Letter to the Editor

Anthropometric correlates of blood pressure in

normotensive Pakistani subjects
Asmatullah Khan
a,1
, Faheem U. Haq
a,1
, Mohammad B. Pervez
a,1
, Danish Saleheen
b
,
Philippe M. Frossard
b
, Mohammad Ishaq
c
, Abdul Hakeem
d
,
Hamza T. Sheikh
e
, Usman Ahmad
b,

a
Medical College, Aga Khan University, Karachi, Pakistan
b
Department of Biological and Biomedical Sciences, Aga Khan University, Stadium Road, 74800 Karachi, Pakistan
c
National Institute of Cardiovascular Diseases, Karachi, Pakistan
d
Department of Internal Medicine, University of Wisconsin Hospital and Clinics, Madison, United States
e
Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, United States
Received 28 October 2006; received in revised form 15 December 2006; accepted 30 December 2006
Available online 3 April 2007
Abstract
Obesity and hypertension are two major inter-related cardiovascular risk factors. Decrease in adiposity is one of the most effective
preventive measures not only in decreasing the overall cardiovascular risk but also the blood pressure. This cross-sectional study measured
the effect of various measures of adiposity on blood pressure in normal healthy subjects of Pakistani origin. 400 normotensive subjects
(247 males and 153 females) were included in this study. Along with data on co-morbid conditions, two blood pressure readings and several
anthropometric measurements were recorded. Age and gender specific analysis was done. Following the WHO cutoffs for Asians, about 52%
of our sample population was found to be overweight or obese. Age was not associated with blood pressure indices in males; however it was
strongly associated with all blood pressure indices in females. Greater Body Mass Index (BMI), Waist Circumference (WC) and Waist to
Height Ratio (WHTR) were associated with higher Systolic and Diastolic Blood pressure. Increasing age was also associated with higher
levels of BMI, WC and WHTR. Anthropometric variables however, were more strongly associated with blood pressure indices than age
in this sample population. In conclusion, we found WC and WHTR to be strongly associated with blood pressure indices in normotensive
Pakistani males.
2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Blood pressure; WaistHip ratio; WaistHeight ratio; BMI
1. Introduction
Obesity and hypertension have a central role in the
pandemics of cardiovascular diseases that have become the
bane of modern day health of populations. Various measures
of obesity including Body Mass Index (BMI), Waist
Circumference (WC), WaistHip ratio (WHR) and Waist
Height ratio (WHTR) have been employed to capture the
obesity related cardiovascular risk. Obesity and hypertension
are known to increase in parallel in both developed and
developing populations [1]. Decrease in adiposity is one of
the most effective preventive measures not only in
decreasing the overall cardiovascular risk but also the
blood pressure [2,3]. WHO has recommended increase in
physical activity and modification of dietary habits as
preventive measures to control the high and increasing
incidence of cardiovascular diseases in developing countries
[4]. South Asians emigrants including the Pakistanis have
high prevalence and incidence of cardiovascular diseases
International Journal of Cardiology 124 (2008) 259262
www.elsevier.com/locate/ijcard

Corresponding author. Tel.: +92 21 4864476; fax: +92 21 4932095.

