EurAsian Journal of BioSciences Eurasia J Biosci 14, 1645-1650 (2020)

The correlation between obesity and hypertension in young adults in Central ,

Arwan Setyo Nugroho 1, Santi Martini 1* 1 Department of Epidemiology, Faculty of Public Health, Universitas Airlangga, Surabaya, 60155, INDONESIA *Corresponding author: [email protected]

Abstract Hypertension can increase due to increased body mass caused by obesity. This study aimed to analyze the correlation between obesity and hypertension in young adults in , Indonesia. This study used cross sectional design. The data held by the Central Java, Indonesia Office obtained from the health profile of Central Java Province in 2015-2017. The number of population cases of hypertension in 2015-2017 was 2.108.732, while the the number of population cases of obesity cases in 2015-2017 was 827.612. The results showed that the significance value of obesity cases was 0.146, while the hypertension case significance value was 0.00. The case between obesity and hypertension was correlational strength of 0.517, while the strong correlation between the two variables was moderate. There was correlation obesity and hypertension in young adults in Central Java, Indonesia population.

Keywords: obesity, Central Java, hypertension

Nugroho AS, Martini S (2020) The correlation between obesity and hypertension in young adults in Central Java, Indonesia. Eurasia J Biosci 14: 1645-1650.

© 2020 Nugroho and Martini This is an open-access article distributed under the terms of the Creative Commons Attribution License.

INTRODUCTION only accounted for 40% of the data taken from Noncommunicable Diseases 2010. Every year in Hypertension is a deadly killer disease. This disease Southeast Asian countries, 1.5 milion people die due to can cause health problems and death. Hypertension hypertension and the number of people with does not show signs and symptoms in patients. Signs hypertension in the Southeast Asian region by 36%. The and symptoms of hypertension are often not realized by number of hypertension sufferers is predicted to patients; the signs and symptoms of hypertension are increase every year. In 2025 it is predicted that adults only known when they check their blood pressure or who suffer from hypertension are around 1.6 billion or after the onset of the organ is damaged. In an adjusted around 29% (Kementrian Kesehatan Republik Indonesia risk factor for cardiovascular disorders, the significance 2013). of blood pressure (BP) has been well established and Hypertension is one of the important factors as a many successful low-cost BP therapies are available. trigger for non-communicable diseases which is Given the fact that quick and cheap treatments are currently the number one cause of death in the world commonplace, easy to detect, available, and effective (Purba et al. 2019).The results of the population census systems for detection and control are a health priority in 2010 indicated that Indonesia is a country that has an (Lamelas et al. 2019). Hypertension is one of the leading old structure. The elderly are people who are 60 years cardiovascular and stroke contributors which together old or older. The increasing number of elderly people in form the leading cause of premature death and disability Indonesia demands special attention to the elderly due worldwide. Continued hypertension can lead to stroke, to the aging process of their physiological, thinking, heart attack, heart failure and a significant cause of emotional, sexual, and social changes (Sulam 2020). In chronic kidney disease (Hardiyanti et al. 2018). 2013 the prevalence of hypertension in Indonesia was Nearly 9.4 million deaths due to cardiovascular slightly lower than in women, which was 22.8%, while in disease, one of which is caused by hypertension. women it was 28.8%. The prevalence of hypertension in Increased coronary heart disease and increased stroke Central Java, Indonesia is greater than the prevalence are mostly caused by hypertension. Hypertension can of Indonesia, which is 26.4% (Kementrian Kesehatan cause an increase in coronary heart disease by 12%, Republik Indonesia 2013). Every year hypertension while hypertension can cause an increase in stroke by 24% (Haldar 2013). WHO stated that hypertension Received: August 2019 sufferers in developed countries only amounted to 35%, Accepted: May 2020 while hypertension sufferers in developing countries Printed: June 2020

