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1.  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.
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.
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.
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.
The BMI curves reflect statistically representative BMI values for Saudi Arabian children and adolescents.
PMCID: PMC3290051  PMID: 19700890
2.  Blood Pressure Standards for Shiraz (Southern Iran) School Children in Relation to Height 
Iranian Journal of Pediatrics  2012;22(2):223-230.
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).
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.
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.
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
3.  Increasing blood pressure and its associated factors in Canadian children and adolescents from the Canadian Health Measures Survey 
BMC Public Health  2012;12:388.
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.
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.
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.
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.
PMCID: PMC3395567  PMID: 22642714
4.  Effects of sleep patterns and obesity on increases in blood pressure over a 5-year period: Report from the Tucson Childrens Assessment of Sleep Apnea Study 
The Journal of Pediatrics  2012;161(1):26-30.
To determine associations between body mass index (BMI) and sleep on blood pressure over a 5-year period from childhood to adolescence.
Study design
A longitudinal, community-based sample of 334 children recruited at ages 6 through 11 years. Each participant underwent in-home polysomnography initially and then 5 years later. Individual systolic (SBP) and diastolic (DBP) blood pressures were calculated at both time points during wake periods and classified as hypertensive if SBP or DBP was ≥ 95th standardized percentiles for height and weight.
Hypertension was present in 3.6% of the sample at time one and increased to 4.2% 5- years later. Obesity prevalence increased from 15.0% to 19.5%. Normal changes in sleep architecture were observed in the sample. Random effects modeling which controlled for age, sex and ethnicity indicated that change in obesity status and decrease in total sleep time were associated with increases in SBP. Change in obesity status was also associated with increases in DBP over the 5-year period. A trend for sleep-disordered breathing to increase SBP was noted.
Increases in SBP and DBP were associated with increasing BMI and decreased total sleep time over a 5-year period from childhood to adolescence.
PMCID: PMC3355235  PMID: 22284918
5.  Regional variations in the growth of Saudi children and adolescents 
Annals of Saudi Medicine  2009;29(5):348-356.
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.
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.
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.
Regional variations in growth need to be taken into consideration when assessing the growth of Saudi children and adolescents.
PMCID: PMC2860399  PMID: 19700891
6.  Education, household wealth and blood pressure in Albania, Armenia, Azerbaijan and Ukraine: Findings from the Demographic Health Surveys, 2005–2009☆ 
While socioeconomic gradients in cardiovascular disease have been well established in high-income countries, this relationship is not well understood in middle-income countries.
Data from Demographic Health Surveys collected in Albania (2008–09), Armenia (2005), Azerbaijan (2006) and Ukraine (2007) were used to estimate age-adjusted differences in systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), hypertension (HTN), elevated blood pressure, and optimal blood pressure across a standardized wealth index, level of educational attainment, and urban versus rural residence.
The wealthiest Albanian females had lower average SBP, DBP, PP (all p<0.01) and HTN status (odds ratio [OR] = 0.3, CI: 0.2–0.5, p<0.001) compared to the poorest; similar education gradients were also found. Such disparities also existed for Albanian men. Among Armenian women, urban (OR=1.4, 1.1–1.8, p<0.01), more educated (OR = 0.7, CI: 0.6–0.9, p<0.01), and wealthier (OR=1.8, 1.4–2.4, p<0.001) women were more likely to have optimal blood pressure. Urban Armenian men were also more likely to have optimal blood pressure (OR=1.8, 1.2–2.9, p<0.01). Wealthier and urban Azerbaijani had lower risk of elevated blood pressure and Azerbaijani women displayed strong wealth gradients with higher quintiles of wealth associated with lower continuous blood pressure measures. There were no socioeconomic gradients for Ukrainian males or females.
There is compelling evidence that wealth and education gradients affect the probability of HTN for women in Albania, Armenia, and Azerbaijan, and for men in Albania.
PMCID: PMC3638237  PMID: 23246126
Eastern Europe; Socioeconomic position; Hypertension; Demographic Health Surveys
7.  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.
