×÷Õߣºmoataz m. abdelª²fattah1, fayssal m. farahat1, abdulª²salam a. alª²shehri2    

¡¾ÕªÒª¡¿  objective: the purpose of this study to determine the prevalence of both preª²hypertension and hypertension and risk factors associated with newly diagnosed saudi military active duty service personnel.methods: communityª²based screening of 1283 saudi military active duty service personnel was conducted during the period september ª² december 2007 at six randomly selected out of a total of 15 military units of taif region, western of saudi arabia. screening tools included selfª²administrated questionnaire, general physical examination, anthropometric measurements and assessment of blood pressure.results: all participants were saudi males. their age ranged from 19ª²56 years old with mean ¡À sd of 37.2 ¡À 7.02. by applying the joint national committee on prevention, detection, evaluation, and treatment of high hypertension (jncª²7) criteria, 214 (17.3%) were considered preª²hypertensive. multivariate logistic regression analysis showed that obesity as measured by body mass index (or=2.71 ci: 1.39ª²5.28), positive family history (or=1.46 ci:1.03ª²2.06), ever smoking (or=1.45 ci:1.05ª²2.02), and increased waist circumference (or=1.04 ci:1.02ª²1.06) were the significant predictors of workplace newly diagnosed hypertension among military active duty personnel. conclusion: preª²hypertension is a common hidden problem and it predicts the development of frank hypertension. findings of the current study support the recommendation of lifestyle modification for preª²hypertension patients. however, further prospective studied are required to determine the role of pharmacotherapy in preª²hypertension.

¡¾¹Ø¼ü´Ê¡¿  screening, preª²hypertension, military

introduction

    hypertension, a major public health problem world wide, is associated with high morbidity and mortality rates£Û1£Ý. the majority of cases is asymptomatic and, therefore, goes unrecognized and untreated, leading to a high risk of coronary artery disease, heart failure, renal failure and cerebrovascular diseases£Û2ª²4£Ý. studies on the prevalence of hypertension in saudi arabia are variant, ranging from 10%ª²30%£Û5ª²7£Ý. this high prevalence rate in the general population is attributed to several cultural and lifestyle factors that had been dramatically changed during the past few years£Û5£¬8£Ý.

    however, military personnel are occupational group with special characteristics. being away from their families for long periods, frequent movement away from their base for military maneuvers, punctual attendance at their place of work and work overload contribute significantly to job strain and consequently stressª²related diseases£Û2£¬3£¬9£Ý. studies that have been conducted to assess the prevalence of hypertension (and other chronic diseases) and associated risk factors among this special young occupational group are very lacking worldwide£Û1£Ý.

    current blood pressure (bp) classification is based on the recent recommendations of joint national committee on prevention, detection, evaluation, and treatment of high blood pressure (jncª²7) and the 2003 european society of hypertensionª² european society of cardiology guidelines for the management of arterial hypertension£Û2,10£Ý. the jncª²7 introduced a new concept, preª²hypertension, for systolic blood pressure (sbp) levels of 120ª²139 and diastolic bp levels of 80 ª² 89 mmhg 1 2 and recommended screening programs for early detection of preª²hypertensive cases and healthª²promoting lifestyle modifications for theses individuals£Û1£Ý.

    the purpose of this study was to determine the prevalence of both preª²hypertension and hypertension and risk factors associated with newly diagnosed saudi military active duty service personnel.

    methods

    communityª²based screening of 1 283 saudi military active duty service personnel was conducted during the period from septemberª²december 2007 at six randomly selected out of a total of 15 military units at taif region, western of saudi arabia. the study was developed and implemented by members of the family and community medicine administration, taif armed forces hospitals. these hospitals are serving military personnel and their families at taif region. the study was conducted during regular working hours (between 8:00 am ª² 4:00 pm) at the clinic of each military unit.

    all military active duty service personnel (conscripts) at the selected units were invited to voluntary participate in this screening survey. a response rate of approximately 90% was obtained.