1645

EurAsian Journal of BioSciences 14: 1645-1650 (2020) Nugroho and Martini cases in Central Java, Indonesia continue to increase. over-time morbidity are difficult to connect at population There were 344,003 cases in 2015 that increased to level. Increased epidemiological surveillance and 611,358 cases in 2016, while in 2017 there was also an information systems are needed as an effort to control increase of 1,153,371 cases (PPJT 2009). hypertension. Besides, the community also needs to Hypertension can be caused by obesity through make vigilance and early detection efforts related to direct or indirect mechanisms. The mechanism is hypertension risk factors, one of which is obesity to directly caused by increasing cardiac output. This prevent hypertension in the community (Zhang et al. increase in cardiac output is caused by a greater body 2018). This study aimed to analyze the correlation mass, causing the amount of circulating blood to between obesity and hypertension in young adults in increase, then it causes cardiac output to also increase Central Java, Indonesia. as well (Liaw et al. 2016). The indirect mechanism is caused by mediators such as cytokines, adipokines, etc. METHODS which are obtained from the stimulation of the Renin- This study used a cross-sectional design. The Angiotensin-Aldosterone System (RAAS) and also from number of population cases of hypertension in 2015- the activity of the sympathetic nervous system that has 2017 was 2.108.732, while the number of population been stimulated. Aldosterone causes blood volume to cases of obesity cases in 2015-2017 was 827.612. The increase because this hormone is very closely related to data held by the Central Java, Indonesia Office obtained water and sodium retention which can cause blood from the health profile of Central Java, Indonesia in volume to increase (Nagase et al. 2009). 2015-2017 were used as secondary data in this study. The population that is obese in 2016 is the adult Criteria for obesity case population in this study were population aged >18 years. The number of people in patients who visited health centers aged ≥ 15 years who 2016 having obesity around 650 million from a total of had been examined for obesity in 35 districts/cities with >1.9 billion adult population experiencing weight gain. In Body Mass Index from one of the criteria according to 2016, there were around 13% of the world’s adult WHO. Body Mass Index (BMI) ≥ 25 (Obesity level I) or population were obese, including 11% of the male BMI ≥ 30 (Obesity level II). Criteria for hypertension case population and 15% of the female population population in this study were patients who visited health (Kementrian Kesehatan Republik Indonesia 2013). centers aged ≥ 18 years who had been examined for Fundamentally, obesity occurs due to an imbalance blood pressure in 35 districts/cities that have blood between intake and expenditure of calories. The pressure from one of the blood pressure criteria of JNC changes in lifestyle especially for people who live in 7, namely hypertension group 1, 140-159mmHg urban areas are considered as an impact of (systolic blood pressure) or 90-99mmHg (diastolic blood westernization in which people are encouraged to have pressure) and hypertension group 2, ≥160mmHg unhealthy behaviors. Indeed, these behaviors might rise (systolic blood pressure) or ≥100mmHg (diastolic blood including in rural areas because the occurrence of pressure) (Schwartz et al. 1999; Normayanti et al., inevitable nutrition transition (Arundhana et al. 2018). 2020). Data analysis used was SPSS 21 using From 1975 to 2016, the prevalence of obesity was Kolmogorov-Smirnov to observe data normality. Since almost tripled worldwide (Haldar 2013). In the province the data in the form of ratio data and data distribution of Central Java in 2015, the number of cases of obesity were not normal, the Spearman correlation test was that was equal to 561.709 cases. In 2016, obesity cases deployed to identify the correlation between variables. decreased to 94,975 cases, while in 2017 there was an increase in cases to 170,928 cases (PPJT 2009). From RESULTS the 2013 WHO data, deaths from non-communicable diseases, especially cardiovascular disease, ranks first Overview of Obesity Cases in 2015-2017 in as the biggest cause of death compared to infectious Central Java, Indonesia diseases. Cardiovascular deaths in 2008 by 18% were From 2015-2017, the proportion of cases of obesity projected to continue to increase, and those who project in Central Java, Indonesia in men was lower and in 2030 cardiovascular deaths reach 24% (Haldar 2013; occurred mostly in women. In Central Java, Indonesia Barner et al., 2019). There are various ways that the from 2015-2017 the proportion of cases of obesity has government has taken to control hypertension, one of decreased, this occurs in women and also men. The which is by making a hypertension control policy through proportion of obesity cases for men in 2015 was 24.04%, guidelines in operational guidelines and technical it decreased to 9.87% in 2016, while in 2017 it guidelines that have been prepared. Different forms of decreased to 4.25% (Table 1). community-based hypertension prevention programs The proportion of obesity cases for women in Central have been implemented by the public and private Java, Indonesia from 2015-2017 had decreased. The sectors in different countries. However, evaluating the proportion of obesity cases for women in 2015 was efficacy of such community-based prevention programs 25.82%, then it decreased to 11.94% in 2016, whereas remains a challenge since the programs’ existence and in 2017 the cases decreased to 7.38% (Table 1). The

