Lubna Raza  ( Dow Medical College, DUHS, Karachi )
Afrina Raza  ( Unaiza College Of Medicine, Qassim University, Saudi Arabia )
Arif Ali  ( Dow University of Health Sciences, Karachi )
Abid Hasnain  ( Department of Food Science and Technology, University of Karachi, Pakistan )

Objective: To compare the occurrence and to determine relationship of dietary practices with hypertension between housewives and working women.
Methods: The cross-sectional study was conducted at Karachi University and Dow University of Health Sciences, Karachi, from January to April 2015, and comprised working women and housewives who were enrolled using convenient sampling. Data was collected on consumption of fruits, vegetables, poultry/fish and fast food. Blood pressure and body mass index were noted and interpreted according to World Health Organisation classification for Asian population. Normal reference range of blood pressure was taken as Systolic100-120mmHg, Diastolic 60-90 mmHg, and mean value as 120/80mmHg. Data analysis was done using SPSS17.
Results: There were 600 subjects; with 300(50%) housewives and as many working women. Mean age of housewives was 35.56}7.53 years, and that of employed women 35.44}6.65 years. Among the housewives, 96(32%) had normal blood pressure while the corresponding number in the other group was 198(66%) (p<0.001). In terms of relationship body mass index with hypertension, out of the 204(68%) hypertensive housewives, 90(44.1%) were overweight, and of the 102 hypertensive working women, 40(39.23%)  had normal weight range. Most housewives reported a sedentary lifestyle as opposed to working women (p<0.001).
Conclusion: Being a housewife was in itself found to be a contributing factor in hypertensive disorders.
Keywords: Dietary habits, Working women, Housewives, Blood pressure. (JPMA 69: 857; 2019)
`
Introduction

In the developing countries the risk of high blood  pressure (BP) and ischaemic heart problems is graduallyincreasing in addition to malnourishment and infectious diseases and the already limited funds and resources of the developing countries and their health systems are  unnecessarily being utilised to combat this problem.¹ Astudy done in Punjab shows crude prevalence of  hypertension (HTN) as 35.1% and age-standardisedprevalence as 34.4%.² Another study outcome pointed towards increased prevalence as well as less control of high BP in the population. The total occurrence of HTN was 26% and was 24% in women. ³ In order to manage the threat of HTN disorders, preventive methodology like dietary changes and lifestyle modifications should be adopted because of low availability of medical care of the disease and its complications. A healthy diet can lower BP and prevent HTN because it has plenty of vitamins fibre, and other nutrients which help to prevent certain diseases. For example, it can reduce weight and cholesterol and help control systolic blood pressure (SBP) up to 11mmHg. Lifestyle intervention trials have uniformly achieved short-term weight loss, primarily through a reduction in total caloric intake. The current challenge to healthcare providers, researchers, government officials and the general public is developing effective strategies that lead to sustained dietary changes among populations groups. ⁴ Elevated BP results from environmental factors, genetic factors and interactions among these factors. Out of the environmental factors, diet has a prominent and likely predominant role in homeostasis. In non-hypertensive individuals, including those with prehypertension, dietary changes have the potential to prevent HTM and thereby lower the risk of complications. ⁵ Women comprise nearly half of the community, and their health directly have impact on the whole family. Mothers with healthy behaviors pass them on to their children. ⁶  Towards midlife, women are exposed to multiple cardiovascular disease (CVD) risk factors, including HTN. Several studies have demonstrated the link between occupation and health in women. CVD risk factors, particularly HTN and obesity also occur with different frequencies in employed women and housewives, with  homemakers showing an increased risk of HTN in contrast to employed women. ^7,8The current study was planned to assess HTN prevalence among housewives and working women, and to determine the relationship of dietary practices with HTN.

