Original Article
Normotension, Prehypertension, and Hypertension in Urban
Middle-Class Subjects in India: Prevalence, Awareness,
Treatment, and Control
Rajeev Gupta,1 Prakash C. Deedwania,2 Vijay Achari,3 Anil Bhansali,4 Bal Kishan Gupta,5 Arvind Gupta,1
Tulika G. Mahanta,6 Arthur J. Asirvatham,7 Sunil Gupta,8 Anuj Maheshwari,9 Banshi Saboo,10
Mallikarjuna V. Jali,11 Jitendra Singh,12 Soneil Guptha13 and Krishna Kumar Sharma1
Objective
We conducted a multisite study to determine the prevalence and
determinants of normotension, prehypertension, and hypertension,
and awareness, treatment, and control of hypertension among urban
middle-class subjects in India.
Methods
We evaluated 6,106 middle-class urban subjects (men 3,371; women,
2,735; response rate, 62%) in 11 cities for sociodemographic and biological factors. The subjects were classified as having normotension
(BP < 120/80), prehypertension (BP 120–139/80–89), and hypertension
(documented or BP ≥ 140/90). The prevalence of other cardiovascular
risk factors was determined and associations evaluated through logistic
regression analysis.
Results
The age-adjusted prevalences in men and women of normotension
were 26.7% and 39.1%, of prehypertension 40.2% and 30.1%, and of
hypertension 32.5% and 30.4%, respectively. The prevalence of normotension declined with age whereas that of hypertension increased
(P-trend < 0.01). A significant association of normotension was found
with younger age, low dietary fat intake, lower use of tobacco, and
low obesity (P < 0.05). The prevalence of hypercholesterolemia,
diabetes, and metabolic syndrome was higher in the groups with
prehypertension and hypertension than in the group with normotension (age-adjusted odds ratios (ORs) 2.0–5.0, P < 0.001). The prevalences
in men and women, respectively, of two or more risk factors were 11.1%
and 6.4% in the group with normotension, 25.1% and 23.3% in the
group with prehypertension, and 38.3% and 39.1% in the group with
hypertension (P < 0.01). Awareness of hypertension in the study population was in 55.3%; 36.5% of the hypertensive group were receiving
treatment for hypertension, and 28.2% of this group had a controlled
BP (< 140/90 mm Hg).
Conclusions
The study found a low prevalence of normotension and high prevalence of hypertension in middle-class urban Asian Indians. Significant
associations of hypertension were found with age, dietary fat, consumption of fruits and vegetables, smoking, and obesity. Normotensive
individuals had a lower prevalence of cardiometabolic risk factors than
did members of the prehypertensive or hypertensive groups. Half of
the hypertensive group were aware of having hypertension, a third
were receiving treatment for it, and quarter had a controlled BP.
Keywords: hypertension; low-income countries; epidemiology; cardiovascular risk factors; blood pressure.
doi:10.1093/ajh/hps013
The lifetime risk of hypertension, according to current definitions, is more than 90% in most high- and middle-income
countries, and slightly lower than this in low-middle and
low-income countries.1 The prevalence of hypertension
has increased to more than 25% of the worldwide adult
population, and it is estimated that more than 1.5-billion
individuals currently have hypertension.2,3 The increasing prevalence of hypertension is the result of population
Correspondence: Rajeev Gupta, ([email protected])
1Department of Medicine, Fortis Escorts Hospital, Jaipur, India;
Prakash C. Deedwania and Rajeev Gupta designed the study, developed
the protocol, and jointly wrote the first and subsequent drafts of the
paper. They were also involved in obtaining funding, investigator
training, and supervised the whole study. Arvind Gupta, Vijay Achari,
Arthur J. Asirvatham, Anil Bhansali, Bal Kishan Gupta, Sunil Gupta,
Mallikarjuna V. Jali, Tulika G. Mahanta, Anuj Maheshwari, Banshi Saboo,
and Jitendra Singh were the site investigators and supervised the
conduct of the study locally. They were involved in data collection and
provided inputs for the article and critically reviewed the whole article
and provided suggestions. RG, KKS and AG were involved in study
supervision, data management and statistical analyses. All the authors
have read the manuscript and agree to its contents.
Hospital, Fresno, CA; 3Department of Medicine, Patna Medical College,
Patna, India; 4Department of Endocrinology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India; 5Department of
Medicine, Sardar Patel Medical College, Bikaner, India; 6Department
of Community Medicine, Assam Medical College, Dibrugarh, India;
7Department of Medicine, Arthur Asirvatham Hospital, Madurai,
India; 8.Diabetes Care’n Research Centre, Nagpur, India; 9Department
of Medicine, Babu Benarasi Das College of Dental Sciences, Lucknow,
India; 10Diacare and Research Centre, Ahmadabad, India; 11Department
of Medicine, Jawaharlal Nehru Medical College, Belgaum, India;
12Department of Medicine, Government Medical College, Jammu, India;
13Jaipur Heart Watch Foundation, Jaipur, India
Initially submitted June 8, 2012; date of first revision August 06, 2012;
accepted for publication September 07, 2012.
2Department of Cardiology, University of California San Francisco and VA
© American Journal of Hypertension, Ltd 2012. All rights reserved.
For Permissions, please email: [email protected].
