EFFECT OF CALCIUM STATUS ON HYPERTENSIVE PATIENTS OF AGE GROUP 35-70YEARS.

BY: SHEHZEEN SALIM GHARE

UNDER THE SUPERVISION OF:

Mrs. ANURADHA SHEKAR

(HOD-PGSSFN, Associate Professor)

INTRODUCTION: Calcium plays an important role in the pathophysiology of essential hypertension. The calcium ion plays

a major role as an intracellular second messenger in excitation contraction coupling in cardiac and

smooth muscle cells. The free intracellular calcium concentration thus, determines the tension in vascular

smooth muscle cells thereby resulting in peripheral vascular resistance. [1] (Mohammed Abdul Hannan Hazari, Mehnaaz

Sameera Arifuddin, Syed Muzzakar and Vontela Devender Reddy “Serum calcium level in hypertension”; North American journal of medical sciences (2012); 4(11):569-72 )

Peripheral resistance is one of the determinants of arterial pressure. It is widely accepted that the increase

in peripheral resistance that characterizes the established phase of hypertension results from an increase

in active tension in the vascular smooth muscle. Calcium plays a key role in vascular smooth muscle

function. Calcium influx through receptor and voltage-operated calcium channels is thought to initiate

vascular contraction; and the fall in the intracellular free calcium concentration is thought to result in

relaxation or vasodilatation. [2] (Takale LR , More UK , Sontakke AN and Tilak MA “Serum Total and Free Calcium in Hypertension”; Indian Journal of

Basic & Applied Medical Research (June 2013); Issue-7, Vol.-2, P. 716-720 )

Consuming a calcium-deficient diet causes a concentration of calcium ions in the intercellular fluid.

This elevates both the active form of vitamin D, vitamin D3, and the parathyroid hormone resulting in

an increased calcium concentration in smooth muscle cells. According to an article published in the

Journal of the American College of Nutrition in February 2009, this shift in calcium concentration

increases vascular resistance, raising blood pressure. [3] (Kamlesh Jha and Poonam Kumari “Serum Calcium in Essential

Hypertension and its Co-relation with Severity of the Disease”; Advanced Studies in Biology (2011); Vol. 3, no. 7, 319 – 325 )

McCarron et al. (1980) hypothesized that chronic calcium depletion may lead to increased arterial

blood pressure. More than 30 published reports supporting an inverse relationship between blood

pressure status and dietary calcium have since been identified (McCarron 1992, McCarron et al.

1982). [4] (M Janet Barger, Lux and Robert Heaney “Symposium required versus optimal intake a look at calcium”; J Nutrition (1994 Aug)

This study is focused on the calcium intakes of people to see the effects on hypertension

1) To study the effect of calcium on blood pressure by evaluating serum

calcium level and total dietary calcium.

2) To assess nutritional status using anthropometric measurements.

3) To evaluate the nutrient intake of the patients by 24hr dietary recall

method.

4) To assess the sodium intake through Salt, processed foods and other

sodium rich foods.

5) To evaluate the physical activity, medical history and drug history.

OBJECTIVES:

Calcium has a positive effect in lowering blood pressure in hypertensive

patients.

HYPOTHESIS:

Research Design of the study the EFFECT OF CALCIUM STATUS ON HYPERTENSIVE PATIENTS OF AGE GROUP 35-70YEARS.80 Hypertensive patients,

35-70 years (male & female)    

40 Grade1 hypertensive patients40 normotensive

Personal informationAnthropometry measurement

Clinical dataBiochemical parameter

Medical HistoryNutritional assessment

Physical activity

      

Summary and ConclusionStatistical analyses (SPSS method) of data, Test used were T-test & Chi-square test followed by results and discussion.

        

METHODOLOGY:80 Hypertensive patients,

35-70 years (male & female)

40 normotensive

patients

40 Grade1

hypertensive patients

1. Personal information

2. Anthropometry measurement

3. Clinical data

4. Biochemical parameter

5. Medical History

6. Nutritional assessment

7. Physical activity

1) Hypertensive patients (M/F).

