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1.  Blood pressure percentiles by age and height for non-overweight Chinese children and adolescents: analysis of the china health and nutrition surveys 1991–2009 
BMC Pediatrics  2013;13:195.
Background
Hypertension is an important health problem in China and raised blood pressure in children may lead to future hypertension. Accordingly we aimed to provide a reference blood pressure table for age, gender and height in Chinese children.
Methods
A reference sample of subjects was drawn from the Chinese Health and National Survey 1999–2009 aged 7–17 years after excluding overweight and obese children, the 50th, 90th and 95th percentiles of systolic and diastolic blood pressure (SBP and DBP)are presented corrected for height and age by gender. These values are compared with existing Chinese and US recommendations.
Results
Results for the 50th, 90th and 95th percentile of SBP and DBP for 6245 boys and 5707 girls were presented by age and height percentiles. These observations were lower than existing Chinese recommendations before 13 years of age at median heightbut went higher in those >13 years old. At same age and height, SBP levels of American children were overall higher than Chinese counterparts from this study by average 9–10 mm Hg, but DBP did not show overall or significant difference.
Conclusions
The first height-specific blood pressure reference values are proposed for Chinese children and adolescents aged 7–17 years. These are lower than existing US reference values and current Chinese cutoffs.
doi:10.1186/1471-2431-13-195
PMCID: PMC4222552  PMID: 24274040
Adolescents; Blood pressure; Hypertension; Prevention; Reference
2.  Body mass index in Saudi Arabian children and adolescents: a national reference and comparison with international standards 
Annals of Saudi Medicine  2009;29(5):342-347.
BACKGROUND AND OBJECTIVES:
Because there are no reference standards for body mass index (BMI) in Saudi children, we established BMI reference percentiles for normal Saudi Arabian children and adolescents and compared them with international standards.
SUBJECTS AND METHODS:
Data from a stratified multistage probability sample were collected from the 13 health regions in Saudi Arabia, as part of a nationwide health profile survey of Saudi Arabian children and adolescents conducted to establish normal physical growth references. Selected households were visited by a trained team. Weight and length/height were measured and recorded following the WHO recommended procedures using the same equipment, which were subjected to both calibration and intra/interobserver variations.
RESULTS:
Survey of 11 874 eligible households yielded 35 275 full-term and healthy children and adolescents who were subjected to anthropometric measurements. Four BMI curves were produced, from birth to 36 months and 2 to 19 years for girls and boys. The 3rd, 5th, 10th, 25th, 50th, 75th, 85th, 90th, 95th, and 97th percentiles were produced and compared with the WHO and CDC BMI charts. In the higher percentiles, the Saudi children differed from Western counterparts, indicating that Saudi children have equal or higher BMIs.
CONCLUSION:
The BMI curves reflect statistically representative BMI values for Saudi Arabian children and adolescents.
doi:10.4103/0256-4947.55162
PMCID: PMC3290051  PMID: 19700890
3.  The Relation of Body Mass Index and Blood Pressure in Iranian Children and Adolescents Aged 7–18 Years Old 
Iranian Journal of Public Health  2010;39(4):126-134.
Background:
The obesity and hypertension are the major risk factors of several life threatening diseases. The present study was aimed to investigate the relation between body mass index (BMI) the validated index of adiposity and different aspect of blood pressure (BP).
Methods:
Systolic and diastolic blood pressures and also weight and height of 7 to 18 years old children and adolescent collected in 2002 and 2004 respectively. Data was consisted of 14865 schoolchildren and adolescents from representative sample of country. BMI was classified according to CDC 2000 standards into normal (BMI<85th percentile), at risk of overweight (BMI≥85th and <95th percentile) and overweight (BMI≥95th percentile). Then, age-sex specific prevalence of being overweight was derived. ANOVA was used to investigate the effect of BMI on systolic blood pressure and diastolic blood pressure and mean arterial pressure of participants.
Results:
Mean systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial blood pressure (MAP) significantly increased with BMI (P< 0.0001) and age groups (P< 0.0001), and was significantly (P< 0.0001) higher in boys than girls especially in older ages. (P< 0.0001, interaction of age and BMI level). The proportion of being overweight was significantly higher in boys than girls was (7.4% vs. 3.6%; P< 0.0001).
Conclusion:
There is an association between BP and BMI in children and adolescence. SBP, DBP and MAP are associated with rise in BMI and age, which was lower in girls. This data can provide basics for public health policy makers and primary prevention policies in the country.
PMCID: PMC3481696  PMID: 23113046
Blood pressure; Body mass index (BMI); Relation; Children; Adolescents
4.  Blood Pressure Standards for Shiraz (Southern Iran) School Children in Relation to Height 
Iranian Journal of Pediatrics  2012;22(2):223-230.
Objective
This study aims at providing local reference values for blood pressure by height and determining distribution pattern of systolic and diastolic blood pressure in 6.5-11.5 elementary school children for the first time in Shiraz (Southern Iran).
Methods
Height, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured with standard methods in 2270 healthy school children (1174 boys, 1096 girls) who were selected by multi-stage random sampling in 2003-2004 academic years. We produced blood pressure percentiles by height percentiles using Healy-Rasbash-Yang method.
Findings
The blood pressure (both systolic and diastolic) tends to increase with age, but after adjusting the measurements for height no significant correlation was found between either systolic blood pressure or diastolic blood pressure and age (r=-0.03 and P=0.15 for systolic blood pressure, r=-0.005 and P=0.8 for diastolic blood pressure). Then systolic and diastolic blood pressure percentile values by age and height percentiles, and blood pressure smoothed centiles by height in 6.5-11.5 years school children were derived.
Conclusion
Due to genetic, cultural and environmental differences among populations, it is suggested to use local blood pressure standards in Iran. We produced blood pressure percentiles by height instead of age because it seems that it would lead to better evaluation for real hypertensive diagnosis.
PMCID: PMC3446070  PMID: 23056890
Blood pressure; Height; Age; Children; Local Reference Value; Percentile
5.  Life Course Trajectories of Systolic Blood Pressure Using Longitudinal Data from Eight UK Cohorts 
PLoS Medicine  2011;8(6):e1000440.
