Abstract
Prevalence of hypertension is increasing to higher levels in South Africa. Anthropometric measures for obesity are well known to predict the development of hypertension. However, the relationship between mid-upper arm circumference (MUAC) and blood pressure (BP) is scant in South African communities such as universities. Therefore, this study was aimed at investigating the correlation between MUAC and BP among the community of Walter Sisulu University (WSU). A total of 230 participants from WSU (students and staff members), 113 females and 117 males aged ≥ 18 years participated in this cross-sectional study. MUAC, systolic BP (SBP) and diastolic BP (DBP) were measured using standard procedures. In a Pearson’s correlation analysis, MUAC was positively correlated with SBP and DBP in both women (SBP; r = 0.53, P< 0.001; DBP; r = 0.45 P < 0.001) and men (SBP; r = 0.29 P = 0.001; DBP; r = 0.25 P = 0.007). Furthermore, in the multivariable-adjusted regression analysis, MUAC was positively associated with SBP in women only (adjusted R2 = 0.489, β = 0.29 (95% CI = 0.16; 2.08)), P =0.023) after adjusted for age, body fat percentage, waist-to-height ratio, smoking and alcohol. MUAC is positively correlated with BP in women, not in men of WSU community. MUAC, as a simple and low-cost quantifiable parameter, could be employed as a risk indicator in the early detection and prevention of cardiovascular diseases (CVDs) in women.
Plain Language Summary
This study investigated the use of an anthropometric measurement as an indicator for hypertension. Anthropometric measurements are non-invasive quantitative measurements of the human body. Within this study, we evaluated the productiveness of mid upper arm circumference (MUAC) as an indicator for hypertension in the WSU community. Studies have shown that MUAC, being a simple and cost-effective method, can be employed in resource-limited settings. Furthermore, the findings of this study have revealed a positive correlation between MUAC and blood pressure in women from the WSU community, indicating that the greater their MUAC, the higher their blood pressure, further emphasizing their increased risk of developing hypertension. Consequently, these findings will contribute in the prevention of hypertension and obesity, even in areas where accessibility to expensive resources is limited. Furthermore, this investigation has raised awareness about hypertension and obesity within the WSU community, encompassing individuals from diverse geographical regions and racial backgrounds. Thus, we firmly believe that this study has had a substantial impact. Additionally, it will serve as a motivation for the community to transition from unhealthy lifestyles to healthier ones, which include dietary improvements, increased physical activity, and decreased alcohol consumption. Ultimately, these changes will significantly reduce the risk of developing cardiovascular diseases.
Introduction
Cardiovascular diseases (CVDs) pose a serious public health threat, which contributes significantly to the global illness burden in both high-, middle- and low-income countries (Jagannathan et al., Citation2019). High blood pressure (BP) is a major risk factor for CVDs and can cause a variety of complications including death if left untreated (World Health Organization (WHO), 2014). Obesity is a major risk factor for a variety of conditions, including high BP (Poirier et al., Citation2006; Abraham et al., Citation2015).
Several anthropometric indicators for obesity are well established (Yang et al., Citation2010, Shifraw et al., Citation2021., Mazıcıoğlu et al., Citation2010). Body mass index (BMI) is the most widely employed anthropometric measurement and is often utilized for determining the prevalence of obesity (Hales et al., Citation2017, Sartorius et al., Citation2015, Pienaar et al., 2015). BMI can be deceiving, especially when considering someone with a high proportion of lean muscle (Rothman, Citation2008). Furthermore, a centrally obese person may have a normal BMI, hence the majority of circumference measurements for obesity such as waist circumference, neck circumference and mid-upper arm circumference (MUAC) are widely employed as indications of central obesity (Ben-Noun and Laor 2003, Fatchurohm et al., 2021, Zhu et al., Citation2020). The MUAC assessment is one of the simplest, inexpensive, rapid, and practical (takes minimal effort from both the examiner and the examinee) and can be used as a screening tool in epidemiological surveys or in low-resource settings (Ramoshaba et al., Citation2015). BMI on the other hand is quite difficult to establish in low-resource settings as it requires height and weight measurements and the standard equipment for the aforementioned is expensive and necessitates calculations (Himes, Citation2009; Sultana et al., Citation2015).
