|Year : 2021 | Volume
| Issue : 2 | Page : 84-91
Obesity in patients with hypertension attending a medical outpatient clinic in a tertiary health facility in Enugu, Southeast Nigeria
Ijoma Uchenna Nkemdilim1, Birinus Adikaibe Ezeala-Adikaibe1, Onodugo Obinna Donatus1, Okoye Innocent2, Nwazor Ernest3, Mbadiwe Nkeiruka1, Orah-Okpala Chidimma1, Onodugo Nkiru Pauline1, Anyim Obumneme Benneth1
1 Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
2 Odimegwu Ojukwu University Teaching Hospital, Awka, Nigeria
3 Federal Medical Center, Owerri, Nigeria
|Date of Submission||31-Mar-2020|
|Date of Acceptance||06-Jun-2020|
|Date of Web Publication||30-Jun-2021|
Dr. Birinus Adikaibe Ezeala-Adikaibe
Department of Medicine, University of Nigeria Teaching Hospital, PMB, Enugu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: The prevalence of obesity is increasing in sub-Saharan Africa which reflects the current global trend. Epidemiological data have consistently shown a strong relationship between obesity and hypertension in Africans, and this association is stronger for central obesity. The aim of this study was to describe the pattern of overweight/obesity among patients living with hypertension in a tertiary hospital in Enugu, Southeast Nigeria. Methods: This was a cross-sectional study conducted in the Medical Out-Patient Clinic of the Enugu State University Teaching Hospital in Enugu, Enugu State, Southeast Nigeria. Data were analyzed using the SPSS version 22. Results: Data were collected from a total of 450 consenting patients, most of whom 64% (288) were females. The mean body mass index (BMI) was 28.9 ± 6.1 kg/m2 higher in females than males (29.8 ± 6.5 kg/m2 vs. 26.7 ± 5.2 kg/m2, P < 0.001). The gender distribution of classes of obesity showed female preponderance. A little more than one-third of the patients were overweight, whereas about four out of every ten patients were obese. While overweight did not differ significantly across gendeWr (P = 0.67), more feWmales than males were significantly obese (P < 0.001). The age distribution of BMI showed increasing rates of underweight and decreasing rate of morbid obesity with age. About 86.8% of the females had substantially increased waist circumference compared to 26.5% of the males. Overall, 53% of the males and 97.6% of the females have abnormal waist circumferences. Waist–hip ratio was equally abnormal in 89.3% of the study population even though no statistically significant difference was observed across gender. Conclusion: Overweight and obesity are common among patients with hypertension as demonstrated in this study. There is need to set up an aspect of health education which specifically sensitizes the public against the untoward consequences of overweight and obesity.
| Abstract in French|| |
Introduction: La prévalence de l'obésité augmente en Afrique subsaharienne (ASS), ce qui reflète la tendance mondiale actuelle. Les données épidémiologiques ont constamment montré une forte relation entre l'obésité et l'hypertension chez les Africains et cette association est plus forte pour l'obésité centrale. Le but de cette étude était de décrire le schéma de surpoids / obésité chez les patients souffrant d'hypertension dans un hôpital tertiaire à Enugu, dans le sud-est du Nigeria. Méthodes: Il s'agit d'une étude transversale menée dans la clinique de consultations externes de l'hôpital universitaire d'Enugu State University à Enugu, dans l'État d'Enugu, dans le sud-est du Nigéria. Les données ont été analysées à l'aide de la version 22 de SPSS. Résultats: Les données ont été recueillies auprès d'un total de 450 patients consentants, dont 64% (288) étaient des femmes. L'IMC moyen était de 28,9 ± 6,1) kg / m2 plus élevé chez les femmes que chez les hommes 29,8 ± 6,5) kg / m2 contre 26,7 ± 5,2 kg / m2, p <0,001). La répartition par sexe des classes d'obésité a montré une prépondérance féminine. Un peu plus d'un tiers des patients étaient en surpoids, tandis qu'environ quatre patients sur dix étaient obèses. Bien que le surpoids ne diffère pas significativement selon le sexe (p = 0,67), plus de femmes que d'hommes étaient significativement obèses. (P <0,001). La répartition par âge de l'IMC a montré une augmentation du taux d'insuffisance pondérale et une diminution du taux d'obésité morbide avec l'âge. Environ 86,8% des femmes avaient considérablement augmenté le tour de taille, contre 26,5% des hommes. Dans l'ensemble, 53% des hommes et 97,6% des femmes ont des circonférences de taille anormales. Le rapport taille / hanche était également anormal et anormal dans 89,3% de la population étudiée, même si aucune différence statistiquement significative n'a été observée entre les sexes. Conclusion: Le surpoids et l'obésité sont courants chez les patients souffrant d'hypertension, comme démontré dans cette étude. Il est nécessaire de mettre en place un aspect de l'éducation sanitaire qui sensibilise spécifiquement le public aux conséquences fâcheuses du surpoids et de l'obésité.
