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Prevalence of hypertension and prehypertension in adolescence in Ahvaz, Iran
G Model DSX 756 No. of Pages 4
Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal homepage: www.elsevier.com/locate/dsx
Original Article
Prevalence of hypertension and prehypertension in adolescence in Ahvaz, Iran Armaghan Moravej Aleali, Seyed Mahmoud Latifi* , Homeira Rashidi, Seyed Peyman Payami, Azar Sabet Diabetes Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, 61357-15794, Iran
A R T I C L E I N F O
A B S T R A C T
Article history: Available online xxx
Background: High blood pressure is a risk factor for some disease like stroke, coronary heart disease, and renal failure. High blood pressure in children is an increasing health problem. Objectives: The aim of this study was to determine prevalence of hypertension and pre-hypertension age between 10 to 17 years old. Patients and methods: This descriptive analytic study was conducted using multiphase sampling method in Ahvaz (Southwest of Iran). A questionnaire include: height, weight, and body mass index, systolic and diastolic blood pressures filled for each participant. Blood pressure was measured twice for each person. For the diagnosis of hypertension, the fourth report of the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents of the National Health Institute of United States was used. Results: Total participants of the study were 1707children and adolescents including 922 boys (54%) and 785 girls (46%). The prevalence of high blood pressure was 1.7% (2.5% in boys and 0.8%). The prevalence of pre-hypertension was 9%(7.6% in boys, 10.6% in girls). The mean systolic and diastolic blood pressures increased with increasing body mass index. Conclusions: The prevalence of high blood pressure was found to be lower than other studies in our country. The prevalence of the high blood pressure in boys was significantly higher than girls. This study, like other studies showed high correlation between being overweight and an increase in systolic and diastolic blood pressure. © 2017 Diabetes India. Published by Elsevier Ltd. All rights reserved.
Keywords: Hypertension Prehypertension Childhood Adolescence
Implication for health policy/practice/research/medical education High blood pressure in children is an increasing health problem. So this study was conducted to determine prevalence of hypertension and pre-hypertension between children and adolescence in Ahvaz. Prevalence of hypertension and pre-hypertension was 1.7% (2.5% in boys and 0.8% in girls) and 9% (7.6% in boys and 10.6% in girls) respectively. 1. Introduction Hypertension is a physiological parameter that can be a significant risk factor for atherosclerosis and its consequences in the coronary vessels, kidney and the brain vessels. In adults,
* Corresponding author. E-mail address: [email protected] (S.M. Latifi).
hypertension can often be a preliminary phase to some dangerous diseases like stroke, coronary heart disease (CHD), congestive heart failure (CHF), Renal failure (RF). There is a possibility that a major proportion of high blood pressure in adults could be a result of high blood pressure in their childhood [1,2]. Hypertension is responsible for 7 million deaths annually around the world [3]. Hypertension in children is an increasing health problem [4] and high secondary blood pressure is more prevalent in children than in adults [5]. Overweight and obesity are highly correlated with hypertension in children [6–8]. Having a family history of hypertension or coronary heart disease, being male, and smoking during pregnancy are other risk factors [9–11]. Moreover, children who are breast fed have lower risk for hypertension. Children with hypertension have shown evidences of disorder in the target organs including hypertrophy of the left ventricle, and pathology of blood vessel changes [12,13]. Primary hypertension in childhood is also related to other risk factors like hyperlipidemia, and diabetes mellitus for coronary and heart diseases [14,15]. Research conducted on different ethnicities shows differences in prevalence of
http://dx.doi.org/10.1016/j.dsx.2017.04.002 1871-4021/© 2017 Diabetes India. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: A.M. Aleali, et al., Prevalence of hypertension and prehypertension in adolescence in Ahvaz, Iran, Diab Met Syndr: Clin Res Rev (2017), http://dx.doi.org/10.1016/j.dsx.2017.04.002
G Model DSX 756 No. of Pages 4
2
A.M. Aleali et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2017) xxx–xxx
hypertension across these ethnicity groups [16,17]. Based on the results of different studies, the prevalence of hypertension in children was between 1.4 to 11% [3,18,19].
Treatment of High blood Pressure in Children and Adolescents was used as the criterion [21]. 3.1. Ethical issues
2. Objectives Considering the changes in the levels of blood pressure from one population to another, this study was conducted to assess prevalence of hypertension and pre-hypertension on the children and adolescents of Ahvaz age range 10 17 years old.
Since all participants were under 18 years old, written informed consent was obtained from their parents. This study was conducted in accordance with the principles laid down in the declaration of Helsinki. The research was approved by the ethical committee of Ahvaz Jundishapur University of Medical Sciences.
