Blood Pressure Is Lower in Children and Adolescents With a Low-Saturated-Fat Diet Since Infancy: The Special Turku Coronary Risk Factor Intervention Project

Pediatric Blood Pressure and Cardiovascular Health in Adulthood

PURPOSE OF REVIEW

This review summarizes current knowledge on blood pressure in children and adolescents (youth), with a focus on primary hypertension-the most common form of elevated blood pressure in this demographic. We examine its etiology, progression, and long-term cardiovascular implications. The review covers definitions and recommendations of blood pressure classifications, recent developments in measurement, epidemiological trends, findings from observational and clinical studies, and prevention and treatment, while identifying gaps in understanding and suggesting future research directions.

RECENT FINDINGS

Youth hypertension is an escalating global issue, with regional and national variations in prevalence. While the principles of blood pressure measurement have remained largely consistent, challenges in this age group include a scarcity of automated devices that have passed independent validation for accuracy and a generally limited tolerance for ambulatory blood pressure monitoring. A multifaceted interplay of factors contributes to youth hypertension, impacting long-term cardiovascular health. Recent studies, including meta-analysis and sophisticated life-course modelling, reveal an adverse link between youth and life-course blood pressure and subclinical cardiovascular outcomes later in life. New evidence now provides the strongest evidence yet linking youth blood pressure with clinical cardiovascular events in adulthood. Some clinical trials have expanded our understanding of the safety and efficacy of antihypertensive medications in youth, but this remains an area that requires additional attention, particularly regarding varied screening approaches. This review outlines the potential role of preventing and managing blood pressure in youth to reduce future cardiovascular risk. A global perspective is necessary in formulating blood pressure definitions and strategies, considering the specific needs and circumstances in low- and middle-income countries compared to high-income countries.

Association of Cardiovascular Health in Young Adulthood With Long-Term Blood Pressure Trajectories

BACKGROUND

Cardiovascular health (CVH) in young adulthood (YA) has been associated with cardiovascular outcomes in older age. However, little is known about the relationship between YA CVH and mid-life blood pressure (BP) trajectories.

METHODS

Baseline CVH (defined by 7 of the American Heart Association's [AHA] Life's Essential 8 [LE8] metrics, excluding BP) was measured in YA with individual metrics scored and averaged as a composite LE8 score. Categorical CVH status was defined as high, moderate, and low. Latent class analysis was used to identify trajectories of mid-BP (mean of systolic blood pressure [SBP] and diastolic blood pressure [DBP]) from average ages 35 to 55 years. Multinomial logistic regression was used to estimate the association of YA CVH status (continuously and categorically) with mid-life BP trajectory group membership.

RESULTS

There were 3,688 participants from the Coronary Artery Risk Development in Young Adults (CARDIA) study in YA with follow-up data for mid-life BP trajectories. We observed 3 BP trajectory groups, labeled as Persistently-Low, Middle, and High-Increasing. On average, each 10-points higher baseline LE8 score (mean [SD] of 73.5 [13.1]) in YA was associated with adjusted odds ratios of 0.78 (95% CI, 0.72-0.84) for membership in the Middle and 0.65 (0.57-0.73) for membership in the High-Increasing trajectory groups. Compared with categorical low CVH status at baseline, those with high CVH were significantly less likely to be in the Middle and High-Increasing BP trajectory groups.

CONCLUSIONS

Moderate or low CVH status in YA is associated with elevated mid-life BP trajectory. These data suggest that young adult CVH promotion may be important for the primordial prevention of hypertension.

Prenatal Household Air Pollution Exposure and Childhood Blood Pressure in Rural Ghana

BACKGROUND

The association between prenatal household air pollution (HAP) exposure and childhood blood pressure (BP) is unknown.

OBJECTIVE

Within the Ghana Randomized Air Pollution and Health Study (GRAPHS) we examined time-varying associations between a) maternal prenatal and b) first-year-of-life HAP exposure with BP at 4 years of age and, separately, whether a stove intervention delivered prenatally and continued through the first year of life could improve BP at 4 years of age.

METHODS

GRAPHS was a cluster-randomized cookstove intervention trial wherein n = 1,414 pregnant women were randomized to one of two stove interventions: a) a liquefied petroleum gas (LPG) stove or improved biomass stove, or b) control (open fire cooking). Maternal HAP exposure over pregnancy and child HAP exposure over the first year of life was quantified by repeated carbon monoxide (CO) measurements; a subset of women (n = 368 ) also performed one prenatal and one postnatal personal fine particulate matter (PM 2.5 ) measurement. Systolic and diastolic BP (SBP and DBP) were measured in n = 667 4-y-old children along with their PM 2.5 exposure (n = 692 ). We examined the effect of the intervention on resting BP z -scores. We also employed reverse distributed lag models to examine time-varying associations between a) maternal prenatal and b) first-year-of-life HAP exposure and resting BP z -scores. Among those with PM 2.5 measures, we examined associations between PM 2.5 and resting BP z -scores. Sex-specific effects were considered.

RESULTS

Intention-to-treat analyses identified that DBP z -score at 4 years of age was lower among children born in the LPG arm (LPG β = - 0.20 ; 95% CI: - 0.36 , - 0.03 ) as compared with those in the control arm, and females were most susceptible to the intervention. Higher CO exposure in late gestation was associated with higher SBP and DBP z -score at 4 years of age, whereas higher late-first-year-of-life CO exposure was associated with higher DBP z -score. In the subset with PM 2.5 measurements, higher maternal postnatal PM 2.5 exposure was associated with higher SBP z -scores.

DISCUSSION

These findings suggest that prenatal and first-year-of-life HAP exposure are associated with child BP and support the need for reductions in exposure to HAP, with interventions such as cleaner cooking beginning in pregnancy. https://doi.org/10.1289/EHP13225.

Blood Pressure at Different Life Stages Over the Early Life Course and Intima-Media Thickness

Importance

Although cardiovascular disease (CVD) begins in early life, the extent to which blood pressure (BP) at different life stages contributes to CVD is unclear.

Objective

To determine the relative contribution of BP at different life stages across the early-life course from infancy to young adulthood with carotid intima-media thickness (IMT).

Design, setting, and participants

The analyses were performed in 2022 using data gathered from July 1989 through January 2018 within the Special Turku Coronary Risk Factor Intervention Project, a randomized, infancy-onset cohort of 534 participants coupled with annual BP (from age 7 months to 20 years), biennial IMT measurements (from ages 13 to 19 years), who were followed up with again at age 26 years.

Exposures

BP measured from infancy (aged 7 to 13 months), preschool (2 to 5 years), childhood (6 to 12 years), adolescence (13 to 17 years), and young adulthood (18 to 26 years).

Main outcomes and measures

Primary outcomes were carotid IMT measured in young adulthood at age 26 years. Bayesian relevant life-course exposure models assessed the relative contribution of BP at each life stage.

Results

Systolic BP at each life stage contributed to the association with young adulthood carotid IMT (infancy: relative weight, 25.3%; 95% credible interval [CrI], 3.6-45.8; preschool childhood: relative weight, 27.0%; 95% CrI, 3.3-57.1; childhood: relative weight, 18.0%; 95% CrI, 0.5-40.0; adolescence: relative weight, 13.5%; 95% CrI, 0.4-37.1; and young adulthood: relative weight, 16.2%; 95% CrI, 1.6-46.1). A 1-SD (at single life-stage) higher systolic BP accumulated across the life course was associated with a higher carotid IMT (0.02 mm; 95% CrI, 0.01-0.03). The findings for carotid IMT were replicated in the Cardiovascular Risk in Young Finns Study that assessed systolic BP from childhood and carotid IMT in adulthood (33 to 45 years).

Conclusion and relevance

In this cohort study, a life-course approach indicated that accumulation of risk exposure to BP levels at all life stages contributed to adulthood carotid IMT. Of those, the contribution attributed to each observed life stage was approximately equal. These results support prevention efforts that achieve and maintain normal BP levels across the life course, starting in infancy.

Sodium - a systematic review for Nordic Nutrition Recommendations 2023

Blood pressure (BP) rises along with increasing sodium intake from early childhood to late adulthood, and leads to hypertension among most men and women living in Nordic and Baltic countries. Elevated BP is the leading global risk factor for premature deaths and disability-adjusted life-years. A reduction in sodium intake is essential in the prevention of hypertension in individuals, in the lowering of BP levels, in the treatment of hypertensive individuals, and in decreasing risks associated with elevated BP. There is a progressive linear dose-response relationship between sodium intake and BP beginning from a sodium intake of less than 0.8 g/day. Sodium reduction decreases BP linearly by a dose-response manner down to a sodium intake level of less than 2 g/day. Randomised intervention studies with a duration of at least 4 weeks confirm the efficiency and safety of reducing blood sodium intake to a level of less than 2 g/day. Results from prospective cohort studies show that higher sodium intake is positively associated with an increased risk of stroke and cardiovascular events and mortality among the general adult population, and the associations are linear in studies using proper sodium assessment methods. Analyses assessing sodium intake using at least two 24-h urine samples have shown a linear positive relationship between sodium intake and the risk of a cardiovascular event or death. Based on an overall evaluation of the available data, a limitation of the sodium intake to 2.0 g/day is suggested for adults. The optimal sodium intake level would be probably about 1.5 g/day. Sodium intake recommended for children can be extrapolated from the recommended sodium intake for adults. According to national dietary surveys, the average sodium intakes in Nordic countries range in adult men from 3.6 to 4.4 g/day and in adult women from 2.6. to 3.2 g/day, and in Baltic countries in men from 2.6 to 5.1 g/day and in women from 1.8 to 3.6 g/day.

Association of tobacco smoke exposure with metabolic profile from childhood to early adulthood: the Special Turku Coronary Risk Factor Intervention Project

AIMS

To investigate the associations between passive tobacco smoke exposure and daily smoking with a comprehensive metabolic profile, measured repeatedly from childhood to adulthood.