1646

EurAsian Journal of BioSciences 14: 1645-1650 (2020) Nugroho and Martini

Table 1. The Proportion of Obesity and Hypertension Cases by Gender in Central Java, Indonesia Year 2015-2017 Proportion of obesity case (%) Proportion of hypertension case (%) Gender 2015 2016 2017 2015 2016 2017 Men 24.04 9.87 4.25 20.88 11.16 13.16 Women 25.82 11.94 7.38 16.28 11.85 13.10

Table 2. Proportion of Obesity Cases Highest in 2015-2017 in 3 Regencies / Cities in Central Java, Indonesia Obesity case 2015 Case proportion (%) 2016 Case proportion (%) 2017 Case Proportion (%) City 71 Sragen 100 City 100 Magelang City 65 100 44.38 65 Salatiga City 61.35 32.05

Table 3. Proportion of Hypertension Cases Highest in 2015-2017 in 3 Regencies / Cities in Central Java, Indonesia Hypertension Case 2015 Case proportion (%) 2016 Case proportion (%) 2017 Case proportion (%) Regency 42.82 Regency 100 Salatiga City 77.72 Regency 40.67 Demak Regency 100 Demak Regency 76.07 Regency 39.55 85.34 66.20

highest proportion of obesity cases in 2015 occurred in there was one from two values less than alpha (α = Salatiga City with a proportion of cases around 71%, 0.05), meaning that from the two data there was one while in 2016 it occurred in Sragen and Demak data that was not normally distributed. Regencies with a proportion of cases at 100%, in 2017 There was a correlation between obesity and it occurred in Magelang City with a proportion of cases hypertension in young adults in the Central Java, at 100% (Table 2). Indonesia population in 2015-2017 with a significance Overview of Hypertension Cases in 2015-2017 value of 0.001 (p <α) from the results of the analysis in Central Java, Indonesia using the Spearman correlation test. The strong In 2015 and 2017 the proportion of hypertension correlation between cases of obesity with cases of cases in Central Java, Indonesia was most prevalent in hypertension in this study was moderate because of the males, while in 2016 it was more prevalent in females correlation strength of 0.517. The direction of the compared to males. The proportion of hypertension correlation between the two positive variables showed cases in men and women in Central Java, Indonesia that the higher the case of obesity in young adults that from 2015-2016 had decreased, but in 2017 there was occurs in Central Java, Indonesia, the higher the cases an increase in cases. The proportion of hypertension of hypertension in young adults in Central Java, cases for men in 2015 was 20.88%, down to 11.16% in Indonesia. 2016, whereas in 2017 there was an increase in cases to 13.16% (Table 1). DISCUSSION The proportion of hypertension cases for women in Proportion Case of obesity in Central Java year Central Java, Indonesia from 2015-2016 had 2015-2017 was mostly occurred in women compared to experienced a decrease in cases, but in 2017 there was men. There’s also an important role in gender. Extreme an increase in cases. The proportion of hypertension obesity (classes 2–3, BMI ≥35 kg/m2) affects women cases for women in 2015 was 16.28%, it decreased to disproportionately than men, regardless of age or 11.85% in 2016, while in 2017 there was an increase in race/ethnicity (Adela Hruby, PhD et al. 2015). Individuals cases to 13.10% (Table 1). > 40 years old will experience a condition where the The highest proportion of hypertension cases in 2015 walls of blood vessels lose their elasticity. This can lead occurred in Wonosobo District with a proportion of cases to increased blood pressure because the blood around 42.82%, while in 2016 it occurred in Demak and continues to pump without the presence of blood vessel Jepara Regencies with a proportion of cases at 100%, dilatation. Hypertension is degenerative and is a disease in 2017 it occurred in Salatiga City with a proportion of that appears slowly, along with age, for years, thus cases at 77.72% (Table 3). patients may experience complications (Syamsi 2019). The Analysis of Case Correlation in Central The proportion of hypertension cases in Central Java, Java, Indonesia between Obesity and Indonesia in 2016 was most common in women Hypertension compared to men, while the proportion of Hypertension The results of normality test data using Kolmogorov- Case in 2015 and 2017 was most prevalent in men. Smirnov showed that the significance value of obesity Another research supports the results of this study that cases was 0.146, while the hypertension case the respondents who suffer the most hypertension are significance value was 0.00. The correlation test used in women (52.6%) compared to men (32.8%) (M. Thaha et this study is the Spearman correlation test because al. 2016).