Analysis of eight population-based and occupational cohorts from the UK reveals the patterns of change of blood pressure in the population through the life course.
Background
Much of our understanding of the age-related progression of systolic blood pressure (SBP) comes from cross-sectional data, which do not directly capture within-individual change. We estimated life course trajectories of SBP using longitudinal data from seven population-based cohorts and one predominantly white collar occupational cohort, each from the United Kingdom and with data covering different but overlapping age periods.
Methods and Findings
Data are from 30,372 individuals and comprise 102,583 SBP observations spanning from age 7 to 80+y. Multilevel models were fitted to each cohort. Four life course phases were evident in both sexes: a rapid increase in SBP coinciding with peak adolescent growth, a more gentle increase in early adulthood, a midlife acceleration beginning in the fourth decade, and a period of deceleration in late adulthood where increases in SBP slowed and SBP eventually declined. These phases were still present, although at lower levels, after adjusting for increases in body mass index though adulthood. The deceleration and decline in old age was less evident after excluding individuals who had taken antihypertensive medication. Compared to the population-based cohorts, the occupational cohort had a lower mean SBP, a shallower annual increase in midlife, and a later midlife acceleration. The maximum sex difference was found at age 26 (+8.2 mm Hg higher in men, 95% CI: 6.7, 9.8); women then experienced steeper rises and caught up by the seventh decade.
Conclusions
Our investigation shows a general pattern of SBP progression from childhood in the UK, and suggests possible differences in this pattern during adulthood between a general population and an occupational population.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
About a third of US and UK adults have high blood pressure (hypertension). Although hypertension has no obvious symptoms, it can lead to life-threatening heart attacks, stroke, and other forms of cardiovascular disease (CVD). It is diagnosed by measuring blood pressure—the force that blood moving around the body exerts on the inside of large blood vessels. Blood pressure is highest when the heart is pumping out blood (systolic blood pressure [SBP]) and lowest when the heart is re-filling with blood (diastolic blood pressure [DBP]). Normal adult blood pressure is defined as an SBP of less than 130 millimeters of mercury (mm Hg) and a DBP of less than 85 mm Hg (a blood pressure of 130/85). A reading of more than 140/90 indicates hypertension. Many factors affect blood pressure, but overweight people and individuals who eat fatty or salty food are at high risk of developing hypertension. Moreover, blood pressure tends to increase with age. Mild hypertension can often be corrected by making lifestyle changes, but many people take antihypertensive drugs to reduce their blood pressure.
Why Was This Study Done?
Several trials have indicated that SBP is an important, modifiable risk factor for CVD. But, to determine the best way to prevent CVD, it is important to understand how SBP changes through life and how lifestyle factors affect this age-related progression. Textbook descriptions of age-related changes in SBP are based on studies that measured SBP at a single time point in groups (cohorts) of people of different ages. However, such “cross-sectional” studies do not capture within-individual changes in SBP and may be affected by environmental effects related to specific historical periods. The best way to measure age-related changes in SBP is through longitudinal studies in which SBP is repeatedly measured over many years in a single cohort. Such studies are underway, but it will be some decades before individuals in these studies reach old age. In this study, therefore, the researchers use data from multiple UK cohorts that had repeated SBP measurements taken over different but overlapping periods of life to investigate the life course trajectory of SBP.
What Did the Researchers Do and Find?
The researchers used statistical models to analyze data from longitudinal studies of SBP in seven population-based cohorts (the participants were randomly chosen from the general population) and in one occupational cohort (civil servants). SBP measurements were available for 30,372 individuals with ages spanning from seven years to more than 80 years. The researchers' analysis revealed four phases of SBP change in both sexes: a rapid increase in SBP during adolescent growth, a gentler increase in early adulthood, a midlife acceleration beginning in the fourth decade of life, and a period in late adulthood when SBP increases slowed and then reversed. This last phase was less marked when people taking antihypertensive drugs were excluded from the analysis. After adjusting for increases in body mass index (a measure of body fat) during adulthood, the magnitude of the SBP age-related changes was similar but the average SBP at each age was lower. Compared to the population-based cohorts, the occupational cohort had a lower average SBP, a shallower annual increase in SBP, and a later midlife acceleration, possibly because of socially determined modifiable SBP-related factors such as diet and lifestyle. Finally, although women had lower SBPs in early adulthood than men, they experienced steeper midlife SBP rises (probably because of a menopause-related effect on salt sensitivity) so that by the seventh decade of life, men and women had similar average SBPs.
What Do These Findings Mean?
These findings describe the general pattern of age-related progression of SBP from early childhood in the UK. The findings may not be generalizable because other populations may be exposed to different distributions of modifiable factors. In addition, their accuracy may be affected by differences between cohorts in how SBP was measured. Nevertheless, these findings—in particular, the slower midlife increase in SBP in the occupational cohort than in the population-based cohorts—suggest that the key determinants of age-related increases in blood pressure are modifiable and could be targeted for CVD prevention. Further research is now needed to identify exactly which factors affect the life course trajectory of SBP and to discover when these factors have their greatest influence on SBP.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000440.
The US National Heart Lung and Blood Institute has patient information about high blood pressure (in English and Spanish)
The American Heart Association provides information on high blood pressure and on cardiovascular diseases (in several languages)
The UK National Health Service Choices Web site also provides detailed information for patients about hypertension and about cardiovascular disease
MedlinePlus provides links to further information about high blood pressure, heart disease, and stroke (in English and Spanish)
doi:10.1371/journal.pmed.1000440
PMCID: PMC3114857  PMID: 21695075
6.  Distribution of blood pressure in school going children in rural area of Wardha district, Maharashatra, India 
Annals of Pediatric Cardiology  2008;1(2):101-106.
Objectives:
To study the blood pressure of school going children in a rural area and its relationship with the anthropometric indices.
Methods:
A prospective, cross-sectional study was carried out from November 2006 to December 2007 in the school going children between the ages of 6–17 years from eight different schools in the rural areas of Wardha district. The height, weight, systolic blood pressure (SBP), and diastolic blood pressure (DBP) were recorded in both sexes followed by complete clinical examination with special emphasis on cardiovascular system. Hypertension (HT) was defined as SBP or DBP exceeding the 95th percentile for age, gender, and height on at least three separate occasions, 1–3 weeks apart. SPSS software was used to analyze the data. Coefficient correlation tests were employed to assess the relation between BP and anthropometric variables.
