University of Ghana http://ugspace.ug.edu.gh RELATIONSHIP BETWEEN DIETARY FIBRE INTAKE AND BLOOD PRESSURE, LIPID PROFILE AND ANTHROPOMETRIC MEASUREMENTS OF HYPERTENSIVE PATIENTS This dissertation is submitted to the University of Ghana, Legon in partial fulfilment of the requirement for the award of MSc. Dietetics Degree By EDINAM AKU NUMADZI (10636303) November, 2020. I University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Edinam Aku Numadzi, hereby declare that this dissertation is the result of my own research carried out in the Department of Dietetics, School of Biomedical and Allied Health Sciences, University of Ghana, under the supervision of Dr. Matilda Asante and Professor George Awuku Asare. All references cited in this work have been fully acknowledged. …………………………………. Edinam Aku Numadzi (Student) …………………………… …. …………………………….. Dr. Matilda Asante Professor George Awuku Asare (Supervisor) (Supervisor) II University of Ghana http://ugspace.ug.edu.gh III University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background Hypertension also known as high blood pressure is an issue of global health concern. Globally, hypertension is estimated to cause about 12.8% of total deaths. Dietary fibre is an important component of a healthy diet and has received much attention in recent times due to the vital functions it plays in the human body. Studies have shown that dietary fibre helps in body weight regulation, lipid reduction, improved glucose metabolism, and blood pressure control. Aim This study sought to determine the relationship between dietary fibre intake and blood pressure, lipid profile and anthropometric measurements of hypertensive patients. Methodology A cross-sectional study was conducted among 190 purposively sampled hypertensive patients. Participants (190) were recruited and interviewed using a structured questionnaire to assess lifestyle factors, demographic and socio-economic information. A quantitative Food Frequency Questionnaire was used to assess dietary fibre intake of the patients. Dietary fibre intake was estimated using the nutrient analysis software Microdiet (version 3.0, Downlee Systems, UK). Blood pressure and anthropometric measurements were also taken. Lipid profile values were obtained from the participant’s folder. Data was analyzed with the Statistical Package for Social Sciences (SPSS 23.0). Categorical variables were presented using frequency distribution tables, graphs and bar charts. Independent t-test was used to compare variables among gender. The relationship between dietary fibre intake, BMI, blood pressure, visceral fat and lipid profile values was determined using Pearson’s correlation. IV University of Ghana http://ugspace.ug.edu.gh Results Mean dietary fibre intake of participants was 15.4 ±7.1 g. The major sources of dietary fibre were cereals and grains. Mean BMI (29.4 ± 5.6 kg/m2) and visceral fat (11.0±3.9) were above normal reference range for both male and female participants. Mean lipid profile values (TC-5.1 ± 1.2 mmol/L, TG-1.4 ± 0.6 mmol/L, HDL-C-1.4 ± 0.5 mmol/L and LDL-C-3.1 ± 1.1 mmol/L) of the participants were within normal range. There was no significant association between dietary fibre and blood pressure, dietary fibre and BMI and dietary fibre and visceral fat (p>0.05). However, there was a negative correlation, though not significant, between dietary fibre intake and TG (p > 0.05, r = -0.09) and dietary fibre and HDL-C (p>0.05, r = -0.85). Conclusion Dietary fibre intake among the hypertensive patients was below the recommended daily intake. Education on adequate dietary fibre intake among these patients must be enhanced by healthcare personnel especially dietitians. Associations between dietary fibre, blood pressure, body mass index, visceral fat and lipid profile were not significant. V University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to my family and friends who have supported me immensely throughout this journey with prayers and moral support. VI University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I would like to thank God Almighty for seeing me through this journey. His protection and provision throughout this time has been tremendous and awesome. I would also like to acknowledge the immense input of my supervisors, Dr. Matilda Asante and Professor George Asare Awuku for their support, motivation, good counsel and constructive comments, I am forever grateful. My gratitude also goes out to the Staff of the Diet Therapy Department of the University of Ghana Hospital who were of great help to me during this research. I also appreciate the contribution of the lecturers and research assistants; Mrs. Portia Nkumsah- Riverson, Mrs. Ruth Nyarko and Ann-Michelle Dakwa. To my sponsor and uncle, Mr. Joseph Atsu Amedzake, words are not enough to express how grateful I am for your great sacrifice and encouragement to further my education. I appreciate the contributions of my mother, Mrs. Florence Numadzi, my siblings and incredible relatives who have supported me in every way possible. I love you all dearly. VII University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ………………………………………………………………………………II ABSTRACT…………………………………………………………………………………....IV DEDICATION………………………………………………………………………………….VI ACKNOWLEDGEMENT……………………………………………………………………..VII LIST OF FIGURES……………………………………………………………………………....i LIST OF TABLES.........................................................................................................................ii LIST OF ABBREVIATIONS…………………………………………………………………..iii GLOSSARY……………………………………………………………………………………..v CHAPTER 1……………………………………………………………………………………..1 1.0 INTRODUCTION…………………………………………………………………………..1 1.2 Problem Statement…………………………………………………………...................4 1.3 Justification......................................................................................................................4 1.4 Aim……………………………………………………………………………………...5 1.5 Hypotheses…………………………………………………...........................................5 CHAPTER 2…………………………………………………………………………………….6 2.0 LITERATURE REVIEW…………………………………………………………………...6 2.1 Hypertension………………………………………………………………………........6 2.2 Dietary Fibre…………………………………………………………………………...12 2.3 Dietary Fibre And Cardiovascular Diseases………………………...............................18 2.4 Dietary Fibre And Lipid Profile…………………………………………………..........20 2.5 Dietary Fibre And Obesity…………………………………………………………….22 2.6 Dietary Fibre And Visceral Fat…………………………………………......................23 CHAPTER 3……………………………………………………………………………………24 3.0 METHODOLOGY…………………………………………………………………………24 3.1 Study Design………………………………………………………………………......24 3.3 Study Population……………………………………………………………………....24 3.4 Sample Size Calculation…………………….................................................................25 3.5 Sampling technique………………………………………………………………........25 3.6 Procedure for data collection…………………………………………………..............26 3.7 Data Management………………………………………………………………...........29 3.8 Ethics…………………………………………………………......................................29 VIII University of Ghana http://ugspace.ug.edu.gh 3.9 Data analysis………………………………………………………………………….29 CHAPTER 4…………………………………………………………………………………..30 4.0 RESULTS…………………………………………………………………………………30 4.1 Socio-demographic data of participants……………………………………………....30 4.4 Consumption of high fibre foods…………………………………………………......36 4.5 Major food sources of fibre………………………………….......................................37 4.6 Frequency of consumption of foods…………………………………..........................38 4.7 Lipid Profile of participants…………………………………………………………...43 4.8 Correlation between mean fibre intake, blood pressure, anthropometry and lipid profile……………………………………………………………………………………...45 5. CHAPTER FIVE……………………………………………………………………………46 5.0 DISCUSSION……………………...……………………………………………………...46 5.1. Background characteristics………………………………………………………… 46 5.2 Anthropometric measurements and blood pressure of the participants.........................48 5.3 Frequency and major sources of dietary fibre………………………………................50 5.4 Nutrient and dietary fibre intake…………………………………................................51 5.5 Lipid Profile of hypertensive patients…………………………………………………53 5.6 Dietary fibre, blood pressure and anthropometry……………………………………..54 5.7 Dietary fibre and lipid profile…………………………................................................55 CONCLUSION………………………………………………………………………………..57 RECOMMENDATIONS……………………………………………………………………...57 LIMITATIONS………………………………………………………………………………..57 REFERENCES………………………………………………………………………………...58 APPENDIX 1………………………………………………………………………………….69 APPENDIX II…………………………………………………………………………………72 IX University of Ghana http://ugspace.ug.edu.gh X University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure.1.1 Chemical structure of cellulose…………………………………………………….12 Figure 1.2 Chemical structure of pectin……………………………………………………….13 Figure 4.4 Consumption of high fibre foods by participants…………………………………..36 i University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 2.1Various components and recommendations of DASH diet…………………………11 Table 2.2 Dietary fibre requirements…………………………………………………………..16 Table 2.3 Fibre content of some foods………………………………………………………...17 Table 4.1 Distribution of socio-demographic data of participants…………………………….31 Table 4.2 Physical activity and medical history of participants……………………………….32 Table 4.3 Blood pressure and anthropometric measurements of participants…………………33 Table 4.4 Energy and nutrient intake of participants………………………………………….34 Table 4.5 Dietary fibre intake among age groups……………………………………………..35 Table 4.6 Major sources of fibre with mean percentage contributions………………………..37 Table 4.7a Cereals and grains………………………………………………………………….39 Table 4.7b Roots, tubers and baked products………………………………………………….40 Table 4.7c Legumes, nuts and seeds…………………………………………………………...41 Table 4.7d Fruits and vegetables……………………………………………………………….43 Table 4.8 Lipid profile values of hypertensive patients………………………………………..44 Table 4.9 Correlation between dietary fibre, blood pressure, anthropometry and lipid profile..45 Table A.2 Detailed correlation table between dietary fibre, blood pressure, Body Mass Index, visceral fat and lipid profile…………………………………………………………………….77 ii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS AACC- American Association of Cereal Chemists ACC- American College of Cardiology AHA- American Heart Association BCA- Body Composition Analyzer BMI- Body Mass Index CAD- Coronary Artery Disease CVD- Cardiovascular Disease DASH- Dietary Approaches to Stop Hypertension GHO- Global Health Observatory GSS- Ghana Statistical Service HDL-C- High Density Lipoprotein cholesterol HM- Hypertension medication LLM- Lipid lowering medication LDL-C- Low Density Lipoprotein cholesterol NCDs- Non communicable diseases NSP- Non-starch Polysaccharides OMNIHeart- Optimal Macronutrient Intake Trial for Heart Health OPD- Outpatients Department iii University of Ghana http://ugspace.ug.edu.gh RO- Resistant Oligosaccharides RS- Resistant Starches SCFAs- Short Chain Fatty Acids TC- Total Cholesterol TG- Triglycerides VF- Visceral fat WHO- World Health Organization iv University of Ghana http://ugspace.ug.edu.gh GLOSSARY Banku- cooked ball of fermented corn and cassava dough Kenkey- cooked ball of fermented corn dough Fufu- pounded boiled cassava and plantain Jollof- Meal prepared from stewed rice Tombrown- porridge prepared from roasted corn flour Tuo zaafi- meal prepared with refined corn flour v University of Ghana http://ugspace.ug.edu.gh CHAPTER 1 1.0 INTRODUCTION Hypertension also known as high blood pressure is an issue of global health concern. It is defined by the American College of Cardiology (ACC) and American Heart Association (AHA), (2017) as blood pressure above 130/80 mmHg (Whelton et al., 2018). It is associated with high morbidity and mortality rates which affects public health and socio-economic conditions worldwide. The prevalence of hypertension in Africa is reported to be the highest and has been estimated at 46% among adults, aged 25 years and above. The lowest prevalence exists in America with a rate of 35.1% (WHO, 2013). In Ghana, 38% of women between the ages of 45- 49 years and 34% of men aged 50-59 years are hypertensive (Ghana Statistical Service (GSS), 2015). According to an annual report by the World Health Organization (WHO), outpatient (OPD) cases of