CONCLUSION

A total of forty-six (37.1%) hypertensive patients had samples taken from them for laboratory investigations. Thirty-two (55.2%) of the 58 subjects with stage 2 hypertension gave consent and reported for laboratory investigation while twenty-six (44.8%) did not give consent for laboratory investigations. Fourteen (21%) of the 66 subjects with stage 1 hypertension gave consent and reported for laboratory investigation, twenty-two (33%) of them did not give consent for laboratory investigations while 30 (45.5%) did not return for follow-up and laboratory investigations.

Out of the 46, fourteen(30.4%) were anaemic, seven (15.2%) had high total serum cholesterol, eight (17.4%) had hypokalaemia and three (6.5%) had hyperkalaemia. Forty (87%) had normal urea levels while six (13%) had high urea levels. Twelve (26.1%) of the subjects had high creatinine level, six(13.0%) had high levels of random serum glucose, fifteen (32.6%) had trace proteinuria and two (4.4%) had significant proteinuria, while four(8.7%) had glycosuria.

The results of the laboratory investigations are shown in Table 7 below.

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The mean packed cell volume (PCV) was 39% and the mean total serum cholesterol was 149.8 mg. The mean serum potassium4.9mmol/L, urea 24.3 mg/dl, serum creatinine 1.2mg/dl, and mean serum random blood sugar was 92.9mg/dl.

Table 7: Laboratory Results of Some Hypertensive Subjects (N = 46) Parameters Normal reference

Range

Normal Abnormal

PCV Male = 45 — 55% 32(69.6) 14(30.4)

Female = 37 — 47% 0(0.0) 0(0.0) Serum potassium 3.5-5.5mmol/L 35(76.1) 11(23.9) Random blood sugar 120—200 mg/dl 40(87.0) 6(13.0)

Serum urea 10 — 55 mg/dl 40(87.0) 6(13.0)

Serum creatinine Male:0.5-1.1mg/dl 20(43.5) 10(21.7)

Female:0.5-1.0mg/dl 12(26.1) 4(8.7)

Total serum cholesterol ≤200mg/dl 29(63.0) 7 (15.2)

Urine protein Negative 16(34.8) 30(65.2)

Urine sugar Negative 39(84.8) 7(15.2)

Table 8: Distribution of Abnormal Laboratory Results among the Hypertensive Subjects.

Abnormal Laboratory Result Stage 1 HTN(%) Stage 2 HTN (%) Total (%)

PCV 6(42.9) 8(57.1) 14 (100)

Serum potassium 5(45.5) 6(54.5) 11 (100)

Random Blood Sugar 3 (50.0) 3 (50.0) 6 (100)

Serum Urea 3(50.0) 3 (50.0) 6 (100)

Serum Creatinine 4(28.6) 10 (71.4) 14 (100)

Total Serum cholesterol 1(14.3) 6 (85.7) 7 (100)

Urine protein 10 (33.3) 20 (66.7) 30 (100)

Urine sugar 2 (28.6.) 5 (71.4). 7 (100)

Thirty (24.2%) of the hypertensive subjects did not come back for follow-up, forty-eight (38.7%) did not give consent for laboratory investigations, amounting to a non compliance/non-adherence rate of 62.9%.

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Table 9: sources of stress named by some subjects* (N=33)

Sources of stress N (%)

Campus activity 5 (15.2)

Daily assault from fellow trader 1 (3.0) Taking care of the family 10 (30.3) Financial problems 25 (75.8)

Illness 5 (15.2)

Infertility 13 (39.4)

Scouting for clients 1 (3.0)

Sleeplessness 5 (15.2)

Thinking (mental stress) 10 (30.3)

Work 15 (45.5)

* Some of the respondents gave multiple responses

From the above,5 respondents said stress can be due to campus activity, 1person it was as a result of daily assault from fellow trader, 10 persons said it could be due to caring for the family, 15vpeople said it is as result of work, 5 persons said it can be caused by sleeplessness while 10 person said it is as result of thinking

