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HYPERTENSION
IN
AN

URBAN ENVIRONMENT

PLAN B Doris M. Witherspoon
Fall term 198h
Dr. Roger Hamlin
UP 898 - Masters Research

II.

III.

V.

VI.

Table of Contents

IntIOduction .0...OOOOOOOOOOOOIOOOOOOOOI0.00000000000000000CI... 1
DefinitionOf HyPertenS1on 0..OOOOOOOOOOI.OOOOOOOOOOOOOOCCOOOOOO 2

Etiology of Hypertension
Associated Risk Factors 1+

Stress 0....IOOOOOOOOOOOOOOOOOOOOOIOOIOIOOOIIOOOOCCCCCUCOOC8

crOWdiM .OOIIOICOOOOOOO...0....0.00.00.00.00.0000COOCOCOO 10

Distribution of Hypertension
National Geographic Distribution ......................... 14
Ethnic Distrib‘ltion 0....0.0.0....I...‘................... 15

Intra urmn Distrib‘ltion 0.0.0.0...OOOOOIOOOIOOOOIIIOIOIOO 1?
Hypertension Screening Programs ............................... 19

Canol‘mion I...OOOOOOOOOOOOOIOOOOIIOOOOIOOIOOOOOOOOOOIOCOOOOOCO 25

Introduction

Hypertension (high blood pressure) is the elevation of blood pressure.
It is one of the most widely occurring diseases and can attack any age or
racial group. However, it is more prevalent among older people, and
occurs the most among the black population. In addition, there have been
numerous studies conducted to determine the relationship between blacks and
hypertension; however, no one has been able to determine the specific
relationship. Nevertheless, hypertension has been known to be one of the
contributory factors in the deaths of several people.

Hypertension is an asymptomatic - without symptoms - disease.
Therefore, an individual could have the disease and may not be aware of it.
Many people often complain of headaches and dizziness: but these are not
symptoms of hypertension.

It can range from mild to severe. High blood pressure can be controlled
with proper medication and dieting depending upon its severity. There are
certain obvious factors associated with an increase in blood pressure and
some not so obvious factors of the occurrence of hypertension among certain
ethnic groups or in certain geographical areas. In other words, there are
several factors associated with increased blood pressure.

This paper addresses the etiology of hypertension and explains the
association of the disease with certain risk factors. Also, this paper
will concentrate on the geographical distribution of hypertension and
screening programs designed to control the problems of hypertension in

an urbanized society.

DEFINITION OF HYPERTENSION

Definition of Hypertension

Hypertension can be medically defined as persistently high arterial
blood pressure. It is the substained elevation of blood pressure. Blood

pressure reading consist of two measurements:

1) systolic (sys-tol-ic) pressure (SBP), is
the force exerted by your blood against
the walls of your arteries when your
heart is pumping or beating.

2) diastolic (dia-stol-ic) pressure (DBP),
is the force exerted by your arteries
when your heart is refilling or at rest.
Therefore, blood pressure is the force
exerted by your blood against the walls
of your arteries during the two major
functions of the heart.

High blood pressure is approximately 20 mm Hg (diastolic and systolic)
above the normal blood pressure reading of 120/80 (SBP/DBP). In order to
determine the blood pressure, whether it is high, low or normal, a blood
pressure measurement is necessary. A "sphygmomananometer" is a device used
to measure blood pressure along with a stethoscope, which is an instrument
used to listen to sounds in the body. As in the case of several other
diseases, there are many types of hypertension. However, the two most
common forms of hypertension are: 1) Essential and 2) Secondary.

1) Essential hypertension is a formal way
of describing an amorphous group of
cases with many things wrong but for
which there is no apparent explanation.
People with essential hypertension have
a heart that pumps too much blood or a

normal heart output but narrowed blood
vessels.

2) Secondary hypertension may be attributed
to several organic causes, such as
hardening of the arteries, kidney diseases
or obstructions to kidney flow, heart and
brain.2

Hypertension can be detrimental to a person's health (life) if it is
not controlled. Therefore, once an individual has been screened as
hypertensives. proper medical care should be considered. It can lead to
many other cardiovascular diseases and complications which may eventually
become fatal if the disease is not controlled. There are several ways of
controlling this disease. Basically, it depends upon the severity, in which
case, controlling hypertension can range from reduction of salt intake
to oral medication.

