Abstract
Objectives: To assess factors associated with prehypertension and hypertension among children in North Africa. Methods: An epidemiological observational, school- and college-based study among 3562 healthy children and adolescents to assess factors associated with blood pressure categories (normal, prehypertensive, hypertensive), including perinatal (gestational age, birth weight, breastfeeding) and current lifestyle characteristics (body mass index, time spent watching a screen and time spent exercising). Results: Prevalence of hypertension increased with age from 8.7% between 6-10 years to 14.7% between 11-15 years, and 15.6% above 15 years. Prevalence of prehypertension and hypertension increased with body mass index from 9.9% and 11.5% among children not overweight to 15.6% (RR 1.58, 95% CI 1.24-2.02, P<0.001) and 17.2% (RR 1.50, 95% CI 1.22-1.85, P<0.001) among those overweight and to 26.8% (RR 2.72, 95% CI 2.04-3.64, P<0.01) and 32.3% (RR 2.82, 95% CI 2.27-3.50, P<0.01) among obese children. There was a trend of association of prehypertension with the time spent watching Television, internet and electronic games. Children whose mother or father had a history of hypertension had a trend to be prehypertensive or hypertensive. A parental hypertension was found in 33.6% of normotensive, 38.2% of prehypertensive, and 42.6% of hypertensive children (P=0.05). Children with prehypertension or hypertension were more likely to have a diabetic father or mother (22.8% and 22.6% vs 15.8%, respectively, P=0.01). Also, prehypertension and hypertension were associated with shorter gestational age, early birth, reduced birth weight, and shorter breastfeeding. Conclusion: Prehypertension and hypertension have a high prevalence among children in North Africa. They are associated with overweight, obesity, diabetes, a shorter gestational age, a lower birth weight and a shorter breastfeeding.
Keywords: Hypertension, prehypertension, childhood, Algeria
Introduction
Recent epidemiological studies have shown that hypertension, a condition formerly confined largely to adults, has pervaded pediatric populations [1-4]. Considering that blood pressure (BP) tracks from childhood into adulthood and that raised BP in early life is an independent risk factor for future cardiovascular disease [4-6], identification of children with elevated blood pressure and early treatment or prevention may have an important impact on the long-term outcome [7].
Factors associated with high blood pressure (HBP) among adults are already detectable in childhood in many instances [1-4]. Early assessment of such risk factors as birth weight [6,8,9], diet and nutritional status in childhood [10-12], social circumstances [13], and the identification of protective factors may contribute to an early intervention in children who are more likely to develop cardiovascular disease. Assessment of socioeconomic factors associated with HBP in children continues being difficult since confounding variables such as nutritional and lifestyle behavioral parameters are associated in most instances, including maternal overweight or hypertension, breastfeeding duration, child overweight, domestic tobacco exposure, reduced physical activity or exercise levels [13].
Finally, most studies conducted in children have been performed in high-income countries [1,3-6,8-10,13]. By contrast, fewer studies are available from either lower-income level countries or socioeconomically disadvantaged areas, where these combinations of risk factors could be expected to result in a higher prevalence of children HBP.
The aims of this study are to determine whether characteristics of a rather socioeconomically disadvantaged community affect BP, prehypertension, and hypertension among children in a large suburban area in North Africa.
Methods
Study population
This is an epidemiological observational, descriptive, cross-sectional school and college-based study in a representative sample of healthy children and adolescents of both genders, residing in a suburban area in Bainem District, Algiers. Between October 2014 and April 2015, children aged 6-18 years in Ain Benian, a 68354 inhabitants city located in a suburban area west to Algiers were screened. The total population of schoolchildren in the district is 9453.
Considering the prevalence of HBP among children in small previous studies [1,4,6,7], at a significance level of 5% and test power of 80%, and a margin error of 1%, the minimum sample size for the present study was estimated to be 1825 children and adolescents. We changed this parameter to get a test-power of 90%. Accordingly, among the 9418 children and adolescents listed, a sample of all apparently healthy children (n=3562) from 3 primary and 6 high schools was selected, corresponding to a test power of 92%.