METHODS AND RESULTS

Study cohort was derived from the Special Turku Coronary Risk Factor Intervention Project (STRIP). Smoking status was obtained by questionnaire, while serum cotinine concentrations were measured using gas chromatography. Metabolic measures were quantified by nuclear magnetic resonance metabolomics at 9 (n = 539), 11 (n = 536), 13 (n = 525), 15 (n = 488), 17 (n = 455), and 19 (n = 409) years. Association of passive tobacco smoke exposure with metabolic profile compared participants who reported less-than-weekly smoking and had serum cotinine concentration <1 ng/mL (no exposure) with those whose cotinine concentration was ≥10 ng/mL (passive tobacco smoke exposure). Associations of daily smoking with metabolic profile in adolescence were analysed by comparing participants reporting daily smoking with those reporting no tobacco use and having serum cotinine concentrations <1 ng/mL. Passive tobacco smoke exposure was directly associated with the serum ratio of monounsaturated fatty acids to total fatty acids [β = 0.34 standard deviation (SD), (0.17-0.51), P < 0.0001] and inversely associated with the serum ratios of polyunsaturated fatty acids. Exposure to passive tobacco smoke was directly associated with very-low-density lipoprotein particle size [β = 0.28 SD, (0.12-0.45), P = 0.001] and inversely associated with HDL particle size {β = -0.21 SD, [-0.34 to -0.07], P = 0.003}. Daily smokers exhibited a similar metabolic profile to those exposed to passive tobacco smoke. These results persisted after adjusting for body mass index, STRIP study group allocation, dietary target score, pubertal status, and parental socio-economic status.

CONCLUSION

Both passive and active tobacco smoke exposures during childhood and adolescence are detrimentally associated with circulating metabolic measures indicative of increased cardio-metabolic risk.

The Influence of Dietary Counseling Over 20 Years on Tracking of Non-High-Density Lipoprotein Cholesterol from Infancy to Young Adulthood

This 26-year study found that non-high-density lipoprotein cholesterol (non-HDL-C) levels tracked from infancy to young adulthood suggesting early-life non-HDL-C could predict future levels. However, infancy-onset dietary counseling reduced the odds of maintaining at-risk non-HDL-C, highlighting the potential importance of early interventions in preventing cardiovascular risk associated with high pediatric non-HDL-C.

Development and piloting of a primary school-based salt reduction programme: Formative work and a process evaluation in rural and urban Malawi

Excess salt intake is a major modifiable risk factor for cardiovascular disease. Promoting salt reduction as part of routine school-health programming may be a pragmatic way to address this risk factor early in the life course but has not been tested in sub-Saharan Africa (SSA). Here we describe the formative work with stakeholders and process evaluation of pilot work to develop a school-based salt reduction programme for children aged 11-14 years, in preparation for a cluster-randomised trial in rural/urban Malawi. Collection of observational data and documentary evidence (meeting minutes/field notes) from the earliest key stakeholder engagement with Malawi Ministries of Health, Education, Local Government and Rural Development and Malawi Institute of Education, and non-governmental stakeholders; and a series of semi-structured interviews and focus groups (with head teachers (n = 2); teachers (n = 4); parents (n = 30); and learners (n = 40)). Data was analysed thematically and conceptualised through a Normalization Process Theory lens. Formative work illustrated a range of administrative, technical, and practical issues faced during development of the programme; including allocation of stakeholder roles and responsibilities, harmonisation with pre-existing strategies and competing priorities, resources required for programme development, and design of effective teaching materials. While participants were positive about the programme, the process evaluation identified features to be refined including perceived challenges to participation, recommended adaptations to the content and delivery of lessons, and concerns related to quantity/quality of learning resources provided. This study demonstrates the importance of comprehensive, sustained, and participatory stakeholder engagement in the development of a novel school health programme in SSA; and highlights the factors that were critical to successfully achieving this. We also demonstrate the value of detailed process evaluation in informing development of the programme to ensure that it was feasible and relevant to the context prior to evaluation through a cluster-randomised trial.

The association of problematic gaming characteristics with dietary habits among Finnish vocational school students

Digital gaming is a popular pastime among young people, but its links to dietary habits have been little studied. The purpose of the study was to describe dietary habits and to examine their associations to problematic gaming behavior with regard to the degree of daily digital gaming time and the overall levels of disordered-like gaming behavior among students in vocational education in the Oulu region of Finland. This cross-sectional study consisted of a total of 773 first-year vocational school students who had played digital games regularly. Data was collected by using an online survey measuring sociodemographic information, dietary habits, amount of digital gaming time, and symptoms of problematic gaming behavior. Most prevalent weekly consumed food types were chicken (90.1%), chips (87.7%), and sausages/cold cuts (85.4%). Around one-fourth of students skipped breakfast on weekdays and at weekends. A higher amount of digital gaming time was associated with skipping breakfast on weekdays. More elevated levels of disordered gaming behavior were particularly associated with the use of a group of food types encompassing carbohydrate-dense and fast food. Current research provides indications that digital gaming may have an impact on youths' dietary habits, while at the same time, however, emphasizing that the issue can be affected by several interrelated and complex factors.

Antenatal Programming of Hypertension: Paradigms, Paradoxes, and How We Move Forward

PURPOSE OF REVIEW

Synthesize the clinical, epidemiological, and preclinical evidence for antenatal programming of hypertension and critically appraise paradigms and paradoxes to improve translation.

RECENT FINDINGS

Clinical and epidemiological studies persistently demonstrate that antenatal factors contribute to programmed hypertension under the developmental origins of health and disease framework, including lower birth weight, preterm birth, and fetal growth restriction. Preclinical mechanisms include preeclampsia, maternal diabetes, maternal undernutrition, and antenatal corticosteroid exposure. However, clinical and epidemiological studies to date have largely failed to adequately identify, discuss, and mitigate many sources and types of bias in part due to heterogeneous study designs and incomplete adherence to scientific rigor. These limitations have led to incomplete and biased paradigms as well as persistent paradoxes that have significantly limited translation into clinical and population health interventions. Improved understanding of these paradigms and paradoxes will allow us to substantially move the field forward.

Are adherence to the Mediterranean diet and siesta individually or jointly associated with blood pressure in Spanish adolescents? Results from the EHDLA study

Background

Both dietary and sleep patterns can influence both blood pressure levels and heart rate, but these associations have been understudied in adolescents. Furthermore, it is not known whether diet and sleep could exert a synergistic effect with respect to the maintenance of optimal BP levels in this population.

Objective

To investigate the relationship of blood pressure levels with the combination of higher adherence to the Mediterranean diet and the habit of siesta (daytime napping) in Spanish adolescents.

Methods

A cross-sectional study was conducted with data obtained through personal interviews and physical examination from a representative sample of 1,378 adolescents (12-17 years of age) from the Valle de Ricote (Region of Murcia, Spain) selected using a simple random sampling technique. Adherence to the Mediterranean diet was assessed with the Mediterranean Diet Quality Index in Children and Adolescents, and the frequency and duration of siesta were self-reported. Objective measurements of systolic and diastolic blood pressure were obtained under standardized conditions. Statistical procedures were performed with SPSS software (v.25) and included logistic and generalized regression models adjusted for sex, age, socioeconomic status, body mass index, total energy intake, nighttime sleep duration, and moderate-to-vigorous physical activity.

Results

Of the 698 adolescents finally studied (mean age 13.9 ± 1.5 years; 56.2% female), 37.1% (n = 259) had high adherence to the Mediterranean diet and 19.6% (n = 137) reported frequent siesta. In the completely adjusted models, compared to adolescents with low Mediterranean diet adherence and no or infrequent siesta, those with high Mediterranean diet adherence and frequent siesta were less likely to have high-normal blood pressure or hypertension (odds ratio = 0.47; 95% confidence interval: 0.26, 0.88) and showed slightly lower systolic blood pressure (ß-coef. = -2.60; 95% CI: -5.18, -0.02).

Conclusion

Greater adherence to the Mediterranean diet and frequent siesta have a synergistic effect on maintaining lower blood pressure levels in adolescence. These findings reinforce that adherence to both Mediterranean lifestyle behaviors early in life may be an important strategy to prevent hypertension throughout adulthood.

The effect of group logotherapy on spirituality and preoperative anxiety in patients seeking open heart surgery referring to Tehran Heart Center in 2020

BACKGROUND AND PURPOSE

Most patients experience anxiety before heart surgery. On the other hand, spiritual health can improve the candidate patient's adaptation to surgery. Therefore, this study aimed to investigate the effect of group logotherapy on spirituality and anxiety of patients undergoing cardiac surgery.

MATERIALS AND METHODS

In this quasi-experimental study, 60 hospitalized candidates for cardiac surgery were randomly assigned to two groups (30 in the experimental group, 30 in the control group). To measure anxiety and relationship with God, Beck Anxiety Questionnaire and the researcher-made scale about relationship with God (reconstruction of Lawrence's scale of perception of God) were used, respectively. In the intervention group, in addition to drug therapy, individuals received two sessions of group discussion and spiritual skills training using the behavioral-cognitive method with emphasis on spiritual thoughts and problem-solving methods, but the control group received only drug therapy. Data were analyzed using SPSS software.

RESULTS

In the experimental group, the anxiety scores mean in the posttest and follow-up were significantly lower than the pretest (P < 0.05), while the mean anxiety in the control group in the posttest stage was not significantly different, but at the follow-up stage, it was significantly lower than the pretest, but the decrease in mean anxiety in the experimental group was greater (P < 0.05). The mean subscales of relationship with god (influence, divine providence, acceptance, presence, challenge, benevolence) were significantly higher in the experimental and control groups in the follow-up stage than the pretest, but the increase in the mean of these variables was more in the experimental group in the follow-up stage (P < 0.05).

CONCLUSION

Findings showed that the components of relationship with God are a good predictor of pre-surgery anxiety, so by focusing on spiritual training of patients who are candidates for surgery, the incidence or severity of anxiety can be reduced.

