35 CHAPTER 2 LITERATURE REVIEW Review of literature is an essential component of research study as it provides a broad understanding of the research problem. The investigator has made a thorough study on the available research sources, which has helped in projecting the widened perspective of the study. This chapter consists of 3 Parts 2.1 PART – I : Theoretical Literature related to Hypertension 2.2 PART – II : Empirical Literature related to 2.2.1 Hypertension 2.2.1.1 Magnitude of the problem 2.2.1.2 Diagnosis of Hypertension 2.2.2 Complimentary/ Alternative medicine(CAM) 2.2.2.1 Effect of Yoga on Blood pressure 2.2.2.2 Effect of yoga on BMI 2.2.2.3 Effect of yoga on Cholesterol 2.2.2.4 Effect of yoga on Anxiety 2.2.2.5 Effect of yoga on stress 2.2.2.6 Hypertension and Need based educational intervention 2.3 PART – III : Conceptual Framework based on Roy’s Adaptation Model.
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35
CHAPTER 2
LITERATURE REVIEW
Review of literature is an essential component of research study as it
provides a broad understanding of the research problem. The investigator has made a
thorough study on the available research sources, which has helped in projecting the
widened perspective of the study.
This chapter consists of 3 Parts
2.1 PART – I : Theoretical Literature related to Hypertension
2.2 PART – II : Empirical Literature related to
2.2.1 Hypertension
2.2.1.1 Magnitude of the problem
2.2.1.2 Diagnosis of Hypertension
2.2.2 Complimentary/ Alternative medicine(CAM)
2.2.2.1 Effect of Yoga on Blood pressure
2.2.2.2 Effect of yoga on BMI
2.2.2.3 Effect of yoga on Cholesterol
2.2.2.4 Effect of yoga on Anxiety
2.2.2.5 Effect of yoga on stress
2.2.2.6 Hypertension and Need based educational
intervention
2.3 PART – III : Conceptual Framework based on Roy’s Adaptation
Model.
36
PART I
2.1 THEORETICAL LITERATURE RELATED TO
HYPERTENSION
Definition: Hypertension, or high blood pressure, is a persistent blood
pressure above 90 mm Hg between the heart beats (diastolic) or over 140 mm Hg at
the beats (systolic)
Causes
� Above 40 Years
� Obesity
� Intake of contraception
� A high fat consume.
� Stress at work and in the daily life.
� Smoking.
� Over-weight.
� Lack of exercise.
High Risk Factors
� A diet high in saturated fat
� Excessive salt consumption
� Overweight and obesity
� A sedentary lifestyle and lack of exercise
� Excessive alcohol consumption
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� Smoking
� Un-managed stress
� A family history of high blood pressure
� Being over 65 years of age
� Co-morbidities such as diabetes
Signs & Symptoms: It is asymptomatic but a person with hypertensive
crisis (very high blood pressure) may experience
� Frequent Headache
� Anxiety
� Fatigue
� Dizziness
� Palpitations
� Tachycardia (rapid heart rate)
� Nosebleeds
� Blurred vision
� shortness of breath
Risk Factors
Modifiable Risk Factors
� Family history
� Age
� Sex
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Non Modifiable Risk Factors
� Obesity
� Diet
� Physical activity
� Smoking
� Alcoholism
Complications
� Heart attacks
� Stroke
� Heart failure
� Aortic dissection (splitting of aorta)
� Kidney damage
� Vision loss
� Erectile dysfunction (a type of impotence)
� Memory loss
� Fluids in the lungs
� Diseases of the peripheral arteries
How to manage high blood pressure
� Eating a healthy diet
� Reducing salt intake
� Exercising regularly
� Stopping smoking
� Reducing alcohol consumption
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� Managing stress
� Having regular blood pressure checks
� Reducing salt consume.
� Reduction of fat consume, and especially of saturated fat consume.
� Weight reduction.
� Relaxing and stress reduction techniques, for example meditation and
autogenic training.
� Regular exercise.
2.2 PART – II: EMPIRICAL LITERATURE
2.2.1 Hypertension
Empirical literature on Hypertension is presented here under the following
headings as
2.2.1.1 Magnitude of the problem
WHO (2013) stated that in Worldwide, high blood pressure is estimated to
affect more than one in three adults aged 25 and over, or about one billion people.