E-mail addresses: usman.ahmad@aku.edu, usman.ahmad@yale.edu
(U. Ahmad).
1
Contributed equally to the study.
0167-5273/$ - see front matter 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijcard.2006.12.040
in general and metabolic syndrome in particular [5]. We
undertook this study to observe the effect of various
measures of adiposity on blood pressure in normal healthy
subjects of Pakistani origin.
2. Methods
We recruited a random sample of healthy adults of
Pakistani origin from three provincial capitals of Pakistan.
Data collection which included complete medical history and
physical examination was conducted by trained medical
personnel. All subjects were in a resting state at the time of
examination. Two blood pressure readings, ten minutes apart
were taken using standard mercury sphygmomanometers
and appropriate cuff sizes. Mean of these two readings was
used for data analysis. Height and weight were recorded
using standard hospital equipment and values were rounded
off to the nearest cm and 0.5 kg, respectively. Height was
measured without shoes. During measurement of weight
men wore minimum clothing however, this could not be
enforced in case of females due to local social limitations.
Hip circumference was measured at the level of greater
trochanters of femur and waist circumference was measured
at a point midway between the ribcage and the iliac crests.
An individual was excluded from data analysis if he/she was
a diagnosed hypertensive, or on an anti-hypertensive
treatment or had even a single blood pressure reading of
systolic (SBP) N140 mmHg / diastolic (DBP) N90 mmHg.
The diagnosis of Diabetes Mellitus (DM) and other
comorbids was based on medical history. The data were
analyzed using SPSS version 10.0 for Windows. BMI was
calculated as kg/m
2
. Quartiles of BMI, WC and WHTR were
created from the frequency tables. Males and females were
analyzed separately. Continuous variables were expressed as
mean1 SD. Linear regression was used to see the effect of
age, smoking, diabetes and the anthropometric factors on
blood pressure indices. Multivariate models were created
based on the results of univariate analysis. Statistical
significance was considered at pb0.05 for all analysis.
3. Results
A total of 400 normotensive subjects (247 males, 153
females) were included in this study. The females were
Table 1
Characteristics of the study population, n=400
Characteristic Total
n=400
Males
n=247
Females
n=153
p value
Age (years) 3614 3312 4016 b0.00
SBP (mmHg) 11314 11213 11315 0.49
DBP (mmHg) 739 749 729 0.017
PP (mmHg) 4012 3813 4211 0.009
Height (cm) 16211 1688 1527 b0.00
Weight (kg) 6212 6612 5612 b0.00
BMI (kg/m
2
) 245 234 245 0.016
Waist circumference (cm) 8414 8212 8717 0.001
Hip circumference (cm) 9313 9110 9715 b0.00
Waist to hip ratio 0.890.089 0.89 0.89 0.4
Waist to height ratio 0.520.10 0.49 0.57 b0.00
Smoking n(%) 113(28.3) 109(44) 4(3) b0.00
Diabetes Mellitus n(%) 24(6) 9(3.6) 15(9.8) 0.012
Family history of
hypertension n(%)
128(32) 83(57) 45(94) b0.00
SBP systolic blood pressure.
DBP diastolic blood pressure.
PP pulse pressure.
Table 2
Factors associated with systolic (A) and diastolic (B) blood pressure, n=400
Males n=247 Females n=153
Univariate Multivariate Univariate Multivariate
A. SBP
Age (years) 0.06(0.070.2) 0.1(0.2 to 0.03) 0.29(0.160.43)
a
0.28(0.130.43)
a
BMI (kg/m
2
) 1.01(0.621.4)
a
0.18(0.70.36) 0.49(0.070.9)
a
0.36(0.240.95)
Waist circumference (cm) 0.54(0.420.66)
a
0.58(0.190.97)
a
0.13(0.10.27)
Waist to hip ratio 32(1549)
a
7.6(2610.7) 16.3(13.846.4)
Waist to height ratio 83(63103)
a
5.8(63.875) 21.5(1.840.3)
a
6.4(34.621.9)
Smoking 0.87(2.54.2) 5.9(20.58.7)
Diabetes Mellitus 13(21 to 4)
a
7.3(15.50.8) 7.5(15.20.28)
B. DBP
Age (years) 0.05(0.050.14) 0.02(0.080.12) 0.13(0.040.22)
a
0.10(0.0060.19)
a
BMI (kg/m
2
) 0.52(0.240.8)
a
0.32(0.80.72) 0.34(0.070.61)
a
0.25(0.030.53)
Waist circumference (cm) 0.23(0.140.33)
a
0.56(0.260.85)
a
0.07(0.020.16)
Waist to hip ratio 17.4(5.429.4)
a
1.6(12.315.4) 12.5(6.831.7)
Waist to height ratio 30.9(15.7 46.1)
a
70.4(123.317.5)
a
10.9(1.523.3)
Smoking 0.09(2.22.4) 1.7(7.711.1)
Diabetes Mellitus 5.8(11.90.32) 3.0(8.01.9)
Age was included in all multivariate analysis even if it did not have significant association in the univariate analysis.
a
Indicates p valueb0.00.
260 A. Khan et al. / International Journal of Cardiology 124 (2008) 259262
relatively older (pb0.00), and had lower height (pb0.00)
and weight (pb0.00) but greater BMI (p=0.02). Table 1,
shows the relevant clinical characteristics of the study
population. Invariably the males and females represented
two characteristically different subgroups of the sample and
hence were analyzed separately. Table 2A, shows the effects
of the anthropometric variables on systolic blood pressure.
Surprisingly, age was not associated with blood pressure
indices in males; however it was strongly associated with all
blood pressure indices in females. BMI, WC, WHR, WHTR,
and DM showed strong association with SBP but in age
adjusted multivariate analysis only WC remained associated
(pb0.00). Age was the only factor significantly affecting
SBP in females. A similar trend was seen in diastolic blood
pressure (Table 2B), where multivariate analysis showed
WC (pb0.00) and WHTR (pb0.00) to be associated with
DBP in males. Univariate and multivariate analysis of DBP
showed age to be the strongest factor in females. We also
studied the effect of anthropometric measures on pulse
pressure (data not shown). In this case, multivariate analysis
showed WHTR to be strongly associated with PP in males
(pb0.00), however age was the only factor affecting PP in
females (pb0.00). Table 3 shows the distribution of age,
