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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 11  |  Page : 1616-1623

Association of blood pressure with dietary intake, physical activity, and anthropometric measurements in Turkish adolescents


1 Department of Nutrition and Dietetics, Kirklareli University College of Health, Kırklareli, Turkey
2 Department of Nutrition and Dietetics, Erciyes University Faculty of Health Sciences, Kayseri, Turkey

Date of Submission24-Dec-2020
Date of Acceptance16-Apr-2021
Date of Web Publication15-Nov-2021

Correspondence Address:
Dr. N H Nogay
Department of Nutrition and Dietetics, Erciyes University Faculty of Health Sciences, Kayseri
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_685_20

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   Abstract 


Background: Determining high blood pressure in childhood is an important step to reduce the risk of occurrence of high blood pressure–related diseases in adulthood. Aims: This study aimed to assess the association of blood pressure with dietary intake, physical activity, and anthropometric measurements in Turkish adolescents. Patients and Methods: This cross-sectional study included 370 students (202 females, 168 males) aged 14 to 18 years from one private and one public school in Kayseri, Turkey. Some anthropometric measurements and 24-hour dietary recall of the students were obtained. Their blood pressures were measured, and the International Physical Activity Questionnaire and the Mediterranean Diet Quality Index (KIDMED) were used. Results: The body mass index (BMI) mean and waist/height ratio of the hypertensive group were significantly higher than those of the prehypertensive group, whereas their daily potassium, calcium, and magnesium intakes were significantly lower than those of the normotensive group. The percentage of individuals with very low diet quality was higher in the hypertensive group than in the normotensive group (P > 0.05). The percentage of participants with sufficient physical activity was higher in the normotensive group than in the prehypertensive and hypertensive groups. Conclusion: Factors such as high BMI and waist/height rates; low calcium, magnesium, and potassium intakes with diet; insufficient physical activity; and low quality of diet might cause an increase in the blood pressure.

Keywords: Adolescent, anthropometric measurement, blood pressure, dietary intake, physical activity


How to cite this article:
Firat S, Nogay N H. Association of blood pressure with dietary intake, physical activity, and anthropometric measurements in Turkish adolescents. Niger J Clin Pract 2021;24:1616-23

How to cite this URL:
Firat S, Nogay N H. Association of blood pressure with dietary intake, physical activity, and anthropometric measurements in Turkish adolescents. Niger J Clin Pract [serial online] 2021 [cited 2021 Nov 28];24:1616-23. Available from: https://www.njcponline.com/text.asp?2021/24/11/1616/330477




   Introduction Top


High blood pressure is a global public health problem.[1] The prevalence of high blood pressure, which is regarded as a disease for adults in childhood and adolescence, has increased, ranging from 2% to 5%.[2] This increase is because of the increase in obesity prevalence among children and adolescents and raised awareness about high blood pressure.[3] Environmental changes, sedentary lifestyle, stress, increase in energy intake, transformed lifestyle in terms of fat, and salt and alcohol consumption also affect the prevalence of high blood pressure.[4]

The blood pressure values in childhood have a significant effect on the blood pressure values in adulthood and emphasize the importance of early intervention.[5] High blood pressure affects almost every system of an individual, leaves irreversible marks, gradually threatens life, and requires long-term and costly treatment in childhood and adolescence in an early stage. Diagnosis of high blood pressure in childhood is an important step to reduce the risk of occurrence of high blood pressure–related diseases in adulthood.[6]

This study aimed to assess the relationship among blood pressure, dietary intake, physical activity, and anthropometric measurements in Turkish adolescents between the ages of 14 and 18 years.


