Blood pressure percentiles in 22,051 German children and adolescents: The PEP Family Heart Study

The ongoing impact of obesity on childhood hypertension

Obesity rates among children have been steadily rising over the past several decades. This epidemic has been accompanied by an increase in the prevalence of childhood hypertension, with children in low- and middle-income countries being affected to the same extent as children in high-income countries. This review will examine the trends in childhood blood pressure and the relationship between excess body weight and the development of hypertension. In addition, distinct mechanisms of obesity-related hypertension will be discussed. There will be an emphasis on recent studies conducted since the publication of new guidelines by the American Academy of Pediatrics in 2017 which resulted in the adoption of lower normative blood pressure cutoffs. The overall intent of this review is to provide the reader with an understanding of the ongoing impact, and complexities, of obesity-related hypertension.

Four-year longitudinal associations of physical activity, waist circumference, and blood pressure in UK adolescents

BACKGROUND

This study assessed the specific influence of physical activity (PA) and waist circumference (WC) on the 4-year growth trajectory of blood pressure in UK high-school students.

METHODS

Four-year longitudinal monitoring of 1501 adolescents was conducted as part of the EoEHHS. Measurements were taken in Grades (G)7, 9, and 11.

RESULTS

Systolic (SBP) and diastolic blood pressure (DBP) increased over the 4-year period (SBP G7 114.6 ± 8.9 mmHg, G9 118.1 ± 9.7 mmHg, G11 122.8 ± 7.8 mmHg; DBP G7 66.7 ± 6.6 mmHg, G9 68.0 ± 6.4 mmHg, G11 70.0 ± 5.2 mmHg). Baseline WC predicted baseline and growth in SBP, but the strongest contribution to SBP came from changes in WC (β = 0.084, p = 0.002). Baseline PAQ-A score (β = -0.822, p = 0.020) and changes in PAQ-A score (β = -0.650, p = 0.019) were associated with smaller increases in DBP over the 4-year measurement period.

CONCLUSIONS

Baseline and change in WC predicted the growth trajectory of SBP, while baseline and change in PA predicted the growth trajectory of DBP. PA and WC have a prognostic value in predicting changes in blood pressure in adolescents. Increasing PA during adolescence could slow the rise in DBP over time. This is meaningful for future hypertension and CVD risk reduction into adulthood.

IMPACT

Hypertension in adolescents is a growing health problem that is often overlooked. Baseline and changes in waist circumference over a 4-year period predicted development of systolic blood pressure, while baseline and changes in physical activity predicted development of diastolic blood pressure. Physical activity and waist circumference have a prognostic value in predicting changes in blood pressure in adolescents and could be valuable in planning programmes to prevent hypertension in similar communities and reduce the risk of future adult hypertension.

Reference blood pressure values obtained using the auscultation method for 2-year-old Japanese children: from the Japan Environment and Children's Study

BACKGROUND

Reference blood pressure (BP) values for Japanese children based on a large number of measurements by auscultation have not yet been established.

METHODS

This was a cross-sectional analysis of data from a birth-cohort study. The data from the sub-cohort study conducted for children at the age of 2 years in the Japan Environment and Children's Study from April 2015 to January 2017 were analyzed. BP was measured via auscultation using an aneroid sphygmomanometer. Each participant was measured in triplicate, and the average value of two consecutive measurements with a difference of less than 5 mmHg was recorded. The reference BP values were estimated using the lambda-mu-sigma (LMS) method and compared with those obtained via the polynomial regression model.

RESULTS

Data from 3361 participants were analyzed. Although the difference between the estimated BP values by the LMS and the polynomial regression model was small, the LMS model was more valid based on the results of the fit curve of the observed values and regression models for each model. For 2-year-old children with heights in the 50th percentile, the 50th, 90th, 95th, and 99th percentile reference values of systolic BP (mmHg) for boys were 91, 102, 106, and 112, and that for girls were 90, 101, 103, and 109, respectively, and those of diastolic BP for boys were 52, 62, 65, and 71, and that for girls were 52, 62, 65, and 71, respectively.

CONCLUSION

The reference BP values for 2-year-old Japanese children were determined based on auscultation and were made available.

Appraisal of Clinical Care Practices for Child Obesity Treatment. Part II: Comorbidities

The objective of this technical report is to provide clinicians with actionable evidence-based information upon which to make treatment decisions. In addition, this report will provide an evidence base on which to inform clinical practice guidelines for the management and treatment of overweight and obesity in children and adolescents. To this end, the goal of this report was to identify all relevant studies to answer 2 overarching key questions: (KQ1) "What are effective clinically based treatments for obesity?" and (KQ2) "What is the risk of comorbidities among children with obesity?" See Appendix 1 for the conceptual framework and a priori Key Questions.

Normative values and a new predicted model of exercise blood pressure in young athletes

OBJECTIVES

Assessing the systolic and diastolic blood pressure during acute physical exertion can allow the discovery of many cardiovascular diseases even at a young age. However, this response depends on the age, sex of the subject, and the modality of the graded exercise test. This study aims to provide sex-and age-related normative values of peak and recovery blood pressure performance and to develop a predicted model of systolic and diastolic blood pressure peak in young athletes.

DESIGN

Retrospective-study.

