1

Angiotensin Converting Enzyme Gene Polymorphism

2
3
(Insertion/Deletion) and Hypertension in Adult Asian Indians:
4 A Population-Based Study from Calcutta, India
5
6 mithun das, 1 susil pal, 2 and arnab ghosh 3
7
8
9 Abstract The angiotensin converting enzyme (ACE) gene insertion/deletion
10 polymorphism has been identified as a potential genetic risk factor for essen-
11 tial hypertension. The purpose of the present study is to investigate the associ-
12 ation of the insertion/deletion polymorphism of the ACE gene with essential
hypertension in adult Asian Indians. Three hundred fifty (184 males and 166 [First Page]
13
females) adult (30 years and older) Asian Indians of Calcutta and its suburbs [303], (1)
14
participated in this population-based cross-sectional study. Anthropometric
15 measures, lipids profiles, blood glucose, and blood pressure measures were
16 collected from participants. ACE insertion/deletion polymorphism was deter-
17 mined by agarose gel electrophoresis and D/D typing was further reconfirmed Lines: 0 to 31
18 using insertion-allele-specific amplification. Essential hypertension was de- ———
19 fined as a systolic blood pressure (SBP) greater than 160 mm Hg and/or a 6.35745pt PgVar
20 diastolic blood pressure (DBP) greater than 90 mm Hg or use of any antihy- ———
21 pertensive treatment by participants. Significantly higher SBP, DBP, and mean Normal Page
22 arterial pressure were recorded in D/D subjects compared to I/I and I/D sub-
jects. We also observed that the odds of being hypertensive were 7.483 (95%
PgEnds: TEX
23
CI = 1.746, 30.192) in D/D individuals compared to those carrying one or no
24
D alleles. This finding suggests that ACE insertion/deletion polymorphism is
25 [303], (1)
associated with essential hypertension in Asian Indians. Moreover, individu-
26 als who are homozygous for the D allele of the ACE gene are more likely to
27 have essential hypertension.
28
29
30 Cardiovascular disease (CVD) will be the largest cause of death and disability
31 in India by 2020, with 2.6 million Indians predicted to die from coronary heart
32 disease (CHD), which constitutes 54.1% of all CVD deaths (Ajay et al. 2002).
33 Nearly half of these deaths are likely to occur in young to middle-aged individu-
34 als (about 30 to 60 years). In people of Indian origin, death from CVD occurs at
35 least a decade earlier than in their counterparts in countries with established mar-
36 ket economies. The Global Burden of Disease Study estimated that about 52% of
37
38 1
Department of Anthropology, Sree Chaitanya College, Habra, West Bengal, India.
2
39 Human Genetic Engineering Research Centre, Calcutta, India.
3
Department of Anthropology, Visva Bharati University, Sriniketan 731 236, West Bengal, India.
40
41 Human Biology, June 2008, v. 80, no. 3, pp. 303–312.
42 Copyright © 2008 Wayne State University Press, Detroit, Michigan 48201-1309

43 key words: ACE gene polymorphism, hypertension, obesity, athero-

44 sclerosis, asian indians.

BOOKCOMP, Inc. — Wayne State University Press / Page 303 / final proof / Human Biology 80-3 / June 2008
 304 / das et al.