2) Age group of 35-70 years .

3) Hypertensive patients along with other medical complications like DM,

CVD, OBESITY etc. shall also be included in the study.

4) Hypertensive menopausal women will also be included.

INCLUSION CRITERIA:

1) Age group below 35yr and above 70yr.

2) Pregnant and breast feeding women.

EXCLUSION CRITERIA:

RESULTS AND DISCUSSION:1) ANTHROPOMETRY MEASUREMENTS

Frequency table of Anthropometry measurement of normotensive &

grade1 hypertensive group. BP Status N Mean Std.

Deviation Std. Error

Mean

Age Normal 40 45.05 11.348 1.794 Grade-1 40 55.55 10.508 1.661

Height Normal 40 160.75 10.431 1.649 Grade-1 40 164.13 9.479 1.499

Weight Normal 40 64.10 9.465 1.496 Grade-1 40 68.78 13.258 2.096

Waist Circumference

Normal 40 84.68 9.426 1.490 Grade-1 40 88.60 9.156 1.448

Hip Circumference Normal 40 95.88 10.936 1.729 Grade-1 40 100.75 10.940 1.730

WHR Normal 40 .8798 .04774 .00755 Grade-1 40 .8775 .04629 .00732

BMI Normal 40 25.0169 4.40769 .69692 Grade-1 40 25.6130 4.80972 .76048

The last column in the t-test (sig. 2 tailed) is called P-value. If P<= 0.05

then the difference between the normal and grade1 hypertensive is

significant.

Table of significance (Anthropometry measurement and blood pressure status)

  t-test for Equality of Meanst df Sig. (2-tailed)

Age   -4.294 78 .000*Height   -1.514 78 .134Weight   -1.815 78 .073Waist Circumference   -1.889 78 .063Hip Circumference   -1.993 78 .050*WHR   .214 78 .831BMI   -.578 78 .565

The difference between the age of normotensive and grade1 hypertensive is

significant as P= 0.000. It can be observed that as age advances

hypertension is more commonly seen. Thus age is positively associated

with hypertension in the present study.

The proportion of hypertension was found to increase steadily with the

increase in age. These findings are coherent with study carried in rural

Wardha. Such changes of blood pressure with age might be due to

changes in vascular system i.e. atherosclerotic changes in blood vessels. [5] (S E Mahmood, Anurag Srivastava, V P Shrotriya, Iram Shaifali and Payal Mishra “prevalence and epidemiological

correlates of hypertension among Labor population”; national journal of community medicine (2011); Volume 2, Issue1)

Canoy et al (2004), in which it was observed that waist and hip circumferences were

positively related to systolic and diastolic blood pressures in male and female

participants who were involved in a Norfolk cohort study. However, hip

circumference was not independently correlated with blood pressure. [6] (Sanya, A.O.,

Ogwumike, O.O., Ige A.P., Ayanniyi and O.A “Relationship of Waist-Hip Ratio and Body Mass Index to Blood Pressure of Individuals in Ibadan

North Local Government”; AJPARS (June 2009); Vol. 1, No. 1, pp. 7-11)

The difference between the hip circumference of normotensive and

grade1 hypertensive is significant as P=0.050. More the Hip

circumference more prone to hypertension. Thus hip circumference is

positively associated with hypertension in the present study.

Based on the WHO cut-offs sample population are classification as per their BMI values.