There have been studies that reported that BP is closely related to MUAC in children both boys and girls from South African rural and urban areas (Ledwaba et al., Citation2014, Ramoshaba et al., Citation2015). In contrary, it has been observed that MUAC predominantly associate with BP in women than men from Indonesia and China (Fatchurohmah et al., Citation2021, Hou et al., Citation2019). However, the relationship between MUAC and BP is scant in South African communities such as historically disadvantaged universities. Therefore, it is crucial to establish the association between MUAC and BP among the Walter Sisulu University (WSU) community, in order to predict the development of hypertension, which will aid in its early prevention. This current study investigated the relationship between MUAC and BP among WSU community.
Methods
Study design and data collection
WSU is one of South Africa’s historically disadvantaged universities, located in the Eastern Cape Province. This study employed a cross-sectional study design, with a sample size of 230 participants from WSU, 185 (18-37 years) students, 45 staff members (18-63 years), both males (n = 117) and females (n = 113). Participants were recruited by word of mouth from their residences and offices to the physiology laboratory where the data were collected. A general demographic and lifestyle questionnaire was completed by each participant and the data with regard to age, gender, ethnicity, self-reported smoking, and self-reported alcohol consumption.
Measurements
Anthropometric measurements
Anthropometric measurements were carried out by researchers and well-trained assistants in accordance with the guidelines of the International Society for the Advancement of Kinanthropometry (Marfell-Jones et al., Citation2012). A tape measure (Lufkin Steel Tape; W606PM; Lufkin, TX, USA; Apex, NC, USA) was used to measure mid-upper arm and waist circumference to the nearest 0.1 cm, the participants settled into a comfortable position with their arms at their sides. The mid-acromiale-radiale was marked. The tape measure was then positioned perpendicular to the long axis of the humerus, where the mid acromiale-radiale was marked, while the muscles of the arm were relaxed, and MUAC measurements were taken. According to Shifraw et al. (Citation2021), MUAC of 24.5 cm is the optimal cutoff in both women and men to identify underweight and the cut-offs to identify overweight and obese are >28.0 cm and >30.0 cm, respectively.
The waist circumference measurements were taken at the level of the narrowest point between the iliac crest and the bottom part of the thoracic cage, with the participants standing in an upright position after mild expiration. The participants assumed a relaxed standing position with their arms folded across the thorax.
A SECA 213 Portable Stadiometer was used to measure the body height to the nearest 0.1 cm (SECA, Hamburg, Germany). The participants had to stand with their feet together and their heels, buttocks, and upper back touching the scale for body height measurements. The participants were instructed to take a deep breath and hold it while keeping their heads in the Frankfort plane. A gentle upward lift was applied through the mastoid processes. The stadiometer’s base was then lowered to the vertex of the head, and if there was a lot of hair on the head, a small amount of pressure was applied to touch the top of the head. Using an electronic scale, the body weight was measured to the nearest 0.1 kg (SECA, Hamburg, Germany). The scale reading was checked before the participants climbed onto it, then they stood on the center of the scale without support and with their weight evenly distributed on both feet. The head was tilted upwards, and the eyes were fixed forward. The waist-to-height ratio (waist circumference (cm)/height (cm)) was calculated.
Body fat percentage was determined using a body composition scale (Omron BF511 Body Composition monitor, China) where the participants stood bare footed on the scale making sure their feet were on the foot electrodes with their head tilted upwards and eyes looking in a forward direction. They then pressed their hands firmly on the grip electrodes and raised their arms vertically. Elbows and arms were extended straight at a 90° angle to the body.
BP measurements
Omron M3 BP monitor was used to assess clinic BP (Omron, Kyoto, Japan). After the participants have been seated for at least five minutes or more, three readings of SBP, DBP, and heart rate were taken at five minutes intervals from the dominant arm (Weber et al., Citation2014). The average of the last two readings were used. The pulse pressure (PP) was determined by subtracting the SBP from the DBP. The BP was categorized into elevated BP (SBP = 120-129 mmHg, DBP < 80 mmHg); prehypertension (SBP = 130-139, DBP = 80-89 mmHg); hypertension (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg) (Carey et al., Citation2018).
