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1.  Blood pressure centiles for Great Britain 
Archives of Disease in Childhood  2006;92(4):298-303.
Objective
To produce representative cross‐sectional blood pressure reference centiles for children and young people living in Great Britain.
Design
Analysis of blood pressure data from seven nationally representative surveys: Health Surveys for England 1995–8, Scottish Health Surveys 1995 and 1998, and National Diet & Nutrition Survey 1997.
Methods
Blood pressure was measured using the Dinamap 8100 with the same protocol throughout. Weight and height were also measured. Data for 11 364 males and 11 537 females aged 4–23 years were included in the analysis, after excluding 0.3% missing or outlying data. Centiles were derived for systolic, diastolic, mean arterial and pulse pressure using the latent moderated structural (LMS) equations method.
Results
Blood pressure in the two sexes was similar in childhood, rising progressively with age and more rapidly during puberty. Systolic pressure rose faster and was appreciably higher in adult men than in adult women. After adjustment for age, blood pressure was related more to weight than height, the effect being stronger for systolic blood pressure. Pulse pressure peaked at 18 years in males and 16 years in females.
Conclusions
These centiles increase our knowledge of blood pressure norms in contemporary British children and young people. High blood pressure for age should be defined as blood pressure above the 98th centile, and high‐normal blood pressure for age as blood pressure between the 91st and 98th centiles. The centiles identify children and young people with increased blood pressure, and will be of benefit to both clinical practice and research.
doi:10.1136/adc.2005.081216
PMCID: PMC2083671  PMID: 16905566
2.  About the need to use specific population references in estimating paediatric hypertension: Sardinian blood pressure standards (age 11-14 years) 
Background
Previous Italian paediatric blood pressure (BP) tables overestimated the prevalence of hypertension in adolescents of specific geographic areas, such as Sardinia, an island in the Mediterranean Sea. This is probably due to a not very homogeneous distribution of the subjects studied, most from Middle and Northern Italy, and the long period from the survey.
Methods
BPs were repeatedly measured over a period of 3 years in 839 children (52.6% males. Age range: from 11 to 14 years during this period), using a standard mercury sphygmomanometer. For each gender, the specific percentile curves of systolic and diastolic BP were constructed.
Results (corrected by the 50th percentile of height)
Males (11-14 years)
mean systolic BP (50th centile): from 111 to 115 mmHg. Hypertensive systolic BP (> 95th percentile): from 127 to 135 mmHg. Mean diastolic BP (50th centile): from 65 to 69 mmHg. Hypertensive diastolic BP (> 95th percentile): from 78 to 82 mmHg.
Females(11-14 years)
mean systolic BP (50th centile): from 110 to 112 mmHg. Hypertensive systolic BP (> 95th percentile): from 127 to 130 mmHg. Mean diastolic BP (50th centile): from 65 to 67. Hypertensive diastolic BP (> 95th percentile): from 78 to 80 mmHg.
Conclusions
Sardinian BP tables emphasizes the need to integrate the previous standards with more up-to-date and representative reports on Italian children, as periodically performed in the USA, in order to increase the number of subjects to be checked, and to obtain a national coverage better and more completely representative of every geographic area of our country.
doi:10.1186/1824-7288-38-1
PMCID: PMC3275472  PMID: 22233935
3.  Role of blood pressure in development of early retinopathy in adolescents with type 1 diabetes: prospective cohort study 
Objective To examine the relation between blood pressure and the development of early retinopathy in adolescents with childhood onset type 1 diabetes.
Design Prospective cohort study.
Setting Diabetes Complications Assessment Service at the Children’s Hospital at Westmead, Sydney, Australia.
Participants 1869 patients with type 1 diabetes (54% female) screened for retinopathy with baseline median age 13.4 (interquartile range 12.0-15.2) years, duration 4.9 (3.1-7.0) years, and albumin excretion rate of 4.4 (3.1-6.8) μg/min plus a subgroup of 1093 patients retinopathy-free at baseline and followed for a median 4.1 (2.4-6.6) years.
Main outcome measures Early background retinopathy; blood pressure.
Results Overall, retinopathy developed in 673 (36%) participants at any time point. In the retinopathy-free group, higher systolic blood pressure (odds ratio 1.01, 95% confidence interval 1.003 to 1.02) and diastolic blood pressure (1.01, 1.002 to 1.03) were predictors of retinopathy, after adjustment for albumin excretion rate (1.27, 1.13 to 1.42), haemoglobin A1c (1.08, 1.02 to 1.15), duration of diabetes (1.16, 1.13 to 1.19), age (1.13, 1.08 to 1.17), and height (0.98, 0.97 to 0.99). In a subgroup of 1025 patients with albumin excretion rate below 7.5 μg/min, the cumulative risk of retinopathy at 10 years’ duration of diabetes was higher for those with systolic blood pressure on or above the 90th centile compared with those below the 90th centile (58% v 35%, P=0.03). The risk was also higher for patients with diastolic blood pressure on or above the 90th centile compared with those below the 90th centile (57% v 35%, P=0.005).
Conclusions Both systolic and diastolic blood pressure are predictors of retinopathy and increase the probability of early retinopathy independently of incipient nephropathy in young patients with type 1 diabetes.
doi:10.1136/bmj.a918
PMCID: PMC2526183  PMID: 18728082
4.  Central overweight and obesity in British youth aged 11-16 years: cross sectional surveys of waist circumference 
BMJ : British Medical Journal  2003;326(7390):624.
Objective
To compare changes over time in waist circumference (a measure of central fatness) and body mass index (a measure of overall obesity) in British youth.
Design
Representative cross sectional surveys in 1977, 1987, and 1997.
Setting
Great Britain.
Participants
Young people aged 11-16 years surveyed in 1977 (boys) and 1987 (girls) for the British Standards Institute (n=3784) and in 1997 (both sexes) for the national diet and nutrition survey (n=776).
Main outcome measures
Waist circumference, expressed as a standard deviation score using the first survey as reference, and body mass index (weight(kg)/height(m)2), expressed as a standard deviation score against the British 1990 revised reference. Overweight and obesity were defined as the measurement exceeding the 91st and 98th centile, respectively.