1647

EurAsian Journal of BioSciences 14: 1645-1650 (2020) Nugroho and Martini

From the 2015-2017 data obtained from the health importance of hypertonia due to obesity has increased profile of Central Java Indonesia, districts/cities with the dramatically to the degree that obesity is recognized as highest proportion of hypertension cases are three. In a major cause of high blood pressure and the 2015, the highest proportion of Hypertension Case combination of obesity and hypertension is recognized occurred in Wonosobo Regency, , and as a major cause of cardiovascular risk (Leggio et al. . In 2016 the highest Proportion case 2017). occurred in , Demak Regency, and This correlation of obesity and hypertension forms Wonosobo Regency. Whereas in 2017 the Highest part of a larger body-to-blood pressure relationship. The Proportion case occurred in Salatiga City, Demak most important factors for hypertension are obesity and Regency, and Banjarnegara Regency (PPJT 2009). weight gain. Another research showed that 10% of body In this study, the spread of hypertension cases did weight growth explains 7 mm Hg in the systolic blood not occur in cities only but spread evenly in each pressure (SBP) in the population. In the case of SBP and district/city. Another study is consistent with this study DBP, decreases of 0.33 and 0.43 mm Hg are also found that cases of hypertension in urban and rural areas are to be correlated with each kilogram of lost excess body different. In rural and urban areas, the prevalences of weight (Lederbogen et al. 2011). high blood pressure (HBP) were 21.1 and 24.7 percent, Another study also said that hypertension was respectively (Bâ et al. 2018). This difference is caused significantly related to residential areas, smoking habits, by a variety of factors, one of which is the greater stress diabetes mellitus, cardiovascular disease, chronic found in urban communities compared to rural kidney disease, BMI, waist circumference size, and communities. Lifestyle differences that are owned by education level (Sulam 2020). The prevalence of urban and rural communities also affect the hypertension in urban residents is associated with hypertension case between urban and rural diabetes mellitus, with cigarette smoking being linked to communities, then the magnitude of social pressure the prevalence of hypertension in rural residents only. obtained by urban and rural communities also affects the Type of work and educational level are associated with hypertension case differences between urban and rural hypertension prevalence only in urban residents (Wei et areas (Lederbogen et al. 2011). al. 2015). Regarding the hypertension correlates, we found By smoking, a cigarette will have a significant that, in line with many previous investigations in influence on the rise in blood pressure. Smoking Cameroon and other countries, the inhabitants of an behavior is a risk factor for hypertension with 6.9 times urban region, older age, diabetes, and higher waist the risk of hypertension, and a study found that there circumference were correlated with hypertension. We was a relationship between the number of cigarettes and also found an inverse correlation between hypertension the incidence of hypertension in patients. Nicotine and and fruit and vegetable intake in rural areas that would carbon dioxide contained in cigarettes will damage the theoretically be consistent with the beneficial effects of endothelial vascular artery layer; the elasticity of the fruit and vegetables. Low perception of hypertension has blood vessels is reduced that lead to increased blood been associated with male sex, low intake of fruit and pressure (Amelia et al. 2019). vegetables as well as diabetes. Whereas, better disease Hypertension can be caused by obesity directly or perception is correlated with older age. In addition, indirectly. The mechanism is directly caused by married status in urban areas is linked to lower