Statistical Analysis
The formal test (Kolmogorov-Smirnov test) and graphical approaches were used to analyze normal data distribution. Continuous data was presented as mean ± standard deviation. The student t-test was used to compare the continuous data by gender. Categorical data was presented as frequencies and proportions. Chi-square tests were used for categorical variables to test differences between men and women. A Pearson correlation analysis was performed to determine the relationship between the MUAC and BP in women and men. A multivariate regression analyses in women and men were performed to investigate associations between the MUAC and BP, adjusted for age, body fat percentage, waist-to-height ratio, smoking and alcohol. All the statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA, 26.0). The statistical significance was set at P < 0.05. A power calculation revealed that a minimum sample size of n = 89 would be required to perform our multivariate regression analysis with an effect size of 0.15, alpha set to 0.05, and power to 0.95.
Results
(available on the last section of the manuscript) shows the characteristics of WSU community by gender, women featured a higher MUAC (29.54 vs. 28.26 cm, P = 0.030) and body fat percentage (40.31 vs. 25.29%, P= <0.001) mean than men. There was no difference in BP by gender. Pearson correlation analyses for women and men MUAC of women revealed a positive correlation with SBP (r = 0.56; P = <0.001 vs. r = 0.29; P = 0.002), DBP (r = 0.46; P vs r = 0.21 P = 0.020) and PP (r = 0.42; P = <0.001 vs. r = 0.22; P = 0.016) than MUAC of men. shows the multivariable-adjusted regression analysis in woman results, the MUAC remained positively associated with SBP in women (adjusted R2 = 0.489, β = 0.29 (95% CI = 0.16; 2.08)), P =0.023) adjusted for age, body fat percentage, waist-to-height ratio, smoking, and alcohol. DBP and PP showed no significant association with MUAC in women. shows the multivariable-adjusted regression analysis in men results, whereby the MUAC showed no significant association with SBP, DBP but PP (adjusted R2 = 0.031 β = 0.29 (95% CI = 0.1;1.3), P =0.027), adjusted for age, body fat percentage, waist-to-height ratio, smoking, and alcohol in men.
Table 1. Characteristics of Walter Sisulu University community.
Table 2. Independent association between BP as dependent variable and MUAC as main independent variable in women.
Table 3. Independent association between BP as dependent variable and MUAC as main independent variable in men.
Discussion
This cross-sectional study investigated the relationship between MUAC and BP among the community of WSU, one of the historically disadvantaged universities. We found a significant positive correlation between the MUAC and BP in women not in men. This means that arm circumferences increase with BP in women more than in men.
The global burden of obesity has been substantially underestimated by the reliance on BMI in previous studies (Yusuf et al., Citation2004, Romero-Corral et al Citation2008). Furthermore, an INTERHEART study provides more insight into the reliability of different anthropometric obesity measurements such as waist to hip ratio, waist and hip circumferences, where waist to hip ratio revealed a highly significant association with myocardial infarction risk attributable to obesity as compared to BMI (Yusuf et al., 2005). In this study, we used a different approach, that has been recently proposed to assess obesity which is MUAC (Shifraw et al., Citation2021). We found that women had bigger MUAC as compared to men in this study.
Previous studies have revealed mixed results on the relationship between MUAC and BP based on gender and age. In children and adolescence, it was reported that MUAC positively correlate with BP in both boys and girls (Bassareo et al 2018; Ramoshaba et al Citation2015). In young adults, Fatchuromah et al (2021) reported no significant relationship between MUAC and BP in men while Hastuti et al (Citation2018) observed that MUAC is the strongest indicator for BP in women than men. Moreover, in older people, MUAC was associated more with high BP in women than in men (Hou et al., Citation2019). These previous findings are precisely in agreement with the results of this study that MUAC relates positively with BP more predominantly in women than men. Therefore, is critical in paying more attention to women with bigger MUAC in the early identification and that will help in prevention of high BP or hypertension.