3. Patients and methods
3.2. Data analysis
In this descriptive-analytic study, using multistage cluster sampling, from 25 health centers in Ahvaz (capital city of Khuzestan province, South West of Iran), four centers from East and two centers from West were chosen. For each health center, several families were randomly selected as the head of cluster and in each cluster, 50 subjects in age 10 to 17 years old were chosen. Necessary information was given to the subjects and their parents. In each center, health workers who were properly trained to help in this research project. A questionnaire filled up for each participant included: age, gender, education level, parents’ job, daily activity, smoking, maternal history, birth weight, parent medical history. The height was measured by standard instrument. Waist circumference (WC) was measured with a non-elastic tape at a point midway between the lower border of the ribcage and the iliac crest at the end of normal expiration. Their weight was measured using Seca weighing scales with standard method. Obesity in children was defined by body mass index (BMI), calculated as weight in kilograms (kg) divided by the square of height in meters (m2). BMI above 85 percentile for age and gender were considered overweight and above 95 were considered obese [20]. Systolic and diastolic blood pressure were taken from the right arm at least after 5 minutes of rest in two occasions with a 30 seconds interval in sitting position using a (mechanical) sphygmomanometer and placing the stethoscope under the cuffs specially suited for the children. During the interval, the arms of the children were in the resting position. The average of the result of the measurement was recorded as the blood pressure of the individual. For the recording of the blood pressure, the sounds of korotkoff in the first and fifth phase was listened to preferably by the bell part of the stethoscope and the values of the blood pressure in korotkoff's first phase was recorded in the form as the systolic blood pressure and the fifth phase as the diastolic blood pressure. In children and adolescents, the normal blood pressure varies according to the size of the body and the age. As a result, the standards based on gender, age and height provide a better criterion of the classification of blood pressure in proportion to the body size. In this study the fourth report of the National Health institute of the United States on the Diagnosis, Evaluation, and
Data were analyzed using the SPSS software (Statistical Package for the Social Sciences, version 18.0, SPSS Inc, Chicago, Ill, USA). We used t-test and analysis of variance (ANOVA) for comparison of means, chi-square for variables relation and Binary logistic for compute odds ratio (O.R). P- Value less than 0.05 was considered significant. 4. Results In this study, 1707 children and adolescents age from 10 to 17 years old evaluated. They lived in Ahvaz and included 922 boys (54%) and 785 girls (46%). 8. 7% [95%C.I. (7.4–10)] of the adolescents were overweight and 3.6% [95%C.I. (2.8–4.4)] of them were obese. Gender-wise, 7%of the boys and 10.7%of the girls were overweight. 2.3% of boys and 5.2% of girls were obese. Table 1 shows mean of BMI, systolic and diastolic blood pressure according to age and sex. Mean BMI in girls is higher than boys significantly (P 0.002). Mean systolic and diastolic blood pressure in varying weight group shows that there is significant different between them (P = 0.0001) (Table 2). Table 3 shows comparison of hypertension and pre-hypertension between to genders. According to Table 4, Model 1 shows being male increased risk of hypertension 3.5 times more than female. Also, being overweight increased risk of hypertension 2.8 times more than normal people. In model 2 increasing height, decreases the risk of having hypertension, while the risk of hypertension in male was 4.8 times more than female. 5. Discussion This study was conducted on 1707 children and adolescents 10 to 17 years of age in Ahvaz. 1.7% of participants were diagnosed with hypertension and 9% with prehypertension. In a study carried out by Kelishadi and et al. on a representative sample of 23 provinces in Iran, with age group 6 to 18 years, prevalence of hypertension was 4.2% [22] and in another study by Ataei and et al. On Tehran adolescents aged 13 to 18 years, was reported 4.7% (2.9%
Table 1 The comparison of mean systolic and diastolic blood pressures and BMI with age and sex. Age
Sex
n (%)
BMI Mean SD
DBP(mm/hg) Mean SD
SBP (mm/hg) Mean SD
10–14
Boys Girls
505(54.2) 426(45.8)
Boys Girls
417(53.7) 359(46.3)
Total
1707(100)
18.34 3.3 19.1 3.9 0.001 20.86 5.2 21.7 3.9 0.002 19.8 4.3
62.2 9.5 63.2 9.1 0.11 66.2 9.7 65.7 8.9 0.47 64.1 9.5
103.3 10 103.4 10.2 0.95 109.2 11 108 9.6 0.42 106 10.8
P Value 15–17 P Value 10–17
DBP: Diastolic blood pressure (mm/hg) SBP: Systolic blood pressure(mm/hg).