Prevention of atherosclerosis from childhood

Cardiovascular diseases caused by atherosclerosis do not typically manifest before middle age; however, the disease process begins early in life. Preclinical atherosclerosis can be quantified with imaging methods in healthy populations long before clinical manifestations present. Cohort studies have shown that childhood exposure to risk factors, such as dyslipidaemia, elevated blood pressure and tobacco smoking, are associated with adult preclinical atherosclerotic phenotypes. Importantly, these long-term effects are substantially reduced if the individual becomes free from the risk factor by adulthood. As participants in the cohorts continue to age and clinical end points accrue, the strongest evidence linking exposure to risk factors in early life with cardiovascular outcomes has begun to emerge. Although science has deciphered the natural course of atherosclerosis, discovered its causal risk factors and developed effective means to intervene, we are still faced with an ongoing global pandemic of atherosclerotic diseases. In general, atherosclerosis goes undetected for too long, and preventive measures, if initiated at all, are inadequate and/or come too late. In this Review, we give an overview of the available literature suggesting the importance of initiating the prevention of atherosclerosis in early life and provide a summary of the major paediatric programmes for the prevention of atherosclerotic disease. We also highlight the limitations of current knowledge and indicate areas for future research.

Birth weight for gestational age and later cardiovascular health: a comparison between longitudinal Finnish and indigenous Australian cohorts

INTRODUCTION

Small or large birth weight for gestational age has been linked with later cardiovascular disease risk. However, cardiovascular risk markers from childhood to adulthood according to birth weight in diverse longitudinal settings globally have not been extensively studied.

OBJECTIVES

To examine the relationship between birth weight and cardiovascular risk profile from childhood until young adulthood in two geographically and socioeconomically distinct cohorts.

METHODS

Data were derived from two longitudinal birth cohort studies; one from southern Finland (Special Turku Coronary Risk Factor Intervention Project, STRIP) and one from northern Australia comprising Indigenous Australians (Aboriginal Birth Cohort, ABC). The sample included 747 Finnish participants and 541 Indigenous Australians with data on birth weight, gestational age and cardiovascular risk factors (body mass index [BMI]), waist-to-height ratio [WHtR], lipid profile, blood pressure) collected at ages 11, 18 and 25 or 26 years. Carotid intima-media thickness (cIMT) was assessed at age 18 or 19 years. Participants were categorised according to birth weight for gestational age (small [SGA], appropriate [AGA] or large [LGA]). Associations between birth weight category and cardiovascular risk markers were studied using a repeated measures ANOVA.

RESULTS

Higher birth weight category was associated with higher BMI later in life in both cohorts (p=.003 for STRIP and p<.0001 for ABC). In the ABC, higher birth weight category was also associated with higher WHtR (p=.004). In the ABC, SGA participants had lower systolic and diastolic blood pressure than AGA participants (p=.028 for systolic, p=.027 for diastolic) and lower systolic blood pressure than LGA participants (p=.046) at age 25. In the STRIP cohort, SGA participants had lower cIMT than LGA participants (p=.024).

CONCLUSIONS

Birth weight can predict future cardiovascular risk profile in diverse populations. Thus, it needs to be included in targeted public health interventions for tackling the obesity pandemic and improving cardiovascular health worldwide.Key messagesThe strongest association between birth weight and later cardiovascular risk profile was manifested as differences in body mass index in two culturally and geographically distinct cohorts.Foetal growth is a determinant for later cardiovascular health in diverse populations, indicating a need to focus on maternal and foetal health to improve cardiovascular health worldwide.

Diet quality trajectories and cardiovascular phenotypes/metabolic syndrome risk by 11-12 years

OBJECTIVE

To investigate associations between early-life diet trajectories and preclinical cardiovascular phenotypes and metabolic risk by age 12 years.

METHODS

Participants were 1861 children (51% male) from the Longitudinal Study of Australian Children. At five biennial waves from 2-3 to 10-11 years: Every 2 years from 2006 to 2014, diet quality scores were collected from brief 24-h parent/self-reported dietary recalls and then classified using group-based trajectory modeling as 'never healthy' (7%), 'becoming less healthy' (17%), 'moderately healthy' (21%), and 'always healthy' (56%). At 11-12 years: During children's physical health Child Health CheckPoint (2015-2016), we measured cardiovascular functional (resting heart rate, blood pressure, pulse wave velocity, carotid elasticity/distensibility) and structural (carotid intima-media thickness, retinal microvasculature) phenotypes, and metabolic risk score (composite of body mass index z-score, systolic blood pressure, high-density lipoproteins cholesterol, triglycerides, and glucose). Associations were estimated using linear regression models (n = 1100-1800) adjusted for age, sex, and socioeconomic position.

RESULTS

Compared to 'always healthy', the 'never healthy' trajectory had higher resting heart rate (2.6 bpm, 95% CI 0.4, 4.7) and metabolic risk score (0.23, 95% CI 0.01, 0.45), and lower arterial elasticity (-0.3% per 10 mmHg, 95% CI -0.6, -0.1) and distensibility (-1.2%, 95% CI -1.9, -0.5) (all effect sizes 0.3-0.4). Heart rate, distensibility, and diastolic blood pressure were progressively poorer for less healthy diet trajectories (linear trends p ≤ 0.02). Effects for systolic blood pressure, pulse wave velocity, and structural phenotypes were less evident.

CONCLUSIONS

Children following the least healthy diet trajectory had poorer functional cardiovascular phenotypes and metabolic syndrome risk, including higher resting heart rate, one of the strongest precursors of all-cause mortality. Structural phenotypes were not associated with diet trajectories, suggesting the window to prevent permanent changes remains open to at least late childhood.

Trends in Blood Pressure and Hypertension Among US Children and Adolescents, 1999-2018

Importance

Higher blood pressure (BP) levels in children are associated with an increased risk for hypertension and subclinical cardiovascular disease in adulthood. Identifying trends in BP could inform the need for interventions to lower BP.

Objective

To determine whether systolic BP (SBP) and diastolic BP (DBP) levels among US children have changed during the past 20 years.

Design, Setting, and Participants

This serial cross-sectional analysis of National Health and Nutrition Examination Survey data included 9117 children aged 8 to 12 years and 10 156 adolescents aged 13 to 17 years, weighted to the US population from 1999-2002 to 2015-2018. Data were collected from March 1999 to December 2018 and analyzed from March 26, 2020, to February 2, 2021.

Exposures

Calendar year.

Main Outcomes and Measures

The primary outcomes were mean SBP and mean DBP.

Results

A total of 19 273 participants were included in the analysis. Among children aged 8 to 12 years in 2015-2018 (mean age, 10.5 [95% CI, 10.5-10.6] years), 48.7% (95% CI, 45.2%-52.2%) were girls and 51.3% (95% CI, 47.8%-54.8%) were boys; 49.7% (95% CI, 42.2%-57.1%) were non-Hispanic White; 13.7% (95% CI, 10.3%-18.1%) were non-Hispanic Black; 25.5% (95% CI, 19.9%-32.0%) were Hispanic; 4.7% (95% CI, 3.2%-6.7%) were non-Hispanic Asian; and 6.5% (95% CI, 4.9%-8.5%) were other non-Hispanic race/ethnicity. Among those aged 13 to 17 years in 2015-2018 (mean age, 15.5 [95% CI, 15.5-15.5] years), 49.1% (95% CI, 46.1%-52.2%) were girls and 50.9% (95% CI, 47.8%-53.9%) were boys; 53.3% (95% CI, 46.4%-60.1%) were non-Hispanic White; 13.9% (95% CI, 10.3%-18.7%) were non-Hispanic Black; 21.9% (95% CI, 16.6%-28.2%) were Hispanic; 4.6% (95% CI, 3.2%-6.5%) were non-Hispanic Asian; and 6.3% (95% CI, 4.7%-8.5%) were other non-Hispanic race/ethnicity. Among children aged 8 to 12 years, age-adjusted mean SBP decreased from 102.4 (95% CI, 101.7-103.1) mm Hg in 1999-2002 to 101.5 (95% CI, 100.8-102.2) mm Hg in 2011-2014 and then increased to 102.5 (95% CI, 101.9-103.2) mm Hg in 2015-2018. Age-adjusted mean DBP decreased from 57.2 (95% CI, 56.5-58.0) mm Hg in 1999-2002 to 51.9 (95% CI, 50.1-53.7) mm Hg in 2011-2014 and increased to 53.2 (95% CI, 52.2-54.1) mm Hg in 2015-2018. Among adolescents aged 13 to 17 years, age-adjusted mean SBP decreased from 109.2 (95% CI, 108.7-109.7) mm Hg in 1999-2002 to 108.4 (95% CI, 107.8-109.1) mm Hg in 2011-2014 and remained unchanged in 2015-2018 (108.4 [95% CI, 107.8-109.1] mm Hg). Mean DBP decreased from 62.6 (95% CI, 61.7-63.5) mm Hg in 1999-2002 to 59.6 (95% CI, 58.2-60.9) mm Hg in 2011-2014 and then increased to 60.8 (95% CI, 59.8-61.7) mm Hg in 2015-2018. Among children aged 8 to 12 years, mean SBP was 3.2 (95% CI, 1.7-4.6) mm Hg higher among those with overweight and 6.8 (95% CI, 5.6-8.1) mm Hg higher among those with obesity compared with normal weight; mean DBP was 3.2 (95% CI, 0.7-5.6) mm Hg higher among those with overweight and 3.5 (95% CI, 1.9- 5.1) mm Hg higher among those with obesity compared with normal weight. Among adolescents aged 13 to 17 years, mean SBP was 3.5 (95% CI 1.9-5.1) mm Hg higher among those with overweight and 6.6 (95% CI, 5.2-8.0) mm Hg higher among those with obesity compared with normal weight, 4.8 (95% CI, 3.8-5.8) mm Hg higher among boys compared with girls, and 3.0 (95% CI, 1.7-4.3) mm Hg higher among non-Hispanic Black compared with non-Hispanic White participants.

Conclusions and Relevance

Despite an overall decline in mean SBP and DBP from 1999-2002 to 2015-2018, BP levels among children and adolescents may have increased from 2011-2014 to 2015-2018.

