Chapter it focused on fasting. From a study on



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In this age, the health problems become more increasing from year to
year. One of health problems that need to focus is hypertension. Hypertension is
known as the high blood pressure that defines as a condition in which the blood
vessels have constantly raised pressure (World Health Organization, 2013). According to WHO (2013),
“blood pressure occurred because the force of blood pushing against the walls
of blood vessels (arteries) as it is pumped by the heart”. High blood pressure
can occur to any persons regardless of their age. Additionally, hypertension
has been identified as one of the major risk factors for non-communicable
disease which is cardiovascular diseases (CVD) such as heart failure, ischemic
heart disease, stroke as well as renal disease (Abdul-Razak et al., 2016;
Liu et al., 2017). As stated before, hypertension can cause a lot of
complication. Hypertension also labelled as “silent killer” by certain people
due to the CVD (Bhatt, Sharma, Gupta, Sinha, & Mehrotra, 2017;
World Health Organization, 2013). Considering that, more studies about hypertension
need to be done.

The previous data also stated that the incidence of hypertension among
adult and older in the U.S with 30.9% or nearly the ratio 1 in 3 adults (Lloyd-Jones & Levy, 2013). Hypertension in the
developed countries and the developing countries also has been burden disease
as well as the greatest threat to health care system (Viera & Hawes, 2016). In Malaysia, the
prevalence of hypertension among adults was 30.3% that including the diagnosed
and undiagnosed hypertension (Institute for Public Health, 2015). The estimated percentage will
be increasing by years due to many factors. The risk factors that contribute to
hypertension are age, weight, lifestyle, smoking as well as nutritional intake
and other risk factors. For nutritional intake, it focused on fasting. From a study
on animals, fasting can cause reduction of nutrients as well as the size of
intestines (Kohl et al., 2014).  Reduction
of nutrients can help obese or overweight people to reduce their weight. The
previous study explained that obesity may prone to hypertension by promoting
renal sodium retention through insulin resistance (Savica, Bellinghieri, & Kopple, 2010). The example of nutrients
are carbohydrate, protein and fat. Therefore, diet modification involving macro
nutrients can prevent and treat hypertension is strong (Pao-Hwa & Liwei, 2012). For
Muslim people, there is one month for fasting, also known as Ramadan. It start
from dawn to sunset, and people are restrained from eating and drinking during
these time (Mohsen et al., 2012). However, there is still no data of prevalence about
hypertension during fasting or Ramadan in Malaysia. Hence, it is needed for
people and health care provider to know about the rising rates of hypertension.


A study in 2010 has mentioned that the prevalence of hypertension in
Kuantan was 35.6% (Akter et al., 2010). Besides that, the previous study also stated that the prevalence
of hypertension has been increased dramatically (Viera & Hawes, 2016). However, the prevalence of hypertension only focused on the
allocated time and not specific time such as the whole year of 2010 or 2015.
This occurrence gives increase concern since the time target is during fasting
in Ramadan. The previous study has mentioned that there is no inadequate
results about the effects of fasting during Ramadan on hypertensive patients (Alinezhad-Namaghi & Salehi,
2016). As we know, nutritional intake plays a crucial part in our
metabolism. When fasting, there will be some changes in our metabolism because
the restriction of taking food or drink during daytime (Patterson et al., 2015). Yet,
there is still inadequate finding of the prevalence of hypertension during
Ramadan. Hopefully, this study can give a better clarification about the
prevalence of hypertension during Ramadan.


This study will helps to provide information and knowledge on prevalence
of hypertension during Ramadan. In addition, this study will also benefit
people to aware of their blood pressure. It is important to know about the
prevalence because it can help to prevent any complication such as
cardiovascular disease. This study will help to fill the gap of association
between fasting during Ramadan with hypertension. Furthermore, this study also
beneficial because hypertensive patients can know whether the fasting can
affect their blood pressure or not by doing some comparison between fasting and
non-fasting months.


1.      What
are the factors that influence hypertension?

2.      What
is the prevalence of hypertension?

3.      Does
fasting affect the high blood pressure?

4.      What
is the prevalence of hypertension during Ramadan?

What are the differences between the prevalence of hypertension during Ramadan and
another months?


To determine the
factors that influence hypertension patients.

To identify the
prevalence of hypertension.

To know the
significant of hypertension and Ramadan fasting.

To examine the
prevalence of hypertension during Ramadan.

To compare the
prevalence data of hypertension during Ramadan and other months.


Null hypothesis

There is no association
between the fasting and prevalence of hypertension among adult and elderly.

Alternative hypothesis

There is an association between the fasting
and prevalence of hypertension among adult and elderly.



High blood pressure defines as a condition in which the blood
vessels have constantly raised pressure.


Prevalence is a measure of the proportion
of a population affected by a specific condition in a specified time period
(Muller, 2011).


Incidence is the number of new cases of a
disease in population (Muller, 2011).

Risk factors

The tendency of people to get hypertension.


Gender can be divided into male and female.


Age is referred to the participants’ age
started from 1st January 2018.


is referred to race in Malaysia which are Malay, Chinese, Indian and others


Weight will be measured using a weighing
scale to the nearest 0.1kg with calibrated weighing scale. 