Please cite this article in press as: A.M. Aleali, et al., Prevalence of hypertension and prehypertension in adolescence in Ahvaz, Iran, Diab Met Syndr: Clin Res Rev (2017), http://dx.doi.org/10.1016/j.dsx.2017.04.002
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3
Table 2 Comparison of mean systolic and diastolic blood pressure in normal, overweight and obese subjects. Age
Blood Pressure
BMI 85(kg/m2) Normal
85 < BMI95(kg/m2) overweight
BMI > 95(kg/m2) obese
P Value
10–14
SBP DBP SBP DBP SBP DBP
103 10 62.3 9.3 108 10.4 65.7 9.4 105.28 10.5 63.7 9.5
108.4 9.6 67.5 8.7 110.1 10.6 66.6 9.3 110.13 10.3 66.9 9.1
109 8.5 67.5 8.5 111.6 9.1 68.8 8.5 110.8 8.9 68.38 8.4
0.0001 0.0001 0.018 0.09 0.0001 0.0001
15–17 10–17
Table 3 Comparison of hypertension and pre-hypertension between to genders. Age
Sex
Hypertension (%)
Pre-hypertension (%)
10–14
Male Female P-value Male Female P-value Male Female P-value
7.9 10.1 P = 0.24 7.2 11.1 P = 0.056 7.6 10.6 P = 0.03
2.6 0.9 P = 0.06 2.4 0.6 P = 0.03 2.5 0.8 P = 0.006
15–17
10–17
Table 4 Binary logistic equations with the age, gender and BMI variables or height and weight. Model 1 Variable Sex (Boys/Girls) Age(year) (15–17/10–14) BMI(Percentile)* (kg/m2) (85–95/ 85) BMI(percential)(kg/m2) (95/ 85) Model 2 Sex (Boys/Girls) Age(year) (15–17/10–14) Weight(kg) Height(cm)
P-Value 0.006 0.44
O.R. 3.5 0.74
95% C.I.(O.R.) 1.43–8.84 0.34–1.6
0.047
2.8
1.01–7.78
0.7
1.47
0.19–11.37
0.001 0.31
4.8 1.93
1.85–12.45 0.68–5.45
0.22 0.002
1.02 0.93
0.98–1.06 0.89–0.97
BMI 85(kg/m2): Normal weigh. 85 < BMI 95(kg/m2): Overweigh. BMI > 95(kg/m2): Obese.
and 3.4%, systolic and diastolic respectively) [2]. Prevalence of prehypertension and hypertension in Chinese children and adolescents were reported 15% and 20.2% [23], in Houston adolescents aged 11 to 17 years, were 9.5% and 9.4% [24] and in Enugu adolescents aged 10 to 18 years in south-east Nigeria were 17.3% and 5.4% respectively [25]. Based on this study results, prevalence of hypertension in Ahvaz is much lower than other studies and 2.5% for boys and 0.8% for girls and significantly higher for boys. Prevalence of prehypertension is consistent only with results of Houston study in America [24]. In study conducted on glucose and lipid in Tehran (TLGS, phase 1), hypertension and prehypertension rates were found 10.6% and 12.3% respectively [26] which show a higher prevalence in both sexes and in addition, higher prevalence in girls than boys contrary to the results of Ahvaz study. There was no statistically significant differences in prevalence of hypertension in both sexes according to Kelishadi and Ataei investigations but In model 1 and model 2 presented in Table 4, male sex increases the risk of hypertension more than 3.5 and 4.8 times respectively. Based on this research, 1.6% of children and adolescents were diagnosed with high systolic blood pressure and
1.3% with high diastolic blood pressure. Also, prevalence of prehypertension was 7.6% for boys and 10.6% for girls and was lower compared to study of glucose and lipid that reported 12.3% and 12.9% prehypertension for boys and girls of Tehran (with statistically significant differences, p = 0.02). These rates were 15.7% and 14.2% for Chinese boys and girls [23] that indicate higher prevalence in both sexes compared to Ahvaz but contrary to Ahvaz, boys had higher rates of prehypertension. Three cross sectional American studies, called national hygienic and nutritional assessment, also showed higher prevalence of prehypertension for boys [27]. Hypertension and prehypertension among Tabriz high school girls have been reported 19.4 and 13.9% respectively [28] that represent higher prevalence than girls in Ahvaz. These observed differences between results of studies may be due to various types of methodology, differences in prehypertension and hypertension detection ranges and finally environmental and quality of life levels. Systolic blood pressure mean in Ahvaz was 106 10.8 and furthermore in accord with initial phase of glucose and lipid study in Tehran (105 11.7) and a study in Nigeria (106.6 11.8) but diastolic blood pressure was obtained 64.1 9.5 and lower than initial phase of study in Tehran (71.4 9.2) and Nigeria (70.25 7.3). In this survey carried out on children and adolescents, 8.7% of samples had overweight and 3.6% were obese. These results were consistent with findings from Klishadi et al. study that has reported 8.82% and 4.5% overweight and obesity based on CDC (Centers for Disease Control) [29]. In addition, mean systolic and diastolic blood pressure in three categories of BMI, were significantly different (P = 0.0001). In the age group 10 to 14, this difference was significant and in the age group 15 to 17 for systolic blood pressure was significant too (P = 0.018) but in diastolic blood pressure there was not found a significant difference (P = 0.09) (Table 3). Morever, glucose and lipid study in Tehran (TLGS, phase 1), has reported mean diastolic blood pressure in three categories of BMI such as present study [30].
6. Conclusion This study like many similar studies showed a strong positive correlation between overweight and increasing in systolic and diastolic blood pressures. The prevalence of hypertension in Ahvaz was lower than other studies in Iran. Prevalence of hypertension was higher in boys than girls significantly. But prevalence of prehypertension was higher in girls than boys.
Authors’ contribution S.M. Latifi analyzed and wrote manuscript draft. Moravej Aleali A. has done searches data collection, edited and submitted manuscript. H. Rashidi designed and supervised study and edited final draft. Sabet. A translated paper to english. All authors read and approved the final manuscript. Thanks to all authors A. sabet for their support and help in this study.