1 CVD deaths occur before the age of 60 years in India compared to 23% in countries
2 with an established market economy. The growing burden of CVD in India could
3 be attributed to the increasing prevalence of CVD risk factors, especially hyper-
4 tension, dyslipidemia, diabetes, visceral obesity, physical inactivity, and tobacco
5 use (McKeigue et al. 1991; Ajay et al. 2002; Ghosh 2007). Essential hypertension
6 is considered one of the prime contributing factors to explain this exaggerated rate.
7 In India, there has been a steady increase in the prevalence of hypertension over
8 the last few decades. However, few studies on the prevalence of essential hyper-
9 tension have been undertaken in the culturally heterogeneous Indian population.
10 The prevalence of hypertension in India was merely 4% in 1951 and went up to
11 29% during the early 1990s (Dubey 1954; Gopinath et al. 1994). Epidemiological
12 studies carried out during the late 1990s demonstrated that the rising prevalence of
13 hypertension in India was as high as 50% in both sexes (Gupta et al. 1995, 2002,
14 2004; Hazarika et al. 2002). [304], (2)
15 A number of known genetic factors affect blood pressure regulation; an-
16 giotensin converting enzyme (ACE) is one of them. ACE is a key component of the
17 renin-angiotensin system (RAS) and is considered important in the etiopathogen- Lines: 31 to 37
18 esis of hypertension and CVD (Crews and Williams 1999). ACE is a well-known ———
19 zinc-metallopeptidase that converts angiotensin I into the potent vasoconstrictor 0.0pt PgVar
20 angiotensin II and that ultimately degrades bradykinin (a powerful vasodilator) ———
21 for regulation of vascular tone cardiac functions (Baudin 2002). Out of several Normal Page
22 allelic polymorphisms, an insertion/deletion polymorphism, a short intronic se- PgEnds: TEX
23 quence, could account for half the variance in plasma ACE level, resulting in large
24 interindividual variability (Rigat et al. 1990; Barley et al. 1994). Several studies
25 have shown a positive association of ACE insertion/deletion polymorphisms and [304], (2)
26 hypertension and other cardiovascular risk factors (Mastana and Nunn 1997; Zee
27 et al. 1999; Zhu et al. 2003; Schut et al. 2004; Jimenez et al. 2007; Higaki et al.
28 2000; Tai and Tan 2004; Slowik et al. 2007; Mattace-Raso et al. 2007; Barbalic
29 et al. 2006; Xu et al. 2004; Thomas et al. 2000), and other studies have shown a
30 negative association (Vassilikioti et al. 1996; Todoroki et al. 2003; Renner et al.
31 2002; Chowdhury et al. 1998) as a result of considerable interindividual and eth-
32 nic variation. In a six-year follow-up study, Di Pasquale et al. (2004) observed and
33 suggested that the ACE DD polymorphism seems to be associated with a higher
34 incidence of hypertension in baseline healthy subjects, irrespective of other con-
35 ventional risk factors.
36 In India, few studies have been undertaken so far to examine ACE inser-
37 tion/deletion polymorphism and hypertension (Nair et al. 2003; Ashavaid et al.
38 2000, 2002; Mastana and Nunn 1997; Singh et al. 2006; Tripathi et al. 2006).
39 However, most of these studies are case-control in nature. To the best of our
40 knowledge, only one population-based study has been undertaken so far; in that
41 study a significant prevalence (association) of the ACE D allele in hypertensive
42 subjects compared to normotensive subjects was observed (Mastana and Nunn
43 1997). A significant positive association between the D allele and hypertension has
44 also been observed in studies pertaining to people of Indian origin, for example,

BOOKCOMP, Inc. — Wayne State University Press / Page 304 / final proof / Human Biology 80-3 / June 2008
 ACE Polymorphism and Hypertension in India / 305

1 Bangladeshis (Morshed et al. 2002) and Pakistanis (Ismail et al. 2004). This in
2 turn raises the possibility that in people of Indian origin, variations in or near the
3 ACE gene locus may contribute to the development and severity of hypertension
4 (Pasha et al. 2002).
5 Keeping this view in mind, we aimed in the present population-based cross-
6 sectional study to look at whether there is any significant association between ACE
7 insertion/deletion polymorphisms and essential hypertension in adult Asian Indi-
8 ans living in eastern India.
9
10
11 Materials and Methods
12 Study Population. The data were collected on adult men and women, age 30
13 years and older, from Calcutta and its suburbs. Three hundred fifty individuals (184
14 [305], (3)
males and 166 females) participated in the study. Before the study, a public adver-
15 tisement was circulated regarding the study with the help of local council officials.
16 Individuals were selected randomly after they responded to the local advertise-
17 Lines: 37 to 78
ment. The response rate was as high as 85%. The institutional ethical committee
18 of Visva Bharati University (Sriniketan, West Bengal, India) approved the study. ———
19 Written consent was obtained from all participants before actual commencement 11.13405pt PgVar
20 of the study. ———
21 Normal Page
22 PgEnds: TEX
23 Anthropometric Measurements. Anthropometric measures (height, weight,
24 waist circumference, and hip circumference) were taken using standard anthro-
25 pometric techniques (Lohman et al. 1988). Height and weight were measured to [305], (3)
26 the nearest 0.1 cm and 0.5 kg, respectively. Waist and hip circumferences were
27 obtained to the nearest 0.1 cm using a nonelastic tape. Body mass index (BMI, in
28 kg/m 2) was calculated accordingly.
29
30 Blood Pressure Measurements. Two morning systolic (SBP) and diastolic
31 (DBP) blood pressure measurements were taken using a sphygmomanometer and
32 stethoscope and were averaged for analysis. A third measurement was taken only
33 when the difference between the two measurements was greater than 5 mm Hg,
34 and the readings were averaged for analysis. A 5-min relaxation period between
35 measurements was maintained for all subjects. Prior medical records (e.g., use
36 of antihypertensive drugs) regarding blood pressure was also considered. Mean
37 arterial pressure (MAP) was calculated accordingly. Subjects were considered hy-
38 pertensive if they had an SBP greater than 160 mm Hg and/or a DBP greater than
39 90 mm Hg or were currently using any antihypertensive medication. The rest of
40 the subjects were considered normotensive.
41
42 Genotyping. DNA was extracted from isolated serum using a QIAamp Kit (Qi-
43 agen, Hilden, Germany). Genomic DNA was amplified using the polymerase chain
44 reaction (PCR) with a thermal cycler (Bio-Rad Corporation, Hercules, California).

