Introduction
High blood pressure (BP) in adolescents and young adults is a major public health challenge of rising concern in today’s world. With a contribution of over 25% in the global population, this segment constitutes the single largest proportion of the entire world’s population.[1] Cardiovascular events the leading cause of disease and disability for over a decade now and were responsible for over 18% of the annual deaths globally in the year 2019.[2] In India alone, the death toll amount to a staggering 2.57 million annual deaths. The current demographic trends in the population of adolescents and young adults, coupled with recent findings of elevation in BPs and greater mortality during the COVID-19 pandemic, will result in an unprecedented increase in demand of preventing and curative services.[3,4]
The current literature suggests that elevated BP is prevalent in around 3%–6% of adolescents (10–19 years of age) and rises to about 12.5% (20–28 years) in younger adults.[5,6] This elevation in BP is directly associated with cardiovascular events later in life and is further correlated with arteriosclerotic changes, hyperlipidemia, and insulin resistance that adds to the disease burden even further.[5] To combat this, there is a need for epidemiological studies and population-based interventions to support health promoting behaviors.[7]
Behavioral factors that largely contribute toward the development of hypertension include tobacco use, alcohol consumption, unhealthy dietary practices, and physical inactivity.[8] Further, a lack of physical activity leads to disturbance in body mass index (BMI), which is could be designated as another risk factor for the development of hypertension.[9] Once the behavioral pattern gets established, it often persists throughout the life and is difficult to change. Nevertheless, if identified timely all such risk factors are modifiable which might play a significant role in the reduction of hypertension prevalence.[10]
Currently, there is a paucity of studies related to hypertension and its risk factors among adolescents and young adults in the Western Rajasthan region. Thus, this study was conducted to assess the prevalence and the association of hypertension and its risk factors among the college students of Jodhpur district.
Methodology
A cross-sectional study was conducted in ten colleges located in the five zones of Jodhpur district, over a period of 6 months. The formula for sample size calculation for cross-sectional studies (n = Z2.pq/L2) and nonresponse rate of 10% was considered to arrive at the sample size of 418, using a prevalence (P) of 44.6% and absolute error (L) of 5%.
Simple random sampling was done to include students between the ages 18 and 26 years and a final 421 participants were recruited for the study. The Modified WHO STEPS questionnaire is a tool to collect data and measure noncommunicable diseases risk factors in a step-wise approach. Based on this tool, a self-administered questionnaire was used. Physical measurements of height and weight and BP of the participants were recorded after resting for at least 5 min. BMI values for Asian Indian population were used for categorizing the study participants into underweight (<18.5 kg/m2), normal (18.5–22.9 kg/m2), overweight (23.0–24.9 kg/m2), and obese (≥25 kg/m2), whereas the values used for designating a participant as hypertensive were of average systolic BP ≥ 140 mmHg or average diastolic BP ≥90 mmHg.[11,12]
Data entry and cleaning was done using MS Excel (version 2016), and IBM SPSS Statistics for Windows (version 25) was used for analysis. Descriptive analysis was done using means and percentages, while statistical significance regarding the risk factors was established using prevalence odds ratio (POR) with 95% confidence interval considering P < 0.05 to be statistically significant.
The entire study was conducted following necessary permissions from the Institutional Ethical Committee of All India Institute of Medical Sciences, Jodhpur, the District Education Officer, the Heads of Institutions and after obtaining informed consent from the study participants.
Results
Out of the total study participants, 251 (59.60%) were males and 170 (40.20%) were females, with a mean age of 20.12 and standard deviation (SD) of 1.79 (males – 20.06 ± 1.83, females – 20.22 ± 1.72). While a majority of the students were from the age group of 18–20 years (n = 268; 63.7%), there was an almost equal distribution of those studying in graduate level courses (n = 218; 51.8%) and those enrolled in a postgraduate course [n = 203; 48.2%, Table 1].
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Table 1: Demographic characteristics of the study participants
Upon exploration of behavior-related aspects, 8 (1.9%) participants admitted to be current smokers and 7 (1.7%) participants to be past smokers. Three (0.7%) were current smokeless tobacco (SLT) users, 18 (4.3%) were past SLT users, and 28 (6.7%) participants admitted to alcohol consumption. Family history revealed that 49 (11.6%) participants were exposed to passive smoking at home [Table 2].
Table 2: Behavioural characteristics and measures of blood pressure and body mass index of the study participants
Further exploration about dietary habits and physical activity revealed only 203 (48.2%) study subjects consumed fruits more than 4 days a week in contrast to 380 (90.3%) participants consuming vegetables more than 4 days a week. Three hundred (71.3%) participants agreed to extra salt intake in their meals, whereas 238 (56.5%) agreed consumption of high salt-containing processed food at least once a week. One hundred and sixty-six (39.4%) participants were involved in vigorous sporting activities, 202 (48%) in moderate activities, whereas 172 (40.9%) (not-mutually-exclusive participants) were involved in daily brisk walk of more than 30-min duration [Table 2].