The theme of the World Health Day 2013 is “Measure your Blood pressure, reduce
your risk” for calling for intensified efforts to prevent and control Hypertension[75].
WHO (2012) estimated that One in three adults worldwide are affected
with raised blood pressure – a condition that causes around half of all deaths from
stroke and heart disease. This report is further evidence of the dramatic increase in
the conditions that trigger heart disease and other chronic illnesses, particularly in
low- and middle-income countries [76].
Pal et al., conducted a study to assess the nature of sympathovagal
imbalance (SVI) in prehypertensives by short-term analysis of heart rate variability
(HRV) to understand the alteration in autonomic modulation and the contribution of
40
BMI to SVI in the genesis of prehypertension. Body mass index (BMI), basal heart
rate (BHR), blood pressure (BP), rate pressure product (RPP) and HRV indices are
measured. The results in three groups of subjects revealed that normotensives having
normal BMI (Group 1), prehypertensives having normal BMI (Group 2) and
prehypertensives having higher BMI (Group 3). SVI was assessed from LF-HF ratio
and correlated with BMI, BHR, BP and RPP in all the groups by Pearson
correlation. . It was advised that life-style modifications such as yoga and exercise
would enable achieve the sympathovagal balance and blood pressure homeostasis in
prehypertensives [77].
WHO (2011) studied the prevalence of Hypertension in India. The
prevalence of Hypertension was found among 33.2% males and 31.7% females and
totally 32.5%. It also states that 9.9% males and 12.2% females and totally 11% are
in overweight category. Moreover, regarding Raised cholesterol 25.8% males,
28.3% females and 27.1% total population [46].
Dutta A and Ray MR studied the prevalence of hypertension, pre-
hypertension and tachycardia among the women in rural areas of West Bengal,
identify co-factors associated with the prevalence and contribute to the body of
evidence for future health programs to identify at-risk groups. A population-based
cross-sectional study was conducted among 1186 remote women participants, aged
18 years or more. They were interviewed using standard structured questionnaire.
For each participant, two blood pressure measurements with an interval of 48 hours.
Overall prevalence of hypertension in the study subjects was 24.7% and that of
pre-hypertension and tachycardia was 40.8% and 6.4%, respectively. Both
hypertension and pre-hypertension were seen to increase with age. Other identified
significant factors were use of biomass fuel for cooking, absence of separate kitchen,
higher body mass index (BMI), education and average family income [78].
Biswas M and Manna CK conducted a cross-sectional, community-based
survey to investigate the prevalence of hypertension among the members of the
households of the Scheduled Caste community of three selected villages in District
Nadia, West Bengal, India, in individuals aged 20-70 years. Prevalence of
41
prehypertension, hypertension, ISH and IDH in the study population was 19.28%,
17.93%, 8.07% and 6.72%, respectively. There was a significant development of
hypertension with increasing age (p<0.001). Males (19.26%) showed a higher
hypertensive rate than females (16.66%); however, this was not significant. In the
three increasing body mass index (BMI) groups (<19.9, 20-24.9 and �25 kg/m2), the
percentages of patients with hypertension were 19.27%, 23.23% and 29.62%,
respectively. Hypertension was higher in the waist hip ratio (WHR) group of
0.90-0.99 (hypertension = 23.12%) than the WHR group of 0.80-0.89
(hypertension=7.89%). BMI and WHR were significantly higher (p<0.001) in the
hypertensive group compared with the non-hypertensive group [79].
Tsugane S et al., quoted the attributable factors and hazard ratios
associated with BP in relation to stroke and CHD. A total of 943 stroke events, 182
CHD events, 262 stroke deaths and 120 CHD deaths occurred between the baseline
questionnaire. BP levels were linearly associated with incidence and mortality of
CVD in men and women. The contribution of normal BP, high normal BP and mild
Hypertension to the occurrence of stroke events were greater than those made by
moderate and severe Hypertension, highlighting the importance of primary
prevention and treatment of low- to- moderate degrees of Hypertension [80].