American Journal of Hypertension 26(1) January 2013 83
Gupta et al.
aging and environmental change.1,2,4 Increased acculturation and changes in lifestyle have resulted in sedentary lifestyles, stress, and an increased consumption of calories, fats,
salt, and alcohol, with an increase in such proximate causes
of high blood pressure (BP) as generalized and abdominal obesity.4–6 The Global Burden of Chronic Disease Risk
Factors Study has reported that although the mean systolic
BP is declining in high- and middle-income countries, it is
increasing in low-middle and low-income countries.3
The focus of epidemiologists and clinicians involved in
hypertension has so far been on individuals with increased
BP. Population-based, prospective observational studies
have reported a continuous and graded relationship of BP
with cardiovascular events and mortality.7 A systolic BP <
120 mm Hg is considered ideal, with each 10 mm Hg increase
in BP above this being accompanied by a 10% greater risk of
cardiovascular events and mortality.7 Multiple studies have
reported prevalences of high BP in the world population
and various subpopulations.1,2,4 Environmental, lifestyle,
and clinical determinants of pre-hypertension (systolic/
diastolic BP 120–139/80–89 mm Hg), stage I hypertension
(BP 140–159/90–99 mm Hg), and stage II hypertension (>
160/> 100 mm Hg) have been identified.2,6 Clinicians have
developed management strategies to decrease elevated BP
through population-based interventions, as well as lifestyle
modifications at the individual level and pharmacological
methods.8 These efforts have achieved considerable success.
In a proportion of population, BP remains normal (BP
< 120/80 mm Hg) even at older age.9 One such population
group, the tribal population in Sub-Saharan Africa, has been
extensively investigated. It has been reported that in this
population, failure to gain weight, low salt consumption,
and an active lifestyle are important in maintaining a normal
BP.10 In low- and low-middle income countries, however, no
studies among the contemporary living urban populations
have determined the prevalence of normotension or identified lifestyle and other determinants of BP. In low-income
countries, only small studies have identified the awareness,
treatment and status of control of hypertension.2,4
We conducted a multisite cross-sectional study to determine the prevalence of normotension, prehypertension, and
hypertension, their determinants, and the clustering of cardiovascular risk factors among urban subjects in India. We
also assessed awareness, treatment, and the control status of
hypertension. The study evaluated risk factors in the urban
middle class, which is the largest subgroup of the Indian population.11 This apparently homogenous subgroup provides a
unique opportunity to identify the influence of lifestyles on
such cardiovascular risk factors as hypertension. A study of
this in the urban Indian population is also important because
this population comprises more than 300 million subjects
and is poorly represented in previous national studies,12 and
because most of the Indian population will reside in urban
locations by the middle of the twenty-first century.13
Methods
The study was directed at identifying the nationwide
prevalence of cardiovascular risk factors in urban populations of India.12 The protocol for the study was approved by
84 American Journal of Hypertension 26(1) January 2013
the institutional ethics committee of the national coordinating centre at Jaipur. Written informed consent was obtained
from all of the study participants. Sociodemographic, physical, and biochemical risk factors for cardiovascular disease
were determined using a common protocol at all of the sites
included in the study, using the methodologies prescribed by
the World Health Organization (WHO)14 and validated and
used previously in our studies.15
Regions and investigators We planned the study to identify the national prevalence
of cardiovascular risk factors in urban populations in India.
Medium-sized cities were identified in each of the large states
of India, and investigators who had an established record
of research in the epidemiology of cardiovascular disease
or diabetes were invited to participate in the study. Twenty
investigators were invited from all of the large states of India,
and 15 agreed to participate in the study. The cities included
in the study were in the northern (Jammu, Chandigarh,
Karnal, Bikaner), western (Ahmadabad, Jaipur), eastern (Lucknow, Patna, Dibrugarh), southern (Madurai,
Hyderabad, Belgaum), and central (Indore, Nagpur) regions
of India. However, four investigators dropped out because of
a nonavailability of technical support and motivation, leaving the 11 investigators who finally conducted the study. In
the 2001 Indian census, the combined population of the 11
cities included in the study was 21 million.16
Sampling Simple cluster sampling was performed at each study site.
A middle-class location was identified at each city in the study.
This depended upon the municipal classification, which is
based on the cost of land, type of housing, public facilities
(roads, sanitation, water supply, electricity, gas supply, etc.),
educational and medical facilities, and taxes.15 A sample size
of about 250 men and 250 women (n = 500) at each site is
considered adequate by World Health Organization (WHO)
to identify a 20% difference in the mean level of biophysical
and biochemical risk factors for cardiovascular disease.14
Estimating a response rate of 70% as reported in previous
studies at similar locations, we invited 800–1,000 consecutive subjects residing at the same geographic location, to
ensure the participation of at least 500 subjects at each site.15
At each site a uniform protocol of recruitment was followed.
Accordingly, a locality within the urban area of the city was
identified, houses were enumerated, the number of subjects
20–75 years living in each house was determined, and all of
these individuals were invited to a local community center or
healthcare facility (clinic, dispensary) for examination and
blood analyses. A reference home within each locality was
identified and every subsequent household was contacted
until the sample size was reached. This procedure ensured
participation of consecutive members of the locality and was
representative even if the survey was prematurely abandoned
at a particular location (e.g., Belgaum, Nagpur). This method
also ensured representativeness at sites at which oversampling
occurred. The surveys were preceded by meetings with community leaders to ensure good participation. Subjects were
Normotension, Prehypertension, and Hypertension in India
invited to come in the fasting state to a community/medical center within each locality either twice or thrice a week
depending upon the local study investigator’s schedule. The
inclusion criterion consisted of all adults aged 20–75 years living in that particular locality. Subjects who were confined to
home with severe debilitating disease, those not likely to survive beyond 6 months, and pregnant women were excluded.
Measurements The study case report form was completed by the research
worker from local investigators’ team after details were
acquired from the subject. Apart from demographic history,
details of socioeconomic status based on educational status
and years of formal education and occupational class were
acquired.14 Details about smoking/tobacco use were acquired
for type of smoking or nonsmoking tobacco use, number of
cigarettes/bidis smoked, and years of smoking or tobacco use.
Intake of alcohol was assessed as number of alcoholic drinks
consumed per week. Dietary fat was assessed through questions about type of cooking oil used and estimated visible
fat intake in grams per day. Fruit and vegetable intake was
assessed by a simple question about the number of helpings
(medium portions) of either fruits or green leafy vegetables.