One of the major reasons why physicians encourage regular blood
pressure measurement is to detect any untreated hypertensives. The
increase of exercises can reduce body fat which can attribute to reducing
the risk of developing hypertension. Factors which are known to be related
to the development of hypertension are: obesity, sodium intake, smoking,

caffeine, etc.

ETIOLOGY OF HYPERTENSION

Etiology of Hypertension

There are several risk factors contributing to the occurrence of
hypertension. In fact, recent studies have also associated caffeine with
hypertension.

Today, many of these associated risk factors can be life-threatening
if hypertension is not controlled.

This section of the paper will focus on some of these associated risk
factors of hypertension - - obesity, sodium intake, smoking, and caffeine.

Hypertension is a serious chronic disease. Many variables can lead
to a person having hypertension. Also, some people with hypertension
believe if they feel well, there is no need to take their medication. How-
ever, internal body organs can be damaged if medication is prolonged.

These associated risk factors, in many instances, can be controlled.
Therefore, an individual with hypertension and any of the risk factors

can lead a normal life.

Associated Risk Factors

Obesity

Obesity can be described as extremely overweight. It is very harmful
to an individual's health and is one of the leading factors associated with
the development of hypertension and other chronic disorders. Studies have
shown that increased weight can increase blood pressure level. In fact,
"the association with the risk of having hypertensive disease is several

3

times as great for overweight persons as it is for persons not overweight."

Hereditary

There have been several discussions comparing the relationship between
family history and hypertension. Many studies have concluded that a positive
relationship exists between the two variables. The risk of developing
hypertension may be positively correlated with family history. According
to Iawo Moriyamo, in his book, "Cardiovascular Diseases in the United States,
(p.flm)

Those who have a family history of the disease
are more likely to be hypertensive than those
who do not. This have been showm repeatedly.
If both parents are involved, the risks are
especially great. The fact is not only
potentially meaningful in terms of unsolved
problems of possible mechanisms, it can also
help to find hypertensive persons early in
life.

Sodium Intake

Another contribtory factor to hypertension is sodium intake. This
is commonly known as "table salt". High sodium intake is known to influence
blood pressure and body functions related to the cardiovascular system. In
other words, an increase in blood pressure occurs because salt intake
which may cause the body to retain water is being stored, instead of
circulating. Therefore, if a person is genetically predisposed and consumes
an excessive amount of salt he/she is more likely to develop hypertension.
The average American diet contains at least
four grams of sodium; by omitting salty foods
and added salt at the table and in cooking,

this amount can be reduced to about one gram
of sodium per day. There is no doubt that

rigid sodium restriction to 0.5 grams of
sodium per day will reduce the blood pressure)+
in a considerable proportion of hypertensive.

Exercise/Diet

There are other ferms of hypertension (i.e. mild) which requires
reduction of certain factors to improve the hypertensive state. For example,
exercise and dieting can reduce the risk of developing hypertension.

Studies have shown that changing the diet and exercising can lower the

blood pressure.
Smoking

Cigarette smoking is another risk factor associated with the development
of hypertension. It is hazardous to an individual's health and can cause
death and/or disability from coronary disease. "In pharmacological experi-
ments, it was found that nicotine raises the blood pressure, through
stimulation of both the vasoconstrictor center and the peripheral

autonomic ganglion".5
Caffeine

One drug which is habitually used by millions
of persons is caffeine. It is the one drug
which is obtained as part of a normal diet.
The average cup of coffge or tea contains
100-150 mg of caffeine.

There is a positive correlation between caffeine intake and hyper-
Several studies have proven this hypothesis to be true. In fact,

Robertson et a1, noted in their study on the effects of caffeine in

in blood pressure, that their subjects had an elevation in both systolic
and diastolic pressures minutes after the administration of caffeine.
According to Freestone et a1,

Nicotine and caffeine are each known to elevate

blood pressure in experimental situations.

