Published online March 1, 2007
PEDIATRICS Vol. 119 No. 3 March 2007, pp. 544-553 (doi:10.1542/peds.2006-2136)
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REVIEW ARTICLE

Has Blood Pressure Increased in Children in Response to the Obesity Epidemic?

Arnaud Chiolero, MD, MSca, Pascal Bovet, MD, MPHa, Gilles Paradis, MD, MScb and Fred Paccaud, MD, MSca

a Community Prevention Unit, Institute of Social and Preventive Medicine, University of Lausanne, Lausanne, Switzerland
b Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada


   ABSTRACT
TOP
 ABSTRACT
METHODOLOGIC ISSUES
 ELEVATED BP IN CHILDREN...
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
The associations between elevated blood pressure and overweight, on one hand, and the increasing prevalence over time of pediatric overweight, on the other hand, suggest that the prevalence of elevated blood pressure could have increased in children over the last few decades. In this article we review the epidemiologic evidence available on the prevalence of elevated blood pressure in children and trends over time. On the basis of the few large population-based surveys available, the prevalence of elevated blood pressure is fairly high in several populations, whereas there is little direct evidence that blood pressure has increased during the past few decades despite the concomitant epidemic of pediatric overweight. However, a definite conclusion cannot be drawn yet because of the paucity of epidemiologic studies that have assessed blood pressure trends in the same populations and the lack of standardized methods used for the measurement of blood pressure and the definition of elevated blood pressure in children. Additional studies should examine if favorable secular trends in other determinants of blood pressure (eg, dietary factors, birth weight, etc) may have attenuated the apparently limited impact of the epidemic of overweight on blood pressure in children.

Key Words: blood pressure • hypertension • obesity • trends • epidemiology

Abbreviations: BP—blood pressure • CVD—cardiovascular disease • NHANES—National Health and Nutrition Examination Survey

Elevated blood pressure (BP) is one of the leading contributors to the global disease burden worldwide and accounts for 7 million deaths each year.1,2 Several causes of hypertension operate early in life.3–5 In particular, BP relates, in children as in adults, to body weight,6 dietary factors,7 physical activity,8 and birth weight.9

Until recently, hypertension was considered to be a rare condition in children.10 However, because the worldwide prevalence of pediatric overweight has increased largely over the last 2 decades11–13 and the association between body weight and BP is well documented in children,3,14–16 it is generally believed that BP in children should have increased in parallel to the overweight epidemic.6,17

Although the prevalence of type 2 diabetes among children has risen worldwide in parallel to the epidemic of overweight,18,19 few reliable population-based data are available to document trends in BP in children and adolescents. A review on trends from 1948 to 1998 reported a decline in BP in high-income countries in children, adolescents, and young adults aged 5 to 34 years.20 Whether the increasing prevalence of overweight in children has resulted in a commensurate increase in BP is an important issue. Elevated BP acquired in childhood tends to track into adulthood,3 and factors that affect BP in childhood are likely to further increase the burden of hypertension-related diseases in adults.

In this article, we aimed to (1) discuss methodologic and other issues that limit the validity of estimates of elevated BP in children, (2) review the prevalence of elevated BP in children and trends over time on the basis of recent methodologically sound population-based studies, and (3) examine if trends in elevated BP in children seem to reflect the rising prevalence of overweight.


   METHODOLOGIC ISSUES
TOP
 ABSTRACT
 METHODOLOGIC ISSUES
ELEVATED BP IN CHILDREN...
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Limitations Related to BP Estimation in Children
There are several methodologic limitations that complicate the valid assessment of BP in children.