PMCID: PMC3332207  PMID: 22577400
8.  Lower Bone Mineral Content in Hypertensive Compared with Normotensive Overweight Latino Children and Adolescents 
American journal of hypertension  2007;20(2):190-196.
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.
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.
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).
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.
PMCID: PMC1852456  PMID: 17261466
Pediatric; Latino; Bone Mineral Content; Blood Pressure; Osteopenia
9.  Blood pressure among Mexican-American, Cuban-American, and mainland Puerto Rican children. 
Public Health Reports  1996;111(Suppl 2):22-24.
LITTLE IS KNOWN ABOUT BLOOD PRESSURE LEVELS and the extent of high blood pressure in Hispanic children and adolescents, especially in groups other than Mexican Americans. The authors of this study investigated the levels of systolic blood pressure (SBP) and diastolic blood pressure (DBP) and the extent of high blood pressure among Mexican-American, Cuban-American, and mainland Puerto Rican children and adolescents who participated in the Hispanic Health and Nutrition Examination Survey (HHANES). Very few children and adolescents in these three Hispanic groups had high normal or high blood pressure. Puerto Rican children had significantly lower DBP than Mexican-American (2.4 mmHg) and Cuban-American (1.8 mmHg) children. Their SBP was also lower (1.7 mmHg) than that of Cuban-American children. These findings should be interpreted cautiously, however, since a significant observer effect was also found in this study. Correlates of blood pressure in children in all three Hispanic groups were consistent with those found in studies of other ethnic groups. Age, body mass index, and pulse rate were significant predictors of both SBP and DBP (P less than 0.05). Gender was an important predictor of SBP but not DBP. Socioeconomic and cultural factors were not significant predictors of blood pressure in these Hispanic groups.
PMCID: PMC1381656  PMID: 8898765
10.  Obesity and blood pressure levels of adolescents in Abeokuta, Nigeria 
Cardiovascular Journal of Africa  2012;23(5):260-264.
We determined the prevalence of general and central obesity and their relationship with blood pressure levels among adolescents in Abeokuta, Nigeria.
We selected 423 adolescents from seven schools in Abeokuta, Nigeria, using a multistage random-sampling technique. Body mass index (BMI), waist circumference (WC) and blood pressures were measured.
Twenty-one (5%) children had general obesity and 109 (24.5%) had central obesity. Of those with general obesity, 20 (95.1%) children were centrally obese. With simple linear regression analysis, BMI and WC explained 10.7 and 8.4%, respectively of the variance in systolic blood pressure (SBP), and 3.6 and 2.7%, respectively of the variance in diastolic blood pressure (DBP). Following logistic regression analysis, BMI was the major factor determining SBP levels (OR 0.8, 95% CI: 0.65–0.99, p < 0.05).
BMI remains an important anthropometric screening tool for high blood pressure in Nigerian adolescents.
PMCID: PMC3721855  PMID: 22038484
overweight; obesity; central obesity; blood pressure; adolescents; Nigeria
11.  Puberty Onset Among Boys in Riyadh, Saudi Arabia 
The ages of onset of pubertal characteristics are influenced by genetic, geographic, dietary and socioeconomic factors; however, due to lack of country-specific norms, clinicians in Saudi Arabia use Western estimates as standards of reference for local children.
The aim of the Riyadh Puberty Study was to provide data on pubertal development to determine the average age of onset of pubertal characteristics among Saudi boys.
Cross-sectional study among male school children in Riyadh, Saudi Arabia, in 2006, 542 schoolboys, aged 6 to 16 years old, from diverse socioeconomic levels were selected into the sample using a cluster sample design. Tanner stages were ascertained during physical examination by pediatric endocrine consultants, and also trained pediatric residents and fellows.