Respondents’ Perception of Hypertension

Sixty-five (52.4%) of the hypertensive subjects responded to some questions about knowledge of hypertension; functions, feelings, fears and ideas about hypertension and their expectations from health care providers. Forty-two (64.6%) of them said they know what having the disease hypertension means. Concerning their knowledge about the cause of hypertension, 33 (50.8%) of the subjects cited stress, 29 (44.6%) said it was due to “too much thinking”, while 13 (20.0%) said it runs in the, family. When asked how they felt and what they feared having known that they were hypertensive, 19 (29.2%) said they were too young to have developed hypertension, 35(53.8%) said “God is in control”, 6(9.2%) said it can cause stroke while 15 (23.1%) said they

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were not worried. On being asked how they felt the disease can affect them, 16(24.6%) said it could incapacitate them, 35 (53.8%) said it will not affect them, while 24(36.9%) had no idea of how the disease can affect them. Forty-three (66.1%) of the subjects expected good treatment from their physicians while 32(49.2%) expected cure. The respondents that mentioned stress as a possible cause of their development of hypertension were asked to name their perceived sources of stress and their responses are listed in Table 9.

Dietary habits

The dietary habits of all the subjects were explored. The patients were asked to recall the quantity of food items known to be associated with the development of hypertension, namely fried foods, cakes and pastries, eggs, fruits and vegetables taken per meal and their frequency of consumption. About 59 (47.9%) of the respondents reported eating moderate quantities while 3 (2.4%) reported eating large quantities of fried foods per meal; 53 (42.8%) and 4 (3.2%) said they eat moderate and large quantities respectively of cakes and pastries per meal; 64 (51.6%) and 14 (11.3%) said they eat moderate and large quantities respectively of egg per meal while 69 (55.7%) and 9 (7.3%) said they eat moderate and large quantities respectively of fruits and vegetables per meal. About 46 (37.1%) said they eat small quantities of fruits and vegetables per meal.

Regarding the frequency of eating these food items, 42 (33.9%) said they eat fried foods occasionally and 65 (52.4%) said they eat fried foods 1-3 times in a week; 68 (54.8%) and 55 (44.4%) said they eat cakes and pastries occasionally and 1-3 times a week respectively; 51 (41.1%) and 70 (56.5%) said they respectively eat eggs occasionally and 1-3 times per week while 50 (40.3%) and 60 (48.4%) said they respectively eat fruits and vegetables occasionally and 1-3 times per week. Their responses are shown in Tables 4.

72 Anthropometric Measurements

Statistical analysis using the independent t-test to compare waist circumference, hip circumference and waist hip ratio with blood pressure revealed a significant association between both waist and hip circumferences with blood pressure, between the hypertensive and non-hypertensive subjects. The results of the t-test analysis were as follows: waist circumference and systolic blood pressure (t = 3.72, df 403, p = 0.000), waist circumference and diastolic blood pressure (t= 4.42, df= 403, p = 0.000), hip circumference and systolic blood pressure (t= 3.54, df

= 403, p = 0.000), hip circumference and diastolic blood pressure (t = 3.72, df= 403, p 0.000).

The above results indicate that the higher the waist and hip circumference, the more likely it is that blood pressure will be high.

However, there was no significant association between waist to hip ratio and systolic blood pressure (t = 1.27, df= 403, p= 0.21), and waist-to-hip ratio and diastolic blood pressure (t

= 1.96, df 403, p = 0.05).

Risk factors

From the 𝜒² analysis on the risk factors of hypertension, it was discovered that only No physical exercise, Use of bleaching creams, Passing scanty or no urine in a whole day, Pain when urinating, Waking up several times at night to urinate, Swelling of the face and/or leg, Illicit drug consumption and experiencing breathlessness were significant since their probability values were less than 0.05 level of significance while other factors were not significant.

Complications

The study revealed 23(18.6%) out of hypertensive subjects had Displaced apex beat, 19(15.3%)of them had Tachycardia, 16(12.9%)had Left parasternal/ apical heave, 8(6.5%) of the hypertensive subjects

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had Triple rhythm,13(10.5%) of them had Systolic murmurs,7(5.6%) of them had Tachypnoea,3(2.4%) of them had Hepatomegaly,3(2.4%) had Retinopathy, 3(2.4%) had Ascites while 29(23.4%) had other form of complications.