Results
Waist circumference increased sharply over the period between surveys (mean increases for boys and girls, 6.9 and 6.2 cm, or 0.84 and 1.02 SD score units, P<0.0001). In centile terms, waist circumference increased more in girls than in boys. Increases in body mass index were smaller and similar by sex (means 1.5 and 1.6, or 0.47 and 0.53 SD score units, P<0.0001). Waist circumference in 1997 exceeded the 91st centile in 28% (n=110) of boys and 38% (n=147) of girls (against 9% for both sexes in 1977-87, P<0.0001), whereas 14% (n=54) and 17% (n=68), respectively, exceeded the 98th centile (3% in 1977-87, P<0.0001). The corresponding rates for body mass index in 1997 were 21% (n=80) of boys and 17% (n=67) of girls exceeding the 91st centile (8% and 6% in 1977-87) and 10% (n=39) and 8% (n=32) exceeding the 98th centile (3% and 2% in 1977-87).
Conclusions
Trends in waist circumference during the past 10-20 years have greatly exceeded those in body mass index, particularly in girls, showing that body mass index is a poor proxy for central fatness. Body mass index has therefore systematically underestimated the prevalence of obesity in young people.
What is already known on this topicThe prevalence of overweight and obesity in youth based on body mass index has increased over the past 10-20 yearsBody mass index gives no indication of body fat distributionWaist circumference is a marker for central body fat accumulation; a large waist circumference is linked to an increased risk of metabolic complicationsWhat this study addsWaist circumference in British youth has increased over the past 10-20 years at a greater rate than body mass index, the increase being greatest in femalesThe accumulation of central body fat has risen more steeply than whole body fatness based on height and weightCurrent and future morbidity in British youth may be seriously affected due to accumulation of excess central fat
PMCID: PMC151972  PMID: 12649234
5.  By how much does dietary salt reduction lower blood pressure? I--Analysis of observational data among populations. 
BMJ : British Medical Journal  1991;302(6780):811-815.
OBJECTIVE--To estimate the quantitative relation between blood pressure and sodium intake. DESIGN--Data were analysed from published reports of blood pressure and sodium intake for 24 different communities (47 000 people) throughout the world. MAIN OUTCOME MEASURE--Difference in blood pressure for a 100 mmol/24 h difference in sodium intake. Allowance was made for differences in blood pressure between economically developed and undeveloped communities to minimise overestimation of the association through confounding with other determinants of blood pressure. RESULTS--Blood pressure was higher on average in the developed communities, but the association with sodium intake was similar in both types of community. A difference in sodium intake of 100 mmol/24 h was associated with an average difference in systolic blood pressure that ranged from 5 mm Hg at age 15-19 years to 10 mm Hg at age 60-69. The differences in diastolic blood pressure were about half as great. The standard deviation of blood pressure increased with sodium intake implying that the association of blood pressure with sodium intake in individuals was related to the initial blood pressure--the higher the blood pressure the greater the expected reduction in blood pressure for the same reduction in sodium intake. For example, at age 60-69 the estimated systolic blood pressure reduction in response to a 100 mmol/24 h reduction in sodium intake was on average 10 mm Hg but varied from 6 mm Hg for those on the fifth blood pressure centile to 15 mm Hg for those on the 95th centile. CONCLUSIONS--The association of blood pressure with sodium intake is substantially larger than is generally appreciated and increases with age and initial blood pressure.
PMCID: PMC1669164  PMID: 2025703
6.  Correlates of blood pressure in 15 year olds in the west of Scotland. 
STUDY OBJECTIVE--The aim was to examine social and physical correlates of blood pressure in 15 year olds. DESIGN--This was the first, baseline, sweep of a longitudinal survey of 15 year olds based on a two stage stratified clustered random sample. SETTING--The Central Clydeside Conurbation, in the West of Scotland. In 1981 this had a population of 1.7 million and a standardised mortality ratio (relative to Scotland as a whole) of 109. SUBJECTS--A random sample of households containing 15 year olds were approached by Strathclyde Regional Council; 70% agreed to have their names passed on to the MRC (15% refused, 10% could not be contacted, and 5% had moved). Of these 1177, 11% refused to participate, 3% were not contactable/had moved, and 4% did not provide full data. Complete blood pressure data are available for 959 15 year olds (464 males and 495 females). MEASUREMENTS AND MAIN RESULTS--Blood pressure, pulse rate, height, weight, and room temperature were measured by nurses in the subjects' homes. Smoking, drinking, and frequency of vigorous exercise were self reported. Maternal height, birthweight, occupation of head of household, and housing tenure were reported by parents. After controlling for the other variables, systolic blood pressure was significantly associated with weight, pulse rate, and room temperature in males and with weight, pulse rate, housing tenure, smoking, and exercise in females. Diastolic blood pressure was associated with room temperature in males and with mother's height, pulse rate, and housing tenure in females. Controlling for current weight, birthweight was inversely related to systolic blood pressure in males and positively associated in females, though in neither case were these associations statistically significant. CONCLUSIONS--In males, blood pressure was mainly related to anthropometric factors whereas in females it was additionally related to socioeconomic and behavioural variables. Although not reaching significance, the weight standardised relationship between birthweight and systolic blood pressure was consistent for males, but not females, with those reported by recent British studies of children and adults. The longitudinal design of this study will allow us to examine correlates of blood pressure in the same individuals as they reach social and physical maturity.
PMCID: PMC1060732  PMID: 2072074
7.  The potential effect of the UK 1990 height centile charts on community growth surveillance. 
Archives of Disease in Childhood  1996;74(5):452-454.
The UK 1990 height charts are derived from an up to date dataset and introduce a change in the centile lines, particularly the addition of the 0.4th centile. This study examined the likely impact of these changes. Height data from London school children (1990-1993) were examined using Tanner and Whitehouse (TW) and UK 1990 charts. Numbers of children with height below TW 3rd centile were compared with numbers below the UK 1990 3rd and 0.4th centiles. The TW charts identified only 1% of children below the TW 3rd centile, while the UK 1990 charts identified 3% below the 3rd and 0.4% below the 0.4th centiles. If the 3rd centile remains as the referral 'cut off' for short stature, the introduction of the UK 1990 charts would increase current workload two- to three-fold, while a change to the 0.4th centile would reduce it by 50%. A significant number of children with abnormalities may be excluded from further assessment as a result of this latter change. In this small scale community study it is not possible to assess the consequences of this change. The heights at diagnosis of children with growth hormone (GH) deficiency (peak GH < 20 mU/l during a standard provocation test) were therefore compared to the 0.4th centile (UK 1990 charts). Sixty eight children with heights < 2nd centile (UK 1990 charts) currently receiving GH replacement (17 female, 51 male, aged 9.7, SD 3.5, years) were assessed, and of these, 28 (41%) had heights at diagnosis between 0.4th and 2nd centile, with a mean height standard deviation score of -2.32 (SD 0.21). This suggests that if the 0.4th centile were to be used as the sole criterion for referral for slow growth, a significant proportion of children with abnormality would not be referred for further assessment. The UK 1990 2nd centile should replace the TW 3rd centile. Children below this should undergo an intermediary medical assessment to confirm height measurement, to exclude from referral children with mild familial short stature and to identify concerns regarding the child.