A first issue relates to the number of readings on which estimates of "elevated BP" are based. BP decreases over subsequent readings during a single visit as well as over readings taken on separate visits. This decrease partly reflects an alert reaction and is observed in both adults21 and children.15,16 It follows that BP obtained at one occasion tends to overestimate usual BP. Most epidemiologic studies have relied on only 1 set of BP readings obtained at a single visit. It is notable that the normative US reference BP data are based on the first BP reading obtained at 1 visit.22 However, in most recent surveys (Table 1), 2 or 3 BP readings were obtained and BP was based on either the mean of 2 readings,23,24 the mean of 3 readings,25 or the mean of the last 2 of 3 readings.14 Normative data recently proposed for English children were determined on the basis of the mean of the last 2 of 3 readings obtained during a single visit.26 However, when BP was measured on different visits, the prevalence of elevated BP decreased from 19.4% (first visit), to 9.5% (second visit), and to 4.5% (third visit) in 1 American study15 and from 8.8% (first visit) to 4.2% (second visit) in 1 European study.16


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  		TABLE 1 Prevalence of Elevated BP in Recent Large Population-Based Surveys of Children and Adolescents

 
The use of different BP-measurement devices also limits the comparability of estimates of elevated BP across studies. Although mercury manometers were used in the past, automated oscillometric devices are now used increasingly often. Electronic devices have several advantages including a greater reliability and the avoidance of observer bias.27 However, proper validation and calibration of such devices are necessary because substantial systematic bias can exist between different models and manufacturers.28–30 Unfortunately, few devices have been validated for use in children.31 Moreover, current validation protocols are quite lenient and allow, for example, for systematic underestimates or overestimates of BP by as much as 5 mmHg.32

The use of the auscultatory technique (mercury or aneroid) raises specific issues.33 Rounding errors, bias related to expected values (which may be stronger in children), and other operator-dependant biases can occur.27 The accuracy of aneroid sphygmomanometers needs to be checked regularly. Moreover, diastolic BP may be difficult to determine when the Korotkoff sounds do not disappear, which can occur in younger children. The choice of either the fourth Korotkoff phase (K4: muffling of sound, eg, to overcome the problem of nondisappearance of Korotkoff sounds in some children) or the fifth phase (K5: disappearance of sound, as usually applied with adults) to define diastolic BP in children has important consequences on BP estimates.34 For example, in a study of school-aged girls, the mean difference in BP between K4 and K5 was 9.9 mmHg.35 The US reference data are based on K5 to define diastolic BP.22

In addition to biases related to BP-measurement procedures, age-adjusted BP in children may be affected by secular trends in children's height.36 BP relates strongly to height independently of age and gender22,37,38 so that secular increases in children's height are likely to translate into some increase in mean BP levels over time. This issue has relevance in view of the largely different mean heights across populations and the substantial increase in children's height over time in many populations. In several recent studies of BP trends in the United States25,39 and United Kingdom,40 the authors did not adjust BP for height, and part of the observed increase in BP over time might relate to a concomitant increase in children's height. In an American study, an observed increase in BP between 1986 and 1996 was largely reduced when adjusted for weight and height.41 The potential confounding effect of height may be especially strong in developing countries, where age-specific height of children may increase rapidly with socioeconomic development.

Current US BP reference data are determined on gender-, age-, and height-adjusted percentiles to take body size into account.22 Reference values have also been proposed for ambulatory BP and are provided according to body size directly (by height increments of 5 cm).42

Definition of Elevated BP in Children
Observational studies and clinical trials in adults indicate that BP is associated with both cardiovascular diseases (CVDs) and total mortality43 and that BP reduction lowers CVD risk.44 Above 115/75 mmHg, the risk of CVD doubles with each increment of 20 mmHg systolic or 10 mmHg diastolic BP.45 However, because the relationship between BP and CVD risk is graded over the entire range of BP, a definition of hypertension is inherently arbitrary. Rose proposed an operational definition of hypertension: "the level [of BP] at which the benefits (...) of action exceed those of inaction."46 Among adults, hypertension is currently defined as a sustained BP ≥140/90 mmHg and/or current use of antihypertensive treatment.45

In children, no cohort data are available to relate BP with CVD mortality or morbidity.17,47 However, elevated BP in children is associated with several intermediate outcomes such as ventricular hypertrophy48 or increased carotid intima-media thickness.49–52 Furthermore, BP tracks from childhood into adulthood, which suggests that elevated BP occurring as early as in childhood may worsen CVD risk in adults. In the Bogalusa Heart Study, BP at age 5 to 14 correlated with BP at age 20 to 31 (correlation coefficients of 0.36–0.50 for systolic BP and 0.20–0.42 for diastolic BP).53