Inclusion criteria
All healthy children and adolescents aged 6-18 years from 3 primary and high schools were included.
This comprised 1661 boys (46.6%) and 1901 girls (53.4%) ranging in age 6-10 years (n=846, 23.8%), 11-15 years (n=1316, 36.9%), and 15-18 years (n=1400, 39.3%).
Exclusion criteria
Children and adolescents with a history of previous disease or with a treatment for any disease or pathological condition were excluded. Ten children with a history of previous disease were excluded, 3 with diabetes, 5 with inflammatory diseases and/or treated with steroids, 1 with nephroblastoma and 1 with congenital atrioventricular block.
Blood pressure
Blood pressure was measured twice in the supine position after 5 minutes of rest with the Omron 705 IT (Omron Healthcare Inc, Cannockburn, IL) with its small cuff (arm circumference 17-22 cm), that is validated in children [14]. If these measurements differed by >10 mmHg, a third measurement was taken. We characterized children as pre-hypertensive if either systolic blood pressure (SBP) or diastolic blood pressure (DBP) was ≥ 90th and ≤ 95th percentile and as hypertensive if either SBP or DBP was ≥ 95th percentile according to the NHANES 1999 to 2000 BP reference for children and adolescents [15-17].
Body mass index
Body mass index (BMI) (kg/m2) and the BMI percentile were calculated for each child, with determination of age- and sex-specific z scores for BMI and length/height using the World Health Organization growth reference [18]. Children with BMI percentile values between 85 and 95 were considered overweight, and those over 95 were classified as obese [18].
Exposure
Medical records provided information on perinatal characteristics including the child’s gender, birth weight, delivery date, and gestational age at birth. Birth weight was categorized into 3 groups, ≤1500 g, 1501-2500 g, and >2500 g. Gestational age was categorized into 3 groups, 25-32 weeks, 33-36 weeks, and >36 weeks.
Mothers reported on their age, educational level, parity, household incomes and paternal height and weight and on breastfeeding duration via interview and questionnaire administered at enrollment.
Breastfeeding was categorized as exclusive breastfeeding (1), no exclusive breastfeeding (with complementary feeding) with breastfeeding only more than 4 months (2), and no exclusive breastfeeding with breastfeeding only less than 4 months (3).
Ethical
Potential participants or the parents of the children who are potential participants received information using a waiver of documentation of consent, as performed in minimal risk research collecting anonymous information only. All mothers provided informed verbal consent at recruitment. All children provided verbal assent at the visit. The institutional review board of the Mustapha hospital approved all study protocols.
Statistical analysis
Statistical analysis investigated the characteristics of the sample and the factors associated with prehypertension and hypertension. Continuous variables were expressed as means with standard deviations and categorical variables as frequencies and percentages. Means’ comparisons were done using the Student’s t-test. Percentages were compared using Pearson chi-square test. A probability of <0.05 was considered as statistically significant and a Bonferroni correction was applied.
In each group, normotensive, prehypertensive, and hypertensive children, univariate analysis was performed using conditional logistic regression models that allowed us to analyze the association between the different variables taken one by one, and also prevalence of prehypertension and hypertension by calculating the relative risks and odds ratio with a confidence interval of 95%.
In this cross-sectional study design, there are more than one important confounder that we would like to adjust for in the design of our study. In this case, we typically match each case patient to one or more controls with the same value of the confounding variables. This approach is often quite reasonable. However, it usually leads to strata (matched pairs or sets of patients) that are too small to be analyzed accurately with logistic regression. In this case, an alternate technique called conditional logistic regression should be used (our case), and in order to simplify the results interpretation, RR (relative risk) are used/preferred to OR (odds ratio), as in cross-sectional data, may serve to calculate relative risks from prevalence.
Data were computed using a statistical package software: SSPS version 1.7 and EPI INFO TM version 6.
Results
Among the 3562 children included, there were 1661 boys (46.6%) and 1901 girls (53.4%). In the distribution by age group, 846 (23.8%) were between 6 and 10 years, 1316 (36.9%) between 11 and 15 years, and 1400 (39.3%) were more than 15 years. Parental consanguinity was observed in 598 children (16.8%).