The probable explanation for the gender difference in the relationship between MUAC and BP in adults could be biological variations between men and women, such as immune system response, physical performance, muscular capacity, and hormone effects. For instance, men often have more muscle mass and capacity than women due to a greater proportion of testosterone, whereas women usually display more upper body adiposity than men (Wells et al Citation2007, Hazlip et al 2015). The gender difference in body fat or adiposity distribution may contribute to more predominant relationship between MUAC and BP among women as compared to men observed in this study.
Generally, precise mechanism that links MUAC and BP is not yet clear, however there is evidence that an elevation in upper body subcutaneous fat measured by MUAC is significantly associated with increased visceral fat and is involved in the development of high BP and metabolic diseases independent of BMI (Liang et al., Citation2013, Yang et al., Citation2010). Jensen et al (2008) and Nielsen et al (Citation2004) briefly noted that upper subcutaneous fat secretes systematic free fatty acids, that will cause insulin resistance, inflammation, and increased triglyceride production and ectopic fat deposition (Kim et al., Citation2007, Hotamisligil, Citation2017). Increased levels of free fatty acids may also cause oxidative stress, by increasing the production of oxygen free radicals which override the antioxidant system (Masschelin et al Citation2020). Oxygen free radicals can elicit the proliferation, hypertrophy, and collagen deposition of vascular smooth muscle cells, which thickens the vascular media and narrows the vascular lumen (Grossman Citation2008). Additionally, oxidative stress has been linked to endothelial damage, impaired endothelium-dependent vascular relaxation, and increased vascular contractile activity, thus leading to elevated BP (Silver et al 2012). Therefore, excess free fatty acid release from arm subcutaneous adipose accumulation could be a plausible mechanism to explain the link between MUAC and BP.
Our findings have some limitations that should be noted. First, because the current study is a cross-sectional study, no causal inference can be drawn. Secondly, although we have adjusted for multiple confounders, family history, food consumption, physical activity and bioelectrical impedance analysis which we did not include might influence these findings. However, we suggest that future studies incorporate these variables into linear regression models in order to confirm our findings among the University communities. Lastly, this study was limited to the WSU community, the generalizability of our findings to other demographic and ethnic communities should be approached with caution.
Conclusion
This study found a positive association between MUAC and BP in women not men from the WSU community. Our findings show that MUAC, as a simple and low-cost quantifiable parameter, could be employed as a risk indicator in the early detection and prevention of CVDs in women.
Authors contributions
All authors contributed to design of the study. Conceptualization: W.S.M., Z.M.M., M.A.M., N.E.R.; Methodology, W.S.M.; analysis, W.S.M., N.E.R., investigation, W.S.M., data curation, W.S.M., and Z.M.M., writing—original draft preparation, W.S.M., writing—review and editing, W.S.M., Z.M.M., M.A.M., N.E.R.; supervision, N.E.R. The final approval of the paper and its revision were accomplished by all writers.
Ethics approval and consent to participate
Ethical clearance was sought-after from the Health Sciences Ethics Committee of Walter Sisulu University, South Africa (protocol number: 068/2022). After detailed explanation of the purpose and aim of the study, as well as a brief demonstration of how the measurement techniques were conducted, written informed consent was sought-after from the participants before enrolment of the study. The study adhered to the standards of reporting and acted in accordance with the National Data Protection Acts, as the identities of the participants were kept confidential.
Consent to publication
Not applicable.
Competing interest
Nil
List of Abbreviations
| BP | = | Blood Pressure |
| BMI | = | body mass index |
| CVDs | = | cardiovascular diseases |
| DBP | = | diastolic blood pressure |
| MUAC | = | mid upper arm circumference |
| PP | = | pulse pressure |
| SBP | = | systolic blood pressure |
| WHO | = | World Health Organization |
| WSU | = | Walter Sisulu University |
Acknowledgements
The authors are indebted to all participants (students and staff members).
Availability of data and materials
The data that support the findings of this study are accessible from the corresponding author, however access to these data is restricted, because they were used under authorization for the current study and hence are not publicly available.
Additional information
Funding
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