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Indian Journal of Community Medicine

Key Predictors of High Blood Pressure and Hypertension among Adolescents: A Simple Prescription for Prevention

Author(s): M.B. Soudarssanane, , M. Karthigeyan, S. Stephen, A. Sahai

Vol. 31, No. 3 (2006-07 - 2006-09)

M.B. Soudarssanane1, M. Karthigeyan1, S. Stephen1, A. Sahai1

Abstract

Research Question: What is the distribution of blood pressure and prevalence of hypertension among adolescents? What are the risk factors involved? Objectives: To assess the blood pressure levels and prevalence of hypertension among adolescents (15-19 years) and identify the risk factors associated with high blood pressure and hypertension. Design: Cross-sectional study and confirmatory community-based case control study. Setting: Jawaharlal Institute Urban Health Center service area at Kuruchikuppam, Pondicherry, India. Participants: 673 adolescents (males 351, females 322) in the 15-19 years age group. Statistical Analysis: Nomogram; Univariate analysis followed by Logistic Regression; Odds Ratio. Results: Mean SBP and mean DBP were 113.6 and 74.3 mm Hg respectively (114.1 & 74.6 in males, 113.1 and 74.1 in females). Mean blood pressure (MBP) showed significant correlation with age. MBP and prevalence of hypertension increased with social class, salt intake, parental history of hypertension, weight, height and BMI. Of these, BMI and higher salt intake emerged as independent predictors by multivariate analysis. Findings were confirmed by the case control study. Conclusion: The major risk factors for hypertension among adolescents are BMI and higher salt intake.

Keywords: Blood Pressure, Prevalence, Hypertension, Adolescents, BMI, Cross Sectional Study, Nested Community-Based Case Control Study.

Introduction

Cardiovascular diseases, particularly hypertension, account for high mortality in the form of coronary heart disease (CHD) in western countries and stroke in countries like India, Taiwan and Japan1. Hypertension also contributes to cardiac or renal failure. The higher the blood pressure the greater is the risk and lower the expectancy of life. Many of the risk factors associated with development of hypertension are preventable. Several community-based studies are available in India regarding prevalence of hypertension2-5.

In Pondicherry, the Department of Preventive and Social Medicine (PSM) in the Urban Field Practice area of Jawaharlal Institute of Post graduate Medical Education and Research (JIPMER) over the last decade have done the following studies on Blood Pressure Distribution and Prevalence of Hypertension so far, among adults. Srinivas6 in 1991 reported mean SBP of 117 mmHg and mean DBP of 74 mmHg among 1025 adults with prevalence of hypertension of 5.5%. Muralidharan7 followed the same cohort in 1996 and recorded mean blood pressure of 121/82 mmHg and prevalence and incidence of 7.1 % and 1.4% respectively. Since data from adolescents of the same population would enable a complete understanding of the dynamics of blood pressure and hypertension, this study was undertaken with the following objectives: To describe the distribution of blood pressure among adolescents aged 15-19 years in an urban slum community and to assess the relationship of blood pressure and hypertension in the study population with factors like age, sex, religion, education, occupation, income, body mass index, physical exercise, stress, salt intake, type of food intake, smoking, alcohol consumption, parental history of diabetes mellitus/ hypertension and use of oral contraceptives (OCP) (as relevant).

Materials and Methods

Ethical clearance for this study was accorded by JIPMER ethical committee in May, 2002. The study was carried at the Jawaharlal Institute Urban Health Center (JIUHC), which is the urban field practice area of Department of PSM, JIPMER, Pondicherry, between March and December 2002 (field work - May to July 2002). The reference population for the study was all adolescents in age group 15-19 yrs. The JIUHC serves a population of approximately 8600 in 1760 families. The center maintains a well-established medical records system, with family folders for every family and separate case sheets for every individual in the family. The population in 15-19 years was only 850 as per records. Hence the whole population was included as the study population.

