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Red Flower Publication Pvt.Ltd Indian Journal of Anatomy Volume 7 Number 1, January - February 2018 DOI: http://dx.doi.org/10.21088/ija.220.0022.7118.15 Original Article Authors Affiliation: 1 Assistant Professor 2 II MBBS Student 5 Post Graduate 6 Professor ead, Department of Anatomy Assistant Professor, Department of Physiology 4 Professor ead, Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram ardha, Maharashtra 442102, India. Correspondin Author: Rutua Bhonle II MBBS Student, Mahatma Gandhi Institute of Medical Sciences, Sevagram ardha, Maharashtra 442102, India. E-mail: [email protected] Received 09.10.2017, Accepted 2.11.2017 Anthropometric Measurements of ypertensive Patients with Special Emphasis on Facial Features Pradeep Bokariya Rutua Bhonle Ruchi Kothari Jyoti Jain Mrinmayee Debbarma M.R. Shende Introduction Anthropometry is a biological anthropology or art of science used for the measurement of soft tissue and body proportions for the study of human evolution 1. Anthropometric measurements are used eventually for various medical researches. Anthropometry is a branch of Morphometry which is the study of sie and shape of biological components and their variations in populations. 2 Morphometrics has gone under revolution in the last two decades as numerous new techniques have been produced to address shortcomings in the Traditional Multivariate Analysis of Linear distances, Angles and Indices . Analysis of Face is not only useful for Identification, Sports Medicine, Tele-Communications but also has got a clinical application for diagnosis of many diseases 4. Changes in lifestyles, nutrition, and ethnic composition of populations lead to changes in the distribution of body dimensions (e.g. the obesity Abstract Context : Anthropometric measurements are being used profusely for various medicalresearches. Studies on craniofacial anthropometry have allowed for identification andquantification of syndromic clinical features, planning for treatment, monitoring ofoperative outcomes and sometimes assessment of longitudinal change.Considering that Anthropometry can be important tool in early suggestion of diseases, anattempt was made to study facial Anthropometry in healthy individuals andhypertensive subjects. Aim: The aim of the study was to compare the Anthropometric Measurements in hypertensivepatients and healthy control subjects. Settings and Design: The study was conducted in the Anthropometry section of Department of Anatomy, Mahatma Gandhi Institute of Medical Sciences (MGIMS) incollaboration with Department of Medicine. It was a cross-sectional, Observational study design incorporating a total of 100subjects. ethods and aterial : Out of hundred registered for study, fifty were healthy controls and fifty patients in theage range of 4-50 years diagnosed to have hypertension from Sevagram village (a rural area in Vidharbha region of Maharshtra). The instruments used for study are Stadiometer, Digital weighing balance, Spreading Caliper, Vernier caliper and measuring tape and sphygmomanometer for measuring Blood Pressure. Various measurements were made pertaining to facial anthropometry andon the basis of the findings as per literature available, the indices calculated are Physiognomic Facial Index, Morphological Facial Index, Mandible idth- Face eight Index, Sagittal Naso-FacialIndex, Mandible-Face idth Index, Chervins Transverse Cephalo- Facial Index. Results: The indices thus obtained are compared for males and females separately. Most of the indices are non- significant except Mandible-Face idth Index in femalesand Physiognomic Facial Index and Morphological Facial Index in males. Conclusion: Facial Anthropometry was done on healthy and hypertensivesubjects. Though the data analysis have not concluded any change in facialanthropometry in hypertensive subjects with affirmation but the data obtained forcontrol subjects in Central Indian Population can further be utilised byAnthropometrics, , Anatomists, Forensic Experts and Plastic surgeons too. Keywords: Anthropometry Facial Anthropometry ypertensive Patients.
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Page 1: Anthropometric Measurements of ypertensive Patients with ...

Indian�Journal�of�Anatomy�/�Volume�7�Number�1�/�January�-�February�2018

78

�Red�Flower�Publication�Pvt.Ltd

Indian�Journal�of�AnatomyVolume�7�Number�1,�January�-�February�2018

DOI:�http://dx.doi.org/10.21088/ija.2�20.0022.7118.15

Original�Article

Author�s�Affiliation:�1Assistant�Professor�2II�MBBS�Student5Post�Graduate� 6Professor����ead,�Department�of�Anatomy�Assistant�Professor,�Department�of�Physiology�4Professor����ead,Department�of�Medicine,�Mahatma�Gandhi�Institute�of�MedicalSciences,�Sevagram��ardha,�Maharashtra�442102,�India.