increasing cardiac output. This increase in cardiac awareness, while diabetes is the only contributing factor output is caused by a greater body mass, causing the to higher awareness of the disease in rural areas amount of circulating blood to increase, then causing the (Lemogoum et al. 2018). cardiac output to also increase (Liaw et al. 2016). There is a correlation between obesity and Stimulation of Renin Angiotensin Aldosterone System hypertension in young adults in Central Java, Indonesia (RAAS) and stimulation of sympathetic nervous system population in 2015-2017. This study is in line with other activity will produce cytokines, adipokines, etc., and this research which states that there is a relationship is the cause of obesity affecting hypertension in terms of between obesity and hypertension. There is a link mechanisms indirectly. Increased blood volume is between hypertension and obesity. The results of this caused by the hormone aldosterone which is closely study found that the average BMI of hypertensive related to water and sodium retention (Nagase et al. respondents was higher than non-hypertensive 2009). Another research is in line with this study, which respondents (Schwartz et al. 1999). The nature of the states that overweight/obesity and hypertension are correlation between blood pressure and body weight related. Women with general obesity and men with remained uncertain until the mid-1980s when basic abdominal obesity have a strong correlation with clinical and population-based research significantly hypertension (Ryu et al. 2019). explained several factors of the association between The emergence of vascular disease and heart these two common and complex regulatory disease is a result of the risk of obesity. Blood pressure disturbances. Over the same time, the clinical can increase due to increased body mass caused by

1648

EurAsian Journal of BioSciences 14: 1645-1650 (2020) Nugroho and Martini obesity. Body mass affects the supply of oxygen and because the data available are only case data per district nutrients needed by body tissues. The increase of blood or city in Central Java, Indonesia. The strength of this pressure caused by blood circulating in the blood study is that researchers do not need to do examination vessels increases yielding in increased arterial blood blood pressure and obesity on patients at the health pressure causing blood pressure to increase (Koliaki et center in Central Java, Indonesia. The data is already al. 2019). A person who is obese having his body tissue available in the annual report of the district or city in which will need more supply of oxygen and food, thus Central Java, Indonesia (PPJT 2009). resulting in increased blood volume, increased blood pressure, and also increased cardiac output. In obesity, CONCLUSION the subcutaneous adipose tissue may fail to This study showed a correlation between obesity and appropriately expand to store the energy surplus hypertension in young adults in Central Java, Indonesia. (Goossens 2017). Increased levels of insulin in the blood The higher case of obesity and hypertension due to the are caused by overweight. This increase in insulin levels correlation between the two positive variables. Health causes blood pressure to rise because it is caused by promotion or education is needed for the community, renal sodium retention (Liaw et al. 2016). especially in young adults about the importance of This study has limitations. This study only explains maintaining healthy lifestyles, eating patterns, and doing the correlation between obesity and hypertension in physical activities that are useful to prevent the young adults in Central Java, Indonesia -based on occurrence of obesity to reduce the incidence of aggregate data per district or city in Central Java, hypertension cases in Central Java, Indonesia. Indonesia. Other variables that cause an increase in cases of obesity and hypertension are unknown