hypertension in Ghana increased from 799,028 in 2011 to 830,620 in 2014 and are recorded as the most occurring among non-communicable diseases (NCDs) (WHO, 2013). Hypertension has been noted as a risk factor for cardiovascular diseases (CVDs) (Wu et al., 2015). It has also been shown to contribute to the incidence of metabolic syndrome and also associated with complications of kidney disease in Ghana (Ato et al., 2013). In Africa, industrial urbanization is one of the leading risk factors of hypertension in recent times, lack of physical activity and a diet poor in fruit and vegetable intake, as well as high intake of sodium, saturated fat and carbohydrate-rich diets that lead to obesity are risk factors (Ibrahim & Damasceno, 2012). A study in Italy found that hypertensive men had comparably more fat in the abdominal visceral region than normotensive men (Sironi et al., 2004). Addo et al. (2012) reported a prevalence of 19.3% and 54.6% for both rural and urban Ghana as 19.3% and 54.6% respectively. Furthermore, a hospital study by Sutherland et al., (2018) on the 1 University of Ghana http://ugspace.ug.edu.gh causes of death in a 37-year review (1979- 2015) revealed that NCDs (60%) were the top cause of death. Among the NCDs, cardiovascular diseases recorded 500 deaths per 1000 between the years 2011 and 2015 making it the leading cause of death in adults followed by cancer. With these stark findings in mind, it is important to note that hypertension is a major risk factor for CVDs such as stroke and ischemic heart disease which are part of the top ten causes of death in the country. Diet plays a critical role in the prevention and incidence of hypertension. Some studies have associated a decreased risk of hypertension with increased consumption of dietary fibre (Lie et al., 2018; Wei et al., 2017). Dietary fibre from foods such as fruits, vegetables, whole grains and cereals has been reported to have a protective effect from cardiovascular diseases (McRae, 2017). The American Association of Cereal Chemists International defines dietary fibre as the edible parts of plants or analogous carbohydrates such as cellulose, pectin, and lignin that are resistant to digestion and absorption in the human small intestine with complete or partial fermentation (American Association of Cereal Chemists, 2001). Dietary fibre can be divided into soluble and insoluble in terms of their physical and chemical properties. Soluble fibre can also be subdivided into viscous (gel forming) and non-viscous (El-Salhy, Ystad, Mazzawi, & Gundersen, 2017). The insoluble fibre can be found in fruits, vegetables, whole grains, legumes, and cereals. Soluble fibre includes pectin, gums, certain hemicelluloses, and storage polysaccharides (Jha, Singh, & Prakash, 2017). Soluble fibre can absorb or bind to lipids present in foods in the gastrointestinal tract which subsequently reduces serum lipids. Soluble fibre also has the ability to swell and become viscous when ingested which increases satiety and thus reduces food intake leading to a lower risk of 2 University of Ghana http://ugspace.ug.edu.gh obesity (Gropper, Smith, & Groff, 2009). Other health benefits of dietary fibre include prevention of constipation, management of gastrointestinal diseases such as inflammatory bowel disease (IBD) and ulcerative colitis etc. The 2015 Dietary guidelines for Americans recommend a dietary fibre intake of 25 g/day for females between the ages of 31–50 and 30 g/day for males of the same age. Also, the Institute of Medicine recommends that adults consume >14 g fibre/1000 kcal (Lie et al., 2018). The recommended dietary fibre intake for Ghanaian adults is 25g daily (Ministry of Health, 2009). Hypertensive patients usually present with poor glycemic control and unfavourable lipid profiles compared with the general population (LaRosa & Kostis, 2013). Diets used in the management of hypertension, such as the DASH and OMNIHeart diets, have been shown to improve blood pressure and blood lipids (Duman, 2013). A study which involved restricted feeding of a high fibre diet which included oats, barley, soy and nuts indicated reductions in low-density lipoprotein cholesterol (LDL-c) (Wong, Comelli, Kendall, Sievenpiper, & Noronha, 2017). An inverse association was also shown between fibre intake, body weight and body fat in cross- sectional observational studies (Parikh et al., 2012). A longitudinal study also found an inverse association between fibre intake and body mass index as well as visceral fat (Slavin, 2005). There is paucity of published studies of dietary fibre intake of hypertensive patients in Ghana. 3 University of Ghana http://ugspace.ug.edu.gh 1.1 PROBLEM STATEMENT Hypertension was reported as the leading cause of cardiovascular mortality in 2013 (World Health Organization, 2013). Worldwide, it has also been estimated that one-third of adults will have hypertension by 2025 (Bhagani, Kapil, & Lobo, 2018). In Africa, a rate above 40% has been recorded for both men and women (WHO, 2013). Hypertension is known to increase risk of cardiovascular diseases making it a public global health concern. A systematic review and meta-analysis confirmed the association of increased consumption of dietary fibre with low systolic and diastolic blood pressure as well as body weight and lipid profile regulation (Threaplton et al., 2013). About 20-30g of dietary fibre per day has been recommended in lowering blood lipids and reducing risk of chronic diseases for which obesity is also a risk factor (Huang et al., 2017; British Nutrition Foundation, 2018). However, there is paucity of data on dietary fibre intake of hypertensive patients in Ghana and any possible relationship with anthropometry and lipid profile is unknown. Also, most of the studies carried out on hypertensive patients in Ghana such as the Ghana Demographic study focused on general dietary patterns of participants (Ghana Statistical Service (GSS), 2015). Hence, data on dietary fibre intake among hypertensive patients as well its effect on blood pressure, serum lipids and weight regulation is undocumented making this study very imperative. 1.3 JUSTIFICATION The findings of this study will provide information on the sources and intake of dietary fibre of hypertensive patients. It would also provide information on the relationship between dietary fibre intake, blood pressure, BMI and lipid profile values. This study will not only add to literature on hypertension in Ghana but will be useful in planning nutrition education programs and nutrition health policies to reduce the prevalence and mortality associated with hypertension in Ghana. 4 University of Ghana http://ugspace.ug.edu.gh It will also be a source of evidence-based data for dietitians and other health care practitioners to support medical nutrition therapy for hypertensive patients. 1.4 AIM The aim of the study is to determine the relationship between dietary fibre intake and blood pressure, lipid profile and anthropometric measurements of hypertensive patients. 1.4.1 Specific Objectives The specific objectives for this study were: 1. To estimate mean dietary fibre intake of the patients 2. To determine the major sources of dietary fibre in the diet of patients. 3. To assess blood pressure, anthropometry and lipid profile values of hypertensive patients. 4. To determine the relationships between fibre intake, blood pressure, BMI, visceral fat and lipid profile of patients. 1.5 Hypotheses Hθ There is no relationship between dietary fibre intake and anthropometric measurements. Hθ There is no relationship between dietary fibre intake and lipid profile indices. Hθ There is no relationship between dietary fibre and blood pressure. 5 University of Ghana http://ugspace.ug.edu.gh CHAPTER 2 2.0 LITERATURE REVIEW 2.1 HYPERTENSION Hypertension is a non-communicable disease associated with high morbidity and mortality. It is considered as a silent threat to the health of people worldwide affecting up to one third of the world’s population (Gyamfi, Obirikorang, Acheampong, Owusu, et al., 2018). Therefore, it is important that blood pressure levels are examined and checked on regular basis (Duman, 2013). 2.1.1 Types of hypertension There are two main types of hypertension namely primary or essential hypertension and secondary hypertension. Primary or essential hypertension is the most common form of hypertension which has no known primary cause. It is usually associated with factors such as diet, genes, lifestyle and stress (Kumar, 2014). Secondary hypertension is a less common type of hypertension due to a specific condition. Hypertension may result as a complication from conditions such as sleep apnea, tumors and kidney failure. Other types of hypertension include isolated hypertension, resistant hypertension and malignant hypertension (Illiades, 2009). Isolated systolic hypertension occurs when the systolic pressure rises above 140 mmHg, while diastolic blood pressure is within the normal range. Malignant hypertension occurs when blood pressure rises very quickly. This requires prompt medical attention. Symptoms include numbness in the arms and legs, blurred vision, confusion, chest pain, and headache. Resistant hypertension occurs when blood pressure is still high even though patient is on treatment (Arakelyan & Sahakyan, 2019). 2.1.2 Classification of hypertension Hypertension is defined into 4 stages namely: normal, elevated, stage 1 and stage 2. However, the term pre-hypertension was introduced as a new class of blood pressure by the 7th Joint 6 University of Ghana http://ugspace.ug.edu.gh National Committee on Prevention, Detection, Evaluation and Treatment of Hypertension (Chobanian et al., 2003). The committee proposed that a systolic BP between 120 and 139 mmHg and/or diastolic BP between 80 and 89 mmHg is indicative of a pre-hypertensive state. People with pre-hypertension have higher chance of developing hypertension and increased risk of major cardiovascular events independent of other risk factors later in life. Stage 1 hypertension is defined as systolic BP of 130 to139 mm Hg or diastolic BP 80 to 89 mm Hg. Stage 2 hypertension is defined as systolic BP >140 mm Hg or diastolic BP >90 mm Hg (Shoulders & Powell, 2019). 2.1.3 Prevalence of hypertension Cardiovascular diseases accounts for approximately 17 million deaths globally. Out of these deaths, complications of hypertension account for 9.4 million deaths worldwide every year. The prevalence of hypertension is highest in the African Region at 46% of adults aged 25 and above, while the lowest prevalence at 35% is found in the Americas (WHO, 2013). A study by WHO-SAGE compared the prevalence of populations over 50 years of age from countries such as China, Ghana, Russia, Mexico, India and South Africa. The highest rate was observed in South Africa which was at a startling rate of 77% due to poor lifestyle choices (Lloyd-sherlock, Beard, Minicuci, Ebrahim, & Chatterji, 2014). Similarly, Gómez-Olivé et al. (2017) observed this same trend in their study where South Africa recorded a significantly higher rate of 54.1% among the countries under investigation. The lowest prevalence of hypertension was among men (19.2%) and women (11.0%) in rural Nanoro, Burkina Faso. In that same study in rural Navrongo, a prevalence of 24.1% was reported for men and 24.8% for women. According to the Ghana Demographic Health Survey (2014), the prevalence of hypertension among women was highest in Greater Accra (17%) and lowest in Upper West 7 University of Ghana http://ugspace.ug.edu.gh (5%). For men, a prevalence of 18.1% and 6.2% was reported in Ashanti and Northern region respectively (Ghana Statistical Service (GSS), 2015). The increasing prevalence of hypertension is attributed to population growth, ageing and behavioural risk factors, such as unhealthy diet, harmful use of alcohol, lack of physical activity, excess weight and exposure to persistent stress (WHO, 2013). 