The most widely used cutoff values for defining elevated BP in children are based on BP percentiles specific for gender, age (1-year intervals), and height (7 categories based on height percentiles).22 These norms were determined on the basis of data in 63227 American children aged 1 to 17 years who were participating in a variety of studies or surveys in the 1970s and 1980s (ie, before the current obesity epidemic)12 and were based on the first BP reading taken during a single occasion. "Elevated BP" is defined for BP values ≥95th gender-, age-, and height-specific percentile, and a child is considered to be "hypertensive" if he or she has elevated BP on at least 3 separate occasions.22

Pooled data from 6 Northwest European studies conducted in 1975–1986, which were based on the first reading taken during a single visit, showed that age-, gender-, and height-adjusted percentiles of systolic/diastolic BP were, on average, 6/3 mmHg higher in European than in American children,54 which underscores the potential limit of using American reference data for European children.


   ELEVATED BP IN CHILDREN AND TRENDS OVER TIME
TOP
 ABSTRACT
 METHODOLOGIC ISSUES
 ELEVATED BP IN CHILDREN...
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
A literature search was undertaken systematically by one of us (Dr Chiolero) by using the Medline/PubMed database with the search terms "children," "blood pressure," and "survey." Chosen articles were restricted to those written in English and published between 1980 and February 2006. References of the selected articles were examined also.

First, we report below (in "Current Prevalence of Elevated BP in Children") the prevalence of elevated BP that was estimated in the available population-based studies. We selected these population studies if (1) the prevalence of elevated BP was specifically addressed, (2) details about BP measurement were provided, and (3) US reference data were used22,38 to define BP percentiles and elevated BP (Table 1). In most of these surveys, elevated BP was defined as BP equal to or above the American gender-, age-, and height-specific 95th percentile (ie, calculated in the 1970s and 1980s, as explained above).22 In addition, the review was limited to large studies (≥2000 children). Large surveys have the power to provide prevalence estimates with some precision; because BP varies by age, gender, and height, prevalence of elevated BP must be examined across a large number of categories of age, gender, and height. Although this was not a requirement of the search strategy, most of these studies also defined overweight as a BMI equal to or above the American gender- and age- specific 95th percentile. It was noticeable that these reference BMI percentiles were determined on the basis of data gathered mostly between 1963 and 1980,55 a time period during which overweight was less frequent.12

Second, we report in "Recent Trends of BP in Children" trends on elevated BP based on single studies. For this purpose, studies were selected it they were based on a cohort study design or on paired surveys, which are suitable to indicate trends over time in mean BP levels or prevalence of elevated BP within defined populations and using comparable BP-measurement procedures (Table 2).


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  		TABLE 2 Trends in BP in Children and Adolescents

 
Current Prevalence of Elevated BP in Children
A convenience sample of American school-aged children aged 10 to 15 years were examined in 1986–1987 (Table 1).23,56 BP was measured with a mercury sphygmomanometer. At the first visit, the prevalence of elevated BP (≥95th percentile) was 2.0% to 2.7%. Students with BP >70th percentile were seen again on a separate day, and the prevalence of elevated BP decreased to 0.4% to 0.8%.

On the basis of BP measured during 1 visit in a representative sample, Pakistani children aged 5 to 14 years seen in 1990–1994 had higher BP24 than US children of the same age range who participated in the Third National Health and Nutrition Examination survey in 1988–1994 (NHANES III). This difference was found despite a mean BMI that was markedly (~3 kg/m2) lower in Pakistani than American children. The authors speculated that these differences could relate, at least partially, to lower birth weight in Pakistani than US children. Low birth weight is a known risk factor for subsequent elevated BP in children57 and in adults.58