Details of physical activity were assessed by questions for
exact daily duration (minutes) of work related-, commute
related- and leisure time physical activity. All of the equipment
for measurements of height, weight, waist and hip size, and
BP was similar at all of the study centers, to ensure uniformity of testing and results. Physical examination emphasized
measurement of height with a stadiometer and measurement of weight using calibrated spring weighing machines;
waist and hip diameters were measured with spring-loaded
tapemeasures, and sitting BP was measured after at least 5
minutes of rest, using BP Omron SDX instruments (Omron
Healthcare, Lake Forest, IL). Three readings were obtained
and were averaged for the data analysis. A fasting blood sample was obtained from all individuals after 8–10 hours of
fasting. Samples were collected at community centers by technicians from local branches of M/S Thyrocare Technologies
Ltd. Laboratory, Mumbai, Maharashtra, India (an accredited
national laboratory, www.thyrocare.com). Blood glucose was
measured at the local biochemistry facility of these laboratories and serum was transported in dry ice to the national referral laboratory at Mumbai, India, where a uniform protocol
was used for measurements. Cholesterol, high-density lipoprotein (HDL) cholesterol, and triglyceride levels were measured with enzyme-based assays with internal and external
quality control (www.thyrocare.com). Values of low-density
lipoprotein (LDL) cholesterol and the ratio of total cholesterol/HDL cholesterol were calculated as in previous studies.15
Diagnostic criteria
Socioeconomic status was categorized according to education and occupation. Educational status was categorized
according to the number of years of formal education into
three groups: less than 10 years (illiterate individuals and
those with less than a secondary education), 10–15 years
(secondary to graduate education), and more than
15 years (postgraduate education) as in previous studies.17
Occupational classes were grouped according to the British
Social Register and categorized into the three groups of high
(class 1–2), medium (class 3 nonmanual and manual), and
low (class 4–5) social class.17 Migrants were subjects who
had been continuously living in urban areas for > 1 year, as in
a previous study.18 Smokers included subjects who smoked
cigarettes, bidis, or other smoked forms of tobacco daily;
past smokers were subjects who had smoked for at least
1 year and had stopped more than a year before being surveyed. Users of other forms of tobacco (nasal, oral, etc.) were
classified as users of nonsmoked tobacco. The diagnostic criteria for tobacco use, as well as other coronary risk factors,
were those established by the World Health Organization
(WHO).14 Subjects consuming more than 20 g of visible fat
daily were categorized as having a high fat intake and those
consuming < 2 servings of fruits or vegetables daily as having
a low intake of fruits and vegetables.19 Individuals involved
in any work- or leisure time- related physical activity were
classified as active and others as not active. Those with no
regular work-related or leisure time-related physical activity
were classified as having low physical activity, as in earlier
studies.15 Overweight or obesity was defined as a body mass
index (BMI) ≥ 25 kg/m2 and truncal obesity was diagnosed
when the waist:hip ratio was > 0.95 in men and > 0.85 in
women or waist circumference was > 100 cm in men and >
90 cm in women according to the US National Cholesterol
Education Program (NCEP) guidelines.20 Hypertension was
diagnosed as a systolic BP ≥ 140 mm Hg or diastolic BP ≥
90 mm Hg or both, or when an individual was known to
have hypertension with or without treatment.
Prehypertension was defined as a systolic BP of 120–
139 mm Hg and diastolic BP of 80–89 mm Hg, and normotension as a systolic BP < 120 and diastolic BP < 80 mm
Hg.6 Dyslipidemia was defined by a high total cholesterol
(≥ 200 mg/dl), high LDL cholesterol (≥ 130 mg/dl), or low
HDL cholesterol (< 40 mg/dl in men and < 50 mg/dl in
women), or a high serum triglyceride (≥ 150 mg/dl) according to the NCEP guidelines.20 Diabetes was diagnosed on the
basis either of a history of known diabetes or a fasting blood
glucose ≥ 126 mg/dl. The diagnosis of metabolic syndrome
was based on standard as well as modified NCEP guidelines.20
Statistical analyses
All of the case-report form data in the study were entered
into a database generated with SPSS version 10.0 (SPSS Inc,
Chicago, IL). Values for men and women were analyzed separately. Numerical variables are reported as means ± 1 SD
and categorical variables as percents. Descriptive statistics
are also presented. Age adjustment was done via the direct method with the 2001 Indian urban census population
as the standard.16 An age-group–specific population distribution of the Indian urban middle class is not available.
Intergroup comparisons (normotesnion vs. prehypertension
and normotension vs. hypertension) were done with the
chi-square test. To identify associations of lifestyle (smoking, use of nonsmoked tobacco, dietary fat intake, fruit/vegetable intake, and physical activity) and biological (obesity,
lipid abnormalities, and metabolic syndrome) factors with
American Journal of Hypertension 26(1) January 2013 85
Gupta et al.
Table 1. Age-specific blood pressure levels in men and women
Study subjects
Age groups
Men
Women
Mean Systolic BP
Total
456
Mean Diastolic BP
Men
Women
Total
Men
Women
Total
123.6 ± 11.4
116.6 ± 12.6
120.5 ± 12.5
79.5 ± 7.6
77.0 ± 7.9
78.4 ± 7.8
20–29
252
204
30–39
565
561
1126
123.9 ± 11.9
120.8 ± 13.8 122.4 ± 12.9
81.2 ± 7.5
78.4 ± 8.2
79.8 ± 8.0
40–49
897
772
1669
126.5 ± 13.0 126.5 ± 14.2 126.5 ± 13.6
82.7 ± 8.6
81.1 ± 8.6
82.0 ± 8.6
50–59
861
631
1492
131.2 ± 15.2 131.0 ± 15.5 131.1 ± 15.3
83.9 ± 9.0
82.9 ± 9.0
83.5 ± 9.0
60–69
533
439
972
134.3 ± 16.2 135.6 ± 17.1 134.9 ± 16.6
83.2 ± 9.1
83.4 ± 9.3
83.3 ± 9.2
≥ 70
263
128
391
139.0 ± 18.2 141.5 ± 18.7 139.8 ± 18.4
82.0 ± 9.7
83.9 ± 10.5
82.6 ± 10.0
Total
3371
2735
6106
129.2 ± 15.0 127.0 ± 16.3 128.6 ± 15.7
82.5 ± 8.7
81.2 ± 9.0
81.9 ± 8.9
-
-
-
128.9 ± 14.8 128.3 ± 14.8 128.6 ± 14.9
82.5 ± 8.8
81.3 ± 8.8
81.9 ± 8.8
Age adjusted
aValues
mean ± SD of BP are in mm Hg.