Results:
Of 2643 school children, 1227 were boys and 1416 girls with a male to female ratio of 1:1.16. In boys, SBP and DBP increased with age except a marginal decline in SBP at the age of 17 years (−0.09) and decrease in the DBP (−1.29) at 16 years of age. In girls, SBP and DBP also increased with age except at 11 years, wherein there was a mild decrease in SBP (−0.09) as well as the DBP (−0.24). Correlation coefficient analysis showed highly significant positive correlation of height with SBP and DBP. There was a significant correlation of SBP and DBP with the weight, and body mass index (BMI). The prevalence of HT was 5.75% (i.e., 3.25% for systolic HT and 2.49% for diastolic HT).
Conclusion:
We recommend that there is a need for checking BP to detect HT in children, so that remedial measures can be initiated as early as possible.
doi:10.4103/0974-2069.43874
PMCID: PMC2840757  PMID: 20300250
Blood pressure; children; hypertension; prevalence study
7.  Blood pressure and associated factors in a North African adolescent population. a national cross-sectional study in Tunisia 
BMC Public Health  2012;12:98.
Background
In southern and eastern Mediterranean countries, changes in lifestyle and the increasing prevalence of excess weight in childhood are risk factors for high blood pressure (BP) during adolescence and adulthood. The aim of this study was to evaluate the BP status of Tunisian adolescents and to identify associated factors.
Methods
A cross-sectional study in 2005, based on a national, stratified, random cluster sample of 1294 boys and 1576 girls aged 15-19 surveyed in home visits. The socio-economic and behavioral characteristics of the adolescents were recorded. Overweight/obesity were assessed by Body Mass Index (BMI) from measured height and weight (WHO, 2007), abdominal obesity by waist circumference (WC). BP was measured twice during the same visit. Elevated BP was systolic (SBP) or diastolic blood pressure (DBP) ≥ 90th of the international reference or ≥ 120/80 mm Hg for 15-17 y., and SBP/DBP ≥ 120/80 mm Hg for 18-19 y.; hypertension was SBP/DBP ≥ 95th for 15-17 y. and ≥ 140/90 mm Hg for 18-19 y. Adjusted associations were assessed by logistic regression.
Results
The prevalence of elevated BP was 35.1%[32.9-37.4]: higher among boys (46.1% vs. 33.3%; P < 0.0001); 4.7%[3.8-5.9] of adolescents had hypertension. Associations adjusted for all covariates showed independent relationships with BMI and WC: - obesity vs. no excess weight increased elevated BP (boys OR = 2.1[1.0-4.2], girls OR = 2.3[1.3-3.9]) and hypertension (boys OR = 3.5[1.4-8.9], girls OR = 5.4[2.2-13.4]), - abdominal obesity (WC) was also associated with elevated BP in both genders (for boys: 2nd vs. 1st tertile OR = 1.7[1.3-2.3], 3rd vs.1st tertile OR = 2.8[1.9-4.2]; for girls: 2nd vs. 1st tertile OR = 1.6[1.2-2.1], 3rd vs.1st tertile OR = 2.1[1.5-3.0]) but only among boys for hypertension. Associations with other covariates were weaker: for boys, hypertension increased somewhat with sedentary lifestyle, while elevated BP was slightly more prevalent among urban girls and those not attending school.
Conclusion
Within the limits of BP measurement on one visit only, these results suggest that Tunisian adolescents of both genders are likely not spared from early elevated BP. Though further assessment is likely needed, the strong association with overweight/obesity observed suggests that interventions aimed at changing lifestyles to reduce this main risk factor may also be appropriate for the prevention of elevated BP.
doi:10.1186/1471-2458-12-98
PMCID: PMC3331812  PMID: 22305045
Adolescent; Blood pressure; Tunisia; Prevalence; Risk factors
8.  The association of blood pressure with body mass index and waist circumference in normal weight and overweight adolescents 
Korean Journal of Pediatrics  2014;57(2):79-84.
Purpose
Overweight can be defined by the body mass index (BMI) and is likely associated with an increased cardiovascular disease risk. However, waist circumference (WC), a central adiposity index, may be a better indicator of cardiovascular disease risk. Studies comparing the effects of BMI and WC on cardiovascular risk factors, such as high blood pressure (BP), are rare in adolescents.
Methods
We analyzed the correlations of BMI and WC with BP in 3,363 Korean adolescents (aged 10-19 years), using data from the Korean National Health and Nutrition Examination Surveys (2009-2011).
Results
Systolic BP (SBP) in both sexes and diastolic BP (DBP) in boys were higher in the high BMI (>85th percentile) and high WC (>90th percentile) groups. High BMI and high WC were positively correlated with high SBP (>90th percentile) in both sexes, and high DBP (>90th percentile), in boys. BMI maintained its positive associations with SBP, DBP, high SBP, and high DBP in the normal weight (BMI≤85th percentile) and overweight (BMI>85th percentile) groups in both boys and girls, as well as in all subjects of both sexes, even after adjustment for WC. However, WC did not correlate with SBP, DBP, high SBP, or high DBP after adjustment for BMI in any group in either sex.
Conclusion
In Korean adolescents, BMI correlated better with BP and high BP levels than WC. Further, BMI was positively associated with BP and high BP in the normal weight group as well as in the overweight group.
doi:10.3345/kjp.2014.57.2.79
PMCID: PMC3965799  PMID: 24678332
Blood pressure; Body mass index; Waist circumference; Adolescent; Obesity
9.  Increasing blood pressure and its associated factors in Canadian children and adolescents from the Canadian Health Measures Survey 
BMC Public Health  2012;12:388.
Background
Canada is facing a childhood obesity epidemic. Elevated blood pressure (BP) is a major complication of obesity. Reports on the impact of excess adiposity on BP in children and adolescents have varied significantly across studies. We evaluated the independent effects of obesity, physical activity, family history of hypertension, and socioeconomic status on BP in a nationally representative sample of children and adolescents.