Cigarette smoking increases blood pressure by

an average 10/8 mm Hg. but only for approximately

15 minutes. Caffeine (250mg) causes a rise

in blood pressure of up to 14/10 mm Hg, lasting

for at least 2% hours. Likewise, the combination

of smoking and caffeine had a significant

increase in blood pressure.7

These are a few of the associated risk factors involved in the
development of hypertension. However, there are some people who will
never experience the development of this disease, even if they encounter
any of these risk factors. In other words, everyone's body react
differently to different circumstances. Therefore, one individual
may develop hypertension whereas, another does not develop the disease
if for instance, they are both caffeine and nicotine lovers.
Basically, there are hosts of other related factors that determine

an individual's risk of developing hypertension. Nevertheless, hypertension

still remains prevalent among certain groups of individuals.

STRESS

"Stress can be caused by environmental factors. It is an affective
behavioral and physiological response to diversive stimuli."8 According
to Norman M. Kaplan, M.D., in his article, "Stress, the Sympathetic

Nervous System and Hypertension", (p. 3), 1978):

Pe0ple exposed to repeated psychogenic
stresses may develop hypertension more
frequently than people who do not experience
psychogenic stress:

— Air traffic controllers; who work
under tremoudous psychological stress,
annually develop hypertension at a rate
of 5.6 times greater than do non-
professional pilots who were initially
comparable in physical charcteristics

- Men repeatedly stressed by high
levels of noise have significantly
higher blood pressures and more
hypertension

- Nuns have lower pressures than
women working outside a sheltered
environment

- In at least 22 instances, populations
living in small, cohesive protected
societies have been found to have
low blood pressures which do not
rise with aging; those who abandon
such an environment and migrate to
more urbanized, modern, disorganized
societies have high blood pressures
which rise with aging. Obviously,
other environmental factors may be
responsible, but in some of these
groups, the association between
hypertension and social disorganization
seems strong.

College students are more likely to develop hypertension than any
other students. Inva recent study of college freshmen, researchers found
that they had developed hypertension by the time of their graduation.

In many instances, the development of hypertension depends upon how the
person works under stress.

Stress is not always a problem for some people. In fact, there are
several people who can work better under stress. In other words, some
people perform much better in a stressful situation. Therefore, stress
may not be detrimental to their health and they may not develop hypertension.
At'any rate, there is a positive relationship between stress and high blood
pressure. When a person experiences stress, the blood pressure tends to
increase.

One of the best methods to control stress is through relaxation.

This can alleviate the possibility of developing hypertension. In the
Detroit Project, Harburg et a1, were able to conclude a positive relation-

ship existed between stress and hypertension.

CROW DING

10

Crowding

Crowding has a variety of meanings, depending
upon the context. Some writers emphasize
physical density or number of people per unit
of space, others stress subjective feelings,

while others focus on physiological responses.9

It can be defined as little space relative to the number of people.
Also, it is the perceptual response to limited space. In his article,
"The Perception of Crowding", Daniel Stokols noted that crowding is a syn-
drome of stress resulting from the disparity between one's supply of and
demand of space. Crowding within an urban area can cause many environmental
problems.

Cities themselves differ considerably in
the amount of space available per person.
Whereas rural areas might have ten people
per square mile, even small towns have
population densities in the hundreds.
Suburban areas and larger cities have many
hundred or several thousand per square
mile. While big cities typically have
population densities in the thousands, even
they differ considerably.10

Several studies have been conducted in reference to the affects that
crowding has on people. There have been relatively few studies that in-
dicate an association between the two variables. One such study conducted
by Freeman et al, believes that crowding does not have a negative effect
on human behavior. However, the majority of the studies support the hypothesis
that a relationship exist between hypertension and crowding. For example,

David D'Atri explains in his article, "Crowding in Prison" (198i):

11

Research conducted in man suggests that
crowding may be deleterious. Ecologic studies,
for instance, have found positive associations
between persons per acre or persons per room
and mortality, psychiatric, hospitalization,
crime, deliquency and illegitmacy.

Harburg et al (1970, 1973), have observed that blood pressure of
certain subgroups was greater in areas of "high stress", one characteristics
of which was high density. They studied the effect of stress on blood
pressure in overcrowded ghetto and suburban conditions in Detroit and
found that:

the proportions of persons with hypertensive-
level blood pressures were significantly
greater in the overcrowded stressful tracts
than in the suburban tracts. The analysis of
the data implicates the psychological construct
of suppressed hostility as the mechanism of
coping response which is characteristic of

those pegsons with the highest blood pressure
levels.

