Abstract
This study aimed to investigate the relationship between parental hypertension and cardiometabolic risk factors in adolescents. The authors analyzed data of 554 adolescents aged 13 to 19 years from the Korean National Health and Nutrition Examination Survey 2013. The associations between parental hypertension and cardiometabolic abnormalities in adolescents were evaluated through multivariate logistic regression. Parental hypertension was noted in 16.2% of participants. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for overweight (OR, 2.08; 95% CI, 1.01–4.28) and obesity (OR, 2.11; 95% CI, 1.09–4.07) were significantly higher in participants with parental hypertension. The adjusted ORs for abdominal obesity (OR, 2.36; 95% CI, 1.01–5.56), high blood pressure (OR, 3.05; 95% CI, 1.19–7.78), and elevated alanine transaminase defined as >35 IU/L (OR, 2.86; 95% CI, 1.03–7.95) were significantly higher in participants with parental hypertension. Prevention of cardiometabolic risk factors should be reinforced in the offspring of hypertensive parents.
1. Introduction
Cardiometabolic abnormality refers to a high lifetime risk for cardiovascular diseases. Some specific factors that can cause increased risk include obesity, type 2 diabetes, hypertension, dyslipoproteinemia, and nonalcoholic fatty liver disease (NAFLD).1 Recently, the presence of cardiometabolic risk factors in adolescents has emerged as a serious problem worldwide. Data from the National Health and Nutrition Examination Survey showed that 17% of all children in the United States were overweight,2 70% to 80% of whom had NAFLD.3 In 2013, it was reported that 12.7% of Korean adolescents were overweight,4 and approximately 60% of these overweight adolescents had at least one cardiovascular risk factor.5
Cardiometabolic risk in children and adolescents is a major health concern, not only because of the accompanying health and social problems in the short term but also because of the possibility that such risk factors may persist into adulthood and affect health in the long term. Previous studies have shown that the pathological processes in the development of associated risk factors occur during childhood.6, 7, 8, 9 A 55‐year follow‐up study showed that adults who were overweight in adolescence had an increased risk of morbidity and mortality from cardiovascular diseases, independent of their adult weight.6 These results demonstrate that primary prevention starting from early in life among high‐risk adolescents is necessary.
In adolescents, the assessment of family history is considered a useful and fundamental tool for screening cardiometabolic diseases. High‐risk adolescents could be influenced by two main factors: hereditary and environmental factors. Parents tend to influence the overall health of their offspring, and the effect of a genetic basis and strong family history exists in the development of cardiometabolic risk in children.10 Children and adolescents usually imitate the unhealthy lifestyle habits of their parents, such as an unbalanced diet, smoking, and physical inactivity, and such shared family habits can lead to an increased risk for cardiometabolic diseases.11
Among the family histories of diseases, parental hypertension is one of the most important in the risk assessment for cardiovascular diseases. A positive family history of hypertension is associated with an increased risk for hypertension and obesity in adults.12 Normotensive adolescent offspring with hypertensive parents were found to have significantly higher serum insulin levels, which indicates that insulin resistance precedes the onset of clinical hypertension in persons genetically predisposed to having hypertension.13 A recent study showed that a family history of hypertension was significantly associated with the risk of overweight in children.14
In this way, evaluating the history of parental hypertension could be helpful in predicting offspring with a higher risk of developing cardiometabolic diseases, even in the preclinical stage. However, there are scant data on this topic in adolescents, and the influence of parental hypertension on cardiometabolic risk factors among their offspring in the early stage of life has not been well characterized. Therefore, in the present study, we aimed to investigate the relationship between parental hypertension and cardiometabolic risk factors in adolescents.