Keywords: Hypertension, Nigeria, obesity, obesity-induced hypertension, overweight
|How to cite this article:|
Nkemdilim IU, Ezeala-Adikaibe BA, Donatus OO, Innocent O, Ernest N, Nkeiruka M, Chidimma OO, Pauline ON, Benneth AO. Obesity in patients with hypertension attending a medical outpatient clinic in a tertiary health facility in Enugu, Southeast Nigeria. Ann Afr Med 2021;20:84-91
|How to cite this URL:|
Nkemdilim IU, Ezeala-Adikaibe BA, Donatus OO, Innocent O, Ernest N, Nkeiruka M, Chidimma OO, Pauline ON, Benneth AO. Obesity in patients with hypertension attending a medical outpatient clinic in a tertiary health facility in Enugu, Southeast Nigeria. Ann Afr Med [serial online] 2021 [cited 2022 Jan 22];20:84-91. Available from: https://www.annalsafrmed.org/text.asp?2021/20/2/84/320035
| Introduction|| |
The prevalence of obesity is increasing in sub-Saharan Africa (SSA) which reflects the current global trend. This rising trend is coupled with high rates of hypertension, diabetes, and other noncommunicable diseases which may arise from complications of obesity. In the West African region, the prevalence of obesity is estimated to be around 10% but varies widely both within and between countries.,,, In SSA, it ranges from 3.5% in Eritrea to about 64% in Seychelles with higher preponderance in females. The prevalence of obesity in Nigeria also varies widely between regions.,,,,,
Similarly, the prevalence of hypertension in SSA and Nigeria varies widely as well and may even be as high as 52% depending on the studies., While many African studies have equally reported a wide variation in hypertension prevalence, North Africa has shown a higher figure.
Overweight/obesity and hypertension are two key aspects of the multidimensional health challenges facing SSA. These two major entities (which are also related to insulin resistance) are modifiable by basic and simple prophylactic measures such physical activity and diet modifications. Epidemiological data have consistently shown a strong relationship between obesity and hypertension in Africans.,,, And generally, this association has been reported to be stronger for central obesity which is better assessed by waist–hip ratio. In the second Nurses' Health Study, increased body mass index (BMI) was reported as the strongest risk factor for developing hypertension.
Current estimates on the prevalence of overweight and obesity and in SSA vary widely because of several overlapping factors: cultural, socioeconomic, levels of physical activity as well as genetic.,,,, These factors are likely to be similar in people with hypertension and obesity. For example, in Sokoto in Northwest Nigeria, 12.5% of the university staff believed that obesity is good, whereas 9.7% attributed it to divine disposition. In southern Nigeria, among the Kalabaris where women were culturally expected to fatten up after delivery, 64.5% of the women were obese. Beliefs and attitudes toward hypertension have also been documented.,,, Azubuike and Kurmi reported a fair public level of awareness and practice of hypertension among rural women among whom only 61.3% practiced preventive lifestyle. Beliefs and attitudes were among some of the reported causes of noncompliance among people living with hypertension in Lagos. In another study, people with hypertension showed a high level of willingness to adopt preventive lifestyle despite not having adequate access to proper public health education. These simple measures which include physical exercise and weight reduction will be extremely beneficial in people with hypertension and obesity. The impact of these cultural beliefs in the epidemiology of obesity and hypertension is related to the level of education. Other factors that have been associated with obesity and hypertension include urban versus rural dwelling.,,,,,, These factors have been related to lower rates of physical activity, unhealthy diet, smoking, and alcohol consumption among the lifestyle factors which have been shown to be higher among urban dwellers. Explanations for these relationships have majorly centered on higher rates of affluence and access to food in urban centers.