Frequency Percent Valid Percent

Cumulative Percent

Valid

Severe thinness (< 16.00) 1 1.3 1.3 1.3 Moderate thinness (16.00 - 16.99) 1 1.3 1.3 2.5 Mild thinness (17.00 - 18.49) 5 6.3 6.3 8.8 Normal range (18.50 - 22.99) 18 22.5 22.5 31.3 Pre-obese (23 - 24.99) 16 20.0 20.0 51.3 Obese class (25 - 27.49) 18 22.5 22.5 73.8 Obese class II (27.5 - 29.99) 10 12.5 12.5 86.3 Obese class II (30 - 32.49) 9 11.3 11.3 97.5 Obese class II (34.5 - 37.49) 1 1.3 1.3 98.8 Obese class III (>= 40.00) 1 1.3 1.3 100.0 Total 80 100.0 100.0

The International Classification of adult underweight, overweight and obesity according to BMI (WHO, 1995, WHO, 2000 and WHO 2004) [7](WHO, www.who.int, 2004 “Global Data Base on Body Composition”)

Classification BMI(kg/m2)

Principal cut-off

points Additional cut-off points

Underweight <18.50 <18.50 Severe thinness <16.00 <16.00 Moderate thinness 16.00 - 16.99 16.00 - 16.99 Mild thinness 17.00 - 18.49 17.00 - 18.49

Normal range 18.50 - 24.99 18.50 - 22.99 23.00 - 24.99

Overweight ≥25.00 ≥25.00

Pre-obese 25.00 - 29.99 25.00 - 27.49 27.50 - 29.99

Obese ≥30.00 ≥30.00

Obese class I 30.00 - 34.99 30.00 - 32.49 32.50 - 34.99

Obese class II 35.00 - 39.99 35.00 - 37.49 37.50 - 39.99

Obese class III ≥40.00 ≥40.00

2) BIOCHEMICAL PARAMETERS Frequency table of calcium and blood pressure status between the two

groups

Table of significance (calcium and blood pressure status)

BP Status N Mean Std. Deviation Std. Error Mean

Serum Ca Normal 40 9.8275 1.21212 .19165 Grade-1 40 9.2050 1.03278 .16330

Dietary Calcium

Normal 40 262.75 53.031 8.385 Grade-1 40 226.68 79.388 12.552

t-test for Equality of Means t df Sig. (2-tailed)

Serum Ca -2.472 78 .016* Dietary Calcium 2.390 68.026 .020*

The last column in the t-test (sig. 2 tailed) is called P-value. If P<= 0.05 then the difference

between the normal and grade1 hypertensive is significant.

The difference between the serum Ca of normotensive and grade1 hypertensive is significant

as P= 0.016. Therefore, in the present study serum Ca level between the two groups is

inversely associated with hypertension.

The study shows significantly reduced serum calcium level in hypertensive individuals as

compared to control group. Grade II hypertensive subjects were found to have lowest

value compared to grade I hypertensive and control group subjects. This shows a direct

inverse relationship between serum calcium level and grade of hypertension. Increase in

calcium intake produced a mild antihypertensive response, with an average decrease of 4-

7 mm Hg systolic and 2-4 mm Hg diastolic blood pressure. [8] (Michele Turcotte (Oct 21, 2013)

“LIVESTRONG.COM”)

The difference between the dietary Ca of normotensive and grade1 hypertensive is

significant as P=0.020.Therefore, Dietary calcium is inversely associated with

hypertension in the present study.

A meta-analysis of observational studies indicated a modest inverse association between

dietary calcium intake and BP. Dietary calcium has been significantly associated with

low levels of systolic BP in the general population, which may be due to higher calcium

intake being a marker of a healthy diet. [9] (Dr Manny Noakes “Summary of evidence statement on the relationships

between dietary electrolytes and cardiovascular disease”; National Heart Foundation of Australia (October 2006); Heartsite

www.heartfoundation.com.au)

The DRIs for calcium are 1000–1300 mg per day. [28] However there is no such

recommendation for calcium intake in hypertension. Where else not consuming calcium in

adequate amount (< DRI) may cause complications. [10] (L A J van Mierlo, L R Arends, M T Streppel, M P A Zeegers, F

J Kok, D E Grobbee and J M Geleijnse “Blood pressure response to calcium supplementation: a meta-analysis of randomized controlled trials”; Journal

of Human Hypertension (4 May 2006); 20, 571–580)