BOOKCOMP, Inc. — Wayne State University Press / Page 305 / final proof / Human Biology 80-3 / June 2008
 306 / das et al.

1 Table 1. Characteristics of the Participants (n = 350)

2
Males (n = 184) Females (n = 166)
3
Variable Mean SD Mean SD P Value
4
5 Age (yrs) 54.04 12.40 48.48 11.57 < 0.001
BMI (kg/m 2) 22.37 4.09 23.20 4.37 0.066
6
Systolic blood pressure (mm Hg) 132.97 24.02 137.21 24.52 0.104
7 Diastolic blood pressure (mm Hg) 82.22 11.41 83.48 10.55 0.286
8 Mean arterial pressure (mm Hg) 107.57 16.53 110.35 16.63 0.119
9
10
11
12
Insertion/deletion polymorphism was determined using agarose gel electrophore-
13
sis with ethidium bromide. D/D polymorphism was further reconfirmed using an [306], (4)
14
insertion-allele-specific amplification according to the standard protocol (Lind-
15
paintner et al. 1995). The following primers were used:
16
17 Lines: 78 to 132
18 Forward: 5′-GCCCTGCAGGTGTCTGCAGCATGT-3′
Reverse: 5′-GGATGGCTCTCCCCGCCTTGTCTC-3′ ———
19 7.04025pt PgVar
20 Insertion-specific, forward: 5′-TGGGACCACAGCGCCCGCCACTAC-3′
———
21 Insertion-specific, reverse: 5′-TCGCCAGCCCTCCCATGCCCATAA-3′
Normal Page
22 PgEnds: TEX
23 To study the ACE insertion/deletion polymorphism and its effect on blood
24 pressure measures, we considered DNA samples of individuals belonging to the
25 highest (90th) and the lowest (10th) percentiles of blood pressure centiles (per- [306], (4)
26 centiles).
27
28 Statistical Analyses. Descriptive statistics such as mean and standard devia-
29 tion (SD) of anthropometric and blood pressure measures were calculated by sex.
30 The sex differences in anthropometric and blood pressure variables were calcu-
31 lated using an unpaired t test. The proportion of I/I, D/D, and I/D individuals by
32 blood pressure status was also undertaken using a chi-square test. The distribution
33 and difference in genotype frequency was examined using binomial test analysis.
34 To find out the effect of genotypes on blood pressure status, we calculated the odds
35 ratio (adjusted for age) using a binary logistic regression (dependent variable was
36 blood pressure status, that is, hypertensive or normotensive).
37 All statistical analyses were computed using SPSS (PC+ version 10.0). A
38 p value less than 0.05 (two-tailed) was considered significant.
39
40
Results
41
42 The characteristics of the participants by sex are presented in Table 1. No sig-
43 nificant sex differences for BMI, SBP, DBP, and MAP were observed; age did show
44 a significant sex difference ( p < 0.001). The prevalence of essential hypertension