   Materials and Methods Top


A school-based cross-sectional study was conducted from May 2017 to November 2017 in Kayseri, Turkey. The minimum number of participants required to make estimations with 99% confidence interval and 5% precision level, when the expected high blood pressure frequency among overweight adolescents between the ages of 14 and 18 years in Kayseri was 15%, was calculated as 338 based on a study conducted in Turkey.[7] This study was finalized with a sample consisting of 370 participants. The inclusion criteria were as follows: have an age range between 14 and 18 years, can understand and answer questions by themselves, can communicate, and are not diagnosed with high blood pressure. The necessary approvals were obtained from the provincial directorate of national education to which the study schools were affiliated. Informed consent forms were separately taken from both parents and children.

The body fat ratios were measured using a tool (Tanita BC-532, Body Composition Monitor, Japan) that worked with bioelectrical impedance analysis according to the measurement technique. The body weight, body height, waist, hip, and mid-upper arm circumferences of the students were also measured. Waist circumference was measured at the midpoint between the lower margin of the last palpable rib and the top of the iliac crest (hip bone), with the arms relaxed at the sides, at the end of a normal expiration. Hip circumference was measured at the maximum circumference over the buttocks.[8] The circumference of the upper arm was measured at its midpoint, located after bending the right elbow to a 90° angle and placing the forearm palm down across the trunk.[9] Waist, hip, and mid-upper arm were measured by using an inelastic measuring tape. Each child's body mass index (BMI) was calculated according to weight/(height)2 formula and assessed according to z score using the World Health Organization (WHO) standards.[10] Birth weight was obtained by parent report.

The Mediterranean Diet Quality Index (KIDMED) and 24-hour dietary recall were used to determine the dietary statuses of the adolescents. The KIDMED consisted of 16 questions. Whereas the questions numbered 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 13, and 15 were positively (+1) assessed, those numbered 6, 12, 14, and 16 were negatively (−1) assessed. The assessment results were as follows: ≥8 points, optimal diet; 4 to 7 points, improvement needed; and ≤ 3 points, very low diet quality.[11] Twenty-four-hour dietary recall of the students were obtained and their daily dietary intake of energy, macro- and micronutrients was calculated using the Nutrition Information Systems Package Program (BEBIS), which was developed in Turkey (http://www.bebis.com.tr). The short version of the International Physical Activity Questionnaire (IPAQ-SF), the self-administered, last 7-day was used to examine the physical activity statuses of the participants. The IPAQ is the most used and practical method to assess the physical activity statuses in studies with large populations. The IPAQ-SF includes seven questions that measure the frequency and duration of walking, moderate intensity activity, and vigorous-intensity activity that occurred for at least 10 minutes at a time over the previous week additionally time spent on sedentary activities. The minutes, day, and MET values (multiples of resting oxygen consumption) are multiplied and a score is obtained as a “MET-minutes/week.” In the calculation of the walking score, the walking time (minutes) is multiplied by 3.3 MET. Also in the calculation 4 MET is used for moderate activity and 8 MET for severe activity. Students were classified by overall activity into three categories based on a combination of duration and severity: low, medium, and high. A “low” activity level shows not meeting the criteria for medium or high activity. The criteria for medium activity are (a) 3 or more days of vigorous-intensity activity of at least 20 minutes per day, (b) 5 or more days of moderate-intensity activity and/or walking of at least 30 minutes per day, or (c) 5 or more days of any combination of walking, moderate-intensity, or vigorous-intensity activities achieving a minimum total PA of at least 600 MET-min/week. The criteria for high activity are (a) vigorous-intensity activity on at least 3 days attaining a minimum total PA of at least 1,500 MET-min/week or (b) 7 or more days of any combination of walking, moderate-intensity, or vigorous-intensity activities attaining a minimum total PA of at least 3,000 MET-min/week.[12]

The blood pressure was measured using an automated sphygmomanometer, which was used in previous studies.[13] Blood pressure measurements were performed three times with 5-minute intervals from the right arm, while the participant was in a sitting position after resting for at least 5 minutes. The mean of these measurements was calculated. The blood pressure values of students younger than the age of 17 years were classified as normotensive (<90th percentile), prehypertensive (between 90th and 95th percentiles), and hypertensive (>95th percentile) based on The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.[14] The Joint National Committee's (JNC7) blood pressure classification was used to assess high blood pressure among 18-year-old adolescents. Accordingly, <120/80, 120–139/80–89, and >140/90 mmHg were classified as normotensive, prehypertensive, and hypertensive, respectively.[15]

