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(Circulation. 2004;110:1832-1838.)
© 2004 American Heart Association, Inc.

Preventive Cardiology

Blood Pressure and Adiposity in Children and Adolescents

Gilles Paradis, MD, MSc, FRCPC; Marie Lambert, MD, FRCPC; Jennifer O’Loughlin, PhD; Claudette Lavallée, MA; Jacinthe Aubin, MA; Edgard Delvin, PhD, FCACB; Emile Lévy, PhD; James A. Hanley, PhD

From the Direction de santé publique de Montréal-Centre (G.P., J.O.), McGill University Health Centre; Department of Epidemiology, Biostatistics and Occupational Health (G.P., J.O., J.A.H.), McGill University; Département de pédiatrie (M.L.), Hôpital Ste-Justine and Université de Montréal; Institut de la statistique du Québec (C.L., J.A.); Département de biochimie clinique (E.D.), Hôpital Ste-Justine and Université de Montréal; and Centre de recherche (E.L.), Hôpital Ste-Justine and Département de nutrition, Université de Montréal, Montréal, Québec, Canada.

Correspondence to Gilles Paradis, MD, MSc, FRCPC, Direction de santé publique de Montréal-Centre, 1301 Sherbrooke St East, Montréal (Québec), Canada, H2L 1M3. E-mail gilles.paradis{at}mcgill.ca

Received February 7, 2004; de novo received April 27, 2004; accepted June 8, 2004.

	Abstract

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Background— Although obesity is associated with important hemodynamic disturbances, there are few data on population-wide blood pressure (BP) distribution in children and adolescents in this era of endemic pediatric obesity.

Methods and Results— We conducted a school-based survey of a representative sample of youth aged 9, 13, and 16 years in Quebec, Canada. Resting BP was measured with an oscillometric device in 3589 subjects (80% response). Additional measures included height, weight, and subscapular and triceps skinfold thickness, an age-appropriate questionnaire, and a fasting blood draw. Mean (SD) systolic/diastolic BP (SBP/DBP) levels in 9-, 13-, and 16-year-olds were 103 (9)/57 (6), 113 (12)/58 (7), and 124 (14)/61 (7) mm Hg in males and 103 (10)/57 (6), 111 (11)/60 (7), and 114 (11)/62 (7) mm Hg in females. The prevalence of high-normal or elevated SBP was 12%, 22%, and 30% among 9-, 13-, and 16-year-old males, respectively, and 14%, 19%, and 17% among same-aged females. The prevalence of high-normal or elevated DBP was <1%. In multiple linear regression analysis, body mass index was consistently associated with SBP and DBP in all age-gender groups.

Conclusions— Mean SBP and the prevalence of high-normal and elevated SBP are elevated in children and adolescents. Public policy, public health programs, and clinical preventive measures are urgently needed to address the obesity epidemic and its hemodynamic consequences.

Key Words: obesity • hypertension • blood pressure • pediatrics • population

	Introduction

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Overweight and obesity are the most common nutritional disorders in North America in adults and children. In the United States, the prevalence of overweight in children aged 6 to 11 years and 12 to 19 years increased from 4% and 6%, respectively, in the period from 1971 to 1974 to 15% in both age groups in 1999 to 2000.¹ In Canada, limited data suggest that mean body mass index (BMI) increased by 0.1 kg/m² per year from 1981 to 1997 among children aged 7 to 13 years.²

Obesity in children and adolescents is associated with several metabolic and hemodynamic abnormalities, including dyslipidemia, elevated blood pressure (BP), impaired glucose tolerance, insulin resistance, and clustering of cardiovascular disease risk factors.³ These risk factors, as well as obesity, track into adulthood and are associated with early atherosclerosis.^4,5 Hypertension in adolescents is associated with increased left ventricular mass and diastolic dysfunction at echocardiography⁶ and with fatty streaks and fibrous plaques in the aorta and in coronary arteries at autopsy.⁵

Although the long-term effects of the metabolic and vascular abnormalities may have widespread clinical and public health importance, there is no documentation of the population-wide health consequences of the current obesity epidemic in children and adolescents. We report the distribution of BP levels, the prevalence of elevated BP, and the association of BP with adiposity in a large, population-based sample representative of children and adolescents in Quebec, Canada.