PMCID: PMC1511551  PMID: 8669965
8.  Blood pressure and smoking: observations on a national cohort. 
Archives of Disease in Childhood  1995;73(4):294-297.
The reasons why adult smokers have lower blood pressure than non-smokers have not been determined. It is possible that low blood pressure might precede the onset of smoking. This study investigates this hypothesis in a national cohort study in Britain. Blood pressures and pulse rates taken on a sample of 5019 members of the British Birth Cohort Study (BCS 70) at the age of 10 years were analysed in relation to self reported smoking behaviour at age 16+ years. Prospectively, those children who had lower diastolic blood pressure or pulse rate at age 10 were more likely to have smoked by age 16+ years. Using analysis of variance, pulse rate was significantly related to smoking in young men (p < 0.001). Seventy per cent of those with lower pulse (below the 10th centile), 58% with medium pulse, and 52% with the higher pulse (above the 90th centile) had ever smoked by age 16+ years. In young women, pulse rate (p = 0.003), diastolic pressure (p = 0.024), and systolic pressure (p = 0.032) at age 10 were all significantly related to smoking at age 16. This longitudinal study found that lower blood pressure and slower pulse rate were related to the onset of smoking in children. More research is needed on this new observation.
PMCID: PMC1511342  PMID: 7492191
9.  A controlled study of eight months of physical training and reduction of blood pressure in children: the Odense schoolchild study. 
BMJ : British Medical Journal  1991;303(6804):682-685.
OBJECTIVE--To examine the effect of physical training on physical fitness and blood pressure in children aged 9-11 years. DESIGN--Prospective randomised controlled intervention study of a sample of children drawn from a population survey of coronary risk factors in children. SETTING--Odense, Denmark. SUBJECTS--69 children with mean blood pressure greater than or equal to 95th centile (hypertensive group) and 68 with mean blood pressure less than 95th centile (normotensive group), randomly selected from a population of 1369 children. INTERVENTION--67 children were randomised to receive three extra lessons a week of an ordinary school physical education programme for eight months. MAIN OUTCOME MEASURES--Physical fitness assessed by calculation of maximum oxygen uptake and blood pressure recorded by one unblinded observer. RESULTS--After three months neither blood pressure nor physical fitness had changed significantly. After adjustment for values in weight, height, heart rate, and the variable in question before training physical fitness rose significantly at the end of eight months' training, by 3.7 mlO2/kg/min (95% confidence interval 2.2 to 5.3) in the normotensive training subgroup and by 2.1 mlO2/kg/min (0.1 to 4.2) in the hypertensive training subgroup compared with that in the controls. Systolic and diastolic blood pressures in the training subgroups fell significantly by 6.5 mm Hg (3.2 to 9.9) and 4.1 mm Hg (1.7 to 6.6) respectively in the normotensive group and by 4.9 mm Hg (0.7 to 9.2) and 3.8 mm Hg (0.9 to 6.6) respectively in the hypertensive group. CONCLUSIONS--Physical training lowers blood pressure and improves physical fitness in children and might have implications for an important non-pharmacological approach to primary prevention of essential hypertension.
PMCID: PMC1670972  PMID: 1912915
10.  Extending World Health Organization weight-for-age reference curves to older children 
BMC Pediatrics  2014;14:32.
Background
For ages 5–19 years, the World Health Organization (WHO) publishes reference charts based on ‘core data’ from the US National Center for Health Statistics (NCHS), collected from 1963–75 on 22,917 US children. To promote the use of body mass index in older children, weight-for-age was omitted after age 10. Health providers have subsequently expressed concerns about this omission and the selection of centiles. We therefore sought to extend weight-for-age reference curves from 10 to 19 years by applying WHO exclusion criteria and curve fitting methods to the core NCHS data and to revise the choice of displayed centiles.
Methods
WHO analysts first excluded ~ 3% of their reference population in order to achieve a “non-obese sample with equal height”. Based on these exclusion criteria, 314 girls and 304 boys were first omitted for ‘unhealthy’ weights-for-height. By applying WHO global deviance and information criteria, optimal Box-Cox power exponential models were used to fit smoothed weight-for-age centiles. Bootstrap resampling was used to assess the precision of centile estimates. For all charts, additional centiles were included in the healthy range (3 to 97%), and the more extreme WHO centiles 0.1 and 99.9% were dropped.
Results
In addition to weight-for-age beyond 10 years, our charts provide more granularity in the centiles in the healthy range −2 to +2 SD (3–97%). For both weight and BMI, the bootstrap confidence intervals for the 99.9th centile were at least an order of magnitude wider than the corresponding 50th centile values.
Conclusions
These charts complement existing WHO charts by allowing weight-for-age to be plotted concurrently with height in older children. All modifications followed strict WHO methodology and utilized the same core data from the US NCHS. The additional centiles permit a more precise assessment of normal growth and earlier detection of aberrant growth as it crosses centiles. Elimination of extreme centiles reduces the risk of misclassification. A complete set of charts is available at the CPEG web site (http://cpeg-gcep.net).
doi:10.1186/1471-2431-14-32
PMCID: PMC3922078  PMID: 24490896
Growth; Growth charts; Anthropometry; Pediatrics; Child
11.  Blood pressure standards for Saudi children and adolescents 
Annals of Saudi Medicine  2009;29(3):173-178.
BACKGROUND AND OBJECTIVES:
Blood pressure levels may vary in children because of genetic, ethnic and socioeconomic factors. To date, there have been no large national studies in Saudi Arabia on blood pressure in children. Therefore, we sought to establish representative blood pressure reference centiles for Saudi Arabian children and adolescents.
SUBJECTS AND METHODS:
We selected a sample of children and adolescents aged from birth to 18 years by multi-stage probability sampling of the Saudi population. The selected sample represented Saudi children from the whole country. Data were collected through a house-to-house survey of all selected households in all 13 regions in the country. Data were analyzed to study the distribution pattern of systolic (SBP) and diastolic blood pressure (DBP) and to develop reference values. The 90th percentile of SBP and DBP values for each age were compared with values from a Turkish and an American study.
RESULTS:
A total of 16 226 Saudi children and adolescents from birth to 18 years were studied. Blood pressure rose steadily with age in both boys and girls. The average annual increase in SBP was 1.66 mm Hg for boys and 1.44 mm Hg for girls. The average annual increase in DBP was 0.83 mm Hg for boys and 0.77 mm Hg for girls. DBP rose sharply in boys at the age of 18 years. Values for the 90th percentile of both SBP and DBP varied in Saudi children from their Turkish and American counterparts for all age groups.