Prevalence of prehypertension and hypertension
Prehypertension was found in 355 (10.0%) and hypertension in 486 (13.6%) children. There were no differences in age, sex, and consanguinity rate between normotensive, prehypertensive, and hypertensive children (Table 1).
Table 1.
Baseline characteristics of the study population
| All, n=3562 | Normotensive, n=2721 | Pre-hypertension, n=355 | Hypertension, n=486 | P= | |
|---|---|---|---|---|---|
| Boys, n= (%) | 1661 (46.6) | 1249 (45.9) | 164 (46.1) | 248 (51.0) | 0.27 (0.99*) |
| Age (years) | |||||
| 6-10 | 846 (23.7) | 683 (25.1) | 89 (25.0) | 74 (15.8) | Age (all) |
| 11-15 | 1316 (36.9) | 981 (36.1) | 141 (39.7) | 194 (39.9) | 0.32 (0.99*) |
| >15 | 1400 (39.3) | 1057 (38.8) | 125 (35.2) | 218 (44.8) | |
| Consanguinity, n= (%) | 598 (16.3) | 447 (16.4) | 64 (18.0) | 87 (17.9) | 0.43 |
| 0.99* | |||||
| Overweight, n= (%) | 558 (15.6) | 390 (14.3) | 72 (20.3) | 96 (19.8) | <0.01 |
| <0.05* | |||||
| Obesity, n= (%) | 219 (6.1) | 108 (4.0) | 40 (11.3) | 71 (14.6) | <0.001 |
| <0.005* |
Adjusted p-value through Bonferroni correction.
Prevalence of hypertension increased with age from 8.7% between 6-10 years to 14.7% between 11-15 years (RR 1.69, 95% CI 1.32-2.17), and 15.6% above 15 years (RR 1.79, 95% CI 1.39-2.27).
Prevalence of prehypertension and hypertension increased with body mass index from 9.9% and 11.5% among children not overweight to 15.6% (RR 1.58, 95% CI 1.24-2.02, P<0.001) and 17.2% (RR 1.50, 95% CI 1.22-1.85, P<0.001) among those overweight and to 26.8% (RR 2.72, 95% CI 2.04-3.64, P<0.01) and 32.3% (RR 2.82, 95% CI 2.27-3.50, P<0.01) among obese children (Table 1).
Overweight was found in 14.3% of normotensive, 20.3% of prehypertensive, and 19.8% of hypertensive children (P<0.01 for both). Obesity was observed in 4% of normotensive, 11.3% of prehypertensive, and 14.6% of hypertensive children (P<0.001 for both) (Table 1).
Children whose mother or father had a history of hypertension had a trend to be prehypertensive or hypertensive. Although not statistically significant, a parental history of hypertension was found in 33.6% of normotensive, 38.2% of prehypertensive, and 42.6% of hypertensive children (P=0.05) (Table 2). Children with prehypertension or hypertension were more likely to have a diabetic father or mother than normotensive children do (22.8% and 22.6% vs 15.8%, P=0.01), respectively (Table 2).
Table 2.
Familial history of the children according to blood pressure categories
| All, n=3562 | Normotensive, n=2721 | Prehypertension, n=355 | Hypertension, n=486 | P= | |
|---|---|---|---|---|---|
| Parental HBP, n= (%) | 1260 (35.4) | 916 (33.6) | 137 (38.2) | 207 (42.6) | 0.05 |
| 0.15* | |||||
| Parental diabetes, n= (%) | 623 (17.4) | 432 (15.8) | 81 (22.8) | 110 (22.6) | 0.01 |
| 0.03* | |||||
| Parental dyslipidemia, n= (%) | 781 (21.9) | 610 (22.4) | 75 (22.1) | 96 (19.7) | 0.21 |
| 0.63* |
Adjusted p-value through Bonferroni correction.
No statistical differences in prevalence of prehypertension and hypertension were observed among children whose parents had or had not a history of increased lipid levels (Table 2).
