Systolic and Fourth- and Fifth-Phase Diastolic Blood Pressure from Ages 8 to 18 Years: Project HeartBeat!

doi:10.1016/j.amepre.2009.04.014

American Journal of Preventive Medicine

Volume 37, Issue 1, Supplement, July 2009, Pages S86-S96

https://doi.org/10.1016/j.amepre.2009.04.014 Get rights and content

Background

Systolic and fourth-phase and fifth-phase diastolic blood pressure (SBP, DBP4, DBP5) have appeared to differ in their patterns of age-related change, and SBP and DBP5 differ in their respective associations with anthropometric variables. Project HeartBeat! investigated trajectories of change in SBP, DBP4, and SBP5 with age and their relationships with indices of adiposity, controlling for energy intake, physical activity, and sexual maturation.

Methods

Project HeartBeat! was a mixed longitudinal study in 678 black and white girls and boys aged 8, 11, or 14 years at first examination, followed at 4-month intervals for up to 4 years (1991–1995). A statistical model was estimated for the trajectory of change in each blood pressure measure from ages 8 to 18 years.

Results

For SBP, DBP4, and DBP5, the trajectories were sigmoid, parabolic, and linear in form, respectively. SBP and DBP4 differed significantly by gender; DBP4 and DBP5 were significantly related to race. Adjusted for age, gender, and race, all relationships of adiposity-related variables (percent body fat, abdominal circumference, skinfold thickness, and BMI and its fat and fat-free components) with SBP were positive and significant. Corresponding relationships for DBP4 were notably weaker but significant, and for DBP5, weak or not significant. After adjusting for diet, physical inactivity, and maturation, no DBP5 relationship with adiposity indices remained significant.

Conclusions

SBP, DBP4, and DBP5 are distinct in patterns of change with age, relationships to gender and race, and patterns of association with multiple anthropometric indices related to adiposity.

Introduction

The Bogalusa Heart Study and the Muscatine Study of cardiovascular disease (CVD) risk factors in childhood and adolescence, begun in the early 1970s, contributed importantly to a body of data useful for establishing population norms for blood pressure levels.¹ The Task Force on Control of Blood Pressure in Children was convened in 1977 by the National Heart, Lung, and Blood Institute (NHLBI) and reported standards² for children's blood pressure—systolic (SBP) and fourth-phase diastolic (DBP4)—by gender and age, for those aged 2–18 years. A second report³ from the Task Force provided revised recommendations and called for measuring DBP4 for infants and children aged ≤12 years but, for comparability with adults, fifth-phase DBP (DBP5) for those aged 13–18 years. An update⁴ provided further normative data by incorporating adjustment for body height, and it called for use of DBP5 as the preferred measure of DBP for all age groups. A fourth report⁵ maintained use of DBP5 as the standard measure for DBP, except when “very low” or zero values are observed, in which case DBP4 should be used.

Among 129 published reports of independently conducted cross-sectional blood pressure surveys in children worldwide, about half of the studies reported diastolic pressures as DBP4 and half as DBP5.6, 7 As a result, blood pressure levels and patterns of change with age could be compared among these three measures—SBP, DBP4, and DBP5. Each measure increased with age in childhood and adolescence, but their patterns of change differed: SBP showed a more clearly curvilinear pattern of change than either measure of DBP; both SBP and DBP5 showed an unexpected decrease in girls in their late teens; and DBP5 showed a continuous increase across the 6- to 18-year age range.

Analysis of data from the National Health and Nutrition Examination Survey I (NHANES) had demonstrated that, among those aged 7–19 years, DBP5 differed from SBP in its pattern of correlation with each of several anthropometric characteristics (weight, height, triceps skinfold, upper-arm girth).8, 9 Correlations for SBP with these measures were stronger than those for DBP5, at every age. They varied systematically for both SBP and DBP5 for successive 2-year age groups, being weakest in the early teenage years.

For this report, data from Project HeartBeat!¹⁰ were used to address two central questions: (1) Do SBP, DBP4, and DBP5 differ in their growth trajectories (age-related changes) from ages 8 to 18 years? (2) Do these three measures of blood pressure differ in their relationship to selected anthropometric indicators, including indicators of adiposity, when adjusted for energy intake, physical activity, and sexual maturation, as well as for age, gender, and race?

Section snippets

Methods

Project HeartBeat!¹⁰ was a mixed longitudinal study of the development of CVD risk factors in childhood and adolescence conducted near Houston in The Woodlands and Conroe TX. Recruitment and enrollment of study participants and the full inventory of examination components have been described previously.¹¹ Participants were placed into one of three age cohorts: 8 years (Cohort 1), 11 years (Cohort 2), or 14 years (Cohort 3) at entry (a total of 678 participants; 49.1% girls and 20.1% blacks).

