Tugas 3 Baru-N

RESEARCH ARTICLE
Sedentary Behavior and Light Physical Activity

Are Associated with Brachial and Central
Blood Pressure in Hypertensive Patients
Aline M. Gerage1*, Tania R. B. Benedetti1, Breno Q. Farah2, Fábio da S. Santana2,
David Ohara3, Lars B. Andersen4,5, Raphael M. Ritti-Dias6
1 Department of Physical Education, Federal University of Santa Catarina, Florianópolis, Santa Catarina,
Brazil, 2 Superior School of Physical Education, University of Pernambuco, Recife, Pernambuco, Brazil,
3 Metabolism, Nutrition and Exercise Research Group, Londrina State University, Londrina, Paraná, Brazil,
4 Department of Exercise Sciences and Clinical Biomechanics, University of Southern Denmark,
Odense, Denmark, 5 Sogn and Fjordane University College, Sogndal, Norway, 6 Hospital Israelita
Albert Einstein, São Paulo, São Paulo, Brazil
* alinegerage@yahoo.com.br
Abstract
OPEN ACCESS
Citation: Gerage AM, Benedetti TRB, Farah BQ, Santana Background
FdS, Ohara D, Andersen LB, et al. (2015) Sedentary
Physical activity is recommended as a part of a comprehensive lifestyle approach in the
Behavior and Light Physical Activity Are Associated with
treatment of hypertension, but there is a lack of data about the relationship between
Brachial and Central Blood Pressure in Hypertensive
Patients. PLoS ONE 10(12): e0146078. differ-ent intensities of physical activity and cardiovascular parameters in hypertensive
doi:10.1371/journal.pone.0146078 patients. The purpose of this study was to investigate the association between the time
Editor: Karen M. Tordjman, Tel Aviv spent in phys-ical activities of different intensities and blood pressure levels, arterial
Sourasky Medical Center, ISRAEL stiffness and auto-nomic modulation in hypertensive patients.
Received: September 22, 2015
Accepted: December 11, 2015 Methods

Published: December 30, 2015 In this cross-sectional study, 87 hypertensive patients (57.5 ± 9.9 years of age) had their
Copyright: © 2015 Gerage et al. This is an open
physical activity assessed over a 7 day period using an accelerometer and the time
access article distributed under the terms of the spent in sedentary activities, light physical activities, moderate physical activities and
Creative Commons Attribution License, which moderate-to-vigorous physical activities was obtained. The primary outcomes were
permits unrestricted use, distribution, and
brachial and central blood pressure. Arterial stiffness parameters (augmentation index
reproduction in any medium, provided the
original author and source are credited.
and pulse wave velocity) and cardiac autonomic modulation (sympathetic and
parasympathetic modulation in the heart) were also obtained as secondary outcomes.
Data Availability Statement: All relevant data are within the
paper and its Supporting Information files.
Funding: AMG was supported by a grant (PhD scholarship) Results

from Coordenação de Aperfeiçoamento de Pessoal de Nível
Sedentary activities and light physical activities were positively and inversely associated,
Superior (CAPES) and RMRD from Conselho Nacional de
Desenvolvimento Científico e Tecnológico (CNPq) (grant

respectively, with brachial systolic (r = 0.56; P < 0.01), central systolic (r = 0.51; P < 0.05),
productivity). brachial diastolic (r = 0.45; P < 0.01) and central diastolic (r = 0.42; P < 0.05) blood pres-
Competing Interests: The authors have sures, after adjustment for sex, age, trunk fat, number of antihypertensive drugs, acceler-
declared that no competing interests exist. ometer wear time and moderate-to-vigorous physical activities. Arterial stiffness
PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 1 / 13

Sedentary Behavior, Light Physical Activity and Hypertension
parameters and cardiac autonomic modulation were not associated with the time spent
in sedentary activities and in light physical activities (P > 0.05).
Conclusion
Lower time spent in sedentary activities and higher time spent in light physical activities
are associated with lower blood pressure, without affecting arterial stiffness and cardiac
auto-nomic modulation in hypertensive patients.
Introduction
Hypertension affects 30 to 45% of adults worldwide[1], and has been associated with
stroke, ischemic heart disease and other cardiovascular diseases[2], being responsible for
approxi-mately 13% of all deaths worldwide[3].
As part of a comprehensive lifestyle modification approach, hypertensive patients are
advised to practice at least 30 min of moderate-to-vigorous physical activity (MVPA) on five
to seven days per week[1, 4, 5]. Interventional studies have shown beneficial effects of
different structured and supervised exercise interventions on cardiovascular variables[6–9].
However, the influence of the amount and intensity of unsupervised daily physical activities
on blood pressure (BP), arterial stiffness—considered as a strong predictor of increased
cardiovascular risk[10]—and in heart rate variability[11] have not been sufficiently studied.
Studies have shown controversial results on the influence of the time spent doing MVPA,
light physical activities (LPA) and sedentary activities (SED) on cardiovascular health[12–
16]. More time spent in MVPA has been associated with lower levels of BP[14] and with
some, but not all, indexes of arterial stiffness[14–16]. Additionally, studies have shown that
the time spent in LPA was associated with lower BP levels[12] and arterial stiffness[12, 16],
but these are not universal findings[13, 15]. Another study has indicated that time spent in
SED is inversely related with arterial stiffness parameters[15], while other researchers
reported no sig-nificant relationships[16]. Interestingly, the single study[14] that analyzed
hypertensive sub-jects observed that lower time spent in SED and higher time spent in LPA
are associated with lower BP and arterial stiffness indicators, suggesting that different
physical activity intensities have the potential to affect cardiovascular parameters in
hypertensive patients. However, since this study did not adjust the regressions for the amount
of time spent in MVPA, which has been shown to influence cardiovascular parameters[16],
studies using this adjustment are needed to confirm these results.
Understanding of how the time spent in physical activity of different intensities affects car-
diovascular parameters in patients with hypertension is necessary to expand public health rec-
ommendations for these patients, including suggestions related to physical activity intensity.
Thus, the purpose of this study was to investigate the association between the time spent in
physical activity of different intensities and BP levels, arterial stiffness and autonomic
modula-tion in hypertensive patients. Our hypothesis was that less time spent in SED and
more time spent in physical activities are associated with better BP, arterial stiffness and
cardiac auto-nomic modulation indicators in hypertensive patients.
Methods
Sample
Recruitment. Patients were recruited for possible enrolment into a Randomized Clinical Trial
(NCT02257268) related to a lifestyle modification program in hypertensive subjects. The

data and analyses for the current cross-sectional study were part of the baseline assessments
obtained for this Randomized Clinical Trial. The recruitment was carried out through local
media advertisements and flyers distributed in hospitals and in the surrounding area of the
University of Pernambuco, Recife, Pernambuco State (northeast of Brazil), in 2014. The
study protocol was approved by the ethics committee of the Federal University of Santa
Catarina (811.266) in compliance with the Brazilian National Research Ethics System
Guidelines. Writ-ten informed consent was obtained from each patient prior to investigation.
Screening. As inclusion criteria, participants were required to be 40+ years old, hyperten-
sive and to have been taking antihypertensive drugs for at least three months prior to the
study. Additionally, participants were required not to have diabetes, other cardiovascular
diseases or physical disabilities, and not to be involved in regular physical activity programs.
Physical activity assessment

Physical activity was assessed by a GT3X or GT3X+ accelerometer (ActiGraph, Pensacola, FL,
USA) and Actilife software (ActiGraph, Pensacola, FL, USA) was used to analyze collected data.
Each participant was instructed to use the accelerometer for seven consecutive days, removing it
only to sleep, bathe or perform activities involving water. The device was attached to an elastic
belt and fixed to the right side of the hip. Data were collected with a 30 Hz sample frequency and
were analyzed using 60 s epochs. Periods with consecutive values of zero (with a 2 min spike
tolerance) for 60 min or longer were interpreted as “accelerometer not worn” and excluded from
the analysis[17]. Physical activity data were included only if the participant had accumulated a
minimum of 10 hours/day of recording for at least four days including one weekend day. The
average time spent in each physical activity intensity was calculated using the cutoff points
proposed by Freedson et al[18], considering SED as 0–99 counts/min, LPA as 100–1951
counts/min, moderate physical activity (MPA) as 1952 counts/min and vigorous/ very vigorous
physical activity as 5725 counts/min using the vertical axis, and analyzed in min/day, adjusting
for the number of days the device was worn.
Outcome measurements
Prior to all outcome measurements, the patients were instructed to avoid physical exercise for
at least 24 hours prior to the visit, avoid smoking, alcohol and caffeine ingestion for at least
12 hours and to eat a light meal before arriving at the laboratory. In the laboratory, a rest
period of 10 min in the supine position prior to taking the measurements was instructed. All
measure-ments were taken in the supine position in a quiet environment, with monitored
temperature. The volunteers were asked to attend the laboratory twice. During the first visit
the patients were submitted to anthropometry, heart rate variability and body composition
assessments. At the end of this first visit, they received the accelerometer to use during the
following seven days. After this period, they returned with the accelerometer to the laboratory
for the second visit, at the same time of the day as the first visit and brachial and central BP
and arterial stiff-ness were evaluated, in this order.
Primary outcome measures

Blood pressure. Brachial systolic and diastolic BP were measured on the left arm using
an automatic oscillometric instrument (Omron HEM 742-E, Bannockburn, USA).
Measurements were taken on two non-consecutive days, and three measurements were
performed on each day, with a one minute interval between measurements. The mean of all
BP values measured was used for analysis. All the measurements were taken by the same
evaluator (systolic BP: ICC = 0.85 and diastolic BP: ICC = 0.92).

Central systolic and diastolic BP were obtained by the pulse wave analysis that was
recorded in the left radial artery using applanation tonometry (SphygmoCor—AtcorMedical,
Sydney, Australia) and the validated transfer function algorithm provided by the
Sphygmocor1 soft-ware. All measurements were performed by the same evaluator (systolic
BP: ICC = 0.84 and diastolic BP: ICC = 0.72), according to guidelines specified by the
Clinical Application of Arte-rial stiffness, Task Force III[19]. To enhance the accuracy of
measurements, only those values whose quality index exceeded 80% were used.
Secondary Outcome Measures

Anthropometry, demography, and use of antihypertensive drugs. Body mass was
mea-sured with participants wearing light clothes and barefoot, using an automatic scale
(Welmy, São Paulo, Brazil) accurate to the nearest 0.1 kg. Height was measured using a
stadiometer con-nected to a scale accurate to the nearest 0.5 cm. Demographic information
and a list of current antihypertensive drugs used were obtained by individual interview.
Body composition. Total body fat and trunk fat were estimated by densitometry scans
for dual-energy X-ray absorptiometry (Lunar Prodigy DXA, model NRL 41990, GE Lunar,
Madison, WI). Scans were performed with patients in the supine position along the longitudi-
nal centerline axis of the table. The software generated standard lines that separated the limbs
from the trunk and head. For the assessment, participants were instructed to remain clothed,
but were asked to remove any metallic objects. The procedure lasted five to ten minutes for
each individual and was carried out by the same technician who calibrated the device. All the
procedures were carried out following the manufacturer’s recommendations. The percentage
of fat was calculated by dividing the amount of fat by the weight of the segment analyzed
(trunk or all body).
Arterial stiffness and wave reflection parameters. The arterial stiffness and wave
reflec-tion parameters were obtained through carotid-femoral pulse wave velocity (cfPWV)
and aug-mentation index respectively. For these measurements, the applanation tonometry
(SphygmoCor—AtcorMedical, Sydney, Australia) method was used. The measurement of
these parameters was performed by the same evaluator (cfPWV: ICC = 0.91 and AI:
ICC = 0.80) according to guidelines specified by the Clinical Application of Arterial
Stiffness, Task Force III[19]. The augmentation index was expressed as a percentage of the
ratio of aug-mented pressure to pulse pressure, based on the pulse wave analysis measured in
the left radial artery. For measurement of cfPWV, the sternal notch to carotid distance was
subtracted from the total distance between carotid and femoral. Simultaneous ECG was
assessed to obtain heart rate and, according to a “foot-to-foot” method, the time difference
between the points was measured. Then, the distance between the two arteries (D) was
divided by the time difference ( t). Thus, the PWV = D/( t) (m/s).
Cardiac autonomic modulation. For cardiac autonomic modulation assessment, R-R interval
was obtained using a heart rate monitor (Polar, RS 800CX; Polar Electro Oy Inc, Kem-pele,
Finland). Participants remained in the supine position for 10 minutes, after approximately 10
minutes at rest. All analyses were performed with Kubios HRV software (Biosignal Analysis and
Medical Imaging Group, Joensuu, Finland) by a single evaluator (ICC = 0.99), following the
recommendations of the Task Force of the European Society of Cardiology and the North
American Society of Pacing and Electrophysiology[20]. The frequency-domain parameters were
analyzed using spectral analysis of heart rate variability. Stationary periods of the tacho-gram of at
least 5 min were broken down into bands of low (LF) and high (HF) frequency using the
autoregressive method with a fixed model order of 12 according to Akaike’s informa-tion criteria.
Frequencies between 0.04 and 0.4 Hz were considered physiologically significant;

the LF component was represented by oscillations between 0.04 and 0.15 Hz, and HF was
rep-resented by oscillations between 0.15 and 0.4 Hz. The power of each spectral component
was normalized by dividing the power of each spectrum band by the total variance, minus the
value of the very low frequency band (<0.04 Hz), and multiplying the result by 100[20]. To
interpret the results, the LF and HF of the heart rate variability, showed in normalized units
(n.u.), were considered, respectively, as markers of predominantly sympathetic and
parasympathetic mod-ulation of the heart[20].
Statistical analyses
The data were stored and analyzed using the Statistical Package for the Social Sciences
(SPSS Version 17.0 for Windows). Normality was checked using the Shapiro-Wilk test and
the Levene test was used to analyze the homogeneity of variances. Continuous variables
were sum-marized as mean and standard deviations or in median and inter-quartile range,
whereas cate-gorical variables were summarized as relative frequencies.
Mean values of cardiovascular risk factors were compared using the ANCOVA one-way
test with sex, age, trunk fat, number of antihypertensive drugs, MVPA and accelerometer
wear time as covariables, according to the level of physical activity, categorized by low,
st nd
moderate and high, according to tertiles, for SED (1 tertile: < 492.42; 2 tertile: 492.42–
rd st nd
570.67; 3 ter-tile: > 570.67 min/day) and LPA (1 tertile: < 297.54; 2 tertile: 297.54–
rd
356.86; 3 tertile: >356.86 min/day). Comparison among patients classified according to
st nd rd
tertiles of minutes spent in MPA (1 tertile: < 12.7; 2 tertile: 12.7–23.1; 3 tertile: > 23.1
min/day) was also tested by ANCOVA one-way, with sex, age, trunk fat, number of
antihypertensive drugs, accel-erometer wear time and LPA as covariables.
Multiple linear regression analyses were conducted to examine the relationship between SED
and LPA and cardiovascular parameters, adjusting for sex, age, trunk fat, number of anti-
hypertensive drugs used and accelerometer wear time (model 1) and also including MVPA
(model 2). The same approach was employed to analyze the relationship between MPA and
cardiovascular parameters adjusting for sex, age, trunk fat, number of antihypertensive drugs
used and accelerometer wear time with and without including LPA. A residual analysis was
performed, and adherence to the normal distribution was tested using the Shapiro-Wilk test.
Multicollinearity analysis was performed assuming variance inflation factors less than five and
tolerance below 0.20. For all the statistical analyses, significance was accepted at P < 0.05.
The required sample size (n = 51) for linear multiple regression test was calculated using
the software GPower (3.1.9), considering the brachial systolic BP as the main variable, an
alpha of 95%, a power of 80%, an effect size of 0.33 predicted by a squared correlation
coefficient of 0.25, and seven variable predictors.
Results
Eighty-seven patients (57.5 ± 9.9 years old; 79% female) participated in this study (Table
1). Minutes spent in SED, LPA, and MVPA accounted for 60 ± 9%, 37 ± 8% and 3 ± 3%
of daily physical activity, respectively.
After adjustments it was observed that the patients with higher time in SED presented
higher systolic (brachial) and diastolic (brachial and central) BP (P < 0.05), while the group
with higher time in LPA presented lower systolic (brachial and central) and diastolic
(brachial) BP (P < 0.05) (Fig 1).
There were no differences in arterial stiffness and in cardiac autonomic parameters among
patients classified according to tertiles of minutes spent in SED or LPA (P > 0.05) (Table 2).