The mean age (standard deviation) at Tanner Stages 2, 3, 4, and 5 for pubic hair development of Saudi boys was 11.4 (1.6), 13.3 (1.3), 14.4 (1.0) and 15.1 (0.8) years old, respectively. For gonadal development, the mean age (standard deviation) at stages 2, 3, 4, and 5 were 11.4 (1.5), 13.3 (1.2), 14.3 (1.1) and 15.0 (0.9) years old, respectively.
The ages of onset of pubertal characteristics, based on gonadal development, among Saudi boys are comparable to those reported in Western populations.
PMCID: PMC3666985  PMID: 23761992
adolescence; boys; pubertal characteristics; puberty onset; Riyadh; Saudi Arabia
12.  Association between body size and blood pressure in children from different ethnic origins 
To assess associations between body size and blood pressure in children (5-6 years) from different ethnic origins.
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.
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.
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.
PMCID: PMC3495733  PMID: 23126496
Blood pressure; Ethnicity; Children; Adiposity; Body size
13.  Secular Trends in BMI and Blood Pressure Among Children and Adolescents: The Bogalusa Heart Study 
Pediatrics  2012;130(1):e159-e166.
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.
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).
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.
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.
PMCID: PMC3382918  PMID: 22665416
BMI; children; DBP; hypertension; obesity; SBP; secular trends
14.  Hypertension Subtype and Risk of Cardiovascular Disease in Chinese Adults 
Circulation  2008;118(15):1558-1566.
We examined the relationship between hypertension subtype and cardiovascular disease (CVD) incidence and mortality in Chinese adults.
Methods and Results
We conducted a prospective cohort study in a nationally representative sample of 169,871 Chinese men and women aged 40 years and older. Data on systolic (SBP) and diastolic blood pressure (DBP) and other variables were obtained at a baseline examination in 1991 using standard protocols. Follow-up evaluation was conducted in 1999–2000, with a response rate of 93.4%. Hypertension subtypes were defined as combined systolic and diastolic hypertension (SDH: SBP≥140 and DBP≥90 mm Hg), isolated systolic hypertension (ISH: SBP≥140 and DBP<90 mm Hg), isolated diastolic hypertension (IDH: SBP<140 and DBP≥90 mm Hg), and two categories of treated hypertension (SBP<140 and DBP<90 mm Hg or SBP≥140 and/or DBP≥90 mm Hg). After excluding participants with missing BP values, 169,577 adults were included in the analyses. Compared to normotensives, relative risks (95% confidence interval) of CVD incidence and mortality were 2.73 (2.60–2.86) and 2.53 (2.39–2.68) for SDH, 1.78 (1.69–1.87) and 1.68 (1.58–1.78) for ISH, 1.59 (1.43–1.76) and 1.45 (1.27–1.65) for IDH, 2.01 (1.64–2.48) and 1.61 (1.28–2.03) for treated hypertension with SBP<140 and DBP<90 mm Hg, and 3.37 (3.07–3.69) and 2.88 (2.60–3.19) for treated hypertension with SBP≥140 and/or DBP≥90 mm Hg, respectively, after adjustment for important covariables.
Our results indicate that all hypertension subtypes are associated with significantly increased risk of CVD in Chinese adults. Primary prevention of hypertension should be a public health priority in the Chinese population.
PMCID: PMC2735390  PMID: 18809800
hypertension; cardiovascular disease; relative risk; Chinese
15.  Blood pressure and body measurements among Navajo adolescents. 
Public Health Reports  1996;111(Suppl 2):44-46.
WE ASSESSED THE PREVALENCE of obesity, high normal blood pressure (BP), and the relationship between BP and anthropometric measurements in a sample of Navajo adolescents. The prevalence of obesity in boys and girls was 3 times that expected in U.S. white adolescents of the same age (17.1% for boys, 15.9% for girls) using body mass index as a criterion. The prevalence of high normal BP (between the 90th and 95th percentiles) was nearly twice that expected by definition (8.7% for boys and 9.1% for girls). Although systolic blood pressure (SBP) and diastolic blood pressure (DBP) increased significantly with age for boys and not for girls, SBP and DBP increased significantly with increasing body mass for both boys and girls. Given the high prevalence of obesity and the observed association with BP, primary prevention of hypertension among the Navajo should emphasize maintaining a healthy body weight at early ages.