2.1.4 Risk factors of hypertension Risk factors for hypertension can either be of genetic, behavioural or environmental origin. These could be further grouped into modifiable and non modifiable risk factors (Ibrahim & Damasceno, 2012). Generally, non modifiable risk factors of hypertension include age, ethnicity and gender. For example, in terms of ethnicity, a study reported that the prevalence of hypertension is twice greater in black people than in white people (Ibrahim & Damasceno, 2012). Similar results have also confirmed that people of black African origin had a higher risk of hypertension compared to white people (Bryson, Ross, Boyko, & Young, 2006; Chaturvedi et al., 2004). Hypertension is also more common in black Caribbean males and females, and less common in Bangladeshi males and females (Erens et al. 2001). In Ghana, a study by Sanuade et al., (2018) observed a higher prevalence among Ewes (16.2%) and lowest among the Mole Dagbani (9.7%). Hypertension is known to be more common in older individuals than younger individuals. The relationship between increasing age and rise in systolic blood pressure has been associated with the length of time people are exposed to modifiable risk factors (Gyamfi et al., 2018). In Africa, significant differences in sex with regards to prevalence of hypertension have shown to be minimal (Sanuade, Boatemaa, & Kushitor, 2018). However, a study by Gómez-Olivé et al. 8 University of Ghana http://ugspace.ug.edu.gh (2017) on the regional and sex differences in the prevalence and awareness of hypertension across 6 sites in Sub-Saharan Africa found a significantly higher prevalence in women than men. On the contrary, studies have also showed a significantly higher prevalence in men than women due to differences in hormonal activity early in life (Hulanicka, Lipowicz, Kozieł, & Kowalisko, 2007; Ojeda, Grigore, Robertson, & Alexander, 2007). Modifiable risk factors of hypertension include diet, physical activity, alcohol, obesity and smoking (Gyamfi, Obirikorang, Acheampong, Danquah, et al., 2018). Increases in the intake of diets rich in sodium, sugar and fats which has led to an increase in the prevalence of obesity, a strong predictor of hypertension (Ibrahim & Damasceno, 2012). 2.1.5 Complications of hypertension Aside from being known as the silent killer, hypertension affects other vital organs of the body over a period (Nshisso et al., 2012). Constant extreme pressure from blood flow can stiffen arteries thereby reducing the flow of blood and oxygen to the heart. Thus, hypertension may lead to angina (chest pain), heart failure, heart attack and arrhythmia resulting in sudden death. Blood vessels that supply blood and oxygen to the brain can burst or become blocked leading to stroke. Furthermore, hypertension can damage the kidney resulting in kidney failure (WHO, 2013). 2.1.6 Management of hypertension Hypertension is an under-treated disease due to its asymptomatic nature. Among 50% of patients who do receive treatment, only 10–20% achieve blood pressure goals. Hypertension can be managed through lifestyle changes and medications. Medications such as calcium channel blockers and loop diuretics are available to manage hypertension. Studies have also shown that lifestyle changes that include high physical activity, avoiding alcohol and tobacco along with 9 University of Ghana http://ugspace.ug.edu.gh dietary changes can help treat and often delay or prevent hypertension (Shoulders & Powell, 2019). Some proposed dietary modifications to lower blood pressure include reduced salt intake, increased potassium intake, and moderation of alcohol consumption. Over the past decade, expert groups such as the American Heart Association and the National Cancer Institute have recommended the DASH (Dietary Approaches to Stop Hypertension) dietary pattern for both the prevention and management of hypertension (Duman, 2013). In the time frame between 1996 and 2001, cohort studies in countries such as the USA, Finland and Norway have all reported that subjects consuming relatively huge amounts of whole grain cereals have significantly lower rates of coronary heart disease (CHD). Increased intake of fibre from cereal sources was associated with a reduced risk of CHD in the Nurses’ Health Study. It was further noted to be inversely associated with the risk of hypertension in the Health Professionals Follow-up Study (Wu et al., 2015). 2.1.7 The DASH diet The DASH diet is a diet regimen used in the management of hypertension. It encourages the intake of twice the daily amount of fruits, vegetables, low-fat dairy products, and complex carbohydrates. This type of diet is lower in fat, cholesterol, and sodium, however, contains large amounts of fibre, potassium (K), magnesium (Mg), and calcium (Ca). It is therefore recommended as a nutritional strategy for lowering blood pressure, overweight and obesity (National Heart, Lung and Blood Institute, 2015). Table 2.1.7 shows the various components and their recommended intake of the DASH diet. 10 University of Ghana http://ugspace.ug.edu.gh Table 2.1Various components and recommended intake of DASH diet Nutrients per day 2,300 mg 1500 mg Calories (kcal) 2027 2078 Total fat (g) 64 68 Saturated fat (g) 13 16 Cholesterol (mg) 114 129 Sodium (mg) 2035 1560 Calcium (mg) 1370 1334 Potassium (mg) 535 542 Magnesium (mg) 4715 4721 Fibre (g) 34 34 Source: (National Heart, Lung and Blood Institute, 2015) A clinical trial study by Sacks et al. (2001) compared the effectiveness of variants of the DASH diet (fruits and vegetables diet and low fat fruit and vegetable diet) with a ‘typical’ diet in the United States in lowering blood pressure. Results showed that both intervention diets reduced blood pressure but the DASH diet was more effective in significantly reducing systolic and diastolic blood pressures for both hypertensive and normotensive participants. The DASH diet was also demonstrated to be effective as nutritional therapy in individuals with stage I isolated systolic hypertension with 78% of the persons on the DASH diet reducing their systolic blood pressure to less than 140 mmHg, in comparison to 24% in the control group (Moore, Conlin, Ard, & Svetkey, 2001). A clinical trial in the United States showed that the DASH diet with sodium restriction in 459 adults provided comparable reductions in blood pressure. The DASH diet reduced both systolic and diastolic blood pressure by 5.5 and 3.0 mmHg more respectively compared to the control diet (Appel et al., 1997). Research has also showed that the DASH diet might also help improve 11 University of Ghana http://ugspace.ug.edu.gh lipid profile, control blood glucose and prevent cardiovascular diseases (Duman, 2013; Reddy & Katan, 2004; Ljubicic et al., 2017). 2.2 DIETARY FIBRE The term ‘dietary fibre’ was first conceived by Eben Hipsley in 1953. It is referred to as edible plant parts, similar to carbohydrates that cannot be digested or absorbed in the small intestines and as such undergo partial or complete fermentation in the large intestine to produce short chain fatty acids (SCFAs) such as acetate, butyrate and propionate (Prasad, Gurav, Zhu, & Martin, 2017). The chemical bonds present in dietary fibre cannot be digested by enzymes in the gastrointestinal tract of humans. The amounts of short chain fatty acids produced in the lumen of the large intestine are approximately in the ratio 60:20:20 respectively (Ljubicic et al., 2017). Liu et al. (2002) also described dietary fibre as a group of plant-based non-starch polysaccharides (NSP) and lignins that are resistant to human digestion. It includes non-starch polysaccharides from sources such as fruits, vegetables, cereals and tubers, resistant oligosaccharides (RO) and resistant starch (RS). Figure 1.1 shows the structure of cellulose. Fig.1.1 Chemical structure of cellulose 12 University of Ghana http://ugspace.ug.edu.gh 2.2.1 Types of dietary fibre Dietary fibres are a large group of diverse polysaccharides that are mainly derived from plant cell walls. The length of the monomer is used to classify dietary fibres as short-chain or long- chain carbohydrates. Some long-chain dietary fibres such as pectin, guar gum, and inulin are soluble and extremely fermentable (Gropper et al., 2009). However, other long-chain dietary fibres, such as cellulose and methylcellulose are insoluble and non fermentable (Reddy & Katan, 2002). Fig. 1.2 shows the structure of pectin. Fig 1.2 Chemical structure of pectin With regards to solubility in water, dietary fibre can be grouped into insoluble dietary fibre (e.g. cellulose or lignin) and soluble dietary fibre (e.g. pectin) (Lin et al., 2019). Soluble dietary fibres are broken down by microorganisms present in the gastrointestinal tract. The insoluble part of dietary fibre is undigested and thus mostly serves as a major component of fecal matter. Therefore, high intake of insoluble dietary fibre helps prevent constipation by facilitating proper bowel movement (Prasad et al., 2017). 13 University of Ghana http://ugspace.ug.edu.gh 2.2.2 Health benefits Dietary fibres are pre-biotics and thus support the growth of some specific constituents of gut microbiota that promote cardiovascular health (Delzenne et al., 2019). Dietary fibre can also affect the digestive process of lipids due to viscous fibre which possesses the ability to alter the microstructure of emulsions formed during digestion (Lin et al., 2019). Intake of food sources of soluble fibre can reduce serum cholesterol to normal concentrations which protects against cardiovascular diseases. Adequate intake of insoluble and non- fermentable fibre has been recognized as important in the treatment of several gastrointestinal disorders such as diverticulosis, irritable bowel syndrome, and constipation (Ljubicic et al., 2017). A generous dietary fibre intake is associated with weight loss or management. High-fibre foods lower the hunger associated with caloric (energy) restriction as well as concurrently extending transit time and hence reducing nutrient absorption and metabolism. The bulk provided by fibre increases satiety with little intake (Slavin, 2013). Dietary fibre has also been associated with delayed postprandial plasma glucose uptake making it useful in the regulation of blood sugars of patients with diabetes (Li et al., 2019). A study by Flint et al., (2009) revealed an association between cereal fibre and reduced blood pressure in adults. 14 University of Ghana http://ugspace.ug.edu.gh 2.2.3 Dietary fibre intake According to WHO guidelines, individuals are advised to consume 400g or have 5 portions of fruits and vegetables to meet their daily dietary fibre requirements (WHO, 2013). Previous studies among African-American women showed that they had lower intakes of dietary fibre than other racial and ethnic group (King, Mainous, & Lambourne, 2012; Kong et al., 2014). A cross-sectional study investigating dietary fibre intake by age, sex, and race reported that non- Hispanic, black females consumed less fibre per day (12.7g/day) compared with European- American women (15.7g/day) as well as non-Hispanic, African-American males (15.0g/day)(Storey & Anderson, 2014). In another cross-sectional study which examined the dietary quality of African-American and Hispanic families in the Special Supplemental Nutrition Program for Women, Infants, and Children, African-American mothers consumed a median fibre intake of 8.8g/day compared to 14.5g/day in Hispanic mothers (Kong et al., 2014). It is reported that dietary fibre intake in Asians is twice greater than Europeans. It is also reported that Mediterranean countries have high intakes of dietary fibre as well (Gunashekar et al., 2017) In Ghana, results from a study showed a dietary fibre intake of 6.7 ± 2.2 g/1000kcal compared to 8.3±3.1 g/1000kcal for diasporic Ghanaian adults living in the UK (Gibson, Knight, Asante, Thomas, & Goff, 2015). 15 University of Ghana http://ugspace.ug.edu.gh Table 2.2 Dietary fibre requirements Population group Age Total fibre (g) Men 19-50 38 >51 31 Women 19-50 25 >51 21 Children 1-3 19 4-8 25 Boys 9-13 31 14-18 38 Girls 9-18 26 (Food and Nutrition Board, 2002) To ensure adequate intake of fibre, food sources of fibre need to be varied and complementary. Assurance of a good intake of fibre requires daily intake of a variety of high-fibre foods (Gropper et al., 2009). The table below shows the fibre content of some foods. 