Methods
We analysed cross-sectional data for 1850 children aged 6 to 17 years who participated in the Canadian Health Measures Survey, Cycle 1, 2007–2009. Systolic BP (SBP) and diastolic BP (DBP) were age-, sex-, and height-adjusted to z-scores (SBPZ and DBPZ). Body mass index (BMI) z-scores were calculated based on World Health Organization growth standards. Multivariate linear regression was used to evaluate the independent effects of relevant variables on SBPZ and DBPZ.
Results
For most age/sex groups, obesity was positively associated with SBP. Being obese was associated with higher DBP in adolescent boys only. The BP effect of obesity showed earlier in young girls than boys. Obese adolescents were estimated to have an average 7.6 mmHg higher SBP than normal weight adolescents. BMI had the strongest effect on BP among obese children and adolescents. Moderately active adolescent boys had higher SBP (3.9 mmHg) and DBP (4.9 mmHg) than physically active boys. Family history of hypertension showed effects on SBP and DBP in younger girls and adolescent boys. Both family income and parent education demonstrated independent associations with BP in young children.
Conclusions
Our findings demonstrate the early impact of excess adiposity, insufficient physical activity, family history of hypertension, and socioeconomic inequalities on BP. Early interventions to reduce childhood obesity can, among other things, reduce exposure to prolonged BP elevation and the future risk of cardiovascular disease.
doi:10.1186/1471-2458-12-388
PMCID: PMC3395567  PMID: 22642714
10.  The association between obesity and blood pressure in Thai public school children 
BMC Public Health  2014;14:729.
Background
The prevalence of obesity has substantially increased in the past 3 decades in both developed and developing countries and may lead to an increase in high blood pressure (BP) at an early age. This study aimed to determine the prevalence of obesity and its association with blood pressure among primary school children in central Thailand.
Methods
A cross-sectional study was conducted in two public schools in Bangkok in 2012. A total of 693 students (317 boys and 376 girls) aged 8–12 years participated voluntarily. Anthropometric measurements of weight, height, waist circumference (WC) and BP were collected. Fasting venous blood samples were obtained for biochemical analysis of fasting plasma glucose (FPG) and lipid parameters. Child nutritional status was defined by body mass index (BMI) for age based on the 2000 Center for Diseases Control and Prevention growth charts. The cutoff for abdominal obesity was WC at the 75 percentile or greater. Hypertension was defined according to the 2004 Pediatrics US blood pressure reference. Multinomial logistic regression was used to examine the relationship between high BP and obesity after controlling for other covariates.
Results
The prevalence of obese children was 30.6% for boys and 12.8% for girls (mean prevalence 20.9%). Pre-hypertension (Pre-HT) was 5.7% and 2.7% for boys and girls and hypertension (HT) was 4.7% for boys and 3.2% for girls, respectively. Children with pre-HT and HT had significantly higher body weight, height, WC, BMI, SBP, DBP, TG, and TC/HDL-C levels but lower HDL-C levels than those children with normotension. After controlling for age, sex, glucose and lipid parameters, child obesity was significantly associated with pre-HT and HT (odds rations (ORs) = 9.00, 95% CI: 3.20-25.31 for pre-HT and ORs = 10.60, 95% CI: 3.75-30.00 for HT). So also was WC (abdominal obesity) when considered alone (ORs = 6.20, 95% CI: 2.60-14.81 for pre-HT and ORs = 13.73, 95% CI: 4.85-38.83 for HT) (p-value < 0.001).
Conclusions
Obesity among school children was positively associated with higher BP. Prevention of childhood obesity should be strengthened to prevent the risk of early high BP including cardiovascular risk factors.
doi:10.1186/1471-2458-14-729
PMCID: PMC4223408  PMID: 25034700
Child obesity; High blood pressure; School children; Waist circumference
11.  Regional variations in the growth of Saudi children and adolescents 
Annals of Saudi Medicine  2009;29(5):348-356.
BACKGROUND AND OBJECTIVES:
No previous study has provided a detailed description of regional variations of growth within the various regions of Saudi Arabia. Thus, we sought to demonstrate differences in growth of children and adolescents in different regions.
SUBJECTS AND METHODS:
The 2005 Saudi reference was based on a cross-sectional representative sample of the Saudi population of healthy children and adolescents from birth to 18 years of age. Body measurements of the length, stature, weight, head circumference and calculation of the BMI were performed according to standard recommendations. Percentile construction and smoothing were performed using the LMS (lambda, mu and sigma) methodology, followed by transformation of all individual measurements into standard deviation scores. Factors such as weight for age, height for age, weight for height, and head circumference for children from birth to 3 years, stature for age, head circumference and body mass index for children between 2-18 years of age were assessed. Subsequently, variations in growth between the three main regions in the north, southwest, and center of Saudi Arabia were calculated, with the Bonferroni: method used to assess the significance of differences between regions.
RESULTS:
There were significant differences in growth between regions that varied according to age, gender, growth parameter and region. The highest variation was found between children and adolescents of the southwestern region and those of the other two regions The regression lines for all growth parameters in children <3 years of age were significantly different from one region to another reaching – 0.65 standard deviation scores for the southwestern regions (P=.001). However, the difference between the northern and central regions were not significant for the head circumference and for weight for length. For older children and adolescents a significant difference was found in all parameters except between the northern and central regions in BMI in girls and head circumference in boys. Finally, the difference in head circumference of girls between southwestern and northern regions was not significant. Such variation affected all growth parameters for both boys and girls.
CONCLUSION:
Regional variations in growth need to be taken into consideration when assessing the growth of Saudi children and adolescents.
doi:10.4103/0256-4947.55163
PMCID: PMC2860399  PMID: 19700891
12.  Lower Bone Mineral Content in Hypertensive Compared with Normotensive Overweight Latino Children and Adolescents 
American journal of hypertension  2007;20(2):190-196.
Background
In adults, hypertension has been shown to be inversely correlated with bone mineral content (BMC); however, the association between blood pressure (BP) and BMC has not been studied in pediatrics.
Methods
Total body BMC of 187 overweight (mean BMI=28.7 kg/m2) Latino children and adolescents (mean age=11.2 years) were measured using dual-energy x-ray absorptiometry. Seated systolic (SBP) and diastolic (DBP) blood pressure were measured using a standard mercury sphygmomanometer. Hypertension was defined by SBP or DBP above the 90th percentile for height, age, and gender.
