Prevalence of hypertension among
adolescents
Pranam G M1 , Usha Pranam
G2, Manjunath G A3
1Dr Pranam GM, Assistant Professor, 2Dr Usha Pranam, Assistant
Professor, 3Dr Manjunath G A, Professor, All are affiliated
with are Department of Pediatrics, Navodaya Medical College,
Raichur, Karnataka, India
Address of correspondence:
Dr Usha Pranam, c/o Dr G A Manjunath, H.No 5, Bheemaraya Colony,
Yeramarus Camp, Raichur, Email id : drushagowdar@rediffmail.com
Abstract
Introduction:
Adolescence is a significant period of growth and maturation. The
emergence of obesity and its sequel as public health problems has
renewed interest in the adolescents as Overweight and obesity act as
risk factors for obesity related diseases. Familial aggregation of
blood pressure is noted among adults, which has been traced to
childhood, as early as one year of age. Methods: a cross
sectional study involving 1000 boys and girls each were subjected to
measurement of anthropometry, blood pressure and BMI. Results: The
Incidence of Raised Blood Pressure in our study was 1.3%. The mean
systolic blood pressure in boys increased from
102.75±3.24mmHg at 12years of age to 105.85±3.58
mmHg at 16years. In girls it rises from 102.04±2.53mmHg at
12 years to 106.48±3.59 mmHg at 16 years. The mean diastolic
blood pressure increased from 66.85±3.45 mmHg at 12years of
age to 67.95±4.24 mmHg at 16years, in boys. In girls it
rises from 66.90±3.38mmHg at 12years to
68.95±4.53 mmHg at 16years. Blood pressure recordings showed
an increasing trend steadily with age in the present study. Conclusion: There is
a strong correlation between systolic blood pressure and weight and
height in both sexes. Majority of the children who were labeled as
hypertensive’s are likely to be suffering from essential
hypertension, because of the asymptomatic nature of their condition.
Hence the adolescent period the most precious stage for early detection
and primary prevention on hypertension.
Keywords: Mean
Blood Pressure, Hypertension. Adolescents, BMI
Manuscript received:
24th Oct 2015, Reviewed: 4th
Nov 2015
Author Corrected:
15th Nov 2015, Accepted
for Publication: 23th Nov 2015
Introduction
Adolescence is a significant period of growth and maturation, unique
changes occur and many adult patterns are established during this
period. Proximity to biological maturity may provide final
opportunities for preventing health problems [1]. It has often failed
to receive the attention given to earlier periods in childhood with
regards to health related issues and interpretation of anthropometry
[2]. Most nutrition research in the developing world focused on
under-nutrition in under-five children. Studies [3, 4] have shown that
many of the developing countries including India are facing the dual
burden of under-nutrition and over-nutrition. Data from National Family
Health Survey 2 (NFHS 2) [5] has identified that significant proportion
of over-weight coexists with high rates of malnutrition, pointing that
the nutrition transition is underway in India. The emergence of obesity
and its sequel as public health problems has renewed interest in the
adolescent anthropometry. Overweight and obesity during this period are
associated with risk factors for obesity related diseases [6, 7]. The
WHO Expert Committee [8] has recommended that measures of height and
weight provide useful source of data for assessment of growth status of
adolescents.
The prevalence of hypertension, and its associated complications has
reached such an enormous proportion, that World Health Organization has
recognized it and expressed its concern about it by observing the year
1978 with the slogan “Down with Blood Pressure”. In
the past decade, many workers have confirmed that familial aggregation
of blood pressure occurs among adults, and such an aggregation, has
been traced to childhood, as early as one year of age and there is some
evidence to believe that such an aggregation begins somewhere between
first week and first month of life [9].
Although the natural history of essential hypertension, in the young is
not clear, there is not great reason to be optimistic that it is
significantly better than in adults. One of the challenges, therefore,
is to try to develop means for identifying youngsters at high risk for
later sustained hypertension and to prevent it [10].
Essential hypertension, a major risk factor for cardiovascular disease
is prevalent in the adult population. A prevalence of 18% has been
reported from Iran. Blood pressure in children is a reliable predictor
of adult blood pressure level, therefore it is important to identify
children and adolescence who are at increased risk of developing
essential hypertension as adults.
