Sodium intake and blood pressure among US children and adolescents

Hypertension in children and adolescents: perspectives in Japan

Hypertension in children and adolescents is associated with increased risk of hypertension and cardiovascular disease (CVD) in adulthood. Therefore, preventing hypertension among children and adolescents is an important public health objective worldwide. Although the importance of hypertension in children and adolescents has increasingly been recognized, the field of research is relatively new and evidence for etiologies, prevention and treatment is sparse. This review mainly summarizes the content regarding hypertension in children and adolescents published in Hypertension Research in 2023/24. Highlights include the following: The prevalence of hypertension was higher in female than male Japanese junior high school students (13.7% vs. 4.7%), but there was no significant gender difference among Japanese senior high school students (7.4% vs. 5.4%). Hematological parameters, including red blood cell counts, hemoglobin counts, hematocrit and iron levels, were positively associated with blood pressure (BP) levels in healthy children and adolescents. Higher-risk longitudinal BP trajectories in early life were associated with increased risk of target organ damage (TOD) and higher combined TOD load in midlife. BP phenotypes (e.g., masked hypertension, white-coat hypertension) assessed using office and 24-h ambulatory BP monitoring were not highly reproducible in children. The salt check sheet was a useful tool for evaluating the approximate dietary salt intake in Japanese children and adolescents. It is recommended that healthcare providers screen for hypertension in children and adolescents and recognize the importance of early intervention for those with elevated BP levels. Beginning in childhood, continuous education on hypertension and proper dietary salt intake are key to reducing the risk of hypertension and decreasing the burden of CVD in adulthood.

Identification of interactions between genetic risk scores and dietary patterns for personalized prevention of kidney dysfunction in a population-based cohort

BACKGROUND & AIM

Chronic kidney disease (CKD) is a heterogeneous disorder that affects the kidney structure and function. This study investigated the effect of the interaction between genetic factors and dietary pattern on kidney dysfunction in Korean adults.

METHODS

Baseline data were obtained from the Ansan and Ansung Study of the Korean Genome and Epidemiology Study involving 8230 participants aged 40-69 years. Kidney dysfunction was defined as an estimated glomerular filtration rate < 90 mL/minute/1.73 m2. Genomic DNAs genotyped on the Affymetrix® Genome-Wide Human SNP array 5.0 were isolated from peripheral blood. A genome-wide association study using a generalized linear model was performed on 1,590,162 single-nucleotide polymorphisms (SNPs). To select significant SNPs, the threshold criterion was set at P-value < 5 × 10-8. Linkage disequilibrium clumping was performed based on the R2 value, and 94 SNPs had a significant effect. Participants were divided into two groups based on their generic risk score (GRS): the low-GR group had GRS > 0, while the high-GR group had GRS ≤ 0.

RESULTS

Three distinct dietary patterns were extracted, namely, the "prudent pattern," "flour-based and animal food pattern," and "white rice pattern," to analyze the effect of dietary pattern on kidney function. In the "flour-based and animal food pattern," higher pattern scores were associated with a higher prevalence of kidney dysfunction in both the low and high GR groups (P for trend < 0.0001 in the low-, high-GR groups of model 1; 0.0050 and 0.0065 in the low-, high-GR groups of model 2, respectively).

CONCLUSIONS

The results highlight a significant association between the 'flour-based and animal food pattern' and higher kidney dysfunction prevalence in individuals with both low and high GR. These findings suggest that personalized nutritional interventions based on GR profiles may become the basis for presenting GR-based individual dietary patterns for kidney dysfunction.

Diagnosis and Management of Hypertension in Adolescents with Obesity

Purpose of Review

Hypertension (HTN) and obesity are increasing in prevalence and severity in adolescents and have significant implications for long term morbidity and mortality. This review focuses on the diagnosis and management of HTN in adolescents with obesity with an emphasis on co-management of the two conditions.

Recent Findings

Recent studies affirm the increasing prevalence of abnormal blood pressures and diagnoses of HTN associated with increased adiposity. Current guidelines recommend routine screening with proper technique for HTN in patients with obesity. Additionally, obesity and HTN related co-occurring medical conditions should be evaluated as there is frequently a bidirectional impact on risk and outcomes. Importantly, advances in adolescent obesity management have subsequently led to positive implications for the management of obesity-related comorbidities such as HTN. The co-management of obesity and HTN is an emerging strategy for treatment and prevention of additional morbidity and mortality as patients progress to adulthood.

Summary

In adolescent patients with obesity, prompt recognition and appropriate diagnosis of HTN as well as related co-occurring conditions are necessary first steps in management. Co-management of obesity and HTN is likely to lead to improved outcomes. While lifestyle interventions serve as the foundation to this management, adjunctive and emerging therapies should be considered to adequately treat both conditions.

Birth History and Cardiovascular Disease Risk Among Youth With Significant Obesity

Children born prematurely have greater lifetime risk for hypertension. We aimed to determine (1) the association between prematurity and cardiovascular disease (CVD) risk factors among 90 children with obesity and elevated blood pressure and (2) if dietary sodium intake modified these associations. Multivariable regression analysis explored for associations between prematurity (<37 weeks gestation; early gestational age) and low birth weight (<2.5 kg) with hypertension, left ventricular mass index (LVMI), and left ventricular hypertrophy (LVH). Effect modification by dietary sodium intake was also explored. Patients were predominately male (60%), black (78%), adolescents (13.3 years), and with substantial obesity (body mass index: 36.5 kg/m2). Early gestational age/low birth weight was not an independent predictor for hypertension, LVMI, or LVH. There was no effect modification by sodium load. Our results suggest the increased CVD risk conferred by prematurity is less significant at certain cardiometabolic profiles. Promoting heart-healthy lifestyles to prevent pediatric obesity remains of utmost importance to foster cardiovascular health.

Spot urinary sodium-to-potassium ratio is associated with blood pressure levels in healthy adolescents: the Wakayama Study

The spot urinary sodium-to-potassium (Na/K) ratio is a simple measure of salt loading and has been shown to be associated with elevated blood pressure (BP) in middle-aged and older adults. This study aimed to evaluate the association between the spot urinary Na/K ratio and BP in 457 healthy adolescents aged 12-15 years in a school-based setting. The mean urinary Na/K ratio was 4.99 ± 2.76, and no significant difference was found between the boys and girls. When the participants were stratified based on urinary Na/K ratio quartile, age- and sex-adjusted systolic and diastolic BP gradually increased as Na/K ratio increased (systolic BP: 106.1, 106.9, 108.2, and 111.5 mmHg, Ptrend < 0.001; diastolic BP: 62.0, 62.4, 63.1, 64.3 mmHg, Ptrend = 0.022). The systolic and diastolic BP were more closely associated with urinary Na/K ratio than with Na and K levels, as well as estimated daily salt intake. In the multiple regression analysis, the urinary Na/K ratio was significantly associated with systolic BP (β = 0.144, P < 0.001) and diastolic BP (β = 0.114, P = 0.015) independent of potential confounding factors. An additional subgroup analysis revealed that the BP of the group with both high salt intake (≥8.5 g/day) and high Na/K ratio (≥6.60) was significantly higher than that of the group with high salt intake alone (systolic BP, 115.0 vs. 109.1 mmHg, P < 0.001; diastolic BP, 66.0 vs. 62.5 mmHg, P = 0.017). These results suggest that the urinary Na/K ratio is associated with BP levels in healthy adolescents and may be useful for assessing salt loading and its effects on BP elevation.

Determinants of Diet Quality in Adolescents: Results from the Prospective Population-Based EVA-Tyrol and EVA4YOU Cohorts

(1) Background: Unhealthy dietary behaviors are estimated to be one of the leading causes of death globally and are often shaped at a young age. Here, we investigated adolescent diet quality and its predictors, including nutrition knowledge, in two large Central European cohorts. (2) Methods: In 3056 participants of the EVA-Tyrol and EVA4YOU prospective population-based cohort studies aged 14 to 19 years, diet quality was assessed using the AHEI-2010 and DASH scores, and nutrition knowledge was assessed using the questionnaire from Turconi et al. Associations were examined utilizing multivariable linear regression. (3) Results: The mean overall AHEI-2010 score was 42%, and the DASH score was 45%. Female participants (60.6%) had a significantly higher diet quality according to the AHEI-2010 and DASH score. AHEI-2010 and DASH scores were significantly associated (p < 0.001) with sex, school type, smoking, and total daily energy intake. The DASH score was additionally significantly associated (p < 0.001) with age, socioeconomic status, and physical activity. Participants with better nutrition knowledge were more likely to be older, to attend a general high school, to live in a high-income household, to be non-smokers, and to have a higher diet quality according to the AHEI-2010 and DASH score. (4) Conclusions: Predictors of better diet quality included female sex, physical activity, educational level, and nutrition knowledge. These results may aid focused interventions to improve diet quality in adolescents.