Statistical analysis

Data were assessed using the SPSS Statistics 20.0 package program. The results were presented using mean ± standard deviation and number (%). The compliance of the quantitative data to a normal distribution was examined using the one-sample Kolmogorov–Smirnov test. The Student t test was used for binary comparison of normally distributed variables, and the Mann–Whitney U test for binary comparison of nonnormally distributed variables. The analysis of variance (ANOVA) test was used for multigroup comparisons of normally distributed variables, and the Kruskal–Wallis test for multigroup comparisons of nonnormally distributed variables. The Tukey test was used for multiple comparisons of homogeneously distributed variables when a difference was found in the ANOVA test result. Researchers tested the relationship among categorical variables using the Chi-square test and the relationship among numerical variables using correlation coefficient. A P value <0.05 was regarded as statistically significant. Receiver operating characteristic (ROC) analysis was performed to determine the highest areas under the curves (AUCs) value in differentiation of children with high blood pressure.


   Results Top


Of the participants, 54.6% were female (n = 202) and 45.4% were male (n = 168). The body weights, body heights, waist circumferences, and mid-upper arm circumferences were significantly lower in female students than in male students (P < 0.05). The body fat percentages were significantly higher in girls than in boys. According to BMI, of the participating males, 11.9% were overweight and 1.2% were obese. Of the girls, 2.9% were overweight and 0.5% were obese. The mean systolic blood pressure value of girls and boys was 99.6 ± 9.8 and 106 ± 11.7 mmHg, respectively, with a statistically significant difference between them (P = 0.000). The mean diastolic blood pressure was 71.1 ± 7.8 mmHg for girls and 68.9 ± 10.2 mmHg for boys, with a statistically significant difference between them (P = 0.020). Of the participating males, 16.7% were hypertensive and 14.9% were prehypertensive. Of the girls, 13.4% were hypertensive and 23.8% were prehypertensive. The number of inactive girls was significantly higher than that of inactive boys according to the IPAQ (P = 0.000) [Table 1].
Table 1: General characteristics of students

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The BMI mean and waist/body height ratio were significantly higher in the hypertensive group than in the prehypertensive group (P < 0.05). The mean waist circumferences and mid-upper arm circumferences were significantly lower in the prehypertensive group than in the hypertensive and normotensive groups. The body height and body weight means were lower in the prehypertensive group than in the normotensive group (P < 0.05) [Table 2].
Table 2: Anthropometric measurements of children according to blood pressure measurement results

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[Table 3] presents some nutritional element intakes of participants according to their blood pressure values. The mean daily protein, total fat, potassium, calcium, and magnesium intakes were significantly lower in the hypertensive group than in the normotensive group (P < 0.05). The mean daily sodium intake was 3177 ± 1601.7, 3093.9 ± 1263.7, and 2807 ± 1531.2 mg in the normotensive, prehypertensive, and hypertensive groups, respectively. The mean daily carbohydrate, multiunsaturated fatty acid, cholesterol, fiber, and sodium intakes were lower in the hypertensive group than in the prehypertensive and normotensive groups, with no statistically significant difference between them (P > 0.05).
Table 3: Some nutrient intakes according to student's blood pressure values

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The percentage of individuals with very low diet quality was higher in the hypertensive group than in the normotensive and prehypertensive groups according to the KIDMED (P > 0.05). The percentage of participants with high physical activity was higher in the normotensive group than in the prehypertensive and hypertensive groups according to the IPAQ (P > 0.05) [Table 4].
Table 4: KIDMED and IPAQ score distribution according to student's blood pressure measurement results