	Methods

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The design and methods of the Quebec Child and Adolescent Health and Social Survey (QCAHS) have been described in detail.⁷ In brief, the QCAHS was a school-based, multistage, stratified, cluster sample survey of Quebec children and adolescents aged 9, 13, or 16 years. Data were collected at school from January to May 1999 by 10 teams of trained interviewers. Data collection included age-appropriate questionnaires, a parent questionnaire, anthropometric and BP measurements, and a fasting blood draw for measurement of lipoproteins and glucose and for storage for future analyses. The youth and parent questionnaires collected data on several health, sociodemographic, and lifestyle characteristics and, for each biological parent, the history of hypertension, including use of medication for hypertension.

BP was measured in the morning and on the right arm of subjects seated and at rest for at least 5 minutes, no less than 30 minutes after breakfast. Cuff size was based on arm circumference according to the Project Heartbeat! protocol.⁸ Three consecutive measures were obtained at 1-minute intervals with an oscillometric device (Dinamap XL, model CR9340, Critikon Co) according to procedures developed by the Child and Adolescent Trial for Cardiovascular Health program.⁹ The average of the last 2 measurements was used in the analyses. Resting pulse and the mean arterial pressure were also recorded. The 10 instruments (1 for each team of interviewers) used for data collection were calibrated against a mercury manometer before data collection. Interviewers were tested and certified for BP measurement.^8,9

Height was measured with a measuring tape to the nearest millimeter during maximal inspiration. Weight was measured to the nearest 0.2 kg in light indoor clothing with a spring scale tested daily for accuracy and calibrated against a set of standard weights. BMI was computed as weight (kg)/height² (m²). Triceps and subscapular skinfold thickness were measured on the right side to the nearest millimeter with a Lange caliper (Beta Technology).¹⁰ All measurements were repeated, and if they differed by more than 0.5 cm for height, 0.2 kg for weight, and 1 mm for skinfolds, a third measure was taken. The average of the 2 closest measures was used in the analyses. Anthropometric measures were repeated by a different interviewer in every tenth subject. Interrater reliability coefficients were 0.99, 0.99, 0.96, and 0.94 for height, weight, subscapular skinfold, and triceps skinfold, respectively.

Ten milliliters of blood was collected in 1 mg/mL EDTA sterile tubes after a 12-hour fast, put on ice, centrifuged on site within 90 minutes, separated into plasma and cell pellet, frozen on dry ice, and sent to the laboratory within 24 hours. Insulin concentrations were determined with ultrasensitive double-antibody sandwich assays with chemiluminescence as the detection method (Access immunoassay system, Beckman-Coulter). The antibodies used are specific to insulin and do not cross-react with proinsulin or peptide C.

Parents and children provided informed written consent. The ethics committee from Ste-Justine Hospital approved the study protocol. Copies of all data-gathering instruments, questionnaires, and the full survey report are available at http://www.stat.gouv.qc.ca/ publications/sante/enfant-ado_pdf_an.htm.¹¹