Please cite this article in press as: A.M. Aleali, et al., Prevalence of hypertension and prehypertension in adolescence in Ahvaz, Iran, Diab Met Syndr: Clin Res Rev (2017), http://dx.doi.org/10.1016/j.dsx.2017.04.002
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A.M. Aleali et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2017) xxx–xxx
Limitations of the study We measured blood pressure twice in single visit. But if we took blood pressure in two different visits and recorded mean of them, more precise estimate of blood pressure level would be obtained. Funding/support Financial support was provided by Vice Chancellor for Research, Ahvaz Jundishapur University of Medical Sciences Ethical considerations Ethical issues (including plagiarism, data fabrication, double publication) have been completely observed by the authors. Conflicts of interest The authors declared no competing interests. Acknowledgement This paper is issued from the research project that registered ((Reg. No. D-8703) in Health Research Institute, Diabetes Research Center, Ahvaz Jundishapur University of Medical Sciences. The authors would like to thank all staffs of diabetes research center, especially Miss Reshadatian, Dehghan and Hardani for their help in this study and also Mr. Sh. Hosseinzadeh for his help in English writing. References [1] Lauer RM, Clarke WR, Beaglehole R. Level, trend, and variability of blood pressure during childhood: the Muscatine study. Circulation 1984;69:242–9. [2] -Ataei N, Aghamohammadi A, Ziaee V, Hosseini M, Dehsara F, Rezanejad A. Prevalence of Hypertension in Junior and Senior High Hypertension in Junior and Senior HighSchool Children in Iran. Iran J Pediatr 2007;17:237–42. [3] Chiolero A, Bovet P, Paradis G, Paccaud F. Has blood pressure increased in children in response to the obesity epidemic. Pediatrics 2007;119:544–53. [4] Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA 2007;298:874–9. [5] National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004;114:555–76. [6] Din-Dzietham R, Liu Y, Bielo MV, Shamsa F. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation 2007;116:1488–96. [7] Falkner B, Gidding SS, Ramirez-Garnica G, Wiltrout SA, West D, Rappaport EB. The relationship of body mass index and blood pressure in primary care pediatric patients. J Pediatr 2006;148:195–200. [8] Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics 2004;113:475–82. [9] Dasgupta K, O'Loughlin J, Chen S, Karp I, Paradis G, Tremblay J. Emergence of sex differences in prevalence of high systolic blood pressure: analysis of a longitudinal adolescent cohort. Circulation 2006;114:2663–70.
[10] Lawlor DA, Najman JM, Sterne J, Williams GM, Ebrahim S, Davey Smith G. Associations of parental, birth, and early life characteristics with systolic blood pressure at 5 years of age: findings from the Mater-University study of pregnancy and its outcomes. Circulation 2004;110:2417–23. [11] Martin RM, Ness AR, Gunnell D, Emmett P, Davey Smith G, ALSPAC Study Team, et al. Does breast-feeding in infancy lower blood pressure in childhood? The Avon Longitudinal Study of Parents and Children (ALSPAC). Circulation 2004;109:1259–66. [12] Brady TM, Fivush B, Flynn JT, Parekh R. Ability of blood pressure to predict left ventricular hypertrophy in children with primary hypertension. J Pediatr 2008;152:73–8. [13] Sorof JM, Alexandrov AV, Garami Z, Turner JL, Grafe RE, Lai D, et al. Carotid ultrasonography for detection of vascular abnormalities in hypertensive children. Pediatr Nephrol 2003;18:1020–4. [14] Duncan GE, Li SM, Zhou XH. Prevalence and trends of a metabolic syndrome phenotype among u.s. Adolescents, 1999–2000. Diab Care 2004;27(10):2438– 43. [15] Boyd GS, Koenigsberg J, Falkner B, Gidding S, Hassink S. Effect of obesity and high blood pressure on plasma lipid levels in children and adolescents. Pediatrics 2005;116:442–6. [16] Ataei N, Aghamohammadi A, Yousefi E, Hosseini M, Nourijelyani K, Tayebi M, et al. Blood pressure nomograms for school children in Iran. Pediatr Nephrol 2004;19:164–8. [17] Jaber L, Eisenstein B, Shohat M. Blood pressure measurements in Israeli Arab children and adolescents. Isr Med Assoc J 2000;2:118–21. [18] Sinaiko AR, Gomez-Marin O, Prineas RJ. Prevalence of significant hypertension in junior high school-aged children: the Children and Adolescent Blood Pressure Program. J Pediatr 1989;114:664–9. [19] Hohn AR, Dwyer KM, Dwyer JH. Blood pressure in youth from four ethnic groups: the Pasadena Prevention Project. J Pediatr 1994;125:368–73. [20] Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendations the maternal and child health bureau, health resources and services administration and the department of health and human services. Pediatrics 1998;102:E29. [21] Falkner B, Daniels SR. Summary of