In Quebec, Canada, BP was measured 3 times during 1 visit in 1999 in a representative sample of children aged 9, 13, and 16 years.14 The prevalence of elevated BP (based on the American reference data) increased across age categories from 7% to 13% and 17%, respectively. The prevalence of overweight was 8% to 9%. Mean BMI was 4 to 6 kg/m2 higher in children with systolic BP ≥95th percentile than in children with systolic BP <25th percentile. It was noticeable that most children with elevated BP had only elevated systolic BP. Less than 1% of children with elevated BP had elevated diastolic BP. Compared with data from an earlier Canadian survey conducted in 1978–1979, mean systolic BP was 4 to 8 mmHg higher, whereas mean diastolic BP was 3 to 10 mmHg lower. However, comparisons are limited because a mercury sphygmomanometer was used in the earlier survey, whereas an automated oscillometric device was used in the latter, and the 2 surveys also had different sampling designs.

Two surveys were conducted at schools in Houston, Texas, in 2000/200159 and 2002.15 In both surveys, BP was measured 3 times during each of up to 3 separate visits if children had BP ≥95th percentile. In the first survey, the prevalence of overweight was 23% (BMI ≥95th percentile). The prevalence of elevated BP was 16.8% on the basis of readings from the first visit and 9.5% on the basis of readings from the third visit. As in the Canadian study mentioned above, the prevalence of elevated diastolic BP was very low. In the second Houston survey, the prevalence of overweight was 20%. The prevalence of elevated BP was 19.4% on the basis of the readings from the first visit and 4.5% on the basis of the readings from the third visit. BMI was strongly associated with systolic BP but not with diastolic BP. The prevalence of hypertension (defined as elevated BP at all 3 visits) was 10.7% in obese children (BMI ≥95th percentile) compared with 2.6% in children with normal BMI (<85th percentile).

In a school-based study performed in a representative sample of children aged 6 to 11 in 2004 in villages around Milan, Italy, the subjects with elevated BP at the first visit had BP measured again 8 to 15 days later.16 The prevalence of elevated BP decreased from 8.8% at the first visit to 4.2% at the second visit. Both systolic and diastolic BP were associated with BMI.

In Delaware, on the basis of electronic medical charts from children aged 2 to 19 attending primary care practices,60 the prevalence of elevated BP (based on only 1 BP reading for each subject) was surprisingly low (7.2%) despite a very large prevalence of overweight (20.2%; BMI ≥95th percentile). In this study, systolic and diastolic BP were related to BMI at all ages and among children aged <5 in particular.

As part of a school-based surveillance system in children of the Republic of Seychelles, a rapidly developing small island state in the African region with a large majority of the population of African descent, BP was measured in all children of 4 grades between ages 5 and 16 in 2002–2004.61,62 Systolic and diastolic BP were associated with BMI independent of gender, age, and height. In categories of children with normal weight (BMI <85th percentile), "at risk of overweight" (BMI ≥85th to <95th), and "overweight" (BMI ≥95th), proportions with elevated BP were 8%, 14%, and 23% in boys and 8%, 16%, and 29% in girls, respectively.

Overall, most of these recent studies reported a high prevalence of elevated BP. However, the prevalence seemed to depend substantially on the methodology used for BP measurement.

Recent Trends of BP in Children
In 2002, McCarron et al20 reviewed data on BP trends among individuals aged 5 to 34 years of both genders in developed countries. They concluded that BP declined between 1948 and 1998. For individuals aged 18 years or less, conclusions were based mostly on the NHANES for the period of 1963/80 and the English Health Surveys for the short period of 1995/1998.40 In the NHANES, BP was measured in American youth aged 6 to 17 years and was lower in 1971/1974 and 1976/1980 compared with 1963/1965. However, BP measurements differed between surveys in these periods: BP was measured in either the supine or sitting positions, the observer was either a physician or a nurse, and the number of readings differed between the surveys.19,25,63 In the NHANES 1971/1974 and 1976/1980 (all measuring with mercury devices), 40% to 50% of the readings had 0 end digits (vs 20% expected if BP was assessed along recommended 2-mmHg increments).63

In the Bogalusa Heart Study, 2 convenience samples of white and black children aged 7 to 9 were examined in 1973 and 198464 (Table 2). The same children were examined again 8 years later in 1981 and 1992 at the age of 15 to 17. The mean of 6 BP readings was used, and the fourth Korotkoff sound was recorded for diastolic BP. Only small BP differences were observed among children aged 7 to 9 in 1973 and 1984. However, children aged 15 to 17 had lower systolic BP in 1992 compared with children of the same age examined in 1981 (except for black boys, who tended to have slightly higher BP in 1992). Only small differences were observed for diastolic BP over time.