Prevalence of metabolic syndrome and its association with oral health: First results from the Kurdish cohort study

Aims

Investigate the association between oral and dental health (ODH) and metabolic syndrome (MetS) in adults aged 35-70 years.

Methods

The study utilized data from the enrollment phase of Dehgolan prospective cohort study in the west of Iran. A cross-sectional assessment was conducted on a total of 3996 participants, involving a comprehensive oral examination and the assessment of their oral hygiene behavior (ODH). MetS was defined according to the updated National Cholesterol Education Program Adult Treatment Panel III. Logistic regression used to calculate odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for sociodemographic characteristics.

Results

MetS was more prevalent among those who not daily brushing and flossing. Participants with missing teeth (MT) show higher prevalent of MetS. Being female, lower age, illiteracy, family history of diabetes, low physical activity, and salt at table were independently associated with increase odds of MetS (p < 0.05). Odds of MetS were significantly decreased with use flossing (OR = 0.75; CI = 0.60-0.93), decayed (OR = 0.83; CI = 0.72-0.97), filled (OR = 0.84; CI = 0.71-0.99), and increased with MT (OR = 1.45; CI = 1.16-1.81) as long as adjusted for ODH factors. When other potential confounder such as sociodemographic, personal and nutritional habits were adjusted, daily flossing was the only factor that still statistically decreased (OR = 0.79; CI = 0.62-0.99) the odds of MetS.

Conclusion

Daily flossing was the only factor that independently associated with MetS. Relationship of other ODH factors with Mets were confounded by sociodemographic characteristics of the participants.

Reducing Dietary Sodium Intake among Young Adults in Ghana: A Call to Action

The positive association between excessive dietary sodium intake, hypertension, and cardiovascular disease (CVD) has been widely investigated in observational studies and clinical trials. Reducing sodium intake is a proven strategy to prevent hypertension and the onset of CVD, a major cause of morbidity and mortality globally. Africa has the youngest population globally, which is key to the continent's sustainable development. However, in Africa, the epidemics of hypertension and CVD negatively impact life expectancy and economic growth. Ghana, like other African countries, is no exception. The factors contributing to the increasing burden of CVD and excessive sodium consumption are multi-faceted and multi-level, including individual lifestyle, neighborhood and built environments, and socio-economic and health policies. Thus, the implementation of evidence-based interventions such as the World Health Organization Best Buys that target the multi-level determinants of sodium consumption is urgently needed in Ghana and other African countries. The aim of this commentary is to highlight factors that contribute to excessive sodium consumption. Second, the commentary will showcase lessons of successful implementation of sodium reduction interventions in other countries. Such lessons may help avert CVD in young adults in Ghana and Africa.

Physical activity and eating behaviors patterns associated with high blood pressure among Chinese children and adolescents

BACKGROUND

Physical activity and eating behavior are associated with hypertension in children and adolescents. Revealing the associations between physical activity patterns, eating behavior patterns and high blood pressure (HBP) could help improve the problem of hypertension from the actual children's physical activities and eating behaviors.

METHODS

A total of 687 students aged 8-15 years were selected from two nine-year primary and secondary schools using stratified cluster random sampling method. The students' body height, weight, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured, and their physical activity time and eating behaviors were surveyed by using CLASS questionnaire and self-made eating behavior questionnaire, respectively. Exploratory factor analysis (EFA) was used to extract moderate to vigorous physical activity factor (MVPAF), sedentary activity factor (SAF), healthy eating behavior factor (HEBF), unhealthy eating behavior factor (UHEBF). MVPAF ≥ SAF was defined as moderate to vigorous physical activity pattern (MVPAP), MVPAF < SAF was defined as sedentary activity pattern (SAP). HEBF ≥ UHEBF was defined as healthy eating behavior pattern (HEBP), while the opposite was defined as unhealthy eating behavior pattern (UHEBP). Lifestyles includes physical activity patterns and eating behavior patterns.

RESULTS

The overall prevalence of hypertension was 5.8% (40/687), and was 5.69% (21/369) in boys and 5.97% (19/318) in girls, respectively. The MVPAF and UHEBF in boys were significantly higher than those in girls (P < 0.01), while the SAF in girls was significantly higher than that in boys (P < 0.05). The SAF was positively correlated with SBP in girls (β(SE) = 0.14 (0.50), P = 0.016), and was positively correlated with SBP (β(SE) = 0.21 (1.22), P = 0.000 and DBP (β(SE) = 0.14 (0.49), P = 0.006) in boys. The MVPAF was negatively correlated with DBP (β(SE)=-0.11 (0.40), P = 0.022) in boys. In boys, the SAP increased the risks of HBP (OR (95% CI):3.34 (1.30-8.63)) and high DBP (OR (95% CI):3.08 (1.02-9.34)) compared with MVPAP.

CONCLUSION

Compared with the boys with MVPAP, boys with SAP may increase the risks of HBP and high DBP. The SAF may be positively associated with SBP in boys and girls, while the MVPAF may be negatively associated with DBP in boys.

Consumption of ultraprocessed food is associated with higher blood pressure among 6-year-old children from southern Brazil

Ultraprocessed foods (UPF) consumption plays a critical role in the development of chronic diseases, but evidence of their effect on children's health is limited. We hypothesized that the consumption of UPF can influence blood pressure levels in 6-year-old children. This study is a secondary analysis of a randomized field trial in Brazil that is registered at clinicaltrial.gov (NCT00635453). Dietary intake was obtained using 2 multiple-pass 24-hour recalls when 305 children were 3 and 6 years old. We classified foods according to the NOVA system and determined the percentage of total energy intake derived from ultraprocessed foods. We collected anthropometric measures from and evaluated systolic and diastolic blood pressures of 6-year-old children. Linear regression analysis was used to assess the association between UPF consumption and blood pressure levels. UPF represented 40.3% (interquartile range, 34.1-48.5) of the total energy intake at 3 years and 45.2% (interquartile range, 41.5-53.2) at 6 years. The adjusted linear regression analyses showed that systolic blood pressure was associated with UPF consumption at 6 years (P = .05), birth weight (P = .02), waist circumference (P < .01), and physical activity (P = .04), whereas diastolic blood pressure was associated with UPF consumption at 3 and 6 years (P = .01 and P < .01, respectively), birth weight (P = .05), and waist circumference (P < .01). Our data suggest that UPF consumption played a role in increasing 6-year-old children's blood pressure. These results reinforce the importance of effective strategies to prevent the excessive consumption of UPF in childhood.

Kidney stones are associated with metabolic syndrome in a health screening population: a cross-sectional study

Background

In parallel with the rise in obesity and metabolic syndrome (MetS), kidney stones are becoming more common. In this study, the relationship between MetS components and kidney stones in a health screening population was examined.

Methods

Subjects who underwent health checkups in the Health Promotion Centre of Sir Run Run Shaw Hospital of Zhejiang University between January 2017 and December 2019 were recruited for this study. In this cross-sectional study, 74,326 participants were aged 18 or older. MetS diagnostic criteria were based on the joint statement of the International Diabetes Federation (IDF) and other associations on MetS in 2009. The association between MetS and its components with kidney stones was examined using multivariable logistic regression.

Results

A total of 74,326 participants took part in this cross-sectional study, including 41,703 men (56.1%) and 32,623 women (43.9%). There were 24,815 (33.4%) patients with MetS and 2,032 (2.7%) patients with kidney stones. The prevalence of kidney stones was 3.3% in subjects with MetS and 2.4% in subjects without MetS (P<0.001). The odds ratio and 95% confidence interval (CI) for kidney stones in MetS patients were 1.157 (95% CI: 1.051-1.273). Accordingly, the prevalence of kidney stones showed a statistically significant trend of gradual increase as the number of MetS components increased (P<0.001). Among the components of MetS, elevated waist circumference, reduced high-density lipoprotein cholesterol (HDL-C), and elevated fasting blood glucose (FBG) were independent influencing factors of kidney stones (P<0.001), with odds ratios of 1.205 (95% CI: 1.085-1.337), 1.222 (95% CI: 1.105-1.351) and 1.335 (95% CI: 1.202-1.482), respectively.

Conclusions

MetS is an independent risk factor for kidney stones. Therefore, the control of MetS may help reduce the incidence of kidney stones.