2. Methods
2.1. Study participants
We conducted a cross‐sectional study by using the data sets of the Korean National Health and Nutrition Examination Survey (KNHANES) performed by the Korean Ministry of Health and Welfare among noninstitutionalized Korean civilians in 2013. A stratified, multistage probability sampling design was used, with selection made from sampling units based on geographic area, sex, and age groups in household registries. We included 694 participants aged 13 to 19 years, both boys and girls. Among them, 117 participants were excluded because of incomplete survey data, including cardiometabolic risk factors. We also excluded 23 participants who reported having no knowledge of their family history. Finally, a total of 554 participants was analyzed. The present study is a secondary analysis of the KNHANES and was approved by the institutional review board (IRB) of the Korean Centers of Disease Control and Prevention (KCDC; IRB approval No. 2013‐07CON‐03‐4C).
2.2. Demographic and lifestyle factors
The household survey consisted of the following three components: health interview survey, health examination survey, and nutrition survey. Household income was calculated on the basis of equalized income (total household income divided by the square root of the number of household members). Dietary intake was assessed by using a single 24‐hour dietary recall method. The participants were instructed to recall and describe any food and beverages consumed during the past 24 hours. The nutrient content of the recorded items was quantified by using a Web‐based program (Nutrition Solution Program; Korea Health Industry Development Institute, 2008).
Physical activity was assessed by using the short‐term Korean Version of International Physical Activity Questionnaire (IPAQ). On the basis of the IPAQ criteria, lack of physical activity was defined as a calculated metabolic equivalent task (min/wk) that does not reach the level of minimal physical activity. Alcohol consumption, smoking status, and sleep duration were assessed by using a self‐administered questionnaire. According to the National Institute on Alcohol Abuse and Alcoholism, underage drinking was defined as alcohol intake of persons younger than the minimum legal age of 19 years in Korea. Current smokers were defined as those who had smoked at least once (even one puff) in the past 30 days. The average amount of sleep per day was recorded, and lack of sleep was defined as <7 hours of sleep per night.
2.3. Parental hypertension
All of the participants underwent a thorough history taking including family history. Data on the family history of hypertension were collected by using an interviewer‐administered questionnaire. Each study participant was directly questioned on whether any of his or her family members had hypertension diagnosed by a physician. The family histories of the father, mother, and siblings were evaluated. The response options were “yes,” “no,” and “don't know.” We defined the presence of parental hypertension as either paternal or maternal hypertension.
2.4. Cardiometabolic risk factors
Well‐trained examiners performed anthropometric measurements, with the participants wearing light clothing and no shoes. Body mass index (BMI) was calculated by dividing the weight (kg) by the height squared (m2). We used the diagnostic criteria of overweight and obesity based on growth charts for Korean children and adolescents (KCDC criteria).15 Overweight was defined as a BMI ≥85th percentile but <95th percentile for children of the same age and sex. Obesity was defined as either a BMI ≥95th percentile for children of the same age and sex, or a BMI ≥25 kg/m2 regardless of age‐ and sex‐specific BMI percentile.15 Waist circumference was taken to the nearest 0.1 cm, measuring from the narrowest point between the lower borders of the rib cage and the iliac crest. Abdominal obesity was defined as waist circumference ≥90th percentile for age and sex15 or beyond the adult cutoff value (≥90 cm for men, ≥85 cm for women).16
Blood pressure (BP) was measured in the sitting position after at least 10 minutes of rest. Three measurements were obtained at least 10 minutes apart, and the average of the second and third measurements was used in the analysis. High BP was defined as systolic BP ≥130 mm Hg or diastolic BP ≥85 mm Hg.17 After a 12‐hour overnight fast, venous blood samples were drawn. We classified the following cardiometabolic risk factors according to laboratory test results: impaired fasting glucose (fasting plasma glucose ≥100 mg/dL),17 hypercholesterolemia (total cholesterol >200 mg/dL),18 hypertriglyceridemia (triglycerides ≥150 mg/dL),17 and low high‐density lipoprotein cholesterol (<40 mg/dL).17 Elevated serum alanine aminotransferase (ALT) was defined as ALT >35 IU/L and considered a surrogate marker for NAFLD in adolescents.19
2.5. Statistical analysis
According to the sampling design of KNHANES, the sampling plan followed a multistage clustered probability design. To provide an equal probability of being sampled, weights were assigned to each respondent, enabling the results to represent the entire Korean adolescent population. This weighting method guaranteed unbiased point estimates of parameters for the entire population and its subsets.