Data collection was done, after obtaining informed consent, by house-to-house visit using pretested questionnaire. In addition to data on identification and socioeconomic status, the following information were collected: Physical exercise (Very good-Physical exercise like manual work per se or sports activity (or) Physical work for more than three hours a day, Moderate- 1 to 3 hours a day, Mild- less than 1 hour a day); Stress- Subjective, based on selected negative life events (Loss of mother/ father/sibling/close relatives/friends, unemployment/ loss of job, low performance in studies, unpleasant relationship in the family, love failure); Per capita salt intake (Total amount used by the family per day in grams / No. of persons in the family); Type of food (vegetarian or non-vegetarian); Parental history of Hypertension/ Diabetes mellitus; OCP use (only for married females); Smoking habits (Light- up to 5 cigarettes/day, Moderate- 6 to 10/day, Heavy – more than 10/day); Alcohol consumption (Occasional- once or twice a month, Frequent- once or twice a week, Alwaysmore than twice a week); Anthropometrical measurements: Height was recorded to the nearest centimeter and weight to the nearest half kilogram. The Quetlet’s index was calculated according to the formula: Quetlet’s index = Weight in Kgs.* 100 / (Height in metres)2. (<5th percentile- Underweight, >5th percentile to <85th percentile- Normal, ≥85th percentile- Risk of overweight, ≥95th percentile-Overweight)8. The WHO criteria9 was followed in recording blood pressure and average of two readings recorded 3 minutes apart was taken as BP. A nomogram for distribution of BP for the individual age and sex in 15-19 yrs age group was constructed; values at 95th percentile and above were taken as hypertension10,11. For an inbuilt cross verification of results, a nested community based case control study was done with the identified hypertensives as cases and controls (matched for age, sex and social class) chosen from within (-)1 SD of blood pressure distribution for each age level, in 1:1 ratio. Analysis was done using SPSS 7.5 package, Pearson’s correlation coefficient, one-way ANOVA, Independent Samples ‘t’ test and multivariate analysis using Logistic regression. Case control study was analyzed using EPI INFO 2000.

Results

Out of the 850 study population, 673 (79.2%) were contacted (351 males and 322 females). Thirty-four people had shifted residences, four did not give consent, and the remaining were untraceable even after four visits.

A nomogram was constructed for the study population (15-19 years). At least 50 males and females were present in each age group. The 5th and 95th percentiles for Systolic Blood Pressure (SBP) for 15 years of age were 91.6 mm Hg and 127 mm Hg respectively, and for Diastolic Blood Pressure (DBP) were 58.3 and 88.7 respectively. At 19 years of age, the 5th and 95th percentiles for SBP were 100.0 and 131.0 and the corresponding values for DBP were 60.0 and 89.0 mm Hg. The details of the nomogram of blood pressure for both genders in all the ages studied are shown in Table I. Overall, the mean SBP and mean DBP were 113.6 mm Hg (range 81 to 169) and 74.3 mm Hg (46 to 101) respectively. Mean SBP among the male participants was 114.1 (81 to 169) and the mean DBP was 74.6 (46 to 101). Females had mean SBP and mean DBP of 113.1 (93 to 138) and 74.1 (49 to100) respectively. The difference of mean blood pressure among the genders was not significant.

Out of 673, 57 had hypertension (prevalence of 8.5%). Among 351 males, 33 were hypertensive (9.4%) and among 322 females, 24 were hypertensive (7.5%). Of the 57 hypertensives, 21.0% (12) had both systolic and diastolic hypertension, 38.6% (22) had Isolated Systolic hypertension (ISH) and the other 40.4% (23) Isolated Diastolic hypertension (IDH). Among males, 39.4% (13) were Systolic hypertensives and 45.5% (15) were Diastolic hypertensives. Among females these were 37.5% (9) and 33.3%(8).

Table I: Blood Pressure Percentiles Among The Study Population

  Percentiles
    Age
(Yrs)
5 10 25 50 75 90 95
Males
n=351
SBP
mm
Hg
15 90.1 93.2 103 111 119 124 130.8
16 96.5 98.8 100.7 103 111 120 12S.2
17 98.9 100.7 108 114 119.8 124 128.2
18 97 103.6 109 115 122 133.2 138.2
19 100 103.1 110 117 124 130 133.9
DBP
mm
Hg
15 55.3 60 67 73 80 84 88.9
16 59.5 60.8 68 73 80 86 87.4
17 SS.6 60 67.3 73.5 79.8 84.9 87.8
18 60 63.4 69 76 82 88 92.5
19 60 61 72 78 81 88 89
SBP
mm
Hg
15 99.3 100 105.3 113.5 117.8 123 124
16 98 100 106 113 117.5 123 128
17 103 107.7 111 115.5 120 122.3 127.8
18 99 101 106 113 118 125.6 129
19 99 103 107 113 117 123.1 127.9
Females
n=322
DBP
mm
Hg
15 59.3 60.5 68.3 75 79 85 88.8
16 58 61 69 75 80 85 88.5
17 56.3 63 69.5 77 75 74.5 77
18 57.8 60 69 75 78 82.6 87.8
19 59.2 61.9 69 74.5 79 81.7 85.9
SBP
mm
Hg
15 91.6 99 104 113 118 123 127
16 98 99 104.8 113 119 123.3 128
17 99.7 103.9 110 114.5 120 123 127.4
18 98.5 101 108 114 120 129 135.1
19 100 103 108.8 115 120 128.7 131
Overall
n=673
DBP
mm
Hg
15 58.3 60 68 74 79.5 84 88.7
16 59.4 61 68.8 74 80 86 87.7
17 56.7 60 69 75.5 80 84 87
18 59 61 69 75 80 85.7 89
19 60 61 70 77 80 85.7 89