BOOKCOMP, Inc. — Wayne State University Press / Page 306 / final proof / Human Biology 80-3 / June 2008
 ACE Polymorphism and Hypertension in India / 307

1 Table 2 Distribution of Hypertensive and Normotensive Individuals by Age Category

2
Hypertensive Normotensive
3
Age Group (Years) Males Females Males Females Total
4
5 30–39 4 8 16 31 59
40–49 9 22 35 26 92
6
50+ 66 56 54 23 199
7 Total 105 80 79 86 350
8
9
10
11
12 by age category and sex is presented in Table 2. The prevalence of hypertension
13 was considerably higher in females (51.8%) than in males (42.9%).
14 Because there was no significant effect of sex on blood pressure measures [307], (5)
15 (results not shown), male and female samples were pooled to differentiate the high-
16 est and lowest groups (90th vs. 10th percentile). The proportions of D/D, I/I, and
17 I/D individuals according to blood pressure status are presented in Table 3. We Lines: 132 to 182
18 observed significant differences (χ 2 = 20.7; p < 0.001) in the distribution of inser-
———
19 tion/deletion genotypes by blood pressure status (hypertensive vs. normotensive).
Furthermore, we noticed significant differences in genotype frequencies between
6.76538pt PgVar
20 ———
21 the highest and lowest percentiles, with the frequency of the D/D genotype being Normal Page
22 relatively high in the 90th percentile. The frequencies of the I and D alleles were
PgEnds: TEX
23 0.259 and 0.471, respectively. The chi-square test revealed a significant differ-
24 ence for the frequency of the D allele between the percentile groups (results not
25 shown). In the 90th percentile, the frequency of the D allele was 0.600 compared [307], (5)
26 to a D allele frequency of 0.471 in the 10th percentile. The binomial test (results
27 not shown) revealed a significant difference (z value of 3.046, p < 0.05) in allele
28 frequencies between hypertensive and normotensive individuals.
29 Blood pressure measures according to the ACE insertion/deletion polymor-
30 phisms are presented in Table 4. Significantly higher SBP, DBP, and MAP were
31 recorded in D/D subjects compared to I/I and I/D subjects (Table 4). A two-way
32 comparison (Table 5) of blood pressure measures and genotypes revealed signifi-
33 cant differences between I/D and D/D individuals for SBP and DBP.
34
35
36
37 Table 3. Proportion of D/D, I/I, and I/D Individuals According to Blood Pressure Status
38 Genotype Normotensive Hypertensive Total
39
I/I 14 (40.0) 12 (34.2) 26
40 I/D 18 (51.4) 4 (11.4) 22
41 D/D 3 (8.5) 19 (54.2) 22
42 Total 35 (100) 35 (100) 70
43 χ 2 = 20.7, df 2; p < 0.001.
44 Percentages are in parentheses.

BOOKCOMP, Inc. — Wayne State University Press / Page 307 / final proof / Human Biology 80-3 / June 2008
 308 / das et al.