Upon measurement of BP and BMI of the participants, 10 (2.4%) were found to have an elevated systolic BP (≥140 mmHg) and 36 (8.6%) had an elevated diastolic BP (≥90 mm of Hg). Thirty-two other participants had measures in the normal range but were prediagnosed hypertensives, already under regular medication. All the participants with raised systolic BP also had elevated diastolic BP, taking the total number of observed hypertensives to 68 (16.2%). The mean height and weight of all the participants were 165.54 cm (SD: 9.73) and 57.74 kg (SD: 47.88), respectively, resulting in 93 (22.1%) participants to be underweight, 60 (14.3%) to be overweight, and 11 (2.6%) obese [Table 2].
Significant associations were observed between male gender and exposure to passive smoke (POR: 2.58; P = 0.008), consumption of fruits (POR: 0.07; P = 0.00), extra salt intake in meals (POR: 3.03; P = 0.00), sport participation more than 30 min/day (POR: 3.28; P = 0.00), bicycling more than 30 min/day (POR: 1.59; P = 0.02), elevation in diastolic BP (POR: 2.54; P = 0.02), and overweight BMI (POR: 3.51; P = 0.01). Similarly, students enrolled in graduate level courses were significantly associated with past SLT use (POR: 17.09; P = 0.006), exposure to passive smoke (POR: 10.01; P = 0.00), alcohol consumption (POR: 0.42; P = 0.04), fruit consumption (POR: 0.41; P = 0.00), high salt intake (POR: 0.67; P = 0.04), sport participation (POR: 1.99; P = 0.00), bicycling (POR: 1.49; P = 0.04), diagnosed hypertensives (POR: 0.28; P = 0.003), underweight BMI (POR: 1.64; P = 0.04), and overweight BMI [POR: 0.29; P = 0.00, Table 2].
During analysis of association of various risk factors with hypertension, significant associations were observed with habit of smoking with habit of smoking (POR = 2.72; P = 0.04), high salt intake in meals (POR = 3.21; P = 0.00), physical activity (POR = 0.30; P = 0.00), overweight BMI (POR = 2.34; P = 0.008), and obese BMI (POR = 4.02; P = 0.02). Positive odds of hypertension were observed with parameters such as male gender (1.51; 0.87–2.62), exposure to SLT (2.72; 0.90–8.23), alcohol consumption (1.45; 0.57–3.74), extra salt in diet (1.25; 0.69–2.27) and underweight BMI (1.57; 0.83–2.99), while negative odds was observed with passive smoking (0.85; 0.37–1.98), fruit consumption (0.76; 0.45–1.29) and vegetable consumption (0.56; 0.26–1.20), although, the findings were not statistically significant [Table 3 and Figure 1].
Table 3: Association of risk factors with hypertension
Figure 1: Odds ratio plot of association of risk factors with hypertension. SLT: Smokeless tobacco
Discussion
The study provided findings regarding prevalence of hypertension as well as prevalence of risk factors for hypertension amongst the college students aged 18–26 years of Jodhpur district. The prevalence of tobacco smoking observed was 1.9% while that of SLT use was 0.7%. These figures are lower to the prevalence mentioned in Global Adult Tobacco Survey-2 India survey for the state of Rajasthan (smoked tobacco - 10.6% and SLT – 11.5%) and the National Family Health Survey (NFHS-5) findings (males – 42% and females – 6.9%).[13,14] This discrepancy is possibly due to the study setting and level of basic education amongst the study participants. Nevertheless, such findings complement the interpretation of a relatively lower age of initiation in this Indian subcontinent of 18.4 years.[13] Similarly, the alcohol consumption prevalence was found to be 6.7%, similar to the findings of Mohanan etal. and Saxena etal.[15,16]
The overall prevalence of hypertension from this study was observed to be 16.2% (8.6% with raised BP and 7.6% with normal BP but under medication). This finding concurs with the findings of Geevar etal. in adult population of South India, Saxena etal. in college students of Uttar Pradesh and Ghosh and Kumar (2019) in a nation-wide estimation form NFHS-4 data.[17–19] However, the findings of this study show an equally high prevalence amongst the college going age group of 18–26 years as in adult population, and an even greater need for implementation of health behaviour interventions from an early age group.
Lastly, while establishing association between the risk factors and hypertension, more odds were observed with male gender, SLT consumption, alcohol consumption, nonconsumption of fruits and vegetables, intake of extra salt in meals and BMI in the category of underweight. However, significant associations were only observed with habit of smoking, consumption of processed food with high salt content, lack of physical activity and BMI in the category of overweight and obese. Many other studies concur with these findings such as those conducted by Virdis etal. on smoking and hypertension, Hendriksen etal. (2014) on elaboration of effects of salt reduction in diet, and Landi etal. describing linear association of BMI with hypertension.[20–22] These findings hold a greater importance when correlated with the significant associations observed between specific risk factors and variables such as gender and type of course enrolled. Thus, specifically focussed interventions may designed using the study findings with targeted planning and implementation of health promotion programs.
Conclusion
The study provided empirical evidence of high prevalence of hypertension and its association with numerous behavioural risk factors such as tobacco, salt intake and physical inactivity amongst college going youth of Jodhpur, Rajasthan. Although the association of risk factors with hypertension is proven by an ample amount of available literature, this study provided data novel to the targeted population age groups and geographic location. Furthermore, specific association were estimated not only between risk factors for disease development but also for risk factors and gender and level of education. Such evidence may be utilised for planning tailor-made health behaviour promotion programs for specific population groups, considering the not only the prevalence of disease, but also the discrepant prevalence of risk factors unique to the region.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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