Table II: Age Wise Distribution of Blood Pressure And Hypertension

Age
(yrs)
Males Females Overall
No. Mean Mean HTc No. Mean Mean HT No. Mean Mean HT
SBPa
(SD)
DBPb
(SD)
No.
(%)
SBP
(SD)
DBP
(SD)
No.
(%)
SBP
(SD)
DBP
(SD)
No.
(%)
15 81 110.8 72.9 5 64 112.6 74.2 3 145 111.6 73.5 8
    (12.4) (9.5) (6.2)   (7.8) (8.b) (4.7)   (10.6) (9.1) (5.5)
16 57 111.8 73.4 4 69 112.2 74.2 4 126 112 73.8 8
    (10.1) (8.6) (7.0)   (8.6) (9.3) (5.8)   (9.3) (8.9) (6.3)
17 56 114 73.3 4 53 115.3 75.1 4 112 114.7 74.2 8
    (8.6) (9.6) (7.1)   (6.9) (8.4) (7.1)   (7.8) (9.0) (7.1)
18 77 116.5 76.1 5 71 113.2 73.4 3 148 114.9 74.8 8
    (12.3) (9.6) (6.5)   (8.9) (8.6) (4.2)   (10.9) (9.2) (5.4)
19 80 116.9 76.5 6 62 112.6 73.8 4 142 115 75.3 10
    (9.9) (8.5) (7.5)   (7.7) (7.7) (6.5)   (9.3) (8.2) (7.0)
Total 351 114.1 74.6 33 322 113.1 74.1 24 673 113.6 74.3 57
    (11.2) (9.3) (9.4)   (8.1) (8.5) (7.5)   (9.8) (8.9) (8.5)
Pearson’s correlation coefficient:
r (overall) = 0.14*(sbp) & 0.78*(dbp)
r (males) = 0.22*(sbp) & 0.16*(dbp)
r (females) = 0.02 (sbp) & -0.03 (dbp)
*significant at 0.05 level
aSystolic blood pressure
bDiastolic blood pressure
cHypertension

Even within this short span of five years in the study group of 15 – 19 years the mean blood pressure increased significantly with age (r = 0.14 for SBP and 0.78 for DBP) (Table II). Although this rising trend was observed in both genders, it was significant only among males (r = 0.22 and 0.16). Analysis of social class was based on Kuppuswamy’s scale12 adjusted for Wholesale Price Index13. Only the overall difference of SBP among the social classes was significant. Of the total 673, none were eligible to be included in the upper social class. The overall mean SBP among upper middle (UM) class was 116.5 mm Hg, lower middle (LM) class was 117.1, upper lower (UL) class was 113.3 and lower class (L) was 112.1 mm Hg. The respective DBP were 76.7, 75.0, 74.2 and 76.6 mm Hg. The overall prevalence of hypertension in UM was 10%, LM 9.8%, UL 8.2% and L class 12.5%. Among males, the prevalence of hypertension was 18.2%, 13.2%, 8.6% and 0% respectively and among females it was 0%, 0%, 7.9% and 12.5%.

Unlike the findings reported in adults, there was no effect of physical exercise, stress, type of food intake, smoking and alcohol consumption on blood pressure among adolescents.

As regards salt intake, the response rate was 93.2% (627), the remaining unable to quantify the salt used. Overall only mean DBP was significantly associated with the amount of salt intake which is also true for both genders. The overall mean SBP was significant at 0.046 level and was not reflected in the genders. The overall prevalence of hypertension was found to increase with increased amount of salt intake (Table III).