In 1973/1974 and 1989/1990, BP was measured in convenience samples of children aged 10 to 14 in Princeton, Ohio.39 In 1973/1974, the reported BP was based on the average of 2 readings, whereas in 1989/1990 it was based on the average of the last 2 of 3 readings. Mean BP was higher in the latter than the former study, whereas the prevalence of elevated BP, surprisingly, tended to decrease. This result may reflect that the distribution of BP did not change uniformly: an increase in the lower range of BP could have occurred without concurrent change in the higher range of BP.

More recently, BP was measured by using the same methods in convenience samples of school-aged children aged 10 to 14 years in 1986 and in 1996 in Minneapolis, Minnesota.41 During the interval, systolic BP increased, but diastolic BP decreased. Adjustment for BMI largely eliminated the systolic BP increase between the 2 periods but did not alter the diastolic BP decrease over time.

In the recent NHANES surveys (1988/1994 and 1999/2000), BP was measured with similar procedures, and 3 BP readings were obtained from most children and adolescents aged 8 to 17 years25 (Table 2). After adjustment for age, race/ethnicity, and gender (but not for height), BP was slightly higher in 1999/2000 compared with 1988/1994. Most of the increase in BP over time could not be accounted for by concurrent trends in BMI: adjustment for BMI could explain only 29% of the increase in systolic BP and 12% of the increase in diastolic BP.25

In the English Health Surveys,40 BP was measured by nurses at the children's homes with an oscillometric automated device (Dinamap 8100; GE Healthcare, Critikon, FL). BP tended to decrease between 1995 and 1998 but increased slightly between 1998 and 2001. In 2004, BP was measured with a new automated device (Omron HEM 807; Omron Healthcare Europe BV, Hoofddorp, Netherlands), which is known to provide higher BP estimates compared with the Dinamap 8100. After data were calibrated to take this bias into account, BP was only slightly higher in 2004 than in 2001 despite a continued increase in the prevalence of overweight.

In 1989/1990 and 1999/2001, BP was measured in a representative sample of Irish adolescents aged 12 and 15 years with a random-zero Hawksley sphygmomanometer.65 The mean of 2 BP readings was used in the first survey (1989/1990), but only 1 BP reading was measured in the second survey (1999/2001). Mean BMI increased significantly in children aged 12 but increased only marginally in children aged 15. In both age groups, BP decreased substantially between the 2 surveys. Adjustment for BMI, age, height, birth weight, and social class changed these estimates only marginally. Such a large decrease in BP is difficult to interpret. BP at the second survey was surprisingly low, particularly if one considers that it was based on 1 BP reading, which is usually a source of overestimation.


   DISCUSSION
TOP
 ABSTRACT
 METHODOLOGIC ISSUES
 ELEVATED BP IN CHILDREN...
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Most recent large population-based surveys have reported a relatively high prevalence of elevated BP in children and adolescents in several populations. However, the majority of the few available trend studies suggest that BP increased, at most, only moderately over time since the 1980s, which is in contrast to substantial increases in the prevalence of overweight reported in these same surveys. Some studies even showed a decrease in BP over time, both small (eg, in the Bogalusa Heart Study64) and substantial (eg, in an Irish study65). In addition, trends in systolic and diastolic BP were not always consistent. More generally, differences in the methods used to measure BP between studies (hence differences in the definition of "elevated BP") strongly limited our ability to draw definitive conclusions on BP trends in children over the past few decades.