Correspondin��Author:�Rutu�a�Bhon�le��II�MBBS�Student,Mahatma�Gandhi� Institute� of�Medical� Sciences,� Sevagram�ardha,�Maharashtra�442102,�India.

E-mail:�[email protected]

Received� �09.10.2017,�Accepted� �2�.11.2017

Anthropometric�Measurements�of��ypertensive�Patients�with�SpecialEmphasis�on�Facial�Features

Pradeep�Bokariya���Rutu�a�Bhon�le���Ruchi�Kothari��� Jyoti� Jain���Mrinmayee�Debbarma��M.R.�Shende�

Introduction

Anthropometry� is� a� biological� anthropology�orart�of�science�used�for�the�measurement�of�soft�tissueand� body� proportions� for� the� study� of� humanevolution� �1�.�Anthropometric�measurements� are

used� eventually� for� various�medical� researches.Anthropometry�is�a�branch�of�Morphometry�whichis� the� study� of� si�e� and� shape� of� biologicalcomponents� and� their� variations� in�populations.2

Morphometrics�has�gone�under� revolution� in� thelast�two�decades�as�numerous�new�techniques�havebeen�produced� to� address� shortcomings� in� theTraditional� Multivariate� Analysis� of� Lineardistances,�Angles�and�Indices����.�Analysis�of�Faceis� not� only� useful� for� Identification,� SportsMedicine,�Tele-Communications�but�also�has�gota� clinical� application� for� diagnosis� of� manydiseases��4�.

Changes� in� lifestyles,� nutrition,� and� ethniccomposition�of�populations�lead� to�changes�in�thedistribution�of� body�dimensions� (e.g.� the� obesity

Abstract

Context:�Anthropometric�measurements�are�being�used�profusely�for�various�medicalresearches.�Studieson�craniofacial�anthropometry�have�allowed�for�identification�andquantification�of�syndromic�clinical�features,planning� for� treatment,�monitoring� ofoperative� outcomes� and� sometimes� assessment� of� longitudinalchange.Considering� that�Anthropometry�can�be� important� tool� in� early�suggestion�of�diseases,� anattemptwas�made�to�study�facial�Anthropometry�in�healthy�individuals�andhypertensive�subjects.�Aim:�The�aim�ofthe�study�was�to�compare�the�Anthropometric�Measurements� in�hypertensivepatients�and�healthy�controlsubjects.�Settings� and�Design:� The� study�was� conducted� in� the�Anthropometry� section� of�Department� ofAnatomy,�Mahatma�Gandhi� Institute� of�Medical� Sciences� (MGIMS)� incollaboration�with�Department� ofMedicine.�It�was�a�cross-sectional,�Observational�study�design�incorporating�a�total�of�100subjects.��ethodsand��aterial:�Out� of�hundred� registered� for� study,� fifty�were�healthy� controls�and� fifty�patients� in� theagerange� of� �4-50� years� diagnosed� to� have� hypertension� from� Sevagram�village� (a� rural� area� in�Vidharbharegion�of�Maharshtra).�The�instruments�used�for�study�are�Stadiometer,�Digital�weighing�balance,�SpreadingCaliper,�Vernier�caliper�and�measuring�tape�and�sphygmomanometer�for�measuring�Blood�Pressure.�Variousmeasurements�were�made�pertaining�to�facial�anthropometry�andon�the�basis�of�the�findings�as�per�literatureavailable,�the�indices�calculated�are�Physiognomic�Facial�Index,�Morphological�Facial�Index,�Mandible��idth-Face��eight�Index,�Sagittal�Naso-FacialIndex,�Mandible-Face��idth�Index,�Chervin�s�Transverse�Cephalo-Facial�Index.�Results:�The�indices�thus�obtained�are�compared�for�males�and�female�s�separately.�Most�of�theindices� are� non-� significant� except�Mandible-Face��idth� Index� in� femalesand�Physiognomic�Facial� Indexand�Morphological� Facial� Index� in�males.�Conclusion:� Facial� Anthropometry�was� done� on� healthy� andhypertensivesubjects.�Though� the�data�analysis�have�not�concluded�any�change� in�facialanthropometry�inhypertensive� subjects� with� affirmation� but� the� data� obtained� forcontrol� subjects� in� Central� IndianPopulation� can� further� be� utilised� byAnthropometrics,� ,� Anatomists,� Forensic� Experts� and� Plasticsurgeons�too.