Abbreviation: BP, blood pressure.
normotension, prehypertension, and hypertension, we performed an age-adjusted logistic regression analysis and calculated ORs and 95% confidence intervals (CIs). A value of
P < 0.05 was considered significant.
Results
The study was conducted from 2006–2010 in 11 cities
located in all regions of India. Of the targeted 9,900 subjects
for the study, 3,426 men and 2,772 women were recruited,
for a response rate of 62%. Details of BP were available for
6,106 subjects (3,371 men and 2,735 women). The social and
demographic characteristics of the men and women in the
study have been previously reported.17 The average age of the
men in the study was slightly greater than that of the women.
Low educational status (illiteracy and < 10 years of formal
education) was greater among women (47.6%) than among
men (22.3%). Most of the subjects belonged to the middle
socioeconomic status. More than half of all of the men and
women in the study lived in joint families and 85.6% were
married, and 17% of the study subjects had migrated from
rural to urban locations.
Age-specific levels of mean BP are shown in Table 1.
Mean systolic and diastolic BP levels were similar in men
and women (age-adjusted systolic BP = 128.2 ± 14.8 mm Hg
vs. 128.6 ± 14.9 mm Hg, diastolic BP = 82.5 ± 8.8 mm Hg vs.
81.3 ± 8.8 mm Hg). An age-associated increase in BP levels
was found in both men and women, with the highest BP levels in the age group of 40–49 years in men and > 60 years
in women. The age-specific prevalences of normotension
(ideal BP < 120/80 mm Hg), prehypertension, and hypertension are shown in Figure 1. With increasing age there
was a decline in the prevalence of normotensive men and
women (Mantel–Haenszel chi-square test, P-trend < 0.05),
as opposed to an increase in the prevalence of subjects with
hypertension (P-trend < 0.001). The prevalence of subjects
with prehypertension remained constant across younger age
groups (< 50 years) and decreased in older age groups. The
age-adjusted prevalence of normotension was 26.7% in men
and 39.1% in women, that of prehypertension was 40.2%
in men and 30.1% in women, and that of hypertension was
32.5% in men and 30.4% in women.
86 American Journal of Hypertension 26(1) January 2013
Sociodemographic, lifestyle, anthropometric, and biochemical variables in subjects with normotension, prehypertension, and hypertension are shown in Tables 2 and 3.
Normotension was more prevalent than prehypertension or
hypertension in men and women in younger age groups.
There was no influence of educational status, occupational
class, migration status, or family type on normotension in
men, whereas in women hypertension was greater among
those less educated and those living in joint families. Table 2
shows that with increasing age there was a decline in the
prevelance of normotension and significant increase in that
of prehypertension and hypertension.
There was no influence of educational status, occupational
class, migration status, or family type on normotension in
men, whereas in women hypertension was more prevalent
among those less educated and those living in joint families. A low level of physical activity was associated with a
lower prevalence of hypertension, whereas a high dietary
fat intake, low fruit/vegetable intake, and smoking or nonsmoking use of tobacco was associated with a greater prevalence of hypertension and prehypertension as compared
with normotension (Table 2). A significantly greater prevalence of hypertension was observed in subjects with obesity
of all grades. At low BMI levels (< 23 and 23–24.9 kg/m2)
there was a greater prevalence of normotension and lower
prevalence of prehypertension and hypertension. The prevalence of hypertension was greater in centrally obese individuals as defined by waist size (Table 3). The prevalence of a
high cholesterol, high triglyceride, and low HDL cholesterol,
and of diabetes, an impaired fasting glucose, and metabolic
syndrome was greater in subjects with prehypertension and
hypertension than in those with normotension (P < 0.001)
(Table 3).
To identify lifestyle and risk-factor associations with normotension, prehypertension, and hypertension, we used
logistic regression analysis. This showed hypertension and
prehypertension as compared with normotension, to be significantly more prevalent among subjects > 50 years of age
among both men (hypertension, OR 3.63, CI 3.00–4.42; prehypertension, OR 1.42, CI 1.17–1.73) and women (hypertension, OR 6.46, CI 5.25–7.95; prehypertension, OR 2.29,
CI 1.83–2.86). Age-adjusted ORs were calculated for the
Normotension, Prehypertension, and Hypertension in India
Figure 1. Age-specific prevalence of normotension (BP < 120/80 mm Hg), prehypertension (BP 120–139/80–89 mm Hg), and hypertension in the study
subjects.
associations of normotension, prehypertension, and hypertension with low educational status (< 10 years education),
low socioeconomic status, depression, smoking or nonsmoking use of tobacco or both, low level of physical activity,
high dietary fat intake (>20 g visible fat/day), low fruit/vegetable intake (< 2 servings/day), obesity (BMI ≥ 25 kg/m2),
and central obesity (Table 4). Significant positive associations
of prehypertension and hypertension as compared with normotension were observed for a high-fat diet, low fruit/vegetable intake, obesity, and central obesity. Associations with
low educational status, low socioeconomic status, and low
level of physical activity were marginal, whereas smoking
and nonsmoking use of tobacco was significantly associated
with prehypertension and hypertension in men (Table 4).