Results
Partial correlations revealed an inverse association between SBP and BMC (r=- 0.24, p=0.02) in boys (n=105); results were non-significant (p=0.27) in girls (n=82). There were no significant correlations between DBP and BMC. When BMI and insulin sensitivity were adjusted for, hypertensive boys (n=21) had lower BMC (1435 versus 1636 g; p=0.03) than normotensive boys (n=84); similarly, hypertensive girls (n=25) had lower BMC (1438 versus 1618 g; p=0.02) than normotensive girls (n=57). In post-pubertal adolescents (Tanner stage 4-5; n= 48), inverse correlations were stronger (r=- 0.40, p=0.007); results were non-significant in pre-pubertal and pubertal children (Tanner stage 1-3; n=139, p=0.57). In post-pubertal girls (n=37), there were no significant correlations (p=0.14); inverse correlations in post-pubertal boys (n=11) became markedly stronger (r= -0.80, p=0.02).
Conclusion
SBP is inversely correlated with BMC in overweight adolescents; additionally, hypertensives have lower adjusted means of BMC than normotensives. These promising new findings suggest that hypertension may be a risk factor for osteopenia in overweight children and adolescents; this risk may be exacerbated in post-pubertal boys.
doi:10.1016/j.amjhyper.2006.07.014
PMCID: PMC1852456  PMID: 17261466
Pediatric; Latino; Bone Mineral Content; Blood Pressure; Osteopenia
13.  Blood pressure tables for Chinese adolescents: justification for incorporation of important influencing factors of height, age and sex in the tables 
BMC Pediatrics  2014;14:10.
Background
Elevated blood pressure (BP) in childhood was a predictor of hypertension in adulthood and contributes to the current epidemic of cardiovascular disease. It is necessary to identify abnormal BP in children and adolescents with accurate BP tables based on several crucial factors. The purpose of this study was to identify the important influencing factors of BP of Chinese adolescents.
Methods
BP, height, and body weight were assessed in 32221 normal-weight Chinese adolescents aged 12–17 years. An equal number of 6815 subjects from boys and girls were individually matched by height and age to assess the independent effect of sex on BP; and an equal number of 1422 subjects from each of the age groups (12, 13, 14, 15, 16 and 17 years) were individually matched by sex and height to estimate the independent effect of age on BP. Height of each sex and age was divided into eight height groups - ~5th, ~10th, ~25th, ~50th, ~75th, ~90th, ~95th, and 95th ~ percentiles- and the Spearman’s correlation between height percentiles and BP was used to examine the independent effect of height on BP.
Results
Boys had higher systolic BP (SBP) and diastolic BP (DBP) than girls after controlling for age and height. BP increased with age after controlling for sex and height. In each age group, both SBP and DBP increased alongside increasing height in boys and girls.
Conclusions
Sex, age and height are all independent determinants for BP levels in Chinese adolescents. It is essential to incorporate these three factors for the establishment of the BP reference tables.
doi:10.1186/1471-2431-14-10
PMCID: PMC3903007  PMID: 24433550
Adolescent; Hypertension; Blood pressure table
14.  Trends in Body Mass Index, Blood Pressure, and Serum Lipids in Japanese Children: Iwata Population-Based Annual Screening (1993–2008) 
Journal of Epidemiology  2010;20(3):212-218.
Background
Current trends in body size, blood pressure, and serum lipids in children are predictors of future disease prevalence. However, there have been no studies of blood pressure and high-density lipoprotein cholesterol (HDL-C) levels in Japanese children.
Methods
We investigated trends in body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), non-HDL-C, and HDL-C using data from annual screenings in 1993 through 2008. The subjects were 14 872 (98.8% of the target population) fifth-graders enrolled in all public schools in the Original Iwata area in Iwata City, Japan. The same examination protocol was used throughout to ensure the uniformity of quality control and the precision of assessment. Trends in the variables in relation to the calendar year were analyzed by using regression models.
Results
In boys, the 95th percentile of BMI increased by 0.09 kg/m2/year. In both sexes, the 5th percentile of BMI decreased by 0.02 to 0.03 kg/m2/year. There was a significant negative correlation between SBP and calendar year, and the 95th percentile of SBP decreased by 0.52 mm Hg/year in boys and by 0.40 mm Hg/year in girls. There was also a significant reduction DBP. However, there were no trends in TC, non-HDL-C, or HDL-C.
Conclusions
The increase in obese and underweight children in Original Iwata was consistent with the findings of a nationwide survey. Although high blood pressure and related risk factors were formerly a serious problem in Japan, blood pressure levels have decreased in schoolchildren from Iwata over the past 15 years.
doi:10.2188/jea.JE20090079
PMCID: PMC3900843  PMID: 20208399
blood pressure; child; cholesterol; epidemiology; risk factors
15.  Secular Trends in BMI and Blood Pressure Among Children and Adolescents: The Bogalusa Heart Study 
Pediatrics  2012;130(1):e159-e166.
OBJECTIVE:
The prevalence of obesity among children and adolescents increased by almost threefold from the 1970s to 2000. We examined whether these secular changes in BMI were accompanied by increases in blood pressure levels.
METHODS:
A total of 24 092 examinations were conducted among 11 478 children and adolescents (aged 5–17 years) from 1974 to 1993 in the Bogalusa Heart Study (Louisiana).
RESULTS:
The prevalence of obesity increased from 6% to 17% during this period. In contrast, only small changes were observed in levels of systolic blood pressure (SBP) and diastolic blood pressure (DBP), and neither mean nor high (based on the 90th percentile from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents) levels increased over the 20-year period. Within each race–gender group, mean levels of SBP did not change, whereas mean levels of DBP decreased by 2 mm Hg (P < .001 for trend). Levels of BMI were positively associated with levels of SBP and DBP within each of the 7 examinations, and controlling for BMI (along with other covariates) indicated that only ∼60% as many children as expected had high levels of blood pressure in 1993.