1 Table 4. Difference in Mean Blood Pressure According to Genotype

2
Systolic Blood Pressure Diastolic Blood Pressure
3
Genotype Mean SD Mean SD
4
5 I/I 137.35 41.71 79.58 18.76
I/D 116.82 30.47 74.50 12.94
6
D/D 165.55 31.28 93.82 13.48
7
8
9
10 The odds ratio (adjusted for age) of ACE insertion/deletion polymorphisms
11 are presented in Table 6. We observed that the odds of being hypertensive for the
12 D/D genotype was 7.483 (95% CI = 1.746, 30.192) compared to the I/I genotype
13 (odds ratio = 1).
14 [308], (6)
15
16 Discussion
17 In the present investigation we examined whether a significant association Lines: 182 to 247
18 exists between ACE insertion/deletion polymorphisms and hypertension in adult ———
19 Asian Indians living in the eastern part of Calcutta. The prevalence of hyperten- -6.6076pt PgVar
20 sion was comparatively higher in females (51.8%) than in males (42.9%). This ———
21 fact reiterates that Indian woman may be comparatively worse off than men in Normal Page
22 many aspects of risk for CVD (Ghosh 2007). Importantly, the D/D genotype was PgEnds: TEX
23 significantly associated with essential hypertension. Furthermore, a significant dif-
24 ference in average blood pressure was observed among individuals with the D/D
25 genotype compared to the I/I or I/D genotype. However, no significant difference [308], (6)
26 was observed for SBP and DBP between I/I and I/D individuals. Moreover, a
27 significant difference in both allele ( p < 0.05) and genotype (< 0.001) frequencies
28 exists between the highest (90th) and the lowest (10th) percentile groups with
29 respect to blood pressure measures. It seems reasonable to argue that ACE in-
30 sertion/deletion polymorphism is playing an important role in regulation of blood
31 pressure in this population. Apparently, the D/D genotype predisposes Asian Indi-
32 ans to hypertension and presumably to metabolic syndrome. Further studies incor-
33 porating a representative sample size of Asian Indians across the Indian diaspora
34 are required to further our understanding of the genetic etiology of essential hy-
35 pertension in this population.
36
37
38 Table 5. Two-Way Comparison of Systolic and Diastolic Blood Pressure by Genotype
39
Systolic Blood Pressure Diastolic Blood Pressure
40
Two-Way Comparison t p t p
41
42 I/I vs. I/D 1.915 0.0617 1.072 0.2894
43 I/I vs. D/D 2.609 0.0122 2.968 < 0.0047
I/D vs. D/D 5.234 < 0.0001 4.850 < 0.0001
44

BOOKCOMP, Inc. — Wayne State University Press / Page 308 / final proof / Human Biology 80-3 / June 2008
 ACE Polymorphism and Hypertension in India / 309

1 Table 6. Odds Ratio (Adjusted for Age) of I/D and D/D Genotypes vs. Hypertension
2 (Dependent Variable Is Hypertensive vs. Normotensive)
3 95% Confidence Interval
4 Genotype Odds Ratio a p Value Lower Limit Upper Limit
5
I/D 0.258 0.047 0.160 0.980
6
D/D 7.483 0.0007 1.746 30.192
7
a. Odds ratio was computed considering the odds of I/I genotype = 1.
8
9
10
11 Investigations across populations provide a substantial database on ACE
12 insertion/deletion polymorphism and associated hypertension (Table 7). Ethnic
13 background appears to influence ACE gene insertion/deletion polymorphism glob-
14 ally. The analysis of distribution of the ACE polymorphism and activity within and [309], (7)
15 across the major human groups appears to be useful in identifying the mechanisms
16 contributing to the emergence of common chronic diseases, such as hypertension,
17 CHD, type 2 diabetes mellitus, and diabetic nephropathy (as part of RAS). Such Lines: 247 to 341
18 comparative studies could be of significant clinical relevance and utility in the ———
19 upcoming field of pharmacogenomics (Pasha et al. 2002). -0.34685pt PgVar
20 This study’s major limitation was that it was performed on a relatively small ———
21 sample size and therefore is not representative of Asian Indians. Because of con- Normal Page
22 siderable ethnic and cultural heterogeneity in Asian Indians, it is necessary to study PgEnds: TEX
23 other ethnic groups to see whether the observed trends exist among them also.
24 The lack of assessment of plasma angiotensin and angiotensin-converting enzyme
25 further limits the study results. [309], (7)
26
27
Acknowledgments The DNA typing of the present study was carried out at the Human
28 Genetic Engineering Research Centre (HGERC), Calcutta, India. We are thankful to all the
29 participants for their sincere cooperation during data collection.
30
31
32 Received 17 September 2007; revision received 5 May 2008.
33
34 Literature Cited
35
Ajay, V. S., R. Gupta, J. Panniyammakkal et al. 2002. National Cardiovascular Disease Database.
36
Delhi: Ministry of Health and Family Welfare, Government of India, and Geneva: World Health
37 Organization.
38 Ashavaid, T. F., K. K. Shalia, A. A. Kondkar et al. 2002. Gene polymorphism and coronary risk factors
39 in Indian population. Clin. Chem. Lab. Med. 40:975–985.
40 Ashavaid, T. F., K. K. Shalia, K. G. Nair et al. 2000. ACE and AT1R gene polymorphisms and hyper-
tension in Indian population. J. Clin. Lab. Anal. 14:230–237.
41
Barbalic, M., T. Skaric-Juric, F. Cambien et al. 2006. Gene polymorphisms of the renin-angiotensin
42 system and early development of hypertension. Am. J. Hypertens. 19:837–842.
43 Barley, J., A. Blackwood, N. Carter et al. 1994. Angiotensin converting enzyme insertion/deletion
44 polymorphism: Association with ethnic origin. J. Hypertens. 12:955–957.