We presented continuous variables as mean±standard error and categorical variables as numbers with percentages. We performed the t test by using a complex sample general linear model for continuous variables and the chi‐square test for categorical variables, to compare the differences in variables between the group with parental hypertension and the group without parental hypertension. Logistic regression analysis was performed to determine the risks of cardiometabolic abnormalities in adolescents according to the presence of a history of parental hypertension. The adjusted odds ratios (ORs) for cardiometabolic risk factors according to parental history of hypertension after adjustment for age, sex, and income are presented together with their 95% confidence intervals (CIs). A P value of <.05 was accepted as statistically significant. All data were analyzed by using SPSS version 21.0 (IBM Corp, Armonk, NY, USA).
3. Results
3.1. Baseline characteristics of the study population
The demographic and lifestyle factors of the study population are presented in Table 1. Of the study participants, 16.2% had positive parental hypertension. Among them, 54.0% were boys and 46.0% were girls. The participants with parental hypertension were somewhat older and had a significantly higher weight compared with those without parental hypertension. Income levels and most of the lifestyle factors, including dietary intake, were not significantly different between the two groups.
Table 1.
Demographic and Lifestyle Factors According to Parental History of Hypertension
| Variables | Without Parental Hypertension (n=462) | With Parental Hypertension (n=92) | P Valuea |
|---|---|---|---|
| Mean (SE) | Mean (SE) | ||
| Age, y | 16.0 (0.1) | 16.4 (0.2) | .04 |
| Height, cm | 166.5 (0.4) | 168.0 (0.8) | .10 |
| Weight, kg | 59.4 (0.7) | 65.0 (2.0) | .01 |
| Energy intake, kcal/d | 2292 (55) | 2155 (110) | .27 |
| Carbohydrates, % | 60.7 (0.6) | 59.1 (1.6) | .36 |
| Protein, % | 14.3 (0.3) | 15.9 (1.5) | .31 |
| Fat, % | 23.6 (0.4) | 22.8 (1.0) | .48 |
| Sex, No. (%) | |||
| Boys | 224 (52.0) | 51 (54.0) | .74 |
| Girls | 238 (48.0) | 41 (46.0) | |
| Income, No. (%) | |||
| Lower | 243 (54.3) | 42 (47.7) | .40 |
| Upper | 217 (45.7) | 49 (52.3) | |
| Lack of physical activity, No. (%) | 163 (36.0) | 35 (39.7) | .61 |
| Underage drinking, No. (%) | 144 (39.5) | 31 (48.3) | .18 |
| Current smoker, No. (%) | 30 (9.8) | 10 (14.4) | .29 |
| Sleep <7 h per night, No. (%) | 171 (39.4) | 30 (39.6) | .97 |
Values are weighted to represent the entire Korean adolescent population.
Abbreviation: SE, standard error.
Analyzed with t test by using a complex sample general linear model for continuous variables and the chi‐square test for categorical variables.
3.2. Cardiometabolic risk factors according to parental hypertension
Table 2 shows the cardiometabolic risk factors among the participants. The mean values of BMI, waist circumference, systolic BP, and ALT level were significantly higher in participants with parental hypertension than those without. The prevalence of overweight, obesity, abdominal obesity, high BP, and elevated ALT was significantly higher among participants with parental hypertension than those without. There was no significant difference in the prevalence of impaired fasting glucose, hypercholesterolemia, hypertriglyceridemia, and low high‐density lipoprotein cholesterol levels between the two groups.
Table 2.