Hurst, in his textbook ‘The Heart’, says that the
diagnosis of hypertension in pediatric patients is truly population
based, since 5% of children with highest blood pressure are diagnosed
with “significant hypertension” and highest 1% are
deemed eligible for pharmacological treatment [11].
Obviously this is a job to be taken up by the pediatricians. It is
being increasingly recognized that essential hypertension in adult does
not appear suddenly beyond the age of 30 years. Children with upper
percentile of blood pressure levels are more likely to become adult
hypertensive. If the trend towards adult hypertension can be recognized
in childhood, it may be possible to alter life style and prevent
systemic hypertension as well as related complications [12].
Ideally hypertension or tendency for hypertension should be detected as
early in life as possible. According to Nelson, to increase early
detection of hypertension, accurate blood pressure measurements should
be part of the routine annual physical, examination of all children,
three years or older [13].
However it is not possible to record reliable blood pressures by
conventional methods in children below 6-7 years of age [14]. Hence the
ideal age, would be between 6-15 years, i.e. school children. This
recognition has made the medical workers and authorities in Western
countries to include routine blood pressure measurements in school
health programmes and in regular office practice. NIH Task force of USA
has even recommended that blood pressure measurements along with weight
and height should be recorded in children, at least once a year
[15,16], But even today in many parts of the world including India,
this practice has not been implemented due to unknown reasons.
The present study was conducted in Raichur both rural and urban area to
evaluate the anthropometric profile and blood pressure in apparently
healthy children of 12-16 years of age group.
Materials
and Methods
The study group comprised of 1000 boys and girls each of ages between
12 to 16 years. Informed consent was obtained from the guardian and a
detailed questionnaire was filled. All the subjects underwent
measurement of height, weight, four skin fold thickness and Blood
pressure, from which the BMI and body fat composition was calculated.
BMI was calculated by the standard formula.
The data thus collected was tabulated according to various
epidemiological parameters. The mean values and standard deviation of
all Anthropometric parameters were calculated. T-test, unpaired, was
used to find the difference between the mean values among boys and
girls concerned with systolic blood pressure, diastolic blood pressure,
height and weight. The Pearson’s or product moment
correlation coefficients (r) were calculated between weight and
systolic blood pressure, weight and diastolic blood pressure, height
and systolic blood pressure, height and diastolic blood pressure both
for boys and girls along with correlation between skin fold thickness
in relation to body mass index in various socioecomic groups for both
boys and girls.
Results
and Analysis
In our study the mean systolic blood pressure in the present study
reveals that mean systolic blood pressure in boys increased from 102.75
± 3.24 mm Hg at 12 years of age to 105.85 ± 3.58
mm Hg at 16 years (table no. 1). In girls mean systolic blood pressure
increased from 102.04 ± 2.53 mm Hg at 12 years to 106.48
± 3.59 mm Hg at 16 years (table no. 2). The mean diastolic
blood pressure increased from 66.85 ± 3.45 mm Hg at 12 years
of age to 67.95 ± 4.24 mm Hg at 16 years, in boys (table no.
3). In girls the mean diastolic blood pressure increased from 66.90
± 3.38 mm Hg at 12 years to 68.95 ± 4.53 mm Hg at
16 years (table no. 4). Blood pressure recordings showed an increasing
trend steadily with age in the present study. The mean blood pressure
when correlated between the boys group and girls there was no
statistically significant difference in the mean systolic as well as
diastolic pressure between the two sexes (Table no.5).