Table 1. General characteristics, physical activity and cardiovascular risk factors information of par-
ticipants (n = 87).
Variable Mean (SD)

Age (years)* 55 (51–64)
Weight (kg)* 76.7 (68.2–87.3)
Height (cm)* 158.0 (154.0–163.0)
2
Body mass index (kg/m ) 31.1 (5.5)
Total body fat (%)* 43.8 (38.1–46.5)
Trunk fat (%)* 43.8 (39.1–47.0)
Number of antihypertensive drugs 2.0 (0.9)
bSBP (mmHg) 133.0 (16.5)
bDBP (mmHg) 80.1 (8.7)
cSBP (mmHg) 126.2 (17.2)
cDBP (mmHg) 81.5 (9.4)
Augmentation index (%) 31.6 (10.0)
††
Pulse wave velocity (m/s) 10.2 (2.2)
Low frequency (n.u.) 52.4 (20.4)
High frequency (n.u.) 47.6 (20.4)
Sedentary time (min/day) 531.8 (95.2)
Light physical activity (min/day) 329.4 (83.3)
Moderate physical activity (min/day) 24.5 ± 22.7
Vigorous physical activity (min/day) 0.2 ± 0.9
Wear time (min/day) 885.8 (88.5)
Days worn (days/week) 6.3 (0.9)
bSBP = brachial systolic blood pressure; bDBP = brachial diastolic blood pressure; cSBP = central systolic
blood pressure; cDBP = central diastolic blood pressure.
*Expressed as median (inter-quartile range).
† n = 55.
doi:10.1371/journal.pone.0146078.t001
Regarding the comparison among patients classified according tertiles of minutes spent
in MPA, significant differences were observed only for LFnu and HFnu (F = 4.59; P =
0.01). Those classified in the first tertile (< 12.7 min/day of MPA) had LF and HF higher
rd
and lower ( = 7.5 (n.u.)), respectively, than those in the 3 tertile (> 23.1 min/day of MPA).
Consider-ing MVPA, the results of this analysis were similar.
Table 3 shows the association between LPA and BP, arterial stiffness and cardiac
autonomic modulation.
Inverse relationships were observed between LPA and BP (brachial and central systolic
and diastolic) (P < 0.05) after adjustment for sex, age, trunk fat, number of antihypertensive
drugs and accelerometer wear time (model 1). When MVPA was included in the adjusted
analysis (model 2) the relationships between LPA and all the BP measurements remained
significant (P < 0.05) (Fig 2). Arterial stiffness parameters and cardiac autonomic
modulation were not related to LPA in both models of adjusted analysis (P > 0.05).
Inversely to results seen with LPA, time spent in SED was positively associated with
brachial and central systolic and diastolic BP both in model 1 (ß = 0.44 to 0.29; P < 0.05) and
model 2 (ß = 0.68 to 0.31; P < 0.05). There were no relationships between SED and arterial
stiffness and cardiac autonomic modulation (P > 0.05).
Time spent in MPA was not associated with BP (bSBP: ß = 0.07 and P = 0.43; bDBP: ß =
-0.02 and P = 0.67; cSBP: ß = -0.01 and P = 0.88; cDBP: ß = -0.05 and P = 0.36), arterial stiffness

Fig 1. Comparison of blood pressure among tertiles of minutes spent in sedentary activities and in light physical activities. bSBP = brachial systolic
blood pressure; bDBP = brachial diastolic blood pressure; cSBP = central systolic blood pressure; cDBP = central diastolic blood pressure. For
sedentary activities, low is < 492.42; mean is 492.42–570.67; and high is > 570.67 min/day. For light physical activities, low is < 297.54; mean is
297.54–356.86; and high is >356.86 min/day. Note: All analyses were adjusted for sex, age, trunk fat, number of antihypertensive drugs, accelerometer
wear time and moderate-to-vigorous physical activities.
doi:10.1371/journal.pone.0146078.g001
(AI: ß = -0.06 and P = 0.30; PWV: ß = -0.003 and P = 0.79) or cardiac autonomic modulation
(LF: ß = -0.20 and P = 0.06; HF: ß = 0.20 and P = 0.06) after adjustment for confounders.
No significant association was observed between SED, LPA or MPA and the number of
anti-hypertensive drugs used (P > 0.05), before or after adjustment for confounders.
Discussion
The main findings of the present study were: (i) SED and LPA were related to both brachial
and central BPs in hypertensive patients; (ii) arterial stiffness and cardiac autonomic
Table 2. Comparison of arterial stiffness and cardiac autonomic modulation among tertiles of minutes spent in sedentary activities and light phys-ical
activities.
Minutes per day in sedentary activities Minutes per day in light physical activities
Low(< 492.42) Mean(492.42–570.67) High(> 570.67) Low(< 297.54) Mean(297.54–356.86) High(>356.86)

AI (%) 32.8 ± 11.5 29.8 ± 10.2 32.3 ± 8.0 30.2 ± 10.3 32.4 ± 11.4 32.3 ± 8.2
††
PWV (m/s) 10.1 ± 1.5 9.9 ± 2.1 10.5 ± 2.8 10.6 ± 3.1 10.2 ± 1.9 9.9 ± 1.6
LF (n.u) 47.9 ± 20.9 53.8 ± 20.3 54.2 ± 20.5 54.1 ± 22.0 51.9 ± 19.3 51.3 ± 20.4
HF (n.u.) 48.0 ± 20.1 54.9 ± 21.3 54.2 ± 19.8 45.9 ± 22.0 48.2 ± 19.3 48.7 ± 20.4
st nd rd
Low = 1 tertile; Mean = 2 tertile; high = 3 tertile; AI = augmentation index; PWV = pulse wave velocity; LF = low-frequency; HF = high frequency.
† n = 55.

Table 3. Relationship between light physical activities and blood pressure, arterial stiffness and car-diac
autonomic modulation parameters in hypertensive patients.
Model 1* Model 2**
ß (95% CI) P ß (95% CI) P

bSBP (mmHg) -0.059 (-0.102; -0.015) 0.009 -0.068 (-0.113; -0.023) 0.003
bDBP (mmHg) -0.035 (-0.059; -0.010) 0.006 -0.036 (-0.061; -0.010) 0.007
cSBP (mmHg) -0.051 (-0.098; -0.004) 0.032 -0.054 (-0.103; -0.006) 0.029
cDBP (mmHg) -0.032 (-0.059; -0.005) 0.022 -0.031 (-0.059; -0.002) 0.033
AI (%) 0.001 (-0.028; 0.030) 0.941 0.005 (-0.025; 0.035) 0.730
††
PWV (m/s) -0.002 (-0.009; 0.004) 0.461 -0.002 (-0.009; 0.005) 0.497
LF (n.u.) -0.049 (-0.104; 0.006) 0.080 -0.038 (-0.094; 0.018) 0.177
HF (n.u.) 0.049 (-0.006; 0.104) 0.080 0.038 (-0.018; 0.094) 0.177
ß (95% CI) = Regression coefficient (95% confidence interval); bSBP = brachial systolic blood pressure; bDBP
= brachial diastolic blood pressure; cSBP = central systolic blood pressure; cDBP = central diastolic
blood pressure; PWV = pulse wave velocity; LF = low frequency; HF = high frequency.
†
n = 55.
*Adjusted for sex, age, trunk fat, number of antihypertensive drugs and accelerometer wear time.
**Adjusted for sex, age, trunk fat, number of antihypertensive drugs, accelerometer wear time
and moderate-to-vigorous physical activities.
modulation parameters were not associated with the time spent in SED and LPA. The BP
results concurred with our hypothesis, while the findings regarding arterial stiffness and
car-diac autonomic modulation parameters did not.
The strengths of the study include the use of scientifically recognized techniques to assess
physical activity, brachial and central BPs. Brachial BP was measured twice in non-consecutive
days and only hypertensive patients were included in the study, contributing to a better com-
prehension about the influence of different physical activity intensities on hypertension. In
addition the inclusion of the trunk fat as a confounder factor should be highlighted, since it was
assessed by one of the best techniques to evaluate body composition[21], and because obe-sity
has been considered the major risk factor for the development of hypertension. Increased
adiposity, especially visceral fat, activates the renin-angiotensin-aldosterone system and the
sympathetic nervous system in addition to a physical compression of the kidneys, leading to
altered intrarenal hemodynamics and impaired sodium excretion, which contribute to increased
BP and to a higher difficulty for BP control[22].
The relationship between the time spent in SED and BP observed in this study is in agree-ment
with a previous study of hypertensive patients[14]. Additionally, the literature has shown a
positive relationship between SED and clustered metabolic syndrome risk score[13] and mor-
tality[23]. Interestingly, in our study the relationships remained significant after adjustments for
trunk fat and MVPA, which could confound this relationship. The mechanisms underlying the
relationship between SED and BP are not well understood, however it has been shown that
decreases in skeletal muscle contraction due to prolonged time spent in SED suppress the lipo-
protein lipase action, increasing free radical production and inflammation and consequently
increasing BP[24]. Nevertheless, future studies are required for a better understanding of the
biological link between the time spent in SED and BP.
Associations between higher time spent in LPA and improvements in several cardiovascular
risk factors such as triglycerides[25], HDL cholesterol[13, 26], and waist circumference[13, 26]
have been previously reported in healthy patients[25] and in subjects with metabolic syndrome

Fig 2. Relationship between light physical activity and brachial and central blood pressure.
bSBP = brachial systolic blood pressure; bDBP = brachial diastolic blood pressure; cSBP = central
systolic blood pressure; cDBP = central diastolic blood pressure; LPA = light physical activities. Note:
All analyses were adjusted for sex, age, trunk fat, number of antihypertensive drugs, accelerometer
wear time and moderate-to-vigorous physical activities.
doi:10.1371/journal.pone.0146078.g002
[13, 26]. This study showed that higher time spent in LPA is also associated with lower BP lev-els
in hypertensive patients, which is in agreement with previous studies involving healthy adults[12]
and patients with hypertension[14], although some researchers did not find the same results[13].
In practical terms, the results of linear regression indicated that each 100 minutes per day
engaging in LPA is associated with a decrease of 6.8 and 3.6 mmHg in brachial systolic and
diastolic BPs, respectively. As a 2 mmHg reduction of systolic BP results in a 6% decrease in
stroke mortality and a 4% decrease in mortality attributable to coronary heart dis-ease[27], these
findings potentially impact the morbidity of hypertensive patients.
Interestingly, LPA was also inversely associated with central BP, indicating that LPA
influ-ences both peripheral and central arteries. Hypertensive patients present increased BP
in both central and peripheral arteries, however antihypertensive treatment strategies have
shown dif-ferent effects on brachial and central BP, most of them acting mainly in peripheral
arteries[28, 29]. As central BP has been considered a strong predictor of cardiovascular
events and target organ damage[30], the beneficial association observed between LPA and a
reduction in central BP indicates a possible effect of physical activity, even in low intensity,
in reducing cardiovas-cular risk in hypertensive patients. The mechanisms linking LPA and
decreases in central BP are not clear. However, considering that central BP has been related
with peripheral vascula-ture[31], we speculate that there is a peripheral effect of LPA[32],
which should be further investigated.
The time spent in MPA was not associated with BP. Although these results are in disagree-
ment with previous studies[14, 33] which showed inverse relationships between MVPA and BP
levels, it is important to highlight that our patients performed less than 1 min/day of vigor-ous
physical activity. As the time spent in moderate and vigorous physical activities has not been
described, it is possible that in previous studies subjects spent more time engaging in

vigorous activity, which could explain the observed associations. In fact, there is
evidence[34] that daily physical activity duration, rather than intensity, is associated with
cardiovascular risk factors in older adults not engaged in exercise programs. Therefore, the
lack of association between MPA and BP may also be related to the short time (low volume)
spent doing this type of activity by patients in this study.
In addition neither SED, LPA nor MPA were associated to arterial stiffness parameters and
cardiac autonomic modulation, which does not concur with previous studies[12, 14, 35]. As the
present study included only subjects not engaged in regular exercise programs and taking
antihypertensive medication, the controversy between studies may be caused by the different
types of physical activity practiced and drugs used. Our results suggest that time spent in SED,
daily low intensity physical activities and unstructured MPA (or MVPA) are not sufficient to
promote benefits in these cardiovascular components. In fact, improvements in arterial stiff-
ness[7, 36] and in heart rate variability[37] have been observed after regular high or moderate
intensity exercise training programs. Thus, a regular training program with adequate exercise
intensity may be necessary to improve arterial stiffness and heart rate variability, instead of
sporadic daily physical activities. Additionally, the influence of medication use on these results
cannot be ignored, considering that other studies[12, 14] included non-medicated subjects.
The positive and inverse relationship between SED and LPA, respectively, and brachial
and central BP show the importance of LPA in hypertensive patients. Thus, physical activity
pre-scription should consider the recommendation of LPA for BP control, especially because
it is easier to include in daily activities[24]. Therefore, we suggest that the physical activity
recom-mendations for hypertensive patients should emphasize the importance of replacing
SED with LPA. Simple changes in daily routine, such as using the stairs instead of the
elevator, walking instead of using the car for short distances, reducing screen time, and
breaking long periods of sitting time with movement could provide benefit to these patients.
The cross-sectional design is the major limitation of this study. Interventional studies are
required to confirm these findings and to make inferences about causality. Additionally, we
suggest for future studies the rigorous control of antihypertensive drugs. The patients were
using different antihypertensive drugs. Although the lack of association between SED, LPA
or MPA and the number of antihypertensive drugs used may be related to other factors
related to cardiovascular control (i.e. genetic, hormones, eating habits, other pathologies),
specific influ-ence of the type and dose can have occurred, which was not controlled in the
study. The small sample size and the impossibility to access cfPWV of all participants due to
technical difficul-ties, should also be considered as limitations of this study, and could
partially help to explain why the expected association between SED and LPA and arterial
stiffness and cardiac auto-nomic modulation was not seen. Finally, as the subjects of this
study were not engaged in regu-lar exercise programs, the results could not be extrapolated
for patients who are engaged in such programs.
In conclusion, this study indicated that lower time spent in SED and higher time spent in
LPA are associated with lower brachial and central BP, without affecting arterial stiffness
and autonomic modulation in hypertensive patients.
Supporting Information
S1 Fig. Comparison of blood pressure among to tertiles of minutes spent in sedentary
activ-ities and in light physical activities. SED = sedentary activities; LPA = light physical
activities; bSBP = brachial systolic blood pressure; bDBP = brachial diastolic blood pressure;
cSBP = central systolic blood pressure; cDBP = central diastolic blood pressure.
(XLS)

S2 Fig. Relationship between light physical activity and brachial and central blood pressure.
LPA = light physical activities; bSBP = brachial systolic blood pressure; bDBP = brachial dia-
stolic blood pressure; cSBP = central systolic blood pressure; cDBP = central diastolic blood
pressure.
(XLS)
Author Contributions
Conceived and designed the experiments: AMG TRBB LBA RMRD. Performed the experi-
ments: AMG BQF FSS DO. Analyzed the data: AMG TRBB BQF FSS DO LBA RMRD. Con-
tributed reagents/materials/analysis tools: BQF DO RMRD. Wrote the paper: AMG
TRBB BQF FSS DO LBA RMRD. Approved the final version of the manuscript: AMG
TRBB BQF FSS DO LBA RMRD.
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Jurnal Gizi Indonesia (The Indonesian Journal of Nutrition)
Rohmah Syahitd h, Choirun Nissa Vol. 7, No. 1, Desember 2018 (54-62)