Among subjects with a high cholesterol or high triglyceride level, diabetes, or metabolic syndrome, the prevalence of
prehypertension as well as of hypertension was two- to fourfold greater than that of normotension (Table 4).
We also determined clustering of the major cardiovascular risk factors smoking or nonsmoking use of tobacco,
hypercholesterolemia, diabetes, and metabolic syndrome in
subjects with various grades of hypertension (Figure 2). The
presence of two or more of these risk factors was significantly
greater in men and women with hypertension than in those
with normotension or prehypertension. The prevalence of
more than two risk factors in men and women, respectively,
was 11.1% and 6.4% in those with normotension, 25.1% and
23.3% in those with prehypertension, and 38.3% and 39.1%
in those with hypertension (P < 0.01). Subjects with normotension had the highest prevalence of no risk factors.
The prevalence of awareness, treatment, and control of
hypertension among the study subjects in different age
groups is shown in Table 5. An age-adjusted analysis showed
that 53.8% of men and 57.3% of women were aware of
hypertension. Among subjects with hypertension, 37.9% of
the men and 34.5% of the women were receiving treatment
American Journal of Hypertension 26(1) January 2013 87
88 American Journal of Hypertension 26(1) January 2013
267(40.2)
309(46.5)
88(13.2)
88(13.2)
341(51.3)
164(24.7)
355(53.5)
227(34.2)
71(10.7)
139(22.9)
235(35.4)
423(63.7)
546(82.2)
108(16.3)
152(22.9)
272(41.0)
226(34.0)
231(34.8)
94(14.1)
424(63.8)
154(23.2)
37(5.6)
176(26.5)
115(17.3)
83(12.5)
428
1,720
964
1,901
974
420
626
1,149
2.147
2,934
369
689
1166
781
1,433
487
2,112
651
172
945
606
515
(n = 664)
Normotension
817
1,758
796
Total (n = 3,371)
356(28.9)
204(16.6)
214(17.4)
786(63.8)
194(15.8)c
58(4.7)
239(19.4)c
542(44.0)c
186(15.1)
1,047(85.0)
155(12.6)a
252(20.5)
447(36.3)a
393(31.9)
800(65.0)
688(55.9)
386(31.3)
124(10.1)
246(20.0)
152(12.3)
637(51.7)
365(29.6)a
368(29.9)c
658(53.4)b
205(16.6)
(n = 1,231)
Prehypertension
413(28.0)
287(19.4)
218(14.8)
907(61.4)
303(20.5)
77(5.2)
c207(14.0)
c660(44.7)
316(21.4)
1,341(90.8)c
106(7.2)c
285(19.3)
447(30.3)c
521(35.3)
942(63.8)
858(58.1)a
361(24.4)c
225(15.2)b
241(16.3)a
188(12.7)
742(50.3)
435(29.5)a
182(12.3)c
791(53.6)b
503(34.1)c
(n = 1,476)
Hypertension
249
38
226
1791
476
93
785
1079
339
2310
351
563
1187
65(8.1)
7(0.9)
65(8.1)
528(65.7)
188(23.4)
30(3.7)
275(34.2)
311(38.7)
114(14.2)
690(85.9)
99(12.3)
171(21.3)
369(45.9)
340(42.3)
454(56.5)
312(38.8)
245(30.5)
222(27.6)
132(16.4)
1,090
689
860
417
1051
1635
223(27.7)
363(45.2)
113(14.1)
401(49.9)
334(41.6)
68(8.5)
(n = 803)
Normotension
812
1,212
392
765
1,403
567
Total (n = 2,735)
71(8.9)
14(1.7)
61(7.6)
533(66.9)
99(12.4)
c18(2.2)
205(25.7)c
301(37.7)
96(12.0)
669(83.9)
100(12.5)
151(18.9)
368(46.2)
303(38.0)*
473(54.8)
313(39.3)
189(23.7)b
260(32.6)
122(15.3)
202(25.3)
376(47.2)
134(16.8)
233(29.2)c
450(56.4)c
114(14.3)c
(n = 797)
Prehypertension
Women
113(9.9)
17(1.5)
100(8.8)
730(64.3)
189(16.6)c
45(3.9)
305(26.8)c
467(41.1)
129(11.3)
951(83.8)
152(13.4)
241(21.2)
450(39.6)b
408(35.9)b
708(62.4)b
465(40.9)
255(22.4)c
378(33.3)b
163(14.3)
387(34.1)b
473(41.7)
145(12.8)
131(11.5)c
619(54.5)c
385(33.9)c
(n = 1,135)
Hypertension
Numbers in parentheses are column percentages; aP < 0.05, bP < 0.01, cP < 0.001; P values are for comparisons of normotension with prehypertension and hypertension.
Age groups, years
• < 40
• 40–59
• 60+
Educational status, years
• 0–10
• 11–15
• > 15
Occupational class
• Professional/business
• Skilled manual/non-manual
• Manual labour/unemployed
Rural-urban migrants
Family type
• Nuclear
• Extended, Joint etc.
Marital status
• Married
• Unmarried
Depression
Low physical activity
Dietary fat intake
• Fat < 20 g/day
• Fat 20–40 g/day
• Fat > 40 g/day
Fruit/vegetable intake
• < 2 servings/day
• 3–4 servings
• > 5 servings/day
Smoking/tobacco use
• Smoking/tobacco
• Smoking
• Other tobacco use
Variables
Men
Table 2. Prevalence of sociodemographic and lifestyle factors in normotension, prehypertension and hypertension (unadjusted data)
Gupta et al.