Keywords:�Anthropometry��Facial�Anthropometry���ypertensive�Patients.

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79

epidemic),� and� require� regular� updating� ofanthropometric� data� collections.� Studies� oncraniofacial� anthropometry� have� allowed� foridentification� and� quantification� of� syndromicclinical�features,�treatment�planning,�monitoring�ofoperative�outcomes,�and�assessment�of�longitudinalchange��5,6�.

��pertension� is� defined� as� systolic� and/ordiastolic� blood� pressure� of� 140/90� mm��g� ormore,� and/or� medication� use� for� decreasinghypertension��7,8,9�.

The� �orld� �ealth� Organi�ation� (��O)categori�es�high�blood�pressure�(BP)�as�the�top�riskfactor�for�death�rate,�accounting�for�1���of�fatalitiesglobally.�Also,�hypertension,�or�the��silent�killer��asit� is� also� known,� has� been� recogni�ed� as� animportant� risk� factor� for� cardiac� arrest,� stroke,kidney�disease,� and� increased�mortality� rates� inadults�(��O�2014)��10�.

�igh�blood�pressure,�also�called��hypertension,�is�a�serious�medical�condition.�It�happens�when�theforce�of�the�blood�pumping�through�your�arteries�istoo�strong.�The� flow�and�pressure�of�blood� in� thearteries� rises�with�each�pump�or�pulse�� this� is� thesystolic�or�higher�pressure�reading.�The�resting�orlower� pressure� between� each�pulse� is� called� thediastolic�pressure.

A�person�s�blood�pressure�reading�includes�bothfigures,�systolic/diastolic,�expressed�in�millimetresof�mercury.

�A�variety�of�symptoms�may�be�indirectly�relatedto�high�BP�but�are�not�always�caused�by�it,�such�asfacial�flushing.��Facial�flushing�occurs�when�bloodvessels�in�the�face�dilate.

Since� edema� is� also� closely� linked� withhypertension,� and� because� the� accumulation� ofan� excessive� amount� of� body� fluid� in� the� tissuespaces� between� cells� or� in� body� cavities� arenoticeable� in� the�overall� physical� appearance�ofthe�individual�especially�the�face��11�.

The� aim� of� the� study� was� to� evaluate� theAnthropometric� Measurements� in� patients� ofhypertension� and� healthy� control� subjects.Following�objectives�were�catered�to:

1. To� study� the� anthropometric� measurementsespecially� the� facial� proportions� ofhypertensive�subjects�and�healthy�controls.

2. To�compare�the�anthropometric�measurementsand� facial� proportion� of� hypertensives� andcontrol� population.� Comparison� was� doneamongst�same�sexes�in�two�groups.

Material�and�Methods

��pe�of�Stud�

It�was� a� cross-sectional,� Observational� studydesign�incorporating�a�total�of�100�subjects.

Stud���articipants

Out� of� 100,� fifty�were� healthy� controls� withSystolic�BP� �120�mm�of��g�or�Diastolic� BP��� 80mm�of��g�and�fifty�patients�in�the�age�range�of��5-50�years�diagnosed�to�have�hypertension�(SystolicBP��140mm�of��g�or�Diastolic�BP���90�mm�of��g),from� Sevagram� village� of� �ardha� region� ofMaharashtra�were� recruited� as� cases� �10�.�Out� ofthese� fifty,�22�were� females� in�both�group�and�28males�in�both�the�group.

Setting

The�study�was�conducted�in�the�Anthropometrysection� of�Department� of�Anatomy,�MahatmaGandhi� Institute� of�Medical� Sciences� (MGIMS)� incollaboration�with�Department�of�Medicine�of� thesame� institute.� It� is� a� rural� Medical�College� �hospital� located�in�a�village,�Sevagram�in��ardhadistrict�in�central�India.

�thics�Consideration

A�written� informed�consent�was�obtained� fromall�study�participants.� It�was�ensured�that�consentis�(a)given�voluntarily,�(b)fully�informed,�(c)and�isobtained� from� the�persons�who� are� competent� todo�so.