WHO studied the prevalence of Hypertension in India, in the study group
aged 20 -60 yrs. The prevalence of Hypertension was 59.5 and 69.9 per 1000 in
males and females respectively in the urban population and 35.5 and 35.9 per 1000
in males and females respectively in the rural population [81].
Sampatti ST et al., conducted a community-based cross-sectional study to
find out prevalence of hypertension in rural areas of Maharashtra. The subjects were
1297 persons aged 19 years and above. A house-to-house survey was conducted and
interviewed the participants by systematic random sampling method, using pretested
structured standard questionnaire. Two independent blood pressure (BP) readings
were taken in sitting position by visiting each participant at their home. Overall
prevalence of hypertension in the study subjects was 7.24%. Multiple logistic
regression analysis identified various factors significantly associated with
42
hypertension were age, sex, BMI, additional salt intake, smoking, DM, alcohol
consumption, and higher socioeconomic status. The overall prevalence of
hypertension in study subjects was 7.24% [82].
Agrawal VK et.al., conducted a cross sectional study on prevalence of
hypertension and its determinants in rural population among 406 people (218 men
and 188 women) of 30 years and above.it was found that Prevalence of systolic
hypertension in rural community was 18.5 % and of diastolic hypertension 15% with
higher prevalence in the age group of 60 years and above, in case of men and
women [83].
Perez LH et al., conducted a study to determine the relation between
overweight, diabetes, stress and hypertension among 228 cases randomly selected in
a rural adult population in Yarumal-Antioquia, Colombia. Obese people (body mass
index (BMI) > or = 30 kg/m2) showed an increased or of hypertension compared to
those with a BMI < 25 kg/m2, OR: 3.83 [95% confidence interval (CI): 1.83-8.00].
A high level of psychological stress was associated with hypertension (measured on
a tension-anxiety scale), OR: 5.02 (95% CI: 2.25-11.19). This study provides
evidence that BMI, stress (feelings of anxiety or tension), and diabetes are
independently associated with an increased risk of hypertension in a rural area of
Colombia [84].
2.2.1.2 Diagnosis of hypertension
Hasumi, Takahiro et al., carried out a study to evaluate the age-specific,
sex-specific, and race-specific prevalence of hypertension among 59, 227 adults
(ages 18 and older) South African adults. The weighted prevalence of self-reported
diagnosis of hypertension by a health professional was 10.4%. The prevalence of
hypertension increased significantly with age for both men and women. In total,
94% of those reporting a diagnosis of hypertension reported taking antihypertensive
medications. The study concluded that there is a significant burden from
hypertension in South Africa, especially as the under-diagnosis of hypertension [85].
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Alonso A et al. explained the association between alcohol consumption,
including the preferential order of alcoholic beverage and the frequency of
consumption per week, and the risk of Hypertension in a Mediterranean cohort. Self-
reported data on Hypertension diagnoses were collected, 554 incident cases of
Hypertension were identified over a total of 43,562 per year. The consumption of
beer was associated with risk of Hypertension. However the weekly pattern of
alcohol consumption did not have a significant impact on the risk of Hypertension
[86].
National Health and Nutrition Survey division (2008) examined whether
Hypertension is associated with CVD mortality risk and whether the association of
BP with CVD outcome is by social demographics or Hypertension treatment and
control. Data collected from the Third National Health and Nutrition Examination
Survey through 2000 were used to estimate the relative risk of death from CVD
Hypertension. The study suggested a strong, significant association of elevated BP
with CVD mortality risk, particularly among persons aged < 65 years. Treatment
and control of Hypertension eliminated the excess CVD mortality risk observed
among the hypertension population [87].
Jacks H et al., explained the prevalence of anxiety symptoms, anxiety
disorder or specified anxiety disorders in adults aged > 60 in either Community or
clinical settings was done . Study concluded that anxiety disorder, particularly
Generalised Anxiety Disorder was common and issue related to Co morbidity and
the nature of anxiety in old age remained unresolved. This hampered the design of
Intervention Programmes and highlighted the need for further research with a
primary focus on anxiety [88].