306(46.1)
159(23.9)
157(23.6)
34(5.1)
418(62.9)
189(28.4)
40(6.0)
562(84.6)
80(12.0)
21(3.1)
464(69.9)
109(16.4)
86(12.9)
3(0.4)
210(31.6)
407(61.3)
45(6.8)
80(12.0)
452(68.1)
87(13.1)
86(12.9)
42(6.3)
71(10.7)
1,621
1,213
469
2,366
731
242
1,848
713
741
31
1,046
2,043
247
844
1,706
397
848
768
1,035
(n = 664)
Normotension
965
755
1,291
328
Total (n = 3,371)
222(18.0)c
288(23.4)c
582(47.3)c
131(10.6)
279(22.7)c
427(34.7)
720(58.5)
76(6.2)
265(21.5)c
c6(0.5)
c310(25.2)
c289(23.5)
617(50.1)
845(68.6)c
289(23.5)c
89(7.2)c
645(52.4)c
432(35.1)b
134(10.9)c
351(28.5)c
296(24.0)
494(40.1)c
80(6.5)
(n = 1,231)
Prehypertension
1470
337
630
809
1159
504(34.1)c
676(45.8)c
81(10.8)
170(21.2)
588(73.2)
88(10.9)
94(11.7)
297(36.9)
379(47.2)
123(15.3)
56(7.0)
584(72.7)
148(18.4)
66(8.2)
1(0.1)
1687
616
392
7
870
1,272
552
553
687(85.5)
89(11.1)
24(3.0)
319(39.7)
335(41.7)
139(17.3)
310(38.6)
145(18.0)
253(31.5)
87(10.8)
(n = 803)
Normotension
1,797
693
215
789
1,078
812
777
470
960
488
Total (n = 2,735)
672(45.5)c
179(12.1)
483(32.2)c
409(27.7)
916(62.0)
126(8.5)
499(33.8)c
767(51.9)c
315(21.3)
b345(23.8)c
22(1.5)a
959(65.0)c
362(24.5)c
132(8.9)c
558(37.8)c
592(40.1)c
295(20.0)c
308(20.8)c
300(20.3)
640(43.3)c
214(14.5)c
(n = 1,476)
Hypertension
199(24.9)c
283(35.5)c
385(48.3)c
85(10.7)
177(22.2)c
234(29.3)b
380(47.7)
173(21.7)b
147(18.4)c
465(58.3)c
193(24.2)b
124(15.5)c
4(0.5)
454(56.9)c
266(33.4)c
67(8.5)c
246(30.8)c
312(39.1)
221(27.7)c
221(27.7)c
150(18.8)
284(35.6)
126(15.8)b
(n = 797)
Prehypertension
Women
529(46.6)c
706(62.2)c
497(43.8)c
164(14.4)a
359(31.6)c
339(29.8)b
513(45.2)
266(23.4)a
350(30.8)c
638(56.2)c
275(24.2)
202(17.8)c
2(0.2)
656(57.8)c
338(29.8)
c124(10.9)c
224(19.7)c
431(38.0)
452(39.8)c
246(21.7)c
175(15.4)
423(37.2)
275(24.2)c
(n = 1,135)
Hypertension
Abbreviations: BMI, body mass index; HDL, high density lipoprotein; FBG, fasting blood glucose; ATP-III, adult treatment panel-III.
Numbers in parentheses are column percentages; aP < 0.05, bP < 0.01, cP < 0.001; values of P are for comparisons of normotension with prehypertension and hypertension.
Obesity, kg/m2
• BMI < 23
• BMI 23–24.9
• BMI 25–29.9
• BMI > 30
Central obesity, cm
• Waist < 90/80
• Waist 90–100/80–90
• Waist > 100/90
Cholesterol, mg/dl
• < 200
• 200–239
• > 240
Triglycerides, mg/dl
• <150
• 150–199
• 200–500
• > 500
HDL cholesterol, mg/dl, men and women
• < 40/45
• 40–59/45–64
• > 60/65
Diabetes
Impaired fasting glucose, mg/dl
• FBG < 100
• FBG 100–109
• FBG > 110
Metabolic syndrome
• ATP-III
• Modified ATP-III
Variables
Men
Table 3. Cardiovascular risk factors in normotension, prehypertension and hypertension (unadjusted data)
Normotension, Prehypertension, and Hypertension in India
American Journal of Hypertension 26(1) January 2013 89
Gupta et al.
Table 4. Age-adjusted odds ratios and 95% confidence intervals for lifestyle and risk factor associations of prehypertension and
hypertension compared to normotension (logistic regression analysis)
Variable
Blood pressure status
Men
Women
Lifestyle factors
Educational status (<10 years vs. > 10 years)
Socioeconomic status (low vs high)
Depression
Physical activity (inactive vs. active)
High dietary fat (> 20 g/day vs. < 20 g/day)
Low fruits/vegetable intake (< 2 vs. > 3 servings/day)
Smoking and/or tobacco use
Overweight/obesity (BMI ≥ 25 kg/m2)
Central obesity (waist size > 100 cm in men, > 90 cm in women)
Normotension
1.0
1.0
Prehypertension
0.79 (0.63–1.00)
0.80 (0.64–0.99)
Hypertension
0.75 (0.59–0.95)
1.09 (0.88–1.35)
Normotension
1.0
1.0
Prehypertension
0.98 (0.66–1.47)
0.75 (0.47–1.19)
Hypertension
0.88 (0.58–1.34)
0.72 (0.46–1.14)
Normotension
1.0
1.0
Prehypertension
0.86 (0.68–1.09)
0.82 (0.64–1.06)
Hypertension
0.90 (0.71–1.14)
0.99 (0.77–1.26)
Normotension
1.0
1.0
Prehypertension
0.88 (0.72–1.07)
1.05 (0.85–1.29)
Hypertension
0.77 (0.63–0.94)
0.79 (0.64–0.97)
Normotension
1.0
1.0
Prehypertension
2.10
(1.68–2.63)a
1.20 (0.96–1.51)
Hypertension
1.85 (1.48–2.31)a
1.14 (0.91–1.42)
Normotension
1.0
1.0
Prehypertension
2.37 (1.87–3.02)a
3.30 (2.60–4.18)a
Hypertension
1.67 (1.31–2.14)a
1.84 (1.44–2.34)a
Normotension
1.0
1.0
Prehypertension
1.15 (0.93–1.42)
1.09 (0.76–1.56)
Hypertension
1.12 (0.90–1.38)
1.20 (0.85–1.70)
Normotension
1.0
1.0
Prehypertension
2.16 (1.77–2.65)b
1.39 (1.14–1.70)b
Hypertension
3.44 (2.80–4.23)b
1.91 (1.56–2.33)b
Normotension
1.0
1.0
Prehypertension
1.81 (1.25–2.62)a
2.54 (2.01–3.21)b
Hypertension
3.40 (2.39–4.83)b
1.70 (1.33–2.17)b
Normotension
1.0
1.0
Prehypertension
2.54 (1.92–3.13)b
3.95 (3.08–5.05)b
Hypertension
2.73 (2.14–3.50)b
2.95 (2.30–3.77)b
Normotension
1.0
1.0
Risk factors
High cholesterol (≥ 200 mg/dl)
High triglycerides (≥ 150 mg/dl)
Prehypertension
Metabolic syndrome (ATP-3 defined)
Diabetes
aP < 0.01; bP < 0.001
Abbreviations: ATP, adult treatment panel; BMI, body mass index.