There are many possible mechanisms by which obesity leads to hypertension. These mechanisms interact with both genetic and environmental factors, and as such, their relationship with hypertension may not be linear., Among these, mechanisms are impairment of renal pressure natriuresis and dysregulation of the sympathetic nervous system., Obesity also predisposes to increased insulin resistance as well as production of leptins,, which are major factors that have been associated with hypertension. Environmental and genetic factors include physical activity, diet, and family history. Again, both hypertension and obesity may also co-occur in the elderly (a population with reduced physical activity and other medical comorbidities) and women after pregnancy. Thus, the relationship hypertension and obesity may be influenced by several factors such as age, gender, and medical comorbidities.
Although overweight and obese persons have higher levels of hypertension,, most of the studies have concentrated on the epidemiology of one or the other. Among urban dwellers with hypertension, the burden obesity is likely to be higher. However, we are not aware of any studies that have specifically assessed the pattern of obesity among people living with hypertension. Describing the pattern of obesity in people with cardiovascular disease such as hypertension is important in delineating a subcategory of individuals that may need special attention and targeted health education. Thus, the aim of this study was to describe the pattern of overweight/obesity among patients living with hypertension in a tertiary hospital in Enugu, Southeast Nigeria.
| Methods|| |
This was a cross-sectional study conducted in the Medical Out-Patient Clinic of the Enugu State University Teaching Hospital (ESUTH) in Enugu, Enugu State, Southeast Nigeria. At the time of the study, ESUTH had 350 beds distributed among the various specialties with 50 inpatient beds for adult admissions for medical cases.
Consecutively consenting outpatients being managed for hypertension were recruited into the study. Weight was measured using a standard bathroom scale in kilograms. Height was measured in centimeters using a straight centimeter ruler. BMI was then calculated using the formula: weight (kg) divided by squared height (m2) and further categorized as underweight <18.5 kg/m2, normal weight 18.5–24.9 kg/m2, overweight 25–29.9 kg/m2, and obese ≥30 kg/m2. Obesity was defined as BMI ≥30 mg/m2 based on the World Health Organization (WHO) criteria.
Waist circumference was measured at the end of several consecutive natural breaths and at a level parallel to the floor, the midpoint between the top of the iliac crest and the lower margin of the last palpable rib in the mid-axillary line. Hip circumference was measured at a level parallel to the floor and at the largest circumference of the buttocks. Both measurements were done with a stretch-resistant tape that is wrapped snugly around the subject but not to the point that the tape is constricting. Risk categorization of waist circumference and waist–hip ratio was based on the WHO cutoff points and risk of metabolic complications. Indicator cutoff points of risk of metabolic complications were categorized, as shown in [Table 1].
|Table 1: World Health Organization risk categorization of waist circumference and waist-hip ratio|
Click here to view
The mean of two consecutive blood pressure (BP) measurements from two previous hospital visits was recorded. History of substance use (alcohol, tobacco, and herbal drugs) was also recorded. History of other comorbidities was retrieved from patients' case files.
Sample size calculation was obtained using the Cochrane formula:
where N is the required sample size, z is the 95% confidence level, e the desired level of precision of 0.05, P is the estimated prevalence of overweight and obesity in Southeast Nigeria, and q is the value of 1 − p.
Thus, N = (1.96)2 (0.84 × 0.16)/0.0025 = 206.5
Assuming 90% response rate, in order to compensate for attrition, a minimum of 228 patients were selected from the pool of medical outpatients for the purpose of this study.
Exclusion criteria were new patients who had not been evaluated at least in the previous three consecutive clinic visits. Pregnant women and cases where anthropometric measurements were not possible were also excluded.
Ethical clearance was obtained from the Ethics Review Board of ESUTH. Ethical conduct was maintained during data collection and throughout the research process.