Cardiometabolic risk factors according to parental history of hypertension
| Variables | Without parental hypertension (n=462) | With parental hypertension (n=92) | P valuea | ||
|---|---|---|---|---|---|
| Mean | (SE) | Mean | (SE) | ||
| BMI, kg/m2 | 21.3 | (0.2) | 22.8 | (0.5) | .02 |
| Waist circumference, cm | 71.0 | (0.6) | 74.2 | (1.4) | .04 |
| Systolic BP, mm Hg | 108.2 | (0.6) | 111.8 | (1.6) | .04 |
| Diastolic BP, mm Hg | 67.6 | (0.5) | 69.4 | (1.2) | .17 |
| Fasting glucose, mg/dL | 89.5 | (0.5) | 59.8 | (1.0) | .81 |
| Total cholesterol, mg/dL | 155.2 | (1.3) | 157.4 | (3.8) | .59 |
| Triglyceride, mg/dL | 54.1 | (2.9) | 96.9 | (7.6) | .12 |
| HDL cholesterol, mg/dL | 53.4 | (0.6) | 51.7 | (1.3) | .23 |
| LDL cholesterol, mg/dL | 85.0 | (1.2) | 86.3 | (2.5) | .64 |
| ALT, IU/Lb | 14.3 | (0.6) | 21.9 | (2.6) | <.01 |
| Overweight, No. (%) | 58 | (14.0) | 17 | (24.5) | <.01 |
| Obesity, No. (%) | 57 | (15.3) | 19 | (26.5) | <.01 |
| Abdominal obesity, No. (%) | 29 | (8.0) | 12 | (17.8) | .02 |
| High BP, No. (%) | 15 | (3.8) | 9 | (11.0) | .01 |
| Impaired fasting glucose, No. (%) | 24 | (7.1) | 11 | (11.2) | .23 |
| Hypercholesterolema, No. (%) | 21 | (4.3) | 4 | (6.0) | .53 |
| Hypertriglyceridemia, No. (%) | 36 | (8.2) | 8 | (9.7) | .70 |
| Low HDL cholesterol, No. (%) | 65 | (13.1) | 14 | (15.6) | .58 |
| Elevated ALT (>35 IU/L), No. (%) | 14 | (4.5) | 8 | (13.1) | .01 |
BMI, body mass index; BP, blood pressure; HDL, high‐density lipoprotein; LDL, low‐density lipoprotein; SE, standard error.
Values are weighted to represent the entire Korean adolescent population.
Analyzed with t test by using a complex sample general linear model for continuous variables and the chi‐square test for categorical variables.
Normal range of ALT in adolescents 12–17 years old, 26 IU/L for boys and 22 IU/L for girls.
3.3. Relationship between parental history of hypertension and cardiometabolic risk factors
The associations between parental history of hypertension and cardiometabolic risk factors are shown in Table 3. In the univariate model, parental history of hypertension was significantly associated with overweight, obesity, abdominal obesity, high BP, and elevated ALT in the offspring. After adjusting for age, sex, and income level, the ORs for overweight (OR, 2.08; 95% CI, 1.01–4.28) and obesity (OR, 2.11; 95% CI, 1.09–4.07) were significantly higher in participants with a parental history of hypertension. The adjusted ORs for abdominal obesity (OR, 2.36; 95% CI, 1.01–5.56), high BP (OR, 3.05; 95% CI, 1.19–7.78), and elevated ALT (OR, 2.86; 95% CI, 1.03–7.95) were significantly higher in participants with a parental history of hypertension than in those without. However, we could not find any associations between parental hypertension and impaired fasting glucose or dyslipidemia.
Table 3.