Factors associated with risk of prehypertension and hypertension
Prehypertension and hypertension were associated with a shorter gestational age, a reduced birth weight, and a shorter breastfeeding (Table 3).
Table 3.
Gestational age, birth weight, and breastfeeding of the children according to blood pressure categories
| All, n=3562 | Normotensive, n=2721 | Prehypertensive, n=355 | Hypertensive, n=486 | P= | P=* | |
|---|---|---|---|---|---|---|
| Gestational age, n=(%) | ||||||
| 25-32 w | 20 (0.6) | 7 (0.3) | 5 (1.4) | 8 (1.6) | <0.001 | <0.005 |
| 33-36 w | 240 (6.7) | 137 (5.0) | 50 (14.1) | 53 (10.9) | 0.01 | 0.03 |
| >36 w | 3302 (92.7) | 2577 (94.7) | 300 (84.5) | 425 (87.5) | 0.07 | 0.21 |
| Birth weight, n=(%) | ||||||
| ≤1500 g | 18 (0.5) | 9 (0.4) | 5 (1.4) | 4 (0.8) | 0.22 | 0.99 |
| 1501-2500 g | 369 (10.4) | 212 (7.8) | 70 (19.7) | 87 (17.9) | <0.0001 | <0.0005 |
| >2500 g | 3175 (86.0) | 2500 (91.8) | 280 (78.9) | 395 (81.3) | 0.01 | 0.03 |
| Breastfeeding, n=(%) | ||||||
| -exclusive | 3064 (86.0) | 2407 (88.5) | 277 (78.0) | 380 (78.2) | <0.0001 | <0.0005 |
| -no exclusive, ≥ 4 months | 2380 (66.8) | 1891 (69.5) | 191 (53.8) | 298 (61.3) | <0.01 | <0.05 |
| -no exclusive, <4 months | 482 (13.5) | 299 (10.9) | 77 (21.7) | 106 (21.8) | 0.38 | 0.99 |
w: weeks.
P: adjusted p-value through Bonferroni correction.
Gestational age
Among children with a gestational age >36 weeks, prevalence of prehypertension and hypertension were 10.4% and 12.2%, increasing to 26.7% (RR 1.56, 95% CI 0.71-3.17, P=0.01) and 22.1% (RR 1.81, 95% CI 1.01-3.26, P<0.05) in those born between 33 and 36 weeks. Prehypertension was observed in 41.7% of those born before 32 weeks (RR 4.0, 95% CI 2.03-5.88, P=0.01).
Birth weight
Among children with a birth weight >2500 g, prevalence of prehypertension and hypertension were 10.2% and 12.7%, increasing to 22.7% (RR 1.58, 95% CI 0.76-3.28, P<0.01) and 22.0% (RR 0.74, 95% CI 1.41-2.14, P<0.01) among those with a birth weight between 1501 and 2500 g, and to 35.7% (RR=3.51, CI 1.72-7.16, P<0.01) and 22.2% (RR 1.76, 95% CI 0.14-4.19, P=0.01) among those with very low birth weight <1500 g.
Breastfeeding
No exclusive breastfeeding with complementary feeding only less than 4 months (3) was associated with a lower prevalence of prehypertension (10.5% vs 12%, RR 1.56, 95% CI 1.25-1.98, P<0.001), however, for hypertension there was no difference with normotensive children (20.5% vs 22.0%, RR 0.96, 95% CI 0.76-1.12, P=0.38).
Lifestyle
There was a trend of association of prehypertension and hypertension with the time spent watching Television (TV), internet and electronic games. Children who spent less than 2 hours watching a screen had a lower prevalence of prehypertension (10.5% vs 12.2%, RR 0.86% CI 0.70-0.98, P=0.01) and hypertension (10% vs 14.2%, RR 0.70, 95% CI 0.62-1.04, P=0.02) than those who spent more than 2 hours per day. However, this association was no longer observed after Bonferroni correction (P=0.06). There was no difference in prevalence of prehypertension and hypertension between children who spent more or less than 2 hours exercising or participating to recreational sport activities (9.6% vs 11.5%, RR 0.83, 95% CI 0.61-1.14, P=0.24, and 9.6% vs 13.2%, RR 0.72, 95% CI 0.64-0.98, P=0.15, respectively) (Table 4).