the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Hypertension 2004;44:387–8. [22] Kelishadi R, Ardalan G, Gheiratmand R, Majdzadeh R, Delavari A, Heshmat R, et al. Blood pressure and its influencing factors in a national representative sample of Iranian children and adolescents: the CASPIAN Study. Eur J Cardiovasc Prev Rehabil 2006;13:956–63. [23] Guo Z, Zheng L, Li Y, Sh YU, Liu Sh Zhou X, et al. Association between sleep duration and hypertension among chinese children and adolescents. Clin Cardiol 2011;34:774–8. [24] McNiece KL, Poffenbarger TS, Turner JL, Franco KD, Sorof JM, Portman RJ. Prevalence of hypertension and pre-hypertension among adolescents. J Pediatr 2007;150:640–4. [25] Ujunwa FA, Ikefuna AN, Nwokocha AR, Chinawa JM. Hypertension and prehypertension among adolescents in secondary schools in Enugu, South East Nigeria. Ital J Pediatr 2013;39:1–6. [26] Ghanbarian A, Salehi P, Rezaii Ghale N, Mortazavi N, Azizi F. The Pattern of hypertension in urban population of the adolescents of Tehran: : Tehran Glucose and Lipid Study. Hakim J 2003;3:21–8. [27] McCrindle BW. Assessment and management of hypertension in children and adolescents. Nat Rev Cardiol 2010;7:155–63. [28] Rafraf M, Gargari BP, Safaiyan A. Prevalence of prehypertension and hypertension among adolescent high school girls in Tabriz, Iran. Food Nutr Bull 2010;31:461–5. [29] Kelishadi R, Ardalan G, Gheiratmand R, Majdzadeh R, Hosseini M, Gouya MM, et al. Thinness, overweight and obesity in a national sample of Iranian children and adolescents: CASPIAN Study. Child Care Health Dev 2008;34:44–54. [30] Mousavi A, Hoseini Esfehani F, Safarkhani M, Mirmiran P, Azizi F. Prevalence trends in adolescent overweight and hypertension in the three cross-sectional surveys of tehran lipid and glucose study, 1999–2008. Iran J Endocrinol Metab 2011;12:483–92.
Please cite this article in press as: A.M. Aleali, et al., Prevalence of hypertension and prehypertension in adolescence in Ahvaz, Iran, Diab Met Syndr: Clin Res Rev (2017), http://dx.doi.org/10.1016/j.dsx.2017.04.002
Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal homepage: www.elsevier.com/locate/dsx
Original Article
Prevalence of hypertension and prehypertension in adolescence in Ahvaz, Iran Armaghan Moravej Aleali, Seyed Mahmoud Latifi* , Homeira Rashidi, Seyed Peyman Payami, Azar Sabet Diabetes Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, 61357-15794, Iran
A R T I C L E I N F O
A B S T R A C T
Article history: Available online xxx
Background: High blood pressure is a risk factor for some disease like stroke, coronary heart disease, and renal failure. High blood pressure in children is an increasing health problem. Objectives: The aim of this study was to determine prevalence of hypertension and pre-hypertension age between 10 to 17 years old. Patients and methods: This descriptive analytic study was conducted using multiphase sampling method in Ahvaz (Southwest of Iran). A questionnaire include: height, weight, and body mass index, systolic and diastolic blood pressures filled for each participant. Blood pressure was measured twice for each person. For the diagnosis of hypertension, the fourth report of the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents of the National Health Institute of United States was used. Results: Total participants of the study were 1707children and adolescents including 922 boys (54%) and 785 girls (46%). The prevalence of high blood pressure was 1.7% (2.5% in boys and 0.8%). The prevalence of pre-hypertension was 9%(7.6% in boys, 10.6% in girls). The mean systolic and diastolic blood pressures increased with increasing body mass index. Conclusions: The prevalence of high blood pressure was found to be lower than other studies in our country. The prevalence of the high blood pressure in boys was significantly higher than girls. This study, like other studies showed high correlation between being overweight and an increase in systolic and diastolic blood pressure. © 2017 Diabetes India. Published by Elsevier Ltd. All rights reserved.
Keywords: Hypertension Prehypertension Childhood Adolescence
Implication for health policy/practice/research/medical education High blood pressure in children is an increasing health problem. So this study was conducted to determine prevalence of hypertension and pre-hypertension between children and adolescence in Ahvaz. Prevalence of hypertension and pre-hypertension was 1.7% (2.5% in boys and 0.8% in girls) and 9% (7.6% in boys and 10.6% in girls) respectively. 1. Introduction Hypertension is a physiological parameter that can be a significant risk factor for atherosclerosis and its consequences in the coronary vessels, kidney and the brain vessels. In adults,
* Corresponding author. E-mail address: [email protected] (S.M. Latifi).