Cardiometabolic Risk Factors According to Parental History of Hypertension
| Variables | Without Parental Hypertension | With Parental Hypertension | |||||
|---|---|---|---|---|---|---|---|
| Univariate Logistic Regression | Multivariate Logistic Regressiona | ||||||
| OR (95% CI) | P Value | OR (95% CI) | P Value | ||||
| Overweight | 1.00 | 2.12 (1.03–4.39) | .02 | 2.08 (1.01–4.28) | .04 | ||
| Obesity | 1.00 | 2.37 (1.25–4.49) | .02 | 2.11 (1.09–4.07) | .04 | ||
| Abdominal obesity | 1.00 | 2.50 (1.12–5.56) | .03 | 2.36 (1.01–5.56) | .04 | ||
| High blood pressure | 1.00 | 3.15 (1.27–7.82) | .01 | 3.05 (1.19–7.78) | .02 | ||
| Impaired fasting glucose | 1.00 | 1.65 (0.72–3.81) | .24 | 1.72 (0.74–4.00) | .21 | ||
| Hypercholesterolemia | 1.00 | 1.44 (0.45–4.59) | .53 | 1.60 (0.50–5.17) | .42 | ||
| Hypertriglyceridemia | 1.00 | 1.20 (0.47–3.03) | .70 | 1.13 (0.43–2.97) | .81 | ||
| Low HDL cholesterol | 1.00 | 1.22 (0.60–2.50) | .58 | 1.22 (0.60–2.50) | .58 | ||
| Elevated ALT (>35 IU/L) | 1.00 | 3.20 (1.21–8.48) | .02 | 2.86 (1.03–7.95) | .04 | ||
Values are weighted to represent the entire Korean adolescent population.
Abbreviations: ALT, alanine transaminase; CI, confidence interval; HDL, high‐density lipoprotein; OR, odds ratio.
Adjusted for sex, age, and income level.
4. Discussion
This study demonstrated the importance of parental hypertension on cardiometabolic risk factors in adolescents. A positive parental history of hypertension was associated with a higher risk of overweight, obesity, abdominal obesity, high BP, and elevated ALT in adolescents. The advantages of obtaining information on family history over other tools include its lower cost, greater acceptability, and ability to provide a reflection of shared genetic and environmental factors.20 As a result, professional guidelines usually include the assessment of family history in health risk evaluations on the individualized or public level. Although most chronic conditions usually do not manifest until adulthood, children and adolescents with family histories of certain conditions already show preclinical signs of those conditions.
The relationship between parental hypertension and increased cardiometabolic risk in offspring could result from both shared environmental and genetic factors. In terms of shared environmental factors, the offspring of hypertensive parents are particularly prone to a high intake of excess sodium.21 Moreover, it has been demonstrated that adolescents with parental hypertension tend to have lower levels of physical activity, which is possibly linked to an increased risk of obesity.22 In our study, participants with parental hypertension had a significantly higher weight than those without parental hypertension at baseline. A patient with higher weight would be expected to have a higher BMI and a higher likelihood of being obese. However, we considered parental hypertension as an independent variable that increased the risks for overweight, obesity, and abdominal obesity.
Similarly, a recent study in Japanese children demonstrated that children with a family history of hypertension were much more likely to be overweight.14 In that study, parental hypertension was categorized as either paternal or maternal hypertension, and it was concluded that maternal hypertension increased the risk of overweight in children. It has been suggested that the disparity in the manifestation of parental transmission on these metabolic risk factors might be a result of mitochondrial DNA–mediated inheritance, transmitted on the maternal lineage.23 Unfortunately, in our study, we were not able to analyze the data according to which parent had hypertension owing to the inadequate number of participants with a positive history of maternal hypertension (n=13). Our study showed that adolescents with parental hypertension had an increased risk of being overweight and having other additional cardiometabolic risk factors.
Adolescents with parental hypertension are at a risk for having abdominal obesity as measured by using waist circumference. A previous study also demonstrated that waist circumference could identify persons with a higher cardiometabolic risk than those identified by using BMI alone.24 In adolescents, although the use of waist circumference to predict cardiometabolic risk factors has been suggested, waist circumference is not well used for screening even in high‐risk groups such as adolescents with a family history of cardiometabolic disease.25 In addition to assessing family history, measurements of waist circumference in addition to BMI could contribute to identifying cardiometabolic risk and monitoring the development of risk factors.