PMCID: PMC1381663  PMID: 8898772
16.  Breathing Awareness Meditation and LifeSkills® Training Programs Influence Upon Ambulatory Blood Pressure and Sodium Excretion Among African American Adolescents 
Evaluate impact of breathing awareness meditation (BAM), Botvin LifeSkills® Training (LST), and health education control (HEC) on ambulatory blood pressure (BP) and sodium excretion in African American (AA) adolescents.
Following three consecutive days of systolic blood pressure (SBP) screenings, 166 eligible participants (i.e., SBP > 50th – 95th percentile) were randomized by school to either BAM (n = 53), LST (n= 69), or HEC (n=44). In-school intervention sessions were administered for three months by health education teachers. Before and after the intervention overnight urine samples and 24-hour ambulatory SBP, diastolic blood pressure (DBP), and heart rate (HR) were obtained.
Significant group differences were found for changes in overnight SBP and SBP, DBP and HR over the 24-hour period and during school hours. The BAM treatment exhibited the greatest overall decreases on these measures (Bonferroni adjusted, ps <.05). For example, for school-time SBP, BAM showed a change of −3.7 mmHg compared to no change for LST and a change of −0.1 mmHg for HEC. There was a non-significant trend for overnight urinary sodium excretion (p = .07) with the BAM group displaying a reduction of −.92 ± 1.1 mEq/hr compared to increases of .89 ± 1.2 mEq/hr for LST, and .58±0.9 mEq/hr for HEC group.
BAM appears to improve hemodynamic function and may impact sodium handling among AA adolescents at increased risk for development of cardiovascular disease (CVD).
PMCID: PMC3026442  PMID: 21185525
adolescents; ambulatory blood pressure; breathing awareness meditation; Botvin LifeSkills® Training; clinical trial; sodium excretion
17.  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.
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).
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.
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).
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
18.  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.
To study the blood pressure of school going children in a rural area and its relationship with the anthropometric indices.
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.
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).
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.
PMCID: PMC2840757  PMID: 20300250
Blood pressure; children; hypertension; prevalence study
19.  Body Mass Index Relates to Blood Pressure Among Adults 
The blood pressure and anthropometric measurements are important for evaluating the health of children, adolescents as well as adults.
The aim is to study the blood pressure and body dimensions and to find out the prevalence of overweight/obesity and hypertension among adults.
Materials and Methods:
A cross-sectional study was conducted of all the people belonging to the Punjabi community, residing in Roshanara area and Jaina building in Delhi, for the past 20 years and aged 18-50 years. The men were engaged in transport business and women were mainly housewives.
Mean values of all the measurements, that is, height, weight, upper arm circumference, pulse rate, systolic blood pressure (SBP), and diastolic blood pressure (DBP) were higher among males as compared with females, except skinfold thicknesses. Body mass index (BMI) and fat percentage was found to be higher among females as compared with males. There was a significant positive correlation between BMI, fat percentage, and blood pressure both SBP as well as DBP. Odds ratio showed that overweight/obese subjects were more likely to have hypertension than those with normal BMI.
Prevalence of prehypertension among overweight/obese suggested an early clinical detection of prehypertension and intervention including life style modification, particularly weight management.