BOOKCOMP, Inc. — Wayne State University Press / Page 309 / final proof / Human Biology 80-3 / June 2008
 9
8
7
6
5
4
3
2
1

44
43
42
41
40
39
38
37
36
35
34
33
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
Table 7. Association Studies Between ACE Insertion/Deletion (I/D) Polymorphism
and Essential Hypertension
Study Phenotype Studied Genes Screened Population(s) Studied Nature of Study Major Findings
Barnas et al. Type 2 diabetes ACE (I/D) Austrians Case-control ACE I/D genotype was an independent risk factor
(1997) mellitus, for the prevalence of diabetic nephropathy. D/D
hypertension, and genotype was more frequent in patients with
310 / das et al.

metabolic control diabetic nephropathy along with high blood

pressure and renal disease.
Cooper et al. Obesity and blood ACE, AGT Jamaicans Population Obesity may alter the levels of ACE and AGT and
(1997) pressure may provide a pathway through which obesity
promotes elevated blood pressure.
Mastana and Essential ACE (I/D) Indians (Sikhs) Population Positive association between ACE I/D
Nunn (1997) hypertension polymorphism and essential hypertension.
Chowdhury et al. Essential ACE (I/D) Bangladeshis Case-control No significant association of ACE I/D
(1998) hypertension polymorphism and hypertension.
Morshed et al. Essential ACE (I/D) Bangladeshis Population Positive association between ACE I/D
(2002) hypertension polymorphism and essential hypertension.
Strazzullo et al. Abdominal ACE (I/D), AGT Italians Population ACE I/D polymorphism was a significant predictor
(2003) adiposity (M235T), AGTR1 (males only) of overweight and abdominal adiposity in men.
(A1166C) D/D homozygosity was associated with larger
increase in body weight, blood pressure in aging
individuals, and higher incidence of overweight.
Zhu et al. (2003) Essential RAS European Americans Case-control Association was confirmed in haplotype analysis for
hypertension and African REN, AGTR1, and ACE in African Americans but
Americans was less significant in European Americans.
Individual variation in the RAS genes may
contribute to hypertension risk.

BOOKCOMP, Inc. — Wayne State University Press / Page 310 / final proof / Human Biology 80-3 / June 2008
Ismail et al. Essential ACE (I/D) Pakistanis Case-control Positive association between ACE I/D
(2004) hypertension polymorphism and essential hypertension.
Present study Essential ACE (I/D) Asian Indians Population Odds of being hypertensive were 7.48 in D/D
(2008) hypertension (Bengalees) individuals.
*
———
———

[310], (8)
[310], (8)