Household disorder and blood pressure in mother-child dyads: A brief report

High blood pressure (BP) is the leading risk factor for cardiovascular disease (CVD). Although factors outside the home, such as crime and noise, have been associated with high BP in women and children, it is unknown if disorder within the home (household disorder) influences BP. We tested the hypothesis that women and children with more household disorder would have higher BP, independent of age, race, sodium intake, and body mass index (BMI). This study was a secondary analysis of data from mother-child dyads (n = 216). Mothers were 87% African American, 34 ± 5 years old, with BMI 33.59 ± 9.43 kg/m². Children were 7 ± 2 (range: 4-10) years of age with BMI z score 0.60 ± 2.07. Household disorder was measured by the Confusion Hubbub and Order Scale. Mother-child dyads were assessed for weight, height, BP (adults), BP percentile (children), energy intake, and sodium intake. The relationship between household disorder and BP was evaluated using Pearson's partial correlation coefficients. In fully adjusted models, household disorder was positively associated with systolic BP for mothers (r = 0.15, p < .05) and tended to be positively associated with diastolic BP (r = 0.11, p = .10). For the children, household disorder was not associated with systolic or diastolic BP percentile. This study's results suggest that household disorder is positively associated with higher BP in adult women, but not their children. Nevertheless, these data suggest that interventions to address household disorder could benefit maternal BP and potentially improve long-term CVD outcomes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Estimation of Salt Intake in Normotensive and Hypertensive Children: The Role of Body Weight

OBJECTIVE

The connection between increased dietary salt intake and arterial hypertension has been recognized for a long time, even in children. This study aimed to investigate salt consumption in normotensive and hypertensive children and evaluate their dietary habits.

MATERIALS AND METHODS

A total of fifty participants were included in this cross-sectional study: twenty-five normotensive children and 25 children of both sexes with essential arterial hypertension from 12-17 years old. Subjects' body mass index, waist-to-hip ratio, body composition and arterial blood pressure were measured, and their daily salt intake was calculated from 24-h urine samples. Using the food frequency questionnaire (FFQ), the data on the average daily total energy and food intakes were collected and analyzed using a suitable program.

RESULTS

Estimated daily salt intake was significantly higher in hypertensive compared to normotensive children, and this is positively associated with blood pressure and body mass index (BMI). Hypertensive children had significantly higher BMIs, which also positively correlated with blood pressure. Consistently, resting metabolic rate (kcal) is higher in hypertensive children compared to normotensive, and this is also associated with blood pressure. Reported energy intake is also enlarged in hypertensive compared to normotensive children and for both groups, levels are significantly higher than the recommended values.

CONCLUSIONS

Our study results confirm the relationship between daily salt consumption, blood pressure and body weight. Sodium consumption related to blood pressure and body weight among children. Cardiovascular disease prevention should start in early childhood by reducing salt intake and preventing overweight/obesity since these are two of the most important modifiable risk factors for hypertension.

Lifestyle Interventions for Elevated Blood Pressure in Childhood-Approaches and Outcomes

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of existing and emerging lifestyle treatments in the clinical management of primary elevated blood pressure and hypertension in pediatric patients. The authors hope to expand the knowledge base surrounding pediatric hypertension and update clinicians on best practices to improve outcomes.

RECENT FINDINGS

Elevated blood pressure is traditionally addressed with broad lifestyle recommendations such as limiting salt consumption and losing weight. This approach is not well adapted for pediatric patients. Novel and often underutilized approaches to the treatment of hypertension in pediatrics include psychological counseling for behavior modification, circadian nutrition, consistent use of interdisciplinary teams, manipulation of macronutrients, stress management, technology-infused interventions, and systemic changes to the food environment. Elevated blood pressure is a pervasive condition affecting cardiovascular disease and mortality risk. Increasingly, pediatric patients are presenting with elevated blood pressure with etiologies known to be affected by lifestyle behaviors. Weight management, dietary modifications, and daily physical activity are well-researched methods for improving individual blood pressure measurements. These strategies can sometimes be as effective as pharmacological interventions at lowering blood pressure. However, compliance with these individual recommendations is not consistent and has led to unsatisfactory results. There are emerging treatment trends that may provide non-traditional and more effective non-pharmacologic routes to blood pressure management in pediatric patients.

Hypertension and Associated Risk Factors among Children with Intellectual Disability: A Cross-Sectional Study

To investigate the prevalence of hypertension and associated risk factors in Chinese children with intellectual disability, a cross-sectional study was conducted in a sample of 558 children with intellectual disability aged 6–18 years in Hong Kong, and 452 (81.0%) with valid data were included in the data analysis. Blood pressure was measured according to a standard protocol. Hypertension was defined using the age-, gender-, and height-specific classification criteria recommended by the 2018 Chinese Guidelines for Children. Multivariate and hierarchical logistic regression was fitted to examine the associations of hypertension with potential risk factors. Overall, 31.4% of the participants were classified as having hypertension. Obese children were more likely to develop hypertension than non-obese children (adjusted OR = 2.77, 95% CI: 1.28, 5.99, p = 0.010). A paternal education of college or above and a paternal occupation of clerks, sales representatives, and workers were also associated with an increased risk of hypertension. The prevalence of hypertension is high among Chinese children with intellectual disability. Obesity was the strongest risk factor. Further longitudinal studies are warranted to confirm our findings. Nevertheless, preventions against obesity are promising to receive doubled benefits in reducing both obesity and hypertension, given its strong relationship with hypertension in this special population.

The Importance of Office Blood Pressure Measurement Frequency and Methodology in Evaluating the Prevalence of Hypertension in Children and Adolescents With Type 1 Diabetes: The SWEET International Database

OBJECTIVE

The prevalence of hypertension is higher in children and adolescents with type 1 diabetes (T1D) compared with those without. This retrospective analysis of a large cohort of children and adolescents with T1D from the SWEET (Better control in Pediatric and Adolescent diabeteS: Working to crEate CEnTers of Reference) international consortium of pediatric diabetes centers aimed to 1) estimate the prevalence of elevated office blood pressure (BP) and hypertension and 2) investigate the influence of BP measurement methodology on the prevalence of hypertension.

RESEARCH DESIGN AND METHODS

A total of 27,120 individuals with T1D, aged 5-18 years, were analyzed. Participants were grouped into those with BP measurements at three or more visits (n = 10,440) and fewer than 3 visits (n = 16,680) per year and stratified by age and sex. A subgroup analysis was performed on 15,742 individuals from centers providing a score indicating BP measurement accuracy.

RESULTS

Among participants with BP measurement at three or more visits, the prevalence of hypertension was lower compared with those with fewer than three visits (10.8% vs. 17.5% P < 0.001), whereas elevated BP and normotension were higher (17.5% and 71.7% vs. 15.3% and 67.1%, respectively; both P < 0.001). The prevalence of hypertension and elevated BP was higher in individuals aged ≥13 years than in younger ones (P < 0.001) and in male than female participants (P < 0.001). In linear regression models, systolic and diastolic BP was independently determined by the BP measurement methodology.

CONCLUSIONS

The estimated prevalence of elevated BP and hypertension in children and adolescents with T1D is ∼30% and depends on the BP measurement methodology. Less frequent BP evaluation may overestimate the prevalence of hypertension.

Salt sensitivity of blood pressure in childhood and adolescence

Although moderation of sodium intake is recommended population-wide, it remains uncertain who benefits from salt restriction. Salt sensitivity refers to changes in blood pressure in response to sodium intake and may occur with or without hypertension. Unfortunately, there is no practical way to assess salt sensitivity in daily practice. Assessment of salt sensitivity even in research studies is challenging with varying protocols utilized which may contribute to differing results. Building on studies in animals and adults, risk factors and conditions associated with salt sensitivity have been identified in the pediatric and young adult populations. This review presents the limited evidence linking obesity, low birth weight, diabetes, chronic kidney disease, and race/ethnicity with salt sensitivity in children, adolescents, and young adults. The impact of stress on sodium handling is also reviewed. The influence of age on the timing of introduction of dietary salt restriction and the long-term influence of salt sensitivity on risk for hypertension are considered. Lastly, interventions other than salt restriction that may improve salt sensitivity and may inform recommendations to families are reviewed.