Jurnal Gizi Indonesia Submitted : 11 Juli 2018, Accepted : 27 Desember 2018
Tersedia Online di https://ejournal.undip.ac.id/index.php/jgi/
Aktivitas fisik, stress, dan asupan makanan terhadap tekanan darah pada
wanita prediabetes
Rohmah Syahitdah, Choirun Nissa*
ABSTRACT
Backgrounds: Prediabetes and hypertension was being a health issue in the world. Prediabetes and hypertension that occur
together will increase the risk of developing Type 2 Diabetes Mellitus (T2DM) and cardiovascular disease. Risk factor of
prediabetes and hypertension who can changed is phyisical activity, stress, and nutrition intake.
Objectives: This study aims to determine the association between physical activity and stress with blood pressure in
prediabetes woman.
Methods: The study was done at Semarang in April-June 2016. The cross-sectional study design with the 28 subjects
predibetes woman aged 35-50 years selected by consecutive-sampling method. The data taken were blood presure, fat, fiber,
sodium, pottasium, calsium, magneisum intake, physical activity score, and stress score. Spearman test were used to determine
the association between physical activity and stress with blood pressure. Linear regression were used to multivariate analysis
Results: Seventy five percent of subjects was hypertensive with mean of blood pressure was 89,25 ± 14,64 mmHg. The result
showed that most subject (64,3%) were minimally active with mean 2.258,4±1.228,8 MET-minutes/week. Majority, subjects
were moderate stress (56,3%). There were an association between physical activity with diastolic pressure, but not in systolic
pressure. There were no association between stress with blood pressure.
Conclusion: Physical activity was only associated with diastolic pressure and stress was not associated with blood pressure.
Keywords: physical activity, stress, prediabetes
ABSTRAK
Latar Belakang:.Prediabetes dan hipertensi merupakan isu kesehatan yang menjadi perhatian dunia. Seseorang yang
mengalami prediabetes dan hipertensi secara bersamaan berisiko lebih tinggi untuk berkembang menjadi Diabetes Mellitus
Tipe 2 (DMT2) dan penyakit kardiovaskuler. Salah satu faktor risiko prediabetes dan hipertensi yang dapat diubah adalah
aktivitas fisik, tingkat stress, dan asupan.
Tujuan: Penelitian ini bertujuan untuk mengetahui hubungan antara aktivitas fisik dan stress dengan tekanan darah wanita
prediabetes usia 35-50 tahun di Semarang.
Metode: Penelitian dilaksanakan di Semarang pada bulan April-Juni 2016. Desain penelitian ini adalah cross-sectional
dengan subjek 28 wanita prediabetes usia 35-50 tahun yang dipilih dengan metode consecutive sampling. Data yang diambil
adalah tekanan darah, skor aktivitas fisik, skor tingkat stress, asupan lemak, serat, sodium, kalium, kalsium, dan magnesium.
Analisis bivariat menggunakan Rank Spearman. Analisis multivariate menggunakan uji regresi linier.
Hasil Penelitian: Mayoritas subjek mengalami hipertensi (75%) dengan rerata tekanan darah 89,25 ± 14,64 mmHg. Sebagian
besar (64,3%) subjek dikategorikan aktif minimal dengan rerata aktivitas fisik 2.258,4±1.228,8 MET-menit/minggu. Tingkat
stress subjek mayoritas adalah sedang (53,6%) dengan skor antara 4-31. Terdapat hubungan yang bermakna antara aktivitas
fisik dengan tekanan darah diastolik, tetapi tidak dengan sistolik. Tidak terdapat hubungan antara stress dengan tekanan
darah.
Simpulan: Aktivitas fisik mempunyai hubungan dengan tekanan diastolik saja dan stress tidak memiliki hubungan dengan
tekanan darah.
Kata kunci: aktivitas fisik, stress, prediabetes, tekanan darah
PENDAHULUAN GDP: 100-125 mg/dL) dan toleransi glukosa terganggu

(TGT dimana GDPP: 140-199 mg/dL).1-5
Prediabetes dan hipertensi merupakan salah satu Penderita prediabetes lebih berisiko berkembang
masalah yang menjadi perhatian dunia. Prediabetes menjadi Diabetes Mellitus Tipe 2 (DMT2).
merupakan fase fisiologis dimana kadar glukosa darah Progresivitas prediabetes menjadi DMT2 sebesar 6-
lebih tinggi diatas normal tetapi belum sampai pada 10% per tahun. Hipertensi juga disebut-sebut menjadi
kriteria diabe tes. Seseorang dikatakan prediabetes salah satu faktor risiko terjadinya DMT2. Penderita
apabila mengalami salah satu atau kedua kondisi prediabetes yang disertai hipertensi lebih berisiko untuk
berikut: glukosa darah puasa terganggu (GDPT dimana berkembang menjadi DMT2 dibanding dengan
Departemen Ilmu Gizi, Fakultas Kedokteran, Universitas Diponegoro. Jl. Prof. Sudarto SH, Tembalang, Semarang, Jawa Tengah 50275, Indonesia
2Korespondensi: E-mail: nissaeyong@gmail.com
54 Copyright © 2018; Jurnal Gizi Indonesia (The Indonesian Journal of Nutrition), 7 (1), 2018
e-ISSN : 2338-3119, p-ISSN: 1858-4942
Aktivitas fisik, stress, dan asupan makanan…
prediabetes tanpa hipertensi. Di Indonesia, hipertensi dengan hipertensi dibanding terjadi secara tunggal. Hal
sangat berpengaruh terhadap prediabetes dengan RR tersebut kemungkinan disebabkan karena faktor risiko
56,5% yang mengindikasikan bahwa apabila hipertensi penyakit hampir sama, seperti misalnya kurangnya
tidak terjadi maka prevalensi prediabetes dapat aktivitas fisik, obesitas, konsumsi alkohol, merokok,
menurun sebesar 56,5%. Oleh karena itu, pengelolaan dll.13
hipertensi di Indonesia menjadi salah satu aspek penting Banyak faktor yang menyebabkan terjadinya
dalam pencegahan DMT2.2 hipertensi pada prediabetes, antara lain adalah
Prevalensi prediabetes semakin meningkat dari meningkatnya usia, adanya riwayat keluarga yang
tahun ke tahun. Di Indonesia, prevalensi prediabetes mengalami diabetes, obesitas terutama obesitas sentral,
meningkat dari 10,2% di tahun 2007 menjadi 29,9% di inflamasi dan stress oksidatif, resistensi insulin,
tahun 2010. Prevalensi pada perempuan lebih besar kurangnya aktivitas fisik, stress, asupan makan yang
dibanding pada laki-laki. Prevalensi prediabetes pada tidak baik (tinggi asupan sodium dan lemak, rendah
perempuan di tahun 2010 adalah 32,7%, sedangkan asupan kalsium, serat, kalium, dan magnesium),
prevalensi prediabetes pada laki-laki adalah sebesar merokok, konsumsi alkohol, dan hiperlipidemia. 3, 14-18
25%. Diantara faktor tersebut, faktor yang dapat diubah
Prediabetes juga lebih banyak terjadi pada penderita adalah kurangnya aktivitas fisik, stress, dan asupan
hipertensi dibanding pada non-hipertensi. Terdapat makan.
hubungan yang erat antara gula darah dengan tekanan Kurangnya aktivitas fisik menyebabkan
darah. Seseorang dengan gula darah yang tinggi penurunan efektivitas insulin dan buruknya penggunaan
lebih berisiko untuk mengalami hipertensi glukosa dan lemak di dalam sel. 3 Banyak penelitian
dibandingkan dengan seseorang yang memiliki gula yang telah menunjukkan bahwa aktivitas fisik yang
darah normal. Hiperinsulinemia mungkin menjadi salah rendah berhubungan dengan hipertensi dan prediabetes,
satu faktor langsung yang menyebabkan naiknya tetapi penelitian di Indonesia menunjukkan hal yang
tekanan darah. Hiperinsulinemia meningkatkan retensi sebaliknya dimana aktivitas fisik tidak berhubungan
sodium di ginjal dan meningkatkan aktivitas sistem dengan prediabetes sehingga bukan merupakan faktor
saraf simpatetik (SNS-sympathetic nervous system), risiko terjadinya prediabetes.2 Selain itu, pada era
dimana aktivitas SNS yang berlebih akan modern dimana kehidupan dipermudah dengan adanya
mengakibatkan resistensi insulin yang memicu teknologi dan sarana transportasi membuat seseorang
terjadinya hipertensi. Resistensi insulin juga lebih cenderung untuk memiliki aktivitas yang rendah.
berpengaruh terhadap menurunnya repson vasodilator Selain aktivitas fisik, faktor lain yang dapat
dan meningkatnya vasokonstriktor pada jaringan diubah adalah stress. Stress terjadi apabila tubuh
perifer, sehingga mengakibatkan meningkatnya tekanan mendapat tekanan baik dari luar maupun dari dalam diri
darah sistolik.6 Prevalensi prediabetes pada penderita sendiri yang berpengaruh terhadap kondisi fisiologis.
hipertensi lebih besar (15,1%) dibanding pada non- Stress yang terjadi secara terus menerus menyebabkan
hipertensi (8,4%).7, 8 stimulasi sistem SNS yang akan meningkatkan denyut
Hipertensi merupakan suatu keadaan dimana nadi dan output jantung, serta aktifnya sistem renin-
tekanan darah lebih dari normal dalam jangka waktu angiotensin-aldosteron (RAAS). Meningkatnya SNS
yang lama. Berdasarkan The Seventh Report of the juga berperan dalan perkembangan gangguan glukosa
Joint National Committee on Prevention, Detection, dan metabolisme lemak.17
Evaluation, and Treatment of High Blood Pressure Penelitian ini bertujuan untuk mengetahui
(JNC 7) seseorang dikatakan mengalami hipertensi hubungan antara aktivitas fisik dan stress dengan
apabila tekanan darahnya diatas 140/90 mmHg. Namun, tekanan darah wanita prediabetes setelah dikontrol
tidak harus tekanan darah sistolik dan diastolik diatas asupan lemak, serat, sodium, kalium, kalsium, dan
normal untuk dapat dikatakan hipertensi, cukup salah magnesium. Pada penelitian ini subjek yang digunakan
satu memenuhi kriteria hipertensi maka ia sudah adalah wanita prediabetes usia 35-50 tahun. Subjek
dikatakan menderita hipertensi. Sebagai contoh, dipilih wanita karena wanita diabetes lebih berisiko
seseorang yang mempunyai tekanan darah 140/80 mengalami hipertensi.19 Wanita dipilih usia 35-50 tahun
mmHg sudah dikatakan mengalami hipertensi walaupun karena berdasarkan data riskesdas tahun 2007 dan 2010,
tekanan darah diastoliknya normal.9 prevalensi prediabetes lebih tinggi pada wanita dengan
Belum ada kriteria khusus mengenai hipertensi usia tersebut dibandingkan pada usia dibawahnya. 7,8
pada penderita diabetes. Namun, karena pada penderita Selain itu, penelitian menyebutkan bahwa perempuan
diabetes terjadi peningkatan risiko penyakit lebih rentan terkena stress dibanding laki-laki. 20
kardiovaskuler maka para ilmuwan menyatakan bahwa Pemilihan subjek prediabetes ini bertujuan untuk
penderita diabetes yang memiliki tekanan darah memperlambat progresivitas terjadinya DMT2 di
≥130/80 mmHg sudah dikatakan hipertensi. 10-12 kemudian hari.
Prediabetes lebih sering ditemukan terjadi bersamaan
Copyright © 2018; Jurnal Gizi Indonesia (The Indonesian Journal of Nutrition), 7 (1), 2018 55
e-ISSN : 2338-3119, p-ISSN: 1858-4942
Rohmah Syahitdah, Choirun Nissa
BAHAN DAN METODE Variabel perancu adalah asupan lemak, sodium,

kalsium, kalium, magnesium, dan serat. Data asupan
Penelitian ini dilaksanakan di wilayah kerja diperoleh melalui wawancara dengan metode Recall 24-
Puskesmas Kedungmundu dan perkantoran di jam selama 3 hari tidak berturut-turut dalam bentuk
Semarang pada bulan April – Juni 2016. Penelitian ini Ukuran Rumah Tangga (URT), kemudian dikonversi
termasuk dalam ruang lingkup keilmuan gizi kedalam gram dan dihitung nilai gizinya menggunakan
masyarakat dengan desain cross sectional. Populasi program komputer.
terjangkau yang digunakan adalah wanita prediabetes Data yang diperoleh kemudian diolah dan
usia 35-50 tahun di wilayah kerja puskesmas dianalisis secara statistik menggunakan program
Kedungmundu dan perkantoran di komputer. Data-data tersebut diuji normalitasnya
Semarang.menggunakan simpang baku rerata 6,09 dan menggunakan uji Shapiro-wilk karena jumlah sampel
tingkat ketepatan absolut (d) 2,5 dan tingkat <50. Analisis univariat digunakan untuk mengetahui
kepercayaan 95% diperoleh jumlah sampel minimal 23 karakteristik subjek penelitian dan mendeskripsikan
orang.21 Hasil perhitungan tersebut ditambah 10% setiap variabel yang diteliti. Data yang bersifat
untuk mengantisipasi adanya drop-out sehingga jumlah kategorik disajikan dalam bentuk persentase, sedangkan
sampel minimal yang dibutuhkan adalah 26 orang. Cara data yang bersifat numerik disajikan dalam bentuk
pengambilan sampel adalah dengan consecutive rerata (mean), standar deviasi, nilai minimum dan nilai
sampling dimana subjek yang ditemui dan memenuhi maksimum dari setiap variabel.
kriteria dimasukkan sampel jumlah subjek terpenuhi. Analisis bivariat dilakukan untuk melihat
Subjek diperoleh melalui dua tahap skrining. hubungan antara variabel bebas dengan variabel terikat.
Tahap pertama melalui kriteria Indeks Massa Tubuh Uji statistik yang digunakan adalah uji korelasi uji
(IMT) ≥ 23 kg/m2, wanita usia 35-50 tahun, lingkar korelasi rank Spearman karena data variabel terikat
pinggang > 80 cm, tidak mengonsumsi alkohol, tidak berdistribusi tidak normal. Pada penelitian ini analisi
merokok, tidak mengonsumsi obat antihiperglikemi dan multivariat tidak dilakukan karena variabel perancu
antihipertensi, tidak sedang hamil atau menyusui. tidak signifikan secara statistik.
Skrining tahap dua adalah memiliki Gula Darah Puasa
(GDP) antara 100-125 mg/dl yang diukur dengan HASIL
metode enzimatis Glucose Oxidase Phenol 4-
Aminophenazone (GODPAP) yang diukur oleh analis Karakteristik Subjek
laboratorium Sarana Medika Semarang. bersedia Subjek yang memenuhi kriteria inklusi pada
menaati prosedur penelitian, dan menandatangani penelitian ini berjumlah 28 orang yang didapatkan melalui
informed consent (IC). Berdasarkan 2 tahap skrining skrining di Sendangmulyo dan Tandang (Kecamatan
tersebut didapatkan 31 subjek. Sebanyak 3 orang drop- Tembalang) serta kantor pemerintah Kota Semarang di
out karena data tidak lengkap sehingga sampel yang Gedung Pandanaran. Usia subjek berkisar antara 35-50
digunakan adalah 28 orang. tahun dengan usia termuda adalah 35 tahun dan usia
Variabel bebas dalam penelitian ini adalah paling tua adalah 49 tahun. Rata-rata usia subjek adalah
aktivitas fisik dan stress. Data aktivitas fisik diperoleh 43,50±3,94 tahun. Rerata gula darah puasa sampel adalah
melalui wawancara menggunakan International 110,61±11,18 mg/dl. Dari 28 subjek, 21 diantaranya
Physical Activity Questionnaire (IPAQ), kemudian masuk dalam kategori hipertensi. Karakteristik subjek
dihitung nilai MET-menit/minggu. Aktivitas fisik penelitian terdapat pada Tabel 1.
dikategorikan tidak aktif apabila <600 MET- Tabel 1 menunjukkan bahwa berdasarkan uji
menit/minggu, aktif minimal apabila antara 600-3000 normalitas menggunakan Saphiro-Wilk variabel tekanan
MET, dan sangat aktif apabila >3000 MET- aktivitas fisik dan stress berdistribusi normal (p>0,05)
menit/minggu. Data stress diperoleh melalui wawancara sedangkan tekanan darah sistolik dan diastolik
menggunakan Perceived Stress Scale-10 (PSS-10), berdistribusi tidak normal. Mayoritas subjek (75%)
dimana hasilnya dikonversikan dalam bentuk angka mengalami hipertensi. Tekanan darah sistolik berkisar
kemudian dihitung nilai totalnya. Termasuk stress antara 78-209 mmHg dengan nilai tengah 123 mmHg.
ringan apabila skor antara 1-13, stress sedang apabila Tekanan darah diastolik berkisar antara 67-121 mmHg
skor antara 14-26, dan stress berat apabila skor antara dengan nilai tengah 86 mmHg. Subjek yang
27-40.22-25 Variabel terikatnya adalah tekanan darah mempunyai tekanan darah sistolik >130 mmHg
sistolik dan diastolic yang diukur menggunakan semuanya memiliki tekanan darah diastolik >80 mmHg,
tensimeter digital Merek Omron HEM8712 dengan tetapi terdapat subjek dengan tekanan sistolik normal
ketelitian 1 mmHg yang diukur oleh enumerator pada meskipun tekanan darah diastoliknya tinggi.
pagi hari pukul 6.00 – 8.00 WIB.
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Tabel 1. Karakteristik Subjek Penelitian

Karakteristik n % Median Mean ± SD
Tekanan Darah 123/86 125,93 ± 24,25/89,25
Hipertensi (≥ 130/80 mmHg) 21 75 ± 14,64
Tidak Hipertensi (< 130/80 mmHg) 7 25
Aktivitas Fisik (MET-menit/minggu) 2.152,5(132-4920) 2.258,4 ± 1.228,8
Tidak aktif (<600) 3 10,7
Aktif minimal (600-3000) 18 64,3
Sangat aktif (>3000) 7 25
Stress (skor) 14.5 (4-31) 14,54 ± 5,96
Ringan (0-13) 12 42,9
Sedang (14-26) 15 53,6
Berat (27-40) 1 3,6
Aktivitas fisik subjek berkisar antara 132-4.920 Tabel 2. Distribusi Kejadian Hipertensi berdasarkan
MET-menit/minggu dengan rerata 2.258,4±1.228,8 Tingkat Aktivitas Fisik dan Stress.
MET-menit/minggu. Secara keseluruhan, 64,3% subjek Hipertensi Normotensi
dikategorikan aktif minimal. Jenis aktivitas yang Kategori
n % N %
dilakukan subjek kebanyakan adalah aktivitas ringan Aktivitas Fisik
dalam kehidupan sehari-hari, misalnya memasak, Tidak aktif 2 66,7 1 33,3
menyapu, mengepel, mencuci, dan menyetrika. Aktif minimal 11 61,1 7 38,9
Kegiatan tersebut pun dibantu oleh alat elektronik Sangat aktif 7 100 - -
sehingga energi yang dibutuhkan lebih ringan. Aktivitas Stress
jalan yang dilakukan juga ringan, yaitu di sekitar rumah Ringan 10 83,3 2 16,7
saja. Subjek dengan kategori sangat aktif (25%) Sedang 10 66,7 5 33,3
memiliki kebiasaan berolahraga 2-4 kali seminggu. Berat 1 100 - -
Jenis olahraga yang dilakukan adalah renang, jogging,
senam aerobik, dan bersepeda.
Tabel 3. Gambaran Asupan Subjek.