16 University of Ghana http://ugspace.ug.edu.gh Table 2.3 Fibre content of some foods FOOD SERVING FIBRE (g) Apple with skin 1 3.3 Banana 1 3.1 Orange 1 3.4 Carrots 1 cup 4.8 Kidney beans 1 cup 16.4 Corn 1 cup 2.1 White rice (cooked) 1 cup 0.6 Bread (white) 1 slice 0.6 Peanuts 1 oz 2.3 Almonds 1 oz 3.3 Waakye 100g 3.4 Banku 100g 0.1 Yam 100g 0.5 Kontomire stew 100g 1.4 (Source: www.ars.usda.gov.) and http://huh.harvard.edu) (Eyeson & Ankrah, 1975) 17 University of Ghana http://ugspace.ug.edu.gh 2.3 DIETARY FIBRE AND CARDIOVASCULAR DISEASES Studies have reported that dietary fibre reduces the risk of CVDs. A review of meta-analyses by McRae (2017) reported that increased dietary fibre intake reduced the relative risk of CVD incidence and mortality. Across all sites of the study, cardio metabolic risk (metabolic syndrome, inflammation and obesity) was inversely associated with dietary fibre intake, such that the prevalence of metabolic syndrome was 13% for those in the lowest quartile of fibre intake, compared to 9% for those in the highest quartile of fibre intake. Interestingly, twice as many of the participants (38%) in the lowest quartile were obese compared to those in the highest quartile of fibre intake (18%). A systematic review and meta-analysis study by Threapleton et al., (2013) also provided evidence of increased consumption of dietary fibre especially β-glucan fibre with lower systolic and diastolic blood pressure. These findings were consistent with results from Khan et al., (2018). However, they concluded that viscous soluble fibre supplementation particularly from psyllium had a modest but significant reduction in systolic and diastolic blood pressure. Another meta-analysis study by Wu et al., (2014) showed that higher fibre intake was associated with decreased incidence of coronary heart disease (CHD). In subgroup analysis, results from studies on different sources of dietary fibre (cereal, fruit and vegetable) intake were analyzed. Results demonstrated a significant association between both higher cereal and fruit fibre intake and decreased CHD incidence (p= 0.032, p= 0.01 respectively). However, higher vegetable fibre intake was not significantly associated with CHD incidence. The study also examined the association between soluble and insoluble fibre intake and incidence of CHD. The results indicated that both types of fibre intake were inversely associated with CHD incidence (soluble fibre r= 0.84, p=0.002), (insoluble fibre, r= 0.85, p= 0.044). It was 18 University of Ghana http://ugspace.ug.edu.gh also discovered that higher fibre intake was significantly associated with decreased mortality of CHD. Consequently, Sun et al. (2018) in a study on the exploration of the association between dietary fibre intake and hypertension among U.S. adults using 2017 American College of Cardiology/American Heart Association Blood Pressure Guidelines found a nonlinear relationship between total fibre intake and hypertension. The risk of hypertension was reduced by 53% when the total fibre intake increased from 0.07 g/kg/day to 0.35 g/kg/day. However, cereal and vegetable fibre intakes had linear inverse associations with the risk of hypertension. A study by Maki et al., (2007) analyzed the effects of consuming foods containing oat β-glucan on blood pressure in hypertensive men and women. They followed a randomized, double-blind, controlled clinical trial design and recruited 97 men and women with resting systolic blood pressure values of 130-179 mmHg and/or diastolic blood pressure levels of 85-109 mm Hg. They were randomly assigned to consume foods containing oat β-glucan or control foods for 12 weeks. Blood pressure responses were not significantly different between groups. However, individuals with a body mass index > 31.5 kg/m2 in the β-glucan group showed decreases in systolic (8.3 mmHg) and diastolic (3.9 mmHg) blood pressures than their control group. 19 University of Ghana http://ugspace.ug.edu.gh 2.4 DIETARY FIBRE AND LIPID PROFILE Some studies have showed that excessive adiposity affects lipid profile. Hence, obese or overweight hypertensive patients usually present with abnormal lipid profile values which increases cardiovascular risk (Spannella et al., 2019). Consumption of foods with low glycaemic index values such as vegetables and legumes improve blood lipid levels with a reduction in total cholesterol (TC), low density lipoprotein cholesterol (LDL-c) and triglycerides (TGs) (Obarzanek et al., 2001). However, some clinical trials have shown inconsistent associations (Sloth et al., 2004; Lin et al., 2012). A meta-analysis study by McRae (2017) showed that fibres such as β-glucan and psyllium supplementation significantly reduced total serum and LDL cholesterol concentrations. The mechanism involved in the reduction of total serum cholesterol of dietary fibre was attributed to soluble fibre’s ability to bind to cholesterol in the lumen of the small intestine and therefore reduces the absorption of cholesterol. Soluble fibre also increases the fecal excretion of bile acids and this diverts hepatic cholesterol for bile acid production which lowers circulating levels of plasma LDL cholesterol (Raman, Ambalam, & Doble, 2018). Another study by Mohammadifard et al., (2014) on the inverse association of legumes and dyslipidemia in randomly selected adults in 3 districts in Iran also suggested that the hypolipidemic effect was due to the increase in steroid fecal excretion. An inverse association between frequency of legume intake and risk of hypertriglyceride, low HDL-C and high LDL-C was observed. In support of their findings, a study by Hermsdoff et al., (2011) also demonstrated that consumption of legume including lentils, chickpeas, peas, or beans (4 servings/week) within a low-calorie diet improved LDL-C and TC values. 20 University of Ghana http://ugspace.ug.edu.gh A double-blinded, randomized clinical study examined the effect of inulin in 12 dyslipidemic obese subjects between 19 and 32 years of age. Subjects received 7 g/day of inulin or placebo in the morning. After 4 weeks, a significant reduction in total cholesterol, low-density lipoprotein (LDL) cholesterol, very low-density lipoprotein (VLDL), and triglyceride levels in blood was observed (Balcazar-Munoz, Martinez-Abundis, & Gonzalez-Ortiz, 2003). In the group consuming inulin, serum triglycerides decreased significantly by 40 mg/dL (P < 0.05). Studies have been conducted to test effectiveness of dietary fibre in improving blood lipid profiles in healthy individuals. In a randomized, double-blinded, placebo-controlled and parallel design, healthy young individuals consumed 50 g of a rice-based ready-to-eat cereal daily with or without 18% inulin for breakfast. After 12 weeks, the group consuming inulin showed significant decrease in plasma total cholesterol and triglycerides by 7.9 ±5.4% (P < 0.05) and 21.2 ± 7.8% (P < 0.005), respectively (Brighenti, Casiraghi, Canzi, & Ferrari, 1999). 21 University of Ghana http://ugspace.ug.edu.gh 2.5 DIETARY FIBRE AND OBESITY Increased intake of refined foods, industrially processed foods, sugary drinks, red meat and processed meat as well as desserts have been associated with obesity and weight gain. Consequently, increased intake of whole cereals and grains, legumes, nuts, fruits and vegetables have been associated with a lower risk of obesity and weight gain (Malinowska, Mlodzik- Czyzewska, & Chmurzynska, 2020). Numerous epidemiological studies suggest that a diet high in fibre, especially intake of whole grains or cereal fibre can prevent excessive weight gain. Results from a 12-year dietary data analysis from the Nurses' Health Study revealed that women with the greatest increase in dietary fibre intake gained 1.53kg less on average than females with the smallest increases in dietary fibre intake (Liu et al., 2002). In that same study, women in the highest quintile of dietary fibre intake had a 49% lower risk of major weight gain than women in the lowest quintile. Results from this study suggested that over the course of the 18-month weight loss maintenance trial, there was a change in the relationship between dietary fibre consumption and BMI over time. At baseline, there was no relationship between dietary fibre consumption and BMI. However, at 6 months, there was a statistically significant negative association between dietary fibre consumption and BMI (p< 0.05). This relation remained significant at 18-months and was even stronger than at 6 months. These findings are consistent with the few existing prospective studies investigating associations between fibre intake and weight in African-American women (Buscemi et al., 2018). Evidence of the association between dietary fibre and obesity has also been confirmed by Ben Slama et al., (2011) in a study on dietary fibre in the diets of urban Tunisian women and its association with BMI, waist circumference and blood chemistry. Results from the study showed 22 University of Ghana http://ugspace.ug.edu.gh that dietary fibre intake was higher in non-obese women than in obese women. A negative correlation however, was found for mean daily fibre intake and BMI of the study population. 2.6 DIETARY FIBRE AND VISCERAL FAT Evidence from studies also supports the association between increased dietary fibre intake and visceral fat. A two-year follow up study in Latino children between the ages of 7-11 revealed that an increase in dietary fibre by 3g per 1000kcal was associated with a 4% reduction in visceral fat while a reduction by the same amount was associated with an increase in visceral fat by 21% (Davis et al., (2009). This was also true for a study by Parikh et al., (2012), after they investigated for associations between dietary fibre intake, inflammatory-related biomarkers and central adiposity in adolescents. The study showed that greater dietary fibre consumption was associated with lower visceral adiposity in adolescents. 23 University of Ghana http://ugspace.ug.edu.gh CHAPTER 3 3.0 METHODOLOGY 3.1 Study Design A hospital-based cross sectional study was conducted among hypertensive patients. 3.2 Study Site The study was carried out at the Dietetic Department of the University Hospital, Legon. The University Hospital was established in 1957 purposely to provide healthcare services for the university staff, staff dependents and students but was open to the general public since 1977. It provides primary, secondary and specialist services in 13 clinical areas which include paediatrics, surgery, obstetrics and gynaecology. It has a 130-bed capacity and an outpatient population of 8000. It is situated in the Ayawaso West Wuogon district (Sutherland, Ansa, Baiden, Quaye, & Amoabeng, 2018). 3.3 Study Population Participants of the study were hypertensive patients who were reporting to the Dietetics department at the University Hospital. 3.3.1 Inclusion and Exclusion criteria Hypertensive patients who did not provide consent to participate in the study were excluded. 24 University of Ghana http://ugspace.ug.edu.gh 3.4 Sample Size Calculation Using a margin of error of 5% at 95% confidence interval and mean fibre intake among a West African population of 5.6g (Ijarotimi & Keshinro, 200 8) and standard deviation of 0.35, a sample size of 190 was computed. n= Z α/2 x standard deviation (SD) 2 , (Glen, 2018) MOE where Zα/2 is the critical value of the normal distribution at α/2 and MOE= margin of error Zα/2= 1.96 MOE = 0.05 n= 1.96 x 0.35 2 0.05 n = 188.24 rounded up to 190 3.5 Sampling technique The total enumeration technique was employed in this study. This technique involves selecting all eligible participants at the study site. Daily visits were paid to the study site and with the assistance of the dietitian at the Dietetics department, eligible patients were identified. The details of the study were explained to them and their written consent obtained before they were recruited into the study. They were interviewed and physical measurements taken. Recruitment continued until the total number of patients needed was obtained. 25 University of Ghana http://ugspace.ug.edu.gh 3.6 Procedure for data collection 3.6.1 Socio-demographic and dietary data Dietary fibre intake of hypertensive patients was assessed using a 31-item quantitative food frequency questionnaire (QFFQ) (Healey et al., 2016). Foods of Ghanaian origin were added to the original questionnaire. The QFFQ listed foods in 7 groups namely; cereals and grains, roots and tubers, breads, legumes, nuts and seeds, baked products, fruits and vegetables. The food frequency questionnaire was validated and pre-tested at the University hospital using 19 participants (10% of calculated sample size). Food models and household handy measures were used to assist in the estimation of portion sizes of usual food intake. Portion sizes were then converted into grams using a food handy measures conversion compilation. The questionnaires were interviewer-administered. A sample of the QFFQ can be found in appendix 1. 