de Ferranti, Sarah D.

Zaidi, Abbas H.

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Thomas Jefferson University Jefferson Digital Commons Department of Pediatrics Faculty Papers Department of Pediatrics 10-31-2022 Prevalence of High Blood Pressure Among Youth in India and Association With Future Cardiovascular Disease Abbas H. Zaidi Sarah D. de Ferranti Follow this and additional works at: https://jdc.jefferson.edu/pedsfp  Part of the Cardiology Commons, and the Pediatrics Commons Let us know how access to this document benefits you This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Department of Pediatrics Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: JeffersonDigitalCommons@jefferson.edu. Invited Commentary | PediatricsPrevalence of High Blood Pressure Among Youth in Indiaand Association With Future Cardiovascular DiseaseAbbas H. Zaidi, MD; Sarah D. de Ferranti, MD, MPHIn this cross-sectional, nationally representative study, Vasudevan et al1 describe the prevalence ofhigh blood pressure (BP) and other cardiovascular disease (CVD) risk factors in children andadolescents enrolled in the 2016-2018 Comprehensive National Nutrition Survey (CNNS) of all 29states of India. The analysis shows an alarming prevalence of high BP in Indian youth: 35% of 10- to12-year-olds and 25% of 13- to 19-year-olds had BP in the stage 1 or 2 hypertension range, definedaccording to 2017 American Academy of Pediatrics cut points. Moreover, youth with high BP weremore likely to have other CVD risk factors, such as overweight or obesity, high blood glucose levels, orlipid abnormalities. Using 2011 Indian census data, this finding translates to approximately 69 millionIndian youth with high BP and possibly other CVD risk factors.The prevalence of high BP in Indian youth is substantially higher in this study1 than previouslyreported. The largest prior study2 from 2007 to 2014 that measured BP in 11 312 youth from centralIndia aged 5 to 15 years reported the prevalence of hypertension as approximately 7%, which issubstantially lower than the current study.1 Another study3 reported variable rates of hypertensionin Indian youth, from approximately 2% to 25%. Geographic variability may be important. Onestudy4 reported that individuals from southern Indian states had higher BP than those from thenorthern Indian states. Variations in diagnostic criteria, the age group studied, and inclusion orexclusion of malnourished children and those with obesity likely also contribute to differences inprevalence rates.The high prevalence of high BP reported in this study could be partly explained by the studymethods. An oscillometric device was used to measure BP instead of a manual one; oscillometric BPsare known to measure higher than manual BPs.5 However, oscillometric BPs have advantages overmanual measurement in avoiding digit preference and overcoming difficulties ascertaining Korotkoffsounds manually in moving children. The frequency of white-coat hypertension in adolescents mightlead to overestimating the prevalence of high BP; however, in this study,1 trained study staff made 3measurements, and the analysis used the mean of the second and third measurements, which mayhave mitigated the effect of the white-coat hypertension response. Use of the 2017 AmericanAcademy of Pediatrics BP cutoffs could have led to a higher prevalence estimate than previouslyreported, particularly in children older than 13 years for whom lower adult cut points are now usedinstead of pediatric percentiles. US normative BP cut points, which are based on BP centiles, may notapply to Indian youth; however, no population-specific BP norms have been published for Indianyouth. Of importance, the prevalence reported by Vasudevan et al1 likely does not reflect theprevalence of diagnosed hypertension, which requires 3 readings at 3 separate sittings; 3 separateassessments would have been challenging to accomplish in this study.However, the prevalence of high BP may reflect current reality for Indian youth. Hypertensionis 1 of India's most common CVD risk factors, affecting approximately 30% of adults.6 Obesity andmetabolic obesity, found in as many as 50% of anthropometrically undernourished and normal-weight Indian children and adolescents, are key drivers for hypertension. High BP was associatedwith overweight and obesity in this study. More children with overweight or obesity children wereincluded in the analysis, and the rates of obesity were higher in this study than in some prior studies.Not unexpectedly, high BP was also associated with high levels of fasting blood glucose, triglycerides,and low-density lipoprotein cholesterol. This finding may reflect the direct effects of poor nutrition+ Related articleAuthor affiliations and article information arelisted at the end of this article.Open Access. This is an open access article distributed under the terms of the CC-BY License.JAMA Network Open. 2022;5(10):e2239290. doi:10.1001/jamanetworkopen.2022.39290 (Reprinted) October 31, 2022 1/3Downloaded From: https://jamanetwork.com/ by a Thomas Jefferson University User  on 11/16/2022or inadequate physical activity; dietary data were not available in the CNNS, and physical activitymeasures were not analyzed in this study.Downstream effects of unfavorable socioeconomic circumstances are likely also contributors;socioeconomic status was a strong correlate of hypertension in this study. Upstream factors may alsobe at play. Hypertension is associated with poor maternal health, which may lead to an unfavorableintrauterine environment, altering gene expression (epigenetic changes), and increasedsusceptibility to developing chronic conditions.7 The