BMI (or any other index of adiposity) is a major determinant of BP, and the absence of a large increase in BP over time in most studies, despite a rising prevalence of overweight, suggests that other factors may also have influenced trends in BP over time. Such factors may include nutrition characteristics, such as the intake of fruits, vegetables, or dairy products7,66,67 or salt.7,68,69 These dietary factors have not been assessed in most of these studies, and so their independent effect on BP trends cannot be assessed. More generally, whereas the total caloric intake has increased largely in most countries worldwide, mixed trends (favorable and unfavorable) have been observed for specific nutrients that relate to hypertension, at least in US children.70–72

Secular changes in nondietary factors may also have impacted on the trends in elevated BP over time. Low birth weight is associated with elevated BP in adults and children.9,58 Mean birth weight has increased throughout the last quarter century in many countries including the United States, Canada, and the United Kingdom and also in developing countries such as India73,74 despite a concomitant increase in preterm births in several of these countries.75 Increasing birth weight over time has been related to decreasing tobacco use among mothers during pregnancy,76 increased stature of mothers,73 favorable changes in socioeconomic factors,73 and other factors such as improved maternal nutrition. Increasing birth weight over the last decades may have accounted for some of the downward trends in BP over time, but no data currently support this possibility. Breastfeeding has been related to lower BP in children, which can be a result of the low salt content and high long-chain polyunsaturated fatty acid content of breast milk.7 However, during the 1990s, breastfeeding practices generally did not change substantially in many countries worldwide.77 Finally, in many countries, the amount of reported physical activity (particularly walking time or leisure exercise) has generally decreased.78 In addition to being a risk factor for obesity (itself related to elevated BP), low physical activity is associated independently with higher BP in children.79 However, precise measurement of all daily physical activity remains a challenge, as is reliable assessment of trends in physical activity over time.

Our findings are consistent with the review by McCarron et al,20 which reported a decline in BP from 1948 to 1998 in children, adolescents, and young adults in high-income countries. We did not perform a meta-analysis to estimate an average BP change over time in children because of excessively high heterogeneity of data in the available surveys and studies.80 First, studies differ widely in their particulars and design (ethnicity, sample, time period, and, most importantly, methodology for BP measurement and definition of elevated BP). Second, trends in BP over time may not be assumed to be similar in different populations in view of the different pace in the pediatric obesity epidemic and possibly also in differences in the relationship between BMI and BP between different populations.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODOLOGIC ISSUES
 ELEVATED BP IN CHILDREN...
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The available data do not support the hypothesis that the worldwide epidemic of overweight in children has resulted in a commensurate increase in BP levels in children. However, none of the available studies on trends in BP over time has accounted for several other BP-related factors. Therefore, it is not possible to assess whether the apparent nonsystematic convergence of trends in elevated BP and overweight over time is related to a weakening in the relationship between BMI and BP over time or to concurrent secular changes over time in other risk/preventive factors of elevated BP. Furthermore, important differences in the methods used to assess BP in different studies limited our ability to directly compare results between populations and over time. This stresses the need for additional epidemiologic studies using standardized methods to measure BP and assessing a wider range of variables related to BP. Also, BP trends should be analyzed by using a life-course perspective81 (eg, by also considering preconceptional parental characteristics, pregnancy course, early life characteristics [eg, birth weight], nutrition, and physical activity during childhood and adolescence, socioeconomic position at different life stages, etc). The lack of firm evidence linking the epidemic of obesity to the prevalence of elevated BP in children, however, is no reason to weaken efforts to curb the current pediatric epidemic of obesity in view of the numerous detrimental consequences of overweight on health in children.13,82–84


   ACKNOWLEDGMENTS
 
This work was funded partially by Swiss National Science Foundation grant 3200B0-109999/1.


   FOOTNOTES
 
Accepted Oct 23, 2006.

Address correspondence to Arnaud Chiolero, MD, MSc, Community Prevention Unit, Institute of Social and Preventive Medicine, University of Lausanne, 17 Rue du Bugnon, 1005 Lausanne, Switzerland. E-mail: arnaud.chiolero{at}chuv.ch

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 METHODOLOGIC ISSUES
 ELEVATED BP IN CHILDREN...
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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