3) NUTRIENT INTAKE OF SAMPLE POPULATION BY 24 hours

DIETARY RECALL METHOD

Frequency table of macronutrient intake from diet between

normotensive and grade1 hypertensive patients

BP Status N Mean Std. Deviation Std. Error Mean

Oil per day Normal 40 32.45 3.686 .583 Grade-1 40 33.25 3.719 .588

Energy Normal 40 1147.85 137.040 21.668 Grade-1 40 1233.80 178.537 28.229

CHO Normal 40 155.48 25.455 4.025 Grade-1 40 167.65 32.177 5.088

Protein Normal 40 29.08 5.136 .812 Grade-1 40 30.00 7.317 1.157

Fat Normal 40 41.53 5.038 .797 Grade-1 40 41.65 5.347 .845

Table of T-significance (Diet intake and blood pressure relation)

The last column in the t-test (sig. 2 tailed) is called P-value.

If P<= 0.05 then the difference between the normal and grade1

hypertensive is significant.

  t-test for Equality of Meanst df Sig. (2-tailed)

Oil per day   -.966 78 .337Energy   -2.415 78 .018*

CHO   -1.877 78 .064Protein   -.654 69.924 .515Fat   -.108 78 .915

The difference between the energy intake of normotensive and grade1

hypertensive is significant as P=0.018. In the present study, energy

intake is positively associated with hypertension.

A reduction in daily caloric intake is associated with a significant

decrease in systolic and diastolic blood pressure levels. [11] (L. Bellows and R.

Moore “Diet and Hypertension”; Colorado State University Extension (January 08, 2014); no. 9.318)

4) CONSUMPTION OF DIETARY SODIUM INTAKE THROUGH

VARIOUS DIET SOURCES AMONG THE SAMPLE POPULATION

Frequency table of dietary sodium intake through various dietary sources

N Minimum Maximum Mean Std. Deviation

Na from Non-veg 80 .5 1.3 .931 .4019 Na from processed foods

80 21 153 59.63 60.805

Dietary Na 80 117 690 329.22 138.967 Na from Salt per day 80 2400 6000 4465.00 1044.709 Total Na 80 2603 6616 4822.41 1015.112

Frequency table of total dietary sodium intake between normotensive

and grade1 hypertensive group

Table of T-test (sodium and blood pressure status)

BP Status N Mean Std. Deviation Std. Error Mean

Total Na Normal 40 4404.33 1071.910 169.484 Grade-1 40 5240.50 761.432 120.393

t-test for Equality of Means

t df Sig. (2-tailed)

Total Na -4.022 70.371 .000* Significant difference*

In the present study, the difference between dietary sodium intake of

normotensive and grade1 hypertensive is significant as P=0.000.

Therefore, dietary sodium intake is positively associated with

hypertension.

Reducing dietary sodium by approximately 1700 mg per day can

lower systolic blood pressure by 4–5 mmHg in hypertensive

individuals and 2 mmHg in normotensive individuals. This may

reduce the need for antihypertensive drugs. [12] (Nancy Huang, Karen Duggan and

Jenni Harman “lifestyle management of hypertension”; Aust Prescr (2008); 31:150–3)

WHO recommends a reduction in sodium intake to reduce blood pressure and risk

of cardiovascular disease, stroke and coronary heart disease in adults (strong

recommendation 1).WHO recommends a reduction to <2 g/day sodium (5 g/day salt)

in adults (strong recommendation). [13] (World Health Organization, 2012 “Sodium intake for adults and children”;

www.who.int)

The DRI for sodium is 1500 mg a day, while 2500 mg has been given as the maximum

level of daily intake that is likely to pose no risk of adverse effects. Hence, the average

current sodium intake of 3000–4500 mg a day in various westernised communities

exceed clearly even the highest sodium intake level, which has been estimated to be safe. [14] (H Karppanen, P Karppanen and E Mervaala “Why and how to implement sodium, potassium, calcium, and magnesium changes in food

items and diets”; Journal of Human Hypertension (2005); 19, S10–S19)

While in the present study, the sodium intake in both the groups have crossed the

maximum level of daily intake (2500mg) and so likely to pose risk of adverse effects .