Wohlwill et a1 stated:

Environmental factors determines how people

will react in crowded situations. People

raised in an urban environment probably

develops a different set of approaches to 13
high density situations than the rural people.

Crowding does not only occur within the cities but, it can occur
within a given environmental situation. Individuals can experience
crowding in a work situation, school setting, prisons, etc. One of the
most widely discussed topics in reference to crowding is the overcrowded

situation in prisons. D'Atri et al (1981) were interested in determing

12

the relationship between housing mode change and blood pressure among
prisoners. Therefore, they conducted an experiment to determine this
relationship. The prisoners were from a county correctional institution
for men located in a northeastern state. All eligible participants

were interviewed and experiments were conducted in terms of relocating the
prisoners in different cells which produced a crowded situation. Their
blood pressure was measured and hypertension was observed. After
analyzing the data, D'Atri et a1 proved their hypothesis (relationship
between crowding and blood pressue is positive) to be true.

There have been numerous other studies that have tested and proved
the hypothesis was true. In fact, more studies actually support that a
relationship exists between the two variables. For example, Larry Dean
et a1 examined a different population group (enlisted Navy men) and their
data yield the same results as the previous study. An association exists
between crowding and the effects on health.

Crowding is a complex subject. It is difficult to overcome crowding
especially in prison setting. However, there are other situations whereby
crowding can be reduced. Some people can c0pe with crowding and others
can not handle the pressure. Those individuals that can not cope with
crowding detriments their health. In addition, this type of situation

can very easily lead to the development of hypertension.

DISTRIBUTION OF HYPERTENSION

13

Distribution of Hypertension

One of the mainstays of epidemiologic research
has always been the study of geographical
differences. With regard to blood pressure,
there is no adequate evidence to prove that
geographic and cultural factors have a
significant effect on thg frequency of
essential hypertension.

Many studies have examine the relationship between geographical
location and the development of hypertension. Some researchers believe that
there is a significant effect on the frequency of hypertension and
geographic area. However, some researchers believe the opposite.

This section of the paper will focus on some of the various types of

distributions of hypertension, namely: national geographic distribution,

ethnic distribution, and intra-urban distribution.

14

National Geographic Distribution

Hypertension is a nationwide chronic disease. It is more prevalent
among the black population. In terms of the national geographic distribution,
the development of hypertension may have the tendency to occur more in
areas where the black population is concentrated. For example, several
black people inhabitant in the southern states of the United States.
Therefore, a pattern showing the distribution of hypertension may be more
defined in these areas. In other words, this pattern develops because a
cluster of black people are living in the area and the prevalence of
hypertension is higher in the black population.

Several researchers have examined hypertension studies by geographic
area. Their findings vary depending upon the population group evaluated.
For example, in the tropical areas, blood pressure is much lower than in
New Guinea. Likewise, blood pressure is higher in Western countries than
among villagers in other countries. As stated previously, hypertension is
more prevalent among obese people. Also, the diet in many countries
are different. Therefore, there is a tendency of blood pressure being
lowered in those countries with a lower average weight.

Lifestyles vary in different parts of the world. Therefore,
hypertension occurring in a geographical area is attributed, more than
likely to environmental factors. Several studies have shown that people

in the Western countries, on the average, have higher blood pressure.

15

Ethnic Distribution

Hypertension is more prevalent among the black population. It is
the number one "killer" disease for blacks. There are certain types of
diseases which affects specific ethnic groups. Even though, hypertension
affects all ethnic groups, it is more commonly known to occur among blacks
than any other racial group. In fact, it affects approximately one out
of every four blacks. Numerous studies on hypertension have proven
this hypothesis is indeed true. Even though certain groups of Indians
(i.e. Pima) have been evaluated and detected for increased blood pressure,
the rate occurs faster among blacks.