METHODS

We analyzed 8224 young athletes (5516 males and 2708 females) aged between 8 and 18. Anthropometric and blood pressure parameters related to the effort are reported. Then, according to sex, graded exercise test modality, and age were calculated 1) the fifth, tenth, fiftieth, ninetieth, and ninety-fifth percentiles for the systolic and diastolic blood pressure at peak and after 1 min of recovery and 2) predictive equations of systolic and diastolic blood pressure at the peak.

RESULTS

Younger athletes show lower peak blood pressure values, gradually increasing as they age. Males showed higher peak systolic blood pressure values starting at 12-13 years on the cycle ergometer and 10-11 years on the treadmill, while there was no difference in peak diastolic blood pressure values.

CONCLUSIONS

Sex, age, and the specificity of the movement performed must be considered in assessing the blood pressure response in the young population. In addition, providing reference values and predictive equations of blood pressure response to acute physical exertion may allow for a better functional assessment of young athletes.

Screening for metabolic complications of childhood and adolescent obesity: A scoping review of national and international guidelines

The rise in prevalence of childhood obesity is paralleled by an increase in obesity-related metabolic complications, which add significantly to the population burden of cardiovascular morbidity in the long term. Early detection of obesity-related metabolic complications through appropriate screening strategies forms a crucial aspect of obesity management. We performed a scoping review of international and national guidelines on the management of pediatric obesity to evaluate the recommendations on screening for metabolic complications, namely, hypertension, diabetes, dyslipidemia, and non-alcoholic fatty liver disease. Thirty guidelines were included, 23 (76.7%) of which had some guidance on screening for metabolic complications. However, there were significant variations in the extent and details of recommendations for screening for these metabolic complications. There has been no consensus on the body mass index (BMI) thresholds, age of onset, frequency, and screening tests recommended for detecting hypertension, diabetes, dyslipidemia, and non-alcoholic fatty liver disease between guidelines. These variations did not appear to be polarized based on geographical location or population ethnicity. We provide our recommendations on metabolic screening based on the strength of evidence in the guidelines, also incorporating recommendations from key childhood hypertension, diabetes, and lipid guidelines. Appropriate implementation of screening strategies is crucial to improve detection of metabolic complications, to allow for earlier or more intensified interventions for affected children with obesity.

The associations between problematic smartphone use and blood pressure among 2,573 aged 9-17 years students in Shanghai, China

Objectives

This study aimed to (1) examine the cross-sectional association between problematic smartphone use (PSU) and blood pressure (BP) in children and adolescents and (2) determine whether the association between PSU and BP differs by the grade of students.

Methods

We recruited a total of 2,573 participants from 14 schools in Shanghai by a two-stage sampling method. We derived BP data from the participant's most recent medical examination data, including systolic blood pressure (SBP) and diastolic blood pressure (DBP). We measured PSU by a modified PSU Classification Scale. We also assessed demographic characteristics, body mass index, behavioral variables, and physiological characteristics.

Results

High school students had higher BP and PSU scores than primary and middle school students. PSU on the dimension of information collection was associated positively with both SBP and DBP among primary and middle school students, with the β (95% CI) values of 0.282 (0.018, 0.546) and 0.229 (0.031, 0.427). Meanwhile, the dimension of the relationship of social network was associated positively with SBP among primary and middle school students, with a β (95% CI) value of 0.390 (0.062, 0.717). PSU on the dimension of information collection was positively associated with the development of high BP, with a OR (95% CI) value of 1.072 (1.011, 1.137) among primary and middle school students.

Conclusions

PSU might be a potential correlate of high BP among school-age children and adolescents. The associations between PSU and BP differed by the grade of students as well as according to the four dimensions of PSU.

Family history of arterial hypertension and central adiposity: impact on blood pressure in schoolchildren

BACKGROUND

A family history of arterial hypertension is an important risk factor for arterial hypertension. This study aimed to verify the mediating role of high central adiposity in the relationship between family history of arterial hypertension and blood pressure in schoolchildren.

METHODS

Cross-sectional study with 118 schoolchildren of both sexes aged between 11 and 17 years. Weight, height, waist circumference and body mass index z score were verified. Somatic maturation was predicted by age for peak growth velocity. The family history of arterial hypertension was verified and defined as hypertensive schoolchildren with systolic blood pressure or diastolic blood pressure. Mediation analysis was used with linear regression models applied by PROCESS macro for SPSS (version 22.0), with significance p < 0.05.

RESULTS

It was observed that 34.7% of the students have family history of arterial hypertension, 36% of the girls and 44.2% of the boys have arterial hypertension. In girls, the relationship between waist circumference and systolic blood pressure was direct (β = 0.535 p = 0.005), and those with a family history of arterial hypertension and who had a waist circumference greater than those without a family history of arterial hypertension was significant (β = -5,437 p = 0.009). Likewise, the relationship between family history of arterial hypertension and systolic blood pressure was attenuated when waist circumference was included in the model (β = -5.544; p = 0.103), indicating waist circumference as a mediator with an influence percentage of 19%. For boys, waist circumference is not a mediator of the relationship between family history of arterial hypertension and blood pressure.

CONCLUSIONS

Elevated central adiposity was a mediator of the relationship between family history of arterial hypertension and high blood pressure in girls, indicating the importance of family health strategies in the prevention and management of arterial hypertension in children and adolescents.

Disparities in the Prevalence of Childhood Obesity-Related Comorbidities: A Systematic Review

Background

Non-communicable diseases among children are serious consequences of childhood obesity. However, less is known about the disparities in childhood obesity comorbidities burden. This review describes the salient pattern of disparities in the prevalence of childhood obesity-related non-communicable diseases and relevant inequalities in both high- and low/medium-income countries.