Intakes of nutrients and food categories in Canadian children and adolescents across levels of sugars intake: cross-sectional analyses of the Canadian Community Health Survey 2015 Public Use Microdata File

Dietary recommendations to reduce sugars consumption may influence choices of sugars-containing foods and affect the intake of key micronutrients. We compared intakes of nutrients and food sources stratified by quintiles of total sugars in Canadian children (2-8 y) and adolescents (9-13 y, 14-18 y) using 24-hour dietary recalls from the 2015 Canadian Community Health Survey-Nutrition. Energy intakes did not differ across quintiles of sugars intake. Those with lower sugars intakes (Q1/Q3) generally had higher protein, fat, sodium, niacin, folate, and zinc and lower vitamin C compared with those with the highest sugars intakes (Q5). Q1 also had lower potassium but higher saturated fat compared with Q5. Further, Q1 generally had higher protein, fats, and niacin compared with Q3, while children in Q3 had higher potassium and riboflavin and older adolescents had higher calcium and fibre. Q5 had highest intakes of multiple sugar-containing food categories (e.g., fruit, confectionary, milks, cakes/pies/pastries), with higher sugars-sweetened beverages in adolescents. Q3 had higher fruit, milks, and fruit juice compared with Q1 and lower sugars/syrups/preserves, confectionary, and fruit juices compared with Q5. Certain nutrient-dense food sources of sugars (fruit, milks) may help increase key nutrients (potassium, calcium, fibre) in older adolescents with low sugars intakes. However, in those with the highest sugars intakes, nutrient-poor foods may displace nutrient-dense foods. Novelty: Canadian children and adolescents with lower sugars intake have better intakes of some nutrients. Energy intakes did not differ across sugars intake. Older adolescents with mean intakes of total sugars had better intakes of some key nutrients (potassium, calcium, fibre).

Estimating the cost-effectiveness of the Sodium Reduction in Communities Program

OBJECTIVE

This study assessed the cost-effectiveness of the Centers for Disease Control and Prevention's (CDC's) Sodium Reduction in Communities Program (SRCP).

DESIGN

We collected implementation costs and performance measure indicators from SRCP recipients and their partner food service organisations. We estimated the cost per person and per food service organisation reached and the cost per menu item impacted. We estimated the short-term effectiveness of SRCP in reducing sodium consumption and used it as an input in the Prevention Impact Simulation Model to project the long-term impact on medical cost savings and quality-adjusted life-years gained due to a reduction in CVD and estimate the cost-effectiveness of SRCP if sustained through 2025 and 2040.

SETTING

CDC funded eight recipients as part of the 2016-2021 round of the SRCP to work with food service organisations in eight settings to increase the availability and purchase of lower-sodium food options.

PARTICIPANTS

Eight SRCP recipients and twenty of their partners.

RESULTS

At the recipient level, average cost per person reached was $10, and average cost per food service organisation reached was $42 917. At the food service organisation level, median monthly cost per food item impacted by recipe modification or product substitution was $684. Cost-effectiveness analyses showed that, if sustained, the programme is cost saving (i.e. the reduction in medical costs is greater than the implementation costs) in the target population by $1·82 through 2025 and $2·09 through 2040.

CONCLUSIONS

By providing evidence of the cost-effectiveness of a real-world sodium reduction initiative, this study can help inform decisions by public health organisations about related CVD prevention interventions.

Assessing the Association of Sodium, Potassium Intake and Sodium/Potassium Ratio on Blood Pressure and Central Adiposity Measurements amongst Ellisras Undernourished, Rural Children Aged 5–13 Years: South Africa

Background: Numerous studies have shown how diet, such as sodium (Na) and potassium (K) intake, is an important risk factor for non-communicable diseases (NCDs). This study aimed to assess the relationship between sodium intake, potassium intake; and sodium/potassium ratio with blood pressure (BP) and abdominal obesity amongst Ellisras rural children. Method: In this cross-sectional study, data on dietary intake of sodium and potassium were collected using a 24-h recall questionnaire from a total of 765 participants, aged 5–13 years. Blood pressure and anthropometric measurements were also collected. Generalised linear models and Pearson correlation were conducted to assess the association of sodium intake, potassium intake; and their ratio with BP, waist circumference (WC), and waist-to-height ratio (WHtR). Results: In both age groups, less than 14.9% of males and 19.8% of females consumed above the recommended adequate intake (AI) of sodium. In addition, both age groups had more than 90% of males and females who consumed below the recommended AI of potassium. Moreover, the sodium/potassium ratio was above the WHO recommended level in more than 30% of males and females. The study found a significant, weak positive correlation of sodium intake with systolic BP (SBP), diastolic BP (DBP), and with WHtR. A significant, weak positive correlation was also found between sodium/potassium ratio and WHtR. In addition, a significant association was found between potassium intake and systolic BP. Conclusion: Although our study found a notable low average intake of sodium and potassium as compared to the recommended values. There was positive correlation found between sodium intake and BP. Furthermore, a positive correlation of sodium intake and sodium/potassium ratio with WHtR was also found.

Difference in the Prevalence of Elevated Blood Pressure and Hypertension by References in Korean Children and Adolescents

The prevalence of pediatric hypertension and obesity has increased over the past decades. Pediatric hypertension and obesity are associated with adult hypertension, metabolic syndrome, and cardiovascular disease. There are two main pediatric blood pressure (BP) classification guidelines, the "Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents" (AAP 2017) and "2016 European Society of Hypertension guidelines for the management of high BP in children and adolescents" (ESH 2016). No study has classified Korean youths with cardiometabolic risk. This study analyzed the prevalence of high BP according to AAP 2017 (elevated BP and hypertension) and ESH 2016 (prehypertension and hypertension) in Korean children. Additionally, the cardiometabolic risk factors (CMRFs) were compared between children who were hypertensive in AAP 2017 but normotensive in ESH 2016 (upward reclassified) to those who were normotensive in both AAP 2017 and ESH 2016. Data were extracted from the Korea National Health and Nutrition Examination Survey, 2016-2018. A total of 1,858 children aged 10-17 years were included in the analysis. The prevalence of elevated BP/prehypertension and hypertension was 4.1 and 6.5% by ESH 2016, and 8.9 and 9.4% by AAP 2017 in Korean youth, respectively. The AAP 2017 reclassified 11.9% of youth in the upper BP class. When those upward reclassified youth were compared to those who were normotensive in both AAP 2017 and ESH 2016, reclassified youth were male predominant (77.1 vs. 49.6%, p < 0.001), older (14.6 vs. 13.8, p < 0.001) and showed higher body mass index (BMI) z-score (0.77 vs. 0.15, p < 0.001) and more overweight/obesity (14.0/30.6 vs. 13.3/6.4%, p < 0.001) and severe CMRFs (triglyceride 83.2 vs. 72.9 mg/dL, p = 0.011; high-density lipoprotein cholesterol 47.3 vs. 51.1 mg/dL, p < 0.001; alanine transaminase 21.7 IU/L vs. 14.7 IU/L, p = 0.001, uric acid 5.89 vs. 5.22 mg/dL, p < 0.001; metabolic syndrome 13.2 vs. 1%, p < 0.001). In conclusion, AAP 2017 showed a higher prevalence of abnormal BP in Korean youth, and those upward reclassified by AAP 2017 were more obese and had severe CMRFs than normotensive Korean children. The AAP 2017 could allow the early detection of Korean youth with more CMRFs.

High blood pressure in children and adolescents: current perspectives and strategies to improve future kidney and cardiovascular health

Hypertension is one of the most common causes of preventable death worldwide. The prevalence of pediatric hypertension has increased significantly in recent decades. The cause of this is likely multifactorial, related to increasing childhood obesity, high dietary sodium intake, sedentary lifestyles, perinatal factors, familial aggregation, socioeconomic factors, and ethnic blood pressure (BP) differences. Pediatric hypertension represents a major public health threat. Uncontrolled pediatric hypertension is associated with subclinical cardiovascular disease and adult-onset hypertension. In children with chronic kidney disease (CKD), hypertension is also a strong risk factor for progression to kidney failure. Despite these risks, current rates of pediatric BP screening, hypertension detection, treatment, and control remain suboptimal. Contributing to these shortcomings are the challenges of accurately measuring pediatric BP, limited access to validated pediatric equipment and hypertension specialists, complex interpretation of pediatric BP measurements, problematic normative BP data, and conflicting society guidelines for pediatric hypertension. To date, limited pediatric hypertension research has been conducted to help address these challenges. However, there are several promising signs in the field of pediatric hypertension. There is greater attention being drawn on the cardiovascular risks of pediatric hypertension, more emphasis on the need for childhood BP screening and management, new public health initiatives being implemented, and increasing research interest and funding. This article summarizes what is currently known about pediatric hypertension, the existing knowledge-practice gaps, and ongoing research aimed at improving future kidney and cardiovascular health.