Data Analysis
Age- and gender-specific means, SDs, and percentile values of systolic BP (SBP) and diastolic BP (DBP) were computed. Nonparametric CIs for the quantiles of interest were constructed with the algorithm described by Hutson.¹² We defined overweight as BMI 85th and <95th percentile and obesity as BMI 95th percentile according to the 2000 Centers for Disease Control and Prevention (CDC) growth charts.¹³ To describe the SBP and DBP levels in each of the quintiles of adiposity indices, we used least-square means adjusted for parental history of hypertension, fasting insulin, and resting heart rate (HR). The prevalence of "high normal" and "elevated" BP was assessed by comparing the subjects’ SBP and DBP with the age-, gender-, and height-specific 90th and 95th percentile reference values from the National High Blood Pressure Education Program (NHBPEP)¹⁴ using CDC growth chart reference percentiles for height.¹³ Multiple linear regression was used to assess the independent contribution of adiposity indicators to SBP and DBP variations while adjusting for the other factors that were associated with BP in univariate analyses, including fasting insulin, resting HR, and parental history of hypertension. All analyses (except multivariate analysis) were weighted to reflect the complex sampling design. Design effects were applied to the calculation of standard errors to take into account the cluster sampling design of the survey. Analyses were conducted with SAS (SAS Institute) and SUDAAN.¹⁵

	Results

Top Abstract Introduction Methods Results Discussion References

 
BP readings were obtained from 82% (1252/1520), 79% (1180/1498), and 77% (1157/1495) of 9-, 13-, and 16-year-olds, respectively; the response proportion was 52% (783/1520), 55% (818/1498), and 59% (874/1495) for the blood draw for 9-, 13-, and 16-year-olds, respectively. No meaningful differences were found between those who did and did not have blood draw.⁷ Sociodemographic characteristics were similar in all age groups except for socioeconomic status level, which was lower among 9-year-olds (Table 1).

View this table: [in this window] [in a new window]   TABLE 1. Sociodemographic and Household Characteristics of Study Subjects in Whom BP Was Measured

The prevalence of overweight and obesity was similar by age (Table 1; P=0.38 and 0.30 for overweight and obesity, respectively) and, for all age groups, by gender (percent difference [probability value] in overweight and obesity between males and females: 2% [P=0.7], 3% [P=0.31], and 2% [P=0.07] for 9-, 13-, and 16-year-olds, respectively). The difference in mean BMI from the lowest to the highest quintile of BMI was 10 kg/m² in all age groups. Mean triceps and subscapular skinfolds were higher among older subjects (Table 1) and were higher among girls (2, 3, and 8 mm among 9-, 13-, and 16-year olds, respectively, for triceps skinfolds and 1, 3, and 3 mm, respectively, for subscapular skinfolds (all P<0.0001)). Mean triceps and subscapular skinfolds increased 19 and 16 mm, respectively, from the lowest to the highest quintile of skinfold thickness.

Mean and percentile values of SBP were similar among 9-year-old males and females (Table 2). The mean SBP of 13- and 16-year-olds was 2 (P=0.004) and 10 (P<0.0001) mm Hg higher, respectively, in males than in females. The difference in SBP between males and females at the 75th, 90th, and 95th percentiles was 3 to 4 mm Hg among 13-year-olds and 13 to 15 mm Hg among 16-year-olds. The 90th and 95th percentile SBP values for 16-year-old males were higher than the adult thresholds defining systolic hypertension. The mean and percentile values of DBP did not differ between males and females.

View this table: [in this window] [in a new window]   TABLE 2. Mean (SD) and Selected Percentile Values for SBP and DBP

Compared with the NHBPEP BP reference values, substantial proportions of youth aged 13 and 16 years presented elevated levels of SBP (Table 3). Only slightly increased proportions of children aged 9 years had high-normal or elevated SBP. The proportion of 9-, 13-, and 16-year-old subjects with high-normal or elevated SBP was 12%, 22%, and 30%, respectively, for males and 14%, 19%, and 17% for females. Elevated SBP occurred in twice as many 16-year-old males as females. Fewer than 1% of subjects had elevated or borderline DBP (Table 3). Almost all subjects with elevated SBP had normal levels of DBP (>99%).