Table 4.
Lifestyle of the children according to blood pressure categories
| All, n=3562 | Normotensive, n=2721 | Prehypertension, n=355 | Hypertension, n=486 | |
|---|---|---|---|---|
| Smoking, n=(%) | 93 (2.6) | 69 (2.5) | 7 (1.9) | 17 (3.5) |
| p=0.50 | ||||
| p=0.99* | ||||
| Sportive activity <2 h per week, n=(%) | 1258 (35.3) | 893 (32.8) | 133 (37.5) | 232 (47.8) |
| P=0.24 | P=0.15 | |||
| P=0.72* | P=0.45* | |||
| TV/internet/electronic games >2 h/day, n=(%) | 1710 (48) | 1154 (42.5) | 236 (66.5) | 320 (65.8) |
| P=0.01 | P=0.02 | |||
| P=0.03* | P=0.06* |
Adjusted p-value through Bonferroni correction.
Co-factors associated with prehypertension and hypertension
Relative risks for prehypertension and hypertension in children and adolescents according to the listed co-factors are listed in Table 5.
Table 5.
Relative risks for prehypertension and hypertension according to age, weight, gestational age, birth weight, breastfeeding, and lifestyle
| Prevalence of prehypertension, % (RR) | Prevalence of hypertension, % (RR) | |
|---|---|---|
| Age, years | ||
| 6-10 | 10.6 | 8.7 |
| 11-15 | 11.5 (RR 0.92, 95% CI 0.72-1.18) | 14.7 (RR 1.69, 95% CI 1.32-2.17) |
| >15 | 12.6 (RR 1.09, 95% CI 0.84-1.41) | 15.6 (RR 1.79, 95% CI 1.39-2.27) |
| Not overweight | 9.9 | 11.5 |
| Overweight | 15.6 (RR 1.58, 95% CI 1.24-2.02) | 17.2 (RR 1.50, 95% CI 1.22-1.85) |
| Obese | 26.8 (RR 2.72, 95% CI 2.04-3.64) | 32.3 (RR 2.82, 95% CI 2.27-3.50) |
| Gestational age | ||
| >36 weeks | 12.2 | 10.4 |
| 33-36 weeks | 26.7 (RR 1.56, 95% CI 0.71-3.17) | 22.1 (RR 1.81, 95% CI 1.01-3.26) |
| ≤32 weeks | 41.7 (RR 4.0, 95% CI 2.03-5.88) | |
| Birth weight, g | ||
| >2500 | 10.2 | 12.7 |
| 1501-2500 | 22.7 (RR 1.58, 95% CI 0.76-3.28) | 22 (RR 1.26, 95% CI 1.41-2.14) |
| <1500 | 35.7 (RR 3.51, 95% CI 1.72-7.16) | 22.7 (RR 1.76, 95% CI 0.14-4.19) |
| Breastfeeding | ||
| Exclusive | 10.5 | 20.5 (RR 0.96, 95% CI 0.76-1.12) |
| No exclusive | 12,0 (RR 1.56, 95% CI 1.25-1.98) | 22.0 |
| Screen | ||
| >2 h/day | 12.2 | 14.2 |
| <2 h/day | 10.5 (RR 0.86% CI 0.70-0.98) | 10.0 (RR 0.70, 95% CI 0.62-1.04) |
| Exercise, sport | ||
| <2 h/day | 11.5 | 13 |
| >2 h/day | 9.6 (RR 0.83, 95% CI 0.61-1.14) | 9.6 (RR 0.72, 95% CI 0.64-0.98) |
Discussion
Compared with data from Western countries, this study from a suburban area of Algiers shows a 2- to 3-fold higher prevalence of prehypertension and hypertension in children even in those with a BMI ranging within normal values. Indeed, hypertension was found in 6.1% non-overweight children and adolescents in Germany [19], 7% in United Kingdom [20], 4.2% in Italy [21], 2 to 4% in the United States [1], and 3.2% in France [22].