3.6.2 Anthropometric data 3.6.2.1 Weight Weight was measured following standard procedures using a calibrated Body Composition monitor (Omron HBF-516C, USA). The participants were asked to remove footwear, heavy clothing and objects inside of pockets of clothing before standing on the scale. Weight was then recorded to the nearest kilogram. Trained personnel were used to take the measurements to ensure reliability of results. 3.6.2.2 Height Height was measured using a stadiometer (Seca 213, Germany). Participants were asked to stand erect on the floor board of the stadiometer with their back to the vertical backboard of the stadiometer. The weight of the participant was distributed on both feet. The heels of the feet were placed together with both heels touching the base of the vertical board. The buttocks, scapulae, and head were positioned to make contact with the vertical backboard. The participant was asked 26 University of Ghana http://ugspace.ug.edu.gh to inhale deeply and to stand fully erect without changing the position of the heels. The head was maintained in the Frankfort Horizontal Plane position and the horizontal bar of the stadiometer was lowered to the top of the head with enough pressure to compress the hair. Hair ornaments, buns etc. were removed to obtain an accurate measurement. The reading was recorded to the nearest 0.1 cm. 3.6.2.3 Body Mass Index (BMI) Body Mass Index was determined using a calibrated Body Composition Monitor (Omron HBF- 516C, USA). A simple range of values defined as underweight (<18.5 kg/m2), normal weight (18.5-24.5kg/m2), overweight (25-29.9 kg/m2), obese class 1(30– 34.4kg/m2), obese class 2 (35- 39.9 kg/m2) and obese class 3 (≥ 40 kg/m2) was used in this study based on the WHO criteria for adults (WHO, 2012). 3.6.2.4 Visceral Fat Visceral fat of participants was assessed using the Body Composition Monitor (Omron HBF- 516C, USA). Classification of visceral fat was obtained from the manual of the Body Composition Monitor and defined as normal (1- 9), high (10 – 15) and very high (>15). 3.6.3 Blood pressure Blood pressure was measured using a calibrated upper arm BP monitor (Omron M2 Basic, USA). Participants were asked to relax sitting in a chair (feet on floor, back supported) for more than 5 minutes before measurement. Participants were asked to be silent during the rest period or during the measurement. All clothing covering the location of cuff placement was removed before measurement. The participant’s arm was supported by resting it on a desk after which the middle of the cuff was positioned on the participant’s upper arm at the level of the right atrium (the midpoint of the sternum). Two separate measurements were taken with an interval of 1–2 27 University of Ghana http://ugspace.ug.edu.gh minutes. The SBP and DBP were then recorded and the average of the two readings were used for analysis (Whelton et al., 2017). 3.6.4 Lipid Profile Total cholesterol (TG), total triglycerides (TG), high density lipoprotein cholesterol (HDL-C) and low density lipoprotein cholesterol (LDL-C) values were obtained from the patient’s folder. These values were determined using the Selective Junior auto analyzer at the hospital laboratory. Test values that were done within 3 months at the time of data collection were used. Lipid profile components were classified as shown below and measured in millimole per litre (mmol/L). Parameter Low Normal High Total cholesterol below 3.0mmol/L 3.0-5.2mmol/L above 5.2mmol/L Total triglyceride below 0.01mmol/L 0.01-1.7mmol/L above 1.7mmol/L HDL-C below 1.03mmol/L 1.03-1.55mmol/L 1.55mmol/L LDL-C below 2.5mmol/L 2.5-3.5mmol/L above 3.5mmol/L (Source- University Hospital Health Information System (HIS), 2019). 28 University of Ghana http://ugspace.ug.edu.gh 3.7 Data Management All questionnaires were kept under lock and were accessible to only the research team during the period of collecting data. Data were entered on a password protected laptop and accessible to only the research team. Patient confidentiality was assured in all reports from the study. 3.8 Ethics The study conformed to the Helsinki Declaration on Human Experimentation of 1975, revised in 1985 and 1989. The proposal was submitted to the University of Ghana, College of Health Sciences Ethics and Protocol Review Committee for ethics approval before the study was carried out (Ref No. EPRC/APRIL/2019). Permission was also sought from the University Hospital, Legon. Consent was finally sought from patients before being recruited into the study. 3.9 Data analysis Dietary fibre intake and consumption of high fibre foods of patients was determined using Microdiet (version 3.0, Downlee Systems, UK) after portion sizes were converted into grams and divided by 7 to obtain daily dietary fibre intake. Data obtained was analyzed using SPSS version 23.0. Differences in means between male and females were tested using the independent sample T-test. Pearson’s Chi Square was used to test for associations between categorical variables. Pearson’s correlation was used to determine relationship between dietary fibre, anthropometry and lipid fibre. Significance was set at a p ≤ 0.05. 29 University of Ghana http://ugspace.ug.edu.gh CHAPTER 4 4.0 RESULTS 4.1 Socio-demographic data of participants Table 4.1 shows the socio-demographic characteristics of the participants. A total of one hundred and ninety (190) participants were recruited for the study. Out of this number, 43.7% were males and 56.3% were females. The mean age of participants was 57.1±12.3 years. The modal age range for the study was 53-59 years (28.42%) followed by the 60-66 years (25.26%). Majority of the participants were Christians (93.2%) and married (74.2%). Table 4.2 also shows physical activity level and medical history of participants. General physical activity level of participants was low. Majority of participants were on hypertensive medication only. 4.2 Blood pressure and anthropometric indices of participants Table 4.3 shows the blood pressure and anthropometric measurements of participants. The mean BMI of the participants in the study was 29.5±5.6kg/m2. About 18% of the patients had a normal BMI and 41.1% were obese. The mean BMI for males was significantly lower (p=0.001) compared to females. The mean visceral fat was 11±3.9. The mean visceral fat was significantly higher (p= 0.013) in males than females. 30 University of Ghana http://ugspace.ug.edu.gh Table 4.1 Socio-demographic data of participants Parameter Male (n = 83) Female (n = 107) Total (n = 190) P-value n (%) n (%) n (%) Age (years) Mean±SD 56.1 ± 14.4 58.0 ± 10.5 57.1 ± 12.3 0.292 15-24 3 (3.6) 1 (0.9) 4 (2.1) 25-34 4 (4.8) 2 (1.9) 6 (3.2) 35-44 11 (13.3) 9 (8.4) 20 (10.5) 45-54 16 (19.3) 18 (16.8) 34 (17.9) 55-64 27 (32.5) 51 (47.7) 78 (41.1) 65-74 15 (18.1) 20 (18.7) 35 (18.4) 75-84 7 (8.4) 6 (5.6) 13 (6.8) Religion Christian 77 (92.8) 100 (93.5) 177 (93.1) 0.976 Muslim 5 (6.0) 6 (5.6) 11 (5.8) Other 1 (1.2) 1 (0.9) 2 (1.1) Marital status Single 14 (16.9) 12 (11.2) 26 (13.7) 0.056 Married 63 (75.9) 78 (72.9) 141 (74.2) Divorced 3 (3.6) 2 (1.9) 5 (2.6) Widowed 3 (3.6) 15 (14.0) 18 (9.5) Employment status Employed 43 (51.8) 58 (54.2) 101 (53.2) 0.019 Unemployed 1 (1.2) 12 (11.2) 13 (6.8) Retired 34 (41.0) 35 (32.7) 69 (36.3) Student 5 (6.0) 2 (1.9) 7 (3.7) Level of education Primary 4 (4.8) 12 (11.2) 16 (8.4) p<0.001 JHS 5 (6.0) 25 (23.4) 30 (15.3) SHS 27 (32.5) 19 (17.8) 46 (24.2) Tertiary 37 (56.6) 41 (38.3) 88 (46.3) Vocational 0 (0.0) 88 (56.3) 8 (4.2) No formal education 0 (0.0) 2 (1.9) 2 (1.1) 31 University of Ghana http://ugspace.ug.edu.gh Table 4.2 Physical activity and medical history of patients Parameter Male (n = 83) Female (n =107) Total (n = 190) P-value n (%) n (%) n (%) Level of physical activity Low 49 (75.4) 71 (85.5) 120 (81.0) 0.041 Moderate 16 (24.6) 8 (9.6) 24 (16.2) High 0 (0) 4 (4.8) 4 (2.7) Medical history 0-2 years 33 (39.7) 27 (25.2) 60 (31.6) 0.004 3-5 years 11 (13.3) 20 (18.7) 31 (16.3) 6-10 years 8 (9.6) 30 (28.0) 38 (20.0) < 10 years 31 (37.4) 30 (28.0) 61 (32.1) Medication No medication 11 (13.3) 11 (10.3) 22 (11.6) 0.046 HM only 45 (54.2) 60 (56.1) 105 (55.3) HM and LLM 27 (32.5) 36 (33.6) 63 (33.2) 32 University of Ghana http://ugspace.ug.edu.gh Table 4.3 Blood pressure and anthropometric measurements of participants Parameter Male (n=81) Female(n=105) Total (n =186) P-value Weight (kg) 78.9 ± 14.5 81.1 ± 18.9 80.2 ± 17.1 0.360 Height (m) 1.7 ± 0.06 1.6 ± 0.2 1.6 ± 0.1 p<0.001 Blood pressure(mmHg) SBP 139.1 ± 18.0 135.4 ± 15.5 136.9 ± 16.7 0.130 DBP 82.6 ± 12.6 81.7 ± 10.6 82.1 ± 11.5 0.580 BMI (kg/m2) 27.5 ± 4.7 30.9 ± 5.9 29.5 ± 5.6 p<0.001 Visceral fat 11.8 ± 4.8 10.4 ± 2.9 11.0 ± 3.9 0.013 BMI classification n(%) Underweight 2 (2.5) 0 (0.0) 2 (1.1) Normal 18 (22.2) 13 (12.4) 31 (16.7) 0.013 Overweight 38 (46.9) 36 (34.3) 74 (39.8) Obese class 1 16 (19.8) 37 (35.2) 53 (28.5) Obese class 2 6 (7.4) 13 (12.4) 19 (10.2) Obese class 3 1 (1.2) 6 (5.7) 7 (3.8) VF classification n(%) Normal 25 (31.3) 36 (34.3) 61 (32.9) 0.001 High 38 (47.5) 65 (61.9) 103 (55.7) Very high 17 (21.3) 4 (3.8) 21 (11.4) Data is presented as means ± SD unless otherwise stated *BMI classification (WHO, 2012) VF classification (BCA manual) 33 University of Ghana http://ugspace.ug.edu.gh 4.3 Nutrient intake 4.3.1 Mean energy, macro-nutrient and fibre intake Table 4.4 displays the nutrient mean energy, macronutrient and fibre intake of the participants. The daily mean intake of fibre of the participants was 15.4 ± 7.1 g. Dietary fibre intake among males was slightly higher than females. However, this was not significant. The mean daily nutrient intake of energy, protein, fat and carbohydrate was significantly higher (p<0.05) in males than females. Percentage contributions for carbohydrate and protein were 68% and 9.5% respectively. The age group between 35-44 years had the highest dietary fibre intake of 20.1±9.7 g while the age group between 65-74 years had the lowest intake (14.1 ± 7.2 g). Table 4.5 also shows dietary fibre intake across age groups. Table 4.4 Energy and nutrient intake of participants Variable Male (n=83) Female (n=107) Total (n=190) P-value Dietary fibre (g) 16.3 ± 7.7 14.6 ± 6.6 15.4 ± 7.1 0.090 Energy (kcal) 2052 ± 860 1780 ± 636 1899 ± 753 0.017 Carbohydrate (g) 352.2 ± 152.4 300.6 ± 116.8 323.4 ± 135.7 0.010 % energy contribution 68.6 67.5 68.0 Protein (g) 49.6 ± 22.7 41.6 ± 16.9 45.1 ± 20.0 0.008 % energy contribution 9.6 9.3 9.5 Fat (g) 66.3 ± 37.8 52.3 ± 24.2 58.4 ± 31.6 0.004 % energy contribution 29.1 26.4 27.7 Data is presented as means ±SD unless otherwise stated 34 University of Ghana http://ugspace.ug.edu.gh Table 4.5 Dietary fibre intake among age groups Age group Dietary fibre intake p-value Mean ± SD 15-24 17.8 ± 5.9 0.476 25-34 18.6 ± 8.6 35-44 20.1 ± 9.7 45-54 14.8 ± 6.7 55-64 14.7 ± 6.6 65-74 14.1 ± 7.1 75-84 14.7 ± 6.5 35 University of Ghana http://ugspace.ug.edu.gh 4.4 Consumption of high fibre foods Figure 4.4 shows the consumption of foods high in dietary fibre among participants. About 64.7% participants consumed mostly cereals and grains. Roots and tubers followed with 18.4% participants consuming them. Foods usually consumed in this category included fufu, plantain and potatoes. Baked products, legumes, nuts and seeds were not commonly consumed by participants. Figure 4.4 Consumption of high fibre foods by participants 36 Percentage of participants University of Ghana http://ugspace.ug.edu.gh 4.5 Major food sources of fibre The major food sources of fibre among participants were foods in the cereals and grains group. Tombrown which was the highest source of fibre contributed 24.52% of overall fibre intake in participants followed by fufu which contributed 15.7%. The major source of fibre was analyzed by using information from the percentage contribution data of the Microdiet software for the various foods to obtain an average percentage. Table 4.6 shows the average percentage contribution of foods. Table 4.6 Percentage contributions of major food sources of fibre in the diet of participants Food item % contribution Tombrown 24.5% Fufu 15.7% Millet porridge 15.3% Oats 15.1% Corn porridge 14.4% Salad 14.4% Kenkey 13.2% Waakye 12.9% Mango 12.7% Wheat 12.6% 37 University of Ghana http://ugspace.ug.edu.gh 4.6 Frequency of consumption of foods Breakfast cereals such as wheat, cornflakes and millet porridge were not commonly consumed as majority of the participants did not consume them during the week. However, 33.3% of participants consumed oats 2-4 times during the week. Foods such as kenkey, jollof and banku were commonly consumed by participants. For roots and tubers, about 62.1% of participants consumed fufu once a week. Plantain and yam were also consumed 2-4 times a week by 42.1% and 49.5% of the participants respectively. With regards to legumes, nuts and seeds, foods such as beans or beans stew, groundnut soup and palm nut soup were consumed once a week by majority of participants. Cashew nuts, roasted groundnuts and koose were not consumed by most participants. Generally, participants consumed fruits and vegetables at least once a week. The fruits which were not consumed by majority of participants were pineapple, grapes and apples. Fruits that were consumed included pawpaw, oranges, bananas and watermelon. Vegetables such as cauliflower, squash and broccoli were also consumed by some participants 2-4 times a week. Stews patronized by majority of participants included vegetable stew (cabbage, carrot, green pepper), kontomire stew, okro stew/soup and tomato stew. About 59.5% of participants consumed vegetable salad at least once a week. Beetroot and other vegetables were not commonly consumed by most of the participants. 