90 American Journal of Hypertension 26(1) January 2013
2.35
(1.92–2.87)b
1.77 (1.43–2.19)b
Hypertension
2.23
(1.82–2.74)b
1.74 (1.41–2.16)b
Normotension
1.0
1.0
Prehypertension
3.28
(2.32–4.63)b
2.83 (2.13–3.75)b
Hypertension
7.09 (5.06–9.92)b
6.26 (4.77–8.20)b
Normotension
1.0
1.0
Prehypertension
2.37 (1.80–3.14)b
3.20 (2.29–4.47)b
Hypertension
3.08 (2.36–4.02)b
4.42 (3.22–6.06)b
Normotension, Prehypertension, and Hypertension in India
Figure 2. Clustering of cardiovascular risk factors (smoking/tobacco use, hypercholesterolemia, diabetes, or metabolic syndrome) in men and women
with various grades of hypertension.
Table 5. Awareness, treatment, and control status of hypertension in men and women Aware n (%)
Age group (years)
20–29
Men
10(23.2)
Women
6(23.0)
Treated n (%)
Total
16(23.2)
Men
5(11.6)
Controlled (BP < 140/90 mm Hg) n (%)
Women
Total
Men
Women
1(3.8)
6(8.7)
5(11.6)
6(23.1)
Total
11(15.9)
30–39
48(34.5)
36(34.3)
84(34.4)
30(21.6)
19(18.1)
49(20.0)
26(18.7)
19(18.1)
45(18.4)
40–49
179(50.5)
160(56.7)
339(53.3)
142(40.1)
102(36.2)
244(38.3)
84(23.7)
78(27.6)
162(25.5)
50–59
261(59.7)
208(61.7)
469(60.6)
194(44.4)
165(48.9)
359(46.4)
122(27.9)
97(28.8)
219(28.3)
60–69
204(62.4)
197(68.9)
401(65.4)
178(54.4)
162(56.6)
340(55.4)
88(26.9)
81(28.3)
169(27.5)
> 70
112(63.6)
66(66.7)
178(64.7)
91(51.7)
57(57.6)
148(53.8)
35(19.9)
18(18.2)
53(19.3)
Total
814(55.1)
673(59.3)
1487(56.9)
640(43.3)
506(44.6)
1146(43.9)
360(24.4)
299(26..3)
659(25.2)
53.8
57.3
37.9
34.5
25.6
31.6
28.2
Age-adjusted %
55.3
for it. Controlled BP (systolic BP < 140 mm Hg and diastolic
BP < 90 mm Hg) was found in 25.6% of the men and 31.6%
of the women with hypertension (28.2% overall). Awareness
of hypertension increased with age in both men and women,
with less than a quarter of men and women under 30 years of
age being aware of hypertension as opposed to two-thirds of
those > 60 years of age. Treatment status also increased with
age, with < 20% of those younger than age 40 years but > 50%
of those over age 60 years receiving treatment. Hypertension
control status did not change significantly with age. Among
the subjects aware of having hypertension, 78.6% of men and
76.1% of women were receiving treatment. Among individuals treated for hypertension, less than half (41.5% of men
and 41.6% of women) had controlled BP.
Discussion
This population-based study among urban middle-class
subjects in India shows a low prevalence of ideal BP (normotension) and high prevalence of hypertension. The prevalence of normotension declined with age whereas that of
hypertension increased. Significant lifestyle and anthropomteric associations with normotension were age, a low dietary fat intake and high fruit/ vegetable intake, nonsmoking
use of tobacco or non-use of tobacco, a normal body weight,
and lower value of central obesity. In subjects with hypertension there was significantly greater clustering of multiple
36.5
cardiovascular risk factors. Only half of subjects with hypertension are aware of the condition, a third were receiving
treatment for it, and less than a quarter of hypertensive
men and women had their BP controlled to the intermediate targets of a systolic BP < 140 mm Hg and diastolic BP <
90 mm Hg.
The American Heart Association has described metrics
for ideal cardiovascular health.21 The seven components of
this are being a nonsmoker; being physically active; having a normal BP (< 120/80 mm Hg), normal blood glucose
(HbA1C < 5.7%), normal total cholesterol (< 200 mg/dl),
and normal weight (BMI < 25 kg/m2); and eating a healthy
diet. Normotension is an important component of this
metric. Determinants of normotension in the present study
were a high level of physical activity, high intake of fruits
and vegetables, low dietary consumption of fat, and nonuse of tobacco. Normotension was also associated with a
low clustering of cardiovascular risk factors (Figure 2). All
of these factors are important components of the metric
for ideal cardiovascular health, and the present study demonstrates that normotension is a marker of good health. In
the US National Health and Nutrition Examination Survey
(NHANES) of 1988–1994, the prevalence of untreated
normotension was 42.4%, in NHANES 1999–2004 it was
40.1%, and in NHANES 2005–2010 it was 42.8%.22 The
prevalence of prehypertension in these same three surveys
was 37.7%, 40.3%, and 41.7%, and that of hypertension was
American Journal of Hypertension 26(1) January 2013 91
Gupta et al.
