteristics of participants Male (n Z 119)

Female (n Z 133)

p

Age (y) 34.2  8.2 33.74  9.8 0.710 Age when polio was 3.2  2.3 3.16  2.1 0.818 contracted (y) Weight (kg) 50.3  11.3 52.9  14.4 0.092 Height (m) 1.49  0.18 1.43  0.15 0.001* Systolic BP 130.5  15.0 124.8  16.1 0.004* (mmHg) Diastolic BP 78.4  12.9 78.4  11.8 0.996 (mmHg) 23.3  7.0 26.4  6.9 <0.001* BMI (kg/m2) * Significant difference between male and female participants at a Z 0.05.

was observed in Lagos (22.2%). The urban nature of Lagos and changes in behavioural patterns, such as westernized lifestyle and diet and more sedentary jobs were reportedly accountable for the high prevalence. Findings from this study fall within this prevalence range. However, while the prevalence of overweight in this study (21.4%) is just slightly higher than the lowest reported national estimate (20.3%) for non-physically challenged individuals, the prevalence of obesity (19.1%) is closer to the highest reported national estimate (22.2%). Although the factors reportedly responsible for the highest prevalence of obesity in Lagos are not applicable to the sample of polio survivors involved in this study, who were of low socioeconomic class and drawn from both urban and rural settings, reduced activity level consequent to reduced mobility could account for the high obesity prevalence among them. Akintunde et al [26] also opined that there is a complex link between poverty and obesity, which may be responsible for the increasing numbers of obese people even among the poorer

25

Figure 1. Distribution of participants according to blood pressure (BP). Based on the BP classification of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [25], participants who fell into the normal and high-normal blood pressure categories above were otherwise classified into the prehypertension category. Thus, 121 (47.8%) participants fell into the prehypertension category if this classification was used.

segments of the society. Low educational attainment, which is a strong predictor of health behaviour, is a major link between poverty and obesity. Many people with disabilities are poor and lacking education, hence, they often engage in very rudimentary feeding and nutrition [27]. In addition, persons with disabilities face significant physical barriers and social exclusion that interfere with their physical activity level and ability to promote their health [28]. A number of well-intentioned health promotion programmes today exclude most people with disabilities and people in the lower rung of the socioeconomic ladder. Judging from the predominant use of one-room accommodation, low educational status, engagement in chiefly unskilled jobs, and lack of ownership of transportation means, it was evident that the majority of polio survivors in this study fall in the low socioeconomic class.

Figure 2. Distribution of participants using the World Health Organization body mass index (BMI) scale. (Only 42.1% of participants were in the normal BMI category, while 58% were underweight, overweight, or obese.)

The obesity prevalence in this study (19.1%) is lower than the prevalence rate of 24.0% reported by Campbell [29] among whites with polio. This lower prevalence could be attributed to economic factors which affect the types and quantity of food available to even an average nonphysically challenged Nigerian. As a result of economic reasons, the polio survivors involved in this study might have engaged in more energy-tasking activities such as walking and manual labour, with consequent greater energy expenditure (despite their physical challenge), than the polio survivors in the previous study. The age difference between participants involved in the two studies could also be a contributory factor. There is a physiological functional decline with age [30], which could encourage weight gain. Participants in the previous study were older, with a mean age of 62.0 years as compared to a mean age of 34.0 years for this study. They are thus, more prone to unwanted weight gain than the younger population. This could be responsible for the higher obesity prevalence rate among them. When compared with findings of Gawne et al [12], which although not primarily an obesity prevalence study, but had BMI assessed as one of the main outcome measures, the total percentage of polio survivors who were either overweight or obese (28.4%) were less than that for this study (40.5%). Gawne et al [12] did not categorize participants’ BMI into either overweight or obesity classes, respectively, since this was not the focus of their study. Thus, all participants having BMI >25 kg/m2 were grouped together in the study, thereby making it difficult to draw inference on the prevalence of obesity from their study. In the systematic review of studies on hypertension among non-physically challenged individuals in Nigeria over the past 5 decades, Ogah et al [31] reported the pooled prevalence of hypertension in the period of 2000e2011 as 22.5%. The 25.1% prevalence of hypertension among polio survivors in this study is higher than the reported prevalence among non-physically challenged individuals. A number of factors may be responsible for this high hypertension prevalence. At the outset, reduced activity level which has been reported among people with physical disabilities [6,7,32,33] contributes to increases in the incidence of hypertension [5,34]. In addition, physical inactivity has an indirect association with the development of hypertension through its association with other risk factors, like obesity [5]. It is also probable that mental, emotional, and physical stresses reported among polio survivors [35,36] may have a negative impact on their BP. In a study on the effects of chronic job stress on the cardiovascular system, chronic stress was shown to increase heart rate and BP [37]. Although stress is not an absolute risk factor for high BP, some individuals cope with stress by engaging in activities that raise their risk for high BP (e.g., overeating or eating unhealthy foods, smoking, drinking, etc.) [38]. Challenges with mobility, inaccessibility to desired facilities, social barriers/isolation, and economic challenges are regular causes of stress for people with disabilities [39]. Most polio survivors surveyed in this study lamented neglect in many ways, which could be a source of chronic emotional stress among them. The prevalence of hypertension in this study is, however, lower than rates reported from previous studies on polio survivors in other countries. Thus, Campbell [29], Gawne

