Obesity and asymptomatic hypertension among children aged 6 13 years living in Bursa, Turkey

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1 Family Practice Advance Access published September 25, 2013 Family Practice doi: /fampra/cmt048 The Author Published by Oxford University Press. All rights reserved. For permissions, please Obesity and asymptomatic hypertension among children aged 6 13 years living in Bursa, Turkey Hakan Demirci a, *, Cagatay Nuhoglu b, Ismail Serkan Ursavas c, Serhat Isildak c, Ebru Onuker Basaran c and Mehmet Yasar Kılıc c a Department of Family Medicine, Sevket Yilmaz Training and Research Hospital, Bursa, b Department of Pediatrics, Haydarpasa Numune Training and Research Hospital, Istanbul and c Department of Family Medicine, Fethiye Bulvar Family Practice Unit, Bursa, Turkey. *Correspondence to Hakan Demirci, Department of Family Medicine, Sevket Yilmaz Training and Research Hospital, Yildirim, Bursa 16310, Turkey; drhakandemirci@hotmail.com Received 5 April 2013; Revised 24 July 2013; Accepted 30 July Introduction. Hypertension is an independent risk factor for cardiovascular disease. It is known that essential hypertension begins at a very early age. Recently, there have been reports of an increase in childhood hypertension, which has been attributed to an increase in the prevalence of childhood obesity. Obesity-dependent or independent asymptomatic hypertension can only be determined by random blood pressure measurements in children. Objective. In this study, we aimed to investigate the prevalence of obesity and asymptomatic hypertension among children living in Bursa, Turkey. Methods. One thousand children living in Nilüfer district and being served by the Fethiye Bulvar Family Health Care Center were enrolled in this study. All seven family physicians working at the centre participated in the study. Results. Eighty-five children (8.5%) were determined to be hypertensive. One hundred and twelve children (11.2%) were obese. Blood pressure and body mass index (BMI) increased with age, with peak prevalence of hypertension at age 12 and of obesity at age 10. Conclusions. The prevalence of obesity and hypertension is high among school-age children in Turkey. Family physicians should consistently perform blood pressure and BMI measurements as a part of well child visits through late childhood. Keywords. Childhood obesity, hypertension (high blood pressure), medical comorbidity, paediatrics, primary care, public health. Introduction Many studies have evaluated the prevalence of obesity and hypertension. 1 4 In the past decade, an increase in childhood hypertension has been noted. This surprising increase has been attributed to a simultaneous increase in obesity, increased salt and calorie consumption, lack of physical activity and other factors, such as stress. 5 Hypertension and related health problems lead to important mortality and morbidity over time. Hypertension in children is less common than in adults; however, it has been suggested that the latter is an extension of the former. 6,7 If this is the case, then diagnosing and treating hypertension at an earlier stage should be a priority. Obesity is another important public health problem and is associated with hypertension, cardiovascular disease, diabetes mellitus and atherosclerosis. Childhood obesity is defined as a body mass index (BMI) over the 95th percentile, adjusted for age and gender. 8 Obesity in childhood is most common in developed countries. For example, 11% of children in the USA are obese. However, recent studies have shown that the prevalence of obesity is increasing all over the world. 9 The prevalence of obesity and hypertension is increasing, and these diseases have a great impact on health. To overcome these diseases, we must know their current prevalence. In this study, we aimed to determine the prevalence of obesity and hypertension in schoolage children as an aid in planning a defence strategy. Methods According to Turkish Health Ministry data, children, aged 6 13 years, were living in Bursa in Using this information and recent data on the prevalence of hypertension and obesity in Bursa and Turkey, Page 1 of 5