Start from dawn to sunset, people are
restrain from eating and drinking with the intention (niat).



At this moment, we have heard about many cases related to hypertension
around us. In addition, hypertension becomes more concern among people when the
new reading of blood pressure was implemented. The new reading for stage 1 of
hypertension was 130-139/80-89 mmHg (Whelton et al., 2017). Since the study aimed to identify about hypertension generally,
the prevalence of hypertension in Hospital Tengku Ampuan Afzan (HTAA) and the
relationship between fasting (Ramadan) will be studied. Furthermore, the
literature review will emphasize the importance of this study and support all
findings related to fasting and non-fasting month about hypertension. 


Prevalence of Hypertension

When blood vessels have constantly raised
pressure, this can lead to high blood pressure because the heart need to pump
the blood harder than normal (WHO, 2013). It could not be denied that most people
do not aware of their blood pressure except for those who regularly do health
check-up about their blood pressure. Non-communicable diseases such as
cardiovascular diseases including stroke, heart failure or ischemic heart
disease as well as renal diseases are the common complication of hypertension
because hypertension is the common risk factors for those diseases (Abdul-Razak et al., 2016;
Akter et al., 2010;
Liu et al., 2017). A study stated that hypertension can occur if the
blood pressure for systolic was ?140 mmHg and diastolic is ?90 mmHg (Hales, Carroll, Simon, Kuo, & Ogden, 2017).  However, the another study has been mention
that the new reading for hypertension was 130-139/80-89
mmHg (Whelton et al., 2017).

Hypertension remains as a significant public health problem even though
there are a lot of studies have been done in order to overcome this problem.
For over the past three decades, the researchers did some studies in order to
understand about the risk factors, pathogenesis and complication of
hypertension as well as multiple trials for indicating the benefits of
antihypertensive therapy (Lloyd-Jones & Levy, 2013). In United State (U.S), the
prevalence of hypertension with diagnosed and without diagnosed achieved 1 in 3
adults (Lloyd-Jones & Levy, 2013). However, the awareness
about hypertension in U.S citizen has been increasing (Hales et al., 2017). In addition, the previous
study in China also mentioned that the prevalence and awareness of hypertension
were 51.93% and 15.28% respectively (Yao et al., 2010). The data showed that people in Xinjiang still have
low awareness about hypertension even though the incidence of hypertension is
quite high. As mentioned by Lloyd-Jones and Levy (2013), hypertension become
one of global burden due to the increase number in the prevalence of
hypertension across all the world.

 Malaysia is one of developing
countries and still facing the same health problem which is hypertension as
other developed and developing counties. The study about hypertension in
Sarawak showed that the prevalence of hypertension was 43.1% and it was higher
compared to another rural area that were reported in the 3rd
Malaysian National Health and Morbidity Survey (Cheah, Lee, Yaman, & Wahab, 2011). In urban area population
such as Penang, the prevalence of hypertension was 62% which is very high
compared to rural are of only 26% (Ong, Oung , Ong, & Tan, 2010). The researchers also
stated that the percentage of hypertension for elderly people that live in an
urban area was higher (Ong et al., 2010). Besides that, the overall
prevalence of hypertension in selected area in Kuantan was 35.6% (Akter et al., 2010). The researchers stated
that the prevalence of hypertension in this area was higher as compared to the
Malaysian National Health and Morbidity Survey but there was still some
limitation (Akter et al., 2010). The small sample size was
used in this study and it does not represent the whole area of Pahang (Akter et al., 2010). Hypertension can occur
because of some risk factors and it can contribute to the percentage of

Risk Factors

Rapid increasing about the incidence of
hypertension occurred because of certain risk factors that associated with
blood pressure.       Age

The prevalence of hypertension keeps
increasing with the advance of age. According to Lloyd-Jones & Levy (2013),
the overall prevalence of hypertension in population will increase with the
aging of the population. The previous study has shown that about 81%
hypertensive patients are age 45 years old and above (Lloyd-Jones & Levy, 2013).
However, high blood pressure still affects adult age from 20 to 40 years old. The
prevalence of hypertension among young adults in Tujia, China has been
increasing from 2011 to 2014 (Liu et al., 2017). The previous study illustrated the higher hypertensive risk goes
to the age above 40 years old (Liu et al., 2017). This happen because of a variety factors but it more related to
changes in arterial compliance and stiffness (Lloyd-Jones & Levy, 2013).
Same goes in Malaysia, the age still become the risk factors for high blood
pressure. The study was done in the elderly population in Penang that indicates
the prevalence of hypertension among elderly was high (Ong et al., 2010). According to Kearney et al, Malaysia had the highest prevalence of
hypertension among adults age more than 18 years old with 32.7% as compared to
Singapore, Indonesia and Thailand (Abdul-Razak et al., 2016).       Weight