Achievement of the Targets of the 20-Year Infancy-Onset Dietary Intervention-Association with Metabolic Profile from Childhood to Adulthood

The Special Turku Coronary Risk Factor Intervention Project (STRIP) is a prospective infancy-onset randomized dietary intervention trial targeting dietary fat quality and cholesterol intake, and favoring consumption of vegetables, fruit, and whole-grains. Diet (food records) and circulating metabolites were studied at six time points between the ages of 9-19 years (n = 549-338). Dietary targets for this study were defined as (1) the ratio of saturated fat (SAFA) to monounsaturated and polyunsaturated fatty acids (MUFA + PUFA) < 1:2, (2) intake of SAFA < 10% of total energy intake, (3) fiber intake ≥ 80th age-specific percentile, and (4) sucrose intake ≤ 20th age-specific percentile. Metabolic biomarkers were quantified by high-throughput nuclear magnetic resonance metabolomics. Better adherence to the dietary targets, regardless of study group allocation, was assoiated with higher serum proportion of PUFAs, lower serum proportion of SAFAs, and a higher degree of unsaturation of fatty acids. Achieving ≥ 1 dietary target resulted in higher low-density lipoprotein (LDL) particle size, lower circulating LDL subclass lipid concentrations, and lower circulating lipid concentrations in medium and small high-density lipoprotein subclasses compared to meeting 0 targets. Attaining more dietary targets (≥2) was associated with a tendency to lower lipid concentrations of intermediate-density lipoprotein and very low-density lipoprotein subclasses. Thus, adherence to dietary targets is favorably associated with multiple circulating fatty acids and lipoprotein subclass lipid concentrations, indicative of better cardio-metabolic health.

Effects of Randomized Controlled Infancy-Onset Dietary Intervention on Leukocyte Telomere Length-The Special Turku Coronary Risk Factor Intervention Project (STRIP)

Reduced telomere length (TL) is a biological marker of aging. A high inter-individual variation in TL exists already in childhood, which is partly explained by genetics, but also by lifestyle factors. We examined the influence of a 20-year dietary/lifestyle intervention on TL attrition from childhood to early adulthood. The study comprised participants of the longitudinal randomized Special Turku Coronary Risk Factor Intervention Project (STRIP) conducted between 1990 and 2011. Healthy 7-month-old children were randomized to the intervention group (n = 540) receiving dietary counseling mainly focused on dietary fat quality and to the control group (n = 522). Leukocyte TL was measured using the Southern blot method from whole blood samples collected twice: at a mean age of 7.5 and 19.8 years (n = 232; intervention n = 108, control n = 124). Yearly TL attrition rate was calculated. The participants of the intervention group had slower yearly TL attrition rate compared to the controls (intervention: mean = −7.5 bp/year, SD = 24.4 vs. control: mean = −15.0 bp/year, SD = 30.3; age, sex and baseline TL adjusted β = 0.007, SE = 0.004, p = 0.040). The result became stronger after additional adjustments for dietary fat quality and fiber intake, serum lipid and insulin concentrations, systolic blood pressure, physical activity and smoking (β = 0.013, SE = 0.005, p = 0.009). A long-term intervention focused mainly on dietary fat quality may affect the yearly TL attrition rate in healthy children/adolescents.

Lipid and saturated fatty acids intake and cardiovascular risk factors of obese children and adolescents

OBJECTIVE

To test the hypothesis that lipid intake is associated with triglycerides to HDL-cholesterol ratio (TG/HDL-cholesterol), a predictor of the development of cardiovascular disease, in obese children and adolescents, independently from the level of overweight, insulin resistance, blood pressure, and non-alcoholic fatty liver disease (NAFLD).

STUDY DESIGN

One hundred and eighty non-diabetic obese children/adolescents (age range 6-16 years) were enrolled. Diet (3-day weighed dietary record), physical and biochemical parameters and liver ultrasonography were measured. The impact of lipid intake on TG/HDL-cholesterol ratio >2.2 was measured by regression models, adjusting for covariates (age, gender, height, weight, systolic and diastolic blood pressure, NAFLD positivity, HOMA-IR, and total energy intake).

RESULTS

Independently from covariates, children consuming a diet with a fat content higher than 35% of total energy had a significantly higher chance [OR = 3.333 (95% CI: 1.113-9.979), P = 0.031] to have a TG/HDL-cholesterol >2.2 than children consuming less than 35% of fat. Moreover, if saturated fatty acids (SFA) intake was higher than 13% of total energy, children had a significantly higher chance [OR = 4.804 (95% CI: 1.312-17.593), P = 0.018] to have a TG/HDL-cholesterol >2.2 than children consuming less than 13% of SFA in their diet.

CONCLUSIONS

High fat intake, especially SFA intake, is associated with TG/HDL-cholesterol levels of obese children and adolescents, independently from other cardiovascular risk co-factors. Further intervention studies will contribute to clarify the potential role of changes in the composition and amount of fat in the diet of obese children and adolescents, on their cardiovascular risk factors.

Attainment of Targets of the 20-Year Infancy-Onset Dietary Intervention and Blood Pressure Across Childhood and Young Adulthood: The Special Turku Coronary Risk Factor Intervention Project (STRIP)

We examined whether success in achieving the key targets of an infancy-onset 20-year dietary intervention was associated with blood pressure (BP) from infancy to young adulthood. In the prospective randomized STRIP (Special Turku Coronary Risk Factor Intervention Project; n=877 children), dietary counseling was provided biannually based on the Nordic Nutrition Recommendations primarily to improve the quality of dietary fat in children's diets and secondarily to promote intake of vegetables, fruits, and whole grains. Dietary data and BP were accrued annually from the age of 13 months to 20 years. The dietary targets for fat quality were defined as the ratio of saturated fatty acids to monounsaturated and polyunsaturated fatty acids <1:2 and intake of saturated fatty acids <10 E%, dietary fiber intake in the top age-specific quintile, and dietary sucrose intake as being in the lowest age-specific quintile. Attaining a higher number of the dietary targets was associated with lower systolic BP (mean [SE] systolic BP, 107.3 [0.3], 107.6 [0.3], 106.8 [0.3], and 106.7 [0.5] mm Hg in participants meeting 0, 1, 2, and 3 to 4 targets, respectively; P=0.03) and diastolic BP (mean [SE] diastolic BP, 60.4 [0.2], 60.5 [0.2], 59.9 [0.2], and 59.9 [0.3] mm Hg; P=0.02). When the lowest age-specific quintile of dietary cholesterol was added as an additional target, the association with systolic BP remained significant (P=0.047), but the association with diastolic BP attenuated (P=0.13). Achieving the key targets of an infancy-onset 20-year dietary intervention, reflecting dietary guidelines, was favorably albeit modestly associated with systolic and diastolic BP from infancy to young adulthood. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT00223600.

Dietary Fats and Atherosclerosis From Childhood to Adulthood

BACKGROUND

The association of dietary fat distribution with markers of subclinical atherosclerosis during early life is unknown. We examined whether success in achieving the main target of an infancy-onset dietary intervention based on the distribution of dietary fat was associated with aortic and carotid intima-media thickness (IMT) and distensibility from childhood to young adulthood.

METHODS

In the prospective randomized controlled Special Turku Coronary Risk Factor Intervention Project trial, personalized dietary counseling was given biannually to healthy children from infancy to young adulthood. The counseling was based on Nordic Nutrition Recommendations, with the main aim of improving the distribution of dietary fat in children's diets. IMT and distensibility of the abdominal aorta and common carotid artery were measured repeatedly at ages 11 (n = 439), 13 (n = 499), 15 (n = 506), 17 (n = 477), and 19 years (n = 429). The targeted distribution of dietary fat was defined as a ratio of saturated fatty acids to monounsaturated and polyunsaturated fatty acids of <1:2 and as an intake of saturated fatty acids of <10% of energy intake. Participants who met ≥1 of these 2 criteria were defined to achieve the main intervention target.

RESULTS

Individuals who achieved the main intervention target had lower aortic IMT (age- and sex-adjusted mean difference 10.4 µm; 95% confidence interval: 0.3 to 20.5 µm) and better aortic distensibility (0.13% per 10 mm Hg; 95% confidence interval: 0.00% to 0.26% per10 mm Hg) compared with their peers who did not meet the target.

CONCLUSIONS

Achieving the main target of an infancy-onset dietary intervention, reflecting dietary guidelines, was favorably associated with aortic IMT and distensibility during the early life course. These data support the recommendation of favoring unsaturated fat to enhance arterial health.

Primordial Prevention of High Blood Pressure in Childhood: An Opportunity Not to be Missed

Hypertension is a condition with increased risk for subsequent adverse events, and treatment of hypertension is prescribed for primary prevention of adverse events. Primordial prevention is a concept that precedes primary prevention and focuses on risk factor prevention. Primordial prevention of hypertension consists of strategies to maintain blood pressure in a normal range and prevent development of elevated blood pressure or hypertension. Childhood is a period in which primordial prevention could be effective and if sustained throughout childhood could contribute to a healthier young adulthood. Targets for primordial prevention in childhood include preventing and reducing childhood obesity, achieving an optimal diet that includes avoiding excessive salt consumption, and removing barriers to physical activity and healthy sleep throughout childhood. Primordial prevention also includes the prenatal period wherein some maternal conditions and exposures are associated with higher blood pressure in child offspring.

Stricter Adherence to Dietary Approaches to Stop Hypertension (DASH) and its Association with Lower Blood Pressure, Visceral Fat, and Waist Circumference in University Students

How diet affects blood pressure (BP) in young adults has not been studied in sufficient depth. For this purpose, we analyzed adherence to the Dietary Approaches to Stop Hypertension (DASH) dietary pattern and BP in Spanish university students. The sample population of our cross-sectional study consisted of 244 subjects (18-31 years old), who were in good health. Measurements were taken of their systolic and diastolic BP. A food frequency questionnaire and 72 h food record were used to assess their dietary intake in the previous year. The resulting DASH score was based on foodstuffs that were emphasized or minimized in the DASH diet. Analysis of covariance adjusted for potential confounding factors showed that the mean values for systolic BP, visceral fat rating, and waist circumference (WC) of the subjects in the upper third of the DASH score were significantly lower than those of the subjects in the lower third (for systolic BP: mean difference -4.36 mmHg, p = 0.004; for visceral fat rating: mean difference -0.4, p = 0.024; for waist circumference: mean difference -3.2, p = 0.019). Stricter adherence to the DASH dietary pattern led to a lower BP, visceral fat rating, and WC values in these university students. Nevertheless, further prospective studies are needed to confirm these results.