CONCLUSIONS:
Our finding that levels of DBP and SBP among children in this large sample did not increase despite the increases that were seen in obesity indicates that changes in blood pressure levels in a population do not necessarily parallel changes in obesity. Additional study of the potential characteristics that have ameliorated the expected increase in high blood pressure could lead to further reductions in risk.
doi:10.1542/peds.2011-3302
PMCID: PMC3382918  PMID: 22665416
BMI; children; DBP; hypertension; obesity; SBP; secular trends
16.  Blood Pressure over Height Ratios: Simple and Accurate Method of Detecting Elevated Blood Pressure in Children 
Background. Blood pressure (BP) percentiles in childhood are assessed according to age, gender, and height. Objective. To create a simple BP/height ratio for both systolic BP (SBP) and diastolic BP (DBP). To study the relationship between BP/height ratios and corresponding BP percentiles in children. Methods. We analyzed data on height and BP from 2006-2007 NHANES data. BP percentiles were calculated for 3775 children. Receiver-operating characteristic (ROC) curve analyses were performed to calculate sensitivity and specificity of BP/height ratios as diagnostic tests for elevated BP (>90%). Correlation analysis was performed between BP percentiles and BP/height ratios. Results. The average age was 12.54 ± 2.67 years. SBP/height and DBP/height ratios strongly correlated with SBP & DBP percentiles in both boys (P < 0.001, R2 = 0.85, R2 = 0.86) and girls (P < 0.001, R2 = 0.85, R2 = 0.90). The cutoffs of SBP/height and DBP/height ratios in boys were ≥0.75 and ≥0.46, respectively; in girls the ratios were ≥0.75 and ≥0.48, respectively with sensitivity and specificity in range of 83–100%. Conclusion. BP/height ratios are simple with high sensitivity and specificity to detect elevated BP in children. These ratios can be easily used in routine medical care of children.
doi:10.1155/2012/253497
PMCID: PMC3332207  PMID: 22577400
17.  Elevated Blood Pressure among Rural South African Children in Thohoyandou, South Africa 
Iranian Journal of Public Health  2013;42(5):489-496.
Background
Whilst there seem to be available data on blood pressure profiles of South African children, especially in urban areas, few data exist on rural children. The aims of this study were to determine the blood pressure profiles of rural South African children residing in Thohoyandou; and to examine the relationship between body mass index and blood pressure among the children.
Methods:
The study involved 296 (134 boys and 135 girls) children aged 7–13 years. Body weight and height were measured using standard procedures. Overweight was defined by body mass index (BMI) for gender and age. Blood pressure was monitored in each child thrice using validated electronic devices (Omron 7051T). Hypertension was determined as the average of three separate blood pressure readings where the systolic or diastolic blood pressure was ≥ 90th percentile for age and sex.
Results:
Overweight among the girls (4.7%) was higher compared with the boys (3.9%). Both systolic and diastolic pressures (SBP and DBP) increase with age in both sexes. The proportion of children with > 90th percentile occur at only ages 12 and 13 years. The incidence of hypertension (SBP > 90th percentile) was 0.4% and 0.2% in boys and girls, respectively. The SBP and DBP pressures significantly (P<0.05) correlate with age; body mass, height and BMI.
Conclusion:
Elevated blood pressure is prevalent among rural South African children residing in this region. Also, blood pressure increased with age in both boys and girls, and this positively correlated with age, body weight, height and BMI.
PMCID: PMC3684457  PMID: 23802106
Overweight; Body mass index; Blood pressure; Rural children; South Africa
18.  Is waist-to-height ratio a useful indicator of cardio-metabolic risk in 6-10-year-old children? 
BMC Pediatrics  2013;13:91.
Background
Childhood obesity is a public health problem worldwide. Visceral obesity, particularly associated with cardio-metabolic risk, has been assessed by body mass index (BMI) and waist circumference, but both methods use sex-and age-specific percentile tables and are influenced by sexual maturity. Waist-to-height ratio (WHtR) is easier to obtain, does not involve tables and can be used to diagnose visceral obesity, even in normal-weight individuals. This study aims to compare the WHtR to the 2007 World Health Organization (WHO) reference for BMI in screening for the presence of cardio-metabolic and inflammatory risk factors in 6–10-year-old children.
Methods
A cross-sectional study was undertaken with 175 subjects selected from the Reference Center for the Treatment of Children and Adolescents in Campos, Rio de Janeiro, Brazil. The subjects were classified according to the 2007 WHO standard as normal-weight (BMI z score > −1 and < 1) or overweight/obese (BMI z score ≥ 1). Systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting glycemia, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglyceride (TG), Homeostatic Model Assessment – Insulin Resistance (HOMA-IR), leukocyte count and ultrasensitive C-reactive protein (CRP) were also analyzed.
Results
There were significant correlations between WHtR and BMI z score (r = 0.88, p < 0.0001), SBP (r = 0.51, p < 0.0001), DBP (r = 0.49, p < 0.0001), LDL (r = 0.25, p < 0.0008, HDL (r = −0.28, p < 0.0002), TG (r = 0.26, p < 0.0006), HOMA-IR (r = 0.83, p < 0.0001) and CRP (r = 0.51, p < 0.0001). WHtR and BMI areas under the curve were similar for all the cardio-metabolic parameters. A WHtR cut-off value of > 0.47 was sensitive for screening insulin resistance and any one of the cardio-metabolic parameters.
Conclusions
The WHtR was as sensitive as the 2007 WHO BMI in screening for metabolic risk factors in 6-10-year-old children. The public health message “keep your waist to less than half your height” can be effective in reducing cardio-metabolic risk because most of these risk factors are already present at a cut point of WHtR ≥ 0.5. However, as this is the first study to correlate the WHtR with inflammatory markers, we recommend further exploration of the use of WHtR in this age group and other population-based samples.
doi:10.1186/1471-2431-13-91
PMCID: PMC3686671  PMID: 23758779
Waist-to-height ratio; Obesity; Insulin resistance; Cardiovascular disease; Body mass index
19.  Childhood Blood Pressure Trends and Risk Factors for High Blood Pressure: The NHANES experience 1988–2008 
Hypertension  2013;62(2):247-254.