2 Page 2 of 5 Family Practice The International Journal for Research in Primary Care Table 1 Gender and age distribution in the study group Female Count % Within gender % Within age (year) Male Count % Within gender % Within age (year) Count % Within gender we calculated a minimum sample size of 306 cases for our study (α = 0.05). Because of our study aims (subgroup size and statistical test selection), we raised our sample size to 1000 children, maintaining a similar gender and age distribution to the population in Bursa while staying within the limits of our study budget. We conducted this cross-sectional study in Nilüfer-9 Fethiye Bulvar Family Practice Offices in Bursa, Turkey. Bursa City is composed of three central urban regions, including Nilüfer district, which is located on the west side of the city. We registered 978 girls and 1120 boys aged 6 13 years. The study lasted for 12 months, from 1 February 2011 through 31 January All seven family practitioners working in the centre participated in the study. A letter with the study description and an invitation to participate was sent to all parents in the study area. The parents of 470 (47%) girls and 530 (53%) boys and the children themselves agreed to participate in the study (Table 1). Physicians measured systolic and diastolic blood pressure (mmhg) with manually operated sphygmomanometers appropriate for the wrist size of each enrolled child. The mean of three consecutive measurements the 95th percentile in one visit with adequate intervals constituted a diagnosis of hypertension. Values between the 90th and 95th percentiles were categorized as pre-hypertension. A nurse measured each child s weight (kg) and height (m) in light clothing with no shoes. A short history was taken for each child, including chronic illnesses and current medications. BMI was calculated as weight/height 2 (kg/m 2 ). BMI scores were evaluated using percentile charts prepared for Turkish children. 8 The Ethics Committee of Istanbul Haydarpaşa Numune Training and Research Hospital approved the study. Trial registration was not required for the study. Statistical analysis was performed using SPSS pocket version 20. We used descriptive statistics (percentage, arithmetic mean and SD), the chi-square test for stratified data, one-way analysis of variance (ANOVA) and the Kruskal Wallis test for multiple independent groups, Student s t-test for two groups, multiple linear regression forward method and linear correlation coefficient. P values <0.05 were considered statistically significant. Results The mean age of the children was 9.1 ± 2.2 years, and the female/male ratio was Gender distribution differences by age group (Table 1) were not statistically significant (χ 2 = 8.710, d.f. = 7, P = 0.274). The mean systolic blood pressure of the girls was 101 ± 12 mmhg and of the boys was 102 ± 12 mmhg. This difference was statistically significant (t = 2.088, d.f. = 998, P < 0.05). Mean diastolic blood pressure was 65 ± 9 mmhg for both girls and boys (P > 0.05). Mean blood pressure results by age and gender are shown in Table 2. For girls, differences among age groups in mean systolic blood pressure (F = , d.f. = 7, P < 0.001) and in diastolic blood pressure (F = 7.601, d.f. = 7, P < 0.001) were statistically significant (one-way ANOVA). Systolic (r = 0.401, P < 0.001) and diastolic (r = 0.313, Table 2 Multiple linear regression analysis of blood pressure results Dependent variable Systolic blood pressure Diastolic blood pressure R 2 β t P Female BMI <0.001 Age <0.001 BMI and age 0.24 Male BMI <0.001 Age <0.001 BMI and age 0.25 Female BMI <0.001 Age <0.001 BMI and age 0.15 Male BMI <0.001 Age <0.01 BMI and age 0.11

3 Obesity and hypertension among Turkish children Page 3 of 5 P < 0.001) blood pressure measurements for girls correlated with age. For boys, differences among age groups in mean systolic blood pressure (Kruskal Wallis, P < 0.001) and mean diastolic blood pressure (one-way ANOVA; F = 6.261, d.f. = 7, P < 0.001) were statistically significant. Systolic (r s = 0.349, P < 0.001) and diastolic (r = 0.260, P < 0.001) blood pressure measurements for boys correlated with age. Eighty-five children (8.5%) had hypertension and 23 (2.3%) had pre-hypertension. Hypertension and prehypertension distributions by age group are shown in Table 3 and Figure 1. Peak obesity prevalence was seen at 10 years of age; peak hypertension prevalence was seen at age 12. Thirty-three children (3.3%) had systolic hypertension and 18 (1.8%) had diastolic hypertension. Thirty-four children (3.4%) had combined systolic and diastolic hypertension. Mean BMI values (17 ± 3 for girls, 18 ± 4 for boys) were not significantly different between gender groups (Mann Whitney U-test, P > 0.05). BMI for each age group is shown in Table 4. Mean BMI values were significantly different among age groups for both girls and boys (Kruskal Wallis, P < 0.001). BMI correlated with age in girls (r s = 0.437, P < 0.001) and in boys (r s = 0.452, P < 0.001). We evaluated blood pressure (dependent variable), BMI and age using forward selection multiple linear regression analysis (Table 5). While BMI and age together explained 24% of systolic blood pressure changes in girls, this proportion was 18% for BMI alone. These proportions were 25% and 22% for boys. While BMI and age explained 17% of diastolic blood pressure changes for girls, this proportion was 15% for BMI alone. These proportions were 13% and 11% for boys. BMI and age significantly correlated with blood pressure levels in children 6 13 years of age. There were 112 children (11.2%) with obesity in the study group. Thirtyfour children (3.4%) had both obesity and hypertension. Discussion Previous studies have found hypertension prevalence ranging from 6.3% to 12.3% among school-age children living in Turkey. 10,11 We determined that the frequency of asymptomatic hypertension in the Nilüfer region was 8.5%. We also found that mean hypertension values Table 3 Mean blood pressure changes by age and gender Blood pressure (mmhg) Systolic Female 95 ± ± ± ± ± ± ± ± ± 12 Male 98 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 12 Diastolic Female 61 ± 7 61 ± 9 64 ± 9 65 ± 9 65 ± ± ± 9 71 ± 7 65 ± 9 Male 62 ± 8 63 ± 8 63 ± 9 64 ± 8 66 ± ± 8 66 ± 9 70 ± 9 65 ± 9 61 ± 7 62 ± 8 63 ± 9 65 ± 8 66 ± ± 9 67 ± 9 71 ± 9 65 ± 9 Figure 1 Hypertension, pre-hypertension and obesity percentage related to age