CONCLUSION:
Blood pressure values in this study differed from those from other studies in developing countries and in the United States, indicating that comparison across studies is difficult and from that every population should use their own normal standards to define measured blood pressure levels in children.
doi:10.4103/0256-4947.51787
PMCID: PMC2813655  PMID: 19448364
12.  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
13.  Association of low blood pressure with anxiety and depression: the Nord‐Trøndelag Health Study 
Background
Low blood pressure has mainly been regarded as ideal, but recent studies have indicated an association with depression in elderly people.
Objective
To investigate whether low blood pressure is associated with anxiety and depression in the general population.
Design
Cross‐sectional study.
Setting
Participants in the population‐based Nord‐Trøndelag Health Study (HUNT‐2, 1995–7), Norway.
Participants
60 799 men and women aged 20–89 years filled in the Hospital Anxiety and Depression Scale as part of a general health study. Systolic and diastolic blood pressure was classified in age‐stratified and sex‐stratified centile groups.
Main results
Compared with participants with systolic blood pressure within the 41–60 centile (reference) group, the odds ratio for anxiety was 1.31 (95% confidence intervals (CI) 1.16 to 1.49), for depression 1.22 (95% CI 1.03 to 1.46), and for comorbid anxiety and depression 1.44 (95% CI 1.24 to 1.68) in the group with ⩽5 centile systolic blood pressure. Slightly weaker associations were found of low diastolic blood pressure with anxiety and depression. These associations were similar across sex and age groups. Physical impairment, smoking and angina pectoris influenced the associations only marginally, whereas stroke, myocardial infarction, use of drugs for hypertension, body mass index and several other covariates had no influence.
Conclusions
This study represents epidemiological evidence for an association of low blood pressure with anxiety and depression, which is not caused by cardiovascular disease.
doi:10.1136/jech.2005.044966
PMCID: PMC2465598  PMID: 17183016
14.  Factors related to total cholesterol and blood pressure in British 9 year olds. 
STUDY OBJECTIVE: To assess which factors are associated with total cholesterol concentration and blood pressure in 9 year olds, and to examine the extent to which a report of a heart attack in a close relative identifies children with a high total cholesterol value or high systolic blood pressure. DESIGN: This was a cross sectional study. SETTING: The analysis was based on 22 study areas from a representative English sample, 14 areas from a representative Scottish sample, and 20 areas from an inner city sample. PARTICIPANTS: There were 1987 children aged 8 or 9 whose blood pressure was measured and 1662 children whose total cholesterol was assessed. MEASUREMENTS AND MAIN RESULTS: Blood pressure was measured using the Dinamap 1846 automated sphygmomanometer and cholesterol using the Lipotrend C. Multiple regression analysis was used to examine the independent associations with each of the outcome variables. Either weight for height or sum of skinfolds measured in four sites was highly associated with the outcome measures in the study (p < 0.001). Fatter or overweight children had higher blood pressure and higher cholesterol concentrations. Child's height was also associated with the outcome measures in most of the analyses, but was positively related to blood pressure and negatively associated with cholesterol value. There was an association between diastolic blood pressure and area of residence as represented by the regional health authority (RHA), but the association was not the same as the association reported between coronary heart disease, standardised mortality ratio, and RHA. Children with low birth weight and those with shorter gestation had higher systolic blood pressure (p < 0.05 and p < 0.01 respectively), but not diastolic blood pressure. A report of a premature heart attack in a parent or a grandparent was not associated with higher cholesterol or blood pressure. CONCLUSIONS: Reducing obesity in children, together with the avoidance of smoking, may be an appropriate action to prevent coronary heart disease in adulthood. A report of heart disease in a close relative is an ineffective means of identifying children at greater risk of high cholesterol or blood pressure without other measurements from relatives.
PMCID: PMC1060341  PMID: 8944856
15.  Population based prevalence of high blood pressure among adults in Addis Ababa: uncovering a silent epidemic 
Background
The prevention and control of high blood pressure or other cardiovascular diseases has not received due attention in many developing countries. This study aims to describe the epidemiology of high blood pressure among adults in Addis Ababa, so as to inform policy and lay the ground for surveillance interventions.
Methods
Addis Ababa is the largest urban centre and national capital of Ethiopia, hosting about 25% of the urban population in the country. A probabilistic sample of adult males and females, 25–64 years of age residing in Addis Ababa city participated in structured interviews and physical measurements. We employed a population based, cross sectional survey, using the World Health Organization instrument for stepwise surveillance (STEPS) of chronic disease risk factors. Data on selected socio-demographic characteristics and lifestyle behaviours, including physical activity, as well as physical measurements such as weight, height, waist and hip circumference, and blood pressure were collected through standardized procedures. Multiple linear regression analysis was performed to estimate the coefficient of variability of blood pressure due to selected socio-demographic and behavioural characteristics, and physical measurements.
Results
A total of 3713 adults participated in the study. About 20% of males and 38% of females were overweight (body-mass-index ≥ 25 kg/m2), with 10.8 (9.49, 12.11)% of the females being obese (body-mass-index ≥ 30 kg/m2). Similarly, 17% of the males and 31% of the females were classified as having low level of total physical activity. The age-adjusted prevalence (95% confidence interval) of high blood pressure, defined as systolic blood pressure (SBP) ≥ 140 mmHg (millimetres of mercury) or diastolic blood pressure (DBP) ≥ 90 mmHg or reported use of anti-hypertensive medication, was 31.5% (29.0, 33.9) among males and 28.9% (26.8, 30.9) among females.
Conclusion
High blood pressure is widely prevalent in Addis Ababa and may represent a silent epidemic in this population. Overweight, obesity and physical inactivity are important determinants of high blood pressure. There is an urgent need for strategies and programmes to prevent and control high blood pressure, and promote healthy lifestyle behaviours primarily among the urban populations of Ethiopia.
doi:10.1186/1471-2261-9-39
PMCID: PMC2736927  PMID: 19698178
16.  Cardiovascular risk factors and blood pressure in a primary care unit: Yugoslav Study of the Precursors of Atherosclerosis in School Children (YUSAD) 
OBJECTIVES
The presence of cardiovascular risk factors in children may be important in the development of atherosclerosis in adulthood. Adequate control of blood pressure is a cornerstone in atherosclerosis prevention. The aim of the Yugoslav Study of the Precursors of Atherosclerosis in School Children (YUSAD) was to identify risk factors for elevated blood pressure in school children.