Variabel n % Median Minimal Maksimal Mean ± SD
Asupan Lemak 39,6 13,53 134,30 47,03 ± 23,69
Kurang (<80%) 15 53,6
Cukup (80-100%) 5 17,9
Lebih (>100%) 8 28,6
Asupan Serat (gr) 6,5 2,50 26,87 8,28 ± 5,41
Kurang (<80%) 28 100
Cukup (80-100%) 0 0
Lebih (>100%) 0 0
Asupan Sodium (mg) 172,61 41,13 1.003,90 324,27 ± 299,33
Kurang (<80%) 28 100
Cukup (80-100%) - -
Lebih (>100%) - -
Asupan Kalium (mg) 1.015,61 361,50 2.896,30 1.084,005 ± 517,54
Kurang (<80%) 28 100
Cukup (80-100%) - -
Lebih (>100%) - -
Asupan Kalsium (mg) 193,53 14,54 461,37 208,75 ± 116,71
Kurang (<80%) 28 100
Cukup (80-100%) - -
Lebih (>100%) - -
Asupan Magnesium (mg) 162,97 62,90 402,50 174,46 ± 73,63
Kurang (<80%) 26 92,9
Cukup (80-100%) - -
Lebih (>100%) 2 7,1
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Sebagian subjek (53,6%) memiliki tingkat stress Asupan Subjek

sedang. Tingkat stress berkisar pada skor antara 4-31 Asupan yang diteliti dalam penelitian ini adalah
dengan rerata 14,54±5,96. Terdapat 1 subjek yang asupan lemak, serat, sodium, kalium, kalsium, dan
dikategorikan stress berat dengan skor 31. Hal tersebut magnesium. Berikut adalah gambaran asupan subjek.
dikarenakan subjek tersebut memiliki berbagai masalah Tabel 3 menunjukkan sebagian besar subjek
dalam keluarga dan kesulitan untuk melakukan strategi memiliki asupan lemak yang kurang, yaitu 15 orang
guna menghadapi stress tersebut (coping). Subjek yang (53,6%). Sumber lemak yang sering dikonsumsi adalah
mengalami hipertensi mayoritas dikategorikan memiliki gorengan, bakso, lauk yang diolah dengan digoreng.
tingkat aktivitas fisik aktif minimal (61,1%) dan subjek Semua subjek memiliki asupan serat, sodium, kalium,
yang mengalami stress cenderung memiliki tekanan dan kalsium kurang. Sebanyak 92,9% subjek memiliki
darah yang tinggi. Distribusi kejadian hipertensi asupan magnesium yang kurang, sedangkan 2 subjek
berdasarkan aktivitas fisik dan stress dapat dilihat pada asupan magnesiumnya berlebih.
Tabel 2.
Tabel 4. Hubungan Antara Aktivitas Fisik dan Stress dengan Tekanan Darah.
Variabel Tekanan Darah Sistolik Tekanan Darah Diastolik

Koefisien korelasi (r) p value Koefisien korelasi (r) p value
Aktivitas Fisik 0,114 0,564 0,333 0,083*
Stress -0,102 0,604 -0,286 0,14
*Signifikan (p<0,05)
Hubungan Antara Aktivitas Fisik dan Stress dengan aktivitas fisik dengan tekanan darah diastolik adalah
Tekanan Darah sedang, dengan arah hubungan positif sehingga semakin
Tabel 4 menunjukkan bahwa aktivitas fisik tidak tinggi aktivitas fisik maka tekanan darah diastolik akan
memiliki hubungan yang bermakna dengan tekanan semakin tinggi. Uji hubungan variabel perancu pada
sistolik (r=-0,114; p=0,564), tetapi memiliki hubungan penelitian ini seperti tingkat kecukupan asupan lemak,
yang bermakna dengan tekanan darah diastolik serat, sodium, kalium, kalsium, dan magnesium dengan
(r=0,333; p=0,083), sedangkan tingkat stress tidak tekanan darah baik sistolik maupun diastolik
memiliki hubungan yang bermakna dengan tekanan menunjukkan tidak terdapat hubungan yang bermakna
darah, baik sistolik maupun diastolik (r=-0,102, (p>0,05) (tabel 5). Oleh karena itu tidak dilanjutkan
p=0,604; r=-0,286, p=0,14). Kekuatan hubungan antara untuk uji multivariat.
Tabel 5. Hubungan Antara Tingkat Kecukupan Asupan Lemak, Serat, Sodium, Kalium, Kalsium, dan Magnesium
dengan Tekanan Darah.
Tekanan Darah Sistolik Tekanan Darah Diastolik
Variabel
Koefisien korelasi (r) p value Koefisien korelasi (r) p value
Tingkat Asupan
Lemak 0,124 0,529 -0,267 0,170
Serat 0,175 0,374 0,142 0,471
Sodium -0,178 0,365 -0,213 0,278
Kalium 0,214 0,218 -0,066 0,783
Kalsium 0,241 0,218 -0,035 0,859
Magnesium 0,05 0,802 -0,148 0,454
PEMBAHASAN wanita prediabetes lebih tinggi dibanding non-

hipertensi (61,6%).27 Sebanyak 21 subjek yang
Karakteristik Subjek mengalami hipertensi diketahui bahwa 57%
Mayoritas subjek dalam penelitian (75%) ini dikategorikan aktif minimal dan 47% mengalami stress
mengalami hipertensi. Ini menunjukkan bahwa sedang.
hipertensi lebih sering ditemukan bersamaan dengan Tingkat aktivitas subjek mayoritas adalah aktif
prediabetes dibandingkan terjadi secara tunggal. 13 Hal minimal (64,3%). Rerata aktivitas fisik dalam penelitian
tersebut sejalan dengan penelitian di China yang ini adalah 2.258,4±1.228,8 MET-menit/minggu. Jenis
menunjukkan bahwa 78,8% penderita prediabetes aktivitas yang lebih sering dilakukan adalah aktivitas
mengalami prehipertensi atau hipertensi. 26 Hasil ringan, misalnya berjalan lambat sekitar rumah,
penelitian ini juga sejalan dengan penelitian Alicia dkk memasak, menyetrika, dll. Hal tersebut menunjukkan
yang menunjukkan bahwa prevalensi hipertensi pada bahwa sebagian besar subjek memiliki aktivitas yang
lebih rendah dibandingkan dengan rekomendasi
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menurut Diabetes Prevention Program (DPP). DPP makin tinggi aktivitas fisik, makin tinggi tekanan darah
merekomendasikan penderita prediabetes untuk diastolik.
melakukan aktivitas fisik minimal 700 kkal/minggu Secara teoritis, aktivitas fisik berpengaruh
atau setara dengan melakukan aktivitas sedang 150 terhadap tekanan darah. Semakin tinggi aktivitas fisik
menit/minggu. Contoh aktivitas sedang yang mudah maka semakin kecil risiko terkena penyakit hipertensi.
dan paling banyak dilakukan adalah berjalan cepat. Seseorang dengan aktivitas ringan memiliki
Aktivitas lain yang bisa dilakukan antara lain adalah kecenderungan sekitar 30-50% terkena hipertensi
senam aerobik, bersepeda, jogging, karate, berenang, dibanding seseorang dengan aktivitas sedang atau berat.
tenis, dan voli.28 Aktivitas fisik yang dilakukan secara teratur dengan
Tingkat stress yang dialami subjek dalam durasi yang tepat dapat menurunkan tekanan darah.
penelitian ini mayoritas adalah sedang (53,6%), ringan Aktivitas fisik yang cukup dapat menguatkan jantung
(42,8%) dan hanya 3% yang memiliki stress berat . sehingga dapat memompa darah lebih baik tanpa harus
Hasil tersebut sejalan dengan penelitian Muhsinin dan mengeluarkan energi yang besar. Semakin ringan kerja
Laksono yang menyebutkan bahwa penderita hipertensi jantung maka semakin sedikit tekanan darah pembuluh
kebanyakan memiliki tingkat stress sedang. 29 Subjek darah arteri sehingga mengakibatkan tekanan darah
yang dikategorikan mengalami stress sedang 66,7% menurun.34 Aktivitas fisik yang dapat menurunkan
diantaranya mengalami hipertensi. tekanan darah tergantung pada jenis aktivitas, durasi,
Stress yang timbul pada penderita hipertensi dan frekuensinya. Aktivitas fisik yang dianjurkan bagi
merupakan hal yang wajar, baik itu disebabkan karena penderita prediabetes adalah melakukan aktivitas fisik
adanya perubahan mendadak pada aktivitas yang sedang pada kebanyakan hari dengan total minimal 150
biasanya pasien lakukan maupun ketidakmampuan menit/minggu. Jenis aktivitas yang disarankan antara
menyesuaikan diri dengan keadaan penyakit. Adanya lain adalah jalan cepat, senam aerobik, bersepeda,
pengobatan dan perubahan perilaku baik secara fisik jogging, tenis, dan berenang.28
maupun emosional juga menjadi stressor bagi pasien Penelitian ini menunjukkan bahwa aktivitas fisik
hipertensi.29 memiliki hubungan yang bermakna dengan tekanan
darah diastolik, tetapi tidak dengan tekanan darah
Hubungan antara Aktivitas Fisik dengan Tekanan sistolik. Hal tersebut dapat dikarenakan karena adanya
Darah perbedaan pengklasifikasian hipertensi. Pada penelitian
Aktivitas fisik didefinisikan sebagai pergerakan ini subjek dianggap mengalami hipertensi apabila
tubuh yang dihasilkan oleh kontraksi otot rangka dan memiliki tekanan darah ≥130/80 mmHg karena pada
dapat meningkatkan energi ekspenditur. Aktivitas fisik penderita prediabetes risiko terkena penyakit
ini mencakup berbagai macam pergerakan tubuh, mulai kardiovaskuler lebih tinggi dibanding orang tanpa
olahraga yang dilombakan, olahraga, hobi, atau prediabetes.10,11 Seseorang tanpa prediabetes baru
aktivitas sehari-hari dalam rumah tangga. dikatakan mengalami hipertensi apabila memiliki
Kebalikannya, fisik yang tidak aktif didefinisikan tekanan darah ≥140/90 mmHg.9
sebagai keadaan dimana tubuh hanya melakukan Selain itu dapat disebabkan karena adanya bias
gerakan minimal dan energi ekspenditur rata-rata adalah ketika pengambilan data tingkat aktivitas fisik
pada keadaan basal.30 menggunakan IPAQ dan tingginya kecenderungan
Berdasarkan uji korelasi menggunakan Rank subjek untuk memberikan hasil yang baik sehingga
Spearman diketahui bahwa pada penelitian ini aktivitas menyebabkan terjadinya overestimate aktivitas fisik.
fisik tidak berhubungan bermakna dengan tekanan Penelitian yang dilakukan oleh Lee dkk menyebutkan
darah sistolik, tetapi berhubungan secara bermakna bahwa IPAQ cenderung memberikan hasil yang
dengan tekanan darah diastolik (p<0,05). Hal ini overestimate sebesar 84%.33,35 Terjadinya overestimate
mungkin disebabkan karena sebagian besar subjek pada terutama adalah pada aktivitas sehari-hari dan aktivitas
penelitian ini melakukan aktivitas yang seragam. Hasil yang berhubungan dengan berkebun.36
penelitian ini sejalan dengan penelitian yang dilakukan Pada penelitian ini aktivitas fisik hanya
oleh Ayu Rahadiyanti dkk yang menyebutkan bahwa berhubungan bermakna dengan tekanan darah diastolik
aktivitas fisik tidak berhubungan dengan hipertensi. 31 (p<0,05). Hal tersebut dapat disebabkan karena 75%
Berbeda dengan penelitian yang dilakukan oleh Sindhu subjek memiliki tekanan darah diastolik ≥80 mmHg.
yang menyebutkan bahwa aktivitas fisik berhubungan Dari 75% subjek yang mengalami hipertensi, 52%
dengan tekanan darah sistolik maupun diastolik dan diantaranya mengalami hipertensi diastolik (tekanan
juga penelitian di Malaysia yang menunjukkan adanya darah diastolik tinggi, tetapi tekanan darah sistolik
hubungan antara aktivitas fisik dengan tekanan darah normal). Tekanan darah diastolik meningkat seiring
sistolik saja.32,33 Penelitian ini menunjukkan bahwa bertambahnya usia, hingga usia mencapai 60 tahun.
hubungan antara aktivitas fisik dan tekanan darah Pada usia 35-50 tahun, secara biologis pembuluh
diastolik menunjukkan hubungan positif yang artinya darah masih berfungsi dengan baik, sehingga
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kemungkinan penyebab tingginya tekanan darah dapat menyesuaikan diri terhadap perubahan yang
diastolik adalah karena terjadinya resistensi pembuluh terjadi.38
darah perifer. Subjek dalam penelitian adalah ini adalah Secara alamiah dalam kondisi seperti ini
wanita prediabetes sehingga dimungkinkan kadar lipid seseorang akan merasakan detak jantung yang lebih
dalam darah tinggi, menyebabkan naiknya kekentalan cepat dan keringat dingin yang mengalir di daerah
darah yang mengakiatkan naiknya resistensi pembuluh tengkuk. Selain itu peningkatan aliran darah ke otot-
darah perifer dan tekanan darah diastolik. Rendahnya otot rangka dan penurunan aliran darah ke ginjal, kulit,
aktivitas fisik juga berpengaruh terhadap kenaikan dan saluran pencernaan juga dapat terjadi karena stres.
tekanan darah. Selain itu, naiknya tekanan darah Kondisi stres membuat tubuh menghasilkan hormon
diastolik juga dipengaruhi oleh stress. Seseorang yang adrenalin lebih banyak, membuat jantung berkerja lebih
mengalami stress, baik stress karena pekerjaan maupun kuat dan cepat. Apabila terjadi dalam jangka waktu
lingkungan, cenderung memiliki tekanan darah yang lama maka akan timbul rangkaian reaksi dari
diastolik yang tinggi dibanding dengan seseorang yang organ tubuh lain. Perubahan fungsional tekanan darah
tidak mengalami stress.37 yang disebabkan oleh kondisi stres dapat menyebabkan
hipertropi kardiovaskuler bila berulang secara
Hubungan antara Stress dengan Tekanan Darah intermiten. Hal ini terlihat pada 1 subjek yang
Berdasarkan uji bivariat yang dilakukan, dalam mengalami stress berat memiliki tekanan darah tinggi
penelitian ini stress tidak berhubungan secara signifikan sampai 182/121 mmHg. Penderita hipertensi yang
dengan tekanan darah sistolik maupun diastolik mengalami stress cenderung memiliki tekanan darah
(p<0,05). Hal ini dapat disebabkan karena subjek yang tetap tinggi atau bahkan semakin tinggi, sehingga
mampu untuk mengatasi stress yang dialami sehingga menyebabkan kondisi hipertensinya makin buruk.38
tidak sampai berpengaruh terhadap kondisi fisiologis.
Kondisi ini terlihat dari sebagian besar stress yang SIMPULAN
dialami responden masuk dalam kategori sedang dan
ringan. Subjek dengan tingkat stress ringan dan sedang Penelitian ini menunjukkan bahwa tidak terdapat
tidak menganggap besar masalah yang dialami, baik itu hubungan yang signifikan antara aktivitas fisik dengan
dari dalam diri subjek sendiri maupun dari lingkungan, tekanan darah sistolik, tetapi terdapat hubungan yang
dan dapat mengalihkan rasa stress tersebut dengan hal signifikan antara aktivitas fisik dengan tekanan darah
lain, misalnya dengan berekreasi, bermain bersama diastolik. Tidak terdapat hubungan yang signifikan
cucu, maupun berolahraga. Hasil penelitian ini berbeda antara tingkat stress dengan tekanan darah, baik sistolik
dengan penelitian Katerin yang menunjukkan adanya maupun diastolik.
hubungan yang bermakna antara stress dengan
hipertensi.38 SARAN
Stress adalah realita kehidupan yang tidak bisa
dihindari. Stress atau ketegangan emosional dapat Perlu dilakukan penelitian lebih lanjut dengan
mempengaruhi sistem kardiovaskuler, khususnya desain yang berbeda untuk melihat faktor risiko
hipertensi. Stress dipercaya dapat meningkatkan risiko aktivitas fisik dan stress terhadap hipertensi.
hipertensi melalui aktivasi sistem saraf simpatis yang
mengakibatkan naiknya tekanan darah secara intermiten
UCAPAN TERIMAKASIH
(tidak menentu). Pada saat seseorang mengalami stres,
hormon adrenalin akan dilepaskan dan kemudian akan
Penelitian ini didanai melalui Hibah Penelitian
meningkatkan tekanan darah melalui kontraksi arteri
(vasokontriksi) dan peningkatan denyut jantung. dosen Fakultas Kedokteran Universitas Diponegoro
Apabila stress berlanjut, tekanan darah akan tetap tinggi tahun anggaran 2016.
sehingga orang tersebut akan mengalami hipertensi. 38
DAFTAR PUSTAKA
Kondisi stress meningkatkan aktivitas saraf
simpatis yang kemudian meningkatkan tekanan darah 5 Anjana RM, Pradeepa R, Deepa M, Datta M,
secara bertahap, artinya semakin berat kondisi stres
Sudha V, Unnikrishnan R, et al. Prevalence of
seseorang maka semakin tinggi pula tekanan darahnya.
diabetes and prediabetes (impaired fasting glucose
Stres merupakan rasa takut dan cemas dari perasaan dan
and/or impaired glucose tolerance) in urban and
tubuh seseorang terhadap adanya perubahan dari
rural India: Phase I results of the Indian Council
lingkungan. Apabila ada sesuatu hal yang mengancam
ofMedical Research–INdia DIABetes (ICMR–
secara fisiologis kelenjar pituitary otak akan
INDIAB) study. Diabetologia. 2011;54:3022–7.
mengirimkan hormon kelenjar endokrin kedalam darah.
6 Soewondo P, Pramono LA. Prevalence,
Hormon ini berfungsi untuk mengaktifkan hormon
characteristics, and predictors of pre-diabetes in
adrenalin dan hidrokosrtison, sehingga membuat tubuh
Indonesia. Med J Indones. 2011;2(4):283-94.
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* Iloh GUP, Uchenna NR, Obiegbu NP. Risk factors † Cheung BMY, Li C. Diabetes and Hypertension: Is
of pre-diabetes among adult Nigerians with There a Common Metabolic Pathway? Curr
essential hypertension in a resource-constrained Atheroscler Rep. 2012;14:160-6.
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Validity of the international physical activity
Rationale and design of the Medication adherence
Improvement Support App For Engagement—Blood
Pressure (MedISAFE-BP) trial
Kyle Morawski, MD, a Roya Ghazinouri, PT, DPT, MS, a Alexis Krumme, MS, a Julianne McDonough, BS, a
Erin Durfee, BS, b Leslie Oley, MS, b Namita Mohta, MD, a Jessie Juusola, PhD, b and Niteesh K. Choudhry, MD, PhD a Boston,
MA and Menlo Park, CA
Background Hypertension is a major contributor to the health and economic burden imposed by stroke, heart disease, and
renal insufficiency. Antihypertensives can prevent many of the harmful effects of elevated blood pressure, but medication
nonadherence is a known barrier to the effectiveness of these treatments. Smartphone-based applications that remind patients
to take their medications, provide education, and allow for social interactions between individuals with similar health concerns
have been widely advocated as a strategy to improve adherence but have not been subject to rigorous testing.
Methods/design The MedISAFE-BP study is a prospective, randomized control trial designed to evaluate the impact on
blood pressure and medication adherence of an mhealth application (Medisafe). Four hundred thirteen patients with
uncontrolled hypertension have been enrolled and randomized in a 1:1 fashion to usual care or to the use of the Medisafe
mhealth platform. Patients will be followed up for 12 weeks and the trial's co-primary outcomes will be change in systolic blood
pressure and self-reported medication adherence.
Discussion The MedISAFE-BP trial is the first study to rigorously evaluate an mhealth application's effect on blood pressure
and medication adherence. The results will inform the potential effectiveness of this simple system in improving cardiovascular
disease risk factors and clinical outcomes. (Am Heart J 2017;186:40-7.)
6
Background The rapid adoption of smartphone technologies makes this
Hypertension is a major contributor to the health and an attractive avenue to help address nonadherence by
economic burden imposed by stroke, heart disease, and delivering reminders about medication administration, offering
renal insufficiency. Worldwide, there are 9.4 million deaths education about healthy behaviors, creating a support network
each year that can be attributed to hypertension through its for caregivers and family members, and monitoring biometric
1
effect on cardiovascular disease, and annual expenditures measurements. Previous studies have shown improvement in
for hypertension have been estimated to be $46 billion in blood pressure when mobile health (mhealth) applications are
2 7,8
the United States alone. Antihypertensives can prevent used to self-monitor, facilitate communication between
9 10,11
many of the harmful effects of elevated blood pressure, but patients and providers, and/or deliver text messages, but
medication nonadherence is a known barrier to the all of these have used technologies in clinic-based settings
3-5
effectiveness of these treatments. It has been estimated within the context of established doctor-patient relationships.
that N50% of those classified as resistant hypertension are In contrast, most mhealth applications are used by patients
actually “pseudoresistant,” with medication nonadherence without the active participation, or even knowledge, of their
5 care providers. The impact of “stand-alone” mhealth tools to
being the cause of uncontrolled blood pressure.
improve medication adherence has not been rigorously
evaluated, especially with regard to its ability to influence
From the aCenter for Healthcare Delivery Sciences (C4HDS) and Division of clinically-relevant health outcomes.
Pharmacoepi-demiology and Pharmacoeconomics, Department of Medicine, Brigham
and Women's Hospital and Harvard Medical School, Boston, MA, and bEvidation
Health, Menlo Park, CA. RCT No. NCT02727543
Funding: This work was supported by a grant from Medisafe Inc.
Methods
Submitted July 6, 2016; accepted November 18, 2016. Trial design
Reprint requests: Niteesh K. Choudhry, MD, PhD, Brigham and Women's Hospital,
Harvard Medical School, 1620 Tremont St, Suite 3030, Boston, MA 02120. E-mail:
The MedISAFE-BP trial is a prospective, intent-to-treat
nkchoudhry@bwh.harvard.edu randomized control trial that aims to evaluate the
0002-8703 impact of the Medisafe mhealth platform on blood
© 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ahj.2016.11.007 pressure control and self-reported medication
adherence for patients with uncontrolled blood
pressure. Patients will be followed up
American Heart Journal
Volume 186
Morawski et al 41
Table I. Inclusion/exclusion criteria