In�the�consent�form,�the�aims�of�the�study�wereexplained,� the� anticipated�benefits� and� the� risks,and�the�right�to�withdraw�from�interview�processat� any� time� without� any� reprisals.� The� use� ofconfidential� patient�data�will� be� fully�within� therecent� guidelines� from� the� Indian� Council� ofMedical� Research� (ICMR)� about� the� use� ofpersonnel� information� in� medical� research.Approval� for� conducting� the� study� from� theinstitutional�Ethics�Committee�was�received�beforecommencement�of�the�study.

Sample�Si�e

Sample� si�e� was� estimated� using� statisticalsoftware�with�following�assumptions.

Confidence�level�-�95�

Confidence�Interval-�10

Pradeep�Bokariya�et.�al.�/�Anthropometric�Measurements�of��ypertensive�Patients�withSpecial�Emphasis�on�Facial�Features

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(Population�of�Sevagram�is�approximately�7000)Sample� si�e� estimated�was� 95.� Taking� this� intoaccount,�we�planned�to�go�for�total�of�100�subjectsdivided� into� two� groups� of� cases� and� controlsubjects�considering�the�economic�feasibility�as�wellas� the� time� frame� required� for� the� completion� ofthe�short�term�research.

Sampling��rocedure

By�Random�sampling�method,�samples�had�beenrecruited.

Inclusion�Criteria

1. Persons�from�age�group�of��5-50�years.

2. Diagnosed�patients�of�hypertension�will�be�thecases�and�healthy�people�of�the�same�age�groupwith�normal�Blood�Pressure�and�without�any�h/o�significant�illness�will�be�included�as�controls.

�xclusion�Criteria

� Previous�history�of�Facial��surgery�or�orthodontictreatment,

� Any�obvious�defect�or�deformity.

� Patients� suffering� from� Diabetes� ,� ThyroidDisease,� Liver� Failure,��aemolytic� Jaundice,Renal�diseases,� Psychosis� and�other�metabolicdisorders.

Anthropometric��easurements

Somatometric�measurements�were� conductedover�both�the�groups�(case�and�control)�by�the�sameindividual�at� the�same�fixed� time�as�per� standardprocedure�laid�by�Singh�P�and�Bhasin�M�(2004)��2�.

�����readth��easurements�of��ead�and��ace

A.��aximum��ead��readth

It�measures�the�straight�distance�between�the�twoeurya(eu).

�.��h�siognomic��acial��eight

It� measures� the� straight� distance� betweentrichion(tr)and�gnathion(gn)

C.��orphological��acial��eight

It� measures� the� straight� distance� betweennasion(n)and�gnathion(gn)

D.��i��gomatic��readth

�It�measures�the�straight�distance�between�the�two�ygia(�y)

�.��igonal��readth

It�measures� the� straight� distance� between� thegonia/gonion.

�.��asal��eight

It� measures� the� straight� distance� betweennasion(n)and�subnasale(sn)

����Indices�of��ace

A.��h�siognomic��acial�Index

Physiognomic� Facial� �eight� �� Bi�ygomaticBreadth��100

�.��orphological��acial�Index

Morphological� Facial� �eight� �� Bi�ygomaticBreadth�100

C.��andible��idth��ace��eight�Index

Bigonal� Breadth�Morphological� Facial��eight�100

D.�Sagittal��aso��acial�Index

Nasal��eight��Morphological�Facial��eight�100

�.��andible��ace��idth�Index

Bigonal�Breadth���Bi�ygomatic�Breadth�100

�.�Chervin�s��ransverse�Cephalo��acial�Index

Bi�ygomatic� Breadth� �� Maximum� �eadBreadth�100

Anthropometric�Instruments�used

Stadiometer,� Digital� weighing� balance,Spreading�Calliper,�Vernier�calliper�and�measuringtape.

��� measurement� was� done� using� mercurysphygmomanometer.

Data�Collection��ethod

All� the�data�were�abstracted�on�a�standardi�eddata�collection�form.�MS�excel�spreadsheet�was�used

Pradeep�Bokariya�et.�al.�/�Anthropometric�Measurements�of��ypertensive�Patients�withSpecial�Emphasis�on�Facial�Features

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to�enter�the�data�electronically.�Data�were�expressedas�mean���SD.