Low-saturated-fat and low-cholesterol diet does not alter pubertal development and hormonal status in adolescents

Aim

The aim was to assess the influence of dietary counselling on the pubertal development and hormonal status in healthy adolescents.

Methods

We used a subcohort of 193 healthy boys (52%) and girls (48%) from the Special Turku Coronary Risk Factor Intervention Project. Participants were recruited by nurses at the well‐baby clinics in Turku Finland in 1990–1992 and randomised into intervention and control groups. Intervention children received low‐saturated fat and low‐cholesterol dietary counselling initiated at seven months of age. Participants were examined once a year with Tanner staging, anthropometric measurements and serial reproductive hormones from 10 to 19 years of age. In girls, postmenarcheal hormones were not analysed.

Results

Pubertal hormones in boys or girls did not differ between the intervention and control groups. However, we observed slight differences in pubertal progression by Tanner staging and in anthropometric parameters. The intervention boys progressed faster to G4 (p = 0.008), G5 (p = 0.008) and P5 (p = 0.03). The intervention boys were taller than control boys (p = 0.04), while weight and body mass index did not differ.

Conclusion

Dietary intervention did not affect pubertal hormonal status. This finding supports the safety of implemented counselling in respect to puberty.

Success in Achieving the Targets of the 20-Year Infancy-Onset Dietary Intervention: Association With Insulin Sensitivity and Serum Lipids

OBJECTIVE

We examined whether success in achieving the key targets of an infancy-onset 20-year dietary intervention associated with insulin sensitivity and serum lipids from early childhood to young adulthood.

RESEARCH DESIGN AND METHODS

The sample comprised 941 children participating in the prospective, randomized Special Turku Coronary Risk Factor Intervention Project (STRIP). Dietary counseling was given biannually based on the Nordic Nutrition Recommendations with the main aim to improve the quality of dietary fat in children's diets and the secondary aim to promote intake of vegetables, fruits, and whole-grain products. Food records and serum lipid profile were studied annually from 1 to 20 years of age, and HOMA of insulin resistance (HOMA-IR) was assessed between 7 and 20 years of age. Meeting the intervention targets for quality of dietary fat was defined as the ratio of saturated fatty acids (SAFA) to monounsaturated and polyunsaturated fatty acids (MUFA + PUFA) <1:2 and intake of SAFA <10% of total energy intake (E%). Meeting the target for intake of whole-grain products, fruits, and vegetables was indicated by a fiber intake ≥3 g/MJ.

RESULTS

Participants in the intervention group had a higher probability of meeting the targets of SAFA/(PUFA + MUFA) <1:2 (risk ratio [RR] 3.91 [95% CI 3.33-4.61]), intake of SAFA <10 E% (RR 3.33 [95% CI 2.99-3.96]), and intake of fiber >3 g/MJ (RR 1.37 [95% CI 1.04-1.80]). Participants who achieved more targets had lower HOMA-IR, lower concentrations of fasting serum glucose, insulin, LDL cholesterol, and non-HDL cholesterol, and a lower ratio of apolipoprotein (Apo) B/ApoA1 (P values all ≤0.003).

CONCLUSIONS

Achieving the key targets of an infancy-onset 20-year dietary intervention was associated with better insulin sensitivity and serum lipid profile throughout the early life course.

Association of eating behaviors, lifestyle, and maternal education with adherence to the Mediterranean diet in Spanish children

BACKGROUND

The Mediterranean diet serves as a proxy of a high-quality diet. Although several factors are known to affect a child's ability to follow a high-quality diet, no prospective data are available on factors that influence adherence to a Mediterranean diet among children. Our objective was to investigate the association of Mediterranean diet adherence with eating behaviors, lifestyle habits, and maternal education in a prospective cohort of children.

METHODS

The present prospective cohort analysis included 1639 children aged 8-10 years. The study was carried out during two academic years, 2012/2014, with an average follow-up of 15 months. Eating behaviors, physical activity, and adherence to Mediterranean diet were estimated by the Dutch Eating Behavior Questionnaire for Children, the Physical Activity Questionnaire for Children, and the KIDMED index, respectively.

RESULTS

Multivariate linear regression analysis adjusted for sex, age, maternal education, baseline adherence to the Mediterranean diet, and intervention group revealed a significant (p < 0.01) inverse association of external eating and screen time with adherence to the Mediterranean diet at follow-up (mean of 15 months). The opposite association was found for meal frequency and physical activity (p < 0.02). A high level of maternal education increased the odds of a child's high adherence to the Mediterranean diet (OR = 1.56 CI 1.13; 2.14) compared to peers whose mothers had only a primary education.

CONCLUSIONS

Screen time, physical activity, meal frequency, and external eating predict adherence to the Mediterranean diet independently of baseline diet quality. Maternal education level is an important prospective determinant for the adherence to the Mediterranean diet.

TRIAL REGISTRATION NUMBER

ISRCTN68403446.

Dietary intake of fat and fatty acids by 1-5-year-old children in Korea: a cross-sectional study based on data from the sixth Korea National Health and Nutrition Examination Survey

BACKGROUND/OBJECTIVES

We examined dietary fat intake and the major food sources by young children in Korea.

SUBJECTS/METHODS

A total of 1,041 children aged 1–5 years were identified from the 2013–2015 Korea National Health and Nutrition Examination Survey. Data on total fat and fatty acid intake were obtained by a single 24-h dietary recall. Food sources were identified based on the amounts of total fat and fatty acids consumption according to each food. Fat and fatty acid intakes and their food sources were presented by age group (1–2-y, n = 401; 3–5-y, n = 640). Fat and fatty acid intakes were also evaluated according to socioeconomic characteristics.

RESULTS

The mean intake of fat was 27.1 ± 0.8 g in the 1-2-y group and 35.5 ± 0.7 g in the 3-5-y group, and about 23% of the total energy was obtained from fat in both age groups. The mean intake of saturated fatty acids (SFA) was 10.5 ± 0.3 g in the 1-2-y group and 12.7 ± 0.3 g in the 3-5-y group, with the 1-2-y group obtaining more energy from SFA than the 3-5-y group (9.2% vs. 8.3%). The mean intake of polyunsaturated fatty acids (PUFA) was 6.3 ± 0.1 g in the total subjects, with 0.8 ± 0.03 g of n-3 fatty acids and 5.5 ± 0.1 g of n-6 fatty acids being consumed. Milk, pork, and eggs were major food sources of total fat, SFA, and monounsaturated fatty acids, and soybean oil was the main contributor to PUFA in both age groups. In the 1-2-y group, children in rural areas had significantly higher intake of PUFA and n-3 fatty acids than did those in urban areas.

CONCLUSIONS

Our findings provide current information on dietary fat intake among young Korean children and could be used to establish dietary strategies for improvement of health status.

Effects of total fat intake on bodyweight in children

BACKGROUND

As part of efforts to prevent childhood overweight and obesity, we need to understand the relationship between total fat intake and body fatness in generally healthy children.

OBJECTIVES

To assess the effects and associations of total fat intake on measures of weight and body fatness in children and young people not aiming to lose weight.

SEARCH METHODS

For this update we revised the previous search strategy and ran it over all years in the Cochrane Library, MEDLINE (Ovid), MEDLINE (PubMed), and Embase (Ovid) (current to 23 May 2017). No language and publication status limits were applied. We searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov for ongoing and unpublished studies (5 June 2017).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 24 months to 18 years, with or without risk factors for cardiovascular disease, randomised to a lower fat (30% or less of total energy (TE)) versus usual or moderate-fat diet (greater than 30%TE), without the intention to reduce weight, and assessed a measure of weight or body fatness after at least six months. We included prospective cohort studies if they related baseline total fat intake to weight or body fatness at least 12 months later.

DATA COLLECTION AND ANALYSIS

We extracted data on participants, interventions or exposures, controls and outcomes, and trial or cohort quality characteristics, as well as data on potential effect modifiers, and assessed risk of bias for all included studies. We extracted body weight and blood lipid levels outcomes at six months, six to 12 months, one to two years, two to five years and more than five years for RCTs; and for cohort studies, at baseline to one year, one to two years, two to five years, five to 10 years and more than 10 years. We planned to perform random-effects meta-analyses with relevant subgrouping, and sensitivity and funnel plot analyses where data allowed.