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The areas under the ROC curve of waist circumference, potassium, protein, magnesium, total fat, and calcium as predictors of high blood pressure and their confidence intervals (95%) can be seen in [Table 5] and in [Figure 1]. According to this, potassium is the most influential variable on blood pressure.
Table 5: Area under the ROC curve and 95% CI between various nutrients, waist circumference, and high blood pressure

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Figure 1: ROC (receiver operating characteristic) curves that compare various nutrients and waist circumference as discriminators of high blood pressure

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   Discussion Top


This study was carried out with 370 students between the ages of 14 and 18 years to assess the relationship among blood pressure, dietary intake, and physical activity in Turkish adolescents. Of the participants, 54.6% were female (n = 202) and 45.4% were male (n = 168).

Various high blood pressure–related studies conducted in numerous countries and mainly in the United States found that the occurrence frequency of prehypertension varied between 3.4% and 25.0% and the occurrence frequency of high blood pressure varied between 3.2% and 17.5%.[16],[17],[18] Recently, two studies conducted in Turkey have found the occurrence frequency of high blood pressure as 7.9% and 9.0%, respectively.[19],[20] The present study found that the percentage of adolescents with prehypertension and high blood pressure was 19.8% and 14.8%, respectively.

A study conducted in Iran with 1,707 children and adolescents aged between 10 and 17 years found that the mean systolic and diastolic blood pressure values of girls were 108 ± 9.6 and 65.7 ± 8.9 mmHg, respectively, and boys were 109.2 ± 11 and 66.2 ± 9.7 mmHg, respectively. However, the difference between genders was not statistically significant.[21] Aounallah-Skhiri et al.[17] conducted a study with 2,870 adolescents between the ages of 15 and 19 years in Tunisia in 2012 and found that the mean systolic and diastolic blood pressures of boys were 114.2 ± 0.4 and 110.9 ± 0.4 mmHg, respectively, and girls were 68.1 ± 0.3 and 66.6 ± 0.4 mmHg, respectively. The present study found that the systolic blood pressure values were higher in girls than in boys, whereas the diastolic blood pressure values were lower in girls than in boys (P < 0.05). Bibiloni et al.[22] conducted a study to examine the relationship between the KIDMED compliance levels and socioeconomic, anthropometric, and lifestyle characteristics of adolescents. They assessed 1,231 adolescents with the ages between 12 and 17 years in 2007 and 2008 and found that the percentage of boys who followed an optimal diet group was higher than that of girls, consistent with the present study.

A study conducted in China with 6,193 adolescents found that the body weights and body heights of adolescents were significantly lower in the normotensive group than in the prehypertensive and hypertensive groups. The percentage of adolescents with mean BMI z scores and waist circumferences >85th percentile was significantly higher in the hypertensive group than in the normotensive group.[23] Other related studies similarly found that the anthropometric measurements of adolescents such as body weight, body height, BMI, waist circumference, thigh circumference, and body fat ratio were lower in the normotensive group than in the hypertensive group.[24],[25] The present study found that the BMI mean and the waist/body height rate were significantly higher in the hypertensive group than in the prehypertensive group (P < 0.05); the mean waist circumference and mid-upper arm circumference were significantly higher in the prehypertensive group than in the hypertensive and normotensive groups (P < 0.05) [Table 2]. Although some studies showed that birth weight may affect blood pressure in a later stage of life,[26],[27] other some studies showed that there was no relation between birth weight and blood pressure.[28],[29] In this study, the relationship between birth weight and blood pressure was evaluated among 72 students, because the birth weight of only 72 students was known.