38 University of Ghana http://ugspace.ug.edu.gh Frequency of foods consumed by participants Table 4.7a: Cereals and grains FOOD ITEM Not consumed Consumed Consumed Consumed Consumed once/week 2-4x /week 5-7x/week >7x/week Oats 77 (40.5) 38 (20.0) 64 (33.7) 10 (5.3) 1 (0.5) Tombrown 95 (50.0) 50 (26.3) 41 (21.6) 4 (2.1) 0 (0) Wheat porridge 135 (71) 29 (15.3) 24 (12.6) 2 (1.1) 0 (0) Corn porridge 87 (45.8) 42 (22.1) 53 (27.9) 8 (4.2) 0 (0) Millet porridge 99 (52.1) 51 (26.8) 31 (16.3) 9 (4.7) 0 (0) Kenkey 56 (29.5) 73 (33.2) 50 (34.7) 5 (2.6) 0 (0) Rice and beans 62 (32.6) 73 (38.4) 50 (26.3) 5 (2.6) 0 (0) Banku 24 (12.6) 43 (22.6) 105 (55.3) 16 (8.5) 2 (1.0) Plain rice/jollof 27 (14.2) 34 (17.9) 111 (58.4) 17 (8.9) 1 (0.5) Brown rice 157 (82.6) 13 (6.8) 14 (7.4) 5 (2.6) 1 (0.5) Cornflakes 174 (91.6) 11 (5.8) 5 (2.6) 0 (0) 0 (0) Weetabix 183 (96.3) 4 (2.1) 3 (1.6) 0 (0) 0 (0) Tuozaafi 106 (55.8) 57 (30.0) 20 (10.5) 6 (3.2) 1 (0.5) D ata is presented as n (%) 39 University of Ghana http://ugspace.ug.edu.gh Table 4.7b: Roots, tubers and baked products Food item Not consumed Consumed Consumed Consumed Consumed once/week 2-4x /week 5-7x/week >7x/week Fufu 35 (18.4) 118 (62.1) 33 (17.4) 4 (2.1) 0 (0) Kokonte 113 (59.5) 59 (31.1) 14 (7.4) 4 (2.1) 0 (0) Boiled/fried 37 (19.5) 66 (34.7) 80 (42.1) 6 (3.7) 1 0.5) plantain Boiled/fried yam 34 (17.9) 58 (30.5) 94 (49.5) 4 (2.1) 0 (0) Gari/eba 148 (77.9) 26 (13.7) 13 (6.8) 3 (1.6) 0 (0) Wheat bread 64 (33.7) 14 (7.4) 43 (22.6) 69 (36.3) 0 (0) White bread 100 (52.6) 19 (10.0) 41 (21.6) 30 (15.8) 0 (0) Pastries(meat pie, 115 (60.5) 62 (32.6) 11 (5.8) 2 (1.1) 0 (0) cake, doughnut etc) D ata is presented as n (%) 40 University of Ghana http://ugspace.ug.edu.gh Table 4.7c: Legumes, nuts and seeds Food item Not Consumed Consumed Consumed Consumed consumed once/week 2-4x/week 5-7x/week >7x/week Cooked beans/beans 55 (28.9) 76 (40.0) 54 (28.4) 5 (2.6) 0 (0) stew Roasted groundnut 117 (61.6) 38 (20.0) 29 (15.3) 6 (3.2) 0 (0) Cashew 180 (94.7) 8 (4.2) 0 (0) 2 (1.1) 0 (0) Agushie 162 (85.3) 11 (5.8) 17 (8.9) 0 (0) 0 (0) Groundnut soup 48 (25.3) 92 (48.4) 45 (23.7) 4 (2.1) 1 (0.5) Palm soup 36 (18.9) 105 (55.3) 45 (23.7) 1 (0.5) 0 (0) Koose 110 (57.9) 51 (26.8) 25 (13.2) 4 (2.1) 0 (0) Da ta is presented as n (%) 41 University of Ghana http://ugspace.ug.edu.gh Table 4.7d: Fruits and vegetables Food item Not Consumed Consumed Consumed Consumed consumed 1-2x/week 2-4x/week 5-7/week >7x/week Pawpaw 72 (37.9) 56 (29.5) 46 (24.2) 16 (8.4) 0 (0) Orange 66 (34.7) 46 (24.2) 59 (31.1) 19 (10) 0 (0) Banana 46 (24.2) 59 (31.1) 65 (34.2) 20 (10.5) 0 (0) Mango 89 (46.8) 56 (29.5) 34 (17.9) 11 (5.8) 0 (0) Watermelon 55 (28.9) 72 (37.9) 44 (23.2) 19 (10) 0 (0) Pineapple 115 (60.5) 37 (19.5) 32 (16.8) 6 (3.2) 0 (0) Grapes 170 (89.5) 19 (10) 1 (0.5) 0 (0) 0 (0) Apple 118 (82.1) 50 (26.3) 20 (10.5) 2 (1.1) 0 (0) Fruit juice 141 (74.2) 31 (16.3) 14 (7.4) 4 (2.1) 0 (0) Others 164 (86.3) 15 (7.9) 7 (3.9) 4 (2.1) 0 (0) Vegetable stew 57 (30.0) 41 (21.6) 80 (42.1) 12 (6.3) 0 (0) Kontomire stew 22 (11.6) 47 (24.7) 114 (60) 7 (3.7) 0 (0) Tomato stew 28 (14.7) 48 (25.3) 93 (48.9) 21 (11.1) 0 (0) Garden egg stew 40 (21.1) 60 (31.6) 88 (46.3) 2 (1.1) 0 (0) Okro/ayoyo/ademe 28 (14.7) 57 (30.0) 91 (47.9) 13 (6.8) 1 (0.5) Salad 77 (40.5) 37 (19.5) 51 (26.8) 24 (12.6) 1 (0.5) Beetroot 164 (86.3) 10 (5.3) 13 (6.8) 3 (1.6) 0 (0) Cauliflower 180 (94.7) 6 (3.2) 3 (1.6) 1 (0.5) 0 (0) Others 175 (92.1) 3 (1.6) 9 (4.7) 2 (1.1) 1 (0.5) Data is presented as n (%) 42 University of Ghana http://ugspace.ug.edu.gh 4.7 Lipid Profile of participants The lipid profile of participants was obtained from their hospital records. Results are shown in Table 4.8. The mean total cholesterol was 5.10±1.24mmol/L. The mean total and HDL cholesterol concentration of male hypertensive patients was significantly lower (p<0.05) compared to females. More than half of the patients (54.1%) had normal total cholesterol, triglycerides and HDL concentration. Forty-two percent (42%) of participants had normal LDL- cholesterol concentrations while 34.2% had high LDL-cholesterol concentrations. 43 University of Ghana http://ugspace.ug.edu.gh Table 4.8: Lipid profile of hypertensive patients Parameter (mmol/L) Male (n=68) Female (n=89) Total (n=157) P-value TC (mean ± SD) 4.83 ± 1.12 5.33 ± 1.30 5.10 ± 1.24 0.012 Normal (3.0-5.2) 38 (55.9) 47 (52.8) 85 (54.1) 0.321 High (>5.2) 27 (39.7) 41 (46.1) 68 (43.3) Low (<3.0) 3 (4.4) 1 (1.1) 4 (2.5) TG (mean ± SD) 1.31 ± 0.58 1.3 9 ± 0.60 1.35 ± 0.58 0.388 Normal (0.01-1.7) 59 (86.8) 73 (82.0) 132 (84.0) 0.416 High (>1.7) 9 (13.2) 16 (18.0) 25 (16.0) HDL-C (mean ± SD) 1.24 ± 0.45 1.44 ± 0.56 1.35 ± 0.52 0.020 Normal (1.03-1.55) 43 (65.2) 49 (57.0) 92 (60.5) 0.025 High (>1.55) 7 (10.6) 25 (29.0) 32 (21.1) Low(<1.03) 16 (24.2) 12 (14.0) 28 (18.4) LDL-C(mean ± SD) 2.98 ± 1.03 3.20 ± 1.16 3.1 ± 1.10 0.190 Normal (2.5-3.5) 30 (45.5) 34 (39.5) 64 (42.1) 0.685 High (>3.5) 21 (31.8) 31 (36.0) 52 (34.2) Low (<2.5) 15 (22.7) 21 (24.4) 36 (23.7) T C-Total cholesterol TG- Triglycerides Data is presented as n (%) unless otherwise stated 44 University of Ghana http://ugspace.ug.edu.gh 4.8 Correlation between mean fibre intake, blood pressure, anthropometry and lipid profile There was no significant association between dietary fibre, blood pressure, anthropometry and lipid profile. A negative relationship, though not significant (p>0.05), was found between dietary fibre intake, triglycerides and HDL-C. Table 4.9 shows the correlation values between mean dietary fibre intake, blood pressure, visceral fat, BMI and lipid profile. Detailed results are shown in Appendix 2. Table 4.9 Correlation between dietary fibre, BP, anthropometry and lipid profile Parameter Correlation value P-value BMI .042 .572 VF .021 .772 TC -.025 .758 TG -.091 .259 HDL-c -.015 .858 LDL-c .056 .497 SBP .078 .285 DBP .132 .070 45 University of Ghana http://ugspace.ug.edu.gh 5. CHAPTER FIVE 5.0 DISCUSSION 5.1. Background characteristics Out of the 190 participants recruited for the study, a greater proportion of the participants were females. This is consistent with findings from a comparative cross-sectional study on the interplay of adipokines in the pathogenesis of essential hypertension in Ghana where 68.5% of participants were females (Asibey et al., 2018). Another study by Guwatudde et al. (2015) on the burden of hypertension in Sub-Saharan Africa confirmed these results where 64.6% of participants were females. Similar results were also observed in a study done in Astana, Kazakstan by Supiyev et al. (2015) which saw a higher prevalence of hypertension in women than men. Gender, marital status and religion were in proportions similar to a cross-sectional study done on the burden and correlates of hypertension in rural Ghana by William et al. (2013). For example, majority of participants in that study were married and Christians as observed in this study. This could be due to Christianity being the dominant religion in Ghana (United States Department of State, 2018) The World Health Organization (2013) notes aging as a risk factor for hypertension as clearly highlighted in this study. Results showed that approximately 59.47% of the participants were within the ages of 55-74 years. Analysis from a study showed that prevalence of hypertension was significantly higher in adults aged 50 years and above compared to adults aged 18 to 29 years (Guwatudde et al., 2015). Hypertension is associated to increasing age due to physiological changes such as arterial and arteriolar stiffness, decreased baroreceptor sensitivity, increased 46 University of Ghana http://ugspace.ug.edu.gh responsiveness to sympathetic nervous system stimuli, changes in renal and sodium metabolism and altered renin-aldosterone relationship (Sanuade et al., 2018). Previous studies carried out on hypertensive patients across different geographical and ethnic barriers have also shown age as a major risk for hypertension (Williams et al., 2013; Colecraft et al., 2018; James, Kamara, Bah, Steel, & Wardle, 2018). With regards to level of education, a study on the prevalence and predictors of hypertension in Ghanaian men found that participants with secondary or higher level of education were more likely to have hypertension compared to those without formal education (Nyarko et al., 2017). Also, in a cross sectional study on the prevalence, awareness, treatment and control of arterial hypertension in Astana, Kazakhstan, majority of participants had attained tertiary or higher level of education (Supiyev, Kossumov, Utepova, & Nurgozhin, 2015). This trend was observed in this study as well and could be attributed to the nature of the study site as it serves as a primary healthcare facility for staff and students of the University of Ghana. Majority of the participants in the study had been diagnosed with hypertension for 6 years and above. Most of them were on one type of antihypertensive medication which correlates with a study by James et al., (2018) on herbal use among hypertensive patients attending private and public health facilities in Freetown, Liberia where most of participants were also on one type of antihypertensive medication. Most participants (77.89%) were engaged in some form of physical activity such as brisk walking, gardening, aerobics etc. However, the level of physical activity was low which could be due to the average age range of the participants which prevented them from engaging in very strenuous physical activity such as running, weight lifting and skipping. 47 University of Ghana http://ugspace.ug.edu.gh 5.2 Anthropometric measurements and blood pressure of the participants Obesity and overweight have been associated with increased risk of hypertension (WHO, 2013). The mean BMI of participants (29.49 kg/m2) was similar to that of participants (29.99 kg/m2) in a study by Lee et al. (2014) on noncompliance with medication in hypertensives in Ghana. However, this figure was found to be slightly higher than that of participants in that study (26.15±1.44kg/m2) in South Asia (Kumar, 2014). Ethnicity, geographical location, diet and physical activity are factors that influence body weight and height and could account for these differences. However, the mean BMI for male and female hypertensive patients corresponds to findings by Supiyev et al (2015). Comparatively, the mean BMI for females was significantly higher than that of males (p<0.05) in this study. The Global Health Observatory (GHO) data on mean BMI for adults aged 18 years and above showed that the mean BMI for women (25.2 kg/m2) was higher than men (23.9 kg/m2) in Ghana as at 2016 (WHO, 2016). These differences could be attributed to women having more body fat percentage than men. Also, a comparative study on the BMI of healthy men and women in the United States showed a range of 19.5-30 kg/m2 for men and 18-30 kg/m2 for women, a finding similar to this study (Ogden et al., 2006). Furthermore, Benkeser et al. (2012) examined 2814 Ghanaian women to determine associated risk factors for obesity. The authors found that 37.1% of women were obese, 27.8% were overweight, and 3.6% were underweight. A similar trend was seen in this study with majority of women being obese. Majority of participants (55.7%) had high visceral fat which is similar to findings from other studies (Sironi et al., 2004; Guo et al., 2019). 