View this table: [in this window] [in a new window]   TABLE 3. Proportion of Children and Adolescents With High-Normal or Elevated BP According to NHBPEP Criteria

Mean BMI was 4 to 6 kg/m² higher among subjects with SBP 95th percentile than among those with SBP <25th percentile in all age-gender groups. After adjustment for fasting insulin, resting HR, and parental history of hypertension, mean SBP and DBP were higher in those in the higher quintiles of BMI (Figure). Similar patterns were seen for subscapular and triceps skinfold quintiles (data not shown). In multivariate analysis, BMI was positively and significantly associated with SBP in all age-gender groups (Table 4). Fasting insulin was significantly associated with SBP among 13-year-old females and males. Resting HR was significantly associated with SBP in all age groups, but only in females. Parental history of hypertension was associated with SBP among 16-year-old females. The R² from the various models varied from 10% to 16%.

View larger version (23K): [in this window] [in a new window]   Mean SBP and DBP according to BMI quintile and gender, adjusted for fasting insulin, resting HR, and parental history of hypertension

View this table: [in this window] [in a new window]   TABLE 4. Independent Correlates of SBP and DBP According to Age and Gender

BMI was also consistently and positively associated with DBP among both males and females. Resting HR was significantly associated with DBP in all age-gender groups. Fasting insulin was significantly associated with DBP among 16-year-old males and was marginally significant among 13-year-old females. Significant associations between parental history of hypertension and DBP were found among 9- and 16-year-old females and 13-year-old males.

	Discussion

Top Abstract Introduction Methods Results Discussion References

 
The impact of the current obesity epidemic on population-wide BP distributions is largely unknown. Because our data were cross-sectional, we cannot establish the directionality of the observed associations, although numerous longitudinal studies have established that excess weight is prospectively associated with increased BP in youth.^16–18 Compared with previous surveys, we found high levels of adiposity and of SBP in this representative sample of Quebec children and adolescents. The Canada Health Survey (CHS) conducted in 1978 and 1979 reported mean SBP 4 to 8 mm Hg lower and DBP 3 to 10 mm Hg higher than observed in the present survey.¹⁹ However, comparisons between the 2 surveys are limited because the earlier survey used mercury manometers and a different sampling design and reported BP for 5-year age groups.

The present data suggest that 12% to 23% of youth aged 9, 13, and 16 years have high-normal or elevated SBP. Given the high degree of tracking of BP, and of SBP in particular, these prevalences are particularly worrisome.²⁰ If these high levels of SBP persist, they could lead to substantial increases in adult BP levels and in the prevalence of hypertension over the next generation, which in turn could result in increased cardiovascular morbidity and mortality. The Bogalusa study showed that youth with elevated and high-normal BP were more likely to become hypertensive as adults.²¹ In the Muscatine study, the relative risk of developing hypertension in adulthood was 2.4 in children with BP levels above the 90th percentile.²²

A recent review of 8 large US studies of BP in children and adolescents conducted from 1978 to 1991 reported mean BP (SBP/DBP) of 100/59, 109/61, and 116/67 mm Hg among 9-, 13-, and 16-year old white males and of 99/60, 108/64, and 109/66 mm Hg among similar-aged white females.²³ The overall prevalence of hypertension defined according to the NHBPEP criteria was 4% for SBP and 3% for DBP. Among males and females of the same age in Quebec, the mean SBP was 3, 4, and 8 mm Hg higher and 4, 3, and 5 mm Hg higher, respectively; the prevalence of elevated BP was substantially higher. Conversely, the DBP was 2 to 7 mm Hg lower among Quebec youth than among the combined US sample. Although BP was not measured with oscillometric devices in these studies, the reason for the lower DBP in the present study are unclear. However, the results are congruent with the increasing body of evidence suggesting a substantial predominance of systolic rather than diastolic hypertension among obese children.¹⁶ Finally, cross-sectional analyses of the baseline data from the National Heart, Lung, and Blood Institute’s Growth and Health Study showed significantly higher SBP (105 versus 100 mm Hg) and DBP (71 versus 65 mm Hg) levels among white females aged 9 years with BMI 85th percentile of the National Health and Nutrition Examination Survey (NHANES) I and II population than among those below the 85th percentile.²⁴