Participants with parental hypertension showed an about three‐fold higher risk of high BP than those without parental hypertension. Among our study population, 16.2% had a parental history of hypertension. The national prevalence of hypertension in Korean adults was 25.5% in 2014.26 Since the participants were adolescents aged 13 to 19 years, it is reasonable to assume that their parents might have been in their 40s. In fact, according to the Korea Statistical Information Service, the prevalence of hypertension in Korean adults aged 40 to 49 years was 17.7% in 2014, which is similar to our data. However, the number of participants with maternal hypertension was relatively small (paternal hypertension 15.8% vs maternal hypertension 2.8%). A possible explanation might be that maternal hypertension had remained in the subclinical stage, as women generally develop hypertension at a later age than men,27 which likely resulted in an underestimation.
The results of our study also showed that a parental history of hypertension in adolescents indicates a greater risk for elevated ALT, suggestive of NAFLD. Although most patients with NAFLD have a benign clinical course, approximately 25% develop nonalcoholic steatohepatitis, which is a more serious form of liver damage.28, 29 In addition, children and adolescents with NAFLD were shown to have a higher prevalence of subclinical atherosclerosis, which is independent of obesity and other established risk factors.9 A study with 10‐ to 18‐year‐old adolescents found strong associations of elevated ALT with most cardiometabolic risk factors.30 The findings of our study support the idea that the offspring of hypertensive parents are particularly prone to showing elevated ALT, which provides a common pathway for the development of metabolic disease.
In clinical practice, the diagnosis of NAFLD is usually suggested by the finding of elevated ALT in combination with liver ultrasound findings.19 Serum ALT activity is a widely available and inexpensive test for screening NAFLD in children and adolescents.31 We defined elevated ALT as >35 IU/L, according to the latest consensus statement of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.19 This cutoff point was higher than the reference range in adolescents 12 to 17 years (26 IU/L for boys and 22 IU/L for girls) that was suggested by the American Gastroenterology Association.32 Therefore, the probability of overestimation of the prevalence of elevated ALT in our study participants might be scarce.
Study Limitations
Our study has several limitations. First, we could not exclude the possibility of underreporting and less accurate evaluation of parental history of hypertension, as the interviewer‐administered questionnaire used in this national survey was answered by adolescents, not by their parents. Moreover, the initial questionnaire did not include information about the age of the parents, gestational history, and adoption. In the future, taking complete data about not only the offspring but also the parents, including the above items, is needed. Second, another potential limitation is recall bias. Dietary surveys from the single 24‐hour recall method and assessment of lifestyle factors cannot be corrected for intraindividual daily variations in consumption. It was also probable for adolescents to underreport unhealthy behaviors such as smoking and alcohol drinking. Third, because our study used a cross‐sectional design, we could not define a causal relationship. Lastly, the cell counts for some cardiometabolic risk factors in patients with parental hypertension were very low and not enough to show statistical significance.
5. Conclusions
We found a strong relationship between parental hypertension and cardiometabolic risk factors in adolescents. Adolescents with parental hypertension have higher risks of having obesity, abdominal obesity, hypertension, and elevated ALT level than those without parental hypertension. Therefore, prevention of and early intervention for cardiometabolic risk in adolescents with parental hypertension should be reinforced.
Disclosure Statement
This research was supported by the Basic Science Research Program through the National Research Foundation of Korea and funded by the Ministry of Education, Science, and Technology (2012‐004869). The authors report no relationships that could be constructed as a conflict of interest.
Yoo JE, Park HS. Relationship between parental hypertension and cardiometabolic risk factors in adolescents. J Clin Hypertens. 2017;19:678–683. 10.1111/jch.12991
References
- 1. Brunzell JD, Davidson M, Furberg CD, et al. Lipoprotein management in patients with cardiometabolic risk: consensus conference report from the American Diabetes Association and the American College of Cardiology Foundation. J Am Coll Cardiol. 2008;51:1512–1524. [DOI] [PubMed] [Google Scholar]
- 2. Centers for Disease Control and Prevention . Prevalence of overweight and obesity among children and adolescents aged 2‐19 years: United States, 1963‐1965 through 2013‐2014. https://www.cdc.gov/nchs/data/hestat/obesity_child_13_14/obesity_child_13_14.htm. Accessed December 22, 2016.