Okayama A, et al., examined the association within high normal BP and
CVD. 5494 Japanese individuals (aged 30 – 79 yrs without at baseline) were
included for the study. The frequencies of high- normal BP and Hypertension Stage
I and Stage II were 18.0%, 20.1% and 10.1% for men and 15.9%, 15.6% and 8.8%
for women respectively. The risk of Myocardial Infarction and Stroke for each BP
category were similar to those of CVD. The study concluded that, high – normal BP
44
is a risk factor for the incidence of stroke and Myocardial Infarction in a general
urban population of Japanese men [89].
Soudarssanane MB et al. conducted a cohort study to measure the
incidence of HT and study the relationship of BP with age, sex, socioeconomic
status, BMI, physical exercise, salt intake, smoking and alcohol consumption. It
consists of 756 subjects (19-24 years) in urban field area of Department of
Preventive and Social Medicine, JIPMER, was followed by house visits for
measurement of sociodemographic variables, anthropometry, salt intake, physical
activity and BP. A total of 555 subjects from the 2002 cohort were contacted
(73.4%), in that 54.5% subjects who were below 5th percentile, 93.6% subjects
between 5th and 95th percentiles and 72% of those above 95th percentile previously
persisted in the same cut-offs for systolic blood pressure (SBP). The corresponding
figures for diastolic blood pressure (DBP) were 46.2, 92.2 and 74.1%, respectively.
Annual incidence of HT was 9.8/1000. Early diagnosis of hypertension even among
adolescents/young adults is an important preventive measure, as tracking exists in
the population [90].
Feldstein CA et al. conducted a Cross-sectional survey to assess the
relationship between 24-h ambulatory blood pressure monitoring (ABPM) and three
commonest anthropometric measurements for obesity [body mass index (BMI),
waist circumference (WC) and waist-hip ratio (WHR)] in patients with essential
hypertension never treated or after a 3 week placebo period, living in Buenos Aires.
Three-hundred seventy-seven essential hypertensives, aged 18-86 years, of either
sex, were consecutively recruited. The prevalence of overweight-obesity was
56.76% in women and 75.86% in men. High WHR prevalence in non-obese women
was 4.5% and 4.1% in non-obese men while high values of WC were observed in
3.0% of non-obese women and in 0% of non-obese men. These results indicated a
high prevalence of overweight-obesity (more than 56% of women and 75% of men)
in our hospital-based sample of essential hypertension and that the WHR offers
additional information beyond BMI and WC to predict the hypertension risk
according to the ABPM [91].
45
Tull S et al., assessed the relationship of abdominal obesity and BP. The
study examined the elevated BP in a population of black Caribbean women aged 20-
55 yrs. 133 randomly selected women from the island of Barbados comprised the
study sample. Data collected included Anthropometric and BP measurements and
information about internalized racism, anxiety and depression. The study concluded
that the abdominal obesity should be taken into account as a risk factor (eg, Diabetes
& CVD) [92].
Singh RB et al. studied the prevalence of central obesity and age-specific
waist:hip ratio of urban women from five Indian cities. Cross-sectional surveys were
conducted in 6-12 urban streets in different parts of India on randomly selected 3212
women, aged 25-64 years, from Moradabad (n = 902), Trivandrum (n = 760),
Calcutta (n = 365), Nagpur (n = 405), and Bombay (n = 780). Evaluation was done
with a questionnaire administered by a physician and a dietician, a physical
examination, and anthropometric measurements. The results revealed that the overall
prevalence of central obesity among the total number of women was 55.0%, with the
highest prevalence in Calcutta (62.2%) and the lowest in Bombay (47.4%). Body
mass index, sedentary lifestyle, and family history of excess intake of fat were
significant risk factors for central obesity [93].
2.2.2 Complimentary/ Alternative Medicine (CAM)
2.2.2.1 Effect of Yoga on Blood pressure
Deepa T. et al. conducted a study to evaluate the Effect of yoga and
meditation on 15 mild to moderate essential hypertensives treated with
antihypertensive drugs along with yoganidra. The study showed a significant fall of
mean blood pressure after 3 months of yoganidra (p <0.01) [94].
Naik A conducted a study to evaluate the effect of left nostril breathing
on 30 hypertensive patients to evaluate the heart rate and blood pressure. The result
showed that the mean pulse rate dropped from 84.73 ± 1.89 per minute to 81.80 ±
1.84per minute. Systolic blood pressure dropped from 144.50 ± 3.68 mmHg to