    screening tools included selfª²administered questionnaire, general physical examination, anthropometric measurements (weight, height and abdominal circumference) and assessment of blood pressure. the questionnaire was consisted of personal history (age, marital status, and educational level), history of morbidities (diabetes mellitus, hypertension), family history of chronic conditions (e.g., diabetes, hypertension, heart disease) and personal smoking history. anthropometric measurements were obtained at initial contact with each participant. a flexible, nonª²stretchable plastic measuring tape was used to determine waist circumference. measurement was made at the midª²point between the costal margin and superior iliac crest to the nearest centimeter. according to national institute of health guidelines, male wc > 102 cm is considered abnormal. height and weight were measured with healthometer scales manufactured by continental scale corporation, bridgeview, illinois, usa. the scales were calibrated daily, before the start of the working day. height was measured to the nearest 0.5 centimeter; barefoot and without any headgear. body weight was measured with a 0.1ª²kgm precision in light clothing. body mass index was calculated by dividing weight in kilograms by the square of height in meters. participants were classified according to world health organization into the following categories: underweight (< 18.5 kgm/m2); normal (18.5ª²24.9 kgm/m2); overweight (25ª²29.9 kgm/m2); obesity (¡Ý 30 kgm/m2). after each participant had seated for 5ª²10 minutes, blood pressure was measured twice to the nearest 2 mmhg with the participant setting and left arm resting on the table using a standard mercury sphygmomanometer (diplomat presameter 660ª²360 manufactured by riester gmbh, germany). the average of the two measurements was used for all analyses. diastolic blood pressure (dbp) was recorded at the 5th korotkoff sound. hypertension was defined as systolic blood pressure (sbp) ¡Ý 140 mmhg and / or dbp ¡Ý 90 mmhg. glucomtere devices were used to measure random serum blood glucose level (rbg) of each participant. individuals with selfª²reported history of diabetes, with antiª²diabetic medication and those with rbg exceeding 199 mg/dl were considered diabetic.

    in order to study risk factors associated with hypertension and preª²hypertyension, a nested caseª²control study was adopted, where those with sbp ¡Ý 140 mmhg and / or dbp ¡Ý 90 mmhg were considered as hypertensives, those with sbp of 120ª²139 and / or dbp levels of 80 ª² 89 mmhg as preª²hypetensives, while others were treated as controls.

    º£ÄÏҽѧԺѧ±¨ vol.15 no.2 feb.2009statistical analysis

    data were entered into the statistical software program, epi info version 3.3, released by centers for disease control and prevention (cdc), atlanta, georgia, in october 2004. hypertension and preª²hypertension were treated separately as dependent variables in both univariate and logistic regression analysis. age, history and duration of smoking, family history of hypertension, body mass index, waist circumference and diabetes mellitus were treated as independent categorical variables. univariate data analysis was performed and expressed as crude odds ratios (ors) and their confidence intervals (95% ci). multiple associations were evaluated in multiple logistic regression model based on the backward stepwise selection, where significant variables from the univariate analysis were included. this procedure allowed the estimation of the strength of the association between each independent variable while taking into account the potential confounding effects of the other independent variables. the covariates were removed from the model if the likelihood ratio statistic based on the maximum likelihood estimates had a probability of > 0.10. each category of the predictor variables was contrasted with the initial category (reference category). the adjusted measure of association between risk factors and hypertension was expressed as the odds ratio (or) with 95% confidence interval (95% ci). adjusted or crude ors with 95% ci that did not include 1.0 were considered significant.

    results

    all participants were saudi males. their age ranged from 19ª²56 years old with mean ¡À sd of 37.2 ¡À 7.02 years. most of them were married (87.2%) and only 6.4% of participants have university education. approximately half of the participants ever smoked (48.5%) with mean (¡Àsd) duration of smoking of 10.97 years (¡À 6.59). obesity in the current study was measured using body mass index and abdominal circumference. bmi revealed that 38% of participants were overweight, 28.8% obese and 7.5% underweight. however, 25.5% have abdominal circumference more than 102 cm (table 1).

    two hundred and seventeen active duty participants (17.53%) were newly diagnosed with high blood pressure (they neither have past history of hypertension nor take any medication for high blood pressure). among those who reported past history of hypertension (n=70), 71.4 % were controlled (either normal or preª²hypertension) compared to 28.6% with uncontrolled high blood pressure (table 2). high systolic and diastolic blood pressure was reported in 5.9% of all participants, high diastolic in 11.8% and high systolic in only 1.5%. by applying the njcª²7 criteria, 214 (17.3%) were considered preª²hypertensive (table 2).

    univariate logistic regression analysis was performed to determine risk factors among newly diagnosed hypertensive and preª²hypertensive participants (n=217 and 194; respectively). risk of hypertension was significantly higher among older participants more than 40 years old (or= 1.71; 95% ci= 1.20 ª² 2.42), positive family history participants (or= 1.46; 95% ci= 1.05 ª² 2.04), everª²smoked (or= 1.51; 95% ci= 1.10 ª² 2.07) as compared to those who never smoked, duration of smoking more than 10 years (or= 1.78; 95% ci= 1.24 ª² 2.54), bmi of 25 ª² 29.9 kg/m2 (or= 3.14; 95% ci= 2.00 ª² 4.94) and bmi ¡Ý 29.9 kg/m2 (or= 6.01; 95% ci= 3.75 ª² 9.67), abdominal circumference ¡Ý 102 cm (or= 3.87; 95% ci= 2.74 ª² 5.46) and diabetics (or= 2.80; 95% ci= 1.63 ª² 4.82) as compared to nonª²diabetics (table 3).