The SPSS version 22 (IBM Corporation, New York, USA) was used for data management and statistical analysis. Data were presented in tables. The statistical methods included Student's t-test for unpaired observations and Chi-squared test for comparison of categorical data. Distribution of obesity was calculated as percentage of participants. Mean values were presented as graphs where applicable. In all, P < 0.05 was regarded as statistically significant. Conclusions were drawn at the level of significance of 95% confidence level.
| Results|| |
Data were collected from a total of 450 consenting patients, most of whom (64%, 288) were females. The male-to-female ratio was 0.6:1. Most of the participants were older than 54 years, but there was no statistically significant age difference between males and females; however, males were taller than females (P < 0.01). Other characteristics of the population and distribution of their medical comorbidities are shown in [Table 2].
Most of them were engaged in business or retired. Male participants drank alcohol more than females (42 [25.9%] vs. 25 [8.9%], P < 0.01]).
Diabetes mellitus (157, 34.9%) was the most frequent comorbidity, followed by hypertensive heart diseases (66, 14.7%). The mean ± standard deviation of systolic and diastolic BPs was 146 ± 21.9 mmHg and 95.5 ± 13.5 mmHg, respectively. The difference in mean systolic and diastolic BP values for both males and females was not statistically significant, as shown in [Table 2].
Waist circumference, waist hip ratio and body mass index
The distribution of BMI, waist circumference, and waist–hip ratio is shown in [Table 3] and [Table 4] and [Figure 1] and [Figure 2]. The mean BMI was 28.9 ± 6.1 kg/m2 higher in females than males (29.8 ± 6.5 kg/m2 vs. 26.7 ± 5.2 kg/m2, P < 0.001). The age-related distribution of mean BMI is shown in [Figure 1], whereas the distribution of classes of obesity by age and gender is shown in [Table 4].
|Table 4: Distribution of obesity classification (body mass index ≥30 km/m2) among the patients by age and gender|
Click here to view
A little more than one-third of the patients were overweight, whereas about four out of every ten patients were obese. While overweight did not differ significantly across gender (P = 0.67), more females than males were significantly obese (P < 0.001). Only 6 (1.3%) of the population studied were underweight. The gender distribution of classes of obesity showed female preponderance, as shown in [Table 4]. The age distribution of BMI showed increasing rates of underweight and decreasing rate of morbid obesity with age. Age wise, overweight, and Class II obesity were more frequent within the 45–54-year age group, and Class I obesity was more frequent before the age of 45 years. Underweight was only seen from 55 years and above [Figure 2].
About 86.8% of the females had substantially increased waist circumference compared to 26.5% of the males. Overall, 53% of the males and 97.6% of the females have abnormal waist circumferences. Waist–hip ratio was equally abnormal in 89.3% of the study population even though no statistically significant difference was observed across gender.
| Discussion|| |
Overweight/obesity is a growing aspect of the multidimensional health challenges facing SSA. Overweight/obesity is strongly related to hypertension, insulin resistance, and cardiovascular mortality., This rising prevalence of obesity in SSA cuts across all age groups and has huge consequences, especially in mid-life and old age. Nevertheless, increasing BMI can be prevented or at least slowed down through simple measures such as public health education, balanced diet, and lifestyle modification. The rates of overweight and obesity among people living with hypertension in the index study were 32.9% and 38.9%, respectively. The mean BMI was also within the overweight category, 28.9 ± 6.1 kg/m2. About 81.5% had increased or substantially increased waist circumference and 89.3% carried a substantial cardiovascular risk related to abnormal waist–hip ratio. Class I obesity was the most common form of obesity; however, a significant 4.9% had Class III obesity. Obesity was more frequent in females. By age, overweight and Class II obesity were more frequent within the 45–54-year age group, and Class I obesity was more frequent before the age of 45 years. Underweight was only seen from 55 years and above.
The prevalence of overweight/obesity in the index study was higher than what was reported in some community-based studies in Nigeria.,,,, A possible explanation to this observation could be related to the clinical characteristics of the study cohort. Many cases of hypertension in this study might be overweight/obesity induced. Besides, other variables such as age of the patients, higher frequency of diabetes as well as other comorbidities might have contributed. These comorbidities might have substantially limited physical activity, hence creating a vicious cycle which perpetuates further increase in weight. The observation of high prevalence of obesity in people with hypertension has been demonstrated in a number of local studies.,, A two-way relation between obesity and hypertension has also been reported in a community-based study in Southeast Nigeria in which 56.5% of people with hypertension had obesity whereas 66.2% of obese people were found to have hypertension. Similarly, in another study from Angola, 28.7% of the individuals with hypertension were found to be overweight, whereas 38.1% of the obese individuals had hypertension.