PMCID: PMC3968571  PMID: 24696830
Body mass index; Blood pressure (SBP and DBP); India; Punjabi adults; Obesity; Prehypertension
20.  Stress Response and the Adolescent Transition: Performance versus Peer Rejection Stressors 
Little is known about normative variation in stress response over the adolescent transition. This study examined neuroendocrine and cardiovascular responses to performance and peer rejection stressors over the adolescent transition in a normative sample. Participants were 82 healthy children (ages 7-12 years, n=39, 22 females) and adolescents (ages 13-17, n=43, 20 females) recruited through community postings. Following a habituation session, participants completed a performance (public speaking, mental arithmetic, mirror tracing) or peer rejection (exclusion challenges) stress session. Salivary cortisol, alpha amylase (sAA), systolic and diastolic blood pressure (SBP, DBP), and heart rate (HR) were measured throughout. Adolescents showed significantly greater cortisol, sAA, SBP and DBP stress response relative to children. Developmental differences were most pronounced in the performance stress session for cortisol and DBP, and in the peer rejection session for sAA and SBP. Heightened physiological stress responses in typical adolescents may facilitate adaptation to new challenges of adolescence and adulthood. In high-risk adolescents, this normative shift may tip the balance toward stress response dysregulation associated with depression and other psychopathology. Specificity of physiological response by stressor type highlights the importance of a multi-system approach to the psychobiology of stress and may also have implications for understanding trajectories to psychopathology.
PMCID: PMC2700625  PMID: 19144222
adolescent; child; stress; cortisol; cardiovascular; amylase; depression
21.  Regional Variation in Prevalence of Overweight and Obesity in Saudi Children and Adolescents 
There are limited data on regional variation of overweight and obesity in the Kingdom of Saudi Arabia. Therefore, the aim of this report is to explore the magnitude of these variation in order to focus preventive programs to regional needs.
Setting and Design:
Community-based multistage random sample of representative cohort from each region.
Patients and Methods:
the study sample was cross-sectional, representative of healthy children and adolescents from 2 to 17 years of age. Body mass index (BMI) was calculated according to the formula (weight/height2). The 2000 center for disease control reference was used for the calculation of prevalence of overweight and obesity defined as the proportion of children and adolescents whose BMI for age was above 85th and 95th percentiles respectively, for Northern, Southwestern and Central regions of the Kingdom. Chi-square test was used to assess the difference in prevalence between regions and a P value of <0.05 was considered significant.
The sample size was 3525, 3413 and 4174 from 2-17 years of age in the Central, Southwestern and Northern regions respectively. The overall prevalence of overweight was 21%, 13.4% and 20.1%, that of obesity was 9.3%, 6% and 9.1% in the Central, Southwestern and Northern regions respectively indicating a significantly-lower prevalence in the Southwestern compared to other regions (P<0.0001).
This report revealed significant regional variations important to consider in planning preventive and therapeutic programs tailored to the needs of each region.
PMCID: PMC3326974  PMID: 22421719
Obesity; prevalence of overweight; regional variations; Saudi children
22.  Comparison of three measures of physical activity and associations with blood pressure, HDL and body composition in a sample of adolescents 
The association of physical activity (PA), measured three ways, and biomarkers were compared in a sample of adolescents.
PA data were collected on two cohorts of adolescents (N=700) in the Twin Cities, Minnesota, 2007–2008. PA was measured using two survey questions (Modified Activity Questionnaire (MAQ)), the 3-Day Physical Activity Recall (3DPAR), and accelerometers. Biomarkers included systolic (SBP) and diastolic blood pressure (DBP), lipids, percent body fat (%BF) and body mass index (BMI) percentile. Bivariate relationships among PA measures and biomarkers were examined followed by generalized estimating equations for multivariate analysis.
The three measures were significantly correlated with each other (r=0.22–0.36, P<0.001). Controlling for study, puberty, age and gender, all three PA measures were associated with %BF (MAQ=-1.93, P<0.001; 3DPAR=-1.64, P <0.001; accelerometer=-1.06, P =0.001). The MAQ and accelerometers were negatively associated with BMI percentile. None of the three PA measures were significantly associated with SBP or lipids. The percentage of adolescents meeting the national PA recommendations varied by instrument.
All three instruments demonstrated consistent findings when estimating associations with %BF, but were different for prevalence estimates. Researchers must carefully consider the intended use of PA data when choosing a measurement instrument.
PMCID: PMC3600646  PMID: 22232509
23.  Blood pressure and associated factors in a North African adolescent population. a national cross-sectional study in Tunisia 
BMC Public Health  2012;12:98.