Method

A systematic literature search was performed in MEDLINE, Embase, CINAHL, PsycInfo, Scopus, and Web of Science databases by two independent reviewers. Inclusion criteria were as follows: age 2–18 years; the prevalence or incidence of childhood obesity comorbidities reported; and studies published in English from January 2010 to date. No restrictions on the setting. The prevalence data were analyzed using range and median for subgroups based on the country's development status, gender, and geographical region.

Results

Our search identified 6,837 articles, out of which we examined 145 full-text articles and included 54 articles in the analysis. The median prevalence of childhood obesity-related hypertension was 35.6 vs. 12.7% among middle- and low-income countries compared with high-income countries; 37.7 vs. 32.9% among boys compared with girls; and 38.6, 25.3, and 20.1% in Asia, South America, and Europe, respectively. For metabolic syndrome, the median prevalence was 26.9 vs. 5.5% among middle- and low-income countries compared with high-income countries; 55.2 vs. 12.0% among boys compared with girls; and 40.3, 25.8, and 7.7% in South America, Asia, and Europe, respectively. The prevalence of childhood obesity-related non-alcoholic fatty liver disease was 47.5 vs. 23% among middle- and low-income countries compared with high-income countries; and 52.1, 39.7, and 23.0% in Asia, South America, and Europe, respectively. The median prevalence of dyslipidemia was 43.5 vs. 63% among middle- and low-income countries compared with high-income countries; 55.2 vs. 12.0% among boys compared to girls; and 73.7 and 49.2% in Australia and Europe, respectively.

Conclusion

There are disparities in the prevalence of childhood obesity-related hypertension, metabolic syndrome, and non-alcoholic fatty liver disease, with middle- and low-income countries, boys, and Asian region having higher prevalence. Implementing targeted interventions for childhood obesity comorbidities should consider socioeconomic disparities and strengthening of research surveillance methods for a better understanding of non-communicable disease burden in the pediatric population.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42021288607.

Migrating Populations and Health: Risk Factors for Cardiovascular Disease and Metabolic Syndrome

PURPOSE OF REVIEW

To summarize results of recent studies of migrants in Europe and North America and ongoing efforts to adapt strategies to provide them with inclusive sensitive health care.

RECENT FINDINGS

Major predisposing factors for developing hypertension, obesity, diabetes, and the metabolic syndrome in migrating populations and refugees were identified. Susceptibility to the metabolic syndrome is predominantly due to environmental factors and psychological stress. Acculturation also contributes to the emergence of cardiovascular (CV) risk factors in first-generation adult immigrants. Increased risk for later development of hypertension and dyslipidemia has also been detected in adolescent immigrants. Targets for public health efforts were based on data that show important differences in CV risk factors and prevalence of the metabolic syndrome among ethnic immigrant groups. Studies in young adults focused on lifestyle and dietary behaviors and perceptions about weight and body image, while the focus for older adults was end-of-life issues. Two important themes have emerged: barriers to health care, with a focus on cultural and language barriers, and violence and its impact on immigrants' mental health.

The prevalence of hypertension in Chinese adolescents aged 15-17 years: A comparison of different criteria

This study intended to compare the prevalence of hypertension in adolescents aged 15–17 years in China according to different criteria defined by various guidelines. We included 28 715 adolescents aged 15–17 years from the China Hypertension Survey study (CHS) 2012–2015, and the 2017 American Association of Pediatrics (AAP) Clinical Practice Guideline and 2018 Chinese guidelines for children and adults were used to define hypertension. The prevalence of hypertension among Chinese adolescents aged 15–17 years was 24.4% according to the 2018 Chinese guidelines for children; the corresponding values were 18.6% according to the 2017 AAP Guidelines, and 3.5% according to 2018 Chinese guidelines for adults. The age‐specific prevalence of hypertension in the age of 15, 16, and 17 years in the same population was 26.2%, 24.4%, and 23.3% according to 2018 Chinese guidelines for children; 18.8%, 17.9%, and 19.2% as per the 2017 AAP Guidelines; 3.4%, 3.4%, and 3.6% as per the 2018 Chinese guidelines for adults. A highest prevalence of hypertension was observed according to 2018 Chinese guidelines for children than the other two guidelines. Compared with the 2018 Chinese guidelines for children, a higher 95^th percentile BP (systolic and diastolic) was also observed in the present study in each gender‐age‐height‐specific group. And the height, which was key factor to influence blood pressure, was similar between adolescents aged 15–17 and adults, and a paralleled result was seen in the present study. Therefore, the 2018 Chinese guidelines for adults may also be appropriate for adolescents aged 15–17 years.

Approach to Hypertension in Adolescents and Young Adults

PURPOSE OF REVIEW

The prevalence of hypertension in adolescents and young adults has increased in part due to the obesity epidemic. The clinical impact and future cardiovascular risk of this underestimated public health problem is an evolving field.

RECENT FINDINGS

The development of hypertension is predicted by tracking of elevated blood pressure from childhood to adulthood. Young hypertensive individuals have lower awareness, slower diagnosis rates, and poorer blood pressure control than older patients. Increased awareness, appropriate screening, early identification, and individualized treatment approaches for elevated blood pressure could prevent development of hypertension in adulthood and cardiovascular events in later life. The optimal blood pressure management for young adults with a low 10-year risk of atherosclerotic cardiovascular disease of < 10% remains challenging due to lack of randomized controlled trials. Evidence-based recommendations are needed to implement appropriate measures for time of treatment initiation, preferred antihypertensive drug class to be used and optimal target blood pressure level from childhood through young adulthood.