hypertension can often be a preliminary phase to some dangerous diseases like stroke, coronary heart disease (CHD), congestive heart failure (CHF), Renal failure (RF). There is a possibility that a major proportion of high blood pressure in adults could be a result of high blood pressure in their childhood [1,2]. Hypertension is responsible for 7 million deaths annually around the world [3]. Hypertension in children is an increasing health problem [4] and high secondary blood pressure is more prevalent in children than in adults [5]. Overweight and obesity are highly correlated with hypertension in children [6–8]. Having a family history of hypertension or coronary heart disease, being male, and smoking during pregnancy are other risk factors [9–11]. Moreover, children who are breast fed have lower risk for hypertension. Children with hypertension have shown evidences of disorder in the target organs including hypertrophy of the left ventricle, and pathology of blood vessel changes [12,13]. Primary hypertension in childhood is also related to other risk factors like hyperlipidemia, and diabetes mellitus for coronary and heart diseases [14,15]. Research conducted on different ethnicities shows differences in prevalence of
http://dx.doi.org/10.1016/j.dsx.2017.04.002 1871-4021/© 2017 Diabetes India. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: A.M. Aleali, et al., Prevalence of hypertension and prehypertension in adolescence in Ahvaz, Iran, Diab Met Syndr: Clin Res Rev (2017), http://dx.doi.org/10.1016/j.dsx.2017.04.002
G Model DSX 756 No. of Pages 4
2
A.M. Aleali et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2017) xxx–xxx
hypertension across these ethnicity groups [16,17]. Based on the results of different studies, the prevalence of hypertension in children was between 1.4 to 11% [3,18,19].
Treatment of High blood Pressure in Children and Adolescents was used as the criterion [21]. 3.1. Ethical issues
2. Objectives Considering the changes in the levels of blood pressure from one population to another, this study was conducted to assess prevalence of hypertension and pre-hypertension on the children and adolescents of Ahvaz age range 10 17 years old.
Since all participants were under 18 years old, written informed consent was obtained from their parents. This study was conducted in accordance with the principles laid down in the declaration of Helsinki. The research was approved by the ethical committee of Ahvaz Jundishapur University of Medical Sciences.
3. Patients and methods
3.2. Data analysis
In this descriptive-analytic study, using multistage cluster sampling, from 25 health centers in Ahvaz (capital city of Khuzestan province, South West of Iran), four centers from East and two centers from West were chosen. For each health center, several families were randomly selected as the head of cluster and in each cluster, 50 subjects in age 10 to 17 years old were chosen. Necessary information was given to the subjects and their parents. In each center, health workers who were properly trained to help in this research project. A questionnaire filled up for each participant included: age, gender, education level, parents’ job, daily activity, smoking, maternal history, birth weight, parent medical history. The height was measured by standard instrument. Waist circumference (WC) was measured with a non-elastic tape at a point midway between the lower border of the ribcage and the iliac crest at the end of normal expiration. Their weight was measured using Seca weighing scales with standard method. Obesity in children was defined by body mass index (BMI), calculated as weight in kilograms (kg) divided by the square of height in meters (m2). BMI above 85 percentile for age and gender were considered overweight and above 95 were considered obese [20]. Systolic and diastolic blood pressure were taken from the right arm at least after 5 minutes of rest in two occasions with a 30 seconds interval in sitting position using a (mechanical) sphygmomanometer and placing the stethoscope under the cuffs specially suited for the children. During the interval, the arms of the children were in the resting position. The average of the result of the measurement was recorded as the blood pressure of the individual. For the recording of the blood pressure, the sounds of korotkoff in the first and fifth phase was listened to preferably by the bell part of the stethoscope and the values of the blood pressure in korotkoff's first phase was recorded in the form as the systolic blood pressure and the fifth phase as the diastolic blood pressure. In children and adolescents, the normal blood pressure varies according to the size of the body and the age. As a result, the standards based on gender, age and height provide a better criterion of the classification of blood pressure in proportion to the body size. In this study the fourth report of the National Health institute of the United States on the Diagnosis, Evaluation, and
Data were analyzed using the SPSS software (Statistical Package for the Social Sciences, version 18.0, SPSS Inc, Chicago, Ill, USA). We used t-test and analysis of variance (ANOVA) for comparison of means, chi-square for variables relation and Binary logistic for compute odds ratio (O.R). P- Value less than 0.05 was considered significant. 4. Results In this study, 1707 children and adolescents age from 10 to 17 years old evaluated. They lived in Ahvaz and included 922 boys (54%) and 785 girls (46%). 8. 7% [95%C.I. (7.4–10)] of the adolescents were overweight and 3.6% [95%C.I. (2.8–4.4)] of them were obese. Gender-wise, 7%of the boys and 10.7%of the girls were overweight. 2.3% of boys and 5.2% of girls were obese. Table 1 shows mean of BMI, systolic and diastolic blood pressure according to age and sex. Mean BMI in girls is higher than boys significantly (P 0.002). Mean systolic and diastolic blood pressure in varying weight group shows that there is significant different between them (P = 0.0001) (Table 2). Table 3 shows comparison of hypertension and pre-hypertension between to genders. According to Table 4, Model 1 shows being male increased risk of hypertension 3.5 times more than female. Also, being overweight increased risk of hypertension 2.8 times more than normal people. In model 2 increasing height, decreases the risk of having hypertension, while the risk of hypertension in male was 4.8 times more than female. 5. Discussion This study was conducted on 1707 children and adolescents 10 to 17 years of age in Ahvaz. 1.7% of participants were diagnosed with hypertension and 9% with prehypertension. In a study carried out by Kelishadi and et al. on a representative sample of 23 provinces in Iran, with age group 6 to 18 years, prevalence of hypertension was 4.2% [22] and in another study by Ataei and et al. On Tehran adolescents aged 13 to 18 years, was reported 4.7% (2.9%
Table 1 The comparison of mean systolic and diastolic blood pressures and BMI with age and sex. Age
Sex
n (%)
BMI Mean SD
DBP(mm/hg) Mean SD
SBP (mm/hg) Mean SD
10–14
Boys Girls
505(54.2) 426(45.8)
Boys Girls
417(53.7) 359(46.3)
Total
1707(100)
18.34 3.3 19.1 3.9 0.001 20.86 5.2 21.7 3.9 0.002 19.8 4.3
62.2 9.5 63.2 9.1 0.11 66.2 9.7 65.7 8.9 0.47 64.1 9.5
103.3 10 103.4 10.2 0.95 109.2 11 108 9.6 0.42 106 10.8
P Value 15–17 P Value 10–17
DBP: Diastolic blood pressure (mm/hg) SBP: Systolic blood pressure(mm/hg).