The obesity epidemic in children makes it plausible that prevalence rates of elevated blood pressure are increasing over time. Yet, previous literature is inconsistent due to small sample sizes. Also, it is unclear whether adjusting for risk factors can explain longitudinal trends in prevalence of elevated blood pressure. Thus, we analyzed a population-based sample of 3,248 children in National Health and Nutrition Examination Survey (NHANES) III (1988–1994) and 8,388 children in continuous NHANES (1999–2008), ages 8–17. Our main outcome measure was elevated blood pressure (systolic blood pressure (SBP) or diastolic blood pressure (DBP) ≥ 90th percentile or SBP/DBP ≥ 120/80mmHg). We found that the prevalence of elevated blood pressure (bp) increased from NHANES III to NHANES 99-08 (Boys: 15.8% to 19.2%, p=0.057; Girls: 8.2% to 12.6%, p=0.007). Body mass index (BMI) (Q4 vs Q1, Odds Ratio (OR) =2.00, p<0.001), waist circumference (Q4 vs Q1, OR=2.14, p<0.001) and sodium (Na) intake (≥3,450mg vs <2,300mg/2,000 calories, OR=1.36, p=0.024) were independently associated with prevalence of elevated blood pressure. Also, mean SBP, but not DBP was associated with increased Na intake in children (quintile 5 (Q5) vs. quintile 1 (Q1) of Na intake, Beta = 1.25 ± 0.58, p=0.034). In conclusion, we demonstrate an association between high Na intake and elevated bp in children. After adjustment for age, gender, race/ethnicity, BMI, waist circumference and sodium intake, OR for elevated bp in NHANES 99-08 vs. NHANES III = 1.27, p=0.069.
doi:10.1161/HYPERTENSIONAHA.111.00831
PMCID: PMC3769135  PMID: 23856492
blood pressure; body mass index; NHANES; nutrition; pediatrics; sodium intake; waist circumference
20.  A survey of blood pressure in Lebanese children and adolescence 
Background:
Blood pressure varies between populations due to ethnic and environmental factors. Therefore, normal blood pressure values should be determined for different populations.
Aims:
The aim of this survey was to produce blood pressure nomograms for Lebanese children in order to establish distribution curves of blood pressure by age and sex.
Subjects and Methods:
We conducted a survey of blood pressure in 5710 Lebanese schoolchildren aged 5 to 15 years (2918 boys and 2792 girls), and studied the distribution of systolic and diastolic blood pressure in these children and adolescents. Blood pressure was measured with a mercury sphygmomanometer using a standardized technique.
Results:
Both systolic and diastolic blood pressure had a positive correlation with weight, height, age, and body mass index (r= 0.648, 0.643, 0.582, and 0.44, respectively) (P < .001). There was no significant difference in the systolic and diastolic blood pressure in boys compared to girls of corresponding ages. However, the average annual increase in systolic blood pressure was 2.86 mm Hg in boys and 2.63 mm Hg in girls, whereas the annual increase in diastolic blood pressure was 1.72 mm Hg in boys and 1.48 mm Hg in girls. The prevalence of high and high-normal blood pressure at the upper limit of normal (between the 90th and 95th percentile, at risk of future hypertension if not managed adequately), was 10.5% in boys and 6.9% in girls, with similar distributions among the two sexes.
Conclusions:
We present the first age-specific reference values for blood pressure of Lebanese children aged 5 to 15 years based on a good representative sample. The use of these reference values should help pediatricians identify children with normal, high-normal and high blood pressure.
doi:10.4297/najms.2011.324
PMCID: PMC3336929  PMID: 22540059
Blood pressure; nomograms; children; adolescents
21.  The correlation of blood pressure with height and weight in Korean adolescents aged 10-19 years; The Korean National Health and Nutrition Examination Surveys (2009-2011) 
Korean Journal of Pediatrics  2014;57(1):35-40.
Purpose
Height-specific blood pressure (BP) is the standard parameter used to diagnose childhood hypertension. However, there has been some argument that weight may be a better variable than height in the reference BP standards. Therefore, before assessing the BP status using the reference BP standards, a basic understanding of the fundamental association of weight and height with BP is required.
Methods
In the present study, we analyzed the correlation of BP with height and weight in Korean adolescents (age, 10-19 years), using data from the Korean National Health and Nutrition Examination Surveys (2009-2011).
Results
Systolic BP (SBP) was more closely correlated with weight than with height in the normal weight (body mass index [BMI], ≤85th percentile) and overweight (BMI, >85th percentile) groups and in the normal waist circumference (WC, ≤90th percentile) and high WC (>90th percentile) groups in both sexes. Diastolic BP (DBP) had a higher correlation with height than with weight in the normal weight and normal WC groups, whereas weight was more closely associated with DBP than height in the overweight and high WC groups in both boys and girls.
Conclusion
In Korean adolescents, weight had a greater effect on SBP than height in both the normal weight and overweight groups. DBP was mainly affected by height in the normal weight group, whereas weight was the major determinant of DBP in the overweight group. Therefore, it may be necessary to consider weight in the establishment of reference BP standards.
doi:10.3345/kjp.2014.57.1.35
PMCID: PMC3935111  PMID: 24578715
Blood pressure; Body height; Body weight; Adolescent; Obesity
22.  Anthropometric indices associated with dyslipidemia in obese children and adolescents: a retrospective study in isfahan 
ARYA Atherosclerosis  2011;7(1):31-39.
BACKGROUND
Central obesity is an important risk factor for cardiovascular diseases (CVD). Preventive interventions from childhood are necessary due to the increasing prevalence of childhood obesity. Body mass index (BMI), waist circumference (WC), waist to hip ratio (WHR) and waist to height ratio (WSR) are anthropometric indices for measurement of obesity. This study aimed to assess the association between these anthropometric indices and dyslipidemia in obese children and adolescents.
METHODS
This retrospective study was done on the records of 2064 obese children and adolescents aged 6-18 years at the obesity clinic, in Isfahan Cardiovascular Research center. Age, gender, weight, height, WC, hip circumference (HC), triglyceride (TG), total cholesterol (TC), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C), Fasting blood sugar (FBS), diastolic blood pressure (DBP) and systolic blood pressure (SBP) were taken from patients’ record. Receiver operating characteristics (ROC) curve and Pearson correlation were used to analyze the data.
