The prevalence of essential hypertension is alarmingly increasing in the Pakistani population. This article discusses the prevalence of hypertension in diabetic patients and possible risk factors in the Pakistani population. Hypertension is a common co-morbidity with diabetes.
Diabetes is a very common metabolic disease though as a disease of affluence (Hassan et al, 2016). Diabetes is a noncommunicable medical disorder characterized by hyperglycemia which is caused by a defect in insulin secretion and is currently amongst the top ten causes of worldwide mortality (World Health Organization, 2011). Diabetes results in dyslipidemia that elevates the total cholesterol, triglycerides and low-density lipoproteins and decreases the high-density lipoproteins which carry beneficial effects (Amini et al, 2011).
Diabetes Mellitus (DM) is a public health concern with multiple complications and increasing prevalence (Meo et al, 2016). According to the World Health Organization (WHO), Diabetes will be the seventh leading cause of mortality of the year 2030 (WHO, 2011). It is estimated that round about 347 million people worldwide have diabetes (Danaei et al, 2011).
According to the International Diabetes Federation, diabetes is a worldwide health problem affecting more than 415 million individuals and expected to reach 642 million individuals by end of 2040 (International Diabetes Federation, 2015). Diabetes is the 4th major reason of death in most developed countries showed in another study (Amos et al, 2010). Pakistan must include diabetes preventive measures in its national health policy to minimize the burden of the disease (Meo et al, 2016). The rapid increase of the diabetes rate still needs an improved understanding of risk factors (Akhtar et al, 2016).
Association with hypertension:
Hypertension was strongly associated with diabetes (meo et al, 2016). Hypertension in most of cases co-exists with diabetes mellitus. Chances of Diabetic patients to have hypertension are three to four times more than in non-diabetic individuals (Zafarullah et al, 2015. Among diabetic patients, hypertension was significantly associated with dyslipidemias and central obesity (Shabnam et al, 2016). High blood pressure (B.P) is called Hypertension which is a chronic medical disorder in which pressure of blood is increased against the arterial wall. When the heart pushes the blood into the blood vessels and arteries impede the blood flow then the blood pressure is generated (Zafarullah et al, 2015). According to the JNC 7 guidelines, the definition of hypertension is when systolic blood pressure is ≥ 140 mm-Hg or diastolic blood pressure ≥ 90 mm-Hg (Premkumar et al, 2016).
Normal blood pressure is in the range of 100–130 mm-Hg systolic and 60–90 mm-Hg diastolic. A person is said to be hypertensive if his/her blood pressure is persistently at or above 140/90 millimeters mercury (mm-Hg) for most of adults (James et al, 2014). About 95% of patients have essential hypertension caused by lifestyle, obesity, diet, stress & Secondary hypertension caused by medication, adrenal disorders and kidney diseases (Colbert, 2013). Blood pressure is measured by two terms, the systolic (maximum pressure) and diastolic (minimum pressures) in the arterial system. When the left ventricle is most contracted, it will be termed as systolic pressure; likewise, when the left ventricle is most relaxed prior to the next contraction, it will be called as diastolic pressure (Zafarullah et al, 2015).
Symptoms of hypertension include blood in the urine, headache, Chest pain and bleeding from the nose (Dandiya et al, 2010). Hypertension is also called a silent killer which is correlated with other diseases like organ damage and other non-communicable diseases (Ogah et al, 2013). The prevalence of essential hypertension is alarmingly increasing in the Pakistani population due to lower body mass index and nutrition (Kalam, 2015). Increasing BMI, higher values of both systolic, and diastolic blood pressure were strongly associated with impaired fasting glucose (Zafar et al, 2011).
The leading causes of hypertension include excessive intake of salt, stress, physiological factors and alcohol consumption (Ibrahim et al, 2012). The factors in Pakistan are increased genetic susceptibility, environmental factors such as gender, urbanization, obesity and sedentary lifestyles particularly in middle age, cultural practices promoting sedentary life style in females (Kalam, 2015).
Ohm’s Law can be applied as follows:
R= ΔP/F, MAP = C.O x SVR,
C.O = SV x HR
MAP = mean arterial blood pressure, estimated by DBP + (SBP – DBP)/3, C.O = cardiac output, SVR = systemic vascular resistance, HR = heart rate, SV = stroke volume (dependent on preload, contractility, after-load) (Zafarullah et al, 2015).
Hypertension is associated with the risk factors and diseases like congestive heart failure (CHF), end-stage renal failure (ESRD), stroke and coronary artery disease (Gupta et al, 2016). Hypertension if not controlled properly may progress toward other complications such as Left ventricular hypertrophy and other cardiovascular diseases (CVD). Hypertension is a common co-morbidity with diabetes mellitus and heart diseases (Zafarullah et al, 2016). The main risk factors of diabetes identified were obesity, overweight and hypertension (Zafar et al, 2011).
Chronic hyperglycemia in diabetes leads to various macrovascular (coronary heart disease, peripheral vascular disease, and stroke) and micro-vascular (retinopathy, neuropathy, and nephropathy) complications (Mehreen, 2014). The risk factors that are included in the analysis of Diabetes are growing age, body mass index (BMI), hypertension, monthly income, exercise, smoking and locality (rural/urban)(Akhtar et al, 2016). Diabetes and hypertension are important and common chronic diseases that have a huge impact on the health of individuals as well as the health care systems (Shabnam et al, 2016). Diabetes increases the risk of many complications which can affect the quality of life (Hassan et al, 2016). There is little awareness about the risk factors for hypertension (Haidar et al, 2014).