Negroes residing in high stress (economically
deprived, densely populated, high incidence
of family instability, high crime rate) and
low stress census tracts in Detroit, Michigan
Harburg, et al, reported a significantly
greater prevalence of hypertension in the
high stress tracts.15

Blood pressure is higher in blacks of all age-sex groups than
whites. Studies have been conducted among black and white populations
in order to detect the rate of hypertension. Many of those studies prove
that hypertension occurs mainly among blacks. However, some studies state
that environmental factors in terms of race will determine the development

of hypertension. For example, D'Atri (1975) stated that in the prison

setting (housing situation) the development of hypertension is the opposite.

16

This finding, although surprising may be
accounted for by the facts that black inmates
were younger, taller, lighter in weight and
much more likely to be recidivists than their
white inmates.

Few studies support the hypothesis that hypertension among blacks is
lower. Basically, the findings of a study depends upon the variables
evaluated. Nevertheless, blood pressure rises higher in blacks: there
are no recent studies to explain this rate. However, some researchers
believe that the prevalence is higher in blacks because of their body's
composition and intake of salt (factor related to increase in blood pressure).
At any rate, there are ongoing studies presently attempting to determine

why this relationship exists.

17

Intra-Urban Distribution

Hypertension is more prevalent in the urban environment than in the
rural areas. Likewise, suburbanians experience hypertension less than
urban dwellers.

There is a significant difference in the development of hypertension
in urban areas compared with other areas. Researchers suggest several
reasons for this pattern. For example, in other areas there tends to be
more space per person. Therefore, crowding does not exist in these areas
as in urban areas. As stated previously, there is a relationship between
crowding and hypertension. Other researchers state that socioeconomic
status can contribute to an individual's health. The health status of
people within a city can vary. For instance, people living in the ghetto
may have higher percentages of hypertension compared with those in the
central city. People in low social class have slightly higher blood
pressures than among the other social classes. Futhermore, there are some
differences (blacks higher) when inner city ghetto children are compared
to children residing in a more middle class, higher socioeconomic

neighborhoods.

It was hypothesized that the more urban
experience accurred by Negroes migrating from
the South to Chicago slums, the more conflict
will exist between any increased aspirations
and their objective social situation. There-
fore, it was further hypothesized, migrants of
longer Chicago residence would be under
greater psychological stress and - if there

is any relationship between long term stress

of everyday life and risk of hypertension - they
should have higpar age-specific prevalence rate
of the disease.

18

Kotchen et al (197#) found that a number of genetic and environmental
variables are associated with the height of the blood pressure in urban
adolescents. Similarily, Burns et al (1980) found that inner city
black males and females had higher blood pressures than black males and
females in suburban areas. This pattern also existed among white males.
However, there was no significant difference in the inner city or suburban
white females.

Futhermore, several hypertension studies have been conducted in terms
of the distribution of high blood pressures in the city. As a result, the
majority of these studies conclude that individuals living in well -
established environments have lower blood pressures than those living in a
low economic status (ghetto). Therefore, within an urban environment,
blood pressure is higher in those areas where the socioeconomic status is

lower.

HYPERTENSION SCREENING PROGRAMS

19

Hypertension Screening Programs

The control of hypertension is highly effective in terms of pre-
venting complications, morbidity, disability and premature death caused
by high blood pressure. Hypertension is a serious disease. Also, there
are medical problems associated with this disease which can cause severe
complications. The three most common problems associated with hypertension
are: cardiovascular (heart) disease, kidney disease, and cerebrovascular
(stroke) disease.

Cardiovascular disease involves the heart and blood vessels. High
blood pressure can make the heart pump harder than necessary causing the
arteries to become less elastic. Hypertensive disease is the most prevalent
detectable cardiovascular disease among the population.

Kidney disease is the prime target of hypertension. Hypertensive
disease is associated with progressive changes in renal (kidney) functions.
In most hypertensive patients, the kidney functions more slowly. How-
ever, the progress may accelerate. Therefore, in the great majority of
patients when this rapid pace supervenes, it usually results in death from
renal insufficiency.

"Cerebrovascular (stroke) disease comprise any disease in which one
or more of the blood vessels of the brain are primarily implicated in a

pathologic process".18

A hypertensive person is more probable to have
a stroke than persons with normal blood pressure.
During the past ten years an increasing number of reports in the

medical literature have indicated: (1967)

20

1) Hypertension can be controlled in the
majority of patients.