    on the other hand, significant higher risk of preª²hypertension was associated only with obesity as measured by bmi ¡Ý 29.9 kg/m2 (or= 1.87; 95% ci= 1.16 ª² 3.02) and abdominal circumference ¡Ý 102 cm (or= 2.48; 95% ci= 1.71 ª² 3.60) (table 3).

    multivariate logistic regression analysis showed that obesity as measured by body mass index, positive family history, ever smoking, and increased waist circumference were the significant predictors of workplace newly diagnosed hypertension among military active duty personnel (table 4).

    table1  demographic characteristics of the

    studied personnel£Ûn (%)£Ý

    variablesvalueage in years, mean (sd); range34.20(7.02);(19ª²56ys)marital status   married1080(87.20)  not married158(12.80)education  primary / intermediate670(54.10)  secondary489(39.50)  university79(6.40)smoking  active smoker424(34.20)  exª² smoker177(14.30)  never smoked637(51.50)duration of smoking, mean (sd), ys10.93(6.61)obesity  underweight (<18.5 kg/m2)93(7.51)  normal weight (18.5ª²24.9 kg/m2)317(25.61)  overweight (25ª²29.9 kg/m2)471(38.04)  obese (30ª²34.9 kg/m2)357(28.84)waist circumference  <102 cm922(74.50)  ¡Ý 102 cm316(25.50)

    table 2  prevalence of newly diagnosed and controlled hypertension in the studied participants(n %)

    blood pressure as measured during screeningnormalpreª²hypertensionhypertensionpast history of hypertension*  negative757 (64.8)194 (16.6)217 (18.6)  positive30 (42.9)20 (28.6)20 (28.6)  total787 (63.6)214 (17.3)237 (19.1)

    * past history of medical diagnosis or treatment of hypertension.

    table 3  univariate logistic regression analysis of independent variables associated with newly diagnosed

    preª²hypertension and hypertension

    blood pressure n(%)normalpreª²hypertensionhypertensionunadjusted or (95% ci)

    preª²hypertension vs

    normalunadjusted or (95% ci)

    hypertension vs

    normalage   < 40 ys600 (67.0)146(16.3)150(16.7)11  ¡Ý 40 ys157(57.7)48(17.6)67(24.6)1.26(0.85ª²1.85)1.71(1.20ª²2.42)smoking  never smoked410(67.8)100(16.5)95(15.7)11  ever smoked348(61.8)93(16.5)122(21.7)1.10(0.79ª²1.52)1.51(1.10ª²2.07)duration of smoking  never smoked410(67.8)100(16.5)95(15.7)11  <10 years155(65.4)39 (16.5)43 (18.1)1.03 (0.67 ª² 1.59)1.20 (0.78 ª² 1.83)  ¡Ý10 ys192 (58.9)55 (16.9)79 (24.2)1.17 (0.80 ª² 1.73)1.78 (1.24 ª² 2.54)family history  negative547 (67.0)130 (15.9)139 (17.0)11  positive210 (59.7)64 (18.2)78 (22.2)1.28 (0.90 ª² 1.82)1.46 (1.05 ª² 2.04)body mass index  normal237 (76.5)42 (13.5)31 (10.0)11  overweight298 (68.0)67 (15.3)73 (16.7)1.27 (0.82 ª² 1.98)3.14 (2.00 ª² 4.94)  obese140 (42.7)78 (23.8)110 (33.5)1.87 (1.16 ª² 3.02)6.01 (3.75 ª² 9.67)waist circumference  <102 cm634 (71.3)131 (14.7)124 (13.9)11  ¡Ý102 cm123 (44.1)63 (22.6)93 (33.3)2.48 (1.71 ª² 3.60)3.87 (2.74 ª² 5.46)diabetes mellitus  negative719 (66.2)178 (16.4)189 (17.4)11  positive38 (46.3)16 (19.5)28 (34.1)1.70 (0.89 ª² 3.23)2.80 (1.63 ª² 4.82)

    table 4  multivariate logistic regression analysis of predictors of hypertension among the studied participants

    independent variablesbsepª² valueadjusted or95% cifamily history0.380.180.031.461.03ª²2.06*smoking0.370.170.031.451.05ª²2.02*overweight (bmi 25ª²29.9 kg/m2)0.330.260.211.390.84ª²2.30obesity (bmi ¡Ý 29.9 kg/m2) 1.000.340.0032.711.39ª²5.28*waist circumference0.040.010.0011.041.02ª²1.06*diabetes mellitus0.560.290.0541.750.99ª²3.11

    logistic regression model includes terms of family history (positive vs. negative), smoking (ever vs. never); overweight and obesity vs. normal weight; waist circumference as a continuous variable and diabetics (high blood sugar or past history of diagnosis and /or treatment) vs. nonª²diabetics. 