Subjects and Methods

The cross-sectional study was conducted at Karachi University (KU) and Dow University of Health Sciences (DUHS), Karachi, from January to April 2015, and comprised working women and housewives who were enrolled using convenient sampling. The subjects were from middle socioeconomic background and were aged 35-45 years. The sample size was calculated using online software Open Epi version 3. ⁹ Considering 95% confidence level with 80% of power, the total calculated sample size was 578 with 289 for each group. We added 4% to cover up for non-respondents. ¹⁰The employed women were working at DUHS and KU, while the housewives were mostly residents of the KU Staff Town. The housewives selected were those who had a minimum of 14 years of education to minimise the confounding effect of knowledge levels between the study groups. Women who had HTN history during pregnancy or were suffering from diabetes, heart diseases, arthritis, tuberculosis and other organic and infectious diseases were excluded. The questionnaire (Annexure)



addressed items about demographic profile, household income, time spent for household support, number of children etc. Participants also answered questions about dietary practices. Data was collected using food frequency questionnaire for dietary habits on dairy, fruit, vegetable, poultry/fish water consumption. Body weight, heights were taken and body mass index (BMI) was calculated and interpreted using standard methods. ¹¹ BP was recorded by sphygmomanometer. BP of the participants was measured twice with the gap of half-an-hour to minimize chances of error. Normal reference range of BP was taken as Systolic 100-120mmHg, Diastolic 60-90mmHg, and mean value as 120/80mmHg.12 Verbal consent was taken from every participant. Data was collected by volunteers who already had practice of measuring BP. Data was analyzed using SPSS 17. The results were considered statistically at p<0.005. Data and analysis related to BMI, assessment of depression level and awareness of calcium and vitamin D deficiency mentioned in the questionnaire have already been published. ^13-15

Results

There were 600 subjects; with 300(50%) housewives in group 1 and as many working women in group 2. Mean age in group 1 was 35.56}7.53 years, and that of group 2 was 35.44}6.65 years (p=0.827). The mean period of marriage was higher in housewives 13.01}9.32 years than working women 11.00}7.14 years (p=0.003). Mean number of children was 3.16}1.97 in group 1 and 2.63}1.59 in group 2 (p<0.001). In group 1, normal BP was found in 96(32%) subjects, while 198(66%) has normal BP in group 2. The hypertensive category showed 204(68) housewives compared to 102(34%) working women (Table-1).



While observing relationship of BMI with HTN, out of 204(68%) hypertensive housewives, 90(44.1%) were overweight. Of the 102(34%) hypertensive working women, 40(39.23%) had normal weight range (Table-2).



Relatively healthy dietary practices were witnessed among working women, but more women with normal BP in both groups were found to be consuming diet containing fruits, green vegetables, whole grains, pulses, poultry and fish (Table-3).



