Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Renal and dietary factors associated with hypertension in a setting of disadvantage in rural India

Abstract

Using a case-control design, we determined risk factors associated with hypertension in a disadvantaged rural population in southern India. Three hundred adults with hypertension and 300 age- and sex-matched controls were extensively phenotyped. Underweight (29%, body mass index < 18.0 kg m−2), chronic kidney disease (25%, estimated glomerular filtration rate <60 ml min−1 1.73 m−2) and anemia (82%) were highly prevalent. The ratio of sodium to potassium excretion was high (8.2). In multivariable conditional logistic regression of continuous variables dichotomized by their median value, hypertension was independently associated with greater abdominal adiposity as assessed by waist–hip ratio [odds ratio (95% confidence interval), 1.89 (1.21–2.97)], lesser protein intake as assessed by 24 h urea excretion [0.39 (0.24–0.65)], and lesser plasma renin activity [0.54 (0.35–0.84)]. Hypertension tended to be independently associated with lesser serum potassium concentration [0.66 (0.44–1.01), P = 0.06]. Furthermore, those with hypertension reported less frequent intake of vegetables and urinary sodium–potassium ratio correlated positively with serum sodium–potassium ratio (r = 0.18). Hypertension was also independently associated with lesser blood hemoglobin concentration [0.48 (0.26–0.88)]. Blood hemoglobin concentration was positively associated with serum iron (r = 0.41) and ferritin (r = 0.25) concentration and negatively associated with total iron binding capacity (r = −0.17), reflecting iron-deficiency anemia. Our findings indicate potential roles for deficient intake of potassium and protein, and iron-deficiency anemia, in the pathophysiology of hypertension in a setting of disadvantage in rural India. Imbalanced intake of potassium and sodium may be driven partly by deficient intake of vegetables or fruit.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Recruitment of cases and controls.
Fig. 2: Relationship between sodium to potassium concentration ratio in urine and serum.

Similar content being viewed by others

References

  1. Global Burden of Disease Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386:2287–323.

    Article  Google Scholar 

  2. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365:217–23.

    Article  Google Scholar 

  3. Ibrahim MM, Damasceno A. Hypertension in developing countries. Lancet. 2012;380:611–9.

    Article  Google Scholar 

  4. Prabhakaran D, Jeemon P, Roy A. Cardiovascular disease in India: current epidemiology and future directions. Circulation. 2016;133:1605–20.

    Article  Google Scholar 

  5. Johnson C, Praveen D, Pope A, Raj TS, Pillai RN, Land MA, et al. Mean population salt consumption in India: a systematic review. J Hypertens. 2017;35:3–9.

    Article  CAS  Google Scholar 

  6. McDonough AA, Veiras LC, Guevara CA, Ralph DL. Cardiovascular benefits associated with higher dietary K+ vs. lower dietary Na+: Evidence from population and mechanistic studies. Am J Physiol Endocrinol Metab. 2017;312:E348–56.

    Article  Google Scholar 

  7. Thrift AG, Evans RG, Kalyanram K, Kartik K, Fitzgerald SM, Srikanth V. Gender-specific effects of caste and salt on hypertension in poverty: a population-based study. J Hypertens. 2011;29:443–50.

    Article  CAS  Google Scholar 

  8. Busingye D, Arabshahi S, Evans RG, Riddell MA, Srikanth VK, Kartik K, et al. Knowledge of risk factors for hypertension in a rural Indian population. Heart Asia. 2019;11:e011136.

    Article  Google Scholar 

  9. Busingye D, Arabshahi S, Evans RG, Srikanth VK, Kartik K, Kalyanram K, et al. Factors associated with awareness, treatment and control of hypertension in a disadvantaged rural Indian population. J Hum Hypertens. 2017;31:347–53.

    Article  CAS  Google Scholar 

  10. Subasinghe AK, Walker KZ, Evans RG, Srikanth V, Arabshahi S, Kartik K, et al. Association between farming and chronic energy deficiency in rural South India. PLoS ONE. 2014;9:e87423.

    Article  Google Scholar 

  11. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16:31–41.

    Article  CAS  Google Scholar 

  12. Jessani S, Levey AS, Bux R, Inker LA, Islam M, Chaturvedi N, et al. Estimation of GFR in South Asians: a study from the general population in Pakistan. Am J Kidney Dis. 2014;63:49–58.

    Article  Google Scholar 

  13. Misra A, Chowbey P, Makkar BM, Vikram NK, Wasir JS, Chadha D, et al. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India. 2009;57:163–70.

    CAS  PubMed  Google Scholar 

  14. Willenberg HS, Kolentini C, Quinkler M, Cupisti K, Krausch M, Schott M, et al. The serum sodium to urinary sodium to (serum potassium)2 to urinary potassium (SUSPPUP) ratio in patients with primary aldosteronism. Eur J Clin Investig. 2009;39:43–50.

    Article  CAS  Google Scholar 

  15. Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al. Prevalence of chronic kidney disease in the United States. JAMA. 2007;298:2038–47.

    Article  CAS  Google Scholar 

  16. World Health Organization. Diet, nutrition and the prevention of chronic diseases. WHO: Geneva; 2003.

  17. O’Donnell M, Mente A, Yusuf S. Sodium intake and cardiovascular health. Circ Res. 2015;116:1046–57.

    Article  Google Scholar 

  18. World Health Organization. Guideline: potassium intake for adults and children. In: WHO; Geneva, 2012.

  19. Sowmya N, Lakshmipriya N, Arumugam K, Venkatachalam S, Vijayalakshmi P, Ruchi V, et al. Comparison of dietary profile of a rural south Indian population with the current dietary recommendations for prevention of non-communicable diseases (CURES 147). Indian J Med Res. 2016;144:112–9.