METHODS
The YUSAD study is a multicentre follow-up study comprised of two cross-sectional surveys conducted five years apart. At baseline, 10-year-old children (3226 boys and 3074 girls [n=6300]) were randomly selected during periodical visits to primary health care centres. The risk factors measured were heart rate, weight, body mass index (BMI), waist-to-hip ratio, grade point average and current smoking status.
RESULTS
Significant age and sex differences were identified in systolic blood pressure, diastolic blood pressure and all investigated independent variables. In a multivariate analysis, diastolic blood pressure in 10-year-old boys was directly and significantly related to total cholesterol and height, whereas it was inversely related to weight. At follow-up, in the multivariate model, only BMI was a significant predictor of diastolic blood pressure in boys. In girls at baseline in the multivariate regression analysis, the only significant predictor of diastolic blood pressure was total cholesterol. In 15-year-old girls, diastolic blood pressure was significantly and directly related to BMI and heart rate, whereas it was inversely related to weight. For both 10- and 15-year-old male and female participants, none of the variables by multivariate analysis were a significant predictor of systolic blood pressure.
CONCLUSIONS
Age, sex, heart rate, cholesterol and weight are the most important predictors of blood pressure in school children.
PMCID: PMC2274857  PMID: 18651041
Atherosclerosis; Blood pressure; Cardiovascular risk factors; School children
17.  Reappraisal of the relation between blood lead concentration and blood pressure among the general population in Taiwan 
OBJECTIVES: The relation between blood lead concentration (PbB) and blood pressure was examined in a Taiwan nationwide population survey of PbB from July 1993 to June 1994. METHODS: After multistage sampling procedures, 2800 subjects (1471 males and 1329 females) with a mean (range) age of 44 (15-85) years were enrolled in this study. Anthropometric, blood pressure, and lifestyle factors were measured during household visits. The PbB was measured with a flameless atomic absorption spectrophotometer and all specimens were analysed in triplicate. RESULTS: The mean (range) PbB among all study subjects was 6.5 (0.1-69.1) micrograms/dl; among males it was 7.3 (0.1-69.1) micrograms/dl and among females 5.7 (0.1-40.1) micrograms/dl). The mean (range) systolic blood pressure among all subjects was 123 (80-210) mm Hg, among males it was 127 (80-200) mm Hg and among females 119 (80- 210) mm Hg. The diastolic blood pressure among all subjects was 78 (40- 150) mm Hg; among males it was 80 (40-130) mm Hg; and among females 75 (40-150) mm Hg. Age, body height, body weight, and body mass index (BMI) were significantly correlated with systolic blood pressure or diastolic blood pressure in both sexes. The PbB (or the natural logarithmic transformed PbB) was not significantly correlated with blood pressure among males or females. After adjustment for the potential confounders of age, age2, BMI, milk intake, alcohol consumption, and cigarette smoking, systolic blood pressure was significantly associated with PbB among males with a regression coefficient (beta) of 0.185 (p = 0.015). No significant association between PbB and blood pressure was found among females. CONCLUSIONS: From this study, only a weak association between systolic blood pressure and PbB was found among males. There was no strong evidence that PbB was a good predictor of blood pressure. However, the possibility that long term high body lead burden could cause high blood pressure could not be ruled out on the basis of this survey.
 
PMCID: PMC1757651  PMID: 10341743
18.  Anthropometry and Prevalence of Common Health Problems among School Going Children in Surathkal, Karnataka 
Aims: To measure the anthropometric data of school children and to compare with the CDC and Agarwal centile Growth charts. The prevalence of thinness, stunting, overweight and obesity were estimated. Children were also screened for hypertension, refractory errors, dental problems, skin disease and other abnormalities.
Design: Study was conducted in November in a central school in Surathkal, Dakshina Kannada, Karnataka, India. All children from nursery up to 10th standard were screened.
Materials and Methods: Weight and Height were measured using standard equipment and plotted on CDC and Agarwal Charts. BMI was calculated and plotted on both charts. Blood Pressure (BP) was taken using mercury sphygmomanometer by a trained nurse. Vision was tested using Snellens chart by refractionist. Dental evaluation was done by dentist.
Statistical analysis: Chi-square test and Student’s unpaired t test were used for statistical analysis. A statistical package SPSS version 17.0 were used. p<0.05 was considered as significant.
Results: Total 755 children were screened. Among these 392 (51.9%) were females and 363 (48.1%) were males. Eighty five (11.3%) children had short stature and 283 (37.5%) had under nutrition when plotted on CDC chart. Values were lower when plotted on Agarwal charts. Thinness was more prevalent than obesity and overweight. Majority were normotensive though hypertension was noted in 6(0.8%) children and prehypertension in 14(1.9%).112 children (16.3%) had undetected refractory error. Common skin disease noted was T.Versicolor in 27 children. Common dental problem noted was Caries teeth (22.9%).
Conclusion: Weight and height were below the CDC centile charts. Under nutrition was more prevalent than overweight and obesity. Majority were normotensive. High prevalence of undetected refractory error and caries teeth were noted. Prevalence of skin disease was low.
doi:10.7860/JCDR/2014/8769.5233
PMCID: PMC4316303  PMID: 25653997
Dental caries; Obesity; Refractory error; Stunting; Thinness
19.  Risk Stratification by Self-Measured Home Blood Pressure across Categories of Conventional Blood Pressure: A Participant-Level Meta-Analysis 
PLoS Medicine  2014;11(1):e1001591.
Jan Staessen and colleagues compare the risk of cardiovascular, cardiac, or cerebrovascular events in patients with elevated office blood pressure vs. self-measured home blood pressure.
Please see later in the article for the Editors' Summary
Background
The Global Burden of Diseases Study 2010 reported that hypertension is worldwide the leading risk factor for cardiovascular disease, causing 9.4 million deaths annually. We examined to what extent self-measurement of home blood pressure (HBP) refines risk stratification across increasing categories of conventional blood pressure (CBP).
Methods and Findings
This meta-analysis included 5,008 individuals randomly recruited from five populations (56.6% women; mean age, 57.1 y). All were not treated with antihypertensive drugs. In multivariable analyses, hazard ratios (HRs) associated with 10-mm Hg increases in systolic HBP were computed across CBP categories, using the following systolic/diastolic CBP thresholds (in mm Hg): optimal, <120/<80; normal, 120–129/80–84; high-normal, 130–139/85–89; mild hypertension, 140–159/90–99; and severe hypertension, ≥160/≥100.