The high-intensity interval training introduced in physical education lessons decrease systole in high blood pressure adolescents

Increased resting blood pressure (BP) is a risk factor for many health complications. The prevalence of elevated BP is growing among adolescents. There is a need to investigate effective ways of decreasing excessive blood pressure in this age group. The study aim was to determine the effect of 10-weeks High-Intensive Interval Training (HIIT)—Tabata protocol—introduced in physical education (PE) lessons on resting blood pressure in adolescents. The sample included 52 boys aged 16.23 ± 0.33 years body height176.74 ± 6.07 (m), body weight 65.42 ± 12.51 (kg), BMI 20.89 ± 3.53 (kg/m²) and 89 girls aged 16.12 ± 0.42 years, body height 164.38 ± 6.54 (m), body weight 56.71 ± 10.23 (kg), BMI 20.93 ± 3.08 (kg/m²) from secondary school. Based on resting BP, the fractions of boys and girls with normal BP and high BP were identified and divided into experimental (EG) and control (CG) groups. EG completed a 10-weeks HIIT program (three cycles of Tabata protocol) implemented in one PE lesson during a week. The duration of the effort was 14 min. The intensity was at 75–80% of maximal heart rate. Changes in systolic and diastolic BP after the experiment were examined. The results indicated the improvement in SBP in EG with high BP compared to the rest of the groups (average reduction of 12.77 mmHg; p < 0.0001). The EG normotensive had a statistically significant higher reduction of SBP comparing CG normotensive (average decrease of 1.81 mmHG; p = 0.0089). HIIT effectively decreases BP in adolescents. Implementing HIIT in PE lessons in secondary school is recommended to improve BP parameters.

Dietary sodium intake and sodium load is associated with arterial stiffness in children and young adults

OBJECTIVE

The aim of this study was to examine the association of sodium intake (g/day) and sodium load (Na-L; mg/kcal/day) on arterial stiffness in youth.

METHODS

A cross-sectional analysis of 723 youth enrolled in a study evaluating the cardiovascular effects of obesity and type 2 diabetes mellitus (T2DM). Three measures of arterial stiffness were evaluated: brachial distensibility (BrachD), carotid-femoral pulse wave velocity (PWVcf) and augmentation index (AIx). Three-day diet histories yielded mean daily sodium and calorie intake. Youth were divided into Na-L tertiles: Low (≤1.67 mg/kcal per day); Medium (1.68--1.98 mg/kcal per day) and High (>1.98 mg/kcal per day). General linear models adjusting for demographics, % body fat, T2DM and SBP z-score evaluated the independent association of Na-L with arterial stiffness.

RESULTS

Mean age was 17.9 years (10-24 years), 35% male, 59% nonwhite and 31% T2DM. Mean (±standard deviation) dietary intake was calories = 2074 (±797) kcal/day; Na = 3.793 (±1567) g/day; Na- = 1.86 (±0.753) mg/kcal per day. With higher levels of dietary Na intake and Na-L, measures of arterial stiffness worsened: BrachD decreased (Na intake: beta = -0.09, P = 0.003; Na-L: beta = -0.28, P < 0.0001), PWVcf increased (Na intake: beta = 0.07, P = 0.007; Na-L: beta = 0.21, P < 0.0001) but AIx did not change (Na intake: beta = -0.4, P = 0.2; Na-L: beta = 0.89, P = 0.11). In multivariable analysis, High Na-L was independently associated with BrachD, PWVcf and AIx (P < 0.05 for all), with age modifying the association of High Na-L with PWVcf and AIx.

CONCLUSION

Sodium intake and load are associated with arterial stiffness, a preclinical measure of CVD, among a paediatric population. Paediatricians should stress healthy dietary choices to reduce accelerated vascular ageing.

Assessment and management of obesity and metabolic syndrome in children with CKD stages 2-5 on dialysis and after kidney transplantation-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Obesity and metabolic syndrome (O&MS) due to the worldwide obesity epidemic affects children at all stages of chronic kidney disease (CKD) including dialysis and after kidney transplantation. The presence of O&MS in the pediatric CKD population may augment the already increased cardiovascular risk and contribute to the loss of kidney function. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. We present CPRs for the assessment and management of O&MS in children with CKD stages 2-5, on dialysis and after kidney transplantation. We address the risk factors and diagnostic criteria for O&MS and discuss their management focusing on non-pharmacological treatment management, including diet, physical activity, and behavior modification in the context of age and CKD stage. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT.

Obesity, Sodium Homeostasis, and Arterial Hypertension in Children and Adolescents

BACKGROUND

The relationship between obesity, arterial hypertension, and excessive salt intake has been known for a long time; however, the mechanism of this relationship remains not clear.

METHODS

The paper presents a current literature review on the relationship between salt consumption and the development of arterial hypertension in children and adolescents with obesity.

RESULTS

In addition to the traditional theory of hypertension development due to the increase in intravascular volume and disturbances of sodium excretion, recent studies indicate the existence of a complex mechanism related to excessive, pathological secretory activity of adipocytes, insulin resistance, and impaired function of the renin-angiotensin-aldosterone axis. That makes obese children and adolescents particularly vulnerable to the development of salt-sensitive arterial hypertension. Studies performed in many countries have shown that children and adolescents consume more sodium than recommended. It is worth noting, however, that the basis for these recommendations was the extrapolation of data from studies conducted on adults. Moreover, more important than sodium intake is the Na/K ratio and water consumption.

CONCLUSION

Regardless of the population-wide recommendations on reducing salt intake in children, specific recommendations for overweight and obese patients should be developed.

Calcium, fiber, iron, and sodium intake in adolescents with intellectual and developmental disabilities and overweight and obesity

BACKGROUND

Adolescents with intellectual and developmental disabilities (IDD) and overweight or obesity (OW/OB) are a nutritionally vulnerable group with increased risk of nutritional deficiencies. However, there are limited data examining micronutrient intake in adolescents with IDD and OW/OB.

OBJECTIVE

The purpose of this study was to assess the adequacy of calcium, iron, fiber, and sodium intake referenced against the United States Dietary Reference Intakes in adolescents with IDD and OW/OB.

METHODS

Three-day image-assisted food records were used to assess dietary intake of 64 adolescents with IDD and OW/OB. A mean ± standard deviation was calculated for mean intake of calcium (mg), fiber (g/1000 kcals energy), iron (mg), and sodium (mg).

RESULTS

A total of 157 nutrient intake observations were completed by 64 participants (56% female, 16.3 ± 2.3 years). Calcium intake for participants ages 14-18 years (n = 57) was 1027.4 ± 607.5 mg, which is below the EAR of 1050 mg. Calcium intake for participants ages ≥19 years (n = 7) was 921.1 ± 596.4 mg, which is greater than the EAR of 840 mg. Fiber intake was 8.4 ± 3.6 g/1000 kcals, which is below the AI of 14 g/1000 kcals. Iron intake for all participants exceeded their respective EARs. Sodium intake was 3180.9 ± 975.9 mg, which above the AI of 2300 mg.

CONCLUSION

Calcium intake was adequate for participants ≥19 years of age, but inadequate for participants 14-18 years. For all participants, iron and sodium intake exceeded the DRI while fiber intake was below the DRI.

Packaged Foods Labeled as Organic Have a More Healthful Profile Than Their Conventional Counterparts, According to Analysis of Products Sold in the U.S. in 2019-2020

The organic food market's recent rapid global growth reflects the public's interest in buying certified organic foods, including packaged products. Our analysis shows that packaged foods containing fewer ingredients associated with negative public health outcomes are more likely to be labeled organic. Previous studies comparing organic and conventional foods focused primarily on nutrient composition. We expanded this research by additionally examining ingredient characteristics, including processing and functional use. Our dataset included nutrition and ingredient data for 8240 organic and 72,205 conventional food products sold in the U.S. from 2019 to 2020. Compared to conventional foods, organic foods in this dataset had lower total sugar, added sugar, saturated fat and sodium content. Using a mixed effects logistic regression, we found that likelihood of classification as organic increased as sodium content, added sugar content and the number of ultra-processed ingredients and cosmetic additives on the product label decreased. Products containing no trans-fat ingredients were more likely to be labeled organic. A product was more likely to be classified "organic" the more potassium it contained. These features of organic foods sold in the U.S. are significant because lower dietary ingestion of ultra-processed foods, added sugar, sodium and trans-fats is associated with improved public health outcomes.