Inclusion Exclusion
Age ≥18 and ≤75 y Current use of a smartphone medication adherence application
Self-reported blood pressure ≥140/90 mmHg No ownership of a smartphone with compatible iOS or Android operating system
Self-reported use of 1-3 of the following antihypertensive Currently taking N3 antihypertensive medications (thiazide, CCB, ß-blocker,
medications (thiazide, CCB, ß-blocker, ACE-I, ARB) ACE-I, ARB) by self-report
Systolic blood pressure ≥140 mm Hg, but ≤180/120 mmHg Currently undergoing dialysis
confirmed by home blood pressurecuff (see text for details) Currently receiving chemotherapy or radiation
Does not understand English
Abbreviations: CCB, calcium-channel blocker; ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker.
for 12 weeks. The study was approved by the Chesapeake a patient's medication taking history, receives alerts when
institutional review board (Columbia, MD) and is registered doses are missed, and can provide peer support. Medication
with clinicaltrials.gov (NCT02727543). The trial protocol was lists can be entered manually, along with timing of
designed and written by the academic investigators. administration as recommended by their doctor, or be auto-
populated through a linkage with an existing record in
Participants those cases where this integration has been established. The
Eligible participants were individuals between 18 and 75 University of Arkansas performed an independent
years of age who self-identify as having inadequately evaluation of usability in all available medication
controlled hypertension (defined as a systolic blood adherence smartphone applications in 2015 and ranked
12
pressure ≥140 mmHg) and who are receiving treatment Medisafe highest.
with at least 1, but not N3, first-line antihypertension
medications (defined as thiazide diuretics, calcium-channel Study procedures
blockers, angiotensin-converting enzyme inhibitors, 3 Recruitment
angiotensin-receptor blockers, or β-blockers). Before Recruitment was being conducted by a Contract
randomization, each participant's blood pressure was Research Organization, Evidation Health (Menlo
verified using a Bluetooth-enabled home blood pressure Park, CA), which uses an online strategy to virtually
cuff (UA-615BLE A&D Medical, San Jose, CA). announce, recruit, verify eligibility, enroll partici-
Individuals were excluded if they are already using a pants in clinical studies, and collect data from
smartphone application to support medication adher-ence, participants once enrolled. Participants were re-
did not own a smartphone, did not live in the United States cruited through online patient communities, social
with a valid mailing address, were undergoing media, pertinent mobile applications, and targeted
hemodialysis or chemotherapy at the time of screening, or advertisements.
had hypertension that required immedi-ate medical
attention (defined as a systolic blood pressureN180 mmHg
or a diastolic blood pressureN120 mmHg) (see Table I). 4 Screening and randomization
As shown in Figure 3, potential study participants
Study enrollment began on April 25,2016 and was were evaluated for inclusion and exclusion criteria,
completed on September 29, 2016. A total of 413 study provided informed consent, and completed a baseline
participants were randomized (Figure 1). Follow-up of all survey consisting of questions about
trial participants will end by December29, 2016. demographics, cardiovascular comorbidities, use of
13
cigarettes, and educational attainment. Baseline
Intervention medication adherence was assessed with the Morisky
The Medisafe smartphone platform and application was 8-item adherence scale, which has been
developed to address nonadherence (Figure 2) and operates validated to accurately capture antihypertensive
on either the iOS (version 6 or newer) or Android mobile medication adherence by self-report.14Baseline
hypertension knowledge was assessed based on the
system (version 4.4 or newer). It provides alerts to patients
methods of Oliveira et al.15Participants were asked
when it is time to take medication. Medisafe also allows
patients to generate weekly reports of medication
to complete the Consumer Health Activation Index
adherence, monitor bio-metric measurements (either as a marker for patient activation, as developed by
directly into the application or through synchronization Wolf et al (personal communication). After
with the smartphone's non-Medisafe health devices), and completing the baseline assessment, partici-pants
designate a “Medfriend” of their choosing, who is granted were sent a Bluetooth-enabled home blood
access to pressure cuff to verify that they have uncontrolled
42 Morawski et al April 2017
Figure 1
Assessed for eligibility

(n = 19,047)
Did not meet inclusion criteria based on screen (n = 10,025)

Not taking blood pressure medication (n = 2,184)
Does not have hypertension (n = 1,833)
Incompatible smartphone (n = 1,814)
Recent medication change (n = 1,653)
Other (age, complex medication regimen, already using app, etc.) (n = 2,541)
Potentially eligible
subjects
(n = 9,022)
Did not complete informed consent

(n = 5,358)
Did not complete initial survey

(n = 78)
Screened for blood

pressure eligibility
(n = 3,586)
Did not provide blood pressure measurement

(n = 2,473)
Did not meet inclusion criteria based on blood pressure

(n = 700)
Randomized
(n = 413)
Medisafe arm Control arm

(n = 210) (n = 203)
Consort diagram of enrolled study participants.
blood pressure (systolic ≥140 mmHg but ≤180/120 minutes apart, but not N30 minutes apart.
mmHg). The cuff was sent by courier to allow the Once their blood pressure readings were confirmed as
tracking of its receipt.Participants were provided with being elevated, participants underwent randomi-
detailed instructions on how to accurately measure zation in a 1:1 ratio to intervention or control using
and transmit their blood pressure readings. In simple randomization with a random number
specific, the study participants were asked to provide generator.
2 measurements that are taken 5 minutes apart, in 7 Treatment arms
accordance with professional society guidelines, and
blood pressure was calculated as the average of these Participants assigned to the intervention arm were
16 e-mailed instructions on how to download the
measurements. All submitted blood pressure
Medisafe application. Participants who did not
measurements were transmitted and logged with a
timestamp. Because of the pragmatic nature of this download the application and have 1 login within
study, acceptable readings were considered as 2 2 days of randomization were contacted by e-mail
measurements that were at least 3 up to 2 times and were provided with the
instructions for downloading the application. If
Volume 186
Morawski et al 43
Figure 2
Smartphone application. A, The home screen of the Medisafe application for a hypothetical patient. B, A weekly report describing the percentage of time
pills was missed. C, A demonstration on how medications can be automatically imported and the use of the Medfriend Alert system.
they still did not login, they were contacted twice via after 3 reminder e-mails and 2 phone calls, they are
telephone, then 1 final time by e-mail. If after these not contacted again for that assessment, but are
attempts, a participant still did not login, they are not contacted to obtain the next scheduled blood pressure
contacted further but they were followed up for reading.
outcomes and analyzed in the intent-to-treat analysis. At 12 weeks, all participants are asked to complete an
exit questionnaire consisting of Morisky 8-item
14
medication adherence scale, hypertension knowl-
15
Patients assigned to the control arm do not receive edge questionnaire, and the Consumer Health
any intervention. Activation Index. Participants who do not complete
the exit questionnaire or take their final blood
* Follow-up assessments pressure measurement are characterized as lost to
Blood pressure measurements are being collected 4, follow-up after the same e-mail and phone call
8, and 12 weeks after randomization. At each of these schedule described previously. After completing the
periods, participants in both treatment groups are study, participants are given the option to keep the
contacted and asked to check their blood pressure blood pressure cuff or donate it to an organization
using the Bluetooth-enabled blood pressure cuff that that recycles digital health and well-ness products for
they were provided at enroll- underserved populations.
ment. Blood pressure is assessed as the average of 2 Participants may choose to take blood pressure
16
measurements, taken at least 5 minutes apart. If no measurements using the Bluetooth-enabled blood
blood pressure measurement is received within 2 pressure cuff more often than the required in the
days after the intended upload date, there are 2 study. Those data will also be stored in the study
reminder e-mails sent until a blood pressure database. Throughout the study, participant data
measurement is received. If there is still no blood including blood pressure measurements and
pressure measurement received, 2 phone calls are
survey data are reviewed by study personnel
made to the study participant, followed by 1 final e-
mail reminder. If they are unable to be reached blinded to treatment assignment to ensure data
quality and consistency. Patients may be
Table II. Outcomes

Outcome Description
Primary (1) Change in blood pressure from baseline to 12 wk after randomization