MAIN RESULTS

We included 24 studies comprising three parallel-group RCTs (n = 1054 randomised) and 21 prospective analytical cohort studies (about 25,059 children completed). Twenty-three studies were conducted in high-income countries. No meta-analyses were possible, since only one RCT reported the same outcome at each time point range for all outcomes, and cohort studies were too heterogeneous to combine.Effects of dietary counselling to reduce total fat intake from RCTsTwo studies recruited children aged between 4 and 11 years and a third recruited children aged 12 to 13 years. Interventions were combinations of individual and group counselling, and education sessions in clinics, schools and homes, delivered by dieticians, nutritionists, behaviourists or trained, supervised teachers. Concerns about imprecision and poor reporting limited our confidence in our findings. In addition, the inclusion of hypercholesteraemic children in two trials raised concerns about applicability.One study of dietary counselling to lower total fat intake found that the intervention may make little or no difference to weight compared with usual diet at 12 months (mean difference (MD) -0.50 kg, 95% confidence interval (CI) -1.78 to 0.78; n = 620; low-quality evidence) and at three years (MD -0.60 kg, 95% CI -2.39 to 1.19; n = 612; low-quality evidence). Education delivered as a classroom curriculum probably decreased BMI in children at 17 months (MD -1.5 kg/m2, 95% CI -2.45 to -0.55; 1 RCT; n = 191; moderate-quality evidence). The effects were smaller at longer term follow-up (five years: MD 0 kg/m2, 95% CI -0.63 to 0.63; n = 541; seven years; MD -0.10 kg/m2, 95% CI -0.75 to 0.55; n = 576; low-quality evidence).Dietary counselling probably slightly reduced total cholesterol at 12 months compared to controls (MD -0.15 mmol/L, 95% CI -0.24 to -0.06; 1 RCT; n = 618; moderate-quality evidence), but may make little or no difference over longer time periods. Dietary counselling probably slightly decreased low-density lipoprotein (LDL) cholesterol at 12 months (MD -0.12 mmol/L, 95% CI -0.20 to -0.04; 1 RCT; n = 618, moderate-quality evidence) and at five years (MD -0.09, 95% CI -0.17 to -0.01; 1 RCT; n = 623; moderate-quality evidence), compared to controls. Dietary counselling probably made little or no difference to HDL-C at 12 months (MD -0.03 mmol/L, 95% CI -0.08 to 0.02; 1 RCT; n = 618; moderate-quality evidence), and at five years (MD -0.01 mmol/L, 95% CI -0.06 to 0.04; 1 RCT; n = 522; moderate-quality evidence). Likewise, counselling probably made little or no difference to triglycerides in children at 12 months (MD -0.01 mmol/L, 95% CI -0.08 to 0.06; 1 RCT; n = 618; moderate-quality evidence). Lower versus usual or modified fat intake may make little or no difference to height at seven years (MD -0.60 cm, 95% CI -2.06 to 0.86; 1 RCT; n = 577; low-quality evidence).Associations between total fat intake, weight and body fatness from cohort studiesOver half the cohort analyses that reported on primary outcomes suggested that as total fat intake increases, body fatness measures may move in the same direction. However, heterogeneous methods and reporting across cohort studies, and predominantly very low-quality evidence, made it difficult to draw firm conclusions and true relationships may be substantially different.

AUTHORS' CONCLUSIONS

We were unable to reach firm conclusions. Limited evidence from three trials that randomised children to dietary counselling or education to lower total fat intake (30% or less TE) versus usual or modified fat intake, but with no intention to reduce weight, showed small reductions in body mass index, total- and LDL-cholesterol at some time points with lower fat intake compared to controls. There were no consistent effects on weight, high-density lipoprotein (HDL) cholesterol or height. Associations in cohort studies that related total fat intake to later measures of body fatness in children were inconsistent and the quality of this evidence was mostly very low. Most studies were conducted in high-income countries, and may not be applicable in low- and middle-income settings. High-quality, longer-term studies are needed, that include low- and middle-income settings to look at both possible benefits and harms.

Habit formation intervention to prevent obesity in low-income preschoolers and their mothers: A randomized controlled trial protocol

BACKGROUND

Low-income and racial/ethnic minority mothers and their young children are at increased risk for obesity. Lack of access to evidence-based obesity prevention and treatment services further contributes to these disparities.

METHODS

This two-arm, parallel, randomized controlled trial (RCT) tests the effectiveness of a simple obesity intervention (HABITS) delivered as part of ongoing home visitation services, compared to the existing home visitation services without obesity-related content on mothers' and children's obesity risks. HABITS focuses on habit formation and modifications of food and activity cues in the home to support habit formation. Habit formation is focused on improving five behaviors: 1) fruits/vegetables, 2) fried foods, 3) sugar-sweetened beverages, 4) physical activity and 5) self-monitoring. Participants will be 298 mothers (>50% African American; 100% low income) and their children (3-5yo at baseline) enrolled in a home visitation program in central Alabama. Home visitors will be randomly assigned to deliver the home visitation curriculum with or without HABITS as part of their weekly home visits for 9 months. Assessments of mothers (weight, waist circumference, and habit strength of targeted behaviors), children (rate of weight gain), and the food/activity household environment will be conducted at enrollment, post-intervention (9 month), and one year post-intervention follow-up.

DISCUSSION

This research is poised to have a substantial impact because the delivery modalities of current obesity efforts disproportionally restrict the reach and engagement of underserved, low-income children and their caregivers who are most at-risk for health and obesity disparities.

Childhood dietary trajectories and adolescent cardiovascular phenotypes: Australian community-based longitudinal study

OBJECTIVE

With the intention to inform future public health initiatives, we aimed to determine the extent to which typical childhood dietary trajectories predict adolescent cardiovascular phenotypes.

DESIGN

Longitudinal study. Exposure was determined by a 4 d food diary repeated over eight waves (ages 4-15 years), coded by Australian Dietary Guidelines and summed into a continuous diet score (0-14). Outcomes were adolescent (Wave 8, age 15 years) blood pressure, resting heart rate, pulse wave velocity, carotid intima-media thickness, retinal arteriole-to-venule ratio. Latent class analysis identified 'typical' dietary trajectories from childhood to adolescence. Adjusted linear regression models assessed relationships between trajectories and cardiovascular outcomes, adjusted for a priori potential confounders.

SETTING

Community sample, Melbourne, Australia.

SUBJECTS

Children (n 188) followed from age 4 to 15 years.

RESULTS

Four dietary trajectories were identified: unhealthy (8 %); moderately unhealthy (25 %); moderately healthy (46 %); healthy (21 %). There was little evidence that vascular phenotypes associated with the trajectories. However, resting heart rate (beats/min) increased (β; 95 % CI) across the healthy (reference), moderately healthy (4·1; -0·6, 8·9; P=0·08), moderately unhealthy (4·5; -0·7, 9·7; P=0·09) and unhealthy (10·5; 2·9, 18·0; P=0·01) trajectories.

CONCLUSIONS

Decade-long dietary trajectories did not appear to influence macro- or microvascular structure or stiffness by mid-adolescence, but were associated with resting heart rate, suggesting an early-life window for prevention. Larger studies are needed to confirm these findings, the threshold of diet quality associated with these physiological changes and whether functional changes in heart rate are followed by phenotypic change.

The fight against overweight and obesity in school children: Public policy in Mexico

Excess weight in schoolchildren is a serious health problem in Mexico. In 2010, the government established General Guidelines for Dispensing or Distribution of Foods and Beverages at School Food Establishments (SFEs) in Elementary Schools with the objective of stopping the epidemic of overweight and obesity. This study aimed to evaluate compliance with the Guidelines during two academic years. With a sample of 39 schools already randomly selected, we carried out a follow-up study. The research team recorded foods and beverages available at schools in two academic years, and compared their nutritional characteristics to those established in the Guidelines. At the schools in both stages of the study, we found broad availability of energy-dense foods not allowed in the SFEs. Vegetables, fruits, and plain water accounted for less than 7 per cent of the foods and drinks. We observed no changes between stages in the compliance the Guidelines.

Effect of Dietary Counseling on a Comprehensive Metabolic Profile from Childhood to Adulthood

OBJECTIVES

To study the effects of repeated, infancy-onset dietary counseling on a detailed metabolic profile. Effects of dietary saturated fat replacement on circulating concentrations of metabolic biomarkers still remain unknown.

STUDY DESIGN

The Special Turku Coronary Risk Factor Intervention Project (STRIP) study is a longitudinal, randomized atherosclerosis prevention trial in which repeated dietary counseling aimed at reducing the proportion of saturated fat intake. Nuclear magnetic resonance metabolomics quantified circulating metabolites from serum samples assessed at age 9 (n = 554), 11 (n = 553), 13 (n = 508), 15 (n = 517), 17 (n = 457), and 19 (n = 417) years.

RESULTS

The intervention reduced dietary intake of saturated fat (mean difference in daily percentage of total energy intake: -2.1 [95% CI -1.9 to -2.3]) and increased intake of polyunsaturated fat (0.6 [0.5-0.7]). The dietary counseling intervention led to greater serum proportions of polyunsaturated fatty acids (P < .001), with greater proportions of both circulating omega-3 (P = .02) and omega-6 (P < .001) fatty acids. The proportion of saturated fatty acids in serum was lower for both boys and girls in the intervention group (P < .001), whereas the serum proportion of monounsaturated fat was lower for boys in the intervention group only (P < .001). The intervention also reduced circulating intermediate-density lipoprotein and low-density lipoprotein lipid concentrations (P < .01). Dietary intervention effects on nonlipid biomarkers were minor except from greater concentrations of glutamine in the intervention group.

CONCLUSIONS

Repeated dietary counseling from infancy to early adulthood yielded favorable effects on multiple circulating fatty acids and lipoprotein subclass lipids, particularly in boys. These molecular effects substantiate the beneficial role of saturated fat replacement on the metabolic risk profile.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00223600.

Effects of total fat intake on bodyweight in children

BACKGROUND

As part of efforts to prevent childhood overweight and obesity, we need to understand the relationship between total fat intake and body fatness in generally healthy children.

OBJECTIVES

To assess the effects of total fat intake on measures of weight and body fatness in children and young people not aiming to lose weight.

SEARCH METHODS

For this update we revised the previous search strategy and ran it over all years in the Cochrane Library, MEDLINE (Ovid), MEDLINE (PubMed), and Embase (Ovid) (current to 23 May 2017). No language and publication status limits were applied. We searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov for ongoing and unpublished studies (5 June 2017).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 24 months to 18 years, with or without risk factors for cardiovascular disease, randomised to a lower fat (30% or less of total energy (TE)) versus usual or moderate-fat diet (greater than 30%TE), without the intention to reduce weight, and assessed a measure of weight or body fatness after at least six months. We included prospective analytical cohort studies in these children if they related baseline total fat intake to weight or body fatness at least 12 months later. We duplicated inclusion decisions and resolved disagreement by discussion with other authors.