Necessity of salt intake reduction education beginning in youth: a cross-sectional survey of sodium-to-potassium ratios in mothers and their preschool children

Urinary sodium-to-potassium ratios are known to be high in preschoolers, but there are no reports comparing these ratios with those of the children's mothers. The aim of this study was to investigate the association between the urinary sodium-to-potassium ratios of mothers and their preschool children under the hypothesis that the ratio is equivalent between the two. We evaluated 297 preschoolers aged four to five attending six kindergartens (four in northern Japan, two in southern Japan), and we also evaluated the children's mothers. We asked the participants to take morning first urine samples for 2 consecutive days in the spring and autumn of the same year (four samples per participant) and to fill out a dietary questionnaire. There was a correlation between the urinary sodium-to-potassium ratios of preschoolers and those of their mothers. However, in a comparison between the preschoolers and their mothers overall, higher values were found in the preschoolers [preschoolers: 4.6 (3.5-6.3) mmol/L/g·Cr; mothers: 4.3 (3.9-4.7) mmol/L/g·Cr, p = 0.003]. These results correlated with the urinary sodium-to-potassium ratios estimated from the dietary questionnaire. The preschoolers showed high sodium and low potassium intake consumption compared to the mothers. Interestingly, these were found to differ by region and gender. In conclusion, the urinary sodium-to-potassium ratio in Japanese preschoolers is related to and higher than that of their mothers. It is important to educate children, their parents, childcare professionals, and society as a whole about proper salt restriction and potassium supplementation, as well as to improve the food environment.

Snacking patterns throughout the life span: potential implications on health

Eating outside the three main meals - in other words, snacking - is a part of the dietary pattern of individuals in all stages of life. The quality and pattern of snacking have an impact on health during the life span. Thus, the aim of this review was to evaluate various patterns and health outcomes of the snacking habits of different demographical groups, from children to the elderly, throughout their life span. We discuss the snacking pattern among children and adolescents, which is characterized by consuming high energy foods with low nutrient value, and which is associated with increased risk of obesity. During university years, study stress and lack of time were obstacles to a healthy dietary pattern involving nutritious snacks, although awareness of the importance of healthy snacks was higher in this group than among younger age groups. Employment status and skipping regular meals were important factors affecting snacking quality and patterns in adulthood. Unhealthy snacks, high in energy, sugar, and salt and low in nutrients, were demonstrated to have a negative impact on individuals' health, such as oral health, blood pressure, obesity, and diabetes. In conclusion, encouraging individuals to consume healthy snacks that are high in nutrients through education to help them plan for their snacks is important to enhance health and reduce disease risk.

Association of Usual Sodium Intake with Obesity Among US Children and Adolescents, NHANES 2009-2016

OBJECTIVE

The purpose of this study was to investigate the association of sodium intake with obesity in US children and adolescents.

METHODS

Cross-sectional data were analyzed for 9,026 children and adolescents in the National Health and Nutrition Examination Survey (NHANES) 2009-2016. Usual sodium intake was estimated from 24-hour dietary recalls using a measurement error model. Logistic regression was used to assess the association of sodium intake with overweight/obesity, obesity, and central obesity (waist to height ratio [WtHR] ≥ 0.5; waist circumferences (WC) ≥ age- and sex-specific 90th percentile).

RESULTS

Mean (SE) sodium intake was 3,010  (9) and 3,404  (20) mg/d for children and adolescents, respectively. The adjusted odds ratio (AOR) comparing Q4 versus Q1 (87.5th vs. 12.5th percentile of sodium intake) among children was 1.98 (95% CI: 1.19-3.28) for overweight/obesity, 2.20 (1.30-3.73) for obesity, 2.10 (1.12-3.95) for WC ≥ 90th percentile, and 1.68 (0.95-2.97) for WtHR ≥ 0.5, adjusting for demographics, energy, and sugar-sweetened beverage intake. Among adolescents, AOR was 1.81 (0.98-3.37) for overweight/obesity, 1.71 (0.82-3.56) for obesity, 1.62 (0.71-3.66) for WC ≥ 90th percentile, and 1.73 (0.85-3.50) for WtHR ≥ 0.5.

CONCLUSIONS

Sodium intake was positively associated with overweight/obesity, obesity, and central obesity among US children independent of energy and SSB intake, but the association did not reach significance among adolescents.

Life-Course Implications of Pediatric Risk Factors for Cardiovascular Disease

The concept that origins of cardiovascular disease (CVD) begin in childhood is supported by substantial evidence. Prospective studies beginning in childhood report associations of childhood obesity, abnormal blood pressure (BP), dyslipidemia, diabetes, and tobacco use with intermediate CVD markers, including left ventricular hypertrophy and vascular stiffness in young adulthood. Trajectory analyses from longitudinal studies describe discrete BP pathways from childhood to young adult status of hypertension and prehypertension. Among individuals with familial hypercholesterolemia, abnormal low-density lipoprotein cholesterol levels are present in childhood. Some children are at risk for future CVD owing to hereditary factors, psychosocial stress, race, low birth weight, or other nonmodifiable exposures. Behavioural factors, including suboptimal diet, sedentary activity, and tobacco use, in childhood augment risk and can be modified to reduce risk. Pharmacologic treatments are reserved for those at high levels of the BP and cholesterol distributions and for those with diabetes and additional risk factors.

Promoting cardiovascular health post-transplant through early diagnosis and adequate management of hypertension and dyslipidemia

Despite correction of underlying solid organ failure by transplantation, pediatric transplant recipients still have increased mortality rates compared to the general pediatric population, in part due to increased cardiovascular risk. In particular, pediatric kidney and non-kidney transplant recipients with chronic kidney disease have significant cardiovascular risk that worsens with declining kidney function. Biomarkers associated with future cardiovascular risk such as casual and ambulatory hypertension, dyslipidemia, vascular stiffness and calcification, and left ventricular hypertrophy can be detected throughout the post-transplant period and in patients with stable kidney function. Among these, hypertension and dyslipidemia are two potentially modifiable cardiovascular risk factors that are highly prevalent in kidney and non-kidney pediatric transplant recipients. Standardized approaches to appropriate BP measurement and lipid monitoring are needed to detect and address these risk factors in a timely fashion. To achieve sustained improvement in cardiovascular health, clinicians should partner with patients and their caregivers to address these and other risk factors with a combined approach that integrates pharmacologic with non-pharmacologic approaches. This review outlines the scope and impact of hypertension and dyslipidemia in pediatric transplant recipients, with a particular focus on pediatric kidney transplantation given the high burden of chronic kidney disease-associated cardiovascular risk. We also review the current published guidelines for monitoring and managing abnormalities in blood pressure and lipids, highlighting the important role of therapeutic lifestyle changes in concert with antihypertensive and lipid-lowering medications.

Development of a prognostic prediction model to estimate the risk of multiple chronic diseases: constructing a copula-based model using Canadian primary care electronic medical record data

Introduction

The ability to estimate risk of multimorbidity will provide valuable information to patients and primary care practitioners in their preventative efforts. Current methods for prognostic prediction modelling are insufficient for the estimation of risk for multiple outcomes, as they do not properly capture the dependence that exists between outcomes.

Objectives

We developed a multivariate prognostic prediction model for the 5-year risk of diabetes, hypertension, and osteoarthritis that quantifies and accounts for the dependence between each disease using a copula-based model.

Methods

We used data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) from 2009 onwards, a collection of electronic medical records submitted by participating primary care practitioners across Canada. We identified patients 18 years and older without all three outcome diseases and observed any incident diabetes, osteoarthritis, or hypertension within 5-years, resulting in a large retrospective cohort for model development and internal validation (n=425,228). First, we quantified the dependence between outcomes using unadjusted and adjusted Ø coefficients. We then estimated a copula-based model to quantify the non-linear dependence between outcomes that can be used to derive risk estimates for each outcome, accounting for the observed dependence. Copula-based models are defined by univariate models for each outcome and a dependence function, specified by the parameter θ. Logistic regression was used for the univariate models and the Frank copula was selected as the dependence function.

Results

All outcome pairs demonstrated statistically significant dependence that was reduced after adjusting for covariates. The copula-based model yielded statistically significant θ parameters in agreement with the adjusted and unadjusted Ø coefficients. Our copula-based model can effectively be used to estimate trivariate probabilities.

Discussion

Quantitative estimates of multimorbidity risk inform discussions between patients and their primary care practitioners around prevention in an effort to reduce the incidence of multimorbidity.

Factors Associated with Primary Hypertension in Pediatric Patients: An Up-to-Date

BACKGROUND

Arterial hypertension in children is considered a common alteration nowadays, mainly because obesity is a growing worldwide problem closely related to increased blood pressure. Childhood hypertension can be classified as primary or secondary, depending on the etiology. Primary or essential hypertension still has its pathophysiology not fully elucidated, and there is no consensus in the literature on most underlying mechanisms. In this review, genetic and environmental factors, including sodium and potassium intake, socioeconomic status, ethnicity, family structure, obesity, sedentary lifestyle, prematurity and low birth weight, prenatal and postnatal exposures are highlighted.