Statistical�Anal�sis

Chi-square� test� and� some� graphical� tools�wereemployed� for� finding� association� betweencategorical�variables.

Results

A�total�of�six�indices�were�obtained�for�both�thesexes�in�each�group.

The�findings�for�females�and�males�are�as�follows:

For�Females-

The�mean��SD�of�Physiognomic�Facial�Index�forexperimental� females� is� found� to� be� 141.71�9.98whereas�for�control�females�it�was�1�6.01�12.07.

The�mean���SD�of�Morphological�Facial�Index�forexperimental� females�was� found� to�be� 85.21�8.04whereas�for�control�females�it�was�84.99�9.26

The� Mandible� �idth-Face� �eight� Index� forexperimental�females�was�obtained�as�10�.88�10.65whereas�for�control�females�it�was�97.28�10.2�.

Sagittal� Naso-Facial� Index� for� experimentalfemales�was� estimated� as� 42.92�6.40�whereas� forcontrol�females�it�was�44.7��6.04.

Mandible-� Face��idth� Index� for� experimentalfemales�was� evaluated� as� 87.42�4.99�whereas� forcontrol�females�it�was�81.92�4.5�.

Chervind�s� transverse�Cephalo-Facial� Index� forexperimental� females�was� found� to�be� 96.�9�4.26whereas�for�control�females�it�was�96.�9�5.48.

For�Males

The�Physiognomic�Facial�Index�for�experimentalmales�was� found� to� be� 1�5.10�8.86�whereas� forcontrol�males�it�was�140.16�10.64.

The�Morphological�Facial�Index�for�experimentalmales�was�found�to�81.�1�6.59�whereas�for�controlmales�it�was�87.59�12.17.

The� Mandible� �idth-Face� �eight� Index� forexperimental�males�was�found� to�be�105.01�12.40whereas� for� control�males� it�was� 100.�8�11.15.Sagittal�Naso-Facial� Index� for�experimental�maleswas� found� to� be� 4�.69�5.76�whereas� for� controlmales�is�4�.79�9.70.

Mandible-� Face��idth� Index� for� experimentalmales� was� found� to� be� 84.74�5.88�whereas� forcontrol�males�it�was�86.80�4.89.

Chervind�s� transverse�Cephalo-Facial� Indexforexperimental�males�was� found� to� be� 101.14�7.�8whereas�for�control�males�it�was�98.91��.86.

The�data�thus�obtained�was�compared�in�controland�cases� group.�The� comparison� is� as� shown� inTable�1���2.

Individual�facial�anthropometric�indices�sex�wiseare�shown�in�Figure1�and�Figure�2.

�able��:�Comparison�of�various�indices�in�Females

p�Value� 0.41� 0.41� 0.09� 0.40� 0.01� 0.19�

� Non-significant� Non-significant� Non-�significant� Non-significant� Significant� Non�significant�

�able��:�Comparison�of�various�indices�in�Males

p�value� 0.05� 0.02� 0.10� 0.48� 0.11� 0.11�

� Significant� Significant� Non-significant� Non-significant� Non-significant� Non-significant�

Pradeep�Bokariya�et.�al.�/�Anthropometric�Measurements�of��ypertensive�Patients�withSpecial�Emphasis�on�Facial�Features

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82

Fi�.��:�The�various�charts�are�showing�depiction�of�individual�findings�obtained�in�controls�and�cases�for�Females

Pradeep�Bokariya�et.�al.�/�Anthropometric�Measurements�of��ypertensive�Patients�withSpecial�Emphasis�on�Facial�Features

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Indian�Journal�of�Anatomy�/�Volume�7�Number�1�/�January�-�February�2018

8�

Fi�.��:�The�various�charts�are�showing�depiction�of�individual�findings�obtained�in�controls�and�cases�for�Females

Pradeep�Bokariya�et.�al.�/�Anthropometric�Measurements�of��ypertensive�Patients�withSpecial�Emphasis�on�Facial�Features

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84

Fi�.��:�Showing�various�charts�of�the�observations�of�different�indices�in�males�in�cases�and�control

Pradeep�Bokariya�et.�al.�/�Anthropometric�Measurements�of��ypertensive�Patients�withSpecial�Emphasis�on�Facial�Features

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85

Fi�.��:�Showing�various�charts�of�the�observations�of�different�indices�in�males�in�cases�and�control

Pradeep�Bokariya�et.�al.�/�Anthropometric�Measurements�of��ypertensive�Patients�withSpecial�Emphasis�on�Facial�Features

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Discussion

Facial�analysis�has�been�quite� crucial� in�studiesof�health�related�concerns��12-15�.��hile�there�arestudies� that� show�minor� anomalies� occurring� innormal� human� populations� at� low� frequencies,deviations�from�normal�values�can�be�indicative�ofa�health�problem��14,15�.