prevalence of low birth weight in India isapproximately 30%, with more than 50% of low birth weight attributable to intrauterine growthrestriction, which can lead to ongoing growth restriction in children.8 The authors were not able toassess the prevalence of low birth weight as a potential explanation for the higher prevalence of highBP in this data set, but stunting affected 25% of younger and 27% of older children and wasassociated with high BP.This study adds to the increasing literature on hypertension as a worldwide public health crisis.The finding that one-quarter to one-third of Indian youth are affected by high BP should raise thealarm for burgeoning future rates of CVD in Southeast Asian populations. Undetected hypertensioncan lead to kidney dysfunction and left ventricular hypertrophy during childhood. Hypertension alsotracks across the lifespan, with childhood hypertension associated with hypertension and CVD inadulthood. South Asian populations are known to be particularly afflicted by CVD, with more severecoronary artery disease that starts at a younger age.9Childhood hypertension screening programs should use best methods to accurately measureBP, conduct a comprehensive CVD risk assessment, and include a survey of social determinants ofhealth, as well as height and weight, birth history, and known CVD risk factors. Prevention effortsshould focus on improving maternal and peripartum factors; minimizing known childhood riskfactors, such as poor diet and inadequate physical activity; and reducing tobacco exposure.ARTICLE INFORMATIONPublished: October 31, 2022. doi:10.1001/jamanetworkopen.2022.39290Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Zaidi AHet al. JAMA Network Open.Corresponding Author: Sarah D. de Ferranti, MD, MPH, Department of Cardiology, Boston Children’s Hospital,300 Longwood Ave, Farley 209, Boston, MA 02115 (sarah.deferranti@cardio.chboston.org).Author Affiliations: Department of Pediatric Cardiology, Nemours Children’s Health, Wilmington, Delaware(Zaidi); Department of Pediatric Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania (Zaidi);Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts (de Ferranti); Department ofPediatrics, Harvard Medical School, Boston, Massachusetts (de Ferranti).Conflict of Interest Disclosures: Dr Zaidi reported receiving a PEDSnet Agency for Healthcare Research andQuality funding K12 award outside the submitted work. Dr de Ferranti reported receiving royalties from anUpToDate online textbook on topics related to cardiovascular risk reduction in childhood.REFERENCES1. Vasudevan A, Thomas T, Kurpad A, Sachdev HS. Prevalence and associated factors of higher blood pressure inIndian adolescents. JAMA Netw Open. 2022;5(10):e2239282. doi:10.1001/jamanetworkopen.2022.392822. Patel A, Bharani A, Sharma M, Bhagwat A, Ganguli N, Chouhan DS. Prevalence of hypertension andprehypertension in schoolchildren from Central India. Ann Pediatr Cardiol. 2019;12(2):90-96. doi:10.4103/apc.APC_13_183. Daniel RA, Haldar P, Prasad M, et al. Prevalence of hypertension among adolescents (10-19 years) in India:a systematic review and meta-analysis of cross-sectional studies. PLoS One. 2020;15(10):e0239929. doi:10.1371/journal.pone.02399294. Krishna P, PrasannaKumar KM, Desai N, Thennarasu K. Blood pressure reference tables for children andadolescents of Karnataka. Indian Pediatr. 2006;43(6):491-501.JAMA Network Open | Pediatrics High Blood Pressure Among Youth in India and Future Cardiovascular DiseaseJAMA Network Open. 2022;5(10):e2239290. doi:10.1001/jamanetworkopen.2022.39290 (Reprinted) October 31, 2022 2/3Downloaded From: https://jamanetwork.com/ by a Thomas Jefferson University User  on 11/16/20225. Duncombe SL, Voss C, Harris KC. Oscillometric and auscultatory blood pressure measurement methods inchildren: a systematic review and meta-analysis. J Hypertens. 2017;35(2):213-224. doi:10.1097/HJH.00000000000011786. Anchala R, Kannuri NK, Pant H, et al. Hypertension in India: a systematic review and meta-analysis ofprevalence, awareness, and control of hypertension. J Hypertens. 2014;32(6):1170-1177. doi:10.1097/HJH.00000000000001467. Huxley RR, Shiell AW, Law CM. The role of size at birth and postnatal catch-up growth in determining systolicblood pressure: a systematic review of the literature. J Hypertens. 2000;18(7):815-831. doi:10.1097/00004872-200018070-000028. Pinheiro A, David A, Joseph B. Pregnancy weight gain and its correlation to birth weight. Indian J Med Sci.2001;55(5):266-270.9. Volgman AS, Palaniappan LS, Aggarwal NT, et al; American Heart Association Council on Epidemiology andPrevention; Cardiovascular Disease and Stroke in Women and Special Populations Committee of the Council onClinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and OutcomesResearch; and Stroke Council. Atherosclerotic cardiovascular disease in South Asians in the United States:epidemiology, risk factors, and treatments: a scientific statement from the American Heart Association.Circulation. 2018;138(1):e1-e34. doi:10.1161/CIR.0000000000000580JAMA Network Open | Pediatrics High Blood Pressure Among Youth in India and Future Cardiovascular DiseaseJAMA Network Open. 2022;5(10):e2239290. doi:10.1001/jamanetworkopen.2022.39290 (Reprinted) October 31, 2022 3/3Downloaded From: https://jamanetwork.com/ by a Thomas Jefferson University User  on 11/16/2022

Prevalence of High Blood Pressure Among Youth in India and Association With Future Cardiovascular Disease

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Prevalence of High Blood Pressure Among Youth in India and Association With Future Cardiovascular Disease

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