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CHAPTER FIVE DISCUSSION 5.1 Discussion

This cross-sectional study was done to define the blood pressure profile as well as the risk factors for hypertension among young adult patients attending the outpatient clinic of Catholic Hospital, Oluyoro Oke-Ofa Ibadan. Also to determine the prevalence of hypertension among these young adults (18-50years), assess the risk factors for hypertension in them and detect complications due to the hypertension.

The hospital prevalence of 30.6% for undetected hypertension in young adult patients found in this study is relatively high, considering the age range of the study population (18-50years). This figure is higher than that of a study which reported a prevalence of 1.6% in young adult military recruits in Singapore, although in that study, they were able to rule out cases of white-coat hypertension.⁹Also in that study, the circumstance surrounding the study is different where as they were young adult military recruits with only one qualification, the study here cut across many qualifications. In another relatively similar study done on adults in a tertiary hospital in Nigeria, about 44% of the subjects were found to have undetected hypertension.²⁰ The difference in prevalence of undetected hypertension in both cases may be attributable to the older age of the subjects in the latter which included young and middle-aged adults. The prevalence of undetected hypertension in young adults found in this study is also significantly higher than that found by Akinkugbe, in a review of hypertension studies done in adult populations in urban and rural Nigeria. The relatively lower prevalence reported by Akinkugbe may, however, be due to the fact that a higher cut-off blood pressure value (160/100 mmHg) was used to define

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hypertension in this study and this study was community based unlike this study that was hospital based.

Literature search yielded an inconsistent definitive age range for young adults. However, for this study, age range 18 — 50 years was used.⁶⁴ Analysis showed a positive and significant relationship between age and blood pressure. This corroborates existing information in most literature with regards to increasing age being a predisposing factor in the development of hypertension.^11,21

A higher proportion of the subjects (62%) were females (m:f= 1:1.6). This, however, may not be unrelated to the fact that a higher proportion of hospital attendees during the period of the study were female¹². Of a total of 9725 adult hospital attendees during the study period(January – March 2011 {three months}), 3934 (40.5%) were males and 5791 (59.6%) were females.

However, sex and blood pressure did not have a significant association. This contrasts findings from literature search which indicate that sex is a risk factor in the development of hypertension in adults generally⁴ and the male sex is more prone to developing hypertension until after age 60 when the female sex becomes more prone, presumably due to the hormonal changes associated with menopause that take place during this period in the female sex and that implies that women

>65years men > 55years have an increased risk for the development of hypertension..^{4, 21}

Most of the subjects were married and hypertension was seen to occur most frequently among the married ones. However, there was no significant association between marital status and hypertension. This is not surprising as marital status was not identified in any of the literature reviewed as one of the risk factors for developing hypertension.

However some other risk factors were identified among the hypertensive subjects. These include lack of physical exercise, positive family history of hypertension, alcohol consumption,

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use of bleaching creams and positive history of stress. Others are adding more salt to food, use of oral contraceptive pills, cigarette smoking, family history of diabetes mellitus and diabetes mellitus in the respondents and the use of oral contraceptives.

Most of the subjects (77.3%) in this study were literate, having attained at least secondary school education. However, no association between educational attainment and blood pressure was found (p = 0.5). This is similar to results obtained from the study done on young adult military recruits in Singapore in which no association was found between hypertension and educational status though this cohort are more or less at all at one level.⁹

The subjects were mainly manual unskilled workers. Again, this is not surprising as most of the subjects attained only a secondary education and are mostly petty traders. There was a significant association between occupation and blood pressure, with differences in mean blood pressure increasing with rise in occupational status. The mean monthly income was N7, 852 (about $52). This amounts to less than N300 ($2) per day. It is surprising that a very large proportion of these traders had no idea of their daily or monthly earnings. Many ascribed this problem to the fact that they feed daily from their daily proceeds. The association between monthly income and blood pressure was not significant and this is in contrast to findings from studies which stated that there is a significant association between socio-economic status and the development of hypertension^6,34,35,36 since monthly income is partly an indication of socio-economic status.

This study revealed an association between age and blood pressure. It shows that those in the older age groups had higher blood pressure than those in the younger age groups and that age is a significant factor influencing blood pressure. It implies a significant difference in age between those whose blood pressure is ≥140/90mmHg and those whose blood pressure is <140/90mmHg.

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The older an individual is, the more likely that he or she will manifest higher blood pressure level.