Trajectories of Change in SBP, DBP4, and DBP5 with Age

The trajectories of change in SBP, DBP4, and DBP5 from ages 8 to 18 years, based on the models presented in Table 3, are shown in Figure 1, Figure 2, Figure 3. The models were developed as described above, and significant terms (p≤0.05, where Estimate/SE≥1.96) are shown. The main points to note are (1) for SBP, only race was not significant, but all three levels of age terms—age, age², and age³—were significant (p<0.01); (2) for DBP4, unlike SBP, race was significant but not age³; and (3) for

Discussion

The two central questions posed for this analysis may be answered in the affirmative: both the trajectories of age-related change and the relationships with selected anthropometric indices differ among the three blood pressure measures: SBP, DBP4, and DBP5. SBP is strongly dependent on age, gender, and anthropometric variables. Associations of SBP with lean mass (FFMI) are stronger than with variables representing fat mass (FMI and the other anthropometric variables). Measures of body fat are

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Males have greater cardiometabolic risk than females, though the reasons for this are poorly understood. The aim of this study was to examine the association between common Y chromosomal haplogroups and cardiometabolic risk during early life.
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A significant downward trend was observed in systolic BP (p = .0006) and diastolic BP (p < .0001) among the students who were exposed to the HEROES initiative. The prevalence of hypertension decreased from 17.1% at baseline to 12.8% at 6 months (p < .0001), 12.0% at 12 months (p < .0001), and 15.0% (p = .0024) at 18 months. Baseline body mass index, increases in body mass index percentiles, and increases of television-viewing hours were associated with BP increases. Increases in frequencies of eating french fries or chips, skipping breakfast, and consuming supersize meals when eating fast food were predictive of systolic BP changes, not of diastolic BP changes.
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This paper provides the rationale and design of Project HeartBeat! as background to the reports that follow in this supplement to the American Journal of Preventive Medicine.1–13 The concept of a longitudinal study of “growth” of risk factors, as well as development of the research proposal and design and methods of the study, are highlighted.
Major cardiovascular disease (CVD) risk factors begin development in childhood and adolescence. Project HeartBeat! studied early development of these risk factors as growth processes. Growth, body composition, sexual maturation, major CVD risk factors, and cardiac structure and function were monitored every 4 months for up to 4 years among 678 children and adolescents (49.1% girls; 20.1% blacks) aged 8, 11, or 14 years at study entry. All resided in The Woodlands or Conroe TX. Interviews were conducted at entry and annually on diet, physical activity, and health history of participants and their families. Data were collected from 1991 to 1995, and study investigators continue data analysis and reporting. Overlap in ages at examination among three cohorts (aged 8–12, 11–15, and 14–18 years at baseline) and use of multilevel modeling methods permit analysis of some 5500 observations on each principal variable for the synthetic cohort from ages 8 to 18 years.
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The factors that determine the levels of these three measures of blood pressure are evidently distinct, as are their trajectories over the same age range of 8–18 years. Increase in both fatness and FFMI was significantly associated with increasing SBP, and in models adjusted for age, gender, and race, successively less strongly with both DBP4 and DBP5.4 After adjustment for energy intake, MVPA, and sexual maturation, these associations remained significant for SBP, were weakened notably for DBP4, and were no longer significant for DBP5.
Project HeartBeat! was a longitudinal “growth” study of cardiovascular disease (CVD) risk factors and body composition in childhood and adolescence. Its findings demonstrate patterns of change from ages 8 to 18 years in anthropometric indicators of adiposity, blood lipid components, and blood pressure measurements, as well as the varying inter-relations among these patterns. Especially noteworthy are differences among associations between the two components of BMI (kg/m²)—the lean or fat-free mass index, and the fat mass index—and each of several CVD risk factors. Policy development and public health recommendations for CVD prevention beginning in childhood have evolved over 30 years or more. A new impetus to action is the recognized increase in the prevalence of childhood overweight and obesity. Intervention to prevent obesity can have a major impact in preventing CVD risk factors more broadly. Opportunities to strengthen interventions for CVD prevention in childhood and adolescence include updated algorithms for monitoring body composition, blood lipids, and blood pressure throughout childhood and adolescence through use of the Project HeartBeat! study results.
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Longstanding concern about early development of these risk factors, which also include tobacco use and diabetes, continues, and in view of the now-epidemic occurrence of childhood obesity, warrants fuller attention and understanding.20–23 This supplement to the American Journal of Preventive Medicine presents articles2–14 from continuing analysis of data from Project HeartBeat! that contributes to the understanding of this urgent public health issue.

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Blood pressure and left ventricular massSystolic and Fourth- and Fifth-Phase Diastolic Blood Pressure from Ages 8 to 18 Years: Project HeartBeat!

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Trajectories of Change in SBP, DBP4, and DBP5 with Age

Discussion

Am J Clin Nutr

Am J Prev Med

Am J Hypertens

Am J Clin Nutr

Lancet

Cardiovascular profile of 15,000 children of school age in three communities 1971–1975

Report of the task force on blood pressure control in children

Pediatrics

Report of the Second Task Force on Blood Pressure Control in Children—1987. Task Force on Blood Pressure Control in Children. National Heart, Lung, and Blood Institute, Bethesda Maryland

Pediatrics

Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: a working group report from the National High Blood Pressure Education ProgramNational High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents

Pediatrics

Fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents

Blood pressure by age in childhood and adolescence: a review of 129 surveys worldwide

Int J Epidemiol

Epidemiology of blood pressure in childhood: an international perspective

Semin Nephrol

Blood pressure during growth and development

Ann Clin Res

HANES Examination staff procedures manual for the Health and Nutrition Examination Survey, 1971–1973, Part 15a, Chapter 11, Blood pressure

Development of cardiovascular risk factors from ages 8 to 18 in Project HeartBeat!Study design and patterns of change in plasma total cholesterol concentration

Circulation

Recruitment and enrollment for Project HeartBeat!Achieving the goals of minority inclusion

Ethn Dis

Training and certification of blood pressure observers

Hypertension

Blood pressure measurement in childhood epidemiological studies

Circulation

The methods of auxological anthropometry

Blood pressure and left ventricular mass
Systolic and Fourth- and Fifth-Phase Diastolic Blood Pressure from Ages 8 to 18 Years: Project HeartBeat!