Please cite this article in press as: A.M. Aleali, et al., Prevalence of hypertension and prehypertension in adolescence in Ahvaz, Iran, Diab Met Syndr: Clin Res Rev (2017), http://dx.doi.org/10.1016/j.dsx.2017.04.002
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Table 2 Comparison of mean systolic and diastolic blood pressure in normal, overweight and obese subjects. Age
Blood Pressure
BMI 85(kg/m2) Normal
85 < BMI95(kg/m2) overweight
BMI > 95(kg/m2) obese
P Value
10–14
SBP DBP SBP DBP SBP DBP
103 10 62.3 9.3 108 10.4 65.7 9.4 105.28 10.5 63.7 9.5
108.4 9.6 67.5 8.7 110.1 10.6 66.6 9.3 110.13 10.3 66.9 9.1
109 8.5 67.5 8.5 111.6 9.1 68.8 8.5 110.8 8.9 68.38 8.4
0.0001 0.0001 0.018 0.09 0.0001 0.0001
15–17 10–17
Table 3 Comparison of hypertension and pre-hypertension between to genders. Age
Sex
Hypertension (%)
Pre-hypertension (%)
10–14
Male Female P-value Male Female P-value Male Female P-value
7.9 10.1 P = 0.24 7.2 11.1 P = 0.056 7.6 10.6 P = 0.03
2.6 0.9 P = 0.06 2.4 0.6 P = 0.03 2.5 0.8 P = 0.006
15–17
10–17
Table 4 Binary logistic equations with the age, gender and BMI variables or height and weight. Model 1 Variable Sex (Boys/Girls) Age(year) (15–17/10–14) BMI(Percentile)* (kg/m2) (85–95/ 85) BMI(percential)(kg/m2) (95/ 85) Model 2 Sex (Boys/Girls) Age(year) (15–17/10–14) Weight(kg) Height(cm)
P-Value 0.006 0.44
O.R. 3.5 0.74
95% C.I.(O.R.) 1.43–8.84 0.34–1.6
0.047
2.8
1.01–7.78
0.7
1.47
0.19–11.37
0.001 0.31
4.8 1.93
1.85–12.45 0.68–5.45
0.22 0.002
1.02 0.93
0.98–1.06 0.89–0.97
BMI 85(kg/m2): Normal weigh. 85 < BMI 95(kg/m2): Overweigh. BMI > 95(kg/m2): Obese.
