Association between Nutritional Status and Hypertension among Female Students in Damanhur University , Egypt

Hypertension in teenagers and young adults is increasing worldwide and necessitates the implementation of scientific studies to identify the underlying aetiology. The purpose of this crosssectional study was to estimate the association between nutritional status and dietary pattern and hypertension among university female students in one of the Egyptian Governorates.A total of 220 female students were randomly selected from four faculties of Damanhur University. Data about socio-demographic characteristics, dietary intake and habits, and life style practices were collected. Blood pressure and anthropometric measurements we reassessed for every student. Hypertension was detected among 17.3% of the studied sample. When body mass index was more than 30 kg/m and waist circumference was more than 88 cm, 33.6% and 33.3% of the students were hypertensive respectively. Hypertension was prevalent among students who usually sleep immediately after consuming meals (24.1%),usually eat outside the home (21.3%),highly consuming salty foods(23.4%) and usually add table salt during consuming meals (23.1%). The high rate of hypertension was also associated with high consumption of fried (28.4%) and fast foods (27.2%) and soft (35.5%) and caffeinated drinks (27.5%).Caloric and other nutrients intakes were higher among hypertensive than normal students as well as sodium intake. Obesity and unhealthy dietary pattern of the university students play a major role in the development of hypertension among young adult females.


INTRODUCTION
Hypertension is an increasingly important medical and public health issue. (1,2)) Hypertension may affect an individual for prolonged periods without showing any symptoms and may be diagnosed only after causing serious irreversible pathology and complications.Hypertension is strongly associated with high mortality and morbidity Bull High Inst Public Health Vol.42 No. 1 [2012]   from cardiovascular (CVD),cerebrovascular and renal disease. (6)The effect of earlyonset hypertension is reflected on CVD death and hypertension hospitalization rates. (7)Its control will significantly reduce the prevalence of these diseases and minimize their negative health impact. (8)pertension occurring in children, adolescents and young adults is uncommon and almost always sparks off an intense search for an underlying aetiology.Though essential hypertension is still the commonest form, secondary hypertension occurs with greater frequency than in adults and is most often due to renal disease, followed by cardiovascular and then endocrine disorders. (9)ysical inactivity, smoking, obesity, stress and family history of hypertension are well-known non-dietary predictors of hypertension. (10,11)The dietary factors associated with the increase in blood pressure are increased salt intake, (12) decreased potassium intake, decreased intake of omega-3 polyunsaturated fatty acid, caffeine, (13) high consumption of fructose and soft drinks. (14,15)An improvement in blood pressure control may be associated with increased consumption of calcium, fibres and vitamins E and C. (13) Female gender, particularly in younger subjects, has been associated with a worse prognosis after acute myocardial infarction, including a greater recurrence of acute coronary syndrome and higher mortality. (16)rthermore, women might have less favourable short-term outcome after myocardial revascularization procedures than do their male counterparts.The increasing prevalence of cardiovascular pathology in women has created a clear and compelling need for identification of those variables specifically relevant to cardiovascular health in women. (17)terature review revealed very little

Study design and sampling:
A cross sectional study was conducted from April to July 2011 on female students in Damanhur University aged 18-25 years.The sample size was determined assuming that the prevalence ofhypertension among young adults (15-34 years) in Egypt was 16.5 %. (5) To achieve a 95% confidence interval around the prevalence and an error of ± 5% around this estimate, the minimum required sample size was estimated as 200 subjects.The

Data collection:
Every student was interviewed using a were referred to tables of dietary reference intake (DRI) (19) to calculate percent adequacy of nutrients as follows: percent adequacy of nutrient = (nutrient intake/DRI of nutrient) x 100.Nutrient density of the consumed diet was calculated for macronutrient as follows: nutrient density = (macronutrient intake x calories of each gram/energy intake) x 100.
Anthropometric measurements were taken from each female at the time of interview.Weight, height and waist circumference were measured according to the criteria of Joliffe, et al. (20) Body mass index (BMI) was calculated by dividing the body weight in kilograms by the square of height in meters.Obese female student was defined if BMI ≥ 30 kg/m 2 .Abdominal obesity was defined if waist circumference ≥ 88 cm. (21)mercury sphygmomanometer with a suitable cuff size was used to measure blood pressure.After 5 minutes rest, the right arm blood pressure of a seated participant was assessed twice, 5 minutes apart, and the average was reported as the final blood pressure measurement.
Hypertension was defined according to the criteria of the Joint National Committee 7 th report, systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg. (1)atistical analysis:

RESULTS
The prevalence of hypertension among university female students is illustrated in Figure1.Results show that 17.3% of the females were hypertensive.
The socio-demographic characteristics of students from both groups are presented in

DISCUSSION
The dramatic changes in the life style and food consumption pattern that have occurred during the last four decades in developing countries have led to the emergence of non communicable diseases such as hypertension as a major public health problem. (22)Hypertension has been classified as one of the major risk factors contributing to the development of coronary artery diseases (23) and cerebrovascular diseases. (24) Egypt, the overall prevalence of hypertension among adults is very high (26.7%)and it is 16.5% among young adults (15-34 years). (5)There is a paucity of data on the prevalence of hypertension in the age of university (18-25 years).It has always been assumed that they are Bull High Inst Public Health Vol.42 No. 1 [2012]   deemed to be at a low risk of developing the disease (25) despite of the published reports describing the association between BMI and blood pressure in paediatric patients (26) and adolescents. (27)e results of the present study showed that the prevalence of hypertension among young adult females in the age group 18 to 25 years was relatively high (17.3%),this rate is slightly lower than that reported in a recent study in Iran which showed that the prevalence of prehypertension and hypertension were 13.9% and 19.4% respectively. (4)e prevalence of hypertension reported in this study was not associated with the age or the housing of the students whether located in urban or rural areas or even by the crowding of their homes (Table 2).This is due to the fact that the age category of the subjects of this study was very narrow and varied between 18 and 25 years and the rural nature of the Governorate where the university is located where the nature of the social and cultural environment does not vary between rural and semi urban areas.
The results presented in Table 2 showed that the practice of physical activity by young adult females had insignificant effect on the prevalence of hypertension.This is not in agreement with published studies confirming the significant positive impact of physical activity in reducing the prevalence rate of hypertension.It was shown that regularly performed aerobic exercises significantly lowered blood pressure in patients with essential hypertension. (28)dentary individuals have a 20 to 50% increased risk of developing hypertension. (29)However, it should be pointed out that the number of females practicing physical exercise in this study is quite limited to draw sound conclusion.This is due to the conservative nature of Damanhur Governorate where the families do not allow their daughters to practice sports in addition to the limited facilities available for females to practice physical activity.
The results also showed that smoking was not associated with the prevalence of hypertension, this is simply due to the under reporting of smoking by female students who are very unlikely to admit the smoking habit which is rejected socially.
The positive family history of hypertension was associated with a high prevalence among females who developed hypertension at a young age (19.6%).
Several reports confirmed the role of family history of hypertension in the development of the disease in children and adolescents. (30,31)Family psychological stress led to even a higher prevalence of that harsh family environments increased blood pressure over time (32) and that psychosocial stress may play an important role in the development of hypertension. (33)is was hypothesized to be caused by stress induced sodium retention. (34)th BMI and waist circumference were significant predictors of high blood pressure in adolescents. (27)Several large epidemiological studies have shown an association between BMI and blood pressure in normal weight and overweight subjects. (26,27,29,35)It was reported that adult Bull High Inst Public Health Vol.42 No. 1 [2012]   weight and weight gain are the major determinants of adult blood pressure (35) and that even modest weight loss can reduce blood pressure levels even without reaching ideal weight. (36)Few studies have shown that waist circumference may be a better predictor of cardiovascular disease than BMI. (27,37)The BMI and waist The high consumption of meals containing large quantities of sodium was significantly associated with higher prevalence of hypertension.This was very evident from data presented in Table 3 which showed that the prevalence of hypertension was high among young adult females eating meals outside their homes where the students usually consume fast foods which are very rich in sodium.
The results presented in Table 4 showed that the dietary intake of hypertensive young adult females was higher than that of the normal subjects.The data showed that hypertensive females consumed more calories, carbohydrates and fats far beyond their recommended daily requirements.
Sodium consumption was higher among hypertensive students than normal subjects.
However the protein density of the normal females was significantly higher than hypertensive subjects indicating a better selection of food and a better quality meal.