In� the� present� study,� the� variations� in� facialmorphometrics�between�diabetics�and�non-diabeticswas� explored.�The� observations� of� this� study� arenot� in�accordance�with�many� studies�which�havereported�changes�in�the�face�of�people�with�chronicdiseases�such�as�diabetes,�hypertension�and�arthritis�16,17,18�.

Based� on� the� analysis� of� landmarks� as� shapevariables,�the�face�shape�of�diabetics�was�found�tobe� rounder� and� less� tapered� compared� to� that� ofnondiabetics�in�a�study�by�Demayo�et�al�(2009)��4�.

They�analy�ed�that�there�is�a�Facial�asymmetry,drooping�of�the�brow�ridge,�compression�of�the�facetowards� center,� downward� folding� of� the� skin� inthe�area�of�the�eyes�in�Diabetics�without�any�sexualvariation� by�Geometric�Morphometrics�by� imageanalysis.

Moore� SE� et� al� (2001)��19�� analy�ed� that� Fetalalcohol�syndrome�(FAS)�and�Parietal�Fetal�alcoholsyndrome(PFAS)� have� a� facial� dysmorphologywhich�could�be�used�for�screening�Prenatal�exposureto� alcohol.� They� had� taken� total� 1�1� studypopulation�amongst�which�100�were�cases�(41�FAS,59�PFAS)�and��1�control�group�for�study�amongstwhich� 6� craniofacial� dysmorphology�have� beenexplored.

McGrath�J�et�al�(2002)��15��have�found�effectivedistinguishing�features� in�Psychotic�disorder�suchas�in�schi�ophrenia,�there�is�smaller�temporal�lobesin�patients� as� comparable� to� controls�based� uponAnthropomorphic� study.�They�have� recruited��10cases�and��0��controls�and�analy�ed�that�Psychoticdisorder� found� to� be�more� in�wider� skull� base,protruding�ears,�shorter�and�wider�palates.

Chandra� �J� et� al� (2012)� �1�� have� obtainedAnthropometric�disproportion� between� the� localpopulations�and�American�Caucasians.�They�havestudied� facial� anthropometric�measurement� in� 50males�and�50�females�of�adult�age�group�belongingto� same� ethnic� group.� They� had� used� standardanthropometric� landmarks� for� Anthropometricmeasurements�and�indices.

Solon� ECC� et� al� (2012)� �20�� � have� surveyedgeometric�morphometrics� by� Image� Analysis

amongst� hypertensive�and�non-hypertensive� andhave� come� to� a� conclusion� that� there� is� facialdysmorphology�between� hypertensive� and�non-hypertensive�patients.

Batiha�AM� (2015)� �21�� et� al� tried� to� find� anycorrelation�between� hypertensive� population� ofJordia�and�their�anthropometric�indices.�They�haveincluded�hip� circumference,�waist� circumference,height,�weight,�waist-to-hip�ratio,�and�a�body�shapeindex�in�their�study.

Conclusion

Though�the�data�analysis�have�not�concluded�anychange� in� facial� anthropometry� in� hypertensivesubjects�with�affirmation�but�the�data�obtained�forcontrol� subjects� in�Central� Indian�Population� canfurther� be�utilised� by�Anthropometrics,� ForensicExperts,�Anatomists�and�Plastic�surgeons�too.�Morefirmly�conclusion�can�be�drawn�if�study�is�carriedout�further�with�larger�number�of�subjects.

Conflicts�of�Interest

There�are�no�conflicts�of�interest�in�this�study.

Acknowled�ement

The� research� is� funded� by� MaharashtraUniversity�of��ealth� Sciences,�Nashik� under� itsSTRG�scheme�for�Undergraduate�students.

References

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