Over 8.3 y, 522 participants died, and 414, 225, and 194 had cardiovascular, cardiac, and cerebrovascular events, respectively. In participants with optimal or normal CBP, HRs for a composite cardiovascular end point associated with a 10-mm Hg higher systolic HBP were 1.28 (1.01–1.62) and 1.22 (1.00–1.49), respectively. At high-normal CBP and in mild hypertension, the HRs were 1.24 (1.03–1.49) and 1.20 (1.06–1.37), respectively, for all cardiovascular events and 1.33 (1.07–1.65) and 1.30 (1.09–1.56), respectively, for stroke. In severe hypertension, the HRs were not significant (p≥0.20). Among people with optimal, normal, and high-normal CBP, 67 (5.0%), 187 (18.4%), and 315 (30.3%), respectively, had masked hypertension (HBP≥130 mm Hg systolic or ≥85 mm Hg diastolic). Compared to true optimal CBP, masked hypertension was associated with a 2.3-fold (1.5–3.5) higher cardiovascular risk. A limitation was few data from low- and middle-income countries.
Conclusions
HBP substantially refines risk stratification at CBP levels assumed to carry no or only mildly increased risk, in particular in the presence of masked hypertension. Randomized trials could help determine the best use of CBP vs. HBP in guiding BP management. Our study identified a novel indication for HBP, which, in view of its low cost and the increased availability of electronic communication, might be globally applicable, even in remote areas or in low-resource settings.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Globally, hypertension (high blood pressure) is the leading risk factor for cardiovascular disease and is responsible for 9.4 million deaths annually from heart attacks, stroke, and other cardiovascular diseases. Hypertension, which rarely has any symptoms, is diagnosed by measuring blood pressure, the force that blood circulating in the body exerts on the inside of large blood vessels. Blood pressure is highest when the heart is pumping out blood (systolic blood pressure) and lowest when the heart is refilling (diastolic blood pressure). European guidelines define optimal blood pressure as a systolic blood pressure of less than 120 millimeters of mercury (mm Hg) and a diastolic blood pressure of less than 80 mm Hg (a blood pressure of less than 120/80 mm Hg). Normal blood pressure, high-normal blood pressure, and mild hypertension are defined as blood pressures in the ranges 120–129/80–84 mm Hg, 130–139/85–89 mm Hg, and 140–159/90–99 mm Hg, respectively. A blood pressure of more than 160 mm Hg systolic or 100 mm Hg diastolic indicates severe hypertension. Many factors affect blood pressure; overweight people and individuals who eat salty or fatty food are at high risk of developing hypertension. Lifestyle changes and/or antihypertensive drugs can be used to control hypertension.
Why Was This Study Done?
The current guidelines for the diagnosis and management of hypertension recommend risk stratification based on conventionally measured blood pressure (CBP, the average of two consecutive measurements made at a clinic). However, self-measured home blood pressure (HBP) more accurately predicts outcomes because multiple HBP readings are taken and because HBP measurement avoids the “white-coat effect”—some individuals have a raised blood pressure in a clinical setting but not at home. Could risk stratification across increasing categories of CBP be refined through the use of self-measured HBP, particularly at CBP levels assumed to be associated with no or only mildly increased risk? Here, the researchers undertake a participant-level meta-analysis (a study that uses statistical approaches to pool results from individual participants in several independent studies) to answer this question.
What Did the Researchers Do and Find?
The researchers included 5,008 individuals recruited from five populations and enrolled in the International Database of Home Blood Pressure in Relation to Cardiovascular Outcome (IDHOCO) in their meta-analysis. CBP readings were available for all the participants, who measured their HBP using an oscillometric device (an electronic device for measuring blood pressure). The researchers used information on fatal and nonfatal cardiovascular, cardiac, and cerebrovascular (stroke) events to calculate the hazard ratios (HRs, indicators of increased risk) associated with a 10-mm Hg increase in systolic HBP across standard CBP categories. In participants with optimal CBP, an increase in systolic HBP of 10-mm Hg increased the risk of any cardiovascular event by nearly 30% (an HR of 1.28). Similar HRs were associated with a 10-mm Hg increase in systolic HBP for all cardiovascular events among people with normal and high-normal CBP and with mild hypertension, but for people with severe hypertension, systolic HBP did not significantly add to the prediction of any end point. Among people with optimal, normal, and high-normal CBP, 5%, 18.4%, and 30.4%, respectively, had a HBP of 130/85 or higher (“masked hypertension,” a higher blood pressure in daily life than in a clinical setting). Finally, compared to individuals with optimal CBP without masked hypertension, individuals with masked hypertension had more than double the risk of cardiovascular disease.
What Do These Findings Mean?
These findings indicate that HBP measurements, particularly in individuals with masked hypertension, refine risk stratification at CBP levels assumed to be associated with no or mildly elevated risk of cardiovascular disease. That is, HBP measurements can improve the prediction of cardiovascular complications or death among individuals with optimal, normal, and high-normal CBP but not among individuals with severe hypertension. Clinical trials are needed to test whether the identification and treatment of masked hypertension leads to a reduction of cardiovascular complications and is cost-effective compared to the current standard of care, which does not include HBP measurements and does not treat people with normal or high-normal CBP. Until then, these findings provide support for including HBP monitoring in primary prevention strategies for cardiovascular disease among individuals at risk for masked hypertension (for example, people with diabetes), and for carrying out HBP monitoring in people with a normal CBP but unexplained signs of hypertensive target organ damage.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001591.
This study is further discussed in a PLOS Medicine Perspective by Mark Caulfield
The US National Heart, Lung, and Blood Institute has patient information about high blood pressure (in English and Spanish) and a guide to lowering high blood pressure that includes personal stories
The American Heart Association provides information on high blood pressure and on cardiovascular diseases (in several languages); it also provides personal stories about dealing with high blood pressure
The UK National Health Service Choices website provides detailed information for patients about hypertension (including a personal story) and about cardiovascular disease
The World Health Organization provides information on cardiovascular disease and controlling blood pressure; its A Global Brief on Hypertension was published on World Health Day 2013
The UK charity Blood Pressure UK provides information about white-coat hypertension and about home blood pressure monitoring
MedlinePlus provides links to further information about high blood pressure, heart disease, and stroke (in English and Spanish)
doi:10.1371/journal.pmed.1001591
PMCID: PMC3897370  PMID: 24465187
20.  Seaweed intake and blood pressure levels in healthy pre-school Japanese children 
Nutrition Journal  2011;10:83.
Background
Few studies have examined whether dietary factors might affect blood pressure in children. We purposed to investigate whether seaweed intake is associated with blood pressure level among Japanese preschool children.