Normal Page
PgEnds: TEX
Lines: 341 to 341

516.0pt PgVar
 ACE Polymorphism and Hypertension in India / 311

1 Barnas, U., A. Schmidt, A. Illievich et al. 1997. Evaluation of risk factors for the development of
2 nephropathy in patients with IDDM: Insertion/deletion angiotensin converting enzyme gene
3 polymorphism, hypertension, and metabolic control. Diabetologia 40:327–331.
Baudin, B. 2002. New aspects on angiotensin-converting enzyme: From gene to disease. Clin. Chem.
4 Lab. Med. 40:256–265.
5 Chowdhury, A. H., M. M. Zaman, K. M. Haque et al. 1998. Association of angiotensin converting en-
6 zyme (ACE) gene polymorphism with hypertension in a Bangladeshi population, Bangladesh.
7 Med. Res. Counc. Bull. 24:55–59.
8 Cooper, R., N. McFarlane-Anderson, F. I. Berinett et al. 1997. ACE, angiotensinogen, and obesity: A
potential pathway leading to hypertension. J. Hum. Hypertens. 11:107–111.
9 Crews, D. E., and S. L. Williams. 1999. Molecular aspects of blood pressure regulation. Hum. Biol.
10 71:475–503.
11 Di Pasquale, P., S. Cannizzaro, and S. Paterna. 2004. Does angiotensin-converting enzyme gene poly-
12 morphism affect blood pressure? Findings after 6 years of follow-up in healthy subjects. Eur.
13 J. Heart Fail. 6:11–16.
Dubey, V. D. 1954. A study on blood pressure amongst industrial workers of Kanpur. J. Indian State [311], (9)
14
Med. Assoc. 23:495–498.
15 Ghosh, A. 2007. Comparison of anthropometric, metabolic, and dietary fatty acids profiles in lean and
16 obese dyslipidemic Asian Indian subjects. Eur. J. Clin. Nutr. 61:412–419.
17 Gopinath, N., S. L. Chadha, P. Jain et al. 1994. An epidemiological study of obesity in adults in the Lines: 341 to 384
18 urban population of Delhi. J. Assoc. Physicians India 42:212–215.
———
19 Gupta, R., V. P. Gupta, M. Sharna et al. 2002. Prevalence of coronary heart disease and risk factors in
an urban Indian population. Indian Heart J. 54:59–66. 6.0pt PgVar
20 Gupta, R., H. Prakash, S. Majumdar et al. 1995. Prevalence of coronary heart disease and coronary ———
21 risk factors in an urban population of Rajasthan. Indian Heart J. 47:331–338. Normal Page
22 Gupta, R., M. Sarna, J. Thanvi et al. 2004. High prevalence of multiple coronary risk factors in Punjabi PgEnds: TEX
23 Bhatia community. Indian Heart J. 56:646–652.
24 Hazarika, N. C., D. Biswas, K. Narain et al. 2002. Hypertension and its risk factors in tea garden
workers of Assam. Natl. Med. J. India 15(2):63–68.
25 [311], (9)
Higaki, J., S. Baba, T. Katsuya et al. 2000. Deletion allele of angiotensin converting enzyme gene in-
26 creases risk of essential hypertension in Japanese men: The Suita Study. Circulation 101:2060–
27 2065.
28 Ismail, M., N. Akhtar, M. Nasir et al. 2004. Association between the angiotensin-converting enzyme
29 gene insertion/deletion polymorphism and essential hypertension in young Pakistani patients.
J. Biochem. Mol. Biol. 37:552–555.
30
Jimenez, P. M., C. Conde, A. Casanegra et al. 2007. Association of ACE genotype and predominantly
31 diastolic hypertension: A preliminary study. J. Renin-Angiotensin-Aldosterone Syst. 8:42–44.
32 Lindpaintner, K., M. A. Pfeffer, and R. Kreutz. 1995. A prospective evaluation of an angiotensin con-
33 verting enzyme gene polymorphism and the risk of ischemic heart disease. New Engl. J. Med.
34 332:706–711.
35 Lohman, T. G., A. F. Roche, and R. Martorell. 1988. Anthropometric Standardization Reference Man-
ual. Champaign, IL: Human Kinetics.
36 Mastana, S., and J. Nunn. 1997. Angiotensin-converting enzyme deletion polymorphism is associated
37 with hypertension in a Sikh population. Hum. Hered. 47:250–253.
38 Mattace-Raso, F. U., M. P. Sie, T. J. van der Cammen et al. 2007. Insertion/deletion gene polymor-
39 phism of the angiotensin-converting enzyme and blood pressure changes in older adults: The
40 Rotterdam Study. J. Hum. Hypertens. 21:736–740.
McKeigue, P. M., B. Shah, and M. G. Marmot. 1991. Relation of central obesity and insulin resistance
41
with high diabetes prevalence and cardiovascular risk in South Asians. Lancet 337:382–386.
42 Morshed, M., H. Khan, and S. Akhteruzzaman. 2002. Association between angiotensin-I converting
43 enzyme polymorphism and hypertension in selected individuals of the Bangladeshi population.
44 J. Biochem. Mol. Biol. 35:251–254.

BOOKCOMP, Inc. — Wayne State University Press / Page 311 / final proof / Human Biology 80-3 / June 2008
 312 / das et al.