The mechanisms by which excess weight may lead to elevated BP are poorly understood. Disturbances in autonomic function and, in particular, sympathetic nervous system hyperactivity associated with a hyperkinetic state, including increased HR and BP variability, have been associated with isolated systolic hypertension in obese children.²⁵ Positive associations between resting HR, pulse pressure, and SBP and obesity were noted in the Bogalusa study.²⁶ Although we could not assess BP variability, HR was positively associated with SBP in females and DBP in both females and males, which suggests some degree of increased sympathetic activity; however, HR was not associated with measures of adiposity (data not shown).

Insulin resistance and increased fasting insulin levels have been associated with elevated SBP.^27,28 However, Sinaiko et al²⁹ failed to show an association between insulin sensitivity, measured by the euglycemic insulin clamp, and SBP. In the present study, although fasting insulin was an independent correlate of SBP in 13-year-old males and females and of DBP in 9- and 16-year-old males, lack of a more consistent association between BP and fasting insulin might be due to the strong correlation between BMI and insulin. Finally, only 10% to 16% of the variance in SBP and DBP was explained by the multivariate models, which emphasizes that much of the variability in BP remains unexplained in this population.

Limitations of the present study include that BP was measured at only 1 visit, which could result in subjects being misclassified as having borderline or elevated BP. In addition, we have no information on the 20% of the sampled subjects who refused to participate in any aspect of the survey.

Measurement error could account for the results of this study if our procedures or the oscillometric device readings led to biased estimates of BP; however, BP readings with the Dinamap are highly correlated with intra-arterial measures.³⁰ In the present study, the staff was tested and certified in the measurement of BP with the device, and all 10 instruments were calibrated against a mercury manometer before the start of the survey. In addition, the distribution of BP values did not vary across the 10 instruments used in the survey. Repeating the analyses after exclusion of 164 subjects with incorrect BP cuff size did not change the results. Finally, because previous studies in adults suggested that the Dinamap may overestimate SBP compared with the mercury manometer,³¹ we conducted a validation study in a convenience sample of 52 children aged 8 to 16 years (BMI range 15 to 45 kg/m²) with random determination of the order of the measurement with the Dinamap or mercury manometer and found no systematic differences in SBP.

In conclusion, our survey identifies important population-wide elevations of SBP distributions compared with North American reference populations and a high prevalence of borderline or elevated SBP in children and adolescents in Quebec. SBP was associated with excess body weight. If these high BP levels persist, they could lead to severe health consequences over the next several decades. Public health programs and policies, as well as clinical and community-based education, are required to increase physical activity and decrease caloric intake in children and adolescents.

	Acknowledgments

 
The survey was funded by the ministère de la Santé et des Services sociaux du Québec and the Bureau of Nutritional Sciences, Health Canada. The analyses were funded in part by the Canadian Institutes of Health Research (MOP 44027). Dr O’Loughlin is an Investigator of the Canadian Institutes of Health Research. We thank Igor Karp and Daniel Cournoyer for data analysis, Ginette Lagacé for laboratory assistance, and Nathalie Théoret and Mireille Paradis for secretarial assistance.

	Footnotes

 
Presented in part at the 43rd Annual Meeting of the Council on Epidemiology and Prevention of the American Heart Association, Miami, Fla, March 5–8, 2003.

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This Article Abstract Full Text (PDF) All Versions of this Article: 110/13/1832    most recent 01.CIR.0000143100.31752.B7v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Paradis, G. Articles by Hanley, J. A. Search for Related Content PubMed PubMed Citation Articles by Paradis, G. Articles by Hanley, J. A. Pubmed/NCBI databases Compound via MeSH Substance via MeSH Medline Plus Health Information High Blood Pressure Obesity Obesity in Children Related Collections Obesity Primary prevention Risk Factors Other hypertension Epidemiology Related Article