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.
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.
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.
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.
PMCID: PMC3331812  PMID: 22305045
Adolescent; Blood pressure; Tunisia; Prevalence; Risk factors
24.  Urbanization, ethnicity and cardiovascular risk in a population in transition in Nakuru, Kenya: a population-based survey 
BMC Public Health  2010;10:569.
Cardiovascular disease (CVD) is the leading cause of death among older people in Africa. This study aimed to investigate the relationship of urbanization and ethnicity with CVD risk markers in Kenya.
A cross-sectional population-based survey was carried out in Nakuru Kenya in 2007-2008. 100 clusters of 50 people aged ≥50 years were selected by probability proportionate to size sampling. Households within clusters were selected through compact segment sampling. Participants were interviewed by nurses to collect socio-demographic and lifestyle information. Nurses measured blood pressure, height, weight and waist and hip circumference. A random finger-prick blood sample was taken to measure glucose and cholesterol levels.
Hypertension was defined as systolic blood pressure (SBP) ≥140 mm Hg, or diastolic blood pressure (DBP) ≥90 mm Hg or current use of antihypertensive medication; Diabetes as reported current medication or diet control for diabetes or random blood glucose level ≥11.1 mmol/L; High cholesterol as random blood cholesterol level ≥5.2 mmol/L; and Obesity as Body Mass Index (BMI)≥30 kg/m2.
5010 eligible subjects were selected, of whom 4396 (88%) were examined. There was a high prevalence of hypertension (50.1%, 47.5-52.6%), obesity (13.0%, 11.7-14.5%), diabetes (6.6%, 5.6-7.7%) and high cholesterol (21.1%, 18.6-23.9). Hypertension, diabetes and obesity were more common in urban compared to rural groups and the elevated prevalence generally persisted after adjustment for socio-demographic, lifestyle, obesity and cardiovascular risk markers. There was also a higher prevalence of hypertension, obesity, diabetes and high cholesterol among Kikuyus compared to Kalenjins, even after multivariate adjustment. CVD risk markers were clustered both across the district and within individuals. Few people received treatment for hypertension (15%), while the majority of cases with diabetes received treatment (68%).
CVD risk markers are common in Kenya, particularly in urban areas. Exploring differences in CVD risk markers between ethnic groups may help to elucidate the epidemiology of these conditions.
PMCID: PMC2956724  PMID: 20860807
25.  Impact of education on obesity and blood pressure in developing countries: A study on the Ibos of Nigeria 
Increase in the prevalence of hypertension, obesity and obesity related diseases has become significant cause of disability and premature death in both developing and newly developed countries, with over bearing demand on national health budgets.
To evaluate the impact of various levels of education on obesity and blood pressure.
Materials and Method:
325 male and 254 female Nigerians of ages 20-80 years of the Ibo ethnicity through random sampling, were selected for this study. The participants were broken into three major groups based on their educational levels; primary, secondary and tertiary levels. systolic and diastolic blood pressure (SBP & DBP) levels, body mass index (BMI), waist hip ratio (WHR), waist height ratio (WHtR), waist circumference (WC),various skin fold thicknesses, and other anthropometric parameters were measured.
For all the indicators of subcutaneous fat, general obesity, and central obesity, largest mean deposition was noted to be highest in the lowest education group and least in the highest education group. Mean blood pressure parameters were also highest in the least education group. While fat deposition was noted to be highest in all the females of all the groups, the males showed larger mean BP values. Education was noted to have a significant inverse relationship with most of the fat indicators and blood pressure parameters and cardiovascular disease risk highest in the least education groups.
Education showed a significant impact on obesity and blood pressure and could be one of the major tools to reduce the high prevalence of obesity, hypertension and other obesity associated diseases.
PMCID: PMC3341639  PMID: 22558581
Anthropometry; obesity; adiposity; blood pressure; BMI; obesity prevalence; obesity related disorder; hypertension; cardiovascular disease risk; waist hip ratio

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