48 University of Ghana http://ugspace.ug.edu.gh High visceral fat is a strong risk factor for cardio-metabolic diseases. Some observational studies have reported associations between visceral fat and dietary fibre intake. The intake of fruit, vegetables, legumes and whole grains help reduce visceral fat mass whereas intake of fried foods and fat, alcohol, red and processed meat, sugar-sweetened beverages and refined grains are associated with higher levels of VF mass (Ozato et al., 2014, 2019; Pallister et al., 2017). The low dietary fibre intake of hypertensive patients may contribute to their high visceral fat. Furthermore, the association between increased dietary fibre intake and visceral fat was also mirrored by a two-year follow up study in Latino children between the ages of 7-11years. Results revealed that an increase in dietary fibre by 3g per 1000kcal was associated with a 4% reduction in visceral fat while a reduction by the same amount was associated with an increase in visceral fat by 21% (Davis et al., 2009). This was also seen for a study by Parikh et al., (2012), where they investigated for associations between dietary fibre intake, inflammatory-related biomarkers and central adiposity in adolescents. The study showed that greater dietary fibre consumption was associated with lower visceral adiposity in adolescents. The mean systolic and diastolic blood pressure of participants was in the stage 1 hypertension category. A study by Williams et al. (2013) on the burden and correlates of hypertension in rural Ghana showed similar results for both SBP and DBP. However, higher results were seen a study by Asibey et al. (2018). 49 University of Ghana http://ugspace.ug.edu.gh 5.3 Frequency and major sources of dietary fibre The major sources of dietary fibre in the diet of participants were cereals and grains. Cereals and grains were also the highest source of fibre in a study investigating dietary fibre intake among students a in tertiary institution contributing 58.2% of fibre (Adegoke, Fadupin, & Ketiku, 2006). In Sub-Saharan African countries such as Ghana, cereals and grains serve as one of the main staples (Galbete et al., 2017; Adegoke et al., 2006; Lie et al., 2018, Steyn & Mchiza, 2014). The major food source of dietary fibre was tombrown contributing an average of 24.52% of fibre. On the contrary, a study by (Sardinha et al., 2014) on dietary sources of fibre intake in Brazil found beans as the major contributor to dietary fibre for Brazilian households. Differences in culture, preferences, geographical location and economic determinants of food choices may have contributed to this. It was also observed that in this study consumption of beans was in the form of waakye (rice and beans). Kenkey (fermented maize ball) was also consumed frequently by most participants in that category. Kenkey and waakye are commonly consumed and easily available food sold by food vendors in the Greater Accra region. They are also relatively cheaper making it affordable for many people in the community (Asante et al., 2015). Consumption of foods from roots and tubers ranked next after cereals and grains with fufu ranking as the frequently consumed food in this category. This reflects the traditional food pattern observed across West African countries especially for both rural and urban settings (Galbete et al., 2017). Fufu was also the second highest major source of fibre for participants and contributed an average of 15.70% in the total group. Fufu is one of Ghana’s common staple foods known all across the country as most food joints and eateries are highly patronized especially on weekends (Lie et al., 2018). 50 University of Ghana http://ugspace.ug.edu.gh Fruits such as grapes and apples were not commonly consumed by participants. This could be due to the fact that these fruits are generally expensive and less readily available on the market compared to other fruits (Florkowski, 2019). Commonly consumed fruits included oranges, bananas, watermelon and pawpaw. This was also observed in a study by Kpodo et al. (2015) on fruit and vegetable consumption patterns and preferences of students in a Ghanaian polytechnic. 5.4 Nutrient and dietary fibre intake The mean dietary fibre (15.4g) intake of the participants was below the recommended intake of 25g/day for both males and females (Ministry of Health, 2014). It was also below the recommended dietary intake for the Institute of Medicine guideline. Comparisons of mean intake of dietary fibre (5.2 g) in a similar study in Nigeria (Ijarotimi et al., 2006) however showed that participants in this study had higher intakes. The low dietary fibre intake of Ghanaian participants could be associated with the high intake of refined foods such as polished rice and white bread. High fibre foods such as unpolished rice (brown rice), fruits and vegetables were not frequently consumed. These findings confirm reports in a systematic review paper on obesity and the nutrition transition in Sub Saharan Africa by Steyn and Mchiza (2014) for adults in Capetown, South Africa. The review showed that dietary fibre intake had decreased from 20.7 g to 16.7 g as a result of changing diet patterns. In a cross-sectional study examining dietary fibre intake by age, sex, and race, Storey et al. (2014) reported that, on average, non-Hispanic, black females consumed less fibre per day (12.7g/day) compared with European-American women (15.7g/day). Thus, European-American women had a higher intake compared to their Ghanaian counterparts (14.6 g) in this study. Non- hispanic, African American males had an intake of 15.0g/day (Storey & Anderson, 2014) which 51 University of Ghana http://ugspace.ug.edu.gh was quite lower than what was observed in this study (16.3 g). In another cross-sectional study examining the dietary quality of African American and Hispanic families, African American mothers had a median fibre intake of 8.8g/day compared to 14.5g/day in Hispanic mothers (Kong et al., 2014). These low intakes in such countries could be attributed to low cost of processed foods which makes them more attractive and convenient compared to expensive unrefined foods high in fibre. A study by Gibson et al. (2015) in which dietary macronutrient components and food sources were compared between native and Diasporic Ghanaian adults showed a lower intake (6.7g) among native Ghanaian adults. The mean energy intake (1899±753 kcal) was also similar to intakes in a Nigerian study (1877 kcal) that investigated the nutritional knowledge, nutritional intake and nutritional status of hypertensive patients in Ondo state. However, values for carbohydrate and fat intake were lower in that study compared to this study. It was also observed that the mean intake for protein for Nigerian participants was higher (89.7 g) compared to Ghanaian participants in this study (45.1±20.0 g). These differences could be due to differences in food patterns and behaviours between the two countries. Compared to acceptable Macronutrient Distribution ranges from IOM (IOM, 2005), fat intake of the participants was within acceptable range of 20-35%. Protein intake was lower than recommended intake of 10-35%. Carbohydrate intake, on the other hand was higher than recommended intake of 45-65%. 52 University of Ghana http://ugspace.ug.edu.gh 5.5 Lipid Profile of hypertensive patients The mean total cholesterol, triglyceride, HDL-C and LDL-C values for participants were within normal range (TC-3.0-5.2 mmol/L, TG-0.10-1.7 mmol/L, HDL-C-1.03-1.55 mmol/L, LDL-C- 2.5-3.5 mmol/L). These results were similar in a comparative cross-sectional study by Asibey et al. (2018) on the interplay of adipokines in the pathogenesis of essential hypertension except for total cholesterol which was high (5.5 ± 1.4 mmol/L) in that study. Also, a cohort study carried out in Sweden on the relation between lipid profile and new-onset atrial fibrillation in patients with systemic hypertension (Swedish Primary Care Cardiovascular Database [SPCCD]) showed normal values for all parameters except total cholesterol (5.4 ±1.1 mmol/L) at baseline (Mourtzinis et al., 2018). Comparisons for gender in this present study, however, showed that the mean lipid profile for females were significantly higher (p<0.05) than males which confirms findings from research show women have more total body fat than men which affects lipid profile. The high amount of adipose tissue in the body causes an increase in the rate of lipolysis and free fatty acid turnover that leads to the pathological damage of non-adipose tissue organs such as the liver, pancreas, and blood vessels. The increased flow of free fatty acids directly from the portal system to the liver leads to an increase in the production of Very Low Density Lipoprotein (VLDL) that is rich in triglycerides. Also, there is an increase in the activity of cholesterol ester transfer protein (CETP) and a decrease in lipoprotein lipase (LPL) activity which leads to increased levels of LDL-C and decreased levels of HDL-C in the blood circulation (Okop, Levitt, & Puoane, 2015; Romano Oliosa, 2019; Schorr et al., 2018; Vuvor & Harrison, 2017). Another study in Hungary by Simonyi et al. in 2007 which sought to determine the relationship between serum lipids and blood pressure in obese patients recorded higher values for mean total 53 University of Ghana http://ugspace.ug.edu.gh cholesterol (7.26 ± 1.86 mmol/L), triglycerides (4.19 ± 2.15 mmol/L) and LDL (4.49 ± 2.15 mmol/L) though HDL (1.39 ± 0.63 mmol/L) was within normal range. Furthermore, higher levels of triglycerides and lower levels of HDL were recorded for hypertensive men in a study that investigated lipid profile in hypertensive men with androgen deficiency (Nasonenko, Vizir, & Sadomov, 2018). Differences in the results of these studies may be as a result of the differences in the study population, geographical location as well as mode of testing. 5.6 Dietary fibre, blood pressure and anthropometry There was no significant relationship (p> 0.001) between dietary fibre and BMI as well as dietary fibre and visceral fat. This result was also observed in a study by Buscemi et al., (2018) where investigators sought to examine the association between fibre consumption and BMI over an 18-month period. There was no significant association between dietary fibre intake and BMI at baseline. However, another study on whole grain and fibre consumption found associations with lower body weight in US adults. Higher consumption of whole grains was inversely associated with lower BMI (O’Neil, Zanovec, Cho, & Nicklas, 2010). This same trend was observed in a cross-sectional study in Saudi Arabian females within the ages of 18 and 30 years. An inverse relationship was found between mean dietary fibre intake, BMI and visceral fat (Bano, Alshammari, & Almedan, 2015). Another study in Japan, showed that soluble dietary fibre intake with other nutrients was significantly inversely associated with visceral fat area (Ozato et al., 2019). Viscous dietary fibre increases satiety due to its bulk and also delays gastric emptying which helps in weight loss thereby accounting for the inverse relationship for both BMI and visceral fat (Slavin, 2013). 