Comparison of China Reference with Different National and International References: The Prevalence of High Blood Pressure in 695,302 Children and Adolescents in a Metropolis of Yangtze River Delta, China

Objectives

This study aimed to compare performances of China reference and different national references on high blood pressure (HBP).

Methods

A cross-sectional study including 695,302 children and adolescents aged 7 to 17 years in Suzhou, China, was conducted to determine the prevalence of HBP based on U.S., international, Europe, and China references in 2016.

Results

Different percentiles of height and blood pressure were found among four references. Referring to U.S. reference, the prevalence of HBP was the highest with 26.0%, followed by International reference with 20.0%, Europe reference with 19.5%, and China reference with 19.2%. McNemar tests indicated statistically significant differences between HBP prevalence comparing China reference with the other 3 references (P < 0.001). The area under the curve was 0.947, 0.851, and 0.949 for U.S., international, and Europe reference, respectively. U.S. reference showed the highest sensitivity (98.2%), but the lowest specificity (91.2%), and Europe reference showed the highest kappa value (0.893).

Conclusions

The prevalence of HBP varied among these four references, and the appropriate choice of reference would be important to recognize high-risk children and judge the trends of HBP prevalence in the targeted population.

MIS-C Treatment: Is IVIG Always Necessary?

Background: MIS-C is a potentially severe inflammatory syndrome associated with SARS-CoV-2 exposure. Intravenous immunoglobulin (IVIG) is considered the first-tier therapy, but it implies infusion of large fluid volumes that may worsen cardiac function. Patients and Methods: Since April 2020, we have developed a treatment protocol that avoids the infusion of IVIG as first-line therapy in the early phase of MIS-C. In this study, we retrospectively analyzed a cohort of consecutive patients treated according to this protocol between 01/04/2020 and 01/04/2021. Results: In the last year, 31 patients have been treated according to the protocol: 25 with high-dose pulse MP (10 mg/kg) and 6 with 2 mg/kg. 67.7% of the patients responded to the initial treatment, while the others needed a step-up, either with Anakinra (25.8%) or with MP dose increase (6.5%). IVIG was administered in four patients. Overall, only one patient (3.2%) needed ICU admission and inotropic support; one patient developed a small coronary artery aneurysm. Conclusions: Timely start of MP therapy and careful fluid management might improve the outcomes of MIS-C patients.

Prevalence of hypertension among adolescents (10-19 years) in India: A systematic review and meta-analysis of cross-sectional studies

BACKGROUND

Despite the well-known short-term and long-term ill effects of elevated blood pressure in children and adolescents, pooled data on its burden among Indian adolescents have not yet been synthesized.

OBJECTIVES

We did a systematic review with meta-analysis to calculate the pooled prevalence of hypertension among adolescents (10-19 years) in India.

METHODS

We searched PubMed, Embase, Cochrane library, Google Scholar and IndMed, and included cross-sectional studies reporting data on hypertension prevalence among 10 to19 years old and published in English language from their inception till 1st March 2020. Modified New castle Ottawa scale was used to assess risk of bias based on research design, recruitment strategy, response rate and reliability of outcome determination. A random effects model was used to estimate pooled prevalence, and heterogeneity was assessed using Cochrane's Q statistic test of heterogeneity and I2 statistic. To explore the heterogeneity, we did a meta-regression, and sub-group analyses based on region, study setting and number of blood pressure readings.

RESULTS

Out of 25 studies (pooled sample of 27,682 participants) six studies were of high, eighteen of moderate, and one was of low quality. The prevalence of hypertension across studies ranged from 2% to 20.5%, with a pooled estimate of 7.6% (95% CI: 6.1 to 9.1%), I2 = 96.6% (p-value <0.001). Sub-group analysis restricted only to the western India demonstrated a smaller heterogeneity (I2 = 18.3%). In univariate model of meta-regression, diagnostic criteria was significantly associated with pooled prevalence (-4.33, 95%CI: -7.532, -1.134).

CONCLUSION

The pooled prevalence of hypertension among adolescent in India is 7.6% with substantial heterogeneity between the studies. To tackle the high prevalence of hypertension among adolescents, early detection by screening under school health programme and opportunistic screening at Paediatric OPD should be implemented by Policy makers.

Updated and revised normal values of aortic pulse wave velocity in children and adolescents aged 3-18 years

Measurement of aortic pulse wave velocity (PWV_ao) is recommended for stratifying individual cardiovascular (CV) risk in adults. Diseases in children and adolescents might influence aortic stiffness. It is necessary to exclude overweight (OW), obese (O) subjects, and individuals with increased systolic (SBP) and/or diastolic blood pressure (DBP) from the population, when creating normal values of PWV_ao in children and adolescents. Body mass index (BMI), SBP/DBP cut-off values have remarkably changed in this population during the last decade. Aims of our study were to expand our previously published PWV_ao database and to revise it by using the recently determined normal values. PWV_ao was measured by an occlusive-oscillometric device (Arteriograph, TensioMed Ltd, Budapest, Hungary) in a healthy population aged 3-18 years. 7940 (4374 boys) participants were recruited, 1912 OW/O subjects and 1368 individuals with high SBP/DBP were excluded. Finally, n = 4690 (2599 boys) participants were enrolled. Mean PWV_ao values increased from 5.4 ± 0.6 to 6.4 ± 0.5 m/s (p < 0.05) in boys and from 5.5 ± 0.6 to 6.4 ± 0.5 m/s (p < 0.05) in girls. Mean PWV_ao values were significantly lower in our new study, in boys in age groups of 9-16, in girls in age groups of 11-17. This is the largest and widest age-ranged database of PWV_ao published to date. Due to the change of BMI and SBP/DBP reference values during the last decade, the "old" database of PWV_ao needed to be revised. As a result of this, normal values of PWV_ao decreased significantly in both sexes.