26 et al [12], and Field and Jette [40] reported the prevalence of hypertension among polio survivors in their studies to be 48.0%, 50.0%, and 50.0%, respectively. In view of the fact that BP increases with age, the observed lower prevalence of hypertension in this study could be related to the younger age of the participants in this study. Participants’ mean age was 34 years as against the mean age of 59e62 years in previous studies [12,29,40]. Given that polio itself is a disease of the anterior horn cells of the spinal cord and does not directly affect the cardiovascular system, its recent identification as a significant risk factor for stroke by Wu et al [13] suggests that it has allied factors that could strongly impact the cardiovascular health. In view of the fact that high BP is the single most important risk factor for stroke, being the number one cause of it [41], it may be extrapolated that polio survivors have an increased risk for developing high BP. Reduction in motor activity following polio infection, which consequently results in overall decline in physical activity level, is apparently culpable. An inactive lifestyle increases the chances of high BP and stroke and also encourages overweight or obesity. By contrast, physical activity assists with weight control and improves blood cholesterol and glucose levels, so that the risk of heart attack and stroke is lower [42]. The high prevalence of hypertension/prehypertension (both totalling 72.9%) in this relatively young sample of polio survivors is a pointer to the extrapolation that polio survivors have established risk factors for high BP. This suggests the need to urgently pay attention to the cardiovascular health of polio survivors in Nigeria. Lifestyle modifications have been advocated for the prevention, treatment, and control of hypertension, with exercise being an integral component [5,43]. Exercise programmes that primarily involve endurance activities prevent the development of hypertension and lower BP in adults with normal BP and those with hypertension [43]. However, inaccessible exercise equipment and other disability-related barriers often discourage persons with physical disabilities from engaging in health-promoting behaviours [7,44]. Pelletier [45] pointed out that despite the established health benefits of exercise, there is very limited, if any, infrastructure in place for long-term exercise services for people with physical challenges. This aptly describes the present state concerning people with disabilities in Nigeria and especially the polio survivors. It is imperative, therefore, that health policies that accommodate the cardiovascular health needs of polio survivors (and other physically challenged persons) should be enacted in Nigeria. Public health interventions, such as awareness talks on lifestyle and dietary habits, with highly subsidised or free cardiovascular health screening, should be routinely conducted and made readily accessible to this population. In addition, community exercise programming and protocols for polio survivors (and other physically challenged persons) should be put in place, since existing literature indicates that the capacity of individuals with disabilities to adapt to increased levels of exercise is similar to that of persons without disabilities [46]. Consequently, polio survivors (and other physically challenged persons) can benefit also from a regular exercise habit like their non-physically challenged counterparts. Thus, as a follow-up to this survey, a study is underway to look at the effects of 12 weeks

A.A. Atowoju et al. of arm ergometry training on some of the observed secondary health problems in polio survivors who participated in the survey phase of the study. Preliminary findings indicate that arm ergometry could be a cost effective approach to reducing cardiorespiratory risk factors among polio survivors and other individuals with physical disabilities. If disability-friendly gymnasia are present in major local government areas in Nigeria to serve a cluster of polio survivors (and other physically challenged persons) in their communities, the health benefits will go at length to reduce the number of hospital visits and improve the quality of life and productivity of this population.

Conclusion The prevalence of hypertension among polio survivors in this study was higher than the national estimate, while the prevalence of obesity was close to the highest reported national estimate among non-physically challenged adults in Nigeria. Considering the growing epidemic of obesity and hypertension, their prevention among polio survivors should be a priority in the Nigerian health sector. Thus, in view of the endemic state of polio in Nigeria and the health burden associated with polio, the use of aerobic exercise to promote the health of polio survivors should be explored.