REFERENCES Adela Hruby, PhD M, Frank B. Hu, MD, PhD M, (2015) The Epidemiology of Obesity: A Big Picture. Pharmacoeconomics. 33(7): 673–689. https://doi.org/10.1007/s40273-014-0243-x Amelia R, Harahap J, (2019) The role of nutritional status, age, genetic factors, and lifestyle on the hypertension prevalence among community in Indonesian coastal area. International Journal on Advanced Science, Engineering and Information Technology 9(4): 1420–1426. https://doi.org/10.18517/ijaseit.9.4.5823 Arundhana AI, Utami AP, Muqni AD, Thalavera MT, (2018) Regional differences in obesity prevalence and associated factors among adults: Indonesia Basic Health Research 2007 and 2013. Malaysian Journal of Nutrition 24(2): 193–201. Bâ HO, Menta I, Camara Y, Sangaré I, Landouré G, Millogo GRC, Coulibaly S, Diall IB, (2018) Cardiovascular Risk Factors (CVrf) in Rural and Urban Areas Mali: Data from the Step 2013 Survey. World Journal of Cardiovascular Diseases 08(01): 35–47. https://doi.org/10.4236/wjcd.2018.81005 Barner Y, Sung JH, Akil L, Leggett SS (2019) Association between Health Insurance and Obesity among Adolescents. European Journal of Environment and Public Health, 3(2): em0031. https://doi.org/10.29333/ejeph/5929 Goossens GH, (2017) The Metabolic Phenotype in Obesity: Fat Mass, Body Fat Distribution, and Adipose Tissue Function. Obesity Facts 10(3): 207–215. https://doi.org/10.1159/000471488 Haldar RN, (2013) Global Brief on Hypertension: Silent Killer, Global Public Health Crisis. Indian Journal of Physical Medicine and Rehabilitation 24(1): 2–2. https://doi.org/10.5005/ijopmr-24-1-2 Hardiyanti, Thaha RM, Russeng SS, (2018) Drug adherence with hypertension status at the bajoe community health centre of bone regency in 2016. Faculty of Public Health, Hasanuddin University, Jl. Perintis Kemerdekaan Km. 10, Kota Makassar, Sulawesi Selatan, 90245, Indonesia: Association for Computing Machinery https://doi.org/10.1145/3239438.3239491 Kementrian Kesehatan Republik Indonesia, (2013) Penyajian Pokok-Pokok Hasil Riset Kesehatan Dasar 2013. Badan Penelitian dan Pengembangan Kesehatan, Kementerian Kesehatan Republik Indonesia. Koliaki C, Liatis S, Kokkinos A, (2019) Obesity and cardiovascular disease: revisiting an old relationship. Metabolism: Clinical and Experimental 92: 98–107. https://doi.org/10.1016/j.metabol.2018.10.011 Lamelas P, Diaz R, Orlandini A, Avezum A, Oliveira G, Mattos A, et al., (2019) Prevalence, awareness, treatment and control of hypertension in rural and urban communities in Latin American countries. Journal of hypertension 37(9): 1813–1821. https://doi.org/10.1097/HJH.0000000000002108