RESULTS
2064 girls and boys aged 6-18 years were divided into 3 age groups of 6-9.9 years, 10-13.9 years and 14-18 years. Prevalence of high LDL-C, TC, TG, FBS, SBP, DBP and low HDL-C was higher among the boys compared to the girls. There was a significant association between TC, LDL-C, TG and FBS with BMI, WC, WHR and WSR. However, no significant correlation was seen between HDL-C and the four anthropometric indices.
CONCLUSION
Our study showed a significant correlation between BMI, WC and WSR with high levels of TC, TG and LDL-C in children and adolescents. Correlation between WHR and dyslipidemia in this study was significant but its predictive value was weaker than other three indices.
PMCID: PMC3347839  PMID: 22577442
Body Mass Index; Waist Circumference; Waist to Hip Ratio; Waist to Height Ratio; Dyslipidemia; Children; Adolescents
23.  C-reactive protein and its relation to high blood pressure in overweight or obese children and adolescents 
Revista Paulista de Pediatria  2013;31(3):331-337.
OBJECTIVE
To investigate the association between C-reactive protein (CRP) and high blood pressure (BP) in overweight or obese children and adolescents.
METHODS
Cross-sectional study with 184 overweight or obese children and adolescents aged from two to 18 years old, from April, 2009 to April, 2010. The classification of nutritional status used the body mass index (BMI). Based on the Centers for Disease Control and Prevention curve, individuals were classified as: overweight (BMI between the 85th-95th percentiles), obesity (BMI between 95th-97th percentiles) and severe obesity (BMI >97th percentile). Abnormal values were considered for systolic BP (SBP) and/or diastolic (DBP) if ≥90th percentile of the BP curve recommended for children and adolescents in the V Brazilian Guidelines on Hypertension, for waist circumference (WC) if ≥90th percentile of the curve established by the National Cholesterol Education Program, and for high sensitive CRP (hs-CRP) if >3mg/dL. To evaluate the association of inadequate values of CRP and the studied groups, chi-square test and analysis of variance were applied, using the Statistical Package for the Social Sciences version 17.0 and adopting a significance level of 5%.
RESULTS
Among the evaluated sample, 66.3% were female, 63.5%, non-white, 64.1% had severe obesity, 78.3% had altered WC and 70.6% presented high BP. There was a significant association of CRP high levels with altered WC and BMI ≥97th percentile. In adolescents, high CRP was related to high SBP. CRP mean values were higher in individuals with elevated SBP.
CONCLUSIONS
Inadequate values of hs-CRP were associated with severe obesity and high SBP in the studied population. These markers can be used to identify children and adolescents at higher risk for developing atherosclerosis.
doi:10.1590/S0103-05822013000300009
PMCID: PMC4182983  PMID: 24142315
arterial pressure; C-reactive protein; obesity; cardiovascular diseases; child; adolescent
24.  Age- and Gender-Specific Reference Intervals for Fasting Blood Glucose and Lipid Levels in School Children Measured With Abbott Architect c8000 Chemistry Analyzer 
Reference intervals for pubertal characteristics are influenced by genetic, geographic, dietary and socioeconomic factors. Therefore, the aim of this study was to establish age-specific reference intervals of glucose and lipid levels among local school children. This was cross-sectional study, conducted among Saudi school children. Fasting blood samples were collected from 2149 children, 1138 (53%) boys and 1011 (47%) girls, aged 6 to 18 years old. Samples were analyzed on the Architect c8000 Chemistry System (Abbott Diagnostics, USA) for glucose, cholesterol, triglycerides, HDL and LDL. Reference intervals were established by nonparametric methods between the 2.5th and 97.5th percentiles. Significant differences were observed between boys and girls for cholesterol and triglycerides levels in all age groups (P < 0.02). Only at age 6–7 years and at adolescents, HDL and LDL levels were found to be significant (P < 0.001). No significant differences were seen in glucose levels except at age 12 to 13 years. Saudi children have comparable serum cholesterol levels than their Western counterparts. This may reflect changing dietary habits and increasing affluence in Saudi Arabia. Increased lipid screening is anticipated, and these reference intervals will aid in the early assessment of cardiovascular and diabetes risk in Saudi pediatric populations.
doi:10.1007/s12291-012-0195-x
PMCID: PMC3358380  PMID: 23542765
Glucose; Lipids; Reference intervals; Children
25.  Association between body size and blood pressure in children from different ethnic origins 
Objective
To assess associations between body size and blood pressure in children (5-6 years) from different ethnic origins.
Method
Five ethnic groups of the ABCD cohort were examined: Dutch (n=1 923), Turkish (n=99), Moroccan (n=187), Black-African (n=67) and Black-Caribbean (n=121). Data on body-mass-index (BMI), waist-to-height ratio (WHtR), fat-mass-index (FMI), and systolic blood pressure (SBP) and diastolic blood pressure (DBP), were collected. Linear regression analysis with restricted cubic splines was used to examine non-linear associations between body size and blood pressure, adjusted for age, sex, height and birth weight.
Results
Ethnic differences were found in associations of BMI with SBP and DBP (SBP: p=0.001 and DBP: p=0.01) and FMI with SBP (p=0.03). BMI and FMI had a relatively large positive association with SBP in Turkish children (BMI: β=2.46mmHg; 95%CI:1.20-3.72; FMI: β=2.41mmHg; 95%CI:1.09-3.73) compared to Dutch (BMI: β=1.31mmHg; 95%CI:0.71-1.92; FMI: β=0.84mmHg; 95%CI:0.23-1.45). Black-Caribbean and Moroccan children showed high blood pressure with low BMI and FMI. Moroccan children showed higher SBP with high BMI and FMI. WHtR was positively associated with SBP and DBP, similar in all ethnic groups. Generally, strongest associations with blood pressure were found for BMI in all ethnic groups.
Conclusion
Ethnic-specific associations between BMI, and FMI and blood pressure are present at young age, with Turkish children showing the highest increase in blood pressure with increasing body size. The higher blood pressure in the Black-Caribbean and Moroccan children with low BMI needs further research. WHtR or FMI do not seem to be associated more strongly to blood pressure than BMI in any ethnic group.
doi:10.1186/1475-2840-11-136
PMCID: PMC3495733  PMID: 23126496
Blood pressure; Ethnicity; Children; Adiposity; Body size

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