- 3. Giorgio V, Prono F, Graziano F, Nobili V. Pediatric non alcoholic fatty liver disease: old and new concepts on development, progression, metabolic insight and potential treatment targets. BMC Pediatr. 2013;13:40. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. You J, Choo J. Adolescent overweight and obesity: links to socioeconomic status and fruit and vegetable intakes. Int J Environ Res Public Health. 2016;13:(3). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Kim HM, Park J, Kim HS, Kim DH, Park SH. Obesity and cardiovascular risk factors in Korean children and adolescents aged 10‐18 years from the Korean National Health and Nutrition Examination Survey, 1998 and 2001. Am J Epidemiol. 2006;164:787–793. [DOI] [PubMed] [Google Scholar]
- 6. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long‐term morbidity and mortality of overweight adolescents: a follow‐up of the Harvard Growth Study of 1922 to 1935. N Engl J Med. 1992;327:1350–1355. [DOI] [PubMed] [Google Scholar]
- 7. Berenson GS, Srinivasan SR, Bao W, Newman WP, Tracy RE, Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. N Engl J Med. 1998;338:1650–1656. [DOI] [PubMed] [Google Scholar]
- 8. Magnussen CG, Venn A, Thomson R, et al. The association of pediatric low‐and high‐density lipoprotein cholesterol dyslipidemia classifications and change in dyslipidemia status with carotid intima‐media thickness in adulthood: evidence from the cardiovascular risk in Young Finns study, the Bogalusa Heart Study, and the CDAH (Childhood Determinants of Adult Health) study. J Am Coll Cardiol. 2009;53:860–869. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Bonci E, Chiesa C, Versacci P, Anania C, Silvestri L, Pacifico L. Association of nonalcoholic fatty liver disease with subclinical cardiovascular changes: a systematic review and meta‐analysis. BioMed Res Int. 2015;2015:213737. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Steinberger J, Daniels SR. Obesity, insulin resistance, diabetes, and cardiovascular risk in children: an American Heart Association scientific statement from the Atherosclerosis, Hypertension, and Obesity in the Young Committee (Council on Cardiovascular Disease in the Young) and the Diabetes Committee (Council on Nutrition, Physical Activity, and Metabolism). Circulation. 2003;107:1448–1453. [DOI] [PubMed] [Google Scholar]
- 11. Noncommunicable diseases; 2015. http://www.who.int/mediacentre/factsheets/fs355/en/. Accessed November 18, 2016.