    discussion

    few national data exist about the prevalence of hypertension and associated risk factors among military personnel. this study provides communityª²based data on abnormal blood pressure among active duty saudi military personnel.

    despite of the young age and potential physical activity of participants, prevalence of hypertension (23.2%) was approximately similar to that of the general population£Û5ª²7£Ý. average of ten plus years of active duty in the military does not confer any longª²term protection against overweight, obesity or the associated coª²morbidities. this may reflect the impact of work related factors to which those military personnel are exposed 4 in addition to other lifestyle determinants of the general population.

    in the current study, obesity as measured by body mass index and waist circumference was the only significant predictor of preª²hypertension and it was significantly associated with newly diagnosed hypertension. this is in accordance with many other researches which recognized obesity as a major risk factor for the development of hypertension£Û1£¬11£¬12£Ý. saudi military is experiencing a trend toward increasing overweight that mirror the pattern among the general population£Û6ª²8£Ý. rise in overweight among the military is not explained by a decrease in physical activity£Û13£Ý. overweight and obesity in the current study was 66.9% compared to similar figures reported among us military male personnel (75%£Û4£Ý; 63%£Û14£Ý). a graded increase in the odds ratio was observed with increasing severity of overweight and obesity 14 similar to the findings of the current study.

    the addition of waist circumference (wc) to body mass index (bmi) predicts a greater variance in health risk than does bmi alone£Û12£¬15£Ý. both wc and bmi were included in the same regression model. waist circumference significantly predicts hypertension when used as a continuous variable. however, whether it is continuous or dichotomized as normal (< 102 cm) or high (¡Ý 102 cm), bmi remains a significant predictor. some researchers concluded that wc, and not bmi, explains obesityª²related health risks£Û15£¬16£Ý. others reported that wc was not predictive of the metabolic syndrome or component risk factors in men£Û12£Ý, or suggested an equivalent value of both methods£Û17£Ý.

    hypertension is common in diabetics and diabetes control is associated with prevention of cardiovascular complications£Û18£¬19£Ý. framingham study reported that 21% of patients with hypertension had high blood sugar£Û20£Ý compared to 12.9% in the current study.

    prevalence of smoking in the current study was considered very high. it is reported that  48.5% were either active or exª²smokers. reports on smoking in the general population range from 10%ª²20% among saudi males£Û6£Ý. the high percentage of smoking in the current study significantly contributes to the increased prevalence of high blood pressure. however, further inª²depth studies are highly recommended to investigate factors associated with smoking at the military workplace and its relation to the work pattern.

    in the current study, positive family history, a known risk factor of hypertension, was reported in 35.9% of newly diagnosed cases compared to 23.6% among all hypertensives (including those with past history of hypertension). this supports the findings of the previous studies£Û7£Ý, in contrary to gan et al£Û21£Ý  who reported that parental history of hypertension does not show significant correlation in the regression model.

    one limitation of this study is the impact of work pattern and job strain on the development of hypertension. work pattern at the military services is unique. soldiers spent 24 hours at the military units for long periods away from their families and homes. living in the units is usually ascribed as tough and difficult. place of work and work overload contribute significantly to job strain and consequently stressª²related diseases £Û2£¬3£¬9£Ý. such risks of workplace hypertension, should be considered in future studies.

    while the prevalence of hypertension is low compared to older age groups, it remains important to detect cases early, as appropriate treatment may mitigate longª²term cardiovascular risks and reduce target organ damage£Û21£Ý. prevention and regular screening for hypertension and significant associated risk factors should be emphasized to improve readiness and reduce health care costs and disease burden among this active group£Û4£Ý.

    preª²hypertension is common£Û1£¬2£¬9£Ý and it predicts the development of frank hypertension. thus subjects with preª²hypertension should be closely followed 9. findings of the current study support the recommendation of lifestyle modification for preª²hypertensive patients £Û1£¬2£Ý. however, further prospective studies are required to determine the role of pharmacotherapy in preª²hypertension.

    concerted efforts should be implemented to prevent and treat documented risk factors (mainly obesity and smoking) rather than just their associated coª²morbidities. these efforts are mainly the responsibility of the armed forces hospitals. these hospitals have a unique opportunity to respond to the epidemic of chronic diseases£Û4£¬22£Ý, where comprehensive approach for workplace health promotion (e.g., weight management programs) can be effectively implemented£Û3£¬23£Ý.

    moreover, there is an urgent need to motivate the physicians at the primary care level to identify the problem and implement requisite remedial measures focusing on lifestyle modification practices.

¡¾²Î¿¼ÎÄÏס¿
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