Table III: Distribution of Blood Pressure And Hypertension According to Salt Intake

Age
(yrs)
Males Females Overall
No. Mean Mean HTC No. Mean Mean HT No. Mean Mean HT
SBPa
(SD)
DBPb
(SD)
No.
(%)
SBP
(SD)
DBP
(SD)
No.
(%)
SBP
(SD)
DBP
(SD)
No.
(%)
<15 238 113.2 73.5 15 238 113.2 74.5 21 476 113.2 74 36
  (10.6) (9.1) (6.3)   (8.1) (8.4) (8.8)   (9.5) (8.8) (7.6)
-20 51 114.9 77.0 10 55 112.6 73.8 2 106 113.6 75.4 12
  (12.1) (8.5) (19.6)   (7.9) (8.6) (3.6)   (10.1) (8.7) (11.3)
-25 22 119.5 76 3 16 114.8 71.9 1 38 117.5 74.2 4
  (14.9) (9.8) (13.6)   (10.0) (8.1) (6.3)   (13.1) (9.2) (10.5)
-30 2 117.5 83.0 0 4 115.8 62 0 6 116.3 69.0 0
  (6.4) (2.8) (0.0)   (3.8) (11.4) (0.0)   (4.2) (14.1) (0.0)
>30 1 129 99 1 0 0 0 0 1 129 99 1
  (0.0) (0.0) ) (100) (0.0) (0.0) (0.0) (0.0)   (0.0) (0.0) (100)
Total 314 113.9 74.4 29 313 113.2 74.1 24 627b 113.6 74.2 53
  (11.3) (9.2) (9.2) (8.1) (8.6) (7.7)   (9.8) (8.9) (8.5)
a P <0.05
b n =627 (For the remaining, reliable information regarding salt intake was not available)

Parental history of hypertension and diabetes mellitus was obtained using the Tamil equivalents ‘ratha kodhipu’ and ‘sakkarai vyadhi’ or ‘thithipu neer’ respectively. Persons with positive history of parental hypertension showed significant elevation in both mean SBP (115.9 mmHg) and mean DBP (76.1) compared to those who gave no history of parental hypertension. Among the genders only the rise in mean SBP among males was significant (Table IV). The overall prevalence of hypertension in persons with positive history of parental hypertension was 11.6% compared to 8% in the other group (males 12.1 & 8.9, females 10.8 & 7).

Table IV: Distribution of Blood Pressure And Hypertension According to Parental History of Hypertension

Pare-ntal
H/O
Hyper-
tension
Males Females Overall
No. Mean
SBPa
(SD)
Mean
DBPb
(SD)
HTC
No.
(%)
No. Mean
SBP
(SD)
Mean
DBP
(SD)
HT
No.
(%)
No. Mean
SBP
(SD)
Mean
DBP
(SD)
HT
No.
(%)
Yes 58 116.9 75.9 7 37 114.2 76.4 4 95 115.9 76.1 11
    (12.0) (9.2) (12.1)   (9.5) (8.3) (10.8)   (11.1) (8.8) (11.6)
No 293 113.6 74.3 26 285 113.0 73.8 20 578 113.3 74.1 46
    (10.9) (9.3) (8.9)   (7.9) (8.5) (7)   (9.5) (8.9) (8.0)
Total 351 114.1 74.6 33 322 113.1 74.1 24 673 113.6 74.3 57
    (11.2) (9.3) (9.4)   (8.1) (8.5) (7.5)   (9.8) (8.9) (8.5)

aP < 0.05

On further analysis based on history of paternal and maternal hypertension, the mean SBP and mean DBP in individuals with history of paternal hypertension were 115.4 mm Hg and 74.8 mm Hg. The values for those with history of maternal hypertension were 114.8 mm Hg and 76.5 mm Hg respectively. It was observed that subjects with both paternal and maternal hypertension had significantly higher mean SBP (124.9 mm Hg) and mean DBP (79.9 mm Hg) than those with either paternal or maternal hypertension. This was true for both genders. The prevalence of hypertension in subjects with both paternal and maternal hypertension was 37.5%, which was higher than that observed in subjects with only paternal (4.9%) of maternal hypertension (13%). The prevalence was 8% in individuals who gave no parental history of hypertension.