SBP and DBP in the quartiles of BMI, WC and WHTR in
males. It is clearly evident that greater BMI, WC or WHTR is
associated with higher SBP and DBP. Increasing age is also
associated with higher levels of BMI, WC and WHTR, but
age is a universal non-modifiable variable and hence this
effect is inevitable. Aging leads to stiffening of vessels and
hence higher blood pressure levels. We have however,
shown in both univariate and multivariate analysis in
Table 2A and B, that anthropometric variables are more
strongly associated with blood pressure indices than age in
this sample population.
4. Discussion
The adverse effects of BMI and waist circumference on
cardiovascular risk have been shown in a multitude of
longitudinal studies including the Framingham Heart study
[6]. The NIH (US) has indicated that there is a graded
increase in health risk with increasing BMI and in each BMI
category increasing WC is associated with higher risk [7].
Other measures of fat distribution including WC, WHR and
WHTR have also been shown to correlate more closely with
cardiovascular risk as compared to BMI.
South Asia is one of the high incidence areas for
cardiovascular diseases in the world [5]. It has recently
been shown that South Asian children have higher body
mass adjusted blood pressure levels than white American
Caucasian children [8]. Furthermore, WHO has also lowered
the cutoffs for overweight and obesity for the Asian
population, which again points to the fact that Asian and
especially south Asian population suffers from an overall
higher obesity related cardiovascular risk. Most studies that
report the relationship between adiposity and blood pressure
include hypertensive populations however our sample
consists of only normotensive people. We have tried to see
the relationship between adiposity and blood pressure in the
pre-hypertensive stages; the actual window where risk factor
modification could actually prevent hypertension.
Our results are in accord with the previous reports. BMI,
WC, WHR and WHTR were found to strongly influence
systolic and diastolic blood pressure indices in males. WC
Table 3
Analysis of variance; distribution of age, SBP and DBP among quartiles of BMI, WC, WHTR in male subjects
BMI (kg/m
2
) quartiles (mean, range) p value
I (18.9, 13.720.5) II (21.7, 20.622.7) III (23.9, 22.825.3) IV (28.9, 25.440.6)
Age (years) 31.914 32.312 32.39 3712 0.04
SBP (mmHg) 10712 11114 11412 11814 b0.00
DBP (mmHg) 718 7310 769 779 b0.00
WC (cm) quartiles (mean, range) p value
I (67.7, 6072) II (76.8, 7380) III (85.3, 80.590) IV (98.8, 90.6120)
Age (years) 2911 3211 3612 3812 b0.00
SBP (mmHg) 10512 10812 11712 12111 b0.00
DBP (mmHg) 708 749 7610 788 b0.00
WHTR quartiles (mean, range) p value
I (0.41, 0.350.43) II (0.46, 0.440.47) III (0.50, 0.480.53) IV (0.59, 0.540.75)
Age (years) 2911 3111 3511 3912 b0.00
SBP (mmHg) 10512 10912 11612 12012 b0.00
DBP (mmHg) 708 7510 779 769 b0.00
Quartiles were generated from frequency tables. Values were rounded off to the nearest second decimal.
SBP systolic blood pressure.
DBP diastolic blood pressure.
261 A. Khan et al. / International Journal of Cardiology 124 (2008) 259262
was the only variable that was consistently associated with
high blood pressure in males. The females in our study
sample were older and had greater BMI. We found age to be
the only factor, significantly associated with blood pressure
indices in the females.
The mean BMI in our study population is lower than that
found in the American population [9]. However, according
to the WHO cutoffs for Asians, about 52% of our sample
population was overweight or obese. The association of WC
with blood pressure in males is consistent across several
populations including American [9], Italian [10] and
Japanese [11]. We did not find any anthropometric variable
to be strongly associated with blood pressure in females.
This could be due to a more complex interaction of female
hormones with blood pressure. About 70% of our female
sample population was pre-menopausal and strong effects
of estrogen could account for our inability to detect the
effect of anthropometric factors on blood pressure. Recently
published results of the National Health Survey of Pakistan
(19901994) showed a high prevalence (25%) of over-
weight and obesity in the Pakistani population. Female
gender was independently associated with being over-
weight or obese [12]. The results also showed a higher
prevalence of coexistence of cardiovascular risk factors in
Pakistani females and increasing age and higher BMI were
among the factors that were independently associated with
the coexistence of risk factors [13]. Our results show a
similar relationship between age and blood pressure in the
females.
WHTR is a relatively new inclusion in the armamentar-
ium of anthropometric variables. It has been proposed to
augment the role of WC in risk prediction people who have
central fat distribution [14]. We found WHTR to be
associated with systolic, diastolic and pulse pressures in
males. It is interesting to note that systolic blood pressure
was most significantly affected by WC, however diastolic
was affected by both WC and WHTR, and pulse pressure
was affected by WHTR only in the multivariate analysis.
In conclusion, we found WC and WHTR to be strong
predictor of blood pressure indices in normotensive Pakistani
males. Age was found to be the strongest factor affecting
blood pressure in females. Anthropometric measurements
should be part of the national health surveys so that high risk
non-diseased population groups can be identified to target
preventive efforts.
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