The study population was basically a lean one with a mean BMI of 23.7kg/m². Some of the subjects were found to be overweight or obese (31.1%). The significant association between BMI and blood pressure supports findings from previous studies which showed consistent increase in frequency of hypertension with increasing BM1.^25,26 This implies that blood pressure rises with increasing body mass index (BMI), that is , subjects with higher BMI are more likely to have higher blood pressure values. Waist circumference also showed a significant correlation to blood pressure. This corroborates evidence from previous studies which showed that waist circumference alone was strongly related to Myocardiac Infarction.^28,29 Waist-to-hip ratio, however, was found not to have a significant association with blood pressure, differing from findings in a study that said WHR is a better predictor of cardiovascular risk than BM1²⁹ but supporting findings from another study which said waist circumference is a better predictor of cardiovascular disease than waist-to-hip ratio.²⁸

The prevalence of hypertension observed in this study is lower than that observed in a similar study done in a tertiary hospital in Nigeria which was carried out on middle aged adults²⁰ but significantly higher than that observed in a cross-sectional study done on young adults⁹ although in the study involving young adults cases of white-coat hypertension were ruled out.

That notwithstanding, analysis revealed that hypertension in this age group could be significant.

This calls for a re-think and re-orientation for health care workers and policy makers towards directing more attention to, and providing funds to increase awareness, detect and adequately manage hypertension, particularly in young adults as virtually all attention has been diverted to management of HIV/AIDS which is very common in this age group, thereby neglecting chronic

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diseases such as hypertension which is silently maiming and killing young adults who make up a large proportion of the work force of the nation and are the potential leaders of tomorrow.

Clinical and laboratory evidence of complications were evident in a small proportion of the subjects: the most occurring was hypertensive heart disease. There were also few cases of congestive cardiac failure, retinopathy and nephropathy. With the proportion of subjects found to be hypertensive in this study, it is obvious that hypertension in young adults may not only be significant, but there may be a significant proportion of young adults with target end-organ damage that could have been detected earlier or prevented if they had been screened during routine examination. Also the non availability of adequate facilities, high cost of treatment and dearth of manpower to manage the existing ones can also contribute to not being able to detect early these health problems.

The hypertensive subjects’ general perception of the disease reveals that a lot still needs to be done as regards patient education about hypertension. The feeling of being too young to have developed hypertension may be in keeping with the general belief and knowledge that hypertension comes with increasing age. They often wondered why they had to have hypertension when they were still young. The response “God is in Control” given by many of the respondents, highlights the frequently encountered spiritual aspect of patients’ responses to diagnosis in this environment. Often times, their response of “God is in control” or “I reject it in Jesus’ Name” or out-rightly declaring that they were not in any way worried about the disease, as observed during this study meant that they are denying the disease and may end up rejecting or not adhering to offered treatment even after being counselled. Their spiritual belief or faith may also occasionally constitute a challenge to their management as a result of the influence this has on treatment compliance.

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Considering the large percentage of the subjects that expected to be cured of the disease, it is obvious that there is a fundamental problem of knowledge about hypertension, the treatment and course among the general populace. The idea of a cure has resulted in many patients ignorantly stopping their drugs after the first prescription or weeks of use, only to return much later with complications. This calls for effective communication on the progression of hypertension at diagnosis and follow-up.

The non-adherence to treatment rate of 62.9% encountered is a strong pointer to the problem of poor or non-adherence to treatment frequently encountered in the management of patients with chronic diseases, especially asymptomatic ones like hypertension. It corroborates findings from a study that revealed that one-third to a half of the patients do not comply with treatment regimens.⁶⁵ This problem of non-adherence to treatment has been described as a significant but often unrecognized cardiovascular risk factor that is universal to all patient population. If a patient does not take medication prescribed to attenuate cardiovascular disease regularly, no potential therapeutic gain can be achieved.⁶⁶ No Significant association was found between lifestyle habit like diet, alcohol consumption, cigarette smoking and physical exercising.

This is in contrast to findings from studies done previously^{32, 47} and corroborates findings from a study done to detect hypertension in young adults.⁹The method of collection of information, especially on diet, may be contributory. This finding notwithstanding, health education on risk factors should always be provided to patients.