OBJECTIVE

The present study aimed to perform an update on primary hypertension in childhood, providing clinicians and researchers an overview of the current state of the literature regarding the influence of genetic and environmental factors.

METHODS

This integrative review searched for articles on genetic and environmental factors related to primary hypertension in pediatric patients. The databases evaluated were PubMed and Scopus.

RESULTS

The studies have provided insights regarding many genetic and environmental factors, in addition to their association with the pathophysiology of primary hypertension in childhood. Findings corroborated the idea that primary hypertension is a multifactorial disease. Further studies in the pediatric population are needed to elucidate the underlying mechanisms.

CONCLUSION

The study of primary hypertension in pediatrics has utmost importance for the adoption of preventive measures and the development of more efficient treatments, therefore reducing childhood morbidity and the incidence of cardiovascular diseases and other health consequences later in life.

Effect of Comprehensive Interventions Including Nutrition Education and Physical Activity on High Blood Pressure among Children: Evidence from School-Based Cluster Randomized Control Trial in China

Childhood hypertension has increasingly become a public health problem globally. However, limited literature research examined the effect of comprehensive interventions including nutrition education and physical activity on blood pressure among children. A total of 6764 children aged 7–13 years were analyzed based on a multicenter randomized controlled trial for comprehensive interventions in 30 primary schools in China to evaluate the effects on blood pressure, which lasted for two semesters. The standards used for the diagnosis of high blood pressure were the cut-off points based on age and sex for Chinese children. Compared with the control group, the intervention effects were −0.5 mm Hg (95% confidence interval (CI): −1.1, 0; p = 0.064) for diastolic blood pressure and −0.9 mmHg (95% CI: −1.5, −0.3; p = 0.005) for systolic blood pressure. For the incidence of high blood pressure, the changes were −1.4% in the intervention group and 0.4% in the control group (1.8% difference between the two groups, p = 0.015) after trial. The school-based comprehensive interventions appeared to have moderate effects on high blood pressure prevention among children in China.

Availability of Lower-Sodium School Lunches and the Association with Selection and Consumption among Elementary and Middle School Students

BACKGROUND

During 2010, the US Department of Agriculture updated the school meals standards, including three progressively decreasing sodium targets. The Target 1 standards went into effect in 2014, but during 2018, the US Department of Agriculture delayed the Target 2 standards until 2024 and eliminated the Target 3 standards citing concerns regarding the availability and acceptability of lower-sodium foods. In addition, there are currently no sugar standards, and it is unknown whether sugar is substituted for salt in lower-sodium school foods.

OBJECTIVE

To examine the availability, selection, and consumption of school lunches already in alignment with the Target 2 and 3 sodium levels and the association between sodium and sugar.

DESIGN

An observational cafeteria-based study conducted during fall 2018.

PARTICIPANTS AND SETTING

Students (n = 1985) in grades three through eight attending 13 elementary/kindergarten through eighth-grade schools in a large, urban school district in New England.

MAIN OUTCOME MEASURES

Availability, selection, and consumption were examined using plate waste methodology.

STATISTICAL ANALYSES PERFORMED

Mixed-model analysis of variance accounting for student demographic characteristics with schools/students as a random effect (students nested within schools) were used to examine differences in availability, selection, and consumption. Linear regression was used to examine the association between sodium and sugar in the school foods.

RESULTS

The majority of meals selected (87%) and consumed (98%) were already in alignment with the Target 2 standards. There were significant inverse associations between sodium levels and consumption; each 100-mg increase in sodium was associated with a decrease in consumption by 2% for entrées (P = 0.002) and 5% for vegetables (P = 0.01). When examining the association between sodium and sugar, each 10-mg reduction in sodium was associated with 1-g increase in sugar among entrées (P < 0.0001), whereas there was a significant positive association between sodium and sugar with vegetables and condiments.

CONCLUSIONS

This study provides some evidence that schools may already have the ability to provide lower-sodium meals that are acceptable to students, and therefore the recent rollbacks to the sodium standards may be unwarranted. Study findings suggest that the US Department of Agriculture should take under consideration policies that would limit added sugar for school meals as sugar may be substituted for salt.

Childhood Maternal School Leaving Age (Level of Education) and Risk Markers of Metabolic Syndrome in Mid-Adulthood: Results from the 1958 British Birth Cohort

PURPOSE

The aim of this study is to investigate the relationship between childhood maternal level of education (CMLE) and changes in anthropometric and laboratory risk markers of metabolic syndrome (MetS) in mid-adulthood using results from the 1958 British Birth Cohort Study.

DESIGN

Cohort study.

PARTICIPANTS

A total of 9376 study samples consisting of subjects that participated in the biomedical survey of the national child development study (NCDS) carried out between 2002 and 2004 were used for the analysis.

MAIN OUTCOME MEASURES

Five risk markers of MetS: (i) HDL-cholesterol (ii) triglyceride (iii) blood pressure (BP) including systolic (SBP) and diastolic (DBP) (iv) waist circumference (WC) and (v) glycated haemoglobin (HbA1c).

METHODS

The NCDS or the 1958 British birth cohort data deposited in the UK data service by the centre for longitudinal studies were used for analyses. Ordinary least squares regression was used to determine unit changes in the outcome variables given CMLE.

RESULTS

The estimates for unadjusted regression analysis of individual risk markers indicated a significant relationship between CMLE and alterations in the five risk markers of MetS (HDL-cholesterol, triglyceride, WC, HbA1c, and BP) in midlife. After adjustment for birth and lifestyle characteristics/health behaviours, the relationship between CMLE and the risk markers was attenuated for HDL-cholesterol, triglycerides, and HbA1c but remained significant for WC 0.70 (95% confidence interval (CI) 0.065-1.30, p<0.001) and SBP 1.48 (95% CI 0.48-2.47 p<0.001).

CONCLUSION

There was a positive association between lower CMLE and the risk of MetS using the NCDS data. Lifestyle characteristics may be influential determinants of MetS risk in mid-adulthood.

Trends in Sodium Intake in Children and Adolescents in the US and the Impact of US Department of Agriculture Guidelines: NHANES 2003-2016

OBJECTIVE

To examine trends in sodium intake and the impact of nutritional guidelines in the US pediatric population.

STUDY DESIGN

Sodium intake data collected between 2003 and 2016 in the US National Health and Nutrition Examination Surveys (NHANES) were analyzed. Trends in intake for individuals aged 4-17 years and subgroups based on age, sex, and race and ethnicity were examined. Adherence to US Department of Agriculture guidelines was assessed.

RESULTS

A total of 16 013 individuals (50.6% male) were included in the analysis. The median sodium intake was 2840 mg/day (95% CI, 2805-2875 mg/day), decreasing from 2912 mg/day (95% CI 2848-2961 mg/day) in 2003-2004 to 2787 mg/day (95% CI, 2677-2867 mg/day) in 2015-2016 (P = .005). Intake increased with age (2507 mg/day for individuals aged 4-8, 2934 mg/day for those aged 9-13 years, and 3124 mg/day for those aged 14-17 years; P < .001) and was greater in males than in females (3053 mg/day vs 2624 mg/day; P < .001). Caucasians, Hispanics, and African Americans consumed 2860, 2733, and 2880 mg/day, respectively (P < .001). Population adherence to US Department of Agriculture recommendations was 25.0% in 2003-2010 and 25.5% in 2011-2016 (P = .677). No age, sex, or racial/ethnicity subgroup had an adherence rate >30% after implementation of pediatric guidelines in 2010.

CONCLUSIONS

Sodium intake remains elevated in all pediatric population segments, and guideline adherence is poor. A greater effort to reduce sodium consumption is needed to mitigate future cardiovascular disease risk.