Table No 1: Observation
of Systolic Blood Pressure in Boys
|
Age
in years
|
N
|
Mean
± SD (mm Hg)
|
Percentiles
(mm Hg)
|
Range
|
|
5th
|
10th
|
25th
|
50th
|
75th
|
90th
|
95th
|
Min-Max (mm Hg)
|
|
12
|
200
|
102.75 ± 3.24
|
101
|
102
|
104
|
106
|
108
|
109
|
110
|
98 – 106
|
|
13
|
200
|
103.81 ± 2.31
|
104
|
105
|
106
|
108
|
110
|
111
|
112
|
100 – 114
|
|
14
|
200
|
104.93 ± 3.31
|
106
|
107
|
109
|
111
|
113
|
114
|
115
|
100 – 116
|
|
15
|
200
|
105.82 ± 3.19
|
109
|
110
|
112
|
113
|
115
|
117
|
117
|
100 – 118
|
|
16
|
200
|
105.85 ± 3.58
|
111
|
112
|
114
|
116
|
118
|
119
|
120
|
100 – 120
|
Table No. 2: Observation
of Systolic Blood Pressure in Girls
|
Age
in years
|
N
|
Mean
± SD (mm Hg)
|
Percentiles
(mm Hg)
|
Range
|
|
5th
|
10th
|
25th
|
50th
|
75th
|
90th
|
95th
|
Min-Max (mm Hg)
|
|
12
|
200
|
102.04
± 2.53
|
102
|
103
|
104
|
105
|
107
|
108
|
109
|
98
– 108
|
|
13
|
200
|
104.72
± 3.40
|
104
|
105
|
106
|
107
|
109
|
110
|
110
|
100
– 110
|
|
14
|
200
|
104.98
± 2.96
|
106
|
106
|
107
|
109
|
110
|
111
|
112
|
100
– 114
|
|
15
|
200
|
105.75
± 3.37
|
107
|
108
|
109
|
110
|
111
|
113
|
113
|
100
– 116
|
|
16
|
200
|
106.48
± 3.59
|
108
|
108
|
110
|
111
|
112
|
114
|
114
|
100
– 120
|
Table No. 3: Observation
of Diastolic Blood Pressure in Boys
|
Age
in years
|
n
|
Mean
± SD (mm Hg)
|
Percentiles
(mm Hg)
|
Range
|
|
5th
|
10th
|
25th
|
50th
|
75th
|
90th
|
95th
|
Min-Max (mm Hg)
|
|
12
|
200
|
66.85
± 3.45
|
64
|
64
|
66
|
68
|
70
|
72
|
74
|
62
– 72
|
|
13
|
200
|
67.05 ± 3.45
|
65
|
65
|
66
|
68
|
70
|
72
|
75
|
60 – 74
|
|
14
|
200
|
67.49 ± 4.42
|
65
|
66
|
67
|
69
|
71
|
73
|
76
|
56 – 78
|
|
15
|
200
|
67.54 ± 4.51
|
66
|
67
|
68
|
69
|
71
|
74
|
78
|
60 – 78
|
|
16
|
200
|
67.95 ± 4.24
|
68
|
69
|
70
|
72
|
74
|
77
|
79
|
62 – 78
|
Table No. 4: Observation
of Diastolic Blood Pressure in Girls
|
Age
in years
|
n
|
Mean
± SD (mm Hg)
|
Percentiles
(mm Hg)
|
Range
|
|
5th
|
10th
|
25th
|
50th
|
75th
|
90th
|
95th
|
Min-Max (mm Hg)
|
|
12
|
200
|
66.90
± 3.38
|
62
|
62
|
66
|
68
|
70
|
72
|
74
|
60
– 74
|
|
13
|
200
|
67.91
± 4.22
|
64
|
64
|
66
|
69
|
71
|
73
|
75
|
60
– 80
|
|
14
|
200
|
68.01
± 4.42
|
66
|
68
|
70
|
72
|
74
|
76
|
78
|
60
– 78
|
|
15
|
200
|
68.82
± 4.44
|
68
|
69
|
71
|
73
|
75
|
77
|
80
|
62
– 78
|
|
16
|
200
|
68.95
± 4.53
|
68
|
70
|
72
|
74
|
76
|
78
|
81
|
58
– 78
|
Table No. 5: Comparison
of Systolic blood pressure between boys and girls
|
Age
in years
|
Systolic
Pressure
|
Diastolic
pressure
|
|
Boys
Mean ± SD (mm Hg)
|
Girls
Mean ± SD (mm Hg)
|
Test
|
Inference
|
Boys
Mean ± SD (mm Hg)
|
Girls
Mean ± SD (mm Hg)
|
Test
|
Inference
|
|
12
|
102.75
± 3.24