A comparison of clinical paediatric guidelines for hypotension with population-based lower centiles: a systematic review

Background

Different definitions exist for hypotension in children. In this study, we aim to identify evidence-based reference values for low blood pressure and to compare these with existing definitions for systolic hypotension.

Methods

We searched online databases until February 2019 (including MEDLINE, EMBASE, Web of Science) using a comprehensive search strategy to identify studies that defined age-related centiles (first to fifth centile) for non-invasive systolic blood pressure in healthy children < 18 years. Existing cut-offs for hypotension were identified in international guidelines and textbooks. The age-related centiles and clinical cut-offs were compared and visualized using step charts.

Results

Fourteen studies with population-based centiles were selected, of which 2 addressed children < 1 year. Values for the fifth centile differed 8 to 17 mmHg for age. We identified 13 clinical cut-offs of which only 5 reported accurate references. Age-related cut-offs for hypotension showed large variability (ranging from 15 to 30 mmHg). The clinical cut-offs varied in agreement with the low centiles. The definition from Paediatric Advanced Life Support agreed well for children < 12 years but was below the fifth centiles for children > 12 years. For children > 12 years, the definition of Parshuram’s early warning score agreed well, but the Advanced Paediatric Life Support definition was above the fifth centiles.

Conclusions

The different clinical guidelines for low blood pressure show large variability and low to moderate agreement with population-based lower centiles. For children < 12 years, the Paediatric Advanced Life Support definition fits best but it underestimates hypotension in older children. For children > 12 years, the Advanced Paediatric Life Support overestimates hypotension but Parshuram’s cut-off for hypotension in the early warning score agrees well. Future studies should focus on developing reference values for hypotension for acutely ill children.

Family Based Prevention of Cardiovascular Disease Risk Factors in Children by Lifestyle Change: The PEP Family Heart Study

AIM

The 14 years' Prevention Education Program PEP was started 1994 among first graders, their siblings and parents living in the half million city Nuremberg (Germany). The aim of prospective family-based observational study was early detection and lifestyle intervention of traditional cardiovascular risk factors.

SUBJECTS AND METHODS

Out of 3370 families 24,927 adults and 23,740 children participated in the PEP Family Heart study. Anthropometric parameters including blood pressure and fasting lipids were measured. Because these variables change specifically because of natural growth and development in 3-18 years old children we had to calculate age-and gender-specific growth curves using the LMS method. Non-overweight (normal weight) is defined as BMI < 85th percentile (pctl), overweight as BMI 85th to <95th percentile, obesity as BMI ≥ 95th percentile and severe obesity as ≥ 120% of the 95th pctl. Prehypertension is categorized as the ≥90th to <95th pctl or ≥120/80 mm Hg and hypertension as ≥95th pctl on ≥3 occasions.

MAIN RESULTS

1. Cardiovascular risk (CVD) factor screening in school children predicted CVD risk in parents. 2. The growths curves for auscultatory systolic (SBP) and diastolic (DBP) blood pressure of non-overweight 8713 boys and 8138 girls nearly identical with the percentile curves of all 11,328 boys and 10,723 girls. 3. The shapes of the 10 lipid percentile curves between the 3rd and 97th pctl differ considerably by age and gender. 4. The wais-to-height ratio (WHtR) percentiles as a measure for abdominal adiposity vary substantially by age and gender 5. Among overweight and obese ≥85th pctl the percentile curves of body fat increase steeply until age 10 years and then decrease slowly in boys whereas the BF% percentile curves in girls increase continuously until age 18 years 6. The prevalence of hypertension increased strongly in severe obesity at the 99th pctl, more steeply beyond 120% of the 95th pctl to 59.1% in boys and 56% in girls. 7. The association between hypertension and normal weight, overweight and obesity increased in boys from 0,5, via 2,7 to 4,3 and in girls from 0,4 via 2,1 to 5,9. 8. Between 2000 and 2007 mean blood pressure decreased from 138.3 ± 18.5 mm Hg to 124.0 ± 13.8 mm Hg in fathers and from 119.1 ± 2.8 mm Hg to 110.4 ± 11.2 mm Hg in mothers. 9. After 1 year weighed dietary protocols demonstrate in 166 fathers a decrease of all six nutrional components like daily energy consumption from 2423 to 2307 Kcal, from 98 g to 91 g fat, from 260 g to 252 g carbohydrates, from 88 g to 84 g protein, cholesterol from 362 mg to 339 mg and alcohol from 19 g to 17 g per day and in 237 mothers from 1915 Kcal to 1830 Kcal, from 79 g to 73 g total fat, from 216 g to 212 g carbohydrates, from 66 g to 64 g protein, from 299 g to 244 mg cholesterol. 10. Sustained intensive individual and family-based lifestyle counseling in daily life in terms of healthy diet, less sedentary behavior and more leisure time physical activity slightly improved the CVD risk factor profiles in parents and their children already after 1 year.