1649

EurAsian Journal of BioSciences 14: 1645-1650 (2020) Nugroho and Martini

Lederbogen F, Kirsch P, Haddad L, Streit F, Tost H, Schuch P, Wüst S, Pruessner JC, Rietschel M, Deuschle M, Meyer-Lindenberg A, (2011) City living and urban upbringing affect neural social stress processing in humans. Nature 474(7352): 498–501. https://doi.org/10.1038/nature10190 Leggio M, Lombardi M, Caldarone E, Severi P, D’emidio S, Armeni M, Bravi V, Bendini MG, Mazza A, (2017) The relationship between obesity and hypertension: An updated comprehensive overview on vicious twins. Hypertension Research 40(12): 947–963. https://doi.org/10.1038/hr.2017.75 Lemogoum D, Van De Borne P, Lele CEB, Damasceno A, Ngatchou W, Amta P, Leeman M, Preumont N, Degaute JP, Kamdem F, Hermans MP, Donnen P, Bovet P, (2018) Prevalence, awareness, treatment, and control of hypertension among rural and urban dwellers of the Far North Region of Cameroon. Journal of Hypertension 36(1): 159–168. https://doi.org/10.1097/HJH.0000000000001513 Liaw JJT, Peplow P V., (2016) Effect of Electroacupuncture on Inflammation in the Obese Zucker Fatty Rat Model of Metabolic Syndrome. JAMS Journal of Acupuncture and Meridian Studies 9(2): 73–79. https://doi.org/10.1016/j.jams.2015.08.004 M. Thaha IL, Anggraeni WA, Sidik DSA, (2016) Kejadian Hipertensi di Wilayah Kerja Puskesmas Segeri Kabupaten Pangkep. Jurnal MKMI 12.2: 104–110. Nagase M, Fujita T, (2009) Mineralocorticoid receptor activation in obesity hypertension. Hypertension Research 32(8): 649–657. https://doi.org/10.1038/hr.2009.86 Normayanti, Suparyatmo JB, Prayitno A (2020) The Effect of Nutrition Education on Body Mass Index, Waist Circumference, Mid-upper Arm Circumference and Blood Pressure in Obese Adolescents. Electronic Journal of General Medicine, 17(5): em221. https://doi.org/10.29333/ejgm/7884 PPJT, (2009) Tentang Provinsi Jawa Tengah. 2011(21 April): Purba EN, Santosa H, Siregar FA, (2019) The relationship of physical activity and obesity with the incidence of hypertension in adults aged 26-45 years in Medan. Open Access Macedonian Journal of Medical Sciences 7(20): 3464–3468. https://doi.org/10.3889/oamjms.2019.447 Ryu S, Frith E, Pedisic Z, Kang M, Loprinzi PD, (2019) Secular trends in the association between obesity and hypertension among adults in the United States, 1999–2014. European Journal of Internal Medicine 62(January): 37–42. https://doi.org/10.1016/j.ejim.2019.02.012 Schwartz GL, Sheps SG, (1999) A review of the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Current Opinion in Cardiology 14(2): 161–168. https://doi.org/10.1097/00001573-199903000-00014 Sulam M, (2020) Correlation Between Nutritional Status And Waist Circumference With The Incidence Of Hypertension In The Elderly. Jurnal Berkala Epidemiologi 8(1): 81–88. https://doi.org/10.20473/jbe.V8I12020.81- 88 Syamsi F, (2019) Hubungan Riwayat Keluarga, Konsumsi Buah dan Sayur, dan Aktivitas Fisik dengan Kejadian Hipertensi. Jurnal Berkala Epidemiologi ,Fakultas Kesehatan Masyarakat, Univerisitas Airlangga, Kota Surabaya, Jawa Timur, Indonesia 7(3): 217–224. https://doi.org/10.20473/jbe.v7i32019.217-224 Wei Q, Sun J, Huang J, Zhou HY, Ding YM, Tao YC, He SM, Liu YL, Niu JQ, (2015) Prevalence of hypertension and associated risk factors in Dehui City of Jilin Province in China. Journal of Human Hypertension 29(1): 64– 68. https://doi.org/10.1038/jhh.2014.32 Zhang D, Pan X, Li S, Liang D, Hou Z, Li Y, Shi L, (2018) Impact of the National Essential Public Health Services Policy on Hypertension Control in China. American Journal of Hypertension 31(1): 115–123. https://doi.org/10.1093/ajh/hpx139

www.ejobios.org

1650