(2) Self-reported medication adherence
Secondary Change in number of participants with well-controlled blood pressure (b140/90 mmHg)
contacted by phone or e-mail to address suspi-cious longitudinal modeling methods that incorporate blood
or unusual data submissions that are suggestive of pressure readings at 4, 8, and 12 weeks after
device malfunctioning or misuse. randomization. If there are additional blood pressure
readings from patients who took their blood pressure
more often than required, we will include these data
Outcomes in exploratory analyses.
The study's co-primary outcomes are change in (a) In subgroup analyses, we will evaluate whether the
systolic blood pressure and (b) self-reported medication impact of the smartphone application differed for
adherence from randomization to 12 weeks later (see Table participants who interacted with it frequently (de-
II). The secondary outcome is change in proportion of fined as being in the upper median based on number
participants who have well-controlled blood pressure of days with use of the application during the study
(b140/90 mmHg). period) and less frequently. We will perform this
analysis by including categorical variables for high
Statistical considerations and low use in our outcome model, whereby control
subjects are indicated by null values for both of these
† Analytic plan indicators. We will also evaluate effect modification
We will report the means and frequencies of 15
prerandomization variables separately for interven- by hypertension knowledge recorded at baseline.
tion and control subject, and between-group
2
differences will be evaluated using ttests and χ tests
† Sample size
and their nonparametric analogs, as appropri-ate. We
will then plot changes in blood pressure for each of Our planned enrollment was 390 patients; how-ever,
the study groups over time. ultimate enrollment in the study was 413. This
provides us with at least 80% power to detect a 5-
Analyses will be performed on an intention-to-treat
mmHg change in systolic blood pressure, with
basis, where participants will be analyzed in the
groups to which they are assigned at randomization. an α of .05, even with a 20% loss to follow-up or
We will use linear regression to assess the impact of anSD of up to 17. A decrease in systolic blood
the smartphone application on the study's co-primary pressure by 5 mm Hg correlates with clinically-
outcomes, change in blood pressure, and self-reported meaningful reductions in coronary heart disease and
20-22
adherence from baseline to 12 weeks. We will stroke. This sample size also provides 87% power
perform crude and adjusted analysis as a sensitivity detect a 0.5 Morisky score difference between the
14
analysis for any unmatched covari-ates despite groups assuming anSD of 1.6 and an α of .05.
randomization.
We will evaluate for rates of missing data between the
2 study arms to ensure it is nondifferential. We will
Funding
use multiple imputation with 5 imputations for data
entries that are unavailable. All analyses will be This study is supported by a grant from Medisafe, Inc.
performed with these imputations, and then data will The authors are solely responsible for the design and
be combined using standard procedures.
17
This conduct of this study, all study analyses, and the drafting
18 and editing of the manuscript and its final contents.
approach has been used previously and minimizes
both false-positive and false-negative
19
conclusions. As a sensitivity analysis, we will
Limitations
analyze only those participants for whom we have
complete outcome data. There are several limitations to this trial. The
In a secondary analysis, we will use multivariable interven-tion lasts for 12 weeks; therefore, we will be
logistic regression to determine the proportion of unable to determine the effect of the smartphone
patients who had their hypertension controlled (ie, application on longer-term outcomes, including stroke
b140/90 mmHg). We will repeat our analyses with or myocardial infarction. However, previous evidence
supports the
Volume 186
Morawski et al 45
notion that short-term adherence is predictive of long-term remove any manual entry, or self-reporting, bias that may
23
adherence, and therefore, results of this trial may signal occur with blood pressure measurements.
longer-term effects for health improvement.
Although the trial aims to be pragmatic with minimal
inclusion and exclusion criteria, because patients are Discussion
primarily recruited through online and virtual methods, the Although there could be as many as 1.7 billion mhealth
results may not be generalizable to other patient 24
users globally by 2018, very few mhealth applications
populations. However, the use of mobile technology, have been adequately tested. Given the near ubiquity of
especially as it pertains to informing medical conditions, is smartphones and other mobile devices, there is great
increasing and may soon be present in N50% of the potential for this technology to increase engagement in the
24
population. In addition, we exclude those with ex-tremely time between clinic visits, and to promote healthier lifestyle
high blood pressure, for which immediate medical attention choices. An especially attractive target is hypertension in
is recommended, and therefore, this intervention may not which there are no daily symptoms, but can have
be applicable to populations with blood pressures greater significant morbidity if left untreated. A 2012 review
than 180 mmHg systolic or 120 mmHg diastolic. Many identified 147 unique smartphone applica-tions available to
patients with this level of blood pressure elevation require target medication adherence, but effectiveness data were
30
careful medical supervision, and therefore, reliance on a lacking. In the years since, the number of adherence apps
stand-alone smartphone application may not be prudent. has increased substantially but the evidencebase supporting
their impact on health care quality remains extremely
Performing this trial through online and virtual methods limited.
also potentially increases the rate of drop-off during the Although there have been several trials evaluating the
recruitment process. Previous hypertension trials have had impact of short message service text messaging on chronic
variable proportions of patients enrolled that begin the 10,31,32
disease management, the randomized trial of an
screening process. The recent SPRINT trial performed mhealth application for patients with hypertension relied
recruitment in the clinical setting and ultimately enrolled heavily on nurse health coaches to provide treatment
25-27 9
64% of those approached for screen-ing, ,whereas the recommendations. In this study, Moore et al evaluated the use
SHEP trial used community adver- of CollaboRhythm, an interface that allows tracking of
tisements, referrals from clinicians, and site enrollment and medications and pairs a patient with a coach to offer
23,24
enrolled 1.06% of those screened. We anticipate recommendations and reminders. After 12 weeks, those in the
that between 2% and 5% of participants screened will intervention arm decreased their blood pressure by 10 mmHg
ultimately enroll in our trial. Because this drop-off is before more than the control group. There was also a trend for a
randomization, and our analysis will be done in an intent- greater proportion in the intervention becoming well
to-treat manner, this will not compromise the internal controlled; however, this did not reach statistical significance.
validity of the trial, but may have implications for the The only published observational study of a “hypertension
generalizability of our results. management app”—created by the study investigators—was a
To assess study outcomes, we are measuring blood preimplementation/postimplementation study that found a
pressure several times over the course of the 12-week trial. statistically significant increase in self-reported medication
This interaction has the potential to increase hypertension adherence after 4 weeks using the modified Morisky
33
awareness and to potentially improve medication adher- scale. As such, MedISAFE-BP trial is, to our knowledge, the
ence itself, or cause healthier lifestyle behaviors that would first randomized trial to evaluate the effect of a stand-alone
lower blood pressure. Home use of blood pressure cuffs has mhealth platform to increase medication adherence and
been shown to decrease systolic blood pressure by 2.5 improve blood pressure control.
mmHg systolic and diastolic blood pressure by 1.8 mmHg. In chronic conditions other than hypertension, there is
7
It is reassuring that any bias this would introduce would be some evidence of benefit for smartphone applications.
nondifferential between the 2 study arms. Bricker et al34evaluated 2 stand-alone smartphone
Finally, we are monitoring blood pressure with applications for smoking cessation and found a nonsig-
ambulatory blood pressure monitors,whereas previous nificant 2.7 times higher odds of quitting at 2 months with
hypertension trials had blood pressures measured in clinic. the use of SmartQuit vs National Cancer Institute's
Although this approach, which minimizes the “white-coat QuitGuide application, although there was no control group
effect” of artificially elevated blood pressure in a medical in this study. Kirwan et al35 randomized 72 individuals with
28 type 1 diabetes to control or the use of “Glucose Buddy,”
clinic and is advocated by the American Heart
29 the most downloaded diabetes man-agement application on
Association for blood pressure monitoring, we are not iOS. They found a statistically significant decrease in
able to verify the accuracy of the blood pressure readings HbA1c of 1.1%, although the baseline HbA 1c and other
that we receive. We are using Food and Drug characteristics of the patients in the 2 treatment arms
Administration–approved blood pressure cuffs and infor-
were not well balanced at baseline
mation will be transmitted automatically in an attempt to
Figure 3
Study flowsheet.
and, as part of the intervention, patients received

†
Burnier M, Wuerzner G. Ambulatory blood pressure and
personalized text messages from a certified diabetes adherence monitoring: diagnosing pseudoresistant
educator. In contrast 2 trials of smartphone applications hypertension. Semin Nephrol 2014;34(5):498-505.
†
Ghembaza MA, Senoussaoui Y, Tani MK, et al. Impact of patient
for patients with obesity found no impact on weight loss,
36,37 knowledge of hypertension complications on adherence to antihy-
even with the use of personal coaching. pertensive therapy. Curr Hypertens Rev 2014;10(1):41-8.
In conclusion, MedISAFE-BP will evaluate the effec- †
Oliveira-Filho AD, de Costa FA, Neves SJF, et al.
tiveness of the stand-alone mhealth application with respect Pseudoresistant hypertension due to poor medication
to its clinical impact on blood pressure control. It will adherence. Int J Cardiol 2014;172(2):e309-10.
inform whether this strategy can improve preventive †
Smith A. U.S. smartphone use in 2015 [Internet]. Pew Research
strategies for cardiovascular morbidity. Center: Internet, Science & Tech. [cited 2016 Jun 13]. Available
from: http://www.pewinternet.org/2015/04/01/us-smartphone-
use-in-2015/2015.
†
Glynn LG, Murphy AW, Smith SM, et al. Interventions used to
improve control of blood pressure in patients with hypertension.
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Original Article
Association between quality of

life and medication adherence in
hypertensive individuals
Associação entre a qualidade de vida e adesão à
medicação de indivíduos hipertensos
Juliét Silveira Hanus1
Priscyla Waleska Simões1
Graziela Amboni1
Luciane Bisognin Ceretta1
Lisiane Generoso Bitencort Tuon1
Keywords Abstract
Primary care nursing; Quality of Objective: To evaluate the association between quality of life and medication
life; Hypertension; Blood pressure; adherence in hypertensive individuals.
Medication adherence Methods: Cross-sectional study carried out with 432 hypertensive subjects registered in a federal public
computerized system. Data were collected in the households through a structured interview with
Descritores questions related to socioeconomic and clinical variables, as well as assessment of treatment
Enfermagem de atenção primária; adherence, and the WHOQOL-BREF for quality of life. The Kruskal-Wallis H test was used to measure
Qualidade de vida; Hipertensão; the association between the scales of quality of life and the classification of treatment adherence.
Pressão sanguínea; Adesão à Results: The lowest scores were present in the self-assessment domain and the highest were found in the social
medicação domain. Individuals with extreme adherence to antihypertensive treatment showed higher scores in assessment of
quality of life compared to individuals classified as extreme non-adherence to antihypertensive treatment.
Conclusion: The association between quality of life and medication adherence in hypertensive
Submitted patients was not predictive. The hypertensive subjects with high medication adherence showed
April 15, 2015 the best scores of quality of life, and the worst scores were presented by individuals classified as
Accepted extreme non-adherence and as borderline to total non-adherence.
May 6, 2015
Resumo
Objetivo: Avaliar a associação entre a qualidade de vida e a adesão a medicação de indivíduos
hipertensos. Métodos: Estudo transversal, realizado com 432 hipertensos cadastrados em sistema
informatizado público federal. Os dados foram coletados no domicilio por entrevista estruturada com
questões relacionadas a variáveis socioeconômicas, clínicas, avaliação da adesão ao tratamento e o
WHOQOL-BREF para a qualidade de vida. Utilizou-se o teste de H de Kruskal-Wallis para medir a
associação entre as escalas da qualidade de vida e a classificação da adesão ao tratamento.
Resultados: Os escores mais baixos estavam presente no domínio autoavaliação e os mais altos
foram encontrados no social. Os indivíduos que possuíam adesão extrema ao tratamento anti-
Corresponding hipertensivo apresentaram escores mais altos na avaliação da qualidade de vida em
author Lisiane Tuon comparação com indivíduos classificados como não adesão extrema ao tratamento anti-
Universitária Avenue, 1105, hipertensivo.
Criciúma, SC, Brazil. Zip Code: Conclusão: A associação entre a qualidade de vida e adesão a medicação em indivíduos
88806-000 ltb@unesc.net hipertensos não foi preditiva, sendo que os melhores escores estavam presentes nos indivíduos
hipertensos que apresentaram alta adesão a medicação e os piores escores da qualidade de
DOI vida se apresentaram nos indivíduos de não adesão extrema e limítrofe a não adesão total.
http://dx.doi.org/10.1590/1982-
0194201500064 Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil.
1
Conflicts of interest: no conflicts of interest to declare.
Acta Paul Enferm. 2015; 28(4):381-7. 381

Association between quality of life and medication adherence in hypertensive individuals
Introduction Within this context, the present study aimed to

evaluate the association between quality of life and
Cardiovascular diseases are the third leading cause of medication adherence in hypertensive individuals.
the global burden of disease, (1) accounting for ap-
proximately 17 million deaths per year. Hyperten-
sion is considered the main risk factor contributing to Methods
the current epidemic of cardiovascular diseases.
5 Each year 7.1 million deaths worldwide are This is a cross-sectional study that included hyper-
at-tributed to hypertension and its prevalence has tensive individuals registered in the federal public
reached nearly 1 billion in 2000 around the computerized system in a city of southern Brazil,
world. This figure is projected to increase by from August to November 2011. The inclusion cri-
29.2%, reach-ing 1.56 billion in 2025.(3) teria were age equal to or over 18 years, diagnosis
Although the treatment for hypertension con-trol of hypertension, being registered at the health
reduces morbidity and mortality, the effective control district, and presence in the domicile at least once
of disease is concerning because the propor-tion of among the three visit attempts.
hypertensive patients with controlled disease has Two health districts were selected for conve-
varied around 50% worldwide.(4,5) nience, where 1,357 hypertensive subjects were
As hypertension is a chronic disease, it re- registered. A simple random sample was calculated
quires continuous treatment, and the adequate with a sampling error of 5% and 95% significance
control is directly related to the degree of ad- level, resulting in 258 hypertensive people in Dis-
herence to antihypertensive therapy.(6) There is trict A and 231 in District B, and the total of 489
evidence that poor adherence affects the clinical hypertensive subjects comprising the sample.
evolution and quality of life of patients negative- Data were collected in structured interviews
ly, causing adverse outcomes such as increased conducted in the homes of registered
morbidity and mortality.(7-9) hypertensive subjects. The interviews involved
The quality of life of hypertensive patients is issues related to socioeconomic and clinical data,
strongly related to how their blood pressure is the Instrument to Assess Treatment Adherence
con-trolled,(10) because symptoms caused by and the WHO-QOL-BREF.
unsatisfac-tory disease control limit the The socioeconomic characteristics were age,
performance of usual daily activities, resulting in gender, marital status, race, family income, educa-
financial difficulties, low self-esteem, feelings of tional level, height, weight, occupation, smoking and
incompetence, social isola-tion, among others.(11) drinking habits. The clinical features investigat-ed
Some studies evaluating the quality of life of were type and amount of antihypertensive drugs
hy-pertensive individuals have suggested that the administered, time from diagnosis of hyperten-sion,
very chronic condition, side effects of the drug systolic and diastolic blood pressure, type and
therapy and clinical complications interfere in the amount of medications prescribed for sleep.
physical, emotional and intellectual state, in social As participants are monitored monthly, infor-
interac-tion, and activities of daily living, which mation such as weight and height were collected
are decisive factors for quality of life. (12-14) from the records in the health booklet of the month in
The quality of life is part of a complex structure which was given medication for hypertension
with psychosocial characteristics that can negatively control. Blood pressure was measured by ausculta-
impact on individuals’ ability to manage their own tion performed with the subject seated 15 minutes
chronic disease, however, the exact mechanism by after initiation of the interview and the cuff at the
which quality of life is associated with treatment ad- level of the heart. Three measurements were taken
herence is still unknown.(15) with one-minute interval between each verification,
382 Acta Paul Enferm. 2015; 28(4):381-7.