|
102.04
± 2.53
|
1.21
|
P > 0.05
|
66.85
± 3.45
|
66.90
± 3.38
|
0.41
|
P > 0.05
|
|
13
|
103.81
± 2.31
|
104.72
± 3.40
|
1.03
|
P > 0.05
|
67.05
± 3.45
|
67.91
± 4.22
|
1.05
|
P > 0.05
|
|
14
|
104.93
± 3.31
|
104.98
± 2.96
|
0.67
|
P > 0.05
|
67.49
± 4.42
|
68.01
± 4.42
|
0.46
|
P > 0.05
|
|
15
|
105.82
± 3.19
|
105.75
± 3.37
|
0.74
|
P > 0.05
|
67.54
± 4.51
|
68.82
± 4.44
|
0.41
|
P > 0.05
|
|
16
|
105.85
± 3.58
|
106.48
± 3.59
|
0.29
|
P > 0.05
|
67.95
± 4.24
|
68.95
± 4.53
|
1.13
|
P > 0.05
|
Analysis of blood pressure based on weight criteria revealed that the
mean systolic pressure in boys steadily increased from 104.8 mm Hg in
16-20 kg weight group to 105.6 mm Hg in 36-40 kg weight group. The mean
systolic blood pressure in girls increased steadily from 103 mm Hg in
16-20 kg weight group to 105.6 mm Hg in 36-40 kg weight group. The mean
diastolic blood pressure in boys steadily increased from 67.2 mm Hg in
16-20 kg weight group, to 67.5 mm Hg in 36-40 kg weight group. The mean
diastolic blood pressure in girls steadily increased from 66.2 mm Hg in
16-20kg weight group, to 69.1 mm Hg in 36-40 kg weight group. The
increase in mean systolic and diastolic blood pressure in both sexes in
relation to weight was steady (Table no.6).
Table No. 6: Distribution
of blood pressure according to weight
|
Weight
(kgs)
|
Boys
|
Girls
|
|
N
|
Systolic BP (mmHg)
|
Diastolic BP (mm Hg)
|
N
|
Systolic BP
(mm Hg)
|
Diastolic BP
(mm Hg)
|
|
|
|
Mean
|
SD
|
Mean
|
SD
|
|
Mean
|
SD
|
Mean
|
SD
|
|
16-20
|
40
|
104.8
|
6.3
|
67.2
|
3.4
|
12
|
103
|
2.9
|
66.2
|
4.5
|
|
21-25
|
121
|
104.7
|
7.2
|
66.9
|
4.1
|
106
|
104.5
|
2.8
|
66.9
|
3.6
|
|
26-30
|
203
|
104.2
|
4.5
|
66.9
|
4.0
|
242
|
104.5
|
3.0
|
67.5
|
3.9
|
|
31-35
|
373
|
105.2
|
4.0
|
67.7
|
4.1
|
367
|
105.6
|
3.4
|
67.6
|
4.5
|
|
36-40
|
263
|
105.6
|
3.7
|
67.5
|
4.4
|
273
|
105.6
|
3.5
|
69.1
|
4.5
|
Analysis of blood pressure based on Height criteria revealed the mean
systolic pressure in boys steadily increased from 103.08 mm Hg in
121-130cm height group to 106.05 mm Hg in 161-170cm height group. The
mean systolic blood pressure in girls increased steadily from 104.16 mm
Hg in 121-130cm height group to 105.96 mm Hg in 161-170cm height group.
The mean diastolic blood pressure in boys steadily increased from 66.06
mm Hg in 121-130cm height group, to 67.43 mm Hg in 161-17cm height
group. The mean diastolic blood pressure in girls steadily increased
from 66.79 mm Hg in 121-130cm height group, to 67.97 mm Hg in 161-170
cm height groups. The increase in mean systolic and diastolic blood
pressure in both sexes in relation to weight was steady (Table no. 7).