These results may be due to several unhealthy dietary habits.One of the notorious food habits in Egypt is the high consumption of pickled foods as a replacement to green salad.In addition many families have the habit of adding table salt to the foods while consuming their meals, such habits increases sodium consumption several times more than the recommended of intake rendering young adults more susceptible to the development of hypertension (Table 3).The frequent consumption of salty foods such as pickles, salted fish and chips on daily basis and the practice of adding table salt is a common practice among hypertensive patients. (38)Dietary intervention to reduce sodium intake and increase potassium intake may be effective in reducing blood pressure, this may be achieved by consuming foods rich in potassium and low in sodium particularly fruits and vegetables. (39)e excessive caloric intake will lead to the development of overweight and obesity and when accompanied by excessive intake will ultimately lead to the elevation of blood sample size was increased to 220 students for more accuracy.Four faculties of Damanhur University were selected randomly from list containing all faculties in the university.These faculties were Art, Education, Agriculture and Commerce.From each faculty about 55 female students were selected randomly from students who accept to participate in the present study.Female students with history of chronic diseases, receiving regular medical treatment or following a dietary regimen were excluded from the study.
analysis was done using SPSS software package, version 17 (Chicago, Illinois, US).The results were expressed and presented as numbers, percentages, mean and standard deviation (SD).Odds ratios (OR) and confidence intervals (CI) are also presented.A P-value <0.05 was considered statistically significant.The comparison of the frequencies of the studied parameters between two groups was done by Chisquare test, and Student's t test was used to evaluate the significance of the difference between means.Stepwise logistic regression analysis was done to estimate the independent association of the studied risk factors with hypertension.Ethical considerations: There were no conflicts of interest.This research received no specific grant from any Bull High Inst Public Health Vol.42 No.1 [2012] funding agency in the public, commercial or not-for-profit sectors.This study was conducted according to the guidelines laid down for medical research involving human subjects and was approved by the ethics committee of the High Institute of Public Health, Alexandria University, Egypt.All measurements were taken in full privacy and the collected data were kept confidential.All female students were informed about the objective of the study and they had the right to accept or refuse to participate in the study, then their written consent was obtained.
pressure.High consumption of fried foods and soft drinks contributed to the increased caloric intake which led to increased body weight, BMI and ultimately a higher prevalence of hypertension (27.5%).Students consume several cups of tea and coffee daily and especially during the evening hours to help them to concentrate on their studies, the excessive consumption of caffeine significantly contributed to the development of hypertension.Caffeine has been used for thousands of years and is one of the most widely consumed active food ingredient throughout the world.It is found in coffee, tea, soft drinks and products containing cocoa or chocolate. (40)The consumption of caffeine resulted in an increase in blood pressure in healthy, normotensive, young, and older men and women which necessitates the consideration of caffeine in the lifestyle interventions recommended for blood pressure control. (41-43)CONCLUSION AND RECOMMENDATIONS Hypertension was detected among 17.3% of female students in Damanhur University.Several dietary risk factors were associated with the high rate of hypertension among university female students.Hypertension was associated with obesity and unhealthy practices such as sleeping immediately after eating meals and eating outside the homes.Faulty food habits such as the excessive intake of salt and high consumption of fried and fast foods contributed to the high rate of hypertension.A nutritional intervention program should be designed to control hypertension among young adult females.The main objective of the program will be the correction of the improper dietary practices to reduce caloric and salt intake, maintain normal body weight, minimize the consumption of fried and fast foods and to replace caffeinated and soft drinks by natural fruit juices.The females should be encouraged to practice physical exercise and to avoid unnecessary psychosocial stress.

Table 1 .
The mean age of females from both groups was comparable and was slightly more [ than 19 years.The rate of hypertension was 13.9% among females living in urban areas and increased to 23.7% among students living in rural areas, however, the difference was not statistically significant.The mean crowding index was slightly but insignificantly higher (2.35 persons/room) among hypertensive females as compared with a slightly lower mean of 2.19 persons/room among normotensive subjects.Figure (1)

Table ( 2) Medical history and life style practices of normal and hypertensive university female students
OR= odds ratios; CI= confidence intervals; † by Chi-squared test; * P < 0.05

Table ( 5) Stepwise logistic regression model for significant factors affecting hypertension
* P < 0.05