Weight is one of the risk factors of hypertension.
People who are overweight or obese has tendency to get hypertension. Obesity is
one of the metabolic syndromes. International Diabetes Federation (IDF) has
established the definition of metabolic syndrome in 2007 after a few
definitions. According to Zimmet, Alberti and Serrano (2005), metabolic syndrome can be
defined as a cluster of metabolic abnormalities including visceral adiposity,
obesity, dyslipidemia, hypertension and hyperglycemia (Zainuddin, Isa, Muda, & Mohamed, 2011). The previous study
mentioned that the prevalence of hypertension among obese individual was higher
as compared to normal weight (Lloyd-Jones & Levy, 2013). It is also
reported in a study that obesity and hypertension in Brazil has no significant
association between weight and hypertension as well as the blood pressure does
not relate to body weight (Bloch et al., 2016). However, there was a cohort study said that the
children who were overweight at ages 5 but had a normal BMI at age 14 had
similar reading of blood pressure (Lloyd-Jones & Levy, 2013). Obesity and
hypertension are the common risk factors for CVD and if a patient has these
problems, the tendency to get CVD is high (Akter et al., 2010). There is one citation in a
research article said that the hypertension has a significant association in
obesity (Akter et al., 2010).       Smoking

Smoking is the most major risk factors for
diseases. Smoking can harm nearly all human organ. The nicotine in tobacco can
cause blood vessels constriction because the nervous system will release
chemical that affect blood vessels and contribute to high blood pressure (Rodriguez, 2009). Additionally, the smoking can cause stiffness of the arterial
blood vessels in hypertension associated with the advancing of age (Saladini et al., 2016). The
previous research mentioned that the high nicotine can increase the sympathetic
nervous system activities and cause the releasing of epinephrine,
norepinephrine and vasopressin hormones (Cryper et al., 1976; Narkiewicz et
al., 1998; Waeber et al., 2003; Li et al., 2017). A finding in previous study
revealed that the blood pressure of current smokers is lower as compared to
non-smokers (Li et al., 2017; Rodriguez, 2009; Yao et al., 2010). However,
smoking cessation was one of risk factors that contribute to the prevalence of
hypertension as compared to current smokers (Li et al., 2017).


The action of abstinence from food and drink
has been practicing a long time ago (Patterson et al., 2015). Ramadan
fasting is referred to restrain from eating and drinking starting from dawn to
sunset with the intention (Mohsen et al., 2012). Patterson et al., mentioned in
their study about fasting which are intermittent and religious fasting (2015).
Alternate day fasting is useful because it helps in reducing total plasma
cholesterol and triglyceride as well as it helps in decreasing fasting insulin
and glucose concentration (Patterson et al., 2015). The
data from the study reported that alternate fasting can involve in weight loss
and can give a positive impact on metabolic pathways (Patterson et al., 2015).  Patterson et al., (2015) explained that
modified fasting regimen can limit the energy consumption around 20-25% of
energy needs on regularly scheduled fasting day. However, the previous study
reveals that the reduction dietary energy intake and weight loss in obese
people may reduce hypertension due to some mechanism (Savica et al., 2010).

Meanwhile for Ramadan fasting, less
consumption of food and fluid cause changes in body weight even though Ramadan
fasting do not need energy restriction (Parekh, Balart, & Johnson, 2015). In
addition, Parekh et al., stated that low density lipoprotein and fasting blood
glucose were reduced during Ramadan (2015). Fasting during daytime helps people
to improve their health because of circadian biology by ensuring that
physiological processes are performed at the right time (Parekh et al., 2015). Besides that, during Ramadan the quality of food and eating
pattern will be changed and Atashi et al. (2000), mentioned that this happened
due to two large meals at dawn and sunset, which was the consumption of more
carbohydrates and sweet foods (Nematy et al., 2012). Patterson et al., (2015) concluded that “every single fasting
interval in human can reduce the basal concentration of many metabolic
biomarkers associated with chronic disease such as insulin and glucose”.


Habbal et al., (1998) mentioned that some
changes will occur in nutritional and behavioural during Ramadan and it can
lead to some physiological changes such as blood pressure (Alinezhad-Namaghi & Salehi,
2016). There will be some changes in blood pressure with multiple
mechanisms due to the changes in the feeding and sleeping habits (Hossein Soltani & Namayandeh,
2016). In addition, fasting can reduce venous return which cause to a
decrease in the sympathetic tone leading to a fall in blood pressure, heart
rate and cardiac output (Azizi, 1996; Salahuddin, Ashfak, Syed, &
Badaam, 2014). The finding
from the recent study revealed that there was no significant changes in blood
pressure during Ramadan fasting (Alinezhad-Namaghi & Salehi,
2016; Hossein Soltani & Namayandeh,
2016; Nematy et al., 2012). However,
another study mentioned that there was significant reduction for systolic and
diastolic blood pressure in hypertensive patients due to Ramadan fasting (Salahuddin, Ashfak, Syed, &
Badaam, 2014). Therefore, Ramadan fasting is safe for hypertensive patients if
they continued taking previous medications (Alinezhad-Namaghi & Salehi,
2016). Due to the increased prevalence of hypertension across the world, a
study of hypertension prevalence during Ramadan will provide some information
to on the association of fasting with hypertension as well as how fasting
affect the prevalence.