The gender distribution of BMI and obesity in the index study is similar to previous reports from the SSA.,,, Several factors have been associated with higher rates of overweight and obesity in females.,,, (Female predominance in the index study, however, was not noted when the mean waist–hip ratio in males and females were compared.) The mean age of the cohort might be contributory to this finding. The higher rates of underweight in older individuals might have different possible explanations such as poverty, chronic debilitating illnesses, and the presence of other comorbidities.,,
The age distribution of overweight and classes of obesity showed an interesting pattern. Individuals older than 44 years had higher rates of overweight and modest rates of Class II obesity, whereas those that were 44 years and below had higher rates of Class I obesity and lower rates of Class III obesity. This observation could be explained by declining level of physical activities following an increase in age and the presence of comorbid chronic conditions such as arthritis and diabetes. A positive association between age and obesity has been demonstrated in several studies from SSA,,, whereas some others reported an inverse relationship.,, Mean BMI in the index study actually decreased with age in both males and females. This age distribution of overweight and obesity is a factor that should be considered by policymakers and public health educators in developing educational interventions in the country.
A significant proportion of patients used alcohol and tobacco. The association between alcohol consumption and obesity is not consistent, and may depend on gender.,, However, considering the effect of alcohol on the sympathetic nervous system, it may have an additive negative effect on BP in people with obesity. Obesity has been reported to be higher among smokers. Tobacco use alone or in conjunction with obesity may likely have a deleterious on the kidneys to propagate high blood pressure and cardiovascular complications.
A bidirectional relationship exists between obesity and hypertension, as has been observed in several studies., Apart from hypertension, weight gain is directly associated diabetes through insulin resistance. The metabolic consequence of insulin resistance is an impaired capacity of postprandial hyperinsulinemia to suppress lipolysis, resulting in greater free fatty acid release. Experimental evidence suggests that these systemic free fatty acids, derived primarily from subcutaneous adipose tissue, may mediate hypertensive mechanisms. Besides, insulin resistance and/or hyperinsulinemia may increase BP through antinatriuretic effect of insulin, increased sympathetic overdrive, augmented responses to endogenous vasoconstrictors, altered vascular membrane cation transport, impaired endothelium-dependent vasodilatation, and stimulation of vascular smooth muscle growth by insulin. Another pathway involved in the genesis of hypertension in obesity is the activation of the sympathetic nervous system and sodium retention due to the activation of the renin–angiotensin system.,,,, Sympathetic nervous system activity is increased in obesity, especially in abdominal obesity, although this is not universal., Obesity-related hypertension has also been directly associated with renal sodium retention and impaired pressure natriuresis which may lead to increased mineralocorticoid activity.,,
While plasma renin concentration adipocyte-derived peptides predict the onset of hypertension possibly through increased sympathetic outflow, gender and ethnic differences have not been shown to be contributory.,,, Finally, obesity is an established cause of obstructive sleep apnea which is a strong risk factor for hypertension.,
The index study while focusing on people with hypertension throws more light in the growing impact of cardiovascular diseases in the country. These intricate and interrelated complex changes in our communities have placed cardiovascular diseases and their complications at the forefront in Nigeria. This is true across all the regions of the country.,,, Stroke which is a major complication of hypertension and other cardiovascular diseases is the most common cause of admission almost in all regions of Nigeria in the last two decades, and this is set to continue. The rates of heart failure and metabolic syndrome are also high among outpatient and in patients. There is, therefore, the need to track these changes by regular studies to provide data for policymakers in the health sector.
The main limitation of this study is that it was hospital based, and findings may not be generalizable. Again, its cross-sectional design does not allow for longitudinal evaluation of patients with a view determining impaired BMI that would interact with other factors to produce hypertension. This study provided data which may be used as a reference for other studies on this subject matter, especially in our environments and beyond.
| Conclusion|| |
Overweight is constituting an increasing health challenge worldwide. Data from SSA have not shown any reducing trend. The relation between obesity and hypertension is well established and has been clearly demonstrated in this study. Thus, there is a need to step up an aspect of health education which specifically sensitizes the public against the untoward consequences of overweight and obesity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]