Lifestyle, anthropometric, socio-demographic and perinatal correlates of early adolescence hypertension: The Healthy Growth Study

BACKGROUND AND AIMS

Various lifestyle, anthropometric, socio-demographic and perinatal characteristics have been separately associated with elevated blood pressure in children and adolescents. The aim of this study was to simultaneously evaluate all potential risk factors and to identify the most dominant correlates of early adolescence hypertension in a large group of school children 9-13 years old.

METHODS AND RESULTS

A cross-sectional study with 1444 schoolchildren 9-13 years old, having full data on lifestyle, anthropometric, socio-demographic and perinatal indices, as well as blood pressure measurements. Early adolescents born large for their gestational age (LGA) (OR, 95% C.I. 0.49 (0.25-0.97)), those with higher levels of moderate to vigorous physical activity (MVPA) (OR, 95% C.I. 0.71 (0.53-0.96)) and those of a higher socioeconomic status (SES) (OR, 95% C.I. 0.51 (0.33-0.79)), had lower risk of hypertension, compared with their counterparts with appropriate birth weight, low levels of PA and with low SES respectively, independently of the variables used in the multivariate model. On the other hand, overweight and obese early adolescents (OR, 95% C.I. 2.61 (1.88-3.62)), those with central obesity (OR, 95% C.I. 1.75 (1.12-2.73)) and those having a hypertensive father (OR, 95% C.I. 1.93 (1.20-3.12)) had higher risk of hypertension compared with normal weight early adolescents and those without a family history of hypertension.

CONCLUSIONS

Among the parameters examined, early adolescence abnormal body weight and central obesity, low PA, non LGA, low SES family and family history of hypertension were found to be independently associated with higher risk of hypertension. The identified correlates of early adolescence hypertension can be used by public health initiatives for early detection and management of this major public health problem, prioritizing early adolescents and families at the highest possible risk for hypertension.

What do we Learn from the Prevention Education Program Family Heart Study about Lifestyle change, Blood Pressure, and Lipids in Children and Parents?

Objectives

The PEP Family Heart Study is a perspective community-based long-term project for the whole family to improve cardiovascular health aiming to assess and to amend risk factors in children and their parents by lifestyle change.

Methods

A total of 48,667 subjects (24,927 adults and 23,740 children) from 3,370 families living in 94% of the elementary school districts of Nuremberg (Germany) participated in this observational study from 1993/1994 -2007/2008. The yearly surveys consisting of personal and family histories, structured interviews on leisure time physical activity and tobacco smoke exposition, physical examinations and nutritional intake as documented by seven days weighed dietary protocols and sustained healthy lifestyle counselling were mainly performed at home. Fasting blood collections for biochemical analyses in the study laboratories, cooking courses and seminars on healthy lifestyle were performed on weekends in central school buildings.

Results

Here we report some of the main results demonstrating e.g., that at least one CVD risk factor in a child conferred a 2-4 fold higher risk among their parents, that obese children and adolescents had a nearly five times higher prevalence of hypertension than non-overweight youths.

Conclusions

Sustained healthy lifestyle behavior can be implemented in daily life of family members which results in amended nutritional intake and improved cardiometabolic risk factors.

Secular Trends in Blood Pressure and Overweight and Obesity in Chinese Boys and Girls Aged 7 to 17 Years From 1995 to 2014

The current study aimed to assess the secular trends in overweight and obesity status and high blood pressure (HBP) in Chinese children and adolescents for 2 decades. Data on 943 128 participants aged 7 to 17 years were obtained from the Chinese National Survey on Students' Constitution and Health from 1995 to 2014. The population attributable risk of overweight status for HBP was calculated. The prevalence of overweight increased from 4.3% in 1995 to 18.4% in 2014, whereas HBP prevalence fluctuated in the range of 4.4% to 6.4% during the same time period, the lowest in 2005. Within each survey year, blood pressure levels and HBP prevalence increased with higher body mass index. Notably, the population attributable risk of HBP because of being overweight steadily increased from 6.3% in 1995 to 19.2% in 2014. The same trends of linear growth for obesity, fluctuating blood pressure, and its sustained increasing population attributable risk for overweight also occurred among the domestic 29 provinces. Despite dramatic increases in overweight prevalence among Chinese children from 1995 to 2014, the HBP prevalence remained relatively stable, suggesting that other independent factors are affecting HBP trends to a greater extent. Yet, over time, the magnitude of the impact of being overweight or obese on HBP increased sharply, predicting looming heavy burden of HBP. Reductions in overweight status may aid in preventing HBP so as to prevent coronary risk in adulthood.

What's new in paediatric hypertension?

Paediatric hypertension predisposes to hypertension and cardiovascular disease in adult life. Despite clear guidelines, there remains a lack of screening. Diagnosis remains challenging given the high rate of false-positive high blood pressure (BP) readings at a single visit; thus, multiple visits are required to confirm the diagnosis. Depending on the normative data sets used, hypertension in overweight and obese children can be underestimated by up to 20%. Specific BP targets are required for subgroups such as adolescents, children with chronic kidney disease (CKD) and type 1 diabetes. High dietary salt intake is a risk factor for cardiovascular disease. Given the rise in processed food consumption, children in developed nations are likely to benefit from salt restriction at a population-based level.