19.9%, 19.6% and 15.5%, respectively. Only a few studies
in other countries have reported prevalences of normotension.23–26 This ranges from 15%–40% in Asian countries,23,24
which is lower than that in Europe.25,26 In the present study,
normotension was much less prevalent than prehypertension or hypertension. This is similar to the findings in other
Asian countries.24
Determinants of normotension have not been well studied
in earlier studies in India.27 There is an association of high BP
with an unhealthy diet, lack of physical activity, high dietary
salt intake, alcohol consumption, and central and generalized
obesity.6 The converse should be true for normotension, and
our study shows that a low fat intake and high intake of fruits
and vegetables, non-use of tobacco, moderate to high physical activity, and low adiposity are significant associations. We
did not study salt intake, which is an important limitation to
our study. Because the prevalence of alcohol intake in our
study population was low, we therefore cannot comment on
its significance. A low prevalence of cardiovascular risk factors in association with normotension has previously been
reported.10 The Framingham study reported that a systolic
BP < 130 mm Hg was associated with a low prevalence of diabetes, clinical cardiovascular disease, and target-organ damage.28 Our studies shows similar associations with a systolic
BP < 120 mm Hg. In our study, the number of cardiovascular risk factors increased with an increasing systolic as well as
diastolic BP.
The prevalence of hypertension in the US is reported to
be about 26%–31% among adults.6 Slightly greater prevalences (about 40%) have been reported in western European
countries.29 Although the prevalences of hypertension in the
US are lower than those in the present study, the rates are
similar to those in western European and Asian countries.2
The prevalence rates of hypertension in the present study
are also similar to those in previous studies in India.27 The
greater prevalence of hypertension in India than in the US
in the present study could have been the result of our measuring BP on a single day, whereas in the US a diagnosis of
hypertension is based on multiple BP measurements.6 We
also did not correct for the regression-dilution bias, which
is important in epidemiological studies.30 Another contributor to a greater prevalence of hypertension is the white-coat
effect.10,31 The prevalence of hypertension with the methodology used in our study is reported to overestimate its true
prevalence by 20%–25%,14 indicating that a more realistic
prevalence of hypertension in the present study would be
lower by this percentage than the prevalence found in the
study, and would be similar to that in the US and many western European countries. A high prevalence of hypertension
in urban Indian middle-class populations suggests evolving
epidemiologic increase in the prevalence of cardiovascular
disease in this population, and is similar to that in other lowand middle-income countries.3
The awareness, treatment, and control status of hypertension have been reported in smaller studies in India.32–41
The rates of awareness of hypertension vary from less than
5% in rural subjects to more than 60% in urban Mumbai
and Kerala. It has been said that in India the rule-of-halves
is not valid, and that only a third of subjects are aware of
hypertension.36 The present study, which is the largest study
92 American Journal of Hypertension 26(1) January 2013
in India to have evaluated the awareness, treatment, and
control status of hypertension, shows that in urban subjects in India the rule-of-halves is still valid and that half
of hypertensive subjects are aware of having hypertension,
slightly less than half those with hypertension are receiving
treatment for it, and half of these subjects, or a quarter of
hypertensive subjects, have their hypertension controlled.
The study shows that despite the launching of a national
cardiovascular diseases control program,42 substantial gaps
remain in the awareness of and in action related to hypertension. The treatment and control status of hypertension
are low and are similar to those previous studies in India
and other low-income countries.2 We did not investigate
the determinants of a low awareness, treatment, or control
status of hypertension in the present study. An Indian study
among women reported that rural residence was the most
important determinant of these three factors.41 Studies in
India and low-income countries have reported that these
subjects are loath to seek treatment and also discontinue
their treatments.43 Other determinants of poor treatment
and control of hypertension are related to healthcare providers, the availability of chronic care, financial status of
the family, and social determinants of health.44 We have not
inquired into details of these factors and cannot comment
on their significance.
Limitations of the present study have been previously discussed17 and include biases introduced because of sampling,
nonrepresentation of the whole Indian population, inclusion
only of urban subjects, low response rates, measurement
techniques, and failure to correct for regression-dilution.
However, as discussed above, many of the limitations of the
present study are inherent in cross-sectional epidemiological
studies, and the study data are similar to those in previous
Indian studies.29 Urban locations are foci of epidemic cardiovascular disease in India and most low-income countries,1,44
and the present study is therefore important. Moreover, the
study used a similar methodology to that in previous Indian
studies, and the data are similarly representative. We did not
study specific dietary determinants of high BP, such as intake
of salt (sodium), potassium, calcium, and fats, or alcohol
abuse. Strengths of the study include its nationwide scope,
adequate representation of men and women, and large size.
In conclusion, this large national epidemiologic study of
BP in India shows a low prevalence of normotension and
high prevalence of hypertension in urban middle-class subjects. The study shows that even in the milieu of a toxic urban
environment it is possible to maintain normotension with
high levels of physical activity and adherence to a healthy diet.
Low levels of awareness, treatment, and control of hypertension are serious concerns. This study reinforces the need to
urgently address the problem of hypertension in India with
established approaches to public and individual health.
Acknowledgments
This study was funded by the South Asian Society of
Atherosclerosis and Thrombosis, Bangalore, India and
Minneapolis, MN. The funding source made no contribution
Normotension, Prehypertension, and Hypertension in India
to the study design, data collection, data interpretation, or
writing of the manuscript.
Disclosure
The authors have no conflicts of interest to declare.
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