Discussion

This study found the occurrence of HTN among housewives to be 68% versus 34% in working females. Also, out of 204 hypertensive housewives, 90(44.1%) were overweight in contrast to 16(15.7%) from the working class. That could be due to the fact that working women have better dietary choices and practices including number of meals per day. Even though most of the working women displayed normal BP, surprisingly, among the 102 hypertensive working women, 40 were those who showed normal weight. The reason could possibly be work-related stress as witnessed in other studies. ^16,17By observing the specific details, like number of meals consumed per day, more housewives were noted as hypertensive in all categories in contrast to working women. Although the result was not significant, more housewives in our study responded that their lifestyle was sedentary compared to that of the working women. A study in Iran also showed that 17% housewives and 9% working women had 4-6 CVD risk factors. ¹⁸ A cross-sectional study of middle-aged Japanese population inspected the relationship of food intake habits and dietary patterns to BP, and after adjustment for confounding factors, the results suggested that habitual intake of dairy products, fruits and meat or chicken may have been associated with the reduction of BP possibly through the intake of protein and potassium. ¹⁹ In the current study, 18 working women and 58 housewives were hypertensive among those who consumed more than 6 ounces of fish or poultry. Furthermore, a greater number of women in both groups — 92 housewives and 82 working women — had high BP who consumed less than 6 ounces of fish or poultry. Research about fruit and vegetable consumption has documented that increased fruit and vegetable intake lowers BP. ^20,21 Almost similar outcomes were noted in our study which demonstrated that greater numbers of hypertensive housewives were seen in the category that was taking less than two servings as well as rare usage of fruits. As far as working women are concerned, no significant difference was noted except for the unexpected more normotensive women who were not used to eating fruits regularly. In the Dietary Approaches to Stop Hypertension (DASH) trial, the groups that increased fruit and vegetable consumption achieved the target of reducing BP. ²² Another study showed that the effect of interventions on housewives was more significant. ²³ In the current study, overall more housewives were hypertensive in all categories of vegetable use. In addition to this, although, generally the number of working women was more in the normotensive group, there were more working women with high BP in the category consuming less than 3 servings of vegetables compared to women eating more vegetables, thereby validating the benefits of vegetable intake. Surprisingly, when the consumption of fast food items was noted, majority of women in both groups responded that they had it sometimes (166 housewives and 170 working women). However, a big number was seen in normotensive category of working women (112) as well as many housewives (54) also showed normal BP. To sum up the consumption of fast food, it was obvious that overall more housewives were hypertensive irrespective of the frequency of fast food usage. In a study done to assess the consumption of fast food items, the number of working women was more in comparison to housewives. But this was noted for the period of the work timings only. The possible reason could be their specific lifestyle along with more hours spending outside home and hence less availability of household items of food. ²⁴ In terms of study's limitations, the ideal check for HTN would have been through multiple readings over a period of one month but due to time constraints, limited human resource and availability issues of the subjects, data was limited to only two readings. Another limitation of the study was that mostly the participants responded that their parents were on hypertensive medicines but they were not sure at what age those medicines had been started, so the family history of HTN could have affected results. Despite the limitations, the information obtained from the study can be utilised to prevent and control HTN as well as promotion of healthy dietary practices, especially in the women population of developing countries. Also, it highlights the need for community-based interventions, especially those targeting housewives.

Conclusion

Diet rich in fibre, minerals, vitamins and healthy proteins was found to be linked to normal BP. Also, among hypertensive women, there were more housewives in contrast to working women, suggesting that being a housewife in itself was also a contributing factor for high BP.

Disclaimer: The article is part of a PhD thesis.
Conflict of Interest: None.
Source of Funding: None.