- 12. Ranasinghe P, Cooray DN, Jayawardena R, Katulanda P. The influence of family history of hypertension on disease prevalence and associated metabolic risk factors among Sri Lankan adults. BMC Public Health. 2015;15:1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Grunfeld B, Balzareti M, Romo M, Gimenez M, Gutman R. Hyperinsulinemia in normotensive offspring of hypertensive parents. Hypertension. 1994;1(suppl):I12–I15. [DOI] [PubMed] [Google Scholar]
- 14. Liu J, Sekine M, Tatsuse T, Hamanishi S, Fujimura Y, Zheng X. Family history of hypertension and the risk of overweight in Japanese children: results from the Toyama Birth Cohort Study. J Epidemiol. 2014;24:304–311. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Moon JS, Lee SY, Nam CM, et al. 2007 Korean National Growth Charts: review of developmental process and an outlook. Korean J Pediatr. 2008;51:1–25. [Google Scholar]
- 16. Lee S, Park HS, Kim SM, et al. Cut‐off points of waist circumference for defining abdominal obesity in the Korean population. Korean J Obesity. 2006;15:1–9. [Google Scholar]
- 17. Zimmet P, Alberti G, Kaufman F, Tajima N. The metabolic syndrome in children and adolescents. The Lancet. 2007;369:2059. [DOI] [PubMed] [Google Scholar]
- 18. Daniels SR, Greer FR. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008;122:198–208. [DOI] [PubMed] [Google Scholar]
- 19. Vajro P, Lenta S, Socha P, et al. Diagnosis of nonalcoholic fatty liver disease in children and adolescents: position paper of the ESPGHAN Hepatology Committee. J Pediatr Gastroenterol Nutr. 2012;54:700–713. [DOI] [PubMed] [Google Scholar]
- 20. Valdez R, Yoon PW, Qureshi N, Green RF, Khoury MJ. Family history in public health practice: a genomic tool for disease prevention and health promotion. Annu Rev Public Health. 2010;31:69–87. [DOI] [PubMed] [Google Scholar]
- 21. Siervogel RM. Genetic and familial factors in essential hypertension and related traits. Am J Phys Anthropol. 1983;26(S1):37–63. [Google Scholar]
- 22. Hansen HS, Nielsen JR, Hyldebrandt N, Froberg K. Blood pressure and cardiac structure in children with a parental history of hypertension: the Odense Schoolchild Study. J Hypertens. 1992;10:677–682. [PubMed] [Google Scholar]
- 23. Rodríguez‐Moran M, Aradillas‐García C, Simental‐Mendia LE, et al. Family history of hypertension and cardiovascular risk factors in prepubertal children. Am J Hypertens. 2010;23:299–304. [DOI] [PubMed] [Google Scholar]
- 24. Klein S, Allison DB, Heymsfield SB, et al. Waist circumference and cardiometabolic risk: a consensus statement from shaping America's health: Association for Weight Management and Obesity Prevention; NAASO, the Obesity Society; the American Society for Nutrition; and the American Diabetes Association. Obesity. 2007;15:1061–1067. [DOI] [PubMed] [Google Scholar]
- 25. Bassali R, Waller JL, Gower B, Allison J, Davis CL. Utility of waist circumference percentile for risk evaluation in obese children. Int J Pediatr Obesity. 2010;5:97–101. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. Korean Statistical Information Service . Statistical database, hypertension: ≥30 years, by sex; 2016. http://kosis.kr/eng/statisticsList/statisticsList_01List.jsp?vwcd=MT_ETITLE&parentId=D#SubCont. Accessed December 9, 2016.
- 27. Maas A, Appelman Y. Gender differences in coronary heart disease. Neth Heart J. 2010;18:598–603. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Adams LA, Lymp JF, Sauver JS, et al. The natural history of nonalcoholic fatty liver disease: a population‐based cohort study. Gastroenterology. 2005;129:113–121. [DOI] [PubMed] [Google Scholar]
- 29. Wong VW, Wong GL, Choi PC, et al. Disease progression of non‐alcoholic fatty liver disease: a prospective study with paired liver biopsies at 3 years. Gut. 2010;59:969–974. [DOI] [PubMed] [Google Scholar]
- 30. Mohammadi F, Qorbani M, Kelishadi R, et al. Association of cardiometabolic risk factors and hepatic enzymes in a national sample of Iranian children and adolescents: the CASPIAN‐III study. J Pediatr Gastroenterol Nutr. 2014;58:463–468. [DOI] [PubMed] [Google Scholar]
- 31. Giorgio V, Prono F, Graziano F, Nobili V. Pediatric non alcoholic fatty liver disease: old and new concepts on development, progression, metabolic insight and potential treatment targets. BMC Pediatr. 2013;13:1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Schwimmer JB, Dunn W, Norman GJ, et al. SAFETY study: alanine aminotransferase cutoff values are set too high for reliable detection of pediatric chronic liver disease. Gastroenterology. 2010;138:1357–1364. e1352. [DOI] [PMC free article] [PubMed] [Google Scholar]