and 3.4%, systolic and diastolic respectively) [2]. Prevalence of prehypertension and hypertension in Chinese children and adolescents were reported 15% and 20.2% [23], in Houston adolescents aged 11 to 17 years, were 9.5% and 9.4% [24] and in Enugu adolescents aged 10 to 18 years in south-east Nigeria were 17.3% and 5.4% respectively [25]. Based on this study results, prevalence of hypertension in Ahvaz is much lower than other studies and 2.5% for boys and 0.8% for girls and significantly higher for boys. Prevalence of prehypertension is consistent only with results of Houston study in America [24]. In study conducted on glucose and lipid in Tehran (TLGS, phase 1), hypertension and prehypertension rates were found 10.6% and 12.3% respectively [26] which show a higher prevalence in both sexes and in addition, higher prevalence in girls than boys contrary to the results of Ahvaz study. There was no statistically significant differences in prevalence of hypertension in both sexes according to Kelishadi and Ataei investigations but In model 1 and model 2 presented in Table 4, male sex increases the risk of hypertension more than 3.5 and 4.8 times respectively. Based on this research, 1.6% of children and adolescents were diagnosed with high systolic blood pressure and
1.3% with high diastolic blood pressure. Also, prevalence of prehypertension was 7.6% for boys and 10.6% for girls and was lower compared to study of glucose and lipid that reported 12.3% and 12.9% prehypertension for boys and girls of Tehran (with statistically significant differences, p = 0.02). These rates were 15.7% and 14.2% for Chinese boys and girls [23] that indicate higher prevalence in both sexes compared to Ahvaz but contrary to Ahvaz, boys had higher rates of prehypertension. Three cross sectional American studies, called national hygienic and nutritional assessment, also showed higher prevalence of prehypertension for boys [27]. Hypertension and prehypertension among Tabriz high school girls have been reported 19.4 and 13.9% respectively [28] that represent higher prevalence than girls in Ahvaz. These observed differences between results of studies may be due to various types of methodology, differences in prehypertension and hypertension detection ranges and finally environmental and quality of life levels. Systolic blood pressure mean in Ahvaz was 106 10.8 and furthermore in accord with initial phase of glucose and lipid study in Tehran (105 11.7) and a study in Nigeria (106.6 11.8) but diastolic blood pressure was obtained 64.1 9.5 and lower than initial phase of study in Tehran (71.4 9.2) and Nigeria (70.25 7.3). In this survey carried out on children and adolescents, 8.7% of samples had overweight and 3.6% were obese. These results were consistent with findings from Klishadi et al. study that has reported 8.82% and 4.5% overweight and obesity based on CDC (Centers for Disease Control) [29]. In addition, mean systolic and diastolic blood pressure in three categories of BMI, were significantly different (P = 0.0001). In the age group 10 to 14, this difference was significant and in the age group 15 to 17 for systolic blood pressure was significant too (P = 0.018) but in diastolic blood pressure there was not found a significant difference (P = 0.09) (Table 3). Morever, glucose and lipid study in Tehran (TLGS, phase 1), has reported mean diastolic blood pressure in three categories of BMI such as present study [30].
6. Conclusion This study like many similar studies showed a strong positive correlation between overweight and increasing in systolic and diastolic blood pressures. The prevalence of hypertension in Ahvaz was lower than other studies in Iran. Prevalence of hypertension was higher in boys than girls significantly. But prevalence of prehypertension was higher in girls than boys.
Authors’ contribution S.M. Latifi analyzed and wrote manuscript draft. Moravej Aleali A. has done searches data collection, edited and submitted manuscript. H. Rashidi designed and supervised study and edited final draft. Sabet. A translated paper to english. All authors read and approved the final manuscript. Thanks to all authors A. sabet for their support and help in this study.
Please cite this article in press as: A.M. Aleali, et al., Prevalence of hypertension and prehypertension in adolescence in Ahvaz, Iran, Diab Met Syndr: Clin Res Rev (2017), http://dx.doi.org/10.1016/j.dsx.2017.04.002
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Limitations of the study We measured blood pressure twice in single visit. But if we took blood pressure in two different visits and recorded mean of them, more precise estimate of blood pressure level would be obtained. Funding/support Financial support was provided by Vice Chancellor for Research, Ahvaz Jundishapur University of Medical Sciences Ethical considerations Ethical issues (including plagiarism, data fabrication, double publication) have been completely observed by the authors. Conflicts of interest The authors declared no competing interests. Acknowledgement This paper is issued from the research project that registered ((Reg. No. D-8703) in Health Research Institute, Diabetes Research Center, Ahvaz Jundishapur University of Medical Sciences. The authors would like to thank all staffs of diabetes research center, especially Miss Reshadatian, Dehghan and Hardani for their help in this study and also Mr. Sh. Hosseinzadeh for his help in English writing. References [1] Lauer RM, Clarke WR, Beaglehole R. Level, trend, and variability of blood pressure during childhood: the Muscatine study. Circulation 1984;69:242–9. [2] -Ataei N, Aghamohammadi A, Ziaee V, Hosseini M, Dehsara F, Rezanejad A. Prevalence of Hypertension in Junior and Senior High Hypertension in Junior and Senior HighSchool Children in Iran. Iran J Pediatr 2007;17:237–42. [3] Chiolero A, Bovet P, Paradis G, Paccaud F. Has blood pressure increased in children in response to the obesity epidemic. Pediatrics 2007;119:544–53. [4] Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA 2007;298:874–9. [5] National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004;114:555–76. [6] Din-Dzietham R, Liu Y, Bielo MV, Shamsa F. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation 2007;116:1488–96. [7] Falkner B, Gidding SS, Ramirez-Garnica G, Wiltrout SA, West D, Rappaport EB. The relationship of body mass index and blood pressure in primary care pediatric patients. J Pediatr 2006;148:195–200. [8] Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics 2004;113:475–82. [9] Dasgupta K, O'Loughlin J, Chen S, Karp I, Paradis G, Tremblay J. Emergence of sex differences in prevalence of high systolic blood pressure: analysis of a longitudinal adolescent cohort. Circulation 2006;114:2663–70.
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Please cite this article in press as: A.M. Aleali, et al., Prevalence of hypertension and prehypertension in adolescence in Ahvaz, Iran, Diab Met Syndr: Clin Res Rev (2017), http://dx.doi.org/10.1016/j.dsx.2017.04.002