4 Page 4 of 5 Family Practice The International Journal for Research in Primary Care Table 4 Changes in mean BMI by age BMI Female 15.5 ± ± ± ± ± ± ± ± ± 3.4 Male 15.8 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 3.5 Table 5 Distribution of obesity and hypertension by age Hypertension 8 (6.7%) 11 (6.0%) 9 (6.6%) 9 (6.8%) 13 (10.1%) 11 (9.3%) 16 (14.4%) 8 (11.1%) 85 (8.5%) Pre-hypertension (0.7%) 2 (1.5%) 5 (3.9%) 6 (5.1%) 4 (3.6%) 5 (6.9%) 23 (2.3%) Obesity 16 (13.4%) 19 (10.4%) 12 (8.8%) 17 (12.9%) 21 (16.3%) 12 (10.2%) 10 (9.0%) 5 (6.9%) 112 (11.2%) increased year by year, with a peak at puberty, probably due to hormonal changes. Kayıran et al. 12 found that the prevalence of childhood obesity was 5.3%. Another study reported an obesity prevalence of 7.1% among school-age children. 13 In the present study, we found that 11.2% of children aged 6 13 years were obese. Lurbe et al. 14 found an association between systolic hypertension and BMI in children. In the present study, we also found that BMI correlated with blood pressure in children. Our study had several limitations. We did not attempt to reach non-responder families once we achieved the target number of participants. However, our results can be generalized to the Bursa population because gender and age distribution of the study group were similar to those found in Bursa. Further research will be needed to confirm whether or not these findings can in turn be generalized to the entire population of Turkey. Invitation to a study with a letter indicating a specific illness might result in a higher response rate from individuals suffering from the indicated health problem. This may cause overestimation of prevalence in epidemiologic studies. However, this is not true for childhood hypertension, which is usually asymptomatic. Finally, it would be better if we had taken the pubertal history of participants to determine the effect of puberty on obesity and hypertension, both of which had peak prevalence at around the time of puberty. Conclusions Our results show that the prevalence of childhood obesity in this urban Turkey population is similar to rates seen in the developed countries such as USA. The peak prevalence of hypertension follows that of obesity in the late childhood period. Importance of the well child visits including BMI and blood pressure measurements through puberty can be emphasized to family physicians for early detection and better management of these conditions. Acknowledgements The authors express their thanks to Dr Bahri Oztürk for his cooperation. Declaration Funding: none. Ethical approval: The Ethics Committee of Istanbul Haydarpaşa Numune Training and Research Hospital approved the study. Conflict of interest: none. References 1 Akgun C, Dogan M, Akbayram S et al. The incidence of asymptomatic hypertension in school children. J Nippon Med Sch 2010; 77: Discigil G, Aydogdu A, Basak O, Gemalmaz A, Gurel SF. Prevalence and predictors of hypertension in primary school children: a population based study in Aydın, Turkey. TJFMPC 2007; 2: Halbach SM, Flynn J. Treatment of obesity-related hypertension in children and adolescents. Curr Hypertens Rep 2013; 15: Flynn J. The changing face of pediatric hypertension in the era of the childhood obesity epidemic. Pediatr Nephrol 2013; 28:

5 Obesity and hypertension among Turkish children Page 5 of 5 5 Akan H. Measurement and assessment of blood pressure in children and adolescents regarding forth report. Turk J Fam Pract 2010; 14: Bao W, Threefoot SA, Srinivasan SR, Berenson GS. Essential hypertension predicted by tracking of elevated blood pressure from childhood to adulthood: the Bogalusa Heart Study. Am J Hypertens 1995; 8: Assadi F. The growing epidemic of hypertension among children and adolescents: a challenging road ahead. Pediatr Cardiol 2012; 33: Neyzi O, Günöz H, Furman A et al. Weight, height, head circumference and body mass index references for Turkish children. Çocuk Sağlığı ve Hastalıkları Dergisi 2008; 51: Dehghan M, Akhtar-Danesh N, Merchant AT. Childhood obesity, prevalence and prevention. Nutr J 2005; 4: Akış N, Pala K, İrgil E, Aydın N, Aksu H. Overweight and obesity among 6-14 year-aged school children at six elementary schools in Orhangazi-Bursa. Uludağ Üniversitesi Tıp Fakültesi Dergisi 2003; 29: Coøpkun Y, Bayraktaroğlu Z. Coronary risk factors in Turkish school children report of a pilot study. Acta Paediatr 1997; 86: Kayıran PG, Taymaz T, Kayıran SM et al. The frequency of overweight, obesity and short stature among primary school students in three different regions of Turkey. Şişli Etfal Hastanesi Tıp Bülteni 2011; 45: Süzek H, Arı Z. The eating habits and prevalences of overweight and obesity in 6 15 years-old school children living in the Villages of Mugla center. Yeni Tıp Dergisi 2010; 27: Lurbe E, Alvarez V, Liao Y et al. The impact of obesity and body fat distribution on ambulatory blood pressure in children and adolescents. Am J Hypertens 1998; 11 (4 Pt 1):

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