Monitoring and management of hypertension with obesity in adolescents

Largely due to the childhood obesity epidemic, there has been an increase in the prevalence of hypertension in children and adolescents. Obesity associated hypertension is the most common hypertension phenotype among adolescents. Approximately 30% of obese adolescents have elevated blood pressure (BP) or hypertension. Updated definitions of elevated BP and hypertension in adolescents are now similar to definitions of BP status in adults. For adolescents ≥13 years of age, elevated BP is 120 to 129/<80 mm Hg. Hypertension, stage 1, is ≥130 to 139/80 to 89 mm Hg, and hypertension, stage 2, is ≥140/90 mm Hg. BP measurements over separate clinic visits are necessary to verify the diagnosis of elevated BP or hypertension. Ambulatory BP monitoring, when available, provides confirmatory data on BP status. Causal mechanisms for obesity associated hypertension include increased sympathetic nervous system activity, increased renal sodium retention secondary to insulin resistance/hyperinsulinemia, and obesity mediated inflammation. The primary treatment for obesity associated hypertension is weight reduction with lifestyle changes in diet and physical activity. Although difficult to achieve, even modest weight reduction can be beneficial. The diet should be rich in fruits, vegetables, fiber, and low-fat dairy with reduction in salt intake. When lifestyle changes are insufficient to achieve BP control, pharmacologic therapy is indicated to achieve a goal BP of <130/80 mm Hg or <90th percentile, whichever is lower. Regular BP monitoring is necessary for ongoing management of obesity associated hypertension in adolescents.

Prevalence of childhood hypertension and hypertension phenotypes by weight status and waist circumference: the Healthy Growth Study

PURPOSE

The aim of the present study was to report for the first time the prevalence of hypertension and its phenotypes in obese children and in children with central obesity in a large sample of Greek children.

METHODS

A regionally representative sample of 2263 schoolchildren (50.3% boys) (9-13 years) having full data on blood pressure assessment, physical examination, anthropometric, and physical activity participated in a cross-sectional study in Greece.

RESULTS

Prevalence of stage 1 and 2 hypertension, of isolated systolic hypertension (ISH) and of combined systolic or diastolic hypertension, was significantly higher for obese children and children on the 3rd tertile of waist circumference in the total sample, as well as in each gender separately. ISH was the most prevalent phenotype reaching 24.3% in obese children and 17.5% in children on the highest tertile of waist circumference. Obese children and children on the highest tertile of waist circumference had 6.31 times and 3.94 times, respectively, higher likelihood to have abnormal systolic or diastolic blood pressure (SBP or DBP) than their normal-weight counterparts.

CONCLUSIONS

Prevalence of hypertension and especially ISH in obese children and in children with central obesity in Greece are among the highest reported in Europe. Future public health initiatives should aim to prevent or tackle several underlying factors related to childhood hypertension, focusing primarily on children with excess body weight.

Prevalence of hypertension and hypertension phenotypes by age and gender among schoolchildren in Greece: The Healthy Growth Study

BACKGROUND AND AIMS

Childhood hypertension is a constantly increasing health problem. Data regarding its prevalence and particularly the prevalence of its phenotypes in the Greek population are limited; therefore, the aim of the study was to determine them in a large sample of Greek children.

METHODS

A sample of 2655 schoolchildren (9-13 years) participated in the Healthy Growth Study, i.e. a cross-sectional epidemiologic study conducted in 77 primary schools in four large regions in Greece. This study shows results on 2571 children (1286 boys), for whom full data on systolic and diastolic blood pressure indices were available, as well as physical examination, anthropometric and physical activity data.

RESULTS

The observed prevalence rates were: prehypertension, 14.2%; stage 1 hypertension, 15.7%; and stage 2 hypertension, 7.3%. Girls had substantially higher hypertension prevalence than boys (25.3% vs. 20.8%). The prevalence rates for prehypertension and stage 2 hypertension were higher in younger than older children (22.4 vs. 13.7% and 8.6 vs. 7.5% respectively), while stage 1 hypertension was higher in children >12 years old compared to younger children (14.9 vs. 12.1%). Isolated systolic hypertension (ISH) was the most prevalent phenotype (11.9%). Moreover, presence of hypertension was positively associated with body mass index (BMI) and waist circumference in both genders, and with sedentary behaviors only in boys.

CONCLUSIONS

The prevalence of hypertension in Greek children and adolescents is alarming and among the highest reported in European countries, while the differences between genders in hypertension phenotype prevalence also provide valuable insight on this problem. The present data may guide future public health initiatives to tackle childhood hypertension in Greece.

Is the prevalence of hypertension in overweight children overestimated?

OBJECTIVES

The aim of this study is to explore different methods for screening and diagnosing hypertension-which definitions and criteria to use-in children and in addition to determine the prevalence of hypertension in Dutch overweight children.

DESIGN

A cross-sectional study performed in the Dutch Child Health Care setting.

SETTING

Four Child Health Care centres in different cities in the Netherlands.

PARTICIPANTS

969 overweight (including obese) and 438 non-overweight children, median age 11.7 years (range 4.1-17.10), 49% boys.

MAIN OUTCOME MEASURES

The main outcome was blood pressure, and the difference in prevalence of hypertension using different criteria for blood pressure interpretation: using the first blood pressure measurement, the mean of two measurements and the lowest of three measurements on two different occasions.