Concomitantly, prevalence of obesity and overweight among these children is consistent with studies from Western countries, accounting for 5-7% of children in Germany [19], Italy [21], France [22], and 16% in the United States [1]. Nonetheless, in our study obese children are more prone to have hypertension, with about one third of them being hypertensive as compared with one fourth in most other studies [1,6,19-23]. This may in turn affect subsequent prognosis, since greater weight in childhood has been associated with higher later life blood pressure [4,8].
Increasing rates of children obesity have been observed worldwide [1,23]. In a large, socially disadvantaged, minority urban population from the United States, 78.6% of obese children and adolescents went on to become obese as adults. Conversely, only 2.1% of non-obese adults were obese as teenagers [24]. Similar findings are observed across Africa, where body mass index and waist-to-height ratio have been reported as significant predictors of high blood pressure [25].
Socioeconomic inequalities play a determinant role in increased overweight and hypertension rates among children. Children from lower socioeconomic families have on average a higher blood pressure and are more likely to have prehypertension and hypertension [13], which is highly predictive for hypertension in later life [1,4].
Increased time spent watching the internet, TV, and electronic games as well as reduced time spent exercising and sports training also promote overweight, and, in turn, blood pressure [26]. This is seen among our children, in whom a trend of association is observed between prehypertension and hypertension and the time spent watching a computer or TV screen >2 hours per day.
In the present study, prehypertension and hypertension are associated with a shorter gestational age, preterm delivery, lower birth weight, and shorter breastfeeding. Low birth weight and fetal growth restriction have been identified as risk factors for raised blood pressure, cardiovascular disorders, coronary artery disease and stroke in later life both in mothers after preterm delivery [27], and in premature children [8]. Children small at birth but overweight later in life have been reported to have excessive weight gain in childhood, which is a determinant factor for subsequent diabetes and hypertension [9,10,28].
The role of complementary feeding has received little attention until now. However, early feeding may be related to later life blood pressure [29]. Recent reports, including the ABCD (Amsterdam Born Children and their Development) study, showed that longer duration of breastfeeding and later introduction of complementary feeding were associated with lower childhood blood pressure [10]. Our results show that exclusive breastfeeding lasting for more than 4 months is associated with a lower risk of subsequent prehypertension and hypertension.
In the present study, children whose mother or father had a history of hypertension has a trend to be prehypertensive or hypertensive. A parental history of hypertension is found in 33.6% of normotensive, 38.2% of prehypertensive, and 42.6% of hypertensive children. Since we found no relationship between parental consanguinity and blood pressure among our children, we suspected that environmental factors such as lifestyle, diet, or salt intake may play a role in the high prevalence of hypertension among children included in the study. Also, a high prevalence of hypertension has been reported in several epidemiological studies from Algeria [30,31].
Several programs of prevention have been developed to address these alarming issues. Interventions focused on parent education around diet and feeding practices as well as trials of breastfeeding promotion and lactation support interventions have been proposed with positive effects in infant diet or responsive feeding behaviors, but with less consistent effects on infant weight in the first 2 years of life [32].
Limitations of the study
Our findings should be interpreted in the context of several limitations. First, it is an observational study and residual confounding may explain the associations seen. Multivariate analysis was not conducted in order to assess the difference so basing our correlations one by one. Second, whereas the relationship between prehypertension, hypertension and BMI has been assumed, only longitudinal studies would be able to assess the evolution of this relationship overtime.
Conclusion
This study shows a high prevalence of prehypertension and hypertension in children living a large suburban area in Northern Africa. This alarming situation is associated with overweight, obesity, and reduced physical activity, which are all potential targets for preventive interventions.
Well-timed diagnosis of childhood hypertension is of outmost importance to start an appropriate therapy and to prevent development of cardiovascular morbidity in later life [33].
Acknowledgements
COCRG, Cardiology Oncology Research Collaborative Group (CORCG), Department of cardiology, CHU Mustapha, Faculty of Medicine BENYOUCEF BENKHEDDA University, Algiers, Algiers. There is no financial relationship with industry.
Disclosure of conflict of interest
None.
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