1 Nair, K. G., K. K. Shalia, T. F. Ashavaid et al. 2003. Coronary heart disease, hypertension, and an-
2 giotensinogen gene variants in Indian population. J. Clin. Lab. Anal. 12:411–418.
Pasha, M. A., A. P. Khan, R. Kumar et al. 2002. Variations in angiotensin-converting enzyme gene
3
insertion/deletion polymorphisms in Indian populations of different ethnic origins. J. Biosoc.
4 Sci. 27:67–70.
5 Renner, W., E. Pabst, B. Paulweber et al. 2002. The angiotensin-converting-enzyme insertion/deletion
6 polymorphism is not a risk factor for peripheral arterial disease. Atherosclerosis 165:175–178.
7 Rigat, B., C. Hubet, F. Alhenc-Gelas et al. 1990. An insertion-deletion polymorphism in the angio-
tensin-I converting enzyme gene accounting for half the variance of serum enzyme levels. J.
8
Clin. Invest. 86:1343–1346.
9 Schut, A. F. C., G. S. Bleumink, B. H. C. Stricker et al. 2004. Angiotensin converting enzyme inser-
10 tion/deletion polymorphisms and the risk of heart failure in hypertensive subjects. Eur. Heart
11 J. 25:2143–2148.
12 Singh, P. P., I. Naz, A. Gilmour et al. 2006. Association of APOE (Hha1) and ACE (I/D) gene polymor-
phisms with type 2 diabetes mellitus in northwest India. Diabetes Res. Clin. Pract. 74:95–102. [Last Page]
13
Slowik, A., T. Dziedic, J. Pera et al. 2007. ACE genotype, risk, and causal relationship to stroke:
14 [312], (10)
Implications for treatment. Curr. Treat. Options Cardiovasc. Med. 9:198–204.
15 Strazzullo, P., R. Iacone, L. Iacoviello et al. 2003. Genetic variation in the renin-angiotensin system and
16 abdominal adiposity in men: The Olivetti Prospective Heart Study. Ann. Intern. Med. 138:17–
17 23. Lines: 384 to 418
Tai, E. S., and C. E. Tan. 2004. Genes, diet, and serum lipid concentrations: Lessons from ethnically
18 ———
diverse populations and their relevance to coronary heart disease in Asia. Curr. Opin. Lipidol.
19 15(1):5–12. 134.264pt PgVar
20 Thomas, G. N., R. P. Young, B. Tomlinson et al. 2000. Renin-angiotensin-aldosterone system gene ———
21 polymorphisms and hypertension in Hong Kong Chinese. Clin. Exp. Hypertens. 22:87–97. Normal Page
22 Todoroki, M., J. Minami, T. Ishimitsu et al. 2003. Relation between the angiotensin-converting en-
zyme insertion/deletion polymorphism and blood pressure in Japanese male subjects. J. Hum.
PgEnds: TEX
23
Hypertens. 17:713–718.
24 Tripathi, G., P. Dharmani, F. Khan et al. 2006. High prevalence of ACE DD genotype among North
25 Indian end-stage renal disease patients. BMC Nephrol. 17:7–15. [312], (10)
26 Vassilikioti, S., M. Doumas, S. Douma et al. 1996. Angiotensin converting enzyme gene polymorphism
27 is not related to essential hypertension in a Greek population. Am. J. Hypertens. 9:700–702.
Xu, Q., Y. H. Wang, W. J. Tong et al. 2004. Interaction and relationship between angiotensin converting
28
enzyme gene and environmental factors predisposing to essential hypertension in Mongolian
29 population of China. Biomed. Environ. Sci. 17:177–186.
30 Zee, R. Y., P. M. Ridker, M. J. Stampfer et al. 1999. Prospective evaluation of the angiotensin converting
31 enzyme insertion/deletion polymorphism and the risk of stroke. Circulation 99:331–333.
32 Zhu, X., Y. P. Chang, D. Yan et al. 2003. Associations between hypertension and genes in the renin-
angiotensin system. Hypertension 41:1027–1034.
33
34
35
36
37
38
39
40
41
42
43
44

BOOKCOMP, Inc. — Wayne State University Press / Page 312 / final proof / Human Biology 80-3 / June 2008