DATA COLLECTION AND ANALYSIS

We extracted data on participants, interventions or exposures, controls and outcomes, and trial or cohort quality characteristics, as well as data on potential effect modifiers, and assessed risk of bias for all included studies. We extracted outcome data using the following time point ranges, when available: RCTs: baseline to six months, six to 12 months, one to two years, two to five years and more than five years; cohort studies: baseline to one year, one to two years, two to five years, five to 10 years and more than 10 years. We planned to perform random-effects meta-analyses with relevant subgrouping, and sensitivity and funnel plot analyses where data allowed.

MAIN RESULTS

We included 24 studies comprising three parallel-group RCTs (n = 1054 randomised) and 21 prospective analytical cohort studies (about 25,059 children completed). Twenty-three were conducted in high-income countries. No meta-analyses were possible, since only one RCT reported the same outcome at each time point range for all outcomes, and cohort studies were too heterogeneous.For the RCTs, concerns about imprecision and poor reporting limited our confidence in our findings. In addition, the inclusion of hypercholesteraemic children in two trials raised concerns about applicability. Lower versus usual or modified total fat intake may have made little or no difference to weight over a six- to twelve month period (mean difference (MD) -0.50 kg, 95% confidence interval (CI) -1.78 to 0.78; 1 RCT; n = 620; low-quality evidence), nor a two- to five-year period (MD -0.60 kg, 95% CI -2.39 to 1.19; 1 RCT; n = 612; low-quality evidence). Compared to controls, lower total fat intake (30% or less TE) probably decreased BMI in children over a one- to two-year period (MD -1.5 kg/m2, 95% CI -2.45 to -0.55; 1 RCT; n = 191; moderate-quality evidence), with no other differences evident across the other time points (two to five years: MD 0.00 kg/m2, 95% CI -0.63 to 0.63; 1 RCT; n = 541; greater than five years; MD -0.10 kg/m2, 95% CI -0.75 to 0.55; 1 RCT; n = 576; low-quality evidence). Lower fat intake probably slightly reduced total cholesterol over six to 12 months compared to controls (MD -0.15 mmol/L, 95% CI -0.24 to -0.06; 1 RCT; n = 618; moderate-quality evidence), but may make little or no difference over longer time periods. Lower fat intake probably slightly decreased low-density lipoprotein (LDL) cholesterol over six to 12 months (MD -0.12 mmol/L, 95% CI -0.20 to -0.04; 1 RCT; n = 618, moderate-quality evidence) and over two to five years (MD -0.09, 95% CI -0.17 to -0.01; 1 RCT; n = 623; moderate-quality evidence), compared to controls. However, lower total fat intake probably made little or no difference to HDL-C over a six- to 12-month period (MD -0.03 mmol/L, 95% CI -0.08 to 0.02; 1 RCT; n = 618; moderate-quality evidence), nor a two- to five-year period (MD -0.01 mmol/L, 95% CI -0.06 to 0.04; 1 RCT; n = 522; moderate-quality evidence). Likewise, lower total fat intake probably made little or no difference to triglycerides in children over a six- to 12-month period (MD -0.01 mmol/L, 95% CI -0.08 to 0.06; 1 RCT; n = 618; moderate-quality evidence). Lower versus usual or modified fat intake may make little or no difference to height over more than five years (MD -0.60 cm, 95% CI -2.06 to 0.86; 1 RCT; n = 577; low-quality evidence).Over half the cohort analyses that reported on primary outcomes suggested that as total fat intake increases, body fatness measures may move in the same direction. However, heterogeneous methods and reporting across cohort studies, and predominantly very low-quality evidence, made it difficult to draw firm conclusions and true relationships may be substantially different.

AUTHORS' CONCLUSIONS

We were unable to reach firm conclusions. Limited evidence from three trials that randomised children to a lower total fat intake (30% or less TE) versus usual or modified fat intake, but with no intention to reduce weight, showed small reductions in body mass index, total- and LDL-cholesterol at some time points with lower fat intake compared to controls, and no consistent differences in effects on weight, high-density lipoprotein (HDL) cholesterol or height. Associations in cohort studies that related total fat intake to later measures of body fatness in children were inconsistent and the quality of this evidence was mostly very low. Twenty-three out of 24 included studies were conducted in high-income countries, and may not be applicable in low- and middle-income settings. High-quality, longer-term studies are needed, that include low- and middle-income settings and look at both possible benefits and risks.

Diets Rich in Fruits and Vegetables Are Associated with Lower Cardiovascular Disease Risk in Adolescents

Obesity and cardiovascular disease (CVD) risk are public health concerns in adolescents, yet few studies have examined the association of their diet to CVD risk factors. This study investigated associations between diet, body mass index (BMI), waist circumference (WC), blood pressure (BP), and blood lipids in 163 16-17 year olds. Diet recall data were converted into Healthy Eating Index-2010 (HEI) to assess diet quality. Differences in diet between groups with normal or obese BMI, normal or hypertensive BP, and normal or altered lipids were determined. Associations between diet and BMI, WC, BP, and lipids, controlling for race, gender, and socioeconomic status, were examined. Mean HEI was 49.2 (±12.0), with no differences observed between groups. HEI was not associated with any CVD risk. Sweetened beverage consumption was higher in obese adolescents, and positively related to total cholesterol (TC). Fruit intake was negatively related to BMI and diastolic BP. Total vegetable intake was negatively related to systolic BP. Greens and beans were negatively related to TC and LDL. Whole grains were negatively related to HDL. This research suggests a cardioprotective effect of diets rich in fruits and vegetables, as well as low in sweetened beverages in adolescents.

Health effects of saturated and trans-fatty acid intake in children and adolescents: Systematic review and meta-analysis

BACKGROUND

Elevated cholesterol has been linked to cardiovascular disease in adults and preclinical markers of atherosclerosis in children, thus reducing saturated (SFA) and trans-fatty acids (TFA) intake from an early age may help to reduce cholesterol and the risk of cardiovascular disease later in life. The aim of this review is to examine the evidence for health effects associated with reducing SFA and TFA intake in free-living children, adolescents and young adults between 2 to 19 years of age.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs) and prospective cohort studies. Study selection, assessment, validity, data extraction, and analysis were undertaken as specified by the Cochrane Collaboration and the GRADE working group. Data were pooled using inverse variance models with random effects.

DATA SOURCES

EMBASE; PubMed; Cochrane Central Register of Controlled Trials; LILACS; and WHO Clinical Trial Registry (up to July 2016).

ELIGIBILITY CRITERIA FOR SELECTING TRIALS

RCTs involving dietary interventions aiming to reduce SFA or TFA intakes and a control group, and cohort studies reporting the effects of SFA or TFA exposures, on outcomes including blood lipids; measures of growth; blood pressure; insulin resistance; and potential adverse effects. Minimum duration was 13 days for RCTs and one year for cohort studies. Trials of weight loss or confounded by additional medical or lifestyle interventions were excluded.

RESULTS

Compared with control diets, there was a highly statistically significant effect of reduced SFA intake on total cholesterol (mean difference (MD) -0.16 mmol/l, [95% confidence interval (CI): -0.25 to -0.07]), LDL cholesterol (MD -0.13 mmol/l [95% CI:-0.22 to -0.03]) and diastolic blood pressure (MD -1.45 mmol/l [95% CI:-2.34 to -0.56]). There were no significant effects on any other risk factors and no evidence of adverse effects.

CONCLUSIONS

Advice to reduce saturated fatty acids intake of children results in a significant reduction in total and LDL-cholesterol levels as well as diastolic blood pressure without evidence of adverse effects on growth and development. Dietary guidelines for children and adolescents should continue to recommend diets low in saturated fat.

2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents

These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.

Longitudinal child-oriented dietary intervention: Association with parental diet and cardio-metabolic risk factors. The Special Turku Coronary Risk Factor Intervention Project

Background The child-oriented dietary intervention given in the prospective Special Turku Coronary Risk Factor Intervention Project (STRIP) has decreased the intake of saturated fat and lowered serum cholesterol concentration in children from infancy until early adulthood. In this study, we investigated whether the uniquely long-term child-oriented intervention has affected also secondarily parental diet and cardio-metabolic risk factors. Methods The STRIP study is a longitudinal, randomized infancy-onset atherosclerosis prevention trial continued from the child's age of 8 months to 20 years. The main aim was to modify the child's diet towards reduced intake of saturated fat. Parental dietary intake assessed by a one-day food record and cardio-metabolic risk factors were analysed between the child's ages of 9-19 years. Results Saturated fat intake of parents in the intervention group was lower [mothers: 12.0 versus 13.9 daily energy (E%), p < 0.0001; fathers: 12.5 versus 13.9 E%, p < 0.0001] and polyunsaturated fat intake was higher (mothers: 6.1 versus 5.4 E%, p < 0.0001; fathers: 6.3 versus 5.9 E%, p = 0.0003) compared with the control parents. Maternal total and low-density lipoprotein cholesterol concentrations were lower in the intervention compared with the control group (mean ± SE 5.02 ± 0.04 versus 5.14 ± 0.04 mmol/l, p = 0.04 and 3.19 ± 0.04 versus 3.30 ± 0.03 mmol/l, p = 0.03, respectively). Paternal cholesterol values did not differ between the intervention and control groups. Other cardio-metabolic risk factors were similar in the study groups. Conclusions Child-oriented dietary intervention shifted the dietary fat intakes of parents closer to the recommendations and tended to decrease total and low-density lipoprotein cholesterol in the intervention mothers. Dietary intervention directed to children benefits also parents.