Methods
The design of the study was cross-sectional and it was conducted in autumn 2006. Subjects were healthy preschoolers aged 3-6 years in Aichi, Japan. Blood pressure and pulse were measured once by an automated sphygmomanometer, which uses oscillometric methods. Dietary data, including seaweed intake, were assessed using 3-day dietary records covering 2 consecutive weekdays and 1 weekend day. Of a total of 533 children, 459 (86.1 percent) agreed to be enrolled in our study. Finally, blood pressure measurement, complete dietary records and parent-reported height and weight were obtained for 223 boys and 194 girls.
Results
When we examined Spearman's correlation coefficients, seaweed intake was significantly negatively related to systolic blood pressure in girls (P = 0.008). In the one-way analysis of covariance for blood pressure and pulse after adjustments for age and BMI, the boys with the lowest, middle and highest tertiles of seaweed intake had diastolic blood pressure readings of 62.8, 59.3 and 59.6 mmHg, respectively (P = 0.11, trend P = 0.038). Girls with higher seaweed intake had significantly lower systolic blood pressure readings (102.4, 99.2 and 96.9 mmHg for girls with the lowest, middle and highest tertiles of seaweed intake, respectively; P = 0.037, trend P = 0.030).
Conclusion
Our study showed that seaweed intake was negatively related to diastolic blood pressure in boys and to systolic blood pressure in girls. This suggests that seaweed might have beneficial effects on blood pressure among children.
doi:10.1186/1475-2891-10-83
PMCID: PMC3199754  PMID: 21827710
blood pressure; child, preschool; diet records; seaweed; nutrition
21.  Increased Cerebral Blood Flow Velocity in Children with Mild Sleep-Disordered Breathing 
Pediatrics  2006;118(4):e1100-e1108.
Objective
Sleep-disordered breathing describes a spectrum of upper airway obstruction in sleep from simple primary snoring, estimated to affect 10% of preschool children, to the syndrome of obstructive sleep apnea. Emerging evidence has challenged previous assumptions that primary snoring is benign. A recent report identified reduced attention and higher levels of social problems and anxiety/depressive symptoms in snoring children compared with controls. Uncertainty persists regarding clinical thresholds for medical or surgical intervention in sleep-disordered breathing, underlining the need to better understand the pathophysiology of this condition. Adults with sleep-disordered breathing have an increased risk of cerebrovascular disease independent of atherosclerotic risk factors. There has been little focus on cerebrovascular function in children with sleep-disordered breathing, although this would seem an important line of investigation, because studies have identified abnormalities of the systemic vasculature. Raised cerebral blood flow velocities on transcranial Doppler, compatible with raised blood flow and/or vascular narrowing, are associated with neuropsychological deficits in children with sickle cell disease, a condition in which sleep-disordered breathing is common. We hypothesized that there would be cerebral blood flow velocity differences in sleep-disordered breathing children without sickle cell disease that might contribute to the association with neuropsychological deficits.
Design
Thirty-one snoring children aged 3 to 7 years were recruited from adenotonsillectomy waiting lists, and 17 control children were identified through a local Sunday school or as siblings of cases. Children with craniofacial abnormalities, neuromuscular disorders, moderate or severe learning disabilities, chronic respiratory/cardiac conditions, or allergic rhinitis were excluded. Severity of sleep-disordered breathing in snoring children was categorized by attended polysomnography. Weight, height, and head circumference were measured in all of the children. BMI and occipitofrontal circumference z scores were computed. Resting systolic and diastolic blood pressure were obtained. Both sleep-disordered breathing children and the age- and BMI-similar controls were assessed using the Behavior Rating Inventory of Executive Function (BRIEF), Neuropsychological Test Battery for Children (NEPSY) visual attention and visuomotor integration, and IQ assessment (Wechsler Preschool and Primary Scale of Intelligence Version III). Transcranial Doppler was performed using a TL2-64b 2-MHz pulsed Doppler device between 2 PM and 7 PM in all of the patients and the majority of controls while awake. Time-averaged mean of the maximal cerebral blood flow velocities was measured in the left and right middle cerebral artery and the higher used for analysis.
Results
Twenty-one snoring children had an apnea/hypopnea index <5, consistent with mild sleep-disordered breathing below the conventional threshold for surgical intervention. Compared with 17 nonsnoring controls, these children had significantly raised middle cerebral artery blood flow velocities. There was no correlation between cerebral blood flow velocities and BMI or systolic or diastolic blood pressure indices. Exploratory analyses did not reveal any significant associations with apnea/hypopnea index, apnea index, hypopnea index, mean pulse oxygen saturation, lowest pulse oxygen saturation, accumulated time at pulse oxygen saturation <90%, or respiratory arousals when examined in separate bivariate correlations or in aggregate when entered simultaneously. Similarly, there was no significant association between cerebral blood flow velocities and parental estimation of child’s exposure to sleep-disordered breathing. However, it is important to note that whereas the sleep-disordered breathing group did not exhibit significant hypoxia at the time of study, it was unclear to what extent this may have been a feature of their sleep-disordered breathing in the past. IQ measures were in the average range and comparable between groups. Measures of processing speed and visual attention were significantly lower in sleep-disordered breathing children compared with controls, although within the average range. There were similar group differences in parental-reported executive function behavior. Although there were no direct correlations, adjusting for cerebral blood flow velocities eliminated significant group differences between processing speed and visual attention and decreased the significance of differences in Behavior Rating Inventory of Executive Function scores, suggesting that cerebral hemodynamic factors contribute to the relationship between mild sleep-disordered breathing and these outcome measures.