Conflicts of interest All contributing authors declare that they have no conflicts of interest.

Funding/support No financial or material support of any kind was received for the work described in this article.

Acknowledgements The authors acknowledge the assistance of Mr. Love Fatusi, the chairman of the Association of Persons with Physical Disabilities in Oyo State, the research assistants, Messrs. Okimi and Olumide, Mrs. Busayo, and the driver, Mr. Idowu, who all, in no small measure, contributed to the success of this study.

References [1] Sani MU, Wahab KW, Yusuf BO, Gbadamosi M, Johnson OV, Gbadamosi A. Modifiable cardiovascular risk factors among apparently healthy adult Nigerian population e a cross sectional study. BMC Res Notes 2010;3:11. [2] Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet 2005;365:217e23. [3] Lang R, Upah L. Scoping study: disability issues in Nigeria. http://www.ucl.ac.uk/lcccr/downloads/dfid_nigeriareport [accessed 24.01.14]. [4] Tsai HC, Hung TH, Chen CC, Lieu FK, Cho H, Tung TH, et al. Prevalence and risk factors for upper extremity entrapment neuropathies in polio survivors. J Rehabil Med 2009;41:26e31.

27 [5] Hagberg JM, Park JJ, Brown MD. The role of exercise training in the treatment of hypertension: an update. Sports Med 2000; 30:193e206. [6] Boslaugh SE, Andresen EM. Correlates of physical activity for adults with disability. Prev Chronic Dis 2006;3:A78. [7] Rimmer JH. The conspicuous absence of people with disabilities in public fitness and recreation facilities: lack of interest or lack of access? Am J Health Promot 2005;19:327e9. [8] Rejeski JW, Focht B. Aging and physical disability: on integrating group and individual counseling with the promotion of physical activity. Exerc Sport Sci Rev 2002;30:166e70. [9] Lexell J. Muscle structure and function in chronic neurological disorders: the potential of exercise to improve activities of daily living. Exerc Sport Sci Rev 2000;28:80e4. [10] Capriotti T. Inadequate cardiovascular disease prevention in women with physical disabilities. Rehabil Nurs 2006;31:94e101. [11] Kang JH, Lin HC. Comorbidity profile of poliomyelitis survivors in a Chinese population: a population-based study. J Neurol 2011;258:1026e33. [12] Gawne AC, Wells KR, Wilson KS. Cardiac risk factors in polio survivors. Arch Phys Med Rehabil 2003;84:694e6. [13] Wu CH, Liou TH, Chen HH, Sun TY, Chen KH, Chang KH. Stroke risk in poliomyelitis survivors: a nationwide population-based study. Arch Phys Med Rehabil 2012;93:2184e8. [14] Chang KH, Lai CH, Chen SC, Hsiao WT, Liou TH, Lee CM. Body composition assessment in Taiwanese individuals with poliomyelitis. Arch Phys Med Rehabil 2011;92:1092e7. [15] Liou TH, Pi-Sunyer FX, Laferrere B. Physical disability and obesity. Nutr Rev 2005;63:321e31. [16] Schwandt P. Can we slow down the global increase of adiposity? Int J Prev Med 2011;2:115e6. [17] Chukwuonye II, Chuku A, John C, Ohagwu KA, Imoh ME, Isa SE, et al. Prevalence of overweight and obesity in adult Nigerians e a systematic review. Diabetes Metab Syndr Obes 2013;6:43e7. [18] Carson AP, Howard G, Burke GL, Shea S, Levitan EB, Munter P. Ethnic differences in hypertension incidence among middleaged and older adults: multi-ethnic study of atherosclerosis. Hypertension 2011;57:1101e7. [19] Brown MJ. Hypertension and ethnic group. BMJ 2006;332: 833e6. [20] Rimmer JH, Wang E, Yamaki K, Davis B. Documenting disparities in obesity and disability. FOCUS: Technical Brief 2010;24:7. [21] Smith L. New American Heart Association recommendations for blood pressure measurement. Am Fam Physician 2005;72: 1391e8. [22] McArdle DM, Katch FI, Katch VL. Essentials of exercise physiology. 2nd ed. Philadelphia PA: Lippincott Williams & Wilkins; 2000. [23] Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, et al. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ 2004; 328:634e40. [24] WHO. Obesity: preventing and managing the global epidemic, WHO factsheet 2000, Geneva. [25] Chobanian AV. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure (JNC 7). NIH Publication, U.S. Department of Health and Human Services 2004;04(5230):iii., http:/ www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf [accessed 12.01.13]. [26] Akintunde AA, Akinwusi PO, Adebayo RA, Ogunyemi S, Opadijo OG. Burden of obesity in essential hypertension: pattern and prevalence. Niger J of Clin Pract 2010;13:399e402. [27] Lwanga-Ntale C. Chronic poverty and disability in Uganda. Development research & training paper. In: International Conference: Staying Poor: Chronic Poverty and Development Policy. Manchester, UK: University of Manchester; 7the9th April 2003.