2) Hypertension should be treated early.

3 Many of the complications of hypertensivg
disease can be minimized or eliminated.1

Hypertension is definitely one of the major causes of death in the
United States because of its fatal complications involving the kidneys,
brain and the heart. However, death can be prevented if treatment is
seek in the early stages of hypertension. If a person is not treated
for the disease, it will impair their life expectancy. In other words,
longevity is reduced as blood pressure increases. However, physicians
agree that effective treatment is needed to reduce mortality and
morbidity.

The only means of detecting hypertension people is to screen for high

blood pressure.

The first criterion to be met by a screening
program for any disease should be that the
natural history of the condition can be im-
proved as a result of the earlier diagnosis
achieved. Screening for hypertension

meets this criterion. A number of major
randomized controlled trials have recently
reported evidence of the benefit conferred

by treating hypertension at a stage before
symptoms have developed and; since there is

a wide choice of effective and well tolerated
antihypertensive drugs available, the case for
detecting and treatfisg symptomless hypertension
is now very strong.

21

Many people have hypertension and are unaware of it. It is more
prevalent among the black population --- one out of every four blacks
have hypertension. Basically, the body is being damaged (i.e. kidneys,
brains, heart) inside these hypertensive people. Blood pressure
measurements will determine the hypertensive population.

Numerous hypertension control studies have been done nationwide.

The screening process is similar in all hypertension programs. For
example, screenes are asked a battery of questions regarding their health.
Their blood pressures are then measured (depending on the protocol, blood
pressure measurement can be taken one to several times). If the screenes
are classified as hypertensive, he/she is recommended for further
evaluation.

Stamler et al reported, in their article, "Hypertension Screening of
One Million Americans, that there was a large percentage of individuals
with either undetected, untreated or uncontrolled hypertension. This
study attracted the majority of its participants in the shopping centers
of forty-two states. Their blood pressure was measured and; they were
classified as hypertensive if their blood pressure measurement exceeded
that identified in the protocol of the study. Consequently, a group of
individuals were identified as hypertension and would not have been if
screening was not done.

Recent studies among high school students have indicated a need to
increase screening in the high schools.

If people are treated for hypertension early in life, it eliminates

some of the medical complications associated with it. Kotchen et al

22

screened a population of urban adolescents in two high schools in
Washington, D.C. Through the screening process, they were able to
identify a large number of students with hypertension, especially in
one of the schools where the majority of students either had the disease
or were probably developing the disease. Also, in the Detroit Project,
Harburg et al reported a greater prevalence of hypertension among the
black population. They would not be able to detect these findings, if
they had not screened for high blood pressure.

In the abovementioned examples, the data indicates a large sample
of hypertensives were identified after being screened. Therefore,
screening is an important concept in the determination of detecting high

blood pressure.

23

Many of the screening programs are successful in terms of identifying
people with high blood pressure. The main incentive of these hypertension
screening programs is to detect hypertension. Generally, a follow-up
is conducted after a population has been identified as having high blood
pressure, if for instance, they are involved in a study for research.
Screening usually takes place in a centrally located area to attract more
people. For example, in the Chicago study, the majority of the screening
was done in the shopping malls. In essence, the success of hypertension
screening progarams is to locate them in areas that are more accessible
to the public. If people have to travel far to participate in a screening
program, more than likely, they will not participate unless an incentive
is involved. Nevertheless, screening has been found to be'successful in
terms of locating people with the disease from the population screened.

The screening of a large number of people in the
general population, such as the middle-aged
adults on a group practice list, can be made
more convenient for both the practic and the
patients if it is properly planned.2?

Once a hypertensive person has been identified, he/she is recommended
to seek further medical attention if the state of hypertension is severe.
Basically, the screenes are given certain recommendations based upon the
severity of the disease, the choice to follow-up on this advice is up to
that individual. Therefore, the major problem results when this hypertensive
person does not comply with the recommendations. In fact, this could
cause the disease to get worst. Therefore, it is very important that once

an individual has been diagnosed as being hypertensive, immediate medical

24

attention is sought. This disease is serious and if it is not treated, it
can lead to death. Even though, the mortality rate for hypertension has
reduced due to the outstanding hypertension screening programs, it is
still a major health problem. In fact, the number of people who actually
die from hypertension is underestimated because of the information

provided on the death certificate.