54 University of Ghana http://ugspace.ug.edu.gh Though other studies have found inverse relationships between dietary fibre, BMI and visceral fat, the direct relationship found in this study could be due to the age range of the population. The studies noted above had populations younger in age compared to this study. A study on BMI in Ghana showed that obesity increased with age especially within the age range of 55-64 years in which the mean age of this study falls (Amoah, 2003). This could also be as a result of the low intake of dietary fibre in this study. There was no significant association between dietary fibre intake and blood pressure which could be due to the low intake of dietary fibre by participants. However, the mechanism for reducing blood pressure by dietary fibre is not fully understood as some studies have shown eithera significant or insignificant relationship (Maki et al., 2007; Sun et al., 2018; Threapleton et al., 2013; Khan et al., 2018) 5.7 Dietary fibre and lipid profile Results from this study showed an insignificant negative correlation (p> 0.05) for both dietary fibre intake and total triglycerides and dietary fibre intake and HDL-C. The decrease of cholesterol and triglycerides is due to the reduction of absorption of cholesterol, the excretion of fat and bile acids, and probably, the inhibition of synthesis of cholesterol in liver (Villanueva- Suárez et al., 2019) Studies that have evaluated the relationship between dietary fibre and HDL-C have given inconsistent results. Studies performed in Asian populations supported the fact that dietary fibre was associated with HDL-C while randomized controlled trials in patients with hypertension suggested that increased intake of soluble dietary fibre was not associated with increased HDL- C. 55 University of Ghana http://ugspace.ug.edu.gh A meta-analysis by Yanai et al., (2014) showed that the use of barley did not significantly alter HDL-C (p = 0.07) in both healthy and hypercholesterolemic individuals. Also, a clinical trial carried out in China examined the effect of oat consumption on cholesterol levels in Chinese adults with mild to moderate hypercholesterolemia. The authors reported that the HDL-C level remained the same in the intervention group after 6 weeks (Zhang et al., 2012). Zhou et al. (2015) found that a dietary fibre intake of over 30 g/day might be beneficial to males for improving their plasma HDL-C while observing no significant association between dietary fibre intake and TC, LDL-C and TG. Hannon et al., (2018) in a cross-sectional study also found an inverse relationship between dietary fibre consumption and triglycerides among adults with overweight and obesity which was also observed in this study. The inverse relationship could have possibly been as a result of bile acids binding to dietary fibre during digestion making them less available for micelle formation. The low rate of micelle formation then affects the absorption of cholesterol and triglycerides (Slavin, 2013). 56 University of Ghana http://ugspace.ug.edu.gh CONCLUSION Dietary fibre is known to have numerous health benefits which include weight regulation. The major source of dietary fibre in this study was cereals and grains. Mean BMI was in the overweight category and visceral fat was high among hypertensive patients though lipid profile was normal for majority of the participants. Finally, findings in this study showed no significant association between dietary fibre, blood pressure, BMI and visceral fat. An insignificant negative correlation, however, was observed for dietary fibre and TC and dietary fibre and HDL-C. RECOMMENDATIONS Education on the adequate intake of dietary fibre among hypertensive patients must be considered and enhanced by healthcare personnel especially dietitians. More studies of this nature must be done in Ghana to quantify the intake of the various types of fibre such as soluble and insoluble fibre in the diet as they have different physiological effects on the body with regards to disease prevention and management. 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Beneficial effect of higher dietary fiber intake on plasma HDL-C and TC/HDL-C ratio among Chinese rural-to- urban migrant workers. International Journal of Environmental Research and Public Health, 12(5), 4726–4738. 68 University of Ghana http://ugspace.ug.edu.gh APPENDIX 1 CONSENT FORM DEPARTMENT OF DIETETICS SCHOOL OF BIOMEDICAL AND ALLIED HEALTH SCIENCES COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA STUDY TITLE: RELATIONSHIP BETWEEN DIETARY FIBRE INTAKE AND BLOOD PRESSURE, LIPID PROFILE AND ANTHROPOMETRIC MEASUREMENTS OF HYPERTENSIVE PATIENTS I am EDINAM AKU NUMADZI, a final year MSc.Dietetics student of the School of Biomedical and Allied Health Sciences, University of Ghana. I wish to conduct a research on anthropometry, dietary fibre and lipid profile of hypertensive patients attending the Dietetics Department of the University of Ghana Hospital in partial fulfillment of my MSc. degree in Dietetics. INFORMATION SHEET This study seeks to determine the relationship between dietary fibre intake on blood pressure, lipid profile and anthropometry of hypertensive patients attending the Dietetics Unit of the University of Ghana Hospital. You have been invited to partake in this study to assess your anthropometry, dietary fibre intake and lipid profile. If you agree, you will be kindly requested to provide information about your health, diet and physical activity. Information from your folder will also be assessed to complete other relevant information pertaining to the study with your permission. No blood samples will be collected in this study. Your participation in the research is entirely voluntary. You may withdraw from the study at any point of the study if you so desire and this will not affect your normal care offered to you at the Dietetics department. You will be given the opportunity to ask any question you do not understand about the research. We do not envisage any risk to your participation in this study apart from some inconveniences 69 University of Ghana http://ugspace.ug.edu.gh that may occur during the interview and your weight and height measurements. Competent and experienced health personnel will ensure that potential discomfort is minimized. Results of the survey will be given to your dietician so that you can be counselled or treated if necessary. All information you provided during this project will be kept confidential. The forms will not bear your name or any other personal identities but codes will be assigned to each questionnaire and documents that will be used during the study. The data obtained from the study will be useful to improve interventions in the dietary management of hypertension. You will not incur any cost as a result of your participation in this study For further enquiries about this research, you can contact the following addresses below: Researcher’s Contact Edinam Aku Numadzi Department of Nutrition and Dietetics University of Ghana +233-501374051 Supervisors’ Contact Dr. Matilda Asante Department of Nutrition and Dietetics University of Ghana +233-244860538 +233-556168949 Prof. George Awuku Asare Department of Medical Lab. Sciences University of Ghana +233-540682892 70 University of Ghana http://ugspace.ug.edu.gh CONSENT FORM I have fully explained to ……………………………………………… the nature and purpose of the above described research, its procedure, risks and benefits. I have allowed the subject to ask questions and have answer and will answer to the best of my ability, all questions relating to the study. I,…………………………………………………………………… have read or has been read to me in a language I understand and understood the nature and purpose of the proposed study. I am aware of the fact that I can withdraw from the study at any point in time without receiving any objection. My signature or thumbprint below indicates that I have given my consent to partake in this study. ……………………………………………………………………………………………………… Name of Researcher Signature Date (+233 200531019) ……………………………………………………………………………………………………… Name of Participant Signature Date ……………………………………………………………………………………………………… Name of Witness Signature Date 71 University of Ghana http://ugspace.ug.edu.gh APPENDIX II PARTICIPANT’S CODE:………………………. DATE: ……………………. SECTION 1: SOCIO-DEMOGRAPHIC DATA 1. Gender… Male [ ] Female [ ] 2. Age ……… years 3. Religion… Christian [ ] Muslim [ ] African Traditionalist [ ] Other ……………….. 4. Marital Status… Single [ ] Married [ ] Divorced [ ] Separated [ ] Widowed [ ] SECTION 2: MEDICAL HISTORY 5. Duration of hypertension diagnosis …………………… 6. Drugs taken ………………… SECTION 3: SOCIO-ECONOMIC DATA 7. What is your employment status? Employed [ ] Unemployed [ ] Retired [ ] 8. Occupation........................................... 9. Educational level Primary [ ] JHS [ ] SHS [ ] TERTIARY [ ] SECTION 4: PHYSICAL ACTIVITY 10. Do you do any form of physical activity/exercise? YES/NO 11. What type of exercise do you do? Slow Walking [ ] Aerobics [ ] Dancing [ ] Household chores [ ] Brisk Walking [ ] Cycling [ ] Swimming [ ] Running [ ] Fast Cycling [ ] Fast Swimming [ ] Gardening [ ] Football [ ] Basketball [ ] Volley Ball [ ] Treadmill [ ] Rowing Machine [ ] Heavy occupational manual work [ ] Jogging [ ] Other …………… 12. How many days in a week do you exercise? Once a week [ ] 2 times a week [ ] 72 University of Ghana http://ugspace.ug.edu.gh 3 times a week [ ] 4 times a week [ ] 5 times a week [ ] 6 times a week [ ] Every Day [ ] 13. How long do you exercise for? 15 minutes [ ] 30 minutes [ ] 40 minutes [ ] 60 minutes [ ] > 60 minutes [ ] 14. During the last 7 days, how much time did you usually spend sitting on a weekday? ___________________ Hours per day ___________________ Minutes per day 15. During the last 7 days how much time did you usually spend sitting on a weekend day? ___________________ Hours per day ___________________ Minutes per day 73 University of Ghana http://ugspace.ug.edu.gh SECTION 5: FOOD FREQUENCY QUESTIONNAIRE For the following foods, please indicate the number of times eaten in a week and how much eaten using the serving models provided. Food Number of times Not applicable Portion size eaten per week CEREALS AND GRAINS Oats ----------- soup ladles Tom brown / Weanimix ----------- soup ladles Wheat porridge ----------- soup ladles Corn porridge (koko) ----------- soup ladles Hausa koko ----------- soup ladles Kenkey (Ga/ Fante) --------- fist size Waakye -------- stew ladles Banku -------- fist size Plain rice / Jollof rice/ fried rice --------- stew ladles Brown/unpolished rice --------- stew ladles Cornflakes --------- cups Weetabix --------- pieces Tuozaafi --------- fist size ROOTS AND TUBERS 74 University of Ghana http://ugspace.ug.edu.gh Fufu --------- fist size Kokonte --------- fist size Boiled/fried plantain -------- full fingers Boiled/ fried yam --------- round slices Gari/eba --------- cups BAKED PRODUCTS Wheat bread --------- slices/rolls Sugar Bread --------- slices/rolls Tea bread --------- slices/rolls Butter bread --------- slices/rolls Meat pie / doughnut / rock buns/biscuit --------- pieces others LEGUMES, NUTS AND SEEDS Cooked beans/ Beans stew --------- stew ladles Roasted Groundnut ---------- cups Roasted cashew nut -------- cups Agushie ---------- cups 75 University of Ghana http://ugspace.ug.edu.gh Groundnut soup ---------- soup ladles Palm soup --------- soup ladles Koose ---------- pieces FRUITS Pawpaw --------- whole fruit Orange --------- whole fruit Banana --------- fingers Mango --------- whole fruit Watermelon -------- wedges Pineapple --------- whole fruit Grapes -------- pieces Apple --------- whole fruit Fruit juice -------- glass others VEGETABLES Vegetable stew ---------- stew ladles Kontomire stew ---------- stew ladles Tomato stew ---------- stew ladles Garden egg stew ---------- stew ladles Okro/ayoyo/ademe 76 University of Ghana http://ugspace.ug.edu.gh soup/stew ---------- stew ladles Salads (lettuce, cabbage, carrot, green pepper, shallot) ---------- stew ladles Beetroot ---------- stew ladles Cauliflower ---------- stew ladles others SECTION 6: ANTHROPOMETRY 1. Weight:…………… kg 2. Height: …………….cm 3. BMI: …………….kg/m2 4. Visceral fat: …… LIPID PROFILE Total Cholesterol- ………………mmol/L Triglycerides- ……………….mmol/L HDL-C- ……………..mmol/L LDL-C- …………….mmol/L Thanks for your cooperation! 77 University of Ghana http://ugspace.ug.edu.gh Table A.2 Detailed correlation table between dietary fibre, blood pressure, BMI, VF and lipid profile. DFI SBP DBP BMI VF TC TG HDL-C LDL-C DFI SBP .078 .285 DSP .132 .577* .07 0.00 BMI .042 .44 .62 .572 .55 .40 VF .021 .136 .052 .620* .772 .063 .477 .000 TC .025 .016 .042 -.023 -.008 .758 .84 .61 .774 .919 TG -.091 .46 .40 .035 .185 .293* .259 .576 .614 .666 .021 .000 HDL-C -.015 .041 .004 .018 -.038 .255* -.112 .858 .612 .567 .830 .641 .002 .171 LDL .056 .008 .017 -.018 -.006 .897 .170 -.040 .497 .925 .832 .824 .946 .000 .037 .623 78 University of Ghana http://ugspace.ug.edu.gh 79