Table No. 7 Distribution
of blood pressure according to Height
|
Height
(in cms)
|
Boys
|
Girls
|
|
N
|
Systolic BP (mmHg)
|
Diastolic BP (mm Hg)
|
n
|
Systolic BP (mm Hg)
|
Diastolic BP (mm Hg)
|
|
|
|
Mean
|
SD
|
Mean
|
SD
|
|
Mean
|
SD
|
Mean
|
SD
|
|
101-110
|
2
|
115
|
24
|
66
|
-
|
-
|
-
|
-
|
-
|
-
|
|
111-120
|
3
|
100.7
|
2.31
|
70
|
3.46
|
-
|
-
|
-
|
-
|
-
|
|
121-130
|
36
|
103.08
|
6.69
|
66.06
|
5.31
|
98
|
104.16
|
2.64
|
66.79
|
3.37
|
|
131-140
|
142
|
104.90
|
8.33
|
66.75
|
3.73
|
102
|
103.87
|
2.41
|
67.0
|
3.41
|
|
141-150
|
180
|
104.32
|
3.76
|
67.05
|
3.70
|
214
|
104.88
|
3.27
|
67.99
|
4.51
|
|
151-160
|
453
|
105.08
|
3.13
|
67.61
|
4.13
|
402
|
105.59
|
3.7
|
67.71
|
4.42
|
|
161-170
|
184
|
106.05
|
3.57
|
67.43
|
4.49
|
184
|
105.96
|
3.37
|
67.97
|
4.41
|
Correlation of Body Mass Index (BMI) with reference to Skin folds
thickness measured values at biceps, triceps, subscapularis and
suprailiac showed a significant negative correlation as shown in Table
No.8
Table No. 8: Correlation
of BMI with reference to Skin folds thickness
|
Skin
fold thickness
|
BMI
|
Inference
|
|
Biceps
|
-0.135
|
P < 0.05
|
|
Triceps
|
-0.135
|
P < 0.05
|
|
Subscapularis
|
-0.140
|
P < 0.05
|
|
Suprailiac
|
-0.140
|
P < 0.05
|
The Incidence of Raised Blood Pressure in Boys and Girls in our study
was 1.3%. We observed 26 subjects with blood pressure more than 95th
percentile of blood pressure but not more than 99th percentile of which
14(1.4%) were boys and 12(1.2%) were girls.
Discussion
In all the studies in India and abroad it has been shown that blood
pressure, both systolic and diastolic, gradually increases with age,
The findings of the present study regarding mean systolic and mean
diastolic pressure are comparable with findings of the study conducted
by N.K. Anand and Lalit Tandon [17]. Their findings (systolic blood
pressure) of 110 mm Hg at 12 years and 117 mm Hg at 16 years for boys
and 110 mm Hg at 12 years and 118 mm Hg at 16 years for girls are close
to the findings of the present study. Similarly mean diastolic
pressures for both boys and girls in the present study and study
conducted by N.K. Anand and Lalit Tandon are comparable [17].
The gradual increase in systolic blood pressure observed in the present
study between 12 -16 years in both sexes has been supported by other
researchers who observed similar rise in systolic blood pressure in
both sexes between 12 to 16 years of age [18]. The gradual increase in
the blood pressure along with increase in age can be explained by the
fact that, the body mass also increases, which is one of the
determinants of blood pressure, along with age. The systolic spurt
observed in the present study can be accounted by the onset of puberty
in both sexes, which results in increase of body weight and height, as
a result of increase in muscular tissue in boys and deposition of
adipose tissue in girls, which begins around 11 to 12 years and reaches
peak levels by 14-15 years of age. The observations of mean diastolic
pressure in the present study resemble those of the study conducted by
N.K. Anand and Lalit Tandon [17]. In the present study it ranged from
56 mm Hg to 78 mm of Hg from 12 to 16 years in boys whereas from 58 to
78 mm of Hg from 12 to 16 years in girls. In the study conducted by
N.K. Anand and Lalit Tandon it ranged from 73 mm Hg at 12 years and 77
mm Hg at 16 years in boys and 73 mm Hg at 12 years and 77mm Hg at 16
years in girls. All the above studies, including present study show, an
approximate increase of diastolic blood pressure by 1 mm Hg per year of
age.
It can be observed from the tables mentioned in above discussion, that
the blood pressure levels in the present study were considerably lower,
both systolic and diastolic pressures, in either sex than the findings
in other Indian studies. Even in the Western studies similar
differences have been observed, the difference between NIH Task Force
readings and Bogalusa heart study being 10-15 mm Hg, with considerably
higher level reported in the NIH report [19, 20]. These marked
differences are very likely related to methodology, even though the
observations are on different populations.