Conclusions
Cerebral blood flow velocities measured by noninvasive transcranial Doppler provide evidence for increased cerebral blood flow and/or vascular narrowing in childhood sleep-disordered breathing; the relationship with neuropsychological deficits requires further exploration. A number of physiologic changes might alter cerebral blood flow and/or vessel diameter and, therefore, affect cerebral blood flow velocities. We were able to explore potential confounding influences of obesity and hypertension, neither of which explained our findings. Second, although cerebral blood flow velocities increase with increasing partial pressure of carbon dioxide and hypoxia, it is unlikely that the observed differences could be accounted for by arterial blood gas tensions, because all of the children in the study were healthy, with no cardiorespiratory disease, other than sleep-disordered breathing in the snoring group. Although arterial partial pressure of oxygen and partial pressure of carbon dioxide were not monitored during cerebral blood flow velocity measurement, assessment was undertaken during the afternoon/early evening when the child was awake, and all of the sleep-disordered breathing children had normal resting oxyhemoglobin saturation at the outset of their subsequent sleep studies that day. Finally, there is an inverse linear relationship between cerebral blood flow and hematocrit in adults, and it is known that iron-deficient erythropoiesis is associated with chronic infection, such as recurrent tonsillitis, a clinical feature of many of the snoring children in the study. Preoperative full blood counts were not performed routinely in these children, and, therefore, it was not possible to exclude anemia as a cause of increased cerebral blood flow velocity in the sleep-disordered breathing group. However, hemoglobin levels were obtained in 4 children, 2 of whom had borderline low levels (10.9 and 10.2 g/dL). Although there was no apparent relationship with cerebral blood flow velocity in these children (cerebral blood flow velocity values of 131 and 130 cm/second compared with 130 and 137 cm/second in the 2 children with normal hemoglobin levels), this requires verification. It is of particular interest that our data suggest a relationship among snoring, increased cerebral blood flow velocities and indices of cognition (processing speed and visual attention) and perhaps behavioral (Behavior Rating Inventory of Executive Function) function. This finding is preliminary: a causal relationship is not established, and the physiologic mechanisms underlying such a relationship are not clear. Prospective studies that quantify cumulative exposure to the physiologic consequences of sleep-disordered breathing, such as hypoxia, would be informative.
doi:10.1542/peds.2006-0092
PMCID: PMC1995426  PMID: 17015501
sleep disordered breathing; cerebral blood flow; transcranial Doppler; executive function; neuropsychological function
22.  Arterial distensibility in children and teenagers: normal evolution and the effect of childhood vasculitis 
Archives of Disease in Childhood  2002;87(4):348-351.
Background: Polyarteritis nodosa is a necrotising vasculitis of the medium sized and small muscular arteries. The inflammatory and subsequent reparative processes may alter the arterial mechanical properties. The effect of vasculitic damage on arterial distensibility has never been explored however.
Aim: To determine the normal values and the effect of childhood vasculitis on arterial distensibility in children and teenagers.
Methods: Distensibility of the brachioradial arterial segment was studied using pulse wave velocity (PWV ∝1/√distensibility), in 13 children with polyarteritis nodosa at a median age of 11.8 (range 4.9–16) years. As a control group, 155 healthy schoolchildren (6–18 years, 81 boys) were studied. PWV was assessed using a photoplethysmographic technique; blood pressure was measured by an automatic sphygmomanometer (Dinamap). Data from patients were expressed as z scores adjusted for age and compared to a population mean of 0 by a single sample t test. Determinants of PWV in normal children were assessed by univariate and multivariate linear regression analyses.
Results: Age, height, weight, and systolic blood pressure correlated individually with the brachioradial PWV. Multivariate analysis identified age as the only independent determinant. Ten of the patients were in clinical remission, while three had evidence of disease activity at the time of study. The PWV in the patient group as a whole was significantly greater than those in healthy children (mean z score +0.99). Raised C reactive protein concentration (>2 mg/dl) in the three patients with active disease was associated with a higher PWV when compared to those in remission (z score +2.78 v +0.45). The diastolic blood pressure of the patients was higher than those of the controls (z score +1.04) while the systolic pressure was similar (z score -0.36).
Conclusions: PWV in the brachioradial arterial segment increases gradually during childhood independent of body weight, height, mass, and blood pressure. Increased PWV, and hence decreased distensibility, in this peripheral arterial segment occurs in polyarteritis nodosa and is amplified during acute inflammatory exacerbation.
doi:10.1136/adc.87.4.348
PMCID: PMC1763025  PMID: 12244018
23.  Growth and very low birth weight. 
Archives of Disease in Childhood  1989;64(3):379-382.
Information on the likelihood of catch up growth in poorly grown very low birthweight children is sparse. The centiles for weight, height, and head circumference were recorded at both 2 and 5 years of age for 135 very low birthweight children and 42 normal birthweight children. At both ages significantly more children of very low birth weight were under the 10th centile for weight and height. Children of birth weight under 1000 g were more often under the 10th centile for weight at 5 years compared with those of birth weight 1000-1500 g. Mean incremental weight gain between 2 and 5 years was significantly less for very low birthweight children. Mean increment in weight from 2 to 5 years was less for very low birthweight children who had been under the 10th centile for weight at 2 years; children who had been under the 10th centile for height also had lower mean height increments. The growth centiles achieved by 2 years of age were useful predictors of poor growth at 5 years, with perinatal data of marginal importance. Only six of 43 (14%) children with a weight at 5 years of age under the 10th centile were small for gestational age at birth. Very low birthweight children who had a weight or height under the 10th centile at 2 years of age usually remained in this category at 5 years with no evidence of catch up growth.
PMCID: PMC1791899  PMID: 2705802
24.  Reduced final height and indications for insulin resistance in 20 year olds born small for gestational age: regional cohort study. 
BMJ : British Medical Journal  1997;315(7104):341-347.
OBJECTIVE: To investigate whether the association between low birth weight and increased risk of developing impaired glucose tolerance, insulin resistance, hypertriglyceridaemia, and hypertension in middle age is apparent by the age of 20 in people born small for gestational age. DESIGN: Regional cohort study. SETTING: Maternity registry, Haguenau, France. SUBJECTS: 236 full term singleton babies born small for gestational age (birth weight or length, or both, below third centile) during 1971-8 and 281 with normal birth weight (between 25th and 75th centile). All subjects were contacted and evaluated at a mean (SD) age of 20.6 (2.1) years. MAIN OUTCOME MEASURES: Adult height; concentrations of glucose, insulin, and proinsulin during an oral glucose tolerance test; lipid and fibrinogen concentrations; and blood pressure. RESULTS: After sex and target height were adjusted for, subjects who had been born small for gestational age were significantly shorter at age 20 than those with a normal birth weight (men 4.5 cm shorter (95% confidence interval 6.0 to 3.0 cm); women 3.94 cm shorter (5.2 to 2.7 cm)). After sex and body mass index were adjusted for, mean plasma glucose concentration 30 minutes after a glucose load, fasting insulin concentration (in women), and insulin and proinsulin concentrations 30 and 120 minutes after a glucose load were significantly higher in subjects who had been born small for gestational age than in those with a normal birth weight. Mean lipid and fibrinogen concentrations and blood pressure were not different between the two groups. CONCLUSIONS: Intrauterine growth retardation has long term consequences such as reduced final height Raised insulin and proinsulin concentrations are present in young adults born small for gestational age and could be markers of early changes in insulin sensitivity.
PMCID: PMC2127259  PMID: 9270455
25.  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

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