Is too much salt harmful? Yes

The contribution of high sodium intake to hypertension and to the severity of immune-mediated diseases is still being heatedly debated in medical literature and in the lay media. This review aims to demonstrate two conflicting views on the topic, with the first part citing the detrimental effects of excessive salt consumption. Sodium plays a central role in volume and blood pressure homeostasis, and the positive correlation between sodium intake and blood pressure has been extensively researched. Despite the fact that the average of global daily salt consumption exceeds recommendations of international associations, health damage from excessive salt intake is still controversial. Individual differences in salt sensitivity are in great part attributed to this contradiction. Patients suffering from certain diseases as well as other vulnerable groups-either minors or individuals of full age-exhibit more pronounced blood pressure reduction when consuming a low-sodium diet. Furthermore, findings from the last two decades give insight into the concept of extrarenal sodium storage; however, the long-term consequences of this phenomenon are lesser known. Evidence of the relationship between sodium and autoimmune diseases are cited in the review, too. Nevertheless, further clinical trials are needed to clarify their interplay. In conclusion, for salt-sensitive risk groups in the population, even stricter limits of sodium consumption should be set than for young, healthy individuals. Therefore, the question raised in the title should be rephrased as follows: "how much salt is harmful" and "for whom is elevated salt intake harmful?"

An Assessment of Turkish Adults' Knowledge Levels About Their Salt and Sugar Consumption, and Their Attitudes Toward Protecting Children from Excessive Salt and Sugar Consumption

PURPOSE

The study aimed to assess adults' knowledge levels about salt and sugar consumption and their attitudes toward protecting children from excessive consumption of them.

DESIGN AND METHODS

A cross-sectional, methodological, descriptive, and correlational study design was conducted. The study was carried out at a family health center and included 377 participants. The results were analyzed using descriptive statistics, reliability analysis and multiple regression.

RESULTS

The participants' knowledge scores accounted for 1.7% of their attitude scores. The participants' socio-demographic characteristics accounted for 13.9% of their knowledge scores, and the model was statistically significant (F = 7.453, p < 0.001). The participants' socio-demographic characteristics accounted for 11% of their attitude scores, and the model was statistically significant (F = 5.672, p < 0.001).

CONCLUSIONS

Children and adults should be protected from salt and sugar overconsumption, which is a risk factor for many diseases. Therefore, adults' knowledge levels about salt and sugar consumption and their attitudes toward protecting children from excessive consumption of them should be improved. It is also important to teach adults how to choose foods and beverages after checking their labels and how to be role models for children in this regard.

PRACTICE IMPLICATIONS

The study results will contribute to the planning of experimental studies to protect children from excessive salt and sugar consumption. In addition, the study results will provide an infrastructure for the preparation of training programs about salt and sugar consume according to the needs of different groups (older adults, young adults etc.).

Metabolic Syndrome in Children and Adolescents: Is There a Universally Accepted Definition? Does it Matter?

The concept of metabolic syndrome (MetS) as a cluster of cardiovascular risk factors (obesity, altered glucose metabolism, dyslipidemia, and hypertension) has been around for more than 30 years. It is considered to be the result of complex interactions between centrally located fat, insulin resistance, subclinical inflammation, and other factors in genetically predisposed individuals. MetS diagnosis in adults has been linked to increased risk for cardiovascular disease (CVD) and type 2 diabetes mellitus (T2D). However, MetS in children and adolescents remains a controversial issue despite the extensive research in the field. It is still uncertain which definition should be used for its diagnosis in this age group, what is the clinical significance of such a diagnosis, and how reliably it can predict the future risk of developing CVD and T2D. Even if a child is diagnosed with MetS, management includes addressing each of the syndrome's components individually with weight loss and lifestyle modifications as the basic approach. Co-morbid conditions, such as nonalcoholic fatty liver disease, obstructive sleep apnea, and polycystic ovary syndrome should also be considered. It seems that MetS in children and adolescents should be used clinically as a conceptual framework for the identification of risk factors clustered around obesity and insulin resistance rather than a syndrome that needs to be diagnosed by measuring absolute "all-or-none" criteria.

Disparities in the Healthfulness of School Food Environments and the Nutritional Quality of School Lunches

The Healthy, Hunger-Free Kids Act (HHFKA), a public law in the United States passed in 2010, sought to improve the healthfulness of the school food environment by requiring updated nutrition standards for school meals and competitive foods. Studies conducted since the passage of the HHFKA indicate improvements in the food environment overall, but few studies have examined whether these improvements varied by the socioeconomic and racial/ethnic composition of students in schools. To better understand the extent of disparities in the school food environment after HHFKA, this paper examined differences in the healthfulness of school food environments and the nutritional quality of school lunches by the school poverty level and racial/ethnic composition of students using data from the School Nutrition and Meal Cost Study. Results from chi-square analyses showed lower proportions of high poverty, majority black, and majority Hispanic schools had access to competitive foods, while higher proportions of these schools had a school wellness policy in addition to a district wellness policy. The overall nutritional quality of school lunches, as measured by total Healthy Eating Index (HEI)-2010 scores, did not vary significantly across school types, although some HEI component scores did. From these findings, we concluded that there were disparities in the school food environment based on the socioeconomic and racial/ethnic composition of students in schools, but no significant disparities in the overall nutritional quality of school lunches were found.

Plant-Based Diets and Hypertension

Hypertension is a global epidemic and a risk factor for many adverse outcomes, including cardiovascular disease, kidney disease, and death. Lifestyle plays a significant role in the development and maintenance of hypertension, and guidelines from several organizations recommend lifestyle modifications as first-line intervention for hypertensive patients. Data supporting the use of plant-based diets in the treatment of hypertension goes back almost a century. More recently, clinical trial data, including randomized controlled trials, have established plant-based diets as an effective lifestyle intervention for high blood pressure (BP). Plant-based diets differ from the standard American diet in a myriad of ways, with some substances being present in either substantially higher or lower amounts. Although the precise mechanism of a plant-based diet's beneficial effects on BP is unknown, many of these differences may be responsible. Attributes of a plant-based diet that may lower BP include a lower energy content leading to weight loss, a lower sodium content, an increased potassium content, reduced oxidative stress, higher bioavailability of the vasodilator nitric oxide, and beneficial effects on the microbiome. The evidenced-based benefits of plant-based diets in treating hypertension should lead providers to advocate for this dietary pattern for their patients.

Elevated blood pressure and its relationship with bodyweight and anthropometric measurements among 8-11-year-old Indonesian school children

Objective: Increased prevalence of elevated blood pressure in children and adolescents was associated with increased body weight and measures. Also, prevalence of elevated blood pressure varies between countries. This study is to investigate the prevalence of elevated blood pressure in Indonesian children and its relationship with bodyweight and anthropometric measures. Methods: This cross-sectional study involved 1010 elementary students aged 8 - 12 years (479 girls, 531 boys). The anthropometric measures and blood pressure were assessed. Elevated blood pressure (EBP) was determined if at the 90^th percentile or above for gender, age, and height. Independent t-test, Chi-square, Pearson correlation, and multivariate logistic regression were applied. Significance was determined at p<0.05. Results: Overall prevalence of EBP was 28.8% (35.9% in girls, 22.4% in boys). BMI, waist circumference (WC), waist to height ratio (WHtR), and abdominal skinfold had significant correlation with EBP. Elevated BP was higher in overweight and obesity than in normoweight (60.5% vs 39.5%, p=0.00). In girls, the OR of EBP for overweight and obesity were 2.33 (95% CI 1.40-3.87, p=0.03) and 3.44 (95% CI 1.98-5.99, p=0.00) whereas in boys were 4.26 (95% CI 2.20-8.28, p=0.00) and 8.82 (95% CI 5.10-15.38, p=0.00). Conclusions: Prevalence of EBP in Indonesian school children aged 8 - 11 years was higher and more prevalent in overweight/ obesity and in girls. Anthropometric measures were correlated with EBP.

Energy Dense Salty Food Consumption Frequency Is Associated with Diastolic Hypertension in Spanish Children

High blood pressure (BP) is a risk factor for cardiovascular disease and sodium consumption is related to high BP. Moreover, sugar-sweetened beverages (SSB) and the Dietary Approach to Stop Hypertension (DASH) influence BP. For this reason, we investigated whether: 1) children with risk of elevated BP had a higher consumption frequency (CF) of energy-dense salty foods (EDSF), high-sugary foods (HSF) and SSB or a low DASH score; and 2) children with a higher CF of EDSF showed a worse anthropometric and metabolic profile. Anthropometry, BP and general biochemical parameters were measured in 687 Spanish children (5-16 years) with normal or excess weight. A food frequency questionnaire was used to calculate EDSF, HSF and SSB consumption, and modified DASH score. Results showed that sex and pubertal stage influenced modified DASH score. Diastolic hypertension was associated to higher CF of EDSF in the whole sample and to higher CF of SSB in pubertal children, both independently of nutritional status. In addition, CF of EDSF was positively associated with CF of HSF and SSB and inversely associated with modified DASH score. Targeted policies and intervention programs, specific for different age ranges, should be established that aim to reduce salt consumption from snacks and processed foods, which could reduce HSF and SSB consumption as well.