References

1. World Health Organization. Diet, nutrition, and the prevention of chronic diseases: report of a joint WHO/FAO expert consultation. The World Health Organization. Geneva: Switzerland, 2003; pp 149.
2. Shafi ST, Shafi T. A survey of hypertension prevalence, awareness, treatment, and control in health screening camps of rural central Punjab, Pakistan. J Epidemiol Glob Health 2017;7:135-140. doi: 10.1016/j.jegh.2017.01.001.
3. Safdar S, Omair A, Faisal U, Hasan H. Prevalence of hypertension in a low income settlement of Karachi, Pakistan. J Pak Med Assoc 2004;54:506-9.
4. Appel LJ, Brands MW, Daniels SR, Karanja N, Elmer PJ, Sacks FM. Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association. Hypertension 2006;47:296-308. doi: 10.1161/01.HYP.0000202568.01167.B6
5. Kastarinen M, Laatikainen T, Salomaa V, Jousilahti P, Antikainen R, Tuomilehto J, et al. Trends in lifestyle factors affecting blood pressure in hypertensive and normotensive Finns during 1982- 2002. J Hypertens 2007;25:299-305. doi:  10.1097/HJH.0b013e328010ca88
6. Colchero MA, Caballero B, Bishai D. The effect of income and occupation on body mass index among women in the Cebu Longitudinal Health and Nutrition Surveys (1983-2002). Soc Sci Med 2008;66:1967-78. doi: 10.1016/j.socscimed.2008.01.008.
7. Ainy E, Azizi F. Women, occupation and cardiovascular risk factors: findings from the Tehran Lipid and Glucose Study. Public Health 2007;121:950-3. doi: 10.1016/j.puhe.2006.12.016
8. Carson AP, Rose KM, Catellier DJ, Diez-Roux AV, Muntaner C, Wyatt SB. Employment status, coronary heart disease, and stroke among women. Ann Epidemiol 2009;19:630-6. doi: 10.1016/j.annepidem.2009.04.008.
9. Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version. [Online] 2013 [Cited 2018 October 05]. Available from URL: https://www.openepi.com/Menu/OE_Menu.htm
10. Navadeh S, Sajadi L, Mirzazadeh A, Asgari F, Haghazali M. Housewives' obesity determinant factors in iran; national survey - stepwise approach to surveillance. Iran J Public Health 2011;40:87-95.
11. World Health Organization. Regional Office for the Western Pacific. The Asia-Pacific perspective: redefining obesity and its treatment. Sydney; Health Communications Australia, 2000.
12. Understanding blood pressure readings. American Heart Association. [Online] 2012 [Cited 2018 October 05]. Available from URL: https://www.heart.org/en/health-topics/high-bloodpressure/ understanding-blood-pressure-readings
13. Raza L, Ali TM, Hasnain A. Dietary practices and severity of depression. Comparative study among housewives and working women in Karachi. J Pak Med Assoc 2017;67:869-872.
14. Raza L, Ali TM, Hasnain A. Comparison of dietary practices and body mass index among educated housewives and working women in Karachi. J Ayub Med Coll Abbottabad 2017;29:293-297.
15. Raza L, Ahmed A, Kumar V, Hasnain A. Study on awareness of osteoporosis and its associated risk factors among housewives and working women in Karachi. J Pak Med Assoc 2017;67:1879- 1883.
16. Patil M. Stress level of working and non working women. Int J Indian Psychol 2016;3:31-7. doi: 10.25215/0302.058
17. Kermane MM. A psychological study on stress among employed women and housewives and its management through progressive muscular relaxation technique (PMRT) and mindfulness breathing. J Psychol Psychother 2016;6:2161-0487.
18. Sadeghi M, Roohafza H, Aghdak P, Sarrafzadegan N. PP-097 comparison of cardiovascular risk factors and healthy lifestyle housewives and working in central Iran–Isfahan healthy heart program. Int J Cardiol 2012;155(Suppl 1):S130-1.
19. Nagata C, Shimizu H, Takami R, Hayashi M, Takeda N, Yasuda K. Association of blood pressure with intake of soy products and other food groups in Japanese men and women. Prev Med 2003;36:692-7.
20. Utsugi MT, Ohkubo T, Kikuya M, Kurimoto A, Sato RI, Suzuki K, et  al. Fruit and vegetable consumption and the risk of hypertension determined by self measurement of blood pressure at home: the Ohasama study. Hypertens Res 2008;31:1435-43. doi: 10.1291/hypres.31.1435.
21. Pienovi L, Lara M, Bustos P, Amigo H. Consumo de frutas, verdurasy presion arterial. Un estudio poblacional [Fruit and vegetable intake, and blood pressure. A population research]. Arch Latinoam Nutr 2015;65:21-6.
22. Bray GA, Vollmer WM, Sacks FM, Obarzanek E, Svetkey LP, Appel LJ, et al. A further subgroup analysis of the effects of the DASH diet and three dietary sodium levels on blood pressure: results of the DASH-Sodium Trial. Am J Cardiol 2004;94:222-7. doi: 10.1016/j.amjcard.2004.03.070
23. Sadeghi M, Aghdak P, Motamedi N, Tavassoli A, Kelishadi R, Sarrafzadegan N. Do intervention strategies of women healthy heart project (WHHP) impact on differently on working and housewives? ARYA Atheroscler 2011;6:129-35.
24. Ersoy C, Imamoglu S. Comparison of the obesity risk and related factors in employed and unemployed (housewife) premenopausal urban women. Diabetes Res Clin Pract 2006;72:190-6. doi: 10.1016/j.diabres.2005.10.010