Conclusion

Hypertension is a serious chronic disease that accounts for many
people's lives. There are many complicating factors associated with severe
forms of hypertension that can cause death, if not treated. Therefore, if
an individual has been screened and diagnosed as having hypertension, he/she
should seek further medical attention. There are many types of medications
that doctors can recommend to control hypertension. Once medication has
been prescribed, it is important to take as suggested. One important factor
is keeping blood pressure down and avoiding any probable complications.

People with hypertension can lead a normal life if their blood pressure
is being controlled. There are several people unaware that they have
hypertension. One of the major reasons is because they have never been
tested for high blood pressure.

Hypertensive disease affects all age groups but, it increases with
age. Several environmental factors can influence the development of
hypertension. Urban residents, especially those living in crowded con-
ditions are more likely to develop hypertension than suburban and rural
residents. Crowding is also associated with the development of increased
blood pressure. Some studies have shown that blood pressure is higher
among certain groups of adolescents compared to their counterparts based
upon, not only environmental factors, but also family history and

socioeconomic status.

25

Footnotes

1
Community/Church Based High Blood Pressure Control, Program Manual.

2Theodore Irwin, "Watch Your Blood Pressure," Public Affair Committee,
(Pamphlet No. #838), 1972.

' 3Ivao M. Moriyama, et al, Cardiovascular Diseases 12 the United States,
Harvard University Press, Cambridge, Massachusetts, 1971, p. 155.

“Jeremiah Stamler M.D., et al, The Epidemiology gf_Hypertension, Grune
and Stratton, New York and London 1967: p. 163.

51bid, p. 208.
6Ibid, p. 265.

7Stephen Freestone et al, "Effects of Coffee and Cigarette Smoking on
the Blood Pressure of Untreated and Diuretic-Treated Hypertensive Patients,"
The American Journal of Medicine, Vol. 73, September 1982, p.3h8.

8David C. Class and Jerome E. Singer, Urban Stress, Academic Press,
New York and London, 1972, p.6.

9Joachim Wohlwill et a1, Environment and the Social Sciences: Perspectives
and.Applications, American Psychological Association, Inc, Washington,
D000: 1972: P0 5-

1°Jonathan L. Freedman, Crowdipg and Behavior, The Viking Press, New York,
1975. DJ-

11
David A. D'Atri et al, "Crowding in Prison: The Relationship Between
Changes in Housing Mode and Blood Pressure, "Psychosomatic Medicine, Vol 43,
No. 2, April 1981, 1981, p.95.

12David A. D'Atri, "Psychophysiological Responses to Crowding," Environment
and Behavior, Vol 7, No. 2, June 1975, p.239.

13’JoachimWohlwill et al, Environment and the Social Sciences: Perspectives
and Applications, American Psychological Association, Inc., Washington, D.C.,

1972: P055-
1h
Jeremiah Stamler, M.D., et al, The Epidemiologyw f Hypertension, Grune
and Stratton, New York and London 1967, p. 155.

15.1ane M. Kotchen et al, "Blood Pressure Distributions of Urban Adolescents,"
American Journal of Epidemiology, Vol 99. No. 5, 1974, p. 323.

16David A. D'Atri, "Psychophysiological Responses to Crowding," Environment
and Behavior, Vol 7 No. 2, June 1975, p. 2h2.

1?

Jeremiah Stamler, M.D., et al, The Epidemiology gf_Hypertension, Grune
and Stratton, New York and London, 1957. p.309.

Harvard University Press, Cambridge, Massachusetts, 1971, p. 175.

19Jeremiah Stamler, M.D. et al, The idemiolo ‘gf_Hypertension, Grune
and Stratton, New York and London, 1537. p. E39.

2°W.E. Miall, Northwick Park Hospital Middlesex, "Screening, Screening
for Hypertension," British Journal of Medicine, June 27 (6), 1977. p- 592.

21Ibid, p. 598.

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