Cardiometabolic Determinants of Carotid and Aortic Distensibility From Childhood to Early Adulthood

Children who are obese or have familial hypercholesterolemia have stiffer arteries compared with lean, healthy peers. Limited data are, however, available on the association of cardiometabolic risk markers and arterial distensibility in healthy children, particularly in a longitudinal setting. Therefore, we studied in the prospective STRIP (Special Turku Coronary Risk Factor Intervention Project) comprising healthy, predominantly normal weight participants the association of several cardiometabolic and dietary risk markers with arterial distensibility from childhood to early adulthood. Carotid and aortic distensibility (cdist, adist) was assessed repeatedly with ultrasonography at the age of 11, 13, 15, 17, and 19 years in the longitudinal atherosclerosis prevention study (n_cdist=420-503, n_adist=407-476). Data on cardiometabolic risk markers and diet were available since early childhood. In multivariable analyses, body mass index (β=-0.0019 [SE 0.0085]; P=0.037), systolic blood pressure (β=-0.0025 [SE 0.00065]; P=0.0001), low-density lipoprotein cholesterol (β=-0.026 [SE 0.012]; P=0.034), and homeostasis model of insulin resistance (β=-0.048 [SE 0.018]; P=0.0071) were independently associated with carotid distensibility. Systolic blood pressure (β=-0.0069 [SE 0.00097]; P<0.0001) and low-density lipoprotein cholesterol (β=-0.039 [SE 0.018]; P=0.031) associated independently with aortic distensibility. Dietary variables were not independently associated with arterial distensibility. Participants with low arterial distensibility had higher body mass index (P_cdist=0.0090, P_adist=0.098) and higher systolic (P_cdist<0.0001, P_adist<0.0001) and diastolic blood pressures (P_cdist<0.0001, P_adist=0.0002) already from early childhood. Body mass index, blood pressure, low-density lipoprotein cholesterol, and homeostasis model of insulin resistance identified since childhood associate with arterial distensibility in healthy children and adolescents. These data support the relevance of these factors as part of primordial prevention.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00223600.

Heritability and risks associated with early onset hypertension: multigenerational, prospective analysis in the Framingham Heart Study

Objective To determine the role of early onset versus late onset hypertension as a risk factor for hypertension in offspring and cardiovascular death.Design Multigenerational, prospective cohort study.Setting Framingham Heart Study.Participants Two generations of community dwelling participants with blood pressure measurements performed at serial examinations spanning six decades: 3614 first generation participants with mortality data and 1635 initially non-hypertensive second generation participants with data available on parental blood pressure.Main outcome measures The main outcome measures were relation of parental early onset hypertension (age <55 years) with incidence of hypertension in offspring, using regression analyses, and relation of age at hypertension onset with cause specific mortality using a case (cardiovascular death) versus control (non-cardiovascular death) design.Results In second generation participants, having one or both parents with late onset hypertension did not increase the risk of hypertension compared with having parents with no hypertension; by contrast, the hazard ratios of hypertension were 2.0 (95% confidence interval 1.2 to 3.5) and 3.5 (1.9 to 6.1) in participants with one and both parents with early onset hypertension, respectively. In first generation decedents, 1151 cardiovascular deaths occurred (including 630 coronary deaths). The odds of cardiovascular death increased linearly with decreasing age of hypertension onset (P<0.001 for trend). Compared with non-hypertensive participants, hypertension onset at age <45 years conferred an odds ratios of 2.2 (1.8 to 2.7) for cardiovascular death and 2.3 (1.8 to 2.9) for coronary death, whereas hypertension onset at age ≥65 years conferred a lower magnitude odds ratios of 1.5 (1.2 to 1.9) for cardiovascular death and 1.4 (0.98 to 1.9) for coronary death (P≤0.002 for differences in odds ratios between hypertension onset at age <45 and age ≥65).Conclusions Early onset and not late onset hypertension in parents was strongly associated with hypertension in offspring. In turn, early onset compared with late onset hypertension was associated with greater odds of cardiovascular, and particularly coronary, death. These findings suggest it may be important to distinguish between early onset and late onset hypertension as a familial trait when assessing an individual's risk for hypertension, and as a specific type of blood pressure trait when estimating risk for cardiovascular outcomes in adults with established hypertension.

Greater adherence to the dietary approaches to stop hypertension (DASH) dietary pattern is associated with lower blood pressure in healthy Iranian primary school children

PURPOSE

The dietary determinants of children blood pressure (BP) are poorly understood. We examined the association between adherence to the dietary approaches to stop hypertension (DASH) dietary pattern and BP in healthy Iranian primary school children.

METHODS

This cross-sectional study was conducted among a representative sample (n = 407) of healthy Shirazi students aged 6-12 years. Subjects' systolic and diastolic BP were measured by a validated oscillometric BP monitor. Usual dietary intakes over the past 12 months were assessed using a valid and reproducible 168-item semi-quantitative food frequency questionnaire via face-to-face interviews. A DASH score was calculated for each subject based on his/her energy-adjusted intakes of 8 major dietary components emphasized or minimized in the DASH dietary pattern. The higher the DASH score of a subject, the more his/her adherence to the DASH dietary pattern.

RESULTS

After controlling for several potential confounders in the analysis of covariance models, multivariable-adjusted means of systolic and mean BP of subjects in the highest tertile of DASH score were significantly lower than those in the lowest tertile (for systolic BP: mean difference -6.2 mmHg, P = 0.010; and for mean BP: mean difference -5.4 mmHg, P = 0.013). Furthermore, a similar but statistically insignificant difference was found in terms of multivariable-adjusted means of diastolic BP (mean difference -3.9 mmHg, P = 0.146).

CONCLUSIONS

The findings suggest that greater adherence to the DASH dietary pattern is associated with lower BP in healthy Iranian primary school children. However, future prospective studies of adequate methodological quality are warranted to confirm these findings.

Dietary intake and prospective changes in cardiometabolic risk factors in children and youth

Only few studies examined the effect of diet on prospective changes in cardiometabolic (CM) risk factors in children and youth despite its importance for understanding the role of diet early in life for cardiovascular disease in adulthood. To test the hypothesis that dietary intake is associated with prospective changes in CM risk factors, we analyzed longitudinal observations made over a period of 2 years among 448 students (aged 10-17 years) from 14 schools in Canada. We applied mixed effect regression to examine the associations of dietary intake at baseline with changes in body mass index, waist circumference (WC), systolic and diastolic blood pressure (SBP and DBP), and insulin sensitivity score between baseline and follow-up while adjusting for age, sex, and physical activity. Dietary fat at baseline was associated with increases in SBP and DBP z scores (per 10 g increase in dietary fat per day: β = 0.03; p < 0.05) and WC (β = 0.31 cm; p < 0.05) between baseline and follow-up. Every additional gram of sodium intake at baseline was associated with an increase in DBP z score of 0.04 (p < 0.05) between baseline and follow-up. Intake of sugar, vegetables and fruit, and fibre were not associated with changes in CM risk factors in a statistically significant manner. Our findings suggest that a reduction in the consumption of total dietary fat and sodium may contribute to the prevention of excess body weight and hypertension in children and youth, and their cardiometabolic sequelae later in life.

Prediction of Blood Pressure and Blood Pressure Change With a Genetic Risk Score

The authors investigated whether a genetic risk score (GRS) constructed of 32 single nucleotide polymorphisms would predict incident hypertension and blood pressure (BP) change over time in a population cohort during an 11-year follow-up (n=5402 at baseline, 3266 at follow-up). In multivariable models, GRS was associated with higher systolic/diastolic BP values at baseline (β±standard error [SE], 1.04±0.14/1.11±0.13 mm Hg; P<.0001 for both) and at reinvestigation (β±SE, 0.84±0.18/0.79±0.16 mm Hg; P<.0001 for both). Among participants who were normotensive at baseline (n=2045), GRS was not independently associated with systolic/diastolic BP change over time (β±SE, 0.16±0.18/0.20±0.18 mm Hg; P≥.28 for both). In participants in the top tertile of the GRS, as compared with the bottom tertile, the predicted increase in systolic/diastolic BP was 1.18±0.78/0.70±0.49 mm Hg (P=.046/.15) greater and the odds ratio for incident hypertension was 33% higher (P=.03). These data show that GRS is strongly associated with BP but weakly associated with BP increase and incident hypertension in a late middle-aged population.

Effect of Islam-based religious program on spiritual wellbeing in elderly with hypertension

Background:

Lack of spiritual health in patients with hypertension leads to many mental, social, and physical effects, On the other hand, considering the prevalence of hypertension among the elderly, interventions to enhance their spiritual wellbeing is essential. Therefore, the aim of this study was to examine the effect of religious programs based on Islam on spiritual wellbeing in elderly patients with hypertension who referred to the health centers of Isfahan in 2014.

Materials and Methods:

This study was a randomized clinical trial. The participants (52 elderly patients with hypertension) were randomly divided in to experimental and control groups. Religious program was implemented for the experimental group in eight sessions in two Isfahan health centers. Spirituality wellbeing survey (SWB) questionnaire was completed in three steps, namely, pretest, posttest and follow-up (1 month) in two groups. In the study, Chi-square test, independent t-test, and repeated-measures analysis of variance were performed for analyzing the data.

Results:

Before the intervention, there was no significant difference between the mean scores of spiritual wellbeing, the religious dimension, and the existential aspect of spiritual wellbeing of the two groups. However in the posttest step and follow-up stage, the mean scores of spiritual wellbeing, the religious dimension, and the existential aspect of spiritual wellbeing in the experimental group was significantly higher than in the control group (P < 0.001).

Conclusions:

The religious program based on Islam promoted the SWB of elderly patients with hypertension; further, nurses can use these programs to promote the SWB of elderly patients with hypertension.

Association Between Adiposity and Left Ventricular Mass in Children With Hypertension

Left ventricular hypertrophy (LVH) is prevalent among hypertensive children; however, blood pressure (BP) does not predict its presence. The authors conducted a 1-year prospective cohort study to examine the hypothesis that obesity-related risk factors are associated with left ventricular mass index (LVMI) in hypertensive children, and the association between adiposity and LVMI is mediated by BP-dependent and -independent pathways. A total of 49 hypertensive children were enrolled: 51% were overweight/obese and 41% had LVH at baseline. Children overweight/obese at baseline and follow-up had a greater LVMI increase than those of healthy weight at each visit: mean change of 6.4 g/m(2.7) vs 0.95 g/m(2.7) . Baseline body mass index z score was independently associated with LVMI change (β=4.08, 1.54-6.61; P=.002). Only pulse pressure and serum aldosterone partially mediated this relationship. Hypertensive youth manifest multiple cardiovascular disease risk factors that worsen over time despite treatment. Of these, adiposity is most associated with LVH and increasing LVMI.