Rebecca Din-Dzietham, Yong Liu, Marie-Vero Bielo and Falah Shamsa
High Blood Pressure Trends in Children and Adolescents in National Surveys, 1963 to
Print ISSN: 0009-7322. Online ISSN: 1524-4539
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High Blood Pressure Trends in Children and Adolescents in
National Surveys, 1963 to 2002
Rebecca Din-Dzietham, MD, MPH, PhD; Yong Liu, MS; Marie-Vero Bielo, MD; Falah Shamsa, PhD
Background—Secular trend data on hypertension in children and adolescents are scarce and inconsistent. In the face of
growing obesity, we sought to assess high blood pressure (HBP) secular trends in children and adolescents enrolled in
national surveys and to determine whether the HBP trend reversed its course with the rise in obesity.
Methods and Results—National survey data obtained from multistage probability sampling of the US noninstitutionalized
population from 1963 to 2002 were examined; 8- to 17-year-old non-Hispanic blacks and whites and Mexican
Americans were included. HBP ascertainment was based on age-, gender-, and height percentile–specific systolic and
diastolic BPs. Weighted analyses were performed to account for the complex design. The BP, pre-HBP, and HBP trends
were downward from 1963 to 1988 and upward thereafter. Pre-HBP and HBP increased 2.3% (P?0.0003) and 1%
(P?0.17), respectively, between 1988 and 1999. Obesity increase, more so abdominal than general obesity, partially
explained the rise in HBP and pre-HBP from 1988 to 1999. BP and HBP reversed their downward trends 10 years after
the increase in the prevalence of obesity. Additionally, an ethnic and gender gap appeared in 1988 for pre-HBP and in
1999 for HBP; non-Hispanic blacks and Mexican Americans had a greater prevalence of HBP and pre-HBP than
non-Hispanic whites, and males had a greater prevalence than females.
Conclusions—HBP and pre-HBP in children and adolescents are on the rise. These new findings have implications for the
cardiovascular disease public health burden, particularly the risk of a new cardiovascular disease transition. They
reinforce the urgent call for early prevention of obesity and HBP and illustrate racial/ethnic disparities in this age group.
Key Words: epidemiology ? hypertension ? obesity ? pediatrics ? trends
roots of essential hypertension may extend back to child-
hood.1With obesity reaching epidemic proportions2and
obesity in children and adolescents being one of the strongest
predictors of young adulthood hypertension,3along with
childhood blood pressure (BP) level and family history of
hypertension, it is important to determine whether the prev-
alence of hypertension is increasing or decreasing in children
and adolescents. This question is even more pertinent when
we consider that the incidence of type 2 diabetes mellitus in
youth is increasing, a direct result of the increase in childhood
obesity.4A recent study in a national sample has documented
the BP increase in children and adolescents since the late
1980s.5However, data on secular trends of BP in children and
adolescents are scarce and inconsistent.6,7Moreover, they are
based on samples that are not nationwide. The limited
national data on hypertension prevalence in children and
adolescents enrolled in the earliest National Health and
Nutrition Examination Survey (NHANES) showed a decreas-
ing trend, although the investigators used the adult definition
ypertension in adults remains a major public health
problem. Several studies support the theory that the
of hypertension.8,9Trends in adult hypertension in NHANES
exhibited an upward slope from 1988 to 1994 after a long
period of downward slope.10,11
Editorial p 1437
Clinical Perspective p 1496
We used the US National Health Surveys data (1963 to
2002) (1) to describe the trends of age-adjusted prevalence of
high BP (HBP) and mean BP for boys and girls 8 to 17 years
of age, (2) to describe these trends by racial/ethnic-gender
and age groups, and (3) to examine the impact of increasing
obesity on these trends, hypothesizing that the HBP trend
would reverse its course in relation to the obesity trend.
The study population consisted of boys and girls aged 8 to 17 years
who participated in the National Health Examination (NHES), the
Hispanic Health and Nutrition Examination Survey (HHANES), and
the NHANES. These surveys were conducted by the National Center
for Health Statistics (NCHS) on a nationwide probability sample of
the civilian noninstitutionalized US population and based on a
Received December 15, 2006; accepted July 19, 2007.
From the Morehouse School of Medicine, Social Epidemiology Research Center (R.D.-D., Y.L., M.-V.B.) and Community Health and Preventive
Medicine (F.S.), Atlanta, Ga.
Correspondence to R. Din-Dzietham, MD, MPH, PhD, Morehouse School of Medicine, Social Epidemiology Research Center, 520 Westview Dr SW,
NCPC-315, Atlanta, GA 30310–1495. E-mail firstname.lastname@example.org
© 2007 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.orgDOI: 10.1161/CIRCULATIONAHA.106.683243
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Using the 1963 to 2002 national survey data, we found that, after a long period of decline, the prevalence of elevated blood
pressure has reversed its trends since 1988. However, the increase over the last 2 survey periods (1988 to 1994 and 1999
to 2002) is greater and significant for pre–high blood pressure (2.3%; P?0.0003) than for high blood pressure (1%;
P?0.17). Because this is the beginning of the upward trend, strong action taken now may prevent the progress of such a
trend. Therefore, it is advisable to measure blood pressure at every visit with the appropriate technique to rank the child’s
measured blood pressure from the Centers for Disease Control and Prevention growth charts and the gender-, age-, and
height-specific blood pressure table (published by the National Task Force) and to follow the recommendations proposed
by this body for elevated blood pressure management. The second observation was that obesity, more so abdominal than
general obesity, partially accounts for the elevated blood pressure trend. For example, had the distribution of waist
circumference remained at the 1988 to 1994 level, the prevalence of pre–high blood pressure in 1999 to 2002 would have
been lower by almost two-thirds. We draw 3 conclusions: (1) Measurement of waist circumference should become a routine
clinical act, along with measurement of height and weight; (2) components of the metabolic syndrome should be monitored;
and (3) pre–high blood pressure should be managed as vigorously as high blood pressure, especially because the Bogalusa
studies have shown that the former leads to early target-organ damage in young adulthood. Special attention must be paid
to minorities, particularly young Mexican American boys. Finally, the Centers for Disease Control and Prevention should
consider building growth charts for waist circumference similar to the other anthropometric variables charts.
September 25, 2007
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