SUMMARY AND CONCLUSION: In the present study, it was found that there exists an inverse relationship between hypertension and calcium

status (serum and dietary) of both the groups (normotensive and hypertensive). Serum Ca level of majority of

the sample population were in the normal range. Only few had it in lower or higher range. Both the groups

(normotensive and grade1 hypertensive) had dietary calcium intake far less than DRI (1000-1300mg/day). It

was also found that age is positively associated with hypertension. As age advances hypertension is more

commonly seen. Hip circumference was seen to be positively associated with hypertension. More the Hip

circumference more prone to hypertension. Total dietary energy intake and total dietary sodium intake was

also found to be positively associated with hypertension. While the sodium intake in both the groups have

crossed the maximum level of daily intake (2500mg) and so likely to pose risk of adverse effects.

Where else, height, weight, BMI, WHR, WC, dietary potassium, carbohydrate, protein, fat, physical activity,

alcohol consumption, tobacco chewing and cigarette smoking were found to be insignificant and so is not

associated with hypertension in the present study.

The prevalence of hypertension has been increasing in India. There

are studies which support that calcium supplementation appears to

have a blood pressure lowering effect. Therefore from the present

study it is concluded that, calcium status does have a significant effect

in lowering hypertension in the patients of age group 35-70years.

BIBLIOGRAPHY:1) Mohammed Abdul Hannan Hazari, Mehnaaz Sameera Arifuddin, Syed Muzzakar and Vontela Devender

Reddy “Serum calcium level in hypertension”; North American journal of medical sciences (2012);

4(11):569-72

2) Takale LR , More UK , Sontakke AN and Tilak MA “Serum Total and Free Calcium in Hypertension”;

Indian Journal of Basic & Applied Medical Research (June 2013); Issue-7, Vol.-2, P. 716-720

3) Kamlesh Jha and Poonam Kumari “Serum Calcium in Essential Hypertension and its Co-relation with

Severity of the Disease”; Advanced Studies in Biology (2011); Vol. 3, no. 7, 319 – 325

4) M Janet Barger, Lux and Robert Heaney “Symposium required versus optimal intake a look at calcium”; J

Nutrition (1994 Aug)

5) S E Mahmood, Anurag Srivastava, V P Shrotriya, Iram Shaifali and Payal Mishra “prevalence and

epidemiological correlates of hypertension among Labour population”; national journal of community

medicine (2011); Volume 2, Issue1

6) Sanya, A.O., Ogwumike, O.O., Ige A.P., Ayanniyi and O.A “Relationship of Waist-Hip Ratio and Body Mass Index to

Blood Pressure of Individuals in Ibadan North Local Government”; AJPARS (June 2009); Vol. 1, No. 1, pp. 7-11

7) WHO, www.who.int, 2004 “Global Data Base on Body Composition”

8) Michele Turcotte (Oct 21, 2013) “LIVESTRONG.COM”

9) Dr Manny Noakes “Summary of evidence statement on the relationships between dietary electrolytes and

cardiovascular disease”; National Heart Foundation of Australia (October 2006); Heartsite www.heartfoundation.com.au

10) L A J van Mierlo, L R Arends, M T Streppel, M P A Zeegers, F J Kok, D E Grobbee and J M Geleijnse “Blood

pressure response to calcium supplementation: a meta-analysis of randomized controlled trials”; Journal of Human

Hypertension (4 May 2006); 20, 571–580

11) L. Bellows and R. Moore “Diet and Hypertension”; Colorado State University Extension (January 08, 2014); no.

9.318

12) Nancy Huang, Karen Duggan and Jenni Harman “lifestyle management of hypertension”; Aust Prescr (2008);

31:150–3

13) World Health Organization, 2012 “Sodium intake for adults and children”; www.who.int

14) H Karppanen, P Karppanen and E Mervaala “Why and how to implement sodium, potassium, calcium, and

magnesium changes in food items and diets”; Journal of Human Hypertension (2005); 19, S10–S19

THANK YOU!