[28] Becker H, Stuifbergen A. What makes it so hard? Barriers to health promotion by people with multiple sclerosis and polio. Fam Community Health 2004;27:75e85. [29] Campbell ML. The changing dynamics of aging with polio. Polio Network News 1999;15(2). www.polioplace.org/sites/default/ files/files/PolioNetworkNews [accessed 28.09.13]. [30] Stolwijk-Swu ¨ste JM, Beelen A, Lankhorst G, Nollet F, CARPA Study Group. Impact of age and co-morbidity on the functioning of patients with sequelae of poliomyelitis: a crosssectional study. J Rehabil Med 2007;39:56e62. [31] Ogah OS, Okpechi I, Chukwuonye II, Akinyemi JO, Onwubere BJ, Falase AO, et al. Blood pressure, prevalence of hypertension and hypertension-related complications in Nigerian Africans: a review. World J Cardiol 2012;4:327e40. [32] Rimmer JH, Riley BB, Rubin SS. A new measure for assessing the physical activity behaviors of persons with disabilities and chronic health conditions: the physical activity and disability survey. Am J Health Promot 2001;16:34e45. [33] Busse ME, Pearson OR, VanDeusen R, Wiles CM. Quantified measurement of activity provides insight into motor function in neurological disease. J Neurol Neurosurg Psychiatr 2004;75: 884e8. [34] Parker ED, Schmitz KH, Jacobs DR, Dengel DR, Schreiner PJ. Physical activity in young adults and incident hypertension over 15 years of follow-up: the CARDIA Study. Am J Public Health 2007;97:703e9. [35] Kling C, Persson A, Gardulf A. The health-related quality of life of patients suffering from the late effects of polio (postpolio). J Adv Nurs 2000;32:164e73. [36] Thoren-Jonsson AL, Hedberg M, Grimby G. Distress in everyday life in people with poliomyelitis sequelae. J Rehabil Med 2001;33:119e27. [37] Torpy JM. Chronic stress and the heart. J Am Med Assoc 2007; 298:1722. [38] American Heart Association. Stress and blood pressure: prevention and treatment (step 5) http://www.heart.org/ HEARTORG/Conditions/HighBloodPressure/ PreventionTreatmentofHighBloodPressure/Stress-and-BloodPressure_UCM_301883_Article.jsp [accessed 27.01.14]. [39] Thompson K. Depression and disability. A practical guide. The North Carolina Office on Disability and Health; 2002. p. 15e9. www.fpg.unc.edu/wncodh/pdfs/depression.pdf [accessed 08.12.12]. [40] Field MN, Jette AM, editors. The Future of Disability in America. Washington (DC): National Academies Press (US); 2007. p. 65, 140e150. [41] American Heart Association. Risk Factors for Stroke. http://www. heart.org/idc/groups/strokepublic/@wcm/@hcm/documents/ downloadable/ucm_309713.pdf [accessed 25.11.13]. [42] Hagberg JM. ACSM information on exercising your way to lower blood pressure. http://www.acsm.org/docs/ brochures/exercising-your-way-to-lower-blood-pressure.pdf [accessed 27.01.14]. [43] Pescatello LS, Franklin BA, Fagard R, Farquhar WB, Kelley GA, Ray CA. American college of sports medicine position stand. Exercise and hypertension. Med Sci Sports Exerc 2004;36:533e53. [44] Smeltzer SC. Improving health and wellness of people with disabilities. In: Stone JH, Blouin M, editors. International Encyclopedia of Rehabilitation; 2013 [accessed 20.03.13], http://cirrie.buffalo.edu/encyclopedia/en/article/300/. [45] Pelletier CA. Incorporating physical activity into the rehabilitation process after spinal cord injury. Open Access Dissertations and Theses. Paper 8336. 2013., https://macsphere. mcmaster.ca/bitstream/11375/13504/1/fulltext.pdf [accessed 13.04.14]. [46] Kilmer D. Response to aerobic exercise training in humans with neuromuscular disease. Am J Phys Med Rehabil 2002; 81(Suppl. 11):S148e150.