Hanus JS, Simões PW, Amboni G, Ceretta LB, Tuon LG
and the mean of the last two was considered. For of Association or Independence. In all analytical
blood pressure measurement were used the calibrat- tests was used a significance level of ɑ=0.05 and
ed sphygmomanometer (Premium® brand) and the confidence interval of 95%.
stethoscope Rappaport model (Premium® brand). The development of the study met national
The Instrument to Assess Treatment Adherence and international standards of ethics in research
was applied to measure users’ treatment adherence. It involv-ing human subjects.
is a questionnaire with ten questions: 1) Adequate
consumption of salt; 2) Adequate consumption of fat;
3) Body mass index; 4) Smoking abstinence; Results
8 No alcohol intake; 6) Regular practice of phys-
ical exercises; 7) Effective stress coping; 8) Proper The 432 hypertensive participants had a mean age
use of medicines, 9) Attendance at monthly visits of 62.1 (±11.0 years), 68.5% were females, 67.8%
and 10) Control of blood pressure levels. The score had not completed elementary school, 44.9% stated
established for assessment of adherence to hyper- to be retired, and 82.9% were white. As for marital
tension treatment is 0-10, with the following clas- status, 73.1% reported living with a partner, 78%
sification of levels of adherence: X≤3 = Extreme reported family income of 1-3 times the minimum
non-adherence (ENA); X>3 and ≤5 = Borderline wage (Table 1).
to total non-adherence (BNA); X>5 and ≤7 = The mean time from diagnosis of respondents
Medium range of adherence (MRA); X>7 and ≤9 was 12.0 years (± 9.4 years). More than half of re-
= Border-line to total adherence (BA); and X>9 = spondents had undergone antihypertensive treat-ment
Extreme adherence (EA). The higher the score, the for more than six years, with medication ex-clusively
greater the adherence to treatment. as the most prevalent type of treatment. Interviewees
For the evaluation of quality of life, we used the used more than four drugs for their antihypertensive
WHOQOL-BREF, an instrument developed by the treatment, and the daily dose of drugs varied between
WHO Quality of Life Group, validated in Brazil, two to three doses in most cases. Physical activity
which has 24 questions covering the following do- practice was uncommon among participants, as
mains: physical, psychological, social relationships, 15.7% reported practicing it regularly, while 14.8%
environment, self-assessment and general assess- did not practice regularly. Smoking and alcohol
ment, providing a comprehensive look of quality of consumption occurred among hypertensive
life. The questionnaire scores the individual from 0 respondents, representing 11.1% and 13%,
to 100, and the higher the score, the better the quality respectively. Regarding consumption of salt in food,
of life. more than half revealed they considered it was
Data were tabulated and analyzed by both the little/weak (Table 1).
Microsoft Excel 2010® and the Statistical Package The analysis of the general classification of the
for the Social Sciences (SPSS), version 22.0. The quality of life and the classification of treatment
absolute and relative frequencies were calculated adherence of respondents were carried out. The
for the qualitative variables, and mean and quality of life assessed by the WHOQOL-BREF
standard de-viation for the quantitative variables. revealed the lowest scores in the domains of self-
Data normality was tested by the Kolmogor-ov- assessment 59.69 (±18.70) and physical 61.
Smirnov test, and since data were not normally 84(±18.06). The highest scores were found in the
distributed, the Kruskal-Wallis H test was used to psychological domain 67.89(±15.32) and the social
measure the association between the scales of quality domain 75.33(±13.20). As for treatment adherence,
of life and the classification of treatment adherence. we found that 40.5% of hypertensive subjects were
Finalizing our analysis, for the evaluation between classified in the medium range of treatment
the domains of quality of life and classification of adherence and 45.8% as borderline to total
treatment adherence, was used the Chi-square test adherence (Table 2).
Acta Paul Enferm. 2015; 28(4):381-7. 383

Table 1. Socioeconomic and hypertension profile of

interviewed individuals Continuation
n(%) n(%)
Variables Variables
n=432 n=432
Mean age 62.1(±11.00) Two doses 206(47.7)
Gender Three 159(36.8)
Male 136(31.5) >4 Doses 27(6.2)
Female 296(68.5) Daily use of medication
Family income Yes 344(79.6)
<1 minimum wage 20(4.6) No 88(20.4)
1-3 minimum wages 337(78.0) Physical activity practice (three or more times
per week)
4-6 minimum wages 61(14.1)
Regular 68(15.7)
>6 minimum wages 12(2.8)
Irregular 64(14.8)
Educational level
No practice 300(69.5)
Cannot read and write 37(8.6)
Smoking habits
Literate (can read and write the name) 20(4.6)
Yes 38(8.8)
Incomplete elementary school 293(67.8)
No 303(70.1)
Complete elementary school 44(10.2)
Sometimes 10(2.3)
Incomplete high school 8(1.9)
Quit 81(18.8)
Complete high school 26(6.0)
Alcohol intake
Incomplete higher education 2(0.5)
Yes, every day 6(1.4)
Complete postgraduate education 2(0.5)
Yes, on weekends 50(11.6)
Marital status
No 371(85.9)
Living with partner 316(73.1)
Abandoned alcohol 5(1.2)
Living with partner – unstable 4(0.9)
Opinion of salt intake in food
Does not live with partner 3(0.7)
Normal 164(38.0)
No partner 60(13.9)
Weak / Little 227(52.5)
Living alone 49(11.3)
Salty 41(9.5)
Occupation
Retired 194(44.9) Source: Data of hypertensive individuals followed in regional health units, Criciúma
(SC), 2011. Values expressed in number (%) or mean (± Standard deviation)
Pensioner 47(10.9)
Homemaker 116(26.9)
Unemployed 3(0.7) Table 2. Global scores of quality of life and
Others 72(16.7)
classification of treatment adherence
Religion
n(%)
Catholic 325(75.2) Variables
n=432
Evangelic 97(22.5) Domains of quality of life
No religion 6(1.4) Physical 61.84(±18.06)
Others 4(0.9) Psychological 67.89(±15.32)
Race Social 75.33(±13.20)
White 358(82.9) Environment 65.32(±11.10)
Brown 11.0(2.5) Self-assessment 59.69(±18.70)
Black 63(14.6)
General assessment 65.70(±11.80)
Time from diagnosis (Standard Deviation) 12.0(±9.4)
Classification of treatment adherence
Time of treatment
Extreme non-adherence 1(0.2)
<1 year 18(4.2)
Borderline to extreme non-adherence 31(7.2)
1-2 years 35(8.1)
Medium range of adherence 175(40.5)
3-5 years 85(19.7)
Borderline to total adherence 198(45.8)
6 years 27(6.2)
Extreme adherence 27(6.2)
>6 years 267(61.8)
Source: Data of hypertensive individuals followed in regional health units, Criciúma (SC), 2011.
Type of treatment Values expressed in Number (%) or Mean (± Standard Deviation); Statistical test: Kruskal-Wallis H test
Exclusively pharmacological 252(58.3)
Exclusively nonpharmacological 2(0.5)
Pharmacological + Nonpharmacological 178(41.2) The distribution can be observed according to
Number of drugs/day
A drug 40(9.3) the domains of quality of life obtained by the
Two drugs 83(19.2) WHOQOL-BREF questionnaire in relation to the
Three drugs 80(18.5)
classification of treatment adherence. In this
>4 drugs 229(53.0)
Number of doses/day analysis, the highest scores associated with
A dose 40(9.3) quality of life were found in extreme adherence
continue... (to treatment), revealing a mean score of 66.80
384 Acta Paul Enferm. 2015; 28(4):381-7.
in the physical domain, 72.38 in the psycholog- Discussion

ical, 79.63 in the social, 68.28 in the environ-
ment, 65.28 in self -assessment, and 69.91 in the The results of this study are related to the cross-
general assessment domain. The lowest scores in sectional design, which does not allow de-fining
quality of life were found in the classifications of relationships of cause and effect between
extreme non-adherence and of borderline to total variables. Note that much of the collected data
non-adherence. were self -reported, which can cause errors or
Although these results may suggest associa- dis-tortions by participants.
tion between treatment adherence and the scores Quality of life is a complex and subjective con-
obtained in the physical, psychological, social, struct that evaluates people’s health in a multifac-
environment, self- assessment and general torial way, in their physical and psychological con-
assess-ment domains, we did not find statistical dition, their level of independence, social relation-
signifi-cance, as shown in table 3. ships, personal beliefs and their relationship with
the environment. In this study, the highest scores in
quality of life were observed in the social and
psychological domains, and the lowest scores were
Table 3. Distribution of data on quality of life x
treatment adherence in the domains of self-assessment and physical. In
Quality of relation to the classification of treatment
Classification of treatment adherence
life
adherence, most participants were classified in the
Borderline
Extreme
to total
Medium
Borderline Extreme category of borderline to total adherence.
non- range of
Variables non- to total adherence p-value The investigation on the relation between the
adherence adherence adherence adherence n= 27
n= 1 n= 31 n= 175 n= 198 quality of life and the adherence to antihyperten-sive
Physical 0.649 treatment enables the development of strategies to
Mean 53.57 60.83 60.98 62.12 66.80
Mean CI - 54.65- 58.13- 59.61- 61.72-
expand assistance programs and policies, aim-ing to
(95%) 67.00 63.83 64.63 71.87 improve the adherence and quality of life of these
SD - 16.84 19.11 17.94 12.83
individuals, and seeking to achieve adequate disease
Psychological 0.151
Mean 50.00 63.84 67.24 68.58 72.38 control goals. There is an increasing search for
Mean CI - 57.97- 65.00- 66.43- 66.26- assessment of the quality of life of hypertensive
(95%) 69.72 69.48 70.73 78.49
SD - 16.00 15.02 15.35 15.47
subjects because this is considered an important in-
Social 0.105 dicator to identify the health status of individuals in
Mean 58.33 72.85 74.33 76.09 79.63 face of the results of antihypertensive treatments. (16)
Mean CI - 67.62- 72.44- 74.18- 75.30-
(95%) 78.08 76.23 78.00 83.95 Besides medical treatment, it is essential that hy-
SD - 14.27 12.71 13.62 10.92 pertensive individuals follow a nonpharmacological
Environment 0.341
Mean 53.12 62.50 65.32 65.41 68.28
treatment, which consists of care for the manage-
Mean CI - 57.57- 63.72- 63.84- 64.74- ment of weight control, diet, reduction of salt and
(95%) 67.43 66.93 66.98 71.83 alcohol consumption, smoking abstention, stress
SD - 13.43 10.76 11.22 8.95
management and regular practice of physical activi-
Self- 0.403
assessment ty.(17) The findings of this study showed that among
Mean 37.50 57.66 58.64 60.29 65.28 the possible managements of nonpharmacological
Mean CI - 50.02- 55.82- 57.70- 58.94-
(95%) 65.30 61.46 62.88 71.61
treatments, the regular practice of physical activity
SD - 20.84 18.89 18.48 16.01 was the item of greatest commitment, since more
General 0.178 than 50% of participants did not have this habit.
assessment
Mean 51.92 63.18 65.12 66.10 69.91 The quality of life of hypertensive individuals
Mean CI
(95%)
- 58.47-
67.89
63.39-
66.85
64.40-
67.80
66.55-
73.27
ends up being worse when compared to healthy in-
SD - 12.84 11.59 12.10 8.49 dividuals. Also, it is dependent on blood pressure
Source: Data of hypertensive individuals followed in regional health units, Criciúma (SC), 2011.
Mean (± Standard Deviation); Statistical test: Chi-square test of association or independence
levels, damage to organs, comorbidities (including
Acta Paul Enferm. 2015; 28(4):381-7. 385

obesity) and treatment (both pharmacological Within this context, a prevalence study was car-
and nonpharmacological).(18) A major challenge ried out in 2010 with 385 hypertensive in two hos-
in con-trolling blood pressure is still due to non- pitals that serve 70% of the Pakistani population. It
adherence to treatment.(12) showed that the relationship between treatment
A randomized clinical trial conducted at the adherence and the quality of life of hypertensive
Cardiology Institute in the city of Kanpur in In-dia, subjects was apparent, i.e., it was not a determinant
evaluated the quality of life of 102 hypertensive factor related to worse quality of life. This charac-
subjects in follow-up by the service. The quality of teristic may indicate that other factors are affecting
life was similar to the findings of the present study, the quality of life during the course of treatment. (22)
noting that the highest scores were in social and A recent systematic review and meta-analysis of
psychological domains, and the lowest scores were observational studies evaluating the quality of life in
found in the domains of self-assessment and phys- hypertensive patients found that hypertension reduces
ical condition. Comparing variables such as age and the quality of life, though in small magni-tude. (4)
gender, the profile of hypertensive individuals is However, the study carried out by Lambert and cols.
similar.(17) Such a comparison may indicate that the (23) suggests that the quality of life in hyper-tensive
hypertensive population has similar character-istics, individuals can be decreased, and also indi-cates that
given that a cross-sectional study carried out with the actual effect of high blood pressure on the quality
2,063 hypertensive patients who attended the of life is still poorly understood.
hospital Isfahan in Iran has found similar data. It
revealed that females were predominant over males,
and the prevalence of hypertension is present in in- Conclusion
dividuals aged 60 years or older.(19)
Comparing the mean values obtained from The association between quality of life and medica-
the scores of the quality of life instrument in our tion adherence in hypertensive patients was not pre-
study, with data from a randomized clinical trial dictive. The hypertensive subjects with high med-
held in Hangzhou (China) with 73 hypertensive ication adherence presented the best scores, while the
patients, the scores are similar, highlighting that worst scores of quality of life were presented by
the social domain had the highest score, and the individuals classified as extreme non-adherence and
domain of assessment of general health status as borderline to total non-adherence.
had the lowest score in both studies.(6)
Another study showed that normotensive subjects Collaborations
had better scores, and a statistically significant differ- Hanus JS participated in the conception and design of
ence was associated only to the environment domain. the project, analysis and interpretation of data, article
This matter suggests that hypertensive individuals may writing and critical review of the relevant intellectual
have lower quality of life scores than normotensive in- content, and final approval of the version to be pub-
dividuals, but their quality of life may not necessarily lished. Tuon LGB and Simões PW contributed to the
be associated with the disease.(11) interpretation of data, relevant critical review and final
Poljičanin et al. suggested that hypertensive approval of the version to be published. Ceretta LB and
patients have the perception of being chronically Amboni G collaborated with the project design and
sick, therefore, they feel more fragile, which final approval of the version to be published.
ends up negatively affecting their quality of life.
(20) The perception of having a chronic disease
may be re-lated to the problems faced by these References

individuals in self-care activities, such as in
blood pressure con-trol, nutrition, weight * Moser KA, Agrawal S, Smith GD, Ebrahim S. Socio-demographic
inequalities in the prevalence, diagnosis and management of
control, care of stress and physical activity.(21)
hypertension in India: analysis of nationally-representative survey data.
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Open Access
Original Article
Depression, anxiety, stress and demographic

determinants of hypertension disease
Mamoona Mushtaq1, Najma Najam2
ABSTRACT
Background and Objective: Research evidence supports the relationship of psychological and
demographic factors with hypertension and these variables are strongest predictors of hypertension
which are scarcely studied in Pakistan. The present study was carried out to explore the correlation of
depression, anxiety, stress and demographic factors with hypertension.
Method: We used correlation research design and a sample of (N = 237), hypertensive patients (N = 137)
and their age matched healthy controls (N = 100) was taken from hospitals. Depression, Anxiety and
Stress Scale (DASS) (Lovibond & Lovibond, 1995) was used to assess depression, anxiety and stress.
Results: Results indicated significant positive correlation between depression (χ 2MH = 104.18, p < 0.001),
anxiety (χ2MH = 78.48, p < 0.001), stress (χ2MH = 110.95, p < 0.001) and overall negative states (χ 2MH =
97.43, p < 0.001) with hypertension. Depression (OR = 1.44, p < 0.01), anxiety (OR = 1. 76, p < 0.01)
stress (OR = 1.37, p < 0.01), job and dependents, working hours and weight turned out as predictors of
hypertension. Conclusion: Hypertension has significant positive relationship with depression, anxiety,
stress and with demographic variables. The findings of the present study will contribute in the existing
knowledge of health professionals to enhance public awareness regarding the harmful outcomes of
depression, anxiety and stress upon human health.
KEY WORDS: Anxiety, Depression, Stress.
doi: http://dx.doi.org/10.12669/pjms.306.5433
How to cite this:
Mushtaq M, Najam N. Depression, anxiety, stress and demographic determinants of hypertension disease. Pak J Med Sci
2014;30(6):1293-1298. doi: http://dx.doi.org/10.12669/pjms.306.5433
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION increase of hypertension among different nations is

a serious issue these days. There were 26%
Escalating health problems in the world necessitate hypertensive adults in America in 2000.1 About
health professionals and researchers to investigate the one billion people are suffering from hypertension
factors responsible for the development of different globally and the prevalence rate will increase up to
diseases in human beings, and one of them includes 1.56 billion by 2025.2 It is reported that consistent
hypertension. Pervasive high blood pressure is damaging the health of
almost 25% of youngsters of both sexes. 3 The
6 Mamoona Mushtaq, PhD, alarming point is that more than 50% hypertensive
7 Najma Najam, PhD, patients do not even know that they are suffering
1-2: Institute of Applied Psychology,
University of the Punjab,
from it.4
Lahore, Pakistan. In Pakistan, the prevalence of hypertension is
Correspondence: 34% in men and 24% in women. 5 Hypertension is
frequently prevalent in men after 35 years of age
Dr. Mamoona Mushtaq,
Assistant Professor of Psychology, than women of that age. Additionally there are an
Govt. M. A. O College, Lahore, Pakistan. estimated 12 million hypertensive patients in
E-mail: mamoonamushtaq@gmail.com
Pakistan.6 Furthermore, in Rawalpindi Division
* Received for Publication: April 10, 2014 about 24.3% of the population over the age of 18
* Revision Received: July 12, 2014 years and overall 36% of population is reported to
* Revision Accepted: July 29, 2014
Pak J Med Sci 2014 Vol. 30 No. 6 www.pjms.com.pk 1293