Overall, subjects whose parents were diabetic had higher SBP and DBP than those with no parental history of diabetes mellitus. A similar rising tendency of blood pressure was found in both genders but no statistical significance emerged. Only 0.9% of the female participants gave history of OCP use. Though no significant difference in blood pressure was found between OCP users and non-users, the variation in DBP (difference of 7.5 mm Hg) was much greater than that in SBP (1.8 mm Hg) between the two groups. The prevalence of hypertension among non-users of OCP was 7.5% and 0% among users.

The overall mean SBP and mean DBP increased significantly with increasing weight (r = 0.44 for SBP and 0.27 for DBP) and height (r=0.21 for SBP and 0.10 for DBP). Observation showed a clear-cut rise in the prevalence of hypertension only with increasing weight (chi sq = 64.84, p<0.05)

A significant positive correlation was found between blood pressure and BMI (r = 0.36 for SBP and 0.24 for DBP). The mean SBP among subjects with underweight was 105.9 mm Hg. Those within the normal range of BMI showed mean SBP of 112.3 mm Hg. Individuals at risk of overweight and those with overweight had mean SBP of 119.3 and 123.9 mm Hg. The respective mean DBP were 72.8, 73.4, 77.8 and 81.1 mm Hg. The significance observed between the groups was true for individual ages and genders.

Table V: Logistic Regression Analysis of Hypertension for Risk Factors Identified By Univariate Analysis

Variables Males Females Both
  B Sig R Exp.B B Sig R Exp.B B Sig R Exp.B
Age -0.4912 0.2627 <0.000 0.6119 0.1106 0.8035 <0.000 1.1170 -0.2071 0.4882 0.0004 0.8130
Social class -0.1553 0.7979 0.0004 0.8562 -7.1669 0.7250 <0.0004 0.0008 -0.4172 0.4002 0.0000 0.6589
Salt Intake 1.2458 0.0047 0.1762 3.4757 -0.7257 0.2623 Z,0.000 0.4840 0.5290 0.1062 0.0410 1.6993
Family
h/o
hypertension
-0.2233 0.6809 <0:0004 1.2502 0.1839 0.7659 L0.0001 1.2020 0.2021 0.6099 0.0000 1.2239
Body mass
Index
1.9959 <0.0004 0.2898 7.3590 1.6304 0.0003 0.2581 5.1059 1.6876 0.0004 0.2766 5.48627

Table VI: Results of Nested Case Control Study As A Confirmation of Findings of Cross Sectional Study

Risk factor Risk Factor present   Exact 95% CI for
  Casesa Controlsa OR OR p value
Salt intakeb 13 8 1.86 0.62-5.82 0.2157
  (10)c (3) (5.00) (1.41-32.20) (0.0230)
Exercise 21 17 1.39 0.58-3.31 0.4202
Stress 4 11 0.31 0.07-1.17 0.0515
Diet 54 54 ... ... ...
Family h/o hypertension 9 2 5.20 0.99-51.22 0.0259
Family h/o Diabetes mellitus 6 8 0.72 0.19-2.58 0.5667
Smoking/d Alcoholism 6 5 1.25 0.28-5.90 0.7386
Body mass index 23 2 19.29 4.18-175.48 < 0.0001

an = 54 as controls were not available for 3 cases.
bn = 47 as data was not available for 4 cases and 3 controls.
cMales (n=24)
dApplicable only for males

Variables found to be significant on univariate analysis (age, social class, salt intake, parental history of hypertension and BMI) were subjected to logistic regression analysis and Body Mass Index in both genders and salt intake among males turned out to be significant risk factors (Table V).

These findings were confirmed by the nested communitybased case control study (n = 54 + 54). Controls were not available for three cases. However, in addition to BMI and salt intake among males, the case control study also identified parental history of hypertension as a significant risk factor (Table VI).

Discussion

In the present study among adolescents aged 15-19 years in urban slum of Pondicherry, both mean SBP and mean DBP were higher among males than females. Elsewhere, studies on population of 13-18 years14, 15-24 years15 and 15-25 years16 observed higher mean SBP among males and higher mean DBP among females.

The definition of hypertension among adolescents is 95th percentile of blood pressure and above10,11. This definition was used in our study. However, since comparative height adjusted values of blood pressure were not available for Indian population, we have used the non-height adjusted values. This is a limitation in the study. Since the definition of hypertension is 95th percentile and above, the prevalence measured is expected to be between 5% and 10%, allowing for a theoretical probability of 5% ISH and 5% IDH. Hence comparison with other studies is not attempted in this discussion. In our study, 38.6% of the hypertensives were due to isolated rise in systolic blood pressure. This Isolated Systolic Hypertension deserves attention as it is an important risk factor of coronary heart disease and stroke independent of diastolic status of the individual17-21.