RESULTS

Looking at the first measurement alone, 33% of overweight and 21% of non-overweight children had hypertension. By comparing the mean of the first two measurements with reference values, 28% of overweight children and 16% of non-overweight children had hypertension. Based on the lowest of three consecutive measurements, the prevalence decreased to 12% among overweight children and 5% among non-overweight children at visit one and at visit two 4% of overweight children still had hypertension.

CONCLUSIONS

The prevalence of hypertension is highly dependent on the definitions and criteria used. We found a prevalence of 4% in overweight children, which is considerably lower than suggested by recent literature (4%-33%). This discrepancy can be explained by our more strict definition of hypertension. However, to draw any conclusions on the prevalence, normal values using the same definition of hypertension should be established. Despite the low prevalence, we recommend measuring blood pressure in all overweight children in view of later cardiovascular morbidity and mortality.

Screening, diagnosis and treatment of hypertension in obese children: an international policy comparison

Hypertension in obese children may require a different diagnostic and treatment approach from that for children with secondary hypertension, yet there is neither consensus nor a clear guideline. The aim of this study was to assess how obese children with hypertension are currently diagnosed and treated by paediatric nephrologists, what obstacles exist and what can be improved. In the period May–November 2014, an online questionnaire was sent to all members of the European Society for Paediatric Nephrology (n = 2148). Questions focused on current practices and obstacles regarding screening, diagnosis and treatment of hypertension in obese children. A total of 214 paediatric nephrologists responded. Although nearly 100 % agreed that screening of obese children for hypertension is indicated, it was current practice in only 56 % of participating countries; 88 % of respondents diagnosed hypertension with 24-h ambulatory blood pressure measurement. Diagnostics used to rule out causes or consequences of hypertension varied among the respondents; they included, in particular, the use of serum renin/aldosterone, urine sodium/potassium, and dimercaptosuccinic acid scan. Concerning treatment, 45 % of respondents preferred to start treatment with a lifestyle program, 2 % with antihypertensive medication, and 40 % with both. For 73 % of respondents, angiotensin-converting enzyme-inhibitors or angiotensin receptor blockers were the drugs of first choice. The findings of this study emphasize the urgent need for an international guideline for screening, diagnosis and treatment of hypertension in obese children.

Establishing International Blood Pressure References Among Nonoverweight Children and Adolescents Aged 6 to 17 Years

BACKGROUND

Several distributions of country-specific blood pressure (BP) percentiles by sex, age, and height for children and adolescents have been established worldwide. However, there are no globally unified BP references for defining elevated BP in children and adolescents, which limits international comparisons of the prevalence of pediatric elevated BP. We aimed to establish international BP references for children and adolescents by using 7 nationally representative data sets (China, India, Iran, Korea, Poland, Tunisia, and the United States).

METHODS AND RESULTS

Data on BP for 52 636 nonoverweight children and adolescents aged 6 to 19 years were obtained from 7 large nationally representative cross-sectional surveys in China, India, Iran, Korea, Poland, Tunisia, and the United States. BP values were obtained with certified mercury sphygmomanometers in all 7 countries by using standard procedures for BP measurement. Smoothed BP percentiles (50th, 90th, 95th, and 99th) by age and height were estimated by using the Generalized Additive Model for Location Scale and Shape model. BP values were similar between males and females until the age of 13 years and were higher in males than females thereafter. In comparison with the BP levels of the 90th and 95th percentiles of the US Fourth Report at median height, systolic BP of the corresponding percentiles of these international references was lower, whereas diastolic BP was similar.

CONCLUSIONS

These international BP references will be a useful tool for international comparison of the prevalence of elevated BP in children and adolescents and may help to identify hypertensive youths in diverse populations.

A Review of the Key Clinical Trials of 2014

INTRODUCTION

Over the last year, multiple, potentially practice-changing, cardiology trials or studies have been published or presented at international meetings including the American College of Cardiology, European Association for Percutaneous Cardiovascular Interventions, European Society of Cardiology, Transcatheter Cardiovascular Therapeutics, Heart Failure Congress, Heart Rhythm Society, Heart Failure Society of America, American Society of Hypertension and the American Heart Association.

METHODS

Clinical trial results presented at major cardiology conferences during 2014 were reviewed by the authors. Search terms included heart failure (HF), acute coronary syndrome, stable coronary disease, interventional cardiology, atrial fibrillation, electrophysiology and coronary prevention. Selection criteria were trials of broad relevance to the cardiology community, those with potential to change current practice and those with potential to guide further phase III research.

RESULTS

In this paper, the authors describe and place in clinical context, new HF, data including neprilysin inhibitors, intravenous ferric carboxymaltose, potassium-absorbing compounds, quadripolar leads for cardiac resynchronization therapy and intraventricular device intervention. New trial data are also described for acute coronary syndromes (clopidogrel, prasugrel, ticagrelor), stable coronary artery disease (ivabradine), percutaneous coronary intervention (the role of thrombectomy or treatment of non-culprit lesions during primary intervention, pressure wire studies and outcomes of new stent designs), transcatheter aortic valve intervention data, atrial fibrillation (anticoagulation and direct current cardioversion), electrophysiology (leadless pacemaker devices, use of quinidine in Brugada syndrome) and coronary prevention (landmark Ezetimibe outcome data, PCSK9 clinical trials, childhood prevalence of hypertension, renal denervation for resistant hypertension and the role of cardiac computerized tomography in cardiovascular screening).

CONCLUSION

This paper summarizes key clinical trials during 2014 and should be of practical interest to clinicians and cardiology researchers.