Mamoona Mushtaq et al.
have high blood pressure. Whereas reported 15% Although the field of psychological risk factors of
over the age of 18 years and 36% over the age of 45 hypertension is not a new subject, still very few
years have the diagnosis of hypertension. 6 Thus it scientific studies have been carried out in developing
appears to be rapidly increasing, neither treated countries especially in South Asia. Regardless of its
nor controlled. Hence, it is emerging as a major significance, psychological aspects of hypertension
health menace in the public health sector.7 have always been overlooked by researchers and
Biological, social and psychological factors are physicians. Few researches conducted in this area are
often considered as significant risks of based upon the data drawn from lower masses
hypertension. Psychological state of an individual only.17Growing literature on hypertension reports
greatly affects the physical condition of human that hypertension control in Pakistan is partially
body. Empirical evidence reports high incidence of achieved.7Therefore, the research was planned to
depression, anxiety and stress among patients with explore the relationship of hypertension with
hypertension.8 Depression is widespread in depression, anxiety, stress, and demographic factors
hypertensive patients and relationship of among hypertensive patients.
depression with hypertension has been established Hypotheses:
by earlier researchers.9 In a study, individuals 9 Depression, anxiety and stress would be
reporting high levels of hopelessness at baseline positively correlated with hypertension among
were found to be 3 times more likely to become hypertensive patients.
hypertensive in near future.10 The research 10 Depression, anxiety, stress and other social
evidence also suggests that anxiety is another variables would be significant predictors of
significant cause of increased blood pressure and is hypertension.
independent predictor of future hypertension.11,12
11 There would be difference on depression,
Stress has been considered an important factor in anxiety and stress between hypertensive men
the etiology of hypertension. Stress is known to be
and women.
significantly correlated with hypertension and
causes many cardiac problems. 13 Natural reaction METHODS
of the cardiovascular response to stress is the
increase in heart rate. Young adults who have Participants and procedure: We used co relational
greater blood pressure response to stress may be at research design for this research. A sample of 237
risk for hypertension as they are grown up.14 participants, hypertensive men (n = 77), women (n
The role of demographic variables is vital in * 60), non-hypertensive men (n = 50), and women
leading to hypertension. Marked social disparities (n = 50), was taken from outdoor departments of 2
in individual’s health exist across all nations of the public hospitals using a purposive sampling
world. Whether the indicator of socioeconomic technique.
status is education, income or occupational status, Inclusion criteria: Inclusion criteria for
people belonging to low SES are at a greater risk of hypertensive patients was (a) those patients who
inducing sickness and easily become victims of had currently been taking antihypertensive
disability or premature death than people medicines (b) participants who were able to read
belonging to high SES. 15 Higher education affects and write Urdu language.
health promoting behavior and resultantly causes Exclusion criteria: Patients suffering from chronic or
lowering prevalence of overweight, which is an terminal illness including (a) coronary heart disease
established risk factor of hypertension.15 Another (b) liver disease (c) renal disease (d) diabetes
important contributing variable to hypertension is (e) malignant disease like cancer. Non-
overweight and obesity.16,17 Long and strenuous hypertensive group: They were matched to every
working hours which is the part and parcel of case of hypertension for age (up to 3 years older
private job culture, is a significant risk factor of and younger), gender, monthly income and
hypertension.18 Therefore the role of social working hours. Non-hypertensive group was
variables need to be understood.14 In the present taken from the hospital and they were the visitors
study, it was predicted that those who experience or non-blood relatives of the cases diagnosed with
high level of depression, anxiety and stress, and hypertension, (b) participants with no past, current
with circumstantial difficulties consequently suffer or family history of hypertension were included in
from hypertension. In other words, are these the sample.
factors correlated with hypertension? Sample characteristics: The age range of the study
participants was from 30 to 65 years (M = 43; SD =
1294 Pak J Med Sci 2014 Vol. 30 No. 6 www.pjms.com.pk

Depression, anxiety & stress in hypertension
Table-I: Demographic characteristic of the research participants (N = 237).

Demographic variables Hypertensives (n = 137) Controls (n =100 )
f % f %
Gender Men 77 56 50 50
Women 60 44 50 50
Occupation No job 50 36 42 42
Office job 62 45 36 36
Business 17 13 18 18
Both 8 6 4 4
Family history of hypertension No 7 5 94 94
Yes 130 95 6 6
Spouse job No 88 64 53 53
Yes 49 36 47 47
8.24). The range of their number of dependents RESULTS

was from 0 to 11. Their weight ranged from 63 to
98 kg (M = 73; SD = 8.02), and working hours from Relationship of depression, anxiety and stress
4 to 16 hours (M = 8.80; SD = 4.08). with hypertension: Mentle Haenzel Chi-square test
Official permission was obtained from hospital of linear association was applied for exploring
authorities for data collection from hypertensive relationship of depression, anxiety and stress with
patients and healthy controls who were visiting the hypertension. If the exposure variable is ordinal,
hospital. Before administration of questionnaires the ordinary chi-square test does not take into
participants were briefed about the purpose of account the inherent order among the categories. It
study. A consent form, demographic information hardly checks the overall departure of observed
form and DASS were independently administered from expected across the r ×2 cells of the table. A
to all research participants. test of linear association (Pearson Chi-square)
between columns and rows will be statistically
Instruments: insufficient, because it fails to distinguish between
1. Demographic information questionnaire: one and two category differences. 21 In the present
Participants completed a comprehensive research each dimension of depression, anxiety
demographic information questionnaire which and stress were categorized in to 3 levels like high,
was prepared by the researchers regarding the medium and low, but the levels are not given in
age, marital status, education, occupation, the table because in all cases “high” was
monthly income, weight, number of children significantly related with hypertension.
and dependents, family history of The results in the Table-II show that there is
hypertension, spouse’s job and working hours significant correlation of hypertension with
of the research participants. depression, anxiety, stress and (DASS) (***p <
† Depression, Anxiety and Stress Scale by Lovibond 0.001). The reliability coefficients indicate that the
& Lovibond (1995):19 DASS is an internationally scales were reliable for the present sample.
standardized protocol. It is a self report Effect of depression, anxiety and stress on
instrument designed to measure 3 relatively hypertension: Binary logistic regression model
negative states of depression, anxiety and stress
Table-II: Relationship between depression, anxiety,
of an individual. It consists of 42 items. Each item
stress and hypertension (N = 237)
has four optional responses which are scored on
Variable M SD α χ2MH (df = 1)
Likert scale from 0 (did not apply to me at all) to 3
Depression 15.78 11.49 0.91 104.18***
(applied to me very much). Cronbach’s α = 0.91
Anxiety 20.62 13.94 0.84 78.48***
for depression scale,
Stress 21.42 11.10 0.90 110.95***
0.84 for anxiety scale and 0.90 for stress scale
DASS 57.62 32.91 0.91 97.43***
are reported by authors.19 In the present study
Note: M = Mean scores; SD = Standard deviation; χ2MH
standardized Urdu translation of DASS by † Maentle Haenzel Chi-square; α = reliability coefficient;
Potangaroa (2006) was used.20 *** = p < 0.000.
Pak J Med Sci 2014 Vol. 30 No. 6 www.pjms.com.pk 1295

Table-III: Depression, anxiety and stress independently Analysis of coefficients: The value of R2 = 62.43
associated with hypertension in hypertensive cases and shows that model is adequately fit and social
controls (N = 237). variables are contributing 62.43% in the hypertension.
Variable B S.E LL OR UL The odds ratio for office job is 1.14 and B = 0.31, and
Constant -13.45** 4.90 the coefficient is positive, therefore as office job
Depression 0.36** 0.13 1.10 1.44 1.88
increases by one scale unit chances of hypertension is
increased 1.14 times. Protective effect of monthly
Anxiety 0.56*** 0.24 1.09 1.76 2.85
income and spouse job is significant in hypertension.
Stress 0.31* 0.15 1.01 1.37 1.85
The odds ratio for monthly income is 1.23 and B =
DASS 0.75*** 0.21 1.45 1.85 3.05
-0.45. The coefficient is negative and odds ratio is
Note: R² = 55.51, Hosmer & Lemeshow), 270 (Cox & 1.23, consequently as the income is increased by one
Snell), .68 (Negelkerke). Model χ2 (21) = 51.60; LL
scale unit chances of hypertension is decreased by a
* p < 0.05, ** p < 0.01.
factor of 1.23 times. The odds ratio for spouse’s job is
was run to find depression, anxiety and stress as 1.64 and B = -0.42, so as spouse job is increased by
predictors of hypertension. one scale unit chances of hypertension is decreased
Analysis of coefficients: The odds ratio given in 1.64 times. The odds ratio for number of dependents
Table-III for depression is 1.44 and coefficient is is 1.42 and B = 0.34. The odds ratio is 1.42, each unit
positive. The value of the coefficient (0.36) reveals increase in the scores of number of dependents is
that an increase of one unit scale in depression is associated with the odds of hypertension increase by
associated with increase in the odds of hypertension a factor of 1.42 (95 % CL, 0.74-1.85). Similarly weight
development by a factor of 1.44 (95% CI, 1.10-1.88, p < and working hours turned out as significant
0.01). The odds ratio for anxiety is 1.76 and B = 0.56. predictors of hypertension (95 % CL, 0.70-1.71, & 95
The coefficient is positive and the odds ratio is 1.76, % CL, 1.03-2.27) respectively.
therefore as the anxiety increases by one scale unit, Difference of variables was also investigated and
chances of hypertension in a person is increased 1.76 significant differences were observed between
times. The OR for stress is 1.37 and coefficient is hypertensive men and women on depression (M =
positive. The value of the coefficient (.45) reveals that 19.82, SD 4.65 & M = 43.53, SD = 10.58, p < 0.001),
an increase of one unit scale in stress is associated anxiety (M = 33.27, SD = 11.92 & M = 19.40, SD =
with increase in the odds of hypertension 6.58, p < 0.001) and stress (M = 47.33, SD 8.53 & M
development by a factor of 1.37 (95% CI, 1.01-1.85, p < = 24.50, SD = 6.52, p < 0.001) respectively.
0.001). Finally the value of combine effect of
DISCUSSION
depression, anxiety and stress (DASS) come out as
predictor of hypertension (95 The present research was conducted to explore the
ß CI, 1.45-3.05, p < 0.001). The prediction value of relationship of hypertension with psychological
R2 = 55.51 indicates that model is adequately fit correlates and to find the significant predictors of
and psychological correlates are contributing hypertension. Inclusion of the control variables
55.51% in the hypertension development. ensured that relationship between psychological
Effect of social variables on hypertension: Logistic variables and hypertension did not owe to these
regression analysis was run to examine social variables. The results of the current study indicate
variables as predictors of hypertension. that hypertension has significant positive
Table-IV: Demographic factors predicting hypertension (N = 237).
Variable B S.E LL OR UL
95% CI
Constant -4.13 0.97
Office job 0.31** 0.17 0.91 1.14 1.72
Monthly income -0.45*** 0.18 1.74 1.23 1.97
Spouse’s job -0.42** 0.23 1.05 1.64 1.83
Number of dependents 0.34** 0.15 0.74 1.42 1.85
Weight 0.28** 0.12 0.70 1.10 1.71
Working hours 0.40** 0.17 1.03 1.56 2.27
Note: R² = 62.43; Hosmer & Lemeshow); 27.31 (Cox & Snell), 0.71 (Negelkerke) Model χ2
(21) = 51.32, **p < 0.01, ***p < 0.001
1296 Pak J Med Sci 2014 Vol. 30 No. 6 www.pjms.com.pk

Depression, anxiety & stress in
hypertension
relationship with depression, anxiety, stress and
with demographic variables. Furthermore men. Moreover, number of dependents appeared
depression, anxiety, stress, monthly income as a significant predictor of hypertension. This
number of dependents, spouse’s job and working explains that more the number of family members
hours turned out to be significant predictors of more the expenditures would be. In Pakistan
hypertension. when women work to add family resources they
The results reveal that there is significant protect their counterparts from being
relationship between depression and hypertension. hypertensive as revealed in the current research.
This finding is in accordance with previous findings In the present research weight appeared as a
which concluded that depression is correlated with significant predictor of hypertension, which is
hypertension and also predicts hypertension. 18 It is consistent with earlier researches in Pakistan. 16,17
reported that the individuals experiencing high Hypertensive patients are not in the habit of going
levels of hopelessness at baseline were 3 times more to gyms to work out and seldom or never do
likely to become hypertensive in near future. 10 cardio exercises.
However researchers also agree that depression and Finally significant gender differences were also
hypertension are reciprocally correlated, depression seen between hypertensive men and women on
leads to hypertension22 and hypertension raises the depression, anxiety and stress. Thus the findings
level of depression.12 of current research establish the role of
Additionally, as hypothesized relationship of depression, anxiety, stress and social factors in
hypertension with anxiety remained statistically developing hypertension.
significant and anxiety was observed a very serious
Limitations: The present research was conducted
disease which brings about harmful effects upon
body.22 Enough research evidence supports anxiety with relatively small sample, thus the need for
as a single most cause of hypertension. 23 It is also further replication is indicated. Moreover, we did
reported that participants developing hypertension not study the covariate factors such as BMI, type
at later stage, have significant anxiety at the baseline of food and smoking. Thus limiting the findings
stage as compared to the participants who remained of present research.
non hypertensive.24 Thus it may be concluded that
anxiety and depression are significant predictors of Implications: As reported by Jaffer, Chaturvedi, and
hypertension.10 Pappas, (2006) high prevalence rate of hypertension
Moreover, stress has been considered a main cause is found among children in Karachi city.17 The
in the etiology of hypertension.13 In a study the findings of the current research can be highlighted
significant effect of laboratory stress was greater through media and public health awareness
upon hypertensives as compare to non-hypertensive programs to prevent the future generations from
controls.13 Existing literature has reported the hypertension. The early identification of negative
relationship of depression, anxiety and stress with emotions in causing hypertension in America has
hypertension.25 Present findings are consistent with yielded some promising results in treating it. The
previous findings, which, convincingly demonstrate findings of this research have implications for
a positive correlation between psychological stress
promoting the understanding of psychological
and hypertension.6,13,15 Hypertension may rightly be
called an emotional disease. If the individual
and demographic factors of hypertension in
combats with severe conflict or frustration, Pakistani population.
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RESEARCH ARTICLE

Sedentary Behavior and Light Physical Activity

Accepted: December 11, 2015 Methods

paper and its Supporting Information files.

Funding: AMG was supported by a grant (PhD scholarship) Results

Desenvolvimento Científico e Tecnológico (CNPq) (grant

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 1 / 13

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 2 / 13

Physical activity assessment

Primary outcome measures

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 3 / 13

Secondary Outcome Measures

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 4 / 13

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 5 / 13

Variable Mean (SD)

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 6 / 13

Low(< 492.42) Mean(492.42–570.67) High(> 570.67) Low(< 297.54) Mean(297.54–356.86) High(>356.86)

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 7 / 13

Model 1* Model 2**

ß (95% CI) P ß (95% CI) P

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 8 / 13

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 9 / 13

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 10 / 13

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 11 / 13

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 12 / 13

PLOS ONE | DOI:10.1371/journal.pone.0146078 December 30, 2015 13 / 13

http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits

Rohmah Syahitd h, Choirun Nissa Vol. 7, No. 1, Desember 2018 (54-62)

Keywords: physical activity, stress, prediabetes

Kata kunci: aktivitas fisik, stress, prediabetes, tekanan darah

PENDAHULUAN GDP: 100-125 mg/dL) dan toleransi glukosa terganggu

BAHAN DAN METODE Variabel perancu adalah asupan lemak, sodium,

Tabel 1. Karakteristik Subjek Penelitian

Tabel 3. Gambaran Asupan Subjek.

Sebagian subjek (53,6%) memiliki tingkat stress Asupan Subjek

Variabel Tekanan Darah Sistolik Tekanan Darah Diastolik

PEMBAHASAN wanita prediabetes lebih tinggi dibanding non-

Table I. Inclusion/exclusion criteria

Assessed for eligibility

Did not meet inclusion criteria based on screen (n = 10,025)

Did not complete informed consent

Did not complete initial survey

Screened for blood

Did not provide blood pressure measurement

Did not meet inclusion criteria based on blood pressure

Medisafe arm Control arm

Consort diagram of enrolled study participants.

Table II. Outcomes

Primary (1) Change in blood pressure from baseline to 12 wk after randomization

and, as part of the intervention, patients received

Available from: http://www.turner-white.com/pdf/ jcom_mar14_hypertension.pdf].

Association between quality of

Conflicts of interest: no conflicts of interest to declare.

Acta Paul Enferm. 2015; 28(4):381-7. 381

Introduction Within this context, the present study aimed to

382 Acta Paul Enferm. 2015; 28(4):381-7.

Acta Paul Enferm. 2015; 28(4):381-7. 383

Table 1. Socioeconomic and hypertension profile of

in the physical domain, 72.38 in the psycholog- Discussion

Acta Paul Enferm. 2015; 28(4):381-7. 385

may be re-lated to the problems faced by these References

386 Acta Paul Enferm. 2015; 28(4):381-7.

Depression, anxiety, stress and demographic