The tendency of blood pressure to rise with age is supported by findings from Turkish study among 13-18 years22, Zambian school children (7-16 years)23 and German study (4-18 years)24. In the Jamaican study (6-16 years)25, blood pressure increased with age in both boys and girls, although the increase was greater for SBP than for DBP; however, the increase of SBP among boys continued after the age of l1 years but that for girls leveled off. In the present study, both SBP and DBP rose with age only among males. The UK study14 found age related rise only in SBP and only in males.

The SBP was significantly related to the socio-economic status of the adolescents as also reported by Gilberts et al2. Life style modification between the upper and lower socioeconomic classes could have had an indirect bearing on the blood pressure levels.

Physical activity influencing the blood pressure is well documented in many studies among adults; however no significant association was found between the two in these urban adolescents. Probably exercise alters blood-pressure levels only in its long-term practice and the follow up study of the cohort may yield different results. However, even among adolescents, inverse relationship between DBP and exercise has been demonstrated14.

It is generally agreed that stress aggravates blood pressure and predisposes the individual to develop hypertension but the present study showed even lower blood pressure (though not significant) in subjects with stress. It is possible. that the subjective method adopted to quantify stress in this study being subjective could have had an impact on the outcome.

Even at this young age, dietary salt significantly affects mean DBP but not mean SBP.

In the present study, subjects in whom positive family history of hypertension was elicited had higher blood pressure. The prevalence of hypertension was also higher in them. This suggests, there is a genetic role to play in the development of hypertension. Familial tendency for developing high blood pressure is well known. A positive parental history of high blood pressure was associated with higher SBP and DBP.14 Individuals for whom both the parents were hypertensive showed significantly higher blood pressure than those with either paternal or maternal hypertension. The prevalence of 37.5% in the former which is definitely higher than the latter (4.9% in paternal hypertension and 13% in maternal hypertension) provides clue to target population for blood pressure screening. Though blood pressure rose with positive parental history of diabetes mellitus, it was not significant. That the parental hypertension / diabetes elicited only by way of history, has a low sensitivity, is a limitation of the study.

Although many studies carried out in adults had put forth strong evidence of association between smoking/alcoholism and hypertension, the present one did not find any significant difference in blood pressure between smokers and nonsmokers in adolescents. The possible explanation is that the amount and duration of exposure to smoking and drinking habits may not be sufficient enough to bring out a real change in blood pressure levels in young age. A follow up study of the cohort could bring out the possible relationship between the two. However, a J shaped association of alcohol intake with blood pressure was shown in young adults aged 18 - 26 years26.

The present study found significant rise in both SBP and DBP with increasing weight in both genders. This compares with the findings from adolescents aged 17 years in Jerusalem27 whereas another study 14 reported weight dependent rise in blood pressure only among males with respect to SBP alone. Studies on population of 4-18 years24 and 7-16 years23 also identified weight to be a major determinant of blood pressure which is important as the childhood weight gain was positively associated with adult blood pressure28. With reference to height, association of blood pressure reported in the present study agrees well with other study14. Some studies have reported the association of blood pressure with both weight and height22,25,29,30.

It is evident from this community based epidemiological survey that increase in BMI predisposes the adolescent individual to higher blood pressure and subsequently hypertension. A similar finding was also reported elsewhere in India31 Hungary32 and France33. Such association in early childhood with SBP alone was reported by Sinaiko et al34 and Hardy et al35. Trevor. J.Orchard14 reported similar association only in SBP among males. Present study results, obtained after multivariate analysis strengthens the independent association of BMI with blood pressure.

Finally, it can be concluded from both the multivariate analysis and the case control study that even in the adolescent population, pathogenesis of higher blood pressure is a process influenced by life style factors like higher BMI and higher salt intake. The case control study however identifies parental history of hypertension also as a risk factor.

Acknowledgements

We gratefully acknowledge Indian Council of Medical Research (ICMR) New Delhi, for sponsoring this study. We thank Mohan Kumar for his assistance in analysis, the staff of JIUHC for their cooperation in the fieldwork and the adolescent participants of this study.

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1 Deptt. of Preventive and Social Medicine,
JIPMER, Pondicherry.
E-mail: [email protected] and [email protected]

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