    Article  Google Scholar 

  20. Zahangir MS, Hasan MM, Richardson A, Tabassum S. Malnutrition and non-communicable diseases among Bangladeshi women: an urban-rural comparison. Nutr Diabetes. 2017;7:e250.

    Article  CAS  Google Scholar 

  21. Yoon H, Lee JH, Kim GS, Kim YJ, Hwang EY, Park CE, et al. The relationship between anemia and pulse pressure and hypertension: the Korea National Health and Nutrition Examination Survey 2010-2012. Clin Exp Hypertens. 2018;40:650–5.

    Article  Google Scholar 

  22. Yokusoglu M, Nevruz O, Baysan O, Uzun M, Demirkol S, Avcu F, et al. The altered autonomic nervous system activity in iron deficiency anemia. Tohoku J Exp Med. 2007;212:397–402.

    Article  CAS  Google Scholar 

  23. De Miguel C, Rudemiller NP, Abais JM, Mattson DL. Inflammation and hypertension: new understandings and potential therapeutic targets. Curr Hypertens Rep. 2015;17:507.

    Article  Google Scholar 

  24. Ganz T. Anemia of inflammation. N Engl J Med. 2019;381:1148–57.

    Article  CAS  Google Scholar 

  25. Singla R, Garg A, Surana V, Aggarwal S, Gupta G, Singla S. Vitamin B12 deficiency is endemic in Indian population: a perspective from North India. Indian J Endocrinol Metab. 2019;23:211–4.

    Article  CAS  Google Scholar 

  26. Coles GA, Meadows JH, Bright C, Tomlinson K. The estimation of dietary protein intake in chronic renal failure. Nephrol Dial Transplant. 1989;4:877–82.

    Article  CAS  Google Scholar 

  27. Tielemans SM, Altorf-van der Kuil W, Engberink MF, Brink EJ, van Baak MA, Bakker SJ, et al. Intake of total protein, plant protein and animal protein in relation to blood pressure: a meta-analysis of observational and intervention studies. J Hum Hypertens. 2013;27:564–71.

    Article  CAS  Google Scholar 

  28. Kodali V, Kodavanti MR, Tripuraribhatla PK, Raghu Ram TC, Eswaran P, Krishnaswamy K. Dietary factors as determinants of hypertension: a case control study in an urban Indian population. Asia Pac J Clin Nutr. 1999;8:184–9.

    Article  CAS  Google Scholar 

  29. Thrift AG, Srikanth V, Fitzgerald SM, Kalyanram K, Kartik K, Hoppe CC, et al. Potential roles of high salt intake and maternal malnutrition in the development of hypertension in disadvantaged populations. Clin Exp Pharmacol Physiol. 2010;37:e78–90.

    Article  CAS  Google Scholar 

  30. Miki A, Hashimoto Y, Tanaka M, Kobayashi Y, Wada S, Kuwahata M, et al. Urinary pH reflects dietary acid load in patients with type 2 diabetes. J Clin Biochem Nutr. 2017;61:74–7.

    Article  CAS  Google Scholar 

  31. Zhang L, Curhan GC, Forman JP. Diet-dependent net acid load and risk of incident hypertension in United States women. Hypertension. 2009;54:751–5.

    Article  CAS  Google Scholar 

  32. Zhu H, Liu X, Zhang C, Li Q, An X, Liu S, et al. Association of urinary acidification function with the progression of diabetic kidney disease in patients with type 2 diabetes. J Diabetes Complications. 2019;33:107419.

    Article  Google Scholar 

  33. Engberink MF, Bakker SJ, Brink EJ, van Baak MA, van Rooij FJ, Hofman A, et al. Dietary acid load and risk of hypertension: the Rotterdam Study. Am J Clin Nutr. 2012;95:1438–44.

    Article  CAS  Google Scholar 

  34. Capolongo G, Sakhaee K, Pak CY, Maalouf NM. Fasting versus 24-h urine pH in the evaluation of nephrolithiasis. Urol Res. 2011;39:367–72.

    Article  Google Scholar 

  35. Liu K, Cooper R, McKeever J, McKeever P, Byington R, Soltero I, et al. Assessment of the association between habitual salt intake and high blood pressure: methodological problems. Am J Epidemiol. 1979;110:219–26.

    Article  CAS  Google Scholar 

Download references

Acknowledgements

We are grateful to the staff at the Monash University Rishi Valley Medical Research Unit and the Rishi Valley Rural Health Center.

Funding

This work was supported by the National Health and Medical Research Council of Australia (1042600, 1005740). AKS and DB received Monash Graduate Scholarships.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Roger G. Evans.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The protocol was approved by the Human Research Ethics Committees of Monash University, the Rishi Valley Education Center (50/1/Indo-CVD/2-8/NCDII) and the Indian Council of Medical Research (2006/073MC). All participants gave written informed consent.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Evans, R.G., Subasinghe, A.K., Busingye, D. et al. Renal and dietary factors associated with hypertension in a setting of disadvantage in rural India. J Hum Hypertens 35, 1118–1128 (2021). https://doi.org/10.1038/s41371-020-00473-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41371-020-00473-5

This article is cited by

Search

Quick links