The diet recommended by the Dietary Approaches to Stop Hypertension is related to low blood pressure and is designed to be high in fiber, magnesium, calcium, and potassium content, and low in sodium, total fat, saturated fat, and cholesterol.[30] Sodium has an important role in determining the fluid balance. A positive sodium balance is necessary for growth. However, excessive sodium intake causes arterial high blood pressure.[31] Higher levels of potassium intake are related to low blood pressure, and the deficiency in the potassium intake causes an increase in blood pressure.[32] Ramírez et al.[33] conducted a study to determine the relationship between the diet factors and blood pressure among individuals aged 8 to 10 years and found that the cholesterol intake of the hypertension group and the sodium intake of the normotensive group were significantly low. Another related study found that the mean daily carbohydrate and sodium intakes of the normotensive group and the mean daily protein and total fat intakes of the hypertensive group were insignificantly lower compared with those in the other groups.[25]

However, the present study found that the mean daily carbohydrate, multiunsaturated fatty acid, cholesterol, fiber, and sodium intakes were numerically lower in the hypertensive group than in the prehypertensive and normotensive groups, and the differences between them were not statistically significant. The mean daily protein, total fat, potassium, calcium, and magnesium intakes were significantly higher in the normotensive group than in the hypertensive group. Also, according to ROC analysis, potassium is the most influential variable on blood pressure [Table 5] and [Figure 1]. Although low potassium, calcium, and magnesium intakes were expected in adolescents with high blood pressure, the present study found that sodium intake was lower in the hypertensive group. These results might be caused by daily individualistic changes in salt intake, the sample size, and the variety of the programs used to assess the salt intake. Moreover, the amount of salt used for cooking (an important dietary sodium source) differs in every family, and also calculating the amount of salt used while eating is difficult as it is nonstandard; all these might have affected the results.

A study reported that the Mediterranean diet style had a decreasing effect on blood pressure.[34] A study conducted with 674 adolescents between the ages of 14 and 17 years in Brazil found no relationship between following a Mediterranean diet and high blood pressure.[35] However, the present study found that the percentage of individuals with a very low diet quality was higher in the hypertensive group than in the normotensive and prehypertensive groups according to the KIDMED (P > 0.05).

The study found that the risk of hypertension was higher among adolescents 14 to 17 years old who were physically less active than who were physically active.[36] Another related study conducted with 496 adolescents found that the prehypertension/high blood pressure rates of adolescents in the inactive, low, and sufficient physical activity groups were 5.7%, 15.2%, and 20.3%, respectively.[37] However, the present study found that the percentage of participants with high physical activity was insignificantly higher in the normotensive group than in the prehypertensive and hypertensive groups [Table 4].

This study has several limitations. Food consumption record was taken only 1 day. Eating behavior varies day to day, and the use of 1 day of dietary intake may not adequately capture the assessment of individual intakes of any food or nutrient. Also, it was shown that food consumption and preferences (type and variety), especially vegetable and fruit consumption, may be affected by seasonal changes in Turkey. Fresh vegetable and fruit consumption increases in the summer than in the winter.[38],[39] Furthermore some of the participants may have given incorrect information when filling in the food recall form. According to the WHO, the period between the ages of 10 and 19 years is defined as adolescent.[40] Adolescent age is accepted to be 10 to 19 years in Turkey for both females and males. Sexual maturation is an important factor that may affect the blood pressure. Another limitation was that we did not assess sexual maturation.


   Conclusion Top


This study concluded that factors such as high BMI and waist/height rates; low calcium, magnesium, and potassium intake with diet; insufficient physical activity; and low quality of diet might cause an increase in blood pressure. Adolescents should be supported to be in normal weights, eat compatible with the Mediterranean diet pattern, which has high magnesium, potassium, fiber, and low sodium content (high consumption of fruits, vegetables, legumes, and whole grain cereals; moderate consumption of fish, dairy products, nuts, and olive oil, low consumption of sweets, fast-foods, salty foods; and not skipping breakfast), and increase their physical activity levels to reduce the risk of high blood pressure in both adolescence and adulthood.

Authors' contribution

S.F. collected and analyzed data, received informed consent, and wrote the manuscript. N.H.N. designed the study and wrote the manuscript, supervised all this work. All authors read and approved the final manuscript.

Ethical statement

This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Erciyes University Ethics Committee. The necessary approvals were obtained from the provincial directorate of national education to which the study schools were affiliated. Written informed consent was obtained from both parents and children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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