The current prevalence of diabetes mellitus in Pakistan is 11.77%. In males, the prevalence is 11.20% and in females 9.19% (Meo et al, 2016). In southern Punjab the prevalence of diabetes in males is 17.4% & in females is 15.38 (Khan et al, 2016). In Pakhtunkhwa province, the prevalence of diabetes in males is 9.2% & in females is 11.6%. In Baluchistan province, the prevalence of diabetes in males is 13.3% & in females is 8.9%. In Punjab province, the prevalence of diabetes in males is 12.14% & in females is 9.83%. In Sindh province the prevalence of diabetes in males is 16.2% & in females is 11.7 (meo et al, 2016).
Fig 2: Prevalence of Diabetes in Pakistan.
The prevalence of hypertension reported from Pakistan is 26% which differs by 34% among males and 24% in females (Ke et al, 2015). Hypertension is a major health issue in Pakistan, 24.3% of people were hypertensive who are above 18 years (WHO, 2013). Raised Blood Pressure (BP) is estimated to cause 7.5 million deaths worldwide, about 12.8% of the total of all deaths World Health Organization (WHO, 2010). The prevalence of coexisting hypertension and diabetes appears to be increasing in industrialized nations because populations are aging and both hypertension and DM incidence increases with age (Atta et al, 2014).
There are at least 970 million people worldwide who have High Blood Pressure (HBP); 640 million in the developing while 330 million in the developed world (World heart federation). Diabetic males (35%) had more chances of hypertension as compared to diabetic females (46%) (Berraho et el, 2012). There are limited data available in Pakistan on the prevalence of hypertension in diabetic patients as well as in the general population (Naveed et al 2016). According to the national diabetes survey, the prevalence of diabetes is higher in males as compared to females while the prevalence of impaired glucose tolerance (IGT) is higher among females as compared to males (Hakeem et al, 2010).
Prevalence of Diabetes in Urban/Rural areas of Pakistan:
Fig 3: Prevalence of Diabetes in Urban/Rural areas of Pakistan.
The prevalence of diabetes in urban area is 14.8% and rural area is 10.34% in Pakistan (meo et al, 2016). National diabetic survey has shown that the overall impaired glucose intolerance IGT) was 22% in urban and 17.1% in rural areas (Shera et al, 2007).
Table 1: Prevalence of Hypertension in Diabetic patients in major cities of Pakistan.
|No. of Diabetic patients||Prevalence of Hypertension||Reference||Year|
|Rawalpindi||Union council||18-56||n=404%||38.3||32.9||Zafar et al,||2016|
|Peshawar||Pak international medical college||20-70||n=500%||25.6||26.8||Gull et al,||2015|
|Karachi||Jinnah Postgraduate Medical Centre||18-80||n=262%||72.5||75.7||Shabnam et al,||2016|
|Southern Punjab||BVH,SZH,NH,CPIEH||25-84||n=200%||30||52||Khan et al,||2016|
|Islamabad||Pakistan Institute of Medical Sciences (PIMS),||21-60||n=456%||67.3||59.2||Khan et al,||2013|
|North Punjab||Cardiology wards||41-60||n=515%||19.4||37||Iqbal et al,||2015|
KEY: BVH-Bahawal Victoria Hospital, SZH-Sheikh Zaid Hospital, NH-Nishtar Hospital, CPIH-Chouhdry Parvaiz Ilahi Institute of cardiology.
The prevalence of hypertension is (32.9%) associated with diabetes (38.3%) study conducted in the union councils of Rawalpindi. The study population is 404 (Zafar et al, 2016). The prevalence of hypertension is (26.8%) associated with diabetes (25.6%) study conducted in the Pak international medical college of Peshawar. The study population is 500 (Gull et al, 2016). The prevalence of hypertension is (75.7%) associated with diabetes (72.5%) study conducted in Jinnah Postgraduate Medical Center of Karachi.
The study population is 262 (Shabnum et al, 2016).In southern Punjab (Bahawal Victoria hospital Bahawalpur, Sheikh Zaid Hospital Rahim Yar Khan, Nishtar Hospital Multan, Chaudhary Pervez Elahi Institute of Cardiology) the prevalence of hypertension is (32.9%) associated with diabetes (38.3%). The no. of participants included in this study are 200 (Khan et al, 2016).In North Punjab, the study conducted in different cardiology wards, the prevalence of hypertension is (37%) associated with diabetes (19.4%) in 505 participants.
Diabetes Mellitus needs serious efforts and focused actions for the prevention of the disease and surely help to reduce the burden of the disease (Akhtar et al, 2016). Different seminars, conferences, articles in printing media and programs in electronic media regarding prevention, detection, evaluation and treatment of hypertension should be arranged to increase awareness among the public and to educate the community (Zafrullah et al, 2015).
In this review, the prevalence of hypertension is high in diabetics. The prevalence of hypertension in diabetic patients is significantly higher as compared to the general population. Health professionals have been active in highlighting diabetes care needs. Early detection and modification of the risk factors for the development of diabetes complications remains the best available option to deal with this alarming disease.
The role of awareness programs and community-based screening campaigns against diabetes should not be overruled. These efforts will surely help reduce the burden of the disease. A timely national program for the prevention, there is a need to lessen the socio-economic burden of the disease by early diagnosis and to address the modifiable risk factors. The results will assist them to understand the effect of associated risk factors of diabetes in the area. Further research is required to find out the association between these risk factors.
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