The mean systolic and mean diastolic blood pressures increase steadily
and proportionately with weight. This finding is in agreement with that
of Agarwal VK et al who found that both systolic and diastolic blood
pressures increased with increase in weight [18]. Rakesh Agarwal, et al
observed that blood pressure is directly proportional to the ratio of
weight/height (kg/cm) [21]. Sachdev [22] found direct correlation
between blood pressure and body weight and Londe found that systolic
pressure is related to weight, but not diastolic pressure in either
sex. In the Bogalusa heart study, a close relationship (linear
relationship) was found between the log of the body weight and blood
pressure [19,20]. The mean systolic and mean diastolic blood pressures
observed in the present study are lower than that of V.K. Agarwal et al
in the comparable weight group [18]. This difference suggests that
factors other than body weight, such as height, dietary habits,
physical activities, geographical locality may be playing a role in the
determination of blood pressure.
The mean systolic blood pressure and mean diastolic blood pressure were
found to increase with increase in the body height in both sexes. D.
Laroia et al noted similar correlation between height and systolic and
diastolic blood pressures in both sexes in the study conducted in 1989
[23]. In contrast to our study V.K. Agarwal et al did not find any
correlation between systolic and diastolic blood pressure with height
[18, 22].
Londe after similar analysis came to conclusion that systolic pressure
is probably related to weight, but not to the height in both sexes and
the diastolic pressure is not related to either weight or height [24].
Berenson comments that in youth, blood pressure levels vary
considerably with height and weight and when children are grouped by
body weight and height the usual positive correlation with age is
lacking [25].
Voors et al. observed that after adjusting for effects of height and
weight on blood pressure levels, age appears to have no relationship to
levels. He also comments that approximately 40% of variability of blood
pressure level seems to be explained by a combination of factors such
as height, weight, triceps skin fold thickness, or arm circumference
[20]. The findings of the present study are in agreement with the
statement that height and weight are the strongest determinants of
blood pressure.
Prevalence of Hypertension: In the present study the prevalence of
hypertension was found to be 1.3% (95thpercentile for age and sex was
cut-off point).Other workers reported a wide range of figures.
Percentage prevalence of hypertension as reported by various workers
Anand N.K. and Lalit Tandon (1996) [17]
0.46%
Agarwal V.K., Rajiv Sharan, Shrivastava AK and Pandey CM (1983)
[18] 1.8%
Rakesh Agarwal, SL Mandowara, B. Bhandari and Garg OP (1982)
[21] 2.6%
Sachdev (1984) [22] 0.54%
Laroia, M Sharma, V. Diwedi, KM Belapurkar and PS Mathur (1989)
[23] 2.93%
Londe (1971) [26] 2.3%
Present study 1.3%
The true incidence of hypertension among children and young adolescents
remains unclear. Some workers consider a child as hypertensive if
his/her blood pressure is more than two standard deviations above the
mean for his/her age on one or more occasions [27]. Various authors
have claimed that 1-11.5% of children will have mild elevation of blood
pressure [28]. But the true incidence lies between 1 to 3% [29]. The
vast majority of these children will have mild elevation of blood
pressure and labeled as essential hypertensive’s [30]. The
observation of the present study are in agreement with the above
statement as all the 26 children who were labeled as raised blood
pressure had only mildly elevated blood pressure and none had severe
elevation of blood pressure (> 99thpercentile). The prevalence
of hypertension in the present study (1.3%) was comparable to most of
the studies conducted in India and abroad.
Conclusion
Blood pressure, both systolic and diastolic gradually increases with
age, the increase being more pronounced in systolic blood pressure than
in diastolic blood pressure. There is no significant difference in
blood pressures of the two sexes. There is a strong correlation between
systolic blood pressure and weight and systolic blood pressure and
height in both sexes. The prevalence of hypertension in the present
study is within the range reported by various workers in the field, in
India and abroad. Majority of the children who were labeled as
hypertensive’s are likely to be suffering from essential
hypertension, because of the asymptomatic nature of their condition.
Funding:
Nil, Conflict of
interest: Nil
Permission from IRB:
Yes
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How to cite this article?
Pranam GM, Usha Pranam G, Manjunath GA. Prevalence of hypertension
among adolescents. Pediatr Rev: Int J Pediatr Res
2015;2(4):191-198.doi:10.17511/ijpr.2015.4.029.